1 | Status of implementation of recommendations from the 4 th African Regional Measles & Rubella TAG Meeting 5 th African Regional Measles & Rubella TAG Meeting 5 th African Regional Measles & Rubella TAG Meeting Nairobi, 2 – 3 June 2015

2 | Summary of Recommendations I.National ownership and resource mobilization (5) II.Aligning &updating policies / guidelines (3) III.Tailoring the implementation of strategies (8)

3 | I.National ownership and resource mobilization 1. … countries that have not yet updated or finalized their measles elimination strategic plans are urged to do so, in alignment with their comprehensive Multi-year plans (cMYPs) and the national health sector plans. (Countries – end March 2014)  Thirty six (36) of the 47 countries have developed strategic plans for measles elimination, at least 3 have drafts,  The remaining (Central African Republic, Equatorial Guinea, Gabon, Sao Tome and Principe, Comoros, Malawi, Mozambique, South Africa, Tanzania) have updated their most recent cMYPs to reflect the major activities related to measles elimination including the organization of measles campaigns and the introduction of MCV2 and MR in routine vaccination schedules.

4 | 2. MRI to use every available opportunity to intensify advocacy towards stronger national ownership and sustainable financing of measles elimination plans, including but not limited to:  the Ministerial conference on the Global Vaccine Action Plan (GVAP) implementation in the African region in June 2014,  the commemoration of the African Vaccination week  the 40 th anniversary of the launch of the Expanded Program on Immunisation  global and regional fora for the evaluation of progress towards the Millennium Development Goals (MDGs). I.National ownership and resource mobilization

5 | 2. …  Various opportunities have been used for advocacy within the Region, and within individual countries, including the African Vaccination Week. The Ministerial conference on GVAP was postponed.  The EPI Managers’ meetings and country level advocacy visits for measles elimination activities have been used as platforms to advocate for national ownership and sustainable financing of measles elimination plans I. National ownership and resource mobilization

6 | I. National ownership and resource mobilization 3. The MRI to work together with other major donors and potential new partner agencies to streamline and improve the coordination of funding, vaccine forecasting and logistics inputs as well as technical support to countries.  Annual vaccine forecasting and coordination meetings are taking place with the participation of all partners - hosted by UNICEF SD.  Regular and frequent exchanges with the GAVI secretariat have managed to close the gap with regards to the activity plans at country level, and to coordinate the timing of GAVI applications.  The GAVI sub regional working group meetings have been used in the past couple of years to discuss measles elimination – with a regular standing agenda.

7 | I. National ownership and resource mobilization 4. Countries, WHO AFRO and regional partners should identify, advocate with and engage potential donors and civil society organisations from within countries and within the Region, in order to diversify their resource mobilisation base, and foster stronger partnerships within countries in the efforts towards measles elimination and rubella vaccine introduction.  There are recent attempts, which are ongoing, to reach out to WAHO/ ECOWAS. A project proposal was developed and is being circulated at AFRO level before submission.

8 | I. National ownership and resource mobilization 5. The TAG notes with concern the limited partner funding available for measles-rubella surveillance and lab network, and is concerned about the continued heavy dependence on funding from the Global Polio Eradication Initiative for disease surveillance in the Region. …TAG requests countries to increase their funding support towards the case-based and lab surveillance systems; … requests Gavi, BMGF and other donors and partners to support the measles and rubella lab network and surveillance activities in the Region.

9 | I. National ownership and resource mobilization 5. …  BMGF has been providing support for lab and surveillance activities through specific grants.  AFRO is currently working on a project proposal to work with ECOWAS in 15 Western African countries.  The issue of having countries increasing their funding support have been addressed during EPI Managers’ meeting and progress is to be monitored regularly.

10 | II.Aligning and updating policies and guidelines 6. … availability of new vaccines, expanded delivery strategies and opportunities, as well as updated guidance from the global and regional advisory bodies, the TAG recommends that all countries regularly update national immunization policy documents, working together with NITAGs or other relevant national advisory bodies. WHO AFRO and HQ to provide the necessary technical support.

11 | II.Aligning and updating policies and guidelines 6… A Review of immunization policy was recently conducted at Regional level to help in these efforts. WHO AFRO/ IST provided policy guidance to:  All countries going for MCV2 and / or MR introduction  Namibia and Botswana on issues related to the choice of vaccine formulations (esp MR vs MMR), and mode of introduction.  The pediatric societies in Botswana and Zimbabwe, as well as the Kenya Measles TAG were involved in local decisions to introduce MCV2 and to apply for MR.  A recent Regional meeting has drawn the way forward with regards to the setting up and support to NITAGs in the Member States, since most of the countries do not have one at the moment.

12 | II.Aligning and updating policies and guidelines 7. WHO AFRO should review the most recent recommendations from the Strategic Advisory Group of Experts (SAGE) from November 2013, especially on:  the use of measles –rubella (MR) vaccine in the first and second doses provided in the routine measles immunization schedule,  the mandatory vaccination of health workers  the recording of all measles doses received during supplemental immunization activities (SIAs) and devise ways to guide countries towards the operationalization of these recommendations within the African context.

