Browsing by Author "Amponsah-Dacosta, Edina"

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    Open Access
    Characterisation of national immunisation programmes in countries experiencing public health emergencies within the WHO African region
    (2021) Chepkurui, Viola; Kagina, Benjamin; Amponsah-Dacosta, Edina; Haddison, Eposi Christiana
    Background: The World Health Organisation (WHO) Africa region experiences multiple public health emergencies (PHEs) annually. PHEs have been documented to affect the provision of health services including immunisation. To our knowledge, there is a scarcity of studies characterising PHEs and the performance of national immunisation programmes (NIPs) in countries within the WHO Africa region that have experienced PHEs. This study assessed PHEs (armed conflicts, disasters, and disease outbreaks) and the performance of NIPs in the context of PHEs using global and regional immunisation targets. Methods Countries in the WHO Africa region that were reported to benefit from the African Public Health Emergency Fund (APHEF) were used as case studies. Data on PHEs and immunisation indicators recorded between 2010 and 2019 in the study countries were extracted from different electronic PHE databases (the Emergency Events database, the Uppsala Conflict Data Program, the WHO Emergency Preparedness and Response, and the Program for Monitoring Emerging Diseases Mail) and the WHO/UNICEF immunisation database, respectively. The PHEs and immunisation indicators were stratified by country and summarised using descriptive statistics. The Mann-Whitney U test was carried out to determine the association between the frequency of PHEs and the performance of NIPs in the selected countries from 2010 to 2019. Statistical significance was defined at p-value < 0.05. Results Thirteen countries were included in this study. A total of 175 disease outbreaks, 288 armed conflicts, and 318 disasters were reported to have occurred within the 13 countries from 2010 to 2019. The Democratic Republic of Congo had the highest total PHE count (n=208), while Liberia had the lowest (n=20). Only three of the 13 countries had a median coverage value for the third dose of the combined Diphtheria, Tetanus, and Pertussis vaccine (DTP3) that had attained the target for ≥90% immunisation coverage. Higher counts of armed conflict and total PHEs were statistically significantly (p=0.03) associated with not attaining MNT elimination. Conclusion PHEs are prevalent in the WHO Africa region, irrespective of the level of a country's immunisation maturity. In absence of effective interventions, PHEs have the potential to derail the progress of NIPs in the WHO Africa region. As we enter the Immunisation Agenda 2030 era, this study advocates for the prioritisation of interventions to mitigate the impacts of PHEs on the NIPs.
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    Descriptive analysis of routine childhood immunisation timelines in the Western Cape, South Africa
    (2021) Blose, Ntombifuthi J; Amponsah-Dacosta, Edina; Kagina, Benjamin M; Muloiwa, Rudzani
    Background: Adherence to the recommended age-specific immunisation schedules is critical in ensuring vaccine effectiveness against vaccine preventable diseases (VPDs). Delays in the uptake of routine childhood immunisations lead to an increase in children susceptible to VPDs. Catch-up vaccination campaigns are strategies aimed at minimising the time at risk of VPDs and alleviating missed immunisation opportunities. However, there is limited data on immunisation timeliness in the Western Cape to contribute to developing effective catch-up vaccination campaigns. Therefore, this study sought to assess the timeliness of age-specific routine childhood immunisation within the Western Cape province of South Africa. Methods: We reviewed 709 participant records from a prospective health-facility based study conducted between 2012 and 2016 in Cape Town, South Africa. The primary outcome of interest was receiving age-specific immunisations ≥ 4 weeks (28 days) of that recommended for age as per the South African Expanded Programme on Immunisation (EPI) schedule. Using secondary data, the prevalence of delayed uptake of immunisations and time-at-risk for each vaccine was determined using proportions and medians and interquartile range (IQR). Multivariable logistic regression (p< 0.05) was used to determine the association between potential socio-economic risk factors and delayed uptake of routine childhood immunisations. Results: A total of 652/709 (91.9%) participants with a median age of 11 [IQR 4.5 – 28.0] months were eligible for analysis in this study. A trend of decreasing immunisation coverage with increasing age was observed among study participants. Notably, a trend of increasing delay in the uptake of routine vaccines and an increasing median time-at-risk of VPDs in age-specific immunisations was observed with increasing age. The highest delay in the uptake of vaccine doses was observed among the 3rd dose of the DTP3 vaccine 163 (34.6%), while the lowest was seen among the birth doses [(BCG – 40 (6.5%) and OPV – 43 (7%)]. The longest median time-at-risk of VPDs, was with the 2nd dose of the measles vaccine dose [12.9 (IQRs 6.7-38.6) weeks] and the lowest was OPV birth dose [6.3 (5.3-9.1) weeks]. Multivariable logistic regression analysis showed that participants who attended pre-school or creche compared to those who did not, were protected against delaying uptake of the 3 rd dose of the Hepatitis B vaccine and 2nd dose of the measles vaccine. While those who had adult caregivers compared to those who had adolescent caregivers, were protected against delaying the uptake of the 1 st rotavirus vaccine dose. Participants from households of low and upper-middle socio-economic IQR compared to high socio-economic status (SES) based on SES scores calculated from household data (i.e., availability and sources of amenities such as water, fuel, toilets, and level of maternal education) were more likely to delay uptake of the 3 rd does of the Pneumococcal Conjugate Vaccine and the 1 st dose of the measles vaccine, respectively. Conclusion: Using DTP3 coverage as proxy for national immunisation coverage, immunisation coverage in this population fell below the recommended 95% immunisation coverage rate. Additional