2012 Ethiopian national immunization coverage survey

Executive summary The Expanded Program for Immunization (EPI) in Ethiopia, launched in 1980, has shown steady progress in increasing coverage for all antigens. Additional vaccines beyond the traditional ones, Hib and Hep‐B in 2007 and PCV in 2011 included in the routine immunization program. Performance report in 2010/11 showed wide variation as reported through HMIS compared to DHS and other assessments. Administrative coverage (through HMIS) was reported as at 87% for DPT‐HepB‐Hib3 in 2010, the Demographic and Health Survey (DHS) estimating DPT‐HepB‐Hib3 (CSA, 2011) to be 36.5% for 2010. In order for meaningful and ongoing program decision‐making, immunization coverage estimates are essential. Such estimates provide data on the success of immunization programs to reach every child and every pregnant woman and also give direction to program experts regarding how to improve programs. Given that coverage surveys should be completed every three to five years (the last was done in 2007), the Federal Minister of Health (FMOH) decided to validate the administrative reports through an exclusive Immunization coverage survey of high quality in 2012. The Interagency Coordination Committee (ICC) organized a task force consisting of representatives from the Ethiopian Health and Nutrition Institute (EHNRI), the Central Statistical Agency (CSA), the Federal Ministry of Health, UNICEF, WHO, Integrated Family Health Partnership, Core Group, The Bill and Melinda Gates Foundation (BMGF) and the Clinton Health Access Initiative. EHNRI administered the survey. The overall objective of the survey was to determine the coverage of all antigens in children 12 to 23 months old and the proportion of children protected at birth from tetanus born to mothers 0 to 11 months prior to the survey at national and regional levels. Methodology The 2012 Immunization Coverage survey was a multi‐stage stratified cluster design cross‐sectional national survey. The survey sample frame was designed to provide estimates for the maternal and infant immunization status at the national level and for each of the nine regions and two city‐administrations. The number of clusters was selected based upon an estimate of the number of eligible children in each cluster and resource availability. A cluster sample size of seven households (HH) for each of the two groups (tetanus immunization and infant immunization groups) was selected after review of inter‐ and intra‐cluster variability in the DHS 2011 survey. These data indicate that seven complete responses per cluster should yield immunization coverage estimates with 95% confidence intervals (CI) that are ±10% precision, based on a coverage estimate of 50% for most regions. At the national level, the precision was designed to be ±5%. In addition to HH surveys, a health facility staff questionnaire was administered at health centers in urban and rural clusters and at health posts only in rural clusters in the nearest functional government health facility for each surveyed cluster. A total of 550 clusters were selected nationally, 50 from each region and in each cluster, 14 households were selected, seven houses with children 12‐23 months and seven houses with infants, 0‐11 months representing recently pregnant mothers. Nineteen clusters were replaced. Of the 3,837 children interviewed and data entered, after cleaning a total of 3,762 caregivers of eligible children from 550 clusters of 11 regions aged 12 ‐ 23 months were analyzed for childhood immunization. A total of 3,843 mothers of children 0‐11 months were interviewed from 550 clusters of 11 regions and analyzed for analysis of maternal tetanus immunization; that is 99.8% of the planned sample. Routine immunization coverage of children 12-­23 months of age For this survey, immunization coverage is defined as reported immunization, evidenced by card, by history from mother/caregiver, or by EPI register from a nearby health facility. Information on child immunization was obtained from 3,762 children aged 12-23 months, of whom 1,756 (46.7%) had immunization cards; and card availability by region ranges from 14.1% in Afar to 94.2% in Addis Ababa. Due to the relatively low‐level of card availability, concerns have been raised about the completeness and accuracy of data collected via caregiver’s recall. The drop‐out rates observed in the data when caregiver recall is the source of information is often twice as high as that seen for cards and EPI register. This analysis adjusts the DPT‐HepB‐Hib‐3 coverage using the DPT‐HepB‐Hib‐1‐3 drop‐out rate from card as a better estimate of the true drop‐out rate for data collected by caregiver recall. The weighted Ethiopian EPI coverage by antigen is BCG 79.6%; DPT‐HepB‐Hib1 80.0%; OPV1 90.1%; adjusted DPT‐ HepB‐Hib3 65.7%; OPV3 70.5%; and measles 68.2%.Coverage for all antigens tends to be higher in children of caregivers with higher educational attainment, higher wealth, children of first parity, and those residing in urban areas. This survey revealed high drop‐out rates in the immunization program. The total unadjusted