Immunization Coverage Survey:

For the Assessment of

Coverage by the Meningitis vaccine, in seven states in Sudan-

2013

The Final Report

Prepared by:

Dr. Muna Hassan Mustafa

Faculty of Medicine, International University of Africa

Email address: mhmhs67@hotmail.com

Mobile Phone: 0912257378

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Contents

Executive summary.............................................................................................................................3
1. Background:................................................................................................................................4
2. Objectives:...................................................................................................................................5
3. Materials and Methods:..............................................................................................................6
3.1. Study design............................................................................................................................6
3.2. Study Area...............................................................................................................................6
3.3. Study population.....................................................................................................................6
3.4. Sampling..................................................................................................................................6
3.5. Data collection........................................................................................................................8
3.6. Pilot study:..............................................................................................................................9
3.7. Implementing a quality control system on data:....................................................................9
3.8. The field work teams:...........................................................................................................10
3.9. Duration of the fieldwork:....................................................................................................10
3.10. Data processing and analysis:..............................................................................................11
3.11. Ethical issues:........................................................................................................................11
4. Results:......................................................................................................................................13
5. Discussion:.................................................................................................................................24
6. Conclusions:..............................................................................................................................25
7. Recommendations:...................................................................................................................25
8. References:................................................................................................................................25
9. Financial Report:.......................................................................................................................26
10. Annexes.................................................................................................................................28

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 Executive summary
In accordance with the World Health Organization recommendations to adopt more effective
and sustainable epidemic control measures, the new meningococcal A conjugate vaccine was
introduced to Sudan in 2012(4).

The first phase of the vaccine introduction plan was implemented in ten states, and Phase two
targeted seven states in Sudan, namely, Kassala, White Nile, Northern, River Nile, Red Sea, S&N
Kordofan states. The campaign started on the 14th - 23rd of September 2013, targeting around 9
million individuals in the age group of 1–29 years.

The aim of this survey was to assess the coverage by meningococcal meningitis vaccine and the
reasons behind failure to receive the vaccines, in Seven states in Sudan. This in order to avail
data for programmatic evaluation, identification of under-vaccinated subpopulations, and for
measurement of the impact of the new vaccine on serogroup A disease and carriage, this
survey was conducted with aim.

For the meningococcal meningitis vaccine coverage data were collected from 360 respondents
aged 1 – 29 years old in each state. The sampling followed the standardized World Health
Organization thirty cluster survey for assessing the immunization coverage. Standardized,
structured questionnaires, adapted from the World Health Organization standard tools used for
assessing the immunization coverage. The variables included immunization of the respondents,
sources of vaccines, and reasons for failure to immunize. The data were collected in the period
from 28th Oct, to the 4th Nov. the average duration for data collection was 6 days.

The results showed that he coverage by meningococcal meningitis vaccine ranged from 93.4%
in Kassala state to 86.8% in the Northern state, the average coverage in all states was 89.8%. In
all the coverage was highest among the age group 5-14- years followed by the age group 1 – 4
years and lastly by the age group 1 – 4 years. The main source for getting the meningococcal
meningitis vaccine was the health center followed by the mobile clinic

In all states the majority of the respondents suffered no side effects (74.6%) following the
administration of meningococcal meningitis vaccine. The most encountered side effect was
fever (8.5%) , pain at the site of the injection(7.1%) and the appearance of swelling at the site of
the injection(4.5%). Lack of information was the most cited reasons for failure to immunize
against meningococcal meningitis (18.4%) followed by fear of side effects (15.1%)
Thus it is concluded that the coverage by meningococcal meningitis vaccine following the
immunization campaign was high and efforts should be directed towards sustaining this level of
coverage.

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1. Background:

Meningococcal meningitis is a bacterial form of meningitis, a serious infection of the

membranes that surrounds the brain and spinal cord (1).

The meningitis belt of sub-Saharan Africa, stretching from Senegal in the west to Ethiopia in
the east, has the highest rates of the disease. In the meningitis belt, serogroup A
meningococcal meningitis is a major cause of death and disability (80–85% of all cases).
Major epidemics occur every 5–12 years, with hundreds of thousands of cases and a case-
fatality ratio of >10% (1,2).

Several vaccines are available to control the disease (1). However, a new meningococcal A
conjugate vaccine was introduced that has several advantages over the existing
polysaccharide vaccines: it induces a higher and more sustainable immune response against
group A meningococcus; it reduces the transmission; it is expected to confer long-term
protection and provide herd immunity; it is available at a lower price than other
meningococcal vaccines; and it is expected to be particularly effective in protecting children
under two years of age (1).

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The new meningococcal A conjugate vaccine was introduced nationwide in Burkina Faso,
and in selected regions of Mali and Niger. Subsequently these countries reported, in 2011,
the lowest number of confirmed meningitis A cases ever recorded during an epidemic
season (1,2).

Currently, the World Health Organization (WHO) promotes a strategy comprising

Prevention through vaccinating all 1-29 year-olds in the African meningitis belt with this
vaccine(3).

High coverage of this target age group, via a national mass immunization campaign, is
expected to eliminate meningococcal A epidemics from this region of Africa (1, 2).

Sudan is one of the countries in the meningitis belt and is prone to meningococcal
meningitis epidemics on annuals basis in certain regions. The last major epidemic in Sudan
occurred during 1999 and resulted in 33,313 cases and 2,386 deaths. Strains MN (A & W35)
are considered as the main responsible bacteria for all epidemics that occurred in Sudan.

Implementing reactive vaccination campaigns using polysaccharide vaccines was the main
measure adopted to combat these pervious epidemics. However, these campaigns faced
many challenges as a result of late implementation and high campaign costs.

Thus, and in accordance with WHO recommendations to adopt more effective and
sustainable epidemic control measures, the new meningococcal A conjugate vaccine was
introduced to Sudan in 2012(4).

