AUTHENTICITY OF DATA OF ROUTINE EPI

AUTHENTICITY OF DATA OF ROUTINE EXPANDED PROGRAMME ON IMMUNISATION (EPI) AT THE LEVEL OF THE HEALTH DISTRICT

INTRODUCTION

The monthly routine EPI indicators of the Health District should be authentic, valid and credible. It is therefore imperative that at all levels of data processing, the data in all the recoding documents should conform and be the same; and that the assessment of the vaccination status of children in the community should produce results corresponding to or better than those declared routinely.

The Norms and Standards of the Expanded Programme on Immunisation (EPI) of Cameroon define the policy and modalities for the administration of vaccines to children aged 0-11 months and pregnant women. This policy document presents the tools for the monthly reporting and monitoring of EPI activities at the level of the health facility, the health area, and the Health District. Registers and tally sheets for children and pregnant women were conceived, produced and distributed to all health Districts by the Central level. Vaccination cards for children 0 – 11 months were also produced and are being given to them free of charge. At the level of the health facility vaccination is carried out and the vaccinated recorded.

The linkage and verification of the data between the principal tools cited above at the level of the health area and the Health District is usually very difficult because of the lack of standardised intermediate tools for the synthesis of monthly EPI data. The author initiated intermediate tools and computer excel programmes that facilitated EPI data processing by the Health Centre and the Health District Service Teams in Bamenda Health District, thus permitting the production of results of routine EPI returns from 1999 to August 2005.

During the synchronised national immunisation days against Polio from 9 – 11 November and 9 – 11 December 2005, the author carried out an integrated supervision concerning the National Immunisation Days (NIDs) and routine EPI, as prescribed to all Provincial Supervisors in Santa Health District. The supervision results on the NIDs had been presented in another report.

This write up will be based only on the supervision of activities and tasks of routine activities of EPI.

This supervision in Santa Health District was used just as an example to highlight some of the problems faced by most Health Districts in processing routine EPI data.

GENERAL OBJECTIVE

Improve the capacity and performance of staff in the activities and data processing in routine EPI at the Health Area and Health District levels.

SPECIFIC OBJECTIVES1) Assess performance in the following domains:

a) Infection prevention - decontamination – laboratory
b) Infection prevention – decontamination – maternity
c) Waste disposal
d) Cold chain
e) Management of materials and vaccines
f) Injection security
g) Monitoring of vaccination coverage
h) Acute Flaccid Paralysis (AFP) surveillance
i) Tools used

2) Propose some intermediate tools for enhancing processing and verification of routine EPI data.


METHOD
A questionnaire based on the terms of reference for provincial supervisors, and on the Norms and Standards on EPI of Cameroon was established and applied by response, and verification wherever possible. During the first round in November 2005 emphasis was laid on the cold chain; the more elaborate questionnaire was used during the second round in December 2005 when all health areas were visited.

Feedback was given immediately and during evaluation meetings on the identified strengths, weaknesses, potentials, and together with the health teams solutions to weaknesses were developed. Some tools for enhancing processing and verification of routine EPI data were provided to the health teams.

RESULTS:

