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Immunization Intensification -network mtg 13 dec 2011
1. 1
June 2011
Health Network meeting
13th December 2011
Intensification of
Routine Immunization
(IRI) in India:
An Update and action plan
for reaching the unreached in
Year 2012
2. Presentation outline
• Status and performance of RI
• Efforts to strengthen RI
• Continued challenges in reaching the unreached
• Action plan for Intensification of RI (IRI) 2012
• Conclusion
4. RAJASTHAN
ORISSA
GUJARAT
MAHARASHTRA
MADHYA PRADESH
BIHAR
UTTAR PRADESH
KARNATAKA
ANDHRA PRADESH
JAMMU & KASHMIR
ASSAM
TAMIL NADU
CHHATTISGARH
PUNJAB
JHARKHAND
WEST BENGAL
ARUNACHAL PR.
HARYANA
KERALA
UTTARANCHAL
HIMACHAL PRADESH
MANIPUR
MIZORAM
MEGHALAYA
NAGALAND
TRIPURA
SIKKIM
GOA
A&N ISLANDS
D&N HAVELI
PONDICHERRY
LAKSHADWEEP
FI: 61%
• OPV3: 70.4%
• DPT3: 71.5%
• Measles: 74.1%
Proportion of Fully immunized (FI) children
DLHS-2
Below 40
40 to 50
50 to 60
60 to 70
Above 70
India State
FI: 62%
• OPV3: 68%
• DPT3: 68%
• Measles: 71%
CES 2006 CES 2009
5. FI coverage: CES 2009 vs CES 2006
-30
-20
-10
0
10
20
30
AN AP AC AS BI CH CG DN DD DL GO GU HA HP JK JH KA KE LD MP MH MN ME MZ NA OR PD PB RJ SI TN TR UP UA WB
Delhi: - 14 %
Haryana: -3 %
Punjab: +8 %
Rajasthan: +6 %
Bihar: +11 % UP: +4 %
MP: - 11 %
12 low performing states improved
However, 17 states declined
Jharkhand: +7 %
Maharastra: +6 %
WB: - 5 %
Assam: +20 %
6. Where are the missed
children?
(Equity in Immunization)
7. Data not available
0-1 %
1-4 %
8 %
10 %
13 %
35 %
5 %
Where are the unvaccinated?
Children not vaccinated with DPT3
Source: DLHS 2007-08; children surveyed were between 12-23 months
72% in 5 states
8. Where are the unvaccinated?
District-level percentage of fully immunized children
FI (DLHS-2)
Below 30
30 to 50
50 to 70
70 to 90
Above 90
Data not available
FI (DLHS-2)
Below 30
30 to 50
50 to 70
70 to 90
Above 90
Data not available
Wide intra-state variations
Source: DLHS 2007-08; children surveyed were between 12-23 months
9. 63
50
63
53
46
73
36
Urban Rural Others Scheduled
Castes
Scheduled
Tribes
Richest
Qunitle
Poorest
Quintile
37
Percentage of children age 12-23 fully immunized
District Level Household Survey 2007-2008
Immunization coverage varies significantly
among different population categories
11. Key Programmatic challenges
• Shortage of trained human resources at all levels
• Coordination and planning:
– Weak inter-sectoral coordination among Health, ICDS and other
ministerial departments (eg education)
– Lack of quality RI micro-plans and PIPs in many districts, states
• Data reporting and use:
– Divergent coverage estimates – survey assessed and reported
– Tracking children
• IEC – Communication for behavior change:
– Inadequate social mobilization and demand generation for
immunization
12. R AJAS TH AN
OR ISS A
GU JA R AT
M AH A R AS H TR A
M AD H YA PR A D ES H
BIH AR
KAR N ATAK A
U TTA R PR A D ES H
AN D H R A P R AD E SH
JA M M U & K AS H M IR
ASS AM
TA M IL N AD U
C H H ATTISG AR H
PU N JA B
JH A R K H AN D
W E ST BE N G AL
AR U N A C H AL P R .