The first phase of the vaccine introduction plan was implemented in ten states, namely
Khartoum, Gazeria, Gadarif, Sennar, Blue Nile and the five Darfur states. The mass
vaccination campaign started on the 7 th of October 2012 and continued for 12 days. Around
17 million individuals in the age group of 1–29 years were vaccinated.
Phase two targeted the remaining seven states in Sudan, namely, Kassala, White Nile,
Northern, River Nile, Red Sea, S&N Kordofan states. The campaign started on the 14 th - 23rd
of September 2013, targeting around 9 million individuals in the age group of 1–29 years.

Accurate vaccination coverage estimates are critical for programmatic evaluation,

identification of under-vaccinated subpopulations, and for measurement of the impact of
the new vaccine on serogroup A disease and carriage. Here comes the importance of
conducting this survey in order provide the necessary information that will enable this.

2. Objectives:
2.1. General Objective:

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 2.1.1. to assess the coverage by meningococcal meningitis vaccine and the
reasons behind failure to receive the vaccine, in Seven states in Sudan –
2013
2.2. Specific Objectives:
2.2.1. To determine the proportion of individuals (1-29 years old) who received
the new conjugate vaccine during the second phase of implementation in
seven states in Sudan – 2013
2.2.2. To identify the reasons behind the failure to receive the meningococcal
meningitis vaccine during the second phase of implementation in seven
states in Sudan – 2013

3. Materials and Methods:

3.1. Study design: cross-sectional, community-based survey.
3.2. Study Area: the survey covered the seven states that were targeted by phase
two of the vaccine implementation plan. These were Kassala, White Nile,
Northern, River Nile, Red Sea, South Kordofan and North Kordofan states.
3.3. Study population: two types of study population:
1. Individuals from both sexes :
1. inclusion criteria:
 In the age group 1 to 29 years old at the time of the
vaccination campaign.
 Were present in the respective state during the
vaccination campaign
2. Exclusion criterion:
 receiving the vaccine during the first vaccination
campaign in October 2012
3.4. Sampling:
1. Sample size:

Meningococcal meningitis vaccination coverage: the calculation of the

sample size per cluster, this survey assumed a significance level of 5%, or
confidence level of 95%, desired level of precision of the estimates of ±
10, expected immunization coverage of 90% and a design effect of 2.
These are the recommended “standard” parameters for doing an
immunization coverage survey(5), this survey targeted 30 clusters in each
state according to the guidelines for EPI immunization coverage survey
(6). Consulting the sample size table provided in (WHO) manual the
number of individuals from each age group (1 - 4 years, 5 – 14 years, 15 –
29 years) to be selected from each cluster was 7 giving a total of 21
individuals of the target population ( 1 – 29 years)

Thus the total sample size from each state was 21 x 30 = 630 participants.

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2. Sampling technique:
 The survey followed a stratified cluster sampling technique. EPI sample
frame was considered as the sampling frame for this survey. For assessing
the meningococcal meningitis vaccination coverage three strata were
defined by the three age groups of the participants to be included in the
survey; 1 – 4 years old, 5- 14 years old and 16-29 years old.
 Selection of Popular Administrative Unit (PAU): A frame of all Popular
Administrative Unit (PAU) (blocks in urban areas and villages in rural
areas) in each state was prepared along with the total number of
population of each. These are the smallest geographical and
administrative units in the sample frame. Thirty PAUs were selected from
each frame using the probability proportional to size technique (5). This
insured a self weighted sample with regards to urban and rural areas. The
cluster size is 7 for the three targeted study groups. Table (a) below
shows the population size and numbers of houses required to fulfill the
recommended sample size for each age group:

Table (a): the required number of households to complete a cluster.

Age group % of Sudan Required Required

total population number of
population size households*
1 – 4 years 15 187 31

5 -14 years 28 100 17

15 -29 years 28 100 17

* The required population size divided by 6 (the average household size in Sudan)

This means that at least 31 house are needed to obtain the cluster size from
each PAU. This was rounded to 50 houses, thus each selected PAU was divided
into segments of around 50 houses (if its size is more than 50 houses). One
segment of these was selected randomly for data collection.

Selection of houses: All the houses in each of the 50-house selected

segments were visited. To select the first house the field supervisor chose
a random direction from the centre of the cluster by spinning a bottle on
even ground and wherever the bottle pointed when it stopped indicated the direction
of the first house. . After visiting the first house, the second house to be
visited was the one that is nearest to the first in an ante-clock direction.
The nearest house defined as the house reachable in the shortest time on
foot from the house just visited. The interviewers then approached the

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 households living in these houses. If more than one household occupied
the house, all of them should were interviewed.

 Selection of participants:
Meningococcal meningitis vaccination coverage: From each
household, interviewers targeted the following types of
participants:
- Children aged 1-4 years
- Children aged 5-14 years
- Individual aged 15 -29 years
- In households with more than one eligible individual from any
of the three age groups, one individual was selected randomly
by writing the names of the individuals in specific age group in
small pieces of paper and selecting one from them.
Interviewers collected data from 7 participants from each age
groups before leaving the cluster area.
If the 50-house segment was completed before fulfilling the cluster size
for any of the age groups, the fieldwork team completed it from the
nearest 50-house segment.

3.5. Data collection:

1. Technique: Data collection was done through face-to-face interviews
with eligible participants or their care takers if they were less than 18
years.

2. Tools:

Meningococcal meningitis vaccination coverage: data were collected

through a structured form (Meningococcal meningitis vaccination
coverage cluster form) adapted from the WHO standard tools used for
assessing the immunization coverage (6). Three versions for each of the
three age groups were developed. Each version was composed of four
sections (see annex1-3):

Section one: background information for the cluster and

participant

Section two: assessment of the coverage by the Meningococcal

meningitis vaccine from a vaccination card or from verbal history
or both, side effects of Meningococcal meningitis vaccine.

