epi for hsso

EPI for HSSO

Dr. Kyaw Kan Kaung

Project Manager/Assistant Director

Department of Health

Ministry of Health

Training on HSSO Naypyitaw 6-7 Feb 2013

The vision

reduction of under 5 morbidity and mortality caused by

vaccine preventable diseases in reaching MDG 4.

The overall objective

to reach the routine immunization coverage of 90% nationally

in children under one with 8 antigens and with TT in pregnant

women, and at least 80% coverage in all townships

Goal and Objectives National Immunization Program -Myanmar

1. To achieve immunization coverage of 90% nationally with at

least 80% coverage in every township for all 8 antigens in under

five and for TT in pregnant women

2. To maintain the elimination status of Maternal and neonatal

tetanus (incidence to less than 1/1000 live-births at the national

level as well as township level)

3. To sustain the interruption of indigenous transmission of wild

and vaccine-derived polio virus and to achieve eradication

status in 2014 Feb.

The specific objectives

4. To achieve measles elimination in 2015

5. To ensure injection safety through universal use of AD

Syringes and appropriate waste management practices.

6. To reduce vertical transmission of hepatitis B through

increased delivery of timely Hepatitis B birth dose.

7. To enable evidence based decision making for introduction

of new vaccine –Rotavirus, Pneumococcal, JE, through

acquiring the needed information on disease burden,

costing, cost effectiveness and global funding environment

8. To increase coverage of other primary health care interventions through improved linkages with immunization – Vitamin A, B1, de-worming, and ITN distribution & use.

Myanmar EPI towards MDG Goal 4 : Reduce child mortality

Target 5 Reduce by two-thirds, between 1990 and

2015, the under-five mortality rate

1. Under-five mortality rate

2. Infant mortality rate

3. Proportion of one-year-old children

immunized against measles

7

0

De

ath

s p

er

1,0

00

LB

20

40

60

80

100

120

140

1990

DOH

1995

DOH

1999

CSO

2003

DOH

2015

U5MR IMR

130

82.4

43.3

66.1

77.7798

55.455.1 49.7

32.7

MDG

Trends in Child Mortality Relative to MDG-4 in Myanmar

Myanmar

2007

DHP

62.1

43.4

(Source: Cause specific under five mortality survey, DOH/UNICEF, 2003)

TRENDS IN CHILD MORTALITY RELATED TO MDG 4, MYANMAR

EPI Schedule in Myanmar before New Vaccine Introduction

Age Vaccines

At Birth BCG, HepB ( Hospital births)

6 weeks DPT -1, OPV -1, HepB

10 weeks DPT -2, OPV -2, HepB

14 weeks DPT -3, OPV-3, HepB

9 months Measles - 1

Penta-1 + OPV-1

Penta-2 + OPV-2

Penta-3 + OPV-3

2 month

4 month

6 month

18 month

New EPI Schedule after New Vaccines Introduction

Measles - 2

Service Delivery Strategy

National Immunization ProgrammeSteering and Formulation

ICC - Interagency Cooperation CommitteeNCIP- National Committee for Immunization PracticesNCCPE - National Certification Committee for Polio Eradication

0-59%

60% - 79%

80% or above

No data

Myanmar Routine ImmunizationDTP 3 Coverage 2011

Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar

National coverage 86%

0-59%

60% - 79%

80% or above

No data

Sub National Routine EPI Coverage 2011

BCG DPT3 OPV3 HepB3

Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar

Routine EPI Coverage 2011 (Townships)

BCG DPT3 OPV3 HepB3 Measles 1 Measles 2

0-59% 60% - 79% 80% or above No data

Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar

0-59%

60% - 79%

80% or above

No data

Sub National Routine EPI Coverage 2011

Measles 2Measles 1

Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar

0-59%

60% - 79%

80% or above

No data

Routine EPI Coverage 2011

TT 2TT 1

Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar

LevelPower

conditionsEquipment

used

Central +2 Main Sores

~24 hrs Walk-in cold roomBack-up generator

Sub-Stores(State or Division level)

at least 8 hrs per day

Freezer & FridgeBack-up generator

Township at least 3 hrs per day

Freezer & Fridge

Solar unit for selected locations

Rural Health Center (RHC)

mostly not available

Cooler box with ice packs (last 5 days)

Solar unit for selected locations

Sub RHC not available Vaccine Carrier for midwife (last only 48hrs)

YangonCentral Coldroom

2 Main Stores( Mandalay&Magway )

Sub - Store … Sub - Store …

Townships

RHCs(4- 5 per tsp)

Sub RHCs(20-40 /tsp)

YangonCentral Coldroom

2 Main Stores( Mandalay&Magway )

Sub - Store … Sub - Store …

330Townships

RHCs(4- 5 per tsp)

Sub RHCs(20-40 /tsp)

Sub - Store …Sub - Store …Total 24 Sub-Stores

Cold chain network in Myanmar

Immunization Safety

Components of Immunization Safety

Vaccine SafetyInjection SafetySafety of Waste Disposal

Vaccine safety and quality

Safe cold-chain practices

Vaccines are sensitive to heat and freezing

kept at the correct temperature from manufactured to used

in order to preserve their qualityThe cold chain consists of a series of storage and transport links

Due to unsafe cold-chain practices :

• has reduced effectiveness in protecting against disease

• can result in higher rates of local reactions

Safe use of diluents• Kept correct diluent and distributed with each vaccine type and

batch.

