This document brings together a range of resources to provide an overview of the global policies, potential interventions and strategies related to the integration of immunization services. It also provides guidance and country examples on the integration of immunization with additional health interventions throughout the life course. It is currently available in English and French   

PAHO is pleased to introduce a new resource publication that contains a set of modules aimed at improving the monitoring of coverage of integrated public health interventions.  To improve the well-being of the population and bridge gaps in health service delivery, it is necessary to guarantee access to various health interventions, including proven strategies such as vaccination and deworming. Meeting program coverage goals, however, depends on identifying and reaching target populations.This means, in turn, promoting universal access to health using integrated approaches and a more efficient use of resources. What’s more, health services must adopt monitoring and systematic analysis of coverage as indispensable activities. Immunization programs in the Americas have extensive experience with the methodologies and tools for monitoring vaccination coverage. Countries have adopted and improved these instruments, adapting them to a range of target populations and epidemiological contexts. Moreover, the accumulative experience gained in the area of vaccine-preventable diseases (VPDs) may be applied to other programs, like deworming, which uses very effective interventions to reduce the burden of disease caused by soil-transmitted helminths. Registries that generate data on administrative coverage are very useful for helping to control, monitor, and evaluate program evaluation. But the quality of numerators and denominators can affect the quality of coverage data. It is thus important to analyze and interpret administrative coverage indicators correctly, supplementing them with other field methodologies that health teams can use to monitor and evaluate health interventions. The Pan American Health Organization’s (PAHO) Comprehensive Family Immunization Unit and Regional Program on Neglected Infectious Diseases (NIDs) have highlighted the need to systematize and integrate methods for monitoring coverage of health interventions among preschool- and school-age populations and are offering strategies and opportunities for collaboration. Publication is also available in Spanish  

Greetings,  A new blog is available on openlmis.org, presenting an exciting collaboration between OpenLMIS and Nexleaf Analytics to incorporate remote temperature monitoring (RTM) data into the OpenLMIS logistics software: http://openlmis.org/integrating-cold-chain-data-openlmis-collaboration-nexleaf-analytics/ This collaboration allows anyone adopting OpenLMIS and utilizing any RTM system to have an informed view of the cold chain status alongside their core vaccine stock and delivery data.  Integrating data systems can reduce data entry, improve data quality and usability, and accelerate insight generation. Combining datasets from different sources provides new opportunities for analysis and insight into the supply chain and streamlines processes for health workers and decision-makers alike. The interfaces developed by OpenLMIS and Nexleaf are open and standards based. This means that any provider of RTM hardware or data analysis systems will be able to integrate with OpenLMIS using the interfaces being developed by this project. This work is designed to benefit all manufacturers and providers of RTM hardware and software systems. We look forward to your feedback on the article. Happy reading and best wishes in your work.  Tenly Snow
OpenLMIS Community Manager   

IAPHL are debating the agenda for their next Webinar. Some are suggesting a focus on aspects of logistics integration for CD and NCD programs. For me, this is the 'Elephant-in-the-room' of future distribution strategy for country health pogrammes. Incorporating the distribution of vaccines and the fast-growing category of medicines that require cooling (i.e. insulin) and CT storage would have much to discuss, including the following three strategic issues: 1. Defining and achieving high efficiency distribution by: requiring that every national list of medicines contains the secondary packed volume of each generic and name-brand medicine so that cooled storage capacity can be correctly anticipated at time of tender; requiring that every medicine procured declares storage conditions (temperature range, humidity, sensitivity to light radiation) to ensure availability of required conditions of transport and storage; assessing in the country context whether the stages of transport in distribution can be more efficiently handled by active-refrigerated vehicles or passive-cooled insulated cold boxes/packaging; employing back-loading practices to bring sealed sharps boxes containing used syringes to central disposal hubs. 2. Optimizing the distribution network by: minimizing the number of stages of transport and storage at which products are handled and repacked for onward distribution; exploiting the current state-of-the-art energy management technologies in the design of new warehousing and for transport. As autonomy of electric vehicles now reaches 400 kms, take advantage of greater efficiency of electric vehicles, lower maintenance and cost reduction by solar-grid linked electricity management; using IT applications to maximise efficiency of supply trips and vehicle loading and also to provide GPS tracking and temperature monitoring with remote alarms. 3. Calm the fears of 'silo' programme logistics officials and support them by: using IT and communications technologies to maintain the control functions (distributing specific groups of vaccines or medicines) entirely in their hands via computer applications; offering freedom of access to vehicles and warehousing for PH officials to ‘control quality’ by inspection and routine review meetings with the distribution central management; as plans are laid for transition to integrated distribution, build time and progressive implementation stage by stage to allow time to build confidence. If outsourcing is introduced or expanded, allow for contract supervision and quality monitoring. Join the IAPHL debate and add your thoughts to theirs?  Lloyd John 26 Novmber 2017  

