Assessment of routine immunization (RI) program at the PHC Barwala of district Panchkula in the Haryana state

 

Meraj M Ausavi^*, Samina M Ausvi^**, Puneet Bhagat^{** *}

 

^*Assistant Professor, ^**Assistant Professor, Great Eastern Medical School, Ragolu, Srikakulam, Andhra Pradesh, INDIA.

^*** Senior DMO (Admin), Northern Railway Central Hospital, New Delhi, INDIA.

Email: ausvisamina@gmail.com

 

Abstract               Background: Fourth Millennium Development Goal to reduce child mortality has immunization as a major strategy. In India, immunization is being provided under Reproductive and Child Health– II program, wherein one latest strategy is the introduction of Pentavalent vaccine in selected states. Objective: Assessment of the Routine Immunization (RI) Program and induction of the Pentavalent vaccine in RI, at a PHC in the Haryana State. Methodology: Cross-sectional study is carried out at one village each of three selected Sub-Centers of the Barwala PHC. Primary data collected using observation, checklist and interview techniques and the secondary data obtained, was analyzed using "MS Office 2007 Excel". Also, qualitative data was dealt with. Results and Conclusions: Coverage under RI was >/= 100% target achievements. Drop-out/Left-out rates were not calculated. "Timeliness of Vaccination" was in 75% of total users - minimum (61.9%) at the village of the farthest sub-centre. Children vaccinated were not observed for AEFI. Supply of vaccines was adequate with the cold chain maintained. Early expiry first out was followed for vaccines. Micro-planning and Alternate vaccine delivery followed guidelines. Vaccine lifting efficiency was 100%. Counterfoils available at session sites were 51.85%. Awareness amongst healthcare providers regarding Pentavalent vaccine was adequate and it was being administered. ANMs were delivering, not, all four key messages to the care-givers. Duplication of work for data reporting was found; data was consistent. Supervision was more by MO than LHV. ASHAs and AWWs were playing good role as mobilizers. Migratory population of the area is a challenge.

Key Words: Routine Immunization Program; Timeliness of Vaccination; Age Appropriateness of Vaccination; Pentavalent Vaccine; Rapid Immunization Coverage Assessment.

 

 

INTRODUCTION

The Govt. of India took steps to strengthen maternal and child health services as early as in the First Five-Year Plan (1951-56). As part of the Minimum Needs Program initiated during the Fifth Five-Year Plan (1974-78), maternal health, child health, and nutrition services were integrated with family planning services. As part of National Health Policy, the National Immunization Program is being implemented now on a priority basis. In the wake of Diphtheria, Pertussis, Measles, Tetanus, and Poliomyelitis and childhood Tuberculosis, the Expanded Program on Immunization (EPI) was initiated in India in the year 1978 making free immunization services easily available. In India, the Universal Immunization Program (UIP) was launched in the year 1985 to extend immunization coverage among the eligible children and to improve the quality of services. However, according to DLHS-3, Panchkula district in the Haryana state has reported full immunization coverage of 78.1%¹. Coverage Evaluation Survey- 2009 reported full immunization of 71.7% (Rural- 69.9% and Urban- 76.1%) for the Haryana State². In year 2000, eight Millennium Development Goals (MDGs) were formulated. The fourth MDG goal is to reduce child mortality; and immunization is a major strategy. In National Rural Health Mission (NRHM), immunization is being provided under Reproductive and Child Health RCH –II program. Many new innovative strategies have been incorporated under this mission like ASHA (Accredited Social Health Activist), VHND (Village Health and Nutrition Day) and latest being induction of Pentavalent vaccine in RI program of some selected states. Pentavalent vaccine has been introduced in the RI program at the state of Haryana on 22^nd December, 2012. This study provides understanding about gaps and administrative issues in the processes for RI program at the PHC level. Timeliness/ Age appropriateness of vaccination ascertainment has not been a feature even of District Health Information Software Version 2.0 (DHIS-2). Shorter intervals of four weeks between DPT 1 and DPT 2 and DPT 2 and DPT 3 confer protection at an earlier age which may be particularly important in Pertussis control³. Also, intervals of two months or more (delay of one month or more) do not offer any advantage over one month intervals for protection against Diphtheria and Tetanus and may not enhance Pertussis protection. It is very important to complete vaccination of all infants up to OPV 3 before six months of age as most Polio cases occur between the ages of 6 months to 3 years, as also a booster OPV dose recommended 12 to 18 months later⁴. Longer dose intervals of more than four weeks for Hep. B vaccination may increase the final anti-HBs titres but not the sero-conversion rates⁵.

