Multi Year Strategic Plan 2005–2010 Universal Immunization ... · 10/04/2003 · ANM Auxiliary...

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Multi Year Strategic Plan 2005–2010

Universal ImmunizationProgramme

Department of Family WelfareMinistry of Health and Family Welfare

Government of IndiaJanuary 2005

Contents

FOREWORD vACRONYMS AND ABBREVIATIONS vii

EXECUTIVE SUMMARY 1

1 INTRODUCTION 51.1 Purpose of this document 51.2 Process 5

2 SITUATIONAL ANALYSIS 52.1 Historical perspective of immunization in India 52.2 Curent vaccine-preventable disease burden 62.3 Current UIP schedule 82.4 Current coverage rates and trends 82.5 Management structure and service delivery 112.6 Current financing and audit mechanisms 122.7 UIP constraints 132.8 Achievements and obstacles 15

3 UIP MEDIUM-TERM PLAN 163.1 Global goal 163.2 India-specific goals 163.3 India’s UIP mission 163.4 Guiding principles 163.5 Target groups 16

4 MEDIUM-TERM GOALS, OBJECTIVES, INDICATORS,MILESTONES AND STRATEGIES 17

5 NATIONAL-LEVEL IMMUNIZATION PLANBUDGET REQUIREMENTS 38

6 MANAGING THE NATIONAL IMMUNIZATION PLAN 396.1 National Government 396.2 State Government (and local self-government) 396.3 Panchayati Raj institutions 396.4 Municipal corporations in urban areas 396.5 Monitoring 396.6 Evaluation 39

7 SUMMARY OF UIP GOALS 40

ANNEX 1: Constitution of the National Technical Advisory Groupon Immunization (NTAGI) 45

ANNEX 2: WHO/UNICEF Review of National Immunization Coverage 47ANNEX 3: Location of infants not fully immunized and dropping out by State 55ANNEX 4: Roles and responsibilities 57ANNEX 5: Proposed National Immunization Cell 60ANNEX 6: Basic assumptions used for costing Multi Year Plan (MYP) 62

Acronyms and Abbreviations

AC Assistant CommissionerAD Auto-disable (syringe)AEFI Adverse Events Following ImmunizationAFP Acute Flaccid ParalysisAG Auditor GeneralANM Auxiliary Nurse–MidwifeAWW Anganwadi WorkerBCG Bacille Calmette-Guerin; vaccine against tuberculosisBDCS Border District Cluster Strategy C&AG Comptroller and Auditor GeneralCBHI Central Bureau of Health Intelligence, MoH&FWCBR Crude Birth RateCMO Chief Medical OfficerCRS Congenital Rubella SyndromeDC Deputy CommissionerDCGI Drug Controller General of IndiaDFID Department for International DevelopmentDHMO District Health Medical OfficerDIO District Immunization OfficerDoFW Department of Family WelfareDPT Diphtheria–Tetanus–Pertussis combination vaccineDPTHepB Diphtheria–Tetanus–Pertussis–Hepatitis B combination vaccineDT Diphtheria–Tetanus combination vaccineEAG Empowered Action Group of StatesEPI Expanded Programme on ImmunizationFDA Food and Drug AuthorityGAVI Global Alliance for Vaccines and ImmunizationGoI Government of IndiaGPS Global Positioning SatelliteHep B Hepatitis BHBV Hepatitis B virusHib Haemophilus influenzae type BHSCC Hospital Services Central Consultancy IAP Indian Academy of PediatricsICC Inter-agency Coordinating CommitteeICDS Integrated Child Development SchemeICMR Indian Council of Medical ResearchIEAG India Expert Advisory Group on immunizationIEC Information Education and CommunicationIFA Information for ActionIMA Indian Medical AssociationIMR Infant Mortality RateINCLEN International Clinical Epidemiological NetworkIPC Interpersonal CommunicationIPV Inactivated Polio VaccineISP Immunization Strengthening Project (World Bank supported project 2000–2003)JE Japanese encephalitisMC Municipal CorporationMDVP Multi-dose vaccine vial policyMICS Multiple Indicator Cluster SurveyMLM Middle-level ManagerMMR Measles, Mumps and Rubella vaccineMOF Ministry of Finance

MoH&FW Ministry of Health and Family WelfareMR Measles and Rubella vaccineMSL MeaslesMSS Mahila Swasthya Sangathan (community women’s organizations)MYP Multi Year PlanNCL National Council of LaboratoriesNIC National Immunization CellNID National Immunization Day for PolioNGO Non-governmental OrganizationNNT Neonatal TetanusNPSP National Polio Surveillance Project (Government of India and

World Health Organization)NRA National Regulatory AuthorityNTAGI National Technical Advisory Group on ImmunizationOPV Oral Polio VaccineORS Oral Rehydration SolutionPAB Protected at BirthPPC Puncture-proof Plastic ContainerPRI Panchayati Raj InstitutionsRCH Reproductive and Child HealthRIMS Routine Immunization Monitoring SystemSIA Supplementary Immunization ActivitySMO Surveillance Medical Officer (Polio)SNID Sub-national Immunization Days (Polio)SoE Statement of ExpendituresSOP Standard Operating ProceduresTT Tetanus Toxoid vaccineUIP Universal Immunization ProgrammeUNICEF United Nations Children’s FundVPD Vaccine-preventable diseaseVVM Vaccine Vial MonitorWHO SEARO South-East Asia Regional Office of the World Health OrganizationWIC Walk-in CoolerWIF Walk-in Freezer

Executive Summary

1. Introduction

India’s Universal Immunization Programme (UIP) isone of the largest in the world in terms of quantities ofvaccine used, number of beneficiaries, number ofimmunization sessions organized and the geographicalspread and diversity of areas covered.

Based on recommendations mainly from theNational Technical Advisory Group on Immunization(NTAGI) and inputs from various partner agencies, the

immunization team in the Department of FamilyWelfare, Ministry of Health and Family Welfare hasprepared this five-year immunization plan 2005–2010.This plan not only provides the framework on whichactivities should be planned to achieve the objectives ofIndia’s immunization policy, but also gives guidancefor the introduction of new vaccines.

The success of the UIP is crucial for the expansionof other public health interventions including promo-tion of maternal and child health.

2. Situational analysisUIP impact: India’s infant mortality rate (IMR) andburden of vaccine-preventable diseases have decreasedmarkedly since the early 1970s. Following polio eradi-cation efforts in the past 8 years, there has been an out-standing decrease in polio cases and reduction in geo-graphical areas where polio is endemic. UIP output: The reported national (administrative)vaccination coverage rates for all antigens haveremained significantly high since the mid-1990s.However, evaluated coverage1 shows generally lowercoverage rates. The coverage rates show a geographicaltrend; generally, the northern States perform poorerthan the southern States. Even within better-performingStates there are significant pockets of poorly perform-ing districts or urban settings. Over time, the RCHRapid Household Surveys performed in 1998–99 andagain in 2002–03 show a worrying decrease in the per-centage of districts achieving >80% DTP3 coverage. In2001–02,17.9 million infants were not immunized inIndia. Of these infants, 40% live either in Uttar Pradeshor Bihar. Stagnating routine immunization rates, highdrop-out rates and a declining trend in some of the dis-tricts in key States (UP, Bihar, Rajasthan, Jharkhand,

West Bengal, AP and Assam) are issues of major con-cern. There are considerable geographical and socialinequities.Administration and financing: Besides theGovernment health services, the private sector pro-vides an estimated 10-15% of immunization services.All operational aspects of the UIP are funded by theGovernment of India (GoI). Funds are released to theStates for disbursal to districts for logistics, cold chainmaintenance, injection safety and payment of immu-nization-related staff. Procurement of vaccines for rou-tine immunization is done centrally using the domesticbudget.Programme constraints: Use of accurate data (deliv-ered in a complete and timely manner) for prioritizationor planning is problematic at all levels. Monitoring andweak supervisory practices remain problematic. Aqualitative study commissioned by UNICEF in 2002highlighted common barriers to low demand for immu-nization services. Lack of public knowledge is a keybarrier to immunization. The number of polio roundsevery year is affecting the amount of time andresources available for other health-related activities,including routine immunization.

3. UIP medium-term planAlthough the UIP is nationwide, special attention willbe focused on strengthening routine immunization inthe northern States (specifically UP, Bihar, Jharkhand,Rajasthan, West Bengal and Assam).UIP mission: ‘To provide high quality immunizationservices to all communities in order to prevent mortal-ity, morbidity and disability from diseases that are pre-ventable through the optimum use of vaccines current-ly available and vaccines that become available from

time to time.’Guiding principles: These five principles includemaximal reach (sustaining demand and ensuring thatall children and pregnant mothers are immunized as perthe national schedule); equity (addressing the needs ofthe underserved); quality and safety (recommendedprocedures for vaccine procurement, storage, distribu-tion and service delivery); sustainability (financial andhuman resource investments) and management excel-lence (optimizing the use of resources).

1 UNICEF and Rapid Household Survey in the RCH project by International Institute for Population Sciences, Mumbai

GoI Immunization Multi Year Plan 2005–2010 1

1. Districts will provideequitable, efficient and safeimmunization services toall infants and pregnantwomen

2. Contribute to globalpolio eradication, measlesmortality reduction andneonatal tetanus elimina-tion

% of districts that achieve>80% DPT3 coverage andBCG–measles drop-out rateof <15%

% of ANMs receivingrefresher training in past 3years

% of districts with 90% iden-tified cold chain equipmentfunctioning

% of districts with no stock-outs of measles vaccine

% of districts supplied withand using AD syringes, nee-dle cutters

Number of wild polio cases

% of districts with over 90%TT2+ coverage for pregnantwomen

% of districts with measlescoverage of at least 90% peryear

% of districts that achieve70% coverage with 2 doses ofvitamin A supplements eachyear for children 9-36 months

Strengthened coordination,national operational guide-lines, strengthening supervisionpractices, prioritizing poorlyperforming districts andunderserved populations,strengthened microplanning,reducing drop-outs and missedopportunities, fixed-day fixed-site, integration with private sector

Strengthen coordination,review and adjust staffing lev-els, strengthen institutionaltraining at national and Statelevels as well as refreshertraining opportunities, decreasefrequency of staff rotation

Strengthen coordination, regu-larly assess and monitor coldchain status, appropriate pro-curement and inventory keep-ing and appropriate repair andmaintenance systems

Strengthen coordination activ-ities to reduce vaccinewastage, implement open vial-vaccine and bundling policies,strengthening of NRA

Introduction of AD syringes,needle cutters for all immuniza-tion sessions

Strengthen routine immuniza-tion delivery systems (goal 1,objective 1.1), quality SIAs,quality AFP surveillance

Strengthen routine immuniza-tion delivery systems (goal 1,objective 1.1),quality surveil-lance and data analysis, safedelivery practices, targeted SIAs

Situational analysis, measlesmortality reduction plan,strengthen routine immuniza-tion delivery systems (goal 1,objective 1.1), strengthen sur-veillance, improve case man-agement and consider apply-ing global strategies

Strengthen routine immuniza-tion delivery systems (goal 1,objective 1.1), adequate train-ing of ANMs and MLMs, IECand ensure that correct therapeuticdoses are given in measles cases

1.1 To ensure that regularquality immunization sessionsare planned and held

1.2 To ensure that adequatetrained staff are empowered toprovide essential qualityimmunization services

1.3 To keep an annuallyupgraded inventory of coldchain according to the levelsof the network, allowing fornew equipment, substitution,replacement, spare parts, fueletc. in order to maintain afunctional status of 90%

1.4 To ensure an efficient vac-cine and injection equipmentmanagement and logistics system to forecast and deliveradequate supplies of vaccinesin a timely manner

1.5 To ensure the implemen-tation of safe injection prac-tices and waste disposal

2.1 To achieve polio eradica-tion certification by 2007

2.2 To eliminate neonataltetanus by 2009

2.3 To reduce measles mortal-ity by two-thirds by 2010,compared to 2000 estimates

2.4 To achieve and maintain alevel of 70% coverage withtwo doses of vitamin A sup-plementation to childrenunder three

GOAL OBJECTIVE KEY INDICATOR STRATEGIES

2 GoI Immunization Multi Year Plan 2005–2010

3. The UIP will have suffi-cient and sustainable fund-ing with established ade-quate, accountable and effi-cient fund flows

4. There is sustaineddemand and reduced socialbarriers to access immu-nization services

5. Accelerated introductionof licensed new and under-utilized vaccines againstdiseases with significantmortality and morbidity inIndia

6. To monitor and use accu-rate, complete and timelydata on vaccine-preventa-ble diseases, AEFIs, anti-gen coverage and drop-outrates by district

GOAL OBJECTIVE KEY INDICATOR STRATEGIES


3.1 To ensure adequate finan-cial resources for the UIP atnational and State levels forthe UIP to achieve its goalsand objectives

3.2 To ensure political com-mitment for adequate annualfunding at all levels

4.1 To ensure widespread sup-port by all families and com-munities so that all eligiblechildren and pregnant womenare immunized

4.2 To ensure high level politi-cal and administrative supportfor immunization as the keypublic good

5.1 To ensure that institutionalmechanisms are in place toadequately obtain, review andutilize information for decid-ing on the introduction of newand underutilized vaccines

5.2 To review the need forMMR or MR vaccine in India’simmunization programme

5.3 To review the need forintroduction of the Japaneseencephalitis (JE) vaccine inselected States

5.4 To implement a phasedintroduction of hepatitis B vac-cine

6.1 To institutionalize surveil-lance for vaccine-preventablediseases and early detection ofany outbreaks

6.2 To strengthen vaccinequality and injection safety bydeveloping a monitoring system for reporting andresponding to AEFI by 2009

6.3 To establish an effective,efficient, complete and timelyimmunization recording andlocal area monitoring systemby 2009

% of districts able to showtracked budget versusexpended resources

% of infants bringing vaccina-tion card to the immunizationsession

Availability of clear policyguidelines for new vaccineintroduction

Progress of MMR studies

Availability of disease burdendata

Number of districts and citiescovered with Hep B vaccina-tion

% of monthly VPD surveil-lance reports received fromdistricts, which are completeand timely

% of districts reporting AEFIstatus on a monthly basis toState level

% of complete and timelymonitoring reports receivedfrom districts

National financial sustainabili-ty plan, capacity building forimmunization health econom-ics, various research options

Political lobbying and partner-ship building

Reach the underserved toincrease demand by influenc-ing behaviour at householdlevel with the print and othermass media strategies and acti-vating wider community anddistrict networks

Advocacy efforts, cost-effec-tiveness studies

Strengthen coordination

Research, advocacy and plan-ning

Geographical delineation,introduction of quality JE vac-cine, strengthened surveillance

Phased expansion, strength-ened surveillance and training,consider tetravalent vaccinewhen affordable

Phased introduction of RIMS,increased accuracy and use ofdata at local levels, private sec-tor and community involve-ment, strengthened laboratorycapacity at all levels

Provide training in AEFI SOPsand standardize reportingmethods along with establish-ing response mechanisms

Increased use of monitoringtools at local level, supportivesupervisory practices, prioriti-zation of blocks and districtsand phased introduction ofRIMS


Pulse PolioEradication$583,198,335

Hepatitis B inexisting 33 districts and 15 cities$17,123,637

Surveillance$327,126

Monitoring$14,594,402

Injection safety $93,448,108

Vaccine procurementand distribution$176,907,473

Cold chain$30,065,273

Human resourcesand training $1,222,933,064

Service delivery$370,813,530

Contingency, operational research,new vaccine initiatives $43,253,021

5. National-level immunization budget requirementsAn estimated average of Rs 20–25,000,000,000 will be required each year.

Contingency, opera-tional research, newvaccine initiatives

Monitoring

Surveillance

Pulse PolioEradication

Hepatitis B in existing33 districts and 15 cities

Injection safety

Vaccine procurementand distribution

Cold chain

Human resources andtraining

Service delivery

April2005-March2006

April2006-March2007

April2007-March2008

April2008-March2009

April2009-March2010

Management of the Programme will be through thenational-level immunization cell, which will beexpanded to include specific officers for procurement,surveillance/monitoring and evaluation, strategic com-munication, operational aspects, financial and adminis-tration, introduction of new vaccines and immunizationsafety issues. The National Government will assist informulating policy, establish national priorities, forecastnational needs and lead in the inter-agency coordination.

States will follow project implementation plans, as partof the RCH II Programme. This national MYP will befor States to use, to be adapted accordingly as a corecomponent of its immunization plans for the next fiveyears. Increasing involvement of the PRIs and munici-pal corporations (in urban areas) will assist in strength-ening the management of the UIP at local levels. Amid-term evaluation is planned in 2007.

Total 2005-2010 budget breakdown

US$

600,000,000

500,000,000

400,000,000

300,000,000

200,000,000

100,000,000

6. Managing the national immunization plan

The six goals, their respective objectives, key indica-tors and strategies are summarized below and detailedin the main body of the plan. Many of these initiativesaddress recommendations that were made during theUIP review in August/September 2004. Key initiativesinclude:Strengthening coordination and capacity: Plansinclude expansion of Central-level technical capacity toform a national immunization cell that will coordinatewith other departments, ministries and partner agen-cies. Coordination at State level will be strengthenedthrough the creation of functioning immunization taskforces.Mobility support for field workers: This includesmethods of increasing the capacity of not only basichealth workers to perform outreach sessions and ensurethat vaccines are transported, but also for increasing themobility of monitors to undertake supportive supervi-sory practices. Alternative vaccine delivery mecha-nisms will also be explored at different levels.Routine immunization monitoring system (RIMS):This system will be introduced in a phased manner andensure that immunization data are transmitted from thedistrict level in a timely and complete manner. The sys-

tem will help increase the capacity to analyse and usedata at district, State and national levels. Training initiatives: The need for in-service refreshertraining has been highlighted and this need is beingaddressed through the Multi Year Plan (MYP). Traininginstitutes will also be identified and their capacitiesreviewed and strengthened.Strengthened microplanning: Districts and Stateswill be technically assisted to produce specific cover-age improvement plans that include plans to addressvaccine and cold chain logistics issues at local levels.Injection safety: Auto-disable syringes (AD) will beintroduced throughout the country from 2005 with safe-ty boxes and needle cutters. Standard guidelines in theiruse will also be supplied, highlighting appropriate dis-posal.Increasing the use of community mechanisms:Increasing the involvement of the Anganwadi Worker(AWW) and use of the Integrated Child DevelopmentScheme (ICDS) will help motivate communities andincrease the demand for immunization. This will alsoincrease the convergence of the immunization pro-gramme into wider health initiatives for women andchildren.

4. Medium-term goals, objectives, indicators and strategies

1. Introduction

India’s Universal Immunization Programme (UIP)is one of the largest in the world in terms of quan-

tities of vaccine used, number of beneficiaries, thenumber of immunization sessions organized, the geo-graphical spread and diversity of areas covered.

Immunization is one of the most cost-effectiveinterventions for disease prevention. Traditionally,the major thrust of immunization services has beenreduction of infant and child mortality. However, vac-cines like Hepatitis B (Hep B), are administered ininfancy and can give lifelong protection against livercancer and other complications of hepatitis B infec-tion in adults. Immunization delivery is also a vehiclefor health promotion and other health servicesaddressing morbidity of public health significance inall age groups. Immunization is thus not simply anitem of national expenditure but truly one of nationalinvestment.

1.1 Purpose of this document

This Multi Year Pan (MYP) is essential for threemain reasons:A. Provide a framework on which to plan activities toachieve the five specific objectives of India’s immu-nization policy:

1. Increasing the accessibility/availability/cover-age of immunization services.

2. Ensuring the quality and reliability of immunization services

3. Increasing the demand for immunization services.4. Monitoring disease incidence and programme

performance.5. Mobilizing resources to sustain and improve

immunization services.B. Avail opportunities to introduce emerging newervaccines. C. The success of the UIP must be used as an oppor-tunity to expand, where feasible, other public healthinterventions such as promotion of Maternal & Childhealth care, breastfeeding, oral rehydration solution(ORS), vitamin A prophylaxis, etc.

The document sets out the medium-term (April2005–March 2010) goals, related objectives, indica-tors, strategies and associated costs. This is a distinctstrategic plan on which to base activities, through aplanned timeline (fiscal years 2005–2010).

1.2 Process

In August 2001, the Department of Family Welfare(DoFW) constituted a National Technical Advisory

Group on Immunization (NTAGI) to prepare a strate-gic framework for immunization. Annex 1 containsthe constitution, terms of reference and roles of theNTAGI. The NTAGI created five sub-committees:

(i) Introduction of new vaccines(ii) Operational issues including injection safety (iii) Monitoring and surveillance(iv) Monitoring quality and national regulatory

authority(v) Research needs and further studiesRecommendations made by each sub-committee

were shared with State health officials, vaccine manu-facturers and non-governmental organizations(NGOs) on 23 December 2002. The recommenda-tions were amended appropriately and presented tothe MoH&FW on 10 April 2003.

These recommendations form the backbone of thisstrategic plan. The strategic plan has been madethrough a close collaborative and iterative processinvolving State authorities, technical agencies, pro-fessional organizations, development partners andimplementing agencies, which provide the goals,objectives, indicators, strategies and costs.

2. Situational analysis2.1 Historical perspective of immunization in India

Vaccination has been practised in India since theearly 1900s, especially against smallpox, and later

against typhoid fever. In 1962, BCG inoculation wasincluded in the National Tuberculosis ControlProgramme. The smallpox eradication programme ofthe 1970s was so successful that disease control throughimmunization became an accepted practice of preven-tive medicine and public health. The National policy ofimmunizing all children during the first year of life withDPT, OPV, BCG and typhoid–paratyphoid fever vac-cine to complete the primary series of vaccinationsbefore reaching the age of one year was adopted in1978, with the launching of the Expanded Programmeon Immunization (EPI). The target was 80% coverage ininfancy. Subsequently, the typhoid–paratyphoid vaccinewas dropped. Tetanus toxoid (TT) immunization ofpregnant mothers was introduced in 1983.

The Programme was launched in 1985 in a phasedmanner to cover the entire country by 1990 under theUIP. Measles vaccine was added in 1985 and vitaminA supplementation was added to the Programme in1990. The objectives of the Programme were to:

(i) Rapidly increase immunization coverage(ii) Improve the quality of services(iii) Establish a reliable cold chain system to

the health facility level

GoI Immun<None>ization Multi Year Plan 2005–2010 5

(iv) Introduce a district-wise system for monitor-ing of performance

(v) Achieve self-sufficiency in vaccine productionThe UIP was given the status of a National

Technology Mission in 1986. A specificImmunization Strengthening Project (ISP) wasdesigned to run from 2000–2003, which includedthree main components (polio eradication, strength-ening routine immunization2 and strategic frameworkdevelopment). The objectives of this three-year planhave mostly been achieved.

