Establishing and strengthening immunization in the second year of life: practices for vaccination beyond infancy

Establishing and strengthening immunization in the second year of life Practices for vaccination beyond infancy Establishing and strengthening immunization in the second year of life: practices for vaccination beyond infancy ISBN 978-92-4-151367-8 © World Health Organization 2018 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. 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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 by büro svenja Printed in Switzerland Establishing and strengthening immunization in the second year of life Practices for vaccination beyond infancy iv Establishing and strengthening immunization in the second year of life CONT EN TS SECTION 1 Purpose and use of this document 9 1.1. Objectives 10 1.2 Intended users 11 1.3 Other publications to consult 11 Acronyms vi Acknowledgements viii SECTION 2 Introduction to life-course vaccination with an emphasis on the second year of life 12 SECTION 3 Background on vaccination in the second year of life and beyond 16 3.1 How widespread is vaccination in the second year of life? 17 3.2 Opportunities and benefits for vaccinating in the second year of life 18 3.3 Challenges to vaccination in the second year of life 22 SECTION 4 Policies and planning for vaccination in the second year of life and beyond 24 4.1 Steps for planning the introduction or strengthening of a 2YL visit 26 4.2 Deciding on the timing of the 2YL visit or visits 29 4.3 Catch-up vaccination at any time a child has contact with health services 30 4.4 Coordinating vaccination with other services in the second year of life 32 SECTION 5 Facility-level planning, service organization, and human resources 35 5.1 Update microplanning tools and processes 36 5.2 Review the implications for human resources for the 2YL visit 37 5.3 Determine the feasibility of providing all services desired for the 2YL visit and the practical issues of patient flow 39 v Establishing and strengthening immunization in the second year of life CONT EN TS Annexes 1. Examples of minimum standard and best practice tally sheets 90 2. Immunization monitoring chart showing MCV1-MCV2 drop-out 92 3. Scenarios for vaccination in the second year of life (for use in training and supervision) 93 4. Illustrative example of job aid on screening for vaccination 96 5. Frequently asked questions about vaccination in the second year of life 98 SECTION 6 Supply chain management for vaccines and other commodities 41 6.1 Commodities needed for vaccination and other services in the second year of life 42 6.2 Vaccines and vaccination supplies in the second year of life 45 SECTION 7 Recording, reporting, and using data for decision-making 48 7.1 Performance indicators 50 7.2 Data requirements 54 7.3 Updating forms and health information systems 56 SECTION 9 Communication, demand promotion, and community engagement 70 9.1 Data collection and analysis: understanding your target groups 74 9.2 Strategic design and planning 75 9.3 Development and testing of messages and materials 77 9.4 Implementation and monitoring 79 9.5 Evaluation and re-planning 80 SECTION 8 Health worker training and capacity-building 59 8.1 Determine required health worker competencies 60 8.2 Prepare the training curriculum 62 8.3 Plan the training strategy 65 8.4 Provide supportive supervision and other forms of post-training support 66 SECTION 10 Strengthening 2YL vaccination performance 82 10.1 Understanding the reasons for low performance 83 10.2 Taking actions to address the problems 87 vi 2YL second year of life AEFI adverse event following immunization BCG bacille Calmette-Guérin (vaccine) CDC Centers for Disease Control and Prevention (USA) CHW community health worker cMYP comprehensive multi-year plan CSO civil society organization DHIS2 district health information system, version 2 DHS demographic and health survey DQS data quality self-assessment DTP diphtheria-tetanus-pertussis containing vaccine DV-DMT district vaccination data management tool EID early infant diagnosis of HIV/AIDS EIR electronic immunization record EPI Expanded Programme on Immunization FAQ frequently asked question FIC fully immunized child GVAP Global Vaccine Action Plan GAVJ Gavi, the Vaccine Alliance GRISP Global Routine Immunization Strategies and Practices HBR home-based record HepB hepatitis B vaccine HepB-BD hepatitis B birth dose Hib Haemophilus influenzae type B HMIS health management information system iCCM integrated community case management ICG Interagency Coordinating Committee IMCI integrated management of childhood illness IPAC Immunization Practices Advisory Committee IPV inactivated polio vaccine ITN insecticide-treated bed net JE Japanese encephalitis KAP knowledge-attitude-practice study MCV measles-containing vaccine MCV1 first dose of measles-containing vaccine MCV2 second dose of measles-containing vaccine A B B R E V I A T I O N S A N D A C R O N Y M S Establishing and strengthening immunization in the second year of life A B B R E V I A T I O N S A N D A C R O N Y M S vii Establishing and strengthening immunization in the second year of life MDVP multi-dose vial policy MenA meningitis A vaccine MICS multiple indicator cluster survey MR measles-rubella vaccine MMR measles-mumps-rubella vaccine MOH Ministry of Health MOV missed opportunities for vaccination MUAC middle upper arm circumference NGO nongovernmental organization NITAG National Immunization Technical Advisory Group OPV oral polio vaccine PCV pneumococcal conjugate vaccine PIE post-introduction evaluation PIRI periodic intensification of routine immunization SAGE Strategic Advisory Group of Experts on Immunization SIA supplementary immunization activity SOP standard operating procedure TCV typhoid conjugate vaccine TOT training of trainers TTCV tetanus toxoid-containing vaccine UNICEF United Nations Children’s Fund VPD vaccine-preventable disease WHO World Health Organization viii Establishing and strengthening immunization in the second year of life A C K N O W L E D G E M E N T S This document was developed by the Expanded Programme on Immunization (EPI) of the World Health Organization (WHO) Department of Immunization, Vaccines and Biologicals with contributions from UNICEF and was prepared by Rebecca Fields of John Snow, Inc. The following individuals contributed substantially to its preparation and their input is gratefully acknowledged: Carolina Danovaro, Rudi Eggers, Messeret Eshetu, Tracey Goodman, Jan Grevendonk, Karen Hennessey, Penelope Kalesha Masumbu, Lisa Menning, Abrahams Mwanamwenge, Ikechukwu Ogbuanu, Stephanie Shendale, Emily Wootton (WHO); Ulla Griffiths, Imran Raza Mirza (UNICEF); Laura Conklin, Mawuli Nyaku, Melissa Wardle, Margie Watkins (CDC), and independent consultants Celestino Costa and Karen Wilkins. The guidance of the WHO Strategic Advisory Group of Experts (SAGE) on Immunization and the Immunization Practices Advisory Committee (IPAC) shaped the key principles and directions that are reflected here. The content of the document is based in part on a review of experience with vaccination in the second year of life in the Republic of Ghana, the Republic of Senegal and the Republic of Zambia. We offer sincere thanks to the Ministries of Health in those countries for having permitted the documentation and analysis of their experience in introducing immunization in the second year of life. www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 1 SECTION 9 Establishing and strengthening immunization in the second year of life Purpose and use of this document www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 10 Establishing and strengthening immunization in the second year of life 1 S E C T I O N This document provides practical guidance on establishing and strengthening immunization in the second year of life (2YL) and beyond. It also suggests ways that immunization visits during the 2YL can be used as a platform for delivery of other child- health services. 1.1 Objectives 1 While this document focuses largely on immunization during a scheduled visit in the second year of life, other health interventions are addressed to a limited extent. Detailed information on these interventions is beyond the scope of this document. Relevant publications are included in the Footnotes. 1. To assist countries in making informed decisions about establishing or strengthening a well- child visit (or visits) in the second year of life that includes vaccina- tion and other services as part of a continuum of care for children.1 2. To provide practical guidance on planning, managing, implement- ing, and monitoring vaccination services and improving immunization coverage during a scheduled visit in the second year of life that may include other health interventions. 3. To provide broad guidance on catch-up vaccination for children older than one year, who are delayed or missing vaccine doses (“un- and/or under- vaccinated”). 11 Establishing and strengthening immunization in the second year of life S E C T I O N 1 1.2 Intended users The intended users of this manual are primarily those who work at country level on immunization and other child-health services. They include: • country-level government decision-makers and programme managers for immunization, child health, nutrition, paediatric HIV/AIDS, community development, health education, health management information systems, cold chain and logistics management; • members of National Immunization Technical Advisory Groups (NITAGs), as well as other technical advisory bodies for child health and nutrition; • national, regional and global level immunization and child health advisors working with partner organizations such as WHO, UNICEF, development partners, and civil society organizations and nongovernmental organizations (NGOs). 1.3 Other publications to consult Some of the material in this document is addressed in greater detail in other publications and on WHO web pages. These are highlighted in key resource boxes throughout this guide. A number of other resources that will be important to consult if establishing or strengthening a 2YL platform are currently under development by WHO and will be available in the near future:2 • Working together: an integration resource guide for planning and strengthening immunization services throughout the life course • Handbook on the collection, assessment, and use of immunization data • Guide to introducing Meningococcal A conjugate vaccine into the routine childhood immunization programme. 2 Information on the latest drafts can be requested by contacting the WHO Department of Immunization, Vaccines and Biologicals at vaccines@who.int 12 Establishing and strengthening immunization in the second year of life 2 SECTION Introduction to life- course vaccination with an emphasis on the second year of life 13 Establishing and strengthening immunization in the second year of life S E C T I O N 2 The Global Vaccine Action Plan (GVAP),3 the global blueprint for action in immunization for the period 2011–2020, calls for the benefits of immunization to be equitably extended to all people. The Action Plan states that “a ‘life-course’ approach should be taken in order to make the benefits of immunization available to all those at risk in every age group” and recognizes that “this will mean creating strategies for reaching individuals throughout their life course and developing plans for the systems that will monitor and track progress.” The WHO’s Global Routine Immunization Strategies and Practices (GRISP) document also identifies vaccination beyond infancy as one of nine transformative actions that are critical to strengthening routine immunization.4 It encourages national immunization programmes to expand scheduled routine vaccination visits beyond the first year of life and provide needed vaccines in the preschool, school and adolescent and adult populations. Vaccination opportunities, such as healthy child visits in the second year of life, preschool preparation visits, and school visits should be used to assess vaccination status and administer any previously missed doses. The proper design, distribution, and long-term retention of home-based records (HBRs) are fundamental to ensure the proper screening and provision of vaccines to all who are eligible for them. While many countries already provide routine vaccine doses to children in the second year of life or later, vaccination after one year of age is expected to increase in the coming years. A booster dose of diphtheria-tetanus-pertussis (DTP) containing vaccine is increasingly recognized as being of public health importance and a second dose of measles-containing vaccine (MCV2) through routine immunization is recommended in all countries, with many countries scheduling it during the second year of life. For some vaccines, including pneumococcal, dengue, and meningitis A, schedule options include one or more routine doses in the second year of life. Some new vaccines, such as for malaria, will likely be recommended for children over one year of age. Having an established platform for vaccination in the second year of life will increase the potential uptake of these vaccines when they are introduced. However, vaccination is just one of many health interventions that young children need in order to thrive. As a health service that is often highly used relative to other interventions, immunization can be a platform to provide other essential services, such as growth monitoring and promotion, management of common illnesses, proper sanitation and, in some places, deworming, vitamin A supplementation, micronutrient supplementation, malaria prevention and care, and HIV/AIDS care.5 Interventions to improve growth and development in the first two years of life have a higher impact than in later years. A scheduled visit during this period is also an 3 www.who.int/immunization/global_vaccine_action_plan/en/ 4 www.who.int/immunization/programmes_systems/policies_strategies/GRISP/en/ 5 www.UNICEF-irc.org/article/958/ 14 Establishing and strengthening immunization in the second year of life 2 S E C T I O N opportunity to provide counselling to parents on nutrition, hygiene, home care practices, family planning, and timely care seeking. Many countries already have policies of regular visits for growth monitoring, promotion, and complementary feeding, but the use of the visits often drops after one year of age, as families and health workers alike may not view them as a priority. If managed strategically, vaccination visits in the second year of life (2YL) can help augment progress both for immunization and other maternal and child health services. B OX 1. K E Y P O I N TS FO R VAC C I N AT I O N I N T H E S EC O N D Y E A R O F L I F E A N D B E YO N D 1. An increasing number of vaccine doses are recommended to be given after one year of age as part of a life course approach to vaccination. WHO global recommendations for doses of childhood vaccines to be given after one year of age include a second dose of measles-containing vaccine (MCV) and booster doses of diphtheria, tetanus, and pertussis- containing vaccines. Additionally, countries may choose to adopt a “2 + 1” schedule for pneumococcal conjugate vaccine (PCV) in which the third dose is administered in the second year of life. WHO also recommends that doses of some regionally-indicated vaccines, including meningitis A (MenA) in the meningitis belt of Africa and Japanese encephalitis in parts of Asia, can be given after one year of age. 2. The extension of the vaccination schedule beyond infancy means that the concept of a “fully immunized child (FIC)” indicator must be expanded in the second year. FIC should be specific to the age of the child and the corresponding set of vaccines that the child should have received, as per the national schedule, by that age. Programmes may choose to track FIC in two or more age categories: FIC<1, FIC<2 (see Section 7.1). 3. With increasing complexity and duration of the vaccination schedule comes increasing importance of home-based records (HBRs), to remind caregivers of when to return to complete the schedule, to allow providers to screen for needed vaccinations, and to serve as a basis for evaluation through population-based coverage surveys. HBRs must be well- designed, available in sufficient supply for all caregivers, used properly by health personnel, and kept safely by caregivers/families. 4. In some settings, concerted efforts, including strong communication and health worker capacity-building, are needed to change conventional thinking that immunization is just for infants. If high levels of coverage in 15 Establishing and strengthening immunization in the second year of life S E C T I O N 2 the second year of life and throughout the life course are to be achieved, then health workers, caregivers, communities, and partners must have a solid understanding of why it is important and what they themselves can do to make it happen. This requires a major shift in thinking and practices by all parties involved. 5. Whereas children should be vaccinated as soon as they are eligible, those who are brought “late” should not be denied vaccination. Timely vaccination is crucial for reducing exposure to vaccine-preventable diseases (VPDs) but, with a few specific exceptions, it is better to vaccinate late than never. For 2YL vaccination, the age of 24 months should not be viewed as a cut-off point after which children are not vaccinated. 6. Achieving high coverage in the second year of life, even with vaccines that have long been part of the vaccination schedule, requires even more attention, visibility and preparation as for introducing a new vaccine, and should not be taken lightly. The very high MCV1 to MCV2 drop-out rates observed in many countries attest to the challenges in vaccinating a new age group. Areas requiring special attention include data management/monitoring and evaluation, communication, and health worker capacity building, including supportive supervision and other forms of post-training support. 7. Data management, monitoring, and evaluation for vaccination in the second year of life pose particular challenges. Tally sheets and other data management tools must be updated carefully to correctly capture all doses administered (even if the doses are not timely) and to encourage proper health worker screening, recording and reporting of doses administered, which will be needed to ensure good vaccine management and estimation of needs. Monitoring progress across at least two birth cohorts and providing meaningful feedback can be challenging. Careful planning and learning from experience to date is needed to address these issues. 8. Vaccination in the second year of life can serve as a platform for providing other essential services to children and mothers. If carefully coordinated with other programmes, immunization services can reinforce and stimulate the uptake of other health services, such as growth monitoring and promotion, nutritional counselling, vitamin A and micronutrient supplementation, deworming, health education and family planning, malaria prevention, and follow-up on early infant diagnosis of HIV/AIDS. Each country must assess the timing and schedules of these services and determine the feasibility of integration based on an examination of the human, material and financial resources needed. 16 Establishing and strengthening immunization in the second year of life 3 SECTION Background on vaccination in the second year of life and beyond 17 Establishing and strengthening immunization in the second year of life S E C T I O N 3 3.1 How widespread is vaccination in the second year of life? While the vaccines given in the second year of life (or later) and the ages at which they are administered vary across countries, vaccination in the second year of life is a widespread practice. As of 2016,6 recommended that DTP4 be given in the second year of life. 6 WHO vaccine-preventable diseases: monitoring system. 2017 global summary. http://apps.who.int/immunization_monitoring/globalsummary/schedules, accessed 18 July 2017. had immunization policies that included at least one dose of any vaccine to be given in the second year of life. included two doses of measles- containing vaccine (MCV) in their routine immunization schedules. recommended that the second dose, MCV2, be given in the second year of life. include both MCV2 and a fourth dose of vaccine containing diphtheria, pertussis, and tetanus (DTP4) at any age. had policies calling for both MCV2 and DTP4 to be provided at the same time in the second year of life. 159 COUNTRIES 86 COUNTRIES 160 COUNTRIES 135 COUNTRIES 107 COUNTRIES 45 COUNTRIES 18 Establishing and strengthening immunization in the second year of life 3 S E C T I O N 3.2 Opportunities and benefits for vaccinating in the second year of life There are several reasons for establishing a strong platform for vaccination and other interventions in the second year of life and beyond. Increase protection against vaccine-preventable diseases (VPDs) The addition of new vaccines, and new doses of existing vaccines, in the second year of life increases the extent to which children can be protected from VPDs, as shown in Table 1 below. The provision of additional doses of vaccines that are already in the national schedule contributes to higher levels of immunity and longer duration of protection. The immune response to tetanus toxoid-containing vaccine (TTCV), for example, decreases with age, which is why WHO recommends that an individual receives six doses (three primary plus three booster doses, one of which should be given in the second year of life).7 TA B L E 1. WHO-RECOMMENDED VACCINES TO BE ADMINISTERED IN THE SECOND YEAR OF LIFE 7 Use of TTCV combinations with diphtheria toxoid (Td or DT) for subsequent tetanus boosters are strongly encouraged, to maintain high immunity to both diphtheria and tetanus throughout life. VAC C I N E W H O R EC O M M E N DAT I O N S Second dose of measles-containing vaccine (MCV2), including measles- rubella (MR) and measles-mumps- rubella (MMR) vaccines WHO recommends that a second dose of MCV be added to the routine immunization schedule in all countries. Where risk of measles mortality among infants remains high, MCV1 should be administered at 9 months of age and MCV2 should be administered at 15–18 months with a minimum interval of four weeks between doses. In countries with low risk of measles infection among infants (i.e. near elimination), MCV1 may be administered at 12 months; the optimal age for delivering MCV2 is based on programmatic considerations that achieve the highest coverage of MCV2. Measles vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). Fourth dose of diphtheria-tetanus- pertussis-containing vaccine (DTP4) WHO recommends that children be given a booster dose of DTP-containing vaccine, preferably during the second year of life, to strengthen immunity against these diseases. Diphtheria vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/diphtheria/en/), Tetanus vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/tetanus/en/), Pertussis vaccines. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/pertussis/en/). 19 Establishing and strengthening immunization in the second year of life S E C T I O N 3 VAC C I N E W H O R EC O M M E N DAT I O N S Pneumococcal conjugate vaccine (PCV) WHO supports the option of a (2p+1) schedule for PCV in which two primary doses are provided in infancy and the third dose (booster) is given at 9-18 months of age.8 The timing of the booster should be selected to maximize coverage (usually 9, 12, 15 or 18 months) depending on operational and programmatic factors, including timing of vaccination contacts in the national immunization schedule for other vaccines. Pneumococcal vaccines. Position paper. Geneva: World Health Organization; 2012 (www.who.int/immunization/policy/position_papers/pneumococcus/en/) and WHO Strategic Advisory Group (SAGE) on Immunization, October 2017. Conclusions and recommendations. Geneva: World Health Organization; 2017 (www.who.int/wer/2017/wer9248/en/). Meningitis A conjugate vaccine (MenA) routine dose WHO recommends a single dose of MenA at 9–18 months based on local programmatic and epidemiological considerations. Meningococcal A conjugate vaccine: updated guidance. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/meningococcal/en/). Typhoid conjugate vac- cine (TCV) WHO recommends a single dose of TCV at 6-23 months in endemic countries. Timing of administration should be based on local epidemiological, geographic and programmatic considerations. WHO Strategic Advisory Group (SAGE) on Immunization, October 2017. Conclusions and recommendations. Geneva: World Health Organization; 2017 (www.who.int/wer/2017/wer9248/en/). Japanese encephalitis (JE) WHO recommends that JE vaccination be introduced into national immunization schedules in all areas where JE is recognized as a public health priority. WHO recommends one or two doses, starting from 6 months of age, with the schedule determined by local epidemiology and type of vaccine. Japanese encephalitis vaccines. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/japanese_encephalitis/en/). Seasonal influenza Country-specific information about risk groups, disease burden and cost-effectiveness are important to aid national policy-makers and health programme planners in making informed decisions about target groups and timing for vaccination. In those countries that decide to introduce it, WHO recommends seasonal influenza vaccination starting from 6 months of life and extending to 23 or 59 months, with two doses separated by at least 28 days for previously unvaccinated children <9 years of age. Vaccines against influenza. Position paper. Geneva: World Health Organization; 2012 (www.who.int/immunization/policy/position_papers/influenza/en/). Table 1. Continued 8 Both schedule options (3p+0 or 2p+1) are recommended. For countries that have yet to introduce PCV, decisions regarding the choice of schedule should take into account operational and programmatic issues, including timeliness of vaccination, coverage expected to be achieved with the third dose, and pneumococcal disease age distribution patterns. 20 Establishing and strengthening immunization in the second year of life 3 S E C T I O N Catch-up children on vaccinations that were missed during the first year of life Vaccination in the second year of life is an opportunity to provide missed doses of several antigens, including BCG,9 MCV, oral and inactivated polio vaccines, pentavalent (or DTP), pneumococcal vaccines, and rotavirus vaccine. In some settings, families may face various social, geographical, and economic barriers to getting their children fully immunized by 12 months of age and this contributes to low coverage. A strong 2YL platform provides an important oppor- tunity to improve overall protection and coverage. For instance, in a country where measles vaccine is given at 9 months of age and where a one-year age limit is enforced, children are by default limited to a three-month window to receive MCV1. This barrier would be removed by expanding vaccination services to the second year of life and encouraging catch-up vaccination beyond one year. Vaccinating children in the 2YL with measles and other vaccine doses missed in the first year of life contributes to higher levels of population immunity. This was demonstrated in a 2009 analysis of Demographic and Health Surveys (DHS) from 45 countries. It showed that while pooled routine immunization coverage for MCV1 by 12 months of age was only about 50%, it rose to over 80% if the doses given after 12 months of age (i.e. “late doses”) were included in the coverage estimates (see Figure 1).10 F I G U R E 1. I N C R E AS E I N E ST I M AT E S O F M CV 1 C OV E R AG E W H E N D OS E S A D M I N I ST E R E D I N T H E S EC O N D Y E A R O F L I F E A R E I N C LU D E D 0 20 40 60 80 100 MCV1 coverage by age category in selected countries Source: Demographic and Health Survey (Date of survey indicted for each country) Afghanistan (2015) Chad (2014) Haiti (2012) Mali (2013) Pakistan (2013) Yemen (2013) Zambia (2014) Coverage in children < 12 months Additional coverage in children 12–23 months 21 Establishing and strengthening immunization in the second year of life S E C T I O N 3 Create opportunities to integrate vaccination with other health and nutrition interventions A scheduled routine contact with the health system in the second year of life is an opportunity to further integrate immunization with other health interventions, such as vitamin A supplementation, nutritional counselling, growth monitoring and promotion, deworming, paediatric HIV/AIDS care, provision of insecticide-treated bed nets (ITNs), or family planning. Figure 2 illustrates the potential gains in coverage for several child health interventions when integrated with the routine immunization platform in Africa. F I G U R E 2. E ST I M AT E D C OV E R AG E O F I N T E RV E N T I O N S A M O N G H O U S E H O L DS W I T H A C H I L D AG E D 1 2 - 2 3 M O N T H S, I F I N T EG R AT E D W I T H RO U T I N E I M M U N I Z AT I O N ( 2 8 SU B -SA H A R A N A F R I CA N C O U N T R I E S ) 0 20 40 60 80 100 Improved source of drinking water* household bed-net ownership child sleeping under bed-net child received vitamin A supplementation Current coverage Likely total coverage *through provision of point-of-use water treatment kits (after Improved source of drinking water) 9 The WHO position paper on BCG vaccines was recently updated to include the recommendation for catch-up vaccination for unvaccinated older infants and children, as evidence shows that it is still beneficial beyond one year of age. BCG vaccines. Position paper. Geneva: World Health Organization; 2018. www.who.int/wer/2018/wer9308/en/ 10 Clark A, Sanderson C. Timing of children’s vaccinations in 45 low-income and middle-income countries: an analysis of survey data. Lancet. 2009;373:1543–9. 22 Establishing and strengthening immunization in the second year of life 3 S E C T I O N Make more efficient use of vaccines Providing two doses of measles-containing vaccine, with one in the second year of life, can potentially reduce vaccine wastage rates as more doses per opened vial of vaccine will be given. This may also be true for catching up children with other vaccine doses that they missed in infancy and are given at a later age. 3.3 Challenges to vaccination in the second year of life Over the past 40 years, immunization programmes have accumulated a wealth of experience in delivering vaccines, primarily to infants. Since vaccination in the second year of life has been introduced in many countries, experience has been mixed. For example, many national programmes assumed the introduction of MCV2 through a new routine visit in the second year of life would be straightforward, as MCV is already in the schedule in the first year of life and therefore, familiar to caregivers and health workers. However, reality has shown that it brings substantial complexity, in some cases of a nature not previously encountered by immunization programmes. High drop-out rates from MCV1 to MCV2 have been a particular concern in many countries. Successful implementation of vaccination in the sec ond year of life requires strong planning, coordination, community mobilization and demand creation, monitoring, and support for implementation. © W H O N epal 23 Establishing and strengthening immunization in the second year of life S E C T I O N 3 Many immunization programmes still view immunization as a health intervention purely for infants, and do not offer vaccinations to children over one year even if they were never vaccinated. While policies must be established for vaccination beyond one year of age, without proper planning, training, and communication, these policies will not automatically translate to widespread changes in vaccination practices. Factors that have been shown to contribute to this situation include: • insufficient messaging to front-line health workers on revised policies regarding provision of vaccination and other health services after one year of age; • health worker hesitation to vaccinate children >12 months of age with MCV1 because it does not contribute to MCV1 coverage and they may worry about not having enough doses for the <12 months children; • lower priority placed on vaccination of older children, compared with vaccination of infants; • Insufficient communication and social mobilization to remind and encourage caregivers to use health services in the second year of life; • complexity in recording, reporting, and analyzing vaccine doses given after one year; • system barriers, such as limited human resources and uncoordinated supply chains, for different commodities. Post-introduction evaluations (PIEs) of measles second dose in several countries, plus case studies on 2YL vaccination, indicate that the introduction of any vaccination after the first year of life should be treated as if it were a new vaccine introduction in terms of attention, visibility, and preparation, and the added complexities of vaccinating a new age group should be adequately accounted for in the planning process. If possible, 2YL vaccination should also be placed within the context of a healthy child visit so that it can reinforce the provision of other health interventions, and vice versa. 24 Establishing and strengthening immunization in the second year of life Policies and planning for vaccination in the second year of life and beyond 4 SECTION 25 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Virtually all countries already have in place policies, guidelines, and other programme supports for child health care through the first five years of life, including growth monitoring and promotion, nutritional counselling, and integrated management of childhood illness, among others. Depending on their health priorities and current vaccination schedule, countries may want to: introduce vaccination in the second year of life as a new inter- vention (through a scheduled visit, or visits and catch-up of missed vaccination) strengthen existing 2YL vaccination (e.g. improve low MCV2 coverage), and/or develop a 2YL vaccination contact as a platform for coordinated delivery of other child health services. In all three situations, systematic planning is needed to address both technical and managerial issues. The second situation (improvement of existing programmes) is addressed in Section 10. 1. 2. 3. © U N IC EF/U N 0 58138/V ishw anathan 26 Establishing and strengthening immunization in the second year of life 4 S E C T I O N 4.1 Steps for planning the introduction or strengthening of a 2YL visit If setting up a new immunization visit in the 2YL, the planning process should begin one year prior to the anticipated launch date to permit sufficient time for the preparations described below. More detail on operatio- nalizing these steps can be found in a companion resource A handbook for planning, implementing, and strengthening vaccination into the second year of life (2YL Handbook).11 Identify a 2YL focal point and establish or activate a 2YL working group The 2YL focal point should be a staff member of the national immunization programme with sufficient authority to convene a working group. The working group should include representation from various areas of the immunization programme, such as data management, communications and service delivery. If other health interventions are to be coordinated with 2YL vaccination, then representation from these groups should also be included. Major stakeholders and partners in immunization and child health should also be involved. Membership in the working group — K E Y R E S O U RC E A handbook for planning, implementing, and strengthening vaccination into the second year of life A companion resource to this document, the 2YL Handbook is intended for use after the decision has been made to extend vaccination into the 2YL, or improve coverage of an existing platform. The 2YL Handbook provides practical guidance on planning, managing, implementing and monitoring vaccination during a scheduled visit, or visits, in the 2YL, as well as useful steps for strengthening vaccination when coverage in the 2YL has not reached programme targets. www.who.int/immunization/ programmes_systems/policies_ strategies/2YL/en/ Establishing and strengthening immunization in the second year of life Handbook may expand as planning evolves. The National Immunization Technical Advisory Group (NITAG) should be engaged and play a leading role in reviewing epidemiological and clinical considerations, as well as immunization programme needs, costing and financing issues, and the development of policies and guidelines. The Interagency Coordinating Committee (ICC) and/or health sector coordinating committees should also be engaged to enlist commitment and to establish a shared understanding of resource requirements. 11 www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 27 Establishing and strengthening immunization in the second year of life S E C T I O N 4 — K E Y R E S O U RC E Tool for estimating the costs of introducing a 2YL healthy child visit13 UNICEF has developed a relatively simple Excel-based costing tool to estimate the costs of introducing a 2YL visit. The tool must be populated with demographic data, commodity prices, health worker salaries and approximate costs for training and communication activities. Results are then presented in terms of total costs, annual costs and costs per visit. Costs are divided into “up-front” costs (such as training) and recurring costs that need to be continually financed (such as vaccines and syringes). The cost analysis can be viewed as an advocacy opportunity for introducing a 2YL visit. The tool should also be used as an integral part of the planning process. Develop a budgeted plan of action and secure funding This should include activities, lead responsibilities, milestones, timelines, and resources needed to address the following actions, and should be informed by lessons learned and challenges from previous vaccine introductions. 1. Update policies and guidelines; obtain necessary approvals; produce and disseminate (print and/or electronically). 2. Define 2YL indicators for recording and reporting, revise health management information system (HMIS) and data management tools (HBRs, registers, monthly reports), and distribute these in advance of the launch date. 3. Identify and address needs for organization of service delivery. 4. Modify supply chain and logistics management tools, as needed, to include new doses of vaccines and other interventions in the second year of life. 5. Prepare, print and distribute a field guide and job aids for health workers. 12 Tools for conducting behavioural analyses, including Guide for studying health worker/caregiver interactions for immunization. Geneva: World Health Organization; 2017 and The guide to tailoring immunization programmes (TIP). Copenhagen: WHO Regional Office for Europe; 2013, are available at: www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/. 13 The 2YL costing tool can be accessed at: www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 6. Develop a training plan and new training and supervision materials, and carry out training. 7. Develop a communication strategy, plan and conduct social mobilization and community engagement activities, including knowledge-attitude-practice (KAP) studies or other behavioural analyses,12 particularly regarding marginalized and hard-to-reach communities. 8. Secure funding for carrying out all preparatory work, and to cover operational and other related costs associated with 2YL. 28 Establishing and strengthening immunization in the second year of life 4 S E C T I O N Policies, guidelines and standards • Vaccination policy and reference manuals • National health/child health policy • Guidelines and other reference materials for health workers, including for IMCI Planning documents • Comprehensive multi-year plan (cMYP) and the annual plan of action for immunization • Formats for microplanning and plans for introducing them Data management tools • HBR • Tally sheets • Monthly reporting forms • Health facility registers • Community registers • HMIS, District Vaccination Data Management Tool (DV-DMT), district health information system, version 2 (DHIS2) • Monitoring tools and charts Training and capacity-building • Curricula for in-service and pre-service training • Supervision instruments • Job aids Supply chain management • Assessment of cold chain, logistics, and available storage • Standard operating procedures (SOPs) for handling of vaccines in 2YL • Vaccine and logistics forecasting tools Communication, demand creation • Communication and community engagement plan and strategy • Plans and materials for launch • Health education materials and job aids Assign clear responsibilities for each aspect of preparation. Groups or committees that have been established to work on such issues, for vaccination campaigns or new vaccine introductions, in the past, can be re-activated. However, if other health interventions are to be included together with 2YL vaccination, then there should also be representation from other programmes, such as nutrition, integrated management of childhood illness (IMCI), malaria, water and sanitation, paediatric HIV/AIDS, etc. Agree on the services or interventions to be provided during the visit and identify the policies, guidelines, and other materials that must be revised. These are likely to include the following, in Table 2 below, but there may be additional materials to revise depending on the country. TA B L E 2. M AT E R I A L S TO R E V I E W A N D U P DAT E FO R 2 Y L VAC C I N AT I O N A N D S E RV I C E S 29 Establishing and strengthening immunization in the second year of life S E C T I O N 4 4.2 Deciding on the timing of the 2YL visit or visits A key step is to decide on the appropriate age at which to schedule the 2YL visit (or visits). This is a function of epidemiological data for the VPDs in question, plus the schedule for other child health services, as specified by national policies. Policy- and decision-makers need to consider public health goals and programmatic issues, using transparent criteria to evaluate their relative importance. National immunization policies and guidelines should be written to clearly articulate the actions needed by health personnel and caregivers. For example: • Clarify that, although it is best to vaccinate children as soon as they become eligible, for most vaccines there is no upper age limit after which the child should be denied the protection of vaccination. The exceptions are rotavirus vaccine, which is not recommended > 24 months of age, and hepatitis B (HepB) birth dose.14 • Convey the intended purpose of the 2YL vaccine doses. If the country is introducing a second dose of MCV into its routine schedule, then the dose must be included in the fully immunized child (FIC) requirement, and the dose should be referred to as Measles 2 or MR2 or MMR2, rather than a booster dose. AG E S FO R S C H E D U L E D 2 Y L V I S I TS FO R VAC C I N AT I O N I N T H R E E C O U N T R I E S One Southern African country decided to provide MCV2 at 18 months because it coincides with the age for vitamin A supplementation. A West African country chose to provide MCV2 at 15 months to minimize the length of potential exposure to measles virus, even though the timing was not synchronized with the schedule for other health services provided during the second year of life. A South Asian country initially introduced MCV2 and DTP4 at different months in the second year of life for epidemiological reasons. However, it was later recognized that this added complexity to the immunization schedule and contributed to missed opportunities for vaccina- tion. The country then modified the schedule to recommend both doses at the same visit. C O U N T RY E X P E R I E N C E 14 It is important that programmes have a clear policy on how late HepB birth dose can be administered. Some countries stop providing HepB birth dose beyond two weeks after birth in order to maintain a four-week gap between doses. However, in countries using a 4-dose schedule (with combination vaccine), a four-week gap is not necessary prior to the first primary dose (as the combination schedule meets the dosing requirements), therefore, HepB birth dose can be given up until the day before the first combination vaccine is due. Both options are acceptable. For more information, see A guide for introducing and strengthening Hepatitis B birth dose vaccination. Geneva: World Health Organization; 2015 (www.who.int/immunization/documents/general/ISBN9789241509831/en/). 30 Establishing and strengthening immunization in the second year of life 4 S E C T I O N • Provide clear instructions on how to properly screen children for eligibility by reviewing HBRs, record doses, report data, and use it for improving services. • Specify the actions that health workers should take when faced with situations that do not represent the ideal, such as children arriving with missing or delayed doses, children arriving with no HBR, etc. (see Annex 3). • Clearly state the policy on vaccinating children who are 12 months or older and missing doses, during periodic intensification of routine immunization (PIRI) activities such as Child Health Days (see Box 2 below). 4.3 Catch-up vaccination at any time a child has contact with health services Sick-child visits and visits to facilities for care of other family members in the second year of life are also opportunities to catch children up on missed doses from the first year of life, and to screen and vaccinate them for doses scheduled for the second year of life. L E A R N I N G F RO M G H A N A’S I M M U N I Z AT I O N P O L I CY The Republic of Ghana’s immunization policy has been updated to provide clear guidance to health workers about vaccinating children older than 12 months of age. Second year of life routine immunization policy Additional routine contact for immunizations will be done during a child’s second year of life at 18 months of age or soon after. Services available at this contact include MR2, MenA, and any intervention deemed appropriate (e.g. Vitamin A supplementation). Catch-up policy All children should be immunized per Ghana’s recommended immunization schedule. Children with any missed doses should be vaccinated with appropriate antigen up to five years of age. During any health visit, a child’s immunization status should be assessed and missed doses administered per the recommended catch-up schedule. Fully immunized child (FIC) The FIC indicator is split into three categories: FIC by age one, FIC by age two, and FIC after age two. A child is considered fully immunized by his/ her age if he/she has received all the age-appropriate vaccines up to that point. C O U N T RY E X P E R I E N C E 31 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Immunization policies and health worker training/ supervision should emphasize the importance of caregivers bringing the child’s HBR to health facilities for every visit and providing catch-up vaccination at any time that a child has contact with the health system. Clear guidelines for catch-up vaccinations for antigens missed in the first year of life should be established and disseminated widely, including an accelerated vaccination schedule for children who present missing multiple vaccine doses. A useful resource for this is the WHO recommendations for catch-up vaccinations, available at: www.who.int/immunization/policy/Immunization_routine_table3.pdf B OX 2. P ROV I D I N G 2 Y L VAC C I N AT I O N D U R I N G P I R I E V E N TS Periodic intensification of routine immunization (PIRI) activities, such as Child Health Days or Maternal and Child Health Weeks, if regularly conducted, should be used to catch-up children for missed doses from the first year of life and to provide 2YL vaccinations for which the child is eligible. Immunization policies and health worker training for the PIRI should provide clear guidance on this point. PIRI activities should also be used as an opportunity to communicate the importance of immunization in the second year of life and the need for children to be brought for all recommended 2YL vaccinations according to the national schedule. PIRI activities should also underscore the importance of encouraging caregivers to bring the child’s HBR to every health contact. Guidance for health workers on screening, provision of services, and recording of doses, both for the routine 2YL doses and for the PIRI, should be included in policies, field manuals, training, and supervision. For more information on best practices for PIRI activities, please see WHO resource Periodic Intensification of Routine Immunization. Lessons learned and implications for action, available at: www.who.int/immunization/ programmes_systems/policies_strategies/piri_020909.pdf? © W H O 32 Establishing and strengthening immunization in the second year of life 4 S E C T I O N 4.4 Coordinating vaccination with other services in the second year of life If it is decided to use the 2YL vaccination visit to deliver additional interventions, then the planning process must engage representatives from other related health programmes. Analyse and compare the technical attributes of other interventions proposed for the scheduled 2YL visit(s) The priorities, objectives, achievements, challenges, and plans of different evidence-based health and nutrition interventions offered in the second year of life should be compared systematically to identify both the opportunities and the limits of a 2YL vaccination contact in reinforcing other services. This may entail convening a meeting, or meetings, to foster direct communication and negotiation among stakeholders regarding the continuum of care for young children and the role of immunization within it. The package of services to be provided during the 2YL visit should be based on a combination of technical, managerial, and client-oriented considerations. Questions to consider in deciding on the components of the package include the following: • What are the established public health priorities of the Ministry of Health? • Which interventions can be provided at ages 12-23 months, are any of these visits already established, and does their timing coincide with a recommended schedule for 2YL vaccination? • Which services, and how many, can be scheduled for a single visit in the 2YL, and will this improve convenience for the child and caregiver? • Can all of the interventions be provided to children through fixed (static), outreach, and mobile services, and are these service delivery strategies fully functional? • Are the proposed interventions for this visit carried out throughout the entire country or only in certain geographic areas? • How similar are the logistical requirements? • What are the implications for human resources, including capacity of staff, time to be spent per patient, and patient flow? • Are sufficient human and financial resources available for providing and sustaining each intervention proposed for the visit? 33 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Some countries have planned for integrated services that include vaccination beyond one year of age and have evaluated the experience to identify ways of improving services. The lessons learned from such experiences can help guide other countries in their decision-making and planning processes. Z A M B I A’S PAC K AG E O F I N T E RV E N T I O N S FO R A C O M P R E H E N S I V E H E A LT H Y C H I L D V I S I T AT 1 8 M O N T H S O F AG E One year after the Republic of Zambia introduced MCV2, the Ministry of Health and partners reviewed the experience in order to decide how to strengthen performance and integrate 2YL vaccination with other services. A meeting was convened in which officials from several programmes, including immunization, nutrition, and child health, as well as representatives from the HMIS, provincial and district teams, and key technical partners, deliberated on ways in which the 2YL visit for MCV2 could serve additional health needs. A key outcome was definition of the package of services shown below. This reflected, in part, a decision by the MOH to shift its delivery strategy for vitamin A supplementation and deworming away from reliance on Child Health Weeks and into routine services. At 18 months, all children now receive the following: • MCV2 • catch-up of other vaccinations that the child missed in the first year of life and for which he or she is still eligible • growth monitoring and promotion • Vitamin A supplementation • deworming treatment (mebendazole). For some children, if indicated, the following are also provided: • follow up/referral on early infant diagnosis (EID) for HIV/AIDS • referral for IMCI or integrated Community Case Management (iCCM) for children with fever or other signs of illness during the visit. C O U N T RY E X P E R I E N C E © U N IC EF/U N 0 152973/Scherm brucker 34 Establishing and strengthening immunization in the second year of life 4 S E C T I O N LESSONS LEARNED FROM HONDURAS IN INTEGRATING I M M U N I Z AT I O N W I T H OT H E R S E RV I C E S I N T H E F I RST F I V E Y E A RS O F L I F E The immunization programme in the Republic of Honduras serves as a strong platform for providing other services from 2-5 years of age. These include vitamin A supplementation, folic acid for mothers, promotion of exclusive breastfeeding, education on identifying ocular tumours, and local time-limited measures to contain cholera outbreaks and control dengue. A study of early experience showed the following. • Close coordination and joint planning across different programmes and different levels of the health system is key to success. • Jointly-prepared technical and programmatic guidelines are essential to clearly define the delivery of the interventions to be provided during the healthy child visits that include immunization. • Health personnel at all levels must be trained on the technical guidelines. • Timely and accurate forecasting, procurement, distribution, and storage are needed for all supplies, not just vaccines, required at health facility level for the healthy child visit. • A communications working group should develop a strategic communication plan that includes materials development, use of mass media, community engagement, and a timeline and budget. • Forms for data recording and reporting must be adapted and the HMIS updated accordingly. • Systematic monitoring, by age group and strategy of progress against goals should be carried out. • Joint supervision with personnel from all relevant programmes should prioritize densely-populated areas and areas at risk. • Challenges to sustained integration include uncertain funding and limited supplies of key commodities. Source: Molina-Aguilera et al. J. Inf. Dis. 2012:205 (Suppl 1) C O U N T RY E X P E R I E N C E © U N IC EF/U N I440 79/D eC esare 5 SECTION 35 Establishing and strengthening immunization in the second year of life Facility-level planning, service organization, and human resources 36 Establishing and strengthening immunization in the second year of life 5 S E C T I O N The introduction of a scheduled 2YL visit for vaccination requires detailed planning to implement it within the existing organization and delivery of fixed, outreach, and mobile services. District and facility supervisors have an important role to play in adjusting microplanning and reviewing the organization of services, patient flow, human resources, and prevention of missed opportunities for vaccination. The national level should provide guidance for updating microplanning templates and for ensuring high-quality service delivery, especially if there is a preferred sequence for administering the interventions. Vaccination, as an invasive procedure, should generally be provided after other procedures.15 However, the health worker should complete the interaction with the caregiver by providing guidance on what to do in the event of side-effects or adverse events, and when and where to return for the next visit. 5.1 Update microplanning tools and processes In many countries, microplanning tools currently in use are designed to support planning for vaccination in the first year of life. To accommodate 2YL vaccination, microplanning tools must be revised and expanded to include the second year cohort aged 12-23 months. The target population is surviving infants from the previous year’s birth cohort. For example, if DTP4 is scheduled to be given to children who are 18 months of age or older, then the target group for microplanning for the current year is the number of surviving infants from the previous year. This information should be available from the previous year’s plans. Timely vaccination during a scheduled visit in the second year of life is highly desirable, but the age of 24 months should not be viewed as a cut-off point after which children are denied vaccination. Microplanning should be based on the cohort aged 12-23 months and, even if children are vaccinated later than the targeted age, it does not affect the number or catchment area of the children to be vaccinated, just the age at which they actually receive the vaccines. As further described in Section 7, all doses, regardless of when they are given, should be recorded on HBRs, tally sheets, facility registers, electronic immunization records (EIRs), and monthly reports, according to the age at which the child actually received the vaccines. 15 Reducing pain at the time of immunization. Position paper. Geneva: World Health Organization; 2015 (www.who.int/wer/2015/wer9039.pdf). 37 Establishing and strengthening immunization in the second year of life S E C T I O N 5 Microplanning should give particular attention to identifying outreach sites that are convenient for the caregiver(s), bearing in mind that a child in the 2YL is now older, heavier, and less easy to transport than an infant. Mothers are also more likely to be working outside the home. To improve access and reduce drop-out rates, the site selection, day of the week, and time of day for outreach sessions should, where possible, be decided in consultation with the community members. The provision of additional health services during the scheduled 2YL visit means that microplanning should address the operational features of those services as well as those of immunization. Personnel responsible for nutrition, child health, water and sanitation, HIV/AIDS, family planning, health education, or other programmes, should be encouraged to take part in the microplanning process. 5.2 Review the implications for human resources for the 2YL visit Many low-resource countries face severe limitations in human resources so that the true staffing situation in health facilities falls short of government standards. The ability to provide multiple services during the visit requires that the right types of health workers are present at each facility. During the 2YL planning phase at national level, health officials should review the actual availability of human resources in health facilities, and provide guidance on which types of staff can carry out each task. Terms of reference and accountabilities may need to be revised. At the clinic level, head nurses or facility in-charges should clearly communicate the sequence of services, both for fixed and outreach services. They should also designate which staff will carry out specific tasks (described further in Section 8). These include: • screening children to determine which services they should receive that day; • providing each service in a pre-defined order: e.g. growth monitoring and promotion, Vitamin A supplementation, deworming, vaccination, counselling; • recording services administered, in all the appropriate tools, immediately after the services are provided; • discussing, with each caregiver, what the child has just received and what further actions the caregiver needs to take. In smaller health facilities where one, or few, staff carry out all functions, it is pref- erable that all health workers at the facility are trained to provide all 2YL services to ensure continuous service delivery when any members of the team are on leave. 38 Establishing and strengthening immunization in the second year of life 5 S E C T I O N At both fixed and outreach service delivery points, community health workers (CHWs) or trained volunteers may be able to assist health workers with patient flow, health education, and possibly some aspects of record keeping. Within the communities, CHW tasks may include recording newborns, maintaining community registers of children 0-59 months of age and pregnant women, defaulter tracking and follow-up, talking with community members about the importance of vaccination and other services in the second year of life, and informing them of when and where to seek services. However, some tasks are less appropriate for CHWs or volunteers. For example, screening of 12-23 month old children for eligibility for vaccination is more complex than for infant vaccination, as the number of doses these children should have received by that age is greater and there may be uncertainty about how to handle missing or late doses. This is, therefore, likely to require trained health workers. In small health facilities with limited staff, it is pref erable that all health workers are trained to provide all 2YL services to ensure continuous service delivery when any members of the team are on leave. © W H O /Reidy 39 Establishing and strengthening immunization in the second year of life S E C T I O N 5 5.3 Determine the feasibility of providing all services desired for the 2YL visit and the practical issues of patient flow In low-resource settings, it may not always be possible to have all the services available at the same time and in the same place. For instance, a national level mandate for daily vaccination may not be feasible in a small facility with only one or two health workers providing all services. In situations like this, it is important to communicate widely and mobilize communities to come for services on the specific days that they are offered. At district and facility level, health officials should consider the following questions: • What would be the specific tasks for each type of health worker in providing vaccination, plus other services, during the 2YL visit? What, if anything, will he/she do differently from current practice on a daily, monthly, quarterly, or annual basis? — K E Y R E S O U RC E S Missed Opportunity for Vaccination (MOV) resource guides The WHO strategy for reducing missed opportunities for vaccination (MOV) aims to increase immunization coverage by making better use of existing vaccination sites (at health centres, hospitals, outreach/ mobile services, etc.) In addition to improving coverage, reducing MOV will improve health service delivery and promote synergy between programmes. www.who.int/immunization/ programmes_systems/policies_ strategies/MOV/en/ • What bottlenecks are likely to occur that may result in long waiting times, especially in high-volume facilities? Clinic supervisors should determine how to reduce waiting times. • In situations where all patients first go through the registration clerk prior to accessing services, can this step be used to communicate with parents, answer their questions, and triage children to the different service points? In some instances, it may be possible to provide certain services at the registration or waiting area before mothers or caregivers disperse to other departments. Immunization or other staff may need to be posted to the registration desk on a rotational basis to assist with this step. 40 Establishing and strengthening immunization in the second year of life 5 S E C T I O N 16 MOV assessments conducted in Chad (2015), Timor Leste (2015), and Burkina Faso (2016) indicated a higher proportion of MOVs occurring in the second year of life. • Are all services proposed to be provided during a 2YL visit for vaccination actually offered and available on the same days? Missed opportunities for vaccination and other services arise when not all staff and services are provided at the same time and place. The added complexity of the 2YL visit may require revising the schedule for outreach services, to optimize the use of human resources. • Are policies and practices in place so that all children carry their HBRs and are screened and vaccinated, as appropriate, when they come for any type of care (curative and/or preventive)? Recent country assessments have shown that rates of missed opportunities for vaccination (MOV) are particularly high during visits in the second year of life.16 Therefore, it is important to design and organize services in ways that encourage coordination across different health interventions. Assessment findings further indicate that only 1-2 visits for preventive care take place during the second year of life, so there is an even greater need to capitalize on these opportunities. If a country has conducted an MOV assessment, the findings should be incorporated into planning to better organize services. Policies should be put in place to ensure that all children carry their HBRs and are screened and vaccinated, if needed, when they come for any type of health service. © W H O 41 Establishing and strengthening immunization in the second year of life Supply chain management for vaccines and other commodities 6 SECTION 42 Establishing and strengthening immunization in the second year of life 6 S E C T I O N 6.1 Commodities needed for vaccination and other services in the second year of life Planners should review all supplies required for the 2YL visit, both for vaccination and other services. Any adjustments needed for forecasting, distribution, and storage should be identified and addressed to ensure that all commodities are available at each service delivery point. Table 3 presents an illustrative example based on the package of services adopted in Zambia. Countries can adapt this to correspond to the package of services that they intend to include in their 2YL healthy child visit. TA B L E 3. I N T E RV E N T I O N S A N D C O M M O D I T I E S FO R VAC C I N AT I O N A N D OT H E R S E RV I C E S I N A S C H E D U L E D 2 Y L V I S I T (illustrative example) S E RV I C E / I N T E RV E N T I O N C O M M O D I T I E S N E E D E D ST E P S TO P R E PA R E FO R 2 Y L V I S I T Vaccine dose recommended in the 2YL (MCV2, MenA, DPT4/Penta booster) • Vaccine • Diluent • Needles and syringes • Safety boxes • Updated data management tools • Forecast additional quantities of vaccine needed, if any • Assess needs for additional cold storage capacity • Forecast additional quantities of needles and syringes needed • Estimate additional safety boxes needed • Review and address increased needs for waste management • Update recording and reporting tools Catch-up of other vaccinations missed in the first year of life • Vaccine • Diluent • Needles and syringes • Safety boxes • Updated data management tools • Forecast additional quantities of vaccine, if needed • Assess needs for additional cold storage capacity • Forecast additional quantities of needles and syringes needed • Estimate additional safety boxes needed • Review and address increased needs for waste management • Ensure data management tools allow for recording/reporting “late” doses 43 Establishing and strengthening immunization in the second year of life S E C T I O N 6 S E RV I C E / I N T E RV E N T I O N C O M M O D I T I E S N E E D E D ST E P S TO P R E PA R E FO R 2 Y L V I S I T Vitamin A supplementation • 200 000 IU capsules of Vitamin A • Clippers/scissors • Data management tools • Forecast quantities needed for vitamin A to be provided through routine 2YL visit. This may represent a change in service delivery strategy (if previously provided through semi-annual Child Health Days, for example) • Review quantities provided in essential drug kits to determine whether they are sufficient to meet needs for routine services • As needed, address gaps between forecasted needs and quantities available through essential drug kits Deworming treatment • Deworming medication • Data management tools • Forecast quantities needed for deworming treatment to be provided through routine 2YL visit • Compare with quantities provided in essential drug kits to determine whether they are sufficient to meet needs for routine services • As needed, address gaps between forecasted needs and quantities available through essential drug kits Growth monitoring and promotion • Weighing scales • Middle upper arm circumference (MUAC) tapes • Counselling materials • Growth record, if separate from HBR • Data management tools • Review availability for all supplies and materials at service delivery point based on estimated levels of utilization and attendance during second year of life Follow-up on early infant diagnosis of HIV/AIDS • Data management tools • Counselling materials • Review whether additional quantities of medications such as cotrimoxazole are needed as part of follow-up steps 17 In general, additional quantities may not be required as these are “delayed vaccinations” of children already accounted for in vaccine forecast of previous year, not additional doses. However, to cover wastage at field level, countries may consider extra doses for catch-up based on previous years’ coverages. 44 Establishing and strengthening immunization in the second year of life 6 S E C T I O N Depending on which interventions countries choose to provide along with immunization in the 2YL, other potential commodities to consider may include: • preventive zinc supplementation or zinc use in diarrhoea management18 • multiple micronutrient powders • treatments for severe acute malnutrition • iron supplements • insecticide-treated bed nets (ITNs) In some countries, commodities such as vitamin A supplementation and deworming medication are provided primarily through campaign-style activities, such as semi-annual Child Health Days or weeks that have their own supply chains, which operate independently of those for routine services. If countries decide to 18 www.who.int/elena/titles/zinc_diarrhoea/en/ 19 www.who.int/nutrition/publications/micronutrients/guidelines/vas_6to59_months/en/ 20 www.who.int/neglected_diseases/preventive_chemotherapy/9789241547109/en/ © U N IC EF/U N I12580 0/N esbitt shift to providing them through an integrated 2YL visit, then they must ensure that there are sufficient quantities at all service delivery points for routine delivery. In countries where these commodities are provided to health facilities as part of essential drug kits, determine whether the kits provide sufficient quantities to meet the needs of 2YL visits. Countries can consult their existing programme guidelines and standards or global references including the WHO guidelines Vitamin A supplementation in infants and children 6–59 months of age19 and Preventive chemotherapy in human helminthiasis. Coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers.20 45 Establishing and strengthening immunization in the second year of life S E C T I O N 6 6.2 Vaccines and vaccination supplies in the second year of life 21 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ — K E Y R E S O U RC E Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring This resource outlines the key principles and issues to be considered when introducing a new vaccine into a national immunization programme, and includes references and tools/checklists for planning, implementation, and monitoring. Importantly, this guide also highlights the ways to use the opportunity of adding a new vaccine to strengthen immunization and health systems. www.who.int/immunization/ programmes_systems/policies_ strategies/vaccine_intro_ resources/nvi_guidelines/en/ Principles and considerations for adding a vaccine to a national immunization programme FROM DECISION TO IMPLEMENTATION AND MONITORING In forecasting requirements for vaccination in the second year of life, the target population is surviving infants from the previous year’s birth cohort. For example, if MenA is scheduled to be given to children at 18 months, then the target group for forecasting purposes for the current year is the number of surviving infants from the previous year. As noted in Box 1, timely vaccination during a 2YL visit is highly desirable, but the age of 24 months should not be viewed as a cut-off point after which children are denied vaccination. The practical implications for forecasting are that it should be based on the cohort aged 12-23 months. If children are vaccinated later than 23 months, it does not affect the number of doses required, just the age at which they actually receive these doses. While the doses should be accurately recorded and reported on tally sheets and monthly reports according to actual age of vaccination, this should not affect stock management practices. Introducing a new vaccine If an entirely new vaccine (for example, MenA) is to be introduced into the routine immunization schedule in the second year of life, then country planners should consult the WHO document Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring. Sections 3.4 and 3.5 contain an in-depth discussion of vaccine management and forecasting.21 The specific modifications to vaccine supply chain management will depend on the characteristics of the new vaccine being introduced. 46 Establishing and strengthening immunization in the second year of life 6 S E C T I O N Adding another dose of a vaccine that is already in the schedule If the 2YL visit will include provision of an additional or booster dose of a vaccine already in the national schedule, the preparations necessary will also depend on the vaccine(s) in question. The introduction of a second dose of measles or MR vaccine in 10-dose vials has been estimated to require a 15-25% increase in cold chain storage space. The need for additional vaccine doses is offset to some extent by an expected reduction in the wastage rate for vaccines in 10-dose vials because, due to the larger target population, more doses will be used per vial. It has been estimated that the measles wastage rate could be reduced by 40% with the switch from a one-dose schedule to a two-dose schedule.22 Programme managers and logisticians also need to monitor and revise the wastage rate and wastage factor for measles-containing vaccine based on any changes in policies, or actual practices, regarding circumstances for health workers to open multi-dose vials of these vaccines. With additional training or skills reinforcement, it should become standard practice for health workers to open 10-dose vials when only one or two children are brought to an immunization session. This practice would improve timely immunization, 22 A guide to introducing a second dose of measles vaccine into routine immunization schedules. Geneva: World Health Organization; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) pp. 21–22. — K E Y R E S O U RC E A guide to introducing a second dose of measles vaccine into routine immunization schedules This resource provides guidance to support policy discussions and operational aspects of the introduction of a second dose of measles vaccine into the routine immunization schedule. It provides useful direction on issues specific to vaccinating in the second year of life, including vaccine forecasting, communications, and data monitoring. http://www.who.int/im- munization/documents/WHO_ IVB_13.03/en/ A Guide to Introducing a Second Dose of Measles Vaccine into Routine Immunization Schedules which is an important programme priority, particularly for measles. However, it could potentially increase wastage rates. With regard to introducing DTP4, the effect on supply chain management is determined by the vaccine product to be used. For example, if a country that uses pentavalent vaccine for infant vaccination plans to provide DTP4 using DTP only, then the situation is similar to adding a new vaccine to the cold chain. If the country 47 Establishing and strengthening immunization in the second year of life S E C T I O N 6 decides instead to provide DTP4 in the form of an additional dose of pentavalent vaccine, then the additional cold storage requirements may be minimized and, programmatically, it will be easier to manage supplies. Using pentavalent vaccine means that additional doses of hepatitis B and Haemophilus influenzae type B (Hib), though not harmful, will be provided without any necessity. This is a decision that will need to be weighed by the country programme. Catch-up vaccination for doses missed in the first year of life Many countries already account for some catch-up vaccination using existing supplies. With the introduction of a 2YL platform and strengthened policies for catch-up vaccination, it is possible that vaccine and logistics requirements will increase in the short term; therefore, managers should monitor trends in vaccine consumption so that they can adjust their vaccine forecasts accordingly. The potential impact on vaccine and cold chain management of catch-up vaccination can be estimated based on a combination of factors, including past trend data on immunization in children over one year of age, the expected number of doses of each vaccine to be given after one year, and whether the vaccine vials in question can be used on subsequent days after being opened, as per the multi-dose vial policy.23 Other commodities for vaccination Increased quantities of needles, syringes and safety boxes are required to accommodate the additional vaccinations to be provided in the second year. Section 3.5 of Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring provides detailed guidance on this topic.24 The quantities of these supplies needed will depend on the estimated coverage for each dose of each vaccine and this is likely to change over time. In some countries, the MCV1 to MCV2 drop-out rate was initially high but then fell within a few years, whereas in others, high drop-out rates have persisted. Programme managers and logisticians should monitor actual patterns of coverage and vaccine consumption each year, and adjust their targets and forecasts accordingly. 23 WHO Policy Statement: Multi-dose vial policy (MDVP), Revision 2014. Geneva: World Health Organization; 2014 (www.who.int/immunization/documents/general/WHO_IVB_14.07/en/). 24 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ 48 Establishing and strengthening immunization in the second year of life 7 SECTION Recording, reporting, and using data for decision-making 49 Establishing and strengthening immunization in the second year of life S E C T I O N 7 The recording, reporting, and use of data at all levels can be the most complex aspect of introducing vaccination in the second year of life. The target groups to be vaccinated, or provided with other services, must be clearly defined and appropriate denominators used to calculate coverage in these target groups. To determine the data requirement, decisions must be made about the types of information and indicators to be used to monitor performance and guide action. Data recording and reporting instruments need to be revised carefully and with input from end-users to ensure that they promote correct screening for eligibility, service provision, and recording and reporting practices by health personnel. This section examines the following topics: 1. PERFORMANCE INDICATORS. Programmes must decide how to monitor introduction and performance and how indicators will be used to guide activities and decision-making. They must also consider alternative ways of obtaining programme data such as through population- based coverage surveys or knowledge- attitude-practice (KAP) surveys. 2. DATA REQUIREMENTS. Once performance indicators are known, data requirements for generating the indicators can be defined. 3. UPDATING DATA FORMS AND SYSTEMS. This includes all recording, reporting, and monitoring tools. © U N IC EF/U N 0 26564/Parry 50 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.1 Performance indicators A core principle in deciding which changes to make to data management tools and procedures is that only those data that are likely to be used should be collected. Countries should be aware that there are certain global immunization indicators that must be reported on a regular basis. However, other data needs may vary across countries, depending on programme priorities and problems. Table 4 presents immunization indicators relevant to establishing or strengthening a 2YL visit. Measuring 2YL indicators requires recording and tallying doses administered by the age of administration. In settings where vaccination is known to happen late and improving timeliness is a priority, tally sheets can be disaggregated to three age groups: 0-11 months, 12-23 months, and >24 months. This will enable the programme to monitor whether timeliness improves over time. A country with a strong record of timely vaccination may not see this as important and may prefer that their tally sheets have only two age groups: 0-11 months, and >12 months. To avoid overloading health workers with reporting requirements, countries should carefully consider what, if any, additional data will be needed for 2YL indicators and take the opportunity to review, and possibly remove, indicators not currently used. On this basis, countries need to decide which data to collect administratively each year, from all vaccine service delivery points and which data to collect less frequently through population-based coverage surveys such as Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), or KAP studies. It is important to differentiate between data collected through each of these methods. Population-based coverage surveys for routine immunization must be adapted to capture data for all doses administered. The WHO Vaccination Coverage Cluster Surveys: Reference Manual (2017)25 provides guidance on defining the target populations to be surveyed if immunization extends beyond one year of age. For coverage of vaccines recommended between 12–23 months of age (for example, MCV2, DTP4), the Reference manual suggests surveying children aged 24–35 months of age in addition to those 12–23 months usually surveyed for vaccines recommended <12 months. Monitoring drop-out from MCV1 to MCV2 MCV1 to MCV2 drop-out should be monitored at national, subnational and facility level based on monthly summary reports. Monitoring charts are also encouraged at facility level. This is complicated by the fact that the doses are scheduled to be 25 www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index2.html 51 Establishing and strengthening immunization in the second year of life S E C T I O N 7 26 A guide to introducing a second dose of measles vaccine into routine immunization schedules. Geneva: World Health Organization; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) Annex 6, p.16. given to two different birth cohorts; however, in reality, the actual difference in size between cohorts for two consecutive years is very small so, for the purpose of calculating the drop-out, the same denominator should be used for calculating coverage of both doses. The recommended denominator to use is surviving infants for the cohort receiving MCV1.26 A sample coverage monitoring chart including MCV1-MCV2 drop-out is included in Annex 2. Monitoring if all interventions to be provided during a scheduled 2YL visit are provided The 2YL visit is an opportunity to provide multiple services to the same child, encouraging greater use of services during a vulnerable age. It is important to have in place a system for monitoring uptake of all interventions provided during the 2YL visit. For example, if performance for immunization is higher than that for other services, it could flag obstacles to delivery and could help managers to identify specific problems and explore solutions. If all services to be provided during the 2YL visit were recorded in the same register, then facility heads and supervisors can perform regular spot checks to assess the extent to which children coming for the 2YL visit receive all of them. On the other hand, recording multiple services in the same place can result in a large unwieldy register that can quickly become impractical. The feasibility of these recording practices should be discussed and tested with health workers. Uptake of integrated interventions can also be monitored through facility visits, surveys and exit interviews. Determining fully immunized child (FIC) The addition of new vaccines and new doses of existing vaccines in the second year of life adds complexity to the health worker’s task of using administrative data to determine a FIC according to age and the country’s immunization schedule. FIC, as an indicator, must be specific to the age of the child and the corresponding set of vaccines that the child should have received by that age, as per the national schedule. It is increasingly the case that a child should receive 15 or more doses of vaccines in the first 15-18 months of life. This increases the amount of time the health worker needs to review the child health card or go through all entries in the register to determine if the child is fully vaccinated. One option is to split the indicator into two or more categories (FIC<12 months, FIC<24 months). Alternatively, programmes may opt not to include FIC in the tally sheets, but rather monitor the indicator(s) through periodic vaccination coverage surveys. 52 Establishing and strengthening immunization in the second year of life 7 S E C T I O N TA B L E 4. SU M M A RY O F I M M U N I Z AT I O N I N D I CATO RS R E L AT E D TO 2 Y L I N D I CATO R RECOMMENDATION I N T E R P R E TAT I O N P OT E N T I A L ACT I O N S I F LOW P E R FO R M A N C E DATA S O U RC E C OV E R AG E ‘Total MCV2’ MCV2 given anytime (timely plus late) Core indicator Proportiona of children vaccinated with at least two routine doses of measles-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of two doses of measles-containing vaccines, or improving defaulter tracing. Administrative data or population-based survey ‘Total DTP4’ Fourth dose of DTP-containing vac- cine given anytime (timely plus late) Core indicator Proportiona of children who received a booster dose of DTP-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of a booster dose, or improving defaulter tracing. Administrative data or population-based survey Doses of other vaccines scheduled to be given after one year of age (e.g. MenA) Core indicator Proportiona of children who received the indicated doses in the vaccination schedule after 12 months Analyse reasons for low performance. Depending on reasons identified, possible actions may include ensuring an adequate supply of vaccine, strengthening health worker skills, and conducting communication or social mobilization activities to promote the demand for, and use of, these vaccines. Administrative data or population-based survey Fully Immunized Child (FIC) by 24 months Optional unless source of data is a population-based survey Proportion of children vaccinated, in a timely manner, with all doses of all vaccines that are in the national immunization schedule to be given by the age of <24 months Review reasons and take actions. If indicated, work to change paradigm of EPI as an infant programme to one that reaches multiple birth cohorts. Actions may include strengthening health worker knowledge and skills through training, supervision, and feedback; strengthening defaulter tracing; improving data reporting, and increasing communication and social mobilization directed at health workers, communities, families, and caregivers. Population-based surveys Other health interventions, e.g., vitamin A supplementation at ages scheduled in country programme Consult relevant pro- gramme for guidance Check with relevant health programmes for interpretation Seek input from other programmes to analyse reasons for low performance and appropriate actions to take. Seek guidance from the relevant programmes T I M E L I N E S S ‘Late DTP3’ DTP3 after 12 months Optional indicator Captures number of children who complete their primary DTP-containing vaccine series late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Implement better recall/reminder systems to timely track potential defaulters. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey ‘Late MCV1’ MCV1 after 12 monthsb Core indicator Captures number of children who receive MCV1 late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey D RO P - O U T MCV1-MCV2 drop-out rate Core indicator Describes those who are not coming back for a second dose of a measles- containing vaccine Through supervision, feedback, and training, improve health worker interpersonal communication to remind caregivers to return for second dose; strengthen health worker technical skills as needed; increase defaulter tracing and communication with communities about need for MCV2 Population-based survey or administrative data at national and subnational levels. It may be possible to analyse such data at the facility level. a Denominator should be birth cohort of 12-23 months (i.e. surviving infants), even if data is age-disaggregated into three groups. b This indicator is most useful in countries where MCV1 is recommended to be given at 9 months. In countries where MCV1 is scheduled to be given at 12 months or later it would need to be modified accordingly. 53 Establishing and strengthening immunization in the second year of life S E C T I O N 7 TA B L E 4. SU M M A RY O F I M M U N I Z AT I O N I N D I CATO RS R E L AT E D TO 2 Y L I N D I CATO R RECOMMENDATION I N T E R P R E TAT I O N P OT E N T I A L ACT I O N S I F LOW P E R FO R M A N C E DATA S O U RC E C OV E R AG E ‘Total MCV2’ MCV2 given anytime (timely plus late) Core indicator Proportiona of children vaccinated with at least two routine doses of measles-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of two doses of measles-containing vaccines, or improving defaulter tracing. Administrative data or population-based survey ‘Total DTP4’ Fourth dose of DTP-containing vac- cine given anytime (timely plus late) Core indicator Proportiona of children who received a booster dose of DTP-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of a booster dose, or improving defaulter tracing. Administrative data or population-based survey Doses of other vaccines scheduled to be given after one year of age (e.g. MenA) Core indicator Proportiona of children who received the indicated doses in the vaccination schedule after 12 months Analyse reasons for low performance. Depending on reasons identified, possible actions may include ensuring an adequate supply of vaccine, strengthening health worker skills, and conducting communication or social mobilization activities to promote the demand for, and use of, these vaccines. Administrative data or population-based survey Fully Immunized Child (FIC) by 24 months Optional unless source of data is a population-based survey Proportion of children vaccinated, in a timely manner, with all doses of all vaccines that are in the national immunization schedule to be given by the age of <24 months Review reasons and take actions. If indicated, work to change paradigm of EPI as an infant programme to one that reaches multiple birth cohorts. Actions may include strengthening health worker knowledge and skills through training, supervision, and feedback; strengthening defaulter tracing; improving data reporting, and increasing communication and social mobilization directed at health workers, communities, families, and caregivers. Population-based surveys Other health interventions, e.g., vitamin A supplementation at ages scheduled in country programme Consult relevant pro- gramme for guidance Check with relevant health programmes for interpretation Seek input from other programmes to analyse reasons for low performance and appropriate actions to take. Seek guidance from the relevant programmes T I M E L I N E S S ‘Late DTP3’ DTP3 after 12 months Optional indicator Captures number of children who complete their primary DTP-containing vaccine series late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Implement better recall/reminder systems to timely track potential defaulters. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey ‘Late MCV1’ MCV1 after 12 monthsb Core indicator Captures number of children who receive MCV1 late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey D RO P - O U T MCV1-MCV2 drop-out rate Core indicator Describes those who are not coming back for a second dose of a measles- containing vaccine Through supervision, feedback, and training, improve health worker interpersonal communication to remind caregivers to return for second dose; strengthen health worker technical skills as needed; increase defaulter tracing and communication with communities about need for MCV2 Population-based survey or administrative data at national and subnational levels. It may be possible to analyse such data at the facility level. 