Section three: Reasons for failure to receive the Meningococcal

meningitis vaccine

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 Section four: identification of the interviewer, field supervisor and
observations on the activities in the clusters and tally of the
households visited and the time taken to complete each cluster.

3.6. Pilot study:

The pilot study was conducted as part of the training of trainers workshop on the
9th Oct, with following objectives:

1. To test the suitability of the questionnaires for data collection

2. To estimate the duration of the interview

The outcomes of the pilot study were the following:

- The space dedicated for writing the date of birth in the

questionnaire is not adequate; hence it was decided to
print and copy the questionnaires in 3A papers
- The average duration of interview with a respondent was
10 minutes; hence it was decided to have one sub-
team(composed of 2 interviewers) per cluster instead of
two sub-teams.

The outcomes of the pilot study were communicated to the survey

mangers during a meeting held on 21st Oct

The finalized questionnaires were copied for the fieldwork in Khartoum and
each survey mangers received the full package of tools before traveling to
the states.

3.7. Implementing a quality control system on data:

The first level - the interviewers: Alternating the duties of asking

questions, observing and checking the recorded responses.

The second level - the field supervisor: Observes and checks that the
interviewers were collecting and recording the data accurately and
completely through:

 Spot checks on the work of the interviewers

 Daily check of the forms by the supervisor at the end of each day and
before leaving the cluster area, so that any errors in completing the
forms can were corrected.

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 The third level – the state survey mangers: these managed the survey at
the state level and they supervised the implementation of the survey
methodology, and reviewed and edited the completed tools

The fourth level the office editors in Khartoum: reviewed the completed
forms for consistency after the end of the fieldwork.

3.8. The field work teams:

From each cluster area, the data were collected by a fieldwork team consisting of
a sub-team of interviewers under the supervision of a field supervisor. Each sub-
team team was composed of two interviewers. Some of the members of
fieldwork teams were recruited from their respected state while some of them
were recruited nationally. All fieldwork teams were trained locally by the state
survey manger who had received a training of trainer at the central level by
principal investigator. The training included:

A. A theoretical part that covered the following:

 Objectives of the immunization coverage survey;
 How the identify the eligible participants and how to conduct the
sampling at different levels.
 How to fill the data collection tool and the purpose of each item
included in it;
 How to edit the completed tools
 Roles and responsibilities of the fieldwork team members.
B. A field practice covering:
 Identification of house/residential units: the first and subsequent
ones;
 Identification of target individuals;
 Asking questions;
 Data recording; and
 Interview duration

3.9. Duration of the fieldwork:

 The fieldwork started in all states by 28th Oct, with the exception of South
Kordofan state where the data collection started on 31st Oct. the fieldwork
was completed in all states by the 4th Nov. the average duration for data
collection was 6 days.
 Replacement of clusters was performed as follows:
o North Kordofan (4 clusters) due to security reasons
o White Nile (one cluster) because the selected area cannot not be
located.
o Red Sea states (one cluster) due to inaccessibility

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  The replacement was performed centrally
3.10. Data processing and analysis:

Before data entry, all the completed cluster forms were reviewed by office editors, for
consistency of coding.

The data entry and analysis were performed through the SPSS. Proportions of
participants who received the vaccine were calculated along with 95% confidence
interval. In addition to that the proportion of participants who failed to immunize
(against meningococcal meningitis) due to any one specific reason were calculated. For
estimation of the total population covered by the Meningococcal meningitis vaccine the
population percentages in the table below were used for weighting. This is necessary
because equal sizes of samples were taken from each age group.

Age % of age
group group 1-29
years
1 – 4 years 21.2

5- 14 years 39.4

15 -29 years 39.4

Total 100

3.11. Ethical issues:

The first phase of this survey which followed the same methodology was approved by
the National Technical and Ethical Committee.

The survey was conducted in accordance with the national policies on ethics for surveys
involving human subjects in maximization benefits and minimizing harm.

Verbal informed consent was obtained from the study participants or their care
takers/legal guardians after explaining the objectives of the survey and before
commencing the data collection process and voluntary participation was granted.

All the information collected from the study participants was anonymous and will not be
revealed to individuals not included in the research team and will not be used for other
purposes.

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4. Results:

Table (1) gender distribution of individuals aged 1 – 29 years old in seven states in Sudan - 2013

Sex Frequency Percent

Male 62950 42.8
Female 84050 57.2
Total 147000 100.0

The sample size for each of the three age groups (1- 4 years, 5 – 14 years, 15- 29 yeas) was
weighted using the proportion of each age group from their total. This was necessary because
the equal sample sizes were taken from three groups not considering the weight of each age
group. The Weighting process will insure accurate estimates of the coverage.

The males constituted 42.8% of the sample while the females constituted 57.2%.

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 Table 2: coverage by Meningococcal meningitis vaccine among individuals aged 1 -1 29 years, Seven states in Sudan , 2013

1- 4 years 5-14 years 15- 29 years Total 95% CI

Card Card + History Card Card + History Card Card + History Card Card + History
Lower Upper
State NO % NO % NO % NO % NO % NO % NO % NO %
Northern 2692 60.5% 4007 90.0% 5595 67.6% 7919 95.7% 3901 47.1% 6304 76.2% 12188 58.0% 18230 86.8% 86.3% 87.3%

R.sea 2247 50.5% 3880 87.1% 5713 69.0% 7998 96.7% 4925 59.5% 6895 83.3% 12885 61.4% 18773 89.4% 89% 90%

Kassala 3286 73.8% 4219 94.8% 7289 88.1% 8116 98.1% 6265 75.7% 7289 88.1% 16840 80.2% 19624 93.4% 93.1% 93.7%

R.Nile 2120 47.6% 3986 89.5% 5161 62.4% 8077 97.6% 3704 44.8% 6383 77.1% 10985 52.3% 18445 87.8% 87.4% 88.2%

W.Nile 2502 56.2% 4113 92.4% 5122 61.9% 7762 93.8% 3979 48.1% 6383 77.1% 11603 55.3% 18257 86.9% 86.4% 87.4%

N.Kordofan 3456 77.6% 4219 94.8% 6540 79.0% 8116 98.1% 5083 61.4% 6974 84.3% 15079 71.8% 19309 91.9% 91.5% 92.3%

S.Kordofan 3265 73.3% 3986 89.5% 6816 82.4% 7801 94.3% 5910 71.4% 7565 91.4% 15991 76.1% 19352 92.2% 91.8% 92.6%

Average 62.8% 91.2% 72.9% 96.3% 58.3% 82.5% 65.% 89.8%

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Table (2) shows the coverage by the meningococcal meningitis vaccine in the seven states,.

