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EPI and VPD surveillance review and post-introduction evaluation of HPV vaccine : Report of the Mission, Bhutan, 18-30 March 2011

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EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine Report of the Mission Bhutan, 18–30 March 2011

Regional Office for South-East Asia

SEA-Immun-65 Distribution: General

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine Report of the Mission Bhutan, 18–30 March 2011

Regional Office for South-East Asia

© World Health Organization 2012 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication 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. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India

Contents Page Acknowledgements ...................................................................................................................... v Acronyms................................................................................................................................... vii Executive summary and recommendations................................................................................... ix 1. Background.........................................................................................................................1 Population ..........................................................................................................................2 2. Purpose and methodology of the review .............................................................................2 2.1 Context.......................................................................................................................2 2.2 Objectives of the review .............................................................................................3 2.3 Methodology of the review .........................................................................................4 3. Findings and recommendations...........................................................................................5 3.1 VPD Surveillance ........................................................................................................5 3.2 Immunization system ..................................................................................................8 3.3 Expert Review Committee (ERC) and National Certification Committee (NCC).........12 3.4 Coordination and support .........................................................................................12

Annexes 1. 2. 3. 4. Deployment of review teams and areas visited ..................................................................14 Laboratory assessment and review.....................................................................................16 HPV Vaccine Post-Introduction Evaluation (PIE) tool results ...............................................19 HPV Vaccine Post-Introduction Evaluation (PIE) tool..........................................................93

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Acknowledgements Members of the joint national and international review team would like to thank everyone who contributed to the work and outcomes of this review. Our field visits could not have been as productive and informative or as pleasant were it not for the commitment, effort and courteous assistance provided by the Ministry of Health, Royal Government of Bhutan. We would also like to express our appreciation to the WHO Representative and her team for their untiring support, hospitality and overall facilitation.

Acronyms AEFI AES AFB AFP BCG BHU CSF DTP ELISA EPI EQA ERC EVM GLP HIV HPV IEC ITAG JE JRF MCH MCV MLM MNT MR NCC NPEV NRHL adverse event following immunization acute encephalitic syndrome acid fast bacilli acute flaccid paralysis Bacille Calmette-Guérin Basic health unit cerbral spinal fluid Diphtheria-tetanus-pertussis enzyme-linked immunosorbent assay Expanded Programme on Immunization external quality assurance Expert Review Committee effective vaccine management good laboratory practice human immunodefiency virus human papillomavirus information, education and communication Immunization Technical Advisory Group Japanese encephalitis Joint Reporting Form maternal and child health measles containing vaccine mid-level manager maternal neonatal tetanus measles-rubella National Certification Committee non-polio enterovirus National Referral Hospital Laboratory

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Report of the Mission

OPV PHL PIE PPE RRHL SEARO STI TB TT UNFPA UNICEF VPD VVM WHO

oral polio vaccine public health laboratory post-introduction evaluation personal protective equipment Regional Referral Hospital Laboratory Regional Office for South-East Asia sexually-transmitted infection tuberculosis tetanus toxoid United Nations Population Fund United Nations Children’s Fund vaccine-preventable disease vaccine vial monitor World Health Organziation

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Executive summary and recommendations A team comprising national and international experts reviewed the Expanded Programme on Immunization (EPI), Vaccine Preventable Disease (VPD) surveillance system and Human Papillomavirus (HPV) vaccine introduction in Bhutan from 18-30 March 2011. The general objectives of the review were to determine the status of the programme, quantify achievements in vaccine-preventable disease control and explore ways to improve implementation. With the recent circulation of wild poliovirus in West Bengal, India, the review teams took this as an opportunity to focus on the acute flaccid paralysis (AFP) surveillance indicators and oral polio vaccine coverage. The methodology and tools for the EPI and VPD surveillance portions of the review were adapted from The Common Assessment Tool for Immunization Services1 and the post-introduction evaluation (PIE) tool was provided by WHO headquarters. In reading the executive summary and recommendations, it is important to remember that there is variation from one district to another. The review team, however attempted to higlight the common challenges observed that were common to all areas visited. One particular challenge was the need for additional supervision and staff training on immunization and surveillance programme activities. This common challenge has led to difficulties in immunization delivery and monitoring as well as surveillance activities. The following are the key findings and recommendations from the review team: Findings

VPD surveillance:       a surveillance system for vaccine-preventable diseases is in place at all levels and is functioning norms and standards are defined and available at all levels VPD surveillance is an integrated system with AFP, measles (rash-illness), neonatal tetanus and acute encephalitic syndrome (AES) existing on the same platform traditional healers are not formally part of the reporting network confusion on case definitions/syndromic aproach to VPDs laboratory and epidemiology case data are not always linked

WHO: Immunization, Vaccine and Biologicals (2002). The Common Assessment Tool for Immunization Services, Geneva, WHO

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  

AES sentinal surveillance is not implemented at all sites inadequate and/or irregular supervision of VPD surveillance by district-level health staff limited capacity for analysis and interpretation of data especially at the district level – date for action.

Immunization delivery:           systems are in place and able to provide coverage >90% for all antigens communities are well informed about the importance of childhood immunization and location of services immunization delivery system is able to absorb new vaccines an Adverse Event Following Immunization (AEFI) reporting system is in place and has the capacity to handle more cases updated 2010 immunization guildlines were available, however multiple copies of different previous versions created confusion lack of standardization of waste management, space is a critical issue in some places cold chain system intact, however there were concerns about the age of some equipment and future capacity of the network high-risk migrant groups and nomads were not well enumerated and consequently not adequately targeted for both immunization and surveillance activities children accompnaying daily wage labourers from India are at a risk for importation of vaccine-preventable diseases (especially wild poliovirus) concerns about preparedness for the re-introduction of pentavalent in June 2011.

HPV vaccine post-introduction evaluation:    high coverage achieved during 2010 school-based campaigns piloting conducted in Paro provided important lessons learned for national campaigns vaccine management, superivsion, transportation and training were well planned and executed during the campaign, which need to be used in the routine immunization programme IEC materials and messages might be overly complicated for the general public lack of clarity on policy for girls who missed doses in 2010/drop-outs/mobile populations lack of clarity on denominator to be used for calculating coverage

  

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

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concerns about freeze sensitivity and lack of vaccine vial monitor (VVM) on current stock of vaccines need clarity on sustainability of HPV vaccine after 2015

Recommendations

VPD surveillance:           ensure syndromic approach to VPD surveillance reporting review and prioritize reporting sites list reporting sites and review at regular intervals include traditional healers in the formal reporting network ensure reporting network captures heatlh seeking behaviour of high-risk groups, migrants and nomads provide refresher training on VPD/AEFI surveillance, supportive supervision, monitoring and evaluation prioritizing at the district level scale-up AES surveillance so that it can be used to effectively monitor the reintroduction of pentavalent vaccine in June 2011 improve active case-finding through regular visits (active case search) to reporting units develop a mechanism for rapidly linking laboratory and epidemiology data collaborate with Indian districts at border areas to identify migrant, nomadic and highrisk populations.

Immunization delivery:      conduct mid-level management (MLM) training for existing health staff and incumbents focusing on district health officers and assistant district health officers ensure that adequate training on AEFI management is provided to health staff before and during the re-introduction of pentavalent in June 2011 map high-risk areas and track migrant children clarify sharps/waste management and universal precaution issues conduct cold chain risk assessment.

HPV vaccine post-introduction evaluation:  re-assess integration of HPV vaccine into the routine immunization schedule in 12 months

Report of the Mission

     

conduct refresher training for EPI staff to transition from campaign to routine immunization modify/simplify IEC materials and messaging to reach a wider audience clarify the denominator and calculation of coverage/drop-outs use freeze tags and cold chain monitoring tools request next order of HPV vaccine to have VVM assess sustainability of HPV vaccine after 2015.

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Background The land locked kingdom of Bhutan, located in the Himalayan mountain range, shares its borders with the Tibetan region of China to the north and the Indian states of Arunachal Pradesh in the east, Assam and West Bengal to the south, and Sikkim to the west. The country is mountainous with more than 72% of the landmass covered by forest. The occasional flat lands are limited to the big river valleys. Bhutan covers an area approximately 38000 square kilometers, roughly 150 kilometres north to south and 300 kilometres east to west. It rises from the plains of India in the south to a height of approximately 7500 metres above sea level in the north. Geographically the area can be divided into three distinct regions – southern sub-tropical, inner Himalayan and the high northern region. The climatic condition in these three regions varies and the rainfall averages from 5000 millimetres per year in the south to 500 millimetres per year in the high northern region. Administratively, the country is divided into 20 Dzongkhags (districts) and 205 gewogs (blocks). Dzongdag is the administrative head of the dzongkhag. Each dzongkhag consists of a number of gewogs, which are formed by a cluster of villages. The headman of the gewog is called a Gup. Figure 1: Map of Bhutan

Bhutan depends heavily on the road transport network that is linked with the India road system. Towns such as Sipsu, Samtse, Phuentsholing, Gelephu, Sarpang, Pangbang, Daifam, and Samdrup Jongkhar are closest to India and are entry points into Bhutan. Roads from some of these points proceed into the interior of the country, usually following the river valleys and connecting settlements and district centres. See Figure 1.

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Population Bhutan is one of the least populated countries in the WHO South-East Asia (SEA) Region. Bhutan reported a population of 683407 with 14605 live births (2009 estimates). A third of the population is below the age of 15 years (211747); and approximately, 85% of the population lives in villages scattered in the arable parts of the country with the remaining living in remote and isolated mountainous areas. Large, northern high altitude areas are virtually empty except for nomadic herders. The urban population is restricted to a few urban centres and townships growing around dzongkhag headquarters. Thimphu in northwest Bhutan is the capital city with a population of approximately 85 000 to 95 000. Other major centres of population are Phuentsholing, Gelephu and Samdrup Jongkhar in the south along the Indian border. These three cities have open borders and are major trading centres of the country. Most Bhutanese still live in extended families with the average family size 5.6 persons.

2. 2.1

Purpose and methodology of the review Context Justification Since the last joint national/international review in 2005, which focused on AFP surveillance, Bhutan has completed a measles catch-up campaign and introduced several new vaccines: DTP-Hib-HepB, measles-rubella (MR) and human papillomavirus (HPV). The newest vaccine added to the routine immunization schedule last year was HPV. A vaccine post introduction evaluation (PIE) is usually conducted to assess if there are any programmatic adjustments that are needed. As significant progress towards polio eradication has been made in the SEA Region in the last 24 months, efforts towards ensuring that all Member States are achieving the surveillance standards and documentation is essential. As part of the certification process, and to identify gaps in the integrated surveillance systems, joint national/international reviews are conducted periodically. The basis for polio-free certification is high-quality AFP surveillance. As such, WHO/SEARO has been assisting Member States in strengthening AFP surveillance. As an integral part of this process, countries are encouraged to conduct periodic internal reviews of AFP surveillance, which are complemented by joint national/international surveillance reviews. Bhutan borders the polio- endemic country of India and also shares a large border with China. As there is significant population movement across these borders, there is always the risk of importation of poliovirus from India or other endemic countries. A comprehensive review of the EPI and VPD surveillance programmes has not previously been conducted in Bhutan.

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

2.2

Objectives of the review The objectives were to:        assess strengths and weaknesses of immunization service delivery at all levels of the health care delivery system analyse managerial and administrative capacity for immunization at the national and sub-national levels assess the introduction of new vaccines, particularly HPV assess strengths and weaknesses of current vaccine distribution mechanisms and cold chain management assess injection safety and waste management for sharps review priority setting for immunization programme sustainability review the capacity of the national surveillance system including laboratory support as applicable to detect and respond to vaccine-preventable diseases (VPD) in a timely manner document the capacity for surveillance and management of adverse events following immunization (AEFI) assess training needs for immunization managers, surveillance staff and health workers (vaccinators) at all levels review the role of the private sector and nongovernmental organizations, as providers of routine immunization services assess communication strategies, including advocacy, partnership, social mobilization and their implementation follow-up on the recommendations made at the national/international AFP surveillance review conducted in 2005 and at the Immunization Technical Advisory Group (ITAG) and EPI managers’ meeting review the activities of the national committees involved in polio eradication (i.e., Expert Review Committee and Laboratory Containment Committee)

    

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The review team aimed to answer the following questions:      Is there capacity for timely and adequate response to VPD outbreaks? Does the system for the delivery of immunization work? Does the system for the surveillance of VPD work? Is AFP, measles, MNT and AES surveillance integrated into VPD surveillance? Does the laboratory network support VPD surveillance?

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2.3

Methodology of the review The review was conducted at national, district and subdistrict levels. Six teams were formed (one central team and five field teams) to review available information and data on the EPI programme at national, district, subdistrict, health center, and other reporting unit levels. Team members interviewed key government officials and individuals involved in the EPI program, VPD surveillance, new vaccine introduction and polio eradication which included: national surveillance officers, district surveillance officers, health-centre staff, beneficiaries, parents, community leaders, laboratory staff, partners and WHOBhutan and UNICEF-Bhutan staff. A laboratory review was included as part of the centrallevel assessment. The HPV PIE was integrated into the EPI/Surveillance review for logistic and administrative efficiency. Selection of sites All major cities/municipalities, border areas, and high-risk populations were included in the review. At each level (national, district and subdistrict), the following key technical areas were reviewed: immunization service delivery, injection safety, vaccine-preventable disease surveillance, functioning of the laboratory network, laboratory support for VPDs, vaccine supply and quality including cold chain management, logistics, advocacy, communications and health system support. The review teams made sure that the areas reviewed were representative of all the regions in Bhutan. The review was divided into four components: (1) orientation (one day) was held in Thimphu where the teams were briefed on the Bhutan health system, EPI/VPD programmes, HPV vaccine introductions and the assessment tools; field level activity (six days) where each team evaluated two to five districts; debriefing session (two days) was held in Thimphu where the teams reviewed and consolidated their findings; and final debriefing (half day) was held in Thimphu with government officials, WHO, UNICEF and UNFPA.

(2) (3) (4)

At each health system level the review activities included: interview of surveillance staff, review of hospital records and observation of immunization sessions. Using structured tools developed for EPI, surveillance and HPV vaccine post-introduction, the following technical areas were assessed:     immunization service delivery injection safety and waste management vaccine management (supply and cold chain) vaccine-preventable disease surveillance (focusing on AFP and measles) including AEFI surveillance

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

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human resource/training capacity advocacy and communication.

One team focused specifically on the laboratory component and looked at laboratory capacity and proficiency, global accreditation, logistics and linkages between laboratory and surveillance programmes (see Annex 2 for laboratory assessment). In addition to the information collected during the review, the following information was also considered: immunization and VPD guidelines, recommendations from the 2005 AFP surveillance review, VPD line listing, aggregated surveillance data, and demographic data. The review team tried to ensure that the areas covered were representative of the different areas of Bhutan. Limitations of the review The review team acknowledged the following limitations in the review process:   time and logistics limited the number of districts reviewed a significant language barrier existed for the international team members, but the national team members contributed significantly in overcoming this barrier.

3. 3.1

Findings and recommendations VPD Surveillance The vaccine-preventable disease surveillance system began with acute flaccid paralysis surveillance in July 1997 and was expanded to include diphtheria, pertussis, measles, rubella, mumps and tetanus. Tables 1 and 2 show the AFP surveillance indicators and the vaccine-preventable diseases detected in Bhutan, respectively. Bhutan has had variable results over the last couple of years in maintaining the certification standards for AFP surveillance (non-polio AFP rate of 2/100 000 under 15 years of age and adequate stool collection rate of 80%).

Report of the Mission

Table 1 : AFP surveillance indicators, Bhutan, 2001-2009 Indicator AFP cases Wild Polio Compatibles AFP Rate 2 Non-Polio AFP Rate 3 Adequate Stool Collection Rate Total Stool Samples Tested % NPEV % Reported Within 14 Days 1 2

2001 4 0 0 1.37 1.37 50% 5 0 100

2002 2003 2 5 0 0 0 0 0.66 1.66 0.66 1.66 0% 0 0 0 33% 8 0 100

2004 3 0 0 1 1 100% 6 0 100

2005 2006 6 6 0 0 0 0 1.99 2.86 1.99 2.86 33% 10 20 100 33% 6 0 100

2007 4 0 0 1.9 1.9 50% 2 0 100

2008 9 0 0 4.28 4.28 67% 27 0 100

2009 1 0 0 0.46 0.46 0% 2 0 100

For 2010 data, See the IVD VPD Weekly Bulletin.

