Discussions marquées : Home-based records

Stemming the Tide of Counterfeit Proof of Vaccination

Recent reports [1] of counterfeit yellow fever vaccination certificates in Zambia follow reports of falsified proof of vaccination documents being used in other countries, including Ethiopia [2], India [3], Nigeria [4], Pakistan [5], Sudan [6], Uganda [7], Tanzania [8] and Zimbabwe [9]. While the World Health Organization (WHO) published guidelines in 1999 [10] to support countries in developing measures to combat counterfeit pharmaceutical products and issued a report in 2017 [11] highlighting the public health and socioeconomic impacts of falsified medical products, neither publication discussed the current problem of false or fraudulently obtained proof of vaccination documentation. Counterfeit proof of vaccination in home-based records (HBRs), particularly those issued to provide documented proof of vaccination against yellow fever virus or polio virus [12], presents a threat to the health and security of countries and their citizens and warrants further discussion and action. Given the imperative of preventing the spread of vaccine-preventable diseases at a time when increased air travel and globalization link communities worldwide as never before [13], efforts seem warranted to (1) understand the magnitude and impact of counterfeit proof of vaccination and (2) work with national health authorities to develop practical counterfeit-deterrent strategies as part of the Eliminate Yellow fever Epidemics (EYE) global strategy (2017–2026) [14] as well as ongoing WHO activity around protection of essential medicines and health products [15]. Efforts to combat counterfeiting are also timely and urgent as part of the Global Health Security Agenda [16] as the likelihood of deadly, cross-border epidemics increases [17] and as countries continue to require international travelers to provide proof of vaccination as a prerequisite for entry (or exit) as part of international health regulations recommended by WHO [18]. This directive combined with improved enforcement at ports of entry into a country and a global yellow fever vaccine shortage [19] could further drive the demand for counterfeit vaccination documents. As providing proof of vaccination for travelers is one of several important HBR functions [20], HBRs deserve particular attention. For many travelers, proof of vaccination status is provided through a duly completed version of the International Certificate of Vaccination or Other Prophylaxis [18] recommended by the World Health Organization. In June 2007, a revised international certificate of vaccination was adopted following the 2005 revision of the International Health Regulations [21]. The revised certificate replaced the International Certificate of Vaccination or Revaccination Against Yellow Fever but did not include any anti-counterfeit guidelines or recommendations. The prevalence and impact of counterfeit medical products highlighted in the 2017 WHO report [11] point to a very real public health problem: a counterfeit problem that is not limited to medicines [22]. In Nigeria counterfeit proof of yellow fever vaccination records have been noted since at least 2012 when travelers from the country holding alleged counterfeit documents were denied entry by officials on arrival in Ghana [23] and South Africa [24]. As a result, the Federal Ministry of Health has attempted to curb the problem by issuing documents that included additional security features; however, a November 2018 report from Lagos airport highlights opportunities for further improvement as the problem of counterfeit documentation may continue [25]. It is far too easy to dismiss HBR counterfeit incidents as a trivial matter. Such incidents are anything but trivial. More must be done to investigate HBR counterfeiting incidents with local authorities. Additionally, we must leverage existing knowledge and explore novel approaches to combat counterfeit proof of vaccination while also exploring design-related solutions to better ensure the integrity of HBRs. The risks of spread of vaccine-preventable diseases by international travelers is a public health concern [26], placing increased importance on safeguarding HBRs as a verified source of travelers’ vaccination status.   Acknowledgement The author acknowledges the editorial support of Ms Stacy Young of Applied Scientific Consulting in preparing this work.   References 1. “Fake Health Certificates Scam Exposed.” Zambia Daily Mail Limited. 29 December 2018. Available online at: http://www.daily-mail.co.zm/fake-health-certificates-scam-exposed/. Accessed 4 January 2019. 2. “Ethiopia to Launch Massive Yellow Fever Vaccination.” Ethio Dailypost. 26 June 2018. Available online at: http://ethiodailypost.com/2018/06/26/ethiopia-to-launch-massive-yellow-fever-vaccination. Accessed 4 January 2019. 3. “Fake Yellow Fever Vaccine Certificates Pose Risk to Whole Indian Population.” RESET. 19 Jul 2013. Available online at: https://reset.org/node/24435. Accessed 4 January 2019. 4. “Ghana denies Nigerians entry over yellow fever card.” Daily Post. 25 July 2012. Available online at: http://dailypost.ng/2012/07/25/ghana-denies-nigerians-entry-yellow-fever-card/. Accessed 4 January 2019. 