EXPANDED PROGRAM ON IMMUNIZATION

The Expanded Program on Immunization is a World Health Organization program with the goal to make vaccines available to all children throughout the world.

HISTORY 

The World Health Organization (WHO) initiated the Expanded Program on Immunization (EPI) in May 1974 with the objective to vaccinate children throughout the world. Ten years later, in 1984, the WHO established a standardized vaccination schedule for the original EPI vaccines: Bacillus Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP), oral polio, and measles. Increased knowledge of the immunologic factors of disease led to new vaccines being developed and added to the EPI’s list of recommended vaccines: Hepatitis B (HepB), yellow fever in countries endemic for the disease, and Haemophilus influenzae meningitis (Hib) conjugate vaccine in countries with high burden of disease.

In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created with the sole purpose of improving child health in the poorest countries by extending the reach of the EPI. The GAVI brought together a grand coalition, including the UN agencies and institutions (WHO, UNICEF, the World Bank), public health institutes, donor and implementing countries, the Bill and Melinda Gates Foundation and The Rockefeller Foundation, the vaccine industry, non-governmental organizations (NGOs) and many more. The creation of the GAVI has helped to renew interest and maintain the importance of immunizations in battling the world’s large burden of infectious diseases.

The current goals of the EPI are: to ensure full immunization of children under one year of age in every district, to globally eradicate poliomyelitis, to reduce maternal and neonatal tetanus to an incidence rate of less than one case per 1,000 births by 2005, to cut in half the number of measles-related deaths that occurred in 1999, and to extend all new vaccine and preventive health interventions to children in all districts in the world.

In addition, the GAVI has set up specific milestones to achieve the EPI goals: that by 2010 all countries have routine immunization coverage of 90% of their child population, that HepB be introduced in 80% of all countries by 2007 and that 50% of the poorest countries have Hib vaccine by 2005.

IMPLEMENTATION

In each of the United Nations’ member states, the individual national governments create and implement their own policies for vaccination programs following the guidelines set by the EPI. Setting up an immunization program is multifaceted and contains many complex components including a reliable cold chain system, transport for the delivery of the vaccines, maintenance of vaccine stocks, training and monitoring of health workers, outreach educational programs to inform the public, and a means of documenting and recording which child receives which vaccines.

Each distinct region has slightly varying ways of setting up and implementing their own immunization programs based on their existing level of health infrastructure. Some areas will have fixed sites for vaccination: healthcare facilities such as hospitals or health posts that include vaccination along with many other health care activities. But in areas where the number of structured health facilities is small, mobile vaccination teams consisting of staff members from a health facility can deliver vaccines straight to individual towns and villages. These ‘outreach’ services are often scheduled throughout the year. However, in especially under-developed countries where proper communication and infrastructure is absent, cancellation of the planned immunization visits leads to deterioration of the program. A better strategy in such countries is the ‘pulse immunization’ technique, where ‘pulses’ of vaccines are given to children in annual vaccination campaigns.

Additional strategies are needed if the area of the immunization program consists of poor urban communities because such areas tend to have low uptake of vaccination programs. Door-to-door canvassing, also referred to as channeling, is used to increase uptake in such hard to reach groups. Finally, periodic national level mass vaccination campaigns are being increasingly included in the immunization programs.

EVALUATION

In each country, immunization programs are monitored using two different methods: an administrative method and through community-based surveys. The administrative method involves using immunization data from public, private, and NGO clinics. Thus the accuracy of the administrative method is limited by the availability and accuracy of reports from these facilities. This method is easily performed in areas where the government services deliver the immunizations directly or where the government supplies the vaccines to the clinics. In countries without the infrastructure to do this, community based surveys are used to estimate immunization coverage.

Community-based surveys are applied using a modified cluster sampling survey method developed by the World Health Organization. Vaccine coverage is evaluated using a two-stage sampling approach in which 30 clusters and seven children within each cluster are selected. Health care workers with no or limited background in statistics and sampling are able to carry out data collection with minimal training. Such a survey implementation provides a way to get information from areas where there is no reliable data source. It is also used to validate reported vaccine coverage (for example, from administrative reports) and is expected to estimate vaccine coverage within 10 percent.

