1. 1 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 New tools and strategies for maternal and neonatal tetanus and measles/rubella elimination - Objectives Highlight tools and strategies for getting back on track for GVAP tetanus and measles/rubella elimination goals Guidelines and tools – MNTE pre-validation “high-risk” assessment guidelines – Programme risk assessment tool – Global guidelines for conducting SIAs with injectable vaccines (including SIA readiness assessment tool)

2. 2 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 New tools and strategies for maternal and neonatal tetanus and measles/rubella elimination– Issues Discussed High-risk MNTE approach – Immunize ALL women of reproductive age in high and medium risk areas – Risk assessment – Core Indicators: Neonatal Tetanus (NT) rate, Access to skilled birth attendants (SBA), TT2+ / PAB coverage rate Surrogate indicators: Antenatal Care (ANC1 & ANC4), Penta/DTP coverage (DTP1 and DTP3), Human Development Index – High Risk districts: 3 rounds 0, 1, 6 months – Medium Risk districts: 2 rounds 0, 1 month

3. Algorithm – to determine NT risk status Is NT rate < 1/1000 LB ? No High Risk Yes Is district NT surveillance sensitive 1 ? Yes Low Risk No Is reported district clean delivery 2 coverage ≥ 70%? Low Risk YesNo Is TT2+/PAB coverage ≥ 80% from routine among pregnant women (or child-bearing aged women in past 5 years) or SIAs (in all 3 rounds)? Low Risk Yes No High Risk 1. Sensitive = a. existence of zero reporting; b. completeness of reporting from all reporting sites ≥ 80%; c. adequate number/distribution of reporting sites (subjective judgement); d. conduct of record reviews at least once annually or active surveillance in local hospital(s); e. if rural, functional community surveillance (subjective judgement); f. detection of neonatal deaths. 2. Defined as delivery by a physician, nurse or trained midwife. MNTE

4. Risk Assessment to continue – even after completion of activities 1. Review progress and reassess the risk If country claims that all activities completed 2. Pre-validation Assessment 3. Send request to WHO for Validation Passed LQA Survey Gaps – go for corrective action Reassess 4. Celebrate & Sustain !!! Passed Identify and bridge gaps MNTE Failed

5. 5 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 Strategies to sustain MNTE Achieved MNTE without Td SIAs o maintain more than 80% TT/Td at sub national (RED/REC) o &/or increase and maintain more than 70% clean delivery Conducted focused TT/Td SIAs in <20% of districts o annual review of district performance to identify medium and high risk districts o use opportunities such as CHDs/MCHW, PIRI, cMYP planning to increase TdCV Conducted large scale TT SIAs o annual review of district performance to identify medium and high risk districts o conducting corrective SIAs & using opportunities such as CHDs/MCHW, PIRI, cMYP o strengthen surveillance including community based surveillance

6. 6 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 New tools and strategies for maternal and neonatal tetanus and measles/rubella elimination– Issues Discussed Measles Risk Assessment Tool – New tool for assessing measles programmatic risk at district level – Uses a combination of factors/indicators of risk, including vaccination coverage – Can help identify at-risk areas for prioritizing programmatic activities – Able to show variation in risk among districts Not for predicting outbreaks but rather for preventing them To guide and prioritize programmatic action, e.g., – Annual updates to monitor progress, supplemental immunization activity (SIA) planning, outbreak response immunization (ORI) planning, measles case-based surveillance reviews and routine immunization (EPI) reviews, supervisory visits, advocacy and resource mobilization

7. 7 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 Measles Programmatic Risk Assessment – Maximum Risk Points for Each Category Range of possible scores: 0-100 *Each category has a list of indicators with various cut-off criteria to assign risk points District-level risk calculated based on data inputs in 4 main categories:

8. 8 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 Measles programmatic risk assessments Zimbabwe Senegal Namibia Philippines Shan Dong Province China Nepal Laos Sudan Uttarakhand State, India

9. 9 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 Comparison of Measles SIA Administrative vs. Survey Coverage, African Region, 2011-2013

10. 10 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 New tools and strategies for maternal and neonatal tetanus and measles/rubella elimination– Issues Discussed SIA Field Guide: Reaching the 5 th Child Systems approach to SIAs – A-Z guide for planning, implementing, monitoring and evaluating all SIAs with injectable vaccines – SIAs as opportunities for RI strengthening Focus on reaching the hard to reach – Identification of hard to reach/high risk groups – Vaccination strategies for the hard to reach/high risk group Improve monitoring and data quality – Use of vaccination cards – SIA preparedness assessment guide – Revised RCM – Post SIA evaluation Emphasis on integration (M and R, other health intervention) etc.

11. 11 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 SIA Preparedness Assessment Tool – National Level

12. 12 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 New tools and strategies for maternal and neonatal tetanus and measles/rubella elimination – Issues discussed Measles SIA guide, con’t – Preparedness assessment to guide preparation of SIAs and for corrective action Assessing preparation essential to ensuring quality campaign Helpful motivational tool Takes a snapshot of state of preparation at different points in time, and “quantifies” the level of preparedness against the expected activities at that point in time Experience from AFRO (Tanzania, Eritrea, Mauritania) and Afghanistan –Local adaptation and context –Structured visits useful; may need to limited to high risk districts Linking to MCV2 introduction (incorporating messages into SIA training) and checklist

13. 13 | Global Immunization Meeting: PIA Sitges, 23-25 June 2015 New tools and strategies for maternal and neonatal tetanus and measles/rubella elimination – Recommendations/Next Steps MNTE – Continue use of High Risk Strategy in countries prior to elimination validation – After validation, continue periodic review of risk w using risk assessment tool and implement corrective measures where necessary to sustain MNT elimination status Measles risk assessment tool – Review utility of risk assessment tool after several years version 2.0 – include more RI indicators, regional risk (beyond immediate borders) – Continue practice of doing population susceptibility profile (accumulation of susceptibles) – If possible, use tool annually at country level to determine high-risk districts – Use tool for RVC to document district-level status over time – Use tool as broader diagnostic check on EPI program SIA field guide – Continue w pilots and roll out of elements of different elements field guide – Campaign preparedness tool : Early introduction, local adaptation, technical assistance; use as part of regular reporting to ICC and partners; use as national management tool Connection with polio strategies; use as readiness vs assessment guide