2.2 Current vaccine-preventable disease burden The impact of the UIP is measured in terms of the vaccine-preventable disease (VPD) burden. Between 1971 and 2002the infant mortality rate (IMR) in India has fallen steadilyfrom 129 to 63 deaths per 1000 live-births (figure 1).

Over the past 15 years there has also been a gener-al decline in the reported number of cases of the sixmain VPDs (figures 2 and 3).

Despite the improvement indicated above, the stat-ed goals were not fully achieved. Thus, there is anurgent need to address deficiencies in the immuniza-

Figure 1: Infant mortality rate (per 1000 live-births), 1971–2002. Source: Sample Registration System, Registrar General, India


Figure 2: Number of reported cases of measles and pertussis, 1988–2002. Source: Central Bureau of Health Intelligence (CBHI)

2 Procurement of cold chain equipment, training of mid-level managers, training of vaccine and cold chain handlers, training of refrig-erator mechanics, review meetings at Central and State levels, mobility support to district immunization officers (DIOs) for monitoringand supervision and computer assistants to the State UIP offices.

tion system and emphasize the need for systemstrengthening and vigilant monitoring and surveillance.

Figure 4 shows the significant decline in poliocases from 1997 to October 2004. In 2002, there wasan outbreak in UP with spill-over to neighbouringStates resulting in 1600 cases. However, with intensi-

fied campaigns in 2003 and 2004, the number of poliocases has declined to 136 as of December 2004.

There has not only been a drop in absolute numbersof polio cases, the geographic spread of the virus hasalso decreased over time, as can be seen from themaps (figure 5).

Figure 3: Number of reported cases of diphtheria, polio and tetanus, 1988–2002. Source: Central Bureau of Health Intelligence (CBHI)

Figure 4: Monthly incidence of polio in India, January 1998–February 2005.* Source: GoI/NPSP


The polio eradication programme has helpedstrengthen surveillance through the SurveillanceMedical Officer (SMO) network and created a rapidresponse system. This has helped identify areas inneed of prioritization.

Hepatitis B disease burden figures are not routine-ly reported. However, it is estimated that between

166,000 and 333,000 neonates are born infected withhepatitis B in India. About 90% of these are likely tobecome chronic carriers, which would add 149,000 to299,000 persons to the carrier pool annually. It hasbeen estimated that India has some 43 million hepati-tis B virus (HBV) carriers, a prevalence rate of 2–4%.

Haemophilus influenzae type B (Hib) disease bur-

Figure 5: Location of poliovirus, October 2002–October 2004.* Source: National Polio Surveillance Project, GoI and WHO


den figures are also not routinely reported. There isonly scanty information about the magnitude of thediseases due to Hib, but it is generally recognized thatHib is a common cause of childhood pneumonias.

2.3 Current UIP schedule

*Hepatitis B vaccination scheduleFirst dose at birth for institutional deliveries, sec-

ond dose at 6th week and third dose at 14th week,along with DPT.

Those not receiving the birth dose should get threedoses at 6, 10 and 14 weeks along with DPT.

Non-vaccinated children and adolescents shouldreceive 3 doses on demand or on payment. Thereshould be an interval of one month between doses 1and 2 and a 3–5 months interval between doses 2 and 3.

2.4 Current coverage rates and trends

The output of the UIP is measured in terms of antigencoverage and drop-out rates.

(i) Antigen coverage rates are a measure of‘access’ to immunization services.

(ii) Drop-out rates indicate service utilization andare useful to consider when prioritizing improvementsfor ‘acceptability’ of services. Reported national antigen coverage: Figure 6shows national reported (administrative) coverage foreach antigen since 1990. Reported coverage rateshave increased, except in 1992 and 2001. BCG cover-age rates have been over 100% for the past three years(perhaps due to underestimation of the denominator).The reported national BCG–measles drop-out rate was10% in 2002. Nationally, 56% of infants were fullyvaccinated in 2002 according to official figures.Variations between States: The variation between

BCG

Oral polio

DPT

Hepatitis B*

Measles

DPT + Oral polioDTTetanus ToxoidVitamin A

18 to 24 months5 yearsAt 10 years and again at 16 years9, 18, 24, 30 and 36 months

Tetanus toxoid (PW) : 1st dose

2nd doseBooster

As early as possible during pregnancyafter 1st trimester1 month after 1st doseIf previously vaccinated within 3 years

VACCINE

Primary vaccination

Booster doses

Pregnant women

AGE

xx x

xx

xxx

xxx

x

Birth 6weeks

10weeks

14weeks

9months

0

20

40

60

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100

120

85-8

6

86-8

7

87-8

8

88-8

9

89-9

0

90-9

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91-9

2

92-9

3

93-9

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'01-

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04

Cov

erag

e (%

)

DPT-3 OPV-3 BCG MSL TT(PW)

Figure 6: Reported national coverage rates by antigen, 1990–2002. Source: Evaluation and Intelligence Division, MoH&FW


States in reported fully vaccinated coverage rates dur-ing 2001–2002 are shown in figure 7. This showsmuch lower coverage rates in the northern States ofUttar Pradesh, Bihar, Rajasthan and Jharkhand, incomparison to the southern States.

Variations between districts: Variation in coveragerates within States is also marked. Figure 8 shows theevaluated district-wise RCH fully immunized cover-age surveys comparing 1998–99 and 2002–2003. Thisnot only emphasizes the low coverage rates in districtswithin the northern States, but also helps identifyareas of poorer performance lying within better per-forming States. For 2002–2003 the results are current-ly available for only 260 districts.

Reported rates are generally higher than rates eval-uated by coverage surveys (annual UNICEF survey orRCH Rapid Household Surveys in 1998–99 or2002–2003). The differences between reported andevaluated coverage rates are highlighted in Annex 2(WHO/UNICEF best estimates of immunization cov-erage). These differences are especially marked in thenorthern States such as Uttar Pradesh, Bihar,Rajasthan, West Bengal and Jharkhand. Coverage fig-ures may be exaggerated due to pressure on the healthstaff to improve performance.Drop in coverage rates over time: Figure 8 demon-strates a worrying trend. Between 1998–99 and2002–03 there was a marked increase in the number ofdistricts, with DPT3 coverage rates of less than 30%.This highlights the need for urgent action in strength-ening immunization systems in these areas. Data areavailable for 244 districts surveyed which can becompared five years apart (1998–99 to 2002–03).

Figure 7: Reported percentage of fully vaccinated children,by State, 2001–2002.Source: Evaluation and Intelligence Division, MoH&FW

Figure 8: Evaluated coverage rates for full immunization, by district, comparing the 1998–99 survey with 2002–03 (260 districts in 2002–03). Source: Rapid Household Survey RCH Project; International Institute for Population Sciences, Mumbai

1998–99 2002–03


A drop in coverage rate is also seen at the Statelevel, as seen in figure 9, which shows the percentageof districts in each State surveyed achieving >80%DPT3 evaluated coverage rates. This shows that theStates with the lowest percentage of districts surveyedachieving >80% DPT coverage in 2002–2003 are:Assam (0%), Bihar (0%), Jharkhand (0%), MadhyaPradesh (0%), Rajasthan (0%), Uttar Pradesh (0%)and West Bengal (12%). The States showing thegreatest drop in percentage of districts achieving>80% coverage between 1998–99 and 2002–03 are:Andhra Pradesh, Gujarat, Haryana, Madhya Pradesh,Maharashtra and Orissa. Where are the unimmunized? 17.9 million infantswere not fully immunized in India in 2001–02, whichrepresents about a third of the global total; 95% ofthese unimmunized infants live in 15 States; 40% livein Uttar Pradesh and Bihar. See Annex 3 for rates andnumbers by State.Drop-out rates: In 2001, the average evaluatedBCG–measles drop-out rate by State was 14.4%. The

drop-out rate is an indicator of acceptability ordemand for immunization services. Drop-out rateswere highest in Andhra Pradesh (37.5%), West Bengal(27%) and Meghalaya (35%). Almost 6.3 million chil-dren who came into contact with immunization serv-ices (receiving BCG) in 2001 did not receive theirmeasles vaccine; 93% of these infants live in 15 Statesand over half live in Andhra Pradesh, Uttar Pradesh,West Bengal and Bihar. Rates and absolute numbersare detailed in Annex 3 by State.

2.5 Management structure and servicedelivery2.5.1 Service deliveryImmunization services are provided through1,37,311 sub-centres, 22,842 primary health centresand 3043 community health centres, subdivision-al/taluk/speciality hospitals, tertiary hospitals,urban health services provided by municipalities,hospitals and dispensaries run by the Railways,defence, public sector undertakings, Employees’State Insurance Scheme hospitals and dispensarieswhich are funded by the Government (State andCentre). This vast infrastructure is unevenly dis-tributed and segments of the population whosehealth care needs are greatest often have pooraccess to health care due to economic, geographicand political constraints.

Besides the Government health services, the pri-vate health sector also provides an estimated 10–15%of immunization services.

176 (72%) districts surveyed showed adecrease in full immunization rates over the fiveyears; average decrease 15.4% (varied from0.1% to 64.2%)

66 (27%) districts surveyed showed anincrease in full immunization rates over the fiveyears; average increase 9.4% (varied from 0.1%to 41.1%)

2 districts showed no change in full immuniza-tion rates

Figure 9: Percentage of districts surveyed with >80% DPT3 coverage in key States in 1998–99 and 2002–03. Source: Rapid Household Survey RCH Project; International Institute for Population Sciences, Mumbai


High drop-out rates highlight the urgent need forimprovements in the management of service delivery to:

(i) Enhance the availability of supplies(ii) Increase the quality and quantity of staff(iii) Increase the demand for services

2.5.2 ResponsibilitiesThe Central Government is currently responsible forthe procurement and supply of vaccines, injectionsand cold chain equipment to the States, training ofpersonnel, supply of stationery, training materials andfunding for specific staff.

The State Governments are responsible for servicedelivery through health facilities and village outreachsessions. Roles and responsibilities are given inAnnex 4. Although these roles and responsibilities aredefined, they are often difficult to implement, due tounclear communication, rapid turnover of Govern-ment staff and weak coordination at all levels.

2.5.3 Management systemCentrally: Currently, the central management of theUIP rests with 2 Assistant Commissioners (ACs)under one Deputy Commissioner (Child Health). TheDC (CH) is supported by one Deputy Secretary (CH).Proposed changes to this structure, in the form of theNational Immunziation Cell (NIC) are summarized inAnnex 5.Peripherally: The implementation of the UIP is thejoint responsibility of the Government at all three lev-els, namely Central, State/Union Territory andDistrict.

The relationship between Central and State immu-nization departments and between State and districtimmunization officers are all critical for efficient andeffective service delivery. Overall coordination andfund and communication flows have been identifiedas key problematic areas.

2.6 Current financing and audit mechanismsAll operational aspects of the UIP are funded by theGovernment of India. The funds are released to theState/SCOVA (a society registered under the SocietiesRegistration Act, 1861) for disbursal to districts forvarious activities such as logistics, cold chain mainte-nance, injection safety and payment of immunization-related staff. The vaccines required are being Centrallyprocured and distributed to the consignee/States.States compile statement of expenditures (SOE) basedupon expenditure statements submitted by the districtsand furnish utilization certificate to GoI.

2.6.1 Current audit mechanism Scope of statutory audit: The Comptroller and

Auditor General (C&AG) of India is vested with thepower and authority to conduct an audit of the expen-diture incurred from the consolidated funds of India.The corresponding mechanism at the State level is theoffice of the Auditor General (AG).

The scope of C&AG audit is to ‘Ascertain whetherthe money shown in the accounts as having being dis-bursed were legally available for and applicable to theservice of purpose for which they have been appliedor charged and whether expenditure conforms to theauthority which governs it.’

The C&AG issues a consolidated report of allschemes under various ministries/departments underthe GoI. In addition, it also carries out a detailedaudit of randomly selecting the period/scheme undervarious ministries and departments. The consolidat-ed report with the detailed audit in respect of theselected scheme is tabled in Parliament for its con-sideration.

The State AGs, similarly, submit a consolidatedreport of all schemes, together with the report of thedetailed audit in respect of the selected schemes, to theconcerned State legislatures.

However, funds channelled through the societymechanism are required to be audited through an inde-pendent auditor. In addition, the SCOVA accounts arealso audited by the C&AG of India.

2.6.2 CostsAn overview and analysis of current and projectedcosts will be undertaken as part of this plan (goal 3 ofthe medium term plan). It is important that costs andfinancing for polio eradication efforts and otherimmunization are kept separate. (a) Routine immunization costs: The specific recur-rent expenditure of UIP is covered by the Governmentof India. This does not include other capital expendi-tures or salaries of health staff (such as ANMsalaries, medical officers or other non-EPI specificpersonnel who are contributing to the programmeimplementation). In addition to the above there aremany other operational hidden costs. (b) Polio programme costs: These include cost oforal polio vaccine (OPV) and operational costs.Operational costs include mobility support, logistics,social mobilization, training, out-of-pocket expensefor volunteers and supervisors, etc. At the current rate,operational costs are around Rs 4 per round per child.The cost of oral polio vaccine per round per child isaround Rs 5.2.6.3 Cost benefit(a) Polio: Based on the census data 1991 it was esti-mated that the locomotor disability load in 1994 wasaround 2,700,000 due to polio. At a conservative esti-mate, annual loss to national GDP due to polio-relat-ed disability works out to be Rs 27,000,000,000 not


including the cost incurred on treatment of poliocases. Thus, the investment for eradicating poliowould result in significant future national economicsavings, apart from saving of cost related to the imple-mentation of the programme. (b) Routine immunization: Since the implementa-tion of the immunization programme in the country in1985, it is estimated that the disease burden due tovaccine-preventable diseases has been reduced by 85%.

2.7 UIP constraints

The most common constraints are:(i) Coverage not uniform(ii) Poor implementation(iii) Poor monitoring (iv) High drop-outs(v) Declining coverage in some major States(vi) Over-reporting(vii) Injection safety(viii) AEFI monitoring(ix) Re-orientation of staff(x) Cold chain replacement plan(xi) Vacancy of staff at the field level(xii) Surveillance of vaccine-preventable diseases(xiii) Vaccine logistics(xiv) Maintenance of equipment

2.7.1 Technical and programme management constraintsNational level: The UIP has recently been strength-ened by positioning two Assistant Commissioners andadditional support staff to look after vaccine logisticsand financial management under the direct supervi-sion of Deputy Commissioner (CH) and Secretary(FW). Still there is a gap in proper data generation andanalysis of performance, evaluation, VPD surveil-lance, inventory management (vaccine, cold chain,and injection safety), field supervision and monitoring.State level: States have a dedicated immunizationfocal point. The technical advice and resources avail-able to these teams would require augmentation.Planning, management and monitoring of immuniza-tion activities at the State level are required to bestrengthened. Timely data generation both in the areaof performance and surveillance, data discrepancies,analysis, feedback for corrective action are few areasthat need immediate attention. District level: Though at the district level the pro-gramme envisages the availability of a district immu-nization officer, however, in some of the major Statesthere is no designated officer entirely for the immu-nization programme. Many posts remain vacant andthe field staff receive little ongoing training. The cur-rent Middle-Level Manager (MLM) training initiativefor district-level managers aims to strengthen district-

level planning, monitoring and supervision. But thereremains a shortage of appropriately qualified staffwho are able to practically plan and manage immu-nization services effectively. A review of district-levelhuman resource needs and training requirements isurgently needed. There is need for timely generationof data, their analysis and transmission to the nexthigher level.

2.7.2. Service deliveryThe stagnating routine immunization coverage rates,high drop-out rates and declining trend in some of thedistricts in key States (UP, Bihar, Rajasthan,Jharkhand, West Bengal, AP and Assam) are issues ofmajor concern. Even within States with higher cover-age rates, there is marked variation between districts.There is little capacity in the system to assess wherethe unimmunized children are and prioritize theseareas (using population, low coverage and high drop-out rates) for targeted attention. This is due to a mix-ture of reasons including human resource capacityconstraints (non-functional or vacant posts), little orno ‘on the job’ training, lack of resources for mobili-ty and poor vaccine availability at the point of servicedelivery. This is also due to the lack of capacity toplan effectively at grassroots levels for routine immu-nization services.

Multiplicity of tasks assigned to peripheral healthfunctionaries are often not planned with the sense ofsynergy or holistic overview. Planning for differenttasks and allocating a time schedule encompassing allpriority health activities need to be strengthened.

Immunization service delivery in urban areas,especially slums and peri-urban areas, where migrantfamilies live, often in semi-legal situations due toweak infrastructure, is a major concern. Improvingcoordination with private practitioners, NGOs, andurban health staff should be undertaken on a priorityto improve immunization services in such areas.

Supervision of immunization service delivery,especially monitoring session regularity and quality,has been problematic due to human resource shortagesand lack of resources limiting greater mobility ofsupervisors.

2.7.3. Data qualityProgramme data often are lacking in terms of accura-cy, completeness and timeliness. Currently, there arelarge differences between reported and evaluated cov-erages, which makes it difficult to use data for action.This also reflects the lack of understanding at thehealth facility level on the importance of accuraterecording and reporting of data for analysis, and iden-tifying for corrective action necessary to improveimmunization coverage.


2.7.4. Vaccine procurement and distribution logisticsProcurement: Procurement of vaccines for routineimmunization is done centrally using the domesticbudget. Estimation of beneficiaries and vaccine isbased on the projected population, latest CBR andIMR, and the process for estimated requirement forthe subsequent year is completed by the month ofDecember each year. The primary supplier/manufac-turer is responsible for supplying quality vaccine atthe consignee point. Often, it is observed that there isa delay in the procurement process resulting in acuteas well as long-term shortages of vaccine, affectingthe performance of the immunization programme.Feedback with regard to vaccine utilization and sup-ply is also not accurate, complete and timely, resultingin overstocking or undersupply. There is also a needfor strengthening planning and logistics of vaccinedistribution at the State and district level with efficientfeedback mechanisms on utilization and future demand.Cold chain: The cold chain consists of walk-in freez-ers/walk-in coolers at State/regional level. Districtsare provided with large-size ILR and deep freezers(DF) for adequate storage capacity to stock the vac-cine required for a period of three months for itscatchment area. Small-size ILR and DF are suppliedto the PHC for storing vaccine for one month for itscatchment area. For outreach sessions, ANMs carrythe vaccine in vaccine carriers with 4 ice packs. TheState cold chain officers and district refrigeratormechanic are responsible for maintenance and repairof the cold chain. Arrangements for replacing ageingcold chain equipment and additional requirement werecompleted in 2003. Plans for replacement of CFC-freeequipment by 2005 and regular replacement of ageingequipment are part of this strategic plan. Though theprogramme envisages hiring of refrigerator mechanicsat all district levels, in many States this has not beendone. Such States have outsourced the maintenance ofcold chain equipment to private agencies. The fundrequired for cold chain maintenance is provided by theNational Government.

However, there is lack of monitoring of the breakdownrate of cold chain equipment and cold chain sickness rate,and the repairing status is a major area of concern.

2.7.5. Injection safety and unsafe waste disposalA recent INCLEN study demonstrated that 73.9% (ofthis, 27.1% due to questionable sterility, 15.2% reuseand 65.5% due to wrong habit) of injections given inthe immunization programme were deemed to beunsafe. WHO estimates that in the South-East AsiaRegion unsafe injections contribute to 31% of new

cases of HIV, 59% of hepatitis B and 92% of hepatitisC. In India out of 25 million infants born every year,over 1 million run the lifetime risk of developingchronic hepatitis B virus infection. This worryingtrend is highlighted in the plan and the GoI is com-mitted to address the issue.

2.7.6. Low demand for and awareness of immu-nization services in key areasAvailable data and research, including monitoringreports, coverage evaluation surveys and special stud-ies all underscore a common theme—families in Stateswhere immunization coverage is low are often unaware orunconvinced of the need for routine immunizationservices. Equally important, low levels of immuniza-tion are also an outcome of poor service delivery.

A qualitative research study commissioned byUNICEF in 20023 highlighted some common barriersto low demand for immunization services at thehousehold and community level. Lack of knowledgeis a key obstacle. Families are not adequatelyinformed about the importance of routine immuniza-tion, where and when to access services, and how torespond to side-effects.

Lack of motivation is a reinforcing barrier.Vaccine-avoidance behaviour and the notion thatchildhood disease ‘simply happens’, is one’s fate, andtherefore cannot be prevented, coexist. The quality ofservice delivery is also likely to shape people’s atti-tudes and decision to immunize their children. Often,the experience of health systems is articulated in termsof poor quality, apathy, discrimination based on casteor religion, corruption and inaccessibility.

Strategic communication, therefore, is a criticalcomponent of this plan for building and sustainingfamily and community demand for immunizationservices. It will need to operate at the level of house-holds, convincing parents of the need for routineimmunization. It will also need to foster a social normat the community level to ensure wider participationand accountability so that all children in a particularcommunity are fully immunized against VPDs.Improving the communication and negotiation skillsof front-line health functionaries is critical to re-estab-lish people’s faith in the health system. This can beachieved through:

(i) Appropriate interpersonal communication training

(ii) Supervision and monitoring(iii) Special efforts to motivate health workersTargeted advocacy is also required to ensure that

immunization services continue to remain responsiveand well supported.

3 EPOS, Understanding barriers to polio eradication in Uttar Pradesh, December 2002, Delhi.


2.7.7. Introduction of new vaccines and researchNew vaccines that may be considered for introductionin India include hepatitis B, MMR, Japaneseencephalitis, HiB, tetravalent (Hep B–DPT) and pos-sibly rotavirus and pneumococcal vaccines.

Weak surveillance systems in India hinder theavailability of accurate information on the diseaseburden of VPDs. There is an acute need for more dis-ease burden studies to quantify problems so that policy-

makers can take informed decisions about the intro-duction of new vaccines.

There is a lack of India-specific cost analysis ofnew vaccines and estimated financial benefits of theirintroduction in India. There is a lack of an institution-al mechanism to assess the need for newvaccines/underutilized vaccines and coordinate appro-priate research into disease burden studies andcost–benefit analysis.

