National vaccination policies for health workers - A cross-sectional global overview.

BACKGROUND: Immunization is essential for safeguarding health workers from vaccine-preventable diseases (VPDs) that they may encounter at work; however, information about the prevalence and scope of national policies that protect health workers through vaccination is limited. Understanding the global landscape of health worker immunization programmes can help direct resources, assist decision-making and foster partnerships as nations consider strategies for increasing vaccination uptake among health workers. METHODS: A one-time supplementary survey was distributed to World Health Organization (WHO) Member States using the WHO/United Nations Children's Fund (UNICEF) Joint Reporting Form on Immunization (JRF). Respondents described their 2020 national vaccination policies for health workers - detailing VPD policies and characterising technical and funding support, monitoring and evaluation activities and provisions for vaccinating health workers in emergencies. RESULTS: A total of 53 % (103/194) Member States responded and described health worker policies: 51 had a national policy for vaccinating health workers; 10 reported plans to introduce a national policy within 5 years; 20 had subnational/institutional policies; 22 had no policy for vaccinating health workers. Most national policies were integrated with occupational health and safety policies (67 %) and included public and private providers (82 %). Hepatitis B, seasonal influenza and measles were most frequently included in policies. Countries both with and without national vaccination policies reported monitoring and reporting vaccine uptake (43 countries), promoting vaccination (53 countries) and assessing vaccine demand, uptake or reasons for undervaccination (25 countries) among health workers. Mechanisms for introducing a vaccine for health workers in an emergency existed in 62 countries. CONCLUSION: National policies for vaccinating health workers were complex and context specific with regional and income-level variations. Opportunities exist for developing and strengthening national health worker immunization programmes. Existing health worker immunization programmes might provide a foothold on which broader health worker vaccination policies can be built and strengthened.

Health workers vaccination: Experience and lessons learned from Costa Rica.

Objective: To describe the decision-making processes, enablers, challenges and lessons learned in Costa Rica for implementing a sustained and multi-pronged approach in health workers vaccination (HW). Methods: A retrospective descriptive analysis was conducted by searching published and grey literature, including scientific publications, legislation, decrees, policies, manuals, technical reports, and platforms used for data register and coverage monitoring. Key informants from the Ministry of Health (MoH), the Costa Rican Social Security Fund (CCSS) were interviewed representing national, subnational and local levels; as well as members of the National Technical Advisory Group (NITAG) and the private sector. Collected data were transcribed and categorized by the following specific topics using a thematic content analysis approach: decision making process, pre-service screening, vaccination for current HWs and engagement with the private sector. Major findings were discussed and organized into enablers, challenges and lessons learned. Results: Decision making processes to establish the vaccination strategies and schedules in Costa Rica were based on the epidemiological trends of vaccine-preventable diseases (VPDs) and cost analysis. Risk assessment and feasibility considerations determined that some vaccines such as hepatitis B, varicella and influenza, were first introduced in HWs and then were expanded to other target populations. These decisions were approved by the NITAG as the advisory technical advisory group of the MoH. Main enablers identified were: high level and sustained political will, decisions based on data analysis and feasibility considerations, HWs knowledge and high vaccine acceptance and demand. Challenges were related to effective coverage monitoring, and private sector engagement. Conclusions: The Costa Rican experience provides lessons learned that can be leveraged by other countries to strengthen HWs vaccination strategies at regional and global levels.

A review of health worker vaccination programs in low, middle and upper middle-income countries.

