6/17/2014

1

INTEGRATED DELIVERY OF

IMMUNIZATION SERVICES

WITH ADDITIONAL HEALTH

INTERVENTIONS

Aaron Wallace, Global Immunization Division, CDC-Atlanta

Ad-Hoc Working Group Meeting IVIR-AC, June 2014

1

Objectives

Discuss current evidence regarding integrated delivery

involving immunizations services in developing countries

Identify practical actions and recommendations for

integrated delivery

Identify potential gaps for future research

Focus in this presentation: Integration at point of

delivery with routine immunization services and

campaigns

2

Defining Integration and Rationale for Use

with Immunization Services

Background

Rationale for Integration & Immunization Services

Immunization programs strong relative to other MCH programs

Coverage reaching >80% of children <1 year of age

Relatively equitable distribution

Overlapping target groups (infants, mothers) with interventions requiring scale-up

Multiple contacts during first 2 years of life when other interventions also critically effective

New vaccines targeting diseases requiring multiple interventions for complete control / elimination

4

6/17/2014

2

Global Health Frameworks, Guidelines &

Integrated Delivery with Immunizations

GIVS, Objective 3

Integrated delivery of MCH interventions

GVAP, Objective 4

Platform for other interventions and vice-versa

Emphasis with pneumonia, diarrhea, cervical cancer vaccines

GAPPD

Deliver packages of interventions in a continuum of care

WHO Guidelines for ARV Use for HIV

HIV screening and testing during immunization visits

5

Evidence on Integrated Delivery of Immunization

Services

Current Evidence

Key Research Questions

1. Benefits and risks?

2. Characteristics of successful integrated programs?

3. Lessons / recommendations from integration

studies?

7

Current Evidence

CDC/GID systematic reviews

1979 – 2011 studies (grey and peer-reviewed)

CDC-sponsored JID integration supplement (2012)

Articles on safe water, “comprehensive integration”, DHS analysis, EPI contact method, child health weeks etc

http://jid.oxfordjournals.org/content/205/suppl_1.toc

Post-review studies (2012-present)

8

6/17/2014

3

About The Systematic Reviews

Peer & grey literature databases

First review: January 1979-June 20051

Second review: 2000 - 20112

Objectives:

Answer which programs integrate, how integrated delivery is structured, benefits, challenges, characteristics of success, outcomes and research limitations

Number of studies reviewed

59 studies on 46 integrated projects

1. Wallace A, Dietz V, Cairns L. Integration of immunization services with other health interventions in the developing world: what works and why? 2009 TMIH, 14(1): 11-19;

2. Wallace A, Ryman T, Dietz V . Experiences integrating delivery of maternal and child health services with childhood immunization programs: Systematic review update. 2012

JID, 205 S6-19 9

Post-Review Studies

PMTCT/RI integration study (2011-12)

Tanzania

WASH/RI integration study (2011)

Kenya

Family Planning/RI integration studies (2013-14)

Ghana, Rwanda

Comprehensive integration project (2010-11)

Cameroon, Ethiopia, Mali

DHS analysis of potential benefits of integration (2012)

Global

10

Current Evidence Outputs

Integration Service Delivery Models

Combined routine service provision

Using routine contact to deliver another health intervention, same facility, same day (33% of systematic review studies)

Single routine service provision + referral

Using routine contact to inform or screen for other services available, follow-up visit, same or another facility (16%)

Combined campaign service provision

Using time-limited activity (campaign, child health week) to deliver additional health interventions (51%)

12

6/17/2014

4

Interventions Linked to Immunizations Intervention Linked with Immunization Services Example countries

Family Planning Ethiopia, Burundi, India, Ghana,

Rwanda, Madagascar*

Intermittent Preventative Treatment of Infants (IPTi) Tanzania, Ghana, Madagascar*

Vitamin A Supplementation Indonesia, Ghana, India, Peru, Guinea-

Bissau, Ethiopia*

Deworming tablets Togo*, Zambia*, Mali*, Mexico*,

Cameroon

Bednets Togo, Zambia, Ghana, Malawi,

Cameroon

HIV testing and counseling Tanzania, South Africa, Zimbabwe

Hearing screening Nigeria, South Africa

Growth monitoring India, Philippines, Ethiopia,

Madagascar*

Safe water interventions Kenya

Health education (Breastfeeding, nutrition)