• Vaccines and diluents must be clearly labelled and identified.

• Diluents must be cooled to between +2°C and +8°C before

reconstitution.

• Draw up the correct number of doses per vial

• Discard reconstituted vaccines after six hours of reconstitution.

• Diluents must not be frozen.

• Sterile water for injection must NOT be used as a vaccine diluent.

Ten critical steps to reconstitute vaccines safely

1. Read the label on the diluent to make sure that it is the correct diluent

2. Check the expiry date 3. Check the status of the (VVM) 4. Cool the diluent to between +2°C and +8°C5. Draw the entire contents of the diluent empty the entire contents into the vaccine vial.

6. Discard the used mixing syringe and needle into a safety box

without recapping.

7. Do not leave the mixing needle in the vaccine vial.

8. Never allow the vial to become immersed in water.

9. Discard all reconstituted vaccine at the end of the session, or

after six hours

10. Use a new auto-disable (AD) syringe and needle ,use the

same needle and syringe for injecting the vaccine.

Multi-dose vial policy (MDVP)

• Multi-dose vials of OPV, DTP, TT, DT, Td, hepatitis B and liquid formulations of Hib vaccinesa maximum of four weeks

provided that all the following conditions are met.1. The expiry date has not passed.2. The vaccines are stored under appropriate cold-chain conditions (+2°C to +8°C).3. The vaccine vial septum has not been submerged in water.4. Aseptic technique has been used to withdraw all doses.5. The VVM, if attached, has not reached the discard point.

Note : reconstituted vaccine must be discarded at the end ofeach immunization session or at the end of six hours, whichever comes first.

vaccines to which the multi-dose vial policy

.

applies Not applied

1. DT vaccine, adsorbed.2. dT.3. Td vaccine for adults, adsorbed.4. TT vaccine, adsorbed.5. DTP vaccine, adsorbed.6. DTP-Hib vaccine, liquid.7. DTP-HepB vaccine.8. HepB vaccine.9. Hib vaccine, liquid.10.Oral polio vaccine.

1. BCG vaccine.2. DTP+Hib vaccine, lyophilized.3. DTP-HepB+Hib vaccine, liquid + lyophilized.4. Hib vaccine, lyophilized.5. Yellow fever vaccine.6. Meningitis vaccine A&C.7. Measles vaccine.8. MMR vaccine

AEFI

Adverse Events Following Immunization(AEFI) surveillance

Definition of AEFI surveillanceAn adverse event following immunization (AEFI) is

defined as a medical event or incident that takes place after an immunization, but is not necessarily caused by immunization. AEFI surveillance includes :

1. detecting, monitoring and responding to adverse events following immunization(AEFI) ;2. implementing appropriate and immediate action to correct any unsafe practices detected through the

AEFI surveillance system, in order to lessen the negative impact on the health of individuals and the reputation of the immunization programme.

Five main types of AEFI

Vaccine Reaction

Rare Serious Reaction

Examples of incorrect immunization practices and associated AEFI

Programme errors and AEFI

• The view that vaccines are the most common cause of

AEFI is incorrect.

• On the contrary, incorrect immunization practices that

can be prevented are more often the cause.

• Careful epidemiological investigation of an AEFI is

needed to pinpoint the cause and to correct these

malpractices.

Estimating Vaccine and Injection Equipments

Estimating vaccine and safe-injection equipmentneeds based on target population

• basic parameters necessary to estimate vaccine and safe injection equipment

• the target population of the area (such as infants or pregnant

women)

• details of vaccines included in the national immunization

schedule, including the number of doses and the number

of doses per vial;

• the wastage multiplication factor (WMF) for each vaccine and

the AD syringes

Estimating annual vaccines and safe-injection equipment requirementsfor a province with a target population of 100 000 infants and pregnant

women

How do I calculate the wastage multiplication factor (WMF)?

• The vaccine wastage rate can vary greatly according to several characteristics of the programme – for example session sizes, session plans, vial presentation and supply management.

Estimating vaccine and safe-injection equipmentneeds based on previous consumption

• Each parameter relative to previous consumption can be affected by many factors especially programme performance, during the supply period in question.

• Estimating needs based on previous consumption may, therefore, not be asreliable as the method based on target population.

• Consider the following measurements when estimating vaccine and safe injection

• equipment needs based on previous consumption:• initial stock (vaccines and safe-injection equipment) at the beginning of the given period;• stock received during the period;• stock at the end of the period.