A. ROUND FOUR SNIDs 09 – 11 NOVEMBER 2005
I. COLD CHAIN

• The centre has a functional refrigerator-----------------------------------7/8 (87.5%)
• Type fridge: 2 Gas; 2 Kerosene; 2 Electric; 7 out of 8 centres visited, Buchi Health Centre has no fridge.
• Refrigerator is correctly installed----------------------------------------------7/7 (100.0%)
• Refrigerator has its temperature chart ---------------------------------- 7/7(100.0%)
• The temperature chart is pasted on fridge ----------------------------- 7/7 (100.0%)
• The fridge has a thermometer ----------------------------------------------7/7 (100.0%)
• Temperatures are noted twice a day ----------------------------------------- 7/7 (100.0%)
• Temperature is written with - or + in front of figures ---------------- 1/7 (14.3%)
• Temperature ranges between (+20 C and +80 C) for the fridge for the last two weeks ----- applicable only in one health facility (14.3%)
• Abnormal temperatures are noted with red colour ---------------------1/1 (100.0%)
• POLIO is in the freezing compartment of the fridge of HC/Health Facility--- 7/7 (100.0%)
• DPTHepB; TT; BCG, Measles, YF are in the cooling compartment ----- 7/7 (100.0%)
• Ice packs are kept in freezing compartment of the fridge --------------- 7/7 (100.0%)
• Ice packs are well arranged vertically in freezing compartment -------- 2/7 (28.6%)
• Fridge is well maintained (not full with ice, and clean) ---------------- 5/7 (71.43%)
• Things other than vaccines not found in the refrigerator --------------------7/7 (100.0%)
• Opened vaccine vials BCG/Measles/YF not found in the fridge ---------7/7 (100.0%)
• Vaccines are scattered in the fridge ----------------------1/7 (14.3%)
• DPTHepB, TT, OPV, are given daily in a centre having a fridge (excluding District Health Service) --------5/6 (83.6%)
• Quantity of Oral Polio Vaccine with VVM bad: 3700 doses (District health service 2000 and Bali Gham Health Centre1700)
• The District Service has a deep freezer ----------------------------------1/1 (100.0%)
• The temperature chart is pasted on the deep freezer ------------------- 0/1 (0.0%)
• The deep freezer has a thermometer -------------------------------------- 1/1 (100.0)
• Temperatures are noted twice a day ------------------------------------ 0/1 (0.0%)
• Temperature is written with - or + in front of figures ---------------- 0 (0.0%)
• Temperature ranges are between (-15°C to – 25°C) for the deep freezer for the last two weeks --- not recorded
• POLIO is in the deep freezer at the District Health Service -------------------- 0 (0.0%)
• Ice packs are kept in the deep freezer at the District Health Service ----- 0 (0.0%)
• Ice packs are placed vertically in the deep freezer at the District Health Service -----0 (0.0%)

II. MANAGEMENT OF MATERIALS AND VACCINES

• There is a register/form for vaccine stock management --------6/8 (75.0%)
• No shortage of vaccine since last 3 months ------------ 8/8 (100.0%)
• Auto-destruct syringes are in sufficient quantity ---------8.8 (100.0%)
• Kerosene reserve (minimum 5l) ---------------------------2/2 (100.0%)
• There is a stand by bottle of gas ---------------------------2/2 (100.0%)

III. MONITORING OF VACCINATION COVERAGE

• The graph for the monitoring of vaccination coverage at HF is used ------- 2/8 (25.0%) Awing HC and the District Health Service
• The annual objective for the vaccination coverage is indicated ---------- 2/8(25.0%) Awing HC and the District Health Service
• Problems are identified from the graph and written ------------------------------------1/8 (12.5%) District Health Service
• Actions are taken to improve or consolidate the coverage ---------------1/8 (12.5%) District Health Service
• Feed back on monitoring graphs from the District Service -------------- 7/7 (100.0%)

IV. AFP SURVEILLANCE

• Supervisors review Consultation registers ---------------------- 6/7 (85.71%)
• Consultation registers are reviewed and signed by supervisors ---------5/7 (71.4%)
• Case definitions of diseases under surveillance (AFP, measles, etc) are displayed at HF- ----- 3/7 (42.86%)
• Social mobilisers carry out active search for cases of AFP in the community ---------7/7 (100.0%)
• Social mobilisers have copies of case definitions of especially AFP, Yellow fever, etc, -0/7 (0.0%)
• Health staffs carry out active search for AFP in the community by ------ 7/7 (100.0%)

V. TOOLS USED

• The current recommended monthly EPI return form is used ----------------------6/8 (75.0%)
• The current recommended tally sheets are used at vaccination centre --- ------- 7/7 (100.0%)
• Health area synthesis from different vaccination centres are made and attached to the health area monthly return form – 0/2 (0.0%)
• The indicators on monthly EPI return form are correctly calculated ----6/8 (75.0%)
• Monthly Return per strategy is made ---------------------------------------7/8 (87.5%)
• Monthly Stock management Return is made ------------------------------5/8 (62.5%) not done at the District Service

B. ROUND FIVE SNIDs 09 – 11 DECEMBER 2005

I. INFECTION PREVENTION – DECONTAMINATION – LABORATORY

• Prepares the 0.5% chlorine solution for decontamination ----------------- 6/9 (66.67%)
• Soaks instruments in decontamination solution for 10 minutes immediately after use –5/9 (55.6%)
• Does not recap needles after use --------------------------5/9 (55.6%)
• Puts syringes and needles in a puncture proof safety box -----------------6/9 (66.67%)

II. INFECTION PREVENTION – DECONTAMINATION – MATERNITY

• Prepares the 0.5% chlorine solution for decontamination -----------------6/9(66.67%)
• Soaks instruments in decontamination solution for 10 minutes immediately after use ----6/9(66.67%)
• Clean the delivery bed after each delivery with the decontamination solution --------6/9 (66.67%)
• There is a placenta pit--------------------------------------------------------3/9(33.3%)

