Back
Year : 2015 | Volume : 3 | Issue : 3 | Page : 174 - 181  


Original Articles
Operationalizing Intensification of Routine Immunization: a simulation, interventional pilot study in four selected rural health Sub-Centres and one urban health Sub centre – experiences from Jharkhand; North India

Narayana Holla V1; Vijaya Kiran M2

1Associate professor, Department of Community Medicine, KVG Medical College and Hospital, Sullia, Karnataka

2Professor and Head, Department of Community Medicine, Malla Reddy Medical College for Women (MRMCW), Hyderabad

Corresponding Author:

Dr. Narayana Holla V

Email: narayana_holla@yahoo.co.in

Abstract:

Government of India (GOI) declared 2012-13 as the year of Intensification of Routine Immunization (IRI) for rapidly raising the coverage in needy states/districts and blocks depicted by DPT3 coverage as per DLHS 3 2007-08. This simulation pilot study was conducted with the objective of operationalizing one of the key strategies of conducting 4 Immunization Weeks (IWs) in 4 successive months and to share the operational impact for statewide application in Jharkhand. Method comprised intervention with enumeration format for enumerating cum line-listing and 4 in 1 format for preparing subcentre level micro-plan blended with supportive supervision, data collection/analysis/providing technical assistance and feedback.

Results were encouraging with significant rise in vaccination coverage: in the rural area, BCG coverage rose from 89 to 98%, DPT 3 from 75 to 99%, Measles 1st dose from 78 to 93%, DPT Booster from 58 to 86%, OPV booster from 44 to 85% and Measles 2nd dose from 41 to 84%. In the urban area all three rose to 68%; DPT booster from 33%, OPV booster from 19% and Measles 2nd dose from 12%.

Key words: Intensification of routine immunization, Simulation study

INTRODUCTION:

Since the inception of Expanded Programme on Immunization in 1978, India is consistently trying to raise and sustain the coverage to >90% with 6 basic vaccines. Coverage is not uniform among the states and among the districts within the state trickling down up to session sites till date.

DLHS3 (2007- 08) revealed National average of 71.5% DPT3 coverage1.14 states had DPT3 coverage less than national average, hence India declared 2012-13 as year of ‘Intensification of Routine Immunization’ (IRI) with an ambition of rapidly raising the coverage by clearing the backlogs under two year children through 4 ‘Immunization Weeks (IWs)’ in 4 successive months as one of the key strategies.2

The state of Jharkhand was carved out of the state of Bihar in 2000. Full Immunization Coverage (FIC) among 12-23 months children was only 8.8% as per National Family Health Survey 2 (NFHS 2-1998-99)3. DPT3 coverage of Jharkhand in 2007-08 (DLHS3) was 62.6%; less by 9% from the national average1.

Jharkhand had 3.3 crore population, sex ratio 948, 75.95% in rural and 24.05% in urban area and female literacy rate of 52.04% as per 2011 census4.

Improving routine immunization coverage was given high priority by the government. Development partners are actively involved for advocacy and technical assistance, as a result, FIC raised to 34.2% in 2005-2006 (NFHS 3)3.

Later, UNICEF Coverage Evaluation Survey 2009 revealed national coverage of 61% FIC among 12-23 months, 71.5% DPT 3; 41.4% DPT Booster and 13% DPT1-DPT3 drop-out5. Jharkhand indicators were below the national average: 59.5% FIC; 68.7 % DPT 3; 42% DPT Booster and 13% DPT1-DPT3 drop out6.

After a couple of years, Annual Health Survey 2011-12 showed higher coverage: FIC- 69.1% and DPT 3- 78%7. With an objective of achieving high coverage through rapidly clearing the backlog among children below 2 years, GOI declared 2012-13 as the year of Intensification of Routine Immunization.

State workshop for launching IRI was held in the beginning of March 2012, the selected districts/blocks were asked to submit the micro-plan in Annex 4 by the month end to start IWs from April 2012. Later it was postponed. Meanwhile, authors who attended the state workshop; planned IRI simulation study for piloting in 4 selected rural Health Sub-Centres (HSCs) and one Urban HSC of 2 composite Districts – Jamtara and Deoghar for statewide application.

Aims/objectives: To study the Impact of operationalizing immunization weeks on raising the coverage with innovative tools and Sharing the strengths of operational research (forms/model micro-plan booklet, study results..) for statewide application and to sustain the outcome.

