bhutan 2014 - south-east asia regional...

World Health Organization• SEARO/FHR/IVD • 22 July 2015 Immunization andVaccine Development

South-East Asia Region

Bhutan 2014

Table 1: Basic information1 2014

Division/Province/State/Region -

Dzongkhag/District 20

Gewog/Block 205

Sub-block/Ward 1,050

Village (approx.) 3,717

Population density (per sq. km) 18

Population living in urban areas 36%

Population using improved drinking-water sources

98%

Population using improved sanitation2 66.3%

Total expenditure on health as % of GDP 3.7%

Births attended by skilled health personnel 58%

Neonates protected at birth against NT 89%

Vaccine Age of administration

BCG At birth

HepB At birth

OPV At birth, 6 weeks, 10 weeks, 14 weeks

DTP-Hib-HepB 6 weeks, 10 weeks, 14 weeks

MR 9 months, 24 months

DTP 24 months

HPV Females 12 years + (0, 2 and 6 months)

Td6 years, 12 years, pregnant women (2 doses for primi-gravidarum, and 1 dose for subsequent pregnancies)

Vitamin A 6 - 59 months

EPI history�� Launched on 15 November 1979.�� TT vaccination for pregnant women

started in 1983.�� Hepatitis B introduced in 1997.�� DTP-HepB introduced in 2003.�� AD syringes introduced in 2003.�� MR introduced in 2006.�� Hib Pentavalent (DTP-Hib-HepB)

introduced in 2009.�� HPV introduced in 2010.�� HepB birth dose introduced in 2011.�� TT replaced by Td vaccine in 2012.

Source: cMYP 2013-2018

Immunization system highlights

� There is a comprehensive multi-

year plan (cMYP) for immunization

covering 2013-2018.

� A national committee on

immunization practices (NCIP)

with formal terms of reference

exists.

� A national system to monitor

adverse events following

immunization (AEFI) exists.

� A national policy for health care

waste management including

waste from immunization

activities exists.

� National Health Survey 2012 was

conducted.

� Bhutan achieved the maternal

neonatal tetanus (MNT)

elimination status in 2000.

� 31% spending on vaccines

financed by the government.

� 31% spending on routine

immunization programme

financed by the government.

� All 20 districts have updated

micro-plans to raise immunization

coverage.

� All 20 districts had >80%

coverage for DTP-Hib-HepB3 and

15 (75%) districts had >90%

coverage for MCV1.

� No district in the country

reported more than 10% drop-

out rate for DTP-Hib-HepB1 to

DTP-Hib-HepB3.

� Plan to introduce IPV in July 2015.

Total population 745,153

Live births (LB) 13,338

Children <1 year 12,938

Children <5 years 89,418

Children <15 years 230,997

Pregnant women 13,338

Women of child bearing age (15-49 years)

176,009

Neonatal mortality rate 21 (per 1,000 LB)

Infant mortality rate 36 (per 1,000 LB)

Under-five mortality rate 45 (per 1,000 LB)

Maternal mortality ratio 120 (per 100,000 LB)

1 SEAR annual EPI reporting form, 2014 and WHO, World Health Statistics 2014

Table 2: Immunization schedule, 2014

Source: WHO/UNICEF joint reporting form (JRF) 2014

Disclaimer: The boundaries and names shown and the designations used on all the maps do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

E P I F A C T S H E E T

World Health Organization• SEARO/FHR/IVD • 22 July 2015

Source: WHO/UNICEF coverage estimates.

Figure 3: DTP-Hib-HepB3 coverage, 2014

Figure 2: DTP3 coverage1, diphtheria and pertussis cases2, 1980-2014

0

20

40

60

80

100

050

100150200250300350400450500

1980 1985 1990 1995 200020052010 2011 2012 2013 2014

% C

over

age

No.

of c

ases

Year

Diphtheria Cases Pertussis Cases DTP3 Coverage

1 WHO/UNICEF coverage estimates 2013.2 WHO vaccine-preventable diseases: monitoring system 2014 & JRF 2014.

1 Country official estimates, 1980-20142 WHO vaccine-preventable diseases: monitoring system 2014 & JRF 2014.Source: SEAR annual EPI reporting form, 2014 (administrative data)

