immunization plus- a framework for action (2003-2007)

8/8/2019 Immunization Plus- A Framework for Action (2003-2007)

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Immunization Plus

A Framework for Action

(2003-2007)

May 2003

INDIA COUNTRY OFFICE

73 LODI ESTATE

NEW DELHI


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Immunization Plus: A Frame work for Action

1

Acknowledgements

The following UNICEF staff contribution must be acknowledged in drafting, revising and

finalizing the current document:

Carrie Auer

Cleopa Mailu

Corinne Woods

Jean Gough

Johan FagerskjoldJohn J Gilmartin

Kate Dickson

Kishanrao Suresh

Marzio Babille

Michael Galway

Nigel Ede

Rakesh KumarSatish Kumar

Shyamkumar Chaturvedi

Siddharth Nirupam

Suresh Joshi

Vijaykumar MosesWerner Schultink

William Thompson

Wing-Sie ChengIn addition, acknowledgement is extended to the Department of Family Welfare, Ministry of

Health & Family Welfare, Government of India (GOI) for offering technical insight, guidance

and approval; the Project Officers of Child Environment, Child Development and Nutrition, ChildProtection of both the Lucknow and Kolkatta UNICEF offices for their contribution to the content

and strategic direction.


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Table of Contents

1. Introduction 2

Part One: Situational Analysis

2. Problem Dimension 3

3. Accelerating Immunization efforts 5

3.1 Polio Eradication: A Compelling Priority 5

3.2 Neonatal Tetanus Elimination 7

3.3 Measles Control 8

3.4 Introduction of Hepatitis B Vaccine 9

3.5 Vitamin A Supplementation 9

Part Two: The Case for Accelerating Routine Immunisation in India

4. Summary Goals and Principles 10

5. The Approach 10

5.1Focus Intensive Interventions in Selected Areas 115.2Adoption of a Proactive and Intensive Approach 115.3 Intensify Advocacy at National and State Levels 11

5.4 Intensify Partnerships for Planning and Service Delivery 12

5.5 Offer Leadership and Coordination 12

6. Guiding Strategies 13

7. Focus of Routine Immunisation Plan 158. Agenda for Action: The Phased-in Intensified Approach 15

9. Strategic Communication 17

10. Service delivery point activities 18

11. Expected Results by End 2003 in Phased-in Districts 19

References 20

Appendix I: 21

1. Accelerating Routine Immunisation within RCH-II Policy:A Strategic Link to National Experiences

1.1 Rationale 211.2 Border District Cluster Strategy 221.3 Immunization Strengthening Project 221.4 Injection Safety 231.5 National Technical Advisory Group on Immunisation 241.6 Introduction of Hepatitis-B vaccine: A Window of Opportunity 24


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Immunization Plus: A Framework for Action

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1. Introduction

In India, the possibility of achieving the Universal Child Immunization goals appeared likely inthe 1990s, when reported coverage levels for all antigens reached more than 85% of eligible

children. The main objectives of Universal Immunization Program (UIP) UIP were: (i) Universal

immunization and reduction in mortality and morbidity due to vaccine preventable diseases

(VPDs); (ii) Self-sufficiency in vaccine production; (iii) Establishment of a functional cold chain

system; and (iv) the introduction of district level monitoring system.

In 1992, a policy change resulted in the UIP initiative being merged with the Child Survival and

Safe Motherhood Mission (CSSM). And in 1997, immunization activities were further

incorporated into the national Reproductive and Child Health (RCH) program. A further change

occurred in 2002, with the introduction of Hepatitis-B injection for the first time to the national

immunization schedule targeting the urban poor. This initiative will be expanded in a phased

manner to cover the entire country as part of the tenth Five-year Plan.

However, of concern to national and state governments was the conclusion of the 2002 RCH

survey that immunization coverage rates have been stagnating, if not declining since 1999, thus

posing a threat to the quality of and equity in service delivery. Weak internal communication

channels, inconsistent supervision and logistic management, and imprecise data collection and

analysis have flawed routine coverage reporting.

On the other hand, the comprehensive picture on routine immunization also demonstrates the

potential to regain the previous momentum. In India, while measles continues to be the major

vaccine preventable disease (VPD) afflicting children, leading to malnutrition and many other

complications, measles morbidity has been reduced by 85% and mortality by 70% since the

introduction of the measles vaccine in 1985.

The purpose of this paper, therefore, is to outline UNICEFs framework for action designed to

support the Government of India to accelerate its Immunization Plus programme in selected

districts and throughout the country.

In general. Immunization services are provided through a network of Sub-centre, primary health

centres and community health centres in rural areas. In the urban areas, most of the government

hospitals and all post-partum centres provide immunisation services. In addition every state offers

fixed immunisation days especially for the outreach sessions. Villages having more than 1000

population are visited and out reach sessions held at least once a month. The fixed immunisation

day has proven to provide positive results for UIP since its implementation in 1985-90 despite the

fact that declining coverage rates in the low performing states depict weaknesses in the planning,implementation and monitoring exercises.

In terms of policy development, the fixed immunisation day is also being used to expand theprimary care service components of an essential package that includes antenatal care, IFA and

vitamin A supplementation, contraceptive distribution and nutrition counselling.


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Part one. Situational Analysis

2. Problem Dimension

As mentioned above, research findingsfor the period 1996-97 to March-May

2001 indicate that immunization

coverage levels have declined over the

past 5-6 years.

Evidence also indicates that coverage

levels are significantly higher in those

areas with regular access to the

services (63%) as compared to those

communities where sessions are less

frequent or irregular (33%).

Routine reporting is currently

complemented by periodical coverage evaluation surveys that offer updated information. The data

indicates that DPT3 reported coverage was 89% in 2000 (MoHFW, GOI) while it was only

63.6% as per the CES-2001 results. Contrary to routine reporting, the 2000-01 DPT3 gap refers to

7 million fewer children under 1 year of age that have missed DPT3. The discrepancy in the

number estimated is more evident in Uttar Pradesh, Bihar, Madhya Pradesh, Orissa and

Rajasthan.

The following graph depicts the evaluated coverage of routine immunization in the Northern

States between 1998 2002. An analysis of the trends demonstrates that West Bengal and

Madhya Pradesh and Uttaranchal experienced a rise in coverage, while Bihar stagnated at a low

of 12%. Delhi underwent a rise to 70% in 2000 2001 that was not sustained in 2002 as coverage

dropped to approximately 65%.

Evaluated Coverage of Routine Immunization in the Northern States Between 1998 2002

0

10

20

30

40

50

60

70

80

Biha

rDe

lhi

Gujar

at

Haryan

a

Jharkh

and

M.Pr

adesh

Rajas

than

Uttar

anch

al UP

WestB

engal

1998-99

1999-00

2000-01

2001-02

National Trend for Fully

Immunized Children (All Surveys)

35.441

67.760.8

50.6

63.3

4237.8

49.8

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

92 -9 3 9 3-9 4 9 4 -9 5 9 5 -9 6 96 -97 97 -9 8 9 8-9 9 9 9 -0 0 0 0 -0 1

N F H S1 R H S-98-99 C E S-98 C E S-9 9

C E S-IC M R -99 N F H S-II M IC S2000 C E S-0 1

Years indicate

reference period

Years indicatereference period


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Amongst some of the reasons cited for the drop in immunization coverage including irregular

sessions are the following:

Date, time and place of vaccination is not known (25.2 percent of respondents)

Caregiver is not aware of the need for full immunization (24.0 percent of respondents)

Child is sick during immunization days, probably a false contraindication. (18.8 percent ofrespondents)

Time and date inconvenient; no one is available to take child to clinic (16.0 percent ofrespondents)

No faith in immunization (5.5 percent of respondents).