Data as of 05 July 2009

Number of discarded AFP cases per 100,000 children under 15 years of age. 3 Percent with 2 specimens 24 hours apart and within 14 days of paralysis onset.

Table 2: Vaccine-preventable diseases, Bhutan, 2002-2009 (WHO; UNICEF JRF) Year 2002 2003 2004 2005 2006 2007 2008 2009 Diphtheria 0 0 0 0 0 0 0 0 Pertussis 0 0 0 1 1 0 0 0 Measles 27 0 3 11 2 11 7 6 Total Tetanus 0 0 0 1 59 20 7 23 Neonatal Tetanus 0 0 0 0 1 0 0 0 Polio 0 0 0 0 0 0 0 0 Rubella ND 350 12 81 11 3 2 15 Mumps ND ND ND 144 ND ND ND ND

VPD surveillance VPD surveillance in Bhutan is an integrated system that includes AFP, measles, MNT and other vaccine-preventable diseases with defined norms and standards. The surveillance network is composed of and includes all government health facilities (hospitals, basic health units and health offices). The review team noted that the health seeking behaviour in Bhutan often initially includes traditional healers. Since traditional healers are not part of the formal surveillance network, vaccine-preventable diseases could be missed or reported late. The surveillance network is currently not prioritized. By prioritizing and expanding the surveillance network, reactivity and sensitivity can be improved. The review team also noted that at district level there was some confusion with case definitions and the sydromic approach to case identification. Again, this approach is important for ensuring a sensitive surveillance network. Systems are in place for reporting laboratory results and linking information with surveillance data; however, the review team noted that delays in linking data made real time decision-making difficult. Ensuring that laboratory data are linked with suspected VPD cases also gives district health officers an opportunity to provide health staff with supportive supervision and feedback. Even though India has made significant progress towards polio eradication in the last 24 months, maintaining AFP surveillance indicators remains important for all countries. 6

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

The AFP surveillance indicators are the hallmark for polio-free certification. All countries in the Region need to maintain global standards for the two AFP surveillance indicators. Table 1 shows the AFP surveillance indicators from 2001 to 2009. Nationally, Bhutan has had difficulty in achieving the minimum AFP surveillance indicators for non-polio AFP rate (2/100,000 population <15 years of age) and adequate stool rates (>80%). During the review, the team noted that there were cases in the hospital registers that could be considered AFP and were not reported (i.e. missed cases). Despite the progress made by India, there remains a substantial risk of polio importation. The risk is especially high considering the shift in the location of the most recent wild polio cases in India from the endemic states of Bihar and Uttar Pradesh to West Bengal (a state that borders Bhutan) in addition to the large number of seasonal and migrant India workers in Bhutan. It is therefore extremely important for Bhutan to enumerate these individuals and maintain a consistently sensitive AFP surveillance system across all communities and areas. Managerial aspects of VPD surveillance

Staffing and training The level of knowledge of staff at all levels was good. However, there needs to be regular refresher and induction trainings to guarantee a high-quality, functioning surveillance system. The requirements for diseases with elimination and eradication goals are constantly being updated and therefore need to be well understood by health staff.

Monitoring and supervision The review team observed that the main challenges facing the surveillance programme were related to monitoring and supervision at the district level, which was often irregular and/or inadequate. As new vaccines are added to the immunization schedule, appropriate surveillance will also need to be added, requiring additional monitoring and supportive supervision by district health officers.

Data for action There is limited capacity to analyse and interpret data at district and basic health centre levels. District health officers should use data collected at the district level to guide case investigations and plan for immunization activities. Acute encephalitis syndrome (AES) surveillance Sentinel surveillance for acute encephalitis syndrome (AES) was established in early 2011 as part of a comprehensive plan for the re-introduction of pentavalent immunization in June 2011. It is currently being implemented at five sites. Four sites are sentinel surveillance sites with laboratory facilities: Jigme Dorji Wangchuck National Referral Hospital, Gelephu Regional Referral Hospital, Mongar Regional Referral Hospital and 7

Report of the Mission

Phuntsholing Hospital. One site, Samdrup Jongkhar Hospital is a sentinel surveillance site without laboratory facilities. AES is defined by fever and altered consciousness (meningitis, cerebral malaria and all forms of encephalitis). District medical officers help collate the line lists and facilitate the transportation of blood and cerebral spinal fluid (CSF) specimens by reverse cold chain. Three of the four sites were visited during the review and the review team noted that AES surveillance had not been fully implemented. There was concern that there may not be enough data to reflect season variation and provide an AES background rate before the re-introduction of pentavalent immunization in June 2011.

Suggestions for improving VPD surveillance  ensure syndromic approach to VPD (particularly important for AFP) surveillance  consider revising IEC materials and posters for basic health units

review and prioritize reporting sites for VPD surveillance list reporting sites and review at regular intervals include traditional healers in the surveillance network ensure the reporting network captures high-risk, migrant and nomadic populations

    

provide refresher training at the district level on VPD surveillance, AEFI surveillance, supportive supervision, monitoring and evaluation scaleup AES surveillance so that it can be used to effectively monitor the reintroduction of pentavalent vaccine in June 2011 improve active case-finding through regular visits (active case search) to reporting sites develop a mechanism for rapidly linking laboratory and epidemiology data collaborate with districts in India at border areas for identifying high-risk, migrant and nomadic populations.

3.2

Immunization system Expanded Programme on Immunization The Expanded Programme on Immunization (EPI) was launched in the major population centres in 1979 and expanded to all districts in 1980. The EPI activities have been fully integrated into the basic health services and delivered as part of the routine health activities by multi-purpose health workers in the maternal child health (MCH) clinics. Figure 2 shows the progress in routine immunization from 1990 to 2009. The coverage remains high for the six basic childhood immunizations.

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Figure 2: Estimated routine immunization coverage, Bhutan 1990-2009 Table 3: Percent Immunization Coverage, 1990 - 2009 (WHO/UNICEF Estimated Coverage) Year OPV3 BCG DTP3 MCV1 100 1990 96 99 96 93 1991 91 95 91 89 1992 85 90 86 86 1993 82 89 79 84 80 1994 84 96 86 81 1995 86 98 87 85 1996 86 98 87 85 60 1997 87 92 87 84 1998 85 94 86 71 1999 89 90 88 76 2000 98 97 92 76 40 2001 88 81 88 78 2002 89 83 86 78 OPV3 2003 96 93 95 88 BCG 2004 90 92 89 87 20 MCV1 2005 95 99 95 93 DTP3 2006 96 92 95 90 2007 93 94 95 95 0 2008 96 99 96 99 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 96 96 96 98 % Coverage

2009

Source: WHO/UNICEF Joint Reporting Form

The routine immunization schedule has been expanded to include a number of new vaccines. See Table 3 for the current immunization schedule. Table 3: Routine Immunization Schedule, 2009 (WHO/UNICEFJRF) Vaccine BCG DTP-Hib-HepB OPV MR TT HPV Vitamin A Birth 6 weeks, 10 weeks, 14 weeks Birth, 6 weeks, 10 weeks, 14 weeks 9 months, 24 months 1st pregnancy, +1 month, 2nd pregnancy, 3rd pregnancy, 4th pregnancy, 5th pregnancy 0 months, +2 months, +6 months 6 months Age of Administration

The national immunization programme provides a birth dose of BCG; DPT-hepatitis B-Hib combination vaccine with oral polio vaccine at 6, 10 and 14 weeks; and, measlesrubella vaccine at nine and 24 months as well as tetanus toxoid (TT) to pregnant women. Pentavalant vaccine containing DTP, hepatitis B (HepB) and Haemophilus influenzae type B (Hib) antigens was introduced on 1 September 2009 and suspended on 23 October 2009 due to temporally related AEFIs. The re-introduction of pentavalent is scheduled for

Report of the Mission

June 2011. The most recent addition to the routine immunization schedule was HPV vaccine in 2010 and its introduction was specifically evaluation in this review. Table 2 shows the routine immunization coverage since 1990, which has been relatively high and conistent for the last five years. Immunization service delivery The health system in Bhutan consists of national referral hospital, regional referral hospitals, district hospitals and basic health units. The review team observed that overall it appears that the immunization system is able to provide coverage greater than 90% for all antigens and able to absorb new vaccines. The review team observed that children in high-risk populations posed a major risk to transporting and/or sustaining vaccinepreventable diseases in Bhutan. These high-risk groups consist of people living and working in areas bordering the Indian states of West Bengal and Assam as well as nomadic populations throughout the country. The children from these high-risk groups were not adequately enumerated and consequently not targeted for both immunization and surveillance activities. Updated immunization guidelines for 2010 were available at many health facilities; however, multiple copies of previous editions created some confusion for health staff.

Suggestions for improving immunization delivery    conduct mid-level manager training (MLM) for existing health staff and incumbents focusing on the district level map high-risk areas and groups to enumerate and track children for immunization and surveillance activities ensure that adequate training on AEFI management is provided to health staff before and during the re-introduction of pentavalent in June 2011 (consider including the media in the process) clarify sharps/waste managment and universal precaution issues.

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HPV vaccine: post-introduction evaluation The HPV vaccine was introduced in 2010 with school based catch-up campaigns with high coverage achieved in all three rounds. Important lessons were learned during the piloting of the vaccine in Paro and allowed for efficient and a well managed roll-out across the country. At the beginning of 2011, HPV vaccine was transitioned to the routine immunization schedule. The review team felt that additional training for health staff at the district level may be required in order to maintain the high coverage achieved during the campaign period. The review team also noted that the IEC material and messaging appeared to be overly complicated and confusing for some girls, parents and basic health care providers. There was a lack of clarity on the denominator to be used for calculating coverage; this was particularly difficult in urban settings. Health-care workers were not 10

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

clear on the policy for girls that either missed doses in 2010, were drop-outs or part of a mobile population. As HPV is an expensive and temperature-labile vaccine, the review team was concerned that the current lot of vaccines did not have VVMs. A descriptive analysis of the result from the HPV vaccine post-introduction evaluation tool is available in annexes 3 and 4.

Suggestions for HPV vaccine delivery     re-assess integration of HPV vaccine into the routine immunization schedule in 12-18 months conduct refresher training for EPI staff to ensure smooth transition from campaigns to routine administration modify/simply IEC materials and messages to reach a wider audience (girls, parents, basic health unit staff) ensure that next shipment of HPV vaccine has vaccine vial monitors (VVM).

Adverse events following immunization (AEFI) The AEFI system is functioning: definitions are available, reporting mechanisms are in place, and validation is standardized and documented. The review team observed that the system for reporting serious cases functions with an AEFI committee at the central level that meets to review serious cases for causality assessment. The AEFI system is capable of handling more cases (minor cases) and will be important for additional new vaccine introduction.

Suggestions for improving adverse events following immunizations (AEFI)  conduct refresher training in AEFI management and reporting for staff at the district and health centre levels particularly before the re-introduction of pentavalent in June 2011 encourage robust reporting of AEFIs through the system.

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Vaccine supply and cold chain management The review team did not observe any stock-outs at the district or facility level. The methods for calculating wastage rate and vaccine consumption was not always well understood at the field level. In terms of the cold chain, norms and standards were available for human resources and cold chain material. The review team observed variability in the age of cold chain equipment.

Report of the Mission

Suggestions for improving vaccine supply and cold chain management    conduct cold chain risk assessment and/or effective vaccine management (EVM) evaluation clarify the source of population data for the denominator that is used to calculate coverage and drop-out rates use freeze tags and/or other cold chain monitoring tools to ensure vaccine efficacy.

3.3

Expert Review Committee (ERC) and National Certification Committee (NCC) As part of the review of the central level, the review team looked at the composition of the Expert Review Committee (ERC) and the National Certification Committee (NCC). The technical composition of the committee was appropriate. The NCC is providing SEARO with annual updates on certification and is actively participating in regional meetings as required.

Suggestion for improving the ERC and NCC  review membership of these two bodies regularly (annually) to ensure continued transparency and independence.

3.4

Coordination and support WHO-SEARO The recommendations for WHO-SEARO focus on providing support to the WHO-Bhutan country office to assist in implementation of the recommendations outlined in this report. The review team felt that the regional and country teams had a lot to contribute to assisting the government of Bhutan to maximize supervision and training opportunities. The Government of Bhutan has made a substantial investment in maintaining and expanding the surveillance network from just AFP surveillance to include measles, neonatal tetanus and acute encephalitic syndrome (AES).

Suggestions for improving coordination and support from WHO-SEARO and WHOBhutan   support mid-level manager (MLM) training for existing health staff and incumbents support refresher training for EPI staff at the district level focusing VPD surveillance and supportive supervision

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine



facilitate regular cross-border meetings between the government of Bhutan and the government of India (at the district level) to review progress and coordinate VPD surveillance and immunization activities conduct a formal follow-up in 18-24 month to review the implementation of these recommendations.



Report of the Mission

Annex 1

Deployment of review teams and areas visited Table 5: Joint review team Team 1 International Team Member Dr Sunil Bahl National Team Member(s) Dr Dhrupthob Sonam (TL) Dr Sonam Ugen 2 Dr Prashanta Roy Mr Sonam Zangpo (TL) Dr Chandralal Mogar Haa Chukha Samtse Tsirang Sarpang Zhemgang Trongsa Wangduphodrang 3 4 5 Dr Abhijeet Anand Dr Ganga Choudhary Dr Madhav Ram Mr Wangchuk Dukpa (TL) Dr Sangay Phuntsho Dr Sonam Tshering (TL) Dr KP Tshering (TL) Mr Sonam Dorji Trashigang Mongar Pema Gatshal S/Jongkhar Trashi Yangtse Bumthang Punakha Wangduphodrang S S Dr Susan Wang Dr Patrick O’Connor Mr Dorji Phub Mr Tshewang Dorji Tamang Mr Dorji Phub Supervisory/briefings HPV PIE Districts

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Figure 5: Districts visited by the joint review team

5 S 1 1 1 2 2

5 2 2

5 3 2 4

5 3 4

Report of the Mission

Annex 2

Laboratory assessment and review The laboratory network was assessed as part of the EPI and VPD surveillance reivew. Dr Nalini Ramamurthy from IVD-SEARO conducted the laboratory assessment with Mr. Sonam Wangchuk and Mr Dorji Phuntsho from 14-18 March 2011. The team visited the following facilities (see Figure 6 for map of the districts visited):  Thimphu  health information management system unit public health laboratory department of laboratory services (JDWNRH)

Gelephu, Sarpang Dzongkhag central laboratory Gelephu district hospital Sarpang basic health unit (BHU) Jigmeling



Phuntsholing, Chukha Dzongkhag hospital laboratory.

The laboratory review consisted of the following activities: review of VPD data at the national and sub-national level, discussions with medical and laboratory focus points at the facilities visited and a physcial assessment of the laboratories to include infrastructure, manpower, diagnostic services, waste management, data management and quality assurance system. Laboratory capacity The review team found that the laboratory network was functioning well from the primary to tertiary heatlh care level with adequately trained personnel for the existing work load. The facilities are commensurate with the level of testing expected at each level:   basic health unit (BHU) laboratory: malaria microscopy, routine urine and blood grouping district laboratory: all BHU laboratory procedures plus AFB microscopy, gram stain, stool examination, serology for rapid test kits

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

 

NRHL/RRHL: all district laboratory procedures plus histopathology, cytology, biochemistry and bacterial culture PHL: national WHO accredited laboratory for measles, rubella, Japanese encephalitis (JE), tuberculosis (TB), HIV and sexually transmitted infections (STI).

For serology, ELISA-based tests (which are more economical) should be considered compared to rapid test kits. ELISA can be easily done at the RRHL with additional equipment and training. For bacteriology, there is adequate capacity for diagnosis of VPD (Hib, streptococcus, pneumococcus, meninigitis) at the NRHL, RRHL and PHL. The PHL has the capacity for molecular testing with additional training. A dedicated bacterial bio-safety cabinet is essential for a clean work space inorder to prepare media/reagents and avoid cross contaimination. The review team observed delays in biochemical test reporting due to limited equipment at the GRRH and Phuntsholing hospital laboratory. An additional photometer or autoanalyser could help with this problem. Biochemical testing is currently not being performed at the district level but should be considered during future expansion of laboratory services. Laboratory space The review team found that there was adequate space at the national level; however there was concern at the sub-national levels (regional referral laboratory and district hospital laboratory). There was inadequate space, overcrowding/inappropriate placement of equipment that compromises best laboratory practices. The PHL in Thimphu at present has adequate space but additional space will be needed if more functions will be added to their responsibilities (quality assurance functions, research and molecular testing). Except at GDWNRH in Thimphu, the segregation and disposal of laboratory waste was not strictly followed as per national guidelines. All laboratories are using safety boxes for the disposal of sharps and needles; however, boxes (containing biological wastes) are not decontamined in laboratories before they are put in disposal pits. Laboratory procurement/equipment/procedures The review team observed that reagents and test kits were in short supply at all levels leading to an interruption of testing abilities. Equipment log books were available and systematically being maintained. The scheduling of preventive maintenance for critical equipment should be streamlined to ensure unterruped testing capacity. Standard operating procedures (SOPs) were not available and need to be prepared and strictly followed as per good laboratory practice (GLP). External quality assurance (EQA) programme is well established and coordinated by the PHL for HIV, TB and malaria microscopy. EQA could be extended to include other bacterial and serologic tests, which will allow for standardization and comparability of results. Quality control and assurance procedures should be reinforced and strengthened through regular laboratory management training.

