Routine Immunization:

Recent initiatives and progress in high risk

areas

23rd India Expert Advisory Group 13-14 July, 2011

Dr Pradeep Haldar, MoHFW, GoI

Presentation outline

Status and performance of RI Efforts to strengthen RI Continued challenges Way forward

Routine immunization performance

FI: 61%• OPV3: 70.4%• DPT3: 71.5%• Measles:

74.1%

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

FI: 62%• OPV3: 68%• DPT3: 68%• Measles:

71%

CES CES 20062006

CES CES 20092009

Full immunization 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 %

Only 12 states improved

23 states declined

Jharkhand: +7 %

Maharastra: +6 %

WB: - 5 %

OPV3 coverage: CES 2009 vs CES 2006

-15

-10

-5

0

5

10

15

20

25

30

35

40

AP AC AS BI CG DL GO GU HA HP JK JH KA KE MP MH MN ME MZ NA OR PB RJ SI TN TR UP UA WB

Delhi: - 1.6 %

Haryana: -7.7 %

Punjab: +14.8 %

Rajasthan: +28 %

Bihar: +17 %

UP: +34.4 %

MP: - 14.2 %

28 states improved

7 states declined

Jharkhand: +27.8 % Maharastra: +20.7

%

WB: +4.2 %

Tamilnadu: - 7 %Andhra Pradesh: - 8 %

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

per

cen

tag

e (%

)

UP State HR blocks

Full immunization coverage: RI monitoring UP & HR Blocks, June’10 – May’11

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 StateUP State State Average = 51%

Children 12-23 months: 207,811HR Blocks CumulativeHR Blocks CumulativeAverage = 43%

Children 12-23 months: 39,346

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

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%41% to 60%61% to 80%> 80%Not 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

2

Col No.

KHA_GOGARIKHA_KHAGARIA URBANMDP_ALAMNAGARMDP_CHAUSAMDP_UDAKISHUNGANJMDB_JAINNAGARMZF_MARWANMZF_MUSAHRINLD_BIHAR SHARIFNLD_SARMERANWD_PAKRIBARAWANPTN_DANAPURPTN_MANERPTN_PHULWARISHARIFPTN_SADARPRN_BAISISAH_MAHISHISAH_SALKHUASAH_SIMRI BAKHTIARPURSAM_BIBHUTIPURSAM_BITHANSAM_HASANPURSAM_SINGHIASAM_WARISNAGAR

Gaya

Patna

Jamui

Rohtas

Purnia

Kaimur

Banka

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

Bihar StateBihar State

State Average = 66%

Children 12-23 months: 87,474

HR Blocks cumulativeHR Blocks cumulative

Average = 66%

Children 12-23 months: 9,733

Full immunization : RI monitoring Bihar & HR Blocks, June’10 – May’11

Immunization status through RI monitoring: June 2010 – May 2011

*WB data for May & June, ’11 only

66%

51%

78%

61%

30%

37%

20%

32%

12%2% 7%5%

0%

20%

40%

60%

80%

100%

Bihar

(n=87,474)

UP

(n=207,811)

J harkhand

(n=11,599)

West Bengal

(n=1,020)

Fully Immunized Partialy Immunized - "drop outs"

No Immunization - "left outs"

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 J harkhand WB

Awareness & Information gap Operational gap

AEFI apprehension Other reasonsData not available

% RI sessions not held: UP & HR blocks

June’10 to May‘11

UP districts – UP districts – cumulativecumulative

State Average: 8.5%

Sessions not held:

6,613 out of 70,851

> 20%

15% to 20%10% to 15%

< 10%

% Sessions not held

Source: RI monitoring data, GoUP and NPSP

HR BlocksHR BlocksState Average:

8.6%

Sessions not Held:

1,196 out of 13,856

817

11

26

0

5

10

15

20

25

30

35

40

45

50

Jun'10 Jul Aug Sep Oct Nov Dec Jan'11 Feb Mar Apr May

perc

en

tag

e (

%)

UP state HR blocks

Due list available: Bihar & HR blocks

June ’10 to May ‘11

Bihar districts Bihar districts CumulativeCumulative

State average = 42 %

13,294 out of 31,736

< 40%

40% to 60%61% to 80%

> 80%

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

HR Blocks CumulativeHR Blocks Cumulative

HR blocks average = 52 %

1,770 out of 3,386

41 42

56 55

0

10

20

30

40

50

60

70

Jun'10 Jul Aug Sep Oct Nov Dec Jan'11 Feb Mar Apr May

per

cen

tag

e (%

)

Bihar State HR Block5

Col No.

