Orientation to Routine Immunization Systems - PowerPoint Presentation

1. Orientation to Routine Immunization SystemsAn overview of routine immunization services in developing countries

2. Presentation I OutlineBroad overview of Routine Immunization (RI)History of Expanded Program on Immunization (EPI)About the RI vaccinesAbout the RI systemGlobal strategies to strengthen RICommon problems of RI services

3. About routine and supplementary immunization activitiesRoutine Immunization (RI) Objective: Provide all vaccinations listed on country RI scheduleServices are provided on an ongoing basis from permanent locationsTiming: throughout the yearTarget: Usually <1 year oldsSupplementary Immunization (SIA)Objective: Provide specific vaccines to those who missed receiving them in RI or who did not seroconvert when receiving RISIAs provided from multiple permanent and temporary locationsTiming: short duration (1 week)Target: Usually <5 or <15 year oldsOther names: campaigns, SIAs, NIDs (National Immunization days), SNIDs (sub-national immunization days)

4. Brief History of Global Immunization Systems1974: Expanded Program on Immunization (EPI) officially created 6 basic antigens for infants: Tuberculosis (BCG)PolioDiphtheria, tetanus, pertussis (DTP) Measles1990: Polio eradication goal globally endorsed 2000: GAVI Alliance created to streamline investment, vaccine introduction2001: Reaching Every District (RED) strategy created to revitalize stagnating RI performance2003: Global Immunization Vision & Strategy (GIVS) framework published to unify partners around common strategies and performance goals for immunization services

5. Global Goals for RIOutlined in the Global Immunization Vision & Strategy Framework 2006 – 2015 and the Global Vaccine Action Plan 2011-2020Outcome goalsNational immunization coverage >90% by 2015District immunization coverage >80% by 2015Decrease in VPD disease incidence by 2/3rd by 2015 from 1990 levelsEradicate polio

6. Global Immunization 1980-2014, DTP3 coverageglobal coverage at 86% in 2014Source: WHO/UNICEF coverage estimates 2014 revision. July 2015Immunization Vaccines and Biologicals, (IVB), World Health Organization.194 WHO Member States. Date of slide: 21 July 2015.

7. 2.5mil deaths 2.5mil deaths avertedWHO, Burden of Disease 2004, released 2008*vaccine preventable component caused by Streptococcus pneumoniae, Haemophilus influenzae type b, JE^, Japanese EncephalitisEstimated Global Annual Vaccine-Preventable Disease (VPD) Deaths Averted and Still Occurring among Children <5 Years, 2004

8. Global Alliance for Vaccines and Immunization (GAVI Alliance)ObjectivesAccelerate access to existing underused vaccinesStrengthen health and immunization systems in countries Introduce innovative new immunization technology, including vaccineswww.vaccinealliance.orgNumbers reflect seats on the GAVI Alliance Board of Directors8

9. About THE Vaccines

10. The Routine VaccinesBacille Calmette-Guérin (BCG) [against tuberculosis] Oral Polio vaccine (OPV)Inactivated Polio Vaccine (IPV)Diptheria, tetanus, pertussis (DTP or DTC or DTaP)Hepatitis B vaccine (HepB or HBV)Haemophilus Influenzae type B vaccine (Hib)Measles containing vaccine (MCV) Rubella Pneumococcal conjugate vaccine (PCV)Rotavirus vaccine (RV)Human Papillomavirus vaccine (HPV)Recommendations for children residing in certain regionsYellow Fever vaccine (YF)Japanese Encephalitis vaccine (JE)Meningococcal A Conjugate vaccine (MAC, MenAfriVac)

11. How Vaccines Are PackagedCertain antigens usually presented as combination vaccinesMR vaccine = measles and rubellaPentavalent vaccine = diptheria, tetanus, pertussis, HepB, HibMost vaccines packaged as multi-dose vialsMeasles vaccine vial = 10-dose, 5-dose, 1-dosePolio vaccine vial = 20-dose, 10-dosePentavalent vaccine vial = 10-doseCertain vaccines are freeze-dried and require reconstitution upon useMeasles, BCG, Yellow Fever and certain Hib formulationsOnce reconstituted, can only be used for 8 hoursVaccines not requiring reconstitution can be used up to 30 days after vial is opened

