Routine vaccine delivery
Pregnant women can be targeted through routine antenatal care; preconception or family planning visits; visits to health-care facilities with their children (e.g. routine childhood immunization); outpatient care (general practice, gynaecology, family planning, high-risk clinics); and any other health settings where pregnant women might seek care for themselves or their children.
WHO estimates that antenatal care visits are attended by an estimated 82% of pregnant women globally [28]. During these visits, health-care worker recommendations could support generation of demand for influenza immunization and could address hesitation or concerns of patients. Antenatal health-care workers should either refer patients for influenza immunization at immunization centres or, if they have sufficient capacity, deliver influenza vaccine directly to pregnant women.
Combining influenza vaccination with other vaccination efforts (e.g. tetanus), programmes such as “clean cord care instruction”, family planning services, or well child care visits beyond regular vaccination activities, may further increase influenza vaccine uptake box below). In addition, when vaccination interventions are combined with respected and desired health services such as antenatal visits, vaccine hesitancy may be minimized.
Combining influenza vaccination with antenatal care services
When deciding to integrate vaccine delivery into antenatal care services, policy-makers must consider several factors that may affect the capacity of existing systems or lead to additional costs. The questions below address some of these factors:
- TIMING: Can/should vaccine be made available all year round in tropical areas with varying influenza virus circulation, or in areas with limited access to vaccinating pregnant women? (See section 5.4)
- SUPPLY CHAIN: Do other antenatal interventions have supply chains that are logistically similar to those of seasonal influenza vaccination? If yes, can both be combined into one supply chain without hampering introduction or coverage of either intervention?
- USE of EXISTING SERVICES: Can vaccination be provided with other health interventions given during an antenatal visit (e.g. co-administration with tetanus toxoid vaccine)? If so, are system planners and primary health-care providers engaged in planning efforts at an early stage? Is there a high drop-out rate of visits or late arrival at antenatal care service clinics that may affect coverage/uptake?
- HEALTH SYSTEM CAPACITY: Is the capacity (e.g. human resources, supply chain, cold chain) of antenatal care services sufficient to provide other antenatal interventions and influenza vaccination together? If not, what additional resources are needed to avoid overburdening existing systems and do the benefits associated with offering influenza vaccination as an antenatal service balance with the additional resource requirements?
- SAFETY and SYSTEM EFFICIENCY: Is there a possibility to introduce/use an existing home-based record/antenatal care record of the mother in order to help health facilities avoid unintended re-vaccination of women who received vaccine in a campaign or at another health facility? Should the vaccination status of the mother appear on the vaccination card of the baby?
- BURDEN ON HEALTH SYSTEM: Could joint administration of influenza vaccine with other interventions promote or detract from utilization of the other interventions?
- ADDITIONAL COSTS: What would be the costs of the additional outreach activities required to reach sufficient coverage among pregnant women? What time, infrastructure and cost will be required to train staff on vaccination procedures, potential AEFI, benefits of influenza vaccination for pregnant women, and data collection and reporting for monitoring uptake?
Maternal tetanus vaccine delivery in Sri Lanka: a case study
Experiences describing the use of maternal influenza vaccination in low- and middle-income resource settings have not yet been extensively documented. Although influenza vaccine differs from tetanus vaccine in terms of procurement, distribution and administration, this example from Sri Lanka on routine use of tetanus vaccine targeting pregnant women helps to illustrate some programmatic aspects when using antenatal care services as the delivery platform.
Sri Lanka’s national immunization programme introduced tetanus toxoid vaccination in pregnancy in 1969 through integrated immunization and maternal and child health services. This approach helped to:
- significantly reduce service delivery costs,
- provide pregnant women with equitable access to tetanus vaccinations, and
- eliminate neonatal tetanus.
Maternal tetanus vaccination is provided through the widespread, nationwide antenatal care clinics by family health workers. A well-established system monitors and evaluates maternal tetanus vaccination with technical support from Medical Officers of Health, regional epidemiologists and the medical officers responsible for maternal and child health at the field level. Provincial and regional directors oversee implementation in their respective provinces and districts. Specialized, vertical epidemiology units and the Family Health Bureau provide policy guidance, technical support, supportive supervision and programme evaluation from the national level.
The decision to use antenatal care services as a delivery platform was supported by the high attendance of pregnant women (75.4% register before 8 weeks of gestation, 94.8% attend antenatal care clinics at least once in their pregnancy, and there are an average 6.6 antenatal visits per pregnant woman according to the Ministry of Health).
In terms of supply and logistics, tetanus vaccines are procured centrally by the Ministry of Health and distributed to the Regional Medical Supply Divisions (RMSDs) in each district. RMSDs distribute vaccines and other supplies to health ministry offices with storage facilities. From these offices, tetanus toxoids are supplied daily to antenatal care clinic services in the field. Health-care facilities with antenatal care clinics receive vaccines directly from the RMSDs. Vaccine movement registers at the clinic and ministry levels and monthly stock returns of vaccines are used to monitor vaccine stock and requisitions.
An immunization information management system is available to report maternal tetanus vaccine coverage data from the clinic to the national level via ministry offices and districts. A separate AEFI reporting system disseminates consolidates AEFI reported to the district and national levels from hospitals and by family health workers. At the field level, family health workers have data on:
- the estimated number of pregnant women,
- the number of registered pregnant women, and
- the number of pregnant women under care.
These figures are used as denominators to monitor coverage of maternal tetanus vaccination. The Family Health Bureau receives information on the vaccination status of mothers at delivery. The coverage is reviewed in monthly Ministry of Health conferences, quarterly reviews of regional epidemiologists and annual district EPI reviews. In 2013, the Ministry of Health reported that 91% of pregnant women receiving tetanus vaccination at antenatal care clinics in the government sector had been protected (TT2+) while the percentage protected among reported deliveries was 99.9%.
Source: WHO Regional Office for South-East Asia.