Immunization Module: Monitoring your Immunization Programme

Study Session 10  Monitoring your Immunization Programme

Introduction

In this study session you will learn about how to monitor your own immunization programme. Monitoring is the routine ongoing collection of data and the assessment of activities, in order to enable the targets you agreed in your action plan to be compared with what you have actually achieved. Monitoring an immunization programme includes the proper use of EPI recording tools to collect reliable data, which can be evaluated to improve the planning and management of the immunization service in the future. So, in this study session, we will teach you about the main recording tools used to collect and report the data from your immunization programme, so you can monitor and evaluate your performance.

The aim of this study session is to teach you how to improve your immunization service by identifying problems and their causes, developing solutions, and incorporating these solutions as activities in your work plan. Your overall goal is to increase immunization coverage rates and reduce dropout, so that babies like the one pictured in Figure 10.1 can be protected from all the vaccine-preventable diseases covered by the EPI.

Figure 10.1  Immunization protects thousands of Ethiopian babies every year. (Photo: Sacca, accessed from Wikimedia Commons)

Learning Outcomes for Study Session 10

• 10.1  Define and use correctly all of the key words printed in bold. (SAQs 10.1 to 10.5)
• 10.2  Describe how to use the basic EPI recording tools: immunization cards, the EPI Registration Book and the tally sheet. (SAQ 10.1)
• 10.3  Explain how you calculate immunization coverage and dropout rates and use them to monitor the success of your immunization programme. (SAQs 10.2, 10.3 and 10.4)
• 10.4  Explain the possible causes of low immunization coverage rates, and/or high dropout rates, and suggest ways to improve these EPI indicators, including systems for tracing defaulters. (SAQs 10.3 and 10.4)
• 10.5  Describe how you make accurate, timely and complete immunization Summary Reports from your Health Post. (SAQ 10.5)

10.1  EPI recording tools

We begin by teaching you about the basic EPI recording tools used in immunization programmes: these are the infant immunization card, the EPI Registration Book, the tally sheet and the Summary Report Form. Already described in earlier study sessions are the Vaccine Stock Register and Family Folder, which are not covered again here.

10.1.1  Infant immunization card

The infant immunization card (or vaccination card) is a small card that contains relevant information about the child and his or her immunization history. It is kept by the mother or other principle caregiver of the infant. It shows:

• a unique identification number (card number)
• name of the infant
• its birth date
• its sex
• name and address of mother/parent
• date that infant was protected at birth (PAB) from neonatal tetanus
• date of each subsequent immunization and vitamin A supplement given
• date when the next immunization is due.

The cards may vary slightly, and some may show additional information, such as the age of the mother and dates of her TT immunizations (Figure 10.2).

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Figure 10.2  Sample infant immunization card used in some parts of Ethiopia. Note that DPT-HepB-Hib vaccine is referred to as pentavalent vaccine on some cards. (Federal Ministry of Health, supplied by Dr Amha Mekasha)

We now consider how you should complete the infant immunization card. You should write down the date for each vaccine administered, or vitamin A supplement given. Include doses of TT given to the mother if she is eligible for a dose. Mark the next appointment date on the card and tell the mother when and where to return for the next dose of the vaccine. Make sure that the appointment date corresponds to a planned immunization session. Remind the mother verbally as well as by writing on the card. Always return the card to the mother or caregiver.

10.1.2  The EPI Registration Book

The EPI Registration Book (or Immunization Register) is a book for entering immunization data. It helps you keep a record of the immunization services you offer to each infant and to women of childbearing age, particularly all those who are pregnant (Figure 10.3). Your Health Post can either have two separate EPI Registration Books, one for recording infant immunizations and another for recording TT given to women, or one book to record both. The Immunization Register can also be used like a birth register. As soon as an infant is born in the community, its name can be entered in the register even before the infant has received any immunizations. This will help you to follow up all infants in the community.

