Introduction and Background

Mass vaccination campaigns are usually instituted to bridge the gaps of poor routine vaccination coverage usually associated with a weak health system. They are also an avenue to expediently fill delivery gaps, provide extra or booster doses of a vaccine to eligible persons, reach previously unreached with the particular antigen, and help attain program targets such as elimination or eradication goals of vaccine-preventable diseases [1-3].

Mass vaccination campaigns usually extend the coverage of the antigens to age groups outside those for Routine Immunization (RI) and as such can cover up to 10 times the number scheduled for RI within a period. Campaigns are also used to prevent or respond to disease outbreaks, and therefore require intensive planning, coordination, training of staff, mobilization of vaccines, documentation, safety surveillance and good execution to achieve the aims of the campaign [4,5].

Nigeria is a signatory to the many disease elimination and eradication goals such as measles elimination, polio eradication, eliminating yellow fever etc. and uses mass vaccination campaigns as one of its methods to achieve these goals. The country has yet to attain high routine immunization coverage to sustain eradication and elimination goals and as such relies on mass vaccination campaigns to boost coverage and achieve herd immunity [6].

An integrated campaign refers to the co-delivery of all or most of the campaign components for two or more health interventions. It could be partial or full integration depending on which areas of the campaign are being integrated [7].

Integration has also been one of the guiding principles of Global Immunization strategies, from Global Immunization Vision and Strategies 2006-2015 (GIVS) to the Global Vaccine Action Plan 2011- 2020 (GVAP) and the recent Immunization Agenda 2030 (IA 2030), as a way to deliver multiple services especially at primary healthcare level in order to improve access through immunization [8-11].

Integration of health services is not new, especially in maternal and child health; advocacy has always been to provide as many interventions as possible when a child or mother presents to the health center, resulting in programs such as Integrated Management of Childhood Illness (IMCI). Kamatsuchi M, et al. found that, on average, 100 integrated child health events take place in sub-Saharan Africa annually between 2005 and 2010 with about 154 events alone in 2010 as child health days or immunization campaigns [12]. Mass measles vaccination campaigns are commonly used as a platform for delivering other interventions, especially Vitamin A and polio vaccine [13,14].

Nigeria context

Nigeria is a signatory to disease elimination and eradication goals, such as measles elimination, polio eradication, and eliminating yellow fever and uses mass vaccination campaigns as one of its methods to achieve these goals. The country has yet to attain high routine immunization coverage to sustain eradication and elimination goals and as such relies on mass vaccination campaigns to boost coverage and achieve herd immunity [6].

The Maternal Neonatal Child Health Week (MNCHW) which has been in practice in Nigeria since 2010 as a biannual event following the recommendation of the National Council of Health delivers integrated maternal and child health services to all pregnant women and children less than five years of age [15,16]. Similarly, Periodic Intensification of Routine Immunization (PIRI) enhances routine immunization in areas with extremely weak infrastructure, security problems, or major geographic and resource challenges and uses an integrated campaign mode to deliver services [17].

In terms of antigen integration as well as integration across interventions, Nigeria has vast experience in conducting partially integrated vaccination campaigns. Immunization Plus Days (IPDs) replaced the National Immunization Days (NIDs) in 2006 as a response to the community needs. Instead of administering the oral polio vaccine alone as was done in NIDs, a range of antigens (measles and DPT vaccines) have been administered with the oral polio vaccines plus other child survival interventions such as anti-helminthics, Vitamin A, and distribution of long-lasting insecticide-treated nets (LLIN) [18].

The integration of most vaccination campaigns in the country involved maternal health and child survival interventions with immunization services. Integration of injectable and noninjectable vaccinations (i.e. measles and polio) was conducted prior to 2019. In the 2013, integrated measles and polio campaign (IMC) in a few Local Government Areas (LGA) attempts were made to include distribution of LLIN. In 2014, two injectable vaccines (tetanus and meningitis A) were combined in some Local government Areas in three states [19,20].

Historically, Nigeria has been involved in stand-alone campaigns for meningitis and measles prior to the 2019 integrated campaign of these antigens. For example, in 2005, the first catchup measles campaign targeting children 9 months to under 15 years of age was conducted in Nigeria and thereafter, stand-alone measles vaccination campaigns have been conducted every two or three years, with that of 2013 along with oral polio vaccine [21].

