Universal immunization programme

UNIVERSAL IMMUNIZATION PROGRAMME

1. UNIVERSAL IMMUNIZATION PROGRAMME 1 Prepared by :- Krenil Parmar Akshika Patel Amisha Patel Guided by:- Dr.Sapna Desai Pioneer Pharmacy Degree College

2. CONTENTS Introduction History Aims Objectives Immunization schedules 1. National Immunization Schedule 2. WHO EPI Schedule New Vaccines Implementation of Routine Immunization Components 1. Strategy and policy 2. Cold Chain System, Vaccines and logistics 3. Injection Safety and Waste disposal 4. AEFI Surveillance System in India 5. Strategic communication 6. Immunization Things 7. Monitoring and Evaluation 2 Pioneer Pharmacy Degree College

3. INTRODUCTION 3 Universal Immunization Programme (UIP) is one of the largest public health programmes targeting close of 2.67 crore newborns and 2.9 crore pregnant women annually. It is one of the most cost-effective public health interventions and largely responsible for reduction of vaccine preventable under-5 mortality rate. Under UIP, immunization is providing free of cost against 12 vaccine preventable diseases: Nationally against 9 diseases - Diphtheria, Pertussis, Tetanus, Polio, Measles, Rubella, severe form of Childhood Tuberculosis, Hepatitis B and Meningitis & Pneumonia caused by Hemophilus Influenza type B Pioneer Pharmacy Degree College

4. Sub-nationally against 3 diseases - Rotavirus diarrhoea, Pneumococcal Pneumonia and Japanese Encephalitis; of which Rotavirus vaccine and Pneumococcal Conjugate vaccine are in process of expansion while JE vaccine is provided only in endemic districts. A child is said to be fully immunized if child receives all due vaccine as per national immunization schedule within 1st year age of child. The two major milestones of UIP have been the elimination of polio in 2014 and maternal and neonatal tetanus elimination in 2015. 4 Pioneer Pharmacy Degree College

5. HISTORY Under Global Smallpox Eradication Programme, it was experienced that immunization is the most powerful and cost effective weapon for the prevention and control and even eradication of a disease. May 1974, WHO officially launched a global immunization programme, known as Expanded Programme of Immunization for the prevention and control of six major, killer disease of children, namely tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles, all over the world by the year 2000. EPI was launched in India in January 1978. 5 Pioneer Pharmacy Degree College

6. It was called Expanded because: -Number of disease covered are more. -Services are extended to all corners of the world, irrespective of cast, creed, community and ability to pay for it. -The child is immunized much before it is born. Beneficiaries were all expectant mothers and children up to 16 years of age. Immunization was recommended from 3 rd month of infancy and for pregnant mothers, 3 doses of TT, respectively during 16-24 weeks, 24-32 weeks and during 36 weeks. 6 Pioneer Pharmacy Degree College

7. Government of India launched same program with same schedule on 1 st January 1978 with the same objectives of reducing child morbidity and mortality rates and to achieve self sufficiency in the production of vaccines. WHO launched a social target of achieving Health for all by 2000 AD. In 1983, the schedule was revised and recommended only 2 doses of TT during pregnancy, respectively during 16-24 weeks and 24-36 weeks and commencing routine immunization as early as 6 weeks during infancy and services were concentrated to under 5. 7 Pioneer Pharmacy Degree College

8. The Programme is now called Universal Child Immunization , 1990- that’s the name given to a declaration sponsored by UNICEF as part of the ‘United Nations’ 40 th anniversary in October 1985 . It is aimed at adding impetus to the global programme of EPI. The Indian version, the ‘Universal Immunization Programme’, was launched on November 19, 1985 and was dedicated to the memory of Smt. Indira Gandhi. The National Health Policy was aimed at achieving universal immunization coverage of the eligible population by 1990 . Impetus was added to the existing program by shifting from under 5 to under 1 year of age and the quality of services was also improved. 8 Pioneer Pharmacy Degree College

9. It was recommended to give 1 st dose of TT to the pregnant mother in the first contact and 2 nd dose after 1 month and BCG and OPV to the new born as early as at birth. During 1992, immunization program become a component of Child Survival and Safe Motherhood (CSSM) program. It was recommended to cover 100% among infant also. In 1995 , Pulse Polio Immunization Programme was launched as a strategy to eradicate poliomyelitis. In 1997 , immunization activities have been important component of National Reproductive and Child Health Programme. 9 Pioneer Pharmacy Degree College

