The Race to
Reach all eligible Children with
Just two drops of Oral Polio Vaccine
2005 NIDs PHASE I
February 2005
Launching of NIDs
Deputy Minister for Health
Bus stop vaccination team
Director General Ghana Health Service
WHO Representative on supervision
BY WHO GHANA; TECHNICAL REPORT, March 2005
EXECTIVE SUMMARY
Ghana has been involved in the Global Polio eradication Initiative through National
Immunization Days since 1996. Accelerated campaigns in form of synchronized House – to –
House NIDs commenced in 2000. The last polio case in Ghana was reported in September 2003,
from Atwima district in Ashanti Region. The quality of rounds has improved tremendously, and
more and more children were reached in every round. The sensitivity of AFP Surveillance is
satisfactory regarding timely notification and investigation, but has been sub-optimal regarding
(quantity) adequate specimen collection from three of the ten regions in 2004.
The role of WHO country office is to provide technical support and guidance towards
implementation of quality NIDs at the national level which translates to district and sub district
levels. Coordination of planning through ICC, revision of technical tools to guide standard
implementation of activities at Pre, during and Post NIDs including support visits were made to
Regions. Support visits were made by WHO officers in Western, Central, Greater Accra and
Eastern, Volta, Northern, Upper East and Upper West Regions particularly to prioritized districts
to assist regions and districts in pre-NID assessment for vaccine and cold chain inventory,
development of micro-plans, support in NID trainings and supervision / monitoring of the
immunization campaigns. Technical support on routine immunization and Integrated Disease
surveillance was also provided at all levels.
Micro-planning at National level commenced early but delayed in most regions. Funds
were released to regions only two weeks prior to NIDs implementation which has limited the
social mobilization activities in districts for the NID. However, the regions and districts prefinanced Micro-planning trainings and some aspects of social mobilization. Distribution of
logistics (Field guide, tally sheets / NID tools, GV, chalk and vaccines) to all levels was timely.
Active social mobilization activities delayed in all regions.
In process rapid assessment was conducted in all districts by the supervisors except team
supervisors, which helped to vaccinate missed children before the end of the round and End –
process rapid assessment was also conducted. Trained Independent Monitors were assigned to
districts to monitor and collect relevant data to determine quality of the NIDs.
First round of NID was conducted from 25th – 27th February and a total of 5,715,817
children age 0-59 months were vaccinated with a coverage of 104%. As a special strategy to reach
every child, many districts started the activities 2-3 days before the due dates particularly in the
Hard-to-reach-areas (HTRAs), markets and schools. The lowest District coverage recorded was
82.4% in Central region (KEEA). Total zero dose children were 55,851 and made of 1 % of total
vaccinated, and 97% of the zero doses were in 0 –11 months and 3% 12 – 59 months respectively.
The cold chain status has been very good in all the districts and there were only report of VVM
change to stage 3 from supervisors.
Main Observations
Strengths
•
Improvement in documentation of NID activities – Micro plan, POA, Maps, NID
Correspondences, Minutes of meetings, training agenda etc
•
Micro-planning training conducted in all Regions and Districts
•
High level of political commitments from National to the district level.
•
Involvement of Assemblies, NGOs and other sectors in NIDs with positive outcome in
most districts e.g. transport, personnel, fund support.
•
Pre-financing of training and some aspects of social mobilization in the regions and
districts
•
Good cross border meetings held with Bukina Faso and Cote d’Ivoire counterparts
•
Adequate cold chain logistics, vaccines, Provision of T-Shirts for volunteers, which
served as incentive and form of identification. Marginal increase in volunteers allowance
•
Considerable improvement in team supervision in most sub-districts
•
Improved data collation and timely transmission from districts to the region and to
national level.
Weakness / Constraints
•
Delay in commencement of active social mobilization due to delay in release of funds.
•
Increase in fuel price in the country affected cost of transportation
•
Delay in displaying banners and/or posters in some districts
•
Non-use of sketch maps by some teams and team supervisors
•
Inadequate supervision of teams in some sub-districts
•
Gentian violet mark on children fades easily
•
Increasing NID fatigue among caretakers / mothers leading to refusals.
•
Delayed micro-plan training in few districts.
•
Low level of practical oriented training (role plays and demonstrations) of volunteers in
some sub-districts.
Key recommendations
•
Early release of fund to all levels in subsequent rounds of NIDs, Increase in funding to
take care of increased price of fuel.