The IPM Project (funded by the Gates Foundation and "MSD for Mothers" - Merck - and implemented by the Senegalese Ministry of Health with technical support from Intrahealth International) managed to cross the "Death Valley" where many projects die after successful pilot phases. Indeed, since October 1, 2017 it is no longer Intrahealth that implements IPM but rather the National Supply Pharmacy (PNA) of Senegal! The struggle lasted 5 years, i.e. two years longer than expected. The horizontal scaling up was completed in 20 months (August 2013 to March 2015) when IPM distribution of contraceptives through private 3rd party logistics service providers (3PLs) covered all 14 Regions, 76 Districts and 1,408 health centers and posts across the country. On the other hand, the vertical scaling up or institutionalization that was to end in July 2016 fired in length until September 30, 2017, i.e. 30 months after! It should be noted that in the meantime, the IPM model was extended from 10 contraceptives to almost 90 health products, including UN lifesaving commodities, products of public health programs (HIV, Malaria and TB) as well as generic essential drugs. The goal is to reach all 118 health products that, according to national policy, make their way up to health posts. The links below will take you to a national TV report on the transfer ceremony of the IPM approach to the PNA, to two short movies on the implementation and results of the project as well as to a technical report on the project: TV Report: https://www.youtube.com/watch?v=7aV3_sSqnh0 Movie on implementation: https://www.youtube.com/watch?v=n325yUICWsY&t=3s Movie on results: https://www.dropbox.com/s/tue0rqt2psaqe1s/film%20les%20bons%20points%20de%20l%27Approche%20IPM%202017.mp4?dl=0 Technical report (MSD for Mothers) :
http://msdformothers.com/docs/senegal-informed-push-model.pdf In order to ensure that the project is well rooted in the national health system, Intrahealth continues its technical assistance to PNA under the leadership of Dr Oumy Kalsoum Ndiaye Ndao, the current IPM Project Director.

Improving supply chain data visibility and data use are showing real impact in Tanzania's integrated logistics system. A study has just been published in the peer-reviewed journal Global Health: Science and Practice Global Health: Science and Practice Advance Access articles for September 6, 2017 Original Article Upgrading Supply Chain Management Systems to Improve Availability of Medicines in Tanzania: Evaluation of Performance and Cost Effects Marasi Mwencha, James E Rosen, Cary Spisak, Noel Watson, Noela Kisoka, Happiness Mberesero Abstract | Full Text (PDF) Investments in a national logistics management unit and electronic logistics management information system resulted in better data use and improvements in some, but not all, management practices. After 1 year, key improvements included reduced stock-out rates, stock-out duration, and expiry rates. Although the upgraded systems were not inexpensive, they contributed to greater system efficiency and generated modest savings that defrayed much of the investment and maintenance costs.