H AR YA N A
KER ALA
U TTA R AN C H AL
H IM A C H AL PR A D ES H
M AN IPU R
M IZO R AM
M EG H AL AYA
N AG AL AN D
TR IP U R A
SIKK IM
GO A
A&N IS LAN D S
D ELH I
D &N H AV EL I
PO N D IC H E R R Y
LAK SH A D W EE P
0 – 10%
10 – 20%
20 - 28%
Source: DLHS 3 2007-08
System weakness in tracking and following
children:
Percentage difference between BCG and MCV1 coverage
13. Improved access but declining utilization
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Full Immunization Partial Immunization No Immunization
Source: DLHS-2 and DLHS-3
14. Analysis of gaps
• Low Access :
– Immunization session sites are not included in
microplan
– Session not attended by ANM – leave, post vacant,
not going to the site
• Poor utilisation:
– Irregular sessions, variable quality of services
– Non-availability of vaccine/logistics
– Poor messaging and communication
– Low community confidence in services
15. Reasons for being partially immunized:
June 2010 – May 2011
*WB data for May & June, ’11 only
33%
41% 37% 37%
8%
5% 9% 5%
23%
23%
11%
26%
18%
16%
22%
16%
18% 16%
22%
16%
0%
20%
40%
60%
80%
100%
Bihar UP Jharkhand WB
Awareness & Inform ation gap Operational gap
AEFI apprehension Other reasons
Data not available
17. Efforts to strengthen RI
1. Policy level initiatives
2. Expanding RI micro planning and monitoring
3. Capacity building
4. Cold chain and vaccine mgt. strengthening
18. 1. Policy level initiatives
• New draft Multiyear Plan (cMYP) developed 2010-17
• Decentralized and flexible funding as per state Project
Implementation Plans (PIP) under NRHM
– District/block specific plans for hard to reach areas (inaccessible,
tribal and urban) are reflected in PIPs
– Funds for Addl. Vaccinators, alternate vaccine delivery, ASHA
• Indian Public Health Standards (IPHS) – revised
• Human resource assessment at national and state level
for UIP ( IIM Ahmedabad 2010)
• Developed National Vaccine Policy in 2011
19. National Vaccine Policy
• Made by Consultative
process
• Core committee incl.
experts, NTAGI
members, UNICEF and
WHO
• Guided by principle of
vaccine security
• Newer vaccine
introduction kept in mind
20. Improving RI microplan
• State initiative supported
by partners
• RI micro-plans revised
using more frequently
updated polio micro -
plans
• Exercise lead to increase
in number of outreach
sessions planned
19,978
9,797
21,104
12,596
0
2500
5000
7500
10000
12500
15000
17500
20000
22500
UP (12 districts) BIHAR(4 districts)
Sessions planned prior to microplan exercise
Sessions planned after microplan exercise
1,126 added
sessions
2,799 added
sessions
21. Harmonization of Polio SIA & RI Microplan
District: Bulandshahr, Uttar Pradesh
Every polio SIA team carries this plan
and must inform parents of when and
where RI sessions are held
SIA component
RI component
Village visited by
SIA team
22. Improving and expanding RI monitoring
• In 2011, more than 9,000 session sites and 90,000
children monitored per month in 3 high priority states
• RI monitoring expanding to other states: West Bengal,
Karnataka, Rajasthan, Punjab, Orissa, Delhi, Assam
RI monitoring: June 2010 – May 2011
State
Sessions
monitored
Children surveyed
0 to 11 months 12 to 23 months
Bihar 36,362 200,015 87,474
Jharkhand 5,158 24,303 12,998
UP 83,890 500,719 170,100
TOTAL 125,410 725,037 270,572
23. 47
57
35
51
20
25
30
35
40
45
50
55
60
65
70
Jun'10 Jul Aug Sep Oct Nov Dec Jan'11 Feb Mar Apr May
percentage(%)
UP State HR blocks
Full immunization coverage: RI monitoring
UP & HR Blocks, June’10 – May’11
Visited
1
Up.shp
BCG_0M
0 - 40
40.1 - 60
60.1 - 80
80.1 - 100
Visited
1
Up.shp
BCG_0M
0 - 40
40.1 - 60
60.1 - 80
80.1 - 100
Data not available
<= 40%
40% to 60%
60% to 80%
>= 80%
Not monitored
UP State
State Average = 51%
Children 12-23 months: 207,811
HR Blocks Cumulative
Average = 43%
Children 12-23 months: 39,346
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
BAD
BJN
PIL
SHA
BRL
MZN
AGR
SHP
ALG
BLS
MRD
MTR
MAI
ETA
MRT
JPN
FER
FKB
RMP
ETW
KAN
GZA
HTR
BGT
GBN
24. % RI sessions not held: UP & HR blocks
June’10 to May‘11
UP districts – cumulative
State Average: 8.5%