Gaya

Patna

Jamui

Rohtas

Purnia

Kaimur

Banka

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

23

27

44

28

0

5

10

15

20

25

30

35

40

45

50

Jun'10 Jul Aug Sep Oct Nov Dec Jan'11 Feb Mar Apr May

per

cen

tag

e (%

)

Bihar State HR Block

UP districts UP districts CumulativeCumulative

State Average = 29%

Hub-cutter available:

20,234 out of 70,851

Availability of hub-cutter: UP & HR blocks

June ’10 to May ‘11

< 40%40% to 60%60% to 80%> 80%

HR BlocksHR BlocksAverage = 20%

Hub-cutter available:

2,513 out of 12,660

By ICDS

UP districts - cumulativeState Average = 34.2%

ICDS found present: 24,249 out of 64,653

Source: RI monitoring data, GoUP and NPSP (Apr’10 to Mar’11)

By ASHA

< 20%

20% to 40% 40% to 60%

> 60%

Mobilization of beneficiaries at monitored RI session sites, Uttar Pradesh April ’10-

March ‘11

UP districts - cumulativeState Average = 63.5%

ASHA found present: 44,981 out of 64,653

Efforts to strengthen RI

Risk scoring: Karnataka, 2011

Criteria for risk categorisation (Karnataka):A summed scored index is computed on following

criteria- Estimated unimmunized for OPV3 in 2010-11

(coverage assumed at DLHS-3 levels) WPV importations in previous years since 2002 Bordering WPV importation districts Clustering of compatibles in the past 3 years AFP Surveillance quality: surveillance index & Migratory population (<5 yr children)

Suggested additional criteria for states:• Measles outbreak data• Vacancy status of service providers• VDPV data• Hard-to-reach areas

(Score 7-16)

(Score 4-6)

(Score 1-3)

BELGAUM

BIJAPUR

GULBARGA

TUMKUR

RAICHUR

SHIMOGA

BIDAR

BELLARY

HASSAN

MYSORE

KOPPAL

HAVERIUTTAR KANNAD

YADGIR

GADAG

UDUPI

BAGALKOT

MANDYA

CHITRADURGA

KOLAR

CHIKMAGLUR

DAVANAGERE

DHARWAD

CHAMARAJNAGAR

RAMANAGARA

DAKSHIN KANNAD

KODAGU(COORG)

CHICKABALLAPUR

BANGALORE(R)

BANGALORE (U)

Nearest RI session site

for each HtH team day area identified

Mapping RI sites in Polio SIA plan: Karnataka, 2011

RI session information added

to polio SIA microplan

Planning for Migrants/ high-risk

populations

Percent validated migrant sites included in RI micro plan, India

Emergency Preparedness and Response Plan, 2011 emphasizes mapping migratory / mobile populations to cover them in both SIA & RI

Mapping & validation of migrant sites is ongoing in states

Following mapping, sites are being incorporated in RI plan

Final data is being compiled from UP, Bihar, Maharastra, Gujarat

Data being compiled

RI microplans should be updated every 6 months to

ensure the inclusion of shifting migrant populations

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

Brick Kilns

Village

Distance

from PHC

Owner & manager of

Kiln

ANM

4 monthly drives

Special RI session for Brick Kilns in Meerut, UP

Special initiatives must to be sustained & incorporated in regular RI microplan

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

StateSessions 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

Use of data for action

RI monitoring systematically shared with District and Block health officials– DTFs pre/post polio SIA– Quarterly DIO review meetings

Jharkhand:– RI Cell meetings held bi-monthly chaired by Director

Health– Development Partners attend the meeting– 2 DIOs (one from better & one from weaker district) are

invited by rotation Bihar:

– At the PHC/Block Level by FVs (every day)– At the District level by SMOs (every week) during District

Control Room meetings– At the State Level (both weekly & monthly)

Other states are instituting RI Cell Meetings

Initiatives in cold chain and vaccine management Strengthening

Human Resource – Recruitment of National vaccine Logistics manager – Cold chain Consultants in state of UP , Jharkhand and Orissa – Regional Vaccine Logistics mangers in Orissa – 221 state trainers, 762 district trainers and 6586 CC handlers

trained Infrastructure strengthening (Dec ’10 – July ’11)

