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Post00248 DRAFT GUIDELINES: NID QUALITY 5 May 2000 CONTENTS 1. RE: DRAFT GUIDELINES FOR REVIEW AND COMMENT 2. THE USE OF "ZERO-DOSE" 1. RE: DRAFT GUIDELINES FOR REVIEW AND COMMENT In Post00245, POLIO NID QUALITY ASSESSMENT GUIDELINES, on 28 April 2000, Bob Davis, UNICEF//ESARO, introduced draft global guidelines for evaluating polio NIDs from the quality standpoint - prepared by Bob Davis and Jane Zucker. In todays postings, Robert Steinglass, BASICS, Bob Keegan, WHO, Alasdair Wylie, and Ellyn Ogden, USAID, provide detailed comments and discussion. A side discussion on polio "zero dosing" has been posed as Item 2. Contributions, comments and additions please: [][/email] or use your reply button [Moderators Note: A document by Mark Weeks et al on monitoring service delivery during NIDs: "Assessing the local capacity to strengthen disease surveillance" is posted on the BASICS web site at: ] ___________________________________________________________________________ Date: Sun, 30 Apr 2000 17:56:00 -0400 From: "Robert Steinglass" To: [][/email], [][/email] Subject: quality NIDs Bob, I think you are pursuing an area and approach which has unfortunately been neglected: improving the quality of NIDs, which after all represents the biggest investment for PEI. Mary Reichler from CDC did some interesting assessments of NIDs in Pakistan in about 1995. She asked a lot of good questions and found a lot of important information which could have been used to improve the quality of future NIDs. However, I don't believe that the approach to NID monitoring was further pursued by CDC, which chose instead to emphasize surveillance. I have a copy of her report somewhere, but I don't have the time to dig it out, sas I recently moved office and my boxes are a mess. I am sure CDC could give it to you and Jane Zucker. I already mentioned as relevant for your purposes the BASICS monitoring article by Weeks, Hasselblad, Fields, Steinglass, et. al. on our web site at There is another article there on a process evaluation done in Bdesh after their first NIDs by Bhattarcharya, et. al. in about 1996, which might be of interest. I only very quickly glanced at your draft article. I just don't have much time as I depart tomorrow on a 5 week trip. I think the zero dose monitoring section is dangerous as it could be interpreted wrongly. Besides year to year the same factors apply, so it should not be necessary to exclude children less than 12 months. I doubt anything could be done "anonymously". The delivery of the form probably depends in many countries on being handed in and not mailed. Robert Robert Steinglass Immunization Team Leader BASICS 1600 Wilson Blvd., Suite 300 Arlington, VA. 22209 USA voice: 1-703-312-6800 fax: 1-703-312-6900 e-mail: [][/email] --- From: "Bob Keegan" To: "'Robert Davis'" , , Subject: RE: DRAFT GUIDELINES FOR REVIEW AND COMMENT Date: Sun, 30 Apr 2000 12:30:28 +0200 Bob, Thanks for inviting comment. Also, thanks for getting a draft out quickly. Bruce and I reviewed your draft. The attached document summarizes our suggestions. For TCG, your presentation might well follow along lines mentioned in our comments e.g., rationale for use, the indicators/scheme of rating, and process for using the indicators. Hope this is helpful. Bob ___________________________________________________________________________ Comments on "Proposed Indicators to assess the Quality of SIAs for Polio Eradication Comments * Nice first draft; short and practical * Background