Figure 10.3  All women of childbearing age should be entered in your EPI Registration Book the first time they come to your Health Post, or outreach site. Their records should also be entered in the Family Folder. (Photo: Basiro Davey)

10.1.3  Immunization tally sheets

Tally sheets are forms on which health workers make a mark every time they administer a dose of vaccine. These are used as the basis for monitoring and making regular summary reports of vaccine use. Use a new tally sheet for each immunization session (Figure 10.4). The same tally sheet can be used to mark vaccines given to infants, and vaccines given to pregnant and non-pregnant women in the childbearing age group.

After you have immunized an infant, record the immunization in the EPI Registration Book and on the infant’s immunization card, and inform the mother which doses were given. On the tally sheet, place a mark next to the dose you have just given. Mark each vaccine dose given on the tally sheet immediately after giving it.

Figure 10.4  Sample tally sheet for recording immunizations. (Source: as in Figure 10.2)

After immunizing any woman, whether she is pregnant or not, record the immunization in the EPI Registration Book and on the woman’s immunization card, and mark it in the correct column of the tally sheet and the Vaccine Stock Register. If no card is available, rely on the woman’s history to tally the dose. For example, if a woman says she has received three doses in the past, tally the new dose as TT4, issue a new card for the woman and mark the card with the date.

Check that the tally sheet is complete at the end of a session. Add up the number of doses of each vaccine that you have given during the session, and check that the number of doses given ‘tallies’ (matches) the number recorded in your EPI Registration Book. You will use this information to monitor your performance and to prepare your monthly Summary Report (described in Section 10.6) to your supervisor and the woreda health office. Keep the tally sheets so that your supervisor can check the data quality (accuracy of reporting).

10.2  Monitoring EPI indicators

For immunization to be effective in reducing cases of vaccine-preventable diseases and deaths, every child should be fully immunized by the age of one year. A [Sometimes you will see this statistic referred to as ‘fully immunized infant’ (FII).] fully immunized child (FIC) has received all doses of all EPI vaccines, including measles vaccine, before the age of one year. In this section, we show you the two main ways to monitor whether your immunization service has the potential to reduce the target EPI vaccine-preventable diseases. You do this by measuring the:

• immunization coverage rate for each vaccine
• dropout rates from completion of scheduled immunizations.

These are the two main EPI indicators that are used internationally to analyse the performance of EPI programmes.

10.2.1  How to measure immunization coverage rates

Immunization coverage is the percentage of eligible fully-immunized infants compared to the total number of surviving infants in the target population. The immunization coverage rate is measured by comparing the number of doses actually given and the number in the target population of surviving infants under one year of age (these are the eligible infants). The result is expressed as a percentage. The equation below shows you how to calculate immunization coverage rate in your kebele.

Immunization coverage rate (for a particular vaccine) =

number receiving all doses ÷ number in the target population x 100%, where:

• number receiving all doses is the number of surviving infants under one year of age receiving all the required doses during the previous 12 months for the selected vaccine.
• target population is the total number of eligible infants under one year of age (or total number of surviving infants) at the start of that reporting period.

If the number of fully immunized infants appears to be greater than the number in the target population, this indicates that some of the recorded information must be incorrect. The reason for this problem should be identified.

10.2.2  How to measure dropout rates

The dropout rate is found by comparing the number of infants who start the immunization schedule with the number who complete it. Two measures of dropout rate are routinely used:

In this section, we refer to pentavalent vaccine, which is also known as DPT-HepB-Hib vaccine.

• the dropout rate between infants receiving the first dose of pentavalent vaccine (Penta1) and the third dose (Penta3)
• the dropout rate between receiving the first dose of pentavalent vaccine (Penta1) and the single dose of measles vaccine.

Pentavalent 1 to measles vaccine dropout rate

There is a very long interval in the EPI schedule in Ethiopia between an infant receiving the first pentavalent immunization at six weeks old, and completing the ‘fully immunized’ schedule with the single dose of measles vaccine at 9 months of age (Figure 10.5). It is very important to complete all the immunizations in order to protect children from all the EPI target diseases.