III. WASTE DISPOSAL

• Uses a dust bin with a cover --------------------------------------------------7/12 ((58.33%)
• Wears utility gloves to clean and dispose waste --------------------------5/12 (41.67%)
• Places all sharps in a puncture proof recipient ---------------------------11/12(91.67%)
  Empties dust bin once a day ---------------------------------------------------5/12 ((41.67%)
• Decontaminate the dust bin before cleaning ----------------------------------------3/12 (25.0%)
• Removes utility gloves and decontaminate them for 10 minutes before washing ---2/12 (25.0%)
• Waste is incinerated (There is an incinerator) ----------------------------1/12 (8.3%)
• There is a pit -----------------------------------------------11/12 (91.8%)
• Waste is burnt before burning ---------------------------------------1/12 (8.3%)

IV. COLD CHAIN

• The centre has a functional refrigerator-----------------------------------10/11 (90.91%)
• Type of refrigerator: 2 Gas; 2 Kerosene; 6 Electric. All health areas have at least one fridge except Buchi health area.
• Refrigerator is correctly installed----------------------------------------------9/10 (90.0%)
• Refrigerator has its temperature chart ---------------------------------- 10/10 (100.0%)
• The temperature chart is pasted on fridge ------------------------------ 10/10 (100.0%)
• The fridge has a thermometer ----------------------------------------------10/10 (100.0%)
• Temperatures are noted twice a day -----------------------------------------10/10 (100.0%)
• Temperature is written with – or + in front of figures ----------------2/10 (20.0%)
• Temperature ranges between (+2° C and +8° C) for the fridge for the last two weeks ------ only in one; the other the temperature ranged from – 2° to +6°C; the rest could not be appreciated because no sign was put in front of the figures.
• Abnormal temperatures are noted with red colour ---------------------1/2 (50.0%)
• POLIO is in the freezing compartment of the fridge of HC/Health Facility ----- 10/10 (100.0%)
• DPTHepB; TT; BCG, Measles, YF are in the cooling compartment -----10/10 (100.0%)
• Ice packs are kept in freezing compartment of the fridge ---------------10/10 (100.0%)
• Ice packs are well arranged vertically in freezing compartment --------7/10 (70.0%)
• Fridge is well maintained (not full with ice, and clean) ----------------7/10 (70.0%)
• Things other than vaccines not found in the refrigerator --------------------9/10 (90.0%)
  Opened vaccine vials BCG/Measles/YF not found in the fridge ---------10/10 (100.0)%
• Vaccines are scattered in the fridge ---------------------- 2/10 (20.0%)
• DPTHepB, TT, OPV, are given daily in centres having fridges --------7/9 (77.78%)
• Quantity of Oral polio vaccine with VVM bad ----------------------0.0%
• The District Service has a functional deep freezer ----------------------------------1/1 (100.0%)
• The temperature chart is pasted on the deep freezer ------------------- 0.0%
• The deep freezer has a thermometer -------------------------------------- 1/1 (100.0)
• Temperatures are noted twice a day ------------------------------------0.0%
• Temperature is written with – or + in front of figures ---------------- 0.0%
• Temperature ranges are between (-15°C to – 25°C) for the deep freezer --- 0.0% (not recorded)
• POLIO is in the deep freezer at the District Health Service --------------------0.0%
  Ice packs are kept in the deep freezer at the District Health Service ----100.0%
• Ice packs are placed vertically in the deep freezer at the District Health Service -----0.0%

V. MANAGEMENT OF MATERIALS AND VACCINES

• There is a register/form for vaccine stock management ---------------------10/11 (90.9%)
• No shortage of vaccine since last 3 months-----------------------------------11/11 (100.0%)
• Auto-destruct syringes are in sufficient quantity ---------------------------11/11 (100.0)
• Kerosene reserve (minimum 5l) ----------------------------------------------2/2 (100.0%)
• There is a stand by bottle of gas----------------------------------------------2/2 (100.0%)

VI. INJECTION SECURITY

• All injections of vaccines are done with auto-destruct syringes ------------10/10 (100.0%)
• No recap of needles is done after use -----------------------------------------11/11 (100.0%)
• Used syringes/needles are put in safety boxes (puncture proof)---------- 11/11 (100.0%)
• Used syringes/needles are destroyed by incineration---------------------1/11 (9.1%)
• Syringes and needles are destroyed by burning before burying ----------6/11 (54.6%)

