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
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.

Mali Health awarded Grand Challenges Explorations grant from Bill & Melinda Gates Foundation

Mali Health awarded Grand Challenges Explorations grant from Bill & Melinda Gates Foundation

Mali Health is happy to announce that we have won a Grand Challenges Explorations (GCE) grant from the Bill & Melinda Gates Foundation. Our proposal, Using Participatory Quality Improvement Methods to Improve Vaccine Timeliness, will bring together maternal care providers, including health center staff, community health workers (ASC) and midwives (matrones), to develop local solutions for improving childhood immunization completion in the Sikasso region, in southern Mali.
Since 2014, we have been developing a participatory, team-based approach that adapts traditional continuous quality improvement tools for use in the community health system. We will bring those participatory quality improvement (QI) methods, created in collaboration with health center partners in peri-urban Bamako, to the Sikasso region in southern Mali, to improve vaccine delivery.
In Bamako, our participatory, community-based QI strategies led to significant improvement in timely vaccine completion. For example, completion of BCG vaccine delivery from 57% to 92% and retention between doses of MMR rose from 38% to 83%. With average completion of childhood vaccines hovering around 20.2% in Mali, there is room for significant improvement, in both rural and urban regions.
Our team is particularly excited about this opportunity because it allows us to continue working with partners in the Sikasso region, where we have worked to implement the Center for Disease Control’s (CDC) post-Ebola Global Health Security Agenda (GHSA). During that work, we observed significant gaps in the health system and integrated some of our quality improvement and governance strategies into the GHSA project. Our participation in that project ended in October 2017, when funding was significantly delayed during the budgeting process. We are glad to renew our relationships with communities and the health system in the Sikasso region, and to build new ones.
Through their GCE program, the Bill & Melinda Gates Foundation “supports innovative thinkers worldwide to explore ideas that can break the mold in how we solve persistent global health and development challenges.” Our project is one of 35 Grand Challenges Explorations Round 20 grants awarded by the Foundation, out of over 1,500 applications received. This is our second GCE grant; the first, a part of Round 12, helped us to develop our QI approach.
Grand Challenges Explorations is a US$100 million initiative funded by the Bill & Melinda Gates Foundation. Launched in 2008, over 1365 projects in more than 65 countries have received Grand Challenges Explorations grants. The grant program is open to anyone from any discipline and from any organization. The initiative uses an agile, accelerated grant-making process with short two-page online applications and no preliminary data required. Initial grants of US$100,000 are awarded two times a year. Successful projects can receive a follow-on grant of up to US$1 million.