Report of the Mission

Figure 6: Districts visited by laboratory reivew team

Suggestions for improving coordination and support from the laboratory network  conduct a comprehensive review of waste disposal mechansims at all levels including hospital waste management   provide autoclave for decontamination of waste conduct training on personal protective equipment (PPE), biosafety and waste disposal

review the responsibilities and workload of the PHL to strengthen and expand diagnositc services for other vaccine-preventable diseases and biochemical testing ensure adequate procurement and maintenance of laboratory equipment streamline procurement of diagnostic kits particularly those with a short shelf-life to avoid stock outs schedule periodic preventive maintenance for critical equipment

 

develop quality assessment and monitoring tools for laboratories at the national level develop training plan for laboratory technologist and technicians on good laboratory practices, quality assurance, biosafety and data management/analysis.

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Annex 3

HPV Vaccine Post-Introduction Evaluation (PIE) tool results Frenquency table for central level: 1 result (please refer to annex 4 for the data dictionary and the exact questionnaire) Question/Field Number of responses Level C1 C2_VacIntro C3_GPop12y C4_IntroDecision C5_NIACSupport C6_CurImmSch C7_ImmSchChanged C8_HPVSchedule C9_HPVLinkedAdoles C10_NatlStrategy C11_CervScreenChanged C12_DiseasePrevent C13_VacIntroPlan C14_Support C15_TrainingAudience C15_TrainingType C15_TrainingBefore C15_TrainingAfter C15_TrainingDays C15_ConductedBy C16_Financed C17_TrainingImprove C18_MaterialProvided 2 Days DHOs+DMOs Much Yes, better to have 2 batches of trainings for larger number of people; educational guide for BHUs HPV introduction guide only Strong political will; ACCF+donation; benefit+cost; sustainability Yes EPI Manual Yes, previously only vaccinated upto 2 yr old. Dose1=0; Dose2=2; Dose3=6 No No No Cervical Cancer + genital wart Yes, both national and district plan/timeline Yes, Technical, Financial supports DMOs+DHOs from all districts at national level Cascade Yes 1 Central Level 5-May-10 National Introduction Response

Report of the Mission

Question/Field C19_Consent C20_issue C21_MethodsUsed C22_ImmDatabase C23_Formula C24_Rubella C25_Coverage C26_FormsSubmited C27_ChangeColdChain C28_Problem C29_FreezeWatch C30_Policy C31_VaccineForcast C32_Estimated C33_VacOrder C34_VacTransport C35_VacSendOut C36_FreqChange C37_Outreach C38_Effect C39_Cost C41_StockOut C42_VacExpire C43_VVM C44_InjSupp C45_Waste C46_FollowGuideline C47_ChangeWaste C48_ChangeGuideline C49_WasteCalculate C50_HPVWaste C51_ReduceWaste 20

Response Nat'l 2010, not in 2011 Yes, people were concerned School health coordinator Not yet, will be separate for several years since printed many form No. doses administered/No. target population * 100

BHU report monthly to district; district report quarterly to central 2010 - new cold room 600 of Bhutan purchased. This was because 1) HPV vaccine, 2) to separate reagents No Problems

Yes, modifying

Mongar+Gelephu EPI van deliver vaccines to hospital Quarterly, vaccine + needles delivered Yes, for campaign 2-3 more shipments. Now goes with other EPI vaccines More vaccine carriers No For campaign extra transport but not this year Yes, September 2010 for 1 week Yes, TT, OPV

It depends By infection control Yes Don't think so No

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Question/Field C52_FreqVisit C53_SupVisit C54_Feedback C55_Issues

Response Twice per year not all district. Twice per year not all BHUs. Depends on districts Yes, Chunkha in Oct 2010 and Mongar in Sep 2010 Written supervisory checklist; Oral discussion with staff Target population not updated at district level; No particular MCH incharge of clinic - identify MCH incharge at district hospital; Should document expiry date of AD syringes Depends on time No Yes, incorporated into EPI manual Yes Same Yes, not serious but for other vaccines Yes, Thimpu at School with Queen Mother, ACCF Radio, TV, Community groups, Celebrity, Government officials Posters, Brochures, banners No, for routine or for HPV only, co-financing for tetra/penta 2008 JCV started funding all traditional vaccine, before it was by JICA 2010-2011 = Merch; 2012-2015=ACCF 2010; Merch-$150,000, ACCF-$150,000, UNFPA-$50,000 Birth dose HepB in May-June 2011; Penta in June 2011; Rota and PCV after study Don't know, depends on IARC work+cancer registry department Yes; by health-care workers, professional societies, government, media Yes, district hospital needed vaccine from regional stores more often for campaign Yes No Yes Yes Yes, meetings, time Improved the EPI programme Smooth, minor problems.

C56_FollowupVisit C57_ReceivedSupVisit C58_AEFIMonitoring C59_CrisisPlan C60_ChangeProtocal C61_AEFIReported C62_Lunch C63_MediaOutlet C64_Materials C65_BudgetVaccine C66_EPIVacFinanced C67_HPVVacPaid C68_Operational C69_NewVaccIntro C70_VacAssessment C71_HPVAccepted C72_ColdChain C72_Trasnport C72_Wastage C72_Comm C72_Training C72_other C73_Effect C74_HPVIntroduction

Report of the Mission

Question/Field C75_Advice

Response Plan well in advance, also for budget, have good guidelines, reference; have advocacy material+adequate training; Depends on country site on whether a pilot project useful, can give more confidence. Yes Yes Yes Yes No Twice daily Yes Yes No yes, all vaccines usable Yes Yes Yes, Adequate Space, clean and dry condition and well organized.

C76_freezer C77_ThermoOutside C78_ThermoInside C79_temperature C80_Log C81_TempRecord C82_Weekends C83_FEFO C84_ExipredVac C85_VVMUsable C86_VVMStage2 C87_Space C88_InjEquip

Frenquency tables for district level (please refer to annex 4 for the data dictionary and the exact questionnaire) District Frequency Valid PUNAKHAA SARPANG Trangsa Hospital TSIRANG WANGDUE ZHEMGANG Total 2 1 1 1 1 1 1 8 Percentage 25.0 12.5 12.5 12.5 12.5 12.5 12.5 100.0 Valid percentage 25.0 12.5 12.5 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 25.0 37.5 50.0 62.5 75.0 87.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D1_DateVac Frequency Valid 04-May-2010 05-May-2010 22-May-2010 Total Missing System Total 1 4 1 6 2 8 Percentage 12.5 50.0 12.5 75.0 25.0 100.0 Valid percentage 16.7 66.7 16.7 100.0 Cumulative percentage 16.7 83.3 100.0

D2_GPop12-18y Frequency Valid 218 2206 3037 5025 931 NA Total 1 1 1 1 1 1 2 8 Percentage 12.5 12.5 12.5 12.5 12.5 12.5 25.0 100.0 Valid percentage 12.5 12.5 12.5 12.5 12.5 12.5 25.0 100.0 Cumulative percentage 12.5 25.0 37.5 50.0 62.5 75.0 100.0

D3_Prevent Frequency Valid CaCx Cancer Total 1 6 1 8 Percentage 12.5 75.0 12.5 100.0 Valid percentage 12.5 75.0 12.5 100.0 Cumulative percentage 12.5 87.5 100.0

Report of the Mission

D4_Plan-Timeline Frequency Valid Yes, both National and District plan/timeline Yes, District plan/timeline Yes, District plan/timeline, No IEC plan Yes, National plan/timeline Total 1 4 1 2 8 Percentage 12.5 50.0 12.5 25.0 100.0 Valid percent 12.5 50.0 12.5 25.0 100.0 Cumulative percentage 12.5 62.5 75.0 100.0

D5_TrainingAudience Frequency Valid Doctors, Nurses, HCW Doctors, Nurses, HCW, BHWs Nurses, HCW Nurses, HCW, BHU staff Nurses, HCW, Pharmacy Technician Nurses, HCW, Pharmacy Technician, Lab technician Total 2 1 2 1 1 1 8 percent 25.0 12.5 25.0 12.5 12.5 12.5 100.0 Valid percentage 25.0 12.5 25.0 12.5 12.5 12.5 100.0 Cumulative percent 25.0 37.5 62.5 75.0 87.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D5_TrainingType Frequency Valid Cascade Cascade, Region-by Region District Level One time training Total 3 1 2 2 8 Percentage 37.5 12.5 25.0 25.0 100.0 Valid percentage 37.5 12.5 25.0 25.0 100.0 Cumulative percentage 37.5 50.0 75.0 100.0

D5_TrainingBeforeIntro Frequency Valid Yes 8 Percentage 100.0 Valid percentage 100.0 Cumulative percentage 100.0

D5_ifYesHowLongBefore Frequency Valid 1 day 2 weeks 3 days 3 weeks 4 weeks 6 weeks Total 1 1 1 1 1 2 1 8 Percentage 12.5 12.5 12.5 12.5 12.5 25.0 12.5 100.0 Valid percent 12.5 12.5 12.5 12.5 12.5 25.0 12.5 100.0 Cumulative percentage 12.5 25.0 37.5 50.0 62.5 87.5 100.0

Report of the Mission

D5_TrainingAfterIntro Frequency Valid No Yes Total 2 5 1 8 Percentage 25.0 62.5 12.5 100.0 Valid percentage 25.0 62.5 12.5 100.0 Cumulative percentage 25.0 87.5 100.0

D5_ifYesHowLongAfter Frequency Valid 6 weeks after 1st round Total 7 1 8 Percentage 87.5 12.5 100.0 Valid percentage 87.5 12.5 100.0 Cumulative percentage 87.5 100.0

D5_TrainingDay Frequency Valid 1 day 2 days Total 2 3 3 8 Percentage 25.0 37.5 37.5 100.0 Valid percentage 25.0 37.5 37.5 100.0 Cumulative percentage 25.0 62.5 100.0

D5_WhoConducted Frequency Valid MO MO & DHO Total 1 3 4 8 Percentage 12.5 37.5 50.0 100.0 Valid percentage 12.5 37.5 50.0 100.0 Cumulative percentage 12.5 50.0 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D6_TrainingFinanced Frequency Valid Adequate budget provided by MOH Central MOH MOH sent the fund RGoB Total 1 1 2 2 1 1 8 Percentage 12.5 12.5 25.0 25.0 12.5 12.5 100.0 Valid percentage 12.5 12.5 25.0 25.0 12.5 12.5 100.0 Cumulative percentage 12.5 25.0 50.0 75.0 87.5 100.0

D7_TrainingImproved Frequency Valid Don't Know No Yes, all health workers Yes, refresher training Total 1 5 1 1 8 Percentage 12.5 62.5 12.5 12.5 100.0 Valid percentage 12.5 62.5 12.5 12.5 100.0 Cumulative percentage 12.5 75.0 87.5 100.0

D8_EduMaterial Frequency Valid EPI manual for health worker Guidelines HIV (vaccination) manual for health worker HPV Manual Training Manual Training module, HPV manual, PowerPoint Total 1 1 1 3 1 1 8 Percentage 12.5 12.5 12.5 37.5 12.5 12.5 100.0 Valid percentage 12.5 12.5 12.5 37.5 12.5 12.5 100.0 Cumulative percentage 12.5 25.0 37.5 75.0 87.5 100.0

Report of the Mission

D9_ConsentRequired Frequency Valid No Yes Total 4 4 8 Percentage 50.0 50.0 100.0 Valid percentage 50.0 50.0 100.0 Cumulative percentage 50.0 100.0

D10_IfYesPoseAnyIssue Frequency Valid No Yes, people worried Yes, some girls were reluctant when consent was required. But did not hesitate when it was not required. Total 3 3 1 1 Percentage 37.5 37.5 12.5 12.5 Valid percentage 37.5 37.5 12.5 12.5 Cumulative percentage 37.5 75.0 87.5 100.0

100.0

D11_MethodsUsed Frequency Valid Advocacy, IEC, IPC card Card Media, TV, posters, brochures, ORC session, public meeting Register Telephone VHW, HWs during 1st and 2nd round Total 2 1 1 1 Percentage 25.0 12.5 12.5 12.5 Valid percentage 25.0 12.5 12.5 12.5 Cumulative percentage 25.0 37.5 50.0 62.5

1 1 1 8

12.5 12.5 12.5 100.0

75.0 87.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D12_DatabaseUpdated Frequency Valid Don't Know No Yes Total 2 4 2 8 Percentage 25.0 50.0 25.0 100.0 Valid percentage 25.0 50.0 25.0 100.0 Cumulative percentage 25.0 75.0 100.0

D13_Formula Frequency Valid No of beneficiaries * 0.25 / No of beneficiaries Standard Total immunized / Target population * 100 Total 2 1 1 4 8 Percentage 25.0 12.5 12.5 50.0 100.0 Valid percentage 25.0 12.5 12.5 50.0 100.0 Cumulative percentage 25.0 37.5 50.0 100.0

D14_RubellaCoverage Frequency Valid Not available, 2006 Total 7 1 8 Percentage 87.5 12.5 100.0 Valid percentage 87.5 12.5 100.0 Cumulative percentage 87.5 100.0

Report of the Mission

D15_FirstDose Frequency Valid 78.4 89.0 97.0 98.8 99.0 100.0 Total Missing System Total 1 1 1 1 1 1 6 2 8 Percentage 12.5 12.5 12.5 12.5 12.5 12.5 75.0 25.0 100.0 Valid percentage 16.7 16.7 16.7 16.7 16.7 16.7 100.0 Cumulative percentage 16.7 33.3 50.0 66.7 83.3 100.0

D15_SecondDose Frequency Valid 90 96 97 99 100 Total Missing System Total 1 1 1 2 1 6 2 8 Percentage 12.5 12.5 12.5 25.0 12.5 75.0 25.0 100.0 Valid percentage 16.7 16.7 16.7 33.3 16.7 100.0 Cumulative percentage 16.7 33.3 50.0 83.3 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D15_LastDose Frequency Valid 81 96 97 98 99 Total Missing System Total 1 1 2 2 1 7 1 8 Percentage 12.5 12.5 25.0 25.0 12.5 87.5 12.5 100.0 Valid percentage 14.3 14.3 28.6 28.6 14.3 100.0 Cumulative percentage 14.3 28.6 57.1 85.7 100.0

D16_ChangeColdChain Frequency Valid 44 thermometer, 3 vaccine carriers additional No Total 1 1 6 8 Percentage 12.5 12.5 75.0 100.0 Valid percentage 12.5 12.5 75.0 100.0 Cumulative percentage 12.5 25.0 100.0

D17_PolicyVacMgt Frequency Valid Yes 8 Percentage 100.0 Valid percentage 100.0 Cumulative percentage 100.0

Report of the Mission

D17_IfYesUpdated Frequency Valid 2007 guidelines, but it does not include HPV But not yet distributed No Separate guideline for HPV Yes Total 3 1 1 1 1 1 8 Percentage 37.5 12.5 12.5 12.5 12.5 12.5 100.0 Valid percentage 37.5 12.5 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 37.5 50.0 62.5 75.0 87.5 100.0

D18_EstimateChange Frequency Valid No Yes Total 5 3 8 Percentage 62.5 37.5 100.0 Valid percentage 62.5 37.5 100.0 Cumulative percentage 62.5 100.0

D19_WasteDisposal Frequency Valid As per the manual Burn and bury at all levels Injection after use are put into safety box and burn Syringes/needles in safety box, pit burn Waste disposal pit, burn & burry Yes Total 1 1 1 2 1 2 8 Percentage 12.5 12.5 12.5 25.0 12.5 25.0 100.0 Valid percentage 12.5 12.5 12.5 25.0 12.5 25.0 100.0 Cumulative percentage 12.5 25.0 37.5 62.5 75.0 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D20_FollowGuideline Frequency Valid No Yes Total 1 7 8 Percentage 12.5 87.5 100.0 Valid percentage 12.5 87.5 100.0 Cumulative percentage 12.5 100.0