drop‐out rate (card, verification and history) for DPT‐HepB‐Hib1‐3 was 25.6% nationally, ranging from 2.6% (Addis Ababa) to 63.8% (Somali). Tetanus toxoid coverage and among mothers of children 0­11 months of age Nationwide the proportion of women who delivered in the last year who received at least one dose of TT is 79.9% and who received a second dose is 72.0% conferring immunity for three years. The coverage of TT doses increases among older women and those with higher child parity, high educational attainment, and those living in urban areas. On the other hand, women below 20 years with primipara and less than two ANC visits have lower coverage. National coverage for TT1 vaccine administered during the last pregnancy was 58.7% and for two or more was 44.8%. According to the definition of neonatal protection at birth used in Ethiopia, the percentage of children protected was 65%. Based on the WHO definition for neonatal tetanus protection at birth, the results revealed that nationally 68% of children born are protected. These figures also vary across the regions ranging from 84% in Addis Ababa to 35% Afar regional state. Attended delivery is one the most important indicators of maternal health care services and prevention of neonatal tetanus. According to the findings of this survey deliveries attended by skilled health professional is, by far, lower than attendance by unskilled professionals and unattended deliveries. Characteristics of health facility serving assessed areas Health facilities (health posts and health centers) and health workers are the backbone of immunization service delivery, ensuring that national immunization policy is translated into an effective and usable service for women and children. In total 585 government‐run health facilities assessed during the Ethiopian EPI Coverage Survey (2012); from this, 298 were health centers and 273 were health posts. The survey showed that 97.1% of the urban surveyed health facilities and 89.2% of rural health facilities provide routine immunization services on a regularly basis. However, routine EPI micro‐plans that show the annual/monthly target number of children and the static and outreach/mobile sessions scheduled were available in just 78.4% of facilities providing immunization services. Of assessed health centers, 51.4% provide daily sessions compared to health posts, which tended to provide immunization services on a monthly basis (75.7%). Though not cross checked from the records and the reporting formats, 42.5% of a health facilities had a planned session interrupted in the last 9 months. The success of immunization depends on reliable provision of commodities through the supply chain and availability for use when and where needed in the correct quantities and at the right time. The results of the survey revealed that 92.1% and 77.9% of health posts and health centers, respectively, received the vaccine at least once in a month. With regard to the cold chain, 45.2% of health posts and 2.1% of health centers, reported absence of a vaccine refrigerator. It is also reported that in health posts with refrigerators, 36.6% of refrigerators were not functioning due to shortage of kerosene while 33.0% of health centers reported non‐functional refrigerators due to a broken part; “refrigerator is not installed” accounts 12.5% of unused refrigerators. In the health facilities assessed that store vaccines overnight, 38.6% of health posts and 43.6% of health center+ experienced stock‐outs for one or more of the antigens during previous 3 months before the survey. Recommendations High immunization drop‐out rates could be improved by identifying and addressing the reasons for high drop‐out. Increasing community participation through intensive and extensive health education campaigns may also be required to increase utilization of MCH services in rural areas. Regular reviews of immunization performance. In addition to reviewing performance, review should monitor data quality so that it accurately reflects true immunization coverage at all levels. Improving mothers’ utilization of ANC services and institutional delivery. Methods may require increased community mobilization and improved service delivery. Every ANC visit should screen TT immunization status of the pregnant women and administer doses to all eligible women. Create community awareness on clean cord care management and educate them on the risk of harmful traditions. The health facilities need to establish a vaccine delivery strategy appropriate for their catchment population supported by updated work plan and available cold‐chain equipment. Proper vaccine stock management is required at all levels, it can be achieved through training and regular monitoring of central, regional, and facility vaccine stocks. Avail transportation for the delivery of the vaccine, which is appropriate to the topography of the area (bicycle, motorcycle). Review deployment and maintenance of cold‐chain equipment periodically at health facility level. There should be a proper in‐service training program of EPI at regional and national level so as to enhance the service.