India's successful journey in immunization program

India's successful journey in immunization program

India's immunization program is one of the largest in the world in terms of quantities of vaccines used, numbers of beneficiaries, and the numbers of immunization sessions organized, the geographical spread and diversity of areas covered.

Delivering effective and safe vaccines through an efficient delivery system is one of the most cost-effective public health interventions. Immunization programs aim to reduce mortality and morbidity due to vaccine preventable diseases (VPDs). The Immunization Program was started in India in 1978 as Expanded Program on Immunization. This gained momentum in 1985 as Universal Immunization Program (UIP). It was implemented in a phased manner to cover all districts in the country by 1989-90.

Under the Immunization Program, vaccines are given to infants and pregnant women for controlling vaccine preventable diseases namely childhood tuberculosis, diphtheria, pertussis, poliomyelitis, measles and neonatal tetanus. Except polio vaccine, which is administered orally, all other vaccines are given as injections.

Significant achievement has been made under this program. At the beginning of the program in 1985-86, vaccine coverage level ranged between 29 percent of BCG and 41 percent for DPT. The household survey conducted in 2002-03 has indicated that the coverage levels in most of the districts have been declining with respect to district level coverage reported in the year 1998-99. The various antigens coverage for the year 2004-05 are i) BCG 99.9 percent ii) DPT 3rd dose 93 percent iii) Polio 3rd dose 94.2 percent iv) Measles 90.3 percent (annual report -2005-06, Department of Health and Family Welfare, Government of India).

Following the successful global eradication of smallpox in 1975 through effective vaccination programs and strengthened surveillance, the Expanded Program on Immunization (EPI) was launched in India in 1978 to control other VPDs. Initially, six diseases were selected: diphtheria, pertussis, tetanus, poliomyelitis, typhoid and childhood tuberculosis. The aim was to cover 80 percent of all infants. Subsequently, the program was universalised and renamed as Universal Immunization Program (UIP) in 1985. Measles vaccine was included in the program and typhoid vaccine was discontinued. The UIP was introduced in a phased manner from 1985 to cover all districts in the country by 1990, targeting all infants with the primary immunization schedule and all pregnant women with tetanus toxoid immunization.

UIP

The UIP envisages achieving and sustaining universal immunization coverage in infants with three doses of DPT and OPV and one dose each of measles vaccine and BCG, and, in pregnant women, with two primary doses or one booster dose of TT. The UIP also requires a reliable cold chain system for storing and transporting vaccines, and attaining self-sufficiency in the production of all required vaccines.

In 1992, the UIP became a part of the Child Survival and Safe Motherhood Program (CSSM), and in 1997, it became an important component of the Reproductive and Child Health Program (RCH). The cold chain system was strengthened and training programs were launched extensively throughout the country. Intensified polio eradication activities were started in 1995-96 under the Polio Eradication Program, beginning with National Immunization Days (NIDs) and active surveillance for Acute Flaccid Paralysis (AFP). The Polio Eradication Program was set up with the assistance of the National Polio Surveillance Project.

Routine immunization program

India's immunization program is one of the largest in the world in terms of quantities of vaccines used, numbers of beneficiaries, and the numbers of immunization sessions organized, the geographical spread and diversity of areas covered. Under the immunization program, six vaccines are used to protect children and pregnant mothers against tuberculosis, diphtheria, pertussis, polio, measles and tetanus. It is also proposed to include Hepatitis B vaccine in UIP in a phased manner.

For a complex and extensive program like immunization, an efficient management information system is necessary to get timely reports at the state and national levels. It is also equally important to provide feedback to the states and districts for undertaking management interventions. At present the program has to depend upon routine reports received as part of the reporting under the Reproductive and Child Health (RCH) program. This system provides feedback on coverage data only. Important information regarding the vaccines and cold chain logistics, which are high cost areas does not get captured in the present system and a lot of effort and time is required in getting the critical data on these issues for planning and forecasting requirements and monitoring the status of vaccine supply and availability. To address these issues now and to collect data from district/PHC level, a computer-based monitoring system (RIMS software) is under development for implementation throughout the country. A prototype of this software to assess practical applicability in the field has been developed.

The government has undertaken measures to strengthen the routine immunization program in the country. It has framed a multi-year strategic plan (2005-09) with definite sets of goals, strategies and indicators. "Monitoring immunization" is a major step under the newly launched National Rural Health Mission. Introduction of Auto Disable Syringes to encourage safe injection practices in the immunization sector, also forms part of the new initiatives.

The government has also increased its planned budget outlay for 2005-06 for routine immunization program from Rs 149.23 crore (actual) to Rs 507 crore. However, for Pulse Polio Immunization program, the government has still kept Rs 877 crore as against actual annual expenditure of Rs 924.83 crore in 2004-05, out of the total budget of Rs 6817.83 crore for 2004-05 and Rs 6453.49 crore for 2005-06 for the department of health and family welfare.

Although there is a difference in the estimates of coverage of different vaccines between the government and the world bodies, one has to agree to the fact that India has achieved tremendous success in implementing the immunization program in the last two decades.

India has to emphasize more on preventive, rather than curative solutions. And there is a need to strengthen our public health system, especially at the village level for more coverage and for the successful implementation of the National Immunization Program.

