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EXPANDED PROGRAMME ON IMMUNIZATION IN NWFP
1.
INTRODUCTION
Thousands of children die each year due to infectious diseases globally, which is a
major health problem in Pakistan as well. Many more are blinded, and crippled for the
rest of their lives. Fortunately, administering respective vaccine by Expanded
Programme on Immunization can prevent these diseases.
Expanded Programme on Immunization (EPI) was started in 1976, as a pilot project
confined to Peshawar and Nowshera, soon after the successful eradication of small
pox. It was included in regular Annual Development Programme (ADP) in 1978 - 79.
Following two major groups of the population are on the target of the programme for
vaccination against the targeted vaccine preventable diseases.
Children of 0 -1 year of age
These are 3.6% of the total population.
Pregnant women
These are 4.1% of the total population.
Besides pregnant women, vaccination services are also offered to the women in the
Child Bearing Age (CBA), 15 – 45 years of age.
The programme provides vaccination services against the seven target childhood
vaccine preventable diseases of Poliomyelitis, Neo Natal Tetanus, Measles, Diphtheria,
Purtussis, Tuberculosis and Hepatitis B up to 2000 target diseases were six and in
2000 then Hepatitis B vaccine was included for the target age group and thus making
the vaccine preventable diseases seven in number. In future there are plans of the
inclusion of other vaccine like Hib and vaccine for Phenomena.
Strategies
Vaccination services are provided through the fixed EPI centres, established within the
health facilities and through outreach sessions, in the catchment area of the health
facilities.
Staff
Expanded Programme on Immunization, at the Provincial level is implemented through
Deputy Director EPI (Provincial Manager), assisted by 2 Assistant Directors. At the
district/agency level, Executive District Officer (Health) looks after the programme.
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Supervisors at various levels supervise implementation of activities. The grass root
work force of EPI is EPI technicians who vaccinate the target population in the field.
Logistics
In 1995 the EPI Programme was included in the recurrent budget with the
understanding that the Federal Government shall be responsible for the supply of
vaccine, syringes and other cold chain equipments while the Provincial Government
shall bear the operational cost.
Vaccines, being sensitive biological substances are sensitive to heat and are stored in
special equipment at the recommended temperature of +2 – +8 degree centigrade. As
a policy, Federal EPI Cell, National Institute of Health (NIH), Islamabad provides
vaccine, in conformity with the target population. The vaccine used in EPI is BCG,
Combo (Tetra valent Vaccine), Measles, Tetanus Toxid (TT) and Oral Polio Vaccine.
After its collection from NIH Islamabad, vaccine is stored in the cold room, situated at
provincial EPI headquarters. Besides the provincial cold room, there are 5 other cold
rooms installed at divisional level, one each at Malakand, Kohat, Bannu, D.I.Khan and
Mansehra, catering to the needs of the respective divisions. The vaccine is supplied
from provincial to the divisional cold rooms and further distributed down to the
districts/agencies stores. While working in the field, EPI technician keeps vaccine in
vaccine carriers, especially designed for the purpose to maintain temperature at the
recommended level, during outreach sessions.
EPI NWFP did a tremendous job over the years to vaccinate the target population.
Year 1990 was declared as the year of Universal Child Immunization (UCI). EPI NWFP
was committed to achieve at least 80 % vaccination coverage by the end of 1990.
According to the results of a national coverage survey conducted in January 1991, EPI
NWFP achieved 96 % immunization coverage and stood on top in Pakistan.
Besides routine vaccination, EPI also runs Supplemental Immunization Activities for
eradication of polio as part of global polio eradication efforts. Special campaigns for
elimination of Maternal and Neo Natal Tetanus have been organized and more are on
the plan. Campaign for reduction of measles is planned during the current year (2007).
At the moment, Global Alliance for Vaccine and Immunization (GAVI) provides
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additional assistance to the programme and that is in the process of utilization through
an approved PC-1. Major partners of EPI are UNICEF, WHO, JICA and GAVI.
2.
Objectives of the programme.
The overall objective of EPI is reduction in morbidity and mortality among children
causing due to 7 target diseases by offering vaccination services.
Specific
objectives/target of the programme are as under.
A.
Attaining and sustaining 90% + immunization coverage.
B.
Eradication of Poliomyelitis.
C.
Elimination of Neo-Natal Tetanus by 2010.
D.
95% reduction in the incidence of Measles and 90% reduction in Measles
deaths, by the year 2010 and ultimate elimination.
E.
Reduction to the minimum level in the incidence of Diphtheria,
Tuberculosis and Pertussis.
Current status
During the current calendar year 2007, 0.821 million children of the target age group,
0 –11 months of age will be provided with EPI Vaccine. Similarly target of the pregnant
women during the current year is 0.953 million. They will be provided with 2 doses of
TT vaccine to protect as well the infants from the deadly disease of Tetanus. The
following immunization schedule is implemented at the moment.
Children
Age
WOMEN
Doses
Time of injection
Doses
At birth
BCG and OPV – 0
At first contact
TT1
6 weeks
Combo-I
At least after one month
TT2
10 Weeks
Combo-II
At least 6 months after
TT3
TT2
14 Weeks
Combo-III
At least one year of TT3
TT4
9 Months
Measles
At least one year of TT4
TT5
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Challenges
•
Deployment of non local EPI technicians.
•
Clustering of EPI technicians in some fixed centers others are vacant.
•
Posts of EPI Supervisors are person specific and upon retirement of present
incumbents the posts automatically stands abolish. This practice leaves no
chance/hope for promotion EPI Technicians, causing de-motivation among them.
Hard and inaccessible areas.
•
Ownership of MO in charge of the health facility.
•
In-sufficient and old vehicles for EPI Coordinators, for supervision of EPI
activities
•
Piecemeal releases of GAVI budget from Islamabad.
•
Complex mechanism of transferring GAVI fund to the province.
Achievement