Between 2011 and 2015, following Gavi’s approval of Nigeria’s proposal to conduct a preventive mass vaccination campaign using the meningitis A conjugate (men. A) vaccine, in 26 high-risk states including the Federal Capital Territory, preventive mass vaccination campaigns were conducted in these states targeting the age group one year to 29 years in phased manner due to the high target population (81.5 million) and availability of vaccine [22].

Nigeria, in keeping with global efforts to reduce the burden of vaccine-preventable diseases conducted mass vaccination campaigns involving measles, meningitis A, tetanus, yellow fever and polio antigens in 2019. The delivery of the meningitis vaccine and measles vaccine second dose were introduced into the routine immunization schedule. In the North (16 out of 20) states including the Federal Capital Territory (FCT) implemented the integrated measles and meningitis A vaccination campaign (IVC). The integration was an innovation as both campaigns were planned earlier as stand-alone campaigns, and for the first time, conducted on a very large scale as integrated.

This paper showcases the actions and steps taken to plan and coordinate the implementation of the largest integrated injectable antigens mass vaccination campaign in 16 northern states of Nigeria and the Federal Capital Territory, mentioning some best practices. The paper also examines some of the benefits of integration and provides recommendations on how to plan and implement integrated vaccination campaigns.

Methodology

Study setting

Sixteen of the 19 states in northern Nigeria and the Federal Capital Territory conducted an integrated vaccination campaign in 2019 except for Kano, Yobe who did stand-alone campaigns and Niger and Kogi states whose campaigns could not take place with the rest because of logistical issues affecting on the availability of the meningitis vaccines.

The planning and implementation of the 2019 integrated measles and meningitis A vaccination campaign was coordinated by the Non-Polio Supplemental Immunization Activities (NPSIA) unit of the Disease Control and Immunization Department of the National Primary Health Care Development Agency (NPHCDA). The coordination platform of the 2019 integrated measles men A campaign was the same as used in the 2017/2018 measles vaccination campaign and operated from the National Polio Emergency Operation Center and was led by Government [23]. Oversight for the team was provided by a steering committee. A Core Group made up of NPHCDA management and heads of both local and international partner agencies working in immunization within Nigeria and external support came from the Country Working Group (CWG). Dedicated staff of World Health Organization (WHO), United Nation Children’s Fund (UNICEF), United State Centers for Disease Control (CDC), the African

Field Epidemiology Network (AFENET), Clinton Health Access Initiative (CHAI), Bill & Melinda Gates Foundation (BMGF), European Union (EU) through her EU Support to Immunization Governance in Nigeria (EU-SIGN) project and the Nigeria Center for Disease Control (NCDC) were nominated from their country offices to support non-polio supplemental immunization activities.

Proposals for 2019 Campaigns

In the 2018 Gavi proposal application window, Nigeria applied for support from Gavi to carry out a multi-year proposal (2019-2021):

1. A follow-up measles campaign in 2019,
2. A measles second dose introduction into the routine immunization schedule in 2019,
3. A yellow fever preventive mass vaccination campaign in four states of Katsina, Ekiti, Edo and Rivers states in 2019. A multi-year proposal (2019-2021)

These proposals were approved by the Gavi Independent Review Committee (IRC) in January 2019 and were proposed as stand-alone. The IRC recommended complementarity in some of the activities because there were other previously approved interventions earmarked for 2019. These interventions are the introduction of the meningitis vaccine into the routine immunization schedule earlier approved for 2016 after the completion of the phased preventive catch-up meningitis A campaign in 2015. This introduction is associated with a “mini catch-up meningitis A campaign” targeting the birth cohorts born after the mass catch-up campaign of 2011 to 2015 and prior to the introduction of meningitis into the routine schedule. Thus, the meningitis A target age group varied across states based on the date of the last meningitis A vaccination campaign in the state. Bauchi, Borno, Gombe, Jigawa, Kano Katsina and Sokoto States targeted children aged 1 to 7 years while the other states targeted children aged 1 to 6 years.

