REGIONAL COMMITTEE
Provisional Agenda item 4.7.2
Sixty-sixth Session SEARO, New Delhi, India 10–13 September 2013
SEA/RC66/14 19 July 2013
Progress reports on selected Regional Committee resolutions: 2012: Year of Intensification of Routine Immunization in the South-East Asia Region: Framework for Increasing and Sustaining Coverage (SEA/RC64/R3) The annual birth cohort in the WHO South-East Asia Region is estimated at about 40 million. In 2011 the regional diphtheria –tetanus–pertussis (DTP3) coverage was only 75%, and WHO estimates that about 9 million children miss out on the most basic package of immunization. Recognizing this, the Sixty-fourth Session of the WHO South-East Asia Regional Committee adopted resolution SEA/RC64/R3 declaring 2012 as the Year of Intensification of Routine Immunization. Pursuant to that resolution, all Member States developed plans of action focusing on high-risk or hard-to-reach areas and populations for intensified efforts to strengthen immunization services and systems in countries. Intensification efforts include a wide range of activities, from training to build capacity of the health workforce to hiring more staff, improving advocacy and communication on immunization, enhancing community participation, partnership-building, better follow-up and tracking of infants for vaccination and, in some cases, supplementary immunization activities to reach those children that may have missed out on routine services. Member States have made progress, albeit some more than others. However, there are still several countries where efforts must continue in order to reach those that are still not receiving routine services, and to sustain the gains made thus far. The High-Level Preparatory (HLP) Meeting held in the Regional Office in New Delhi from 1 to 3 July 2013 reviewed the attached working paper and made the following recommendations: Actions by Member States (1) To review multi-year national plans of action for immunization to improve focus on specific strategies to reach the hard-to-reach areas or pockets of population in otherwise high coverage areas.
(2) (1)
To support the implementation of high-quality surveillance for vaccine-preventable diseases. To ensure the availability of national resources necessary for a sustainable immunization programme, while making every effort to mobiize additional resources from donors.
Actions by WHO-SEARO (1) (2) (3) To work with partners to explore mechanisms to obtain vaccines at the best prices possible, particularly for those small countries who do not require bulk purchase. To provide technical support to countries in the development of their multi-year routine immunization plans of action, monitoring and evaluation activities. To provide technical support to countries for the development of high-quality vaccinepreventable disease surveillance.
The working paper and HLP meeting recommendations are submitted to the Sixtysixth Session of the Regional Committee for its consideration.
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Introduction 1. The Sixty-fourth Session of the WHO South-East Asia Regional Committee in September 2011, vide resolution SEA/RC64/R3, declared 2012 as the “Year of Intensification of Routine Immunization” in South-East Asia. Member States committed “to develop national and sub national level plans of action based on risk analysis to intensify routine immunization coverage”. This regional initiative is aligned to the strategic objectives and targets outlined in the Global Vaccine Action Plan (GVAP) endorsed by all Member States at the Sixty-fifth World Health Assembly in 2012. 2. Based on the resolution of the Regional Committee, all countries prepared plans of action, focusing primarily on high-risk areas or groups, to intensify routine immunization activities to enhance coverage and to reach more children with immunization. The following is an update on the progress of actions Member States have taken in fulfilment of resolution SEA/RC64/R3, and their results.
Action plans for the strengthening of routine immunization in Member States 3. WHO/UNICEF estimate that in 2011 almost 23 million children worldwide missed out on routine immunization, and that 9 million of these missed children were in the South-East Asia Region alone. In 2011, at least three countries in the Region had a national DTP3 coverage <80%. Clearly, strengthening of routine immunization in several countries of the South-East Asia Region is a priority consideration. 4. Following the adoption of resolution SEA/RC64/R3 by the Sixty-fourth Session of the Regional Committee, all Member States developed a plan of action to strengthen routine immunization in their country. These intensification plans were focused on identifying poorly performing or hard-to-reach areas or population groups. For example, in Bangladesh 32 out of 70 districts, in Bhutan hard-to-reach pockets of floating population across the country, in India 239 out of 644 districts, in Indonesia 36 districts across 7 provinces, and in Thailand 3 southern provinces, were identified for targeted immunization activities. Such activities included improving enumeration, tracking drop-outs, mobilizing community participation, intensifying communication and advocacy and, in some cases, conducting supplementary immunization activities (SIA) to cover vaccine doses missed by children in such areas. For example, in India 120 million children aged 9 months to 10 years in 367 districts received a second opportunity for measles vaccination through SIA. In addition, nearly 400 000 settlements have been identified as high-risk to be targeted for emergency preparedness and response planning for polio eradication. 5. For sustainable immunization programmes in countries, attention to capacity-building and systems strengthening is important. In the intensification of routine immunization, countries paid great attention to immunization systems strengthening and capacity-building, for example:
