Reaching under-immunized children missed during COVID-19

Reaching under-immunized children missed during COVID-19

In the first quarter of 2022, Bamako recorded nearly fifty suspected cases of measles. Public health officials collected samples and fourteen cases were confirmed at the national reference laboratory.  Several of the 14 positive cases were concentrated in Communes I and IV of Bamako. This distribution of cases meant that Bamako had reached an epidemic threshold, which required a response in both communes and the surrounding areas. Measles is extremely contagious, and unfortunately, Mali registered in the top 10 countries for the highest number of cases reported from September 2021 – February 2022.

The primary reason for the measles outbreak is that thousands of children missed their routine vaccinations due to the COVID-19 pandemic, though the exact number of under-immunized and “zero-dose” children is unknown. But Mali is not unique in experiencing a measles outbreak. Just as we saw with Ebola, the interruption of routine primary healthcare caused by the pandemic could be as or more deadly than the coronavirus itself.

In order to support the regional health authorities in containing the epidemic, the Mali Health team initiated and supported a vaccination campaign to reach unvaccinated children in partner communities across Bamako.

The vaccination campaign mobilized more than 200 vaccination teams over a period of five days to vaccinate children age 9 – 59 months. Each vaccination team was composed of three agents including one agent for the mobilization and organization of the community, one agent to conduct the injections, and one agent to maintain the documentation and records. Though we requested 120 000 doses of VAR vaccines, only 45 000 doses were made available, along with 4,000 vaccine registry forms.

A member of the vaccination team completes the vaccine registry
A member of the vaccination team completes the vaccine registry

The vaccination campaign included the following activities:

  • Communication and outreach: The vaccination teams shared health information messages about measles and vaccination throughout 17 communities by working with the ASACOs (community health association) in each community, as well as a network of women leaders to whom we connected through our partners in the Service Local de Développement Social et de l’Economie Solidaire (SLDSES). Some of the concerns among the community included hesitation and misinformation about vaccines in general, as well as mistrust related to COVID-19 disinformation and rumors.
  • Case identification and management: The vaccination team actively searched for suspected measles cases in each community. Of those suspected, 12 cases were confirmed through the collection and analysis of samples.
  • Monitoring of adverse events following immunization (AEFI): Some minor AEFIs (fever, vomiting, pain at the injection site in older children) were reported during the campaign, which were referred to the CSCom (community health center) teams, who provided treatment and case management.
  • Safe waste disposal: The proper treatment of medical waste is one of the many areas we work on in our participatory quality improvement program, but resources can often be limited at CSComs. All injection and vaccine materials during this campaign were disposed of in safety boxes and packaged in waterproof cartons to hold them safely until they could be incinerated.
  • Sharing results: To ensure transparency and build tryst, Mali Health shared the results of the vaccination campaign with community leaders and community members from the areas served.
  • Monitoring and field supervision: To support each vaccination team, 5 additional agents in each community (85 total) were deployed alongside them to help support and manage the flow of vaccination activities, ensure the vaccination teams remained fully equipped, coordinate with the community health system (CSCom), and assist in any other needs that arose for the vaccination teams. They monitored results and progress each day and were in the field with the vaccination teams for all five days of the campaign.
During the campaign, Dr. Bathily reviews the day's progress with a vaccination team
During the campaign, Dr. Bathily reviews the day’s progress with a vaccination team

The vaccination teams deployed across 17 communities over five days achieving the following results:

  • 44,685 children vaccinated
    • 16,082 under age 1 (between 9-11 months)
    • 28,603 age 1 – 5 years
  • 94.6% of children under age 1 (15,211) received their first dose of measles vaccine (VAR)
  • 90% of children age 1- 5 years (25,754) received their first dose of measles vaccine (VAR)

Despite these results, we estimate that there are approximately 117,795 children under age 5 across the 17 target communities, leaving tens of thousands of more children in need of vaccinations. Based on the results of this vaccination campaign, it is likely that the majority of these remaining children are also unvaccinated.

While every child enrolled in our community health program received their vaccines on-time throughout the pandemic, and we worked very hard to support our partner health centers in maintaining the continuity of care for women and children in their communities, tens of thousands of children across remain unreached and under-immunized. We hope to continue vaccination activities as we search for more funding to meet urgent needs and as more vaccines are made available.