METHODS:

GOI provided detailed guidelines focusing mainly on strategies, activities, timeline, the job responsibilities, 3 Annexes: 4 as planning template, 5 and 6 for reporting the performance at session site and planning unit level respectively2. No fixed target was imposed as the objective was to raise the coverage by clearing the backlog, session site wise, identified by the grass root level workers- the ANM/AWW/ASHA. These numbers were expected to decline after every IW to touch the basal minimum of fresh due beneficiaries.

For preparing Annex 4 at the planning unit level, exact number of ‘target beneficiaries’- (0 to 2yr children and pregnant women-PWs) for every antigen / every dose was required, for which author developed a format for enumerating cum line-listing the dates of vaccination of every child born since April 2010, to be certified by the ANM for the ownership and shared with Anganwadi worker (AWW)/Accredited Social Health Activist (ASHA) for reaching each and every child for social mobilization of due children; adequately addressed left-out and drop-out in triangulation. Session sites were categorized as A/B or C as per IRI guidelines2.

Study population: A cohort of children born between 1st April 2010 and 31st March 2012 were included in the study and followed up for recording backlog clearance. Cohort consisted of 1031 children 0 to 2 years from 22,873 population. [Children: urban=277; rural=754, Population: urban=7252, rural=15,621].

Study setting: Four rural – 2 per each district and one urban Health Sub-Centre of Deoghar were selected on the basis of operational feasibility.

Study period: 8 months, one preparatory month in March + six months:- four months for 4 IWs with intensified interventions- April to July 2012 for 4 Iws with intesified interventions in the IRI mode in the regular in the outreach sessions itself, two follow-up months- Aug and Sep for data validation/cleaning/updating and the eighth month for data analysis and report writing in Oct 2012.

Data was analysed using Microsoft excel and SPSS 17.

Every session site was the operational unit. Another format was developed for recording the number of doses, antigen-wise to calculate the full vials and the Auto Disable Syringes (ADS) required per session. The same format has provision for recording the number of children vaccinated on the session day, functioning as feeder form for reporting the performance in the Annex 5 provided by GOI (session site reporting). With this format, ANM measured the backlog clearance instantaneously; generated the work load (due target children) and logistic plan for the next session at the session site itself soon after completion of session held. Thus it did four major functions; hence nicknamed as “4 in 1” tool by the author. Later, on launching the programme state-wide in July 2012, these formats were adopted with a little modification and circulated as “Due List format and Compiler sheet” (Diagrams 1 & 2).

Technical assistance was provided in developing model HSC level micro-plan, compilation and consolidation at the block level (Diagrams 3 & 4).

Interventions were held in the regular monthly outreach sessions without incurring additional fatigue and financial burden. 28 Sessions of 5 HSCs per month were closely monitored by the author, supportive supervision provided, data collected on a regular basis, concurrently analyzed, time to time interim results were shared with grass root level workers, Medical Officers, District RCH officers and the state for feedback and further fine tuning. Director Immunization was appraised and model micro-plan booklet was shared by the author during his midcourse district visit.

RESULTS:

In every round the backlog got visibly cleared, rapidly and dramatically reached towards saturation as per the expectations of IRI – unprecedented in the past. During the course, due doses were administered close to the schedule as a natural phenomenon attaining early herd immunity.

In the rural area, BCG coverage rose from 89 to 98%, DPT 3 from 75 to 99%, Measles 1st dose from 78 to 93%, DPT Booster from 58 to 86%, OPV booster from 44 to 85% and Measles 2nd dose from 41 to 84%. p<0.05. Tables 1 and 3; (Diagram5).

In the urban HSC, BCG coverage increased from 67 to 98%, DPT 3 from 71 to 96%, Measles 1st dose from 71 to 92%; at par with rural area but for booster doses and Measles 2nd dose; though statistically significant (p<0.05); could not cross 85%. (DPT booster rose from 33 to 68%, OPV booster from 19 to 68% and Measles 2nd dose from 12 to 68%).Tables 2 and 4; (Diagram6).

DISCUSSION:

Since the raising of Jharkhand state, immunization coverage was on the rise from 8.8% as per NFHS 2:1998-99 to 59.5% as per CES-2009 and 69.1% as per AHS 2011-12. Since 1978 many stones were turned to raise the coverage. Expanded Programme on Immunization expanded the schedule, took the vaccination services from institution to the outreach: sub-centers and villages with expanded cold chain. UIP added measles and quality to the services through extensive training. NRHM strengthened RI in multiple ways- by providing alternate vaccine delivery, social mobilizer – the ASHA etc8. Since Dec 2009, novel Mother and Child Tracking System for online registration and tracking, computer generated duelist was introduced9. All are aiming at the common objective of raising the coverage and minimizing the drop-out.