population delays in the uptake of vaccine doses increases the time during which infants and children are susceptible to potential fatal VPDs. The observed increase in delayed immunisation and increased time-at-risk of VPDs, calls for an urgent need to address timing of vaccination particularly in late infancy and in the second year of life. There is an urgent need to develop strategies aimed at mitigating factors associated with delay in uptake of routine childhood vaccines in the Western Cape Province. Since creche attendance conferred protection against the delay in uptake of vaccines, mitigation strategies implemented upstream by the department of basic education, as well as health and immunisation service providers should strengthen collaborations to ensure that timely vaccine uptake among creche attendees is regularly monitored. Where delays are identified, catch-up strategies can be implemented at educational facilities or referrals to immunization clinics. It is important that this strategy is coupled with caregiver and healthcare worker vaccine education on the importance of timely immunisation uptake. Education about timely vaccine uptake will aid in the provision of informed council from healthcare providers to – not only adult caregivers - but adolescent caregivers as well, with the aim to reduce delayed uptake of vaccine amongst those raised by adolescent caregiver. The health system and the Expanded Programme of Immunisation on South Africa (EPISA) should couple these interventions with effective mobile reminder systems. These reminder systems will particularly serve the purpose to remind those caregivers whose delay uptake of vaccines as a result of a busy schedule. This could improve adherence to the recommended childhood immunisation schedule. Generally, for such interventions to work, effective monitoring and surveillance of immunisation services and vaccines is critical in achieving a high immunisation coverage and timely uptake of vaccines. Future studies should continuously monitor immunisation coverage and timeliness data in the Western Cape Province and South Africa as a whole to support evidence-based strengthening of provincial and national immunisation services.
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    Health systems constraints and facilitators of national immunization programs in low- and middle- income countries
    (2019) Amponsah-Dacosta, Edina; Olivier, Jill; Kagina, Benjamin
    Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned.
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    Health systems determinants of delivery and uptake of maternal vaccines in low and middle-income countries: A qualitative systematic review
    (2022) Davies, Bronte; Olivier, Jill; Amponsah-Dacosta, Edina
    Maternal vaccination has been widely recognised as a key component of the comprehensive package of antenatal care aimed at improving maternal and child health. Low- and middle-income countries (LMICs) are currently falling short of maternal and neonatal mortality targets, with gaps in quality health coverage and a high burden of vaccine-preventable diseases that affect both maternal and child health (MCH). There is a variety and increase of grey and published literature in recent years from LMICs on maternal vaccination programmes and their importance in addressing these gaps in MCH. However, there is a gap in the available literature for research on the role of health systems in the functioning of maternal vaccination programmes, particularly in LMICs. Based on available evidence, understanding health systems determinants of maternal vaccine uptake and delivery requires qualitative insight to inform maternal vaccine programming. A qualitative systematic review was conducted in two phases: a rapid scoping review exploring maternal vaccination and health systems was followed by a systematic review to identify health systems determinants of maternal vaccine delivery and uptake in LMICs. The systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines. Six electronic databases were searched for primary research from LMICs published in English between 2009 and 2021. A qualitative approach to data extraction and evidence synthesis was guided by conceptual health systems framing developed through the scoping review. Thematic analysis identified key descriptive and analytical themes to explore the health systems barriers and enablers of maternal vaccine delivery and uptake in LMICs. Of the 1 242 records identified through database searches, 47 studies were included in the systematic review from 28 LMICs. The majority of included studies were from the South America region (28/47) and included pregnant women as the primary population study group (38/47). Included literature explored mainly Influenza (25/47) and Tetanus toxoid (18/47) maternal vaccine uptake and delivery. Health systems enablers of maternal vaccine uptake included high level of maternal trust in healthcare providers and policy-makers. Barriers to uptake include out-of-pocket spending for vaccination services. Poor communication of policy and guidelines between policy-makers and public/private healthcare providers was identified as a barrier to vaccine delivery, in addition to reliance on external donor funding for vaccine programme implementation and reliance on paper-based antenatal and vaccination records. Urban residence and shorter travelling times to facilities enabled vaccine uptake during pregnancy, while influence of family and influential community members serves as a barrier to vaccine uptake. Limited healthcare worker capacity and subsequent decreased time spent educating patients is a barrier to both vaccine uptake and delivery for pregnant women. Health systems determinants of maternal vaccine delivery and uptake identified and explored in this review study highlight the need for improved communication of vaccine policy guidelines and safety between healthcare providers, policy-makers, pregnant women and the broader community. Monitoring and reporting systems for vaccine delivery in MCH need to be strengthened to inform service delivery policies. This review study provides a health systems approach to maternal vaccination and contributes to the increasing body of work in MCH that can inform future introduction of new maternal vaccines in LMICs.