Introduction

The United Nations Sustainable Development Goals (SDGs), also known as Global goals were countries’ commitments toward the ending hunger, protecting the planet, and ensuring that by 2030 all people enjoy peace and prosperity. Reduction of measles mortality will contribute to the attainment of SDG3 which aims to end preventable deaths of newborns and children under 5 with all countries striving to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births amongst other indicators by 2030 [1,2].

Measles is one of the key contributors to child mortalities, especially in South Asia and Sub Saharan Africa [3]. The measles vaccine was among the antigens introduced in Nigeria’s Expanded Program on Immunization (EPI) schedule in 1979, and it is administered to children 9 months of age. Since then, coverage of the first dose of Measles Containing Vaccine (MCV1) through the routine immunization program has been fluctuating and also very suboptimal to provide the needed herd immunity to prevent its transmission among children [4].

The World Health Organization and United Nations Children Fund Estimates of National Immunization Coverage (WUENIC) for Nigeria from 2009 to 2017 for MCV1 coverage averaged 49.4% [5]. The National Immunization Cluster Survey (NICS) of 2016 - 2017 coverage for MCV1 prior to the 2017/2018 measles vaccination campaign was 42%. However, variation exists across zones and states with Lagos state having an average coverage of 88% in the 2016 - 2017 NICS [6]. It is worth noting that at the time the 2017/2018 measles vaccination campaign was carried out in Nigeria; was yet to introduce a measles second dose in her routine immunization schedule. Measles second dose has been shown to improve seroconversion for children, which ultimately takes care of primary vaccine failure [7]. The SIA that targeted a wider age group (9-59 months) offered the second dose opportunity to reduce the buildup of susceptible due to poor routine and primary vaccine failure.

As previously mentioned, persistently low MCV1 coverage and relatively low SIAs coverages in the measles follow-up campaigns (74% in 2013 and 84.5% in 2015) have resulted in a low population immunity profile that has allowed increased transmission of measles virus among children. The low immunity profile was the basis for the 2017/2018 nationwide measles mass vaccination campaign. Also of note is that as of 2017/2018 measles vaccination campaign, Nigeria had not introduced the measles second dose into her routine immunization schedule missing the opportunity of increasing the immunity of the children against the measles virus.

Nigeria adopted the WHO African Regional office 2011 measles elimination goal by the year 2020. One of the major targets in achieving the 2020 goal is the attainment of ≥ 95% coverage in MCV1 at National and subnational levels in both routine immunization and supplemental immunization activities. The approach comprised four key strategies of Supplemental Immunization Activities (SIAs) in the form of catch-up campaigns and follow-up campaigns, case-based surveillance for measles, and routine immunization as the core strategy. Measles outbreak response, measles case based management and vitamin A supplementation were also integrated into the key strategies [8,9].

The 2005/2006 nationwide catch-up campaign targeted 56 million eligible children aged 9 months through 14 years irrespective of vaccination status. This campaign was implemented in two phases; phase one covered the Northern states and was conducted in December 2005, while the second phase involving the Southern states was conducted in October 2006. Since then, Nigeria conducts nationwide follow-up campaigns every two or three years. All the country’s measles vaccination campaigns have adopted the same approach of implementing campaigns in two phases with states in each phase implementing the campaign across all Local Government Areas (LGAs) in the state at once irrespective of available resources.

Lessons learned from those SIAs have shown that implementing campaigns using this strategy did not achieve the desired goals as the teams are usually overstretched within the stipulated days thereby missing some of the targeted population. To implement a quality SIA, adequate human and materials resources – skilled health workers and Cold Chain Equipment (CCE) – are needed. The sub-optimal performance in the previous campaign was attributed to shortage of skilled health workers and inadequate CCEs [10].

To bridge this gap the country introduced innovative strategies in the 2017/18 MVC to improve the performance of states. One of these strategies was changing the two-phase National approach and increasing the number of streams of the campaign to regional levels [11]. At the state level, a staggering approach of the vaccination campaign was adopted in some states to take care of the resources gaps.

Staggering simply refers to the arrangement of events or activities to commence at different times. Staggering of the campaign was necessitated based on the available qualified health workers, cold chain available for implementation as well as human resources for monitoring and supervision of the campaign. Since the 2005/2006 catch-up campaign and the subsequent follow-up campaigns, the 2017/2018 follow-up campaign was the first that staggering was introduced at the state level.

This article describes how Lagos state staggered the implementation of the 2018 measles vaccination campaign and the impact it had on reaching more of the targeted children in the state. We also highlighted the effectiveness of this staggering approach by analyzing previous measles vaccination campaign results and that of the 2018 measles vaccination campaign that was staggered to fill resources gaps.

