Immunization Update
DIO/M&E Officers
Sensitization & review mtg
18 Aug 2010
Dr OR Goldie Dr Balwinder Singh,
DHS Office, Punjab
1
Presentation outline
• EPI Coverage: Where does Punjab stand ?
• Efforts to strengthen RI
• Measles second dose
• Way forward
2
High priority districts in Punjab
• Based on composite indicators (CBR, MMR, IMR
socio economic & demographic progress) GoI has identified
264 districts in the country to focus & improve
• 4/20 districts in Punjab declared high priority
– Nawan shahar
– Mukatsar
– Jalandhar
– Faridkot
• NRHM asked to tilt PIP for any interventions (if reqd)
• Focused monitoring from state task force is planned.
RI coverage
Understanding who and where
the unvaccinated children are located
What do we mean by
a fully immunized child ??
A child that has received
BCG + 3 doses of DPT +3 doses of OPV
+3 doses of Hep B +Measles
before completion of one year of age.
All the above doses of vaccine before the
first
birthday of the child
5
DLHS III Punjab : Full Immunization coverage
GU R D A SP U R
A M R IT S A R
H O S H IA R P U R
TA R N T A R A N
KAP U R T H A LA
JA L A N D H A R
N AW AS H ER
R OO PN A GA R
LU D H IA N A
M O H A LI
M OG A
FE R O Z E P U R
FA T E H G A R H -S A H I B
FA R ID K O T
BAR N ALA
P A T IA LA
M U KTSA R
SAN GR U R
B H A TIN D A
M AN S A
DLHS-III
(2007-08)
6
7
39
36
34
Uttar Pradesh
40
Meghalaya
41
MP
50
Tripura
50
Bihar
51
Rajasthan
54
Mizoram
55
Assam
60
Jharkhand
60
Gujarat
62
Chhattisgarh
63
Haryana
68
Orissa
69
Uttrakhand
70
Andhra Pradesh
73
Delhi
76
Maharashtra
77
Chandigarh
78
West Bengal
80
Karnataka
80
Sikkim
80
Kerala
80
Punjab
82
Puducherry
83
Himachal Pradesh
90
Tamilnadu
100
Goa
Fully Immunization status
DLHS 3 (2007-2008)
(most latest evaluated coverage available)
93
67
59
49
30
30
20
10
0
DLHS III : BCG Coverage
GU R D A SP U R
A M R IT S A R
H O S H IA R P U R
TA R N T A R A N
KAP U R T H A LA
JA L A N D H A R
N AW AS H ER R OO PN A GA R
LU D H IA N A
We do start the program well…
M O H A LI
M OG A
FE R O Z E P U R
FA T E H G A R H -S A H I B
FA R ID K O T
BAR N ALA
P A T IA LA
M U KTSA R
SAN GR U R
B H A TIN D A
M AN S A
DLHS-III
(2007-08)
8
DLHS3- DROP-OUT (BCG-DPT3
Punjab (distts)
< 10%
10% to 20%
20% to 30%
> 30%
Number of BCG-DPT3
Dropout Children (10%)
46350
9
Slide Source : Punjab state ppt SEPIO mtg 7-9 June 2010
DLHS III : Measles Coverage
Punjab (distts)
GU R D A SP U R
A M R IT S A R
H O S H IA R P U R
TA R N T A R A N
KAP U R T H A LA
A few districts pull down
State immunization coverage…
JA L A N D H A R
N AW AS H ER R OO PN A GA R
LU D H IA N A
M O H A LI
M OG A
FE R O Z E P U R
FA T E H G A R H -S A H I B
FA R ID K O T
BAR N ALA
P A T IA LA
M U KTSA R
SAN GR U R
B H A TIN D A
M AN S A
DLHS-III
(2007-08)
10
0
11
GOA
TAMIL NADU
HIMACHAL PRADESH
PONDICHERRY
PUNJAB
SIKKIM
MIZORAM
CHANDIGARH
DELHI
ANDHRA PRADESH
UTTARANCHAL
KERALA
MAHARASHTRA
KARNATAKA
ORISSA
WEST BENGAL
JHARKHAND
CHHATTISGARH
RAJASTHAN
GUJARAT
BCG
HARYANA
TRIPURA
ASSAM
MEGHALAYA
100
UTTAR PRADESH
MADHYA PRADESH
BIHAR
BCG to measles coverage drop
DLHS 3 (2007-2008)
Measles
90
80
70
60
50
40
30
20
10
AFP Cases (Age 6 Mths – 5 Yrs)
