Immunization Program Managers Research Articles

Analysis of the Federal Section 317 Immunization Program and Routine Adult Immunization Activities, United States, 2022-2023.

The federal Section 317 Immunization Program, administered by the Centers for Disease Control and Prevention (CDC), provides funding to support adult immunization efforts; however, current information on program implementation at the jurisdictional level is limited. We assessed the use of Section 317 and other funding sources to support routine adult immunization activities among the 64 immunization programs ("awardees"). We conducted a survey and key informant interviews with awardees in October to December 2022 to collect quantitative and qualitative data on current adult vaccine purchase and program operation activities funded by Section 317 and other funding sources. We assessed total vaccine cost and data on vaccine purchase projections for each awardee with CDC's Cost and Affordability Tool for 2023. Immunization program managers or their designees from 62 of 64 awardees (97%) completed the survey; 12 awardees participated in key informant interviews. Of 62 awardees, 32 (52%) used a single funding source to support adult vaccine purchases, of which 29 (91%) used only Section 317 funds, 21 (34%) reported not planning to purchase ≥1 age-based recommended vaccine for adults in 2023, and 33 (53%) reported using Section 317 funds only to support adult immunization program operations. Key informant interviews showed varied operational activities among awardees, but 8 awardees stated the need for additional staff to expand adult immunization program services in health care provider education (n = 5), program administration (n = 5), and site visits (n = 6). Additional efforts are needed to understand how to better support routine adult immunization activities implemented at the jurisdictional level.

Assessing the Implementation Determinants of Pilot Malaria Vaccination Programs in Ghana, Kenya, and Malawi through a Complexity Lens: A Rapid Review Using a Consolidated Framework for Implementation Research.

In 2019, national immunization programs in Ghana, Kenya, and Malawi commenced the implementation of RTS,S/AS01 vaccination in large-scale pilot schemes. Understanding the implementation context of this malaria vaccination in the pilot countries can provide useful insights for enhancing implementation outcomes in new countries. There has not yet been a proper synthesis of the implementation determinants of malaria vaccination programs. A rapid review was conducted to identify the implementation determinants of the pilot malaria vaccination programs in Ghana, Kenya, and Malawi, and describe the mechanism by which these determinants interact with each other. A literature search was conducted in November 2023 in PubMed and Google Scholar to identify those studies that described the factors affecting malaria vaccine implementation in Ghana, Kenya, and Malawi. Thirteen studies conducted between 2021 and 2023 were included. A total of 62 implementation determinants of malaria vaccination across all five domains of the consolidated framework for implementation research (CFIR) were identified. A causal loop diagram showed that these factors are interconnected and interrelated, identifying nine reinforcing loops and two balancing loops. As additional countries in Africa prepare for a malaria vaccine roll-out, it is pertinent to ensure that they have access to adequate information about the implementation context of countries that are already implementing malaria vaccination programs so that they understand the potential barriers and facilitators. This information can be used to inform context-specific systems enhancement to maximize implementation success. Going forward, primary implementation studies that incorporate the causal loop diagram should be integrated into the malaria vaccine implementation program to enable immunization program managers and other key stakeholders to identify and respond to emerging implementation barriers in a timely and systematic manner, to improve overall implementation performance.

Abstract 721: Vaccination barriers for HPV vaccine initiation and completion: A perception analysis using the Association of Immunization Managers annual survey