5. “India warns against ‘fake polio certificates’.” DAWN. 9 October 2014. Available online at: https://www.dawn.com/news/1136759. Accessed 4 January 2019. 6. “Sudan’s Vaccination Card Black Market.” The Daily Beast. 31 August 2015. Available online at: https://www.thedailybeast.com/sudans-vaccination-card-black-market. Accessed 4 January 2019. 7. “Travellers Resort to Fake Yellow Fever Cards.” TravelSafe Clinic. 28 October 2016. Available online at: http://travelsafeclinic.com/travellers-resort-to-fake-yellow-fever-cards-uganda/. Accessed 4 January 2019. 8. “Seven in Trouble Over Fake Vaccination Cards.” Daily News. 28 January 2017. Available online at: https://www.dailynews.co.tz/news/seven-in-trouble-over-fake-vaccination-cards.aspx. Accessed 4 January 2019. 9. “Fake vaccination certs sold.” The Zimbabwean. 9 January 2013. Available online at: http://www.thezimbabwean.co/2013/01/fake-vaccination-certs-sold/. Accessed 4 January 2019. 10. World Health Organization. Counterfeit Drugs. Guidelines for the development of measures to combat counterfeit drugs. Geneva: World Health Organization, 1999. Available online at: http://apps.who.int/medicinedocs/en/d/Jh1456e/. Accessed 4 January 2019. 11. World Health Organization. A study on the public health and socioeconomic impact of substandard and falsified medical products. Geneva: World Health Organization; 2017. License: CC BY-NC-SA 3.0 IGO. Available online at: https://www.who.int/medicines/regulation/ssffc/publications/se-study-sf/en/. Accessed 4 January 2019. 12. Soghaier MA, Saeed KMI, Zaman KK. Public Health Emergency of International Concern (PHEIC) has Declared Twice in 2014; Polio and Ebola at the Top. AIMS Public Health. 2015;2(2):218-222. doi: 10.3934/publichealth.2015.2.218. 13. Brent SE, Watts A, Cetron M, German M, Kraemer MU, Bogoch II, Brady OJ, Hay SI, Creatore MI, Khan K. International travel between global urban centres vulnerable to yellow fever transmission. Bull World Health Organ. 2018;96(5):343-354B. doi: 10.2471/BLT.17.205658. 14. World Health Organization. Eliminate Yellow fever Epidemics (EYE): a global strategy, 2017–2026. Wkly Epidemiol Rec. 2017;92(16):193-204. 15. World Health Organization. Essential medicines and health products. Available online at: https://www.who.int/medicines/about/en/. Accessed 4 January 2019. 16. Katz R, Sorrell EM, Kornblet SA, Fischer JE. Global health security agenda and the international health regulations: moving forward. Biosecur Bioterror. 2014;12(5):231-8. doi: 10.1089/bsp.2014.0038. 17. Suk JE, Van Cangh T, Beauté J, Bartels C, Tsolova S, Pharris A, Ciotti M, Semenza JC. The interconnected and cross-border nature of risks posed by infectious diseases. Glob Health Action. 2014;7:25287. doi: 10.3402/gha.v7.25287. 18. World Health Organization. International Health Regulations (2005). Third Edition. Geneva: World Health Organization, 2005. Available online at: https://www.who.int/ith/en/. Accessed 4 January 2019. 19. “What is behind the global shortage in yellow fever vaccine?” VOA News. 5 May 2016. Available online at: https://www.voanews.com/a/what-is-behind-the-global-shortage-in-yellow-fever-vaccine/3316820.html. Accessed 4 January 2019. 20. World Health Organization. Practical Guide for the Design, Use and Promotion of Home-based Records in Immunization Programmes. Geneva: World Health Organization, 2015. Available online at: https://www.who.int/immunization/monitoring_surveillance/routine/homebasedrecords/en/. Accessed 4 January 2019. 21. Gostin LO, DeBartolo MC, Friedman EA. The International Health Regulations 10 years on: the governing framework for global health security. Lancet. 2015;386(10009):2222-6. 22. Hamisu Hassan, Kate Kolaczinski, and Angela Acosta. Preventing, identifying, and mitigating the impact of fraud, theft, and diversion of insecticide treated nets: A summary of experience and best practices from country programs. VectorWorks Project, Johns Hopkins University-Center for Communication Programs (JHU-CCP), and Tropical Health LLP. 2016. Available online at: https://www.continuousdistribution.org/wp-content/uploads/2017/05/Preventing-Identifying-and-Mitigating-the-Impact-of-Fraud-Theft_mi.pdf. Accessed 4 January 2019. 23. “Ghana denies Nigerians entry over yellow fever card.” Daily Post. 25 July 2012. Available online at: http://dailypost.ng/2012/07/25/ghana-denies-nigerians-entry-yellow-fever-card/. Accessed 4 January 2019. 24. “On Yellow Fever, Yellow Cards, Nigeria And South Africa.” Nigeria Health Watch. 6 March 2012. Available online at: https://nigeriahealthwatch.com/on-yellow-fever-yellow-cards-nigeria-and-south-africa/#.XDUAU1xKg2w. Accessed 4 January 2019. 25. “Investigation: Inside Nigerian airport where cleaners, touts issue fake yellow cards to travelers.” Premium Times. 10 November 2018. Available online at: https://www.premiumtimesng.com/news/headlines/294967-investigation-inside-nigerian-airport-where-cleaners-touts-issue-fake-yellow-cards-to-travelers-2.html. Accessed 4 January 2019. 26. Gautret P, Botelho-Nevers E, Brouqui P, Parola P. The spread of vaccine-preventable diseases by international travellers: a public-health concern. Clin Microbiol Infect. 2012;18 Suppl 5:77-84. doi: 10.1111/j.1469-0691.2012.03940.x.

