Need for pre-emptive intervention

MEENAKSHI DATTA GHOSH

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IMMUNIZATION uses the body’s natural defence mechanism, the immune response, to build resistance to specific infections. Immunization requires vaccinating a child (or adult) with either a live attenuated vaccine derived from disease-causing viruses or bacteria that have been weakened under laboratory conditions, or inactivated/killed formulations of these viruses/bacteria. In the former, the live attenuated virus/bacteria replicates in the individual vaccinated; however, since these have been weakened, they cause either no disease or only a mild form of the disease. The BCG, measles, and the oral polio vaccines fall in this category.

In the second category of vaccines, since the small doses of inactivated or killed bacteria cannot grow in the individual vaccinated, they cannot cause the disease. These vaccines are less effective and require multiple doses for full protection, as well as booster doses to maintain immunity. Three doses of DPT for instance, provide over 95 per cent protection against diphtheria, 80 per cent against pertussis and 100 per cent against tetanus.

Since vaccinating a child significantly reduces the likelihood of the immunized child developing illness, immunization becomes a critical part of disease prevention. The higher the number of children immunized in a population cohort, the lower the chances of rampant spread of infection. Immunization of infants and children is absolutely critical, both for their survival as well as to contain the spread of infection and disease.

The Government of India launched the National Rural Health Mission (NRHM) in the fiscal year 2005-06, as also the National Nutrition Mission (NNM) in the same year. The global community designated halving between 1990 and 2015 the pre-valence of underweight children as a key indicator of progress toward the Millennium Development Goal (MDG) of eradicating poverty and extreme hunger. Economic growth alone, though impressive, would not reduce malnutrition sufficiently to meet the MDG target for nutrition. India’s main early childhood development intervention, the Integrated Child Development Services (ICDS) programme, was reviewed during 2005. This review had a direct impact on the evolution of the immunization programme under the NRHM.

 

India’s Universal Immunization Programme (UIP) is one of the largest in the world in terms of quantities of vaccines used, the sheer number of beneficiaries targeted, the number of immunization sessions organized, and the geographical spread and diversity in physical coverage. Six vaccines protect children and pregnant mothers against tuberculosis, diphtheria, pertussis, polio, measles and tetanus. In recent years, the hepatitis B vaccine and the JE vaccines have been introduced into the UIP. However, the fact is that despite the concerted efforts of the Union and state governments in partnership with NGOs, CBOs, and local governments, approximately 10 million vulnerable infants and children across India remain un-immunized, the highest proportion globally vis-a-vis population. Roughly coinciding with the launch of the NRHM, the National Family Health Survey(2005-06) reported that only 43.5 per cent children in India received all their primary vaccinations by 12 months of age.

Milestones in the Immunization Programme in India

1978

Expanded Programme of Immunization (EPI) introduced. Vaccines protecting children against BCG, DPT, OPV, Typhoid limited mainly to the urban poor

1984

Universal Immunization Programme (UIP) introduced as protection against six Vaccine Preventable Diseases (VPDs)

1985

Oral rehydration therapy programme introduced for prevention of deaths due to diarrhoea. Measles vaccine introduced. Close monitoring of below one year age group

1986

Technology Mission on Child Immunization set up

1990

UIP and ORT universalized in all districts. Vitamin A supplementation introduced

1992

Child immunization becomes part of child survival and safe motherhood programme

1995

Polio National Immunization Day introduced

1997

Subsumed in the Reproductive and Child Health Programme (RCH-I)

2005

RCH-II subsumed in the National Rural Health Mission. The district is made fully responsible/accountable for planning, coordinating and implementing the child immunization programme

Immunization services are offered free in public health facilities, but we continue to encounter wide variation in immunization outcomes across states. States with poorer immunization coverage have higher child mortality rates. Although the immunization programme became operational over three decades ago, several mismatches between the programme design and its actual implementation have prevented it from reaching its potential. A recent internal evaluation within the Union Ministry of Health and Family Welfare indicates the ground reality.

