Poor cold chain at private health facilities: Report Banjot Kaur Bhatia, TNN | Sep 22, 2014, 01.31AM IST

PATNA: Most parents prefer private healthcare facilities for their infants' routine immunization (RI). But do a reality check before doing so next time. For, a recent Unicef survey reveals not even one of the 104-odd private facilities the Unicef experts visited in Patna has proper cold chain for storing those vaccines.

The survey was conducted from February to April this year and a copy of the survey report has also been submitted to State Health Society of Bihar. According to the survey report, not a single facility had ice-lined refrigerator (ILR) for storing vaccines. Instead, 97% of the healthcare facilities stored them in domestic refrigerators.

"This raises serious concern about the efficacy of vaccines as temperature regulator is not calibrated regularly," says the report and adds these vaccination points are never visited by government officials to monitor their quality.
ILRs are specially designed for storing vaccines and WHO does not recommend their storage in domestic refrigerators because they cannot maintain temperature for more than four hours, affecting potency of vaccines. Unicef's Dr Ghanashyam Sethy said domestic refrigerators were simultaneously used for drinking water too. The refrigerators were therefore opened many a time, which reduces the cooling effect of the refrigerator.

However, Dr Awadh Agarwal, a faculty member of State Institute of Health and Family Welfare who was also a part of this study, said, "Though WHO recommends usage of ILR, domestic refrigerators can also be used if certain guidelines are followed."

Adverse events following immunization (AEFI) are a major concern of any immunization programme. 

Common

 AEFI include fever or swelling at the site of injection. At times, the reaction can be severe and, albeit in rare cases, may lead to death. Most of the surveyed immunization points had facilities to manage minor AEFI cases, but none of them had a proper AEFI kit (set of emergency medicines) to manage serious cases. Only 4.8% of these immunization points had some reporting mechanism of AEFI to a government institution. Its reportage is significant to study overall effect of the vaccine.

Maintenance of immunization record was poor with only 17% of the surveyed immunization points doing so. As many as 90% facilities are not reporting immunization record to the government. This creates a scenario of low immunization coverage of the state.

Dr Agrawal said there is no proper format for doctors to do the same. However Dr Sethy said, "Civil surgeons have issued letters many a time, but doctors do not heed to the instruction.'

It was also found only 60% facilities used hubcutter or needle syringe terminator which is mandatory in public health. The syringe of both these kinds is broken after one usage and can be easily disposed of compared to other syringes. About 5% doctors were found purchasing vaccines from nearby pharmacists who are not allowed to store RI vaccines.

Certain good practices are also highlighted in the report. At as many as 77% of the surveyed immunization points, doctors, not nurses or pharmacists, administered vaccines.

Source-

http://timesofindia.indiatimes.com/city/patna/Poor-cold-chain-at-pvt-health-facilities-Report/articleshow/43171600.cms

Govt adds 4 vaccines to immunisation programme - government will be providing free vaccines against 13 life threatening diseases to 27 million children annually

New Delhi: The government will add four vaccines as part of a programme to reduce child mortality by two-thirds by next year and meet global polio eradication targets, Prime Minister Narendra Modi announced on Thursday. With these vaccines will be introduced as part of the Universal Immunization Programme (UIP), government will be providing free vaccines against 13 life threatening diseases to 27 million children annually, the largest birth cohort in the world. Vaccines against rotavirus, rubella and polio (injectable) will collectively expedite India’s progress on meeting the Millennium Development Goal 4 targets to reduce child mortality by two-thirds by the year 2015 and meet global polio eradication targets. In addition, an adult vaccine against Japanese encephalitis will be introduced in districts with high levels of the disease. Along with the recent introduction of the pentavalent vaccine, this decision represents one of the most significant policy leaps in 30 years in public health, preventing at least one lakh infant deaths, deaths of adults in working age group and up to 10 lakhs hospitalizations each year. “The introduction of four new lifesaving vaccines will play a key role in reducing the childhood and infant mortality and morbidity in the country,” Modi said. “Many of these vaccines are already available through private practitioners to those who can afford them. The government will now ensure that the benefits of vaccination reach all sections of the society, regardless of social and economic status,” he said. “India is committed to tackle child mortality and provide health for all through multiple initiatives taken up by the government. Strengthening routine immunization is an essential investment in India’s children and will ensure a healthy future of the country,“ Modi said. Diarrohea caused by rotavirus kills nearly 80,000 children each year, results in up to 10 lakh hospitalizations, pushing many Indian families below the poverty line. It also imposes an economic burden of over Rs 300 crore each year to the country. India has developed and licensed its first indigenous rotavirus vaccine developed under a public-private partnership by the ministry of science and the ministry of health and family welfare. This vaccine will be introduced in a phased manner.

Read more at: http://www.livemint.com/Politics/dRUdNB3m65UAGb0RAmvWTO/Govt-adds-4-vaccines-to-immunisation-programme.html?utm_source=copy

Source-
http://www.livemint.com/Politics/dRUdNB3m65UAGb0RAmvWTO/Govt-adds-4-vaccines-to-immunisation-programme.html

Improving measles control in India

April 2013

India is building on its polio eradication campaign experience to ensure more children get vaccinated against measles.

It is now more than two years since a child has been infected with polio in India, once considered the global epicentre of the disease.

The country’s polio eradication campaign, led by the Government of India and its partners, including the World Health Organization, has been one of the biggest, most complex, and most meticulously implemented vaccination campaigns in human history.

