INTENSIFICATION OF ROUTINE IMMUNIZATIONDR GAURIJ HOOD

INTRODUCTION

• Immunization Programme in India was introduced in 1978 as Expanded Programme of Immunization (EPI)

• The programme gained momentum in 1985 and was expanded as Universal Immunization Programme (UIP) to be implemented in phased manner to cover all districts in the country by 1989-90.

• UIP become a part of Child Survival and Safe Motherhood Programme in 1992

• Between 1985 to 1995, the coverage levels for various vaccines reached 70-85% and the incidence of various VPDs rapidly declined in the country

• The UIP in India targets 27 million infants and 30 million pregnant women every year.

• Since, 1997, immunization activities have been an important component of National Reproductive and Child Health Programme and is currently one of the key areas under National Rural Health Mission (NRHM) since 2005

• Introduction of the second dose of measles, and Hib containing pentavalent vaccine, initially in two states as part of routine immunization are other major initiatives

IMMUNIZATION COVERAGE - INDIA

Source Coverage Evaluation Survey (CES) 2009

DLHS-3 (2007-08)

Full Immnunization 61 53.5

BCG 86.9 86.7

OPV3 70.4 65.6

DPT 3 71.5 63.4

Measles 74.1 69.1

No Immunization 7.6 4.6

o

IRI STRATEGY

• Receipt of three doses of diphtheria- tetanus -pertussis vaccine (DTP3) is the commonly used indicator for assessing the effectiveness of routine immunization services as it reflects the proportion of children among the target population less than 1 year of age who had at least three contacts with the immunization services

• The Global Immunization Vision and Strategy (GIVS) was adopted by the 58th World Health Assembly (2005) as the framework for strengthening of national immunization programmes between 2006 and 2015.

• The Regional Immunization and Vaccine Development Strategic Plan ( 2010-2013) reflects the GIVS goals of achieving 90% DTP3 coverage at the national level and 80% coverage at the district level.

• Member states in the region have aligned the national immunization programmes as guided by GIVS and SEAR Immunization Strategic Plan.

IRI Inception

• Brings the member states in the region closer to achieving the MDG-4 for child mortality reduction and reducing maternal mortality through integrated approaches linking maternal health to achieve progress to meet MDG 5 goals.

• The Regional Director after reviewing the situational analysis has called for the member states to declare the year 2012 as year of intensification of routine immunization in SEA Region

• Seven member states [Bangladesh, Bhutan, DPR Korea, Maldives, Myanmar, Sri Lanka and Thailand] have already achieved >90% coverage for DTP3 at national level.

• Focuses on “techniques and technologies” to overcome barriers

• Application of current evidence base to intensify routine immunization through strengthening the delivery of quality assured vaccines

Six Key Determinants

• For sub optimal routine immunization coverage in the region have been identified as

1. Access2. Resource Availability (skilled human resources, vaccines, cold chain etc)3. Service delivery4. Information use5. Managerial Capacity6. Management of adverse event following Immunization( AEFI)

What are the different types of immunization sessions that needplanning for?

1) Fixed facility: Regular delivery of vaccinations in health facility on specified days of a week and hours of the day,

• Immunization clinics in District, Sub-divisional and referral hospitals and even larger Community and Primary Health centers.

• Vaccines are stored in ILRs in these fixed facilities

2) Outreach: Delivery of services to people who stay far away from the health facility• Vaccines need to be delivered for the immunization sessions. • No arrangement for overnight storing of vaccines • Sub centers, Anganwadi centers, urban and village session sites etc.

3) Mobile strategy: To reach remote or hard-to-reach areas, vaccination teams with adequate logistics

• May not be accessible in all months of year • Good planning has to be made to reach during accessible months. • Mobile teams would then move to these areas, as planned, to vaccinate eligible beneficiaries. • To complete the vaccination schedule at least four such visits should be planned in course of

a year.

WHY IRI ?

• The Universal Immunization Programme in India is one of the largest programmes in the world, targeting to reach approximately 29 million pregnant women and 26 million infants every year.

• India’s full immunization coverage stands at 61% (CES 2009) and there are large number of beneficiaries which are either not reached (left out) or are not tracked for full immunization (drop out).

• Majority of these children reside in Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand, Orissa, Gujarat and Assam.

• In order to improve immunization coverage and performance, particularly among the priority districts of the country, Government of India has declared year 2012-13 as the “Year of Intensification of Routine Immunization (IRI)”.

The strategic framework for IRI includes:

• Advocacy for political and bureaucratic commitment for the program

• Strengthening communication, social mobilization

• Review mechanisms at different levels

• Implementation of area specific coverage improvement plans

• Institutional capacity building

• Strengthening of cold chain infrastructure and vaccine logistics management

• Institutionalization of AEFI and VPD surveillance and

• Building partnership with stakeholders

Strategic Framework

• In addition to this, four rounds of immunization weeks will be conducted during the year specifically focusing on unreached and under reached areas and underserved populations, tribal, hard to reach areas, urban and peri-urban

areas and migrant population.

