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Lao PDR demonstrates what it takes to reach ‘every female’ in a tetanus campaign

© UNICEF Lao/2010/Philippe Blanc 
A young Akha mother takes her third injection of tetanus toxoid vaccine.

By Karen Emmons

VIENTIANE, Lao People’s Democratic Republic, 16 February 2011– Too many mornings, too many village women had darted for their rice fields rather than stop by the  temporary vaccination post the Lao Government had set  up to immunize them against the deadly threat of tetanus.

Vilayvanh Sivilay and her co-vaccinators from the Long District Health Office were frustrated at missing the hill tribe women, regarding them and their newborns as the most vulnerable of the vulnerable to tetanus infection. Two doses of tetanus toxoid vaccine provides a shield for up to three years against the bacteria that thrives in soil, animal waste and even dust; six vaccinations over a lifetime are considered optimal to prolong the duration of protection.

Joining the global push to eliminate maternal and neonatal tetanus (MNT) – 39 countries have not yet achieved this status – the Lao Ministry of Health launched a three-round campaign to offer three free tetanus vaccine doses over a year’s period, which started in November 2009 and just wrapped up this past December.

“The campaign is considered necessary because routine tetanus toxoid coverage has been consistently below the recommended 80 per cent threshold in many districts,” commented Dr Ataur Rahman, Immunization Specialist, UNICEF Lao PDR. “Combined with high rates of unattended births and weak reporting systems for neonatal tetanus deaths, boosting tetanus protection levels across the community are critical to achieve elimination of MNT.”

Although anyone can get a tetanus infection, females of childbearing age are considered highly susceptible in countries where births with unskilled health attendants are common, as in the Lao People’s Democratic Republic where up to 80 per cent of births take place at home, where conditions are typically unhygienic.

So just after the sun rose on a recent December morning, the mobile vaccination team skipped the village health clinic and planted themselves en route to the fields. “We sat on the path and waited for them,” chuckles Ms Sivilay.

The following week, Ms Sivilay’s team returned to the Sen Kam Kham Mai village of the Akha minority at the end of a roller-coaster loop of a red dirt road that dipped in and out of the misting clouds. Sen Kam Kham Mai sits in the northern Lao mountains of Luangnamtha province, 2 km from the border with Myanmar. The team was intent on rounding up the women they had missed the week before.

© UNICEF Lao/2010/Philippe Blanc
Vilayvanh Sivilay from the Long district health team prepares to give a dose of tetanus toxoid vaccine.  

To be sure no one was missed again, Onekeo Ounmaykoum, from the district Expanded Programme for Immunization, went a day early and gathered the families together for a health education lesson and to explain the importance of the tetanus vaccination. To be doubly sure, he dangled the promise of visiting VIPs, including the Long district health officer, to observe their participation in the Lao Government’s campaign to eliminate maternal and neonatal tetanus across the country.

Down in the urban lowlands, the vaccinators had shrewdly set up posts in bus stations, temples, outside schools and in public markets to reach as many women as possible. They went to the national airport, inoculating stewardesses and check-in counter staff. Occasionally, they went door to door. 

The challenges

The looping, the re-routing and the house calls illustrate the lengths that district health workers took to reach every female of childbearing age with three doses of the tetanus toxoid vaccination. Lao PDR is 87 per cent mountainous, with extremely low density – about 26 persons per square kilometre. Most of the population belongs to one of at least 49 ethnic minority groups and a large proportion of them do not speak the Lao language (the only local language which appears in printed material). Reaching everyone takes industrious lengths.  

Most of the challenge is topographical. “Some villages are still not accessible by road, they can only be reached by foot,” explains Dr Aboudou Karimou Andele, Chief of Health and Nutrition, UNICEF Lao PDR.

But there are also cultural issues. “Here you have to understand about modern medicine and the tradition of minority groups,” explained Latda Pathammavong, Director of the National Commission for Mothers and Children Secretariat (NCMC), who had just returned from observing the campaign’s third round in several provinces and pleased with the results so far.  “If the husband says no, a woman can’t get vaccinated.”