D21_ChangeWasteDisp Frequency Valid No Total 1 7 8 Percentage 12.5 87.5 100.0 Valid percentage 12.5 87.5 100.0 Cumulative percentage 12.5 100.0

D22_ChangeInjectSafety Frequency Valid No Yes Total 7 1 8 Percentage 87.5 12.5 100.0 Valid percentage 87.5 12.5 100.0 Cumulative percentage 87.5 100.0

D23_formulaVaccWaste Frequency Valid (Total doses - doses used)/Total Doses * 100 EPI formula used No of vaccine given / No of vaccine doses issued * 100 Same formula Vaccine wastage not calculated Total 3 1 1 1 1 1 8 Percentage 37.5 12.5 12.5 12.5 12.5 12.5 100.0 Valid percentage 37.5 12.5 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 37.5 50.0 62.5 75.0 87.5 100.0

Report of the Mission

D24_WastageRate Frequency Valid ?0 0 Total 4 1 3 8 Percentage 50.0 12.5 37.5 100.0 Valid percentage 50.0 12.5 37.5 100.0 Cumulative percentage 50.0 62.5 100.0

D25_ReduceWR Frequency Valid No Total 1 7 8 Percentage 12.5 87.5 100.0 Valid percentage 12.5 87.5 100.0 Cumulative percentage 12.5 100.0

D26_Regional Frequency Valid 0 1 2 Total Missing System Total 1 1 1 3 5 8 Percentage 12.5 12.5 12.5 37.5 62.5 100.0 Valid percentage 33.3 33.3 33.3 100.0 Cumulative percentage 33.3 66.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D26_District Frequency Valid 5-6 times Once in each round Total 6 1 1 8 Percentage 75.0 12.5 12.5 100.0 Valid percentage 75.0 12.5 12.5 100.0 Cumulative percentage 75.0 87.5 100.0

D26_HealthFacility Frequency Valid 2 Once in each round Quarterly Twice a year Total 4 1 1 1 1 8 Percentage 50.0 12.5 12.5 12.5 12.5 100.0 Valid percentage 50.0 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 50.0 62.5 75.0 87.5 100.0

D27_SupVisit Frequency Valid Yes 8 Percentage 100.0 Valid percentage 100.0 Cumulative percentage 100.0

Report of the Mission

D27_IfYesHowOften Frequency Valid By medical officer by Medical superintendent During all 3 rounds During the campaign by MO/DHO Once, by DHO Some BHU quarterly, some not done Three months Yes, every round Total 1 1 1 1 1 1 1 1 8 Percentage 12.5 12.5 12.5 12.5 12.5 12.5 12.5 12.5 100.0 Valid percentage 12.5 12.5 12.5 12.5 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 12.5 25.0 37.5 50.0 62.5 75.0 87.5 100.0

D28_Feeback Frequency Valid Discussion with staff Send site visit report Send site visit report, discussion with staff Supervisory Checklist, discussion with staff Supervisory Checklist, Send site visit report, discussion with staff Supervisory logbook, oral Visitor's register, discussion with staff, telephone Total 1 1 2 1 1 1 1 8 Percentage 12.5 12.5 25.0 12.5 12.5 12.5 12.5 100.0 Valid percentage 12.5 12.5 25.0 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 12.5 25.0 50.0 62.5 75.0 87.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D29_IssueHPV Frequency Valid At some sites, there was space issue, small room Disposal, documentation Many girls were reluctant to receive second dose due to AEFI in others No No problem Total 1 1 1 1 3 1 8 Percentage 12.5 12.5 12.5 12.5 37.5 12.5 100.0 Valid percentage 12.5 12.5 12.5 12.5 37.5 12.5 100.0 Cumulative percentage 12.5 25.0 37.5 50.0 87.5 100.0

D30_FupVisit Frequency Valid No No (no inadequate performance) Yes Total 4 1 3 8 Percentage 50.0 12.5 37.5 100.0 Valid percentage 50.0 12.5 37.5 100.0 Cumulative percentage 50.0 62.5 100.0

D31_SupervisoryVisit Frequency Valid No Yes Yes, national supervisor for HPV campaign Total 3 3 2 8 Percentage 37.5 37.5 25.0 100.0 Valid percentage 37.5 37.5 25.0 100.0 Cumulative percentage 37.5 75.0 100.0

Report of the Mission

D32_MonitoringAEFI Frequency Valid No Yes Total 2 6 8 Percentage 25.0 75.0 100.0 Valid percentage 25.0 75.0 100.0 Cumulative percentage 25.0 100.0

D33_CrisisPlan Frequency Valid Guideline NA No Yes, all vaccinators carry emergency kits Yes, emergency kit Total 1 1 3 1 2 8 Percentage 12.5 12.5 37.5 12.5 25.0 100.0 Valid percentage 12.5 12.5 37.5 12.5 25.0 100.0 Cumulative percentage 12.5 25.0 62.5 75.0 100.0

D34_ChangeProtocal Frequency Valid NA No Total 1 1 6 8 Percentage 12.5 12.5 75.0 100.0 Valid percentage 12.5 12.5 75.0 100.0 Cumulative percentage 12.5 25.0 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D35_AEFIReported Frequency Valid Don't know No Yes, 14 (HPV) had giddiness, fainting and they were treated in the hospital Total 1 6 1 Percentage 12.5 75.0 12.5 Valid percentage 12.5 75.0 12.5 Cumulative percentage 12.5 87.5 100.0

100.0

D36_OfficialLunch Frequency Valid No Yes Total 4 4 8 Percentage 50.0 50.0 100.0 Valid percentage 50.0 50.0 100.0 Cumulative percentage 50.0 100.0

D37_Media Frequency Valid Community groups, Other - school health /principals DYT, school Radio, TV Radio, TV, community groups, government officials Radio, TV, community groups, HWs, government officials Radio, TV, government officials, HWs TV TV, community groups, local Media, newspaper, district level meeting Total 1 1 1 1 1 1 1 1 8 Percentage 12.5 12.5 12.5 12.5 12.5 12.5 12.5 12.5 100.0 Valid percentage 12.5 12.5 12.5 12.5 12.5 12.5 12.5 12.5 100.0 Cumulative percentage 12.5 25.0 37.5 50.0 62.5 75.0 87.5 100.0

Report of the Mission

D38_HEMaterial Frequency Valid No Posters Posters, Brochures Posters, Brochures, Flyers Total 1 1 5 1 8 Percentage 12.5 12.5 62.5 12.5 100.0 Valid percentage 12.5 12.5 62.5 12.5 100.0 Cumulative percentage 12.5 25.0 87.5 100.0

D39_HCW Frequency Valid Yes 8 Percentage 100.0 Valid percentage 100.0 Cumulative percentage 100.0

D39_Societies Frequency Valid Yes Total 1 7 8 Percentage 12.5 87.5 100.0 Valid percentage 12.5 87.5 100.0 Cumulative percentage 12.5 100.0

D39_Community Frequency Valid Yes Total 1 7 8 Percentage 12.5 87.5 100.0 Valid percentage 12.5 87.5 100.0 Cumulative percentage 12.5 100.0

D39_Govt Frequency Valid Yes 8 Percentage 100.0 Valid percentage 100.0 Cumulative percentage 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D39_Media Frequency Valid Yes Total 1 7 8 Percentage 12.5 87.5 100.0 Valid percentage 12.5 87.5 100.0 Cumulative percentage 12.5 100.0

D40_ColdChain Frequency Valid No Total 2 6 8 Percentage 25.0 75.0 100.0 Valid percentage 25.0 75.0 100.0 Cumulative percentage 25.0 100.0

D40_VacTrans Frequency Valid No Total 2 6 8 Percentage 25.0 75.0 100.0 Valid percentage 25.0 75.0 100.0 Cumulative percentage 25.0 100.0

D40_Wastage Frequency Valid No Total 2 6 8 Percentage 25.0 75.0 100.0 Valid percentage 25.0 75.0 100.0 Cumulative percentage 25.0 100.0

Report of the Mission

D40_ComMaterial Frequency Valid No Total 3 5 8 Percentage 37.5 62.5 100.0 Valid percentage 37.5 62.5 100.0 Cumulative percentage 37.5 100.0

D40_Training Frequency Valid No Total 2 6 8 Percentage 25.0 75.0 100.0 Valid percentage 25.0 75.0 100.0 Cumulative percentage 25.0 100.0

D40_Other Frequency Valid No Total 2 6 8 Percentage 25.0 75.0 100.0 Valid percentage 25.0 75.0 100.0 Cumulative percentage 25.0 100.0

D41_Effect Frequency Valid No effect 8 Percentage 100.0 Valid percentage 100.0 Cumulative percentage 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

D42_Process Frequency Valid Smooth - minor problem Smooth - minor problem (IEC materials) Very smooth - no problem Total 1 1 6 8 Percentage 12.5 12.5 75.0 100.0 Valid percentage 12.5 12.5 75.0 100.0 Cumulative percentage 12.5 25.0 100.0

D43_Advice Frequency Valid Awareness creation about the benefit of vaccine, even parents to be well informed, high level political commitment, inter-sectoral collaboration. Awareness must be thoroughly discussed Coordination from school, avoid written consent Inform public about its benefits Mass awareness essential, community leaders should be involved, commitment of HW Proper awareness among the public. Total 2 1 Percentage 25.0 12.5 Valid percentage 25.0 12.5 Cumulative percentage 25.0 37.5

1 1 1 1

12.5 12.5 12.5 12.5

50.0 62.5 75.0 87.5

1 8

12.5 100.0

100.0

Report of the Mission

Frenquency tables for health facility level (please refer to annex 4 for the data dictionary and the exact questionnaire) District/HF Frequency Valid Bajo BHU - 1 Changangkha School Chapaha BHU Damphu Hospital, CHU Gyelposing BHU Jigmecholing BHU JWDRNH Kabesa BHU Mendvelgap BHU - II Nobgang BHU Phangny BHU Punakha Radi BHU SARPANG Tongtophey BHU Trangsa Hospital Trongsa Wangdue Yebitaplsa Hospital Total 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19 Percentage 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Valid percentage 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 5.3 10.5 15.8 21.1 26.3 31.6 36.8 42.1 47.4 52.6 57.9 63.2 68.4 73.7 78.9 84.2 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

TypeHF Frequency Valid BHU Gelephu Hospital, CHU Health Centre/Clinic Hospital Clinic School Total 3 2 1 11 1 1 19 Percentage 15.8 10.5 5.3 57.9 5.3 5.3 100.0 Valid percentage 15.8 10.5 5.3 57.9 5.3 5.3 100.0 Cumulative percentage 15.8 26.3 31.6 89.5 94.7 100.0

H1_Working Frequency Valid No Yes Total 1 1 17 19 Percentage 5.3 5.3 89.5 100.0 Valid percentage 5.3 5.3 89.5 100.0 Cumulative percentage 5.3 10.5 100.0

H2_DateVacIntro Frequency Valid 05-May-2010 13-Mar-2011 05-May-2011 Total Missing System Total 14 1 1 16 3 19 Percentage 73.7 5.3 5.3 84.2 15.8 100.0 Valid percentage 87.5 6.3 6.3 100.0 Valid percentage 87.5 93.8 100.0

Report of the Mission

H3_NumTrained Frequency Valid 1 2 3 6 12 16 Total Missing System Total 2 7 4 2 1 1 17 2 19 Percentage 10.5 36.8 21.1 10.5 5.3 5.3 89.5 10.5 100.0 Valid percentage 11.8 41.2 23.5 11.8 5.9 5.9 100.0 Valid percentage 11.8 52.9 76.5 88.2 94.1 100.0

H3_WhoTrained Frequency Valid ACO, Nurse All HWs BHW, HA, Nurses BHW, HA, Pharmacy Technician HA HA, BHW Medical Officer Vaccinators Total 5 1 1 1 1 2 6 1 1 19 Percentage 26.3 5.3 5.3 5.3 5.3 10.5 31.6 5.3 5.3 100.0 Valid percentage 26.3 5.3 5.3 5.3 5.3 10.5 31.6 5.3 5.3 100.0 Valid percentage 26.3 31.6 36.8 42.1 47.4 57.9 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H3_NumWorking Frequency Valid 1 2 3 4 6 9 16 Total Missing System Total 2 7 3 1 2 1 1 17 2 19 Percentage 10.5 36.8 15.8 5.3 10.5 5.3 5.3 89.5 10.5 100.0 Valid percentage 11.8 41.2 17.6 5.9 11.8 5.9 5.9 100.0 Valid percentage 11.8 52.9 70.6 76.5 88.2 94.1 100.0

H3_TrainingDays Frequency Valid 1 day 2 days 3 days Total 12 5 2 19 Percentage 63.2 26.3 10.5 100.0 Valid percentage 63.2 26.3 10.5 100.0 Valid percentage 63.2 89.5 100.0

Report of the Mission

H3_Topics Frequency Valid As per manual Cold chain, vaccine safety, vaccine wastage, coverage Disease it prevents, schedule, AEFI reporting Disease it prevents, schedule, AEFI, emergency kit, reporting Disease, HPV, AEFI monitoring Genital warts, cervical cancer HPV New vaccine, AEFI HPV vaccination, target age, side effects, manage, keep for 15-30 mins HPV vaccine, AEFI, immunization schedule, safety, disease prevented HPV vaccine, AEFI, immunization schedule, safety, waste management New vaccine introduction No. of doses, AEFI, disease prevented, reporting Target girls, AEFI, disease it prevents, Reporting Target population, transmission of HPV, prevention, recording and reporting Total 1 4 1 1 1 1 1 1 1 Percentage 5.3 21.1 5.3 5.3 5.3 5.3 5.3 5.3 5.3 Valid percentage 5.3 21.1 5.3 5.3 5.3 5.3 5.3 5.3 5.3 Valid percentage 5.3 26.3 31.6 36.8 42.1 47.4 52.6 57.9 63.2

2 1

10.5 5.3

73.7 78.9

1 1 1 1

5.3 5.3 5.3 5.3

84.2 89.5 94.7 100.0

100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H3_Skill Frequency Valid 90degree, IM injection Yes Total 13 1 5 19 Percentage 68.4 5.3 26.3 100.0 Valid percentage 68.4 5.3 26.3 100.0 Cumulative percentage 68.4 73.7 100.0

H3_TrainedOther Frequency Valid No Yes Total 3 13 3 19 Percentage 15.8 68.4 15.8 100.0 Valid percentage 15.8 68.4 15.8 100.0 Cumulative percentage 15.8 84.2 100.0

H3_TrainingBeforeVaccine Frequency Valid No Yes Total 1 18 19 Percentage 5.3 94.7 100.0 Valid percentage 5.3 94.7 100.0 Cumulative percentage 5.3 100.0

Report of the Mission

H3_IfYesHowLongBefore Frequency Valid 1 day 1 month 2 weeks 3 weeks 4 weeks 6 weeks Few months Total 5 1 2 5 1 3 1 1 19 Percentage 26.3 5.3 10.5 26.3 5.3 15.8 5.3 5.3 100.0 Valid percentage 26.3 5.3 10.5 26.3 5.3 15.8 5.3 5.3 100.0 Cumulative percentage 26.3 31.6 42.1 68.4 73.7 89.5 94.7 100.0

H3_TrainingAfterVaccine Frequency Valid No Yes Total 2 16 1 19 Percentage 10.5 84.2 5.3 100.0 Valid percentage 10.5 84.2 5.3 100.0 Cumulative percentage 10.5 94.7 100.0

H3_IfYesHowLongAfter Frequency Valid 4 weeks Total 18 1 19 Percentage 94.7 5.3 100.0 Valid percentage 94.7 5.3 100.0 Cumulative percentage 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H3_WhoConducted Frequency Valid CMO DHO District MO MO & DHO No one Total 7 1 1 1 5 3 1 19 Percentage 36.8 5.3 5.3 5.3 26.3 15.8 5.3 100.0 Valid percentage 36.8 5.3 5.3 5.3 26.3 15.8 5.3 100.0 Cumulative percentage 36.8 42.1 47.4 52.6 78.9 94.7 100.0

H4_TrainingImprove Frequency Valid Don't know No Yes Yes, 2-4 days would be better for more detailed information whether really an AEFI or not, whether to use adrenaline or not Yes, refresher courses/training Yes, type of vaccine was explained but forgot. More on vaccine component. Yes, would be good if all health workers could get the training Yes, would be good if others in BHU could be trained Total 2 10 2 1 Percentage 10.5 52.6 10.5 5.3 Valid percentage 10.5 52.6 10.5 5.3 Cumulative percentage 10.5 63.2 73.7 78.9

