Interim Guidelines on the Implementation of Polio Epidemic Response for cVDPV Type 1 in Mindanao during the COVID-19 Pandemic

May 27, 2020

DOH DEPARTMENT CIRCULAR NO. 2020-0223

 

I. BACKGROUND AND RATIONALE

Following the confirmation of poliovirus type 1 re-emergence in Basilan and Sultan Kudarat, the Department of Health (DOH) together with the Centers for Health Development in Mindanao, Ministry of Health-Bangsamoro Autonomous Region of Muslim Mindanao (MOH-BARMM) and the local government units (LGUs) conducted the first two (2) of the three (3) rounds of Sabayang Patak Kontra Polio (SPKP). Round three (3) of the SPKB was scheduled on 23 March-4 April, 2020.

On 7 March 2020, DOH announced local transmission of COVID-19. Following the confirmation of local transmission, partial lockdown in the National Capital Region was implemented. As more confirmed COVID-19 cases are reported, enhanced community quarantine (ECQ) in the entire island of Luzon and other high-risk areas was enforced on 16 March 2020.

In light of the declaration of public health emergency due to COVID-19, the conduct of the round three (3) SPKP in Mindanao regions using bivalent oral polio vaccine (bOPV) was temporarily suspended.

While it is important that health service delivery is focused towards COVID-19 support, polio outbreak response needs to proceed cognizant of the paralyzing effects of polio as a result of disrupted immunization services.

After reevaluation of the status of the COVID-19 situation and vaccine preventable disease risk assessment on polio, Department of Health (DOH) together with the Centers for Health Development in Mindanao, Ministry of Health-Bangsamoro Autonomous Region of Muslim Mindanao (MOH-BARMM) and LGUs will conduct round three (3) of polio response immunization. This is a critical action to guarantee high population immunity among vulnerable children and protect the population from the consequences of polio virus recirculation.

II. SCOPE AND COVERAGE

This Order shall provide technical guidance to the Centers for Health Development in Mindanao, MOH-BARMM, LGUs, all health care workers and other partners in the country on the implementation of a polio epidemic response immunization in Mindanao.

III. OBJECTIVES

A. To ensure a high-quality polio epidemic response immunization in every barangay, municipality, and city in Mindanao.

B. To interrupt the transmission of poliovirus in all regions in Mindanao by ensuring that at least 95% of children aged <10 years in Basilan, Sulu, and Tawi Tawi, Zamboanga City, Isabela City and Lambayong, and children aged <5 years in the rest of the regions, provinces/cities in Mindanao are vaccinated with bOPV regardless of polio immunization status.

IV. GENERAL GUIDELINES

1. Round 3 polio outbreak response immunization for poliovirus type 1 recirculation shall be conducted in all regions in Mindanao.

Date	Areas to be Covered	Activity	Vaccine to Use	Target Age Group
July 20-August 2, 2020	Basilan, Sulu, Tawi Tawi, Zamboanga City, Isabela City, Lambayong	Synchronized Polio Vaccination in all Barangays and mop up of missed children	bivalent Oral Polio Vaccine (bOPV)	0-119 months old (<10 years old)
Remaining Provinces/Cities in Region IX, XII, BARMM and remaining regions in Mindanao	Synchronized Polio Vaccination in all Barangays and mop up of missed children	bivalent Oral Polio Vaccine (bOPV)	0-59 months old (<5 years old)

 

2. All children aged under ten (10) years regardless of polio immunization status shall be vaccinated with bivalent Oral Polio Vaccine (bOPV) in the following areas:

a. Basilan,

b. Sulu,

c. Tawi Tawi, CAIHTE

d. Zamboanga City,

e. Isabela City, and

f. Lambayong.

3. All children aged under five (5) years regardless of polio immunization status shall be vaccinated with bivalent Oral Polio Vaccine (bOPV) in the remaining provinces/cities in Region IX, XII, BARMM, and the remaining regions in Mindanao.

4. The activity shall be synchronized in all regions in Mindanao and should be completed within two (2) weeks including rapid coverage assessment (RCA) and mop up.