Surveys or questionnaires, though frequently considered inaccurate due to self-reporting, can provide more detailed information than administrative reports alone. If home based records are available, not only can vaccination status be determined but also dates of vaccination can be reviewed to determine if vaccinations were given at an ideal age and in appropriate intervals. Missed immunizations can be identified and further qualified. Importantly, other systems of vaccine delivery besides clinics used for administrative evaluation can be identified and included in analysis.

RESULTS

Prior to the initiation of the EPI, child vaccination coverage for tuberculosis, diphtheria, pertussis, tetanus, polio and measles was estimated to be fewer than 5 percent. Now, not only has coverage increased to 79 percent, but it has also been expanded to include other vaccinations such as for hepatitis B, Haemophilus influenzae type B, rubella, tetanus and yellow fever. The impact of increased vaccination is clear from the decreasing incidence of many diseases. For example, measles deaths decreased by 60% worldwide between 1999 and 2005, and polio, although missed the goal of eradication by 2005, has decreased significantly as there were less than 2000 cases in 2006.

PATH - INITIATION TO IMMUNIZATION

Collaborating locally to bring health within reach

PATH works in India’s highest-need, hardest-to-reach areas

PATH began working in India in 1978 to address some of the country’s crucial health problems. Over more than three decades, our program in the region has grown to become one of our largest. We work in some of the country’s highest-need and hardest-to-reach areas, collaborating with governments, communities, companies, researchers, and public health practitioners to find health solutions.

Preventing disease through vaccines and immunizations

PATH works in India to help develop new vaccines and vaccine technologies and strengthen immunization services  to reach even the most remote villages. We’re advancing new vaccines against malaria, meningitis, pneumococcal disease (the most common  cause of severe pneumonia), and rotavirus (the most common  cause of severe diarrhea) by collaborating with partners on vaccine development, formulation, manufacturing, and compliance with regulatory authorities.

We work closely with the Government of India to strengthen health systems to introduce new vaccines and improve access to immunization services. PATH is helping to increase immunization coverage for young children in the slums of Mumbai and the state of Madhya Pradesh. Through our partnership with the Indian government, we helped ensure that 78 million children nationwide received vaccine against Japanese encephalitis, a debilitating disease that in India strikes mainly poor, rural communities. We helped introduce hepatitis B vaccine in the routine immunization program. The vaccine is now available free of cost in most state immunization programs.

PATH also facilitates research in India on methods to protect vaccines from damage due to exposure to extreme temperatures during transport and storage. Because reuse of needles can increase the risk of spreading HIV, hepatitis B, and other infections, PATH has supported manufacturers to mass-produce single-use syringes to make them available and affordable.

Improving health for mothers and children

Every year, thousands of children in India die within a month of birth. Thousands more survive, but grow up weak or sickly. Often, these outcomes could be avoided with increased health education. Through PATH’s Sure Start project, we and our nearly 90 local partners are enhancing India’s health system while helping families understand simple steps they can take to help their babies thrive.

Despite advances, women in India continue to be threatened by two highly preventable causes of death: postpartum hemorrhage and cervical cancer. India’s maternal mortality rate is 407 per 100,000 live births; 30 percent of the deaths are due to excessive bleeding after childbirth. PATH is working to understand the factors that lead to the inappropriate use of oxytocin—a drug with the potential to dramatically decrease postpartum hemorrhage—and to determine how to use it safely. We’re also gathering information that will help India establish a comprehensive cervical cancer prevention plan.

Access to safe water and healthy food

Millions of poor families in India lack access to safe drinking water, a condition that poses a daily threat to their health. We conducted extensive testing with potential users to design a household water treatment and storage device for Indian families. Now, we’re collaborating with manufacturers and distributors to provide a product that has the potential to make safe drinking water available and affordable.

