India committed to reducing pneumonia, diarrhoea deaths

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Getting to 90 percent full immunization coverage

India, as a signatory to the United Nations’ Sustainable Development Goals, is committed to ensure healthy lives and promote well-being for all. High immunization coverages are expected to contribute towards reducing newborn, under-five morbidity and mortality. India has made remarkable progress in this field, with 48 percent reduction in infant mortality and 54 percent reduction in under-five mortality during 1992-2016. ,

India has demonstrated its commitment to saving children under-five years of age by expanding new vaccines, keeping the country polio-free, maintaining maternal and neonatal tetanus elimination status and working towards the goal of 90 percent full immunization coverage (FIC).

Recognising the challenges of immunization in urban areas, the Ministry of Health and Family Welfare (MoHFW) put exceptional efforts during the Intensified Mission Indradhanush (IMI) to reach out to left outs and dropouts in urban areas. The slow progress in immunization coverage in urban areas necessitates particular attention to the areas of infrastructure and manpower planning, coordination with other partners and addressing demand-side interventions through a robust evidence-based communication strategy.

In the first quarter of 2018, preparations for the expansion of the pneumococcal vaccine in Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan and rotavirus vaccine in Jharkhand in the Universal Immunization Programme continued in full swing. The Measles-Rubella vaccination campaign has been completed in 13 states. Six states are prepared to launch the campaign in April. After the launch, by Hon’ble President of India, two Polio National Immunization Days have been observed across the country, with an estimated coverage of 97 percent as per independent monitoring.

As we move into the second quarter of the year, the focus is to have mechanisms in place to achieve 90 percent full immunization coverage by December 2018. The Ministry is focusing on multiple strategies to achieve the goal, including efforts to converge with all relevant ministries for support to operational components; social mobilisation for routine immunization and support to priority states to prepare their immunization coverage improvement plans after conducting comprehensive immunization reviews. Simultaneously, the Immunization Division of the MoHFW has also undertaken surveys after the IMI to access increase in immunization coverage. All these steps will indeed help save lives!

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Quarterly 2018, Issue 2

IMMUNIZATION NEWSLETTER

Dr Mahesh Kumar AggarwalDeputy Commissioner - UIP, Ministry of Health and Family Welfare

When Ridhi was two months old, she had difficulty in breathing. She was rushed to the hospital, where an X-ray was conducted, and she was given oxygen. The doctors told her mother Anuradha that Ridhi had developed pneumonia. Anuradha, recalls that her husband had to close his grocery shop in Bareilly, Uttar Pradesh for five days and they spent anxious moments at the hospital until Ridhi was deemed fit and discharged.

To curb deaths by both pneumococcal pneumonia and rotavirus diarrhoea, the Ministry of Health and Family Welfare (MoHFW), Government of India, introduced two vaccines –the Pneumococcal Conjugate Vaccine (PCV) and Rotavirus Vaccine (RVV) in the Universal Immunization Programme (UIP) in a phased manner.

In 2016, the MoHFW introduced the Rotavirus Vaccine in Haryana, Himachal Pradesh, Andhra Pradesh and Odisha. In 2017, RVV was scaled up to five more states Rajasthan,

Madhya Pradesh, Assam, Tripura and Tamil Nadu. As a part of the RVV expansion plan, the vaccine will now be introduced in Jharkhand in April 2018. Rotavirus accounts for 40 percent of hospitalisation due to diarrhoea amongst children in India. According to an estimate in 2014, rotavirus is responsible for nearly 32.7 lakh outpatient visits, 8.72 lakh hospitalisations and 78,000 deaths annually in India of which 59,000 occur in the first two years of life.

PCV protects children against severe forms of the pneumococcal disease, such as pneumonia and meningitis. In May 2017, the MoHFW introduced the PCV in the UIP. In the first year, the vaccine was introduced in Himachal Pradesh and 17 districts of Bihar and 6 districts of Uttar Pradesh. In 2018, the vaccine is now being expanded to the remaining districts of Bihar, 6 more districts in Uttar Pradesh, all districts in Madhya Pradesh and 9 districts in Rajasthan.

