COMMUNITY BASED LEARNING AND EDUCATION

Seventh Community Posting at District Level

In depth study on BCG Vaccination Program of Nuwakot District

A Report Submitted by:

Anjit Phuyal

Submitted to:

Department of Community Health Sciences

School of Medicine

Patan Academy of Health Sciences

December, 2014

Acknowledgement

I would like to thank the entire PAHS faculties for an opportunity to perform an in-depth study on BCG vaccination program. I am thankful to all our faculties of DCHS for their continuous guidance on and off the field.

I would like to appreciate the cooperation and support of all the staffs of Nuwakot District health office (DHO) especially immunization supervisor Mr. Amrit Maharjan, cold chain officer Mr. Sanat Kumar Khadka and Statistical assistant Mr. Bishnu Rijal.

I am also thankful to the community people of Nuwakot district for their cordial cooperation and kind information without which this report would never have been possible.

I would also like to thank all those people who have directly and indirectly helped me to fulfill my objectives.

Thank You

II

Executive Summary

Tuberculosis (TB) continues to be a major public health problem around the world. For

preventive interventions, the only available and licensed vaccine thus far is BCG, which is

routinely administered to infants and young children. For high-incidence, developing countries,

the BCG vaccine was included in the Expanded Program on Immunization as of 1974. In Nepal,

EPI was introduced in the fiscal year 1978/79.

The objective of the study was in-depth analysis the BCG vaccine program in Nuwakot district.

Data on BCG vaccination was obtained from the HMIS section of Nuwakot DHO for the study

purpose. Qualitative information was obtained through key informant interviews with staffs of

district health office.

The National Immunization Program (NIP) is a high priority program of Government of Nepal.

The goal of National Immunization Program is to reduce child morbidity, mortality and disability

associated with vaccine preventable diseases. The main objective is Achieve and maintain at

least 90% vaccination coverage for all antigens at national and district level by 2016. BCG

coverage of Nuwakot district has increased from past year but still below national and regional

coverage. BCG vaccine wastage is higher than national target in both national and district level.

Vacant posts of vaccinators is the main hindrance in achieving the national target of BCG

vaccine coverage but no initiative has been taken at the district level to fulfill the sanctioned

posts of vaccinators. No effective measures have been taken at both national and district level to

decrease vaccine wastage rate. High vaccine wastage and inability to take any effective measures

shows the failure of management.

III

Acronyms

BCG Bacillus Calmette Guerin

CHS Community Health Sciences

DCHS Department of Community Health Sciences

DHO District Health Office/r

DoHS Department of Health Services

EPI Extended Program on Immunization

FCHV Female Community Health Volunteer

FY Fiscal Year

HP Health Post

PAHS Patan Academy of Health Sciences

SHP Sub-Health Post

VDC Village Development Committee

VPD Vaccine Preventable Disease

IV

Contents

1. Introduction.............................................................................................................................................1

1.1.Background of study..........................................................................................................................1

1.2. Objective of study.............................................................................................................................1

2. Methodology...........................................................................................................................................2

2.1.Methodology.....................................................................................................................................2

2.2. Limitations........................................................................................................................................2

3. Findings...................................................................................................................................................3

3.1. National Policy..................................................................................................................................3

3.2. Goal..................................................................................................................................................3

3.3. Objectives.........................................................................................................................................3

3.4. Strategies..........................................................................................................................................4

3.5. Activities...........................................................................................................................................4

3.6. Data Analysis....................................................................................................................................5

3.6.1. Coverage....................................................................................................................................5

3.6.2. Wastage.....................................................................................................................................6

4. Discussion................................................................................................................................................7

5. Recommendations...................................................................................................................................8

6. Conclusion and Lesson Learnt.................................................................................................................9

6.1. Conclusion........................................................................................................................................9

6.2. Lesson Learnt....................................................................................................................................9

7. References.............................................................................................................................................10

