Validation of Administrative Coverage for Vitamin a Supplementation and Deworming through Integrated National Immunization Days in Guinea.

Objectives: Since 2007, distribution of vitamin A supplementation (VAS) and deworming has been integrated with polio vaccination through twice-yearly National Immunization Days (NIDs) in Guinea. Although reported administrative coverage for VAS and deworming are consistently ≥90%, validation of coverage is needed as denominators are based on the number of children reached during the previous year and many districts report coverage of >100%. Methods: A post-event coverage (PEC) survey was conducted in the regions of Boké and Faranah to validate coverage following the NIDs in May 2013. Boké and Faranah regions were selected as their administrative VAS coverage was among the lowest (87%) and highest (102%) reported in Guinea, respectively. 900 caretakers were interviewed in each region using a PPS randomized 30x30 cluster design and WHO EPI sampling methodology. Results: VAS coverage by PECS for children 6-59 months was similar in Boké (89.4%) and Faranah (92.4%) among children 6-59 months despite large variability in administrative data. Deworming coverage reported by PECS was significantly lower than VAS and polio coverage in Boké (73.9%, 88.9%, 87.1%) and Faranah (65.2, 93.1%,91.8%), respectively, for children 12-59 months and significantly lower than deworming administrative coverage (Boke: 93.1%, Faranah: 111%). Conclusions: Despite significant variability in administrative coverage, VAS coverage measured by PEC survey in Boké and Faranah regions of Guinea was comparable and high. Deworming coverage however was significantly lower than that reported by administrative data and that reported for similar interventions. Follow-up is needed to address the large discrepancy between PEC and administrative data for deworming.

Factors Affecting the Performance of Community Volunteers during Child Health Days in Douala, Cameroon.

Objectives: In the Littoral region of Cameroon, targeted awareness and social mobilization has increased coverage of vitamin A supplementation (VAS) during Child Health Days (CHDs) from 52.9%% in 2011 to 71.6% in 2012. Following this increase, coverage stagnated for the 2nd round of 2012 (71.0%) and the first round in 2013 (71.4%) thus falling short of the national target of 90% coverage of children 6-59 months. Methods: To determine barriers to high VAS coverage, targeted interviews were conducted with community volunteers participating in CHDs to identify factors contributing to CHD performance. Community volunteers were categorized as having "acceptable performance" or "poor performance" based whether their team met the daily target of reaching at least 120 children per day. Results: Interviews were conducted with 61 community volunteers with poor performance and 39 with acceptable performance from 6 health districts. The main factors found to influence performance were caretakers' awareness of the event and age of the volunteer (p<0.10). When asked how the campaign could be improved to reach all children, the most common response among both groups was better sensitization of parents (57%), ensuring stock (14%) and increasing the volunteer's allowance (12%). 37% of volunteers cited resistance by parents as the barrier that prevented teams from achieving universal coverage. Conclusions: Although door-to-door distribution is used to deliver services during CHDs to facilitate delivery, interviews with community volunteers indicate that better sensitization of caretakers prior to CHDs is still critical to achieving high coverage.

Routine Delivery of Vitamin A Supplementation at Six Months in Senegal Using SMS Reminder Messages.

Objectives: National guidelines in Senegal indicate the first dose of Vitamin A Supplementation (VAS) should be received at six months; however children usually receive their first dose at an average age of nine months through twice-yearly VAS days. To increase provision of VAS to children at six months, the routine provision of VAS was piloted along with a set of SMS-based interventions. Methods: From September 2012 to April 2013, a pilot was conducted in three intervention districts in which a new child health card and vaccination calendar including a six-month contact point for VAS were introduced. SMS appointment reminders were sent to all caregivers in intervention districts when their child turned six months. Each intervention district was paired with a comparable control district that received regular services. Results: Coverage of VAS at six months in intervention districts was 70% with higher coverage in rural (100%) than semi-rural (69%) and urban (45%) districts (p<0.001). Coverage ranged from 5- 7% in control districts. 35% of caretakers reported receiving information on the six-month visit by SMS, with phone calls and mobilization by health workers other common sources. Average age of VAS receipt in intervention districts was 6.5 months. Conclusions: The addition of a six-month contact point into the routine immunization schedule was effective in increasing VAS coverage at six months. The six-month contact point should be integrated into the vaccination calendar in Senegal, and SMS messages may be helpful at increasing coverage at visits. Further strategies may be needed to achieve high coverage in urban and semi-urban areas.