Building on success of polio campaigns

WHO/A. Caballero-Reynolds

Intense, six-day polio vaccination campaigns have been run several times a year in India since 1996. During each campaign, 2.3 million vaccinators go door-to-door, visiting 191 million homes to vaccinate 172 million children a year.

Now India is building on the success of the polio eradication strategy to ensure that more children are immunized against other dangerous illnesses.

Measles, for 

example

, is still one of the leading causes of death in young children. A highly contagious disease, it spreads like wildfire in communities where children are unvaccinated. And because the virus reduces immunity, children who have had measles – especially those who are undernourished – may die of pneumonia, diarrhoea and encephalitis later on.

Safe and effective measles vaccine exists

This need not happen. A safe and effective vaccine exists, and has played a major role in reducing the global number of measles deaths from 548 000 to 158 000 a year between 2000 and 2011. But more children need that vaccine: in 2011, 20 million children worldwide remained unimmunized.

“Laboratory-based field surveillance network is providing vital assistance for measles control activities in the country”

Dr Nata Menabde, WHO Representative to India

Because measles is so infectious, a country needs to ensure that at least 95% of all children receive two doses of the vaccine. About 15% of vaccinated children fail to develop immunity from the first dose, meaning that if only 80% are fully immunized, an outbreak is likely.

More than one third of all measles deaths worldwide (around 56 000 in 2011) are among children in India. With support from WHO, in November 2010, India launched a massive polio-style measles vaccination project in 14 high-burden states, in a three-phase campaign.

Increasing child vaccination

Health workers were trained to detect and report measles outbreaks, and they found an unexpectedly high number of infections. The government responded by establishing a system to ensure that every child who receives a first dose of the vaccine routinely gets a second. They also initiated ‘catch-up’ campaigns in areas where first-dose coverage was less than 80%.

WHO/A. Caballero-Reynolds

With two phases of the measles vaccination campaign completed, and the third phase ongoing, more than 102 million children in 344 districts have been vaccinated, achieving between 87% and 90% coverage.

According to Dr Nata Menabde, WHO Representative in India, the lessons learnt through the polio programme are working. “The laboratory-based field surveillance network, which we are supporting, is providing vital assistance for measles control activities in the country,” she says.

While it is not yet possible to assess national impact, as the campaign is in different phases in different states, in some states the impact has been dramatic. Gujarat, for example, has gone from nearly 1000 cases in 2010 to none in 2012.

In Bihar, once the state with the lowest immunization coverage levels in the country, the proportion of children immunized against common childhood diseases tripled as polio eradication activities intensified (from 18.6% in 2005 to 66.8% in 2010), underscoring the synergistic links between polio and measles efforts.

“India is a good example of a large and diverse country with many health systems challenges,” says Dr Hamid Jafari, WHO’s Director of Polio Operations and Research. “This programme demonstrates the impact that can be achieved by linking efforts to eradicate polio with those to improve routine immunization against a disease such as measles.”

SOURCE AND IMAGE COURTESY- http://www.who.int/features/2013/india_measles/en/

Polio-free India – 5 amazing facts about the journey that helped us eradicate polio

India’s victory against polio is arguably the most amazing healthcare feat the world has ever witnessed. Most experts felt that India with its huge population, poor healthcare services and numerous other hurdles would remain the most polio-endemic region in the world. But the nation hasn’t reported a new case since early 2011, which led WHO Director-General Margaret Chan to remark: ‘India has shown the world that there is no such thing as impossible.’ Here are 5 facts about India’s journey to being a polio-free country:

India had the most number of polio cases

According to the WHO, India accounted for 40,000 polio cases in 1980s and even in 2002, only UP accounted for 2/3rd of the world’s polio cases. While polio was eradicated in the Americas by 1991, Europe by 1998 and by 2011 only 44 cases were reported worldwide, mostly in Pakistan, India hasn’t reported a new case since 2011. 

It was the largest PPP initiative in the world

The polio eradication movement was a joint effort between the Indian government, WHO, Rotary, the Bill and Melinda Gates Foundation, the Global Polio Initiative and various other NGOs. It involved around two million staff who vaccinated around 170 million throughout the country on two dates per year, to finally help wipe out the disease.

Celebrities gave the campaign a voice

The government’s massive campaign was called ‘Do Boond Zindagi Ki’ pulse polio campaign and celebrities played a major part in it including Amitabh Bachchan, Sachin Tendulkar and even Jackie Shroff (whose blooper from a 1998 campaign went viral in 2012). Amitabh participated in numerous campaigns shouting at people ‘Sharm aani chaahiye humein! (We should be ashamed)’.  These campaigns went a long way in educating people about polio, particularly those from lower socio-economic groups. 

Everyone came together for a great cause

Most experts believed that India would be the last country to eradicate polio. There were just too many hurdles – poor healthcare services, a huge population, lack of awareness, religious beliefs, geographical barriers and a host of other problems. However, everyone managed to roll up their sleeves and join together to fight the scourge of polio – religious leaders urged their communities to get the children vaccinated; volunteers reached every nook and cranny of the country; parents turned up with their children for massive vaccination drives and celebrities lent their voice to the cause.

We still have to remain vigilant

India still lies adjacent to Pakistan which is the most polio epidemic region in the world, and there still might be some unreported cases. Because of this, India needs to remain very vigilant and to remain polio-free, we must make sure that every child gets the polio vaccine drops. 