Vaccine Confidence: Results and Lessons Learned

Vaccine Confidence: Results and Lessons Learned

Our project to assess and address vaccine confidence using a local, women-designed technology demonstrated that the use of participatory methods and tools to develop and disseminate voice-based social media messages improved both knowledge of, and confidence in, vaccination against COVID-19 in underserved peri-urban communities in Bamako, Mali.

The project used a mix of qualitative and quantitative evaluation methods, including individual interviews and focus groups discussions. The project relied and built on a participatory evaluation of social and gender norms conducted in the target community before the project began.

The key results of this project include: 

  • 100% of women who accessed voice-based health messages demonstrated improved knowledge about the benefits of vaccination against COVID-19
  • 75% of women who used the application expressed confidence in vaccination against COVID-19
  • 73% of women who used the application shared the information they learned with others
  • 60% of women who used the application felt better equipped to convince others to get vaccinated against COVID-19
A woman in Kalabambougou shares her experience using Keneya Blon

Part of the purpose of the project was to generate lessons for how to use social media tools and messages to address vaccine hesitancy and misinformation. Our particular focus was on hard-to-reach populations in marginalized communities, especially women. Drawing from both our work to develop Kènèya Blon, and its application to COVID-19 vaccination, we summarize our lessons learned as:

  • Community driven: A tool designed by women living in peri-urban communities to increase access to health information proved to be relevant and impactful, despite limited access to information technology; when trying to meet the needs of hard-to-reach or marginalized communities, they should be involved at every step, including data collection and technology design
  • Targeted: Technology and digital interventions must be adapted to the realities of each community or population it is trying to serve; this adaptation can include the form and function of the application or the types of content used (language, images, etc.), but also contextual factors such as social/gender norms, the kinds of misinformation circulating, etc.
  • Coordination: When coordinating with offline health or vaccination services, ensure the quality and availability of a respondent for interactions with users, as well as the quality and availability of the vaccination service at the health center level; when possible, train these providers in the use of digital tools/messages being used in their communities
  • Ongoing: Campaigns implemented once or over a limited period of time will lose impact over time; the dissemination of messages relating to COVID-19 must be ongoing and consistent until public health and vaccination targets are reached
  • Accessible technology: Though access to technology is increasing, it will continue to be a limiting factor for millions, especially for women who have limited skills or experience that allow them to use it effectively. This project recommends the integration of relevant, local digital tools into mobilization strategies around vaccination against Covid-19 while also continuing the search for strategies that can share voice-based messages on the types of phone and technologies that are most available to marginalized communities
  • Mixed methods: Promote the use of the digital tools within target communities with on-the-ground and face-to-face strategies to build trust
Improving community awareness and confidence in COVID-19 vaccines with local women-designed technology

Improving community awareness and confidence in COVID-19 vaccines with local women-designed technology

As the world has seen and experienced during the pandemic, vaccinating populations requires much more than a vaccine. While the availability of a vaccine is one important component, a variety of factors can influence vaccination rates and coverage. Some, like geographic, logistical, and health system factors have been a challenge to ensuring complete and timely vaccination of children for underserved communities for decades; the pandemic has exacerbated these problems. Other factors can be related to gender, social norms, or misinformation.

From October 2021 to February 2022 with funding from the Vaccine Confidence Fund, Mali Health worked with women and communities to understand the factors influencing knowledge of and confidence in COVID-19 vaccination in underserved peri-urban communities. We then developed and tested messages for Kènèya Blon, the local, voice-based smartphone application that we developed with women in Sabalibougou, a peri-urban community in Bamako.

Collecting data directly from community members was essential to understanding the factors that influenced confidence in the vaccine, and therefore how to address them. The end users were involved in every step of the original development of the Kènèya Blon platform. When assessing how to use it to address vaccine confidence as a part of this project, their participation was vital again.

We used participatory methods to understand attitudes and behaviors related to vaccination, and the norms which govern them. At the beginning of project, 95% of those surveyed did not trust COVID-19 vaccines and had no intention of getting vaccinated. According to the same survey, the primary reason given was a lack of access to trusted health sources that could provide accurate information, or correct misinformation. A lack of access to health professionals and reliable health information was a key factor in acting on misinformation and the adoption of positive behavior changes.

These findings reinforced what we learned earlier during our work as a part of the WomenConnect Challenge, Then, we learned that access to reliable health information is one of the highest priorities and biggest challenges for the women we serve. Access to information was even linked to gender equality, not only in the minds of women, but in the minds of men and community leaders. Because women living in peri-urban communities had limited opportunities to go to school where they could gain reading and writing skills, they face barriers to accessing reliable information.

