Vaccine preventable diseases (VPDs) are still
responsible for about 25% of the 10 million deaths occurring
annually among children under five years of age [1]. In 2005, the
58th World Health Assembly (WHA), recognizing the role that vaccines
and immunization can play in reducing under-five mortality, welcomed
the Global Immunization Vision and Strategy (GIVS) 2006–2015
developed by WHO and UNICEF as a framework for strengthening
national immunization programs [2]. The specific goals of GIVS are
achieving 90% DTP3 coverage at national level and 80% coverage at
district level [2,3]. The collective recognition of immunization’s
potential has further led the global health community to call for
the "Decade of Vaccines"(DoV) [4]. The purpose of the DoV is to
extend, by 2020 and beyond, the full benefits of immunization to all
people, regardless of where they are born, who they are, or where
they live. In May 2011, the 64th
WHA endorsed the development of a Global Vaccine Action Plan (GVAP).
This plan is built on the success of the GIVS and is aimed to bring
all stakeholders together to ascertain collectively what countries
and the entire immunization community wants to achieve over the next
decade, determine concrete actions to make change happen, and define
indicators and processes to monitor and evaluate progress [5].
Considering the poor state of routine
immunization (RI) in few countries of South East Asia Region (SEAR),
the SEAR director has declared 2012 as the Year for Intensifying
Routine Immunization in the region to catalyze all immunization
systems stakeholders [6]. This initiative will focus on
intensification of RI in 2012 and sustaining the coverage thereafter
in countries with moderate immunization coverage.
Current Status of Immunization in India
Universal Immunization Program (UIP) performed
quite well in the first decade of its introduction in India. Between
1985 to 1995, the coverage levels for various vaccines reached
70-85% and the incidence of various VPDs rapidly declined in the
country [7]. However, since then, there has been a decline by 15 to
20% in the coverage of different vaccines [7]. Surveys carried out
during National Family Health Survey (NFHS) I, II and III and by
independent agencies such as UNICEF, have revealed that the coverage
levels may be lower by as much as 15-40% (8,9), compared to reported
levels of coverage in the UIP. Indeed, there are a few states in
India that have efficiently running UIP and several that do not.
According to most recent Coverage Evaluation
Survey (CES) 2009, a nationwide survey covering all States and Union
Territories of India conducted during November 2009 to January 2010
by UNICEF, the national fully immunized (FI) coverage against the
six vaccines included in UIP in the age-group of 12-23 month old
children is 61% whereas it was 54.1% and 47.3% as reported by
District Level Household and Facility Survey (DLHS-3) (2007-08) and
NFHS-III (2005-06), respectively [8-10]. Regarding coverage of
individual antigens in the similar age group, the CES 2009 reported
BCG, OPV and DTP3 doses coverage, and measles first dose coverage as
86.9%, 70.4%, 71.5%, and 74.1%, respectively (9). The corresponding
figures cited by DLHS-3 and NFHS-3 were 86.7%, 66%, 63.5%, and
69.5%, and 78.1%, 78.2%, 55.3%, and 58.8%, respectively [8,10]. As
far as newer antigens are concerned, the 3 doses of Hepatitis B
vaccine coverage among children 12-23 months in 16 States/UT where
it is part of UIP evaluated to be 58.9% by CES 2009 [9]. However,
birth dose administration is still a challenge in all these states.
There is gradual albeit a slow progress in the
performance of RI in India over last few years. There is marginal
improvement in many states recently. Six states with high population
contribute to 80% of 8.1 million unimmunized children in the
country, 52% of the total unimmunized reside in Uttar Pradesh and
Bihar alone [11].
New initiatives
The UIP in India targets 27 million infants and
30 million pregnant women every year. Since the launch of National
Rural Health Mission (NRHM) in 2005, more than 15 billion dollars
have been provided to the states in addition to their budgets, for
strengthening health systems and infrastructure with key focus on
reproductive and child health, including immunization [12].
India has introduced vaccine for Japanese
Encephalitis in 111 districts in 15 states having a high disease
burden. Hepatitis B vaccine, earlier introduced in 10 states, is now
being extended to the entire country. Introduction of the second
dose of measles, and Hib containing pentavalent vaccine, initially
in two states as part of routine immunization are other major
initiatives [12]. Another major step has been the framing of the
National Vaccine Policy [13]. India has also joined the global
post-marketing surveillance network for reporting AEFI associated
with new vaccines and Maharashtra is the participating state.
Barriers to achieve high RI rates
In a recent study conducted in 225 villages in 12
districts spread across the Western, Central and Eastern regions of
Uttar Pradesh, lack of faith in vaccination at the family level,
particularly among family elders, lack of vaccine-related knowledge,
fear of side effects of vaccination, lack of family support, lack of
knowledge of the place and day of immunization, uncertainty of
service provision, and limited counseling by health workers were
found to be major barriers to achieve high RI rates [14].
