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Indian Journal of Community Medicine

Vol. 28, No. 2 (2003-04 - 2003-06)

Editorial

Innovative Approaches to Universalize Immunization in Rural Areas

Sunder Lal, B.M. Vashisht* Prof. & Head, Reader* Deptt, of SPM Pt. BDS PGIMS, Rohtak

The Universal Immunization Programme despite achieving nearly total coverage during Technology Mission days has faltered particularly in northern states1. The concern, on declining coverage of routine immunization has been voiced at several national fora. Evidence has been provided by several coverage evaluation surveys about overall decline. Currently, immunization coverage of young children is far from universal Of children aged 12-23 months, only 42% are fully vaccinated, 44% have received some vaccination and 14% have received no vaccination (NFHS-2)2. Similarly, EPI survey done in March-May 2001 by UNICEF for Govt. of India reported overall coverage of fully immunized children around 50%3, coverage was highly uneven between various states3, only 11% of children in Bihar and 14-17% in Nagaland, Meghalaya, Assam and Rajasthan were fully vaccinated; by contrast, in Tamil Nadu, Himachal Pradesh, Goa and Kerala 80% or more were fully vaccinated2. Immunization coverage of India as reported by WHO (2002) is reproduced below3.

Immunization profile - India :

Routine Immunization, by and large have been provided through Public Sector, the Private Sector has played marginal role. It is credible to observe that cold chain system is maintained much better by public system as compared to private sector, however to enhance coverage and reach larger segment of vulnerable population, role of Private Sector needs to be enhanced, by promoting partnership between these two sectors.

The reasons for declining trends of coverage are many. The predominant reasons are; poor identification and registration of pregnant women and births through routine system and consequently poor tracking system and contact with pregnant women and young children. At national level only about 55% of the births are being covered by the registration machinery5. At present identification of pregnant women and their registration may be as bad as birth registration. Once this is the level of registration, the plight of immunization coverage can be well imagined.

Annual surveys to identify eligible couples, pregnant and lactating women and young children for immunization as advocated under RCH programme for community needs assessment approach appears to be poor model as it can pick up pregnant women who were pregnant at that point of time (April of every year)4. At best this mechanism can capture half of the pregnant women provided the survey is complete and correct methods to identify pregnant women are undertaken and ensured by all health workers, which is seldom the case. Therefore, to have full account of pregnant women a surveillance system is to be adopted for continuous registration of pregnant women in the area of subcentre. The practical way to ensure this is through self reporting of women to subcentre if the services are attractive, the benefits are valued and perceived in right perspective, as also the attitude and behaviour of worker is supportive. Regular home contacts/visits by health workers can be yet another mechanism for complete registration of pregnant women but the home contacts and visits are gradually diminishing. NFHS 2 data indicates that only 14% of rural and 10% of urban women have received a home visit in the past one year2. The other powerful mechanism of surveillance of pregnant women could be through ICDS, anganwadi workers and the functional linkages between anganwadi workers and health workers can enhance this yield to a significant level.

Since, under Decentralization and devolution of powers the village panchayats have been made responsible at village level for compulsory registration of births, marriages, pregnancies, universalizing the small family norm, increasing safe deliveries, bringing in reduction in infant and maternal mortality and promoting compulsory education upto age 14, the opportunity should be used to promote universal immunization, by linking the health, development, ICDS and educational activities through self help groups as also NGOs6.

It has been observed that out of all the agencies available at village level the resident Anganwadi worker was the most efficient agency to register the events of births (over 96%) hence linkage with ICDS system can improve the coverage of immunization. Scheme of birth registration should be linked with child care, through early and effective response for mother and child care to ensure better survival and reduction of morbidity and mortality through appropriate actions as deemed necessary7.

The other reason for pitfall in routine immunization has been lack of information about outreach immunization sessions (MCH sessions) and as many as 60% of outreach sessions are missed in some situation. Though the national programme on Immunization has fixed Wednesday for outreach sessions, the workers have poor capacity to adhere to fixed work schedule, because of several operational problems. Workers are required to collect the vaccine from nearby Primary Health Centre, which means travel to respective PHC, spending money and time apart from lifting the load of vaccine carriers. Whole of the Wednesday or at least half of that day, gets spent as travel time. Supply of syringes and needles appears to be inadequate and boiling of needles and syringes takes extra time of workers. The workers are left with no option but to resort to immunization as and when it is convenient to them. There is a tendency on the part of workers to over report their performance because of pressure of superior authorities.