section is too long, contains some irrelevant material. Suggest you edit out most of the first page and introduce it with 1-2 sentences which state/summarize the need for improved quality and purpose/use of indicators. (Just the facts, Ma'm) * More use of bulleted text would make for easier reading if you do decide to go heavy on text. * Suggest that entire paper be limited to three parts (1) brief intro/context, (2) one-page indicators/rating scheme and (3) process for use. * Indicators might include o written planning documents with maps o total/percentage immunized o zero-dose children immunized o percent districts missed o supervisory visits (including visits to areas, not vaccination posts) o grab surveys o fast cold chain/VVM strategy in different areas o house-to-house component * Process for use might include: o Role of ICC o Meeting one day after NIDs o Establish consensus on quality after feedback from evaluators o Present to Minister o Steps to improve * Document would benefit from professional editing to make language clear and simple. * Suggest reorder the bullets at bottom of Background into logical sequence. E.g., social mobilization should be before monitoring number of children immunized. * Under Coverage section, suggest mentioning that districts which report greater than 100% coverage are frequently high risk districts. Such districts are at high risk because they typically have incorrect denominator coverage, vaccination of large numbers of children above target age, use incorrect means to calculate coverage (e.g., counting each empty vial as 20 kids immunized), and /or falsify records. * Re zero dose monitoring, we strongly disagree with premise that this is useful "if and only if infant vaccinations are excluded." All children in polio-endemic countries should receive a birth dose and doses at 6, 10, and 14 weeks of age. The proposed zero-dose monitoring appears technically incorrect and would unnecessarily complicate monitoring. * Re underperforming districts, suggest listing what we already know from experience. Districts or portions of districts with slums, minority groups, migrants, etc are likely to be underperforming areas. * A "secret ballot" is likely to be a political problem for some. Postcard polls don't sound practical in terms of timeliness or response rate. * Grab surveys (convenience samples) of parents with children From: "Ellyn Ogden" Reply-To: Subject: DRAFT GUIDELINES FOR REVIEW AND COMMENT Bob: Thanks for the opportunity to comment on the draft indicators. The comments provided are my own. I'm looking forward to seeing the next version. Regards, Ellyn ___________________________________________________________________________ ELLYN OGDEN'S COMMENTS IN CAPS 4/28/00 Proposed Indicators to Assess the Quality of Implementation of Supplemental Immunization Activities for Polio Eradication Background: Tremendous progress continues to be made toward the goal of polio eradication - the total number of polio-infected countries has decreased to 30 from 50 from 1998 to 1999. The number of cases reported so far for 1999 is 6,659. This figure is similar to that of 1998, due in part to improved surveillance, but also to a large outbreak (1,103 cases) which occurred in Angola. The majority of poliovirus transmission continues to be found in South Asia and the African continent. Of these, there are 14 countries which are identified as priorities for success of the initiative - based on size, inaccessibility to children due to conflict, and documented presence of wild