Equitable Immunisation Research Articles

How to evaluate the implementation of complex health programmes in low-income settings: the approach of the Gavi Full Country Evaluations.

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia. We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation. Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

What are the challenges in the vaccination of migrants in Norway from healthcare provider perspectives? A qualitative, phenomenological study

BackgroundMigrant populations in the European Union (EU) suffer a disproportionate burden of infectious diseases and may be particularly vulnerable due to poor conditions in countries of origin or throughout transit...

Determinants of geographical inequalities for DTP3 vaccine coverage in sub-Saharan Africa

Childhood immunization is one of the most effective health interventions, making it a key indicator of progress towards universal health coverage. In the last decade, improvements in coverage have been made globally, however, slow progress has been documented in sub-Saharan Africa with considerable subnational variations. We explore potential drivers of equitable immunization services based on subnational DTP3 coverage estimates.Using vaccine coverage at the 5 by 5 km area from 2000 to 2016, we quantify inequality using three measures. We assess the shortfall inequality which is the average deviation across subnational units from that with the highest coverage for each country. Secondly we estimate the threshold index, the proportion of children below a globally set subnational coverage target, and lastly, a Gini coefficient representing the within-country distribution of coverage. We use time series analyses to quantify associations with immunization expenditures controlling for country socio-economic and population characteristics.Development assistance, maternal education and governance were associated with reductions in inequality. Furthermore, high quality governance was associated with a stronger relationship between development assistance and reductions in inequality. Results from this analysis also indicate that countries with the lowest coverage suffer the highest inequalities. We highlight growing inequalities among countries which have met national coverage targets such as South Africa and Kenya. In 2016, values for the shortfall inequality ranged from 1% to 43%, the threshold index from 0% to 100% and Gini coefficient from 0.01 to 0.37. Burundi, Comoros, Eswatini, Lesotho, Namibia, Rwanda, and Sao Tome and Principe had the least shortfall inequality (<5%) while Angola, Ethiopia and Nigeria had values greater than 40%. A similar picture was noted for the other dimensions of inequality among these particular countries.Immunization program investments offer promise in addressing inequality, however, domestic mechanisms for resource implementation and accountability should be strengthened to maximize gains in coverage.

IMMUNIZATION AND VACCINE DEVELOPMENT: Progress towards High and Equitable Immunization Coverage in the Africa Region from 2012 to 2016

This paper gives a brief update on the status of the immunization and vaccine development in the WHO African Region. It also highlights the progress on the control, elimination or eradication of vaccine preventable diseases in the African Region.The paper reviews national immunization programme data as well as WHO-UNICEF Estimates for Immunization Coverage (WUENIC) in the African Region from 2012-2016.It revealed that there has been considerable success with the development and introduction of new vaccines in the Region. However, uptake of these vaccines has not matched the level of success in new vaccine introduction. This has made the goal of reaching high and equitable immunization coverage a mirage in the Region. Multiple barriers have been blamed for this, chief among which are inadequate commitment of national governments and weak community engagement to immunization service delivery in the Region. Steps are taken to address these issues, including sensitization of government of the African Region to prioritize Universal Access to Immunization as a Cornerstone for Health and Development in Africa. This is because it is argued that development efforts are link to the human beings for whom progress is targeted and/or agents that bring about development.Saving human lives therefore is critical to the realization of development goals. It is important that immunization coverage is universal to achieve the control/elimination of vaccine preventable diseases.

