Overview of EPI ,Myanmar

Dr Aung Kyaw Moe

Assistant Director
Expanded Programme on immunization
12th July 2017
 A comprehensive multiyear plan (cMYP)
for immunization ( 2017-2021)
• To strengthen immunization programme management, human
resources, financing and service delivery to provide equitable
service to all target populations
• To improve demand creation and ownership of immunization
• To strengthen immunization supply chain (iSC), vaccine
management and build stronger cold chain systems at all levels
• To maintain zero polio cases and vaccine derived poliovirus
(VDPV))
• To maintain MNTE status
• To achieve elimination of measles and control of rubella and CRS by
2020
• To strengthen and maintain strong surveillance systems for adverse
events following immunization (AEFI) and other priority VPDs
• To introduce new and underused vaccines and new technology into
routine immunization
Prevent; Immunization: background

3
Routine vaccination schedule (July 2016)

4
 Targeted Vaccine Preventable Diseases
1. Diphtheria . 11. Japanese encephalitis
2. Pertussis
12. Rotavirus gastroenteritis
3. Tetanus
4. Tuberculosis 13. Human papillomavirus
5. Poliomyelitis infection and cervical
cancer
6. Measles 14. Seasonal influenza
7. Hepatitis B 15. Yellow fever
8. Haemophilus influenzae 16. Meningococcal disease
type b disease 17. Mumps
9. Rubella and congenital
rubella syndrome
10. Pneumococcal disease
Five components of the immunization system
 National immunization coverage ,
2010-2016 (Administrative data)
100

90

80

70
2010
60 2011
2012
% 50
2013
40 2014
30 2015
2016
20

10

0
BCG Penta 3 MSL 1 TT2
 MCV 1 and MCV 2 coverage (2008 -2016)

100
90
80
70
60
% 50 MCV 1
40 MCV2
30
20
10
0
2008 2009 2010 2011 2012 2013 2014 2015 2016
 Routine Penta -3 Coverage 2014-2016

2014 2015 2016

Number of Townships with Number of Townships with Number of Townships with

<80% coverage = 57 <80% coverage = 48 <80% coverage = 40

0-59%
60% - 79%
80% or above
No data
 Routine Measles Coverage by Township 2014-2016
MCV1/MR
2014 2015

MCV 2

0-59%
60% - 79%
80% or above
No data
 Incidence of VPD cases (2013-2016)

Disease 2013 2014 2015 2016

Diphtheria 38 29 87 136
Japanese 3 50 113 393
encephalitis
Measles 1010 122 6 266
Pertussis 14 5 5 2
Polio* 0 0 0**-- 0
Rubella 23 30 34 10
Neonatal tetanus 39 32 30 21
National Committees for Immunization
ICC
Inter-agency
Coordination
Committee
 Source of financing for vaccines
(2016-2018)
Vaccine 2016 2017 2018 onwards
BCG UNICEF Government Government

OPV UNICEF Government Government

TT /Td UNICEF Government Government

MSL GAVI GAVI (2Q)

Switch to MR (2Q)
MR UNICEF UNICEF (1 Q) Government
Government (3 Q)
IPV GAVI GAVI GAVI

Penta GAVI and GAVI and GAVI and

Gov’t co-financed Gov’t co-financed Gov’t co-financed
PCV GAVI and GAVI and GAVI and
Gov’t co-financed Gov’t co-financed Gov’t co-financed
 VPD and Vaccine
• What is the --------disease ?
• How is it spread?
• What are the symptoms and signs of disease ?
• What are the complications of disease ?
• What is the treatment for disease?
• How is the disease prevented?
• What are the vaccines for that disease?
• How safe is the vaccine and what are the potential
adverse events following immunization?
• When are the vaccines administered?
 The Vaccine

1. Type of vaccine
2. Schedule
3. Booster
4. Contraindication
5. Adverse events
6. Special precautions
7. Dosage
8. Injection site
9. Injection type
10. Storage
Vaccine should always be stored between +2 °C and +8 °C
 Cold chain network in Myanmar
Power
Yangon Level
conditions
Equipment used
Central Coldroom
Central + ~24 hrs Walk-in cold room
2 Main Back-up generator
Sores
2 Main Stores
(Mandalay&Magway)

Sub-Stores at least 8 hrs Freezer & Fridge

Total 22 Sub-Stores per day Back-up generator
(State or
Sub-Store… Sub-Store… Sub-Store… Division
level)

Township at least 3 hrs Freezer & Fridge

per day
330
Solar unit for selected
Townships locations

Rural Health mostly not Cooler box with ice

Center available packs (last 5 days)
RHCs (RHC)
(4-5 per tsp) Solar unit for selected
locations

Sub RHC not available Vaccine Carrier for

midwife (last only
48hrs)
Sub RHCs
(20-40 /tsp)
17
umuG,faq;rsm;ESifh tylaMumifh ysufpD;vG,fjcif;jyZ,m;
 Figure 5.3
How to read a vaccine vial monitor
 Freeze sensitive vaccines

