EPI and MMS Expanded Programme on Immunisation, report, assignment

EPI program is to reduce child morbidity, mortality, and disability associated with vaccine-preventable diseases, MMS as MiniMicroSpheres with Delivery of Services, its Indicators, analysis, and report of achievements.

Expanded Programme on Immunisation

Background:

The National Immunisation Programme (NIP) is a high priority program (P1) of the Government of Nepal. Immunization is considered as one of the most cost-effective health interventions. Effective implementation of the Immunization program is considered to contribute directly to the reduction of infant, child morbidity and mortality and ultimately will contribute to achieving millennium development goal.

Vaccine-preventable diseases (VPDs) are routinely reported through the HMIS and outbreak response complemented by active integrated surveillance of AFP with the support of Immunization Preventable Diseases/WHO. This includes surveillance of Measles, NT and Japanese Encephalitis.

The National immunization program covers all the 75 districts of the country. It is striving hard to have uniform high coverage in all the districts and sustain it (i.e. at least 90 percent for BCG, OPV3, DPT-Hepatitis B3, and measles vaccine in children under one year of age and 80 percent for TT2+ in pregnant women). There are still pockets of low coverage VDCs and districts. Due to weak immunization structure coverage is low in most of the municipalities.

1.1 GOAL

The overall goal of the EPI program is to reduce child morbidity, mortality, and disability associated with vaccine-preventable diseases.

1.2 Objectives

1.2.1 Achieve and sustain immunization coverage of >90 percent in National level with >80 percent in all districts and below for all antigens.

1.2.2 Maintain a polio-free status.

1.2.3 Eliminate maternal and neonatal tetanus by 2005 and sustain the status.

1.2.4 Reduce measles mortality by 50 percent from 2003 levels and sustain the achievement.

1.2.5 Integrate the surveillance of additional VPDs into the existing surveillance system.

1.2.6 Strengthen and sustain the vaccine and logistics management system.

1.2.7 Introduce new and underused vaccines into the National Immunization Program on the basis of disease burden.

1.3 Targets

1.3.1 All infants (under one year – 12 months) for BCG, DPT-HepB, OPV, and Measles vaccines

1.3.2 All pregnant women for TT2+ vaccine

1.3.3 All 1, 2 and 3-grade students for School Immunization Programme.

The table below provides a schedule for immunizations at different ages.

Immunization Schedule

Immunization Schedule
Type of Vaccine	Number of Doses	Recommended Age
BCG	1	At birth or on the first contact
OPV	3	6, 10, and 14 weeks of age
DPT – Hep B	3	6, 10, and 14 weeks of age
Measles	1	9 months of age
TT	2	Pregnant women
JE	1	Under discussion

NIP under Child Health Division has a lead role in all immunization-related activities at the National level including coordinated actions with other Divisions of the DoHS and all other partners. The Regional Health Directorate (RHD) acts as a facilitator between the Central and the District levels. It is the responsibility of the D(P)HO to ensure that a successful immunization program is implemented at the district level. Primary Health Centers (PHCs), Health Posts (HPs), and Sub-Health Posts (SHPs) implement immunization programs in their Village Development Committees (VDCs)

Delivery of Services

NIP delivers the Immunization services through Routine and Supplemental Immunization Programs

1. Routine Immunization

The National Immunization Program delivers routine immunization through fixed health facilities, outreach programs, and mobile teams.

• Fixed facilities: Immunization services are provided at hospitals, primary healthcare centers, health posts, and sub-health posts. Some health facilities equipped with refrigerators provide immunizations daily and some provide weekly.
• Outreach services: Provide access to the people who have difficulty in reaching health facilities due to long distance to travel, three to five immunization sessions a month are conducted at several locations in each VDC. The frequency of outreach services is based on village setting, population density, and seasonal variations. These sessions account for more than 90 percent of immunization coverage.
• Mobile teams: Geographical conditions such as lack of roads and bridges hamper immunization in remote areas. Due to vacant or frequent absenteeism of health worker in remote areas, there is poor access of target population to routine immunization. These areas are identified and appropriate strategy are developed during micro-planning. To address these issues, at least four visits to identified hard-to-reach areas by vaccinators are mandatory through mobile teams to immunize targeted population.

