NATIONAL IMMUNIZATION PROGRAMME AND RECENT ADVANCES

IN IT.

Name of PresenterDr. Rama Shankar

PG resident

Name of ModeratorDr. Nirankar Singh

Professor

Department of Community Medicine Muzaffarnagar Medical College

27/4/20161

Outline of the Presentation• Introduction

• Timeline of vaccination efforts in India ( Ancient time-till 1977)

• National Immunization Programme in India ( 1978 onwards)• Micro planning• Cold Chain• Immunization coverage• AEFI• Online Support• Recent advances• Summary• References

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Introduction• Vaccination is a proven and the most effective child survival interventions.

• There are at least 27 causative agents against which vaccines are available & more agents are targeted for development of vaccine.

• The first vaccine ( small pox) was discovered in 1798 and the success can be seen in the form of eradication of smallpox disease from the planet.

• Immunization avert 2 to 3 million deaths every year but still 18.7 million infants worldwide are missing out of basic vaccines

• Every year in India, 5 lakh children die due to VPD. 89 lakh children remain at risk because they are either not immunised or partial immunised.

• Full Immunization is critical if we need to reduce the mortality.

Brief History of Immunization in India

• Ancient times till first documented smallpox vaccination in India in 1802

• Vaccination in India (1802-1899)• Vaccination in India (1900-1947)• Vaccination in India (1947-1977)

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Ancient time: Smallpox known to people

- 3000 BC: Smallpox is believed to have originated from India or Egypt.

- 300BC: Description of smallpox in Sanskrit literature

1000 AD: Inoculation documented from China and India also

910 AD: Smallpox differentiated from Measles by Abu Bakr

• 1545: Smallpox outbreak reported from Goa, India• 1600: Documented evidences of practice of inoculation

( variolation) from India. • 1767: Dr. Holwell described practice of inoculation in

India to college of physicians in London

- 1774:Benjamin Jesty did experiment on his wife and two children by injecting cow-pox matter.

- 1796: Edward Jenner conducted the famous observation on milk maids.

- 1798: Jenner's observations were published and smallpox vaccine was discovered

1802: First smallpox vaccination done in India.

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1804: The practice of inoculation was banned in some provinces of India

- 1820s: Vaccination continued to increase in India specially Bombay and Bengal presidency.

- 1830s-1850s: Some initial research on smallpox vaccination conducted in India.

- 1850s: Initial resistance to smallpox vaccination due to multiple reasons

1810: Gennaro Galbiati , an Italian physician used cows for vaccine production

• 1870:Animal vaccine production in USA. First vaccine farm in Lakeview, New Jersey USA.

• 1879: First Laboratory vaccine produced by Louis Pasteur for Chicken Cholera.

• 1890: First animal vaccine depot was set up in Shillong.

• 1892: Compulsory Vaccination Act passed by GOI. • 1893: Cholera vaccine trial conducted in Agra, India. • 1896: Epidemic act was passed in the wake of plague

epidemic in India

1898: Initial Stringent regulations for vaccine production released

1899: Plague Laboratory was set up in Bombay ( later renamed as Haffkine Institute in 1925).

1897: First plague vaccine was developed by Dr.Haffkine in Laboratory, in Bombay

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1902: A few deaths were reported after plague vaccination in Punjab Province of India, major set-back to plague

vaccination and at the reputation of Haffkine ( years later, death were found due to programmatic error).

1909: Lucien Camus develop first air dried smallpox vaccine in Paris

1958: WHA passed a resolution to eradicate smallpox.

• 1910-1930: A number of vaccine institutes set up in different provinces of the country.

• 1948: BCG Laboratory in Guindy, Madras set up. BCG vaccination started at pilot level.

• 1951: BCG mass campaign were started in India.

1974: WHO announces EPI

1975: Last case of smallpox was reported

1962: National Smallpox Eradication Programme launched. National Tuberculosis control Programme started with BCG

vaccine being offered to the people.

1904-1908:Typhoid vaccine trial was done on British Army officials posted to India ( and Egypt also)

1977: Last case of smallpox was reported from the world 1977: India declared smallpox free.

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• 1978: EPI Launched In India.• 1980: World Declared smallpox free. It becomes the first disease to be eradicated from the

planet.

• 1988: WHA passes a resolution to eradicate polio by the year 2000.• 1989: First comprehensive review of UIP in India conducted.• 1990: UIP universalised to cover the entire country.• 1991: Cold chain maintenance was taken over by the state governments.

• 2000: Border District Cluster Strategy for Immunization strengthening in border districts implemented. Immunization strengthening Project (ISP) implemented.