Figure 4: TT2+ coverage1 and NT cases2, 1980-2014

Table 3: OPV supplementary immunization activities (SIA)

Year Antigen Activity Target population (age)

Date of 1st round Date of 2nd round 1st round coverage (%)

2nd round coverage (%)

1995 OPV NID 80,336 (<5 yrs) 11-Oct-95 8-Nov-95 99 100

1996-1997 OPV SNID 37,107 (<5 yrs) 7-Dec-96 11-Jan-97 100 100





2001 OPV SNID 36,753 (<5 yrs) 3-Nov-01 7-Dec-01 100 100

2002 OPV SNID 37,665 (<5 yrs) 9-Nov-02 14-Dec-02 96 100

Figure 1: National immunization coverage, 1980-2014

Source: WHO/UNICEF JRF

1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014BCG 43 54 99 98 97 92 96 95 95 97 99DTP3 6 41 96 87 92 95 91 95 97 97 99OPV3 4 41 96 86 98 95 92 95 97 97 98MCV1 21 44 93 85 78 93 95 95 95 94 97

0

20

40

60

80

100

% C

over

age

<70% 70% - 79% 80% - 89% > 90%

1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014

NT cases TT2+

0

20

40

60

80

100

0

1

2

3

4

5

% C

over

age

No. o

f cas

es

No data

1 Number of discarded AFP cases per 100,000 children under 15 years of age. 2 Percent with 2 specimens, 24 hours apart and within 14 days of paralysis onset.3 2005 to 2007 result reported within 28 days and 2008 onwards result reported within 14 days of sample received at laboratory.

Table 4: AFP surveillance performance indicators, 2005-2014

Figure 5: Non-polio AFP rate by district, 2014 Figure 6: Adequate stool specimen collection percentage by district, 2014

Last clinically-confirmed polio case was reported in 1986.

<1 1 – 1.99 >2 No non-polio AFP case 80%> No AFP< 60% 60% – 79%–

Indicator 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

AFP cases 6 6 4 9 1 6 6 10 10 11

Wild poliovirus confirmed cases 0 0 0 0 0 0 0 0 0 0

Compatible cases 0 0 0 0 0 0 0 0 0 0

AFP rate 1.99 2.86 1.90 4.28 0.46 2.83 2.74 5.14 4.52 4.84

Non-polio AFP rate1 1.99 2.86 1.90 4.28 0.46 2.83 2.74 5.14 4.52 4.84

Adequate stool specimen collection percentage2 33% 33% 50% 67% 0% 67% 83% 70% 80% 73%

Total stool samples collected 10 6 2 27 2 4 7 21 11 22

% NPEV isolation 20 0 0 0 0 0 0 0 0 9

% Timeliness of primary result reported3 100 100 100 100 100 100 71 100 100 100

Year Polio Diphtheria Pertussis Neonatal Tetanus(% of all Tetanus)

Measles Rubella Mumps Japanese Encephalitis

Congenital Rubella Syndrome

2005 0 0 1 0 11 81 144 ND ND

2006 0 0 1 1 (2%) 2 11 ND ND ND

2007 0 0 0 0 11 3 ND ND 0

2008 0 0 0 0 7 2 ND ND 0

2009 0 0 0 0 6 15 ND 0 0

2010 0 0 0 0 21 9 218 0 0

2011 0 0 1 0 10 3 262 3 0

2012 0 0 0 0 1 2 198 0 0

2013 0 0 0 0 0 6 20 0 0

2014 0 0 0 0 0 0 206 0 0

Table 5: Reported cases of vaccine preventable disease, 2005-2014

Source: WHO/UNICEF JRF ND=No data

Immunization andVaccine Development


<70% 70% - 79% 80% - 89% > 90%1 WHO/UNICEF coverage estimates, 2014-MCV2 coverage not available.2 WHO vaccine-preventable diseases: monitoring system 2014 & JRF 2014.

