Improving Timeliness of Birth Dose Vaccines in 15 Health Facilities in Cameroon Through Integrating Immunizations Into Maternity and Newborn Care Services: A Feasibility Assessment
Phase: NA
Conditions: Hepatitis B
Sponsor: Clinton Health Access Initiative Inc.

 
 
 
Improving timeliness of birth dose vaccines in 15 
health Facilities in Cameroon through integrating 
immunizations into maternity and newborn care 
services:  
A Feasibility Assessment 
 
 
 
 
Submitted by 
Expanded Program on Immunization  
&  
The Clinton Health Access Initiative 
 
 
 
 
 
Document date: 2021- Jan 27 
  
 
 
 

2 
 
 
 
 
 
 
 
 
 
Principal Investigator:   
Professor Ankouane  Andoulo Firmin 
 
 
 
 
Faculty of Medicine and Bio-Medical Sciences, University of Yaoundé I 
 
 
 
Co-Investigators:  
 
Dr. Shalom Ndoula 
 
 
 
 
Permanent Secretary, Expanded Program on Immunization 
 
Dr. Yauba Saidu 
 
 
 
 
Deputy Country Director, Clinton Health Access Initiative 
 
Delphine M. Kamga, MPH 
 
 
 
 
Senior Associate, Vaccines Service Delivery 
 
Marta Prescott, PhD, MPH 
 
 
 
 
Senior Technical Advisor, Analytics and Implementation Research 
 
Dr. Jude Nkwain 
 
 
 
 
Program Manager, Vaccines 
 
 
 
 
 
Dr. Tambasho Afizu 
 
 
 
 
Chef d’unité, Vaccination de Routine 
 
 
 
 
 
 
 
 
 

3 
 
Investigators 
 
Name 
Ankouane  Andoulo Firmin, Associate Professor  
Institution 
Faculty of Medicine and Bio-Medical Sciences, University of Yaoundé I 
Address 
Yaoundé, Tel : 677 56 40 70 
Email 
Ankouane andoulo@yahoo.com   
Signature 
 
 
 
 
 
 
 
 
 
 

4 
 
Sponsor 
 
Project Sponsor 
Bill & Melinda Gates Foundation 
Address 
500 Fifth Avenue North 
Seattle, WA 98109 
United States 
 
 
 

5 
 
 
 

6 
 
Table of Contents 
 
 
Request for ethical clearance from Cameroon IRB 
Error! Bookmark not defined. 
Executive Summary 
9 
1 
Introduction 
10 
1.1 
Background 
10 
1.2 
Study Aim and Objectives 
12 
1.3 
Justification for Pilot Study 
12 
2 
Methodology 
13 
2.1 
Study Design 
13 
2.2 
Study sites 
14 
2.3 
Study Period 
14 
2.4 
Study Population 
14 
2.5 
Site selection criteria 
14 
2.6 
Facility sensitization and workflow creation and vaccine availability 
15 
2.7 
Training Sessions 
16 
2.7.1 
Intervention training 
16 
2.7.2 
Data collectors training 
18 
2.8 
Ongoing trouble-shooting touch points 
18 
2.9 
Data Sources and Collection 
19 
2.9.1 
Birth registry and immunization registry 
19 
2.9.2 
Birth dose reporting form 
20 
2.9.3 
HCW surveys 
21 
2.10 
Study Outcomes 
21 
2.11 
Data Analysis 
22 
2.12 
Data Quality Control Measures and Security 
22 
2.13 
Dissemination 
22 
2.14 
Limitations 
23 
3 
COVID-19 Impacts 
23 
3.1 
Cameroon COVID-19 Situation 
23 
3.2 
Infection Control Procedures 
24 
4 
Ethical Considerations 
25 

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4.1 
Informed Consent and Confidentiality 
25 
4.2 
Potential Risks for Participants 
25 
4.3 
Benefits for Participants 
25 
5 
Study Tools 
27 
5.1 
Information Notice 
27 
Participant Information Notice for Baseline 
27 
Notice information pour participants (version Française) 
Error! Bookmark not defined. 
5.2 
Informed Consent Form 
30 
Informed Consent 
Error! Bookmark not defined. 
Formulaire de consentement éclairé 
Error! Bookmark not defined. 
5.3 
Data collection tools 
32 
HCW Questionnaire 
32 
Immunisation register extraction 
40 
Delivery register extraction 
41 
Newborn data tool 
42 
Notes for touchpoint calls 
43 
Questionnaire du Prestataire de soins 
Error! Bookmark not defined. 
Extraction du registre de vaccination 
Error! Bookmark not defined. 
Données du registre d’accouchement 
Error! Bookmark not defined. 
Outil de collecte des données sur les nouveau-nés 
Error! Bookmark not defined. 
Notes pour les appels de suivi 
Error! Bookmark not defined. 
5.4 
Project Timeline 
44 
5.5 
Budget 
Error! Bookmark not defined. 
5.6 
References 
46 
 
 
 

8 
 
List of Abbreviations 
 
BCG 
Bacillus Calmette–Guérin vaccine 
BD 
Birth Dose 
bOPV 
Bivalent Oral Polio Vaccine 
CCE 
Cold Chain Equipment 
CHAI 
Clinton Health Access Initiative 
cMYP 
CMA 
Comprehensive Multi-year Plan 
Centre Médicalise d’Arrondissement 
CNERSH 
Comité National d'Éthique de la Recherche pour la Santé Humaine 
COVID-19 
Corona virus disease 
CS 
Centre de santé 
DHIS 
District Health Information Software 
DN 
Dose de naissance 
EPI 
Expanded Program on Immunization 
HCW 
Health Care workers 
Hep B 
Hepatitis B Virus 
IRB 
Institutional Review Board 
NITAG 
National Immunization Technical Advisory Group    
OPV 
Oral Polio Vaccine 
PEV 
Programme Elargie de vaccination 
TB 
Tuberculoses 
VPO 
Vaccin Polio orale 
 

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Executive Summary 
In the Cameroon Expanded Program on Immunization (EPI), the birth dose vaccine for oral polio vaccine (OPV-
0) and tuberculosis vaccine (BCG), are recommended with a third birth dose vaccine for hepatitis B (HepB-
BD) being considered for introduction.  
Although Cameroon introduced the HepB antigen as part of the Pentavalent vaccine into the immunization 
program in 2005, infants are currently unprotected until the first Penta shot at six weeks. Introduction of 
HepB-BD is a key priority for the Cameroon government through the National Cancer Strategy document as 
well as the Hepatitis Prevention and Treatment Guidelines. However, the timeliness of administration of 
Hepatitis B vaccine within 24 hours of birth is critical to ensure the highest efficacy and prevent transmission 
of the virus. 
While coverage rates for BCG and OPV 0 are relatively high (91% and 78% respectively), these vaccines are 
often administered weeks or months after birth1, not within the 24-hour timeframe recommended for 
Hepatitis B birth dose. Therefore, there are concerns from the Cameroon National Immunization Technical 
Advisory Group (NITAG) and other stakeholders on the feasibility of achieving high timely coverage of HepB-
BD. The timeliness of administration of the birth dose vaccines within facilities relies on many system 
components including integrated processes between maternity and immunization units and healthcare 
worker awareness of birth dose administration guidelines.  
The main aim of this pilot study is to assess the feasibility of immunizing newborns with BCG and OPV0 (and 
eventually HepB-BD) within 24 hours of birth by integrating routine immunization into maternity and 
immediate newborn care in 15 facilities in Cameroon.  
Further, the specific objectives of this pilot study are to: 
1. Integrate birth dose immunizations into maternity and immediate newborn care 
services 
2. Measure the change in proportion of newborn receiving birth doses BCG and OPV0 
within 24 hours compared to baseline data  
3. Measure the change in average age of babies receiving birth doses of BCG and OPV0 
4. Assess the operational feasibility and acceptability of interventions and describe any 
factors (barriers and enablers) that may influence further implementation of birth dose 
strategies 
 
This feasibility assessment is to provide quantitative findings of an intervention integrating immunizations 
into maternity and newborn care across 15 health facilities in Cameroon. Overall, in 20 weeks an intervention 
phase will be followed by a final assessment. The approach will utilize quantitative data from healthcare 
worker surveys, the birth registry and immunization registry, and maternity unit reporting forms. The study 
findings will be used to inform strategy on HepB-BD introduction in Cameroon as well as interventions to 
strengthen service delivery structures for newborns.  
 
 
1 Chiabi et al, Vaccination of infants aged 0 to 11 months at the Yaounde Gynaeco-obstetric and pediatric hospital in Cameroon: how 
complete and how timely?, BMC Pediatrics, 2017 

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1 
Introduction 
1.1 Background 
 
In the Cameroon routine immunization program, two vaccines are recommended for administration as soon 
as possible after birth (oral polio vaccine/OPV0 and tuberculosis vaccine/BCG) with a third birth dose vaccine 
(hepatitis B birth dose/HepB-BD) being considered for introduction. These recommendations for timely 
administration of the birth dose vaccines are in line with the position of the World Health Organization (WHO) 
on birth vaccines, as summarized below:   
 
● BCG: in countries or settings with a high incidence of Tuberculosis (TB) and/or high leprosy burden, 
a single dose of BCG vaccine should be given to all healthy neonates at birth. If the BCG vaccine 
cannot be given at birth, it should be given at the earliest opportunity before exposure to infection2. 
● OPV0: in polio-endemic countries and in countries at high risk for importation and subsequent spread 
of poliovirus, WHO recommends a bOPV birth dose also called ‘zero dose’ followed by a primary 
series of three bOPV doses and at least one IPV dose. The bOPV zero dose of bOPV should be 
administered at birth, or as soon as possible after birth, to maximize seroconversion rates following 
subsequent doses and to induce mucosal protection before enteric pathogens may interfere with the 
immune response.3 
 
● HepB birth dose (HepB-BD): All newborn (including low birth weight and premature newborn) should 
receive their first dose of Hepatitis B vaccine as soon as possible after birth, ideally within 24 hours to 
be effective against vertical transmission. The timeliness of HepB-BD is important because the risk of 
developing chronic Hepatitis B virus (HBV) infection varies inversely with age: 80-90% of infants 
infected during their first year of life develop chronic infections, as opposed to 30-50% of children 
infected before the age of 6 years and 1-5% of adults1. 
 