54 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.2 Data requirements Determining denominators For vaccinations scheduled to be given after the first year of life, the best target is the estimate of surviving infants from the previous year’s birth cohort. Administrative vaccine coverage can then be estimated by dividing the current year’s administered doses (numerator) by the estimated number of surviving children from last year’s birth cohort (denominator). Recording doses administered Vaccine doses should be tallied in at least two age groups (0–11 months, and >12 months) as a minimum standard or, preferably, three age groups (0–11 months, 12–23 months, >24 months) as a best practice. Examples of tally sheets with these two alternative age groupings are shown in Annex 1. The creation of additional subcategories for recording doses, such as service delivery (fixed or outreach), adds to the workload for health workers and increases the potential for mistakes; therefore, disaggregating by extra groupings beyond age must be carefully considered. The ways in which such additional data will be used to guide activities should be clearly identified in order to determine if it actually needs to be collected. If required, separate tally sheets can be used for fixed and outreach sessions, and monthly reporting sheets should have separate rows for fixed and outreach sessions against each antigen. Monitoring health indicators by sex has been recommended by some to ensure equity; however, coverage surveys have shown repeatedly that the child’s gender is FIC, as an indicator, must be specific to the age of the child and the corresponding set of vaccines that the child should have received by that age, as per the national schedule. © U N IC EF/U N 0 59893/Rom eo 55 Establishing and strengthening immunization in the second year of life S E C T I O N 7 27 State of Inequality: Childhood immunization. Geneva: World Health Organization; 2016 www.who.int/gho/health_equity/report_2016_immunization/en/ B OX 3. P RO M OT I N G AC C U R AT E R EC O R D I N G A N D R E P O RT I N G TO I M P ROV E S E RV I C E S Health workers may be reluctant to record doses accurately if they fear that they will be disciplined for documenting practices that are not in accordance with national standards. Proper documentation of actual practices is essential if problems are to be detected and addressed; therefore, accurate recording and reporting must be encouraged and supported. For example, if a first dose of MCV is given after one year of age, it needs to be recorded as the first dose, regardless of the age of the child. If health workers feel pressure to report that they have not exceeded established vaccine wastage rates, they may turn mothers and children away unimmunized if just one or two children show up for MCV or other lyophilized vaccines in multi-dose vials that must be discarded within six hours of reconstitution. Denying these children vaccination on that day is a missed opportunity for vaccination, prolongs exposure to disease and risks losing these children from the system for good. Supervisors have an important role to play in promoting accurate recording and reporting of data and in supporting health workers with decision-making when they face less than ideal circumstances. not a barrier for vaccination.27 Hence, given the added complexity that stratification places on the administrative system, WHO does not recommend tallying doses by sex. Similarly, it is not advisable to try to separate doses given to children within a catchment area versus those outside the catchment area. If concerns exist about inequalities in childhood immunization, by sex or other characteristics, it is recommended that when surveys are implemented, they be powered to detect inequalities or disparities in coverage. Including three age groupings to record doses addresses the common problem of how to record late doses of vaccine. If children come for immunization or other 2YL services at 24 months of age or older, they should not be denied vaccination or other care. Health workers should provide the doses and services and record them on the tally sheet, HBR, child register, and monthly summary report, in the age column that corresponds to the child’s age when the dose or services were actually received. Country field guides should provide clear instructions and scenarios on administering, tallying, recording, and reporting of late doses. 56 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.3 Updating forms and health information systems All data collection and reporting instruments should be reviewed and revised, as needed, to accommodate 2YL data requirements. A user-centered approach to the design of data instruments should be used to foster proper screening, vaccination, recording, and reporting of doses. Data recording tools should promote the key concept that full immunization includes doses given in the second year of life or later. As health workers are expected to use HBRs, tally sheets, and registers on a daily basis, the tools should be designed with their input and formally pre-tested to assess how well they are understood and how easy they are to use. These steps will help avert problems in recording data or even in vaccination practices, such as denying vaccination if a child comes late. The pre-test findings should inform the revision of the tools themselves and strengthen training on their proper use. Functionality of current tools should be reviewed, on an ongoing basis, through data quality reviews or assessments,28 in order to eliminate or revise aspects that are not being used properly, or at all. Engage representatives from HMIS and all programmes involved to develop a plan to review and revise the system and to ensure updates are synchronized with the dissemination of paper-based tools, including HBRs. Reporting systems should be examined to eliminate duplication and contradiction among parallel systems (for example, the HMIS and DV-DMT or other vaccination- specific information systems) in order to avoid increased workload and reduce the possibility of health worker confusion. Prepare a plan with budget, timeframe, and secure funding, for revising all data collection and reporting instruments. The plan should designate lead responsibilities, processes for review, timeframe, quantities required, budget, funding source, and a clear dissemination plan. The budget should include the costs for printing sufficient quantities of HBRs and all new forms plus distributing them to all facilities to replace older forms and registers. All new instruments should be ready in time for training of health workers so that they can gain direct experience with using them. If electronic immunization records (EIRs) and other electronic systems are used at health facility level, the changes in 28 For example, the Data Quality Self-assessment (DQS). The DQS is a flexible toolbox of methods used to evaluate different aspects of the immunization monitoring system at district and health facility levels. For details and tools visit: www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index3.html 57 Establishing and strengthening immunization in the second year of life S E C T I O N 7 all aspects of the system must be made in time for training, so that health workers are able to practice using them. Revise all relevant data collection instruments. • HBRs should contain sufficient space for the health worker to record all routine doses of vaccines, their dates of admin- istration, and other services provided during the 2YL visit. HBR design should allow for easy screening by all health workers (including non-immunization staff providing curative care) for doses due. The WHO Practical guide for the design, use and promotion of home-based records in immunization programmes (see Key Resource) provides user-friendly advice for producing high-quality HBRs. • Tally sheets should be designed in a way that guides health workers to accurately record doses administered, disaggregated by age groups, as described above and shown in Annex 1. • Monthly summary reports should capture and summarize all data produced by the tally sheets. For example, if the tally sheet contains space for reporting doses ad- ministered outside the recommended age range, or fixed/outreach sessions, then the monthly summary should also capture this so that health workers do not have to improvise their own solutions. • Registers should include space for additional doses (and possibly other interventions) to be provided in the 2YL visit, and beyond, without restricting the recording of doses to the second year of life. The amount of data to be entered should be determined by how it will be used, time needed to enter the data, cost, and the bulkiness of the registers. It is also crucial that registers, or tickler files, be organized in a manner that facilitates tracking defaulters. — K E Y R E S O U RC E Practical guide for the design, use and promotion of home-based records in immunization programmes HBRs, such as vaccination cards or integrated child health records, should be designed to serve the needs of the health system and promote appropriate health practices among caregivers. They must be made available to all caregivers free of charge, and properly filled in. Health workers should encourage caregivers to safeguard HBRs and retain them for several years. However, they should not punish or deny services to those who have lost or forgotten them, as this could discourage caregivers from returning for immunization or other essential services. Lost or damaged HBRs should be replaced free of charge. www.who.int/immunization/ monitoring_surveillance/ routine/homebasedrecords/en/ FOR THE DESIGN,USE AND PROMOTION OF IN IMMUNIZATION PROGRAMMES PRACTICAL GUIDE HOME-BASED RECORDS 58 Establishing and strengthening immunization in the second year of life 7 S E C T I O N B OX 4. H B RS FO R I M M U N I Z AT I O N A N D OT H E R C H I L D H E A LT H S E RV I C E S With immunization extending into the second year of life and beyond, and more vaccines included in the vaccination schedule, it is increasingly important that all mothers or caregivers have HBRs that document children’s vaccination status and provide key information on immunization and health. Immunization policies and health worker training/ supervision should emphasize the importance of caregivers bringing the child’s HBR to health facilities for every visit to screen for vaccine eligibility at any time that a child has contact with the health system. Some countries have introduced immunization status checks at the time of enrolment in primary education (school registration), and caregivers should be reminded of the importance to save the HBR until the child is enrolled in the education system. As described in Section 8, training and supervision should address unusual circumstances that health workers are likely to encounter that would complicate the ability to record and report doses accurately. Annex 3 provides some sample scenarios for illustrative purposes. © W H O 59 Establishing and strengthening immunization in the second year of life 8 SECTION Health worker training and capacity-building 60 Establishing and strengthening immunization in the second year of life 8 S E C T I O N The success of any health intervention depends on competent front-line health workers and managers. In health worker capacity-building, “competencies” are defined as being comprised of skills, knowledge, and attitudes. For vaccination and other well-child services in the second year of life to be viewed as a priority, health workers’ interpersonal skills, motivations and attitudes need to be addressed in training, supervision, and the feedback they are given. Training is essential for introducing new skills, but must be followed with post-training support to reinforce skills and improve practices on an ongoing basis. Representatives from all programmes involved in a 2YL vaccination visit should contribute to the process of developing the training curriculum. A training workplan, timeline, and budget for developing the training materials should be developed so that there is clear, shared understanding of responsibilities and deadlines for drafting, reviewing, finalizing, and producing the training materials and any supporting materials, such as slides, job aids, materials for exercises, etc. Training, supervision, and other means of post-training support should reinforce policies and standard operating procedures including the core principle that timely vaccination is ideal but (with few exceptions) late vaccination is preferable to no vaccination at all. 8.1 Determine required health worker competencies A key step is to identify the competencies required of all cadres of health personnel involved in vaccination and other health and nutrition interventions in the second year of life and later. A task analysis or learning needs assessment should be conducted to clearly identify which staff are responsible for carrying out specific duties, as noted in Section 5. For a 2YL visit that includes other health services, trainers should identify the expected tasks and required competencies of: • vaccinators; • other health care providers involved in an integrated 2YL visit; • health facility supervisors or in-charges; • community health workers (CHWs); • district- or regional-level staff responsible for immunization, child health, logistics management, data management, and advocacy, communication, community engagement and social mobilization. 61 Establishing and strengthening immunization in the second year of life S E C T I O N 8 One way to approach this is to list the specific changes to health worker responsibilities on a daily, weekly, monthly, and annual basis, that result from introducing vaccination after one year of age. B OX 5. H E A LT H WO R K E R C O M P E T E N C I E S FO R 2 Y L VAC C I N AT I O N Training and capacity-building for 2YL vaccination must ensure that health workers can correctly carry out the following tasks. 1. Prepare microplans and forecast commodity needs for reaching an additional cohort based on a correct estimate of the target population.29 2. Screen children properly to determine any vaccine doses needed. This requires knowledge of the immunization schedule (including whether there is an upper age limit for any vaccines or doses), the minimum interval between doses, what to do in case of late or interrupted vaccinations, how to screen for eligibility if the child lacks a HBR, and whether a child who has come for curative care can be vaccinated. 3. Communicate clearly with caregivers as follows: • When caregivers bring their children for vaccination in the first year of life, particularly for MCV1, explain the reasons and benefits for returning for vaccination and other services in the 2YL. Clearly inform caregivers of when they should return and indicate this on the HBR. • During the 2YL visit, thank the caregiver for coming and provide standard information on the vaccines received, including the fact that receiving simultaneous injections is safe, and address caregiver concerns about side-effects. 4. Provide child with other services during the 2YL visit, such as growth monitoring and promotion, vitamin A supplementation, and deworming medication, as per national policy. 5. Record and report the doses administered during the 2YL visit on tally sheets, HBRs, child registers, and monthly summary reports. 6. Identify and trace defaulters so that they complete the vaccination schedule. This may entail managing and supporting CHWs. 7. Review the facility’s data to assess performance and problem-solve to address issues related to 2YL vaccination that need attention. 29 For information and tools for effective micro-planning, see Chapter 3 of Reaching Every District (RED): A guide to increasing coverage and equity in all communities in the African Region, 2017 revision, available at: www.afro.who.int/publications/reaching-every-district-red-guide-increasing-coverage-and-equity-all-communities 62 Establishing and strengthening immunization in the second year of life 8 S E C T I O N 8.2 Prepare the training curriculum Much of the technical content on proper administration of vaccines and the provision of other well-child services is already available in existing training materials. It can be adapted and updated as needed for 2YL training. The curricula for other programmes that may be integrated with 2YL vaccination, such as nutrition and child health, should also be reviewed and updated as needed. New training content should be developed for the 2YL-specific competencies noted above. These competencies serve as the basis for defining the learning objectives for the training curriculum. The learning objectives help to focus the training on the “must know” as opposed to “nice-to-know” content. Learning objectives are also a useful basis for meaningful pre- and post-test questions. The use of well-designed pre- and post-tests based on the learning objectives serves two purposes. First, they give information on the effectiveness of the training itself and can therefore help identify ways to strengthen it. Second, they identify areas of limited understanding. This information can then be used to focus post-training support through supervision, feedback, on-the-job training, and other means. The learning objectives for training in the Republic of Senegal, shown below, address the introduction of a second dose of measles-rubella vaccine. For a 2YL visit with multiple interventions, the learning objectives for such a training would need to reflect the competencies described above, as well as for other services to be provided during the 2YL visit. The success of any health intervention depends on competent front-line health workers and managers. © W H O M aldives 63 Establishing and strengthening immunization in the second year of life S E C T I O N 8 L E A R N I N G O B J ECT I V E S F RO M S E N EGA L FO R T R A I N I N G O N I N T RO D U C I N G A S EC O N D D OS E O F M E AS L E S - RU B E L L A VAC C I N E ( M R 2 ) The training curriculum for the introduction of MR2 in Senegal outlined clear learning objectives. By the end of training, health workers will be able to do the following. • Describe the new vaccination schedule for providing MR2. • Identify the target group for MR2 vaccination. • Correctly estimate MR vaccine needs taking into account MR2. • Correctly fill out all management tools, including the child register, tally sheet, monthly report, stock management record, and vaccination card. • Cite at least three benefits of providing MR2. • Explain to parents at least two reasons why they should retain the vaccination card and return for MR2. • Cite the number of vaccination contacts that a child needs to be fully vaccinated. • Describe at least four tasks for community mobilizers to carry out to support MR2. C O U N T RY E X P E R I E N C E When preparing the training curriculum, it is important to incorporate the use of adult learning methods. Examples of these methods are provided in the Box 6 below. B OX 6. E F F ECT I V E L E A R N I N G M E T H O DS Effective learning in adults occurs when the content is clearly relevant to the learner’s own experience, has immediate application, and clearly serves a practical purpose. Whenever possible, interactive methods that permit the practice of skills should be used. For the 2YL visit, useful interactive methods can include: • skills practice for interpersonal communication, including responding accurately to questions in a manner that fosters trust • hypothetical scenarios for screening, administration, recording, and reporting of doses (several examples for 2YL immunization are shown in Annex 3). • case studies and problem-solving for situations with low coverage of 2YL doses. 64 Establishing and strengthening immunization in the second year of life 8 S E C T I O N Experience with MCV2 vaccination in several countries has shown that screening, recording and reporting doses in the second year of life or later can be challenging because health workers face a wide variety of situations that do not correspond exactly to the vaccination schedule. Health workers need clear guidance on such points as: • how to record a first dose of MCV that is given after 12 months (in a country that recommends MCV1 at nine months of age); • what to do when a mother brings the child for the 2YL visit after 23 months; • the minimum interval between doses; and • how to implement strategies to reduce pain from multiple injections.30 Annex 3 presents several scenarios that health workers may encounter and suggests how they can be addressed directly during training. Annex 4 provides an example of a job aid to assist health workers to determine the vaccines for which a child is eligible. Training also provides an opportunity to address known areas of weak performance. For example, it can be used to promote the practice of opening a vial to provide MCV even if only one or two children come for an immunization session. District- level supervisors must support this principle if front-line health workers are to carry out this practice successfully. 30 Reducing pain at the time of vaccination. Position paper. Geneva: World Health Organization; 2015 (www.who.int/wer/2015/wer9039.pdf). © U N IC EF/U N 0 125857/Sharm a 65 Establishing and strengthening immunization in the second year of life S E C T I O N 8 8.3 Plan the training strategy Planners should develop a training strategy for building the skills of health workers, their direct supervisors, district health teams, and trainers. Several points should be addressed: Identify who will conduct the training sessions and provide them with thorough orientation on both the technical content and how to train others. Prepare a detailed training schedule. Work backwards from the anticipated date for launching 2YL vaccination and take into consideration any other concurrent events, such as holidays, elections, or vaccination campaigns that may cause delays. If other new vaccine introductions are planned to take place in the same timeframe, it may be possible to combine this with the 2YL training to improve efficiency. Time the training so that front-line health workers receive it two to three weeks before the 2YL launch takes place. Ensure that printing and/or electronic distribution of updated data collection tools are available to be used for skills practice during the training. Print and disseminate other key materials, such as technical guidelines or operational field guides, job aids, behaviour change communication materials (see Section 9) and training reference materials, for participants to share with other staff at their facility. For longer term, ensure that information is incorporated into pre-service and continuing education curricula. Cascade training is often used to reach large numbers of health personnel in a short period of time. However, the quality of training is known to erode and become more variable with each level of cascade; hence, it is best to limit the number of cascade levels to two or three at a maximum. If a cascade strategy is used, the following tips can help maintain the quality of training. • Use the “teach-back” method during the training of trainers (TOT). In this method, a portion of the TOT time is spent having some participants practice their skills by simulating a training of other participants, and vice versa. • Produce hypothetical scenarios for simulations, with mock history and mock HBRs, during interactive training sessions. If health workers use handheld EIR 66 Establishing and strengthening immunization in the second year of life 8 S E C T I O N devices, conduct real-life simulations of recording data with the devices and review the records together with participants. • Include some higher-level trainers in the training sessions at the lower levels. • Use post-test results of earlier training sessions to adapt and improve the training for later sessions. • Produce interactive DVDs to use at all levels of the cascade to ensure that the most complex content is addressed in a standardized way. For the 2YL visit, this would include screening and recording and reporting of vaccine doses given to children over the age of one year. The possible use of DVDs requires first assessing whether appropriate equipment for using them is available at all levels. • Work with instructional designers to ensure that the teaching methods are appropriate for training adults. 8.4 Provide supportive supervision and other forms of post-training support A single training session is often insufficient to bring about mastery of new and complex subject matter. Post-training support is needed to strengthen skills and practices, both to reinforce content introduced during training and to orient new staff or those who were unable to attend the training. Supportive supervision is a standard, essential method for reinforcing skills. However, it requires both reliable funding and transportation, which can be lacking in many settings. The planning for a 2YL vaccination visit is an opportunity to highlight the importance of supportive supervision and advocate for adequate levels of funding. Prepare an integrated supportive supervision visit checklist for the 2YL visit. Countries can adapt their existing supportive supervision checklists to include specific 2YL questions. These questions can also be asked during informal on-the- job training: Are 2YL guidelines, job aids, and revised data management instruments, including HBRs, available at the facility? Is the MCV1-MCV2 drop-out rate being monitored? If yes, how much higher is the MCV1-MCV2 drop-out rate compared to that for Penta1- Penta3, PCV1-PCV3, or rotavirus1-rotavirus last dose? 67 Establishing and strengthening immunization in the second year of life S E C T I O N 8 If children come for the 2YL visit later than the target age, how do health workers respond? Do these children receive vaccinations? Which ones? How are the doses recorded and reported? Is the provision of immunization coordinated with other services or are there missed opportunities for doing so? In what ways do CHWs identify and mobilize parents to bring their children for the 2YL visit? Are there sufficient supplies of all commodities needed for the 2YL visit? Supervisors should provide written feedback that remains at the facility for future reference. Additional types of post-training support may take the following forms. Prepare a job aid to guide health workers to screen and vaccinate children that have missed doses, are late with vaccinations, or who do not have a vaccination card. A flow chart or algorithm may be useful for this purpose. Figure 3 provides an example of a decision-making flow chart adapted from Ghana. The job aid might also include key messages to assist in responding to common questions or con- cerns from caregivers or community members. See Annex 4 for another sample job aid to guide health workers to determine a child’s eligibility for vaccination. Develop a poster or job aid on patient flow to remind all health workers in the facility, as well as parents and caregivers, how services should be organized during the 2YL visit. The job aid should particularly emphasize referral between different departments. Prepare a list of frequently asked questions (FAQ) so that health workers are capable and confident to respond to a variety of questions and situations. Annex 5 contains an example of a FAQ list that countries can adapt. Plan for refresher training to take place one to two years following initial training. Provide health workers with a support phone number (e.g. to a supervisor or a hotline) and encourage them to call and check if they are unsure how to vaccinate a child or record a vaccination. Explore alternative means of post-training support. Depending upon country circumstances, these could include: • peer exchanges or quarterly review meetings; 68 Establishing and strengthening immunization in the second year of life 8 S E C T I O N • a hotline that health workers can use to consult experts when they have questions; • reminder SMS texts or other mobile messages sent to health workers’ phones to reinforce practices. Text messages can also be used to provide recognition for correct and timely recording and reporting of data; • in settings where health workers have high access to smart phones, a WhatsApp group or similar chat application can provide peer-to-peer and regular supervisory support. F I G U R E 3. E X A M P L E F RO M G H A N A O F A N A LG O R I T H M FO R D E T E R M I N I N G E L I G I B I L I T Y FO R M E N I N G I T I S A A N D M E AS L E S - RU B E L L A VAC C I N E Algorithm for Measles-Rubella (MR) and Men A administration Check Child Health Record Book/Weight Card Give any missed vaccines and Vitamin A Counsel to return at date of appropriate age for next due vaccine(s) Counsel to return for Child Care Welfare Clinic at appropriate age ASSESS AGE OF CHILD Child is less than 9 months Do not give MR1 Do not give MR2 Has the child received MR1? Has the child received MR2 Give Men A Give MR2 Has the child received Men A Child is less than 18 months Child is 18 months or more Give MR1 Child is 9 months or more NOYES NOYESNOYES 69 Establishing and strengthening immunization in the second year of life S E C T I O N 8 B OX 7. D E T E R M I N I N G E L I G I B I L I T Y FO R M CV 2 WHO recommends that, where risk of measles mortality among infants remains high, MCV2 should be administered at 15–18 months, with a minimum interval of four weeks after MCV1. In settings where utilization of health services drops considerably after the first year, ensuring caregivers bring their babies for the second dose at 18 months, for example, is challenging and the risk of drop-outs can be quite high. An alternative approach in these cases may be to stipulate that if a child presents any time between 12 and 18 months, it is better to vaccinate with MCV2 immediately, rather than hoping that they will return again at 18 months. From an immunological perspective, as long as 4 weeks has elapsed their first dose, and they are in the 2YL, then a child is already technically eligible for MCV2. Understandably however, this may cause confusion for health workers, and a policy based on interval rather than strict adherence to a schedule may not work in all settings. Ultimately it rests with the programme to set a policy on this and ensure the proper training and tools are available to health workers to make these decisions. Strategies to reduce drop-outs and ensure that the child returns at 18 months include: 1) providing counselling to caregivers, emphasizing the importance of MCV2 and the time to return; 2) active follow-up through a call or home visit with the caregiver to remind them about the visit; 3) in some settings, providing vaccinations at their home if they do not return at 18 months or soon after. 70 Establishing and strengthening immunization in the second year of life Communication, demand promotion, and community engagement 9 SECTION 71 Establishing and strengthening immunization in the second year of life S E C T I O N 9 Communication is an important factor for the success of vaccination in the second year of life and beyond. A comprehensive, but targeted, communication strategy that is fully costed and implemented, including a high visibility launch and ongoing community engagement activities, is key to promoting demand for, and generating utilization of, 2YL vaccination and other services. To succeed in building and maintaining confidence in immunization requires a mix of approaches that focus on building knowledge and awareness, but also take into consideration the individual, social, and structural/political dynamics that shape vaccination behaviours. Table 5 provides the key elements of a 2YL behaviour change strategy to build acceptance and uptake. It lists target groups, key areas of knowledge, and desired actions to be promoted through communication, community engagement, and other coordinated programme interventions. This information serves as the basis for deciding which materials, messages, and activities are required to promote demand for, and utilization of, 2YL services. TA B L E 5. E L E M E N TS O F T H E 2 Y L B E H AV I O U R C H A N G E C O M M U N I CAT I O N F R A M E WO R K TA RG E T G RO U P K E Y A R E AS O F K N OW L E D G E D E S I R E D ACT I O N S Caregivers and families • The importance of vaccination and benefits of vaccines for preventing disease/death • Vaccination continues into the 2YL • Reasons why 2YL vaccination and other well-child care beyond one year of age are important • Timing for scheduled 2YL visits • Importance of safekeeping the HBRs until child starts school and beyond • Take children for the 2YL vaccination and other well-child services • Keep the HBR and bring it to every health contact Health workers • Vaccination and other services to be provided in a 2YL visit; 2YL as opportunity for catch-up vaccination • Why 2YL vaccination is important for child health • How and when to provide and record vaccinations • How and when to communicate with caregivers about 2YL services, particularly during the MCV1 visit (see Section 8) • How to promote 2YL services to the community • Communicate with care- givers in the first year of life to encourage them to come for 2YL visit and retain HBR • Communicate key informa- tion during the 2YL visit • Correctly screen, provide services, record, and report data • Engage their communities to help encourage 2YL visits 72 Establishing and strengthening immunization in the second year of life 9 S E C T I O N TA RG E T G RO U P K E Y A R E AS O F K N OW L E D G E D E S I R E D ACT I O N S District-level managers and supervisors to health workers • Review data and identify gaps in the knowledge and skills of health workers • Provide feedback and technical support to health workers and motivate them on the importance of 2YL vaccination and other services • Support health workers in providing high-quality services Community health workers • The importance of 2YL vaccination and the age to bring child for a scheduled visit • How to trace defaulters for 2YL vaccination • Other services provided during 2YL visit • Provide key information on importance of 2YL visit and when to bring child • Mobilize families to bring their children • Trace defaulters Community lead- ers and politicians (chiefs, parliamen- tarians, councilors, civil authorities, religious leaders) • The importance of 2YL vaccination and the age to bring child for a scheduled visit • Other services provided during 2YL visit • When and where 2YL services are offered • Immunization is free-of-charge • Encourage families to bring their children for 2YL services • Communicate on the importance of vaccination The media • The importance of vaccination and other child health services during infancy and into the second year of life • When and where 2YL services are offered • Immunization is free-of-charge • Provide coverage on the launch of the 2YL visit • Provide accurate, timely information to the public to encourage vaccination and the use of 2YL services Professional and medical associa- tions • Current science and policy considerations to inform the development of policies and practices with regard to 2YL visit • Contribute to development of policies, guidelines and materials • Promote proper practice among constituents • Provide support to community leaders in reinforcing the importance of vaccination Teachers, counsellors, pre-school/ day-care providers • The importance of 2YL vaccination and other services beyond one year of age • Immunization is free-of-charge • Encourage families to bring their children for 2YL services 73 Establishing and strengthening immunization in the second year of life S E C T I O N 9 The broad steps needed to plan for promoting or increasing demand for 2YL vaccination and other services are shown in Figure 4, and described in the sections below. F I G U R E 4. D E M A N D A N D P RO M OT I O N P L A N N I N G CYC L E These steps are elaborated throughout the following sections. ST E P DATA C O L L ECT I O N A N D A N A LYS I S ST E P ST R AT EG I C D E S I G N A N D P L A N N I N G ST E P D E V E LO P M E N T A N D T E ST I N G O F M E S SAG E S A N D M AT E R I A L S ST E P I M P L E M E N TAT I O N A N D M O N I TO R I N G ST E P E VA LUAT I O N A N D R E- P L A N N I N G 1 2 5 4 3 ©W HO Bhu tan 74 Establishing and strengthening immunization in the second year of life 9 S E C T I O N 9.1 Data collection and analysis: understanding your target groups Communication plan and working group A multi-partner communications working group should be convened (or reconvened, if it already exists for the immunization programme in general) to develop a demand promotion plan for 2YL vaccination. Though the plan should address the unique features and challenges of 2YL vaccination, it should also be aligned and linked with the overall communication plan for the national immunization programme. This will help ensure that communication activities, messages and targeting are harmonized and support the strengthening of routine immunization. The working group should coordinate closely with others planning the aspects of 2YL to ensure that their work is mutually reinforcing and technically consistent. The 2YL communication plan should agree on the key audiences and stakeholders, communication needs and desired actions by each group, tailoring it from Table 5, as needed. This information serves as the basis for deciding which materials, messages, and activities are needed to promote uptake of 2YL services, and accordingly which data and background information is necessary to shape these efforts. Data collection and analysis Initial data collection and analysis is essential to understand the reasons why different target groups would, or would not, carry out the desired actions in Table 5. A situation analysis and a behavioural analysis (for example, a Knowledge, Attitudes, and Practices (KAP) study, or other similar research activity) can together identify the barriers that need to be addressed and the factors that promote the desired intentions © W H O 75 Establishing and strengthening immunization in the second year of life S E C T I O N 9 and behaviours. They can also provide key information to decide how messages should be worded and the appropriate materials, media, and channels for reaching each target group. This helps ensure that resources are used effectively and efficiently. For example, brochures or posters about 2YL vaccination could be found to be less important to caregivers than having health workers use the opportunity of the MCV1 visit to provide reminder messages and to note the return date for 2YL vaccination on the child’s HBR. In such cases, resources might be better spent on health worker capacity-building and the design of the HBR. Understanding health worker views about 2YL vaccination, including their perceptions of obstacles and enabling factors, is particularly important. Health workers are the most frequently cited source of vaccine information, and a recommendation by a health worker is one of the strongest factors associated with vaccine acceptance. They have a key role to play in interpersonal communication with caregivers on the need for, and timing of, the 2YL visit. Information collected on health worker perspectives about 2YL vaccination should feed directly into the design of the training curriculum, supervision instruments, job aids, data management tools, and communication messages and materials. 9.2 Strategic design and planning Involvement of key stakeholders As with any new development in the health system, the engagement of well-known, credible national level stakeholders is important to focus the public’s attention on the topic and create trust. For introducing 2YL vaccination or increasing attention to it, planners should reach out to well-known health officials and trusted political, community, and academic leaders. Medical associations, schools and daycares, civil society organizations (CSOs), and NGOs are other influential players whose show of commitment to 2YL vaccination and other services can encourage appropriate actions among their constituents and communities. Communication planners should engage with them, provide them with talking points or other materials, and jointly identify specific opportunities, such as press conferences, launch ceremonies, or annual meetings, for demonstrating their support for 2YL vaccination. Community engagement Depending on the community structures and leaders that are active and functional in a given area, different types of volunteers or community members have a role to play in supporting 2YL vaccination. They can be engaged to provide reminder messages, trace defaulters, and keep community attention focused on the 2YL visit after it is launched. 76 Establishing and strengthening immunization in the second year of life 9 S E C T I O N District health and community development teams should identify community networks that are actively functioning and outline a realistic set of steps for CHWs or volunteers to carry out to support the 2YL visit. Printed reminder materials or other aids should be developed for this purpose that give information on all components of the 2YL visit, not just vaccination. Community members can also assist health care providers to select where and when to provide outreach services and how to reach the most marginalized or underserved populations. These are groups for which the risk of non-use of 2YL services is the highest. The following checklist can help ensure that all the key steps of the communication planning process are followed. B OX 8. C O M M U N I CAT I O N P L A N N I N G C H EC K L I ST  Is there a government-endorsed, multi-agency communications working group in place to support the 2YL visit? Has a situation analysis been completed? Has a behavioural analysis been completed? What messages and materials are required? Has a plan of action (budgeted) been developed? Have you secured funding for the implementation of the plan? Have the communication products/materials been pre-tested? Is there a distribution plan for the materials? Is there a crisis communication plan, including explicitly agreed partner roles and responsibilities, and does it include the relevant elements for 2YL? Have agreed spokespeople been identified and trained? 77 Establishing and strengthening immunization in the second year of life S E C T I O N 9 9.3 Development and testing of messages and materials Messages and materials All messages and materials should clearly state when caregivers should take their children for 2YL vaccination and what they can expect to receive during the 2YL visit. Suggested content of key messages to support 2YL vaccination, tailored to different audiences, is shown in Table 5. These messages should be adapted and pre-tested before incorporating them into communication materials, training, or radio or TV spots. Additional messages specific to MCV2 are found in A guide to introducing a second dose of measles vaccine into routine immunization schedules.31 Community networks have a key role to play in supporting the 2YL platform and communicating the importance of the 2YL visit as part of a continuum of care for the entire first five years of the child’s life. 31 www.who.int/immunization/documents/WHO_IVB_13.03/en/, p. 27. 78 Establishing and strengthening immunization in the second year of life 9 S E C T I O N TA B L E 6. E X A M P L E S O F K E Y M E S SAG E TO P I C S TO SU P P O RT 2 Y L VAC C I N AT I O N AU D I E N C E : H E A LT H WO R K E RS The reasons to provide vaccination and other child health interventions after one year of age. The age at which vaccinations in the 2YL are scheduled to be given and the importance of providing doses of antigens missed in the first year of life. There is no upper age limit or cut-off for most vaccines. “It is never too late to vaccinate.” During the MCV1 visit, the need to inform the caregiver when to bring the child back for 2YL vaccination and discuss why it is important. A child can only be considered fully immunized when they have received all doses, including those scheduled to be given after one year of age. Coverage of the ‘FIC’ indicator must include vaccinations given in the second year of life, or be separated by age categories (i.e. FIC by 1 yr year, FIC by 2 yrs). The other services to provide during the 2YL visit, e.g., growth monitoring and promotion, nutritional counseling. How to respond to caregivers with any questions or concerns about vaccination AU D I E N C E : C O M M U N I T I E S A N D CA R EG I V E RS To be classified as fully vaccinated, children need to have completed the required schedule of vaccinations during infancy, 2YL and beyond, as necessary. The age at which vaccinations in the 2YL are scheduled to be given and the importance of catching up on any vaccines missed in the first year of life. There is no upper age limit or cut-off for most vaccines. “It is never too late to vaccinate.” The importance of keeping the home-based record throughout childhood and bringing it for each contact with the health system. The benefits to the child (and family) of receiving vaccination and other services into the 2YL. 79 Establishing and strengthening immunization in the second year of life S E C T I O N 9 9.4 Implementation and monitoring A strong communication plan cannot be successful unless it is fully executed. This means: • the strategic plan must be fully budgeted with funds secured well in advance of the launch in order to produce sufficient supplies of materials; • materials and messages must be translated into the commonly used local languages as needed; • materials must be systematically disseminated to intended audiences at the appropriate time, in advance of when they are to be used; • messages for health worker interpersonal communication with mothers must be finalized in time for them to be incorporated into training materials, and the training designed in such a way that permits adequate time for health workers to practice these communication skills. Formal launch for 2YL visit Lessons learned from past introductions of MCV2 indicate that it is important to conduct a formal launch for the 2YL visit to raise awareness, convey key information, demonstrate high-level political and community support from credible spokespersons, and promote the use of the 2YL services. The engagement of influential community leaders must begin well before the launch takes place. They need to understand why the 2YL visit is being introduced, how it benefits their community, and what actions they can take to support its success. This engagement should continue on a regular basis, even after the launch, to ensure that relationships are maintained and that community leaders are able to continue to advocate for vaccination. The 2YL visit should be positioned as part of a continuum of care for the entire first five years of the child’s life. The introduction of the 2YL visit is an opportunity to highlight the importance of services that have been available in the past but have not been fully utilized. Following the launch of the 2YL visit Communication officials at the national level of the immunization programme should continue to interact with counterparts at subnational level to monitor the implementation of the communication plan and to enquire about any issues or obstacles that may be emerging so that corrective actions can be taken. 80 Establishing and strengthening immunization in the second year of life 9 S E C T I O N 9.5 Evaluation and re-planning In keeping with the overall communication strategy for immunization and child health, monitoring and evaluation of communication efforts should be carried out by the working group on a regular basis. Based on the data gathered and reviewed in Step 1 above, indicators or measures should be established – covering both process, outcomes, and impact – that can be tracked through implementation of the various communications and engagement activities. The findings should be used to inform decisions about the corrective actions to take. To evaluate communication and demand promotion activities, it is ideal to carry out a survey or rapid research exercise targeting caregivers, health workers and, potentially, community leaders or stakeholders. Such an assessment will provide a systematic and structured approach to learning about what people know about 2YL vaccination, how they developed this knowledge, what they think it means, and whether they intend to take the desired actions. The findings should inform adjustments to communications or demand promotion strategies, so that they may be more targeted or impactful in future. If resources are not available for a large- scale study, then the points raised in Section 10 can be used to understand reasons for low demand and utilization of 2YL vaccination. B OX 9. E X A M P L E S O F P OT E N T I A L O U TC O M E I N D I CATO RS TO E VA LUAT E C O M M U N I CAT I O N A N D D E M A N D P RO M OT I O N ACT I V I T I E S • % caregivers with correct knowledge of the schedule and timings of when a child needs to be brought for vaccination in the first two years of life • % caregivers who say they intend to fully vaccinate their children, including the 2YL visits • % vaccinators with correct knowledge of the national schedule • % vaccinators who consistently and correctly communicate to caregivers the timing of the infant’s next visit for vaccination, including the 2YL visits 81 Establishing and strengthening immunization in the second year of life S E C T I O N 9 R A I S I N G AWA R E N E S S A B O U T I M M U N I Z AT I O N A F T E R O N E Y E A R O F AG E I N TA N Z A N I A United Republic of Tanzania’s post-introduction evaluation for MCV2 revealed that many parents interviewed were not aware of the need for further vaccination after their children received MCV1 at nine months. Although children were supposed to attend clinics for growth monitoring after they were one year old, mothers no longer considered it important to come for these monitoring visits. Health officials raised community awareness about the need for vaccination and other services beyond the first year of life through: • broadcasting radio and TV spots; • conducting a seminar with journalists from various local media to get the word out; • conducting meetings on MCV2 with regional primary health care committees; • providing health education about MCV2 to women who attended antenatal and postnatal care visits. C O U N T RY E X P E R I E N C E 82 Establishing and strengthening immunization in the second year of life Strengthening 2YL vaccination performance 10 SECTION 83 Establishing and strengthening immunization in the second year of life S E C T I O N 10 Understanding the reasons for low performance If the national immunization programme and partners observe that 2YL vaccination coverage is low and that the MCV1-MCV2 drop-out rate is high, they should systematically review existing data and assess the situation to identify key problems and their root causes. Decisions on how to use resources to improve the situation should be based on these findings, rather than assumptions that the problem is due, for example, to low demand or insufficient vaccine supply. A starting point would be to review the quality of the reported data to determine if it can be considered complete, timely, reliable, and accurate. At national level, review the geographic scope of the 2YL performance problem. If widespread, then examine system-wide factors, including the following. 1. Are policies and guidelines complete, clear, accurate, and easy to understand and use? 2. Have policies and guidelines been disseminated systematically? 3. Does the training curriculum cover all key points and use effective methods for adult learning? 4. Has the training strategy reached all vaccinators and their supervisors? Are there any known shortcomings in how it has been implemented? 5. Were supervision instruments updated to include 2YL vaccination, and have they been widely disseminated and used? 6. Were data management tools updated, and do they support all aspects of the policy and guidelines? Did they include input from end-users or pre-testing to determine how easy they are to use? Have they been disseminated systematically? 7. Has there been a high-visibility launch to focus attention on the introduction of 2YL vaccination? Was the communication strategy for 2YL vaccination sufficiently developed, budgeted, and carried out as planned? If the problem of 2YL vaccination performance is localized to particular geographic areas, then follow-up with health officials from those subnational/district teams is necessary, as well as visits to facilities to gain a first-hand understanding of the problems and their root causes. 10.1 84 Establishing and strengthening immunization in the second year of life 10 S E C T I O N At subnational/district level, review data to see how geographically widespread the problem is. If it is widespread, review factors that may affect 2YL vaccination, including the following. 1. Have there been shortages or stockouts of the vaccines used for immunization in the second year of life? 2. Are there challenges with human resources that would affect 2YL vaccination, such as insufficient staffing or high turnover? Have health workers received training on 2YL vaccination? Has the district provided supportive supervision or other feedback/post-training support since the initial training was conducted? 3. Are there any particular circumstances or characteristics of the population in this district that would pose challenges to 2YL vaccination, e.g. population movement, high levels of employment of mothers after the child is one year of age, remote populations with difficult access to facilities or to information about changes in the vaccination schedule, lack of social support systems, or vaccine hesitancy? 4. Have updated data management tools been systematically introduced to all facilities, or are old forms and tools still widely in use? 5. What issues or problems with data quality have been observed? Have data quality assessments been carried out to assess the reliability and consistency of data on 2YL vaccination? What are the findings and what corrective actions are needed? 6. Have community leaders and influential persons been educated on the need for 2YL vaccination and why it is important? What actions do they take to encourage families to seek vaccination after one year of age? 7. Are there functional systems of CHWs or volunteers in the district who have been oriented on 2YL vaccination? Do they know how to trace defaulters and encourage families to bring their children for 2YL vaccination? Do they regularly carry out these tasks? 85 Establishing and strengthening immunization in the second year of life S E C T I O N 10 At health facility level, discuss 2YL vaccination with health workers and with caregivers at the facility and in the community. Health worker interviews. Questions to ask health workers include the following. 1. Tell me what you know about 2YL vaccination? How, or from whom, did you learn these things? 2. How frequently are you visited for supportive supervision? If you have a question about something, who do you ask for support or where do you seek help? 3. Do you know your facility’s coverage for 2YL vaccination and MCV1-MCV2 drop-out rate? 4. If 2YL vaccination rates are low, what are the reasons? 5. Are any reference materials on 2YL vaccination (e.g. field guide, training materials, job aids) available at the facility? 6. When is a child considered fully immunized – after they have received which doses of vaccine? 7. Have there been stockouts or shortages of the vaccines used for 2YL vaccination? 8. Does the health facility have a system for tracing defaulters, particularly for 2YL vaccination? What is the system and how well does it work? 9. What information do you give to caregivers who bring children for the MCV1 visit? 10. What do you do if a child is brought “late” for vaccination? Are there any circumstances where you would send away an unvaccinated child who has been brought for vaccination? What are they? Do you believe that there are upper age limits for 2YL vaccination? What are they? 11. If a child comes to your facility for vaccination in the second year of life, do they receive other services as well? What are they? Are they always available? 12. Are updated recording and reporting forms (HBRs, tally sheets, registers, monthly summary reports) available at the facility? If yes, what are the steps for recording and reporting 2YL vaccination? Do caregivers bring updated HBRs? If not, are 2YL doses recorded on the HBR? [Ask to see samples of recording and reporting tools and ask where the 2YL vaccinations are recorded] 86 Establishing and strengthening immunization in the second year of life 10 S E C T I O N 13. Has any comparison been done of 2YL data recorded on tally sheets, monthly reports, child registers, and HBRs, as part of a data quality assessment? If so, what have the findings indicated? Exit interviews. Health officials can visit several facilities, on days when routine immunization sessions are being held, and interview caregivers whose children have received MCV1. Questions to ask caregivers include the following. 1. Has your child received all vaccines in the national immunization schedule or do you need to bring your child back for more doses of vaccines? 2. [If applicable]: Are you able to tell me when you will bring your child next time and which vaccines he/she should recieve at that time? 7. What, if anything, would make this difficult for you? What would make it easier? Community discussions. Visit communities and ask community members what they know about vaccination in the second year of life. 1. By what age should a child have completed the full vaccination schedule? 2. If a child receives measles by the time he/she is one year old, do you need to bring the child back for more vaccinations? At what age? 3. [For those who know about 2YL vaccination]: How did you learn that you needed to take your child for immunization after one year of age? 4. If you brought your child for 2YL vaccination, what was your experience? Which vaccines did you receive? Did your child receive other services? Do you need to return for further vaccinations? 5. If your child is over the age of two and you did not bring them for 2YL services, what were the reasons? 6. What would help you to bring your child for 2YL services? [Probe: reminder materials; a visit by a CHW; more information about why it is needed] Without conducting a major assessment, health managers can add some of the above questions to their supportive supervision visits and augment them by conducting exit interviews with caregivers whose children have just been vaccinated. They can also do exit interviews with mothers who have brought young children for curative care, or other preventive services, to see if they were screened for 87 Establishing and strengthening immunization in the second year of life S E C T I O N 10 immunization and vaccinated. During supervision visits, district health officials can talk with community leaders who may provide insight as to the level of awareness of 2YL vaccination among the community. Additional guidance on how to integrate a small assessment to strengthen 2YL performance into a national immunization programme review is included in the WHO Guide for conducting an Expanded Programme on Immunization (EPI) review.32 10.2 Taking actions to address the problems The findings from the reviews described above should be used to decide what steps to take to strengthen 2YL vaccination. Health managers should convene a discussion to review the problems and their root causes in order to identify solutions and develop a plan for implementing them. Table 7 presents several illustrative examples of possible actions that programmes can take to improve 2YL performance.This list is not exhaustive; rather, it is intended to stimulate thinking about solutions that can be implemented using existing resources or with limited additional funds. Furthermore, the most appropriate actions to take will depend upon a deep understanding of the problems and of the context in which they occur. During supervision visits, health managers can speak with mothers whose children have just been vaccinated, or who have brought young children to the health facility for other services, and ask if they were screened for immunization. 32 Guide for conducting an Expanded Programme on Immunization (EPI) review. Geneva: World Health Organization; 2017. www.who.int/immunization/documents/WHO_IVB_17.17/en/ © W H O 88 Establishing and strengthening immunization in the second year of life 10 S E C T I O N TA B L E 7. COMMON PROBLEMS AND POSSIBLE ACTIONS TO STRENGTHEN 2YL VACCINATION P RO B L E M S / I S SU E S E X A M P L E S O F P OS S I B L E ACT I O N S Persistent low coverage and high drop-out rates • Mobilize CHWs or volunteers to trace defaulters and encourage 2YL vaccination among community members. • Improve the convenience of locations for outreach sessions so that it is easier for caregivers or mothers of two year-old children to bring them for vaccination. • Consider offering routine immunization sessions at fixed facilities at a time of day that is more convenient for mothers of older children. Outreach sessions are not conducted as often as planned • Compare actual outreach sessions conducted during the last six months with the number of scheduled outreach sessions in the microplan. If there is a clear discrepancy, find out why the outreach is not being implemented. Stockouts of vaccines and supplies • Review the availability of vaccines needed for 2YL vaccination at all levels to ensure that sufficient supplies are available. • If concerns over high wastage rates are deterring health workers from opening a vial of MCV for small numbers of children, review national policies on this topic and reinforce during supportive supervision visits. Remind health workers that 2YL vaccination may result in lower levels of MCV vaccine wastage. Deficiencies in health worker practices • Address health worker motivation: recognize and praise those who have achieved high coverage. Ask them to share their experience through peer learning with health workers at other facilities. Remind health workers of the reasons for 2YL vaccination and note that immunization programme performance is also based on coverage with vaccinations given after one year of age. • Provide on-the-job training during supportive supervision visits to address the deficiencies. • If shortages of human resources are contributing to suboptimal health worker performance (overburdened staff), review the possible role of volunteers to help assume some of the less technical duties. However, recognize that volunteers need technical orientation and management, and that their contribution is voluntary. • Refer to Section 8.4 for more possible actions, e.g. WhatsApp groups, telephone hotlines, SMS texting to reinforce key points. 89 Establishing and strengthening immunization in the second year of life S E C T I O N 10 P RO B L E M S / I S SU E S E X A M P L E S O F P OS S I B L E ACT I O N S Problems with screening, recording, reporting doses • Review data management instruments and revise, if needed, to make them more user-friendly, to enable proper practice for screening, recording, and reporting. • Ongoing supervision and feedback on how to use the data collection instruments. • Job aids, hotlines or WhatsApp groups to help address particular problem areas, e.g. difficulties with screening, recording, reporting. • Conduct data quality assessments and use the findings to correct particular problems and monitor progress. Low awareness or demand for 2YL vaccination • Strengthen health worker skills in interpersonal communication to remind caregivers when to return for vaccination in the second year of life. • Engage community leaders to get the word out to families about when and where to go for 2YL vaccination and why it is important. Use the occasion of community meetings to give feedback on coverage for 2YL vaccination and discuss how to improve it. • Work with local NGOs to explore how they can support 2YL vaccination; for example, by mobilizing resources for outreach sessions in convenient locations in the community. • Re-launch 2YL through high-visibility activities such as press conferences, ceremonies, meetings, radio, SMS, etc. • Use radio talk shows to discuss 2YL vaccination and increase attention around the need for 2YL vaccination. Develop songs or memorable jingles that can be broadcast to remind communities of the need for 2YL vaccination. 90 Establishing and strengthening immunization in the second year of life 1 A N N E X Annex 1a: Example of minimum standard tally sheet for vaccination33 ANTIGENS/ ITEMS 0-11 MONTHS TOTAL 12 MONTHS OR OLDER TOTAL TOTAL VACCINATED BCG Hep B BD OPV 0 OPV 1 OPV 2 OPV 3 IPV Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/ Other* Vitamin A Long lasting insecticidal net* 33 As described in Section 7 *depending on national health priorities and schedule of services Date: Region: District: Health Facility: Service Delivery Strategy: fixed outreach mobile Location: 91 Establishing and strengthening immunization in the second year of life Annex 1b: Example of best practice tally sheet for vaccination33 ANTIGENS/ ITEMS 0-11 MONTHS TOTAL 12–23 MONTHS TOTAL 24 MONTHS OR OLDER TOTAL TOTAL vaccinated BCG Hep B BD OPV 0 OPV 1 OPV 2 OPV 3 IPV Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/Other* Vitamin A Long lasting insecticidal net* 33 As described in Section 7 *depending on national health priorities and schedule of services Date: Region: District: Health Facility: Service Delivery Strategy: fixed outreach mobile Location: A N N E X 1 92 Establishing and strengthening immunization in the second year of life 2 A N N E X Annex 2: Immunization monitoring chart showing MCV1-MCV2 drop-out Health Facility: Year: A drop-out more than 10% is an indication for immediate action Annual target population (0-11 months): Annual target population (12-23 months): Minimum coverage target for the year—BCG: Minimum coverage target for the year—MCV1: Minimum coverage target for the year—MCV2: Vaccine Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec BCG A Total immunized this month Cumulative total for the month MCV1 B Total immunized this month Cumulative total for the month MCV2 C Total immunized this month Cumulative total for the month BCG-MCV1 DROP-OUT RATE = Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec MCV1-MCV2 DROP-OUT RATE = Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ** Plot for only BCG, MCV1, MCV2 M on th ly tr ag et c ov er ag e 25% 75% 50% 100% A-B A * 100 B-C B * 100 93 Establishing and strengthening immunization in the second year of life A N N E X 3 Annex 3: Scenarios for vaccination in the second year of life (for use in training and supervision) Vaccinators encounter many situations where they are not sure what to do if the child has missed previous doses, has come late for vaccination, or lacks a home-based record. The following are real situations that have been reported from different countries. These scenarios are based on a schedule that includes MCV1 at nine months of age and MCV2 at 18 months of age. They should be adapted to fit the appropriate vaccine schedule and country context. These scenarios can be used during training for interactive discussions and skill building for proper screening, administration, recording, and reporting of doses. In each case, trainers can show just the first two columns, or print out hard copies of the scenarios and ask training participants to review them in pairs. Afterwards, discuss as follows. • Do you think the health worker did the right thing? • If not, what should have been done differently? • How could this problem be prevented? The third and fourth columns are for use by training facilitators and supervisors. The third column provides the correct response. The fourth column presents some possible responses that can be further developed and discussed. Annual target population (0-11 months): Annual target population (12-23 months): Minimum coverage target for the year—BCG: Minimum coverage target for the year—MCV1: Minimum coverage target for the year—MCV2: FOR TRAINING PARTICIPANTS FOR TRAINING FACILITATORS AND SUPERVISORS SCENARIO HEALTH WORKER “INCORRECT” RESPONSE WHAT SHOULD THE HEALTH WORKER HAVE DONE? HOW COULD THIS PROBLEM BE PREVENTED? (for discussion) 1. A child is brought late for MCV1 at 14 months of age The health worker vaccinates the child and records and reports the dose as MCV2 because the child is over one year of age. The health worker believes that only doses given under one year of age can be considered as MCV1. 1. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 2. A child is brought for his first dose of MCV at 18 months of age (the time of the scheduled MCV2 visit) The health worker vaccinates the child and records and reports the dose as MCV2 because the child has come at the time when MCV2 is scheduled to be given. 2. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months.” She should have advised the caregiver to bring the child back for MCV2 after 4 weeks. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 3. At a rural facility with infrequent outreach and few children seen before the age of 12 months, a 15-month old boy is brought in who has never received measles vaccine. The health worker believes the child is not eligible for MCV1 because he is too old to receive it. She also believes he is not eligible for MCV2 because he has not received MCV1. So she sends him away without vaccinating him against measles. 3. She should have vaccinated the child and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision to emphasize that it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet • Job aid 4. Children at one clinic are often brought for MCV1 at 10, 11, 12, or 13 months of age. The health worker tells the mothers to come back 9 months later for MCV2, believing that it is the 9-month interval and not the target age (of 18 months) that is important. 4. She should have advised the caregivers to bring their children back for MCV2 at 18 months of age. • Training and supervision to emphasize that it is the age of vaccination that is most important, as long as there is one month minimum interval between MCV doses. 6. A child is brought for MCV2 at 3 years of age. The child has already received MCV1 at 9 months. The health worker does not vaccinate the child because they are older than 23 months. 6. She should have given the child MCV2 and recorded the dose as MCV2 in the column of the tally sheet for “12 months or older” or “24 months or older” • Training and supervision to emphasize that the need for MCV does not stop at 24 months (no upper limit – all children need 2 doses of MCV), and it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet 7. A child is brought for MCV2 at 2-1/2 years of age. The child has already received MCV1 at 9 months. The health worker vaccinates the child but records the dose on a special register so that it is not included in estimates of coverage. 7. She should have recorded the dose as MCV2 on the column of the tally sheet for “12 months or older” or “24 months of older” • MOH needs to design the tally sheet to permit recording and reporting of doses given to children 24 months or older 8. The health worker says that she cannot provide a measles second dose because she has no “MSD” vaccine. The health worker does not provide a second dose of measles to any children. 8. She should have provided MCV2 doses to all eligible children who are over the age of one. • Field guide, training, supervision, data recording forms, social mobilization should use more familiar convention of numbered doses (e.g. measles1/ measles2, MR1/MR2) for measles or measles rubella 9. A child is brought for MCV2 at 18 months. The mother does not have a vaccination card but remembers that her baby received MCV1 soon before he started walking. The health worker vaccinates him but records it as MCV1 and tells the mother to come back in one month for MCV2. 9. She should have first checked the child’s age and vaccination status in the child health register to ascertain whether the child received MCV1 at or soon after 9 months. If no record is found, then the health worker response was correct. A new vaccine card should have been provided. If a record is found, the health worker should have given MCV2, and transferred the information from the registry to a new vaccination card. • Field guide should provide clear guidance on what health workers should do in the absence of an HBR or record of the child in the health facility register. 94 Establishing and strengthening immunization in the second year of life 3 A N N E X These scenarios are based on a schedule that includes MCV1 at nine months of age and MCV2 at 18 months of age. FOR TRAINING PARTICIPANTS FOR TRAINING FACILITATORS AND SUPERVISORS SCENARIO HEALTH WORKER “INCORRECT” RESPONSE WHAT SHOULD THE HEALTH WORKER HAVE DONE? HOW COULD THIS PROBLEM BE PREVENTED? (for discussion) 1. A child is brought late for MCV1 at 14 months of age The health worker vaccinates the child and records and reports the dose as MCV2 because the child is over one year of age. The health worker believes that only doses given under one year of age can be considered as MCV1. 1. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 2. A child is brought for his first dose of MCV at 18 months of age (the time of the scheduled MCV2 visit) The health worker vaccinates the child and records and reports the dose as MCV2 because the child has come at the time when MCV2 is scheduled to be given. 2. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months.” She should have advised the caregiver to bring the child back for MCV2 after 4 weeks. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 3. At a rural facility with infrequent outreach and few children seen before the age of 12 months, a 15-month old boy is brought in who has never received measles vaccine. The health worker believes the child is not eligible for MCV1 because he is too old to receive it. She also believes he is not eligible for MCV2 because he has not received MCV1. So she sends him away without vaccinating him against measles. 3. She should have vaccinated the child and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision to emphasize that it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet • Job aid 4. Children at one clinic are often brought for MCV1 at 10, 11, 12, or 13 months of age. The health worker tells the mothers to come back 9 months later for MCV2, believing that it is the 9-month interval and not the target age (of 18 months) that is important. 4. She should have advised the caregivers to bring their children back for MCV2 at 18 months of age. • Training and supervision to emphasize that it is the age of vaccination that is most important, as long as there is one month minimum interval between MCV doses. 6. A child is brought for MCV2 at 3 years of age. The child has already received MCV1 at 9 months. The health worker does not vaccinate the child because they are older than 23 months. 6. She should have given the child MCV2 and recorded the dose as MCV2 in the column of the tally sheet for “12 months or older” or “24 months or older” • Training and supervision to emphasize that the need for MCV does not stop at 24 months (no upper limit – all children need 2 doses of MCV), and it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet 7. A child is brought for MCV2 at 2-1/2 years of age. The child has already received MCV1 at 9 months. The health worker vaccinates the child but records the dose on a special register so that it is not included in estimates of coverage. 7. She should have recorded the dose as MCV2 on the column of the tally sheet for “12 months or older” or “24 months of older” • MOH needs to design the tally sheet to permit recording and reporting of doses given to children 24 months or older 8. The health worker says that she cannot provide a measles second dose because she has no “MSD” vaccine. The health worker does not provide a second dose of measles to any children. 8. She should have provided MCV2 doses to all eligible children who are over the age of one. • Field guide, training, supervision, data recording forms, social mobilization should use more familiar convention of numbered doses (e.g. measles1/ measles2, MR1/MR2) for measles or measles rubella 9. A child is brought for MCV2 at 18 months. The mother does not have a vaccination card but remembers that her baby received MCV1 soon before he started walking. The health worker vaccinates him but records it as MCV1 and tells the mother to come back in one month for MCV2. 9. She should have first checked the child’s age and vaccination status in the child health register to ascertain whether the child received MCV1 at or soon after 9 months. If no record is found, then the health worker response was correct. A new vaccine card should have been provided. If a record is found, the health worker should have given MCV2, and transferred the information from the registry to a new vaccination card. • Field guide should provide clear guidance on what health workers should do in the absence of an HBR or record of the child in the health facility register. 95 Establishing and strengthening immunization in the second year of life A N N E X 3 96 Establishing and strengthening immunization in the second year of life 4 A N N E X Annex 4: Illustrative example of job aid on screening for vaccine eligibility The sample job aid is adapted from Timor Leste (IMMUNIZATIONbasics, 2007) and is based on a child immunization schedule that calls for BCG and hepatitis B at birth; Pentavalent, oral polio vaccine (OPV), pneumococcal conjugate vaccine (PCV), and rotavirus (RV) doses at 6, 10, and 14 weeks; inactivated polio vaccine (IPV) at 14 weeks; MCV1 at nine months; and MCV2, MenA and DTP4 at 18 months of age. Please adapt this document to match your local immunization schedule. This, along with other 2YL tools and resources, can be found at www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Instructions: Step 1: Praise the parent or caregiver for bringing their child for vaccination today. Find out from the child’s immunization record or the caregiver: 1. How old is the child today? 2. Which vaccines has the child already received? (Check the home-based record or child register) Step 2: Use the chart to the right to decide what to give. The child should already have received all vaccines due up until their current age. If they are missing doses, it is not too late. Administer the vaccines for which they are eligible, respecting the necessary spacing (see far right column). Step 3: Remind the caregiver when to bring the child back for the subsequent doses due. Take this opportunity to emphasize the importance of receiving the complete series of vaccines for the child to be fully protected. † In certain situations, MCV can be given from 6 months of age. This dose should be considered a zero dose (“MCV0”) and two subsequent doses (MCV1 and MCV2) should still be provided according to the national schedule. Measles vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). 97 A N N E X 4 At 6 weeks (or as soon as possible thereafter) HepB BD: As soon as possible after birth, ideally within 24 hours, and up to 6 weeks BCG: As soon as possible after birth HepB BD: Not after 6 weeks At 10 weeks (or as soon as possible thereafter), and at least 4 weeks after dose 1 At 9 months (or as soon as possible thereafter) At 18 months (or as soon as possible thereafter), and at least 4 weeks since previous dose MCV2: Not before 4 weeks has passed since MCV1 DTP4: Not before 4 weeks has passed since Penta3 MenA: Not before 9 months of age (except where indicated) Even if a long time has passed between doses, there is no need to restart the series from the beginning. There is no upper age limit for most vaccines (except rotavirus <2yrs and hepatitis B birth dose <6 weeks) WHEN TO GIVE “It is better to vaccinate late than never!” WHICH VACCINES CAN BE GIVEN TODAY? Use this chart to determine which vaccines should be given to a child at or after a specific age. WHEN TO NOT GIVE RV1: Not after 2 years of age Not before 4 weeks has passed since previous dose RV2: Not after 2 years of age At 14 weeks (or as soon as possible thereafter), and at least 4 weeks after dose 2 Not before 4 weeks has passed since previous dose RV3: Not after 2 years of age Not before 9 months of age (except where indicated)† OPV 2 Penta 2 PCV 2 RV 2 OPV 3 Penta 3 PCV 3 RV 3 IPV MCV 1 MCV 2 MenA OPV 1 PCV 1 DTP4 (or Penta4) 6 WEEKS 14 WEEKS 9 MONTHS 18 MONTHS 2 YEARS 10 WEEKS BIRTH HepB BD BCG Penta 1 RV 1 98 Establishing and strengthening immunization in the second year of life 5 A N N E X Annex 5: Frequently asked questions about vaccination in the second year of life The following questions can help health workers respond to questions about vaccination in the second year of life or later. 1. Why is it important to vaccinate children after their first birthday? Both the level of protection and the duration of immunity are increased by providing additional doses of vaccine after the child has reached one year of age. This means that older children will continue to be protected from many vaccine-preventable diseases. For measles, a second dose ensures early protection of the individual child and also reduces the rate of accumulation of susceptible children and the risk of an outbreak. 2. Which vaccines, and at what age, should children receive vaccines after the first year of life? This depends on the schedule of the national immunization programme in each country. • WHO has recommended that all countries provide a second dose of measles-containing vaccine after one year of age. Many countries schedule it in the second year of life. • WHO also recommends a booster dose of vaccine containing diphtheria, tetanus, and pertussis, to be given in the second year of life. • Other vaccines that may be scheduled between 12-23 months include those against meningitis A, Japanese encephalitis, typhoid and yellow fever. • Many countries also recommend catch-up vaccination to provide doses of vaccines missed in the first year of life. 3. Are there some vaccines or doses that should not be given to a child in the second year of life or later? Vaccination in the second year of life is an opportunity to increase the level and duration of protection against vaccine preventable diseases. If children 34 Available at: www.who.int/immunization/documents/positionpapers/en/ 99 Establishing and strengthening immunization in the second year of life A N N E X 5 are missing doses of certain vaccines that they should have received in the first year of life, in general, it is better to vaccinate late than never. There are certain exceptions as indicated in the national immunization schedule and noted in WHO position papers.36 These are: • Birth doses of hepatitis B vaccine should be given only in the newborn period, as stipulated in the national policy. • Rotavirus vaccination after 24 months is not considered necessary because of the age distribution of rotavirus gastroenteritis. 4. On what occasions should a child over one year of age be vaccinated? • When they come for a scheduled vaccination visit according to the national immunization schedule • Any time they are in contact with the health system, including if they come for curative care. Mild illness is not a reason to deny vaccination to a child, and screening sick children for immunization eligibility is a standard component of IMCI. If children have been brought for growth monitoring and nutritional counselling, this also provides an opportunity for screening and vaccinating them. Another opportunity for screening and vaccination is if the child has accompanied one of their family members, such as a sibling or mother, coming for care.35 • During a scheduled Child Health Week, or other similar campaign or event in which catch-up vaccination is provided. 5. What messages should the mother or caregiver be given during their infant’s last vaccination contact before reaching one year of age? For most children, the measles contact is the last vaccination visit before the child reaches one year of age. During that visit, the health worker should make sure to inform the mother as follows. • It is important for her child to come back at the scheduled time [depending on the national vaccination schedule] to receive the remaining doses of vaccine to be given in the second year of life. Unlike in the past, the child cannot be considered fully immunized until they receive these recommended vaccine doses as well. 35 For more information, refer to the WHO missed opportunities for vaccination (MOV) strategy. Available at: www.who.int/immunization/programmes_systems/policies_strategies/MOV/en/ 100 Establishing and strengthening immunization in the second year of life 5 A N N E X • These additional doses will provide stronger and longer-lasting protection against important childhood diseases. With additional doses, this protection will last beyond early childhood. • Be sure to keep the home-based record, such as vaccination card, in a safe place and bring it the next time they come for vaccination, and any time they come to a health facility for services. • She should bring her child for vaccination at the next scheduled time [specify the date]. However, if she is unable to come at that time, to come as soon as possible thereafter. 6. If a child comes for services substantially later than the scheduled time, should they still be vaccinated? Yes. While timely vaccination as soon as the child is eligible is highly desirable to reduce potential exposure to disease, it is always important that the child receive protection from vaccination and not be sent away if they come for vaccination late. With very few exceptions, as explained in Question 3 above, it is “better to vaccinate late than never”. 7. If a child comes late for the 2YL vaccination visit and they are older than 23 months, should the dose be recorded as given in the second year of life (12-23 months)? • Always record and report the dose accurately so that it corresponds to the age at which the child actually received it. This will depend on how the tally sheets and monthly reporting forms are designed. • If they contain two age groups (“0-11 months” and “over 12 months”), then record the doses as being given “over 12 months”. • If they contain three age groups (“0-11 months”, “12-23 months”, and “24 months or over”), then record the doses as being given at “24 months or older”. 8. Is it safe to vaccinate children after one year of age? Are there any additional risks? It is safe and there are no additional or different risks to vaccinating children after one year of age compared with vaccinating them during infancy. 101 Establishing and strengthening immunization in the second year of life A N N E X 5 9. What other services or care can the child receive when they come for vaccination in the second year of life? • Growth monitoring and promotion, nutritional counselling, advice on hygiene and sanitation, and, depending on national policies, vitamin A or deworming medication can be provided during a visit for vaccination in the second year of life. • Some countries may decide to provide additional services, such as follow-up on early infant diagnosis of HIV/AIDS, or family planning services for mothers. © J Sw artz 102 Establishing and strengthening immunization in the second year of life www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Tables 1. WHO-recommended vaccines to be administered in the second year of life 18 2. Materials to review and update for 2YL vaccination and services 28 3. Interventions and commodities for vaccination and other services in a scheduled 2YL visit (illustrative example) 42 4. Summary of immunization indicators related to 2YL 52 5. Elements of the 2YL behaviour change communication framework 71 6. Examples of key message topics to support 2YL vaccination 78 7. Common problems and possible actions to strengthen 2YL vaccination 88 Figures 1. Increase in estimates of MCV1 coverage when doses administered in the second year of life are included 20 2. Estimated coverage of interventions among households with a child aged 12-23 months, if integrated with routine immunization (28 sub-Saharan African countries) 21 3. Example from Ghana of an algorithm for determining eligibility for meningitis A and measles rubella vaccine 68 4. Demand and promotion planning cycle 73

104 Establishing and strengthening immunization in the second year of life C O N T E N T S This document provides practical guidance on establishing and strengthening immunization in the second year of life (2YL) and beyond. It also suggests ways that immunization visits during the 2YL can be used as a platform for delivery of other child-health services. For tools and resources on immunization in the 2YL, please visit www.who.int/immunization/programmes_systems/ policies_strategies/2YL/en/ This document was published by the Expanded Programme on Immunization (EPI) of the Department of Immunization, Vaccines and Biologicals and is available at: www.who.int/immunization/documents Copies of this document as well as additional materials on immunization, vaccines and biologicals may be requested from: World Health Organization Department of Immunization, Vaccines and Biologicals CH-1211 Geneva 27 Switzerland Email: vaccines@who.int Web: www.who.int/immunization/en ISBN 978-92-4-151367-8