- See more at: http://www.biospectrumindia.com/biospecindia/news/157285/indias-successful-journey-immunization-program#sthash.vRz7NqeM.dpuf

Source-
http://www.biospectrumindia.com/biospecindia/news/157285/indias-successful-journey-immunization-program

Title: Inequalities in routine immunization coverage in primary care: a multi-level mixed methods study from three Indian states

Title: Inequalities in routine immunization coverage in primary care: a multi-level mixed methods
study from three Indian states
Swati Srivastava*
, Sakthivel Selvaraj, Preeti Kumar, Habib Hasan, Maulik Chokshi, Indranil
Mukhopadhyay, Pallav Bhatt, Ravi Kumar
*
Corresponding author
Public Health Foundation of India
ISID Campus, Plot No.4, Institutional Area
Vasant Kunj, New Delhi- 110070, India
Phone: +91-11-49566000 Ext 6055
Fax: +91-11-41648513
Mobile: +91-9015942985
Email: swati.srivastava@phfi.org

Background: Immunization is key to prevent vaccine-preventable disease yet almost half of Indian
children do not receive age-appropriate vaccinations. While individual and family level characteristics
related to immunization uptake have been explored extensively, areas needing investigation include
outreach services, vaccine supply and logistics, human resources issues and training, financing, and
service delivery.

Methods: We conducted an embedded multi-level mixed methods study exploring programmatic and
beneficiary-level constraints in immunization, to understand the roles these factors are playing in
immunization uptake. Methodological triangulation was conducted between a qualitative strand
consisting of data collected from multiple levels of health care providers and beneficiaries, and a
quantitative strand using structured questionnaires. The study was conducted in 11 districts of three
states (Uttar Pradesh, Rajasthan, and Himachal Pradesh) from September-November, 2012.

Results: Overall, vaccine supply was adequate. Mismatch in vaccine demand and supply, poor financial
allocation for supplies and cold chain maintenance, human resource constraints (shortages and poor
competencies), infrequent training and lack of monitoring and supervision, and inconsistent staff
incentives, was hampering progress. Urban areas had special requirements due to lack of infrastructure,
staff, and systematic mechanisms. Novel target setting, beneficiary estimations, and linking
immunization to institutional delivery incentives showed marked improvements. National Rural Health
Mission has contributed to improvement through financial and technical support, supplementing and
supplying vaccines, consumables and cold chain equipment, and utilization of untied and flexible funds.

Discussion: There has been significant progress in immunization in the states. However programmatic,
financial, human resource and infrastructural challenges remain to improve access and quality of
services. At the beneficiary level, societal biases, knowledge gaps, and increasing community's trust in
the system, especially in those not accessing services, are important. Consistently, an increased level of
awareness among the people for immunization and dedication and leadership from health staff were
associated with better coverage.

SOURCE-
http://www.ev4gh.net/wp-content/uploads/2013/09/swati_srivastava_abstract.pdf

IMAGE COURTESY- Google

Routine Immunisation in India: Long Way to Go

Routine Immunisation in India: Long Way to Go

By Damanjeet Kohli, Save the Children India

Mukesh Kumari has been working as a health worker in her village for the last 20 years. Every week, the 45 year old goes door-to-door urging families to get their children vaccinated. But even after so many years of persistence, her village has not achieved full immunization rate.

“The main reason is that many families don’t feel the need to get their children vaccinated. Some also think it will harm their kids,” she says.

Mukesh’s story is that of many health workers across India. Lack of awareness is the biggest barrier to achieving full immunisation rate in the country.

Immunization is one of the most effective methods of reducing child mortality. However, vaccine-preventable diseases still form a large part of the cause for under-5 deaths in India. At 54%, India still has a long way to go before attaining the ideal 85% full immunization rate.

Equity Gap

Often those children who are left out or drop out belong to the poorest and most marginalised areas.

According to Save the Children India’s research on routine immunization in the state of Uttar Pradesh, children belonging to wealthy households were four times more likely to be fully immunized as compared to their low-income counterparts.

Girls fare uniformly worse than boys and higher birth order infants have lower vaccination coverage. Also mother’s education level and the religion of the family negatively impact health-seeking behaviour.

“Panchayati Raj Institution’s (local governance body) involvement in the programme is limited, thus there is no ownership of closing the equity gap at the ground level,” says one of the development partner working with Save the Children in Uttar Pradesh, adding, “The uptake among communities is low as they are not even aware of where, when, why & what will be offered. Massive revamp of IEC for routine immunisation is needed, especially in local language.”

Learning from Polio Eradication

The success of polio eradication programme provides a ray of hope.

With sustained efforts and a decade long campaign to promote polio vaccine, the state of Uttar Pradesh has remained polio free for three years now.

A massive publicity campaign driven by local and national influencers ensured that parents came out to get their children vaccinated. The increased demand was met with dedicated immunisation booths set up at railway stations, inside long distance trains, major bus stops, market places, religious congregations, major road crossings.

But the real success of the campaign came from regular monitoring that ensured no child dropped out.

“We need to develop a model sub-centre in a village and showcase the best practices to other PHCs & districts for better performance of immunisation services”, suggests an Additional District Immunisation Officer. (ADIO)

“We need vaccines on timely basis (monthly basis with two months additional buffer stock), we need more vaccinators, planned implementation of programme and dedicated honest monitoring of programme,” adds the District Immunisation Officer of Uttar Pradesh.

2012 – Year of Immunisation

The government of Uttar Pradesh intensified its campaign by declaring 2012 as the year of immunisation in the state to cover left out and drop out children.

Concentrated were made through sensitisation workshops for the community and microplanning to cover high risk pockets. This was closely linked with firming up the supply side by providing alternate vaccine delivery through mobile vans and volunteers. Strong monitoring and session wise reporting ensured drop outs were mapped effectively.

The campaign has certainly shown promising results. And with solid political commitment, the state is building up the momentum towards full immunisation.

