Presentation on theme: "HOUSE TO HOUSE MOBILIZATION FOR SUCCESSFUL MEASLES SIAs: SITREP AFTER FIVE YEARS IN AFRICA Bob Davis Measles/Health Delegate American Red Cross."— Presentation transcript:
HOUSE TO HOUSE MOBILIZATION FOR SUCCESSFUL MEASLES SIAs: SITREP AFTER FIVE YEARS IN AFRICA Bob Davis Measles/Health Delegate American Red Cross
WHOM DO WE HAVE TO REACH TO STOP MEASLES TRANSMISSION? Ethno-linguistic minorities and slum dwellers Marginalized and floating populations, both urban, peri-urban, and rural In a nutshell: Those who dont watch CNN, dont listen to the BBC, and dont read the New York Times Solution, for both polio and measles: next slide 1 Photo, Prof. Stanley Foster
THE HOUSE TO HOUSE STRATEGY For GPEI, OPV SIA policy since 2001 PAHO policy in Latin America for measles SIAs: H2H mobilization in campaigns which vaccinated from fixed posts and fixed mobile posts H2H mobilization a best practice, UN supported measles SIA, Ethiopia, 2010 Used in Red Cross supported campaigns in 10 African countries: Benin, Burundi, C.A.R., Kenya, Mali, Mozambique, Namibia, Senegal, Tanzania, Uganda 2
COMMUNITY MONITORING AS PART OF H2H MOBILIZATION Wherever possible, line list the 9- to 59-month-olds in the week before the campaign, using RC volunteers, then trace defaulters after Day 1 of the campaign to bring them in from home. Example from Tanzania: 3
HOUSE TO HOUSE MOBILIZATION (cont.) Does H2H mobilization produce better results in measles SIAs? Probably: Traditional mass media approaches may miss the least readily accessible populations, even in urban areas. Herd immunity is more easily achievable when we systematically reach populations who lack, e.g., radio and TV. Data from 8 countries tend to support this hypothesis. 4
DISTRICTS WITH CANVASSINGDISTRICTS WITHOUT CANVASSING KIBERA, 57%DAGORETTI, 64% KASARANI, 83%WESTLANDS, 62% EMBAKASI, 80%CENTRAL, 68% PUMWANI, 58% MAKADARA, 53% UNWEIGHTED AVERAGE, 73 %UNWEIGHTED AVERAGE, 61% ADMINISTRATIVE COVERAGE ESTIMATES IN DISTRICTS WITH AND WITHOUT KENYA RED CROSS HOUSE TO HOUSE CANVASSING, 2009 MEASLES CAMPAIGN, NAIROBI
COMPARATIVE CAMPAIGN COVERAGE, BAMAKO, MALI, 2011 Red Cross Zones Target 660,000 Coverage 93.6% Others Target 210,317 Coverage 87.8% 7 Do these percentages make a difference? Yes, when herd immunity starts at > 90%
RESULTS OF SITE INTERVIEWS WITH CAREGIVERS, TWO RURAL PROVINCES COVERED BY BURUNDI RC, 2012 SIA HOUSE VISITS RADIOCHURCHES ALL OTHER POPULATION RED CROSS VOLUNTEERS Ruyigi2319715505710562 Gitega32312369201361022 Total5550302114258461584
ADMIN COVERAGE ESTIMATES, BURUNDIS 2012 SIA, NATIONWIDE AND IN THE FOUR REGIONS WITH H2H MOBILIZATION NATIONWIDE AVERAGE GITEGAMAKAMBAMUYINGARUYIGI 103%104%116%106%115% AVE + 1AVE + 13AVE + 3AVE + 12 AVE + 8 IN H2H REGIONS, BASED ON WEIGHTED AVERAGE
SOURCES OF INFORMATION CITED BY MOTHERS, ABOMEY, BENIN, SEPTEMBER 2011: 1/5 OF ALL VOLUNTEER MENTIONS FROM THE 4 PERCENT OF VOLUNTEERS WITH MEGAPHONES! SOURCE OF INFO CUMULATIVE FIGURES Public CriersMonday, 53 mentions by mothers and other caregivers Wednesday, 65 mentions Friday, 63 mentions Red Cross Volunteers 49 Mentions House to house volunteers, 28 30104 House to house volunteers with megaphones, 15 2010 Volunteers at fixed posts, 6 375 Radio37 mentions87110
H2H EVALUATED AS BEST PRACTICE, BENIN CAMPAIGN, 2011 CRITERIAANALYSIS BY CRITERIONCONCLUSION Effectiveness - Strong mobilization of the parents of children targeted at the time of the passage of the teams in the villages - Better knowledge of the populations of the campaign schedule, of the strategy of progression of the teams and of the campaigns target disease Satisfactory Efficiency - Reduction of the number of people reluctant to vaccinate - Improvement of the vaccine coverage in the localities benefiting from the support of mobilizers Satisfactory Relevance - Facilitate the acceptance of vaccination by the populations in the urban zones Satisfactory Feasibility- Valid for all the vaccination campaigns even the JNV polioSatisfactory Reproducibility - Implementation in the countrys 3 largest cities and in 12 other communes of the country Satisfactory Participation of the partners - Activities mainly undertaken by the volunteers of the Red Cross, the Community and members of the Church of Jesus Christ of Latter Day Saints Satisfactory
Large chunks of the urban population, and even of many rural populations, are accessible through mass media approaches. However, we are unlikely to achieve herd immunity in campaigns without house to house mobilization. In addition to campaigns, intercampaign house canvassing, 1 ½ years after the SIA, is a promising possibility to reduce the risk of outbreaks between campaigns. WHAT THE DATA SHOWS
METHODS FOR EVALUATING COMPARATIVE PERFORMANCE OF H2H AND CONVENTIONAL APPROACHES BEST OF ALL POSSIBLE WORLDSPLANET EARTH 30 cluster surveys, intervention and non- intervention areas Yes; so far, only in mainland Tanzania, with results ranging from 72 to 100 percent in areas with house visiting. Admin coverage estimates Yes, but check your denominators. With data retention and/or recording errors, check your numerators as well. Spot surveys at vaccination sites to ascertain mothers source of info. Cheap and easy; permits assessment of comparative role of H2H and other info sources Compare to IM data where available.