The following table depicts the burden of vaccine preventable diseases in India (GOI, 1999).

Disease Est. cases Reported cases Est. deaths Reported deaths

Measles 2,300,000 21,013 230,000 457

Diphtheria 20,000 1786 400 257

Pertussis 60,000 11,264 600 Nil N.Tetanus 12,200 610 7500

Polio - 1234 - Nil

In general, as recently outlined by the Department of Family Welfare (DFW) in its call to

accelerate routine immunization in the Northern States, reported coverage rates are typically

higher -- sometimes double those estimated by the surveys. Four of the ten states have statewide

coverage greater than 50% (Gujarat, Chhattisgarh, Orissa and West Bengal), but none of the ten

states have achieved coverage higher than 29% in their lowest coverage district. Cold chain

Reasons for Low Coverage

Not aware of need for

full immunization

24%

Other

10%

Sick child (falsecontraindications)

18.8%

Inconvenient date and

time; no one to take

16%

Not aware of date,

time, place of

immunization

25.2%

Doctor's advice

1%No faith in

immunization

5.5%


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equipment has been imported but technical assistance is lacking. The reliability and continuity of

power supply is also identified as a major system problem for adequate vaccine management and

cash to comply with fuel for generators sets represents a major state drawback in Uttar Pradesh,

Bihar, Jharkhand, West Bengal.

It has become apparent that unless routine immunization services are strengthened or accelerated

in all these states as a matter of urgency, there will be a generalized re-occurrence of Diphtheriaand Pertussis, as well as measles foci. Furthermore, Hepatitis B vaccine will be available to no

more than 5% to 30% of the children in the lowest coverage areas. Hence the opportunity towidely introduce the GAVI-funded Hepatitis B vaccine will be missed.2

3. Accelerating Immunization efforts

3.1 Polio Eradication: A compelling priority

Recognizing that polio eradication is predicated on sound routine coverage of the susceptible

population, with particular reference to the new birth cohorts, the declining trend in coverage for

Routine Immunization in the least performing states requires urgent policy attention, government

commitment, and appropriate financial support from partners.

The following section outlines the history and present epidemiological situation of the wild

poliovirus in India.

Epidemiology of Wild Poliovirus in India

India has long been a major reservoir for wild poliovirus. Since the establishment of AFP

surveillance in 1997, the extent and intensity of wild poliovirus circulation has been effectively

documented. In 1997, it was clear that all three types of wild poliovirus were present in India andthat distribution of the viruses was widespread. In 1995, India began conducting supplementary

immunization activities (SIAs) for polio eradication.

As a result, polio in India declined 42 percent from 1934 virus positive cases in 1998 to 1126

cases in 1999. By 2000, India reported only 265 cases of polio, a decline of 76 percent in just one

year. Of the cases reported in 2000, UP accounted for 68 percent and Bihar 19 percent. With the

implementation of responsive mop-ups in states outside of UP and Bihar in 2000, the rest of India

was rapidly cleared of polio. This was confirmed by high quality AFP and poliovirus

surveillance, which achieved globally accepted standards in 1998.

Type 2 wild poliovirus has not been seen in India since October 1999 although few cases have

recently reoccurred in western UP districts due to a likely laboratory contamination. Given the

high quality of AFP surveillance, it appears that India may be free of type 2 when latest

laboratory investigations in Western UP are completed.

Between December 2000 and October 2001, India conducted a NID followed by two SNID

rounds in high-risk areas of UP and Bihar in April and May 2001, and a SNID in October in high-

risk states. In addition, responsive mop-ups were conducted following the isolation of wild

2 Of note is the possibility for UNICEF to provide complementary management, supply and mobility support to aWorld Bank project presently underway to strengthen the Indian Universal Immunization Program. The weaknessesoutlined in this document lead to an expenditure of barely 8% in 2002.


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poliovirus in several states. In UP and Bihar, at least 5 rounds of SIAs were conducted, with

some districts in western UP implementing up to 8 rounds.

Despite these activities, 268 cases were reported in 2001. The increase in the absolute number of

cases between 2000 and 2001 was already concerning. The initial progress showing that the

geographic distribution of the virus had become more focal (i.e.: infected districts declined in

India from 89 in 2000 to 63 in 2001) and that bio-diversity had decreased in early 2002 were

countered by the dramatic resurgence of polio cases statewide.

The Situation of Wild Polio Virus in 2002 and early 2003During 2002 to date, India reported 1677 cases (1599 in 2002 and 77 by mid May 2003) in 159

and 40 districts respectively. UP reported 1254 cases, Bihar 123, Haryana 38, Gujarat 26, West

Bengal 58, Madhya Pradesh 26, Uttaranchal 14, Jharkhand 12, and Delhi 27.

2002 (1599 cases) as 31 December 2002

Uttar Pradesh 1241Bihar 121West Bengal 48Rajasthan 41Haryana 37Delhi 25Gujarat 24Madhya Pradesh 21Uttaranchal 14Jharkhand 12Maharashtra 6Orissa 4Punjab 2Chandigarh 1Chhattisgarh 1

Jammu & Kashmir 1

2003 (77 cases) as for 15 May

Uttar Pradesh 24West Bengal 23Bihar 8Madhya Pradesh 7Rajasthan 4Gujarat 3Delhi 3

Orissa 2Haryana 2Maharashtra 1

In Bihar, transmission has so far been highly focused in districts north of Patna across theGanges, and all virus isolated is Type 1. All cases are from a single lineage. No virus has been


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reported from the previous focus of transmission in southeastern Bihar since October 2001.

Because of the very focused nature of transmission, the absence of type 3, and the single lineage

represented currently, one may conclude that Bihar has an excellent opportunity to interrupt

transmission in the forthcoming year.

Poliovirus circulation continued to be intense in 2002 in 18 districts and 61 blocks of west UP.

Based on analysis of data collected during NIDs/SNIDs, HRRIs and mop-ups, coverage surveysand qualitative studies, it is now clear that the SIAs in these areas have not achieved uniform and

consistent quality. Data from SIA monitoring indicates that between 8% and 12% of householdshave children under five years that have been missed each round. The principal reasons for

missing these children are:

failure of immunization teams to correctly identify all eligible children once they havereached the household,

poor or non-existent supervision in many areas, so that immunization teams do not have theirwork supported and mistakes corrected, and

poor participation of families in areas which have under-served communities, through lack ofknowledge of the activities or lack of motivation.