Source- http://www.thehealthsite.com/healthcare/polio-free-india-5-amazing-facts-about-the-journey-that-helped-us-eradicate-polio-n214/

Cervical Cancer Vaccination

`It is now possible to prevent cervical cancer in women by vaccination`

By Shruti Saxena | Last Updated: Wednesday, September 10, 2014 - 16:19

Cervical cancer is the leading cause of cancer deaths among women in India, with approximately 1.32 lakh new cases of cervical cancer being diagnosed and about 74,000 deaths occurring annually, accounting for nearly one-third of cervical cancer deaths across the world.

According to 'Cervical Cancer Global Crisis Card' released by the Cervical Cancer-Free Coalition, India represents 26.4 percent of all women dying of cervical cancer globally, with China, Bangladesh, Pakistan, Indonesia and Thailand also showing high death incidence. But the good news is that cervical cancer is treatable, if found early enough.

In an exclusive interview with Shruti Saxena of ZeeNews.com, Dr Meenakshi Ahuja, the director (Gynaecology & Obstetrics) Fortis La Femme, speaks about various aspects of the disease.

Shruti: Please tell us about what actually is cervical cancer?

Dr Meenakshi: Cervical cancer is the commonest cancer among women in India. Every seven minutes, a woman dies of cervical cancer. Cervical cancer is the cancer of mouth of uterus or womb, known as cervix.

Shruti: What are the first signs that indicate one might be suffering from cervical cancer?

Dr Meenakshi: Unfortunately, early signs of cervical cancer are very non-specific like vaginal discharge with an unpleasant odor, or tinged with blood, and lower abdomen pain. Later, symptoms like pain and bleeding during intercourse, weight loss etc may develop.

Shruti: How can Human Papillomavirus (HPV) infection develop cervical cancer?

Dr Meenakshi: All incidence points out that cervical cancer is caused by infection by a virus, called the Human Papillomavirus or HPV. Certain strains of this virus are oncogenic or cancer causing, especially 16, 18 infections.

Shruti: Does leading a unhealthy lifestyle contribute to the risk of developing cervical cancer?

Dr Meenakshi: Sexual activity in early age and multiple sexual partners increase the chances of HPV transmission and cervical cancer. Low immune status will also cause rapid spread of the disease.

Shruti: What are the methods of prevention and treatment of cervical cancer?

Dr Meenakshi: It is now possible to prevent cervical cancer in women by vaccination. Three doses of the vaccine are recommended for all women belonging to the age group of 9- 45 years. The earlier the vaccine is given, better the protection. Annual screening for cervical cancer is recommended in all women if they are over 30 years of age or sexually active for three years, irrespective of their immunisation status.

Treatment of cervical cancer is by extensive surgery, radiotherapy or chemotherapy depending on the stage of the disease.

Source-

http://zeenews.india.com/exclusive/it-is-now-possible-to-prevent-cervical-cancer-in-women-by-vaccination_1467743.html

 Image Courtesy- Google

India Polio Fact Sheet

Cases in 2011: 1 (last case 13 January 2011)
Cases in 2010: 42
Cases in 2009: 741
Cases in 1991: 6,028
Cases in 1985: 150,000
Last wild poliovirus type 1 (WPV1) case: 13 January 2011, Howrah, West Bengal
Last wild poliovirus type 2 (WPV2) case: October 1999, Aligarh, Uttar Pradesh
Last wild poliovirus type 3 (WPV3) case: 22 October 2010, Pakur, Jharkhand
Last positive case from monthly environmental sewage sampling (conducted in Delhi, Mumbai and Patna): November
2010, Mumbai
Number of Supplementary Immunization Activities in 2011:
- 2 National Immunization Days (NIDs) immunizing 172 million children <5 years in five days
- 7 Sub-National Immunization Days (sNIDs) immunizing 50-70 million children each
- 1 Mop-up Emergency Activity immunizing 2.6 million children
Number of Oral Polio Vaccine (OPV) doses administered in 2011: 900 million

SITUATION IN 2012
 India has made unprecedented progress against polio in the last two years, reporting only one case of
polio in 2011, on 13 January, compared with 42 polio cases in 2010 and 741 cases in 2009. The lone polio
case in 2011 was reported in a two-year-old girl in Howrah, close to Kolkata, West Bengal.
 On 13 January, 2012, India will reach a major milestone in the history of polio eradication – a 12-month
period without any case of polio being recorded. This date marks the unprecedented progress in India and is
an endorsement of the effectiveness of the polio eradication strategies and their implementation in India.
 Since the launch of the Global Polio Eradication Initiative in 1988, the incidence of wild poliovirus has reduced by
99 per cent – from 350,000 children paralyzed or killed annually in 125 endemic countries in 1988 to 620 cases
reported in 16 countries in 2011 (as of 3 January, 2012). In 2006, the number of polio-endemic countries
(countries that have never stopped indigenous wild poliovirus transmission) was reduced to four – India, Nigeria,
Pakistan and Afghanistan.
 If all testing for WPV in India through January – including laboratory analysis of acute flaccid paralysis cases with
onset up to mid-January and environmental sewage sampling – returns negative, India will officially be deemed
to have stopped indigenous WPV and will be removed from the list of WHO polio-endemic countries (by
mid-February), reducing that group to a historical low of three.
 One of the three types of wild poliovirus – wild poliovirus type 2 (WPV2) has been eradicated globally. The last
case of WPV2 was in Aligarh, India, in October, 1999.
 When the Pulse Polio Immunisation Programme was launched in India in 1995 an estimated 150,000 polio cases
were reported across the country each year.
 The two polio-endemic states of Uttar Pradesh and Bihar have not reported any case of polio since April 2010 and
September 2010, respectively.
 The transmission of the most dangerous WPV1, which caused 95 per cent of polio in India until 2006, dropped to
record low levels in 2010. Uttar Pradesh, the epicenter of most polio outbreaks in the country, has not reported
any WPV1 cases since November 2009.
 This progress follows intensive immunization campaigns focusing on areas at highest risk of transmitting polio
and the most vulnerable populations, such as newborns (>500,000 children are born in UP and Bihar each month)
and migrants; use of the more efficacious monovalent oral polio vaccines and, since 2010, the bivalent oral polio
vaccine (bOPV) which protects against both P1 and P3 concurrently.
 In India, the polio partnership is led by the Government of India, with continued support from WHO’s National
Polio Surveillance Project (NPSP), Rotary International, the US Centers for Disease Control and Prevention
(CDC) and UNICEF, as well as significant contributions by the Bill and Melinda Gates Foundation.