Abstract Background: Human Papillomavirus (HPV) is the most common sexually transmitted infection in the United States of America (USA) and it is associated with six types of cancers. Vaccines that protect against HPV infection have been introduced since 2006. Despite many national efforts, vaccination rates remain under 80% and many individual and systematic barriers influence HPV vaccine uptake and completion. Addressing the stem of these barriers at a national level and their regional differences, will help in understanding necessary policies for the acceptance of HPV vaccine. Objective: This study aims to describe the frequency of immunization program managers’ perceptions of the most relevant barriers to HPV vaccination in each national jurisdiction. Methods: Immunization Program Managers (IPMs) in the USA were surveyed from August 2021 to February 2022 as part of the Implementation of School-Entry Policies for Papilloma Virus Vaccination (HPV-PIVac) study with the collaboration of the Association of Immunization Managers. We gathered IPMs perceptions on the most relevant barriers to HPV vaccination within their jurisdiction. Four vaccine barriers were evaluated; for each one, IPMs reported the level (moderate, significant, no barrier) in a three-item scale. The three-item scale was merged into a two-item scale (low/high) and multiple answers from the same state were grouped. Descriptive analysis was performed for each question and results were mapped. Fisher’s exact test was performed to determine the relation between barriers. IPMs that refused or didn’t know their jurisdiction’s barriers were removed from the analysis. Results: 49 IPMs from 31 states and territories participated, resulting in a 53.4% participation rate. For the cost barrier to complete HPV vaccination of children, most IPMs perceived low barriers (51.7%) within their jurisdiction. For the perception of geographical difficulties to complete HPV vaccination, higher barriers (67.9%) were reported among participants. Limited number of providers offering the HPV vaccine was perceived equally as low or high level (50.0%), whereas lack of a strong provider recommendation or failure of providers to discuss and strongly recommend the HPV vaccine was the most significant barrier with a higher level (96.7%). Fisher’s exact test indicated independency between all barriers (p>0.05). For most variables, the Western region reported a greater level of barriers. Conclusion: This analysis documents the IPMs perception of prevalent HPV vaccine barriers for vaccine initiation and completion nationally. These results confirmed the need of further engagement for the accessibility of the vaccine, as preliminary data from NIS-Teen 2021 shows an average adolescent HPV vaccine initiation and UTD coverage of 78.2 and 62.7, respectfully. Funding: NCI Grant #R01CA232743 Citation Format: Alondra Katerina Mercado-Andino, Erick L. Suárez-Pérez, Olga L. Díaz-Miranda, Diana T. Medina-Labees, Ana P. Ortiz, Katelyn Wells, Vivian Colón-López. Vaccination barriers for HPV vaccine initiation and completion: A perception analysis using the Association of Immunization Managers annual survey [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 721.

Abstract A128: National partnerships for HPV promotion: An evaluation using the Association of Immunization Managers annual survey

Abstract Background: Human Papillomavirus (HPV) is the most common sexually transmitted infection in the United States of America (USA). Strategies from immunization programs aimed to promote HPV vaccine uptake through different alliances, including health community-based organizations and coalitions have been implemented nationally. Despite these efforts, vaccination rates remain under 80%. Understanding the extent of these partnerships and the geographic differences in the number of collaborations will aid in identify successful alliances at the national level for the promotion of HPV vaccine. Objective: This study aims to describe the frequency and the degree of partnerships for the promotion of the HPV vaccine. Methods: Immunization Program Managers (IPMs) in the USA were surveyed from August 2021 to February 2022 as part of the Implementation of School-Entry Policies for Papilloma Virus Vaccination (HPV-PIVac) study. A survey gathered information from IPMs on established partnerships and their extent of collaborations at two different levels. Of 22 partners, IPMs reported which groups or organizations had partnerships for HPV vaccine promotion occurred within the past year. Then, from each of the partnerships reported, IPMs categorized their collaboration strength by rank (networking, cooperating, coordinating, and/or collaborating). Descriptive and inferential analyses were performed to assess the patterns in the number of collaborations and their strength. The results were geographically mapped among the participant states and territories that completed the survey. To assess the relationship between the number of collaborations and the strength of collaborations, the Pearson correlation coefficient was estimated. Afterward, a linear regression model was used to compare the magnitude of association between the number of collaborations and the strength of those collaborations. Results: A total of 49 IPMs from 32 different states and territories participated, resulting in a 54.2% participation rate. The most common partnerships reported were with local health departments (80.0%), community health centers (78.0%), American Cancer Society (74.0%), and immunization coalitions (74.0%). The relationship between number of collaborations and strength of collaborations resulted in a positive and strong linear relationship (r = 0.91; p<0.05). For each unit of increment in the number of partnerships, the estimated strength of these partnerships increases by 2.78 (95% CI: 2.29-3.26). The Western region had a greater number of collaborations varying between moderate and strong number of partnerships in states such as Arizona and Utah. Likewise, the Western region had a greater extent of those partnerships fluctuating between strong and moderate strength. Conclusion: This study documents the prevalent dynamic of partnerships and alliances among IPMs nationally. A higher number of partnerships is associated with the strength of these collaborations, which encourages further engagement in states whose partnerships are weak. Funding: NCI Grant #R01CA232743 Citation Format: Alondra K. Mercado-Andino, Yiana G. Toro-Garay, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Ana P. Ortiz, Katelyn Wells, Erick Suárez, Vivian Colón-López. National partnerships for HPV promotion: An evaluation using the Association of Immunization Managers annual survey [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A128.

