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
1997-1998 OPV SNID 37,465 (<5 yrs) 7-Dec-97 18-Jan-98 100 100
1998-1999 OPV SNID 36,006 (<5 yrs) 7-Dec-98 18-Jan-99 100 100
1999-2000 OPV SNID 36,541 (<5 yrs) 7-Dec-99 18-Jan-00 100 100
2000-2001 OPV SNID 38,604 (<5 yrs) 7-Dec-00 18-Jan-01 100 100
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
South-East Asia Region
<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
South-East Asia Region
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