Since the immunization programme has been included in the 20 point programme, the pressure on district Civil Surgeon remains very high. District health authorities expect cent per cent coverage and this message goes down the line to achieve predetermined magic target. District magistrates are at commanding position and Dist. Civil Surgeon has to obey and achieve this level of immunization by all means and by any mean, and in the process things go wrong and over reporting is the temptation. Therefore, this vital service for mothers and children should be delinked from 20 point programme and let it be monitored by the community say village panchayat. District health authorities should evolve innovative strategies like the one described hereunder and should facilitate and ensure regular sessions on the site and fixed day.

Routine immunization coverage depends upon good infrastructure. Inadequacies in the existing health infrastructure have led to high unmet needs of immunization and obvious gaps in coverage and outreach. Health centres struggle to provide services with limited resources of manpower and equipment and supply of vaccines. In difficult and remote areas deficiencies of staff may be as high as 25-50%. Participation of male workers in immunization session tends to be minimal, at places the male workers help to bring vaccines from the PHC; they seldom perform immunization work. Moreover, over 50% of positions of male workers are lying vaccant at most of places and the states are not ready to fill these posts. Inaccessible areas can be covered by male worker with the help of anganwadi workers. This problem is being addressed partially through additional ANMs appointed on contractual basis for remote and inaccessible and difficult subcentre areas, under RCH programme. Efficient use of available workforce is a local management skill which should be built in increasingly to multiply resources, logistics and using available manpower effectively for ensuring outreach sessions at least once a month in remote, inaccessible and sparsely populated areas. Hiring of vehicles and power of resource generation must be vested with village Panchayats and local Medical Officers.

The infrastructure in urban slum areas for "Primary Health Care" tends to be weak and unorganized, hence the poor coverage of immunization and impending threat of outbreak of vaccine preventable diseases always exists. Most polio cases have been reported from urban slum areas8. Special efforts are needed in urban slums to enhance the coverage level of routine immunization.

Lack of supportive supervision, lack of training in interpersonal communication and inadequate functioning of Manila Swasthya Sanghs, non resident status of health workers and poor motivation comes in the way of Reproductive and Child Health Services including immunization. Immunization should be linked with Reproductive and Child Health Services for universal coverage and outreach of antenatal, natal and postnatal health care. To achieve universal coverage of immunization amongst women and young children universal identification and registration of pregnant women and births becomes essential. Identification of pregnant women and their registration may not be an easy task for MPHW(F) who has large areas and many villages under her jurisdiction. This has been facilitated to a great extent by establishing functional linkage between MPHW(F) and anganwadi workers under ICDS system.

Effective Model:

Innovative and most productive approach is being followed at field practice areas attached with PGIMS, Rohtak ever since 1985-86. Our experience with ICDS to enhance coverage of immunisation and other maternal and child health services has been quite rewarding.

Each ANM(MPHW(F) has been linked with 5 anganwadi workers. MPHW(F) and MPHW(M) work with and work through the system of anganwadis. They prepare their work plan jointly and persue the activities of mother and child care as a team, supported by their supervisors. Functional linkage has ensured continuous surveillance of marriages and women of reproductive age group, through regular contacts by home visits or self reporting of women to subcentre and anganwadis to derive benefits of antenatal care and supplementary nutrition, apart from child care services. Pregnant women and young children get enumerated anganwadi-wise and tracking becomes easier through resident anganwadi workers who are able to locate women and children in their homes precisely. Tracking of pregnancy continues till delivery and even during lactation period of 6 months after delivery. Tracking of young children continues till they attain 5 years of age and become eligible for school enrolment.

Planning of outreach immunization sessions (MCH sessions) happens to be a joint activity of MPHW(F), MPHW(M) and anganwadi workers along with their supervisors and team leaders. The beneficiaries (pregnant women and infants) for immunization are identified well in advance jointly and unmet needs of immunization are identified jointly by subcentre team once every month. Number of infants and pregnant women to be immunized in that session are listed and accordingly vaccine requirements are arrived at by each team which are subsequently communicated to the Medical Officers and Senior Medical Officer of the Community Health Centre. Invariably this is done at the sector level meeting which happens in the last week of every month at sector headquarter village. Feed back of preceding outreach sessions is also made available to the supervisors and team leaders to rectify the faults and inadequacies in the system.

