thực trạng chương trình tiêm chủng mở rộng ở việt nam

Thc trng chng trnh tim chng m rng Vit Nam1. S ra i v pht trin ca chng trnh tim chng m rng quc giaChng trnh Tim chng m rng (TCMR) bt u c trin khai Vit Nam t nm 1981, n nm 1985 chng trnh c y mnh v trin khai trn phm vi c nc. Trong cc nm tip theo, chng trnh tip tc c y mnh, m rng c v a bn v s lng tr em c th hng..Din trin khai tim chng m rng quc gia c th c th hin qua bng sau:NmDin trin khai

1981-1984Trin khai th im

1985100% s tnh trin khai TCMR

1989100% s huyn trin khai TCMR

1995100% s x trin khai TCMR

1997-1998Xo bn trng v TCMR

V cc chng loi vc xin, nm 1985, chng trnh trin khai 6 loi vc xin phng cc bnh nguy him l bnh Lao, Bch hu, Ho g, Un vn, Si, Bi lit.Nm 1997 bn vc xin mi c tip tc trin khai min ph trong chng trnh tim chng m rng ca Vit Nam l: vc xin vim gan B, vc xin vim no Nht Bn B, vc xin thng hn v vc xin t. Thng 6/2010, vc xin Hib phng cc bnh vim phi nng v vim mng no m do Hib c trin khai trn ton quc, nh du vc xin th 11 c a vo TCMR Vit Nam. Cng vi vic a thm vc xin Hib vo chng trnh tim chng m rng, vic b sung thm mi tim nhc i vi vc xin kt hp bch hu ho g un vn, v b sung mi tim si mi 2 cho tr 18 thng vo chng trnh cng c trin khai.Ngy 17/03/2010, B y t xy dng v ban hnh lch tim chng thng nht cc loi vc xin cho tr em t 0 n 18 thng tui.Mt s loi vc xin trong chng trnh tim chng m rng quc gia:- Vc xin bch hu ho g un vn: y l vc xin dng dung dch, mt liu tim kt hp cho c 3 bnh l bch hu, bnh ho g v bnh un vn. S liu tim cn thit l 3 liu v 1 liu nhc li nu nhng khu vc c iu kin. Nhng phn ng cho tr sau khi tim vc xin thng nh, ch yu bao gm st, au nhc v quy khc.- Vc xin si: Vc xin si l loi vc xin sng gim c lc. S liu tim thng l 1 liu v liu th 2 (liu nhc li) nu tim th yu cu phi cch liu mt ti thiu 1 thng. Vc xin si thng c tim cho tr tui t 9 n 11 thng tui. Tr em nhng vng c nguy c cao thng c tim vc xin si t lc 6 thng tui v liu nhc li vo lc 9 thng tui.- Vc xin bi lit: Vc xin bi lit l vc xin sng gim ng lc dng ung c ng gi di dng dung dch 2 hnh thc: ng vc xin nh bng nha v l thy tinh v ng nh git c ng trong ti ring. S liu ung l 3 liu ln lt khi tr c 2, 3, 4 thng tui. Liu nhc li thng c din ra trong cc t thanh ton bi lit.- Vc xin un vn: Vc xin un vn gip c th phng bnh un vn. Vc xin un vn c dng dung dch ng trong l thy tinh. Ngoi ra n cn c ng sn trong bm kim tim t kha. Vc xin un vn c th c tim c lp hoc tim kt hp trong mt liu vi cc vc xin bch hu, ho g hoc vi vc xin bch hu. Vc xin un vn khi c tim cho b m mang thai c th va to min dch cho b m, va to min dch un vn s sinh cho thai nhi. S mi tim c bn m bo kh nang min dch l 3 mi.- Vc xin phng lao: Vc xin phng lao c dng phng bnh lao tr. Phn ln tr em u c phn ng ti ch tim. Thng thng, ngay sau khi tim vc xin lao, nt nh s xut hin ti ch tim v bin mt sau 30 pht. Sau khong 2 tun, ch tim xut hin mt vt lot c kch thc bng u bt ch. 2 tun tip, vt lot t lnh li mt so nh c ng knh 5mm. iu chng t tr c min dch. S liu tim l 1 liu v tr cn c tim ngay sau khi sinh, cng sm cng tt.