Recently to mark the state’s achievement of eradicating polio, the Chief Minister, Akhilesh Yadav promised to continue the fight for other vaccine preventable diseases as well. “Not a single polio case has been reported in UP in the last three years. I have urged my state’s health officials to sustain the momentum to guard the state against the virus and also scale up vaccination for other diseases,” he said.

“Integrating the campaign with present evidence based strategies can go a long way in improving routine immunisation coverage. Steps like improving women’s education, increasing awareness, conditional cash transfers and promoting institutional deliveries, antenatal care and post natal care will increase the uptake of vaccines,” says Kanika Singh, project director of the New Born Child Sruvival Campaign of Save the Children India, adding, “on the delivery side, we need to integrate and strengthen different health structures and have regular catch-up rounds for drop outs.”

Although India’s success has not been spectacular, it has indeed eradicated small pox, and now on the verge of eradicating polio. Immunisation coverage has improved in the last few years in the country. We now need to step up our efforts to reach the underserved population as well as invest heavily in R&D to achieve immunization’s full potential and a healthier nation.

 Source and Image Courtesy-

http://everyone.savethechildren.net/articles/routine-immunisation-india-long-way-go

Recommendations of Polio Eradication Committee of Indian Academy of Pediatrics

In 1995 Government of India launched the Pulse Polio Immunization (PPI) for the eradication of poliomyelitis. In 1999, a vastly intensified pulse polio campaign entailing enormous economic and logistic burdens was conducted with the aim to give a final push to eradication. Instead of achieving the hoped-for zero polio status in 2002, the number of cases actually increased many fold. Type 1 wild virus had survived in Uttar Pradesh and Bihar in 2001 and caused this outbreak, which spilled over to several states that had been polio-free for a few years. Independent surveys indicate that this was due to woefully inadequate routine immunization coverage compounded by the failure to reach all children during the pulse immunization. Also, of concern to us is the decline in the routine immunization achievements in many states. The Indian Academy of Pediatrics (IAP), along with other partners involved in polio eradication efforts, are disappointed, but are reinvigorating our efforts to catch up with the eradication programme and to improve routine immunization. The IAP Committee on Polio Eradication met on 4th January 2003 in Mumbai and after deliberations on various issues, the following recommendations were approved (participants of the meeting are listed in Annexure). We submit them to the Government of India and to the governments of the states affected by the spread of wild polioviruses in 2002.

Suggestions to improve routine immunization

1. District Task Forces on immunization should be formed in all the districts of the affected states. Professional bodies (including IAP, Indian Medical Associa-tion) and community leaders, particularly from minority communities should be represented on them. The District Task Force should meet every month round the year and should monitor progress in strengthening routine immunization and consequent achievements.

2. Intensive Information, Education, Communication (IEC) campaign should be launched to create awareness and demand for routine immunization. Make use of audio-visual, print and electronic media to propagate routine immunization round the year.

3. Government should ensure that at least one day a week, such as every Wednesday is kept sacrosanct for immunization outreach programs by the staff, no matter what other programs are highlighted for the season, including preparation for pulse immunization for polio eradication.

4. Fix accountability of the public sector health care provider responsible for routine immunization in a specific area.

5. Specific action plans and monitoring mechanisms should be developed to provide routine immunization to children living in urban slums.

6. All vacant posts of health workers relevant to primary health care, especially those concerned with immunization, should be immediately filled up.

7. Hospital based immunization clinics should become user friendly. Make immunization available every day in large or busy clinics and hospitals; both in public sector and private sector establish-ments and at least one day a week in smaller clinics, health centers and small hospitals. Instead of limited time periods in the day, immunization session should continue during the whole working hours.

8. Vaccination should be offered to children accompanying mothers for Reproductive and Child Health (RCH) clinics.

9. In every institutional birth, the infant should be given one dose of OPV before discharge.

Suggestions to improve quality of Supple-mental Immunization Activities (SIA)

l. Monitoring of Polio Eradication Program should be done from the level of Chief Minister and Chief Secretary.

2. Emphasis should be on improving the quality of National Immunization Days (NIDs) rather than increasing the numbers.

3. There is a need to involve all local area practitioners of medicine actively right from the planning stage of SIA.

4. In UP only one immunization card per child should be used to record routine as well as pulse polio doses. Immunization cards should have a column for NID and SNID along with other vaccines and proposed due dates filled in as declared every year. It should be clearly printed in bold letters in immunization cards "immunization is not complete if any pulse polio dose is missed up to the age of 5 years, just as in the case of routine immunization where not a single dose should be missed from the immunization schedule."

5. As house-to-house immunization follow-ing booth-based pulse immunization is adversely affecting the routine immuniza-tion services; house-to-house immuniza-tion should be discontinued as part of NID in all states except the high-risk states. There is need for having a fresh look at the need for house-to-house strategy in these states also.

6. Mop-ups should not be conducted in the states going for SNIDs.

We request the governments and con-cerned authorities to consider and implement these recommendations.

The Committee had also made specific recommendations to the Branches and members of IAP, which may be found in the Editorial titled "Setback in polio eradication in India in 2002: Reasons and Remedies" in the March 2003 issue of Indian Pediatrics.

Indian Academy of Pediatrics through its Polio Eradication Committee, network of Regional and District Polio Coordinators, lAP districts branches and 14000 members will continue to help in achieving polio eradication in India.

