Expanded program of immunization

Situation analysis

Although administrative reports of immunization coverage tend to be rather high in Mozambique, DHS surveys show that between 1997 and 2003, immunization coverage for all major vaccine preventable diseases, namely polio, measles, tuberculosis, diphtheria, pertussis and tetanus, (fully immunized) increased from 47% to 63%. Despite progress registered, the overall immunization coverage in Mozambique is still low and is not equally spread throughout the country. For instance, children in Zambézia province are the most disadvantaged, with an immunization coverage rate of only 45%. Further, fully immunized children coverage is 81% for the urban population against only 56% for the rural settlements (DHS, 2003).

While fully immunized child in general continued to increase to 66.4% in 2005 according to the community survey for routine immunization held in December 2005, the situation seems to have worsened between 2003 and 2005 in most provinces, including those provinces in southern region that used to have high coverage rates, which have experienced a decline in their coverage for all antigens. For instance, Measles coverage decreased from very high levels of over 90% in 2003 to around 80% in 2005 in all four southern provinces. Meanwhile, DPT/HepB3 declined from above 90% to 83% and 75% in two of the provinces, namely Inhambane and Maputo city, respectively, with particular concern to the later that decreased by around 20%.

Many districts have communities that are difficult to access with the existing health services infrastructure, making outreach essential to improve coverage at district level. However, only 30% fixed vaccination units are provided with transport needed to conduct outreach activities.

Moreover, low population density in some districts turns the Reaching Every District (RED) strategy expensive but essential to increase the number of fully immunised children.

Furthermore, high dropout at district level is still a matter of concern. The national dropout rate was 13% in 2006. Almost all districts have a dropout rate above 10%. The hardest hit provinces are Maputo and Niassa where the dropout rates reached 19%.

In what concerns disease surveillance, as of November 2007, only 2 out of 11 provinces achieved the Non-Acute Flaccid Paralysis (AFP) rate of at least 2/100,000 children under 15 years old. Nampula and Zambezia, the most populated provinces in the country, hosting a little more than 40% of the country's population, are amongst the low performing provinces, with special concern for Nampula with the lowest non-AFP rate of 0.1 (Figure 1). Meanwhile, stool adequacy (stool collected within the first 14 days of onset of paralysis) is of concern in a number of provinces, not reaching the minimum acceptable rate of 80%.

In what concerns disease surveillance, as of November 2007, only 2 out of 11 provinces achieved the Non-Acute Flaccid Paralysis (AFP) rate of at least 2/100,000 children under 15 years old. Nampula and Zambezia, the most populated provinces in the country, hosting a little more than 40% of the country's population, are amongst the low performing provinces, with special concern for Nampula with the lowest non-AFP rate of 0.1 (Figure 1). Meanwhile, stool adequacy (stool collected within the first 14 days of onset of paralysis) is of concern in a number of provinces, not reaching the minimum acceptable rate of 80%.

Challenges

• Shortage of trained staff / Weak program management at lower levels;
• Data unreliable / Weak program data management;
• Inadequate program logistic equipment, mainly cold chain system;
• Insufficient and inadequate transportation means for integrated outreach activities.

Achievements

• Achieved, as of November 2007, a non Polio AFP rate of 1.9/100,000 children under 15 years and 81% stool adequacy samples;
• Created the National Certification Committee (NCC) and National Polio Experts Committee (NPEC);
• Introduced nationwide the Measles case-based surveillance and integrated into the already existing AFP surveillance system;
• Trained 98 health professionals on measles surveillance, amongst clinicians (22 – 2 per province), provincial surveillance officers (11 – 1 per province), heads of laboratory at provincial level (11 – 1 per province), and laboratory technicians (54) at provincial and district levels;
• Trained 440 health professionals on the Reaching Every District (RED) strategy amongst staff at provincial, district and health facility levels;
• Conducted Tetanus campaign in 15 high risk districts with overall coverage above 90%;
• Developed the comprehensive Multi-Year Plan (cMYP) 2007-09, of the Expanded Program on Immunization;
• Submitted to GAVI Alliance (Global Alliance for Vaccines and Immunisation) the application for new vaccine(DPTHepB+Hib) introduction;
• Submitted to GAVI Alliance the application for Health System Strengthening (HSS).

Next steps

• Implement RED approach countrywide
• Improve Acute Flaccid Paralysis (AFP) and Measles case-based surveillance in every district so as to achieve and maintain Polio certification standard indicators and measles elimination indicators by 201;
• Eliminate maternal and neonatal tetanus by 2012;
• Introduce hemophilus Influenza type B vaccine countrywide by 2009; (We now know that the approval has been for 2009)
• Improve the quality of EPI data management; (Note that this point was attached to the previous one)
• Introduce vaccine management tools at provincial and district levels by 2008;
• Conduct cold chain inventory and develop a cold chain rehabilitation plan