Strengthening immunization service delivery post Ebola virus disease (EVD) outbreak in Liberia 2015-2017.

INTRODUCTION: The Ebola virus disease (EVD) outbreak in Liberia from 2014-2015 setback the already fragile health system which was recovering from the effects of civil unrest. This led to significant decline in immunization coverage and key polio free certification indicators. The Liberia investment plan was developed to restore immunization service delivery and overall health system. METHODS: We conducted a desk review to summarize performance of immunization coverage, polio eradication, measles control, new vaccines and technologies. Data sources include program reports, scientific and grey literature, District Health Information System (DHIS2), Integrated Diseases Surveillance and Response (IDSR) database, auto visual AFP detection and reporting (AVADAR) and ONA Servers. Data analysis was done using Microsoft excel spreadsheets, ONA software and Arc GIS. RESULTS: There was a 36% increase in national coverage for Penta 3 in 2017 compared to 2014 from WUENIC data. Penta 3 dropout rate reduced by 2.5 fold from 15.3% in 2016 to 6.4% in 2017; while MCV1 coverage improved by 23% from 64% in 2015 to 87% in 2017. There was a rebound of non-polio AFP rate (NPAFP) rate from 1.2 in 2015 to 4.3 in 2017. Furthermore, there was a 2-fold increase in the number of AFP cases receiving 3 or more doses of OPV from 36% in 2015 to 61% in 2017. CONCLUSION: Liberia demonstrated strong rebound of immunization services following the largest and most devastating EVD outbreak in West Africa in 2014 - 2015. Immunization coverage improved and dropout rates reduced. However, there are still opportunities for improvement in the immunization program both at national and sub-national levels.

Successful proof of concept of family planning and immunization integration in Liberia.

Globally, unmet need for postpartum family planning remains high, while immunization services are among the most wide-reaching and equitable interventions. Given overlapping time frames, integrating these services provides an opportunity to leverage existing health visits to offer women more comprehensive services. From March through November 2012, Liberia's government, with support from the Maternal and Child Health Integrated Program (MCHIP), piloted an integrated family planning and immunization model at 10 health facilities in Bong and Lofa counties. Vaccinators provided mothers bringing infants for routine immunization with targeted family planning and immunization messages and same-day referrals to co-located family planning services. In February 2013, we compared service statistics for family planning and immunization during the pilot against the previous year's statistics. We also conducted in-depth interviews with service providers and other personnel and focus group discussions with clients. Results showed that referral acceptance across the facilities varied from 10% to 45% per month, on average. Over 80% of referral acceptors completed the family planning visit that day, of whom over 90% accepted a contraceptive method that day. The total number of new contraceptive users at participating facilities increased by 73% in Bong and by 90% in Lofa. Women referred from immunization who accepted family planning that day accounted for 44% and 34% of total new contraceptive users in Bong and Lofa, respectively. In Lofa, pilot sites administered 35% more Penta 1 and 21% more Penta 3 doses during the pilot period compared with the same period of the previous year, while Penta 1 and Penta 3 administration decreased in non-pilot facilities. In Bong, there was little difference in the number of Penta 1 and Penta 3 doses administered between pilot and non-pilot facilities. In both counties, Penta 1 to Penta 3 dropout rates increased at pilot sites but not in non-pilot facilities, possibly due to higher than average background dropout rates at pilot sites prior to the intervention in Lofa and the disproportionate effect of data from 1 large facility in Bong. The project provided considerable basic support to assess this proof of concept. However, results suggest that introducing a simple model that is minimally disruptive to existing immunization service delivery can facilitate integration. The model is currently being scaled-up to other counties in Liberia, which could potentially contribute to increased postpartum contraceptive uptake, leading to longer birth intervals and improved health outcomes for children and mothers.