Scoping Literature Review of Facilitators and Barriers to Routine Immunization Data Quality and use in Decision Making in Sub-Saharan Africa

ABSTRACT Availability of high-quality data alone, is not sufficient to ensure the effective use of the data in decision making. Therefore, this study aims to identify the facilitators and barriers to generating quality data and usage for decision making in routine immunization program management in Sub-Saharan Africa. Scoping literature review was conducted on empirical and non-empirical literature on immunization data in sub-Saharan Africa from 2010 to 2020. The review adopted Arksey and O’Malley’s theoretical framework and Donabedian’s model in the abstraction and analysis of data, and in the synthesis of the findings. The structural factors that facilitate routine immunization data quality and use include, the availability of trained data managers (n=7) and relevant data management tools (n=15). The procedural facilitators are existence of routine data quality assessment processes such as supportive supervision and data review meetings (n=29), and the use of decision support systems like data monitoring charts and dashboards (n=18). Conversely, the barriers to routine immunization data quality and use were inadequate human resources for data management (n = 4), poor staff attitudes to data management (n = 4), insufficient capacity of data managers to use decision support tools (n=7), and poor supervision and tracking of immunization coverage data (n=21). This study found that structural and procedural factors greatly influenced quality of immunization data. The conceptualization, design, and implementation of interventions and strategies for improving the quality and use of immunization data should leverage the facilitators and mitigate the barriers.

Abstract A129: National assessment of the HPV acceptance: Public attitudes and policy climate

Abstract Background: Human Papillomavirus (HPV) is a common sexually transmitted infection that has been associated with the development of cancers, most of them preventable if the HPV vaccine is administered before exposure. HPV school-entry policies could affect the HPV rates at a population level, hence the need for monitoring nationally the support of policies to assess acceptance at different levels. Objective: This study describes the state-level immunization program managers’ (IPMs) perception of the degree of the general public and policymakers’ acceptance or opposition to the HPV vaccine policies to increase HPV vaccination across their state or territory. Methods: As part of the study entitled Implementation of School-Entry Policies for Human Papilloma Virus Vaccination (HPV-PIVac), IPMs were surveyed about their perception regarding the acceptance or opposition of either (1) the public and (2) policymakers towards HPV vaccine policies. Five questions inquired about the degree of public concern towards HPV-related cancers, public hesitancy towards the HPV vaccine, public opposition towards HPV policies, and acceptance or resistance from policymakers regarding HPV vaccine policies using a five-item scale transformed into a three-item scale. Descriptive statistics were used to assess the managers perception about HPV vaccine policies. Fisher’s exact test was conducted to assess regional differences and the relationship between perception items from the public and policymakers. Results: 49 IPMs from 32 different states and territories participated in this study. In relation to the public concern towards HPV-related cancers, 93.8% of IPMs perceived that the public from their participant states and territories had moderate/mild concern. In comparison, only 6.3% perceived strong/overwhelming concern. For public hesitancy towards the HPV vaccine, 81.3% of IPMs perceived that the public had moderate/mild hesitancy, while 18.8% perceived strong/overwhelming reluctance. For public opposition towards HPV vaccine policies, 21.9% of IPMs perceived strong/overwhelming opposition. On the other hand, 40.6% of IPMs reported that the policymakers were resistant to education policies that promote the HPV vaccine. Similarly, 59.4% of IPMs reported that policymakers were resistant to HPV-school entry vaccination policies. No significant differences between regions were observed in the items analyzed (p>0.05). Fisher’s exact test indicated a significant association between the public opposition towards the HPV vaccine policies and the posture of policymakers towards HPV education policies (p<0.05). Conclusion: Results highlight that IPM’s perceive moderate/mild hesitancy and moderate/mild opposition by the public towards HPV vaccines and HPV policies; these attitudes could translate into resistance towards HPV policies by policymakers in the US. Findings support the need for active public engagement strategies to increase policymakers' support for promoting HPV vaccine policies and requirements. Funding: NCI Grant #R01CA232743. Citation Format: Yiana G. Toro-Garay, Alondra K. Mercado-Andino, Olga L. Diaz-Miranda, Diana T. Medina-Laabes, Ana P. Ortiz, Katelyn Wells, Erick Suárez, Vivian Colón-López. National assessment of the HPV acceptance: Public attitudes and policy climate [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A129.