Validation of Vitamin A Supplementation Coverage Using Post-event Coverage Surveys in 11 Sub- Saharan African Countries.

Objectives: Twice-yearly child health days (CHDs) have had remarkable success reaching children twice-yearly with life-saving interventions, including vitamin A supplementation (VAS). In 2012, over 80% of targeted children in Sub-Saharan Africa received VAS according to tally-sheet data. All countries implementing CHDs use tally-sheet data to measure coverage; however, coverage measured from tally-sheets is prone to errors due to inaccurate census data, incorrect tallying and mathematical errors totaling coverage across districts and regions. Methods: To validate coverage reported by tally-sheets, Helen Keller International implemented Post-Event Coverage Surveys (PECS) using a 30x30 cluster design and standard WHO EPI cluster sampling methodology in 11 countries in sub-Saharan Africa. For each survey, 900 caretakers of children 6-59 months were interviewed within six weeks of CHDs to reduce recall bias. Results: Thirty-five post event coverage surveys were conducted between January 2010 and July 2013. PECS coverage was lower than administrative coverage in 33/35 (94%) of cases. PECS and administrative coverage data were within a 5% margin of difference in 5 cases (14%), and within >5-10% in 8 cases (23%). However, in 11 cases (31%), results differed by >10-20%, and in 11 cases (31%), results differed by 21-82%. Conclusions: PEC surveys indicate considerable over-reporting of coverage by tally-sheets and provide critical data that is essential to evaluate and improve VAS distribution during CHDs. The continued use of PEC surveys is recommended in areas where tally-sheet data has not been confirmed or has been shown to be unreliable.

Feasibility and Effectiveness of Introducing a Six-month Contact Point for Vitamin A Supplementation into the Tanzanian EPI Vaccination Calendar.

Objectives: The study was seeking to; 1. Obtain the age at first vitamin A dose in comparison to current practices. 2. Assess acceptability of a new 6 month contact point by caretakers and health care workers. Methods: A randomized, facility-based intervention trial was implemented in four intervention and two control health facilities. Children (435 intervention, 137 control) were enrolled at 12-14 weeks of age during their DPT3 visit and followed until they were nine months. At intervention facilities, VAS, growth monitoring and IYCF counseling were provided at six months while standard care of growth monitoring was offered at control facilities. Results: The median (IQR) age at first receipt of VAS was 6.3 (6.0, 6.8) months in the intervention group and 9.3 (9.1, 9.6) months in the control group (p<0.001). At six-months of age, clinic attendance was 88% in the intervention group compared with 0% in the control group. Health workers reported no negative effect on their routine work and 93% recommended the six-month contact point to be implemented in other facilities. Conclusions: Introduction of a six-month contact point into the EPI vaccination calendar significantly reduced the age of first receipt of VAS for children and was well-accepted by health workers.

Experiences Using Mobile Phone Surveys to Monitor and Evaluate the Distribution of Health Services in Sierra Leone.