Establishing and strengthening immunization in the second year of life Practices for vaccination beyond infancy Establishing and strengthening immunization in the second year of life: practices for vaccination beyond infancy ISBN 978-92-4-151367-8 © World Health Organization 2018 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. 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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 by büro svenja Printed in Switzerland Establishing and strengthening immunization in the second year of life Practices for vaccination beyond infancy iv Establishing and strengthening immunization in the second year of life CONT EN TS SECTION 1 Purpose and use of this document 9 1.1. Objectives 10 1.2 Intended users 11 1.3 Other publications to consult 11 Acronyms vi Acknowledgements viii SECTION 2 Introduction to life-course vaccination with an emphasis on the second year of life 12 SECTION 3 Background on vaccination in the second year of life and beyond 16 3.1 How widespread is vaccination in the second year of life? 17 3.2 Opportunities and benefits for vaccinating in the second year of life 18 3.3 Challenges to vaccination in the second year of life 22 SECTION 4 Policies and planning for vaccination in the second year of life and beyond 24 4.1 Steps for planning the introduction or strengthening of a 2YL visit 26 4.2 Deciding on the timing of the 2YL visit or visits 29 4.3 Catch-up vaccination at any time a child has contact with health services 30 4.4 Coordinating vaccination with other services in the second year of life 32 SECTION 5 Facility-level planning, service organization, and human resources 35 5.1 Update microplanning tools and processes 36 5.2 Review the implications for human resources for the 2YL visit 37 5.3 Determine the feasibility of providing all services desired for the 2YL visit and the practical issues of patient flow 39 v Establishing and strengthening immunization in the second year of life CONT EN TS Annexes 1. Examples of minimum standard and best practice tally sheets 90 2. Immunization monitoring chart showing MCV1-MCV2 drop-out 92 3. Scenarios for vaccination in the second year of life (for use in training and supervision) 93 4. Illustrative example of job aid on screening for vaccination 96 5. Frequently asked questions about vaccination in the second year of life 98 SECTION 6 Supply chain management for vaccines and other commodities 41 6.1 Commodities needed for vaccination and other services in the second year of life 42 6.2 Vaccines and vaccination supplies in the second year of life 45 SECTION 7 Recording, reporting, and using data for decision-making 48 7.1 Performance indicators 50 7.2 Data requirements 54 7.3 Updating forms and health information systems 56 SECTION 9 Communication, demand promotion, and community engagement 70 9.1 Data collection and analysis: understanding your target groups 74 9.2 Strategic design and planning 75 9.3 Development and testing of messages and materials 77 9.4 Implementation and monitoring 79 9.5 Evaluation and re-planning 80 SECTION 8 Health worker training and capacity-building 59 8.1 Determine required health worker competencies 60 8.2 Prepare the training curriculum 62 8.3 Plan the training strategy 65 8.4 Provide supportive supervision and other forms of post-training support 66 SECTION 10 Strengthening 2YL vaccination performance 82 10.1 Understanding the reasons for low performance 83 10.2 Taking actions to address the problems 87 vi 2YL second year of life AEFI adverse event following immunization BCG bacille Calmette-Guérin (vaccine) CDC Centers for Disease Control and Prevention (USA) CHW community health worker cMYP comprehensive multi-year plan CSO civil society organization DHIS2 district health information system, version 2 DHS demographic and health survey DQS data quality self-assessment DTP diphtheria-tetanus-pertussis containing vaccine DV-DMT district vaccination data management tool EID early infant diagnosis of HIV/AIDS EIR electronic immunization record EPI Expanded Programme on Immunization FAQ frequently asked question FIC fully immunized child GVAP Global Vaccine Action Plan GAVJ Gavi, the Vaccine Alliance GRISP Global Routine Immunization Strategies and Practices HBR home-based record HepB hepatitis B vaccine HepB-BD hepatitis B birth dose Hib Haemophilus influenzae type B HMIS health management information system iCCM integrated community case management ICG Interagency Coordinating Committee IMCI integrated management of childhood illness IPAC Immunization Practices Advisory Committee IPV inactivated polio vaccine ITN insecticide-treated bed net JE Japanese encephalitis KAP knowledge-attitude-practice study MCV measles-containing vaccine MCV1 first dose of measles-containing vaccine MCV2 second dose of measles-containing vaccine A B B R E V I A T I O N S A N D A C R O N Y M S Establishing and strengthening immunization in the second year of life A B B R E V I A T I O N S A N D A C R O N Y M S vii Establishing and strengthening immunization in the second year of life MDVP multi-dose vial policy MenA meningitis A vaccine MICS multiple indicator cluster survey MR measles-rubella vaccine MMR measles-mumps-rubella vaccine MOH Ministry of Health MOV missed opportunities for vaccination MUAC middle upper arm circumference NGO nongovernmental organization NITAG National Immunization Technical Advisory Group OPV oral polio vaccine PCV pneumococcal conjugate vaccine PIE post-introduction evaluation PIRI periodic intensification of routine immunization SAGE Strategic Advisory Group of Experts on Immunization SIA supplementary immunization activity SOP standard operating procedure TCV typhoid conjugate vaccine TOT training of trainers TTCV tetanus toxoid-containing vaccine UNICEF United Nations Children’s Fund VPD vaccine-preventable disease WHO World Health Organization viii Establishing and strengthening immunization in the second year of life A C K N O W L E D G E M E N T S This document was developed by the Expanded Programme on Immunization (EPI) of the World Health Organization (WHO) Department of Immunization, Vaccines and Biologicals with contributions from UNICEF and was prepared by Rebecca Fields of John Snow, Inc. The following individuals contributed substantially to its preparation and their input is gratefully acknowledged: Carolina Danovaro, Rudi Eggers, Messeret Eshetu, Tracey Goodman, Jan Grevendonk, Karen Hennessey, Penelope Kalesha Masumbu, Lisa Menning, Abrahams Mwanamwenge, Ikechukwu Ogbuanu, Stephanie Shendale, Emily Wootton (WHO); Ulla Griffiths, Imran Raza Mirza (UNICEF); Laura Conklin, Mawuli Nyaku, Melissa Wardle, Margie Watkins (CDC), and independent consultants Celestino Costa and Karen Wilkins. The guidance of the WHO Strategic Advisory Group of Experts (SAGE) on Immunization and the Immunization Practices Advisory Committee (IPAC) shaped the key principles and directions that are reflected here. The content of the document is based in part on a review of experience with vaccination in the second year of life in the Republic of Ghana, the Republic of Senegal and the Republic of Zambia. We offer sincere thanks to the Ministries of Health in those countries for having permitted the documentation and analysis of their experience in introducing immunization in the second year of life. www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 1 SECTION 9 Establishing and strengthening immunization in the second year of life Purpose and use of this document www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 10 Establishing and strengthening immunization in the second year of life 1 S E C T I O N This document provides practical guidance on establishing and strengthening immunization in the second year of life (2YL) and beyond. It also suggests ways that immunization visits during the 2YL can be used as a platform for delivery of other child- health services. 1.1 Objectives 1 While this document focuses largely on immunization during a scheduled visit in the second year of life, other health interventions are addressed to a limited extent. Detailed information on these interventions is beyond the scope of this document. Relevant publications are included in the Footnotes. 1. To assist countries in making informed decisions about establishing or strengthening a well- child visit (or visits) in the second year of life that includes vaccina- tion and other services as part of a continuum of care for children.1 2. To provide practical guidance on planning, managing, implement- ing, and monitoring vaccination services and improving immunization coverage during a scheduled visit in the second year of life that may include other health interventions. 3. To provide broad guidance on catch-up vaccination for children older than one year, who are delayed or missing vaccine doses (“un- and/or under- vaccinated”). 11 Establishing and strengthening immunization in the second year of life S E C T I O N 1 1.2 Intended users The intended users of this manual are primarily those who work at country level on immunization and other child-health services. They include: • country-level government decision-makers and programme managers for immunization, child health, nutrition, paediatric HIV/AIDS, community development, health education, health management information systems, cold chain and logistics management; • members of National Immunization Technical Advisory Groups (NITAGs), as well as other technical advisory bodies for child health and nutrition; • national, regional and global level immunization and child health advisors working with partner organizations such as WHO, UNICEF, development partners, and civil society organizations and nongovernmental organizations (NGOs). 1.3 Other publications to consult Some of the material in this document is addressed in greater detail in other publications and on WHO web pages. These are highlighted in key resource boxes throughout this guide. A number of other resources that will be important to consult if establishing or strengthening a 2YL platform are currently under development by WHO and will be available in the near future:2 • Working together: an integration resource guide for planning and strengthening immunization services throughout the life course • Handbook on the collection, assessment, and use of immunization data • Guide to introducing Meningococcal A conjugate vaccine into the routine childhood immunization programme. 2 Information on the latest drafts can be requested by contacting the WHO Department of Immunization, Vaccines and Biologicals at vaccines@who.int 12 Establishing and strengthening immunization in the second year of life 2 SECTION Introduction to life- course vaccination with an emphasis on the second year of life 13 Establishing and strengthening immunization in the second year of life S E C T I O N 2 The Global Vaccine Action Plan (GVAP),3 the global blueprint for action in immunization for the period 2011–2020, calls for the benefits of immunization to be equitably extended to all people. The Action Plan states that “a ‘life-course’ approach should be taken in order to make the benefits of immunization available to all those at risk in every age group” and recognizes that “this will mean creating strategies for reaching individuals throughout their life course and developing plans for the systems that will monitor and track progress.” The WHO’s Global Routine Immunization Strategies and Practices (GRISP) document also identifies vaccination beyond infancy as one of nine transformative actions that are critical to strengthening routine immunization.4 It encourages national immunization programmes to expand scheduled routine vaccination visits beyond the first year of life and provide needed vaccines in the preschool, school and adolescent and adult populations. Vaccination opportunities, such as healthy child visits in the second year of life, preschool preparation visits, and school visits should be used to assess vaccination status and administer any previously missed doses. The proper design, distribution, and long-term retention of home-based records (HBRs) are fundamental to ensure the proper screening and provision of vaccines to all who are eligible for them. While many countries already provide routine vaccine doses to children in the second year of life or later, vaccination after one year of age is expected to increase in the coming years. A booster dose of diphtheria-tetanus-pertussis (DTP) containing vaccine is increasingly recognized as being of public health importance and a second dose of measles-containing vaccine (MCV2) through routine immunization is recommended in all countries, with many countries scheduling it during the second year of life. For some vaccines, including pneumococcal, dengue, and meningitis A, schedule options include one or more routine doses in the second year of life. Some new vaccines, such as for malaria, will likely be recommended for children over one year of age. Having an established platform for vaccination in the second year of life will increase the potential uptake of these vaccines when they are introduced. However, vaccination is just one of many health interventions that young children need in order to thrive. As a health service that is often highly used relative to other interventions, immunization can be a platform to provide other essential services, such as growth monitoring and promotion, management of common illnesses, proper sanitation and, in some places, deworming, vitamin A supplementation, micronutrient supplementation, malaria prevention and care, and HIV/AIDS care.5 Interventions to improve growth and development in the first two years of life have a higher impact than in later years. A scheduled visit during this period is also an 3 www.who.int/immunization/global_vaccine_action_plan/en/ 4 www.who.int/immunization/programmes_systems/policies_strategies/GRISP/en/ 5 www.UNICEF-irc.org/article/958/ 14 Establishing and strengthening immunization in the second year of life 2 S E C T I O N opportunity to provide counselling to parents on nutrition, hygiene, home care practices, family planning, and timely care seeking. Many countries already have policies of regular visits for growth monitoring, promotion, and complementary feeding, but the use of the visits often drops after one year of age, as families and health workers alike may not view them as a priority. If managed strategically, vaccination visits in the second year of life (2YL) can help augment progress both for immunization and other maternal and child health services. B OX 1. K E Y P O I N TS FO R VAC C I N AT I O N I N T H E S EC O N D Y E A R O F L I F E A N D B E YO N D 1. An increasing number of vaccine doses are recommended to be given after one year of age as part of a life course approach to vaccination. WHO global recommendations for doses of childhood vaccines to be given after one year of age include a second dose of measles-containing vaccine (MCV) and booster doses of diphtheria, tetanus, and pertussis- containing vaccines. Additionally, countries may choose to adopt a “2 + 1” schedule for pneumococcal conjugate vaccine (PCV) in which the third dose is administered in the second year of life. WHO also recommends that doses of some regionally-indicated vaccines, including meningitis A (MenA) in the meningitis belt of Africa and Japanese encephalitis in parts of Asia, can be given after one year of age. 2. The extension of the vaccination schedule beyond infancy means that the concept of a “fully immunized child (FIC)” indicator must be expanded in the second year. FIC should be specific to the age of the child and the corresponding set of vaccines that the child should have received, as per the national schedule, by that age. Programmes may choose to track FIC in two or more age categories: FIC<1, FIC<2 (see Section 7.1). 3. With increasing complexity and duration of the vaccination schedule comes increasing importance of home-based records (HBRs), to remind caregivers of when to return to complete the schedule, to allow providers to screen for needed vaccinations, and to serve as a basis for evaluation through population-based coverage surveys. HBRs must be well- designed, available in sufficient supply for all caregivers, used properly by health personnel, and kept safely by caregivers/families. 4. In some settings, concerted efforts, including strong communication and health worker capacity-building, are needed to change conventional thinking that immunization is just for infants. If high levels of coverage in 15 Establishing and strengthening immunization in the second year of life S E C T I O N 2 the second year of life and throughout the life course are to be achieved, then health workers, caregivers, communities, and partners must have a solid understanding of why it is important and what they themselves can do to make it happen. This requires a major shift in thinking and practices by all parties involved. 5. Whereas children should be vaccinated as soon as they are eligible, those who are brought “late” should not be denied vaccination. Timely vaccination is crucial for reducing exposure to vaccine-preventable diseases (VPDs) but, with a few specific exceptions, it is better to vaccinate late than never. For 2YL vaccination, the age of 24 months should not be viewed as a cut-off point after which children are not vaccinated. 6. Achieving high coverage in the second year of life, even with vaccines that have long been part of the vaccination schedule, requires even more attention, visibility and preparation as for introducing a new vaccine, and should not be taken lightly. The very high MCV1 to MCV2 drop-out rates observed in many countries attest to the challenges in vaccinating a new age group. Areas requiring special attention include data management/monitoring and evaluation, communication, and health worker capacity building, including supportive supervision and other forms of post-training support. 7. Data management, monitoring, and evaluation for vaccination in the second year of life pose particular challenges. Tally sheets and other data management tools must be updated carefully to correctly capture all doses administered (even if the doses are not timely) and to encourage proper health worker screening, recording and reporting of doses administered, which will be needed to ensure good vaccine management and estimation of needs. Monitoring progress across at least two birth cohorts and providing meaningful feedback can be challenging. Careful planning and learning from experience to date is needed to address these issues. 8. Vaccination in the second year of life can serve as a platform for providing other essential services to children and mothers. If carefully coordinated with other programmes, immunization services can reinforce and stimulate the uptake of other health services, such as growth monitoring and promotion, nutritional counselling, vitamin A and micronutrient supplementation, deworming, health education and family planning, malaria prevention, and follow-up on early infant diagnosis of HIV/AIDS. Each country must assess the timing and schedules of these services and determine the feasibility of integration based on an examination of the human, material and financial resources needed. 16 Establishing and strengthening immunization in the second year of life 3 SECTION Background on vaccination in the second year of life and beyond 17 Establishing and strengthening immunization in the second year of life S E C T I O N 3 3.1 How widespread is vaccination in the second year of life? While the vaccines given in the second year of life (or later) and the ages at which they are administered vary across countries, vaccination in the second year of life is a widespread practice. As of 2016,6 recommended that DTP4 be given in the second year of life. 6 WHO vaccine-preventable diseases: monitoring system. 2017 global summary. http://apps.who.int/immunization_monitoring/globalsummary/schedules, accessed 18 July 2017. had immunization policies that included at least one dose of any vaccine to be given in the second year of life. included two doses of measles- containing vaccine (MCV) in their routine immunization schedules. recommended that the second dose, MCV2, be given in the second year of life. include both MCV2 and a fourth dose of vaccine containing diphtheria, pertussis, and tetanus (DTP4) at any age. had policies calling for both MCV2 and DTP4 to be provided at the same time in the second year of life. 159 COUNTRIES 86 COUNTRIES 160 COUNTRIES 135 COUNTRIES 107 COUNTRIES 45 COUNTRIES 18 Establishing and strengthening immunization in the second year of life 3 S E C T I O N 3.2 Opportunities and benefits for vaccinating in the second year of life There are several reasons for establishing a strong platform for vaccination and other interventions in the second year of life and beyond. Increase protection against vaccine-preventable diseases (VPDs) The addition of new vaccines, and new doses of existing vaccines, in the second year of life increases the extent to which children can be protected from VPDs, as shown in Table 1 below. The provision of additional doses of vaccines that are already in the national schedule contributes to higher levels of immunity and longer duration of protection. The immune response to tetanus toxoid-containing vaccine (TTCV), for example, decreases with age, which is why WHO recommends that an individual receives six doses (three primary plus three booster doses, one of which should be given in the second year of life).7 TA B L E 1. WHO-RECOMMENDED VACCINES TO BE ADMINISTERED IN THE SECOND YEAR OF LIFE 7 Use of TTCV combinations with diphtheria toxoid (Td or DT) for subsequent tetanus boosters are strongly encouraged, to maintain high immunity to both diphtheria and tetanus throughout life. VAC C I N E W H O R EC O M M E N DAT I O N S Second dose of measles-containing vaccine (MCV2), including measles- rubella (MR) and measles-mumps- rubella (MMR) vaccines WHO recommends that a second dose of MCV be added to the routine immunization schedule in all countries. Where risk of measles mortality among infants remains high, MCV1 should be administered at 9 months of age and MCV2 should be administered at 15–18 months with a minimum interval of four weeks between doses. In countries with low risk of measles infection among infants (i.e. near elimination), MCV1 may be administered at 12 months; the optimal age for delivering MCV2 is based on programmatic considerations that achieve the highest coverage of MCV2. Measles vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). Fourth dose of diphtheria-tetanus- pertussis-containing vaccine (DTP4) WHO recommends that children be given a booster dose of DTP-containing vaccine, preferably during the second year of life, to strengthen immunity against these diseases. Diphtheria vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/diphtheria/en/), Tetanus vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/tetanus/en/), Pertussis vaccines. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/pertussis/en/). 19 Establishing and strengthening immunization in the second year of life S E C T I O N 3 VAC C I N E W H O R EC O M M E N DAT I O N S Pneumococcal conjugate vaccine (PCV) WHO supports the option of a (2p+1) schedule for PCV in which two primary doses are provided in infancy and the third dose (booster) is given at 9-18 months of age.8 The timing of the booster should be selected to maximize coverage (usually 9, 12, 15 or 18 months) depending on operational and programmatic factors, including timing of vaccination contacts in the national immunization schedule for other vaccines. Pneumococcal vaccines. Position paper. Geneva: World Health Organization; 2012 (www.who.int/immunization/policy/position_papers/pneumococcus/en/) and WHO Strategic Advisory Group (SAGE) on Immunization, October 2017. Conclusions and recommendations. Geneva: World Health Organization; 2017 (www.who.int/wer/2017/wer9248/en/). Meningitis A conjugate vaccine (MenA) routine dose WHO recommends a single dose of MenA at 9–18 months based on local programmatic and epidemiological considerations. Meningococcal A conjugate vaccine: updated guidance. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/meningococcal/en/). Typhoid conjugate vac- cine (TCV) WHO recommends a single dose of TCV at 6-23 months in endemic countries. Timing of administration should be based on local epidemiological, geographic and programmatic considerations. WHO Strategic Advisory Group (SAGE) on Immunization, October 2017. Conclusions and recommendations. Geneva: World Health Organization; 2017 (www.who.int/wer/2017/wer9248/en/). Japanese encephalitis (JE) WHO recommends that JE vaccination be introduced into national immunization schedules in all areas where JE is recognized as a public health priority. WHO recommends one or two doses, starting from 6 months of age, with the schedule determined by local epidemiology and type of vaccine. Japanese encephalitis vaccines. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/japanese_encephalitis/en/). Seasonal influenza Country-specific information about risk groups, disease burden and cost-effectiveness are important to aid national policy-makers and health programme planners in making informed decisions about target groups and timing for vaccination. In those countries that decide to introduce it, WHO recommends seasonal influenza vaccination starting from 6 months of life and extending to 23 or 59 months, with two doses separated by at least 28 days for previously unvaccinated children <9 years of age. Vaccines against influenza. Position paper. Geneva: World Health Organization; 2012 (www.who.int/immunization/policy/position_papers/influenza/en/). Table 1. Continued 8 Both schedule options (3p+0 or 2p+1) are recommended. For countries that have yet to introduce PCV, decisions regarding the choice of schedule should take into account operational and programmatic issues, including timeliness of vaccination, coverage expected to be achieved with the third dose, and pneumococcal disease age distribution patterns. 20 Establishing and strengthening immunization in the second year of life 3 S E C T I O N Catch-up children on vaccinations that were missed during the first year of life Vaccination in the second year of life is an opportunity to provide missed doses of several antigens, including BCG,9 MCV, oral and inactivated polio vaccines, pentavalent (or DTP), pneumococcal vaccines, and rotavirus vaccine. In some settings, families may face various social, geographical, and economic barriers to getting their children fully immunized by 12 months of age and this contributes to low coverage. A strong 2YL platform provides an important oppor- tunity to improve overall protection and coverage. For instance, in a country where measles vaccine is given at 9 months of age and where a one-year age limit is enforced, children are by default limited to a three-month window to receive MCV1. This barrier would be removed by expanding vaccination services to the second year of life and encouraging catch-up vaccination beyond one year. Vaccinating children in the 2YL with measles and other vaccine doses missed in the first year of life contributes to higher levels of population immunity. This was demonstrated in a 2009 analysis of Demographic and Health Surveys (DHS) from 45 countries. It showed that while pooled routine immunization coverage for MCV1 by 12 months of age was only about 50%, it rose to over 80% if the doses given after 12 months of age (i.e. “late doses”) were included in the coverage estimates (see Figure 1).10 F I G U R E 1. I N C R E AS E I N E ST I M AT E S O F M CV 1 C OV E R AG E W H E N D OS E S A D M I N I ST E R E D I N T H E S EC O N D Y E A R O F L I F E A R E I N C LU D E D 0 20 40 60 80 100 MCV1 coverage by age category in selected countries Source: Demographic and Health Survey (Date of survey indicted for each country) Afghanistan (2015) Chad (2014) Haiti (2012) Mali (2013) Pakistan (2013) Yemen (2013) Zambia (2014) Coverage in children < 12 months Additional coverage in children 12–23 months 21 Establishing and strengthening immunization in the second year of life S E C T I O N 3 Create opportunities to integrate vaccination with other health and nutrition interventions A scheduled routine contact with the health system in the second year of life is an opportunity to further integrate immunization with other health interventions, such as vitamin A supplementation, nutritional counselling, growth monitoring and promotion, deworming, paediatric HIV/AIDS care, provision of insecticide-treated bed nets (ITNs), or family planning. Figure 2 illustrates the potential gains in coverage for several child health interventions when integrated with the routine immunization platform in Africa. F I G U R E 2. E ST I M AT E D C OV E R AG E O F I N T E RV E N T I O N S A M O N G H O U S E H O L DS W I T H A C H I L D AG E D 1 2 - 2 3 M O N T H S, I F I N T EG R AT E D W I T H RO U T I N E I M M U N I Z AT I O N ( 2 8 SU B -SA H A R A N A F R I CA N C O U N T R I E S ) 0 20 40 60 80 100 Improved source of drinking water* household bed-net ownership child sleeping under bed-net child received vitamin A supplementation Current coverage Likely total coverage *through provision of point-of-use water treatment kits (after Improved source of drinking water) 9 The WHO position paper on BCG vaccines was recently updated to include the recommendation for catch-up vaccination for unvaccinated older infants and children, as evidence shows that it is still beneficial beyond one year of age. BCG vaccines. Position paper. Geneva: World Health Organization; 2018. www.who.int/wer/2018/wer9308/en/ 10 Clark A, Sanderson C. Timing of children’s vaccinations in 45 low-income and middle-income countries: an analysis of survey data. Lancet. 2009;373:1543–9. 22 Establishing and strengthening immunization in the second year of life 3 S E C T I O N Make more efficient use of vaccines Providing two doses of measles-containing vaccine, with one in the second year of life, can potentially reduce vaccine wastage rates as more doses per opened vial of vaccine will be given. This may also be true for catching up children with other vaccine doses that they missed in infancy and are given at a later age. 3.3 Challenges to vaccination in the second year of life Over the past 40 years, immunization programmes have accumulated a wealth of experience in delivering vaccines, primarily to infants. Since vaccination in the second year of life has been introduced in many countries, experience has been mixed. For example, many national programmes assumed the introduction of MCV2 through a new routine visit in the second year of life would be straightforward, as MCV is already in the schedule in the first year of life and therefore, familiar to caregivers and health workers. However, reality has shown that it brings substantial complexity, in some cases of a nature not previously encountered by immunization programmes. High drop-out rates from MCV1 to MCV2 have been a particular concern in many countries. Successful implementation of vaccination in the sec ond year of life requires strong planning, coordination, community mobilization and demand creation, monitoring, and support for implementation. © W H O N epal 23 Establishing and strengthening immunization in the second year of life S E C T I O N 3 Many immunization programmes still view immunization as a health intervention purely for infants, and do not offer vaccinations to children over one year even if they were never vaccinated. While policies must be established for vaccination beyond one year of age, without proper planning, training, and communication, these policies will not automatically translate to widespread changes in vaccination practices. Factors that have been shown to contribute to this situation include: • insufficient messaging to front-line health workers on revised policies regarding provision of vaccination and other health services after one year of age; • health worker hesitation to vaccinate children >12 months of age with MCV1 because it does not contribute to MCV1 coverage and they may worry about not having enough doses for the <12 months children; • lower priority placed on vaccination of older children, compared with vaccination of infants; • Insufficient communication and social mobilization to remind and encourage caregivers to use health services in the second year of life; • complexity in recording, reporting, and analyzing vaccine doses given after one year; • system barriers, such as limited human resources and uncoordinated supply chains, for different commodities. Post-introduction evaluations (PIEs) of measles second dose in several countries, plus case studies on 2YL vaccination, indicate that the introduction of any vaccination after the first year of life should be treated as if it were a new vaccine introduction in terms of attention, visibility, and preparation, and the added complexities of vaccinating a new age group should be adequately accounted for in the planning process. If possible, 2YL vaccination should also be placed within the context of a healthy child visit so that it can reinforce the provision of other health interventions, and vice versa. 24 Establishing and strengthening immunization in the second year of life Policies and planning for vaccination in the second year of life and beyond 4 SECTION 25 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Virtually all countries already have in place policies, guidelines, and other programme supports for child health care through the first five years of life, including growth monitoring and promotion, nutritional counselling, and integrated management of childhood illness, among others. Depending on their health priorities and current vaccination schedule, countries may want to: introduce vaccination in the second year of life as a new inter- vention (through a scheduled visit, or visits and catch-up of missed vaccination) strengthen existing 2YL vaccination (e.g. improve low MCV2 coverage), and/or develop a 2YL vaccination contact as a platform for coordinated delivery of other child health services. In all three situations, systematic planning is needed to address both technical and managerial issues. The second situation (improvement of existing programmes) is addressed in Section 10. 1. 2. 3. © U N IC EF/U N 0 58138/V ishw anathan 26 Establishing and strengthening immunization in the second year of life 4 S E C T I O N 4.1 Steps for planning the introduction or strengthening of a 2YL visit If setting up a new immunization visit in the 2YL, the planning process should begin one year prior to the anticipated launch date to permit sufficient time for the preparations described below. More detail on operatio- nalizing these steps can be found in a companion resource A handbook for planning, implementing, and strengthening vaccination into the second year of life (2YL Handbook).11 Identify a 2YL focal point and establish or activate a 2YL working group The 2YL focal point should be a staff member of the national immunization programme with sufficient authority to convene a working group. The working group should include representation from various areas of the immunization programme, such as data management, communications and service delivery. If other health interventions are to be coordinated with 2YL vaccination, then representation from these groups should also be included. Major stakeholders and partners in immunization and child health should also be involved. Membership in the working group — K E Y R E S O U RC E A handbook for planning, implementing, and strengthening vaccination into the second year of life A companion resource to this document, the 2YL Handbook is intended for use after the decision has been made to extend vaccination into the 2YL, or improve coverage of an existing platform. The 2YL Handbook provides practical guidance on planning, managing, implementing and monitoring vaccination during a scheduled visit, or visits, in the 2YL, as well as useful steps for strengthening vaccination when coverage in the 2YL has not reached programme targets. www.who.int/immunization/ programmes_systems/policies_ strategies/2YL/en/ Establishing and strengthening immunization in the second year of life Handbook may expand as planning evolves. The National Immunization Technical Advisory Group (NITAG) should be engaged and play a leading role in reviewing epidemiological and clinical considerations, as well as immunization programme needs, costing and financing issues, and the development of policies and guidelines. The Interagency Coordinating Committee (ICC) and/or health sector coordinating committees should also be engaged to enlist commitment and to establish a shared understanding of resource requirements. 11 www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 27 Establishing and strengthening immunization in the second year of life S E C T I O N 4 — K E Y R E S O U RC E Tool for estimating the costs of introducing a 2YL healthy child visit13 UNICEF has developed a relatively simple Excel-based costing tool to estimate the costs of introducing a 2YL visit. The tool must be populated with demographic data, commodity prices, health worker salaries and approximate costs for training and communication activities. Results are then presented in terms of total costs, annual costs and costs per visit. Costs are divided into “up-front” costs (such as training) and recurring costs that need to be continually financed (such as vaccines and syringes). The cost analysis can be viewed as an advocacy opportunity for introducing a 2YL visit. The tool should also be used as an integral part of the planning process. Develop a budgeted plan of action and secure funding This should include activities, lead responsibilities, milestones, timelines, and resources needed to address the following actions, and should be informed by lessons learned and challenges from previous vaccine introductions. 1. Update policies and guidelines; obtain necessary approvals; produce and disseminate (print and/or electronically). 2. Define 2YL indicators for recording and reporting, revise health management information system (HMIS) and data management tools (HBRs, registers, monthly reports), and distribute these in advance of the launch date. 3. Identify and address needs for organization of service delivery. 4. Modify supply chain and logistics management tools, as needed, to include new doses of vaccines and other interventions in the second year of life. 5. Prepare, print and distribute a field guide and job aids for health workers. 12 Tools for conducting behavioural analyses, including Guide for studying health worker/caregiver interactions for immunization. Geneva: World Health Organization; 2017 and The guide to tailoring immunization programmes (TIP). Copenhagen: WHO Regional Office for Europe; 2013, are available at: www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/. 13 The 2YL costing tool can be accessed at: www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 6. Develop a training plan and new training and supervision materials, and carry out training. 7. Develop a communication strategy, plan and conduct social mobilization and community engagement activities, including knowledge-attitude-practice (KAP) studies or other behavioural analyses,12 particularly regarding marginalized and hard-to-reach communities. 8. Secure funding for carrying out all preparatory work, and to cover operational and other related costs associated with 2YL. 28 Establishing and strengthening immunization in the second year of life 4 S E C T I O N Policies, guidelines and standards • Vaccination policy and reference manuals • National health/child health policy • Guidelines and other reference materials for health workers, including for IMCI Planning documents • Comprehensive multi-year plan (cMYP) and the annual plan of action for immunization • Formats for microplanning and plans for introducing them Data management tools • HBR • Tally sheets • Monthly reporting forms • Health facility registers • Community registers • HMIS, District Vaccination Data Management Tool (DV-DMT), district health information system, version 2 (DHIS2) • Monitoring tools and charts Training and capacity-building • Curricula for in-service and pre-service training • Supervision instruments • Job aids Supply chain management • Assessment of cold chain, logistics, and available storage • Standard operating procedures (SOPs) for handling of vaccines in 2YL • Vaccine and logistics forecasting tools Communication, demand creation • Communication and community engagement plan and strategy • Plans and materials for launch • Health education materials and job aids Assign clear responsibilities for each aspect of preparation. Groups or committees that have been established to work on such issues, for vaccination campaigns or new vaccine introductions, in the past, can be re-activated. However, if other health interventions are to be included together with 2YL vaccination, then there should also be representation from other programmes, such as nutrition, integrated management of childhood illness (IMCI), malaria, water and sanitation, paediatric HIV/AIDS, etc. Agree on the services or interventions to be provided during the visit and identify the policies, guidelines, and other materials that must be revised. These are likely to include the following, in Table 2 below, but there may be additional materials to revise depending on the country. TA B L E 2. M AT E R I A L S TO R E V I E W A N D U P DAT E FO R 2 Y L VAC C I N AT I O N A N D S E RV I C E S 29 Establishing and strengthening immunization in the second year of life S E C T I O N 4 4.2 Deciding on the timing of the 2YL visit or visits A key step is to decide on the appropriate age at which to schedule the 2YL visit (or visits). This is a function of epidemiological data for the VPDs in question, plus the schedule for other child health services, as specified by national policies. Policy- and decision-makers need to consider public health goals and programmatic issues, using transparent criteria to evaluate their relative importance. National immunization policies and guidelines should be written to clearly articulate the actions needed by health personnel and caregivers. For example: • Clarify that, although it is best to vaccinate children as soon as they become eligible, for most vaccines there is no upper age limit after which the child should be denied the protection of vaccination. The exceptions are rotavirus vaccine, which is not recommended > 24 months of age, and hepatitis B (HepB) birth dose.14 • Convey the intended purpose of the 2YL vaccine doses. If the country is introducing a second dose of MCV into its routine schedule, then the dose must be included in the fully immunized child (FIC) requirement, and the dose should be referred to as Measles 2 or MR2 or MMR2, rather than a booster dose. AG E S FO R S C H E D U L E D 2 Y L V I S I TS FO R VAC C I N AT I O N I N T H R E E C O U N T R I E S One Southern African country decided to provide MCV2 at 18 months because it coincides with the age for vitamin A supplementation. A West African country chose to provide MCV2 at 15 months to minimize the length of potential exposure to measles virus, even though the timing was not synchronized with the schedule for other health services provided during the second year of life. A South Asian country initially introduced MCV2 and DTP4 at different months in the second year of life for epidemiological reasons. However, it was later recognized that this added complexity to the immunization schedule and contributed to missed opportunities for vaccina- tion. The country then modified the schedule to recommend both doses at the same visit. C O U N T RY E X P E R I E N C E 14 It is important that programmes have a clear policy on how late HepB birth dose can be administered. Some countries stop providing HepB birth dose beyond two weeks after birth in order to maintain a four-week gap between doses. However, in countries using a 4-dose schedule (with combination vaccine), a four-week gap is not necessary prior to the first primary dose (as the combination schedule meets the dosing requirements), therefore, HepB birth dose can be given up until the day before the first combination vaccine is due. Both options are acceptable. For more information, see A guide for introducing and strengthening Hepatitis B birth dose vaccination. Geneva: World Health Organization; 2015 (www.who.int/immunization/documents/general/ISBN9789241509831/en/). 30 Establishing and strengthening immunization in the second year of life 4 S E C T I O N • Provide clear instructions on how to properly screen children for eligibility by reviewing HBRs, record doses, report data, and use it for improving services. • Specify the actions that health workers should take when faced with situations that do not represent the ideal, such as children arriving with missing or delayed doses, children arriving with no HBR, etc. (see Annex 3). • Clearly state the policy on vaccinating children who are 12 months or older and missing doses, during periodic intensification of routine immunization (PIRI) activities such as Child Health Days (see Box 2 below). 4.3 Catch-up vaccination at any time a child has contact with health services Sick-child visits and visits to facilities for care of other family members in the second year of life are also opportunities to catch children up on missed doses from the first year of life, and to screen and vaccinate them for doses scheduled for the second year of life. L E A R N I N G F RO M G H A N A’S I M M U N I Z AT I O N P O L I CY The Republic of Ghana’s immunization policy has been updated to provide clear guidance to health workers about vaccinating children older than 12 months of age. Second year of life routine immunization policy Additional routine contact for immunizations will be done during a child’s second year of life at 18 months of age or soon after. Services available at this contact include MR2, MenA, and any intervention deemed appropriate (e.g. Vitamin A supplementation). Catch-up policy All children should be immunized per Ghana’s recommended immunization schedule. Children with any missed doses should be vaccinated with appropriate antigen up to five years of age. During any health visit, a child’s immunization status should be assessed and missed doses administered per the recommended catch-up schedule. Fully immunized child (FIC) The FIC indicator is split into three categories: FIC by age one, FIC by age two, and FIC after age two. A child is considered fully immunized by his/ her age if he/she has received all the age-appropriate vaccines up to that point. C O U N T RY E X P E R I E N C E 31 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Immunization policies and health worker training/ supervision should emphasize the importance of caregivers bringing the child’s HBR to health facilities for every visit and providing catch-up vaccination at any time that a child has contact with the health system. Clear guidelines for catch-up vaccinations for antigens missed in the first year of life should be established and disseminated widely, including an accelerated vaccination schedule for children who present missing multiple vaccine doses. A useful resource for this is the WHO recommendations for catch-up vaccinations, available at: www.who.int/immunization/policy/Immunization_routine_table3.pdf B OX 2. P ROV I D I N G 2 Y L VAC C I N AT I O N D U R I N G P I R I E V E N TS Periodic intensification of routine immunization (PIRI) activities, such as Child Health Days or Maternal and Child Health Weeks, if regularly conducted, should be used to catch-up children for missed doses from the first year of life and to provide 2YL vaccinations for which the child is eligible. Immunization policies and health worker training for the PIRI should provide clear guidance on this point. PIRI activities should also be used as an opportunity to communicate the importance of immunization in the second year of life and the need for children to be brought for all recommended 2YL vaccinations according to the national schedule. PIRI activities should also underscore the importance of encouraging caregivers to bring the child’s HBR to every health contact. Guidance for health workers on screening, provision of services, and recording of doses, both for the routine 2YL doses and for the PIRI, should be included in policies, field manuals, training, and supervision. For more information on best practices for PIRI activities, please see WHO resource Periodic Intensification of Routine Immunization. Lessons learned and implications for action, available at: www.who.int/immunization/ programmes_systems/policies_strategies/piri_020909.pdf? © W H O 32 Establishing and strengthening immunization in the second year of life 4 S E C T I O N 4.4 Coordinating vaccination with other services in the second year of life If it is decided to use the 2YL vaccination visit to deliver additional interventions, then the planning process must engage representatives from other related health programmes. Analyse and compare the technical attributes of other interventions proposed for the scheduled 2YL visit(s) The priorities, objectives, achievements, challenges, and plans of different evidence-based health and nutrition interventions offered in the second year of life should be compared systematically to identify both the opportunities and the limits of a 2YL vaccination contact in reinforcing other services. This may entail convening a meeting, or meetings, to foster direct communication and negotiation among stakeholders regarding the continuum of care for young children and the role of immunization within it. The package of services to be provided during the 2YL visit should be based on a combination of technical, managerial, and client-oriented considerations. Questions to consider in deciding on the components of the package include the following: • What are the established public health priorities of the Ministry of Health? • Which interventions can be provided at ages 12-23 months, are any of these visits already established, and does their timing coincide with a recommended schedule for 2YL vaccination? • Which services, and how many, can be scheduled for a single visit in the 2YL, and will this improve convenience for the child and caregiver? • Can all of the interventions be provided to children through fixed (static), outreach, and mobile services, and are these service delivery strategies fully functional? • Are the proposed interventions for this visit carried out throughout the entire country or only in certain geographic areas? • How similar are the logistical requirements? • What are the implications for human resources, including capacity of staff, time to be spent per patient, and patient flow? • Are sufficient human and financial resources available for providing and sustaining each intervention proposed for the visit? 33 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Some countries have planned for integrated services that include vaccination beyond one year of age and have evaluated the experience to identify ways of improving services. The lessons learned from such experiences can help guide other countries in their decision-making and planning processes. Z A M B I A’S PAC K AG E O F I N T E RV E N T I O N S FO R A C O M P R E H E N S I V E H E A LT H Y C H I L D V I S I T AT 1 8 M O N T H S O F AG E One year after the Republic of Zambia introduced MCV2, the Ministry of Health and partners reviewed the experience in order to decide how to strengthen performance and integrate 2YL vaccination with other services. A meeting was convened in which officials from several programmes, including immunization, nutrition, and child health, as well as representatives from the HMIS, provincial and district teams, and key technical partners, deliberated on ways in which the 2YL visit for MCV2 could serve additional health needs. A key outcome was definition of the package of services shown below. This reflected, in part, a decision by the MOH to shift its delivery strategy for vitamin A supplementation and deworming away from reliance on Child Health Weeks and into routine services. At 18 months, all children now receive the following: • MCV2 • catch-up of other vaccinations that the child missed in the first year of life and for which he or she is still eligible • growth monitoring and promotion • Vitamin A supplementation • deworming treatment (mebendazole). For some children, if indicated, the following are also provided: • follow up/referral on early infant diagnosis (EID) for HIV/AIDS • referral for IMCI or integrated Community Case Management (iCCM) for children with fever or other signs of illness during the visit. C O U N T RY E X P E R I E N C E © U N IC EF/U N 0 152973/Scherm brucker 34 Establishing and strengthening immunization in the second year of life 4 S E C T I O N LESSONS LEARNED FROM HONDURAS IN INTEGRATING I M M U N I Z AT I O N W I T H OT H E R S E RV I C E S I N T H E F I RST F I V E Y E A RS O F L I F E The immunization programme in the Republic of Honduras serves as a strong platform for providing other services from 2-5 years of age. These include vitamin A supplementation, folic acid for mothers, promotion of exclusive breastfeeding, education on identifying ocular tumours, and local time-limited measures to contain cholera outbreaks and control dengue. A study of early experience showed the following. • Close coordination and joint planning across different programmes and different levels of the health system is key to success. • Jointly-prepared technical and programmatic guidelines are essential to clearly define the delivery of the interventions to be provided during the healthy child visits that include immunization. • Health personnel at all levels must be trained on the technical guidelines. • Timely and accurate forecasting, procurement, distribution, and storage are needed for all supplies, not just vaccines, required at health facility level for the healthy child visit. • A communications working group should develop a strategic communication plan that includes materials development, use of mass media, community engagement, and a timeline and budget. • Forms for data recording and reporting must be adapted and the HMIS updated accordingly. • Systematic monitoring, by age group and strategy of progress against goals should be carried out. • Joint supervision with personnel from all relevant programmes should prioritize densely-populated areas and areas at risk. • Challenges to sustained integration include uncertain funding and limited supplies of key commodities. Source: Molina-Aguilera et al. J. Inf. Dis. 2012:205 (Suppl 1) C O U N T RY E X P E R I E N C E © U N IC EF/U N I440 79/D eC esare 5 SECTION 35 Establishing and strengthening immunization in the second year of life Facility-level planning, service organization, and human resources 36 Establishing and strengthening immunization in the second year of life 5 S E C T I O N The introduction of a scheduled 2YL visit for vaccination requires detailed planning to implement it within the existing organization and delivery of fixed, outreach, and mobile services. District and facility supervisors have an important role to play in adjusting microplanning and reviewing the organization of services, patient flow, human resources, and prevention of missed opportunities for vaccination. The national level should provide guidance for updating microplanning templates and for ensuring high-quality service delivery, especially if there is a preferred sequence for administering the interventions. Vaccination, as an invasive procedure, should generally be provided after other procedures.15 However, the health worker should complete the interaction with the caregiver by providing guidance on what to do in the event of side-effects or adverse events, and when and where to return for the next visit. 5.1 Update microplanning tools and processes In many countries, microplanning tools currently in use are designed to support planning for vaccination in the first year of life. To accommodate 2YL vaccination, microplanning tools must be revised and expanded to include the second year cohort aged 12-23 months. The target population is surviving infants from the previous year’s birth cohort. For example, if DTP4 is scheduled to be given to children who are 18 months of age or older, then the target group for microplanning for the current year is the number of surviving infants from the previous year. This information should be available from the previous year’s plans. Timely vaccination during a scheduled visit in the second year of life is highly desirable, but the age of 24 months should not be viewed as a cut-off point after which children are denied vaccination. Microplanning should be based on the cohort aged 12-23 months and, even if children are vaccinated later than the targeted age, it does not affect the number or catchment area of the children to be vaccinated, just the age at which they actually receive the vaccines. As further described in Section 7, all doses, regardless of when they are given, should be recorded on HBRs, tally sheets, facility registers, electronic immunization records (EIRs), and monthly reports, according to the age at which the child actually received the vaccines. 15 Reducing pain at the time of immunization. Position paper. Geneva: World Health Organization; 2015 (www.who.int/wer/2015/wer9039.pdf). 37 Establishing and strengthening immunization in the second year of life S E C T I O N 5 Microplanning should give particular attention to identifying outreach sites that are convenient for the caregiver(s), bearing in mind that a child in the 2YL is now older, heavier, and less easy to transport than an infant. Mothers are also more likely to be working outside the home. To improve access and reduce drop-out rates, the site selection, day of the week, and time of day for outreach sessions should, where possible, be decided in consultation with the community members. The provision of additional health services during the scheduled 2YL visit means that microplanning should address the operational features of those services as well as those of immunization. Personnel responsible for nutrition, child health, water and sanitation, HIV/AIDS, family planning, health education, or other programmes, should be encouraged to take part in the microplanning process. 5.2 Review the implications for human resources for the 2YL visit Many low-resource countries face severe limitations in human resources so that the true staffing situation in health facilities falls short of government standards. The ability to provide multiple services during the visit requires that the right types of health workers are present at each facility. During the 2YL planning phase at national level, health officials should review the actual availability of human resources in health facilities, and provide guidance on which types of staff can carry out each task. Terms of reference and accountabilities may need to be revised. At the clinic level, head nurses or facility in-charges should clearly communicate the sequence of services, both for fixed and outreach services. They should also designate which staff will carry out specific tasks (described further in Section 8). These include: • screening children to determine which services they should receive that day; • providing each service in a pre-defined order: e.g. growth monitoring and promotion, Vitamin A supplementation, deworming, vaccination, counselling; • recording services administered, in all the appropriate tools, immediately after the services are provided; • discussing, with each caregiver, what the child has just received and what further actions the caregiver needs to take. In smaller health facilities where one, or few, staff carry out all functions, it is pref- erable that all health workers at the facility are trained to provide all 2YL services to ensure continuous service delivery when any members of the team are on leave. 38 Establishing and strengthening immunization in the second year of life 5 S E C T I O N At both fixed and outreach service delivery points, community health workers (CHWs) or trained volunteers may be able to assist health workers with patient flow, health education, and possibly some aspects of record keeping. Within the communities, CHW tasks may include recording newborns, maintaining community registers of children 0-59 months of age and pregnant women, defaulter tracking and follow-up, talking with community members about the importance of vaccination and other services in the second year of life, and informing them of when and where to seek services. However, some tasks are less appropriate for CHWs or volunteers. For example, screening of 12-23 month old children for eligibility for vaccination is more complex than for infant vaccination, as the number of doses these children should have received by that age is greater and there may be uncertainty about how to handle missing or late doses. This is, therefore, likely to require trained health workers. In small health facilities with limited staff, it is pref erable that all health workers are trained to provide all 2YL services to ensure continuous service delivery when any members of the team are on leave. © W H O /Reidy 39 Establishing and strengthening immunization in the second year of life S E C T I O N 5 5.3 Determine the feasibility of providing all services desired for the 2YL visit and the practical issues of patient flow In low-resource settings, it may not always be possible to have all the services available at the same time and in the same place. For instance, a national level mandate for daily vaccination may not be feasible in a small facility with only one or two health workers providing all services. In situations like this, it is important to communicate widely and mobilize communities to come for services on the specific days that they are offered. At district and facility level, health officials should consider the following questions: • What would be the specific tasks for each type of health worker in providing vaccination, plus other services, during the 2YL visit? What, if anything, will he/she do differently from current practice on a daily, monthly, quarterly, or annual basis? — K E Y R E S O U RC E S Missed Opportunity for Vaccination (MOV) resource guides The WHO strategy for reducing missed opportunities for vaccination (MOV) aims to increase immunization coverage by making better use of existing vaccination sites (at health centres, hospitals, outreach/ mobile services, etc.) In addition to improving coverage, reducing MOV will improve health service delivery and promote synergy between programmes. www.who.int/immunization/ programmes_systems/policies_ strategies/MOV/en/ • What bottlenecks are likely to occur that may result in long waiting times, especially in high-volume facilities? Clinic supervisors should determine how to reduce waiting times. • In situations where all patients first go through the registration clerk prior to accessing services, can this step be used to communicate with parents, answer their questions, and triage children to the different service points? In some instances, it may be possible to provide certain services at the registration or waiting area before mothers or caregivers disperse to other departments. Immunization or other staff may need to be posted to the registration desk on a rotational basis to assist with this step. 40 Establishing and strengthening immunization in the second year of life 5 S E C T I O N 16 MOV assessments conducted in Chad (2015), Timor Leste (2015), and Burkina Faso (2016) indicated a higher proportion of MOVs occurring in the second year of life. • Are all services proposed to be provided during a 2YL visit for vaccination actually offered and available on the same days? Missed opportunities for vaccination and other services arise when not all staff and services are provided at the same time and place. The added complexity of the 2YL visit may require revising the schedule for outreach services, to optimize the use of human resources. • Are policies and practices in place so that all children carry their HBRs and are screened and vaccinated, as appropriate, when they come for any type of care (curative and/or preventive)? Recent country assessments have shown that rates of missed opportunities for vaccination (MOV) are particularly high during visits in the second year of life.16 Therefore, it is important to design and organize services in ways that encourage coordination across different health interventions. Assessment findings further indicate that only 1-2 visits for preventive care take place during the second year of life, so there is an even greater need to capitalize on these opportunities. If a country has conducted an MOV assessment, the findings should be incorporated into planning to better organize services. Policies should be put in place to ensure that all children carry their HBRs and are screened and vaccinated, if needed, when they come for any type of health service. © W H O 41 Establishing and strengthening immunization in the second year of life Supply chain management for vaccines and other commodities 6 SECTION 42 Establishing and strengthening immunization in the second year of life 6 S E C T I O N 6.1 Commodities needed for vaccination and other services in the second year of life Planners should review all supplies required for the 2YL visit, both for vaccination and other services. Any adjustments needed for forecasting, distribution, and storage should be identified and addressed to ensure that all commodities are available at each service delivery point. Table 3 presents an illustrative example based on the package of services adopted in Zambia. Countries can adapt this to correspond to the package of services that they intend to include in their 2YL healthy child visit. TA B L E 3. I N T E RV E N T I O N S A N D C O M M O D I T I E S FO R VAC C I N AT I O N A N D OT H E R S E RV I C E S I N A S C H E D U L E D 2 Y L V I S I T (illustrative example) S E RV I C E / I N T E RV E N T I O N C O M M O D I T I E S N E E D E D ST E P S TO P R E PA R E FO R 2 Y L V I S I T Vaccine dose recommended in the 2YL (MCV2, MenA, DPT4/Penta booster) • Vaccine • Diluent • Needles and syringes • Safety boxes • Updated data management tools • Forecast additional quantities of vaccine needed, if any • Assess needs for additional cold storage capacity • Forecast additional quantities of needles and syringes needed • Estimate additional safety boxes needed • Review and address increased needs for waste management • Update recording and reporting tools Catch-up of other vaccinations missed in the first year of life • Vaccine • Diluent • Needles and syringes • Safety boxes • Updated data management tools • Forecast additional quantities of vaccine, if needed • Assess needs for additional cold storage capacity • Forecast additional quantities of needles and syringes needed • Estimate additional safety boxes needed • Review and address increased needs for waste management • Ensure data management tools allow for recording/reporting “late” doses 43 Establishing and strengthening immunization in the second year of life S E C T I O N 6 S E RV I C E / I N T E RV E N T I O N C O M M O D I T I E S N E E D E D ST E P S TO P R E PA R E FO R 2 Y L V I S I T Vitamin A supplementation • 200 000 IU capsules of Vitamin A • Clippers/scissors • Data management tools • Forecast quantities needed for vitamin A to be provided through routine 2YL visit. This may represent a change in service delivery strategy (if previously provided through semi-annual Child Health Days, for example) • Review quantities provided in essential drug kits to determine whether they are sufficient to meet needs for routine services • As needed, address gaps between forecasted needs and quantities available through essential drug kits Deworming treatment • Deworming medication • Data management tools • Forecast quantities needed for deworming treatment to be provided through routine 2YL visit • Compare with quantities provided in essential drug kits to determine whether they are sufficient to meet needs for routine services • As needed, address gaps between forecasted needs and quantities available through essential drug kits Growth monitoring and promotion • Weighing scales • Middle upper arm circumference (MUAC) tapes • Counselling materials • Growth record, if separate from HBR • Data management tools • Review availability for all supplies and materials at service delivery point based on estimated levels of utilization and attendance during second year of life Follow-up on early infant diagnosis of HIV/AIDS • Data management tools • Counselling materials • Review whether additional quantities of medications such as cotrimoxazole are needed as part of follow-up steps 17 In general, additional quantities may not be required as these are “delayed vaccinations” of children already accounted for in vaccine forecast of previous year, not additional doses. However, to cover wastage at field level, countries may consider extra doses for catch-up based on previous years’ coverages. 44 Establishing and strengthening immunization in the second year of life 6 S E C T I O N Depending on which interventions countries choose to provide along with immunization in the 2YL, other potential commodities to consider may include: • preventive zinc supplementation or zinc use in diarrhoea management18 • multiple micronutrient powders • treatments for severe acute malnutrition • iron supplements • insecticide-treated bed nets (ITNs) In some countries, commodities such as vitamin A supplementation and deworming medication are provided primarily through campaign-style activities, such as semi-annual Child Health Days or weeks that have their own supply chains, which operate independently of those for routine services. If countries decide to 18 www.who.int/elena/titles/zinc_diarrhoea/en/ 19 www.who.int/nutrition/publications/micronutrients/guidelines/vas_6to59_months/en/ 20 www.who.int/neglected_diseases/preventive_chemotherapy/9789241547109/en/ © U N IC EF/U N I12580 0/N esbitt shift to providing them through an integrated 2YL visit, then they must ensure that there are sufficient quantities at all service delivery points for routine delivery. In countries where these commodities are provided to health facilities as part of essential drug kits, determine whether the kits provide sufficient quantities to meet the needs of 2YL visits. Countries can consult their existing programme guidelines and standards or global references including the WHO guidelines Vitamin A supplementation in infants and children 6–59 months of age19 and Preventive chemotherapy in human helminthiasis. Coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers.20 45 Establishing and strengthening immunization in the second year of life S E C T I O N 6 6.2 Vaccines and vaccination supplies in the second year of life 21 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ — K E Y R E S O U RC E Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring This resource outlines the key principles and issues to be considered when introducing a new vaccine into a national immunization programme, and includes references and tools/checklists for planning, implementation, and monitoring. Importantly, this guide also highlights the ways to use the opportunity of adding a new vaccine to strengthen immunization and health systems. www.who.int/immunization/ programmes_systems/policies_ strategies/vaccine_intro_ resources/nvi_guidelines/en/ Principles and considerations for adding a vaccine to a national immunization programme FROM DECISION TO IMPLEMENTATION AND MONITORING In forecasting requirements for vaccination in the second year of life, the target population is surviving infants from the previous year’s birth cohort. For example, if MenA is scheduled to be given to children at 18 months, then the target group for forecasting purposes for the current year is the number of surviving infants from the previous year. As noted in Box 1, timely vaccination during a 2YL visit is highly desirable, but the age of 24 months should not be viewed as a cut-off point after which children are denied vaccination. The practical implications for forecasting are that it should be based on the cohort aged 12-23 months. If children are vaccinated later than 23 months, it does not affect the number of doses required, just the age at which they actually receive these doses. While the doses should be accurately recorded and reported on tally sheets and monthly reports according to actual age of vaccination, this should not affect stock management practices. Introducing a new vaccine If an entirely new vaccine (for example, MenA) is to be introduced into the routine immunization schedule in the second year of life, then country planners should consult the WHO document Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring. Sections 3.4 and 3.5 contain an in-depth discussion of vaccine management and forecasting.21 The specific modifications to vaccine supply chain management will depend on the characteristics of the new vaccine being introduced. 46 Establishing and strengthening immunization in the second year of life 6 S E C T I O N Adding another dose of a vaccine that is already in the schedule If the 2YL visit will include provision of an additional or booster dose of a vaccine already in the national schedule, the preparations necessary will also depend on the vaccine(s) in question. The introduction of a second dose of measles or MR vaccine in 10-dose vials has been estimated to require a 15-25% increase in cold chain storage space. The need for additional vaccine doses is offset to some extent by an expected reduction in the wastage rate for vaccines in 10-dose vials because, due to the larger target population, more doses will be used per vial. It has been estimated that the measles wastage rate could be reduced by 40% with the switch from a one-dose schedule to a two-dose schedule.22 Programme managers and logisticians also need to monitor and revise the wastage rate and wastage factor for measles-containing vaccine based on any changes in policies, or actual practices, regarding circumstances for health workers to open multi-dose vials of these vaccines. With additional training or skills reinforcement, it should become standard practice for health workers to open 10-dose vials when only one or two children are brought to an immunization session. This practice would improve timely immunization, 22 A guide to introducing a second dose of measles vaccine into routine immunization schedules. Geneva: World Health Organization; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) pp. 21–22. — K E Y R E S O U RC E A guide to introducing a second dose of measles vaccine into routine immunization schedules This resource provides guidance to support policy discussions and operational aspects of the introduction of a second dose of measles vaccine into the routine immunization schedule. It provides useful direction on issues specific to vaccinating in the second year of life, including vaccine forecasting, communications, and data monitoring. http://www.who.int/im- munization/documents/WHO_ IVB_13.03/en/ A Guide to Introducing a Second Dose of Measles Vaccine into Routine Immunization Schedules which is an important programme priority, particularly for measles. However, it could potentially increase wastage rates. With regard to introducing DTP4, the effect on supply chain management is determined by the vaccine product to be used. For example, if a country that uses pentavalent vaccine for infant vaccination plans to provide DTP4 using DTP only, then the situation is similar to adding a new vaccine to the cold chain. If the country 47 Establishing and strengthening immunization in the second year of life S E C T I O N 6 decides instead to provide DTP4 in the form of an additional dose of pentavalent vaccine, then the additional cold storage requirements may be minimized and, programmatically, it will be easier to manage supplies. Using pentavalent vaccine means that additional doses of hepatitis B and Haemophilus influenzae type B (Hib), though not harmful, will be provided without any necessity. This is a decision that will need to be weighed by the country programme. Catch-up vaccination for doses missed in the first year of life Many countries already account for some catch-up vaccination using existing supplies. With the introduction of a 2YL platform and strengthened policies for catch-up vaccination, it is possible that vaccine and logistics requirements will increase in the short term; therefore, managers should monitor trends in vaccine consumption so that they can adjust their vaccine forecasts accordingly. The potential impact on vaccine and cold chain management of catch-up vaccination can be estimated based on a combination of factors, including past trend data on immunization in children over one year of age, the expected number of doses of each vaccine to be given after one year, and whether the vaccine vials in question can be used on subsequent days after being opened, as per the multi-dose vial policy.23 Other commodities for vaccination Increased quantities of needles, syringes and safety boxes are required to accommodate the additional vaccinations to be provided in the second year. Section 3.5 of Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring provides detailed guidance on this topic.24 The quantities of these supplies needed will depend on the estimated coverage for each dose of each vaccine and this is likely to change over time. In some countries, the MCV1 to MCV2 drop-out rate was initially high but then fell within a few years, whereas in others, high drop-out rates have persisted. Programme managers and logisticians should monitor actual patterns of coverage and vaccine consumption each year, and adjust their targets and forecasts accordingly. 23 WHO Policy Statement: Multi-dose vial policy (MDVP), Revision 2014. Geneva: World Health Organization; 2014 (www.who.int/immunization/documents/general/WHO_IVB_14.07/en/). 24 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ 48 Establishing and strengthening immunization in the second year of life 7 SECTION Recording, reporting, and using data for decision-making 49 Establishing and strengthening immunization in the second year of life S E C T I O N 7 The recording, reporting, and use of data at all levels can be the most complex aspect of introducing vaccination in the second year of life. The target groups to be vaccinated, or provided with other services, must be clearly defined and appropriate denominators used to calculate coverage in these target groups. To determine the data requirement, decisions must be made about the types of information and indicators to be used to monitor performance and guide action. Data recording and reporting instruments need to be revised carefully and with input from end-users to ensure that they promote correct screening for eligibility, service provision, and recording and reporting practices by health personnel. This section examines the following topics: 1. PERFORMANCE INDICATORS. Programmes must decide how to monitor introduction and performance and how indicators will be used to guide activities and decision-making. They must also consider alternative ways of obtaining programme data such as through population- based coverage surveys or knowledge- attitude-practice (KAP) surveys. 2. DATA REQUIREMENTS. Once performance indicators are known, data requirements for generating the indicators can be defined. 3. UPDATING DATA FORMS AND SYSTEMS. This includes all recording, reporting, and monitoring tools. © U N IC EF/U N 0 26564/Parry 50 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.1 Performance indicators A core principle in deciding which changes to make to data management tools and procedures is that only those data that are likely to be used should be collected. Countries should be aware that there are certain global immunization indicators that must be reported on a regular basis. However, other data needs may vary across countries, depending on programme priorities and problems. Table 4 presents immunization indicators relevant to establishing or strengthening a 2YL visit. Measuring 2YL indicators requires recording and tallying doses administered by the age of administration. In settings where vaccination is known to happen late and improving timeliness is a priority, tally sheets can be disaggregated to three age groups: 0-11 months, 12-23 months, and >24 months. This will enable the programme to monitor whether timeliness improves over time. A country with a strong record of timely vaccination may not see this as important and may prefer that their tally sheets have only two age groups: 0-11 months, and >12 months. To avoid overloading health workers with reporting requirements, countries should carefully consider what, if any, additional data will be needed for 2YL indicators and take the opportunity to review, and possibly remove, indicators not currently used. On this basis, countries need to decide which data to collect administratively each year, from all vaccine service delivery points and which data to collect less frequently through population-based coverage surveys such as Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), or KAP studies. It is important to differentiate between data collected through each of these methods. Population-based coverage surveys for routine immunization must be adapted to capture data for all doses administered. The WHO Vaccination Coverage Cluster Surveys: Reference Manual (2017)25 provides guidance on defining the target populations to be surveyed if immunization extends beyond one year of age. For coverage of vaccines recommended between 12–23 months of age (for example, MCV2, DTP4), the Reference manual suggests surveying children aged 24–35 months of age in addition to those 12–23 months usually surveyed for vaccines recommended <12 months. Monitoring drop-out from MCV1 to MCV2 MCV1 to MCV2 drop-out should be monitored at national, subnational and facility level based on monthly summary reports. Monitoring charts are also encouraged at facility level. This is complicated by the fact that the doses are scheduled to be 25 www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index2.html 51 Establishing and strengthening immunization in the second year of life S E C T I O N 7 26 A guide to introducing a second dose of measles vaccine into routine immunization schedules. Geneva: World Health Organization; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) Annex 6, p.16. given to two different birth cohorts; however, in reality, the actual difference in size between cohorts for two consecutive years is very small so, for the purpose of calculating the drop-out, the same denominator should be used for calculating coverage of both doses. The recommended denominator to use is surviving infants for the cohort receiving MCV1.26 A sample coverage monitoring chart including MCV1-MCV2 drop-out is included in Annex 2. Monitoring if all interventions to be provided during a scheduled 2YL visit are provided The 2YL visit is an opportunity to provide multiple services to the same child, encouraging greater use of services during a vulnerable age. It is important to have in place a system for monitoring uptake of all interventions provided during the 2YL visit. For example, if performance for immunization is higher than that for other services, it could flag obstacles to delivery and could help managers to identify specific problems and explore solutions. If all services to be provided during the 2YL visit were recorded in the same register, then facility heads and supervisors can perform regular spot checks to assess the extent to which children coming for the 2YL visit receive all of them. On the other hand, recording multiple services in the same place can result in a large unwieldy register that can quickly become impractical. The feasibility of these recording practices should be discussed and tested with health workers. Uptake of integrated interventions can also be monitored through facility visits, surveys and exit interviews. Determining fully immunized child (FIC) The addition of new vaccines and new doses of existing vaccines in the second year of life adds complexity to the health worker’s task of using administrative data to determine a FIC according to age and the country’s immunization schedule. FIC, as an indicator, must be specific to the age of the child and the corresponding set of vaccines that the child should have received by that age, as per the national schedule. It is increasingly the case that a child should receive 15 or more doses of vaccines in the first 15-18 months of life. This increases the amount of time the health worker needs to review the child health card or go through all entries in the register to determine if the child is fully vaccinated. One option is to split the indicator into two or more categories (FIC<12 months, FIC<24 months). Alternatively, programmes may opt not to include FIC in the tally sheets, but rather monitor the indicator(s) through periodic vaccination coverage surveys. 52 Establishing and strengthening immunization in the second year of life 7 S E C T I O N TA B L E 4. SU M M A RY O F I M M U N I Z AT I O N I N D I CATO RS R E L AT E D TO 2 Y L I N D I CATO R RECOMMENDATION I N T E R P R E TAT I O N P OT E N T I A L ACT I O N S I F LOW P E R FO R M A N C E DATA S O U RC E C OV E R AG E ‘Total MCV2’ MCV2 given anytime (timely plus late) Core indicator Proportiona of children vaccinated with at least two routine doses of measles-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of two doses of measles-containing vaccines, or improving defaulter tracing. Administrative data or population-based survey ‘Total DTP4’ Fourth dose of DTP-containing vac- cine given anytime (timely plus late) Core indicator Proportiona of children who received a booster dose of DTP-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of a booster dose, or improving defaulter tracing. Administrative data or population-based survey Doses of other vaccines scheduled to be given after one year of age (e.g. MenA) Core indicator Proportiona of children who received the indicated doses in the vaccination schedule after 12 months Analyse reasons for low performance. Depending on reasons identified, possible actions may include ensuring an adequate supply of vaccine, strengthening health worker skills, and conducting communication or social mobilization activities to promote the demand for, and use of, these vaccines. Administrative data or population-based survey Fully Immunized Child (FIC) by 24 months Optional unless source of data is a population-based survey Proportion of children vaccinated, in a timely manner, with all doses of all vaccines that are in the national immunization schedule to be given by the age of <24 months Review reasons and take actions. If indicated, work to change paradigm of EPI as an infant programme to one that reaches multiple birth cohorts. Actions may include strengthening health worker knowledge and skills through training, supervision, and feedback; strengthening defaulter tracing; improving data reporting, and increasing communication and social mobilization directed at health workers, communities, families, and caregivers. Population-based surveys Other health interventions, e.g., vitamin A supplementation at ages scheduled in country programme Consult relevant pro- gramme for guidance Check with relevant health programmes for interpretation Seek input from other programmes to analyse reasons for low performance and appropriate actions to take. Seek guidance from the relevant programmes T I M E L I N E S S ‘Late DTP3’ DTP3 after 12 months Optional indicator Captures number of children who complete their primary DTP-containing vaccine series late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Implement better recall/reminder systems to timely track potential defaulters. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey ‘Late MCV1’ MCV1 after 12 monthsb Core indicator Captures number of children who receive MCV1 late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey D RO P - O U T MCV1-MCV2 drop-out rate Core indicator Describes those who are not coming back for a second dose of a measles- containing vaccine Through supervision, feedback, and training, improve health worker interpersonal communication to remind caregivers to return for second dose; strengthen health worker technical skills as needed; increase defaulter tracing and communication with communities about need for MCV2 Population-based survey or administrative data at national and subnational levels. It may be possible to analyse such data at the facility level. a Denominator should be birth cohort of 12-23 months (i.e. surviving infants), even if data is age-disaggregated into three groups. b This indicator is most useful in countries where MCV1 is recommended to be given at 9 months. In countries where MCV1 is scheduled to be given at 12 months or later it would need to be modified accordingly. 53 Establishing and strengthening immunization in the second year of life S E C T I O N 7 TA B L E 4. SU M M A RY O F I M M U N I Z AT I O N I N D I CATO RS R E L AT E D TO 2 Y L I N D I CATO R RECOMMENDATION I N T E R P R E TAT I O N P OT E N T I A L ACT I O N S I F LOW P E R FO R M A N C E DATA S O U RC E C OV E R AG E ‘Total MCV2’ MCV2 given anytime (timely plus late) Core indicator Proportiona of children vaccinated with at least two routine doses of measles-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of two doses of measles-containing vaccines, or improving defaulter tracing. Administrative data or population-based survey ‘Total DTP4’ Fourth dose of DTP-containing vac- cine given anytime (timely plus late) Core indicator Proportiona of children who received a booster dose of DTP-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of a booster dose, or improving defaulter tracing. Administrative data or population-based survey Doses of other vaccines scheduled to be given after one year of age (e.g. MenA) Core indicator Proportiona of children who received the indicated doses in the vaccination schedule after 12 months Analyse reasons for low performance. Depending on reasons identified, possible actions may include ensuring an adequate supply of vaccine, strengthening health worker skills, and conducting communication or social mobilization activities to promote the demand for, and use of, these vaccines. Administrative data or population-based survey Fully Immunized Child (FIC) by 24 months Optional unless source of data is a population-based survey Proportion of children vaccinated, in a timely manner, with all doses of all vaccines that are in the national immunization schedule to be given by the age of <24 months Review reasons and take actions. If indicated, work to change paradigm of EPI as an infant programme to one that reaches multiple birth cohorts. Actions may include strengthening health worker knowledge and skills through training, supervision, and feedback; strengthening defaulter tracing; improving data reporting, and increasing communication and social mobilization directed at health workers, communities, families, and caregivers. Population-based surveys Other health interventions, e.g., vitamin A supplementation at ages scheduled in country programme Consult relevant pro- gramme for guidance Check with relevant health programmes for interpretation Seek input from other programmes to analyse reasons for low performance and appropriate actions to take. Seek guidance from the relevant programmes T I M E L I N E S S ‘Late DTP3’ DTP3 after 12 months Optional indicator Captures number of children who complete their primary DTP-containing vaccine series late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Implement better recall/reminder systems to timely track potential defaulters. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey ‘Late MCV1’ MCV1 after 12 monthsb Core indicator Captures number of children who receive MCV1 late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey D RO P - O U T MCV1-MCV2 drop-out rate Core indicator Describes those who are not coming back for a second dose of a measles- containing vaccine Through supervision, feedback, and training, improve health worker interpersonal communication to remind caregivers to return for second dose; strengthen health worker technical skills as needed; increase defaulter tracing and communication with communities about need for MCV2 Population-based survey or administrative data at national and subnational levels. It may be possible to analyse such data at the facility level. 54 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.2 Data requirements Determining denominators For vaccinations scheduled to be given after the first year of life, the best target is the estimate of surviving infants from the previous year’s birth cohort. Administrative vaccine coverage can then be estimated by dividing the current year’s administered doses (numerator) by the estimated number of surviving children from last year’s birth cohort (denominator). Recording doses administered Vaccine doses should be tallied in at least two age groups (0–11 months, and >12 months) as a minimum standard or, preferably, three age groups (0–11 months, 12–23 months, >24 months) as a best practice. Examples of tally sheets with these two alternative age groupings are shown in Annex 1. The creation of additional subcategories for recording doses, such as service delivery (fixed or outreach), adds to the workload for health workers and increases the potential for mistakes; therefore, disaggregating by extra groupings beyond age must be carefully considered. The ways in which such additional data will be used to guide activities should be clearly identified in order to determine if it actually needs to be collected. If required, separate tally sheets can be used for fixed and outreach sessions, and monthly reporting sheets should have separate rows for fixed and outreach sessions against each antigen. Monitoring health indicators by sex has been recommended by some to ensure equity; however, coverage surveys have shown repeatedly that the child’s gender is FIC, as an indicator, must be specific to the age of the child and the corresponding set of vaccines that the child should have received by that age, as per the national schedule. © U N IC EF/U N 0 59893/Rom eo 55 Establishing and strengthening immunization in the second year of life S E C T I O N 7 27 State of Inequality: Childhood immunization. Geneva: World Health Organization; 2016 www.who.int/gho/health_equity/report_2016_immunization/en/ B OX 3. P RO M OT I N G AC C U R AT E R EC O R D I N G A N D R E P O RT I N G TO I M P ROV E S E RV I C E S Health workers may be reluctant to record doses accurately if they fear that they will be disciplined for documenting practices that are not in accordance with national standards. Proper documentation of actual practices is essential if problems are to be detected and addressed; therefore, accurate recording and reporting must be encouraged and supported. For example, if a first dose of MCV is given after one year of age, it needs to be recorded as the first dose, regardless of the age of the child. If health workers feel pressure to report that they have not exceeded established vaccine wastage rates, they may turn mothers and children away unimmunized if just one or two children show up for MCV or other lyophilized vaccines in multi-dose vials that must be discarded within six hours of reconstitution. Denying these children vaccination on that day is a missed opportunity for vaccination, prolongs exposure to disease and risks losing these children from the system for good. Supervisors have an important role to play in promoting accurate recording and reporting of data and in supporting health workers with decision-making when they face less than ideal circumstances. not a barrier for vaccination.27 Hence, given the added complexity that stratification places on the administrative system, WHO does not recommend tallying doses by sex. Similarly, it is not advisable to try to separate doses given to children within a catchment area versus those outside the catchment area. If concerns exist about inequalities in childhood immunization, by sex or other characteristics, it is recommended that when surveys are implemented, they be powered to detect inequalities or disparities in coverage. Including three age groupings to record doses addresses the common problem of how to record late doses of vaccine. If children come for immunization or other 2YL services at 24 months of age or older, they should not be denied vaccination or other care. Health workers should provide the doses and services and record them on the tally sheet, HBR, child register, and monthly summary report, in the age column that corresponds to the child’s age when the dose or services were actually received. Country field guides should provide clear instructions and scenarios on administering, tallying, recording, and reporting of late doses. 