Friends and Family of Immunization, I hope you will join me over the next six weeks before the TechNet Conference in Portugal to debate important futures for the vaccine supply chain. Each week, I will start a discussion on a topic and ask for your reactions. If you participate, you will also have the chance each week to respond to an online survey, just one or two questions, to express your agreement, interest or despair! The choice of topics is mine, not necessarily shared with any organization or individual. I chose them because they seem to respond to the changing needs of the vaccine cold chain and, collectively, they respond to most of the important challenges and opportunities that are on the horizon. They are: Merging vaccine and medicine distribution Advancing technologies of cooled-distribution Changing vaccines and their administration Introducing data-driven, remote oversight Addressing safety to maintain acceptance At the end of these discussions, it may become clear whether collectively we are aligned towards this view of immunization futures or towards a different course. I will present the results of the survey in a summary posted before Technet. We expect to organize an event at the TechNet Conference to give a further chance to discuss these topics with other participants.   Topic one: Merging vaccine and medicine distribution In the late 1970s, the vaccine supply chain was deliberately separated from other medical distribution systems. It was recognized at that time that vaccines occupied a small storage volume compared to that of medicines. Vaccines were different from medicines. They required special cooled handling procedures, a higher frequency of distribution and more timely arrival of fresh supplies.   Increased need for cooling of medicines The volume of cooled medicines (+2/8C & +20/25C) is likely to be in the order of twenty times that of vaccines within the next few years. The demand for certain temperature products, such as insulin, is increasing and international standards (EU, US) have recently been established for handling all medicines. This is provoking extensive re-equipping of stores and re-mapping of transport. Ministries of Health are recognizing the economies of merging the distribution of vaccines with pharmaceuticals. WHO expressed the goal of integration in the Global Vaccine Action Plan 2011-2020 (GVAP) and many countries have already moved to integrate specific components of the supply chain. The volume of cooled medicines (+2/8C & +20/25C) is likely to be in the order of twenty times that of vaccines within the next few years. The demand for certain temperature products, such as insulin, is increasing and international standards (EU, US) have recently been established for handling all medicines. This is provoking extensive re-equipping of stores and re-mapping of transport. Ministries of Health are recognizing the economies of merging the distribution of vaccines with pharmaceuticals. WHO expressed the goal of integration in the Global Vaccine Action Plan 2011-2020 (GVAP) and many countries have already moved to integrate specific components of the supply chain.   Rationalization of the distribution network So many countries have now choosen to establish para-statal organizations that handle the distribution of vaccines, medicines and supplies. The process of integrating warehousing and distribution needs for medical products compels Ministries of Health to reconsider the network of intermediate stores linking districts with the central, national store. Instead of 40m3 ready-made, ‘plug-and-play’ cold rooms that are fitted into spare storage spaces, large-scale 5000m3 cold-room facilities are planned for large countries on the basis of efficient use of the road network and optimizing storage sites. Discussion point #1: Do the existing primary stores and transport infrastructure provide the most efficient network for future distribution of temperature-sensitive medicines and vaccines?   Vaccine volumes now require refrigerated vehicles Cold boxes or vaccine packaging cooled by ice-packs are typically loaded onto trucks and used for most journeys between stores. Frozen ice-packs increase the risk of freezing in transport and a high level of compliance is needed to reduce the risk. The increased volume of vaccines to be transported is becoming unmanageable. Hundreds of packs are loaded into 25l insulated boxes that occupy six times the storage volume of vaccines to be transported and exceed the capacity of trucks.   Integrated transport by refrigerated vehicle Refrigerated vehicles are efficient in the use of transportable volume per km. They require less re-packing time and staff resources and most already carry temperature-recording devices that will soon be merged with the monitoring equipment standardized for vaccine refrigerators. In addition, satellite-positioning systems in the trucks will enable LMIS systems to automatically track distribution timeliness and arrival at each delivery point on optimized road circuits. Refrigerated vehicles will improve the timeliness of the delivery system and will raise the standard of vaccine handling. Refrigerated vehicles are the mode of choice for store-to-store pharmaceutical distribution and will replace passive cooling at central and intermediate stores. Icepack freezing will still remain an important option at the level of service delivery. Discussion point #2: When planning transport for store-to-store delivery of vaccine, do country managers evaluate the costs and benefits of sharing refrigerated vehicles and integrating with supply of temperature controlled medicines?   Please click this link to complete a short questionnaire: https://www.surveymonkey.com/r/3F6K5TL I will return the analysis to you at the end of this week and the results will be posted before TECHNET for all five topics. Thank you!  

How vertical is the immunization service delivery and supply chain information managment system when they are migrated into electronic paltform? Should it be part of routine HMIS or LMIS system? or a separate one?