Cameroon’s HepB prevalence is estimated to be 11.9%, which is nearly double the African average prevalence 
(6.1%) and triple the global average prevalence (3.5%)4. Although Cameroon introduced the HepB antigen as 
part of the Pentavalent vaccine into the immunization program in 2005, infants are currently unprotected 
until the first Penta shot at six weeks. Furthermore, vertical transmission during this period tends to be 
particularly common in countries with high HBV prevalence5. The monovalent hepatitis B vaccine that can be 
given at birth is inexpensive, costing between $0.29 and $0.42 per dose, thus making it a small investment 
for a major step towards eliminating HBV completely. Further, as of 2021, Gavi will start funding HepB-BD. 
 
2 WHO position paper on BCG vaccines, February 2018 
3 WHO position paper on Polio vaccines, March 2016 
4 Global Hepatitis Report, 2017 & Bigna JJ, Amougou MA, Asangbeh SL, et al Seroprevalence of hepatitis B virus infection in 
Cameroon: a systematic review and meta-analysis BMJ Open 2017;7:e015298. doi: 10.1136/bmjopen-2016-015298 
5 Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. 2014;6:605-611. 
Published 2014 Jun 10. doi:10.2147/IJWH.S51138 

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The Cameroon government previously expressed the desire to introduce HepB-BD and developed a draft 
HepB introduction plan in 2016 with budget provisions for two consecutive years. This Plan were suspended 
pending the decision from GAVI to fund HepB-BD introductions. However, this will be reviewed during the 
preparation of the National Immunization Strategy 2021-2025. Currently, HepB-BD is included as a key 
priority in the National Cancer Strategy document as well as the National Strategic Plan for the Control of 
Viral Hepatis.  
Administrative and survey coverage data in Cameroon does not capture the timing of vaccination so coverage 
of birth dose vaccines within 24 hours is unknown. To better understand the current service delivery system 
and needs for birth vaccines in Cameroon, CHAI and EPI carried out a field study in 2019 with the objective 
to describe timeliness of current birth dose vaccines and the barriers and facilitating factors that influence 
timeliness and coverage. The study was approved by the Cameroon National Ethics Committee for Human 
Health Research (2019/03/4447/CE/CNERSH/SP). 
This was a cross-sectional study of 30 selected sites with both an immunization and labor and delivery unit 
across three regions (Center, Far North, and West) within Cameroon, utilizing both qualitative and 
quantitative approaches. The findings from the study indicate that across the 30 sites, only 4% and 7% of 
newborn received BCG and OPV0, respectively, within 24 hours. The reported key barriers hindering timely 
birth dose administration included: (i)maternity units were not equipped functioning fridges, (ii) lack of 
awareness and insufficient demand by caregivers for birth dose vaccines (e.g. birth dose education at 
antenatal visits, (iii)vaccine hesitancy among caregivers mainly due to religious beliefs, myths and rumors. 
The key facilitators were (i) raising awareness among caregivers on the importance of birth dose vaccinations, 
(ii) improving access to functioning fridges in the maternity unit and (ii) addressing practices on multidose 
vial policies.  
 
Attaining high timely coverage with birth dose vaccines is a common challenge among low- and middle-
income countries. This challenge has been attributed to numerous barriers including, lack of integration into 
maternal and newborn health programs and protocols, lack of healthcare worker and caregiver knowledge, 
unavailability of cold chain storage, fear of vaccine wastage for multi-dose vials, high proportions of out of 
facility births, and difficulties of access and demand for target cohort.6,7,8,9 These barriers echo those 
identified in 2019 in Cameroon Global best practices and lessons learned from other countries suggest that 
successful timely administration of the birth dose vaccines relies on many system components including 
integrated processes between maternity and immunization units, healthcare worker awareness of birth dose 
administration guidelines, and demand from mothers and community.  
 
6 WHO. Practices to improve coverage of the hepatitis B birth dose vaccine, January 2013. 
7 Miyahara, R., Jasseh, M., Gomez, P., Shimakawa, Y., Greenwood, B., Keita, K., Ceesay, S., D'Alessandro, U., & Roca, A. (2016). 
Barriers to timely administration of birth dose vaccines in The Gambia, West Africa. Vaccine, 34(29), 3335–3341. 
https://doi.org/10.1016/j.vaccine.2016.05.017 
8 Gavi the Vaccine Alliance, Annex C: Hepatitis B Birth Dose Investment Case. October 2018. 
9 Country presentations at WHO AFRO regional workshop on Hepatitis B birth dose, June 2019. 

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1.2 Study Aim and Objectives 
The main aim of the pilot study aim is to assess the feasibility of immunizing newborns, within selected 
facilities, with BCG and OPV0 within 24 hours of birth by integrating routine immunization into maternity and 
early newborn care. In this study only the current birth vaccines (BCG and OPV) will be assessed. The findings 
will inform strategies for strengthening the birth platform as well as HepB-BD introduction which is envisaged 
in the cMYP (2016-2021). 
 
Further, the specific objectives of this pilot study are to: 
1. Integrate birth dose immunizations into facility-based maternity services 
2. Measure the change in proportion of facility births receiving birth doses BCG and OPV0 
within 24 hours  
3. Measure the change in average age of all babies receiving birth doses of BCG and/or 
OPV0 at the facility 
4. Assess the operational feasibility and acceptability of interventions and describe any 
factors (barriers and enablers) that may influence further implementation of birth dose 
strategies 
1.3 Justification for Pilot Study 
Cameroon’s national policy recommends that OPV0 and BCG be administered as soon as possible after birth. 
While coverage rates for BCG (84%) and OPV0 (79%)10 are relatively high in Cameroon, it is estimated that 
these vaccines are often administered weeks or months after birth,11 not within the timeframe recommended 
for their administration or that which will be needed for a successful HepB-BD program (<24 hours after 
birth).12 Currently, most health facilities do not administer vaccines every day, but rather only on designated 
immunization days. With babies being born every day, this poses a challenge to reach newborns via the 
current immunization service delivery system. Based on the study conducted in 2019 that highlighted the 
barriers and facilitators of timely birth dose administration, the Ministry of Public Health with support of CHAI 
decided to pilot facility specific HepB BD integration programs. A component that arose from the 2019 study 
that was of key concern was the lack of communication and integration between the immunization and 
maternity wards. Thus, this pilot work proposes a facility-based approach to better integrate birth dose 
vaccination into the broader facility-based maternity and newborn care processes to ensure newborns born 
within facilities are vaccinated within the recommended timeframe. While the previous assessment and 
studies have identified many common barriers to timely birth dose administration, the purpose of this work 
is to focus on the feasibility of integrating the birth dose vaccine process into maternity practices.  
 
 
10 EPI administrative data 2018 
11 Chiabi A., Nguefack F., Njapndounke F., Kobela M, Kenfack K, Nguifack S., Mah E, Nguefac-Tsague G., Angwafo F., (2017). 
Vaccination of infants aged 0 to 11 months at the Yaounde Gynaeco-obstetric and pediatric hospital in Cameroon: how complete 
and how timely?. BMC Pediatrics. 2017. 17:206. DOI 10.1186/s12887-017-0954-1 
12 WHO (2015). A Guide for Introducing and Strengthening HepB-BD Vaccination. www.who.int/immunization/documents 

13 
 
2 Methodology 
2.1 Study Design 
This is a three-part intervention study; baseline, implementation and final assessment. The purpose of this 
feasibility assessment is to report on the quantitative findings of an intervention integrating immunizations 
into maternity and newborn care across 15 health facilities in Cameroon. The overall aim is to assess the 
feasibility of administering OPV0 and BCG birth doses within 24 hours of birth in Cameroon: 
 
1) Baseline data collection (4 weeks to complete) 
2) Intervention implementation including health care worker training, and ongoing monitoring of 
the project (12 weeks to complete) 
3) Final assessment to gather an end line estimate of the outcomes (4 weeks to complete) 
 
The figure below is a graphic representation of the study outline. 
Figure 1: Outline of pilot study 
 
 
This pilot study is expected to take 20 weeks (see appendix 5.1 for a detailed project timeline) not including 
initial preparations such as obtaining ethics approval and training of data collectors. There is a possibility for 
delays due to an increase in COVID-19 pandemic. The study team will ensure the proper conduct of the study 
while respecting strict barrier measures.  