Positive Role of HBR in Immunization Programme: EuVac Baby award

Dear viewers, On behalf of the KVG team, I wish to share the PPT on Eu-Vac Baby presented during the regular Academic Society Meeting today. Laasya, D/O Chaitra C.G is the indexed Eu-Vaccinee who timely graduated as a fully immunized child (FIC) before first birthday and “complete” immunization in the 17th month. As agreed among local stakeholders, babies and their parents will receive the Eu-Vac Baby award next 14th Nov 2018, which is “Children’s day” in India, hoping for a successful public health-related event. This is made possible thanks to the revised design of the vaccination card in the integrated “Thayicard” – the HBR of Govt of Karnataka and the Combocard –, and the Vaccination+ card of KVG Medical College & Hospital Sullia that was issued to the parents at the time of discharge. If all the private birthing facilities providing vaccination services would use this example as a good practise, the population immunity gap will shrink, helping the country and the world to achieve goals and objectives of Routine Immunization [RI] programmes well in advance. I sincerely thank all the parents, especially the dedicated mothers who are bringing their children precisely on the stipulated due date or very close to the schedule date, vaccinators [Staff nurses] of the vaccination clinic for their dedicated services & my colleagues who edited the PPT, HOD who moderated the session. With regards, the KVG Team

New WHO guidelines released on home-based records

Dear Colleagues, WHO guidelines for home-based records were just recently released - WHO recommendations on home-based records for maternal, newborn and child health. Geneva: World Health Organization; 2018. The recommendations, rationale and remarks below are abstracted from the document, which has been uploaded to the TechNet-21 Resource Library (TRL) here. The document is also available online here: http://www.who.int/maternal_child_adolescent/documents/home-based-records-guidelines/en/.  Readers of the HBR recommendations will find that published evidence demonstrating benefits of HBRs is limited. Many of us on the Guideline Development Group (GDG) knew this to be the case before the guideline development work began. As a professional who believes in evidence-based approaches to public health, some may question why I (and many others) remain resolute ambassadors for home-based records and their role as a key component of immunization service delivery.  First and foremost, I believe that every parent has a right to a documented record of what interventions have been taken with their child by healthcare professionals, vaccination included. I also beleive very strongly in the importance of informed decisions by healthcare workers, and I recognize home-based records serve as a tool designed to provide frontline health workers with a standardized patient history that is convenient, comprehensive and vital to making such informed decisions about the need for care and immunization services. Without a doubt, gaps in our collective knowledge of the benefits of home-based records exists and these gaps need to be filled. But let's not lose the momentum that has been built over the past several years to re-energize the functional importance of home-based records within immunization service delivery.  Recommendations. Two primary recommendations resulted from the Guideline Development Group (GDG) consultations. These include: The use of home-based records, as a complement to facility-based records, is recommended for the care of pregnant women, mothers, newborns and children, to improve care-seeking behaviours, male involvement and support in the household, maternal and child home care practices, infant and child feeding, and communication between health providers and women/caregivers. (Low-certainty evidence) There was insufficient evidence available to determine if any specific type, format or design of home-based records is more effective. Policy-makers should involve stakeholders to discuss the important considerations with respect to type, content and implementation of home-based records. Rationale. The rationale for these recommendations was as follows. The GDG considered the evidence presented and judged that, overall, the certainty of evidence of the effectiveness of home-based records was low. They recognized that the existing evidence base has limitations, including: the small number of studies found, half of which were conducted in high-income countries; the age of these, with some conducted before 2000; and the variety in the studies, which looked at different types of home-based records and measured a broad array of outcomes. The impact varied by outcome. Some studies showed a positive effect on maternal health immunization care-seeking, outcomes related to a supportive home environment for maternal and child health (MCH) care, improved infant feeding and other child health care practices, improved child growth and development, improved continuity of care across MCH, and improved communication with health providers. However, there was also no significant effect reported on many maternal, newborn and child care-seeking and care practice outcomes. For many outcomes, no studies were found. Although the evidence base has its limitations, the GDG determined that the desirable effects outweigh any undesirable effects, and also considered in their judgements the fact that home-based records have a long history and are implemented in at least 163 countries. Furthermore, they considered the qualitative evidence that reports women, caregivers and providers from a variety of settings value different forms of home-based records. The GDG also noted that home-based records contribute to a larger objective of ensuring the right to access to information and are in line with global efforts for people-centred care, which WHO embraces. Remarks. Further remarks around these recommendations included the following. In remote and fragile settings, where health systems are weak or where health information systems are absent or poor, and in locations where caregivers may use multiple health facilities, home-based records may be of greater value than in more developed settings and health systems. Concerns about the privacy of online or electronic records were reported in studies. The GDG highlighted the potential sensitivity of information in home-based records on HIV testing, status or treatment. Careful consideration should be given as to what personal information is necessary to include in home-based records, to avoid stigma and discrimination. Countries currently using home-based records should consider appropriate use, design and content, as well as sustainable financing to maximize their use and impact. Additional research is needed on the benefits of using home-based records for recording information on single aspects of care, versus home-based records that include wider MNCH aspects for health education purposes. Evidence was not available at this time to inform this priority question for countries.

A true story of an "EuVac" Baby in positive role.

Dear colleagues We feel proud to share a true story of an “EuVac” bay in positive role. Three days back we shared the story of an “ANISOTIC” Baby in negative role. These illustrations highlight the need for an appropriate Home Based Record [HBR] as recommended by WHO. Both the illustrations are qualitative and hence single “story” is the story of millions. Unique bottom up approach of learning by doing & working together is the methodology used in 4 studies: viz. IRI simulation study, Promoting HepB birth dose in a tertiary care hospital [for this Rush University awarded best podium presentation award], Immunogram and Mission Indradhanush Simulation Study: all yielded unprecedented results in the shortest duration.  Honorable Prime Minister of our country while addressing 153 Nations iterated “we are working together not just for better future for ourselves but for the whole world” for which there was 7th standing ovation from the audience.   We wish happy reading of the attached true story of an “EuVac” baby in positive role. best wishes KVG Team


Dear viewers In India, an estimated 90 lakhs children are either partially vaccinated or unvaccinated and the GOI aims to attain >90% Full Immunization Coverage by 2018 through Intensified Mission Indradhanush [IMI] – an ambitious flagship programme of the country with utmost commitment. We are left with 5 months more from now. Constraints and problems are innumerable with rural urban differentiation. One such ubiquitous grievous problem is dissimilarity [ANISOSIS] of vaccination cards [HBR-Home Based vaccination Records] in the private sector. In urban areas as high as 40% and in rural area ~10% are vaccinated by private service providers whose  schedule is not matching with National Immunization schedule hence their vaccination status cannot be transmitted through Health Management Information System (HMIS). As a majority of these children mainly of high income group are deprived of Mother & Child Protection Card [MCP Card / Taayi Card] from the government, they do not have unique number to feed the data online to Mother and Child Tracking system [MCTS]. In response to this, Indian Academy of Pediatrics [IAP] – strong supporter of Immunization programme, on 03rd Sep 2016, removed the revised IAP schedule 2016 perceiving it as controversial and promised to come out with new NIS Compatible version in 2017. However this is not being communicated effectively to the private service providers – the attached is one such illustration of >20lakhs of children in India afflicted by “ANISOSIS” of vaccination card [HBR]. Dr David Brown et al from WHO, did extensive work on HBR emphasizes that a proper HBR definitely helps in adequate documentation of vaccination dates, educates parents and service providers, facilitates timely completion of vaccination schedule and much more to the country and the world. Hope the attached illustration will be useful in understanding the dilemma both for the parents and the nation. Warm regards Holla n team

Understanding a Parent’s View of Their Child’s Vaccination Card

In our work, we often focus on how health care workers and program managers use immunization data and less about how parents use data. Through JSI's recent activities to strengthen the availability and use of home-based records or vaccination cards, we have also explored how cards are used and valued by parents and caregivers. A new blog post on The Pump summarizes what we learned about parents' perspective on these important documents. 