157 additional EPI vaccinators have been recruited under GAVI PC-1.

Mobility support in the shape of 2 Pick Ups, single cabin, 150 motorcycles to
earthquake affected districts and 290 motorcycles have been provided to
other districts.

420 bicycles supplied by UNICEF have been distributed among EPI workers.

Involvement of LHWs in routine EPI has been initiated in seven phase one
districts of the province. First phase of training in 7 districts have been
completed and 2nd phase is in progress.

Logistics support of furniture, timely provision of vaccines and disposable
syringes according to their targets, Cold chain equipment, Desktop
computers and budgetary support for mobility of the supervisory staff has
been provided.

Maintenance/repair of divisional cold rooms and other cold chain equipment
carried out.

Off road vehicles put on road.

Refresher for EPI technicians in phase one districts and in the earthquake
affected district carried out with the assistance from UNICEF.

As part of communication and advocacy, advertisements are being given in
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the press.

In order to take community fully on board, district Specific communication
plans in phase one district have been developed.

Quarterly review meetings of the districts are regularly being convened.

72% of the children have been provided with three doses of DPT vaccine.

Due to continued efforts of health department supported by all other
Governmental and Non-Governmental organizations and with the
cooperation from the community, the poliovirus circulation is confined to few
areas of the province for the last couple of years. The High Risk Districts in
NWFP have been identified and now are under sever focus.
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ERADICATION OF POLIO FROM NWFP
Background
Polio is an acute viral infection, the outcome of which ranges from a mild infection to a
paralytic disease, that can even result in death. The most commonly affected are
children below 5 years of age. Keeping in view the disease burden of poliomyelitis
across the globe, World Health Assembly passed a resolution in 1988 for eradication of
polio by the year 2000. Due to some genuine reasons the goal has not yet been
achieved. World Health Organization (WHO) in view of the infective patterns of the
disease recommended additional campaign of polio to bring the circulation of poliovirus
to a halt. In order to save the Pakistani children from this fatal and disabling disease,
Pakistan joined the race for polio eradication and started National Immunization Days
(NIDs) against Polio in 1994. Pakistan is still one of the polio endemic countries.
In line with the federal government, NWFP started the campaign against polio in 1994
in the shape of National Immunization Days. The number of polio cases has been
reduced from 419 in 1993 to 16 in 2006 and 11 cases in 2007. In the current year 2008
so far 35 polio cases have been reported. 15 from Peshawar, 2 from Nowshera, 1 from
Kohat, 3 from Swat, 3 from Bajour, 1 from Mardan, 2 from Dir Upper, 1 from
Charsadda, 4 from Khyber, 1 from Batagram and 2 from Mohammand. Circulation of
poliovirus has been localized to a few districts which are now under special attention.
The campaign against polio is still going on with full swing in the entire province with the
target to reach each and every child under the age of 5 years.
Current Status of N.W.F.P.:
Year
1993
2001
2002
2003
2004
2005
2006
2007
2008
Number of reported polio cases
Pakistan
NWFP
1803
419
119
31
88
33
103
33
43
8
28
5
40
16
32
11
93
35
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Actions taken by the Provincial Government/Department of Health
In order to completely cut the transmission of poliovirus in the province, the present
Government and the Department of Health adopted a multi-pronged strategy to involve
all the stakeholders and the following measures have been taken.