Status of OPV Dose : Polio SIAs - 2009
Punjab
Non- Migrant
1-3 Doses, 1,
0%
Migrant
1-3 Doses, 3,
5%
0 Dose, 0, 0%
0 Dose, 1, 0%
4-6 Doses, 35,
16%
4-6 Doses, 11,
20%
7 Doses, 41,
75%
7 Doses, 181,
84%
N=218
N=55
13
Slide Source : NPSP Data (from CIF)
AFP Cases (Age 6 Mths – 5 Yrs)
Status of OPV doses: Routine Immunization – 2009
PUNJAB
Non- Migrant
Migrant
0 dose
1 dose
6%
2%
2 doses
4%
0 dose
21%
1 dose
4%
2 doses
8%
>=3 doses
67%
>=3 doses
88%
Special RI strategy required for migrant
populations
(N=215)
(N=52)
14
data as on 26th June, 2010
Slide Source : NPSP Data (from CIF)
Possible reasons for low access
• Not reaching the community (Weak microplans)
– Immunization session site not in the microplan
– Session site in the microplan but poor service delivery
(services not provided by the vaccinator – leave, post vacant,
not going to the site)
• Hard to reach areas – not being reached
• Over reported data. Inadequate data analysis &
feedback
• Weak monitoring support by district officials.
15
DIO / M&E review mtg,18 Aug 2010
NRHM Initiatives for RI service delivery
 Strengthening of monitoring
 AEFI surveillance
 Strengthening program management
capacity
 Introduction of Auto Disabled syringes
 Introduction of under utilized and new
vaccines.
16
DIO / M&E review mtg,18 Aug 2010
Efforts to strengthen routine
immunization
DIO / M&E review mtg,18 Aug 2010
Immunization Training of Medical
Officers
• Immunization Handbook, Fac.
Guide and Training kits
developed in 2008.
• TOTs conducted for 1500
trainers from all states during
2009.
• MO-Training started and
~11500 out of 62000 (18%)
MOs trained.
• Slow / No progress in 22
states.
• Monitoring needs to be
strengthened.
Not Started
< 30%
30 % - 50%
50 % -80%
> 80%
J A M M U & K A S H M IR
H IM A C H A L P R A D E S H
P UN JA B
UT TA R A N CH A L
HAR YAN A
ARU N ACH AL PR .
S IK K IM
RA J A S TH A N
UT TA R P R A DE S H
ASSAM
B IH A R
NAG ALAND
MEG HALAYA
M A N IP U R
JH A RK H A N D
G UJ AR AT
MAD H YA PR ADESH
W EST BENGAL
T R IP U R A
M IZ O R A M
C H H A T T IS G A R H
O R IS S A
D&N H AVELI
MA H A R A S H TR A
AND H RA PR AD ESH
GOA
KARN AT AKA
A & N IS L A N D S
P O N D IC H E R R Y
T A M IL N A D U
LA K S H A D W E E P K E R A L A
As on 1 June10
19
DIO / M&E review mtg,18 Aug 2010
Immunization training of Health workers
• District
ImmunizationTraining
Handbook
targetand Facilitator
Total trained
Guide developed in2009-10
2006
•
•
% Trained
2009-10
2009-10
50 % - 80 %
> 80 %
ToTs held in 2007
J A M M U & K A S H M IR
P UN JA B
UT TA R A N CH A L
Fatehgarh
92
87
• Sahib
~175,000 out of 220,000 (79%) HWs
trained.
• Performance Assessment of HW-
119
95
HAR YAN A
RA J A S TH A N
72%
ARU N ACH AL PR .
S IK K IM
UT TA R P R A DE S H
ASSAM
B IH A R
NAG ALAND
MEG HALAYA
M A N IP U R
JH A RK H A N D
G UJ AR AT
124
Completed
H IM A C H A L P R A D E S H
HW Trainings started in 2007-08
Mohali
< 30%
Funds
utilized
30% - 50 %
2009-10
MAD H YA PR ADESH
W EST BENGAL
C H H A T T IS G A R H
96
D&N H AVELI
MA H A R A S H TR A
O R IS S A
T R IP U R A
M IZ O R A M
85%
AND H RA PR AD ESH
Training conducted in 40 districts across 7
Patiala
297
279
GOA
94
KARN AT AKA
states during 2009.