The decision to change from stand-alone to integrated campaigns

Nigeria’s immunization calendar for 2019 was busy as it had multiple antigen campaigns and two introductions of vaccines into the routine immunization schedule: the measles second dose starting with the seventeen southern states and meningitis A vaccine introduction starting in the nineteen northern states as well as the FCT. The supplemental immunization activities were measles follow-up campaign in the 19 northern states and the FCT, yellow fever mass preventive campaign in Edo, Katsina, Ekiti and Rivers states as well as meningitis A follow up campaign in 25 states with variation in the target age group per state. The polio immunization programs (outbreak response and planned national and subnational polio campaigns) were also being carried out side by side with the busy programs in line with the country’s polio eradication efforts. In the same vein, Maternal and Neonatal Tetanus Elimination (MNTE) campaigns were planned for implementation across 108 Local Government Areas in the Northern and Southern states.

The Leadership of the National Primary Health Care Development Agency, the CORE Group made up of team leaders of immunization Partners in the country (WHO, UNICEF, CDC, AFENET, EU, BMGF, World Bank etc.), the Country Working Group (external support to immunization campaigns with Gavi and US CDC as alternate chair) all had various meetings to review the way forward to address the busy immunization Agenda for 2019. Coincidentally, at the same time, the government of Nigeria was unable to provide her counterpart funds for the planned measles campaign due to the economic crunch in the nation following falling crude oil prices globally. This led to the government’s decision to integrate men A, which had operational funding, with the measles campaign. The decision was backed by Gavi which pooled Gavi’s in-country resources domiciled with WHO and UNICEF to mitigate the financial shortfall and alleviate the unusually busy immunization calendar. This led to the development of a revised chronogram.

Reviews of reports

We reviewed the minutes of meetings and activities of all the technical working groups, NPSIA unit, Steering committee, Core group and Country Working Group. These meetings were held at various levels:

1. High-level meetings/engagement with global partners - Country Working Group (CWG), Gavi and United States Centers for Disease Control made up the secretariat for the group.
2. Meetings with the Steering committee and the Core group that was chaired by the Executive Director of the NPHCDA.
3. Technical working committee meetings (Training, Logistics, Advocacy, Communication, and social mobilization etc.)
4. Campaign coordinating committee activities and weekly meetings.

The minutes gave the authors insight to the various steps taken in arriving at a decision to integrate the campaign and actions taken to mitigate likely challenges that could emanate from the decision.

Similarly, we reviewed the Gavi IRC approved budgets for the stand-alone campaigns – for men A, the measles vaccination campaign and the yellow fever campaigns approved by Gavi and also the later approved integrated campaign budgets for the northern states that integrated their men A with measles antigens. The review of the budget is to see areas where savings were generated due to the integration. The operational cost of the campaign is arrived at by summing up all the cost related to activities such as implementation trainings at the states, LGAs and ward levels, campaign waste management, ACSM activities including ACSM tracking and job aids. Others are personnel allowances national, states and LGA supervisors, stipends for transportation of vaccination team, LGA team, independent monitors as well as transportation and logistics for the campaign.

We also reviewed the activities carried out during the integration to document what the authors considered as best practices and challenges encountered during the integration. The integrated post-campaign coverage survey results from the National Bureau of statistics (NBS) for the measles and meningitis A in the study states (integrated and stand-alone campaigns) were also reviewed. Post campaign coverage surveys are conducted after a vaccination campaign by an independent body to estimate the coverage of the antigen at state level. The review was to ascertain if there were any significant differences between the stand-alone and integrated states in the number of children reached during the campaign.

Results

Planning and Coordination

Minutes of Meetings of the Steering Committee, CORE Group and Country Working Group - Following the approval of the measles vaccination campaigns and the measles second dose introduction proposal, the campaign coordinating committee made up of Partners and the government made regular presentations on preparations for the campaigns as well as the measles second dose introduction to the above committees on a regular basis as detailed in Table 1.

Meetings	CORE Group	Steering Committee	Country Working Group	NPSIA Meetings	Teleconference with States	Stakeholder meetings
Monthly/weekly Frequency	As needed	Monthly then weekly	Weekly except public holidays and days of states engagement	Twice weekly from January to Nov 2019	Weekly (Wed, Thurs, Fridays 10 am - 3 pm (states were batched	Once
Total No of meetings held	6	24	29	60	12 meetings per batch	5 (integration meeting with Polio and the routine immunization committee)

Presentations at these meetings were centered around the development of a chronogram of activities to cover the four (4) antigens, funding and financing updates for the campaigns, readiness, coordination at national and state levels, logistics, advocacy and social mobilization, and human resources.