Objectives: Evidence-based programs to reduce child mortality and morbidity such as twice-yearly vitamin A supplementation (VAS) and mass drug administration (MDA) for neglected tropical diseases require real-time coverage data to ensure that all populations are reached with equitable coverage. Methods: The EpiSurveyor platform was introduced in 2011 for 'in' and 'end' process monitoring of VAS distribution and MDA for lymphatic filariasis (LF), and was later used in 2012 for a LQAS of the supplementary measles immunization program. In 2013, the Magpi platform was piloted for VAS distribution and MDA-LF, and the CommCare platform was piloted for routine reporting of MDA. Results: Twelve nation-wide surveys were conducted with a total of 266 enumerators and 59,465 respondents. Data compilation was available to the account administrator within 48 hours of field-work completion with all three applications. The CommCare platform had several benefits over EpiSurveyor/Magpi: (1) faster programming of skip logic with a friendlier interface (2) ability of the administrator to respond to an enumerator via SMS from the server (3) a prompt for photo evidence and/or Global Positioning System (4) automatic server-input synchronization during network availability (5) ability to program an 'other' category for questions allowing multiple responses. Conclusions: Monitoring and evaluation was enhanced in timeliness and data quality by all three applications. CommCare was found to be more comprehensive and user-friendly compared with EpiSurveyor and Magpi.

Integrating a Six-Month Contact Point for Vitamin A Supplementation, Infant and Young Child Feeding Counselling and Family Planning within Routine Health Services in Sierra Leone.

Objectives: Since 2004, twice-yearly mass vitamin A supplementation (VAS) has reached >85% of children 6-59 months. Although VAS coverage is consistently high, an additional 2.4% reduction in infant mortality could be achieved if all children receive VAS as soon as they turn six months. Therefore, the effectiveness of integrating a six-month contact point with VAS into the routine EPI schedule was examined. Methods: Twelve health units matched according to staff levels, cadre and work load were assigned to provide either a ‘full package’ of 1)VAS, 2)Infant and Young Child Feeding counselling (IYCF), and 3)family planning (FP) counselling and commodities; a ‘mini package’ of 1)VAS and 2)IYCF or control’ with routine health services. 400 infants were enrolled into each group between birth and 3 weeks of age and followed until they were 12 months old. Caregivers of all enrolled children received modified child health cards with a six-month contact point Results: More children in the full (74.5%) and mini (71.7%) groups received VAS at six months compared with the control group (60.2%)(p<0.05). At 9 and 12 months of age, mean WAZ was significantly higher for the full (0.24±0.98; 0.90±0.81), versus the mini (-0.05±1.05; 0.26±0.93) and control groups (-0.55±1.24; 0.39±1.41)(p<0.0001, p<0.01), respectively. FP commodities were provided to 67.3% of mothers in the full group compared with 3.0% in the mini and control groups (p<0.0001). Conclusions: A six-month contact point integrated into the EPI schedule increased VAS coverage and provision of family planning commodities at six months and was associated with improved growth in late infancy.

Reaching the Hard to Reach with Vitamin A Supplementation in Low-performing Health Zones of DR Congo.

Objectives: Since 2002, mass campaigns have been held twice-yearly to reach children 6-59 months with vitamin A supplementation (VAS) and deworming, with coverage consistently over 80% in the majority of DR Congo's 515 health zones (HZ). However, between 2006-2010, 25 HZ achieved coverage <80% in at least 4/10 rounds, and were selected for formative research to identify barriers and motivators to receipt of VAS and inform delivery strategy. Methods: Based on the formative research findings, a communication strategy was implemented to address barriers (husband disapproval, rumors, access to services) and motivators (will of God, self-motivation) in six low-performing HZ. A post-event coverage survey was conducted in December 2012 after two rounds of implementation using a WHO EPI methodology 30x30 cluster design to evaluate the effectiveness of these activities and identify remaining barriers to receipt. Results: Eighty-five percent of caretakers reported their child received VAS during the last campaign (n=909) compared with administrative coverage of 104% and previous round administrative coverage of 72.8%. The primary sources of campaign information were town criers (65%), television (40%) and radio (40%). The most commonly cited reason for not receiving VAS was that the caretaker or child was not home when the distributors passed (37%). Conclusions: Use of criers and television/radio spots broadcast in local languages were most effective in increasing awareness of the campaigns. Both community and national radio and television stations played a variety of communication advertisements prior to and during the campaign, which helped achieve coverage of over 80% to meet child mortality reduction guidelines.