Report on the Endline Immunization Coverage Survey in Dowa and Ntchisi Districts

The aim of the endline survey was to measure immunization coverage levels in the two districts post-MCSP support and to compare results with baseline findings from 2015. Endline data collection was conducted by EPI program district staff from Dowa and Ntchisi under the supervision of national and zonal EPI program officers. The proportion of children receiving BCG and Pentavalent 1 vaccine measured at endline was above 80% by card alone, reflecting high immunization system access. Coverage for the other antigens was also high (above 80% for card alone). Immunization system utilization at endline – assessed through dropout rates – was good, with no difference measured between Penta 1 and Penta 3 doses administered in both districts. Valid doses for most antigens were high (above 90%), however the proportion of children fully immunised at one year of age with valid doses was low (78% for Dowa and 76% for Ntchisi). At endline 83% of infants were protected at birth indicating that they were born to mothers who had received either two doses of tetanus and diphtheria (Td) during pregnancy or had previously taken sufficient doses of tetanus toxoid (TT) to protect their babies from tetanus. Reasons cited at endline for non-vaccination of children mostly included vaccine stock-outs at the point of delivery, long distances to health facilities, and child illness on vaccination day. Immunization coverage in both districts was high at endline as documented by card (above 80% for most antigens). At the same time, there were invalid doses being administered and the coverage of fully immunized children by one year of age for valid doses was less than 80% coverage in both districts. Malawi's EPI program is aimed at reducing childhood morbidity and mortality from vaccine preventable diseases. Initially, EPI in Malawi targeted six childhood diseases: measles, tuberculosis, whooping cough, diphtheria, poliomyelitis, and tetanus. Since 2002, the country has introduced four new vaccines with funding from the Gavi alliance. In 2002, the DPT-HepB+Hib (also known as pentavalent) vaccine was introduced which protects children against diphtheria, pertussis, tetanus, hepatitis B, and meningitis and pneumonia caused by Haemophilus influenza type B. In 2011, Malawi introduced pneumococcal conjugate vaccine (PCV) which protects against pneumonia caused by Streptococcus pneumoniae bacteria. In 2012, Malawi introduced the rotavirus vaccine which protects children against childhood diarrhea and, in 2015, the measles vaccine second dose to provide booster immunity against measles in the second year of life. In 2017, Malawi introduced the measles rubella vaccine which offers protection against both measles and rubella. The country also switched from administration of tetanus toxoid (TT) vaccine for women of childbearing age to tetanus and diphtheria (Td) vaccine. The EPI program should focus on reducing missed opportunities for vaccination and ensure that all children are vaccinated on time. District Health Offices must ensure that immunization sessions are not cancelled. They should ensure availability of transport, vaccines, gas, and repair of refrigerators. District Health Management Teams and partners should conduct supportive supervision to assist HSAs in adhering to the immunization schedule to avoid administering invalid doses. Health workers should support community leaders to mobilize eligible children for timely vaccination, conduct defaulter tracing, and monitor infant immunization status in their villages. Health workers should improve the screening of children eligible for vaccinations in the second year of life, e.g., MCV 2.