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2.2 Study sites 
Health facilities across Cameroon are classified under six categories namely: category one: General hospitals, 
category two: Central hospitals, category three: Regional hospitals, category four: district Hospital, category 
five: Medicalized Health centers and category six: Integrated Health centers.  We purposefully selected 15 
health facilities from these categories. These health facilities were also selected from three regions based on 
their dissimilar characteristics in geography, culture and immunization coverage. We also selected a mix of 
public and privately owned as well as semi-rural and urban health facilities. For the purpose of this study, we 
define semi-rural health facility as one serving a community that depends predominantly on agricultural 
activities for subsistence. For logistic reasons, more facilities were selected in the center region. 
Study sites selected are as follows:  
 
Table 1: List of study sites by region 
Adamawa 
Center 
West 
1. 
Hospital Protestant de 
Ngaoundéré  
2. 
CMA de Mbe 
3. 
CMA Dibi 
 
4. 
Hôpital Nicolas Barre 
5. 
HD Biyem Assi  
6. 
HD Obala  
7. 
Centre Medical Marie Reine Etoudi 
8. 
HD Cite Verte 
9. 
CS Catholique Nkoabang 
10. CMA Ahala  
11. CS Deo Gracia, Nkolbisson 
12. CSI Urbain Mbalmayo 2 
 
13. HD Mifi 
14. HD Foumbot 
15. CSI Catholique 
Baham 
2.3 Study Period 
The study is scheduled to take place for 20 weeks between January and April 2021. 
2.4 Study Population 
The study population will include: 
• 
All babies received in the maternity unit, or EPI unit for OPV0 and/or BCG vaccines in the 15 study 
facilities, during the 1-year baseline period and the intervention period; 
• 
HCW from the 15 facilities involved in either EPI or maternity and newborn care 
2.5 Site selection criteria 
The 15 health facilities will be selected based on the following inclusion and exclusion criteria while ensuring 
a mixture of semi-rural and urban, and large and small facilities, private and public facilities to observe 
feasibility and challenges across different levels of health care. Below are the proposed facilities purposefully 
selected through an iterative process with key stakeholders and EPI regional managers.  
 
Table 2: Site selection criteria 

15 
 
 
 
Characteristics of health 
facilities selected 
Urban setting 
 
Semi-rural district 
High volume   
(Above 100 average monthly deliveries) 
• 
Hôpital Nicolas Barre 
• 
HD Biyem Assi 
• 
HD Mifi 
• 
Hospital Protestant de Ngaoundéré 
• 
HD Obala 
 
Medium volume 
 (50 – 100 average monthly deliveries) 
• 
Centre Medical Marie Reine Etoudi 
• 
HD Cite Verte 
 
• 
CS Catholique Nkoabang  
• 
CMA de Mbe 
• 
HD Foumbot 
Low volume  
(Below 50 average monthly deliveries) 
• 
CMA Ahala  
• 
CSI Catholique Baham 
• 
CMA Dibi 
• 
CS Deo Gracia, Nkolbisson 
• 
CSI Urbain Mbalmayo 2 
 
Inclusion criteria: 
• 
Facilities providing maternity and newborn services including immunization services 
• 
Facilities with either functional cold chain equipment with reliable power sources on site OR those 
located within one km of the district or another facility with cold chain equipment on site for easy 
access 
 
Exclusion criteria: 
• 
Facilities participating in research or interventions that will impact the outcomes measured 
• 
Facilities experiencing higher than normal demand of COVID-19 patients will be excluded to not 
overburden HCWs further and potentially impact ongoing services 
• 
Health facilities that participated in the 2019 birth platform assessment  
2.6 Facility sensitization and workflow creation and vaccine availability 
Study staff will introduce the purpose of the study to the selected study sites and gain permission to conduct 
the study overall. Study staff will set up a time to meet with the facility to discuss the process of integration 
and discuss facility-specific situations. A workflow of facility-specific integration will be proposed and further 
refined during the intervention training.  
 
Further, vaccines available to the EPI units will be used for this study. No vaccines or consumables will be 
procured separate from the usual channels. Currently, EPI has the following vaccines in stock at the central, 
regional, district and health facility stores.   
 
 
 
 

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Table 3: Details of vaccines (BCG and OPV) currently available at EPI  
 
Vaccine Manufacturer 
Country  
BCG 
GreenSignal Biofarma Pvt Ltd 
India 
BCG 
BB-NCIPD Ltd 
Bulgaria 
bVPO 
Bharat Biotech 
India 
bVPO 
GlaxoSmithKline 
Belgium 
 
2.7 Training Sessions 
2.7.1 
Intervention training 
 
Training sessions will be held at each of the 15 facilities separately, with the same study members leading 
the sessions. Rather than a central training, we will conduct training at each facility, thus reducing mass 
gatherings during the COVID-19 pandemic. Please see the infection control section (Section 3.2) for COVID-
19 related processes during training. At each individual training, all relevant and available health staff, 
including EPI focal points and maternity and newborn staff, will be asked to participate. In facilities where 
not all staff are able to attend training, we will ensure at least 1 staff member per shift is able to attend, to 
enable the information to be passed down to all staff members. During the touch points with the facility, 
staff will assess if the information was indeed passed down.  The sessions will be split into two half day to 
prevent the facility from closing for a day and to allow for staff to be properly distanced. Moreover, training 
sessions will be held outside where possible. Ahead of training, a member of the study team will discuss 
potential training dates with the facility in-charge, ensuring dates occur when most convenient for the staff. 
The principal investigator will ensure that participants are comfortable throughout training and data 
collection. The training session will incorporate the below components.  
 
Table 4: Summary of components included in training session 
 
Training Component 
Details 
Maternity and newborn 
clinical protocols  
Knowledge reinforcement for topics relating to birth dose 
immunizations including: 
• 
Immunization basics (Note: the HCW participating in the study 
are anticipated to be well-versed in this already, however we 
can leverage modules from Vaccination in Practice training to 
provide targeted refreshers based on the audience) 
• 
Birth dose vaccine information for OPV0 and BCG including 
safety information and contraindications 

17 
 
• 
Immunization technique including vaccine handling and site of 
administration 
• 
Directly address hesitancy surrounding opening a multi-dose 
vaccine vial for only 1 baby by sharing PEV policy on opening 
vials for one child as well as training on practices to carry this 
out effectively (e.g. updating wastage rates in forecasts for 
ordering, calculating shelf life once opened, etc.) 
• 
Reinforce incorporating birth dose conversations into routine 
antenatal care visits and adding messaging into ANC talking 
points 
Roles and 
responsibilities of 
different providers 
Outline detailed roles and responsibility for each HCW involved in birth 
dose vaccinations. 
 
Develop and train on facility-specific work flows (see section 2.5 above) 
which will orient HCW to how the birth dose administration fits into 
maternal and newborn care in terms of sequencing of services, process 
for recording and reporting and collecting the vaccines (see below), and 
mitigation plans and reminders (e.g. to follow safe newborn checklist 
and best practices in terms of handling emergencies first, etc.) 
Policy for birth dose 
administration 
Provide information on updated policy for the birth dose vaccines to be 
administered in the maternity unit.  
Cold chain storage 
planning 
During the baseline assessment, study members will assess each 
maternity unit’s 24/7 access to a working refrigerator for vaccine 
storage. Each facility will have a plan (as part of the integrated 
workflow) on how to access the vaccines immediately after a birth 
takes place and will be outlined. 
 
For facilities without cold chain equipment, a daily schedule (including 
weekends and holidays) will be implemented where a morning trip is 
made to the closest health facility or district health service with CCE to 
pick up vaccines and an evening trip is done to return unused vaccines 
to the same health facility. 
Recording and reporting 
harmonization 
To ensure birth doses vaccines are properly recorded in both facility 
records and for the purposes of this pilot study, two record changes will 
take place and will be described in detail. 
 
Birth dose maternity reporting form 
For the duration of the pilot study maternity units will be provided with 
a simple recording form with space to document each birth and 
information on birth doses given. Scenarios for accurately filling out the 
form will be discussed. 
 
Updated birth registry 

18 
 
The birth registry will also be updated to include a column to check if 
the baby received the birth doses of BCG and OPV0 within 24 hours. At 
the end of each day, this paper will be brought to the EPI unit to 
incorporate into their record books. In addition, child health cards will 
need to be stored in maternity units so caregivers can acquire the book 
at the time of the birth dose administration, and the updated birth 
dose information is recorded on the health card.  
Out of facility births 
We will use this opportunity to brainstorm strategies to address birth 
dose timeliness among out of facility births for future studies. 
 
 
Contingency plan: 
In the event of worsening COVID-19 pandemic, the pilot study will be restricted to facilities that have already 
completed training sessions and the intervention for the remaining facilities will be on hold until it is safe to 
continue with the intended pilot study. 
2.7.2 
Data collectors training 
 
Training for baseline will occur for this group approximately 1 week before data collection begins and will last 
for 3 days. The data collection training will cover the purpose of the study, methods in quantitative data 
collection, electronic data collection methods, ethics, and a thorough review of the data collection tools. The 
training will be didactic with role-playing scenarios and data collectors practicing the data collection tools on 
example registers. A refresher for end line data collection and any changes in language will be emphasized in 
a morning review before data collection. In addition to training required for this pilot study, training will also 
cover COVID-19 transmission information and the importance of avoiding touching one’s face, shaking hands, 
and safe coughing and sneezing etiquette. For additional information on infection control, please see section 
3.2. Guidelines for reporting all illnesses to study staff and refraining from working when sick will be outlined. 
The infection control plan for each data collection activity outlined in this protocol will also be discussed and 
hard copies shared with data collectors to ensure they are aware of expectations. 
 
In the final day of training, the data collectors will pilot the data collection tools in 2 health facilities. Through 
the pilot, any changes or edits in data collection tools will be incorporated.  
 
