Innovative Approaches in Routine Immunization

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• Innovative Approaches in Routine Immunization
• By
• Vinay Kumar Director Operations India

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PATH in India
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Our Vision

• A world where
• innovation ensures that
• health is within reach
• for everyone.

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Our Mission

• To improve the health of people around the world
  by
• advancing technologies
• strengthening systems
• encouraging healthy behaviors

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Innovations in Infectious Diseases

• Children Vaccine Program
• Japanese Encephalitis
• HPV vaccine project
• Advancing rotavirus vaccine development
• HIV and sexual reproductive health

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Content Outline

• Andhra Pradesh partnership project
• About the project
• How did we plan implement
• What worked, what didn't work
• Lessons learned, influencing National decisions.

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Objectives

• Strengthen Immunization services
• Promote Injection safety
• Introduce Hepatitis B vaccine
• Name Based Registry
• Control Japanese encephalitis by using vaccine

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Andhra Pradesh Immunization Project

• 5 years partnership project between A.P.
  Government and PATH
• Program period April 2001 to March 2006,
  extended to Dec 2006 on request by GoAP
• Governed by a co-operative agreement based on
  spirit of equal partnership
• Implementation staggered into 3 phases

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3 Phased Expansion

• New methods and services were introduced in the
  first two-and-a-half years of the project.
• The following two-and-a-half years we
  consolidated the gains and raised the quality of
  the services.
• In the last year social mobilization was started

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Mechanism for funding

• Incremental cost share by Government of AP to
  attain sustainability by the end of the project
  period
• As of September 2006, all recurrent costs are
  paid by the Government.

Recurrent costs were planned to be progressively
taken over by the Government of AP
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Major Interventions of the Program

• Training of the health personnel
• Strengthening of supportive supervision
• Introduction of logistic management system
• Introduction of mechanisms for vaccine safety
• Strengthening cold chain system
• Planning for outreach seasons
• Rationalization of workload for immunization
  sessions
• Scale up of Hepatitis B vaccination

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Training

• Large number of logisticians and supervisors
  were trained in the fourth year reflecting the
  change in the programme from expansion to
  consolidation
• Training was reduced to maintenance levels for
  ANMs in the final two years and for all
  activities in the final year.
• Training through supportive supervision took
  over from formal courses

Over 33,000 people re-trained to manage the
renewed immunization programme
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Supportive Supervision
Corrective action at FIELD LEVEL DISTRICT
LEVEL STATE LEVEL
Through PATH CONSULTANTS, MEDICAL
COLLEGE FACULTY
Develop Plan

• Visit all institutions.
• On site corrections
• Orientation of health functionaries
• Collection of critical data to take managerial
  decisions

PATH, State the District officials develop plan
Implement
Analyze Data
The Institution, DIO, DMHO CFW
FEED BACK
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Logistic Management
Use of vaccine logistic forms as tools to monitor
supplies to outreach
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Better Logistic Management
one central store and six regional stores were
relocated into new premises
Web-based software to track supplies was installed
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Long Distance Transport Schedules Made More
Efficient
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Strengthening Cold Chain System
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Training Undertaken for Cold Chain Maintenance
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Micro Planning
Planning for Outreach Sessions
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Workload was Rationalized
Better management of immunization sessions
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Introduction of mechanisms for tracking of
dropouts
Innovation
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Injection safety

• Use of Auto-disable Syringes
• Training, implementation, national advocacy
• Waste management options
• Safety boxes-two generations tried and failed
• Needle removers-pilot trial and scaled up to
  entire state, national decision now
• Review of drugs inventory by state procurement
  agency APHMHIDC to reduce injectables-success in
  state.

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Hub cutters, Puncture proof containers twin
buckets replace safety boxes
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Existing Safety Pit Integrated into the System
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14000 Bundled Kits were Procured
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Now HIV Testing Centers also Uses this System
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Model Injection Center at Niloufer Hospital

• Practice and demonstrate safe injections
• Learning centre for students from medical,
  nursing paramedical
• Resource center for professionals from
  IMA,IAP,TNAI
• Awareness building to general public

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The first two supervisory visits had a much
bigger impact than expected.

• second visit six weeks later
• Plans available at 100 of health centre
• Safety pit used in 83 of health centres
• Health centre record kept in 67 of Primary
  Health Centres
• AD syringes used for 100 of immunizations
• Temperature chart maintained in 100 of health
  centres

• First visit
• Plans available in 7 of health centres
• Safety pit used in 27 of health centres
• Health centre record kept in 7 of Primary Health
  Centres
• AD syringes used for 40 of immunizations
• Temperature chart maintained in zero health
  centres

Example
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Improving the Quality of the Service

• gt1,500 Primary health centres and outreach
  immunizations sessions are visited by a trained
  supervisor every six months
• Nine medical colleges have been contracted to
  cover nine districts (pop. about 30 million)
• The quality of the service has improved
  enormously
• Regular supervision visits are replacing much of
  the need for re-training

The Government of AP have committed to continuing
this work after the project ends.
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The program is showing results
In November 2003 a WHO team from Geneva and
New Delhi reviewed the status of neonatal tetanus
in Andhra Pradesh with the Government and
certified an incidence rate of less than 1 case
per thousand live births in all districts
Neonatal tetanus certified eliminated by WHO
November 2003
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Price reduction of Hep B and AD syringes
Hep B from about Rs.57 to Rs. 5 per dose
Two manufacturers to four now in India
AD syringes from Rs.7 to now Rs.2.50
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The project is having an impact beyond Andhra
Pradesh
Impact

• AD syringes first introduced in AP are now a
  nation-wide policy and practice
• HB vaccine first introduced in AP is being
  introduced in 10 other states with GAVI support
• APs injection safety procedures have been
  adopted by the Government of India
• The Indian Medical association with 150,000
  members released a policy on safe injections.

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Govt. of India Takes a Decision to Introduce AD
Syringes
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In summary

• Raise full immunization coverage from 70 to 85
• Raise hepatitis B vaccine coverage from 10 to
  85
• Overhaul the logistics system
• Safe injections for all immunization
• Build a system to track immunization defaulters
• Establish a working supervision system
• Eliminate Japanese encephalitis
• WHO certified neonatal tetanus eliminated

Being documented now (First results look good)
Achieved November 2006
Achieved November 2003
Not achieved as planned. (Dropout rate DPT 3 to
measles reduced from 15 to 4)
Map of India showing AP
Achieved
Achieved November 2003