India, Philippines

*integrated campaign or child health week; otherwise, study used routine delivery 13

Study Design Quality

Majority of study designs observational

44% used pre/post design

Control groups uncommon (10%)

Trials with coverage outcomes uncommon (3 studies)

Most trial studies examined clinical outcomes of linking IPTi

19% documented impacts on costs, resources

Few report impacts on immunization services

12% reported pre AND post vaccination coverage

7% reported only pre OR post vaccination coverage

Most pre/post studies (91%) reported linked intervention change in coverage

14

Did Linked Intervention Coverage Reach Vaccination

Coverage Levels?

-60

-50

-40

-30

-20

-10

0

10

Nig

er

©

Nig

er

©

Togo ©

Mala

wi1

Mala

wi1

Nig

er

©

Tanza

nia

©

Togo ©

Phili

ppin

es

Nig

eria

Sout

h A

fric

a

Tanza

nia

©

Togo ©

India

Phili

ppin

es

Tanza

nia

©

Bednet usage Bednet ownership F.P. Hearingscreening

Mebendazole N.C. Vitamin A

Perc

enta

ge P

oin

t D

iffe

rence

In C

overa

ge

Percentage point difference in post-intervention coverage between vaccination indicator and

intervention indicator, for systematically reviewed studies

©Study completed in campaign setting, otherwise setting was routine services 1 In Malawi, 2 intervention locations were used with different coverage differences

F.P: Family Planning; N.C: Nutrition Counseling

Hypotheses:

• ‘Simpler’ interventions (Vitamin A,

deworming) appear to more easily

reached vaccination coverage levels

• Interventions requiring more behavior

change had greater differences

(bednet ownership vs usage)

15

Identified Benefits

Most papers do not discuss benefits

Benefits mentioned but not quantified

Rapid uptake of linked intervention compared to previous uptake speed Fast uptake of IMCi attributed to existing community trust in EPI

Decreased competition for resources 4 studies (campaigns with multiple interventions)

Time-saving strategy for beneficiary, health system 4 studies (campaigns with multiple interventions)

16

6/17/2014

5

Identified Challenges

Community acceptability

Variable levels of behavior change needed for certain interventions

Bednet use, water treatment use, family planning adherence

Stigma & unintended consequences

PMTCT services with routine immunizations

Community concerns / stigma of certain interventions vary widely by country

Supply chain complexity

Linked intervention commodities may not be available with same reliability as vaccinations

17

Identified Challenges

Measuring outcomes How to measure quality and outcome of combined services

Potential service quality impacts

Increased workload and potential reduction of quantity/quality of

immunization services

Wait times exacerbated by poor implementation of integrated delivery

Variable complexity of delivery Multiple components can create additional delays and complexity when

not well planned with good patient flow procedures

Vaccination sessions generally rapid; other interventions may break this patient flow

18

03:00 06:00 09:00 12:00

Vitamin A supplementation (n=37)

infant vaccination (n=201)

Family planning (recurrent method) (n=34)

Infant growth monitoring (n=46)

Bednet distribution (n=14)

Newborn care promotion (n=29)

Antenatal care (n=103)

Sick infant treatment (n=34)

HIV prevention/counseling (n=9)

Breastfeeding education (n=48)

Family planning (IUD method) (n=7)

Observed duration to deliver intervention (in minutes:seconds)

Challenge –Delivery Time Differences

Between Interventions

*Wallace A, Ryman T et al. Strengthening evidence-based planning of integrated service delivery through local measures of health intervention

delivery times. JID 2012: 205;S1 19

Length of time for health worker to deliver listed intervention; Ethiopia, Cameroon, Mali time-motion study

Planning integrated

delivery may require

understanding patient

flow per intervention

Lessons For Implementation

Multiple challenges not integration-specific Well-functioning health systems needed: supply, human resources

Two weak services ≠ one strong integrated service

Manage expectations on speed of success Integration not a magic bullet for overcoming coverage barriers

Strategy requires extensive planning, resources, managerial buy-in

Integration country/context specific Do not integrate time-intensive or sensitive services into

campaigns

Consider community-level stigma with certain services

Mix of integrated and non-integrated activities needed Use dedicated providers for certain services (behavior change)

M&E should track appropriate outcomes & processes

20

6/17/2014

6

Key Knowledge Gaps, Areas For Future

Research and Study Design Considerations

Key Gaps

Where are the Remaining Gaps?

