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“Concepts in evaluation of vaccination programs in low income countries"

“Concepts in evaluation of vaccination programs in low income countries" . Jagrati Jani Section for International Health Department of Community Medicine Institute for Health and Society Faculty of Medicine University of Oslo. Presentation Outline Introduction

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“Concepts in evaluation of vaccination programs in low income countries"

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  1. “Concepts in evaluation of vaccination programs in low income countries" JagratiJani Section for International Health Department of Community Medicine Institute for Health and Society Faculty of Medicine University of Oslo

  2. Presentation Outline • Introduction • Epidemiological transition • Evaluation conceptual framework • Expanded Program on Immunisation Goals and main Indicators • Vaccine Coverage and health Information System • Disease surveillance and health Information System • Final remarks

  3. Transition in thepopulation DemographicEpidemiologicalNutrition transitiontransitiontransition Highfertility/mortalityHighincidenceHighprevalence ofcommunicablediseasesundenutrition SocioeconomicVaccinationSafe water Improved diet Decreasedfert./mortReduction in infectiousdiseasesReducedundernutrition Increasedovernutrition Rise ofChronicDiseases Popkin et al

  4. Evaluation • Is a systematic investigation of the structure, activities and results of public health programs • Achieve its goals and objectives Source: Center for Disease Control (CDC) Atlanta 2009

  5. Evaluation methods • MethodQualitative, Quantitative or Both • “HARD AND OBJECTIVE, SOFT AND SUBJECTIVE” • Cross sectional • Retrospective • Prospective • Data collection instrument • Primary data (use of research instruments) • Questionnaire • Interviews • Observations • Secondary data (data already existing) • Statistics on health • Reports Start AIM Planning an evaluation $ Field work Data collection Data analyze Interpretation of findings Report • How to apply the findings • Dissemination

  6. Conceptual framework Impact evaluation Aim of the program • Impact • Disease incidence • Mortality, morbidity Process evaluation • Outcomes • Targeted population • receiving the intervention • Vaccine coverage • Vaccine Effectiveness Impact • Outputs • Plans • Number of vaccines • administrated • Number train staff • Health system • Service availability • Quality of services Formative evaluation Activities Effectiveness Inputs Data Finances Sustainability Efficiency Adapted from the source: Health Care Evaluation. Open University Press, 2005

  7. EPI goal To reduce mortality and morbidity from the targeted diseases among the target group. Indicators Vaccine coverage and vaccine efficacy Incidence of the disease

  8. Output: Service availability • Health system Health facility Curative care Preventive care vaccination Outreach program Supplementary vacc. program Health facility

  9. Immunization Program • Data collection • Data register Knowledge information management & register • Condition and • maintenance • of the equipment Cold Chain Vaccine & transport management • Availability • Inventory • stocks Vaccine admin And safety Contact with the client demand, risk factors for not immunize • Community level

  10. Factors influencing the programme performance: • Intrinsic factors • Change in resources • External donors • National commitment • Programme structure, management or activities • Changes in vaccination schedule • Vaccine shortage • Additional activities- campaigns • Human resources Extrinsic factors Political stability Population accuracy Accessibility to the HF Acceptability ( BCG Magude)

  11. The reasons not to vaccinate Source: J. V. Jani, C. De Schacht, I.V. Jani and G. Bjune: Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique. BMC Public Health, 2007

  12. The Cow-Pock. The Cow-Pock or theWonderfulEffectsofthe New Inoculation! by James Gillraywaspublished in England in 1802 by theAnti-Vaccine Society. The etching, which shows Edward Jenneramongpatients in theSmallPox and Inoculation Hospital at St Pancras (London), suggests thetransformationintocowsofindividualsvaccinated by Jenner Vaccinesafety–vaccinebenefits: science and thepublic’sperception. Nature ReviewImmunology, Nov 2001

  13. Output Challenges Vaccination Cold chain Vaccination technique Vaccination at right age (Mab interference) Immunization Outcome Vaccine effectiveness Impact

