Reporting and Investigating Adverse Events Following Immunization Campaigns in Afghanistan

This document provides a guideline for managers and others responsible for immunisation programmes on the surveillance and appropriate response of adverse events following immunisation (AEFI) in Afghanistan. As indicated here, vaccines can cause adverse events - from the inherent properties of the vaccine (vaccine reaction) or error in the immunisation process (programme error). The event may be unrelated to the immunisation, but have a temporal association with it (coincidental event). Anxiety-related reactions can arise from fear or pain from the injection (injection reactions) rather than the vaccine itself. Whatever the reason, AEFIs can negatively affect community confidence related to immunisation services.

The document recommends that AEFI surveillance in Afghanistan prioritise the detection of AEFIs due to programme errors - placing emphasis on pre-campaign planning, selection of vaccinators, training, and supportive supervision.

Partnership is also noted here as a key strategy for dealing with AEFI. The Expanded Program on Immunization (EPI) Unit at the Ministry of Health (MoH) is ultimately responsible for the AEFI surveillance with the Regional EPI Management Team (REMT) and the Provincial EPI Management Team (PEMT). At all levels, UNICEF and WHO will provide technical and logistic support. According to this document, additional training opportunities for the MoH, the United Nations Children's Fund (UNICEF), and the World Health Organization (WHO) staff on general epidemiological investigation and injection safety should be explored to improve their capacity in AEFI surveillance and response.

Also, as noted here, AEFI following campaigns should be recorded at the Acute Flaccid Paralysis (AFP) sentinel sites, which "should be the primary mechanism of reporting cases of AEFI and they need to be sensitized in order to be vigilant particularly for a period of two months after each campaign." The document also recommends regular visits by the Provincial Polio Officers (PPO) and National Immunization Day (NID) monitors to the districts. Another opportunity for detecting AEFI is during the disbursement of incentives following a campaign, when vaccinators and supervisors can be asked about AEFI in their communities. Whatever the source, according to this document, the information should be passed on to the Provincial EPI Management Team (PEMT), which is responsible for confirming the existence of the AEFI.

Once the investigation is concluded and the cause of the AEFI is ascertained, communication comes very strongly into play. For instance: "the cause of the event(s) needs to be communicated to the community. This must include information about the steps being taken to remedy the situation and to prevent a recurrence.

Trust is a key component of the exchange of information at every level, and overconfidence about risk estimates that are later shown to be incorrect contributes to a breakdown of trust among people involved. Admit uncertainty, investigate fully, and keep the community informed. Avoid making a premature statement about the cause of the event before the investigation is complete. If the cause is identified as program error, it is vital not to lay personal blame on anyone, but to focus on system-related problems, which resulted in the program error(s) and steps being taken to correct the problem...

In communicating with the community, it is useful to develop links with community leaders and the peripheral health workers so that information can be rapidly disseminated. Maintaining lines of communication with the community is important throughout the investigation. The head of the PEMT or REMT will be responsible for communications with the committee with support of UNICEF and WHO provincial teams. Feedback should also be provided to the health workers or community members who reported cases of AEFI and their contribution should be commended...

The media (newspaper, radio, and television) play an important role in public perception. Understanding what the media want from a story, will assist communication with them (see Annex E).

In certain situations, media coverage is likely to raise public concern about immunization. In these situations, it is important to communicate with professional organizations, health professionals and workers before the media. The communication should include preparation on how to deal with the public concern on this issue, to minimize the potential harm. It is also useful to have other groups and individuals that have public respect and authority to make public comments to endorse and strengthen key messages. Designating the spokesperson(s) to communicate with the media limits the possibility of conflicting messages coming from different sources. The spokesperson should have some training on media relations, and be designated and trained before any vaccine safety issues arise, so that the spokesperson can develop a relation with key reporters. The head of the REMT or the PEMT will be responsible for dealing with media at the local level. At the national level, the National EPI Manager will be the person responsible of liaison with the media. In all cases (and all levels), support will be provided by UNICEF and WHO staff."

The document concludes by noting that the AEFI surveillance system should be regularly evaluated to see if it is meeting its objectives. Indicators should be identified to assess the timeliness and appropriateness of the response. In addition, AEFI questions should be included in all post campaign coverage surveys to estimate the sensitivity of the system. Finally, AEFI data should be reviewed and lessons learned discussed at the annual EPI review meeting.