Question #1. Should Harmonia conduct an EPI survey early next year? What are your considerations?

Based on the options available as outlined in the detailed paper, Option 2 of conducting an EPI survey early next year seems appropriate and in fact a priority, as it will help to:

Monitor performance of the routine immunisation programme
Measure effectiveness of recent interventions
Understand and address gaps in immunisation services
Improve immunisation data quality to inform programme
Assess the health system preparedness for new vaccines

We will of course seek views of the steering committee and I am happy to present these options to support this discussion. However, as highlighted above, there are potential challenges with this option, such as outdated denominators, resource constraints and logistics, so we will need specialist technical input to design and implement the survey.

Question #2. The steering committee includes representatives from the national Ministry of Health, National Statistics Office, WHO, UNICEF, and a donor. Given what you have already learned about Harmonia, what do you think will be their primary question of interest for the survey (estimation, comparison, or classification)? Why?

In my view, the primary question of interest for the steering committee will be coverage estimation i.e.– what are the latest age appropriate coverage estimates for all the EPI vaccines, including the PCV vaccine. This includes the full immunisation coverage and antigen wise estimates. In addition, I think that the committee would be interested in comparing coverage between different geographic areas and population groups, which may help understand reasons for low coverage and drop-out rates for DTP.

I am happy to work with the Ministry and the steering committee to design and implement a high-quality EPI survey based on the 2015 WHO Vaccination Coverage Cluster Survey Reference Manual. As the National Statistics Office is already a member of the steering committee, we can work with them to involve their statistician to plan a robust survey design. To overcome the issue of outdated denominators, my suggestion is to include a houselisting exercise prior to conducting the coverage survey, so we can collect accurate latest denominator data. Even if the census starts next year, the results may not be available until at least a year later, so houselisting will help to establish denominators for the survey. The survey should use probability sampling to reduce any bias during field work.

Question #3. Who will comprise the target population and why?

As the primary question of interest is likely to be coverage estimation for all EPI antigens for the full immunisation coverage at first birthday, main target population should be 12-23 months age group. This will capture all routine primary vaccinations. For TT, we can include women who gave birth in the last 12 months. If MCV2 is of interest, then we can consider a separate survey or intensify monitoring for the age group 24-35 months in selected districts known to have lower coverage, to get insights for improving MCV coverage. The target population can be finalised based on the primary question of interest.

I have would like to find out some additional information which would be relevant during further discussions such as:

When was the last EPI cluster survey conducted in Harmonia and what were the coverage estimates? Can you share a copy of the same with me?
Given that our MCV coverage is 75%, have there been any supplementary immunisation activities? If yes, was coverage measured after that?
Were the reasons for DTP1-3 drop-outs explored and what were these?
What are the timescales for introduction of rotavirus vaccine?
When is the census planned to be rolled out next year, and will this include household level mapping?
Do you have any information whether the donor would be supportive of the EPI survey?

We need to build on the momentum for improving data quality as Harmonia has already initiated several data quality improvement activities. Whilst planning and designing a new EPI survey will be resource intensive and challenging, I believe that this will be a great investment towards improving our EPI. This will ensure that programmatic improvements are evidence-based, using latest and accurate data, and are resource efficient. This is a great opportunity to make a strong case for funding through our health system strengthening grant from our donors (and possibly GAVI), to conduct this EPI survey.

I would be very happy to discuss this further with you and the steering committee and look forward to working with you on this.

Thanks