Strategies to Improve Coverage of Typhoid Conjugate Vaccine (TCV) Immunization Campaign in Karachi, Pakistan

"...the biggest takeaway is that every interaction can serve as an intervention, and community engagement is an essential component of any immunization campaign."

Only 35% of the population in Sindh Province receives immunisation as part of the Expanded Programme for Immunization (EPI) in Pakistan, where polio eradication is a national emergency. A lack of community awareness, misconceptions, religious beliefs, illiteracy, rumours, and fears related to vaccines circulating through social media are contributing factors to vaccine hesitancy and resistance within communities. Pakistan also struggles with typhoid fever, which is a major cause of febrile illness, especially among children, in many low- and middle-income countries (LMICs). In response to the emergence and spread of extensively drug-resistant (XDR) typhoid in Karachi, Pakistan, a mass immunisation campaign with typhoid conjugate vaccine (TCV) was conducted in Lyari Town, Karachi. This paper describes the strategies used to improve acceptance and coverage of Typbar TCV® in Lyari Town.

Before the implementation of the newly introduced vaccine, the local context of the urban slum area was carefully considered. A review of new and existing activities and strategies to successfully address vaccine hesitancy was used to help prioritise the project activities and strategies based on an evaluation of their potential impact. The advocacy and communication strategies evolved based on the day-to-day experiences and lessons learnt as the project moved ahead.

Conducted from April 10 2019 until October 24 2019, the school- and hospital-based vaccination campaign was designed to reach children between the ages of 6 months and 15 years. During the summer vacation, the school-based vaccination team pivoted activities to actively engage in advocacy and community mobilisation, which helped to increase the number of children vaccinated in hospitals in May and June. The team also visited the local general physicians (GPs)' offices and private clinics to share campaign information and to help disseminate safety awareness messages. A mobile vaccination campaign was added to cope with high absenteeism and non-response from parents in schools and to cover children out of school. Two team members set up the camps at places provided voluntarily by community members (e.g., the houses of community and religious leaders, as well as the offices of members of political parties) and communicated to the school-based vaccination teams on where to resume community mobilisation activities after completing their school targets.

A live dashboard was available to the research supervisors to monitor the daily field activities and vaccination coverage summaries. Periodically, vaccine coverage was calculated at each union council (UC) to help identify the pockets of low coverage. The vaccination plans were guided by live geographic information system (GIS) maps to keep the coverage homogenous across the UCs.

Different strategies were found to be effective in increasing the vaccination coverage and in tackling vaccine hesitancy. In short, they include:

• Stakeholder engagement - For example, government and school officials were involved from the start, and a stakeholder group helped develop the micro-plan and a social map of Lyari Town.
• Vaccine education sessions in schools and at religious institutions - The team found that acquiring parental consent for their children's immunisation was challenging - in part because the school administrators were not engaged in speaking to the parents about the significance of the vaccine. In response, interactive sessions for school administrators, principals, teachers, and, in some schools, parents, were designed to address concerns regarding the vaccine and to increase confidence in vaccination.
• Community engagement and social media campaign - Activities included house-to-house canvassing, distributing handbills and pamphlets, placing banners and pamphlets at prominent community places, using megaphones to make street and market announcements, displaying pamphlets and banners at popular community locations, identifying and approaching social activist and community groups, asking political and community leaders to arrange community meetings at their offices to influence people to get their children vaccinated, holding meetings with religious leaders and making announcements in mosques (where allowed), and playing a typhoid jingle along with campaign announcements via a megaphone placed in vehicles that were driven throughout the areas adjacent to community camps. On the social media front, various WhatsApp and Facebook groups were identified, and their administrators were approached to disseminate awareness messages on their respective platforms. For instance, some of the participating schools with their own Facebook pages uploaded pictures and videos of the vaccination activities at their school, which helped gain cooperation from other schools. Aga Khan Secondary Care Hospital sent mobile text messages to a population of 50,000 living in Lyari Town.
• Staff trainings and field supervision - A single adverse event may create rumours in the community and endanger the whole campaign. Thus, medical staff members of the team (2 doctors and 2 nurses) were trained on adverse event following immunisation (AEFI) management and essential referral and response protocols, and a 24-hour hotline number for the reporting of AEFI was included on the back of each child's vaccination card. In addition, a crisis management plan with communication strategies was prepared and shared with team members.
• Healthcare provider education - The team visited all local healthcare clinics in Lyari Town and educated the healthcare providers about the ongoing typhoid fever outbreak and immunisation campaign. Information, education, and communication (IEC) materials were developed in the local language, Urdu, and posted in the waiting areas of the local GPs' offices to increase patients' awareness. Pamphlet stands with information to bring children for vaccination were placed outside the health facilities.

Based on an analysis of the children reached, the researchers suggest: "By utilizing a multi-component campaign approach and incorporating several strategies to raise awareness and increase engagement at multiple levels of the community, we were able to successfully reach our target immunization coverage rate as well as earn the community's trust, cooperation, and support for typhoid vaccination. This approach allowed for a genuine 2-way exchange of ideas with community members, providing us with valuable feedback to help us better understand what approaches are the most appropriate for the local context."

Grounded in this experience, suggested recommendations include:

1. Before implementation of any mass immunisation programme, it is wise to evaluate the strategies best suited for the local context.
2. In the case of urban slum areas, pamphlets, handbills, banners and announcements alone are not enough; opportunities for open, direct communication with parents and children are important.
3. Multiple permanent, temporary, and mobile vaccination posts enable widespread reach throughout the population.
4. Continuous data analysis and periodical calculation of coverage in targeted areas and neighbourhoods helps to identify pockets of low-coverage and prioritise further activities in a timely manner.
5. The use of technology may assist not only in sharing messages for vaccination but also for real-time data collection for timely action.
6. Bringing all community stakeholders on board may help implement field operations in high-refusal areas.
7. Microplanning should include social mapping of local influencers in the community.
8. A strong AEFI management and referral plan should be in place, especially in a politically unstable setting.
9. Effective use of technology is the most cost-effective way to promote vaccination and enhance awareness.
10. Community members should be asked for their assistance, suggestions, and feedback.
11. Safety and security of field staff in the community should be assured.
12. Discussions with and engagement of physicians are mandatory to impart the correct messages to the community.