Methods

Study Setting

Lagos state is the commercial capital of Nigeria, and it is located in the southwestern part of the country. It shares boundaries with Ogun state at the North-East border, Benin Republic in the west, and the Atlantic Ocean in the South. It is a highly commercial town, it has a small landmass but has the highest urban population in Nigeria. Movement in and out of the city is constant as people live in the neighboring Ogun state yet work in Lagos state. Visitors from all over West Africa visit the states because of its commercial activities. According to the National Population Commission, in 2017 Lagos state had a projected population of 12,615,361 people [12]. The state targeted a total of 3,660,480 children 9 months to 59 months for the campaign.

2017/2018 Measles Vaccination Campaign

Microplanning Process

Immunization services be it routine services or the supplemental immunization activities requires a lot of planning to know the available resources – human, financial, storage space, as well as the demographic statistics of the recipients. For cost effectiveness of immunization, one must know the target population [13,14]. Microplanning is a bottom-up process of estimating the resources (human and material) needed for the successful implementation of any activity. The output of any SIA microplanning process should include the requirement and availability for data tools, qualified personnel and functional CCE to reach the target population. The micro plan document will identify the required, available and surplus or gaps of these resources at all levels for proper planning.

The micro-planning process in each ward was facilitated by a Ward Focal Person (WFP) in collaboration with all key stakeholders at the operational level. Micro plans were developed by all 245 implementing wards in the 20 LGAs in Lagos state to ascertain the number of children in the target population to be reached, and human, material and financial requirements for the campaign. Other outputs of the process include the list of settlements, health facilities, special places, Daily Implementation Plans (DIPs) including team movement to special places and settlements without vaccination posts., number of vaccination teams, number of vaccination posts, waste management plans. Identification and selection of vaccination posts is one of the key outputs of the microplanning process and it contributes to the success of the SIAs in general. The major aim of using vaccination posts is to ensure there is a conducive and easily accessible place for the vaccination exercise to take place. According to the 2017/2018 NPSIAs field guide, vaccination posts should be ≤ 1KM from the client. Some other key factors to consider when selecting a site to serve as a vaccination post are each settlement should have a vaccination post, shelter, free flow of clients and health workers. Vaccination posts are either fixed posts or temporary fixed posts. Fixed posts are posts where vaccination exercise will implemented for the entire duration of the campaign. Temporary fixed posts are vaccination posts were vaccinations would take place for a period depending on the target population in the catchment area.

To ensure good quality of the exercise, supervision was undertaken by the state/LGA teams using a paper-based checklist and Open Data Kit (ODK).

Micro-Plan Phase 1 Verification

Following the development of the micro-plans, the next step was the verification process, which was implemented in 2 phases for the micro-plans developed. Micro plan verification is an endprocess activity conducted in 2 phases after micro-plan data has been collated at the state level. Phase 1 of the verification is done at the ward level by the LGA and state verification team comprising government and partners. A random selection of 30% of the wards was conducted for the micro plan phase 1 verification process and all LGAs encompassing these wards were directly assessed by the state verification team comprising the state Government and partners present [15].

Micro-plan Phase 2 Verification

The standard micro-plan phase 2 verification process for the measles SIA required that after reviewing the phase 1 verified micro-plan at the National level, a team of two members of the National Measles Technical Coordinating Committee (NMTCC) is deployed to the state for phase 2 verification purposes and joint decision making on how to resolve the identified issues. Among those issues was deciding how the implementation will be handled by not doing business as usual. The phase 2 verification process used the WHO measles high-risk assessment tool correlated with the state findings during the phase 1 verification process in terms of challenges for choosing the two LGAs where to verify and the four facilities by LGA to go to and complete the process. The phase 2 verification process involves three stages [1] desk review of the microplanning templates, [2] field visit and [3] debriefing of the state policymakers [15]. Epe LGA and Surulere were selected accordingly using the measles high risk assessment tool.

Human resources required for a successful measles follow-up vaccination campaign

According to the 2017/2018 measles vaccination field guide, the estimated workload for a vaccination team is 175 and 125 per day in an urban and rural areas respectively with an average of 150 per team [16].

Cold chain equipment required for a successful measles followup vaccination campaign

The 2017/2018 measles vaccination field guide stipulates the basic minimum cold chain requirement for a successful campaign at the ward and vaccination team level. A ward should have a minimum of 2 cold boxes and each cold box requires 24 0.6 icepacks. For vaccine carriers, each vaccination team requires at least 2 vaccine carriers and 4 icepacks per vaccine carrier [16].