Existing research studies still minimal for the complete answer

Yet question is no longer whether but how and when to integrate

Suggested priority research questions*

How does integrated delivery affect quality of service provision?

Does integration lead to cost-savings and other efficiencies in organization and use of human resources?

How is the success or failure of integrated delivery affected by contextual factors (e.g. health system strength; stigma) within the service setting and community?

How do we ‘optimize’ integrated service delivery via patient flow measures, thoughtful packaging of services, ensured confidentiality of services and acceptable workloads?

*Developed in during FP/EPI Working Group discussions and CDC routine immunization research review 22

Suggested Topic Areas for Research

PMTCT Increasingly common, not well-documented

ANC – EPI linkages Particularly of use in countries with ANC coverage higher

than EPI coverage

Non-infant immunization opportunities Maternal immunization Immunizations after first year of life (HPV, booster doses,

MCV2, TT)

Assessing role / lessons for integration of other health system components Integrated data management; monitoring; supervision; supply

23

Study Design Considerations

Strengthened study designs: Data on process indicators based on identified benefits, challenges

Implementation research trials where possible

Quasi-experimental designs

Encourage publication of both unsuccessful and successful projects

Many integration experiences not documented

Suggested guidelines for indicators to measure in integration studies and designs to use See example of FP-EPI Working Group documents at :

https://www.k4health.org/sites/default/files/FP%20Immunization%20Monitoring%20and%20Evaluation%20Briefer_0.pdf

https://www.fphighimpactpractices.org/sites/fphips/files/hip_fp_imz_brief.pdf

24

6/17/2014

7

Considerations for Full IVIR meeting

Recommended areas for research

Presentation of specific study findings of critical

interest, e.g.:

HIV

Family planning

Country lessons on implementing comprehensive

integrated packages similar to those in GAPPD

Ethiopia, Zambia, Ghana

25

Conclusions

26

Very real benefits exist

Coverage can rapidly improve for simple, more compatible interventions

Integrated delivery does not solve all problems

Poorly performing programs don’t necessarily become good programs with integrated delivery alone

Clear & realistic expectations of outcomes necessary

Proper planning is crucial

Clear understanding of and mitigation against potential negative impacts

Map out patient flow, operating procedures

Thank You!

Acknowledgements

Margie Watkins, CDC

Samir Sodha, CDC

Vance Dietz, CDC

28

6/17/2014

8

ADDITIONAL SLIDES

29

Topics To Assess in Integration Studies*

Coverage of each intervention

How to measure for each intervention appropriately and fairly

Quality of services

Measuring quality difficult but track supervision frequency as proxy of quality

Acceptability

Evaluation can confirm that added efficiency of integrated service delivery has not unintentionally reduced demand or acceptance of services offered

Complexity

Evaluation can determine whether complexity introduction with integration is not excessive but remains consistent with program, healthcare worker and population capacities

Unintended consequences

Problems with a component service inadvertently harm perceptions about other services and should be monitored

*Schuchat A, De Cock K. The value of science in integration of services. JID 2012:205 30

Studies of Interventions Linked to Immunizations Program linking to Immunization Services Example countries

Family Planning (FP) – refer mother to FP services held within same facility at time of routine or

campaign immunization contact

Ethiopia, Togo, Zaire, Burundi,

India, Ghana, Rwanda,

Madagascar*

Intermittent Preventative Treatment of Infants (IPTi) - give malaria treatment at time of routine or

campaign immunization contact

Tanzania, Ghana, Mozambique,

Madagascar*

Vitamin A Supplementation (VAS) - give Vitamin A tablets at time of campaign or routine

immunization contact

Indonesia, Ghana, India, Peru,

Guinea-Bissau, Ethiopia*

Deworming tablets (DW)- give deworming tablets at time of campaign immunization contact Togo*, Zambia*, Mali*, Ethiopia,

