Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Ghana: Learnings and best practices on the planning and implementation of yellow fever vaccination campaigns – a case study Ghana country case study October 2022 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Ghana: Learnings and best practices on the planning and implementation of yellow fever vaccination campaigns – a case study Ghana country case study October 2022 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026: Ghana: Learnings and best practices on the planning and implementation of yellow fever vaccination campaigns – a case study © WHO African Region, 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026: Ghana: Learnings and best practices on the planning and implementation of yellow fever vaccination campaigns – a case study. Brazzaville: WHO African Region, 2023. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Designed in Brazzaville, Congo ISBN: 978-929031490-5
Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 iii Contents Abbreviations ............................................................................................................iv Acknowledgements .....................................................................................................v 1. Introduction ...........................................................................................................1 2. Methods and approach ............................................................................................2 2.1 Data collection and analysis ................................................................................................ 2 2.2 Limitations ........................................................................................................................... 2 3. Findings .................................................................................................................4 3.1 Involving civil society and community structures in the planning and implementation of preventive mass yellow fever vaccination campaigns .................................................... 4 3.2 Tailored and targeted approaches to reach underserved populations with yellow fever vaccination ................................................................................................................... 8 3.3 Integration of COVID-19 vaccination into reactive yellow fever vaccination campaigns ........................................................................................................................... 14 Annexes ...................................................................................................................20 Annex 1: Bibliography ...............................................................................................21 Annex 2: List of informants ........................................................................................22 Annex 3: Interview guide ...........................................................................................24 Table of figures Figure 1: Administrative versus survey coverage for the 2018 PMVC, Ghana (GHS, 2019) ............. 6 Figure 2: Summary of regional and national administrative coverage rate of the 2020 PMVC, Ghana ................................................................................................................................. 7 Figure 3: Map of reactive yellow fever vaccination campaigns in Ghana, December 2021 and February 2022 ........................................................................................................... 10 Figure 4: Community-specific administrative yellow fever vaccination coverage rates, Nsuaem subdistrict, February–March 2022................................................................................... 16 iv Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Abbreviations CSO civil society organization EYE eliminate yellow fever epidemics FDA Food and Drugs Authority FDG focus group discussion GHS Ghana Health Service ICG International Coordinating Group JSI John Snow Inc. KII key informant interview MOH Ministry of Health NGO nongovernmental organization PMVC preventive mass Vaccination Campaign RI routine immunization UNICEF United Nations Children’s Fund VPDs vaccine-preventable diseases WHO World Health Organization Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 v Acknowledgements We would like to thank the WHO Representative to Ghana, Dr Francis Kasolo, for his overall support for the case study, and Dr Michael Adjabeng (National Professional Officer-Surveillance, WHO-Ghana) for his immense support in coordinating this case study and facilitating access to documents for review. Additionally, we would like to acknowledge the great support from: the technical team at WHO Country Office-Ghana, particularly Dr Elizabeth Juma (Cluster Lead-UCN) and the Emergency preparedness and response team, Mr Fred Osei-Sarpong (Technical Officer - Immunization, WHO- Ghana), Dr Felix Osei Sarpong (Health Specialist, UNICEF Country Office-Ghana), Dr Franklin Asiedu-Bekoe (Director, Public Health Division, Ghana Health Service (GHS)), Dr Charity Sarpong (Regional Director, GHS, Greater Accra Region), Dr Emmanuel Tinkorang (Regional Director, GHS, Ashanti Region) and his team, Dr Ruth Obeng Asare (Municipal Director, GHS, Ga South), Madam Francisca Ahiavih (District Director, GHS, Bosome Freho District) and Dr Kwaku Poku Asante (Director, Kintampo Health Research Centre, GHS) for their helpful contributions to the success of this mission. Mr Solomon Appau (Disease Control Officer, GHS, Bosome Freho District) and Mr Jones Anim (Disease Control Officer, Ga South) provided data and literature for the desk review. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 1 1. Introduction Two country case studies (in Brazil and Ghana) were planned for the mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017–20261 with the overall purpose of learning and documenting best practices on the implementation of various key EYE actions in different contexts. The final learning themes for the two countries were agreed through a collaborative process involving key stakeholders at the country level. The main objectives of the country case studies within the EYE mid-term evaluation are to: • document lessons learnt and best practices in the implementation of the EYE strategy • identify critical factors and key enablers for the successful implementation of specific components of the EYE strategy • identify potential for scale-up, replication and sustainability. Ghana has adopted the global EYE strategy which aims to protect at-risk populations, prevent international spread, and rapidly contain yellow fever outbreaks.2 This case study focuses on specific EYE learning points from Ghana, implemented during the 2017–2022 EYE implementation period, on the planning and implementation of yellow fever vaccination campaigns. The following themes are specifically addressed: 1. Community engagement in the planning and implementation of yellow fever vaccination campaigns. 2. Tailored and targeted approaches to reach underserved populations with yellow fever vaccination. 3. Integration of COVID-19 vaccination with a reactive yellow fever vaccination campaign. 1 Eliminate Yellow Fever Epidemics (EYE) 2017 – 2026. Geneva: EYE Partnership; 2018. 2 Annual report: 2018. Accra: World Health Organization Ghana; 2018. 