Is there a place for home-based records alongside electronic health records and/or electronic registries?

In some communities, electronic health information systems (a topic discussed here in TechNet periodically and within the Immunization Information Systems Group), including electronic nominal immunization registries, are being implemented. Some believe that electronic health information systems and electronic health records will replace the idea of keeping a physical, paper copy of the home-based record (HBR) that includes the individual's vaccination history and perhaps other recorded primary health care information. Others (myself included) believe that there is a place for physical HBRs to co-exist with electronic health records. It is useful to keep in mind that in many countries, electronic health information systems remain in their infancy. As these systems continue to mature, and perhaps even beyond, a physical HBR system is important to maintain in case the electronic system is interrupted or is not fully functional across an entire country. In some countries, the necessary infrastructure (electricity, connectivity, health worker computer literacy, etc) for a reliable electronic information system remains years away. In other settings, reliable electronic information systems exist, but systems may not be fully interconnected across sub-national units to allow for health information exchange (e.g., a health worker in one state can query and edit records in the electronic system in her state, but she cannot access the information system of a neighbouring state). Health information exchanges between public and private providers, between health agencies and educational departments and schools as well as across national borders are also a challenge in many places. In communities like Monrovia, Liberia where caregivers frequently change healthcare providers in search of high quality care, a physical HBR is a necessary information source for care providers to know what immunization services an individual has and has not received since they will likely not have seen the child before and thus have no existing facility-based record. In Lesotho, where caregivers may take their children into South Africa for healthcare services, a HBR is necessary given the absence of health information systems that communicate seamlessly across national borders between the two countries. And in the United States of America, where electronic immunization registries exist in all states with a range of participation levels and where one-in-five children have visited more than one health provider by the age of two years, HBRs remain an important tool for providers and caregivers in monitoring immunization services received. These issues, and others not noted here, provide a basis for maintaining a physical HBR system while continuing to pursue and improve upon efficient, effective and nationally owned health information systems. So, in response to the question posed in the title to this posting, YES!!! there is a place for HBRs alongside electronic health records and nominal electronic registries.   Please do not forget to visit the TechNet HBR page at www.homebasedrecords.org.    Abstracted from information previously posted by David Brown on http://en.citizendium.org/wiki/Home-based_records.  

Home-based record stock-outs: updated data

A new report has been released that updates information on the occurrence of home-based record (e.g, vaccination cards, child health books) stock-outs. The open access article can be accessed online, and is also attached here. Similar to vaccine stock-outs, disruptions in the supply chain of home-based records (HBRs) are avoidable events that create inefficiencies for immunization service delivery. Several key words there: DISRUPTIONS, AVOIDABLE, INEFFICIENCIES. Following a review of data on HBR stock-outs reported by national immunization programmes, the new report highlights several important themes. First, many programmes confront on-going challenges with ensuring the availability of a durable HBRs in the right place, at the right time and in the right quantity. In 2016, 29 countries reported a national-level HBR stock-out, more than in 2015 or 2014. Second, some programmes appear to not have mechanisms in place to monitor and track the HBR supply chain. During 2016, one-third of countries reporting to WHO failed to report whether a stock-out did or did not occur. Whether countries lack this information; have the information, but not in a readily accessible form for reporting; or are choosing not to report information on supply levels when information exists is unclear. And lastly, HBR financing and printing are complex processes that often involve the national immunization programme and its many partners. In 2016, 44 countries reported two or more HBR funding sources and 22 countries shared responsibility for printing HBRs. It is very possible that these complex financing arrangements may be associated with the occurrence of HBR stock-outs. Immunization programmes are encouraged to take time to evaluate their HBR system along with their partners in the Ministry of Health if immunization and nutrition along with other maternal and/or child health programmes share responsibility. Resources from a prior workshop are available to help guide the evaluation. Let's work together to critically assess the HBR system in each of our countries and identify and implement appropriate, sustainable solutions.

Standardising vaccination (immunization) cards

Dear all Please find the attached example, illustrating the grievous impact of using vaccination cards that are not compatible with the current National Immunization Schedule (NIS). As per the study conducted recently, >10% beneficiaries avail vaccination services from the private sector ranging from clinics to Medical Colleges even in the rural area. Field supervisors / monitors have easy access to such vaccination cards both at the facility level and in the field. Negative impact strikes more than millions of children in the country. This issue can be easily addressed as already happened elsewhere in the country through advocay and supportive supervision. With best wishes Holla n team

