Implementation of integrated supportive supervision in the context of coronavirus 19 pandemic: its effects on routine immunization and vaccine preventable diseases indicators in the East and Southern African Countries
Isah Mohammed Bello1,&, Emmaculate Lebo1, Messeret Eshetu Shibeshi1, Godwin Ubong Akpan2, Jethro Chakauya1, Balcha Girma Masresha2, Fussum Daniel1
1World Health Organization (WHO), Inter-Country Support Team office for East and Southern Africa, P.O. Box 5160, Harare, Zimbabwe, 2World Health Organization (WHO), Regional Office for Africa, Cite de Djoue, Brazzaville, Congo
Isah Mohammed Bello, World Health Organization (WHO), Inter-Country Support Team office for East and Southern Africa, P.O. Box 5160, Harare, Zimbabwe
the coronavirus disease (COVID-19) global pandemic has caused serious disruption to almost all aspect of human endeavor forcing countries to implement unprecedented public health measures aimed at mitigating its effects, such as total lockdown (inter and intra), travel bans, quarantine, social distancing in an effort to contain the spread of the virus. Supportive supervision is a functional component of the immunization systems that allows identification of existing gaps, provides an opportunity for onsite training, and document real-time findings for improvement of the program. The control measures of COVID -19 pandemic has also resulted in limitation of operations of the immunization system including Supportive supervision. This has limited many aspects of supportive supervision for surveillance and routine immunization monitoring system in the East and Southern African countries. The aim of this study is to identify the effects of COVID-19 on Integrated Supportive Supervision visits for expanded programme on immunization (EPI) programme and how it influences the immunization and VPD surveillance indicators, and its short-term effect towards notification of increase or decrease morbidity and mortality.
we reviewed the integrated supportive supervision (ISS) data and the routine administrative coverage from 19 countries in the East and Southern Africa (ESA) for the period January to August 2019 to analyze the trends in the number of visits, vaccine-preventable diseases (VPD), and routine Immunization (RI) indicators using t-test, and compare with the period January to August 2020 during the months of the COVID-19 pandemic.
thirteen countries out of the 19 considered, had shown a decline in the number of integrated supportive supervision (ISS) visits, with 10 (77%) having more than 59% decrease during the January-August 2020 as compared to the same period 2019. 11 (57%) of the countries have shown a decrease (p-value < 0.05). Ethiopia and Kenya had the highest drop (p-value < 0.000). 6(32%) have an increase in the number of visits, with Madagascar, Zambia, and Zimbabwe having >100% increase in the number of visits. 67% of the countries that have decreased in the number of ISS visits have equally witnessed a drop in DPT3 administrative coverage. Countries with a low proportion of outreach sessions conducted in the period of January - August 2020, have all had sessions interruption, with more than 40% of the reasons associated with the lockdown.
countries have experienced a decrease in the number of supportive supervision visits conducted, during the period of the COVID-19 pandemic and, this has influenced the routine immunization and vaccine-preventable diseases surveillance (VPD) process indicators monitored through the conduct of the visits. Continuous decrease in these performance indicators pose a great threat to the performance sustained and the functionality of the surveillance and immunization system, and consequently on increased surveillance sensitivity to promptly detect outbreaks and aiming to reducing morbidity and mortality in the sub-region.
In 2015, member states in the African region under the leadership of the World Health Organisation (WHO) and other stakeholders adopted a strategic plan on immunization (2014-2020), which is aimed at improving immunization coverage, it was built on the lessons learned from the 2009-2013 Global Immunization Vision and Strategy (GIVS) framework that was translated through the Global Vaccine Action plan ( GVAP) guiding regional and global response to address immunization gaps, interrupt the transmission of poliovirus, containment and achieve measles elimination .
According to WHO, the number of infants who did not receive the third dose of DTP vaccines in 2014 in the region was estimated to be around 7.4 million out of an annual birth cohort of 32.7 million representing 23%. The coverage has remained stagnant at around 70% for a long period of time . Some of The challenges that the immunization programme is facing includes lack of adequate and sustainable resources, logistics and laboratory facilities, data quality and frequent vaccine stock out . Several countries in the region had come up with annual and operational plans, which are geared towards improving coverage and at both national and subnational levels in order to interrupt poliovirus, certification and close immunity gaps including mitigation measures taken guided by periodic risk assessments.