In the Northern state the crude coverage by the meningococcal meningitis vaccine ( card
plus history) was 90%, 95.7% and 76.2% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 58% while the coverage from both card and history was 86.8% (95% CI: 86.3% -
87.3%)

In the Red Sea state the crude coverage by the meningococcal meningitis vaccine ( card plus
history) was 87.1 %, 96.7%and 83.3% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 61.4% while the coverage from both card and history was 89.4%(95% CI: 89% -
90%)

In Kassala state the crude coverage by the meningococcal meningitis vaccine ( card plus
history) was 94.8% , 98.1%and 88.1% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 80.2% while the coverage from both card and history was 93.4% (95%CI: 93.1% -
93.7%)

In River Nile state the crude coverage by the meningococcal meningitis vaccine ( card plus
history) was 89.5% , 97.6% and 77.1% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 52.3% while the coverage from both card and history was 87.8% (95%CI :87.4% -
88.2%)

In White Nile state the crude coverage by the meningococcal meningitis vaccine ( card plus
history) was 92.4% , 93.8% and 77.1% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 55.3% while the coverage from both card and history was 86.9% (95%CI 86.4% -
87.4%)

In North Kordofan state the crude coverage by the meningococcal meningitis vaccine ( card
plus history) was 94.8% , 98.1% and 84.3% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 71.8% while the coverage from both card and history was 91.9% (95%CI: 91.5% -
92%)

In South Kordofan state the crude coverage by the meningococcal meningitis vaccine ( card
plus history) was 89.5% , 94.3% and 91.4% among 1- 4 years group, 5 – 14 years group, and
and15- 29 yeas group respectively. The valid total coverage (ascertained by card) for all age
groups was 76.1% while the coverage from both card and history was 92.2% (95%CI: 91.8 -
92.6%)

In all states the highest average crude and valid coverage was among the age group 5 - 14
years ( 96.3% crude and valid 72.9%) followed by the age group 1 – 4 years (crude 91.2%

15
and valid 62.8%) the least coverage was among the 15 – 29 years ( crude 82.5% and valid
58.3%)

Figure (1): coverage by Meningococcal meningitis

vaccine, Seven states in Sudan , 2013

100% 93.40%
89.40% 91.90%
90% 86.80% 87.80% 86.90%
80.20%
80%
71.80%
70%
61.40% card
60% 58.00% 55.30%
52.30% history+card
50%
40%
30%
20%
10%
0%
Norther R Sea Kassala R Nile W Nile N Kordofan

Figure (1) shows that highest crude and valid coverage by Meningococcal meningitis vaccine
was attained in Kassala (crude = 93.4% and valid 80.2%) state followed by North Kordofan
State ( crude 91.9%. and valid 71.8%) the lowest coverage was observed in the Northern
state ( crude 86.8% and valid 58%) and River Nile state( 87.8% and valid 52.3%).

The states with highest retention of the vaccination cards were also Kassala and North
Kordofan states. The states with lowest retention for vaccination cards were River Nile State
and White Nile State

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Table 3: availability of Meningococcal meningitis vaccine card, Seven states in Sudan , 2013

Reason card not available

Not given Lost Other Missing
State NO % NO % NO % NO % Total
Northern 42 .7% 5858 96.9% 64 1.1% 79 1.3% 6042
R.sea 0 0.0% 5369 91.2% 518 8.8% 0 0.0% 5888
Kassala 721 25.9% 2024 72.7% 39 1.4% 0 0.0% 2785
R.Nile 142 1.9% 6260 83.9% 1058 14.2 0 0.0% 7460
%
W.Nile 164 2.5% 6070 91.2% 421 6.3% 0 0.0% 6654
N.Kordofan 1300 30.7% 2930 69.3% 0 0.0% 0 0.0% 4230
S.Kordofan 476 14.2% 2885 85.8% 0 0.0% 0 0.0% 3361

Average 10.8% 84.4% 4.5% 0.2%

Table (3) shows the reasons for unavailability of vaccination cards. In the Northern state, the
majority of the respondents who failed to show the vaccination card, said they had lost the
card (96.9%) while only 0 .7% said they had not been given a card by the vaccination team.

In the Red sea state the majority of the respondents who failed to show the vaccination
card, said they had lost the card (91.2%) , while 8.8% of them cited other reasons for not
showing the card.

In Kassala state, the majority respondents who failed to show the vaccination card, said they
had lost the card (72.1%) , while around one quarter of them claimed to have not received a
card from the vaccination team

In River Nile state, the majority of the respondents who failed to show the vaccination card,
said they had lost the card (83.9%), while 14.2% cited other reasons for not showing the
card.

In White Nile state, the majority of the respondents who failed to show the vaccination
card, said they had lost the card (91.2%) while 6.3% cited other reasons for not showing the
card.