Appendix...................................................................................................................................................11

Appendix 1: Data of BCG Vaccination status.........................................................................................11

V

List of Tables

Table 1 Ilaka wise BCG coverage of Nuwakot district...............................................................................11

Table 2 Health Facility wise BCG coverage of Nuwakot District, 2070/71...............................................11

List of Figures

Figure 1. BCG coverage at different levels...................................................................................................5

Figure 2. BCG coverage at Ilaka levels.........................................................................................................5

Figure 3. BCG Wastage at different levels....................................................................................................6

VI

1. Introduction

1.1.Background of study

Tuberculosis (TB) continues to be a major public health problem around the world1.One third of

the global population is estimated to be infected with TB bacillus. 9 million people fell ill with

TB in 2013, including 1.1 million cases among people living with HIV. In 2013, 1.5 million

people died from TB, including 360,000 among people who were HIV-positive. 510.000 women

died from TB in 2013, including 180,000 among women who were HIV-positive2.Tuberculosis is

one of the most prevalent infectious disease and significant public health problem in Nepal and

continues to pose serious threat to the health of the population and development of the country.

Currently nearly 80,000 people have tuberculosis in Nepal, with more than 40,000 new cases

arising every year3.

Different measures are available for TB control. Curative interventions include the early

detection of the disease by purified protein derivative (PPD) skin test, followed by isoniazid

preventive therapy for positive cases or chemotherapy treatment. For preventive interventions,

the only available and licensed vaccine thus far is BCG, which is routinely administered to

infants and young children. More than 4 billion people have been vaccinated with BCG, since its

first use in 1921. For high-incidence, developing countries, the BCG vaccine was included in the

Expanded Program on Immunization as of 19744. In Nepal, EPI was introduced in the fiscal year

1978/79.

The mechanism of protection from BCG vaccination involves a reduction of the haematogenous

spread of bacilli from the site of primary infection. It protects against the acute manifestations of

the disease, and reduces the lifelong risk of endogenous reactivation and dissemination

associated with foci acquired from prior infection1.

1.2. Objective of study 1. To analyze BCG vaccine coverage wastage of Nuwakot district for last

three years.2. To know the National plans, policies and strategies on BCG vaccination3. To compare the findings with the national average

1

2

2. Methodology

2.1.Methodology

For in-depth study, topic was selected by the group and was allocated individually according to

the interest of the students. These topics were further reviewed by the faculties. Data on BCG

vaccination was obtained from the HMIS section of Nuwakot DHO for the study purpose. Data

was analyzed using Microsoft excel. Qualitative information was obtained through key informant

interviews with staffs of district health office.

2.2. Limitations

1. This study might not reflect the true vaccination coverage of the district as secondary data

from HMIS has been used and the children vaccinated outside the district are not

included in the data.

2. I could not talk to the village health system In-charges, so a lot of reasons for the low

coverage and high drop-out could not be identified.

3

3. Findings

3.1. National Policy

The National Immunization Program (NIP) is a high priority program of Government of Nepal.

The comprehensive multi-year plan (cMYP 2011- 2016) is the guiding document for national

immunization program. The cMYP aims to achieve the immunization related goals expressed by

the Government of Nepal in various policy documents, the Millennium Development Goals

(MDGs), Global Immunization Vision and Strategy (GIVS) and World health assembly (WHAs)

resolutions5.All immunization costs are included in the national work plan and budget. All

routine vaccines are procured using Government funds5.

3.2. Goal

The goal of National Immunization Program is to reduce child morbidity, mortality and disability

associated with vaccine preventable diseases5.