Consequently, outbreaks of vaccine preventable diseases (VPD) like Yellow Fever, Lassa Fever, Ebola etc. have had an adverse effect on the performance of the health system in general, thereby affecting both access and utilization as well as disruption of the health service delivery in some African countries . Measles outbreaks are mostly occurring in communities with low or partially immunized children , which are communities with low or no herd immunity, strong enough to prevent disease transmission in these areas . One of the approaches adopted in African region is the adoption and use of the Reaching Every District (RED), which has played an important role in strengthening the immunization systems to achieve equity and increasing coverage, the RED strategy is built upon five (5) key principles that include planning and management of resources, community engagement, supportive supervision, reaching all eligible and target population and monitoring and use of for action .
Supportive supervision (SS) as one of the strategies of RED has continued to attract attention as an effective tool in managing and improving the quality of health services , it is seen to be an effective strategy towards promoting the delivery of public health services and the quality of health system at all levels through development and increasing the knowledge and competence of health care workers . SS help tightens the relationships that exist in a system, with emphasis on identifying and resolving problems onsite, as well as optimizing the allocation of resources and promoting team work and communication .
The World Health Organization had on March 2020 declared an outbreak of the coronavirus (COVID-19) disease as a global pandemic, which is a public health problem that is threatening the entire world [9, 10]. COVID-19 is a contagious disease that is rapidly spreading from Wuhan City, Hubei Province of China to the rest of the world. Globally, as at November 11th 2020 as of 09:43am GMT+2, a total of 50,810,763 confirmed cases of COVID-19, including 1,263,844 deaths have been reported . In Africa, all the countries in the region had been affected with a cumulative total number of 1,363,929 confirmed cases and 30,883 deaths .
Countries had adopted several strategies in trying to reduce the spread of the disease and breaking the chain of transmission as a standard precautionary measure for fighting the COVIID-19 pandemic, through the application of strict control measures, which includes total lockdown, (intra and inter), social distancing among others, and that had led to disruption of routine preventive and curative health services among others . The routine immunization programme had been affected due alleged fears on contracting the disease in health facilities, staff shortage due to reassignment of health care workers to support the COVID-19 outbreak response, stock-out of vaccines and devices supplies, leading partial or closure of some health facilities, this also includes planned mass vaccination campaign for vaccine preventable diseases (VPD) in some countries that had to be postponed . Fear of contracting the virus, with a significant shift in parents and community behaviour due to social distancing are forcing parents and caregivers to hesitate to go for routine immunizations .
It becomes imperative to understand the effects of COVID-19 on basic routine immunisation services as it continued to be disrupted, especially with the impending warning from health experts on the possible resurgence of Polio and VPD outbreaks in polio-free countries . The World Health Organisation (WHO) had also developed guidance for countries as measures for preventing COVID-19 transmission in health care settings, in an effort to ensure the continuity of basic essential health services, including immunization [17, 18]. In the African region, supportive supervision is conducted using mobile phone-based data collection with the Open Data Kit (ODK) application, which started in Nigeria in 2015 and was then enrolled to other countries of the region . This paper examines the effects of the COVID-19 pandemic on the performance of the ISS in the 19 countries of East and Southern African Countries (ESA) by comparing the number of ISS visits and some VPD and RI indicators in the first 3 quarters of 2020 (COVID-19 pandemic) and same period in 2019 (Before the COVID-19 Pandemic) in the countries.
Data stored on the server for 19 countries in the ESA sub-region implementing the integrated supportive supervision was used, it is a mixture of countries with different population size, having both fragile and weak health system and those with matured health system and sustained high coverage . Monthly routine administrative immunization data was also used for the same period January to August 2019 and 2020. The data was prepared for analysis in Microsoft Excel, with the domain of analysis being country level. Prepared data was analysed in SPSS to assess the level of significance differences, while some of the data sets were analysed in excel. We reviewed the number of integrated supportive supervision (ISS) visits for the Expanded Programme on Immunization (EPI) programme for the period January to August 2019/2020 to compare the trends in the number of ISS visits conducted monthly. We also analysed some selected indicators that are being monitored on monthly basis for vaccine preventable diseases (VPD) and routine immunization (RI) before and after the onset of the COVID-19 pandemic using paired t-test comparing both absolute values and proportions. The indicators considered for VPD surveillance are Proportion of Health.
