Expanded programme on Immunization (EPI) factsheet 2019: Bhutan

World Health Organization • SEARO/FGL/IVD • 31 October 2019 BHutAn FActSHEEt 2019 ExpAnDED pROGRAmmE On ImmunIzAtIOn (EpI) Table 1: Basic information2018 Table 2: Immunization schedule, 2018 Table 3: Immunization system highlights EPI hIsTory • EPI launched on 15 November 1979 • TT for pregnant women introduced in 1983 • HepBvaccine introduced in 1997 • DTP-HepBvaccine introduced in 2003 • AD syringes introduced in 2003 • MR vaccine introduced in 2006 • DTP-Hib-HepBvaccine introduced in 2009 • HPV vaccine introduced in 2010 • HepB birth dose introduced in 2012 • TT vaccine replaced by Td vaccine in 2012 • IPV vaccine introduced in 2015 • tOPV to bOPV switched on 25 April 2016 • Mumps vaccine introduced in 2016 • Verification of endemic measles elimination in 2017 Source: cMYP 2014-2018 and VPDP/MOH Disclimer: The boundaries and names shown and the designations used on all the maps do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Total population1 734,374 Live births1 12,096 Children <1 year1 11,337 Children <5 years1 57,474 Children <15 years1 189,417 Pregnant women1 12,288 WCBA1 (15-49 years) 179,627 Neonatal mortality rate2 16.9 (per 1,000 LB) Infant mortality rate2 25.6 (per 1,000 LB) Under-five mortality rate2 30.8 (per 1,000 LB) Maternal mortality ratio2 148 (per 100,000 LB) Division/Province/State/Region - Dzongkhag/District 20 Gewog/Block 205 Sub-block/Ward 1,050 Village (approx.) 3,717 Population density (per sq. km)1 20.93 Population living in urban areas2 40.2% Population using at least basic drinking- water services2 98% Population using at least basic sanitation services2 63% Total expenditure on health as % of GDP3 3.71% Births attended by skilled health personnel2 96.4% Neonates protected at birth against NT2 89% 1 SEAR annual EPI reporting form, 2018 2 WHO, Global Health Observatory (GHO) data http://apps.who.int/gho/data accessedon 19 May 2019 3 National health accounts Vaccine Age of administration BCG Birth HepB Birth OPV Birth, 6 weeks, 10 weeks and 14 weeks DTP-Hib-HepB 6 weeks, 10 weeks and 14 weeks IPV 14 weeks MMR 9 months and 24 months DTP 24 months HPV Females12 years and grade VI girls (two doses 6 months apart) Td 6 and 12 years; during pregnancy (at first contact and one month later) Vitamin A 6 to 59 months Source: WHO/UNICEF JRF 2018 cMYP for immunization 2014-2018 NTAGI fully functional Spending on vaccines financed by the government 47% Spending on routine immunization programme financed by the government 48% Updated micro-plans that include activities to improve immunization coverage 20 districts (100%) National policy for health care waste management including waste from immunization activities in place National system to monitor AEFI in place Most recent EPI CES National Health Survey 2012 >80% coverage for DTP-Hib-HepB3 19 districts (95%) >90% coverage for MCV1 16 districts (80%) >90% coverage for MCV2 13 districts (65%) >10% drop-out rate for DTP-Hib-HepB1 to DTP-Hib-HepB3 none Source: WHO/UNICEF JRF 2018 Figure 1: National immunization coverage, 1980-2018 Source: WHO and UNICEF estimates of immunization coverage, July 2019 revision Figure 2: DTP3 coverage1, diphtheria and pertussis cases2, 1980-2018 Table 4: reported cases of vaccine preventable diseases, 2013-2018 Figure 3: TT2+ coverage1 and NT cases2, 1980-2018 1 WHO and UNICEF estimates of immunization coverage, July 2019 revision 2 WHO vaccine-preventable diseases: monitoring system 