Also, as a strategy to address childhood malnutrition, Immunization Division, MoHFW has also planned a road-map to scale up PCV and RVV vaccines in districts identified by Ministry of Women and Child Development under the National Nutrition Mission (NNM). Out of 201 districts under NNM, 90 and 124 districts are already covered under UIP for PCV and RVV introduction, respectively.

All these efforts will allow many young infants to reach their fifth birthday and live a more meaningful and productive life.

Immunization Newsletter2

Thank you all for the positive response to the first Immunization Newsletter. Going forward, we will continue to share insights from the immunization space - both at the national and state levels.

It gives me immense pleasure to present the April 2018 Immunization Newsletter which covers different aspects. In March, women in the immunization space from high-level Government officials to health workers - ANMs, ASHAs and Anganwadi Workers continued their relentless zeal to immunise children. Many frontline workers are known to travel miles through harsh terrain carrying vaccines to reach children who would otherwise be left out. We salute their passion with our Page 6 feature dedicated to International Women’s Day.

Apart from this, the Director General (DG) of the World Health Organization Dr Tedros Adhanom Ghebreyesus during a visit to India, was given an overview of India’s efforts to strengthen the routine immunization programme. He appreciated the Ministry’s efforts and remarked - Other countries can learn from India!

This issue also covers the expansion of the Pneumococcal Conjugate Vaccine (PCV) and Rotavirus Vaccine (RVV) in the Universal Immunization Programme (UIP), to more states. There is a status update of the Comprehensive Multi-Year Plan (cMYP), the five-year plan for immunization for integrated programming with a strategic framework and roadmap for the UIP. There are also updates on all the immunization partners’ recent meeting to structure the comprehensive UIP reviews being anchored by ITSU and the overview of the National AEFI committee meeting.

This edition also features a heartwarming story from the Measles Rubella campaign in Odisha shared by UNICEF.

I hope you enjoy reading the April 2018 Immunization Newsletter. We look forward to your feedback and suggestions!

Dr Pritu DhalariaDirector, Immunization Technical Support Unit

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Immunization Newsletter2

How a pre-assessment is delivering resultsThe Government of India in February 2017, launched the Measles-Rubella (MR) campaign, to eliminate measles and control rubella. The MR vaccine prevents measles and rubella and has been launched in the form of a public health campaign, currently one of the largest in the world. The campaign targets children of age 9-15 years irrespective of their previous vaccination status with Measles Containing Vaccine (MCV) or history of illness. Both doses of measles vaccine, currently provided at 9-12 months and 16-24 months of age, will be replaced by MR vaccine under routine immunization, immediately after the campaign.

Planned in a phased manner, the campaign in India targets nearly 410 million children across the country in two years. The campaign has been rolled out in 15 states including few North Eastern States. Nationwide campaigns such as the scale of the MR campaign through schools and outreach requires significant efforts in mobilisation these demanding immense preparation both at the state and district level. This also includes overhauling the logistic system, the orientation of health workers to the mobilisation of community and stakeholders.

Learnings from Phase One of the campaign revealed that preparation time was a pre-requisite for the success of the campaign. Keeping this in mind, the Ministry of Health and Family Welfare (MoHFW) planned preparedness assessments for the campaign at state, district and sub-district levels to identify critical bottlenecks, provide supportive supervision and monitoring and suggest a mid-course correction.

Pooling technical expertise from all immunization partners, the pre-assessment aims not only to monitor preparation but also mentor and provide ‘on the spot’ guidance and solutions to the gaps and challenges faced by the districts and states. The pre-assessment teams inform the state and the Ministry if the states have adequate preparation to go ahead with the campaign. A tool with clear indicators prepared at the national level help rank the districts and states by the assessment findings into ‘Go’ and ‘Wait & Go’ states. The ranking criteria include indicators on service delivery and demand-side aspects.