Facilities visited with Good knowledge of Measles Case Definition and the Number of suspected unreported AFP and measles cases found during the visit, while the indicators considered for routine immunisation (RI) are, the proportion of health facilities (HF) visited with reaching every district (RED) microplan available, proportion of fixed and outreach sessions conducted against planned and the proportion of health facilities (HF) visited with updated monitoring chart. The routine immunisation indicators (RI) are calculated using the last and most current visit made to the health facility after removing duplicates (previous visits) as the denominator. The results were generated at 95% confidence level, with significant level pegged at 5%, and with a corresponding test statistic, 95% confidence differences and p-values in some tables. We also we reviewed and examine the ISS data for 2020 on the reasons for session interruption and included the additional option of covid19 lockdown, which was not available in 2019.
The ISS data is collected using a standard checklist , which was designed to collect information on vaccine preventable disease (VPD) surveillance and routine immunisation process indicators at the health facility with additional features of coordinates location, in-built constraints for easy flow of questions, pictures for validation etc. A Power-BI dashboard was linked to the ISS checklist on the ODK to fetch the data in real time, which allow program managers monitor the performance of the programme. ISS visits are conducted at different frequency depending on the country context (Weekly, Bi-Weekly, Monthly and Quarterly).
The status of COVID-19 reported cases and deaths based on reports received from countries through the World Health Organization (WHO) emergency programme as depicted in Table 1, showed the level of transmission as at the end of August 2020, the tables depicts that three (3) countries have sporadic cases, four (4) countries have cluster of cases while the remaining twelve (12) countries are having active community transmission. South Africa have the highest cumulative case per 1 million population of 10,497, while Eritrea and Seychelles have 0. The number of integrated supportive supervision (ISS) visits has dropped from 34,983 in January - August 2019 to 26,691 same period of 2020, representing a 24% drop. Thirteen (13) countries (68%) have witnessed a decrease in the number of visits as shown in Table 2, while 6(32%) have an increase in the number of visits. Madagascar, Zambia and Zimbabwe have > 100% increase in the number of visits. Seven countries showed difference in the number of visits made (p < 0.05), with the most difference noted in Ethiopia (p-value = 0.001), Kenya (p-value = 0.000, Mauritius (p-value = 0.003) and Uganda (p-value = 0.002).
The VPD surveillance indicator, which looks at the proportion of health care workers with adequate knowledge of Acute Flaccid Paralysis (AFP) and measles case definition in the health facilities visited in the period January - August 2019 showed a decline in 9(47%) and 13 (68%) out of the 19 countries respectively p-value< 0.05) as compared to January - August 2020. Nine (9) and Four (4) countries representing 47% and 32% respectively have either increase or have equal the proportion when compared to same period 2019 and 2020, while Lesotho did not conduct any ISS visit in the period January - August, 2020 (Table 3).
The number of unreported suspected AFP and measles cases found during the ISS visits also dropped from 222 and 1,419 records in the period January - August 2019 to 157 and 500 in 2020 same period respectively. More so, measles suspected unreported cases have shown > 50% decrease in five (5) countries, with four (4) countries having percentage increase of more than 30% when compared to same period, four (4) countries did not report any case, while 1 country (Zimbabwe) have cases reported in January - August 2020 only, with no case reported in the period January - August 2019. Conversely the number of suspected unreported AFP cases definition have equally dropped from 222 to 157 when comparing data for the period January - August 2019/2020. Only four (4) countries have reported more cases in 2020 as compared to 2019 for the period January - August 2019/2020 (Table 3).
Health Workers´ knowledge on AFP and Measles case definition was discordant in seven countries, with the remaining being equal. Not much difference was noted on the health workers knowledge on AFP in Madagascar when two years were compared (p-value=0.065), whereas for measles, a noticeable difference was observed (p-value = 0.001). Ethiopia, Uganda and Zambia have knowledge on both AFP and measles being the same (p-value = 0.0001) (Table 3).
This study reveals that the proportion of health facilities with RED microplan available showed a drop (p-value < 0.05) in 12(63%) countries when comparing data for January - August 2019 (pre-COVID-19) and January - August 2020 (During COVID-19), six (6) countries representing 32% have an increase when comparing the data for same period January - August 2019 and 2020, (p-value >0.05). One country (Lesotho) did not had any single visit in the period under review (Table 4).