VII. MONITORING OF VACCINATION COVERAGE

• The graph for the monitoring of vaccination coverage at HF is used—3/11 (27.27%)
• The annual objective for the vaccination coverage is indicated ----------2/11 (18.18%)
• Problems are identified from the graph ------------------------------------1/11 (9.09%)
• Actions are taken to improve or consolidate the coverage ---------------1/11 (9.1%)
• Feed back on monitoring graphs from the District Service -------------- 10/10 (100.0%)

VIII. ACUTE FLACCID PARALYSIS (AFP) SURVEILLANCE

• Consultation registers are reviewed by supervisors ---------------------- 9/11 (81.8%)
• Consultation registers are reviewed and signed by supervisors ---------6/11 (54.55)
• Case definitions of diseases under surveillance (AFP, measles, etc) are displayed at health facilities ---5/11 (45.5%)
• Social mobilisers carry out active search for cases of AFP in the community --- 10/10 (100.0%)
• Social mobilisers have copies of case definitions of AFP, Yellow fever, measles, etc ----- 0.0%
• Health staff carries out active search for AFP in the community by ------10/10 (100.0%)

IX. TOOLS USED

• The current recommended EPI return form is used ----------------------8/11 (%)
• The current recommended tally sheets are used at vaccination centre ---10/10 (100.0%
• Health area synthesis are made and attached to the health area return form ---- -0/5 (0.0%)
• The indicators on monthly EPI return form are correctly calculated ----8/11 (72.7%)
• Monthly Return per strategy is made --------------------------------------- 10/11 (90.91%)
• Monthly Stock management Return is made ------------------------------ 8./11 (72.5%)

Detailed results per health facility is presented in the tables of the synthesis of the supervision checklist

DISCUSSION

Most of the activities and tasks of routine EPI are correctly carried out.

Preparation and utilisation of 0.5% chlorine solution for decontamination is not optimum, and recapping of needles is still practiced in some laboratories. Dettol (parachlorometaxylenol) and Salvon (Cetrimide) are used as disinfectants, instead of as antiseptics in some health facilities.

The placenta pits are abandoned old pit latrines. A placenta pit should be of about one metre in diameter and two metres deep, having an airtight concrete slap with a concrete cover. The pit should have a ventilation pipe.

The temperature charts of refrigerators could not be well appreciated because only 2/10 (20%) put – or + in front of the recorded temperature figures.

In November 2005 only 2/7 (28.6%) fridges had ice packs arranged vertically in freezing compartment compared to 7/10 (70.0%) in December 2005 because of the immediate feedback.

In reality only one health facility attempted using the monitoring graph for the monitoring of vaccination coverage rate; but all had feed back on monitoring graphs from the Health District Service

Integrated surveillance of diseases with epidemic potentials needs improvement in the following aspects: reviewing and signing of consultation registers by supervisors, displaying case definitions at health facilities, and providing flyers of case definitions with pictures to social mobilisers.

The performance of each vaccination centre in health areas with many vaccination centres cannot be easily appreciated because health area syntheses from the different vaccination centres are not made and attached to the health area monthly EPI return form.

Although most health areas forward the monthly stock management returns to the District Service, the Health District synthesis is not easily done.

The monthly synthesis of EPI returns at the District Service is done manually; but the form for the compilation of data is very inadequate.

Syringes and needles are put in safety boxes at all vaccination units but at other posts they are disposed of in dustbins in some health facilities. Only one health facility has and uses an incinerator.

Most health facilities have pits, but they are not the recommended models; waste are more often not burnt immediately before putting in the pits.

The filing system at all levels needs great improvement.

Potentials of the Health District:

• The District Health Service has a complete computer set and a photocopy machine
• It can be used by the District Chief of Service of Public Health
• Most members of the District Health Service and Health Centre teams have been trained in the components of the Norms and Standards on EPI

The author had updated the tools of the norms and standards on EPI Cameroon as more information was requested by the Central level, and elaborated intermediate tools to facilitate the compilation and verification of data on routine EPI; and the monitoring of the evolution of vaccination coverage rates used in Bamenda Health District up to August 2005:

1. Form for the monthly report of activities and surveillance of target diseases of EPI (Norms and standards)
2. Form for health area summary of EPI returns for the month before filling the health area monthly return form for health area with many vaccinating centres, and out reach posts.
3. Monitoring of the evolution vaccination coverage rate (EPI norms and standards)
4. Graph for the monitoring of vaccination activities using the indicators calculated in the monthly EPI return form