ANNEXURE

Participants of Polio Eradication Committee Meeting on 4th January, 2003 at Renaissance Hotel, Mumbai

C.P. Bansal (Zonal coordinator), Swati Y. Bhave (Invitee), A.P. Dubey (Member), Ajay Gaur (Invitee), Virudha Giri (Invitee), Mahesh Kumar Goel (Joint-State Coordinator UP), J.K. Jain (District Coordinator), T. Jacob John (Chairman), V.K. Kapoor (District Coordinator), S.A. Krishna (Zonal Co-ordinator), Rajeev Kumar (State Coordinator – Uttranchal), Rajesh Mehta (Invitee), Dilip Mukherjee (Invitee), MKC Nair (President-Elect IAP), R.S. Panwar (Regional Coordinator–UP), Ashok Rai (Joint-State Coordinator UP), HPS Sachdev (Ex-officio member), Vineet Kumar Saxena (District Coordinator–UP), Raju C. Shah (Invitee), R.N. Srivastava (Invitee), Naveen Thacker (Convener), Vipin M. Vashishtha (Co-convener).

Correspondence to:
Naveen Thacker,
Convener,
Polio Eradication Committee of IAP,
208, Sector 1-A, Gandhidham, Kutch,
Gujarat 370 201, India,
E-mail: naveen@wilnetonline.net

SOURCE-

http://www.indianpediatrics.net/apr2003/apr-320-322.htm

IMAGE COURTESY- Google

Why infants miss vaccination during routine immunization sessions? Study in a rural area of Anand district, Gujarat

Why infants miss vaccination during routine immunization sessions? Study in a rural area of Anand district, Gujarat

Tushar A Patel¹, Niraj B Pandit^2
1 Assistant Professor, Department of Community Medicine, Pramukh Swami Medical College, Karamsad, Guajrat, India
² SBKS Medical Institute and Research Centre, Pipariya, Gujarat, India

Date of Web Publication

30-Jan-2012

Correspondence Address:
Tushar A Patel
402, Radhasharnam Apartment, Near Bhaikaka Statue, Vallabh Vidyanagar, Dist - Anand, Gujarat
India

Abstract

A cross-sectional study was conducted in a rural area of Anand District, Gujarat to measure the efficiency of immunization sessions and to identify the reasons for missing a vaccine in a session. Caregivers of infants aged less than one year and in need of any vaccine as per routine immunization schedule were interviewed by a house-to-house survey after immunization session was completed. Efficiency of immunization session was 66.7%. Reasons for 'missed' vaccination were prior reminder not given (32.9%, P<0.01); mother's forgetfulness (26.6%); unavailability of vaccine (15%). Higher birth order (OR=2.86; 3.16-2.56), mother's current residence at father's home (OR=3.17; 3.53-2.81) were associated with 'missed' vaccination. There are barriers in health care system such as lack of prior reminder and unavailability of vaccines which should be assessed and eliminated.

Keywords: Missed vaccine, Routine immunization, Mother′s forgetfulness, Reminder regarding vaccination

Only 45.2% of children in the age group of 12-23 months are 'fully immunized' in Gujarat. ^[1] Studies have been conducted to identify the reasons for non-immunization, but most of them are part of coverage evaluation surveys in which subjects are in the age group of 12 to 23 months, so there is a chance of recall bias. These studies have not considered the factors related to health service delivery. The present study is conducted with the objective of measuring the efficiency of immunization sessions and identifying the barriers in provision and utilization of routine immunization service.

A cross-sectional study using survey method was carried out in the rural areas of Anand district, Gujarat in the period of October 2008 to November 2009. Children aged less than one year and in need of any vaccine as per routine immunization schedule were included in the study. 

According to District Level Health Survey-III, 26.8% of children in Anand district were not 'fully' immunized and missed at least one vaccine. ^[2]Sample size was determined with the formula n=4pq/L ² (P = 26.8% and allowable error L=10%). Sample size required was 1093 infants. In each session, it was estimated that at least 10 infants will be vaccinated. Subjects were selected with multi-stage sampling. It was decided to include all 44 PHCs of the district. In each PHC, three sub-centers were selected by lottery method. Sub-centers organize immunization sessions in rotation as per Anganwadi area which usually caters 1000 population. In each sub-center, one session was studied, accounting to 132 sessions in total. From 132 sessions, a total of 1296 infants were studied.

Andersen's behavioural model ^[3] of Health Services Utilization was used as a conceptual framework. It considers two aspects for studying vaccination use and its determinants.

1. Infant and family characteristics which include infant's gender, birth order, mother's current residence, knowledge about schedule, ritual belief etc. 2. Health Care System which includes availability of vaccine, distance from session site, reminder given by health staff etc. Efficiency of immunization session was defined as percentage of eligible infants who received their required vaccine.

The dependent variable was defined as the child who either had or had not received all required vaccine. Vaccines and schedule recommended by National Immunization Programme was followed to consider infant due for vaccination. The independent variables were the population and health care system characteristics. 

Children aged less than one year and in need of any vaccine as per routine immunization schedule were included as study subjects. It was decided to interview all infants due for vaccination during that session. Study subjects were identified by a house-to-house survey. If there was no exact information on previous date of vaccination and thus inability to decide whether infant is due for vaccination, subjects were excluded.

The survey instrument was a structured questionnaire which was finalized after pre-testing and pilot study. Details regarding health system characteristics, such as availability of vaccine and staff, were collected from session site. After immunization session was closed, a house-to-house survey was conducted to identify eligible infants. Interview of adults primarily responsible for the child's care was taken after obtaining informed consent. Information on vaccination was collected from immunization card. Births of order three and above were considered as higher-order births. Measurement of distance was taken on approximate basis. Mother's forgetfulness was considered if reminder was given by health staff, but mother forgot to visit session site or gave priority to other work. Information was also collected on ritual belief, without completing rites which is usually done at one month when neonate cannot be moved outside home, to test its association with delayed initiation of vaccination. Data was collected by resident and internees after training.