Development of Staggering Plan

Communication for staggering/implementation days

A very robust communication plan contributes to the success of any SIA from the planning to the implementation phase. There were several Advocacy, Communication, Social Mobilization (ACSM) activities implemented during the 2017/2018 measles SIA to sensitize, create demand and increase awareness among the population. During implementation, the town announcer of a vaccination team visited a catchment area on their Daily Implementation Plan (DIP) the evening before the visit of the vaccination team the following day. The visit was to inform clients/caregivers on the place and time of the visit from the vaccination team the following day. This information will also be communicated periodically during the implementation day to support the work of the H2H mobilizers so the staggering date is communicated to them.

National verifiers and the state team reviewed all the LGAs verified microplans for the measles vaccination campaign in the presence of all LGA team members. The microplan template was used to estimate the requirements by the state for the campaign including human resources and CCEs. We estimated the human resource and cold chain equipment required for the campaign in the state using the guidelines of the measles vaccination field guide. We then compared the required human resource and cold chain needs with what was available in the LGAs to identify gaps.

Based on the gaps identified, the LGAs were split into two phases (phase 1 and phase 2) to implement the campaign. LGAs in phase 1 were then paired with LGAs that implemented in phase 2 to support them with their human resources and CCEs to bridge the gaps. Ten LGAs implemented in the first phase while the remaining ten implemented in the second phase.

Quantitative data measure was used to estimate the human resources and cold chain equipment and the vaccination campaign outcome of the 2018 campaign in Lagos State. Data management and analysis were performed using spreadsheets and statistical applications such as MS Excel and Statistical Package for Social Sciences version 20 (SPSS). Simple frequency tables, Cross tabulations, charts and maps were used to present analysis outcomes.

Results

Staggering Plan

Lagos state adopted the inter LGA staggering after the assessment of the available resources (Health workers and CCEs) and the LGAs were paired to support each other during the two phases of the campaign in the state. Table 1 shows the pairing of the LGAs and the implementation days of the measles vaccination campaign. The staggering was discussed at the state level and all the LGA officials were told of the support they are either rendering or receiving from their paired LGAs. Health workers that provided support during the staggering are those licensed to give injection and they worked with the primary owners of the LGA who are conversant with the terrain and developed the daily implementation plans.

Table 1: Pairing of LGAs with implementation dates by phases.

Using the lessons learnt from the concluded three streams of campaigns in the Northern part of the country as shown in figure 2, Lagos state implemented the campaign using the national guidelines by adopting the inter LGA staggering in (19/20) LGAs while one LGA (1/20) namely Ojo implemented using Intra LGA staggering because of the huge shortfall in human resources after adding the support from Badagry LGA. The staggering was important in Lagos state considering it as the most populous state in the country and its dynamics.

We found out that Lagos state could not have been able to reach the microplan estimate of 3,660,480 children targeted for the 2018 campaign within the stipulated time if there was no staggering of the campaign. The staggering of the campaign helped to minimize the human and cold chain equipment gaps.

Functional cold chain availability is the bedrock for any immunization activity. The needs become more in immunization campaigns as more storage is needed for the extra supplies encountered during SIAs. The observed cold chain equipment shortages in Lagos were not peculiar to Lagos alone as the 2017 Effective Vaccine Management Assessment report shows that storage capacity at local government and service delivery points were 70% and 59% respectively of the required capacity [17]. Similarly, in Ojo et al 2015 assessment of Challenges in the Logistics Management of Vaccine Cold Chain System in Ile-Ife, Osun State, Nigeria, only 45.7% of the required cold boxes in assessed facilities in the LGAs were functional [18] (Figure 6).

Figure 6: Lagos State 2018 MVC Admin. Coverage, End Process, and Survey Coverage Result, Lagos State 2018 MVC.

Health workforce is one of the six WHO health system building blocks necessary for good health outcomes. Service delivery is affected when there is shortage in the human resources for health. This is more noticeable in immunization campaigns where all hands are mobilized to attain the desired goal and in this case coverage of ≥95% in the post campaign coverage survey. From our findings, the shortage in the human resources needed for the measles vaccination campaign in Lagos could have made it impossible to carry out an effective vaccination campaign. This is in line with Manyazewal T, 2017 assertion that “a well-performing health workforce is one that works in responsive ways, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances” in his survey of using health care professionals to determine performances of public health facilities in Ethiopia [19].

The staggering of the campaign helped to minimize the shortage of health workers which as reported by Akwataghibe, et al in their 2019 study is one of the major barriers to immunization services while exploring factors influencing immunization utilization in Nigeria. The study stated clearly “Health workforce shortage was a frequently mentioned problem which hindered immunization service delivery” [20].