Governor NWFP hosted an awareness seminar for tribal elders, political agents,
Senators and MNAs from FATA.

Governor NWFP wrote letters form time to time for involvement of DCOs, district
nazims, political agents and tribal maliks.

Chief Minister has directed all DCOs, District Nazims and Political Agents to
remain fully involved and contribute towards success of the campaign.

Chief Minister also announced one holiday for school, during December 2003
round.

Federal Minister for Health chaired meeting of District Nazims/DCOs, EDOs(H)
and Agency Surgeons of all the high-risk districts.

Prominent public representatives like Qazi Hussain Ahmad and Maulana Fazal
ur Rahman inaugurated rounds of Polio campaigns.

Other dignitaries like Canadian High Commissioner and ambassador of Japan
was invited to inaugurate various rounds of polio campaign.

A seminar for prominent religious scholars and district Khateebs from all the
districts was held at Peshawar presided over by Minister for Health NWFP.

A meeting of all the DCOs and Nazims regarding polio campaign was convened.
The mister for health chaired the meeting.

In order to take the education department fully on board, a seminar for EDOs
education and principals of girls colleges was organized at Peshawar. Minister
for health presided over the event.

The minister for health personally monitored the activities of campaign taking
place in the field.

Chief Secretary wrote a letter to all DCOs in June to fully participate in the
campaign.

Chief Secretary convened meeting of all Nazims and DCOs of the high risks
districts, to take them further on board. Minister for Health chaired the meeting.
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
Secretary health requested:
o All the administrative secretaries to mobilize their district resources for
involvement in the campaign at the grass root level.
o The Political Agents in FATA to coordinate and cooperate with the health
authorities within their respective agencies and also involve tribal maliks
in the campaign.

Moreover, secretary health directed to:
o Convene meetings of all EDOs to properly review each campaign.
o Initiate actions against the workers who are reported unwilling during the
evening meetings of the campaign days.
o Ensure participation of female team members to explore all other sectors
besides health, e.g education, social welfare department and community
based organizations.

Secretary health personally supervised and monitored the activities in the filed
during campaign and chaired evening meetings.

The Director General is very closely involved in the pre and post campaign
activities. Meetings of the steering committee for polio eradication are regularly
held under his chairmanship and recommendations implemented.

All the Executive District Officers Health have been directed to ensure female
participation in the vaccination teams to make certain vaccination of all the target
children.

EDOs have been further directed to ensure inter-sectoral cooperation at their
districts and fully involve union council nazims and religious leaders in the
campaign.

A provincial Polio Control Room has been set up at the Directorate General
Health Services since January 2004, to collect quick information regarding the
campaign and sort out remedial measures wherever required.

Very prompt actions were taken in case of the troubled districts like North
Waziristan and Lakki Marwat. High-level meetings were held to discuss and
immediately resolve issues in these areas.

Cross border vaccination posts has been established with the support of
UNICEF at prominent cross border point with Afghanistan
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Future Plans

Capacity building of LHWs on routine EPI.

Training and involvement of paramedical staff in routine EPI.

Refresher trainings for EPI workers.

Communication and advocacy.

Involvement of private sector.

Mobility support to the districts.

Mobile vaccination for hard to reach areas from the GAVI reward money.

