INTRODUCTION · Web viewThe antigens currently offered in Kenya routine immunization schedule...

REPUBLIC OF KENYA

MINISTRY OF HEALTH

Kenya Measles Rubella Vaccine Campaign Plan, 2015

Prepared by:

Unit of Vaccines and Immunization Services (UVIS)

January 2015

Kenya Measles Rubella Vaccine Campaign Plan, 2015 Page 1

Table of ContentsINTRODUCTION...........................................................................................................................................3

CONTEXT: SITUATION ANALYSIS OF THE IMMUNIZATION PROGRAMME...................................................3

OBJECTIVES, TARGETS AND JUSTIFICATION.................................................................................................5

Overall Objective.....................................................................................................................................5

Specific Objectives...............................................................................................................................5

Targets.....................................................................................................................................................5

Indicators/outputs...............................................................................................................................5

Justification..............................................................................................................................................6

LINKAGES WITH OTHER INTERVENTIONS..................................................................................................10

COSTING AND FINANCING.........................................................................................................................10

LESSONS LEARNED.....................................................................................................................................10

PARTNER SUPPORT....................................................................................................................................11

PLANNING AND IMPLEMENTATION..........................................................................................................11

Campaign Planning and Task Forces......................................................................................................12

COLD CHAIN..............................................................................................................................................13

STRATEGIES...............................................................................................................................................14

COMMUNICATIONS AND SOCIAL MOBILISATION......................................................................................14

Strengthening routine immunisation through the campaign................................................................15

Waste Management..............................................................................................................................15

ADVERSE EVENT REPORTING AND MANAGEMENT...................................................................................15

APPROACH TO MONITORING AND EVALUATION AND DISEASE SURVEILLANCE........................................16

GANTT CHART FOR THE MEASLES RUBELLA CATCH UP CAMPAIGN..........................................................17


INTRODUCTION Kenya is situated in East Africa and is one of the countries in the HOA. It borders Tanzania to the South, Uganda to the West, Ethiopia and South Sudan to the North, Somalia to the Northeast, and the Indian Ocean to the Southeast. It has a surface area of 582, 646 square kilometers and approximately 80% is either arid or semi-arid while only 20% is arable. Kenya’s economy relies on agriculture- both commercial and subsistence and tourism. Livestock production and fishing are additional sources. There are two main religions in Kenya: Christianity and Islam although other religions such as Hindu and African traditionalists do exist. Kenya has 42 tribes with various cultural diversities and traditions. Following the promulgation of the new Constitution of Kenya in August 2010 the country is now administratively divided into 47 counties with delivery of health services devolved to County level.The last Kenya population and housing census was done in 2009 and reported a total population of 38,610,097. The annual population growth rate is estimated at 3.0%, live births 3.6%, surviving infants 3.4%, and pregnant women 4%. The 2015 population is projected to be 44,758,100 of which 1,521,776 will be the number of surviving infants and 18,972,922 is estimated to be the population aged between 9 months and 14 years.

The National health sector in Kenya has undergone major and rapid changes recently due to the 2010 Constitution that mandates devolution (a decentralized system with devolution of budgets and autonomy to the counties), the political reorganization of the country into 47 counties and 290 sub-counties, and the merging of two Health Ministries on March 2013. The Ministry of Health (MOH) is still working towards harmonizing information systems from the two ministries and establishing roles and responsibilities for central and county-level governance. Despite these constraints, the country is committed to the Immunization Programme as a pillar for child survival and development whose main objective is to reduce morbidity and mortality from vaccine preventable diseases (MDG 4). A comprehensive multi-year plan (cMYP 2013-2017); aligned to the country’s 5- year Health Sector Strategic Plan was developed to guide the program towards its objectives. The cMYP will be updated in the course of the year to reflect the introduction of rubella-containing vaccine into its routine immunization schedule.

According to the World Bank, in 2012 the Total Health Expenditure per capita in Kenya was US$45 with an estimated 4.7% of the national budget dedicated to health. Over the years, the immunisation programme has benefited from government and political commitment at all levels. The Government of Kenya currently finances the cost of all traditional vaccines and co-finances the cost of four new vaccines already introduced into the routine Immunization schedule with significant support from GAVI. An estimated 10 million US dollars is spent by the government annually on procurement of vaccines, devices and operational costs.

