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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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