house to house mobilization for successful measles sias: sitrep after five years in africa
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HOUSE TO HOUSE MOBILIZATION FOR SUCCESSFUL MEASLES SIAs: SITREP AFTER FIVE YEARS IN AFRICA Bob Davis Measles/Health Delegate American Red Cross. WHOM DO WE HAVE TO REACH TO STOP MEASLES TRANSMISSION?. Ethno-linguistic minorities and slum dwellers - PowerPoint PPT PresentationTRANSCRIPT
HOUSE TO HOUSE MOBILIZATION FOR
SUCCESSFUL MEASLES SIAs: SITREP AFTER
FIVE YEARS IN AFRICA
Bob DavisMeasles/Health Delegate
American Red Cross
WHOM DO WE HAVE TO REACH TO STOP MEASLES TRANSMISSION?
Ethno-linguistic minorities and slum dwellers
Marginalized and ‘floating’ populations, both urban, peri-urban, and rural
In a nutshell:Those who don’t watch CNN, don’t listen to the BBC, and don’t read the New York Times
• Solution, for both polio and measles: next slide
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Photo, Prof. Stanley Foster
THE HOUSE TO HOUSE STRATEGY
For GPEI, OPV SIA policy since 2001 PAHO policy in Latin America for measles SIAs: H2H
mobilization in campaigns which vaccinated from fixed posts and fixed mobile posts
H2H mobilization a best practice, UN supported measles SIA, Ethiopia, 2010
Used in Red Cross supported campaigns in 10 African countries: Benin, Burundi, C.A.R., Kenya, Mali, Mozambique, Namibia, Senegal, Tanzania, Uganda
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COMMUNITY MONITORING AS PART OF H2H MOBILIZATION
Wherever possible, line list the 9- to 59-month-olds in the week before the campaign, using RC volunteers, then trace defaulters after Day 1 of the campaign to bring them in from home.
Example from Tanzania:
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HOUSE TO HOUSE MOBILIZATION (cont.)
Does H2H mobilization produce better results in measles SIAs?
Probably: Traditional mass media approaches may miss the least readily accessible populations, even in urban areas. Herd immunity is more easily achievable when we systematically reach populations who lack, e.g., radio and TV.
Data from 8 countries tend to support this hypothesis.
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DISTRICTS WITH CANVASSING DISTRICTS WITHOUT CANVASSING
KIBERA, 57% DAGORETTI, 64%
KASARANI, 83% WESTLANDS, 62%
EMBAKASI, 80% CENTRAL, 68%
PUMWANI, 58%
MAKADARA, 53%
UNWEIGHTED AVERAGE, 73 % UNWEIGHTED AVERAGE, 61%
ADMINISTRATIVE COVERAGE ESTIMATES IN DISTRICTS WITH AND WITHOUT KENYA RED CROSS HOUSE TO HOUSE CANVASSING,
2009 MEASLES CAMPAIGN, NAIROBI
COMPARATIVE CAMPAIGN COVERAGE, NAMPULA PROVINCE, MOZAMBIQUE, 2008
Red Cross Districts
Target 413,005 Vaccinated 401,604 Coverage 97.2%
Others
Target 214,481 Vaccinated 188,064 Coverage 87.7%
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COMPARATIVE CAMPAIGN COVERAGE, BAMAKO, MALI, 2011
Red Cross Zones
Target 660,000 Coverage 93.6%
Others
Target 210,317 Coverage 87.8%
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Do these percentages make a difference? Yes, when herd immunity starts at > 90%
RESULTS OF SITE INTERVIEWS WITH CAREGIVERS, TWO RURAL PROVINCES COVERED BY BURUNDI RC,
2012 SIA
HOUSE VISITS
RADIO CHURCHESALL
OTHERPOPULATION
RED CROSSVOLUNTEERS
Ruyigi 23 19 7 15 505710 562
Gitega 32 31 23 6 920136 1022
Total 55 50 30 21 1425846 1584
ADMIN COVERAGE ESTIMATES, BURUNDI’S 2012 SIA, NATIONWIDE AND IN THE FOUR REGIONS
WITH H2H MOBILIZATION
NATIONWIDE AVERAGE
GITEGA MAKAMBA MUYINGA RUYIGI
103% 104% 116% 106% 115%
AVE + 1 AVE + 13 AVE + 3 AVE + 12
AVE + 8 IN H2H REGIONS, BASED ON WEIGHTED AVERAGE
SOURCES OF INFORMATION CITED BY MOTHERS, ABOMEY, BENIN, SEPTEMBER 2011: 1/5 OF ALL
VOLUNTEER MENTIONS FROM THE 4 PERCENT OF VOLUNTEERS WITH MEGAPHONES!