The Kènèya Blon platform was designed to address this primary challenge. During the project, users had access to accurate public health information about COVID-19 and that addressed rumors and misninformation circulating in their community. They were also able to access health personnel to express their concerns related to COVID-19 vaccination and receive responses to their questions. These features were designed by women, for women – using a what we call women-centered design approaches – but its impact extends far beyond its users.

We attribute the significant short-term results of the project to this rapid access to trusted information, because it met the primary need community members expressed. To learn more about the results and lessons we documented about vaccine confidence, please continue reading our next post.

Keeping communities informed about COVID-19

Keeping communities informed about COVID-19

Mali Health is dedicated to working with communities to strengthen local health systems, so that all mothers and children can stay healthy and have access to quality care. During the past eight months, we have continued to mobilize communication events and activities to help inform peri-urban communities in Bamako about COVID-19 and how to stay safe. Since the beginning of the year, our activities have included:

Two mothers at the COVID-19 caravan in Bakaribougou

1. Education talks on COVID-19

Since the beginning of the pandemic, our community health workers have continued to visit the families in their care, ensuring both the continuity of maternal and child healthcare and sharing information about COVID-19. They make sure mothers and caregivers understand what COVID-19 is, methods of transmission, how to prevent it, as well as symptoms and how to respond. Since January, they have conducted 2,810 talks in households during their home visits, reaching 4,973 people.

In addition to sharing information during home visits, our team is also sharing information at savings group meeting, which have been able to restart safely. So far, 310 talks during group meetings have reached 4,941 women.

Students demonstrate how to wear new masks at Samè COVID-19 caravan

2. COVID-19 Caravan

From mid-May to mid-June, we conducted 13 caravans in communities across all 6 Communes of Bamako, and Mandé:

  • Sikoro-Sourakabougou
  • Sotuba
  • Bakaribougou
  • Lafiabougou
  • Lassa
  • Djicoroni-Para
  • Kalabambougou
  • Sabalibougou
  • Niamakoro
  • Yirimadio
  • Badialan
  • Samè
  • Kanadjiguila

The messages shared during the caravan were those developed by the national health authorities, including a definition of COVID-19, its spread, its symptoms, and the risks of infection. The caravans were held in public, accessible locations, including schools, markets, and open fields. We estimate to have reached about 46,000 people during these caravans, including 18,500 women, 10,500 men, and 17,000 school-aged children.

The COVID-19 caravan travelled to 13 communities in Bamako.

3. Radio programming

We developed and produced two 30-minute radio programs about COVID-19 prevention on two different subjects – how to remain vigilant about COVID-19 prevention and how to manage distancing and contact with someone who is suspected to be COVID-19 positive. We also developed informational radio spots to encourage continued use of barrier measures and to combat misinformation. They also covered three key subjects being encountered in the communities we serve: stigma against recovering COVID-19 patients, protecting vulnerable populations (particularly elders), and how to manage suspected contacts. The spots are being broadcast 180 times on radio stations across Bamako.

A young woman asks a question at the COVID-19 caravan in Bakaribougou

A special thank you to IZUMI Foundation, GlobalGiving, and Fonds d’Appui à l’Autonomisation de la Femme et à l’Epanouissement de l’Enfant (FAFE) for their continued support of our COVID_19 response efforts.

Access by any other name: Equity and the COVID-19 vaccine

Access by any other name: Equity and the COVID-19 vaccine

This post was written by Mali Health board member, Lisa Nichols. Lisa has served on the Mali Health board since 2014 and worked in Mali for 15 years. She is a Principal Associate in the International Development Division at Abt Associates Inc.

The word “access” implies a simple physical opportunity to achieve or attain something. However, access to COVID-19 vaccines has become an equity issue with big and richer nations deciding who gets what and with countries scrambling to purchase or beg for vaccines from wealthy countries.

Fact: 85% of vaccines are being administered in wealthy countries.

On social media, in international conferences, and in diplomatic missions and negotiations, the campaign to get wealthy countries to donate vaccines to low and middle income countries (LMIC) is raging. It circulates among the Twitter-verse through #VaccineEquity and #DonateDosesNow.

Are we hoarding vaccines? Not an unlikely conclusion as we all lived through the early COVID-19 days of hoarding of Personal Protective Equipment (PPE), cleaning supplies, and even oxygen supplies. It seems to be a wealthy country reaction that totally overwhelms any high-minded equity goal — for how can we achieve equity without control of the supply chain?

