Polio Supplementary Immunization Activities (SIAs) during the COVID-19 Pandemic: Experience from Penampang District, Sabah, Malaysia

Before planning the SIAs, the Penampang District Health Office carried out a situational assessment to study the population of interest and issues that may affect implementation. Micro-planning was then developed to, for example, identify measures to increase the uptake of immunisation. At this planning phase, vaccine hesitancy was part of the conversation, with organisers aware that addressing this problem must be done at every level of society. Public health practitioners were tasked with promoting vaccination and educating the general public by providing a platform for interaction and communication with their clients. Any doubts or myths related to vaccination were addressed accordingly. In addition, all the appointed SIA team members were trained; community health volunteers, a health advisory panel, religious leaders, and government retirees were also involved as community mobilisers.

The implementation of polio SIAs was divided into 2 phases: (1) bOPV, which started in January 2020, and (2) mOPV, which commenced in July 2020. (BOPV contains only attenuated virus of serotypes 1 and 3, while mOPV covers type 2 poliovirus. Both vaccines consist of 2 doses with an interval of 1 week to 10 days.) Multiple vaccination strategies were utilised: static posts, mobile posts, house-to-house visits, school visits, and mobile clinics. All vaccinated children received an indelible marking on one of their fingers or toenails and were given a vaccination card to keep track of their immunisation status. The state health department carried out intra-campaign monitoring of the SIAs to ensure quality and provided technical guidance whenever necessary. Continuous supervision and training were conducted to ensure competency and compliance with safety protocols during field activities.

School authorities were important partners in the polio SIAs, since more than half of the population to be reached were preschool and primary school children. Healthcare liaison officers were constantly in contact with the teachers to arrange vaccination activities. In addition, the teachers assisted in mobilising their students and maintaining order. When COVID-19 restrictions led to the temporary closure of schools, schoolgoing children were given an appointment for vaccination at the nearest post or, beginning in August 2020, were reached via a drive-through vaccination campaign instituted to reduce congestion in the static and mobile posts. The drive-through polio vaccination station in Penampang was widely publicised and even attracted clients from another district.

Ongoing advocacy on the polio SIAs was conducted in collaboration with the District Office, education officials, local radio and television stations, village heads, private health clinics, non-governmental organisations (NGOs), and religious institutions. Information on the SIAs was broadcast via mainstream and social media. Messages on vaccine-preventable diseases (VPDs) were also conveyed during the school's parent-teacher association (PTA) meetings. Small group talks were conducted frequently (with caution) during the COVID-19 pandemic. Weekly sessions were conducted in several schools, commercial premises (shopping malls, supermarkets, and eateries), and residential areas throughout the SIAs. In addition, a series of meetings and dialogs between the health authorities and community representatives were conducted periodically.

During such communications, parents were helped to understand that not vaccinating may lead to contracting VPDs and the disruption of herd immunity. During the public dialog sessions, for example, it was important to engage with the audience and communicate risk effectively. Communicating with both parents and their children was a strategy for identifying and addressing barriers related to vaccination delay. Health professionals also emphasised giving information about common but minor side effects, as well as rare but serious ones.

Approximately 49,000 health promotion flyers were distributed all over Penampang, primarily in the commercial premises, residential areas, government premises, villages, healthcare facilities, and schools. Visual aids proved to be very useful in disseminating information, as graphics made it easier for the public to digest the content. In primary care facilities, health education materials were provided not only in paper format but electronically, as the number of internet users in Sabah continues to rise due to wider coverage and improved network quality. However the information was delivered, organisers found that informed parents were more likely to appreciate the benefits of vaccines.

Furthermore, every primary care facility engaged with the head or representative of localities under its operational areas, including migrant communities. Throughout the implementation of polio SIAs, a total of 426 public announcement sessions were carried out by the Mobile Health Promotion Unit. Most of these sessions took place in hard-to-reach areas and localities with a high density of undocumented migrants. Culturally sensitive health education was found to be essential to ensure information could be delivered effectively among undocumented migrants. The use of mobile SIAs was the best approach to reach undocumented migrants, as they feared possible arrest and deportation. Mobile vaccination teams were equipped with personal protective equipment (PPE) when carrying out SIAs.

Immunisation and Vaccines, COVID-19.

Beginning in mid-March 2020, the COVID-19 pandemic affected the progress of polio SIAs. The Movement Control Order (MCO) forced many institutions, such as schools, to close. Furthermore, several mitigation measures were imposed: closure of borders, inter-district and interstate movement restriction, suspension of international flights, restriction of eateries' operating hours, and prohibition on mass gathering. The pandemic also restricted healthcare operations for both primary care facilities and field activities. Primary healthcare workers faced various challenges in completing the SIAs according to schedule. For instance, they had to deal with parents who were worried about going to healthcare facilities.

Overall, the SIAs described above achieved more than 90% coverage for both bOPV and mOPV. Reflecting on the factors that contributed to that success, the organisers write that: "Community engagement is more than involvement, as it encompasses participation, engagement, and ownership by the communities. Large-scale health programs can be geographically challenging. Health inequalities can occur whenever there are disadvantaged groups in achieving health services. Engagement with community leaders or representatives can help to mobilize the rest of the community, especially in the rural areas to gain access to health services."