2 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 2. Methods and approach 2.1 Data collection and analysis The case study used a mixed-methods approach, combining qualitative and quantitative methods for data collection and analysis. An initial document and data review was supplemented by primary data collection through key informant interviews (KIIs) and focus group discussions (FGDs), undertaken during the period 20 September–5 October 2022, with key stakeholders involved in yellow fever prevention and response at the national and subnational levels. From the national to the subdistrict level, key stakeholders were purposely selected to take part in KIIs and FGDs in order to collect relevant information and encourage experience sharing for learning. Representatives from the Ghana Health Service (GHS) at the national and subnational levels, including senior officials and health care workers such as vaccinators and supervisors, and representatives from the WHO and the United Nations Children’s Fund (UNICEF) country offices participated in one-on-one interviews and focus groups. The case study included field visits to Bosome Freho District in the Ashanti Region and the Ga South Municipality in the Greater Accra Region. A total of 15 KIIs and two FGDs were conducted, with four and eight participants respectively, with 26 stakeholders sharing their experiences. A list of all key informants and FGD participants is provided in Annex 2. The KIIs were conducted using a semi-structured interview guide that listed a predetermined set of questions relating to the themes of this country case study. Informants in the FGDs were asked to reflect on the questions asked by the interviewer, provide their own comments, listen to what others in the group had to say and react to their observations. Data from the KIIs and FGDs were recorded in notes and analysed and organized by theme and content. The best practices and lessons were explored with emphasis on key enablers, critical factors, specific results and their potential for replication, scaling up and sustainability. 2.2 Limitations The Ghana country case study was restricted by time and scope, and included relatively few informants. However, key informants were carefully selected to bring forward perceptions from a variety of stakeholders on the selected themes and lessons to be documented. Competing priorities of key stakeholders were a limitation to this case study. Many targeted key informants were occupied with several assignments in and outside the country by the time of data collection, which delayed the process and extended the set timeframe for data collection. Due to this limitation, some planned interviews were conducted virtually instead of face-to-face. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 3 In addition, data availability for vaccination coverage surveys was limited in a few cases and concerns remain about the quality of administrative coverage data. When interpreting the report findings, these limitations should be taken into consideration. Nevertheless, important lessons, opportunities and gaps have been presented in this report, with considerations for potential scale-up and replication. 4 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 3. Findings The sections below show the best practices and learning points from the Ghana case study, under three themes: (1) civil society and community engagement in yellow fever vaccination campaigns; (2) tailored and targeted approaches to reach underserved populations with yellow fever vaccination; and (3) integration of a yellow fever vaccination campaign with a COVID-19 vaccination campaign. 3.1 Involving civil society and community structures in the planning and implementation of preventive mass yellow fever vaccination campaigns Background The highly effective yellow fever vaccine was introduced into Ghana’s routine immunization (RI) programme nearly three decades ago with consistently high coverage rates above 80% since 2004, reaching 94% coverage in 2021.3 To further boost Ghana’s population immunity, yellow fever preventive mass vaccination campaigns (PMVCs) were introduced in 2005 to complement RI efforts.4 Following a yellow fever risk assessment in 2010, PMVCs were repeated in 2011 and 2012 to protect at-risk populations in targeted districts.4 After Ghana adopted the EYE strategy, two additional PMVCs were carried out in 20185 and 2020 to include districts that had not been covered in earlier campaigns. In recent years, Ghana has intensified civil society and community engagement in yellow fever vaccination campaigns to improve vaccination coverage. Engaging civil society and communities in PMVCs - lessons learnt Civil society organizations (CSOs) have played a significant role in promoting yellow fever vaccination campaigns in Ghana by supporting social mobilization efforts at all levels, from national to local. Their representatives also served on the national committee, providing technical support for planning and implementation, while their members, who are well known in the communities where they live and work, organized local residents for vaccination campaigns. Civil society has been an integrated and key player from the initial planning of PMVCs at national, regional, and district levels. PMVCs were planned through the collaborative efforts multiple key partners, including: GHS, WHO, UNICEF, Centers for Disease Control and Prevention (CDC), Ghana Coalition for NGOs in Health (a CSO), and other partners such as district assemblies, the Food and Drugs Authority (FDA), John Snow Inc. and PATH. A national intersectoral committee 3 Immunization dashboard. World Health Organization; 2022. 4 Expanded programme on immunization: report on yellow fever mass vaccination campaign in Ghana (phase B) [un- published report]. Ghana Health Service; 2020. 5 Expanded programme on immunization: 2018 subnational yellow fever preventive mass vaccination campaign (PMVC) coverage survey report [unpublished report]. Ghana Health Service; 2019. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 5 chaired by the GHS Director of Public Health,5 and including civil society organizations, oversaw every aspect of the campaign, while subcommittees organized the technical aspects, such as planning and coordination, communication and social mobilization, training, vaccines and logistics, and monitoring and evaluation. This structure was widely adopted by the relevant government and nongovernment stakeholders at the regional and district levels. The key partners, WHO and UNICEF, provided support for various aspects of the planning, including International Coordination Group (ICG) applications, budgeting, fund sourcing, vaccine availability, communication and social mobilization, logistics and technical support. To mobilize communities more successfully for campaigns, GHS and its partners made extensive use of the expertise and support of CSOs. CSOs are active at all levels of the healthcare system, in particular the Ghana Coalition for NGOs in Health. WHO and UNICEF have supported the GHS to build the capacity of CSOs to promote and create demand for vaccination campaigns. Community access was facilitated by community leaders such as chiefs and queen mothers. Durbars were held to inform community stakeholders about the campaigns. Information about the campaigns was disseminated through channels such as community information centres, churches, mosques, local radio stations and village criers and gong-gong beaters. Religious leaders allowed vaccination teams to use their premises as vaccination posts. For each locality, context-specific factors were taken into account before selecting the best community engagement approach. Community members were also utilized to dispel rumours about the 2020 PMVCs and the December 2020 elections.6 Selected quotes from key informants on the importance of community engagement in achieving high coverage in yellow fever vaccination campaigns are provided below: “If you want to deliver any intervention in the community, and you fail to engage community structures, then you are planning to fail.” “I think over the years, Ghana has been quite successful in our campaigns, and our coverages have been quite impressive. Apart from for COVID-19…I think that there’s a lot of trust between Government and the indigenes because we use the local people in our health programmes.” “We shouldn’t assume that communities do not have the capacity to or they do not have trusted voices to be able to lead their own communication. When you build their capacities and leave the communication to them, they will ensure that every other person in the community gets vaccinated. That was one of the strongest lessons.” “Engaging (community)stakeholders should be our number one priority.” 6 Expanded programme on immunization: report on yellow fever mass vaccination campaign in Ghana (phase B) [un- published report]. Ghana Health Service; 2020. 