Though the immunization service is mainly delivered through government health network, there is an increasing trend of immunization service delivery through the private sector. This is due to the realization of Public-Private Partnership in Health Sector Reform Strategies of government. In the private sector, immunization services are delivered through private clinics, hospitals, nursing homes as well as NGOs. Government supplies all vaccines and immunization related logistics to these private institutions free of cost. All vaccine under the National Immunization Program are given free of cost or there is no cost-sharing / recovery.

1.4 Indicators

The indicators used for National Immunization program monitoring are as follows:

Main Indicators	Numerator and Denominator
1 Immunization coverage	Number of children under one year of age immunized with a specific dose of antigen
Total estimated number of children under one year of age
2 Immunization coverage for TT2+ vaccine	Number of pregnant women immunized with TT2+
Total estimated number of pregnant women
3 DPT-Hep-B drop-out rates (DPT-HepB1 vs. DPT-HepB3)	Number of children received DPT-HepB1 – Number of children received DPT-HepB3
Number of children received DPT-HepB1
5 Measles drop-out rates (BCG vs. Measles vaccine)	Number of children received BCG – Number of children received Measles vaccine
Number of children received BCG
6 Vaccine Wastage Rate	Number of vaccine doses received – Number of vaccine doses used
Number of vaccine doses received
7 Immunization Session	Number of Immunization Session conducted in a year
Number of total immunization session planed in a year
8 AFP Surveillance	At least 2 AFP cases in 100,000 population per year
9. NT Surveillance	No or less than one NT case in 1,000 live birth per year per district

For the purpose of monitoring of the EPI activities wastage rate and morbidity due to vaccine-preventable diseases is also taken into consideration.

1.5 Strategies

The strategies to achieve the above objectives are:

1.5.1 Provide immunization services through all health facility, EPI outreach sessions; Mobile Clinics

1.5.2 Conduct supplemental immunization activities for:

– Polio eradication

– Measles and JE control

1.5.3 Expansion of School Immunization Program to sustain MNT elimination

1.5.4 Strengthen monitoring system of Immunization Program:

• VDCs wise data analysis, categorization, and prioritization for action at districts level
• Use of immunization monitoring chart
• Review of Immunization Program at a different level and feedback

1.5.5 Conduct districts level Micro-planning

1.5.6 Strengthen and expand integrated surveillance of VPDs built on AFP Surveillance (AFP, Measles, Neonatal Tetanus and Japanese encephalitis) and initiation of the study of the disease burden of other vaccine-preventable diseases like Hib and Rubella.

1.5.7 Control outbreak of VPDs through appropriate interventions;

1.5.8 Increase and promote public awareness and demand through social mobilization for immunization services and IEC/BCC interventions.

1.5.9 Strengthening of cold chain capacity in all 75 districts and ensure their functioning

1.5.10 Training to Health Workers (Mid Level Manager and Cold Chain Assistant)

1.5.11 Strengthening and expansion of AEFI surveillance

1.5.12 Strengthen supportive supervision

2 ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES

2.1 Major Activities Carried Out in FY 2062/63 (2005/2006)

The following were the major activities carried out during FY 2062/63

2.1.1 Conduction of immunization services through three to five outreach immunization sessions per Village Development Committee (VDC) per month;

2.1.2 Continuation of immunization services through health facility-based clinics located at the hospitals, PHCCs, HPs and SHPs;

2.1.3 Provided training on immunization for various levels of health workers (Mid Level Manager and Cold Chain Assistant training).

2.1.4 Expanded and continued integrated VPDs Surveillance (AFP, Measles, and NT) including JE Surveillance.

2.1.5 Initiated Hib diseases burden study

2.1.6 Conducted Responsive Mopping-up activity in 5 Terai districts of Nepal

2.1.7 Conducted Sub-National Immunization Days (SNID) for Polio Eradication Initiatives in 21 high-risk districts of Nepal (bordering with India).

