Vaccination Utilization and Subnational Inequities during the COVID-19 Pandemic: An Interrupted Time-Series Analysis of Administrative Data across 12 Low- and Middle-Income Countries.

BACKGROUND: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. METHODS: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. RESULTS: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI -1.2%, -9.8%) in Guinea and ~19% (95% CI -16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (-4%, 95% CI -1%, -7%), Ghana (-3%, 95% CI -1%, -5%), Haiti (-7%, 95% CI -1%, -12%), and Kenya (-3%, 95% CI -1%, -4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. CONCLUSIONS: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

Co-implementing vitamin A supplementation with seasonal malaria chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study.

BACKGROUND: Bi-annual high dose vitamin A supplements administered to children aged 6-59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes. This study explored the feasibility and acceptability of integrating VAS with SMC in one local government area in Sokoto State. METHODS: A concurrent QUAN-QUAL mixed methods study was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one LGA of Sokoto state. Existing SMC implementation tools and job aids were revised and SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were subsequently assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The qualitative component involved key informant interviews and focus group discussions with policymakers, programme officials and technical partners to explore feasibility and acceptability. Thematic analysis was carried out on the qualitative data. RESULTS: At endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2 to 59% (p < 0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p = 0.412) at endline. There was no significant change (p = 0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at baseline (54%) compared to endline (68%). The qualitative findings are presented as two overarching themes relating to feasibility and acceptability of the integrated VAS-SMC strategy, and within each, a series of sub-themes describe study participants' views of important considerations in implementing the strategy. CONCLUSION: This study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaigns can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

Acceptance and compliance with micronutrient powder (MNP) among children aged 6-23 months in northern Nigeria.

This study sought to understand the utilization patterns and influencing factors of micronutrient powder (MNP) use among children aged 6-23 months in northern Nigeria as part of formative research to inform the design of an infant and young child feeding (IYCF) intervention. It had an iterative, multi-phase design whereby mixed methods data were collected from 144 households participating in an 8-week home-feeding trial. During the first four weeks, 12-hour direct observations were conducted with 24 households using MNP. Over the next four weeks, 18 of the same households were observed. In-depth interviews were also conducted among 27 caregivers to understand factors related to utilization. Unannounced spot checks (n = 86) were also conducted to gauge MNP compliance. Most households (76.7%) (66/86) adhered to instructions for using MNP (Adamawa (34/44 = 77.3%) and Kebbi (32/42 = 76.2%)). Facilitating factors to MNP adherence were identified, most notably the high ease of utilization, with 90.0% of caregivers indicating the MNP was 'easy' or 'very easy' to use. Several barriers to MNP compliance were identified and organized into three domains: product-related (e.g. difficulty opening sachet), child-related (e.g. not finishing fortified staple), and caregiver-related (e.g. difficulty making food daily). In Kebbi and Adamawa, MNP was accepted and utilized according to guidelines among most study participants. Findings may be used for scaling up MNP within a more comprehensive IYCF intervention in northern Nigeria.

A feasibility study to assess non-clinical community health workers' capacity to use simplified protocols and tools to treat severe acute malnutrition in Niger state Nigeria.