•
Intensify social mobilization activities with emphasis on need for extra doses to reduce
caretakers / mothers fatigue and resistance.
•
Continue effort to improve EPI/NID quality and in reaching ALL eligible children
through better understanding and use of recommendation stipulated in the National
guideline, Consider use of Indelible ink as marker than GV
•
Sstrengthen and sustain EPI programme and AFP surveillance/IDSR (and maximize their
use) i.e. through quality Micro planning, staffing, training, facilitative supervision,
constructive feedback, communication, cold chain management etc.
INTRODUCTION
PROGRESS IN POLIO ERADICATION INITIATIVES AND AFP SURVEILLANCE
Expanded Programme on Immunization (EPI) has been introduced in 1978, and the
programme has been operational in all the regions of Ghana since 1985. NIDs have been
conducted since 1996 and more and more children have been vaccinated in every round. The
strategy used to be ‘fixed posts’ before 1999. Since 1999 the strategy was changed to ‘house to
house’ visit by vaccination teams to reach all target children. Following good quality of NIDs in
1999, 2000 and 2001, the wild polio transmission was interrupted in Ghana, and only 1 WPV was
reported in 2000.
The sensitivity of AFP Surveillance also improved over the years and no WPV was
reported in 2001, 2002. In 2003, 8 wild polioviruses were isolated in six regions namely Northern
Region (3), Ashanti (1), Western (1), Eastern (1), Brong Ahafo (1) and Greater Accra (1). The index
case was related to virus strain circulating in Nigeria and Niger, which indicated importation of
wild poliovirus. To interrupt the transmission, 4 rounds of Supplementary Immunization
Activities (2SNID/2NID) were conducted in 2003 and 4 rounds of NID were conducted in
(February- March, October-November) 2004.
Figure I: NUMBER OF CHILDREN VACCINATED AND NUMBER OF WILD POLIO
VIRUS CASES REPORTED SINCE 1996 IN GHANA
Ghana : No of children vaccinated and # of Wild
Polio Virus
23
9
8
2
3
1
0
0
0
0
0
0
25
20
15
10
5
0 0
19
96
19
97
19
98
19
SN 9 9
ID
-0
N 0
ID
SN 00
ID
-0
N 1
ID
SN 01
ID
S N 02
ID
-0
3
N
FE
ID
B/
M 03
AR
O
ct 04
/N
ov
04
6000000
5000000
4000000
3000000
2000000
1000000
0
R1
R2
WPV
AFP SURVEILLANCE INDICATORS
100
2.5
80
2
60
1.5
40
1
20
0.5
0
% Timely specimen
collection
Non-Polio AFP rate
3
0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Non polio AFP rate
% timely specimen collection
Figure 2: AFP Surveillance indicators National level (Source National Surveillance unit, GHS)
WHO’s role is to provide standard guideline on quality NIDs implementation to sustain
interruption of wild poliovirus transmission through provision of technical support and
coordination. WHO officers made visits to Western, Central, Greater Accra, Northern, Upperr
East, Upper West, Volta and Eastern Region particularly to prioritized districts to assist regions
and districts in pre-NID assessment for vaccine and cold chain inventory, development of
micro-plans, support in NID trainings and supervision / monitoring of the immunization
campaigns. Technical support on routine immunization and Integrated Disease surveillance
was also provided at all levels.
WHO facilitated the independent monitors training and facilitated coordination of their
assignments and follow up of reports. The School of Public health identified 20 Senior
graduating class from the MPH course (2 per region) and the Rural Training school identified
55 monitors to work in the Northern Sector of the country (one per each district). Technical
orientation was provided with WHO’s support and Ghana Health Service EPI Program. In
addition 3 staffs from CDC Atlanta participated as independent monitors while 3 are now
working as STOP teams in the regions who participated as independent monitors. Partners
from USAID also took part in the monitoring of NIDs after technical brief from WHO.
All regions conducted the 1st round of the synchronized National Immunization Days
along with the other adjoining countries from 25th – 27th March 2005. The house-to-house
strategy was used during the round to reach children 0 –59 months in households, schools,
markets, farms, etc. In some places NIDs commenced 2-3 days earlier as a strategy to get
children vaccinated in hard-to-reach-areas, markets and schools. In some places like borders
and hard-to-reach areas vaccination continued 1-3 days later.