5. All bOPV vaccines and recommended Personal Protective Equipment (PPE) for vaccination teams shall be sourced from DOH.

6. 95% coverage should be targeted in order to attain herd immunity and address the current polio epidemic.

7. All regions in Mindanao shall organize a Regional Polio Incident Management Team and activate its Emergency Operation Centers (EOC). (See Annex A)

8. The Regional Polio Incident Management Team shall coordinate, monitor, and report the progress of the implementation of the polio outbreak response immunization to the National Polio Technical Team.

9. All provinces, cities and municipalities shall likewise organize their respective Incident Management Team and activate their EOCs.

V. SPECIFIC GUIDELINES

A. Preparatory Activities

1. Social Preparation

The Polio Incident Management Team at all levels shall be activated and conduct meetings and consultations with Local Chief Executives (LCEs) and other partners.

2. Orientation and Training

The Polio Incident Management Team shall conduct orientation/re-orientation to concerned health staff of the Provincial/City Health Offices and other stakeholders on the polio response immunization for the poliovirus type 1 epidemic.

In view of the COVID-19 pandemic, it is recommended that this activity be done remotely when feasible. In areas where face to face orientation/re-orientation will be conducted, physical distancing and adherence to infection control policies shall be ensured.

It is essential that health personnel are fully trained and are aware of infection prevention and control measures. EPI managers shall crosscheck and verify awareness of health personnel on COVID-19 infection prevention measures.

3. Microplanning

As part of the orientation, the Regional Polio Incident Management Team shall conduct microplanning with LGUs which shall include the following steps:

a. Calculation of the target population of every city and municipality to be given bOPV;

b. Creation/updating of operational spot maps of the areas to be covered for immunization;

c. Calculation and identification of the number of children to be vaccinated per day and the vaccination teams needed to prepare a daily immunization schedule for the vaccination team, including the areas to be visited;

d. Calculation of the vaccine and other logistics needed, including the cold chain equipment;

e. Calculation of recommended personal protective equipment (PPE) for vaccination;

f. Filling-up of the Daily Immunization Session Plan (itinerary) of the Vaccination Teams;

g. Development of an Immunization Activity Plan for the catchment areas of a health facility;

h. Crafting of a supervisory and monitoring schedule;

i. Development of an RCA plan;

j. Development of a follow-up schedule and mop-up plans;

k. Development of a Human Resource Contingency Plan for the redeployment or redistribution of vaccinators in case of staff absence due to sickness or other emergencies.

B. Campaign Strategies

1. Polio Immunization Schedule

The Polio Response Immunization Round 3 for poliovirus type 1 outbreak shall be conducted for two (2) weeks including weekends and holidays. This is to ensure that the vaccinees' parents/caregivers are at home to provide consent for vaccination.

The following table of activities is recommended for an effective campaign:

Round 3

Campaign Day	Main Activity	Remarks
Day 1-5	Intensive and simultaneous vaccination in all barangays	• With intra-campaign monitoring and supportive supervision
Day 6-7	Follow-up and mop up based on recorded missed children	• Door-to-door teams do 2nd visit in assigned areas to cover all recorded missed children
		• Fixed and special session teams to continue to work in assigned areas and locations
Day 8-14	Rapid coverage assessment (RCA) to look for missed children with mop up	• Door-to-door RCA of high-risk areas
		• Market survey/congregation point survey

 

2. Target, Vaccine and Vaccine Administration

a. All children aged under 10 years regardless of immunization status shall be vaccinated with bivalent oral polio vaccine (bOPV) in the following areas:

i. Basilan,

ii. Sulu,

iii. Tawi Tawi,

iv. Zamboanga City,

v. Isabela City, and

vi. Lambayong.

b. All children aged under five (5) years regardless of immunization status shall be vaccinated with bivalent oral polio vaccine (bOPV) in the following:

i. Remaining Provinces/Cities in Regions IX, XII and BARMM

ii. Remaining regions in Mindanao

c. Two (2) drops of bOPV shall be given directly into the mouth without touching the skin or mucosa of the oral cavity. This is critical to avoid contamination of the vaccine and prevent the spread of disease. DETACa

d. bOPV is presented in a 20-dose vial with a vaccine vial monitor (VVM) on the label. The vaccine is WHO-prequalified and Philippine FDA certified (Note: 1 dose = 2 drops).

e. bOPV is safe to be administered to all targeted children irrespective of their current health condition.