WHY WE NEED MORE SPOT SURVEYS Cluster coverage surveys, with more scientific rigor, are not always done, and rarely permit comparison between areas with and without house visiting. Admin coverage data are based on high side population figures (Eritrea) or low side population figures (Uganda). >>100% coverage = high degree of flakiness; true of ½ of all districts in Ugandas 2012 measles SIA. Data retention by health workers (Senegal, Kampala) makes it impossible to calculate SIA admin coverage.
COSTING OF HOUSE TO HOUSE MOBILIZATION Vitamin m, the indispensable micronutrient Single partner funding by American Red Cross is not a viable option for H2H mobilization to go to scale.
ADDED COST PER BENEFICIARY, H2H STRATEGY, FIVE MOST RECENT NATIONAL CAMPAIGNS, AVERAGE $0.32. UNIT COSTS VARY. TANZANIA FINANCED DAR ES SALAAM, WITH LOW UNIT COSTS. NAMIBIA FINANCED RURAL AREAS. BENIN, 2011 BURUNDI, 2012 NAMIBIA, 2012 TANZANIA, 2011 UGANDA, 2012 BUDGET FOR HOUSE VISITING USD 99,233 USD 154,546USD 95,759USD 272,957 (exclusive of UNICEF funding) USD 272,957 BENEFICIARIES322,572473,890166,7501,687,0001,300,000 COST PER BENEFICIARY USD 0.31USD 0.33USD 0.57USD 0.16USD 0.21 VOLUNTEERS WORKING ON CAMPAIGN 6853100145026792911
CONCLUSIONS In areas with H2H mobilization, measles SIA cost per child rises from ~$1 to ~$1.32 or more. We need to be selective in choosing areas for H2H. Selection criteria used by American Red Cross and, in some countries, UNICEF: Underserved populations, especially slums Areas with low coverage and/or high cases based on case based surveillance Geographically remote areas
CONCLUSIONS (CONT.) Some countries (Kenya, Burkina Faso) have widespread viral seeding from town to country. There, it may be necessary there to target whole cities, not just slums. In some settings, the dollar goes farther in urban H2H mobilization (Tanzania vs. Namibia). Where funding is short, first priority goes to underserved urban and periurban areas.
THE MAGIC FORMULA There is no magic formula for targeting areas to cover through H2H. Where viral seeding is well documented, target the source of the viral seeding. Where coverage data are reliable, target areas with low coverage. Where case based surveillance is good, target areas with cases (Burundi: 4/17 regions were home to 29/30 confirmed measles cases).
URBAN PARTICULARITIES Weekend SIA start is preferable; no traffic jams to tie up logistics; pulpit announcements on Fridays and Sundays Multilingual house visitors and vaccinators are needed – Dakar, Nairobi, for example. Mapping of neighborhoods with many migrants and floating populations, for special emphasis by govt, RC and other partners
H2H CANVASSING FOR ROUTINE IMMUNIZATION? American Red Cross & partners need to consult on how best to apply lessons learned from SIAs to routine immunization. A network of volunteers already exists to sensitize the community. Possible modalities: birth registration and follow-up; periodic village canvasses; linkages to health facilities for defaulter follow-up
SO WHERE IS H2H GOING? Depends on decisions made by the MRI, as by the GPEI in 2001, when the polio initiative opted for H2H OPV SIAs. If H2H mobilization goes global with measles, as with polio, then more resources and partners will be needed. You cant go global on a shoestring, and you cant do it with 1 or 2 partners, as at present. Decision whether to go global with H2H should predate any WHA resolution. No 1988-2001 gap as with GPEI, SVP!
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