AIMS AND OBJECTIVES

The study was carried out 1) to assess the Routine Immunization (RI) Program (in terms of the Output and the Quality) at PHC Barwala; 2) to find out the awareness amongst healthcare providers regarding the newly introduced Pentavalent vaccine in RI program of the State. And 3) to evolve recommendations for improvement in the implementation of the RI program at the PHC.

 

MATERIAL AND METHODS

It is a descriptive, cross-sectional study carried out at the PHC Barwala, District Panchkula of Haryana State during the month of January, 2013. Study population included the children less than 2 yr covered under the PHC. The information was collected from their mother/ care giver. Purposive sampling was done for selecting the Sub-Centers. Thus, three out of the four Sub-centers were selected – One at the PHC head-quarters - SC Barwala, one nearest to the PHC headquarters - SC Bhareli and other farthest from the PHC - SC Kakrali. Twenty two (88%) of total 25 users (children less than 2 yr) from the three session sites (Village Barwala under SC Barwala- 7/7; Village Bhagwanpur under SC Bhareli - 4/4 and Village Natwal under SC Kakrali - 11/14) were included in the study. Rapid Immunization Coverage Assessment Surveys were also conducted to include total 30 children between 1 – 2 year from the community (Household visit); ten each from village Barwala, Bhagwanpur and Natwal. The RI providers included were - three ANMs - one for each of the three selected sub-center, two LHVs and two MOs (Medical Officer) from the PHC. Primary data was collected using Observation, Check-list and Interview techniques. Secondary data was obtained from records, reports, registers, documents and HMIS. The data was analyzed using "MS Office 2007 Excel" computer software program; also the qualitative data was dealt with separately.

 

RESULTS

Results are described in four sub-headings - 1) From PHC; 2) From Session Sites; 3) From Rapid Immunization Coverage Assessment for RI by House to House Surveys and 4) Timeliness of Vaccination from Session sites and Rapid RI Coverage surveys Combined Together.

From PHC: Coverage for Immunization under RI was >/= 100% target achievements for the years 2009-10 and 2010-11. Session-wise reporting was done at PHC by all ANMs. Monthly Immunization reports submitted timely and regularly. Drop-out/Left-out rates were not calculated. New DHIS-2 Single Reporting Format and HMIS Format submitted timely and regularly since Oct. 2012. Hard copy reports of the same were also submitted (Duplication of the work). MCTS entry being done regularly as per schedule displayed. The entries in users' RI/MCP Card, available counterfoils, tally sheets, register no. 3 at sub-centers, reports and HMIS entries matched each other (Consistent data). AWWs have immunization register for the records. ASHAs record it in their ASHA Diary. RI Coverage Monitoring Chart for the year 2012-13 was displayed at the PHC. Vaccine preventable disease (VPD) case or Serious AEFI case has not been reported in the last year. AFP (Acute Flaccid Paralysis) cases reported were, one each in June 2011 and June 2012. Their Stool Samples reported Negative for Wild Polio Virus/ Polio Vaccine virus. Adequate and trained (for RI and HMIS) human resource and pro-active MO I/C was the strength, except for vacant posts of One HA- Male and Four MPW- Male. All ASHAs were trained in seven modules. Supervision was done more by MO I/C than LHV for the RI sessions. There was no supervisory visit by LHV in the last month to the session sites. Supervisory visit by district officials to the PHC were purposeful. One RI review meeting was held at PHC in the last month. There was one inter-sectoral coordination meeting during the last month for RI related issues attended by Health and ICDS agencies. Micro-planning including specific plan for hard to reach areas, its implementation and Alternate vaccine delivery (AVD) were according to guidelines. Plan for organizing missed session was available. As planned, each ANM carried out 4x3 = 12 sessions in last 3 months. Daily RI Sessions were held at the PHC. Vaccine lifting efficiency was 100% in the last three months. One ILR, Two Deep-Freezers, Four inverters and Four stabilizers were in working condition/ Functional. Vaccine carriers were 50 in number. One cold box available was used for transportation and emergency storage of vaccines and ice-packs. There was no Generator at the PHC, demand for which was already placed. Vaccine and Logistics Stock Registers and Distribution/Issue Registers and Temperature Log Books for all cold chain equipments were properly maintained and up-to-date. ILR cabinet temperature ranged between +2 to +8 degree centigrade (+3 degree centigrade on observation). Deep freezer cabinet temperature ranged between -15 to -25 degree centigrade (-20 centigrade on observation). EEFO (Early expiry first out) was followed for vaccines and diluents. There was no stock out of any vaccine or the other logistics in the last 3 months. Statements of expenditures were being submitted to District HQ on monthly basis. Cold chain handlers were fixed and trained. BCG, BCG diluent, DPT, Measles, Measles diluent, t-OPV, Hep B, TT, Pentavalent vaccine, AD (0.1ml) Syringes, AD (0.5ml) Syringes, 5 ml Reconstitution Syringes, Vitamin-A Solution and Blank RI/MCP Cards were available at the PHC adequately for the next one month. All available vaccines were stored inside ILR. No frozen DPT/DT/TT/Hepatitis B vaccines were present inside ILR, neither expired vaccines were present. No other medicines (besides vaccines) were stored inside ILR. Ice packs were correctly placed inside Deep freezer. Most of the Counterfoils of RI/MCP card for SC Barwala were available. Other logistics available at the PHC included – ORS Packets, Plastic spoon for Vitamin A, Paracetamol tab/syrup, tracking bag (14 pockets), nutritional supplements, BP Apparatus, Functional Hub Cutter, IFA tablets, Weighing Machines, AEFI Kit etc. Returned vials retrieved from vaccine carriers returned to PHC from session sites. Segregated Immunization waste from the session sites was carried to the PHC for storage. Bio-Medical Waste (BMW) management was outsourced to a private agency. BMW was transported by the agency, thrice a week, from the PHC.