Figure 10.5  All children in Ethiopia should be fully immunized according to the EPI schedule before their first birthday. (Photo: Lesley-Anne Long)

The pentavalent 1 to measles vaccine dropout rate is calculated using the following equation:

• Penta1 to measles vaccine dropout rate = (Penta1 – measles) ÷ Penta1 x 100%, where:

• Penta1 is the number (or percentage) of infants receiving the first pentavalent 1 dose
• measles is the number (or percentage) of infants receiving the measles vaccine.

If there is a high dropout rate between Penta1 and the measles immunization, it suggests that there is a problem for parents of utilising (making use of) the health services generally. A dropout rate of more than 10% indicates that the particular Health Post has a utilisation problem — i.e. many people are not using the services on offer.

10.2.3  Calculating the number of un-immunized infants

You should also calculate the annual number of un-immunized infants — i.e. eligible infants who have not completed any of the scheduled immunizations. You do this using the following equation:

• number of un-immunized infants = target population – fully-immunized infants, where:

• target population is the total number of eligible infants in the target age-group for immunization (under one year)
• fully-immunized infants is the number in the target age-group who have received all doses of all the EPI vaccines.

10.3  Analysing and interpreting immunization data

After determining the immunization coverage and dropout rates, you need to analyse and interpret the data in relation to your planned targets.

10.3.1  What data should you analyse?

You should analyse your data in terms of the categories listed in Box 10.1 for each reporting period (monthly or quarterly).

For continuous self-monitoring at Health Post level, we suggest you use wall charts to record such indicators as actual immunization coverage rates for each quarter of the year, compared with the planned targets for that period (Figure 10.6).

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Figure 10.6  Wall chart showing actual immunization coverage (number and percentage) for the first quarter of the year, and the planned targets for the remaining quarters at Fura Health Post in SNNPR. (Photo: Janet Haresnape)

Figure 10.7 illustrates how to enter data into an immunization monitoring chart, in order to assess your monthly progress in meeting a 100% immunization coverage target.

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Figure 10.7  Immunization monitoring chart with examples of data for a Health Post with a monthly target of 13 eligible infants (out of the total of 156) immunized with Penta1 and Penta3. The bottom two rows calculate the number and the percentage who dropped out between Penta1 and Penta3.

Every Health Post should display a chart like Figure 10.7 where it can be seen by all staff every day. The diagonal line from zero to the top right-hand corner (labelled 100%) shows the ideal rate of progress if every eligible infant is immunized on time.

Next we discuss how to analyse immunization coverage and dropout data to shed light on what may be causing low coverage and/or high dropout.

10.3.2  Analysis of access and utilisation problems

The commonly used immunization coverage and dropout rate indicators, and what they may indicate, are summarised in Table 10.2.

Table 10.3 shows you how to assess whether low immunization coverage or high dropout rates are due to a problem of access (coming to the immunization services) or to a problem of utilisation (usage of immunization services). You should use the results of your assessment to identify and prioritise problems in your immunization programme, and work out possible solutions, as described in Section 10.4.

10.4  What could be causing immunization problems?

Some possible local causes of low immunization uptake or high dropout rates are summarised in this section, which includes two new key terms (in bold).

Service organisation problems:

• Community not clearly informed of dates/times of immunization sessions at the Health Post, at outreach sites, or via mobile teams
• Immunization sessions not frequent enough, or at inconvenient sites
• Immunization session dates/times conflict with farming or family duties
• Poor vaccine quality, e.g. due to cold chain breakdown or usage after the expiry date
• Vaccine or other equipment shortages.