poliovirus: DR Congo, Nigeria, Republic of Congo, Chad, Niger, Ethiopia, Somalia, Angola, India, Pakistan, Bangladesh, Afghanistan, Sudan (Khartoum and OLS), and Iraq. Despite the progress being made, wild poliovirus continues to be identified in countries that have conducted multiple rounds of NIDs. Experience in 1999 with conducting house to house strategies for NIDs has consistently demonstrated improved coverage in the range of 10% to 40% with this approach. One dramatic example is the house to house sNIDS that were conducted in Nigeria in the spring of 1999 when 40% more children were immunized than were originally targeted. Similarly, in both India and Pakistan, approximately 10% to 15% of additional children were immunized with house to house polio activities. This has highlighted the fact and led to recognition that the coverage and quality of NIDs has not been sufficiently high to interrupt poliovirus transmission iN some highly endemic countries. Two joint strategy meetings between WHO and UNICEF were held in February and March 2000 to address the need for acceleration in polio eradication efforts. The March meeting was convened by the Executive Director of UNICEF and the Director General of WHO with the UNICEF and WHO Representatives of the 14 priority countries listed above. An key recommendation and priority action was the need to improve the quality of implementation of NIDs and to develop indicators to monitor progress and quality. An important vehicle for this improvement is the National Inter-Agency Coordinating Committees (ICCs) through direct involvement of WHO and UNICEF country representatives. Components of quality highlighted were: * Better microplanning [I BELIEVE THIS NEEDS MORE GUIDANCE; RAPID DISSEMINATION OF STRATEGIES THAT WORK], mapping, supervision, and monitoring at the district level, especially in high-risk, hard to reach, and conflict areas; * Monitoring the total number of children immunized and number of zero-dose children [SEE MY EMAIL TO ALASDAIR THAT I'M GOING TO FORWARD TO YOU.] vaccinated in successive rounds; * Timely disbursements and accounting for cash advances and local procurements; * Enhancing social mobilization efforts [NEEDS BETTER GUIDANCE]; * Identifying innovative approaches to sustain motivation; and * Developing independent monitoring and evaluation mechanisms and sharing lessons learned widely. Furthermore, it was recommended that indicators to monitor quality if NIDs be developed, field tested, and the results would be used for further improvements. Purpose: To develop and TEST field indicators to monitor quality of NIDs. Proposed indicators: RE-FORMATTING SUGGESTED. CONSIDER THE FOLLOWING 1-PAGE FORMAT FOR EACH INDICATOR: Rationale, Recommended Indicator, Explanation, Example, Interpretation/action) Caveats: focus is on quality of NIDS - going beyond traditional coverage statistics, looking at process and qualitative assessments, in addition to quantitative assessments. Surveillance is not included. Intended to complement field guides and implementation manuals, BUT ALSO HIGHLIGHTS AREAS OF THE FIELD GUIDE THAT ARE WEAK OR MISUNDERSTOOD. AS USUAL, MY SUGGESTIONS TEND TO SUGGEST THE SOLUTIONS IN ADDITION TO COLLECTING THE INFORMATION. (WHAT GETS COLLECTED GETS DONE. SO LET'S COLLECT INFORMATION ON THE WEAKEST LINKS.) 