ORIGINAL ARTICLE
Int Health 2015; 7: 26–31 doi:10.1093/inthealth/ihu073 Advance Access publication 14 October 2014
High coverage of vitamin A supplementation and measles vaccination during an integrated Maternal and Child Health Week in Sierra Leone Fatmata F. Sesaya,*, Mary H. Hodgesa, Habib I. Kamaraa, Mohamed Turaya, Adam Wolfeb, Thomas T. Sambac, Aminata S. Koromad, Wogba Kamarae, Amadou Fallf, Pamela Mitulaf, Ishata Contehf, Nuhu Makshag and Amara Jambaih a
Helen Keller International, PO Box 369, Freetown, Sierra Leone; bColumbia University, Mailman School of Public Health, New York, NY USA; Child Health and Expanded Program on Immunization, Ministry of Health and Sanitation, Freetown, Sierra Leone; dNutrition Program, Ministry of Health and Sanitation Sierra Leone, Youyi Building Brookfields, Freetown Sierra Leone; eNational HIV/AIDS Secretariat, Ministry of Health and Sanitation, Kingharman Road Freetown, Sierra Leone; fWorld Health Organization, Country Office, Sierra Leone and Inter Country Support Team for West Africa (IST-WA); gUnited Nations Children’s Fund, Country Office, Sierra Leone; hDirectorate of Disease Prevention and Control, Ministry of Health and Sanitation, Freetown, Sierra Leone c
Received 28 December 2013; revised 25 May 2014; accepted 9 June 2014 Background: In May 2012, the twice-yearly Maternal and Child Health Week (MCHW) integrated vitamin A supplementation (VAS) and supplementary measles vaccination to reach all children 6–59 months in Sierra Leone. Following the MCHW, a post event coverage survey was conducted to validate VAS coverage and assess adverse events following immunization. Methods: Using the WHO Expanded Program on Immunization sampling methodology, 30 clusters were randomly selected using population proportionate to size sampling. Fourteen caregivers of children 6–59 months were interviewed per cluster for precision of+5%. Responses were collected via mobile phones using EpiSurveyor. Results: Overall VAS and measles coverage was 91.9% and 91.6%, respectively, with no significant differences by age group, sex, religion or occupation. Major reasons given for not receiving VAS and measles vaccination were not knowing about the MCHW or being out of the area. Significantly more mild adverse events (fever, pain at injection site) were reported via the post event coverage survey (29.1%) than MCHW (0.01%) (p,0.0001). Conclusion: The MCHW reached .90% of children in Sierra Leone with equitable coverage. Increased reporting of mild adverse events during the survey may be attributed to delayed onset after measles vaccination and/or direct inquiry from enumerators. Even mild adverse events following immunization requires strengthened reporting during and after vaccination campaigns. Keywords: Adverse events, Coverage, Episurveyor, Measles, Vaccination, Vitamin A supplementation
Introduction Measles control activities in Sierra Leone started in 1975 with the Expanded Programme on Immunization (EPI). Coverage of 75% was recorded in 1990 but declined during the civil conflict (1991–2002) before increasing to 90% in 2006.1 Despite the high administrative coverage of 97% recorded in 2010, an EPI cluster survey conducted that year found measles coverage confirmed by card of 57%, and valid coverage by 52 weeks of age of 31%.2 Measles supplemental immunization activities have been conducted every three years in Sierra Leone since 2003. From 2008–10,
the West African region experienced measles outbreaks: the largest in a decade started in Sierra Leone. The 2010 outbreak confirmed 1094 cases and 9 deaths: 292 (26.7%) were children ,1 year of age, 424 (38.8%) were 1–4 years of age.3 Vitamin A deficiency in children causes significant increases in the risk of morbidity and mortality from common childhood infections, such as diarrhoeal disease and measles, and visual impairment. There is robust evidence to show that in settings where vitamin A deficiency is prevalent, twice yearly vitamin A supplementation (VAS) to at least 80% of the target population (6–59 months of age) contributes to reduced risk of child mortality from measles by an average 50%. In addition, VAS is included in
# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
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*Corresponding author: Present address: Helen Keller International, 35 Nelson Lane, Tengbeh Town, Freetown, Sierra Leone, West Africa. Tel: +23 27 835 6172; E-mail: [email protected]
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size sampling. The enumeration areas (collection of households grouped within defined administrative boundaries) were the primary sample clusters. In each cluster, 14 households were randomly selected from which a care-giver of a child aged 6–59 months was randomly selected and interviewed. This gave a sample size of 420 caregivers in each district, giving the desired precision value of +5% at 95% CI.16 The selection of the clusters used the national 2004 census. If a compound or building contained more than one household or was occupied by several families, surveyors randomly selected one household using a random number table. Eligibility of caretakers to be interviewed was defined by their child having slept at the household the night before, had been resident in the selected cluster during the MCHW and was within the eligible age range. If there was more than one eligible child in the household, surveyors used the random number table to select the child to be interviewed. A child was considered vaccinated for measles or supplemented with vitamin A if the caregiver presented the measles/VAS card from the MCHW. Surveyors also recorded verbal affirmation if a caregiver did not have or was not able to locate their MCHW card. Age was confirmed by verbal recall from mothers, child health card, birth certificate or any relevant document showing the child’s age. If the date of birth was not available the age was estimated by the surveyors from a calendar of local events.
Methods Maternal and Child Health Week Sierra Leone conducted its bi-annual MCHW including a supplementary immunization activity for measles from 25–30 May 2012 in all 14 districts targeting total populations of 1 155 401 and 1 234 000 for measles vaccination and VAS, respectively. The MCHW employed a combination of fixed distribution and mobile teams (house to house). VAS was administered as a single dose to children 6–59 months using 100 000 IU for children 6–11 months and 200 000 IU for children 12–59 months. The measles vaccines used were Measles Containing Vaccine (Serum Institute of India, Pune, India. http://www.seruminstitute.com/ index.html) 10 dose vial for children 9–59 months.
Lot quality assurance sampling Lot quality assurance sampling was conducted during the last two days of the MCHW to ensure all 14 districts had reached minimal accepted coverage. Thirty six non-overlapping lots were randomly selected by population proportionate to size. Five enumeration areas were randomly selected within each lot and the caregivers of 10 eligible children randomly selected from each enumeration areas. The surveying teams collected information on measles vaccination and VAS for eligible children aged. A lot was rejected if 8/50 or more unvaccinated children were found. Any eligible child not having evidence on the MCHW card was considered unvaccinated/unsupplemented. A one day extension of activities was implemented by the rejected districts.15
Surveyor training and data collection A two-day training was conducted for 57 surveyors of which 53 were selected after a post-test. Training included the EpiSurveyor (DATADYNE, Washington DC & Nairobi, Kenya; http://home.magpi. com/) application to collect, store and send data on Nokia mobile phones. Data collection took 5 days using both EpiSurveyor and hard copy questionnaire. Thirteen supervisors were also trained on the methodology to oversee and support the surveyors for quality assurance.