The Community Health Centre (effectively Primary Health Centre) happens to be the hub of outreach immunization sessions. Total requirement of vaccines of each subcentre under the jurisdiction of CHC, every month, is known to Medical Officers, Senior Medical Officer (SMO) and Block supervisor MPHW(F) through meticulous microplanning activities undertaken by each subcentre team; well before the session date. Required quantity of vaccines for each station (subcentre/MPHW(F) is packed in each vaccine carrier in a polythene bag, alongwith frozen ice packs, late evening or early morning depending upon the weather conditions. Required quantity of each vaccine, name of the subcentre village and health worker is indicated/ pasted on each vaccine carrier. The boxes (vaccine carriers) are loaded in two vehicles made available at CHC by pooling on the fixed date. The vaccines reach each subcentre/station through vehicles of CHC (including vehicle of CDPO or arranged from PGIMS, Rohtak or Civil Surgeon or other sources under the supervision of Medical Officer of each PHC. On one day 10-12 subcentres are reached through pre-determined route plan; by 8 AM the supplies are available at each subcentre on fixed date. Alongwith the vaccine adequate number of pre-sterilized (autoclaved) reusable syringes and needles packed in a tray are provided to each station.

Two days operation helps to mobilize the required number of health workers (vaccinators) and supervisors (MPHW(F) from one area to another area within the jurisdiction of the CHC as on required basis. The fixed dates are well publicized through anganwadi workers, mahila swasthya sangh members, women groups and village panchayats. Printed reporting proformae are provided to each station/MPHW(F). The session is conducted at fixed site in each village either subcentre or predetermined site of anganwadi. The session is jointly conducted by MPHW(F) and male and anganwadi workers. Helpers and women groups of subcentre and anganwadi workers act as agent of social mobilization and informant to women at their homes. Supervision of the outreach (MCH session) session is done by the respective Medical Officer and the health supervisors Male and Female, to ensure quality coverage and meet out the deficiencies if any through reserves/extra supplies carried in the allocated vehicle. At the end of the session the report is prepared by respective worker on prescribed proforma giving an account of vaccine consumed and left over, children covered for different immunization agents. The supervisors collect the report and left over vaccine and vaccine carriers, used needles and syringes; back to destination of CHC. Thus, the whole operation gets monitored adequately and performance report is available on the same day, avoiding any chance of over-reporting or manipulation. Recording system over the years have been evolved innovatively. Each anganwadi worker records the date of immunization (under each immunization, agent) against each infant, identified by date of birth, parents name, for easy tracking for later dates. Respective MPHW(F) prepares separate records for immunization in her own register, this duplication is necessary evil to satisfy the audit requirements. Reporting of the performance on immunization is done jointly at the sector meeting day.

Chronological order of recording of all the births by anganwadi workers in their area is a wonderful and extremely useful record for tracking and even evaluation of coverage of immunization apart from monitoring and introspection by anganwadi workers themselves. You need not to undertake the separate coverage evaluation surveys to determine the coverage levels. The record of AWW in these areas is a ready reckoner to evaluate, age of initiation, completion, time interval between doses and coverage of immunization during infancy and beyond.

Home based records of immunization are made available to mother or grandmother or whosoever comes alongwith that child and subsequently mothers are contacted during home visit to explain the conduct of immunization. In our settings, men hardly accompany children for getting them immunized at outreach session, hence they are most ignorant on the subject of immunization done to their children. Moment you meet any man/men and question them on immunization, Vit. A or IFA they will direct you to mother of the child for obtaining answer to that query. This is most disturbing as most men are illiterate and even many of the literate do not read the immunization card available in their home.

These outreach immunization sessions are used to enrich the spectrum of services to achieve the ideals of "Mother and Child Protection Session". Quite often, iron and folic acid tablets, Vit A prophylaxis, ORS and health check-up are combined, however, regular antenatal check up and regular weighing of all children who attend these sessions has not become a universal culture/practice. At times mothers themselves weigh or insist weighing their children to know the progress of weight gain. This may come up in a way of its own right as and when the clients become quality conscious.

Aggressive participation of male health workers, anganwadi workers and mothers themselves have produced favourable results in our settings. Rapid followup of all children is ensured through home visits during the next two to three days following immunization session by AWW and health workers to observe any untoward reactions and management thereof. Feed back on reaction is given to respective Medical Officer and area is supervised for quick response. It was distressing to observe that untoward/adverse reactions after immunization are seldom reported to avoid wrath of superior officers. Similarly, reporting of vaccine preventable diseases has been neglected altogether, as it is viewed as bad and seldom taken in good spirits by the superior officers. VPD surveillance has been neglected in the system. Routine reports are thus poor indicators to judge the situation of occurrence of vaccine preventable diseases; exception to the rule may be AFP surveillance which is vertical nationwide activity, persued as independent activity8.

To enhance the utilization of maternal and child health services including immunization, interpersonal communication channels are used to the maximum by using anganwadi workers, mahila swasthya sangh, women panchayat members and health workers9. Communication efforts were further augmented by launching of radio in support of maternal and child health services focussing on first year of life, pregnant and lactating mothers. The anganwadi workers acted as group animators to promote organized listening groups of women. Mass media focussed on communication needs of women in the area of maternal and child health, including immunization. This unique activity was a landmark, commenced at Rohtak and subsequently taken up by other states of the country. The impact was obvious as the outreach sessions were fully utilized and high coverage levels were achieved through these efforts.

