Implementing Nationwide Measles Supplemental Immunization Activities in Ethiopia in the Context of COVID-19: Process and Lessons Learnt

"Very good turnout was reported in many places starting from the first day of the SIAs. There was no major challenge reported with regards to hesitancy against the SIAs."

The COVID-19 pandemic has disrupted immunisation activities in many countries, such as by forcing the postponement of scheduled supplemental immunisation activities (SIAs). Following the declaration of the pandemic, Ethiopia postponed a nationwide follow-up measles preventive vaccination campaign that was scheduled for April 2020. This article documents the process undertaken by the Federal Ministry of Health (FMoH) to implement the SIAs within the context of COVID-19, and the outcomes thereof. The summary below focuses on the communication-related elements of the process.

In May 2020, the FMoH held several consultations with the Secretariat of the National COVID-19 Pandemic Prevention and Control Ministerial Coordination Committee, the Regional Health Bureaus, immunisation technical partners, the National Immunization Technical Advisory Group (NITAG), and other senior health authorities about the risks for measles outbreaks, the modelling of the impact of COVID-19 on child mortality, and the requirements to conduct measles SIAs safely. On May 15 2020, the NITAG recommended that the nationwide measles SIAs be conducted in order to prevent outbreaks.

As per World Health Organization (WHO) recommendations, the following key elements were put in place:

• Evaluation of the country's capacity to implement a mass vaccination campaign safely and effectively under the strain of COVID-19;
• Listing of actions to be taken to conduct high-quality and safe vaccination campaigns without undue harm to health workers and the community;
• Efforts to understand the demand of the community in the midst of COVID-19 and the need to engage community leaders in the planning and implementation;
• Coordination with the COVID-19 task force to reflect on the strategies that need to be applied to infection prevention and control (IPC) measures;
• Assurance of the availability of adequate IPC supplies, including personal protective equipment (PPE) for mitigation of COVID-19 transmission;
• Training of health workers and volunteers to strictly adhere to IPC recommendations while organising vaccination sites and during vaccination; and
• Confirmation that a strong and effective supervision and monitoring mechanism is in place at all levels.

Taking these points into consideration, preparatory activities were conducted, such as the following around communication and social mobilisation:

• Briefings by local health authorities and health workers, messages from religious and community leaders, and spot announcements were broadcast via major television, FM radio, and community radio channels. These were aired starting 5 days before the start of the SIAs and throughout the duration of the SIAs.
• Media briefings were provided on the need to maintain essential services by FMoH leadership. For example, the FMoH director and immunisation programme manager appeared on national radio and television channels and provided messages on the SIAs. All of the regions used local media extensively to provide similar messages. Broadcasted massages included announcements on the nature, the dates, and age range for the campaign, as well as precautionary measures to be taken by clients at the vaccination site.
• National-level leadership developed posters and brochures in 4 local languages and distributed them to the regions.
• The composition of the vaccination team was revised to include a total of six persons (three health workers and three volunteers), including one who was added to the team to handle COVID-19 screening and awareness raising.

Once the campaign started, town criers mobilised communities by moving across villages using megaphones. Community and religious leaders, as well as members of the health development team and volunteer youth, undertook grassroots social mobilisation, transported bundled vaccines, communicated the need to maintain physical distancing at service delivery posts, prepared the handwashing setup, and encouraged clients to wash hands.

In most cases, printed mobilisation materials (posters and brochures), as well as bundled vaccines, monitoring tools, facemasks, and hand sanitizers, were distributed as a package based on micro-plans. The distribution took place in the last half of June 2020, and started from remote woredas to facilitate logistics and avoid possible disruptions with the rainy season. Five regions (Amhara, Afar, Benshangul Gumuz, Tigray, and Gambella) launched the campaign as per schedule on June 30 2020; the rest of the regions delayed their starting date from 3-7 days for various reasons. Coverage ranged from 95.2% of the target in Harari region to 126% in Addis Ababa.

Despite what the organisers consider to be the nationwide campaign's clear success, there were some challenges, such as an internet shutdown following political unrest that occurred over the 10-day period of the SIAs. This shutdown interrupted both the mass mobile messaging platforms (on Telegram group messaging App) that were set up for the coordination of the SIAs and the real-time mobile supervisory data capture system (using One Data Kit software). As reported here, most of the challenges were overcome through regular communication and coordination between the different levels, as well as proactive leadership and coordination from the federal level. For example, in the absence of internet connection, the immunisation programme managers at all levels and the vaccination teams utilised short text messaging services (SMS) and telephone calls to coordinate and share administrative coverage data and other information on the conduct of the SIAs.

Factors that facilitated the nationwide measles SIAs included:

• A risk-benefit analysis based on available evidence, which led to an informed decision;
• Wide consultation among stakeholders (e.g., the NITAG and partner agencies), which helped to gain overall support;
• Strong commitment of the political-administrative leadership, public health leaders, and health workers;
• Assurance of strong public demand through multi-channel communication, social mobilisation, and community engagement;
• Timely partner support to mobilise additional resources, which helped support COVID-19 prevention activities;
• Efforts to prevent congestion during the mass vaccination exercise (e.g., by adopting a mobile-fixed approach where vaccinators move their posts to get closer to settlements on different days);
• The availability of digital communication to conduct technical consultations, trainings, coordination with partners and stakeholders, and coordination and communication with teams in the field; and
• The availability of adequate PPE and IPC supplies.

In conclusion: "The measles SIAs has helped to put the routine immunization system high on the agenda at all levels, and to revitalize task forces. The SIAs mobilized a considerable number of health workers and community volunteers who were not actively engaged due to COVID-19 related state of emergency. The bottom-up micro-planning helped to map all villages and demarcate catchment areas, for later use in the routine immunization system. The SIAs training was an opportunity to improve knowledge, skill and practice of health workers....The SIAs reached a considerable number of children who were not vaccinated before."