This document outlines the goals and objectives of Myanmar's National Immunization Program, including reducing under-5 mortality from vaccine-preventable diseases and reaching routine immunization coverage targets. It discusses strategies to strengthen routine immunization through the RED approach, which focuses on re-establishing outreach services, supportive supervision, community linkages, monitoring data use, and resource planning and management at the township level. Proper vaccine and equipment supply management, cold chain maintenance, and adverse event monitoring are also covered to help ensure vaccine quality and safety.

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. 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. 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.
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. 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. 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. 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. 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. Service Delivery Strategy

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. 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. 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. 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. 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. 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. 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. Immunization Safety
Components of Immunization Safety
Vaccine Safety
Injection Safety
Safety of Waste Disposal

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. Due to unsafe cold-chain practices :
• has reduced effectiveness in
protecting against disease
• can result in higher rates of local
reactions

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. 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. 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. 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. 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. AEFI

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. Five main types of AEFI

28. Vaccine Reaction

29. Rare Serious Reaction

30. Examples of incorrect immunization practices and associated
AEFI

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. Estimating Vaccine and Injection Equipments

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. Estimating annual vaccines and safe-injection equipment requirements
for a province with a target population of 100 000 infants and pregnant
women

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. 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. 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. Recommended temperatures and length of storage at various levels of
the cold chain

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. 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. Conditioning ice pack

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. Refrigerator temperature chart

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. 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. What is RED Strategy?

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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

58. Please contact kyawkankaungmo@gmail.com
09-8702267