PRE-NIDS ACTIVITIES
Micro plan
National micro-plan was conducted with participants from all Regions at a workshop
held 17th December 2004. Micro-planning training and development of micro-plans was
conducted at Regional and district levels from 1st Feb – 18th Feb 2005. Micro-plans were
developed based on budgetary guide developed at the National level and consideration for
population density and hard to reach communities.
Developed micro plan drafts reports were to contain: sketch maps of their respective
areas, logistic spread sheet, POA leading to the campaign including social mobilization, cross
boarder activities, HTRAs/population and envisaged strategies to use. Micro plans were revised
where necessary before the second round. While most districts had narrative micro-plans
indicating details of strategies for reaching the children a few had only time line of activities.
Training
Quality issues on HH campaign were discussed e.g. Supervision, mapping and
movement plans, marking, OPV administration, VVM and cold chain management,
recording/tallying and reporting and key messages to care takers (routine EPI, 2nd round etc). One
sheet vaccination guide were given to volunteers and used as training material.
Communication on NIDs
Regional and Districts executives were briefed and provided support for the NIDs.
Schedules of activities for social mobilization were developed and mostly implemented at all
levels commencing two weeks pre NIDs.
The national launching of the NIDs by the deputy minister of Health was held in Atwima
district of Ashanti region on 16th February 2005. The launching was also attended be other
partners including the Danish Ambassador to Ghana.
FM Radios announcements on NIDs in English and local languages were aired few days
pre and during NIDs. Strategically banners in all sub districts were mounted though this was
delayed in most districts because they were not available on time. Public Address system were
mounted on vans and used to disseminate information on NIDs in some communities targeted.
Gong- Gong beating was done in most communities in all sub districts
Announcements and letters on NIDs were written and sent to key figures and public
institution e.g. District Assembles, school, churches, mosque etc. Banners and posters were
produced and distributed to all sub-districts though this was delayed due to late funding.
Cold chain/logistics
There were adequate cold chain logistics and vaccine arrived timely for this round at all
levels. Freezing of ice packs started on time in most sub-districts. A few districts had erratic
power supply from the National grid and alternative power sources were used. Transport needs
were mostly inadequate in many districts. Transport needs were complicated by the recent fuel
price increase in the country.
Funding
Funds arrived late for micro-planning, social mobilization and training but early enough
for implementation from national to the regional level and from region to districts in most
regions. All regions pre-financed micro-planning, training and some aspects of social
mobilization. Most districts received financial and material support from the district assemblies
and in few cases from non-governmental organizations. The support from district assemblies and
other partners at the district level assisted significantly to reduce the problem resulting from fuel
price increase.
Cross-border activities
Cross-border, meetings with international border counterparts were planned and
conducted at district level. Cross-border meetings were held with counterparts at district level
with neigbouring countries of Togo, Bukina Faso and Cote d’Ivoire. Joint launching of the round
1 NIDs at Regional level was done by Burkina Faso and Ghana at Paga (Ghana border town).
IMPLEMENTATION
The first round of the NIDs was implemented from 25th February 2005. House-to-house
strategy was used to deliver OPV vaccine to children 0-59 months. In some places like schools,
hard to reach areas, markets immunization commenced 1 –2 days before or continued 1 –2 days
later. At international borders, immunization started on 24th February and continued till 28th
February in this round. Children immunized were marked with GV paints on the left little finger
and the houses marked according to the National Guidelines. Teams were also assigned to cover
markets, schools, lorry stations and check points border posts, etc.
NID RESULTS
During first round, 5,781,560 children in 0-59 months were vaccinated. The national
coverage was 104%. Total zero dose children was 1% and is made up of 97% and 3% among the 0
–11 months and 12 – 59 months children respectively.
From the end-process rapid assessment of independent monitors 2.0% of children were
unvaccinated (0 – 11 months 0.8% and 12 – 59 months 1.3%) and 2.4 % houses not reached.
Among the children not vaccinated, the reasons for non-vaccination were; Child absent at time ot
team visit (47.3%), home not visited (14.6%) and home not revisited (26.4%). Among the refusals,
beliefs (61.5%) was the most mentioned reason.
The caretakers that were aware of the NIDs before arrival of the teams was 85% and the
common sources of information was radio and television 84.3%, Health workers (45.2%) and
Gong-Gong beating (40.6%).
The cold chain maintenance has been good in every region and none of the districts
reported major problem regarding VVM change to stage 3 or 4.