2.1.8 Established Polio static booths (131 booths) on bordering districts with Bihar and UP of India in response to the supplementary immunization activities.

2.1.9 Completed districts micro-planning in 20 districts

2.1.10 Conducted performance review of immunization program at a different level

2.1.11 Developed a multi-year plan of action (2007-2011)

2.1.12 Implemented of School Immunization Activities in 8 districts

2.1.13 Developed and print Immunization Atlas of Nepal.

2.1.14 Revised, Printed and Distributed Immunization Monitoring Chart

2.1.15 Completed JE Vaccination Campaign in 6 hyperendemic districts

2.1.16 Districts NIP performance was verified through Data Quality Self Assessment in 10 districts

2.2 TARGET vs. ACHIEVEMENT, FY 2062/63 (2005/2006)

During FY 2062/63, the EPI target was to cover 90 percent of under-one-year children. However, the achievement shows that the BCG coverage was 96.1 percent, DPT3 93.0 percent, OPV3 91.9 percent and Measles 87.5 percent. Overall coverage for all the vaccines increased in this FY compared to previous fiscal year 2061/62.

SN	Activities	Unit	Targets	Achievement	Target vs. Achievement (percent)
1	BCG vaccination	Infants	742,164	713,086	96.1
2	DPT1 vaccination	Infants	742,164	690,496	93.0
3	DPT2 vaccination	Infants	742,164	681,006	91.8
4	DPT3 vaccination	Infants	742,164	690,298	93.0
5	Hepatitis B I vaccination	Infants	742,164	655,774	88.4
6	Hepatitis B II vaccination	Infants	742,164	653,122	88.0
7	Hepatitis B III vaccination	Infants	742,164	661,584	89.1
8	Polio1 vaccination	Infants	742,164	684,053	92.2
9	Polio2 vaccination	Infants	742,164	675,059	91.0
10	Polio3 vaccination	Infants	742,164	682,401	91.9
11	Measles vaccination	Infants	742,164	649,390	87.5
12	TT2 vaccination	Pregnant women	941,890	482,841	51.3
13	Polio Responsive Mopping-up activity €“ I Round	Under 5 yrs Children	475,617	471,460	99.1
14	Polio Responsive Mopping-up activity €“ II Round	Under 5 yrs Children	475,617	476,586	100.2
15	Polio Responsive Mopping-up activity €“ III Round	Under 5 yrs Children	475,617	482,922	101.5
16	Polio SNID in 15 Districts €“ I Round	Under 5 yrs Children	1,796,760	1,756,422	97.8
17	Polio SNID in 15 Districts €“ II Round	Under 5 yrs Children	1,796,760	1,770,453	98.5
18	Polio SNID in 6 Districts €“ I Round	Under 5 yrs Children	597,683	554,452	92.8
19	Polio SNID in 6 Districts €“ II Round	Under 5 yrs Children	597,683	546,951	91.5

Source: HMIS/MD and EPI/CHD, DoHS

Analysis of the reports from all 75 districts of the country for FY 2062/63 shows that overall coverage level for BCG vaccination is 96.1 percent, measles vaccination is 87.5 percent, DPT3 93.0 percent, OPV3 91.9 percent and Tetanus Toxoid (TT2) is 51.3 percent. However, coverage for all antigens are not uniform among the districts and within the VDCs of the districts, some of the districts achieving more than 100 percent coverage, and others are far behind.

2.3 ANALYSIS OF SERVICE STATISTICS

The table 2a.1 and figure 2a.1 present the annual immunization coverage of BCG, DPT, OPV, and measles vaccine in Nepal from FY 2060/61 to 2062/63. The figures are expressed in percentage of the targeted population for each fiscal year. It has been observed that the coverage of all antigens increased in FY 2062/63 compared to FY 2061/62.