- Vc xin vim gan B: Vc xin vim gan B c dng dung dch ng l 1 liu hoc 2 liu hoc trong bm kim tim t kha. N c th c tim dng c lp hoc kt hp vi mt vi loi vc xin khc. Khi vc xin vim gan B c tim ngay sau khi sinh, ngi ta ch s dng dng c lp. Cc loi vc xin kt hp ch c s dng nhng liu sau. S liu tim cn thit l 3 liu, ln lt khi tr c 2, 3, 4 thng tui.- Vc xin vim no Nht Bn: y l vc xin bt hot c sn xut t no chut gy nhim vi vi rt Vim no Nht Bn chng Nakayama. Vc xin dng dung dch ng l 10 liu. Vc xin c bo qun nhit t 2oC n 8C v khng c ng bng.- Vc xin t: Vc xin t l vc xin dng ung, c iu ch t cc chng vi khun t thuc tp sinh hc c in v chng mi O139. y l vc xin ton thn vi khun c bt hot.- Vc xin thng hn: Vc xin thng hn c lm t v vi khun thng hn Salmonella typhi. Vc xin c bo qun dng dung dch ng l 20 liu, nhit t 2oC n 8C, khng c ng bng.2. Nhng yu t thun li i vi s pht trin ca chng trnh tim chng m rng quc giaa. S tin b ca cng ngh y sinh hc trong nc Tin b ca cng ngh y sinh hc trong nc gip nc ta c th ch ng sn xut c cc loi vc xin cn thit. Vic sn xut trong nc vi chi ph thp hn nhp khu gp phn gim bt gnh nng ngn sch cho chng trnh tim chng m rng, nhanh chng a thm nhiu loi vc xin mi vo trong chng trnh tim chng m rng quc gia. ng thi vic ch ng c ngun cung vc xin gip chng ta p ng tt hn nhu cu tim vc xin ca tr em trn c nc. Hin nay, hu ht cc loi vc xin trong chng tnh tim chng m rng l vc xin ni. Chng ta cng xut khu c vc xin Vim no Nht Bn sang th trng n v s tip tc m rng thm nhiu th trng khc trong nm 2015.b) S pht trin ca cc yu t kinh t - x hiS tin b ca kinh t x hi c ng gp to ln vo thnh cng v hiu qu ca chng trnh tim chng m rng. H thng ng s cc vng nng thn c ci thin to iu kin tt hn gip nng cao t l tim chng. Nhng ci thin ca c s vt cht bo qun vc xin v phc v cho hot ng tim chng cng nh i ng nhn lc cht lng cao gip m bo cht lng vc xin, tng t l min dch sau khi tim, nht l khi vc xin cn phi vn chuyn xa, iu kin i li kh khn.c) Thnh cng ca cng tc tuyn truyn, nng cao nhn thc ca nhn dni vi mt s loi vc xin, vic tim chng cho tr ngay sau khi sinh l rt cn thit. Vic tuyn truyn, nng cao nhn thc ca nhn dn v tim chng m rng gp phn m bo cho ngy cng nhiu tr em c tim chng ng thi im, tng hiu qu min dch. Cng nh nhn thc r rng v ngha ca vic tim chng, nhiu bc cha m cn ch ng cho con mnh tim cc liu nhc li, m bo tt hn t l min dch sau khi tim.d) S h tr t cng ng quc tMt phn ln kinh ph ca cc t tim chng m rng quc gia l c h tr bi T chc y t th gii v Qu nhi ng lin hp quc, Lin minh ton cu v vc xin v tim chng (GAVI). Cc nc trn th gii cng dnh cho chng ta rt nhiu s h tr hiu qu. Trong nm 2002 2003 vi s h tr to ln v vc xin si v vt t tim chng ca chnh ph Nht Bn, Vit Nam t chc thnh cng chin dch quc gia tim vc xin si cho 15.112.779 tr em t 9 thng n mi tui trong ton quc., t t l trn 99% tr em i tng c tim vc xin mi 2 si.3. Nhng thnh tu m chng trnh tim chng m rng quc gia t ca. t v duy tr t l tim chng caoT nm 1993 n nay, mc d c mt vi bin ng t l tim chng y cho tr em di 1 tui lun t trn 90%.