1) COVERAGE OF TARGET POPULATION - disaggregated by district Note: population-based estimates are the most available and most often quoted, but lack in reliability in those countries which have not had a good recent census [EVEN THOSE WITH A GOOD CENSUS TEND TO MISS THE SAME GROUPS OF CHILDREN MOST OFTEN OVERLOOKED BY THE POLIO PROGRAM - URBAN SLUMS, HIGH- RISES, MIGRANT GROUPS, TRIBAL AREAS - I WOULD DELETE THE NOTE. AT SOME POINT IT WOULD BE GOOD TO POINT OUT THAT THE UNDER 5 POPULATION NID DATA IS THE BETTER DATA TO PLAN FROM FOR OTHER HEALTH PROGRAMS]. Rationale: Recommended indicator: Use indicators based on year to year and round to rounds comparisons. EXPLANATION: POPULATION-BASED ESTIMATES ARE THE MOST AVAILABLE AND MOST OFTEN QUOTED, BUT LACK IN RELIABILITY. At all levels, and especially in pinpointing districts, the crude vaccination statistics, if kept in the same way from round to round, avoid the pitfalls of demographics. EXAMPLE: [SIMPLIFY] One can reliably say that if District X halved (or doubled) its NIDs vaccinations between 1999 and 2000, this is statistically significant. INTERPRETATION: Another, related indicator, again based on available data, is performance over time in districts where the door to door strategy has been introduced. If house to house starts in 2000, then 2000 vaccinations should, district by district, exceed 1999 vaccinations. If they don't, something went wrong. 2) ZERO DOSE MONITORING RATIONALE: THE PE MICROPLANNING SHOULD IMPROVE AFTER EACH ROUND IF PLANNERS KNOW WHERE THERE ARE POCKETS OF UNREACHED CHILDREN. ZERO-DOSE MONITORING IS IT IS PATICULARLY IMPORTANT TO INCLUDE A FULL EXPLANATION OF THE APPROPRIATE MEANS OF COLLECTING THIS DATA DURING TRAINING FOR VACCINATORS. IF VACCINATORS DON'T "GET IT", THEN THIS SHOULD BE LEFT TO SUPERVISORS OR MONITORS TO COLLECT. (SEE MY EMAIL ON THIS SUBJECT) etc. zero dose reporting as a proportion of the total is useful if and only if infant vaccinations are excluded. It should be based on 12- to 59-month-olds; otherwise, you are mixing kids who should have been vaccinated with those who were too young to have been. Zero dose reporting is most useful in doing district to district comparisons. 3) INDICATORS BASED ON IDENTIFICATION OF UNDERPERFORMING DISTRICTS [THIS SHOULD COME BEFORE ZERO-DOSE MONITORING] This is the heart of the matter. If you want to make an impact, you find the underperformers and send in the marines. How to identify? Informal polls of nationals. Better yet, meetings of district NIDs managers after the first round of NIDs to prepare (by secret ballot) a list of the underperfomers. Anonymous postcard polls are the [ONE] ideal way to identify underperforming districts, especially when done among peripheral health workers, who know in more detail than their superiors what went wrong. GRAB SAMPLES ARE ANOTHER. Here is my anonymous ballot paper for NIDs performance. [BOB, FIRST, WE ALREADY KNOW WHERE MOST OF THE UNDERPERFORMING DISTRICTS ARE. THE PROBLEM IS HOW TO CORRECTLY ADDRESS THE BARRIERS/CONSTRAINTS AND TAKE APPROPRIATE ACTION TO SOLVE THE PROBLEM. TOO OFTEN THE BARRIERS ARE CULTURAL/RELIGIOUS/ETHNIC - WHICH ARE VERY DIFFICULT TO ADDRESS FROM "WITHIN". THEY NEED TO BE IDENTIFIED BY BOLD AND FEARLESS PEOPLE WHO CAN NEGOTIATE WITH GOVERNMENT. OPERATIONAL BARRIERS ARE A BIT EASIER TO IDENTIFY FROM WITHIN-IF THERE IS A GOOD UNDERSTANDING OF HOW AN OPTIMAL PROGRAM SHOULD BE DESIGNED AND IMPLEMENTED. TO A CERTAIN EXTENT I AGREE WITH YOU THAT PERIPHERAL HEALTH WORKERS KNOW WHAT DIDN'T GO WELL ACCORDING TO PLAN. UNFORTUNATELY, I'VE ALSO SEEN TOO MANY EXAMPLES WHERE HEALTH WORKERS DIDN'T RECOGNIZE A PROBLEM/GAP/OPPORTUNITY WHEN THEY SAW IT (it wasn't in the plan) E.G. VACCINE MANAGEMENT/NOT FROZEN ICE PACKS OR VACCINE