Administrative coverage Reported coverage was estimated by dividing the tally of vaccines or vitamin A capsules administered by the adjusted target population projections from the National Census Population of 2004 and recent MCHWs.17
Statistical analysis Data collected with EpiSurveyor were exported into Microsoft Excel 2007 (Microsoft Corp., Redmond, WA, USA) and cleaned by comparing with the hard copies. Coverage was calculated, and statistical significance between groups tested by ANNOVA and x2 tests at p,0.05 using SPSS V20 (IBM, Armonk, NY, USA).
Results Lot quality assurance sampling
Post event coverage survey The WHO EPI cluster sampling method was used to randomly select 30 clusters in each district using population proportion to
Eleven out of 36 lots were rejected during the lot quality assurance sampling representing six districts: Bo (1), Bombali (2), Kenema (2), Moyamba (1), Tonkolili (1) and Western Area (4).
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the treatment protocols for children with xerophthalmia, measles, lower respiratory tract infections, persistent diarrhea and severe acute malnutrition.4 In areas where vitamin A deficiency exists, VAS is also one of the most cost effective child survival strategies, contributing to a reduction in all-cause mortality in children 6–59 months by an average 24%.5,6 Measles vaccination, VAS and other interventions have contributed to the reductions in child mortality from 267 in 2005 to 118/1000 in 2010 in Sierra Leone.7–9 In 2012, the Ministry of Health conducted a nationwide integrated Maternal and Child Health Week (MCHW) with measles vaccination for children 9–59 months old and VAS for children 6–59 months old. Although measles is highly infectious, high quality implementation of mass vaccination can rapidly increase herd immunity, reduce measles transmission and help attain the goal of eliminating measles.10–14 The MCHW was integrated with other interventions including de-worming with albendazole for children 12–59 months old and defaulter tracing to prevent mother to child transmission of HIV for pregnant women. Immediately following the MCHW, a post event coverage survey (PECS) was conducted. The PECS collected data to evaluate the coverage of interventions, communication strategy, the reasons for missed children and adverse events following immunization (AEFI).
F. F. Sesay et al.
Post event coverage survey Sample characteristics
Vitamin A supplementation and measles coverage Overall coverage for VAS was 91.9% (4910/5342; 95% CI 90.8– 92.9%) by card confirmation and 96.3% (5147/5342; 95% CI 94.3–98.3%) by verbal affirmation (Table 1). There had been 0.1% (7/5342) refusals for VAS by caregivers. There was no significant difference in VAS coverage confirmed by card between children 6–11 months old (88.9%; 233/262) vs children 12–59 months (92.1%; 4677/5080). Tonkolili district had significantly lower VAS coverage confirmed by card 69.4% (297/428) compared with any other district (p,0.0001). All other districts had VAS coverage rates between 84.2% and 99.8%. There was no significant difference in VAS coverage by caregiver’s religion (Muslim
Vitamin A supplementation and Maternal and Child Health Week Of the 5147 caregivers that verbally affirmed their child received VAS, 58.9% (3030) reported their child received VAS at a health centre, 40.1% (2061) from a mobile team going house to house and 1.1% (56) could not recall. Coverage for VAS and measles did not vary significantly by education level of the caregiver, gender of the child or caregiver’s occupation. The most frequent sources of information about MCHW were community health workers (39.8%; 2486/6243), town criers (31.3%; 1956) and radio (4.5%; 903). Of the caregivers interviewed, 3.8% (1945/5147) and 3.9% (209) reported their child did not receive VAS or measles vaccine respectively. The major reasons given were not knowing about the MCHW (VAS: 27.1% 55/203; measles: 26.1% 55/211) and being out of the area (VAS: 21.2% 43/203; measles: 19.0% 40/211) (Table 2).
Table 1. Comparison of coverage by Ministry of Health Sanitation reports vs the post event coverage survey District
Bo Bombali Bonthe Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun Tonkolili UWA RWA Overall
Vitamin A supplementation (VAS)
Measles
Target population 6–59 months
6–59 VAS doses given
MoHS VAS coverage %
PECS VAS coverage % (95% CI)
Target population 9–59 months
9–59 months immunized
MoHS coverage %
PECS measles coverage % (95% CI)
98 108 79 479 25 200 70 475 50 921 98 610 60 144 82 245 53 323 91 219 50 417 77 946 250 122 145 790 1 234 000
99 628 79 605 25 488 70 382 50 958 98 806 60 250 82 746 54 279 91 308 50 912 78 825 257 373 135 052 1 235 612
101.5 100.2 101.1 99.9 100.1 100.2 100.2 100.6 101.8 100.1 101.0 101.1 102.9 92.6 100.1
95.2 (94.2–96.2) 92.9 (91.9–94.0) 92.8 (91.8–93.9) 93.5 (92.5–94.6) 98.6 (97.6–99.6) 84.2 (83.2–85.3) 98.0 (97.0–99.0) 91.7 (90.7–92.8) 91.6 (90.5–92.7) 96.2 (95.2–97.2) 99.8 (98.8–100.8) 69.4 (68.3–70.5) 93.6 (89.6–91.6) 90.6 (92.6–94.7) 91.9 (90.9–92.9)
91 859 74 417 23 595 65 987 47 677 92 329 56 313 77 007 49 927 85 409 47 205 72 981 234 191 136 504 1 155 401
93 413 76 452 23 978 65 884 47 755 92 638 56 468 77 554 50 870 85 531 47 720 73 865 254 097 133 380 1 179 605
101.7 102.7 101.6 99.8 100.2 100.3 100.3 100.7 101.9 100.1 101.1 101.2 108.5 97.7 102.1
96.1 (95.1–97.1) 92.3 (91.3–93.4) 92.1 (91.1–93.2) 94.1 (93.1–95.2) 98.2 (97.2–99.2) 85.4 (84.4–86.5) 97.9 (96.9–98.9) 91.6 (90.6–92.7) 89.6 (88.5–90.7) 96.1 (95.1–97.1) 99.8 (98.8–100.8) 69.8 (68.7–70.9) 93.7 (89.2–91.6) 90.2 (92.7–94.8) 91.6 (90.6–92.6)
MCHW: Maternal and Child Health Week; MoHS: Ministry of Health and Sanitation; PECS: post event coverage survey; VAS: vitamin A supplementation.
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A total of 5621 caregivers were interviewed of the targeted 5880: 4.3% of Ennumeration Areas (18/420) could not located by the PECS surveyors. Completed interviews were obtained from 5342 caregivers of children 6–59 months old (47.8% male, 52.2% female), including 5292 children 9–59 months old (47.8% [2553] male, 52.2% [2789] female). The date of birth of 19.4% (1038) of children was estimated by a calendar of local events. Most caregivers were mothers: 76.1% (4064) or grandmothers: 9.9% (531) and 68.3% (3649) had had no formal education. The most common caregiver occupations were farming (55.5%; 2964) and petty trading (21.3%; 1136). Significantly more caregivers were Muslim (73.0%; 3902) than Christian (26.4%; 1401) (p,0.0001).