THE POLIO PROGRAMME
During each NID, nearly 2.3 million vaccinators under the direction of 155,000 supervisors visit 209 million houses to
administer OPV to around 172 million children under 5 years of age across the country. To reach people on the move,
mobile vaccination teams immunize children at railway stations, inside running trains, at bus stands, market places,
construction sites, etc. Around 5 million children are immunized by transit and mobile teams during every round in UP,
Bihar and Mumbai alone.
Between 50-70 million children are vaccinated with OPV during SNIDs which cover the endemic states of UP and Bihar,
re-infected states such as West Bengal and Jharkhand, polio high-risk areas of Delhi and Mumbai (and their surrounding
areas). Migrant and mobile populations in Punjab, Haryana, Chandigarh, Rajasthan and Gujarat are also covered in the
SNIDs.

Progress in India follows: 

 The strong commitment of the Government of India and the endemic and high-risk states, ensuring that the entire 

government machinery is geared for the polio eradication programme down to the block and village level.

 Intense and focused measures with tailored tools and strategies to reach and deliver the maximum possible 

protection to children in the highest-risk areas and among the highest-risk populations. 

 The concerted and tireless efforts of the millions of frontline workers – vaccinators and community mobilizers -

braving all odds and challenges to ensure that children <5 years are protected with OPV in each immunization 

round.

An intense surveillance network for polio, ensuring rapid detection of polioviruses for a timely response.

 A huge network of nearly 8,500 community mobilisers in polio-endemic and high-risk states of Uttar 

Pradesh, Bihar and West Bengal, which is continuously counseling families in the highest-risk areas and tracking 

and reaching out to the most vulnerable migrant and mobile populations to ensure their children are protected 

against polio in every polio round, and for routine immunization. The community mobilisers are now also 

spreading awareness about polio-associated risk factors: the need to protect children with life-saving vaccines 

being offered free of cost under Routine Immunization; hygiene and sanitation; hand-washing; exclusive breast 

feeding up to six months; and diarrhea management with ORS and zinc.

CHALLENGES & PROGRAMME PRIORITIES

 The key challenge now is to ensure any residual or imported poliovirus in the country is rapidly detected 

and eliminated. This requires very high levels of vigilance and emergency preparedness to respond to 

any importation of wild poliovirus. The importation of wild poliovirus into China in 2011 highlights the risk 

that India faces of polio returning to the country.

 The Government of India and all states are putting together Emergency Preparedness and Response Plans to 

ensure a rapid and appropriate response to any case of polio in the country.

 The challenge is to ensure all children up to 5 years of age continue to take OPV at every available 

opportunity (polio campaigns and routine immunization) both in and outside the polio-endemic states until 

global eradication is achieved.

 Ensuring populations on the move – migrants, nomads and cross-border movements – both inside and 

outside polio-endemic, high-risk and re-infected states and entering India from neighboring Pakistan and Nepal, 

are protected with OPV in each round. 

 Tackling the risk of complacency among the community and within the polio programme in view of zero cases.

 Keeping polio eradication as a key health priority in India until global eradication.

SOURCE-

http://www.polioeradication.org/Portals/0/Document/InfectedCountries/India/PolioIndiaFactSheet.pdf

IMAGE COURTESY- GOOGLE

SOLUTION to the Challenges faced by Routine Immunization

How to measure effectiveness of RI program?

Does coverage of individual antigen the only yardstick to measure effectiveness of the RI program? Or the intended end result, i.e. the absence of a particular VPD should serve as a better correlate? There are vaccines like polio, measles, etc that possess considerable ‘herd effect’, and if they behave true to their presumed potential, achieving more than 90% coverage may not always be mandatory and the target disease should disappear well before achieving that high coverage. In other words, if potent and effective antigens are employed judiciously the problem of inadequate coverage can be sorted out to certain extent. Even then, the dismal rates of immunization coverage in few states are not going to be acceptable. Hence, the best correlate for an effective RI program should be the control or elimination of a VPD rather than mere coverage rates. Here comes the role of VPD surveillance which is unfortunately non-existent in the country.

 How to effectively incorporate ‘newer vaccines’ in to RI program?