• A mechanism for delivery of vaccines and logistics to the outreach session sites will also be launched during the year by name “Teeka Express”.

• The proposed Regional Strategic Framework describes the key determinants, goal, objectives, the guiding principles, the strategies, priority areas, and concludes with roles and responsibilities of the all stakeholders.

• The key message in this paper is equitable access to immunization which promotes the right of every child to highest attainable standards of health.

• Three strategies have been outlined as

1. Building an enabling political and economic environment to intensify routine immunization in SEAR member states

2. Responding to country needs to increase and sustain high immunization coverage

3. Strengthening Immunization service delivery, Information use and management capacity

WHAT IS NEEDED?

Address the barriers to achieve high RI rates• Focus should be on increasing demand for vaccination by using effective IEC and bringing

immunization closer to the communities.

• The immunization services provided at the fixed sites should be improved. There should be better monitoring and supervision, and district authorities should be made accountable for the performance of RI in their district

Induct innovative methods to improve RI• The number of immunization ‘delivery points’ especially in rural and remote areas having

poor access to health facility, should be increased.

• ‘Immunization booths’ should be constructed at every locality in urban areas particularly in slums, and local municipality board member should be made accountable for their performances.

• Large and varied cadres of volunteers, including, for example, local medical practitioners, pharmacists, chemists and retired nurses and other health personnel can be recruited to offer immunization services.

What needs to be done ….

• Proper training including maintenance of cold chain and basic minimum education on vaccines must be imparted to all of them.

• Complete immunization should be made mandatory to get admission in school by appropriate legislation.

• Incentives in cash and kind may be offered to those families having fully immunized kids.

Proper monitoring of the program• The unsatisfactory performance of UIP in India is due to managerial, administrative

and governance-related inadequacies, and not due to financial constraints or technical inadequacies

• The need to monitor the progress of control of diseases under UIP has not been realized; one element of the poor performance of UIP is precisely this lack of

monitoring.

IRI IN INDIA

•

• Strategy discussed within Immunization Division of Ministry of Health and Family Welfare with partners

• Framework for IRI in states

• Guidelines to state to improve coverage

• List 200 districts prioritized for focused interventions

• Operational guidelines for Immunization Weeks

• National Technical Advisory Group on Immunization (NTAGI)

Prioritization of states for IRI 2012-13

Category DPT3 Coverage Names of States Remarks

Low performing States

Less than national average of 71.5% (NE states excluded)

MP, UP, Bihar, Rajasthan , Jharkhand,Orissa, Gujarat,Chhatisgarh

Need high focus to provide support after gap analysis

Good and average performing states

DPT coverage more than national average(NE states excluded)

Rest of the states Low coverage areas to be prioritised for focused intervention

North Eastern states

Not considered Assam, Sikkim,Arunachal Pradesh, Manipur, Mizoram,Nagaland, Tripura, Meghalaya

Difficult to access during large part of year, need focused intervention

Prioritization

• Prioritization of districts is also being done based on % of fully immunised children as per DLHS 3 survey.

• Districts with <50% FI children are prioritized for focused interventions to improve coverage

• Prioritization of blocks will be done based on Risk analysis using-i) High risk population data collected for Polio based on Emergency Preparedness

and Response Plan (EPRP)ii) Outbreaks of measles or other VPDsiii) Key basic parameters as coverage, dropouts, session monitoring data,

accessibility, and availability of services, human resources

STRATEGIES FOR IRI

1. Enhance political commitment and increase community demand for routine immunization

2. Improve reach and quality of immunization services

3. Strengthen institutional capacity for program management

4. Strengthen partnership with all stakeholders

5. Conduct Operational research

Proposed activities for IRI

1. National and State level advocacy2. Strengthening communication and social mobilization3. Regular program reviews at all levels4. Development of Coverage Improvement Plans5. Institutional Capacity building6. Vaccine and logistics management7. Cold chain strengthening and maintenance8. Teeka Express9. Immunization weeks10. Strengthening RI monitoring and supervision11. Institutionalizing AEFI and VPD surveillance12. Strengthening partnership with all stakeholders13. Operational Research studies

Guidelines for States to Improve Immunization Coverage

Step 1- Conduct Risk analysis to identify and prioritize high risk block/areas

• Who will do- State Immunisation officer , state officials , development partners• What to do- Analyze data from HMIS and other sources• Milestone- High risk areas and blocks identified by end of January 2012

Step 2- Conduct gap analysis to identify the bottlenecks in high risk blocks and areas to take corrective action

• Who will do- DIO and MOIC with partners• What to do – Identify gaps in following components, discuss in DTF for corrective action and ask

for state support Human resource vacancies and training status, Vaccine and cold chain logistics management,

