Initiatives to improve UIP including convergence with polio activities Dr. Pradeep Haldar 24 th Meeting of IEAG March, 2012

Presentation outline  Situation analysis and continued challenges  New initiatives and ongoing efforts to strengthen UIP in India  Way forward

Polio-free India and routine immunization Strengthening UIP is essential to maintain high levels of population immunity and maintain polio free status!!!

Proportion of Fully Immunized* Children (12-23 months) National Full Immunization Coverage (FIC) = 61 % Source: Coverage Evaluation Survey, 2009, UNICEF * Full Immunization Coverage is: BCG + 3 doses tOPV + 3 doses DPT + MCV

Data not available Below 5 % 5 % - 10 % >10 % - 25% >25 % Where are we missing the maximum number of children? 69% of partially and un-immunized children in 6 states:  Uttar Pradesh  Bihar  Madhya Pradesh,  Rajasthan  West Bengal  Jharkhand Source: CES 2009; Full immunization of children surveyed months

Immunization coverage varies significantly among different population categories Source: Coverage Evaluation Survey 2009, UNICEF

ANM vacancies: Bihar and Uttar Pradesh State Number of Sub- centres Number of ANM in Position ANM : Sub- Centre ratio Bihar State9,42215, HR Blocks6731, Uttar Pradesh State20,62120,658>1.0 HR Blocks1,7941, State Number of Sub- centres Number of SC without ANM % of Vacant SC Bihar State9,4221, HR Blocks Uttar Pradesh State20,6211, HR Blocks1, SC=Sub-centre; ANM=Auxilary Nurse Mid-wife Inspite of having at least one ANM per one SC, irrational deployment of ANMs results in vacant SCs The problem of vacant SC is more acute in HR blocks Data as of 12 February 2012

Vaccination status and reasons for incomplete immunization %Awareness & Information Gap %Operational Gap %AEFI Apprehension%Other Reasons % Data not available FIC Source: RI monitoring data Jan – Dec % of reasons provided for incomplete immunization are related to lack of awareness and information related to vaccination and apprehension related to AEFI

Mobilization by ASHAs and AWWs Source: RI session monitoring data, Jan-Dec 2012  Incentivised ASHA provided for each session  Between 37% - 56% of RI sessions are not mobilized by ASHA  Suboptimal convergence with ICDS  Unacceptably high % of RI session that are not supported by ASHA or AWW in UP and WB States with RI session monitoring High Risk Areas Number of sessions monitored Presence of ASHA Presence of AWW Neither ASHA nor AWW Bihar 4,23263 %73 %10 % Jharkhand 1,91861 %52 %6 % Uttar Pradesh 19,62347 %34 %39 % West Bengal %34 %41 %

Analysis of programme gaps  Planning and coordination: –Lack of quality RI micro-plans and PIPs in many districts, states –Weak inter-sectoral coordination among Health, ICDS and other ministerial departments  Data reporting and use: –Divergent coverage estimates – survey assessed and reported –Tracking children and drop-outs  IEC and communication for behavior change: –Inadequate social mobilization and demand generation for immunization  Human resource management  Vaccine management

Efforts to strengthen RI

: Year of intensification of UIP

Intensification of UIP: Prioritization of the states CategoryDPT3 coverageNames of the states Poor performing statesDPT3 coverage less than national average (NE states excluded) MP, UP, Bihar, Rajasthan, Jharkhand, Orissa, Gujarat, and Chhattisgarh Good and medium performing states DPT3 coverage more than national average (NE states excluded) Rest of the states North Eastern statesNot consideredAssam, Sikkim, Arunachal Pradesh, Manipur, Mizoram, Nagaland, Tripura, Meghalaya

Intensification of UIP Specific objectives:  Conduct Immunization Weeks in in NE states, UP, Bihar, MP, Rajasthan, Gujarat and Jharkhand  Strengthen RI in identified 239 districts (< 50% FIC, DLHS3) through detailed robust microplanning  Inclusion of EPRP identification and prioritization of high risk areas including urban zones

Convergence with EPRP and improving UIP microplans  Inclusion of migrant and high risk sites in UIP microplans as identified by EPRPs  Polio and RI microplan convergence: –Uttar Pradesh  22,758 villages/urban areas identified that were not part of UIP microplan  Periodic review: –Bihar  distribution of outreach sessions assessed; 8,000 brick-kilns and 5,000 nomadic sites identified and to be added Migrant sites HR sites in settled populations

Harmonization of Polio SIA & RI Microplan District: Bulandshahr, Uttar Pradesh Every polio SIA team carries this plan and must inform parents of when and where RI sessions are held SIA component RI component Village visited by SIA team