2.8 Achievements and obstacles

ACHIEVEMENTS OBSTACLES

POLIO

NEONATAL TETANUS

MEASLES

HEPATITIS B

INJECTION SAFETY

ROUTINE IMMUNIZATION

VITAMIN A

Reaching underserved populations

• Campaigns difficult to sustain• Lack of integration into surveillance

• Persistent low coverage in certain areas leading to outbreaks

• Measles laboratory network (only two) not fully established

Slow implementation in cities due topoor health service delivery in slums

• Financial implications• Lack of policy on safe disposal

Disparity between reported and evaluat-ed coverage

Administration of other dosesdue to lack of information and education

• Reported cases lowest level ever (2004)• Well-established polio laboratory ne

work• Effective surveillance system estab-

lished• Infrastructure for cold chain strength-

ened• Social mobilization

• Steady decline over the years• Some successful campaigns in high-risk

areas

Significant decline due to high routineimmunization in certain parts of the country

Introduced into 33 (of 593) districts andslums of 15 major cities (as a pilot project)

Introduction of AD syringes in 33 (of593) districts and slums of 15 major citiescovered under Hep B pilot project and inBDCS districts

Expansion nationwide

First dose coverage rates have improvedin certain areas where linked with measlesvaccination


3. UIP Medium-term Plan

This medium-term plan seizes on the opportunity toaddress geographic and social inequities in immu-

nization coverage rates and the issues highlighted in2.7. It aims to increase awareness of all stakeholdersabout strengthening immunization and managementroles at each of three specific levels: Central,State/Union Territory and district. The plan aims tostrengthen the immunization infrastructure within thebroader RCH programme as well as intersectoral link-ages.

3.1 Global goal

With an annual birth cohort of over 25 million andunder-five population of 120 million, India's immu-nization policy and medium-term plan will contributesignificantly to the global fourth MillenniumDevelopment Goal:

3.2 India-specific goals

Under the National Population Policy 2000, theNational Sociodemographic Goals for 2010 concern-ing child health are:

3.3 India’s UIP mission

3.4 Guiding principlesThe guiding principles of India’s UIP to achieve thismission will be:(a) Maximal reach: To overcome barriers at all levels,to sustain demand and ensure all pregnant mothers andchildren are immunized as per the national schedule(b) Equity: To reduce disparities in services byaddressing the needs of the underserved(c) Quality and safety: The immunization pro-gramme will follow recommended practices in vac-cine procurement, storage, distribution and servicedelivery(d) Sustainability: Esuring sufficient financial andhuman resources for long-term needs for immuniza-tion services, through investments by the GoI and keypartners(e) Management excellence: The UIP, in collabora-tion with key partner agencies and professional organ-izations, will optimize the use of resources followingresult-based principles and evidence-based practices.

3.5 Target group

The identification and fixing of immunization targetsis essential for proper planning and monitoring of theUIP. Emphasis will always be given to the primaryseries of immunization.

The target groups are highlighted in the nationalimmunization schedule in the national policy docu-ment.(a) Primary immunization—All children under one year shall be provided withthe primary series of immunizations according to theNational immunization schedule.—All pregnant mothers shall be the target for TT vacci-nation, according to the National immunization sched-ule.(b) Boosters—All children between the ages of eighteen to twen-ty-four months will receive booster doses of DPT andOPV.—All children at 5 years, or at school entry, shallreceive DT.—All children at 10 years and 16 years shall be thetargets for TT.(c) Vitamin A—All children aged nine, eighteen, twenty-four, thirtyand thirty-six months will receive vitamin A to a totalof five doses.

Reducing under-five mortality by 2/3 between 1990and 2015Measured by: Under-5 mortality rate

Infant mortality rate% infants immunized against measles

Reduce the infant mortality rate to below 30 per 1000live-births.Achieve universal immunization of children againstall vaccine-preventable diseases.

To provide high-quality immunization services to allcommunities in order to prevent mortality, morbidityand disability from diseases that are preventablethrough the optimum use of currently available vac-cines and vaccines that become available from time totime.


4. Medium-term goals,objectives, indicators,milestones and strategies

The medium-term plan envisions six goals, eachwith its own set of objectives, strategies to reach

those objectives and indicators to measure progress.Key annual milestones are also used for each objec-tive to benchmark the progress by year. There willobviously be great variation between and withinStates. Although the UIP is nationwide, specialattention will be given to strengthening routineimmunization in States highlighted in the situationanalysis: Uttar Pradesh, Bihar, Rajasthan, WestBengal, Jharkhand and Assam. The six goals andtheir respective objectives and milestones are sum-marized in section 6.

OBJECTIVE 1To ensure that regular quality immunization

sessions are planned and held

INDICATORS

Quality of service delivery is related to immunizationcoverage and drop-out rates, which are reflected in theindicators:! % of districts with BCG coverage rate of ≥80%! % of districts with BCG–measles drop-out rate of

≤15%! % of districts with DPT3 coverage rate of ≥80%! % of districts holding 80% of the planned

sessions.

STRATEGIES

Immunization delivery will be part of comprehensiveprimary health care including static health facilities,outreach clinics, antenatal clinics and schools. Gainsand lessons learnt from the polio eradication projectwill be built on for strengthening routine immunization.1. Coordination: National-level quarterly meetingsof all State EPI officers will strengthen feedback fromthe States and provide an update on new technologies.These were stopped in 1995 and have had an effect oninter-State communication and national to State-levelcommunication.2. National operational guidelines: Although thereare a wide variety of contexts in which immunizationservices are delivered in India, there is a need for stan-dardization of simple to use service delivery guide-lines. These will also include basic standardizedmicroplanning tools and monitoring guides for routineimmunization, which will be developed and field-test-ed throughout 2005.3. Strengthening supervision: Supervision of immu-nization services will be strengthened by the develop-ment, field-testing and implementation of a systemat-ic approach to supervision and global best practices. Aseries of supervisory guidelines will be distributed toStates for adaptation to State contexts and for use atdistrict and facility levels. The guidelines will allowcomparison over time and hence follow-up, provide acopy in the health facility/district, track the mostimportant parameters and identify remedial activities.Supportive supervision will include not just the use ofchecklists but will encourage on-the-job and partici-patory training of staff. Service monitoring visits willinclude % sessions planned versus those held, % drop-outs and vaccine utilization at every level for eachantigen. Where there are no regular supervisors (forexample, in slum areas) medical officers will super-vise outreach camps.4. Prioritization of poorly performing districts:States will undertake situational analysis/review on aquarterly basis of poorly performing districts interms of coverage and drop-out rates, identify bottle-necks and take necessary action through strength-


G O A L 1 Districts will provide efficient and safe

immunization services to all infants and pregnant women

M I L E S T O N E S

Although these milestones reflect national strategic planning, they will need to be adapted for each State.

2005: 35% of districts achieve DPT3 coverage of ≥80% and BCG–measles drop-out rate of ≤15% 2006: 50% of districts achieve DPT3 coverage of ≥80% and BCG–measles drop-out rate of ≤15%2007: 65% of districts achieve DPT3 coverage of ≥80% and BCG–measles drop-out rate of ≤15%2008: 80% of districts achieve DPT3 coverage of ≥80% and BCG–measles drop-out rate of ≤15%2009: 90% of districts achieve DPT3 coverage of ≥80% and BCG–measles drop-out rate of ≤15%

ened microplanning, prioritized training, andstrengthened supervision practices.5. Prioritization of underserved4 populations with-in districts: Extra efforts will be made at the districtlevel to identify and serve those populations who livein areas which are underserved, who are mobile orlive in peri-urban slums. These efforts will includeidentification of appropriate outreach sessions coor-dinated by the district and PHC medical officers, inconsultation with DIOs.

State Governments should mobilize resources toprovide fixed-day outreach sessions in urban slumsettings. ANM services will be utilized for outreachcamps on days when no fixed-day immunizationservice is being provided. The outreach camps willbe supervised by medical officers.6. Microplanning: Microplanning has strengthenedthe polio eradication process, which can also be usedfor routine immunization (mapping areas of under-served populations, session planning and districtwork plans). The UIP will provide updated guide-lines for microplanning and assist districts to imple-ment them. Every site (both public and private) pro-viding immunization services will devise and imple-ment annual microplans. Microplans will includeaspects of vaccine delivery and transport within theState and districts. 7. Missed opportunities, reducing drop-outs andensuring booster doses: Together with enhancingcommunication between service providers and moth-ers (as detailed in goal 4) this approach aims toreduce the number of drop-outs and increase thechances of children to receive vaccinations beyondthe primary immunization schedule.

(a) Health facilities: Every contact of the healthcare system with children of vaccination age will beused to enquire about the child’s vaccination status.Vaccines will be administered where applicable, pro-vided the minimum interval between doses isrespected. Possible reasons for non-vaccination shallbe identified and addressed. ANMs will be responsi-ble for delivering the DPT booster. The LHV (super-visor) will coordinate and ensure administration ofDT and TT to children as per the national schedule.

(b) Schools: School health programmes will bestrengthened. LHVs will visit every school withANMs at least once a year with vaccines to assessthe immunization status of children and ensure vac-cination with DT of children aged 4–6 years and TTvaccination for children aged 10 and 16 years. 8. Registration: All administered doses of vaccineswill be recorded in the immunization register and the

recipient’s immunization card (that can be used inboth government and private systems). Doses givenoutside the target age group will be entered on therecipient’s card, as well as in a separate column inthe immunization register. Innovative ways toincrease card retention by the recipient will beexplored.9. Responsibilities

(a) District immunization officers (DIO): Theywill be responsible for ensuring the availability ofvaccines at immunization sites, especially thosewhich are difficult to reach. This will help decreasethe health workers’ time spent visiting PHCs to col-lect vaccines. The DIOs will be responsible for mon-itoring and providing supportive supervision foreffective implementation of the programme in thedistrict. Together with ICDS supervisors, the DIOswill jointly undertake monthly reviews of the immu-nization programme PHC-wise and take necessarycorrective action to improve performance in poor-performance areas.

(b) First-line supervisors: LHVs, Male HealthSupervisors, and the PHC medical officer will ensurethat all planned immunization sessions are actuallyheld and ensure that every child/pregnant woman isfollowed up for full vaccination with quality vac-cines and safe injection practices.10. Fixed-day and fixed-time strategy: Policy rec-ommendations from the GoI and State Governmentswill include fixed-day strategies throughout the coun-try to ensure that communities are aware of the immu-nization day. This will also help in the developmentand dissemination of information through the massmedia and interpersonal communication. 11. Fixed-site strategy: The GoI and State policyrecommendations will include immunization sitesbeing fixed for each habitation, preferably at sub-centres in villages, at anganwadi centres, panchayatghar, etc. This will ensure easy accessibility by allcommunities and help the community to know whereto go for vaccination.12. Integration with the private sector: All privatepractitioners delivering immunization services willbe part of the UIP. All public and private practition-ers providing vaccination will be provided, free ofcharge, vaccine, family retained immunization cards,etc. All private practitioners offering vaccinationservices will be expected to maintain appropriateinstitutional records retrievable on demand. Privatesector accountability and quality issues will be coor-dinated by the nodal medical authority providing thevaccines.


4 Although 80% infants in India live within 0.5 km of an immunization provider, ‘underserved’ populations include mobile, migrant populations, those living in urban and peri-urban areas with poor infrastructure and those living in rural areas that are difficult to accessfor geographic or economic reasons.

OBJECTIVE 2To ensure that adequate trained staff are empow-

ered to provide essential quality immunizationservices

INDICATORS

! % of districts with >80% ANM posts filled.! % of ANMs who have received immunization

training in the past three years.! % of DIOs having received MLM training in the

State in the past five years.

STRATEGIES

1. Coordination: Training is commonly given bymultiple agencies with little coordination. It is there-fore recommended that each State creates a trainingcell that can screen and approve training initiativesappropriately. Control of training coordination needsto be handed back to the States.2. Increase the number of staff: A regular review ofimmunization personnel requirements will be under-taken and financial and human resources will bemobilized (by GoI and State Governments) to allowthe training of new cadres of ANMs, based on Census2001. Many female staff require maternity leave. Tocompensate for this there must be a leave vacancyreserve of 5–10% of the total strength.3. Strengthen training: Immunization training activi-ties are integrated with the RCH Programme.Refresher training for all categories of staff will beundertaken every three years through the State Instituteof Health and Family Welfare (SIHFW). All traininginitiatives will be followed up through supervision vis-its. A single contact point in the MoH&FW will coor-dinate all training programmes. All States will alsohave designated immunization training focal points by2005. Guidelines for immunization training by the pri-

vate sector will be formulated in 2005. Existing train-ing modules for field staff and mid-level managers(MLM) will be updated by 2006 to reflect changes inpolicies and new initiatives, incorporating the opera-tional guidelines.

(a) National and State levels: A review of rolesand staff capacity at national and State levels isrequired to improve the implementation capacity. Anational immunization training cell will be createdunder the MoH&FW. This review would produce rec-ommendations for improvement and potentialchanges in functions. Every State Training Instituteshould select trainers with an aptitude for training andprovide periodic training to these trainers. Once ayear, trainers will receive training in this institute andbe assessed by the State institute faculty by develop-ing standard training objective formats.

(b) Training of MLM: Current MLM training hascovered about 80% of DIOs nationally. However, thiscourse material needs to be made more concise andpractical. Key components also require strengthening:

(i) Hepatitis B vaccine introduction(ii) AD syringe introduction(iii) Analysing and using monitoring data at local

levels for planning(iv) Prioritizing areas on the basis of coverage

rates and drop-out rates(v) Safe injection practices and waste management(vi) AEFI monitoring, reporting and responding(vii) Wastage reduction (viii)Monitoring and supervision(ix) Microplanning(x) Training in epidemiology(xi) Financial managementState-level immunization training centres will pro-

vide continuing medical education annually for med-ical officers of each block and sub-block.

M I L E S T O N E S

These milestones reflect national strategic planning and each state will need to review their own milestones accordingly.

2005: State- and district-level immunization human resource and managerial capacity is reviewed.Mid-level Manager training in all districts is complete. Further training needs of field functionaries are identified.Adapted field-level operational guidelines are finalized and used countrywide.

2006: Recommendations from the human resource and managerial review are implemented.A countrywide human resource needs review is completed.All ANMs have attended a training course on safe injection practices, waste disposal and AEFI reporting and Hep B vaccine introduction.

2007: Recommendations from the review of human resource needs are implemented.Framework for involvement of the private sector for the immunization programme is reviewed and strengthened.

2008: Re-orientation and training needs of DIOs and field functionaries are assessed and implemented.2009: Re-orientation and training of DIOs and field functionaries are completed.


(c) Training of field-level staff: High-qualitytraining would continue to be provided to peripheralhealth workers and auxiliary health staff. The trainingwould be expanded to include the above topics and:(a) community mobilization, drop-out tracking, andIPC; (b) proper recording, and (c) effective cold chainmaintenance. Formulation of a national guideline oninjection safety, and a comprehensive manual on UIPoperational guidelines shall be made available anddisseminated to all health facilities. The manual willserve as technical guidelines for immunization servicedelivery, immunization safety, monitoring for andmanaging AEFIs, logistics management, surveillanceand outbreak response. Special attention will be paidto giving adequate time for training vaccinators toimprove injection techniques of vaccine administra-tion, sterilization and use of AD syringes. Basic strate-gies will include:

(i) On-the-job refresher training every 3 years forevery ANM

(ii) Each State will identify core district trainingteams for each district. This team will move to eachblock identifying gaps in knowledge and train appro-priately

(iii) Monthly block meetings will provide anopportunity for supervisors to help identify gaps inknowledge and provide some training.4. Decrease frequent staff rotation: Transfer of staffat all levels decreases the systems’ capacity to gener-ate institutional memory and decreases staff motiva-tion. Within the human resource review there will berecommendations made regarding the time for eachposting and ways of reducing staff turnover. StateGovernments should consider a policy which ensuresthat chief medical officers (CMOs) and DIOs are inplace for two and five years, respectively.

OBJECTIVE 3To keep an annually upgraded inventory of

cold chain according to the levels of the network,allowing for new equipment, substitution,

replacement, spare parts, fuel and others in orderto maintain a functional status of 90%

INDICATORS

! % of districts with immunization cold chainequipment and vehicle inventory

! % of districts identified with 90% functioningcold chain equipment

! % of districts having refrigerator mechanics! % of districts where refrigerator mechanics at the

district level and cold chain handlers at the PHClevel are trained

STRATEGIES

1. Coordination: Cold chain focal points at the

national, State and district levels will have the ulti-mate responsibility for procurement, inventory, distri-bution, and repair and maintenance of appropriatecold chain equipment. All States will have a coldchain officer at the State level and a refrigeratormechanic at the district level responsible for preven-tive maintenance, as well as repair of cold chainequipment. A focal point at every health facility willbe designated with responsibility for cold chain main-tenance. 2. Cold chain assessments: Prioritized States willreview the cold chain over a period of five years to:

(a) Identify weaknesses(b) Review State cold chain requirements over 5

M I L E S T O N E S

2005: Cold chain reviews are undertaken at EAGStates.A national cold chain focal point is estab-lished (procurement and logistics) at thenational level to look after forecasting and uti-lization and to assist State estimates forrequirement.80% of identified cold chain equipment isfunctioning at any given point of time.Training materials for cold chain training atall levels will be standardized and finalized.60% of identified cold chain equipment isfunctional.Training material for cold chain training isdrafted (with system and equipment training).

2006: Cold chain review in West Bengal, Assam, Andhra Pradesh and Karnataka.85% of identified cold chain equipment isfunctioning at any given point of time.30% of State cold chain officers and districtrefrigerator mechanics are trained. 75% of identified cold chain equipment is func-tional. All State cold chain officers and all districtrefrigerator mechanics are trained in EAGStates.

2007: 90% of identified cold chain equipment isfunctioning at any given point of time.30% of State cold chain officers and districtrefrigerator mechanics are trained.

2008: 90% of identified cold chain equipment isfunctioning and maintained at any given pointof time.40% of State cold chain officers and districtrefrigerator mechanics are trained.

2009: Computerized immunization cold chain andspare parts inventory system available in allStates and at the national level.


years with precise plans and budgets for strengtheningthe cold chain (repair and maintenance plans) andswitching to CFC-free equipment.

(c) Make recommendations for planning and budg-eting for strengthening, substitution, replacement,spare parts and fuel, etc. in the cold chain, ensuringadequate maintenance and repair.

(d) Review cold chain training requirements forstaff at all levels.

(e) Cold chain repair and maintenance plans will beincorporated in all district microplans.3. Procurement and installation of cold chainequipment: Comprehensive procurement, distribu-tion and installation of cold chain equipment will bean effort of the National UIP Programme. 4. Training: A cold chain training focal point willbe identified nationally by 2005. Cold chain trainingmaterials will be reviewed and adapted for stan-dardization by 2005.

These will be used for training national, State, dis-trict and peripheral cold chain staff. The training willinclude:(a) Repair and maintenance of new CFC-free equip-

ment as well as existing equipment(b) Inventory planning and computer database plan-

ning(c) Appropriate vaccine storage(d) 1998 Technet Recommendations5

(e) Supportive supervision training on cold chain issues5. Inventory: An inventory of all cold chain equip-ment will be maintained and updated at the central,regional and district levels. Inventory systems will beused to plan for maintenance and replacement ofequipment and to monitor appropriateness of the coldchain system.6. Cold chain maintenance and repairs: Eachrefrigerator mechanic at the district level will beequipped with a basic tool set, to carry out minorrepairs and maintenance. Local staff will do day-to-day maintenance of the cold chain equipment. Localstaff will be trained in cold chain handling7. Vaccine storage capacity: Vaccine storage capaci-ty will be assessed and upgraded to meet any expan-

sion of services. The State/regional and district levelstores should have vaccine storage capacity for threemonths. At the health facility level the storage capac-ity is for one month. All storage points should have icepack freezing capacity.

OBJECTIVE 4 To ensure an efficient system for vaccine and

injection equipment management and logistics toforecast and deliver adequate supplies of

vaccines in a timely manner

INDICATOR

! % of districts reporting any vaccine stock-out (>1month no vaccine available during the year)

STRATEGIES

1. Coordination: A designated Assistant Commis-sioner for procurement and supplies at the nationallevel is established. A focal point will be designatedat the State level to coordinate physical asset man-agement functions and to track assets accordingly.Logistics training will be provided for regional storemanagers.2. Reduction of vaccine wastage: Microplanningprocesses should help increase service delivery effi-ciency. Distribution shall be made as per forecastedneed of health facilities to accommodate the changesin needs to reduce vaccine wastage. Although vac-cine wastage rates will be monitored to identify keyareas, strict enforcement of wastage rates shouldnever interfere with the need to vaccinate a child. 3. Multi-dose vaccine vial policy:6 India will adoptthe Multi-dose vaccine vial policy (MDVP) for OPV,as outlined by WHO,7,8 in order to reduce wastage,and to allow for improved vaccination services byreducing missed opportunities. However, before con-sidering an MDVP for other vaccines, there is a needto consider introduction of freezing indicators on thevials. The UIP will purchase vaccines with vaccinevial monitors (VVMs), wherever applicable.4. Vaccine and supply requirements: Vaccineneeds will be assessed nationally, based on the pro-

5 World Health Organization: Recommendations of the Technet Consultation, 16–20 March 1998, Copenhagen, Denmark, WHO document, 19986 Opened vials of TT, DPT, Td, DT, OPV and Hepatitis B vaccines can be stored continuously in a refrigerator, until the VVM (if attached)has reached the discard point, or the expiry date has been reached, or contamination is suspected. Vaccines used during outreach activi-ties can be returned to the cold chain after the session, provided they have a VVM, and provided the VVM discard point or expiry date hasnot been reached and contamination is not suspected. Measles and BCG vaccines must be discarded not later than 6 hours after recon-stitution in all settings (Ref: Expanded Programme on Immunization: Vaccine Vial Monitors and the Multi-dose Vaccine Vial Policy, DraftDocument distributed at the Sixth Meeting of the WHO/SEAR Technical Consultative Group on Vaccine Preventable Diseases, Bangladesh,3–6 May 1999)7 World Health Organization: Recommendations of the Technet Consultation, 16–20 March 1998, Copenhagen, Denmark, WHO docu-ment, 19988 World Health Organization: Vaccine Vial Monitor and Open Vial Policy—Questions and Answers, WHO DocumentWHO/EPI/LHIS/96.01


jected mid-year population, CBR and IMR with duevalidation by States. The allocations to the States foreach of the vaccines would be made after deductingthe stock in hand and supply order in the pipeline.Health staff at health facilities, district, State andnational levels will be trained in vaccine need esti-mation, vaccine stocks and inventory management,handling, VVM interpretation, open-vial policy andon how to reduce vaccine damage and wastage. Thistraining will be incorporated in the operationalguidelines. Vaccine and vaccination supplies stocksledgers shall be properly maintained at all levels.Decentralization/outsourcing of some of the suppliessuch as immunization cards, registers, stationery, etc.to avoid lapses/delays will be done. Regular supplyof vaccines from the manufacturer to the Stateregional stores will be enhanced through timelyordering and efficient distribution by the GoI.Transport and supply of vaccines will be reflected inlocal microplanning processes.5. Quality control of vaccines: All vaccines used inIndia will be in line with the basic quality standards

established by the National Regulatory Authority(NRA). The NRA is already in place and will bestrengthened as necessary. Standardized NationalControl Laboratories (NCL) will carry out qualitycontrol of vaccines. Monitoring of vaccine qualitywill be enhanced through visits by the Central andState Drug Regulatory Agencies. Post-marketingquality will be monitored through monitoring ofAEFI. 6. ‘Bundling policy’: The policy of bundling shallbe adopted for all vaccines, AD syringes and safetyboxes to reduce wastage and improve logistic effi-ciency, wherever applicable.