3. Immunization Service Delivery

In the delivery of immunization services, all health personnel should be adequately protected to carry out their duties safely in the context of the COVID-19 pandemic.

The immunization service delivery strategy shall be aligned with the National, Regional and Local Government COVID-19 preparedness and response plan and relevant local government policies on containment and quarantine.

Immunization service delivery shall include a mix/combination of the following strategies:

a. Door-to-Door (D2D)

i. The Door-to-door vaccination approach shall be the primary and preferred approach for the campaign when feasible, especially in the following areas. Door-to-door vaccination provides the opportunity to engage families and convince them of its benefits.

• Areas where demand for vaccination has decreased

• Areas with incidence of vaccination refusal

• Highly dense urban slums with complex multiple dwelling places

• Rural areas where physical access to the health facility is difficult for parents and caregivers to avoid missed children

• Areas with affluent populations (e.g., gated communities, apartments/townhouses, and subdivisions)

ii. In each household visited, one member of the team shall tally the number of eligible children in the household and the children who receive vaccine.

iii. All children vaccinated with bOPV shall be finger-marked in the left index (pointer) finger.

iv. If eligible children cannot be vaccinated during the visit — the team shall record and conduct a follow-up visit to reach the missed child/children.

b. Fixed Post (FP)

i. Fixed posts are located at permanent health facilities such as hospitals, health centers, rural health units or barangay health stations. Immunization services shall be separated from curative services where acutely ill individuals are more likely to be present.

ii. Immunization services shall be provided at the health facilities for the whole day and daily, including weekends and holidays, for the whole duration of the campaign.

iii. Routine immunization services will continue at all fixed posts as per national immunization schedule except for bOPV. bOPV campaign dose shall not be considered as routine dose, and as such, shall not be entered in the Target Client List (TCL).

iv. Each child of eligible age who receives bOPV vaccine will be recorded on the tally sheet and will get a fingermark in the LEFT INDEX (POINTER) FINGER.

Note: Routine immunization with other antigen shall not be stopped during the campaign dates.

c. Special Vaccination (SV) Sessions

i. Special Vaccination (SV) Sessions are required for areas with very small and/or disperse populations, hard-to-reach areas or Geographically Isolated and Disadvantaged Areas (GIDA), rural communities that are too remote or too small in size to have a health facility or fixed vaccination post.

ii. The vaccination teams shall set up the temporary vaccination post for the time needed to complete the task before moving on to the next location; After completing the session, they shall move on foot in the area to ensure all children have been vaccinated.

iii. SV sessions can be done in the following locations:

• Government establishments, such as barangay halls and public schools;

• Transportation hubs, such as bus stations, seaports, and airports;

• Gathering areas, such as markets, churches, malls, basketball courts and playgrounds;

• Daycare centers, schools, orphanages, and other social service institutions where children are housed;

• Cemeteries, under the bridges, parks, or open spaces where some families with eligible children are living;

• Other strategic areas to capture highly mobile groups such as urban poor, street children, indigenous people, and the like;

• Gated communities and condominiums requiring permissions from authorities for entry of vaccination teams.

4. Vaccination Team

a. Vaccination teams shall be organized based on the target number of children and the vaccination strategy to be employed;

b. The vaccination team should ensure that every child targeted is vaccinated following the micro plan.

c. The vaccination team shall be composed of at least:

i. One (1) vaccinator (health staff, trained health worker or civil society volunteers);

ii. One (1) recorder (health staff or trained volunteer/BHW); and

iii. One (1) guide (optional). aDSIHc

d. In compliance to infection control protocol, the vaccination team shall ensure that:

i. Necessary supplies for infection prevention and control shall be in place as part of the immunization sessions.

ii. Performance of hand hygiene in between clients using soap and water shall be strictly followed if access to water is guaranteed. If soap and water is not available, alcohol-based preparation can be used.

iii. In healthcare facilities where immunization services are maintained, vaccination shall be performed in areas that are disinfected, well ventilated, and spacious to allow vaccinees to maintain physical distance of at least one (1) meter from other clients.