• DTwP-hepatitis B-Hib (pentavalent)

• Hepatitis B (Hep B)
• Human papillomavirus (HPV)
• Inactivated poliovirus (IPV)
• Pneumococcal
• Rotavirus (liquid and freeze-dried)
• Tetanus, DT, Td
Cold Chain ( ILR , Cold Box & Vaccine Carrier )
 Continuous Temperature Monitoring Devices

Vaccines OK Do shake test

Temperature Monitoring Chart
Shake Test
 Fridge – tag zwf&IykH

• &ufaygif; (30)twGif; pOfqufrjywf

tylcsdefapmifhMuyfpdppfaom ud&d,mjzpfonf/
• • uGefysLwmESifh csdwfqufxm;jcif;jzifh &ufaygif; (60)txd
tcsuftvufrsm;udk Fridge – tag wGif zwf&I
• rSwfom;edkifygonf/
a&cJbl;jym;rsm; aumif;pGmjyKjyifxm;Ny;D (Conditioned Ice Pack)
jzpfaMumif; ppfaq;aeykH

Listen for the

water
 WHO Multi-dose Vial Policy (MDVP), 2014

All opened WHO-prequalified multi-dose vials of vaccines

should be discarded at the end of the immunization session,
or within six hours of opening, whichever comes first,
unless the vaccine meets all four of the criteria listed below.

If the vaccine meets the four criteria, the opened vial can
be kept and used for up to 28 days after opening. The
criteria are as follows:
 Four criteria for MDVP
1. The vaccine is currently prequalified by WHO.
2. The vaccine is approved for use for up to 28 days after
opening the vial, as determined by WHO.
3. The expiry date of the vaccine has not passed.
4. The vaccine vial has been, and will continue to be, stored
at WHO- or manufacturer-recommended temperatures;
furthermore, the vaccine vial monitor, if one is attached, is
visible on the vaccine label and is not past its discard point,
and the vaccine has not been damaged by freezing.
 Examples of incorrect immunization practices

•
•
• Injection at incorrect site
•
•
Safe Injection and waste disposal

Unsafe injections can harm

Recipient

Health worker

Community
 Immunization Safety

• Vaccine safety and quality

• Safe injections and waste disposal
• Adverse Events Following Immunization (AEFI)
surveillance
Unsafe immunization practices
Adverse event(s) following immunization (AEFI)

AEFI are defined as

“any untoward medical occurrence that follows
immunization and which does not necessarily have a
causal relationship with the usage of the vaccine.”
The adverse event may be any unfavorable or
unintended sign, abnormal laboratory finding,
symptom or disease.
 AEFI categories

1. Vaccine product-related reaction

2. Vaccine quality defect-related reaction
3. Immunization error-related reaction
4. Immunization anxiety-related reaction
5. Coincidental event
 Managing an immunization session

1. Preparing for the session

2. Communicating with caregivers
3. Assessing infants for vaccination.
4. Giving vaccinations
5. Closing the session
6. Recording data
Prepare the workplace
Immunization session
Immunization station:
 2. Communicating with caregivers

The actual content of communication ultimately depends

on
• what caregivers want to know (their own questions) and
• the key information that must be given
Essential elements of every encounter
 Micro-planning for reaching every community

1. Making or updating a map

2. Identifying priority health centres and communities
Analysis of immunization data
3. Identifying barriers to access and utilization
Household survey of immunization status
Community discussion
4. Identifying solutions and preparing a workplan
5. Making a session plan
6.Finding defaulters
Example health centre map
 Deciding immunization delivery strategy
Fixed Delivery of services in a HF Serves the community
within easy access to
the HF

Outreach Delivery of services in an Area around the HF

'outreach site' that the staff can visit in
one day

Mobile Delivery of services beyond Areas, not possible to

teams the 'outreach area' cover in one day,
requires overnight stay
Health centre-level list of catchment area
communities and populations
 Prioritizing village

Village
Name
A 50 %
B 60 %
C 70 %
D 20 %
E 75 %
Prioritizing village according to total unimmunized infants

Village
Name

A 50 % 10000 200 100 2

B 60 % 7500 150 60 4
C 70 % 12000 240 72 3
D 20 % 1000 20 16 5
E 75 % 25000 500 125 1
 How to prioritize health centres using district
immunization data

• Use all available information

• Rank health centres by the number of unimmunized
infants; the one with the highest number of
unimmunized children is ranked first (1) and so on
• Consider prioritizing health centres that –
 have inaccurate data;
(-negative values for unimmunized children due to
inaccurate population data or
- negative vaccine wastage rates )
 with known management problems.
Health centre data analysis:
Identified solutions list
Monitoring and Surveillance
 Tools for monitoring