Analysis was done using Epi-Info 3.4.3 software. For testing, association of multiple variables logistic regression was applied while for other variables Z test was applied. 

Out of a total of 1296 infants expected to be vaccinated, 864 (66.7%) infants received their all required vaccines from routine immunization session. Efficiency of immunization session was lowest for BCG vaccine (62.9%) and was higher for DPT and OPV (68.8%) vaccine.

Reminder not given by the health staff and mother's forgetfulness were the two most common reasons for missing vaccination in 432 eligible infants. Among vaccinated infants, 63 (7.3%) mothers did not receive any reminder by health staff for vaccination. While among unvaccinated infants, 142 (32.9%) mothers didn't receive reminder. (SE=2.88, Z=8.86, P<0.01). 115 (26.6%) infants missed vaccination because of mother's forgetfulness. 65 (15%) of infants missed vaccination because required vaccine was not available at session site.

[Table 1] depicts the association of different factors with missed vaccination. Higher birth order, female sex of infant, mother's illiteracy, mother's residence at father's home and far distance were associated with 'missed' vaccination. Higher birth order [OR=2.86 (2.56-3.16) Z=6.83] and mother's stay at father's home [OR=3.17 (2.81-3.53) Z=6.48] were showing strongest association.

Table 1: Association of different factors with 'missed' vaccination (logistic regression) Click here to view

Association of mothers getting reminder by health staff with various factors (like distance from session site, working mother and mother's current residence at father's home) was tested with logistic regression analysis. Association with mother's current stay at father's home [OR=1.45 (1.11-1.79) Z=2.19] was significant. If mother is at father's home, she is less likely to get reminder from health staff. Working mothers and mothers staying at far distance were not obstacles in giving reminder.

Association of mother's forgetfulness with different factors was also tested by applying logistic regression. Female child [OR=1.58 (1.26-1.9)Z=2.19], illiteracy [OR=2.58 (2.28-2.88) Z=4.31] and distance > 1 km [OR=1.95 (1.63-2.27) Z=3.13] were significantly associated with mother's negligence. Association of working mothers and higher order birth with mother's forgetfulness was not significant.

Date of first dose of vaccination was available in 1179 infants. 234 (19.8%) of infants received their first dose of vaccine after two and a half months of age. Due to ritual belief, initiation of vaccination was delayed. (Z=10.22, SE=3.49, P<0.01).

As mentioned above, reminder not given by the health staff and mother's forgetfulness were the two most common reasons for missing vaccination in the present study, followed by unavailability of vaccine. Infant's sickness was also significant for non-vaccination.

Female health workers are supposed to prepare due beneficiary list and give reminder to mothers about need of vaccination and date of immunization session. But lack of prior reminder has remained the most common cause of missing vaccination. In a study on immunization coverage in Bihar, lack of awareness has been mentioned as the main reason for non-immunization. ^[4] In Gujarat, mothers frequently travel between husband's home and father's home during postnatal period. The findings of the present study suggest this social behaviour as the major obstacle in giving reminder. Previous studies are not available for support of this observation. Health workers register deliveries of only daughter-in-laws of the family, not of daughters in the family, to avoid duplication of birth registration. It is likely that mothers staying at father's home will miss reminder.

Supporting the present findings, a study conducted in Rajasthan has also mentioned laziness and forgetfulness as the second most important reasons. ^[5] Mother's forgetfulness was associated with sex of the child, mother's illiteracy and far distance, which had corroborated with data from three consecutive rounds of the Indian National Family Health Survey that girls have significantly lower immunization coverage than boys.^[6] 

Unavailability of vaccine was the third reason for missing vaccination in the present study. Immunization service assessment in India done by Global Alliance for Vaccines and Immunization has found that due to irregular delivery, stocks tend to be below target amounts at state, district and PHC levels. ^[7] There was significant association between ritual belief and delayed initiation of vaccination.

Poor active tracking and irregular vaccine supply are the major obstacles in utilization of routine immunization service. Intervention based on health metrics strategy in which each child is tracked with computerized database for timely immunization has proven effective. ^[8] Regular and sufficient vaccine supply is a must for universal immunization coverage and can be achieved with appropriate logistic management.

SOURCE-

http://www.ijph.in/article.asp?issn=0019-557X;year=2011;volume=55;issue=4;spage=321;epage=323;aulast=Patel

 