Contingency plan: 
In the event of worsening COVID-19 pandemic that occurs before data collection training, the pilot study will 
be on hold until it is safe to continue. 
2.8 Ongoing trouble-shooting touch points 
To enable touch points to discuss problems during the 12-week intervention and foster a relationship 
between the study team and maternity staff, ongoing monitoring of the intervention will occur. Due to 

19 
 
COVID-19, this will be occurring remotely. Every two weeks the head of the delivery unit will take a photo of 
the birth dose maternity reporting forms and send it to the study team for review of progress. Once the photo 
is obtained a brief telephone conversation will occur to troubleshoot immediate challenges, check on the 
pilot study progress, and to further strengthen the relationship.  
 
Contingency plan: 
In the event of worsening COVID-19 pandemic and facilities see a large increase in case load, scheduling the 
phone meetings will be delayed until it is reasonable to continue. 
2.9 Data Sources and Collection  
2.9.1 
Birth registry and immunization registry 
 
To obtain accurate data on birth dose timeliness, the birth registry and immunization registry will be utilized 
(Section 5.4). At each birth maternity staff record birth details into a birth register which includes the 
newborn’s first and last name, date of delivery, type of delivery, complications, sex, and date of discharge 
(however, it is common for not all sections to be fully completed). Each health facility also maintains an 
immunization registry containing information on each child and all vaccinations given at the facility with the 
corresponding date. The baseline and end line assessment of timeliness are each expected to last two weeks 
and will consist of data collectors visiting each facility and collecting information using electronic data 
collection and tablets. Two methods will be employed to capture different indicators around timing of 
administration for birth dose vaccines. Both will utilize registry extraction of the immunization register and 
birth register. Data collectors will ask permission before utilizing the registers and assure that the data 
collection will not disrupt ongoing facility activities. 
 
Age of babies at time of receiving birth vaccines (BCG and OPV0) – Immunization registry extraction 
 
At baseline:  
Data extraction for children in the immunization register will occur by using a sampling interval to 
ensure children are sampled throughout the entire year. The sampling interval will be created by 
taking the total number of children entered into the immunization register for the previous 12 
months and dividing by our required sample size (N = 30). For instance, if 90 children were entered 
into the register in the past 12 months, the sampling interval will be 3; if only 30 children were 
entered into the register in the past 12 months, the sampling interval will be 1. With the sampling 
interval, the data collector will count backwards from the most recent entry in the immunization 
register and begin gathering data. The data collector will record the name, date of birth, and record 
the date(s) of immunization for each of the birth vaccines in the immunization register. Using the 
name and date of birth, the data collector will then cross-check with the maternity registers to 
confirm that same child’s date of birth.  Records that are missing either a date of immunization or 
date of birth will be recorded to help determine how many children were potentially born out of the 
facility, or have incomplete records, but will not count towards the total desired sample size for 
timeliness coverage. Data collectors will continue working backwards through the registers entering 
data for every Xth child (according to the sampling interval) until they have successfully recorded the 

20 
 
date of immunization and date of birth for 30 children. If they reach the end of the year without 
entering complete data on 30 children, the data collector will be instructed to loop back through the 
year but start now on the second child registered when counting.  
 
At end line: 
The end line registry extraction will utilize the same sampling technique as baseline. The same sample 
size (N = 30) will be used with the sampling period being the duration of the study period.  
 
Proportion of babies born in facilities receiving birth dose vaccines within 24 hours – Maternity registry 
extraction 
 
At baseline:  
The same sampling interval/methodology described above will be utilized again, only this time the 
data collectors will begin with the birth registers to determine their sampling interval. Then this 
interval will be used to pull names first from the birth register to select a sampling of babies that 
were born in that specific facility and then cross-checked with immunization dates for birth vaccines 
in the immunization registers. Records that are missing either a date of immunization or date of birth 
will be recorded to help determine how many children were not vaccinated at that facility or lack 
complete records. Data collectors will continue working backwards through the registers entering 
data for every Xth child (according to the sampling interval) until they have successfully recorded the 
date of birth and date(s) of immunization for 30 children.  
 
At end line: 
The end line registry extraction will utilize the same sampling technique as baseline. The same sample 
size (N = 30) will be used with the sampling period being the duration of the study period. As there 
will be children who may not receive their birth dose vaccines before the end line data collection, 
this indicator will focus on those children who did/did not receive the vaccine within 24 hours.   
 
Contingency plan: 
In the event of worsening COVID-19 transmission, facility staff will locate the relevant registry pages and will 
send photo records of the pages to study staff. Study staff will then continue with data extraction as outlined. 
2.9.2 
Birth dose reporting form 
To obtain information on the specifics of the birth dose administration, the reporting forms created for this 
pilot study will be used (Section 5.4). After each birth, a member of the maternity unit staff will fill out the 
birth dose reporting form, in addition to normal recording procedures. As part of the ongoing supervisory 
check-in the reporting forms will be sent through email or WhatsApp to study members for brief review. 
While data collectors are at each facility for registry extraction at end line, they will collect the completed 
birth dose reporting forms. 
 
Contingency plan: 
As the hard copy forms will be gathered at the end line of the study, in the event of worsening COVID-19 
transmission, data collectors will delay collecting the birth dose reporting forms until it is safe to do so. 

21 
 
2.9.3 
HCW surveys 
To obtain HCW knowledge on birth dose vaccines and corresponding policies, we will conduct HCW surveys 
(Section 5.4). During the baseline, midline, and end line assessment, HCW’s from the 15 facilities will be asked 
to participate in a survey over the phone with the intention to include a minimum of 3 HCW’s from each 
facility. The survey is expected to take 1 hour and will consist of closed and open-ended questions. The 
baseline survey will be updated with appropriate language and indicators for the midline and end line survey. 
Telephone surveys will be scheduled at a time most convenient for the HCW. During the baseline assessment 
and before any surveys are conducted, copies of the consent form will be left at each facility for survey 
participants to read through. Prior to beginning the survey, we will read through the consent form to obtain 
verbal consent. The data collection team will conduct the surveys and will input the participant’s survey 
responses on electronic tablets with all data to be stored on an encrypted server and accessed only by study 
team members. 
 
Contingency plan: 
In the event of worsening COVID-19 transmission and HCW’s see a substantial increase in workload with no 
available time to complete the survey during working hours, surveys outside of working hours will be 
arranged. If this is required HCW’s will be compensated for personal cell phone minutes. 
2.10 Study Outcomes 
The primary outcome of this pilot study is change in proportion of newborns receiving birth doses of BCG 
and OPV0 within 24 hours. The key indicators from HCW surveys will be updated to include those from 
midline and end line surveys and will be sent for review prior to conducting those surveys.  
 
Table 5. List of key indicators and sources 
Key Indicator 
Source (data 
collection tool) 
Assessed at 
baseline 
Assessed at 
midline 
Assessed 
at end line 
Average age of babies at time of 
receiving birth dose vaccines (BCG 
and OPV0)  
Birth registry and 
immunization 
record 
× 
 
× 
Proportion of babies born/received 
in facilities receiving birth dose 
vaccines (BCG and OPV0) within 24 
hours 
× 
 
× 
The reason why BCG and OPV0 birth 
dose vaccines were not administered 
within 24 hours 
Birth 
dose 
reporting form 
 
× 
× 
 
 
× 
× 
 
 
× 
× 
 
HCW survey 
× 
× 
× 
Proportion of HCWs that know ideal 
timing for birth dose vaccines 
× 
× 
× 

22 
 
 
× 
× 
× 
Reported 
concerns 
with 
administering birth dose vaccines 
within 24 hours 
× 
× 
× 
Reported barriers to administering 
birth dose vaccines within 24 hours 
× 
× 
× 
Reported barriers to educating 
caregivers on birth dose vaccines 
× 
× 
× 
Maternity unit’s access to birth dose 
vaccines 
× 
× 
× 
2.11 Data Analysis 
All outcomes will be descriptive in nature with the intent to assess preliminary impact and not statistically 
significant findings. For both measures of timing of birth dose vaccines, we will compare the facility-level 
value at baseline to end line of the intervention. Basic statistics (means and proportions) will be performed 
on the HCW surveys and the new birth dose reporting forms. Information and recommendations reported in 
open-ended questions from HCW surveys may inform final recommendations of the project but only at an 
aggregated level and would not be published, shared, or reported at the individual level. 
 
To identify indications of COVID-19 impacting in-facility births, we will use the information contained in the 
DHIS2 over the last 2 years to compare historical yearly birth trends for the 15 included facilities, with the 
trends we observed during this pilot study. Due to the small sample size of health facilities and short nature 
of this study any potential findings of changes in time trends will be descriptive in nature. During check-ins 
with the facilities the team will also document other factors due to the pandemic that may impact the study 
such as stock outs or changes on guidance. As this data is not formally gathered, this will be documented and 
descriptive in nature. Please refer to study tool “Notes for touch point calls” in Section 5.4 that will gather 
informal information about the health facility-specific processes.    
2.12 Data Quality Control Measures and Security 
All surveys will be completed in an electronic format using a tablet with incorporated skip patterns to confirm 
the highest quality data. All data to be stored on a secure server and accessed only by the study team. To 
minimize data collection errors, daily supervision of data entry into the tablets will be reviewed.  
2.13 Dissemination 
Upon the completion of this study, the primary dissemination aim is to provide information that is valuable 
to the RDPH, EPI, NITAG, Department of Family Health -, and implementing partners for purposes of 
improving early coverage of birth dose vaccines and preparing for a potential HepB-BD introduction. The 
design of the evaluation, methods used to collect and analyze data, and results will be synthesized with input 
from the co-investigators into a technical report, which will be presented and shared with relevant 
stakeholders. With approval from MOPH, the key findings, lessons learned and recommendations resulting 

23 
 
from this feasibility assessment will also be shared more broadly with the global health community to inform 
the delivery of birth dose services in other countries.  
2.14 Limitations 
This pilot study will have several key limitations. The sample of the study will be small and purposeful in that 
it will only include 15 health facilities that meet a set of pre-defined criteria (see above). Therefore, this work 
will not be statistically precise nor be nationally representative and the participating sites will likely not 
experience certain challenges pertaining to birth vaccines that are undoubtedly experienced elsewhere in 
Cameroon as a whole (such as sites located in conflict zones, etc.). Instead, the purpose of the sample is to 
assess the feasibility of integration of birth dose vaccines BCG and OPV0 in maternity and newborn care 
services to gather lessons and formulate recommendations for the broader routine immunization and 
maternal and child health programs. 
 