In Sen Kam Kham Mai village, the 25 females the team missed in the previous week’s visit streamed into the stilted wooden multipurpose hut that serves as the health clinic, the older ones in their native Akha dress and carrying bowls of peanuts, popcorn, sugar cane and white turnip to honour the occasion. Some grandmothers came topless while other grandmothers were still young enough to be in the 15- to 45-year-old target group. The women’s old French and Chinese coins and tinny balls dangling from brightly coloured strings wrapped around their bodies or off their box-shaped hats chimed with their chatter. The demure teenagers stood out in their T-shirts and sarongs. 

© UNICEF Lao/2010/Philippe Blanc
An Akha woman in a remote village in Northern Lao safeguards her yellow tetanus toxoid campaign card in her hat.

The campaign targeted 99 (of 142) districts considered at high risk of neonatal tetanus. To kick off, the first round partnered with Child Health Days, which included delivery of additional maternal and child survival interventions, such as the oral polio vaccine in some districts for children younger than 5 years. Deworming tablets were provided for both the females of child-bearing age and children aged 1–5 years; vitamin A supplements were included in all three rounds for children aged 6 months to 5 years.

© UNICEF Lao/2010/Philippe Blanc
Children receiving deworming pills and a vitamin A supplement during the tetanus campaign.

In some areas, the H1N1 vaccination was also offered, largely because the ‘swine flu’ is a more recognizable fear that locals have picked up from popular foreign television programmes that air across Lao PDR. Because so few people have witnessed a tetanus death, which is horribly unforgettable, the offer of the H1N1 vaccination seemed to act as a magnet for those who were not familiar with tetanus.

Mobilizing the campaign

To cope with the remoteness as well as the mindsets, the Lao Ministry of Health worked closely with the NCMC and mass organizations, such as the Lao Women’s Union, the Lao Youth Union and the Lao Front for National Construction, to mobilize the communication it takes to convince people to participate.

“We started with a decree from the Standing Deputy Prime Minister as the Chairman of the NCMC that went to all the Provincial Commissions for Mothers and Children, as well as district committees,” said Ms Pathammavong. “That letter was very important to ask for the full support of the Provincial authorities.”

The logistical orchestration was delegated to each district health office, which had to present a detailed micro plan for reaching the targeted group before receiving the funds needed to conduct the campaign, which UNICEF provided with Procter and Gamble support.

The Center for Information and Education for Health of the Health Ministry, which produced all the MNT campaign material, relied on the slogan typically used for any immunization campaign: “If you love your wife and your children, bring them to receive a vaccination.”

© UNICEF Lao/2010/Philippe Blanc
Mothers and children in Sen Kam Kham Mai village wait for their tetanus toxoid vaccination during a follow-up visit by the district health team.

Results of the campaign

Although the campaign appears to have concluded with over 80 percent coverage, more work needs to be done on educating communities about the disease, which can cause a horrible death if not caught early enough for treatment.

Global estimates suggest that the disease kills one baby every nine minutes.  Death is preceded by excruciating pain – newborns become incapable of suckling and suffer repeated, painful convulsions and experience extreme sensitivity to light and touch. Most die because they do not receive essential health care.

Due to the important impact of vaccination, tetanus cases are now rarely seen among newborns and many Lao women connect the disease with exposure to rust through an injury. “Only older people die from the infection from injuries,” explained a young woman waiting in the Vientiane bus station.

Or they don’t know it can be fatal. “I never heard people could die from this disease,” said the mother of three children who is a university lecturer, as she passed through the Vientiane bus station.  She had actually received five doses of the vaccination.

Additionally, many women participating in the campaign were not clear on the protection they now carried.

“I just know this vaccination can prevent disease, but I don’t know which disease,” admitted Ton Chu, 22 and eight months pregnant, who had waited for the vaccinators to set up in the open-air market where she sells appliances in the capital city of Oudamxay province.

Agreeing there indeed were weaknesses in the health communication, Ms Pathammavong of the NCMC was still impressed with the organization and results of the campaign. “I’m very happy…I feel we have done our best.”  


VIDEO: UNICEF's Rachel O'Brien reports on the UNICEF-supported national campaign to eliminate maternal and neonatal tetanus in Lao PDR by 2012. Watch in RealPlayer



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