Sciences & Ingénierie, Sorbonne Universite, Paris, France
UMR 224 MIVEGEC, Univ. Montpellier-CNRS-IRD, Montpellier, France.
BMJ Glob Health. 2022 Jan;7(1). doi: 10.1136/bmjgh-2021-006824.
To reach global immunisation goals, national programmes need to balance routine immunisation at health facilities with vaccination campaigns and other outreach activities (eg, vaccination weeks), which boost coverage at particular times and help reduce geographical inequalities. However, where routine immunisation is weak, an over-reliance on vaccination campaigns may lead to heterogeneous coverage. Here, we assessed the impact of a health system strengthening (HSS) intervention on the relative contribution of routine immunisation and outreach activities to reach immunisation goals in rural Madagascar.
We obtained data from health centres in Ifanadiana district on the monthly number of recommended vaccines (BCG, measles, diphtheria, tetanus and pertussis (DTP) and polio) delivered to children, during 2014-2018. We also analysed data from a district-representative cohort carried out every 2 years in over 1500 households in 2014-2018. We compared changes inside and outside the HSS catchment in the delivery of recommended vaccines, population-level vaccination coverage, geographical and economic inequalities in coverage, and timeliness of vaccination. The impact of HSS was quantified via mixed-effects logistic regressions.
The HSS intervention was associated with a significant increase in immunisation rates (OR between 1.22 for measles and 1.49 for DTP), which diminished over time. Outreach activities were associated with a doubling in immunisation rates, but their effect was smaller in the HSS catchment. Analysis of cohort data revealed that HSS was associated with higher vaccination coverage (OR between 1.18 per year of HSS for measles and 1.43 for BCG), a reduction in economic inequality, and a higher proportion of timely vaccinations. Yet, the lower contribution of outreach activities in the HSS catchment was associated with persistent inequalities in geographical coverage, which prevented achieving international coverage targets.
Investment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.
为实现全球免疫目标，国家免疫规划需要在卫生机构常规免疫的基础上，结合疫苗接种运动和其他外展活动（如接种周），在特定时间提高覆盖率，帮助减少地域不平等。然而，在常规免疫薄弱的地方，过度依赖疫苗接种运动可能导致覆盖率参差不齐。在这里，我们评估了一项卫生系统强化（HSS）干预对常规免疫和外展活动在马达加斯加农村地区实现免疫目标的相对贡献的影响。
我们从伊法纳迪亚纳区的卫生中心获得了 2014-2018 年期间每月向儿童提供的推荐疫苗（卡介苗、麻疹、白喉、破伤风和百日咳（DTP）和脊髓灰质炎）数量的数据。我们还分析了 2014-2018 年在 HSS 集水区内外每两年在 1500 多个家庭中进行的具有代表性的区代表队列的数据。我们比较了 HSS 集水区内外推荐疫苗接种的交付、人群级别的疫苗接种覆盖率、覆盖率的地理和经济不平等以及疫苗接种的及时性方面的变化。通过混合效应逻辑回归来量化 HSS 的影响。
HSS 干预与免疫率的显著提高相关（麻疹的 OR 介于 1.22 和 1.49 之间，DTP 的 OR 介于 1.22 和 1.49 之间），但随着时间的推移逐渐减弱。外展活动与免疫率提高一倍有关，但在 HSS 集水区的影响较小。对队列数据的分析表明，HSS 与更高的疫苗接种覆盖率相关（麻疹每年增加 1.18 个，BCG 每年增加 1.43 个），经济不平等减少，及时接种的比例更高。然而，HSS 集水区外展活动贡献较低与地理覆盖范围持续不平等有关，这阻碍了实现国际覆盖目标。
对更强有力的初级保健系统的投资可以通过增加常规免疫来提高疫苗接种覆盖率、减少不平等现象并提高疫苗接种的及时性。