Generally, the proportion of HF with RED micro-plan was low across all the countries with an average of 30% in 2019 and 25% in 2020 January- August. The proportion of session conducted against planned for both fixed and outreach session also depicts that 9(47%) of the countries have decrease for fixed session during the period January-August 2019 against 2020, nine (9) countries have increase, 1 country (Lesotho) did not record any ISS visit in the period January - August 2020 (Table 4). There was also a corresponding decrease in 12(63%) of the countries for outreach session planned when comparing January-August 2019 and 2020, with 7(32%) of the countries having an increase in the proportion ( p-value > 0.05), one country (Lesotho) did not report any visit in the period January-August 2020. One of the countries (Seychelles) have both achieved 100% in both periods under consideration for both fixed and outreach sessions planned
Regarding the proportion of health facilities (HFs) with updated monitoring chart, 11 (58%) of the countries witnessed a reduction (p-value <0.05) for the entire period January-August 2019 as compared to January-August 2020. On the other hand, Malawi, Mauritius, Mozambique, Namibia, Rwanda, South Sudan and Zimbabwe had an increase in the proportion of health facilities with monitoring chart with (p-value >0.05), while Lesotho did not record any ISS visit in the period January- August 2020 (Table 4).
All countries have reported session interruption with reasons in the period January - August 2019 except for Zimbabwe, who reported session interruption, without indicating the reasons for interruption. Eight (8) of these countries representing 43% have >50% of the reasons for interruptions as Others (Logistics, Insecurity, lack of funding etc.). In 2020 same period, fifteen (15) countries have indicated session interruption with reasons, while 5 countries did not indicate the reasons for interruption. Eight (8) countries representing 53% have reasons for session interruption as others (logistics, insecurity, lack of funding and lockdown etc.), the other reasons for session interruption are related to availability of functional fridges/EPI supplies and health workers having 33% and 37% for 2019, and 27% and 31% for 2020 respectively (Figure 1).
The routine immunization coverage also depicts that 7(37%) countries have increased administrative coverage for DPT3 containing vaccine, 10(53%) countries have witnessed drop in coverage, and 2(11) countries have maintained the same coverage when comparing the period January - August 2019/2020. In contrast, 6(32%) of the countries have increasing coverage for Measles containing vaccine (MCV1), while the remaining 13(68%) have decrease in coverage using administrative data comparing the period January - August 2019 and 2020 respectively (Figure 2).
In this study, we have found out that the situation in the countries across the sub-region varies considerably, with decrease in the number ISS visits during the early period of COVID-19 pandemic in 13 countries. Five (5) countries (Ethiopia, Kenya, Madagascar, South Sudan and Uganda) contributed more than 85% of the visit in January-August 2019, but only two (2) countries (Madagascar and South Sudan) have shown an increase in the period January - August 2020, with Ethiopia, Kenya and Uganda having shown a decline of greater than 35%, this also correlate with the incidence of COVID-19 cases in Ethiopia and Kenya who are having community transmission and having the highest number of reported cases in the sub-region aside from South Africa. However, the increase in the number of ISS does not necessarily translate to improvement in all VPD surveillance indicators, All the six (6) countries that have increased number of visits, have witnessed a corresponding increase in knowledge of AFP case definition except Zambia, whereas all the countries showed decline in knowledge of measles case definition. On the other hand, only Three (3) countries (Kenya, Mozambique and Tanzania) with an increase in the proportion of fixed and outreach session conducted have a corresponding increase in DPT3 and MCV1 coverage, this shows that there is direct relationship between the increase in the proportion of session conducted and the outcome (immunisation coverage), similar to findings that link conduct of sessions to increasing coverage [21-23]. Four (4) countries (Madagascar, South Sudan, Zambia and Zimbabwe), with >= 30% increase in number of visits when compared with last year same period (January-August, 2019/2020) representing 67% have community transmission, while the remaining two countries (Botswana and Rwanda) having only 20% and 9% increase respectively have cluster of cases. This suggests a direct relationship between increased number of visits and transmission dynamics, and coincided with studies that affirmed the effectiveness of non-pharmaceutical interventions on COVID-19 transmission dynamics [24, 25].