The conditions in these areas greatly favour transmission of wild poliovirus namely:

very high population density;

very low routine immunization coverage;

generally poor sanitation and hygiene conditions; and

Children below 24 months of age in particular in under-served communities, be they Muslimor Hindu depending on location, are vulnerable to infection.

There has been some questioning of the eradication strategies given ongoing transmission of wild

poliovirus in northern India, particularly western UP. Evidence demonstrates that ineffective

implementation has been the major problem in northern India and the SIA strategy needs to be

backed up by acceleration f routine immunization. Polio remains endemic in northern India, and

especially west UP, because not enough children are given sufficient doses of OPV.

Ongoing poliovirus transmission in Uttar Pradesh, Bihar, West Bengal, Rajasthan, Gujarat and

Madhya Pradesh and to a significant extent the rest of the country poses risks for polio-free

Indian states and other countries. It could mean that: 1) undue delay in interrupting transmission

results in frustration and fatigue in the field and communities that would be difficult to overcome.

and 2) the risk of importation of wild poliovirus from reservoir areas into other states and

countries will require continued activities throughout the region.

3.2 Neonatal Tetanus EliminationThe initial global target for neonatal tetanus (NNT) elimination was not met by 1995 and wasrevised to 2007. In India today, nearly 49,000 NNT deaths are estimated to occur annually

(Global WHO/UNICEF estimates). India started reporting NNT cases separately since 1992.

There was a reduction of the reported number of cases from over 11,000 in 1988 to 1,527 in1996. However since then the number of reported cases have fluctuated between 2000-3000 a

year, and rose to 3,214 in 2000.

Surveillance and case reporting was never satisfactory and has deteriorated further in the last 5

years. An assessment by WHO in 1996-97 indicated that around 251 districts out of 479, NNT


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was still endemic. More than one-fourth of the districts in some of the major states were endemic,

namely Assam (10), Bihar (36), Jammu and Kashmir (15), Karnataka (8), Madhya Pradesh (28),

Orissa (7), Rajasthan (22), Uttar Pradesh (45) and West Bengal (11).

In 1998, Rajasthan paved the way for a NNT elimination initiative, followed by Madhya Pradesh

in 1999, and West Bengal and Assam in 2000. Nearly 8.5 million women in the childbearing age

were immunized across the states of Rajasthan, 10 districts of Madhya Pradesh, one district ofWest Bengal and two districts of Assam between 1998-2001. A subsequent joint WHO/UNICEF

study in 2000 underscored the potential of TT immunisation campaigns in Tonk district,Rajasthan to achieve NNT elimination by vaccinating women in their child-bearing years.

The current strategy seeks to strengthen the routine immunisation program rather than pursue a

campaign approach. Towards this end, it is expected that the country will reach elimination status

in all districts by end 2007.

The immediate objectives of the strategy include:

90% decrease in NNT deaths and 80 % reduction in NNT endemic districts

Tetanus toxoid vaccine will be accessible to 100% women in UNICEF supported and other

districts) skilled birth attendance available in 50% of home deliveries and

50% of primary caretakers of pregnant women should adequately explain why repeated TTimmunization is needed.

In addition, states and districts will be encouraged to document the status of elimination using the

UNICEF/WHO Algorithm and thereafter undergo a validation exercise.

3.3 Measles Control

Measles is a relentless disease and kills more children than any other disease currently

preventable through vaccination. Just 20 countries account for 85% of all global deaths and India

alone contributes 27% of the measles deaths of under five children. In 2000, the reported measlescases were around 38,000 in comparison to 247,519 in 1987. Needless to say, it is estimated that

about 20 million cases and 200,000 deaths still occur annually. This indicates a high degree of

under reporting and also a lack of understanding amongst families regarding the seriousness of

measles as a potential childhood killer.

A strategy undertaken to control measles in India focussed on 13 cities in 1999, 47 additional

cities in 2000, and 14 more in 2001. Reports indicate that more than 3 million children between

the ages of 9-59 months were immunized between 1999-2001 (3-calendaryears). The evaluation

done in Gujarat indicates a decline in the number of cases, thus demonstrating the potential of

such interventions and control strategies in the reduction of measles mortality and incidence in

selected cities.

Measles control efforts will now be implemented through improving routine immunisation. It is

anticipated that the strategy will lead to a 90% decrease in measles deaths and 80 % reduction in

measles cases/outbreaks by the end of 2007. Measles vaccine will be accessible to 100% of the

children residing in UNICEF-supported districts while 50% of primary caretakers of pregnant

women will be able to correctly explain the importance of repeated measles immunization.


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3.4 Introduction of Hepatitis B Vaccine

Within the RCH framework, financial and human resources are being freed for undertaking fresh

initiatives to eradicate polio, increase coverage for multiple antigen immunisation, and offer

quality RCH services closer to where people live. At the same time, the Ministry of Health and

Family Welfare is taking measures to strengthen the immunisation programme as well as toimprove the outreach of reproductive and child health services. The intention is to improve the

quality of services and ensure an enhanced coverage of infants with the vaccines used in theUniversal Immunisation Programme.

Hepatitis B vaccine is now being integrated into the existing routine/universal immunisation in

India. The strategy seeks to promote healthy competition among districts and states for

heightened performance and to give priority attention to the most needy. This new vaccine isbeing introduced in 15 cities and 32 districts in the initial phase.

An overriding objective in the selection specific cities and districts for this new vaccine is to

achieve 80% DPT3 coverage or more under routine immunisation of infants with the existing

vaccines based on the coverage evaluation surveys. The vaccine is being provided free of cost tothe infants living in the slums. The programme will be expanded to include additional cities and

districts within a certain timeframe.

In addition to the new vaccine being introduced, UNICEF and other donors, together with

technical support to ensure their safe disposal and to improve hospital waste management will

initially supply auto-disable (AD) syringes. There will also be a renewed emphasis on the

maintenance of the cold chain to ensure the quality of the vaccines. The country envisages that

Hepatitis B vaccine will be introduced in all districts of India by 2007, and that AD syringes will

be used for all routine vaccines in the areas introducing Hepatitis B vaccine.

3.5 Vitamin A supplementation

Vitamin A deficiency in India has officially been recognized as a public health problem as far

back as 1970. At that time a supplementation program was initiated with the main aim to

eliminate blindness caused by Vitamin A deficiency. Vitamin A supplements are distributed

through the routine contacts with the public health system linked to routine immunization and

health service delivery. Ideally, a child should get 100,000 I.U at 9 months and 200,000 I.U at 18,

24, 30 and 36 months of age. Bi-annual monthly supplementation of Vitamin A is a key strategy

in ensuring reach and adequate coverage.

In the latter half of the 1990s the performance of the vitamin A supplementation program was not

satisfactory. A nationally representative survey conducted in 1998-1999 (National Family Health

Survey; NFHS-2) among some 20,000 children aged 12-35 months indicated that about 17% of

the children had received a vitamin A dose in the period 6 months prior to the survey, and thatabout 30% of the children had received at least one dose of vitamin A ever.