In North Kordofan state, the majority the respondents who failed to show the vaccination
card, said they had lost the card (69.3%), however, a considerable proportion of them
claimed to have not received a card from the vaccination team(30.7%)

17
In South Kordofan state, the majority the respondents who failed to show the vaccination
card, said they had lost the card (85.8%), while 14.2% of them claimed to have not received
a card from the vaccination team

In all states the most frequent reason for not showing the vaccination card was that it had
been lost

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Table 4: source of Meningococcal meningitis vaccine, Seven states in Sudan , 2013

Meningitis source
Academic
Mobile clinic Hospital Health center Private clinic NGOs center institute Other Missing/DK
State NO % NO % NO % NO % NO % NO % NO % NO % Total
Northern 3039 16.7% 224 1.2% 6167 33.8% 21 .1% 0 0.0% 4382 24.0% 2767 15.2% 1630 8.9% 18230
R.sea 5509 29.3% 164 .9% 4682 24.9% 0 0.0% 0 0.0% 3306 17.6% 4342 23.1% 770 4.1% 18773
Kassala 7003 35.7% 0 0.0% 9721 49.5% 0 0.0% 0 0.0% 1388 7.1% 0 0.0% 1512 7.7% 19624
R.Nile 3773 20.5% 639 3.5% 7645 41.4% 0 0.0% 42 .2% 4631 25.1% 1427 7.7% 288 1.6% 18445
W.Nile 5833 32.0% 61 .3% 5718 31.3% 0 0.0% 79 .4% 3888 21.3% 1406 7.7% 1273 7.0% 18257
N.Kordofan 5673 29.4% 100 .5% 2403 12.4% 0 0.0% 0 0.0% 1794 9.3% 5894 30.5% 3445 17.8% 19309
S.Kordofan 6197 32.0% 103 .5% 8721 45.1% 0 0.0% 0 0.0% 1694 8.8% 2215 11.4% 421 2.2% 19352
Average 27.9% 1.0% 34.1% 0.0% 0.1% 16.2% 13.7% 7.0%

19
Table (4) shows the distribution of the immunized individuals according to the source of
Meningococcal meningitis vaccine

In the Northern state the highest proportion of the immunized individuals received the
vaccine at a health center (33.8%) followed by 24% who received the vaccine at an academic
institution, then another 16.7% who received it at a mobile clinic.

In the Red sea the highest proportion of the immunized individuals received the vaccine
through a mobile clinic (29.3%) followed by 24.9% who received the vaccine at a health
center, then another 17.6% who received it at an academic institution

In Kassala state the highest proportion of the immunized individuals received the vaccine at
a health center (49.5%%) followed by 35.7% who received the vaccine through a mobile
clinic, then another 7.1% who received it at an academic institution

In River Nile state the highest proportion of the immunized individuals received the vaccine
at a health center (41.4%%) followed by 25.% who received the vaccine at an academic
institution, then another 20.5% who received through a mobile clinic

In White Nile state the highest proportion of the immunized individuals received the vaccine
through a mobile clinic (32%) followed by 31.3% who received the vaccine at a health
center, then another 21.3% who received it at an academic institution

In North Kordofan state the highest proportion of the immunized individuals received the
vaccine at different locations including the houses of the local leaders (30.5%) followed by
29.4% who received the vaccine at through mobile clinic, then another 12.4% who received
it at health center

In south Kordifan state the highest proportion of the immunized individuals received the
vaccine at a health center (45.1%) followed by 32% who received the vaccine through a
mobile clinic, then another 11.4% who received it at other locations

In all states, the most frequently used source for vaccination against meningococcal
meningitis was the health center (34,1%) followed by the mobile clinics (27.9%) and then by
the academic institutions (16.2%)

20
 Table:5 side effects following the meningococcal meningitis vaccine administration, Seven
states in Sudan , 2013

Redne Irritabilit Skin Hyperse No side

ss Swelling Pain Fever y Headache Vomiting rash nsitivity Stroke Other effects
State % % % % % % % % % % % %
Northern 3.1% 5.8% 6.0% .7% .4% 0.0% .3% .2% 0.0% .2% 0.0% 82.7%
R.sea 0.0% 1.1% 4.8% 3.5% .2% .4% .2% .3% .1% .2% .2% 84.3%
Kassala 1.4% 3.0% 5.8% 6.7% .4% 2.2% 0.0% .2% 0.0% 0.0% .2% 77.8%
R.Nile 1.2% 5.4% 11.3% 5.9% .8% 1.2% 0.0% .7% .4% 0.0% 0.0% 72.9%
W.Nile 3.3% 7.8% 5.4% 12.1% 1.0% 1.1% .1% .3% .2% 0.0% .2% 73.6%
N.Kordofan .7% 3.7% 9.1% 17.1% 1.9% .2% 0.0% .5% 0.0% .3% 0.0% 63.8%
S.Kordofan .2% 4.4% 7.0% 13.4% .8% 1.4% .8% 1.2% .3% 0.0% .2% 67.2%
Average 1.4% 4.5% 7.1% 8.5% 0.8% 0.9% 0.2% 0.5% 0.1% 0.1% 0.1% 74.6%

Table (5) shows the occurrence of side effects among those who received the vaccine within
one month of taking the dose. In all states the majority of the respondents (74.6%) suffered
no side effects. The most encountered side effect was fever affected 8.5% of all the
respondents who received the vaccine, this was followed by pain at the site of the
injection(7.1%) followed by the appearance of swelling at the site of the injection (4.5%).