Trong nm 2011, c 1.529.589 tr trn ton quc c tim y vc xin phng cc bnh bch hu, ho g, un vn, vin gan B, vim phi do Hib, t t l 95,2%. Trong min Bc t 96,716%, min Trung t 97,142%, khu vc Ty Nguyn 94,569% v min Nam t 92,521%.

b) Nng cao hiu qu phng bnh, m bo sc khe cng ng- Bnh bi lit:Nm 1984 c nc c 1.223 ca mc bi lit. T nm 1998, c nc khng ghi nhn ca bi lit. n nm 2000, Vit Nam chnh thc thanh ton c bnh bi lit.T l tr c ung vc xin phng bi lit tng t 5% nm 1984 ln 97% nm 2010.

- Bnh un vn s sinh:Bnh un vn s sinh c bt u trin khai tim chng m rng nm 1991 vi s ca mc trn c nc l 334, n nm 2011, c nc ch cn 32 ca, gim 70 ln s ca mc bnh v t l mc bnh trn 100.000 dn ch cn 0,04. Nm 2005, Vit Nam loi tr c un vn s sinh. C c thnh qu nh vy l nh t l tim chng c tng ln t 4% nm 1991 ln 94% nm 2011.

- Bnh si: T nm 1984 n nm 2001, bnh si gim 23 ln s ca mc bnh. T l mc bnh si trn 100.000 dn nm 1984 l 1505,2 v nm 2011 l 3,6. T l tim vc xin si cng tng ln tng ng t 4% ln 96%. Nm 2010, t l tim vc xin si trn c nc ln ti 98%.

- Bnh bch hu: S ca mc bnh trn c nc gim xung 167 ln t 2.177 ca mc nm 1984 xung cn 13 ca nm 2011. T nm 1984, t l tim chng vc xin bch hu t mc 70%, con s nm 2011 l 95%.

Biu 5. T l tim vc xin DPT3 v t l mc bch hu ti Vit Nam, 1984-2011- Bnh ho g: Nm 1984 c nc 44.926 ca mc. Nm 2011, c nc ghi nhn 105 ca mc. T l mc bnh trn 100.000 dn trong 3 nm 2009, 2010, 2011 u c duy tr mc 0,1. T l tim chng nm 2011 l 95%.

Biu 6. T l tim vc xin DPT3 v t l mc ho g ti Vit Nam, 1984-2011- Bnh vim gan B tr em: Vc xin vim gan B c Vit Nam trin khai trong chng tnh tim chng m rng t nm 1997 v bt u nhng vng nguy c cao ca bnh. T nm 2003, c s h tr ca Lin minh ton cu v vc xin v tim chng (GAVI) vc xin vim gan B c trin khai trn ton quc cho tr di 1 tui. T nm 2006 n nay t l tim vc xin vim gan B 3 mi tr di 1 tui lun t trn 90%. Cng vi l vic thc hin vic tim mi 0 vc xin vim gan B cho tr trong vng 24 gi u sau khi sinh phng ly truyn t m sang con. n nm 2011, c 884.332 tr c tim vc xin vim gan B liu s sinh, t l t c l 55%.