2019 1 Country official estimates, 1980-2018 2 WHO vaccine-preventable diseases: monitoring system 2019 MNT elimination in 2000 Figure 4: 2017 DTP-hib-hepB3 coverage by district Figure 5: 2018 Source: SEAR annual EPI reporting form, 2017 and 2018 (administrative data) Source: WHO/UNICEF JRF (multiple years) *Import and/or import related ND = No data Year Polio Diphtheria Pertussis NT (% of all tetanus) Measles rubella Mumps JE Crs 2013 0 0 0 0 0 6 20 0 0 2014 0 0 0 0 0 0 206 2 0 2015 0 0 12 0 11* 1 620 5 0 2016 0 0 4 0 45* 3 795 5 0 2017 0 0 15 0 66* 9 259 3 0 2018 0 0 8 0 18* 11 27 1 0 <70% 70% - 79% 80% - 89% >90% 464 Diphtheria Cases Pertussis Cases DTP3 Coverage Table 5: AFP surveillance performance indicators, 2013-2018 Table 6: oPV sIA Non-polio AFP rate by district Adequate stool specimen collection percentage by district Source: WHO/UNICEF JRF (multiple years) Indicator 2013 2014 2015 2016 2017 2018 AFP cases 10 11 9 11 10 8 Wild poliovirus confirmed cases 0 0 0 0 0 0 Compatiblecases 0 0 0 0 0 0 Non-polio AFP rate1 4.52 4.84 4.18 5.11 4.04 3.24 Adequate stool specimen collection percentage2 80% 73% 67% 73% 80% 88% Total stool samples collected 11 22 16 20 8 14 % NPEV isolation 0 9 0 0 25 14 % Timeliness of primary result reported3 100 100 100 100 100 100 • Last clinically-confirmed polio case was reported in 1986. 1 Number of discarded AFP cases per 100,000 children under 15 years of age. 2 Percent with 2 specimens, 24 hours apart and within 14 days of paralysis onset. 3 Result reported within 14 days of sample received at laboratory. Figure 6: 2017 Figure 8: 2017Figure 7: 2018 Figure 9: 2018 <1 1 – 1.99 >2 No non-polio AFP case <60% 60% - 79% >80% No AFP year Antigen Geographic coverage Target age Target population Coverage (%) round 1 round 2 round 1 round 2 1995 OPV NID <5 years 80,336 99 100 1996-1997 OPV SNID <5 years 37,107 100 100 1997-1998 OPV SNID <5 years 37,465 100 100 1998-1999 OPV SNID <5 years 36,006 100 100 1999-2000 OPV SNID <5 years 36,541 100 100 2000-2001 OPV SNID <5 years 38,604 100 100 2001 OPV SNID <5 years 36,753 100 100 2002 OPV SNID <5 years 37,665 96 100 Vaccines Protect SUSTAIN. ACCELERATE. INNOVATE. World Health Organization • SEARO/FGL/IVD • 31 October 2019 Figure 10: MCV1 & MCV2 coverage1 and measles, rubella cases2, 1980-2018 Table 7: MCV sIAs MCV1 coverage by district MCV2 coverage by district Source: SEAR annual EPI reporting form, 2017 and 2018 (administrative data) *Number of persons vaccinated Source: WHO/UNICEF JRF (multiple years) 1 WHO and UNICEF estimates of immunization coverage, July 2019 revision 2 WHO vaccine-preventable diseases: monitoring system 2019 Figure 11: 2017 Figure 13: 2017 Figure 14: 2018Figure 12: 2018 <80% 80% - 89% 90% - 94% > 95% year Antigen Geographic coverage Target group Target Coverage % 1995 M nationwide 9 months to 15 years 69,285 100% 2000 M nationwide 9 months to 15 years 214,128 100% 2006 MR nationwide 9 months to 14 years children and 15 years to 44 years women 338,040 98% 2016 MR subnational 418 100% 2017 MR nationwide 9 months to 40 years 267,280 98% 2018 MR subnational 9 months to 40 years 14,698* year Measles Cases Rubella cases MCV1 Coverage MCV2 Coverage 0 20 40 60 80 100 0 100 200 300 400 500 1980 1985 1990 1995 2000 2005 2010 2016 2017 2018 % C ov er ag e N o. o f c as es 1642 819 Figure 15: Immunity against measles - immunity profile by age in 2018 Figure 17: sub-national risk assessment - measles and rubella Figure 16: Immunity against rubella through