Category Archives: Biomarkers

27 Apr 2016

The Vaccination Landscape: Changes and Challenges

What was the last vaccination you received? The one before that? When did you receive them?  Where was the vaccine administered – your arm? Your thigh? The right or the left? For most of us, this is not easy information to remember. And yet it’s what we ask many women to recall for their children in DHS interviews.

A child in Lhoksemawe, Aceh, Indonesia, receives a vaccine injection.

© 2012 Armin Hari/INSIST, Courtesy of Photoshare

Since 1984, The DHS Program has collected data on vaccinations in over 80 countries.  During this time, the vaccination landscape has changed dramatically. Initially, BCG, DPT (Diphtheria; Pertussis, or whooping cough; and Tetanus), Polio, and Measles were the only childhood vaccines most countries administered. These data were collected only from vaccination cards.

As time went on, our methodology expanded to include data collection from mother’s recall to clarify incomplete vaccination cards. In cases where there is no vaccination card, mothers are asked whether or not her child received each type of vaccine and the number of doses.

Today, the number of vaccines standardly administered is much higher. This is good news — it means millions more lives saved — but it introduces data collection challenges.

The vaccination data collected in a standard DHS questionnaire are far more elaborate than any time in our history: BCG remains; for Polio a birth dose is added; DPT is now combined into a pentavalent vaccine with Hepatitis B and Haemophilus influenza type B (Hib); 3 doses of a pneumococcal vaccine and 3 doses of a rotavirus vaccine are now included; and the measles vaccine has been replaced with a measles combination vaccine. For countries that are transitioning between vaccination schedules or have more complicated schedules, the landscape becomes more challenging to navigate.

Data collection is relatively straightforward when a child has an up-to-date and complete vaccination card.  But in many cases, changing vaccine schedules and inconsistent record-keeping render the cards incomplete or unclear. Worse, vaccination cards are often missing or otherwise unavailable.

Indeed, a recent study revealed that in 4 of the 10 countries with the largest birth cohorts that had carried out either a DHS or MICS survey in 2010-2013, less than 50% of children had home-based vaccination records.

A happy mother shows her child's vaccination card in New Delhi, India.

© 2012 Bhupendra/MCHIP, Courtesy of Photoshare

When a vaccination card is unavailable, it is the mother who is expected to fill in the gaps.  But a mother’s recall is not 100% reliable. Keeping track of vaccines for multiple children and for combination vaccines is challenging enough, but even more so if the mother isn’t present for every vaccination event.

Knowing whether newer and existing vaccines are reaching their target population and doing so on schedule is valuable information to many. What can be done to maintain and even improve data quality when the complexity of the data needs on vaccine coverage continue to grow?

The DHS Program, in collaboration with the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and other experts in the field, are pursuing several options. One involves visiting health facilities to compare the information collected during the interview to the vaccination information recorded at the health facility.

This process has been used previously in Central Asian countries and in Albania, where facility-based documentation is strong. It is now being pilot-tested in Ethiopia; however, the method of record-keeping varies by location and includes instances where records are kept based on the date of visit and not based on the child’s name or date of birth. Country-specific challenges such as these require additional flexibility and coordination between survey implementers, Ministries of Health, and health facilities.

There is unlikely a one-size-fits-all solution to the challenge of accurately measuring vaccination coverage.  But from the perspective of global health, this is a good problem to have.  More children worldwide are being protected from a host of illnesses.  We are proud to be sharing data to help track progress towards closing the gap as our implementing partners reach more children with a larger variety of vaccines.

10 Mar 2015

Training the Next Generation of DHS Program Biomarker Consultants

In January, 2015, 11 biomarker specialists from 8 countries met in Uganda to participate in the first-ever South-to-South DHS Program Biomarker Workshop. Participants all had previous experience with DHS surveys, either as consultants or as in-country staff. The objectives of the training were to emphasize mastery of technical biomarker content and training materials, strengthen consultants training and facilitation skills, and to pilot test the newly designed DHS Program Biomarker Curriculum. Ultimately, it is hoped that many of the participants from this workshop will be able to serve as DHS Program biomarker consultants for future surveys.

There were many lessons learned from the training. For example, while DHS Program staff have been training biomarker specialists in survey countries for decades, their training has been limited to their specific role in one country. The new biomarker curriculum is broader, allowing biomarker consultants to see how biomarker data collection fits into the larger survey process, and which aspects of the standard methodologies are applied in all survey settings.

CS blog biomarkers 2

Biomarker specialists visit a Ugandan laboratory as an experiential activity.