A new homepage for home-based records (HBRs) within TechNet

A new area focused on home-based records (HBRs) has been added to TechNet! This new HBR topic area, which can be accessed at https://www.technet-21.org/en/topics/home-base-records or www.homebasedrecords.org, further builds on prior sites aimed at raising awareness of HBRs as critical tool within immunization service delivery and facilitating the exchange of information on HBR design. Presently, around 360 HBRs have been entered into the system from 158 countries. The exchange of HBR design ideas improves with an expanded set of HBRs to view. We encourage everyone, particularly TechNet users at country-level, to add HBRs if they are not currently in the system. A map on the HBR home page helps identify countries with and without HBR submissions. To facilitate viewing HBRs across countries, users can search HBRs by country, WHO region, remit (national or subnational), language as well as physical characteristics such as HBR format, size and type of information included. To further facilitate the exchange of information on the HBR systems, both successes and challenges, links are provided to background material, relevant resources and TechNet forum postings. It is hoped that the TechNet HBR topic area will become a central repository of the evolving knowledge of HBR systems for TechNet users and beyond. We look forward to your contributions! Please share any comments and feedback on the HBR topic area.   HOME-BASED RECORDS. CHECK. KNOW. PROTECT. www.homebasedrecords.org or https://www.technet-21.org/en/topics/home-base-records

Acting locally for achieving globally – HBR for the private sector – INDIA

Dear viewers  For some long standing problems, solution can be very siimple - we have to just do it. For saving the children from the lethal Vaccine Preventable Diseases (VPDs), they are to be vaccinated timely, with all the vaccines included in the National Immunization Schedule (NIS) and also optional vaccines applicable to the country. In India, for attaining Full Immunization (FIC), a child has to receive one dose of BCG, 3 doses of DPT (now included in Pentavalent), 3 doses of bOPV other than Zero OPV and one dose of Measles Containing Vaccine (MCV) before the first birth day. For complete immunization, after attaining FIC, child has to receive DPT 1st Booster and OPV between 16-24 months, with which MCV 2 is administered. Since April 2016; two doses of 0.1ml IPV are administered intradermally along with first & third doses of OPV & Pentavalent. JE / Rota and PCV are administered in selected states / districts. As per “PRACTICAL GUIDE FOR THE DESIGN, USE AND PROMOTION OF HOME BASED RECORDS IN IMMUNIZATION PROGRAMMES” by Immunization, Vaccines and Biologicals – (WHO); home-based records (HBR) currently vary in complexity across and sometimes within countries and lack standardization in content. Please find the attachment for the simplest solution. Best  wishes Holla  

Immunization data quality and use - learning from the field

Greetings, colleagues. With increasing importance on user-focused improvements in routine, administrative immunization data quality and use, it is useful to have some experience-sharing from country learning and implementation. Linked below are a few recent blog posts and an article on in-country review meetings that may be of interest. These include experiences from Zimbabwe, Tanzania, Kenya, Ethiopia, Madagascar and Uganda. 1) Zimbabwe defaulter tracking: http://thepump.jsi.com/community-leaders-use-simple-tools-to-track-immunization-defaulters-in-zimbabwe/ 2) Use of immunization data for local decision-making (including Madagascar example): http://thepump.jsi.com/data-for-decision-making-empowering-local-data-use/ 3) Use of data by health workers in Tanzania: http://thepump.jsi.com/health-workers-improve-service-delivery-and-data-quality-at-a-health-center-in-tanzania/ 4) Home based records and reminder dates (with links to experiences from Ethiopia and Madagascar): http://thepump.jsi.com/how-is-your-memory-due-dates-home-based-records-and-vaccination/ 5) Immunization Review Meetings - capacity building and data quality improvement (examples from Ethiopia, Kenya, Tanzania, and Uganda): http://www.panafrican-med-journal.com/content/series/27/3/21/full/#.WYNRKVWGOUm   We hope that these are helpful to those working with/in countries. Please share. Comments and questions are welcome.   Best regards,

Home-based record revitalization workshop in Africa: report summary

by Dr Blanche ANYA and Dr David BROWN During 21-24 February 2017, representatives from Cameroon, Ethiopia, Liberia, Nigeria, Rwanda and Uganda gathered in Kampala, Uganda to rethink and improve their country’s current home-based record design and functionality as well as the broader system that supports the home-based record to address issues such as stock-outs described previously here. Participants not only walked away from the workshop with a new paper prototype of their improved home-based records (e.g., vaccination card, child health book) and an implementation plan to move forward, but they left the workshop with a conviction that addressing the needs of primary users ensures that the home-based record is valued by, and meaningful to, the intended users while also made available in the right place, at the right time and in the right quantity. Following a user-centered approach, participants of the Africa workshop conducted pre-workshop activities that included health facility visits to talk with and observe caregivers and health workers, as well as to collect information to map out how their home-based records are prepared, produced, distributed and used. Participants brought this information,which was shared across country teams, as input to the cross-country workshop to help the teams think beyond usual assumptions and ground their decisions on actual observations rather than perception. We encourage readers to take a quick read through the final workshop report available below.

Consideration of further refining exisiting SOPs for imaging home-based records during vaccination coverage surveys

Some may be aware that the revised WHO vaccination coverage cluster survey manual encourages consideration of imaging (whether through photographing or handheld scanner) home-based records as part of vaccination coverage survey field work. Within the TechNet resource library there is a standard operating procedure(SOP) that has naturally evolved out of practical needs for survey staff guidance in one national vaccination coverage survey. While the existing SOP provides a starting point, in many ways it falls short. I would like to propose consideration of developing a practical field guide or protocol based on professional expertise in the field of digital imaging and archiving of documents to help guide field-based imaging of home-based records. Such a guide would establish the ideal situation with a recognition of the minimal training that would be available to field staff and the need to photograph under suboptimal conditions (i.e., no tripod, damaged documents, etc). The guide or protocol would establish clear parameters based on best practice while remaining practical to help guide field staff training and evaluation during field work. For example, the current SOP raises awareness of avoiding glare from the sun or artificial light, but it does not provide much more guidance on what to do and may lead someone to photograph indoors where lighting may be suboptimal. In fact, if possible, photographs should be taken in daylight which often may require the document to be taken outside. Similarly, it is often important to avoid placing the document on reflective surfaces which can produce a wash out of the detail (overexposure) and the handwritten information may become less visible on the photograph. The guide would perhaps discuss issues of equipment selection and identify the top five or ten most important considerations for field staff when taking a photograph of a HBR (e.g., lighting, where to focus in order to get a clear image, angle of camera to document, distance of digital camera/smartphone/tablet to document, shooting against a white rather than dark background, turning flash off when photographing a document printed on glossy paper, etc). The guide may also provide trouble shooting advice for those who have to take photographs in poor conditions (e.g., when using the flash in poor lighting conditions, be sure to take photos from a distance of approximately 50 cm). There is a recognition that SOPs for imaging home-based records during vaccination coverage surveys should not become overly technical. The SOP must remain practical for the settings in which it will be used. But, there is some feeling that the SOP should provide more explicit advice and detail than the existing SOP based on professional best practicesin the field of digital imaging and archiving of documents. Beyond this, I certainly hope that there is an active sharing of lessons learned, both good and bad, around imaging home-based records during vaccination coverage surveys here on TechNet.