56 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.3 Updating forms and health information systems All data collection and reporting instruments should be reviewed and revised, as needed, to accommodate 2YL data requirements. A user-centered approach to the design of data instruments should be used to foster proper screening, vaccination, recording, and reporting of doses. Data recording tools should promote the key concept that full immunization includes doses given in the second year of life or later. As health workers are expected to use HBRs, tally sheets, and registers on a daily basis, the tools should be designed with their input and formally pre-tested to assess how well they are understood and how easy they are to use. These steps will help avert problems in recording data or even in vaccination practices, such as denying vaccination if a child comes late. The pre-test findings should inform the revision of the tools themselves and strengthen training on their proper use. Functionality of current tools should be reviewed, on an ongoing basis, through data quality reviews or assessments,28 in order to eliminate or revise aspects that are not being used properly, or at all. Engage representatives from HMIS and all programmes involved to develop a plan to review and revise the system and to ensure updates are synchronized with the dissemination of paper-based tools, including HBRs. Reporting systems should be examined to eliminate duplication and contradiction among parallel systems (for example, the HMIS and DV-DMT or other vaccination- specific information systems) in order to avoid increased workload and reduce the possibility of health worker confusion. Prepare a plan with budget, timeframe, and secure funding, for revising all data collection and reporting instruments. The plan should designate lead responsibilities, processes for review, timeframe, quantities required, budget, funding source, and a clear dissemination plan. The budget should include the costs for printing sufficient quantities of HBRs and all new forms plus distributing them to all facilities to replace older forms and registers. All new instruments should be ready in time for training of health workers so that they can gain direct experience with using them. If electronic immunization records (EIRs) and other electronic systems are used at health facility level, the changes in 28 For example, the Data Quality Self-assessment (DQS). The DQS is a flexible toolbox of methods used to evaluate different aspects of the immunization monitoring system at district and health facility levels. For details and tools visit: www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index3.html 57 Establishing and strengthening immunization in the second year of life S E C T I O N 7 all aspects of the system must be made in time for training, so that health workers are able to practice using them. Revise all relevant data collection instruments. • HBRs should contain sufficient space for the health worker to record all routine doses of vaccines, their dates of admin- istration, and other services provided during the 2YL visit. HBR design should allow for easy screening by all health workers (including non-immunization staff providing curative care) for doses due. The WHO Practical guide for the design, use and promotion of home-based records in immunization programmes (see Key Resource) provides user-friendly advice for producing high-quality HBRs. • Tally sheets should be designed in a way that guides health workers to accurately record doses administered, disaggregated by age groups, as described above and shown in Annex 1. • Monthly summary reports should capture and summarize all data produced by the tally sheets. For example, if the tally sheet contains space for reporting doses ad- ministered outside the recommended age range, or fixed/outreach sessions, then the monthly summary should also capture this so that health workers do not have to improvise their own solutions. • Registers should include space for additional doses (and possibly other interventions) to be provided in the 2YL visit, and beyond, without restricting the recording of doses to the second year of life. The amount of data to be entered should be determined by how it will be used, time needed to enter the data, cost, and the bulkiness of the registers. It is also crucial that registers, or tickler files, be organized in a manner that facilitates tracking defaulters. — K E Y R E S O U RC E Practical guide for the design, use and promotion of home-based records in immunization programmes HBRs, such as vaccination cards or integrated child health records, should be designed to serve the needs of the health system and promote appropriate health practices among caregivers. They must be made available to all caregivers free of charge, and properly filled in. Health workers should encourage caregivers to safeguard HBRs and retain them for several years. However, they should not punish or deny services to those who have lost or forgotten them, as this could discourage caregivers from returning for immunization or other essential services. Lost or damaged HBRs should be replaced free of charge. www.who.int/immunization/ monitoring_surveillance/ routine/homebasedrecords/en/ FOR THE DESIGN,USE AND PROMOTION OF IN IMMUNIZATION PROGRAMMES PRACTICAL GUIDE HOME-BASED RECORDS 58 Establishing and strengthening immunization in the second year of life 7 S E C T I O N B OX 4. H B RS FO R I M M U N I Z AT I O N A N D OT H E R C H I L D H E A LT H S E RV I C E S With immunization extending into the second year of life and beyond, and more vaccines included in the vaccination schedule, it is increasingly important that all mothers or caregivers have HBRs that document children’s vaccination status and provide key information on immunization and health. Immunization policies and health worker training/ supervision should emphasize the importance of caregivers bringing the child’s HBR to health facilities for every visit to screen for vaccine eligibility at any time that a child has contact with the health system. Some countries have introduced immunization status checks at the time of enrolment in primary education (school registration), and caregivers should be reminded of the importance to save the HBR until the child is enrolled in the education system. As described in Section 8, training and supervision should address unusual circumstances that health workers are likely to encounter that would complicate the ability to record and report doses accurately. Annex 3 provides some sample scenarios for illustrative purposes. © W H O 59 Establishing and strengthening immunization in the second year of life 8 SECTION Health worker training and capacity-building 60 Establishing and strengthening immunization in the second year of life 8 S E C T I O N The success of any health intervention depends on competent front-line health workers and managers. In health worker capacity-building, “competencies” are defined as being comprised of skills, knowledge, and attitudes. For vaccination and other well-child services in the second year of life to be viewed as a priority, health workers’ interpersonal skills, motivations and attitudes need to be addressed in training, supervision, and the feedback they are given. Training is essential for introducing new skills, but must be followed with post-training support to reinforce skills and improve practices on an ongoing basis. Representatives from all programmes involved in a 2YL vaccination visit should contribute to the process of developing the training curriculum. A training workplan, timeline, and budget for developing the training materials should be developed so that there is clear, shared understanding of responsibilities and deadlines for drafting, reviewing, finalizing, and producing the training materials and any supporting materials, such as slides, job aids, materials for exercises, etc. Training, supervision, and other means of post-training support should reinforce policies and standard operating procedures including the core principle that timely vaccination is ideal but (with few exceptions) late vaccination is preferable to no vaccination at all. 8.1 Determine required health worker competencies A key step is to identify the competencies required of all cadres of health personnel involved in vaccination and other health and nutrition interventions in the second year of life and later. A task analysis or learning needs assessment should be conducted to clearly identify which staff are responsible for carrying out specific duties, as noted in Section 5. For a 2YL visit that includes other health services, trainers should identify the expected tasks and required competencies of: • vaccinators; • other health care providers involved in an integrated 2YL visit; • health facility supervisors or in-charges; • community health workers (CHWs); • district- or regional-level staff responsible for immunization, child health, logistics management, data management, and advocacy, communication, community engagement and social mobilization. 61 Establishing and strengthening immunization in the second year of life S E C T I O N 8 One way to approach this is to list the specific changes to health worker responsibilities on a daily, weekly, monthly, and annual basis, that result from introducing vaccination after one year of age. B OX 5. H E A LT H WO R K E R C O M P E T E N C I E S FO R 2 Y L VAC C I N AT I O N Training and capacity-building for 2YL vaccination must ensure that health workers can correctly carry out the following tasks. 1. Prepare microplans and forecast commodity needs for reaching an additional cohort based on a correct estimate of the target population.29 2. Screen children properly to determine any vaccine doses needed. This requires knowledge of the immunization schedule (including whether there is an upper age limit for any vaccines or doses), the minimum interval between doses, what to do in case of late or interrupted vaccinations, how to screen for eligibility if the child lacks a HBR, and whether a child who has come for curative care can be vaccinated. 3. Communicate clearly with caregivers as follows: • When caregivers bring their children for vaccination in the first year of life, particularly for MCV1, explain the reasons and benefits for returning for vaccination and other services in the 2YL. Clearly inform caregivers of when they should return and indicate this on the HBR. • During the 2YL visit, thank the caregiver for coming and provide standard information on the vaccines received, including the fact that receiving simultaneous injections is safe, and address caregiver concerns about side-effects. 4. Provide child with other services during the 2YL visit, such as growth monitoring and promotion, vitamin A supplementation, and deworming medication, as per national policy. 5. Record and report the doses administered during the 2YL visit on tally sheets, HBRs, child registers, and monthly summary reports. 6. Identify and trace defaulters so that they complete the vaccination schedule. This may entail managing and supporting CHWs. 7. Review the facility’s data to assess performance and problem-solve to address issues related to 2YL vaccination that need attention. 29 For information and tools for effective micro-planning, see Chapter 3 of Reaching Every District (RED): A guide to increasing coverage and equity in all communities in the African Region, 2017 revision, available at: www.afro.who.int/publications/reaching-every-district-red-guide-increasing-coverage-and-equity-all-communities 62 Establishing and strengthening immunization in the second year of life 8 S E C T I O N 8.2 Prepare the training curriculum Much of the technical content on proper administration of vaccines and the provision of other well-child services is already available in existing training materials. It can be adapted and updated as needed for 2YL training. The curricula for other programmes that may be integrated with 2YL vaccination, such as nutrition and child health, should also be reviewed and updated as needed. New training content should be developed for the 2YL-specific competencies noted above. These competencies serve as the basis for defining the learning objectives for the training curriculum. The learning objectives help to focus the training on the “must know” as opposed to “nice-to-know” content. Learning objectives are also a useful basis for meaningful pre- and post-test questions. The use of well-designed pre- and post-tests based on the learning objectives serves two purposes. First, they give information on the effectiveness of the training itself and can therefore help identify ways to strengthen it. Second, they identify areas of limited understanding. This information can then be used to focus post-training support through supervision, feedback, on-the-job training, and other means. The learning objectives for training in the Republic of Senegal, shown below, address the introduction of a second dose of measles-rubella vaccine. For a 2YL visit with multiple interventions, the learning objectives for such a training would need to reflect the competencies described above, as well as for other services to be provided during the 2YL visit. The success of any health intervention depends on competent front-line health workers and managers. © W H O M aldives 63 Establishing and strengthening immunization in the second year of life S E C T I O N 8 L E A R N I N G O B J ECT I V E S F RO M S E N EGA L FO R T R A I N I N G O N I N T RO D U C I N G A S EC O N D D OS E O F M E AS L E S - RU B E L L A VAC C I N E ( M R 2 ) The training curriculum for the introduction of MR2 in Senegal outlined clear learning objectives. By the end of training, health workers will be able to do the following. • Describe the new vaccination schedule for providing MR2. • Identify the target group for MR2 vaccination. • Correctly estimate MR vaccine needs taking into account MR2. • Correctly fill out all management tools, including the child register, tally sheet, monthly report, stock management record, and vaccination card. • Cite at least three benefits of providing MR2. • Explain to parents at least two reasons why they should retain the vaccination card and return for MR2. • Cite the number of vaccination contacts that a child needs to be fully vaccinated. • Describe at least four tasks for community mobilizers to carry out to support MR2. C O U N T RY E X P E R I E N C E When preparing the training curriculum, it is important to incorporate the use of adult learning methods. Examples of these methods are provided in the Box 6 below. B OX 6. E F F ECT I V E L E A R N I N G M E T H O DS Effective learning in adults occurs when the content is clearly relevant to the learner’s own experience, has immediate application, and clearly serves a practical purpose. Whenever possible, interactive methods that permit the practice of skills should be used. For the 2YL visit, useful interactive methods can include: • skills practice for interpersonal communication, including responding accurately to questions in a manner that fosters trust • hypothetical scenarios for screening, administration, recording, and reporting of doses (several examples for 2YL immunization are shown in Annex 3). • case studies and problem-solving for situations with low coverage of 2YL doses. 64 Establishing and strengthening immunization in the second year of life 8 S E C T I O N Experience with MCV2 vaccination in several countries has shown that screening, recording and reporting doses in the second year of life or later can be challenging because health workers face a wide variety of situations that do not correspond exactly to the vaccination schedule. Health workers need clear guidance on such points as: • how to record a first dose of MCV that is given after 12 months (in a country that recommends MCV1 at nine months of age); • what to do when a mother brings the child for the 2YL visit after 23 months; • the minimum interval between doses; and • how to implement strategies to reduce pain from multiple injections.30 Annex 3 presents several scenarios that health workers may encounter and suggests how they can be addressed directly during training. Annex 4 provides an example of a job aid to assist health workers to determine the vaccines for which a child is eligible. Training also provides an opportunity to address known areas of weak performance. For example, it can be used to promote the practice of opening a vial to provide MCV even if only one or two children come for an immunization session. District- level supervisors must support this principle if front-line health workers are to carry out this practice successfully. 30 Reducing pain at the time of vaccination. Position paper. Geneva: World Health Organization; 2015 (www.who.int/wer/2015/wer9039.pdf). © U N IC EF/U N 0 125857/Sharm a 65 Establishing and strengthening immunization in the second year of life S E C T I O N 8 8.3 Plan the training strategy Planners should develop a training strategy for building the skills of health workers, their direct supervisors, district health teams, and trainers. Several points should be addressed: Identify who will conduct the training sessions and provide them with thorough orientation on both the technical content and how to train others. Prepare a detailed training schedule. Work backwards from the anticipated date for launching 2YL vaccination and take into consideration any other concurrent events, such as holidays, elections, or vaccination campaigns that may cause delays. If other new vaccine introductions are planned to take place in the same timeframe, it may be possible to combine this with the 2YL training to improve efficiency. Time the training so that front-line health workers receive it two to three weeks before the 2YL launch takes place. Ensure that printing and/or electronic distribution of updated data collection tools are available to be used for skills practice during the training. Print and disseminate other key materials, such as technical guidelines or operational field guides, job aids, behaviour change communication materials (see Section 9) and training reference materials, for participants to share with other staff at their facility. For longer term, ensure that information is incorporated into pre-service and continuing education curricula. Cascade training is often used to reach large numbers of health personnel in a short period of time. However, the quality of training is known to erode and become more variable with each level of cascade; hence, it is best to limit the number of cascade levels to two or three at a maximum. If a cascade strategy is used, the following tips can help maintain the quality of training. • Use the “teach-back” method during the training of trainers (TOT). In this method, a portion of the TOT time is spent having some participants practice their skills by simulating a training of other participants, and vice versa. • Produce hypothetical scenarios for simulations, with mock history and mock HBRs, during interactive training sessions. If health workers use handheld EIR 66 Establishing and strengthening immunization in the second year of life 8 S E C T I O N devices, conduct real-life simulations of recording data with the devices and review the records together with participants. • Include some higher-level trainers in the training sessions at the lower levels. • Use post-test results of earlier training sessions to adapt and improve the training for later sessions. • Produce interactive DVDs to use at all levels of the cascade to ensure that the most complex content is addressed in a standardized way. For the 2YL visit, this would include screening and recording and reporting of vaccine doses given to children over the age of one year. The possible use of DVDs requires first assessing whether appropriate equipment for using them is available at all levels. • Work with instructional designers to ensure that the teaching methods are appropriate for training adults. 8.4 Provide supportive supervision and other forms of post-training support A single training session is often insufficient to bring about mastery of new and complex subject matter. Post-training support is needed to strengthen skills and practices, both to reinforce content introduced during training and to orient new staff or those who were unable to attend the training. Supportive supervision is a standard, essential method for reinforcing skills. However, it requires both reliable funding and transportation, which can be lacking in many settings. The planning for a 2YL vaccination visit is an opportunity to highlight the importance of supportive supervision and advocate for adequate levels of funding. Prepare an integrated supportive supervision visit checklist for the 2YL visit. Countries can adapt their existing supportive supervision checklists to include specific 2YL questions. These questions can also be asked during informal on-the- job training: Are 2YL guidelines, job aids, and revised data management instruments, including HBRs, available at the facility? Is the MCV1-MCV2 drop-out rate being monitored? If yes, how much higher is the MCV1-MCV2 drop-out rate compared to that for Penta1- Penta3, PCV1-PCV3, or rotavirus1-rotavirus last dose? 67 Establishing and strengthening immunization in the second year of life S E C T I O N 8 If children come for the 2YL visit later than the target age, how do health workers respond? Do these children receive vaccinations? Which ones? How are the doses recorded and reported? Is the provision of immunization coordinated with other services or are there missed opportunities for doing so? In what ways do CHWs identify and mobilize parents to bring their children for the 2YL visit? Are there sufficient supplies of all commodities needed for the 2YL visit? Supervisors should provide written feedback that remains at the facility for future reference. Additional types of post-training support may take the following forms. Prepare a job aid to guide health workers to screen and vaccinate children that have missed doses, are late with vaccinations, or who do not have a vaccination card. A flow chart or algorithm may be useful for this purpose. Figure 3 provides an example of a decision-making flow chart adapted from Ghana. The job aid might also include key messages to assist in responding to common questions or con- cerns from caregivers or community members. See Annex 4 for another sample job aid to guide health workers to determine a child’s eligibility for vaccination. Develop a poster or job aid on patient flow to remind all health workers in the facility, as well as parents and caregivers, how services should be organized during the 2YL visit. The job aid should particularly emphasize referral between different departments. Prepare a list of frequently asked questions (FAQ) so that health workers are capable and confident to respond to a variety of questions and situations. Annex 5 contains an example of a FAQ list that countries can adapt. Plan for refresher training to take place one to two years following initial training. Provide health workers with a support phone number (e.g. to a supervisor or a hotline) and encourage them to call and check if they are unsure how to vaccinate a child or record a vaccination. Explore alternative means of post-training support. Depending upon country circumstances, these could include: • peer exchanges or quarterly review meetings; 68 Establishing and strengthening immunization in the second year of life 8 S E C T I O N • a hotline that health workers can use to consult experts when they have questions; • reminder SMS texts or other mobile messages sent to health workers’ phones to reinforce practices. Text messages can also be used to provide recognition for correct and timely recording and reporting of data; • in settings where health workers have high access to smart phones, a WhatsApp group or similar chat application can provide peer-to-peer and regular supervisory support. F I G U R E 3. E X A M P L E F RO M G H A N A O F A N A LG O R I T H M FO R D E T E R M I N I N G E L I G I B I L I T Y FO R M E N I N G I T I S A A N D M E AS L E S - RU B E L L A VAC C I N E Algorithm for Measles-Rubella (MR) and Men A administration Check Child Health Record Book/Weight Card Give any missed vaccines and Vitamin A Counsel to return at date of appropriate age for next due vaccine(s) Counsel to return for Child Care Welfare Clinic at appropriate age ASSESS AGE OF CHILD Child is less than 9 months Do not give MR1 Do not give MR2 Has the child received MR1? Has the child received MR2 Give Men A Give MR2 Has the child received Men A Child is less than 18 months Child is 18 months or more Give MR1 Child is 9 months or more NOYES NOYESNOYES 69 Establishing and strengthening immunization in the second year of life S E C T I O N 8 B OX 7. D E T E R M I N I N G E L I G I B I L I T Y FO R M CV 2 WHO recommends that, where risk of measles mortality among infants remains high, MCV2 should be administered at 15–18 months, with a minimum interval of four weeks after MCV1. In settings where utilization of health services drops considerably after the first year, ensuring caregivers bring their babies for the second dose at 18 months, for example, is challenging and the risk of drop-outs can be quite high. An alternative approach in these cases may be to stipulate that if a child presents any time between 12 and 18 months, it is better to vaccinate with MCV2 immediately, rather than hoping that they will return again at 18 months. From an immunological perspective, as long as 4 weeks has elapsed their first dose, and they are in the 2YL, then a child is already technically eligible for MCV2. Understandably however, this may cause confusion for health workers, and a policy based on interval rather than strict adherence to a schedule may not work in all settings. Ultimately it rests with the programme to set a policy on this and ensure the proper training and tools are available to health workers to make these decisions. Strategies to reduce drop-outs and ensure that the child returns at 18 months include: 1) providing counselling to caregivers, emphasizing the importance of MCV2 and the time to return; 2) active follow-up through a call or home visit with the caregiver to remind them about the visit; 3) in some settings, providing vaccinations at their home if they do not return at 18 months or soon after. 70 Establishing and strengthening immunization in the second year of life Communication, demand promotion, and community engagement 9 SECTION 71 Establishing and strengthening immunization in the second year of life S E C T I O N 9 Communication is an important factor for the success of vaccination in the second year of life and beyond. A comprehensive, but targeted, communication strategy that is fully costed and implemented, including a high visibility launch and ongoing community engagement activities, is key to promoting demand for, and generating utilization of, 2YL vaccination and other services. To succeed in building and maintaining confidence in immunization requires a mix of approaches that focus on building knowledge and awareness, but also take into consideration the individual, social, and structural/political dynamics that shape vaccination behaviours. Table 5 provides the key elements of a 2YL behaviour change strategy to build acceptance and uptake. It lists target groups, key areas of knowledge, and desired actions to be promoted through communication, community engagement, and other coordinated programme interventions. This information serves as the basis for deciding which materials, messages, and activities are required to promote demand for, and utilization of, 2YL services. TA B L E 5. E L E M E N TS O F T H E 2 Y L B E H AV I O U R C H A N G E C O M M U N I CAT I O N F R A M E WO R K TA RG E T G RO U P K E Y A R E AS O F K N OW L E D G E D E S I R E D ACT I O N S Caregivers and families • The importance of vaccination and benefits of vaccines for preventing disease/death • Vaccination continues into the 2YL • Reasons why 2YL vaccination and other well-child care beyond one year of age are important • Timing for scheduled 2YL visits • Importance of safekeeping the HBRs until child starts school and beyond • Take children for the 2YL vaccination and other well-child services • Keep the HBR and bring it to every health contact Health workers • Vaccination and other services to be provided in a 2YL visit; 2YL as opportunity for catch-up vaccination • Why 2YL vaccination is important for child health • How and when to provide and record vaccinations • How and when to communicate with caregivers about 2YL services, particularly during the MCV1 visit (see Section 8) • How to promote 2YL services to the community • Communicate with care- givers in the first year of life to encourage them to come for 2YL visit and retain HBR • Communicate key informa- tion during the 2YL visit • Correctly screen, provide services, record, and report data • Engage their communities to help encourage 2YL visits 72 Establishing and strengthening immunization in the second year of life 9 S E C T I O N TA RG E T G RO U P K E Y A R E AS O F K N OW L E D G E D E S I R E D ACT I O N S District-level managers and supervisors to health workers • Review data and identify gaps in the knowledge and skills of health workers • Provide feedback and technical support to health workers and motivate them on the importance of 2YL vaccination and other services • Support health workers in providing high-quality services Community health workers • The importance of 2YL vaccination and the age to bring child for a scheduled visit • How to trace defaulters for 2YL vaccination • Other services provided during 2YL visit • Provide key information on importance of 2YL visit and when to bring child • Mobilize families to bring their children • Trace defaulters Community lead- ers and politicians (chiefs, parliamen- tarians, councilors, civil authorities, religious leaders) • The importance of 2YL vaccination and the age to bring child for a scheduled visit • Other services provided during 2YL visit • When and where 2YL services are offered • Immunization is free-of-charge • Encourage families to bring their children for 2YL services • Communicate on the importance of vaccination The media • The importance of vaccination and other child health services during infancy and into the second year of life • When and where 2YL services are offered • Immunization is free-of-charge • Provide coverage on the launch of the 2YL visit • Provide accurate, timely information to the public to encourage vaccination and the use of 2YL services Professional and medical associa- tions • Current science and policy considerations to inform the development of policies and practices with regard to 2YL visit • Contribute to development of policies, guidelines and materials • Promote proper practice among constituents • Provide support to community leaders in reinforcing the importance of vaccination Teachers, counsellors, pre-school/ day-care providers • The importance of 2YL vaccination and other services beyond one year of age • Immunization is free-of-charge • Encourage families to bring their children for 2YL services 73 Establishing and strengthening immunization in the second year of life S E C T I O N 9 The broad steps needed to plan for promoting or increasing demand for 2YL vaccination and other services are shown in Figure 4, and described in the sections below. F I G U R E 4. D E M A N D A N D P RO M OT I O N P L A N N I N G CYC L E These steps are elaborated throughout the following sections. ST E P DATA C O L L ECT I O N A N D A N A LYS I S ST E P ST R AT EG I C D E S I G N A N D P L A N N I N G ST E P D E V E LO P M E N T A N D T E ST I N G O F M E S SAG E S A N D M AT E R I A L S ST E P I M P L E M E N TAT I O N A N D M O N I TO R I N G ST E P E VA LUAT I O N A N D R E- P L A N N I N G 1 2 5 4 3 ©W HO Bhu tan 74 Establishing and strengthening immunization in the second year of life 9 S E C T I O N 9.1 Data collection and analysis: understanding your target groups Communication plan and working group A multi-partner communications working group should be convened (or reconvened, if it already exists for the immunization programme in general) to develop a demand promotion plan for 2YL vaccination. Though the plan should address the unique features and challenges of 2YL vaccination, it should also be aligned and linked with the overall communication plan for the national immunization programme. This will help ensure that communication activities, messages and targeting are harmonized and support the strengthening of routine immunization. The working group should coordinate closely with others planning the aspects of 2YL to ensure that their work is mutually reinforcing and technically consistent. The 2YL communication plan should agree on the key audiences and stakeholders, communication needs and desired actions by each group, tailoring it from Table 5, as needed. This information serves as the basis for deciding which materials, messages, and activities are needed to promote uptake of 2YL services, and accordingly which data and background information is necessary to shape these efforts. Data collection and analysis Initial data collection and analysis is essential to understand the reasons why different target groups would, or would not, carry out the desired actions in Table 5. A situation analysis and a behavioural analysis (for example, a Knowledge, Attitudes, and Practices (KAP) study, or other similar research activity) can together identify the barriers that need to be addressed and the factors that promote the desired intentions © W H O 75 Establishing and strengthening immunization in the second year of life S E C T I O N 9 and behaviours. They can also provide key information to decide how messages should be worded and the appropriate materials, media, and channels for reaching each target group. This helps ensure that resources are used effectively and efficiently. For example, brochures or posters about 2YL vaccination could be found to be less important to caregivers than having health workers use the opportunity of the MCV1 visit to provide reminder messages and to note the return date for 2YL vaccination on the child’s HBR. In such cases, resources might be better spent on health worker capacity-building and the design of the HBR. Understanding health worker views about 2YL vaccination, including their perceptions of obstacles and enabling factors, is particularly important. Health workers are the most frequently cited source of vaccine information, and a recommendation by a health worker is one of the strongest factors associated with vaccine acceptance. They have a key role to play in interpersonal communication with caregivers on the need for, and timing of, the 2YL visit. Information collected on health worker perspectives about 2YL vaccination should feed directly into the design of the training curriculum, supervision instruments, job aids, data management tools, and communication messages and materials. 9.2 Strategic design and planning Involvement of key stakeholders As with any new development in the health system, the engagement of well-known, credible national level stakeholders is important to focus the public’s attention on the topic and create trust. For introducing 2YL vaccination or increasing attention to it, planners should reach out to well-known health officials and trusted political, community, and academic leaders. Medical associations, schools and daycares, civil society organizations (CSOs), and NGOs are other influential players whose show of commitment to 2YL vaccination and other services can encourage appropriate actions among their constituents and communities. Communication planners should engage with them, provide them with talking points or other materials, and jointly identify specific opportunities, such as press conferences, launch ceremonies, or annual meetings, for demonstrating their support for 2YL vaccination. Community engagement Depending on the community structures and leaders that are active and functional in a given area, different types of volunteers or community members have a role to play in supporting 2YL vaccination. They can be engaged to provide reminder messages, trace defaulters, and keep community attention focused on the 2YL visit after it is launched. 76 Establishing and strengthening immunization in the second year of life 9 S E C T I O N District health and community development teams should identify community networks that are actively functioning and outline a realistic set of steps for CHWs or volunteers to carry out to support the 2YL visit. Printed reminder materials or other aids should be developed for this purpose that give information on all components of the 2YL visit, not just vaccination. Community members can also assist health care providers to select where and when to provide outreach services and how to reach the most marginalized or underserved populations. These are groups for which the risk of non-use of 2YL services is the highest. The following checklist can help ensure that all the key steps of the communication planning process are followed. B OX 8. C O M M U N I CAT I O N P L A N N I N G C H EC K L I ST  Is there a government-endorsed, multi-agency communications working group in place to support the 2YL visit? Has a situation analysis been completed? Has a behavioural analysis been completed? What messages and materials are required? Has a plan of action (budgeted) been developed? Have you secured funding for the implementation of the plan? Have the communication products/materials been pre-tested? Is there a distribution plan for the materials? Is there a crisis communication plan, including explicitly agreed partner roles and responsibilities, and does it include the relevant elements for 2YL? Have agreed spokespeople been identified and trained? 77 Establishing and strengthening immunization in the second year of life S E C T I O N 9 9.3 Development and testing of messages and materials Messages and materials All messages and materials should clearly state when caregivers should take their children for 2YL vaccination and what they can expect to receive during the 2YL visit. Suggested content of key messages to support 2YL vaccination, tailored to different audiences, is shown in Table 5. These messages should be adapted and pre-tested before incorporating them into communication materials, training, or radio or TV spots. Additional messages specific to MCV2 are found in A guide to introducing a second dose of measles vaccine into routine immunization schedules.31 Community networks have a key role to play in supporting the 2YL platform and communicating the importance of the 2YL visit as part of a continuum of care for the entire first five years of the child’s life. 31 www.who.int/immunization/documents/WHO_IVB_13.03/en/, p. 27. 78 Establishing and strengthening immunization in the second year of life 9 S E C T I O N TA B L E 6. E X A M P L E S O F K E Y M E S SAG E TO P I C S TO SU P P O RT 2 Y L VAC C I N AT I O N AU D I E N C E : H E A LT H WO R K E RS The reasons to provide vaccination and other child health interventions after one year of age. The age at which vaccinations in the 2YL are scheduled to be given and the importance of providing doses of antigens missed in the first year of life. There is no upper age limit or cut-off for most vaccines. “It is never too late to vaccinate.” During the MCV1 visit, the need to inform the caregiver when to bring the child back for 2YL vaccination and discuss why it is important. A child can only be considered fully immunized when they have received all doses, including those scheduled to be given after one year of age. Coverage of the ‘FIC’ indicator must include vaccinations given in the second year of life, or be separated by age categories (i.e. FIC by 1 yr year, FIC by 2 yrs). The other services to provide during the 2YL visit, e.g., growth monitoring and promotion, nutritional counseling. How to respond to caregivers with any questions or concerns about vaccination AU D I E N C E : C O M M U N I T I E S A N D CA R EG I V E RS To be classified as fully vaccinated, children need to have completed the required schedule of vaccinations during infancy, 2YL and beyond, as necessary. The age at which vaccinations in the 2YL are scheduled to be given and the importance of catching up on any vaccines missed in the first year of life. There is no upper age limit or cut-off for most vaccines. “It is never too late to vaccinate.” The importance of keeping the home-based record throughout childhood and bringing it for each contact with the health system. The benefits to the child (and family) of receiving vaccination and other services into the 2YL. 79 Establishing and strengthening immunization in the second year of life S E C T I O N 9 9.4 Implementation and monitoring A strong communication plan cannot be successful unless it is fully executed. This means: • the strategic plan must be fully budgeted with funds secured well in advance of the launch in order to produce sufficient supplies of materials; • materials and messages must be translated into the commonly used local languages as needed; • materials must be systematically disseminated to intended audiences at the appropriate time, in advance of when they are to be used; • messages for health worker interpersonal communication with mothers must be finalized in time for them to be incorporated into training materials, and the training designed in such a way that permits adequate time for health workers to practice these communication skills. Formal launch for 2YL visit Lessons learned from past introductions of MCV2 indicate that it is important to conduct a formal launch for the 2YL visit to raise awareness, convey key information, demonstrate high-level political and community support from credible spokespersons, and promote the use of the 2YL services. The engagement of influential community leaders must begin well before the launch takes place. They need to understand why the 2YL visit is being introduced, how it benefits their community, and what actions they can take to support its success. This engagement should continue on a regular basis, even after the launch, to ensure that relationships are maintained and that community leaders are able to continue to advocate for vaccination. The 2YL visit should be positioned as part of a continuum of care for the entire first five years of the child’s life. The introduction of the 2YL visit is an opportunity to highlight the importance of services that have been available in the past but have not been fully utilized. Following the launch of the 2YL visit Communication officials at the national level of the immunization programme should continue to interact with counterparts at subnational level to monitor the implementation of the communication plan and to enquire about any issues or obstacles that may be emerging so that corrective actions can be taken. 80 Establishing and strengthening immunization in the second year of life 9 S E C T I O N 9.5 Evaluation and re-planning In keeping with the overall communication strategy for immunization and child health, monitoring and evaluation of communication efforts should be carried out by the working group on a regular basis. Based on the data gathered and reviewed in Step 1 above, indicators or measures should be established – covering both process, outcomes, and impact – that can be tracked through implementation of the various communications and engagement activities. The findings should be used to inform decisions about the corrective actions to take. To evaluate communication and demand promotion activities, it is ideal to carry out a survey or rapid research exercise targeting caregivers, health workers and, potentially, community leaders or stakeholders. Such an assessment will provide a systematic and structured approach to learning about what people know about 2YL vaccination, how they developed this knowledge, what they think it means, and whether they intend to take the desired actions. The findings should inform adjustments to communications or demand promotion strategies, so that they may be more targeted or impactful in future. If resources are not available for a large- scale study, then the points raised in Section 10 can be used to understand reasons for low demand and utilization of 2YL vaccination. B OX 9. E X A M P L E S O F P OT E N T I A L O U TC O M E I N D I CATO RS TO E VA LUAT E C O M M U N I CAT I O N A N D D E M A N D P RO M OT I O N ACT I V I T I E S • % caregivers with correct knowledge of the schedule and timings of when a child needs to be brought for vaccination in the first two years of life • % caregivers who say they intend to fully vaccinate their children, including the 2YL visits • % vaccinators with correct knowledge of the national schedule • % vaccinators who consistently and correctly communicate to caregivers the timing of the infant’s next visit for vaccination, including the 2YL visits 81 Establishing and strengthening immunization in the second year of life S E C T I O N 9 R A I S I N G AWA R E N E S S A B O U T I M M U N I Z AT I O N A F T E R O N E Y E A R O F AG E I N TA N Z A N I A United Republic of Tanzania’s post-introduction evaluation for MCV2 revealed that many parents interviewed were not aware of the need for further vaccination after their children received MCV1 at nine months. Although children were supposed to attend clinics for growth monitoring after they were one year old, mothers no longer considered it important to come for these monitoring visits. Health officials raised community awareness about the need for vaccination and other services beyond the first year of life through: • broadcasting radio and TV spots; • conducting a seminar with journalists from various local media to get the word out; • conducting meetings on MCV2 with regional primary health care committees; • providing health education about MCV2 to women who attended antenatal and postnatal care visits. C O U N T RY E X P E R I E N C E 82 Establishing and strengthening immunization in the second year of life Strengthening 2YL vaccination performance 10 SECTION 83 Establishing and strengthening immunization in the second year of life S E C T I O N 10 Understanding the reasons for low performance If the national immunization programme and partners observe that 2YL vaccination coverage is low and that the MCV1-MCV2 drop-out rate is high, they should systematically review existing data and assess the situation to identify key problems and their root causes. Decisions on how to use resources to improve the situation should be based on these findings, rather than assumptions that the problem is due, for example, to low demand or insufficient vaccine supply. A starting point would be to review the quality of the reported data to determine if it can be considered complete, timely, reliable, and accurate. At national level, review the geographic scope of the 2YL performance problem. If widespread, then examine system-wide factors, including the following. 1. Are policies and guidelines complete, clear, accurate, and easy to understand and use? 2. Have policies and guidelines been disseminated systematically? 3. Does the training curriculum cover all key points and use effective methods for adult learning? 4. Has the training strategy reached all vaccinators and their supervisors? Are there any known shortcomings in how it has been implemented? 5. Were supervision instruments updated to include 2YL vaccination, and have they been widely disseminated and used? 6. Were data management tools updated, and do they support all aspects of the policy and guidelines? Did they include input from end-users or pre-testing to determine how easy they are to use? Have they been disseminated systematically? 7. Has there been a high-visibility launch to focus attention on the introduction of 2YL vaccination? Was the communication strategy for 2YL vaccination sufficiently developed, budgeted, and carried out as planned? If the problem of 2YL vaccination performance is localized to particular geographic areas, then follow-up with health officials from those subnational/district teams is necessary, as well as visits to facilities to gain a first-hand understanding of the problems and their root causes. 10.1 84 Establishing and strengthening immunization in the second year of life 10 S E C T I O N At subnational/district level, review data to see how geographically widespread the problem is. If it is widespread, review factors that may affect 2YL vaccination, including the following. 1. Have there been shortages or stockouts of the vaccines used for immunization in the second year of life? 2. Are there challenges with human resources that would affect 2YL vaccination, such as insufficient staffing or high turnover? Have health workers received training on 2YL vaccination? Has the district provided supportive supervision or other feedback/post-training support since the initial training was conducted? 3. Are there any particular circumstances or characteristics of the population in this district that would pose challenges to 2YL vaccination, e.g. population movement, high levels of employment of mothers after the child is one year of age, remote populations with difficult access to facilities or to information about changes in the vaccination schedule, lack of social support systems, or vaccine hesitancy? 4. Have updated data management tools been systematically introduced to all facilities, or are old forms and tools still widely in use? 5. What issues or problems with data quality have been observed? Have data quality assessments been carried out to assess the reliability and consistency of data on 2YL vaccination? What are the findings and what corrective actions are needed? 6. Have community leaders and influential persons been educated on the need for 2YL vaccination and why it is important? What actions do they take to encourage families to seek vaccination after one year of age? 7. Are there functional systems of CHWs or volunteers in the district who have been oriented on 2YL vaccination? Do they know how to trace defaulters and encourage families to bring their children for 2YL vaccination? Do they regularly carry out these tasks? 85 Establishing and strengthening immunization in the second year of life S E C T I O N 10 At health facility level, discuss 2YL vaccination with health workers and with caregivers at the facility and in the community. Health worker interviews. Questions to ask health workers include the following. 1. Tell me what you know about 2YL vaccination? How, or from whom, did you learn these things? 2. How frequently are you visited for supportive supervision? If you have a question about something, who do you ask for support or where do you seek help? 3. Do you know your facility’s coverage for 2YL vaccination and MCV1-MCV2 drop-out rate? 4. If 2YL vaccination rates are low, what are the reasons? 5. Are any reference materials on 2YL vaccination (e.g. field guide, training materials, job aids) available at the facility? 6. When is a child considered fully immunized – after they have received which doses of vaccine? 7. Have there been stockouts or shortages of the vaccines used for 2YL vaccination? 8. Does the health facility have a system for tracing defaulters, particularly for 2YL vaccination? What is the system and how well does it work? 9. What information do you give to caregivers who bring children for the MCV1 visit? 10. What do you do if a child is brought “late” for vaccination? Are there any circumstances where you would send away an unvaccinated child who has been brought for vaccination? What are they? Do you believe that there are upper age limits for 2YL vaccination? What are they? 11. If a child comes to your facility for vaccination in the second year of life, do they receive other services as well? What are they? Are they always available? 12. Are updated recording and reporting forms (HBRs, tally sheets, registers, monthly summary reports) available at the facility? If yes, what are the steps for recording and reporting 2YL vaccination? Do caregivers bring updated HBRs? If not, are 2YL doses recorded on the HBR? [Ask to see samples of recording and reporting tools and ask where the 2YL vaccinations are recorded] 86 Establishing and strengthening immunization in the second year of life 10 S E C T I O N 13. Has any comparison been done of 2YL data recorded on tally sheets, monthly reports, child registers, and HBRs, as part of a data quality assessment? If so, what have the findings indicated? Exit interviews. Health officials can visit several facilities, on days when routine immunization sessions are being held, and interview caregivers whose children have received MCV1. Questions to ask caregivers include the following. 1. Has your child received all vaccines in the national immunization schedule or do you need to bring your child back for more doses of vaccines? 2. [If applicable]: Are you able to tell me when you will bring your child next time and which vaccines he/she should recieve at that time? 7. What, if anything, would make this difficult for you? What would make it easier? Community discussions. Visit communities and ask community members what they know about vaccination in the second year of life. 1. By what age should a child have completed the full vaccination schedule? 2. If a child receives measles by the time he/she is one year old, do you need to bring the child back for more vaccinations? At what age? 3. [For those who know about 2YL vaccination]: How did you learn that you needed to take your child for immunization after one year of age? 4. If you brought your child for 2YL vaccination, what was your experience? Which vaccines did you receive? Did your child receive other services? Do you need to return for further vaccinations? 5. If your child is over the age of two and you did not bring them for 2YL services, what were the reasons? 6. What would help you to bring your child for 2YL services? [Probe: reminder materials; a visit by a CHW; more information about why it is needed] Without conducting a major assessment, health managers can add some of the above questions to their supportive supervision visits and augment them by conducting exit interviews with caregivers whose children have just been vaccinated. They can also do exit interviews with mothers who have brought young children for curative care, or other preventive services, to see if they were screened for 87 Establishing and strengthening immunization in the second year of life S E C T I O N 10 immunization and vaccinated. During supervision visits, district health officials can talk with community leaders who may provide insight as to the level of awareness of 2YL vaccination among the community. Additional guidance on how to integrate a small assessment to strengthen 2YL performance into a national immunization programme review is included in the WHO Guide for conducting an Expanded Programme on Immunization (EPI) review.32 10.2 Taking actions to address the problems The findings from the reviews described above should be used to decide what steps to take to strengthen 2YL vaccination. Health managers should convene a discussion to review the problems and their root causes in order to identify solutions and develop a plan for implementing them. Table 7 presents several illustrative examples of possible actions that programmes can take to improve 2YL performance.This list is not exhaustive; rather, it is intended to stimulate thinking about solutions that can be implemented using existing resources or with limited additional funds. Furthermore, the most appropriate actions to take will depend upon a deep understanding of the problems and of the context in which they occur. During supervision visits, health managers can speak with mothers whose children have just been vaccinated, or who have brought young children to the health facility for other services, and ask if they were screened for immunization. 32 Guide for conducting an Expanded Programme on Immunization (EPI) review. Geneva: World Health Organization; 2017. www.who.int/immunization/documents/WHO_IVB_17.17/en/ © W H O 88 Establishing and strengthening immunization in the second year of life 10 S E C T I O N TA B L E 7. COMMON PROBLEMS AND POSSIBLE ACTIONS TO STRENGTHEN 2YL VACCINATION P RO B L E M S / I S SU E S E X A M P L E S O F P OS S I B L E ACT I O N S Persistent low coverage and high drop-out rates • Mobilize CHWs or volunteers to trace defaulters and encourage 2YL vaccination among community members. • Improve the convenience of locations for outreach sessions so that it is easier for caregivers or mothers of two year-old children to bring them for vaccination. • Consider offering routine immunization sessions at fixed facilities at a time of day that is more convenient for mothers of older children. Outreach sessions are not conducted as often as planned • Compare actual outreach sessions conducted during the last six months with the number of scheduled outreach sessions in the microplan. If there is a clear discrepancy, find out why the outreach is not being implemented. Stockouts of vaccines and supplies • Review the availability of vaccines needed for 2YL vaccination at all levels to ensure that sufficient supplies are available. • If concerns over high wastage rates are deterring health workers from opening a vial of MCV for small numbers of children, review national policies on this topic and reinforce during supportive supervision visits. Remind health workers that 2YL vaccination may result in lower levels of MCV vaccine wastage. Deficiencies in health worker practices • Address health worker motivation: recognize and praise those who have achieved high coverage. Ask them to share their experience through peer learning with health workers at other facilities. Remind health workers of the reasons for 2YL vaccination and note that immunization programme performance is also based on coverage with vaccinations given after one year of age. • Provide on-the-job training during supportive supervision visits to address the deficiencies. • If shortages of human resources are contributing to suboptimal health worker performance (overburdened staff), review the possible role of volunteers to help assume some of the less technical duties. However, recognize that volunteers need technical orientation and management, and that their contribution is voluntary. • Refer to Section 8.4 for more possible actions, e.g. WhatsApp groups, telephone hotlines, SMS texting to reinforce key points. 89 Establishing and strengthening immunization in the second year of life S E C T I O N 10 P RO B L E M S / I S SU E S E X A M P L E S O F P OS S I B L E ACT I O N S Problems with screening, recording, reporting doses • Review data management instruments and revise, if needed, to make them more user-friendly, to enable proper practice for screening, recording, and reporting. • Ongoing supervision and feedback on how to use the data collection instruments. • Job aids, hotlines or WhatsApp groups to help address particular problem areas, e.g. difficulties with screening, recording, reporting. • Conduct data quality assessments and use the findings to correct particular problems and monitor progress. Low awareness or demand for 2YL vaccination • Strengthen health worker skills in interpersonal communication to remind caregivers when to return for vaccination in the second year of life. • Engage community leaders to get the word out to families about when and where to go for 2YL vaccination and why it is important. Use the occasion of community meetings to give feedback on coverage for 2YL vaccination and discuss how to improve it. • Work with local NGOs to explore how they can support 2YL vaccination; for example, by mobilizing resources for outreach sessions in convenient locations in the community. • Re-launch 2YL through high-visibility activities such as press conferences, ceremonies, meetings, radio, SMS, etc. • Use radio talk shows to discuss 2YL vaccination and increase attention around the need for 2YL vaccination. Develop songs or memorable jingles that can be broadcast to remind communities of the need for 2YL vaccination. 90 Establishing and strengthening immunization in the second year of life 1 A N N E X Annex 1a: Example of minimum standard tally sheet for vaccination33 ANTIGENS/ ITEMS 0-11 MONTHS TOTAL 12 MONTHS OR OLDER TOTAL TOTAL VACCINATED BCG Hep B BD OPV 0 OPV 1 OPV 2 OPV 3 IPV Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/ Other* Vitamin A Long lasting insecticidal net* 33 As described in Section 7 *depending on national health priorities and schedule of services Date: Region: District: Health Facility: Service Delivery Strategy: fixed outreach mobile Location: 91 Establishing and strengthening immunization in the second year of life Annex 1b: Example of best practice tally sheet for vaccination33 ANTIGENS/ ITEMS 0-11 MONTHS TOTAL 12–23 MONTHS TOTAL 24 MONTHS OR OLDER TOTAL TOTAL vaccinated BCG Hep B BD OPV 0 OPV 1 OPV 2 OPV 3 IPV Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/Other* Vitamin A Long lasting insecticidal net* 33 As described in Section 7 *depending on national health priorities and schedule of services Date: Region: District: Health Facility: Service Delivery Strategy: fixed outreach mobile Location: A N N E X 1 92 Establishing and strengthening immunization in the second year of life 2 A N N E X Annex 2: Immunization monitoring chart showing MCV1-MCV2 drop-out Health Facility: Year: A drop-out more than 10% is an indication for immediate action Annual target population (0-11 months): Annual target population (12-23 months): Minimum coverage target for the year—BCG: Minimum coverage target for the year—MCV1: Minimum coverage target for the year—MCV2: Vaccine Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec BCG A Total immunized this month Cumulative total for the month MCV1 B Total immunized this month Cumulative total for the month MCV2 C Total immunized this month Cumulative total for the month BCG-MCV1 DROP-OUT RATE = Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec MCV1-MCV2 DROP-OUT RATE = Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ** Plot for only BCG, MCV1, MCV2 M on th ly tr ag et c ov er ag e 25% 75% 50% 100% A-B A * 100 B-C B * 100 93 Establishing and strengthening immunization in the second year of life A N N E X 3 Annex 3: Scenarios for vaccination in the second year of life (for use in training and supervision) Vaccinators encounter many situations where they are not sure what to do if the child has missed previous doses, has come late for vaccination, or lacks a home-based record. The following are real situations that have been reported from different countries. These scenarios are based on a schedule that includes MCV1 at nine months of age and MCV2 at 18 months of age. They should be adapted to fit the appropriate vaccine schedule and country context. These scenarios can be used during training for interactive discussions and skill building for proper screening, administration, recording, and reporting of doses. In each case, trainers can show just the first two columns, or print out hard copies of the scenarios and ask training participants to review them in pairs. Afterwards, discuss as follows. • Do you think the health worker did the right thing? • If not, what should have been done differently? • How could this problem be prevented? The third and fourth columns are for use by training facilitators and supervisors. The third column provides the correct response. The fourth column presents some possible responses that can be further developed and discussed. Annual target population (0-11 months): Annual target population (12-23 months): Minimum coverage target for the year—BCG: Minimum coverage target for the year—MCV1: Minimum coverage target for the year—MCV2: FOR TRAINING PARTICIPANTS FOR TRAINING FACILITATORS AND SUPERVISORS SCENARIO HEALTH WORKER “INCORRECT” RESPONSE WHAT SHOULD THE HEALTH WORKER HAVE DONE? HOW COULD THIS PROBLEM BE PREVENTED? (for discussion) 1. A child is brought late for MCV1 at 14 months of age The health worker vaccinates the child and records and reports the dose as MCV2 because the child is over one year of age. The health worker believes that only doses given under one year of age can be considered as MCV1. 1. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 2. A child is brought for his first dose of MCV at 18 months of age (the time of the scheduled MCV2 visit) The health worker vaccinates the child and records and reports the dose as MCV2 because the child has come at the time when MCV2 is scheduled to be given. 2. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months.” She should have advised the caregiver to bring the child back for MCV2 after 4 weeks. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 3. At a rural facility with infrequent outreach and few children seen before the age of 12 months, a 15-month old boy is brought in who has never received measles vaccine. The health worker believes the child is not eligible for MCV1 because he is too old to receive it. She also believes he is not eligible for MCV2 because he has not received MCV1. So she sends him away without vaccinating him against measles. 3. She should have vaccinated the child and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision to emphasize that it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet • Job aid 4. Children at one clinic are often brought for MCV1 at 10, 11, 12, or 13 months of age. The health worker tells the mothers to come back 9 months later for MCV2, believing that it is the 9-month interval and not the target age (of 18 months) that is important. 4. She should have advised the caregivers to bring their children back for MCV2 at 18 months of age. • Training and supervision to emphasize that it is the age of vaccination that is most important, as long as there is one month minimum interval between MCV doses. 6. A child is brought for MCV2 at 3 years of age. The child has already received MCV1 at 9 months. The health worker does not vaccinate the child because they are older than 23 months. 6. She should have given the child MCV2 and recorded the dose as MCV2 in the column of the tally sheet for “12 months or older” or “24 months or older” • Training and supervision to emphasize that the need for MCV does not stop at 24 months (no upper limit – all children need 2 doses of MCV), and it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet 7. A child is brought for MCV2 at 2-1/2 years of age. The child has already received MCV1 at 9 months. The health worker vaccinates the child but records the dose on a special register so that it is not included in estimates of coverage. 7. She should have recorded the dose as MCV2 on the column of the tally sheet for “12 months or older” or “24 months of older” • MOH needs to design the tally sheet to permit recording and reporting of doses given to children 24 months or older 8. The health worker says that she cannot provide a measles second dose because she has no “MSD” vaccine. The health worker does not provide a second dose of measles to any children. 8. She should have provided MCV2 doses to all eligible children who are over the age of one. • Field guide, training, supervision, data recording forms, social mobilization should use more familiar convention of numbered doses (e.g. measles1/ measles2, MR1/MR2) for measles or measles rubella 9. A child is brought for MCV2 at 18 months. The mother does not have a vaccination card but remembers that her baby received MCV1 soon before he started walking. The health worker vaccinates him but records it as MCV1 and tells the mother to come back in one month for MCV2. 9. She should have first checked the child’s age and vaccination status in the child health register to ascertain whether the child received MCV1 at or soon after 9 months. If no record is found, then the health worker response was correct. A new vaccine card should have been provided. If a record is found, the health worker should have given MCV2, and transferred the information from the registry to a new vaccination card. • Field guide should provide clear guidance on what health workers should do in the absence of an HBR or record of the child in the health facility register. 94 Establishing and strengthening immunization in the second year of life 3 A N N E X These scenarios are based on a schedule that includes MCV1 at nine months of age and MCV2 at 18 months of age. FOR TRAINING PARTICIPANTS FOR TRAINING FACILITATORS AND SUPERVISORS SCENARIO HEALTH WORKER “INCORRECT” RESPONSE WHAT SHOULD THE HEALTH WORKER HAVE DONE? HOW COULD THIS PROBLEM BE PREVENTED? (for discussion) 1. A child is brought late for MCV1 at 14 months of age The health worker vaccinates the child and records and reports the dose as MCV2 because the child is over one year of age. The health worker believes that only doses given under one year of age can be considered as MCV1. 1. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 2. A child is brought for his first dose of MCV at 18 months of age (the time of the scheduled MCV2 visit) The health worker vaccinates the child and records and reports the dose as MCV2 because the child has come at the time when MCV2 is scheduled to be given. 2. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months.” She should have advised the caregiver to bring the child back for MCV2 after 4 weeks. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 3. At a rural facility with infrequent outreach and few children seen before the age of 12 months, a 15-month old boy is brought in who has never received measles vaccine. The health worker believes the child is not eligible for MCV1 because he is too old to receive it. She also believes he is not eligible for MCV2 because he has not received MCV1. So she sends him away without vaccinating him against measles. 3. She should have vaccinated the child and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision to emphasize that it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet • Job aid 4. Children at one clinic are often brought for MCV1 at 10, 11, 12, or 13 months of age. The health worker tells the mothers to come back 9 months later for MCV2, believing that it is the 9-month interval and not the target age (of 18 months) that is important. 4. She should have advised the caregivers to bring their children back for MCV2 at 18 months of age. • Training and supervision to emphasize that it is the age of vaccination that is most important, as long as there is one month minimum interval between MCV doses. 6. A child is brought for MCV2 at 3 years of age. The child has already received MCV1 at 9 months. The health worker does not vaccinate the child because they are older than 23 months. 6. She should have given the child MCV2 and recorded the dose as MCV2 in the column of the tally sheet for “12 months or older” or “24 months or older” • Training and supervision to emphasize that the need for MCV does not stop at 24 months (no upper limit – all children need 2 doses of MCV), and it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet 7. A child is brought for MCV2 at 2-1/2 years of age. The child has already received MCV1 at 9 months. The health worker vaccinates the child but records the dose on a special register so that it is not included in estimates of coverage. 7. She should have recorded the dose as MCV2 on the column of the tally sheet for “12 months or older” or “24 months of older” • MOH needs to design the tally sheet to permit recording and reporting of doses given to children 24 months or older 8. The health worker says that she cannot provide a measles second dose because she has no “MSD” vaccine. The health worker does not provide a second dose of measles to any children. 8. She should have provided MCV2 doses to all eligible children who are over the age of one. • Field guide, training, supervision, data recording forms, social mobilization should use more familiar convention of numbered doses (e.g. measles1/ measles2, MR1/MR2) for measles or measles rubella 9. A child is brought for MCV2 at 18 months. The mother does not have a vaccination card but remembers that her baby received MCV1 soon before he started walking. The health worker vaccinates him but records it as MCV1 and tells the mother to come back in one month for MCV2. 9. She should have first checked the child’s age and vaccination status in the child health register to ascertain whether the child received MCV1 at or soon after 9 months. If no record is found, then the health worker response was correct. A new vaccine card should have been provided. If a record is found, the health worker should have given MCV2, and transferred the information from the registry to a new vaccination card. • Field guide should provide clear guidance on what health workers should do in the absence of an HBR or record of the child in the health facility register. 95 Establishing and strengthening immunization in the second year of life A N N E X 3 96 Establishing and strengthening immunization in the second year of life 4 A N N E X Annex 4: Illustrative example of job aid on screening for vaccine eligibility The sample job aid is adapted from Timor Leste (IMMUNIZATIONbasics, 2007) and is based on a child immunization schedule that calls for BCG and hepatitis B at birth; Pentavalent, oral polio vaccine (OPV), pneumococcal conjugate vaccine (PCV), and rotavirus (RV) doses at 6, 10, and 14 weeks; inactivated polio vaccine (IPV) at 14 weeks; MCV1 at nine months; and MCV2, MenA and DTP4 at 18 months of age. Please adapt this document to match your local immunization schedule. This, along with other 2YL tools and resources, can be found at www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Instructions: Step 1: Praise the parent or caregiver for bringing their child for vaccination today. Find out from the child’s immunization record or the caregiver: 1. How old is the child today? 2. Which vaccines has the child already received? (Check the home-based record or child register) Step 2: Use the chart to the right to decide what to give. The child should already have received all vaccines due up until their current age. If they are missing doses, it is not too late. Administer the vaccines for which they are eligible, respecting the necessary spacing (see far right column). Step 3: Remind the caregiver when to bring the child back for the subsequent doses due. Take this opportunity to emphasize the importance of receiving the complete series of vaccines for the child to be fully protected. † In certain situations, MCV can be given from 6 months of age. This dose should be considered a zero dose (“MCV0”) and two subsequent doses (MCV1 and MCV2) should still be provided according to the national schedule. Measles vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). 97 A N N E X 4 At 6 weeks (or as soon as possible thereafter) HepB BD: As soon as possible after birth, ideally within 24 hours, and up to 6 weeks BCG: As soon as possible after birth HepB BD: Not after 6 weeks At 10 weeks (or as soon as possible thereafter), and at least 4 weeks after dose 1 At 9 months (or as soon as possible thereafter) At 18 months (or as soon as possible thereafter), and at least 4 weeks since previous dose MCV2: Not before 4 weeks has passed since MCV1 DTP4: Not before 4 weeks has passed since Penta3 MenA: Not before 9 months of age (except where indicated) Even if a long time has passed between doses, there is no need to restart the series from the beginning. There is no upper age limit for most vaccines (except rotavirus <2yrs and hepatitis B birth dose <6 weeks) WHEN TO GIVE “It is better to vaccinate late than never!” WHICH VACCINES CAN BE GIVEN TODAY? Use this chart to determine which vaccines should be given to a child at or after a specific age. WHEN TO NOT GIVE RV1: Not after 2 years of age Not before 4 weeks has passed since previous dose RV2: Not after 2 years of age At 14 weeks (or as soon as possible thereafter), and at least 4 weeks after dose 2 Not before 4 weeks has passed since previous dose RV3: Not after 2 years of age Not before 9 months of age (except where indicated)† OPV 2 Penta 2 PCV 2 RV 2 OPV 3 Penta 3 PCV 3 RV 3 IPV MCV 1 MCV 2 MenA OPV 1 PCV 1 DTP4 (or Penta4) 6 WEEKS 14 WEEKS 9 MONTHS 18 MONTHS 2 YEARS 10 WEEKS BIRTH HepB BD BCG Penta 1 RV 1 98 Establishing and strengthening immunization in the second year of life 5 A N N E X Annex 5: Frequently asked questions about vaccination in the second year of life The following questions can help health workers respond to questions about vaccination in the second year of life or later. 1. Why is it important to vaccinate children after their first birthday? Both the level of protection and the duration of immunity are increased by providing additional doses of vaccine after the child has reached one year of age. This means that older children will continue to be protected from many vaccine-preventable diseases. For measles, a second dose ensures early protection of the individual child and also reduces the rate of accumulation of susceptible children and the risk of an outbreak. 2. Which vaccines, and at what age, should children receive vaccines after the first year of life? This depends on the schedule of the national immunization programme in each country. • WHO has recommended that all countries provide a second dose of measles-containing vaccine after one year of age. Many countries schedule it in the second year of life. • WHO also recommends a booster dose of vaccine containing diphtheria, tetanus, and pertussis, to be given in the second year of life. • Other vaccines that may be scheduled between 12-23 months include those against meningitis A, Japanese encephalitis, typhoid and yellow fever. • Many countries also recommend catch-up vaccination to provide doses of vaccines missed in the first year of life. 3. Are there some vaccines or doses that should not be given to a child in the second year of life or later? Vaccination in the second year of life is an opportunity to increase the level and duration of protection against vaccine preventable diseases. If children 34 Available at: www.who.int/immunization/documents/positionpapers/en/ 99 Establishing and strengthening immunization in the second year of life A N N E X 5 are missing doses of certain vaccines that they should have received in the first year of life, in general, it is better to vaccinate late than never. There are certain exceptions as indicated in the national immunization schedule and noted in WHO position papers.36 These are: • Birth doses of hepatitis B vaccine should be given only in the newborn period, as stipulated in the national policy. • Rotavirus vaccination after 24 months is not considered necessary because of the age distribution of rotavirus gastroenteritis. 4. On what occasions should a child over one year of age be vaccinated? • When they come for a scheduled vaccination visit according to the national immunization schedule • Any time they are in contact with the health system, including if they come for curative care. Mild illness is not a reason to deny vaccination to a child, and screening sick children for immunization eligibility is a standard component of IMCI. If children have been brought for growth monitoring and nutritional counselling, this also provides an opportunity for screening and vaccinating them. Another opportunity for screening and vaccination is if the child has accompanied one of their family members, such as a sibling or mother, coming for care.35 • During a scheduled Child Health Week, or other similar campaign or event in which catch-up vaccination is provided. 5. What messages should the mother or caregiver be given during their infant’s last vaccination contact before reaching one year of age? For most children, the measles contact is the last vaccination visit before the child reaches one year of age. During that visit, the health worker should make sure to inform the mother as follows. • It is important for her child to come back at the scheduled time [depending on the national vaccination schedule] to receive the remaining doses of vaccine to be given in the second year of life. Unlike in the past, the child cannot be considered fully immunized until they receive these recommended vaccine doses as well. 35 For more information, refer to the WHO missed opportunities for vaccination (MOV) strategy. Available at: www.who.int/immunization/programmes_systems/policies_strategies/MOV/en/ 100 Establishing and strengthening immunization in the second year of life 5 A N N E X • These additional doses will provide stronger and longer-lasting protection against important childhood diseases. With additional doses, this protection will last beyond early childhood. • Be sure to keep the home-based record, such as vaccination card, in a safe place and bring it the next time they come for vaccination, and any time they come to a health facility for services. • She should bring her child for vaccination at the next scheduled time [specify the date]. However, if she is unable to come at that time, to come as soon as possible thereafter. 6. If a child comes for services substantially later than the scheduled time, should they still be vaccinated? Yes. While timely vaccination as soon as the child is eligible is highly desirable to reduce potential exposure to disease, it is always important that the child receive protection from vaccination and not be sent away if they come for vaccination late. With very few exceptions, as explained in Question 3 above, it is “better to vaccinate late than never”. 7. If a child comes late for the 2YL vaccination visit and they are older than 23 months, should the dose be recorded as given in the second year of life (12-23 months)? • Always record and report the dose accurately so that it corresponds to the age at which the child actually received it. This will depend on how the tally sheets and monthly reporting forms are designed. • If they contain two age groups (“0-11 months” and “over 12 months”), then record the doses as being given “over 12 months”. • If they contain three age groups (“0-11 months”, “12-23 months”, and “24 months or over”), then record the doses as being given at “24 months or older”. 8. Is it safe to vaccinate children after one year of age? Are there any additional risks? It is safe and there are no additional or different risks to vaccinating children after one year of age compared with vaccinating them during infancy. 101 Establishing and strengthening immunization in the second year of life A N N E X 5 9. What other services or care can the child receive when they come for vaccination in the second year of life? • Growth monitoring and promotion, nutritional counselling, advice on hygiene and sanitation, and, depending on national policies, vitamin A or deworming medication can be provided during a visit for vaccination in the second year of life. • Some countries may decide to provide additional services, such as follow-up on early infant diagnosis of HIV/AIDS, or family planning services for mothers. © J Sw artz 102 Establishing and strengthening immunization in the second year of life www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Tables 1. WHO-recommended vaccines to be administered in the second year of life 18 2. Materials to review and update for 2YL vaccination and services 28 3. Interventions and commodities for vaccination and other services in a scheduled 2YL visit (illustrative example) 42 4. Summary of immunization indicators related to 2YL 52 5. Elements of the 2YL behaviour change communication framework 71 6. Examples of key message topics to support 2YL vaccination 78 7. Common problems and possible actions to strengthen 2YL vaccination 88 Figures 1. Increase in estimates of MCV1 coverage when doses administered in the second year of life are included 20 2. Estimated coverage of interventions among households with a child aged 12-23 months, if integrated with routine immunization (28 sub-Saharan African countries) 21 3. Example from Ghana of an algorithm for determining eligibility for meningitis A and measles rubella vaccine 68 4. Demand and promotion planning cycle 73

104 Establishing and strengthening immunization in the second year of life C O N T E N T S This document provides practical guidance on establishing and strengthening immunization in the second year of life (2YL) and beyond. It also suggests ways that immunization visits during the 2YL can be used as a platform for delivery of other child-health services. For tools and resources on immunization in the 2YL, please visit www.who.int/immunization/programmes_systems/ policies_strategies/2YL/en/ This document was published by the Expanded Programme on Immunization (EPI) of the Department of Immunization, Vaccines and Biologicals and is available at: www.who.int/immunization/documents Copies of this document as well as additional materials on immunization, vaccines and biologicals may be requested from: World Health Organization Department of Immunization, Vaccines and Biologicals CH-1211 Geneva 27 Switzerland Email: vaccines@who.int Web: www.who.int/immunization/en ISBN 978-92-4-151367-8