3.3. Objectives

The objectives of the National Immunization Program as per cMYP: 2011/12‐2015/16 is as

follows5

Achieve and maintain at least 90% vaccination coverage for all antigens at national and

district level by 2016

Ensure access to vaccines of assured quality and with appropriate waste management

Achieve and maintain polio free status

Maintain maternal and neonatal tetanus elimination status

Achieve measles elimination status by 2016

Accelerate control of vaccine‐preventable diseases through introduction of new and

underused vaccines

Strengthen and expand VPD surveillance

Continue to expand immunization beyond infancy

4

3.4. Strategies

The strategies of the National Immunization Program as per cMYP: 2011/12‐2015/16 is as

follows5

Increase access and utilization to vaccination by implementing RED strategies in every

district

Enhance human resources capacity for immunization management

Strengthen immunization monitoring system at all levels

Strengthen communication, social mobilization, and advocacy activities

Strengthen immunization services in the municipalities

Strengthen the vaccine management system at all levels

Expand VPD surveillance to include vaccine preventable diseases of public health

concern.

Strengthen and expand laboratory support for surveillance.

3.5. Activities

Following activities are being conducted at the Nuwakot district to achieve national target of BCG coverage6

With exception of Dashain and Tihar Immunization clinics are running regularly even on

public holidays.

Conduction of awareness programs.

Establishment of Cold-chain sub center.

Regular supervision of Immunization clinics and timely feedback

Timely supply of vaccine

Review of immunization status at VDC, Ilaka and District levels.

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3.6. Data Analysis

3.6.1. Coverage

BCG coverage has increased from past year but still below national and regional coverage.

Nuwakot CDR Nepal0

20

40

60

80

100

120

70

97 96

67

91 9087 92 93

Three years BCG Coverage Comparision

206720682069

% C

over-age

BCG Coverage

Figure 1. BCG coverage at different levels

Ilaka wise BCG coverage analysis showed that the BCG coverage is highest in Rautbesi HP and

lowest in Nuwakot HP.

Deural

i PHC

Kakan

i PHC

Kharanita

r PHC

Bhadrat

ar HP

Chatural

e HP

Kaule

HP

Khadag

Bhanjya

ng HP

Rautbesi

HP

Samari

HP

Samundrat

ar HP

Shikh

arbesi

HP

Nuwakot H

P

Salle

maidan

HP

Distric

t Total

0

20

40

60

80

100

120

86

66

8977

8673

82

106

6575

103

4864

85

Ilaka wise BCG Coverage 2070/71

Coverage

% C

over-age

BCG Coverage

Figure 2. BCG coverage at Ilaka levels

6

Health facility wise analysis of data showed that Barsunchet SHP has highest BCG coverage

(288.89%) and Nuwakot HP has lowest coverage (5.45%). 21 health facilities has BCG coverage

above 90% in fiscal year 2071/70. (See Appendix 1).

3.6.2. Wastage

BCG vaccine wastage is higher than national target in both national and district level.

2067 2068 20690

102030405060708090

10088 88 88

79 79 80

Vaccine Wastage by Region

Nuwakot Nepal

% C

overage

Vaccine Wastage

Figure 3. BCG Wastage at different levels

Ilaka wise analysis showed that the wastage is least in Rautbesi HP (87.59%) and highest in

Sallemaidan HP (93.90%) in the fiscal year 2070/71.

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4. Discussion

Nepal has already achieved 98.9% coverage of BCG vaccine5 but despite the rising trend of the

vaccine coverage in past three years Nuwakot has not yet achieved the national target of >90%

BCG vaccine coverage. According to the EPI supervisor 22 posts of vaccinators are vacant but

no initiative has been taken at the district level to fulfill the sanctioned posts of vaccinators. The

target is set at the national level but the local factors like migration also affects the target.

Inappropriate target might be another reason for the lower coverage of BCG vaccine. Nuwakot is

connected to Kathmandu and a lot of people visit hospitals in Kathmandu for delivery that might

also show lower coverage of BCG vaccine at Nuwakot as HMIS data only gives the information

about the services provided by the health facility. During our previous posting we have also seen

the health facility staffs reporting wrong data which might be another reason for lower coverage

of the vaccine.

