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.
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