Establishing and strengthening immunization in the second year of life Practices for vaccination beyond infancy Establishing and strengthening immunization in the second year of life: practices for vaccination beyond infancy ISBN 978-92-4-151367-8 © World Health Organization 2018 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. 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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 by büro svenja Printed in Switzerland Establishing and strengthening immunization in the second year of life Practices for vaccination beyond infancy iv Establishing and strengthening immunization in the second year of life CONT EN TS SECTION 1 Purpose and use of this document 9 1.1. Objectives 10 1.2 Intended users 11 1.3 Other publications to consult 11 Acronyms vi Acknowledgements viii SECTION 2 Introduction to life-course vaccination with an emphasis on the second year of life 12 SECTION 3 Background on vaccination in the second year of life and beyond 16 3.1 How widespread is vaccination in the second year of life? 17 3.2 Opportunities and benefits for vaccinating in the second year of life 18 3.3 Challenges to vaccination in the second year of life 22 SECTION 4 Policies and planning for vaccination in the second year of life and beyond 24 4.1 Steps for planning the introduction or strengthening of a 2YL visit 26 4.2 Deciding on the timing of the 2YL visit or visits 29 4.3 Catch-up vaccination at any time a child has contact with health services 30 4.4 Coordinating vaccination with other services in the second year of life 32 SECTION 5 Facility-level planning, service organization, and human resources 35 5.1 Update microplanning tools and processes 36 5.2 Review the implications for human resources for the 2YL visit 37 5.3 Determine the feasibility of providing all services desired for the 2YL visit and the practical issues of patient flow 39 v Establishing and strengthening immunization in the second year of life CONT EN TS Annexes 1. Examples of minimum standard and best practice tally sheets 90 2. Immunization monitoring chart showing MCV1-MCV2 drop-out 92 3. Scenarios for vaccination in the second year of life (for use in training and supervision) 93 4. Illustrative example of job aid on screening for vaccination 96 5. Frequently asked questions about vaccination in the second year of life 98 SECTION 6 Supply chain management for vaccines and other commodities 41 6.1 Commodities needed for vaccination and other services in the second year of life 42 6.2 Vaccines and vaccination supplies in the second year of life 45 SECTION 7 Recording, reporting, and using data for decision-making 48 7.1 Performance indicators 50 7.2 Data requirements 54 7.3 Updating forms and health information systems 56 SECTION 9 Communication, demand promotion, and community engagement 70 9.1 Data collection and analysis: understanding your target groups 74 9.2 Strategic design and planning 75 9.3 Development and testing of messages and materials 77 9.4 Implementation and monitoring 79 9.5 Evaluation and re-planning 80 SECTION 8 Health worker training and capacity-building 59 8.1 Determine required health worker competencies 60 8.2 Prepare the training curriculum 62 8.3 Plan the training strategy 65 8.4 Provide supportive supervision and other forms of post-training support 66 SECTION 10 Strengthening 2YL vaccination performance 82 10.1 Understanding the reasons for low performance 83 10.2 Taking actions to address the problems 87 vi 2YL second year of life AEFI adverse event following immunization BCG bacille Calmette-Guérin (vaccine) CDC Centers for Disease Control and Prevention (USA) CHW community health worker cMYP comprehensive multi-year plan CSO civil society organization DHIS2 district health information system, version 2 DHS demographic and health survey DQS data quality self-assessment DTP diphtheria-tetanus-pertussis containing vaccine DV-DMT district vaccination data management tool EID early infant diagnosis of HIV/AIDS EIR electronic immunization record EPI Expanded Programme on Immunization FAQ frequently asked question FIC fully immunized child GVAP Global Vaccine Action Plan GAVJ Gavi, the Vaccine Alliance GRISP Global Routine Immunization Strategies and Practices HBR home-based record HepB hepatitis B vaccine HepB-BD hepatitis B birth dose Hib Haemophilus influenzae type B HMIS health management information system iCCM integrated community case management ICG Interagency Coordinating Committee IMCI integrated management of childhood illness IPAC Immunization Practices Advisory Committee IPV inactivated polio vaccine ITN insecticide-treated bed net JE Japanese encephalitis KAP knowledge-attitude-practice study MCV measles-containing vaccine MCV1 first dose of measles-containing vaccine MCV2 second dose of measles-containing vaccine A B B R E V I A T I O N S A N D A C R O N Y M S Establishing and strengthening immunization in the second year of life A B B R E V I A T I O N S A N D A C R O N Y M S vii Establishing and strengthening immunization in the second year of life MDVP multi-dose vial policy MenA meningitis A vaccine MICS multiple indicator cluster survey MR measles-rubella vaccine MMR measles-mumps-rubella vaccine MOH Ministry of Health MOV missed opportunities for vaccination MUAC middle upper arm circumference NGO nongovernmental organization NITAG National Immunization Technical Advisory Group OPV oral polio vaccine PCV pneumococcal conjugate vaccine PIE post-introduction evaluation PIRI periodic intensification of routine immunization SAGE Strategic Advisory Group of Experts on Immunization SIA supplementary immunization activity SOP standard operating procedure TCV typhoid conjugate vaccine TOT training of trainers TTCV tetanus toxoid-containing vaccine UNICEF United Nations Children’s Fund VPD vaccine-preventable disease WHO World Health Organization viii Establishing and strengthening immunization in the second year of life A C K N O W L E D G E M E N T S This document was developed by the Expanded Programme on Immunization (EPI) of the World Health Organization (WHO) Department of Immunization, Vaccines and Biologicals with contributions from UNICEF and was prepared by Rebecca Fields of John Snow, Inc. The following individuals contributed substantially to its preparation and their input is gratefully acknowledged: Carolina Danovaro, Rudi Eggers, Messeret Eshetu, Tracey Goodman, Jan Grevendonk, Karen Hennessey, Penelope Kalesha Masumbu, Lisa Menning, Abrahams Mwanamwenge, Ikechukwu Ogbuanu, Stephanie Shendale, Emily Wootton (WHO); Ulla Griffiths, Imran Raza Mirza (UNICEF); Laura Conklin, Mawuli Nyaku, Melissa Wardle, Margie Watkins (CDC), and independent consultants Celestino Costa and Karen Wilkins. The guidance of the WHO Strategic Advisory Group of Experts (SAGE) on Immunization and the Immunization Practices Advisory Committee (IPAC) shaped the key principles and directions that are reflected here. The content of the document is based in part on a review of experience with vaccination in the second year of life in the Republic of Ghana, the Republic of Senegal and the Republic of Zambia. We offer sincere thanks to the Ministries of Health in those countries for having permitted the documentation and analysis of their experience in introducing immunization in the second year of life. www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 1 SECTION 9 Establishing and strengthening immunization in the second year of life Purpose and use of this document www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 10 Establishing and strengthening immunization in the second year of life 1 S E C T I O N This document provides practical guidance on establishing and strengthening immunization in the second year of life (2YL) and beyond. It also suggests ways that immunization visits during the 2YL can be used as a platform for delivery of other child- health services. 1.1 Objectives 1 While this document focuses largely on immunization during a scheduled visit in the second year of life, other health interventions are addressed to a limited extent. Detailed information on these interventions is beyond the scope of this document. Relevant publications are included in the Footnotes. 1. To assist countries in making informed decisions about establishing or strengthening a well- child visit (or visits) in the second year of life that includes vaccina- tion and other services as part of a continuum of care for children.1 2. To provide practical guidance on planning, managing, implement- ing, and monitoring vaccination services and improving immunization coverage during a scheduled visit in the second year of life that may include other health interventions. 3. To provide broad guidance on catch-up vaccination for children older than one year, who are delayed or missing vaccine doses (“un- and/or under- vaccinated”). 11 Establishing and strengthening immunization in the second year of life S E C T I O N 1 1.2 Intended users The intended users of this manual are primarily those who work at country level on immunization and other child-health services. They include: • country-level government decision-makers and programme managers for immunization, child health, nutrition, paediatric HIV/AIDS, community development, health education, health management information systems, cold chain and logistics management; • members of National Immunization Technical Advisory Groups (NITAGs), as well as other technical advisory bodies for child health and nutrition; • national, regional and global level immunization and child health advisors working with partner organizations such as WHO, UNICEF, development partners, and civil society organizations and nongovernmental organizations (NGOs). 1.3 Other publications to consult Some of the material in this document is addressed in greater detail in other publications and on WHO web pages. These are highlighted in key resource boxes throughout this guide. A number of other resources that will be important to consult if establishing or strengthening a 2YL platform are currently under development by WHO and will be available in the near future:2 • Working together: an integration resource guide for planning and strengthening immunization services throughout the life course • Handbook on the collection, assessment, and use of immunization data • Guide to introducing Meningococcal A conjugate vaccine into the routine childhood immunization programme. 2 Information on the latest drafts can be requested by contacting the WHO Department of Immunization, Vaccines and Biologicals at vaccines@who.int 12 Establishing and strengthening immunization in the second year of life 2 SECTION Introduction to life- course vaccination with an emphasis on the second year of life 13 Establishing and strengthening immunization in the second year of life S E C T I O N 2 The Global Vaccine Action Plan (GVAP),3 the global blueprint for action in immunization for the period 2011–2020, calls for the benefits of immunization to be equitably extended to all people. The Action Plan states that “a ‘life-course’ approach should be taken in order to make the benefits of immunization available to all those at risk in every age group” and recognizes that “this will mean creating strategies for reaching individuals throughout their life course and developing plans for the systems that will monitor and track progress.” The WHO’s Global Routine Immunization Strategies and Practices (GRISP) document also identifies vaccination beyond infancy as one of nine transformative actions that are critical to strengthening routine immunization.4 It encourages national immunization programmes to expand scheduled routine vaccination visits beyond the first year of life and provide needed vaccines in the preschool, school and adolescent and adult populations. Vaccination opportunities, such as healthy child visits in the second year of life, preschool preparation visits, and school visits should be used to assess vaccination status and administer any previously missed doses. The proper design, distribution, and long-term retention of home-based records (HBRs) are fundamental to ensure the proper screening and provision of vaccines to all who are eligible for them. While many countries already provide routine vaccine doses to children in the second year of life or later, vaccination after one year of age is expected to increase in the coming years. A booster dose of diphtheria-tetanus-pertussis (DTP) containing vaccine is increasingly recognized as being of public health importance and a second dose of measles-containing vaccine (MCV2) through routine immunization is recommended in all countries, with many countries scheduling it during the second year of life. For some vaccines, including pneumococcal, dengue, and meningitis A, schedule options include one or more routine doses in the second year of life. Some new vaccines, such as for malaria, will likely be recommended for children over one year of age. Having an established platform for vaccination in the second year of life will increase the potential uptake of these vaccines when they are introduced. However, vaccination is just one of many health interventions that young children need in order to thrive. As a health service that is often highly used relative to other interventions, immunization can be a platform to provide other essential services, such as growth monitoring and promotion, management of common illnesses, proper sanitation and, in some places, deworming, vitamin A supplementation, micronutrient supplementation, malaria prevention and care, and HIV/AIDS care.5 Interventions to improve growth and development in the first two years of life have a higher impact than in later years. A scheduled visit during this period is also an 3 www.who.int/immunization/global_vaccine_action_plan/en/ 4 www.who.int/immunization/programmes_systems/policies_strategies/GRISP/en/ 5 www.UNICEF-irc.org/article/958/ 14 Establishing and strengthening immunization in the second year of life 2 S E C T I O N opportunity to provide counselling to parents on nutrition, hygiene, home care practices, family planning, and timely care seeking. Many countries already have policies of regular visits for growth monitoring, promotion, and complementary feeding, but the use of the visits often drops after one year of age, as families and health workers alike may not view them as a priority. If managed strategically, vaccination visits in the second year of life (2YL) can help augment progress both for immunization and other maternal and child health services. B OX 1. K E Y P O I N TS FO R VAC C I N AT I O N I N T H E S EC O N D Y E A R O F L I F E A N D B E YO N D 1. An increasing number of vaccine doses are recommended to be given after one year of age as part of a life course approach to vaccination. WHO global recommendations for doses of childhood vaccines to be given after one year of age include a second dose of measles-containing vaccine (MCV) and booster doses of diphtheria, tetanus, and pertussis- containing vaccines. Additionally, countries may choose to adopt a “2 + 1” schedule for pneumococcal conjugate vaccine (PCV) in which the third dose is administered in the second year of life. WHO also recommends that doses of some regionally-indicated vaccines, including meningitis A (MenA) in the meningitis belt of Africa and Japanese encephalitis in parts of Asia, can be given after one year of age. 2. The extension of the vaccination schedule beyond infancy means that the concept of a “fully immunized child (FIC)” indicator must be expanded in the second year. FIC should be specific to the age of the child and the corresponding set of vaccines that the child should have received, as per the national schedule, by that age. Programmes may choose to track FIC in two or more age categories: FIC<1, FIC<2 (see Section 7.1). 3. With increasing complexity and duration of the vaccination schedule comes increasing importance of home-based records (HBRs), to remind caregivers of when to return to complete the schedule, to allow providers to screen for needed vaccinations, and to serve as a basis for evaluation through population-based coverage surveys. HBRs must be well- designed, available in sufficient supply for all caregivers, used properly by health personnel, and kept safely by caregivers/families. 4. In some settings, concerted efforts, including strong communication and health worker capacity-building, are needed to change conventional thinking that immunization is just for infants. If high levels of coverage in 15 Establishing and strengthening immunization in the second year of life S E C T I O N 2 the second year of life and throughout the life course are to be achieved, then health workers, caregivers, communities, and partners must have a solid understanding of why it is important and what they themselves can do to make it happen. This requires a major shift in thinking and practices by all parties involved. 5. Whereas children should be vaccinated as soon as they are eligible, those who are brought “late” should not be denied vaccination. Timely vaccination is crucial for reducing exposure to vaccine-preventable diseases (VPDs) but, with a few specific exceptions, it is better to vaccinate late than never. For 2YL vaccination, the age of 24 months should not be viewed as a cut-off point after which children are not vaccinated. 6. Achieving high coverage in the second year of life, even with vaccines that have long been part of the vaccination schedule, requires even more attention, visibility and preparation as for introducing a new vaccine, and should not be taken lightly. The very high MCV1 to MCV2 drop-out rates observed in many countries attest to the challenges in vaccinating a new age group. Areas requiring special attention include data management/monitoring and evaluation, communication, and health worker capacity building, including supportive supervision and other forms of post-training support. 7. Data management, monitoring, and evaluation for vaccination in the second year of life pose particular challenges. Tally sheets and other data management tools must be updated carefully to correctly capture all doses administered (even if the doses are not timely) and to encourage proper health worker screening, recording and reporting of doses administered, which will be needed to ensure good vaccine management and estimation of needs. Monitoring progress across at least two birth cohorts and providing meaningful feedback can be challenging. Careful planning and learning from experience to date is needed to address these issues. 8. Vaccination in the second year of life can serve as a platform for providing other essential services to children and mothers. If carefully coordinated with other programmes, immunization services can reinforce and stimulate the uptake of other health services, such as growth monitoring and promotion, nutritional counselling, vitamin A and micronutrient supplementation, deworming, health education and family planning, malaria prevention, and follow-up on early infant diagnosis of HIV/AIDS. Each country must assess the timing and schedules of these services and determine the feasibility of integration based on an examination of the human, material and financial resources needed. 16 Establishing and strengthening immunization in the second year of life 3 SECTION Background on vaccination in the second year of life and beyond 17 Establishing and strengthening immunization in the second year of life S E C T I O N 3 3.1 How widespread is vaccination in the second year of life? While the vaccines given in the second year of life (or later) and the ages at which they are administered vary across countries, vaccination in the second year of life is a widespread practice. As of 2016,6 recommended that DTP4 be given in the second year of life. 6 WHO vaccine-preventable diseases: monitoring system. 2017 global summary. http://apps.who.int/immunization_monitoring/globalsummary/schedules, accessed 18 July 2017. had immunization policies that included at least one dose of any vaccine to be given in the second year of life. included two doses of measles- containing vaccine (MCV) in their routine immunization schedules. recommended that the second dose, MCV2, be given in the second year of life. include both MCV2 and a fourth dose of vaccine containing diphtheria, pertussis, and tetanus (DTP4) at any age. had policies calling for both MCV2 and DTP4 to be provided at the same time in the second year of life. 159 COUNTRIES 86 COUNTRIES 160 COUNTRIES 135 COUNTRIES 107 COUNTRIES 45 COUNTRIES 18 Establishing and strengthening immunization in the second year of life 3 S E C T I O N 3.2 Opportunities and benefits for vaccinating in the second year of life There are several reasons for establishing a strong platform for vaccination and other interventions in the second year of life and beyond. Increase protection against vaccine-preventable diseases (VPDs) The addition of new vaccines, and new doses of existing vaccines, in the second year of life increases the extent to which children can be protected from VPDs, as shown in Table 1 below. The provision of additional doses of vaccines that are already in the national schedule contributes to higher levels of immunity and longer duration of protection. The immune response to tetanus toxoid-containing vaccine (TTCV), for example, decreases with age, which is why WHO recommends that an individual receives six doses (three primary plus three booster doses, one of which should be given in the second year of life).7 TA B L E 1. WHO-RECOMMENDED VACCINES TO BE ADMINISTERED IN THE SECOND YEAR OF LIFE 7 Use of TTCV combinations with diphtheria toxoid (Td or DT) for subsequent tetanus boosters are strongly encouraged, to maintain high immunity to both diphtheria and tetanus throughout life. VAC C I N E W H O R EC O M M E N DAT I O N S Second dose of measles-containing vaccine (MCV2), including measles- rubella (MR) and measles-mumps- rubella (MMR) vaccines WHO recommends that a second dose of MCV be added to the routine immunization schedule in all countries. Where risk of measles mortality among infants remains high, MCV1 should be administered at 9 months of age and MCV2 should be administered at 15–18 months with a minimum interval of four weeks between doses. In countries with low risk of measles infection among infants (i.e. near elimination), MCV1 may be administered at 12 months; the optimal age for delivering MCV2 is based on programmatic considerations that achieve the highest coverage of MCV2. Measles vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). Fourth dose of diphtheria-tetanus- pertussis-containing vaccine (DTP4) WHO recommends that children be given a booster dose of DTP-containing vaccine, preferably during the second year of life, to strengthen immunity against these diseases. Diphtheria vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/diphtheria/en/), Tetanus vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/tetanus/en/), Pertussis vaccines. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/pertussis/en/). 19 Establishing and strengthening immunization in the second year of life S E C T I O N 3 VAC C I N E W H O R EC O M M E N DAT I O N S Pneumococcal conjugate vaccine (PCV) WHO supports the option of a (2p+1) schedule for PCV in which two primary doses are provided in infancy and the third dose (booster) is given at 9-18 months of age.8 The timing of the booster should be selected to maximize coverage (usually 9, 12, 15 or 18 months) depending on operational and programmatic factors, including timing of vaccination contacts in the national immunization schedule for other vaccines. Pneumococcal vaccines. Position paper. Geneva: World Health Organization; 2012 (www.who.int/immunization/policy/position_papers/pneumococcus/en/) and WHO Strategic Advisory Group (SAGE) on Immunization, October 2017. Conclusions and recommendations. Geneva: World Health Organization; 2017 (www.who.int/wer/2017/wer9248/en/). Meningitis A conjugate vaccine (MenA) routine dose WHO recommends a single dose of MenA at 9–18 months based on local programmatic and epidemiological considerations. Meningococcal A conjugate vaccine: updated guidance. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/meningococcal/en/). Typhoid conjugate vac- cine (TCV) WHO recommends a single dose of TCV at 6-23 months in endemic countries. Timing of administration should be based on local epidemiological, geographic and programmatic considerations. WHO Strategic Advisory Group (SAGE) on Immunization, October 2017. Conclusions and recommendations. Geneva: World Health Organization; 2017 (www.who.int/wer/2017/wer9248/en/). Japanese encephalitis (JE) WHO recommends that JE vaccination be introduced into national immunization schedules in all areas where JE is recognized as a public health priority. WHO recommends one or two doses, starting from 6 months of age, with the schedule determined by local epidemiology and type of vaccine. Japanese encephalitis vaccines. Position paper. Geneva: World Health Organization; 2015 (www.who.int/immunization/policy/position_papers/japanese_encephalitis/en/). Seasonal influenza Country-specific information about risk groups, disease burden and cost-effectiveness are important to aid national policy-makers and health programme planners in making informed decisions about target groups and timing for vaccination. In those countries that decide to introduce it, WHO recommends seasonal influenza vaccination starting from 6 months of life and extending to 23 or 59 months, with two doses separated by at least 28 days for previously unvaccinated children <9 years of age. Vaccines against influenza. Position paper. Geneva: World Health Organization; 2012 (www.who.int/immunization/policy/position_papers/influenza/en/). Table 1. Continued 8 Both schedule options (3p+0 or 2p+1) are recommended. For countries that have yet to introduce PCV, decisions regarding the choice of schedule should take into account operational and programmatic issues, including timeliness of vaccination, coverage expected to be achieved with the third dose, and pneumococcal disease age distribution patterns. 20 Establishing and strengthening immunization in the second year of life 3 S E C T I O N Catch-up children on vaccinations that were missed during the first year of life Vaccination in the second year of life is an opportunity to provide missed doses of several antigens, including BCG,9 MCV, oral and inactivated polio vaccines, pentavalent (or DTP), pneumococcal vaccines, and rotavirus vaccine. In some settings, families may face various social, geographical, and economic barriers to getting their children fully immunized by 12 months of age and this contributes to low coverage. A strong 2YL platform provides an important oppor- tunity to improve overall protection and coverage. For instance, in a country where measles vaccine is given at 9 months of age and where a one-year age limit is enforced, children are by default limited to a three-month window to receive MCV1. This barrier would be removed by expanding vaccination services to the second year of life and encouraging catch-up vaccination beyond one year. Vaccinating children in the 2YL with measles and other vaccine doses missed in the first year of life contributes to higher levels of population immunity. This was demonstrated in a 2009 analysis of Demographic and Health Surveys (DHS) from 45 countries. It showed that while pooled routine immunization coverage for MCV1 by 12 months of age was only about 50%, it rose to over 80% if the doses given after 12 months of age (i.e. “late doses”) were included in the coverage estimates (see Figure 1).10 F I G U R E 1. I N C R E AS E I N E ST I M AT E S O F M CV 1 C OV E R AG E W H E N D OS E S A D M I N I ST E R E D I N T H E S EC O N D Y E A R O F L I F E A R E I N C LU D E D 0 20 40 60 80 100 MCV1 coverage by age category in selected countries Source: Demographic and Health Survey (Date of survey indicted for each country) Afghanistan (2015) Chad (2014) Haiti (2012) Mali (2013) Pakistan (2013) Yemen (2013) Zambia (2014) Coverage in children < 12 months Additional coverage in children 12–23 months 21 Establishing and strengthening immunization in the second year of life S E C T I O N 3 Create opportunities to integrate vaccination with other health and nutrition interventions A scheduled routine contact with the health system in the second year of life is an opportunity to further integrate immunization with other health interventions, such as vitamin A supplementation, nutritional counselling, growth monitoring and promotion, deworming, paediatric HIV/AIDS care, provision of insecticide-treated bed nets (ITNs), or family planning. Figure 2 illustrates the potential gains in coverage for several child health interventions when integrated with the routine immunization platform in Africa. F I G U R E 2. E ST I M AT E D C OV E R AG E O F I N T E RV E N T I O N S A M O N G H O U S E H O L DS W I T H A C H I L D AG E D 1 2 - 2 3 M O N T H S, I F I N T EG R AT E D W I T H RO U T I N E I M M U N I Z AT I O N ( 2 8 SU B -SA H A R A N A F R I CA N C O U N T R I E S ) 0 20 40 60 80 100 Improved source of drinking water* household bed-net ownership child sleeping under bed-net child received vitamin A supplementation Current coverage Likely total coverage *through provision of point-of-use water treatment kits (after Improved source of drinking water) 9 The WHO position paper on BCG vaccines was recently updated to include the recommendation for catch-up vaccination for unvaccinated older infants and children, as evidence shows that it is still beneficial beyond one year of age. BCG vaccines. Position paper. Geneva: World Health Organization; 2018. www.who.int/wer/2018/wer9308/en/ 10 Clark A, Sanderson C. Timing of children’s vaccinations in 45 low-income and middle-income countries: an analysis of survey data. Lancet. 2009;373:1543–9. 22 Establishing and strengthening immunization in the second year of life 3 S E C T I O N Make more efficient use of vaccines Providing two doses of measles-containing vaccine, with one in the second year of life, can potentially reduce vaccine wastage rates as more doses per opened vial of vaccine will be given. This may also be true for catching up children with other vaccine doses that they missed in infancy and are given at a later age. 3.3 Challenges to vaccination in the second year of life Over the past 40 years, immunization programmes have accumulated a wealth of experience in delivering vaccines, primarily to infants. Since vaccination in the second year of life has been introduced in many countries, experience has been mixed. For example, many national programmes assumed the introduction of MCV2 through a new routine visit in the second year of life would be straightforward, as MCV is already in the schedule in the first year of life and therefore, familiar to caregivers and health workers. However, reality has shown that it brings substantial complexity, in some cases of a nature not previously encountered by immunization programmes. High drop-out rates from MCV1 to MCV2 have been a particular concern in many countries. Successful implementation of vaccination in the sec ond year of life requires strong planning, coordination, community mobilization and demand creation, monitoring, and support for implementation. © W H O N epal 23 Establishing and strengthening immunization in the second year of life S E C T I O N 3 Many immunization programmes still view immunization as a health intervention purely for infants, and do not offer vaccinations to children over one year even if they were never vaccinated. While policies must be established for vaccination beyond one year of age, without proper planning, training, and communication, these policies will not automatically translate to widespread changes in vaccination practices. Factors that have been shown to contribute to this situation include: • insufficient messaging to front-line health workers on revised policies regarding provision of vaccination and other health services after one year of age; • health worker hesitation to vaccinate children >12 months of age with MCV1 because it does not contribute to MCV1 coverage and they may worry about not having enough doses for the <12 months children; • lower priority placed on vaccination of older children, compared with vaccination of infants; • Insufficient communication and social mobilization to remind and encourage caregivers to use health services in the second year of life; • complexity in recording, reporting, and analyzing vaccine doses given after one year; • system barriers, such as limited human resources and uncoordinated supply chains, for different commodities. Post-introduction evaluations (PIEs) of measles second dose in several countries, plus case studies on 2YL vaccination, indicate that the introduction of any vaccination after the first year of life should be treated as if it were a new vaccine introduction in terms of attention, visibility, and preparation, and the added complexities of vaccinating a new age group should be adequately accounted for in the planning process. If possible, 2YL vaccination should also be placed within the context of a healthy child visit so that it can reinforce the provision of other health interventions, and vice versa. 24 Establishing and strengthening immunization in the second year of life Policies and planning for vaccination in the second year of life and beyond 4 SECTION 25 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Virtually all countries already have in place policies, guidelines, and other programme supports for child health care through the first five years of life, including growth monitoring and promotion, nutritional counselling, and integrated management of childhood illness, among others. Depending on their health priorities and current vaccination schedule, countries may want to: introduce vaccination in the second year of life as a new inter- vention (through a scheduled visit, or visits and catch-up of missed vaccination) strengthen existing 2YL vaccination (e.g. improve low MCV2 coverage), and/or develop a 2YL vaccination contact as a platform for coordinated delivery of other child health services. In all three situations, systematic planning is needed to address both technical and managerial issues. The second situation (improvement of existing programmes) is addressed in Section 10. 1. 2. 3. © U N IC EF/U N 0 58138/V ishw anathan 26 Establishing and strengthening immunization in the second year of life 4 S E C T I O N 4.1 Steps for planning the introduction or strengthening of a 2YL visit If setting up a new immunization visit in the 2YL, the planning process should begin one year prior to the anticipated launch date to permit sufficient time for the preparations described below. More detail on operatio- nalizing these steps can be found in a companion resource A handbook for planning, implementing, and strengthening vaccination into the second year of life (2YL Handbook).11 Identify a 2YL focal point and establish or activate a 2YL working group The 2YL focal point should be a staff member of the national immunization programme with sufficient authority to convene a working group. The working group should include representation from various areas of the immunization programme, such as data management, communications and service delivery. If other health interventions are to be coordinated with 2YL vaccination, then representation from these groups should also be included. Major stakeholders and partners in immunization and child health should also be involved. Membership in the working group — K E Y R E S O U RC E A handbook for planning, implementing, and strengthening vaccination into the second year of life A companion resource to this document, the 2YL Handbook is intended for use after the decision has been made to extend vaccination into the 2YL, or improve coverage of an existing platform. The 2YL Handbook provides practical guidance on planning, managing, implementing and monitoring vaccination during a scheduled visit, or visits, in the 2YL, as well as useful steps for strengthening vaccination when coverage in the 2YL has not reached programme targets. www.who.int/immunization/ programmes_systems/policies_ strategies/2YL/en/ Establishing and strengthening immunization in the second year of life Handbook may expand as planning evolves. The National Immunization Technical Advisory Group (NITAG) should be engaged and play a leading role in reviewing epidemiological and clinical considerations, as well as immunization programme needs, costing and financing issues, and the development of policies and guidelines. The Interagency Coordinating Committee (ICC) and/or health sector coordinating committees should also be engaged to enlist commitment and to establish a shared understanding of resource requirements. 11 www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 27 Establishing and strengthening immunization in the second year of life S E C T I O N 4 — K E Y R E S O U RC E Tool for estimating the costs of introducing a 2YL healthy child visit13 UNICEF has developed a relatively simple Excel-based costing tool to estimate the costs of introducing a 2YL visit. The tool must be populated with demographic data, commodity prices, health worker salaries and approximate costs for training and communication activities. Results are then presented in terms of total costs, annual costs and costs per visit. Costs are divided into “up-front” costs (such as training) and recurring costs that need to be continually financed (such as vaccines and syringes). The cost analysis can be viewed as an advocacy opportunity for introducing a 2YL visit. The tool should also be used as an integral part of the planning process. Develop a budgeted plan of action and secure funding This should include activities, lead responsibilities, milestones, timelines, and resources needed to address the following actions, and should be informed by lessons learned and challenges from previous vaccine introductions. 1. Update policies and guidelines; obtain necessary approvals; produce and disseminate (print and/or electronically). 2. Define 2YL indicators for recording and reporting, revise health management information system (HMIS) and data management tools (HBRs, registers, monthly reports), and distribute these in advance of the launch date. 3. Identify and address needs for organization of service delivery. 4. Modify supply chain and logistics management tools, as needed, to include new doses of vaccines and other interventions in the second year of life. 5. Prepare, print and distribute a field guide and job aids for health workers. 12 Tools for conducting behavioural analyses, including Guide for studying health worker/caregiver interactions for immunization. Geneva: World Health Organization; 2017 and The guide to tailoring immunization programmes (TIP). Copenhagen: WHO Regional Office for Europe; 2013, are available at: www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/. 13 The 2YL costing tool can be accessed at: www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 6. Develop a training plan and new training and supervision materials, and carry out training. 7. Develop a communication strategy, plan and conduct social mobilization and community engagement activities, including knowledge-attitude-practice (KAP) studies or other behavioural analyses,12 particularly regarding marginalized and hard-to-reach communities. 8. Secure funding for carrying out all preparatory work, and to cover operational and other related costs associated with 2YL. 28 Establishing and strengthening immunization in the second year of life 4 S E C T I O N Policies, guidelines and standards • Vaccination policy and reference manuals • National health/child health policy • Guidelines and other reference materials for health workers, including for IMCI Planning documents • Comprehensive multi-year plan (cMYP) and the annual plan of action for immunization • Formats for microplanning and plans for introducing them Data management tools • HBR • Tally sheets • Monthly reporting forms • Health facility registers • Community registers • HMIS, District Vaccination Data Management Tool (DV-DMT), district health information system, version 2 (DHIS2) • Monitoring tools and charts Training and capacity-building • Curricula for in-service and pre-service training • Supervision instruments • Job aids Supply chain management • Assessment of cold chain, logistics, and available storage • Standard operating procedures (SOPs) for handling of vaccines in 2YL • Vaccine and logistics forecasting tools Communication, demand creation • Communication and community engagement plan and strategy • Plans and materials for launch • Health education materials and job aids Assign clear responsibilities for each aspect of preparation. Groups or committees that have been established to work on such issues, for vaccination campaigns or new vaccine introductions, in the past, can be re-activated. However, if other health interventions are to be included together with 2YL vaccination, then there should also be representation from other programmes, such as nutrition, integrated management of childhood illness (IMCI), malaria, water and sanitation, paediatric HIV/AIDS, etc. Agree on the services or interventions to be provided during the visit and identify the policies, guidelines, and other materials that must be revised. These are likely to include the following, in Table 2 below, but there may be additional materials to revise depending on the country. TA B L E 2. M AT E R I A L S TO R E V I E W A N D U P DAT E FO R 2 Y L VAC C I N AT I O N A N D S E RV I C E S 29 Establishing and strengthening immunization in the second year of life S E C T I O N 4 4.2 Deciding on the timing of the 2YL visit or visits A key step is to decide on the appropriate age at which to schedule the 2YL visit (or visits). This is a function of epidemiological data for the VPDs in question, plus the schedule for other child health services, as specified by national policies. Policy- and decision-makers need to consider public health goals and programmatic issues, using transparent criteria to evaluate their relative importance. National immunization policies and guidelines should be written to clearly articulate the actions needed by health personnel and caregivers. For example: • Clarify that, although it is best to vaccinate children as soon as they become eligible, for most vaccines there is no upper age limit after which the child should be denied the protection of vaccination. The exceptions are rotavirus vaccine, which is not recommended > 24 months of age, and hepatitis B (HepB) birth dose.14 • Convey the intended purpose of the 2YL vaccine doses. If the country is introducing a second dose of MCV into its routine schedule, then the dose must be included in the fully immunized child (FIC) requirement, and the dose should be referred to as Measles 2 or MR2 or MMR2, rather than a booster dose. AG E S FO R S C H E D U L E D 2 Y L V I S I TS FO R VAC C I N AT I O N I N T H R E E C O U N T R I E S One Southern African country decided to provide MCV2 at 18 months because it coincides with the age for vitamin A supplementation. A West African country chose to provide MCV2 at 15 months to minimize the length of potential exposure to measles virus, even though the timing was not synchronized with the schedule for other health services provided during the second year of life. A South Asian country initially introduced MCV2 and DTP4 at different months in the second year of life for epidemiological reasons. However, it was later recognized that this added complexity to the immunization schedule and contributed to missed opportunities for vaccina- tion. The country then modified the schedule to recommend both doses at the same visit. C O U N T RY E X P E R I E N C E 14 It is important that programmes have a clear policy on how late HepB birth dose can be administered. Some countries stop providing HepB birth dose beyond two weeks after birth in order to maintain a four-week gap between doses. However, in countries using a 4-dose schedule (with combination vaccine), a four-week gap is not necessary prior to the first primary dose (as the combination schedule meets the dosing requirements), therefore, HepB birth dose can be given up until the day before the first combination vaccine is due. Both options are acceptable. For more information, see A guide for introducing and strengthening Hepatitis B birth dose vaccination. Geneva: World Health Organization; 2015 (www.who.int/immunization/documents/general/ISBN9789241509831/en/). 30 Establishing and strengthening immunization in the second year of life 4 S E C T I O N • Provide clear instructions on how to properly screen children for eligibility by reviewing HBRs, record doses, report data, and use it for improving services. • Specify the actions that health workers should take when faced with situations that do not represent the ideal, such as children arriving with missing or delayed doses, children arriving with no HBR, etc. (see Annex 3). • Clearly state the policy on vaccinating children who are 12 months or older and missing doses, during periodic intensification of routine immunization (PIRI) activities such as Child Health Days (see Box 2 below). 4.3 Catch-up vaccination at any time a child has contact with health services Sick-child visits and visits to facilities for care of other family members in the second year of life are also opportunities to catch children up on missed doses from the first year of life, and to screen and vaccinate them for doses scheduled for the second year of life. L E A R N I N G F RO M G H A N A’S I M M U N I Z AT I O N P O L I CY The Republic of Ghana’s immunization policy has been updated to provide clear guidance to health workers about vaccinating children older than 12 months of age. Second year of life routine immunization policy Additional routine contact for immunizations will be done during a child’s second year of life at 18 months of age or soon after. Services available at this contact include MR2, MenA, and any intervention deemed appropriate (e.g. Vitamin A supplementation). Catch-up policy All children should be immunized per Ghana’s recommended immunization schedule. Children with any missed doses should be vaccinated with appropriate antigen up to five years of age. During any health visit, a child’s immunization status should be assessed and missed doses administered per the recommended catch-up schedule. Fully immunized child (FIC) The FIC indicator is split into three categories: FIC by age one, FIC by age two, and FIC after age two. A child is considered fully immunized by his/ her age if he/she has received all the age-appropriate vaccines up to that point. C O U N T RY E X P E R I E N C E 31 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Immunization policies and health worker training/ supervision should emphasize the importance of caregivers bringing the child’s HBR to health facilities for every visit and providing catch-up vaccination at any time that a child has contact with the health system. Clear guidelines for catch-up vaccinations for antigens missed in the first year of life should be established and disseminated widely, including an accelerated vaccination schedule for children who present missing multiple vaccine doses. A useful resource for this is the WHO recommendations for catch-up vaccinations, available at: www.who.int/immunization/policy/Immunization_routine_table3.pdf B OX 2. P ROV I D I N G 2 Y L VAC C I N AT I O N D U R I N G P I R I E V E N TS Periodic intensification of routine immunization (PIRI) activities, such as Child Health Days or Maternal and Child Health Weeks, if regularly conducted, should be used to catch-up children for missed doses from the first year of life and to provide 2YL vaccinations for which the child is eligible. Immunization policies and health worker training for the PIRI should provide clear guidance on this point. PIRI activities should also be used as an opportunity to communicate the importance of immunization in the second year of life and the need for children to be brought for all recommended 2YL vaccinations according to the national schedule. PIRI activities should also underscore the importance of encouraging caregivers to bring the child’s HBR to every health contact. Guidance for health workers on screening, provision of services, and recording of doses, both for the routine 2YL doses and for the PIRI, should be included in policies, field manuals, training, and supervision. For more information on best practices for PIRI activities, please see WHO resource Periodic Intensification of Routine Immunization. Lessons learned and implications for action, available at: www.who.int/immunization/ programmes_systems/policies_strategies/piri_020909.pdf? © W H O 32 Establishing and strengthening immunization in the second year of life 4 S E C T I O N 4.4 Coordinating vaccination with other services in the second year of life If it is decided to use the 2YL vaccination visit to deliver additional interventions, then the planning process must engage representatives from other related health programmes. Analyse and compare the technical attributes of other interventions proposed for the scheduled 2YL visit(s) The priorities, objectives, achievements, challenges, and plans of different evidence-based health and nutrition interventions offered in the second year of life should be compared systematically to identify both the opportunities and the limits of a 2YL vaccination contact in reinforcing other services. This may entail convening a meeting, or meetings, to foster direct communication and negotiation among stakeholders regarding the continuum of care for young children and the role of immunization within it. The package of services to be provided during the 2YL visit should be based on a combination of technical, managerial, and client-oriented considerations. Questions to consider in deciding on the components of the package include the following: • What are the established public health priorities of the Ministry of Health? • Which interventions can be provided at ages 12-23 months, are any of these visits already established, and does their timing coincide with a recommended schedule for 2YL vaccination? • Which services, and how many, can be scheduled for a single visit in the 2YL, and will this improve convenience for the child and caregiver? • Can all of the interventions be provided to children through fixed (static), outreach, and mobile services, and are these service delivery strategies fully functional? • Are the proposed interventions for this visit carried out throughout the entire country or only in certain geographic areas? • How similar are the logistical requirements? • What are the implications for human resources, including capacity of staff, time to be spent per patient, and patient flow? • Are sufficient human and financial resources available for providing and sustaining each intervention proposed for the visit? 33 Establishing and strengthening immunization in the second year of life S E C T I O N 4 Some countries have planned for integrated services that include vaccination beyond one year of age and have evaluated the experience to identify ways of improving services. The lessons learned from such experiences can help guide other countries in their decision-making and planning processes. Z A M B I A’S PAC K AG E O F I N T E RV E N T I O N S FO R A C O M P R E H E N S I V E H E A LT H Y C H I L D V I S I T AT 1 8 M O N T H S O F AG E One year after the Republic of Zambia introduced MCV2, the Ministry of Health and partners reviewed the experience in order to decide how to strengthen performance and integrate 2YL vaccination with other services. A meeting was convened in which officials from several programmes, including immunization, nutrition, and child health, as well as representatives from the HMIS, provincial and district teams, and key technical partners, deliberated on ways in which the 2YL visit for MCV2 could serve additional health needs. A key outcome was definition of the package of services shown below. This reflected, in part, a decision by the MOH to shift its delivery strategy for vitamin A supplementation and deworming away from reliance on Child Health Weeks and into routine services. At 18 months, all children now receive the following: • MCV2 • catch-up of other vaccinations that the child missed in the first year of life and for which he or she is still eligible • growth monitoring and promotion • Vitamin A supplementation • deworming treatment (mebendazole). For some children, if indicated, the following are also provided: • follow up/referral on early infant diagnosis (EID) for HIV/AIDS • referral for IMCI or integrated Community Case Management (iCCM) for children with fever or other signs of illness during the visit. C O U N T RY E X P E R I E N C E © U N IC EF/U N 0 152973/Scherm brucker 34 Establishing and strengthening immunization in the second year of life 4 S E C T I O N LESSONS LEARNED FROM HONDURAS IN INTEGRATING I M M U N I Z AT I O N W I T H OT H E R S E RV I C E S I N T H E F I RST F I V E Y E A RS O F L I F E The immunization programme in the Republic of Honduras serves as a strong platform for providing other services from 2-5 years of age. These include vitamin A supplementation, folic acid for mothers, promotion of exclusive breastfeeding, education on identifying ocular tumours, and local time-limited measures to contain cholera outbreaks and control dengue. A study of early experience showed the following. • Close coordination and joint planning across different programmes and different levels of the health system is key to success. • Jointly-prepared technical and programmatic guidelines are essential to clearly define the delivery of the interventions to be provided during the healthy child visits that include immunization. • Health personnel at all levels must be trained on the technical guidelines. • Timely and accurate forecasting, procurement, distribution, and storage are needed for all supplies, not just vaccines, required at health facility level for the healthy child visit. • A communications working group should develop a strategic communication plan that includes materials development, use of mass media, community engagement, and a timeline and budget. • Forms for data recording and reporting must be adapted and the HMIS updated accordingly. • Systematic monitoring, by age group and strategy of progress against goals should be carried out. • Joint supervision with personnel from all relevant programmes should prioritize densely-populated areas and areas at risk. • Challenges to sustained integration include uncertain funding and limited supplies of key commodities. Source: Molina-Aguilera et al. J. Inf. Dis. 2012:205 (Suppl 1) C O U N T RY E X P E R I E N C E © U N IC EF/U N I440 79/D eC esare 5 SECTION 35 Establishing and strengthening immunization in the second year of life Facility-level planning, service organization, and human resources 36 Establishing and strengthening immunization in the second year of life 5 S E C T I O N The introduction of a scheduled 2YL visit for vaccination requires detailed planning to implement it within the existing organization and delivery of fixed, outreach, and mobile services. District and facility supervisors have an important role to play in adjusting microplanning and reviewing the organization of services, patient flow, human resources, and prevention of missed opportunities for vaccination. The national level should provide guidance for updating microplanning templates and for ensuring high-quality service delivery, especially if there is a preferred sequence for administering the interventions. Vaccination, as an invasive procedure, should generally be provided after other procedures.15 However, the health worker should complete the interaction with the caregiver by providing guidance on what to do in the event of side-effects or adverse events, and when and where to return for the next visit. 5.1 Update microplanning tools and processes In many countries, microplanning tools currently in use are designed to support planning for vaccination in the first year of life. To accommodate 2YL vaccination, microplanning tools must be revised and expanded to include the second year cohort aged 12-23 months. The target population is surviving infants from the previous year’s birth cohort. For example, if DTP4 is scheduled to be given to children who are 18 months of age or older, then the target group for microplanning for the current year is the number of surviving infants from the previous year. This information should be available from the previous year’s plans. Timely vaccination during a scheduled visit in the second year of life is highly desirable, but the age of 24 months should not be viewed as a cut-off point after which children are denied vaccination. Microplanning should be based on the cohort aged 12-23 months and, even if children are vaccinated later than the targeted age, it does not affect the number or catchment area of the children to be vaccinated, just the age at which they actually receive the vaccines. As further described in Section 7, all doses, regardless of when they are given, should be recorded on HBRs, tally sheets, facility registers, electronic immunization records (EIRs), and monthly reports, according to the age at which the child actually received the vaccines. 15 Reducing pain at the time of immunization. Position paper. Geneva: World Health Organization; 2015 (www.who.int/wer/2015/wer9039.pdf). 37 Establishing and strengthening immunization in the second year of life S E C T I O N 5 Microplanning should give particular attention to identifying outreach sites that are convenient for the caregiver(s), bearing in mind that a child in the 2YL is now older, heavier, and less easy to transport than an infant. Mothers are also more likely to be working outside the home. To improve access and reduce drop-out rates, the site selection, day of the week, and time of day for outreach sessions should, where possible, be decided in consultation with the community members. The provision of additional health services during the scheduled 2YL visit means that microplanning should address the operational features of those services as well as those of immunization. Personnel responsible for nutrition, child health, water and sanitation, HIV/AIDS, family planning, health education, or other programmes, should be encouraged to take part in the microplanning process. 5.2 Review the implications for human resources for the 2YL visit Many low-resource countries face severe limitations in human resources so that the true staffing situation in health facilities falls short of government standards. The ability to provide multiple services during the visit requires that the right types of health workers are present at each facility. During the 2YL planning phase at national level, health officials should review the actual availability of human resources in health facilities, and provide guidance on which types of staff can carry out each task. Terms of reference and accountabilities may need to be revised. At the clinic level, head nurses or facility in-charges should clearly communicate the sequence of services, both for fixed and outreach services. They should also designate which staff will carry out specific tasks (described further in Section 8). These include: • screening children to determine which services they should receive that day; • providing each service in a pre-defined order: e.g. growth monitoring and promotion, Vitamin A supplementation, deworming, vaccination, counselling; • recording services administered, in all the appropriate tools, immediately after the services are provided; • discussing, with each caregiver, what the child has just received and what further actions the caregiver needs to take. In smaller health facilities where one, or few, staff carry out all functions, it is pref- erable that all health workers at the facility are trained to provide all 2YL services to ensure continuous service delivery when any members of the team are on leave. 38 Establishing and strengthening immunization in the second year of life 5 S E C T I O N At both fixed and outreach service delivery points, community health workers (CHWs) or trained volunteers may be able to assist health workers with patient flow, health education, and possibly some aspects of record keeping. Within the communities, CHW tasks may include recording newborns, maintaining community registers of children 0-59 months of age and pregnant women, defaulter tracking and follow-up, talking with community members about the importance of vaccination and other services in the second year of life, and informing them of when and where to seek services. However, some tasks are less appropriate for CHWs or volunteers. For example, screening of 12-23 month old children for eligibility for vaccination is more complex than for infant vaccination, as the number of doses these children should have received by that age is greater and there may be uncertainty about how to handle missing or late doses. This is, therefore, likely to require trained health workers. In small health facilities with limited staff, it is pref erable that all health workers are trained to provide all 2YL services to ensure continuous service delivery when any members of the team are on leave. © W H O /Reidy 39 Establishing and strengthening immunization in the second year of life S E C T I O N 5 5.3 Determine the feasibility of providing all services desired for the 2YL visit and the practical issues of patient flow In low-resource settings, it may not always be possible to have all the services available at the same time and in the same place. For instance, a national level mandate for daily vaccination may not be feasible in a small facility with only one or two health workers providing all services. In situations like this, it is important to communicate widely and mobilize communities to come for services on the specific days that they are offered. At district and facility level, health officials should consider the following questions: • What would be the specific tasks for each type of health worker in providing vaccination, plus other services, during the 2YL visit? What, if anything, will he/she do differently from current practice on a daily, monthly, quarterly, or annual basis? — K E Y R E S O U RC E S Missed Opportunity for Vaccination (MOV) resource guides The WHO strategy for reducing missed opportunities for vaccination (MOV) aims to increase immunization coverage by making better use of existing vaccination sites (at health centres, hospitals, outreach/ mobile services, etc.) In addition to improving coverage, reducing MOV will improve health service delivery and promote synergy between programmes. www.who.int/immunization/ programmes_systems/policies_ strategies/MOV/en/ • What bottlenecks are likely to occur that may result in long waiting times, especially in high-volume facilities? Clinic supervisors should determine how to reduce waiting times. • In situations where all patients first go through the registration clerk prior to accessing services, can this step be used to communicate with parents, answer their questions, and triage children to the different service points? In some instances, it may be possible to provide certain services at the registration or waiting area before mothers or caregivers disperse to other departments. Immunization or other staff may need to be posted to the registration desk on a rotational basis to assist with this step. 40 Establishing and strengthening immunization in the second year of life 5 S E C T I O N 16 MOV assessments conducted in Chad (2015), Timor Leste (2015), and Burkina Faso (2016) indicated a higher proportion of MOVs occurring in the second year of life. • Are all services proposed to be provided during a 2YL visit for vaccination actually offered and available on the same days? Missed opportunities for vaccination and other services arise when not all staff and services are provided at the same time and place. The added complexity of the 2YL visit may require revising the schedule for outreach services, to optimize the use of human resources. • Are policies and practices in place so that all children carry their HBRs and are screened and vaccinated, as appropriate, when they come for any type of care (curative and/or preventive)? Recent country assessments have shown that rates of missed opportunities for vaccination (MOV) are particularly high during visits in the second year of life.16 Therefore, it is important to design and organize services in ways that encourage coordination across different health interventions. Assessment findings further indicate that only 1-2 visits for preventive care take place during the second year of life, so there is an even greater need to capitalize on these opportunities. If a country has conducted an MOV assessment, the findings should be incorporated into planning to better organize services. Policies should be put in place to ensure that all children carry their HBRs and are screened and vaccinated, if needed, when they come for any type of health service. © W H O 41 Establishing and strengthening immunization in the second year of life Supply chain management for vaccines and other commodities 6 SECTION 42 Establishing and strengthening immunization in the second year of life 6 S E C T I O N 6.1 Commodities needed for vaccination and other services in the second year of life Planners should review all supplies required for the 2YL visit, both for vaccination and other services. Any adjustments needed for forecasting, distribution, and storage should be identified and addressed to ensure that all commodities are available at each service delivery point. Table 3 presents an illustrative example based on the package of services adopted in Zambia. Countries can adapt this to correspond to the package of services that they intend to include in their 2YL healthy child visit. TA B L E 3. I N T E RV E N T I O N S A N D C O M M O D I T I E S FO R VAC C I N AT I O N A N D OT H E R S E RV I C E S I N A S C H E D U L E D 2 Y L V I S I T (illustrative example) S E RV I C E / I N T E RV E N T I O N C O M M O D I T I E S N E E D E D ST E P S TO P R E PA R E FO R 2 Y L V I S I T Vaccine dose recommended in the 2YL (MCV2, MenA, DPT4/Penta booster) • Vaccine • Diluent • Needles and syringes • Safety boxes • Updated data management tools • Forecast additional quantities of vaccine needed, if any • Assess needs for additional cold storage capacity • Forecast additional quantities of needles and syringes needed • Estimate additional safety boxes needed • Review and address increased needs for waste management • Update recording and reporting tools Catch-up of other vaccinations missed in the first year of life • Vaccine • Diluent • Needles and syringes • Safety boxes • Updated data management tools • Forecast additional quantities of vaccine, if needed • Assess needs for additional cold storage capacity • Forecast additional quantities of needles and syringes needed • Estimate additional safety boxes needed • Review and address increased needs for waste management • Ensure data management tools allow for recording/reporting “late” doses 43 Establishing and strengthening immunization in the second year of life S E C T I O N 6 S E RV I C E / I N T E RV E N T I O N C O M M O D I T I E S N E E D E D ST E P S TO P R E PA R E FO R 2 Y L V I S I T Vitamin A supplementation • 200 000 IU capsules of Vitamin A • Clippers/scissors • Data management tools • Forecast quantities needed for vitamin A to be provided through routine 2YL visit. This may represent a change in service delivery strategy (if previously provided through semi-annual Child Health Days, for example) • Review quantities provided in essential drug kits to determine whether they are sufficient to meet needs for routine services • As needed, address gaps between forecasted needs and quantities available through essential drug kits Deworming treatment • Deworming medication • Data management tools • Forecast quantities needed for deworming treatment to be provided through routine 2YL visit • Compare with quantities provided in essential drug kits to determine whether they are sufficient to meet needs for routine services • As needed, address gaps between forecasted needs and quantities available through essential drug kits Growth monitoring and promotion • Weighing scales • Middle upper arm circumference (MUAC) tapes • Counselling materials • Growth record, if separate from HBR • Data management tools • Review availability for all supplies and materials at service delivery point based on estimated levels of utilization and attendance during second year of life Follow-up on early infant diagnosis of HIV/AIDS • Data management tools • Counselling materials • Review whether additional quantities of medications such as cotrimoxazole are needed as part of follow-up steps 17 In general, additional quantities may not be required as these are “delayed vaccinations” of children already accounted for in vaccine forecast of previous year, not additional doses. However, to cover wastage at field level, countries may consider extra doses for catch-up based on previous years’ coverages. 44 Establishing and strengthening immunization in the second year of life 6 S E C T I O N Depending on which interventions countries choose to provide along with immunization in the 2YL, other potential commodities to consider may include: • preventive zinc supplementation or zinc use in diarrhoea management18 • multiple micronutrient powders • treatments for severe acute malnutrition • iron supplements • insecticide-treated bed nets (ITNs) In some countries, commodities such as vitamin A supplementation and deworming medication are provided primarily through campaign-style activities, such as semi-annual Child Health Days or weeks that have their own supply chains, which operate independently of those for routine services. If countries decide to 18 www.who.int/elena/titles/zinc_diarrhoea/en/ 19 www.who.int/nutrition/publications/micronutrients/guidelines/vas_6to59_months/en/ 20 www.who.int/neglected_diseases/preventive_chemotherapy/9789241547109/en/ © U N IC EF/U N I12580 0/N esbitt shift to providing them through an integrated 2YL visit, then they must ensure that there are sufficient quantities at all service delivery points for routine delivery. In countries where these commodities are provided to health facilities as part of essential drug kits, determine whether the kits provide sufficient quantities to meet the needs of 2YL visits. Countries can consult their existing programme guidelines and standards or global references including the WHO guidelines Vitamin A supplementation in infants and children 6–59 months of age19 and Preventive chemotherapy in human helminthiasis. Coordinated use of anthelminthic drugs in control interventions: a manual for health professionals and programme managers.20 45 Establishing and strengthening immunization in the second year of life S E C T I O N 6 6.2 Vaccines and vaccination supplies in the second year of life 21 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ — K E Y R E S O U RC E Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring This resource outlines the key principles and issues to be considered when introducing a new vaccine into a national immunization programme, and includes references and tools/checklists for planning, implementation, and monitoring. Importantly, this guide also highlights the ways to use the opportunity of adding a new vaccine to strengthen immunization and health systems. www.who.int/immunization/ programmes_systems/policies_ strategies/vaccine_intro_ resources/nvi_guidelines/en/ Principles and considerations for adding a vaccine to a national immunization programme FROM DECISION TO IMPLEMENTATION AND MONITORING In forecasting requirements for vaccination in the second year of life, the target population is surviving infants from the previous year’s birth cohort. For example, if MenA is scheduled to be given to children at 18 months, then the target group for forecasting purposes for the current year is the number of surviving infants from the previous year. As noted in Box 1, timely vaccination during a 2YL visit is highly desirable, but the age of 24 months should not be viewed as a cut-off point after which children are denied vaccination. The practical implications for forecasting are that it should be based on the cohort aged 12-23 months. If children are vaccinated later than 23 months, it does not affect the number of doses required, just the age at which they actually receive these doses. While the doses should be accurately recorded and reported on tally sheets and monthly reports according to actual age of vaccination, this should not affect stock management practices. Introducing a new vaccine If an entirely new vaccine (for example, MenA) is to be introduced into the routine immunization schedule in the second year of life, then country planners should consult the WHO document Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring. Sections 3.4 and 3.5 contain an in-depth discussion of vaccine management and forecasting.21 The specific modifications to vaccine supply chain management will depend on the characteristics of the new vaccine being introduced. 46 Establishing and strengthening immunization in the second year of life 6 S E C T I O N Adding another dose of a vaccine that is already in the schedule If the 2YL visit will include provision of an additional or booster dose of a vaccine already in the national schedule, the preparations necessary will also depend on the vaccine(s) in question. The introduction of a second dose of measles or MR vaccine in 10-dose vials has been estimated to require a 15-25% increase in cold chain storage space. The need for additional vaccine doses is offset to some extent by an expected reduction in the wastage rate for vaccines in 10-dose vials because, due to the larger target population, more doses will be used per vial. It has been estimated that the measles wastage rate could be reduced by 40% with the switch from a one-dose schedule to a two-dose schedule.22 Programme managers and logisticians also need to monitor and revise the wastage rate and wastage factor for measles-containing vaccine based on any changes in policies, or actual practices, regarding circumstances for health workers to open multi-dose vials of these vaccines. With additional training or skills reinforcement, it should become standard practice for health workers to open 10-dose vials when only one or two children are brought to an immunization session. This practice would improve timely immunization, 22 A guide to introducing a second dose of measles vaccine into routine immunization schedules. Geneva: World Health Organization; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) pp. 21–22. — K E Y R E S O U RC E A guide to introducing a second dose of measles vaccine into routine immunization schedules This resource provides guidance to support policy discussions and operational aspects of the introduction of a second dose of measles vaccine into the routine immunization schedule. It provides useful direction on issues specific to vaccinating in the second year of life, including vaccine forecasting, communications, and data monitoring. http://www.who.int/im- munization/documents/WHO_ IVB_13.03/en/ A Guide to Introducing a Second Dose of Measles Vaccine into Routine Immunization Schedules which is an important programme priority, particularly for measles. However, it could potentially increase wastage rates. With regard to introducing DTP4, the effect on supply chain management is determined by the vaccine product to be used. For example, if a country that uses pentavalent vaccine for infant vaccination plans to provide DTP4 using DTP only, then the situation is similar to adding a new vaccine to the cold chain. If the country 47 Establishing and strengthening immunization in the second year of life S E C T I O N 6 decides instead to provide DTP4 in the form of an additional dose of pentavalent vaccine, then the additional cold storage requirements may be minimized and, programmatically, it will be easier to manage supplies. Using pentavalent vaccine means that additional doses of hepatitis B and Haemophilus influenzae type B (Hib), though not harmful, will be provided without any necessity. This is a decision that will need to be weighed by the country programme. Catch-up vaccination for doses missed in the first year of life Many countries already account for some catch-up vaccination using existing supplies. With the introduction of a 2YL platform and strengthened policies for catch-up vaccination, it is possible that vaccine and logistics requirements will increase in the short term; therefore, managers should monitor trends in vaccine consumption so that they can adjust their vaccine forecasts accordingly. The potential impact on vaccine and cold chain management of catch-up vaccination can be estimated based on a combination of factors, including past trend data on immunization in children over one year of age, the expected number of doses of each vaccine to be given after one year, and whether the vaccine vials in question can be used on subsequent days after being opened, as per the multi-dose vial policy.23 Other commodities for vaccination Increased quantities of needles, syringes and safety boxes are required to accommodate the additional vaccinations to be provided in the second year. Section 3.5 of Principles and considerations for adding a vaccine to a national immunization programme. From decision to implementation and monitoring provides detailed guidance on this topic.24 The quantities of these supplies needed will depend on the estimated coverage for each dose of each vaccine and this is likely to change over time. In some countries, the MCV1 to MCV2 drop-out rate was initially high but then fell within a few years, whereas in others, high drop-out rates have persisted. Programme managers and logisticians should monitor actual patterns of coverage and vaccine consumption each year, and adjust their targets and forecasts accordingly. 23 WHO Policy Statement: Multi-dose vial policy (MDVP), Revision 2014. Geneva: World Health Organization; 2014 (www.who.int/immunization/documents/general/WHO_IVB_14.07/en/). 24 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ 48 Establishing and strengthening immunization in the second year of life 7 SECTION Recording, reporting, and using data for decision-making 49 Establishing and strengthening immunization in the second year of life S E C T I O N 7 The recording, reporting, and use of data at all levels can be the most complex aspect of introducing vaccination in the second year of life. The target groups to be vaccinated, or provided with other services, must be clearly defined and appropriate denominators used to calculate coverage in these target groups. To determine the data requirement, decisions must be made about the types of information and indicators to be used to monitor performance and guide action. Data recording and reporting instruments need to be revised carefully and with input from end-users to ensure that they promote correct screening for eligibility, service provision, and recording and reporting practices by health personnel. This section examines the following topics: 1. PERFORMANCE INDICATORS. Programmes must decide how to monitor introduction and performance and how indicators will be used to guide activities and decision-making. They must also consider alternative ways of obtaining programme data such as through population- based coverage surveys or knowledge- attitude-practice (KAP) surveys. 2. DATA REQUIREMENTS. Once performance indicators are known, data requirements for generating the indicators can be defined. 3. UPDATING DATA FORMS AND SYSTEMS. This includes all recording, reporting, and monitoring tools. © U N IC EF/U N 0 26564/Parry 50 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.1 Performance indicators A core principle in deciding which changes to make to data management tools and procedures is that only those data that are likely to be used should be collected. Countries should be aware that there are certain global immunization indicators that must be reported on a regular basis. However, other data needs may vary across countries, depending on programme priorities and problems. Table 4 presents immunization indicators relevant to establishing or strengthening a 2YL visit. Measuring 2YL indicators requires recording and tallying doses administered by the age of administration. In settings where vaccination is known to happen late and improving timeliness is a priority, tally sheets can be disaggregated to three age groups: 0-11 months, 12-23 months, and >24 months. This will enable the programme to monitor whether timeliness improves over time. A country with a strong record of timely vaccination may not see this as important and may prefer that their tally sheets have only two age groups: 0-11 months, and >12 months. To avoid overloading health workers with reporting requirements, countries should carefully consider what, if any, additional data will be needed for 2YL indicators and take the opportunity to review, and possibly remove, indicators not currently used. On this basis, countries need to decide which data to collect administratively each year, from all vaccine service delivery points and which data to collect less frequently through population-based coverage surveys such as Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), or KAP studies. It is important to differentiate between data collected through each of these methods. Population-based coverage surveys for routine immunization must be adapted to capture data for all doses administered. The WHO Vaccination Coverage Cluster Surveys: Reference Manual (2017)25 provides guidance on defining the target populations to be surveyed if immunization extends beyond one year of age. For coverage of vaccines recommended between 12–23 months of age (for example, MCV2, DTP4), the Reference manual suggests surveying children aged 24–35 months of age in addition to those 12–23 months usually surveyed for vaccines recommended <12 months. Monitoring drop-out from MCV1 to MCV2 MCV1 to MCV2 drop-out should be monitored at national, subnational and facility level based on monthly summary reports. Monitoring charts are also encouraged at facility level. This is complicated by the fact that the doses are scheduled to be 25 www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index2.html 51 Establishing and strengthening immunization in the second year of life S E C T I O N 7 26 A guide to introducing a second dose of measles vaccine into routine immunization schedules. Geneva: World Health Organization; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) Annex 6, p.16. given to two different birth cohorts; however, in reality, the actual difference in size between cohorts for two consecutive years is very small so, for the purpose of calculating the drop-out, the same denominator should be used for calculating coverage of both doses. The recommended denominator to use is surviving infants for the cohort receiving MCV1.26 A sample coverage monitoring chart including MCV1-MCV2 drop-out is included in Annex 2. Monitoring if all interventions to be provided during a scheduled 2YL visit are provided The 2YL visit is an opportunity to provide multiple services to the same child, encouraging greater use of services during a vulnerable age. It is important to have in place a system for monitoring uptake of all interventions provided during the 2YL visit. For example, if performance for immunization is higher than that for other services, it could flag obstacles to delivery and could help managers to identify specific problems and explore solutions. If all services to be provided during the 2YL visit were recorded in the same register, then facility heads and supervisors can perform regular spot checks to assess the extent to which children coming for the 2YL visit receive all of them. On the other hand, recording multiple services in the same place can result in a large unwieldy register that can quickly become impractical. The feasibility of these recording practices should be discussed and tested with health workers. Uptake of integrated interventions can also be monitored through facility visits, surveys and exit interviews. Determining fully immunized child (FIC) The addition of new vaccines and new doses of existing vaccines in the second year of life adds complexity to the health worker’s task of using administrative data to determine a FIC according to age and the country’s immunization schedule. FIC, as an indicator, must be specific to the age of the child and the corresponding set of vaccines that the child should have received by that age, as per the national schedule. It is increasingly the case that a child should receive 15 or more doses of vaccines in the first 15-18 months of life. This increases the amount of time the health worker needs to review the child health card or go through all entries in the register to determine if the child is fully vaccinated. One option is to split the indicator into two or more categories (FIC<12 months, FIC<24 months). Alternatively, programmes may opt not to include FIC in the tally sheets, but rather monitor the indicator(s) through periodic vaccination coverage surveys. 52 Establishing and strengthening immunization in the second year of life 7 S E C T I O N TA B L E 4. SU M M A RY O F I M M U N I Z AT I O N I N D I CATO RS R E L AT E D TO 2 Y L I N D I CATO R RECOMMENDATION I N T E R P R E TAT I O N P OT E N T I A L ACT I O N S I F LOW P E R FO R M A N C E DATA S O U RC E C OV E R AG E ‘Total MCV2’ MCV2 given anytime (timely plus late) Core indicator Proportiona of children vaccinated with at least two routine doses of measles-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of two doses of measles-containing vaccines, or improving defaulter tracing. Administrative data or population-based survey ‘Total DTP4’ Fourth dose of DTP-containing vac- cine given anytime (timely plus late) Core indicator Proportiona of children who received a booster dose of DTP-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of a booster dose, or improving defaulter tracing. Administrative data or population-based survey Doses of other vaccines scheduled to be given after one year of age (e.g. MenA) Core indicator Proportiona of children who received the indicated doses in the vaccination schedule after 12 months Analyse reasons for low performance. Depending on reasons identified, possible actions may include ensuring an adequate supply of vaccine, strengthening health worker skills, and conducting communication or social mobilization activities to promote the demand for, and use of, these vaccines. Administrative data or population-based survey Fully Immunized Child (FIC) by 24 months Optional unless source of data is a population-based survey Proportion of children vaccinated, in a timely manner, with all doses of all vaccines that are in the national immunization schedule to be given by the age of <24 months Review reasons and take actions. If indicated, work to change paradigm of EPI as an infant programme to one that reaches multiple birth cohorts. Actions may include strengthening health worker knowledge and skills through training, supervision, and feedback; strengthening defaulter tracing; improving data reporting, and increasing communication and social mobilization directed at health workers, communities, families, and caregivers. Population-based surveys Other health interventions, e.g., vitamin A supplementation at ages scheduled in country programme Consult relevant pro- gramme for guidance Check with relevant health programmes for interpretation Seek input from other programmes to analyse reasons for low performance and appropriate actions to take. Seek guidance from the relevant programmes T I M E L I N E S S ‘Late DTP3’ DTP3 after 12 months Optional indicator Captures number of children who complete their primary DTP-containing vaccine series late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Implement better recall/reminder systems to timely track potential defaulters. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey ‘Late MCV1’ MCV1 after 12 monthsb Core indicator Captures number of children who receive MCV1 late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey D RO P - O U T MCV1-MCV2 drop-out rate Core indicator Describes those who are not coming back for a second dose of a measles- containing vaccine Through supervision, feedback, and training, improve health worker interpersonal communication to remind caregivers to return for second dose; strengthen health worker technical skills as needed; increase defaulter tracing and communication with communities about need for MCV2 Population-based survey or administrative data at national and subnational levels. It may be possible to analyse such data at the facility level. a Denominator should be birth cohort of 12-23 months (i.e. surviving infants), even if data is age-disaggregated into three groups. b This indicator is most useful in countries where MCV1 is recommended to be given at 9 months. In countries where MCV1 is scheduled to be given at 12 months or later it would need to be modified accordingly. 53 Establishing and strengthening immunization in the second year of life S E C T I O N 7 TA B L E 4. SU M M A RY O F I M M U N I Z AT I O N I N D I CATO RS R E L AT E D TO 2 Y L I N D I CATO R RECOMMENDATION I N T E R P R E TAT I O N P OT E N T I A L ACT I O N S I F LOW P E R FO R M A N C E DATA S O U RC E C OV E R AG E ‘Total MCV2’ MCV2 given anytime (timely plus late) Core indicator Proportiona of children vaccinated with at least two routine doses of measles-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of two doses of measles-containing vaccines, or improving defaulter tracing. Administrative data or population-based survey ‘Total DTP4’ Fourth dose of DTP-containing vac- cine given anytime (timely plus late) Core indicator Proportiona of children who received a booster dose of DTP-containing vaccine, including both timely and late doses Analyse reasons for low performance. Depending on reasons identified, possible actions may include strengthening skills of health workers, social mobilization and communication activities on importance of a booster dose, or improving defaulter tracing. Administrative data or population-based survey Doses of other vaccines scheduled to be given after one year of age (e.g. MenA) Core indicator Proportiona of children who received the indicated doses in the vaccination schedule after 12 months Analyse reasons for low performance. Depending on reasons identified, possible actions may include ensuring an adequate supply of vaccine, strengthening health worker skills, and conducting communication or social mobilization activities to promote the demand for, and use of, these vaccines. Administrative data or population-based survey Fully Immunized Child (FIC) by 24 months Optional unless source of data is a population-based survey Proportion of children vaccinated, in a timely manner, with all doses of all vaccines that are in the national immunization schedule to be given by the age of <24 months Review reasons and take actions. If indicated, work to change paradigm of EPI as an infant programme to one that reaches multiple birth cohorts. Actions may include strengthening health worker knowledge and skills through training, supervision, and feedback; strengthening defaulter tracing; improving data reporting, and increasing communication and social mobilization directed at health workers, communities, families, and caregivers. Population-based surveys Other health interventions, e.g., vitamin A supplementation at ages scheduled in country programme Consult relevant pro- gramme for guidance Check with relevant health programmes for interpretation Seek input from other programmes to analyse reasons for low performance and appropriate actions to take. Seek guidance from the relevant programmes T I M E L I N E S S ‘Late DTP3’ DTP3 after 12 months Optional indicator Captures number of children who complete their primary DTP-containing vaccine series late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Implement better recall/reminder systems to timely track potential defaulters. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey ‘Late MCV1’ MCV1 after 12 monthsb Core indicator Captures number of children who receive MCV1 late; in 2YL or later. Measure of 2YL visit used for catch-up Increase communication to families and caregivers about the importance of timely immunization. Administrative data (if data are age-disaggregated and known to be of high quality) or population- based survey D RO P - O U T MCV1-MCV2 drop-out rate Core indicator Describes those who are not coming back for a second dose of a measles- containing vaccine Through supervision, feedback, and training, improve health worker interpersonal communication to remind caregivers to return for second dose; strengthen health worker technical skills as needed; increase defaulter tracing and communication with communities about need for MCV2 Population-based survey or administrative data at national and subnational levels. It may be possible to analyse such data at the facility level. 54 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.2 Data requirements Determining denominators For vaccinations scheduled to be given after the first year of life, the best target is the estimate of surviving infants from the previous year’s birth cohort. Administrative vaccine coverage can then be estimated by dividing the current year’s administered doses (numerator) by the estimated number of surviving children from last year’s birth cohort (denominator). Recording doses administered Vaccine doses should be tallied in at least two age groups (0–11 months, and >12 months) as a minimum standard or, preferably, three age groups (0–11 months, 12–23 months, >24 months) as a best practice. Examples of tally sheets with these two alternative age groupings are shown in Annex 1. The creation of additional subcategories for recording doses, such as service delivery (fixed or outreach), adds to the workload for health workers and increases the potential for mistakes; therefore, disaggregating by extra groupings beyond age must be carefully considered. The ways in which such additional data will be used to guide activities should be clearly identified in order to determine if it actually needs to be collected. If required, separate tally sheets can be used for fixed and outreach sessions, and monthly reporting sheets should have separate rows for fixed and outreach sessions against each antigen. Monitoring health indicators by sex has been recommended by some to ensure equity; however, coverage surveys have shown repeatedly that the child’s gender is FIC, as an indicator, must be specific to the age of the child and the corresponding set of vaccines that the child should have received by that age, as per the national schedule. © U N IC EF/U N 0 59893/Rom eo 55 Establishing and strengthening immunization in the second year of life S E C T I O N 7 27 State of Inequality: Childhood immunization. Geneva: World Health Organization; 2016 www.who.int/gho/health_equity/report_2016_immunization/en/ B OX 3. P RO M OT I N G AC C U R AT E R EC O R D I N G A N D R E P O RT I N G TO I M P ROV E S E RV I C E S Health workers may be reluctant to record doses accurately if they fear that they will be disciplined for documenting practices that are not in accordance with national standards. Proper documentation of actual practices is essential if problems are to be detected and addressed; therefore, accurate recording and reporting must be encouraged and supported. For example, if a first dose of MCV is given after one year of age, it needs to be recorded as the first dose, regardless of the age of the child. If health workers feel pressure to report that they have not exceeded established vaccine wastage rates, they may turn mothers and children away unimmunized if just one or two children show up for MCV or other lyophilized vaccines in multi-dose vials that must be discarded within six hours of reconstitution. Denying these children vaccination on that day is a missed opportunity for vaccination, prolongs exposure to disease and risks losing these children from the system for good. Supervisors have an important role to play in promoting accurate recording and reporting of data and in supporting health workers with decision-making when they face less than ideal circumstances. not a barrier for vaccination.27 Hence, given the added complexity that stratification places on the administrative system, WHO does not recommend tallying doses by sex. Similarly, it is not advisable to try to separate doses given to children within a catchment area versus those outside the catchment area. If concerns exist about inequalities in childhood immunization, by sex or other characteristics, it is recommended that when surveys are implemented, they be powered to detect inequalities or disparities in coverage. Including three age groupings to record doses addresses the common problem of how to record late doses of vaccine. If children come for immunization or other 2YL services at 24 months of age or older, they should not be denied vaccination or other care. Health workers should provide the doses and services and record them on the tally sheet, HBR, child register, and monthly summary report, in the age column that corresponds to the child’s age when the dose or services were actually received. Country field guides should provide clear instructions and scenarios on administering, tallying, recording, and reporting of late doses. 56 Establishing and strengthening immunization in the second year of life 7 S E C T I O N 7.3 Updating forms and health information systems All data collection and reporting instruments should be reviewed and revised, as needed, to accommodate 2YL data requirements. A user-centered approach to the design of data instruments should be used to foster proper screening, vaccination, recording, and reporting of doses. Data recording tools should promote the key concept that full immunization includes doses given in the second year of life or later. As health workers are expected to use HBRs, tally sheets, and registers on a daily basis, the tools should be designed with their input and formally pre-tested to assess how well they are understood and how easy they are to use. These steps will help avert problems in recording data or even in vaccination practices, such as denying vaccination if a child comes late. The pre-test findings should inform the revision of the tools themselves and strengthen training on their proper use. Functionality of current tools should be reviewed, on an ongoing basis, through data quality reviews or assessments,28 in order to eliminate or revise aspects that are not being used properly, or at all. Engage representatives from HMIS and all programmes involved to develop a plan to review and revise the system and to ensure updates are synchronized with the dissemination of paper-based tools, including HBRs. Reporting systems should be examined to eliminate duplication and contradiction among parallel systems (for example, the HMIS and DV-DMT or other vaccination- specific information systems) in order to avoid increased workload and reduce the possibility of health worker confusion. Prepare a plan with budget, timeframe, and secure funding, for revising all data collection and reporting instruments. The plan should designate lead responsibilities, processes for review, timeframe, quantities required, budget, funding source, and a clear dissemination plan. The budget should include the costs for printing sufficient quantities of HBRs and all new forms plus distributing them to all facilities to replace older forms and registers. All new instruments should be ready in time for training of health workers so that they can gain direct experience with using them. If electronic immunization records (EIRs) and other electronic systems are used at health facility level, the changes in 28 For example, the Data Quality Self-assessment (DQS). The DQS is a flexible toolbox of methods used to evaluate different aspects of the immunization monitoring system at district and health facility levels. For details and tools visit: www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index3.html 57 Establishing and strengthening immunization in the second year of life S E C T I O N 7 all aspects of the system must be made in time for training, so that health workers are able to practice using them. Revise all relevant data collection instruments. • HBRs should contain sufficient space for the health worker to record all routine doses of vaccines, their dates of admin- istration, and other services provided during the 2YL visit. HBR design should allow for easy screening by all health workers (including non-immunization staff providing curative care) for doses due. The WHO Practical guide for the design, use and promotion of home-based records in immunization programmes (see Key Resource) provides user-friendly advice for producing high-quality HBRs. • Tally sheets should be designed in a way that guides health workers to accurately record doses administered, disaggregated by age groups, as described above and shown in Annex 1. • Monthly summary reports should capture and summarize all data produced by the tally sheets. For example, if the tally sheet contains space for reporting doses ad- ministered outside the recommended age range, or fixed/outreach sessions, then the monthly summary should also capture this so that health workers do not have to improvise their own solutions. • Registers should include space for additional doses (and possibly other interventions) to be provided in the 2YL visit, and beyond, without restricting the recording of doses to the second year of life. The amount of data to be entered should be determined by how it will be used, time needed to enter the data, cost, and the bulkiness of the registers. It is also crucial that registers, or tickler files, be organized in a manner that facilitates tracking defaulters. — K E Y R E S O U RC E Practical guide for the design, use and promotion of home-based records in immunization programmes HBRs, such as vaccination cards or integrated child health records, should be designed to serve the needs of the health system and promote appropriate health practices among caregivers. They must be made available to all caregivers free of charge, and properly filled in. Health workers should encourage caregivers to safeguard HBRs and retain them for several years. However, they should not punish or deny services to those who have lost or forgotten them, as this could discourage caregivers from returning for immunization or other essential services. Lost or damaged HBRs should be replaced free of charge. www.who.int/immunization/ monitoring_surveillance/ routine/homebasedrecords/en/ FOR THE DESIGN,USE AND PROMOTION OF IN IMMUNIZATION PROGRAMMES PRACTICAL GUIDE HOME-BASED RECORDS 58 Establishing and strengthening immunization in the second year of life 7 S E C T I O N B OX 4. H B RS FO R I M M U N I Z AT I O N A N D OT H E R C H I L D H E A LT H S E RV I C E S With immunization extending into the second year of life and beyond, and more vaccines included in the vaccination schedule, it is increasingly important that all mothers or caregivers have HBRs that document children’s vaccination status and provide key information on immunization and health. Immunization policies and health worker training/ supervision should emphasize the importance of caregivers bringing the child’s HBR to health facilities for every visit to screen for vaccine eligibility at any time that a child has contact with the health system. Some countries have introduced immunization status checks at the time of enrolment in primary education (school registration), and caregivers should be reminded of the importance to save the HBR until the child is enrolled in the education system. As described in Section 8, training and supervision should address unusual circumstances that health workers are likely to encounter that would complicate the ability to record and report doses accurately. Annex 3 provides some sample scenarios for illustrative purposes. © W H O 59 Establishing and strengthening immunization in the second year of life 8 SECTION Health worker training and capacity-building 60 Establishing and strengthening immunization in the second year of life 8 S E C T I O N The success of any health intervention depends on competent front-line health workers and managers. In health worker capacity-building, “competencies” are defined as being comprised of skills, knowledge, and attitudes. For vaccination and other well-child services in the second year of life to be viewed as a priority, health workers’ interpersonal skills, motivations and attitudes need to be addressed in training, supervision, and the feedback they are given. Training is essential for introducing new skills, but must be followed with post-training support to reinforce skills and improve practices on an ongoing basis. Representatives from all programmes involved in a 2YL vaccination visit should contribute to the process of developing the training curriculum. A training workplan, timeline, and budget for developing the training materials should be developed so that there is clear, shared understanding of responsibilities and deadlines for drafting, reviewing, finalizing, and producing the training materials and any supporting materials, such as slides, job aids, materials for exercises, etc. Training, supervision, and other means of post-training support should reinforce policies and standard operating procedures including the core principle that timely vaccination is ideal but (with few exceptions) late vaccination is preferable to no vaccination at all. 8.1 Determine required health worker competencies A key step is to identify the competencies required of all cadres of health personnel involved in vaccination and other health and nutrition interventions in the second year of life and later. A task analysis or learning needs assessment should be conducted to clearly identify which staff are responsible for carrying out specific duties, as noted in Section 5. For a 2YL visit that includes other health services, trainers should identify the expected tasks and required competencies of: • vaccinators; • other health care providers involved in an integrated 2YL visit; • health facility supervisors or in-charges; • community health workers (CHWs); • district- or regional-level staff responsible for immunization, child health, logistics management, data management, and advocacy, communication, community engagement and social mobilization. 61 Establishing and strengthening immunization in the second year of life S E C T I O N 8 One way to approach this is to list the specific changes to health worker responsibilities on a daily, weekly, monthly, and annual basis, that result from introducing vaccination after one year of age. B OX 5. H E A LT H WO R K E R C O M P E T E N C I E S FO R 2 Y L VAC C I N AT I O N Training and capacity-building for 2YL vaccination must ensure that health workers can correctly carry out the following tasks. 1. Prepare microplans and forecast commodity needs for reaching an additional cohort based on a correct estimate of the target population.29 2. Screen children properly to determine any vaccine doses needed. This requires knowledge of the immunization schedule (including whether there is an upper age limit for any vaccines or doses), the minimum interval between doses, what to do in case of late or interrupted vaccinations, how to screen for eligibility if the child lacks a HBR, and whether a child who has come for curative care can be vaccinated. 