CONTEXT: SITUATION ANALYSIS OF THE IMMUNIZATION PROGRAMMEKenya Expanded Programme on Immunization (KEPI) was started as a unit within the Ministry of Health in 1980 with the goal of immunizing all children in the country against the six traditional EPI diseases. It was renamed the Division of Vaccines and Immunization (DVI) in 2007 and later Unit of Vaccines and Immunization Services (UVIS) following its


expansion to handle more vaccines in addition to the childhood vaccine preventable diseases in the EPI program; such as Anti Rabies Vaccine, Anti snake venom, Yellow Fever for travellers and at risk communities, and Hepatitis B for high risk groups.UVIS mandate is to coordinate and provide oversight for all immunization services in the country. The overall objective is to avail quality immunization services by providing equitable access to, a n d u t i l i za t i on o f i mm u n i z a t i o n services in a l l sub counties, to reduce morbidity and mortality from Vaccine preventable diseases in line with MDG 4 and 5.

The antigens currently offered in Kenya routine immunization schedule include BCG, OPV, Measles, DTP-HepB-Hib, PCV10, Rotavirus and Yellow Fever (in endemic sub-counties). The last four are significantly supported by GAVI through a co-financing agreement with the Government.

Vaccine preventable diseases still remain a significant contributor of childhood morbidity and mortality in many rural and urban populations in Kenya and a cause of disease outbreaks. One of the GIVS goals is to attain over 95% coverage for routine vaccination to achieve adequate population immunity. The country has made progress towards achieving high immunization coverage; according to WHO UNICEF best estimates, the country reported national DPT3 coverage of 88%, 83% and 76% in 2010, 2011 and 2012 respectively. In 2013 and 2014, the national DPT3 coverage was estimated at 76%and 82% respectively (UVIS administrative Data).For 2012 measles campaign, post-campaign survey showed national coverage of 90% by recall and 88% by finger marking. Figure 1: Administrative Data on EPI Coverage Trends 2010-2014;(UVIS administrative Data)

2010 2011 2012 2013 20140

20

40

60

80

100

120

Routine Immunization Performance 2010-2014

BCG Penta 1 Penta 3 Measles FIC% Covergage

Devolution of health services provides the immunization program with an opportunity to further improve access and utilization of its services to the community through county specific strategies that are tailor made to reach the unreached children. Additional health work force being recruited by county governments including geographically hard to reach regions will further strengthen the immunization system and open new immunizing sites.


The programme currently focuses on increasing immunization coverage, reducing dropout rates and missed opportunities, replacing inadequate and aging cold chain equipment to effectively achieve its goals in the face of other competing child survival programme activities. However, the greatest challenge of achieving high immunization coverage for all vaccines remains reaching a rapidly growing and mobile population often located in hard-to-reach parts of the country.

Kenya conducted its first measles catch-up campaign in 2002; the biggest ever to be launched in Africa, with the primary objective of reducing measles related mortality through the provision of a second opportunity for measles vaccination. Since then, the country has consistently implemented recommended measles control and elimination strategies. The latest measles follow-up campaign was conducted in 2012 and targeted nearly 6 million children aged between 6 and 59months. For this later campaign, post-campaign survey showed national coverage of 90% by recall and 88% by finger marking. In addition, a second dose of measles-containing vaccine (MCV) was introduced into the routine immunization schedule in 2013 as one of the strategies to achieve measles elimination. Currently MCV2 coverage is very low (below 50% ) with incomplete reporting and lack of clarity on applicable denominator being the major challenges. The programme leverages on every opportunity to encourage the public and health workers on the significance of giving the second dose as was done during rotavirus vaccine introduction.

OBJECTIVES, TARGETS AND JUSTIFICATION

Overall ObjectiveTo introduce MR vaccine so as to further reduce morbidity and mortality due to measles and rubella and help the country progress towards global measles and rubella control and elimination goals.

Specific Objectives To vaccinate at least 95% of children aged 9 months to 14 years nationwide with measles

rubella vaccine. To reduce number of Measles and Rubella susceptible. To create demand for measles-rubella vaccine among communities. To orient health workers on MR vaccination campaign and eventual introduction of RCV

into the routine immunisation programme.