21
 Table 6: reasons for failure to immunize against meningococcal meningitis, Seven states in
Sudan , 2013

N .Kordofa Averag
Northern R.sea Kassala R .Nile W .Nile n S. Kordofan e
Reasons
N N N
NO C% NO C% O C% NO C% NO C% O C% O C%
Lack of 198 71.8 133 60.1 79 57.7 127 39.5 177 64.5 69 41.2 84 51.5 55.2%
information 8 % 9 % 4 % 9 % 0 % 7 % 8 %
Unaware of 39 1.4% 700 31.4 0 0.0% 158 4.9% 197 7.2% 0 0.0% 10 6.2%
need for % 3 7.3%
immunization
Place and/or 479 17.3 276 12.4 47 34.8 406 12.6 655 23.9 18 10.8 27 16.9
time of % % 9 % % % 2 % 9 %
immunization 18.4%
unknown
Fear of side 855 30.9 182 8.2% 19 14.3 79 2.4% 618 22.5 43 25.8 21 1.3% 15.1%
reactions % 7 % % 6 %
Wrong ideas 61 2.2% 39 1.8% 79 5.7% 118 3.7% 0 0.0% 39 2.3% 0 0.0%
about
contraindicatio 2.2%
ns
Other 555 20.0 142 6.4% 39 2.9% 518 16.0 300 10.9 39 2.3% 44 27.0 12.2%
% % % 5 %
Lack of 139 5.0% 339 15.2 61 4.4% 139 4.3% 79 2.9% 17 10.6 46 27.9 10.0%
motivation % 9 % 1 %
Not important 100 3.6% 79 3.5% 61 4.4% 0 0.0% 39 1.4% 11 7.0% 15 9.6% 4.2%
8 8
Rumors 0 0.0% 200 9.0% 0 0.0% 0 0.0% 0 0.0% 21 1.3% 16 9.7% 2.9%
1
Other 39 1.4% 61 2.7% 0 0.0% 139 4.3% 39 1.4% 39 2.3%     1.7%

Obstacles 642 23.2 548 24.6 52 37.9 181 56.1 894 32.6 81 48.2 33 20.6 34.8%
% % 1 % 5 % % 5 % 9 %
Place of 79 2.8% 42 1.9% 0 0.0% 124 3.8% 39 1.4% 0 0.0% 39 2.4%
immunization 1.8%
too far
Time of 21 .8% 79 3.5% 61 4.4% 79 2.4% 158 5.7% 11 7.0% 79 4.8%
immunization 8 4.1%
inconvenient
Vaccinator 21 .8% 21 1.0% 39 2.9% 79 2.4% 100 3.6% 21 1.3% 0 0.0% 1.7%
absent
Vaccine not 0 0.0% 21 1.0% 21 1.5% 82 2.5% 0 0.0% 39 2.3% 0 0.0% 1.0%
available
Too busy 64 2.3% 121 5.4% 42 3.1% 321 9.9% 200 7.3% 10 5.9% 61 3.7% 5.4%
0
Ill 100 3.6% 21 1.0% 0 0.0% 61 1.9% 0 0.0% 10 5.9% 0 0.0% 1.8%
0
Long waiting 0 0.0% 0 0.0% 39 2.9% 61 1.9% 0 0.0% 0 0.0% 21 1.3% 0.9%
time
Other 358 12.9 242 10.9 31 23.1 100 31.2 397 14.5 43 25.8 13 8.5% 18.1%
% % 8 % 9 % % 6 % 9

Lack of information about the time and site of vaccination was the most cited reason for failure
to immunize against meningococcal meningitis in most of the states ( Northern, Red
Sea ,Kassala, White Nile and South Kordofan) fear of side effects associated with vaccine came
next (table 6).

22
23
5. Discussion:

The coverage by the meningococcal meningitis vaccine in the seven states collectively following
the vaccination campaign was high mounting to around 90%. Although this level of coverage
was lower than the coverage attained in Burkina Faso (95.9%) following the immunization
campaign, this level of coverage in Sudan demonstrates successful introduction of a new
vaccine through a mass immunization campaign, and demonstrates that mass vaccination of a
large proportion of the population is an effective strategy to rapidly achieve high vaccine
coverage (2). This is necessary to reduce carriage and transmission of the bacteria rapidly in
order to reduce rates of death and illness caused by the disease. Because large population
groups were vaccinated in a short period of time, the benefits of immunization should be
quickly visible and their impact is expected to be considerable (1).

Like with Burkina Faso the age group 15 – 29 years was the least covered age group and the 5 -
14 years attained the highest coverage (2). The 5 – 14 years age group includes kindergarten
and school students, and in their institutions these groups constitute a suitable setting for
administering a vaccine through a vaccination campaign. This survey revealed the important
role the health centers could play in a vaccination campaign, because they are the most
accessible type of health facilities to the population.

The main reason for failure to vaccinate against Meningococcal Meningitis found by this survey
is similar to that reported from the Burkina Faso, which was the lack of information about the
time and site of the vaccination (2). The second frequently mentioned reason was the fear of
side effects of the vaccine. This is a known barrier to vaccination against many communicable
diseases (7, 8). Especially when the prevalence or incidence of a disease is not high people tend
to consider that the side effects of vaccines pose a greater health threat than the diseases
themselves (8). This survey showed minimal side effects following the vaccine administration.
This supports the results of the trials that have been carried out in the Gambia, Ghana, India,
Mali and Senegal and have shown the vaccine to be safe in addition to be highly immunogenic
(1)

As shown by this study the vaccination card retention was low despite the short duration
between the vaccination campaign and the survey. In Burkina Faso 74.3% of the respondents
retained their vaccination cards one year after the vaccination campaign (2). However, the
potential for recall bias among those who reported vaccination by recall only might be
counterweighted by the short duration since the campaign, and the high-profile nature of the
disease. In addition to that the Meningococcal Meningitis vaccination campaign is unlikely to
be confused with other vaccination campaigns because it was targeting older age groups unlike
other campaigns implemented by the EPI.

As with the case of Burkina Faso, achievement of high vaccination coverage demonstrates that
coordinated preparation, community engagement and mobilization, and development of a

24
comprehensive communication plan are critical to successful vaccination campaigns (2). To
eliminate epidemics of meningococcal meningitis, high population immunity is necessary. After
the initial campaigns targeting persons aged 1–29 years, maintenance of high immunity through
protection of each birth cohort is necessary, either by routine immunization services or periodic
mass campaigns targeting 1-4 year-olds every five years (1,2).