6 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Results of PMVCs conducted in 2018 and 2020 The PMVCs implemented in 2018 and 2020 aimed at reaching all districts in Ghana, targeting populations between 10 and 60 years of age (with the expectation that children aged 0–9 years would have been reached by RI).7 In 2018, a total of 5.5 million people were vaccinated in nine subregions in 65 selected high-risk districts, and in 2020, 5.3 million people were vaccinated in 14 subregions in 82 districts. Ghana achieved high reported coverage of the PMVCs in both 2018 and 2020. Figure 1 displays the administrative coverage and post-campaign survey findings for the 2018 PMVC. The administrative coverage and post-campaign survey findings had different coverage rates. The national coverage rate according to the post-campaign survey was 84%, whereas the administrative coverage rate was 107%. Administrative coverage calculations are affected by data quality issues and should be interpreted with caution as the denominator is estimated from old census data.5 With the exception of two, all the implementing regions had post-campaign survey coverage rates above 80%. The lowest post-campaign coverage rate was reported by the Greater Accra Region, at 58%. Figure 1: Administrative versus survey coverage for the 2018 PMVC, Ghana (GHS, 2019) Source: Expanded programme on immunization, Ghana Health Service, 2018 subnational yellow fever preventive mass vaccination campaign (PMVC) coverage survey report 2019 For the 2020 PMVC, the national administrative coverage rate was reported to be 94%, with regional differences as presented in Figure 2. According to post-campaign surveys, overall coverage was 83% (85% in urban areas and 80% in rural areas - post-campaign survey data for 7 Country profile yellow fever: Ghana [unpublished report]. World Health Organization; 2022. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 7 2020 PMVCs were not available by region).8 The 2020 PMVCs were thus considered successful despite the ongoing COVID-19 pandemic and the need for strict precautionary measures. The main reasons for non-vaccination were reported to be: absence of the target population during the vaccination campaign (35%); not being informed about the vaccination campaign (24%); and being too busy during the vaccination campaign (12%). Figure 2: Summary of regional and national administrative coverage rate of the 2020 PMVC, Ghana Source: Expanded programme on immunization, Ghana Health Service. Report on yellow fever mass vaccination campaign in Ghana (Phase B), 12–18 November 2020. Key enablers, gaps and challenges Strong multi-partner collaboration, broad community engagement and detailed planning were identified as key enablers for success of the PMCVs in 2018 and 2020. GHS and its partners collaborated well, playing different roles in a coordinated manner to plan and implement the campaign effectively. The planning for the PMVCs started at least six months before implementation and took into consideration context-specific problems that could hamper vaccination efforts. These included community reluctance due to a lack of a clear public health threat, the existence of remote settlements that are difficult to access, and areas with security risks. Additionally, campaign planning was improved by applying the lessons learnt from earlier campaigns. Ghana has a well-organized health system, which facilitates the planning of public health interventions. The implementation of the PMVCs, however, required considerable financial support from Gavi for operational costs (amounting to US$ 3.5 million for the PMVC in 20189) 8 Expanded programme on immunization: Yellow fever post-campaign coverage survey 2020 analysis report [unpublished report]. Ghana Health Service; 2020. 9 Ghana YF preventive campaign budget (phase A) (unpublished report). Ghana Health Service; n.d. 8 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 and vaccines (fully covered by Gavi), and technical support from other collaborating partners such as WHO and UNICEF. Despite the successful nationwide campaigns that achieved high overall coverage rates, and sustained high RI coverage for almost two decades, a large disruptive yellow fever outbreak was reported in October 2021, with 60 confirmed yellow fever cases. The first cases were reported in the Savannah region among nomadic populations, but spread to several regions and districts of Ghana. During the implementation of the PMVC the following challenges were noted10: 1. The lack of an obvious public health threat during a PMVC, as opposed to a reactive campaign that is carried out in response to an outbreak, requiring substantial health education. 2. The occurrence of a public health crisis such as COVID-19 which may divert attention and require additional planning effort and resources to ensure adherence to preventive measures. 3. Hard-to-reach populations: places affected by conflict and hard-to-reach remote settlements. In urban areas, challenges in reaching certain populations such as those who live in high-security gated communities and in urban slums have also been reported. 4. Data quality and accuracy of denominators: administrative coverage denominators rely on population estimates that may be outdated; and several key informants questioned the reliability of coverage data. High quality post-campaign coverage surveys are necessary to validate administrative data on PMVCs, which require adequate financial and human resources. National authorities and WHO concluded that the yellow fever outbreak in 2021 in Ghana was possible because of pockets of unreached populations during PMVCs and RI rollout. This aspect is further explored in the next section. 3.2 Tailored and targeted approaches to reach underserved populations with yellow fever vaccination Background Despite Ghana’s generally high RI coverage and concluded nationwide PMVCs, segments of the population remained at risk, which led to the continued transmission of the yellow fever virus and outbreaks observed in 2021. During the period 15 October 2021–27 November 2021, a total of 60 confirmed cases of yellow fever, were reported in Ghana, of which 20% (12 people) died,11 representing about one third of all confirmed yellow fever cases recorded in African countries in 2021.12 Cases were detected in 14 districts in five regions (Bono, Eastern, Northern, Savannah 10 Expanded programme on immunization: yellow fever post-campaign coverage survey, 2020 analysis report [unpublished report]. Ghana Health Service, 2020; Expanded programme on immunization: 2018 subnational yellow fever preventive mass vaccination campaign (PMVC) coverage survey report [unpublished report]. Ghana Health Service; 2019. 11 Country profile yellow fever: Ghana (unpublished report). World Health Organization; 2022. 12 Weekly bulletin of outbreaks and emergencies. World Health Organization; 2022. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 9 and Upper West regions) with most of the cases reported from the Savannah Region. In 2022, so far, one confirmed case has been reported from the Eastern Region of Ghana.13 Further analysis found that the 2021 yellow fever outbreak in Ghana began in a community of nomads14 who were predominantly unvaccinated and may have entered the country after the last PMVC.15 The nomadic populations reportedly had moved from Nigeria into a forest reserve in Ghana’s Savannah Region.16 Implementing targeted reactive vaccination campaigns The GHS and its partners such as WHO, UNICEF, CDC and CSOs implemented reactive yellow fever vaccination campaigns in Ghana in December 2021 and February 2022, in subdistricts with yellow fever cases, but also in adjacent high-risk districts, targeting populations between nine months and 60 years of age. Figure 3 shows a map of the targeted areas of the two reactive campaigns in Ghana. The risk of transmission was assessed based on field epidemiological links, entomology, and vaccination coverage to determine the areas to respond.17 The main criteria delineated subdistricts within communities where at least one laboratory-confirmed case (IGM or PCR) had been reported. The criteria excluded district-wide vaccination because all the affected regions have been covered previously through PMVC. In total, 32 subdistricts in 19 districts across seven regions organized a reactive yellow fever vaccination campaign from 