The experience of the first phase of the MR campaign in 2017 also highlighted the need to strengthen strategic communication interventions in the states, to inform parents and community

stakeholders about the importance of the MR vaccine and its efficacy to ensure that an enabling, supportive environment is built for rolling out the MR campaign. Communication has been the centrepiece of the campaign and communication planning, monitoring and supervision have been emphasised under the pre-assessment.

HOW IT IS DONE: The pre-assessment teams comprising technical experts drawn from the Immunization Technical Support Unit and immunization partner agencies WHO, UNICEF, UNDP, CORE, GHS and NCCVMRC were oriented on the MR assessment templates and deployed to states and districts for a week. Each expert was allocated one district to monitor and mentor. During the week, the monitors visited the toughest district and their health facilities, schools, met community members, briefed stakeholders of Education Department and share IEC materials with them as a team.

At the end of the week, the National Monitor briefed the Chief Medical Officer and District Immunization Officer and the District Magistrate of each district on the critical observations, gaps and provided suggestions to improve on the shortcomings. Following this, all teams congregated at the state headquarters, met the Mission Director, the SEPIO and the key officials and gave them an overview of the observations, issues and overall progress on the preparation. The team also presented the status of ‘GO’ or ‘Wait & GO’ to each district on the basis the composite score of service delivery and demand-side indicators.

Recently pre-assessment visits to states such as Odisha, Uttarakhand, Manipur and Arunachal Pradesh have facilitated the preparation for the MR campaign and roll out. An immunization official from a district remarked, “This visit from the national level has been a boost to our morale as we were apprehensive that we will not be able to meet the target in our district. It was an opportunity for us to clear many of our doubts and queries on technical aspects and on communication before the campaign.”

Measles Rubella Campaign

Immunization Newsletter 3

Other countries can learn from India: WHO DG

Vaccinate4Life

The Director-General of the World Health O r g a n i z a t i o n (WHO) Dr Tedros Adhanom G h e b r e y e s u s , during his recent visit to India spent time at the National Institute of Health and Family Welfare (NIHFW), in New Delhi.

A c c o m p a n i e d by Dr Tedros, Ms Vandana Gurnani, the

Joint Secretary, Reproductive and Child Health (JS-RCH), and Dr Pradeep Haldar, the Deputy Commissioner-Immunization in-charge, both from the Ministry of Health and Family Welfare (MoHFW), inspected the Intensified Mission Indradhanush poster exhibition. He was informed of the massive efforts taken up to reach India’s unreached children.

Through a video, he was familiarised with National Cold Chain Management Information System and electronic Vaccine Intelligence Network (eVIN). This was followed by a demonstration on eVIN application by Deputy Commissioner-UIP, MoHFW Dr MK Aggarwal and an auxiliary nurse midwife (ANM).

Walking through the National Cold Chain & Vaccine Management Resource Centre lab, NIHFW, Director Dr JK Das, explained the functioning of temperature loggers, solar cold chain equipment, walk-in freezers and walk-in coolers. At the Daksh-Skill lab, Dr Tedros witnessed a demonstration on newborn resuscitation on shock management and cardiopulmonary resuscitation. There are five national and 54 state skills labs that develop competent health service providers. WHO in partnership with Liverpool School of Tropical Medicine supports quality assurance, supportive supervision and data quality assurance. So far, 2,000 master trainers and nearly 30,000 service providers have been trained.

Joint JS (RCH), Ms Vandana Gurnani took Dr Tedros, around the Mother & Child Tracking Facilitation Centre and explained the

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158.4 lakh vaccine administered

6.0 lakhsession held in 24 states

11.9 lakh

14.0 lakhPregnant Women Immunized

Children Fully immunized

Data as on 27th March, 2018

We are strengthening the WHO-#India collaboration. Not only did we sign an

agreement with @MoHFW_INDIA – but we are engaging more with the Ministry of External Affairs @MEAIndia, and the

Ministry of Finance @FinMinIndia – joint work is critical to deliver #HealthForAll.