The vaccine wastage rate is high in both national level and at Nuwakot. No effective measures

have been taken at both national and district level to decrease vaccine wastage rate. A vial of

BCG contains 20 doses and once opened all doses should be given within 6 hours. Since, only

one to two children are immunized at one immunization clinic the wastage of BCG and Measles

is high. Lack of proper mechanism to return the vaccines to the cold chain centers or to store

them at the immunization clinics also increases the rate of vaccine wastage. High vaccine

wastage and inability to take any effective measures shows the failure of management.

8

5. Recommendations

The quality of the HMIS data should be improved by strengthening the supervision at all level,

periodic review of reported data and increasing the supervisory visit to the health facilities where

under and over reporting has been a problem. The vacant posts of vaccinators should be fulfilled.

Alternatively, local resources can be mobilized and vaccinators appointed from the VDC.

Available health staffs should be used in the immunization clinics. Target should be set at the

local level.

If possible cold chain sub centers should be established at all health facilities so that unopened

vials can be used in next sessions. Government should try to provide vaccines in smaller vials.

Any change in vaccine vial size, or formulation should be complimented with revised micro-

plans and training of frontline workers. Wastage of vaccine at the supply chain is not being

analyzed. Analysis of the vaccine wastage at the supply chain should be carried out. Maximum

vaccine wastage occurs at the outreach session sites, optimization of outreach session

(Weekly/Monthly/Quarterly based on injection load) will greatly influence overall vaccine

wastage7.

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6. Conclusion and Lesson Learnt

6.1. Conclusion

The coverage of BCG vaccine is low at the district level than that of national level. Vaccine

wastage is high in both national and district level. The problems with reporting, inadequate

supervision and feedback and inadequate manpower are the major reasons for low coverage and

higher wastage of the vaccine. Despite its extensive use, the BCG vaccine lacks the ability to

fully control the TB-endemic and -pandemic situations4. At the current level of efficacy, the

MVA85A vaccine is neither effective nor cost-effective and, therefore, not a good use of limited

resources8. And with such a high wastage rate, the cost effectiveness of BCG vaccine in the

context of Nepal needs to be further analyzed through appropriate studies. Proper and timely

assessment of vaccine wastage and timely implementation of plans to reduce vaccine wastage is

necessary at the national level.

6.2. Lesson Learnt

District health system is responsible for immediate control, monitoring, supervision and

feedback of the peripheral level health centers. Timely and proper supervision and feedback can

play vital role to improve the overall health system. In the absence of adequate manpower, the

supply of adequate logistic does not ensure the quality of service. Inadequate manpower

increases the wastage and adds economic burden to the health system. So there should be balance

in manpower and supply of logistics to provide quality health services.

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7. References

1. Aebelaez MP, Nelson KE, Munoz A. BCG vaccine effectiveness in preventing

tuberculosis and its interaction with human immunodeficiency virus infection, Int. J.

Epidemiol[Internet]. 2000 [cited 2014 Nov 10]; 29 (6): 1085-109. Available from:

http://ije.oxfordjournals.org/content/29/6/1085.full.pdf+html

2. Tuberculosis (TB) [Internet] 2014 [cited 2014 Nov 10]. Available from:

http://www.who.int/gho/tb/en

3. Government of Nepal, Ministry of Health and Population, Department of Health

Services, National Tuberculosis Center. National Tuberculosis Program, General Manual.

