Strategies to improve immunization services in urban Africa

The urban poor constitute a rapidly increasing proportion of the population in developing countries. Focusing attention on underserved urban slums and squatter settlements will contribute greatly to immunization programme goals, because these areas account for 30-50% of urban populations, usually provide low access to health services, carry a large burden of disease mortality, and act as sources of infection for the city and surrounding rural areas. Improvement of urban immunization programmes requires intersectorial collaboration, use of all opportunities to vaccinate eligible children and mothers, identification of low-coverage neighbourhoods and execution of extra activities in these neighbourhoods, and community mobilization to identify and refer persons for vaccination. Improved disease surveillance helps to identify high-risk populations and document programme impact. New developments in vaccines, such as the high-dose Edmonston-Zagreb vaccine, will allow changes in the immunization schedule that facilitate the control of specific diseases. Finally, operational research can assist managers to conduct urban situation assessments, evaluate programme performance at the "micro" level, and design and monitor interventions

The use of evaluation to improve the expanded programme on immunization in Mozambique

Reported are the results of an evaluation of process indicators and outputs for the Expanded Programme on Immunization (EPI) in Mozambique which were used to modify immunization strategies from 1985 to 1987. In 1986 according to cluster sample surveys, 84% of children in Maputo, the capital, were fully vaccinated. In other cities in the country, vaccination coverage increased from an average of 36% in 1985 to 55% in 1987. The major determinants of low vaccination coverage were provision of vaccination services at health centres on less than 3 days per week; missed opportunities; and vaccinating too early or with too short an interval between doses. The results of sentinel site surveillance in Maputo indicated that EPI had a marked impact on neonatal tetanus and to a lesser extent on poliomyelitis and measles. Evaluation led to changes in EPI policy in Mozambique (e.g., adoption of a uniform national vaccination schedule and discontinuation of the use of expired vaccine) and strategies (elaboration of different strategies for urban areas, rural areas, and displaced people). Also, performance was improved by involving programme managers and implementors in evaluation, and by providing timely and widespread feedback of results to policy-makers, peripheral health workers, and the community

Application of multiple methods to study the immunization programme in an urban area of Guinea

During 1988-89, studies were conducted to evaluate the immunization system in Conakry, Guinea. The first, a health facility survey, found that health staff screened the vaccination status of only 30% of children who presented for curative care. A sterile syringe and needle were used for less than half of the injections. In the second survey, key informant interviews with vaccinators and health centre chiefs showed that there were minimal lines of communication between health workers and the community, but that health workers did not perceive this to be a problem. Focus group discussions in the community revealed a high level of general knowledge about vaccine-preventable diseases. However, mothers did not know how many vaccinations their children should receive or by what age they should be completed. They complained of long waiting times in health centres, the high costs of vaccination, poor rapport with health workers, and the occurrence of abscesses after vaccination. The final study, a "knowledge, attitudes, and practice" community survey, showed that missed immunization opportunities and inappropriately timed vaccinations reduced potential vaccine coverage by almost 30% among children with vaccination cards. Higher socioeconomic status, delivery in hospital, and whether mothers perceived the vaccinations to be affordable affected whether the child began the immunization series. Once a child had entered the immunization system, completion of the series was determined by the mother's education level, employment status, and experience with vaccination services