Objectives: Health workers (HW) are at risk of contracting vaccine preventable diseases when caring for patients and communities. This study aims to evaluate the existing literature on the routine vaccination of health workers against a variety of antigens in low and middle income countries, focusing on facilitators, barriers, and considerations in the implementation of immunization programs and campaigns. Study design: A PubMed Literature search. Methods: A PubMed search was conducted to find articles that addressed vaccination programs and policies for HW in low-income countries (LIC), lower middle-income countries (LMIC), and upper middle-income countries (UMIC). Original articles, meta-analyses, and reviews published in English between January 2000 and July 2022 were included in the search. Inductive content analysis was used to identify themes that illustrate facilitators, barriers, and considerations in the implementation of immunization programs and campaigns. Results: The search identified 4240 studies, 90 were used for analysis as they provided antigen specific details on immunization policies or programs. Hepatitis B was the most frequently discussed antigen, followed by Influenza, then Measles, Rubella and Mumps. With considerable variability by vaccine and country, in most cases the vaccination was not offered free to HW or included in a regular vaccination schedule. Utilizing existing immunization infrastructure such as the Expanded Programme on Immunization (EPI) and having effective management of vaccination programs were found to be key facilitators to vaccinate HW. Conclusions: The low vaccination coverage of health workers in LMIC is of concern; attention towards the key considerations, barriers and facilitators of immunization implementation is central to the advancement of health worker vaccination coverage in LMIC's. The COVID-19 pandemic necessitated the swift vaccination of HW. Many LIC countries lacking established HW immunization infrastructure are now administering COVID-19 vaccines. As we move beyond the pandemic's acute phase, there is a chance for those countries to enhance their immunization initiatives and policies for HW concerning other antigens, even if it is not a standard practice currently.

Cost-effectiveness of measles and rubella elimination in low-income and middle-income countries.

BACKGROUND: Since 2000, the incidence of measles and rubella has declined as measles-rubella (MR) vaccine coverage increased due to intensified routine immunisation (RI) and supplementary immunisation activities (SIAs). The World Health Assembly commissioned a feasibility assessment of eliminating measles and rubella. The objective of this paper is to present the findings of cost-effectiveness analysis (CEA) of ramping up MR vaccination with a goal of eliminating transmission in every country. METHODS: We used projections of impact of routine and SIAs during 2018-2047 for four scenarios of ramping up MR vaccination. These were combined with economic parameters to estimate costs and disability-adjusted life years averted under each scenario. Data from the literature were used for estimating the cost of increasing routine coverage, timing of SIAs and introduction of rubella vaccine in countries. RESULTS: The CEA showed that all three scenarios with ramping up coverage above the current trend were more cost-effective in most countries than the 2018 trend for both measles and rubella. When the measles and rubella scenarios were compared with each other, the most cost-effective scenario was likely to be the most accelerated one. Even though this scenario is costlier, it averts more cases and deaths and substantially reduces the cost of treatment. CONCLUSIONS: The Intensified Investment scenario is likely the most cost-effective of the vaccination scenarios evaluated for reaching both measles and rubella disease elimination. Some data gaps on costs of increasing coverage were identified and future efforts should focus on filling these gaps.

Use of catch-up vaccinations in the second year of life (2YL) platform to close immunity gaps: A secondary DHS analysis in Pakistan, Philippines, and South Africa.

BACKGROUND: Immunity gaps caused by COVID-19-related disruptions highlight the importance of catch-up vaccination. Number of countries offering vaccines in second year of life (2YL) has increased, but use of 2YL for catch-up vaccination has been variable. We assessed pre-pandemic use of 2YL for catch-up vaccination in three countries (Pakistan, the Philippines, and South Africa), based on existence of a 2YL platform (demonstrated by offering second dose of measles-containing vaccine (MCV2) in 2YL), proportion of card availability, and geographical variety. METHODS: We conducted a secondary data analysis of immunization data from Demographic and Health Surveys (DHS) in Pakistan (2017-2018), the Philippines (2017), and South Africa (2016). We conducted time-to-event analyses for pentavalent vaccine (diphtheria-tetanus-pertussis-Hepatitis B-Haemophilus influenzae type b [Hib]) and MCV and calculated use of 2YL and MCV visits for catch-up vaccination. RESULTS: Among 24-35-month-olds with documented dates, coverage of third dose of pentavalent vaccine increased in 2YL by 2%, 3%, and 1% in Pakistan, Philippines, and South Africa, respectively. MCV1 coverage increased in 2YL by 5% in Pakistan, 10% in the Philippines, and 3% in South Africa. In Pakistan, among 124 children eligible for catch-up vaccination of pentavalent vaccine at time of a documented MCV visit, 45% received a catch-up dose. In the Philippines, among 381 eligible children, 38% received a pentavalent dose during an MCV visit. In South Africa, 50 children were eligible for a pentavalent vaccine dose before their MCV1 visit, but only 20% received it; none with MCV2. CONCLUSION: Small to modest vaccine coverage improvements occurred in all three countries through catch-up vaccination in 2YL but many missed opportunities for vaccination continue to occur. Using the 2YL platform can increase coverage and close immunity gaps, but immunization programmes need to change policies, practices, and monitor catch-up vaccination to maximize the potential.

Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries.

The role of gender inequality in childhood immunization is an emerging area of focus for global efforts to improve immunization coverage and equity. Recent studies have examined the relationship between gender inequality and childhood immunization at national as well as individual levels; we hypothesize that the demonstrated relationship between greater gender equality and higher immunization coverage will also be evident when examining subnational-level data. We thus conducted an ecological analysis examining the association between the Subnational Gender Development Index (SGDI) and two measures of immunization-zero-dose diphtheria-tetanus-pertussis (DTP) prevalence and 3-dose DTP coverage. Using data from 2010-2019 across 702 subnational regions within 57 countries, we assessed these relationships using fractional logistic regression models, as well as a series of analyses to account for the nested geographies of subnational regions within countries. Subnational regions were dichotomized to higher gender inequality (top quintile of SGDI) and lower gender inequality (lower four quintiles of SGDI). In adjusted models, we find that subnational regions with higher gender inequality (favoring men) are expected to have 5.8 percentage points greater zero-dose prevalence than regions with lower inequality [16.4% (95% confidence interval (CI) 14.5-18.4%) in higher-inequality regions versus 10.6% (95% CI 9.5-11.7%) in lower-inequality regions], and 8.2 percentage points lower DTP3 immunization coverage [71.0% (95% CI 68.3-73.7%) in higher-inequality regions versus 79.2% (95% CI 77.7-80.7%) in lower-inequality regions]. In models accounting for country-level clustering of gender inequality, the magnitude and strength of associations are reduced somewhat, but remain statistically significant in the hypothesized direction. In conjunction with published work demonstrating meaningful associations between greater gender equality and better childhood immunization outcomes in individual- and country-level analyses, these findings lend further strength to calls for efforts towards greater gender equality to improve childhood immunization and child health outcomes broadly.

Feasibility of measles and rubella vaccination programmes for disease elimination: a modelling study.

BACKGROUND: Marked reductions in the incidence of measles and rubella have been observed since the widespread use of the measles and rubella vaccines. Although no global goal for measles eradication has been established, all six WHO regions have set measles elimination targets. However, a gap remains between current control levels and elimination targets, as shown by large measles outbreaks between 2017 and 2019. We aimed to model the potential for measles and rubella elimination globally to inform a WHO report to the 73rd World Health Assembly on the feasibility of measles and rubella eradication. METHODS: In this study, we modelled the probability of measles and rubella elimination between 2020 and 2100 under different vaccination scenarios in 93 countries of interest. We evaluated measles and rubella burden and elimination across two national transmission models each (Dynamic Measles Immunisation Calculation Engine [DynaMICE], Pennsylvania State University [PSU], Johns Hopkins University, and Public Health England models), and one subnational measles transmission model (Institute for Disease Modeling model). The vaccination scenarios included a so-called business as usual approach, which continues present vaccination coverage, and an intensified investment approach, which increases coverage into the future. The annual numbers of infections projected by each model, country, and vaccination scenario were used to explore if, when, and for how long the infections would be below a threshold for elimination. FINDINGS: The intensified investment scenario led to large reductions in measles and rubella incidence and burden. Rubella elimination is likely to be achievable in all countries and measles elimination is likely in some countries, but not all. The PSU and DynaMICE national measles models estimated that by 2050, the probability of elimination would exceed 75% in 14 (16%) and 36 (39%) of 93 modelled countries, respectively. The subnational model of measles transmission highlighted inequity in routine coverage as a likely driver of the continuance of endemic measles transmission in a subset of countries. INTERPRETATION: To reach regional elimination goals, it will be necessary to innovate vaccination strategies and technologies that increase spatial equity of routine vaccination, in addition to investing in existing surveillance and outbreak response programmes. FUNDING: WHO, Gavi, the Vaccine Alliance, US Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation.