Data collected from registers to determine timing of vaccine administration results is a limitation in that it 
requires us to have both a date of birth and date of vaccination in facility registers. Therefore, babies who 
were born out of the facility (either at home or in a different facility) will not contribute to the aggregated 
figures, the same goes for babies who were born in the health facilities but receive vaccination elsewhere. 
Furthermore, we cannot guarantee the accuracy of the facility records. Key barriers and factors associated 
with the birth dose process will be descriptive in nature.   
3 COVID-19 Impacts 
3.1 Cameroon COVID-19 Situation 
Given the changing COVID-19 situation, we will do our utmost to guarantee the safety of participating staff, 
implementation facilities, and communities. Prior to launching the pilot study, the in-charge of each selected 
facility will be briefed on the purpose of the pilot study as well as the risks and benefits of participating during 
the COVID-19 pandemic. The in-charge will grant permission for the pilot study to occur, or request that the 
facility be excluded due to the burden of COVID-19 pandemic and limited HCW staff. Such decisions to 
exclude facilities will also occur along with key government officials. In addition, prior to travelling for 
community visits, study staff will contact community leaders and key community contacts through telephone 
calls, where possible, to discuss the pilot study and assess the communities’ willingness to have non-
community members come to conduct a visit. Any formal requests for information or permission will be 
respected and followed. 
 
Throughout this proposal we have outlined contingency plans for each intervention activity and data 
collection procedure. We will conduct weekly reviews and work from a decision framework that reviews 
multiple sources. The decision framework includes: 
 

24 
 
• 
Review government recommendations and restrictions: If the government has institutionalized 
closures or the National Ethics Committee recommends research to be suspended, we will not 
proceed. Instead, we will continue remote data collection where possible, but hold off on further 
implementation.  
• 
Review of Imperial model estimation of Rt: The model currently estimates for 6-week forecasts. 
We will review the current transmission rate from this model listed in the weekly Imperial situation 
reports. If the rate reaches above 1, we will consider suspending the pilot study implementation. 
For comparison, we will also compare the Cameroon Rt to other African countries. If we decide to 
suspend activities, we may continue remote data collection where possible, but hold off on further 
implementation.  
• 
Review of the Imperial model and IHME projections: In addition to the estimated transmission 
rate, we will pull the projections for future transmission from the Imperial model as well as IHME. 
Both models build projections under varying scenarios (e.g. reducing transmission by requiring 
masks) and will help us examine potential risks in the future. If there is a projected spike in virus 
transmission, we may decide to suspend activities until after the transmission spike.  
• 
While reviewing the data we will take into consideration the burden on HCWs and we will 
consider not conducting surveys during any spikes in COVID-19 transmission. 
• 
It is important to note that the proposed contingency framework will be relying on model 
projections and country-reported data. All discussions and decisions will recognize the challenge 
of modeling for an entire country (i.e. lack of sub-national projections), COVID-19 testing, and 
data reporting systems. 
3.2 Infection Control Procedures 
For each activity, we will implement WHO guidelines on prevention and control of infection as follows: 
 
• 
Training sessions will be held outdoors whenever possible 
• 
All participants in the training sessions will be required to wear masks and observe social distancing 
measures (2 meters). Masks will be provided for all study personnel and gloves for trainers to pass 
out tablets 
• 
Study staff and data collectors will not attend training if they have or are presenting with flu-like 
symptoms. Study staff and data collectors will be screened ahead of training. We will only invite those 
who have not experienced COVID-19 symptoms and we will ask for them to not attend training or 
data collection if they do experience symptoms 
• 
alcohol-based hand sanitizer and disinfectant will be provided to study team and health facility staff. 
In addition, soap and water or alcohol-based hand sanitizer will be easily accessible at study sites  
• 
All training session attendants will be required to wash their hands with soap and water or alcohol-
based hand sanitizer at the beginning of each day, at regular intervals throughout the day. 
Handwashing will also be required before and after any refreshments.  
• 
Sufficient training materials and office supplies will be provided to prevent sharing among training 
participants 
• 
All surfaces will be disinfected before and after each day’s training or data collection 
• 
Tablets will be disinfected before and after each use  

25 
 
• 
Data collectors will visit the site at the quietest time of day to minimize contact with facility staff and 
community members 
• 
Data collectors will be required to wear masks and social distancing of 2 meters will be required when 
in the facility. If the facility itself does not allow for social distancing, the training and registry data 
extraction will occur outside where it will be possible.  
• 
In training recommendations, we will let folks know not to come if they have symptoms. We will only 
invite those without symptoms and confirm they only attend if they don’t have symptoms. Study 
staff will ask participants to opt-out if they develop symptoms. Data collectors will be sent home if 
they present with flu-like symptoms 
• 
Prior to entering the facility, at regular intervals throughout, and at the days end, data collectors will 
be required to wash their hands with alcohol-based hand sanitizer 
• 
For data collector’s relying on public transportation to the participating facilities, alternative options 
will be discussed to minimize risk 
4 Ethical Considerations 
4.1 Informed Consent and Confidentiality 
In accordance with Ethics Guidelines for Health Research Involving Human Participants in Cameroon and 
CHAI’s Human Research Guidelines, we are seeking approval from CHAI’s internal Scientific and Ethics Review 
Committee (SERC) and the National Ethics committee in Cameroon.  
All HCW’s who participate in the HCW surveys will provide informed consent. All study staff, including data 
collectors, will undergo ethical training sessions. In order to ensure confidentiality, all data collectors will sign 
a confidentiality agreement. Their activities and data safety measures will be supervised in the field by study 
managers. 
4.2 Potential Risks for Participants 
As the purpose of this work is to assess the integration of birth dose vaccination into the maternity process, 
there is no specific physical or psychological harm for participants. Personal information such as name will 
not be gathered in surveys; there is minimal risk to participants’ data being identified. Child-level data from 
birth registries may have names of the children included but the names will be removed from the database, 
thus all datasets will be de-identified.  The data will be kept on a secure server and only accessed by study 
staff using password encrypted computers. 
4.3 Benefits for Participants 
As the pilot include capacity building for service integration, HCW’s will benefit from training and supportive 
supervision. Newborns born in participating health facilities during the study will benefit from immunization 
and protection from potential infections. In addition, the data and report will potentially benefit the 

26 
 
population health of Cameroon as the findings will contribute towards strengthening the service delivery of 
birth vaccines.  
 

27 
 
5 Study Tools 
5.1 Information Notice 
Participant Information Notice for Baseline 
Study Title: « Improving timeliness of birth dose vaccines in 15 health facilities in Cameroon 
through integrating immunizations into maternity and newborn care services: A Feasibility 
Assessment». 
 
Principal investigator:  
Name 
Ankouane  Andoulo Firmin 
Institution 
Faculty of Medicine and Bio-Medical Sciences, University of Yaoundé I 
Address 
Yaoundé, Tel : 677 56 40 70 
Email 
Ankouane andoulo@yahoo.com 
 
Invitation of participant in the study: 
Dear participants, we solicited your participation in this study which aims to assess the feasibility of 
immunizing newborns with BCG and OPV0 birth doses within 24 hours of birth.   
Study objective: The objective of the study is to integrate routine immunization into maternity and early 
newborn care in select facilities. 
To this end, there are several sub-objectives: 
Study period and population: 
1. Integrate birth dose immunizations into maternity and early newborn care services 
2. Measure the change in proportion of births receiving birth doses BCG and OPV0 
within 24 hours during the intervention period compared to during baseline  
3. Measure the change in average age of babies receiving birth doses of BCG and OPV0 
during the intervention period compared to during baseline 
4. Assess the operational feasibility and acceptability of interventions and describe 
any factors (barriers and enablers) that may influence implementation of birth dose 
strategies 

28 
 
Data collection for the study will take place between January and April 2021. The study population is Health 
care workers (HCWs) attending either maternity or immunization units within the participating facilities. 
Data collection procedure with participants: 
As a HCW, if you agree to participate, we will ask you to complete a short survey that will take approximately 
one hour. Since the interview is long, you will be asked to participate at a time and location that is most 
convenient for you. The purpose of the questionnaire is to obtain knowledge and perspectives of HCWs 
regarding the birth dose policies and administration practices. The responses will be documented by the 
interviewer on a tablet. No personal identifiers will be collected during the interviews. If you agree to 
participate, the study staff will request that you find a time to talk with the interviewer that is convenient for 
you and allows for privacy.   
Right of withdrawal without prejudice to participation: 
It is understood that your participation in this study is voluntary and you remain free to terminate it at any 
time. If any question makes you uncomfortable, you have the right to not answer. If you decide to opt out of 
the research, you can contact the researcher or study coordinator at 651050700. It is important to note that 
the data gathered cannot be directly linked to you and your information will be confidential if you agree to 
participate.  
Disadvantages, risks and advantages that may arise from this participation: 
As the purpose of this work is to assess the feasibility of a process, there is no specific risk for participants. 
Though personal information such as name and personal health information will not be gathered in 
interviews, there is minimal risk to participant data being identified.  
Compensation: 
No compensation is provided for this study. 
Full address of main researcher and other persons to contact if needed. 
Study Coordinator: Delphine Kamga, MPH, Clinton Health Access Initiative, Y Building rue 1775 nouvelle route 
Bastos, P.O. Box 5241, Yaoundé, Email: dkamga@clintonhealthaccess.org , Tel: +237 651050700 
National Ethical Committee of research for Human Health (NECRHH), Technical Secretariat, Tél: 243 67 43 
39, email: cnethique_minsante@yahoo.fr  . 
 