Table 2a.1 Annual Immunisation Coverage in Nepal, FY 2060/61 to 2062/63

Year	BCG	DPT3	OPV3	Measles
2060/61 2003/2004	96.3%	90.3%	90.2%	85.4%
2061/62 2004/2005	92.4%	80.0%	83.0%	79.3%
2062/63 2005/2006	96.1%	93.0%	91.9%	87.5%

Source: HMIS/MD, DoHS

Based on DPT3 coverage and DPT1 vs. DPT3 dropout rates, categorizations of the districts as per their performance are shown in the District Categorized table. Districts under category 4, 3 and 2 respectively are the most concerned for NIP to address their access and utilization problem. Activities carried out to address the problems were to revise immunization session through micro-planning, to trace missed children for successive doses, to mobilize FCHVs and involve community leaders. Districts under category 1 were continuously monitored for sustaining their achievements.

Table 2a.2 Immunisation Coverage (Percent), by Region, FY 2060/61 to 2062/63

Indicators	Year	Region	National Total
EDR	CDR	WDR	MWDR	FWDR
BCG (<1 year) Coverage	2060/61 2003/04	97.3	106.1	88.5	92.9	85.0	96.3
2061/62 2004/05	94.3	102.5	86.1	86.3	79.7	92.4
2062/63 2005/06	97.3	103.5	87.6	96.9	86.7	96.1
DPT3 (<1 year) Coverage	2060/61 2003/04	94.0	97.5	85.5	85.3	77.5	90.3
2061/62 2004/05	82.6	83.2	80.9	73.8	72.8	80.0
2062/63 2005/06	95.8	98.0	84.4	96.1	84.8	93.0
Polio3 (<1 year) Coverage	2060/61 2003/04	93.5	97.7	85.4	85.8	77.3	90.2
2061/62 2004/05	87.9	87.1	81.0	77.2	73.4	83.0
2062/63 2005/06	94.5	96.1	84.4	95.3	84.5	91.9
Measles (<1 year) Coverage	2060/61 2003/04	87.7	89.9	81.5	84.5	76.4	85.4
2061/62 2004/05	84.4	81.2	77.4	76.3	71.2	79.3
2062/63 2005/06	89.6	91.1	80.0	91.6	81.1	87.5
TT2 Coverage (Pregnant women)	2060/61 2003/04	45.8	44.2	40.0	36.8	39.9	42.3
2061/62 2004/05	50.9	45.0	43.1	41.0	39.1	44.9
2062/63 2004/05	56.4	49.4	49.2	52.3	48.1	51.3

Source: HMIS/MD, DoHS

Figure 2a.2 shows the trend in coverage of Measles vaccine for last 3 FYs. The coverage has increased in all the regions in FY 2062/63 with highest coverage (91.6 percent) being in MWDR and lowest (80.0 percent) in WDR. The national coverage of Measles vaccination is increased by 8.2 percent in FY 2062/63 as compared to FY 2061/62.

Figure 2a.4 shows the DPT1 vs. DPT3 dropout rate by region. The drop out rate stands between -2.1 to 1.6 percent in FY 2062/63 with the highest rate in CDR (1.6 percent) and lowest in EDR (-2.1 percent). The national figure for the DPT1 vs DPT3 dropout rate stands at 0.0 percent in the FY 2062/63, which is a significant achievement of the NIP program of Nepal. As shown in figure 2a.3, the national coverage for TT2 vaccination in pregnant women was 44.9 percent in 2061/62. However, in FY 2062/63 the TT2 coverage increased by 6.4 percent points at the National level (51.3 percent). The percentage of pregnant women immunized with TT2 vaccine increased in all the region in the FY 2062/63. The coverage was highest in EDR (56.4 percent) and lowest in FWDR (48.1 percent).

The Vaccine Wastage Rate (figure 2a.6) of all antigens has been observed as follows in FY 2062/63: BCG 74.8 percent, DPT 21.3 percent, Polio 24.7 percent and Measles 59.4 percent. The wastage rate of vaccines, especially BCG & Measles compared to normally accepted rate is still a challenge. Figure 2a.5 shows the BCG vs. Measles dropout rate. It has decreased from 14.2 percent in FY 2061/62 to 8.9 percent in FY 2062/63 at National level. The highest dropout rate was observed in the CDR with 12.0 percent and lowest in MWDR 5.5 percent. There is a trend of improvement in the dropout rate in general.