OBJECTIVE 5To ensure the implementation of safe injection

practices and waste disposal, the GoI has decided to introduce auto-disable (AD) syringes,

with satisfactory disposal mechanisms not contravening environmental protection

from 2005

INDICATORS

! % of districts in which AD syringes and needlecutters are introduced

! % of ANMs who have received training in the useof AD syringes

STRATEGY

Introduction of AD syringes and needle cutters:From 2005, AD syringes will be introduced for allinjections given in the immunization sector. Needlecutters (to be used after each injection) will also beintroduced.

The MoH&FW will issue guidelines regardingappropriate disposal of plastic AD syringes after liai-son with the Department of Environment andPollution Control. A single needle, single syringe persingle dose policy will be strictly followed.

M I L E S T O N E S

2005–2010: All districts are supplied with and areusing AD syringes and needle cutters

M I L E S T O N E S

2005: 30% of districts being monitored for microplanfor vaccine forecasting and procurement50% of districts with no measles vaccinestock-out




2009: 100% of districts being monitored formicroplan for vaccine forecasting and procure-ment100% of districts with no measles vaccinestock-out


Immunization campaigns are useful for three mainreasons:

(a) Pulse immunization for polio(b) Crisis management by campaigns in low cover-

age areas to rapidly achieve high coverage(c) Outbreak control

Campaign approaches for any other reason will bediscouraged and the ultimate decision on appropriatecampaigns will rest with advice from the India ExpertAdvisory Group on Immunization (IEAG) andapproval by the Secretary of the Ministry of Healthand Family Welfare.

OBJECTIVE 1To achieve polio eradication certification

by 2007

INDICATORS

! Number of wild polio cases in India! Number of AFP cases per 100,000 population per

district! Number of non-polio AFP cases per 100,000 pop-

ulation under 15 years—Target: >1! Number of AFP cases with adequate stool speci-

men collection—Target: 80%

STRATEGIES

The polio eradication programme currently imple-mented by the GoI through its existing immunizationprogramme essentially consists of a three-prongedapproach.1. Routine immunization for polio: All strategieshighlighted for goal 1 will be used for strengtheningroutine immunization.

2. Supplementary immunization campaigns:(strategies recommended by IEAG and approved bySecretary, MoH&FW). Ownership of the immuniza-tion programme at all levels to ensure participation ofall government and non-government sectors in theprogramme.

(a) Ensuring microplans for all rural and urbanareas to ensure that booths are available and accessi-ble to all sections of the community. A house-to-housesearch is made in all areas to vaccinate children notvaccinated at booths during each campaign.

(b) Ensuring that well-trained and motivated man-power is available to provide service during each cam-paign.

(c) Strategic communication to increase demandand adequate community participation in the pro-gramme.

(d) Regular State/district analysis of data to reviewprogress and prioritization of corrective action takenby districts.3. AFP virological surveillance:

(a) AFP and virological surveillance conducted byGoI/NPSP, WHO-SEARO and Polio LaboratoryNetwork

(b) Establishment of a network for reporting casesof AFP

(c) Clinical investigation and stool examination ofall AFP cases

(d) Establishment of a WHO accredited laboratorynetwork for isolation of wild poliovirus from thestools of AFP cases and contacts

(e) Management of AFP case data with regularanalyses at the State and district levels to measure theprogress in polio eradication and to guide supplemen-tary immunization activities

(f) Vaccine procurement and supply under theexisting UIP through the GoI

g) As part of AFP surveillance, activities will beundertaken to accelerate the certification processincluding implementation of the plan of action for lab-oratory containment of stocks of wild poliovirus

G O A L 2 Contribute to global polio eradication, measles

mortality reduction and neonatal tetanus elimination

M I L E S T O N E S

2005: Zero wild polio cases in IndiaAFP surveillance is maintained to ≥1 non-polio AFP case per 100,000 population under 15 years80% of AFP cases sampled with adequate stool sample

2006: AFP surveillance is maintained to ≥1 non-polio AFP case per 100,000 population under 15 years80% of AFP cases sampled with adequate stool sample

2007: Certification of polio eradication in SEAR (India and other countries) AFP surveillance is maintained to ≥1 non-polio AFP case per 100,000 population under 15 years80% of AFP cases sampled with adequate stool sample

2008:2009: Decision on the use of OPV versus IPV (dependent on global certification of polio eradication)


infectious materials and potential wild poliovirusinfectious materials.

These efforts will continue till polio is completelyeradicated, hopefully by 2007.

OBJECTIVE 2To eliminate neonatal tetanus (NNT) by 20099

This objective will be monitored State by Statethrough special reviews, surveys and routine reports,where elimination is defined as: ‘Less than one case ofneonatal tetanus per thousand live-births in every dis-trict.’INDICATORS

! % of districts with over 90% TT2+ coverage forpregnant women

! % of States validated as NNT eliminated

STRATEGIES

1. Strengthen service delivery: Ensure that TT isoffered at all antenatal sessions and routine immu-nization sessions. Provide two TT doses for the firstpregnancy (with immunization card) and further dosesaccording to the national schedule. The overall coor-dination of NNT elimination will be the responsibilityof the national NNT coordinator. 2. Increase reporting and action on cases: ReportNNT cases from every health facility and establishNNT as a reportable disease. NNT will be includedwith weekly AFP in active surveillance and zeroreporting. Case investigations for hospital-based casesand cases in low-risk areas (areas where NNT is no

longer considered a problem). Targeted action will betaken around reported and investigated cases byimproving and promoting routine TT immunizationfor pregnant women and clean deliveries in the com-munity concerned.3. Data analysis: Reported data will be analysed atdistrict and State levels for incorporation into ongoingmicroplanning processes. A national NNT databasewill be established with regular review of indicatorsand identifying high-risk districts within States. High-risk districts within States will be validated for elimi-nation of NNT by LQA surveys and districts priori-tized on the basis of this for targeted corrective action.4. Safe delivery practices will be coordinated withthe Maternal Health Division of the MoH&FW.5. Targeted SIAs: Attempts to improve TT coveragethrough uniform routine immunization should beensured in all areas. However, in isolated areas withlow coverage, there is a need to improve coverage andSIA may be considered.

OBJECTIVE 3To reduce measles mortality by two-thirds

by 2010, compared to 2000 estimates10

INDICATORS

! % of districts with measles coverage of at least90% per year

! % reduction of measles cases and deaths com-pared to 2000 estimates

! % of measles outbreaks reported which are inves-tigated

STRATEGIES

A first-dose measles vaccine will be delivered to chil-dren through strengthening routine immunization. Tomake an impact on measles mortality reduction, a sec-ond opportunity for measles immunization throughroutine immunization will be considered in Stateswhere routine measles coverage exceeds 90% andlocal resources are available to sustain the strategy.

There is no role of response immunization to ameasles outbreak to stop the spread of measles duringoutbreaks. The first dose of vitamin A will be deliv-ered with routine measles immunization and the sub-sequent dose as per national schedule.1. Situation analysis: States and districts will be pri-oritized according to performance indicators (espe-cially measles coverage rates and BCG–measles drop-out rates) according to surveillance and immunizationto enable prioritization for immunization strengthen-ing and corrective action.2. Planning: In the post polio eradication phase the

M I L E S T O N E S

2005: National focal point for NNT is createdAll States have an NNT focal point30% of States have eliminated NNT50% of districts in each State have >90%TT2 coverage for pregnant women

2006: 70% of districts in each State have >90%TT2 coverage for pregnant womenA national NNT case-based database is created

2007: 50% of States have eliminated NNT80% of districts in each State have >90%TT2 coverage for pregnant women

2008: 90% of districts in each State have >90%TT2 coverage for pregnant women

2009: 100% of States have eliminated NNT100% of districts have >90% TT2 coveragefor pregnant women

9 Less than one case of NNT per thousand live-births in every district by 200910 Consistent with national infant mortality reduction goal


GoI will consider setting up a national expert group toprepare a National Measles Mortality Reduction Plan.This will then be submitted to the GoI and StateGovernments for approval. A national measles focalpoint within the MoH&FW and State focal points formeasles will be established. States will introducemeasles mortality reduction strategies in a phasedmanner, based upon:

(a) epidemiological evidence(b) programmatic and service delivery situation (c) cost–benefit of introducing and sustaining

measles mortality reduction strategies.3. First opportunity: First opportunity for measlesimmunization will depend on reliable routine immu-nization at immunization sites (strategies highlightedfor goal 1):

(a) routine immunization sessions planned andimplemented regularly at every immunization site

(b) regular analysis of routine immunization andcorrective action to ensure a sustained increase in thecoverage of measles vaccination.4. Surveillance: Twice-yearly State-by-State reviewof all measles data with district indicators will beavailable.

(a) Measles cases and deaths will be reported withactive surveillance for other VPDs supported by themeasles laboratory network in a phased manner

(b) Tracking of measles outbreaks will be based onreported cases and surveillance data

(c) Prompt investigation of outbreaks will includeinvestigations to understand the epidemiology ofmeasles infection, factors associated with measlesoutbreaks, identifying populations at risk, immuniza-tion services (routine coverage, vaccine efficacy, ses-sion plans, supplies, facilities, etc.) in the area of theoutbreak. Outbreak investigation reports will suggestways to avoid outbreaks in future

(d) Laboratory confirmation of measles outbreaksby random testing of 5–10 blood samples for measlesIgM

(e) During measles outbreaks, virus isolation willbe attempted from a few cases of each chain of trans-mission as appropriate

(f) Routine immunization will be promoted incommunities affected by the measles outbreak

(g) Establishment of a measles laboratory network,including one regional reference laboratory.5. Case management: Case management guidelineswill be nationally standardized and promoted.Appropriate case management to accompany outbreakinvestigation, including provision of 2 doses of vita-min A, antibiotics, ORT and referral, if needed. 6. Global initiative ‘sustainable measles mortalityreduction with regional measles elimination’:Through supplementary immunization activities formeasles, countries in the American subcontinent have

eliminated measles. Currently European, EasternMediterranean and South African block countrieshave adopted the same strategy for achieving measleseradication goals. International agencies such asWHO, UNICEF, American Red Cross are supportingthese activities in the post polio eradication phase. Itwould be important to consider adopting in future thefollowing strategies for measles eradication in India.

(a) ‘Catch-up’ campaigns: The target of thesecampaigns are normally populations 9 months to 15years to provide a second opportunity rapidly to pro-tect susceptible children with primary vaccine failureas well as children who were not vaccinated previous-ly. These will only be considered to provide secondopportunity measles vaccination as a ‘one-time’ strat-egy under the following circumstances:! Epidemiological analysis based upon local datawill help to determine the population at risk and geo-graphical area. Given the magnitude of India and thelarge population, the catch-up campaigns shouldcover States in a phased manner and the target agegroups could be prioritized to match the resourcesavailable.! Adequate logistical, financial and (trained) humanresources to achieve a high-quality campaign reach-ing at least 90% coverage of the target population.! High-quality planning with sufficient time forcareful implementation and supervision.! Since campaigns are normally implementedthrough fixed sites, a high-quality mass media cam-paign will be needed to achieve a high level of com-munity participation.! Based on the above, a National ‘Catch-up’Campaign plan with a timeline should be prepared,which should forecast the resources needed to imple-ment this plan.! A catch-up campaign should not be done withOPV SIAs (at least until India is free of polio).! Catch-up campaigns should ideally be done inStates where high attendance at fixed sites is likelyto be achieved (based upon current routine immu-nization performance), since house-to-house deliveryis not feasible.

(b) ‘Follow-up’ campaigns prevent accumulationof cohorts of susceptible children since the catch-upcampaign. ! Follow-up campaigns will only be considered inthose States that have already implemented ‘Catch-up campaigns’. ! The gap between the catch-up campaign and fol-low-up campaign is usually 4 years. However, thegap would be varied according to routine immuniza-tion coverage to prevent the occurrence of outbreaks.! The surveillance data should determine the targetpopulation. The target population should be childrenwho have been born after the catch-up campaign.


! Other factors remain the same as for the catch-upcampaign.

(c) Keep up: Strengthening and sustaining highroutine immunization coverages.

OBJECTIVE 4To achieve and maintain a 70% level of coverage with two doses of vitamin A

supplementation to children under three years

INDICATOR

! % of districts that achieve 70% coverage with 2doses of vitamin A supplements each year for children9–36 months

STRATEGIES

1. Training: Vaccinators and other health staff aretrained at the time of ANM training, MLM trainingand supportive supervision monitoring visits to cor-rectly administer vitamin A according to the nationalschedule at fixed and outreach immunization ses-sions. Training in the stock management of vitamin Awill be given at the time of other immunization train-ing. Staff will be able to forecast the needs for routineimmunization, measles outbreaks and therapeuticuse.2. Education: Vitamin A will be included in thestrategic communication activities to increase aware-ness of the need and create demand for vitamin A.3. Therapeutic doses: Correct therapeutic doses ofvitamin A to measles cases will be administered dur-ing measles outbreaks to reduce mortality and disabil-ity caused by measles disease.

M I L E S T O N E S

2005: Measles laboratory network assessedNational and State measles nodal points identified5 major States have established activemeasles surveillance50% of outbreaks are investigated in these 5States50% of districts have at least 90% measlesvaccine coverage10% reduction in measles mortality as com-pared to 2000 estimates

2006: Measles laboratory network is initiated5 additional States have established activemeasles surveillance50% of outbreaks are investigated in these 10States60% of districts have at least 90% measlesvaccine coverage20% reduction in measles mortality as com-pared to 2000 estimates

2007: 10 additional States have established activemeasles surveillance50% of outbreaks are investigated in these 20States65% of districts have at least 90% measles vaccine coverage30% reduction in measles mortality as com-pared to 2000 estimates

2008: 10 additional States have established activemeasles surveillance50% of outbreaks are investigated in these 30States75% of districts have at least 90% measlesvaccine coverage45% reduction in measles mortality as com-pared to 2000 estimates

2009: 5 remaining States have established activemeasles surveillance50% of outbreaks are investigated80% of districts have at least 90% measlesvaccine coverage60% reduction in measles mortality as com-pared to 2000 estimates

M I L E S T O N E S

2005: A national plan for vitamin A supplementa-tion is updated and implementedA national vitamin A focal point and Statevitamin A focal points are established

2006: 40% of districts achieved 70% coverage withvitamin A

2007: 60% of districts achieved 70% coverage withvitamin A 100% of children who receive measles vac-cine also receive vitamin A All measles outbreaks provide vitamin A tomeasles cases in outbreaks

2008: 80% of districts achieved 70% coverage withvitamin A

2009: 100% of districts annually achieve 70% cov-erage of 2 doses of vitamin A for children9–36 months


OBJECTIVE 1To ensure adequate and reliable financial

resources at the national, State and local levels forthe UIP to achieve its goals and objectives

Currently, the GoI is responsible for procurement anddistribution of all vaccines, cold chain equipment andinjection safety equipment used under the UIP. Theexisting health infrastructure and human resourcesprovide immunization services to the beneficiaries.

INDICATORS

! Tracked budget versus expended resources! National annual budget shows provision for pur-

chase of vaccines for routine immunizations! National annual budget shows provision for injec-

tion supplies (syringes, needles, sharps boxes) forroutine immunization

! National annual budget having adequate provisionfor cold chain equipment

! National annual budget having adequate provisionfor improving service delivery at State/district/block levels

! National annual budget showing % funding fromdomestic budget versus external resources

STRATEGIES

1. National financial sustainability plan: Variouscosting estimates have been made for different com-ponents of the immunization programme. A core teamfor immunization financing will be established withinthe immunization department. Using tools that arealready available, this team will analyse current andprojected immunization costs. These will be com-pared to projected finances available and funding gapswill be highlighted. Methods of raising additional rev-enues will be analysed and communicated to appro-priate levels. The assumptions used for costing arehighlighted in Annex 6.2. Capacity building for immunization health eco-nomics: The core team will include increased link-ages with institutes that may have future interests intraining and research in immunization financingissues. 3. Cost-effectiveness studies of introduction of newvaccines and technologies: Commissioning of stud-ies exploring cost-effectiveness issues surroundingimmunization will help policy-makers take moreinformed decisions. The initial focus will be on newvaccine and immunization initiatives.

OBJECTIVE 2To ensure political commitment for adequate

annual funding at all levels

INDICATOR

! To have a reliable sysytem to generate periodicalMIS, financial reports.

STRATEGIES

Political lobbying: Monitoring reports, action plansand research information will be presented conciselyand in a targeted fashion to inform opinions within theMoH&FW about the need for sustained support forimmunization. Partnership building: Partnerships with immuniza-tion partners will be strengthened (including WHO,UNICEF). The ICC remains an ideal forum not onlyfor technical support to the immunization department,but can also act as a lobbying body for resource mobi-lization.

G O A L 3 The UIP will have sufficient and sustainable

funding with established adequate, accountableand efficient fund flows

M I L E S T O N E S

2005: A national core immunization financing team isestablished and functioningAll States have a focal point for immunizationfinancing issuesNational budget shows provision for purchaseof vaccines for routine immunization, injectionsupplies100% of districts are able to show tracked budget versus expended resources


Strong community participation with immunizationservices not only improves equity and access toimmunization services but also increases the demandfor quality services.

OBJECTIVE 1To ensure widespread support by all families andcommunities and to ensure that all eligible chil-

dren and pregnant women are immunized

INDICATORS

! % of primary caregivers of infants who know(correctly or within two weeks of the date) whenthe next immunization is due, the number of visitsneeded for complete childhood immunization ofinfants under the age of 1 year, where to take theirchild and the need for full immunization

! % of infants bringing vaccination cards to theimmunization session

! % of service providers who communicate to care-givers regarding the next immunization session.

STRATEGIES

Communication activities will take a two-prongedapproach: (a) to reach the underserved or hard to reach pop-ulations with targeted interventions and convincethose who have never participated before, or who arenot participating consistently because of a lack ofknowledge, doubts and misconceptions, or frustrationwith the quality of health services.

(b) to increase the demand for services of those whohave historically participated in routine immunization,but whose interest might be decreasing due to insuffi-cient institutional support for RI. These two approaches will use two main strategies:Influence behaviour at household level: Print mediaand other mass media are effective strategies for rais-ing awareness and influencing behaviour. Inter-per-sonal communication (IPC) with families and com-munities is also critical in bringing about the desiredchange in attitude and behaviour of service users.

(a) IPC through ANMs, AWWs, local mobilizersand influential persons; IEC material for providers aswell as clients (e.g. on frequently asked questions)

(b) Continued media interventions addressingusers’ doubts and misconceptions

(c) MOs and health workers will be trained toimprove IPC skills at ANM training and supervisorymonitoring visits to promote behaviour changes.

(d) During home visits by the ANM or AWW, par-ents will be encouraged to immunize their children.The MO will monitor these visits.

(e) IPC with pregnant mothers during TT immu-nization contact shall be the focus of the communica-tion for enhancing coverage and reducing the drop-outrate.

(f) Local IEC/social mobilization methods (flockmedia) will be adapted and developed for demandgeneration (not just mass media; press/radio and tele-vision).

(g) The AWW will be partnered for effectivedemand generation and information.

(h) Anganwadi centres will also be used as immu-nization sites and fixed immunization days displayedwith the name of the ANM.

(i) Immunization schedule information will be partof all IEC/social mobilization exercises.


G O A L 4 There is sustained demand for and reduced social

barriers to access of immunization services

M I L E S T O N E S

2004: A national focal point and State focal points for strategic communication are establishedA national communications strategic plan is drafted and implemented (involving consensus for accel-erating routine immunization, with particular focus on low-coverage States)

2005: At least 20% of districts in the twelve selected States (UP, Bihar, Rajasthan, West Bengal, Assam,Orissa, Gujarat, Uttaranchal, Karnataka, Andhra Pradesh, Madhya Pradesh and Jharkhand) have inte-grated communication work plans (minimum component IEC training, mobilization of local leaders,effective branding of IEC material)

2006: 40% of districts in the 12 selected States have integrated communication plans2007: 60% of districts in the 12 selected States have integrated communication plans

Mid-term review, assessing impact in terms of key knowledge, attitude and practice indicators2008: 80% of districts in the 12 selected States have integrated communication plans

Accelerated communication activities targeting drop-outs and the introduction of new vaccines 2009: 100% of districts in the 12 selected States have integrated communication plans

(j) Involvement of link workers, e.g. Janmangalcouple.Activation of wider community and district net-works: Social mobilization activities to activate widernetworks and groups.

(a) Immunization session plans will be communicat-ed to the beneficiary population, the DIO and SIOs todisplay information on the site and days of outreach ses-sions in the village at prominent places.

(b) The education sector, Panchayati Raj Institutions,MSS and ICDS will be mobilized to use their wide reachto mobilize families and communities.

(c) DIO and CMO/DHMO/CS will ensure imple-mentation of communication activities for routineimmunization.

(d) Community and religious leaders, NGOs andcommunity volunteers will become actively involvedwith immunization.

(e) Routine immunization microplanning with com-munities and increasing a participatory approach willbenefit the programme greatly, enhancing sustainability.

OBJECTIVE 2To ensure high-level political and

administrative support for immunization as the key public good

Targeting key decision-makers to sustain policy, and

administrative and financial support to the pro-gramme will help create a more enabling environ-ment for strengthening and revitalizing routineimmunization services.

STRATEGIES

1. Advocacy efforts: These shall be directedthrough an active ICC to sustain the interest ofpartners in the immunization programme. Theefforts will include the enrolment of national andState-level politicians, media and civil societygroups to publicly support the acceleration of rou-tine immunization services.2. Cost-effectiveness issues: The highly cost-effec-tive nature of immunization services will be empha-sized to key policy-makers with thoroughly well-researched information.3. Identification and mobilization of private sec-tor partnerships (business houses, service organiza-tions, sports groups)4. Global perspective: Opportunities will be seizedat health and economic fora to inform the interna-tional community about India’s progress in acceler-ating routine immunization.5. Increase confidence in vaccine safety: The GoIwill be regularly informed about the safety of itsimmunization programme so that the GoI may beable to inspire confidence in vaccines.