10. In 2005 , immunization schedule was revised incorporating Hepatitis vaccine, 2 doses of JE vaccine in selected endemic district, 1 st during 9-12 months and 2 nd during 16-24 months and 2 doses of Measles vaccine, 1 st dose during 9-12 months and 2 nd dose during 16-24 months, under National Rural Health Mission (NRHM). In 2012 , GOI declared 2012 as the “Year of Intensification of Routine Immunization”. In 2013 , GOI along with other S-E Asia regions, declared commitment towards measles elimination and congenital Rubella syndrome control by 2020. 10 Pioneer Pharmacy Degree College

11. In 2014 , India was certified as “Polio free country”. To strengthen routine immunization, Government of India has planned the State Programme Implementation Plan (PIP) part C. 11 Pioneer Pharmacy Degree College

12. AIMS 100% coverage of expectant mothers with 2 doses of Tetanus toxoid(TT). At least 85% coverage of infants with 3 doses DPT and OPV 1 dose each of BCG and Measles vaccine before child’s 1 st birthday. 12 Pioneer Pharmacy Degree College

13. OBJECTIVES Rapidly increase immunization coverage. Improve the quality of services. Establish a reliable cold chain system to the health facility level. Introduce a district-wise system for monitoring of performance. Achieve self-sufficiency in vaccine production. Elimination of neonatal tetanus. Eradication of paralytic poliomyelitis. 13 Pioneer Pharmacy Degree College

14. Under UIP, following vaccines are provided: 1. BCG (Bacillus Calmette Guerin 2. DPT (Diphtheria, Pertussis and Tetanus Toxoid) 3. OPV (Oral Polio Vaccine) 4. Measles 5. Hepatitis B 6. TT (Tetanus Toxoid) 7. JE vaccination (Japanese Encephalitis) - (in selected high disease burden district) 8. Hib containing Pentavalent vaccine (DPT+Hep B+Hib) - (in selected states) 14 Pioneer Pharmacy Degree College

15. Immunization Schedules 1. National Immunization Schedule The Indian Academy of Paediatrics(IAP) recommends inclusion of more vaccines in the immunization schedule. These vaccines are not included in the UIP because of financial constraints. 15 Pioneer Pharmacy Degree College

16. The immunization schedule approved by the IAP is: BCG - Birth - 2 weeks OPV - Birth; 6 weeks, 10 weeks and 14 weeks; 16-18 months, 5 years DPT - 6 weeks, 10 weeks and 14 weeks; 16-18 months, 5 years Hepatitis B - Birth, 6 weeks and 14 weeks or 6 weeks, 10 weeks and 14 weeks Hib Conjugate - 6 weeks,10 weeks and 14 weeks Measles - 9 months, 16-24 months MMR - 15 months Typhoid - 2 years, 5 years, 8 years, 12 years TT/Td - 10 years, 16 years TT - 2 doses one month apart for pregnant women, or booster dose if previously immunized. 16 Pioneer Pharmacy Degree College

17. Vaccines that can be given after discussion with parents: Varicella - 15 months (or after 1 year) Hepatitis A - High-risk selected infants, 18 months, and 6 months later Pneumococcal - 6 weeks conjugate vaccine Influenza vaccine - 6 months of age to high risk selected infants anually 17 Pioneer Pharmacy Degree College

18. National Immunization Schedule (NIS) contd… Vaccine When to give Max. Age Dose Diluent Route Site For Pregnant Women TT- 1 Early in pregnancy 0.5 ml NO Intra-muscular Upper arm TT- 2 4 weeks after TT-1 0.5 ml NO Intra-muscular Upper arm TT- Booster If received TT dose in pregnancy within the last 3 years 0.5 ml NO Intra-muscular Upper arm 18 Pioneer Pharmacy Degree College

19. Vaccine When to give Max. Age Dose Diluent Route Site For Infants BCG At birth Till 1 year of age 0.1 ml (0.05 ml until 1 month of age) Sodium chloride Intra-dermal Left upper arm Hepatitis B At birth Within 24 hrs 0.5 ml NO Intra-muscular Antero-lateral side of mid thigh OPV-0 At birth Within the first 15 days 2 drops NO Oral OPV- 1,2 & 3 At 6,10 and 14 wks Till 5 years of age 2 drops NO Oral 19 Pioneer Pharmacy Degree College

20. Rota Virus vaccine At 6,10 and 14 wks Till 1 year of age 5 drops NO Oral IPV At 14 wks Up to 1 year of age 0.5 ml NO Intra-muscular Antero-lateral side of mid thigh Pentavalent 1,2 & 3 At 6,10 and 14 wks Till 1 year of age 0.5 ml NO Intra-muscular Antero-lateral side of mid thigh Measles 1 st dose 9-12 completed months Till 5 years of age 0.5 ml Sterile water Sub-cutaneous Right upper arm JE 1 st dose 9-12 completed months Till 15 years of age 0.5 ml Phosphate buffer Sub-cutaneous Left upper arm 20 Contd… Pioneer Pharmacy Degree College