91.4%; 3565/3902) vs Christian 93.6%; 1320/1410). There was no significant difference in VAS coverage estimated by the current PECS vs the 2011 PECS (92.4%; 812/879).18 Overall coverage for measles vaccination by card confirmation was 91.6% (4849/5292; 95% CI 89.6–93.6%) (Table 1) and by verbal affirmation was 96.1% (5083/5292; 95% CI 94.1–98.1%). Vaccine confirmation by card in Tonkolili was significantly lower vs all other districts (p,0.0001). There was no significant difference in measles coverage in children 9–11 months old (95.7%; 203/212; 95% CI 94.6–96.8%) vs 12–59 months old (96.1%; 4880/5080; 95% CI 95.0–97.2%) by caregiver’s religion (Muslim: 96.3% [3757/3902] vs Christian 96.7% [1364/1410)].
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Adverse events Health workers reported AEFIs from the MCHW in 0.01% (109/ 1 179 605) of children, most commonly fever: 0.006%, (79/ 1 179 605) pain at the injection site: 0.002% (32/1 179 605) or rash: 0.0008% (9/1 179 605). One health worker in Pujehun district reported a child had a high fever and died 3 days later. During the PECS 1477/5147 caregivers (29.1%) reported a total of 121/1490 AEFIs; significantly more than reported to by the MCHW p,0.0001). Common AEFIs reported during the PECS included fever (24.9% 1266/1490) and rashes (2.4% 121) (Table 3).
Overall VAS coverage reported by the Ministry of Health was 100.1% (1 235 612 capsules used for a target population of 1 234 000) (Table 1). Coverage of VAS in 6–11 month olds was 86.4% (135 820/157 197) and in 12–59 month olds was 102.1% (1 099 792/1 076 803).
Table 2. Reasons given by caretakers during the post event coverage survey for why children did not attend Maternal and Child Health Week (MCHW)
Reason Did not know about the MCHW Child was out of area Unknown Journey was too far Child was ill Too much work at home Refusal The line was too long Health facility ran out of vaccine
VAS n¼203
Measles n¼211
n (%) 55 (27.1) 43 (21.2) 28 (13.8) 24 (11.8) 24 (11.8) 15 (6.9) 7 (3.4) 3 (1.5) 3 (1.5)
n (%) 55 (26.1) 40 (19.0) 41 (19.4) 23 (10.9) 20 (9.5) 17 (7.5) 5 (2.4) 4 (1.9) 5 (2.4)
VAS: vitamin A supplementation.
Table 3. Types and frequency of adverse events following measles vaccination reported by 5083 caregivers interviewed during the post event coverage survey Type
No. cases
% of those vaccinated
Abscess Collapse/Faint Fever Rash Redness Swelling Total
14 3 1266 121 11 75 1490
0.3 0.1 24.9 2.4 0.2 1.5 29.3
Discussion The use of lot quality assurance sampling to identify districts with low coverage during the MCHW and the addition of a 1 day extension helped improve coverage in all the rejected districts. All the rejected lots were in districts that have been rapidly growing due to internal displacement and post conflict employmentseeking migration. Overall, coverage for both measles and VAS was high by verbal affirmation and by card confirmation. Coverage across districts was also high. The disparity in Tonkolili between coverage by verbal affirmation vs card confirmation was investigated and it appeared that health workers had vaccinated and supplemented children promising to return later with the cards when they were less busy but had not done so before the PECS. This practice is unsatisfactory and leaves the caregiver with an inadequate record of their child’s health services. The measles outbreak in 2009–10 had started 2 weeks before the supplementary immunization activities so this interval was reduced to 2.5 years to pre-empt future outbreaks.19 In 2011 there were no reported cases of measles and a total of just six cases by mid-2012. This is encouraging, but in the medium/long term, institutionalizing of effective routine contacts for children at 9 months of age and introducing a second dose of measles vaccination has been recommended. One innovation strategy to increase attendance is the fuller integration of family planning for caregivers accessing routine child health services which is being scaled up nationwide by the Ministry of Health. Significantly more AEFIs were reported during the PECS than the MCHW. As health workers often work in outreach settings during MCHW, they may be less aware of AEFIs. From this remote rural setting, it was unclear whether the one reported death was an AEFI or a coincidental event. The interval between immunization and the presentation of fever is unknown. No autopsy was conducted to ascertain the cause of death but common childhood illnesses such as malaria are a leading cause of fever and mortality in Sierra Leone. The health worker did not consider this death as an AEFI thus it is not represented in Table 3. Some AEFIs can occur up to 45 days post-measles vaccination and thus would not have been recorded during the MCHW or the PECS. Refusals during the MCHW were low, demonstrating a successful communication strategy via the community health volunteers/ workers, town criers and radio. How best to sensitize caregivers of missed children in future MCHWs requires further strategic planning. Identifying alternative communication channels including religious leaders who can explain the benefits of measles vaccination and VAS to their followers may further increase coverage. Identifying Koranic and biblical passages to support the concept of preventative child health care has been attempted in Africa.20 Encouraging and enabling community health volunteers/workers to adapt to caregivers’ occupations and provide services in the late afternoon or very early morning have also been discussed.
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Ministry of Health administrative coverage by tally sheets for measles and vitamin A supplementation
Overall measles vaccination coverage reported by the Ministry of Health was: 102.3% (1 179 605 vaccines for a target population of 1 155 401). Coverage for children 9–11 month olds was 99.0% (77 813/78 599) and 12–59 months olds: 102.3% (1 101 792/ 1 076 802).
F. F. Sesay et al.
Children who were missed in the MCHW have an opportunity to catch up from routine child health services or subsequent campaigns. There is a standard EPI integrated into the routine care. The health facilities provide routine services and the provision of routine VAS integrated into the EPI schedule has since been launched in early 2014.
Administrative coverage and population projections
Limitations of the study Vaccination or supplementation status was primarily determined by recall of caregivers and by card confirmation which may be subject to recall bias. AEFIs may have been misclassified or over-reported by caregivers during the PECS as well as under-reported by health workers during the MCHW. Administrative data used is projected from the denominators of the 2004 population census which is widely considered now to under-represent this target group.
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In May 2012 the MCHW, successfully provided 1.2 million measles vaccines and vitamin A supplements to children, reaching over 90% of eligible children.