TargetsA total of 18,972,922 children aged 9 months to 14 years in all sub-counties represent the total target population for measles-rubella vaccination.

At least a 95% Measles/-rubella coverage among 9 months to 14 years At least a 95% of care givers able to state at least 3 benefits of the campaign

Indicators/outputs % of targeted children who received measles-rubella vaccination Proportion of care givers or parents who can state at least 3 benefits of the campaign


JustificationMeasles is a highly contagious viral disease spread by contact with an infected person through coughing and sneezing. It is estimated that 30 per cent of reported cases develop one or more complications, most among age groups under five and over twenty years. Malnourished children are more prone to developing severe complications due to measles. A well-established measles case based surveillance system exists within Kenya’s unit of disease surveillance and response (DSRU) .Through this active measles surveillance system, rubella cases are investigated and evidence shows an average of 400 cases of rubella are confirmed annually countrywide, but this could be underestimated (Kombich BMC Public Health 2009)).Availability of these data in addition to public awareness on the inherent risks posed by rubella infection has led to mounting pressure on the government to introduce RCV into its routine immunization system.

In 2014 the DSRU investigated 1570 suspected measles cases out of which 557 cases were rubella positive. Over 97% of the confirmed rubella cases with information on age were children under 15 years. By sex distribution, 55% of confirmed cases were male and 45% female. In fact, the proportion of rubella confirmed cases is steadily growing bigger than that of confirmed measles cases as depicted in the table below; confirming the exposure of groups at risk to rubella related complications (CRS).

Table 1. Rubella positive cases & Measles cases-based surveillanceYear Reported

cases of rash illness

Confirmed Measles

Confirmed Rubella

CRS

2012 3486 2604 300 (8.6%) No data

2013 609 154 342 (56.1%) No data

( Up to Nov) 2014

1570 339 557 (35.5%) No data

While the ultimate aim of rubella vaccination is to eliminate CRS occurrence, data on incidence of CRS in Kenya is scanty however, evidence from countries in the epidemiological bloc prior to the introduction of rubella vaccine into RI (Ethiopia, Uganda) and review of measles case-based surveillance suggest that communities in Kenya are at high risk of rubella outbreaks. This evidence supported the decision of the NITAG, during its meeting late last year, to recommend the establishment of CRS diseases burden and the introduction of rubella vaccine into the routine immunization schedule with the aim of preventing rubella related complication among high risk populations.

The NITAG was reassured by the country’s program experience in introducing new vaccines into the routine immunization schedule and considered the 2011 WHO recommendation to all countries that have not yet introduced rubella vaccine, and are providing 2 doses of measles vaccine in routine immunization, or SIAs, or both to include rubella containing vaccines (RCVs) in their immunization programme.


The tables and charts below show the rubella disease burden at country level.

Figure 2. Measles Rubella disease burden at country level




LINKAGES WITH OTHER INTERVENTIONSThe MR campaign is planned for mid-November 2015 and will be integrated with Vitamin A supplementation. Planning, orientation of health workers, advocacy and communication and supervision for the MR campaign and IPV introduction will be done together. The platform for MR campaign orientation will also be used to address other notable gaps in routine immunisation including modalities of increasing coverage for MCV2.

COSTING AND FINANCINGThe cost of the campaign takes into consideration that all training, orientations, advocacy and communication will be done together for the MR campaign, Vitamin A supplementation and IPV introduction into routine immunisation. The campaign operational funds will come from GAVI, Government and other partners; Vitamin A procurement will be supported by the Micronutrient Initiative and GOK. Additional operational fund from the government of Kenya mainly involve staff salaries and amenities costs and so have not been costed. The government will also provide vehicles for the exercise the fuel of which has been included in the budget.

LESSONS LEARNEDThe following were some of the lessons learnt during previous campaigns. The country will capitalise on these as they have helped attain high coverage during campaigns: Multi-sector approach will address any concerns raised by stakeholders and ensure their

support before the exercise commences.


Mixed campaign strategy for House-to-house and fixed post vaccinations that integrated two interventions (OPV and Tetanus) proved to be successful in the counties that carried it out and can be considered for MR campaign.

Local leadership involvement (chiefs, village elders, religious leaders, and media) during social mobilisation helped to lure more care givers to bring children for vaccinations.