6. Conclusions:
 A high level of coverage was attained by meningococcal meningitis vaccine following the
immunization campaign. The coverage by meningococcal meningitis vaccine ranged
from 93.4% in Kassala state to 86.8% in the Northern state, the average coverage in all
states was 89.8%. In all the coverage was highest among the age group 5-14- years
followed by the age group 1 – 4 years and lastly by the age group 1 – 4 years.
 The main source for getting the meningococcal meningitis vaccine was the health center
in four states (northern, Kassala, River Nile, south Kordofan) followed by the mobile
clinic as the main source in two states (Red Sea, White Nile).
 In all states the majority of the respondents suffered no side effects (74.6%). The most
encountered side effect was fever (8.5%) followed by pain at the site of the
injection(7.1%) followed by the appearance of swelling at the site of the injection(4.5%)
 Lack of information was the most cited reasons for failure to immunize against
meningococcal meningitis specifically the lack of information and fear of side effects
associated with vaccine.
7. Recommendations:
 Maintenance of high immunity attained against meningococcal meningitis through
protection of each birth cohort, either by routine immunization services or periodic
mass campaigns.
 In future follow-up vaccines campaigns the following should be considered:
 Intensifying the pre-campaign advocacy activities regarding the source and time of
vaccination
 Addressing the concerns of the population regarding the side effects associated the
vaccine.
 Implementing the campaign during the academic year to insure reaching a high
proportion of kindergarten-age children

8. References:
.1. Meningococcal meningitis fact sheet , WHO, 2012 available at: www.who.int
.2. Médah I et al, “Serogroup A Meningococcal Conjugate Vaccine Coverage After the First
National Mass Immunization Campaign — Burkina Faso, 2011” Morbidity and Mortality
Weekly Report. December 21, 2012 / Vol. 61 / No. 50
.3. Immunization, Vaccines and Biologicals , WHO, 2011 available at
http://www.who.int/immunization/newsroom/multimedia/podcasts_meningitis_vaccin
e_project/en/

25
.4. Meningitis case-based surveillance in Sudan at, WHO, available at
http://www.emro.who.int/sdn/sudan-events/meningitis-surveillance.html
.5. LWANGA S, et al, “immunization coverage cluster survey manual” WHO, Switzerland,
Geneva , 2005.
.6. World Health Organization, “Training for mid-level managers’ the EPI coverage Survey”
Switzerland, Geneva , 2008.
.7. Carole J, “Overcoming barriers to influenza vaccination” Nursing Times, Vol 108 No 37 ,
2012. available at: www.nursingtimes.net
.8. Bloom D E, Canning D and Weston M, “The Value of Vaccination” WORLD ECONOMICS •
Vol. 6 ,No. 3 , 2005

a through 2011

9. Financial Report:

No Item Number Total SDG

.
1 Per diem of state survey mangers 3000 SDG X 3 9000
managers
2 Travel expenses for three state 300 SDG + 120 SDG 650
mangers + 230 SDG
3 Extra accommodation expenses for 500 SDG X 7 3500
state survey mangers mangers
4 Per diem of the principal investigator 20850

5 Total 34000

26
27
10. Annexes
Annex1

Immunization Coverage survey for Assessment of Meningitis mass campaign and routine immunization in seven states in Sudan
Meningococcal meningitis vaccination coverage cluster form (1- 4 years)

(1) cluster number Child name ‫المجموع‬

(2) date ‫ تاريخ‬+‫كرت‬
(3) area ‫تاريخ‬
Range of birth date from
From
To
Respondent number in cluster 1 2 3 4 5 6 7
((6) birth date
(7) sex 1. Male 2. Female
(8) vaccination card 1. yes 2. no

(9) if no card, why 1. Not given

2. lost
3. other
(10) MCMV Date/+/0
source
(11) side effects 1. yes 2. no
( within month)
Side effects 1.Redness at the site of injection
2. swelling at the site of injection
3. pain at the site of injection
4. fever
5. irritability
6. headache
7. vomiting
8. skin rash
9. hypersensitivity reaction
10. other (specify)

(13) if not vaccinated , what was the main reason? 1 2 3 4 5 6 7 ‫كرت‬ + ‫كرت‬
‫تاريخ‬
Lack of a. Unaware of need for
information immunization
b. Place and/or time of
immunization unknown
c. Fear of side reactions
d. Wrong ideas about
contraindications
e. other
Lack of f. No faith in immunization
motivation j. Rumours

28
 h Other
Obstacles I. Place of immunization too far
j. Time of immunization
inconvenient
k. Vaccinator absent
l. Vaccine not available
m. too busy
n. ill —
o. Long waiting time
q. other
Source (example) key: Key:
1 = Outreach Date/+/0:
2 = Hospital Date = Copy date of immunization from card, if available
3 = Health centre + = Mother reports immunization was given
4 = Private 0 = Immunization not given
5 = Non-governmental organization
6= academic institute
7= other
(13) tally households visited
(14) tally individuals who received the MCMV in another state during the first phase
(15) name ans signature of data collector (16) name and signature of supervisor

29
Annex 2
Immunization Coverage survey for Assessment of Meningitis mass campaign and routine immunization in seven states in Sudan
Meningococcal meningitis vaccination coverage cluster form (5 - 14 years)

(1) cluster number name ‫المجموع‬

(2) date ‫ تاريخ‬+‫كرت‬
(3) area ‫تاريخ‬
Range of birth date from
From
To
Respondent number in cluster 1 2 3 4 5 6 7
((6) birth date
(7) sex 1. Male 2. Female
(8) vaccination card 1. yes 2. no

(9) if no card, why 1. Not given

2. lost
3. other
(10) MCMV Date/+/0
source
(11) side effects 1. yes 2. no
( within month)
Side effects 1.Redness at the site of injection
2. swelling at the site of injection
3. pain at the site of injection
4. fever
5. irritability
6. headache
7. vomiting
8. skin rash
9. hypersensitivity reaction
10. other (specify)