A global comprehensive vaccine-preventable disease surveillance strategy for the immunization Agenda 2030

As part of the Immunization Agenda 2030, a global strategy for comprehensive vaccine-preventable disease (VPD) surveillance was developed. The strategy provides guidance on the establishment of high-quality surveillance systems that are 1) comprehensive, encompassing all VPD threats faced by a country, in all geographic areas and populations, using all laboratory and other methodologies required for timely and reliable disease detection; 2) integrated, wherever possible, taking advantage of shared infrastructure for specific components of surveillance such as data management and laboratory systems; 3) inclusive of all relevant data needed to guide immunization program management actions. Such surveillance systems should generate data useful to strengthen national immunization programs, inform vaccine introduction decision-making, and reinforce timely and effective detection and response. All stakeholders in countries and globally should work to achieve this vision.

Innovation and immunization program management: traceability and quality in Latin America and the Caribbean, laying the groundwork for a regional action plan

ABSTRACT Introduction The Latin American Society of Pediatric Infectious Diseases (SLIPE by its Spanish acronyms) is working to understand the current situation, gaps, and opportunities for traceability of the quality vaccination process in Latin America and the Caribbean. Areas covered On September 24th and 25th, a Latin American forum of experts in immunization programs was held through the Zoom platform; the topics discussed included: computerized systems for recording immunizations, vaccination programs traceability, challenges, and information systems for the integrated management of vaccination. Expert opinion Latin American countries have transitioned from having a nominal registration system to a nominal tracking system, with many of them not migrating their platforms to new technologies; therefore, the low-quality data, fragmented databases, and slow information traffic present a challenge that must be taken on.

ECHO Elimination of Cervical Cancer in Latin America (ECHO ELA): Lessons Learned From Promoting WHO’s Cervical Cancer Elimination Goals ‘90-70-90’

PURPOSE Cervical cancer (CC) is one of the leading causes of cancer deaths among women in some countries in the Region of the Americas.1 CC is preventable through HPV vaccination, screening and treatment of precancerous lesions, and can be effectively treated if diagnosed early. METHODS Under the framework of the Global Strategy to Accelerate the Elimination of CC as a Public Health Problem, The University of Texas MD Anderson Cancer Center (MD Anderson), the US National Cancer Institute (NCI), and the Pan American Health Organization (PAHO) partnered to develop the Project ECHO for the elimination of CC in Latin America (ECHO ELA). ECHO ELA is modeled on Project ECHO® (Extension of Community Healthcare Outcomes) a hub-and-spoke knowledge-sharing approach where expert teams lead virtual didactic lectures and case discussions, building capacity for participants to deliver best-practice programs to their regions.3 ECHO ELA consists of monthly, Spanish telementoring conferences to assist Latin American (LA) countries reaching the WHO CC elimination goals “90-70-90:” vaccinating 90% of girls against HPV by the age of 15, screening 70% of women for cervical cancer at ages 35 and 45 and treating 90% of women diagnosed with pre-invasive disease or cervical cancer. Program targets professionals from Ministries of Health, including Immunization and Screening Program Managers, and cervical cancer stakeholders. RESULTS In the first year of the program (2020-2021), 294 participants from 22 countries were registered. Fourteen sessions were held averaging 77 participants per session on topics spanning comprehensive program planning, presenting country experiences on HPV vaccination strategies, new technologies for screening and treatment. Eighteen participants completed the post survey addressing priorities, capacity, and desired outcomes, and two focus groups collected facilitators/barriers to achieving goals. CONCLUSION ECHO ELA is potentially an effective tool to enhance collaboration and support countries’ progress towards the elimination of CC.