Coverage

States / Union Territories

LOW

(below 50%

Uttar Pradesh, Meghalaya, Madhya Pradesh, Tripura, Arunachal Pradesh, Bihar, Manipur and Rajasthan

MEDIUM

(50-70%)

Mizoram, Assam, Jharkhand, Gujarat, Chhattisgarh, Haryana, Orissa, Jammu and Kashmir, Uttarakhand, Andhra Pradesh, Delhi, Dadra & Nagar Haveli, and Maharashtra

HIGH

(>70%)

Chandigarh, West Bengal, Karnataka, Sikkim, Kerala, Punjab, Pondicherry, Himachal Pradesh, Tamil Nadu, Andaman and Nicobar Islands, Daman & Diu, Goa and Lakshadweep

 

Under the NRHM, there has been a visible scaling up in the universal access to immunization. There is a push towards micro-planning, towards getting the ASHAs (Accredited Social Health Activists) to target and mobilize beneficiaries with the highest unmet need for immunization, a serious emphasis on improving cold chain management, and on the introduction of newer vaccines for more comprehensive child protection. During 2009-10, the immunization programme across the country targeted 26 million infants and 30 million pregnant women. Immunization coverage has shown an improvement since the commencement of the NRHM in 2005.

 

One, the NRHM has introduced several immunization-specific measures. First, there are the new vaccines introduced. Hepatitis B and Japanese Encephalitis have been added to the immunization programme. The JE vaccination has been extended to 62 endemic districts in 11 states.The Hepatitis B programme has been expanded to 10 states. In January 2010, the Bivalent Polio Vaccine was introduced to counter wild poliovirus (P1 and P3).A second vaccination for measles and a catch-up campaign for measles has been introduced to address the incidence of child mortality estimated at four per cent on account of primary/recurrence of measles. That aside, there was the introduction of the Hib vaccine in Uttar Pradesh, and the elimination of neonatal tetanus has been pursued beyond the 15 states where this was validated.

Two, all the states and union territories are now engaged in preparing their respective state Programme Implementation Plans (PIPs) for immunization as part ‘C’ of NRHM PIP so that they can address their specific epidemiology, disease profile and quality of care.

Three, the NRHM has resulted in improved immunization service delivery with strengthening of human resources. The selection and deployment of over 700,000 ASHAs – essentially women community health volunteers, community mobilizers, and facilitators – has been a game changer. When the ASHA combines with the anganwadi worker (AWW), they are together able to mobilize targeted beneficiaries, constantly improve immunization outreach and coverage, and encourage the increased utilization of public spaces. Other than the ASHA, over 100,000 skilled health workers have been added in the field to revitalize the public health system.

 

Four, with so many more hands and feet on the ground, the NRHM has communitized the delivery of and access to immunization through the creation of numerous platforms and spaces. The more prominent among these are the village health and sanitation committees, village health and nutrition days, catch-up rounds for different vaccines, immunization days, immunization week, public participation in hospital development committees, and support to community monitoring programmes.

Source

Coverage evaluation survey(CES)

 

District level household survey(DLHS)

 

Time Period

2006

2009

DLHS 2(2002-04)

DLHS 3(2007-08)

Full Immunization

62.4

61.0

45.9

53.5

BCG

87.4

86.9

75.0

86.7

OPV3

67.5

70.4

57.3

65.6

DPT3

68.4

71.5

58.3

63.4

Measles

70.9

74.1

56.1

69.1

No Immunization

7.6

19.8

4.6

(Figures are in %)

Five, immunization efforts have been bolstered by improvements in health infrastructure. The upgrade of health facilities at multiple levels in all states is directly reflected in increased out-patient and in-patient attendance, as well as in increased institutional deliveries. The NRHM is addressing the infirmities in the existing public health infrastructure with a view to strengthening the management of public health and service delivery.

Health sub-centres increased from 146,026 in 2005 to 167,069 in 2010, primarily in the states of Chhattisgarh, Haryana, Jammu and Kashmir, Maharashtra, Orissa, Punjab, Rajasthan, Tamil Nadu, Tripura and Uttarakhand. Some 9,144 health sub-centres received new buildings and another 8,997 health sub-centres had their infrastructure upgraded or renovated.

In the same period some 437 new PHCs were added. Over 1,000 PHCs got new buildings, and the infrastructure of over 2,000 PHCs was upgraded. There has been an increase of 1,189 Community Health Centres in Arunachal Pradesh, Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Jammu & Kashmir, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Punjab, Rajasthan, Tamil Nadu, Uttarakhand, Uttar Pradesh, and West Bengal. In many of these states, immunization-related activities have achieved coverage and outreach far in excess of their previous best.