To alleviate the debilitating effects of micronutrient malnutrition, PATH developed a pasta-like “grain” called Ultra Rice® that is manufactured from rice flour and essential vitamins and minerals. When blended with milled rice, typically at a 1:100 ratio, the resulting fortified rice is nearly identical to traditional rice in smell, taste, and texture. In India, we’ve established the safety and efficacy of the Ultra Rice® technology and are now working with partners of the Government’s Mid-Day Meal program to serve fortified rice to 185,000 schoolchildren daily.

Controlling tuberculosis

India has the highest burden of tuberculosis (TB) in the world. With 1.8 million cases occurring annually and 333,000 deaths from TB, India accounts for one-fifth of the world’s new TB cases and two-thirds of the cases in Southeast Asia. More than 70 percent of cases occur in the economically productive 15– to 54-year-old age group. Their deaths take a terrible toll on families and economies. PATH supports the government nationally and across 26 states by strengthening communication, laboratories, infection control, and surveillance of multidrug-resistant TB.

IMMUNIZATIONS AND VACCINES ARE NECESSARY

Immunizations, or vaccines as they're also known, safely and effectively use a small amount of a weakened or killed virus or bacteria or bits of lab-made protein that imitate the virus in order to prevent infection by that same virus or bacteria.

When you get an immunization, you're injected with a weakened form of (or a fragment of) a disease. This triggers your body's immune response, causing it to either produce antibodies to that particular ailment or induce other processes that enhance immunity.

Then, if you're ever again exposed to the actual disease-causing organism, your immune system is prepared to fight the infection. A vaccine will usually prevent the onset of a disease or else reduce its severity.

Why Should Someone Get Immunized?

The goal of public health is to prevent disease. It's much easier and more cost-effective to prevent a disease than to treat it. That's exactly what immunizations aim to do.  

Immunizations protect us from serious diseases and also prevent the spread of those diseases to others. Over the years immunizations have thwarted epidemics of once common

 infectious diseases such as measles, mumps, and whooping cough. And because of immunizations we've seen the near eradication of others, such as polio and smallpox.

Some vaccines need to be given only once; others require updates or "boosters" to maintain successful immunization and continued protection against disease.

Which Immunizations Do My Children Need?

Because proof of immunization is often a prerequisite for enrollment in school or day care, it's important to keep your children up to date on their vaccines. The benefit of doing so is that your children will be protected from diseases that could cause them serious health problems. The recommended immunizations for children 0-6 years of age include:

• Hepatitis B
• Rotavirus
• Diphtheria, tetanus, pertussis
• Haemophilus influenzae type B
• Pneumococcal
• Poliovirus
• Influenza
• Measles, mumps, rubella
• Varicella (chickenpox)
• Hepatitis A
• Meningococcal (for certain high-risk groups)

At one time or another, each of the diseases addressed by these vaccines posed a serious health threat to children, taking their lives by the thousands; today most of these diseases are at their lowest levels in decades, thanks to immunizations.

WORLD IMMUNIZATION WEEK

Ditta and Richard meant to take Dora, their younger child, for her second dose of the combined measles/mumps/rubella vaccine, but somehow it just slipped their minds. As working parents, there was so much to juggle in their home and professional lives that it was all too easy for that crucial second dose to fall off the ‘to do’ list. However, their memories were jogged in a less than pleasant way, when they visited relatives in an area of the UK in the grip of a measles outbreak.

Many children missing immunizations

WHO/F. K. Vorting

Immunization prevents an estimated 2-3 million deaths worldwide every year. Yet 1 in 5 children still misses out. In 2013, a number of European countries experienced large measles outbreaks, but the region has targeted the disease for elimination by 2015.

As more and more people—including busy parents—are won over by the user-friendly convenience of smart phones, their appetite for “apps” is growing by the day. Naturally, many public health authorities have recognized this as a major opportunity. A range of smart phone apps has appeared for purposes as diverse as treating your depression to calculating how many units of alcohol you might have consumed that week.