Less than 20 percent of women were aware that vaccinations can
protect a child against whooping cough, TB and diphtheria. Nine
percent of women and 11% of ASHAs reported non-availability of the
ANM on the scheduled immunization day as a reason for no or partial
immunization. On the other hand, women’s education, knowledge of the
next scheduled immunization date, knowledge of the side effects of
vaccination, awareness of risk if the child is not fully immunized,
credibility of frontline workers as a source of information, and
ensuring the availability of health providers and supplies were
found to be key facilitating factors for full immunization [14].
Apart from the above mentioned barriers, there
are some other challenges to achieving high RI rates and they
include inadequate delivery of health services (supply shortages,
vacant staff positions, lack of training); lack of accountability,
inadequate supervision and monitoring; lack of micro-planning at
district level; general lack of inter-sectoral coordination
resulting in missing opportunities to improve immunization coverage
and quality; lack of support for ANMs from other staff at the health
centers; parental time constraints and parental non-acceptance of
immunization [15]. The above barriers are further compounded by a
weak VPD surveillance system in the country. There is lack of
disease burden data on many important VPDs in India that results in
the perception that the disease is not important public health
problem. Further, there is utter lack of diagnostic tools for
certain VPDs. Lack of baseline surveillance data also is a
bottleneck in monitoring the impact of vaccination. These challenges
need to be addressed to improve the Immunization Program’s
performance in India.
What is Needed?
Address the barriers to achieve high RI rates
Focus should be on increasing demand for
vaccination by using effective IEC and bringing immunization closer
to the communities. The immunization services provided at the fixed
sites should be improved. There should be better monitoring and
supervision, and district authorities should be made accountable for
the performance of RI in their district [15].
Induct innovative methods to improve RI
The number of immunization ‘delivery points’
especially in rural and remote areas having poor access to health
facility, should be increased. ‘Immunization booths’ should be
constructed at every locality in urban areas particularly in slums,
and local municipality board member should be made accountable for
their performances. Large and varied cadres of volunteers,
including, for example, local medical practitioners, pharmacists,
chemists and retired nurses and other health personnel can be
recruited to offer immunization services. Proper training including
maintenance of cold chain and basic minimum education on vaccines
must be imparted to all of them. Complete immunization should be
made mandatory to get admission in school by appropriate
legislation. Incentives in cash and kind may be offered to those
families having fully immunized kids.
Proper monitoring of the program
The unsatisfactory performance of UIP in India is
due to managerial, administrative and governance-related
inadequacies, and not due to financial constraints or technical
inadequacies [16]. The need to monitor the progress of control of
diseases under UIP has not been realized; one element of the poor
performance of UIP is precisely this lack of monitoring.
To target only the coverage reached with
different vaccines may be misleading and may fall short of achieving
full objectives. The more important item to be monitored is the
‘impact’ or ‘output’ of entire vaccination program. ‘Output’
consists of disease reduction and demand creation. The neglect to
monitor and measure the outcome is the most glaring defect in the
UIP system [16]. Outcome measurement by disease surveillance is
essential to evaluate the success of UIP and to assess input
efficiency. Every "case" detected under UIP is evidence of the
success of the monitoring process as well as evidence for suboptimal
output of UIP or suboptimal efficacy or schedule of a particular
vaccine that call urgent remedial measures [16]. This will allow
program managers to move beyond the monitoring of immunization
coverage and understand the broader impact of immunization on
disease reduction.
Develop effective surveillance systems
UIP can seize the opportunity and establish a
surveillance system for all important childhood infectious diseases.
As has been demonstrated by the AFP surveillance network in India,
efficient surveillance systems can be established, even in
resource-poor settings, at quite low cost relative to the cost of
the intervention itself. Where appropriate, this network should
serve as the platform both for an integrated disease surveillance
system that provides epidemiological data on other communicable
diseases, and for detection and response to emerging infectious
disease threats. Funding for disease surveillance is usually disease
specific and time limited. In the presence of weak national systems,
parallel systems tend to be established in order to generate data
suited to the needs of specific programs. Integrated Disease
Surveillance Project (IDSP)- a state based decentralized
surveillance program in the country launched by Ministry of Health
and Family Welfare, Government of India (GoI) in November 2004, and
IDsurv–a web-based infectious disease surveillance program developed
by IAP–are laudable efforts in this regard [17,18]. These
uncoordinated efforts may address short-term needs, but we need more
comprehensive, coordinated efforts in the line of Active Bacterial
Core surveillance (ABCs)-a population-based surveillance system run
by Centers for Disease Control and Prevention (CDC), Atlanta in US
[19]. Similarly, there is need of having a functional real-time
adverse event following immunization (AEFI) and post-marketing
surveillance system in the country.