The choice of newer vaccines to be included in theUIP will be determined and periodically reviewed bythe MoH&FW, taking guidance from the NTAGI.Basic clinical and operations studies will be encour-aged to provide inputs for NTAGI. These studies willprovide evidence for decisions on the timing andselection of new vaccine introduction and provideguidelines for the use of these new vaccines. Suchanalysis will include the major mortality-causing dis-eases of children in India, namely acute diarrhoealdiseases and acute respiratory diseases, in anticipationof rotavirus vaccine and pneumococcal vaccinebecoming available. Disease burden and health eco-nomic analyses will help assess the cost–benefit ratiosof new vaccine introduction. Specific recommenda-tions of the NTAGI on the introduction of new vac-cines have been taken into account to develop thisgoal.

OBJECTIVE 1To ensure that institutional mechanisms are inplace to adequately obtain, review and utilize

information for deciding on the introduction ofnew and underutilized vaccines

There are currently four main bodies concerned withthe introduction of new vaccines in India:

(i) National Technical Advisory Group on Immunization (NTAGI)

(ii) Indian Council of Medical Research (ICMR)(iii) Drug Controller General of India (DCGI)(iv) National Regulatory Authority (NRA)

The introduction of new vaccines involves review-ing all licensed vaccines in different global regions

and identifying those that would be relevant to Indiain the context of the country’s disease profile. Thereare vaccines that are popular in the private market, andthose that are recommended by the Indian Academyof Pediatrics. Accurate information on which to basethe decision of introducing a new vaccine to the UIPrequires periodic review by all agencies concerned.This process requires strong coordination and collab-oration.

A formal mechanism of coordination and collabo-ration between these four agencies is therefore urgent-ly required to establish closer links, pool resourcesmore efficiently, plan research more effectively andshare results of studies more freely. This will help theGoI make better informed decisions for resource allo-cation when deciding on new vaccine introduction.

INDICATORS

! Number of studies completed on prioritized vaccines! Availability of clear policy guidelines for new

vaccine introduction

STRATEGIES

Improve coordination: A new vaccine focal pointwithin the MoH&FW will be established to improvelinks with the MoH&FW. A technical group for newvaccine review will be established with members fromall four agencies. This technical group will have themandate to advise the GoI on:

(a) Designing and drafting the NationalImmunization Policy for the GoI


G O A L 5 Accelerated introduction of licensed new andunderutilized vaccines against diseases with significant mortality and morbidity in India

Principles to guide the addition of new vaccines

1. The vaccine should be safe and effective.2. The disease burden should be judged to be

sufficient to warrant introduction of the vaccineinto the national programme.

3. Cost of the vaccine should be judged reason-able and suitable for absorption into the budgetprovision even if the introduction is funded.

4. Financial sustainability should be built intothe plan of new vaccine introduction.

M I L E S T O N E S

2005: A national focal point for new vaccineintroduction within the MoH&FW is estab-lishedThe NTAGI meets every six monthsA technical group for new vaccine review isestablished with functional links with theGoI and research institutesNational immunization policy is in placeand available

2006: Research needs are reviewed for rotavirus,Haemophilus influenzae type B (HiB),pneumococcus, measles, mumps, rubella(MMR) and Japanese encephalitis (JE),typhoid Policy in place for use of vaccines againsttyphoid fever and JE, both within and out-side the UIP

2007:2008: 2009: Hib probe study result available

(b) Defining policies on vaccine use againsttyphoid fever, varicella, Japanese encephalitis, hepati-tis A both within and outside the UIP

(c) Coordination of studies on disease burden, vac-cine efficacy trials and health economic issues of newvaccine introduction (with special focus on the Hibvaccine)

(d) Together with partner agencies such as WHOand Global Alliance for Vaccines and Immunization(GAVI), review the rates of introduction of new vac-cines in other parts of the world, since 1990, includingidentifying a suitable model that may be adapted forthe Indian context

(e) Advising on advertisements for new vaccinesapproved by the DCGI

(f) Together with academic institutes review newimmunization technologies and research as appropri-ate to the Indian context.

OBJECTIVE 2 To review the need for MMR or MR vaccine in

India’s immunization programme

The need for the introduction of a measles, mumpsand rubella-containing vaccine (MMR) or a measlesand rubella-containing vaccine (MR) will bereviewed. Mumps is not a significant cause of mortal-lity or morbidity and the MR vaccine is cheaper, so itmay be worth reviewing the introduction of the MRvaccine.

INDICATORS

! Progress of studies! Coverage of routine immunization to above 85%

STRATEGIES

1. Research: Consolidation of existing knowledgeand research into congenital rubella syndrome (CRS)and mumps. Commissioning of studies to assess thedisease burden of CRS and mumps in India. 2. Advocacy: Publication and dissemination ofresearch results to policy-makers, donors and partneragencies.

3. Planning: Financial and logistics consequences areconsidered part of research scenarios.

OBJECTIVE 3 To review the need for introduction of Japanese encephalitis (JE) vaccine in

selected States

INDICATORS

! Availability of disease burden data! Availability of a safe and effective JE vaccine

STRATEGIES

1. Geographical delineation: JE-endemic/pronedistricts and risk-free districts will be plottedthrough active research and data surveillance.Results will be presented to policy-makers and rec-ommendations made on where JE vaccine should beintroduced.2. Introduction of quality JE vaccine: Sources ofquality vaccine will be reviewed until it becomesavailable.3. Surveillance: Disease surveillance for JE will beintegrated into the regular surveillance mechanisms.

OBJECTIVE 4To implement a phased introduction of Hepatitis

B vaccine

On 22 May 2002, the Prime Minister announced thelaunching of Hepatitis B vaccine in selected centres inIndia. In June 2002, the GoI prepared the operationsguide for programme managers for introduction ofHepatitis B vaccine in the UIP. In this first phase theintroduction of Hep B vaccine in slums of 15 selectedcities and 33 districts was planned. This has currentlyreached 14 cities and 33 districts. Subsequently, theentire 14 cities are being covered for Hep B vaccina-tion under a pilot project.INDICATOR

! Number of districts and cities covered with Hep B vaccine


M I L E S T O N E S

2005: Mumps and rubella disease burden studiesare completed

2006: Cost-effectiveness study of MMR introduc-tion completed

2007: If epidemiological and costing analysis sug-gests the need and suitability, MMR is intro-duced in the national immunization schedule

M I L E S T O N E S

2005: Geographic mapping of districts prone to JEand those that are risk-free is completedJE disease burden studies are completedwithin selected StatesCost-effectiveness study of JE introduction iscompleted

2006: JE vaccine is introduced into States consid-ered prone to JE

2007: JE is integrated into the regular surveillancemechanisms

STRATEGIES

1. Phased expansion: Hep B expansion will be con-sidered in future. However, until 2007 Hep B intro-duction will be limited to the 15 cities and 33 dis-tricts selected. Expansion to other States with DTP3coverage >75% may be considered after 2007. 2. Administration of doses will follow the nation-al immunization schedule, which includes a birthdose for institutional births. Subsequent doses willbe given at 6 weeks and 14 weeks. When the birthdose has not been given, Hep B vaccine will beadministered at 6, 10 and 14 weeks.3. Training: ANMs will be trained in Hep B vac-cine administration as part of regular training.Mid-level managers (MLM) will be trained duringtheir MLM training.4. Surveillance: Annual analysis of blood banksfor Hepatitis B prevalence will be introduced in theregular VPD surveillance mechanism.5. Record-keeping: All institutions or healthworkers offering Hep B vaccine will ensure insti-

tution-retained and client-retained record-keeping.6. Tetravalent vaccine: When DPT–Hep B combi-nation vaccine is available (predicted mid-2006)and affordable, the combination vaccine willreplace the monovalent vaccines. Affordabilitywill be analysed during the scenario-building ofthe financial sustainability plan and with coordi-nated research into the cost-effectiveness oftetravalent vaccine introduction.


M I L E S T O N E S

2005: A Hep B immunization focal point is estab-lished in the MoH&FW33 districts and 15 cities are covered with Hep B

2006: 33 districts and 15 cities are covered with Hep B

2007: –2008: –2009: –


The impact of the UIP is measured in terms of diseaseburden by accurate surveillance mechanisms. Theseare essential not only for reviewing the impact of theUIP, but also for responding to VPD outbreaks.

The safety of the UIP may be monitored through theadverse events following immunization (AEFI) sur-veillance system. AEFI surveillance is crucial forensuring rapid response to low quality and potentiallydangerous immunization services.

The efficiency of the UIP is measured by monitoringcoverage rates and drop-out rates by district. This iscrucial for prioritizing geographical areas and popula-tions for strengthening immunization and targetingresources appropriately.

OBJECTIVE 1To institutionalize surveillance for vaccine-

preventable diseases and early detection of anyoutbreaks

VPDs that will be monitored through this systeminclude those that are currently in the UIP schedule, orthose that will be reviewed for new vaccine introduc-tion during this Plan. These include polio, diphtheria,pertussis, neonatal tetanus (NNT), measles, rubellaand Hep B.

The surveillance initiative should build on thestrengths of the current AFP surveillance network, yetnot dilute its effectiveness. These strengths can be

used for other VPDs and include:! Complete and timely reporting! Case investigation! Detailed data analysis to monitor progress and

target action! Immediate reporting of VPDs and monthly

aggregate reporting of data from districts! Collaboration between laboratory and

epidemiology units.

INDICATORS

! Number of VPD cases reported! Number of cases/outbreaks investigated by

laboratory! Number of outbreaks reported and investigated

within 48 hours! % of monthly VPD surveillance reports received

by districts that are complete! % of VPD surveillance reports received by

districts that are received monthly on time! % of States able to report monthly on VPDs

electronically.

STRATEGIES

Disease reporting is currently done monthly by avariety of mechanisms that make it difficult toanalyse or use the information locally. It is often dif-ficult to obtain accurate information from districts toStates and at the national level. This results in delaysin detecting VPDs and in responding with improvedimmunization efforts. Early detection of clustering isessential for applying interventions for preventionand control. India is in the process of developing adisease surveillance system in which disease infor-mation is used for immediate local intervention.

Ultimately, VPD surveillance should become a partof (be integrated with) the national disease surveil-lance system; however, immediate strengthening ofVPD surveillance at all levels is required. The

G O A L 6 To monitor and use accurate, complete andtimely data on vaccine-preventable diseases,AEFIs, and antigen coverage and drop-out

rates by district

M I L E S T O N E S

2005: A national focal point for monitoring VPDs, AEFI surveillance and antigen coverage rates is established20% of districts able to electronically report monthly on VPDs to the national level40% of States have a focal point for VPD surveillance and monitoring which has access to and is ableto use the database for planning immunization activities

2006: 50% of districts able to electronically report monthly on VPDs to the national level70% of States have a focal point for VPD surveillance and monitoring which has access to and is ableto use the database for planning immunization activities

2007: 50% of districts able to electronically report monthly on VPDs to the national level100% of States have a focal point for VPD surveillance and monitoring which has access to and is ableto use the database for planning immunization activities

2008: 70% of districts able to electronically report monthly on VPDs to the national level2009: 100% of districts able to electronically report monthly on VPDs to the national level

District/Municipal Corporation will be the surveil-lance unit for action and reporting to the State.

Each health facility is responsible for reportingVPDs immediately by phone, telegram, card or emailto the district officer. Eventually, the disease surveil-lance system will require a district epidemiology offi-cer. At present, the DIO can function as theSurveillance Officer (VPD). The district is responsi-ble for conducting outbreak investigations, imple-menting preventive measures and preparing a month-ly consolidated report for the State. VPDs will grad-ually be integrated into a comprehensive disease sur-veillance system.

The main features of VPD reporting will include thefollowing:! Case-based reporting from the health facility to

the district ! Monthly aggregate reporting to the State! State to report monthly aggregated data to the

Centre

In case of outbreaks, immediate investigation(within 48 hours) will be conducted by the respectivedistricts/MC using the existing infrastructure. Ifinvestigation confirms an outbreak, immediate inter-vention will be initiated by the DHMO/DiseaseSurveillance Officer assisted by the DIO. Every con-firmed outbreak and investigation will be reportedimmediately from the district to the State and theState is responsible for informing the Centre. Diseaseclusters are also to be detected and investigated asearly signals of potential outbreaks.

A monthly disease summary will be prepared bythe DIO/District Surveillance Officer and reported tothe State and all surveillance units. 1. Phased introduction of RIMS: A routine immu-nization monitoring system (RIMS) has been devel-oped. This system incorporates elements of VPDcases, mapping, database and analysis. This phasewill include training in software use, installation anddata analysis. All reporting from the district level andabove will be done electronically with key standard-ized tools that can be easily analysed at the districtlevel. 2. Increase accuracy and use of data at local levels:The District/Municipal Corporation will be the unitfor surveillance and outbreak control. The DIO willbe responsible for surveillance activities; assisted byeither a district focal epidemiologist,11 statistician ordata analyst to increase the capacity of data use foraction at the local level. Together with supportivesupervision, monthly feedback from Centre to State,State to district and district to health facility levels

should increase motivation for reporting accurately.Supportive supervision visits by first-line supervisorsusing a standardized tool will help minimize over-reporting, identify area-specific problems and findlocal solutions.3. Private sector and community involvement: Inview of the number of patients using private health-care, lessons learnt from Kerala will be used to linksurveillance and monitoring mechanisms with theprivate sector. Community reporting of VPDs willalso be encouraged and specific strategies will bereviewed. Mechanisms for coverage data collection,compilation and flow from session sites/sub-centres/private clinics to the district and then to the State onuniform patterns will be highlighted. VPD surveil-lance mechanisms will attempt to integrate as muchas possible with other surveillance mechanisms,without losing the required responsiveness for out-break response or diluting the focus on AFP surveil-lance.4. Laboratory confirmation and strengthenedlinkages with surveillance: Laboratory diagnosticsupport will be provided through a network of cur-rently available institutions and by establishing addi-tional facilities. This will ensure prompt feedback tofield investigators as well as to district, State andnational level authorities.

OBJECTIVE 2To strengthen vaccine quality and injection

safety by developing a monitoring system forreporting and responding to AEFI by 2010

Vaccine manufacturers produce vaccines with thehighest safety and quality standards available withcurrent technology. However, no biological producthas yet been developed which is 100% safe and 100%effective. Consequently, some very rare vaccine-related adverse events may occur, especially when alarge number of people are vaccinated. Programmemanagers and vaccinators need to know what theycan expect as ‘common’ (mild, subsiding withouttreatment and leaving no long-term consequences)and ‘rare’ (anaphylaxis, febrile seizure, encephalopa-thy, etc.).

Programmatic errors are the cause for most com-monly reported adverse events. These occur as aresult of inappropriate storage, handling, preparationand administration of vaccines. It is extremely impor-tant that these AEFI are reported and investigated asthey require a rapid response and corrective measuresto prevent additional cases. A programme error oftenoccurs if a vaccinator does not follow the standard


11 Medical officer in charge of RCH/immunization may be given suitable training to fulfil the functions of the district epidemiologist.

immunization policies and practices established andtaught during training.

AEFI, particularly when they are not properlymanaged, represent a genuine threat to the immuniza-tion programme and, in some cases, to the health ofpatients. To protect the public and the success of theimmunization services, it is therefore critical thatAEFI are detected, reported and investigated, andprogrammatic errors promptly corrected to preventfurther risk of harm. Because of the inevitable natureof AEFI, communication plans must be in place toprevent a loss of confidence in vaccines or the vacci-nation services.

INDICATORS

! National guidelines on AEFI updated and widelydistributed

! AEFI investigation team established in each dis-trict and AEFI review committee established ineach State

! % of districts reporting AEFI on a monthly basisto the State level (allowing zero reporting)

! % of severe AEFI reported within 24 hours! % of severe AEFI cases investigated within 48

hours (expected 100%).

STRATEGIES

The strategy is to capitalize on the existing systemand experience of States that have succeeded inestablishing AEFI surveillance systems to strengthenthe system in States where AEFI surveillance is notfunctional. In 2005–06 a series of workshops mustbe conducted, initially targeting States that haveachieved high immunization coverage includingthose with an AEFI monitoring system. State EPImanagers, local Food and Drug Authority (FDA)officials and representatives of medical institutes and

vaccine producers will be invited for a workshop to:! Review and update information on tasks and

responsibilities of key players in the AEFI sys-tem, including the Drug Controller General ofIndia (DCGI), FDA officials, national UIP man-agers and State-level UIP managers.

! Share experiences on existing AEFI activities inselected model States.

! Discuss current barriers to reporting and identifymeasures to overcome constraints to reduce AEFI.

! Review and finalize the proposed core list ofAEFI to be reported, procedures to conduct caseinvestigations and to report to the State andnational levels.

! Agree on a standardized procedure for laborato-ry investigation (when a vaccine test is needed,which test is needed under what circumstances,etc.).

! Review (and strengthen) procedures for causalityassessment.

The experience and technical expertise in surveil-lance systems gained by the well-performing Stateswill be an asset to finalize guidelines and reportingforms, to identify solutions to address barriers toreporting and to assist States with no AEFI surveil-lance system. The second set of workshops will beconducted with the participation of less-performingStates. The main objective will be to initiate a report-ing system for these States using the experience andmaterial finalized during the first series of workshopswith well-performing States.

During the workshop with well-performing Statesit is expected that a pool of UIP and FDA managerswill be identified to serve as facilitators and technicalresources for States that have low or medium cover-age and no AEFI system.

M I L E S T O N E S

2005: All States have instituted an AEFI investigation team and causality committeesA national AEFI focal point is appointed within the national immunization department30% of districts are able to report the AEFI status on a monthly basis to the State level30% of States have drafted and are implementing an AEFI response plan

2006: 50% of States have drafted and are implementing an AEFI response plan50% of districts are able to report the AEFI status on a monthly basis to the State level



2009: 100% of districts are able to report the AEFI status on a monthly basis to the State level100% of States have drafted and are implementing an AEFI response plan


OBJECTIVE 3To establish an effective, efficient, complete andtimely immunization recording and local area

monitoring system by 2010

INDICATORS

! % of districts with less than 10% discrepancybetween evaluated and reported DPT3 coverage

! % of monitoring reports received by districts thatare complete

! % of monitoring reports received by districts thatare received on time

! % of districts reporting an adequate number of monitoring forms available for health facilities

STRATEGIES

1. Strengthen the monitoring system at the locallevel: Through training and appropriate logistics sup-ply mechanisms:

(a) All health units will have access to and correct-ly use tally sheets, monitoring charts, immunizationregisters, immunization cards and a ‘tickler box’ sys-tem for following up defaulters.

(b) Each health facility/health worker will maintainan immunization register showing resident children’snames (irrespective of place of birth), the actual vac-cination against each child/mother and report only theactually vaccinated number from the tally sheet.

(c) Health workers should be encouraged to main-tain and use village/ward-wise Family Registers.

(d) The health worker should also make efforts toaccess the revenue department birth registers wherev-er necessary so that the accuracy of the denominatorcan be maintained.

(e) Periodic surveys should be undertaken by thehealth system to identify unregistered/in-migratedchildren. (The frequency of such surveys may vary asper the local situation, ranging from once in threemonths to once every year.)

(f) All possible efforts should be made to cross-notify the concerned health facility/worker on immu-nization of in-migrated children.

(g) Family retained immunization records will be

made available to each child/mother to ensure that allvaccinations can be recorded, irrespective of thesource. These will be provided on every birth regis-tration and standardized nationally, printed in region-al languages and in English for the choice of family.

(h) An additional column should be included in thevaccination records to trace where the child was vac-cinated.

(i) All efforts should be made to validate the report-ed data by supervisors and monitors at all levels.

(j) Legislation is recommended to bring urbanhealth into the MoH&FW, pending which urban unitsmust function like a district.2. Decentralization of monitoring to strengthenlocal use of information for action:

(a) Decentralized programme monitoring will becentred round the district unit. The information onmonitoring indicators should be fed back by the DIOduring the monthly meetings. The district epidemiolo-gist/statistician or data analyst and immunization offi-cer will monitor data, the reported coverage, vaccinesupply, vaccine utilization, sessions planned versussessions held on a monthly basis. When gross dis-crepancies are noted in districts, 30-cluster samplingsurveys may be conducted to evaluate coverage.

(b) Supply and utilization of vaccines will be mon-itored at the PHC/health facility level and reviewedby the DIO both during his monitoring and during themonthly meetings.

(c) Analyses of the data based on the above infor-mation will be done to identify discrepancies in theprocess and geographical areas with problems.

(d) Potentially vulnerable communities (slums,migrant workers and tribal areas) will be regularlymonitored for coverage among infants and older pre-school children, both by vaccine supply/utilizationrecords and by surveys at least once a year.

(e) District-level Officers will monitor through sup-portive supervisory visits records maintained by healthworkers—both denominator and beneficiaries. TheDistrict Officers must certify the validity of the moni-toring data, which will be liable for extrinsic evaluation.

(f) When gross discrepancies are detected, the DIO

M I L E S T O N E S

2005: 25% of districts with less than 10% discrepancy between evaluated and reported DPT3 coverage60% of monitoring reports received by districts are complete

2006: 80% of monitoring reports received by districts are complete2007: 50% of districts with less than 10% discrepancy between evaluated and reported DPT3 coverage

100% of monitoring reports received by districts are complete2008: 80% of districts with less than 10% discrepancy between evaluated and reported DPT3 coverage2009: 100% of districts with less than 10% discrepancy between evaluated and reported DPT3 coverage


will discuss with concerned supervisors to identifyreasons for these and take corrective action. 3. Use of data at different levels: Based on data fromdistricts, these will be aggregated at the State andnational level for policy and programme reviews.Data will be used to prioritize districts and districtswill be able to prioritize health facilities by analysinginformation into:

Priority 1: areas with <80% DPT3 coverage and>10% DPT1–DPT3 drop-out rate

Priority 2: areas with <80% DPT3 coverage and<10% DPT1–DPT3 drop-out rate

Priority 3: areas with >80% DPT3 coverage and>10% DPT1–DPT3 drop-out rate

4. Use of surveys: Multiple external coverage evalu-ations by various agencies add to the confusion andwill not be encouraged. Coverage surveys will be con-ducted wherever VPD is reported in clusters or withunexpected frequency. If coverage is inadequate,action will be taken to improve the coverage rapidly.The district survey data (rapid RCH survey) will bedisseminated widely for transparency and better per-formance. Coverage evaluation surveys will beincluded as part of the independent evaluation of theprogramme. An independent evaluation mechanismshould be instituted at every State and at the nationallevel for the same. The coverage survey data findingswill be shared with the States/districts at the earliestfor corrective action and better performance.5. Routine immunization monitoring system(RIMS): A software (RIMS) has already been devel-

oped and will be introduced at the national, State anddistrict levels. It aims to speed up the transfer of datafrom the district to the national level. General moni-toring activities will be through identification of vari-ous officials who will act as monitors. The States willbe monitored by the national level, districts by Statesand the national level, blocks by the State and districtlevel, and sessions by district- and block-level offi-cials. Appropriate formats covering relevant indica-tors applicable to the respective level being monitoredwill be available along with a mechanism for compi-lation of the monitoring data and data analysis, andidentification of action points based on monitoringfeedback. The use of independent monitors for assist-ing the State may be considered.6. Linkages with the private sector: Involvementof the private sector is essential and public–privatepartnership will be strengthened. All private agen-cies providing vaccination should give family-retained immunization cards and also maintainappropriate records retrievable on demand. If vac-cines were collected from government sources, aregular utilization report should be submitted. Whenvaccines are given from the private market, immu-nization cards and institution-retained registers willdocument this information. Health functionariesshould be provided these documents on demand.Medical colleges, professional organizations such asthe Indian Academy of Pediatrics (IAP) and IndianMedical Association (IMA) should be included toassist in building public–private partnerships.