Adolescent immunisation in India: need of the hour- PART 3- Future Challenges

Adolescent immunisation in India: need of the hour

Ananya Ray Laskar, Anita S Acharya Department of Community Medicine, Lady Hardinge Medical College, New Delhi. India Corresponding Author: Ananya Ray Laskar A-601, Abhyant Apartments, Vasundhra Enclave, Delhi-110096. India. Email: ananya.ray.laskar@gmail.com  Future Challenges: Barriers to adolescent vaccination may be of three types- Beneficiary or family-related, provider related or system-related. i) Beneficiary related barriers: Changing behaviour among adolescents and their parents or guardians will require education and outreach. While younger children have little or no control over health care decisions, adolescents often play a key role in decision making. Therefore, it is vital that adolescents, as well as their parents, are educated about the need for vaccinating the adolescents and the seriousness of vaccine-preventable diseases. Once empowered, they may generate discussion with their health care providers about vaccines and other preventive health measures. ii) Provider related barriers: Vaccine delivery strategies may be school-based programmes, pulsed delivery through child health days, vaccination days, periodic campaigns, routine provision through health facilities, or combination of strategies can be adopted. Further seroepidemiological studies are needed to be carried out to know the epidemiological patterns and burden of vaccine preventable diseases among adolescents in India. The already existing mechanism for routine immunisation can be utilised optimally by appropriate training and sensitisation. iii) System related barriers: The choice of which vaccine to give, target population among the adolescent age group and mode of administration are important policy decisions that must be guided by a strong scientific rationale, with rigorous inputs from multicentric field epidemiology, irrespective of policies in western countries. Cost-benefit as well as risk-benefit assessment of vaccinating adolescents should be carried out in India, taking into account local serotypes and variations in indigenous host - pathogen - environment interactions. The public sector undertakings manufacturing indigenous vaccines should berevived and upgraded [20]. Conclusion Effective planning of immunisation services for the adolescent will require careful weighing of theadvantages and disadvantages of each individual vaccine by the policy makers. Currently, only a fewvaccines fulfill the criteria for widespread use in adolescents. In the future, we might even have a vaccine against HIV/AIDS to be used in adolescents and many more. So the need of the hour is health promotional messages for the adolescents and their families to convince them that the recommended vaccines are safe and effective and relevant for themselves. Key Points Guidelines for the adolescent vaccination should be incorporated in the National Immunisation Schedule and widely disseminated. A modification such as replacement of TT vaccine with Td (adult type) is recommended for 10 and 16 years. Hepatitis-B vaccine and MR vaccine may be given as catch-up vaccines. In addition, JE vaccine should be included for all adolescents in endemic states in view of the age shift in the incidence. SOURCE- http://www.ijms.in/articles/3/1/adolescent-immunisation-in-india.html

Adolescent immunisation in India: need of the hour- PART 2- Individual Vaccines and recommendations