Relook at the UIP in India
The decades old Expanded Program of Immunization
(EPI) which was adopted in India as UIP needs a revamp with
inclusion of certain new vaccines. On immunological basis also the
EPI schedule currently adopted by many countries is not impeccable
[20].
Can India think of deviating from the WHO
recommended 6, 10, 14-week schedule and consider immunologically
more sound and appropriate 2, 4, 6-month schedule? Besides ensuring
superior immunogenicity, it has the advantage of facilitating visits
at the crucial ages of 4 and 6 months when infants are being weaned
(from breast feeding) and hence vulnerable to development of
malnutrition in the absence of proper nutritional advice. It will
also help to reduce the large gap and hence drop-out rate (between
the third DPT at 14 weeks and measles vaccine at 9 months) and
thereby ensure implementation of more comprehensive child health
practices like growth monitoring, nutritional advice, etc [20]. The
latter schedule will also be more appropriate immunologically once
many new vaccines like H. influenae b, rotavirus,
pneumococcal, etc are also incorporated in the UIP. Apart from the
proper schedule for UIP, one also needs to address the issue of
poor, ineffective quality of vaccines like BCG. Incorporation of
second dose of measles-containing vaccine in the Indian UIP is a
welcome move.
Integrated delivery of health interventions
Strengthening of immunization systems in such a
way that they support and integrate with other preventive health
services like providing vitamin A supplementation, deworming, growth
monitoring, distribution of insecticide-treated bed nets, etc. offer
the opportunity to create synergies and facilitate the delivery of
services to bolster comprehensive disease prevention and control.
Incorporating immunization into integrated primary health care
programs may also facilitate social mobilization efforts, help
generate community demand for services and address equity issues.
The strategy of child health days, led by UNICEF, has also helped to
promote routine immunization [21].
Improving operational efficiency and ‘Reaching
every community’
Urgent action needs to be taken to re-design and
re-define the roles and responsibilities and, working relationships
among the three levels: the center, state and district. The best
level to achieve and monitor disease control by vaccinations is
local, sub-district level, supervised and coordinated at district
level. In other words, the UIP system must be district-based in
terms of inputs, output and monitoring/evaluation. In 2002, WHO,
UNICEF, and other partners introduced the concept of "Reaching Every
District," which was a first step toward achieving more equitable
coverage. This approach has started yielding good results whereever
it was introduced [22]. To go even further, the experience of
successful polio vaccination campaigns that have aimed to reach
every child, even those outside of typical government outreach, can
be leveraged, and the "Reach Every District" strategic approach can
be recast as "Reaching Every Community."
Clear-cut policies on new/ underutilized vaccines
In a situation where there is abundance of new
and expensive vaccines on one hand and limitations of resources on
the other, it becomes imperative that use of vaccines through
introduction in the UIP as well as in the free market is done
through a framework of decision-making that confers positive health
and economic benefits to the society.
Decisions on implementing new and underutilized
vaccines require scientific evidence and data, a reliable supply of
affordable vaccines, which are adapted to the country’s immunization
schedule, and an integrated disease monitoring and surveillance
system. The fast progress in introducing new vaccines has been
facilitated by member states’ growing recognition of the value of
the protection conferred by vaccines and immunization. Such progress
has also been made possible by the establishment of global financing
mechanisms, including the Global alliance for Vaccines and
immunization (GAVI), and the important role played by regional
procurement mechanisms.
Although introduction of new vaccines is
important, this should not be at the expense of sustaining existing
immunization activities. Instead, the introduction of a new vaccine
should be viewed as an opportunity to strengthen immunization
systems, increase vaccine coverage and reduce inequities of access
to immunization services [23].
Conclusions
Developments in vaccines and immunization provide
us with tremendous opportunities to impact the health of our
populations, particularly the health of poor and marginalized
communities who carry a disproportionate burden of disease. Now is
the time to seize this momentum and commit to achieving
immunization’s full potential. Immunization is, and should be
recognized as, a core component of the human right to health and a
personal and collective community responsibility.
To be successful in the future, we must tackle
the technical, logistics, political and social obstacles that are
hampering progress in reaching every child with available vaccines.
Indeed, both coverage expansion to reach the never/unreached with
traditional EPI vaccines and the addition of a number of new
vaccines available in coming years are critical elements of global
health. Much remains to be done if the full potential of
immunization is to be exploited in achieving the health-related
MDGs.
Funding: None; Conflict of interest:
None.
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