(12) pregnant 1. yes 2. no

during the
campaign?
If, pregnant, age of
pregnancy in weeks

(13) if not vaccinated , what was the main reason? 1 2 3 4 5 6 7 ‫كرت‬ + ‫كرت‬
‫تاريخ‬
Lack of a. Unaware of need for
information immunization
b. Place and/or time of
immunization unknown
c. Fear of side reactions
d. Wrong ideas about
contraindications

30
 e. other
Lack of f. No faith in immunization
motivation j. Rumours
h Other
Obstacles I. Place of immunization too far
j. Time of immunization
inconvenient
k. Vaccinator absent
l. Vaccine not available
m. too busy
n. ill —
o. Long waiting time
q. other
Source (example) key: Key:
1 = Outreach Date/+/0:
2 = Hospital Date = Copy date of immunization from card, if available
3 = Health centre + = Mother reports immunization was given
4 = Private 0 = Immunization not given
5 = Non-governmental organization
6= academic institute
7= other
(14) tally households visited
(15) tally individuals who received the MCMV in another state during the first phase
(16) name ans signature of data collector (17) name and signature of supervisor

Annex3
Immunization Coverage survey for Assessment of Meningitis mass campaign and routine immunization in seven states in Sudan
Meningococcal meningitis vaccination coverage cluster form (15 -29 years)

(1) cluster number name ‫المجموع‬

(2) date ‫ تاريخ‬+‫كرت‬
(3) area ‫تاريخ‬
Range of birth date from
From
To
Respondent number in cluster 1 2 3 4 5 6 7
((6) birth date
(7) sex 1. Male 2. Female

31
(8) vaccination card 1. yes 2. no

(9) if no card, why 1. Not given

2. lost
3. other
(10) MCMV Date/+/0
source
(11) side effects 1. yes 2. no
( within month)
Side effects 1.Redness at the site of injection
2. swelling at the site of injection
3. pain at the site of injection
4. fever
5. irritability
6. headache
7. vomiting
8. skin rash
9. hypersensitivity reaction
10. other (specify)

(12) pregnant 1. yes 2. no

during the
campaign?
If, pregnant, age of
pregnancy in weeks

(13) if not vaccinated , what was the main reason? 1 2 3 4 5 6 7 ‫كرت‬ + ‫كرت‬
‫تاريخ‬
Lack of a. Unaware of need for
information immunization
b. Place and/or time of
immunization unknown
c. Fear of side reactions
d. Wrong ideas about
contraindications
e. other
Lack of f. No faith in immunization
motivation j. Rumours
h Other
Obstacles I. Place of immunization too far
j. Time of immunization
inconvenient
k. Vaccinator absent
l. Vaccine not available
m. too busy
n. ill —
o. Long waiting time
q. other
Source (example) key: Key:

32
1 = Outreach Date/+/0:
2 = Hospital Date = Copy date of immunization from card, if available
3 = Health centre + = Mother reports immunization was given
4 = Private 0 = Immunization not given
5 = Non-governmental organization
6= academic institute
7= other
(13) tally households visited
(14) tally individuals who received the MCMV in another state during the first phase
(15) name ans signature of data collector (16) name and signature of supervisor

33
 Annex 4:
1. Survey team – roles and responsibilities:
o Principal Investigator:

 Prepare the survey protocol based on the WHO guidelines

 Conduct training of the states’ coordinators on survey management
 Conduct training of the states’ trainers for field supervisors and data
collectors
 Conduct training of the state supervisors
 Supervise the training of the data collectors at state level
 Supervise the field work for data collection in the seven states
 Supervise data entry and verification
 Supervise analysis and interpretation of the data
 Write the survey report
 Assist in publication

o State Survey Manager (7): University graduates, with extensive

experience in Research and national surveys:
 Manages the implementation of survey at the state level
 Developing a plan (road map) for implementing the fieldwork in the
state.
 Recruit and train the fieldwork teams at state level
 Supervise the field work for data collection in the seven states
 Monitor the quality of data collected in the seven states
 Submit the completed format to the National EPI survey focal person

o State co-coordinator (I per state): the manger of State Expanded

Programme of Immunization.
 Overseeing the implementation of the immunization coverage survey
at the his/her state;
 Ensuring the cooperation of other relevant local government and
other agencies;
 Providing information about the selected cluster areas including their
location and accessibility.
 Arranging transportation of the fieldwork teams to selected cluster
areas.
 Arranging the submission of the competed forms to the principal
investigator.

34
o Field supervisor (5 per state): University graduates, with previous
experience of field supervision, preferably related to immunization
coverage survey. Has the following responsibilities:
 Insuring local authorities and community leaders in the areas to be
covered by the survey are contacted before the start of work in a
cluster to explain the purpose of the survey and gain their consent
and support;
 Insuring interviewers are fully familiar with their task;
 Insuring each member of their teams has the necessary materials for
their daily activities;
 Insuring data collection is done according to the stated instructions
 Insuring completed forms are carefully reviewed before leaving the
survey area for completeness and checking for errors;
 Insuring the completed data collection forms are given to the state
coordinator; and

• Insuring the welfare and security of the members of the team are
ensured.

o Interviewers (10 per state): university graduates with previous

experience of data collection preferably related to immunization
coverage survey. Interviewers were responsible for collecting the data
according to the instructions given in the data collection forms.
o Data editors (2): university graduate with background in statistics or
demography. They were responsible for:
 Editing the completed forms, submitted from the states for
consistency and completeness.
o Data entry clerks (3): university graduates with previous experience of
data entry into electronic spread sheets (excel – SPSS...etc), they will be
responsible of data entry into the WHO excel workbook tool.
o Statistician (1): with expertise in sampling procedures and processing and
analysis of large data sets. Familiarity with WHO excel workbook tool is
preferred. s/he is responsible for:
 Selection of the primary sampling units using the Sudan 2009 Sudan
Census frame.
 Training office editors on reviewing the completed forms
 Training the data entry clerk on data entry
 Supervise the process of data entry
 Checking quality of the entered data
 Producing the survey indicators using the WHO excel workbook tool
Data

35