As part of the current program of cooperation between UNICEF and the Government of India,

support is provided to reduce vitamin A deficiency. The objective is to improve Micronutrientsupplementation rates (Vitamin A and Iron-Folate) through the strengthening of routine

distribution systems. This support is in line with the recommendations of the Steering Committee

on Nutrition for the Tenth Five-Year Plan in which the elimination of vitamin A deficiency as a

public health problem is set as a goal.


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Part Two: The Case for Accelerating Routine Immunisation in India

4. Summary Goals and Principles

In dealing with accelerating RI, GOI and UNICEF should address not only the theoretical issues

that guided the base UIP/CSSM Programme, but also ways to overcome the existing system

problems that are: vacancies; poor motivation of health workers; insufficient supervision; lack of

feedback and support; and, finally, the idea that UIP is an old-fashioned intervention. Therefore,

the fundamental question is how to ensure correct and consistent reorientation of existing routine

immunization at all levels? The response revolves around the already articulated Government of

India policies and interventions and the commitment of partners to support them succeed.

Towards this end, UNICEFs ultimate goal of intervention is to increase childrens access to

multiple antigen immunization and Vitamin A coverage.

UNICEF:

Positions itself to promote awareness among decision makers, donors/partners,state and local government and programme managers that effective routine

immunisation is a crucial investment on the overall health of the community. It

also represents a decisive component in strengthening and reforming the health

system and to increase recognition of and commitment to an expanded financial

support for public health services delivery.

Helps MOHFW build stronger infrastructures, management and monitoring forimmunisation than ever before in those states where these are required (UP,

Bihar, WB, Rajasthan, MP, and other emerging states).

Points out that as required by the 73 rd Amendment, the three-tier structure of PRI(Zila Panchayat, Panchayat Samiti and Gram Panchayat) at state level can be

strengthened with respect to its functions and powers in the revitalization of

routine immunization efforts.

Intimates that vaccine and vitamin A supply security and costs are issues to be better and more realistically focused. Immunization cannot be done well or

revitalized on the cheap.

Reiterates also that funding is not everything: a critical requirement for success isthe commitment of each state government to improving its own immunization

systems, a buy-in at state and country level.

Notes that the introduction of Hepatitis B immunization is an extraordinaryopportunity as a multiplier effect helping to strengthen the sub-centre level and

the health system as a whole.

5. The Approach

In India, the 2001 National Population Policy contemplates the achievement of "Universal

Immunisation of Children against all vaccine preventable diseases (VPDs)". Further, it calls for a

policy framework to give an added impetus to the Universal Immunisation Programme (UIP).

Lessons learned over the past years are leading UNICEFs work to strengthen and reinforce the

immunization plus activities in UP, Bihar and other least performing states.


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The approach takes into account work already been done by GOI, state governments,

development agencies and funding partners as part of the polio eradication and strengthening

immunization interventions. It is therefore not intended to replace existing initiatives and efforts,

but to complement and enhance them in the interest of accelerating progress on immunization and

bridging the immunity gap. While UNICEF continues with its current involvement in IPPI,

special efforts and resources will be devoted to the acceleration strategy in order to achievecredible outcomes by 2004, so we can keep our promise to the Indian children.

The main purpose of the strategy is to provide an agreed platform for accelerating and

coordinating work on progammes and activities in immunization, in a manner that would result in

robust and sustainable outcomes. Whilst the central focus is clearly on the achievement of

Millennium Development Goals for 2005 and 2015, it should be emphasized that the rationale for

this acceleration strategy is to address multiple agendas. They relate to contributing to theachievement of goals outlined in the World Fit For Children and, finally reaching MTSP targets

for immunization plus.

5.1 Focus Intensive Interventions in Selected Areas

Given UNICEF widespread presence in the field, the focus on a set of high-risk, low performing

states will be maintained. Within those states, priority for acceleration will be given to BDCS

districts. Whilst other projects will continue everywhere, there would be a concentration of

additional resources and intervention measures also in selected districts as suggested by GOI and

state governments, that will result in accelerated and maximum impact on childrens

immunization and supplementation of Vitamin A by 2004.

5.2 Adoption of a Proactive and Intensive Approach

Urgent work needs to be done on enhanced strategies for advocacy and communication in favour

of childrens immunization. Critical to the results-based approach is the need to adopt a proactiveand intensive approach that concentrates expertise, knowledge and other resources on reaching

the unreached children and households and helping them to overcome the barriers to obtain

routine immunization and vitamin A supplementation as part of the minimum package of primary

health services for a good start in life.

5.3 Intensify Advocacy at National and State Levels

Accelerating progress in routine immunization implies to intensify advocacy at the national, state,

district and sub-district level in order to: (i) Transform political will into government action to

fulfil their obligation on childrens immunization and ensure this is reflected in national and state

plans and budgets; (ii) Contribute to polio eradication efforts as part of the two-track strategy

necessary to reduce the immunity gap and protect the incoming birth cohorts; (iii) Create agroundswell of local demand for routine immunization and primary services, transparency and

accountability; (iv) Mobilize financial resources and donor commitment to immunization as the

main leverage on the national RCH II plans for achieving increased coverage and impact on

infant mortality and morbidity.


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5.4 Intensify Partnerships for Planning and Service Delivery

UNICEF will build on the success of existing progammes and initiatives in order to enhance the

presence, quality and effective engagement of other stakeholders in the acceleration efforts and

prioritize the coordination of efforts by partner agencies, donors, professional associations, civil

society and private sector. UNICEF will contribute to the monitoring and evaluation process and

help other agencies to obtain the best possible data for decision making. UNICEF will have astronger presence at policy fora ensuring sufficient coordination to make a unified contribution

where key decisions are taken on investments and strategies to achieve the RCH II goals.

5.5 Offer Leadership and Co-ordination

UNICEF will coordinate activities of partner agencies (government line ministries, NGOs, private

sector, etc.) being brought on board for both routine immunization and polio communication;match partner resources with high risk areas; provide technical and planning inputs to partners in

developing and implementing action plans; identify and solicit support from new partners on an

ongoing basis; help monitor partner activities; identify gaps where communication activities are

absent; liaise with NPSP SMO network to ensure no duplication of effort.

UNICEF will continue to promote an integrated routine immunization strategy for polio

eradication, measles control, neonatal tetanus elimination accelerating routine immunization and

Vitamin A supplementation at states, district and sub-district level. The focus will be in EAG

states (Uttar Pradesh, Jharkhand, Bihar, West Bengal, Rajasthan, Madhya Pradesh) and BDCS

districts starting from May-June 2003.

Priority will be given to promoting and training of district and sub-district level capacity to

manage, expand and improve the quality of RI through the reduction of drop out rates and

increase outreach sessions.

Strong management principles and systems are at the core of UNICEFs approach to ensure its

resources are used efficiently and with maximum impact. The first tier of focus must be at thesub-centre and block level, as a prerequisite for improving the immunization services. Existing

and new management tools will ensure that UNICEF expands its coordination/networking role to

identify social mobilizers with the most appropriate profile guided by clear terms of reference.

UNICEF will provide/share with states criteria for identifying where to best deploy resources,

systems to evaluate performance effectively, and mechanisms to collect and analyse activities

planned and undertaken. Specific support to management and supervision will be provided.