Another significant development is the availability of many new vaccines and renewed global interest in the ‘developing world’s’ immunization programs, along with availability of new funding opportunities and schemes by many giant multinational NGOs. These funding schemes provide great opportunities as well as incentive to strengthen routine immunization in developing countries.

Immunization programs need continued support with proven strategies and fresh approaches to permit the ‘effective’ introduction of new vaccines. Here, the emphasis is on ‘effective’-meaning thereby introduction of a vaccine in to national immunization schedule that has a measurable impact on the epidemiology of the disease. Merely making the vaccine available in few pockets, for certain sections and for limited duration will not have any impact at national level. The ‘equity’ needs to be ensured so that the vaccine reaches to the section of the society who needs it the most. According to recent reports, there are at least 23 new or improved vaccines for children and adolescents in development(6,7). Integrating these vaccines into routine programs will be a real challenge. Though these vaccines will be available to poor developing countries like India at subsidized rates, they will substantially increase the expenditure on routine immunizations. To fully take advantage of these new vaccines, it is essential to identify novel strategies and utilize proven strategies for improving routine immunization at the service delivery level. Despite the attention that global immunization has attracted in recent years in terms of the introduction of new vaccines and the strengthening of health systems, there is a clear need to ensure that program managers are aware of what strategies at the health facility level will be needed to strengthen programs(7).

What is the Way Forward?

The above analysis has put forward many issues that need urgent attention from all stakeholders and partners. The main issues are poor utilization of available vaccines due to inadequate coverage, lack of an effective VPD surveillance system, ineffective vaccines and inappropriate vaccination schedules. Certain vaccines like BCG, OPV are found to be wanting as far as their effectiveness is concerned. Many experts believe that EPI schedule is flawed on immunological grounds and has also outlived its utility. With the advent of many new antigens and combinations, there is an urgent need to revise it comprehensively. But, before dwelling on the technical aspects, let’s first concentrate on how to take the most out of the existing resources and pave way for future expansion. The most daunting task is how to improve immunization coverage? The issues are mainly managerial and can be addressed in five broad groups:

(i) bringing immunization closer to communities;

(ii) using effective IEC to increase demand for vaccination;

(iii) improving practices at fixed sites;

(iv) better monitoring and supervision, and fixing accountability at district level; and

(v) exploring and adopting innovative methods and practices.

Bringing immunization closer to communities: Non-health workers should be involved to encourage people to seek immunization services, or increased access to immunization services by bringing services to community. For example, in Bangladesh semi-literate and illiterate local women were employed in an urban setting to track defaulters, to refer them to services and accompany mothers to immunization clinics(8). In Kenya, school buildings were utilized as immunization centers, with schoolchildren circulating immunization information within their communities(9). In Nigeria, access to immunization services was improved by increasing the number of locations offering immunization and adding mobile clinics in the evenings(10). We can learn from these experiences and try to curtail the distance between the community and service providers. In India, we can also seek the services of ‘quacks’ and utilize their services to reach unreached section of the society after imparting them adequate training and resources. They have fair chances of success because of their community knowledge, the respect they are given by the community, and the fact that they have access to community members who may not be reached by mass media.

Using effective IEC to increase demand: All elements of an immunization program need to be addressed. Information can be provided through numerous channels to either increase awareness of the benefits of immunization or to promote participation. These strategies increase demand for vaccination without changing the service delivery. Mass communication campaigns have the potential to reach large numbers of people, if access to the type of media selected is good(7).

Improving practices at fixed sites: Improved health facility practices can increase coverage through reducing "drop-outs" and "missed opportunities". In Ethiopia, the use of reminder stickers for parents resulted in nearly 50% decrease in dropout between DPT1 and DPT2(11).

Better monitoring and supervision, and fixing accountability: This is probably the key to success at micro-level. The success of SIAs in polio eradication program has highlighted the significance of these measures. This approach coupled with intensive micro-planning as done prior to a SIA round should pave the way for better coverage in poorly performing states.

Exploring and adopting innovative methods: Involvement of ‘quacks’ and other non-health workers are examples of innovative ways to improve RI. We need to not only constantly explore ways to augment rates, but at the same time adopt them in to the practice also. For instance, in Nicaragua, food incentives were introduced to create demand for immunization services(12). Use of mobile vans and teams, use of auto-disable syringes, peer-training of health workers from well-performing health facilities to poorly-performing centers, ‘cash-incentives’, involving community pharmacists for RI services, making RI compulsory before school admission are few examples of innovative ways of improving RI coverage(7,13,14).

Role of iap and private practitioners

Pediatricians and immunization providers are among key opinion leaders at the national and state level and also have a voice in local communities. Therefore, continued support of pediatricians will be essential to sustain acceptance of vaccines, thus improving routine immunization rates. The recommendations and guidelines of IAPCOI and other sub-committees are religiously followed by almost all IAP members across the country. Recommendations on improvement of RI have been recently published, where role of an IAP member is clearly defined(15). Apart from it, IAP is now invited to many national meetings related to formulation of national immunization program and regularly invited to NTAGI. Hence, it is our duty to not only issue recommendations that are technically sound for individual protection, but also keep the larger public interest in perspective while drafting them. We must walk this tight rope with perfection. Furthermore, our technical advice to the government on probable introduction of any new vaccine should be based on local need, proper evaluation of the quality of the product, feasibility of its widespread use, and its potential impact on disease epidemiology.