Dr. Tedros’s Tweeted:Dr. Tedros’s Tweeted:

features of the Centre to him. The presentation on Mother & Child Tracking Sys tem/Reproduct i ve and Child Health Portal/ANM Online covered the name-based tracking of beneficiaries and monitoring of service delivery, full Ante Natal Care services, Post Natal Care services, encouraging institutional delivery particularly of high-risk mothers and timely vaccination.

Later, at a meeting with Union Health Minister Mr JP Nadda, Dr Tedros complimented the Mother and Child Tracking Centre, Vaccine Supply Chain management, and eVIN cold chain management facilities and added, “Other countries can learn from India”.

Immunization Newsletter4

Fourth National AEFI Committee Meeting

Dr Pradeep Haldar, Dr N K Arora, Dr Satinder Aneja, Dr M K Aggarwal, Dr Anju Seth, Dr Veena Dhawan at the National AEFI Committee meeting held on March 13, 2018, at New Delhi

State-specific immunization systems strengthening plans

Immunization is a proven, cost-effective and the most powerful public health intervention to prevent morbidities and mortalities from vaccine-preventable diseases (VPD). India’s resolve for child health is reflected in its Universal Immunization Programme (UIP), which is the most extensive public health programme in the world, catering to more than 26 million birth cohort and 30 million pregnant women, through 9 million sessions planned every year.

In 2012, India endorsed the resolution to prevent millions of deaths by 2020 through more equitable access to existing vaccines by adopting Global Vaccine Action Plan’s (GVAP) framework. The

country remains committed to ensuring equitable access to all available vaccines.

To address the coverage inequity issue, Mission Indradhanush (MI) was launched in December 2014 initially focusing on 201 districts in the country. Gradually, in the four phases of Mission Indradhanush, 528 districts across 34 States and Union Territories were covered. While acknowledging the impact of Mission Indradhanush in improving immunization coverage across the districts over the phases , Honourable Prime Minister through Pro-Active Governance and Timely Implementation (PRAGATI) platform, emphasised the need to increase the immunization coverage to 90 percent by

December 2018. To achieve this, Ministry of Health and Family Welfare (MoHFW) launched Intensified Mission Indradhanush (IMI) in October 2017, in 190 high focus districts and cities of the country.

To achieve the goal of 90 percent full immunization coverage (FIC) in a time-bound manner, it is pertinent for states to have a state-specific immunization system strengthening plan, which can be guided by measurable indicators by identifying gaps in immunization service usage, access, supply and demand. However, it is seen that different fragmented assessments and reviews are conducted to assess the immunization programme, which serves well to determine

the desired component but does not provide a comprehensive programme status which can guide the development of state-specific immunization Coverage Improvement Plans (iCIPs).

This necessitates aligning and integrating different assessments in the form of comprehensive review for UIP. These iCIPs can guide states in achieving 90 percent FIC as per the directives by the Hon’ble Prime Minister of India. Immunization partners like WHO, UNICEF, UNDP, CORE, Global Health Strategies and JSI are already working with the ITSU to develop and roll out these comprehensive immunization reviews and help the states establish their need-based coverage improvement plans.

The fourth and last National AEFI committee meeting of 2017-18 was held on March 13, 2018, at New Delhi. Organized by AEFI Secretariat, Immunization Technical Support Unit, it was attended by committee members who are experts from the field of paediatrics, community medicine, pathology, microbiology, immunology. The committee also has representatives from national drug controller, Integrated Disease Surveillance Project, communication specialists, professional bodies (Indian Medical Association and

Indian Academy of Paediatrics) and partner organisations such as UNICEF and WHO.

The meeting was chaired by Dr Satinder Aneja, Professor, Department of Paediatrics, Sharda University (Chairperson) and Dr NK Arora, INCLEN Trust (Advisor) and Dr MK Aggarwal, DC Universal Immunization Programme, MoHFW were also present. Dr Pradeep Haldar, DC (Immunization, In-charge) and Dr Veena Dhawan, AC (Immunization) also attended the meeting and contributed to the proceedings. Representatives of State AEFI Committees of Karnataka,

Odisha, Uttarakhand and Arunachal Pradesh were special invitees and shared their views on AEFI surveillance issues in their states.