Key Challenges and Opportunities for Implementing School Located Vaccination Clinics for COVID-19 and Influenza: Roundtables With School Nurses and Immunization Programs.

School-located vaccination clinics (SLVs) are an established strategy to offer influenza and routine vaccinations and improve student and community health. The COVID-19 pandemic has led many communities to expand SLVs to include COVID-19 vaccines. However, these SLVs are less documented than in the past due to the fast-paced nature of the pandemic and the additional pressures put on schools and public health organizations. We conducted five virtual roundtables with 30 school nurses and state immunization program managers from across the United States to gain insight into SLVs occurring during the COVID-19 pandemic. Roundtables explored participants' experiences planning and implementing SLVs, including factors influencing success and available resources. Findings highlighted SLVs as an opportunity to increase access and equity for vaccines. Participants shared strategies for School-located vaccination (SLV) funding, partnership building, vaccine storage and management, consent, data sharing, messaging, and promotion. These shared experiences offer useful insights for those interested in future and sustained SLV implementation.

Analysis of Immunization Program Management in Achieving Universal Child Immunization (UCI) Coverage at Bebesen Health Center, Central Aceh Regency

The purpose of the study was to analyze the implementation of immunization program management in an effort to achieve UCI at the Bebesen Health Center, Central Aceh Regency. This research uses descriptive qualitative method. The research location is Bebesen Public Health Center, Central Aceh Regency. Sources of data used consisted of primary data, secondary data and tertiary data. Data collection techniques in the form of observation, in-depth interviews with 10 informants and documentation. Data analysis techniques are carried out through data reduction, data presentation and drawing conclusions. To analyze the availability of resources for the implementation of the immunization program at the Bebesen Health Center, Central Aceh Regency, the researchers used management theory including input, process and output consisting of the availability of officers, sources of funds and facilities and infrastructure. The implementation of the immunization program consists of planning, implementation, monitoring and evaluation. The output can be seen in the UCI coverage at the Bebesen Health Center. It has not yet reached the target where the achievement is still 71.4%. The conclusion of this study is that the staff's resources have met the qualification standards, namely having a medical or nursing educational background and having STR with a minimum education of DIII in the field of Health, as well as sufficient funds, facilities and infrastructure. The evaluation has been carried out and it is necessary to increase cross-sectoral collaboration.

Partnering with healthcare systems to improve HPV vaccination:The perspective of immunization program managers

ABSTRACT The US’s 64 CDC-funded immunization programs are at the forefront of efforts to improve the quality of adolescent vaccination services. We sought to understand immunization program managers’ perspectives on partnering with healthcare systems to improve HPV vaccine uptake. Managers of 44 state and local immunization programs completed our online survey in 2019. Immunization managers strongly endorsed the importance of partnering with systems to improve HPV vaccine uptake (mean = 3.8/4.0), and most wanted to do so in the next year (mean = 3.5). Immunization managers reported that common barriers included difficulty contacting systems’ leadership (57%), differing organizational cultures (52%), and time (52%). Many perceived systems as not prioritizing HPV vaccination (77%). Immunization managers expressed strong interest in participating in a training on partnering with systems (mean = 3.5). Overall, immunization managers are highly interested in partnering with systems to improve HPV vaccine uptake. Training and other support are needed to expand programs’ capacity for such partnerships.