Authors’ contributions: FS, MH, IC, PM, AF and AJ conceived the study. FS, IC, WK, HK, TS supported the implementation and trained the surveyors. IC, FS, WK, HK performed the monitoring and supportive supervision. FS, IC and HK coordinated the field data collection. HK and MT prepared EpiSurveyor, and conducted initial data analysis with support from AW. FS drafted the manuscript and MH supervised the data analysis and revised the manuscript. NM, PM, ASK and AF reviewed the paper. All authors reviewed and approved the final manuscript. MH is the guarantor of this paper. Acknowledgements: The authors would like to thank the Ministry of Health and Sanitation, World Health Organization and community health volunteers for supporting the MCHW. Funding: This work was funded by the Canadian International Development Agency (CIDA) through Helen Keller International and United Nations Children’s Fund (UNICEF). Competing interests: None declared. Ethical approval: Not required.
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The Ministry of Health reported coverage over 100% for both VAS and measles. This may be due to under-projection of the target population from the 2004 census, vaccinating children outside of the target age, and/or due to over-reporting by health workers. Future PECS will be necessary to measure coverage since administrative data is prone to these errors.21 A PECS can also evaluate quality of implementation, caregiver-awareness and health workers’ practices. Adjustment of population estimates is an important component of macro-planning: ordering an appropriate number of vitamin A capsules, albendazole and vaccines and micro-planning for more accurate allocation of supplies within districts to prevent shortages during the MCHW. In rapidly urbanizing countries the migration of children may play a major role in measles transmission.22,23 There were eight confirmed measles cases in 2012. The vaccination of the ‘hard to reach’ children in new settlements, urban slums and rapidly urbanizing towns should be further prioritised. Some districts, notably Tonkolili and Bombali, have undergone rapid population growth since the opening of the iron ore mines and railroad. This has increased the health workers’ workload and also contributed to attrition as they leave for more lucrative positions within the industrial sector.20 Rapid urbanisation, greater than the 2.4% projected by the national census, and rapid reduction in child mortality pose challenges for estimating target populations and makes coverage based solely on projected populations difficult to interpret. The cost incurred for the lot quality assurance sampling, PECS and MCHW were US$21 965, US$25 935 and US$1 471 245 respectively, for a total of US$1 518 597 and a cost per child 6–59 months of US$1.23. The Government of Sierra Leone contributed 2 billion Leones (US$465 000) to the MCHW following the advocacy visit conducted by the Measles and Rubella Partnership. Leadership by the Ministry of Health demonstrated government ownership and the critical importance of successful collaboration with non-governmental organizations, United Nations agencies and district councils. The Government of Sierra Leone and partners should continue to implement the MCHWs, perform PECSs, identify missed children and increase accessibility to routine child health services to enable universal coverage.
Conclusions
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9 UNICEF, Sierra Leone, Ministry of Health and Sanitation. Report on the Nutritional Situation in Sierra Leone. 2010. http://wcaronutritionsurveys. files.wordpress.com/2011/03/sierra-leone-nutrition-survey-jun-aug2010.pdf [accessed 3 December 2011]. 10 Moss WJ, Griffin D.E., Global measles elimination. Nat Rev Microbiol 2006;4:900–8. 11 Ciccone FH, Carvalhanas TR, Afonso AM et al. Investigation of measles IgM-seropositive cases of febrile rash illnesses in the absence of documented measles virus transmission, State of Sa˜o Paulo, Brazil, 2000-2004. Rev Soc Bras Med Trop 2010;43:234–9 http://www.scielo. br/scielo.php?script=sci_arttext&pid=S0037-86822010000300004&lng= en&nrm=iso&tlng=en [accessed 28 January 2010].
13 Flugsrud LB, Rłd TO, Aasen S, Berdal BP. Measles antibodies and herd immunity in 20- and 40-year-old Norwegians. Scand J Infect Dis 1997;29:137–40. 14 Pickering LK, Baker CJ, Freed GL et al. Immunization programs for infants, children, adolescents and adults: clinical guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:817–40. 15 WHO. Monitoring Immunization Services using the Lot Quality Technique. Geneva: World Health Organization; 1996. 16 WHO. Department of Immunization, Vaccines and Biologicals, Vaccine Assessment and Monitoring Team. Immunization Coverage Cluster
17 Koroma DS, Turay AB, Moigua MB. Republic of Sierra Leone 2004 population and housing census: analytical report on population projection for Sierra Leone. Freetown, Sierra Leone: SSL; 2006. 18 Hodges MH, Sesay FF, Kamara HI et al. Large scale vitamin A supplementation coverage knowledge and barriers reported by post event coverage surveys in Sierra Leone. Glob Health Sci Pract June 26 2013;1:172–9 10.9745. 19 WHO, UNICEF. Joint Annual Measles Report. Strengthening Immunization Services through Measles Control; 2010 http://www. measlesrubellainitiative.org/wp-content/uploads/2013/06/MRI-2010Annual-Report.pdf [accessed20 July 2012d]. 20 Murray CJ, Shengelia B, Gupta N et al. Validity of reported vaccination coverage in 45 countries. Lancet 2003;362:1022–7. 21 Ayoya MA, Benedech MA, Baker SK et al. Determinants of high vitamin A supplementation coverage among pre-school children in Mali: the National Nutrition Weeks experience. Public Health Nutr 2007;10: 1241–6. 22 Yame´ogo KR, Perry RT, Yame´ogo A et al. Migration as a risk factor for measles after a mass Immunization campaign, Burkina Faso. Int J Epidemiol 2005;34:556–64. 23 Hodges MH, Sonnie M, Turay H et al. Maintaining effective mass drug administration for lymphatic filariasis through in-process monitoring in Sierra Leone. Parasit Vectors 2012;5:232.
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12 Peng ZQ, Chen WS, He Q et al. Evaluation of the mass measles vaccination campaign in Guangdong Province, China. Int J Infect Dis 2012;16:e99–103. http://www.sciencedirect.com/science/article/ pii/S1201971211002177 [accessed 28 November 2011].
Survey: Reference Manual. Geneva: World Health Organization; 2005. http://apps.who.int/iris/handle/10665/69087 [accessed 25 May 2012].