1 1

5.3 5.3

84.2 89.5

1 1 19

5.3 5.3 100.0

94.7 100.0

Report of the Mission

H5_Materials Frequency Valid Yes Total 2 17 19 Percentage 10.5 89.5 100.0 Valid percentage 10.5 89.5 100.0 Cumulative percentage 10.5 100.0

H6_Satisfied Frequency Valid No, large group of participants Yes Total 1 1 17 19 Percentage 5.3 5.3 89.5 100.0 Valid percentage 5.3 5.3 89.5 100.0 Cumulative percentage 5.3 10.5 100.0

H7_Consent Frequency Valid No No consent form at clinic. Only at school Yes Total 2 7 1 9 19 Percentage 10.5 36.8 5.3 47.4 100.0 Valid percentage 10.5 36.8 5.3 47.4 100.0 Cumulative percentage 10.5 47.4 52.6 100.0

H8_IfYesAnyIssue Frequency Valid No Total 12 7 19 Percentage 63.2 36.8 100.0 Valid percentage 63.2 36.8 100.0 Cumulative percentage 63.2 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H9_MethodsRecall Frequency Valid ask school health Awareness before vaccination, during round 1 & 2 to complete Call each due month for contact Call teacher in school to find girl; use mobile phones of parent Card Dates on card, register, informed on advance, school health teachers Information during meeting 1st and 2nd round Information on importance completing during meeting at 1st and 2nd dose vaccination Informed before and during 1st and 2nd rounds Informed during 1st round to complete all the doses Informed during vaccination, noted down phone number Informed through meeting during 1st and 2nd dose vaccination MCH register Register Vaccination card Total 1 1 1 1 1 4 1 1 1 Percentage 5.3 5.3 5.3 5.3 5.3 21.1 5.3 5.3 5.3 Valid percentage 5.3 5.3 5.3 5.3 5.3 21.1 5.3 5.3 5.3 Cumulative percentage 5.3 10.5 15.8 21.1 26.3 47.4 52.6 57.9 63.2

1 1 1 1 1 1 1 19

5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0

68.4 73.7 78.9 84.2 89.5 94.7 100.0

Report of the Mission

H10_Pop Frequency Valid 10 16 23 35 40 120 197 308 310 492 621 1110 Total Missing System Total 1 1 1 1 1 1 1 1 1 1 1 1 12 7 19 Percentage 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 63.2 36.8 100.0 Valid percentage 8.3 8.3 8.3 8.3 8.3 8.3 8.3 8.3 8.3 8.3 8.3 8.3 100.0 Cumulative percentage 8.3 16.7 25.0 33.3 41.7 50.0 58.3 66.7 75.0 83.3 91.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H11_Formula Frequency Valid Did not calculate, but send the reports to DHO End of year, calculate coverage MR/LB * 100 N/A Not calculated Not calculated. Calculate at district level Standard formula Total immunized / Total target * 100 Vaccine given / Target * 100 Total 6 1 1 1 1 1 1 1 5 1 19 Percentage 31.6 5.3 5.3 5.3 5.3 5.3 5.3 5.3 26.3 5.3 100.0 Valid percentage 31.6 5.3 5.3 5.3 5.3 5.3 5.3 5.3 26.3 5.3 100.0 Cumulative percentage 31.6 36.8 42.1 47.4 52.6 57.9 63.2 68.4 94.7 100.0

H12_Rubella Frequency Missing System 19 Percentage 100.0

Report of the Mission

H13_FirstDose Frequency Valid 96 97 98 98 99 100 100 105 111 Total Missing System Total 1 2 1 1 1 7 1 1 1 16 3 19 Percentage 5.3 10.5 5.3 5.3 5.3 36.8 5.3 5.3 5.3 84.2 15.8 100.0 Valid percentage 6.3 12.5 6.3 6.3 6.3 43.8 6.3 6.3 6.3 100.0 Cumulative percentage 6.3 18.8 25.0 31.3 37.5 81.3 87.5 93.8 100.0

H13_SecondDose Frequency Valid 97 98 99 99 100 100 100 101 102 105 Total Missing System Total 2 2 1 2 1 4 1 1 1 1 16 3 19 Percentage 10.5 10.5 5.3 10.5 5.3 21.1 5.3 5.3 5.3 5.3 84.2 15.8 100.0 Valid percentage 12.5 12.5 6.3 12.5 6.3 25.0 6.3 6.3 6.3 6.3 100.0 Cumulative percentage 12.5 25.0 31.3 43.8 50.0 75.0 81.3 87.5 93.8 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H13_ThirdDose Frequency Valid 95 97 97 97 98 99 99 99 99 100 100 102 Total Missing System Total 1 1 3 1 1 1 1 1 1 1 3 1 16 3 19 Percentage 5.3 5.3 15.8 5.3 5.3 5.3 5.3 5.3 5.3 5.3 15.8 5.3 84.2 15.8 100.0 Valid percentage 6.3 6.3 18.8 6.3 6.3 6.3 6.3 6.3 6.3 6.3 18.8 6.3 100.0 Cumulative percentage 6.3 12.5 31.3 37.5 43.8 50.0 56.3 62.5 68.8 75.0 93.8 100.0

H14_DateReporting Frequency Valid After every round Monthly Monthly; after each HPV dose report Often each dose round Routine (Monthly), HPV (after campaign) Total 2 1 7 1 1 7 19 Percentage 10.5 5.3 36.8 5.3 5.3 36.8 100.0 Valid percentage 10.5 5.3 36.8 5.3 5.3 36.8 100.0 Cumulative percentage 10.5 15.8 52.6 57.9 63.2 100.0

Report of the Mission

H15_RegistryHPV Frequency Valid Health card, tally sheets No No update No, separate register/form Vaccine registry/logbook, health card, tally sheets Vaccine registry/logbook, health card, vaccine stock forms Yes, vaccine registry/logbook Yes, Vaccine registry/logbook, health card, tally sheet, vaccine stock forms Total 1 1 4 1 7 1 1 1 2 19 Percentage 5.3 5.3 21.1 5.3 36.8 5.3 5.3 5.3 10.5 100.0 Valid percentage 5.3 5.3 21.1 5.3 36.8 5.3 5.3 5.3 10.5 100.0 Cumulative percentage 5.3 10.5 31.6 36.8 73.7 78.9 84.2 89.5 100.0

H16_DaysOutreach Frequency Valid 7 outreach community Monthly Monthly ORC, 2 times BHU One day per month ORC - once in month; BHU - twice in month ORC - one; BHU - for DPT/OVP/DT ORC - one; Clinic - daily ORC - twice month; BHU - once month ORC - twice month; Clinic twice month in BHU Total 1 1 10 1 1 1 1 1 1 1 19 Percentage 5.3 5.3 52.6 5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Valid percentage 5.3 5.3 52.6 5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 5.3 10.5 63.2 68.4 73.7 78.9 84.2 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H17_OutreachData Frequency Valid HH survey MCH Register MCH register, Talley sheet Register Register, Tally sheet Register+note from ORC Talley sheet used VHW Total 3 1 1 1 8 2 1 1 1 19 Percentage 15.8 5.3 5.3 5.3 42.1 10.5 5.3 5.3 5.3 100.0 Valid percentage 15.8 5.3 5.3 5.3 42.1 10.5 5.3 5.3 5.3 100.0 Cumulative percentage 15.8 21.1 26.3 31.6 73.7 84.2 89.5 94.7 100.0

H18_ChangeOutreach Frequency Valid No changes required Other, dates of different rounds Total 3 15 1 19 Percentage 15.8 78.9 5.3 100.0 Valid percentage 15.8 78.9 5.3 100.0 Cumulative percentage 15.8 94.7 100.0

H19_VacStored Frequency Valid Refrigerator Refrigerator, Cold storage box Total 1 17 1 19 Percentage 5.3 89.5 5.3 100.0 Valid percentage 5.3 89.5 5.3 100.0 Cumulative percentage 5.3 94.7 100.0

Report of the Mission

H20_EquipOutreach Frequency Valid Cold boxes Vaccine carrier Total 3 1 15 19 Percentage 15.8 5.3 78.9 100.0 Valid percentage 15.8 5.3 78.9 100.0 Cumulative percentage 15.8 21.1 100.0

H21_PowerCut Frequency Valid Cold box Cold box, Kerosene model Kerosene used No No major problem No problem with electricity Sometime, twice per month not more than 1 day Sometimes for a few minutes Switched on to Kerosene model Transfer to cold box Used generator Used kerosene Used kerosene refrigerator Total 1 2 1 2 2 1 1 1 1 2 2 1 1 1 19 Percentage 5.3 10.5 5.3 10.5 10.5 5.3 5.3 5.3 5.3 10.5 10.5 5.3 5.3 5.3 100.0 Valid percentage 5.3 10.5 5.3 10.5 10.5 5.3 5.3 5.3 5.3 10.5 10.5 5.3 5.3 5.3 100.0 Cumulative percentage 5.3 15.8 21.1 31.6 42.1 47.4 52.6 57.9 63.2 73.7 84.2 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H22_ChangesColdChain Frequency Valid Got more vaccine carriers, cold boxes, ice packs No No changes for routine, special for campaign. Requested more vaccine carriers, ice packs, cold boxes, and distributed to all BHUs Total 3 1 13 1 1 Percentage 15.8 5.3 68.4 5.3 5.3 Valid percentage 15.8 5.3 68.4 5.3 5.3 Cumulative percentage 15.8 21.1 89.5 94.7 100.0

100.0

H23_ProblemColdChain Frequency Valid No Problem Total 1 18 19 Percentage 5.3 94.7 100.0 Valid percentage 5.3 94.7 100.0 Cumulative percentage 5.3 100.0

H24_VMPolicy Frequency Valid No Yes Total 3 2 14 19 Percentage 15.8 10.5 73.7 100.0 Valid percentage 15.8 10.5 73.7 100.0 Cumulative percentage 15.8 26.3 100.0

Report of the Mission

H24_IfYesUpdated Frequency Valid No update required Old EPI manual Separate guideline for HPV Separate HPV manual Total 15 1 1 1 1 19 Percentage 78.9 5.3 5.3 5.3 5.3 100.0 Valid percentage 78.9 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 78.9 84.2 89.5 94.7 100.0

H25_VacForcast Frequency Valid As per consumption/school record Based on no. of ORC sessions, 1 vial for each session Based on past quarters' use Based on target population Before - past experience; Present formula as per manual Consumption - no specific formula Consumption basis Health officer estimated Household/school information Max-AMC*4month for Max stock; Min-AMC*0.5 for Min stock Minimum and maximum Minimum and maximum stock Use target population Total 1 1 1 1 5 1 1 1 1 1 1 1 1 2 19 Percentage 5.3 5.3 5.3 5.3 26.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 10.5 100.0 Valid percentage 5.3 5.3 5.3 5.3 26.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 10.5 100.0 Cumulative percentage 5.3 10.5 15.8 21.1 47.4 52.6 57.9 63.2 68.4 73.7 78.9 84.2 89.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H26_ChangEstimate Frequency Valid No Yes, non-enumerated girls came for the vaccination Total 6 12 1 19 Percentage 31.6 63.2 5.3 100.0 Valid percentage 31.6 63.2 5.3 100.0 Cumulative percentage 31.6 94.7 100.0

H27_Order Frequency Valid BHU BHW Both staff CHU I/C CHU staff HA Incharge Incharge MCH Indent Indent form Indent staff MO incharge Self Sr HA, indent book Total 3 1 1 1 1 1 3 1 1 1 1 1 1 1 1 19 Percentage 15.8 5.3 5.3 5.3 5.3 5.3 15.8 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Valid percentage 15.8 5.3 5.3 5.3 5.3 5.3 15.8 5.3 5.3 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 15.8 21.1 26.3 31.6 36.8 42.1 57.9 63.2 68.4 73.7 78.9 84.2 89.5 94.7 100.0

Report of the Mission

H27_Delivery Frequency Valid Monthly Quarterly Quarterly to hospital and monthly to BHU Total 4 9 5 1 19 Percentage 21.1 47.4 26.3 5.3 100.0 Valid percentage 21.1 47.4 26.3 5.3 100.0 Cumulative percentage 21.1 68.4 94.7 100.0

H28_VacExpire Frequency Valid No Yes Yes, some OPV Yes, TT vaccine Yes; BCG-1 vial, OPV-2 vials Yes; BCG-560 doses, OPV1020 doses Yes; OPV-27 vials, TT-83 vials Total 2 8 4 1 1 1 1 1 19 Percentage 10.5 42.1 21.1 5.3 5.3 5.3 5.3 5.3 100.0 Valid percentage 10.5 42.1 21.1 5.3 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 10.5 52.6 73.7 78.9 84.2 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H28_Action Frequency Valid Burn Discarded Disposed Form filled and sent to DUED Informed DVO Total 14 1 1 1 1 1 19 Percentage 73.7 5.3 5.3 5.3 5.3 5.3 100.0 Valid percentage 73.7 5.3 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 73.7 78.9 84.2 89.5 94.7 100.0

H29_VVM Frequency Valid No Yes, disposed off Total 4 14 1 19 Percentage 21.1 73.7 5.3 100.0 Valid percentage 21.1 73.7 5.3 100.0 Cumulative percentage 21.1 94.7 100.0

Report of the Mission

H30_VacShortage Frequency Valid No Yes (DPT-HepB for 1 month in Aug 2010) Yes (DPT-HepB for 1 month) Yes (DPT-HepB for 1 week due to stock out at regional store) Yes (DPT-HepB for 1 week in 2010) Yes (DPT-HepB for 1.5 month due to stock out at regional store) Yes (DPT-HepB for 3 weeks in 2010) Total 2 11 1 1 1 Percentage 10.5 57.9 5.3 5.3 5.3 Valid percentage 10.5 57.9 5.3 5.3 5.3 Cumulative percentage 10.5 68.4 73.7 78.9 84.2

1 1

5.3 5.3

89.5 94.7

1 19

5.3 100.0

100.0

H31_Injection Frequency Valid No Yes Total 2 2 15 19 Percentage 10.5 10.5 78.9 100.0 Valid percentage 10.5 10.5 78.9 100.0 Cumulative percentage 10.5 21.1 100.0

H31_Stock Frequency Valid Yes Total 6 13 19 Percentage 31.6 68.4 100.0 Valid percentage 31.6 68.4 100.0 Cumulative percentage 31.6 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H32_ChangeWasteDisposal Frequency Valid No Yes Yes, autoclave and burnt Total 1 15 2 1 19 Percentage 5.3 78.9 10.5 5.3 100.0 Valid percentage 5.3 78.9 10.5 5.3 100.0 Cumulative percentage 5.3 84.2 94.7 100.0

H33_ProblemWaste Frequency Valid No Yes, no autoclave Yes, pit with no roof Total 1 16 1 1 19 Percentage 5.3 84.2 5.3 5.3 100.0 Valid percentage 5.3 84.2 5.3 5.3 100.0 Cumulative percentage 5.3 89.5 94.7 100.0

Report of the Mission

H34_FormulaWaste Frequency Valid (B+D+E)-C/B+D+E * 100 (Total doses used - total immunized)/Total doses used * 100 As per the formula provided Doses used+doses discarded (expiry & frozen) - doses used/doses used+doses discarded * 100 No of doses used / No of doses issued * 100 No vaccine used - no immunized / Total vaccine used * 100 Standard formula Vaccine wastage not calculated. Calculated at national level Total 8 1 2 1 2 Percentage 42.1 5.3 10.5 5.3 10.5 Valid percentage 42.1 5.3 10.5 5.3 10.5 Cumulative percentage 42.1 47.4 57.9 63.2 73.7

1 1 2 1 19

5.3 5.3 10.5 5.3 100.0

78.9 84.2 94.7 100.0

H35_WastageRate Frequency Valid 0 First round - 3 vials, Second round 4 vials NA Total 4 13 1 1 19 Percentage 21.1 68.4 5.3 5.3 100.0 Valid percentage 21.1 68.4 5.3 5.3 100.0 Cumulative percentage 21.1 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H36_ChangetoReduce Frequency Valid Fix the dates No Total 7 1 11 19 Percentage 36.8 5.3 57.9 100.0 Valid percentage 36.8 5.3 57.9 100.0 Cumulative percentage 36.8 42.1 100.0

