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Strengthening immunisation services in East Africa through training - Lessons from the ECAVI Vaccinology Course for healthcare workers

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Abstract

Vaccination is a key strategy for prevention of communicable diseases, which contribute more than two-thirds of the U5MR in the East African region. The overwhelming response by HCWs to previous ECAVI vaccinology course adverts, resulting in a growing waiting list of applicants, coupled with representation from beyond Eastern Africa, shows that many HCWs are eager for training on current and new vaccines and how to improve their immunization practices. Kenya and Uganda have recently experienced increased public resistance and negative sentiments against tetanus toxoid, measles-rubella, hepatitis B (Hep B) and oral poliovirus (OPV) vaccines, which may contribute to declining uptake. Of Kenyan and Ugandan children aged 12-23 months, 68% and 52% respectively are fully vaccinated.12-13 In 2014 Uganda rolled out human papillomavirus (HPV) vaccination against cervical cancer; however, only 48% and 1% of the targeted girls respectively were reached for the first and second doses. The Uganda National EPI (UNEPI) attributes this low uptake of the HPV vaccine to inadequate community mobilization and poor HCW knowledge on the vaccine roll-out strategy. However, vaccine hesitancy, vaccine refusal and rumours of adverse events following immunization (AEFI) may have contributed as well. ECAVI aims at improving this situation, by contributing to immunization programmes through strengthening systems and education of HCWs. There are group and plenary sessions with the participants interacting with over 20 facilitators to share views, research findings, experiences, successes, challenges, and formulate possible interventions for improving their own roles which are part of the larger national immunization programmes. The course also promotes education and knowledge among vaccinators, empowering them to be vaccine advocates and immunization champions. To ensure relevance and applicability, the expert facilitators are largely professors and senior lecturers from medical schools, MoH EPI officers, and stakeholders who participate in vaccination-related decision-making at the highest level in Eastern Africa.
Africa Health
11
January 2020
Strengthening immunisation services in East
Africa through training
Lessons from the ECAVI Vaccinology Course for healthcare workers
highlight the importance of continuous professional development
Oliver Ombeva Malande, East Africa Centre for Vaccines
and Immunization (ECAVI) and Makerere University, Rachel
Nakatugga Afaayo, East Africa Centre for Vaccines and Im-
munization (ECAVI), Carine Dochez ,The Network for Education
and Support in Immunisation (NESI), University of Antwerp,
Belgium, Johanna Catharina Meyer, AndrewMunyalo Musyoki
& Rosemary Joyce Burnett, Sefako Makgatho Health Sciences
University (SMU), Pretoria, South Africa The South African Vac-
cination & Immunisation Centre (SAVIC).
Vaccine-preventable diseases (VPDs) are a major con-
tributor to morbidity and mortality in low-income coun-
tries (LICs).1 Vaccination is an important child-survival
strategy especially in high-burden LICs where more than
10 million children under 5 die annually.1-3 Immunisa-
tion, a major pillar for attaining Sustainable Develop-
ment Goal (SDG) 3 (aiming to reduce the under-ve
year-old mortality rate[U5MR]to less than 25/1000 live
births by 2030) can prevent almost three million deaths
annually.4-5 Challenges facing immunisation coverage in
LICs include language barriers, transport-related access
problems, terrain-related accessibility barriers, low edu-
cation and socio-economic status of caregivers, refugee
status, cultural barriers, religious beliefs, young age of
caregivers, population mobility, vaccine hesitancy and
negative messaging.6-11 Research in LICs has identied
healthcare worker (HCW) training as a major interven-
tion needed to increase vaccination coverage.1,2,6,9,11
The resurgence of VPDs which were earlier thought to
be under control, such as measles, has heightened the
need for innovative strategies to control this spread. In
March 2019, 26 districts in Uganda were identied by
the Ministry of Health (MoH) as experiencing recurrent
measles outbreaks. This led to the MoH and Parliament
initiating a measles action plan to combat the re-emer-
gence of the disease in these districts, with enhanced
HCW training and community/social mobilisation
central to this plan.
Defining the problem
The launch of the SDGs in 2016 to replace the Mil-
lennium Development Goals (MDGs), came with the
sad realisation that none of the countries in East Africa
attained MDG 4 that aimed to reduce U5MR by two-
thirds. According to the 2014 Kenya Demographic and
Health Survey, infant mortality was 39/1000 live births
with U5MRof 52/1000 live births, implying that at least
one in every 19 children born in Kenya in 2014 died
before reaching their fth birthday.12 The 2016 Uganda
Demographic and Health Survey reported an U5M-
Rof 90/1000 live births, and an infant mortality rate
of 43/1000 live births.11 While these indicators have
declined across East Africa, the improved child survival
rates are attributed to increases in mosquito net use
among children, and improvements in maternal health,
including increases in the proportion of births deliv-
ered in health facilities assisted by skilled HCWs, and
increases in postnatal care. However, the deaths from
pneumonia, diarrhoea and other VPDs remain high, and
are the actual drivers of child morbidity and mortality.