Staffing problems:

• Inadequate staffing levels to provide enough immunization sessions
• Inadequate training or supportive supervision for a high quality immunization service
• Health staff perceived as hostile or poor communicators by parents
• Incorrect contraindication practices, e.g. not immunizing children with minor illnesses, low grade fever, etc. which should not prevent them from receiving vaccines
• Missed opportunities to immunize, e.g. not immunizing children who visit the Health Post for another reason, unrelated to immunization.

Data collection and reporting problems:

• Incomplete or inaccurate data collection and analysis
• Failure to report monitoring data regularly
• No active follow-up of defaulters.

We conclude this study session by explaining how the last two solutions in the above list should be implemented.

10.5  Systems for tracing defaulters

In this section you will learn how you trace (track) defaulters. Defaulters are those infants who started the routine EPI immunizations but failed to complete the schedule for whatever reason. If you trace defaulters regularly every month, it will make the task of follow-up much easier. You may be able to contact the mothers directly, or ask other members of the community to help you to find them. Try to ensure that every infant receives the immunizations that are overdue. There are many ways to monitor and follow-up on defaulters. Here we describe two tracking systems that can easily be used.

Using the EPI Registration Book

At the end of each month, review the EPI Registration Book to identify infants and mothers who have not received doses of vaccine at the appropriate time, according to the recommended EPI schedule.

Using reminder cards

Make reminder cards, which are copies of the infant’s immunization cards. File them in a box behind the divider for the month when the infant’s next immunization is due (Figure 10.8). Refer to these every month to identify the defaulters.

Figure 10.8  Box for storing immunization reminder cards. (Source: WHO 2001, Immunization in Practice, Module 7, Monitoring and Using your Data, Figure 7F, p.11)

10.6  Making immunization Summary Reports

The monitoring data you have collected on your immunization programme has to be organized into a Summary Report for transmission from the Health Post to the Health Centre that supervises you. The Health Centre collects data from all the satellite Health Posts and transmits it to the woreda (district) health office. The woreda compiles data from health facilities in the district for transmission to the higher level, and eventually to the Federal Ministry of Health. At each level the data should be analysed and used to improve the immunization programme.

10.6.1  What data should the Summary Report contain?

The Summary Report from your Health Post should include the following information:

• Vaccinations and vitamin A supplements given to infants and women. Data collected on the tally sheets should be organised clearly (see the sample monthly report forms shown in Appendix 10.1 and 10.2 at the end of this study session).
• Vaccine-preventable diseases in your area. State the number of cases of each vaccine-preventable disease and the immunization status of each case. Even if there are no cases of a disease during the reporting period, you should still provide a ‘zero’ report.
• Adverse events following immunization (AEFI). If there have been any adverse events during the month, the details of any that are life-threatening, resulted in hospitalisation, disability (or have the potential to result in disability), or resulted in death should be reported. If there are no cases, provide a ‘zero’report.
• Vaccine usage and wastage patterns. The usage and wastage of vaccines will vary from one session to another. However it is useful to monitor wastage and usage patterns regularly at all immunization sessions, in order to improve supply and avoid stock shortages. This can be done by recording the number of vaccine vials at the start and end of every session, and the number of vials received or wasted each month.

  Vaccine supply and stock management were described in detail in Study Session 5.

• Any specific problems encountered during the reporting period (e.g. stock shortages, transportation problems, cold chain failure, etc.).

10.6.2  Preparing good Summary Reports

You should ensure that the Summary Reports you prepare on your immunization service are:

• Complete: Ensure all the sections of the reports have been completed; no parts have been left blank and all reports due from outreach sites or mobile teams have been received.
• Timely: When reports are sent and received on time, there is a greater possibility of a prompt and effective response to any problems you have identified.
• Accurate: Before sending the reports, check the totals and all calculations to make sure that the reported figures correspond to the actual figures in the tally sheets, the EPI Registration Book and the immunization cards. This helps you to evaluate the accuracy of your recorded data and identify and resolve any discrepancies. The district, provincial and national levels should keep track of the completeness and timeliness of reporting at your level, and remind you about any missing or late reports.