Bhaktapur: National Tuberculosis Center; 2012.p.9

4. Tu HT, Vu HD, Rozenbaum MH, Woerdenbag HJ, Postma MJ, A Review of the

Literature on the Economics of Vaccination Against TB, Expert Rev Vaccines

[Internet].. 2012 [cited 2014 Nov 10]; 11(3):303-317. Available from:

http://www.medscape.com/viewarticle/760578

5. Government of Nepal, Ministry of Health and Population. Department of Health and

Services. Annual Report 2012/2013. Kathmandu: Ministry of Health; 2014.p. 24-35

6. Nuwakot District Health Office. District Health Profile 2012/2013. Nuwakot, Nepal;

2071. p.12-15

7. Unicef, National rural health mission. Vaccine wastage assessment. India; 2010. p.41

8. Channing L, Sinanovic. Modelling the cost-effectiveness of a new infant vaccine to

prevent tuberculosis disease in children in South Africa. Cost Effectiveness and Resource

Allocation [Internet]. 2014 [cited 2014 Nov 10], 12:20. Available from:

http://www.resource-allocation.com/content/12/1/20

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Appendix

Appendix 1: Data of BCG Vaccination status

Table 1Ilaka wise BCG coverage of Nuwakot district

Ilaka % Total Coverage

(Year 68/69)

% Total Coverage

(Year 69/70)

% Total Coverage

(Year 70/71)

Deurali PHC 71.2 74 85.84

Kakani PHC 51.19 63.58 66.29

Kharanitar PHC 80.85 100.17 88.95

Bhadratar HP 47.60 56.25 77.33

Chaturale HP 81.73 96.99 85.91

Kaule HP 56.46 66.9 73.26

KhadagBhanjya

ng HP

70.23 78.31 82.4

Rautbesi HP 96.10 125 106.05

Samari HP 46.06 52.01 65.13

Samundratar

HP

62.46 88.66 75.42

Shikharbesi HP 100.62 132.03 102.67

Nuwakot HP 49.79 54.94 47.95

Sallemaidan HP 49.88 59.57 63.7

District Total 66.61 87.34 84.97

Table 2 Health Facility wise BCG coverage of Nuwakot District, 2070/71

Health Facility % Coverage

Barsunchet SHP 288.89

Samundratar HP 134.09

12

Urleni HP 125.56

Kharanitar PHC 119.44

Beteni SHP 113.13

Sunkhani SHP 111.54

Kabilas HP 105.81

Rautbesi HP 105.19

Shikharbesi HP 103.80

Ghyangphedi HP 101.41

Taruka HP 99.12

Gaunkharka SHP 97.22

Lachyang HP 96.08

Chaturale HP 95.71

Bageswori SHP 95.41

Ratmate SHP 95.24

Dangsing SHP 94.74

KholegaunKhanigaun

SHP

93.16

Ganeshthan SHP 92.68

Gorsyang HP 91.89

Sallemaidan HP 90.57

Kintang SHP 88.37

Chaughada SHP 88.33

Bhalche SHP 88.31

Panchkanya SHP 87.93

Samundradevi SHP 87.50

Thansing SHP 86.15

Gerkhu SHP 86.13

Kumari HP 84.18

Charghare SHP 83.05

Deurali PHC 82.28

KhadagBhanjyang HP 80.74

13

Kaule HP 80.00

Suryamati SHP 77.22

Kalikahalde HP 77.22

Talakhu SHP 76.19

Balkumari SHP 74.55

Belkot HP 72.35

Bungtang SHP 71.11

Mahakali HP 66.67

Tupche SHP 66.07

Salme SHP 66.00

Okharpauwa SHP 64.44

Ralukadevi SHP 64.29

Bhadratar HP 62.32

Sundaradevi SHP 59.26

Kakani PHC 58.02

Fikuri HP 57.14

Thaprek SHP 56.32

Jiling SHP 56.12

Narjamandap SHP 54.24

Madanpur SHP 52.04

Kalyanpur SHP 46.72

ThapDuipipal SHP 46.59

Samari HP 46.55

Chauthe SHP 44.87

Budhasing HP 44.44

Manakamana SHP 43.06

Chhap SHP 39.13

ThapSamari SHP 37.93

Thanapati SHP 35.00

Duipipal HP 34.09

ThapBudhasing SHP 33.33

14

Sikre SHP 24.24

Sisdol HP 8.89

Nuwakot HP 5.45

15