 

Six, the NRHM attempted to address some glaring shortcomings as well. Soon after 2005, it became clear that the then RCH programme yielded feed-back in respect of immunization almost exclusively focused on coverage data, that is, how many more were immunized? Equally, though reports were received from numerous units dispersed across the country, but paper-based reports, besides being tedious to submit and analyze, failed to capture real-time data!

Critical information on programme implementation such as the availability and supply of vaccines, the demand for vaccines, and the logistics of cold chain management was not being reported upon. This information is germane for forecasting requirements, for monitoring the status of vaccine supply, and for future planning.

To address these infirmities the NRHM has introduced a computer-based, routine immunization monitoring system: the RIMS software. This has enabled rapid data compilation from PHC levels, as well as from other reporting units in respect of the following five broad categories: immunization and vitamin A; vaccine supply; vaccine preventable disease (VPD) surveillance; status of cold chain equipment; and adverse event following immunization (AEFI).

The RIMS analyzes data and generates useful reports for the use of UPI managers at all levels – district, state and national – and is a useful tool to monitor the UIP programme. Steps are in hand to extend the RIMS beyond the 300 districts in the low-performing states. Comprehensive reports from all the 610 districts will soon become available.

 

Seven, in recent years, there have been a number of innovations in implementing the UIP. These include introduction of AD (auto-disposable) syringes throughout the country; permitting alternate vaccinators in pockets/subdivisions where there are no ANMs, as well as in peri-urban areas; enabling alternate vaccine delivery systems; bridging the gaps in coverage and outreach through catch-up rounds; and installing systems for name-based tracking of pregnant women and children, particularly for antenatal care and immunization, so as to capture the beneficiaries targeted, whether pregnant women, infants or older children.

Eight, there has been a concerted effort to increase UIP coverage in low performing states, and a variety of experiments and projects have been pursued. Under the NRHM umbrella, there has been implementation of catch-up rounds and immunization weeks, plus other interventions (vitamin A, deworming, and so on) in Uttar Pradesh, Bihar, Chhattisgarh, Jharkhand and the North East states. There has also been strengthening of external quality assurance mechanisms and the network for health worker training in Bihar and Rajasthan.

 

Nine, in underserved areas immunization has been outsourced to NGOs, as in Arunachal Pradesh. In Jharkhand and Orissa, health workers have been incentivized. Reinvigorating monitoring and field supervision through regular reviews of all immunization outreach sessions in the poor performing states is a priority. Compliance using RIMS has been pushed through across states, first in the 300 identified districts and then beyond.

Ten, there were efforts to augment management of vaccines, cold chains and logistics and programme monitoring and supervision through a series of wide-ranging initiatives:

* Management of vaccine, cold chain and logistics (setting up a fund for emergency vaccine procurement; installing systems for management of vaccine stocks in Tamil Nadu and Maharashtra).

* Strengthening programme monitoring and supervision (setting up a state task force/operational core group for monitoring in Kerala and Karnataka; ensuring district level supervision in Punjab; engaging in close monitoring, cluster and internal evaluation and supportive supervision of low performing pockets in Kerala, Karnataka, Andhra Pradesh, Tamil Nadu and Maharashtra).

* Programme monitoring and supervision (implementing a district level Coverage Evaluation Survey in Bihar and Gujarat; monitoring with the support of partners in Uttar Pradesh, Bihar, Rajasthan, Jharkhand and Madhya Pradesh; supportive supervision in Jharkhand and Madhya Pradesh; division level reviews in Uttar Pradesh).

* Implementing strategies to bridge the gaps in high performing states (public-private partnerships with medical colleges and youth organizations in Karnataka and Mizoram; establishing support groups in Maharashtra; engaging with panchayati raj institutions to mobilize beneficiaries in Kerala; operationalizing additional static and mobile clinics for immunization in Mizoram and Delhi; involving private medical practitioners and outsourcing immunization to NGOs in Maharashtra, Goa, Kerala and Delhi).