A higher degree of co-ordination and a strategic role of supervision are managementchallenges that could be facilitated by UNICEF presence in all technical cells or working groups

established or to be established at the DFW, and in UP, the communication cluster in Lucknow

and the district task force groups. The success in building better co-ordination mechanisms at thenational and district level, drawing lessons from all projects experimenting improvement of

routine immunization and social mobilization is an evidence that work can be done together more

effectively.


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6. Guiding Strategies

The global strategy recommended by UNICEF is pragmatic and results oriented. The strategy

comprises a set of tasks as follows:

The first set of tasks pertains to continuous monitoring and supervision to ensurehigh quality full coverage paving the way for accelerated disease control (Polio

eradication, NNT elimination and Measles control).

The second set of tasks regards the identification of underserved children,vaccine logistics, cold chain and the critical need to ensure injection safety.

Create a user-based reporting for tracking immunisation for every child and

defaulter tracking and tracing.

The third set of tasks addresses issues of management and technical assistanceaimed at sensitising and involving community level PRI members to use powers

and functions at each of their levels for RI revitalization. More specifically, use

PRI powers to I) allocate resources 2) provide co-ordination at lower levels 3)

exercise control over government functionaries 4) establish, manage and regulate

melas and 5) advise the state government.

The fourth set of tasks encourages governments to be forward looking and startintroducing Hepatitis B and other newer vaccines, allocating adequate financial

resources and removing structural barriers to immunisation.

Based on the foregoing broad strategies and the set of tasks deemed necessary to improvecoverage, and bring about quality, there are a number of needs and commitments which have

been identified in which:

UNICEF and its partners will support GOI and state governments in their

response to the request for routine immunization and other services. Stepsare being taken to respond to the existing demand, starting from the most

disadvantaged areas, as shown by the CES 2002. Support to expand outreach

sessions in all villages will be the main strategy to achieve increased and sustain

the immunization coverage. This will also benefit the Polio Eradication program,

and prevent reemergence of vaccine preventable diseases like diphtheria,

whooping cough and neonatal tetanus. As a strategic priority UNICEF will

continue to strengthen the current administration of vitamin A within the existing

routine mechanisms

Management support to district and sub-district operations has been shown oneof the weakest points in the UIP management in least performing states. During

the weeks prior and following the NIDs/SNIDs UNICEF and partners will provide maximum support, supervision and monitoring to the sub-district and

district level to ensure identification of catchment areas and service delivery to

users (multi-antigen immunization, distribution of vitamin A, curative care to 0-2

year children).

Supply and support systems have suffered lack of supervision and need amanagerial boost for the revitalization of RI to be successful over the mid- long

term. Performance of cold chain in different states remains quite varied and


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continuous power supply is a major drawback in EAG states. UNICEF and state

officials recently assessed the status of equipment classified as under/awaiting

repair in 16 major states. The overall downtime status and need for repair of

ILR/Freezers amount at present to approximately 2.3% (against a target of 5%). UNICEF has

offered over many years monitoring and supervision of the status of the coldchain equipment. Supporting offshore spare parts and supervision needs to

continue for proper planning and implementation of immunization activities.

Specific, ad hoc support would be considered upon request.

There is widespread consensus to increase the coverage of fully immunizedchildren to 60% by end 2004 and Measles vaccination to 80%. It would bedifficult for the states to achieve the target unless UNICEF and partners provide

logistics support. In particular, the supply of AD syringes remains crucial to the

Injection Safety that recently emerged as a major policy concern at national

level. The introduction of Hepatitis B vaccine as part of the UIP in selected areasand the establishment of the injection safety (IS) Coalition at national levelalready contributed to raise the awareness towards the use of AD syringes for

routine immunization or catch-up rounds for measles. The use of AD syringes for

hard to reach and outreach sessions is considered mandatory.

A strongereducational component will be integrated within the immunization plus interventions. Monitoring current health services for immunization will

guarantee sustainability of effort, provide training to strengthen capacity of

existing staff reducing drop out rates, increasing outreach, programme

communication will complement other sets of strategies. As evidence shows,

illiterate people are easy victims of rumours and misconceptions. Therefore, it is

important to think in terms of people right to information and services andconsider caretakers as clients, rather than beneficiaries. Immunization is notabout charity, but about fulfilling the childrens right to health and development.

UNICEFs support for IEC/social mobilization will be built around strong community participation and responsibility, by actively engaging community-

based groups, women self help groups and activists, with the specific

involvement of underserved representatives of the community.

Communication efforts will keep up the commitment of health workers andvaccinators to do an effective job to reach all villages/municipal slums, to

sustain demand and talk to clients in a respectful way, and to respond correctly to

their questions. Ensuring their commitment implies recognition of their efforts bytheir supervisors and local authorities. It also requires a clearguide of conductforhealth workers and vaccinators.

The behavioural change communication strategy is built around the principle thatwhile accessibility can be improved by implementing outreach sessions strategy,

acceptability cannot be imposed without appropriate information. Breaking

reluctance and making communities understand the sense of urgency to revitalize


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the RI system and start addressing the issue of vitamin A supplementation and

environmental degradation are an integral part of UNICEF strategy. A mid term,

community based approach will be implemented. Acceptability needs to be

gained by addressing socio-cultural and behavioural issues and improving the

provision of complementary health and environmental services.

7. Focus of Routine Immunisation Plan

As mentioned above, strengthening RI in India is a felt need at the national and across states. Thisis as a result of declining trends in coverage emerging from a series of Coverage Evaluation

Surveys (CES) including data from NFHS-2. With this recognition, GOI and state governments

have continued to mobilise partners and resources to implement activities that will address the

mitigating factors to reverse the trend. At the same time, the country has been faced with an

upsurge of wild poliovirus transmission that threatens to erode previous gains in the polioeradication initiative.

Within the context of the Government of India and State Governments planning processes,

UNICEF will lead with its partners, the formation of Routine Immunization Units, Task Forces

and Working Groups established to consolidate the routine immunization initiative at state anddistrict levels.

Planning at the district, block and sub-centre levels will broadly revolve around five components

namely1) Management, monitoring and supervision 2) Training and capacity building 3) Cold

chain, logistics and supplies 4) Social mobilisation and strategic communication 5) Transport and

mobility support. In addition, plans will include a component defining approaches and

interventions to reach the disadvantaged in municipalities.

The plans will also specifically endeavour to: a) create awareness and a sustained demand for

services, b) building on the existing good practices and experiences, c) bring about community

empowerment via local government institutions and self-help groups, d) enhance community

participation, including children e) reach the un-reached, the underserved and disadvantaged, f)strengthen monitoring and collecting of new data for decision making (BDCS framework for

action), g) bring about integration and or Programme convergence, cross sectoral collaboration,

and h) child rights to health linked to the rights of others.

8. Agenda for Action: The Phased-in Intensified Approach

The underlying principle in this approach is to demonstrate results and build on the lessons

learned as activities are extended to other districts. Towards this end, the BDCS districts will be

the essential part of the acceleration strategy country and statewide. In specific instances, and

responding to state governments requests, UNICEF will activate RI acceleration in broader

areas.