 

29 
 
 
 

30 
 
5.2 Informed Consent Form 
  
Do you agree to participate in the following study: « Improving timeliness of birth dose vaccines in 15 
health facilities in Cameroon through integrating immunizations into maternity and newborn care 
services: A feasibility assessment».  
Conducted by the following investigator: Ankouane  Andoulo Firmin, Faculty of Medicine and Bio-Medical 
Services, University of Yaoundé I, Tel : 677 72 92 70, Email: Ankouane andoulo@yahoo.com  
Do you fully understand the participant information notice concerning this study; 
Or  
o a copy of the participant information notice for this study has been given to me; 
o the participant information notice for this study has been read and explained to me fully; 
o I have fully understood the objectives of this study; 
o I have received answers to all the questions I have about the study; 
o The risks and benefits of participating in this study have been fully explained to me; 
o I understand that I can accept or deny to participle in this study; 
o I understand that I can decide to stop participating in the study at any time 
o My consent to participate in the study does not disengage the researcher from his ethical 
obligations; 
o I reserve all my rights according to the law. 
I agree to voluntarily participate in this research according to the stipulations of the information notice 
by: 
 
□ Responding to interview questions where comfortable 
□ Answering a questionnaire 
 
Done in _____________________________Did the study participant provide verbal consent? Y      N 
 
Principal Investigator: 
 
 
 
 
Study Participant: 
Ankouane  Andoulo Firmin 
 
 

31 
 
 
 

32 
 
5.3 Data collection tools 
HCW Questionnaire 
Facility Health Care Worker Survey Questionnaire 
 
Facility ID: ________________________ 
 
Instructions: Please pay close attention to the instructions of the question as not everyone is eligible for 
these questions. Additionally, please pay close attention to the skip patterns.  
 
Section I: Consent  
NO. 
QUESTION 
RESPONSE CODE 
SKIP 
HCW 
-1.1 
DID YOU ADDRESS ALL THE QUESTION THAT THE 
FACILITY HCW HAD DURING THE CONSENT 
PROCESS?  
YES ........................................................... 1 
NO  ........................................................... 2 
IF NO, 
PLEASE GO 
BACK AND 
ANSWER 
QUESTIONS. 
HCW 
 -1.2 
IS THE FACILITY HCW OVER THE AGE OF 18?  
 
YES ........................................................... 1 
NO  ........................................................... 2 
IF NO, 
THANK AND 
END SURVEY 
HCW 
-1.3 
DID YOU OBTAIN VERBAL CONSENT FROM THE 
FACILITY HCW?  
YES ........................................................... 1 
NO............................................................ 2 
IF NO, 
THANK AND 
END SURVEY 
Section I: Site Information 
NO. 
QUESTION 
RESPONSE CODE 
SKIP 
ID1 
RECORD SURVEY START TIME 
 
 
ID2 
 
SELECT THE REGION 
 
Select the name in 
Survey CTO 
 
REGION 1 .................................................. 1 
REGION 2 .................................................. 2 
REGION 3 .................................................. 3 
 
 
ID3 
SELECT IF THE AREA IS URBAN OR 
SEMI-RURAL 
URBAN ...................................................... 1 
SEMI-RURAL ............................................... 2 
 

33 
 
ID4 
SELECT IF THIS IS A PUBLIC OR 
PRIVATE FACILITY 
PUBLIC ...................................................... 1 
PRIVATE FOR PROFIT .................................... 2 
PRIVATE FAITH-BASED .................................. 3 
 
ID5 
PLEASE SELECT THE FACILITY 
LEVEL 
 
LEVEL 1: (REGIONAL AND REFERRAL HOSPITAL) . 1 
LEVEL 2: (DISTRICT, CMA SOME FAITH-BASED) . 2 
LEVEL 3: (IHC, HC)  .................................... 3 
OTHER (SPECIFY) ......................................... 4 
 
 
ID6 
SELECT THE HEALTH FACILITY 
NAME 
Select the name in 
Survey CTO 
 
 
FACILITY 1.................................................. 1 
FACILITY 2.................................................. 2 
FACILITY 3.................................................. 3 
FACILITY 4.................................................. 4 
 
 
ID7 
ENUMERATOR ID 
 
Select your name 
 
NAME 1 .................................................... 1 
NAME 2 .................................................... 2 
NAME 3 .................................................... 3 
NAME 4 .................................................... 4 
NAME 5 .................................................... 5 
NAME 6 .................................................... 6 
 
 
 
ID8 
SUPERVISOR ID 
 
Select your supervisor’s 
name 
 
NAME 1 .................................................... 1 
NAME 2 .................................................... 2 
NAME 3 .................................................... 3 
NAME 4 .................................................... 4 
NAME 5 .................................................... 5 
NAME 6 .................................................... 6 
 
Section 2: Facility and respondent details  
NO. 
QUESTION 
RESPONSE CODE 
SKIP 
FD1 
OVERALL POPULATION OF THE 
HEALTH AREA 
 
[___|___|___|___|___|___|___] CATCHMENT POP 
DON’T KNOW ................................. 99999  
 
FD2 
WHAT IS YOUR PRIMARY JOB 
TITLE? 
 
FACILITY IN-CHARGE ..................................... 1 
HEAD MATRON ........................................... 2 
NURSE ...................................................... 3 
PHYSICIAN/DOCTOR .................................... 4 
 
OTHER (SPECIFY) ......................................... 6 
 

34 
 
FD3 
WHAT UNIT ARE YOU WORKING 
IN? 
Read out loud and select 
most appropriate 
MATERNITY ................................................ 1 
IMMUNIZATION .......................................... 2 
BOTH MATERNITY AND IMMUNIZATION ........... 3 
 
OTHER (SPECIFY) ......................................... 6 
 
FD4 
HOW LONG HAVE YOU BEEN 
WORKING IN MATERNITY 
AND/OR EPI UNIT? 
Select most appropriate 
combined experience in 
one or both units 
 
LESS THAN 6 MONTHS .................................. 1 
6 - 12 MONTHS .......................................... 2 
12- 24 MONTHS ......................................... 3 
24-36 MONTHS .......................................... 4 
OVER 36 MONTHS ....................................... 5 
 
  
 
FD5 
HOW MANY YEARS HAVE YOU 
BEEN STATIONED AT THIS 
HEALTH FACILITY? 
[____] .............................. NUMBER OF YEARS 
IF LESS THAN 1 ............................................ 0 
 
SECTION 3: HCWs knowledge 
NO. 
QUESTION 
RESPONSE CODE 
SKIP 
B1 
ACCORDING TO EPI NORMS AND 
STANDARDS, WHAT ARE THE 
VACCINES THAT ARE ADMINISTERED 
BEFORE THE 6 WEEK IMMUNIZATION 
VISIT? 
(DO NOT PROBE, SELECT ALL THAT 
APPLY) 
 
OPV0 ....................................................... A 
BCG ......................................................... B 
PENTA ....................................................... C 
PCV ........................................................ D 
HEP B ....................................................... E 
OTHER (PLEASE SPECIFY:____) ...................... F 
NONE ........................................................ X 
DON’T KNOW ............................................. Y 
 
Select all that 
apply 
A→Answer 
B2 
B→ Answer 
B3 
C→Answer B4 
D-X→B5 
B2 
IN AN IDEAL SITUATION, WHEN 
SHOULD OPV0 VACCINE SHOULD BE 
ADMINISTERED TO A NEWBORN 
INFANT, ACCORDING TO EPI NORMS 
AND STANDARDS? 
 (Read out loud and have the 
participant select most 
appropriate) 
WITHIN 24 HOURS OF BIRTH .......................... 1 
AFTER 24HRS AND WITHIN TWO WEEKS OF BIRTH  ........ 2 
TWO WEEKS AFTER BIRTH .............................. 3 
AFTER TWO WEEKS OF BIRTH  ......................... 4 
DON’T KNOW ........................................... 99 
 
B3 
IN AN IDEAL SITUATION, WHEN 
SHOULD BCG VACCINE SHOULD BE 
ADMINISTERED TO A NEWBORN 
INFANT, ACCORDING TO EPI NORMS 
AND STANDARDS? 
 (Read out loud and have the 
participant select most 
appropriate) 
Within 24 hours of birth .............................1 
After 24 h of birth but within two weeks of birth 
 ....................................................................2 
Six weeks of birth .......................................3 
After six weeks of birth ...............................4 
Don’t know ...............................................99 
 

35 
 
B4 
HOW MANY CHILDREN NEED TO BE 
PRESENT FOR A VIAL OF OPV TO BE 
OPENED? 
[___|___] .............................. No. of children 
Don’t Know ...............................................99 
 
B5 
HOW MANY CHILDREN NEED TO BE 
PRESENT FOR A VIAL OF BCG TO BE 
OPENED? 
[___|___] .............................. No. of children 
Don’t Know ...............................................99 
 
B6 
IF YOUR FACILITY PROVIDES HEPB 
VACCINE AT BIRTH, HOW MANY 
CHILDREN NEED TO BE PRESENT FOR 
A VIAL OF HEP B TO BE OPENED? 
[___|___] .............................. No. of children 
Does not provide HepB birth dose……98 
Don’t Know ...............................................99 
 