 

Eleven, the increasing institutional deliveries through the NRHM have ensured that infants delivered each year receive somewhat more professional neo-natal care, with all mandatory immunizations duly administered. In a simultaneous exercise, these infants continue to be tracked for administering the booster doses of critical vaccines, and this is reflected in the higher coverage and outreach of infant and child immunization (Coverage Evaluation Survey 2009).

There is no doubting that NRHM brought about higher performance levels in infant and child immunization. However, this cannot overlook, or in any way minimize, the major challenges that remain. What stymies the child immunization programme?

For a start, we examine supply related issues. Newer vaccines are needed. Although additional vaccines have been introduced into the immunization programme, these are required to be made routine as early as is feasible. The fact remains that infants and children across the country need newer vaccines in response to disease specific mortality and morbidity indicators. This initiative would include the HepB-DPT-HiB pentavalent vaccine, the second dose of measles and rubella in select states, and expanding the JE vaccine in the remaining 42 districts.

 

Shortage of vaccines and cold chain equipment needs to be urgently addressed. With immunization-specific initiatives under the NRHM moving forward, confidence has been restored. Footfalls as well as participation have visibly increased at the immunization site sessions and during the immunization week. However, often vaccines fall short either because there are genuine shortages (since manufacturing units had been shut down, but will hopefully now be restored to better health), or on account of maldistribution within the state, poor inventory management or poor anticipation of actual requirements.

Is there a verifiable inventory of vaccine stock in community health centres and primary health centres being duly maintained, monitored and managed? Are there sufficient stocks of vaccines and supplies for all immunization sessions? Frequent reports of some vaccines being delivered in excess of requirement cause anxiety. Such erroneous excess delivery comes at the cost of adequate quantities of other significant vaccines. Is there some monitoring of the demand and supply patterns across clusters of districts and driven by disease profile (for instance the JE vaccine is directed towards specific districts)? Is there a verifiable schedule for regular delivery and distribution of vaccines and supplies to ANMs and health workers at outreach session sites through multiple vaccine delivery channels?

Does the district headquarters cold chain ensure monitoring and review visits every month? The NRHM has set up a cold chain at 25,000 sites, across 600 districts. As such, there are some 40 points per district where the vaccines are safe. However, the size of many districts and the never ending requirement for vaccines from the sheer numbers in need of being administered renders this huge progress inadequate. Related to this is the issue of management of cold chain and logistics.

 

There are difficulties at the outreach session sites. True, community health centres, primary health centres and health sub-centres have been strengthened. There are higher numbers of skilled personnel in position (although mostly far short of the required strength) than ever before. Medicines, drugs and vaccines are being pushed from central and state levels to district and sub-district level health facilities in abundant quantities. And higher mobility has been sanctioned for field staff. However, the fact is that only up to 80 per cent of beneficiaries targeted through the infant and child immunization programme are accessed, annually, through 800,000 immunization outreach session sites. Essentially, the ANM, the ASHA, the AAW converge in village visits and their combined efforts yield a diverse cohort of pregnant women, new-born infants, as well as children below 5 and 10 years of age. These outreach operations have become vital to the current strategy for implementing the immunization programme.

Moreover, despite our best efforts, the outreach operations often fail to sustain the initial level of curiosity, enthusiasm and participation. The ANM was envisaged to implement her charter of responsibilities for a population of 5,000; today she is more often looking after a population of over 12,000-20,000, and may not always reach the immunization session site for genuine reasons. Despite a more liberal approach, there remains inadequate mobility of health workers and supervisors at district and sub-district levels. In urban settings, this is compounded by inadequate health infrastructure, multiple agencies and poor coordination.

Should the ANM, the ASHA or the AAW be unavailable for one or more sessions, then the cohort they have motivated is lost. There are no feasible replacements. The success of each outreach session becomes somewhat unpredictable. Moving forward, these cohorts must eventually be integrated into routine immunization activities so that each infant or child is fully traced and tracked for receiving the full complement of vaccines. This integration is not happening at the pace at which it should, while outreach sessions continue to proliferate.

 

We now turn to demand related issues. Despite the gains in outreach and coverage, supplemented by improvements in the universal immunization programme, there remain demand issues that need to be addressed. The fact is that each infant born has an opportunity of some four specific contacts with the health system by the time she or he is 12 months old. This amazing opportunity is wholly underutilized and under-projected and directly responsible for the avoidable incidence of vaccine preventable disease, unnecessary morbidity and even child mortality.