Figure 7: MCV1 & MCV2 coverage1 and measles cases2, 1980-2014

0

20

40

60

80

100

050

100150200250300350400450500

1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014

% C

over

age

No. o

f cas

es

Year

Measles Cases MCV1 Coverage MCV2 coverage

Figure 8: MCV1 coverage by district, 2014

Source: SEAR annual EPI reporting form, 2014 (administrative data)

Table 6: MCV supplementary immunization activities

Year Vaccine, geographic coverage, target group

Target Coverage Achieved

1995M, nationwide, 9 months

to 15 years69,285 100%

2000M, nationwide, to 15

years214,128 100%

2006

MR, nationwide, 9 months to 14 years

children and 15 years to 44 years women

338,040 98%

Year Number of districts %

2010 12 60

2011 8 40

2012 8 40

2013 9 45

2014 11 55

Table 7: Districts with more than 95% MCV1 coverage

Source: WHO/UNICEF JRFs Source: WHO/UNICEF JRF (multiple years)

0

2

4

6

8

10

12

14

Jan-

10Fe

b-10

Mar

-10

Apr-

10M

ay-1

0Ju

n-10

Jul-1

0Au

g-10

Sep-

10Oc

t-10

Nov-

10De

c-10

Jan-

11Fe

b-11

Mar

-11

Apr-

11M

ay-1

1Ju

n-11

Jul-1

1Au

g-11

Sep-

11Oc

t-11

Nov-

11De

c-11

Jan-

12Fe

b-12

Mar

-12

Apr-

12M

ay-1

2Ju

n-12

Jul-1

2Au

g-12

Sep-

12Oc

t-12

Nov-

12De

c-12

Jan-

13Fe

b-13

Mar

-13

Apr-

13M

ay-1

3Ju

n-13

Jul-1

3Au

g-13

Sep-

13Oc

t-13

Nov-

13De

c-13

Jan-

14Fe

b-14

Mar

-14

Apr-

14M

ay-1

4Ju

n-14

Jul-1

4Au

g-14

Sep-

14Oc

t-14

Nov-

14De

c-14

No. o

f cas

es

Sporadic measles Outbreak associated measles

Figure 9: Sporadic and outbreak associated measles cases* by month and MR SIA coverage, 2010-2014

*Includes laboratory confirmed and epidemiologically linked casesSource: SEAR Monthly VPD reports.

Figure 10: Immunity against measles: Immunity profile by age in 2015*

Figure 11: Immunity against measles: Immunity profile by age in 2016*

* Based on coverage data for 2014 and no SIAs from 2009 to 2014Source: Modeled using MSP tool ver 2

* Assuming 96% coverage of 1st dose at age 9 months; 92% coverage of 2nd dose at 24 months in 2015 and no SIAs between 2009-2015Source: Modeled using MSP tool ver 2

Figure 12: Confirmed (Lab and Epi linked) measles outbreak associated cases, by age, 2010-2014

Figure 13: Unimmunized confirmed (Lab and Epi linked)measles outbreak associated cases, by age, 2010-2014

Source: SEAR annual EPI reporting form (multiple years) Source: SEAR annual EPI reporting form (multiple years)

Table 8: Suspected sporadic and Outbreak associated measles and rubella cases, 2010-2014

Year Routine/sporadic cases Outbreak associated cases

No. of suspected

case

No. of death

No. of lab-confirmed measles cases

No. of lab-confirmed

rubella cases

No. of suspected outbreak

No. of Outbreak

Investigated

No. of case

No. of death

No. of measles

outbreak*

No. of confirmed measles

case*

No. of confirmed

rubella outbreak*

No. of confirmed

rubella cases*

2010 92 0 21 9 3 0 0 0 0 0 0 0

2011 98 1 10 3 0 0 0 0 0 0 0 0

2012 85 0 13 15 0 0 0 0 0 0 0 0

2013 99 0 0 6 0 0 0 0 0 0 0 0

2014 69 0 0 4 0 0 0 0 0 0 0 0

Source: Monthly VPD Reporting to WHO/SEARO * Laboratory confirmed & epidemiologically- linked

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Perc

ent o

f pop

ulat

ion

Age (in years)Protected by maternal antibodies Protected by routine vaccination with 1st doseProtected by routine vaccination with 2nd dose Protected by SIAsImmune due to past infection Susceptible