National, provincial, and district command centres (data management centres) with WHO technical support to monitor daily coverage of target population at national level help to track progress and intervene on time whenever problems surface.

Involvement of community leadership to spearhead the process enhances community ownership of the programme.

Community Health Workers are integral to community mobilization and program communication.

Engagement of guide from the nomadic community for tracing the current location of the mobile population

Early engagement of local partners and vaccination objectors is critical to programme success.

Massive mass media involvement and awareness of the campaign through SMS messages should be mentioned as best practices

PARTNER SUPPORTWHO, UNICEF, Clinton Health Access Initiative (CHAI) and Micronutrient Initiative (MI) work closely with EPI and will provide technical assistance at national and subnational levels in planning, coordinating, implementing, supportive supervision and monitoring of the MR campaign. These activities will incorporate other local partners taking into consideration their comparative advantage e.g. supplies and logistics, communication, disease surveillance and epidemiology. As already explained, the country will use experience from previous campaigns to engage local and international partners to work with in this campaign. This will include NGOs, CBOs, and other Government Departments, traditional leadership, Church organisations and the business community among others. These will be involved right from planning to evaluation. The country itself has local expertise in relation to epidemiologists, logisticians, laboratory, advocacy and communication and any external support in these areas can be requested should the need arise.

PLANNING AND IMPLEMENTATIONPreparatory activities will include advocacy meetings, planning and orientation meetings, pre and during campaign supportive visits, campaign launch, revision and distribution of data collection tools, production and dissemination of campaign materials. The WHO SIAs readiness assessment tool will be used to monitor preparedness at national and county level to ensure quality SIAs prerequisites are adhered at each level. Stakeholders at national level will be briefed of the campaign through ICC. A national planning meeting targeting national and county health management teams will be conducted to provide and share information on how the MR campaign will be conducted. Similar meetings will be held at sub county level mainly to review micro plans and polish preparedness plans. Relevant ministries, civil society, village and religious leaders, and grassroots organizations will be co-opted into the planning committees at


all levels. Health workers at service delivery level will be trained/oriented on the campaign including introduction of MR and IPV into routine immunisation. Other health worker knowledge gaps regarding routine immunisation will also be addressed during the training. Vaccines and supplies will be distributed to health facilities in such a manner that each facility has its supplies at least one week prior to implementation.

A national launch will be conducted just before the start of the campaign. This will be followed by roll out of the campaign nationwide. All fixed facilities and outreach points established in consultation with community leaders will give MR vaccines and Vitamin A supplementation. Supervisory teams from national, county and sub county levels will be deployed to cover all districts to ensure compliance with requirements and to monitor progress. Data will be collected on daily basis by the sub county data officers, who will compile the data and transmit it to the county and national level data centres on daily basis. AEFI will be monitored continuously during the period, as described below in the section on adverse event reporting. Daily meetings will be conducted at all levels to review data and take any corrective action. Independent monitors will be engaged and deployed to some counties to conduct in process checks using standardized monitoring tools. The campaign will be followed by a Post SIAs Coverage Survey using acceptable methodology and in conjunction with an independent survey entity.

Campaign Planning and Task ForcesThe National Steering committee will oversee the planning and implementation of the campaign. The technical working group is the coordinating body for campaigns and can co-opt other ministries such as Education, Local Government, Social Services and Transport. All the co-opted members will be part of the planning, implementation, monitoring and evaluation process. It has been noted that school children have been effective in disseminating health information to communities therefore the Ministry of Education will play a critical role.

As is the norm, task forces for the campaign with clear terms of reference will be activated at all aspects of planning. The proposed task forces include training, logistics, surveillance, advocacy and communication among others that may be deemed necessary at local level.The country has local expertize in all these areas (WHO, CHAI & UNICEF) and external support can be requested when the need arises.

County and sub county committees will coordinate activities at lower levels and will be encouraged to mobilise local resources, e.g. transport, fuel, local media engagement and personnel from local partners and business community.