Our information, education and communication campaigns need to emphasize (for the benefit of parents and guardians who hesitate to have their wards inoculated) that disease spreads from person to person and therefore if every child is immunized (and where necessary, adults as well), this will pre-empt any rampant spread of disease through the population and protect everyone.

Diseases such as smallpox and polio have nearly disappeared because of immunization. When addressing pregnant women and their families, and since most children get their inoculations during infancy and early childhood, we need an aggressive community awareness campaign across every gram panchayat, tehsil and block of the country called (as elsewhere) ‘Every Child by Two’. This will educate and urge parents to make sure their new-borns receive the full complement of vaccinations for comprehensive protection against major childhood diseases, and that if the older siblings have missed out they too should and can be protected.

We have to begin to visualize every school as an immunization outreach site. The NRHM must renew its efforts at integrating public health interventions in high visibility areas across the social sector. What come to mind immediately are school admissions. With the Sarva Shiksha Abhiyan now reinforced by the Right to Education (RTE) Act, can we not ‘catch’ our target population at school? Every parent is or will soon be sending his or her child to some school. Every school should become our most reliable outreach immunization site.

 

We must begin with toddlers in play school/pre-nursery, and ensure that in every district the ‘immunization team’ visits every crèche, playschool/pre-nursery and primary as well as secondary school for administering the full complement of age specific vaccinations prescribed in the national immunization schedule (developed by the Ministry of Health and Family Welfare). In fact, school admissions should require that every child entering school is mandatorily immunized with the consent of the parents/guardians. This will ensure that every child receives the full complement of vaccinations.

China has systematically strengthened its school entry immunization checks, and has established September 18-25 as the annual ‘Back to School Immunization’ period in order to vaccinate under-immunized children entering pre-school and primary school. We also need to create a health card for every child in school that will include a record of immunization. If created on an e-platform, it will remain life-long and indestructible.

Schools must perceive immunization as a basic need for children. It protects them from developing a potentially serious disease, and directly helps reduce the spread of infectious disease within the school (and in the community as well). This is commonly practised in developed countries. Students who transfer into the school system or who start kindergarten without all of the required vaccinations may be allowed to stay in school for up to 30 days while they complete their course of immunizations. India’s school health programme (in need of revamping) must be reinvented to include the administration of vaccines to all children from the ages of three to 16 in accordance with the national immunization schedule.

 

The demand for immunization could dramatically improve if reliable supply of free immunization services is coupled with incentives. In several African countries, coupling the distribution of vaccines and bed nets increased ownership of bed nets by more than 40 percentage points. In Nicaragua, attendance at an immunization campaign increased from 77 to 94 per cent when food incentives equivalent to about three to five days of wages were introduced to encourage vaccination.

Financial incentives such as conditional cash transfer programmes, popular in Latin American countries, have been effective in promoting the use of certain preventive healthcare services and also had a positive impact on health outcomes for women and children. Small non-financial incentives such as the introduction of a packet of lentils (perceived as useful for the whole family and of nutritional value) by Sewa Mandir in resource poor settings in Udaipur district, Rajasthan, has been seen as significantly boosting immunization rates.

 

There are long standing structural bottlenecks. Most child deaths occur on account of the cumulative effect of malnutrition, infectious diseases and co-morbidities. Child undernutrition in India (admittedly among the highest in the world) has dire consequences for morbidity and mortality. A major review of the ICDS programme (2005) concluded that the ICDS had not succeeded in making a significant dent in child malnutrition, primarily because the actual implementation of this flagship programme deviated from the original design.

ICDS was intended to offer a wide range of health, nutrition and education services to children, women, and adolescent girls, to target the needs of the poorest and the most under-nourished, while also reaching out to age groups that represent a significant ‘window of opportunity’ for nutrition investments – that is, children under three, pregnant and lactating mothers.

* The popular assumption that food insecurity is the primary, even sole, cause of malnutrition skewed the programme priorities towards food supplementation and pre-school education for children aged four to six years (when malnutrition has already set in) at the expense of other programme components.