From Session Sites: RI session day was Wednesday. Session sites were Anganwadi Centers (AWC) of 1. Village Barwala, Sub-centre (SC) Barwala; 2. Village Bhagwanpur, SC Bhareli; and 3. Village Natwal, SC Kakrali. All three were outreach sessions, which were as per microplan and along with VHND. There was Alternate Vaccine Delivery at these sites. Banner for Immunization Session was displayed at each site. VHNDs were not so informative. Vaccine carriers had four icepacks each, at all the sites. BCG, BCG diluent, DPT, Measles, Measles diluent, t-OPV, Hep B, TT, Pentavalent vaccine, AD (0.1ml) Syringes, AD (0.5ml) Syringes, 5 ml Reconstitution Syringes, Vitamin-A Solution, Blank RI Card were available. Vaccine and diluents were kept in the vaccine carrier in zipper bags. ANMs did not record vaccine/ diluent batch number and vaccine/ diluent expiry date. It was recorded at the PHC. VVMs did not change colors for any of the vials at the sites. Other logistics available at the session sites were- ORS Packets, Plastic spoon for Vitamin A, Paracetamol tab/syrup, nutritional supplements, BP Apparatus, Functional Hub Cutter, Zinc tablet, IFA tablets, weighing machine. Tracking bag was available at respective sub-centers. Counterfoils available at session sites were – 6/7 Barwala (85.71%, Maximum); 2/6 Bhagwanpur (33.33%, Minimum); 6/14 Natwal (42.86%); and Total 14/27 = 51.85%. Due list for beneficiaries was available with ANM and with the Mobilizer (ASHA/ AWW) at all the three villages. Total Children vaccinated as per due list were 25/47 = 53.19%.

Table 1: Actual number of children immunized, out of total expected as per due list

Village	Total expected beneficiaries n	Actual number of children immunized n	% of children immunized from the due list %	Reasons for non-turnout
				Visiting PHC n	Non-availability at home/ out station n	Ill children N	Sub-total n
Barwala	20	7	35%	13	0	0	13
Bhagwanpur	9	4	44.44%	0	5	0	5
Natwal	18	14	77.78%	0	3	1	4
Total	47	25	53.19%	13 (59.09%)	8 (36.36%)	1 (4.55%)	22 (100%)

 