SOURCE OF INFO
CUMULATIVE FIGURES
Public Criers Monday, 53 mentions by mothers and other caregivers
Wednesday, 65 mentions
Friday, 63 mentions
Red Cross Volunteers
49Mentions
House to house volunteers, 28
30 104
House to house volunteers with megaphones, 15
20 10
Volunteers at fixed posts, 6
37 5
Radio 37 mentions 87 110
H2H EVALUATED AS BEST PRACTICE, BENIN CAMPAIGN, 2011
CRITERIA ANALYSIS BY CRITERION CONCLUSION
Effectiveness - Strong mobilization of the parents of children targeted at the time of the passage of the teams in the villages
- Better knowledge of the populations of the campaign schedule, of the strategy of progression of the teams and of the campaign’s target disease
Satisfactory
Efficiency - Reduction of the number of people reluctant to vaccinate
- Improvement of the vaccine coverage in the localities benefiting from the support of mobilizers
Satisfactory
Relevance - Facilitate the acceptance of vaccination by the populations in the urban zones
Satisfactory
Feasibility - Valid for all the vaccination campaigns even the JNV polio Satisfactory
Reproducibility - Implementation in the country’s 3 largest cities and in 12 other communes of the country
Satisfactory
Participation of the partners
- Activities mainly undertaken by the volunteers of the Red Cross, the Community and members of the Church of Jesus Christ of Latter Day Saints
Satisfactory
Large chunks of the urban population, and even of many rural populations, are accessible through mass media approaches.
However, we are unlikely to achieve herd immunity in campaigns without house to house mobilization.
In addition to campaigns, intercampaign house canvassing, 1 ½ years after the SIA, is a promising possibility to reduce the risk of outbreaks between campaigns.
WHAT THE DATA SHOWS
METHODS FOR EVALUATING COMPARATIVE PERFORMANCE OF H2H AND CONVENTIONAL
APPROACHES
BEST OF ALL POSSIBLE WORLDS PLANET EARTH
30 cluster surveys, intervention and non-intervention areas
Yes; so far, only in mainland Tanzania, with results ranging from 72 to 100 percent in areas with house visiting.
Admin coverage estimates Yes, but check your denominators. With data retention and/or recording errors, check your numerators as well.
Spot surveys at vaccination sites to ascertain mothers’ source of info. Cheap and easy; permits assessment of comparative role of H2H and other info sources
Spot surveys at vaccination sites to ascertain mothers’ source of info. Cheap and easy; permits assessment of comparative role of H2Hand other info sourcesCompare to IM data where available.
WHY WE NEED MORE SPOT SURVEYS
Cluster coverage surveys, with more scientific rigor, are not always done, and rarely permit comparison between areas with and without house visiting.
Admin coverage data are based on high side population figures (Eritrea) or low side population figures (Uganda). >>100% coverage = high degree of flakiness; true of ½ of all districts in Uganda’s 2012 measles SIA.
Data retention by health workers (Senegal, Kampala) makes it impossible to calculate SIA admin coverage.
COSTING OF HOUSE TO HOUSE MOBILIZATION
Vitamin m, the indispensable micronutrient Single partner funding by American Red Cross is
not a viable option for H2H mobilization to go to scale.
ADDED COST PER BENEFICIARY, H2H STRATEGY, FIVE MOST RECENT NATIONAL CAMPAIGNS, AVERAGE $0.32. UNIT COSTS VARY. TANZANIA FINANCED DAR ES SALAAM, WITH LOW UNIT
COSTS. NAMIBIA FINANCED RURAL AREAS.