Bakunda Kamaranzi, a Laboratory Training Coordinator from the Uganda Ministry of Health, elaborates: “I was invited from Uganda, and had a fair understanding of the DHS Program, having participated in more than one DHS survey. In as much as I thought I knew quite a bit about the program, by the end of the first day, I knew and agreed with my colleagues that there was a lot to learn, a lot more that we did not know.”

One of the challenges of training a group of future consultants is that the participants must not just be able to implement data collection protocols and practices, but they must also be able to explain them to dozens of future trainees. This requires that these consultants understand the “why” of the way we do things. Why must the blood drops be totally dry before packing? Why do we wipe away the first drop of blood during a finger prick? Why do we measure younger children lying down? The South-to-South training allowed for a discussion of all this important background information.

Zoulkarneiri Issa (Togo), Jean de Dieu Butura (Rwanda) and Tharcisse Munyaneza (Rwanda) wrote: “En effet, ils nous rappelaient à chaque moment sur notre rôle de consultant et par conséquent, nous devons maitriser tous les contours scientifiques et même épidémiologiques des thématiques à enseigner. Ce qui nous permettra de faire face aux éventuelles questions et préoccupations des autorités sanitaires et administratives des pays où nous serons appelés à consulter.”

English: “In fact, [the facilitators] reminded us every moment of our consulting role and that we were expected to master all the scientific and epidemiological concepts and the teaching thematic concepts. This will enable us to deal with any issues and concerns of health and administrative authorities of the countries where we are called to provide technical assistance.”

Lastly, most biomarker specialists had no previous experience with adult learning techniques; few had been trained in training or facilitation. If The DHS Program hopes to use these participants as future biomarker consultants, they will, in turn, be expected to train all of the in-country biomarker survey staff on biomarker data collection. Simply knowing the technical material is not enough. They will need to know how to train people to do this correctly.

Jean de Dieu Butura, Kamarazni Bakunda, and Mike Amakyi practice storing blood samples.

For the teach back exercise, Jean de Dieu Butura, Kamarazni Bakunda, and Mike Amakyi practice proper storage of blood samples.

Bakunda Kamaranzi explains: Then came the training-of trainers. At the beginning we were introduced to new theories and names; Bloom’s taxonomy, Edgar Dale’s cone of learning, David Kolb’s experiential learning cycle, all which some of us were seeing for the very first time. By the end of the day, we were able to relate the theories to training and it all made a lot of sense.  The teaching methods learned in the TOT session were used during the teach-back sessions and, we are better trainers than we were on the 19th of January when we reported to the workshop. The trainers guide will definitely improve the way we deliver Biomarker training for DHS surveys.”

The January 2015 South-to-South Biomarker Training is one of many activities The DHS Program is undertaking to formalize our capacity strengthening efforts, and empower a wider group of experts to assist in the implementation of DHS surveys globally. The reach of these trainings is limitless:  as we train our colleagues to be trainers, they can train hundreds more. Ultimately, these South-to-South consultants will be leaders in DHS survey management, and, more broadly, will contribute to improved quality of data collection of other surveys in their region.

Biomarker specialists learning proper DBS collection.

Biomarker specialists learning proper DBS collection.

Michel Toukam, Lecturer at the Faculty of Medicine and Biomedical Sciences, University of Yaounde, Cameroon, summarizes: With this workshop, the consultants have acquired more knowledge on adult’s training methodology and techniques (Andragogy), on the DHS gold standards, protocols and procedures. They will form a network of DHS Program consultants in which experiences in learning techniques and follow up of DHS survey biomarker procedures will be shared. They will be more confident when they are leading training sessions in surveys.”

Nsobya Samuel Lubwama, Senior Lecturer at the Department of Pathology, School of Biomedical Science, Makerere University College of Health Sciences in Uganda, adds: “With my laboratory background experience of over 20 years, this workshop was timely to enrich me with new skills by expert facilitators…I am now able to train health laboratory technicians worldwide with very minimum supervision on other biomarkers namely:  anthropometry, DBS collection, measuring pressure, blood glucose, Hemoglobin, HIV. I have also been empowered with new knowledge how to plan for survey in advance such as advising the country policy makers on what is needed to collect biomarkers of interest in relation to country specific needs.”


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Anthropometry measurement (height and weight) is a core component of DHS surveys that is used to generate indicators on nutritional status. The Biomarker Questionnaire now includes questions on clothing and hairstyle interference on measurements for both women and children for improved interpretation.