Policy and practice of checking vaccination status at school in 2018, a global overview.

BACKGROUND: Checking vaccination status at school is widely recommended as a strategy to strengthen routine childhood vaccination coverage. Documentation of approaches, challenges, strengths, and impact of this strategy in a variety of contexts is key to enhancing adoption and implementation. However, there is limited information about the prevalence of policies and the implementation of checking vaccination status at school globally. METHODS: A one-time supplementary survey was circulated with the annual World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF) Joint Reporting Form in 2019 to all WHO member states and non-member state reporting entities. Additional publicly available country-level data, including primary school enrollment, home-based record (HBR) ownership, and World Bank income classification were linked to the supplementary survey responses, which were descriptively analyzed. RESULTS: We received survey responses from 130 of the 194 (67%) WHO member states and 15 non-member state reporting entities. Almost half (46%) of the respondents reported having a law requiring proof of vaccination to enter at least one level of education, and 60% of the respondents reported having a law that requires checking vaccination status at school in 2018. Three-quarters of the respondents (77%) reported the practice of routinely checking vaccination status at school. Both laws and the practice of checking were more common in the WHO Region of the Americas and the WHO European Region, and in high- and upper-middle-income countries. Individual HBR was the document most frequently checked. Catch-up vaccination occurred most frequently at health centers. Evaluation of checking vaccination status at school to determine what has worked and its effect was infrequently reported. CONCLUSION: Despite widespread implementation of checking vaccination status at school in 2018, documentation of the experiences in planning and implementing this strategy, and its effects remains sparse, particularly in low- and middle-income countries.

Feasibility assessment of measles and rubella eradication.

This report addresses the epidemiological aspects and feasibility of measles and rubella eradication and the potential resource requirements in response to the request of the Director-General at the Seventieth World Health Assembly held on May 31, 2017. A guiding principle is that the path toward measles and rubella eradication should serve to strengthen primary health care, promote universal health coverage, and be a pathfinder for new vision and strategy for immunization over the next decade as laid out in the Immunization Agenda 2030. Specifically, this report: 1) highlights the importance of measles and rubella as global health priorities; 2) reviews the current global measles and rubella situation; 3) summarizes prior assessments of the feasibility of measles and rubella eradication; 4) assesses the progress and challenges in achieving regional measles and rubella elimination; 5) assesses additional considerations for measles and rubella eradication, including the results of modelling and economic analyses; 6) assesses the implications of establishing a measles and rubella eradication goal and the process for setting an eradication target date; 7) proposes a framework for determining preconditions for setting a target date for measles and rubella eradication and how these preconditions should be understood and used; and 8) concludes with recommendations endorsed by SAGE.

Assessment of missed opportunities for vaccination (MOV) in Burkina Faso using the World Health Organization's revised MOV strategy: Findings and strategic considerations to improve routine childhood immunization coverage.

