1. Immunization Update DIO/M&E Officers Sensitization & review mtg 18 Aug 2010 1 Dr OR Goldie Dr Balwinder Singh, DHS Office, Punjab

2. Presentation outline EPI Coverage: Where does Punjab stand ? Efforts to strengthen RI Measles second dose Way forward 2

3. High priority districts in Punjab Based on composite indicators (CBR, MMR, IMR socio economic & demographic progress) GoI has identified 264 districts in the country to focus & improve 4/20 districts in Punjab declared high priority – Nawan shahar – Mukatsar – Jalandhar – Faridkot NRHM asked to tilt PIP for any interventions (if reqd) Focused monitoring from state task force is planned.

4. RI coverage Understanding who and where the unvaccinated children are located

5. What do we mean by a fully immunized child ?? A child that has received BCG + 3 doses of DPT +3 doses of OPV +3 doses of Hep B +Measles before completion of one year of age. 5 All the above doses of vaccine before the first birthday of the child

6. DLHS III Punjab : Full Immunization coverage DLHS-III (2007-08) 6

7. 7 Fully Immunization status DLHS 3 (2007-2008) (most latest evaluated coverage available)

8. DLHS III : BCG Coverage DLHS-III (2007-08) 8 We do start the program well…

9. DLHS3- DROP-OUT (BCG-DPT3 Punjab (distts) > 30% 20% to 30% 10% to 20% < 10% Slide Source : Punjab state ppt SEPIO mtg 7-9 June 2010 Number of BCG-DPT3 Dropout Children (10%) 46350 9

10. DLHS III : Measles Coverage Punjab (distts) DLHS-III (2007-08) 10 A few districts pull down State immunization coverage…

11. 11 BCG to measles coverage drop DLHS 3 (2007-2008)

12. DLHS III Punjab : DPT-3 Coverage DLHS-III (2007-08) 12

13. AFP Cases (Age 6 Mths – 5 Yrs) Status of OPV Dose : Polio SIAs - 2009 N=218N=55 Non- Migrant Migrant Punjab Slide Source : NPSP Data (from CIF) 13

14. AFP Cases (Age 6 Mths – 5 Yrs) Status of OPV doses: Routine Immunization – 2009 data as on 26th June, 2010 (N=52)(N=215) Slide Source : NPSP Data (from CIF) Non- Migrant Migrant PUNJAB Special RI strategy required for migrant populations 14

15. Possible reasons for low access Not reaching the community ( Weak microplans) – Immunization session site not in the microplan – Session site in the microplan but poor service delivery (services not provided by the vaccinator – leave, post vacant, not going to the site) Hard to reach areas – not being reached Over reported data. Inadequate data analysis & feedback Weak monitoring support by district officials. 15 DIO / M&E review mtg,18 Aug 2010

16. NRHM Initiatives for RI service delivery  Strengthening of monitoring  AEFI surveillance  Strengthening program management capacity  Introduction of Auto Disabled syringes  Introduction of under utilized and new vaccines. 16 DIO / M&E review mtg,18 Aug 2010

17. REPORTED COVERAGE 2009-10( %) BCG 471650101.8 DPT1 468901101.2 DPT3 45504998.2 OPV1 467706100.9 OPV3 45536898.2 Hep B 1 440960 Hep B 3 42015 Measles 434181 93.7 Full Immunized 434181 93.7 DPT booster (16-24 mths) 37567381 17 DIO / M&E review mtg,18 Aug 2010

18. Efforts to strengthen routine immunization DIO / M&E review mtg,18 Aug 2010

19. As on 1 June10 < 30% 50 % -80% 30 % - 50% > 80% Not Started Immunization Training of Medical Officers Immunization Handbook, Fac. Guide and Training kits developed in 2008. TOTs conducted for 1500 trainers from all states during 2009. MO-Training started and ~11500 out of 62000 (18%) MOs trained. Slow / No progress in 22 states. Monitoring needs to be strengthened. PunjabPunjab 19 DIO / M&E review mtg,18 Aug 2010

20. As on 1 June 10 < 30% 50 % - 80 % > 80 % 30% - 50 % Completed Immunization training of Health workers Immunization Handbook and Facilitator Guide developed in 2006 ToTs held in 2007 HW Trainings started in 2007-08 ~175,000 out of 220,000 (79%) HWs trained. Performance Assessment of HW- Training conducted in 40 districts across 7 states during 2009. P u nj a b 20 DIO / M&E review mtg,18 Aug 2010 DistrictTraining target 2009-10 Total trained 2009-10 % Trained 2009-10 Funds utilized 2009-10 Fatehgarh Sahib 92879572% Mohali1241199685% Patiala2972799489%

21. Immunization trg :Scenario-2009-10 TRAININGS StaffTraining LoadTrainedPercentage Regular ANM 246148519.7 Contractual ANM 756Nil- Health Assistant (M) 1800Nil- LHV 650Nil- Other Staff Nil - Medical officers 82477393.8 Cold Chain Handler 13710878.8 Cold Chain Technician 14 100 Slide Source : Punjab state ppt SEPIO mtg 7-9 June 2010 21 DIO / M&E review mtg,18 Aug 2010

22. Microplanning and child tracking Improve RI micro-planning by using existing polio micro-plans to: Strengthen linkages with pulse polio teams: – Polio microplan to include RI session site information (where, when and by whom) – Teams to share information during H-t-H vaccination Pulse polio vaccinator training to include key messages on routine immunization Use of pulse polio newborn information (if being collected) to follow up on RI doses Name based child tracking 22