* The ICDS failed to reach children under three. Skewed priorities were implemented at the expense of interventions on child care behaviour, on educating parents on how to improve nutrition within the family food budget. ICDS needed to focus on the critical determinants of malnutrition. Programmatically, this means emphasizing disease control and prevention activities, domestic childcare and feeding practices, and micronutrient supplementation. Greater convergence with the health sector, and in particular with the RCH programme, would be invaluable.

* From the perspective of disease control and prevention, the ICDS was designed, inter alia, to be the link with RCH services for immunization, vitamin A supplementation, and referral of high-risk children and pregnant women to the auxiliary nurse cum midwife (ANM). In practice, this linkage between the ICDS and the RCH remained somewhat limited (except in islands of excellence) largely because there was never any designated person or body to oversee, review and remedy implementation of this collaboration.

* On the ground, the anganwadi worker (AWW) does not actually pursue whether pregnant women are duly registered with the ANM, and are receiving ante-natal care. Similarly, anganwadi centre records do not reflect regular visits by the ANM. In the circumstances, the numerous immunization outreach sessions implemented jointly by the AWW, the ASHA and the ANM (under the aegis of the NRHM), address a felt need, and provide a long overdue corrective in the implementation of routine immunization. This collaboration currently serves to provide over 70 per cent of immunization coverage. Children under three are being accessed in huge numbers. This collaboration needs to be mainstreamed and institutionalized and not be confined to outreach sessions.

Infant mortality is declining, but not as rapidly as it should. The fact is that infant mortality is ‘neither counted, nor countered, nor accounted for’, according to Abhay Bang. Prior to the NRHM (barring exceptions), the infant mortality rate did not count in the performance appraisal of the ANM, the PHC, or the District Health Officer, but the number of tubectomies and the oral polio vaccine administered did. Neonatal mortality accounts for 66 per cent of IMR. The NRHM must implement the Integrated Management of Neonatal Management of Childhood Illnesses (IMNCI), and also home based newborn care as part of the RCH. This will include a focus on completing the full complement of vaccines for comprehensive protection of the neo-nate.

Newborns remain somewhat neglected. Newborns do not merit a hospital bed, stay appendages of their mothers, and are deprived provision of physical space, staff and dedicated equipment for their care and survival in hospitals. The SRS classification of causes of death does not reflect the true cause of infant and child mortality. There is also a crisis of under-recording. The NRHM must make mandatory 100% recording of child deaths, to be monitored at the operational level, with reports to district headquarters. This will raise the profile of, and hence accountability for, the IMR and the CMR (child mortality rate) at operational levels.

 

In conclusion, let me turn the problem on its head. There are public health situations where we need to be fully vigilant precisely because the appropriate vaccine has not been introduced. Cholera is a case in point.

Does the NRHM ensure that the current strategy for the control of cholera outbreak is being followed? Typically, cholera prevention measures include the provisioning of safe drinking water, appropriate sanitation, excreta and garbage disposal, and site planning. Cholera outbreak preparedness can be achieved by training health staff at different levels in the clinical management of patients with acute diarrhoea, maintaining additional stocks of oral rehydration salts, intravenous fluids, in the proper use of antibiotics, as well as through continual health education for the community. Response to a cholera outbreak would call for the setting up of a cholera treatment centre, epidemiological surveillance, active case finding, activation of mobile intervention teams, and proper case management.

 

The NRHM would do well to establish or strengthen surveillance systems for acute diarrhoea and cholera. These surveillance systems are critical for assessing the true burden of disease, identifying the areas at highest risk, and detecting outbreaks of cholera at the earliest possible stage. In India, a single dose vaccine could be of higher potential interest in pockets of recurrent outbreaks.

Sporadic outbreaks of cholera in urban slums or in flood affected populations can unendingly affect large communities. The WHO has been pursuing a dialogue since 1995 on the role of vaccines in the prevention and control of cholera outbreaks and endemic diseases. In Uganda in 1997, the Oral Cholera Vaccine (OCV) was used to prevent outbreaks of cholera among a stable group of refugees. Similarly, Vietnam also vaccinated populations affected by flooding in the Mekong delta as a pre-emptive strategy.

These are lessons on prevention and implementation to be imbibed in the design and roll out of the child immunization programme.

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