HOUSE TO HOUSE MOBILIZATION FOR
SUCCESSFUL MEASLES SIAs: SITREP
AFTER FIVE YEARS IN AFRICA
Bob Davis
Measles/Health Delegate
American Red Cross
WHOM DO WE HAVE TO REACH TO STOP
MEASLES TRANSMISSION?
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Ethno-linguistic minorities and slum
dwellers
Marginalized and ‘floating’ populations,
both urban, peri-urban, and rural
In a nutshell:
Those who don’t watch CNN, don’t listen to
the BBC, and don’t read the New York
Times
•
Solution, for both polio and measles:
next slide
Photo, Prof. Stanley Foster
1
THE HOUSE TO HOUSE STRATEGY
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For GPEI, OPV SIA policy since 2001
PAHO policy in Latin America for measles SIAs: H2H
mobilization in campaigns which vaccinated from
fixed posts and fixed mobile posts
H2H mobilization a best practice, UN supported
measles SIA, Ethiopia, 2010
Used in Red Cross supported campaigns in 10
African countries: Benin, Burundi, C.A.R., Kenya,
Mali, Mozambique, Namibia, Senegal, Tanzania,
Uganda
2
COMMUNITY MONITORING
AS PART OF H2H MOBILIZATION
Wherever possible, line list the 9- to 59-month-olds in
the week before the campaign, using RC volunteers,
then trace defaulters after Day 1 of the campaign to
bring them in from home.
Example from Tanzania:
3
HOUSE TO HOUSE MOBILIZATION (cont.)
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Does H2H mobilization produce better results in
measles SIAs?
Probably: Traditional mass media approaches may
miss the least readily accessible populations, even in
urban areas. Herd immunity is more easily
achievable when we systematically reach
populations who lack, e.g., radio and TV.
Data from 8 countries tend to support this hypothesis.
4
ADMINISTRATIVE COVERAGE ESTIMATES IN DISTRICTS WITH AND
WITHOUT KENYA RED CROSS HOUSE TO HOUSE CANVASSING,
2009 MEASLES CAMPAIGN, NAIROBI
DISTRICTS WITH CANVASSING
DISTRICTS WITHOUT CANVASSING
KIBERA, 57%
DAGORETTI, 64%
KASARANI, 83%
WESTLANDS, 62%
EMBAKASI, 80%
CENTRAL, 68%
PUMWANI, 58%
MAKADARA, 53%
UNWEIGHTED AVERAGE, 73 %
UNWEIGHTED AVERAGE,
61%
COMPARATIVE CAMPAIGN COVERAGE,
NAMPULA PROVINCE, MOZAMBIQUE, 2008
Red Cross Districts
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Target 413,005
Vaccinated 401,604
Coverage 97.2%
Others
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Target 214,481
Vaccinated 188,064
Coverage 87.7%
6
COMPARATIVE CAMPAIGN COVERAGE,
BAMAKO, MALI, 2011
Red Cross Zones
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Target 660,000
Coverage 93.6%
Others
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Target 210,317
Coverage 87.8%
Do these percentages make a difference?
Yes, when herd immunity starts at > 90%
7
RESULTS OF SITE INTERVIEWS WITH CAREGIVERS,
TWO RURAL PROVINCES COVERED BY BURUNDI RC,
2012 SIA
HOUSE
VISITS
RADIO CHURCHES
ALL
RED CROSS
POPULATION
OTHER
VOLUNTEERS
Ruyigi
23
19
7
15
505710
562
Gitega
32
31
23
6
920136
1022
Total
55
50
30
21
1425846
1584
ADMIN COVERAGE ESTIMATES, BURUNDI’S 2012 SIA,
NATIONWIDE AND IN THE FOUR REGIONS
WITH H2H MOBILIZATION
NATIONWIDE
AVERAGE
GITEGA
MAKAMBA
MUYINGA
RUYIGI
103%
104%
116%
106%
115%
AVE + 1
AVE + 13
AVE + 3
AVE + 12
AVE + 8 IN H2H REGIONS,
BASED ON WEIGHTED AVERAGE
SOURCES OF INFORMATION CITED BY MOTHERS,
ABOMEY, BENIN, SEPTEMBER 2011: 1/5 OF ALL
VOLUNTEER MENTIONS FROM THE 4 PERCENT OF
VOLUNTEERS WITH MEGAPHONES!
SOURCE OF
INFO
Public Criers
Red Cross
Volunteers
CUMULATIVE
FIGURES
Monday, 53 mentions by mothers
and other caregivers
49
House to house
Mentions
volunteers, 28
House to house
volunteers with
megaphones,
15
Volunteers at
fixed posts, 6
Radio
37 mentions
Wednesday, 65
mentions
30
Friday, 63
mentions
104
20
10
37
5
87
110
H2H EVALUATED AS BEST PRACTICE,
BENIN CAMPAIGN, 2011
CRITERIA
Effectiveness
Efficiency
Relevance
Feasibility
Reproducibility
Participation of
the partners
ANALYSIS BY CRITERION
- Strong mobilization of the parents of children targeted at the
time of the passage of the teams in the villages
CONCLUSION
Satisfactory
- Better knowledge of the populations of the campaign
schedule, of the strategy of progression of the teams and of
the campaign’s target disease
- Reduction of the number of people reluctant to vaccinate
Satisfactory
- Improvement of the vaccine coverage in the localities
benefiting from the support of mobilizers
- Facilitate the acceptance of vaccination by the populations in
the urban zones
- Valid for all the vaccination campaigns even the JNV polio
- Implementation in the country’s 3 largest cities and in 12
other communes of the country
- Activities mainly undertaken by the volunteers of the Red
Cross, the Community and members of the Church of
Jesus Christ of Latter Day Saints
Satisfactory
Satisfactory
Satisfactory
Satisfactory
WHAT THE DATA SHOWS
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Large chunks of the urban population, and even of
many rural populations, are accessible through
mass media approaches.