• 1992: UIP became part of CSSM in the country. Another international review of UIP in India conducted.

• 1995: India conducted first NID for polio eradication.• 1997: UIP became part of RCH. NPSP launched

• 1985: UIP launched in 31 districts of India with a plan for expansion to the entire country.• 1986: Immunization became one of the five National Technology Missions in India.

• 2001: NTAGI in India formed.• 2004: International review of UIP conducted.

• 2003/2004: First Maternal and Neonatal tetanus elimination (MNTE) validation done.

• 2005: UIP became part of NRHM. First MYP for UIP in India (2005-2010) released. AEFI surveillance and response operational guidelines released.

• 2005/06: The glass syringes in UIP was replaced by the policy of the use of AD syringe only.• 2006: Country conducted first immunization weeks for improving coverage with UIP antigens in

poor performing districts.

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2007/08: National, State and Districts level AEFI committee constituted. State and districts level training in AEFI conducted

2009: Guidelines for the involvement of private practitioner in UIP released. National Vaccine Wastage Survey conducted.

2011: Last wild polio virus case reported from India. National Vaccine Policy of India released. Open Vial Policy was implemented for select vaccines in UIP.

2010: Indian became the last country of the world to introduce measles second dose in the national immunization programme; 21 states provided MCV 2 in RI and rest of the states started conducting measles catch up campaigns.

2008: Immunization Handbook for Medical Officer released and training started. National cold chain assessment conducted

2012: Draft comprehensive MYP for UIP (2012-2017) ready. Declared as Year of Intensification of Routine Immunization in India. WHO removed India from endemic countries.

2014: WHO declared SEAR polio free on 27th March 2014. Mission Indradhanush launched on 25th December 2014.

• 2015/16: 1st Phase of Mission Indradhanush ( 4 rounds ). First in April, 2nd in May, 3rd in June and 4th in July 2015 starting 7th of each month.

• 2nd Phase of Mission Indradhanush ( 4 rounds). First in October, 2nd in November, 3rd in December and 4th in Jan 2016 starting 7th of each month.

tOPV-bOPV switch on 25th April 2016. 9

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National Immunization SchedulePregnant Women

TT-1 Early in PregnancyTT-2 4 weeks after TT-1TT

Bosster If received 2 dose of TT in pregnancy within the last 3 years

Children

Age Earlier Immunization ScheduleImmunization schedule (post pentavalent/IPV/Rota/bOPV

IntroductionAt Birth BCG, OPV (0 dose), Hep B ( Birth

dose)BCG, bOPV (0 dose), Hep B ( Birth

dose)6 weeks OPV-1, DPT-1, Hep B-1 bOPV-1, Pentavalent-1 ( Rota)

10 weeks OPV-2, DPT-2, Hep B-2 bOPV-2, Pentavalent-2 ( Rota)

14 weeks OPV-3, DPT-3, Hep B-3 bOPV-3, Pentavalent-3 ( IPV, Rota)

9 months MCV-1 JE-1 ( Where Applicable) MCV-1 JE-1 ( Where Applicable)

16-24 months

DPT- booster first dose, MCV-2, OPV booster dose, JE-2 ( where

applicable)DPT- booster first dose, MCV-2, bOPV booster dose, JE-2 ( where applicable)

5-6 years DPT-booster second dose DPT-booster second dose

10 years TT first booster dose TT first booster dose

16 years TT second booster dose TT second booster dose

Vaccine Dose Diluent Route Site

TT 0.5 ml No IM Upper Arm

BCG 0.1 ml (0.05 ml)

Sodium Chloride ID Left upper arm

Hepatitis B 0.5 ml No IM Antero-lateral part of mid

thigh (left)

OPV 2 drops No OralRota 5 drops NO Oral

IPV 0.5 ml No IM Antero-lateral part of mid thigh Right

Pentavalent 0.5 ml No IM Antero-lateral part of mid

thigh ( Left)

Measles 0.5 ml Distil Water SC Right upper arm

JE 0.5 ml Phosphate Buffer SC Left upper arm

DPT 0.5 ml No IM Antero-lateral part of mid thigh ( Left)11

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Presentation and Dosage form

- IPV is a liquid vaccine- No reconstitution is

required- In UIP it will be

available in 5 or 10 dose vial

- VVM present on vial- IPV is freeze sensitive

vaccine- Shake test not

applicable

Vaccine CostIPV is an expensive vaccine

Each dose is (Approx)Rs 120-150

Each 5 dose vial is Rs 600Each 10 dose vial is Rs 1200

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RI Microplanning: A Snapshot