Injection safety and Waste management, Microplanning status, Data quality and use of data for action, Supportive Supervision visits, communication,

Surveillance of VPDs and AEFIs

• MILESTONE- Gaps identified in High risk blocks/areas by January end and corrective actions taken by April 2012

Step 3 – Review and update the microplan of high risk block/areas

• Who will do- MOIC with support of DIO and partners• What to do – Desk Review – a) Get list of villages under each subcenter at block level b) Cross verify this list with villages and area lists c) Identify missed villages/areas and allocate them to existing areas

Block level meeting to update sub-center microplans

a) Share updated list of villages with HW in meeting at block levelb) Ensure that these villages are included in microplans to be prepared by HWc) Decide on location and timing of sessions with inputs from HWd) Rationalize workload among HW and prepare quarterly microplane) Prepare plan to inform beneficiaries

Special Planning for high risk areas eg. Urban slums, brick kilns, and riverine areas

Milestone- Micro plans of high risk areas updated by end of March 2012.

Step 4- Strengthen monitoring and supervision of RI session sites and community

Who will do- DIO with support of SEPIO and partners

What to do – • Identify monitors/supervisors at state, district and block level• Allocate high risk pockets and villages to be visited by them• Provide hands on training to monitors in using std. checklists to monitor PHC, session sites

and community• Devise a system of submission of filled in checklists, data entry and analysis • Share monitoring information fortnightly • Ensure monthly reporting of monitoring information at state level• Ensure that corrective actions are taken based on monitoring data• Review and update microplans quarterly

Milestone- Continuous activity started in April 2012

Reaching the unreached

• During Immunization weeks, it is important to immunize hard to reach and underserved populations that are often missed by routine vaccination

• Who are unreached, Where they are and Why are they underserved

i) Areas not regularly reached by health functionariesii) Un-immunized or partially immunized children in urban and peri-urban areasiii) Difficult or mountainous terrain, marshy areas, islands and other difficult to access

areasiv) Refugees, internally displaced persons, migrant workers and other transient

populationsv) Socially marginalized populations or minority groups, religious groups that oppose

vaccinationvi) Communities at international borders and intra- state administrative bordersvii) Populations known to have a disproportionate share of disease burdenviii) Populations in places, where sanitation is poor

FOCUS of IRI

• Target Population – Children under 2 years and pregnant women who have not received all due vaccines according to NIS

• Target Areas- Areas for holding immunization weeks should be identified at

planning units/blocks.

Category A (Highest priority)- Areas which are never or rarely reached Urban slums, Villages with poor access, Villages not included in micro-plan,Vacant sub-centers, Migrant and mobile populations, marginalized populations

Category B ( Second priority) – Areas where immunization was planned but not held during previous 3-4 months

Category C ( Third priority )- Villages/urban areas where RI is normally done but coverage is considered low

Steps for Planning of Immunization Weeks

1) State Level : a) Sensitization meeting : To sensitize for additional efforts for extending coverage

and Technical preparation (Chief Secretary – H & FW, DM/DC, CMO/DIO)b) State Planning meeting – (atleast 8 weeks before start of activity )• Outline objectives of immunization week• Technical guidance for PIP, Resolve issues on microplanning, logistics, HR, AEFI, BCC

2) District Level :a) Sensitization meeting : ( Officers /representatives from administration, health,

ICDS, Education, PRI, NGOs, Professional bodies , religious leadersb) District Planning meeting : atleast 6 weeks before start of activity ( DM/CMO, DIO,

DPM, MOIC/PHC, District cold chain and logistics incharge, CDPO, LHVs, pharmacist, NGOs,partners)

3) Block/PHC level : Planning meeting – atleast 4 weeks before start of activity

Schedule/Calender

States Round 1 Round 2 Round 3 Round 4

NE States : Assam, Manipur,Meghalaya, Mizoram, Arunachal Pradesh, Nagaland, Sikkim, Tripura

January February March April

All Other States April May June July

Note : During immunization Weeks, regular RI days will not be disturbed

TAKE HOME MESSAGE

• Intensified Coverage• Motivated communities and health workforce• Monitored performance• Universally accessible• National Priority• Innovative strategies• Zealous Partners• Evidence based approach

REFERENCES

• Strategic Framework for Intensification of Routine Immunization(IRI) in India: Coverage Implementation Plans for 2012-13, Immunization Division, MOHFW, GOI,2012

• 2012: Year of Intensification of Routine Immunization in the South-East Asia Region: Framework for Increasing and Sustaining Immunization Coverage

• Progress Towards Global Immunization Goals – 2011,Summary presentation of key indicators Updated August 2012

• Immunization and Vaccine Development South East Asia Region, Strategic Plan ‐(2010 2013)‐

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