– 27 WIC, 8 WIF, 4650 ILR, 6070 DF supplied – 300 combo solar equipment supplied to 16 states – Temperature monitoring devices installed in 9 State vaccine

stores – National Cold Chain and Vaccine management Resource

Center at NIHFW initiated National Cold chain MIS developed by SHTO-Pune Reviews and Monitoring

– National partners and experts subgroup meeting in Jan 2011– CCOs review in April 2011

Improving AEFI surveillance National AEFI guidelines

revised in 2010

25,000 copies disseminated to all the states

Training package with revised AEFI guidelines prepared, workshops conducted in several states to date

50,000 copies of SOPs on AEFI operational guidelines for BMOs in print

Post Marketing Surveillance (PMS) network in Maharashtra

Training on causality assessment is scheduled for September/ October

New vaccine introduction

Hepatitis B vaccine expansion– Ongoing in 15 states/UTs

– Expansion to all remaining areas

Pentavalent (DPT-HepB-Hib)– Introduction to TN and Kerala

Measles 2nd dose in RI– Given with 1st DPT booster (16-

24 months) in 21 states

– MCUP in phases in 14 states

– MCV2 in RI for districts that have completed MCUP 6 m back

Continued challenges

42

0

20

PAKU

R

GARH

WA

BOKA

RO

CHAT

RA

DEOG

HAR

DHAN

BAD

DUMKA

GIRI

DIH

GODDA

GUM

LA

HAZA

RIBA

GH

JAM

TARA

KHUN

TI

KODE

RMA

LATE

HAR

LOHA

RDAG

A

PALA

MU

RAM

GARH

RANCH

I

SAHIBG

ANJ

SARA

IKELL

A

SIMDE

GA

SINGH

BHUM

EAST

SINGH

BHUM

WES

T

Involvement of Govt in RI monitoring: HR blocks of Jharkhand, June ’10 – May ‘11

n=number of sessions monitored

HR Blocks monitored (2 Blocks)

HR Blocks not monitored (28 Blocks)

12

10

2

4

6

8

10

12

14

CHAM

PARAN

EAST

SAH

ARSA

ARARIA

BEG

USA

RAI

BH

AGALP

UR

DARBH

AN

GA

GAYA

JEH

AN

ABAD

KH

AGARIA

MADH

EPU

RA

MADH

UBAN

I

MU

ZAFF

ARPU

R

NALA

NDA

NAW

ADA

PATN

A

PURN

IA

SAM

AST

IPU

R

SITA

MARH

I

VAIS

HALI

Involvement of Govt in RI monitoring: HR blocks of Bihar, June ’10 – May ‘11

n=number of sessions monitored Jun10 to May11

HR Blocks monitored (3 blocks)HR Blocks not monitored (38 blocks)

2

Col No.

KHA_GOGARIKHA_KHAGARIA URBANMDP_ALAMNAGARMDP_CHAUSAMDP_UDAKISHUNGANJMDB_JAINNAGARMZF_MARWANMZF_MUSAHRINLD_BIHAR SHARIFNLD_SARMERANWD_PAKRIBARAWANPTN_DANAPURPTN_MANERPTN_PHULWARISHARIFPTN_SADARPRN_BAISISAH_MAHISHISAH_SALKHUASAH_SIMRI BAKHTIARPURSAM_BIBHUTIPURSAM_BITHANSAM_HASANPURSAM_SINGHIASAM_WARISNAGAR

Gaya

Patna

Jamui

Rohtas

Purnia

Kaimur

Banka

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

157 168203

99

43

148

245

48

109 111 126

59 60

126 140 154

71 8948

020406080

100120140160180200220240260280300320340

Involvement of Govt in RI monitoring: HR blocks of UP, June ’10 – May ‘11

HR Blocks monitored (39 blocks)HR Blocks not monitored (27 blocks)

Utilisation of Govt manpower for RI

monitoring – still scope for improvement

n=number of sessions monitored Jun10 to May11

Way forward

States are to convene quarterly review meeting of DIOs on RI with participation from GoI and partners

Continued RI-polio convergence:– Migrant & mobile mapping

– Updating RI microplan with polio microplans

– Polio SIA newborn tracking for RI – link with MC tracking

Intensifying RI monitoring:– All states to initiate monitoring

– Adapt GoI strategy and tools to local context

– Ensure feedback and use of data for programme decisions

RIMS to be universally used for RI data uploading and analysis for local action

Thank you

Additional slides