An immunization app

So Robb Butler and Ajay Goel of WHO’s European Region Vaccine Preventable Diseases and Immunization Programme decided an app would be the ideal way to help parents keep track of when their children are due for immunizations. However, they were also aware that many countries would find it difficult, if not impossible, to create such an app from scratch, for lack of funds or technical expertise. This was clearly somewhere WHO could lend a helping hand.

In 2013, they set about finding the right people to develop the code for a smart phone immunization reminder app to be made freely available to health authorities. Countries would then be able take the code and customize it to make an app to meet their particular needs. Writing code is the biggest piece of the work to develop a new app, leaving those who have access to the code with only the finishing touches left to do—the icing on the cake—quickly and cheaply.

“This app will make it easier for parents to know which vaccines their children need and when, through automatic reminders.”

Robb Butler, WHO European Region

The app that WHO has developed contains information on vaccines, the diseases they prevent and the immunization schedule of the country where it will be made available. Parents who download it just put in the names and dates of birth of their children and their phone sends them a reminder each time a new immunization is due, even offering them the option of dialling the doctor’s number with one click.

“We know that convenience is an important factor for busy parents and it’s all too easy to just forget whether your child has had all the necessary vaccinations. This app will make it easier for parents to know which vaccines their children need and when, through automatic reminders,” explains Robb Butler.

World Immunization Week

The slogan for World Immunization Week 2014 is “Immunize for a healthy future: Know, Check, Protect”. WHO encourages families to learn more about vaccine-preventable diseases, check whether they are up-to-date with recommended vaccines, and visit their health provider to get protected.

In countries where more than one language is spoken, a language switch button has been added to the app in order to provide the same standard of service for all communities.

The current version of the app is intended for parents of 0–10-year-olds receiving standard vaccines. However, strong interest from other countries has spurred plans to produce a new version which will allow for optional vaccines to be included. Future versions will also allow users to add other family members not in the 0-10 year age range.

“We were lucky,” says Richard, “our daughter didn’t catch measles but I was uncomfortable with the fact that we left it to chance. The first thing we did when we got home was make an appointment with the nurse. Ditta and I both wished we’d had a system to remind us. We will definitely be downloading the app.”

UNIVERSAL IMMUNIZATION PROGRAMME (UIP)

Introduction

India's Universal Immunisation Programme (U.I.P.) is one of the largest in the world in terms of quantities of vaccine used, the number of beneficiaries, the number of Immunisation session organised, the geographical spread and diversity of areas covered.

The national policy of Immunisation of all children during the first year of life with DPT, OPV, BCG to complete the series of primary vaccination before reaching the age of one year was adopted in 1978 with the lunching of EPI to increase the Immunisation coverage in infancy to 80%. Universal Immunisation programme UIP was lunched in 1985 in a phased manner. The measles vaccine was added in 1985 and in 1990 Vit A supplementation was added to the program.

The Vaccination Schedule under the UIP is:

1. BCG (Bacillus Calmette Guerin) 1 dose at Birth (upto 1 year if not given earlier)

2. DPT (Diphtheria, Pertussis and Tetanus Toxoid) 5 doses; Three primary doses at 6,10,14 weeks and two booster doses at 16-24 months and 5 Years of age

3. OPV (Oral Polio Vaccine) 5 doses; 0 dose at birth, three primary doses at 6,10 and 14 weeks and one booster dose at 16-24 months of age

4. Hepatitis B vaccine 4 doses; 0 dose within 24 hours of birth and three doses at 6, 10 and 14 weeks of age.

5. Measles 2 doses; first dose at 9-12 months and second dose at 16-24months of age

6. TT (Tetanus Toxoid) 2 doses at 10 years and 16 years of age

7. TT – for pregnant woman two doses or one dose if previously vaccinated within 3 Year

8.  In addition, Japanese Encephalitis (JE vaccine) vaccine was introduced in 112 endemic districts in campaign mode in phased manner from 2006-10 and has now been incorporated under the Routine Immunisation Programme...

