Update on the Implementation of Measles 2nd Dose in India

Ms. Anuradha Gupta

Joint Secretary, Ministry of Health

Govt. of India

Global Measles and Rubella Management Meeting

Salle B, WHO Headquarters, Geneva, Switzerland

15-17 March, 2011

Presentation outline

Context

Introducing 2nd dose of measles vaccine in India- MCV2 – Routine immunization

- MCV2 – Catch-up campaigns

Road map and way forward

India Context

India steps up public investment in health National Rural Health Mission (NRHM)

provides augmented funding to states to the tune of over INR 550 billion (>$12 billion) during 2005-2010

System strengthening - HR Augmentation: 2nd ANM*, 800 000 ASHAs#, additional

doctors

- Infrastructure, Ambulance networks

- Communitization

- Flexible financing

* ANM: Auxiliary Nurse Midwife # ASHA: Accredited Social Health Activist

Global Context: Worldwide measles vaccination delivery strategies, mid-2010

MCV1 & MCV2, no SIAs (40 member states or 21%)

MCV1 & regular SIAs (59 member states or 31%)

MCV1, MCV2 & one-time catch-up (36 member states or 19%)

MCV1, MCV2 & regular SIAs (57 member states or 28%)

Single dose (1 member state or 1%)

Data source: WHO/IVB measles database as of 26 January 2010

India national immunization programme introduced

second dose of measles in 2010

Recommendations from expert Indian committees

National Technical Advisory Group on Immunization (NTAGI) recommended:

1. States with MCV1 coverage <80%: Second opportunity for measles vaccine through measles catch-up campaigns in 9 months - 10 years age

2. States with MCV1 coverage >80% MCV2 through routine immunization at 16-24 months of age

Ad hoc expert review committee reviewed above strategy in early 2010 and endorsed the NTAGI recommendation

MCV2 introduction: State-specific delivery strategies

SIA in 14 states:- Target population (9 mo-10

years): 134 million

- Vaccine doses and AD syringes: 147 million

- Mixing syringe : 29.5 million

MCV2 in routine immunization in 21 states: - Annual targets

1-2 year population: ~10 million

Vaccine doses: ~12 million

RI: MCV1 > 80%: 21 states

SIA: MCV1 <80%: 14 states

Introduction of 2nd dose of Measles in RI, India

Annual Target 1-2 year

Ongoing: 4 states (0.4 million)

2010: 3 states (1.2 million)

2011: 11 states (5.9 million)

To be decided: 3 states (2.2 mln)

Measles Catch-up campaigns

MCV2 introduction through catch-up vaccination campaign (MCUP) Phase 1

In three phases- Target: 134 million in 351

districts

Phase 1: - 45 districts from 13 states with

~13 million target children 9 district from Chhattisgarh

5 districts from each of the 6 states (Bihar, Jharkhand, Rajasthan, Madhya Pradesh, Gujarat & Haryana)

1 district from each of the North-East states

Phase 2 to take place from September 2011

Phase 3 in 2012

Key operational strategies: MCUP-1

Immunization from fixed posts to ensure safe injection practices- Routine immunization and outreach sites used

- Additional sites added as needed

- Schools with children under 10 years targeted

- Specific plans for hard to reach areas and/or underserved populations

Average campaign duration: 3 weeks = 12 working days- 1st week: School based campaign (for 5-10 year children)

- 2nd & 3rd weeks: Community based campaign for remaining children

Medical officers trained to establish AEFI management networks equipped with management kits

Regular weekly RI sessions continued without interruption- Measles catch-up campaign activities conducted during remaining days

of week

Measles catch-up campaign budget

1. Vaccine/ADS, 33.2 million USD

2. Op cost 25.9 million USD

3. Total 59.1 million USD

Target 134 million

Per child cost 0.44 USD

State (No. of Districts covered in phase 1)

Administrative coverage achieved in MCUP1@

0

10

20

30

40

50

60

70

80

90

100

Arun

acha

l Pr. (1)

Assa

m (1)

Bihar (5

)

Harya

na (5

)

Mad

hya P

rade

sh (5

)

Man

ipur (

1)

Rajas

than

(5)

Chha

ttisg

arh (

9)

Jharkh

and*

(5)

Nagala

nd* (

1)

Tripu

ra* (

1)

% Co

vera

ge

10.2 million children vaccinated so far (92% coverage) in 39 districts across 11 states

* Provisional data @ From 39 districts where campaign completed

20.2

11.3

1.819.9

8.6

10.0

9.1

15.5

1.11.3

1.0

Parents didn't know about campaign

Parents didn't know place or date of thecampaignFear of injection

Fear of AEFI

Parents didn't give importance tocampaignChild was sick

There was no vaccine at the site

There was no vaccinator at the site

Site was too far

Child was traveling

Other Reason

Reasons for non-vaccination in MCUP1 (from Monitoring data)*

Source: MoHFW, RCA monitoring

Communicati

on related

Operational

* As reported by caregivers to monitors

Experiences from Phase 1 catch-up campaigns

GoI supported all logistic and operation costs of the activities- Budget committed for subsequent phases

Cold chain capacity and management met expectations

No major issues with vaccine and injection equipment management

Large scale campaigns with injectable vaccines can be conducted safely in India- Medical officers in all SIA districts trained in AEFI management, reporting

- No instance of AEFI due to programme error detected

- All reported AEFIs managed effectively

Administrative coverage variable across states:- 39 districts completed campaigns so far

- 49% (19/39) with >= 90% coverage

Areas for improvement

Coordination and planning- Better coordination among the three primary departments of

Health, Education and ICDS

- Flexible approach with states for timeline; but stringent adherence to agreed upon timeline

Communication and advocacy- IEC and interpersonal communication at grass-root level

- Civil society and professional bodies: Indian Academy of Pediatrics, Indian Medical Association, Others

- Private schools

Vaccination in urban areas poses special challenges Injection waste management needs strengthening Supervision needs to be improved at all levels.

Way forward

MCV2 introduction

- Routine Immunization (21 states): Started in 7 states; will start in all 21 by 2011

- Catch-up: Will complete in all 14 states by 2012State and national review meetings to compile best practices and

lessons learned planned in April 2011

Measles mortality reduction through immunization plus NRHM initiatives to improve access to health care at grassroots

Laboratory supported measles surveillance initially in states with higher burden

- At least one state level laboratory in each state for measles serology

Build synergies of catch-up campaigns with Routine Immunization