Stop the spots: Measles vaccinations in Malawi

10 August 2017


If you grew up in North America or Europe, chances are good that measles isn’t something you’ve ever really had to think about. A measles vaccine was developed and introduced into the US in the 1960s (followed by combination vaccines like MMR); thanks in part to a strong vaccination program, public health officials declared that measles had been eliminated from the US in 2000.

For millions of people across Africa and Asia, however, the measles virus presents a very real threat. Measles is one of the most contagious diseases ever known and it is a leading cause of death among children – despite the existence of a safe and effective vaccine. In 2001, the American Red Cross helped to found the Measles & Rubella Initiative (M&RI) with a group of global partners. Through country-specific vaccination campaigns, M&RI has helped to vaccinate over 2 billion children and prevented an estimated 20 million deaths.

More than 10 million people are still affected by measles each year. The American Red Cross is committed to supporting efforts to eliminate the disease.

Malawi Campaign

In June, the American Red Cross supported a measles and rubella immunization campaign in Malawi in partnership with the Malawi Ministry of Health, UNICEF, WHO, CDC, and other M&RI partners. This campaign acted as a supplementary activity to Malawi’s regular public health activities and was intended as a catch-up for children who may have missed their routine immunization. Over the course of one week, the Malawi Ministry of Health delivered vaccines to children around the country aged from 9 months up to 15 years – targeting approximately 8 million children.

To support this massive effort, the Red Cross assisted with social mobilization in five districts across the country: Lilongwe, Blantyre, Mangochi, Mzimba, and Zomba. Three thousand local Malawi Red Cross volunteers in these districts were trained on key messages and conducted roughly 100,000 house-to-house visits over three days. Volunteers ensured that the households heard about the campaign and provided an opportunity to ask questions about the vaccine and the campaign – providing an important avenue to address the concerns of those who might not otherwise have brought their children to be immunized.

Malawi Red Cross social mobilization volunteers in Lilongwe. CC-BY American Red Cross

As a special part of this campaign, the volunteers in some areas also collected information from caregivers about their young (12-23 months old) children’s routine immunization status – asking to see the child’s health passport and looking for a measles vaccination record or mark in in his/her vaccination history. This information enables us to identify younger children have missed routine vaccinations; in the future this could help partners to follow up with those children in specific to ensure that they are reached by the health system.

Malawian health passport, in which parents record their child’s vaccinations. CC-BY American Red Cross

The American Red Cross also supported rapid convenience monitoring (RCM) during the vaccination campaign. The goal of RCM is to act as internal feedback during the campaign, to get a sense of whether the vaccination activities reached the target population, or if more efforts are needed. To do this, monitors visit vulnerable areas that were vaccinated the previous day and complete 15 house-to-house visits and 10 children in a public place to check whether all the children in those areas were vaccinated. If a certain target is not met, this tells health officials that they need to consider conducting additional vaccinations in that area. Timely information about the campaign allows the staff to act while activities are ongoing – meaning that there are still resources, staff, and supplies that can be mobilized.

The American Red Cross GIS team supported the M&RI field activities by introducing mobile data collection into the house-to-house social mobilization and RCM.

Social mobilization

For the social mobilization, we provided mobile phones for 85 volunteers in Lilongwe (repurposed from the West Africa project and trained them on the OpenDataKit (ODK) Android app for data collection. Half of the time, these volunteers asked households the additional routine immunization questions. The other half of the time, the volunteers did not. This was randomly set within the ODK survey (link to download ODK survey template) and enabled us to compare the additional time required for the extra data collection, which will help the Red Cross determine whether or not the data collection can be done on a larger scale. We also had a group conducting this work on paper forms as a control group.

Prepping apps and settings on over 100 phones. CC-BY American Red Cross

Volunteers discussed the campaign with each household and then asked a series of questions about:

  • Name and contact phone number for the mother/caregiver
  • Number of children in the household aged 9 months up to 15 years
  • Number of children in the household, aged 12-23 months, with a health passport
  • Number of children with health passport who have a measles vaccination marked in it
  • Photo of immunization record in the health passport
  • Whether the mother/caregiver was aware of the current measles campaign
  • How she/he heard about the measles campaign

When the caregiver did have a health passport for a child, the volunteer also took a photo of the immunization record in the passport. This enables a quality check of the data afterwards.

Social mobilization visit by a Malawi Red Cross volunteer in Lilongwe. CC-BY American Red Cross

At the end of each day, we visited volunteers at central locations and collected their data using POSM (Portable OpenStreetMap), an open-source offline server that enables mapping and data collection in offline environments. This negated the need for SIM card and data bundles and allowed us to review the data in an offline environment. Data were encrypted on the phones to protect the sensitive data, stored on the POSM servers, and were later downloaded and decrypted with a private key using ODK Briefcase. Over three days, the volunteers using mobile data collection visited roughly 8,000 households.

RCM: Real-time monitoring

The GIS team also supported nationwide real-time monitoring for the RCM. As a collaboration with the Ministry of Health, we trained 58 Red Cross monitors and government health staff from across the country on OpenDataKit for RCM monitoring. These individuals supplied and used their own smartphones for the activities, and we reimbursed them with air credit for the data uploads. During the RCM, they collected and submitted the monitoring results, which fed into an interactive dashboard that displayed the results in real-time. Over the course of the week-long campaign, 73 monitors in 22 districts conducted 440 RCM sets – representing 13,743 children.

A district health officer checks for a finger mark (indication of having received the measles vaccine) during RCM in a village in Nkhotakota. CC-BY American Red Cross

RCM results fed into an interactive online dashboard, accessible for those working on the campaign. (Special thanks to the British Red Cross for assisting with dashboard development!) CC-BY American Red Cross

Each district had a daily meeting during the campaign to discuss daily activities. We sent the dashboard information ahead of time so that health officers would be aware of the website and could access the information. In the future, now that we have a smooth process for the technical side of this work, we would focus even more on building the local health staff’s awareness of the dashboard and their comfort in using it.

Role of Missing Maps

For important base map data, we relied on the contributions of over 3,000 Missing Maps volunteers, who traced nearly 400,000 buildings across Malawi, equating to the homes of roughly 1.7 people. This data played an important role in planning our fieldwork and the logistics required. Additionally, the base data in OpenStreetMap was the background layer in the nationwide RCM dashboard, and for all our analytics and data visualizations. Without the many volunteers who contributed, the data collected would have simply been points on a blank canvas. Many thanks to all who helped with tracing in Malawi!

The paper map is not dead! Planning logistics and meet-up locations for social mobilization in Lilongwe. Map data from OpenStreetMap… made possible by Missing Maps volunteers. Thanks! CC-BY American Red Cross

OpenStreetMap data with social mobilization locations overlaid. The detail and quality of mapping across Malawi gave us high-resolution to examine and display results for both the RCM and social mobilization activities. CC-BY American Red Cross

We are also grateful for Facebook’s high-resolution population data for Malawi, which helped us to identify areas with and without concentrations of people. This made the tracing much, much faster – we filtered uninhabited areas out of the tracing tasks so that we could direct remote mappers towards areas that had features for them to map.

Next steps

Now that we have returned from Malawi, we are conducting data analysis and investigating possible support activities for a future campaign. We are excited to continue working with M&RI and look forward to implementing the lessons learned in this pilot!

Beyond the mobile data collection activities, the GIS team is looking ahead to explore ways that we could use population and OSM data to inform logistical planning or population estimates for a vaccination campaign. We are eager to support as the Red Cross and the rest of the Measles & Rubella Initiative moves forward to combat measles and improve outcomes for children around the world.

by Emily Eros, Ashley Schmeltzer