Adolescent immunisation in India: need of the hour

Ananya Ray Laskar, Anita S Acharya Department of Community Medicine, Lady Hardinge Medical College, New Delhi. India Corresponding Author: Ananya Ray Laskar A-601, Abhyant Apartments, Vasundhra Enclave, Delhi-110096. India. Email: ananya.ray.laskar@gmail.com  Individual Vaccines and recommendations  Diphtheria, Pertussis and Tetanus (DPT): Diphtheria- The duration of immunity against diphtheria may depend on exposure to diphtheria organisms and thus varies geographically. Data on the persistence of immunity in developing countries like India are scarce. But even where vaccination coverage rates have been high for 5 to 10 years, diphtheria outbreaks have been reported. These are characterised by high case fatality  rates, a large proportion of patients with complications, and occurrence in both younger and older age groups [4]. Epidemics in previously well-controlled settings in Eastern Europe have raised awareness of the need for wider vaccination strategies. Though there is a dearth of studies reporting the actual disease burden of diphtheria in adolescents and adults, several outbreaks have been reported in India [5-9] which points towards waning immunity beyondchildhood. Pertussis- Although the majority of adolescents have received one or more doses of DPT in infancy, there is evidence that protective immunity to pertussis may wane [4]. The duration of immunity following DPT immunisation is not precisely known. Epidemiological investigations with whole-cell pertussis vaccine suggest that the efficacy of the vaccine falls with time after immunisation [10]. An increasing incidence of pertussis cases among adolescents and adults in developed countries may reflect decreasing levels of immunity in these groups. Some serological observations suggest that past infection may not provide protection and that the widely held belief that infection with B. pertussis confers lifelong immunity is probably wrong [11]. Tetanus- National Immunisation Schedule has already targeted adolescents of 10 and 16 years as well as pregnant women to receive tetanus toxoid (TT). As discussed above, TT should be replaced by Td in all states that have had DPT-3 coverage of 70% or more for at least 5 years as per WHO [4]. Recommendations: According to the 2012 guidelines given by the Advisory Committee on Immunisation Practices (ACIP) of CDC, adolescents aged 11 through 18 years who have not received Tdap vaccine should receive a dose, followed by  tetanus and diphtheria toxoids (Td) booster doses every 10 years thereafter [12]. However due to the cost factor, it is not feasible to adapt this guideline in the Indian scenario. The latest National Immunisation Schedule of India recommends that DPT vaccine can be given up to 7 years of age, but no specific changes in recommendations are suggested for adolescents [13]. For those who can afford the vaccine, the preferred age for TdaP is 11-12 years. Lower dose of thediphtheria component of the vaccine , (recommended for persons over the age of 7 years) are advised to minimise adverse reactions [14]. Recent field trials conducted in Italy, Sweden, and Germany indicate that 'acellular’ pertussis vaccines cause significantly lower rates of reactions than whole cell pertussis vaccines, and also that acellular vaccines are 70%-90% effective in preventing severe pertussis cases [15]. However considering the cost of acellular pertussis vaccine, only Td vaccine may be feasible for adolescents at 10 and 16 years as nation-wide guideline. School-based programmes for administering booster doses of Td may be the best strategy to cover the gaps in immunity. Measles, Mumps and Rubella (MMR): Measles- Single dose of measles vaccine given at 9 months is effective in protecting 85% of infantsvaccinated. Rationale for second dose is to achieve levels of protection (>92%) where reduction intransmission is achieved; further the second dose addresses the 15% non-responders at first immunisation. Overall, based on these well established scientific facts, changing from one dose to two dose strategy would help catch up those missed but more importantly elevate the level of immunity to break transmission of disease. Even in a developed country like USA where first dose of measles vaccine is given as a part of MMR vaccine at 12-15 months, a second dose of measles vaccine is recommended at 4-6 years, to overcome initial vaccine failures which form a small fraction of vaccines, as well as to boost the falling titres ofprotective antibodies over a period of time [16]. Rubella is a benign disease of childhood but has serious teratogenic effects in the baby in the form ofCongenital Rubella Syndrome. The rate of perinatal transmission is 40-50% overall and 90% during the first trimester of pregnancy. As about 40% women in reproductive age group in India are susceptible to rubella, vaccination against this is desirable in adolescent girls [17]. A community based study by All India Institute of Medical Sciences, India in unmarried adolescent girls reported high seronegativity indicating high susceptibility to rubella infections [18]. It has been seen that inadequate coverage may decrease rubella virus circulation in children sufficiently with the resultant upward shift of the median page at infection; thus leading to higher proportion of girls remaining susceptible up to adulthood leading to a paradoxical increase in the number of rubella infections and of cases of Congenital Rubella Syndrome [17]. Thereforeintroduction of rubella vaccine for adolescent girls is recommended to offset the potential of increase of susceptible women in reproductive age group, if children alone are vaccinated. Mumps does not pose a significant public health problem in children as it is uncommon in children less than 12 months of age and has negligible mortality. Mumps is similar to measles but less transmissible in household setting and has lower crude herd immunity. However some complications are known to occur if the disease occurs after puberty. Orchitis occurs in 37% of the post-pubertal males after mumps while 31% of the affected females have mastitis and pelvic pain due to oophoritis. Also an increase in foetal deaths has been observed in women who develop mumps in the first trimester [19]. Recommendations: A one-time measles “catch-up” campaign targeting children 9 months to 14 years ofage may be carried out at national level to immunise susceptible, accumulated since vaccine introduction [11]. Among the neighbouring countries, Sri Lanka, Bhutan, Maldives and Thailand have already introduced MR/MMR in their national immunisation programme. National Technical Advisory group has proposed the introduction of rubella vaccine as MR/MMR in the Universal Immunisation Programme in states which have the ability to achieve and sustain routine immunisation coverage of >80% [13]. This would also provide asecond opportunity for measles vaccination. Specific choice of MR/MMR should be made on the basis of incremental cost between the two [20]. Thus all adolescents in the country should be immunised regardless of their measles vaccination status. Hepatitis B vaccine: It can be used effectively through routine infant immunisation, but is effective at any age though less after the age of 40 years. If given prior to exposure, it can prevent infection in almost all individuals,  and will reduce dramatically rates of liver cancer later in life [21,22]. Most persons infected with hepatitis B virus (HBV) acquire their infection as young adults or adolescents. Any reduction in HBV- related liver disease resulting from universal vaccination of infants cannot be expected until vaccinated children reach adolescence and adulthood [23]. In 2002, Government of India had launched Hepatitis-B immunisation as part of routine immunisation in 33 districts and 15 metropolitan cities with Global Alliance for Vaccine and Immunisation (GAVI) support [24] and recently it is proposed to be expanded to the whole country [13]. However given that the majority of today’s adolescents will not have received this vaccine in infancy, a short-term programme of immunisation for adolescents may also be indicated as a catch-up strategy [23]. Recommendations: A schedule of 0, 1-2, and 4-6 months is recommended. Flexibility in scheduling is an important factor for achieving high rates of vaccination in adolescents. When the vaccination schedule is interrupted, the vaccine series does not require re-initiation [23]. Studies of "off-schedule" vaccinations indicate that if the series is interrupted after the first dose, the second dose should be administered as soon as possible, and the second and third doses should be separated by an interval of at least 2 months. If only the third dose is delayed, it should be administered as soon as possible. Intervals of up to 1 year between administration of the first and third doses induce excellent antibody responses, and studies are in progress to evaluate longer intervals [23]. As per IAP recommendations there are certain special conditions that warrant special mention to administer the vaccine to high risk adolescents [14]. These are health workers, travellers to endemic countries, intravenous drug users, males having sex with men, an intimate contact with HBs antigen positive patients, patients regularly receiving blood or haemodialysis.  