17 to 21 December 2021.18 The Savannah Region had already started a “local” reactive campaign in early November 2021, using national EPI yellow fever vaccines, before the approval and arrival of ICG-supported vaccines. The reactive campaign in December 2021 reached a total of 535 562 people out of 568 467 targeted (9 months–60 years target population) for a coverage rate of 93%. Of the population reached, 37% (n=196 986) had already been vaccinated as evidenced by a yellow fever vaccination card. A total of 338 757 people did not present a yellow fever vaccination card and were vaccinated during this reactive campaign. High coverage (above 80% were either vaccinated during the campaign or screened for previous vaccination) was reported from all regions except one (Upper West) where only 54% of the targeted population was reached. Updated laboratory data from December 2021 showed additional positive cases from new subdistricts not covered in the first phase of the reactive campaign, including those from the Savannah Region and in subdistricts of three additional regions with new cases. A second (phase 2) reactive vaccination campaign was thus initiated in February 2022, targeting all remaining subdistricts in the Savannah Region (n=24) and all subdistricts with new confirmed yellow fever cases since December 2021, reaching a total of 538 905 people (more than 300 000 in Savannah Region alone) across 43 sub districts in February 2022, with a coverage rate of 89% of the targeted population (603 394).19 Of the population reached, 37% (199 345) had previously been vaccinated, 13 Country profile yellow fever: Ghana [unpublished report]. World Health Organization; 2022. 14 Yellow fever Ghana. World Health Organization; 2021. 15 Yellow fever Ghana. World Health Organization; 2021. 16 Yellow fever Ghana. World Health Organization; 2021. 17 Reactive yellow fever vaccination campaign in select districts of Ghana, phase 1: a technical report (unpublished report). Ghana Health Service; 2021. 18 Reactive yellow fever vaccination campaign in select districts of Ghana, phase 1: a technical report (unpublished report). Ghana Health Service; 2021. 19 Reactive yellow fever vaccination campaign in select districts of Ghana, phase 2: a technical report [unpublished report]. Ghana Health Service; 2022. 10 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 as evidenced by a yellow fever vaccination card, and 63% (339 560) were vaccinated during the phase 2 vaccination campaign. As part of the preparation towards the reactive campaigns, districts conducted rapid assessments of communication barriers and mapped stakeholders and channels. This helped the teams to formulate appropriate messages and risk communication channels. Vaccination sessions for both reactive campaigns took place in health centres and provisional vaccination posts in markets, transportation hubs and stations, schools, churches and municipal and district assemblies. Some teams also travelled to island and riverine communities to ensure that target communities received vaccines. The reactive campaigns built on the good experience of engaging communities as described under the PMVC section above. Subdistrict teams organized advocacy and awareness meetings with traditional, religious and other community leaders (e.g., local assembly leaders, school managers, youth leaders and women’s groups). In addition to these groups, the Savannah Region, also engaged with butchers and nomad herdsmen to reach the nomadic population. Through the implementation of the reactive campaigns, Ghana managed to rapidly contain the outbreak with only one additional confirmed case reported in 2022. Figure 3: Map of reactive yellow fever vaccination campaigns in Ghana, December 2021 and February 2022 Source: GHS. Reactive yellow fever vaccination campaign in select districts of Ghana, phase 2: a technical report 26 February–2 March 2022. Notes: Phase 1: Yellow fever reactive campaign in December 2021. Phase 2: Yellow fever reactive campaign in February 2022 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 11 Gaps and challenges One of the lessons learnt from the reactive campaigns was that hot spot areas, such as the Savannah Region, should have responded with a large-scale and comprehensive campaign during the first reactive campaign. The first reactive vaccination campaign in December 2021 covered only 16 out of 40 subdistricts in the Savannah Region and new confirmed cases were discovered in subdistricts in the Savannah Region not covered by the first campaign after December 2021. This was addressed by a full-scale coverage reactive vaccination phase in February 2022. Furthermore, a large proportion (63%) of the population reached during both reactive campaigns presented without proof of previous yellow fever vaccination. This may be caused by several factors: (1) people who had previously been vaccinated for yellow fever but had lost, forgotten or never received a yellow fever vaccination card; or (2) data quality concerns with coverage data from previous PMVCs and RI; or (3) a result of effective outreach to under-immunized populations during the reactive campaigns. It is most likely that a combination of all three factors contributed to this finding. Nevertheless, there is room for strengthening coverage data and analysis from PMVCs and RI; and the report from the latest reactive campaign recommended conducting post- coverage surveys and printing yellow fever vaccination cards, as there were no stocks available at national level stores.20 The COVID-19 pandemic presented less of a challenge to rolling out the reactive campaigns than expected. Effective planning, procurement of personal protective equipment (PPE) and training staff in using operational manuals on how to conduct vaccination sessions during the pandemic were initiated, building on previous vaccination campaigns implemented in 2020 (yellow fever PMCV and polio). Less information was available on how to potentially co-administer the yellow fever vaccine with COVID-19 vaccination campaigns, which were running simultaneously in the same target areas. Some districts opted for an integrated co-administrated approach, which is further explored in detail under section 3.3. As noted above, the 2021 outbreak was traced back to nomadic populations. Nomadic communities are often untraceable by governments, and porous borders and extensive cross- border movements of these populations exacerbate the risk of international spread. Apart from their migratory lifestyle, nomadic communities tend to settle in remote, forested areas of the country that are largely unknown or underserved by health care providers, making it difficult to include them in vaccination campaigns, even during periods of settlement. Learning from the epidemiology of the 2021 outbreak, gaps and challenges during PMVC and reactive campaigns, Ghana has since embarked on the development of a framework and tailored approaches to increase vaccination coverage among nomadic populations, based on implementation research. This will be explored further below as an example of “best practice.” 20 Reactive yellow fever vaccination campaign in select districts of Ghana phase 2: a technical report [unpublished report]. Ghana Health Service; 2022. 