Mexico*, Cameroon

Bednets (ITN) - distribute bednets at time of routine or campaign immunization contact Togo, Zambia, Mali, Senegal,

Ghana, Malawi, Cameroon

HIV testing and counseling - provide HIV testing to infant and mother during a routine vaccination

visit

Tanzania, South Africa, Zimbabwe

Hearing screening - Vaccinator refers child to a hearing-screening team in separate testing room Nigeria, South Africa

Nutrition and growth monitoring- weigh child during comprehensive check-up visit; provide

mothers information on good feeding practices, breastfeeding practices

India, Philippines, Ethiopia,

Madagascar*

Safe water – offer hygiene kits and education to the caregiver by nurse or community member during

an infant immunization visit

Kenya

*integrated campaign or child health week, otherwise, study used routine delivery 31

Outcomes from integration studies (I)

32

Country Delivery type Immunization coverage change Linked intervention change Intervention length

Zambia Campaign Fully immunized: 18% ITN ownership: 63% 1 week

Togo Campaign Measles coverage: 17% ITN ownership: 61% 1 week

Ghana Campaign ITN ownership: 75%

Child sleeping under net: 54%

1 week

Mali Routine Measles coverage: 51%

Fully immunized: 44%

Vitamin A: 50%

Child sleeping under net: 80%

3 years

Senegal Routine Measles coverage: 13%

Fully immunized: 50%

Vitamin A: 26%

Child sleeping under net: 86%

3 years

Ethiopia Referral Measles coverage: 1% Family planning acceptance: 4% 1 year

Togo Referral Family planning acceptance: 27%

2 months

Burundi Referral Measles coverage: 0%

Family planning acceptance: 5%

5 months

6/17/2014

9

Outcomes from integration studies (II)

33

Country Setting Ttile Outcomes

Cameroon Routine Cameroon Expanded Impact Child Survival Project Mid-term evaluation 200% coverage on average for vaccination indicators

DR Congo Campaign Impact of coupling vitamin A supplementation with deworming into

immunization activities in the Republic of Congo Significant improvement in coverage for VAS and Deworming (>90%) DR Congo Campaign Action Against Worms

Ethiopia CHD The cost of Child Health Days: a case study of Ethiopia's Enhanced

Outreach Strategy (EOS)

Cost/child: 0.57/round w/o measles and 1.04/round with measles.

Cost/DALY: $9 and $2 for total versus VAS. Total cost/life saved: $228; if

only VAS: $56.

Ghana Routine

Is the Expanded Programme on Immunisation the most appropriate

delivery system for intermittent preventive treatment of malaria in West

Africa? P.E. for 11 W. Africa countries was 5% to 20%. Lowest was Nigeria b/c of

DPT3 coverage. 10% of expected cases would be averated in <1yr olds

India Routine Use of multiple opportunities for improving feeding practices in under-

twos within child health programmes

Impact on EPI: Significant increase in vistis to EPI sessions (3,6,9mo visits),

weighitn sessions and govt health centers. Intervention mothers possessed

cards 87% of time vs 74% in control. 30-47% of mothers reported zero

counsels. Those with only 1 channel counseled: 56% through EPI. Significant

assocation between # of contacts and breastfeeding uptake.

India Campaign

An educational intervention to promote appropriate complementary

feeding practices and physical growth in infants and young children in

rural Haryana, India No effect on weight; small improvement in length

Madagascar CHD

The challenge of shifting from Vitamin A Supplementation Campaign to

Delivering a Package of key interventions during ‘Mother and Child

Health Week' By October 2006, VAS and deworming coverage had dropped <90% in 15

districts versus 5 in May 2006

Malawi Routine Integration of insecticide-treated net distribution into routine

immunization services in Malawi: a pilot study

FIC: Intervention district 1: 33% pre to 63% post. Intervention district 2: 49%

pre to 68% post. Control district: 47% pre to 79% post. For Both

Interventions: (1) 14% to 40%; (2) 10% to 44%; (ctrl3) 18% to 24%. ITN

12-23 mo under net: (int1) 25% to 52%; (2) 26%-69% and (ctrl3) 29% to

28%

Mexico CHD Using national health weeks to deliver deworming to children: lessons

from Mexico Pre infection: 20%; 15% (1993). Post infection: 8,4%; 11.1% (1998)

Mozambique Routine Community response to intermittent preventive treatment delivered to

infants (IPTi) through the EPI system in Manhica, Mozambique

People were already familiar with SP. Impact on EPI: Most aware that EPI

separate from the "tablet" and knew this through the additional procedures.