Our study has shown that there was shortage of both qualified health workers and cold chain equipment to reach the target population for the duration of the campaign and this was mitigated by the staggering approach adopted in the 2018 MVC in Lagos state.

The outcome of the 2018 measles vaccination campaign in Lagos was positive as there was a marked improvement in the postcampaign coverage survey result of 59.3% in 2013, 88% in 2016 and 94% in 2018 [21-23]. Other innovations could have contributed to the improvement in the coverage but we believe the ability to reach most of the targeted children as evidenced by the end process monitoring data that shows less than 5% of the children were missed in all the LGAs could only have been possible because of the mitigation of a major gap in human resources and CCEs by the staggering approach adopted by the state.

Limitations

The staggering plan in Lagos showed some limitations, especially with the link to the Phase 2 LGAs as some phase 1 LGAs were reluctant to deploy the total qualified staff needed to support the phase 2 LGAs as they were continuing with mop-up vaccination. The mop-up vaccination became necessary following the results of the end-process monitoring in their respective wards and the rapid convenience monitoring carried out by the National and the State supervisors. This was done because the State Government was following up on all the actions on daily basis and any failure was said to be sanctioned [24,25]. This made the phase 2 LGAs to carry the vaccination exercise for a longer period and the campaign was completed only after three weeks as they were pushed to the extreme to achieve good results. Similarly, there was no standardized way of selecting the qualified health workers that were deployed to carry out routine services during instead of taking part in the campaign as the routine immunization work going on that same time did not attract any extra stipend so there may be bias in selection across the various LGAs.

Finally, the improvement in the performance of the 2018 campaign in Lagos state when compared to the previous campaigns of 2013 and 2015/2016 may not be entirely due to the staggering alone as such the result should be interpreted with caution. In the same vein, the methodologies used in the post-campaign coverage survey for 2013, 2015/2016 were different and comparing the coverage is a limitation of the study.

Conclusion

The study found that Lagos state leveraged the staggering approach of the campaign to bridge the human and materials resource gaps to implement a quality measles vaccination campaign. The result also provides supporting evidence to highlight the staggering approach as being effective in addressing human resources and CCE gaps, especially in resource-limited areas. We recommend that considering the human resource for health gaps in most lower and middle-income countries, staggering should be considered when planning their supplemental immunization activities.

Credit Authorship Contribution Statement

Chimaobi Ihebuzor: Conceptualization, Methodology, Formal analysis, Writing – Original draft, Writing – Review and editing, Visualization – Tables and figures. Joseph Oteri: Conceptualization, Methodology, Formal analysis, Writing – Original draft, Writing – Review and editing, Visualization – Tables and figures. Boubacar Dieng: Conceptualization, Methodology, Writing – Review and editing. Samuel Bawa: Conceptualization, Methodology, Writing – Review and editing, Visualization – Tables and figures. Adejoke Oladele Kolawole: Conceptualization, Methodology, Writing – Review and editing. Bolanle Orefejo: Conceptualization, Methodology, Writing – Review and editing, Visualization – Tables and figures. Anne Eudes Jean Baptiste: Conceptualization, Methodology, Writing – Review and editing, Visualization – Tables and figures. Nneka Onwu: Review and editing, Validation.

Acknowledgments

We wish to acknowledge the immense support of the State primary health care board and all the Partners that supported the 2018 measles vaccination campaign in Lagos state. Our appreciations also go to the vaccination team members and the community for their immense contributions towards the successful implementation of the Measles vaccination campaign. We also acknowledge Jude Asolo (UNICEF) and Sam Ibizugbe (CHAI) for their wonderful inputs to the development of the states’ staggering maps.

Authors’ Contribution

CI, AJO, and SB conceived the study idea and contributed to the study design and literature search. CI, AJO, BD, SB, AOK, BO, AEJB, and NO contributed to data collection, preparation of figures and tables, and performed the analysis. All contributed to interpretation and writing.

Research Data for this Article

Some of the data sets used in this paper are publicly available via the sources referenced in the manuscript. Other data was generated as part of the activities supporting the measles elimination strategy and SIA. The datasets analysed during the current study are available in the folder (Lagos state measles 2017/2018 microplan data) https://drive.google.com/drive/ folders/1t6lFW9XmcRCjwm9OHJGrX--c-fsSFLzl?usp=sharing

The data set contains the Lagos state and the twenty Local Government Areas microplans and the daily call-in data that was used to derive the administrative coverage used in the analysis.

Funding

This research was part of the documentation of the best practices from the 2018 Measles vaccination campaign and did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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