R K Agarwal,
President IAP 2008,
R K Hospital,
5/A, Madhuban, Udaipur 313 001, India.
Email: rk_hospital@hotmail.com

Source-

http://www.indianpediatrics.net/aug2008/aug-625-628.htm

Challenges for Immunization In India

Immunization programs are the cornerstone of public health, world over. Vaccination was practiced in India since the early 1900s, especially against small pox, in late 1940’s. In 1962, BCG inoculation was included in the National Tuberculosis Control Program. A formal program under the name of Expanded Program of Immunization (EPI) was launched in 1978(1). This gained momentum in 1985 under Universal Immunization Program (UIP). UIP was merged in child survival and safe motherhood program (CSSM) in 1992-93. Since 1997 immunization activities are an important component of Reproductive and Child Health (RCH) program. A National Technical Advisory Group on Immunization (NTAGI) was set up in 2003, and a Midterm Strategic Plan (MTSP) developed in 2004. From April 2005, immunization is an important component of RCH II under the National Rural Health Mission (NRHM).

Current Scenario

India has one of the lowest routine immunization (RI) rates in the world(2). Estimates from the 2005-2006 Indian National Family Health Survey (NFHS-3) indicate that only 43.5% of children age 12-23 months were fully vaccinated (received BCG, measles, and 3 doses of DPT and polio vaccines), and 5% had received no vaccinations at all(3). Given an annual birth cohort of 24 million surviving infants and an under 5 year mortality rate of 74/1000(4), this results in over 12.5 million under-immunized children each year. While national-level immunization rates are an important indicator of population protection, hetero-geneity in sub-national and local immunization coverage often provides a critical mass of susceptible individuals that can result in outbreaks. For example, in Utter Pradesh (UP) and Bihar, only 23% and 32.8% of all children age 12-23 months, respectively were fully vaccinated(3). Heterogeneity of coverage rates is not the only problem faced by RI in India, the falsification of data and over-reporting of rates, are other big concerns. Routine reporting is currently complemented by periodic Coverage Evaluation Surveys (CES) that offer updated information. The data indicates that DPT3 reported coverage is more than 90% in 2006 (MoHFW, GOI) while it was only 68% as per the CES-2006 results(1). The discrepancy in the number estimated is more evident in Uttar Pradesh, Bihar, Madhya Pradesh, Orissa and Rajasthan. Evidence also indicates that coverage levels are significantly higher in those areas with regular access to the services (63%) as compared to those communities where sessions are less frequent or irregular (33%)(1).

Challenges Ahead for Routine Immunization

The size and diversity of India make successful implementation of RI program more challenging, as do resource constraints and competing priorities. Considering the current state, the challenges in front of RI programs in India can be grouped in to three major groups:

• How best to utilize available vaccines?

• How to measure effectiveness of RI program?

• How to effectively incorporate ‘newer vaccines’ in to RI?

A. How best to utilize available vaccines?

Availability of vaccines used for RI program in India is not a major issue. But how to achieve uniformly high coverage with available vaccines, particularly in the states having higher disease burden, is the major challenge. Several reasons are cited for poor immunization rates(1,4,5); few are enumerated below:

• Inadequate delivery of health services (supply shortages, vacant staff positions, lack of training);

• Lack of information on the specific locations and age recommendations for receiving immuni-zations;

• Lack of accountability, inadequate supervision and monitoring, and no micro-planning at district level;

• Over-emphasis given to PPI/SIAs rounds of OPV and their adverse impact on RI;

• Weak surveillance for all vaccine preventable diseases (VPD) except polio;

• General lack of inter-sectoral coordination, resulting in missing opportunities to improve immunization coverage and quality;

• Varying date, place, and time of immunization sessions, making it difficult for parents to access services;

• Complacency, for reasons such as the belief that uncommon diseases are not important, or a mistaken belief that measles is common and therefore not a dangerous disease;

• Lack of support for ANMs from other staff at the health centers;

• Lack of awareness that children need routine immunizations and the belief that vaccines are not effective or, that only the polio vaccine is necessary;

• Parental time constraints and parental non-acceptance of immunization etc.

Thus, the problem lies at various levels in the system, including planning, training, implementation and monitoring of the program.

Source- 

http://www.indianpediatrics.net/aug2008/aug-625-628.htm

Adult Vaccination in India

Adult VaccinationDr.Shobhana Mohandas.