Int Health 2015; 7: 26–31 doi:10.1093/inthealth/ihu073 Advance Access publication 14 October 2014
High coverage of vitamin A supplementation and measles vaccination during an integrated Maternal and Child Health Week in Sierra Leone Fatmata F. Sesaya,*, Mary H. Hodgesa, Habib I. Kamaraa, Mohamed Turaya, Adam Wolfeb, Thomas T. Sambac, Aminata S. Koromad, Wogba Kamarae, Amadou Fallf, Pamela Mitulaf, Ishata Contehf, Nuhu Makshag and Amara Jambaih a
Helen Keller International, PO Box 369, Freetown, Sierra Leone; bColumbia University, Mailman School of Public Health, New York, NY USA; Child Health and Expanded Program on Immunization, Ministry of Health and Sanitation, Freetown, Sierra Leone; dNutrition Program, Ministry of Health and Sanitation Sierra Leone, Youyi Building Brookfields, Freetown Sierra Leone; eNational HIV/AIDS Secretariat, Ministry of Health and Sanitation, Kingharman Road Freetown, Sierra Leone; fWorld Health Organization, Country Office, Sierra Leone and Inter Country Support Team for West Africa (IST-WA); gUnited Nations Children’s Fund, Country Office, Sierra Leone; hDirectorate of Disease Prevention and Control, Ministry of Health and Sanitation, Freetown, Sierra Leone c
Received 28 December 2013; revised 25 May 2014; accepted 9 June 2014 Background: In May 2012, the twice-yearly Maternal and Child Health Week (MCHW) integrated vitamin A supplementation (VAS) and supplementary measles vaccination to reach all children 6–59 months in Sierra Leone. Following the MCHW, a post event coverage survey was conducted to validate VAS coverage and assess adverse events following immunization. Methods: Using the WHO Expanded Program on Immunization sampling methodology, 30 clusters were randomly selected using population proportionate to size sampling. Fourteen caregivers of children 6–59 months were interviewed per cluster for precision of+5%. Responses were collected via mobile phones using EpiSurveyor. Results: Overall VAS and measles coverage was 91.9% and 91.6%, respectively, with no significant differences by age group, sex, religion or occupation. Major reasons given for not receiving VAS and measles vaccination were not knowing about the MCHW or being out of the area. Significantly more mild adverse events (fever, pain at injection site) were reported via the post event coverage survey (29.1%) than MCHW (0.01%) (p,0.0001). Conclusion: The MCHW reached .90% of children in Sierra Leone with equitable coverage. Increased reporting of mild adverse events during the survey may be attributed to delayed onset after measles vaccination and/or direct inquiry from enumerators. Even mild adverse events following immunization requires strengthened reporting during and after vaccination campaigns. Keywords: Adverse events, Coverage, Episurveyor, Measles, Vaccination, Vitamin A supplementation
Introduction Measles control activities in Sierra Leone started in 1975 with the Expanded Programme on Immunization (EPI). Coverage of 75% was recorded in 1990 but declined during the civil conflict (1991–2002) before increasing to 90% in 2006.1 Despite the high administrative coverage of 97% recorded in 2010, an EPI cluster survey conducted that year found measles coverage confirmed by card of 57%, and valid coverage by 52 weeks of age of 31%.2 Measles supplemental immunization activities have been conducted every three years in Sierra Leone since 2003. From 2008–10,
the West African region experienced measles outbreaks: the largest in a decade started in Sierra Leone. The 2010 outbreak confirmed 1094 cases and 9 deaths: 292 (26.7%) were children ,1 year of age, 424 (38.8%) were 1–4 years of age.3 Vitamin A deficiency in children causes significant increases in the risk of morbidity and mortality from common childhood infections, such as diarrhoeal disease and measles, and visual impairment. There is robust evidence to show that in settings where vitamin A deficiency is prevalent, twice yearly vitamin A supplementation (VAS) to at least 80% of the target population (6–59 months of age) contributes to reduced risk of child mortality from measles by an average 50%. In addition, VAS is included in
# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
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*Corresponding author: Present address: Helen Keller International, 35 Nelson Lane, Tengbeh Town, Freetown, Sierra Leone, West Africa. Tel: +23 27 835 6172; E-mail: [email protected]
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size sampling. The enumeration areas (collection of households grouped within defined administrative boundaries) were the primary sample clusters. In each cluster, 14 households were randomly selected from which a care-giver of a child aged 6–59 months was randomly selected and interviewed. This gave a sample size of 420 caregivers in each district, giving the desired precision value of +5% at 95% CI.16 The selection of the clusters used the national 2004 census. If a compound or building contained more than one household or was occupied by several families, surveyors randomly selected one household using a random number table. Eligibility of caretakers to be interviewed was defined by their child having slept at the household the night before, had been resident in the selected cluster during the MCHW and was within the eligible age range. If there was more than one eligible child in the household, surveyors used the random number table to select the child to be interviewed. A child was considered vaccinated for measles or supplemented with vitamin A if the caregiver presented the measles/VAS card from the MCHW. Surveyors also recorded verbal affirmation if a caregiver did not have or was not able to locate their MCHW card. Age was confirmed by verbal recall from mothers, child health card, birth certificate or any relevant document showing the child’s age. If the date of birth was not available the age was estimated by the surveyors from a calendar of local events.
Methods Maternal and Child Health Week Sierra Leone conducted its bi-annual MCHW including a supplementary immunization activity for measles from 25–30 May 2012 in all 14 districts targeting total populations of 1 155 401 and 1 234 000 for measles vaccination and VAS, respectively. The MCHW employed a combination of fixed distribution and mobile teams (house to house). VAS was administered as a single dose to children 6–59 months using 100 000 IU for children 6–11 months and 200 000 IU for children 12–59 months. The measles vaccines used were Measles Containing Vaccine (Serum Institute of India, Pune, India. http://www.seruminstitute.com/ index.html) 10 dose vial for children 9–59 months.
Lot quality assurance sampling Lot quality assurance sampling was conducted during the last two days of the MCHW to ensure all 14 districts had reached minimal accepted coverage. Thirty six non-overlapping lots were randomly selected by population proportionate to size. Five enumeration areas were randomly selected within each lot and the caregivers of 10 eligible children randomly selected from each enumeration areas. The surveying teams collected information on measles vaccination and VAS for eligible children aged. A lot was rejected if 8/50 or more unvaccinated children were found. Any eligible child not having evidence on the MCHW card was considered unvaccinated/unsupplemented. A one day extension of activities was implemented by the rejected districts.15
Surveyor training and data collection A two-day training was conducted for 57 surveyors of which 53 were selected after a post-test. Training included the EpiSurveyor (DATADYNE, Washington DC & Nairobi, Kenya; http://home.magpi. com/) application to collect, store and send data on Nokia mobile phones. Data collection took 5 days using both EpiSurveyor and hard copy questionnaire. Thirteen supervisors were also trained on the methodology to oversee and support the surveyors for quality assurance.
Administrative coverage Reported coverage was estimated by dividing the tally of vaccines or vitamin A capsules administered by the adjusted target population projections from the National Census Population of 2004 and recent MCHWs.17
Statistical analysis Data collected with EpiSurveyor were exported into Microsoft Excel 2007 (Microsoft Corp., Redmond, WA, USA) and cleaned by comparing with the hard copies. Coverage was calculated, and statistical significance between groups tested by ANNOVA and x2 tests at p,0.05 using SPSS V20 (IBM, Armonk, NY, USA).
Results Lot quality assurance sampling
Post event coverage survey The WHO EPI cluster sampling method was used to randomly select 30 clusters in each district using population proportion to
Eleven out of 36 lots were rejected during the lot quality assurance sampling representing six districts: Bo (1), Bombali (2), Kenema (2), Moyamba (1), Tonkolili (1) and Western Area (4).