The loose interpretation of immunization concept meant they did not expect

immunization agaistn malari and they kept sleeping under nets.

Outcomes from integration studies (III)

34

Country Setting Ttile Outcomes

Niger Campaign Insecticide-treated net ownership and usage in Niger after a nationwide integrated

campaign

ITN ownership: 6.3% pre and 65% post. 1 month post: 99.5% still had ITN. 6 months post:

97.7% had ITN. Equity ratio: 0.17 pre and 0.79 post. ITN use: 44% in dray season ; 38%

of <5 slept under ITN. 82% in rainy season; 56% of <5 slept under ITN. 23% of <5 lived

in HHS w/o an ITN

Niger Campaign Niger welcomes largest bednet distribution in history 90% of families <5 have nets and 20% of families with <5 use nets (post campaign)

Nigeria Routine Community-based infant hearing screening for early detection of permanent hearing

loss in Lagos, Nigeria: a cross-sectional study

75% of BCG vaccination were administered in 1st month of life. Mean screening age= 17.7

days w/s.d. 19.1 days. 88% of babies were screened; 14% referred; 50% of babies were

born outside hospital.

Philippines Routine 'EPI plus' (Expanded program on immunization plus) FIC: 20% pre; 10% post. FamPlan: 30% pre; 20% post. VAS: 30% pre; 10% post.

Rwanda Routine Integrating HIV clinical services into primary health care in Rwanda: a measure of

quantitative effects

Mean coverage for vaccinations completed increased from 72 to 79. Vax coverage rate

increased from 79% to 87%. There was no significant association between increase in

vaccination rates and HIV Care being offered, but rather it was associated with Insurance

being offered

South Africa Routine Surveillance of mother-to-child transmission prevention programmes at immunization

clinics: the case for universal screening 37% of infants with HIV. Mother varied by age = 16-20yr (21%); 20-29yr (46%); >j30yr

(38%). 20% infant infection rate.

South Africa Routine Infant hearing screening at immunization clinics in South Africa

4% of 510 infants did not receive hearing screening. 14% referral rate. 40% of referrals

came for follow-up. 95% of all ears and 93% for bilateral screening obtained

(bencmark=95%). 4% referral rate.

Tanzania Campaign Distribution of free untreated bednets bundled with insecticide via an integrated child

health campaign in Lindi region, Tanzania: lessons for future campaigns

Mebendazole coverage: 39% pre, 81% at campaign and 86% post. Vitamin A: 67% pre,

85% during and 93% post. Bednet possession: 53% pre and 69% post. E.R.: 0.6 pre and

0.86 post. For <5 households, possession increased from 61% to 91%.

Togo Campaign Distribution of insecticide-treated bednets during and integrated nationwide

immunization campaign-Togo, West Africa, December 2004 Post coverage/ownership for all: 93% MCV; 94% OPV; 91% ITN; 93% mebendazole

Togo Campaign Cost-effectiveness analysis of insecticide-treated net distribution as part of the Togo

Integrated Child Health Campaign 75% of costs due to malaria. 61% of costs due to LLITN. Shared costs = 1.1m (16%). 1.2m

cases of malaria averted over 3 years = 1.39m saved => net=3.99million for malaria.

Zambia Campaign Integrating insecticide-treated bednets into a measles vaccination campaign achieves

high, rapid and equitable coverage with direct and voucher-based methods

Ownership: 21% pre and 88% post in rural. 81% received net in campaign in rural. Any

net sued in previous nite <5 = 56% in rural. Child under campaign ITN = 48% in rural.

Receiving an ITN was associated with higher vaccination coverage (86% vs 49%).