The committee deliberated on the progress made in AEFI surveillance. Appreciating the efforts of the states to improve reporting of serious and severe AEFI cases, the committee suggested measures to further strengthen AEFI surveillance. A total of 168 cases which were reported and investigated by the states were causally assessed by the expert group for classification. Also, measures to handhold states in

improving and strengthening AEFI surveillance at the state level were deliberated, which included the support extended by zonal AEFI consultants to the states, training plan for regional level training on AEFI surveillance and the potential roll out of Vaccine Adverse Events Immunization Management System (VAEIMS) in the country.

The National AEFI Committee meets once every quarter. The next meeting is expected to be held in the first half of June 2018.

Partners meeting on Comprehensive Routine Immunization Review

Immunization Newsletter 5

identified two MR Warriors. We will support the campaign as it is a good initiative by the government and is for the betterment of our children,” added the Principal of UGME School, Motta Village, Khurda Block (Rural).

Government and private schools across Odisha are

identifying and engaging adolescent children as “MR warriors” to support school authorities, teachers and health workers with various activities. These include motivating other students to take MR vaccination, helping teachers with the registration of students, and maintaining proper queues. Maintaining discipline at the vaccination site (they are very strict and ensure that no child is able to peep into the vaccination room and see another child being vaccinated, one of the essential prerequisites of the campaign). Distributing vaccination certificates, engaging fellow students in observation rooms after vaccination and notifying the school teachers and health team in case of any adverse event.

As on date, the state of Odisha has already immunized 109.74 lakh children (as on 29th March 2018) against a target of 11.2 lakh eligible children.

“It’s such a mammoth project. The entire society has to be sensitised about the issue,” said Dr KK Das, SEPIO. In Odisha alone, nearly 6,900 women health workers and 47,000 ASHA workers and 71,129 Anganwadi workers have been engaged in the drive.

So far, across 16 States and Union Territories, 7.72 crore children between the age group of nine months to 15 years have been vaccinated with this safe and efficacious Measles-Rubella vaccine. The States covered include Karnataka, Tamil Nadu, Goa,

MR Warriors battle the deadly Measles Rubella

cMYP 2018-22: Sustaining 90 percent full immunization coverage

Hari Prasad, an 11-year-old from Project UP School, Golamundula, Kabisuryanagar, Ganjam was very excited about his role as a “Measles Rubella Warrior” and proudly sported his MR Warrior branded T-shirt that he received when entrusted with this responsibility. He is the only child in his school who bagged the precious tag after winning a general knowledge quiz on Measles Rubella disease. The state of Odisha has thousands of “MR Warriors” like Hari who are supporting the massive Measles-Rubella vaccination drive in the state.

“Me and my friend Kiran are telling our friends and other students in the school to take the MR vaccine injection as it will protect us from khasra (local term used for Measles) and Rubella,” says Gauri. Gauri is a MR Warrior from upgraded Government Middle English (UGME) School, Motta Village, Khurda Block (Rural).

‘’During the orientation on Measles-Rubella Campaign at the District headquarter-Khurda, we were asked to conduct competitions like quiz, painting, essay, poem etc. and select winners as MR Warriors to support the campaign activities. We immediately held a quiz competition on MR and

Andhra Pradesh, Himachal Pradesh, Kerala, Uttarakhand, Telangana, Arunachal Pradesh and five Union Territories, Puducherry, Lakshadweep, Chandigarh, Daman & Diu and Dadra & Nagar Haveli. The campaign is on going in Odisha and Manipur.

ANDHRA PRADESH

PUDUCHERRY

TELANGANA

TAMIL NADULAKSHADWEEP

KERALA

KARNATAKA

GOA

D&N HAVELI

DAMAN & DIUODISHA

ARUNACHAL PRADESH

HIMACHAL PRADESH

CHANDIGARH

The Comprehensive Multi-Year Plan (cMYP) is a five-year immunization plan for integrated programming with a strategic framework and roadmap for the Universal Immunization Programme. The current country’s multi-year plan for 2018-22, drafted as a consolidated effort of the Ministry of Health and Family Welfare (MoHFW) and partners provides a comprehensive layout of core areas with nine interlinked objectives covering various aspects of UIP with strategies and activities to achieve them. The global and regional priorities are also aligned to develop this cMYP to achieve and sustain the target of 90 percent full immunization coverage.