Percentage of children from due list vaccinated was minimum (35%) at Village Barwala; where others visited the PHC at the same village for immunization as there were RI sessions held daily at the PHC. It was maximum (77.78%) at village Natwal, which is under farthest sub-centre from the PHC. From amongst those who did not turn-out at session sites 36.36% belonged to migratory population who were not available at home or were out-stations. ANMs did not write time of reconstitution on the vial/s at these sessions (Session duration left was also less than four hours at the time reconstitution and number of beneficiaries were one each for Measles as per due list). Measles vaccine was given sub-cutaneously – Right Upper Arm. DPT vaccine given on outer (antero-lateral) aspect of mid thigh. Pentavalent vaccine was administered at all the three sites. Circle mark put on vial for Pentavalent vaccine after its use. AD syringes were used to inject vaccines. No touch to needle technique was followed. No recapping done after giving injection. ANMs were cutting each syringe with hub cutter just after its use. ANMs segregated immunization waste in Red and Black bags. Segregated Immunization waste was carried to the PHC from all the session sites for storage. ANMs recorded data in register/diary after vaccinating each child and also filled the Tally sheet. Counterfoil was filled if available. AEFI Kit was available at two of the three sites. It was not available at the session in Barwala village (PHC headquarters). Children immunized were not asked to wait for 30 min after the dose/s to observe for AEFI at all the three sessions. All the three ANMs knew it correctly that a child needs to be vaccinated if comes with mild fever/ loose motions. Also, newly introduced Pentavalent vaccine is to be given to new children for the first time at 6wks; and circle mark to be put if the vial is used while returning it back to the PHC each time. The left-over after third circular mark is to be discarded at the PHC. MO I/C visited each of the sites for supervision (in last 3 months). LHV visited to Natwal once (in last 3 months).

 

Table 3: Summary of the Interview with the users (their mother/ care giver) at Session Sites and Verification of their RI/MCP Cards available

Village	Timeliness of vaccination   n; %	Types of delay			Reasons for delay
		Delay for DPT 1 / Penta 1 n	Delay bet-n DPT 1 and 2 n	Delay bet-n DPT 2 and 3 n	LBW   n	Not available at home/ out-stations n
Barwala	5/7 (71.43%)	1	1	0	1	1
Bhagwanpur	3/4 (75%)	0	0	1	0	1
Natwal	7/11 (63.64%)	1	3	0	1	3
Total	15/22 (68.18%)	2	4	1	2	5*

LBW - Low Birth Weight; * - Belonged to migratory population; Delay for DPT= Delay for DPT/OPV/Hep B; Penta - Pentavalent Vaccine.

Timeliness of vaccination from amongst users of RI from session sites was maximum (75%) at the village under the SC nearest to the PHC while it was minimum (63.64%) at the village under the SC farthest from the PHC. There was no serious AEFI case. No user received any message through MCTS regarding immunization.

From Rapid Immunization Coverage Assessment for RI by House to House Surveys: Total Children = 30. All thirty children surveyed were fully immunized.

Table 4: Background Information of the Children: Rapid Immunization Coverage

RI/MCP card was available for 90% of the children surveyed.

Table 5: Summary of Rapid Immunization Coverage Assessment for RI by House to House Surveys and Verification of available RI/MCP Cards of the children

LBW - Low Birth Weight; * - Belonged to migratory population; Delay for DPT= Delay for DPT/OPV/Hep B.

Timeliness of vaccination from Rapid Immunization Coverage Assessment was maximum (100%) at village of PHC head-quarters, while it was minimum (60%) at village under SC farthest from the PHC. There was no serious AEFI case. No user received any message through MCTS regarding immunization.

Timeliness of Vaccination from Session Sites and Rapid RI Coverage Surveys Combined Together:

Table 6: Timeliness of Vaccination from Session Sites and Rapid RI Coverage Surveys Combined Together

Timeliness of vaccination for PHC Barwala ascertained from users of RI at session sites and from rapid immunization coverage evaluation surveys combined together was in (15/22 at session sites and 24/30 in the community) (Total 39/52 users = ) 75%. This timeliness of vaccination was minimum at village Natwal (61.90%) which is under the sub-centre farthest from the PHC, while it was maximum (88.24%) at the village of PHC head-quarters.

 

Table 7: Distribution of children in whom timeliness of vaccination was not followed

M = Male; F = Female.

The percentage of female children amongst those in whom timeliness of vaccination was not followed was 46.15% (n=6/13), while for male children it was 53.85% (n=7/13).             