Abstract 53: Promoting WHO's Cervical Cancer Elimination Goals ‘90-70-90' by Developing, Implementing, and Evaluating the ECHO Latin America (ECHO ELA) Program

Abstract Purpose: Cervical cancer is one of the leading causes of cancer deaths among women in some countries in the Region of the Americas.1 Cervical cancer is preventable through HPV vaccination, screening and treatment of precancerous lesions, and can be effectively treated if diagnosed early.2 Methods: Under the framework of the Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem, the US National Cancer Institute (NCI), the University of Texas MD Anderson Cancer Center (MD Anderson) and the Pan American Health Organization/World Health Organization (PAHO/WHO) partnered to develop ECHO Latin America (ECHO ELA). ECHO ELA is modeled on Project ECHO® (Extension of Community Healthcare Outcomes) a hub-and-spoke knowledge-sharing approach where expert teams lead virtual didactic lectures and case discussions, amplifying the capacity for participants to deliver best practice programs to their regions. ECHO ELA consists of monthly, Spanish-language telementoring conferences about cervical cancer prevention and control. The program targets Ministries of Health, Immunization Program Managers and key cervical cancer stakeholders in Latin American (LA) countries. Its primary goal is to assist countries in reaching their WHO cervical cancer elimination goals “90-70-90:” vaccinating 90 percent of girls against HPV by the age of 15, screening 70 percent of women for cervical cancer at ages 35 and 45, and treating 90 percent of women diagnosed with pre-invasive cervical lesions or cervical cancer. Results: To date, 222 participants from 21 countries have registered. Seven sessions have been held averaging 93 participants per session. 85 participants completed the baseline survey addressing priorities, capacity, and desired outcomes. Baseline, mid-year evaluation results, within the COVID-19 context, and learned lessons will be presented. Conclusion: ECHO ELA is potentially an effective tool to convene participants from multiple countries to enhance collaboration and support countries' progress towards the elimination of cervical cancer in the Americas. Citation Format: Sandra L. San Miguel-Majors, Edward L. Trimble, Doug Lowy, Melissa Lopez-Varon, Ellen Baker, Kathleen Schmeler, Silvina Arrossi, Maria Tereza da Costa Oliveira, Mauricio Maza, Jane R. Montealegre, Mila P. Salcedo, Lucia Helena de Oliveira, Silvana Luciani. Promoting WHO's Cervical Cancer Elimination Goals ‘90-70-90' by Developing, Implementing, and Evaluating the ECHO Latin America (ECHO ELA) Program [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 53.

Immunisation program training needs in 9 countries in the African Region.

Introductionregular in-service training of healthcare workers within the immunization program is critical to address the program needs created by the introduction of new vaccines and technologies, as well as the expanding scope of immunisation programmes beyond infant immunization and towards a life-course approach. National immunization programs conduct in-service training of health workers depending on program needs and particularly when new program elements are introduced.Methodswe conducted a survey of national and provincial level immunization program staff in 9 countries in the World Health Organization (WHO) African Region to determine the perceived needs and preferred training methods for capacity building in immunisation.Resultsnearly all of the respondents (98.3%) stated that there are skill gaps at their respective levels in the immunization program which require training, with 88% indicating that mid-level program management (MLM) training was needed to train new program staff, while 78% indicated program performance gaps and 60% of the respondents stated that refresher training is needed. Program areas identified as top priorities for training included immunisation monitoring and data quality, sustainable immunization financing, adverse events monitoring and community mobilization. More than three quarters of the respondents (78%) think that online MLM training is adequate to address program gaps. Only four of the 9 immunization program managers indicated that they regularly monitor the number of MLM trained staff within their national program.Conclusionthere is a strong need for in-service training of immunization program officers in the countries surveyed, especially at the subnational levels. Program managers should conduct regular monitoring of the training status of staff, as well as conduct detailed training needs assessments in order to tailor the training approaches and topics. Online training provides an acceptable approach for capacity building of immunization program staff.

Caregiver and service provider vaccine confidence following the Changchun Changsheng vaccine incident in China: A cross-sectional mixed methods study