Sessions not held:
6,613 out of 70,851
> 20%
15% to 20%
10% to 15%
< 10%
% Sessions not held
HR Blocks
State Average: 8.6%
Sessions not Held:
1,196 out of 13,856
SHP
PIL
RMP
FKB
SHA
ETA
KAN
ALG
MTR
JPN
BRL
AGR
BAD
HTR
GBN
BJN
MZN
BLS
ETW
MAI
MRD
MRTBGT
GZA
FER
SHP
PIL
RMP
FKB
SHA
ETA
KAN
ALG
MTR
JPN
BRL
AGR
BAD
HTR
GBN
BJN
MZN
BLS
ETW
MAI
MRD
MRTBGT
GZA
FER
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
25. By ICDS
UP districts - cumulative
State Average = 34.2%
ICDS found present: 24,249 out of 64,653
By ASHA
< 20%
20% to 40%
40% to 60%
> 60%
Mobilization of beneficiaries at monitored RI
session sites, U.P. April ’10-March ‘11
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
<Empty Picture><Empty Picture><Empty Picture>UP districts - cumulative
State Average = 63.5%
ASHA found present: 44,981 out of 64,653
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRP
BST
KPN
CKT
MTR
MAI
KPD
SULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
26. Training & Capacity
Building
• Health Workers:
– Re- started in year 2007, majority of HW got 2 days
training exclusively on immunization
– Evaluation of HW training done in year 2009-10
– New Training material developed, refresher training
started this year (Feb 2011)
• Medical Officers:
– Ongoing in most states
– 60,000 Medical Officers to be trained
– Approx. 60% have been trained by now
27. Action Plan to improve RI
coverage with Equity
( Year of intensification 2012)
Detailed guidelines under development
28. Prioritization of the states
Category DPT3 coverage Names of the states Remarks
Poor performing
states
DPT3 coverage
less than national
average (NE
states excluded)
MP, UP, Bihar,
Rajasthan,
Jharkhand, Orissa,
Gujarat, and
Chhattisgarh
Good and medium
performing states
DPT3 coverage
more than
national average
(NE states
excluded)
Rest of the states
North Eastern
states
Not considered Assam, Sikkim,
Arunachal Pradesh,
Manipur, Mizoram,
Nagaland, Tripura,
Meghalaya
Difficult to access,
geographical
terrain, during a
large part of the
year
29. Grouping of the states for IRI in India-2012
North-East states
Poor performing states
Good & medium performing states
Note: These states have been categorized, based upon DPT3 coverage in India, as per CES-2009
30. Identification and prioritization
low coverage areas
Strategy
• Risk analysis using block as unit
• key basic parameters for risk analysis are
– Immunization coverage, drop-out,
– outbreaks of measles or other VPDs,
– session monitoring data,
– accessibility, and availability of services,
– human resource availability
– high risk population data collected for Polio under the
RRT (EPRP)
31. Special strategies (1/3)
• Development of action plan with clear timelines.
• Suggested components to include but is not
limited to
– Up-dation of micro-plan
– Reallocation of human resource
– Trainings
– Intensive IEC activities
– Catch up vaccination (Immunization weeks) b/w
Jan- April 2012 to raise the profile of Imm. Program
and to reach the unreached
32. Special strategies (2/3)
• Communication strategy and operational plan to
be rolled out in Q1, 2012
– Awareness about session site (visibility)
– Branding of immunization
– Advocacy with media and partners
• HR strengthening
– strengthening in management structure, Technical
support unit (TSU) be set up at national/ state level in
accordance with HR assessment report
– Filling up vacancies at all levels including ASHA and
AWW
– Detailed guideline under development
33. Special strategies (3/3)
• Teeka Express
– Strengthening AVD
– to provide a branded vaccine
delivery van to cold chain point
for the delivery of vaccine to the
session site and return back
– In underserved populations,
tribal, hard to reach areas, LWE
areas, urban and peri-urban
areas
• Improved supervision (addl.
Funding under PIP)
• Cold chain & VM
34. To conclude..
• India accounts for highest
number of un- immunized
children in the world
• Disparity exists among rich/
poor, rural/ urban and social
groups
• Year of intensification 2012
has provided an opportunity
to accelerate efforts to reach
the unreached.