BACKGROUND: Severe acute malnutrition (SAM) is a major determinant of childhood mortality and morbidity. Although integrated community case management (iCCM) of childhood illnesses is a strategy for increasing access to life-saving treatment, malnutrition is not properly addressed in the guidelines. This study aimed to determine whether non-clinical Community Health Workers (called Community-Oriented Resource Persons, CORPs) implementing iCCM could use simplified tools to treat uncomplicated SAM. METHODS: The study used a sequential multi-method design and was conducted between July 2017 and May 2018. Sixty CORPs already providing iCCM services were trained and deployed in their communities with the target of enrolling 290 SAM cases. Competency of CORPs to treat and the treatment outcomes of enrolled children were documented. SAM cases with MUAC of 9 cm to < 11.5 cm without medical complications were treated for up to 12 weeks. Full recovery was at MUAC≥12.5 cm for two consecutive weeks. Supervision and quantitative data capturing were done weekly while qualitative data were collected after the intervention. RESULTS: CORPs scored 93.1% on first assessment and increment of 0.11 (95% CI, 0.05-0.18) points per additional supervision conducted. The cure rate from SAM to full recovery, excluding referrals from the denominator in line with the standard for reporting SAM recovery rates, was 73.5% and the median length of treatment was 7 weeks. SAM cases enrolled at 9 cm to < 10.25 cm MUAC had 31% less likelihood of recovery compared to those enrolled at 10.25 cm to < 11.5 cm. CORPs were not burdened by the integration of SAM into iCCM and felt motivated by children's recovery. Operational challenges like bad terrains for supervision, supply chain management and referrals were reported by supervisors, while Government funding was identified as key for sustainability. CONCLUSION: The study demonstrated that with training and supportive supervision, CORPs in Nigeria can treat SAM among under-fives, and refer complicated cases using simplified protocols as part of an iCCM programme. This approach seemed acceptable to all stakeholders, however, the effect of the extra workload of integrating SAM into iCCM on the quality of care provided by the CORPs should be assessed further.

Acute Malnutrition Among Children, Mortality, and Humanitarian Interventions in Conflict-Affected Regions - Nigeria, October 2016-March 2017.

A public health emergency was declared by the Nigerian Federal Ministry of Health in northeastern Nigeria in June 2016 and escalated by the United Nations to a Level 3 Emergency in August 2016, after confirmation of wild poliovirus and measles outbreaks and evidence that prevalence of acute malnutrition exceeded emergency thresholds in areas newly liberated from Boko Haram control (1,2). To monitor rates of mortality, acute malnutrition among children, infectious disease morbidity, and humanitarian interventions after the emergency declaration, a series of cross-sectional household surveys were conducted in fall 2016 and winter 2017 in the northeastern states of Borno and Yobe using a cluster methodology. All-cause mortality among all age groups (crude mortality) and among children aged <5 years (under-five mortality) were above emergency thresholds in 2017 and significantly increased from 2016, despite evidence of increased preventive public health interventions, including measles vaccination. Access to treatment for common childhood illnesses remained very low, as evidenced by reports of fewer than one in six children in areas outside Borno's capital receiving any care for diarrhea. The data from these surveys provide evidence of excessively high mortality (particularly among children), highlight the impact of ongoing violence, and underscore the need for humanitarian efforts to scale up access to treatment services in conflict-affected areas.

Improving estimates of the burden of severe acute malnutrition and predictions of caseload for programs treating severe acute malnutrition: experiences from Nigeria.

BACKGROUND: The burden of severe acute malnutrition (SAM) is estimated using unadjusted prevalence estimates. SAM is an acute condition and many children with SAM will either recover or die within a few weeks. Estimating SAM burden using unadjusted prevalence estimates results in significant underestimation. This has a negative impact on allocation of resources for the prevention and treatment of SAM. A simple method for adjusting prevalence estimates intended to improve the accuracy of burden estimates and caseload predictions has been proposed. This method employs an incidence correction factor. Application of this method using the globally recommended incidence correction factor has led to programs underestimating burden and caseload in some settings. METHODS: A method for estimating a locally appropriate incidence correction factor from prevalence, population size, program caseload, and program coverage was developed and tested using data from the Nigerian national SAM treatment program. RESULTS: Applying the developed method resulted in errors in caseload prediction of about 10%. This is a considerable improvement upon the current method, which resulted in a 79.5% underestimate. Methods for improving the precision of estimates are proposed. CONCLUSIONS: It is possible to considerably improve predictions of caseload by applying a simple model to data that are readily available to program managers. This implies that more accurate estimates of burden may also be made using the same methods and data.