But to achieve Goal 4 of Millennium Development Goals (MDG) 2000 in a short duration by 201510 needs extraordinary approach with specific tools for which India declared 2012-13 as the year of IRI.

Like in any new intervention, for IRI also, guidelines/strategies/job responsibilities/timeline /financial guideline/authorization and 3 Annexes: 4, 5 and 6 were provided by GOI & GOJ-enough to reach up to HSC/session site. Beyond this, to reach every beneficiary, dose-wise/antigen-wise; specific tools were developed by working closely with the grass-root level service providers (ANM/AWW/ASHA) by the author, field tested for uniform, non-ambiguous operational feasibility to obtain expected outcome. Retrospective vaccination status of each and every child born between 1st April 2010 and 31st March 2012 was enumerated and chronologically line-listed in the enumeration format in triangulation with AWW’s and ASHA’s; eliminating left-out forever (Diagram 1). Every session site was the outreach micro-planning unit. All 3 A’s had common format – ‘hard copy’ and displayed at the session site helped in entering the newborns from 01st April 2012 for continuation to study the prospective impact (not a part of this study), marking child specific due doses, mobilizing them on session day, recording the vaccination dates in the respective slots, again marking due doses for the coming session. However for this study, cohort of children born between 01st April and 31st March 2012 were included.

The due doses in numbers obtained from the enumeration form were entered in the 4 in 1 tool to estimate required vaccine vials/diluents/syringes per IW, record the number vaccinated against each dose of the antigen in the same tool (Diagram 2) to transfer the data to Annex 5 – the session reporting format of IRI guideline. 4 in 1 tool provided denominators, numerators and indicators. ANMs evaluated their own performance. They enjoyed the session as they mobilized, vaccinated, cleared the backlog and improved the coverage. The cycle was repeated, it is ongoing, changed the work culture, regular outreach session graduated to IRI session in the study area. During the intervention period, through mutual learning by doing, ANMs earned the ownership of the programme and inculcated custodianship of vaccination services. They became the master trainers in their district. With the introduction of this system, births and newborn vaccination data were entered within 24 hrs irrespective of place of birth while existing practice was to enter the data only after the arrival of mother and the child from maternal place after a gap of 3 to 6 months.

These formats of all the session sites were collated, Annex 4 of IRI was made (Diagram 3), HSC map added to make a model HSC micro-plan, shared with the GOJ for statewide application. Annex 4 of all HSCs were compiled and consolidated at the block level in the block compilation form and block plan was made under the technical assistance by the author (Diagram 4).

During the course “filtration” was discovered, i.e. once the major backlog was cleared and the number reduced to minimum; IRI session could be discontinued / merged with routine session which minimized human fatigue and financial burden. When launched, it was thought that once the IWs initiated it should mandatorily complete the course of 4 sessions in 4 months, but need not be so. On the contrary, in problematic urban areas there was a need to continue.

General tendency in public health for solving a long-standing problem is ‘staging’ i.e. raising by a fixed percent per year over a few years. Immunization coverage has grown by just 1% every year since 2009; Health ministry has set a target of over 5% every year as per Mission Indradhanush launched on Good Governance Day- 25th Dec 201411. But our IRI simulation study revealed that, one could achieve high coverage in a very short period of 4 to 6 months irrespective of the baseline coverage in immunization programme:- 89 to 98% for BCG; 41 to 84% for Measles 2nd dose in the rural area of Jharkhand. Another similar interventional study also confirmed dramatic rise in vaccination coverage:- 2nd dose of measles coverage rose from 55% to 89% in consecutive 3 sessions in 3 months and the entire backlog got cleared in a Primary Health Centre, Karnataka, South India12.

During the interaction, Urban ANM narrated a few important reasons specific to her area but many are common to any urban area viz. Non Anganwadi areas, no clear area demarcation, absence of social mobilizer, inadequate survey, care takers availing services from private sector not willing to share the information with AWW; ANM to do hospital work on non session days – no adequate time for house visits for mobilization and the like.

CONCLUSION:

Rapid improvement in the coverage justified IRI strategy. Coverage dramatically improved irrespective of baseline coverage (89 to 98% for BCG in rural area, for Measles 2nd dose- 41 to 84% in rural and 12 to 68% in urban). Enumeration format helped in simple but perfect line-listing and subsequent due list generation. The 4 in 1 format helped in self evaluating the performance as it had denominator/numerator/ indicator and again to make logistic plan for the next session – thus helped in rapidly clearing the backlog with perfect and simple but adequate documentation, vaccinating close to the schedule closing the population immunity gap – the basic principle in controlling/eliminating/eradicating Vaccine Preventable Disease(s).