Dear Colleagues,
JSI is pleased to announce a new publication in the Getting Products to People series: How Private Sector Solutions Can Strengthen Supply Chains for Public Health For years, experts in the field working on strengthening supply chains to support public health programs have emphasizedthe importance of the private sector role in extending the reach and improving the performance of the supply chainsthat serve the public with the health products they need. The private sector has often been deemed thesolutionto efficiency challenges and improving value for money.JSI has extensive experience working on designing private sector solutions that work in both low and middle income countries. We have found that although the private sector is definitely part of the solution, there are many models that work and extensive privatization is not necessarily always the panacea to our supply chain problems.We determine it will take anuanced approachto building agile supply chains and strong and sustainable healthcare marketplaces to meet our universal health coverage goals. This will include the private sector but does not presuppose full health sector privatization. The public will always need to serve as a good steward for public health and equitable access to products and services.It is strong, visionary supply chain leaders who will design and oversee supply chains that work and leverage the capacity of the private sector to help in these endeavors.

This content is best viewed here: https://www.k4health.org/toolkits/family-planning-immunization-integration. Extracted from the website with thanks!

Providing family planning information and services to postpartum women during their infants’ immunization visits provides an opportunity to reach women with unmet need for family planning. While evidence of the effect of integration on immunization services is limited, it is possible that effective integration may result in strengthened health systems, more focus and attention brought to immunization services and outcomes, and more efficient use of staff time and resources.

To be successful, integrated immunization and family planning service provision requires actions that support family planning and immunization alike. Supportive policies, evidence-based service delivery guidelines, capable service providers and managers, strong logistics to ensure availability of supplies, and broad acceptance by both communities and health workers are essential.

This toolkit, developed by the Family Planning and Immunization Integration Working Group, houses relevant resources developed by partner institutions. The objectives of the toolkit are:

To provide a repository of information on integrated family planning and immunization service delivery.
To make evidence-based information and tools accessible for health professionals and others around the world.
To identify gaps in existing resources and provide new resources and tools as needed to fill gaps.

This toolkit contains the following sections:

1. Essential Knowledge: highlights the rationale for integration and presents key resources documenting the evidence around FP & immunization integration
2. Evidence-based Advocacy: presents advocacy considerations, as well as briefs, reports, and presentations used to advocate for FP & immunization integration among key stakeholders
3. Implementation Tools: includes field-tested tools used to guide implementation of integrated service delivery, such as tools for screening and referral, training, supervision, and cost assessment
4. Social & Behavior Change Communication: provides a range of tools and materials for designing a strategic approach integrated service delivery, including tools for formative assessment, sample job aids and IEC materials, and guidance on SBCC strategy design
5. M&E and Research Tools: presents guidance documents and tools to guide monitoring and evaluation of integrated family planning and immunization service delivery, including recommended indicators and priority research questions
6. Country Experiences: offers examples of country experiences with integrating family planning and immunization services, and highlights various strategies used, challenges faced, and lessons learned
7. The Working Group: includes FP/Immunization Integration Working Group meeting reports and other documents.

Family planning and immunization integration has been recognized by USAID as a “Promising Practice” for family planning. USAID maintains a map and inventory list of countries implementing FP and immunization integration activities through their Family Planning High Impact Practices site.

We welcome additional resources for inclusion in the toolkit! Please email us at toolkits@k4health.org or fill out the feedback form if you have a relevant resource that you would like to share.

Passing along this link to a recent article from Prashant Yadav published in Vaccine on a framework for supply chain integration.

http://www.sciencedirect.com/science/article/pii/S0264410X14013589

Highlights
• Integration with other supply chains is often presented as a strategy to improve the efficiency of vaccine supply chains.
• Integration with other supply chains can be challenging in quantification, procurement and ordering/requisitioning.
• Integration with other supply chains presents strongest opportunities in storage, transport and IT.
• Product segmentation for supply chain integration helps identify products with greatest potential for integration with vaccines.
• Systematic data on efficiency needs to be captured to rigorously understand the benefits of integration with other supply chains.

