# Reaching Never- and Incompletely-Vaccinated Children with Routine Immunization: A Proof-of-Concept Activity Using Geo-Referenced Microplans in Two Health Zones in Maniema Province, Democratic Republic of the Congo

## TL;DR

This study shows how using geographic data to target vaccination efforts helped reach thousands of unvaccinated children in remote areas of the Democratic Republic of the Congo.

## Contribution

The use of geo-referenced microplans to identify and vaccinate never- and incompletely-vaccinated children in hard-to-reach areas is a novel approach.

## Key findings

- Geo-referenced microplans successfully identified and vaccinated thousands of children in Kindu and Kibombo.
- Over 90% of localities with high proportions of unvaccinated children were reached during the PIRIs.
- Knowledge and access barriers were the main reasons for non-vaccination in the study areas.

## Abstract

Background/Objectives: The Democratic Republic of the Congo (DRC) has a history of low coverage (<50%) with all first-year-of-life vaccines for children aged 12–23 months, resulting in frequent outbreaks of vaccine-preventable diseases. In response, the DRC’s Expanded Program on Immunization (EPI) is applying innovations to improve vaccination coverage, including using geospatial data to inform vaccination planning (geo-referenced microplans). This report describes a proof of concept to geo-locate, by locality of residence, never-vaccinated children (NVC) or incompletely vaccinated children (IVC); use those data to prepare geo-referenced microplans for rounds of Periodic Intensification of Routine Immunization (PIRIs); and implement the PIRIs. Methods: In 2022, in Kindu and Kibombo Health Zones (HZs), Maniema Province, DRC, children aged 0–23 months were enumerated with inquiries about their vaccination status and reasons for non-vaccination by locality of residence. The enumeration was coupled with the collection of the localities’ geographic coordinates, facilitating the spatial illustration of estimated proportions of NVC by locality. Coordinates for HZ and health area (HA) landmarks and borders were also collected. We created maps that informed geo-referenced PIRI microplans, placing an emphasis on deploying vaccination teams to localities with high proportions of NVC, especially those in remote and riverine locations. To account for inclusion of children aged up to 59 months in the PIRIs, enumeration data were extrapolated to estimate the numbers of NVC and IVC in this wider age range. Volunteers mobilized communities for the PIRIs, HA staff vaccinated age-eligible children, and vaccination teams were geographically tracked. Results: In Kindu, 29,837 children aged 0–23 months were enumerated in 430 localities; among them, 38% were NVC and 6% IVC. In Kibombo, 9582 children aged 0–23 months were enumerated in 168 localities; among them, 50% were NVC and 16% IVC. In both HZs, reasons for never vaccination were primarily associated with knowledge- or belief-related factors, while reasons for incomplete vaccination were associated with access-related factors. Between HAs and localities, there was heterogeneity in the proportions of NVC and IVC and in the reasons for non-vaccination. The numbers of NVC and IVC aged 0–59 months were estimated at 28,220 and 4613 in Kindu and 12,038 and 3785 in Kibombo. Approximately 2000 health staff and community volunteers were engaged for implementation of each of the three PIRIs. The number of children vaccinated during the three PIRIs ranged from 15,500 to 26,500 and from 10,500 to 15,500 in Kindu and Kibombo, respectively. Data suggest that vaccinated children originated from >90% of localities identified during the cartography. Tracking data showed that vaccination teams visited localities with high proportions of NVC, including those that were remote and riverine. Conclusions: Geo-referenced microplanning with engagement of health staff and communities succeeded in vaccinating at least 40,000 children who were not routinely benefiting from health services in two HZs in the DRC; similar innovative strategies could be considered elsewhere. Applying new technologies to existing microplanning strategies can enhance their success.