3. Communicate clearly with caregivers as follows: • When caregivers bring their children for vaccination in the first year of life, particularly for MCV1, explain the reasons and benefits for returning for vaccination and other services in the 2YL. Clearly inform caregivers of when they should return and indicate this on the HBR. • During the 2YL visit, thank the caregiver for coming and provide standard information on the vaccines received, including the fact that receiving simultaneous injections is safe, and address caregiver concerns about side-effects. 4. Provide child with other services during the 2YL visit, such as growth monitoring and promotion, vitamin A supplementation, and deworming medication, as per national policy. 5. Record and report the doses administered during the 2YL visit on tally sheets, HBRs, child registers, and monthly summary reports. 6. Identify and trace defaulters so that they complete the vaccination schedule. This may entail managing and supporting CHWs. 7. Review the facility’s data to assess performance and problem-solve to address issues related to 2YL vaccination that need attention. 29 For information and tools for effective micro-planning, see Chapter 3 of Reaching Every District (RED): A guide to increasing coverage and equity in all communities in the African Region, 2017 revision, available at: www.afro.who.int/publications/reaching-every-district-red-guide-increasing-coverage-and-equity-all-communities 62 Establishing and strengthening immunization in the second year of life 8 S E C T I O N 8.2 Prepare the training curriculum Much of the technical content on proper administration of vaccines and the provision of other well-child services is already available in existing training materials. It can be adapted and updated as needed for 2YL training. The curricula for other programmes that may be integrated with 2YL vaccination, such as nutrition and child health, should also be reviewed and updated as needed. New training content should be developed for the 2YL-specific competencies noted above. These competencies serve as the basis for defining the learning objectives for the training curriculum. The learning objectives help to focus the training on the “must know” as opposed to “nice-to-know” content. Learning objectives are also a useful basis for meaningful pre- and post-test questions. The use of well-designed pre- and post-tests based on the learning objectives serves two purposes. First, they give information on the effectiveness of the training itself and can therefore help identify ways to strengthen it. Second, they identify areas of limited understanding. This information can then be used to focus post-training support through supervision, feedback, on-the-job training, and other means. The learning objectives for training in the Republic of Senegal, shown below, address the introduction of a second dose of measles-rubella vaccine. For a 2YL visit with multiple interventions, the learning objectives for such a training would need to reflect the competencies described above, as well as for other services to be provided during the 2YL visit. The success of any health intervention depends on competent front-line health workers and managers. © W H O M aldives 63 Establishing and strengthening immunization in the second year of life S E C T I O N 8 L E A R N I N G O B J ECT I V E S F RO M S E N EGA L FO R T R A I N I N G O N I N T RO D U C I N G A S EC O N D D OS E O F M E AS L E S - RU B E L L A VAC C I N E ( M R 2 ) The training curriculum for the introduction of MR2 in Senegal outlined clear learning objectives. By the end of training, health workers will be able to do the following. • Describe the new vaccination schedule for providing MR2. • Identify the target group for MR2 vaccination. • Correctly estimate MR vaccine needs taking into account MR2. • Correctly fill out all management tools, including the child register, tally sheet, monthly report, stock management record, and vaccination card. • Cite at least three benefits of providing MR2. • Explain to parents at least two reasons why they should retain the vaccination card and return for MR2. • Cite the number of vaccination contacts that a child needs to be fully vaccinated. • Describe at least four tasks for community mobilizers to carry out to support MR2. C O U N T RY E X P E R I E N C E When preparing the training curriculum, it is important to incorporate the use of adult learning methods. Examples of these methods are provided in the Box 6 below. B OX 6. E F F ECT I V E L E A R N I N G M E T H O DS Effective learning in adults occurs when the content is clearly relevant to the learner’s own experience, has immediate application, and clearly serves a practical purpose. Whenever possible, interactive methods that permit the practice of skills should be used. For the 2YL visit, useful interactive methods can include: • skills practice for interpersonal communication, including responding accurately to questions in a manner that fosters trust • hypothetical scenarios for screening, administration, recording, and reporting of doses (several examples for 2YL immunization are shown in Annex 3). • case studies and problem-solving for situations with low coverage of 2YL doses. 64 Establishing and strengthening immunization in the second year of life 8 S E C T I O N Experience with MCV2 vaccination in several countries has shown that screening, recording and reporting doses in the second year of life or later can be challenging because health workers face a wide variety of situations that do not correspond exactly to the vaccination schedule. Health workers need clear guidance on such points as: • how to record a first dose of MCV that is given after 12 months (in a country that recommends MCV1 at nine months of age); • what to do when a mother brings the child for the 2YL visit after 23 months; • the minimum interval between doses; and • how to implement strategies to reduce pain from multiple injections.30 Annex 3 presents several scenarios that health workers may encounter and suggests how they can be addressed directly during training. Annex 4 provides an example of a job aid to assist health workers to determine the vaccines for which a child is eligible. Training also provides an opportunity to address known areas of weak performance. For example, it can be used to promote the practice of opening a vial to provide MCV even if only one or two children come for an immunization session. District- level supervisors must support this principle if front-line health workers are to carry out this practice successfully. 30 Reducing pain at the time of vaccination. Position paper. Geneva: World Health Organization; 2015 (www.who.int/wer/2015/wer9039.pdf). © U N IC EF/U N 0 125857/Sharm a 65 Establishing and strengthening immunization in the second year of life S E C T I O N 8 8.3 Plan the training strategy Planners should develop a training strategy for building the skills of health workers, their direct supervisors, district health teams, and trainers. Several points should be addressed: Identify who will conduct the training sessions and provide them with thorough orientation on both the technical content and how to train others. Prepare a detailed training schedule. Work backwards from the anticipated date for launching 2YL vaccination and take into consideration any other concurrent events, such as holidays, elections, or vaccination campaigns that may cause delays. If other new vaccine introductions are planned to take place in the same timeframe, it may be possible to combine this with the 2YL training to improve efficiency. Time the training so that front-line health workers receive it two to three weeks before the 2YL launch takes place. Ensure that printing and/or electronic distribution of updated data collection tools are available to be used for skills practice during the training. Print and disseminate other key materials, such as technical guidelines or operational field guides, job aids, behaviour change communication materials (see Section 9) and training reference materials, for participants to share with other staff at their facility. For longer term, ensure that information is incorporated into pre-service and continuing education curricula. Cascade training is often used to reach large numbers of health personnel in a short period of time. However, the quality of training is known to erode and become more variable with each level of cascade; hence, it is best to limit the number of cascade levels to two or three at a maximum. If a cascade strategy is used, the following tips can help maintain the quality of training. • Use the “teach-back” method during the training of trainers (TOT). In this method, a portion of the TOT time is spent having some participants practice their skills by simulating a training of other participants, and vice versa. • Produce hypothetical scenarios for simulations, with mock history and mock HBRs, during interactive training sessions. If health workers use handheld EIR 66 Establishing and strengthening immunization in the second year of life 8 S E C T I O N devices, conduct real-life simulations of recording data with the devices and review the records together with participants. • Include some higher-level trainers in the training sessions at the lower levels. • Use post-test results of earlier training sessions to adapt and improve the training for later sessions. • Produce interactive DVDs to use at all levels of the cascade to ensure that the most complex content is addressed in a standardized way. For the 2YL visit, this would include screening and recording and reporting of vaccine doses given to children over the age of one year. The possible use of DVDs requires first assessing whether appropriate equipment for using them is available at all levels. • Work with instructional designers to ensure that the teaching methods are appropriate for training adults. 8.4 Provide supportive supervision and other forms of post-training support A single training session is often insufficient to bring about mastery of new and complex subject matter. Post-training support is needed to strengthen skills and practices, both to reinforce content introduced during training and to orient new staff or those who were unable to attend the training. Supportive supervision is a standard, essential method for reinforcing skills. However, it requires both reliable funding and transportation, which can be lacking in many settings. The planning for a 2YL vaccination visit is an opportunity to highlight the importance of supportive supervision and advocate for adequate levels of funding. Prepare an integrated supportive supervision visit checklist for the 2YL visit. Countries can adapt their existing supportive supervision checklists to include specific 2YL questions. These questions can also be asked during informal on-the- job training: Are 2YL guidelines, job aids, and revised data management instruments, including HBRs, available at the facility? Is the MCV1-MCV2 drop-out rate being monitored? If yes, how much higher is the MCV1-MCV2 drop-out rate compared to that for Penta1- Penta3, PCV1-PCV3, or rotavirus1-rotavirus last dose? 67 Establishing and strengthening immunization in the second year of life S E C T I O N 8 If children come for the 2YL visit later than the target age, how do health workers respond? Do these children receive vaccinations? Which ones? How are the doses recorded and reported? Is the provision of immunization coordinated with other services or are there missed opportunities for doing so? In what ways do CHWs identify and mobilize parents to bring their children for the 2YL visit? Are there sufficient supplies of all commodities needed for the 2YL visit? Supervisors should provide written feedback that remains at the facility for future reference. Additional types of post-training support may take the following forms. Prepare a job aid to guide health workers to screen and vaccinate children that have missed doses, are late with vaccinations, or who do not have a vaccination card. A flow chart or algorithm may be useful for this purpose. Figure 3 provides an example of a decision-making flow chart adapted from Ghana. The job aid might also include key messages to assist in responding to common questions or con- cerns from caregivers or community members. See Annex 4 for another sample job aid to guide health workers to determine a child’s eligibility for vaccination. Develop a poster or job aid on patient flow to remind all health workers in the facility, as well as parents and caregivers, how services should be organized during the 2YL visit. The job aid should particularly emphasize referral between different departments. Prepare a list of frequently asked questions (FAQ) so that health workers are capable and confident to respond to a variety of questions and situations. Annex 5 contains an example of a FAQ list that countries can adapt. Plan for refresher training to take place one to two years following initial training. Provide health workers with a support phone number (e.g. to a supervisor or a hotline) and encourage them to call and check if they are unsure how to vaccinate a child or record a vaccination. Explore alternative means of post-training support. Depending upon country circumstances, these could include: • peer exchanges or quarterly review meetings; 68 Establishing and strengthening immunization in the second year of life 8 S E C T I O N • a hotline that health workers can use to consult experts when they have questions; • reminder SMS texts or other mobile messages sent to health workers’ phones to reinforce practices. Text messages can also be used to provide recognition for correct and timely recording and reporting of data; • in settings where health workers have high access to smart phones, a WhatsApp group or similar chat application can provide peer-to-peer and regular supervisory support. F I G U R E 3. E X A M P L E F RO M G H A N A O F A N A LG O R I T H M FO R D E T E R M I N I N G E L I G I B I L I T Y FO R M E N I N G I T I S A A N D M E AS L E S - RU B E L L A VAC C I N E Algorithm for Measles-Rubella (MR) and Men A administration Check Child Health Record Book/Weight Card Give any missed vaccines and Vitamin A Counsel to return at date of appropriate age for next due vaccine(s) Counsel to return for Child Care Welfare Clinic at appropriate age ASSESS AGE OF CHILD Child is less than 9 months Do not give MR1 Do not give MR2 Has the child received MR1? Has the child received MR2 Give Men A Give MR2 Has the child received Men A Child is less than 18 months Child is 18 months or more Give MR1 Child is 9 months or more NOYES NOYESNOYES 69 Establishing and strengthening immunization in the second year of life S E C T I O N 8 B OX 7. D E T E R M I N I N G E L I G I B I L I T Y FO R M CV 2 WHO recommends that, where risk of measles mortality among infants remains high, MCV2 should be administered at 15–18 months, with a minimum interval of four weeks after MCV1. In settings where utilization of health services drops considerably after the first year, ensuring caregivers bring their babies for the second dose at 18 months, for example, is challenging and the risk of drop-outs can be quite high. An alternative approach in these cases may be to stipulate that if a child presents any time between 12 and 18 months, it is better to vaccinate with MCV2 immediately, rather than hoping that they will return again at 18 months. From an immunological perspective, as long as 4 weeks has elapsed their first dose, and they are in the 2YL, then a child is already technically eligible for MCV2. Understandably however, this may cause confusion for health workers, and a policy based on interval rather than strict adherence to a schedule may not work in all settings. Ultimately it rests with the programme to set a policy on this and ensure the proper training and tools are available to health workers to make these decisions. Strategies to reduce drop-outs and ensure that the child returns at 18 months include: 1) providing counselling to caregivers, emphasizing the importance of MCV2 and the time to return; 2) active follow-up through a call or home visit with the caregiver to remind them about the visit; 3) in some settings, providing vaccinations at their home if they do not return at 18 months or soon after. 70 Establishing and strengthening immunization in the second year of life Communication, demand promotion, and community engagement 9 SECTION 71 Establishing and strengthening immunization in the second year of life S E C T I O N 9 Communication is an important factor for the success of vaccination in the second year of life and beyond. A comprehensive, but targeted, communication strategy that is fully costed and implemented, including a high visibility launch and ongoing community engagement activities, is key to promoting demand for, and generating utilization of, 2YL vaccination and other services. To succeed in building and maintaining confidence in immunization requires a mix of approaches that focus on building knowledge and awareness, but also take into consideration the individual, social, and structural/political dynamics that shape vaccination behaviours. Table 5 provides the key elements of a 2YL behaviour change strategy to build acceptance and uptake. It lists target groups, key areas of knowledge, and desired actions to be promoted through communication, community engagement, and other coordinated programme interventions. This information serves as the basis for deciding which materials, messages, and activities are required to promote demand for, and utilization of, 2YL services. TA B L E 5. E L E M E N TS O F T H E 2 Y L B E H AV I O U R C H A N G E C O M M U N I CAT I O N F R A M E WO R K TA RG E T G RO U P K E Y A R E AS O F K N OW L E D G E D E S I R E D ACT I O N S Caregivers and families • The importance of vaccination and benefits of vaccines for preventing disease/death • Vaccination continues into the 2YL • Reasons why 2YL vaccination and other well-child care beyond one year of age are important • Timing for scheduled 2YL visits • Importance of safekeeping the HBRs until child starts school and beyond • Take children for the 2YL vaccination and other well-child services • Keep the HBR and bring it to every health contact Health workers • Vaccination and other services to be provided in a 2YL visit; 2YL as opportunity for catch-up vaccination • Why 2YL vaccination is important for child health • How and when to provide and record vaccinations • How and when to communicate with caregivers about 2YL services, particularly during the MCV1 visit (see Section 8) • How to promote 2YL services to the community • Communicate with care- givers in the first year of life to encourage them to come for 2YL visit and retain HBR • Communicate key informa- tion during the 2YL visit • Correctly screen, provide services, record, and report data • Engage their communities to help encourage 2YL visits 72 Establishing and strengthening immunization in the second year of life 9 S E C T I O N TA RG E T G RO U P K E Y A R E AS O F K N OW L E D G E D E S I R E D ACT I O N S District-level managers and supervisors to health workers • Review data and identify gaps in the knowledge and skills of health workers • Provide feedback and technical support to health workers and motivate them on the importance of 2YL vaccination and other services • Support health workers in providing high-quality services Community health workers • The importance of 2YL vaccination and the age to bring child for a scheduled visit • How to trace defaulters for 2YL vaccination • Other services provided during 2YL visit • Provide key information on importance of 2YL visit and when to bring child • Mobilize families to bring their children • Trace defaulters Community lead- ers and politicians (chiefs, parliamen- tarians, councilors, civil authorities, religious leaders) • The importance of 2YL vaccination and the age to bring child for a scheduled visit • Other services provided during 2YL visit • When and where 2YL services are offered • Immunization is free-of-charge • Encourage families to bring their children for 2YL services • Communicate on the importance of vaccination The media • The importance of vaccination and other child health services during infancy and into the second year of life • When and where 2YL services are offered • Immunization is free-of-charge • Provide coverage on the launch of the 2YL visit • Provide accurate, timely information to the public to encourage vaccination and the use of 2YL services Professional and medical associa- tions • Current science and policy considerations to inform the development of policies and practices with regard to 2YL visit • Contribute to development of policies, guidelines and materials • Promote proper practice among constituents • Provide support to community leaders in reinforcing the importance of vaccination Teachers, counsellors, pre-school/ day-care providers • The importance of 2YL vaccination and other services beyond one year of age • Immunization is free-of-charge • Encourage families to bring their children for 2YL services 73 Establishing and strengthening immunization in the second year of life S E C T I O N 9 The broad steps needed to plan for promoting or increasing demand for 2YL vaccination and other services are shown in Figure 4, and described in the sections below. F I G U R E 4. D E M A N D A N D P RO M OT I O N P L A N N I N G CYC L E These steps are elaborated throughout the following sections. ST E P DATA C O L L ECT I O N A N D A N A LYS I S ST E P ST R AT EG I C D E S I G N A N D P L A N N I N G ST E P D E V E LO P M E N T A N D T E ST I N G O F M E S SAG E S A N D M AT E R I A L S ST E P I M P L E M E N TAT I O N A N D M O N I TO R I N G ST E P E VA LUAT I O N A N D R E- P L A N N I N G 1 2 5 4 3 ©W HO Bhu tan 74 Establishing and strengthening immunization in the second year of life 9 S E C T I O N 9.1 Data collection and analysis: understanding your target groups Communication plan and working group A multi-partner communications working group should be convened (or reconvened, if it already exists for the immunization programme in general) to develop a demand promotion plan for 2YL vaccination. Though the plan should address the unique features and challenges of 2YL vaccination, it should also be aligned and linked with the overall communication plan for the national immunization programme. This will help ensure that communication activities, messages and targeting are harmonized and support the strengthening of routine immunization. The working group should coordinate closely with others planning the aspects of 2YL to ensure that their work is mutually reinforcing and technically consistent. The 2YL communication plan should agree on the key audiences and stakeholders, communication needs and desired actions by each group, tailoring it from Table 5, as needed. This information serves as the basis for deciding which materials, messages, and activities are needed to promote uptake of 2YL services, and accordingly which data and background information is necessary to shape these efforts. Data collection and analysis Initial data collection and analysis is essential to understand the reasons why different target groups would, or would not, carry out the desired actions in Table 5. A situation analysis and a behavioural analysis (for example, a Knowledge, Attitudes, and Practices (KAP) study, or other similar research activity) can together identify the barriers that need to be addressed and the factors that promote the desired intentions © W H O 75 Establishing and strengthening immunization in the second year of life S E C T I O N 9 and behaviours. They can also provide key information to decide how messages should be worded and the appropriate materials, media, and channels for reaching each target group. This helps ensure that resources are used effectively and efficiently. For example, brochures or posters about 2YL vaccination could be found to be less important to caregivers than having health workers use the opportunity of the MCV1 visit to provide reminder messages and to note the return date for 2YL vaccination on the child’s HBR. In such cases, resources might be better spent on health worker capacity-building and the design of the HBR. Understanding health worker views about 2YL vaccination, including their perceptions of obstacles and enabling factors, is particularly important. Health workers are the most frequently cited source of vaccine information, and a recommendation by a health worker is one of the strongest factors associated with vaccine acceptance. They have a key role to play in interpersonal communication with caregivers on the need for, and timing of, the 2YL visit. Information collected on health worker perspectives about 2YL vaccination should feed directly into the design of the training curriculum, supervision instruments, job aids, data management tools, and communication messages and materials. 9.2 Strategic design and planning Involvement of key stakeholders As with any new development in the health system, the engagement of well-known, credible national level stakeholders is important to focus the public’s attention on the topic and create trust. For introducing 2YL vaccination or increasing attention to it, planners should reach out to well-known health officials and trusted political, community, and academic leaders. Medical associations, schools and daycares, civil society organizations (CSOs), and NGOs are other influential players whose show of commitment to 2YL vaccination and other services can encourage appropriate actions among their constituents and communities. Communication planners should engage with them, provide them with talking points or other materials, and jointly identify specific opportunities, such as press conferences, launch ceremonies, or annual meetings, for demonstrating their support for 2YL vaccination. Community engagement Depending on the community structures and leaders that are active and functional in a given area, different types of volunteers or community members have a role to play in supporting 2YL vaccination. They can be engaged to provide reminder messages, trace defaulters, and keep community attention focused on the 2YL visit after it is launched. 76 Establishing and strengthening immunization in the second year of life 9 S E C T I O N District health and community development teams should identify community networks that are actively functioning and outline a realistic set of steps for CHWs or volunteers to carry out to support the 2YL visit. Printed reminder materials or other aids should be developed for this purpose that give information on all components of the 2YL visit, not just vaccination. Community members can also assist health care providers to select where and when to provide outreach services and how to reach the most marginalized or underserved populations. These are groups for which the risk of non-use of 2YL services is the highest. The following checklist can help ensure that all the key steps of the communication planning process are followed. B OX 8. C O M M U N I CAT I O N P L A N N I N G C H EC K L I ST  Is there a government-endorsed, multi-agency communications working group in place to support the 2YL visit? Has a situation analysis been completed? Has a behavioural analysis been completed? What messages and materials are required? Has a plan of action (budgeted) been developed? Have you secured funding for the implementation of the plan? Have the communication products/materials been pre-tested? Is there a distribution plan for the materials? Is there a crisis communication plan, including explicitly agreed partner roles and responsibilities, and does it include the relevant elements for 2YL? Have agreed spokespeople been identified and trained? 77 Establishing and strengthening immunization in the second year of life S E C T I O N 9 9.3 Development and testing of messages and materials Messages and materials All messages and materials should clearly state when caregivers should take their children for 2YL vaccination and what they can expect to receive during the 2YL visit. Suggested content of key messages to support 2YL vaccination, tailored to different audiences, is shown in Table 5. These messages should be adapted and pre-tested before incorporating them into communication materials, training, or radio or TV spots. Additional messages specific to MCV2 are found in A guide to introducing a second dose of measles vaccine into routine immunization schedules.31 Community networks have a key role to play in supporting the 2YL platform and communicating the importance of the 2YL visit as part of a continuum of care for the entire first five years of the child’s life. 31 www.who.int/immunization/documents/WHO_IVB_13.03/en/, p. 27. 78 Establishing and strengthening immunization in the second year of life 9 S E C T I O N TA B L E 6. E X A M P L E S O F K E Y M E S SAG E TO P I C S TO SU P P O RT 2 Y L VAC C I N AT I O N AU D I E N C E : H E A LT H WO R K E RS The reasons to provide vaccination and other child health interventions after one year of age. The age at which vaccinations in the 2YL are scheduled to be given and the importance of providing doses of antigens missed in the first year of life. There is no upper age limit or cut-off for most vaccines. “It is never too late to vaccinate.” During the MCV1 visit, the need to inform the caregiver when to bring the child back for 2YL vaccination and discuss why it is important. A child can only be considered fully immunized when they have received all doses, including those scheduled to be given after one year of age. Coverage of the ‘FIC’ indicator must include vaccinations given in the second year of life, or be separated by age categories (i.e. FIC by 1 yr year, FIC by 2 yrs). The other services to provide during the 2YL visit, e.g., growth monitoring and promotion, nutritional counseling. How to respond to caregivers with any questions or concerns about vaccination AU D I E N C E : C O M M U N I T I E S A N D CA R EG I V E RS To be classified as fully vaccinated, children need to have completed the required schedule of vaccinations during infancy, 2YL and beyond, as necessary. The age at which vaccinations in the 2YL are scheduled to be given and the importance of catching up on any vaccines missed in the first year of life. There is no upper age limit or cut-off for most vaccines. “It is never too late to vaccinate.” The importance of keeping the home-based record throughout childhood and bringing it for each contact with the health system. The benefits to the child (and family) of receiving vaccination and other services into the 2YL. 79 Establishing and strengthening immunization in the second year of life S E C T I O N 9 9.4 Implementation and monitoring A strong communication plan cannot be successful unless it is fully executed. This means: • the strategic plan must be fully budgeted with funds secured well in advance of the launch in order to produce sufficient supplies of materials; • materials and messages must be translated into the commonly used local languages as needed; • materials must be systematically disseminated to intended audiences at the appropriate time, in advance of when they are to be used; • messages for health worker interpersonal communication with mothers must be finalized in time for them to be incorporated into training materials, and the training designed in such a way that permits adequate time for health workers to practice these communication skills. Formal launch for 2YL visit Lessons learned from past introductions of MCV2 indicate that it is important to conduct a formal launch for the 2YL visit to raise awareness, convey key information, demonstrate high-level political and community support from credible spokespersons, and promote the use of the 2YL services. The engagement of influential community leaders must begin well before the launch takes place. They need to understand why the 2YL visit is being introduced, how it benefits their community, and what actions they can take to support its success. This engagement should continue on a regular basis, even after the launch, to ensure that relationships are maintained and that community leaders are able to continue to advocate for vaccination. The 2YL visit should be positioned as part of a continuum of care for the entire first five years of the child’s life. The introduction of the 2YL visit is an opportunity to highlight the importance of services that have been available in the past but have not been fully utilized. Following the launch of the 2YL visit Communication officials at the national level of the immunization programme should continue to interact with counterparts at subnational level to monitor the implementation of the communication plan and to enquire about any issues or obstacles that may be emerging so that corrective actions can be taken. 80 Establishing and strengthening immunization in the second year of life 9 S E C T I O N 9.5 Evaluation and re-planning In keeping with the overall communication strategy for immunization and child health, monitoring and evaluation of communication efforts should be carried out by the working group on a regular basis. Based on the data gathered and reviewed in Step 1 above, indicators or measures should be established – covering both process, outcomes, and impact – that can be tracked through implementation of the various communications and engagement activities. The findings should be used to inform decisions about the corrective actions to take. To evaluate communication and demand promotion activities, it is ideal to carry out a survey or rapid research exercise targeting caregivers, health workers and, potentially, community leaders or stakeholders. Such an assessment will provide a systematic and structured approach to learning about what people know about 2YL vaccination, how they developed this knowledge, what they think it means, and whether they intend to take the desired actions. The findings should inform adjustments to communications or demand promotion strategies, so that they may be more targeted or impactful in future. If resources are not available for a large- scale study, then the points raised in Section 10 can be used to understand reasons for low demand and utilization of 2YL vaccination. B OX 9. E X A M P L E S O F P OT E N T I A L O U TC O M E I N D I CATO RS TO E VA LUAT E C O M M U N I CAT I O N A N D D E M A N D P RO M OT I O N ACT I V I T I E S • % caregivers with correct knowledge of the schedule and timings of when a child needs to be brought for vaccination in the first two years of life • % caregivers who say they intend to fully vaccinate their children, including the 2YL visits • % vaccinators with correct knowledge of the national schedule • % vaccinators who consistently and correctly communicate to caregivers the timing of the infant’s next visit for vaccination, including the 2YL visits 81 Establishing and strengthening immunization in the second year of life S E C T I O N 9 R A I S I N G AWA R E N E S S A B O U T I M M U N I Z AT I O N A F T E R O N E Y E A R O F AG E I N TA N Z A N I A United Republic of Tanzania’s post-introduction evaluation for MCV2 revealed that many parents interviewed were not aware of the need for further vaccination after their children received MCV1 at nine months. Although children were supposed to attend clinics for growth monitoring after they were one year old, mothers no longer considered it important to come for these monitoring visits. Health officials raised community awareness about the need for vaccination and other services beyond the first year of life through: • broadcasting radio and TV spots; • conducting a seminar with journalists from various local media to get the word out; • conducting meetings on MCV2 with regional primary health care committees; • providing health education about MCV2 to women who attended antenatal and postnatal care visits. C O U N T RY E X P E R I E N C E 82 Establishing and strengthening immunization in the second year of life Strengthening 2YL vaccination performance 10 SECTION 83 Establishing and strengthening immunization in the second year of life S E C T I O N 10 Understanding the reasons for low performance If the national immunization programme and partners observe that 2YL vaccination coverage is low and that the MCV1-MCV2 drop-out rate is high, they should systematically review existing data and assess the situation to identify key problems and their root causes. Decisions on how to use resources to improve the situation should be based on these findings, rather than assumptions that the problem is due, for example, to low demand or insufficient vaccine supply. A starting point would be to review the quality of the reported data to determine if it can be considered complete, timely, reliable, and accurate. At national level, review the geographic scope of the 2YL performance problem. If widespread, then examine system-wide factors, including the following. 1. Are policies and guidelines complete, clear, accurate, and easy to understand and use? 2. Have policies and guidelines been disseminated systematically? 3. Does the training curriculum cover all key points and use effective methods for adult learning? 4. Has the training strategy reached all vaccinators and their supervisors? Are there any known shortcomings in how it has been implemented? 5. Were supervision instruments updated to include 2YL vaccination, and have they been widely disseminated and used? 6. Were data management tools updated, and do they support all aspects of the policy and guidelines? Did they include input from end-users or pre-testing to determine how easy they are to use? Have they been disseminated systematically? 7. Has there been a high-visibility launch to focus attention on the introduction of 2YL vaccination? Was the communication strategy for 2YL vaccination sufficiently developed, budgeted, and carried out as planned? If the problem of 2YL vaccination performance is localized to particular geographic areas, then follow-up with health officials from those subnational/district teams is necessary, as well as visits to facilities to gain a first-hand understanding of the problems and their root causes. 10.1 84 Establishing and strengthening immunization in the second year of life 10 S E C T I O N At subnational/district level, review data to see how geographically widespread the problem is. If it is widespread, review factors that may affect 2YL vaccination, including the following. 1. Have there been shortages or stockouts of the vaccines used for immunization in the second year of life? 2. Are there challenges with human resources that would affect 2YL vaccination, such as insufficient staffing or high turnover? Have health workers received training on 2YL vaccination? Has the district provided supportive supervision or other feedback/post-training support since the initial training was conducted? 3. Are there any particular circumstances or characteristics of the population in this district that would pose challenges to 2YL vaccination, e.g. population movement, high levels of employment of mothers after the child is one year of age, remote populations with difficult access to facilities or to information about changes in the vaccination schedule, lack of social support systems, or vaccine hesitancy? 4. Have updated data management tools been systematically introduced to all facilities, or are old forms and tools still widely in use? 5. What issues or problems with data quality have been observed? Have data quality assessments been carried out to assess the reliability and consistency of data on 2YL vaccination? What are the findings and what corrective actions are needed? 6. Have community leaders and influential persons been educated on the need for 2YL vaccination and why it is important? What actions do they take to encourage families to seek vaccination after one year of age? 7. Are there functional systems of CHWs or volunteers in the district who have been oriented on 2YL vaccination? Do they know how to trace defaulters and encourage families to bring their children for 2YL vaccination? Do they regularly carry out these tasks? 85 Establishing and strengthening immunization in the second year of life S E C T I O N 10 At health facility level, discuss 2YL vaccination with health workers and with caregivers at the facility and in the community. Health worker interviews. Questions to ask health workers include the following. 1. Tell me what you know about 2YL vaccination? How, or from whom, did you learn these things? 2. How frequently are you visited for supportive supervision? If you have a question about something, who do you ask for support or where do you seek help? 3. Do you know your facility’s coverage for 2YL vaccination and MCV1-MCV2 drop-out rate? 4. If 2YL vaccination rates are low, what are the reasons? 5. Are any reference materials on 2YL vaccination (e.g. field guide, training materials, job aids) available at the facility? 6. When is a child considered fully immunized – after they have received which doses of vaccine? 7. Have there been stockouts or shortages of the vaccines used for 2YL vaccination? 8. Does the health facility have a system for tracing defaulters, particularly for 2YL vaccination? What is the system and how well does it work? 9. What information do you give to caregivers who bring children for the MCV1 visit? 10. What do you do if a child is brought “late” for vaccination? Are there any circumstances where you would send away an unvaccinated child who has been brought for vaccination? What are they? Do you believe that there are upper age limits for 2YL vaccination? What are they? 11. If a child comes to your facility for vaccination in the second year of life, do they receive other services as well? What are they? Are they always available? 12. Are updated recording and reporting forms (HBRs, tally sheets, registers, monthly summary reports) available at the facility? If yes, what are the steps for recording and reporting 2YL vaccination? Do caregivers bring updated HBRs? If not, are 2YL doses recorded on the HBR? [Ask to see samples of recording and reporting tools and ask where the 2YL vaccinations are recorded] 86 Establishing and strengthening immunization in the second year of life 10 S E C T I O N 13. Has any comparison been done of 2YL data recorded on tally sheets, monthly reports, child registers, and HBRs, as part of a data quality assessment? If so, what have the findings indicated? Exit interviews. Health officials can visit several facilities, on days when routine immunization sessions are being held, and interview caregivers whose children have received MCV1. Questions to ask caregivers include the following. 1. Has your child received all vaccines in the national immunization schedule or do you need to bring your child back for more doses of vaccines? 2. [If applicable]: Are you able to tell me when you will bring your child next time and which vaccines he/she should recieve at that time? 7. What, if anything, would make this difficult for you? What would make it easier? Community discussions. Visit communities and ask community members what they know about vaccination in the second year of life. 1. By what age should a child have completed the full vaccination schedule? 2. If a child receives measles by the time he/she is one year old, do you need to bring the child back for more vaccinations? At what age? 3. [For those who know about 2YL vaccination]: How did you learn that you needed to take your child for immunization after one year of age? 4. If you brought your child for 2YL vaccination, what was your experience? Which vaccines did you receive? Did your child receive other services? Do you need to return for further vaccinations? 5. If your child is over the age of two and you did not bring them for 2YL services, what were the reasons? 6. What would help you to bring your child for 2YL services? [Probe: reminder materials; a visit by a CHW; more information about why it is needed] Without conducting a major assessment, health managers can add some of the above questions to their supportive supervision visits and augment them by conducting exit interviews with caregivers whose children have just been vaccinated. They can also do exit interviews with mothers who have brought young children for curative care, or other preventive services, to see if they were screened for 87 Establishing and strengthening immunization in the second year of life S E C T I O N 10 immunization and vaccinated. During supervision visits, district health officials can talk with community leaders who may provide insight as to the level of awareness of 2YL vaccination among the community. Additional guidance on how to integrate a small assessment to strengthen 2YL performance into a national immunization programme review is included in the WHO Guide for conducting an Expanded Programme on Immunization (EPI) review.32 10.2 Taking actions to address the problems The findings from the reviews described above should be used to decide what steps to take to strengthen 2YL vaccination. Health managers should convene a discussion to review the problems and their root causes in order to identify solutions and develop a plan for implementing them. Table 7 presents several illustrative examples of possible actions that programmes can take to improve 2YL performance.This list is not exhaustive; rather, it is intended to stimulate thinking about solutions that can be implemented using existing resources or with limited additional funds. Furthermore, the most appropriate actions to take will depend upon a deep understanding of the problems and of the context in which they occur. During supervision visits, health managers can speak with mothers whose children have just been vaccinated, or who have brought young children to the health facility for other services, and ask if they were screened for immunization. 32 Guide for conducting an Expanded Programme on Immunization (EPI) review. Geneva: World Health Organization; 2017. www.who.int/immunization/documents/WHO_IVB_17.17/en/ © W H O 88 Establishing and strengthening immunization in the second year of life 10 S E C T I O N TA B L E 7. COMMON PROBLEMS AND POSSIBLE ACTIONS TO STRENGTHEN 2YL VACCINATION P RO B L E M S / I S SU E S E X A M P L E S O F P OS S I B L E ACT I O N S Persistent low coverage and high drop-out rates • Mobilize CHWs or volunteers to trace defaulters and encourage 2YL vaccination among community members. • Improve the convenience of locations for outreach sessions so that it is easier for caregivers or mothers of two year-old children to bring them for vaccination. • Consider offering routine immunization sessions at fixed facilities at a time of day that is more convenient for mothers of older children. Outreach sessions are not conducted as often as planned • Compare actual outreach sessions conducted during the last six months with the number of scheduled outreach sessions in the microplan. If there is a clear discrepancy, find out why the outreach is not being implemented. Stockouts of vaccines and supplies • Review the availability of vaccines needed for 2YL vaccination at all levels to ensure that sufficient supplies are available. • If concerns over high wastage rates are deterring health workers from opening a vial of MCV for small numbers of children, review national policies on this topic and reinforce during supportive supervision visits. Remind health workers that 2YL vaccination may result in lower levels of MCV vaccine wastage. Deficiencies in health worker practices • Address health worker motivation: recognize and praise those who have achieved high coverage. Ask them to share their experience through peer learning with health workers at other facilities. Remind health workers of the reasons for 2YL vaccination and note that immunization programme performance is also based on coverage with vaccinations given after one year of age. • Provide on-the-job training during supportive supervision visits to address the deficiencies. • If shortages of human resources are contributing to suboptimal health worker performance (overburdened staff), review the possible role of volunteers to help assume some of the less technical duties. However, recognize that volunteers need technical orientation and management, and that their contribution is voluntary. • Refer to Section 8.4 for more possible actions, e.g. WhatsApp groups, telephone hotlines, SMS texting to reinforce key points. 89 Establishing and strengthening immunization in the second year of life S E C T I O N 10 P RO B L E M S / I S SU E S E X A M P L E S O F P OS S I B L E ACT I O N S Problems with screening, recording, reporting doses • Review data management instruments and revise, if needed, to make them more user-friendly, to enable proper practice for screening, recording, and reporting. • Ongoing supervision and feedback on how to use the data collection instruments. • Job aids, hotlines or WhatsApp groups to help address particular problem areas, e.g. difficulties with screening, recording, reporting. • Conduct data quality assessments and use the findings to correct particular problems and monitor progress. Low awareness or demand for 2YL vaccination • Strengthen health worker skills in interpersonal communication to remind caregivers when to return for vaccination in the second year of life. • Engage community leaders to get the word out to families about when and where to go for 2YL vaccination and why it is important. Use the occasion of community meetings to give feedback on coverage for 2YL vaccination and discuss how to improve it. • Work with local NGOs to explore how they can support 2YL vaccination; for example, by mobilizing resources for outreach sessions in convenient locations in the community. • Re-launch 2YL through high-visibility activities such as press conferences, ceremonies, meetings, radio, SMS, etc. • Use radio talk shows to discuss 2YL vaccination and increase attention around the need for 2YL vaccination. Develop songs or memorable jingles that can be broadcast to remind communities of the need for 2YL vaccination. 90 Establishing and strengthening immunization in the second year of life 1 A N N E X Annex 1a: Example of minimum standard tally sheet for vaccination33 ANTIGENS/ ITEMS 0-11 MONTHS TOTAL 12 MONTHS OR OLDER TOTAL TOTAL VACCINATED BCG Hep B BD OPV 0 OPV 1 OPV 2 OPV 3 IPV Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/ Other* Vitamin A Long lasting insecticidal net* 33 As described in Section 7 *depending on national health priorities and schedule of services Date: Region: District: Health Facility: Service Delivery Strategy: fixed outreach mobile Location: 91 Establishing and strengthening immunization in the second year of life Annex 1b: Example of best practice tally sheet for vaccination33 ANTIGENS/ ITEMS 0-11 MONTHS TOTAL 12–23 MONTHS TOTAL 24 MONTHS OR OLDER TOTAL TOTAL vaccinated BCG Hep B BD OPV 0 OPV 1 OPV 2 OPV 3 IPV Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/Other* Vitamin A Long lasting insecticidal net* 33 As described in Section 7 *depending on national health priorities and schedule of services Date: Region: District: Health Facility: Service Delivery Strategy: fixed outreach mobile Location: A N N E X 1 92 Establishing and strengthening immunization in the second year of life 2 A N N E X Annex 2: Immunization monitoring chart showing MCV1-MCV2 drop-out Health Facility: Year: A drop-out more than 10% is an indication for immediate action Annual target population (0-11 months): Annual target population (12-23 months): Minimum coverage target for the year—BCG: Minimum coverage target for the year—MCV1: Minimum coverage target for the year—MCV2: Vaccine Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec BCG A Total immunized this month Cumulative total for the month MCV1 B Total immunized this month Cumulative total for the month MCV2 C Total immunized this month Cumulative total for the month BCG-MCV1 DROP-OUT RATE = Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec MCV1-MCV2 DROP-OUT RATE = Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ** Plot for only BCG, MCV1, MCV2 M on th ly tr ag et c ov er ag e 25% 75% 50% 100% A-B A * 100 B-C B * 100 93 Establishing and strengthening immunization in the second year of life A N N E X 3 Annex 3: Scenarios for vaccination in the second year of life (for use in training and supervision) Vaccinators encounter many situations where they are not sure what to do if the child has missed previous doses, has come late for vaccination, or lacks a home-based record. The following are real situations that have been reported from different countries. These scenarios are based on a schedule that includes MCV1 at nine months of age and MCV2 at 18 months of age. They should be adapted to fit the appropriate vaccine schedule and country context. These scenarios can be used during training for interactive discussions and skill building for proper screening, administration, recording, and reporting of doses. In each case, trainers can show just the first two columns, or print out hard copies of the scenarios and ask training participants to review them in pairs. Afterwards, discuss as follows. • Do you think the health worker did the right thing? • If not, what should have been done differently? • How could this problem be prevented? The third and fourth columns are for use by training facilitators and supervisors. The third column provides the correct response. The fourth column presents some possible responses that can be further developed and discussed. Annual target population (0-11 months): Annual target population (12-23 months): Minimum coverage target for the year—BCG: Minimum coverage target for the year—MCV1: Minimum coverage target for the year—MCV2: FOR TRAINING PARTICIPANTS FOR TRAINING FACILITATORS AND SUPERVISORS SCENARIO HEALTH WORKER “INCORRECT” RESPONSE WHAT SHOULD THE HEALTH WORKER HAVE DONE? HOW COULD THIS PROBLEM BE PREVENTED? (for discussion) 1. A child is brought late for MCV1 at 14 months of age The health worker vaccinates the child and records and reports the dose as MCV2 because the child is over one year of age. The health worker believes that only doses given under one year of age can be considered as MCV1. 1. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 2. A child is brought for his first dose of MCV at 18 months of age (the time of the scheduled MCV2 visit) The health worker vaccinates the child and records and reports the dose as MCV2 because the child has come at the time when MCV2 is scheduled to be given. 2. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months.” She should have advised the caregiver to bring the child back for MCV2 after 4 weeks. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 3. At a rural facility with infrequent outreach and few children seen before the age of 12 months, a 15-month old boy is brought in who has never received measles vaccine. The health worker believes the child is not eligible for MCV1 because he is too old to receive it. She also believes he is not eligible for MCV2 because he has not received MCV1. So she sends him away without vaccinating him against measles. 3. She should have vaccinated the child and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision to emphasize that it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet • Job aid 4. Children at one clinic are often brought for MCV1 at 10, 11, 12, or 13 months of age. The health worker tells the mothers to come back 9 months later for MCV2, believing that it is the 9-month interval and not the target age (of 18 months) that is important. 4. She should have advised the caregivers to bring their children back for MCV2 at 18 months of age. • Training and supervision to emphasize that it is the age of vaccination that is most important, as long as there is one month minimum interval between MCV doses. 6. A child is brought for MCV2 at 3 years of age. The child has already received MCV1 at 9 months. The health worker does not vaccinate the child because they are older than 23 months. 6. She should have given the child MCV2 and recorded the dose as MCV2 in the column of the tally sheet for “12 months or older” or “24 months or older” • Training and supervision to emphasize that the need for MCV does not stop at 24 months (no upper limit – all children need 2 doses of MCV), and it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet 7. A child is brought for MCV2 at 2-1/2 years of age. The child has already received MCV1 at 9 months. The health worker vaccinates the child but records the dose on a special register so that it is not included in estimates of coverage. 7. She should have recorded the dose as MCV2 on the column of the tally sheet for “12 months or older” or “24 months of older” • MOH needs to design the tally sheet to permit recording and reporting of doses given to children 24 months or older 8. The health worker says that she cannot provide a measles second dose because she has no “MSD” vaccine. The health worker does not provide a second dose of measles to any children. 8. She should have provided MCV2 doses to all eligible children who are over the age of one. • Field guide, training, supervision, data recording forms, social mobilization should use more familiar convention of numbered doses (e.g. measles1/ measles2, MR1/MR2) for measles or measles rubella 9. A child is brought for MCV2 at 18 months. The mother does not have a vaccination card but remembers that her baby received MCV1 soon before he started walking. The health worker vaccinates him but records it as MCV1 and tells the mother to come back in one month for MCV2. 9. She should have first checked the child’s age and vaccination status in the child health register to ascertain whether the child received MCV1 at or soon after 9 months. If no record is found, then the health worker response was correct. A new vaccine card should have been provided. If a record is found, the health worker should have given MCV2, and transferred the information from the registry to a new vaccination card. • Field guide should provide clear guidance on what health workers should do in the absence of an HBR or record of the child in the health facility register. 94 Establishing and strengthening immunization in the second year of life 3 A N N E X These scenarios are based on a schedule that includes MCV1 at nine months of age and MCV2 at 18 months of age. FOR TRAINING PARTICIPANTS FOR TRAINING FACILITATORS AND SUPERVISORS SCENARIO HEALTH WORKER “INCORRECT” RESPONSE WHAT SHOULD THE HEALTH WORKER HAVE DONE? HOW COULD THIS PROBLEM BE PREVENTED? (for discussion) 1. A child is brought late for MCV1 at 14 months of age The health worker vaccinates the child and records and reports the dose as MCV2 because the child is over one year of age. The health worker believes that only doses given under one year of age can be considered as MCV1. 1. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 2. A child is brought for his first dose of MCV at 18 months of age (the time of the scheduled MCV2 visit) The health worker vaccinates the child and records and reports the dose as MCV2 because the child has come at the time when MCV2 is scheduled to be given. 2. She should have given the vaccine and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months.” She should have advised the caregiver to bring the child back for MCV2 after 4 weeks. • Proper training and supervision for immunization after one year of age • Well-designed tally sheet • Job aid to promote correct screening, recording, reporting 3. At a rural facility with infrequent outreach and few children seen before the age of 12 months, a 15-month old boy is brought in who has never received measles vaccine. The health worker believes the child is not eligible for MCV1 because he is too old to receive it. She also believes he is not eligible for MCV2 because he has not received MCV1. So she sends him away without vaccinating him against measles. 3. She should have vaccinated the child and recorded the dose as MCV1 in the column of the tally sheet for “12 months or older” or “12-23 months” and advised the caregiver to bring the child back for a scheduled MCV2 visit at 18 months. • Proper training and supervision to emphasize that it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet • Job aid 4. Children at one clinic are often brought for MCV1 at 10, 11, 12, or 13 months of age. The health worker tells the mothers to come back 9 months later for MCV2, believing that it is the 9-month interval and not the target age (of 18 months) that is important. 4. She should have advised the caregivers to bring their children back for MCV2 at 18 months of age. • Training and supervision to emphasize that it is the age of vaccination that is most important, as long as there is one month minimum interval between MCV doses. 6. A child is brought for MCV2 at 3 years of age. The child has already received MCV1 at 9 months. The health worker does not vaccinate the child because they are older than 23 months. 6. She should have given the child MCV2 and recorded the dose as MCV2 in the column of the tally sheet for “12 months or older” or “24 months or older” • Training and supervision to emphasize that the need for MCV does not stop at 24 months (no upper limit – all children need 2 doses of MCV), and it is better to vaccinate late than to send a child away unvaccinated • Well-designed tally sheet 7. A child is brought for MCV2 at 2-1/2 years of age. The child has already received MCV1 at 9 months. The health worker vaccinates the child but records the dose on a special register so that it is not included in estimates of coverage. 7. She should have recorded the dose as MCV2 on the column of the tally sheet for “12 months or older” or “24 months of older” • MOH needs to design the tally sheet to permit recording and reporting of doses given to children 24 months or older 8. The health worker says that she cannot provide a measles second dose because she has no “MSD” vaccine. The health worker does not provide a second dose of measles to any children. 8. She should have provided MCV2 doses to all eligible children who are over the age of one. • Field guide, training, supervision, data recording forms, social mobilization should use more familiar convention of numbered doses (e.g. measles1/ measles2, MR1/MR2) for measles or measles rubella 9. A child is brought for MCV2 at 18 months. The mother does not have a vaccination card but remembers that her baby received MCV1 soon before he started walking. The health worker vaccinates him but records it as MCV1 and tells the mother to come back in one month for MCV2. 9. She should have first checked the child’s age and vaccination status in the child health register to ascertain whether the child received MCV1 at or soon after 9 months. If no record is found, then the health worker response was correct. A new vaccine card should have been provided. If a record is found, the health worker should have given MCV2, and transferred the information from the registry to a new vaccination card. • Field guide should provide clear guidance on what health workers should do in the absence of an HBR or record of the child in the health facility register. 95 Establishing and strengthening immunization in the second year of life A N N E X 3 96 Establishing and strengthening immunization in the second year of life 4 A N N E X Annex 4: Illustrative example of job aid on screening for vaccine eligibility The sample job aid is adapted from Timor Leste (IMMUNIZATIONbasics, 2007) and is based on a child immunization schedule that calls for BCG and hepatitis B at birth; Pentavalent, oral polio vaccine (OPV), pneumococcal conjugate vaccine (PCV), and rotavirus (RV) doses at 6, 10, and 14 weeks; inactivated polio vaccine (IPV) at 14 weeks; MCV1 at nine months; and MCV2, MenA and DTP4 at 18 months of age. Please adapt this document to match your local immunization schedule. This, along with other 2YL tools and resources, can be found at www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Instructions: Step 1: Praise the parent or caregiver for bringing their child for vaccination today. Find out from the child’s immunization record or the caregiver: 1. How old is the child today? 2. Which vaccines has the child already received? (Check the home-based record or child register) Step 2: Use the chart to the right to decide what to give. The child should already have received all vaccines due up until their current age. If they are missing doses, it is not too late. Administer the vaccines for which they are eligible, respecting the necessary spacing (see far right column). Step 3: Remind the caregiver when to bring the child back for the subsequent doses due. Take this opportunity to emphasize the importance of receiving the complete series of vaccines for the child to be fully protected. † In certain situations, MCV can be given from 6 months of age. This dose should be considered a zero dose (“MCV0”) and two subsequent doses (MCV1 and MCV2) should still be provided according to the national schedule. Measles vaccines. Position paper. Geneva: World Health Organization; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). 97 A N N E X 4 At 6 weeks (or as soon as possible thereafter) HepB BD: As soon as possible after birth, ideally within 24 hours, and up to 6 weeks BCG: As soon as possible after birth HepB BD: Not after 6 weeks At 10 weeks (or as soon as possible thereafter), and at least 4 weeks after dose 1 At 9 months (or as soon as possible thereafter) At 18 months (or as soon as possible thereafter), and at least 4 weeks since previous dose MCV2: Not before 4 weeks has passed since MCV1 DTP4: Not before 4 weeks has passed since Penta3 MenA: Not before 9 months of age (except where indicated) Even if a long time has passed between doses, there is no need to restart the series from the beginning. There is no upper age limit for most vaccines (except rotavirus <2yrs and hepatitis B birth dose <6 weeks) WHEN TO GIVE “It is better to vaccinate late than never!” WHICH VACCINES CAN BE GIVEN TODAY? Use this chart to determine which vaccines should be given to a child at or after a specific age. WHEN TO NOT GIVE RV1: Not after 2 years of age Not before 4 weeks has passed since previous dose RV2: Not after 2 years of age At 14 weeks (or as soon as possible thereafter), and at least 4 weeks after dose 2 Not before 4 weeks has passed since previous dose RV3: Not after 2 years of age Not before 9 months of age (except where indicated)† OPV 2 Penta 2 PCV 2 RV 2 OPV 3 Penta 3 PCV 3 RV 3 IPV MCV 1 MCV 2 MenA OPV 1 PCV 1 DTP4 (or Penta4) 6 WEEKS 14 WEEKS 9 MONTHS 18 MONTHS 2 YEARS 10 WEEKS BIRTH HepB BD BCG Penta 1 RV 1 98 Establishing and strengthening immunization in the second year of life 5 A N N E X Annex 5: Frequently asked questions about vaccination in the second year of life The following questions can help health workers respond to questions about vaccination in the second year of life or later. 1. Why is it important to vaccinate children after their first birthday? Both the level of protection and the duration of immunity are increased by providing additional doses of vaccine after the child has reached one year of age. This means that older children will continue to be protected from many vaccine-preventable diseases. For measles, a second dose ensures early protection of the individual child and also reduces the rate of accumulation of susceptible children and the risk of an outbreak. 2. Which vaccines, and at what age, should children receive vaccines after the first year of life? This depends on the schedule of the national immunization programme in each country. • WHO has recommended that all countries provide a second dose of measles-containing vaccine after one year of age. Many countries schedule it in the second year of life. • WHO also recommends a booster dose of vaccine containing diphtheria, tetanus, and pertussis, to be given in the second year of life. • Other vaccines that may be scheduled between 12-23 months include those against meningitis A, Japanese encephalitis, typhoid and yellow fever. • Many countries also recommend catch-up vaccination to provide doses of vaccines missed in the first year of life. 3. Are there some vaccines or doses that should not be given to a child in the second year of life or later? Vaccination in the second year of life is an opportunity to increase the level and duration of protection against vaccine preventable diseases. If children 34 Available at: www.who.int/immunization/documents/positionpapers/en/ 99 Establishing and strengthening immunization in the second year of life A N N E X 5 are missing doses of certain vaccines that they should have received in the first year of life, in general, it is better to vaccinate late than never. There are certain exceptions as indicated in the national immunization schedule and noted in WHO position papers.36 These are: • Birth doses of hepatitis B vaccine should be given only in the newborn period, as stipulated in the national policy. • Rotavirus vaccination after 24 months is not considered necessary because of the age distribution of rotavirus gastroenteritis. 4. On what occasions should a child over one year of age be vaccinated? • When they come for a scheduled vaccination visit according to the national immunization schedule • Any time they are in contact with the health system, including if they come for curative care. Mild illness is not a reason to deny vaccination to a child, and screening sick children for immunization eligibility is a standard component of IMCI. If children have been brought for growth monitoring and nutritional counselling, this also provides an opportunity for screening and vaccinating them. Another opportunity for screening and vaccination is if the child has accompanied one of their family members, such as a sibling or mother, coming for care.35 • During a scheduled Child Health Week, or other similar campaign or event in which catch-up vaccination is provided. 5. What messages should the mother or caregiver be given during their infant’s last vaccination contact before reaching one year of age? For most children, the measles contact is the last vaccination visit before the child reaches one year of age. During that visit, the health worker should make sure to inform the mother as follows. • It is important for her child to come back at the scheduled time [depending on the national vaccination schedule] to receive the remaining doses of vaccine to be given in the second year of life. Unlike in the past, the child cannot be considered fully immunized until they receive these recommended vaccine doses as well. 35 For more information, refer to the WHO missed opportunities for vaccination (MOV) strategy. Available at: www.who.int/immunization/programmes_systems/policies_strategies/MOV/en/ 100 Establishing and strengthening immunization in the second year of life 5 A N N E X • These additional doses will provide stronger and longer-lasting protection against important childhood diseases. With additional doses, this protection will last beyond early childhood. • Be sure to keep the home-based record, such as vaccination card, in a safe place and bring it the next time they come for vaccination, and any time they come to a health facility for services. • She should bring her child for vaccination at the next scheduled time [specify the date]. However, if she is unable to come at that time, to come as soon as possible thereafter. 6. If a child comes for services substantially later than the scheduled time, should they still be vaccinated? Yes. While timely vaccination as soon as the child is eligible is highly desirable to reduce potential exposure to disease, it is always important that the child receive protection from vaccination and not be sent away if they come for vaccination late. With very few exceptions, as explained in Question 3 above, it is “better to vaccinate late than never”. 7. If a child comes late for the 2YL vaccination visit and they are older than 23 months, should the dose be recorded as given in the second year of life (12-23 months)? • Always record and report the dose accurately so that it corresponds to the age at which the child actually received it. This will depend on how the tally sheets and monthly reporting forms are designed. • If they contain two age groups (“0-11 months” and “over 12 months”), then record the doses as being given “over 12 months”. • If they contain three age groups (“0-11 months”, “12-23 months”, and “24 months or over”), then record the doses as being given at “24 months or older”. 8. Is it safe to vaccinate children after one year of age? Are there any additional risks? It is safe and there are no additional or different risks to vaccinating children after one year of age compared with vaccinating them during infancy. 101 Establishing and strengthening immunization in the second year of life A N N E X 5 9. What other services or care can the child receive when they come for vaccination in the second year of life? • Growth monitoring and promotion, nutritional counselling, advice on hygiene and sanitation, and, depending on national policies, vitamin A or deworming medication can be provided during a visit for vaccination in the second year of life. • Some countries may decide to provide additional services, such as follow-up on early infant diagnosis of HIV/AIDS, or family planning services for mothers. © J Sw artz 102 Establishing and strengthening immunization in the second year of life www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Tables 1. WHO-recommended vaccines to be administered in the second year of life 18 2. Materials to review and update for 2YL vaccination and services 28 3. Interventions and commodities for vaccination and other services in a scheduled 2YL visit (illustrative example) 42 4. Summary of immunization indicators related to 2YL 52 5. Elements of the 2YL behaviour change communication framework 71 6. Examples of key message topics to support 2YL vaccination 78 7. Common problems and possible actions to strengthen 2YL vaccination 88 Figures 1. Increase in estimates of MCV1 coverage when doses administered in the second year of life are included 20 2. Estimated coverage of interventions among households with a child aged 12-23 months, if integrated with routine immunization (28 sub-Saharan African countries) 21 3. Example from Ghana of an algorithm for determining eligibility for meningitis A and measles rubella vaccine 68 4. Demand and promotion planning cycle 73

104 Establishing and strengthening immunization in the second year of life C O N T E N T S This document provides practical guidance on establishing and strengthening immunization in the second year of life (2YL) and beyond. It also suggests ways that immunization visits during the 2YL can be used as a platform for delivery of other child-health services. For tools and resources on immunization in the 2YL, please visit www.who.int/immunization/programmes_systems/ policies_strategies/2YL/en/ This document was published by the Expanded Programme on Immunization (EPI) of the Department of Immunization, Vaccines and Biologicals and is available at: www.who.int/immunization/documents Copies of this document as well as additional materials on immunization, vaccines and biologicals may be requested from: World Health Organization Department of Immunization, Vaccines and Biologicals CH-1211 Geneva 27 Switzerland Email: vaccines@who.int Web: www.who.int/immunization/en ISBN 978-92-4-151367-8

Estabelecer e reforçar a vacinação no segundo ano de vida: práticas de vacinação para além da infância Estabelecer e reforçar a vacinação no segundo ano de vida: práticas de vacinação para além da infância [Establishing and strengthening immunization in the second year of life: practices for immunization beyond infancy] ISBN 978-92-4-851367-1 © Organização Mundial da Saúde 2018 Alguns direitos reservados. Este trabalho é disponibilizado sob licença de Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Nos termos desta licença, é possível copiar, redistribuir e adaptar o trabalho para fins não comerciais, desde que dele se faça a devida menção, como abaixo se indica. Em nenhuma circunstância, deve este trabalho sugerir que a OMS aprova uma determinada organização, produtos ou serviços. O uso do logótipo da OMS não é autorizado. 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A responsabilidade pela interpretação e utilização deste material recai sobre o leitor. Em nenhum caso se poderá responsabilizar a OMS por qualquer prejuízo resultante da sua utilização. Printed in Switzerland Estabelecer e reforçar a vacinação no segundo ano de vida: práticas de vacinação para além da infância iv Estabelecer e reforçar a vacinação no segundo ano de vida Í N D I C E SECÇÃO 1 Finalidade e utilização deste documento 9 1.1. Objectivos 10 1.2 Destinatários 11 1.3 Outras publicações a consultar 11 Abreviaturas e siglas vi Agradecimentos viii SECÇÃO 2 Introdução à vacinação ao longo da vida com ênfase no segundo ano de vida 12 SECÇÃO 3 Contexto sobre a vacinação no segundo ano de vida e posteriormente 16 3.1 Estará generalizada a vacinação no segundo ano de vida? 17 3.2 Oportunidades e benefícios da vacinação no segundo ano de vida 18 3.3 Desafios da vacinação no segundo ano de vida 22 SECÇÃO 4 Políticas e planeamento para a vacinação no segundo ano de vida e posteriormente 24 4.1 Passos para o planeamento da introdução ou do reforço de uma visita no 2º ano de vida 26 4.2 Decidir a calendarização da visita ou visitas no 2º ano de vida 29 4.3 Actualizar a vacinação sempre que uma criança tenha contacto com os serviços de saúde 30 4.4 Coordenar a vacinação com outros serviços no segundo ano de vida 32 SECÇÃO 5 Planeamento ao nível das unidades, organização dos serviços e recursos humanos 35 5.1 Actualizar as ferramentas e os processos de microplaneamento 36 5.2 Rever as implicações nos recursos humanos para a visita no 2º ano de vida 37 5.3 Determinar a viabilidade de proporcionar todos os serviços desejados para a visita no 2º ano de vida e as questões práticas do fluxo de pacientes 39 v Estabelecer e reforçar a vacinação no segundo ano de vida Í N D I C E Anexos 1. Exemplos de folhas de inventário de padrões mínimos e melhores práticas de vacinação 90 2. Gráfico de monitorização da vacinação, mostrando o abandono da MCV1–MCV2 92 3. Cenários sobre vacinação no segundo ano de vida (a utilizar na formação e supervisão) 93 4. Exemplo ilustrativo de um auxiliar de trabalho no rastreio para vacinação 96 5. Perguntas frequentes sobre a vacinação no segundo ano de vida 98 SECÇÃO 6 Gestão da cadeia de abastecimento de vacinas e outros produtos 41 6.1 Produtos necessários para a vacinação e outros serviços no segundo ano de vida 42 6.2 Vacinas e materiais de vacinação no segundo ano de vida 45 SECÇÃO 7 Registo, reporte e utilização de dados para a tomada de decisões 48 7.1 Indicadores de desempenho 50 7.2 Requisitos de dados 54 7.3 Actualizar formulários e sistemas de informações de saúde 56 SECÇÃO 9 Comunicação, promoção da procura e envolvimento da comunidade 70 9.1 Recolha de dados e análise: compreender os seus grupos-alvo 74 9.2 Concepção e planeamento estratégicos 75 9.3 Desenvolvimento e teste de mensagens e materiais 77 9.4 Implementação e monitorização 79 9.5 Avaliação e replaneamento 80 SECÇÃO 8 Formação de profissionais de saúde e desenvolvimento de competências 59 8.1 Determinar as competências necessárias aos profissionais de saúde 60 8.2 Preparar o currículo de formação 62 8.3 Planear a estratégia de formação 65 8.4 Proporcionar supervisão de apoio e outras formas de apoio pós-formação 66 SECÇÃO 10 Reforço do desempenho da vacinação no 2º ano de vida 82 10.1 Compreender os motivos do baixo desempenho 83 10.2 Tomar medidas para tratar dos problemas 87 vi 2YL segundo ano de vida API avaliação pós-introdução AQD auto-avaliação da qualidade dos dados ASV actividade suplementar de vacinação BCG bacilo Calmette-Guérin (vacina) CAP estudo de conhecimentos-atitudes-práticas CDC Centros de Prevenção e Controlo de Doenças (EUA) CTI criança totalmente imunizada DHIS2 sistema de informação de saúde distrital, versão 2 DIP diagnóstico infantil precoce de VIH/SIDA DTP vacina contra a difteria-tétano-tosse convulsa DV-DMT ferramenta de gestão de dados de vacinação distritais EAPV evento adverso pós-vacinação EJ encefalite japonesa PAV Programa Alargado de Vacinação FAQ perguntas frequentes FDF formação de formadores GAVI Gavi, a Aliança para as Vacinas GICC gestão integrada de casos comunitários GIDI gestão integrada das doenças da infância GRISP Estratégias e Práticas Globais de Vacinação de Rotina HBR boletim de saúde HepB vacina da hepatite B HepB-BD dose da hepatite B à nascença Hib Haemophilus influenzae tipo B IAIM inquérito de aglomeração de indicadores múltiplos ICG Comissão Coordenadora Interagências IDS inquérito demográfico e de saúde IPAC Comissão de Aconselhamento de Práticas de Vacinação IPVR intensificação periódica da vacinação de rotina ITN rede mosquiteira tratada com insecticida MCV vacina contra o sarampo MCV1 primeira dose da vacina contra o sarampo MCV2 segunda dose da vacina contra o sarampo MdS Ministério da Saúde MenA vacina contra a meningite A A B R E V I A T U R A S E S I G L A S Estabelecer e reforçar a vacinação no segundo ano de vida A B R E V I A T U R A S E S I G L A S vii Estabelecer e reforçar a vacinação no segundo ano de vida MMR vacina contra o sarampo, papeira e rubéola MR vacina contra o sarampo e rubéola MUAC circunferência do braço médio NITAG Grupo Técnico Consultivo Nacional sobre Vacinação OMS Organização Mundial de Saúde ONG organização não governamental OPV oportunidades perdidas de vacinação OSC organização da sociedade civil PAGV Plano de Acção Global de Vacinas PCV vacina conjugada pneumocócica PFM política de frascos multidose POP procedimento operacional padrão PPA plano plurianual abrangente PSC profissional de saúde comunitário RV vacina contra o rotavírus RVE registo de vacinação electrónico SAGE Grupo Consultivo Estratégico de Peritos de Imunização SIGS sistema de informação de gestão da saúde SMN suplementos de micronutrientes SVA suplementação da vitamina A TCV vacina conjugada contra a febre tifóide TTCV vacina contra o toxóide tetânico UNICEF Fundo das Nações Unidas para a Infância VIP vacina inactivada contra a poliomielite VOP vacina oral da poliomielite VPD doenças preveníveis pela vacinação viii Estabelecer e reforçar a vacinação no segundo ano de vida A G R A D E C I M E N T O S Este documento foi desenvolvido pelo Programa Alargado de Vacinação (PAV) do Departamento de Imunização, Vacinas e Produtos Biológicos da Organização Mundial de Saúde (OMS) com contributos da UNICEF e elaborado por Rebecca Fields, da John Snow, Inc. Os seguintes indivíduos contribuíram de modo substancial para a sua preparação e os seus contributos são reconhecidos com gratidão: Carolina Danovaro, Rudi Eggers, Messeret Eshetu, Tracey Goodman, Jan Grevendonk, Karen Hennessey, Penelope Kalesha Masumbu, Lisa Menning, Abrahams Mwanamwenge, Ikechukwu Ogbuanu, Stephanie Shendale, Emily Wootton (OMS); Ulla Griffiths, Imran Raza Mirza (UNICEF); Laura Conklin, Mawuli Nyaku, Melissa Wardle, Margie Watkins (CDC) e os consultores independentes Celestino Costa e Karen Wilkins. A orientação do Grupo Consultivo Estratégico de Peritos (SAGE) da OMS sobre Vacinação e da Comissão de Aconselhamento de Práticas de Vacinação (IPAC) moldaram os princípios e orientações essenciais aqui reflectidos. O conteúdo do presente documento baseia-se parcialmente numa análise da experiência com a vacinação no segundo ano de vida na República do Gana, na República do Senegal e na República da Zâmbia. Manifestamos os mais sinceros agradecimentos aos Ministérios da Saúde desses países, por terem permitido a documentação e análise da sua experiência na introdução da vacinação no segundo ano de vida. www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 1 SECÇÃO 9 Estabelecer e reforçar a vacinação no segundo ano de vida Finalidade e utilização deste documento www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 10 Estabelecer e reforçar a vacinação no segundo ano de vida 1 S E C Ç Ã O Este documento fornece orientações práticas para estabelecer e reforçar a vacinação no segundo ano de vida (2YL) e posteriormente. Também sugere formas de utilizar as visitas de vacinação no 2º ano de vida como uma plataforma para a prestação de outros serviços de saúde infantil. 1.1 Objectivos 1 Apesar de este documento se centrar maioritariamente na vacinação durante uma visita agendada no segundo ano de vida, são abordadas outras intervenções de saúde, de forma limitada. As informações detalhadas sobre estas intervenções excedem o âmbito deste documento. As publicações relevantes estão incluídas nas Notas de rodapé. 1. Auxiliar os países na tomada de decisões informadas sobre o estabelecimento ou reforço de uma visita (ou visitas) de avaliação infantil de rotina no segundo ano de vida, que inclua a vacinação e outros serviços como parte de cuidados infantis continuados.1 2. Proporcionar uma orientação prática em relação ao planeamento, gestão, implementação e monitorização dos serviços de vacinação e melhorar a cobertura de vacinação durante uma visita agendada no segundo ano de vida, que poderá incluir outras intervenções de saúde. 3. Proporcionar orien- tações mais amplas sobre vacinação de recuperação para crianças maiores de um ano, que estejam atrasadas ou tenham perdido doses de vacinas (“não vacinadas e/ou sub-vacinadas”). 11 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 1 1.2 Destinatários O presente manual destina-se principalmente às pessoas que trabalham na vacinação e outros serviços de saúde infantil ao nível nacional. Incluem-se: • decisores ao nível nacional e gestores de programas de vacinação, saúde infantil, nutrição, VIH/SIDA pediátrica, desenvolvimento comunitário, educação para a saúde, sistemas de informação de gestão de saúde, cadeia de frio e gestão de logística; • membros dos Grupos Técnicos Consultivos Nacionais sobre Vacinação (NITAG), bem como outros órgãos de consultoria sobre saúde e nutrição infantil; • consultores de vacinação e saúde infantil ao nível nacional, regional e global que trabalhem com organizações parceiras como a OMS, UNICEF, parceiros de desenvolvimento, organizações da sociedade civil e organizações não governamentais (ONG). 1.3 Outras publicações a consultar Alguns dos materiais contidos neste documento são abordados mais detalhadamente noutras publicações e nos sites da OMS, que estão destacados em caixas de recursos essenciais ao longo deste guia. Vários outros recursos que serão de consulta importante no caso do estabelecimento ou reforço de uma plataforma do 2º ano de vida estão actualmente em desenvolvimento pela OMS e ficarão disponíveis em breve.2 • Trabalhar em conjunto: um guia de recursos de integração para o planeamento e reforço de serviços de vacinação ao longo da vida. • Manual sobre a recolha, avaliação e utilização de dados sobre vacinação. • Guia para introdução da vacina conjugada meningocócica A no programa de vacinação infantil de rotina. 2 As informações sobre os últimos rascunhos podem ser solicitadas contactando o Departamento de Imunização, Vacinas e Produtos Biológicos da OMS, em vaccines@who.int. 12 Estabelecer e reforçar a vacinação no segundo ano de vida 2 SECÇÃO Introdução da vacinação ao longo da vida com ênfase no segundo ano de vida (2YL) 13 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 2 O Plano de Acção Global de Vacinas (PAGV),3 o quadro de referência global para acção na vacinação para o período de 2011-2020, apela ao alargamento equitativo dos benefícios da vacinação a todas as pessoas. O Plano de Acção indica que deve ser tomada “uma abordagem de ‘ao longo da vida, de modo a tornar os benefícios da vacinação disponíveis para todos os que estão em risco em cada grupo etário” e reconhece que “isso significará criar estratégias para atingir os indivíduos ao longo de toda a sua vida e desenvolver planos para os sistemas que irão monitorizar e rastrear o progresso.” O documento Estratégias e Práticas Globais de Vacinação de Rotina (GRISP) da OMS também identifica a vacinação para além da infância com uma de nove acções transformadoras que são essenciais para o reforço da vacinação de rotina.4 Encoraja os programas de vacinação nacionais a expandirem as visitas de vacinação agendadas para além do primeiro ano de vida e a proporcionarem as vacinas necessárias às populações pré-escolares, escolares, adolescentes e adultas. As oportunidades de vacinação, por exemplo, as visitas infantis de rotina no segundo ano de vida, as visitas de preparação do pré-escolar e as visitas escolares devem ser utilizadas para avaliar o estado da vacinação e administrar as doses anteriores em falta. A adequada concepção, distribuição e retenção a longo prazo dos boletins de vacinas (HBR) são fundamentais para assegurar o devido rastreio e fornecimento de vacinas a todos os que são para elas elegíveis. Apesar de muitos países já proporcionarem doses de vacinas de rotina a crianças no segundo ano de vida e posteriormente, espera-se que a vacinação após um ano de idade aumente nos próximos anos. Uma dose de reforço da vacina contra a difteria- tétano-tosse convulsa (DTP) é cada vez mais reconhecida como tendo importância de saúde pública e é recomendada uma segunda dose da vacina contra o sarampo (MCV2), através da vacinação de rotina, em todos os países, sendo que muitos deles a agendam durante o segundo ano de vida. Para algumas vacinas, incluindo a pneumocócica, do dengue e da meningite A, as opções de agendamento incluem uma ou mais doses de rotina no segundo ano de vida. Algumas novas vacinas, tais como a vacina contra a malária, serão provavelmente recomendadas para crianças com mais de um ano de idade. Estabelecer uma plataforma para a vacinação no segundo ano de vida irá aumentar a adopção potencial dessas vacinas quando forem introduzidas. Contudo, a vacinação é apenas uma das muitas intervenções de saúde de que as crianças pequenas necessitam para crescerem saudáveis. Como um serviço de saúde que é, muitas vezes, frequentemente utilizado em vez de outras intervenções, a vacinação pode ser uma plataforma para proporcionar outros serviços essenciais, tais como a monitorização e promoção do crescimento, gestão de doenças comuns, saneamento adequado e, em alguns locais, desparasitação, suplementação de vitamina A, suplementos de micronutrientes, prevenção e tratamento da malária e cuidados para o VIH/SIDA.5 As intervenções para melhorar o crescimento e desenvolvimento 3 www.who.int/immunization/global_vaccine_action_plan/en/ 4 www.who.int/immunization/programmes_systems/policies_strategies/GRISP/en/ 5 www.UNICEF-irc.org/article/958/ 14 Estabelecer e reforçar a vacinação no segundo ano de vida 2 S E C Ç Ã O nos primeiros dois anos de vida têm um impacto mais elevado do que em anos posteriores. Uma visita agendada durante este período também é uma oportunidade para proporcionar aconselhamento aos pais sobre nutrição, higiene, práticas de cuidados domésticos, planeamento familiar e procura de cuidados atempada. Muitos países já têm políticas de visitas regulares para monitorização do crescimento, promoção e alimentação complementar, mas a utilização das visitas diminui muitas vezes após um ano de idade, pois tanto as famílias e como os profissionais de saúde podem não as encarar como uma prioridade. Se geridas de forma estratégica, as visitas de vacinação no segundo ano de vida (2YL) podem ajudar a aumentar o progresso da vacinação e outros serviços de saúde materno-infantil. CA I X A 1. P O N TOS F U LC R A I S PA R A A VAC I N AÇÃO N O S EG U N D O A N O D E V I DA E P OST E R I O R M E N T E 1. Um número crescente de doses de vacinas são recomendadas para administração após um ano de idade como parte de uma abordagem à vacinação ao longo da vida. As recomendações globais da OMS para doses de vacinas infantis a serem dadas após um ano de idade incluem uma segunda dose da vacina contra o sarampo (MCV) e doses de reforço das vacinas contra a difteria, o tétano e a tosse convulsa. Adicionalmente, os países poderão optar por uma calendarização “2 + 1” para a vacina conjugada pneumocócica (PCV), na qual uma terceira dose é administrada no segundo ano de vida. A OMS também recomenda que as doses de algumas vacinas indicadas regionalmente, incluindo a meningite A (MenA) na cintura africana da meningite e a encefalite japonesa em zonas da Ásia, possam ser dadas após 1 ano de idade. 2. A extensão do plano de vacinação para além da infância significa que o conceito de um indicador de “criança totalmente imunizada (CTI)” deve ser prolongado no segundo ano. O CTI deve ser específico à idade da criança e ao conjunto correspondente de vacinas que uma criança deve ter recebido, de acordo com o plano nacional, até essa idade. Os programas poderão decidir rastrear o CTI em duas ou mais categorias etárias: CTI<1, CTI<2 (consultar a Secção 7.1). 3. O crescimento da complexidade e duração do plano de vacinação implica uma maior importância dos boletins de saúde (HBR), de modo a relembrar aos cuidadores quando devem regressar para completar o plano, para permitir aos prestadores de cuidados rastrearem as vacinas necessárias e para servir de base para avaliação através de inquéritos de cobertura com base na população. Os HBR devem ser bem concebidos, estar disponíveis em número suficiente para todos os cuidadores, utilizados devidamente pelo pessoal de saúde e mantidos de forma segura pelos cuidadores/famílias. 15 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 2 4. Em alguns cenários, são necessários esforços concertados, incluindo uma comunicação intensa e o desenvolvimento de competências dos profissionais de saúde para mudar a mentalidade convencional de que a vacinação é ape- nas para bebés. Se o objectivo for atingir altos níveis de cobertura no segundo ano de vida e ao longo da vida, então, os profissionais de saúde, cuidadores, comunidades e parceiros devem ter uma compreensão sólida da importância do que eles próprios podem fazer para isso acontecer. Isto requer uma grande alteração de mentalidade e práticas de todas as partes envolvidas. 5. Apesar de as crianças deverem ser vacinadas assim que forem elegíveis, não deve ser negada vacinação àquelas que forem trazidas “mais tarde”. A vacinação atempada é crucial para reduzir a exposição a doenças preveníveis pela vacinação (VPD) mas, salvo algumas excepções específicas, é melhor vacinar mais tarde do que nunca. Para a vacinação no 2º ano de vida, a idade de 24 meses não deve ser encarada como um ponto de corte a partir do qual as crianças não são vacinadas. 