VACCINATION OF SEASONAL FLU

Vaccination & Vaccine Safety

Everyone 6 months of age and older should get the flu vaccine. Seasonal flu vaccines have a very good safety track record.

AVAILABILITY

The flu vaccine is available by shot or nasal spray. Get your flu shot or spray as soon as the vaccine is available in your area. It is especially important to get the vaccine if you, someone you live with, or someone you care for is at high risk of complications from the flu. Mild reactions such as soreness, headaches, and fever are common side effects of the flu vaccine. If you experience a severe reaction such as difficulty breathing, hives, or facial swelling, seek medical attention immediately.

Where can I get the vaccine?

Use the Flu Vaccine Finder to find a flu vaccine location near you this flu season. The 2014-2015 vaccine is now available.

How should I get the vaccine?

There are two different types of flu vaccines, trivalent and quadrivalent.

Trivalent vaccines protect against 3 strains of the flu, A/H3N2, A/H1N1, and influenza B. Trivalent vaccines are available in:

• Traditional flu shots, approved for anyone 6 months and older
• Intradermal shots, which use a shorter needle, approved for anyone 18-64
• High dose shots approved for people over 65
• Cell based shots created using viruses grown in animal cells and approved for anyone over 18
• Recombinant shots created using DNA technology, approved for people 18-49 with severe egg allergies

Quadivalent vaccines protect against 4 strains of the flu, A/H3N2, A/H1N1, and 2 strains of influenza B. Quadrivalent vaccines are available in:

• Traditional flu shots, approved for anyone 6 months and older
• Nasal spray, approved for healthy people from 2-49, except pregnant women

Does the flu vaccine work right away?

It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against influenza virus infection. In the meantime, you are still at risk for getting the flu. That's why it's better to get vaccinated early in the fall, before the flu season really gets under way.

Is the vaccine safe?

Seasonal flu vaccines have a very good safety track record. Although there are possible side-effects to vaccination, the Centers for Disease Control and Prevention and the Food and Drug Administration closely monitor the safety of seasonal flu vaccines.

PULSE POLIO IMMUNIZATION PROGRAM

The Pulse Polio Immunization Program was started in 1995 to eradicate polio. Under this program, all children below the age of 5 years are administered two doses of the oral polio vaccine per year. The oral polio vaccine is administered in the program, since it not only protects the child, but also gets disseminated to the community, thus resulting in widespread protection. The government of India with a vision of eradicating poliomyelitis or polio from the country had initiated an immunization campaign during the period 1995-96. By this, it was intended to vaccinate all children under the age of 5yrs. This program has been receiving support of various international institutions, state governments and NGOs.

Pulse polio campaign in India a success

It is evident that the World Health Organization (WHO) had removed India from the list of polio-endemic countries. If no fresh case is reported till 2014, the country will be declared polio free, officially. So far, for last four years not even a single case of polio has been reported in India, thereby virtually making India polio free. It’s only the official announcement that is awaited.

HEALTH IS WEALTH

A cornerstone of the polio eradication strategy is the need to ensure high (more than 80%) immunization coverage of children in the first year of life with at least three doses of oral polio vaccine as part of national routine immunization schedules.

While routine immunization alone cannot eradicate the disease, good routine oral polio vaccine coverage increases population immunity, reduces the incidence of polio and makes eradication feasible.If uniformly high immunization coverage is not maintained, pockets of non-immunized children build up, favouring continued spread and outbreaks of the poliovirus. 

According to WHO/UNICEF immunization coverage estimates, 86% of infants received three doses of oral polio vaccine in 2010, compared with 75% in 1990.Polio-free countries must continue to ensure high levels of immunization coverage to prevent the re-establishment of poliovirus through importations from other countries. This can happen through international travellers, migrant populations or population sub-groups who refuse immunization.