Development of One Microplan and Tool - Microplan, which is a detailed bottom-up planning process conducted at the ward level and aggregated from the state to the national level quantifies the human, material and financial resources required to reach all the targeted persons in a campaign. Microplanning processes, which included training and the two-stage verification processes of the states’ microplan for measles and the Men. A vaccination campaign was harmonized from the planning stage since it involved the same persons at the lowest (ward) levels. It was cost and timesaving to have one microplan activity covering all the SIAs. The electronic copy of the tool was also integrated with routine immunization features, as the country was planning to introduce the second dose of measles onto the routine immunization schedule. (Link below shows a sample template of one of the states (Plateau).

https://docs.google.com/spreadsheets/d/1_3ji6RZoScXNX7kVH Qz6zsLqpJ6DxHB/edit?usp=sharing&ouid=109599797999890257930&rtpof=true&sd=true)

Micro plan verification, a part of the microplanning process, stands out as one of the core components of pre-implementation activity and is the final step before the plans are used. It is a 2-step process conducted at the state level. Microplanning, entails physically confirming the detailed inputs, such as population size by wards, LGAs, terrain of targeted places, names of religious places, schools, influential persons in the community, required commodities (vaccines and devices) for implementation etc. This variety of data is entered into the microplanning tools at the state level.  The verification is conducted after a desk review and field visit to selected Local Government Areas to ensure all the aspects of the microplanning tools are correctly filled.  The Daily Implementation Plans (DIP) drawn from the microplan are used to inform and train state and LGA teams on the approach for integration [24].

One Advocacy, Communication, and Social Mobilization (ACSM)/Stakeholders Plan – Advocacy, communication and social mobilization activities are key to generating demand, increasing uptake, and improving knowledge about vaccines whether during SIAs (Polio and Non-Polio) or RI implementation. A harmonized meeting was held with various stakeholders such as professional medical bodies, other Government Ministries, Department and Agency (e.g., education, National Youth Service Corps, Information, etc.,) Trade Unions, Development partners etc. informing the stakeholders of the integrated SIA and their roles to ensure a successful implementation.

Immunization Chronogram for 2019

Following the approval of the various immunization interventions for 2019, a chronogram of activities, especially the second half of the year when the majority of the planned interventions were to be implemented was developed as shown in Figure 1.

 

Figure 1: Immunization chronogram for 2019 based on the approvals.

With the decision to integrate the measles and men A vaccination campaigns in some states a new chronogram was developed as shown in Figure 2.

 

Figure 2: Revised chronogram of immunization activities for 2019.

Training plans

Training, is a major component of vaccination campaigns as health workers’ knowledge is critical for the effective delivery of immunization programs [25]. In the planning for a vaccination campaign, various trainings are carried out to ensure adequate knowledge of the health workers. For the 2019 integrated Men A and measles vaccination campaign, PowerPoint presentations for use at the subnational levels were developed by the National implementing team i.e. government and partners and these presentations covered all the thematic areas of the vaccination campaign; Coordination, planning and financing, cold chain and logistics, ACSM activities, monitoring, supervision and evaluation, data and management of AEFI and surveillance used in monitoring the preparation and readiness of the states using the campaign readiness dashboard [5].

With the integration of the antigens, revisions to the earlier plans ensured a seamless implementation of the integrated campaign. Major additional topics introduced at the implementation training were: https://docs.google.com/spreadsheets/d/1_I3ji6R-ZoScXNX7kVHQz6zsLqpJ6DxHB/edit?usp=drive_link&ouid=109599797999890257930&rtpof=true&sd=true

1. Vaccination Post Layout: Since the integration involved a huge number of clients of different ages, there was a special need to guard against wrong administration of vaccines for age, for example, children 9 months to 11 months were to receive only measles vaccination and could easily be mistakenly given meningitis A vaccine that was not intended for them at that age. Similarly, a child could mistakenly receive two shots of same antigen in place of the two different antigens if the layout was wrong and the team members were not specially trained. This led to the development of a special training on vaccination post layout (Figure 3) and flow of clients including specified roles and responsibilities in the team composition (Figure 4). An animated video was developed which team members downloaded and shared in their mobile phones for ease of understanding the layout, team composition and client flow.https://drive.google.com/drive/folders/1uOPVY47aO7zNs6YbEZ hw8BtKGxlqE0E2?usp=sharing

2. Special instruction was also passed down to ensure that cold boxes and other cold chain materials were labeled in what antigens they contained to avoid mixing up the two antigens.