Similarly, the study also found that eight (8) countries representing 67% that have decrease in the number of ISS visits have equally witnessed a drop in DPT3 coverage when comparing the period January - August 2019 and 2020, signifying a relationship in the effects of the visits on the outcome indicator (DPT3) as evidence from a similar study in India, which suggest that supportive supervision improves immunization coverage, and equally serves as a good tool for strengthening health system at the local level . It also support the fact that increased number of ISS visits does not necessarily improve immunization coverage as all the countries with increased visits in period January - August 2019 as against January-August 2020, the administrative coverage has dropped except in Botswana and South Sudan for DPT3 only, this is in agreement with studies that defies linking supportive supervision with direct positive effects to outcome [27, 28]. It was also noted that countries with low proportion of outreach session conducted in the period January - August 2020, have all had session interruption, with more than 40% of the reasons associated with lockdown this goes to show that the lockdown has had a negative effect on the conduct of outreach session in these countries. The data for others was further aggregated and it was found that in the period January - August 2020, 68% of the reasons for others is due to lockdown restriction. However, other reasons for session interruption (Functional fridges/EPI supplies and Health workers availability) also constitutes more 50% of the reasons, with two countries (Namibia and South Africa) having more than 80% in both periods under consideration (2019/2020), indicating systemic issues with the immunisation system in these countries, but studies suggests that reasons for session interruption differs from country to country and these factors include among others parent/caregivers attitude, logistics, health workers knowledge and availability etc. that are affecting immunization service delivery [29, 30].
The reduction in the number of ISS visits, which gave rise the a reduction in the number of unreported suspected AFP and measles cases during the period January - August 2020 as compared to same period of 2019 increases the likelihood of missing possible outbreak of both diseases, the possibility of having outbreaks cannot be overruled. In addition to the drop in MCV1 across 12 (63%) countries in the sub-region during the period of January - August 2019 coupled with reduction in the number of fixed and outreach session, in addition to the disruptions in routine immunization services, the chances of having accumulation of susceptible young children, who will be at risk of causing measles outbreaks is high [31, 32]. In the midst of the COVID-19 pandemic, basic health services had been disrupted and the World Health Organization (WHO) have released guidance to support countries on ensuring the continuity of basic health services, while at the same time maintaining all the necessary COVID-19 infection and prevention control (IPC) measures . Countries could explore other opportunities of maintaining supportive supervision in the context of the pandemic through the use of virtual remote supportive supervision, when physical (in-person) visits are not feasible due to the coronavirus pandemic, this will ensure the continuity of services and will further provide support to health care workers in the field and increase their confidence [33, 34]. Some of the limitations of our study is the use of routine immunization administrative coverage data for the period January - August 2019 and 2020, which does not give true coverage as compared to a more recognised WHO/UNICEF estimate or community-based surveys. We also use Penta-3 and MCV1, which are widely used to measure the performance of the immunisation system. Our analysis also considers the period of January to August 2019 and 2020, whereas the COVID-19 pandemic started around March for all the countries in the region. Also, we have noted the differences of the cadres of the staff supervised may be different across different facility, district and states. Hence, the need for further studies to consider the cadres of health workers supervised, their years of service, as well as their training level on the job.
The implementation of integrated supportive supervision (ISS) in the context of COVID-19 pandemic during the period January - August 2020 using the open data kit (ODK) that provides real time value has had varying level of effects by countries in the sub-region, based on the number of visits, the process indicators that are being monitored as well as the outcome indicator (coverage). There was a general decline in most countries on the number of visits conducted, which influenced the indicators that are associated with the visits in some countries. It is therefore important for countries to monitor closely the trend in the number of supportive supervision visits and the frequency at which the visits are conducted, they are also encouraged to explore other opportunities of implementing these visits through piloting the remote supportive supervision based on their peculiarity and feasibility towards ensuring that health workers in the field are provided with the necessary support they require to maintain surveillance and immunisation services.
What is known about this topic
- Supportive Supervision using the right tool build health workers confidence and improved immunization performance, and it also seen as an efficient tool for strengthening health system;
- The COVID-19 pandemic had caused disruption to basic health services including immunization and vaccine preventable diseases (VPD) surveillance in so many countries of the world;
- Government and WHO, with other partners in the East and Southern African countries are implementing an integrated supportive supervision approach within the Expanded Programme on Immunisation (EPI) using mobile data collection to monitor the performance of the system.