6. Atingir uma elevada cobertura no segundo ano de vida, mesmo com vacinas que fazem parte do plano de vacinação há muito tempo, requer ainda mais atenção, visibilidade e preparação do que a introdução de uma nova vacina, não devendo ser encarada de forma ligeira. As taxas muito elevadas de abandono da MCV1 para a MCV2, observadas em muitos países, são prova dos desafios da vacinação de um novo grupo etário. As áreas que requerem atenção especial incluem: gestão /monitorização e avaliação de dados; comunicação e desenvolvimento de competências de profissionais de saúde, incluindo supervisão de suporte e outras formas de apoio pós-formação. 7. A gestão, monitorização e avaliação de dados sobre vacinação no segundo ano de vida colocam desafios particulares. As folhas de inventário e outras ferramentas de gestão de dados devem ser actualizadas cuidadosamente para captar correctamente todas as doses administradas (mesmo se as doses não forem atempadas) e para encorajar o devido rastreio, registo e reporte das doses administradas feitos pelos profissionais de saúde, que serão necessários para assegurar a boa gestão das vacinas e a estimativa das necessidades. A monitorização do progresso em, pelo menos, duas coortes de nascimentos e proporcionar feedback significativo podem ser aspectos problemáticos. É necessário um planeamento cuidadoso e uma aprendizagem com a experiência até à data para tratar estas questões. 8. A vacinação no segundo ano de vida pode servir de plataforma para proporcionar outros serviços essenciais a crianças e mães. Se cuidadosa- mente coordenados com outros programas, os serviços de vacinação podem reforçar e estimular a aceitação de outros serviços de saúde, tais como a monitorização e promoção do crescimento, aconselhamento nutricional, suplementação de vitamina A e micronutrientes, desparasitação, educação para a saúde e planeamento familiar, prevenção da malária e acompanhamento aquando de um diagnóstico infantil precoce de VIH/ SIDA. Cada país deve aferir a periodicidade e os planos desses serviços e determinar a viabilidade da integração, com base num exame dos recursos humanos, materiais e financeiros necessários. 16 Estabelecer e reforçar a vacinação no segundo ano de vida 3 SECÇÃO Contexto sobre a vacinação no segundo ano de vida e posteriormente 17 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 3 3.1 Estará generalizada a vacinação no segundo ano de vida? Apesar de as vacinas administradas no segundo ano de vida (ou mais tarde) e de as idades em que são administradas variarem conforme os países, a vacinação no segundo ano de vida é uma prática generalizada. A partir de 2016,6 recomendaram que a DTP4 fosse dada no segundo ano de vida. 6 doenças preveníveis pela vacinação OMS: sistema de monitorização. Resumo global de 2017, aferido a 18 de Julho de 2017. países tinham políticas de vacinação que incluíam, pelo menos, uma dose de qualquer vacina a ser dada no segundo ano de vida. incluíram duas doses da vacina contra o sarampo (MCV) nos seus planos de vacinação de rotina. recomendaram que uma segunda dose, a MCV2, fosse dada no segundo ano de vida. incluem a MCV2 e uma quarta dose da vacina contra a difteria, a tosse convulsa e o tétano (DTP4) em qualquer idade. tinham políticas que suportavam a administração da MCV2 e da DTP4 ao mesmo tempo, no segundo ano de vida. 159 PAÍSES 86 PAÍSES 160 PAÍSES 135 PAÍSES 107 PAÍSES 45 PAÍSES 18 Estabelecer e reforçar a vacinação no segundo ano de vida 3 S E C Ç Ã O 3.2 Oportunidades e benefícios da vacinação no segundo ano de vida Existem vários motivos para o estabelecimento de uma plataforma forte para a vacinação e outras intervenções no segundo ano de vida e posteriormente. Aumentar a protecção contra doenças preveníveis pela vacinação (VPD) A adição de novas vacinas, e de novas doses das vacinas existentes, no segundo ano de vida aumenta a extensão da protecção das crianças contra as VPD, como indicado na Tabela 1, abaixo. A administração de doses adicionais de vacinas que já estão no plano nacional contribui para níveis mais elevados de imunidade e uma duração mais prolongada da protecção. A resposta imunitária à vacina contra o toxóide tetânico (TTCV), por exemplo, diminui com a idade, sendo por isso que a OMS recomenda que um indivíduo receba seis doses (três primárias mais duas doses de reforço, uma das quais deve ser administrada no segundo ano de vida).7 TA B E L A 1. VACINAS RECOMENDADAS PELA OMS A SEREM ADMINISTRADAS NO SEGUNDO ANO DE VIDA 7 A utilização de combinações TTCV com toxóide da difteria (Td ou DT) para revacinações de tétano subsequentes é vivamente encorajada, para manter uma alta imunidade à difteria e ao tétano ao longo da vida. VAC I N A R EC O M E N DAÇ Õ E S DA O M S Segunda dose da vacina contra o sarampo (MCV2), incluindo as vacinas contra o sarampo e rubéola (MR) e contra o sarampo, papeira e rubéola (MMR) A OMS recomenda que uma segunda dose da MCV seja adicionada ao plano de vacinação de rotina em todos os países. Onde o risco de mortalidade por sarampo entre os bebés permanece elevado, a MCV1 deve ser administrada aos 9 meses de idade e a MCV2 deve ser administrada aos 15-18 meses, com um intervalo mínimo de quatro semanas entre doses. Em países com baixo risco de infecção por sarampo entre bebés (ou seja, perto da eliminação), a MCV1 poderá ser administrada aos 12 meses; a idade ideal para administração da MCV2 baseia-se nas considerações programáticas que atingem a maior cobertura da MCV2. Vacinas contra o sarampo. Documento da posição. Genebra: Organização Mundial de Saúde; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). Quarta dose da vacina contra a difteria-tétano-tosse convulsa (DTP4) A OMS recomenda que as crianças recebam uma dose de reforço da vacina contra a DTP, preferencialmente durante o segundo ano de vida, para reforçar a imunidade contra estas doenças. Vacinas da difteria. Documento da posição. Genebra: Organização Mundial de Saúde; 2017 (www.who.int/immunization/policy/position_papers/diphtheria/en/), Vacinas do tétano. Documento da posição. Genebra: Organização Mundial de Saúde; 2017 (www.who.int/immunization/policy/position_papers/tetanus/en/), Vacinas da tosse convulsa. Documento da posição. Genebra: Organização Mundial de Saúde; 2015 (www.who.int/immunization/policy/position_papers/pertussis/en/). 19 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 3 VAC I N A R EC O M E N DAÇ Õ E S DA O M S Vacina conjugada pneumocócica (PCV) A OMS suporta a opção8 de um plano (2p+1) para a PCV, no qual duas doses principais são administradas enquanto bebé e a terceira dose (reforço) é dada entre os 9 e os 18 meses de idade. A periodicidade do reforço deve ser seleccionada para maximizar a cobertura (normalmente, 9, 12, 15 ou 18 meses), dependendo dos factores operacionais e do programa, incluindo a periodicidade dos contactos de vacinação no plano nacional de vacinação para outras vacinas. Vacinas pneumocócicas. Documento da posição. Genebra: Organização Mundial de Saúde; 2012 (www.who.int/immunization/policy/position_papers/ pneumococcus/en/) e Grupo Consultivo Estratégico de Peritos (SAGE) da OMS sobre Vacinação, Outubro de 2017. Conclusões e recomendações. Genebra: Organização Mundial de Saúde; 2017 (www.who.int/wer/2017/wer9248/en/). Vacina conjugada da Meningite A (MenA) dose de rotina A OMS recomenda uma dose única da MenA entre os 9 e os 18 meses, com base em considerações programáticas e epidemiológicas locais. Vacina conjugada da Meningite A: orientação actualizada. Documento da posição. Genebra: Organização Mundial de Saúde; 2015 (www.who.int/immunization/policy/position_papers/meningococcal/en/). Vacina conjugada contra a febre tifóide (TCV) A OMS recomenda uma dose única da TCV entre os 6 e os 23 meses, em países endémicos. A periodicidade da administração deve basear-se em considerações epidemiológicas, geográficas e programáticas. Grupo Consultivo Estratégico de Peritos (SAGE) da OMS sobre Imunização, Outubro de 2017. Conclusões e recomendações. Genebra: Organização Mundial de Saúde; 2017 (www.who.int/wer/2017/wer9248/en/). Encefalite japonesa (EJ) A OMS recomenda que a vacinação contra a EJ seja introduzida nos planos nacionais de vacinação em todas as áreas em que a EJ é reconhecida como uma prioridade de saúde pública. A OMS recomenda uma ou duas doses, a partir dos 6 meses de idade, com o calendário determinado pela epidemiologia local e o tipo de vacina. Vacinas da encefalite japonesa. Documento da posição. Genebra: Organização Mundial de Saúde; 2015 (www.who.int/immunization/policy/position_papers/ japanese_encephalitis/en/). Gripe sazonal As informações específicas em termos nacionais sobre grupos de risco, carga da doença e eficácia em termos de custos são importantes para auxiliar os legisladores nacionais e os organizadores do programa de saúde a tomarem decisões informadas sobre grupos-alvo e a periodicidade da vacinação. Nos países que a decidam introduzir, a OMS recomenda a vacinação contra a gripe sazonal a partir dos 6 meses de idade prolongando-se aos 23 ou 59 meses, com duas doses separadas por, pelo menos, 28 dias, para crianças <9 anos de idade não vacinadas anteriormente. Vacinas contra a gripe. Documento da posição. Genebra: Organização Mundial de Saúde; 2012 (www.who.int/immunization/policy/position_papers/influenza/en/). Tabela 1. 8 São recomendadas ambas as opções de calendário (3p+0 ou 2p+1). Para países que ainda não introduziram a PCV, as decisões relacionadas com a escolha de calendário devem ter em consideração as questões operacionais e de programa, incluindo a oportunidade da vacina, a cobertura que se espera atingir com uma terceira dose e os padrões de distribuição etários da doença pneumocócica. 20 Estabelecer e reforçar a vacinação no segundo ano de vida 3 S E C Ç Ã O Actualizar as crianças em relação a vacinas perdidas durante o primeiro ano de vida A vacinação no segundo ano de vida é uma oportunidade para proporcionar doses em falta de vários antigénios, incluindo a BCG,9 MCV, vacinas orais e inactivadas contra a poliomielite, pentavalente (ou DTP), vacinas pneumocócicas e vacina contra o rotavírus. Em alguns contextos, as famílias poderão enfrentar várias barreiras sociais, geográficas e económicas à vacinação total dos filhos até aos 12 meses de idade, o que contribui para a baixa cobertura. Uma plataforma forte no segundo ano de vida proporciona uma oportunidade importante para melhorar a protecção e cobertura globais. Por exemplo, num país onde a vacina contra o sarampo é administrada aos 9 meses de idade e onde é imposto um limite de um ano, as crianças ficam, à partida, limitadas a uma janela de três meses para receber a MCV1. Esta barreira deve ser removida, expandindo os serviços de vacinação para o segundo ano de vida e encorajando a vacinação de actualização para além de um ano. Vacinar crianças no 2º ano de vida com as vacinas do sarampo e outras a que não tiveram acesso no primeiro ano de vida contribui para níveis mais elevados de imunidade na população. Isto foi demonstrado numa análise de 2009 dos Inquéritos Demográficos e de Saúde (IDS) de 45 países. Demonstrou que, apesar de a cobertura da imunização de rotina agrupada para a MCV1 até aos 12 meses de idade ser de apenas cerca de 50%, subia para 80% se as doses administradas após os 12 meses de idade (ou seja «doses tardias») fossem incluídas nas estimativas de cobertura (consultar a Figura 1).10 F I G U R E 1. AU M E N TO N AS E ST I M AT I VAS D E C O B E RT U R A DA M CV 1 Q UA N D O SÃO I N C LU Í DAS AS D OS E S A D M I N I ST R A DAS N O S EG U N D O A N O D E V I DA 0 20 40 60 80 100 Afeganistão (2015) Chade (2014) Haiti (2012) Mali (2013) Paquistão (2013) Iémen (2013) Zâmbia (2014) Cobertura em crianças <12 meses Cobertura adicional em crianças de 12-23 meses. Cobertura da MCV1 por categoria etária nos países selecionados Fonte: Inquérito demográfico e de saúde (data do inquérito indicada para cada país) 21 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 3 Criar oportunidades para integrar a vacinação com outras intervenções de saúde e nutrição Um contacto de rotina agendado com o sistema de saúde no segundo ano de vida é uma oportunidade para integrar ainda mais a vacinação com outras intervenções de saúde, tais como a suplementação de vitamina A, aconselhamento nutricional, monitorização e promoção do crescimento, desparasitação, cuidados de VIH/SIDA pediátricos, fornecimento de redes mosquiteiras tratadas com insecticida (ITN) ou planeamento familiar. A Figura 2 ilustra os potenciais ganhos de cobertura para várias intervenções de saúde infantil em África, quando integradas com a plataforma de vacinação de rotina F I G U R A 2. C O B E RT U R A E ST I M A DA DAS I N T E RV E N Ç Õ E S E N T R E AG R EGA D OS FA M I L I A R E S C O M U M A C R I A N ÇA E N T R E OS 1 2 E OS 2 3 M E S E S, S E I N T EG R A DA N A VAC I N AÇÃO D E ROT I N A ( 2 8 PA Í S E S DA Á F R I CA SU B -SA H A R I A N A ) 0 20 40 60 80 100 Fonte melhorada de água potável* Propriedade de rede mosquiteira do agregado Criança dorme sob a rede mosquiteira Criança recebe suplementação de Vitamina A Cobertura actual Cobertura total provável *Pelo fornecimento de kits de tratamento de água (após melhoramento da fonte de água potável) 9 O documento da posição da OMS sobre vacinas BCG foi recentemente actualizado para incluir a recomendação para vacinação de actualização para bebés e crianças mais velhas, uma vez que as evidências demonstram que ainda é benéfica para além do ano de idade. Grupo Consultivo Estratégico de Peritos (SAGE) da OMS sobre Imunização, Outubro de 2017. Conclusões e recomendações. Genebra: Organização Mundial de Saúde; 2017 Documento da posição actualizado a ser publicado em Fevereiro de 2018). 10 Clark A, Sanderson C. Periodicidade das vacinações infantis em 45 países de baixo e médio rendimento: uma análise dos dados do inquérito. Lancet. 2009;373:1543–9. 22 Estabelecer e reforçar a vacinação no segundo ano de vida 3 S E C Ç Ã O Fazer uma utilização mais eficiente das vacinas Proporcionar duas doses da vacina contra o sarampo, com uma no segundo ano de vida, pode reduzir potencialmente as taxas de desperdício da vacina, uma vez que serão administradas mais doses por frasco de vacina aberto. Isto também poderá ser verdade para actualizar as crianças com outras doses de vacinas que perderam em bebés e que lhes são administradas numa idade posterior. 3.3 Desafios da vacinação no segundo ano de vida Nos últimos 40 anos, os programas de vacinação acumularam um manancial de experiência na administração de vacinas, principalmente a bebés. Desde que a vacinação no segundo ano de vida foi introduzida em muitos países, a experiência tem sido mista. Por exemplo, muitos programas nacionais presumiram que a introdução da MCV2 através de uma nova visita de rotina no segundo ano de vida não traria complicações, uma vez que a MCV já está no calendário no primeiro ano de vida e, por conseguinte, os cuidadores e profissionais de saúde já a conhecem. Contudo, a realidade demonstrou que isso traz consigo uma complexidade substancial, em alguns casos de uma natureza não encontrada anteriormente pelos programas de vacinação. As elevadas taxas de abandono da MCV1 para a MCV2 têm sido uma preocupação particular em muitos países. A implementação bem sucedida da vacinação no segundo ano de vida requer solidez no planeamento, coordenação, mobilização comunitária e geração da procura, monitorização e apoio à implementação. © W H O N epal 23 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 3 Muitos programas de vacinação ainda encaram a vacinação como uma intervenção de saúde apenas para bebés, não oferecendo vacinas a crianças com mais de um ano de idade, mesmo que nunca tenham sido vacinadas. Apesar de ser necessário estabelecer políticas para a vacinação para além de um ano de idade, sem planeamento, formação e comunicação apropriados, estas políticas não se traduzirão automaticamente em alterações generalizadas nas práticas de vacinação. Os factores que se tem verificado contribuírem para esta situação incluem: • mensagens insuficientes para os profissionais de saúde de primeira linha sobre as políticas revistas em relação ao fornecimento de vacinação e outros serviços de saúde após um ano de idade; • hesitação dos profissionais de saúde em vacinarem crianças >12 meses de idade com a MCV1, pois não contribui para a cobertura da MCV1 e poderão preocupar-se em não terem doses suficientes para as crianças < 12 meses; • prioridade mais baixa colocada na vacinação das crianças mais velhas, em comparação com a vacinação de bebés. comunicação e mobilização social insuficientes para relembrar e encorajar os cuidadores a utilizarem os serviços de saúde no segundo ano de vida; • complexidade nos registos, reporte e análise das doses das vacinas dadas após um ano de idade; • barreiras do sistema, tais como recursos humanos limitados e cadeias de abastecimento descoordenadas, para diferentes produtos. As avaliações pós-introdução (API) da segunda dose da vacina do sarampo em vários países, assim como estudos de caso sobre vacinação no 2º ano de vida, indicam que a introdução de qualquer vacinação após o primeiro ano de vida deve ser tratada como se fosse a introdução de uma nova vacina, em termos de atenção, visibilidade e preparação, devendo-se ainda ter em conta as complexidades acrescidas à vacinação de um novo grupo etário no processo de planeamento. Se possível, a vacinação no 2º ano de vida também deve ser colocada no contexto de uma visita de rotina, para que possa reforçar a administração de outras intervenções de saúde, e vice-versa. 24 Estabelecer e reforçar a vacinação no segundo ano de vida Políticas e planeamento para a vacinação no segundo ano de vida e posteriormente 4 SECÇÃO 25 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 4 Virtualmente todos os países já têm em vigor políticas, directrizes e outros apoios de programa para os cuidados de saúde infantis ao longo dos primeiros cinco anos de vida, incluindo a monitorização e promoção do crescimento, aconselhamento nutricional e gestão integrada das doenças da infância, entre outros. Dependendo das suas prioridades de saúde e plano de vacinação actual, os países poderão querer: introduzir a vacinação no segundo ano de vida como uma nova intervenção (através de uma visita agendada, ou visitas e actualização da vacinação em falta) reforçar a vacinação existente no 2º ano de vida (por exemplo, melhorar a fraca cobertura da MCV2) e/ou desenvolver um contacto de vacinação no 2º ano de vida como uma plataforma para a prestação coordenada de outros serviços de saúde infantis. Nas três situações, é necessário um planeamento sistemático para tratar tanto as questões técnicas como as de gestão. A segunda situação (melhoria de programas existentes) é abordada na Secção 10. 1. 2. 3. © U N IC EF/U N 0 58138/V ishw anathan 26 Estabelecer e reforçar a vacinação no segundo ano de vida 4 S E C Ç Ã O 4.1 Passos para o planeamen- to da introdução ou do reforço de uma visita no 2º ano de vida Se o objectivo for o estabelecimento de uma nova visita de vacinação no 2º ano de vida, o processo de planeamento deve começar um ano antes da data de lançamento prevista, de modo a permitir tempo suficiente para os preparativos descritos abaixo. Podem ser encontrados mais detalhes sobre a operacionalização desses passos num recurso adicional Um manual para o planeamento, implementação e reforço da vacinação no segundo ano de vida (Manual 2YL). Identificar um ponto focal no 2º ano de vida e estabelecer ou activar um grupo de trabalho para o 2º ano de vida O ponto focal do 2º ano de vida deve ser um membro do pessoal do programa de vacinação nacional, com autoridade suficiente para convocar um grupo de trabalho. O grupo de trabalho deve incluir representação de várias áreas do programa de vacinação, tais como gestão de dados, comunicações e prestação de serviços. Se se desejar a coordenação de outras intervenções de saúde com a vacinação do 2º ano de vida, também deve ser incluída a representação desses grupos. Devem ser — R EC U RS O E SS E N C I A L Um manual para o planeamento, implementação e reforço da vacinação no segundo ano de vida Um recurso adicional a este documento, o Manual 2YL destina-se à utilização após ter sido tomada a decisão de prolongar a vacinação no 2º ano de vida, ou melhorar a cobertura de uma plataforma existente. O Manual 2YL fornece orientações práticas sobre o planeamento, gestão, implementação e monitorização da vacinação durante uma visita ou visitas agendadas no 2º ano de vida, bem como passos úteis para o reforço da vacinação quando a cobertura no 2º ano de vida não tenha atingido as metas do programa. www.who.int/immunization/ programmes_systems/policies_ strategies/2YL/en/ Establishing and strengthening immunization in the second year of life Handbook envolvidos também os principais intervenientes e parceiros na vacinação e saúde infantil. Os membros do grupo de trabalho poderão aumentar à medida que o planeamento evolui. O Grupo Técnico Consultivo Nacional sobre Vacinação (NITAG) deve estar envolvido e desempenhar um papel de liderança na revisão de consider- ações epidemiológicas e clínicas, bem como as necessidades, custos e questões financeiras do programa de vacinação e o desenvolvimento de políticas e directrizes. A Comissão Coordenadora Interagências (CCI) e/ou as comissões coordenadoras do sector da saúde também devem ser envolvidas, de modo a garantir o empenho e a estabelecer uma compreensão partilhada dos recursos necessários. 11 www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ 27 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 4 — R EC U RS O E SS E N C I A L Ferramenta para estimar os custos de introdução de uma visita infantil de rotina no 2º ano de vida.13 A UNICEF desenvolveu uma ferramenta de cálculo de custos relativamente simples, com base em Excel, para estimar os custos da introdução de uma visita no 2º ano de vida. A ferramenta deve ser preenchida com dados demográficos, preços de produtos, salários de profissionais de saúde e custos aproximados para actividades de formação e comuni- cação. Os resultados são então apresentados em termos de custos totais, custos anuais e custos por visita. Os custos são divididos em custos «adiantados» (por exemplo, a formação) e custos recorrentes que precisam de ser continuamente finan- ciados (tais como vacinas e seringas). A análise de custos pode ser encarada como uma oportunidade de defesa da introdução de uma visita no 2º ano de vida. A ferramenta também deve ser utilizada como parte integrante do processo de planeamento. Desenvolver um plano de acção orça- mentado e assegurar o financiamento Isto deve incluir actividades, principais re- sponsabilidades, marcos, cronologia e recursos necessários para tratar as seguintes acções, devendo ser informado por lições aprendidas e desafios das introduções de vacinas anteriores. 1. Actualizar políticas e directrizes; obter as aprovações necessárias; produzir e dissemi- nar (em papel e/ou electronicamente). 2. Definir os indicadores do 2º ano de vida para registo e reporte, rever o sistema de informação de gestão da saúde (SIGS) e as ferramentas de gestão de dados (HBR, registos, relatórios mensais) e distribuí-los antes da data de lançamento. 3. Identificar e tratar das necessidades para a organização da prestação de serviços. 4. Modificar as ferramentas de gestão da cadeia de abastecimento e da logística, conforme necessário, para incluir novas doses de vacinas e outras intervenções no segundo ano de vida. 5. Preparar, imprimir e distribuir um guia de campo e auxiliares de trabalho para profissionais de saúde. 6. Desenvolver um plano de formação e novos materiais de formação e supervisão e realizar a formação. 7. Desenvolver uma estratégia de comuni- cação, planear e conduzir actividades de mobilização social e envolvimento comunitário, incluindo estudos de 12 Ferramentas para conduzir análises comportamentais, incluindo um Guia para estudar as interações profissional de saúde/cuidador para a vacinação. Genebra: Organização Mundial de Saúde; 2017 e O guia para personalizar programas de vacinação (TIP). Copenhaga: Gabinete Regional da OMS para a Europa; 2013, estão disponíveis em: www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/. 13 A ferramenta de cálculo de custos do 2º ano de vida pode ser acessada em: www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ conhecimentos-atitudes-práticas (CAP) ou outras análise comportamentais,12 particularmente em relação a comunidades marginalizadas e de difícil acesso. 8. Assegurar o financiamento para executar todo o trabalho de preparação e para cobrir os custos operacionais e outros custos relacionados com o 2º ano de vida. 28 Estabelecer e reforçar a vacinação no segundo ano de vida 4 S E C Ç Ã O Políticas, directrizes e normas • Política de vacinação e manuais de referência • Política de saúde infantil/de saúde nacional • Directrizes e outros materiais de referência para profissionais de saúde, inclusive sobre GIDI Documentos de planeamento • Plano plurianual abrangente (PPA) e o plano anual de acção para a vacinação • Formatos para microplaneamento e planos para os introduzir Ferramentas de gestão de dados • HBR • Folhas de inventário • Formulários de relatório mensal • Registos de unidades sanitárias • Registos comunitários • SIGS, Ferramenta de Gestão de Dados de Vacinação Distritais (DV-DMT), sistema de informação de saúde distrital, versão 2 (DHIS2) • Ferramentas e gráficos de monitorização Formação e desenvolvimento de competências • Currículo para formação inicial e em serviço • Instrumentos de supervisão • Auxiliares de trabalho Gestão da cadeia de abastecimento • Avaliação da cadeia de frio, da logística e do armazenamento disponível • Procedimentos operacionais padrão (POP) para o manuseamento de vacinas no 2º ano de vida • Ferramentas de previsão de vacinas e logística Comunicação, geração da procura • Comunicação e plano e estratégia de envolvimento comunitário • Planos e materiais para o lançamento • Materiais de educação para a saúde e auxiliares de trabalho Atribuir responsabilidades claras para cada aspecto da preparação. Podem ser reactivados os grupos ou comissões que, no passado, tenham sido estabelecidos para trabalhar nessas questões, para campanhas de vacinação ou novas introduções de vacinas. Contudo, se se desejar a inclusão de outras intervenções de saúde juntamente com a vacinação do 2º ano de vida, também deve ser incluída a representação de outros programas, como nutrição, gestão integrada de doenças da infância (GIDI), malária, água e saneamento, VIH/SIDA pediátrico, etc. Chegar a acordo sobre os serviços ou intervenções a proporcionar durante a visita e identificar as políticas, directrizes e outros materiais que devem ser revistos. É provável que entre estes se incluam os apresentados na Tabela 2, abaixo, mas poderá haver materiais adicionais a rever, dependendo do país. TA B E L A 2. MATERIAIS A REVER E ACTUALIZAR PARA A VACINAÇÃO E SERVIÇOS NO 2º ANO DE VIDA 29 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 4 4.2 Decidir a calendarização da visita ou visitas no 2º ano de vida Um passo essencial passa por decidir a idade apropriada para a qual agendar a visita (ou visitas) do 2º ano de vida. Trata-se de uma função de dados epidemiológicos para as VPD em questão, mais o plano para outros serviços de saúde infantil, conforme especificado pelas políticas nacionais. Os legisladores e decisores precisam de considerar os objectivos de saúde pública e as questões programáticas, utilizando critérios transparentes para avaliar a sua importância relativa. As políticas e directrizes de vacinação nacionais devem estar escritas de modo a articularem claramente as acções necessárias dos profissionais de saúde e dos cuidadores. Por exemplo: • Esclarecer que, apesar de ser melhor vacinar as crianças assim que se tornam elegíveis, para a maioria das vacinas não existe limite de idade superior após o qual se deva negar à criança a protecção da vacinação. As excepções são a vacina contra o rotavírus, que não é recomendada >24 meses de idade e a dose da hepatite B (HepB) à nascença.14 • Transmitir o objectivo pretendido das doses de vacina no 2º ano de vida. Se o país estiver a introduzir uma segunda dose da MCV no seu plano de rotina, então a dose deve ser incluída no requisito de criança totalmente imunizada (CTI) e deve ser referenciada como Sarampo 2 ou MR2 ou MMR2, em vez de uma dose de reforço. I DA D E S PA R A V I S I TAS AG E N DA DAS N O 2 º A N O D E V I DA PA R A VAC I N AÇÃO, E M T R Ê S PA Í S E S Um país da África Austral decidiu fornecer a MCV2 aos 18 meses, pois coincide com a idade para a suplementação de vitamina A. Um país da África Ocidental escolheu fornecer a MCV2 aos 15 meses para minimizar o período de tempo de exposição potencial ao vírus do sarampo, apesar de a periodicidade não estar sincronizada com o calendário para outros serviços de saúde prestados durante o segundo ano de vida. Um país do Sul da Ásia introduziu inicialmente a MCV2 e a DTP4 em meses diferentes no segundo ano de vida, por motivos epidemiológicos. Contudo, foi mais tarde reconhecido que isto adicionava complexidade ao plano de vacinação e contribuía para a perda de oportunidades de vacinação. O país modificou então o plano de modo a recomendar ambas as doses na mesma visita. E X P E R I Ê N C I A N AC I O N A L 14 É importante que os programas tenham uma política clara em relação até quão tarde a dose da HepB à nascença pode ser administrada. Alguns países param de proporcionar a dose da HepB à nascença para além de duas semanas após o nascimento, de modo a manter um intervalo de quatro semanas entre doses. Contudo, em países que utilizam um calendário com 4 doses (com vacinas combinadas), não é necessário um intervalo de quatro semanas antes da primeira dose principal (uma vez que o calendário de combinação cumpre os requisitos de dosagem) e, por conseguinte, a dose da HepB à nascença pode ser administrada até ao dia antes de ter de ser administrada a primeira vacina combinada. Ambas as opções são aceitáveis. Para mais informações, consultar Um guia para a introdução e fortalecimento da vacinação da dose da hepatite B à nascença. Genebra: Organização Mundial de Saúde; 2015. (www.who.int/immunization/documents/general/ISBN9789241509831/en/). 30 Estabelecer e reforçar a vacinação no segundo ano de vida 4 S E C Ç Ã O • Fornecer instruções claras sobre como rastrear adequadamente crianças quanto à elegibilidade para revisão de HBR, registar doses, relatar dados e utilizá-los para melhorar os serviços. • Especificar as acções que os profissionais de saúde devem tomar quando se deparam com situações que não representam o ideal, tais como quando chegam crianças com doses perdidas ou em atraso, crianças sem HBR, etc. (consultar o Anexo 3). • Indicar com clareza a política sobre a vacinação de crianças com 12 ou mais meses e doses em falta, durante actividades de intensificação periódica da vacinação de rotina (IPVR), tais como os Dias de Saúde Infantil (consultar a Caixa 2, abaixo). 4.3 Actualizar a vacinação sempre que uma criança tenha contacto com os serviços de saúde As visitas de crianças doentes e visitas a unidades para cuidados de outros membros da família no segundo ano de vida também são oportunidades para actualizar as doses perdidas pelas crianças no primeiro ano de vida, bem como para fazer o rastreio e vaciná-las com as doses agendadas para o segundo ano de vida. A P R E N D E R C O M A P O L Í T I CA D E VAC I N AÇÃO D O GA N A A política de vacinação da República do Gana foi actualizada para fornecer orientações claras aos profissionais de saúde sobre a vacinação de crianças com mais de 12 meses de idade. Política de vacinação de rotina no segundo ano de vida O contacto de rotina adicional para vacinações será feito durante o segundo ano de vida de uma criança, aos 18 meses ou logo após. Os serviços disponíveis neste contacto incluem MR2, MenA e qualquer intervenção considerada apropriada (por exemplo, suplementação de vitamina A). Política de actualização Todas as crianças devem ser vacinadas de acordo com o plano de vacinação recomendado do Gana. As crianças com doses em falta devem ser vacinadas com o antigénio apropriado até aos cinco anos de idade. Durante qualquer visita de saúde, deve ser aferido o estado de vacinação de uma criança e administradas as doses em falta, de acordo com o plano de actualização recomendado. Criança totalmente imunizada (CTI) O indicador CTI divide-se em três categorias: CTI até ao um ano de idade, CTI até aos dois anos de idade e CTI após os dois anos de idade. Uma criança é considerada como estando totalmente imunizada de acordo com a sua idade, se tiver recebido todas as vacinas apropriadas para a idade até essa altura. E X P E R I Ê N C I A N AC I O N A L 31 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 4 As políticas de vacinação e a formação/supervisão dos profissionais de saúde devem enfatizar a importância de os cuidadores trazerem o HBR da criança até às unidades sanitárias em cada visita e o fornecimento de vacinação de actualização sempre que uma criança tenha contacto com o sistema de saúde. Devem ser estabelecidas e amplamente divulgadas directrizes claras sobre vacinações de actualização para antigénios perdidos no primeiro ano de vida, incluindo um plano de vacinação acelerado para crianças que apresentem várias doses de vacinas em falta. Um recurso útil neste aspecto são as recomendações da OMS sobre vacinações de actualização, disponíveis em: www.who.int/immunization/policy/Immunization_routine_table3.pdf CA I X A 2. P RO P O RC I O N A R VAC I N AÇÃO D O 2 º A N O D E V I DA D U R A N T E E V E N TOS D E I P V R As actividades de intensificação periódica da vacinação de rotina (IPVR), tais como os Dias de Saúde Infantil ou as Semanas de Saúde Materno-infantil, se conduzidas com regularidade, devem ser utilizadas para actualizar crianças com doses em falta do primeiro ano de vida e fornecer as vacinas do 2º ano de vida às quais a criança tem direito. As políticas de vacinação e a formação dos profissionais de saúde para as IPVR devem proporcionar orientações claras sobre este ponto. As actividades de IPVR também devem ser utilizadas como uma oportunidade para comunicar a importância da vacinação no segundo ano de vida e a necessidade de as crianças serem trazidas para todas as vacinas do 2º ano de vida, de acordo com o plano nacional. As actividades de IPVR devem também sublinhar a importância do encorajamento aos cuidadores para trazerem o HBR da criança para cada contacto de saúde. Nas políticas, manuais de campo, formação e supervisão, devem ser incluídas orientações para profissionais de saúde sobre rastreio, prestação de serviços e registo de doses, tanto para as doses de rotina no 2º ano de vida como para as actividades de IPVR. Para mais informações sobre as melhores práticas para actividades de IPVR, consultar o recurso da OMS Intensificação periódica da vacinação de rotina. Lições aprendidas e implicações na actuação. Disponível em : www.who.int/ immunization/programmes_systems/policies_strategies/piri_020909.pdf? 32 Estabelecer e reforçar a vacinação no segundo ano de vida 4 S E C Ç Ã O 4.4 Coordenar a vacinação com outros serviços no segundo ano de vida Caso seja decidido utilizar a visita de vacinação do 2º ano de vida para proporcionar intervenções adicionais, o processo de planeamento deve envolver representantes dos outros programas de saúde relacionados. Analisar e comparar os atributos técnicos de outras intervenções propostas para a(s) visita(s) de rotina no 2º ano de vida As prioridades, objectivos, conquistas, desafios e planos de diferentes intervenções de saúde e nutrição com base em evidências, oferecidas no segundo ano de vida, devem ser sistematicamente comparados para identificar as oportunidades e os limites do contacto de vacinação no 2º ano de vida, no sentido de reforçar outros serviços. Isto poderá implicar a convocação de uma reunião, ou reuniões, para favorecer a comunicação e negociação directas entre os intervenientes em relação à prestação contínua de cuidados a crianças pequenas e ao papel da vacinação nesse âmbito. O pacote de serviços a prestar durante a visita do 2º ano de vida deve ser baseado numa combinação de considerações técnicas e de gestão orientadas para o cliente. As questões a considerar na decisão dos componentes do pacote incluem as seguintes. • Quais são as prioridades de saúde pública estabelecidas pelo Ministério da Saúde? • Que intervenções podem ser proporcionadas nas idades dos 12 aos 23 meses, estarão algumas dessas visitas já estabelecidas e será a sua periodicidade coincidente com um plano recomendado para a vacinação do 2º ano de vida? • Que serviços, e quantos, podem ser agendados para uma única visita no 2º ano de vida e irá isto melhorar a conveniência para a criança e o cuidador? • Poderão as intervenções ser todas proporcionadas às crianças através de serviços fixos (estáticos), de locais de proximidade e móveis e serão essas estratégias de prestação de serviços plenamente funcionais? • As intervenções propostas para esta visita são realizadas por todo o país ou apenas em determinadas áreas geográficas? • Qual a semelhança nos requisitos logísticos? • Quais são as implicações para os recursos humanos, incluindo capacidade de pessoal, tempo a despender por paciente e fluxo de pacientes? • Estarão disponíveis recursos humanos e financeiros suficientes para proporcionar e sustentar cada intervenção proposta para visita? 33 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 4 Alguns países planearam serviços integrados que incluem a vacinação para além de um ano de idade e avaliaram a experiência para identificarem formas de melhorar os serviços. As lições aprendidas de tais experiências podem ajudar a guiar outros países nos seus processos de tomada de decisões e planeamento. O PAC OT E D E I N T E RV E N Ç Õ E S DA Z Â M B I A PA R A U M A V I S I TA D E ROT I N A A B R A N G E N T E AOS 1 8 M E S E S D E I DA D E Um ano após a República da Zâmbia ter introduzido a MCV2, o Ministério da Saúde e parceiros analisaram a experiência de modo a decidir como fortalecer o desempenho e integrar a vacinação no 2º ano de vida com outros serviços. Foi convocada uma reunião na qual funcionários de vários programas, incluindo vacinação, nutrição e saúde infantil, bem como representantes do SIGS, equipas provinciais e distritais e parceiros técnicos fulcrais, deliberaram sobre formas de a visita no 2º ano de vida para a MCV2 poder servir necessidades de saúde adicionais. Um resultado essencial foi a definição do pacote de serviços indicado abaixo. Isto reflectiu, em parte, uma decisão do MdS no sentido de alterar a sua estratégia de fornecimento da suplementação de vitamina A e desparasitação para a afastar das Semanas de Saúde Infantil e as aproximar dos serviços de rotina. Com 18 meses, todas as crianças recebem agora o seguinte: • MCV2 • Actualização de outras vacinações que a criança perdeu no primeiro ano de vida e para as quais ainda é elegível • Monitorização e promoção do crescimento • Suplementação da vitamina A • Tratamento de desparasitação (mebendazol) Para algumas crianças, se indicado, também são fornecidos os seguintes: • Seguimento/encaminhamento para diagnóstico infantil precoce (DIP) de VIH/SIDA; • Encaminhamento para a GIDI ou Gestão integrada de casos comunitários (GCCI) para crianças com febre ou outros sinais de doença durante a visita. E X P E R I Ê N C I A N AC I O N A L © U N IC EF/U N 0 152973/Scherm brucker 34 Estabelecer e reforçar a vacinação no segundo ano de vida 4 S E C Ç Ã O LIÇÕES APRENDIDAS COM AS HONDURAS NA INTEGRAÇÃO DA VACINAÇÃO COM OUTROS SERVIÇOS NOS PRIMEIROS CINCO ANOS DE VIDA O programa de vacinação na República das Honduras serve de plataforma sólida para a prestação de outros serviços dos 2 aos 5 anos de idade. Estes incluem a suplementação de vitamina A, ácido fólico para as mães, promoção da amamentação em exclusivo, educação sobre a identificação de tumores oculares e medidas locais limitadas no tempo para conter surtos de cólera e controlar o dengue. Um estudo da experiência inicial identificou o que se segue. • Uma coordenação e planeamento conjunto próximos entre os diferentes programas e diferentes níveis do sistema de saúde são essenciais para o sucesso. • São essenciais directrizes técnicas e programáticas preparadas em conjunto para definir com clareza a prestação das intervenções a serem providenciadas durante as visitas de rotina que incluem vacinação. • Os profissionais de saúde, em todos os níveis, devem ter formação sobre as directrizes técnicas. • É necesário prever, adquirir, distribuir e armazenar atempadamente e com rigor todos os materiais, e não apenas as vacinas, necessários ao nível da unidade sanitária para a visita de rotina. • Um grupo de trabalho de comunicações deve desenvolver um plano de comunicações estratégico que inclua o desenvolvimento de materiais, a utilização dos meios de comunicação, o envolvimento da comunidade, bem como uma cronologia e orçamento. • Os formulários para registo e reporte dos dados devem ser adaptados e o SIGS actualizado em conformidade com os mesmos. • Deve ser executada a monitor- ização sistemática, por faixa etária e estratégia de progresso em relação aos objectivos. • A supervisão conjunta com o pessoal de todos os programas relevantes deve dar prioridade a áreas de grande densidade populacional e áreas em risco. • Os desafios à integração sustentada incluem o financia- mento incerto e o abastecimento limitado de produtos essenciais. Fonte: Molina-Aguilera et al. J. Inf. Dis. 2012;205 (Supl. 1). E X P E R I Ê N C I A N AC I O N A L 5 SECÇÃO 35 Estabelecer e reforçar a vacinação no segundo ano de vida Planeamento ao nível das unidades, organização dos serviços e recursos humanos 36 Estabelecer e reforçar a vacinação no segundo ano de vida 5 S E C Ç Ã O A introdução de uma visita agendada no 2º ano de vida para a vacinação requer um planeamento detalhado para a implementar no seio da organização existente e para a prestação de serviços fixos, de locais de proximidade e móveis. Os supervisores das unidades e distritais têm um papel importante a desempenhar no ajustamento do microplaneamento e na revisão da organização dos serviços, fluxo de pacientes, recursos humanos e prevenção de oportunidades perdidas de vacinação. O nível nacional deve proporcionar orientações para a actualização de modelos de microplaneamento e para assegurar uma prestação de serviços de alta qualidade, especialmente se existir uma sequência preferencial para a administração das inter- venções. A vacinação, como um procedimento invasivo, deve ser administrada, em geral, após outros procedimentos.15 Contudo, o profissional de saúde deve concluir a interacção com o cuidador dando orientações sobre o que fazer em caso de efeitos secundários ou eventos adversos e quando e onde regressar para a próxima visita. 5.1 Actualizar as ferramentas e os processos de microplaneamento Em muitos países, as ferramentas de microplaneamento actualmente em utilização são concebidas para suportar o planeamento da vacinação no primeiro ano de vida. Para acomodar a vacinação no 2º ano de vida, as ferramentas de microplaneamento devem ser revistas e expandidas de modo a incluir a coorte do segundo ano, com idades entre os 12 e os 23 meses. A população-alvo são os bebés sobreviventes da coorte de nascimentos do ano anterior. Por exemplo, se a DTP4 estiver agendada para ser administrada a crianças que tenham 18 meses de idade ou mais, então o grupo- alvo para o microplaneamento do ano corrente é o numero de bebés sobreviventes do ano anterior. Estas informações devem estar disponíveis nos planos do ano anterior. A vacinação atempada durante uma visita agendada no segundo ano de vida é altamente desejável, mas a idade de 24 meses não deve ser encarada como um ponto de corte, a partir do qual as crianças não são vacinadas. O microplaneamento deve ser baseado na coorte com idades entre os 12 e os 23 meses e, mesmo que as crianças sejam vacinadas para além da idade-alvo, não afecta o número ou área de captação das crianças a serem vacinadas, apenas a idade em que realmente recebem as vacinas. Como é descrito em maior detalhe na Secção 7, todas as doses, independente- mente de quando são administradas, devem ser registadas em HBR, folhas de inventário, registos da unidade, registos de vacinação electrónicos (RVE) e relatórios mensais, de acordo com a idade em que a criança realmente recebeu as vacinas. 15 Reduzir a dor no momento da vacinação. Documento da posição. Genebra: Organização Mundial de Saúde; 2015. (www.who.int/wer/2015/wer9039.pdf). 37 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 5 O microplaneamento deve prestar particular atenção à identificação de locais de proximidade que sejam convenientes para o(s) cuidador(es), tendo em conta que uma criança no 2º ano de vida é agora mais velha, mais pesada e mais difícil de transportar do que um bebé. Também é mais provável que as mães estejam a trabalhar fora de casa. Para melhorar o acesso e reduzir as taxas de abandono, a selecção do local, dia da semana e hora para as sessões em locais de proximidade devem, sempre que possível, ser decididas através de consulta com os membros da comunidade. A prestação de serviços de saúde adicionais durante a visita agendada do 2º ano de vida significa que o microplaneamento deve tratar as funcionalidades operacionais desses serviços, bem como as da vacinação. O pessoal responsável pela nutrição, saúde infantil, água e saneamento, VIH/SIDA, planeamento familiar, educação para a saúde ou outros programas, deve ser encorajado a participar no processo de microplaneamento. 5.2 Rever as implicações nos recursos humanos para a visita no 2º ano de vida Muitos países de baixos recursos enfrentam limitações severas em termos de recursos humanos, pelo que a verdadeira situação do pessoal nas unidades sanitárias fica aquém dos padrões governamentais. A capacidade de proporcionar serviços variados durante a visita requer que estejam presentes os tipos certos de profissionais de saúde em cada unidade. Durante a fase de planeamento do 2º ano de vida ao nível nacional, os funcionários da saúde devem rever a disponibilidade real dos recursos humanos nas unidades sanitárias, sendo-lhes fornecidas orientações sobre os tipos de pessoal que podem executar cada tarefa. Poderá ser necessário rever os termos de referência e responsabilidades. Ao nível clínico, os enfermeiros-chefes ou chefes de unidade devem comunicar com clareza a sequência de serviços, tanto para os serviços fixos, como de locais de proximidade. Também devem designar que pessoal irá executar tarefas específicas (descritas mais detalhadamente na Secção 8). Estas incluem: • rastreio de crianças para determinar que serviços devem receber nesse dia; • proporcionar cada serviço numa ordem pré-definida, por exemplo, monitorização e promoção do crescimento, suplementação de vitamina A, desparasitação, vacinação, aconselhamento; • registo dos serviços administrados, em todas as ferramentas apropriadas, imediatamente após os serviços serem proporcionados; • discutir, com cada cuidador, o que a criança acabou de receber e que mais acções o cuidador precisa de tomar. 38 Estabelecer e reforçar a vacinação no segundo ano de vida 5 S E C Ç Ã O Em unidades sanitárias mais pequenas, em que um, ou alguns, membro do pessoal executa todas as funções, é preferível que os profissionais de saúde na unidade recebam formação para proporcionarem todos os serviços do 2º ano de vida, de modo a assegurar uma prestação de serviços contínua quando quaisquer membros da equipa estiverem de licença. Tanto nos pontos de prestação de serviços fixos como de locais de proximidade, os profissionais de saúde comunitários (PSC), ou voluntários com formação, poderão ser capazes de auxiliar os profissionais de saúde com o fluxo de pacientes, educação para a saúde e, possivelmente, alguns aspectos da manutenção de registos. No seio das comunidades, as tarefas do PSC poderão incluir o registo de recém-nascidos, manutenção dos registos comunitários das crianças dos 0 aos 59 meses de idade e de grávidas, rastreio pré-definido e seguimento, conversas com os membros da comunidade sobre a importância da vacinação e de outros serviços no segundo ano de vida, informando-os de quando e onde procurar os serviços. Contudo, algumas tarefas são menos apropriadas para PSC ou voluntários. Por exemplo, o rastreio de crianças dos 12 aos 23 meses sobre a elegibilidade para a vacinação é mais complexo do que o da vacinação de bebés, uma vez que o número de doses que estas crianças já deveriam, nessa idade, ter recebido, é superior e poderá haver incertezas sobre como lidar com doses em falta ou em atraso. Portanto, provavelmente, isto irá requerer profissionais de saúde com formação. Em unidades sanitárias mais pequenas com pessoal limitado, é preferível que todos os profissionais de saúde recebam formação para proporcionarem todos os serviços do 2º ano de vida, de modo a assegurar uma prestação de serviços contínua quando quaisquer membros da equipa estiverem de licença. © W H O /Reidy 39 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 5 5.3 Determinar a viabilidade de proporcionar todos os serviços desejados para a visita no 2º ano de vida e as questões práticas do fluxo de pacientes Em contextos de baixos recursos, poderá não ser sempre possível ter todos os serviços disponíveis ao mesmo tempo e no mesmo local. Por exemplo, um mandado a nível nacional para a vacinação diária poderá não ser exequível numa unidade pequena, apenas com um ou dois profissionais de saúde que proporcionam todos os serviços. Em situações como esta, é importante comunicar amplamente e mobilizar as com- unidades para virem em busca dos serviços nos dias específicos em que são oferecidos. Ao nível distrital e das unidades, os funcionários da saúde devem ter em mente as seguintes questões: • Quais seriam as tarefas específicas para cada tipo de profissional de saúde no fornecimento da vacinação, mais outros serviços, durante a visita do 2º ano de vida? O que, se algo, fará de modo — R EC U RS OS E S S E N C I A I S Guias de recursos de Oportunidades Perdidas de Vacinação (OPV) A estratégia da OMS para a redução das oportunidades perdidas de vacinação (OPV) pretende aumentar a cobertura da vacinação, fazendo uma melhor utilização dos locais de vacinação existentes (em centros de saúde, hospitais, serviços de proximidade/móveis, etc.). Para além de melhorar a cobertura, reduzir as OPV irá melhorar a prestação de serviços de saúde e promover a sinergia entre programas. www.who.int/immunization/ programmes_systems/policies_ strategies/MOV/en/ diferente da prática actual numa base diária, mensal, trimestral ou anual? • Que constrangimentos é provável ocorrerem que possam resultar em tempos longos de espera, especialmente em unidades com muito volume? Os supervisores clínicos devem determinar como reduzir os tempos de espera. • Em situações em que todos os pacientes passam primeiro pelo funcionário de registo antes do acesso aos serviços, poderá este passo ser utilizado para comunicar com os pais, responder às suas questões e fazer a triagem das crianças para os diferentes pontos de serviço? Em alguns casos, pode ser possível proporcionar determinados serviços na área de registo ou de espera, antes de as mães ou cuidadores se dispersarem para outros departamentos. Poderá ser necessário destacar pessoal da vacinação ou de outros departamentos para o balcão de registo de forma rotativa, para auxiliar neste passo. 40 Estabelecer e reforçar a vacinação no segundo ano de vida 5 S E C Ç Ã O 16 As avaliações OPV executadas no Chade (2015), Timor-Leste (2015) e Burkina Faso (2016) indicaram que ocorre uma proporção maior de OPV no segundo ano de vida. • Todos os serviços propostos a serem fornecidos durante uma visita do 2º ano de vida para vacinação são realmente fornecidos e estão disponíveis nos mesmos dias? Surgem oportunidades de vacinação perdidas e outros serviços quando nem todo o pessoal ou serviços são fornecidos à mesma hora, no mesmo lugar. A complexidade adicional da visita do 2º ano de vida poderá requerer a revisão do plano para os serviços de locais de proximidade, de forma a optimizar a utilização dos recursos humanos. • Existem políticas e práticas em vigor para que todas as crianças tenham os seus HBR e sejam rastreadas e vacinadas, conforme apropriado, quando vêm em busca de qualquer tipo de cuidados (curativos e/ou preventivos)? As avaliações nacionais recentes demonstraram que as taxas de oportunidades perdidas de vacinação (OPV) são particularmente elevadas durante as visitas no segundo ano de vida.16 Por conseguinte, é importante conceber e organizar os serviços de formas que encoragem à coordenação ente as diferentes intervenções de saúde. As conclusões da avaliação indicam também que apenas 1 a 2 visitas para cuidados preventivos ocorrem durante o segundo ano de vida, pelo que existe uma necessidade ainda maior de capitalizar nessas oportunidades. Num país que tenha levado a cabo uma avaliação de OPV, as conclusões devem ser incorporadas num planeamento para melhor organizar os serviços. Políticas devem ser postas em prática para assegurar que todas as crianças carreguem seus HBRs e sejam rastreadas e vacinados, se necessário, quando eles vierem para qualquer tipo de serviço de saúde. © W H O 41 Estabelecer e reforçar a vacinação no segundo ano de vida Gestão da cadeia de abastecimento de vacinas e outros produtos 6 SECÇÃO 42 Estabelecer e reforçar a vacinação no segundo ano de vida 6 S E C Ç Ã O 6.1 Produtos necessários para a vacinação e outros serviços no segundo ano de vida Os organizadores devem rever todos os bens necessários para a visita do 2º ano de vida, quer para vacinação como para outros serviços. Quaisquer ajustes necessários para previsão, distribuição e armazenamento devem ser identificados e tratados de modo a assegurar que todos os produtos estão disponíveis em cada ponto de prestação de serviços. A Tabela 3 apresenta um exemplo ilustrativo com base no pacote de serviços adoptado na Zâmbia. Os países podem adaptá-lo para corresponder ao pacote de serviços que pretendem incluir na sua visita de rotina do 2º ano de vida. TA B E L A 3. I N T E RV E N Ç Õ E S E P RO D U TOS D E VAC I N AÇÃO E O U T ROS S E RV I Ç OS N U M A V I S I TA AG E N DA DA N O 2 º A N O D E V I DA (exe m p l o i l u s t rat i vo) S E RV I Ç O/ I N T E RV E N ÇÃO P RO D U TOS N EC E S SÁ R I OS PAS S OS A P R E PA R A R PA R A A V I S I TA D O 2 º A N O D E V I DA Dose de vacina recomendada no 2º ano de vida (MCV2, MenA, reforço DPT4/Penta) • Vacina • Solução de diluição • Agulhas e seringas • Caixas de segurança • Ferramentas de gestão de dados actualizadas • Prever quantidades adicionais de vacinas necessárias, se existentes • Aferir as necessidades para maior capacidade de armazenamento a frio • Prever quantidades adicionais de agulhas e seringas necessárias • Estimar as caixas de segurança adicionais necessárias • Rever e tratar o aumento das necessidades de gestão de resíduos • Actualizar as ferramentas de registo e reporte Actualização de outras vacinações que a criança perdeu no primeiro ano de vida • Vacina • Solução de diluição • Agulhas e seringas • Caixas de segurança • Ferramentas de gestão de dados actualizadas • Prever quantidades adicionais de vacinas, se necessárias17 • Aferir as necessidades para maior capacidade de armazenamento a frio • Prever quantidades adicionais de agulhas e seringas necessárias • Estimar as caixas de segurança adicionais necessárias • Rever e tratar o aumento das necessidades de gestão de resíduos • Assegurar que as ferramentas de gestão de dados permitem o registo/reporte de doses «atrasadas» 43 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 6 S E RV I Ç O/ I N T E RV E N ÇÃO P RO D U TOS N EC E S SÁ R I OS PAS S OS A P R E PA R A R PA R A A V I S I TA D O 2 º A N O D E V I DA Suplementação da vitamina A • Cápsulas de 200 000 IU de Vitamina A • Pinças/tesouras • Ferramentas de gestão de dados • Prever as quantidades necessárias para o fornecimento de vitamina A na visita de rotina do 2º ano de vida. Isto poderá representar uma alteração na estratégia de prestação de serviços (se anterior- mente prestados através de Dias de Saúde Infantil semi-anuais, por exemplo) • Rever as quantidades fornecidas nos kits de medicamentos essenciais, de modo a determinar se são suficientes para suprir as necessidades para os serviços de rotina • Conforme necessário, tratar das dis- crepâncias entre as necessidades previs- tas e as quantidades disponíveis através dos kits de medicamentos essenciais Tratamento de desparasitação • Medicação de desparasitação • Ferramentas de gestão de dados • Prever as quantidades necessárias para o tratamento de desparasitação a adminis- trar na visita de rotina do 2º ano de vida • Comparar com as quantidades fornecidas nos kits de medicamentos essenciais, de modo a determinar se são suficientes para suprir as necessidades para os serviços de rotina • Conforme necessário, tratar das dis- crepâncias entre as necessidades previs- tas e as quantidades disponíveis através dos kits de medicamentos essenciais Monitorização e promoção do crescimento • Balanças • Fitas de circunferência do braço médio (MUAC) • Materiais de aconselhamento • Registo de crescimento, se separado do HBR • Ferramentas de gestão de dados • Rever a disponibilidade de todos os produtos e materiais no ponto de prestação de serviços, com base nos níveis estimados de utilização e frequência durante o segundo ano de vida Seguimento do diagnóstico infantil precoce de VIH/SIDA • Ferramentas de gestão de dados • Materiais de aconselhamento • Analisar se são necessárias quantidades adicionais de medicamentos como o cotrimoxazol como parte dos passos de seguimento 17 No geral, poderão não ser necessárias quantidades adicionais, pois estas são «vacinações atrasadas» de crianças já contabilizadas na previsão de vacinas do ano anterior, não doses adicionais. Contudo, para cobrir os desperdícios ao nível do campo, os países poderão considerar doses adicionais para actualização com base nas coberturas dos anos anteriores. 44 Estabelecer e reforçar a vacinação no segundo ano de vida 6 S E C Ç Ã O Dependendo das intervenções que os países escolham proporcionar em conjunto com a vacinação no 2º ano de vida, outros potenciais produtos a considerar poderão incluir: • suplementação de zinco preventiva ou utilização do zinco na gestão da diarreia18 • vários pós de micronutrientes • tratamentos para má nutrição aguda grave • suplementos de ferro • redes mosquiteiras tratadas com insecticida (ITN) Em alguns países, os produtos como a suplementação de vitamina A e a medicação de desparasitação são fornecidos principalmente através de actividades do estilo de campanhas, como os Dias de Saúde Infantil semi-anuais ou semanas que têm as suas próprias cadeias de abastecimento, que operam de forma independente das dos serviços de rotina. Se os países decidirem passar a fornecê-los através de uma visita integrada no 2º ano de vida, então devem assegurar que existem quantidades suficientes em todos os pontos de prestação de serviços para uma prestação de rotina. Em países em que esses produtos são fornecidos às unidades sanitárias como parte dos kits de medicamentos essenci- ais, determinar se os kits fornecem quantidades suficientes para suprir as necessidades das visitas do 2º ano de vida. Os países podem consultar as directrizes e normas do seu programa existente ou referências globais, incluindo as directrizes da OMS Suplementação da vitamina A em bebés e crianças dos 6 aos 59 meses de idade19 e Quimioterapia de prevenção na helmintíase humana. Utilização coordenada de medicamentos anti-helmínticos em intervenções de controlo: um manual para profissionais de saúde e gestores de programas.20 18 www.who.int/elena/titles/zinc_diarrhoea/en/ 19 www.who.int/nutrition/publications/micronutrients/guidelines/vas_6to59_months/en/ 20 www.who.int/neglected_diseases/preventive_chemotherapy/9789241547109/en/ 45 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 6 6.2 Vacinas e materiais de vacinação no segundo ano de vida 21 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ — R EC U RS O E SS E N C I A L Princípios e considerações para adicionar uma vacina a um programa nacional de vacinação. Da decisão à implementação e monitorização Este recurso explica os princípios essenciais e questões a serem considerados ao introduzir uma nova vacina num programa nacional de vacinação e inclui referências e ferramentas/listas de verificação para o planeamento, implementação e monitorização. Cabe realçar que este guia também destaca as formas de utilizar a oportunidade de adicionar uma nova vacina para reforçar os sistemas de saúde e de vacinação. www.who.int/immunization/ programmes_systems/policies_ strategies/vaccine_intro_ resources/nvi_guidelines/en/ Na previsão dos requisitos para a vacinação no segundo ano de vida, a população-alvo são os bebés sobreviventes da coorte de nascimentos do ano anterior. Por exemplo, se a MenA estiver agendada para ser administrada a crianças que tenham 18 meses de idade, então o grupo-alvo para fins de previsão para o ano corrente é o numero de bebés sobreviventes do ano anterior. Como indicado na Caixa 1, a vacinação atempada durante uma visita do 2º ano de vida é altamente desejável, mas a idade de 24 meses não deve ser encarada como um ponto de corte, a partir do qual as crianças não são vacinadas. As implicações práticas para a previsão são de que esta se deve basear na coorte dos 12 aos 23 meses. Se as crianças forem vacinadas para além dos 23 meses, isso não afecta o número de doses necessárias, apenas a idade em que realmente recebem essas doses. Apesar de as doses deverem ser registadas e reportadas com precisão em folhas de inventário e relatórios mensais de acordo com a idade real da vacinação, isto não deve afectar as práticas de gestão de stocks. Introduzir uma nova vacina Caso se vá introduzir uma vacina completa- mente nova (por exemplo, MenA) no plano de vacinação de rotina no segundo ano de vida, então os organizadores nacionais devem consultar o documento da OMS Princípios e considerações para adicionar uma vacina a um programa nacional de vacinação. Da decisão à implementação e monitorização. As Secções 3.4 e 3.5 contêm uma discussão aprofundada da gestão e previsão das vacinas.21 As modificações específicas na gestão da cadeia de abastecimento irão depender das características da nova vacina a ser introduzida. 46 Estabelecer e reforçar a vacinação no segundo ano de vida 6 S E C Ç Ã O Adicionar outra dose de uma vacina que já se encontra no plano Se a visita do 2º de ano de vida for incluir o fornecimento de uma dose adicional ou de reforço de uma vacina que já faz parte do plano nacional, os preparativos necessários também irão depender da(s) vacina(s) em questão. A introdução de uma segunda dose da vacina contra o sarampo ou MR em frascos de 10 doses foi estimada como requerendo um aumento de 15 a 25% no espaço de armazena- mento da cadeia de frio. A necessidade de doses de vacinas adicionais é compensada em certa medida por uma redução esperada na taxa de desperdício para vacinas em frascos de 10 doses, pois devido ao aumento da população-alvo, serão utilizadas mais doses por frasco. Foi estimado que a taxa de desperdício da vacina contra o sarampo poderá ser reduzida em 40% com a mudança de um plano com uma dose para um plano com duas doses. 22 Os gestores de programas e técnicos de logística também precisam de monitorizar e rever a taxa de desperdício e o factor de desperdício para a vacina contra o sarampo, com base em quaisquer alterações nas políticas, ou práticas concretas, em relação às circunstâncias para profissionais de saúde abrirem frascos de várias doses dessas vacinas. Com formação adicional ou reforço das competências, deve tornar-se prática corrente 22 Um guia para a introdução de uma segunda dose da vacina contra o sarampo nos calendários de vacinação de rotina. Genebra: Organização Mundial de Saúde; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) pp. 21–22. — R EC U RS O E SS E N C I A L Um guia para a introdução de uma segunda dose da vacina contra o sarampo nos planos de vacinação de rotina Este recurso proporciona orientação para suportar as discussões de política e aspectos operacionais da introdução de uma segunda dose da vacina contra o sarampo no plano de vacinação de rotina. Fornece indicações úteis sobre assuntos específicos à vacinação no segundo ano de vida, incluindo a previsão de vacinas, comuni- cações e monitorização de dados. http://www.who.int/ immunization/documents/WHO_ IVB_13.03/en/ A Guide to Introducing a Second Dose of Measles Vaccine into Routine Immunization Schedules os profissionais de saúde abrirem frascos de 10 doses quando apenas uma ou duas crianças forem trazidas a uma sessão de vacinação. Esta prática iria melhorar a vacinação atempada, que é uma prioridade importante do programa, em particular para o sarampo. Contudo, poderia potencialmente aumentar as taxas de desperdício. Em relação à introdução da DTP4, o efeito na gestão da cadeia de abastecimento é determinado pelo produto de vacina a ser utilizado. Por exemplo, se um país que 47 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 6 utiliza a vacina pentavalente para a vacinação de bebés planeia proporcionar a DTP4 utilizando apenas a DTP, então a situação é semelhante a adicionar uma nova vacina à cadeia de frio. Se o país, por outro lado, decidir proporcionar a DTP4 na forma de uma dose adicional da vacina pentavalente, então os requisitos adicionais de armazenamento a frio poderão ser minimizados e, em termos de programa, será mais fácil gerir os materiais. A utilização da vacina pentavalente significa que as doses adicionais de hepatite B e Haemophilus influenzae tipo B (Hib), apesar de não serem prejudiciais, irão ser proporcionadas sem qualquer necessidade. Trata-se de uma decisão que necessitará de ser ponderada pelo programa nacional. Vacinação de actualização para doses perdidas no primeiro ano de vida Muitos países já contabilizam alguma vacinação de actualização utilizando os produtos existentes. Com a introdução de uma plataforma para o 2º ano de vida e políticas reforçadas para actualização da vacinação, é possível que os requisitos de vacinas e logística aumentem a curto prazo; por conseguinte, os gestores devem monitorizar as tendências no consumo de vacinas, para que possam ajustar as suas previsões de vacinas em conformidade. O impacto potencial na gestão das vacinas e da cadeia de frio da vacinação de actualização pode ser estimado com base numa combinação de factores, incluindo dados de tendências anteriores sobre a vacinação em crianças maiores de um ano, o número previsto de doses de cada vacina a ser dada após um ano de idade e se os frascos das vacinas em questão podem ser utilizados em dias subsequentes depois de terem sido abertos, de acordo com a política de frascos multidose.23 Outros produtos para vacinação São necessárias quantidades acrescidas de agulhas, seringas e caixas de segurança para acomodar as vacinas adicionais a dar no segundo ano. A Secção 3.5 de Princípios e considerações para adicionar uma vacina a um programa nacional de vacinação. Da decisão à implementação e monitorização fornece orientações detalhadas sobre este assunto.24 As quantidades necessárias destes produtos irão depender da cobertura estimada para cada dose de cada vacina e é provável que isto se altere com o tempo. Em alguns países, a taxa de abandono da MCV1 para a MCV2 era inicialmente elevada, mas depois caiu passados alguns anos, enquanto que noutros persistiram taxas de abandono elevadas. Os gestores de programa e técnicos de logística devem monitorizar os padrões reais de cobertura e o consumo de vacinas todos os anos, ajustando as suas metas e previsões em conformidade. 23 Declaração de Política da OMS: Política de frascos multidose (PFM), revisão de 2014. Genebra: Organização Mundial de Saúde; 2014 (www.who.int/immunization/documents/general/WHO_IVB_14.07/en/). 24 www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines/en/ 48 Estabelecer e reforçar a vacinação no segundo ano de vida 7 SECÇÃO Registo, reporte e utilização de dados para a tomada de decisões 49 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 7 O registo, reporte e utilização de dados a todos os níveis pode ser o aspecto mais complexo da introdução da vacinação no segundo ano de vida. Devem ser clara- mente definidos os grupos-alvo a serem vacinados, ou a quem serão prestados outros serviços, devendo ser utilizados denominadores apropriados para calcular a cober- tura nesses grupos-alvo. Para determinar o requisito de dados, devem ser tomadas decisões sobre os tipos de informação, devendo ser utilizados indicadores para monitorizar o desempenho e guiar as acções. Os instrumentos de registo de dados e reporte precisam de ser revistos cuidadosamente e com contributos dos utilizadores finais, de modo a assegurar que promovem o rastreamento correcto para a elegibilidade, prestação de serviços e práticas de registo e reporte por parte dos profissionais de saúde. Esta secção examina os seguintes tópicos. 1. INDICADORES DE DESEMPENHO. Os programas devem decidir como moni- torizar a introdução e o desempenho e como os indicadores serão utilizados para guiar as actividades e a tomada de decisões. Devem também consid- erar formas alternativas de obter os dados do programa, por exemplo, através de inquéritos de cobertura com base na população ou inquéritos de conhecimentos- atitudes-práticas (CAP). 2. REQUISITOS DE DADOS. Assim que os indica- dores de desempenho forem conhecidos, podem ser definidos os requisitos de dados para a geração dos indicadores. 3. ACTUALIZAR FORMULÁRIOS E SISTEMAS DE DADOS. Isto inclui todas as ferramentas de registo, reporte e monitorização. © U N IC EF/U N 0 26564/Parry 50 Estabelecer e reforçar a vacinação no segundo ano de vida 7 S E C Ç Ã O 7.1 Indicadores de desempenho A core principle in deciding which changes to make to data management tools and Um princípio nuclear na decisão sobre que alterações devem ser feitas nas ferramentas e procedimentos de gestão de dados é que devem ser recolhidos apenas os dados que têm probabilidade de serem utilizados. Os países devem ter noção de que existem determinados indicadores globais de vacinação que devem ser reportados regular- mente. Contudo, outras necessidades de dados poderão variar de país para país, dependendo das prioridades e problemas do programa. A Tabela 4 apresenta indicadores de vacinação relevantes para o estabelecimento ou reforço de uma visita no 2º ano de vida. A medição de indicadores do 2º ano de vida requer o registo e marcação das doses administradas até à idade de administração. Em cenários em que se sabe que a vacinação acontece tarde e a melhoria das cronologias é uma prioridade, as folhas de inventário podem ser desagregadas em três grupos etários: 0–11 meses, 12–23 meses e >24 meses. Isto irá permitir que o programa monitorize se a pontualidade melhora ao longo do tempo. Um país com um registo forte de vacinação atempada poderá não ver isto como importante, preferindo que as suas folhas de inventário tenham apenas dois grupos etários: 0–11 meses e >12 meses. Para evitar a sobrecarga dos profissionais de saúde com os requisitos de reporte, os países devem ponderar cuidadosamente quais, se alguns, dados adicionais serão necessários para os indicadores do 2º ano de vida e aproveitarem a oportunidade para rever e, possivelmente, remover os indicadores que não são utilizados actualmente. Nesta base, os países precisam de decidir que dados recolher de forma administrativa todos os anos, de todos os pontos de prestação de serviços de vacinas, e que dados recolher com menor frequência através de inquéritos de cobertura com base na população, tais como Inquéritos Demográficos e de Saúde (IDS), Inquéritos de Aglomeração de Indicadores Múltiplos (IAIM) ou estudos CAP. É importante diferenciar entre os dados recolhidos através de cada um destes métodos. Os inquéritos de cobertura com base na população para a vacinação de rotina devem ser adaptados para captar dados sobre todas as doses administradas. O documento Inquéritos de aglomeração de cobertura de vacinação: manual de referência (2017)25 da OMS proporciona orientação para definir as populações-alvo a serem inquiridas se a vacinação se prolongar para além de um ano de idade. Para cobertura das vacinas recomendadas entre os 12 a 23 meses de idade (por exemplo, MCV2, DTP4), o Manual de referência sugere sondar as crianças entre os 24 e 35 meses de idade, para além daquelas com 12 a 23 meses de idade, normalmente sondadas sobre as vacinas recomendadas <12 meses. Monitorização do abandono da MCV1 para a MCV2 O abandono da MCV1 para a MCV2 deve ser monitorizado ao nível das unidades, subnacional e nacional, com base em relatórios de resumo mensais. Também se 25 http://www.who.int/immunization/documents/who_ivb_18.09/en/ 51 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 7 26 Um guia para a introdução de uma segunda dose da vacina contra o sarampo nos calendários de vacinação de rotina. Genebra: Organização Mundial de Saúde; 2013 (www.who.int/immunization/documents/WHO_IVB_13.03/en/) Anexo 6, p.16. encorajam gráficos de monitorização ao nível das unidades. Isto complica-se com o facto de as doses estarem agendadas para serem administradas a duas coortes de nascimentos diferentes; contudo, na realidade, a diferença real no tamanho entre coortes para dois anos consecutivos é muito pequena, pelo que, para efeitos do cálculo do abandono, deve ser utilizado o mesmo denominador para ambas as doses. A recomendação é utilizar como denominador os bebés sobreviventes na coorte a receber a MCV1.26 Um gráfico de monitorização de cobertura de amostra, incluindo o abandono da MCV1 para a MCV2, é incluído no Anexo 2. Monitorizar se são providenciadas todas as intervenções previstas para uma visita agendada no 2º ano de vida A visita no 2º ano de vida é uma oportunidade para proporcionar inúmeros serviços à mesma criança, encorajando uma maior utilização dos serviços durante uma idade vulnerável. É importante ter em funcionamento um sistema para monitorizar a entrada de todas as intervenções proporcionadas durante a visita do 2º ano de vida. Por exemplo, se o desempenho para a vacinação for superior ao de outros serviços, pode sinalizar obstáculos no fornecimento e ajudar os gestores a identificar problemas específicos e explorar soluções. Se todos os serviços a serem proporcionados durante a visita do 2º ano de vida forem registados no mesmo registo, então os chefes e supervisores de unidade podem executar verificações pontuais regulares para aferir até que ponto as crianças que vêm para a visita do 2º ano de vida recebem todos esses serviços. Por outro lado, registar vários serviços no mesmo lugar pode resultar num registo grande e incontrolável que rapidamente se pode tornar inútil. A exequibilidade destas práticas de registo devem ser discutidas e testadas com os profissionais de saúde. A captação de intervenções integradas também pode ser monitorizada através de visitas às unidades, inquéritos e entrevistas de saída. Determinar a criança totalmente imunizada (CTI) A adição de novas vacinas e novas doses de vacinas existentes, no segundo ano de vida, adiciona complexidade à tarefa do profissional de saúde de utilizar dados administrativos para determinar uma CTI, de acordo com a idade e com o plano de vacinação nacional. O CTI, como indicador, deve ser específico à idade da criança e ao conjunto correspondente de vacinas que a criança deve ter recebido, até essa idade, de acordo com o plano nacional. Cada vez se verifica mais o caso de uma criança dever receber 15 ou mais doses de vacinas nos primeiros 15 a 18 meses de vida. Isto aumenta a quantidade de tempo de que um profissional de saúde necessita para rever o cartão de saúde da criança ou ver todas as entradas do registo para determinar se a criança está totalmente imunizada. Uma opção é dividir o indicador em duas ou mais categorias (CTI <12 meses, CTI <24 meses). Em alternativa, os programas poderão optar por não incluir CTI nas folhas de inventário, mas em vez disso monitorizar o(s) indicador(es) através de inquéritos de cobertura de vacinação periódicos. 52 Estabelecer e reforçar a vacinação no segundo ano de vida 7 S E C Ç Ã O TA B E L A 4. R E SU M O D OS I N D I CA D O R E S D E VAC I N AÇÃO R E L AT I VOS AO 2 º A N O D E V I DA I N D I CA D O R RECOMENDAÇÃO I N T E R P R E TAÇÃO AÇ Õ E S P OT E N C I A I S N O CAS O D E D E S E M P E N H O BA I XO FO N T E D OS DA D OS C O B E RT U R A ‘Total MCV2’ MCV2 administrada em qualquer altura (atempada mais tardia) Indicador nuclear Proporção de crianças vacinadas com, pelo menos, duas doses de rotina da vacina contra o sarampo, incluindo tanto as doses a tempo como as doses tardias Analisar os motivos do baixo desempenho. Dependendo das razões identificadas, as acções possíveis poderão incluir o reforço das competências dos profissionais de saúde, mobilização social e actividades de comunicação sobre a importância das duas doses das vacinas contra o sarampo, ou da melhoria do rastreio padrão. Dados administrativos ou inquérito com base na população ‘Total DTP4’ Quarta dose da vacina contra a DTP administrada em qualquer altura (atempada mais tardia) Indicador nuclear Proporção de crianças que receberam uma dose de reforço da vacina contra a DTP, incluindo doses a tempo e doses tardias Analisar os motivos do baixo desempenho. Dependendo das razões identificadas, as acções possíveis poderão incluir actividades de reforço das competências dos profissionais de saúde, mobilização social e actividades de comunicação sobre a importância da dose de reforço, ou da melhoria do rastreio padrão. Dados administrativos ou inquérito com base na população Doses de outras vacinas agendadas para serem dadas após um ano de idade (por exemplo, MenA) Indicador nuclear Proporção de crianças que receberam as doses indicadas no plano de vacinação após 12 meses Analisar os motivos do baixo desempenho. Dependendo dos motivos identificados, as possíveis acções poderão incluir assegurar um fornecimento adequado da vacina, reforçar as competências dos profissionais de saúde e conduzir actividades de comunicação e mobilização social para promover a procura e a utilização dessas vacinas. Dados administrativos ou inquérito com base na população Criança totalmente imunizada (CTI) aos 24 meses Opcional excepto se a fonte dos dados for um inquérito com base na população Proporção de crianças vacinas, de forma atempada, com todas as doses de todas as vacinas que estejam no plano nacional de vacinação a serem administradas até à idade de < 24 meses Rever as razões e tomar as medidas. Se indicado, trabalhar para alterar o paradigma do PAI como programa de bebés para um que atinja coortes à nascença múltiplas. As acções poderão incluir o reforço dos conhecimentos e competências dos profissionais de saúde através da formação, supervisão e comentários; reforço do rastreio padrão; melhorar o reporte de dados e aumentar a comunicação e mobilização social direccionadas aos profissionais de saúde, comunidades, famílias e cuidadores. Inquéritos com base na população Outras intervenções de saúde, por exemplo, suplementação de vitamina A em idades agendadas no programa nacional Consultar o programa relevante para orientação Verificar junto dos programas de saúde relevantes para interpretação Procurar contributos de outros programas para analisar os motivos para o baixo desempenho e acções apropriadas a tomar. Procurar orientação a partir dos programas relevantes P O N T UA L I DA D E ‘DTP3 tardia’ DTP3 após 12 meses Indicador opcional Captura o número de crianças que completam a sua série primária de vacinas contra a DTP mais tarde; no 2º ano de vida ou mais tarde.Medição da visita no 2º ano de vida para actualização Aumentar a comunicação para famílias e cuidadores sobre a importância da vacinação atempada. Implementar melhores sistemas de recordação/lembrete para rastrear os infratores atempadamente. Dados administrativos (se os dados são desagregados por idade e conhecidos como sendo de elevada qualidade) ou inquérito com base na população ‘MCV1 tardia’ MCV1 após 12 mesesb Indicador nuclear Captura o número de crianças que receberam a MCV1 mais tarde; no 2º ano de vida ou mais tarde. Medição da visita no 2º ano de vida para actualização Aumentar a comunicação para famílias e cuidadores sobre a importância da vacinação atempada. Dados administrativos (se os dados são desagregados por idade e conhecidos como sendo de elevada qualidade) ou inquérito com base na população A BA N D O N O Taxa de abandono da MCV1 para a MCV2 Indicador nuclear Descreve todos os que não regressam para uma segunda dose de uma vacina contra o sarampo Através da supervisão, feedback e formação, melhorar a comunicação interpessoal do profissional de saúde para relembrar aos cuidadores para regressarem para a segunda dose; reforçar as competências técnicas do profissional de saúde conforme necessário; aumentar o rastreio padrão e a comunicação com as comunidades sobre a necessidade da MCV2. Inquérito com base na população ou dados administrativos aos níveis subnacional e nacional. Poderá ser possível analisar tais dados ao nível da unidade. 53 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 7 TA B E L A 4. R E SU M O D OS I N D I CA D O R E S D E VAC I N AÇÃO R E L AT I VOS AO 2 º A N O D E V I DA I N D I CA D O R RECOMENDAÇÃO I N T E R P R E TAÇÃO AÇ Õ E S P OT E N C I A I S N O CAS O D E D E S E M P E N H O BA I XO FO N T E D OS DA D OS C O B E RT U R A ‘Total MCV2’ MCV2 administrada em qualquer altura (atempada mais tardia) Indicador nuclear Proporção de crianças vacinadas com, pelo menos, duas doses de rotina da vacina contra o sarampo, incluindo tanto as doses a tempo como as doses tardias Analisar os motivos do baixo desempenho. Dependendo das razões identificadas, as acções possíveis poderão incluir o reforço das competências dos profissionais de saúde, mobilização social e actividades de comunicação sobre a importância das duas doses das vacinas contra o sarampo, ou da melhoria do rastreio padrão. Dados administrativos ou inquérito com base na população ‘Total DTP4’ Quarta dose da vacina contra a DTP administrada em qualquer altura (atempada mais tardia) Indicador nuclear Proporção de crianças que receberam uma dose de reforço da vacina contra a DTP, incluindo doses a tempo e doses tardias Analisar os motivos do baixo desempenho. Dependendo das razões identificadas, as acções possíveis poderão incluir actividades de reforço das competências dos profissionais de saúde, mobilização social e actividades de comunicação sobre a importância da dose de reforço, ou da melhoria do rastreio padrão. Dados administrativos ou inquérito com base na população Doses de outras vacinas agendadas para serem dadas após um ano de idade (por exemplo, MenA) Indicador nuclear Proporção de crianças que receberam as doses indicadas no plano de vacinação após 12 meses Analisar os motivos do baixo desempenho. Dependendo dos motivos identificados, as possíveis acções poderão incluir assegurar um fornecimento adequado da vacina, reforçar as competências dos profissionais de saúde e conduzir actividades de comunicação e mobilização social para promover a procura e a utilização dessas vacinas. Dados administrativos ou inquérito com base na população Criança totalmente imunizada (CTI) aos 24 meses Opcional excepto se a fonte dos dados for um inquérito com base na população Proporção de crianças vacinas, de forma atempada, com todas as doses de todas as vacinas que estejam no plano nacional de vacinação a serem administradas até à idade de < 24 meses Rever as razões e tomar as medidas. Se indicado, trabalhar para alterar o paradigma do PAI como programa de bebés para um que atinja coortes à nascença múltiplas. As acções poderão incluir o reforço dos conhecimentos e competências dos profissionais de saúde através da formação, supervisão e comentários; reforço do rastreio padrão; melhorar o reporte de dados e aumentar a comunicação e mobilização social direccionadas aos profissionais de saúde, comunidades, famílias e cuidadores. Inquéritos com base na população Outras intervenções de saúde, por exemplo, suplementação de vitamina A em idades agendadas no programa nacional Consultar o programa relevante para orientação Verificar junto dos programas de saúde relevantes para interpretação Procurar contributos de outros programas para analisar os motivos para o baixo desempenho e acções apropriadas a tomar. Procurar orientação a partir dos programas relevantes P O N T UA L I DA D E ‘DTP3 tardia’ DTP3 após 12 meses Indicador opcional Captura o número de crianças que completam a sua série primária de vacinas contra a DTP mais tarde; no 2º ano de vida ou mais tarde.Medição da visita no 2º ano de vida para actualização Aumentar a comunicação para famílias e cuidadores sobre a importância da vacinação atempada. Implementar melhores sistemas de recordação/lembrete para rastrear os infratores atempadamente. Dados administrativos (se os dados são desagregados por idade e conhecidos como sendo de elevada qualidade) ou inquérito com base na população ‘MCV1 tardia’ MCV1 após 12 mesesb Indicador nuclear Captura o número de crianças que receberam a MCV1 mais tarde; no 2º ano de vida ou mais tarde. Medição da visita no 2º ano de vida para actualização Aumentar a comunicação para famílias e cuidadores sobre a importância da vacinação atempada. Dados administrativos (se os dados são desagregados por idade e conhecidos como sendo de elevada qualidade) ou inquérito com base na população A BA N D O N O Taxa de abandono da MCV1 para a MCV2 Indicador nuclear Descreve todos os que não regressam para uma segunda dose de uma vacina contra o sarampo Através da supervisão, feedback e formação, melhorar a comunicação interpessoal do profissional de saúde para relembrar aos cuidadores para regressarem para a segunda dose; reforçar as competências técnicas do profissional de saúde conforme necessário; aumentar o rastreio padrão e a comunicação com as comunidades sobre a necessidade da MCV2. Inquérito com base na população ou dados administrativos aos níveis subnacional e nacional. Poderá ser possível analisar tais dados ao nível da unidade. a O denominador deve ser a coorte à nascença dos 12 aos 23 meses (ou seja, bebés sobreviventes), mesmo se os dados estiverem desagregados em três grupos etários. b Este indicador é mais útil em países onde se recomenda a administração da MCV1 aos 9 meses. Em países onde a MCV1 está agendada para ser administrada aos 12 meses ou depois, precisaria de ser modificada para se adequar. 54 Estabelecer e reforçar a vacinação no segundo ano de vida 7 S E C Ç Ã O 7.2 Requisitos de dados Determinar os denominadores Para vacinações agendadas para serem administradas após o primeiro ano de vida, a melhor meta é a estimativa de bebés sobreviventes da coorte de nascimentos do ano anterior. A cobertura administrativa das vacinas pode então ser estimada dividindo as doses administradas do ano corrente (numerador) pelo número estimado das crianças sobreviventes da coorte à nascença do último ano (denominador). Registo das doses administradas As doses de vacinas devem ser marcadas em, pelo menos, dois grupos etários (0 aos 11 meses e >12 meses), como um padrão mínimo ou, preferencialmente, três grupos etários (0 aos 11 meses, 12 aos 23 meses, >24 meses) como a melhor prática. São apresentados exemplos de folhas de inventário com estes dois grupos etários alternativos no Anexo 1. A criação de subcategorias adicionais para o registo das doses, tais como prestação de serviços (fixos ou de locais de proximidade), aumenta o volume de trabalho dos profissionais de saúde e a probabilidade de erros; por conseguinte, a desagregação por grupos extra para além da idade deve ser cuidadosamente considerada. As formas como tais dados adicionais serão utilizados para guiar as actividades devem ser claramente identificadas, de modo a determinar se esses dados precisam mesmo de ser recolhidos. Se necessário, podem ser utilizadas folhas de inventário para as sessões de serviços fixos e de locais de proximidade, sendo que as folhas de reporte mensais devem ter linhas separadas para cada antigénio para sessões de serviços fixos e de locais de proximidade. Alguns intervenientes recomendaram a monitorização dos indicadores de saúde por sexo, de modo a assegurar a equidade; contudo, os inquéritos de cobertura demon- straram repetidamente que o sexo de uma criança não é uma barreira à vacinação.27 O CTI, como indicador, deve ser específico à idade da criança e ao conjunto correspondente de vacinas que uma criança deve ter recebido, de acordo com o plano nacional, até essa idade. © U N IC EF/U N 0 59893/Rom eo 55 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 7 27 Estado de desigualdade: vacinação na infância. Genebra: Organização Mundial de Saúde; 2016 . www.who.int/gho/health_equity/report_2016_immunization/en/ CA I X A 3. P RO M OV E R R EG I STOS E R E P O RT E S P R EC I S OS PA R A M E L H O R A R OS S E RV I Ç OS Os profissionais de saúde poderão ter relutância em registar doses de modo preciso, se recearem sofrer sanções disciplinares por documentarem práticas que não estão de acordo com os padrões nacionais. É essencial a documentação adequada das práticas reais se se quiser detectar e resolver os problemas; por conseguinte, o registo e reporte adequados devem ser encorajados e apoiados. Por exemplo, se a primeira dose da MCV for administrada após o ano de idade, precisa de ser registada como a primeira dose, independentemente da idade da criança. Se os profissionais de saúde sentirem pressão para relatar que não excederam as taxas de desperdício de vacinas estabelecidas, poderão mandar mães e crianças embora sem vacinação se só aparecerem uma ou duas crianças para a MCV ou outras vacinas liofilizadas em frascos multidose, que têm de ser descartados no prazo de seis horas após a reconstituição. Negar a essas crianças a vacinação nesse dia é uma oportunidade de vacinação perdida, prolonga a exposição à doença e arrisca a perda dessas crianças no sistema para sempre. Os supervisores têm uma função importante a desempenhar na promoção de registos e reportes de dados e no apoio a profissionais de saúde na tomada de decisões quando enfrentam circunstâncias não ideais. Por conseguinte, dada a complexidade adicional que a estratificação coloca no sistema administrativo, a OMS não recomenda a marcação de doses por sexo. De igual modo, não é aconselhável tentar separar as doses administradas a crianças dentro de uma área de captação em relação àquelas fora da área de captação. Se existirem preocupações sobre desigualdades na imunização na infância, por sexo ou outras características, recomenda-se que quando os inquéritos forem implementados, sejam potenciados para detectar desigualdades ou disparidades na cobertura. Incluir três grupos etários para registar doses coloca em perspectiva o problema comum de como registar as doses tardias da vacina. Se as crianças vierem para a vacinação ou outros serviços do 2º ano de vida aos 24 meses de idade ou mais tarde, não lhes deve ser negada a vacinação ou outros cuidados. Os profissionais de saúde devem proporcionar as doses e serviços e registá-los na folha de inventário, HBR, registo infantil e relatório de sumário mensal, na coluna da idade que corresponde à idade da criança quando a dose ou serviços foram realmente recebidos. Os guias de campo nacionais devem proporcionar instruções e cenários precisos em relação à administração, marcação, registo e reporte das doses tardias. 