CONCLUSIONS

Adequate and trained human resource and pro-active MO I/C was the strength for 100% target achievements for RI for the last 2 yr. Yet, timeliness of vaccination for users of RI at session sites and from rapid immunization coverage evaluation surveys (all 30 children surveyed were fully immunized) combined together was in 75%. It was minimum (61.90%) at the village Natwal which is under the sub-centre farthest from the PHC. This reveals that- villagers living far away from PHC are relatively more deprived of quality healthcare services; strategic location of health services delivery plays a vital role. The percentage of female children amongst those in whom timeliness of vaccination was not followed was 46.15% as against 53.85% males, showing gender difference but no gender bias against girls. Vaccine preventable disease (VPD) case or Serious AEFI case has not been reported in the last year. Supply of vaccines was adequate and cold chain was maintained as per norms. EEFO followed for vaccines and diluents. Micro-planning and Alternate vaccine delivery (AVD) were according to guidelines. Vaccine lifting efficiency was 100%. ANMs did not record vaccine/ diluent batch number and vaccine/ diluent expiry date at the session sites. However, it was recorded at the PHC. ANMs did not write time of reconstitution on the vial/s. Children immunized were not asked to wait for 30 min after the dose/s to observe for AEFI. It may be either indifference or lesser sensitivity to the concepts. Counterfoils available at session sites were – 51.85%. Supervision was more by MO I/C than LHV for the RI sessions. ASHAs and AWWs were the mobilizers for RI program, playing good role. VHNDs were not so informative. Awareness amongst healthcare providers regarding the newly introduced Pentavalent vaccine in RI program of the State was adequate. Pentavalent vaccine was available and was administered at all the three session sites. However, ANMs were not delivering all four key messages to the care-givers. The most commonly missed messages were message 1 and message 4 (Table 2). Reporting was regular including New DHIS-2 Single Reporting Format and HMIS Format and Hard copy reports (Duplication of work). The data available for RI was consistent. However, Drop-out/Left-out rates were not calculated at the PHC. MCTS entry was being done regularly as per schedule displayed, but it was not being used fully for tracking purpose. Migratory population due to seasonal industries (Brick kiln and Poultry farms etc.) in the area is a challenge. It leads to drop-outs or delays in immunizations, as children in due list are not always available at homes or are out-stations at the time of planned immunization sessions.

 

RECOMMENDATIONS GIVEN

1. To have regular immunization review meetings at the PHC;
2. To increase community awareness and participation;
3. To focus on the importance of timeliness of vaccination during VHNDs;
4. Migratory population to be advised/counseled to have their children vaccinated at travel destinations;
5. Drop-out rate and Left-out rates to be calculated every month;
6. Tracking Bag, RI/ MCP Card Counterfoils and MCTS to be utilized purposefully for the tracking; and
7. Supervisory visits by LHV (HA Female) to immunization session sites to be ensured, particularly for the sub-centre farthest from the PHC.

 

REFERENCES

1. International Institute for Population Sciences (IIPS) Mumbai, (2010): District Level Household and Facility Survey (DLHS-3), 2007-08: India. Haryana; p.15.
2. Coverage Evaluation Survey- 2009, All India Report, UNICEF, (2010), p.33-36. -http://www.unicef.org/india/health.html and http://www.unicef.org/india/resources_6679.htm and http://www.unicef.org/india/1_-_CES_2009_All_India_Report.pdf
3. K. Park (2013): Park's Text Book of Preventive and Social Medicine, 22nd Edition; Jabalpur (India), M/s Banarsidas Bhanot Publishers; p.153. Cross reference- WHO (1983) WHO Chr., 37 (6), p.191.
4. K. Park (2013): Park's Text Book of Preventive and Social Medicine, 22nd Edition; Jabalpur (India), M/s Banarsidas Bhanot Publishers; p.187.
5. K. Park (2013): Park's Text Book of Preventive and Social Medicine, 22nd Edition; Jabalpur (India), M/s Banarsidas Bhanot Publishers; p.196.
6. Immunization Guide for Block Program Managers, MoHandFW, GOI, p.96.
7. Immunization Coverage Cluster Survey Reference Manual, Immunization Vaccines and Biologicals, WHO, (2005), WHO/IVB/04.23. – http://www.who.int/vaccines-documents and https://extranet.who.int/aim_elearning/en/measles/resources/pdf/Cluster_survey_manual_WHO.pdf