12. WHO-Recommended#Routine Immunizations & Immunization Schedule AgeTraditional VaccinesHepatitis B Vaccine1 or 2H. InfluenzaeNewer vaccinesBirthBCG, OPV0HepB16 weeksDTP1, OPV1HepB2HepB1Hib1PCV1, RV1*10 weeks DTP2, OPV2HepB2Hib2PCV2, RV2*14 weeksDTP3, OPV3HepB3HepB3Hib3PCV3, RV3*9 or 12 monthsMeasles, Rubella (YF and JE**)9-13 yearsHPV1-3***#See WHO recommendation summary tables: http://www.who.int/immunization/policy/immunization_tables/en/index.html * doses required for Rotarix; 2 doses required for Rota Teq**Yellow fever and JE vaccine are given to children residing in certain regions***HPV-quadrivalent requires 3 doses; 2nd dose given 2 months after 1st and 3rd dose given 4 months after 2nd dose.

13. Schedules Do Vary By CountryAgeBangladeshKenyaHaitiBirthBCGBCG, OPV0BCG, OPV06 weeksPenta1, OPV1Penta1, OPV1, PCV1DTP1, OPV110 weeks Penta2, OPV2Penta2, OPV2, PCV2DTP2, OPV214 weeksPenta3, OPV3Penta3, OPV3, PCV3DTP3, OPV336 weeksOPV4, Measles9 monthsMeasles, Yellow FeverMeasles-RubellaSource: WHO immunization schedule database, October 2011http://www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm

14. Example: Vaccination Schedule Poster

15. About Country RI Guidelines & PoliciesCountries often have an EPI policy and implementation documentCommon policies includeThe immunization scheduleThe eligible age of vaccination per vaccineHow a vaccinator should administer vaccinations (e.g. dosage, route, site of administration)Which staff are allowed to administer vaccinationsStorage of vaccines, use of opened vialsContraindications to vaccinationHow to respond to adverse events following immunizationCold chain maintenanceRecording and reporting practicesHow to conduct social mobilization to mothers, local leaders and key stakeholdersResponsibilities of each administrative level / staff memberKey methods for providing immunization services

16. About the RI System

17. RI System Components Immunization SystemHealth SystemExternalEnvironmentThe Immunization System EnvironmentImmunization Service DeliveryVaccine Supply & QualityCommunications & Community LinksPlanning & ManagementSurveillanceMonitoring & Using Data for Action (Response)Human Resources & Capacity BuildingFinanceThe Routine Immunization SystemCold Chain & Logistics

18. HUMAN RESOURCES & CAPACITY BUILDING

19. Human Resources: The EPI staffNational levelMinistry of Health immunization teamLed by EPI managerMajor immunization partnersWorld Health Organization: EPI team lead by EPI focal pointUNICEF: Maternal & Child health team with EPI focal pointRegion/district levelsGovernment immunization focal point / managermanage district-wide operations including RIFacility levelFacility medical officer-in-charge (MOIC, OIC, IC)Oversee reporting process, approves expenses, supervises health workersUsually is VPD surveillance focal pointHealth worker or vaccinatorProvides vaccinationsCompletes monthly reports, immunization registerTracks immunization performance via monitoring charts, other monitoring toolsRoutine & supplementary activities are often managed by same staff (e.g. EPI = all immunization activities in the country)

20. Example: Human Resources for Immunization in LiberiaMinistry of Health12 person team: team lead, surveillance officers, communication officers, data managers, SIA and RI focal pointsCounty health team: staff member assigned as EPI focal point Facility officer-in-charge: responsible for facility surveillanceFacility vaccinator: provides vaccinations, monitors service performance, mobilizes mothersWorld Health OrganizationHeavily support VPD surveillance system financially and manageriallySupport all all other aspects of Liberia’s EPI10 person team: team lead, surveillance officers, communication officers, data managers, SIA and RI focal pointsUNICEFImmunization work conducted by Maternal and child health teamResponsible for procurement of all EPI vaccines for countryMultiple NGOsConduct district-level supervisionProvide funding for many RI expenses (vehicles, fuel)USAIDProvides majority of WHO immunization budget