Zimbabwe Routine Implementing a rural programme of prevention of mother-to-child transmission of HIV

in Zimbabwe: first 18 months of experience Infant: 69%; Mother: 63%

Next Steps

Studies under discussion

“Optimizing” integrated delivery

Improving patient flow for integrated delivery in Tanzania

Calculating health facility resource needs & gap based on

planned delivery of an integrated package of interventions

(proposed)

PMTCT/EPI integration

Re-assess if any negative changes in coverage were short-term

due to “start-up” challenges

35

The Comprehensive Integration

Project 36

6/17/2014

10

Study Background

Rationale

Multiple demonstration projects recently conducted

Research question shifting from “whether to do integration” to “how to do integration”

Evidence & tools still needed to assist countries in designing and rolling out a comprehensive health package

Observations that systematic issues likely played a critical role to success of integrated delivery

Supply for all commodities; sufficient HRH; facility layout

Objectives

Develop methods to gather local information to assist in scaling up integrated delivery activities and health packages

Quantify resources to deliver health interventions in an integrated manner at scale

Assess community and health worker perceptions of integrated services to identify perceived benefits and concerns

37

Study Site Selection

1 country per sub-region in Africa

Mali (December 2009)

Ethiopia (February 2010)

Cameroon (March 2010)

Per country, ≥2 districts purposefully selected to increase

diversity of findings

Selected by local MOH, WHO and CDC staff

1 urban, 1 rural district

2 health facilities per district

1 outreach site

38

Data Collection

Interviews Immunization staff at national, district, & facility levels

Key informants e.g., community leaders, chiefs, women's groups

Exit interviews with mothers (Mali only)

Focus Groups (FG) Decision-makers on infant receiving health services

Mothers, fathers, & mothers-in-law

Time Observations 30 maternal and child health interventions

Interventions broken down into tasks

Time for each task measured by stopwatch

39

Findings:

Mali FGs & Interviews

Integration benefits:

Convenient for mothers

Efficient, cost-saving

Increased utilization of

services

Reduced disease

Integration concerns:

Increased wait times

Ability of HWs to manage other services

Ability of mother to retain info

Stockouts

Stigma of HIV & FP services – preferred

if not offered with EPI

EPI widely accepted; primary reason to visit HF

Preferred quick, high-impact services (e.g., VitA, ITNs)

40

6/17/2014

11

Findings:

Ethiopia FGs & Interviews

Integration benefits:

All satisfied with integration

Education seen as important

Some concern about retention of

multiple messages

Neither stigma nor privacy issues were

raised - reports of services being less

stigmatized when integrated

Integration concerns:

Stockouts

Inadequate staff

Desire to improve current

services before further

integration - although interest in

integration of nutrition services

Highly integrated health system with 16 services delivered by

“Health Extension Workers” (HEWs)

41

Findings:

Cameroon FGs & Interviews

Health education important – multiple messages can be

confusing

Requests for additional services included: FP, nutrition/food

incentives, ITNs, and HIV services

Integration benefits:

Multiple services at one time

Efficient, cost-saving

Treatment more holistic

Confidentiality better protected

Staff efficiency maximized

Reduced reporting forms

Integration concerns:

Workload - time

required for give

multiple services

Inadequate staff

Wait times for

beneficiaries

42

Findings:

Time Observations

425 beneficiary visits observed across all 3 countries

11 of 30 interventions had >5 observations

2 tasks consumed the majority of intervention visits

(mean % time):

22% for providing education

27% for record-keeping

43

03:00 06:00 09:00 12:00

Vitamin A supplementation (n=37)

infant vaccination (n=201)

Family planning (recurrent method) (n=34)

Infant growth monitoring (n=46)

Bednet distribution (n=14)

Newborn care promotion (n=29)

Antenatal care (n=103)

Sick infant treatment (n=34)

HIV prevention/counseling (n=9)

Breastfeeding education (n=48)

Family planning (IUD method) (n=7)

Duration of intervention (in minutes:seconds)

Findings: Mean Intervention Delivery

Duration

44

6/17/2014

12

Vaccination Visit (mean length 3:17 minutes)

Update register / card,

21%

Educate, 20%

Prepare vaccine, 20%

Refer to other service, 12%

Document weight/age,

11%

Give vaccine, 6%

Examine physically, 6%

Clean up intervention,

5%

45

Family Planning (recurrent) (mean length 3:11 minutes)

