by Sandra Michie.

The needs

Years ago in Zambia our tiny mission hospital was regularly over-filled with epidemic patients. Whooping cough and measles were the two worst and best remembered epidemics. In 1967 at least one child died from measles in every surrounding village. Often three or more died and since villages were very small - often with just one extended family - you can imagine the grief and despair.

In a country where there is malnutrition, measles may often be fatal. Perhaps the worst thing about this for us as health workers, was that we were not always able to help medically. We could only give supportive care to the children who suffered. We had to stand back and watch many die. We also suffered with the parents the awful tragedies of damaged hearing or blindness in many children who did recover.

The difficulties

It was 1968 when we were first able to obtain supplies of the measles vaccine. Other vaccines had been available for some time, but were not understood or well accepted by our community in a very isolated and rural part of Zambia. It was a large area with a fairly small population scattered around vast plains that flooded in the rainy season. Families moved from season to season as they followed the annual cycle of food supply. For example: work in the fields far from home meant living there until that work finished; the flood season brought the fish harvest so they would move to the flood plains perhaps many miles away; and sometimes... they were at home!

In order to register the children in some way the names used had to be ones that would be consistent. This is not easy where a child can have a first name from either side of the family, one given by the midwife and also a western name - and each group would only use ‘their’ name for that child. Then the surname or father’s name might be that of the ‘father who gave them birth’ or perhaps their uncle’s name, or even the name of the relative with whom they were temporarily staying or...? The children could choose their own names when they went to school and also again when they reached their teenage years!

The plan of action

After much prayer and considerable thought we worked out a plan to visit every single home in the local and surrounding area within a distance of 30 miles, and to register every child under 14 years of age. This proved to be about 3,000 children and took myself and my colleagues many long hot days of hard walking to achieve.

We decided to use the mother’s most common name for the child and the ‘father who gave them birth’ for the surname and file them alphabetically. The staff often found difficulty in this way of filing but it worked better than filing by number. The medical staff were amazingly good at finding wrongly filed cards.

All of this work took many months as it was done in addition to our already full workload, but in many ways this was the easiest part of the work.  What lay ahead were years of hard work, teaching, consistency, relationship building, disappointments, study to keep up to date with new procedures and so on.

The steps we used

1. TEAMWORK
Teamwork is absolutely essential. The team consisted of the medically based people and the leaders of the communities concerned. One person may have a vision for a task, but unless they are able to inspire others to share that vision and contribute their ideas and abilities, such a project will fail. All our staff were encouraged to ‘catch’ children - for example noticing health problems such as malnutrition and encouraging the parents to bring them for care. This included all the cleaners and outdoor workers who were very good at recognising families where immunization was not a priority.

2. REGISTRATION
This has to be planned carefully in order to achieve the best result with the least waste of time and energy. Such a task is hard work anyway. We searched out all the children by door to door visiting. We also used to challenge community leaders to aim to become the area with the highest immunization levels. This rivalry brought out a fairly large number of children who had at first missed the registration.

On our registration campaign we aimed to...

  • issue every child aged 0-4 years with a home-based ‘Road to Health’ card 
  • issue every child aged 5-14 years with a vaccine record card 
  • find that child’s medical record from the clinic and change the name if necessary to match the home record 
  • teach the community leaders and parents about the importance of immunization.

From this information, separate registers were finally made for the local areas. For each area we planned visits with mobile clinics. These registers grouped together children of the same age and had columns for necessary details and immunizations. 

Home-based cards

Every mother had to have a card for every child. They were already used to the idea of every adult needing a registration card. We encouraged them to give the child’s card the same priority.  When produced, these cards gave us the child’s name and details of any vaccines received elsewhere. We encouraged the mother to use their own records in other clinics as universal cards for that child’s health.

3. IMMUNIZATION
This was on-going and continuous.

Mobile clinics were planned according to the population density, and we did not take on too much at the beginning. When one area was fairly well immunized, we would maintain this area and also begin work in another area. All children from all areas were registered from the beginning to enable us to catch them whenever they visited the health centre.

There was a daily check of all children in the out-patients department before any other member of the family was treated. So if a mother came for treatment for herself, the baby on her back was weighed or immunized as necessary as well as any other children with her, before the mother’s needs were looked at. We aimed to weigh all children at least once a month. This was done whether or not the mother had brought in the child’s card.

Regular mobile clinics were held in the centre of a village with the scales hung from a tree, and a table borrowed for the vaccines. Be trustworthy - if you say there will be a clinic on a certain day, make sure there is one! On the rare occasions when it was impossible for us to attend, we always sent a messenger with apologies and clear arrangements for the substitute clinic.

