Integrating immunisation services into nutrition sites to improve immunisation status of internally displaced persons’ children living in Bentiu protection of civilian site, South Sudan

Introduction The protracted war in South Sudan has led to severe humanitarian crisis with high level of malnutrition and disruption of the health systems with continuous displacement of the population and low immunization coverage predisposing the population to vaccine preventable diseases. The study aimed at evaluating the effect of integrating immunization services with already established nutrition services on immunization coverage in resource-constrained humanitarian response. Methods A community and health facility based interventional study involving integration of immunization into nutrition services in two Outpatient Therapeutic Program(OTP)centers in Bentiu PoC between January-December 2017. The main hypothesis was that inclusion of immunization services during nutrition services both at the OTP and community outreaches be an effective strategy for reducing missed opportunity for immunizing all eligible children accessing nutrition services. Data analyzed using STATA version 15 and bivariate analysis using logistic regression was conducted to identify predictor of missed vaccinations. Results Integration of immunization into the nutrition services through the OTP centres increased the number of children immunized with various antigens and the dropout rate was much lower and statistically significant among children who received immunization at the OTP centers than those in the Primary Health Care Centers (PHC Centers) in the study sites. Children who were vaccinated at the OTP centre in sector 2 were 45% less likely to miss vaccination than those vaccinated at the PHCC (OR: 0.45; 95%CI:0.36- 0.55), p<0.05 while those vaccinated at the OTP sector in sector 5 were 27% less likely to miss vaccination than those vaccinated at the PHCC (OR: 0.27; 95%CI: 0.20 -0.35) p<0.05). Conclusion This study indicated that immunization coverage improved effectively with integration with nutrition services as a model of an integrated immunization programme for child health in line with the Integrated Management of Childhood Illnesses (IMCI) and the Global Immunization Vision and Strategy (GIV).


Introduction
Expanded Program on Immunization (EPI) has become one of the most successful public health programmes, reaching over 85% of the world's children [1]. However, EPI coverage has been plateauing the last 10 years and having not reached the set coverage targets; twenty-two million children, mostly living in the world's poorest countries who haven't received the full course of recommended vaccine by the age of 1 year [1] and integrated and comprehensive service delivery has been reported to have potential to generate demand, strengthen routine immunization services, reduce missed opportunities and improve coverage [2]. The especially among the IDPs due to poor immunization coverage [3].
In the Bentiu PoC, measles vaccination coverage verified by immunization card was found to be 23.4% during SMART survey conducted in 2016 and there was also reported outbreak of measles in 2016 as a result of significant unimmunized children with missed opportunities during provision of nutrition services in the camp [4].
A child who is borderline nourished will tip into malnutrition if he or she contracts an infectious disease such as measles. As part of an integrated health approach, immunization plays a critical role in curbing the devastating impact of malnutrition.
WHO and UNICEF developed the Global Immunization Vision and Strategy (GIVS), in 2005, to expand the reach of EPI, and prevent more disease [5]. In May 2012, the Global Vaccine Action Plan (GVAP) framework was endorsed at the World Health Assembly (WHA) to achieve the Decade of Vaccines' vision of delivering universal access to immunizations [1]. One of the six GVAP principles is integration, stating: "strong immunization systems, as part of broader health systems and closely coordinated with other primary health care delivery programmes, are essential for achieving immunization goals." This promotes a strong immunization system as an integral part of a well-functioning health system, as well as the development of appropriate interventions for integration, to maximize the synergistic effects [1,5]. However, various studies have suggested that the design of integrated outreach services should be informed by local experience supplemented by lessons learned elsewhere [6][7][8]. In most countries, there are more service delivery points for immunization than other services like nutrition and in such settings, immunization platforms are being used to improve access to non-vaccine programs [1]. However, in South Sudan similar to what obtains in other low-income countries, lack of regular or adequate funding has been commonly cited for poor implementation of immunization outreach activities. For example, cost and financing assessment for Ethiopia's National Immunization Program [9] found that operational costs (primarily transport and per diem payments) for integrated outreach were consistently underfunded or not funded at all. In response to the food crises being reported in most of the conflict affected states in South Sudan including the study site, significant fund has been deployed to address the malnutrition associated with the food crises and so better resources are available for nutrition platform to be used in improving immunization services especially community outreaches.
In addition, the Ready to use Therapeutic Food (RUTF) being provided to the malnourished children at the Out Patient Therapeutic Program (OTP) centers serve as a form of incentives for mother and care givers to travel long distance when needed to access the nutrition services much more than they do to receive immunization services for their children This study aimed at evaluating the effect of integrating immunization services in the nutrition services on immunization coverage in a resource constrained humanitarian response.
Justification for the study: The OTP centers are located few meters to the PHC centers where immunizations are being conducted and mothers were usually asked to go to the PHCC after being attended to at the OTP centers for their children immunization. However, it was observed that most of the children referred from the OTP centers to the PHCC for immunization services didn't go. During a focus group discussion conducted among the mothers/care givers some of the reasons given by the mothers/care givers for not taking their children for immunization at the PHCC when referred from OTP centers included being tired after spending some considerable time at the OTP centre and the need to go back home to continue their work or household chores. Some caregivers reported that on few occasions they went, the vaccinators were not around to provide the services or being asked Page number not for citation purposes 3 to queue up again on getting to the clinic instead of being attended to immediately while others reported they forgot the immunization cards and had to go back home but late to go back to the clinic for that day leading to missed opportunity to improve immunization coverage in the camp.