Figure 3.Structure of vaccine introduction working groups

COLD CHAINKenya conducted a Cold Chain Assessment in 2014 where capacity gaps were noted, particularly at the Sub county vaccine stores. As a result of increased investment in cold chain capacity, the country has adequate capacity at National and Regional stores. Additional cold chain equipment procured through funding from German government (KFW) ensured all Sub county stores have adequate capacity to store vaccines for 3 months as defined by vaccination policy. Spare parts have also been procured through the same resources to repair non-functional equipment at all levels. A draft cold chain equipment replacement, expansion and maintenance plan has been finalized and will be implemented once HSS funds are availed. The country is planning to replace all gas (LPG) powered refrigerators with electric and solar powered refrigerators in order to help the country own and sustain its cold chain. In addition, refresher training for medical engineering technicians on cold chain equipment management drawn from all counties is slated for February 2015 to ensure durability and functionality of the equipment.

The Central Vaccine Store (new and old combined) has a total net capacity of 126cbm for positive temperature cold storage. Storage requirement in 2015 with introduction of IPV is about 94.5 cbm. Introduction of MR into routine is not expected to require additional cold storage as its packed volume is almost similar to MCV. However during SIAs huge volumes of vaccines are received at once hence huge demand for cold chain capacity. For MR campaign an estimate 52.5cbm will be required. The current storage capacities at central and regional depots will be sufficient for the vaccines ordered. The vaccines will also be scheduled to arrive in country when stocks of other vaccines are not at peak levels.


Steering CommitteeChair: Principal Secretary,

Ministry of Health

Training, Monitoring and Evaluation subcommittee

MOH,WHO,UNICEF,CHAI,

USAID, KEMRI,CDC

Advocacy, Communication and Social Mobilization

MOH,WHO,UNICEF, CHAI, USAID, CDC, Other local

partners

Logistics subcommitteeMOH, WHO, UNICEF,

CHAI, USAID

Technical Working GroupChair: Head UVIS

Members: from subcommittees

Storage capacity for both positive and negative temperature storage at all the 9 Regional stores is adequate.

Table 2.Cold chain requirement versus capacity (National Vaccine store)NATIONAL VACCINE STORE REQUIREMENTS (2013 – 2018) in LitresCapacity 2013 2014 2015 2016 2017 2018Positive temperature Required

36,483

86,935

94,566 97,312 99,674 102364

Positive temperature Surplus

89,517

39,065

31,434 28,687 26326 23,636

STRATEGIESVaccinations will be carried out at all fixed healthcare facilities, temporary fixed sites and outreach points such as schools. Door to door strategy will be employed in some hard to reach communities. All the vaccination teams both mobile and at static facilities will comprise of 4 people i.e. two vaccinators, one data entry volunteer and crowd controller. Each vaccination team will be expected to vaccinate on average 400 children per day. Through micro planning, the hard to reach will be identified and then appropriate strategies employed to reach them e.g. door to door for some vaccination objectors and mobile for hard to reach by distance. Additional teams will be considered for these areas. Community health workers and local leaders will be used to track defaulters. All this will be preceded by an effective advocacy, social mobilization and communication. The following are some of the strategies to be employed;

Mapping of the hard to reach populations by CHWs in consultation with local leadership. Door to door social mobilization activities will be conducted Partner and grassroots organization involvement during the SIAs to ensure good

participation Vaccination per village approach will be employed as it has paid dividend before CHWs and Village elders will be used to track defaulters Special arrangements will be made to cater for objectors due to religious beliefs.

All vaccinated children will be finger marked for ease of identification during the end process monitoring.

COMMUNICATIONS AND SOCIAL MOBILISATIONAdvocacy and communication activities will be undertaken at all levels, IEC materials will be developed, printed and distributed nationwide. Some IEC materials and messages will be translated to the local dialect at county level. Health education and health messages will be transmitted through inter-personal communication, electronic and print media. Media will also be briefed on the MR campaign and subsequent introduction into routine immunization to ensure responsible and informed reporting.

At sub county level Focused Group Discussions (FGD) will held with community leaders/community health workers and the community. Door to Door interpersonal


communication will be conducted for vaccination objectors. All health workers and communities will be sensitized on AEFIs.

