Introduction of Typhoid Conjugate Vaccine (TCV) in Nepal: Role of the Vaccination Campaign in Identifying and Reaching Zero-Dose Children

"Grassroot health workers believed that the TCV campaign was an important pathway to reach ZD children. The TCV campaign made people aware of the need for vaccination, which in turn helped the cause of vaccinating ZD children."

Zero-dose (ZD) and under-immunised children are clustered in marginalised communities across Nepal. In April 2022, the Government of Nepal launched typhoid conjugate vaccine (TCV) into the country's routine immunisation programme. From the Gavi Zero-Dose Learning Hub (ZDLH) , this case study explores the strategies used in leveraging the 2022 TCV campaign to reach ZD children in Nepal and to further link them to the routine immunisation system, with the ultimate goal of reaching full immunisation. Practitioners working to reach ZD children and missed communities can use the findings from this case study, which features insights from key informant interviews (KIIs) with those involved in the campaign, to inform their own outreach efforts.

The TCV campaign was conducted between April 8 - May 1 2022 in all 77 districts across 7 provinces of Nepal. A range of stakeholders were involved, including government functionaries, international and United Nations (UN) agencies, female community health volunteers, and school teachers. During the microplanning stage, the villages/wards/residential areas of participants were mapped, the number of participants estimated, logistics requirements assessed, and plans put in place. The local volunteers were also provided with a one-day training session on executing community engagement initiatives for the TCV campaign. This training was focused on attending to societal norms, timing the activities, considering participant demographics, and other factors. Following the provincial and district coordination meetings, as well as communication campaigns through visual, print, social and informal/folk media, the rollout began. It featured:

• Vaccination campaign in a single phase;
• Coordination, cooperation, and ownership by the federal, provincial, and local levels;
• Logistic management and capacity building of human resources;
• Information, education, and communication (IEC) approaches, including social mobilisation and school education;
• Strengthening of routine immunisation and promotion of hygiene and sanitation through the campaign; and
• Implementation of a post-campaign vaccine coverage survey.

The TCV campaign used several communication tools, including a campaign invitation card that provided the full immunisation schedule on the reverse side. These cards were distributed to all households with children in the eligible age range. There was also a campaign vaccination card with two versions: one for children aged 15 to 24 months and the other for children aged 2 to 14 years. The card included a counterfoil that was designed to be torn off and kept at the health facility for tracking children with missed doses. Health workers recorded children with missed doses in the counterfoil for follow up and completion of all recommended routine doses.

Furthermore, health workers at vaccination sessions provided counseling to caregivers of children under 24 months on the importance of routine immunisation and, given the specific age group, assessed them for measles-rubella vaccine status (provided at 15 months) along with other routine vaccines. This action was one of the TCV campaign's built-in mechanisms to look for and identify ZD children. They were subsequently brought under catch-up service coverage after the campaign. Patterns:

• ZD children were mainly located in urban slums and remote areas with a higher concentration of underserved communities, including minority groups. Said one KII respondent: "To cover them, local leaders, city health volunteers, as well as female community health workers micro plan and mobilized the community and cover all those marginalized areas."
• Certain religious affiliations were also found to be associated with ZD status, which health workers addressed by mobilising and sensitising relevant community and opinion leaders. A KII respondent explained: "[In cases] where most children (zero dose and missed doses) belonged to a specific community like the Muslim community, we provided counseling to the community leader, maulana, and teacher."

Door-to-door rapid convenience monitoring (RCM) during the TCV campaign in Nepal was used to identify and reach children who were missed by the initial vaccination campaign efforts and to increase coverage. The World Health Organization (WHO) developed an application-based system for use on both android and iOS platforms to monitor 46,000 children in 75 districts during the RCM phase. The app-based monitoring was done by the WHO, while the routine RCM was carried out using a pen and paper by government functionaries concurrently with the TCV campaign. Both monitoring exercises were planned and conducted in communication with each other so that there was no duplication.

All told, the TCV campaign reached over 7 million children across Nepal through its catch-up strategy, in addition to those reached through the post-campaign introduction of TCV into the routine immunisation programme.

Stakeholders highlighted the challenges of coordinating and conducting a campaign on a national scale in addition to the difficulties of managing logistics, training, and mobilisation across the entire country. With regard to facilitators for TCV introduction:

• During the TCV campaign, the focus on ZD children was an explicit objective that was taken into consideration from the onset and throughout the planning and implementation of the campaign. Related actions included the revision of the immunisation policy to administer missed doses to children up to the age of 5 and the training of health workers and monitors to identify ZD children.
• The spread of information about the TCV campaign exceeded expectations, with the cooperation of all stakeholders including media and civil society. Interview respondents cited the high level of political commitment, stakeholder engagement and advocacy, and community participation as the main facilitators of this success.
• Some KII respondents mentioned that, traditionally, Nepal has a history of successful community uptake of vaccines. Routine immunisation coverage is high, and vaccines are widely accepted by communities in Nepal. The country has introduced many new vaccines in the past, which set a positive stage for the introduction of TCV.
• Prior to the TCV campaign background analysis, the team conducted a disease burden analysis to understand coverage gaps. Topography and programmatic challenges were addressed locally, on a case-by-case basis. Where electronic or mass media was not available, the team identified community volunteers who linked community members to the healthcare delivery system and played an instrumental role in the smooth implementation of the campaign. According to one KII respondent: "We do have different traditional announcers like chaukidar who have a traditional role to give a message. We used them, we trained them to provide immunization messages. Basically, they are the villagers; where there is no television, no means of communication, they were the main source of information."
• Immunisation invitation cards were provided to the community, which made them feel valued. The implementation of vaccine cards in a campaign can significantly enhance vaccine uptake via ensuring continuity of care, tracking of vaccinations, and promoting overall awareness.
• Multilevel involvement during the TCV campaign was another example of a best practice. Three levels of government - federal, local, and community - took part in the campaign. Per one KII respondent, "The TCV campaign had very high-level advocacy, high-level endorsement, and actually TCV vaccination campaign was also launched by honorable President of Nepal, so high level advocacy was there, so I think all of these factors including support by the partners at the national and subnational level contributed for the success of the campaign." Political commitment and engagement play an essential role in driving the success of any vaccine campaign.
• A unified approach between various sectors, including government bodies, non-governmental organisations (NGOs), and community-based organisations (CBOs), created a robust foundation for delivering vaccines to those who may have been missed or under immunised.
• Stakeholders acknowledged that their learning from COVID-19 work - their leveraging of information, resources, and/or partnerships developed for the COVID-19 vaccination campaign - benefited the TCV campaign and identification of ZD children.
• Introduction of the electronic application-based system streamlined data management, enhanced accessibility, and boosted overall efficiency within vaccination processes.

Funded by Gavi, ZDLH focuses on improving immunisation equity and reducing the number of ZD and under-immunised children globally by facilitating high-quality evidence generation and uptake. It also serves as the global learning partner and enables sharing and learning across 4 country learning hubs (CLHs) in Bangladesh, Mali, Nigeria, and Uganda to advance the uptake of evidence by synthesising and disseminating key learnings.