12 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Developing a framework and tailored approaches to guide vaccination campaigns among nomadic populations Studying nomadic populations to guide implementation is key. UNICEF requested and funded research to determine the movement patterns of nomads in Ghana, identify and map locations, and determine their health-seeking behaviours and context- appropriate social and behavioural change approaches. The research was conducted by the GHS Kintampo Health Centre in selected districts in the Upper West, Savannah, Bono East, and Ashanti regions of Ghana, and results were recently disseminated to key stakeholders.21 The evidence is currently being used to develop a framework to guide vaccination campaigns in Ghana for yellow fever and other vaccine-preventable diseases (VPDs) in this specific population. Using the right entry points and platforms It was widely reported by key informants who had done research in this area that nomadic populations have no objection to immunization per se. However, how well they are integrated into their larger communities can affect their trust in health authorities and their willingness to use health services available. Furthermore, their migratory patterns are seasonal and can be predicted/mapped, with days such as Fridays more appropriate for offering vaccination services.22 In the early phases of the reactive vaccination campaign, nomadic communities generally tended to avoid health authorities. Using community leaders and key respected locals as entry points to nomadic communities and involving their leaders in the campaign and social mobilization, won their trust and support. The GHS, WHO, UNICEF and other partners relied on local stakeholders such as butchers, proprietors of community pharmacies and chemical stores, and cattle owners, for mobilizing the nomadic community for yellow fever vaccination services. Leaders of nomadic communities were engaged and their capacities were built to support both the planning and implementation of the reactive vaccination campaign. Examples of quotes from key informants are shown below: “You can have a good message, but if you have a bad (the wrong) messenger you will not succeed in communicating.” “The use of the nomadic leadership in reaching out to them in every facet of their life remains important. If we do away with the leadership, we run into trouble...When we were commencing this, we thought it was a very dangerous ground to tread, because it had security implications. But, at the end of the day, when we mapped out strategies and started using their community leaders, you would be surprised that before you get to one community and start talking to them, the leader has already called (informed) them… The leaders were happy that for the first time a group was coming to them to talk to them about issues around their health. So, it remains important that we use their leaders….” 21 Nomadic study disseminates findings. Ghana Health Service; 2022. 22 Nomadic study disseminates findings. Ghana Health Service; 2022. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 13 Health education and attention to possible gender bias The research study among nomadic communities found that uptake of vaccination services depends on the risks of the disease and how common/widespread it is perceived to be, and recommended the use of radio and information centres for health education.23 Some key informants reported that men in the nomadic community often excluded women and children from campaign-related discussions. The women acknowledged, in a separate meeting, how they were ignored on similar matters and reported not having the support of their men in other areas, including antenatal care. According to key informants, the women were often more knowledgeable about yellow fever than the men, and many of their children had received the yellow fever vaccine when their vaccination records/cards were checked. It will be important to address any practices that may result in gender disparities in access to health information or services and to ensure that women are involved. Reaching nomadic populations requires additional resources Due to the remote settlement of nomadic populations, health workers need additional resources to cover transportation and logistics to be able to reach out to them. It was further recommended that vaccination centres/points be established in strategic locations closer to the nomadic settlements. Potential of replication, scale-up and sustainability The examples above demonstrate the importance of “knowing your epidemic,” having reliable data systems and conducting studies into the lifestyles of vulnerable populations such as nomadic communities, to provide evidence for planning and implementing context-appropriate and tailored strategies. Implementation research efforts on yellow fever vaccination among nomadic populations conducted by the GHS, UNICEF and its partners can be replicated in different settings and among various vulnerable, high-risk and hard-to-reach populations to improve access to yellow fever vaccination services. Other high-risk groups for yellow fever, other than nomads in Ghana, include farming, lumbering and mining workers who are at increased risk of sylvatic transmission.24 Tailored approaches to service delivery for nomadic populations can be further expanded to increase the use of other health care services (other VPDs, antenatal care etc.). Using the right community entry points and engaging local stakeholders is a sustainable way to bring immunization and health services closer to this special population. Tailored outreach approaches to nomadic populations are more costly as they require research into migration patterns, health-seeking behaviour, and appropriate social and behavioural change approaches. Likewise, delivering services in remote areas entails more costs. It is 23 Nomadic study disseminates findings. Ghana Health Service; 2022. 24 Yellow fever Ghana. World Health Organization; 2021 (https://www.who.int/emergencies/disease-outbreak-news/ item/yellow-fever---ghana). 14 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 expensive and tedious to undertake immunization campaigns utilizing a mobile team strategy in settings with geographically hard-to-reach areas. This is partly due to the lack of accessible public transportation to remote settlements. An effective mobility strategy must be put in place for vaccination teams, and funds allocated to provide suitable transportation logistics such as motorbikes. Personal protective equipment such as wellington boots must also be provided for vaccination teams working in wet or flood-prone areas. The possibility of assigning more vaccination teams to these locations should be considered. Partners must work together to identify sources of funding for research activities and for follow- up on research findings and recommendations. Preparations for similar efforts should take into account appropriate transportation and security procedures and adequate financial arrangements. 3.3 Integration of COVID-19 vaccination into reactive yellow fever vaccination campaigns Background Since March 2021, Ghana has had access to COVID-19 vaccines, which have so far been distributed in phases.25 In October 2021, a yellow fever outbreak began in the Savannah Region, and spread to several other regions. The GHS and its partners launched reactive subnational vaccination campaigns in December 202126 and February 202227 as described in more detail in section 3.2. Some regional and district health teams took the opportunity to offer COVID-19 vaccination through the roll-out of the reactive yellow fever campaigns, by offering available COVID-19 vaccines to the target population. Bosome Freho, is one of the most deprived districts of the Ashanti Region, with a number of remote settlements that are difficult to access due to poor road networks.28 A reactive yellow fever campaign was required, following an outbreak in its Nsuaem subdistrict. The district implemented the reactive yellow fever campaign from 26 February to 2 March 2022, while simultaneously offering COVID-19 vaccines to the eligible target population. A similar approach was employed in the Amanfro subdistrict of the predominantly urban Ga South Municipality in the Greater Accra Region, during the same period. Implementing the integrated campaign The initiative for the dual antigen campaign was led by regional and district health authorities of the target subdistricts. The simultaneous administration of two life-saving vaccines was initiated to benefit the population, while saving operational costs by using the same personnel and logistics, and sharing cold chains etc., as expressed by a key informant: 25 Information on the COVID vaccine. Ghana Health Service and United Nations Children’s Fund; n.d. 26 Reactive yellow fever vaccination campaign in select districts of Ghana, phase 1: a technical report (unpublished report). Ghana Health Service; 2021. 27 Reactive yellow fever vaccination campaign in select districts of Ghana (Phase 2): a technical report [unpublished report]. Ghana Health Service; 2022. 28 Bosome Freho District Health Directorate: District profile [unpublished report]. Ghana Health Service; 2022. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 15 “There were gains in terms of ensuring that people also had COVID-19 (vaccination). We were experiencing multiple public health emergencies. Aside protecting them from yellow fever, they were also at risk of dying from COVID-19. So, it was a good initiative.” Regional and district health teams worked collaboratively to plan the campaign, train vaccinators and supervisors, and monitor campaign activities. Vaccination teams comprised one health care worker and two community volunteers. They were stationed at strategic locations in the communities, or travelled from home to home, stopping at social gatherings, places of work, schools, and other venues to provide vaccines to beneficiaries. COVID-19 and yellow fever vaccines were stored in separate vaccine carriers. Health authorities held daily review meetings with vaccination teams and supervisors. District assemblies, civil society organizations, local chiefs, religious leaders, community volunteers, and other community stakeholders were involved at every stage of the campaign. Technical assistance was provided by national representatives, such as the EPI office, and partner organizations, such as UNICEF, who had initially visited the sites to supervise the reactive vaccination campaigns. Results of the dual-antigen vaccination campaign In Nsuaem, 11 638 persons aged nine months to 60 years received the yellow fever vaccine during the dual-antigen campaign. The overall coverage of the subdistrict was 105%, taking into account the 3730 people having previous yellow fever vaccination records. The administrative coverage rates for each community, however, varied from 71% to 147%29 (Figure 4). The yellow fever vaccination coverage is thus comparable to single-antigen reactive yellow fever campaigns implemented in other subdistricts of Ghana during the same period.30 Uptake of the COVID-19 vaccine was however much lower. During the integrated campaign roll- out, only 495 people received the COVID-19 vaccine, including 203 for the first time, 163 for the second time, and 129 for the third time (booster dose).31 The previous single- antigen COVID-19 mass vaccination campaign that took place from 2 to 6 February 2022 in the same subdistrict had reached 1000 persons.32 29 Bosome Freho District Health Directorate: Ghana reactive yellow fever vaccination campaign [unpublished report]. Ghana Health Service; 2022. 30 Reactive yellow fever vaccination campaign in select districts of Ghana (Phase 2): a technical report [unpublished report]. Ghana Health Service; 2022. 31 Bosome Freho District Health Directorate: COVID-19 mass vaccination [unpublished report]. Ghana Health Service; 2022. 32 Bosome Freho District Health Directorate: COVID-19 mass vaccination [unpublished report]. Ghana Health Service; 2022. 16 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Figure 4: Community-specific administrative yellow fever vaccination coverage rates, Nsuaem subdistrict, February–March 2022 Source: Bosome Freho District Health Directorate, Ghana Health Service, Ghana reactive yellow fever vaccination campaign, 26 February–2 March 2022 In the Amanfro subdistrict, administrative yellow fever coverage was 80.3%, with 84 588 out of 105 305 people vaccinated,33 which is also comparable to single-antigen yellow fever reactive vaccination campaigns in other subdistricts during the same period.34 Gaps and challenges The significant variation in COVID-19 and yellow fever vaccine uptake during the integrated campaign was generally perceived to be attributed to COVID-19 hesitancy and a recent mass COVID-19 vaccination campaign in the same district. Indeed, one of the major challenges perceived by health teams, and reported by vaccination teams in relation to this dual antigen campaign was COVID-19 vaccine hesitancy. One focus group participant had this to say: “I was afraid of people, the community members. Because during the COVID-19 (vaccination campaign) alone it wasn’t easy. Now, we’re adding another thing. It wasn’t an oral one. Another injection. I really thought about it before stepping out”- FGD participant 33 Ga South Municipal Health Directorate: Municipal report for yellow fever vaccination campaign. Ghana Health Service; 2022. 34 Reactive yellow fever vaccination campaign in select districts of Ghana (Phase 2): a technical report [unpublished report]. Ghana Health Service; 2022. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 17 According to the health authorities and vaccinators interviewed, uptake of the COVID-19 vaccine from the previous mass campaign was also low - this is supported by the data presented above - mainly due to vaccine hesitancy and conspiracy surrounding the COVID-19 vaccine. In addition, some community members had the misconception that COVID-19 vaccines were being administered under the guise of yellow fever vaccines. Vaccinators said they spent a lot of time educating some community members, in some cases, making several home visits to inform people about the benefits of receiving both vaccines. They were not always successful. Another focus group participant said: “For you to be talking, talking (and) talking, (Yet), in the long run the person will not even take it (the vaccine) and will be insulting you (made the work tedious) – FGD participant Concerns were also raised regarding the side effects of the COVID-19 vaccine. To address this, some vaccinations were given in the late afternoon, when recipients had completed most of their day’s activities. However, in some cases, the dual antigen campaign appeared to increase community trust in COVID-19 vaccines, as expressed by another key informant: “Although there was a lot of conspiracy around COVID-19, there’s no conspiracy when it comes to yellow fever because the disease is known. The vaccines have been in existence for a long time and they were ready for the yellow fever vaccine. By having yellow fever and COVID-19 vaccines on the same table, being administered by a vaccinator or nurse they could trust, gave them confidence”. Key enablers and lessons learnt Key enablers and lessons learnt from delivering the dual-antigen campaign included the need for: comprehensive training to ensure staff motivation and commitment; clear communication strategies; effective community engagement and outreach activities; uninterrupted vaccine supply and separation of vials, and robust monitoring of campaign activities. Comprehensive training and ensuring staff motivation and commitment Immunization teams were thoroughly briefed on their roles and responsibilities. Role-playing exercises and practical lessons were provided on how to distinguish between a COVID-19 vaccine vial and a yellow fever vaccine vial, and how to use the appropriate record-keeping tools for each vaccination. Even though health teams were exhausted following a recent mass immunization campaign for COVID-19, they committed to making the campaign a success once they understood its importance. In this campaign, vaccination and health teams had to work twice as hard, communicating the risks of two different diseases, mobilizing communities for two different vaccines, and recording vaccination data, using several recording tools. However, 18 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 because the funds allocated to the district from the national level were intended for a yellow fever vaccination campaign and not an integrated campaign, the personnel did not receive extra remuneration. The frequent use of this model without addressing staff demotivation could have a negative impact on the quality of results obtained during such campaigns. Clear communication strategy The campaign’s communication strategy attempted to make a clear distinction between the vaccines and the benefits of getting both shots. Due to COVID-19 vaccine hesitancy, messages were framed to allay concerns about the COVID-19 vaccine. Additionally, adequate information was provided on how and where to report adverse events following immunization (AEFI). To allay any doubts or concerns that beneficiaries may have about the vaccination, some vaccination teams showed them their personal vaccination cards. It is