Epi for hsso


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  • Township collects needed vaccine from Subdepots. BHS then carry vaccine in vaccine carrier and vaccinate targeted children and pregnant women.
  • Epi for hsso

    1. 1. EPI for HSSO Dr. Kyaw Kan Kaung Project Manager/Assistant Director Department of Health Ministry of Health Training on HSSO Naypyitaw 6-7 Feb 2013
    2. 2. Goal and Objectives National Immunization Program -Myanmar The vision reduction of under 5 morbidity and mortality caused by vaccine preventable diseases in reaching MDG 4. The overall objective to reach the routine immunization coverage of 90% nationally in children under one with 8 antigens and with TT in pregnant women, and at least 80% coverage in all townships
    3. 3. The specific objectives 1. To achieve immunization coverage of 90% nationally with at least 80% coverage in every township for all 8 antigens in under five and for TT in pregnant women 2. To maintain the elimination status of Maternal and neonatal tetanus (incidence to less than 1/1000 live-births at the national level as well as township level) 3. To sustain the interruption of indigenous transmission of wild and vaccine-derived polio virus and to achieve eradication status in 2014 Feb.
    4. 4. 4. To achieve measles elimination in 2015 5. To ensure injection safety through universal use of AD Syringes and appropriate waste management practices. 6. To reduce vertical transmission of hepatitis B through increased delivery of timely Hepatitis B birth dose. 7. To enable evidence based decision making for introduction of new vaccine –Rotavirus, Pneumococcal, JE, through acquiring the needed information on disease burden, costing, cost effectiveness and global funding environment
    5. 5. 8. To increase coverage of other primary health care interventions through improved linkages with immunization – Vitamin A, B1, de-worming, and ITN distribution & use.
    6. 6. Myanmar EPI towards MDG Goal 4 : Reduce child mortality Target 5 Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate 1. Under-five mortality rate 2. Infant mortality rate 3. Proportion of one-year-old immunized against measles children
    7. 7. TRENDS IN CHILD MORTALITY Trends in Child Mortality RELATED TO MDG 4, MYANMAR Relative to MDG-4 in Myanmar Myanmar 140 130 MDG 120 82.4 100 80 98 66.1 62.1 60 B L 0 , 1 r p s h t a e D 77.77 55.4 55.1 49.7 40 43.3 43.4 20 32.7 0 1990 1995 1999 2003 2007 DOH DOH CSO DOH DHP U5MR 2015 IMR (Source: Cause specific under five mortality survey, DOH/UNICEF, 2003) 7
    8. 8. EPINew EPI Schedule after New Vaccines Introduction Schedule in Myanmar before New Vaccine Introduction Age Vaccines At Birth BCG, HepB ( Hospital births) 6 weeks 2 month DPT -1, OPV -1, HepB 10month 4 weeks DPT -2, OPV -2, HepB 14month 6 weeks DPT -3, OPV-3, HepB 9 months Measles - 1 18 month Measles - 2 Penta-1 + OPV-1 Penta-2 + OPV-2 Penta-3 + OPV-3
    9. 9. Service Delivery Strategy
    10. 10. National Immunization Programme Steering and Formulation ICC - Interagency Cooperation Committee NCIP- National Committee for Immunization Practices NCCPE - National Certification Committee for Polio Eradication
    11. 11. Myanmar Routine Immunization DTP 3 Coverage 2011 National coverage 86% 0-59% 60% - 79% 80% or above No data Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar
    12. 12. Sub National Routine EPI Coverage 2011 BCG DPT3 0-59% 60% - 79% 80% or above No data Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar OPV3 HepB3
    13. 13. Routine EPI Coverage 2011 (Townships) BCG DPT3 0-59% OPV3 60% - 79% Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar HepB3 Measles 1 80% or above No data Measles 2
    14. 14. Sub National Routine EPI Coverage 2011 Measles 1 0-59% 60% - 79% 80% or above No data Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar Measles 2
    15. 15. Routine EPI Coverage 2011 TT 1 0-59% 60% - 79% 80% or above Source- Central Expanded Programme on Immunization, CEU ,DoH, MoH Myanmar TT 2
    16. 16. Cold chain network in Myanmar Yangon Central Coldroom Level Power conditions Equipment used Central + 2 Main Sores ~24 hrs Walk-in cold room Back-up generator Sub-Stores (State or Division level) at least 8 hrs per day Freezer & Fridge Back-up generator Township at least 3 hrs per day Freezer & Fridge 2 Main Stores ( Mandalay&Magway ) Total 24 Sub-Stores Sub - Store … Sub - Store … Sub - Store … 330 Townships Solar unit for selected locations Sub RHCs (20- 40 /tsp) mostly not available Sub RHC RHCs (4- 5 per tsp) Rural Health Center (RHC) not available Cooler box with ice packs (last 5 days) Solar unit for selected locations Vaccine Carrier for midwife (last only 48hrs)
    17. 17. Immunization Safety Components of Immunization Safety Vaccine Safety Injection Safety Safety of Waste Disposal
    18. 18. Vaccine safety and quality Safe cold-chain practices Vaccines are sensitive to heat and freezing kept at the correct temperature from manufactured to used in order to preserve their quality The cold chain consists of a series of storage and transport links
    19. 19. Due to unsafe cold-chain practices : • has reduced effectiveness in protecting against disease • can result in higher rates of local reactions
    20. 20. Safe use of diluents • Kept correct diluent and distributed with each vaccine type and batch. • Vaccines and diluents must be clearly labelled and identified. • Diluents must be cooled to between +2°C and +8°C before reconstitution. • Draw up the correct number of doses per vial • Discard reconstituted vaccines after six hours of reconstitution. • Diluents must not be frozen. • Sterile water for injection must NOT be used as a vaccine
    21. 21. Ten critical steps to reconstitute vaccines safely 1. Read the label on the diluent to make sure that it is the correct diluent 2. Check the expiry date 3. Check the status of the (VVM) 4. Cool the diluent to between +2°C and +8°C 5. Draw the entire contents of the diluent empty the entire contents into the vaccine vial.