Waiting for COVID-19 vaccine and supply donations is not the only solution. As countries wait, people are getting infected and dying. There is also a strong link between the COVID-19 and the interruption of routine services such as childhood immunization, antenatal care, and other essential primary health care.

Fortunately, the African continent is moving ahead on several fronts:

  1. Fast tracking the upcoming production of vaccines
    Many vaccines are coming online and will be ready to ship soon. COVAX, the Gavi and donor-supported initiatives are accessing many vaccines as I write this. Countries like Mali have prepared National Deployment and Vaccine Plans to receive COVAX shipments, targeting 20% coverage of the population. Mali has received 1,332,000 doses from the COVAX facility and is in line to receive more as they become available.
  2. Increasing vaccine manufacturing capacity on the continent
    Dr. John Nkengasong of Africa CDC talks about Africa’s ambitions and efforts to “future proof” itself by producing its own vaccines. Last month, the US International Development Finance Corporation (a US Government agency) announced a technical assistance grant to Fondation Institut Pasteur de Dakar, a vaccine manufacturer in Senegal that could serve the entire West African region.
  3. Addressing vaccine hesitancy
    Even when the COVID-19 vaccine is available, sluggish uptake is a reality in many parts of the world. We need to emphasize the importance of vaccine understanding and acceptance. The role of NGOs and community organizations has already made a significant contribution to successful efforts like the Global Polio Eradication Initiative and reducing disease transmission during the Ebola outbreak. Countries will be leveraging this valuable community capital as we move ahead.

Community mobilization is a significant component of Mali Health’s strategy to serve peri-urban communities in Mali and strengthen local health systems. Our team continues to inform and generate demand for the COVID-19 vaccine, facilitate community vaccine delivery systems, and reduce community transmission of COVID-19. Mali Health will continue to support this historic global vaccination effort until all members of the communities we serve are protected.

Dr. Sogoba serving as a voice for community health at the highest levels

Dr. Sogoba serving as a voice for community health at the highest levels

At the end of April, Dr. Sogoba attended a weeklong workshop in Fana. It was the latest meeting for the development of the national plan for the extension of community-based epidemiological surveillance (SEBAC). Dr. Sogoba, the director of our Health Department, is representing the needs of community health systems in this national policy process, alongside international NGOs and regional and national health authorities.

Dr. Sogoba has been helping to ensure that the surveillance priorities and strategies being developed are feasible and realistic for health workers, health centers, and partners on the ground. He is relying on our experience during both the Ebola outbreak, and the health security and systems strengthening efforts that followed it, as well as our participatory quality improvement and community health worker programs.

What is community-based epidemiological surveillance?

The Direction Générale de la Santé et de l’Hygiène Publique (DGSHP) explains why an implementation guide for SEBAC is so important :

characterized by the increasing globalization of emergencies and public health events, the evolution of diseases at the epidemiological level underline the importance of community monitoring in order to move quickly from detection to confirmation and response.

The emergence and earliest detection of infectious diseases – like Ebola or COVID-19 – often occur at the community level. The quicker that the community health system can identify and respond, the quicker an outbreak can be contained, and communities can stay safe. A strong response requires a variety of systems to be strengthened, including a trained health workforce, decentralized and accessible laboratory capacity, and clear response protocols at the local, regional and national levels.

A long-term planning process

At the invitation of the DGSHP, Mali Health has been participating as a technical partner in the development of the national SEBAC guide since 2019. First, a draft of the guide was developed at a workshop in Bamako. It was then tested in the Kadiolo health district, in Sikasso region.

At a workshop in Bamako at the end of 2019, Dr. Sogoba had the chance to present our approach to community health to the entire planning group. He also shared our experiences supporting community health partners during the Ebola outbreak and with the following Djomi project, which was a part of the Global Health Security Agenda (GHSA). We are honored by the opportunity to represent the needs of the community health system, and our efforts to support it, in this national process.

The objective of this latest workshop in Fana was to analyze results from the test in Kadiolo district and to develop a final extension plan. The next step is to submit that final plan to the DGSHP for validation and approval, and to identify a donor to finance the extension of the surveillance program. If a donor can be identified, the entire process of disseminating and implementing the plan in all regions of Mali will take 5 years.

Meeting of SEBAC participants in Fana