23. Improved monitoring to identify programme gaps GoI RI monitoring system revised in 2009 Started in in Bihar, Jharkhand and UP Shortly starting in Rajasthan, Maharashtra, N Delhi, MP, Gujarat. Data outputs – Session site: Availability of manpower and logistics Reasons for session not held Safe injection practices and waste disposal – Household (community) monitoring RI coverage and gaps in community Reasons for left-outs and drop-outs 23

24. RI monitoring: Immunization status of monitored children - UP October – December 2009 Reason for children not being fully immunized Fully Immunized Partially Immunized No Immunization n=children 12 to 23 months of age n=1,956 n=4,365 24

25. Introduction of Measles 2 nd Dose into RI Pneumonia and Diarrhea Corneal scarring, causing blindness Encephalitis 25

26. Nationwide second measles opportunity introduced (46) No second opportunity introduced (1) Measles Mortality Reduction 47 UNICEF / WHO Priority Countries December, 2008 26 DIO / M&E review mtg,18 Aug 2010

27. Secretary health letter Punjab- 2 nd dose Measles

28. 2 nd dose Of Measles Measles Mortality Reduction Strategies for India National Technical Advisory Group on Immunization (NTAGI) has recommended States with MCV1 coverage <80%: Second opportunity through measles catch-up campaigns in 9 mo-10 yrs age group States with MCV1 coverage >80% second dose (MCV2) through routine immunization Applying the cut-off of 80% MCV1 evaluated coverage (DLHS-3) 14 states which qualify for catch-up campaign 21 states which qualify for MCV2 through UIP – 4 States/UTs viz. Delhi, Goa, Sikkim & Poducherry already introduced 2nd dose in RI 28 DIO / M&E review mtg,18 Aug 2010

29. 2nd opportunity of Measles vaccine: State specific Delivery strategies 2nd Dose of RI (>80%) Catch-up Campaigns (<80%) * DLHS3 data Not Available States <90% Measles Coverage Punjab 29 DIO / M&E review mtg,18 Aug 2010

30. Requirements for Measles Control with 2 nd dose Measles in RI Achieve 1 st dose coverage (at 9-12 months) of >90- 95% Also achieve 2 nd dose coverage (at 16-24 months) of >90-95% Sustain high coverage Backed by good measles surveillance system 30 DIO / M&E review mtg,18 Aug 2010

31. DPT Booster coverage in States proposed for RI Source: CES, 2006 Punjab 31 DIO / M&E review mtg,18 Aug 2010

32. Factors Affecting Introduction of Measles 2nd Dose The key factor is a well functioning Routine Immunization Programme. Some of factors for low coverage are: – Inadequate access- Lack of outreach services – High Dropout- Weak tracking system – Human resources- Poorly trained or untrained staff – Lack of supervision – Poor monitoring and reporting systems – Weak community demand Times of India 32 DIO / M&E review mtg,18 Aug 2010

33. Challenges Managing competing priorities Linking polio efforts with RI activities – Specific RI messages by vaccinators during polio SIAs – Use of newborn tracking data Reaching unreached in urban and peri-urban areas Strengthen inter-agency coordination Improving the reporting and utilization of RI data Improving social mobilization and demand generation for immunization 33 DIO / M&E review mtg,18 Aug 2010

34. Way forward from here…. Microplans Update fixed day, fixed site microplans (Mamta Diwas) Wed/ Sat to be immunization day Update and operationalize RI micro-plans. Monitor fund utilization / program performance Scale-up revised RI session and house-to-house monitoring targeting high risk areas Increase district involvement in RI monitoring & review mech. Before start of 2 nd dose Measles - Improve DPT booster (16-24 mths) HW and data handlers trainings Data handlers proposed for Sept-Oct 2010. Distt Cold chain store incharge training proposed Sept 2010.

35. Issues in Pulse Polio Expenditure Report 2008-09 DistrictsRemarks Amritsar Nov 08, Dec 08, Jan 09 and Mar 09 round – Expenditure Reports not received Ferozepur Jul 08, Nov 08, Dec 08, Jan 09 and Mar 09 round – Reports not received Gurdaspur Nov 08, Dec 08, Jan 09 and Mar 09 (Fax not in a position to read & hard copy not received Jalandhar Jul 08, Dec 08, Jan 09 and Mar 09 round – Reports not received Sangrur Jul 08, Oct 08, Nov 08, Dec 08, Jan 09 and Mar 09 round – Reports not received Amritsar, Barnala, Ferozepur, Gurdaspur, Hoshiarpur, Jalandhar, Kapurthala, Ludhiana, Mansa, Moga, Mohali, Patiala, Ropar, SBS Nagar, Sangrur & Tarn Taran Expenditure report received but does not match with Audit Report GOI seeks clarification GOI is repeatedly asking Punjab to reconcile and produce desired information

36. List of EPI Reports to be forwarded from District S. No.Name of ReportTime Line 1EPI Performance Report (HMIS)Upto 10th Every month 2Polio Expenditure Report Immediately after completion of Polio campaign 3Immunization Expediture Report Annexure 6Upto 10th Every month 4 Revised Tour Notes (On Govt. of India Monitoring forms) – PHC, session site and village visit forms (As per Annexure 1, 2 & 3 PIP guidelines) Upto 5th of every month 5 Evaluation Reports MPHW/ ANMs/ Urban Slum (HMIS) Upto 10th Every month 6 Cold Chain Sickness/ Status Report (Existing Proforma) Upto 10th Every month 7 Refrigerator Mechanic Observation report (Proforma in folder) Signed by Refregrator Mech & Forwarded by DIO) Upto 5th of every month 8 Refrigerator Mechanic Observation report (Proforma in folder) Signed by Refregrator Mech & Forwarded by DIO) Upto 5th of every month 9 PIP Fund Utilization Indicators form

37. Thank you for your time !! 37 DIO / M&E review mtg,18 Aug 2010

38. Additional slides