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the treatment protocols for children with xerophthalmia, measles, lower respiratory tract infections, persistent diarrhea and severe acute malnutrition.4 In areas where vitamin A deficiency exists, VAS is also one of the most cost effective child survival strategies, contributing to a reduction in all-cause mortality in children 6–59 months by an average 24%.5,6 Measles vaccination, VAS and other interventions have contributed to the reductions in child mortality from 267 in 2005 to 118/1000 in 2010 in Sierra Leone.7–9 In 2012, the Ministry of Health conducted a nationwide integrated Maternal and Child Health Week (MCHW) with measles vaccination for children 9–59 months old and VAS for children 6–59 months old. Although measles is highly infectious, high quality implementation of mass vaccination can rapidly increase herd immunity, reduce measles transmission and help attain the goal of eliminating measles.10–14 The MCHW was integrated with other interventions including de-worming with albendazole for children 12–59 months old and defaulter tracing to prevent mother to child transmission of HIV for pregnant women. Immediately following the MCHW, a post event coverage survey (PECS) was conducted. The PECS collected data to evaluate the coverage of interventions, communication strategy, the reasons for missed children and adverse events following immunization (AEFI).
F. F. Sesay et al.
Post event coverage survey Sample characteristics
Vitamin A supplementation and measles coverage Overall coverage for VAS was 91.9% (4910/5342; 95% CI 90.8– 92.9%) by card confirmation and 96.3% (5147/5342; 95% CI 94.3–98.3%) by verbal affirmation (Table 1). There had been 0.1% (7/5342) refusals for VAS by caregivers. There was no significant difference in VAS coverage confirmed by card between children 6–11 months old (88.9%; 233/262) vs children 12–59 months (92.1%; 4677/5080). Tonkolili district had significantly lower VAS coverage confirmed by card 69.4% (297/428) compared with any other district (p,0.0001). All other districts had VAS coverage rates between 84.2% and 99.8%. There was no significant difference in VAS coverage by caregiver’s religion (Muslim
Vitamin A supplementation and Maternal and Child Health Week Of the 5147 caregivers that verbally affirmed their child received VAS, 58.9% (3030) reported their child received VAS at a health centre, 40.1% (2061) from a mobile team going house to house and 1.1% (56) could not recall. Coverage for VAS and measles did not vary significantly by education level of the caregiver, gender of the child or caregiver’s occupation. The most frequent sources of information about MCHW were community health workers (39.8%; 2486/6243), town criers (31.3%; 1956) and radio (4.5%; 903). Of the caregivers interviewed, 3.8% (1945/5147) and 3.9% (209) reported their child did not receive VAS or measles vaccine respectively. The major reasons given were not knowing about the MCHW (VAS: 27.1% 55/203; measles: 26.1% 55/211) and being out of the area (VAS: 21.2% 43/203; measles: 19.0% 40/211) (Table 2).
Table 1. Comparison of coverage by Ministry of Health Sanitation reports vs the post event coverage survey District
Bo Bombali Bonthe Kailahun Kambia Kenema Koinadugu Kono Moyamba Port Loko Pujehun Tonkolili UWA RWA Overall
Vitamin A supplementation (VAS)
Measles
Target population 6–59 months
6–59 VAS doses given
MoHS VAS coverage %
PECS VAS coverage % (95% CI)
Target population 9–59 months
9–59 months immunized
MoHS coverage %
PECS measles coverage % (95% CI)
98 108 79 479 25 200 70 475 50 921 98 610 60 144 82 245 53 323 91 219 50 417 77 946 250 122 145 790 1 234 000
99 628 79 605 25 488 70 382 50 958 98 806 60 250 82 746 54 279 91 308 50 912 78 825 257 373 135 052 1 235 612
101.5 100.2 101.1 99.9 100.1 100.2 100.2 100.6 101.8 100.1 101.0 101.1 102.9 92.6 100.1
95.2 (94.2–96.2) 92.9 (91.9–94.0) 92.8 (91.8–93.9) 93.5 (92.5–94.6) 98.6 (97.6–99.6) 84.2 (83.2–85.3) 98.0 (97.0–99.0) 91.7 (90.7–92.8) 91.6 (90.5–92.7) 96.2 (95.2–97.2) 99.8 (98.8–100.8) 69.4 (68.3–70.5) 93.6 (89.6–91.6) 90.6 (92.6–94.7) 91.9 (90.9–92.9)
91 859 74 417 23 595 65 987 47 677 92 329 56 313 77 007 49 927 85 409 47 205 72 981 234 191 136 504 1 155 401
93 413 76 452 23 978 65 884 47 755 92 638 56 468 77 554 50 870 85 531 47 720 73 865 254 097 133 380 1 179 605
101.7 102.7 101.6 99.8 100.2 100.3 100.3 100.7 101.9 100.1 101.1 101.2 108.5 97.7 102.1
96.1 (95.1–97.1) 92.3 (91.3–93.4) 92.1 (91.1–93.2) 94.1 (93.1–95.2) 98.2 (97.2–99.2) 85.4 (84.4–86.5) 97.9 (96.9–98.9) 91.6 (90.6–92.7) 89.6 (88.5–90.7) 96.1 (95.1–97.1) 99.8 (98.8–100.8) 69.8 (68.7–70.9) 93.7 (89.2–91.6) 90.2 (92.7–94.8) 91.6 (90.6–92.6)
MCHW: Maternal and Child Health Week; MoHS: Ministry of Health and Sanitation; PECS: post event coverage survey; VAS: vitamin A supplementation.
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A total of 5621 caregivers were interviewed of the targeted 5880: 4.3% of Ennumeration Areas (18/420) could not located by the PECS surveyors. Completed interviews were obtained from 5342 caregivers of children 6–59 months old (47.8% male, 52.2% female), including 5292 children 9–59 months old (47.8% [2553] male, 52.2% [2789] female). The date of birth of 19.4% (1038) of children was estimated by a calendar of local events. Most caregivers were mothers: 76.1% (4064) or grandmothers: 9.9% (531) and 68.3% (3649) had had no formal education. The most common caregiver occupations were farming (55.5%; 2964) and petty trading (21.3%; 1136). Significantly more caregivers were Muslim (73.0%; 3902) than Christian (26.4%; 1401) (p,0.0001).
91.4%; 3565/3902) vs Christian 93.6%; 1320/1410). There was no significant difference in VAS coverage estimated by the current PECS vs the 2011 PECS (92.4%; 812/879).18 Overall coverage for measles vaccination by card confirmation was 91.6% (4849/5292; 95% CI 89.6–93.6%) (Table 1) and by verbal affirmation was 96.1% (5083/5292; 95% CI 94.1–98.1%). Vaccine confirmation by card in Tonkolili was significantly lower vs all other districts (p,0.0001). There was no significant difference in measles coverage in children 9–11 months old (95.7%; 203/212; 95% CI 94.6–96.8%) vs 12–59 months old (96.1%; 4880/5080; 95% CI 95.0–97.2%) by caregiver’s religion (Muslim: 96.3% [3757/3902] vs Christian 96.7% [1364/1410)].