Storage of vaccines and safe injection equipment

• Storing vaccines

• Vaccine storage conditions

• Temperature sensitivity of vaccines

• Loss of potency due to heat

• Loss of potency due to Freezing

Recommended temperatures and length of storage at various levels of the cold chain

Diluent

• if diluent is supplied separately, it can be stored outside the cold chain

• but must be cooled before use, preferably for a day or for a period of time

• sufficient to ensure that the vaccine and diluent are both at temperatures between +2 °C and +8 °C when they are reconstituted.

• Never freeze diluent.

Photosensitivity

• Some vaccines are very sensitive to light and their exposure to ultraviolet light causes loss of potency.

• BCG, measles, MR, MMR and rubella vaccines are equally light-sensitive and must always be protected from sunlight and fluorescent (neon) light.

• manufacturers provide these vaccines in vials made of a darker glass.

Conditioning ice pack

Temperature monitoringMonitoring the temperature in vaccine refrigerators

• WHO advocates the use of new time-temperature devices for continuous temperature recording.

• In the absence of such devices• a thermometer;• a temperature chart that you tape to the outside of the refrigerator door.

Refrigerator temperature chart

Using the VVM to monitor the quality of vaccine vials

The four different VVM types and their relationship to temperature sensitivity in EPI vaccines

Reducing vaccine wastage

Unavoidable vaccine wastage factors• The most important unavoidable wastage factors involve: reconstituted

vaccines that have to be discarded at the end of a session.

Avoidable vaccine wastage factors• Factors that can be controlled by improving vaccine management include:

• poor stock management resulting in over-supply and vaccines reaching expiry before use;

• cold-chain failure that exposes vaccines to unacceptably high unacceptably low temperatures;

• incorrect dosage, e.g. the administration of 3 drops of OPV instead of 2 drops or the injection of 0.6 ml of vaccine

instead of 0.5 ml;• failure to comply with the multi-dose vial policy;• the loss, breakage or theft of vials.

What is RED Strategy?

Identifying H2RHealth Center

Areas Current Implementation Strengthening RI with HSS or REC

Total Ward/ Village

Routine REC Uncovered

IRI HSS Still Uncovered

Reason

MCH 5/112 5/112 0 0 0 0 0 0

Yankha RHC

79 61 18 - - 18 - -

Mine Khon RHC

139 88 8 43 - 8 43 SatffTransportSecurity

Win Bo RHC

101 52 43 - - 43 - -

Kat Taung RHC

224 205 19 - - 19 - -

Mine king

8 8 8

Background

• RED (Reaching Every District ) is a strategy developed by WHO, UNICEF, CDC, CVP/PATH and USAID.

• The strategy specifically aimed at overcoming the most common barriers to improving access to immunization services and to achieve sustainable and equitable access to quality immunization services for every infant.

• The focus of RED is on planning at the sub-national administrative level (Township)

• The level is closest to service delivery where there is potential managerial capacity to improve services.

The RED strategy has the following five

operational components

1. Re-establishment of outreach services

2. Supportive supervision

3. Community link with service delivery

4. Monitoring and use of data for action

5. Planning and management of resources

The five RED operational components

1. Re-establishing outreach vaccination services

A large proportion of the population only have access to immunization through outreach

Outreach sessions, by mobile immunization teams also present opportunities to provide other interventions such as administering vitamin A and deworming tablets with immunization

Include other interventions during crash programme in hard to reach areas where feasible

The five RED operational components

2. Supportive supervision providing regular on-site or on- the- job training and

assistance by supervisors to health workers in Township during supervisory visits or at regular monthly meetings

offers the opportunity to integrate supervision of other health interventions, for example Integrated Management of Childhood Illness (IMCI).

The five RED operational components

2. Supportive supervision Update and use standardized supervisory checklist Training of supervisors(TMO,THO.HA1,THN at SD

levelSupport mobility of supervisors atl all level Provision feedback at all opportunitiesPrioritize areas to be supervised based on

coverage/drop-out.

The five RED operational components

3. Linking services with communities Immunization services need to integrated better into

community structures. This can be achieved by involving the community in the

planning and delivery of health services, Including immunization,

such as identifying community volunteers and designating responsibilities

identifying newborns and performing regular follow-up on mothers whose children are

not fully immunized

The five RED operational components

3. Linking services with communities Promotion of benefit of immunization at all

opportunities. Explore the possibilities of increasing use of mass

media for promoting routine immunization Increase training for health workers and volunteers

to communicate effectively with mothers ideally in local languages

The five RED operational components

4. Monitoring and use of data for action Monitoring of immunization activities and using the data

for action is critical in strengthening the immunization system

Simple monitoring tools such as wall charts of vaccination coverage can be used to track monthly progress

Information on logistics, vaccine supply and surveillance which is collected every month should be analyzed together with the coverage data to improve the immunization system.

The five RED operational components

5. Planning and management of resources • A township/RHC micro plan is the key to the RED

strategy. • At each level, micro plans should contain details of

the financial and human resources required to reach every district in a sustainable manner.

Please contact kyawkankaungmo@gmail.com 09-8702267