In-process assessment showed that out of 1,337 teams seen by monitors 85.9%) had at
least one person recruited from the local area, 55.72% had maps and used the maps, 4.21% had
vaccine stock out, 0.45% were found using OPV in stages 3 & 4. Team supervisors visited 80.84%
teams at least once in a day.
Main achievements
•
Improvement in documentation of NID activities – Micro plan, POA, Maps, NID
Correspondences, Minutes of meetings, training agenda etc
•
Micro-planning training conducted in all Regions and Districts
•
High level of political commitments from National to the district level.
•
Involvement of Assemblies, NGOs and other sectors in NIDs with positive outcome in
most districts e.g. transport, personnel, fund support.
•
Willingness of many district Assemblies to provide fund to take care of recent fuel price
increase in the country.
•
Pre-financing of training and some aspects of social mobilization in the regions and
districts
•
Good cross border meetings held with Bukina Faso and Cote d’Ivoire counterparts
•
Adequate cold chain, logistics and vaccines,Provision of T-Shirts for volunteers, which
served as incentive and form of identification.
•
Considerable improvement in team supervision in most sub-districts
•
All areas were accessible due to good weather – very little rain.
•
Marginal increase in volunteers allowance
•
Improved data collation and timely transmission from districts to the region and to
national level.
Weakness
•
Delay in commencement of active social mobilization due to delay in release of funds.
•
Delayed micro-plan training in few districts.
•
Low level of practical oriented training (role plays and demonstrations) of volunteers in
some sub-districts.
•
Supervision has been sub-optimal in some districts.
•
Non-use of sketch maps by some teams and team supervisors
•
Low level of commitment by volunteers particularly in urban areas e.g. Accra, Tema. Not
enough effort is made to ensure that houses that need to be re-visited are re-visited. A lot
of assumption that children absent from home would have been vaccinated outside.
•
Gentian violet used for identifying vaccinated children fades easily
•
Inadequate deployment of teams to large markets.
•
Most mothers/caretakers were not reminded about dates for 2nd round and to take their
children for routine immunization.
Constraints
•
Delay in getting funds to regions for pre-NID activities.
•
Increase in fuel price in the country affected cost of transportation and affected quality of
supervision in some sub-districts.
•
Increasing NID fatigue among caretakers / mothers leading to resistance.
•
Highly mobile population (traders, fishing communities, etc) making it difficult for teams
to reach every child.
•
Competing priorities / activities at National, Regional and District levels around NID
period affecting adequate attention.
•
Inadequate vehicles particularly motorbikes in most sub-districts for effective
supervision.
•
Delay in release of vehicles from other sectors in the Districts for the campaign.
Challenges
•
Political instability in neighbouring countries of Togo and Cote d’Ivoire.
Routine EPI
In 2004, 57 of the 110 districts in Ghana achieved OPV3 of at least 80% and 23 districts achieved at
least 90% OPV3 coverage. Some poor performing districts were visited. Factors contributing to
low performance in these districts include:
•
Inadequate manpower to run service in some sub-districts
•
Inadequate transport for immunization outreaches
•
Non-provision of transport money for health staff to undertake outreaches where
vehicles are not available (T&T).
•
Inadequate social mobilization on routine NIDs to create demand by the mothers.
•
Drifting fishing population.
Immunizatio n perfo rmance - 2004
120
100
80
60
40
20
0
B CG
P enta3
OP V3
M LS
YF
0
0
0
0
1
28
50<x<80%
22
53
53
53
53
57
x=80%
88
57
57
57
56
25
x <50%
A ntigen
Source- GHS- EPI
AFP SURVEILLANCE / IDSR
TT2+
During visits to regions, districts and sub-districts the Integrated disease surveillance was reemphasised. Visits were also made to silent districts and strategies to improve surveillance
discussed. At the national level, feedbacks to the lower levels have been strengthened and
notification for 60-day follow-up of cases developed.
Yellow fever surveillance has been stepped up in the country in view of the confirmed case of
Yellow fever reported in Upper Denkyira district of Central Region late in 2004 and Jirapa in
Upper West in January 2005. Most districts report measles to higher levels and take specimens for
investigation.
Active surveillance is not yet adequate in most regions / districts and documentation is still poor.
Most districts do not put enough measures for improving AFP surveillance from the beginning of
the year. Efforts to report AFP are often intensified towards end of the year to avoid being
regarded as silent district.