B7 
IS IT RECOMMENDED TO ADMINISTER 
BCG AT BIRTH TO HEALTHY AND 
CLINICALLY STABLE LOW BIRTH 
WEIGHT INFANTS (<2500 
GRAMS)?    
Yes ..............................................................1 
No ...............................................................2 
Don’t Know ...............................................99 
 
B8 
IS IT RECOMMENDED TO ADMINISTER 
OPV0 AT BIRTH TO HEALTHY AND 
CLINICALLY STABLE LOW BIRTH 
WEIGHT INFANTS (<2500 
GRAMS)?    
Yes ..............................................................1 
No ...............................................................2 
Don’t Know ...............................................99 
 
 
SECTION 4: General Unit information on Birth Dose 
NO. 
QUESTION 
RESPONSE CODE 
SKIP 
CA1 
HOW MANY HCWS WORK ON THE 
MATERNITY UNIT? 
[___|___] .................................. No. of HWs  
Don’t Know ............................................... 99 
 
CA2 
HOW MANY HCWS WORK ON THE 
IMMUNIZATION UNIT? 
[___|___] .................................. No. of HWs  
Don’t Know ............................................... 99 
 
CA3 
 
IN THIS FACILITY, WHICH VACCINES 
ARE ADMINISTERED BEFORE 
NEWBORN DISCHARGE? 
Read list and select all that 
apply 
 
OPV0 .......................................................... A 
BCG ............................................................. B 
HepB0 ......................................................... C 
None .......................................................... D 
Other (Specify) ........................................... X 
Do not know ............................................... Y 
 
CA4 
IN THIS FACILITY, DOES THE 
MATERNITY UNIT ADMINISTER BIRTH 
VACCINES BEFORE NEWBORN 
DISCHARGE? 
Yes .............................................................. 1 
No ............................................................... 2 
 

36 
 
CA5 
HOW DOES THE FACILITY INFORM 
MOTHERS ABOUT THE BIRTH DOSE 
VACCINES? 
Do not read list. Select all that 
apply 
 
Pamphlet ................................................... A 
Posters ........................................................ B 
Talking with them when they visit ............. C 
Talking to people out in the community ... D 
Other (Specify) ........................................... X 
No information provided ............................ Y 
 
CA6 
WHAT INFORMATION DO YOU 
PROVIDE TO MOTHERS ABOUT THE 
BIRTH DOSE VACCINES? 
Do not read list. Select all that 
apply 
 
Schedule .................................................... A 
Importance ................................................. B 
Side effects ................................................. C 
Other ......................................................... D 
No information provided ............................ X 
 
CA7 
WHAT ARE THE CHALLENGES TO 
ADMINISTERING A BIRTH DOSE 
VACCINE WITHIN 24 HOURS OF 
BIRTH? 
[Open-ended] 
 
CA8 
WHERE ARE VACCINES STORED IN THIS 
FACILITY? 
Read list. Select all that apply 
In Maternity............................................... A 
In EPI ........................................................... B 
Office of facility in charge ........................... C 
Other (Please specify) ................................ X 
Don’t Know ................................................. Y 
 
CA9 
PLEASE SELECT HOW THE VACCINES 
ARE STORED FOR EACH LOCATION 
LISTED ABOVE 
Read list. Select all that apply 
A: In Maternity 
Fridge ......................................................... A 
Cold Box...................................................... B 
Cool Water Pack ......................................... C 
Fridge tag  .................................................. D 
B: In EPI 
Fridge ......................................................... A 
Cold Box...................................................... B 
Cool Water Pack ......................................... C 
Fridge tag ................................................... D 
C: Office of facility in-charge 
Fridge ......................................................... A 
Cold Box...................................................... B 
Cool Water Pack ......................................... C 
Fridge Tag  ................................................. D 
 
CA10 DOES THIS FACILITY KEEP THE 
OXYTOCIN OR VITAMIN K COLD? 
A: Oxytocin 
Yes .............................................................. 1 
No ............................................................... 2 
Do not have Oxytocin ................................. 3 
Don’t Know ................................................. 9 
 
B: Vitamin K 
Yes .............................................................. 1 
No ............................................................... 2 
Do not have Vitamin K ................................ 3 
Don’t Know ................................................. 9 
 
A →1 answer 
CA12, CA13, 
CA14 
B→1 
Answer CA14, 
CA15, CA17 
 
Otherwise, 
skip to CA18 

37 
 
CA11 
WHERE IS THE OXYTOCIN STORED? 
Do not read list. Select all that 
apply 
In Maternity............................................... A 
In EPI ........................................................... B 
Office of facility in charge ........................... C 
Do not have Oxytocin ................................ D 
Other (Please specify) ................................ X 
Don’t Know ................................................. Y 
 
CA12 
 
HOW THE OXYTOCIN IS KEPT COLD? 
Read list. Select all that apply 
 
Fridge ......................................................... A 
Cold Box...................................................... B 
Cool Water Pack ......................................... C 
Other (Please specify) ................................ X 
Don’t Know ................................................. Y 
 
CA13 
WHO IS RESPONSIBLE FOR 
ADMINISTERING OXYTOCIN IN THIS 
FACILITY? 
Do not read list. Select all that 
apply 
Doctor ........................................................ A 
Midwife ...................................................... B 
Maternity staff ........................................... C 
Other (Please specify) ................................ X 
Don’t Know ................................................. Y 
 
CA14 
WHERE IS VITAMIN K STORED IN THIS 
FACILITY?  
Do not read list. Select all that 
apply 
In Maternity............................................... A 
In EPI ........................................................... B 
Office of facility in charge ........................... C 
Other (Please specify) ................................ X 
Don’t Know ................................................. Y 
 
CA15 
 
HOW THE IS THE VITAMIN K KEPT 
COLD? 
Do not read list. Select all that 
apply 
 
Fridge ......................................................... A 
Cold Box...................................................... B 
Cool Water Pack ......................................... C 
Do not have Vitamin K ............................... D 
Other (Please specify) ................................ X 
Don’t Know ................................................. Y 
 
CA16 
WHO IS RESPONSIBLE FOR 
ADMINISTERING VITAMIN K IN THIS 
FACILITY? 
Do not read list. Select all that 
apply 
Doctor ........................................................ A 
Midwife ...................................................... B 
Maternity staff ........................................... C 
Other (Please specify)  ........................................ X 
Don’t Know ................................................. Y 
 
CA17 
DOES THE MATERNITY UNIT STAFF 
HAVE 24/7 ACCESS TO VACCINES IN 
THE IMMUNIZATION UNIT? 
Yes .............................................................. 1 
No ............................................................... 2 
Don’t Know ................................................. 9 
 
CA18 
IF A VACCINE NEEDED TO BE ACCESSED 
LATE AT NIGHT OR ON THE WEEKEND, 
COULD MATERNITY STAFF ACCESS IT? 
Yes .............................................................. 1 
No ............................................................... 2 
Don’t Know ................................................. 9 
 
CA19 WHAT DOES THE MOTHER PAY FOR 
VACCINATION BOOKLET/CARD? 
Booklet [___|___] ................................. cost 
Don’t Know ............................................... 99 
 
 
SECTION 5: HCW perspectives  
NO. 
QUESTION 
RESPONSE CODE 
SKIP 

38 
 
E1 
WHAT CONCERNS DO YOU HAVE ABOUT 
ADMINISTERING OPV0 WITHIN 24 
HOURS OF BIRTH? 
Do not read list. Select all that 
apply 
Adverse events following immunization ... A 
Inadequate personnel training ................... B 
Inadequate guidance (SOPs) ...................... C 
Uncertainty on contraindications .............. D 
Multiple vaccines administered together .. E 
No concerns ................................................ F 
Other (please specify) ................................ X 
 
E2 
WHAT CONCERNS DO YOU HAVE ABOUT 
ADMINISTERING BCG WITHIN 24 HOURS 
OF BIRTH? 
Do not read list. Select all that 
apply 
 
Adverse events following immunization ... A 
Inadequate personnel training ................... B 
Inadequate guidance (SOPs) ...................... C 
Uncertainty on contraindications .............. D 
Multiple vaccines administered together .. E 
No concerns ................................................ F 
Other (please specify) ................................ X 
  
 
E3 
WHAT BARRIERS HAVE YOU FACED 
WHEN EDUCATING MOTHERS ABOUT THE 
BIRTH DOSE VACCINES? 
Do not read list. Select all that 
apply 
Mothers think education is a waste of timeA 
Custom of sequestering new-borns ........... B 
Not enough time during visits .................... C 
Lack of appropriate education materials for 
mothers ..................................................... D 
No barriers.................................................. E 
Other (please specify) ................................ X 
 
 
 
SURVEY RESULT 
NO. 
QUESTION 
RESPONSE CODE 
SKIP 
RESULT 
Record the result of the survey. 
 