21. Planning & Management

22. Immunization Action PlansAction plans exist at all administrative levelsNational plans known as comprehensive multi-year plans (CMYPs) Include coverage goal, major program changes (vaccine introduction), new strategies to reach goalOften used to procure financing from external sourcescreated every 5-10 yearsDistrict, facility level plans known as microplans District plans used to consolidate information on facilities (target information, vaccine needs, expected performance)Facility plans used to identify when, where and how to hold immunization sessions throughout facility catchment areaupdated multiple times per year Country national plans can be found at:http://www.who.int/immunization_financing/countries/en/

23. About facility & district microplansMicroplans commonly includeCatchment target populationVaccine forecast informationList of villages with population data and session typeList of planned and held outreach sessions and applicable villagesMap with distances, hard to reach areas, villages and their populations, outreach sitesSocial mobilization activities

24. Example facility microplan from India

25. Catchment area: service delivery area assigned to facility Planning: Catchment Area MapMaps are created by vaccinators and district focal pointsMaps info includesHealth facility locationVillage locations, population, distance from HFSession type for villageCold chain storage pointsMajor area barriers

26. Example: Catchment map from Sierra Leone

27. Planning: Target populationTarget population defined asPortion of population which should receive all vaccines listed in country’s immunization scheduleTarget population set by the country’s immunization policyEPI target age group often is children <1 of ageTarget population source usually from census dataSome locations may conduct local headcounts when census data is considered inaccuratePopulation numbers are given to district, facility health staff to use for ordering vaccines, monitoring program performance and planning sessions

28. Managing RI services: SupervisionSupervision is a common national and district activity to ensure RI services are functioningSupervision objectiveProvide constructive feedback to facility staff on performance and help remedy problemsSupervisor commonly uses a checklist to cover all aspects of EPIDistrict to facility supervisionDistrict EPI focal point visits facility EPI staff every few monthsDistrict may also hold monthly meetings of facility staff at district capitalNational to district supervisionNational level staff from MoH, partners (WHO, UNICEF) visit district health teamsFeedback to superviseeWritten in a supervisory ledger or just verbalCopy of supervisory checklist results may be left with vaccinatorFeedback is followed up in next visit

29. Supervision checklist often used to guide the supervision visit

30. Cold Chain & LogisticsCold chain, Injection safety, waste management, vaccine management

31. The Cold Chain is EPI’s supply chain for vaccinesUNICEF supply divisionUNICEF country officeCountry Ministry of HealthThe EPI supply chain also transports safety boxes, syringes

32. Cold Chain Equipment (I)Freezers (-15 to -25 degrees C)Used for freezing ice packs at facility, district levelsUsed to store some vaccines at national levelRefrigerators (usually w/freezer)Used for vaccine storage at all levelsPower can be fromElectricityGenerators/ Voltage Stabilizers requiredKerosene LP GasSolar

33. Cold Chain Equipment (II)Vaccine carriers Commonly used for Transporting vaccine and diluents for outreach sessionsTemporarily holding vaccines on fixed delivery daysCarriers lined with frozen ice packsVaccines remain viable up to 48 hours in carrierIce packs also used during immunization session to keep vials coolIce packs should be “conditioned” prior to this use“Conditioned” = Allow ice packs to partially melt so vaccine is not directly exposedto freezing temperature

34. Monitoring cold chain equipmentTwice-daily, everyday recording of temperature for each equipment Equipment often have multiple thermometers due to malfunctionIf temperature outside range, reported to higher levelsVaccine will be moved if cold chain equipment fails

35. Vaccine Supply & QualityCold chain, Injection safety, waste management, vaccine management

36. Routine Vaccine ForecastingAll levels (facility, district, national) create forecasts of the number of RI doses required for use during a specific time periodForecasted number used when requesting RI doses from next higher levelVaccine forecast based on:Target populationWastage factor based on endorsed vaccine wastage rate “Wastage” is any dose not used to vaccinate a targeted personCountries set acceptable wastage rates e.g. the proportion of a vial which can be wasted due to various reasonMeasles, BCG, YF forecasts often use rates between 35-50%Pentavalent, Polio forecasts often use rates between 10%-30%Vaccine wastage factor formula = 100% / (100% – wastage rate)

37. Example: vaccine forecast in Liberia

38. Practice: Vaccine ForecastTarget population = 1000Wastage rate = 25%DTP requires 3 doses per childExpected coverage = 70%Doses are supplied every 3 months (1/4 year)Facility currently has a 300 dose balanceQuestion 1: How many doses are required for the 3 month period?Question 2: How many doses should the facility request for the 3 month period?