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Bangladesh: midlevel managers (MLM) training was conducted; additional vaccine transport cost for hard-to-reach areas was provided; support was given for volunteers to fill vacant posts. India: establishment of an Immunization Technical Support Unit (ITSU); alternative vaccine delivery (AVD); 28 out of 35 states established a Task Force for Immunization; training was given to more than 34 000 front-line health workers in different categories. Indonesia: MLM training was conducted in 36 districts for expanded programme on immunization (EPI) officers; local area monitoring was strengthened; a new communication plan for immunization was developed. Myanmar: MLM training was conducted; more funds were allocated for operations costs. Nepal: microplans for 56 districts were updated; vaccinators were recruited; cold chain facilities were upgraded. Sri Lanka: the national immunization policy was developed/updated; MLM and adverse events following immunization (AEFI) training was delivered; effective vaccine management assessment was conducted. Box 1. Case-study: Strengthening routine immunization in Timor-Leste
Timor-Leste has a population of about 1.1 million people with an annual estimated birth cohort of 42 000. The country is divided into 13 districts, 65 subdistricts and 442 villages. In 2011, national DTP3 coverage was only 67%. Partners stepped in to supplement government efforts to increase routine immunization coverage and strengthen the national immunization programme. A USAID-supported programme covered seven districts; WHO/UNICEF covered two districts each; the Coffee Growers Association (Café Clinic Timor) covered the remaining two districts. The focus of activity was on micro-planning at the local level, and on hiring additional staff to make regular house-to-house visits both for enumeration of pregnant mothers and children who needed follow-up, including tracking dropouts. The support of the village elders and village chiefs were sought for community mobilization. Transport support, such as vehicles at the district level and motorbikes for outreach services, was provided; in some cases supplemental funds for fuel were given. The results of the above intensification efforts showed that for 2012, the national DTP coverage had risen to 82.6%* and, except for two districts, all other districts achieved routine coverage well above 70%. The case of Timor-Leste is illustrative of the possibilities to improve routine immunization where focused efforts are crucial at the local level to drive health services to the community. * Source: data from Statistics Department, 2013
6. In many of the countries, such intensification required partners to support government efforts; as always WHO and UNICEF were fully engaged in supporting national governments. Other partners were also involved; for example, the involvement of the Lions Club for social mobilization and PATH to strengthen cold chain and logistics in Indonesia; GAVI reprogramming of health systems strengthening grants for funding intensification activities in some countries;
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WHO/UNICEF and several local NGOs in Timor-Leste (Box 1). Similarly, joint media sensitization workshops with UNICEF were conducted in five countries (India, Indonesia, Maldives, Myanmar and Nepal) to address demand issues. As part of intensification efforts, the Region joined a global movement to use World Immunization Week as an opportunity to raise awareness of the benefits of immunization, along with all other WHO regions. Therefore, partnerships are important, not only to enhance immunization coverage, but also to sustain high coverage. 7. All countries have planned to continue intensification efforts beyond 2012 by incorporating elements into their multiyear national immunization plan. The impact on coverage will be reviewed in 2014, when more complete information is available from countries.
Challenges and lessons learnt 8. Some of the lessons learnt from this one year of intensification of routine immunization efforts are as follows. (i) (ii) There is political commitment to improve immunization in Member States, but commitment needs to be better translated into actions at local level. Despite good progress, there is still more to be done to sustain the gains in many countries; even in best-performing countries there are pockets of underserved population.
(iii) Although much has been achieved, availability of resources always remains a challenge. It is vital that political commitment and resource allocation work in tandem so that visions can become a reality. Continued efforts are needed to mobilize both internal and external support to strengthen and sustain high-quality immunization services in countries.
Conclusions and recommendations 9. The declaration of 2012 as the Year of Intensification of Routine Immunization in the South-East Asia Region was timely. All Member States have risen to the challenge and have carried out a range of activities to strengthen routine immunization in countries. The efforts have helped to reach those children in the most hard-to-reach areas, or those population groups such as floating (migratory) populations who often miss out on routine services. While acknowledging progress, it is also important to emphasize that in several countries further efforts are needed to reach remaining unreached areas, as well as to sustain the gains made thus far. To do this, strong political commitment backed with resources is vital to continue to make further gains. The framework to continue to strengthen routine immunization and introduce new vaccines is outlined well in the GVAP adopted by the Sixty-fifth World Health Assembly in 2012, and the commitment of Member States to achieve the goals and vision of the GVAP was further reiterated at the Sixty-sixth World Health Assembly meeting in 2013.