Injection safety is a step forward to improve the quality of immunization and to reduce the untoward reactions. Injection safety is assuming great significance in view of spread of infectious diseases like HIV, Hepatitis B and C etc. We provide enough number of presterilized needles and syringes to ensure separate syringe and needle for every child and correct immunization technique. Use of disposable syringes and needles is also widespread now and people themselves insist and bear the cost of this. National Technical Advisory Group on Immunization (NTAGI) has proposed use of Auto-disable syringes, but this is yet to be introduced in the system. Good practices of disposal of used syringes and needles at local level to be introduced, meeting the standard criteria. The other aspect of safe injection is site of injection-gluteal region must be avoided to safeguard against injury to nerve and this practice must be changed. Only lateral site of thigh should be chosen. All workers must be trained on safe injection and safe disposal of waste material to minimize the after effects of vaccinations.

Home based records as evolved under the programme were used (Jacha-Bacha Raksha Card) in the system10. It has the inherent advantage of uniformity besides identity. It served as self explanatory tool for effective communication through pictorials and printed messages for antenatal check up, diet, iron and folic acid supplementation for prophylaxis and treatment, immunization, breast feeding, spacing and Vit. A prophylaxis. It also facilitated for ascertaining the date of birth and quality of immunization done. No doubt it involved extra-work and labour for health workers. Coverage evaluation surveys revealed that the practice of retaining of this card with mothers was distressingly low varying from 0-41.8%. The supply of these cards remained erratic in most of the situations11. Material and quality of this card needs to be improved to make it more attractive, user friendly and attractive for better retention. Its need is seldom felt once the immunization for child gets completed and this card has no linkages with other services.

This card should be accepted as birth certificate and should continue with mother till the child attains eligible age for entry to school, with appropriate inventories of services provided by health, ICDS and other systems if any.

Immunization (MCH) Sessions create an opportunity of contact with parents and children. It may be used as spring board to enhance maternal and child health services12. Sub centre team should come into full swing action and undertake multitude of activities, apart from immunization, ensure quality antenatal check up of all pregnant women, promote breast feeding, contraception services, Iron and folic acid supplementation, growth monitoring, Vit.A prophylaxis, promotion of ORS and management of ARI. Parents/mothers involvement should be pivotal activity for building sustained educational activities to promote behaviour change and create more demand for maternal and child health services, to promote immunization quality and coverage13-15.

References:

  1. National Mission on Immunization. Deptt, of Family Welfare MOH&FW, Deptt, of Biotechnology Government of India New Delhi. 1988.
  2. National Family Health Survey (NFHS-2) key findings, International Institute of Population sciences, Deonar Mumbai, 1998-99.
  3. Vaccines and Biologicals - WHO vaccine preventable diseases monitoring system 2002 global summary World Health Organization pp 121 - Immunization profile - India.
  4. Manual on community needs assessment approach (formerly target free approach) in Family Welfare Programme. Department of Family Welfare, MOH&FW, GOI, 1998.
  5. Report of the working groups on Registration of births, deaths and marriages. NCP, Govt. of India, 2001.
  6. National Population Policy 2000, Deptt, of Family Welfare, MOKFW, GOI, Nirman Bhawan, New Delhi.
  7. Immunizing more children. Towards greater community participation UNICEF. Regional office South Central Asia, UNICEF House, New Delhi, 1984.
  8. AFP Alert. National Polio. Surveillance Project. A Govt. of India - WHO Initiative volume 6, No. 3, July 2002-Dec. 2002.
  9. Facts for life A communication challenge, Indian Edition published by UNICEF India Country Office, New Delhi, India, Jan. 1990.
  10. National Child Survival and Safe Motherhood Programme, MOH&FW GOI, New Delhi 1992.
  11. National Review of Immunization Programme in India, NIHFW, New Delhi, 1989.
  12. Report of the Expanded Programme on Immunization Global Advisory Group meeting 17-21 Oct. 1988 Abidjan, Coate d'Ivoire. WHO/EPI/Gen/89.1.
  13. The State of the World Children 1989. UNICEF Imunization a Public Health Revolution. pp4.
  14. Immunization strengthening project and scheme for strengthening outreach services . Ministry of Health and Family Welfare, Government of India.
  15. The State of the World Children 1988 UNICEF Immunization a progress report pp4, 32.

Sunder Lal, - Prof. & Head, Reader*

B.M. Vashisht*- Deptt, of SPM Pt. BDS PGIMS, Rohtak

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