IntroductionThe Changchun Changsheng Vaccine Incident (CCVI) occurred mid-2018 and involved irregularities in the manufacture and quality control of diphtheria-tetanus-acellular-pertussis and rabies vaccines. This study investigates vaccine confidence amongst Chinese caregivers and vaccination-service providers (VSPs) six months after the CCVI. MethodsQuantitative surveys were conducted in January 2019 with 2124 caregivers of children and 555 VSPs in three areas in China. The proportions of respondents who agreed to the four statements from the Vaccine Confidence Index™ were used to measure vaccine confidence. Descriptive and univariate analyses were performed to study the level of vaccine confidence. Semi-structured interviews were conducted with 48 caregivers, 43 VSPs and 9 immunization program managers. Interviews were analyzed thematically using a combination of deductive and inductive coding. Media surveillance was conducted to monitor public responses to the CCVI. ResultsMedia surveillance indicated that public attention to vaccine-related issues increased sharply immediately post-CCVI but declined rapidly thereafter. Six months post-CCVI, 96.0% of caregivers and the same proportion of VSPs reported that vaccination was important and compatible with their religious beliefs. 82.7% and 88.2% of caregivers agreed that vaccines were safe and effective. 92.8% and 94.6% of VSPs agreed that vaccines were safe and effective. Both caregivers and VSPs reported an immediate decline in vaccine confidence post-CCVI. In most cases this trust was regained over time following government and public health responses, however some people remained hesitant about vaccinating their children. Many VSPs were overwhelmed by consultations, workload and psychological pressure after the CCVI. ConclusionAfter an initial decline, vaccine confidence recovered to pre-incident levels six months after the CCVI. However, some caregivers moved from the higher to the lower end of the vaccine confidence spectrum, pointing to the need to promote the acceptance of vaccination especially given the need for new vaccines to control the coronavirus epidemic.

A cost-effectiveness analysis of traditional and geographic information system-supported microplanning approaches for routine immunization program management in northern Nigeria

Effective RI microplanning requires accurate population estimates and maps showing health facilities and locations of villages and target populations. Traditional microplanning relies on census figures to project target populations and on community estimates of distances, while GIS microplanning uses satellite imagery to estimate target populations and spatial analyses to estimate distances. This paper estimates the cost-effectiveness of geographical information systems (GIS)-based microplanning for routine immunization (RI) programming in two states in northern Nigeria.For our cost-effectiveness analysis, we captured the cost of all inputs for both approaches to capture the incremental cost of GIS over traditional microplanning and present the incremental cost-effectiveness ratios for each vaccine-preventable illness, death, and disability-adjusted life year (DALY) averted.We considered two scenarios for estimating vaccine requirements for each microplanning approach, one based on administrative vaccination coverage rates and one based on National Nutrition and Health Survey rates. With the administrative rates, GIS microplanning projected approximately 194,000 and 157,000 more required vaccinations than traditional microplanning in Bauchi and Sokoto States; with the survey rates, the additional number of vaccinations required was nearly 113,000 in Bauchi and about 47,000 in Sokoto. For each state under each scenario, we present numbers of and costs per measles and pertussis cases, deaths, and DALYs averted by the additional vaccinations, as well as annual costs.As expected, GIS-based microplanning incurs higher costs than traditional microplanning, due mainly to the additional vaccinations required for populations previously unreached. Our estimates of cost per DALY averted suggest, however, that GIS microplanning is more cost-effective than traditional microplanning in both states under both coverage scenarios and that the higher costs incurred by GIS microplanning are worth adopting.

The distribution and use of feedback bulletins among national immunization program management teams in East and Southern Africa.

IntroductionImmunization program monitoring includes numerous activities, some of which include monitoring of vaccination coverage, surveillance performance and epidemiological patterns. The provision of timely, high quality and actionable feedback is an essential component of strengthening health systems. Within the African region of the WHO, various bulletins are produced and disseminated regularly to provide feedback on the performance of immunization programs and vaccine preventable disease control initiatives.MethodsThe 2019 annual national immunization program managers’ meeting for countries in the eastern and southern African subregion was held in Asmara from 18 - 20 March 2019. A survey questionnaire was administered to the participants representing the national programs and in-country partners across the 20 countries.ResultsOn average, the 75 respondents receive 1.8 e-mailed feedback bulletins monthly. Twenty-three (31%) respondents receive 3 or more written feedback bulletins per month, and 72% receive the bulletins regularly. On a scale of 1 - 5 (from lowest to highest), 87% participants rated the relevance of the bulletins they receive at 4 - 5. Only 19% of the respondents responded that the results are discussed within the national immunization program, and 14% stated that action points are generated based on the feedback received. Fifty-nine (79%) respondents want to receive more frequent feedback on routine immunization performance. Among the EPI program managers and the EPI program data managers, the access to these feedback bulletins was quite limited. Even though the primary objective of the bulletins is to initiate discussions and action based on the provided feedback, such discussions do not happen regularly at country level. The programmatic use and advocacy value of the bulletins is not optimal.ConclusionWe recommend integrating program feedback, regularly updating the distribution lists, the additional use of instant messaging platforms for distribution, as well as online posting of the bulletins for wider availability.