According to figure 2a.7, the lowest number of BCG vaccination was observed during the month of Chaitra. The month-wise BCG vaccination trend is seen to be considerably better in FY 2062/63 compared to FY 2060/61 and FY 2061/62.

2.4.1 National Immunisation Days (NIDs) for Polio Eradication2.4 SUPPLEMENTARY IMMunization activities

To eradicate poliomyelitis, EPI continued to implement a program of "Intensified National Immunization Days" (INID) in two rounds from 2053/54 to FY 2060/61. In the first year NIDs were conducted successfully in two rounds in 2053/54 (on 6 December 1996 and 17 January 1997). Consecutively every year two rounds of NIDs were being conducted. Besides, Sub-National Immunization Days, Pre-emptive Mopping-up and Responsive Mopping-up Activities in high-risk districts mainly districts bordering with India and Kathmandu Valley were also conducted. Intensified National Immunisation Days were not implemented during FY 2061/62 and 2062/63.

Nepal has not detected any poliomyelitis case caused by wild poliovirus for the last four years (the year 2001 to 2004) most probably because of high NID coverage of around 100 percent (see above figures). But in the FY 2061/62, four polio cases were detected in Sarlahi and Rautahat district which were imported from India one polio case was detected in 2062/2063 in Dailekh district of Nepal. Acute Flaccid Paralysis (AFP) Surveillance, is becoming a major activity in the eradication of polio from the country. Nepal has expanded active surveillance of polio to neonatal tetanus and measles from FY 2060/61 through the AFP-surveillance site and in FY 2061/62 JE surveillance was also integrated with VPDs surveillance.

2.4.2 Measles Campaign to Control Measles in Nepal

It was estimated that every year some 150,000 children are infected with measles and some 2,700 die due to its consequences. To prevent this huge amount of deaths and measles cases, Nepal conducted a successful campaign throughout the Kingdom aiming to reduce 50 percent of child mortality due to measles complications. The success of this campaign created history in the field of public health by immunizing about 10 million children. The Measles Campaign was conducted in a phase-wise manner and the coverage of measles through the campaign was very satisfactory in the year 2004 and 2005. Good social mobilization, active local participation, and assistance from various partner agencies contributed to the success of NIDs, Measles campaign and MNTE activities. The result of this campaign is very encouraging in terms of reduction of measles outbreaks and children affected. However, to sustain this status is a challenge and to overcome this situation, initiatives like increasing coverage above and around 80 percent be reached through routine immunization strategies. Hence, RED strategies have been incorporated in the multi-year plan of action 2007-2011, which clearly states the activity to strengthen routine immunization.

Table Showing Effect of Measles Campaign:

Indicators	2004	2005	2006
Measles outbreaks (Lab confirmed)	138	1
Children affected	6,050	12

Note: Data as of 05 December 2005 (through active surveillance) Source: WHO/IPD

2.5 INTRODUCTION OF HEPATITIS B VACCINE

Introduction of Hepatitis B in the routine immunization program was done in all 75 districts by FY 2061/62. From the FY 2062/63 DPT-HepB (Combo Vaccine) vaccine has replaced the DPT vaccine in all Districts of Nepal.