Nation friendly "Combo" schedule to strengthen national immunization programme

Dear members and viewers of technet For the successful implementation of routine immunization, country should have a specific IMMUNIZATION SCHEDULE. Members of National Technical Advisory Group on Immunization periodically meet and review the progress involving the collaborative development partners and major stakeholders. Generally, there will be one National Immunization Schedule (NIS) so that all the beneficiaries will get the vaccines as per schedule even if they move out of regular residential area or visit different facilities irrespective public sector or private sector within the country. NIS expands to meet the goals and objectives of Global Vaccination Action Plan (GVAP). There can be delay in communicating the revised schedule to all service providers especially to private sector. In India, Indian Association of Pediatricians (IAP) has always played an important role in the immunization programme. However IAP recommended immunization schedule has not one but multiple versions, some times in the same facility especially private Medical Colleges. Often, both, the parents and the facility that provided vaccination service found it very difficult to decipher the vaccines administered. Parents are provided with the “Tayicard”, MCP card and the equivalent by the Govt and the private card with IAP schedule; parents get totally confused and lose faith with both the sectors. ANMs provide vaccination services at the outreach and at planning units (PHC/CHC/Govt Hosp). They expressed that there should be only one immunization schedule for all the vaccines supplied by the Govt which we call as “ESSENTIAL VACCINES – Part A” and other vaccines available in the private sector which we call as “OPTIONAL VACCINES – Part B” as one “combo-card”. This will strengthen the Routine immunization programme of the country and promote child’s health. Keeping this in mind, we critically reviewed the revised IAP schedule, shared our “Draft” observations with a few pediatricians, IAP and local development partners for additional inputs and further revision. The same is attached for sharing with the technet community and viewers for valuable inputs. Regards Holla and the team

Home-based record stock-outs — a quiet problem challenging immunization programmes that needs attention. Is bundling with other vaccine delivery supplies a reasonable solution?

Posting by: David W Brown, Brown Consulting Group International, LLC, North Carolina, USA Marta Gacic-Dobo, World Health Organization, Geneva, Switzerland The WHO and UNICEF recommend that immunization programmes order and supply vaccines bundled with safe-injection equipment (e.g., diluents, auto-disable syringes, reconstitution syringes and safety boxes) to better ensure that AD syringes along with other safe-injection equipment are available together with vaccines in appropriate corresponding quantities at the point of delivery, thereby promoting overall safe injection practice [1]. Overall, the use of bundling vaccines with safe-injection equipment appears to be a success story. As children receive recommended immunization services necessary to be protected from vaccine-preventable diseases, it is important for healthcare workers to deliver and caregivers to keep legibly completed records of the vaccinations that the child receives, particularly given recent increases in the number of vaccinations in recommended immunization schedules and mixed results of caregiver’s ability to accurately recall their child’s vaccination history. Home-based records (HBRs) (e.g., vaccination card, maternal/child health book) are used by health authorities alongside facility-based records, to document an individual’s vaccination history (as well as other primary care services in some countries) and as a communication and information resource to encourage a partnership in the care of the child between the healthcare worker and the caregiver. Not only do HBRs serve as a vehicle for health education to empower caregivers about which primary healthcare services have been received and those which remain outstanding, HBRs (when available and complete), also enhance health professionals’ ability to make appropriate clinical decisions (e.g., which vaccinations have been received already and which vaccinations remain outstanding) and improve continuity of care across providers in the absence of other health records and support public health monitoring efforts, such as in vaccination coverage surveys [2]. However, HBRs are currently unable to fulfil their intended purpose in many communities either because the HBR is not functionally well-designed to serve the needs above, not made available, not fully adopted and/or not appropriately utilized by caregivers and/or health workers. Of particular concern are the occurrence of HBR stock-outs in many countries. According to data reported by national immunization programmes to the WHO and UNICEF, of the more than 140.2 million estimated births during 2015, roughly 9% or estimated 12.4 million children were born in 22 countries reporting a national level HBR stock-out that year. Two-thirds (or 8.3 million) of these children resided in one of 12 countries in the WHO African Region, and more than half (4.8 million) of these children resided in the Democratic Republic of Congo or Kenya. DRC along with Chad, Guinea Bissau and Venezuela has reported HBR stock-outs during 2013, 2014 and 2015. Other countries with large (>500,000) birth cohorts reporting national level stock-outs during 2015 included Philippines, Ghana, Cameroon, Malawi, Chad and Venezuela (overall, five countries reporting HBR stock-outs were from the Western Pacific Region, three from the Region of the Americas and one each from the Eastern Mediterranean and South-East Asia Regions). Two-thirds of the countries reporting HBR stock-outs during 2015 were Gavi-eligible. Information on HBR stock-outs was either not available or not reported by 53 (11 were Gavi-eligible) countries for 2015. These HBR stock-outs are quietly occurring against a back-drop of increased attention to the immunization supply chain [3,4] and need to improve availability and use of data for decision making at all levels of the immunization programme. Unfortunately, there appears to be little attention towards exploring the root causes for why these HBR stock-outs are occurring and what practical steps can be taken to prevent them. Make no mistake, each and every one of these HBR stock-outs — not unlike stock-outs of vaccines — is an avoidable event with proper planning. So, similar to the initial proposal for bundling AD syringes with vaccines, we propose further exploration and consideration of the bundling concept for HBRs to better ensure that HBRs are available at the point of delivery for recording of vaccines delivered. We have previously posted to TechNet to get feedback from our colleagues with expertise in market shaping for vaccines and safe-injection equipment. We reach out again to our colleagues in immunization supply chain to solicit feedback on the feasibility of implementing a bundling policy inclusive of HBRs alongside the vaccines and safe-injection equipment. We see potential benefits, but we also realize that there may be risks and practical challenges, all of which we hope to identify, understand and address. We look forward to learning from our logistician colleagues and your responses! References: 1. World Health Organization. Training for mid-level managers (MLM). Module 1. Cold chain, vaccines and safe-injection equipment management. Geneva, Switzerland: World Health Organization, 2008. Available online at http://whqlibdoc.who.int/hq/2008/WHO_IVB_08.01_eng.pdf Accessed 21 October 2016. 2. World Health Organization. Practical Guide for Home-based Records in Immunization Programmes. Geneva, Switzerland: World Health Organization, 2015. Available online at http://apps.who.int/iris/bitstream/10665/175905/2/WHO_IVB_15.05_eng.pdf . Accessed 21 October 2016. 3. UNICEF. Immunization Supply Chain Strengthening. October 2015. Available online at http://www.unicef.org/supply/files/1_-_iSC_Introduction_20151026.pdf . Accessed 21 October 2016. 4. Gavi, the Vaccine Alliance. Gavi Immunization Supply Chain Strategy. Available online at http://www.gavi.org/library/publications/gavi-fact-sheets/gavi-supply-chain-strategy/ . Accessed 21 October 2016.