However, we are unlikely to achieve herd immunity
in campaigns without house to house mobilization.
In addition to campaigns, intercampaign house
canvassing, 1 ½ years after the SIA, is a promising
possibility to reduce the risk of outbreaks between
campaigns.
METHODS FOR EVALUATING COMPARATIVE
PERFORMANCE OF H2H AND CONVENTIONAL
APPROACHES
BEST OF ALL POSSIBLE WORLDS
PLANET EARTH
30
cluster surveys, intervention and nonintervention areas
Yes;
Admin
Yes,
Spot
coverage estimates
surveys at vaccination sites to ascertain
mothers’ source of info. Cheap and easy;
permits assessment of comparative role of H2H
and other info sources
so far, only in mainland Tanzania, with
results ranging from 72 to 100 percent in areas
with house visiting.
but check your denominators. With data
retention and/or recording errors, check your
numerators as well.
Spot
surveys at vaccination sites to ascertain
mothers’ source of info. Cheap and easy;
permits assessment of comparative role of
H2Hand other info sources
Compare to IM data where available.
WHY WE NEED MORE SPOT SURVEYS
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Cluster coverage surveys, with more scientific rigor, are not
always done, and rarely permit comparison between areas
with and without house visiting.
Admin coverage data are based on high side population
figures (Eritrea) or low side population figures (Uganda).
>>100% coverage = high degree of flakiness; true of ½ of
all districts in Uganda’s 2012 measles SIA.
Data retention by health workers (Senegal, Kampala)
makes it impossible to calculate SIA admin coverage.
COSTING OF HOUSE TO HOUSE
MOBILIZATION
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Vitamin m, the indispensable micronutrient
Single partner funding by American Red Cross is not
a viable option for H2H mobilization to go to scale.
ADDED COST PER BENEFICIARY, H2H STRATEGY, FIVE MOST
RECENT NATIONAL CAMPAIGNS, AVERAGE $0.32. UNIT COSTS
VARY. TANZANIA FINANCED DAR ES SALAAM, WITH LOW UNIT
COSTS. NAMIBIA FINANCED RURAL AREAS.
BENIN,
2011
BURUNDI,
2012
NAMIBIA,
2012
TANZANIA,
2011
UGANDA,
2012
BUDGET FOR
HOUSE VISITING
USD
99,233
USD 154,546
USD 95,759
USD 272,957
(exclusive of
UNICEF
funding)
USD 272,957
BENEFICIARIES
322,572
473,890
166,750
1,687,000
1,300,000
COST PER
BENEFICIARY
USD 0.31
USD 0.33
USD 0.57
USD 0.16
USD 0.21
VOLUNTEERS
WORKING ON
CAMPAIGN
685
3100
1450
2679
2911
CONCLUSIONS
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In areas with H2H mobilization, measles SIA cost per child
rises from ~$1 to ~$1.32 or more.
We need to be selective in choosing areas for H2H.
Selection criteria used by American Red Cross and, in
some countries, UNICEF:
 Underserved populations, especially slums
 Areas with low coverage and/or high cases based on case
based surveillance
 Geographically remote areas
CONCLUSIONS (CONT.)
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Some countries (Kenya, Burkina Faso) have
widespread viral seeding from town to country.
There, it may be necessary there to target whole
cities, not just slums.
In some settings, the dollar goes farther in urban
H2H mobilization (Tanzania vs. Namibia). Where
funding is short, first priority goes to underserved
urban and periurban areas.
THE MAGIC FORMULA
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There is no magic formula for targeting areas to
cover through H2H.
Where viral seeding is well documented, target the
source of the viral seeding.
Where coverage data are reliable, target areas with
low coverage.
Where case based surveillance is good, target areas
with cases (Burundi: 4/17 regions were home to
29/30 confirmed measles cases).
URBAN PARTICULARITIES
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Weekend SIA start is preferable; no traffic jams to tie
up logistics; pulpit announcements on Fridays and
Sundays
Multilingual house visitors and vaccinators are
needed – Dakar, Nairobi, for example.
Mapping of neighborhoods with many migrants and
floating populations, for special emphasis by gov’t,
RC and other partners
H2H CANVASSING
FOR ROUTINE IMMUNIZATION?
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American Red Cross & partners need to consult on
how best to apply lessons learned from SIAs to
routine immunization.
A network of volunteers already exists to sensitize
the community.
Possible modalities: birth registration and follow-up;
periodic village canvasses; linkages to health
facilities for defaulter follow-up
SO WHERE IS H2H GOING?
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Depends on decisions made by the MRI, as by the
GPEI in 2001, when the polio initiative opted for
H2H OPV SIAs.
If H2H mobilization goes global with measles, as
with polio, then more resources and partners will be
needed. You can’t go global on a shoestring, and
you can’t do it with 1 or 2 partners, as at present.
Decision whether to go global with H2H should
predate any WHA resolution. No 1988-2001 gap as
with GPEI, SVP!
THANK YOU/ASANTE SANA/ AMESEGNALEHU/SIYABONGA/
MERCI/OBRIGADO/MUCHAS GRACIAS
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