RECOMMENDATIONS
NID
•
Social mobilization activities should start at all levels, as early as possible and should be
sustained throughout the rounds in future.
•
Early disbursement of funds to all levels in subsequent rounds
•
Increase funding of transportation (fuel) in the budget to take care of fuel price increase
in the country.
•
Retraining of volunteers before to emphasise on areas of weaknesses
•
Consider use of long lasting alternative to Gentian violet in subsequent rounds.
•
All districts with large markets to develop improved strategies for effective coverage of
the markets through team deployment and supervision.
•
Strengthen supervision at all levels, and monitor the supervision very closely and make
team supervisor responsible for missed children in his/her area.
•
Implement corrective measures of the findings by Independent monitors & supervisors
EPI
•
Identify poor performing districts/ sub districts and communities where coverage is low.
NID under 1 population can be used to estimate coverage at the community level.
•
Improve routine immunization coverage particularly in hard to reach areas by improving
transport, training, supervision, and resources allocation (districts to budget T&T for
outreaches).
•
Intensify social mobilization for routine immunization using appropriate IEC strategies.
AFP Surveillance / IDSR
•
Strengthen Active surveillance for Integrated Disease Surveillance through improvement
in supervision by the upper levels.
•
Design and disseminate IEC messages targeting the general public on AFP surveillance.
•
Sustain current feedback mechanism on surveillance.
•
Improve the adequate specimen collection rate for AFP cases with reorientation of district
focal persons (specially regarding adequate quantity) and persons responsible for
specimen collection at the health facilities/or at DCU.
•
Intensification of surveillance activities from the beginning of the year and sustaining it
till end of the year at all levels.
•
Reinvigorate the community based surveillance system through retraining and
supervision in places wheretheir performance is declining.
Acknowledgements
We wish to thank Dr Melville George, WHO Representative in Ghana; Dr M Kamwa,
West Block EPI Team Leader; WHO Team , Dr.Tanimola Akande, Dr Goli Lamiri ,
Mr. Stanley Diamenu, NPO Routine EPI; National EPI Manager, Dr KO Antwi-Agyei,
Dr. L. Ahadzie, National Surveillance Head and all Regional / district / sub-district NID
personnel. We also would like to thank our local partners USAID, UNICEF, CDC staff
and STOP Teams and Independent monitors who participated in the exercise for the
quality of NIDs in Ghana.
Our Special thanks goes to team of rural training school at Kintampo whose
contribution was highly valued and to Dr.T.Akande our WHO Consultant who made
it possible to get all the reports on time.
Annexes:
Result of NIDs round 1 by Region
Map of key indicators
Independent monitors End process summary data
Map of key indicators
D
Vaccine
wastage rate
C
No. OPV Vials
(in doses)
returned
empty
children 0-11
mon.received
OPV before
today
Children 12-59
months
received OPV
for first time
today
Children 12-59
months
received OPV
for before
today
B
Zero dose
children (%)
A
Total children
0-59 months
vaccinated
with OPV
T
children 0-11
mon.received
OPV first time
today
Population 0-59
months from
previous
maximum NIDs
REGION
Target
DATE: 25th - 27th March 2005
E=
(A+B+C+D)
F
G
H
Greater Accra
799,997
5,968
149,681
561
730410
886,620
0.74
949,220
6.59
Ashanti
931,576
12,234
150,852
77
805142
968,080
1.27
1,096,100
11.68
Central
522,831
4,191
87,855
53
441658
533,757
0.80
592,543
9.92
Upper East
184,812
1,722
28,825
118
157386
188,051
0.98
196,090
4.10
Upper West
309,035
3,232
51,284
66
251209
305,791
1.08
323,265
5.41
Northern
650,173
6,304
120,158
83
527705
654,250
0.98
679,571
3.73
Brong Ahafo
568,615
5,888
91,387
115
491884
589,274
1.02
620,612
5.05
Volta
366,654
5,357
54,034
159
264655
324,205
1.70
104,626
Western
651,134
5,129
124,612
26
524092
653,859
0.79
709,740
7.87
Eastern
597,786
3,551
96,813
13
511146
611,523
0.58
666,785
8.29
TOTAL
5582613
53,576
955,501
1271
4,705,287
5,715,410
0.96
5,938,560
120
1.8
1.6
100
1.4
80
1.2
1
60
0.8
40
0.6
0.4
20
0.2
OPV coverage(%)
Zero dose(%)
TA
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