38G

oI Im

mu

nizatio

n M

ulti Y

ear Plan

2005–2010

PROGRAMME COST: ROUTINE IMMUNIZATION PROGRAMME—MULTI YEAR PLANin rupees

COMPONENT April 2005–March 2006 April 2006–March 2007 April 2007–March 2008 April 2008–March 2009 April 2009–March 2010 TOTAL

3,155,417,747 3,176,017,036 3,219,693,402 3,265,553,586 3,313,706,780 16,130,388,549

9,674,020,950 10,078,971,998 10,586,601,297 11,190,608,562 11,667,385,490 53,197,588,297

342,063,419 303,300,241 323,501,009 277,167,773 61,806,916 1,307,839,358

1,337,464,105 1,431,441,021 1,532,021,224 1,639,668,696 1,754,880,016 7,695,475,062

1,155,205,933 739,703,431 725,728,241 769,386,215 674,968,878 4,064,992,698

143,278,772 146,071,376 148,919,242 151,823,507 154,785,331 744,878,228

8,148,812,287 5,201,687,609 3,827,127,584 4,004,356,460 4,187,143,640 25,369,127,581

119,466,310 122,888,987 126,756,695 130,779,637 134,964,838 634,856,467

414,718,173 364,463,046 370,631,975 383,002,955 348,690,284 1,881,506,433

24,497,792,916 21,566,376,039 20,862,584,823 21,814,030,567 22,300,098,321 111,040,882,666

7,345,220 1,831,295 1,604,154 1,683,175 1,766,148 14,229,992

1. Service delivery

2. Human resources and training

3. Cold chain

4. Vaccine procurement and distribution

5. Injection safety

6. Hepatitis B in existing 33 districts and 15 cities

7. Pulse polio eradication

8. Surveillance

9. Monitoring

TOTAL (rupees)

10.Contingency, operational research, new vaccine initiatives

in US$

COMPONENT April 2005–March 2006 April 2006–March 2007 April 2007–March 2008 April 2008–March 2009 April 2009–March 2010 TOTAL

72,538,339 73,011,886 74,015,940 75,070,197 76,177,167 370,813,530

222,391,286 231,700,506 243,370,145 257,255,369 268,215,758 1,222,933,064

7,863,527 6,972,419 7,436,805 6,371,673 1,420,849 30,065,273

30,746,301 32,906,690 35,218,879 37,693,533 40,342,069 176,907,473

26,556,458 17,004,677 16,683,408 17,687,039 15,516,526 93,448,108

3,293,765 3,357,963 3,423,431 3,490,196 3,558,283 17,123,637

187,329,018 119,579,026 87,979,944 92,054,172 96,256,176 583,198,335

2,746,352 2,825,034 2,913,947 3,006,428 3,102,640 14,594,402

9,533,751 8,378,461 8,520,275 8,804,666 8,015,869 43,253,021

563,167,653 495,778,760 479,599,651 501,471,967 512,645,938 2,552,663,969

168,856 42,099 36,877 38,694 40,601 327,126

1. Service delivery

2. Human resources and training

3. Cold chain

4. Vaccine procurement and distribution

5. Injection safety

6. Hepatitis B in existing 33 districts and 15 cities

7. Pulse polio eradication

8. Surveillance

9. Monitoring

TOTAL (US$)

10. Contingency, opera tional research, new vaccine initiatives

5. National-level Immunization Plan Budget Requirements (see Annex 6)


6. Managing the NationalImmunization Plan

To implement this five-year, six-goal, twenty-objec-tive plan will require great strengthening of the

management system at all levels; national, State, dis-trict, and Panchayati Raj Institutions (PRIs). There will begreater transparency and more effective communication.

6.1 National GovernmentSee Annexes 4 and 5. The UIP shall be a separate divi-sion with a Deputy Commissioner (DC) for immuniza-tion as the overall technical and management focal pointfor immunization in India. Under the DC (Immuni-zation) will be a sufficient number of AssistantCommissioners (ACs) who will act as national technicaland management focal points for their respective duties.The areas that would need individual attention are:! procurement, cold chain and logistics! surveillance, monitoring and evaluation! new vaccines (Hep B, MMR, JE and tetravalent)! training in immunization and human resource allocation! strategic communication! accelerated disease control (polio, tetanus,

measles and vitamin A deficiency)! safety issues (safe injection and waste disposal,

and AEFI surveillance, monitoring and response)! Financial administration and legal matters within

the UIPThis will help channellize communication and

information appropriately and would free the DC toundertake more of a strategic management role.

The role of the National Government will be policyformulation and ensuring the quality of servicesthrough monitoring, supervision, training logistics andsupply of vaccines, coordination of the programmeand providing technical and financial resources,involvement in work delegation and team building,establishing priorities, forecasting needs, carrying outstrategic planning and inter-agency coordination.

Planning, monitoring and evaluation for immunizationactivities will be carried out by the immunization sectionof the Child Health Division. In this respect, collaborationand cooperation will be sought from other ministries,departments, agencies and non-governmental organiza-tions (NGOs) as well as private institutions working in thefield of health. Every effort will be made to immunizeevery eligible child. An overview of the new NationalImmunization Cell (NIC) is presented in Annex 5.

6.2 State Government (and local self-government)These are basically implementing agencies (see Annex 4).Maintenance of assets will be the joint responsibility of

the implementing agencies (State Government/localself-government) and the national government. DIOswill continue to be paid by the Central Government inthe medium term. Maintenance of staff and assets pro-cured by the State Government/local self-governmentwill be the responsibility of the State Government.

States will have the freedom to introduce new vac-cines, depending on their felt need, and should haveidentified new vaccines. However, policy approval willneed to be obtained from the national government, thevaccine should be passed by the NRA and funding willneed to be available from the State if it is not a nation-wide approach. DIOs will be duty bound to give thevaccine through the programme if the State decides tointroduce a new vaccine.

6.3 Panchayati Raj InstituitionsIn view of the fact that in some States several healthsector functions have been handed over to PRIs, therole of the PRI will be reviewed and strengthened ineach State. This will involve a review process thatincludes financial strengthening and an increase indecision-making powers.

6.4 Municipal corporations in urban areasCoordination will be established to ensure that allhealth activities and management of municipal townsand city corporations are synergized under theMinistry of Health and the Directorate of HealthServices of the State. This will improve not only com-munication between departments, but should also improveoverall immunization services provided to urban areas.

6.5 MonitoringThe highlighted indicators will be measured at thefield level and milestones will be monitored by theCentral level. The UIP will be constantly monitoredthrough public and private health sector mechanisms,the formal and informal surveillance and immunizationmonitoring systems, as well as PRI systems.

The national-level UIP shall monitor States’ perform-ance and the State UIP shall monitor the districts’ per-formance. The DIOs shall analyse facility reports month-ly and perform assessments of performance includingtimeliness, accuracy and completeness of reports. Theindicators to be monitored are highlighted under each goal.

6.6 EvaluationA mid-term review and final evaluation will be exe-cuted by an independent body or group of agencies,designated by the MoH&FW. Recommendations fromthe mid-term review will be fed into strategies andmethods for implementing the remainder of the plan.

The final evaluation will act as a catalyst for devis-ing the next immunization plan.

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7. Summary of UIP goals, objectives and milestones

GOAL 1. Districts will provide equitable, efficient and safe immunization services to all infants and pregnant women

35% of districts achieve DTP3 cov-erage of ≥80% and BCG–measlesdrop-out rate of ≤15%.

State- and district-level immu-nization human resource andmanagerial capacity is reviewed.Mid-level manager training in alldistricts is completed. Further training need of fieldfunctionaries is identified.Adapted field-level operationalguidelines are finalized and usedcountrywide.

Cold chain reviews are undertak-en in EAG states.A national cold chain focal pointis established (procurement andlogistics) at the national level tolook after forecasting and utiliza-tion and to assist State estimatesfor requirement.

80% of identified cold chainequipment is functioning at anygiven point of time.Training at materials for coldchain training at all levels will bestandardized and finalized.

60% of identified cold chainequipment is functional.Training material for cold chaintraining (include system andequipment training) is provided.

30% of districts being monitoredfor microplan for vaccine fore-casting and procurement

50% of districts with no measlesvaccine stock-out

All districts are supplied withand are using AD syringes, nee-dle cutters.


Recommendations from thehuman resource and managerialreview are implemented.A countrywide human resourceneeds review is completed.All ANMs have attended a train-ing course on safe injection prac-tices, waste disposal and AEFIreporting and Hep B vaccineintroduction.

Cold chain review in WestBengal, Assam, Andhra Pradeshand Karnataka

85% of identified cold chainequipment is functioning at anygiven point in time.

30 % of State cold chain officersand district refrigerator mechan-ics trained.

75% of identified cold chainequipment functional. All Statecold chain officers and all dis-trict refrigerator mechanicstrained in EAG states




65% of districts achieve DTP3coverage of ≥80% and BCG–measles drop-out rate of ≤15%

Recommendations from humanresource needs review are imple-mented.Framework for involvement ofthe private sector for the immu-nization the programmereviewed and strengthened.

90% of identified cold chainequipment is functioning at anygiven point of time.

30 % of State cold chain officersand district refrigerator mechan-ics trained.




80% of districts achieve DTP3 cov-erage of ≥80% and BCG–measlesdrop-out rate of ≤15%

Re-orientation and trainingneeds of DIOs and field func-tionaries assessed and imple-mented

90% of identified cold chainequipment is functioning andmaintained at any given point oftime.

40 % of State cold chain officersand district refrigerator mechan-ics trained





Re-orientation and training ofDIOs and field functionariescompleted.

Computerized immunizationcold chain and spare parts inven-tory system available in allStates and at national level.

100% of districta being moni-tored for microplan for vaccineforecasting and procurement

100% of districts with nomeasles vaccine stock-out


1. To ensure that regular, qual-ity immunization sessionsare planned and held

2. To ensure that adequatetrained staff are empow-ered to provide essentialquality immunizationservices

3. To keep an annuallyupgraded inventory of thecold chain according tothe levels of the network,allowing for new equip-ment, substitution, replace-ment, spare parts, fueland others in order tomaintain a functional sta-tus of 90%

4. To ensure an efficient vac-cine and injection equipmentmanagement and logisticssystem to forecast and deliv-er adequate supplies of vac-cines in a timely manner

5. To ensure the implemen-tation of safe injectionpractices and waste dis-posal

OBJECTIVE 2005 2006 2007 2008 2009

GOAL 2. Contribute to global polio eradication, measles mortality reduction and neonatal tetanus elimination

Zero wild polio cases in IndiaAFP surveillance is maintainedto ≥1 non-polio AFP case per100,000 population under 15years80% of AFP cases sampled withan adequate stool sample

National focal point for NNT iscreated.All States have an NNT focalpoint.30% of States have eliminatedNNT.50% of districts in each Statehave >90% TT2 coverage forpregnant women.

Measles laboratory networkassessedNational and State measles nodalpoints identified5 major States have establishedactive measles surveillance50% of outbreaks are investigat-ed in these 5 States50% of districts have at least90% measles vaccine coverage10% reduction in measles mor-tality as compared to baselinedata of 2000A national plan for vitamin Asupplementation is updated andimplemented.

A national vitamin A focal pointand State vitamin A focal pointsare established.

AFP surveillance is maintained to≥1 non-polio AFP case per100,000 population under 15 years80% of AFP cases sampled withan adequate stool sample

70% of districts in each Statehave >90% TT2 coverage forpregnant womenA national NNT case base data-base is created

Measles laboratory network isinitiated5 additional States have estab-lished active measles surveil-lance50% of outbreaks are investigat-ed in these 10 States60% of districts have at least90% measles vaccine coverage20% reduction in measles mor-tality as compared to baselinedata of 2000

40% of districts achieved 70%coverage with vitamin A

Certification of polio eradicationin the South-East Asia Region(India and other countries)AFP surveillance is maintained to≥1 non-polio AFP case per100,000 population under 15 years80% of AFP cases sampled withan adequate stool sample

50% of States have eliminatedNNT80% of districts in each Stateshave >90% TT2 coverage forpregnant women

10 additional States have estab-lished active measles surveil-lance50% of outbreaks are investigat-ed in these 20 States65% of districts have at least90% measles vaccine coverage30% reduction in measles mor-tality as compared to baselinedata of 2000

60% of districts achieved 70%coverage with vitamin A 100% of children who receivemeasles vaccine also receivevitamin A All measles outbreaks providevitamin A to measles cases inoutbreaks

90% of districts in each Statehave >90% TT2 coverage forpregnant women

10 additional States have estab-lished active measles surveil-lance50% of outbreaks are investigat-ed in these 30 States75% of districts have at least90% measles vaccine coverage45% reduction in measles mor-tality as compared to baselinedata of 2000

80% of districts achieved 70%coverage with vitamin A

Decision on use of OPV versusIPV (dependent on global certifi-cation of polio eradication)100% of States have eliminatedNNT

100% of districts have >90%TT2 coverage for pregnantwomen

5 remaining States have estab-lished active measles surveil-lance50% of outbreaks are investigated80% of districts have at least90% measles vaccine coverage60% reduction in measles mor-tality as compared to baselinedata of 2000

100% of districts annuallyachieve 70% coverage of 2 dosesof vitamin A for children 9–36months

OBJECTIVE 2005 2006 2007 2008 20091. To achieve polio eradica-

tion certification by 2007

2. To eliminate neonataltetanus by 2009

3. To reduce measles mortal-ity by two-thirds by 2010,compared to 2000 esti-mates

4. To achieve and maintain alevel of 70% coverage withtwo doses of vitamin Asupplementation to chil-dren under three years

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GOAL 3. The UIP will have sufficient and sustainable funding with established adequate, accountable and efficient fund flows

A national core immunizationfinancing team is established andfunctioning.All States have a focal point forimmunization financing issues.The national budget shows provi-sion for purchase of vaccines forroutine immunization and injec-tion supplies.100% of districts are able toshow tracked budget versusexpended resources.

OBJECTIVE 2005 2006 2007 2008 2009

1. To ensure adequate finan-cial resources for the UIPat national and State levelsfor the UIP to achieve goalsand objectives

2. To ensure political commit-ment for adequate annualfunding at all levels

GOAL 4. There is sustained demand and a reduction in social barriers to access immunization services

At least 20% of districts in the 12selected States (UP, Bihar,Rajasthan, West Bengal, Assam,Orissa, Gujarat, Uttaranchal,Karnataka, Andhra Pradesh,Madhya Pradesh and Jharkhand)have integrated communicationwork plans (minimum compo-nent IEC training, mobilizationof local leaders, effective brand-ing of IEC material).

40% of districts in the 12 select-ed States have integrated com-munication plans.

60% of districts in the 12 select-ed States have integrated com-munication plans.Mid-term review, assessingimpact in terms of key knowl-edge, attitude and practice indi-cators.

80% of districts in the 12 select-ed States have integrated com-munication plans.Accelerated communicationactivities targeting drop-outs andthe introduction of new vaccines

OBJECTIVE 2005 2006 2007 2008 2009

100% of districts in the 12selected States have integratedcommunication plans.

1. To ensure widespread sup-port by all families andcommunities so that all eli-gible children and preg-nant women are immu-nized

2. To ensure high-level politi-cal and administrative sup-port for immunization asthe key public good

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GOAL 5. Accelerated introduction of licensed new and underutilized vaccines against diseases with significant mortality andmorbidity in India

A national focal point for newvaccine introduction within theMoH&FW is established.The NTAGI meets regularly andestablishes functional links withthe GoI and research institutes.National immunization policy isin place and available.

Mumps and rubella disease bur-den studies are completed.

Geographic mapping of districtsprone to JE and those risk-free iscompleted.JE disease burden studies arecompleted within selected States.Cost-effectiveness study of JEintroduction is completed.

A hepatitis B immunization focalpoint is established in theMoH&FW33 districts and all 15 cities arecovered with Hep B vaccine.

Research needs are reviewed forrotavirus, Haemophilus influen-zae type B (HiB), pneumococ-cus, measles, mumps rubella(MMR) and Japanese encephali-tis (JE), typhoid.Policy in place for use of vac-cines against typhoid fever andJE, both within and outside theUIP

Cost-effectiveness study ofMMR introduction completed.

JE vaccine is introduced intoStates considered prone to JE.

33 districts and all 15 cities arecovered with Hep B vaccine.

If epidemiological and costinganalyses suggest need and suit-ability, MMR is introduced tothe national immunizationschedule.

JE is introduced in regular sur-veillance mechanisms

OBJECTIVE 2005 2006 2007 2008 20091. To ensure that institution-

al mechanisms are in placeto adequately obtain,review and utilize infor-mation for deciding on theintroduction of new andunderutilized vaccines

2. To review the need forMMR or MR vaccine inIndia’s immunization pro-gramme

3. To review the need forintroduction of Japaneseencephalitis (JE) vaccinein selected States

4. To implement a phasedintroduction of hepatitis Bvaccine

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GOAL 6. To monitor and use accurate, complete and timely data on vaccine-preventable diseases, AEFIs, and antigen coverageand drop-out rates by district

A national focal point for VPD,AEFI surveillance and antigencoverage rate monitoring isestablished.20% of districts able to electron-ically report monthly on VPDs tothe national level.40% of States have a VPD sur-veillance and monitoring focalpoint that has access to and isable to use the database for plan-ning immunization activities.

All States have instituted anAEFI investigation team andcausality committees.A national AEFI focal point isappointed within the nationalimmunization department.30% of districts are able to reportthe AEFI status on a monthlybasis to the State level.30% of States have drafted andare implementing an AEFIresponse plan.

25% of districts with less than10% discrepancy between evalu-ated and reported DPT3 coverage60% of monitoring reportsreceived by districts are com-plete.

1. To institutionalize surveil-lance for vaccine-preventa-ble diseases and earlydetection of any outbreaks

2. To strengthen vaccine qual-ity and injection safety bydeveloping a monitoringsystem for reporting andresponding to AEFI by2009

3. To establish an effective,efficient, complete andtimely immunization record-ing and local area monitor-ing system by 2009

50% of districts are able to elec-tronically report monthly onVPDs to the national level.70% of States have a VPD sur-veillance and monitoring focalpoint that has access to and isable to use the database forplanning immunization activi-ties.

50% of States have drafted andare implementing an AEFIresponse plan.50% of districts are able to reportthe AEFI status on a monthlybasis to the State level.

80% of monitoring reportsreceived by districts are com-plete.

50% of districts are able to elec-tronically report monthly onVPDs to the national level.100% of States have a VPD sur-veillance and monitoring focalpoint that has access to and isable to use the database for plan-ning immunization activities.


50% of districts with less than10% discrepancy between evalu-ated and reported DPT3 cover-age.100% of monitoring reportsreceived by districts are com-plete.

70% of districts are able to elec-tronically report monthly onVPDs to the national level.


OBJECTIVE 2005 2006 2007 2008 200995% of districts are able to elec-tronically report monthly onVPDs to the national level.

100% of districts are able toreport the AEFI status on amonthly basis to the State level.100% of States have drafted andare implementing an AEFIresponse plan.

100% of districts with less than10% discrepancy between eval-uated and reported DPT3 cover-age.

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ANNEX 1 CONSTITUTION OF THE NATIONAL TECHNICAL

ADVISORY GROUP ON IMMUNIZATION

The National Technical Advisory Group on Immunization has been constituted with the approval of the Secretary (FW), Government of India with the following members and terms of reference.

Composition 1. Secretary (FW) Chairman

Department of Family Welfare2. Joint Secretary (RCH) Member 3. Deputy Commissioner (CH) -do-4. Assistant Commissioner (Imm.) -do-

Representatives of National Organizations5. Indian Council of Medical Research (ICMR) -do-6. National Institute of Virology, Pune -do-7. National Institute of Communicable Disease (NICD), Delhi -do-8. National Institute of Health and Family Welfare (NIH&FW) -do-9. National Institute of Immunology, Delhi -do-

Representatives of Professional Organizations 10. Indian Academy of Pediatrics -do-11. Indian Medical Association -do-12. Indian Association of Preventive and Social Medicine -do-

State Government Representatives/Programme Managers 13. Secretary (FW), Orissa -do-14. Secretary (FW), Uttar Pradesh -do-15. State Director/State RCH Officer, Tamil Nadu -do-16. Director (FW), Maharashtra -do-17. Director (FW), Madhya Pradesh -do-

Representatives of Government Departments 18. Department of Women and Child Development -do-19. Internal Finance Division, MoH&FW -do-20. Department of Biotechnology -do-21. Planning Commission -do-22. Drug Controller General of India (DCGI) -do-

Experts23. Dr Jacob John -do-24. Dr Ranjit Roy Chaudhury -do-25. Dr Shanti Ghosh -do-26. Dr K.B. Banerjee -do-27. Dr J. Sokhey -do-28. Representative from UNICEF -do-29. Representative from WHO -do-30. Representative from World Bank -do-


Major roles of the Technical Advisory Group

! To be an advisory body to assist the Government of India in developing a nationwidepolicy framework for vaccines and immunization

! To prioritize immunization activities and set attainable targets! Identify critical gaps in policy and programme, and identify studies, assessment and

research areas to be addressed! To review periodic assessment of the national immunization programme, including

immunization performance and disease incidence.

Terms of Reference

! Identify reasons for the decline in immunization coverage levels, identify bottlenecksand suggest measures to revitalize routine immunization activities.

! Establish criteria for ensuring a cost-effective expansion/renewal plan for the coldchain.

! Set up norms for periodic evaluation of the immunization programme (frequency sur-veys, methodology to be adopted, mechanism for data dissemination, etc.).