    22. 22. 6. Discard the used mixing syringe and needle into a safety box without recapping. 7. Do not leave the mixing needle in the vaccine vial. 8. Never allow the vial to become immersed in water. 9. Discard all reconstituted vaccine at the end of the session, or after six hours 10. Use a new auto-disable (AD) syringe and needle ,use the same needle and syringe for injecting the vaccine.
    23. 23. Multi-dose vial policy (MDVP) • Multi-dose vials of OPV, DTP, TT, DT, Td, hepatitis B and liquid formulations of Hib vaccines a maximum of four weeks provided that all the following conditions are met. 1. The expiry date has not passed. 2. The vaccines are stored under appropriate cold-chain conditions (+2°C to +8°C). 3. The vaccine vial septum has not been submerged in water. 4. Aseptic technique has been used to withdraw all doses. 5. The VVM, if attached, has not reached the discard point. Note : reconstituted vaccine must be discarded at the end of each immunization session or at the end of six hours, whichever comes first.
    24. 24. vaccines to which the multi-dose vial policy applies 1. DT vaccine, adsorbed. 2. dT. 3. Td vaccine for adults, adsorbed. 4. TT vaccine, adsorbed. 5. DTP vaccine, adsorbed. 6. DTP-Hib vaccine, liquid. 7. DTP-HepB vaccine. 8. HepB vaccine. 9. Hib vaccine, liquid. 10.Oral polio vaccine. Not applied . 1. BCG vaccine. 2. DTP+Hib vaccine, lyophilized. 3. DTP-HepB+Hib vaccine, liquid + lyophilized. 4. Hib vaccine, lyophilized. 5. Yellow fever vaccine. 6. Meningitis vaccine A&C. 7. Measles vaccine. 8. MMR vaccine
    25. 25. AEFI
    26. 26. Adverse Events Following Immunization (AEFI) surveillance Definition of AEFI surveillance An adverse event following immunization (AEFI) is defined as a medical event or incident that takes place after an immunization, but is not necessarily caused by immunization. AEFI surveillance includes : 1. detecting, monitoring and responding to adverse events following immunization(AEFI) ; 2. implementing appropriate and immediate action to correct any unsafe practices detected through the AEFI surveillance system, in order to lessen the negative impact on the health of individuals and the reputation of the immunization programme.
    27. 27. Five main types of AEFI
    28. 28. Vaccine Reaction
    29. 29. Rare Serious Reaction
    30. 30. Examples of incorrect immunization practices and associated AEFI
    31. 31. Programme errors and AEFI • The view that vaccines are the most common cause of AEFI is incorrect. • On the contrary, incorrect immunization practices that can be prevented are more often the cause. • Careful epidemiological investigation of an AEFI is needed to pinpoint the cause and to correct these malpractices.
    32. 32. Estimating Vaccine and Injection Equipments
    33. 33. Estimating vaccine and safe-injection equipment needs based on target population • basic parameters necessary to estimate vaccine and safe injection equipment • the target population of the area (such as infants or pregnant women) • details of vaccines included in the national immunization schedule, including the number of doses and the number of doses per vial; • the wastage multiplication factor (WMF) for each vaccine and the AD syringes
    34. 34. Estimating annual vaccines and safe-injection equipment requirements for a province with a target population of 100 000 infants and pregnant women
    35. 35. How do I calculate the wastage multiplication factor (WMF)? • The vaccine wastage rate can vary greatly according to several characteristics of the programme – for example session sizes, session plans, vial presentation and supply management.
    36. 36. Estimating vaccine and safe-injection equipment needs based on previous consumption • • • • Each parameter relative to previous consumption can be affected by many factors especially programme performance, during the supply period in question. Estimating needs based on previous consumption may, therefore, not be as reliable as the method based on target population. Consider the following measurements when estimating vaccine and safe injection equipment needs based on previous consumption: • initial stock (vaccines and safe-injection equipment) at the beginning of the given period; • stock received during the period; • stock at the end of the period.