H37_SupVisit Frequency Valid 1 visit, written report kept at district level 2 times 2 times, no written visit report 2-3 times 3 times, written report available 4 times, (1 written report) All 3 rounds during HPV campaign Daily, person near by for campaign, not during routine Frequently by DHO/others No report, central level supervisor in Feb 2011 Once, no written visit report Quarterly, no written report Twice in a year, written report available Total 1 1 2 2 2 1 1 2 1 1 1 2 1 1 19 Percentage 5.3 5.3 10.5 10.5 10.5 5.3 5.3 10.5 5.3 5.3 5.3 10.5 5.3 5.3 100.0 Valid percentage 5.3 5.3 10.5 10.5 10.5 5.3 5.3 10.5 5.3 5.3 5.3 10.5 5.3 5.3 100.0 Cumulative percentage 5.3 10.5 21.1 31.6 42.1 47.4 52.6 63.2 68.4 73.7 78.9 89.5 94.7 100.0

Report of the Mission

H38_WhoVisited Frequency Valid DHO DHO, DG DHO, other officials DHO/ADHO DMO/DHO HPV Supervisor MO, DHO MOH staff National supervisor RH-PO & WHO Total 5 4 1 1 2 1 1 1 1 1 1 19 Percentage 26.3 21.1 5.3 5.3 10.5 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Valid percentage 26.3 21.1 5.3 5.3 10.5 5.3 5.3 5.3 5.3 5.3 5.3 100.0 Cumulative percentage 26.3 47.4 52.6 57.9 68.4 73.7 78.9 84.2 89.5 94.7 100.0

H39_AEFI Frequency Valid Yes Total 3 16 19 Percentage 15.8 84.2 100.0 Valid percentage 15.8 84.2 100.0 Cumulative percentage 15.8 100.0

H40_ChangeProtocal Frequency Valid NA No Yes, complain form Total 3 1 14 1 19 Percentage 15.8 5.3 73.7 5.3 100.0 Valid percentage 15.8 5.3 73.7 5.3 100.0 Cumulative percentage 15.8 21.1 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H41_AEFIReport Frequency Valid No No (1 Abscess due to DPTHepB, treated in Hospital) Yes, 1 (headache) Total 2 15 1 1 19 Percentage 10.5 78.9 5.3 5.3 100.0 Valid percentage 10.5 78.9 5.3 5.3 100.0 Cumulative percentage 10.5 89.5 94.7 100.0

H42_LunchHPV Frequency Valid No No (Principal for lunching) Yes Total 1 15 1 2 19 Percentage 5.3 78.9 5.3 10.5 100.0 Valid percentage 5.3 78.9 5.3 10.5 100.0 Cumulative percentage 5.3 84.2 89.5 100.0

H43_HEMaterials Frequency Valid Health education sessions, public meeting Posters Posters, Brochures Posters, brochures, health education sessions, public meetings Posters, health education sessions, public meetings Public meetings Total 1 1 1 1 8 Percentage 5.3 5.3 5.3 5.3 42.1 Valid percentage 5.3 5.3 5.3 5.3 42.1 Cumulative percentage 5.3 10.5 15.8 21.1 63.2

5 2 19

26.3 10.5 100.0

89.5 100.0

Report of the Mission

H44_Resistance Frequency Valid No Yes, 1 girl (who later got the vaccine) Yes, only on the 1st day of 1st round when consent form was required Yes, people from town came after the 1st round Total 2 14 1 1 Percentage 10.5 73.7 5.3 5.3 Valid percentage 10.5 73.7 5.3 5.3 Cumulative percentage 10.5 84.2 89.5 94.7

1 19

5.3 100.0

100.0

H45_MediaFocus Frequency Valid No Yes Yes; Radio Yes; Radio & Newspaper Yes; Radio, TV & Newspaper Yes; TV & Newspaper Yes; TV & Radio Yes; TV, Radio & Official info Total 2 2 1 4 1 5 2 1 1 19 Percentage 10.5 10.5 5.3 21.1 5.3 26.3 10.5 5.3 5.3 100.0 Valid percentage 10.5 10.5 5.3 21.1 5.3 26.3 10.5 5.3 5.3 100.0 Cumulative percentage 10.5 21.1 26.3 47.4 52.6 78.9 89.5 94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H46_HPVSchedule Frequency Valid 0 day, after 2 months and after 6 months of 1st dose 0 day, after 2 months of 1st dose and after 4 months of 2nd dose 0,2,6 0,2,6 months Integrated to regular EPI Regular schedule Schedule not clear Total 2 4 4 Percentage 10.5 21.1 21.1 Valid percentage 10.5 21.1 21.1 Cumulative percentage 10.5 31.6 52.6

5 1 1 1 1 19

26.3 5.3 5.3 5.3 5.3 100.0

78.9 84.2 89.5 94.7 100.0

H47_Disease Frequency Valid CaCx Cervical cancer + genital warts Total 1 17 1 19 Percentage 5.3 89.5 5.3 100.0 Valid percentage 5.3 89.5 5.3 100.0 Cumulative percentage 5.3 94.7 100.0

Report of the Mission

H48_Information Frequency Valid Benefits to the girl, vaccine schedule/when to return, normal side effects Benefits to the girl, vaccine schedule/when to return, normal side effects, what side effects they should return for Benefits to the girl, vaccine schedule/when to return, what side effects they should return for Disease it protects against, benefits to the girl, vaccine schedule/when to return, normal side effects Diseases it protects against, vaccine schedule/when to return, what side effects they should return for, other health message Diseases it protects against, benefits to the girl, vaccine schedule/when to return, what side effects they should return for, bring vaccination card, other health message Name of the vaccine, benefits to the girl, vaccine schedule/when to return, normal side effects Name of the vaccine, Diseases it protects against, benefits to the girl, vaccine schedule/when to return, normal side effects, bring vaccination card Name of the vaccine, Diseases it protects against, benefits to the girl, vaccine schedule/when to return, normal side effects, risk of synkopy, what side effects they should return for, bring vaccination card Name of the vaccine, Diseases it 2 1 Percentage 10.5 5.3 Valid percentage 10.5 5.3 Cumulative percentage 10.5 15.8

5.3

21.1

5.3

26.3

5.3

31.6

5.3

36.8

5.3

42.1

5.3

47.4

15.8

63.2

5.3

68.4

10.5

78.9

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Frequency protects against, benefits to the girl, vaccine schedule/when to return, what side effects they should return for, bring vaccination card, other health message Name of the vaccine, Diseases it protects against, vaccine schedule/when to return, normal side effects Name of the vaccine, Diseases it protects against, vaccine schedule/when to return, normal side effects, bring vaccination card Name of the vaccine, Diseases it protects against, vaccine schedule/when to return, what side effects they should return for Total 1

Percentage

Valid percentage

Cumulative percentage

5.3

84.2

10.5

94.7

5.3

100.0

H49_ColdChain Frequency Valid Don't know No Total 5 1 13 19 Percentage 26.3 5.3 68.4 100.0 Valid percentage 26.3 5.3 68.4 100.0 Cumulative percentage 26.3 31.6 100.0

H49_VacTrans Frequency Valid No Total 6 13 19 Percentage 31.6 68.4 100.0 Valid percentage 31.6 68.4 100.0 Cumulative percentage 31.6 100.0

Report of the Mission

H49_Wastage Frequency Valid NA No Total 6 1 12 19 Percentage 31.6 5.3 63.2 100.0 Valid percentage 31.6 5.3 63.2 100.0 Cumulative percentage 31.6 36.8 100.0

H49_ComMaterial Frequency Valid No Total 7 12 19 Percentage 36.8 63.2 100.0 Valid percentage 36.8 63.2 100.0 Cumulative percentage 36.8 100.0

H49_Training Frequency Valid No Total 6 13 19 Percentage 31.6 68.4 100.0 Valid percentage 31.6 68.4 100.0 Cumulative percentage 31.6 100.0

H49_Other Frequency Valid No Total 7 12 19 Percentage 36.8 63.2 100.0 Valid percentage 36.8 63.2 100.0 Cumulative percentage 36.8 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H50_Effect Frequency Valid Improved the EPI programme No No effect Total 2 1 1 15 19 Percentage 10.5 5.3 5.3 78.9 100.0 Valid percentage 10.5 5.3 5.3 78.9 100.0 Cumulative percentage 10.5 15.8 21.1 100.0

H51_Process Frequency Valid Generally smooth - minor problem Very smooth - no problem Total 2 2 15 19 Percentage 10.5 10.5 78.9 100.0 Valid percentage 10.5 10.5 78.9 100.0 Cumulative percentage 10.5 21.1 100.0

Report of the Mission

H52_Advice Frequency Valid Advocacy, involvement of media, benefits of the vaccine to be explained properly. Already have connection MOE+MOH Awareness among people, training, supervision Awareness and advantages of the vaccine, collaboration from school & community Awareness at all levels. Explain vaccine safety and its benefit, and it is free of cost. Awareness to community, HW to be confident, prepare for AEFI management Awareness, cooperation from all relevant stakeholders, health educators Create adequate awareness of HPV vaccine and the problems of CaCx Explain the problem of CaCx to public and its prevention. Intersectoral coordination funds NA Need to sensitize the population, explain importance, address rumors, village leaders No major AEFI, no major cold chain Plan, more space, post observation, training space Total 6 1 Percentage 31.6 5.3 Valid percentage 31.6 5.3 Cumulative percentage 31.6 36.8

1 1 1

5.3 5.3 5.3

42.1 47.4 52.6

5.3

57.9

5.3

63.2

5.3

68.4

1 1

5.3 5.3

73.7 78.9

1 1

5.3 5.3

84.2 89.5

1 1 19

5.3 5.3 100.0

94.7 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H53_Reconstituted Frequency Valid Yes Total 13 6 19 Percentage 68.4 31.6 100.0 Valid percentage 68.4 31.6 100.0 Cumulative percentage 68.4 100.0

H54_VacStored Frequency Valid Yes Total 13 6 19 Percentage 68.4 31.6 100.0 Valid percentage 68.4 31.6 100.0 Cumulative percentage 68.4 100.0

H55_Administration Frequency Valid No vaccination today Not observed Yes Total 13 1 4 1 19 Percentage 68.4 5.3 21.1 5.3 100.0 Valid percentage 68.4 5.3 21.1 5.3 100.0 Cumulative percentage 68.4 73.7 94.7 100.0

H56_ADSyringes Frequency Valid Yes Total 13 6 19 Percentage 68.4 31.6 100.0 Valid percentage 68.4 31.6 100.0 Cumulative percentage 68.4 100.0

Report of the Mission

H57_Recapped Frequency Valid No Total 13 6 19 Percentage 68.4 31.6 100.0 Valid percentage 68.4 31.6 100.0 Cumulative percentage 68.4 100.0

H58_Disposed Frequency Valid Yes Total 14 5 19 Percentage 73.7 26.3 100.0 Valid percentage 73.7 26.3 100.0 Cumulative percentage 73.7 100.0

H59_DateOpened Frequency Valid Yes Total 14 5 19 Percentage 73.7 26.3 100.0 Valid percentage 73.7 26.3 100.0 Cumulative percentage 73.7 100.0

H59_VialDiscarded Frequency Valid No, except BCG/MR Yes Total 14 1 4 19 Percentage 73.7 5.3 21.1 100.0 Valid percentage 73.7 5.3 21.1 100.0 Cumulative percentage 73.7 78.9 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H59_Observation Frequency Missing System 19 Percentage 100.0

H60_NumUnsafe Frequency Missing System 19 Percentage 100.0

H61_GirlsObserved Frequency Valid Yes Yes, half-an hour Total 14 4 1 19 Percentage 73.7 21.1 5.3 100.0 Valid percentage 73.7 21.1 5.3 100.0 Cumulative percentage 73.7 94.7 100.0

H62_Refrigerator Frequency Valid Yes Total 1 18 19 Percentage 5.3 94.7 100.0 Valid percentage 5.3 94.7 100.0 Cumulative percentage 5.3 100.0

H63_ThermoOutside Frequency Valid No Yes Total 1 5 13 19 Percentage 5.3 26.3 68.4 100.0 Valid percentage 5.3 26.3 68.4 100.0 Cumulative percentage 5.3 31.6 100.0

Report of the Mission

H64_ThermoInside Frequency Valid Yes Total 1 18 19 Percentage 5.3 94.7 100.0 Valid percentage 5.3 94.7 100.0 Cumulative percentage 5.3 100.0

H65_Temp Frequency Valid No, 9dC (power failed for half an hour) Yes Yes, 2dC Yes, 3dC Yes, 4dC Yes, 5dC Yes, 6dC Total 1 1 5 2 3 4 2 1 19 Percentage 5.3 5.3 26.3 10.5 15.8 21.1 10.5 5.3 100.0 Valid percentage 5.3 5.3 26.3 10.5 15.8 21.1 10.5 5.3 100.0 Cumulative percentage 5.3 10.5 36.8 47.4 63.2 84.2 94.7 100.0

H66_Log Frequency Valid Yes Total 2 17 19 Percentage 10.5 89.5 100.0 Valid percentage 10.5 89.5 100.0 Cumulative percentage 10.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H67_TempRecord Frequency Valid Daily Twice daily Total 1 3 15 19 Percentage 5.3 15.8 78.9 100.0 Valid percentage 5.3 15.8 78.9 100.0 Cumulative percentage 5.3 21.1 100.0

H68_WeekedRecord Frequency Valid No (if vaccine required on holiday - done, and not done for only 1 day holiday) Yes Total 3 1 Percentage 15.8 5.3 Valid percentage 15.8 5.3 Cumulative percentage 15.8 21.1

15 19

78.9 100.0

100.0

H69_FEFO Frequency Valid Yes Total 2 17 19 Percentage 10.5 89.5 100.0 Valid percentage 10.5 89.5 100.0 Cumulative percentage 10.5 100.0

H70_VacExpire Frequency Valid No Yes Total 1 14 4 19 Percentage 5.3 73.7 21.1 100.0 Valid percentage 5.3 73.7 21.1 100.0 Cumulative percentage 5.3 78.9 100.0

Report of the Mission

H70_IfYesVacNum Frequency Valid As noted before OPV-1 vial OPV-27 vials and TT-83 vials Total 16 1 1 1 19 Percentage 84.2 5.3 5.3 5.3 100.0 Valid percentage 84.2 5.3 5.3 5.3 100.0 Cumulative percentage 84.2 89.5 94.7 100.0

H71_VVM Frequency Valid Yes, all vaccine usable Yes, all vaccine usable (except expired one) Total 1 17 1 19 Percentage 5.3 89.5 5.3 100.0 Valid percentage 5.3 89.5 5.3 100.0 Cumulative percentage 5.3 94.7 100.0

H72_VacVVM Frequency Valid NA Not applicable, no stage 2 Yes Total 1 1 12 5 19 Percentage 5.3 5.3 63.2 26.3 100.0 Valid percentage 5.3 5.3 63.2 26.3 100.0 Cumulative percentage 5.3 10.5 73.7 100.0

H73_AirCirculation Frequency Valid Yes Total 2 17 19 Percentage 10.5 89.5 100.0 Valid percentage 10.5 89.5 100.0 Cumulative percentage 10.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H74_Poster Frequency Valid Yes Total 3 16 19 Percentage 15.8 84.2 100.0 Valid percentage 15.8 84.2 100.0 Cumulative percentage 15.8 100.0

H75_AdqSpace Frequency Valid Yes Total 4 15 19 Percentage 21.1 78.9 100.0 Valid percentage 21.1 78.9 100.0 Cumulative percentage 21.1 100.0

H75_Clean Frequency Valid Yes Total 17 2 19 Percentage 89.5 10.5 100.0 Valid percentage 89.5 10.5 100.0 Cumulative percentage 89.5 100.0

H75_Organized Frequency Valid Yes Total 17 2 19 Percentage 89.5 10.5 100.0 Valid percentage 89.5 10.5 100.0 Cumulative percentage 89.5 100.0

Report of the Mission

H76_Dispose Frequency Valid Open bucket Safety box Total 2 1 16 19 Percentage 10.5 5.3 84.2 100.0 Valid percentage 10.5 5.3 84.2 100.0 Cumulative percentage 10.5 15.8 100.0

H77_SafetyBox Frequency Valid Pit-burned Pit-burned, Pit-buried Total 3 14 2 19 Percentage 15.8 73.7 10.5 100.0 Valid percentage 15.8 73.7 10.5 100.0 Cumulative percentage 15.8 89.5 100.0

H78_NeedlesObserved Frequency Valid No Total 4 15 19 Percentage 21.1 78.9 100.0 Valid percentage 21.1 78.9 100.0 Cumulative percentage 21.1 100.0