The phased-in approach relies on a specific geographical area programming. Its rationale is to

prioritize interventions according to coverage data and epidemiological evidence. It encompasses

not only the BDCS districts where micro planning and monitoring is already addressed by a

sustained effort, but also those districts that have been and are struck by highest risk of incidenceof poliomyelitis.

A series of state consultations will be advocated by UNICEF and organized by state governments.

UP and West Bengal successfully undertook these consultations in late February and March 2003.


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The participation of district task forces with multiplerepresentation from DFW, DWCD and local

government allowed a participatory analysis of coverage and bottlenecks at district and sub-

district level as well as a detailed mapping exercise. Further state level consultations, starting

from Jharkhand in June 2003 will offer opportunities for state officials and partners to use a

planning and policy forum where the most striking managerial priorities are discussed and rapidly

addressed. Of utmost importance, the quality of micro plans, supervisory checklists and timeline

of activities will be focused on. As it has been said at the outset, while it is very important toenhance and maintain the operational quality of SIAs to guarantee wide immunization by OPV,

the time of operations should not exceed 7-10 days. This would offer enough room for the healthsystem to undertake fixed-day, fixed-site immunization and, in particular, outreach sessions in

order to cover every village eligible children at least once a month.

In UP, the first phase will involve 11 districts (6 BDCS districts; Ghazipur where and intensified

approach on vitamin A supplementation takes place under the MOST targeted intervention; and,finally other high priority districts) starting from April 2003 and phase-in other districts every

quarter, according to government and partners determinations. A suitable alternative would be for

partners to adopt districts and start simultaneous work with UNICEF and other stakeholders. In

the former way, the acceleration process will be completed within fifteen months.

In West Bengal, activities will start in 6 high-risk districts, one of which is part of the BDCS lot.Jharkhand, Bihar, Rajasthan, and Madhya Pradesh will be phased-in in the process by the same

logic starting from BDCS districts and expanding upon request and discussion among partners.

UNICEFs targeted interventions will be to:

Improve the quality of micro planning, management, monitoring andsupervision at all levels.

Support for planning and conducting assertive outreach sessions in allvillages of the sub-centre. At least one session will be held in each of the village

every month.

The availability of safe vaccines, safe injections, safe delivery of vitamin Aliesat the center of immunization services and vitamin A supplementation.

Reach and mobilize families and individualsat the community level especiallyin resistant pockets to ensure that all children are fully protected against all

vaccine-preventable diseases. Appropriate supply and use of immunization cards

would be supervised and ensured.

Inform, educate and motivatefamilies, local influencers and service providersabout the importance of routine immunization through research-based and

professionally designed IEC materials.

Advocate with decision-makers and influencers at all levels to strengthen andsustain routine immunization.

Enhance collaboration with other organizations with a geographic presence andwith different comparative advantages, while sharing the same objectives.


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9. Strategic Communication

UNICEFs overall communication strategy is available as a separate document. This paper does

not supercede or replace it, but rather uses it as a basis for action in accelerating routine

immunization.

UNICEF-supported activities will take a two-pronged approach, 1) reach with targetedinterventions the underserved or hard to reach and convince those who have never participated

before, or who are not participating consistently out of sheer lack of knowledge, or because ofdoubts or misconceptions. Whereas services may be inadequate, in some cases health care

providers and information have never reached the people, and 2) sustain demand for services of

those who have historically participated in routine immunization, but whose interest might be

decreasing due to insufficient institutional support for RI. The comprehensive communication

strategy is already outlined in the strategic document depicting polio and routine immunizationtogether.

Inter-personal communication (IPC) with families and communities through the use of local

mobilizers and influential persons represent the strategies of choice to bring about the desired

change in attitude and behaviour of users. This approach will be combined with continued mediainterventions that address users doubts and misconceptions. It will also be combined with well-

placed advocacy efforts to create an enabling environment for strengthening and revitalizing

routine immunization services.

9.1 Communication Imperatives

Communication activities will try to infuse in clients a body of knowledge to be able to make

positive, informed decisions and choices for themselves and their children. This will not only spur

demand but also ensure sustained utilisation for services. The strategy will ensure that parents and

caregivers including women of childbearing age (WCBA) have information on the need for

timely and full immunisation for pregnant mothers and children (< I year), understand the routes

of administration for each antigen and possible adverse effects following immunisation (AEFI).With regard to safety of injection, caregivers will be made aware of the use of AD or disposable

syringes during fixed or outreach sessions. Families will also be made to understand the rationale

of providing TT to pregnant mothers and WCBA. Above all, families will be informed well in

advance on the date/day, time, and place of the fixed and outreach sessions to enable them to

attend or bring eligible children.

RI Strengthening requires a sound strategic communication plan and activities, whose main goals

are to:

1) Reduce dropouts due to user barriers

2) Reach the underserved

3) Advocate among key constituencies to sustain the immunization program.

Specific activities will be conceived according to state priorities and funding status, according to

the current, agreed upon Communication Strategy Paper for 2003.


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Reduce Dropouts Due to Consumer Barriers

The objectives are to: 1) ensure caregivers know the date and time of vaccination programs, 2)

ensure caregivers know when to come for the next vaccine 3) educate parents on the importance

of measles vaccine 4) dispel myths about side effects and contraindications 5) reduce number of

AEFI i.e. improve injection safety 6) maintain a high profile for immunization throughout the

year and 7) market the concept of full immunization

Reach theUnderserved

The objectives are to: 1) Increase participation/ownership of professional groups, institutions,

and NGOs in underserved areas 2) increase health service access and utilization 3) increase

distribution/utilization of immunization cards 4) increase outreach to slum areas 5) increase

outreach to low-literate and poverty-level mothers and 6) increase outreach to tribal groups andscheduled castes.

Advocate within Government to Sustain the Immunization Program

The objectives are to: 1) increase participation of government in reinforcing key messages 2)improve public perception of immunization program 3) increase number of supporters for

immunization services 4) engage other governmental departments in the effort to improve

immunization coverage and 5) engage other NGOs and give them a long-term role in sustaining

the program.

10. Service Delivery Point Activities

Essential components will be:

to ensure one planned session in every village every month

to ensure availability of adequate logistics and supplies (syringes, vaccine,injection equipment) and

to ensure effective social mobilization and communication.

A schematic, exemplified approach would include the following:

Development/improvement of Sub-centre and village level micro plan.

All the villages under a sub-centre will be divided into two categories namelyeasy to reach and difficult to reach villages. The difficult to reach villages would

require extra inputs like mobility support. In a sub-centres catchment area of

nearly 8,000, around 240 new births are expected every year (20 per month).

Each child requires 4-5 contacts for the completion of Routine Immunization

schedule. Thus, the total number of contacts that an ANM is supposed toestablish is 100-125 per month.

When organizing 8 sessions per month, every ANM would have a workload of15-20 contacts per village. Taking children up to 2 years of age then the number

may double if no immunization sessions have been undertaken earlier. Similarly

the logistic support can also be calculated.


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While holding a session, the ANM would maintain a MCH/Immunizationregister, which specifies the reasons for a visit and the services, extended. She

would also up-date the Immunization card

Mobility support will be provided for hard to reach areas.