BACKGROUND: Despite the remarkable achievements of the Expanded Programme on Immunization (EPI) in Burkina Faso, numerous challenges remain, including missed opportunities for vaccination (MOV) which occur when people visit a health facility with at least one vaccine due according to the national immunization schedule, are free of contraindications, and leave without receiving all due vaccine doses. In 2016, we used the revised World Health Organization's (WHO) MOV strategy to assess the extent of and reasons for MOV in Burkina Faso. METHODS: We purposively selected 27 primary health facilities (PHFs) from the eight health districts with the highest absolute numbers of children who missed the first dose of measles-rubella (MR1) in 2015. We conducted exit interviews with caregivers of children aged 0-23 months, and requested health workers to complete a self-administered knowledge, attitudes and practices (KAP) questionnaire. RESULTS: A total of 489 caregivers were interviewed, of which 411 were eligible for inclusion in our analysis. Medical consultation (35%) and vaccination (24.5%) were the most frequent reasons for visiting PHFs. Among the 73% of children eligible for vaccination, 76% of vaccination opportunities were missed. Among eligible children, the percentage with MOV was significantly higher in those aged ≥12 months and also in those attending for a reason other than vaccination. A total of 248 health workers completed the KAP questionnaire. Of these, 70% (n = 168/239) considered their knowledge on immunization to be insufficient or outdated; 83% failed to correctly identify valid contraindications to vaccination. CONCLUSION: Addressing MOV offers the potential for substantial increases in vaccine coverage and equity, and ultimately reducing the burden of vaccine-preventable diseases (VPDs). This will require the implementation of a series of interventions aimed at improving community knowledge and practices, raising health workers' awareness, and fostering the integration of immunization with other health services.

Immunization governance: Mandatory immunization in 28 Global NITAG Network countries.

International trends currently favour greater use of mandatory immunization. There has been little academic consideration or comparison of the existence and scope of mandatory immunization internationally. In this paper, we examine mandatory immunization in 28 Global NITAG (National Immunization Technical Advisory Group) Network (GNN) countries, including countries from every WHO region and World Bank income level classification. We found that although mandatory immunization programs, or mandatory elements within broader immunization programs, are relatively common, jurisdictions vary significantly with respect to the immunizations required, population groups affected, grounds for exemptions, and penalties for non-compliance. We also observed some loose associations with geography and income level. Based on these data, we categorized policies into a spectrum ranging from Narrow to Broad scope.

Assessment of missed opportunities for vaccination in Kenyan health facilities, 2016.

BACKGROUND: In November 2016, the Kenya National Vaccines and Immunization Programme conducted an assessment of missed opportunities for vaccination (MOV) using the World Health Organization (WHO) MOV methodology. A MOV includes any contact with health services during which an eligible individual does not receive all the vaccine doses for which he or she is eligible. METHODS: The MOV assessment in Kenya was conducted in 10 geographically diverse counties, comprising exit interviews with caregivers and knowledge, attitudes, and practices (KAP) surveys with health workers. On the survey dates, which covered a 4-day period in November 2016, all health workers and caregivers visiting the selected health facilities with children <24 months of age were eligible to participate. Health facilities (n = 4 per county) were purposively selected by size, location, ownership, and performance. We calculated the proportion of MOV among children eligible for vaccination and with documented vaccination histories (i.e., from a home-based record or health facility register), and stratified MOV by age and reason for visit. Timeliness of vaccine doses was also calculated. RESULTS: We conducted 677 age-eligible children exit interviews and 376 health worker KAP surveys. Of the 558 children with documented vaccination histories, 33% were visiting the health facility for a vaccination visit and 67% were for other reasons. A MOV was seen in 75% (244/324) of children eligible for vaccination with documented vaccination histories, with 57% (186/324) receiving no vaccinations. This included 55% of children visiting for a vaccination visit and 93% visiting for non-vaccination visits. Timeliness for multi-dose vaccine series doses decreased with subsequent doses. Among health workers, 25% (74/291) were unable to correctly identify the national vaccination schedule for vaccines administered during the first year of life. Among health workers who reported administering vaccines as part of their daily work, 39% (55/142) reported that they did not always have the materials they needed for patients seeking immunization services, such as vaccines, syringes, and vaccination recording documents. CONCLUSIONS: The MOV assessment in Kenya highlighted areas of improvement that could reduce MOV. The results suggest several interventions including standardizing health worker practices, implementing an orientation package for all health workers, and developing a stock management module to reduce stock-outs of vaccines and vaccination-related supplies. To improve vaccination coverage and equity in all counties in Kenya, interventions to reduce MOV should be considered as part of an overall immunization service improvement plan.