Ensuring judicious utilization and placement of EPI technicians.

Feed back mechanism of EPI activities to be established.

Involvement of all line department.

Inaugurations and media briefings prior to the rounds of campaign.

Addressing refusals through districts specific social mobilization plans.

Establishment of cross border vaccination points.
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EPI and GAVI PC-1
Global Alliance for Vaccines and Immunizations (GAVI)
Introduction
GAVI is a coalition of public and a private interest that was formed in 1999 to ensure
that every child is protected against vaccine-preventable diseases. The GAVI partners
include national Governments, the Bill and Melinda Gates Children’s Vaccine
Programme, International federation of Pharmaceutical Manufactures Association,
research and technical health institutions, Rockefeller foundation, UNICEF, the World
Bank, and WHO.
A major priority of GAVI is to see that all countries of the world achieve at least 80%
immunization coverage by 2005.
As part of the policies to achieve the 80%
immunization objectives, the GAVI partners has announced a multi million dollar fund
for children’s vaccine- ‘The Global Fund for Children’s Vaccine’ (GFCV)
Objectives
The strategic objective of GAVI is to ensure that every child is protected against vaccine
preventable diseases. This includes actions to:

Improve access to sustainable immunization services.

Expand the use of all existing cost effective vaccines.

Accelerate the development and introduction of new vaccines.

Accelerate research and development efforts on vaccines and related products
specifically needed by developing countries.

Make immunization coverage an integral part of the design and assessment of
health systems and international development efforts.
Provincial situation
EPI NWFP developed a PC – 1 for a period of 5 years, to secure the GAVI support for
expansion of immunization services and strengthening of the existing programme. The
PC – 1 has been approved by ECNEC.
The basic objective of the PC – 1 is to:
a.
Strengthening of existing programme.
b.
Strengthening of monitoring and supervision.
c.
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Strengthening cold chain, through availability of new and replacement of
ageing equipment.
d.
Expansion of EPI services to those health facilities EPI services is not
available at the moment.
The Project was recommended by PDWP on 22-8-2002 and subsequently
by CDWP on 23-12-2002. Finally ECNEC approved the project on 11-8-2003 and
Administrative Approval was accorded on 4 - 9- 2003.
Summary of the project is as under
Name of the Scheme
10046-Expanded Programme on Immunization in NWFP
Total cost of the project
Rs. 337.602 million (for 5 years)
GAVI share (Foreign aid) Rs. 284.81 (85% of the total cost)
Government share
Rs. 52.791 million (15% )
Implementation of the project has been started during 2003–04.
Although
implementation was started late due to some procedural constraints but still about 53%
of the allocated budget for the mentioned year was utilized. Following is the year wise
information of the project so far.
Financial progress
Summary of the released amount and expenditure is under.
Year
Total released
Expenditure
Saving/surrender
%
(Rs. Million)
(Rs. Million)
(Rs. Million)
Expenditure
2003-04
5.517
2.919
2.600
53%
2004-05
6.762
4.724
2.038
69.86%
2005-06
15.867
12.638
3.229
80%
2006-07
28.155
23.858
4.297
85%
2007-08
28.158
11.031
In progress
In progress
Total
84.459
55.170
In progress
In progress
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Physical Progress

Funds have been placed at the disposal of Executive District Officers (Health)
for expenditure at their door step.

Appointment has been made.

Furniture purchased.

Training conducted.

Repair of cold chain and vehicles have been carried out.

Print media activated.

Rewards finalized and some amount utilized for mobile vaccination in 5 Union
Council of coverage below 50% in each district of NWFP and as cash incentive
Rs. 5000/- for 10 best performance EPI workers.
Constraints

Delayed supplies of hardware (vehicles and cold chain equipment etc.).

Complex mechanism of fund transfer. Federal ministry of health issue advice to
release fund to state bank Karachi. The funds meant for province is transferred
to the State Bank of Pakistan, Peshawar Branch. The same is transferred to the
Government treasury and upon confirmation of the receipt finance department
release the fund to health department. The Programme Manager gets approval
for expenditure of the release fund. The case goes trough the Director General
Health and Secretary Health Department to Finance Department after final
approval, the programme is able to start expenditure.