Biu 7. T l tim vc xin VGB3 v t l tim vc xin vim gan B liu s sinhtrong 24 gi u sau sinh, 2003-20114. nh gi nhng kh khn, hn ch ca chng trnh tim chng m rng quc gia giai on hin nay.a) H thng c s vt cht cn nhiu hn chMc dng cc iu kin kinh t x hi c nhiu tin b cc kh khn m chng trnh tim chng m rng gp phi vn cn rt ln. Kinh ph hot ng y t ni chung v TCMR ni ring b hn ch. Ngun kinh ph huy ng t ngi dn cho chng trnh tim chng m rng rt hn ch, cn ang phi da kh nhiu vo h tr quc t khin cho vic duy tr chng trnh tim chng m rng tr nn thiu bn vng. H thng ng s, phng tin giao thng t huyn n x c bit t x n cc thn bn nhiu vng rt kh khn do vy nh hng n vic tr em v ph n tip cn cc dch v tim chng. H thng dy chuyn lnh bo qun vc xin ch trang b ti tuyn tnh, huyn. Tuyn x ch c phch vc xin bo qun vc xin di 24 gi. Cc trang thit b cn thit phc v cho cng tc tim chng m rng cc tuyn c s cng vn cn thiu v cha m bo nhu cu, c bit vi cc tnh min ni, ni m i a s cc liu vc xin c tim ti cc im tim ngoi trm th tnh trng thiu thn c s vt cht cn thit li cng trm trng.

b) Ngun nhn lc cho chng trnh tim chng m rng cn rt nhiu hn chLc lng cn b y t d phng c s thiu v yu. Cc c s y t x thng b qu ti v cng vic do phi m nhn nhiu chng trnhtrong khi bin ch ch c t 3-5 ngi. Kin thc v trnh ca cc nhn vin y t cn rt hn ch, khng ng u v vic bt ng ngn ng gia cn b lm cng tc tim chng vi b con vng cao dn n ngi dn thiu thng tin v nhn thc v tm quan trong cua cng tac tim chung nn khng thc hin tim s mi theo quy nh. S lng cn b c bi dng v o to hng nm ch chim mt t l nh khi ton b nhn vin ca cc trm y t c s u tham gia vo cng tc tim chng m rng. Cng tc qun l, gim st cc hot ng tim chng cng vn cn mang tnh hnh thc, cc cn b y t vn cn nhiu sai st trong bo qun vc xin v t chc tim chng. Ch i ng ca nh nc i vi cn b lm cng tc y t d phng cn cha tng xng l mt trong nhng nguyn nhn nh hng n thi gn b v cng hin v cng vic ca cn b v cng khng gip thu ht c ngi c nng lc vo lm vic trong lnh vc d phng ni chung v tim chng m rng ni ring.c) Nhng thay i mang tnh tiu cc trong nhn thc ca nhn dn v tim chng m rngVic nng cao v m bo cht lng cng nh nhng nh hng ca chng trnh tim chng m rng rt cn n s ng h v nhng nhn thc ng n t pha ngi dn. Tuy vy, hin nay, vn v tai bin do vc xin ang gy nn nhng thay i tiu cc trong nhn thc v nh gi ca nhn dn v cng tc tim chng m rng v tr thnh mt thch thc ln i vi chng trnh tim chng m rng quc gia. V d, nhng d lun v cac ca phan ng sau tim chung vcxin vim gan B 24 gi sau khi sinh v vcxinQuinvaxemdn n ngi dn khng a con i tim chng, t khin tnh trng b st mi tim cn cao v hiu qu phng bnh ca vc xin hn ch.

Ngoi ra, vic cha th ch ng sn xut c mt s loi vc xin cn thit, v d nh vc xin Quinvaxem trong chng trnh tim chng m rng cng gy nn nhng kh khn nht nh cho cng tc tim chng m rng, c bit vo nhng thi im m nhu cu tim chng tng cao nh trong thng 10 v 11 nm 2009. Cng tc nghin cu, ch to v sn xut vc xin mi yu cu thi gian lu v chi ph rt cao lm chm li qu trnh b sung cc loi vc xin mi vo chng trnh tim chng m rng, nh hng n quyn li ca tr em v sc khe cng ng