21. Vitamin A (1 st dose) At 9 completed months with measles Till 5 years of age 1 ml (1 lakh IU) NO Oral For Children DPT Booster-1 16-24 months 7 years 0.5 ml NO Intra-muscular Antero-lateral side of mid thigh Measles 2 nd dose 16-24 months Till 5 years of age 0.5 ml Sterile water Sub-cutaneous Right upper arm OPV Booster 16-24 months Till 5 years of age 2 drops NO Oral 21 Contd… Pioneer Pharmacy Degree College

22. JE 2 nd dose 16-24 months 0.5 ml Phosphate buffer Sub-cutaneous Left upper arm Vitamin A (2 nd to 9 th dose ) 16 month then 1 dose every 6 months Till 5 years of age 2 ml (2 lakh IU) NO Oral DPT Booster 2 nd dose 5-6 years 7 years 0.5 ml NO Intra-muscular Upper arm TT 10 years and 16 years 0.5 ml NO Intra-muscular Upper arm 22 Contd… Pioneer Pharmacy Degree College

23. 2. WHO EPI Schedule The purpose is to assist health planners to develop an appropriate country specific immunization schedule based on local conditions. The health care workers should refer to their national immunization schedules. The WHO EPI Global Advisory Committee has strongly recommended BCG and Polio vaccine to be given at birth or at first contact, in countries where Tuberculosis and Polio have not be controlled. In all countries routine immunization with DPT and oral Polio vaccine can be safely and effectively initiated at 6 weeks of age. 23 Pioneer Pharmacy Degree College

24. New vaccines can be safely being added for the vaccination schedule e.g., Hepatitis B, Rubella and Japanese Encephalitis(JE) vaccines are now included in several country’s programmes. The immunization schedule may be altered to suit the local needs of individuals and groups. Interruption of the schedule with a delay between doses does not interfere with the final immunity achieved. There is no basis for the mistaken belief that if a second (or third) dose in an immunization is delayed, the immunization schedule must be started all over again. 24 Pioneer Pharmacy Degree College

25. The WHO Scientific Advisory Group of Experts to EPI has indicated the need to expand immunization activities beyond infancy, either as part of routine immunization services or as part of disease elimination or eradication measure. The vaccines of interest are MR and MMR as part of Measles outbreak prevention or elimination campaign, Td as booster dose for neonatal Tetanus elimination, Hepatitis B, Influenza, Varicella and HPV vaccines etc. 25 Pioneer Pharmacy Degree College

26. NEW VACCINES In April 2016 , India introduced the use of Fractional dose IPV (FIPV) into the routine immunization programme in 8 states (Odisha, Andhra Pradesh, Telangana, Karnataka, Tamil Nadu, Pondicherry and Maharashtra). Since March 2017 has been scaled up nationwide in all 36 states. 2 fractional doses of IPV 0.1 ml, are being given intradermally at 6 and 14 weeks. On 5 th Feb 2017 , The Ministry of Health and Family Welfare launched Measles Rubella (MR) vaccination campaign in the country, following immunization, replacing the currently given 2 doses of measles vaccine, at 9-12 months and 16-24 months of age in 5 states (karnataka, Tamil Nadu, Pondicherry, Goa and Lakshadweep) 26 Pioneer Pharmacy Degree College

27. In March 2016 , the Rotavirus vaccine was first introduced in 4 states (Haryana, Himachal Pradesh, Andhra Pradesh and Odisha). On 18 Feb 2017, Union Minister for Health and Family Welfare announced the expansion of the Rotavirus vaccine under its UIP in five additional states of Assam, Tripura, Madhya Pradesh, Rajasthan and Tamil Nadu. On 13 May 2017 , Union Minister for Health and Family Welfare, announced the introduction of pneumococcal conjugate vaccine(PCV) in the UIP. Currently, the vaccine is being rolled out to approximately 21 lakh children in Himachal Pradesh and parts of Bihar and Uttar Pradesh in the first phase. This will be followed by eventually be expanded to the country in a phased manner. 27 Pioneer Pharmacy Degree College

28. Implementation of Routine Immunization RI targets vaccinate 26 million new born each year with all primary doses and ~100 million children of 1-5 year age with booster doses of UIP vaccines. In addition, 30 million pregnant mothers are targeted for TT vaccination each year. To vaccinate this cohort of 156 million beneficiaries, ~9 million immunization sessions are conducted, majority of these are at village level. As per Coverage Evaluation Survey (2009), 89.8% of vaccination in India is provided through Public sector [(53%) from outreach session held at Anganwadi centre (25.6%), sub centre (18.9%) etc.] while private sector contributed to only 8.7%. 28 Pioneer Pharmacy Degree College

