Routine Immunization current status & low coverage areas

identification Strategy & way forward

SEPIO meeting18-20 May 2011

Dr Pradeep Haldar, MoHFW, GoI

Presentation Outline

• Routine immunization Current Status

• Evidence from the field

• Low RI coverage area - Identification

• Way forward

CES 2009: FI 61 %

Routine Immunization in India Proportion of Fully immunized children (12 – 23 months)

Source: http://www.mohfw.nic.in

DLHS-2Below 4040 to 5050 to 6060 to 70Above 70

India State

Challenges: Access & Utilisation

Source: DLHS-3 Data

Improved access but declining utilisation

Source: DLHS-2 and DLHS-3

Assessing utilisation and access of servicesDLHS 2 versus DLHS 3

Full Immunization Improved Utilisation

Improvement Decline

Access

Improvement

Andhra Pr, Assam, Goa, HP, Karnataka, Kerala,

Lakshadweep, Mizoram, Orissa, Punjab, Uttarakhand,

WB

Uttar Pradesh, Bihar, Madhya Pradesh, Chhattisgarh, D&D,

Jharkhand

Decline

A & N Islands, Chandigarh, Delhi, Gujarat, Haryana,

J&K, Manipur, Meghalaya, Tripura

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

DLHS-2 v/s DLHS 3

Full Immunization Declined

Utilization

Improvement Decline

Access

Improvement Tamil Nadu

Decline D& NH, Poducherry, Maharashtra,

BCG (HIMS 10-11 Vs CES-09)

BCG (HIMS 10-11 Vs CES-09)

DPT (HIMS 10-11 Vs CES-09)

DPT (HIMS 10-11 Vs CES-09)

Measles (HIMS 10-11 Vs CES-09)

Measles (HIMS 10-11 Vs CES-09)

Vaccine Supply Vs HIMS 10-11

Vaccine Supply Vs HIMS 10-11 Cont

Findings from RI Monitoring

% RI session held – UP, Bihar and Jharkhand (Year - 2010)

n=number of sessions monitored

83.0% 82.5%74.5%

3.0% 4.3% 14.6%

14.0% 13.2% 10.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bihar (n=30,604)

Jharkhand(n=3,164)

Uttar Pradesh(n=65,500)

Session held as per microplan Session held not as per microplan Session not held

15 to 25% sessions not held / not held as per microplan

Due to absence of ANM and/or vaccine, logistics

Availability of vaccine & diluent at RI sessions January – December 2010

n=number of RI session found conducted

94% 98%92% 93%

83%94% 98% 92% 93%

81%89%

98% 92%86%

74%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BCG + Diluent DPT tOPV Measles +Diluent

All Vaccine +Diluent

UP (n=58,368) Bihar (n=26,248) Jharkhand (n=2,746)

% availability of all Vaccines on sessions sites (Year – 2010 & 1st Quarter 2011)

JBSA – Jachha Bachha Suraksha Abhiyan -UP

80% 80% 80% 80%

70%

80% 80%

70%

50%

80%

90%

80% 81% 80%

88%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

JBSA started form August’10

Visited1

Up.shp

BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100

Visited1

Up.shp

BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100

Data not available

<= 40%

40% to 60%

60% to 80%>= 80%Not monitored

UP districts Cumulative Jan’10 - Dec’10 : 80%

Sessions held- 59,811

UP districts CumulativeJan’11 – Mar’11: State Average- 83%

Sessions held- 17,573

KRI

SBD

STP

LLP

HDO

JAL

JNS

AHB

BJN

BAD

BRC

PIL

RBL

SHA

SUL

MZP

BBK

BRL

FTP

BNA

JNP

UNN

AZG

MZN

AGR

ALG

SHP

HMP

BLS

GND

PTG

KSN

MRD

BRP

GZP

BAL

GRPBST

KPN

CKT

MTR

MAI

KPD

MHB

FAI

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

AEFI of Mohanlal Ganj (Lucknow)

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

GRPBST

KPN

CKT

MTR

MAI

KPDSULCSN

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

GRPBST

KPN

CKT

MTR

MAI

KPDSULCSN

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><Empty Picture>

Availability of all UIP vaccines and diluent at RI sessions, Bihar - 2010

Year 2010:Total 30,604 RI sessions monitored

Col No.

KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA

Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad

Sheikhpura

Sheohar

<=50%51 - 70%70 - 90%91 - 100%

75 77 80 82 82 84 84 8480

76 78 79

0

10

20

30

40

50

60

70

80

90

100

Jan'1

0

Feb'1

0

Mar

'10

Apr'10

May

'10

Jun'10

Jul'1

0

Aug'10

Sep'1

0

Oct'10

Nov'10

Dec'10

GUMLA

GIRIDIH

RANCHI

PALAMU

DUMKA

LATEHAR

CHATRAGARHWA

SIMDEGA

SINGHBHUM WEST

HAZARIBAGH

KHUNTI

GODDA

BOKARO

PAKUR

DEOGHAR

SARAIKELLA

DHANBAD

JAMTARA

SINGHBHUM EAST

SAHIBGANJ

RAMGARH

KODERMA

LOHARDAGA

% Sessions where all RI vaccines and AD syringes were available, Jan-Dec 2010, Jharkhand