Japanese Encephalitis (JE): It is the leading viral cause of Acute Encephalitis Syndrome (AES) in India. 70% of those who develop illness either die or survive with a long-term neurological disability. Government of India made the decision to control JE by introducing a mass vaccination programme in 104 endemic districts in 11 states of India in a phased manner for 5 years from 2006-2011 by using the live attenuated SA 14-14-2 JE vaccine manufactured in Chengdu Institute of Biological Products, China [25]. Since the disease primarily affects children underthe age of fifteen years, a one-time JE massimmunisation campaign targeting all the children in the 1-15 years age group in the high-risk districts was also started. Some districts of Manipur, Nagaland, Arunachal Pradesh and Uttarakhand showing evidence of ongoing JE transmission were also included in 2010 [25]. A recently conducted hospital-based study among AES patients in Assam reported 259 (47.1%) serologically confirmed cases as JE, of which 66.4% were adult and 33.6% were paediatric. This age shift may be due to the invasion of the disease into new demography or some change in the virus strain over time [26]. The Assam Government has initiated a pilot project to expand JE vaccination in adults in the worst-hit districts of Assam from October 2011. Recommendations for use of JE vaccines: Currently the vaccine has been integrated into the Universal Immunisation for children 16-24 months in all the endemic states in India [25]. In view of the age-shift in the incidence of the disease, JE vaccination should be recommended across all agegroups including adolescents in endemic areas, as part of national immunisation. Haemophilus influenza vaccine: The H. influenzae pitman type b (Hib) organism, which can cause severe bacterial meningitis and pneumonia, is estimated to kill more than 370,000 children worldwide each year. Nearly 20% of these deaths occur in India. Preliminary data from six surveillance centres indicates case fatality rate of Hib meningitis is 25%, 76% cases occur in infants and 40-50% of isolates are resistant to first-line antibiotics. Clinical trials of Hib conjugate vaccines have demonstrated that this vaccine can prevent 20-25% radiologically confirmed pneumonia with consolidation [27]. However there is dearth of studies to estimate the burden of disease in adolescents. A study conducted in the Department of Child Health, CMC Vellore [28] reported that even at relatively low coverage through private sector distribution, Hib vaccine has significant community impact on Hib disease. The annual mean number of Hib cases was 10.7 before Hib vaccine introduction, falling to 3.8 cases following its Recommendations: The risk of disease in adolescents is extremely low and thus routineimmunisation is not indicated for healthy individuals above 5 years as per IAP guidelines [14]. However, in some special conditions like chronic respiratory diseases- asthma, immunocompromisedadolescents like splenectomised or post-bone marrow transplant patients a single dose 0.5 ml byintramuscular route may be administered annually [29]. Chicken Pox: It is another common disease and is mild with low mortality if occurs in childhood. Primary varicella has a mortality rate of 2-3 per 100,000 cases with lowest case fatality rates among children aged 1-4 years and 5-9 years. Most children are infected by age of 15 years with fewer than 5% adults remaining susceptible. Disease is often severe if it occurs after adolescence or in adults. Natural infection provides lifelong immunity [30]. Recommendations: Varicella vaccine is not recommended for children in routine immunisation schedule. At ages 11–12 years, providers should assess the adolescent’s need for varicella virus vaccine, and administer the vaccine to those who are eligible and do not have a reliable history of chickenpox. When administered to children <13 years of age, a single dose of vaccine induces protective antibodies in >95% of recipients. For susceptible persons 13 years and above, two doses separated by 4–8 weeks are recommended. But thevaccine is costly as it costs about Rs.1200 per dose. Therefore, in case of financial constraints parents may be given the option to get their child immunised if they can afford it [29]. Moreover varicella vaccine should not be given to adolescents who are known  to be pregnant or to adolescents who are planning pregnancy within 1 month of vaccination. However the vaccine must be recommended to household contacts of immuno-compromised children or health care workers in ‘Infectious disease hospitals’. Meningococcal Vaccines: Invasive meningococcal disease is most common in children with rates of more than 25/1,00,000 population in the first four months of life. Almost 50% cases occur in children less than 2 years of age. Meningococcal vaccine is a polysaccharide vaccine effective against meningococcemia as well as N. meningitidis meningitis which have a high mortality rate. However, being a polysaccharide vaccine it is poorly immunogenic in children less than two years of age, though its protein conjugate variant has been shown to be efficacious [31]. Recommendations: Currently a quadrivalent vaccine is available (against A, C, Y and W135 strains). As one dose of vaccine provides protection for 3-5 years and repeated doses result in hyporesponse, meningococcal vaccine is recommended for prevention among the close contacts and for control of epidemics and not as a part of routine immunisation [32]. Human Papilloma Virus (HPV) Vaccines Cervical cancer is the most common cancer in women in India. HPV infections are very common among sexually transmitted infections and the lifetime risk of acquired HPV infection is 70–80% in many developing countries [33]. With the advent of two new vaccines, one quadrivalent vaccine “Gardasil” ® (against HPV-6, -11, -16, and -18) developed by Merck and one bivalent “Cervarix” ® (against HPV-16, and -18) by GSK , may hold newer promises for prevention and control of the disease. However, a word of caution that vaccination alone does not prevent all cervical cancers. Nearly 30% of cancers are not prevented by the currently available vaccines [34]. Therefore, age-appropriate screening programmes for cervical cancer should go hand in hand. Also, thecost of this vaccine is a major factor along with other issues such as public awareness and acceptability of the vaccine. Many conservative elements of the society have expressed their concern that it might encourage promiscuity among unmarried. Also there is a question of whether to offer it to boys. Hence, various regulatory and policy changes along with awareness among parents may need to be undertaken to address these issues. Recommendations: The primary target population should be young adolescent girls as vaccination is most efficacious in girls who have not become sexually active. So, the programmes should determine the primary target age group based on data on the age of sexual initiation and the feasibility of reaching young adolescent girls through schools, health-care facilities or community-based methods [35]. The vaccinemanufacturers recommend three doses of the vaccine to be administered to females aged 10-26 years. CDC recommends either HPV4 or HPV2 for females and HPV4 for males aged 11 or 12 years in a 3-dose series. The vaccine series can be started beginning at age 9 years. The second dose to be administered 1 to 2 months after the first dose and the third dose 6 months after the first dose [12]. But each dose cost about Rs. 3000/- and hence is not recommended as part of routine immunisation in adolescents [33]. However, it can be made optional for those who can afford them. In addition, screening at regular intervals after initiation of sexual activity cannot be over-emphasised along with creating public awareness regarding cervical cancer and HPV vaccine. So, currently, only a few vaccines fulfill the criteria for widespread use in adolescents. A summary of theIAP and the recommendations for the National Immunisation for adolescents have been presented in table 1. Table 1- Recommendations for adolescent immunisation SOURCE- http://www.ijms.in/articles/3/1/adolescent-immunisation-in-india.html