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Adverse events Health workers reported AEFIs from the MCHW in 0.01% (109/ 1 179 605) of children, most commonly fever: 0.006%, (79/ 1 179 605) pain at the injection site: 0.002% (32/1 179 605) or rash: 0.0008% (9/1 179 605). One health worker in Pujehun district reported a child had a high fever and died 3 days later. During the PECS 1477/5147 caregivers (29.1%) reported a total of 121/1490 AEFIs; significantly more than reported to by the MCHW p,0.0001). Common AEFIs reported during the PECS included fever (24.9% 1266/1490) and rashes (2.4% 121) (Table 3).
Overall VAS coverage reported by the Ministry of Health was 100.1% (1 235 612 capsules used for a target population of 1 234 000) (Table 1). Coverage of VAS in 6–11 month olds was 86.4% (135 820/157 197) and in 12–59 month olds was 102.1% (1 099 792/1 076 803).
Table 2. Reasons given by caretakers during the post event coverage survey for why children did not attend Maternal and Child Health Week (MCHW)
Reason Did not know about the MCHW Child was out of area Unknown Journey was too far Child was ill Too much work at home Refusal The line was too long Health facility ran out of vaccine
VAS n¼203
Measles n¼211
n (%) 55 (27.1) 43 (21.2) 28 (13.8) 24 (11.8) 24 (11.8) 15 (6.9) 7 (3.4) 3 (1.5) 3 (1.5)
n (%) 55 (26.1) 40 (19.0) 41 (19.4) 23 (10.9) 20 (9.5) 17 (7.5) 5 (2.4) 4 (1.9) 5 (2.4)
VAS: vitamin A supplementation.
Table 3. Types and frequency of adverse events following measles vaccination reported by 5083 caregivers interviewed during the post event coverage survey Type
No. cases
% of those vaccinated
Abscess Collapse/Faint Fever Rash Redness Swelling Total
14 3 1266 121 11 75 1490
0.3 0.1 24.9 2.4 0.2 1.5 29.3
Discussion The use of lot quality assurance sampling to identify districts with low coverage during the MCHW and the addition of a 1 day extension helped improve coverage in all the rejected districts. All the rejected lots were in districts that have been rapidly growing due to internal displacement and post conflict employmentseeking migration. Overall, coverage for both measles and VAS was high by verbal affirmation and by card confirmation. Coverage across districts was also high. The disparity in Tonkolili between coverage by verbal affirmation vs card confirmation was investigated and it appeared that health workers had vaccinated and supplemented children promising to return later with the cards when they were less busy but had not done so before the PECS. This practice is unsatisfactory and leaves the caregiver with an inadequate record of their child’s health services. The measles outbreak in 2009–10 had started 2 weeks before the supplementary immunization activities so this interval was reduced to 2.5 years to pre-empt future outbreaks.19 In 2011 there were no reported cases of measles and a total of just six cases by mid-2012. This is encouraging, but in the medium/long term, institutionalizing of effective routine contacts for children at 9 months of age and introducing a second dose of measles vaccination has been recommended. One innovation strategy to increase attendance is the fuller integration of family planning for caregivers accessing routine child health services which is being scaled up nationwide by the Ministry of Health. Significantly more AEFIs were reported during the PECS than the MCHW. As health workers often work in outreach settings during MCHW, they may be less aware of AEFIs. From this remote rural setting, it was unclear whether the one reported death was an AEFI or a coincidental event. The interval between immunization and the presentation of fever is unknown. No autopsy was conducted to ascertain the cause of death but common childhood illnesses such as malaria are a leading cause of fever and mortality in Sierra Leone. The health worker did not consider this death as an AEFI thus it is not represented in Table 3. Some AEFIs can occur up to 45 days post-measles vaccination and thus would not have been recorded during the MCHW or the PECS. Refusals during the MCHW were low, demonstrating a successful communication strategy via the community health volunteers/ workers, town criers and radio. How best to sensitize caregivers of missed children in future MCHWs requires further strategic planning. Identifying alternative communication channels including religious leaders who can explain the benefits of measles vaccination and VAS to their followers may further increase coverage. Identifying Koranic and biblical passages to support the concept of preventative child health care has been attempted in Africa.20 Encouraging and enabling community health volunteers/workers to adapt to caregivers’ occupations and provide services in the late afternoon or very early morning have also been discussed.
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Ministry of Health administrative coverage by tally sheets for measles and vitamin A supplementation
Overall measles vaccination coverage reported by the Ministry of Health was: 102.3% (1 179 605 vaccines for a target population of 1 155 401). Coverage for children 9–11 month olds was 99.0% (77 813/78 599) and 12–59 months olds: 102.3% (1 101 792/ 1 076 802).
F. F. Sesay et al.
Children who were missed in the MCHW have an opportunity to catch up from routine child health services or subsequent campaigns. There is a standard EPI integrated into the routine care. The health facilities provide routine services and the provision of routine VAS integrated into the EPI schedule has since been launched in early 2014.
Administrative coverage and population projections
Limitations of the study Vaccination or supplementation status was primarily determined by recall of caregivers and by card confirmation which may be subject to recall bias. AEFIs may have been misclassified or over-reported by caregivers during the PECS as well as under-reported by health workers during the MCHW. Administrative data used is projected from the denominators of the 2004 population census which is widely considered now to under-represent this target group.
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In May 2012 the MCHW, successfully provided 1.2 million measles vaccines and vitamin A supplements to children, reaching over 90% of eligible children.
Authors’ contributions: FS, MH, IC, PM, AF and AJ conceived the study. FS, IC, WK, HK, TS supported the implementation and trained the surveyors. IC, FS, WK, HK performed the monitoring and supportive supervision. FS, IC and HK coordinated the field data collection. HK and MT prepared EpiSurveyor, and conducted initial data analysis with support from AW. FS drafted the manuscript and MH supervised the data analysis and revised the manuscript. NM, PM, ASK and AF reviewed the paper. All authors reviewed and approved the final manuscript. MH is the guarantor of this paper. Acknowledgements: The authors would like to thank the Ministry of Health and Sanitation, World Health Organization and community health volunteers for supporting the MCHW. Funding: This work was funded by the Canadian International Development Agency (CIDA) through Helen Keller International and United Nations Children’s Fund (UNICEF). Competing interests: None declared. Ethical approval: Not required.