• Immunization register
• Immunization card
• Defaulter tracking list.
 ကာကွယ်ေဆးထိုးနှံနည်းစနစ်အလိုက်ဧရိယာလွှမ်းြခုံမှု
(Area Coverage)
ကာကွယ်ေဆးထိးု နှနံ ည်းစနစ်အလိက
ု ် ကာကွယ်ေဆးထိးု
လောထားေသာ ရပ်ကွက်/ေကေးရွာအေရအတွက် ဧရိယာလွှမ်းြခုံမှု (ရပ်ကွက်
ရပ်ကွက် နှင့် ေကေးရွာ)
စဉ် Township ေကေးရွာ
လုးံ ဝ
စုစေု ပါင်း လစဥ် ဧရိယာ REC/IRI/ လွှမ်းြခုံ
မလွှမ်း မလွှမ်းြခုံ %
ပုမံ ှန် ေအ /ဘီ Crash %
ြခုံနိငု ်
 ကာကွယ်ေဆးထိုးနှံနည်းစနစ်အလိုက်
(၁) နှစ်​ ေအာက်လူဦးေရလွှမ်းြခုံမှု (Population Coverage)
ကာကွယ်ေဆးထိးု နှနံ ည်းစနစ်အလိက
ု ် လောထားေသာ ကာကွယ်ေဆးထိးု
(၁) နှစ်​
(၁) နှစ်​ေအာက်ကေလးဦးေရ < 1 လူဦးေရလွှမ်းြခုံမှု
ေအာက်
စဉ် Township ရည်မှန်း လစဥ် ဧရိယာ REC/IRI/ လုးံ ဝ မလွှမ်း လွှမ်းြခုံ
ဦးေရ မလွှမ်းြခုံ %
ပုမံ ှန် ေအ /ဘီ Crash ြခုံနိငု ် %
 Routine Immunization Drop-Out Rate

Vaccines Number immunized Drop-Out %

BCG 200
30 15
MR1 170
Penta1 200
20 10
Penta 3 180
OPV1 200
20 10
OPV3 180
TT1 210
10 4.7
TT2 200

MR1 170
20 11.7
MSL2 150
Access and utilization problem analysis
flowchart and graph
Examples of Common problems associated with
poor access and utilization
Type of problem Examples of common problems
Supply quantity

Supply quality

Staffing quality

Staffing quantity

Service quality and demand

Advocacy and communication

Monitoring and supervision

Reporting
 Any single problem identified may just be a
symptom of many underlying problems in the
immunization system.

Low coverage

denominator data staffing levels

equipment
stock control maintenance
training

Hidden problems
 Problems and Solutions

• Hard to reach areas

Geographical hard to reach CRASH programme
Socially hard to reach
• Mobile peri-urban
Fixed/Outreach
Area of migrants expansion
Work sites
Farming places Creation of demand
generation
 Partnering with communities

• Learn about the community

• Plan services with communities
• Involve communities in monitoring and surveillance
• Inform and engage community members
• Address resistant groups
 Reaching Every District (RED)
implementation and monitoring tools

• Re-establishing outreach services

• Supportive supervision

• Linking services with communities

• Monitoring and use of data for action

• Planning and management of resources

Thanks
Immunization service supervisory
visit checklist

Question Yes/ Comments Corrective

No action
on-site
Immunization service supervisory
visit checklist
Question Yes/ Comments Corrective
No action
on-site
Immunization service supervisory
visit checklist

Question Yes/ Comments Corrective

No action
on-site
Immunization service supervisory
visit checklist

Question Yes/ Comments Corrective

No action
On-site
 Examples of incorrect immunization practices
and possible AEFI

•
 Examples of incorrect immunization practices
and possible AEFI

•
•

•
 Examples of incorrect immunization practices
and possible AEFI
Incorrect practice Possible AEFI

Injection at incorrect site such as:

• BCG given subcutaneously -Local reaction or abscess
• DTP/DT/dT/TT too superficial -Local reaction or abscess
• injection into buttocks -Sciatic nerve damage

•
•
Examples of Common problems associated with
poor access and utilization
Type of problem Examples of common problems
Supply quantity Stock-outs of vaccine(s), AD syringes,
diluents, safety boxes, immunization cards

Supply quality Expired vaccine(s)

• VVMs show that vaccine has reached
the discard point
• Frozen DTP- and HepB-
Vaccine wastage rate exceeded expected
rate
Staffing quality Some staff are not using correct
protocols/procedures
Irregular supervisory visits

Staffing quantity Vacant positions; general staff shortage

 Examples of Common problems associated with
poor access and utilization,
Type of problem Examples of common problems
Service quality and demand Poor attendance at sessions and poor utilization in
some areas

Mothers lose or do not bring the immunization cards

Parents fear adverse events and/ or there are rumours

that Injection practices are not 100% safe
Unreliable information about catchment population

Inaccurate coverage data

Some areas are distant and underserved
Transport not available for some outreach sessions

Failure of outreach services in hard-to-reach areas

Poor attendance at antenatal care (ANC) clinics
Examples of Common problems associated with
poor access and utilization,
Type of problem Examples of common problems
Advocacy and communication

Monitoring and supervision

Reporting Timeliness
Completeness