Qualitative insights into reasons for missed opportunities for vaccination in Kenyan health facilities.

BACKGROUND: In 2016, Kenya conducted a study of missed opportunities for vaccination (MOV)-when eligible children have contact with the health system but are not fully vaccinated-to explore some of the reasons for persistent low vaccination coverage. This paper details the qualitative findings from that assessment. METHODS: Using the World Health Organization MOV methodology, teams conducted focus group discussions among caregivers and health workers and in-depth interviews of key informants in 10 counties in Kenya. Caregivers of children <24 months of age visiting the selected health facilities on the day of the assessment were requested to participate in focus group discussions. Health workers were purposively sampled to capture a broad range of perspectives. Key informants were selected based on their perceived insight on immunization services at the county, sub-county, or health facility level. RESULTS: Six focus group discussions with caregivers, eight focus group discussions with health workers, and 35 in-depth interviews with key informants were completed. In general, caregivers had positive attitudes toward healthcare and vaccination services, but expressed a desire for increased education surrounding vaccination. In order to standardize vaccination checks at all health facility visits, health workers and key informants emphasized the need for additional trainings for all staff members on immunization. Health workers and key informants also highlighted the negative impact of significant understaffing in health facilities, and the persistent challenge of stock-outs of vaccines and vaccination-related supplies. CONCLUSIONS: Identified factors that could contribute to MOV include a lack of knowledge surrounding vaccination among caregivers and health workers, inadequate number of health workers, and stock-outs of vaccines or vaccination-related materials. In addition, vaccination checks outside of vaccination visits lacked consistency, leading to MOV in non-vaccinating departments. Qualitative assessments could provide a starting point for understanding and developing interventions to address MOV in other countries.

Strengthening vaccination frameworks: Findings of a study on the legal foundations of National Immunization Technical Advisory Groups (NITAGs).

In 2017, the Strategic Advisory Group of Experts on Immunization's Assessment Report of the Global Vaccine Action Plan noted the need to "better document the ways in which legislation and regulations have been used to promote or undermine immunization at the national level". Despite National Immunization Technical Advisory Groups (NITAGs) now existing in over 134 countries worldwide, there has been very little academic consideration of their legal underpinnings. In this paper, we compare the legal foundations and authority of 28 NITAGs from the six WHO Regions. All are members of the Global NITAG Network. We categorize the NITAGs based on their legal foundation and on the authority granted to them by their government, organizing them into a taxonomy of models. We then propose legal considerations for governments contemplating establishing or reforming a NITAG.

Selective Hepatitis B Birth-Dose Vaccination in São Tomé and Príncipe: A Program Assessment and Cost-Effectiveness Study.

São Tomé and Príncipe (STP) uses a selective hepatitis B birth-dose vaccination (HepB-BD) strategy targeting infants born to mothers who test positive for hepatitis B virus (HBV) surface antigen. We conducted a field assessment and economic analysis of the HepB-BD strategy to provide evidence to guide development of cost-effective policies to prevent perinatal HBV transmission in STP. We interviewed national stakeholders and key informants to understand policies, knowledge, and practices related to HepB-BD, vaccine management, and data recording/reporting. Cost-effectiveness of the existing strategy was compared with an alternate approach of universal HepB-BD to all newborns using a decision analytic model. Incremental cost-effectiveness ratios (ICERs) were calculated in 2015 USD per HBV-associated death and per chronic HBV case prevented, from the STP health-care system perspective. We found that STP lacked national or facility-specific written policies and procedures related to HepB-BD. Timely HepB-BD to eligible newborns was considered a high priority, although timeliness of HepB-BD was not monitored. Compared with the existing selective vaccination strategy, universal HepB-BD would result in a 19% decrease in chronic HBV infections per year at overall cost savings of approximately 44% (savings of USD 5,441 each year). We estimate an ICER of USD 5,012 saved per HBV-associated death averted. The existing selective HepB-BD strategy in STP could be improved through documentation of policies, procedures, and timeliness of HepB-BD. Expansion to universal newborn HepB-BD without maternal screening is feasible and could result in cost savings if actual implementation costs and effectiveness fall within the ranges modeled.