10.7  In conclusion

Now that you have completed this Module, you should be well prepared for the practical skills training that accompanies it. Be proud that you have the opportunity to improve the health of your community and save many young lives by delivering a well-managed and effective immunization service.

Summary of Study Session 10

In Study Session 10, you have learned that:

1. Monitoring of immunization programmes is very important for the planning and management of the EPI. It is the process of continuous observation and data collection, with the aim of comparing what you have achieved with your planning targets.
2. Monitoring your immunization programme includes proper use of EPI recording tools: the infant immunization cards, the EPI Registration Book (Immunization Register) and the tally sheets for each immunization session.
3. The Immunization Register helps you record the immunization services offered to each client. You must register infants and pregnant women as soon as they arrive at your Health Post or outreach site, before giving any immunizations or vitamin A supplements.
4. Tally sheets are used as the basis of your monthly or quarterly Summary Reports.
5. EPI indicators include Penta1 to Penta3 coverage, Penta1 to measles vaccine coverage, percentage of fully immunized children, percentage of women in the childbearing age-group (pregnant and non-pregnant) receiving more than two doses of TT vaccine, and protection at birth (PAB) against neonatal tetanus.
6. Estimates of whether implementation of the immunization service will (or has the potential to) reduce the target EPI diseases are obtained through measuring immunization coverage rates and dropout rates for each vaccine.
7. Pentavalent 1 coverage (and Penta1 to Penta3 dropout) is an internationally accepted measure of accessibility to the health facility; pentavalent 3 coverage (and Penta3 to measles vaccine dropout) is a measure of utilisation of health services.
8. It is important to trace defaulters by using the immunization register or reminder cards.
9. The immunization data collected should be organised into a complete, timely and accurate summary form. These reports enable you, your supervisor and the woreda health office to monitor the performance of your immunization service and quickly address any problems.

Self-Assessment Questions (SAQs) for Study Session 10

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 10.3 (tests Learning Outcomes 10.1, 10.3 and 10.4)

Figure 10.9 shows the percentage immunization coverage for Penta1 and Penta3 in two districts, labelled A and B. Based on the information in this figure, answer the following questions:

• a.Calculate the pentavalent dropout rate for the two districts A and B.
• b.Do the dropout rates suggest that access or utilisation is the major problem for the immunization service in each district? Explain how you reached your answer.
• c.What are the possible solutions for the problems in each district?

Figure 10.9  Percentage immunization coverage rates for pentavalent 1 and pentavalent 3 vaccine doses in two districts, A and B.

Answer

(a)  Calculation of dropout rates.

District A:

Figure 10.10 shows that 50% of infants received pentavalent 1 vaccine, and 42% completed the three-dose schedule (using pentavalent 3 coverage as the indicator). The dropout rate is calculated using the equation:

Penta1 to Penta3 dropout rate = (Penta1 – Penta3) ÷ Penta1 x 100%

The dropout rate in District A is therefore (50 – 42) ÷ 50 x 100 % = 16%.

District B:

Figure 10.10 shows that 85% of infants received pentavalent 1 vaccine, but only 58% completed the three-dose schedule (received pentavalent 3). The dropout rate in District B is therefore:

(85 – 58) ÷ 85 x 100% = 32%.

(b)  In District A, the major problem is low coverage, as only 50% of children received the first pentavalent dose, which indicates an access problem for parents or caregivers. In District B, the major problem is the high dropout rate of 32%, which indicates a general problem of utilisation of health services.

c)  In District A, priority should be given to raising the pentavalent 1 coverage rate, by aiming to immunize the 50% of children who have never been reached by the immunization service. In District B, the priority should be given to following up on defaulters and persuading them to complete the schedule of immunization, so the pentavalent 3 coverage rate rises from 58% to closer to the 85% who received pentavalent 1.

Appendix 10.1  Example of a Summary Report Form for infants

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Appendix 10.2  Example of a Summary Report Form for women

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