Annotated bibliography on home-based records

The function and importance of home-based records (HBRs) in immunization service delivery has been described and practical guidelines for HBR design released by the WHO (http://www.who.int/immunization/monitoring_surveillance/routine/homebasedrecords/en/). The annotated bibliography attached here attempted to bring together available literature on home-based records as a form of personal health record supportive of primary health care including literature describing corrective interventions as well as studies demonstrating impact of home-based records on behaviour, knowledge or health service utilization. Perhaps unsurprisingly, the existing literature describing interventions to improve the availability, retention and/or appropriate utilization of personal health records, in general, and home-based vaccination records more specifically, continues to mature. General findings that may be of interest follow. The literature review found little evidence related to the design of effective home-based records and on effective strategies to improve and/or maintain high levels of availability, retention and appropriate utilization of home-based records in primary health care. The few intervention studies that were identified were riddled by unclear evidence and lacking with regards to selection of controls against which intervention groups were compared. The review found that while caregiver-centric interventions are becoming more fundamentally accepted as an important approach, to-date only provisional steps have been taken to improve our understanding of how caregivers engage with the home-based records as a part of the primary health care system. The lack of a developed business case around home-based records and their potential role in improving the cost effectiveness of child survival interventions such as immunization services may hinder activity to improve widespread adoption and utilization. Among the several identified intervention studies, none included an economic evaluation. Attention is needed to explore opportunities on the supply side and potential solutions to supply challenges such as bundling with other commodities in the immunization supply chain and innovative market shaping of design and production systems. While the available evidence reveals more questions than answers, opportunities abound for developing and implementing innovative solutions to improve the effectiveness and impact of home-based records as a form of personal health record supportive of primary health care. This bibliography is meant to be a dynamic document that will be updated moving forward. If you are aware of operational research that resides in the peer-review or grey literature that is not noted in the bibliography, please share by way of reply to this posting.

Immunization card - "A Template" for private practitioners.

A week before (on 28-05-2015) when a couple came with an immunization card developed in a tertiary care centre which created confusion as to what all vaccines thier child should receive made Sampaje team to evolve a user frindly immunization card. This card is evolved considering National Immunization Schedule of India, Karntaka specific, also keeping in mind the candidate vaccines anounced by the Govt (Rotavirus vaccine and Injectable Polio Vaccine one dose with third dose of OPV/Pentavalent) and Table 1: Summary of WHO Position Papers - Recommendations for Routine Immunization. The prototype developed was shared with stakeholders for additional inputs. However with the help of post graduate students, local health care providers we could almost fine tune and posting now for use by the needy service providers. There is always scope for improving hence this may be firther fine tuned by the stake holders.

Help us develop a thesaurus of terms used for Home-based Records around the world.

A home-based vaccination record is a document (more often physical rather than electronic) --- issued by an official authority (may be sub-national or national) to an individual person and maintained in the household by an individual or individual’s caregiver (e.g., mother, father, grandparent, etc) --- on which an individual’s vaccination history (vaccine received, date vaccine received) or status is recorded by a health worker. In some places, the home-based record is referred to by the following English terms: • vaccination or immunization card • vaccination or immunization record • vaccination (history) or immunization (history) record • child health book • infant health book • child health record • well baby book We are currently developing a thesaurus of terms used across countries in the respective local context (with English translation where available and necessary) for referring to home-based records in all member states. For example, in Angola, the home-based record is referred to as the cartão de saúde infantil or child health card. In Japan, the home-based record is referred to by Boshi Techo, or handbook of mothers and children. It is hoped that the population of this thesaurus will facilitate better communication around home-based records when interacting with immunization and child health programmes at the country level by partners including DHS and MICS survey coordinators. To complete the 4 question form, visit http://bit.do/HBR-names. Concerns and / or corrections are always welcomed and can be communicated to David BROWN at dbrown@unicef.org.