56 Estabelecer e reforçar a vacinação no segundo ano de vida 7 S E C Ç Ã O 7.3 Actualizar formulários e sistemas de informações de saúde Todos os instrumentos de recolha de dados e reporte devem ser revistos, conforme necessário, para acomodar os requisitos dos dados do 2º ano de vida. Deve ser utilizada uma abordagem centrada no utilizador em relação à concepção dos instrumentos de dados para promover um rastreio, vacinação, registo e reporte de doses adequados. As ferramentas de registo de dados devem promover o conceito essencial de que a vacinação completa inclua doses administradas no segundo ano de vida ou mais tarde. Como se espera que os profissionais de saúde utilizem os HBR, folhas de inventário e registos diariamente, as ferramentas devem ser concebidas com o seu contributo e testadas previamente, de modo formal, para aferir se são bem compreendidas e de fácil utilização. Estes passos irão ajudar a evitar problemas no registo de dados ou até nas práticas de vacinação, tais como negar a vacinação se uma criança vier atrasada. As conclusões pré-teste devem informar a revisão das próprias ferramentas e reforçar a formação sobre a sua utilização adequada. A funcionalidade das ferramentas actuais deve ser revista, de forma contínua, através de revisões ou avaliações da qualidade dos dados,28 de modo a eliminar ou rever aspectos que não estão a ser utilizados devidamente ou nem sequer são utilizados. Envolver os representantes do SIGS e de todos os programas envolvidos para desenvolver um plano para a revisão do sistema e assegurar que as actualizações estão sincronizadas com a disseminação das ferramentas com base em papel, incluindo os HBR. Os sistemas de reporte devem ser examinados para eliminar a duplicação e contradição entre sistemas paralelos (por exemplo, o SIGS e o DV-DMT ou outros sistemas de informação específicos da vacinação), de modo a evitar o aumento da carga de trabalho e reduzir a possibilidade de confusão dos profissionais de saúde. Preparar um plano com o orçamento, prazo e financiamento assegurado para rever todos os instrumentos de recolha de dados e reporte. O plano deve designar as principais responsabilidades, processos para revisão, prazo, quantidades necessárias, orçamento, fonte de financiamento e um plano de disseminação claro. O orçamento deve incluir os custos para a impressão de quantidades suficientes de HBR e de todos os novos formulários, para além da sua distribuição a todas as unidades, de modo a substituir os formulários e registos antigos. Todos os novos instrumentos devem estar prontos a tempo da formação de 28 Por exemplo, a Auto-avaliação de qualidade dos dados (AQD). A AQD é uma caixa de ferramentas flexível de métodos utilizados para avaliar diferentes aspectos do sistema de monitorização da vacinação aos níveis da unidade sanitária e do distrito. Para dados e ferramentas visite: www.who.int/immunization/monitoring_surveillance/routine/coverage/en/index3.html 57 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 7 profissionais de saúde, de modo a permitir-lhes ganhar experiência directa na sua utilização. Se os registos de vacinação electrónicos (RVE) e outros sistemas electrónicos forem utilizados ao nível da unidade sanitária, as alterações em todos os aspectos do sistema devem ser feitas a tempo da formação, para que os profissionais de saúde possam treinar a sua utilização. Rever todos os instrumentos de recolha de dados relevantes • Os HBR devem conter espaço suficiente para o profissional de saúde registar todas as doses de rotina das vacinas, as suas datas de administração e outros serviços proporcionados durante a visita do 2º ano de vida. O formato do HBR deve permitir o fácil rastreamento das doses em atraso por parte de todos os profissionais de saúde (incluindo pessoal não afecto à vacinação que preste cuidados curativos). O Guia prático para a concepção, utilização e pro- moção de boletins de saúde em programas de vacinação da OMS (consultar o Recurso Essencial) dá conselhos simples para a produção de HBR de elevada qualidade. • As folhas de inventário devem ser concebidas de forma a guiar os profissionais de saúde para registarem de modo preciso as doses administradas, desagregadas por grupos etários, conforme descrito acima e ilustrado no Anexo 1. • Os relatórios de resumo mensal devem captar e resumir todos os dados produzidos pelas folhas de inventário. Por exemplo, se uma folha de inventário contiver espaço para o reporte de doses administradas fora da faixa etária recomendada, ou sessões fixas/ de locais de proximidade, então o resumo mensal também deve captar isto, de forma a que os profissionais de saúde não tenham de improvisar as suas próprias soluções. — R EC U RS O E SS E N C I A L Guia prático para a concepção, utilização e promoção de boletins de saúde em programas de vacinação Os HBR, tais como os cartões de vacinas ou registos de saúde infantil integrados, devem ser concebidos de forma a servir as necessidades do sistema de saúde e a promover as práticas de saúde apropriadas entre os cuidadores. Devem ser disponibilizados a todos os cuidadores de forma gratuita e devidamente preenchidos. Os profissionais de saúde devem encorajar os cuidadores a salvaguardarem os HBR e a retê-los durante vários anos. Contudo, não devem castigar ou negar serviços a quem os tiver perdido ou esquecido, pois isto pode desencorajar os cuidadores de regressarem para a vacinação ou outros serviços essenciais. Os HBR perdidos ou danificados devem ser substituídos gratuitamente. www.who.int/immunization/ monitoring_surveillance/ routine/homebasedrecords/en/ FOR THE DESIGN,USE AND PROMOTION OF IN IMMUNIZATION PROGRAMMES PRACTICAL GUIDE HOME-BASED RECORDS 58 Estabelecer e reforçar a vacinação no segundo ano de vida 7 S E C Ç Ã O CA I X A 4. H B R PA R A VAC I N AÇÃO E O U T ROS S E RV I Ç OS D E SAÚ D E I N FA N T I L Com a vacinação a prolongar-se no segundo ano de vida e posteriormente, e com a inclusão de mais vacinas no plano de vacinação, é cada vez mais importante que as mães ou cuidadores tenham HBR que documentem o estado de vacinação das crianças e proporcionem informações-chave sobre vacinação e saúde. As políticas de vacinação e a formação/supervisão dos profissionais de saúde devem enfatizar a importância de os cuidadores trazerem o HBR da criança até às unidades sanitárias para cada visita, de forma a rastrear a elegibilidade para as vacinas em qualquer momento em que uma criança tenha contacto com o sistema de saúde. Alguns países introduziram verificações do estado de vacinação no momento da inscrição na educação primária (matrícula na escola) e os cuidadores devem ser relembrados da importância de guardarem o HBR até a criança estar matriculada no sistema educativo. • Os registos devem incluir espaço para doses adicionais (e, possivelmente, outras intervenções) a serem dadas na visita do 2º ano de vida e posteriormente, sem restringir o registo das doses no segundo ano de vida. A quantidade de dados a inserir deve ser determinada pela forma como serão utilizados, tempo necessário para os inserir, custo e o volume dos registos. Também é crucial que os registos, ou ficheiros de controlo, estejam organizados de forma a facilitar o rastreamento dos incumpridores. Conforme descrito na Secção 8, a formação e supervisão devem abordar circunstâncias invulgares que é provável os profissionais de saúde encontrarem e que possam complicar a capacidade de registar e reportar as doses com precisão. O Anexo 3 proporciona alguns cenários de amostra para fins ilustrativos. 59 Estabelecer e reforçar a vacinação no segundo ano de vida 8 SECÇÃO Formação de profissionais de saúde e desenvolvimento de competências 60 Estabelecer e reforçar a vacinação no segundo ano de vida 8 S E C Ç Ã O O sucesso de cada intervenção de saúde depende de profissionais de saúde de primeira linha e gestores competentes. No desenvolvimento de competências dos profissionais de saúde, as «competências» são definidas como sendo compostas por aptidões, conhecimentos e atitudes. Para a vacinação e outros serviços de bem-estar infantil no segundo ano de vida serem encarados como uma prioridade, as competências interpessoais, motivações e atitudes dos profissionais de saúde precisam de ser tratadas na formação e supervisão, bem como as opiniões que recebem. A formação é essencial para introduzir novas competências, mas deve ser seguida pelo suporte após a formação, tal como o acompanhamento e supervisão de apoio, para reforçar as competências e melhorar as práticas de forma contínua. Os representantes de todos os programas envolvidos numa visita de vacinação no 2º ano de vida devem contribuir para o processo de desenvolvimento do currículo de formação. Deve ser elaborado um plano de trabalho de formação, cronologia e orçamento para o desenvolvimento de materiais de formação, para que exista uma compreensão clara e partilhada das responsabilidades e prazos para esboçar, rever, finalizar e produzir os materiais de formação e quaisquer materiais de apoio, tais como diapositivos, auxiliares de trabalho, materiais para exercícios, etc. A formação, supervisão e outros meios de apoio pós-formação devem reforçar as políticas e procedimentos operationais padrão, incluindo o princípio nuclear de que a vacinação atempada é ideal mas, com algumas excepções, a vacinação atrasada é preferível a nenhuma vacinação. 8.1 Determinar as competências necessárias aos profissionais de saúde Um passo essencial é identificar as competências requeridas em todos os quadros de profissionais de saúde envolvidos na vacinação e outras intervenções de saúde e nutrição no segundo ano de vida e mais tarde. Deve ser realizada uma análise de tarefas ou avaliação de necessidades de aprendizagem para identificar com clareza que profissionais são responsáveis pela execução de funções específicas, como indicado na Secção 5. Para uma visita no 2º ano de vida, que inclua outros serviços de saúde, os formadores devem identificar as tarefas esperadas e competências necessárias de: • vacinadores; • outros prestadores de cuidados de saúde envolvidos numa visita do 2º ano de vida integrada; • supervisores da unidade sanitária ou chefias; • profissionais de saúde comunitários (PSC); • profissionais ao nível regional ou distrital responsáveis pela vacinação, saúde infantil, gestão da logística, gestão dos dados e defesa, comunicação, envolvimento comunitário e mobilização social. 61 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 8 CA I X A 5. C O M P E T Ê N C I AS N EC E S SÁ R I AS AOS P RO F I S S I O N A I S D E SAÚ D E PA R A A VAC I N AÇÃO N O 2 º A N O D E V I DA A formação e o desenvolvimento de competências para a vacinação do 2º ano de vida devem assegurar que os profissionais de saúde possam executar correctamente as seguintes tarefas. 1. Preparar microplanos e prever as necessidades de produtos para atingir uma coorte adicional, com base numa estimativa correcta da população-alvo. 2. Rastrear as crianças de forma adequada para determinar que doses de vacinas são necessárias. Isto requer conhecimento do plano de vacinação (incluindo se existe um limite superior etário para quaisquer vacinas ou doses), o intervalo mínimo entre doses, o que fazer em caso de vacinas tardias ou interrompidas, como rastrear a elegibilidade se a criança não tiver um HBR e se uma criança que tiver vindo para cuidados curativos pode ser vacinada. 3. Comunicar claramente com os cuidadores, da seguinte forma. • Quando os cuidadores trazem os filhos para a vacinação no primeiro ano de vida, particularmente para a MCV1, os profissionais de saúde devem explicar os motivos e benefícios de voltarem para vacinação e outros serviços no segundo ano de vida. Também devem informá-los com clareza de quando devem regressar e indicar isto no HBR. • Durante a visita do 2º ano de vida, o profissional de saúde deve agradecer ao cuidador por vir e fornecer informações padrão sobre as vacinas recebidas, incluindo o facto de que receber várias injecções é seguro, e falar das preocupações do cuidador sobre efeitos secundários. 4. Proporcionar à criança outros serviços durante a visita do 2º ano de vida, tais como monitorização e promoção do crescimento, suplementação de vitamina A e medicação de desparasitação, de acordo com a política nacional. 5. Registar e reportar as doses administradas durante a visita do 2º ano nas folhas de inventário, HBR, registos infantis e relatórios de resumo mensais. 6. Identificar e rastrear os incumpridores para que possam completar o plano de vacinação. Isto poderá pressupor a gestão e suporte de PSC. 7. Rever os dados da unidade para aferir o desempenho e resolução de problemas para tratar questões relacionadas com a vacinação do 2º ano de vida que precisem de atenção. Uma forma de abordar esta questão é listar as alterações específicas nas responsabilidades do profissional de saúde, numa base diária, semanal, mensal e anual, que resultam da introdução da vacinação após um ano de idade. 29 Para informações e ferramentas para um microplaneamento eficiente, consultar o Capítulo 3 do Atingir Todos os Distritos (RED): Um guia para aumentar a cobertura e equidade em todas as comunidades na Região Africana, revisão de 2017. Disponível em : www.afro.who.int/publications/reaching-every-district-red-guide-increasing-coverage-and-equity-all-communities 62 Estabelecer e reforçar a vacinação no segundo ano de vida 8 S E C Ç Ã O 8.2 Preparar o currículo de formação Muitos dos conteúdos técnicos sobre a administração apropriada de vacinas e a prestação de outros serviços de bem-estar infantil já estão disponíveis em materiais de formação existentes. Podem ser adaptados e actualizados conforme necessário para a formação sobre o 2º ano de vida. O currículo para outros programas que possam ser integrados com a vacinação do 2º ano de vida, tais como a nutrição e saúde infantil, também deve ser revisto e actualizado, conforme necessário. Devem ser desenvolvidos novos conteúdos de formação para as competências específicas do 2º ano de vida, indicadas acima. Essas competências servem como a base para definir os objectivos de aprendizagem para o currículo de formação. Os objectivos de aprendizagem ajudam a focar a formação nos conteúdos «essenciais» e não em «curiosidades». Os objectivos de aprendizagem também são uma base útil para questões pré e pós-teste significativas. A utilização de pré e pós-testes bem concebidos com base nos objectivos de aprendizagem serve dois propósitos. Em primeiro lugar, dão informações sobre a eficácia da própria formação e, por conseguinte, ajudam a identificar formas de a reforçar. Em segundo lugar, identificam áreas de compreensão limitada. Estas informações podem então ser utilizadas para focarem o suporte pós-formação através de supervisão, feedback, formação no trabalho e outros meios. Os objectivos de aprendizagem para a formação na República do Senegal, indicados abaixo, abordam a introdução de uma segunda dose da vacina contra o sarampo e rubéola. Para uma visita do 2º ano de idade com intervenções múltiplas, os objectivos de aprendizagem para tal formação necessitam de reflectir as competências descritas acima, bem como para outros serviços a serem proporcionados durante a visita do 2º ano de vida. O sucesso de cada intervenção de saúde depende de profissionais de saúde de primeira linha e gestores competentes. © W H O M aldives 63 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 8 CA I X A 6. M É TO D OS D E A P R E N D I Z AG E M E F I C I E N T E S A aprendizagem eficiente nos adultos ocorre quando o conteúdo é claramente relevante para a própria experiência do aluno, tem aplicação imediata e serve claramente um intuito prático. Sempre que possível, devem ser utilizados métodos interactivos que permitam a prática de competências. Para a visita do 2º ano de vida, os métodos interactivos úteis podem incluir: • prática de competências para comunicação interpessoal, incluindo responder com precisão às questões, de uma forma que fomente a confiança • cenários hipotéticos para rastreamento, administração, registo e reporte das doses. São exibidos vários exemplos para a vacinação do 2º ano de vida, no Anexo 3. • Estudos de caso e resolução de problemas para situações com baixa cobertura de doses no 2º ano de vida. OBJECTIVOS DE APRENDIZAGEM DO SENEGAL PARA FORMAÇÃO SOBRE A INTRODUÇÃO DE UMA SEGUNDA DOSE DA VACINA CONTRA O SARAMPO E RUBÉOLA (MR2) O currículo de formação para a introdução da MR2 no Senegal delineou objectivos de aprendizagem claros. No final da formação, os profissionais de saúde conseguirão fazer o seguinte. • Descrever o novo plano de vacinação para proporcionar a MR2. • Identificar o grupo-alvo para a vacinação MR2. • Estimar correctamente as necessidades da vacina MR, tendo em conta a MR2. • Preencher correctamente todas as ferramentas de gestão, incluindo o registo infantil, folha de inventário, relatório mensal, registo de gestão de stocks e cartão de vacinação. • Citar, pelo menos, três benefícios de providenciar a MR2. • Explicar aos pais, pelo menos, duas razões pelas quais devem reter o cartão de vacinação e regressar para a MR2. • Citar o número de contactos de vacinação de que uma criança necessita para estar totalmente imunizada. • Descrever, pelo menos, quatro tarefas para mobilizadores comunitários desempenharem o suporte MR2. E X P E R I Ê N C I A N AC I O N A L Ao preparar o currículo da formação, é importante incorporar a utilização de métodos de aprendizagem de adultos. Exemplos desses métodos são fornecidos na Caixa 6, abaixo. 64 Estabelecer e reforçar a vacinação no segundo ano de vida 8 S E C Ç Ã O A experiência com a vacinação MCV2 em vários países demonstrou que o rastreamento, registo e reporte de doses no segundo ano de vida ou mais tarde podem ser problemáticos, pois os profissionais de saúde enfrentam uma vasta gama de situações que não correspondem exactamente ao plano de vacinação. Os profissionais de saúde precisam de orientação clara em pontos como: • como registar uma primeira dose de MCV que é administrada após os 12 meses (num país que recomenda a MCV1 aos nove meses de idade); • o que fazer quando uma mãe traz a criança para a visita do 2º ano de vida após os 23 meses; • o intervalo mínimo entre a administração das doses; • como implementar estratégias para reduzir a dor de várias injecções.30 O Anexo 3 apresenta vários cenários que os profissionais de saúde poderão encontrar e sugere como podem ser tratados directamente durante a formação. O Anexo 4 proporciona um exemplo de um auxiliar de trabalho para ajudar os profissionais de saúde a determinarem as vacinas para as quais uma criança é elegível. A formação também proporciona uma oportunidade para abordar áreas conhecidas de fraco desempenho. Por exemplo, pode ser utilizada para promover a prática de abertura de um frasco para dar a MCV, mesmo se vier apenas uma ou duas crianças para uma sessão de vacinação. Os supervisores ao nível distrital devem suportar este princípio para os profissionais de saúde de primeira linha poderem executar esta prática com sucesso. 30 Reduzir a dor no momento da vacinação. Documento da posição. Genebra: Organização Mundial de Saúde; 2015. (www.who.int/wer/2015/wer9039.pdf). © U N IC EF/U N 0 125857/Sharm a 65 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 8 8.3 Planear a estratégia de formação Os organizadores devem desenvolver uma estratégia de formação para aumentar as competências dos profissionais de saúde, dos seus supervisores directos, equipas de saúde distritais e formadores. Devem ser abordados vários pontos: Identificar quem irá conduzir as sessões de formação e proporcionar-lhe uma orientação rigorosa sobre o conteúdo técnico e como formar os outros. Preparar um plano de formação detalhado. Trabalhar para trás a partir da data prevista para o lançamento da vacinação no 2º ano de vida e ter em consideração quaisquer outros eventos concorrentes, tais como feriados, eleições ou campanhas de vacinação que possam causar atrasos. Se forem planeadas outras introduções de novas vacinas no mesmo período, poderá ser possível combiná-las com a formação sobre o 2º ano de vida, para melhorar a eficiência. Agendar a formação para que os profissionais de saúde de primeira linha a recebam duas a três semanas antes do lançamento do 2º ano de vida. Garantir que a impressão e/ou distribuição electrónica de ferramentas de recolha de dados actualizadas estejam disponíveis para serem utilizadas na prática de competências durante a formação. Imprimir e divulgar outros materiais essenciais, tais como directrizes técnicas ou guias de campo operacionais, auxiliares de trabalho, materiais de comunicação de alteração de comportamentos (consultar a Secção 9) e materiais de referência de formação, para os participantes partilharem com outros profissionais na sua unidade. A longo prazo, certificar-se de que a informação é incorporada no currículo de formação inicial e contínua. A formação em cascata é muitas vezes utilizada para atingir um grande número de profissionais de saúde num curto período de tempo. Contudo, sabe-se que a qualidade da formação vai decaindo e torna-se mais variável em cada nível da cascata; por conseguinte, é melhor limitar o número de níveis de cascata a dois ou três, no máximo. Se for utilizada uma estratégia em cascata, as seguintes sugestões podem ajudar a manter a qualidade da formação. • Utilizar o método “re-ensino” durante a formação de formadores (FDF). Neste método, uma parte do tempo da FDF é passada com alguns participantes a praticarem as suas competências, simulando uma formação de outros participantes e vice-versa. 66 Estabelecer e reforçar a vacinação no segundo ano de vida 8 S E C Ç Ã O • Produzir cenários hipotéticos para simulações, com histórias falsas e HBR falsos, durante as sessões de formação interactivas. Se os profissionais de saúde utilizarem dispositivos de RVE manuais, levar a cabo simulações de registo de dados na vida real com os dispositivos e rever os registos em conjunto com os participantes. • Incluir alguns formadores de nível mais elevado nas sessões de formação nos níveis inferiores. • Utilizar os resultados pós-teste das sessões de formação anteriores para adaptar e melhorar a formação para sessões posteriores. • Produzir DVD interactivos para utilizar em todos os níveis da cascata para assegurar que o conteúdo mais complexo seja tratado de forma padronizada. Para a visita no 2º ano de vida, isto incluiria o rastreamento, registo e reporte das doses da vacina dadas a crianças acima do ano de idade. A possível utilização de DVD requer que se verifique primeiro se o equipamento apropriado para os utilizar está disponível em todos os níveis. • Trabalhar com criadores pedagógicos para assegurar que os métodos de ensino são apropriados para a formação de adultos. 8.4 Proporcionar supervisão de apoio e outras formas de apoio pós-formação Uma única sessão de formação é muitas vezes insuficiente para que haja domínio de uma matéria nova e complexa. É necessário apoio pós-formação para reforçar as competências e práticas, tanto para consolidar conteúdos introduzidos durante a formação como para orientar novos profissionais ou aqueles que não puderam estar presentes na formação. A supervisão de apoio é um método padrão, essencial para reforçar competências. Contudo, requer financiamento e transporte fiáveis, que podem faltar em muitos cenários. O planeamento de uma visita do 2º ano de vida é uma oportunidade para destacar a importância da supervisão de apoio e defender níveis adequados de financiamento. Preparar uma lista de verificação de visita de supervisão de apoio para a visita do 2º ano de vida. Os países podem adaptar as suas listas de verificação da supervisão de apoio para incluírem questões específicas do 2º ano de vida. Estas questões também podem ser colocadas durante a formação informal no trabalho: 67 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 8 Estão disponíveis na unidade as directrizes sobre o 2º ano de vida, auxiliares de trabalho e instrumentos de gestão de dados revistos, incluindo HBR? A taxa de abandono da MCV1 para a MCV2 está a ser monitorizada? Em caso afirmativo, em que medida é mais elevada a taxa de abandono da MCV1 para a MCV2 em comparação com a da Penta1 para a Penta3, PCV1 para a PCV3 ou da última dose da rotavirus1 para a rotavírus? Se as crianças vierem para a visita do 2º ano de vida mais tarde do que a idade-alvo, como é que os profissionais de saúde respondem? Estas crianças recebem vacinas? Quais? Como é que as doses são registadas e reportadas? A prestação da imunização é coordenada com outros serviços ou existem oportunidades perdidas para o fazer? De que formas é que os PSC identificam e mobilizam os pais para trazerem as suas crianças para a visita do 2º ano de vida? Existem provisões suficientes de todos os produtos necessários para a visita do 2º ano de vida? Os supervisores devem prover comentários por escrito, a permanecerem na unidade para referência futura. Tipos adicionais de apoio pós-formação poderão assumir as seguintes formas. Preparar um auxiliar de trabalho para guiar os profissionais de saúde no rastreamento e vacinação de crianças que têm doses em falta ou vacinas em atraso, ou que não têm um cartão de vacinação. Poderá ser útil um fluxograma ou algoritmo para este fim. A Figura 3 mostra um exemplo de um fluxograma de tomada de decisões adaptado da República do Gana. O auxiliar de trabalho também poderá incluir mensagens essenciais para auxiliarem na resposta a questões ou preocupações comuns dos cuidadores ou membros da comunidade. Consultar o Anexo 4 sobre outro exemplo de auxiliar de trabalho para guiar os profissionais de saúde a determinarem a elegibilidade de uma criança para a vacinação. Desenvolver um cartaz ou auxiliar de trabalho sobre o fluxo de pacientes para lembrar a todos os profissionais de saúde da unidade, bem como pais e cuidadores, como os serviços devem ser organizados durante a visita do 2º ano de vida. O auxiliar de trabalho deve sublinhar em particular o encaminhamento entre os diferentes departamentos. Preparar uma lista de perguntas frequentes (FAQ) para que os profissionais de saúde sejam capazes e estejam confiantes para responder a uma série de questões e situ- ações. O Anexo 5 contém um exemplo de uma lista de perguntas frequentes que os países podem adaptar. Planear a formação de actualização, de modo a decorrer um a dois anos após a formação inicial. Facultar aos profissionais de saúde um número de telefone de apoio (por exemplo, para um supervisor ou linha de atendimento) e encorajá-los a ligarem e esclarecerem as dúvidas que tiverem sobre como vacinar uma criança ou registar uma vacina. 68 Estabelecer e reforçar a vacinação no segundo ano de vida 8 S E C Ç Ã O Explorar meios alternativos de apoio pós-formação. Dependendo das circunstâncias do país, estes podem incluir: • trocas entre pares ou reuniões de revisão trimestrais; • uma linha de atendimento que os profissionais de saúde possam utilizar para consultarem peritos quando têm dúvidas; • textos de SMS de lembrete ou outras mensagens móveis enviadas para os telefones dos profissionais de saúde para reforçar práticas. As mensagens de texto podem também ser utilizadas para proporcionar o reconhecimento pelo registo e reporte correctos e atempados dos dados; • Em contextos em que os profissionais de saúde têm elevado acesso a smartphones, um grupo WhatsApp ou uma aplicação de mensagens instantâneas semelhante pode proporcionar apoio entre pares e de supervisão regular. F I G U R A 3. E X E M P LO D O GA N A D E U M A LG O R I T M O PA R A D E T E R M I N A R A E L EG I B I L I DA D E PA R A A VAC I N A DA M E N I N G I T E A E C O N T R A O SA R A M P O E RU B ÉO L A Algoritmo para administração das vacinas sarampo-rubéola e Men A Verificar o Boletim de Saúde/Cartão de Pesagens da criança Dar vacinas em falta e vitamina A Aconselhar a regressar em data da idade apropriada para a(s) próxima(s) vacina(s) em falta Aconselhar a regressar para Consulta de Bem-Estar Infantil na idade apropriada IDADE DE AVALIAÇÃO DA CRIANÇA A criança tem menos de 9 meses Não dar MR1 Não dar MR2 A criança recebeu a MR1? A criança recebeu a MR2? Dar Men A Dar MR2 A criança recebeu a Men A? A criança tem menos de 18 meses A criança tem 18 meses ou mais Dar MR1 A criança tem 9 meses ou mais NÃOSIM NÃOSIMNÃOSIM 69 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 8 CA I X A 7. D E T E R M I N A R A E L EG I B I L I DA D E PA R A A M CV 2 A OMS recomenda que, onde o risco de mortalidade por sarampo entre os bebés permaneça eleva- do, a MCV2 deve ser administrada aos 15–18 meses, com um inter- valo mínimo de quatro semanas após a MCV1. Em contextos onde a utilização dos serviços de saúde decaia consideravelmente após o primeiro ano, é problemático assegurar que os cuidadores tragam os seus bebés para a segunda dose aos 18 meses, por exemplo, e o risco de abandonos pode ser bastante elevado. Uma abordagem alternativa nestes casos poderá ser estipular que se uma criança se apresentar em qualquer momento entre os 12 e 18 meses, é melhor vacinar com a MCV2 imediatamente, em vez de esperar que regresse novamente aos 18 meses. De uma perspectiva imunológica, desde que tenham passado quatro semanas desde a sua primeira dose e desde que se encontrem no 2º ano de vida, então uma criança já é tecnicamente elegível para a MCV2. Contudo, compreensivelmente, isto poderá causar confusão aos profissionais de saúde, sendo que uma política com base nos intervalos em vez de uma aderência estrita a um plano poderá não funcionar em todos os contextos. Em última análise, cabe ao programa definir uma política sobre isto e assegurar que estejam disponíveis a formação e ferramentas adequadas para os profissionais de saúde tomarem essas decisões. As estratégias para reduzir o abandono e assegurar que a criança regresse aos 18 meses incluem: 1) proporcionar aconselhamento aos cuidadores, sublinhando a importância da MCV2 e o momento do regresso; 2) seguimento activo através de uma chamada ou visita domiciliária ao cuidador, de modo a relembrá-lo da visita; 3) em alguns contextos, proporcionar as vacinas em casa, caso não regressem aos 18 meses ou logo em seguida. 70 Estabelecer e reforçar a vacinação no segundo ano de vida Comunicação, promoção da procura e envolvimento da comunidade 9 SECÇÃO 71 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 9 Communication is an important factor for the success of vaccination in the second A comunicação é um factor importante para o sucesso da vacinação no segundo ano de vida e posteriormente. É essencial uma estratégia de comunicação abrangente, mas direccionada, que seja totalmente financiada e implementada, incluindo um lançamento de alta visibilidade e actividades de envolvimento da comunidade contínuas, para a promoção da procura e para gerar a utilização da vacinação no 2º ano de vida e outros serviços. O sucesso na construção e manutenção da confiança na vacinação requer uma mistura de abordagens que se centre na construção de conhecimentos e consciencialização, mas que também tenha em consideração as dinâmicas individuais, sociais e estru- turais/políticas que moldam os comportamentos de vacinação. A Tabela 5 apresenta os elementos essenciais de uma estratégia de mudança de comportamento no 2º ano de vida para aumentar a aceitação e adesão. Indica grupos-alvo, áreas essenciais de conhecimento e as acções desejadas a serem promovidas através da comunicação, envolvimento comunitário e outras intervenções do programa coordenadas. Estas informações servem de base para decidir que materiais, mensagens e actividades são requeridas para promover a procura e a utilização dos serviços do 2º ano de vida. TA B E L A 5. E L E M E N TOS D O Q UA D RO D E C O M U N I CAÇ Õ E S D E A LT E R AÇ Õ E S D O C O M P O RTA- M E N TO N O 2 º A N O D E V I DA G RU P O -A LVO PRINCIPAIS ÁREAS DE CONHECIMENTO AÇ Õ E S D E S E JA DAS Cuidadores e famílias • A importância da vacinação e os benefícios das vacinas para prevenir doenças/mortes • A vacinação continua no 2º ano de vida • Motivos por que são importantes a vacinação no 2º ano de vida e outros cuidados de bem-estar infantil para além de um ano de idade • Periodização das visitas agendadas do 2º ano de vida • Importância da salvaguarda dos HBR até a criança começar a escola e para além disso • Levar as crianças à vacinação do 2º ano de vida e outros serviços de bem-estar infantil • Manter o HBR e trazê-lo a cada contacto de saúde Profissionais de saúde • Vacinação e outros serviços a serem proporcionados numa visita do 2º ano de vida; O 2º ano de vida como oportunidade para a vacinação de actualização • Porque é importante para a saúde infantil a vacinação no 2º ano de vida • Como e quando dar e registar as vacinas • Como e quando comunicar com os cuidadores sobre os serviços do 2º ano de vida, particularmente durante a visita da MCV1 (consultar a Secção 8) • Como promover serviços do 2º ano de vida junto da comunidade • Comunicar com os cuidadores no primeiro ano de vida para os encorajar a virem à visita do 2º ano de vida e reterem os HBR • Comunicar informações essenciais durante a visita do 2º ano de vida • Rastrear, proporcionar serviços, registar e reportar dados correctamente • Envolver as suas comuni- dades de forma a encorajar as visitas do 2º ano de vida 72 Estabelecer e reforçar a vacinação no segundo ano de vida 9 S E C Ç Ã O G RU P O -A LVO PRINCIPAIS ÁREAS DE CONHECIMENTO AÇ Õ E S D E S E JA DAS Gestores ao nível distrital e supervisores dos profissionais de saúde • Rever os dados e identificar as falhas de conhecimentos e competências dos profissionais de saúde • Proporcionar comentários e suporte técnico aos profissionais de saúde e motivá-los sobre a importância da vacinação no 2º ano de vida e outros serviços • Dar apoio aos profissionais de saúde na prestação de serviços de alta qualidade Profissionais de saúde comunitários • A importância da vacinação no 2º ano de vida e a idade para levar uma criança a uma visita agendada • Como rastrear incumpridores para a vacinação do 2º ano de vida • Outros serviços proporcionados durante a visita do 2º ano de vida • Proporcionar informações essenciais sobre a importância da visita do 2º ano de vida e quando trazer a criança • Mobilizar as famílias para trazerem os seus filhos • Rastrear incumpridores Líderes da comunidade e políticos (chefes, deputados, conselheiros, autoridades civis, líderes religiosos) • A importância da vacinação no 2º ano de vida e a idade para levar uma criança a uma visita agendada • Outros serviços proporcionados durante a visita do 2º ano de vida • Quando e onde são oferecidos os serviços do 2º ano de vida • A vacinação é gratuita • Encorajar as famílias para trazerem os seus filhos para os serviços do 2º ano de vida • Comunicar sobre a importância da vacinação Os meios de comunicação • A importância da vacinação e de outros serviços de saúde infantil durante a infância e no segundo ano de vida • Quando e onde são oferecidos os serviços do 2º ano de vida • A vacinação é gratuita • Proporcionar cobertura sobre o lançamento da visita do 2º ano de vida • Proporcionar informações precisas e atempadas ao público, de forma a encorajar a vacinação e a utilização dos serviços do 2º ano de vida Associações profissionais e médicas • Ciência actualizada e considerações políticas para informar o desenvolvimento de políticas e práticas em relação à visita do 2º ano de vida • Contribuir para o desen- volvimento de políticas, directrizes e materiais • Promover a prática adequada entre os constituintes • Prestar apoio aos líderes comunitários no reforço da importância da vacinação Professores, conselheiros, prestadores de serviços pré- escolares/de creche • A importância da vacinação no 2º ano de vida e outros serviços para além de um ano de idade • A vacinação é gratuita • Encorajar as famílias para trazerem os seus filhos para os serviços do 2º ano de vida 73 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 9 Os amplos passos necessários para o planeamento da promoção ou do aumento da procura da vacinação no 2º ano de vida e outros serviços são indicados na Figura 4 e descritos nas secções abaixo. F I G U R A 4. C I C LO D E P L A N E A M E N TO DA P RO C U R A E P RO M O ÇÃO Estes passos são elaborados ao longo das secções seguintes. PAS S O R EC O L H A E A N Á L I S E D E DA D OS PAS S O C O N C E P ÇÃO E P L A N E A M E N TO E ST R AT ÉG I C OS PAS S O D E S E N VO LV I M E N TO E T E ST E D E M E N SAG E N S E M AT E R I A I S PAS S O I M P L E M E N TAÇÃO E M O N I TO R I Z AÇÃO PAS S O AVA L I AÇÃO E R E P L A N E A M E N TO 1 2 5 4 3 ©W HO Bhu tan 74 Estabelecer e reforçar a vacinação no segundo ano de vida 9 S E C Ç Ã O 9.1 Recolha de dados e análise: compreender os seus grupos-alvo Plano de comunicação e grupo de trabalho Deve ser criado (ou convocado, se já existir para o programa de vacinação no geral) um grupo de trabalho de comunicações com vários parceiros) para desenvolver um plano de promoção da procura da vacinação no 2º ano de vida. Apesar de o plano dever abordar as funcionalidades e desafios únicos da vacinação no 2º ano de vida, também deve estar alinhado e relacionado com o plano de comuni- cações global para o programa de vacinação nacional. Isto irá ajudar a assegurar que as actividades de comunicação, mensagens e direccionamento são harmonizadas e também suportam o reforço da vacinação de rotina. O grupo de trabalho deve coorde- nar-se de forma estreita com outros, planeando os aspectos do 2º ano de vida de modo a assegurar que o seu trabalho se reforça mutuamente e é tecnicamente consistente. O plano de comunicações do 2º ano de vida deve concordar em relação às audiências- alvo e intervenientes, necessidades de comunicação e acções desejadas por cada grupo, personalizando-o a partir da Tabela 4, conforme necessário. Estas informações servem como base para decidir que materiais, mensagens e actividades são requeridos para promover a adesão aos serviços do 2º ano de vida e, de igual modo, que dados e informações de antecedentes são necessários para moldar esses esforços. Recolha e análise de dados A recolha e a análise de dados iniciais são essenciais para compreender os motivos pelos quais os diferentes grupos-alvo iriam, ou não, realizar as acções desejadas indicadas na Tabela 5. Uma análise da situação e uma análise comportamental (por exem- plo, um estudo de Conhecimentos, Atitudes e Práticas (CAP) ou outra actividade de pesquisa semelhante) podem identificar em conjunto as barreiras que necessitam de ser resolvidas e os factores que promovem as intenções e comporta- mentos desejados. Também podem proporcionar informações essenciais para decidir como é que as mensagens devem ser formuladas e os materiais, meios e canais apropriados para chegar a cada grupo-alvo. Isto ajuda a assegurar que os recursos são 75 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 9 utilizados de forma eficaz e eficiente. Por exemplo, pode descobrir-se que as brochuras e cartazes sobre a vacinação no 2º ano de vida são menos importantes para os cuidadores do que os profissionais de saúde utilizarem a oportunidade da visita MCV1 para proporcionarem mensagens de lembretes e apontarem a data de regresso para a vacinação do 2º ano de vida no HBR da criança. Em tais casos, os recursos poderão ser melhor aplicados no desenvolvimento das competências dos profissionais de saúde e na concepção do HBR. É particularmente importante saber as opiniões dos profissionais de saúde sobre a vacinação no 2º ano de vida, incluindo as suas percepções de obstáculos e factores de favorecimento. Os profissionais de saúde são a fonte mais citada de informações sobre as vacinas, sendo que uma recomendação da parte de um profissional de saúde é um dos factores mais fortes associados à aceitação das vacinas. Têm um papel crucial a desempenhar na comunicação interpessoal com os cuidadores sobre a necessidade e periodização da visita no 2º ano de vida. As informações recolhidas sobre as perspectivas dos profissionais da saúde sobre a vacinação no 2º ano de vida devem ser directamente colocadas na concepção do currículo de formação, instrumentos de supervisão, auxiliares de trabalho, ferramentas de gestão de dados e mensagens e materiais de comunicação. 9.2 Concepção e planeamento estratégicos Envolvimento dos intervenientes principais Tal como em qualquer novo desenvolvimento no sistema de saúde, o envolvimento de intervenientes conhecidos e credíveis ao nível nacional é importante para focar a atenção do público no assunto e criar confiança. Para introduzir a vacinação no 2º ano de vida ou aumentar a atenção para ela, os organizadores devem contactar funcionários de saúde bem conhecidos e líderes políticos, comunitários e académicos de confiança. As associações médicas, escolas e creches, organizações da sociedade civil (OSC) e ONG são outros intervenientes influentes, cuja demonstração de compromisso para com a vacinação no 2º ano de vida e outros serviços pode encorajar acções apropriadas entre os seus constituintes e comunidades. Os organizadores de comunicação devem envolver-se com eles, proporcionar-lhes temas de conversa ou outros materiais, identificando em conjunto oportunidades específicas, tais como conferências de imprensa, cerimónias de lançamento ou reuniões anuais, para demonstrar o seu apoio à vacinação no 2º ano de vida. Envolvimento da comunidade Dependendo das estruturas e líderes comunitários que estiverem activos e funcionais numa determinada área, diferentes tipos de voluntários ou membros da comunidade têm um papel a desempenhar no apoio à vacinação no 2º ano de vida. Podem ser envolvidos para fornecerem mensagens de lembretes, rastrear incumpridores e manter a atenção da comunidade centrada na visita do 2º ano de vida após o seu lançamento. 76 Estabelecer e reforçar a vacinação no segundo ano de vida 9 S E C Ç Ã O CA I X A 8. LISTA DE VERIFICAÇÃO DE PLANEAMENTO DE COMUNICAÇÃO  Existe um grupo de trabalho de comunicações multi-agências apoiado pelo governo para apoiar a visita do 2º ano de vida? Foi realizada uma análise da situação? Foi realizada uma análise comportamental? Que mensagens e materiais são necessários? Foi desenvolvido um plano de acção (orçamentado)? Foi assegurado o financiamento para a implementação do plano? Os produtos/materiais de comunicação foram testados previamente? Existe um plano de distribuição dos materiais? Existe um plano de comunicação de crise, incluindo funções e responsabilidades de parceiros explicitamente acordadas, e inclui os elementos relevantes para o 2º ano de vida? Foram identificados e formados os porta-vozes acordados? As equipas de saúde distrital e desenvolvimento comunitário devem identificar as redes comunitárias que estejam a funcionar activamente e delinear um conjunto de passos realista para os PSC ou voluntários prestarem apoio à visita no 2º ano de vida. Para este fim, devem ser desenvolvidos materiais de lembrete impressos ou outros auxiliares, dando informações sobre todas as componentes da visita no 2º ano de vida, não apenas sobre a vacinação. Os membros da comunidade também podem auxiliar os prestadores de cuidados de saúde na selecção de onde e quando se prestam serviços de locais de proximidade e na melhor forma de chegar às populações mais marginalizadas e com falta de s erviços. É nestes grupos que o risco da não utilização dos serviços no 2º ano de vida é mais elevado. A lista de verificação que se segue pode ajudar a assegurar que são seguidos todos os passos essenciais do processo de planeamento de comunicação. 77 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 9 As estruturas comunitárias têm um papel fundamental a desempenhar no apoio à vacinação no 2º ano de vida e na comunicação a importância da visita do 2º ano de vida como parte dos cuidados continuados nos primeiros cinco anos da vida da criança. 31 www.who.int/immunization/documents/WHO_IVB_13.03/en/, p. 27. 9.3 Desenvolvimento e teste de mensagens e materiais Mensagens e materiais Todas as mensagens e materiais devem indicar claramente quando é que os cuidadores devem levar os filhos à vacinação do 2º ano de vida e o que podem esperar receber durante a visita do 2º ano de vida. O conteúdo sugerido das mensagens essenciais para apoiar a vacinação do 2º ano de vida, personalizado para diferentes públicos, é indicado na Tabela 5. Estas mensagens devem ser adaptadas e testadas previamente, antes de serem incorporadas nos materiais de comunicação, formação ou anúncios de rádio ou TV. Encontram-se mensagens adicionais específicas da MCV2 em Um guia para a introdução de uma segunda dose da vacina contra o sarampo nos planos de vacinação de rotina.31 78 Estabelecer e reforçar a vacinação no segundo ano de vida 9 S E C Ç Ã O TA B E L A 6. E X E M P LOS D E TÓ P I C OS D E M E N SAG E N S E S S E N C I A I S PA R A SU P O RTA R A VAC I N AÇÃO N O 2 º A N O D E V I DA D E ST I N ATÁ R I OS : P RO F I S S I O N A I S D E SAÚ D E Os motivos para proporcionar vacinação e outras intervenções de saúde infantil após um ano de idade. A idade em que as vacinas no 2º ano de vida são agendadas e a importância de proporcionar essas doses de antigénios perdidos no primeiro ano de vida. Não existe limite etário superior ou corte para a maioria das vacinas. “Nunca é demasiado tarde para vacinar”. Durante a visita da MCV1, a necessidade de informar o cuidador sobre quando voltar com a criança para a vacinação do 2º ano de vida e discutir porque é que é importante. Uma criança só pode ser considerada totalmente imunizada quando tiver recebido todas as doses, incluindo as agendadas para administração após um ano de idade. A cobertura do indicador CTI deve incluir as vacinas administradas no segundo ano de vida ou ser separada por categorias etárias (ou seja, CTI ao 1 ano, CTI aos 2 anos). Outros serviços a serem proporcionados durante a visita do 2º ano de vida, por exemplo, monitorização e promoção do crescimento e aconselhamento nutricional. Como responder a cuidadores com quaisquer questões ou preocupações sobre a vacinação. D E ST I N ATÁ R I OS : C O M U N I DA D E S E C U I DA D O R E S Para serem classificadas como totalmente imunizadas, as crianças precisam de ter completado o plano requerido de vacinas durante a infância, 2º ano de vida e posteriormente, conforme necessário. A idade em que as vacinas no 2º ano de vida são agendadas e a importância de actualizar algumas dessas vacinas perdidas no primeiro ano de vida. Não existe limite etário superior ou corte para a maioria das vacinas. “Nunca é demasiado tarde para vacinar”. A importância de manter o boletim de saúde ao longo da infância e de o trazer para cada contacto com o sistema de saúde. Os benefícios para a criança (e família) por receber a vacinação e outros serviços no 2º ano de vida. 79 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 9 9.4 Implementação e monitorização Um plano de comunicação forte não pode ser bem-sucedido se não for executado na sua totalidade. Isto significa que: • o plano estratégico deve ser totalmente orçamentado com fundos assegurados, com bastante antecedência do lançamento, de modo a produzir o fornecimento suficiente dos materiais; • os materiais e mensagens devem ser traduzidos nos idiomas locais vulgarmente usados, conforme necessário; • os materiais devem ser sistematicamente disseminados junto dos destinatários, no momento apropriado e com antecedência em relação à sua utilização; • as mensagens para a comunicação interpessoal dos profissionais de saúde com as mães devem ser finalizadas a tempo de serem incorporadas nos materiais de formação, devendo a formação ser concebida de forma a permitir um tempo adequado para que os profissionais de saúde pratiquem essas competências de comunicação. Lançamento formal da visita do 2º ano de vida As lições aprendidas com as introduções passadas da MCV2 indicam que é importante realizar um lançamento formal da visita do 2º ano de vida, de forma a aumentar a consciencialização, transmitir informações essenciais, demonstrar o apoio político e comunitário de alto nível de porta-vozes credíveis e promover a utilização dos serviços do 2º ano de vida. O envolvimento de líderes comunitários influentes deve começar bastante antes do lançamento. Precisam de compreender porque é que a visita do 2º ano de vida está a ser introduzida, como beneficia a sua comunidade e que acções podem realizar para suportar o seu sucesso. Este envolvimento deve continuar regularmente, mesmo após o lançamento, de forma a assegurar que as relações são mantidas e que os líderes comunitários conseguem continuar a defender a vacinação. A visita do 2º ano de vida deve ser posicionada como parte dos cuidados continuados nos primeiros cinco anos da vida da criança. A introdução da visita do 2º ano de vida é uma oportunidade para destacar a importância dos serviços que já estavam disponíveis antes, mas que não foram totalmente utilizados. Após o lançamento da visita do 2º ano de vida Os funcionários de comunicações ao nível nacional do programa de vacinação devem continuar a interagir com os seus homólogos ao nível subnacional, de modo a monitorizarem a implementação do plano de comunicação e a investigarem quaisquer questões ou obstáculos que possam estar a surgir, para poderem ser tomadas acções correctivas. 80 Estabelecer e reforçar a vacinação no segundo ano de vida 9 S E C Ç Ã O CA I X A 9. E X E M P LOS D E P OT E N C I A I S I N D I CA D O R E S D E R E SU LTA D OS PA R A AVA L I A R AS ACT I V I DA D E S D E C O M U N I CAÇÃO E A P RO M O ÇÃO DA P RO C U R A • % dos cuidadores com o conhecimento correcto do plano e/ou periodicidade das visitas de vacinação nos primeiros dois anos de vida • % dos cuidadores que dizem que pretendem vacinar totalmente os seus filhos, incluindo as visitas no 2º ano de vida • % dos vacinadores com conhecimento correcto do plano nacional • % dos vacinadores que comunicam de forma consistente e correcta aos cuidadores a periodicidade da próxima visita do bebé para vacinação, incluindo as visitas do 2º ano de idade 9.5 Avaliação e replaneamento Mantendo a consonância com a estratégia de comunicação global para vacinação e saúde infantil, a monitorização e avaliação dos esforços de comunicação devem ser executadas pelo grupo de trabalho de forma regular. Com base nos dados recolhidos e revistos no Passo 1, acima, devem ser estabelecidos indicadores ou medidas – cobrindo o processo, os resultados e impactos - que possam ser rastreados através da implementação das várias actividades de comunicação e envolvimento. As conclusões devem ser utilizadas para informar as decisões sobre as acções correctivas a tomar. Para avaliar as actividades de comunicação e promoção da procura, é ideal realizar um inquérito ou exercício de pesquisa rápido com os cuidadores, profissionais de saúde e, potencialmente, líderes comunitários ou intervenientes como alvo. Tal avaliação deve proporcionar uma abordagem sistemática e estruturada à apren- dizagem sobre o que as pessoas sabem sobre a vacinação no 2º ano de vida, como desenvolveram este conhecimento, o que pensam que significa e se pretendem tomar as acções desejadas. As descobertas devem comunicar os ajustes às estratégias de comunicação e promoção da procura, para que possam ser mais direccionadas e tenham mais impacto no futuro. Se não estiverem disponíveis recursos para o estudo em grande escala, então os pontos suscitados na Secção 10 podem ser utilizados para compreender os motivos da fraca procura e utilização da vacinação do 2º ano de vida. 81 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 9 SU S C I TA R A C O N S C I E N C I A L I Z AÇÃO S O B R E A VAC I N AÇÃO A P ÓS U M A N O D E I DA D E , N A TA N Z Â N I A A avaliação pós-introdução da MCV2 na República Unida da Tanzânia revelou que muitos pais inquiridos não estavam cientes da necessidade de mais vacinação após os seus filhos receberem a MCV1 aos nove meses. Apesar de ser suposto as crianças irem a consultas para monitorização do crescimento após um ano de idade, as mães já não consideravam importante vir às visitas de monitorização. Os funcionários de saúde elevaram a consciencialização comunitária sobre a necessidade da vacinação e outros serviços para além do primeiro ano de vida através de: • transmissão de anúncios na rádio e TV; • realização de um seminário com jornalistas de vários meios de comunicação locais para passar a palavra; • realização de reuniões sobre a MCV2 com comissões de cuidados de saúde primários regionais; • disponibilização de educação para a saúde sobre a MCV2 a mulheres que frequentaram visitas de cuidados pré e pós-parto. E X P E R I Ê N C I A N AC I O N A L 82 Estabelecer e reforçar a vacinação no segundo ano de vida Reforço do desempenho da vacinação no 2º ano de vida 10 SECÇÃO 83 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 10 Compreender os motivos do baixo desempenho Se o programa de vacinação nacional e os parceiros observarem que a cobertura da vacinação do 2º ano de vida é baixa e que a taxa de abandono da MCV1 para a MCV2 é elevada, devem rever sistematicamente os dados existentes e aferir a situação para identificar problemas fulcrais e as suas causas de raiz. As decisões sobre como utilizar os recursos para melhorar a situação devem ser baseadas nestes resultados, em vez de suposições de que o problema se deve, por exemplo, à baixa procura ou fornecimento de vacinas insuficiente. Um ponto de partida deverá ser rever a qualidade dos dados reportados para determinar se podem ser considerados completos, atempados, fiáveis e precisos. Ao nível nacional, rever o âmbito geográfico do problema de desempenho do 2º ano de vida. Se generalizado, examinar então factores ao nível do sistema, incluindo os seguintes. 1. As políticas e directrizes estão completas, são claras, precisas e fáceis de compreender e utilizar? 2. As políticas e directrizes foram disseminadas sistematicamente? 3. O currículo de formação cobre todos os pontos essenciais e utiliza métodos eficazes de aprendizagem de adultos? 4. A estratégia de formação atingiu todos os vacinadores e os seus supervisores? Existem lacunas conhecidas sobre como foi implementada? 5. Os instrumentos de supervisão foram actualizados para incluir a vacinação do 2º ano de vida e foram amplamente disseminados e utilizados? 6. As ferramentas de gestão de dados foram actualizadas e suportam todos os aspectos da política e directrizes? Incluíram contributos dos utilizadores finais ou testes prévios para determinar se são fáceis de utilizar? Como foram disseminados sistematicamente? 7. Foi realizado um lançamento de alta visibilidade para focar a atenção na introdução da vacinação do 2º ano de vida? A estratégia de comunicação para a vacinação do 2º ano de vida foi suficientemente desenvolvida, orçamentada e executada conforme planeado? Se o problema do desempenho da vacinação no 2º ano de vida estiver localizado em áreas geográficas particulares, então, é necessário o seguimento com os funcionários de saúde dessas equipas subnacionais/distritais, bem como visitas às unidades para ganhar uma compreensão em primeira mão dos problemas e das suas causas raiz. 10.1 84 Estabelecer e reforçar a vacinação no segundo ano de vida 10 S E C Ç Ã O Ao nível subnacional/distrital, rever os dados para avaliar a cobertura geográfica do problema. Se a cobertura for grande, rever os factores que poderão afectar a vacinação no 2º ano de vida, incluindo os seguintes. 1. Houve falhas ou esgotamentos do stock das vacinas utilizadas para a vacinação no segundo ano de vida? 2. Existem desafios com os recursos humanos, que possam afectar a vacinação no 2º ano de vida, tais como meios humanos insuficientes ou volume elevado? Os profissionais de saúde receberam formação sobre a vacinação no 2º ano de vida? O distrito proporcionou supervisão de apoio ou outro feedback/apoio pós-formação desde que a formação inicial foi conduzida? 3. Existem circunstâncias ou características particulares da população neste distrito, que possam colocar desafios à vacinação no 2º ano de vida, por exemplo, movimento da população, elevados níveis de emprego das mães depois de a criança ter um ano de idade, populações remotas com acesso difícil às unidades ou informações sobre alterações no plano de vacinação, falta de sistemas de apoio social ou hesitação perante as vacinas? 4. As ferramentas de gestão de dados actualizadas foram sistematicamente introduzidas em todas as unidades ou ainda se utilizam amplamente os formulários e ferramentas antigos? 5. Que questões ou problemas com a qualidade dos dados foram observados? Foram realizadas avaliações da qualidade dos dados para aferir a fiabilidade e consistência dos dados sobre a vacinação no 2º ano de vida? Quais são os resultados e que acções correctivas são necessárias? 6. Os líderes comunitários e pessoas influentes foram educados sobre a necessidade da vacinação no 2º ano de vida e porque é que é importante? Que acções tomam para encorajarem as famílias a procurarem a vacinação após um ano de idade? 7. Existem sistemas funcionais de PSC ou voluntários no distrito que foram orientados sobre a vacinação no 2º ano de vida? Sabem como rastrear os incumpridores e encorajar as famílias a trazerem os seus filhos para a vacinação no 2º ano de vida? Executam regularmente estas tarefas? 85 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 10 Ao nível da unidade sanitária, discutir a vacinação no 2º ano de vida com os profissionais de saúde e com os cuidadores na unidade e na comunidade. Entrevistas de profissional de saúde. As perguntas a fazer aos profissionais de saúde incluem as seguintes. 1. Diga-me o que sabe sobre a vacinação no 2º ano de vida. Como e com quem aprendeu estas coisas? 2. Com que frequência é visitado para supervisão de apoio? Caso tenha uma questão sobre alguma coisa, a quem pede apoio ou onde procura ajuda? 3. Sabe a cobertura da sua unidade para a vacinação no 2º ano de vida e a taxa de abandono da MCV1 para a MCV2? 4. Se as taxas de vacinação no 2º ano de vida forem baixas, quais são os motivos? 5. Existem materiais de referência sobre a vacinação no 2º ano de vida (por exemplo, guia de campo, materiais de formação, auxiliares de trabalho) disponíveis na unidade? 6. Quando é que uma criança é considerada totalmente imunizada - após ter recebido que doses de vacina? 7. Houve esgotamentos ou falhas do stock das vacinas utilizadas para a vacinação no 2º ano de vida? 8. A unidade sanitária tem um sistema para o rastreio padrão, especialmente para a vacinação no 2º ano de vida? Qual é o sistema e como funciona? 9. Que informações dá aos cuidadores que trazem crianças para a visita da MCV1? 10. O que faz se uma criança for trazida «tarde» para a vacinação? Existem algumas circunstâncias em que recusaria uma criança por vacinar que foi trazida para a vacinação? Quais são? Acredita que existem limites etários superiores para a vacinação no 2º ano de vida? Quais são? 11. Se uma criança vier à sua unidade para a vacinação no segundo ano de vida, recebe também outros serviços? Quais são? Estão sempre disponíveis? 12. Existem formulários de registo e reporte actualizados (HBR, folhas de inventário, registos, relatórios de resumo mensais) disponíveis na unidade? Se sim, quais são os passos para registo e reporte da vacinação no 2º ano de vida? Os cuidadores trazem HBR actualizados? Em caso negativo, as doses do 2º ano de vida são registadas no HBR? [Peça para ver amostras das ferramentas de registo e reporte e pergunte onde são registadas as vacinações do 2º ano de vida] 86 Estabelecer e reforçar a vacinação no segundo ano de vida 10 S E C Ç Ã O 13. Foi feita alguma comparação dos dados do 2º ano de vida registados nas folhas de inventário, relatórios mensais, registos infantis e HBR, como parte de uma avaliação da qualidade dos dados? Em caso afirmativo, o que indicaram os resultados? Entrevistas de saída. Os funcionários de saúde podem visitar várias unidades, nos dias em que estão a decorrer sessões de vacinação de rotina, e entrevistar os cuidadores cujos filhos tenham recebido a MCV1. As perguntas a fazer aos cuidadores incluem as seguintes. 1. O seu filho recebeu todas as vacinas do plano nacional de vacinação ou precisa de voltar a trazê-lo para mais doses de vacinas? 2. [Se aplicável]: consegue dizer-me quando vai voltar a trazer o seu filho e que vacinas ele deve receber nessa ocasião? 3. O que é que, se algo, tornaria isto difícil para si? O que o facilitaria? Discussões comunitárias. Visitar as comunidades e perguntar aos membros da comunidade o que sabem sobre a vacinação no segundo ano de vida. 1. Até que idade deveria uma criança ter completado todo o plano de vacinação? 2. Se uma criança receber a vacina contra o sarampo até ter um ano de idade, precisa de a trazer de volta para mais vacinas? Em que idade? 3. [Para aqueles que sabem sobre a vacinação no 2º ano de vida]: como soube que precisava de levar o seu filho para a vacinação após um ano de idade? 4. Se levou o seu filho à vacinação do 2º ano de vida, qual foi a sua experiência? Que vacinas recebeu? O seu filho recebeu outros serviços? Precisa de regressar para mais vacinas? 5. Se o seu filho tiver mais de dois anos de idade e não o tiver levado para os serviços do 2º ano de vida, quais foram os motivos? 6. O que ajudaria a que trouxesse o seu filho para os serviços do 2º ano de vida? [Sondagem: materiais de lembrete; uma visita de um PSC; mais informações sobre por que motivo é necessária]. Sem conduzir uma avaliação em grande escala, os gestores de saúde podem adicionar algumas das questões acima às suas visitas de supervisão de apoio e expandi-las conduzindo entrevistas de saída com os cuidadores cujos filhos tenham acabado de ser vacinados. Também podem fazer entrevistas de saída com mães que tenham trazido crianças pequenas para cuidados curativos, ou outros serviços 87 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 10 de prevenção, para ver se foram rastreadas para a vacinação e vacinadas. Durante as visitas de supervisão, os funcionários de saúde distritais podem falar com os líderes comunitários, que poderão proporcionar conhecimentos em relação ao nível de consciencialização da vacinação no 2º ano de vida entre a comunidade. Estão incluídas orientações adicionais sobre como integrar uma pequena avaliação para fortalecer o desempenho no 2º ano de vida numa revisão do plano nacional de vacinação no Guia para conduzir uma revisão do Programa Alargado de Vacinação (PAV) da OMS. 10.2 Tomar medidas para tratar dos problemas As descobertas sobre as revisões descritas acima devem ser utilizadas para decidir quais os passos a tomar para reforçar a vacinação no 2º ano de vida. Os gestores de saúde devem convocar uma discussão para rever os problemas e as suas causas raiz, de modo a identificar soluções e desenvolver um plano para as implementar. A Tabela 7 apresenta vários exemplos ilustrativos de possíveis acções que os pro- gramas podem tomar para melhorar o desempenho no 2º ano de vida. Esta lista não é exaustiva; em vez disso, destina-se a estimular o pensamento sobre soluções que podem ser implementadas utilizando os recursos existentes ou com fundos adicionais limitados. Para além disso, as acções mais apropriadas a tomar irão depender de uma compreensão profunda dos problemas e do contexto em que ocorrem. Durante as visitas de supervisão, os gestores de saúde podem falar com as mães que tenham trazido crianças pequenas para cuidados curativos, ou outros serviços de prevenção, para ver se foram rastreadas para a vacinação e vacinadas. 32 Guia para conduzir uma revisão do Programa Alargado de Vacinação (PAV). Genebra: Organização Mundial de Saúde; 2017. Disponível em: www.who.int/immunization/documents/WHO_IVB_17.17/en/ © W H O 88 Estabelecer e reforçar a vacinação no segundo ano de vida 10 S E C Ç Ã O TA B E L A 7. PROBLEMAS COMUNS E POSSÍVEIS ACÇÕES PARA REFORÇAR A VACINAÇÃO NO 2º ANO DE VIDA P RO B L E M AS/Q U E STÕ E S E X E M P LOS D E AC Ç Õ E S P OS S Í V E I S Cobertura baixa e taxas de abandono elevadas persistentes • Mobilizar os PSC ou voluntários para rastrearem os incumpridores e encorajar a vacinação no 2º ano de vida entre os membros da comunidade. • Melhorar a conveniência das localizações para sessões de locais de proximidade, para que seja mais fácil aos cuidadores ou mães de crianças de dois anos levá-las à vacinação. • Considerar oferecer sessões de vacinação de rotina em unidades fixas a uma hora que seja mais conveniente para as mães de crianças mais velhas. As sessões de locais de proximidade não são executadas com a frequência planeada • Comparar sessões de locais de proximidade reais conduzidas nos últimos seis meses com o número de sessões de locais de proximidade agendadas no microplano. Caso exista uma discrepância clara, descobrir por que motivo o local de proximidade não está a ser implementado. Esgotamento de stocks de vacinas e materiais • Rever a disponibilidade das vacinas necessárias para a vacinação do 2º ano de vida a todos os níveis, para assegurar que estão disponíveis materiais suficientes. • Se as preocupações com as taxas de desperdício elevadas estiverem a dissuadir os profissionais de saúde de abrir um frasco de MCV para um pequeno número de crianças, rever as políticas nacionais sobre este tópico e reforçar durante as visitas de supervisão de apoio. Lembrar os profissionais de saúde de que a vacinação no 2º ano de vida poderá resultar em níveis mais baixos de desperdício da vacina MCV. Deficiências nas práticas dos profissionais de saúde • Perspectivar a motivação do profissional de saúde: reconhecer e louvar aqueles que atingiram uma elevada cobertura. Pedir-lhes para partilharem a sua experiência através da aprendizagem entre pares com profissionais de saúde de outras unidades. Lembrar os profissionais de saúde dos motivos para a vacinação no 2º ano de vida e indicar que o desempenho do programa de vacinação também se baseia na cobertura com as vacinas dadas após um ano de idade. • Proporcionar formação no trabalho durante as visitas de supervisão de apoio para resolver as deficiências. • Se as faltas de recursos humanos estiverem a contribuir para um desempenho do profissional de saúde abaixo do nível ideal (pessoal sobrecarregado), rever o possível papel dos voluntários para ajudar a assumir algumas das funções menos técnicas. Contudo, reconhecer que os voluntários precisam de orientação técnica e de gestão e que o seu contributo é voluntário. • Consultar a Secção 8.4 para mais acções possíveis, por exemplo, grupos do WhatsApp, linhas de apoio telefónico e mensagens SMS para reforçar os pontos fulcrais. 89 Estabelecer e reforçar a vacinação no segundo ano de vida S E C Ç Ã O 10 P RO B L E M AS/Q U E STÕ E S E X E M P LOS D E AC Ç Õ E S P OS S Í V E I S Problemas com o rastreamento, registo e reporte das doses • Rever os instrumentos de gestão de dados e voltar a avaliar, se necessário, para os tornar mais fáceis de utilizar, de modo a permitirem a prática adequada para rastreamento, registo e reporte. • Supervisão e feedback contínuos sobre como utilizar os instrumentos de recolha de dados. • Auxiliares de trabalho, linhas de apoio ou grupos do WhatsApp para ajudar a endereçar áreas problemáticas particulares, por exemplo, dificuldades com o rastreamento, registo ou reporte. • Conduzir avaliações da qualidade dos dados e utilizar os resultados para corrigir problemas particulares e monitorizar os progressos. Baixa consciencialização ou procura da vacinação no 2º ano de vida • Reforçar as competências do profissional de saúde na comunicação interpessoal para lembrar os cuidadores sobre quando regressar para a vacinação no segundo ano de vida. • Envolver os líderes comunitários para espalhar a palavra às famílias sobre quando e onde ir para a vacinação no 2º ano de vida e porque é que é importante. Utilizar as reuniões comunitárias como oportunidade para dar feedback sobre a cobertura da vacinação no 2º ano de vida e discutir como a melhorar. • Trabalhar com as ONG locais para explorar a forma como podem dar apoio à vacinação no 2º ano de vida, por exemplo, mobilizando recursos para sessões de locais de proximidade em locais convenientes na comunidade. • Voltar a lançar a vacinação no 2º ano de vida através de actividades de alta visibilidade, como por exemplo conferências de imprensa, cerimónias, reuniões, rádio, SMS, etc. • Utilizar programas de rádio para discutir a vacinação no 2º ano de vida e para aumentar a atenção em redor da necessidade da vacinação no 2º ano de vida. Desenvolver canções ou spots publicitários fáceis de memorizar que possam ser difundidos para relembrar as comunidades da necessidade da vacinação no 2º ano de vida. 90 Estabelecer e reforçar a vacinação no segundo ano de vida 1 A N E X O Anexo 1a: Exemplo de folha de inventário de padrão mínimo para a vacinação33 ANTIGÉNIOS/ ITENS 0–11 MESES TOTAL 12 MESES OU MAIS TARDE TOTAL TOTAL VACINADOS BCG Hep B BD VOP 0 VOP 1 VOP 2 VOP 3 VIP Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/ Outra* Vitamina A Rede com insecticida duradoura* 33 Conforme descritos na Secção 7. *Dependendo das prioridades de saúde nacionais e plano de serviços. Data: Região: Distrito: Unidade sanitária: Estratégia de prestação de serviços: fixos de locais de proximidade móveis Localização: _____________________________________________________________ Anexo 1b: Exemplo de folha de inventário de melhores práticas de vacinação33 91 Estabelecer e reforçar a vacinação no segundo ano de vida 33 Conforme descritos na Secção 7. *Dependendo das prioridades de saúde nacionais e plano de serviços. ANTIGÉ- NIOS/ITENS 0–11 MESES TOTAL 12-23 MESES TOTAL 24 MESES OU MAIS TARDE TOTAL TOTAL VACINADOS BCG Hep B BD VOP 0 VOP 1 VOP 2 VOP 3 VIP Penta 1 Penta 2 Penta 3 Rota 1 Rota 2 Rota 3* PCV 1 PCV 2 PCV 3 M/MR 1 M/MR 2 DTP4/Outra* Vitamina A Rede com insecticida duradoura* Data: Região: Distrito: Unidade sanitária: Estratégia de prestação de serviços: fixos de locais de proximidade móveis Localização: A N E X O 1 92 Estabelecer e reforçar a vacinação no segundo ano de vida 2 A N E X O Anexo 2: Gráfico de monitorização da vacinação mostrando o abandono da MCV1–MCV2 Unidade sanitária: Ano: Uma taxa de abandono de mais de 10% é um indicativo para acções imediatas População-alvo anual (0 aos 11 meses): População-alvo anual (12 aos 23 meses): Meta de cobertura mínima para o ano - BCG: Meta de cobertura mínima para o ano - MCV1: Meta de cobertura mínima para o ano - MCV2: Vacina Jan Fev Mar Abr Mai Jun Jul Ago Set Out Nov Dec BCG A Total de vacinados este mês Total cumulativo para o mês MCV1 B Total de vacinados este mês Total cumulativo para o mês MCV2 C Total de vacinados este mês Total cumulativo para o mês TAXA DE ABANDONO BCG-MCV1 = Jan Fev Mar Abr Mai Jun Jul Ago Set Out Nov Dez TAXA DE ABANDONO DA MCV1 PARA A MCV2 = Jan Fev Mar Abr Mai Jun Jul Ago Set Out Nov Dez ** Traçado apenas para BCG, MCV1, MCV2 C ob er tu ra -a lv o m en sa l 25% 75% 50% 100% A-B A * 100 B-C B * 100 93 Estabelecer e reforçar a vacinação no segundo ano de vida A N E X O 3 Anexo 3: Cenários sobre vacinação no segundo ano de vida (a utilizar na formação e supervisão) Os vacinadores encontram muitas situações em que não estão certos sobre o que fazer se uma criança tiver perdido doses anteriores, tiver chegado atrasada à vacinação ou não tiver boletim de saúde. As situações que se seguem são situações reais que foram reportadas em diferentes países. Estes cenários baseiam-se num plano que inclui a MCV1 aos nove meses de idade e a MCV2 aos 18 meses de idade. Devem ser adaptados para se enquadrarem no plano de vacinas apropriado e contexto do país. Estes cenários podem ser utilizados durante a formação para discussões interactivas e desenvolvimento de competências para o rastreamento, administração, registo e reporte de doses de forma adequada. Em cada caso, os formadores podem apenas mostrar as primeiras duas colunas ou imprimir cópias físicas dos cenários e pedirem aos participantes da formação que as revejam aos pares. Depois, fazer a discussão como se segue. • Acha que o profissional de saúde fez a coisa certa? • Em caso negativo, o que deveria ter sido feito de forma diferente? • Como é que este problema poderia ser evitado? A terceira e a quarta coluna são para serem utilizadas pelos facilitadores e supervisores da formação. A terceira coluna indica a resposta correcta. A quarta coluna apresenta algumas respostas possíveis que podem ser mais desenvolvidas e discutidas. População-alvo anual (0 aos 11 meses): População-alvo anual (12 aos 23 meses): Meta de cobertura mínima para o ano - BCG: Meta de cobertura mínima para o ano - MCV1: Meta de cobertura mínima para o ano - MCV2: PARA PARTICIPANTES DA FORMAÇÃO PARA FACILITADORES E SUPERVISORES DA FORMAÇÃO CENÁRIO RESPOSTA «INCORRECTA» DO PROFISSIONAL DE SAÚDE O QUE DEVERIA O PROFISSIONAL DE SAÚDE TER FEITO? COMO É QUE ESTE PROBLEMA PODERIA SER EVITADO? (para discussão) 1. Uma criança é trazida tardiamente para a MCV1 aos 14 meses de idade O profissional de saúde vacina a criança e regista e reporta a dose como MCV2, pois a criança tem mais de um ano de idade. O profissional de saúde pensa que apenas as doses dadas abaixo de um ano de idade podem ser consideradas como MCV1. 1. Devia ter administrado a vacina e registado a dose como MCV1 na coluna da folha de inventário para «12 meses ou mais» ou «12 a 23 meses» e aconselhado o cuidador a voltar com a criança para uma visita agendada para a MCV2 aos 18 meses. • Formação e supervisão adequada para a vacinação após um ano de idade • Folha de inventário bem concebida • Auxiliar de trabalho para promover o rastreamento, registo e reporte correctos 2. Uma criança é trazida para a sua primeira dose da MCV aos 18 meses de idade (no momento da visita agendada da MCV2) O profissional de saúde vacina a criança e regista e reporta a dose como MCV2, pois a criança veio numa altura em que a MCV2 está agendada. 2. Devia ter dado a vacina e registado a dose como MCV1 na coluna da folha de inventário para «12 meses ou mais tarde» ou «12-23 meses». Devia ter aconselhado o cuidador a voltar a trazer a criança para a MCV2 após quatro semanas. • Formação e supervisão adequada para a vacinação após um ano de idade • Folha de inventário bem concebida • Auxiliar de trabalho para promover o rastreamento, registo e reporte correctos 3. Numa unidade rural com locais de proximidade pouco frequentes e poucas crianças vistas antes dos 12 meses, é trazido um menino de 15 meses que nunca recebeu a vacina contra o sarampo O profissional de saúde pensa que a criança não é elegível para a MCV1 porque é demasiado velha para a receber. Também acredita que ele não é elegível para a MCV2 porque não recebeu a MCV1 e, portanto, manda-o embora sem o vacinar contra o sarampo. 3. Devia ter vacinado a criança e registado a dose como MCV1 na coluna da folha de inventário para «12 meses ou mais» ou «12 a 23 meses» e aconselhado o cuidador a voltar com a criança para uma visita agendada para a MCV2 aos 18 meses. • Formação e supervisão adequadas para enfatizar que é melhor vacinar tarde do que mandar a criança embora sem ser vacinada • Folha de inventário bem concebida • Auxiliar de trabalho 4. As crianças numa clínica são muitas vezes trazidas para a MCV1 aos 10, 11, 12 ou 13 meses de idade O profissional de saúde diz às mães para voltarem nove meses mais tarde para a MCV2, achando que o importante é o intervalo de nove meses e não a idade-alvo (de 18 meses). 4. Devia ter aconselhado os cuidadores a voltarem a trazer as crianças para a MCV2 aos 18 meses de idade. • Formação e supervisão para enfatizar de que é a idade de vacinação que é mais importante, desde que haja um intervalo mínimo de um mês entre as doses da MCV 5. Uma criança é trazida para a MCV2 aos 22 meses de idade. A criança já recebeu a MCV1 aos nove meses O profissional de saúde não fornece a MCV2, por achar que a criança é demasiado velha para a receber. 5. Devia ter dado a MCV2 à criança e registado a dose como MCV2 na coluna da folha de inventário para «12 meses ou mais tarde» ou «12–23 meses». • Formação e supervisão para enfatizar que a MCV2 deve ser dada a partir dos 18 meses de idade, mas sem terminar aos 18 meses (sem limite superior - todas as crianças precisam de duas doses da MCV) • Folha de inventário bem concebida 6. Uma criança é trazida para a MCV2 aos três anos de idade. A criança já recebeu a MCV1 aos nove meses O profissional de saúde não vacina a criança porque esta tem mais de 23 meses de idade. 6. Devia ter dado a MCV2 à criança e registado a dose como MCV2 na coluna da folha de inventário para «12 meses ou mais tarde» ou «24 meses ou mais tarde». • Formação e supervisão para enfatizar que a necessidade para a MCV não termina aos 24 meses (sem limite superior - todas as crianças precisam de duas doses de MCV) e que é melhor vacinar tarde do que mandar a criança embora sem ser vacinada • Folha de inventário bem concebida 7. Uma criança é trazida para a MCV2 aos 2,5 anos de idade. A criança já recebeu a MCV1 aos nove meses O profissional de saúde vacina a criança, mas regista a dose num registo especial, para que não seja incluído nas estimativas de cobertura. 7. Devia ter registado a dose como MCV2 na coluna da folha de inventário para «12 meses ou mais tarde» ou «24 meses ou mais tarde». • O MdS precisa de conceber a folha de inventário de modo a permitir o registo e reporte das doses administradas às crianças com 24 meses ou mais tarde 8. O profissional de saúde diz que não pode providenciar a segunda dose da vacina contra o sarampo porque não existe uma vacina «MSD» O profissional de saúde não proporciona uma segunda dose da vacina do sarampo a nenhuma criança. 8. Devia ter proporcionado doses MCV2 a todas as crianças elegíveis com mais de um ano de idade. • O guia de campo, formação, supervisão, formulários de registo de dados e mobilização social deveriam utilizar uma convenção mais familiar das doses numeras (por exemplo, sarampo1/sarampo2, MR1/MR2) para a vacina contra o sarampo ou contra o sarampo e rubéola 9. Uma criança é trazida para a MCV2 aos 18 meses. A mãe não tem um cartão de vacinação, mas lembra-se de que o seu bebé recebeu a MCV1 mesmo antes de começar a andar A profissional de saúde vacina-o, mas regista-o como MCV1 e diz à mãe para voltar um mês depois para a MCV2. 9. Devia primeiro ter verificado a idade da criança e o estado de vacinação no registo de saúde da criança, para verificar se a criança recebeu a MCV1 aos os nove meses ou logo após. Se não for encontrado nenhum registo, então a actuação do profissional de saúde foi correcta. Devia ter sido fornecido um novo cartão de vacinas. Se tivesse sido encontrado um registo, o profissional de saúde deveria ter dado a MCV2 e transferido a informação do registo para um novo cartão de vacinação. • O guia de campo deveria proporcionar orientações claras sobre o que os profissionais de saúde devem fazer na ausência de um HBR ou registo da criança no registo da unidade sanitária 94 Estabelecer e reforçar a vacinação no segundo ano de vida 3 A N E X O Estes cenários baseiam-se num plano que inclui a MCV1 aos nove meses de idade e a MCV2 aos 18 meses de idade. PARA PARTICIPANTES DA FORMAÇÃO PARA FACILITADORES E SUPERVISORES DA FORMAÇÃO CENÁRIO RESPOSTA «INCORRECTA» DO PROFISSIONAL DE SAÚDE O QUE DEVERIA O PROFISSIONAL DE SAÚDE TER FEITO? COMO É QUE ESTE PROBLEMA PODERIA SER EVITADO? (para discussão) 1. Uma criança é trazida tardiamente para a MCV1 aos 14 meses de idade O profissional de saúde vacina a criança e regista e reporta a dose como MCV2, pois a criança tem mais de um ano de idade. O profissional de saúde pensa que apenas as doses dadas abaixo de um ano de idade podem ser consideradas como MCV1. 1. Devia ter administrado a vacina e registado a dose como MCV1 na coluna da folha de inventário para «12 meses ou mais» ou «12 a 23 meses» e aconselhado o cuidador a voltar com a criança para uma visita agendada para a MCV2 aos 18 meses. • Formação e supervisão adequada para a vacinação após um ano de idade • Folha de inventário bem concebida • Auxiliar de trabalho para promover o rastreamento, registo e reporte correctos 2. Uma criança é trazida para a sua primeira dose da MCV aos 18 meses de idade (no momento da visita agendada da MCV2) O profissional de saúde vacina a criança e regista e reporta a dose como MCV2, pois a criança veio numa altura em que a MCV2 está agendada. 2. Devia ter dado a vacina e registado a dose como MCV1 na coluna da folha de inventário para «12 meses ou mais tarde» ou «12-23 meses». Devia ter aconselhado o cuidador a voltar a trazer a criança para a MCV2 após quatro semanas. • Formação e supervisão adequada para a vacinação após um ano de idade • Folha de inventário bem concebida • Auxiliar de trabalho para promover o rastreamento, registo e reporte correctos 3. Numa unidade rural com locais de proximidade pouco frequentes e poucas crianças vistas antes dos 12 meses, é trazido um menino de 15 meses que nunca recebeu a vacina contra o sarampo O profissional de saúde pensa que a criança não é elegível para a MCV1 porque é demasiado velha para a receber. Também acredita que ele não é elegível para a MCV2 porque não recebeu a MCV1 e, portanto, manda-o embora sem o vacinar contra o sarampo. 3. Devia ter vacinado a criança e registado a dose como MCV1 na coluna da folha de inventário para «12 meses ou mais» ou «12 a 23 meses» e aconselhado o cuidador a voltar com a criança para uma visita agendada para a MCV2 aos 18 meses. • Formação e supervisão adequadas para enfatizar que é melhor vacinar tarde do que mandar a criança embora sem ser vacinada • Folha de inventário bem concebida • Auxiliar de trabalho 4. As crianças numa clínica são muitas vezes trazidas para a MCV1 aos 10, 11, 12 ou 13 meses de idade O profissional de saúde diz às mães para voltarem nove meses mais tarde para a MCV2, achando que o importante é o intervalo de nove meses e não a idade-alvo (de 18 meses). 4. Devia ter aconselhado os cuidadores a voltarem a trazer as crianças para a MCV2 aos 18 meses de idade. • Formação e supervisão para enfatizar de que é a idade de vacinação que é mais importante, desde que haja um intervalo mínimo de um mês entre as doses da MCV 5. Uma criança é trazida para a MCV2 aos 22 meses de idade. A criança já recebeu a MCV1 aos nove meses O profissional de saúde não fornece a MCV2, por achar que a criança é demasiado velha para a receber. 5. Devia ter dado a MCV2 à criança e registado a dose como MCV2 na coluna da folha de inventário para «12 meses ou mais tarde» ou «12–23 meses». • Formação e supervisão para enfatizar que a MCV2 deve ser dada a partir dos 18 meses de idade, mas sem terminar aos 18 meses (sem limite superior - todas as crianças precisam de duas doses da MCV) • Folha de inventário bem concebida 6. Uma criança é trazida para a MCV2 aos três anos de idade. A criança já recebeu a MCV1 aos nove meses O profissional de saúde não vacina a criança porque esta tem mais de 23 meses de idade. 6. Devia ter dado a MCV2 à criança e registado a dose como MCV2 na coluna da folha de inventário para «12 meses ou mais tarde» ou «24 meses ou mais tarde». • Formação e supervisão para enfatizar que a necessidade para a MCV não termina aos 24 meses (sem limite superior - todas as crianças precisam de duas doses de MCV) e que é melhor vacinar tarde do que mandar a criança embora sem ser vacinada • Folha de inventário bem concebida 7. Uma criança é trazida para a MCV2 aos 2,5 anos de idade. A criança já recebeu a MCV1 aos nove meses O profissional de saúde vacina a criança, mas regista a dose num registo especial, para que não seja incluído nas estimativas de cobertura. 7. Devia ter registado a dose como MCV2 na coluna da folha de inventário para «12 meses ou mais tarde» ou «24 meses ou mais tarde». • O MdS precisa de conceber a folha de inventário de modo a permitir o registo e reporte das doses administradas às crianças com 24 meses ou mais tarde 8. O profissional de saúde diz que não pode providenciar a segunda dose da vacina contra o sarampo porque não existe uma vacina «MSD» O profissional de saúde não proporciona uma segunda dose da vacina do sarampo a nenhuma criança. 8. Devia ter proporcionado doses MCV2 a todas as crianças elegíveis com mais de um ano de idade. • O guia de campo, formação, supervisão, formulários de registo de dados e mobilização social deveriam utilizar uma convenção mais familiar das doses numeras (por exemplo, sarampo1/sarampo2, MR1/MR2) para a vacina contra o sarampo ou contra o sarampo e rubéola 9. Uma criança é trazida para a MCV2 aos 18 meses. A mãe não tem um cartão de vacinação, mas lembra-se de que o seu bebé recebeu a MCV1 mesmo antes de começar a andar A profissional de saúde vacina-o, mas regista-o como MCV1 e diz à mãe para voltar um mês depois para a MCV2. 9. Devia primeiro ter verificado a idade da criança e o estado de vacinação no registo de saúde da criança, para verificar se a criança recebeu a MCV1 aos os nove meses ou logo após. Se não for encontrado nenhum registo, então a actuação do profissional de saúde foi correcta. Devia ter sido fornecido um novo cartão de vacinas. Se tivesse sido encontrado um registo, o profissional de saúde deveria ter dado a MCV2 e transferido a informação do registo para um novo cartão de vacinação. • O guia de campo deveria proporcionar orientações claras sobre o que os profissionais de saúde devem fazer na ausência de um HBR ou registo da criança no registo da unidade sanitária 95 Estabelecer e reforçar a vacinação no segundo ano de vida A N E X O 3 96 Estabelecer e reforçar a vacinação no segundo ano de vida 4 A N E X O Anexo 4: Exemplo ilustrativo de um auxiliar de trabalho no rastreio para vacinação O modelo de auxiliar de trabalho é adaptado da República Democrática de Timor- Leste (Coisas básicas sobre IMUNIZAÇÃO, 2007) e baseia-se num plano de vacinação infantil que pede as vacinas da BCG e da hepatite B à nascença; As doses da pen- tavalente, vacina oral da poliomielite (VOP), vacina conjugada pneumocócica (PCV) e rotavírus (RV) são dadas às 6, 10 e 14 semanas; vacina inactivada contra a poliomielite (VIP) às 14 semanas; MCV1 aos nove meses; e MCV2, MenA e DTP4 aos 18 meses de idade. Adaptar este documento em conformidade com o plano de vacinação local. Este documento e outras ferramentas e recursos sobre o 2º ano de vida encontram-se em: www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Instruções: Step 1: Elogiar o pai/a mãe ou cuidador por trazer a criança à vaci- nação. Descobrir pelo registo de vacinação da criança ou pelo cuidador: 1. Que idade tem a criança hoje? 2. Que vacinas é que a criança já recebeu? (Verificar o boletim de saúde ou o registo da criança) Passo 2. Utilizar o gráfico abaixo para decidir o que dar. A criança já deve ter recebido todas as vacinas devidas até à idade actual. Se lhe faltarem doses, ainda não é tarde. Administrar as vaci- nas para as quais é elegível, respeitando o tempo de separação necessário (consultar a coluna da direita). Passo 3: Lembrar ao cuidador quando deve voltar com a criança para as devidas doses posteriores. Aproveitar a oportunidade para salientar a importância de a criança receber a série completa de vacinas para ficar totalmente protegida. † Em determinadas situações, a MCV pode ser administrada aos 6 meses de idade. Esta dose deve ser considerada como a dose zero (“MCV0”) e as duas doses subsequentes (MCV1 e MCV2) devem ser proporcionadas na mesma de acordo com o plano nacional. Vacinas contra o sarampo. Documento da posição. Genebra: Organização Mundial de Saúde; 2017 (www.who.int/immunization/policy/position_papers/measles/en/). Às 6 semanas (ou assim que possível desde aí) Dose da hepatite B à nascença: Assim que possível após o nascimento, idealmente no prazo de 24 horas e até às 6 semanas BCG: Assim que possível após o nascimento Dose da hepatite B à nascença: Após as 6 semanas Às 10 semanas (ou assim que possível desde aí) Aos 9 meses (ou assim que possível desde aí) A os 18 meses (ou assim que possível desde aí) e pelo menos 4 semanas após a dose anterior MCV2: Antes de decorridas 4 semanas desde a MCV1 DTP4: Antes de decorridas 4 semanas desde a Penta3 MenA: Antes dos 9 meses de idade (excepto quando indicado) Não existe necessidade de reiniciar as doses, mesmo que tenha passado muito tempo entre as doses. Não existe limite etário superior para maior parte das vacinas (excepto o rotavírus <24 meses e a dose da hepatite B à nascença <6 semanas. QUANDO DAR “É melhor vacinar tarde do que nunca!” NÃO DAR RV1: Após os 2 anos de idade Antes de decorri- das 4 semanas desde a dose anterior RV2: Após os 2 anos de idade Às 14 semanas (ou assim que possível desde aí) e Pelo menos 4 semanas após a dose 2 Antes de decorridas 4 semanas desde a dose anterior RV3: Após os 2 anos de idade Antes dos 9 meses de idade (excepto quando indicado)† VOP 2 Penta 2 PCV 2 RV 2 VOP 3 Penta 3 PCV 3 RV 3 VIP MCV 1 MCV 2 MenA VOP 1 PCV 1 DTP4 (ou Penta4) 6 SEMANAS 9 MESES 18 MESES 2 ANOS NASCENÇA HepB BD BCG Penta 1 RV 1 10 SEMANAS 14 SEMANAS 97 A N E X O 4 QUE VACINAS PODEM SER DADAS HOJE ? Utilizar o gráfico abaixo para decidir quais vacinas devem ser administradas a uma criança em ou após uma idade específica. 98 Estabelecer e reforçar a vacinação no segundo ano de vida 5 A N E X O Anexo 5: Perguntas frequentes sobre a vacinação no segundo ano de vida As seguintes perguntas podem ajudar os profissionais de saúde a responder a questões sobre a vacinação no segundo ano de vida ou mais tarde. 1. Porque é que é importante vacinar as crianças após o seu primeiro aniversário? Tanto o nível de protecção como a duração da imunidade aumentam proporcionando-se doses adicionais da vacina depois de a criança ter atingido um ano de idade. Isto significa que as crianças mais velhas irão continuar a estar protegidas contra muitas doenças preveníveis pela vacinação. Para o sarampo, uma segunda dose assegura uma protecção precoce de cada criança e também reduz a taxa de acumulação de crianças susceptíveis e o risco de um surto. 2. Com que vacinas, e em que idade, é que as crianças devem ser vacinadas após o primeiro ano de vida? Isto depende do calendário do programa nacional de vacinação de cada país. • A OMS recomendou que todos os países proporcionem uma vacina contra o sarampo após um ano de idade. Muitos países agendam-na para o segundo ano de vida. • A OMS também recomenda que seja dada uma dose de reforço da vacina contra a difteria, o tétano e a tosse convulsa no segundo ano de vida. • Outras vacinas que poderão ser agendadas entre os 12 e os 23 meses incluem aquelas contra a meningite A, encefalite japonesa, febre tifóide e febre amarela. • Muitos países também recomendam a actualização da vacinação para fornecer doses perdidas no primeiro ano de vida. 3. Existem algumas vacinas ou doses que não devam ser dadas a uma criança no segundo ano de vida ou mais tarde? A vacinação no segundo ano de vida é uma oportunidade para aumentar o nível e duração da protecção contra as doenças preveníveis pela vacinação. Existem algumas excepções, conforme indicado no plano nacional de vacinação e nos documentos de posição da OMS. São as seguintes. 34 Disponível em: www.who.int/immunization/documents/positionpapers/en/ 99 Estabelecer e reforçar a vacinação no segundo ano de vida A N E X O 5 • A dose da vacina da hepatite B à nascença deve ser administrada apenas no período de recém-nascido, conforme estipulado na política nacional. • A vacinação do rotavírus após os 24 meses não é considerada necessária, devido à distribuição etária da gastroenterite causada pelo rotavírus. 4. Em que ocasiões é que uma criança acima de um ano de idade deve ser vacinada? • Quando vem para uma visita agendada para vacinação de acordo com o plano nacional de vacinação. • Em qualquer altura em que esteja em contacto com o sistema de saúde, incluindo quando venha fazer cuidados curativos. Uma doença que não seja grave não é motivo para negar a vacinação a uma criança e o rastreamento de crianças doentes para elegibilidade da vacinação é um componente padrão da GIDI. Se as crianças tiverem sido trazidas para monitorização do crescimento e aconselhamento nutricional, isto também proporciona uma oportunidade para o seu rastreio e vacinação. Outra oportunidade de rastreio e vacinação é se a criança tiver acompanhado um dos familiares, como um irmão ou mãe, que venha receber cuidados. • Durante uma Semana da Saúde Infantil agendada, ou outra campanha ou evento semelhante, em que seja proporcionada vacinação de actualização. 5. Que mensagens devem ser dadas à mãe ou cuidador durante o último contacto de vacinação do seu bebé, antes de atingir um ano de idade? Para a maioria das crianças, o contacto do sarampo é a última visita de vacinação antes de a criança atingir um ano de idade. Durante essa visita, o profissional de saúde deve certificar-se de que informa a mãe do seguinte modo. • É importante que o seu filho regresse na data agendada (dependendo do programa nacional de vacinação) para receber as doses restantes da vacina a serem dadas no segundo ano de vida. Ao contrário do que acontecia no passado, a criança não pode ser considerada totalmente imunizada até ter recebido também as doses de vacina recomendadas. • Estas doses adicionais irão proporcionar protecção mais forte e duradoura contra doenças importantes na infância. Com doses adicionais, esta protecção irá durar para além da primeira infância. 35 Para obter mais informações, consultar a estratégia de Oportunidades Perdidas de Vacinação (OPV) da OMS. Disponível em: www.who.int/immunization/programmes_systems/policies_strategies/MOV/en/ 100 Estabelecer e reforçar a vacinação no segundo ano de vida 5 A N E X O • Certifique-se de que mantém o boletim de saúde, como o cartão de vacinas, num local seguro e o traz da próxima vez que vier à vacinação, bem como em qualquer altura em que vá a uma unidade sanitária para receber serviços. • Deve trazer o seu filho para fazer a vacinação na próxima data agendada [especificar a data]. Contudo, se ela não puder vir nessa altura, que venha assim que seja possível depois. 6. Se uma criança vier receber serviços substancialmente mais tarde do que a data agendada, a criança ainda deve ser vacinada? • Sim. Apesar de a vacinação atempada assim que a criança é elegível ser altamente desejável para reduzir a exposição potencial à doença, é sempre importante que a criança receba a protecção da vacinação e não seja mandada embora se vier receber a vacinação com atraso. Com muito poucas excepções, como explicado na Questão 3, acima, «é melhor vacinar tarde do que nunca». 7. Se a criança vier atrasada para a visita da vacinação do 2º ano de vida e tiver mais de 23 meses de idade, a dose deve ser registada como dada no segundo ano de vida (12-23 meses)? • Registe e reporte sempre a dose de forma precisa, para que corresponda à idade em que a criança realmente a recebeu. Isto irá depender de como as folhas de inventário e os formulários de reporte mensais foram concebidos. • Caso contenham dois grupos etários (“0–11 meses” e “mais de 12 meses”), registe as doses como sendo administradas aos “mais de 12 meses”. • Caso contenham três grupos etários (“0–11 meses”, “12–23 meses” e “mais de 24 meses”), registe as doses como sendo administradas aos “mais de 24 meses”. 8. É seguro vacinar as crianças depois de um ano de idade? Existem riscos adicionais? É seguro e não existem riscos adicionais ou diferentes entre vacinar as crianças após um ano de idade, em comparação com a vacinação durante a infância. 9. Que outros serviços ou cuidados pode a criança receber quando vem fazer a vacinação no segundo ano de vida? • A monitorização e promoção do crescimento, aconselhamento nutricional, aconselhamento sobre higiene e saneamento e, dependendo das políticas nacionais, a vitamina A ou a medicação de desparasitação podem ser proporcionados durante uma visita para vacinação no segundo ano de vida. 101 Estabelecer e reforçar a vacinação no segundo ano de vida A N E X O 5 • lguns países poderão decidir proporcionar serviços adicionais, como o seguimento do diagnóstico infantil precoce de VIH/SIDA ou serviços de planeamento familiar para as mães. © J Sw artz 102 Estabelecer e reforçar a vacinação no segundo ano de vida www.who.int/immunization/programmes_systems/policies_strategies/2YL/en/ Tabelas 1. Vacinas recomendadas pela OMS a serem administradas no segundo ano de vida 18 2. Materiais a rever e actualizar sobre vacinação e serviços no 2º ano de vida 28 3. Intervenções e produtos de vacinação e outros serviços numa visita agendada no 2º ano de vida (exemplo ilustrativo) 42 4. Resumo dos indicadores de vacinação relativos ao 2º ano de vida 52 5. Elementos do quadro de comunicações de alterações do comportamento no 2º ano de vida 71 6. Exemplos de tópicos de mensagens essenciais para suportar a vacinação no 2º ano de vida 78 7. Problemas comuns e possíveis acções para reforçar a vacinação no 2º ano de vida 88 Figuras 1. Aumento nas estimativas de cobertura da MCV1 quando são incluídas as doses administradas no segundo ano de vida 20 2. Cobertura estimada das intervenções entre agregados familiares com uma criança entre os 12 e os 23 meses, se integrada na vacinação de rotina (28 países da África Sub-Sahariana) 21 3. Exemplo da República do Gana de um algoritmo para determinar a elegibilidade para a vacina da meningite A e contra o sarampo e rubéola 68 4. Ciclo de planeamento da procura e promoção 73

104 Estabelecer e reforçar a vacinação no segundo ano de vida Í N D I C E Este documento fornece orientações práticas para estabelecer e reforçar a vacinação no segundo ano de vida (2YL) e posteriormente. Também sugere formas de utilizar as visitas de vacinação no segundo ano de vida como uma plataforma para a prestação de outros serviços de saúde infantil. Para ferramentas e recursos sobre vacinação no segundo ano de vida, visite: www.who.int/immunization/programmes_ systems/policies_strategies/2YL/en/ Este documento foi publicado pelo Programa Alargado de Vacinação (PAV) do Departamento de Imunização, Vacinas e Produtos Biológicos e está disponível na Internet em: www.who.int/immunization/documents Poderão ser solicitadas cópias deste documento, bem como materiais adicionais sobre vacinação, vacinas e produtos biológicos, através dos seguintes contactos: Organização Mundial de Saúde Departamento de Imunização, Vacinas e Produtos Biológicos CH-1211 Genebra 27 Suíça E-mail: vaccines@who.int Internet: www.who.int/immunization/en ISBN 978-92-4-851367-1