3. The sitting arrangement of the vaccinator and recorder was set in such a way that the measles team didn’t have anything to do with the meningitis team as depicted in the pictures showing best practices from Nasarawa state (Figures 5-9) and no person was allowed to swap or work for the other person to avoid confusion in the vaccination arrangement. 

 

Figure 5: Orderly arrangement of vaccination post with children and caregivers queuing for their turn.

 

Figure 6: Sitting arrangement in a temporary fixed post showing the two different antigens with different vaccine storages and the two different recorders for each antigen.

 

Figure 7: Sitting arrangement of vaccinators and recorders made to prevent a child receiving one antigen twice in error. The cold boxes only store a particular antigen and diluents to avoid mix-up.

 

Figure 8: Showing orderly arrangement at a temporary vaccination post to avoid errors. Yellow circle - screening area, Pink and purple - vaccination points and Green - post vaccination waiting area.

 

Figure 9: Sitting arrangement in a vaccination post between care givers, vaccinator and recorders. Note caregiver sits across from 2 vaccinators. First one administers menA, then mother turns child and 2nd vaccinator injects MCV. Recorders sitting next to them hand cards to caregiver after both injections complete.

The training modules were developed and vetted for use at the implementing sub-national level by the Steering Committee.

Budgets

Table 2 shows the summary of the operational cost of the campaign by reviewing the budget for the measles and the meningitis A stand-alone and that of the integrated campaign in the implementing states. The operational cost for the earlier planned measles stand-alone and the meningitis A vaccination campaign for the study states was 2,666,198,363.66 Naira and 1,839,553,529.36 Naira respectively, totaling 4,505,751,893.02 Naira while the integrated measles and meningitis A operational cost was 2,112,533,935.92 Naira, a difference of 2,393,217,957.10 Naira. The average cost saving with the integration of the two vaccination campaigns was 45.83% with FCT savings being the lowest at 39.66% while savings from Borno was 53.56%.

Table 2: Summary budget for standalone and integrated campaign for the states.

Post Campaign Coverage Survey

Table 3 shows the post-campaign coverage survey results for both antigens including the coverage for Kano state that conducted two stand-alone campaigns. For meningitis A, the state with the least coverage at 78.5% was Kebbi while the highest was Kwara with 95.4% coverage. For the measles vaccine, Kebbi had the lowest coverage of 80.6% while Kwara state also had the highest coverage of 95.9%. Comparing coverage between the two antigens, in the PCCS, Kano state which conducted two stand-alone campaigns had a range of 6.8% while for the states that targeted children 12-83 months for meningitis A, Zamfara state had a range of -4.8%, while Gombe and Sokoto states was -1.8%. For states that targeted children 12 months to 59 months, Taraba state had a range of -2.4% while Benue was 0.1%.

 

Table 3: 2019 Post campaign coverage survey result for Measles and Men A vaccines.

Discussion

The ever-increasing burden of limited resources to carry out health campaigns was a driver for integrating the many mass vaccination campaigns that were slated for 2019 in Nigeria. Personnel, funds, time etc. were in short supply in an unusually busy immunization year. From our results, we presented findings in integrating the measles and meningitis A vaccination campaign.

Time saved

From the chronograms in Figures 1 and 2, all the twelve months had an immunization activity across all the states, and it was obvious that without the decision to integrate the measles and the meningitis A vaccination, it could have been impossible to effectively carry out the 2019 Gavi approved interventions.  This became more pertinent as, at least twenty-eight days could have been needed to administer two live vaccines if not administered at the same time [26,27], that time could have further stretched the immunization calendar further into the following year. Anambra state was scheduled to carry out integrated meningitis and yellow fever campaign, but this could not happen because when the mandatory twenty-eight days interval needed for injecting another live vaccine after the measles second dose introduction in the state was projected, their campaign fell into the Christmas season, and this was not advisable. Based on lessons learnt, December being holiday season is not the best of time to schedule any major health intervention as the quality will not only be poor, some, of the targeted clients would have been missed because of travels as found in other studies on holiday migration [28].