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Calculation of monthly working stock requirement for each antigen in doses as under;

BCG= YIT X1 dose X2.0 ( wastage )/12DPT= YIT X2 dose X1.11 ( wastage )/12OPV= YIT X 5 dose X 1.11 ( wastage )/12IPV=YIT X1 dose X 1.11 ( wastage )/12MCV=YIT X2 dose X 1.33 ( wastage )/12TT= YT(PW) X3.5 dose X 1.11 ( wastage )/12Hep B=YIT X1 dose X 1.11 ( wastage )/12LPV= YIT X3 dose X 1.11 ( wastage )/12JE= YIT X2 dose X 1.33 ( wastage )/12RVV=YIT X 3 dose X 1.33 ( wastage )/12

For Syringes 0.1 ml syringes: YIT, X 1 X 1.11/120.5 ml syringes: YIT X ( 1 {Hep B}+ 2 {DPT}+3 {LPV}+1 {IPV}+2 {MCV}+2 {JE}+3.5 {TT}) X 1.1/125 ml Syringe: Annual Requirement (BCG+MCV+JE) X1.1/12

Wastage rate: (Dose Issued-Dose administered ) X100/Dose Issued

WMF=100/100-WR

e.g BCG, DI=10 and DA is 5 then

WR=(10-5)X100/10=50%

WMF=100/100-50=2

* Yearly infant target

Immunization supply levels in India

MOHFW Immunization

Division

Manufacturer

GMSD (4)( Primary Vaccine

Store)

State vaccine store (53)

District Vaccine Store (666)

PHC/UHCLast cold chain

point

AVDS

Session site outreach

Block Vaccine Store (CHC/PHC)

Regional Vaccine store (110)

25,555

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- BCG ( After reconstitution)

- OPV, Rotavirus vaccine

- IPV

- Measles ( Before and after reconstitution)

- JE ( Before and after reconstitution)

- DPT

- BCG (( After reconstitution)

- TT/Pentavalent , Hep B Least Sensitive

Most Sensitive

Heat Sensitivity

- Hep B

- Pentavalent

- IPV

- DPT

- TT

Freeze Sensitivity

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Cold Chain Equipment

Storage Transportation

Electrical

Solar

Non-Electrical

WICWIFILRDFDR

Solar refrigerator BatterySolar Refrigerator Direct Drive

Cold Box/Vaccine Carrier

Refrigerated Vaccine vanInsulated Vaccine van

Cold boxVaccine carrier

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Deep Freezer

Make Model Net storage No. of icepacks storage capacity Size

Haier HBD-286 200 350 LargeHaier HBD-116 80 140 Small

Vestfrost MF-314 264 380 LargeVestfrost MF-114 72 130 Small

ILRVestfrost MK-304 108

NA

LargeVestfrost MF-114 45 Small

Haier HBD-200 100 LargeHaier HBD-70 50 Small

In right quantityIn right qualityIn right timeIn right temperatureIn right placeTo right beneficiary

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• All waste generated before vaccination should go in Black Bag.

• All waste generated after vaccination should go in Red Bag

• All broken vials/diluents should go in Hub Cutter

Full Im-muniza-

tion

BCG (%) 3 dose of OPV (%)

3 dose of DPT (%)

1 dose of MCV (%)

0

20

40

60

80

100

3662 54 52 4242

72 63 55 5144

78 7855 59

NFHS 1 NFHS 2 NFHS 3

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Full Im-muniza-

tion

BCG (%) 3 dose of OPV (%)

2 dose of DPT (%)

1 dose of MCV (%)

0

22.5

45

67.5

90

112.5

5473 68 66

504675

57 58 565487

66 64 70

DLHS 1 DLHS 2 DLHS 3

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Full Im-mu-niza-tion

BCG (%)

OPV1 OPV2 OPV3 DPT1 DPT2 DPT3 MCV 10

22.5

45

67.5

90

112.5

6187 83 78 70

83 78 72 74

CES 2009

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FI BCG (%) 3d OPV 3 d DPT MCV 1 3 d Hep B

0

25

50

75

100

6292 73 80 79 66

BIHAR

DPTPolioMeaslesHep-B

Peumococcal

Rotavirus0 22.5 45 67.5 90

86

86

85

82

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Global Immunization coverage 2014

World Immunization coverage

vacc

ine

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Importance of Immunization monitoring chart

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AEFI

Currently used: An adverse event following immunization is a medical incident that take place after an immunization, causes concern, and is believed to be caused by the Immunization.

Revised Definition: An AEFI is any untoward medical occurrence which follows immunization and which does not necessarily have a causal relationship with the usage of the vaccine.