vaccination - immunity profile by age in 2018 *Modeled using WHO and UNICEF estimates and JRF (multiple years) and does not include immunity due to natural infection *Modeled using MSP tool ver 2 Very High Risk High Risk Medium Risk Low Risk Not Available Figure 18: sporadic and outbreak associated measles cases* by month and 2016-2018 *Includes laboratory confirmed and epidemiologically linked cases Source: SEAR Monthly VPD reports 0% 20% 40% 60% 80% 100% Pe rc en t o f p op ul at io n Protected by maternal antibodies Protected by routine vaccination with 1st dose Protected by routine vaccination with 2nd dose Protected by SIAs Immune due to past infection Susceptible Vaccines Protect SUSTAIN. ACCELERATE. INNOVATE. Figure 19: Vaccination status of confirmed (laboratory, epi-linked and clinically compatible) measles cases, by age in 2018 Table 8: surveillance performance indicator for measles and rubella, 2013-2018 Table 9: Performance of laboratory surveillance, 2013-2018 Figure 20: Laboratory network year No. of suspected Measles Case classification (number) Indicators Measles rubella D is ca rd ed n on - m ea sl es n on -ru be lla ca se s A nn ua l i nc id en ce o f co nf ir m ed M ea sl es ca se s pe r m ill io n to ta l po pu la ti on A nn ua l i nc id en ce o f co nf ir m ed r ub el la ca se s pe r m ill io n to ta l po pu la ti on Pr op or ti on o f a ll su sp ec te d m ea sl es an d ru be lla c as es t ha t ha ve h ad a n ad eq ua te in ve st ig at io n in it ia te d w it hi n 48 h ou rs o f no ti fic at io n D is ca rd ed n on - m ea sl es n on -ru be lla in ci de nc e pe r 10 0, 00 0 to ta l p op ul at io n Pr op or ti on o f d is tr ic ts re po rt in g at le as t tw o di sc ar de d no n- m ea sl es no n- ru be lla c as es pe r 10 0, 00 0 to ta l po pu la ti on Pr op or ti on o f s ub - na ti on al s ur ve ill an ce un it s re po rt in g to t he na ti on al le ve l o n ti m e La b- co nf ir m ed Ep i-L in ke d Cl in ic al ly - co nf ir m ed La b- co nf ir m ed Ep i-L in ke d Target  - - 80% 2 80% 80% 2013 99 0 0 0 6 0 93 0 4.2 0 13.3 ND ND 2014 69 0 0 0 4 0 65 0 2.8 0 9.3 ND ND 2015 120 11* 0 0 1 0 108 16 0.13 0 0 0 0 2016 146 45* 0 0 3 0 106 53 4 ND 14 ND ND 2017 449 66* 4 8 9 0 383 100 11.5 100 49.4 ND 100 2018 405 18* 0 0 11 0 376 25 15 78 51.2 ND 100 Source: SEAR Annual EPI Reporting Form, 2018 *Import and/or import related ND=No data Source: SEAR Annual EPI Reporting Form, 2018 ND=No data Source: SEAR measles case-based data Public Health Laboratory • National measles/rubella laboratory • National Japanese encephalitis laboratory For contact or feedback: Expanded Programme on Immunization Ministry of Health, Thimphu, Bhutan Tel: +975-2-332296, Fax: +975-2-332296 Email: ttamang@health.gov.bt www.health.gov.bt Immunization and Vaccine Development (IVD) WHO-SEARO, IP Estate, MG Marg, New Delhi 110002, India Tel: +91 11 23370804, Fax: +91 11 23370251 Email: SearEpidata@who.int, www.searo.who.int/entity/immunization year serum specimen collected from suspected measles cases serum specimen received in laboratory within 5 days of collection specimen positive for measles IgM specimen positive for rubella IgM % results within 4 days of receipt Genotypes detected No. (%) No. (%) No. % No. % Measles rubella 2013 99 (100) 57 (69) 0 0 6 6 52 - - 2014 69 (100) 30 (43) 0 0 4 6 100 - - 2015 120 (100) 120 (100) 11 9 1 1 100 - - 2016 146 (100) 146 (100) 40 27 3 2 ND - - 2017 441 (98) 177 (40) 66 15 9 2 100 D8 - 2018 427 (95) 125 (29) 18 4.4 11 2.7 73 - -