! Examine the current status of surveillance under the RCH Programme and suggestmechanisms for integrating the National Polio Surveillance Project network with theexisting surveillance system once polio is eradicated.

! Firm up guidelines for epidemic/outbreak control measures for VPDs.! Establish standards and criteria for the introduction of new vaccines under the

Universal Immunization Programme. ! Guide policy for the introduction of injection safety technology into the immuniza-

tion programme. ! Suggest innovative strategies for introducing demand-generation strategies in the pro-

gramme. ! Examine the role of the private sector vis-a-vis immunization and suggest measures

for a more effective programme with private sector partnership. ! Identify strategies would be required under special circumstances, for instance (i) in

underserved areas such as urban slums and tribal areas, (ii) immunization during nat-ural calamities.

! Identify areas that need research studies including cost-effectiveness analysis, burdenof diseases studies, operations research, etc. and suggest modalities for conductingthe same.

! Suggest mechanisms and modalities for improving vaccine quality assurance throughthe National Regulatory Authority (DCGI).

! Examine the need for decentralization of programme implementation and suggest thedegree and modalities for effecting the same.


ANNEX 2

WHO/UNICEFReview of National Immunization Coverage

1980–2003

IndiaDRAFT

June 2004

47

Trends in officially reported data show an increase incoverage beginning in the early to mid-1980s, reflectingthe phased geographic expansion of the ExpandedProgramme on Immunization (EPI) from 31 districts in1985, to all 452 districts by 1990. In 1985, the UniversalImmunization Programme (UIP), the inclusion of immu-nization in India’s Technology Mission (one of 5 mis-sions reporting directly to the Prime Minister) and theinfusion of resources associated with the globalUniversal Childhood Immunization (UCI) goal, resultedin rapidly increasing coverage in the late 1980s.

While official reports describe sustained high levelsof coverage following 1990, survey data suggest signif-icantly lower coverage beginning in the late 1980s.Officially reported data may be overestimations due tothe methods used for ascertaining the size of the targetpopulation. Coverage for 1990 and 1991 was estimatedto have been 66% and 62%, respectively, based on anextensive sub-national Immunization Coverage Surveyof 1991 and results from the 1992 National FamilyHealth Survey (NFHS). Estimates prior to 1990 weremade by calibrating the data reported to UNICEF by the

1990 estimate, established by an evaluation of the 1991and 1992 surveys. The marked increase up to 1990 andthe subsequent decline are attributed to the extensive(but unsustained) efforts to reach UCI goals. Coverageprior to 1990 is below that of DPT3, probably due to thenumber of home deliveries. The estimates for the peri-ods following 1995 are based primarily on the CoverageEvaluation Surveys (CES), MICSs, and a second NFHS(1997/98), and show a marked decline in coverage dur-ing this period. Estimates for 1993 through 1995 areinterpolated between the levels established by the 1992and 1996 surveys. The estimates for 1995–1997 arebased on an evaluation of the survey data. The estimateof 1997 is based on the CES. The estimate of 72% issupported by results from the 1997 Reproductive andChild Health Survey and NFHS (1997/98). The 1995peak was established from data in the 1996 CES thatdescribed coverage in a cohort 25–36 months of age.The 1999 estimate is based on the MICS. The recentincrease is supported by the 2001 and 2002 CES sur-veys. The estimated coverage for 2003 is 81%.

48 WHO/UNICEF Review of National Immunization Coverage 1980–2003

Infant mortality rate (per 1000 live-births), 1971–2002

Trends in officially reported data show an increase incoverage beginning in the early to mid-1980s, reflect-ing the phased geographic expansion of the EPI from31 districts in 1985 to all 452 districts by 1990. In1985, the Universal Immunization Programme (UIP),the inclusion of immunization in India's TechnologyMission (one of 5 missions reporting directly to thePrime Minister) and the infusion of resources associat-ed with the global Universal Childhood Immunization(UCI) goal resulted in rapidly increasing coverage inthe late 1980s.

While official reports describe sustained high cover-age following 1990, survey data suggest significantlylower coverage beginning in the late 1980s. Officiallyreported data may be overestimations due to the meth-ods used for ascertaining the size of the target popula-tion. Coverage for 1990 and 1991 was estimated to havebeen 70% and 57%, respectively, based on an extensivesub-national Immunization Coverage Survey of 1991and results from the 1992 National Family HealthSurvey (NFHS). Estimates prior to 1990 were made bycalibrating the data reported to UNICEF by the 1990estimate, established by an evaluation of the 1991 and1992 surveys. The marked increase up to 1990 and thesubsequent decline are attributed to the extensive (butunsustained) efforts to reach UCI goals. The estimatesfor the periods following 1995 are based on theCoverage Evaluation Surveys (CES), MICSs, and a sec-ond NFHS (1997/98), and show a marked decline incoverage during this period. Estimates for 1993 through1995 are interpolated between the levels established bythe 1992 and 1996 surveys. The estimates for

1995–1997 are based on an evaluation of the surveydata. Results from previous Demograhic and HealthSurveys (similar to the NFHS and MICS) suggest thatcoverage values based on the mother’s history are affect-ed by a recall bias for the multi-antigen vaccines (i.e.OPV 1, 2, 3 and DPT 1, 2, 3), which would most likelyoccur in longer surveys covering a variety of indicators.It does not appear to be a problem in surveys focused onimmunization coverage such as the EPI 30-cluster sur-veys and the CES. To control for this bias we haveadjusted the DPT3 card or history value by calculatingthe drop-out rate from DPT1 to DPT3 based on cardresults and applying this multiplier to the DPT1 card orhistory value. This adjustment may result in an overesti-mation since children without a card are less likely to beimmunized than children with a card.

The 1996 and 1997 results of the CES seem to esti-mate the upper range of actual coverage. The drop-outrate of 6% from DPT1 to DPT3 in the 1998/1999 CESis unusually low (the drop-out rate from the NFHS98/99 is 13% based on card only data). The estimate of1997 is based on an adjustment of the NFHS (1997/98)results to account for recall bias and the CES. The esti-mate of 62% is supported by the results of the 1997Reproductive and Child Health Survey. The 1995 peakwas established from data in the 1996 CES thatdescribed coverage in a cohort 25–36 months of age.The 1999 estimate is based on the MICS adjusted forrecall bias. The recent increase is supported by the2001 and 2002 CES. The estimated coverage for 2003is 70%.

WHO/UNICEF Review of National Immunization Coverage 1980–2003 49

Trends in officially reported data show an increase incoverage beginning in the early to mid-1980s, reflectingthe phased geographic expansion of the EPI from 31districts in 1985 to all 452 districts by 1990. In 1985, theUniversal Immunization Programme (UIP), the inclu-sion of immunization in India’s Technology Mission(one of 5 missions reporting directly to the PrimeMinister) and the infusion of resources associated withthe global Universal Childhood Immunization (UCI)goal, resulted in rapidly increasing coverage in the late1980s. While official reports describe sustained highlevels of coverage after 1990, survey data suggest sig-nificantly lower coverage beginning in the late 1980s.Officially reported data may be overestimations due tothe methods used for ascertaining the size of the targetpopulation. Coverage for 1990 and 1991 was estimatedto have been 66% and 58%, respectively, based on anextensive sub-national Immunization Coverage Surveyof 1991 and results from the 1992 National FamilyHealth Survey (NFHS). Estimates prior to 1990 weremade by calibrating the data reported to UNICEF by the1990 estimate, which was done by an evaluation of the1991 and 1992 surveys. The marked increase up to 1990and the subsequent decline are attributed to the exten-sive (but unsustained) efforts to reach UCI goals. Theestimates for the periods following 1995 are based pri-marily on the Coverage Evaluation Surveys (CES),MICSs and a second NFHS (1997/98), and show amarked decline in coverage during this period.Estimates for 1993 through 1995 are interpolatedbetween the levels established by the 1992 and 1996

surveys. The estimates for 1995–1997 are based on anevaluation of the survey data. Results from previousDemographic and Health Surveys (similar to the NFHSand MICS) suggest that coverage values based on themother’s history are affected by a recall bias for multi-antigen vaccines (i.e. OPV 1, 2, 3 and DPT 1, 2, 3),which is most likely to occur in longer surveys coveringa variety of indicators. It does not appear to be a prob-lem in surveys focused on immunization coverage suchas the EPI 30-cluster surveys and the CES. To controlfor this bias we have adjusted the OPV3 card or historyvalue by calculating the drop-out rate from OPV1 toOPV3 based on card results and applying this multipli-er to the OPV1 card or history value. This adjustmentmay result in an overestimation since children without acard are less likely to be immunized than children witha card. The 1996 and 1997 results of the CES seem toestimate the upper range of actual coverage. The drop-out rate of 6% from OPV1 to OPV3 in the 1998/1999CES is unusually low (drop-out rate from the NFHS98/99 is 13% based on card only data). The estimate of1997 is based on an adjustment of the NFHS (1997/98)results to account for recall bias and the CES. The esti-mate of 63% is supported by results from the 1997Reproductive and Child Health Survey. The 1995 peakwas established from data in the 1996 CES, whichdescribed coverage in a cohort 25–36 months of age.The 1999 estimate is based on the MICS adjusted forrecall bias. The recent coverage level of 70% is sup-ported by the 2001 and 2002 CES. The estimated cov-erage for 2003 is 70%.


Measles vaccine was introduced in 1985. Trends inofficially reported data show a rapid increase in cov-erage reflecting the phased geographic expansion ofthe EPI from 31 districts in 1985 to all 452 districts by1990. In 1985, the Universal ImmunizationProgramme (UIP), the inclusion of immunization inIndia’s Technology Mission (one of 5 missions report-ing directly to the Prime Minister) and the infusion ofresources associated with the global UniversalChildhood Immunization (UCI) goal, resulted in rap-idly increasing coverage in the late 1980s. While offi-cial reports describe sustained high levels of coverageafter 1990, survey data suggest significantly lowercoverage beginning in the late 1980s. Officiallyreported data may be overestimations due to the meth-ods used for ascertaining the size of the target popula-tion. Coverage for 1990 and 1991 was estimated tohave been 56% and 43%, respectively, based on anextensive sub-national Immunization CoverageSurvey of 1991 and results from the 1992 NationalFamily Health Survey (NFHS). Estimates prior to1990 were made by calibrating the data reported to

UNICEF by the 1990 estimate, which was done by anevaluation of the 1991 and 1992 surveys. The markedincrease up to 1990 and the subsequent decline areattributed to the extensive (but unsustained) efforts toreach UCI goals.

The estimates for the periods following 1995 arebased primarily on the Coverage Evaluation Surveys(CES), MICSs and a second NFHS (1997/98), andshow a marked decline in coverage during this period.Estimates for 1993 through 1995 are interpolatedbetween the levels established by the 1992 and 1996surveys.

The estimates for 1995–1997 are based on an eval-uation of the survey data. The estimate of 1997 isbased on the CES. The estimate of 55% is supportedby results from the 1997 Reproductive and ChildHealth Survey and NFHS (1997/98). The 1995 peakwas established from data in the 1996 CES thatdescribed coverage in a cohort 25–36 months of age.The 1999 estimate is based on the MICS. The recentincrease is supported by the 2001 and 2002 CES. Theestimated coverage for 2003 is 67%.

Measles Vaccine Estimates, India, 1980–2003




India WHO/UNICEF estimates of the percentage of children born in 2000–2003 protected against tetanus by vaccination of their mothers with tetanus toxoid (protected at birth [PAB])

In most instances, PAB reflects the number of mothers receiving two doses of tetanus toxoid dur-ing pregnancy. In some cases, the mother may have received an adequate number of doses of tetanustoxoid prior to the pregnancy, protecting the child, even though no doses were received during thecurrent pregnancy.

These estimates are based on data provided through the WHO/UNICEF Joint Reporting Form onVaccine Preventable Diseases and have been supplemented by information from national householdsurveys conducted under the auspices of the national government and from data available in thepublished literature.



ANNEX 3 LOCATION OF INFANTS NOT FULLY IMMUNIZED

AND DROPPING OUT BY STATE

Percentage of fully immunized infants and absolute numbers of not fully immunized infants, by State, 2001–2002

Source: UNICEF Multi-cluster surveys 2001–2002 and National Census 2001 (assumes 3.5% of populationis under one year of age).

Rank State

Percentage of infants partially or not fully immu-nized: 2001–2002, by State

BiharUttar PradeshJharkhandRajasthanAndhra PradeshNagalandUttaranchalManipurMadhya PradeshOrissaMeghalayaWest BengalTripuraHaryanaGujaratKarnatakaAssamArunachal PradeshChhatisgarhDelhiPunjabSikkimMizoramD&N HaveliChandigarhJammu & KashmirMaharashtraDaman & DiuTamil NaduKeralaPondicherryHimachal PradeshGoaLakshadweepA&N Islands

10.019.224.230.241.744.246.348.350.052.553.356.456.857.759.359.960.462.970.470.672.576.778.880.882.784.685.686.787.188.790.092.593.394.291.9

9080.875.869.858.355.853.751.75047.546.743.643.242.340.740.139.637.129.629.427.523.321.219.217.315.414.413.312.911.3107.56.75.88.1

1234567891011121314151617181920212223242526272829303132333435

Fullyimmunizedinfants (%)

Partiallyimmunized orunimmunized

infants (%)

State average percentage of infantspartially immunized or not fullyimmunized

35.4

Rank State

Percentage of infants partially or not fully immunized: 2001–2002, by State

Uttar PradeshBiharAndhra PradeshRajasthanWest BengalMadhya PradeshKarnatakaGujaratJharkhandOrissaMaharashtraAssamHaryanaTamil NaduPunjabChhatisgarhUttranchalDelhiKeralaJammu & KashmirTripuraManipurNagalandMeghalayaHimachal PradeshArunachal PradeshMizoramChandigarhSikkimPondicherryGoaD&N HaveliA&N IslandsDaman & DiuLakshadweep

80.890.058.369.843.650.040.140.775.847.514.439.642.312.927.529.653.729.411.315.443.251.755.846.77.537.121.217.323.310.06.719.28.113.35.8

5,811,8502,900,7582,650,6461,976,5592,807,7412,113,4791,845,6891,770,895941,8301,284,7423,386,329932,344737,9052,173,879850,125727,858296,785482,4041,114,352352,447111,69183,60269,60280,712212,70438,18931,18731,53218,91734,08447,0407,71612,4695,5322,121

4,695,9752,610,6821,545,2201,379,6381,224,1751,056,740740,121720,754713,907610,253487,631369,208312,134280,430233,784215,446159,373141,287125,92254,27748,25043,22238,83837,69315,95314,1686,6125,4554,4083,4083,1521,4811,010736123

1234567891011121314151617181920212223242526272829303132333435

Partiallyimmunized orunimmunized

infants (%)

No. of infants(assuming

3.5% of Censuspopulation)

No. of infantspartially immu-nized or not fullyunimmunized

Total number of infants partiallyimmunized or not fully immunized

17,902,008


Percentage of BCG–measles drop-out rates and absolute numbers of infants dropping out between BCG and measles, by State, 2001–2002

Source: UNICEF Multi-cluster surveys 2001–2002 and National Census 2001 (assumes 3.5% of populationis under one year of age).

Rank State

BCG–measles drop out-rate, by State, 2001–2002

Andhra PradeshMeghalayaWest BengalOrissaTripuraRajasthanMadhya PradeshChhatisgarhGujaratManipurBiharHaryanaJharkhandD&N HaveliNagalandUttar PradeshPunjabAssamDelhiUttaranchalKarnatakaArunachal PradeshChandigarhDaman & DiuSikkimKeralaJammu & KashmirTamil NaduMaharashtraMizoramGoaPondicherryLakshadweepHimachal PradeshA&N Islands

88.390

87.884.285.654.577.794.684.370.832

82.743.199.268.343.391.380.889.366.778.977.994.898.391.798.892.599.295.891.310098.399.296.7100

50.855

60.862.163.634.557.87565

51.713.364.327

83.352.528.176.366.375

54.667.167.184.388.382.591.185

91.788.584.295

93.395

93.394.1

37.53527222220

19.919.619.319.118.718.416.115.915.815.215

14.514.312.111.810.810.5109.27.77.57.57.37.155

4.23.45.9

1234567891011121314151617181920212223242526272829303132333435

BCG coverage rate (%)

Measles coverage rate (%)

BCG–measles drop-out rate (%)

State average BCG–measles drop-out rate (%)

14.4

Rank State

Absolute numbers of infants dropping out ofBCG–measles, by State, 2001–2002

Andhra PradeshMeghalayaWest BengalBiharMadhya PradeshRajasthanGujaratOrissaMaharashtraKarnatakaTamil NaduJharkhandChhatisgarhHaryanaAssamPunjabKeralaDelhiUttaranchalMeghalayaJammu & KashmirTripuraManipurNagalandHimachal PradeshArunachal PradeshChandigarhGoaMizoramSikkimPondicherryD&N HaveliDaman & DiuLakshadweepA&N Islands

37.515.227

18.719.920

19.322.17.311.87.516.119.618.414.5157.714.312.1357.522

19.115.83.410.810.5

57.19.25

15.9104.25.9

2,650,4645,811,8502,807,7412,900,7582,113,4791,976,5591,770,8951,284,7423,386,3291,845,6892,173,879941,830727,858737,905932,344850,1251,114,352482,404296,78580,712352,447111,69183,60269,602212,70438,18931,53247,04031,18718,91734,0847,7165,5322,12112,469

993,924883,401758,090542,442420,582395,312341,783283,928247,202217,791163,041151,635142,660135,774135,190127,51985,80568,98435,91128,24926,43424,57215,96810,9977,2324,1243,3112,3522,2141,7401,7041,22755389736

1234567891011121314151617181920212223242526272829303132333435

BCG coverage rate (%)

Total number of infants droppingout between BCG and measles

6,261,741

No. of infants(assuming 3.5%of Census pop-ulation 2001)

No. of infantsdropping out

between BCGand measles


The National ImmunizationDepartment will:

! Determine the national policy.! Determine the five-year strategy. ! Prepare an annual national plan of action for

immunization activities—based on the policiesof the MoH&FW and including budget and logis-tics requirements.

! Take the lead in all immunization-related activities.

! Coordinate all immunization-related activitieswith other departments in the MoHFW.

! Vaccine requirements: Provide WHO-certifiedvaccines. Review and estimate national vaccinerequirements working towards reducing vaccinewastage and saving resources.

!Cold chain and immunization equipment:Review and monitor the status of the nationalcold chain, logistics system, transport systems.

! Staffing: Review and advise concerned min-istries/agencies on staffing levels, transfers,vacancies and prioritization to fill vacancies.

! Technical guidelines: Develop technical andadministrative guidelines for standard programmeimplementation. Provide guidelines for monitor-ing, supervision and evaluation, including provid-ing feedback. Provide guidelines for budgetdevelopment for training, routine and specificcold chain activities and the maintenance of vac-cine potency, including surveys to evaluate theprogramme, in accordance with the decentraliza-tion concept. Develop guidelines for cold chainavailability and immunization logistics.

! Training: The national training focal point willcoordinate technical aspects of training and re-orientation of health staff in immunization poli-cies, strategies and activities. Update trainingmaterials on an ongoing basis.

! IEC: Coordinate standards and technical aspectsof immunization-related IEC activities.

! Data analysis and surveillance: The national-level surveillance and monitoring officer willanalyse available data to guide the immunizationprogramme and provide feedback to the States onimmunization-related activities.

! Outbreak investigations: Guide States in out-break investigations of vaccine-preventable dis-eases coordinating with related divisions and agencies.

! Supplemental immunization activities: Plan and

implement supplemental immunization activitiesas necessary.

! Convene the Inter-agency CoordinatingCommittee (ICC) at least quarterly.

! Hold national-level consultation meetings andprovide assistance to the States/Union Territories.

! Become actively involved in international activi-ties, in collaboration with government agenciesoutside of the MoH&FW.

! Initiate and cultivate intersectoral programmeactivities at the national level.

The State/Union Territory level will:

! Develop programme implementation plans inaccordance with national and State Governmentpolicies.

! Planning and review: Organize a planning meet-ing for all districts of the State on an annual basisto review annual performance and plan for thefuture. Analyse and develop district or city opera-tional plans to conform to the national or Statestrategy and policies.

! Vaccine requirements: Compile and review vac-cine requests from districts, and send theserequests through proper channels. Oversee vac-cine quality maintenance, cold chain facilities andlogistics.

! Cold chain and immunization equipment:Review and monitor regionwide needs to upgrade,replace, maintain and expand the cold chain, logi-stics system, transport systems, sterilization equip-ment. Ensure upkeep of a State cold chain repaircentre.

! Staffing: Prioritize staffing needs and fill vacan-cies. Enhance the knowledge and skills of thetechnical and administrative staff.

! Supervision: Coordinate and participate in thesupervision of immunization-related activities.Perform district monitoring, supervision and eval-uation.

! Data analysis and surveillance: Analyse avail-able data to guide the immunization programme.Provide feedback to the districts on immuniza-tion-related activities. Keep an updated districtprofile on immunization activities. Provide assis-tance in determining targets at district and citylevels. Provide feedback based on the data analy-ses to the district/city including reports to thenational level.

ANNEX 4

ROLES AND RESPONSIBILITIES


!Outbreak investigations: Assist districts in out-break investigations of vaccine-preventable dis-eases, as per the guidelines provided by theEpidemiology and Diseases Control Division(EDCD).

! Supplemental immunization activities:Coordinate supplemental immunization activitiesas per the national guidelines.

! Develop intersectoral collaboration at the Statelevel.

! Cultivate roles for the community and private sector.

District level

The ultimate target is to ensure that every child isimmunized with all the recommended antigens (byensuring that every infant has contact with immu-nization services at least five times).

! Vaccine requirements: Compile and review esti-mates for vaccine requirements.

! Distribution: Work out details on vaccine and icepack distribution in the district, including dates,persons responsible and back-up plans.

! Cold chain and immunization equipment:Ensure proper maintenance, repair and, if needed,replacement of equipment.

! Staffing: Advise the State level on staffing needs.! Training: Ensure staff training and re-orientation

sessions on a regular basis.! IEC: Carry out advocacy and IEC activities

aimed at promoting immunization, and immuniz-ing every eligible child.

! Supervision: Carry out supervisory visits tohealth institutions and immunization outreach ses-sions on a regular basis, and report to the con-cerned authorities.

! Recording and reporting: Keep a record ofimmunizations by the health facility in theapproved forms.

! Data analysis and surveillance: Analyse thedata from health institutions to guide them on theongoing immunization programme. Provide tech-nical information and feedback to health institu-tions/health workers on immunization-relatedactivities.

! Outbreak investigations: Carry out outbreakinvestigations of vaccine-preventable diseases, asper guidelines.