State average 2010: 69.8%

Nil1 - 30 %31 - 59 %60 - 79 %>= 80 %Data Not Available

Source: RI session monitoring dataN = 5692 RI session found held

Full immunization status and BCG-measles drop out rates, 2010 – Uttar Pradesh

Fully Immunized20 % to 40 %40 % to 50 %50 % to 60 %60 % to 76.3%

Up.shpBCG-Measles Drop-out

Below 1010 % to 30 %30 % to 50 %50% to 60 %

Up.shpFIC (Fully immunized coverage)

BCG-measles drop out rate

n= 1,76,634 children 12 to 23 month of age

KRI

SBD

STP

LLP

HDO

JAL

JNS

AHB

BJN

BAD

BRC

PIL

RBL

SHA

SUL

MZP

BBK

BRL

FTP

BNA

JNP

UNN

AZG

MZN

AGR

ALG

SHP

HMP

BLS

GND

PTG

KSN

MRD

BRP

GZP

BAL

GRPBST

KPN

CKT

MTR

MAI

KPD

MHB

FAI

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

RBL

SHA

SUL

MZP

BBK

BRL

FTP

BNA

JNP

UNN

AZG

MZN

AGR

ALG

SHP

HMP

BLS

GND

PTG

KSN

MRD

BRP

GZP

BAL

GRPBST

KPN

CKT

MTR

MAI

KPD

MHB

FAI

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

Full immunization status and BCG-measles drop out rates, Bihar, Jan-Mar 2011

BCG-Measles Drop-outBelow 1010 % to 30 %30 % to 50 %50% to 60 %

Up.shpFIC (Fully immunized coverage)

BCG-measles drop out rate

n = 20,872 children 12 to 23 month of age

Col No.

KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA

Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad

Sheikhpura

Sheohar

Col No.

KAIMURKATIHARKHAGARIAKISHANGANJLAKHISARAIMADHEPURAMADHUBANIMUNGERMUZAFFARPURNALANDANAWADAPATNAPURNIAROHTASSAHARSASAMASTIPURSARANSHEIKHPURA

Gaya

Patna

Jamui

Rohtas

Purnia

KaimurBanka

Araria

Saran

Katihar

Siwan

Supaul

Madhubani

Nawada

Champaran West

BhojpurBuxar

Nalanda

Muzaffarpur

Bhagalpur

Aurangaabad

Sitamarhi

Vaishali

Darbhanga

Champaran East

Samastipur

Gopalganj

Saharsa

Begusarai

Munger

Khagaria

Madhepura

Kishanganj

ArwalLakhisaraiJehanabad

Sheikhpura

Sheohar

20 - 39%40 - 49%50 - 59%60 - 90%

GUMLA

GIRIDIH

RANCHI

PALAMU

DUMKA

LATEHAR

CHATRAGARHWA

SIMDEGA

SINGHBHUM WEST

HAZARIBAGH

KHUNTI

GODDA

BOKARO

PAKUR

DEOGHAR

SARAIKELLA

DHANBAD

JAMTARA

SINGHBHUM EAST

SAHIBGANJ

RAMGARH

KODERMA

LOHARDAGA

By district, Year 2010State average : 76.1%

Jharkhand: Monitoring community coverage gaps:% Fully immunized children, children 12-23 months

Upbijh.shp16.3 - 4040.1 - 6060.1 - 8080.1 - 100

Upbijh_state.shpPercent fully immunized

Source: RI h-t-h monitoring dataN = 12485 Children 12-23 month

Improving access and utilisation of RI:Lessons from pulse polio activities (1)

• Social mobilization in Polio to increase utilisation;– Messages tailored for specific audience

– Use of local resources (community members, local leaders, and influential people)

– Religious sites and gatherings for message delivery

• Strengthen linkages with pulse polio teams activities:

– Polio microplans to include RI session site information (where, when and by whom)

– Teams provide RI card to families during the house-to-house visits and share information on RI sessions

Improving access and utilisation of RI:Lessons from pulse polio activities (2)

• Strong inter-sectoral coordination (health, education and ICDS):– Pooling of human resources, venue, vehicles and leadership

prior and during rounds– ANM and ASHA (Health), AWW (of ICDS), School

teachers (education) works together. – Evening briefings attended by MOI/Cs, CDPOs, BEO and

community members for better planning

• Replicating and extending coordination in support of RI:– RI monitoring feedback during coordination meetings– Preparing joint strategies to strengthen RI at different

levels

Low coverage area Identification

• populations known to have a disproportionate share of the disease burden;

• un-immunized or under-immunized children in urban and peri-urban areas;

• populations in places where sanitation is poor;

• populations inhabiting difficult or mountainous terrain, marshy areas, islands

• refugees, internally displaced persons, migrant workers and other transient populations;

• politically and or socially marginalized populations or minority groups;

• religious groups that oppose vaccination.

• Communities at international borders and Intra-State administrative borders.

Identification and prioritization low coverage areas

1. URBAN Strategy

2. Rural Strategy1. First priority to the villages/habitations which are

never (rarely) reached

2. Then the villages / habitations in which immunization was planned but not held during previous 3-4 months.

3. Villages where RI is normally done but coverage is low

4. Convergence of Microplan – for uncovered areas

Way forward

• Experience from Polio SIAs to be used for RI improvement

– Improved access and utilization

– Updating micro-plans

– Social mobilization

• Expand RI monitoring to other states and locations

Thank you