What this study adds
- The COVID-19 pandemic has influenced the conduct of integrated supportive supervision (ISS) visits in most countries of the East and Southern Africa;
- The study identifies that some countries have experienced drop in the number of visits and that has affected the performance of the immunization systems using real time data for action by management team using the ODK platform;
- The study has indicated the need for countries to explore other options of conducting supportive supervision like the remote supportive supervision based on their peculiarity and its feasibility.
The authors declare no competing interests.
IMB, EL, MES, GUA, JC and DF contributed to the conceptualisation of the study and led the drafting of the manuscript. All authors reviewed and approved the final manuscript and contributed to the review of literature.
We acknowledge efforts made by all WHO EPI Focal Persons, Data Managers, and EPI program managers in the 19 countries of East and Southern Africa. There is no funding taken to design, review, and write up of the manuscript.
Tables and figures
Table 1: COVID-19 incidence and transmission status in East and Southern African (ESA) countries as of end August 2020
Table 2: comparison between number of integrated supportive supervision (ISS) visits (January - August 2019/2020)
Table 3: vaccine preventable disease (VPD) indicators comparison (January - August 2019/2020)
Table 4: routine immunization (RI) indicators comparison (January - August 2019/2020)
Figure 1: routine immunisation (RI) administrative coverage (January - August 2019/2020)
Figure 2: reasons for session interruption (January - August 2019/2020)
- Regional Strategic Plan for Immunization. 2020. Google Scholar
- Mihigo R, Okeibunor J, Anya B, Mkanda P, Zawaira F. Challenges of immunization in the African Region. The Pan African medical journal. 2017 Jun 21;27(Suppl 3):12. PubMed | Google Scholar
- Masresha BG, Luce R, Weldegebriel G, Katsande R, Gasasira A, Mihigo R. The impact of a prolonged ebola outbreak on measles elimination activities in Guinea, Liberia and Sierra Leone, 2014-2015. The Pan African medical journal. 2020 Jan 6;35(Suppl 1):8. PubMed | Google Scholar
- WHO. 2015 Assessment Report of the Global Vaccine Action Plan. Igarss. 2014;1:pp1-5. Google Scholar
- Oyo-Ita A, Wiysonge CS, Oringanje C, Nwachukwu CE, Oduwole O, Meremikwu MM. Interventions for improving coverage of childhood immunisation in low- and middle-income countries. Cochrane Database of Systematic Reviews. 2016 Jul 10;7(7):CD008145. PubMed | Google Scholar
- World Health Organization. Reaching Every District (RED). 2017 Edition. 2017.
- Bello DA, Hassan ZI, Afolaranmi TO, Tagurum YO, Chirdan OO, Zoakah AI. Supportive supervision: An effective intervention in achieving high quality malaria case management at primary health care level in Jos, Nigeria. Annals of African Medicine. Oct-Dec 2013;12(4):243-51. PubMed | Google Scholar
- Som M, Panda B, Pati S, Nallala S, Anasuya A, Chauhan AS et al. Effect of Supportive Supervision on Routine Immunization Service Delivery-A Randomized Post-Test Study in Odisha. Global Journal of Health Science. 2014 Jun 30;6(6):61-7. PubMed | Google Scholar
- Peeri NC, Shrestha N, Rahman MS, Zaki R, Tan Z, Bibi S et al. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned?. International journal of epidemiology. 2020 Jun 1;49(3):717-726. PubMed | Google Scholar
- WHO. Coronavirus disease (COVID-19) outbreak. Emergencies - Diseases. 2020.
- World Health Organization. Weekly Epidemiological Update on COVID-19. November 2020;3: p1;4. Google Scholar
- WHO-Regional Office for Africa Coronavirus. COVID-19. [Online]. Accessed on 01 Dec 2020.