H79_WastSite Frequency Valid No Yes Total 5 12 2 19 Percentage 26.3 63.2 10.5 100.0 Valid percentage 26.3 63.2 10.5 100.0 Cumulative percentage 26.3 89.5 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

H80_Observation Frequency Valid Open pit Separate disposal pit for vials and sharps Well maintained Total 16 1 1 1 19 Percentage 84.2 5.3 5.3 5.3 100.0 Valid percentage 84.2 5.3 5.3 5.3 100.0 Cumulative percentage 84.2 89.5 94.7 100.0

Frenquency tables for interview with girls (please refer to annex 4 for the data dictionary and the exact questionnaire) District Frequency Valid Jigmecholing Pondkllha Punakha SARPANG Trangsa Hospital Trongsa (T/Phy) Tsirang WANGDUE Yebitaplsa Hospital Total 5 1 2 5 7 5 9 6 5 45 Percentage 11.1 2.2 4.4 11.1 15.6 11.1 20.0 13.3 11.1 100.0 Valid percentage 11.1 2.2 4.4 11.1 15.6 11.1 20.0 13.3 11.1 100.0 Cumulative percentage 11.1 13.3 17.8 28.9 44.4 55.6 75.6 88.9 100.0

Report of the Mission

G1_HealthCard Frequency Valid N/A No Yes Total 1 1 10 33 45 Percentage 2.2 2.2 22.2 73.3 100.0 Valid percentage 2.2 2.2 22.2 73.3 100.0 Cumulative percentage 2.2 4.4 26.7 100.0

G1_VacToday Frequency Valid HPV Total 7 38 45 Percentage 15.6 84.4 100.0 Valid percentage 15.6 84.4 100.0 Cumulative percentage 15.6 100.0

G1_CardUpdated Frequency Valid Old health card - not updated to include new vaccine Separate card for HPV Total 20 24 1 45 Percentage 44.4 53.3 2.2 100.0 Valid percentage 44.4 53.3 2.2 100.0 Cumulative percentage 44.4 97.8 100.0

G2_VacReceived Frequency Valid Does not know N/A Total 42 2 1 45 Percentage 93.3 4.4 2.2 100.0 Valid percentage 93.3 4.4 2.2 100.0 Cumulative percentage 93.3 97.8 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

G3_KnowHPV Frequency Valid No Yes Total 1 4 40 45 Percentage 2.2 8.9 88.9 100.0 Valid percentage 2.2 8.9 88.9 100.0 Cumulative percentage 2.2 11.1 100.0

G3_IfYesPrevent Frequency Valid Answer correct Answer incorrect Does not know Total 4 32 7 2 45 Percentage 8.9 71.1 15.6 4.4 100.0 Valid percentage 8.9 71.1 15.6 4.4 100.0 Cumulative percentage 8.9 80.0 95.6 100.0

G4_Message Frequency Valid BBS, teacher BHU staff BHU staff, teacher HA HCW HCW, friend, public meeting HCW, Teacher Health coordinator, BBS, Newspaper Health coordinator, principal Health educator, teacher, radio, TV Health worker, BBS, teacher 1 1 4 2 1 1 1 1 1 1 1 Percentage 2.2 2.2 8.9 4.4 2.2 2.2 2.2 2.2 2.2 2.2 2.2 Valid percentage 2.2 2.2 8.9 4.4 2.2 2.2 2.2 2.2 2.2 2.2 2.2 Cumulative percentage 2.2 4.4 13.3 17.8 20.0 22.2 24.4 26.7 28.9 31.1 33.3

Report of the Mission

Frequency Hospital staff, school Hospital staff, teachers, friends Hospital staff, teachers, parents Newspaper, teacher Newspaper, TV, HCW Newspaper, TV, HCW, teacher Parents Parents, TV School School health incharge School health incharge, Friends School health incharge, health campaign School teacher, BBS School, BAU staff School, BHU staff School, hospital staff School, TV, Poster Teacher Teacher, health minister's message Teacher, Radio, TV Teacher, TV TV TV, friend TV, friends TV, friends, teacher TV, School Health coordinator, Friends Total 1 3 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 2 1 1 1 1 1 1 1 1 45

Percentage 2.2 6.7 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 4.4 2.2 2.2 4.4 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 100.0

Valid percentage 2.2 6.7 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 4.4 2.2 2.2 4.4 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 100.0

Cumulative percentage 35.6 42.2 44.4 46.7 48.9 51.1 53.3 55.6 57.8 60.0 62.2 64.4 66.7 68.9 73.3 75.6 77.8 82.2 84.4 86.7 88.9 91.1 93.3 95.6 97.8 100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

G5_NextVaccination Frequency Valid No Yes - answer correct Yes - answer incorrect Total 4 1 38 2 45 Percentage 8.9 2.2 84.4 4.4 100.0 Valid percentage 8.9 2.2 84.4 4.4 100.0 Cumulative percentage 8.9 11.1 95.6 100.0

G6_Reaction Frequency Valid No Yes - answer correct Yes - answer incorrect Total 7 8 25 5 45 Percentage 15.6 17.8 55.6 11.1 100.0 Valid percentage 15.6 17.8 55.6 11.1 100.0 Cumulative percentage 15.6 33.3 88.9 100.0

Report of the Mission

G7_Comments Frequency Valid Benefits all women Explain detail HPV purposes and benefits Good to get the vaccine which prevents CaCx Important Information to have vaccination to prevent cervical cancer It benefits to all women to prevent from cervical cancer It should be given to all women It should continue Need more awareness No comments Saving life Saving life from this dying disease Should be given to all children Thanks for government for giving this vaccine free of cost to prevent cervical cancer Thanks for government for giving this vaccine to prevent cervical cancer To continue providing this vaccine to all girls Total 6 1 1 1 1 1 1 1 1 1 21 1 1 2 2 Percentage 13.3 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 46.7 2.2 2.2 4.4 4.4 Valid percentage 13.3 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 2.2 46.7 2.2 2.2 4.4 4.4 Cumulative percentage 13.3 15.6 17.8 20.0 22.2 24.4 26.7 28.9 31.1 33.3 80.0 82.2 84.4 88.9 93.3

4.4

97.8

1 45

2.2 100.0

100.0

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Annex 4

HPV Vaccine Post-Introduction Evaluation (PIE) tool HPV Questionnaires Each question in the questionnaire is accompanied by an abbreviation, explained below. Abbreviation GEN Explanation Generic PIE questions should be included in all evaluations Comment

CENT

Questions to be asked at the central level only

These questions are shaded in grey

DIST

Questions to be asked at the district level only

Questionnaire 1.1 Questionnaire 1.2 Questionnaire 1.3

Central/District Health Facility Interview with girls

Report of the Mission

Questionnaire 1.1 — CENTRAL/DISTRICT OBLIGATORY HPV Vaccination

Date of interview: ________________ Name of interviewer: ______________________________ This questionnaire was conducted at: (insert name of country, region or district)  Central level:  District level: _____________________ _____________________

Name(s) and title(s) of person(s) interviewed (please list all persons that you interviewed): EPI manager/person responsible for vaccinations (or their deputy) should be interviewed Name: ________________________ Title: _______________________ Name: ________________________ Title: _______________________ Name :________________________ Title: _______________________ Contact details of most senior person: Telephone: __________________ E-mail address: _______________________

Name of new vaccine(s) being evaluated: _______________________ New vaccine preparation: (e.g. fully liquid, liquid lyophilized, manufacturer) _____________________________________________________________ New vaccine presentation: (e.g. prefilled syringe, 1-dose vial, 2-dose vial) ______________________________________________________________

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Documents to request at beginning of interview: Document received Document reported to exist but not available at time of interview Document unavailable

Document/data

Copy of national immunization schedule (central level only) Introduction plan for new vaccine Training materials/reference documents utilized at new vaccine training Vaccine management guidelines Media campaign/social mobilization/education materials (e.g. brochures, posters, pamphlets) Vaccine stock records Supervisor's book/site-visit reports (regional and district level only) Injection safety/waste-management policy document Wastage reports AEFI protocol/reporting form AEFI logbook/registry National coverage and drop-out rates (central level)

Report of the Mission

Abbreviation GEN

Background information 1. Date of obligatory HPV Vaccination was started at national/regional/district level Note: If interviewing region or district, put date for appropriate area.

Central/Regional/District Questionnaire (DD/MM/YYYY) _____ / _____/ ______

CENT

2. Was the HPV Vaccine introduced nationwide or was it a phased introduction?

 National introduction (all regions and districts at once)  Phased introduction (explain) _______________________ Number of girls 12 years of age ______________ Source/Year____________ Check all that apply  Strong political will  Strong gynecologist/oncologist associations  Introduction by neighbouring countries  Disease burden data available nationally  Visit by international adviser  Other influences (specify)

GEN

3. What is the population of girls 12 years of age in this country/region/ district? 4. What factors influenced the decision for introduction of the HPV vaccine?

CENT

5. Was the national immunization advisory committee supportive of the decision to introduce the new vaccine?

 Yes  No  Don’t know If no, what were their reasons: _________________________

CENT

6. What is the current national immunization schedule? Note: Ask for a copy of the schedule for all EPI vaccines (central level only).

Copy of schedule received  Yes  No

CENT

7. Was the immunization schedule changed when the new vaccine was introduced? If yes, why?

 Yes  No  Don’t know If yes, reason _______________________________

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

CENT

8. What is the schedule for the HPV Vaccine?

Insert age that dose is given Schedule: Dose 1 ___________ Dose 2 ___________ Dose 3 ___________

CENT

9. Was HPV vaccination linked to any adolescent health package?

 Yes  No  Don’t know If yes, please describe ________________________________  Yes  No  Don’t know If yes, please describe ________________________________  Yes  No  Don’t know If yes or no, please describe _______________________________

CENT

10. Does MKD have a National Strategy for cervical cancer prevention and control? 11. Has the cervical screening programme strategy been changed since introduction of HPV vaccine? 12. Could you please tell what disease(s) does HPV Vaccine prevent? Note: HPV cervical precancer and cancer caused by serotypes included into vaccine (around 70% of all). For quadrivalent vaccine – anogenital warts. Pre-Implementation Planning and Vaccine Introduction Process

CENT

GEN (optional)

Central/District Questionnaire  Yes, national plan/timeline  Yes, district plan/timeline Interviewer, please ask for a copy at time of interview. Review later to ensure essential components are included.  No. If no, why not? ______________________________

GEN

13. Do you have a central/district HPV Vaccine introduction plan or timeline for introduction activities? Note: For example, if someone from the district only has a national plan, just check national plan. If they have a national and a district plan check both.

Report of the Mission

CENT

Ask only if response to question 13 was "yes" 14. Did you receive support or use guidelines to develop your introduction plan/timeline?

 Yes. If yes, specify support? _______________________  No. If no, why not? ________________________  Don’t know

Training GEN 15. Describe the training organized for your employees for the HPV Vaccine introduction, if any.

Central/District Questionnaire Target audience for the training  Doctors  Nurses  Health-care workers  Other (specify) Type of training  Cascade  Region-by-region  Other (specify) Was training conducted before vaccine introduction  Yes  No If yes, how long before _________________ Was training conducted after vaccine introduction  Yes  No If yes, how long after ____________________  How long was the training? ________________ Who conducted the training at each level? Regions__________________________ District ___________________________ Health facilities _____________________ Other comments on training _______________________

GEN

16. How were the trainings financed?

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

GEN

17. Do you think there are any ways in which the training could be improved for next time?

 Yes  No  Don’t know If yes, please describe ________________________________

GEN

18. What educational and reference materials were provided to participants at time of training? Ask for samples. Vaccine Delivery Central/District Questionnaire  Yes  No  Yes  No

GEN GEN GEN

19. Is informed consent required? 20. If yes, does it pose any issues? 21. What methods were used for recall or to enhance completion of 3–dose schedule? Please list the methods Vaccine Coverage

Central/District Questionnaire  Yes  No  Don’t know

GEN

22. Was the immunization database updated to accommodate information on the new vaccine? 23. What formula do you use to calculate vaccine coverage? Include the source of the numerator (doses administered) and denominator (target population). 24. What was rubella vaccine coverage in girls of 14 years of age in the year before the HPV vaccine introduction? Note: Use year before new vaccine introduction or closest administrative period.

GEN

Formula Numerator source _____________________ Denominator source___________________ Correct formula used  Yes  No Rubella coverage _________ year _________

GEN

25. What is the coverage of the first and last dose of the HPV vaccine for the most recent administrative period?

HPV first dose coverage

_________

HPV second dose coverage _________ HPV last dose coverage Specify the period; _________

Report of the Mission

CENT

26. In the last year, what proportion of regions/districts/health facilities sent all monthly immunization summary forms completed and submitted on time?

Percentage of regions/districts/health facilities submitting reports on time every month ______ Percentage reports complete _________ (Of reports received, how many have all key information completed for every month)?

Cold-Chain Management GEN 27. Discuss any changes you had to make in the cold chain before introduction of the HPV vaccine. Note: Try to distinguish cold chain expansion/replacement of equipment that is part of normal cold-chain rehabilitation from changes made specifically to accommodate the new vaccine. CENT 28. Were any problems with the cold chain identified after the introduction of the HPV vaccine? If yes, what were the problems and how have the problems been addressed?

Central/District Questionnaire

 No problems  Inadequate space  Frozen vaccine  Malfunctioning refrigerators  Power supply/fuel shortage  Other (specify)

CENT

29. Do you use freeze watch monitors during vaccine transportation? Vaccine Management, Transport & Logistics

 Yes  No  Don’t know

Central/District Questionnaire  Yes  No

GEN

30. Do you have immunization policy guidelines for vaccine management? If yes, have they been updated to include the new vaccine? Please provide a copy at time of interview. 31. How do you forecast vaccine requirements? 32. Did the estimated needs change with introduction of the HPV vaccine?

CENT GEN

 Yes  No  Don’t know If yes, why? ___________________

100

EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

CENT CENT

33. How are vaccines ordered? 34. Please describe how vaccines are transported to the regions/districts/health facilities. 35. How often do you send out vaccine shipments and supplies from your level to the next level? 36. Did the frequency of deliveries change with introduction of the HPV vaccine? If yes, by how much?  Yes  No  Don’t know If yes, Frequency of delivery before introduction ______ times/year Frequency of delivery after introduction ________ times/year Reason for change?

CENT

37. Please describe how the transportation of vaccines to outreach sites has changed with the introduction of the HPV vaccine. 38. What effect did the HPV vaccine have on dry storage space requirements? 39. What were the costs associated with increased transport or coldchain requirements? Please state how many of the following were required: Extra trucks/cars rental or purchase _____________________ Extra logistic staff __________________________________ Extra petrol _______________________________________ Extra cold-chain space _______________________________ Other costs (specify) ________________________________

CENT

101

Report of the Mission

CENT CENT

40. Who paid for these extra costs? 41. Did you run out of any vaccines, including the HPV vaccine, or vaccine supplies in the past six months?  Yes, vaccines (specify) ___________  Yes, vaccine supplies (specify) ___________  No If yes, how many weeks ___________ If yes, reason for stock out _____________

CENT

42. Have you had any vaccine expirations in the last six months? If yes, what did you do with the expired stock? 43. Have you had any vaccine with the vaccine vial monitor (VVM) in stage III or IV in the last six months? If yes, what did you do with these vaccines? 44. Are vaccine orders/deliveries tied to injection supplies (i.e. bundling)? Note: Look at stock records to get this information. Waste Management & Injection Safety

 Yes  No If yes, action taken _______________

CENT

 Yes

 No

If yes, action taken ____________

CENT

 Yes  No Verified by checking stock records  Yes  No

Central/District Questionnaire

GEN GEN GEN

45. Describe the waste-disposal policy/plan at each level. 46. Does each level generally follow these guidelines? 47. Did you have to make changes to your guidance for your wastedisposal system for introduction of the HPV vaccine? If yes explain. 48. Did you have to make changes to your guidelines regarding injection safety for introduction of the HPV vaccine? If yes, explain.  Yes  No  Don’t know

GEN

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EPI and VPD Surveillance Review and Post-introduction Evaluation of HPV Vaccine

Vaccine Wastage GEN 49. What formula is used to calculate vaccine wastage and what is the source of the data. Ask for wastage report.

Central/District Questionnaire  Vaccine wastage not calculated Formula: Data source, numerator ______________________ Data source, denominator ____________________ Is provided formula correct? (See Table 10)  Yes  No Source of data:  Stock books  Summary sheets  Other

GEN

50. What is the vaccine wastage rate of the HPV vaccine? Note: If vaccine wastage rate is unknown for new vaccine because PIE is done before administrative data are available, record anecdotal reports or attempt part-year calculation.