Cold chain and vaccine management  Human Resources: –Recruitment of additional HR for vaccine and logistics management –Development of training material (modules, film) and facilitation of training of cold chain handlers & technicians  Infrastructure strengthening: –Procurement of additional cold rooms, solar and DF/ ILRs as per recommendations of National Cold Chain Assessment –Strengthening of SHTO Pune training center –Establishment of national cold chain and vaccine management resource center in Delhi  Development of National Cold chain MIS: (  Vaccine Wastage Assessment carried out in 5 states: –Indicates vaccine wastage range from 34% (DPT) to 63% (BCG) at session site

Intensification of UIP: Strategies Immunization Weeks:  4 rounds of Immunization Weeks planned in low performing areas to rapidly improve coverage  5 Northeastern states have already begun: –Arunachal Pradesh (7 districts), Manipur, Meghalaya, Nagaland and Tripura –Assam, Sikkim and Mizoram yet to start.  Rest of the states are expected to start from April 2012.

Immunization Weeks Summary feedback – 3 states  Meghalaya: –2 rounds conducted: (1) Jan 2012; (2) 27 Feb - 3 March 2012 –Coverage reports for first round are still awaited –Community mobilization and due-listing of beneficiaries needs to be improved  Manipur: –First round conducted 30 Jan – 4 Feb 2012 –Coverage reports still awaited  Nagaland: –First round held 23 – 31 Jan 2012 –Community mobilization and due-listing of beneficiaries needs to be improved

Intensification of UIP: Strategies  Teeka Express –Piloted in selected low coverage districts in 2012 –To provide a branded vaccine delivery van to cold chain point –In underserved populations, tribal, hard to reach areas, LWE areas, urban and peri- urban areas  Communication strategy –To be rolled out in Q2, 2012 –Awareness about session site (visibility) –Branding of immunization –Advocacy with media and partners  HR strengthening –Technical support unit (TSU) be established at national/ state level in accordance with HR assessment report –Detailed guidelines under development

RI session and community monitoring  In 2011, more than 13,000 session sites and 100,000 children monitored per month in priority states of Bihar, UP and Jharkhand  2 new states added – Karnataka and West Bengal  Rajasthan and Punjab monitoring RI sessions however not entering and analyzing data  All other states should initiate RI session and community monitoring on a priority basis

Web-based mother and child tracking

Conclusion  Strengthening UIP and immunization coverage is a priority and requires engagement of all stake holder at the highest level  Many challenges remain related to programme access and utilization  The intensification of UIP ( ) and activities related to EPRP for polio are synergistic and need appropriate coordination

Questions for IEAG  What are the key lessons from polio eradication efforts in India that can be used to assist with improving UIP?  What are the implications of the polio endgame requirements on UIP in India?

Thank You

Policy level initiatives  Developed National Vaccine Policy in 2011  New draft Multiyear Plan (cMYP) ready for endorsement  Decentralized and flexible funding as per state Project Implementation Plans (PIP) under NRHM –District/block specific plans for hard to reach areas (inaccessible, tribal and urban) are reflected in PIPs –Funds for Addl. Vaccinators, alternate vaccine delivery, ASHA  Human resource assessment at national and state level for UIP (IIM Ahmedabad 2010)

Introduction of new vaccines  Hepatitis B vaccine expanded to all States and UTs  Hib containing pentavalent vaccine –Introduced Kerala and TN in December 2011 –Proposed expansion to 6 additional states in 2012  Measles 2nd dose in RI –Given with 1st DPT booster – States have introduced

Source: Based on target population available with GoI * Provisional data as of 1 st week of March 2012; 7 districts have not yet started the campaign ** Phase 3 will be conducted during Fiscal Year Phase Number of State Number of District Target Population (9 m - 10 yrs) % Coverage Phase ,845, Phase ,931, * Phase 3**15157~ 73,000,000 Introduction of second dose measles containing vaccine (MCV2) MCV2 through UIP is being introduced 6 months following catch-up campaigns

Implementation of effective vaccine preventable disease surveillance  Expansion of laboratory supported measles surveillance to 11 states is providing key epidemiologic data and evidence of impact of MCV2 introduction activities  WHO NPSP to support the establishment of best practices for VPD surveillance, outbreak and laboratory support in one sentinel site of 5 high burden priority states

Maternal and Neonatal Tetanus Elimination  Since 2003, a total of 15 states and UTs validated for MNT Elimination  4 more states (Orissa, Uttarakhand, Delhi and Mizoram) planned in 2012 Validated for MNTE

Reasons for incomplete immunization: RI monitoring data, Jan – Dec 2011 Source: RI community monitoring; (number of children months of age) *WB data for May to December’11 only **Karnataka data for April to December’11 only 50-75% of reasons provided for incomplete immunization are related to lack of awareness and information related to vaccination and apprehension related to AEFI