Even with only three or four visits a year, it is possible to immunize all children effectively if they attend each time. More frequent visits are wise at first. Notify people clearly and send reminders about a week before the next clinic.

Follow-up all those who do not attend. This is sheer hard work after a busy clinic! Often children aged two or three years will be left at home because they cannot walk so far. A reminder may bring them next time.

Competitiveness between areas can be encouraged - for example in attendance or the highest fully vaccinated rate.

Cold chain

It is absolutely essential to ensure that the vaccines are viable when given to the child. Vaccine failure not only puts the child’s life at risk but it also removes confidence.

Good record keeping

The time spent in keeping careful records was very well spent.

All immunizations were recorded on...

  • the mother’s card
  • our record card
  • the area register.

A major problem was the loss of home-based cards. Our system of duplicating these records proved its worth through the years. The registers allowed us to easily take a copy of all records whenever we went into the villages and to check the details of any children who happened to be staying with ‘Grandmother’ or some other family member. Despite the problems with the home-based records, I still feel they are an essential part of the whole programme, keeping the mother responsible for her own child and enabling her to visit any other medical centre with the same card.

Education and communication

Good relationships and communication with the community are essential for such a programme to succeed. Take time to build good relationships with staff, community leaders, parents and grandparents.

Ensure that the whole community is reached with teaching about immunization. Older children too can be encouraged to help - for example by using the Child-to-Child teaching methods through the local schools.

Keep up to date with WHO and national guidelines about vaccines. Make sure you know the latest information about the maximum effective intervals between doses of vaccines, the schedules for immunization and the levels of immunization needed to protect the community. Be willing to make changes with new information.

The results

By 1988 many of the younger mothers had never seen a measles or whooping cough epidemic so were careless about immunizations until epidemics throughout Zambia gave them a real fright. Children were dying all around the country but our 1,000 square mile protected ‘patch’ was wonderfully clear of infection. At that time we had reached and then maintained for over 10 years an 85 - 90% immunization rate for all children. A few children who were not vaccinated suffered, but most kept well - and the attendance at immunization clinics rose rapidly!

Were all the efforts worthwhile? One mother gave us the answer. A measles epidemic was raging throughout Zambia and she had walked in 30 miles to the clinic for her baby’s first DPT injection. We asked if measles had reached her village area. She looked surprised and replied ‘no’. When asked why not, her reply was, ‘Because you have immunized our children of course!’ ‘Of course!’ What a wonderful reply from a woman who ten years earlier had not seen any need to have her children immunized, and where others around her had deliberately kept their children away. Now the level of fully immunized children was high enough to stop the epidemic and she was willing to walk 30 miles to protect her new baby. How our hearts were filled with praise!

Good record keeping is a vital part of any successful campaign. This is one of the pages from the hospital’s Area Register.

Year 1988      AREA 9  - Mukelangombe

Names

Village

Born

Polio

DPT - TETANUS

Measles

BCG

Protected Child

Last seen

 

 

 

1

2

3

4

1

2

3

4

5

 

 

 

 

Kakoma Yowano

Muheto

1-7-88

12/88

2/89

3/89

4/92

12/88

2/89

3/89

4/92

 

4/89

12/88

 yes

88/89/90/91/92

Alan Kasoka

Kamboyi

1/3/88

6/88

7/88

9/88

 

6/88

7/88

9/88

 

 

1/89

6/88

 yes

88/89

Kayombo Zwali

Mauili

16/9/88

10/89

12/89

10/90

 

10/89

12/89

10/90

 

 

10/89

10/89

 yes

89/90

Peter Luneta

Muheto

12/9/88

3/89

10/89

 

 

3/89

10/89

 

 

 

10/89

10/89

 

89

Yowano Kapanji

Muheto

14/4/88

1/90

3/90

6/90

 

1/90

3/90

6/90

 

 

1/90

1/90

 yes

90

Joy Kamboyi

Amboyi

23/2/88

3/90

 

 

 

3/90

 

 

 

 

3/90

3/90

 

90

 

Sandra Michie worked for 25 years in rural Zambia with mission medical work, mainly involved with preventative health care.

 

Essentials for an effective immunization campaign

  • Commitment of all staff from cleners to doctors
  • Good communication
  • Co-operation of village leaders
  • Daily checking of all children in clinic
  • Regular and dependable mobile clinics
  • Hard work