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.

Critical issues in implementing a national integrated all-vaccine preventable disease surveillance system.

In 2007, the World Health Organization published the Global Framework for Immunization Monitoring and Surveillance (GFIMS) outlining measures to enhance national surveillance for vaccine preventable diseases (VPDs). The GFIMS emphasized that VPD surveillance should be integrated and placed in a 'unified framework' building upon the strengths of existing surveillance systems to prevent duplication of activities common to all surveillance systems and to minimize human resource and supply expenditures. Unfortunately, there was little experience in actually developing integrated VPD surveillance. We describe the process of developing operational guidance for ministries of health to implement such an integrated surveillance system for multiple VPDs.

Vaccination coverage in Haiti: results from the 2009 national survey.

INTRODUCTION: Since 1977, vaccinations to protect against tuberculosis, diphtheria, tetanus, pertussis, polio, and measles (and rubella since 2009) have been offered to children in Haiti through the routine immunization program. From April to July 2009, a national vaccination coverage survey was conducted to assess the success of the routine immunization program at reaching children in Haiti. METHODS: A multi-stage cluster survey was conducted using a modified WHO method for household sampling. A standardized questionnaire was administered to collect vaccination histories, demographic information, and reasons for under-vaccination of children aged 12-23 months. A child who received the eight recommended routine vaccinations was considered fully vaccinated. The routine vaccination schedule was used to define valid doses and estimate the percentage of children vaccinated on time. RESULTS: Among 1345 children surveyed, 40.4% (95% CI: 36.6-44.2) of the 840 children with vaccination cards had received all eight recommended vaccinations. Coverage was highest for the Bacille Calmette-Guérin vaccine (87.3%), the first doses of the diphtheria-tetanus-pertussis vaccine (92.0%), and oral poliovirus vaccine (93.4%) and lowest for measles vaccine (46.9%). Timely vaccination rates were lower. Assuming similar coverage for the 505 children without cards, coverage with the complete vaccination series among all surveyed children 31.9%. Reasons for under-vaccination included not having enough time to reach the vaccination location (24.8%), having a child who was ill (13.8%), and not knowing when, or forgetting, to go for vaccination (12.8%). CONCLUSIONS AND RECOMMENDATIONS: Coverage for early-infant vaccines was high; however, most children did not complete the full vaccination series, and many children received vaccinations later than recommended. Efforts to improve the immunization program should include increasing the frequency of outreach services, training for vaccination staff to minimize missed opportunities, and better communicating the timing of vaccinations to encourage caregivers to bring their children for vaccinations at the recommended age. Efforts to promote the benefits of vaccination and card retention are also needed.

Haiti 2007-2008 national measles-rubella vaccination campaign: implications for rubella elimination.

BACKGROUND: A national campaign was conducted in Haiti in 2007-2008 to vaccinate all children and adolescents aged 1-19 years with measles-rubella vaccine in support of achieving the Region of the Americas' 2010 goal of eliminating rubella and congenital rubella syndrome (CRS). Measles-rubella vaccine was introduced into the country's routine childhood immunization schedule after the campaign. METHODS: A nationwide, stratified, multistage cluster sample survey of 20859 children was conducted to assess coverage using house-to-house interviews. RESULTS: Estimated national coverage with measles-rubella vaccine was 79.2% (95% confidence interval, 77.6%-80.7%), ranging from 90.2% in Nord-Ouest Department to 70.0% in Cite Soleil Metropolitan Area. National coverage was lower for children aged 1-5 years (76.7%) than for those aged 6-19 years (80.3%) (P< .001) but similar in rural departments (79.4%) and metropolitan areas (78.6%; P = .61). The reasons most frequently cited for nonparticipation in the campaign were that the child was ill or unavailable (18.6%), did not know vaccinations were important (13.8%), did not know when to go or forgot to go (13.3%), and did not have enough time (12.3%). CONCLUSIONS: The measles-rubella vaccination campaign was critical for raising rubella immunity levels in children and adolescents in Haiti. To remain free of rubella transmission and CRS, Haiti must also achieve and sustain high routine measles-rubella vaccination coverage and maintain high-quality integrated measles-rubella and CRS surveillance, including laboratory-based confirmation for reported rash illnesses. If routine measles-rubella vaccination coverage is suboptimal or if gaps in coverage are identified, additional mass campaigns with measles-rubella vaccine will be necessary.