epi for hsso
TRANSCRIPT
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 [email protected] 09-8702267