The cMYP provides strategies and activities to improve service delivery and data management, strengthen vaccine logistics and cold chain management, strengthen AEFI system and VPD surveillance. It includes activities to increase confidence and demand for vaccines in the community, ensure measles

elimination and rubella control, sustenance of achievements under the polio programme and smooth introduction and scale-up of new vaccines.

The strategies and activities under cMYP are devised after conducting a detailed situational analysis of the immunization programme for the period of planning. This strategic document for the period 2018-22 focuses on the sustainability of the activities under Gavi Health Systems Strengthening 2. The details of financing pattern of the Indian immunization programme including baseline and projected expenditure for immunization activities are an essential component of cMYP 2018-22. The document provides an overview of the Government of India’s support towards giving financial and technical resources to the states to strengthen programme management, improve vaccine logistics and cold chain system, introduce new vaccines, and bring in higher efficiency and accountability in service delivery.

Women have been the backbone of India’s massive immunization drive. In the past quarter - International Women’s Day was just another acknowledgement to many of these women whose perseverance and leadership is helping the country inch towards increasing immunization coverage

Right from the leadership at the Ministry of Health and Family Welfare (MoHFW), to state and district level officials to frontline health workers. Let’s meet a few:

Seen here interacting with a new mother during the November 2017 Intensified

Mission Indradhanush to help her overcome barriers against immunization.

Meenu has motivated many families in Jalalabad, Kannauj through one-to-one meetings. She has mobilised more than 90 percent beneficiaries at Village Health Nutrition Day session site.

With support from the Gram Pradhan and Panchayat members, she has influenced and counselled resistant family members. She has been successful in her endeavours with some vaccine-hesitant Muslim families. She is able to pursue them for immunization and family planning.

Shared via WhatsApp: A frontline worker in Himachal inches through muddy slush with a vaccine carrier during an IMI round. There is just no stopping the grit and determination of these women.

A 52-year old ANM from Jhansi has been working tirelessly for the last 15

years. Today the immunization coverage in her area is more than 90 percent.

Despite the lack of public commute in her area, she walks and always reaches the session site on time. Recently, she

utilised sub-centre untied funds to clean, paint and repair hand pump at

sub-centre.

As part of the MoHFW’s national monitors, Dr Dhawan reviewed and guided Intensified Mission Indradhanush sessions in Solapur district of Maharashtra. The national monitoring visits were rolled out to help States explore newer possibilities to increase coverage.

Monitoring an urban session in Patna, Bihar. Under her leadership, many new vaccines have been introduced/expanded since 2014 that include Measles-Rubella, Rotavirus, Pneumococcal Conjugate Vaccine and the adult Japanese Encephalitis.

Counselling a pregnant woman on the importance of vaccination in Ghaziabad during an Intensified Mission Indradhanush session in January 2018. Counselling mothers help Ashima work with them through their pregnancy and delivery of a healthy child.

Ms. Vandana Gurnani Joint Secretary Reproductive and Child Health, MoHFW

Dr. Veena Dhawan Assistant Commissioner, MoHFW

Deepa Singh District Immunization Officer, Bareilly,

Uttar Pradesh

Ashima ANM, Ghaziabad, Uttar Pradesh

Meenu Awasthi ASHA, Kannuaj, Uttar Pradesh

Immunization Warrior ASHA, Himachal Pradesh

Meena Yadav ANM, Jhansi, Uttar Pradesh

B-28, First floor, Qutub Institutional Area, Opposite Rockland Hospital, New Delhi. 110016

011-41213100 www.itsu.org.in @Vaccinate4LifeVaccinate4Lifeitsu_info@in.jsi.com

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