Survey complete ........................................ 1 
Survey partially complete .......................... 2 
 
Other (specify) ........................................... 6 
 
Record ending time of the survey 
 
DATA COLLECTOR COMMENTS 
NO. 
QUESTION 
RESPONSE CODE 
SKIP 

39 
 
COMMENTS 
 
Record any comments that 
you have about the survey, 
particularly anything that 
may have affected the survey 
completion or quality of data 
entry or the survey 
 
-------------------------------------------------------- 
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-------------------------------------------------------- 
-------------------------------------------------------- 
-------------------------------------------------------- 
-------------------------------------------------------- 
-------------------------------------------------------- 
-------------------------------------------------------- 
-------------------------------------------------------- 
-------------------------------------------------------- 
 
 
 
 

40 
 
Immunisation register extraction 
Immunization register extraction 
 
Facility ID: ________________________ 
 
Date: ________________________ 
 
Please collect data until 30 entries are complete (all dates included) using sampling interval with both date 
of birth AND date of administration. For sampling interval, count how many children are entered within a 
year of today’s date. Divide this total number by 30 to get your sampling interval. For instance, if there are 
300 children within the year, your sampling interval is 300/30 or 10. Therefore, you will enter every 10th child 
until you reach 30 children in total with both a birth date AND a date of administration. 
 
Child number 
Q1. Date of Birth 
Q2. Date of OPV0 
administration 
Q3. Date BCG 
administration 
1 
A - Date of birth listed. 
1 = Yes, 2 = No (If no, skip 
Q1.B) 
 
B - Date listed  
 
A – Was vaccine 
administered?  
1 = Yes, 2 = No (If no, skip 
Q2.B) 
 
B - Date listed  
 
A – Was vaccine 
administered?  
1 = Yes, 2 = No (If no, skip 
Q3.B) 
 
B - Date listed  
 
 
 
 
 

 Delivery register extraction 
 
Facility ID: ________________________ 
 
Date: ________________________ 
 
Does the register have the dates or administration listed for birth dose vaccines: 1 = Yes, 2 = No.  
 
Does the register have the dates or administration listed for birth date: 1 = Yes, 2 = No. 
 
For sampling interval, count how many children are entered within a year of today’s date. Divide this total number by 30 to get your sampling 
interval. For instance, if there are 300 children within the year, your sampling interval is 300/30 or 10. Therefore, you will enter every 10th child 
until you reach 30 children in total. For this work you will also be looking the child up in the immunization register. Please ask the in-charge and 
the EPI nurse to gather this information when it is not in use. 
 
  
 
Delivery register 
Immunization register 
Child 
Name 
Q1. Date of Birth 
Q2. Date of OPV0 
administered 
Q3. Date BCG 
administered 
Q4. Were you able to find 
this child based on name 
and birth date in the 
register? 
1 = Yes, 2 – No  
(if no, skip Q5 and Q6) 
 
 
Q5. Date of OPV0 
administered 
Q6. Date BCG administered 
 
A - Date of birth 
listed? 
1 = Yes, 2 = No (If 
no, skip Q1.B) 
 
B - Date listed  
 
C – Time of Birth 
 
A – Was vaccine 
administered?  
1 = Yes, 2 = No (If no, 
skip Q2.B) 
 
B - Date listed  
 
C – Time of vaccine 
administration 
A – Was vaccine 
administered?  
1 = Yes, 2 = No (If no, 
skip Q3.B) 
 
B - Date listed  
C – Time of vaccine 
administration 
A – Was vaccine 
administered?  
1 = Yes, 2 = No (If no, 
skip Q5.B) 
 
B - Date listed  
 
C – Time of vaccine 
administration 
 
A – Was vaccine 
administered?  
1 = Yes, 2 = No (If no, skip 
Q6.B) 
 
B - Date listed  
 
C – Time of vaccine 
administration 
 

Newborn data tool  
This form should be used to record data about each delivery during the study period. Data should be completed by a delivery nurse and 
shortly after the baby is discharged. 
Child #: 
 
Facility 
Code: 
 
Date: 
   __ __ / __ __ __  / __ __  
 
Delivery Information  → 
 
OPV0→ 
GENDER 
Male ................................................. 1 
Female ............................................. 2 
 
OPV0 
Yes ............................................................. 1 
No .............................................................. 2 
DATE OF BIRTH, 
TIME OF BIRTH, 
AND BIRTH 
WEIGHT 
 
__  __  / __  __    __  __  : __  __   
(DD/MM  HH:mm) 
______________Grams 
 
DATE AND TIME 
THE BABY RECEIVED 
OPV0  
 
  __  __  / __  __          __  __  : __  __   
(DD/MM   hh:mm) 
CIRCLE ALL 
SERVICES 
PROVIDED 
 
EPI visit .............................................A 
Dr visit .............................................. B 
PNC................................................... C 
Other ................................................ X 
 If other, specify: 
 
 
IF NO, PLEASE 
CIRCLE THE 
PRIMARY REASON 
Caregiver refused ...................................... 1 
Stock out ................................................... 2 
Scheduled for later .................................... 3 
EPI was not open....................................... 4 
Left before receiving the vaccine .............. 6 
Too few children to open a vial................. 7 
Not eligible for clinical reasons ................. 8 
Not enough time for vaccination .............. 9 
Other ....................................................... 10 
If other, specify: 
OXYTOCIN 
GIVEN? 
Yes .................................................... 1 
No ..................................................... 2 
 
BCG→ 
DISCHARGE DATE 
AND TIME 
__  __  / __  __     __  __  : __  __   
 
BCG 
Yes ............................................................. 1 
No .............................................................. 2 
PLEASE LIST ANY COMPLICATIONS OR COMMENTS ON THE BIRTH:    
 
 
DATE AND TIME 
THE BABY RECEIVED 
BCG 
__  __  / __  __          __  __  : __  __   
 
IF NO, PLEASE 
CIRCLE THE 
PRIMARY REASON 
Caregiver refused ...................................... 1 
Stock out ................................................... 2 
Scheduled for later .................................... 3 
EPI was not open....................................... 4 
Left before receiving the vaccine .............. 6 
Too few children to open a vial................. 7 
Not eligible for clinical reasons ................. 8 
Not enough time for vaccination .............. 9 
Other ......................................................... 6 
If other, specify: 
 

Notes for touchpoint calls  
This form should be used to record any facility-specific information about the intervention including occurrence of stock outs, cold chain 
equipment challenges, or any unforeseen challenges that may have been discussed that relate to the intervention.  
 
Area 
Description 
 
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44 
 
 
5.4 Project Timeline 
The study will commence after all relevant stakeholders have aligned on the project and any necessary 
administrative and ethical approvals for the protocol have been obtained and data collectors have been 
identified and trained.  
 
Activities 
Week 
 
 
 
 
1 
2 
3 
4 
5 
6 
7 
8 
9 
1
0 
1
1 
1
2 
1
3 
1
4 
1
5 
1
6 
1
7 
1
8 
1
9 
2
0 
Baseline Assessment 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
 
 
 
Facility visits to collect baseline 
data 
x 
x 
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
 
 
 
Conduct baseline surveys with 
HCWs 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preliminary analysis to 
determine current timing of 
birth vaccines 
 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intervention implementation 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
 
 
 
 
 
Carry out on-site training for 
health facility staff 
  
  
  
  
x  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Support any adjustments 
needed to service delivery 
processes (e.g. adjusting cold 
chain storage, etc.) 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Carry out twice monthly 
mentorship meetings to 
monitor progress and 
troubleshoot as needed 
 
 
 
 
 
 
x 
 
x 
 
 
 
x 
 
x 
 
 
 
 
 
Conduct mid-point surveys 
with HCWs 
 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
Final assessment 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
Collect final data on timing of 
birth dose vaccine 
administration 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
x 
 
 
 
Conduct final surveys with 
HCWs 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
x 
 
 
 
Data analysis  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
 
 
Technical report development 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
 
 

45 
 
 
 
 

46 
5.5 References 
1. 
Chiabi et al, Vaccination of infants aged 0 to 11 months at the Yaounde Gynaeco-obstetric and pediatric hospital in Cameroon: 
how complete and how timely?, BMC Pediatrics, 2017 
2. 
WHO position paper on BCG vaccines, February 2018 
3. 
WHO position paper on Polio vaccines, March 2016 
4. 
Global Hepatitis Report, 2017 & Bigna JJ, Amougou MA, Asangbeh SL, et al Seroprevalence of hepatitis B virus infection in 
Cameroon: a systematic review and meta-analysis BMJ Open 2017;7:e015298. doi: 10.1136/bmjopen-2016-015298 
5. 
Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. Int J Womens Health. 2014;6:605-611. 
Published 2014 Jun 10. doi:10.2147/IJWH.S51138 
6. 
Note de Recommandation n°001/2019 du GTCNV- Cameroun a/s Introduction de la Dose de Naissance du Vaccin contre 
l’Hépatite B, January 2019 
7. 
WHO Practices to improve coverage of the hepatitis B birth dose vaccine, January 2013. 
8. 
Miyahara, R., Jasseh, M., Gomez, P., Shimakawa, Y., Greenwood, B., Keita, K., Ceesay, S., D'Alessandro, U., & Roca, A. (2016). 
Barriers to timely administration of birth dose vaccines in The Gambia, West Africa. Vaccine, 34(29), 3335–3341. 
https://doi.org/10.1016/j.vaccine.2016.05.017 
9. 
Gavi the Vaccine Alliance, Annex C: Hepatitis B Birth Dose Investment Case. October 2018. 
10. Country presentations at WHO AFRO regional workshop on Hepatitis B birth dose, June 2019. 
11. EPI administrative data 2018 
12. Chiabi A., Nguefack F., Njapndounke F., Kobela M, Kenfack K, Nguifack S., Mah E, Nguefac-Tsague G., Angwafo F., (2017). 
Vaccination of infants aged 0 to 11 months at the Yaounde Gynaeco-obstetric and pediatric hospital in Cameroon: how 
complete and how timely?. BMC Pediatrics. 2017. 17:206. DOI 10.1186/s12887-017-0954-1 
13. WHO (2015). A Guide for Introducing and Strengthening HepB-BD Vaccination. www.who.int/immunization/documents