0

50

100

150

200

250

300

350

400

450

500

2010 2011 2012 2013 2014<1 year 1-4 years 5-9 years 10-14 years 15+ years

n=0 n=0 n=0 n=0 n=0

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Perc

ent o

f pop

ulat

ion

Age (in years)Protected by maternal antibodies Protected by routine vaccination with 1st doseProtected by routine vaccination with 2nd dose Protected by SIAsImmune due to past infection Susceptible

n=0 n=0 n=0 n=0 n=0(0%) (0%) (0%) (0%) (0%)

0

50

100

150

200

250

300

350

400

450

500

2010 2011 2012 2013 2014

<1 year 1-4 years 5-9 years 10-14 years 15+ years

No outbreaks reported No outbreaks reported

E P I F A C T S H E E T

World Health Organization• SEARO/FHR/IVD • 22 July 2015 Immunization andVaccine Development


Gasa

Punakha

Thimphu

Paro

Haa

Samtse Chhukha

Dagana

Wangduephodrang

Trongsa

Bumthang

Tsirang

Sarpang

Zhemgang

Lhuentse

TrashiyangtsaTrashiyangtsa

Mongar Trashigang

Samdrup JongkharPemagatshel

For contact or feedback:

Expanded Program on ImmunizationMinistry of Health, Thimphu, Bhutan

Tel: +975-2-332296, Fax: +975-2-332296

Email: [email protected], [email protected]

www.health.gov.bt

Immunization and Vaccine Development (IVD)WHO-SEARO, IP Estate, MG Marg, New Delhi 110002, India

Tel: +91 11 23370804, Fax: +91 11 23370251

Email: [email protected],

www.searo.who.int/entity/immunization

Table 9: Quality of field and laboratory surveillance for measles and rubella, 2012-2014

Year

No. o

f Sus

pect

ed M

easl

es

Case classification (number)Indicators

Measles Rubella

Disc

arde

d no

n-m

easl

es n

on-r

ubel

la

case

s

Annu

al in

cide

nce

of c

onfir

med

Mea

sles

ca

ses

per m

illio

n to

tal p

opul

atio

n

Annu

al in

cide

nce

of c

onfir

med

Rub

ella

ca

ses

per m

illio

n to

tal p

opul

atio

n

Prop

ortio

n of

all

susp

ecte

d m

easl

es

and

rube

lla c

ases

that

hav

e ha

d an

ad

equa

te in

vest

igat

ion

initi

ated

with

in

48 h

ours

of n

otifi

catio

n

Disc

arde

d no

n-m

easl

es n

on-r

ubel

la

inci

denc

e pe

r 100

,000

tota

l pop

ulat

ion

Prop

ortio

n of

sub

natio

nal a

dmin

istra

tive

units

repo

rting

at l

east

two

disc

arde

d no

n-m

easl

es n

on-r

ubel

la c

ases

per

10

0,00

0 to

tal p

opul

atio

n

Prop

ortio

n of

sub

-nat

iona

l sur

veill

ance

un

its re

porti

ng to

the

natio

nal l

evel

on

tim

e

Lab-

confi

rmed

Epi-L

inke

d

Clin

ical

ly-c

onfir

med

Lab-

confi

rmed

Epi-L

inke

d

Target � - - 80% 2 80% 80%

2012 82 1 0 0 2 0 80 0.7 1.4 0 11.4 ND ND

2013 99 0 0 0 6 0 93 0 4.2 0 13.3 ND ND

2014 69 0 0 0 4 0 65 0 2.8 0 9.3 ND ND

Source: SEAR Annual EPI Reporting Form, 2014 ND=No data

Table 10: Performance of Laboratory Surveillance, 2012-2014

Year

% Serum specimen collected

from suspected measles cases

Total Serum

Specimen received in Laboratory

% serum specimens

tested

Specimen Positive for Measles IgM

Specimen Positive for Rubella IgM

% Results within 4 of

receipt

% Outbreak tested

for viral detection

Genotypes detected

No. % No. % Measles Rubella

2012 100 82 100 1 1% 2 2% 37 0 - -

2013 100 99 100 0 0% 6 6% 52 0 - -

2014 100 69 100 0 0% 4 6% 36 0 - -

Source: SEAR Annual EPI Reporting Form, 2014 ND=No data

Figure 14: Network of WHO supported surveillance medical officers and laboratories, 2014

Public Health Laboratory - National measles/rubella laboratory - National Japanese encephalitis laboratory

bhutan 2014 - south-east asia regional...

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