Note: In performing immunization session, observing physical distance of at least 1 meter between a vaccinator and vaccinee/community member is not feasible. To minimize exposure to COVID-19, vaccinators are advised to maintain the essential/unavoidable physical distance for delivering vaccine.

C. Vaccine Storage, Transport and Disposal

1. Oral polio vaccine (OPV) is heat sensitive and shall be stored at +2ºc to +8ºC (body of refrigerator) at the Rural Health Units or Barangay Health Stations;

2. During immunization sessions, OPV vaccines shall be transported and stored using the recommended vaccine carriers with preconditioned ice packs;

3. All OPV vaccines come with an attached "Vaccine Vial Monitor" (VVM). The VVM should be regularly checked before using the vaccine;

4. All OPV vaccines with VVM at discard point should not be used; and

VVM Stage

5. The use of OPV follows the multi-dose vial policy.

D. Co-administration with Other Vaccines

Bivalent oral polio vaccine (bOPV) can be given simultaneously with other routine vaccines. It recommended that routine immunization SHALL NOT BE WITHHELD in all health centers (HC) and barangay health stations (BHS) during the SPV.

E. Recording and Reporting

1. Finger Marking: Every child vaccinated with bOPV shall be marked with indelible ink on the on the left index (pointer) finger. This will help both the health workers, supervisors, monitors and RCA validators to determine missed children and ascertain the completeness of vaccination in an area. The mark should cover the entire nail and adjoining skin/cuticle.

Finger Marking for bOPV

2. Master listing of children is not recommended and should not be done during the campaign as basis for target.

3. The vaccination team shall be provided with Daily Tally Sheets (Annex B). Every child vaccinated should be recorded (ticked) in the Daily Tally Sheet. Name, age, and address of those children deferred/refused shall be listed at the back of Daily Tally Sheet. It is also important to note details of vaccine vials received on the tally sheet.

4. The vaccination team should record the total children vaccinated for the day using the Daily Summary Reporting Form (Annex C) and submit to the supervisor at the end of the day.

5. The consolidated daily summary reporting shall be submitted by the supervisor to the DOH-Central Office through the next administrative level EOC.

6. In recording of missed children, the door-to-door team shall record any child missed during vaccination, including the reason for missing the vaccination and schedule time for follow up. This information will help the team to track and vaccinate all missed children during follow-up visits.

7. In recording Routine Immunization at fixed posts, vaccination teams shall:

a. First, vaccinate with bOPV if not already vaccinated (check finger mark);

b. Second, administer scheduled Routine Immunization vaccines;

c. Finally, record the routine immunization doses on the health card of the child as per usual practice (no finger marking, or tally recording shall be done for the routine immunization).

Supervisors must ensure that door-to-door teams and special vaccination post teams are recording missed children at the back of the tally sheet for use during follow up visits.

F. Supervision of the Vaccination Team(See Annex D)

One supervisor will be assigned for every five (5) vaccination teams. The supervisor will have the following functions:

1. Key activities — Precampaign

a. Oversee and follow up micro plan development

b. Use checklists to review SIA readiness and take timely corrective measures

c. Review and validate supervisory plans and map

d. Ensure team geographical boundaries are clear

e. Ensure all team members have been trained on vaccine administration, vaccine management, and COVID-19 infection prevention measures and no untrained members of the team are used as substitutes

f. Ensure availability of the following immunization logistics, including recommended PPEs for immunization, and deployment arrangements: ETHIDa

i. Transportation for hard to reach areas;

ii. Cold chain arrangements (functional refrigerators, cold boxes, vaccine carriers with ice packs);

iii. Vaccines; and

iv. Dry logistics (finger markers, recording and reporting formats, and IEC materials including flyers, banners).

g. Ensure community preparation, including the conduct of the following activities:

i. Meetings with partners and stakeholders for community mobilization

ii. Meetings with Department of the Interior and Local Government and other stakeholders at the regional level

iii. Arrangements for local announcements: radio/television, social media

iv. Meetings with local chief executives and barangay officials to discuss the objectives of the campaign, specific date(s) of the actual vaccination, and specific assistance the teams require from the officials.