    37. 37. Storage of vaccines and safe injection equipment • Storing vaccines • Vaccine storage conditions • Temperature sensitivity of vaccines • Loss of potency due to heat • Loss of potency due to Freezing
    38. 38. Recommended temperatures and length of storage at various levels of the cold chain
    39. 39. Diluent • if diluent is supplied separately, it can be stored outside the cold chain • but must be cooled before use, preferably for a day or for a period of time • sufficient to ensure that the vaccine and diluent are both at temperatures between +2 °C and +8 °C when they are reconstituted. • Never freeze diluent.
    40. 40. Photosensitivity • Some vaccines are very sensitive to light and their exposure to ultraviolet light causes loss of potency. • BCG, measles, MR, MMR and rubella vaccines are equally light-sensitive and must always be protected from sunlight and fluorescent (neon) light. • manufacturers provide these vaccines in vials made of a darker glass.
    41. 41. Conditioning ice pack
    42. 42. Temperature monitoring Monitoring the temperature in vaccine refrigerators • WHO advocates the use of new timetemperature devices for continuous temperature recording. • In the absence of such devices • a thermometer; • a temperature chart that you tape to the outside of the refrigerator door.
    43. 43. Refrigerator temperature chart
    44. 44. Using the VVM to monitor the quality of vaccine vials The four different VVM types and their relationship to temperature sensitivity in EPI vaccines
    45. 45. Reducing vaccine wastage • • Unavoidable vaccine wastage factors The most important unavoidable wastage factors involve: reconstituted vaccines that have to be discarded at the end of a session. Avoidable vaccine wastage factors Factors that can be controlled by improving vaccine management include: • poor stock management resulting in over-supply and vaccines reaching expiry before use; • cold-chain failure that exposes vaccines to unacceptably high unacceptably low temperatures; • incorrect dosage, e.g. the administration of 3 drops of OPV instead of 2 drops or the injection of 0.6 ml of vaccine instead of 0.5 ml; • failure to comply with the multi-dose vial policy; • the loss, breakage or theft of vials.
    46. 46. What is RED Strategy?
    47. 47. Identifying H2R Health Center Areas Current Implementation Strengthening RI with HSS or REC Total Ward/ Village Routine REC Uncovere d IRI HSS Still Uncovere d Reason MCH 5/112 5/112 0 0 0 0 0 0 Yankha RHC 79 61 18 - - 18 - - Mine Khon RHC 139 88 8 43 - 8 43 Satff Transport Security Win Bo RHC 101 52 43 - - 43 - - Kat Taung RHC 224 205 19 - - 19 - - Mine king 8 8 8
    48. 48. Background • RED (Reaching Every District ) is a strategy developed by WHO, UNICEF, CDC, CVP/PATH and USAID. • The strategy specifically aimed at overcoming the most common barriers to improving access to immunization services and to achieve sustainable and equitable access to quality immunization services for every infant. • The focus of RED is on planning at the sub-national administrative level (Township) • The level is closest to service delivery where there is potential managerial capacity to improve services.
    49. 49. The RED strategy has the following operational components 1. Re-establishment of outreach services 2. Supportive supervision 3. Community link with service delivery 4. Monitoring and use of data for action 5. Planning and management of resources five
    50. 50. The five RED operational components 1. Re-establishing outreach vaccination services  A large proportion of the population only have access to immunization through outreach  Outreach sessions, by mobile immunization teams also present opportunities to provide other interventions such as administering vitamin A and deworming tablets with immunization  Include other interventions during crash programme in hard to reach areas where feasible
    51. 51. The five RED operational components 2. Supportive supervision  providing regular on-site or on- the- job training and assistance by supervisors to health workers in Township during supervisory visits or at regular monthly meetings  offers the opportunity to integrate supervision of other health interventions, for example Integrated Management of Childhood Illness (IMCI).
    52. 52. The five RED operational components 2. Supportive supervision  Update and use standardized supervisory checklist  Training of supervisors(TMO,THO.HA1,THN at SD level  Support mobility of supervisors atl all level  Provision feedback at all opportunities  Prioritize areas to be supervised based on coverage/drop-out.
    53. 53. The five RED operational components 3. Linking services with communities  Immunization services need to integrated better into community structures.  This can be achieved by involving the community in the planning and delivery of health services,  Including immunization,  such as identifying community volunteers and designating responsibilities  identifying newborns and  performing regular follow-up on mothers whose children are not fully immunized
    54. 54. The five RED operational components 3. Linking services with communities  Promotion of benefit of immunization at all opportunities.  Explore the possibilities of increasing use of mass media for promoting routine immunization  Increase training for health workers and volunteers to communicate effectively with mothers ideally in local languages
    55. 55. The five RED operational components 4. Monitoring and use of data for action  Monitoring of immunization activities and using the data for action is critical in strengthening the immunization system  Simple monitoring tools such as wall charts of vaccination coverage can be used to track monthly progress  Information on logistics, vaccine supply and surveillance which is collected every month should be analyzed together with the coverage data to improve the immunization system.
    56. 56. The five RED operational components 5. Planning and management of resources • A township/RHC micro plan is the key to the RED strategy. • At each level, micro plans should contain details of the financial and human resources required to reach every district in a sustainable manner.
    57. 57. Please contact kyawkankaungmo@gmail.com 09-8702267