Wait for patient, 14%

Update health register/health

card, 14%

Document weight/age, 3%

Advice/educate, 14%

Prepare commodity,

10%

Administer commodity/servi

ce, 2%

Examine physically, 29%

Refer to other service, 5% Clean-up,

8%

Family planning recurrent method (length: 03:11)

46

Conclusions:

FGs & Interviews

Similarities across countries:

EPI widely accepted & trusted

Integration viewed positively

Mothers liked multiple services at one time

Mothers viewed addition of other services as incentive

Interest in integration of nutrition services

Concerns were generally health system issues exacerbated by integration (e.g., stockouts, HW capacity, wait times)

Education interventions mentioned as very critical – concern about multiple message retention

Differences between countries:

Privacy & stigma issues

47

Conclusions:

Time Observations

Vaccinations are much shorter in duration relative to

most interventions proposed for integration

In planning integrated services, consider:

Longer beneficiary wait times

Realistic expectations on vaccinator workload

Staffing modifications

Patient flow changes

48

6/17/2014

13

PMTCT/EPI Integration Study 49

Tanzania PMTCT/RI Integration Study

Objective

Improve identification and follow up of HIV exposed &

infected infants using routine immunization visits

Key questions

What is impact of integrating services on both

immunization and HIV services?

Study design

8 health facilities piloted the integrated intervention

April 2009 – September 2011

Mid-term assessment in August 2011

50

Key Results: Midterm Assessment

7500~ infants attended 1st month vaccination visit

98% of mothers had documented HIV status

330 HEIs identified, 300 HEIs enrolled

At 6 month follow-up: 74% remained enrolled, 46% remained on CTX

20 tested HIV+, 13 initiated ART

1st month vaccination decreased although there was variability among study sites

Of 8 study sites, compared to rest of district, vaccination decreased >5% at 4 sites for DPT1 and at 6 sites for OPV1

Qualitative summary

Mothers and health workers want integrated services to scale up

Issues around fear of HIV testing, stigma, confidentiality, patient flow, spousal acceptance

Rural sites had the most challenges

51

Key Assessment Recommendations

Recommendations relevant to today’s discussion

Health sector:

Provide counseling during ANC visits to ensure mothers understand that HIV

testing is not required to receive other services (i.e. EPI)

Restructure facilities and patient flow to ensure confidentiality during service

delivery

Reduce waiting times by delivering all of the integrated services during the first

contact with health provider at site

Provide training to health workers to

Ensure the infant receives vaccinations regardless of the mother’s acceptance of

HIV testing

Promote the benefits of integrated services and to reduce stigma of HIV testing

in the community

Community:

Utilize village leaders as advocates for family-centered HIV counseling and testing

52

6/17/2014

14

SUMMARY OF THOUGHTS

ON INTEGRATION

53 Lessons Learned for FP & Immunization

Integration Activities

Many highlighted challenges are systematic issues not directly

related to integration

Commodity supply chains; HRH availability; HRH skill; existing stigma of

certain health conditions

Community concerns vary by location and will affect success

Comprehensive monitoring/reporting systems for both research

studies and programmatic activities are needed

Monitor & report performance of all linked interventions

Patient flow critical for speed and confidentiality as integrated

packages scale up

54

WASH/EPI STUDY

Objective

Improve access to safe drinking water and increase immunization coverage

Intervention

Pilot distribution of “hygiene kit” at immunization session visits to improve coverage of all interventions

Hygiene kit: WaterGuard and soap

Intervention: March 2009 to Feb 2010

Assessment

Baseline and follow-up coverage surveys

Key results

Marginal change in immunization coverage (>90% pre and post)

Presence of soap high at baseline and did not change

Increase in reported use of WaterGuard

No apparent actual change in use of WaterGuard (as measured by chlorine levels in drinking water)

55

DHS analysis of potential value-add of

integrating services with EPI

Objective

Determine the coverage of 5 non-vaccine interventions which could be delivered during a routine vaccination visit

Methods

Analysis of DHS data from 28 sub-Saharan African countries

Key findings

In 74% (range, 49%-92%) of cases where mothers had unmet need for contraception, the child had received measles vaccination

