HOUSE TO HOUSE MOBILIZATION FOR SUCCESSFUL MEASLES SIAs: SITREP AFTER FIVE YEARS IN AFRICA Bob Davis Measles/Health Delegate American Red Cross.

HOUSE TO HOUSE MOBILIZATION FOR

SUCCESSFUL MEASLES SIAs: SITREP AFTER

FIVE YEARS IN AFRICA

Bob DavisMeasles/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 don’t watch CNN, don’t listen to the BBC, and don’t read the New York Times

• Solution, for both polio and measles: next slide

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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

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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:

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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.

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DISTRICTS WITH CANVASSING DISTRICTS 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, NAMPULA PROVINCE, MOZAMBIQUE, 2008

Red Cross Districts

Target 413,005 Vaccinated 401,604 Coverage 97.2%

Others

Target 214,481 Vaccinated 188,064 Coverage 87.7%

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COMPARATIVE CAMPAIGN COVERAGE, BAMAKO, MALI, 2011

Red Cross Zones

Target 660,000 Coverage 93.6%

Others

Target 210,317 Coverage 87.8%

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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

RADIO CHURCHESALL

OTHERPOPULATION

RED CROSSVOLUNTEERS

Ruyigi 23 19 7 15 505710 562

Gitega 32 31 23 6 920136 1022

Total 55 50 30 21 1425846 1584

ADMIN COVERAGE ESTIMATES, BURUNDI’S 2012 SIA, NATIONWIDE AND IN THE FOUR REGIONS

WITH H2H MOBILIZATION

NATIONWIDE AVERAGE

GITEGA MAKAMBA MUYINGA RUYIGI

103% 104% 116% 106% 115%

AVE + 1 AVE + 13 AVE + 3 AVE + 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 Criers Monday, 53 mentions by mothers and other caregivers

Wednesday, 65 mentions

Friday, 63 mentions

Red Cross Volunteers

49Mentions

House to house volunteers, 28

30 104

House to house volunteers with megaphones, 15

20 10

Volunteers at fixed posts, 6

37 5

Radio 37 mentions 87 110

H2H EVALUATED AS BEST PRACTICE, BENIN CAMPAIGN, 2011

CRITERIA ANALYSIS BY CRITERION CONCLUSION

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 campaign’s 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 polio Satisfactory

Reproducibility - Implementation in the country’s 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 WORLDS PLANET 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

Spot surveys at vaccination sites to ascertain mothers’ source of info. Cheap and easy; permits assessment of comparative role of H2Hand other info sourcesCompare 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 Uganda’s 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 154,546 USD 95,759 USD 272,957(exclusive of UNICEF funding)

USD 272,957

BENEFICIARIES 322,572 473,890 166,750 1,687,000 1,300,000

COST PER BENEFICIARY

USD 0.31 USD 0.33 USD 0.57 USD 0.16 USD 0.21

VOLUNTEERS WORKING ON CAMPAIGN

685 3100 1450 2679 2911

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 gov’t, 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 can’t go global on a shoestring, and you can’t 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!

THANK YOU/ASANTE SANA/ AMESEGNALEHU/SIYABONGA/ MERCI/OBRIGADO/MUCHAS GRACIAS

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