Measles, a re-emerging VPD in East Africa, currently
poses the biggest challenge to immunisation pro-
grammes around the world. The World Health Organi-
zation (WHO) African Regional Committee has adopted
a regional measles elimination goal for 2020, urging all
countries to achieve an incidence of conrmed measles
of <1 case per million population and to attain the
elimination of measles through achieving and sustaining
measles vaccination coverage of ≥95% at national and
district levels, and supplementary immunisation activity
(SIA) coverage of 95% in all districts.14
Evolution of the ECAVI Vaccinology Course
The East Africa Centre for Vaccines and Immuniza-
tion (ECAVI) is an initiative of HCWs, working under
the auspices of paediatric associations of participating
countries, to promote advocacy, training, research and
strengthening of immunisation programmes in East Af-
rica. Founded in 2014 and registered as an international
non-governmental organisation in both Kenya and
Uganda, ECAVI promotes improved uptake and training
on new and available vaccines, towards the prevention
and control of morbidity and mortality associated with
VPDs and cancers in East Africa. ECAVI plays a leading
role in organising vaccinology symposia during annual
scientic conferences for paediatric associations across
East Africa, and closely partners with the WHO, UNI-
CEF and MoHs in the region, to launch new vaccines
and update vaccination schedules for recommended
Expanded Programme on Immunisation (EPI) vaccines
in the region.
Since 2016, ECAVI, working with partners and
stakeholders, has trained over 500 HCWs through its
annual vaccinology course held over ve days. Of those
trained, 49% are from Uganda, 29% from Kenya, 6%
from Tanzania, 5% from South Sudan, 4% from Nigeria,
3% from Somalia/Somaliland, 2% from Rwanda, 1%
from Ethiopia, and 0.5% each from Sudan and Afghani-
stan. ECAVI plans to hold its sixth vaccinology course
from 22-26 June 2020, in Kampala Uganda. This course
will focus on current and new developments in the use
of vaccines in the East African region, targeting 100
Feature
Immunisation
January 2020
12
Africa Health
HCWs from across East Africa, in line with ECAVI’s aim
of training 1000 HCWs over a period of 10 years. The
course is designed for HCWs working in the eld of vac-
cination administration and delivery [nurses, midwives,
cold chain managers, EPI focal persons, medical doc-
tors, masters students (MPH, MSc, and MMed), pharma-
cists, public health professionals, vaccine programme
administrators] and HCWs who are interested in the
clinical aspects of vaccines and immunisation.
Central to successful organisation of this course, has
been the major role played by two key partners – the
South African Vaccination and Immunisation Centre
(SAVIC) at Sefako Makgatho Health Sciences University
(SMU) in South Africa and the Network for Education
and Support in Immunisation (NESI) at the University
of Antwerp, Belgium. These two organisations have
extensive experience and a great history for supporting
advocacy, training and capacity-building towards im-
proved immunisation systems in Africa. SAVIC and NESI
have been central and pivotal to generation of course
content, course administration, course delivery and the
continuous evaluation and improvement of the course.
The full list of organisations partnering with ECAVI in or-
ganising and running this course include the following:
Makerere University (MU), Kampala, Uganda
SAVIC at SMU, South Africa
NESI at the University of Antwerp, Belgium
Uganda National Academy of Sciences (UNAS)
Kabarak University (KU), Nakuru Kenya
Uganda Paediatric Association
Kenya Paediatric Association
Kenya, Tanzania and Uganda EPIs
Paediatric Association of Tanzania
University of Nairobi (UON), Kenya
The Centre for Health Advancement, Research
and Resource Mobilisation (CHARRM) based in
Kampala, Uganda.
Justification for the course
Vaccination is a key strategy for prevention of commu-
nicable diseases, which contribute more than two-thirds
of the U5MR in the East African region. The overwhelm-
ing response by HCWs to previous ECAVI vaccinology
course adverts, resulting in a growing waiting list of
applicants, coupled with representation from beyond
East Africa, shows that many HCWs are eager for train-
ing on current and new vaccines and how to improve
their immunisation practices. Kenya and Uganda have
recently experienced increased public resistance and
negative sentiments against tetanus toxoid, measles-
rubella, hepatitis B (HepB) and oral poliovirus (OPV)
vaccines, which may contribute to declining uptake.
Of Kenyan and Ugandan children aged 12-23 months,
68% and 52% respectively are fully vaccinated.12-13 In
2014 Uganda rolled out human papilloma virus (HPV)
vaccination against cervical cancer; however, only 48%
and 1% of the targeted girls respectively were reached
for the rst and second doses. The Uganda National EPI
(UNEPI) attributes this low uptake of the HPV vaccine
to inadequate community mobilisation and poor HCW
knowledge on the vaccine roll-out strategy. However,
vaccine hesitancy, vaccine refusal and rumours of ad-
verse events following immunisation (AEFI) may have
contributed as well. ECAVI aims at improving this situ-
ation, by contributing to immunisation programmes
through strengthening systems and education of HCWs.