REFERENCES:

  1. District level house-hold and facility survey 2007-08, Ministry of health and family welfare. Govt of India.
  1. Government of India, Ministry of Health and Family Welfare, Immunization Division. Strategic framework for Intensification of Routine Immunization in India. Coverage Improvement Plan 2012-13, 1-40
  2. National fact sheet, Coverage evaluation survey report 2009. Ministry of health and family welfare. Govt of India 2009 p 2.
  3. Jharkhand Population Census data 2011 accessed from http://www.census2011.co.in/census/state/jharkhand.html on 17-03-2014
  4. Government of India, Ministry of Health and Family Welfare National fact sheet, Coverage evaluation Survey report. UNICEF 2009, 2-10. Last accessed from http://www.unicef.org/india/National_Fact_Sheet_CES_2009.pdf on 05/03/2013
  5. Government of India, Ministry of Health and Family Welfare. Jharkhand fact sheet Coverage Evaluation Survey. UNICEF 2009, 1-8. Last Accessed from http://www.unicef.org/india/Karnataka_Fact_Sheet.pdf on 05/03/2013.
  6. Annual Health Survey 2011 - 12 Fact Sheet, accessed from http://www.censusindia.gov.in/vital_statistics/AHSBulletins/AHS_Factsheets_2011_12/Jharkhand_Factsheet_2011-12.pdf on 17-03-2014
  7. Govt. of India (2006), Annual Report 2005-06, Ministry of Health and Family Welfare, New Delhi.
  8. Mother and Child Tracking System (EMTS), http://health.cg.gov.in/ehealth/MISManuals/EMTS_Overview.pdf accessed on 18-03-2015.
  9. UNDP, Human Development Report 2003, Millennium Development Goals: A compact among nations to end human poverty, Oxford University Press.
  10. Mission Indradhanush Concept Note, http://ipa-world.org/society-resources/code/images/349bc28-mission%20Indradhanush%20Concept%20Note.pdf accessed on 18-03-2015.
  11. Holla N & Borker S (2014). An interventional study of reaching every child with every antigen through the tool “Immunogram” and approach “IgM2+ Application”, experience from a PHC in South India. Carta Medica. 1(2): 39-43.

Table 1. Baseline coverage – rural area of 4 HSCs; Population: 15,621

 

BCG

OPV1

OPV2

OPV3

DPT1

DPT2

DPT3

Measles 1

OPV B

DPT B

Measles 2

N

366

710

685

646

712

686

647

469

249

249

249

Achievement

No %

326 (89)

640 (90)

568 (83)

483 (75)

662 (93)

608 (89)

533 (82)

366 (78)

109 (44)

144 (58)

103 (41)

Table 2. Baseline coverage – urban area of 1 HSCs; Population: 7252

 

BCG

OPV1

OPV2

OPV3

DPT1

DPT2

DPT3

Measles 1

OPV B

DPT B

Measles 2

N

134

269

262

248

269

262

248

178

101

101

101

Achievement

No %

90 (67)

202 (75)

178 (68)

158 (64)

231 (86)

205 (78)

175 (71)

127 (71)

19 (19)

33 (33)

12

(12)

Table 3. Post intervention coverage – rural area of 4 HSCs

 

BCG

OPV1

OPV2

OPV3

DPT1

DPT2

DPT3

Measles 1

OPV B

DPT B

Measles 2

N

366

754

750

749

754

750

749

692

453

453

453

Achievement

No %

366 (100)

749 (99)

740 (99)

727 (97)

750 (99)

739 (99)

732 (98)

646 (93)

387 (85)

389 (86)

381 (84)

Table 4. Post intervention coverage – urban HSC

 

BCG

OPV1

OPV2

OPV3

DPT1

DPT2

DPT3

Measles 1

OPV B

DPT B

Measles 2

N

134

277

277

277

277

277

277

255

171

171

171

Achievement

No %

131 (98)

269 (97)

268 (97)

265 (96)

270 (97)

269 (97)

266 (96)

235 (92)

116 (68)

116 (68)

116 (68)

Table 5. Rural Urban comparative table

 

 

 

OPV B

DPT B

Measles 2

Rural %

Before

n=249

44

58

41

After

n=453

85

86

84

Urban %

Before

n=101

19

33

12

After

n=171

68

68

68

Diagram 1: Enumeration form

Diagram 2. 4 in 1 tool – compiler sheet

Diagram 3 Annex 4: HSC Level

Diagram 4 Annex 4: Block level consolidation

Diagram 5:IMPACT RURAL