  14. Conceptual framework Aim of the program Impact Process evaluation • Outcomes • Targeted population • receiving the intervention • Vaccine Coverage • Vaccine Effectiveness Impact • Outputs Activities Inputs Effectiveness Efficiency Sustainability Adapted from the source: Health Care Evaluation. Open University Press, 2005

  15. Outcome Challenges • Accessibility (hard-to-reach pop) • Health services • ( coverage, staff, availability of vaccines etc.- MOV) • Unstable vaccine supplies • (stock out, release of funds)- MOV • Demand/utilisation still low • due to lack of awareness • or illegal payments or side • Effects • Weak register management Outcome Vaccination Vaccine coverage Immunization Impact

  16. Challenges outcome Cold chain Vaccination technique Vaccination at right age (Mab interference) Health status of the individual Vaccine failure (hard-to-reach population) Genetic determination of MHC Major Histocompatibility Complex (MHC) Human Leukocyte Ag Vaccination Disease control Vaccine coverage Vaccine effectiveness Immunization Herd Immunity Demand Laboratory surveillance Disease elimination

  17. An example of Vaccine Coverage Sum (n* of children vaccinated) Vaccine coverage = ____________________________ Sum (n* of children in target group) Mathematician (exact number) Clinician EPI technician (work performance indicator) Mother Evaluator (hot issue)

  18. Methods of assessing immunisation coverage Administrative method Sum ( n* of children vaccinated) Vaccine coverage % = __________________________ Sum ( n* of children in target group) • Integral part of service delivery • Data useable at all levels • Prompt analyses and action is possible • Is a complementary method • and addresses denominator • Issues • Recall biases RH card • 30 by 7 cluster sample • N= 210 Survey method Sum ( n* of children vaccinated) Vaccine coverage % = ________________________ Sum ( n* of children surveyed)

  19. Vaccine coverage • Numerator issues • Vaccination after target age included? • Campaigns included? ( polio-measles plus Vit A) • Private sector included?

  20. Vaccine coverage • How good is the denominator? • Quality of census data/ Vital registers • Method of population projection ( 2,6%) • Uncertainty at the local level • Migration • Major population shifts ( refugees) • Births or surviving infants

  21. Coverage more 100% Problems with denominator Problems with numerator ( the case of Magude District) Strategies to reach high coverage All opportunities to immunised National vaccination days

  22. Fragmentation of different data sources Demographic Health Survey PopulationCensus Vital Registration Health System Routine information system HR IS Finance IS Disease Surveillance Vaccine IS Other PHC programs IS Other HH Surveys HH survey

  23. An example of DTP

  24. DTP coverage trend 1990 2000 Figs: Survey-based coverage of DTP3 from bidirectional distance dependent regression with 95% uncertainty intervals from 1986-1996 by Global burden of disease study Source: The Lancet 2008; 372: 2031-72

  25. Additional children immunized and immunization service support payments in countries receiving GAVI support up to 2006 Source: The Lancet 2008; 372: 2031-72

  26. Challenges to explain vaccine coverage discrepancies • Intentionally over report or • Errors in stages of the data gathering or reporting process.

  27. Challenges to evaluate outcome ( VE) • Surveillance system Challenges Information gap on new diseases Depends on the coverage of the health system

  28. Flow of the disease surveillance in the health system, Mozambique Source: BMC Infectious Diseases 2006, 6:29

  29. Source: BMC Infectious Disease, 2006; (6)-1-9

  30. Final remark • Vaccine coverage is not the only indicator (immunity, equity, efficiency and sustainability all matter) • December 2008 was 60th anniversary of the Universal Declaration of Human Rights –right to health.

  31. Vaccine Coverage Challenges • There are problems with data quality and unharmonized donor requirements for M&E—a situation of too much data, not enough information • Indicators that need more than one data base

  32. Millennium Development Goals Unprecedented commitment by the world’s leaders to tackle the most basic forms of injustice and inequality in our world: poverty, illiteracy and ill-health. Globalization of humanities basic values: human rights and human development including human health of all The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations-and signed by 147 heads of state and governments during the UN Millennium Summit in September 2000 The eight MDGs break down into 21 quantifiable targets that are measured by 60 indicators

  33. Knowledge Standardized packages of information Vaccine supply Cold Chain Disease surveillance system

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