Initiatives to improve UIP including convergence with polio

activities

Dr. Pradeep Haldar24th Meeting of IEAG15-16 March, 2012

Presentation outline

Situation analysis and continued challenges

New initiatives and ongoing efforts to strengthen UIP in India

Way forward

Polio-free India and routine immunization

Strengthening UIP is essential to maintain high levels of population immunity and maintain polio free

status!!!

Proportion of Fully Immunized* Children (12-23 months)

National Full Immunization Coverage (FIC) = 61 %

< 61%>= 61%

Source: Coverage Evaluation Survey, 2009, UNICEF

*Full Immunization Coverage is: BCG + 3 doses tOPV + 3 doses DPT + MCV

Data not available

Below 5 %

5 % - 10 %

>10 % - 25%

>25 %

Where are we missing the maximum number of children?

69% of partially and un-immunized children in 6 states:Uttar Pradesh BiharMadhya Pradesh, Rajasthan West BengalJharkhand

Source: CES 2009; Full immunization of children surveyed 12-23 months

Immunization coverage varies significantly among different population categories

Source: Coverage Evaluation Survey 2009, UNICEF

ANM vacancies: Bihar and Uttar Pradesh

StateNumber of Sub-

centres Number of ANM

in PositionANM : Sub-Centre ratio

BiharState 9,422 15,899 2.5HR Blocks 673 1,193 1.8

Uttar PradeshState 20,621 20,658 >1.0HR Blocks 1,794 1,527 0.9

StateNumber of Sub-

centres Number of SC without ANM

% of Vacant SC

BiharState 9,422 1,267 13.4HR Blocks 673 145 19.0

Uttar PradeshState 20,621 1,776 8.6HR Blocks 1,794 400 22.3

SC=Sub-centre; ANM=Auxilary Nurse Mid-wife

• Inspite of having at least one ANM per one SC, irrational deployment of ANMs results in vacant SCs

• The problem of vacant SC is more acute in HR blocks

Data as of 12 February 2012

74.6

23.2

2.2

Jharkhandn=16,913

Vaccination status and reasons for incomplete immunization

67.3

29.2

3.5

Bihar n=107,407

10.927

4.6

21.5

35.9

%Awareness & Information Gap %Operational Gap

%AEFI Apprehension %Other Reasons

% Data not available

56.3

34.2

9.4

Uttar Pradeshn=244,724

5.530

6.9

17.5

40.1

72.4

24.1

3.4

West Bengaln=5,627

10.3

30.9

4.66.8

47.5

9.911.5

7.6

33.038.0

FICFIC

FICFIC

Source: RI monitoring dataJan – Dec 2011

50-75% of reasons provided for incomplete immunization are related to lack of awareness and information related to

vaccination and apprehension related to AEFI

Mobilization by ASHAs and AWWsSource: RI session monitoring data, Jan-Dec 2012

Incentivised ASHA provided for each session Between 37% - 56% of RI sessions are not mobilized by

ASHA Suboptimal convergence with ICDS Unacceptably high % of RI session that are not supported

by ASHA or AWW in UP and WB

States with RI session monitoring

High Risk Areas

Number of sessions

monitored

Presence of ASHA

Presence of AWW

Neither ASHA nor

AWW

Bihar 4,232 63 % 73 % 10 %

Jharkhand 1,918 61 % 52 % 6 %

Uttar Pradesh 19,623 47 % 34 % 39 %

West Bengal 755 44 % 34 % 41 %

Analysis of programme gaps

Planning and coordination:– Lack of quality RI micro-plans and PIPs in many districts,

states– Weak inter-sectoral coordination among Health, ICDS

and other ministerial departments Data reporting and use:

– Divergent coverage estimates – survey assessed and reported

– Tracking children and drop-outs IEC and communication for behavior change:

– Inadequate social mobilization and demand generation for immunization

Human resource management Vaccine management

Efforts to strengthen RI

2012-2013: Year of intensification of UIP

Intensification of UIP:Prioritization of the states

Category DPT3 coverage Names of the states

Poor performing states DPT3 coverage less than national average (NE states excluded)

MP, UP, Bihar, Rajasthan, Jharkhand, Orissa, Gujarat, and Chhattisgarh

Good and medium performing states

DPT3 coverage more than national average(NE states excluded)

Rest of the states

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

Intensification of UIP

Specific objectives:

Conduct Immunization Weeks in in NE states, UP, Bihar, MP, Rajasthan, Gujarat and Jharkhand

Strengthen RI in identified 239 districts (< 50% FIC, DLHS3) through detailed robust microplanning

Inclusion of EPRP identification and prioritization of high risk areas including urban zones

Convergence with EPRP and improving UIP microplans

Inclusion of migrant and high risk sites in UIP microplans as identified by EPRPs

Polio and RI microplan convergence:– Uttar Pradesh 22,758

villages/urban areas identified that were not part of UIP microplan

Periodic review:– Bihar distribution of outreach

sessions assessed; 8,000 brick-kilns and 5,000 nomadic sites identified and to be added

Migrant sites

HR sites in settled populations

Harmonization of Polio SIA & RI MicroplanDistrict: Bulandshahr, Uttar Pradesh

Every polio SIA team carries this plan and must inform

parents of when and where RI sessions are held

SIA component

RI component

Village visited by SIA team

Cold chain and vaccine management

Human Resources: – Recruitment of additional HR for vaccine and logistics

management

– Development of training material (modules, film) and facilitation of training of cold chain handlers & technicians