There are group and plenary sessions with the partici-
pants interacting with over 20 facilitators to share views,
research ndings, experiences, successes, challenges,
and formulate possible interventions for improving their
own roles which are part of the larger national immuni-
sation programmes. The course also promotes education
and knowledge among vaccinators, empowering them
to be vaccine advocates and immunisation champions.
To ensure relevance and applicability, the expert facili-
tators are largely professors and senior lecturers from
medical schools, MoHEPI ofcers, and stakeholders
who participate in vaccination-related decision-making
at the highest level in East Africa.
Content of the course
The course content includes:
Introduction and history of vaccination in East
Africa
Basic immunology of vaccines (immune system,
how vaccines work, current/new vaccines, and
Feature Feature
Immunisation
An ongoing session at the 5th vaccinology course.
Africa Health
13
January 2020
vaccines under development)
Vaccine development and pharmacology (for-
mulation/composition, indications and admin-
istration)
Vaccine evaluation process: Preclinical, Phase
I, Phase II and Phase III trials; and regulatory
approval and registration
Overview of VPDs
Vaccine safety and AEFIs surveillance: Post-
licensure and post-introduction monitoring of
vaccine safety and effectiveness; identication,
management and reporting of AEFI
Vaccine registration and WHO prequalication;
the process of introduction of a new vaccine
into a national immunisation programme: im-
portant considerations; vaccination policy and
immunisation schedules in Eastern Africa
Current safety issues and controversies regarding
immunisation (the media, language, terrain, be-
liefs, age, culture, communication on vaccines,
vaccine hesitancy and negative messaging)
Roles of Gavi, the WHO Global Vaccine Action
Plan, EPI, National Immunisation Technical
Advisory Groups, and national and subnational
SIAs
Vaccines for special groups and populations
(pregnant women, adolescents, adults, and im-
munocompromised patients)
Vaccine related logistics (integrating immunisa-
tion into health systems; cold chain manage-
ment; communicable disease surveillance
Immunisation data management and record
keeping: monitoring and evaluation, data cap-
ture, storage, analysis and sharing
Practical skills training in immunisation, discus-
sion, knowledge and experience sharing among
participants
Participant selection
A maximum of 100 participants per course are targeted
through adverts emailed to members of the various pae-
diatric/medical associations, medical schools, selected
hospitals and EPI ofcials, and also posted on the ECAVI
website and Facebook page. Any interested HCWs
must submit their CV with a formal application and
motivation for attending, to the course administrator. A
selection committee comprising of the course coordina-
tors and course administrator vets the applications and
selects 100 participants for the course.
Teaching methods
The mode of course delivery includes formal lectures;
case studies and scenarios; videos; debate and discus-
sions; practical demonstrations; site visits; participant
presentations; assessments and evaluations. Participants
answer a series of structured questions at the end of
each day to reinforce key messages. They furthermore
complete a daily course evaluation/feedback for future
course improvement. Participants who attend more than
90% of sessions earn continuing professional develop-
ment points and receive a certicate of attendance.
Conclusion and lessons learned
The WHO recently declared vaccine hesitancy, which
results in sub-optimal vaccination coverage and
outbreaks of VPDs, as a threat to global public health.
Vaccination coverage and adherence to immunisation
schedules can be improved through strengthening im-
munisation programmes and educating HCWs. ECAVI’s
vaccinology courses address these issues by training and
empowering HCWs to become local vaccine advocates
and experts throughout the East African region. Mov-
ing forward, engagements with participants from the
various participating countries in the region identied
the following ten focus areas urgently requiring atten-
tion to improve immunisation coverage in East Africa:
vaccine hesitancy and negative messaging; identica-
tion, management and reporting of AEFIs; preventing
re-emergence of measles and tetanus in older children;
introducing Hep B birth dose and rubella vaccine into
national EPIs; preventing polio eradication bottlenecks;
improving inuenza surveillance and vaccination cover-
age; strengthening cold chain systems and preventing
vaccine stock-outs through strengthening transportation/
delivery to rural and remote areas of East Africa; im-
proved HCW training and supervision support; expand-
ing HPV vaccine roll-out and coverage; and improving
maternal vaccination coverage to prevent VPDs in early
infancy.
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Immunisation
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State of the World's Vaccines and Immunization: World Health Organization
  • J M Maurice
  • S Davey
Maurice JM, Davey S. State of the World's Vaccines and Immunization: World Health Organization. 2009.
Uganda Health sector quality improvement framework and strategic plan
  • Moh
MoH.Uganda Health sector quality improvement framework and strategic plan 2015/16-2019/20.