Abstract
One of the primary objectives of National Immunization Programs is to strengthen and optimize immunization supply chains so that vaccines are delivered to the end recipients effectively, efficiently and sustainably. As a result of larger investments in global health and a wider portfolio of vaccines, global agencies are recognizing the need for vaccine supply chains to operate at their most optimal levels. Integration with other supply chains is often presented as a strategy to improve efficiency. However, it remains unclear if the proposed benefits from integration of vaccine supply chains with other supply chains will outweigh the costs. This paper provides a framework for deciding where such integration offers the most significant benefits. It also cautions about the pitfalls of integration as a one size fits all strategy. It also highlights the need for systematic collection of cost and efficiency data in order to understand the value of integration and other such initiatives.

Keywords
Vaccine supply chain; Supply chain integration; Vaccine delivery; Vaccine distribution; Cold chain logistics; Supply chain segmentation

The Journal of Infectious Diseases has a special issue (March 1, 2012: Suppl.1) devoted to the very important topic of integration of immunization with health services delivery. The wide-ranging articles cover experiences, integration framework, integration in outreach services, improving coverage of multiple health interventions, and impact of integration, among others.

The following two articles are available under open access for a specific time-period:

1. Integrated Delivery of Health Services During Outreach Visits: A Literature Review of Program Experience Through a Routine Immunization Lens by Tasnim Partapuri, Robert Steinglass and Jenny Sequeira
Abstract
Full Text (HTML)
Full Text (PDF)

2. Vaccination Week in the Americas: An Opportunity to Integrate Other Health Services With Immunization by Alba Maria Ropero-Álvarez, Hannah J. Kurtis, M. Carolina Danovaro-Holliday, Cuauhtémoc Ruiz-Matus, and Gina Tambini
Abstract
Full Text (HTML)
Full Text (PDF)
Supplementary Data

The USAID-supported MCHIP project is convening an online forum on integration of family planning and immunization services, July 6-15. Please see below and attached for details. We are hoping to have good participation from colleagues representing both technical areas, family planning and immunization, and invite you to join in the discussion. Please feel free to share this with other colleagues who may be interested.

Thanks,
Rebecca Fields
Senior Technical Advisor for Immunization
The MCHIP Project
John Snow, Inc.


EVENT ANNOUNCEMENT:
Global Online Forum on Integrated Service Delivery of Immunization and Family Planning, July 6-15

Please join MCHIP and the Immunization/Family Planning Integration Working Group for a global online discussion forum highlighting new and emerging field experiences, lessons learned, and opportunities for Immunization and Family Planning Integrated Service Delivery. The discussion will highlight opportunities for integrated programming, recent developments in Immunization/FP integration and how to make integration a win/win for both immunization and family planning outcomes.

Experts representing a variety of organizations will share field experiences and provide insights on successes and lessons learned from integrated programs within these key areas, along with potential strategies for scale-up and recommendations for future work in this area. MCHIP welcomes all interested participants to join in this rich discussion.

During the forum, you will receive one or two emails per day (during July 6-15) from the forum administrators, with all contributions screened and presented as a single, well organized digest.

If you are interested in participating, please send your Name, Title, Organization and Email address to Elizabeth Sasser at esasser@jhpiego.net.

Are dairy chains and routine vaccine chains complementary? In Karnataka (South India) milk unions pick-up milk from even remote villages with amazing regularity/predictability (without special technology to speak of). Vehicles with "chillers" travel empty, and return with milk to the semi-urban processing plant. Could the empty "front-haul" be utilized for routine immunization activities? Is this an experiment worth trying? Would love to hear your thoughts.

This message has been cross-posted from HPV Vaccine Global Community of Practice. With many thanks to Robert Steinglass.

Dear Lisa,

I agree with Sarah Mullins that there is a great opportunity to find links with a larger package of interventions, including tetanus vaccination. The following four resources provide some relevant background information.

a) To read about school-based immunization experiences, much of which has been based on administration of tetanus toxoid, documented from Indonesia, Malaysia, Sri Lanka and Tunisia, readers may be interested in visiting the WHO web site at:
http://www.who.int/immunization_delivery/systems_policy/school-based-immunization/en/index.html

b) Hard to locate information from a slide presentation from 2009 on the “Potential Role of School-Based Immunization in Protecting More Children: Results of an e-mail survey” is attached. Again much of the experience is based on administration of tetanus toxoid.