Infrastructure strengthening:– Procurement of additional cold rooms, solar and DF/ ILRs as

per recommendations of National Cold Chain Assessment

– Strengthening of SHTO Pune training center

– Establishment of national cold chain and vaccine management resource center in Delhi

Development of National Cold chain MIS: (www.nccvmtc.org)

Vaccine Wastage Assessment carried out in 5 states:– Indicates vaccine wastage range from 34% (DPT) to 63% (BCG)

at session site

Intensification of UIP: Strategies

Immunization Weeks: 4 rounds of Immunization Weeks

planned in low performing areas to rapidly improve coverage

5 Northeastern states have already begun:– Arunachal Pradesh (7 districts),

Manipur, Meghalaya, Nagaland and Tripura

– Assam, Sikkim and Mizoram yet to start.

Rest of the states are expected to start from April 2012.

Immunization WeeksSummary feedback – 3 states

Meghalaya: – 2 rounds conducted: (1) 23 - 30 Jan 2012; (2) 27 Feb -3

March 2012 – Coverage reports for first round are still awaited – Community mobilization and due-listing of beneficiaries

needs to be improved Manipur:

– First round conducted 30 Jan – 4 Feb 2012– Coverage reports still awaited

Nagaland:– First round held 23 – 31 Jan 2012– Community mobilization and due-listing of beneficiaries

needs to be improved

Intensification of UIP: Strategies

Teeka Express– Piloted in selected low coverage districts in

2012

– To provide a branded vaccine delivery van to cold chain point

– In underserved populations, tribal, hard to reach areas, LWE areas, urban and peri-urban areas

Communication strategy – To be rolled out in Q2, 2012

– Awareness about session site (visibility)

– Branding of immunization

– Advocacy with media and partners

HR strengthening– Technical support unit (TSU) be established

at national/ state level in accordance with HR assessment report

– Detailed guidelines under development

RI session and community monitoring

In 2011, more than 13,000 session sites and 100,000 children monitored per month in priority states of Bihar, UP and Jharkhand

2 new states added – Karnataka and West Bengal

Rajasthan and Punjab monitoring RI sessions however not entering and analyzing data

All other states should initiate RI session and community monitoring on a priority basis

Web-based mother and child tracking

Conclusion

Strengthening UIP and immunization coverage is a priority and requires engagement of all stake holder at the highest level

Many challenges remain related to programme access and utilization

The intensification of UIP (2012-2013) and activities related to EPRP for polio are synergistic and need appropriate coordination

Questions for IEAG

What are the key lessons from polio eradication efforts in India that can be used to assist with improving UIP?

What are the implications of the polio endgame requirements on UIP in India?

Thank You

Policy level initiatives

Developed National Vaccine Policy in 2011

New draft Multiyear Plan (cMYP) ready for endorsement

Decentralized and flexible funding as per state Project Implementation Plans (PIP) under NRHM– District/block specific plans for

hard to reach areas (inaccessible, tribal and urban) are reflected in PIPs

– Funds for Addl. Vaccinators, alternate vaccine delivery, ASHA

Human resource assessment at national and state level for UIP (IIM Ahmedabad 2010)

Introduction of new vaccines Hepatitis B vaccine

expanded to all States and UTs

Hib containing pentavalent vaccine– Introduced Kerala and TN in

December 2011– Proposed expansion to 6

additional states in 2012 Measles 2nd dose in RI

– Given with 1st DPT booster– 17 + 4 States have

introduced

Source: Based on target population available with GoI* Provisional data as of 1st week of March 2012; 7 districts have not yet started the campaign** Phase 3 will be conducted during Fiscal Year 2012-2013

PhaseNumber

of State

Number of

District

Target Population

(9 m - 10 yrs)

% Coverage

Phase 1 13 45 13,845,686 87.2

Phase 2 14 150 42,931,906 82.9*

Phase 3** 15 157 ~ 73,000,000

Introduction of second dose measles containing vaccine (MCV2)

MCV2 through UIP is being introduced 6 months following

catch-up campaigns

Implementation of effective vaccine preventable disease surveillance

Expansion of laboratory supported measles surveillance to 11 states is providing key epidemiologic data and evidence of impact of MCV2 introduction activities

WHO NPSP to support the establishment of best practices for VPD surveillance, outbreak and laboratory support in one sentinel site of 5 high burden priority states

Maternal and Neonatal Tetanus Elimination

Since 2003, a total of 15 states and UTs validated for MNT Elimination

4 more states (Orissa, Uttarakhand, Delhi and Mizoram) planned in 2012

Validated for MNTE

36 3851

41 43

2511

1425

3210

10

3 6

115

86

7

42433

26 2210

0%

20%

40%

60%

80%

100%

Bihar (31,365) J harkhand (3,917) Karnataka** (256) UP (83,800) WB* (1,415)

Awareness & Information gap AEFI apprehension Operational gap

Other reasons Data not available

Reasons for incomplete immunization:RI monitoring data, Jan – Dec 2011

Source: RI community monitoring; (number of children 12-23 months of age)

*WB data for May to December’11 only

**Karnataka data for April to December’11 only

50-75% of reasons provided for incomplete immunization are related to lack of awareness and information related to

vaccination and apprehension related to AEFI