Governing off-label vaccine use: An environmental scan of the Global National Immunization Technical Advisory Group Network

BackgroundNational Regulatory Authorities approve the indications for vaccine use in the product information. Occasionally, National Immunization Technical Advisory Groups (NITAGs) make off-label recommendations for use in different age groups, populations, and dosing schedules from the product information. We sought to determine the rationale, policies and procedures for NITAG off-label recommendations. MethodsWe conducted an environmental scan of Global NITAG Network members, immunization program managers and regulators in 38 high-, middle- and low-income countries. Participants completed an online survey regarding policies, procedures, and legislation governing development of off-label recommendations. A sub-sample of respondents met for a focus group and interviews which were analyzed qualitatively. ResultsThirty-four people responded from 26/38 (68%) countries surveyed; 76% of respondents were NITAG members or immunization program managers. Recommendations for off-label vaccine use were made in 14/26 (54%) countries; the NITAG made those recommendations in 8/14 (57%) countries. Reasons for off-label vaccine recommendations included response to disease outbreaks or vaccine shortages. Only one country had standard operating procedures for developing off-label recommendations while 6/14 (43%) countries had policies for implementing off-label recommendations. Nine respondents from 8 countries agreed to participate in a focus group (n = 6) or individual interviews (n = 3). Barriers to off-label recommendations included legal concerns, lack of standard definition for off-label use, and manufacturer reluctance to update product information. Facilitators included confidence in the decision-making process, and transparency of open communication among stakeholders. ConclusionsBest practice guidelines are needed that define off-label use and outline a transparent, evidence-based approach to develop off-label recommendations.

Developing standardized competencies to strengthen immunization systems and workforce

Despite global support for immunization as a core component of the human right to health and the maturity of immunization programs in low- and middle-income countries throughout the world, there is no comprehensive description of the standardized competencies needed for immunization programs at the national, multiple sub-national, and community levels. The lack of defined and standardized competencies means countries have few guidelines to help them address immunization workforce planning, program management, and performance monitoring. Potential consequences resulting from the lack of defined competencies include inadequate or inefficient distribution of resources to support the required functions and difficulties in adequately managing the health workforce. In 2015, an international multi-agency working group convened to define standardized competencies that national immunization programs could adapt for their own workforce planning needs. The working group used a stepwise approach to ensure that the competencies would align with immunization programs’ objectives. The first step defined the attributes of a successful immunization program. The group then defined the work functions needed to achieve those attributes. Based on the work functions, the working group defined specific competencies. This process resulted in three products: (1) Attributes of an immunization program described within eight technical domains at four levels within a health system: National, Provincial, District/Local, and Community; (2) 229 distinct functions within those eight domains at each of the four levels; and (3) 242 competencies, representing eight technical domains and two foundational domains (Management and Leadership and Vaccine Preventable Diseases and Program). Currently available as a working draft and being tested with immunization projects in several countries, the final document will be published by WHO as normative guidelines. Vertical immunization programs as well as integrated systems can customize the framework to suit their needs. Standardized competencies can support immunization program improvements and help strengthen effective health systems.

Public Health Opportunities to Improve Late-Adolescent Immunization.

Seven state/local immunization program managers were convened to discuss how public health immunization programs could enhance their efforts to promote adolescent vaccination, with an emphasis on late adolescence (ages 16-18 years). The Centers for Disease Control and Prevention's revised childhood immunization schedule for 2017 and a recently proposed preventive care platform at 16 years of age provide a unique opportunity to focus on increasing adolescent immunization rates in this population. Public health officials discussed challenges to immunizing this population and suggested key strategies for supporting late-adolescent immunization, including partnerships between public health and immunization providers; nationally supported public information campaigns; and using immunization data specific to this population to track progress.