89%
A & N IS L A N D S
P O N D IC H E R R Y
T A M IL N A D U
LA K S H A D W E E P K E R A L A
20
DIO / M&E review mtg,18 Aug 2010
As on 1 June 10
Immunization trg :Scenario-2009-10
TRAININGS
Staff
Training Load
Trained
Percentage
2461
485
19.7
756
Nil
-
1800
Nil
-
650
Nil
-
Nil
Nil
-
Medical officers
824
773
93.8
Cold Chain Handler
137
108
78.8
14
14
100
Regular ANM
Contractual ANM
Health Assistant (M)
LHV
Other Staff
Cold Chain Technician
21
DIO / M&E review mtg,18 Aug 2010
Slide Source : Punjab state ppt SEPIO mtg 7-9 June 2010
Microplanning and child tracking
• Improve RI micro-planning by using existing polio micro-plans to:
• Strengthen linkages with pulse polio teams:
– Polio microplan to include RI session site
information (where, when and by whom)
– Teams to share information during H-t-H vaccination
• Pulse polio vaccinator training to include key
messages on routine immunization
• Use of pulse polio newborn information (if being collected) to follow
up on RI doses
• Name based child tracking
22
Improved monitoring to identify
programme gaps
• GoI RI monitoring system revised in 2009
• Started in in Bihar, Jharkhand and UP
• Shortly starting in Rajasthan, Maharashtra,
N Delhi, MP, Gujarat.
• Data outputs
– Session site:
• Availability of manpower and logistics
• Reasons for session not held
• Safe injection practices and waste disposal
– Household (community) monitoring
• RI coverage and gaps in community
• Reasons for left-outs and drop-outs
23
Introduction of Measles
2nd Dose into RI
Corneal scarring,
causing blindness
Pneumonia and
Diarrhea
Encephalitis
25
Measles Mortality Reduction
47 UNICEF / WHO Priority Countries
December, 2008
Nationwide second measles opportunity introduced (46)
No second opportunity introduced (1)
26
DIO / M&E review mtg,18 Aug 2010
Secretary health
letter
Punjab- 2nd
dose Measles
2nd dose Of Measles
Measles Mortality Reduction Strategies for India
• National Technical Advisory Group on
Immunization (NTAGI) has recommended
• States with MCV1 coverage <80%: Second opportunity through
measles catch-up campaigns in 9 mo-10 yrs age group
• States with MCV1 coverage >80% second dose (MCV2) through
routine immunization
• Applying the cut-off of 80% MCV1 evaluated coverage
(DLHS-3)
• 14 states which qualify for catch-up campaign
• 21 states which qualify for MCV2 through UIP
– 4 States/UTs viz. Delhi, Goa, Sikkim & Poducherry already introduced
2nd dose in RI
28
DIO / M&E review mtg,18 Aug 2010
0
29
DIO / M&E review mtg,18 Aug 2010
83.1
82.8
82.1
81.4
81.1
79.9
Delhi
West Bengal
Uttarakhand
Jammu & Kashmir
Orissa
Chhattisgarh
64.4
Assam
51.8
Tripura
Nagaland*
47.0
52.5
Meghalaya
Uttar Pradesh
54.2
Bihar
57.7
65.5
Arunachal Pradesh
Madhya Pradesh
67.5
Rajasthan
58.9
69.0
Haryana
States <90% Measles Coverage
Manipur
70.5
Jharkhand
72.6
83.9
Mizoram
Gujarat
84.4
87.3
Chandigarh
D&NH
87.9
Kerala
84.5
88.6
Andhra Pradesh
Maharashtra
89.1
Punjab
85.2
90.9
Daman & Diu
100
Karnataka
91.1
97.6
Pondicherry
10
91.9
20
Lakshadweep
30
92.5
40
Sikkim
50
92.8
60
A & N Islands
70
94.5
80
Himachal Pradesh
Tamil Nadu
99.1
90
Goa
2nd opportunity of Measles vaccine:
State specific Delivery strategies
2nd Dose of RI (>80%)
Catch-up Campaigns (<80%)
* DLHS3 data Not Available
Requirements for Measles Control
with 2nd dose Measles in RI
• Achieve 1st dose coverage (at 9-12 months) of >9095%
• Also achieve 2nd dose coverage (at 16-24 months) of
>90-95%
• Sustain high coverage
• Backed by good measles surveillance system
30
DIO / M&E review mtg,18 Aug 2010
0
30
20
Punjab
40
10
31
DIO / M&E review mtg,18 Aug 2010
58.5
Sikkim
Source: CES, 2006
West Bengal
Uttarakhand
Karnataka
Punjab
Orissa
Chhattisgarh
Kerala
32.8
35.8
39.7
42.0
48.5
50.7
52.7
55.3
60.2
Jammu & Kashmir
Dadra & Nagar Haveli
60.4
64.7
Lakshadweep
Daman & Diu
65.0
Chandigarh
61.0
66.3
Maharashtra
Andhra Pradesh
78.3
72.7
68.3
50
Delhi
60
70.1
70
Himachal Pradesh
Tamil Nadu
A & N Islands
82.6
80.7
80
Mizoram
Goa
90
87.1
100
Puducherry
DPT Booster coverage
in States proposed for RI
Factors Affecting Introduction of Measles 2nd
Dose
• The key factor is a well functioning
Routine Immunization Programme.