• Recruitment rate: (cumulative BCG/F) x 100
• Achievement rate: (cumulative Measles/F) x 100
• Complete coverage rate: (cumulative DPTHepB3/F) x 100
• Monthly proportion vaccinated (% vaccinated in the month) = (DPTHepB3 in the month/E) x 100

E = Total annual target population / 12
F = Target (0-11m) monthly cumulative population since Jan = (E x number of the month
A computer example of this form is shown in the next Post

1. Manual synthesis of EPI returns at the Health District Service.
2. Daily vaccination session report with emphasis on children 0 – 11months, 12 months and above. This tool permits the personnel and supervisors to easily identify each child vaccinated in the register and to ensure that the number of children vaccinated corresponds to that in the tally sheet.
3. Form for the monitoring of types of EPI returns and dates received at the District Health Service; it permits the appreciation of Completeness and Timeliness
4. Form for the assessment of vaccination status of vaccination status of children 0-11 months in the community
5. Form for synthesis of the assessment/monitoring of vaccination status of children 0-11 months in the community. The two above forms are very useful for the monitoring of declared vaccination coverage rates, and for providing facts for social mobilisation activities in that community.
6. Monthly report of vaccines, vitamin A, and cold chain management (Norms and standards)
7. Report of monthly vaccination activities by strategies (Norms and standards)

Proximity social mobilisation in the community should be done using flyers of simple vaccination calendars for children and pregnant women. It should also be based on facts that are obtained by the intermittent assessment (every 3, 4, or 6 months) of vaccination status of children 0 – 11 months in the community by social mobilisers and staff of the health area, using the appropriate tools proposed in this write up. By so doing a strong community adhesion to and participation in EPI will be achieved. The results thus obtained will be compared with those declared through the declared routine EPI data.

The manual synthesis of complex data collection forms by the District Health Team is usually very difficult and strenuous, but since many health District Service presently have computers, simple excel computers will greatly help the District Service Team in data processing. The author has developed and used the following programmes in the Bamenda Health District for many years:

• The programme for the Health District synthesis of the form for the monthly report of activities and surveillance of target disease of EPI
• The programme for the Health District synthesis of the report of monthly activities by strategy.
• The programme for the Health District synthesis of monthly report of vaccines, vitamin, and cold chain management.

CONCLUSION

The use of well designed intermediate EPI tools and simple computer excel programmes that permit one to verify routine EPI data reported by the Health District, and the confirmation through formative supervision that these data are exact and the same in all these tools including the National tools render the Health District monthly report authentic.

The production of authentic EPI data in the Health District requires:

• Commitment of the health staff to produce correct, exact, realistic, and valid data.
• Willingness and enthusiasm of the health personnel to acquire innovations.
• Use of intermediate tools for synthesis at the level of health area and Health District Service
• Use of simple excel computer programmes for Health District syntheses where ever possible
• Capacity building of District Health Service and Health Facility teams in the Norms and Standards of EPI of Cameroon
• Supportive/formative supervision of Health Centre and Health District Service teams using appropriate checklists.
• A good filing and documentation system at all levels; this will facilitate verification of the process and results.

Capacity building of Health Centre and Health District Service teams is primordial and should be continuous, during all appropriate occasions, for a Chief of Health Centre told the author ‘Doctor I did nursing because of it had no mathematics, but now I am involved in a lot of difficult mathematics’

The periodic assessment of the vaccination status of children 0 – 11 months in the community by social mobilisers and staff of the health area is an effective means of monitoring the authenticity of results obtained through declared routine EPI data.

***This write up is a modest contribution towards ensuring the authenticity of routine EPI data declared by Health Districts.***



REFERENCE
I. Mid-Level Management Course for EPI Managers; WHO Regional Office for Africa.

II. Expanded Programme on Immunisation (EPI) in Bamenda health district- Cameroon from 1999 – August 2005 (September 2005); Dr Mfonfu Daniel; website: www. mfonfudaniel.blogspot.com

III. Demographic and health survey 2004, Cameroon; Vaccination coverage rate in children 12-23 months

IV. Normes et Standards du Programme Elargi de Vaccination (PEV), Cameroun, Ministère de la Santé Publique, Janvier 2005

V. Infection Prevention for Family Planning Service Programs; JHPIEGO; Lind Tietjen, Wendy Cronin, Noel McIntosh:
***View related tables and graphs on next Post****