Injection equipment: Re-usable syringes for the routine immunizationstrengthening. One rack of sterilized syringes/needles (45-50) would be sufficient

for one planned session in a village. AD syringes are to be introduced for everyoutreach session.

Monitoring support will be by the existing public health system (Healthsupervisors, MOs, MO I/Cs, Deputy CMOs, and CMOs). Neutral cross-sectoral

observers may also be deputed for monitoring.

Support to ensure adequacy of the cold chain will have been factored in the microplan.

IEC targeting the involvement of communities through Village HealthCommittees and their revitalization.

11. Expected Results by end 2004 in Phased-in Districts

RI coverage will exceed 60% for all EPI vaccines (BCG, OPV, DPT, andMeasles) in children < 12 months in selected districts of selected states.

District Task Force in place with under-served segments' representation,statewide.

Verified by survey, all immunization sessions will be able to demonstrateadequate supply of vaccines and appropriate quality of cold chain.

Leveraging the existing health infrastructure and system to take on additionalintegrated health services for children.

Creation of full awareness and involvement of the PRI.

Block Development Committees geared up on RI and a working with ademonstrable inter-sectoral collaboration.

Sub-centre level catchment areas identified and mapped (focus on newborn and0-2 yr. old children).

Availability and implementation of quality district and sub-centre micro plans foroutreach.

Village level organization, plan and logistics via Swastya Ghar or similarinitiatives.

Training of health workers in the use of AD syringes at district and sub-centrelevel completed.

AD syringes for all UIP vaccines including Hepatitis B vaccine introduced in aphased manner.

Combined DPT-Hepatitis B vaccine introduced for use when it becomesavailable.

State Assessment on Injection Safety in 2003 and support to implementation of aNational Injection Safety policy.

Strengthening the strategy for integration of new vaccine in the existingProgramme.

Address health sector reforms by use of AD syringes.

Together with WHO, support establishment of Surveillance systems for VPDsand AEFI.


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References

AIIMS. (2000). Lessons learnt from pulse polio immunization programme: Report.Journal of theIndian Medical Association, 98 (1): 18-21.

Gounder, C. (1998). The progress of the polio eradication initiative: What prospects foreradicating measles?Health Policy and Planning, 13 (3): 212-233.

Hull, H.F., Ward, N.A., Hull, B.P., Milstien, J.B., & de Quadros C. (1994). Paralytic

poliomyelitis; seasoned strategies, disappearing disease. Lancet, 343: 1331-1337.

Pande, R.P., & Yazbeck, A.S. (2002).Beyond national averages for immunizations in India:Income, gender, and regional inequalities. HNP Discussion Paper. World Bank, DC

Razum, O., Liyanage, J., & Nayar, K.R. (2001). Difficulties in polio eradication.Lancet, 19:357.

EPOS (2002). Cultural barriers to polio eradication: a quantitative and quantitative assessment,

a joint WHO/UNICEF supported study, New Delhi, 2002.

Bonu, S., Ravi, M., Baker, T.D. (2003), in press. The impact of national polio immunizationcampaign on levels and equity in immunization coverage: evidence from rural North India.Social Science and Medicine, 2003.

Das J., Das S., (2003). Trust, Learning and Vaccination: a case study of a Northern Indian

Village. Social Science and Medicine, 57: 97-112


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Appendix I

1. Accelerating Routine Immunisation within RCH-II Policy:

A Strategic Link to National Experiences

1.1 Rationale

During three public national and international occasions in April and May 2003, the Secretary

DFW indicated that routine immunisation has been neglected and requires attention and

revitalization. Of concern is the principal finding of the 2002 RCH survey that the immunisationcoverage rates for other non-polio vaccinations have declined or stagnated despite the

implementation of the PPI campaign. While a number of studies have shown a positive link

between the polio eradication programme on other EPI vaccinations and health systems, they are,

however, qualitative and anecdotal in nature, and are primarily based on interviews with

community leaders or health staff (AIIMS, 2000; Gounder, 1998; Hull, Ward, Milstien & De

Quadros, 1994.). On the other hand, a number of studies have reported some disruption of other

health activities as an outcome of PPI (AIIMS, 2000; Chowdry & Ramos-Jimensez, 1999a, b;Razum et al., 2001, John et al., 2002). And in some instances, there is a growing concern that the

PPI campaign might have helped to stem the deterioration in routine immunisation that was seen

in the early 1990s.

Chincholikar and Prayag (2000) concluded from their evaluation of PPI in rural areas of

Maharashtra that the PPI campaign raised general awareness about polio immunisation among

illiterate mothers, but not specific knowledge of the importance of immunisation in general. Data

from the World Bank funded Reproductive and Child Health surveys conducted in 1998 (after

implementation of six rounds of NIDs) also suggests that almost two-thirds of mothers of un-

immunized children from rural areas were either unaware of the need of routine immunisation, or

did not know a source of immunisation services (Pande & Yazbeck, 2002).

Beyond other relevant issues, a recent UNICEF-WHO sponsored study on cultural barriers to

polio immunisation in UP suggests that under-served and illiterate mothers, regardless of specific

communication techniques used, are unlikely to distinguish between various vaccines, and may

not take the child for other immunisations, on the assumption that the child received all the

vaccines during NIDs/SNIDs (EPOS, 2002). Evidence from health workers and public

perceptions in the same study indicates that rigid hierarchies, as in the case of Uttar Pradesh (UP),

and single-minded commitment to achieve short-term quantitative goals for polio immunisation

through SIAs may have discouraged long-term efforts for creating and sustaining the demand for

preventive services in general, and immunisation services in particular.

Finally, data from 2002 and 2003 PPI indicates that persistent inequities in coverage by caste andreligion may impede PPI from achieving its ultimate goal eradication of polio as lower castes

and minorities tend to live in clusters in Northern India. Persistence of even small pockets of

unvaccinated new-borns and young children increases the risk of resurgence of local transmission

foci in polio-free states such as West Bengal, Rajasthan, Gujarat, Madhya Pradesh and the risk of

sudden outbreaks of poliomyelitis as occurred in 2002 in Uttar Pradesh (UP).

Experience has shown that a development objective, however well-meaning could not be imposed

upon supposed beneficiaries unless their right to information, knowledge and consultative

dialogues, and in many instances their right to basic services is addressed.


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Since 1999-2000 the national government with the help of many partner agencies has started

steps towards revitalising routine immunisation with an emphasis on quality improvement of

service delivery. Schemes to Strengthen Outreach Services have been devised by the GOI within

the current policy framework that contributes to improve the quality of services and enhance

coverage ofinfants namely:

1.2 Border District Cluster Strategy

The Border District Cluster Strategy (BDCS) is a joint GOI-UNICEF supported initiative tocontribute strengthening the health system and improving the quality of service delivery. Its main

thrusts are community based planning and monitoring and providing a minimum intervention

package of basic services (immunisation plus and basic maternal care) and an expanded

intervention package (Integrated Management of Neonatal and Childhood IllnessesIMNCI,

Emergency Obstetric Care--EOC). Forty-eight districts are covered under the scheme in 15 majorstates. Villages in the intervention districts are classified into three categories. Type A villages

are the head quarter village of the sub-centre (SC), while type B villages are those which could

be reached within half-an-hour walk or having public transportation available from the SC and

type C are those which are beyond half-an-hour walking distance. Comprehensive primary

health care services are provided through the health and nutrition teams once every monththrough out-reach sessions. In order to improve out-reach sessions, an incentive of Rs20/- per

session for 4 sessions per sub-centre per month has been provided. Provision of mobility support

for routine catch-up sessions in hard to reach areas has also been made.