WITH VVMS AT STAGE 2 GOING TO THE HEALTH WORKERS TRAVELING THE FURTHEST DISTANCE; HEALTH WORKERS GOING TO THE ENTRANCE OF A STREET/VILLAGE AND NOT ENTERING THE HOUSES AND ASKING FOR THE SLEEPING, SICK, YOUNG CHILDREN; TOO FEW FEMALE VACCINATORS ON MOBILE TEAMS IN AREAS WHERE MALE HEALTH WORKERS CAN'T ENTER HOUSES; SENDING VACCINATORS OF ONE ETHNIC/CASTE/RELIGIOUS GROUP INTO AN AREAPREDOMINANTLY OF MINORITIES; LACK OF UNDERSTANDING ABOUT "WHAT TO SAY/WHAT NOT TO SAY". I PREFER THE GRAB SAMPLE METHODOLOGY TO THE BALLOTAPPROACH. REGARDLESS OF WHETHER GRAB SAMPLES OR BALLOTS ARE USED, IN ORDER FOR THE FINDINGS TO BE EXTREMELY HELPFUL, AS OPPOSED TO MODERATELY HELPFUL, I THINK THE TRAINING AND SUPERVISION ISSUES NEED TO BE ADDRESSED SO THAT EVERYONE UNDERSTANDS THE "OPTIMUM" STANDARD. IN ADDITION, IF WE ARE GOING TO GO TO THE TROUBLE OF COLLECTING BALLOTS, AT SOME POINT THE SUPERVISOR AND VACCINATORS NEED TO BE EMPOWERED TO TAKE ACTION BASED ON THE INFORMATION. THIS GETS BACK TO MY SUGGESTION FOR BETTER GUIDANCE IN PLANNING, TRAINING AND SUPERVISION.] ANONYMOUS BALLOT PAPER, DISTRICT ..........., STATE OF ............ PLEASE RETURN THIS PAPER UNSIGNED TO YOUR MEDICAL OFFICER OF HEALTH, CIRCLING FOR EACH OF THE QUALITY INDICATORS LISTED HOW YOU PERCEIVE THE PERFORMANCE OF THE MOST RECENT POLIO CAMPAIGN IN YOUR DISTRICT. 4) COLD CHAIN AND LOGISTICS VERY GOOD GOOD MEDIOCRE POOR VERY POOR - Was the cold chain implemented and managed according to standards (HOW FAR IN ADVANCE DID THE VACCINE ARRIVE? HOW MUCH VACCINE WAS LEFT AT THE END OF THE ROUND? WAS THIS AMOUNT REPORTED BACK TO THE CENTRAL LEVEL TO FACILITATE DISTRIBUTION FOR THE NEXT ROUND/ROUTINE EPI?) - Were VVMs still showing potent vaccine when examined by supervisors (DISTRIBUTED APPROPRIATELY TO TEAMS DURING 'STAGING"?/ IF NOT, WAS THIS AN ISSUE AT THE COLD STORES OR OF THE ICE PACKS/DISTRIBUTION? I THINK THE ANSWERS WILL HELP IDENTIFY THE SOLUTIONS. - was there sufficient quantity of OPV for each team (WASTAGE?) 5) PLANNING and TRAINING VERY GOOD GOOD MEDIOCRE POOR VERY POOR THIS SECTION SHOULD RECOMMEND SEPARATE TRAINING FOR SUPERVISORS AND INDEPENDENT MONITORS. TYPICALLY, THE SUPERVISORS ATTEND THE VACCINATOR TRAINING, WHICH IS IMPORTANT, BUT THEY DO NOT RECEIVE SPSECIAL TRAINING IN HOW TO SUPERVISE/MAKE DECISIONS/USE THE DATA. THIS SECTIONS SHOULD BE EXPANDED TO INCLUDE: DID MICROPLANNING TAKE INTO ACCOUNT EACH OF THE TYPICALLY MISSED GROUPS? WERE VACCINATORS INSTRUCTED TO GO CHILD-TO-CHILD? (AVOID THE USE OF HOUSE-TO-HOUSE --TOO OFTEN THIS IS INTERPRETED AS ANY DWELLING WITH A COOKSTOVE. I'VE SEEN VERY WELL MOTIVATED TEAMS WALK RIGHT PAST A TEMPORARY DWELLING (TARP IN SLUM) , CHILDREN AT THE WORKPLACE (BONDED LABOR CAMPS, MARKETS, CHILDREN AT SCHOOL/CHURCH, ETC). WAS THE GENDER MIX/ETHNIC OR RELIGIOUS MIX OF THE TEAMS APPROPRIATE TO THE CATCHMENT AREA? DID THE TEAMS HAVE A COMMUNITY GUIDE TO FACILITATE THEIR ENTRANCE INTO "HOMES" OR "RISKY" AREAS? WAS THERE TRANSPORTATION FOR THE VACCINATORS AND SUPERVISORS IN REMOTE AREAS? WERE VACCINATORS INSTRUCTED ABOUT THINGS TO SAY/NOT TO SAY? COULD THEY INTERPRET A VVM? DID THEY UNDERSTAND THE ZERO-DOSE CONCEPT? - were microplans developed at the district level SUPERVISORS: WERE THERE ENOUGH? TRANSPORT? WHAT TASKS WERE THEY ASSIGNED? OPV-RESTOCKING ONLY? DISTRIBUTION OF FUNDS? ENABLED TO TAKE MID-COURSE CORRECTIONS TO ADD TEAMS, REDIRECT SOCMOB ACTIVITIES? WERE SUPERVISORS INSTRUCTED TO DO APPROPRIATE GRAB SAMPLES AND DID THEY UNDERSTAND WHAT ACTIONS TO TAKE BASED ON THEIR FINDINGS? 