Home-based record (HBR) ownership and use of HBR recording fields in selected Kenyan communities: Results from the Kenya Missed Opportunities for Vaccination Assessment.

BACKGROUND: Home-based records (HBRs), which take many forms, serve as an important tool for frontline health workers by providing a standardized patient history vital to making informed decisions about the need for immunization services. There are increasing concerns around HBRs with recording areas that are functionally irrelevant because records are incomplete or not up-to-date. The aim of this report was to describe HBR ownership and report on the utilization of selected recording areas in HBRs across selected study communities in Kenya. METHODS: The Kenya Missed Opportunities for Vaccination Assessment utilized a mixed-methods approach that included exit interviews, using a standardized questionnaire, among a convenience sample of caregivers of children aged <24 months attending a health facility during November 2016 as well as interviews of health staff and facility administrators. In addition to the exit interview data, we analysed data obtained from a review of available HBRs from the children. RESULTS: A total of 677 children were identified with a valid date of birth and who were aged <24 months. A HBR was in hand and reviewed for three-quarters of the children. Nearly one-third (n = 41) of those without a HBR in hand at the visit noted that they did not know the importance of bringing the document with them. Roughly two-thirds (n = 443) of caregivers noted they were asked by clinic staff to see the HBR during the clinic visit. Across the 516 reviewed HBRs, recording areas were most commonly identified for the child's demographic information (80% of HBRs) and vaccination history (82%) with information marked in >90% of records. Recording areas were less frequently available for child early eye / vision problems (61%), growth monitoring (74%) and vitamin A (76%); with information marked in 33%, 88% and 60% of records, respectively. CONCLUSIONS: Critical to the reduction of missed opportunities for vaccination, the HBR's importance must be emphasized and the document must be requested by health workers at every health encounter. Health workers must not only ensure that all children receive a HBR and counsel caregivers of its importance, but they must also ensure that all sections of the record are legibly completed to ensure continuity of care. Programmes are encouraged to periodically review and critically assess the HBR to determine whether the document's design and content areas are optimal to end user needs.

Implementing a Birth Dose of Hepatitis B Vaccine in Africa: Findings from Assessments in 5 Countries.

INTRODUCTION: Few African countries have introduced a birth dose of hepatitis B vaccine (HepB-BD) despite a World Health Organization (WHO) recommendation. HepB-BD given within 24 hours of birth, followed by at least two subsequent doses, is 90% effective in preventing perinatal transmission of hepatitis B virus. This article describes findings from assessments conducted to document the knowledge, attitudes, and practices surrounding HepB-BD implementation among healthcare workers in five African countries. METHODS: Between August 2015 and November 2016, a series of knowledge, attitude and practices assessments were conducted in a convenience sample of public and private health facilities in Botswana, the Gambia, Namibia, Nigeria, and São Tomé and Príncipe (STP). Data were collected from immunization and maternity staff through interviewer-administered questionnaires focusing on HepB-BD vaccination knowledge, practices and barriers, including those related to home births. HepB-BD coverage was calculated for each visited facility. RESULTS: A total of 78 health facilities were visited: STP 5 (6%), Nigeria 23 (29%), Gambia 9 (12%), Botswana 16 (21%), and Namibia 25 (32%). Facilities in the Gambia attained high total coverage of 84% (range: 60-100%) but low timely estimates 7% (16-28%) with the median days to receiving HepB-BD of 11 days (IQR: 6-16 days). Nigeria had low total (23% [range: 12-40%]), and timely (13% [range: 2-21%]) HepB-BD estimates. Facilities in Botswana had high total (94% [range: 80-100%]), and timely (74% [range: 57-88%]) HepB-BD coverage. Coverage rates were not calculated for STP because the maternal Hepatitis B virus (HBV) status was not recorded in the delivery registers. The study in Namibia did not include a coverage assessment component. Barriers to timely HepB-BD included absence of standard operating procedures delineating staff responsible for HepB-BD, not integrating HepB-BD into essential newborn packages, administering HepB-BD at the point of maternal discharge from facilities, lack of daily vaccination services, sub-optimal staff knowledge about HepB-BD contraindications and age-limits, lack of outreach programs to reach babies born outside facilities, and reporting tools that did not allow for recording the timeliness of HepB-BD doses. DISCUSSION: These assessments demonstrate how staff perceptions and lack of outreach programs to reach babies born outside health facilities with essential services are barriers for implementing timely delivery of HepB-BD vaccine. Addressing these challenges may accelerate HepB-BD implementation in Africa.