The potential increase in coverage if integration occurred

Median % of mothers using contraceptives among those who do not want to become pregnant in the next 2 years could reach 78% (range, 51%-94%)

Likely coverage if integration occurred

Intention to use contraception in future varied considerably between countries

Based on estimates, 46% (range, 20%-88%) of women would likely use modern contraceptives if offered with infant’s vaccinations

56

6/17/2014

15

57

GENERAL ASSESSMENT

APPROACH

58

GID & Integration Research

2004/2005

GID began integration research after publication of the Global Immunization Vision and Strategy promoted integration in 2004

Landscape analysis of immunization and integration: literature review of articles from 1980-2005

Multiple research gaps led to demonstration projects

2005-2011

GID partners on multiple integration demonstration projects

Comprehensive integration project – capstone integration project to address broader decision-making issues related to integrated delivery

2011

Publication of CDC-sponsored supplement to share findings from multiple demonstration projects, updated reviews, DHS analyses

59

GID’s Recent Integration Work

PMTCT/RI integration study

Tanzania

WASH/RI integration study

Kenya

Malaria control / RI integration studies

Malawi, Indonesia

Child Health Weeks assessments

Nigeria, Somalia

Comprehensive integration project

Cameroon, Ethiopia, Mali

Literature reviews and DHS analyses

Global

60

6/17/2014

16

EPI & Family Planning Work

Attempted demonstration study in 2008 with CDC

Reproductive Health colleagues

Ethiopia, Zambia, Uganda, Malawi explored

Study designs

FP referrals during infant immunization visit

Varying challenges hindered study

Concerns among EPI staff about FP acceptance

MOH staff already felt they were integrating FP & EPI

Maintaining commodity supply was key bottleneck instead

Desire to determine how integration is working; cost-effectiveness

of approach; what additional resources are needed to support

effective integration; community perceptions

61

Rationale for integration (review)

Potential benefits

Improve efficiency and reduce redundancy/cost

Improve user satisfaction and convenience

Benefit to other programs

Reach and coverage of immunizations is often greater than other

health programs

Routine immunizations are among the most equitably delivered

Reduce stigma

Benefit to EPI

Increase demand for immunization

62

CDC/GID Integration Research

2004/2005

GID began integration research after publication of the Global Immunization Vision and Strategy promoted integration in 2004

Landscape analysis of immunization and integration: literature review of articles from 1980-2005

Multiple research gaps led to demonstration projects

2005-2011

GID partners on multiple integration demonstration projects

Comprehensive integration project – capstone integration project to address broader decision-making issues related to integrated delivery

2011

Publication of CDC-sponsored supplement to share findings from multiple demonstration projects, updated reviews, DHS analyses

63

Approach to Assessing Integration

Systematic

Reviews of

Integration Studies

Multiple

Demonstration

Studies including

by GID

Guidance on Integration

to Program Managers

And Researchers

Scale up integrated

Services

Evaluate

64

6/17/2014

17

Limitations to Fully Understanding the

Integration Strategy

Lack of well-designed studies

Very little economic impact information

Use of control groups

Better documentation of impact on immunization services

Unsuccessful projects may not be reported

Many anecdotal stories of integrated projects

Few interventions scientifically analyzed

65

Article references

DHS analysis

Anand et al. Building on Success—Potential to Improve Coverage of Multiple Health Interventions Through Integrated Delivery With Routine Childhood Vaccination. 2012 JID, 205:S56-62

PMTCT integration

Goodson et al. Evaluation of using routine immunization visits to identify and follow-up HIV exposed infants and their mothers in Tanzania. Submitted for publication.

Wallace et al. Qualitative assessment of the integration of HIV services with infant routine immunization visits in Tanzania. Submitted for publication.

Comprehensive integration

Ryman et al. Community and health worker perceptions and preferences regarding integration of other health services with routine vaccinations: Four case studies. 2012 JID, 205:S49-55

Literature reviews

Wallace et al. Integration of immunization services with other health interventions in the developing world: what works and why? 2009 TMIH, 14(1): 11-19

Wallace et al. Experiences integrating delivery of maternal and child health services with childhood immunization programs: Systematic review update. 2012 JID, 205 S6-19

66