6) SOCIAL MOBILIZATION VERY GOOD GOOD MEDIOCRE POOR VERY POOR - WERE MATERIALS PRE-TESTED? WAS THE MIX OF STRATEGIES, MASS MEDIA - PRINT - IPC APPROPRIATE/COST-EFFECTIVE? - timely distribution of materials - strategies to identify minority or unreached population AS DESCRIBED IN THE MICROPLAN employed? WERE ADDITIONAL STRATEGIES ADDED? - were additional strategies besides posters/banners/T- shirts used ? WERE THEY EFFECTIVE? - were special efforts undertaken in underperforming districts - WERE MEETINGS WITH COMMUNITY/RELIGIOUS/OPINION LEADERS CONDUCTED? - WERE MIS-INFORMATION CAMPAIGNS PRE-EMPTED? 7) CASH ADVANCES / IN-KIND SUPPORT VERY GOOD GOOD MEDIOCRE POOR VERY POOR - available in a timely way not to disrupt or delay activities - LUNCHES/FOOD/WATER PROVIDED? 8) IMPLEMENTATION VERY GOOD GOOD MEDIOCRE POOR VERY POOR - were maps used for house to house activities DID EACH TEAM HAVE A COPY OF THE MAP? DID THE SUPERVISOR? - WERE ALL SECTORS FULLY ENGAGED? WHO ELSE COULD HAVE BEEN INCLUDED (E.G. NETWORKS OF ORGANIZATIONS, PVOS, POLICE/MILITARY, PROFESSIONAL ASSOCIATIONS) - were special plans made for "border" areas - in urban areas were there plans to go to everyone floor in high rise buildings? - was supervision sufficient (numbers, checklists completed DID EACH SUPERVISOR HAVE A CHECKLIST?, results reviewed) - were independent monitors used - were specific efforts to target low performing and/or "high" risk areas - were special plans undertaken to immunize "unreached", hard to reach communities (for example, displaced communities, nomads, urban slums) - for house to house activities, were children (or houses) who were immunized "marked" APPROPRIATELY - IF BOOTHS WERE USED, WERE THERE AS MANY AS PLANNED? WERE THEY FULLY STAFFED? QUALITY OF CLIENT FLOW/VACCINE/SOCMOB? DO THE TALLEY SHEETS REFLECT THE NUMBER OF DOSES/EMPTY VIALS AVAILABLE? 9) OVERALL MANAGEMENT VERY GOOD GOOD MEDIOCRE POOR VERY POOR 10) WHAT WOULD YOU DO DIFFERENTLY? 11) YOU MAY WANT TO CONSIDER AN INDICATOR ON EMPOWERMENT. COLLECTING ALL OF THIS INFORMATION IS FINE, BUT IF SUPERVISORS/NID PLANNERS CAN'T TAKE IMMEDIATE ACTION AND CORRECT THE PROBLEM - WHAT'S THE POINT? IF THIS IS A WAR, WE CAN'T CONTINUE TO DISCUSS EVERYTHING IN A COMMITTEE AND WAIT FOR IT TO WORK ITS WAY THROUGH APPROPRIATE CHANNELS. LET'S FIND A WAY TO KEEP THE INDICATORS AND THE ACTIONS AS CLOSE TO THE IMPLEMENTATION LEVEL AS POSSIBLE. Proposed Timeline, Plans, and Use of Indicators: 1) Timeline: Review proposed indictors in UNICEF April 28 Circulate proposed indicators among partners May 1 Present to TCG May 9 Field test June/August Revise for use in Fall NIDs September/October 2) Disseminate at appropriate meetings: TCGs for EMRO - June, SEARO - August, AFRO - December and respective UNICEF meetings. OTHER DISSEMINATION CHANNELS INCLUDE TECHNET; NGOS/PVOS 3) UNICEF and WHO will test these indicators in a sample of the 14 priority countries (to be decided) 4) UNICEF and WHO will use the (ICCs) to establish consensus on the quality of each NID round by using the indictors. The ICC should use the information to advocate with the government for necessary support to improve quality. I WOULD SUGGEST THE DATA AND QUALITY BE DISCUSSED AT THE REGIONAL/PROVINCIAL LEVEL FIRST - DON'T WAIT FOR NATIONAL LEVEL BLESSING IF ACTION CAN BE TAKEN LOCALLY. NATIONAL LEVEL INVOLVEMENT IS MOST IMPORTANT FOR ISSUES THAT CAN'T BE RESOLVED AT LOWER LEVELS OR THAT ARE PRIMARILY IMPLEMENTED AT THE NATIONAL LEVEL E.G. MASS MEDIA 5) WHO and UNICEF country representatives (and/or the ICC) should