13 | II.Aligning and updating policies and guidelines 7…  Countries introducing MR and MCV2 were guided appropriately using various fora on the best approach regarding the first and second doses.  Some countries are showing reluctance to introduce MR given the fact that GAVI support for MR introduction into routine immunization services is limited to a grant for introduction activities, and financing Measles component cost of MR vaccine for the second dose  WHO AFRO is also advising countries on the vaccination of health workers, especially in outbreak response activities, and a few countries have already included this into their policy documents. However, this is not yet implemented systematically in all countries, esp in IST W.  The recording of SIAs doses will need further discussion regarding operationalization.

14 | II.Aligning and updating policies and guidelines 8. WHO AFRO is requested to update its generic Regional guidelines and tools for the implementation of measles elimination strategies ( eg., SIAs, surveillance), ensuring that the best practices from the Region are incorporated, and provide guidance for all countries to standardize their approach including, but not limited to:  efforts to identify and implement local best practices in the implementation of strategies,  the implementation of house-to-house mobilization before and during SIAs in priority areas  efforts to develop specific and focused strategies to optimise routine immunization and SIAs coverage in large urban and peri-urban areas  the factors to consider in the determination of the target age group for follow up SIAs  systematic approaches to utilize the opportunity of SIAs planning, preparation and implementation to reinforce efforts to strengthen routine immunization systems  ensuring that standard coverage surveys are done following all SIAs by individuals or bodies independent of the implementation of SIAs.

15 | II.Aligning and updating policies and guidelines 8...  The Regional measles and rubella surveillance guideline was finalized and has been disseminated to countries.  Final edits remaining on the updated Regional SIAs preparation and implementation field guide, which has accommodated the above points.  Post campaign coverage surveys are done by bodies independent of the implementation of SIAs in almost all countries.

16 | III.Tailoring the implementation of strategies 9….high routine immunization coverage (1 st & 2 nd dose of MCV) is imperative to reach the measles elimination targets and in view of the current coverage stagnation in the region, the TAG recommends that WHO/AFRO and partners provide adequate support to countries to:  implement the Reaching Every District (RED) approach systematically  to conduct operational research into the reasons for stagnating coverage (particularly in view of the wide diversity at subnational levels within the large countries)  to plan appropriate responses based on local evidence

17 | III.Tailoring the implementation of strategies 9…implement the Reaching Every District (RED) approach systematically The 64 th session of the WHO Regional Committee (Nov. 2014) endorsed the Regional Strategic Plan for Immunization: The document reiterates the central role of the Reaching Every District (RED) strategy as a key implementation approach and the use of other locally tailored approaches to maximize accessibility and utilization of immunization services. The strategic plan further stresses the need to move from reaching every district to reaching every child with priority given to hard-to- reach and marginalized populations.

18 | III.Tailoring the implementation of strategies 9… implement the Reaching Every District (RED) approach systematically AFRO in collaboration with its partners has continued to provide technical & financial support to countries with a specific focus in countries with the highest number of unimmunized children (Nigeria, Ethiopia, Uganda, DR Congo & Chad) by supporting the development and implementation of specific strategies aiming at filling the population immunity gaps in an equitable manner. As a result, most of those countries have reduced the number of un-immunized from 2013 to Country # unvaccinated for measles in 2013 # unvaccinated for measles in 2014 MCV1 coverage 2013 MCV1 coverage 2014 Chad 104, ,880 79% DR Congo 340, ,851 88%89% Ethiopia 658, ,755 78%84% Nigeria 1,883,978 1,853,747 73% Uganda 45,394 62,342 97%96%

19 | III.Tailoring the implementation of strategies 9…to conduct operational research into the reasons for stagnating coverage (particularly in view of the wide diversity at subnational levels within the large countries)  AFRO provided technical and financial support to conduct two studies in Angola and Uganda. These studies are “Community Linkages with Health Services: Implications for immunization uptake among community members in Luanda”, and “Reasons for vaccine refusal in Uganda”.  Other studies are on-going in Kenya (factors contributing to low immunization services uptake amongst the hard to reach population) and Nigeria (Assessing community and health services linkages and its implication for immunization uptake in Kano State, Nigeria). Chad is undertaking a study of reasons for non-vaccination and stagnation in coverage.  Two other studies (planned to be implemented in Uganda, in a collaboration of the WHO country office and University researchers) are currently undergoing review for ethical clearance under the WHO/AFRO ethical Review Committee.  “Assessment of immunization coverage data quality and validity”  “Assessment of the impact of the implementation of mutual expectations of health-care workers (HCWs) and the community on immunization coverage”

20 | III.Tailoring the implementation of strategies 9… to plan appropriate responses based on local evidence Results of these studies are currently been used in the development of these countries CMYP and annual plan to improve vaccine uptake