BENIN, 2011
BURUNDI, 2012
NAMIBIA, 2012
TANZANIA, 2011
UGANDA, 2012
BUDGET FOR HOUSE VISITING
USD 99,233
USD 154,546 USD 95,759 USD 272,957(exclusive of UNICEF funding)
USD 272,957
BENEFICIARIES 322,572 473,890 166,750 1,687,000 1,300,000
COST PER BENEFICIARY
USD 0.31 USD 0.33 USD 0.57 USD 0.16 USD 0.21
VOLUNTEERS WORKING ON CAMPAIGN
685 3100 1450 2679 2911
CONCLUSIONS
In areas with H2H mobilization, measles SIA cost per child rises from ~$1 to ~$1.32 or more.
We need to be selective in choosing areas for H2H. Selection criteria used by American Red Cross and, in
some countries, UNICEF: Underserved populations, especially slums Areas with low coverage and/or high cases based on case
based surveillance Geographically remote areas
CONCLUSIONS (CONT.)
Some countries (Kenya, Burkina Faso) have widespread viral seeding from town to country. There, it may be necessary there to target whole cities, not just slums.
In some settings, the dollar goes farther in urban H2H mobilization (Tanzania vs. Namibia). Where funding is short, first priority goes to underserved urban and periurban areas.
THE MAGIC FORMULA
There is no magic formula for targeting areas to cover through H2H.
Where viral seeding is well documented, target the source of the viral seeding.
Where coverage data are reliable, target areas with low coverage.
Where case based surveillance is good, target areas with cases (Burundi: 4/17 regions were home to 29/30 confirmed measles cases).
URBAN PARTICULARITIES
Weekend SIA start is preferable; no traffic jams to tie up logistics; pulpit announcements on Fridays and Sundays
Multilingual house visitors and vaccinators are needed – Dakar, Nairobi, for example.
Mapping of neighborhoods with many migrants and floating populations, for special emphasis by gov’t, RC and other partners
H2H CANVASSING FOR ROUTINE IMMUNIZATION?
American Red Cross & partners need to consult on how best to apply lessons learned from SIAs to routine immunization.
A network of volunteers already exists to sensitize the community.
Possible modalities: birth registration and follow-up; periodic village canvasses; linkages to health facilities for defaulter follow-up
SO WHERE IS H2H GOING? Depends on decisions made by the MRI, as by the
GPEI in 2001, when the polio initiative opted for H2H OPV SIAs.
If H2H mobilization goes global with measles, as with polio, then more resources and partners will be needed. You can’t go global on a shoestring, and you can’t do it with 1 or 2 partners, as at present.
Decision whether to go global with H2H should predate any WHA resolution. No 1988-2001 gap as with GPEI, SVP!
THANK YOU/ASANTE SANA/ AMESEGNALEHU/SIYABONGA/ MERCI/OBRIGADO/MUCHAS GRACIAS
AMESEGNALEHU ANSAKUSU ARIGATO ASANTE SANA BAIE DANKIE BARKA BEDANKT BINOBONDI DEUS PAGARAPUSUNKI DHANJABHAT DJERE DIEUF DIOKO NDIAL DYARAAMA/FOOFU DZIĘKUJEMY DUNABAT EFHARISTO ESE GELETOMA GRAMACI (PROVENÇAL) HAKHENTSA HARTELIJK DANK! HSEHSE HVALA INITCHIE INKOSI KAMSAHAMNIDA KANIMAMBO KEAITUMETSE
KEA LEBOHA KHOBKHUN MAG KIITOS PALION (FINNISH)
KÖSZÖNÖN LONGONIA MINGI LOSAKA MADLOBT (DIDI MADLOVA) MAHADSANIT MANAM MAZVITA MEDASE MERCI MILLE GRAZIE MIRISE MISAOTRA MUCHAS GRACIAS MURAKOZE CYANE MWASHUMA MPUSIYA NAGODE NAMVERA NAPANDULA NASOM NATONDI NDAU YA NDUNA NDA BOKA NDIYABULELA NGASSAKIDILA
OKUHEPA PANDU RE A LEBOGA RO LIVHUWA SALAMAT SHNORHAKALOUTYOUN SINGUILA MINGUI SHUKRAN SIYABONGA SOSONGO SPASIBA TATENDA TERIMAKASIH TEŞEKKŰRLER TODAH RABAH TSE ZU TIN BA DEH TVASAKIOILA TWATASHA TWATOTELA VIELEN DANK VILLMOLS MERCI WAKOOZECHANE WEBAALE NNYO YABONGA YAQENYILEY ZIKOMO