routinely present information on the quality of NIDs as well progress of polio eradication to the highest-level authorities (e.g. Head of State, Minister of Health, etc.). THIS INFORMATION SHOULD ALSO BE PROVIDED BACK TO THE HEALTH WORKERS AND MID-LEVEL MANAGERS TO IMPROVE PERFORMANCE, KEEP THEM MOTIVATED, SET OUT CHALLENGES AND TO ENCOURAGE REPORTING OF PROBLEMS/SHOW THEIR SUGGESTIONS REAP RESULTS. ____________________________________*______________________________________ 2. THE USE OF "ZERO-DOSE" This is a side discussion of the points raised in Item 1 of this TECHNET Forum posting. Contributions, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ From: "Alasdair Wylie" , on 04/15/2000 4:57 PM: Dear Ellyn I see that this just got posted although you sent it in a while ago; haven't looked through it properly yet but well done for putting it together. On the Child to Child work, we found during the urban EPI review in Bangladesh in Jan that they had started this during the Nov/Dec 99 NIDS, with examples of places where it was clearly being done quite throroughly, but managers were not (yet) making use of the "zero dose" data collected......maybe because apparently the national guidelines for this new element had been prepared and disseminated extremely late, and did not include (or emphasize) how to monitor the quality/completeness of it and what to do with the information collected. My related interest in this is that it may well be a tool which for the first time can help identify and characterise the hard core 5% - 10% of infants who are zero dose for all EPI antigens even in the best national programmes. Any examples yet of countries trying this, even in selected areas/localities? All the best Alasdair --- Alasdair: I've observed the use of "zero-dose" in Nigeria, Ethiopia, India and Nepal. In Nigeria, the training was done pretty well in the area that I observed (Abia State). The vaccinators understood what they were asking about, used the tally sheets correctly and seemed to understand the implications of the data. In Ethiopia, they tried to identify "zero-dose" children during the "house- to-house" NIDs. The training for this wasn't very good, vaccinators didn't understand what the term meant exactly and failed to use the tally sheet appropriately. The whole concept was very confusing. This was in Addis and within a 3 hour drive. In India, the "independent monitors" were collecting this information using a sampling methodology and it seemed to be going pretty well. In addition, in some areas, the "house-to-house" vaccination teams were also trying to collect the information. Again, where the training was well done, the data was collected and the implications immediately understood. Where training was done poorly, supervision was bad or where the DMO wasn't motivated -- the whole concept wasn't understood and caused lots of confusion. In Nepal, I observed a very small location, but the supervisors were well informed and they seemed to be collecting the information ok. I didn't get a chance to delve into this as much as I have in other countries. Also, we've incorporated this indicator into our grants with the CORE PVO's who will be working on intensified NIDs/SNIDs/Mop-ups and they hope to use it for other antigens. Of course, these PVOs are/will be well trained and have a good working knowledge of their communities. I hope this answers your questions. Ellyn ____________________________________*______________________________________

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