21 | III.Tailoring the implementation of strategies 10. WHO and partners are requested to support countries to develop stronger links with national professional societies (e.g., nursing, medical, public health, pediatrics, and other societies) and with academia in order to further support the capacity building, advocacy, and research efforts related to measles elimination and rubella/ congenital rubella syndrome (CRS) control, and immunization in general.  DRC, Kenya, Zimbabwe, Burundi, Ethiopia have good track record of engaging the national medical and public health professional associations. In DRC, pediatric society members have been involved in the ICC, and in advocacy and supervision of measles campaigns.  National professional societies are part of ICC technical committees or NITAGs in a number of countries. Civil and professional societies (eg. Pediatricians and nurses) are involved at regional and country level in many countries for the planning, implementation, monitoring and financing of immunization activities; more focus may be requested on measles and rubella elimination activities

22 | III.Tailoring the implementation of strategies 11. WHO and partners are requested to ensure that high quality technical support to countries preparing to submit GAVI applications for the introduction of MCV2 and MR vaccine, followed by pre-introduction assessments, post-Introduction evaluation and validation surveys as appropriate.  A workshop was conducted by IST ESA in Dec 2014 to guide countries expecting to apply to GAVI, where they were taken through the application process, introduction provided to the technical documents.  Country specific technical assistance was provided to STP, Burundi, Burkina Faso for MCV2 introduction, and to Cameroon for MR application. MCV2 PIE activities were conducted in BUR, STP, ERI, ZAM, KEN in 2014 – May 2015.

23 | III.Tailoring the implementation of strategies 12. Countries conducting measles and MR SIAs should routinely utilize the WHO recommended pre-campaign and intra-campaign monitoring mechanisms and process monitoring indicators in order to ensure high quality SIAs outcomes.  Intra-campaign monitoring has been a standard element in SIAs planning. Nearly all SIAs utilize some form of Rapid Convenience Monitoring. Most are using the standard 20 households/ 20 children method that has been advocated as RCM, while a few (eg Nigeria) use the PEI method of in-house and out-of-house in-process and end-process monitoring.

24 | III.Tailoring the implementation of strategies  Mauritania, Eritrea and Tanzania introduced and implemented the campaign readiness assessment tool in Measles SIAs in 2014/  Not properly launched in Mauritania owing to the 4 large SIAs (polio NIDs, Measles SIAs, meningitis preventive campaigns) within a space of 3 months  Implementation was not very structured, tools were utilized only by the WHO consultants and was not used by the national authorities  There were gaps and incomplete capture of information.  better preparation needed to ensure that the tool is well utilized  Poor preparation and implementation reported in Eritrea as well.  Namibia, Uganda, Zimbabwe have planned to use the SIAs readiness assessment tool while Ethiopia opted to use their own dashboard for 2015.

25 | III.Tailoring the implementation of strategies 13. … consistently weak performance of measles CBS in certain countries particularly when these countries have proven their capacity to attain high quality AFP surveillance performance. WHO and partners should support countries with measles surveillance performance gaps to conduct in-depth reviews to identify and address barriers that prevent the attainment of sensitive measles and rubella surveillance. Surveillance reviews were conducted as part of a stand-alone exercise or as a component of integrated reviews done in  5 countries in IST C in 2014,  4 countries in IST ESA (Lesotho, Rwanda & Zambia, and in Q in Uganda). Plans are underway to do reviews in Tanzania and Malawi before end of Q  IST W- All activities were postponed given the emergency response to the EVD outbreak. However, the IST is planning to conduct in-depth reviews in Algeria, Cape Verde, Guinea Bissau and Mali in Desk reviews to be conducted in Benin, Ghana and Niger.

26 | III.Tailoring the implementation of strategies 14. Considering the current fragility of the measles/ MR vaccine market and the necessity for robust forecasting of needs across the Region and beyond, countries planning to conduct measles/ MR SIAs in a particular year are urged to finalise and submit to the MRI their SIAs plans endorsed by the respective Inter-Agency Coordination Committees (ICC) by June of the year preceding the scheduled SIAs.  Getting plan documents earlier has been a huge challenge in 2014 owing to a number of factors, one of which was the absence of key WHO staff due to deployment to EVD affected countries. POAs still outstanding for 2015 SIAs from 3 countries.  The submission of country applications to GAVI has been taking a parallel track in a few countries, with very little inputs from the WHO and UNICEF teams in country/ IST/ ROs, and so requires better coordination in future.

27 | III.Tailoring the implementation of strategies 15. All MRI partners should comply with the standards for high quality SIAs, respecting the WHO recommended minimum period of 9 months for the preparation of SIAs, and ensure to support countries accordingly, including the timely release of funds to enable high quality and early preparations.  This has been a challenge to implement rigorously in all SIAs, especially with the delays in mobilizing AND channeling funds to countries for key preparatory activities.

28 | III.Tailoring the implementation of strategies 16. The TAG endorses the African Regional Measles Elimination Strategic plan (2012 – 2020), and requests MRI partner agencies to support the implementation of the plan in the region.  WHO AFRO is implementing this plan, and has ensured that it has been adequately reflected and incorporated into the Regional Strategic Plan for Immunisation: , which was approved by the RC in Sept 2014.