 Key Pre-Campaign Activities

 Micro plan

 All Barangays included in every plan

 All items included according to template with correct calculations

 Identify any supply shortfall. What action is needed

 Maps: shows catchment areas location of posts/teams per day

 Budget accurately calculated

 High risk areas

 High risk Barangays/puroks identified

 High risk area coverage plans available with supervisors/sites/dates

 High risk areas prioritized in supervision and monitoring plans

 Cold chain logistics supply

 Adequate vaccine storage space for mopv2 vaccine in health facilities

 Adequate vaccine carriers/ice packs/freezer capacity

 Logistics/supply transport plan available to supply all areas

 Contingency plan for replenishment for health facility if stocks run low

 Advocacy

 Mayors have been informed and ready to participate/contribute

 Local NGO meetings held to enlist their support for monitoring and transport of supervisors/teams

 Social mobilization

 Soc. Mob materials available

 Plan for Barangay Health Worker training available

 Plan for involving Barangay officials and volunteers

 Plan for identification of community focal points in Barangays

 Immunization safety

 All supervisors know how to report AEFI

 AEFI Investigation forms and SOPs available to supervisors

 Plan for waste disposal available

 Team management

 Plan for team training available with simple training materials/tally sheets

 Team strategy: fixed post, door-to-door team, special session used in teams' activity plans

 Teams available for mop-up if RCA fails

 Team/post distribution plan is available

 Reporting system

 System for daily collection and consolidation of tally sheets into reports

 Mechanism in place for submission of reports and sending to district/province/region

 Monitoring system

 HC has system to react on a daily basis to failed RCA by ordering immediate mop-up

2. Key activities — Intra campaign

a. Prepare logistics and transportation for the teams before deployment in field

b. Brief the teams every morning before deployment

c. Deploy all teams on time

d. Manage any absentees

e. Conduct supervisory visits to vaccination teams to:

i. Make onsite corrections in the field to implement corrective actions immediately

ii. Educate and train concerned health personnel on the job

iii. Provide feedback and recommend measures for improvement/mid-course correction

f. Conduct support monitors for conducting RCAs in areas covered based on the daily activity plan of the team

g. Conduct daily evening review meetings with teams: Major challenges and observation, RCA findings, decisions for corrective action, follow up on last days pending actions

h. Conduct daily compilation of data and reporting to city/district concerned focal persons

i. Ensure special attention for high risk areas, special sessions at busy congregation points, and security compromised, or conflict affected area

j. Ensure mop up activities in all poorly covered areas during second week of the campaign

3. Key activities — Post campaign

a. Compile and submit coverage reports — The final report of coverage must be compiled at the end of the campaign and shared with district/city administration focal person cSEDTC

b. Conduct waste management

c. Conduct campaign review meeting with all stakeholders to share updates about coverage achieved, strengths, challenges, and lessons identified, and plan ahead for corrective action before next round of campaign

G. Rapid Coverage Assessment (RCA) of the Areas Visited for Vaccination(See Annex E)

H. Surveillance of Adverse Events Following Immunization (AEFI)

1. All detected AEFIs both minor and serious, shall be reported to the nearest health facility. The existing DOH guidelines on AEFI surveillance and response (Administrative Order No. 2016-2006) shall be observed for this purpose.

2. AEFI cases needing hospitalization shall be managed and referred to the appropriate health facility following A.O. 2016-0025: Guidelines on the Referral System for Adverse Events.

For your guidance and strict compliance.

(SGD.) FRANCISCO T. DUQUE III, MD, MSC

Secretary of Health

ANNEX A

Incident Management Organizational Structure

ANNEX B

Recording Form: Daily Tally Sheet of Vaccinated Children

ANNEX C

Daily Summary Reporting Form

ANNEX D

Supervisor's Checklist for Vaccination Teams

ANNEX E

Rapid Coverage Assessment (RCA Form)