I Vaccination in the adult could pave way for prevention of many infective pathologies, which were hitherto bereft of solutions other than antibiotics, to which organisms are increasingly becoming resistant.    Vaccination in the adult, has, however, taken a backseat in India.  The nation has, as yet, not completed immunizing the paediatric population fully against all preventable infective diseases, and so the onus of immunizing the adult population has as yet not received any impetus in the country.  However , it is useful to know the adult vaccinations currently available and the possible populations in whom they could be useful.  Tetanus Toxoid. This is the commonest vaccination given in India, and is prescribed after a cut or a wound, beside pregnant women. Dosage: The full basic course of immunisation against tetanus toxiod consists of three primary doses of 0.5ml at least four weeks apart, deep intramuscularly, followed by booster doses at 18 months, 5 years, 10 years and 16 years and then every 10 years.   Where the immunization history is inadequate 1500 IU tetanus antiserum and 0.5ml Tetanus toxoid should be injected, with separate syringes, to different body sites. (If available, 250 units of tetanus immune globulin (human origin) can be substituted for the tetanus antiserum). A second 0.5ml dose of toxoid is recommended after 2 weeks and a third dose after a further 1 month. Tetanus, diphtheria, acellular pertussis (Tdap) vaccine Tdap/DTaP vaccines which are now available in India are a newer version of DTP vaccine. Tdap/DTaP vaccine which contains acellular pertusis vaccine is safer as it causes lesser adverse reactions than the older DTP vaccine. Indications:  Expert Group of the Association of Physicians of India on Adult Immunization in India recommends routine Tdap vaccination for all adults not immunized earlier. For adults in the age group of 18 to 64 years who have completed their childhood vaccination schedule, a booster dose of Td vaccine is indicated once every 10 years till the age of 65 years; one dose of Tdap vaccine may be administered in place of Td vaccine. Dose:  For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the third dose 6–12 months after the second. If incompletely vaccinated (i.e., less than 3 doses), administer remaining doses. Cholera Assossiation of Physicians of India (API) expert group does not recommend the available oral vaccines for routine adult immunization.   Some of them have waning efficacy and some, insufficient data. Hepatitis A vaccine Indication:  At present there is lack of evidence for recommending universal vaccination against hepatitis A in India.   close personal contacts; child-care center staff, attendees, and household members of the attendees  and persons exposed to a common source, such as infected food handlers need protection after exposure to hepatitis A.  Immune status for hepatitis A should be checked prior to vaccination. In healthy persons aged between 1 and 40 years, a single-antigen hepatitis A vaccine is preferred.  However, after 40 years, the manifestations of hepatitis A are more severe.  For them, administration of anti-HAV immunoglobulin (0.02 ml/kg, intramuscularly) as soon as possible, within two weeks following exposure is preferred since little information is available regarding the performance of the vaccine in this age group. If the anti-HAV immunoglobulin is not available, the vaccine can be used. Dose:   Glaxo's HAV costs Rs 1,000 per dose.` Primary vaccination protects the person for up to one year and a booster dose administered after six months provides protection for 20 years. Thus it should be administered as 2 doses 6- 12 months apart 1 ml IM . Merck’s Vaqta can alternately be used, in dose of 1ml in 2 doses, second dose 6-18months later.  Hepatitis B vaccine Indication:  Hepatitis B vaccination is indicated for all unvaccinated adults at risk for HBV infection and all adults seeking protection from HBV infection including post-exposure prophylaxis. They include patients with sexual exposure. injection-drug users; household contacts of persons with chronic HBV infection; inmates and staff of institutions for developmentally disabled persons in long-term care facilities; dialysis staff, laboratory staff dealing with blood samples, blood bank staff, nurses working in intensive care units, operation theaters and surgeons and other doctors at high-risk ; patients who are HIV-seropositive, patients with CLD, chronic kidney disease (CKD); diseases where blood products or multiple blood transfusions are required such as hemophilia, aplastic anemia, leukemia, hemoglobinopathies, and patients awaiting major surgeries.  homosexuals; promiscuous heterosexuals; commercial sex workers; and sex partners of HBsAg-positive persons. Dose:   For immunocompetent adults, 20 µg of recombinant vaccine is administered at 0, 1, and 6 months .  If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, give 3 doses at 0, 1, and 6 months; alternatively, a 4-dose Twinrix schedule, administered on days 0, 7, and 21–30 followed by a booster dose at month 12 may be used.  Herpes Zoster vaccination Indications:The expert group from API  observed that presently herpes zoster vaccine is not recommended for use in adult population, with or without comorbid conditions as reliable epidemiological data are not available from India regarding the burden of herpes zoster. Dose: Herpes zoster vaccine is administered as a single 0.65 ml dose subcutaneously in the deltoid region of the upper arm. Varicella vaccine: Indications: Varicella vaccine is recommended for post-exposure administration for unvaccinated persons without other evidence of immunity against varicella. It should preferably be given within 3 days of exposure to varicella rash and can be given up to 5 days of exposure to rash .  In case of an outbreak, it can be used to control the outbreak by vaccinating  unaffected people.   It is also  strongly recommended in adults at increased risk for exposure of varicella such as health care personnel, household contacts of immunocompromised persons, non-pregnant women of childbearing age, persons who live or work in environments in which transmission of VZV is likely (e.g., teachers, day-care employees, residents and staff in institutional settings), persons who live or work in environments in which transmission has been reported (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, and international travelers.  Dose:   Two vaccines for varicella virus are currently available in India. These are Varilrix and Okavax .  Two doses (0.5 ml each) of varicella vaccine subcutaneously over the deltoid region. Minimum interval between first and the second doses should be 4 weeks. If more than 8 weeks elapse after the first dose, the second dose may be administered without restarting the schedule. Those who have received one dose of vaccine in childhood are advised to get their second dose.   Varicella zoster immune globulin (vzig) is at present not available in India.  