Monitoring and Validation of the Global Replacement of tOPV with bOPV, April-May 2016.

The phased withdrawal of oral polio vaccine (OPV) associated with the Polio Eradication and Endgame Strategic Plan 2013-2018 began with the synchronized global replacement of trivalent OPV (tOPV) with bivalent OPV (bOPV) during April - May 2016, a transition referred to as the "switch." The World Health Organization's (WHO) Strategic Advisory Group of Experts (SAGE) on Immunization recommended conducting this synchronized switch in all 155 OPV-using countries and territories (which collectively administered several hundred million doses of tOPV each year via several hundred thousand facilities) to reduce risks of re-emergence of vaccine-derived polioviruses. Safe execution of this switch required implementation of an associated independent monitoring strategy, the primary objective of which was verification that tOPV was no longer available for administration post-switch. This strategy had to be both practical and rigorous such that tOPV withdrawal could be reasonably employed and confirmed in all countries and territories within a discreet timeframe. Following these principles, WHO recommended that designated monitors in each of the 155 countries and territories visit all vaccine stores as well as a 10% sample of highest-risk health facilities within two weeks of the national switch date, removing any tOPV vials found. National governments were required to provide the WHO with formal validation of execution and monitoring of the switch. In practice, all countries reported cessation of tOPV by 12 May 2016 and 95% of countries and territories submitted detailed monitoring data to WHO. According to these data, 272 out of 276 (99%) national stores, 3,741 out of 3.968 (94%) regional stores, 16,144 out of 22,372 (72%) district level stores, and 143,050 out of 595,401 (24%) of health facilities were monitored. These data, along with field reports suggest that monitoring and validation of the switch was efficient and effective, and that the strategies used during the process could be adapted to future stages of OPV withdrawal.

Financial Support to Eligible Countries for the Switch From Trivalent to Bivalent Oral Polio Vaccine-Lessons Learned.

The global switch from trivalent oral polio vaccine (tOPV) to bivalent oral polio vaccine (bOPV) ("the switch") presented an unprecedented challenge to countries. In order to mitigate the risks associated with country-level delays in implementing the switch, the Global Polio Eradication Initiative provided catalytic financial support to specific countries for operational costs unique to the switch. Between November 2015 and February 2016, a total of approximately US$19.4 million in financial support was provided to 67 countries. On average, country budgets allocated 20% to human resources, 23% to trainings and meetings, 8% to communications and advocacy, 9% to logistics, 15% to monitoring, and 5% to waste management. All 67 funded countries successfully switched from tOPV to bOPV during April-May 2016. This funding provided target countries with the necessary catalytic support to facilitate the execution of the switch on an accelerated timeline, and the mechanism offers a model for similar support to future global health efforts, such as the eventual global withdrawal of bOPV.