How to … implement a dual vaccine launch – lessons from Ghana

As the first developing country to deliver two immunisation campaigns at the same time, Ghana made history. Here are 10 lessons health officials can learn from the west African state

When Ghana announced plans for the double delivery of pneumococcal and rotavirus vaccines, the international immunisation community was happy but also nervous. The logic was clear: accelerating access to these two vaccines would provide protection from the primary causes of pneumonia and diarrhoea respectively – diseases that rank as the top two killers of under-fives in the world.

However, no other developing country’s health system had successfully managed such a rapid rollout. In the event, Ghana defied the odds in April this year and made immunisation history. This week Tanzania will also attempt to do the double.

In October, Tanzania’s health and social welfare ministry made a fact-finding visit to their counterparts in Ghana to guide their own ‘dual vaccine launch’. Based on meetings with frontline health workers, paediatricians and other officials, here are the top 10 lessons from Ghana for other countries hoping to perform the same feat:

1. Priority number one – build a strong health system

Well-trained and motivated staff are essential, from the national and district level down to the local health worker responsible for running community immunisation sessions. It’s also important to have a comprehensive national immunisation programme already in place. In Ghana and Tanzania, routine vaccines reach 90% of the birth cohort. Tanzanian officials also repeatedly heard about the strong sense of pride in vaccine implementation at the district level in Ghana.

2. Plan ahead

Ghana began planning for the introduction of pneumococcal and rotavirus vaccines three years ago, and submitted its application for funding support from Global Alliance for Vaccines and Immunisation (Gavi) in 2010. Ghana’s Expanded Programme on Immunisation (EPI) – set up by the World Health Organisation in the 1970s to ensure all developing countries have access to basic vaccines – appointed a new vaccine co-ordinator to oversee the planning and implementation process.

Planning also included advocating for government support through budget and resource allocation. Advocating for appropriate legislation can also help: Ghana’s 1998 Children’s Act includes the right to immunisation.

3. Get the message right

Do extensive research into the beliefs, attitudes and existing practices of local communities. This ensures messages are sensitive to their needs.

Ghana understood early on that mothers might worry about the pain that their children might suffer because of having two vaccines not one, as well as the risk of minor side effects such as swelling and fever. Clearly communicating the value of the new vaccines in protecting children against pneumonia and diarrhoea was therefore central to the success of Ghana’s rollout. For example, mothers were told that the rotavirus vaccine is administered orally not through injection.

4. Keep vaccines cool

Vaccines must be transported and stored within a very narrow temperature range. Expanding the ‘cold chain’ of proper refrigeration, from central depositary to local communities, is a priority for delivering two new vaccines simultaneously, especially in countries with sweltering temperatures like Ghana and Tanzania. Lack of storage space, unreliable electricity and the long distances between healthcare facilities could damage the vaccines.

The increased volume of additional vaccines may also mean health workers travelling to immunisation sessions may no longer be able to fit all the vaccines into one insulated cool box. And carrying two boxes on poor roads, by foot or on bicycle, is very difficult. Factor this in.

5. Train health workers

Training health workers to deliver two new vaccines requires careful planning. The ‘vaccinators’ must understand the new dosage schedules; what minor adverse reactions may occur, such as swelling and fever and how they should be treated, and what to do if there are more severe reactions.

For example, rotavirus vaccines are of a greater volume than oral polio vaccines; health workers must take great care to ensure babies do not spit out the vaccine.

6. Provide clear and simple instructions

During the introduction phase, incorporating new multiple-dose vaccines into existing multiple-dose vaccination schedules is complicated. Pneumococcal vaccines require three doses and rotavirus two or three, depending on the manufacturer.

Tell health workers the importance of a minimum age, in some cases a maximum age and a minimum period between vaccine doses.

7. Think of the baby

Health workers should think of the baby (and mother) when delivering new vaccines. Oral vaccines are the most easily accepted by the baby and should be given first, followed by injectable vaccines. Pneumococcal vaccines are more painful than the other injectable vaccines and should be the last ones given to the baby during a vaccination session.

8. Manage data

Whether one or two vaccines are being introduced, managing data is essential to monitoring vaccine supply, administration and impact. Space for new vaccines should be added to children’s immunisation cards. There should be a process for forecasting vaccine demand to help order and procure the right number of vaccines. Nurses should always confirm that specific vaccines are delivered in the same place on a baby’s body, so any problems can be traced to the exact vaccine.

9. Dispose safely of used syringes

Used syringes and other waste associated with immunisation increases with the introduction of two new vaccines. Assess waste disposal capacity nationwide and make early provisions for incinerators. Beware of local politics: for example, district A may not want to share its incinerator with neighbouring district B.

10. Co-ordinate the involvement of partners

There are many organisations with a key role in delivering new vaccines to developing countries. National and local government train health workers, WHO sets standards and monitors implementation, Gavi provides funding support, Unicef procures the vaccines and oversees the cold chain expansion, civil society organisations help deliver the vaccines while community leaders explain to families the need to immunise their children.

For a dual rollout, co-ordination between partners is critical to ensure these different skills are focused on a single mission: delivering the vaccines.

Christopher Endean is digital media manager at GAVI

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