References 1 United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2008 Revision, Highlights. Working Paper No. ESA/P/WP.210. New York: United Nations; 2009. http:// www.slideshare.net/Water_Food_Energy_Nexus/un-world-populationprospects-the-2008-revision-highlights [accessed 18 March 2011]. 2 Pezzoli L, Conteh I, Kamara W et al. Yellow fever and measles post-campaign immunization coverage survey in Sierra Leone, BMC Public Health 2012;12:415. 3 Centers for Disease Control and Prevention. Progress in global measles control and mortality reduction, 2000–2006. MMWR Morb Mortal Wkly Rep 2007;56:1237–41. 4 Sudfeld CR, Navar AM, Halsey NA. Effectiveness of measles vaccination and vitamin A treatment. Int J Epidemiol 2010;39(Suppl 1):i48–55. 5 Imdad A, Herzer K, Mayo Wilson E et al. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database Syst Rev 2010;(12):CD008524. 6 Beaton GH, Martorell R, Aronson KJ et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. Geneva: WHO Administrative Committee on Coordination-Subcommittee on Nutrition; 1993. 7 Statistics Sierra Leone, ICF Macro. Sierra Leone Demographic and Health Survey 2008. Calverton, MD, USA: SSL and ICF Macro; 2009. 8 Statistics Sierra Leone and UNICEF-Sierra Leone. Sierra Leone Multiple Indicator Cluster Survey 2010, Final Report. Freetown, Sierra Leone: Statistics Sierra Leone and UNICEF-Sierra Leone. 2011. http://www. childinfo.org/files/MICS4_SierraLeone_2010_FinalReport.pdf [accessed 3 December 2012].
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The Ministry of Health reported coverage over 100% for both VAS and measles. This may be due to under-projection of the target population from the 2004 census, vaccinating children outside of the target age, and/or due to over-reporting by health workers. Future PECS will be necessary to measure coverage since administrative data is prone to these errors.21 A PECS can also evaluate quality of implementation, caregiver-awareness and health workers’ practices. Adjustment of population estimates is an important component of macro-planning: ordering an appropriate number of vitamin A capsules, albendazole and vaccines and micro-planning for more accurate allocation of supplies within districts to prevent shortages during the MCHW. In rapidly urbanizing countries the migration of children may play a major role in measles transmission.22,23 There were eight confirmed measles cases in 2012. The vaccination of the ‘hard to reach’ children in new settlements, urban slums and rapidly urbanizing towns should be further prioritised. Some districts, notably Tonkolili and Bombali, have undergone rapid population growth since the opening of the iron ore mines and railroad. This has increased the health workers’ workload and also contributed to attrition as they leave for more lucrative positions within the industrial sector.20 Rapid urbanisation, greater than the 2.4% projected by the national census, and rapid reduction in child mortality pose challenges for estimating target populations and makes coverage based solely on projected populations difficult to interpret. The cost incurred for the lot quality assurance sampling, PECS and MCHW were US$21 965, US$25 935 and US$1 471 245 respectively, for a total of US$1 518 597 and a cost per child 6–59 months of US$1.23. The Government of Sierra Leone contributed 2 billion Leones (US$465 000) to the MCHW following the advocacy visit conducted by the Measles and Rubella Partnership. Leadership by the Ministry of Health demonstrated government ownership and the critical importance of successful collaboration with non-governmental organizations, United Nations agencies and district councils. The Government of Sierra Leone and partners should continue to implement the MCHWs, perform PECSs, identify missed children and increase accessibility to routine child health services to enable universal coverage.
Conclusions
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9 UNICEF, Sierra Leone, Ministry of Health and Sanitation. Report on the Nutritional Situation in Sierra Leone. 2010. http://wcaronutritionsurveys. files.wordpress.com/2011/03/sierra-leone-nutrition-survey-jun-aug2010.pdf [accessed 3 December 2011]. 10 Moss WJ, Griffin D.E., Global measles elimination. Nat Rev Microbiol 2006;4:900–8. 11 Ciccone FH, Carvalhanas TR, Afonso AM et al. Investigation of measles IgM-seropositive cases of febrile rash illnesses in the absence of documented measles virus transmission, State of Sa˜o Paulo, Brazil, 2000-2004. Rev Soc Bras Med Trop 2010;43:234–9 http://www.scielo. br/scielo.php?script=sci_arttext&pid=S0037-86822010000300004&lng= en&nrm=iso&tlng=en [accessed 28 January 2010].
13 Flugsrud LB, Rłd TO, Aasen S, Berdal BP. Measles antibodies and herd immunity in 20- and 40-year-old Norwegians. Scand J Infect Dis 1997;29:137–40. 14 Pickering LK, Baker CJ, Freed GL et al. Immunization programs for infants, children, adolescents and adults: clinical guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:817–40. 15 WHO. Monitoring Immunization Services using the Lot Quality Technique. Geneva: World Health Organization; 1996. 16 WHO. Department of Immunization, Vaccines and Biologicals, Vaccine Assessment and Monitoring Team. Immunization Coverage Cluster
17 Koroma DS, Turay AB, Moigua MB. Republic of Sierra Leone 2004 population and housing census: analytical report on population projection for Sierra Leone. Freetown, Sierra Leone: SSL; 2006. 18 Hodges MH, Sesay FF, Kamara HI et al. Large scale vitamin A supplementation coverage knowledge and barriers reported by post event coverage surveys in Sierra Leone. Glob Health Sci Pract June 26 2013;1:172–9 10.9745. 19 WHO, UNICEF. Joint Annual Measles Report. Strengthening Immunization Services through Measles Control; 2010 http://www. measlesrubellainitiative.org/wp-content/uploads/2013/06/MRI-2010Annual-Report.pdf [accessed20 July 2012d]. 20 Murray CJ, Shengelia B, Gupta N et al. Validity of reported vaccination coverage in 45 countries. Lancet 2003;362:1022–7. 21 Ayoya MA, Benedech MA, Baker SK et al. Determinants of high vitamin A supplementation coverage among pre-school children in Mali: the National Nutrition Weeks experience. Public Health Nutr 2007;10: 1241–6. 22 Yame´ogo KR, Perry RT, Yame´ogo A et al. Migration as a risk factor for measles after a mass Immunization campaign, Burkina Faso. Int J Epidemiol 2005;34:556–64. 23 Hodges MH, Sonnie M, Turay H et al. Maintaining effective mass drug administration for lymphatic filariasis through in-process monitoring in Sierra Leone. Parasit Vectors 2012;5:232.
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12 Peng ZQ, Chen WS, He Q et al. Evaluation of the mass measles vaccination campaign in Guangdong Province, China. Int J Infect Dis 2012;16:e99–103. http://www.sciencedirect.com/science/article/ pii/S1201971211002177 [accessed 28 November 2011].
Survey: Reference Manual. Geneva: World Health Organization; 2005. http://apps.who.int/iris/handle/10665/69087 [accessed 25 May 2012].