39. Managing vaccine supplyManaging vaccine stock (supply) requires tracking stock informationRoutine stock management registers used at each administrative levelRegisters used to track following infoNumber of vaccine doses received at levelNumber of vaccine doses used at levelCurrent balance of doses at levelBatch numbers, VVM status, expiry date of each vial

40. Example: stock management register from Nigeria

41. Monitoring vaccine qualityVaccine vial monitorsSticker on vialChanges color if exposed to heatTemperature loggersElectronic device to monitor actual temperatureUsually has log of last 30 to 60 daysFreeze Watch IndicatorChanges color if exposed to freezing temperatureNot commonly used in most countriesShake testMethod to determine if vaccine has been frozenCan be time-consuming as requires a suspect vial to be frozen, thawed and then testedDate of expiryIndicated on side on vial

42. Reading a Vaccine Vial Monitor (VVM)

43. Vaccine Waste ManagementUsed syringes placed in safety boxes during immunization sessionSafety boxes are burned in incinerators or buried in closed or opened pitsPits/incinerators are ideally fenced for safety

44. SERVICE DELIVERY: ConducTING IMMUNIZATION SESSIONS

45. Service delivery methods: FixedFixed immunization sessions“Fixed” location = health facilityFixed immunization sessions may happen everyday or only specific days each weekSome vaccines may have special session dayMost common for Measles and BCG vaccine due to special usage requirement e.g. once vial is opened, can only be used for single dayChildren are “batched” to ensure low wastage of doses in vials

46. Service delivery methods: OutreachOutreach immunization sessionsSessions which are conducted in communities far from health facilityVaccinator usually has multiple outreach locationsOutreach must be conducted at least 5x per year to each communityOutreach session scheduleIncludes locations, dates, target population for each planned outreach sessionsChallengesLack of fuel, transport, poor planning with community

47. Recording information during sessionsThe immunization registerUsed to record beneficiary information:Beneficiary name, address, phone, parents’ info, DOBDates when vaccines are receivedTally sheetsUsed to record number of doses administered in an immunization sessionNo child information, just number of doses given for each vaccine within a single immunization sessionTally sheet data is consolidated into monthly reporting formsHealth cardBeneficiary’s record of vaccination datesUsed to remind beneficiary when to return

48. EPI Register Example

49. Tally Sheet Example

50. Disease Surveillance

51. Schematic of surveillance system (1)Facility levelMedical staff monitor for suspected diseases Surveillance focal point collect surveillance data Analyze and use dataRoutinely report to the next level (monthly etc)District/intermediate levelAnalyze trends and performanceUse information (identify problem, propose solution, action)Routinely report to the next level (monthly etc)

52. Schematic of surveillance system (2)National level Keep databasesImmediate / weekly reportable diseasesMonthly IDS summary report Other quarterly reportsLaboratory (bacteriology, YF, measles & PBMS)Case-based (AFP, measles, YF, NNT)Monitor surveillance indicators using global standardsExample: % of cases with specimens collected within 14 daysRegular detailed analysis and feedbackExample: Newsletters and feedback to district staff Monitor surveillance system reportingTimeliness and completeness of reporting at lower levels

53. COMMUNICATIONS: CREATING COMMUNITY DEMAND FOR RI

54. RI Communications StrategyVillage structures utilized to mobilize mothers for RI includeVillage health volunteers Village chiefsVillage health committeesTown criers Village structures used to support RI system includingVaccine transportPlanning location of outreach servicesInforming mothers of time and location of RI servicesFinding infants who have dropped out of RI services

55. Community Links: Lady Health Workers in PakistanDuties: birth registration defaulter follow-up ‘catch-up’ routine immunization (including TT)

56. Key Communications MessagesDuring a vaccination visitWhen to return for next vaccinationThe potential adverse events that may occurImportance of vaccinationDuring a community meetingWhen and where outreach sessions should/will happenWhen and where fixed sessions happen“Special” vaccination days (e.g. for measles, BCG, YF)Importance of vaccination

57. Monitoring & Response: data for action

58. Monitor & Use Data for ActionCompile dataAnalyze data to identify problemsDecide what activities needed to solve problems: existing resources or extra resourcesGo back to your work plan and add these activities, prioritizeMonitor and evaluate impactTopic of the next talk (Part II)

59. ThanksQuestions?