noteworthy, however, that despite efforts to communicate the risks and benefits effectively and clearly, some recipients initially refused the yellow fever vaccine because they thought it was a COVID-19 vaccine. Some of them later agreed to take the vaccine after learning from locals that the yellow fever vaccine was not only necessary to protect against yellow fever but was also required for international travel. Effective community engagement and outreach activities Another key enabler was the use of community structures and key community stakeholders such as chiefs, assembly members, religious leaders and community volunteers to lead the mobilization (as also described in 3.1 and 3.2). These respected community members were involved in educating communities about the campaign and mobilizing them for it. This helped to gain the trust and support of community members for the dual campaign. Volunteers were also selected from the beneficiary communities to serve on the vaccination teams. The use of both mobile and static vaccination teams ensured that those who would have missed their vaccination owing to work schedules, vaccine hesitancy, or lack of knowledge about the campaign, were all reached. As one focus group participant noted: “The moment we brought the vaccines to their homes, they were very grateful” – FGD participant Uninterrupted vaccine supply and separation of vials Mobile teams had to cover long distances on foot to reach recipients in remote areas. It was very beneficial to make sure that vaccination teams had access to a steady supply of vaccines to prevent shortages. As a further measure to maintain the vaccine at the correct temperature at all times, team supervisors frequently provided frozen ice packs. Clear labelling of vials and separation of the two antigens was also important. Robust monitoring of campaign activities Daily review meetings held by regional, district and subdistrict supervisory teams helped the health authorities to track the progress of the campaign, identify gaps and address them in a timely manner. Regional, district and subdistrict teams monitored the campaign daily while Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 19 officials from the national EPI office and partner organizations provided additional technical support when they visited the subdistrict during the campaign period. Potential for replication, scale-up and sustainability The dual-antigen vaccination campaign described above was an innovative strategy to protect the same population from two disease outbreaks using the same logistics and personnel. It reduced the time and funds that would have been required if the vaccines had been distributed through two different single-antigen campaigns. Additionally, it was convenient for beneficiaries who wished to have both vaccinations. However, this strategy should only be replicated after careful consideration of lessons learnt and specific circumstances. It is crucial to take into account contextual factors that could affect the delivery or uptake of the campaign, such as community buy-in and staff readiness. Critical thought must be given to the types of vaccines to be combined, their mode of administration, and the target populations. The experience of integrating COVID-19 and yellow fever vaccination campaigns in Ghana showed the risk of lower uptake if precautionary measures are not implemented in the form of clear communication strategies. In the case presented above, yellow fever vaccination coverage remained high and comparable to other single-antigen reactive campaigns implemented in other subdistricts of Ghana, despite vaccine hesitancy and conspiracy surrounding the COVID-19 vaccine. In order to select the best combinations of intervention and delivery strategies, it is crucial to carefully evaluate the lessons learnt from other contexts where multi-antigen vaccination campaigns have been implemented. Also, it may be necessary to make additional financial arrangements to compensate personnel who deliver integrated campaigns. 20 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Annexes Annex 1: Bibliography Annual report: 2018. Accra: World Health Organization Ghana; 2018 (https://www.afro.who. int/sites/default/files/2019-09/WHO%20Ghana%202018%20Annual%20Report.pdf). Bosome Freho District Health Directorate: COVID-19 mass vaccination (unpublished report). Ghana Health Service; 2022. Bosome Freho District Health Directorate: District profile (unpublished report). Ghana Health Service; 2022. Bosome Freho District Health Directorate: Ghana reactive yellow fever vaccination campaign (unpublished report). Ghana Health Service; 2022. Bosome Freho District Health Directorate: Ghana yellow fever vaccination rollout [unpub- lished report]. Ghana Health Service; 2022. Country profile, yellow fever: Ghana [unpublished report]. World Health Organization; 2022. Expanded programme on immunization: 2018 subnational yellow fever preventive mass vaccination campaign (PMVC) coverage survey report (unpublished report). Ghana Health Service; 2019. Expanded programme on immunization: report on yellow fever mass vaccination campaign in Ghana (Phase B) (unpublished report). Ghana Health Service; 2020. Expanded programme on immunization: yellow fever post-campaign coverage survey 2020 analysis report [unpublished report]. Ghana Health Service; 2020. Fifth eliminate yellow fever epidemic (EYE) strategy annual partners’ meeting (unpublished report). Geneva: World Health Organization; 2021. Ga South Municipal Health Directorate: municipal report for yellow fever vaccination cam- paign. Ghana Health Service; 2022. Ghana YF preventive campaign budget (Phase A) (unpublished report). Ghana Health Service; n.d. Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 21 Immunization dashboard. World Health Organization; 2022 (https://immunizationdata.who. int/). Information on the COVID vaccine. Ghana Health Service & United Nations Children’s Fund; n.d. (https://www.unicef.org/ghana/information-covid-19-vaccine). Nomadic study disseminates findings. Ghana Health Service; 2022 (https://kintampo-hrc.org/ pages/normadic-team.html). Reactive yellow fever vaccination campaign in select districts of Ghana (Phase 1): a technical report (unpublished report). Ghana Health Service; 2021. Reactive yellow fever vaccination campaign in select districts of Ghana (Phase 2): A technical report [unpublished report]. Ghana Health Service; 2022. Weekly bulletin of outbreaks and emergencies. World Health Organization; 2022 (https://apps. who.int/iris/bitstream/handle/10665/362389/OEW36-290804092022.pdf). Yellow fever Ghana. World Health Organization; 2021 (https://www.who.int/emergencies/dis- ease-outbreak-news/item/yellow-fever---ghana). Yellow fever mass vaccination ends today. Graphic online; 2022 (https://www.graphic.com.gh/ news/general-news/yellow-fever-mass-vaccination-ends-today.html). 22 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Annex 2: List of informants No. Name Title Institution Interview type, date and location 1 Dr Michael Rockson Adjei Immunization Officer, SSA WHO-Ghana KII 20/09/2022 WHO Country Office 2 Mr Fred Osei Sarpong Technical Officer - Immunization WHO-Ghana KII 25/09/2022 Virtual 3 Dr Peter Gyamfi Kwarteng Health and Nutrition Specialist UNICEF-Ghana KII 1/10/2022 Virtual 4 Mr Al-hassan Hudi Consultant - Social and Behaviour Change and Immunization UNICEF Ghana KII 29/09/2022 Virtual 5 Dr Samuel Afari-Asiedu Research Fellow/Medi- cal Sociologist Kitampo Health Research Centre, GHS KII (2 participants) 30/09/2022 Virtual 6 Mr Lawrence Gyabaa Febir Research Fellow/So- ciologist Kitampo Health Research Centre, GHS 7 Dr Franklin Asiedu- Bekoe Director, Public Health Public Health Division, GHS KII 05/10/2022 Public Health Division Office 8 Dr Kwame Amponsa- Achiano Manager, Expanded Programme on Immu- nization Public Health Division, GHS KII 28/09/2022 WHO Country Office 9 Mr Mahama Seidu Deputy Director-Re- search & Healthy Public Policy Health Promotion Division, GHS KII 23/09/2022 Health Promotion Division Office 10 Mr Solomon Boakye Regional Disease Con- trol/EPI Officer GHS, Ashanti Region KII 27/09/2022 Regional Health Directorate, Ashanti Region Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 23 