29. ASHA and AWW support ANM by mobilizing eligible children to session site thus try to ensure that no child is missed. ASHA is also provided an incentive of Rs.150/- per session for this activity. To ensure potent and safe vaccines are delivered to children, a network of ~27,000 cold chain points have been created across the country where vaccines are stored at recommended temperatures. 29 Pioneer Pharmacy Degree College

30. COMPONENTS 1 . Strategy and Policy: Directed towards achieving an acceptable, affordable and sustainable standard of health through an appropriate health system. Provision of universal immunization of children against vaccine preventable disease is one of the major goals under this policy. 30 Pioneer Pharmacy Degree College

31. Country developed a comprehensive Multi Year Strategic Plan for Immunization in 2005 with an addendum in 2010 to achieve these targets of improving access and utilization of immunization in the country. Ministry of Health and Family Welfare also revised the National Vaccine Policy in 2011. Goal - develop a long term plan to strengthen the UIP. 31 Pioneer Pharmacy Degree College

32. 2 . Cold Chain System, Vaccines and Logistics: Cold Chain is a system of storing and transporting vaccine at the recommended temperature range from the point of manufacture to point of use. The vaccines are supplied by manufactures directly to 4 Government Medical Store Depots (at Karnal, Mumbai,Chennai and Kolkata) and state and regional vaccine stores. Transportation of vaccines from states/regional stores to divisions and districts is done in cold boxes using insulated vaccine vans. 32 Pioneer Pharmacy Degree College

33. Vaccine carriers with ice packs are used to transport vaccines from PHCs to the outreach sessions in the village. At the PHCs and CHCs, cold chain handlers, who are health personnel (pharmacists, male and female multi-purpose health workers, etc) have been tasked with proper storage and handling of vaccines and daily upkeep of Ice Lined Refrigerators (ILRs) and Deep Freezers (DFs) including temperature charting. The performance and efficiency of the cold chain system at different levels is monitored continuously, through supervisory visits, review meetings. 33 Pioneer Pharmacy Degree College

34. 3 . Injection safety and Waste Disposal: To ensure safe injection practices, Government of India endeavors to ensure continuous supply of injection safety equipments (AD syringes, reconstitution syringes, hub cutters and waste disposal bags). Disposal of immunization waste is strictly as per Central Pollution control Board (CPCB) guidelines for biomedical waste disposal. 34 Pioneer Pharmacy Degree College

35. 4 . AEFI Surveillance System in India: The WHO defines AEFI as “A medical incident that takes place after an immunization, causes concern, and believed to be caused by immunization”. AEFI surveillance in country monitors immunization safety, detects and responds to adverse events following immunization; corrects unsafe immunization practices, reduces the negative impact of the event on health and contributes to the quality of immunization activities. 35 Pioneer Pharmacy Degree College

36. 5 . Strategic Communication: Strategic Communication refers to policy-making and guidance for consistent information activity through coherent messaging. The issue of media advocacy, proactive planning and effective media response is emerging as one of the key elements of strategic communication support to achieving full Routine Immunization coverage in the country. 36 Pioneer Pharmacy Degree College

37. 6. Immunization Trainings: The Immunization Programme runs due to the coordinated efforts of different cadres of health staff working in the States at different levels(States, districts, PHCs and CHCs). In the year of intensification of routine immunization (2012-2013), the government of India has supported the training of approximately 12,50,000 frontline workers (ANMs, LHVs, anganwadi workers and ASHAs) in 9 high priority States-UP, MP, Rajasthan, Bihar, Chhattisgarh, Jharkhand, Haryana, Gujarat and West Bengal. The objective is to motive and strengthen the capacity of frontline workers to reduce dropouts and left outs and improve the quality of services. The process followed is a cascade model. 37 Pioneer Pharmacy Degree College

38. 7. Monitoring and evaluation UIP performs monitoring and evaluation at three levels. There is a regular reporting system from the health sub-centre to PHC, districts, state and national level. To evaluate immunization coverage, country conducts population based surveys. These include National Family Health Surveys(NFHS), District Level Health Surveys(DLHS), Annual Health Survey(AHS) and UNICEF coverage evaluation survey(CES). In between periodic surveys and administrative reporting, country also plans targeted studies and surveys to evaluate the performance of various components under UIP. 38 Pioneer Pharmacy Degree College

39. References Park’s Textbook of Preventive and Social Medicine;Bhanot;23 rd edition,page no.122-123. Patnaik L. Universal Immunization Programme;slideshare;2018. Dixit S. Universal Immunization Programme;slideshare;2017 Universal Immunization Programme,Government of India,Ministry of Health and Family Welfare;2017. 39 Pioneer Pharmacy Degree College

40. THANK YOU 40 Pioneer Pharmacy Degree College