Influenza vaccine Indication: In the absence of epidemiological surveillance regarding the influenza serotypes in our country, the Expert Group of API observed that presently the use of influenza vaccine in India is not recommended. Dose: Trivalent inactivated influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV) are available for use in adults.    In India it will cost around 1350R. The TIV is administered by an annual, single intramuscular dose of 0.5 ml.for all agegroups.   Measles Mumps rubella vaccine Indications:  A ll adults (except those who have medically documented history of having suffered from all the three disease; those who have received two doses of MMR vaccine in the childhood; and those with any contraindications for receiving this vaccine), should receive one dose of the MMR vaccine.  Hospital employees, particularly those working in the O and G Department are at risk. At the start of their employment, the health care workers should be vaccinated.  Provision of this vaccine to both medical and nursing students before they enter the hospital environment (ie pre-clinical phase) would help prevent the hospital-based outbreaks and would protect the female health personnel before their first pregnancy.  Dose: For adult immunization, two doses of the vaccine are recommended 4-6 weeks apart.  Meningococcal vaccine: Indication: Routine  vaccination of all adults is not recommended in view of the short lived protection provided by the currently available polysaccharide vaccines. The meningococcal vaccine can be used in selected populations in certain situations such as during an outbreak, during inter epidemic periods to persons living in dormitories and immunocompromised individuals, to travellers, pilgrims, people attending fairs and festivals in large numbers. Dose: In India bivalent (A+C) and quadrivalent (A,C, Y, W 135) polysaccharide meningococcal vaccines are marketed by few multinational companies.  A single dose of 0.5 ml of reconstituted vaccine is administered subcutaneously in the deltoid region for adults. Immunity is conferred for a period of only three to five years. Pneumococcal Polysacharide vaccine (PPSV) Indications:  Although PPV is efficacious in preventing invasive pneumococcal disease among adults, routine PPV administration to adults is not likely to be cost-effective in India.     Dose:  Single dose vaccination.    cost: around Rs. 4,500.   Human Papilloma Virus Vaccines Two HPV vaccines are commercially available. These include Gardasil, a quadrivalent vaccine containing the HPV virus L1 protein like particles of HPV 6,11,16, and 18; Cervarix is a bivalent vaccine containing L1 VLPs of HPV 16,18.   Dose:  For the Gardasil vaccine, 3 doses are administered as 0.5 ml intramuscular injection at 0, 2, and 6 months. The minimum interval between the 1st and 2nd doses and the 2nd and 3rd doses should be 4 weeks and 12 weeks respectively. For the Cervarix  vaccine, 3 doses are administered as 0.5 ml intramuscular injection at 0, 1 and 6 months. Immunization must precede the sexual debut. initiation for vaccination is recommended to be 10 - 12 years . Catch-up vaccination can be advised up to the age of 26 years for Gardasil vaccine and 45 years for Cervarix vaccine . The HPV vaccine is contraindicated during pregnancy and in patients with hypersensitivity to any of the vaccine components. In case a patient becomes pregnant during the course of vaccination, the subsequent doses should be delayed till delivery, but, should be completed within 1 year.  Screening for cervical cancer should be continued in spite of HPV vaccination. Rabies Indications: Rabies vaccine is indicated, in two categories of people with exposure. Category III: Single or multiple transdermal bites, scratches or contamination of mucous membrane with salinva (i.e.licks), exposure to bats:  In these cases, vaccination and the use of rabies immunoglobulin is indicated in addition to wound management. Category II: If there are only minor scratches or abrasions without bleeding or licks on broken skin and nibbling of uncovered skin, use of vaccine alone is sufficient. Category I: In case of just touching, feeding of animals or licks on intact skin, no prophylaxis is needed. Dose: The tissue culture rabies vaccines are administered in the deltoid muscle or in the anterolateral part of the thigh. They are not to be injected in the gluteal region. Five doses of the vaccine are administered on days 0, 3, 7, 14, and 28. Optionally on day 90 a sixth dose may be given.  Following exposure, there is no need to wait for laboratory confirmation of diagnosis to start treatment. Immediately after exposure, wound care is started, and the degree of exposure is classified and the post-exposure treatment is started. The animal is to be observed for 10 days. Post-exposure vaccination can be discontinued if the animal is healthy after 10 days. Persons who present for evaluation and prophylaxis even months after having been bitten should be dealt with in the same manner as if the contact occurred recently. Passive immunization is carried out with human rabies immunoglobulin (HRIG) (20 IU/kg body weight; up to a maximum of 1500 IU or equine rabies immunoglobulin (ERIG) (40 IU/kg body weight; maximum of 3000 IU). The ERIG must be given only after administering the test dose as per the manufacturer’s guidelines.  Re exposure: On re-exposure following a full course of either pre-or post-exposure vaccination, 2 booster doses are to be administered intramuscularly or intradermally on days 0 and 3 irrespective of category of exposure or time that has elapsed since previous vaccination. Rabies immunoglobulin is not indicated in this scenario. All subjects who have received incomplete vaccination should be treated as fresh cases. Yellow fever vaccine. Indication: for travelers to African continent. The vaccine may only be administered  through clinics and sites  registered as yellow fever vaccine  distribution sites.  Travelers should be vaccinated at least 10 days before arrival in a risk zone. The vaccine  is generally safe. It is associated with a risk for vaccine-associated neurologic disease and viscerotropic disease, the latter of which may be fatal.  Risk increases with age, and the risk for either approximates 1 in25 000 among recipients older than 70 years. Japanese encephalitis. Japanese encephalitisis a mosquito-borne viral infection in Asia. It is a tissue-culture– derived vaccine administered as 2 doses (day 0 and 28) and is currently approved for use in travelers 17 years of age and older. Conclusion: The middleclass in India is becoming stronger, and there is a sizeable upper class population.  At least in this population should be sensitized about adult immunization in selected groups.  Once a start is made, these vaccines will be available more freely, bringing down the cost, leading to more universal acceptance in the future. Source- http://www.gynaecologythrissur.com/gynaecology/Adult%20vaccination.htm Image Courtesy- Google