No. Name Title Institution Interview type, date and location 11 Mr Daniel Yeboah Asiamah Regional Surveillance Officer GHS, Ashanti Region KII 27/09/2022 Regional Health Directorate, Ashanti Region 12 Madam Francisca Esenam Ahiavih District Director GHS, Bosome Freho, Ashanti Region KII 26/09/2022 District Health Directorate, Bosome Freho, Ashanti Region 13 Mr Solomon Appau Disease control officer GHS, Bosome Freho, Ashanti Region KII 26/09/2022 District Health Directorate, Bosome Freho, Ashanti Region 14 Madam Rita Kyei Health Promotion Officer GHS, Bosome Freho, Ashanti Region KII 26/09/2022 District Health Directorate, Bosome Freho, Ashanti Region 15 Madam Joyce Kobia Registered Community Nurse GHS, Bosome Freho, Ashanti Region FGD (4 participants) 26/09/2022 Nsuaem CHPS, Bosome Freho, Ashanti Region 16 Madam Hawah Karim Community Health Nurse GHS, Bosome Freho, Ashanti Region 17 Madam Adiza Salia Enrolled Nurse GHS, Bosome Freho, Ashanti Region 18 Madam Christiana Owusu Enrolled Nurse GHS, Bosome Freho, Ashanti Region 19 Mr Quarcoo Anselm Public Health Officer GHS, Ga South, Greater Accra Region FGD (8 participants) 30/09/2022 Amanfro Polyclinic, Ga South, Greater Accra Region 20 Madam Prudence Boadi Community Health Nurse GHS, Ga South, Greater Accra Region 21 Madam Priscilla Mensah Nursing Officer GHS, Ga South, Greater Accra Region 22 Madam Caroline Armarboye Principal Nursing Officer GHS, Ga South, Greater Accra Region 23 Madam Justina Kwofie Senior Health Educator GHS, Ga South, Greater Accra Region 24 Madam Margaret Ayi-Bonte Deputy Chief Nursing Officer GHS, Ga South, Greater Accra Region 25 Mr Jones Anim Senior Public Health Officer GHS, Ga South, Greater Accra Region 26 Madam Rita Quainoo Health Promotion Officer GHS, Ga South, Greater Accra Region 24 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 Annex 3: Interview guide Introduction Euro Health Group has been commissioned by the WHO Evaluation Office to conduct a mid-term evaluation of the EYE strategy 2017–2026. The evaluation has both a summative component, which will assess progress of the strategy implementation to date, and a formative component, which will focus on the way forward. The temporal scope covers the period from 2017 to mid- 2022, and the geographical scope covers the global, regional and country levels (the country level comprises 40 high-risk countries in Africa and the Americas). As part of the mid-term evaluation, two country case studies will be undertaken (in Ghana and Brazil) to generate lessons and best practices on implementing the EYE strategy interventions. The main objectives of the country case study in Ghana are to: 1. document best practices in the implementation of the EYE strategy; 2. identify critical factors and key enablers for successful implementation of specific components of the EYE strategy; 3. identify potential for scale-up and replication, including investments/costs required. We will limit this interview to approximately one hour. Please note that all information shared for this evaluation, will be kept confidential and anonymized. Any citations and quotes will not be traceable to individuals or their titles/positions. 1. Introductory question Please introduce yourself and your role and engagement in yellow fever prevention/response in Ghana. 2. Experience with the COVID-19 and yellow fever integrated dual-antigen vaccination campaign in Ghana • Can you please explain the background of this specific dual-antigen vaccination campaign (why it was decided to use this approach) and how it was practically implemented? • From your perspective, what were the benefits (actual, not expected) of this approach (compared to separate single-antigen vaccination campaigns)? • In your view, what were the potential risks of delivering this dual-antigen vaccination campaign, and how were these risks addressed? Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 25 • How did vaccinators, health care workers, district health teams and communities/ beneficiaries receive this dual-antigen COVID-19 and yellow fever vaccination campaign (any concerns, any hesitations, gratitude, etc.)? • What were the specific results of this dual-antigen vaccination campaign? Do you have disaggregated data on the reach (gender, age, vulnerable communities etc)? • To your knowledge, what are the key enablers and critical factors that need to be in place for a successful dual-antigen vaccination campaign which includes yellow fever vaccine (factors that facilitated successful implementation of the intervention)? • In your view, should this approach be applied more often? and why/why not? • To what extent were gender, equity and human rights concerns addressed during the delivery of the dual-antigen vaccination campaign? • Do you have any costing data on the dual-antigen vaccination campaign? 3. Experience with the planning and implementation of yellow fever preventive mass vaccination campaigns in Ghana – including reaching vulnerable populations (e.g., nomadic populations and others) • Can you please explain the background of the yellow fever preventive mass vaccination campaigns (why was it decided to use this approach, what were the targets etc.?) • How was the yellow fever preventive mass vaccination campaign planned? Who was involved in the planning (agencies, national health authorities, CSOs), and what were their respective roles? How did this collaboration work? How long did it take to plan for this? • Were subnational yellow fever risk assessments used to guide the planning of target areas for the campaign? If so, who led this process, did they use a specific tool, etc.? • Did Ghana receive support from the WHO Regional Office for Africa or WHO headquarters during the campaign planning? If so, how did they use toolkits, direct support, country calls etc.? • Which potential challenges did you perceive in the planning and implementation of the yellow fever mass preventive vaccination campaigns, and how were these challenges overcome? • Who are the key vulnerable groups for yellow fever in Ghana - where are the immunity gaps, and how do you know this? What data exist on this? Which data are missing? What has been done so far to address this? Does it include reaching nomadic populations? How can data for yellow fever vaccination coverage among vulnerable groups be improved? 26 Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 • What specific strategies were used to reach vulnerable populations, including nomadic populations? What are the main lessons learnt about reaching vulnerable communities? • How were CSOs and communities involved in the yellow fever preventive mass vaccination campaigns? What are the lessons learnt in this regard? • In your view, what are the key enablers and critical factors that need to be in place for a successful yellow fever preventive mass vaccination campaign (factors that facilitated the successful implementation of the intervention)? • What were the specific results of this preventive mass vaccination campaign? Do you have disaggregated data on the reach (gender, age, vulnerable communities etc.)? • To what extent and how were gender, equity and human rights concerns addressed during the delivery of the yellow fever preventive mass vaccination campaign? • Going forward, what do you think are the opportunities for reaching high coverage of vulnerable populations with yellow fever vaccination? • Do you have any costing data on this preventive mass vaccination campaign and outreach to vulnerable communities, including nomadic populations? 4. Research to explore potential opportunities for improving vaccination coverage among nomadic populations. • How did the research come about? Who requested it? Who funded it? • Who are the collaborating partners, if any? What is the nature of the collaboration? • What are the objectives of the research? • How is the evidence from the research expected to be used? • Do you have any preliminary results to share/discuss? • What are the timelines for the research? 5. Are there any other key informants you would recommend we talk to? 6. Do you wish to add anything further? Any comments or questions for us? Mid-term evaluation of the Global strategy to eliminate yellow fever epidemics (EYE) 2017-2026 27