Leveraging delivery of immunization services through schools to motivate improved current ownership of home-based records – an opportunity to further explore

Current ownership of home-based records for recording vaccinations is far too low in many countries. One possible means towards motivating caregivers to retain home-based records through the first year of a child’s life and beyond is to link documentation of a child’s vaccination history to school entry. Using data from 35 countries that conducted a Demographic and Health Survey during 2010–2013, we observed that countries delivering immunization services through schools had a higher median current home-based record prevalence among children aged 12–23 months than countries that did not deliver immunization through schools. This ecological study suggests further exploration of the potential benefits of requiring documentation of vaccination history at the time of school entry as one mechanism for motivating improved home-based record ownership and maintenance may be warranted. The attached white paper describes in more detail what was observed. Constructive comments welcomed.

Home-based records and market shaping opportunities moving forward

Home-base records constitute an inexpensive yet effective instrument for systematically documenting the immunization services received by an individual. A revitalized discussion of home-based records is taking place against the backdrop of a dynamic environment with new vaccine introductions that is also dealing with increasingly scarce health resources (human and financial), demographic shifts and calls for improved data quality including more frequent independent validation of immunization coverage through representative population-based household surveys (e.g., EPI cluster surveys, Demographic and Health Surveys, Multiple Indicator Cluster Surveys) to which home-based records are critical for obtaining documented evidence on vaccination history. While these discussions largely centre on gaining a better understanding of the factors related to whether records are made available to caregivers and low levels of retention in the household by caregivers, there is the need for a parallel discussion around how national immunization programmes might collectively ensure the variety of their needs with respect to procuring (perhaps (re-)designing as well) home-based records for their respective annual birth cohorts is matched by a diverse arena of support within a broad market capable of meeting those needs with appropriate quality and efficiency considerations. The market demand for home-based records is fairly stable, at least on a year-to-year basis. Each and every year, national immunization programmes are charged with vaccinating an annual birth cohort (as well as vaccinating individuals at older ages) with a series of vaccinations recommended by the World Health Organization. During 2014, the estimated global birth cohort totalled nearly 140 million newborns and in theory (if all programmes were using physical rather than electronic home-based records), one would expect national immunization programmes to have procured at least this many home-based records with additions for records that may have been lost or destroyed. This level of demand (in theory) begs the question, are there opportunities at hand for groups of national immunization programmes, either regionally or sub-regionally, to either pool resources to procure durable, high-quality home-based vaccination records at the lowest price --- not unlike what has been accomplished for vaccines by the Revolving Fund of the Pan American Health Organization for countries in the Americas or by Gavi, the Vaccine Alliance for low-income countries --- or to leverage (sub-)regional markets in a more effective manner? There is a growing understanding of the challenges that many national immunization programmes are routinely confronted with, such as sub-optimal home-based record designs that may impact on the function of the document, lacking awareness of or access to more durable options that could extend the life of a home-based record as well as complex multi-partner financing of home-based records. These issues are further complicated by lacking authority and decision-making power by some national immunization programmes over their own budgets, in particular how much is or is not spent on recording and monitoring of the immunization services their programme delivers. Market shaping around home-based records may serve as a key enabler for ensuring national immunization programmes can exercise choice and control over a meaningful range of high quality options that meet their needs and aspirations. At present, there is little if any coordination across countries with regards to the production or procurement of home-based vaccination records. Certainly on one hand the lack of coordination can be understood since, unlike syringes or cotton swabs, substantial variations currently exist in home-based vaccination record content and design across countries. But, this does not have to be the case. Even if the variation remains, there may be advantages to coordinating efforts across countries with regards to accessing durable, water-resistant paper options or design/print services. Moving forward, ensuring access to a stable supply of durable, high quality and affordable home-based records by all national immunization programmes is seemingly important and it will be critical to leverage the resources of global, regional and national partners as well as the experience of supply chain specialists and others with insights and experience in the market for immunization-related supplies. With an awareness of the successes, challenges, and lessons learned from market shaping around vaccines as well as in other areas, a vision that encompasses regional coordinating groups to stimulate, manage and shape markets for home-based vaccination records with the full engagement of the national immunization programmes from within the (sub-)regions seems within reach. The success of such market shaping will rely on strong partnerships and shared risks as well as a willingness by national immunization programmes to take the lead in a proactive and coordinated manner. To those with much more expertise in the successes and failures of market shaping exercises that have taken place around vaccines and delivery equipment, I ask, what are your thoughts on the lessons learned that may be relevant for addressing this issue for home-based records?

Home-based vaccination records

Posted by: David Brown UNICEF / Marta Gacic Dobo WHO All too often overlooked, the home-based vaccination record maintains a central role in documenting immunization services received across the lifespan. WHO and UNICEF are working to heighten awareness of the importance of the home-based vaccination record as a means to foster coordination and continuity across service providers, facilitate communication between service providers and parents, empower parents in their child’s healthcare, and to support public health monitoring. To this end, a website, immunizationcards.org, has been established to facilitate the free and open exchange of information related to home-based vaccination record content and design. In addition, a blog has been established, http://moot.it/immunizationrecords, for people to share experiences related to improving the availability, utilization and retention of home-based vaccination records and experiences related to the revision and update of home-based vaccination records. Finally we share several papers that discuss home-based vaccination records further. Brown DW. Child immunization cards: essential yet underutilized in national immunization programmes. Open Vaccine J 2012;5:1-7. Available online at http://www.benthamscience.com/open/tovacj/articles/V005/1TOVACJ.pdf Brown DW, Gacic-Dobo M, Young SL. Home-based vaccination records – A reflection on form. Vaccine 2014; http://dx.doi.org/10.1016/j.vaccine.2014.01.098" target="_blank">http://dx.doi.org/10.1016/j.vaccine.2014.01.098 " target="_blank">http://dx.doi.org/10.1016/j.vaccine.2014.01.098
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