User and country empowerment to address coverage gaps for rotavirus vaccination

13th Rotavirus Symposium, Minsk

Presented by:

Lora Shimp, RAVIN

Immunization Center Technical Director, JSI

31 August 2018

Who are the decision-makers for vaccine introduction and sustainability?

Ministry of Health and Country Government

National Immunization Technical Advisory Group (NITAG) &Inter-agency Coordinating Committee (ICC)______________________________________________

Health staff, communities, and parents/caregivers

Cost and benefit of vaccine Ensuring

long-term delivery & equity

MOH, NITAG & ICC Priorities

Primary tasks

ICC (and technical sub-

committees)

Coordination with GAVI and initiatives

(polio, measles)

Macro-planning(link with cMYP and

HSS)

Support for sub-national

microplanning

Implementation strategies (fixed, outreach, mobile)

Support for management,

reporting, sustainability

Links with RI system, broader CH/

prevention

MOUs and key task agreement

NITAG scientific consensus

and guidance

Disease burden, vaccine efficacy and safety, cost-

effectiveness and cost-benefit (prevention and treatment),

etc

MOH/EPIleadership in decision-making;

intra-government coordination and agreement

NITAG – national immunization technical advisory groupICC – inter-agency coordinating committee

Note on “country-led” decision making

Need to continually engage NITAGs and MOH/EPI leadership

Challenges with vaccine availability and delays can compromise confidence in the EPI program, notably when countries have already introduced or have started preparations (i.e. training materials already developed, cold chain assessments based on particular vaccine, VIG already disbursed)

Empower countries to think towards sustainability –

beyond the Post-Introduction Evaluation (PIE) and first year of introduction need for additional, longer-term technical guidance (i.e. more than 1 year) for

financial planning and to help address service delivery gaps and equity? provide advance awareness of vaccines on the horizon and alternative delivery

strategies – revised schedules, new technologies/vaccine presentations

Ensure country access to and incorporation of technical information – at all levels (beyond EPI and cascade training)

• Are resources available in other languages beyond English? Adapted in local languages?

• Are updates shared with sub-national staff?

• How are we helping MOHs in countries to address GAPPD, GVAP, etc more holistically for diarrhea prevention, control, and treatment?

Advocacy resources

ROTA Council advocacy toolkit

Talking points

Fact sheets

Data

Presentations

Reports

rotacouncil.org/toolkit

Are countries aware of, adapting and utilizing exiting resources –and considering long-term rotavirus vaccine sustainability as part of routine immunization?

Who are the “users” in the health system?

Health Ministry Officials

monitor performance and deploy resources

Health Care Workers

Deliver care effectively and extend reach of

their services

Caregiversunderstand and accept

services for their children (and when and where to seek these)

What has worked for rotavirus vaccine coverage sustainability?

1) Hands-on training (for vaccine administration, data use, reporting)

2) Practical and repeated reinforcement of health worker skills to:

monitor and use RVV data locally to identify gaps, under-vaccinated (and liaise with communities for tracking)

Provide parents with information on the vaccination schedule and reminders on return dates/appointments

3) Updating vaccination cards and using these for information sharing with caregivers

Successes: - additional countries preparing introduction (7+)- India – 10 States (including Jharkhand; UP to launch in Sept; additional states by Mar 2019)

Global vaccine coverage estimates, 1980-2016BCG, DTP 1st and 3rd, Measles 1st and 2nd, Rubella 1st, HepB birth

and 3rd, Hib3, Pol3, YFV, PCV3 and Rota (last dose)

Source: WHO/UNICEF coverage estimates 2016 revision, July 2017.Immunization Vaccines and Biologicals, (IVB), World Health Organization.194 WHO Member States. Date of slide: 15 July 2017.

0102030405060708090

100

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

% c

over

age

bcg dtp1 dtp3 hepb3 hib3pcv3 pol3 rotac yfv hepbbmcv2 mcv1 rcv1

Rotaviruslast dose coverage

Are Rotavirus Vaccine coverage data being tracked and compared?

Focus for routine immunization coverage reporting is DPT and measles, not RVV

Although RVV coverage data collected (e.g. through DVDMT, DHIS2), insufficient attention to whether there is parity in coverage between RVV & other antigens administered at same contact

Timeliness and drop-out of RVV (i.e. according to 6, 10, and 14 week schedule) not closely monitored

0

20

40

60

80

100

Cove

rage

(%)

DTP1

RVV1

DTP3

RVV2

* Data not available in WUENIC

Comparison of penta (DPT) and rotavirus vaccine coverage, 2017

Source: WHO vaccine-preventable diseases: monitoring system 2018 global summary

*

RVV coverage data collected at facilities, but are they analyzed and used?

Kenya example: MCH Booklets used for child vaccination tracking, but updated versions not always available or correctly completed

Country RVV coverage analysis – Madagascar example

RVV1 and RVV2 Coverage Rates by District (Jan – June 2017 and Jan - June 2018), Madagascar

• Issues with timeliness of vaccination (infants often start vaccination after 2 months, including BCG)

• Inconsistent funding for outreach, notably at start of calendar/fiscal year

• Potential residual issues with RVV age restriction?

Cumulative RVV2 coverage by # of infants, % and completenessof Health Center reporting (January to June 2017 and 2018)

How complete is the tracking and reporting?

Learning from Home-based Records analysis and Data Quality Improvement Planning

1. Health workers not always familiar with vaccination schedule and the importance of RVV timeliness

2. Reminders and appointments/return dates are important for parents, including understanding their individual child’s schedule

3. Data tools need to be used and monitored –e.g. RVV in immunization registers, vaccination cards, monthly reports

4. RVV coverage should be more actively tracked and monitored – not “over-looked” with focus on measles and pentavalent (DPT) coverage

www.jsi.com/homebasedrecordsproject

Possible opportunities?:

1) Ethiopia has updated their cards – can help with tracking nomadic and urban populations who use multiple facilities

2) Increased attention to communication on benefitsof vaccination and promoting confidence –with health workers and parents

How to improve RVV routine immunization coverage?

1) Encourage data triangulation, analysis and use (implement Data Quality Improvement Plans) – including review of RVV1 and RVV2 administrative reporting

2) Promote importance of routine immunization (including RVV) timeliness and equity -- utilize strategies like RED, PIRI, TIPs, community engagement, advocacy)

3) Share impact data and advocate for benefit of RV vaccination as part of package of integrated diarrhea prevention and control strategies

Thank you!