• Some of factors for low coverage
are:
– Inadequate access- Lack of outreach
services
– High Dropout- Weak tracking system
– Human resources- Poorly trained or
untrained staff
– Lack of supervision
– Poor monitoring and reporting systems
– Weak community demand
32
DIO / M&E review mtg,18 Aug 2010
Challenges
• Managing competing priorities
• Linking polio efforts with RI activities
– Specific RI messages by vaccinators during polio SIAs
– Use of newborn tracking data
• Reaching unreached in urban and peri-urban areas
• Strengthen inter-agency coordination
• Improving the reporting and utilization of RI data
• Improving social mobilization and demand generation for
immunization
DIO / M&E review mtg,18 Aug 2010
33
Way forward from here….
Microplans
• Update fixed day, fixed site microplans (Mamta Diwas)
• Wed/ Sat to be immunization day
• Update and operationalize RI micro-plans .
• Monitor fund utilization / program performance
• Scale-up revised RI session and house-to-house monitoring targeting high
risk areas
• Increase district involvement in RI monitoring & review mech.
• Before start of 2nd dose Measles - Improve DPT booster (16-24 mths)
• HW and data handlers trainings
• Data handlers proposed for Sept-Oct 2010.
• Distt Cold chain store incharge training proposed Sept 2010.
Issues in Pulse Polio Expenditure Report 2008-09
Districts
Remarks
Amritsar
Nov 08, Dec 08, Jan 09 and Mar 09 round – Expenditure
Reports not received
Ferozepur
Jul 08, Nov 08, Dec 08, Jan 09 and Mar 09 round –
Reports not received
Gurdaspur
Nov 08, Dec 08, Jan 09 and Mar 09 (Fax not in a
position to read & hard copy not received
Jalandhar
Jul 08, Dec 08, Jan 09 and Mar 09 round – Reports not
received
Sangrur
Jul 08, Oct 08, Nov 08, Dec 08, Jan 09 and Mar 09 round
– Reports not received
Amritsar, Barnala,
Ferozepur, Gurdaspur,
Hoshiarpur, Jalandhar,
Kapurthala, Ludhiana,
Mansa, Moga, Mohali,
Patiala, Ropar, SBS Nagar,
Sangrur & Tarn Taran
Expenditure report received but does not match
with Audit Report
GOI seeks clarification
List of EPI Reports to be forwarded from District
S. No.
Name of Report
Time Line
1
EPI Performance Report (HMIS)
Upto 10th Every month
2
Polio Expenditure Report
Immediately after completion of
Polio campaign
3
Immunization Expediture Report Annexure 6
Upto 10th Every month
4
Revised Tour Notes (On
Govt. of India Monitoring forms) –
PHC, session site and village visit forms (As
per Annexure 1, 2 & 3 PIP guidelines)
Upto 5th of every month
5
Evaluation Reports MPHW/ ANMs/ Urban
Slum (HMIS)
Upto 10th Every month
6
Cold Chain Sickness/ Status Report
(Existing Proforma)
Upto 10th Every month
7
Refrigerator Mechanic Observation report
(Proforma in folder)
Signed by Refregrator Mech & Forwarded by
DIO)
Upto 5th of every month
8
Refrigerator Mechanic Observation report
(Proforma in folder)
Signed by Refregrator Mech & Forwarded by
DIO)
Upto 5th of every month
9
PIP Fund Utilization Indicators form
Thank you for your time !!
37
DIO / M&E review mtg,18 Aug 2010
Additional slides