The adverse event may be any unfavourable or unintended sign, abnormal laboratory finding, symptom or disease.

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Cause specific definition of AEFI

1Vaccine product- related reaction

An AEFI that is caused or

precipitated by a vaccine due to one

or more of the inherent properties

of the vaccine product

Example

Extensive limb swelling following DTP vaccination.

2Vaccine quality defect-

related reaction

An AEFI that is caused or precipitated by a

vaccine that is due to one or more quality

defects of the vaccine products including its

administration device as provided by the manufacturer

ExampleFailure by the

manufacturer to completely inactivate a lot of IPV leads to cases

of Paralytic polio.

3Immunization error-

related reaction

An AEFI that is caused by inappropriate vaccine handling

prescribing or administration.

ExampleTransmission of

infection by contaminated multi

dose vial.

4Immunization

anxiety-related reaction

An AEFI arising from anxiety about the

immunisation.

ExampleVasovagal syncope in

an adolescent following vaccination

5Coincidental event

An AEFI that is caused by something other

than the vaccine product, Immunization error or immunization

anxiety.

ExampleA fever after

vaccination and malarial parasite isolated from

blood.

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Causality Assessment

Final assessment -district reports to state

Preliminary investigation -district reports to state

District decision on investigation and inform state

Medical officer visit and reports to districts

Case Notification

24 hrs

48 hrs

Day 10

Day 100

Day 130

Day 0

24 hrs

48 hrs

Day 10

Day 70

Day 100

Day 0

DIR including state causality

assessment

PIR

FIR

Only serious AEFI cases Existing guidelines Severe and serious AEFI

cases. Revised Guidelines

state causalityassessment

report

Final case investigation form

(CIF)

Preliminary case investigation form

(PCIF)

Case reporting form (CRF)

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Mother and Child Tracking System

Steps to generate the month wise services given to

beneficiaries

Step 1: Go to mcts site nrhm-mcts.nic.in

Select the Mother Child Tracking System (Reports)

Step 2: On this page click the Login

Step 3: Select the State and enter the block user id and password and press Login

Step 4: From this window click on Scheduled Report

Step 5: Under the schedule report select the Report Type

T. Facility wise work plan and services given

Step 6: Select the year, Month, Health Facility Type, Health Facility Name, Type of report and Services Given and Click on

Submit

Step 7: In a new window HSC wise report get generatedThere might be need to allow the Pop-up blocker

Similarly services given for children >1 years can be generated

Main highlights of first phase of MI.

9.4 lakhs sessions organised in 4 rounds.

2 crores vaccines given to pregnant and children

More than 20 lakhs PW were vaccinated with TT.

75.5 lakh children vaccinated and 20 lakh children were fully Immunised.

57 lakhs Zinc tablet and 16 lakhs ORS given to children during MI.

Mission Indradhanush

The ultimate goal of MI isto ensure FULL IMMUNIZATION

with all available vaccines for children up to 2 years and PW.

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24-30 April 2016

India joined Cambodia, Madagascar, and Mauritania in eliminating Maternal and neonatal tetanus

Today one in every 5 children worldwide are still missing routine Immunization for preventable disease.

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GVAP

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SummaryImmunization is a proven tool for controlling and eliminating life-threatening infectious diseases and is estimated to avert 2 and 3 million deaths each year.

18.7 million infants worldwide are still missing out on basic vaccine.

Global vaccination coverage is generally holding steady.

GOI is toiling hard in pushing full Immunization from 65% to 90% through Mission Indradhanush, strengthening ongoing Routine Immunization.

tOPV -bOPV switch is a milestone achieved in the course of polio eradication!!!!

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References1.Review Article Indian J Med Res 139, April 2014, pp 491-511, A brief

history of vaccines & vaccination in India Chandrakant Lahariya Formerly Department of Community Medicine, G.R. Medical College, Gwalior, India

2.http://www.who.int/immunization/en/

3.http://www.who.int/immunization/global_vaccine_action_plan/en/

4.Handbook for vaccine and cold chain Handlers 2nd edition India 2016, Immunization division/Ministry of Health and Family Welfare GOI.

5.www.shsbihar.org, Routine Immunization micro planning system version 3, {courtesy WHO, NPSP Khagaria Division}

6. Park's Textbook of PSM 23rd Edition/Epidemiology/National Health Programme

7. rchiips.org/nfhs,1,2,3,4

8.http://www.nhp.gov.in/1mission-indradhanush_pg43

Thank You!!!!

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http://www2a.cdc.gov/nip/kidstuff/newscheduler_le/

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