Strengthening routine immunisation through the campaign All aspects of the MR campaign will help to strengthen routine immunization through orientation of health workers on all the EPI operational areas, ensuring adequate supplies and logistics. Supportive visits before, during and after the campaign will also be focusing on routine aspects of the programme. The WHO SIAs readiness assessment tool will be adapted to systematically improve on preparation. Health workers at service delivery level will be trained/oriented on the campaign including introduction into routine immunisation of MR and IPV including strategies to increasing coverage of MCV2. Other knowledge gaps identified in routine immunisation will also be addressed during the trainings and supervision.Capacity of district staff will be built in management of cold chain, AEFIs, waste and injection safety. Repair of broken down cold chain equipment will be done during the campaign. Health workers will also be oriented in disease surveillance. Partnerships with stakeholders (NGOs, partners, and other line ministries, political, traditional and local leaders) will further be strengthened including for routine vaccinations.

Waste ManagementThe National policy of waste disposal is either incineration or burn and bury so all facilities will be required to follow this policy. All vaccines will be procured with adequate supply of AD syringes and safety boxes. These will be provided to all facilities before implementation of the campaign. The existing injection safety and waste management system is adequate to accommodate the MR campaign as demonstrated in previous campaigns. Supervisors and monitors will check on proper handling of injection material and safety boxes. Some health facilities without incinerators will transport waste to a central incineration point while others will practice the burn and bury method on site.

ADVERSE EVENT REPORTING AND MANAGEMENTUVIS has AEFI policy and tools that are used to report any suspected AEFI. It is anticipated that with any new vaccine introduction, increased awareness of the vaccine will contribute to an increase in reporting of adverse events, even if they are not serious. Nevertheless, healthcare providers should be aware of the probable AEFI, including coincidental illnesses that can be wrongly linked to vaccination and be prepared to manage and report them. Healthcare providers will be re-sensitized on AEFI reporting and management during pre-introduction trainings to reinforce knowledge and skills in this program area. Through existing systems, UVIS will monitor the situation closely to ensure that any reported adverse effects are investigated and managed appropriately.

Each adverse event will be investigated and efforts made to determine the cause and managed appropriately. An emergency kit will be available at all levels of care including outreach for management of anaphylactic shock.


A communication plan for managing and responding to any possible AEFI will be developed, including identification of focal points at various levels. The ASCM committee will be responsible for the AEFI communication. Risk communication training will be provided to health workers.

APPROACH TO MONITORING AND EVALUATION AND DISEASE SURVEILLANCEContinuous monitoring and evaluation will be an important component for campaign success.Review of data collection tools will be done to capture MR vaccination data for both campaign and routine immunization.Pre campaign preparedness visit will be conducted using preparedness checklist tools to identify any gaps and take corrective action before the actual implementation. During the campaign implementation supportive supervision will be conducted by various stake holders using a standard check list and independent monitors will be engaged as alluded to before and these will take stock of any unvaccinated children including gaps. The results of in-process monitoring will be shared during daily review meetings and corrective actions taken. Sub-county, County data officers and National Supervisors will be responsible for daily data management, analysis and transmission to National level and giving feedback aimed at improving performance.Where performance is below expectation, a mop up operation might be considered. A post SIAs coverage survey using appropriate methodology will be conducted and documented.Kenya has a sound measles surveillance system with all performance indicators on track and plans are underway to establish CRS surveillance in selected sentinel sites within the year.


GANTT CHART FOR THE MEASLES RUBELLA CATCH UP CAMPAIGN

2015Activity Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecDraft MR and OPV NIDs Plan of actionShare draft plan with NITAG and ICCBrief key stakeholders at national level through ICCBrief key stakeholders at all levelsDevelop of communication plan and materialsDistribution of IEC materialMedia briefing and airing of messagesDevelop NIDs guidelines and data collection toolsEstablish CRS Sentinel surveillanceVaccine and supplies arrival in countryFinancial resources received at central levelDisbursement of funds to countiesDevelop county SIAs plansDevelopment of County implementation planMicro-planning at Sub county levelsFinalise budgetImplement training planImplement communication planTransport vaccine to Regional and Sub county storesPre implementation support visit to assess preparedness at all levelsDelivery of MR/Vit A to target population (SIA)Institute monitoring of AEFIs for MRSupportive supervision to all levels during implementationCompile NIDs reportConduct Post SIAs coverage surveySharing Coverage survey report



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INTRODUCTION · Web viewThe antigens currently offered in Kenya routine immunization schedule...

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