Lessons Learned from the CORE Group Polio Project and Their Relevance for Other Global Health Priorities.

Despite numerous setbacks, the Global Polio Eradication Initiative has implemented various community strategies with potential application for other global health issues. This article reviews strategies implemented by the CORE Group Polio Project (CGPP), including pursuit of the missed child, microplanning, independent campaign monitoring, using community health workers and community mobilizers to build community engagement, community-based surveillance, development of the capacity to respond to other health needs, targeting geographic areas at high risk, the secretariat model for non-governmental organization collaboration, and registration of vital events. These strategies have the potential for contributing to the reduction of child and maternal mortality in hard-to-reach, underserved populations around the world. Community-based surveillance as developed by the CGPP also has potential for improving global health security, now a global health priority.

The value of tailoring vial sizes to populations and locations.

BACKGROUND: Frequently, a country will procure a single vaccine vial size, but the question remains whether tailoring the use of different size vaccine vial presentations based on populations or location characteristics within a single country could provide additional benefits, such as reducing open vial wastage (OVW) or reducing missed vaccination opportunities. METHODS: Using the Highly Extensible Resource for Modeling Supply Chains (HERMES) software, we built a simulation model of the Zambia routine vaccine supply chain. At baseline, we distributed 10-dose Measles-Rubella (MR) vials to all locations, and then distributed 5-dose and 1-dose MR vials to (1) all locations, (2) rural districts, (3) rural health facilities, (4) outreach sites, and (5) locations with average MR session sizes <5 and <10 children. We ran sensitivity on each scenario using MR vial opening thresholds of 0% and 50%, i.e. a healthcare worker opens an MR vaccine for any number of children (0%) or if at least half will be used (50%). RESULTS: Replacing 10-dose MR with 5-dose MR vials everywhere led to the largest reduction in MR OVW, saving 573,892 doses (103,161 doses with the 50% vial opening threshold) and improving MR availability by 1% (9%). This scenario, however, increased cold chain utilization and led to a 1% decrease in availability of other vaccines. Tailoring 5-dose MR vials to rural health facilities or based on average session size reduced cold transport constraints, increased total vaccine availability (+1%) and reduced total cost per dose administered (-$0.01) compared to baseline. CONCLUSIONS: In Zambia, tailoring 5-dose MR vials to rural health facilities or by average session size results in the highest total vaccine availability compared to all other scenarios (regardless of OVT policy) by reducing open vial wastage without increasing cold chain utilization.

Doses per vaccine vial container: An understated and underestimated driver of performance that needs more evidence.

The widespread use of multidose vaccine containers in low and middle income countries' immunization programs is assumed to have multiple benefits and efficiencies for health systems, yet the broader impacts on immunization coverage, costs, and safety are not well understood. To document what is known on this topic, how it has been studied, and confirm the gaps in evidence that allow us to assess the complex system interactions, the authors undertook a review of published literature that explored the relationship between doses per container and immunization systems. The relationships examined in this study are organized within a systems framework consisting of operational costs, timely coverage, safety, product costs/wastage, and policy/correct use, with the idea that a change in dose per container affects all of them, and the optimal solution will depend on what is prioritized and used to measure performance. Studies on this topic are limited and largely rely on modeling to assess the relationship between doses per container and other aspects of immunization systems. Very few studies attempt to look at how a change in doses per container affects vaccination coverage rates and other systems components simultaneously. This article summarizes the published knowledge on this topic to date and suggests areas of current and future research to ultimately improve decision making around vaccine doses per container and increase understanding of how this decision relates to other program goals.

Engaging communities with a simple tool to help increase immunization coverage.

The level of vaccination coverage in a given community depends on both service factors and the degree to which the public understands and trusts the immunization process. This article describes an approach that aims to raise awareness and boost demand. Developed in India, the "My Village Is My Home" (MVMH) tool, known as Uma Imunizasaun (UI) in Timor-Leste, is a poster-sized material used by volunteers and health workers to record the births and vaccination dates of every infant in a community. Introduction of the tool in 5 districts of India (April 2012 to March 2013) and in 7 initial villages in Timor-Leste (beginning in January 2012) allowed community leaders, volunteers, and health workers to monitor the vaccination status of every young child and guided reminder and motivational visits. In 3 districts of India, we analyzed data on vaccination coverage and timeliness before and during use of the tool; in 2 other districts, analysis was based only on data for new births during use of the tool. In Timor-Leste, we compared UI data from the 3 villages with the most complete data with data for the same villages from the vaccination registers from the previous year. In both countries, we also obtained qualitative data about perceptions of the tool through interviews with health workers and community members. Assessments in both countries found evidence suggesting improved vaccination timeliness and coverage. In India, pilot communities had 80% or higher coverage of identified and eligible children for all vaccines. In comparison, overall coverage in the respective districts during the same time period was much lower, at 49% to 69%. In Timor-Leste, both the number of infants identified and immunized rose substantially with use of the tool compared with the previous year (236 vs. 155, respectively, identified as targets; 185 vs. 147, respectively, received Penta 3). Although data challenges limit firm conclusions, the experiences in both countries suggest that "My Village Is My Home" is a promising tool that has the potential to broaden program coverage by marshalling both community residents and health workers to track individual children's vaccinations. Three states in India have adopted the tool, and Timor-Leste had also planned to scale-up the initiative.

Drivers of routine immunization coverage improvement in Africa: findings from district-level case studies.

There is limited understanding of why routine immunization (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, we conducted in-depth case studies to understand pathways to coverage improvement by comparing immunization programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques we compared the experience of districts where diphtheria-tetanus-pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunization services and drivers of coverage improvement. The results informed a model for immunization coverage improvement that emphasizes the dynamics of immunization systems at district level. In all districts, whether improving or steady, we found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. We found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness. We identified six common drivers of RI coverage performance improvement-four direct drivers and two enabling drivers-that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasize the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.

Applying an equity lens in the Decade of Vaccines.

Addressing inequities in immunisation must be the main priority for the Decade of Vaccines. Children who remain unreached are those who need vaccination - and other health services - most. Reaching these children and other underserved target groups will require a reorientation of current approaches and resource allocation. At the country level, evidence-based and context-specific strategies must be developed to promote equity in ways that strengthen the system that facilitates vaccination, are sustainable and extend benefits across the life cycle. At the global level, more attention must go on ensuring sustainable and affordable supply for low- and middle-income countries to vaccine products that are appropriate for the contexts where needs are greatest. Finally, data must be disaggregated and used at all levels to monitor and guide progress to reach the unreached.

Impact of targeted programs on health systems: a case study of the polio eradication initiative.

The results of 2 large field studies on the impact of the polio eradication initiative on health systems and 3 supplementary reports were presented at a December 1999 meeting convened by the World Health Organization. All of these studies concluded that positive synergies exist between polio eradication and health systems but that these synergies have not been vigorously exploited. The eradication of polio has probably improved health systems worldwide by broadening distribution of vitamin A supplements, improving cooperation among enterovirus laboratories, and facilitating linkages between health workers and their communities. The results of these studies also show that eliminating polio did not cause a diminution of funding for immunization against other illnesses. Relatively little is known about the opportunity costs of polio eradication. Improved planning in disease eradication initiatives can minimize disruptions in the delivery of other services. Future initiatives should include indicators and baseline data for monitoring effects on health systems development.