c) Experience in immunizing school-age children and adolescents is summarized in Vaccine 28(5):1138-47 (2009).
Immunizing school-age children and adolescents: Experience from low- and middle-income countries.
Maria Sophia Mackroth, Kathleen Irwin, Jos Vandelaer, Joachim Hombach and Linda O Eckert
http://pubget.com/search?q=authors%3A%22Maria%20Sophia%20Mackroth%22

d) The following excerpt from a BASICS monograph on sustaining neonatal
tetanus elimination (available under the maternal and neonatal tetanus which is available athttp://http://www.immunizationbasics.jsi.com/Resources_DiseaseControl.htm) --
before the advent of HPV vaccine -- might be of some interest: "To sustain the progress made by immunizing both childbearing-age women in high-risk areas and infants, many countries should consider adopting a supplementary population-based approach to immunizations, such as school-age boosters. School-based immunizations are an investment in today’s children that will produce future benefits when these children become parents. In countries with a high female primary school enrollment, school immunizations may be a cost-effective investment for tetanus prevention, especially if they are part of an integrated primary health care strategy that includes health education and the simultaneous administration of anthelmintics, screening and treatment for trachoma, treatment for lymphatic filariasis, group A meningococcal meningitis immunization, typhoid immunization, and others." Source: Steinglass, Robert. 1998. "Using Early Childhood Booster Doses to Maintain the Elimination of Neonatal Tetanus." Based on a paper delivered at the World Health Organization (WHO) Neonatal Tetanus Elimination Technical Consultation, Geneva, 1997. Published for the U.S. Agency for International Development (USAID) by the Basic Support for Institutionalizing Child Survival (BASICS) Project. Arlington, Va.:

Robert

Attachment: school tetanus GIM09 - Session 1 - J Vandelaer.ppt

Robert Steinglass forwards this request.
Greetings,
Are you familiar with efforts to integrate child immunization and family planning services? If so, we need your help.

Family Health International (FHI) through its PROGRESS project and the Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego with multiple partners including JSI (which has a long history of working on immunization projects), are collaborating to create an interactive, online map that will indicate countries where family planning messages and/or services have been integrated into child immunization programs.

The online map will include information about where each family planning and child immunization integration project is located, a brief 2-4 sentence summary of each project, and a link to an organization, if applicable. We are gathering country-level experiences worldwide. If possible, please take a few moments to send us brief responses to the questions below.

Family Planning and Child Immunization Integration:
Where have family planning messages or services for postpartum women been incorporated into child immunization visits since 2000?If family planning services have been offered with child immunization contacts, what form has the integration taken? For example, do immunization providers provide referrals to family planning services? Do immunization providers provide family planning methods during the same visit at a facility? Are immunization services offered with family planning through outreach services?If family planning services have been offered with child immunization programs, what types of services were they: group education and/or information sharing?individualized screening and referral?service provision? (If so, what family planning methods were offered?other? What, if any, research projects or data analyses have been conducted or are underway to assess an integrated approach to family planning and immunization service delivery?What existing national policies or guidelines are in place that support or impede integration?[/list] If you would prefer to discuss these questions via the phone, please let us know and we can set up a call. Please also send us the names and email addresses of colleagues who you think should receive this email, or please forward this message directly to them. Responses are requested by May 15, 2010 and can be sent to [email=krademacher@fhi.org]krademacher@fhi.org[/email]

We greatly appreciate your assistance with this project. Your responses will help us to capture and disseminate information about research and programmatic efforts that are underway at a country-level—information which is not currently available or easily accessible. We would be happy to keep you informed about our progress as this effort unfolds. You can also find out more about PROGRESS and MCHIP projects at www.fhi.org/progressand at http://www.mchip.net/ respectively.

Sincerely,

Holly Blanchard, MCHIP
Lisa Dulli, FHI, PROGRESS
Bill Finger, FHI, PROGRESS
Kate Rademacher, FHI, PROGRESS
Lora Shimp, MCHIP
John Stanback, FHI, PROGRESS
Robert Steinglass, MCHIP
Gwyneth Vance, FHI, PROGRESS
Trinity Zan, FHI, PROGRESS