3 PROBLEMS/CONSTRAINTS AND ACTIONS TO BE TAKEN

Problems/Constraints	Action was taken	Responsibility
Denominator problem	Local Health facility will generate their denominator using local resources like FCHVs and compare with given denominator. The district will validate the denominator of each health facility	HMIS, CHD, DHO and local health facility
Some of the newly supplied freezes and unfreezes to districts and sub-center are not functioning	LMD, RMS with the assistance of CHD and partners will assess and fix the problem of freezes.	LMD/CHD
The problem for regular cold chain maintenance No trained manpower for repairing the nonfunctioning cold chain equipment at regional/ District level No contingency plan for cold chain	The technician at center, region, and CCA of the district should be trained for general maintenance of freezes. Preventive Maintenance Plan for the regular repair of cold chain equipment is prepared Manual for the repair of €œavailable freezes" be prepared and placed to DHO. Contingency Plan for cold chain management is prepared at Central, Regional and District cold room.	CHD/ LMD/DHO
Delayed procurement of vaccine Irregular and short supply vaccine	Vaccine forecasting and procurement should be done timely. A standard POA will be developed and adopted for timely procurement of vaccines to avert shortfall of the vaccine. All level stores should have clear vaccine requirement and distribution plan and must ensure its implementation.	LMD/CHD
Some of the VHWs are old and disable, cannot conduct the EPI session.	Districts should manage alternatives in the local context (MCHW/ VHW whoever is in place could run immunization) EPI session at health facility level should be conducted by health manpower available in HF (HFI, AHW, ANM, VHW, MCHW)	CHD/ DHO and Health facility
Immunization in municipalities is weak No sanctioned post of VHW/MCHW at Municipality. No organized immunization service delivery structure. CHD and local development ministry will find out means to develop a model of immunization services of municipalities and will adopt timely. Develop a strategy to set up urban EPI clinics A detailed micro-planning involving municipalities, district health office, and all NGOs/INGOs should be conducted Districts can better utilize vaccinators through local NGOs INGOs for local management.		MoHP/ CHD/LMD.
Coverage to hard to reach the population	IDENTIFY THE UNDERSERVED or missed children Use maps Aim for greatest numbers of un / partially -immunized children, not just low coverage rates Prioritize Ensure micro-plans are in place and work plans are being implemented Follow up and supervision	The health facility, DHO/PHO/ CHD
There is no clear guideline to send HA, SAHW, Staff Nurse for EPI outreach clinics	As per strategic guideline, HA/ AHW / staff nurse/ANM should conduct immunization session in the absence of VHWs /MCHWs. This should be addressed during micro-planning at the local level and managed at the district level.	CHD/DoHS
Regular monitoring of immunization program using developed monitoring tools and quality information collection on immunization	Timely, report collection will be reinforced and follow up will be done on immunization coverage drop out and surveillance of VPDs EPI supervisors and health facility in-charge should monitor and supervise to verify the information and avoid inconsistency.	Health facility in-charge /District EPI Supervisors /DHO/DPHO
Injection safety in immunization And AEFI surveillance	Collection of injection sharp will be in safety boxes and disposal will be done by burning and buried at health facility level Low-cost incinerator construction at HF level will be encouraged below districts AEFI surveillance will be expanded from 31 sentinel sites to 51 sites. The health worker will be encouraged to report each and every AEFIs and investigate major one and use the result for improvement of the program	DHOs/ RHDs/ CHD
Social mobilization, community participation, and local ownership	District level and health facility level performance, weakness and strength should be shared with community, NGOs, INGOs and plan to work together to achieve the target	DHO and Local Health facility
Quality of review at a different level and micro-planning and data quality self-assessment	Review of access and utilization of immunization services at Centre, region, district and health facility level, comparing with RCS, LQAS and DQSA findings. Micro planning at district headquarters or at the health facility level	CHD/RHD, DHO and HF management committee.
Vaccine management at a different level is poor leading to irregularity in session conduction and increase in vaccine wastage	Appropriate vaccine and logistic requirement and distribution plan at each level and ensure its implementation	DHO/LMD/CHD
BCC activities to increase demand for immunization	Community mobilization Involvement School teacher and student Use of electronic media	NHEICC/ CHD
Weak supportive supervision	Planned supervision with checklist and follow-up	All levels
Training manuals need to be revised as per the present context	Adaptation of immunization in practice in Nepali Health worker manual and cold chain manual needs to be revised	CHD

4 TARGETS FOR FY 2063/64 (2006/2007)

S.N.	Activities	Unit	Annual Targets
1	Routine Immunisation activities aiming for higher coverage	Children <1 year	747,567
2	TT2+ Immunisation for all pregnant women	Pregnant women	961,241

Source: EPI/CHD, DoHS

Note: For detailed, district-specific data and analysis on this program/project, please refer to the relevant annexes in this document.