- Ghosal S, Bhattacharyya R, Majumder M. Impact of complete lockdown on total infection and death rates: a hierarchical cluster analysis. Diabetes and Metabolic Syndrome: Clinical Research and Reviews. 2020. Google Scholar
- Masresha BG, Luce Jr R, Shibeshi ME, Ntsama B, N'diaye A, Chakauya J, Poy A. The performance of routine immunization in selected African countries during the first six months of the COVID-19 pandemic. Pan African Medical Journal. 2020 Sep 18;37(Suppl 1):12. PubMed | Google Scholar
- Chandir S, Siddiqi DA, Mehmood M, Setayesh et al. Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data. Vaccine. 2020 Oct 21;38(45):7146-7155. PubMed | Google Scholar
- Goldstein M. Protecting lifesaving immunization services during COVID-19: New guidance from WHO. Neonatology Today. 2020. Google Scholar
- World Health Organization. COVID-19: Operational guidance for maintaining essential health services during an outbreak - Interim guidance 25 March 2020. World Health Organization (WHO). 2020. Google Scholar
- World Health Organization (WHO). Maintaining essential health services: operational guidance for the COVID-19 context. 2020. Google Scholar
- Tegegne SG, Shuaib F, Braka F, Mkanda P, Erbeto TB, Aregay A et al. The role of supportive supervision using mobile technology in monitoring and guiding program performance: A case study in Nigeria, 2015-2016,” BMC Public Health. 2018 Dec 13;18(Suppl 4):1317. Google Scholar
- World Health Organization (WHO). Business case for WHO immunization activities on the African continent. 2018. Google Scholar
- Pradhan N, Tove Ryman K, Varkey S, Gupta SK, Krishna G, Swetanki RP et al. Expanding and improving urban outreach immunization in Patna, India. Tropical Medicine and International Health. 2012 Mar;17(3):292-9. PubMed | Google Scholar
- Crocker-Buque T, Mindra G, Duncan R, Mounier-Jack S. Immunization, urbanization and slums - A systematic review of factors and interventions. BMC Public Health. 2017 Jun 8;17(1):556. PubMed | Google Scholar
- Kisakye AN, Kananura RM, Elizabeth Ekirapa-Kiracho, John Bua, Akulume M, Namazzi G et al. Effect of support supervision on maternal and newborn health services and practices in rural Eastern Uganda. Global Health Action. 2017 Aug;10(sup4):1345496. PubMed | Google Scholar
- Bo Y, Cui Guo, Lin C, Zeng Y, Hao Bi Li, Zhang Y et al. Effectiveness of non-pharmaceutical interventions on COVID-19 transmission in 190 countries from 23 January to 13 April 2020. International Journal of Infectious Diseases. 2021 Jan;102:247-253. PubMed | Google Scholar
- Liu Y, Morgenstern C, Kelly J, Lowe R, Jit M. The impact of non-pharmaceutical interventions on SARS-CoV-2 transmission across 130 countries and territories,” medRxiv. 2021 Feb 5;19(1):40. Google Scholar
- Babu GR, Singh VV, Nandy S, Jana S, Sathyanarayana TN, Sadhana SM. Supportive supervision and immunization coverage: Evidence from India. Internet Journal of Epidemiology. 2011;9(2). Google Scholar
- Madede T, Mohsin Sidat, Eilish McAuliffe, Sergio Rogues Patricio, Ogenna Uduma, Marie Galligan et al. The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: A cluster-controlled trial. Human Resources for Health. 2017 Sep 2;15(1):58. PubMed | Google Scholar
- Bosch-Capblanch X, Liaqat S, Garner P. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Database of Systematic Reviews. 2011 Sep 7;2011(9):CD006413. PubMed | Google Scholar
- Songane M. Challenges for nationwide vaccine delivery in African countries. International Journal of Health Economics and Management. 2018 Jun;18(2):197-219. PubMed | Google Scholar
- Nelson KN, Wallace AS, Sodha SV, Daniels D, Dietz V. Assessing strategies for increasing urban routine immunization coverage of childhood vaccines in low and middle-income countries: a systematic review of peer-reviewed literature. Vaccine. 2016 Nov 4;34(46):5495-5503. PubMed | Google Scholar
- Technology Networks. Major Measles Outbreak Predicted in Wake of COVID-19. [Online]. Accessed on 01 Dec 2020.
- Mulholland K, Kretsinger K, Wondwossen L, Crowcroft N. Action needed now to prevent further increases in measles and measles deaths in the coming years,” The Lancet. 2020 Dec 5;396(10265):1782-1784. Google Scholar
- Supervision RS. Guidance on remote supportive supervision during COVID-19. 2004.
- Relan P, Yiu KCY, Lin HC, Loh LC. Remote Supervision in Short-Term Global Health Experiences. Journal of Tropical Medicine. 2018 Oct 2;2018:5629109. PubMed | Google Scholar