Introduction of universal human papillomavirus vaccination of girls aged 11 years to the National Immunization Program in Brazil: a cost-effectiveness analysis

BackgroundEconomic evaluations in Brazil are part of the decision processes for incorporation of new health technology, and all vaccines introduced since 2005 in the National Immunization Program had cost-effectiveness studies done. We assessed the cost-effectiveness of introducing universal human papillomavirus (HPV) vaccination into the National Immunization Program. MethodsWe did this modelling study with the CERVIVAC decision support model, to compare two strategies: (1) status quo with the present Papanicolaou screening programme, and (2) the present screening programme plus vaccination of a cohort of girls aged 11 years. We estimated parameters for national epidemiology, resource use, and cost, on the basis of public health information, national surveys, and published studies. We applied a 5% discount to both future costs and future health benefits. We assessed cost-effectiveness from three perspectives: government (public healh system), health system (public and private health system), and society (health systems and population). We did the analyses with Microsoft Excel. FindingsVaccination of each successive cohort would result in 229 deaths avoided and 6677 disability-adjusted life-years averted. The incremental cost-effectiveness ratio per DALY averted for the Brazilian Government (US$7663), health system (US$7413), and society (US$7298) would be deemed cost-effective, according to WHO parameters. Incremental cost-effectiveness ratios were most sensitive to variations in disease burden, vaccine efficacy, and coverage of serotypes 16 and 18. Vaccine prices have reduced greatly since 2012, and cost, an important driver in previous cost-effectiveness studies, was no longer as important. InterpretationHPV vaccination would be cost-effective with additional benefits for the control of cervical cancer if long term vaccine efficacy is confirmed, but initial large investments are needed from the National Immunization Program. Attaining favourable results will require a sustainable and equitable immunisation programme, an improved screening programme, and a surveillance system. FundingConselho Nacional de Pesquisa.

The public perception of the value of vaccines - the case of Switzerland.

AimIn this original article, we seek to analyse the environment in which immunisation policies are adopted and, more specifically, the way the public perception of vaccines influences decision-making, by looking more closely at the case of Switzerland.Subjects and methodsHistorical and present-day examples of attitudes towards immunisation and specific vaccines, both on the part of the public and of health-care workers, are reviewed.ResultsDecision-making with regard to vaccine policy implementation has been and is still most often driven by fear: fear of disease (when perceived as rampant and/or dangerous), but also fear of vaccine-associated adverse events (when the disease is less or no longer “visible”). However, methodology for introducing evidence-based immunisation policies exists and can be used by public health authorities, while vaccination information systems (such as the Swiss InfoVac) have proven their usefulness in providing trustworthy, peer-based knowledge to health-care workers.ConclusionOnly information based on clear, evidence-based data gathered and analysed according to solid methodological criteria coupled with adequate information of health-care workers (and thus patients) can ensure in future the implementation of scientifically coherent, publicly acceptable, and equitable immunisation policies.

A five minute stain for Campylobacter in tissue.

Strengthening data use and quality is critical to achieving high, equitable immunization coverage. One approach that is being increasingly recognized as effective in improving data use and quality is data triangulation, which can provide more information for decision making in public health programs. In Ethiopia, immunization program data has had ongoing quality challenges, including timeliness, completeness, and accuracy. Some data are reported through different systems to different departments, and coordination between departments is limited. JSI, through the Universal Immunization through Improving Family Health Services (UI-FHS) project, introduced a data review process and an Excel tool for triangulating immunization program data and vaccine supply data to improve data quality and programmatic decision making. The user-friendly Immunization Data Triangulation Tool (IDTT) provides decision-support information—such as scoring of districts based on performance—and suggests follow-up actions. It also highlights gaps between vaccines supplied and consumed and helps managers determine the next steps to address programmatic, supply, or data quality issues. The data review process and IDTT were rolled out in 2 regions in Ethiopia. UI-FHS documented learning to understand the feasibility of the IDTT’s application as a decision-making tool by conducting key informant interviews and observing how the IDTT was used at monthly data review meetings. Health managers who used the tool reported ease of use and clear benefits, including more accessible and synthesized data, which prompted decision making and actions to improve services and supply, such as expanding the number of immunization sites. Challenges with the availability of vaccine supply data hindered managers9 ability to leverage triangulated data fully, but the data triangulation process prompted cross-departmental collaboration to address this gap. These early findings show promise in the ability of immunization programs to successfully use triangulated data to address challenges and provide lessons for introducing new tools or processes into health systems.