Methods
This was a community and health facility based interventional study during which immunization services were integrated with nutrition services in OTP centres and nutrition outreaches where immunization was previously not provided. The community nutrition volunteers tracked children who defaulted from both the nutrition and immunization programs using the facility records and child health cards. The defaulter tracking was incorporated as part of the community outreaches so any child who had missed any immunization session was appropriately vaccinated.
The main hypothesis was that inclusion of immunization services during nutrition services both at the OTP and community outreaches be an effective strategy for reducing missed opportunity for immunizing all eligible children accessing nutrition services.

Results
The comparison analysis of the immunization data showed that

Discussion
In most studies on integration [8,11], immunization program was used as platform for integrating other MNCH services unlike this study where nutrition program was used as the entry point/ platform for integration of immunization services. Most studies [12][13][14] where integration was done using nutrition program as platform, were mostly co-location than co-delivery where children who came for nutrition services were referred to other immunization services delivery points unlike this study where both immunization and nutrition services were co-delivered both at the OTP centres and during outreaches. In this study there was increase in the immunization services among the vulnerable population this is similar to findings from two studies [15,16] where nutrition was used as platform for integration on immunization services. In these two related studies [15,16] on Growth Monitoring Program Plus programme, which involved providing monthly outreach services implemented in peri-urban areas of Lusaka, Zambia immunization coverage was shown to significantly increase. In a randomised controlled intervention trial [14] conducted in seven Special Supplementary Program for Women, Infant and Children sites (WICs) in Chicago, in the intervention sites immunization activities were included in the routine nutrition activities which involved screening for all children under 5 during every visit to the WIC, referral of every eligible children for immunization and use of food vouchers for mothers to bring their children for immunization when needed, the vaccination coverage was reported significantly increased in the intervention group. However, the study showed that that conducting assessment and referral of women, infant and children in the nutrition program to immunization points without other accompanying interventions did not raise vaccination coverage and showed no evidence that immunization assessment and referral alone increased immunization coverage in this population and concluded that the use of voucher incentives has the strongest evidence of effectiveness in increasing immunization rates. This is the belief in this study that the plumpy nuts provided would have been a form of incentives to care givers and mothers to bring their children for the services.
In this study, the dropout rate was much lower and statistically significant among children who received immunization at the OTP centres than those in the PHC Centre, this may be attributed to the incentives received at the clinic in term of therapeutic food by the child parents and the tracking of defaulter integrated with the tracking of OTP patients, this is similar to a randomised controlled intervention trial [15]  Integration has evolved to be one of the service delivery models with the potential to enhance improve coverage, efficiencies, synergies and child survival outcomes [19]. Yet, understanding and implemented for decades [20] but have failed to adequately institutionalize their integration and co-delivery of services in one encounter [21].

Conclusion
This study indicated that retention rates and completed vaccination  Integration reduced greatly the missed opportunity for immunization services among the vulnerable population. 7   Tables and figures   Table 1: Immunization coverage among children malnourished vaccinated at the OTP centers in sector 2 and sector 5 Table 2: Immunization coverage among children vaccinated at the OTPs and PHCCs in sector 2 and sector 5