! Supplemental immunization activities:Coordinate and implement supplemental immu-nization activities as directed.

! Microplanning: Organize detailed microplanningfor immunization activities annually at the district

level, with inputs from both private and publichealth centres. Microplans must address the fol-lowing issues:

! Vaccine requirements: Provide details on vac-cine requirements by immunization sessions,based on the census or estimated target popula-tions.

! Distribution: Provide details on vaccine and icepack distribution in the district, including dates,persons responsible, and back-up plans.

! Cold chain: Draw up a detailed maintenanceschedule for the cold chain. Make provisions toaccommodate emergency repair requests.

! IEC and training: Prepare a summary of trainingand IEC needs for forwarding to the nationallevel.

! Investigations: Provide details of outbreak inves-tigations and translate investigations into reportson AEFI, including the coordinator’s name, teamcomposition, investigation and reporting proce-dures, feedback mechanisms.

! Coverage and case reporting: Provide detailsand feedback on data collection (cases and cover-age) by antigen.

! Supervision: Prepare supervision schedulesincluding names of supervisors and tentativedates. Surprise visits are to be encouraged.

! Outreach: Provide details on outreach activitiesby health centres.

! Involvement of partners: Provide details on col-laboration, advocacy and fundraising efforts

! Develop programme plans in accordance with theguidelines from the State and the results of situa-tional analysis.

! Together with the health facilities, determine cov-erage targets.

! Guide and develop a work plan for the healthfacility in accordance with the directions from theState, and the results of the situational analysis ofthe health unit.

! Evaluate and analyse the plan for vaccines, coldchain and immunization supply needs at healthunits.

! Evaluate and analyse human resource needs fromhealth units.

! Oversee vaccine quality maintenance, cold chainfacilities and logistics.

! Hold consultation meetings and provide technicalassistance to field staff at the health units.

! Conduct supportive supervision sessions using asupervisory checklist, and assist health units inproblem-solving.

! Provide feedback to the health units and submitreports to the State level.

The tasks for local-level governments are:

! To increase and sustain the immunization cover-age rate at above 80%, and make proposals toachieve universal immunization coverage.

! To endeavour to achieve elimination of neonataltetanus, eradication of polio, and reduction ofmeasles through a targeted high-risk approach

! To improve service quality! To enhance programme effectiveness! To effectively and efficiently utilize district or

city resources

! To enhance intersectoral collaboration and com-munity participation.

All health institutions will be responsible for imple-menting the immunization programme in the field.These health institutions will participate in the dis-trict-level microplanning, assess vaccine needs,maintain the cold chain on a day-to-day basis,administer vaccines, and report cases and coverage.


ANNEX 5

Proposed National Immunization Cell

A National Immunization Cell (NIC) is beingplanned, which will focus on strengthening immu-nization activities. The Cell will accommodate allgovernment functionaries engaged in immunization(including those supported by WHO and UNICEF)under one roof. This will help in improved inter-unitcoordination and functioning. As a prelude to the for-mation of the immunization cell, the organizationalstructure with the various work areas and job allot-ments have been worked out among the officers of theDepartment of Family Welfare. The proposed struc-ture of the various units, including the composition ofthe Procurement Unit, under the Director (UIP), andthe work distribution is seen below. Existing andadditional areas of support and the administrativestaff from developmental partners have also beenidentified and proposed.

The proposed office space is at Bikaner House. Toassist in efficient functioning of the immunizationcell, a space will be provided to accommodate theessential support staff. This is a critical requirementfor the initiation and functioning of the immunizationcell. The total requirement for an office space for theimmunization cell (including the Procurement Unit) isestimated to be around 2000 sq.ft.

Apart from the officers and support staff (includingthose from WHO and NPSP) who are alreadyassigned to work for immunization, additional sup-port staff (Management/Administrative assistants,data entry operators) is a critical requirement for effi-cient functioning of the Cell. The list of additionalstaff required is given below. WHO and UNICEF havebeen requested to provide for these over a period oftime.

NATIONAL IMMUNIZATION CELL STRUCTURE

JS (IMM)

DC (IMM)NATIONAL TECHNICAL ADVISOR

DIRECTOR (VACCINE COLD

CHAIN LOGISTICS)

!Assess and processprocurement of vaccine, syringes,and cold chain equipment

! Supply chain management (manage-ment and monitoringof vaccine and coldchain equipment supply)

!Cold chain maintenance

AC(PROGRAMME

IMPLEMENTATION)

! Polio eradication ! RI implementation! Training! Strategic

communication! Inter-agency

coordination! Research and

studies! Vaccine quality and

NRA

AC(PROGRAMME

MONITORING ANDSURVEILLANCE)

! Hepatitis B vaccineand introduction ofnewer vaccines

! Immunization moni-toring (RIMS)

! VPD surveillance! Programme evalua-

tion! Injection safety ! AEFI

ADMINISTRATIVE AND FINANCE UNIT

! Release of funds andmonitoring of expen-diture

! Human resourcedevelopment

! Resource mobilization! Parliament and

judicial matters! Audit! Inter- and intra-

departmental coordination

! Secretarial support


Existing and additional staff required

Polio eradication

RI implementation and training

Strategic communication

Inter-agency coordination

Research and studies

Vaccine quality and NRA

Hepatitis B vaccine and introduc-tion of newer vaccines

Immunization monitoring (RIMS)

VPD surveillance

Programme evaluation

Injection safety and AEFI

!"NPSP!"CH Section (1 SO, 1

Statistical Assistant)!"NTA !"2 Assistants, NPSP/WHO

!"WHO!"4 State Immunization

Officers, NPSP/WHO in BI,JH, UP, RJ

!"NIHFW

DS (IEC)

--!"ICMR!"WHO!"WHO

!"WHO!"WHO!"1 assistant (?PATH)

!"E&I Division!"WHO!"WHO

CBHI

E&I Division

!"WHO !"WHO

1 Management Assistant (WHO)1 Part-time IEC officer fromUNICEF

2 Data entry operators (WHO)

Programme evaluation to beundertaken by WHO andUNICEF

The proposed activities of theProgramme Implementation andPolio Eradication sub-unit wouldgenerate considerable paper workincluding correspondence withthe States on RI implementation,etc. The existing staff support tothe officers for these activities isgrossly inadequate. In view ofthis, it is proposed to seek 1Management Assistant for han-dling paper work.

With the installation of a routineimmunization monitoring systemto be implemented at districtlevel, considerable data will flowfrom the States/districts and thesame will have to be entered inthe computer. This voluminousjob would require 2 data entryoperators.

Dealing Officer Functions Existing support Additional support required Justification for additionalsupport

PROGRAMME IMPLEMENTATION AND

POLIO ERADICATION Dr P Biswal AC (I)

PROGRAMME MONITORINGAND SURVEILLANCEDr P Haldar AC (UIP)

Go

I Imm

un

ization

Mu

lti Year P

lan 2005–2010

61

ANNEX 6

BASIC ASSUMPTIONS USED FOR COSTING MYP

GENERAL DATA

Population*

Number of live-births

Infant mortality rate

Surviving infants

EAG population

Pregnant women (live-births+10%)

Numbers—5 years of age in thepopulation1



1,108,625,817

29,267,722

66 per 1000

27,336,052

652,580,683

32,194,494

24,250,364

26,375,339

24,168,675

1,130,022,295

29,832,589

66 per 1000

27,863,638

665,175,490

32,815,847

24,718,396

26,884,383

24,635,130

1,151,831,726

30,408,358

66 per 1000

28,401,406

678,013,377

33,449,193

25,195,461

27,403,252

25,110,588

1,174,062,078

30,995,239

66 per 1000

28,949,553

691,099,035

34,094,763

25,681,733

27,932,134

25,595,222

1,196,721,476

31,593,447

66 per 1000

29,508,279

704,437,247

34,752,792

26,177,391

28,471,225

26,089,210

2005–06 2006–07 2007–08 2008–09 2009–10

DEMOGRAPHIC DATA

*Calculated figures based on the 2001 Census population of 1,027,015,247 with an annual growthrate of 1.93% (annualized from 1991–2001)

Annual population growth rate : 1.93% (as per 2001 Census figures)Crude birth rate : 2.64% (Office of the Registrar General)Infant mortality rate : 66 per 1000 live-births (Office of the Registrar General)

1 Government of India—Immunization Department data

Other assumptions:Number of States : 35 (average number of districts 17 per State)Number of districts : 593 (average number of PHCs 39 per district)Number of CHC/FRUs : 3043Number of PHCs : 22,842 (average number of SHCs 6 per PHC)Number of sub-centres : 137,311Number of slums and : Assumed to be 10% of the total population and 10,876 slums esti-

mated tounderserved areas be in the country (Census data) and 1 ANM per 10,000 population

in the slumsInflation rate : 5% (applied to all unit costs—Government policy)24% of the total population is urban (estimate by the immunization department)10% of the total cost (excluding vaccine cost) is allowed in the last two years as (a) Contingency


SERVICE DELIVERY

!"Additional mobility support for DIOs @ Rs 50,000 per district (for POL and maintenance)per year.

!"16.67% of the vehicle maintenance cost is assumed to be on account of immunization(Immunization Department and used within the RCH Programme)

!"Proportionate infrastructure costs for immunization: 16.67% of Rs 1,000,000 per districtover a period of 5 years. This cost is appropriated over five years of the MYP. However, theactual cost would be depending on the state PIP for phase II of the RCH Programme.

!"Mobilization of children through Anganwadi Workers/ASHA (estimated at 600,000) @ Rs2400/- p.a. per worker (Rs 200/- p.m.)

Alternative vaccine deliveryAlternative vaccine delivery support for 4 sessions p.m.@ Rs 50/- per session = Rs 200/- persub-centre p.m., which is Rs 2400/- per sub-centre p.a.

Focus on slum and underserved areasHiring an ANM/paramedical staff @ Rs 300/session for six sessions/month/slum and Rs 200/-p.m. as contingency per slum, i.e. total expense of Rs 2000/- p.m. per slum.

Urban health facilities represent 24% of all health facilities.

Vehicle costsCapital costs for vehicles are NOT covered in the MYP costing (assumed to be covered in the RCH).

HUMAN RESOURCES

Immunization team salaries—100% charged to immunization(a) National—technical, support staff and costs of office(b) State—technical, support staff and costs of office(c) District—DIO and support staff(d) Salaries of district cold chain handlers and mechanics(e) Salaries of first-line LHV supervisors(f) Salary for Assistant to DIO per district @ Rs 7000 p.m.(g) Salaries of additional staff—Financial Specialist, Financial Consultant, Cold Chain

Consultant, Logistics Consultant and Data Analyst.

Immunization team salaries—part charged to immunization(h) One-third of ANM salaries on the assumption that the ANM spends one-third (33%) of her

time on routine immunization (ANM salary assumed at Rs 7000/- p.m.).(i) 16.67% of salaries of the CHC, BMO and PHC MO, health supervisors, drivers and PHC

cleaners(j) PHC medical officers, LHVs and multi-purpose worker (4 days out of 24 working days per

month)—one-sixth (equivalent to 16.7%).

TRAINING

!" In view of completed MLM trainings during 2004–05, the next MLM trainings will be con-ducted only in 2007–08.


(b) State activities(c) Operational research(d) Extra surveillance, monitoring and AEFI activities, as necessaryEAG States represent approximately 60% of India’s population (GoI data).

!"National-level training to 72 trainers drawn from different States and medical colleges for 3days to further train health functionaries at the regional level.

Participants 72 Travel cost Rs 10,000/-Per diem Rs 1000/-Institutional charges Rs 2000/- per participant

!"Regional-level training to State Director (FW), State Immunization Officer, DistrictImmunization Officers, CMOs and other facilitators (total about 1440 in number) for 3 daysto further train health functionaries below district level.

Participants 14402

Travel cost Rs 1000/-Per diem Rs 100/-Institutional charges Rs 600/- per participant

!"District-level training to ANMs, Multi-purpose Health Workers (Male), LHVs, HealthAssistant (Male/Female), Nurse–midwives, BEEs and other specialists (total about 300,000in number) for 3 days.

Participants 300,0003

Cost Rs 100/- per day Institutional charges Rs 50/- per participant

COLD CHAIN

Life of cold chain Walk-in coolers (WIC) and

Walk-in Freezers (WIF) : 15 yearsILR and deep freezers : 7 yearsCold boxes (all sizes) : 5 yearsVaccine carriers : 3 years

Hardware supply (ILRs, freezers, generators, voltage stabilizers, cold boxes, insulated vaccine vans)allowing for replacement of existing CFC equipment. The replacement is planned to be carried outover four years:

First year 30%Second year 25%Third year 25%Fourth year 20%

!"10% expansion over five years on the baseline for the year 2004–05!"Replacement required of all CFC cold chain equipment issued up to 1992–93

Walk-in coolers and freezers Volume of each WIC and WIF : 16.5 cmmStorage capacity : 15–20 lakh doses each4

Total number of units in the : WIC—145country WIF—32

New procurementsUnits to be replaced : WIC—115(installed up to 1992–93) WIF—9Additional units required for : WIC—15

new States and expansion5 WIF—11

2 State Immunization Officer+Director (FW), DIO, CMOs, facilitators 6=35+35+593+593+36=14403 137,000 ANMs,70153 MPWs(M),19,855 LHVs/HAs(F),19,927 HAs(M),27,336 Nurse–Midwives, 5700 BEEs, 25,774 MOs, 5000 Other specialists=305,745 (approximated to 300,000)4 Depending on the vial size and type of vaccine5 Infrastructural requirement for newly formed states viz. Jharkhand, Chattisgarh, Uttaranchal etc. as most WIC and WIF capacities

remained with the parent states after bifurcation and expansion in some of the states where they are not in adequate numbers.


Total projected procurementsWIC (115+15) : 130WIF (9 +11) : 20

Equipment costsILR (large) : Rs 33,000/-ILR (small) : Rs 24,000/-Deep freezer (large) : Rs 23,000/- Deep freezer (small) : Rs 17,000/- Voltage stabilizer (small) : Rs 1,000/-Vaccine storage thermometer : Rs 140/- Cold box (large) : Rs 3,200/-Cold box (small) : Rs 2,250/-Vaccine carrier : Rs 300/-Ice-packs : Rs 10/-Insulated vaccine van : Rs 440,000/-Walk-in coolers : Rs 600,000/-Walk-in freezers : Rs 800,000/-

!"National and State cold chain coordination costs and six-monthly meetings at national level.Distribution cost assumed to be 5% of hardware costs per year.Maintenance costs assumed to be 5% of hardware costs per year.

Cold chain reviewCold chain reviews of 12 States per year over five yearsNumber of participants : 2 people coming to the StatePeriod of review : 14 days reporting back to State/Central level Per diem : Rs 1000/-Transport to State : Rs 10,000/- per participantLocal travel : Rs 10,000/- per participantInstitutional cost : Rs 16,000/- per participantTotal cost for review : Rs 100,000/-

District-level, for training of refrigerator mechanics Frequency : Once in two yearsDays : 2 daysNumber of participants : 5Travel allowance : Rs 1000/- per participantPer diem : Rs 250/-Training materials and contingency: Rs 100/- per participant per dayTotal training cost Rs 8500 per district

VACCINE PROCUREMENT!"Vaccine supplies are based on the number of surviving infants.! For budgetary purposes, the coverage targets are 100% for every antigen (this obviates the

need to calculate doses required after drop-out rates).! NO buffer stock is provided for antigens since they are part of the existing procurement system.! Vaccine wastage rates are as per the national policy.! Birth (zero) dose polio is given in all institutional deliveries, which is assumed to be 30%

of all deliveries.! Cost per vial includes transport and handling charges.! TT costs include two booster doses (at 10 and 16 years) and 1.5 TT doses for every preg-

nant woman.! Assumes GoI–Immunization Department data for estimating numbers of the target popula-

tion of 10 and 16 years.


BCG

OPV

DPT

Measles

TT

DT

2.0

1.33

1.33

1.33

1.33

1.33

1

5

4

1

3.5booster doses at 10 and 16 years,Pregnant women 1 dose ASAP

Second dose 1 month after first dose2

1

100%

100%

100%

100%

100%

100%

20

20

10

5

10

10

20

69.5

12.15

41.71

6.1

7.49

1 This is much lower than UNICEF prices but are GoI procurement figures.2 This averages over the five-year MYP to 3.5 doses of TT

Wastage factor

Number of doses in nationalimmunization schedule

Coverage targets

Number ofdoses per vial

Cost per vial(2004)1

SAFE INJECTIONS AND INJECTION WASTE DISPOSAL!"AD syringes will be introduced all over the country in 2005–06. Glass syringes, needles and

KOL will also be supplied in 2005–06 for smooth transition to AD syringes.

Number of injections (according to India’s national immunization schedule):

Primary schedule: 1 BCG (birth)3 DPT (6, 10, 14 weeks)1 measles (9 months)

Pregnant women: 1 TT pregnant women*

Booster doses 2 TT booster doses (at 10 and 16 years)1 DPT (18–24 months)1 DT (5 years)

Hepatitis B vaccine: 3 (only in the existing 33 districts and 15 metros)

TOTAL: 10.5 UIP injections +3 Hep. B vaccine injections=13.5 injections (Hep. B vaccine inexisting districts/cities ONLY)*TT at 10 and 16 years requires 2 injections and pregnant women require 1.5 injections, whereasthe coverage for TT at 10 and 16 years of age falls short of 100%. Hence, the procurement madeon account of AD syringes for TT (10 and 16 years) could be used for pregnant women. Thus, 1injection has been estimated per TT pregnant women (to reduce procurement wastages).

!"Separate cohort of 10- and 16-year-old beneficiaries for TT booster doses used in the ADsyringe calculations from the information supplied by GoI–Immunization Department asper the GoI policy.

!"Estimates for glass syringes include assumptions that 5000 people live around a sub-centre, a syringe can be used for 40 injections and a needle for 7 injections.

!"KOL at Rs 240/- per year per health facility, assuming that all health facilities already have functional stoves and operational pressure cookers


!"Cost of all AD syringes (0.5 ml and 0.1 ml) @ Rs 2.50 (wastage 1.11) with deflation @5%, assuming an increase in suppliers and reduction in costs

!"Costs of injection safety supplies include transportation and handling expenses.!"Cost of safety box (1 box per 100 syringes) @ Rs 20 (wastage 1.11)!"Ordinary disposable syringes (standard 2.5 ml) budgeted for reconstitution

Costing for provisional injection waste disposal plan

Cost of constructing a needle pit - Rs 5000/-(estimated to last 5–6 years)

Cost of puncture-proof container - Rs 10/- (TWO per ANM, 50% quantity of the replaceable annually)

Cost of a mechanical needle remover - Rs 700/-(THREE per PHC, replaceable every 3 years)

Sieve and bucket for syringe body disinfection - Rs 250/-(ONE set per PHC, replaceable every 3 years)

Hypochlorite 1% solution for syringe body - Rs 3/- per litredisinfection (1 litre per week per PHC)

Medium-sized, thick plastic bags for syringe - Rs 2/- per bagbodies (one bag per PHC per week, with 1.11 wastage rate)

Training costs

Designing and printing of multilingual pictorial brochures Rs 3/- each detailing AD syringe use and disposal methodology (approximately 300,000 brochures)

Cost of refreshments for a TWO-hour hands-on training Rs 250/- per PHCfor PHC staff by the Medical Officer in-charge on ADsyringe use and disposal (from the instruction set provided)

Provisional AD syringe disposal plan

!"Each ANM will be provided with a re-usable puncture-proof plastic container with lid(PPC), which can take up to 15 syringes (enough for an immunization session). A back-upPPC is also provided to take care of breakdowns and/or increased workload.

!"The used syringes (after each injection) are placed in the container (needle towards the bottom of the container) and brought back to the PHC.

!"At the PHC, the needles are removed using a mechanical needle remover. Only one syringeat a time is taken out of the PPC and its needle removed immediately. The plastic syringebodies are then put in a sieve/bucket containing 1% hypochlorite solution for disinfection for2 hours before being transferred to a plastic bag.

!"The needle remover container, when full (approximately after 250 needles), shall beremoved from the device and immediately emptied into the secure needle pit constructed atthe PHC. The pit shall have a lockable lid under the control of LHV who will monitor itsusage. NO OTHER waste except needles shall go into the pit.

!"The ANM/PHC shall be allowed to dispose of the disinfected syringe bodies as per theexisting law, i.e. deep burial OR disposal into a plastic recycler.


HEPATITIS B VACCINE(Continuation at the existing levels of 15 cities and 33 districts—no expansion planned)

!"Continuation of the Hep B Project in 15 cities and 33 districts!"Cost of Hep B vaccine Rs 15.36 per dose (5-dose vials)!"Wastage factor 1.33!"Buffer stock 25% per year.

SURVEILLANCE

!"Software development for a national web-based server with training to district and State lev-els. This system will increase the responsiveness of the data available on surveillance andmonitoring issues. The cost does not include hardware.

!"Cost of hardware for a national-level server is provided and it is assumed that computers areinstalled and functional at all State and district headquarters.

!"New surveillance staff at the national level—recruitment of 4 people (data coordinator, ana-lyst, 2 operators) for the years 2004–2006 and during the years 2006–2009; when the systembecomes operational only 2 people, i.e. 1 coordinator, 1 analyst.

Reporting!"Sub-centre to PHC–district (manual basis Form 9); cost of mobility to be taken from

total cost of mobility under various heads—training, vaccine delivery, meetings,review

!"District to State (computer in each district), in existing system (computers alreadyexist in present system)

!"Software package (floppy) for each district for transmitting to the State!"State to Central level through the web-based server!"Coordination between laboratory and epidemiology units (meetings and regu

lar reporting).

MONITORING

! Production and dissemination of monitoring tools such as tally sheet, monitoring chart, ticklerbox, vaccine inventory chart, register, cold chain chart @ Rs 250 each to 200,0006 immuniza-tion centres

! Immunization card (mother–child card) (quantity budgeted on the basis of Rs 2/-per card)

! Focus on slum areas! Survey to be assumed on 32-cluster survey per district, assuming a cost of

Rs 100,000/- per survey per district

OPERATIONAL RESEARCH AND STRENGTHENINGAn amount equivalent to 10% of ISP costs (excluding vaccine procurement costs) has been provided to take care of!"State-specific expenditure!"Unexpected additionalities in vaccine and AD syringe procurements due to outbreak

responses and special immunization campaigns!"Any unplanned contingency


6 23,000 PHCs+130,000 sub-centres+35 State hospitals+593 district hospitals+6070 block hospitals + 40,000 private health facilities

MMuullttii YYeeaarr SSttrraatteeggiicc PPllaann 22000055--22001100Universal Immunization Programme

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