After the last national review in April 2002, the introduction of the concept of learningdistricts initially in selected areas and over time in all BDCS districts contributes to secure:a) Immunization Plus: acceleration of EPI Plus (including Vitamin A) and of expanded ANC at

sub-centers and RCH outreach.

b) I-ECD and survival: Community and home based interventions, especially home based

prevention and management of Asphyxia, Hypothermia, Low Birth Weight, Neonatal Sepsis as

well as Pneumonia and Diarrhea in young children.

c) Referral Care especially improved EOC, Neonatal Care and IMNCI in FRUs.

1.3 Immunisation Strengthening Project

This is a major attempt made by the GOI to address the inadequacies and constraints identified by

coverage evaluation surveys and other similar studies. It takes advantage of the new experiences

gained in the Pulse Polio Programme (PPI), namely, mass mobilization, surveillance and building

commitment among programme implementers and the public towards the immunisation

programme. The project is a three-year undertaking initiated in 2000-01 as a component of the

ongoing World Bank supported RCH Programme and its cost estimate is Rs.1, 118.41 Crores. It

recognizes the following objectives:

1.3.1 Eliminating polio incidence and achieving polio eradication.1.3.2 Strengthening routine immunisation and Vitamin A supplementation with the

aim of raising the percentage of fully immunised children to above 80%.

1.3.3 Reviewing and developing a new vision of the immunisation programme in themedium term keeping in view the development of new epidemiological patterns,availability of new vaccines and delivery mechanisms and advances in cold chain

technologies.

1.3.4 Improving surveillance and monitoring mechanisms.


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The polio eradication component of the project facilitated the ongoing efforts of the Government

in Polio eradication. The other two components of the Project relating to strengthening of routine

immunisation and Strategic Framework Development are currently operationalized.

The inputs of the project include:

assistance for the cold chain equipment replacement or new installation;

replacement of injection safety equipment, supplied about 15 years ago computerisation of information related to vaccine and cold chain logistics for

improving supervision and monitoring

mobility support for state programme officers

operational system of quarterly review meetings at the national and state levels

technical assistance for programme monitoring

finance activities for formulating mid-term goals for the programme as well asfor programme development. In particular, it will support extension of disease

surveillance of measles, support epidemiological studies and communitysurveillance in UP and Bihar

strengthening outreach services by providing inputs for micro planning,

supervision, IEC (Information Education Communication) development, socialmobilisation and improving service delivery mechanisms.

This scheme was started in 50 poorly performing districts of 8 priority states of UP, Bihar,Madhya Pradesh, Rajasthan, Orissa, Gujarat, Assam and West Bengal during 2000-01. In 2001-

02 an additional 101 weak districts from other poorly performing States have also been included.

The scope of the scheme is likely to be expanded to cover some additional districts in 2003.

1.4 Injection Safety

Since its inception, UIP provided reusable glass syringes and needles with the necessary

equipment for sterilization. Unfortunately, recent evidence has indicated that over 30% of

vaccinations were unsafe. Since 1998, Auto-disable Syringes (ADS) for catch up rounds of

measles (target: children of 9-59 months) and tetanus toxoid (target: women of childbearing age)

have been supplied with the help of UNICEF. Over 10 million syringes have been used so far in

the country and the experience has been encouraging indicating user friendliness and satisfaction

among clients. The introduction of Hepatitis B in select areas under GAVI support mandates use

of AD syringes for all vaccines. Towards this end, the national government has recently decided

to replace the reusable syringes with ADS in a phased manner as part of the RCH-II policy.

To provide an insight, a nation wide study on the prevalent injection practices in the country has

been commissioned. India-Clinical Epidemiological Network of medical colleges will conduct

this study. The study would focus on issues such as injection prescribing behaviour of providers

and the adoption of safety measures by health professionals in order to investigate practices of

disposal of syringes and needles at the point of service delivery. The study will be conducted not

only in the public sector but also include private sector institutions and health care providers.

Injection practices will be studied both in programme situations (focusing on the Immunisation

Programme) and clinical facilities. The Indian Academy of Paediatrics (IAP), Indian Medical

Association, Federation of Obstetricians and Gynaecologists Society of India, Neonatology

Forum, and the Indian Association of Preventive and Social Medicine have been associated to get

arealistic situational analysis of injection practices in the country. Based on the study results and

the recommendations, specific interventions will be launched.


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1.5 National Technical Advisory Group on Immunisation

The Department of Family Welfare has established a National Technical Advisory Group on

Immunisation (NTAGI) on 28 August 2001. The committee has been set with comprehensive

Terms of Reference for its effective functioning to take on the following major roles:

To be an advisory body to assist the Government of India in developing a nation-wide policy framework for vaccines and immunisation;

To prioritise immunisation activities and set attainable targets;

Identify critical gaps in policy and programme and identify studies, assessmentsand research areas to address the same; and

To review periodic assessments of the national immunisation programmeincluding immunisation performance and disease incidence.

1.6 Introduction of Hepatitis-B Vaccine: A Window of Opportunity

It is estimated that 60% of liver diseases are due to Hepatitis-B infection and 80% of liver cancer

cases in India arise from Hepatitis B. Vaccination against Hepatitis B protects individuals fromthe risk of Hepato-cellular carcinoma and Hepatitis-B vaccine is thus the first vaccine available

against any type of cancer.

In India, the Ninth Five-Year Plan Approach Paper has recommended introduction of Hepatitis-B

immunisation in the UIP. Within the 10 th National Health Plan, both financial and human

resources will be freed for undertaking fresh initiatives. Concurrently, as a measure to strengthen

the immunisation programme and improve the outreach of RCH services, Hepatitis B vaccine is

now being integrated into the existing routine/universal immunisation in India by the MOFW.

The strategy of its addition is planned to promote healthy competition among districts and states

for better performance and to provide due priority to the most disadvantaged.

One of the main objectives in selecting specific cities and districts for the introduction of this new

vaccine is to achieve 80% coverage or more under routine immunization of infants with the

existing vaccines on the basis of coverage evaluation surveys. This strategy is designed to

encourage more cities and districts to be included as the program expands. In the pilot phase the

vaccine is being provided free of cost only to infants living in slums to ensure that the most

disadvantaged get due preference. Additional inputs being provided for the introduction of this

new vaccine are: 1) Auto-disable (AD) syringes (to be supplied by UNICEF and other donors

initially) and their safe disposal (to attract attention towards bigger issues of hospital waste

management) and 2) Renewed emphasis on maintenance of cold chain (for ensuring potency of

all the vaccines).

immunization plus- a framework for action (2003-2007)

Documents