HPV vaccine wastage rate _____________%

GEN

51. Did you change anything about the way you administer vaccines, to reduce wastage of the HPV vaccine? Monitoring and Supervision Central/Regional/District Questionnaire Regional level ___________ District level ___________ Health-facility level ___________

GEN

52. How often are supervisory visits made to the regional/district/health-facility level?

GEN

53. Have you or a member of your staff or a partner organization made supervisory visits, to the districts/health facilities since HPV vaccine introduction? If so, how often and by whom?

 Yes  No If yes, how often _____________ By whom ___________________ If no, why not? ________________

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GEN

54. How do supervisors give feedback to sites visited?

 Written     Supervisory logbook Supervisory checklist Send site visit report Other (specify) ________

 Oral   GEN 55. What are the main issues that came up at the last two supervisory visits? Are they specifically related to introduction of the HPV vaccine? How have they been resolved? a. Discussion with staff Other (specify) ________

GEN

56. Are follow-up visits conducted at sites with inadequate performance and continuing problems? 57. Have you received a supervisory visit? If yes, when and by whom?

 Yes  No

GEN

 Yes  No When _______________ By whom ________________________ Ask to see a copy of the visit report.

Adverse Events Following Immunization (AEFI) GEN 58. Do you have a system and written protocol for monitoring and reporting AEFIs for all vaccines? Please describe the procedure. Ask for a copy of the AEFI protocol and reporting form. GEN 59. Do you have a crisis plan in place to manage AEFIs? Please describe.

Central/Regional/District Questionnaire  Yes  No If no, why not _______________________

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GEN

60. Did you make any changes to the AEFI protocol specifically for the HPV vaccine? 61. Have you had any reported AEFIs for the HPV vaccine or another vaccine since the HPV vaccine was introduced? Note: Verify using AEFI logbook/registry if available.  Yes  No  Don’t know If yes, How many for the HPV vaccine _________________________ How many for a traditional vaccine (specify) _______________ What were the AEFIs_________________________ How were they handled? _________________________ Advocacy & Communication Central/Regional/District Questionnaire  Yes  No  Don’t know If yes, describe ________________________ If no, why not? ________________________

GEN

62. Did you have an official launch ceremony at the time of the HPV vaccine introduction? Note: If yes, what did it involve, was it successful, did it get much media coverage, how long before the introduction of the HPV vaccine did it take place?

GEN

63. Did you use any media outlets to promote the HPV vaccine and inform/educate the community about the vaccine? Note: Please ask for copies of any materials.

Check all that apply:  Radio  Television  Community groups  Town crier  Celebrity  Government officials  Other (specify) Main messages ______________________________________

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GEN

64. Did you prepare or distribute any health education material for the community on the HPV vaccine? If yes, what were they? Who were the target audiences? When and how were they distributed? Note: Please ask for copies of any materials.

Check all that apply:  Posters  Brochures  Flyers  Clothing (t-shirts, hats etc.)  Other (specify) Target audiences ____________________________________ Main messages _____________________________________

Sustainability CENT 65. Is there a budget line for vaccine purchases in the national budget? 66. How are traditional EPI vaccines financed? Note: List all sources that pay for the vaccine. CENT 67. How is the HPV vaccine paid for? Note: List all sources that pay for the vaccine. CENT 68. How are the operational delivery costs of HPV vaccine paid for? Note: List all sources that pay for the vaccine. CENT 69. Do you plan to introduce any more new vaccines in the future? If yes, which one(s) and when? Note: If they say no, this is an opportunity to mention new vaccines, such as pneumococcal vaccine, rotavirus vaccine, are available

Central/Regional Questionnaire

CENT

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Impact Assessment CENT 70. Are you conducting, or do you plan to conduct, a vaccine impact assessment, i.e. a study to determine if the HPV vaccine is reducing disease burden? General Impressions GEN 71. How well was the HPV vaccine accepted? If there were any problems, please comment for each group. Note: Was it considered to be a safe and effective, and needed vaccine?

Central/Regional Questionnaire  Yes  No  Don’t know If yes, give details __________________________ If no, why not? __________________________ Central/Regional/District Questionnaire New vaccine well accepted Health-care workers Y  N

Professional societies Y  N Community/public Government Media Y  N Y  N Y  N

On what is your answer based? _________________ Discuss any problems _________________________ GEN 72. Were there financial implications in introducing the HPV vaccine for each of the following areas? Ask about the financial implications of each of the following: Cold chain Y  N If yes, specify:____________________ Vaccine transport Y  N If yes, specify:______________ Wastage Y  N If yes, specify:________________ Communication materials/media Y  N If yes, specify:_______ Training Y  N If yes, specify:____________________ Other costs? Y  N If yes, specify:____________________

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GEN

73. What effect has the introduction of the HPV vaccine had on your EPI programme?

Please check one that best describes the introduction:  Improved the EPI programme. Please explain ________________________________________  Made the EPI programme worse. Please explain ________________________________________  No effect. Please explain ________________________________________

GEN

74. In your opinion, was the introduction of the HPV vaccine a smooth process or problematic? Please explain.

Please check one that best describes the introduction:  Very smooth. No problems  Smooth, minor problems. Please explain ________________________________________  Somewhat smooth, some major problems. Please explain _________________________________  Not smooth at all, some major problems. Please explain _________________________________

GEN

75. Many other countries will be introducing this and other new vaccines soon. What have you learned from this experience, and what advice do you have for other countries to ensure a smooth introduction? Observation of Vaccine Storage Area at the Central/Regional/District Levels Central/Regional/District Questionnaire

CENT CENT CENT CENT

76. Are all freezers and refrigerators clean and functioning properly? 77. Are there thermometers outside the freezers and refrigerators? 78. Are there thermometers inside the freezers and refrigerators? 79. Is the temperature inside the refrigerators currently between +2° and +8° C?

Y N  Y  N  Some  Y  N  Some  Y  N  Some

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CENT

80. Is there a log of freezer and refrigerator temperatures?

 Y  N  Some If yes, has temperature consistently been between +2° and +8°C for refrigerators in the last two months?  Y  N  Some

CENT

81. How often are temperatures recorded?

 Twice daily  Daily  No records  Other (specify) ____________________  Y  N  Sometimes

CENT

82. Are temperatures monitored and recorded on weekends and holidays? Note: Check specifically for holidays in ____________(insert date of most recent holiday).

CENT

83. Are all vaccines arranged as “First expiry, First out”?

Y  N If no, why not? _______________________  Not applicable. Why? ____________________

CENT

84. Did you observe any expired vaccines?

Y N If yes, which vaccine, and how many? _______________________________

CENT

For vaccines with a VVM 85. Did the VVMs that you observed indicate that vaccine is usable, i.e. Stage 1 or 2

 Yes, all vaccines usable  No, some vaccines Stage 3 or 4 (unusable) Specify vaccine and proportion unusable _______________________________

CENT

For vaccines with a VVM 86. Are vaccines with VVM in Stage 2 arranged so that they are used first?

 Y  N  Not applicable, no Stage 2

CENT

87. Are there spaces between the vaccine boxes/trays to allow air circulation?

Y N

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CENT

88. Is injection equipment stored in good condition?

Adequate space  Y  N Clean and dry conditions  Y  N Well organized (i.e. easily accessible)  Y  N  Other observation (specify) ___________________________________

Notes and Comments GEN If you were unable to visit the cold store or dry store area, please mention reason. Record any interesting positive or negative anecdotes or comments by immunization staff.

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Questionnaire 1.2 — health facility OBLIGATORY immunization ONLY

Date of interview: ________________ Name of interviewer: _____________________ This questionnaire was conducted at Region: ______________________ District: ______________________ Health-facility name: ___________

Type of health facility (check one):  Health Centre/Clinic  Health Post/Outpost  Other (specify) ____________________ Name(s) and title(s) of person(s) interviewed (please list all the persons that you interviewed): EPI Senior Nurse/Health-care worker responsible for vaccinations (or their deputy) should be interviewed Name________________________ Title _______________________ Name________________________ Title _______________________ Name________________________ Title _______________________ Contact details of most senior person: Telephone __________________ e-mail address _______________________

 Denotes Suggested Key Finding (see Appendix 3).

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Documents to request at beginning of interview: (check appropriate boxes) Document received Document reported to exist but not available at time of interview Document unavailable

Document / data

Introduction plan for new vaccine Training materials/reference documents utilized during new vaccine training Vaccine management guidelines Media campaign/social mobilization/education materials (brochures, posters, pamphlets, etc.) Vaccine stock records Supervisor's book/site visit reports Injection safety/waste-management policy document Wastage reports AEFI protocol/reporting form AEFI logbook/registry Sample health card/immunization card Immunization logbooks, monitoring forms, tally sheets, vaccine registries

Abbreviation GEN

Pre- Implementation Planning 1. Were you (interviewee) working at this health facility at the time of the HPV vaccine introduction?

Health-Facility Questionnaire  Yes  No Interviewer: If "No", try to get a staff member who was present when the new vaccine was introduced to participate. If not, continue with the interview although it may not be possible to answer all questions. (MM/YYYY) _________/______  Don’t know

GEN

2. When was the HPV vaccine first administered at this health facility?

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Training GEN 3. Please describe health-facility staff training for the HPV vaccine introduction, if any.

Health-Facility Questionnaire How many people from this health facility were trained? ______________ Who from this health facility was trained? _________________ How many of them are still working at this health facility? _________ How long was the training for health facility staff? __________ What were the key topics covered in the training? _____________ Were there any opportunities to practice the new skills to administer the new vaccine correctly? _____________________ Did the person from this health facility who was trained, train others in the health facility?  Yes  No  Don’t know Was training conducted before vaccine introduction  Yes  No If yes, how long before? _________________ Was training conducted after vaccine introduction  Yes  No If yes, how long after? ____________________ Who conducted the training for health-facility staff? __________________________ Other comments on training _________________________

GEN

4. Do you think there are any ways in which the training could be improved for next time?

 Yes  No.  Don’t know If yes, please describe ___________________________ Yes  No  Don’t know Key Finding: Guidelines/training materials provided?

GEN

5. Are HPV vaccine introduction guidelines or educational and reference materials from the training available? Ask to see samples.

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GEN

6. Overall, were you satisfied with the training provided? Vaccine Delivery

Yes  No  Not applicable Key Finding: Satisfaction with training? Central/Regional/District Questionnaire  Yes  No  Yes  No

GEN GEN GEN

7. Is informed consent required? 8. If yes, does it pose any issues? 9. What methods were used for recall or to enhance completion of 3–dose schedule? Please list the methods Vaccine Coverage

Health-Facility Questionnaire Girls 12 years of age:______________________ Source of data _______________________

GEN

10. What is the size of the target population for HPV immunizations in this health facility? What is the source of this figure?

GEN

11. What formula do you use to calculate vaccine coverage? Include the source of the numerator (doses administered) and denominator (target population). 12. What was RUBELLAvaccine coverage among girls 14 yars of age in the year before the HPV vaccine introduction? Note: use 2009 data. 13. What is the coverage of the first, second and third dose of the HPV vaccine for the most recent administrative period?

Formula Numerator source _____________________ Denominator source___________________

GEN

Rubella _________ year _________

GEN

HPV vaccine first dose (HPV-1) coverage ______________ HPV vaccine second dose coverage ___________ HPV vaccine third dose (HPV-3) coverage _______________

GEN

14. How often do you report immunization data to the higher level? Ask to see a report.

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GEN

15. Have immunization registries/child health cards, etc. been updated to include the HPV vaccine?

Check box if updated  Vaccine registry/logbook  Health card  Tally sheets/district reporting forms  Vaccine stock forms  Other (specify)

GEN

16. How many days a week does your site perform outreach immunization sessions, i.e. immunization sessions not conducted at the health facility? 17. How outreach data are collected? 18. What changes, if any, did you have to make to outreach sessions when you introduced the HPV vaccine?

 Outreach not performed _______ times per week

GEN GEN

 No changes required  More vaccine carriers required  Increased number of outreach sessions  Other changes (specify)

Cold-Chain Management GEN 19. How vaccines are stored at your health facility?

Health-Facility Questionnaire Check all that apply  Cold storage box  Refrigerator  Other (specify) _________________

20. What cold chain equipment is utilized during out reach services? GEN 21. The last time there was an interruption in your power supply, what did you do? 22. Discuss any changes you had to make in the cold chain before introduction of the HPV vaccine. Note: Try to distinguish cold-chain expansion/replacement of equipment that is part of normal cold-chain rehabilitation from changes specifically for the new vaccine.

GEN

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GEN

23. Were there any problems with the cold chain recognized after the introduction of the HPV vaccine? If yes, what were the problems and have the problems been addressed? If they have been addressed, how were they addressed?

 No problems  Inadequate space  Frozen vaccine  Malfunctioning refrigerators  Power supply  Other (specify) How resolved? _______________________________________ Key Finding: Percentage health facilities observed or reported problems with the cold chain

Vaccine Management, Transport & Logistics GEN 24. Do you have immunization policy guidelines for vaccine management? If yes, have they been updated to include the HPV vaccine? Please provide a copy at time of interview. 25. How do you forecast vaccine requirements? 26. How did estimated requirements change following introduction of the HPV vaccine? 27. Please describe how vaccines are ordered and delivered to the health facility.

Health-Facility Questionnaire  Yes  No

GEN

 Yes  No  Don’t know If yes, why? ___________________

GEN

Who orders? _______________________________ How often are vaccines delivered? _____________ Any problems with this? ______________________

GEN

28. Have you had any vaccine expirations in the last six months? If yes, what did you do with the expired stock?

 Yes  No If yes, action taken_________________________________

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GEN

29. Have you had any vaccine with VVM in Stage III or IV in the last six months? If yes, what did you do with these vaccines? 30. Did you run out of any vaccines, including the HPV vaccine, or vaccines supplies in the past six months?

 Yes  No If yes, action taken _________________________________  Yes  No

GEN

 Yes, vaccines (specify)  Yes, vaccine supplies (specify)  No If yes, how many weeks? ___________ If yes, reason for stock out _____________ Key Finding: Percentage of health facilities reporting vaccine or supply stock out in last six months

GEN

31. Are vaccine orders/deliveries tied to injection supplies (i.e. bundling)? Note: Look at stock records to get this information. Waste Management and Injection Safety

 Yes  No Verified by checking stock records  Yes  No

Health-Facility Questionnaire  Yes  No If yes, explain ______________________________

GEN

32. Did you have to make any changes to your waste-disposal system for introduction of the HPV vaccine? If yes, explain. 33. Have you experienced any problems with your wastedisposal system? Observe site.

GEN

 Yes  No If yes, explain ______________________________

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Vaccine Wastage GEN 34. What formula is used to calculate vaccine wastage and what is the source of the data. Ask for wastage report.

Health-Facility Questionnaire  Vaccine wastage not calculated Formula: (See Table 10) Data source, numerator ______________________ Data source, denominator ____________________ Is formula provided correct? (See Table 10)  Yes  No Source of data:  Stock books  Summary sheets  Other Key Finding: Wastage report on site? Yes  No

GEN

35. What is the vaccine wastage rate of the HPV vaccine? Note: If vaccine wastage rate is unknown for new vaccine because PIE is done before administrative data are available, record anecdotal reports or attempt part-year calculation.

HPV vaccine wastage (this administrative period) _____________%

GEN

36. Did you change anything about the way you administer vaccines, to reduce wastage of the HPV vaccine? Monitoring and Supervision Health-Facility Questionnaire Number of visits ___________ Is there a written report of the visit? Yes  No Key Finding: At least one documented visit Yes  No

GEN

37. How many times in the past six months have you received a supervisory visit from district or regional level or from a partner agency? Was the visit documented? Ask to see the supervisory book, copy of last report.

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GEN

38. If yes, who visited, and what were the problems identified?

Who visited? _______________________________ (job title) Problems identified _________________________________

Adverse Events Following Immunization (AEFI) GEN 39. Do you have a system and written protocol for monitoring and reporting AEFIs for all vaccines? Please describe the procedure. Ask for a copy of the AEFI protocol and reporting form. GEN 40. Did you make any changes to the AEFI protocol specifically for the HPV vaccine? 41. Have you had any reported AEFIs for the HPV vaccine or another vaccine since the HPV vaccine was introduced? Note: Verify using AEFI log book/registry, if one.

Health-Facility Questionnaire Yes  No If no, why not? ______________________________ Key Finding: AEFI system/protocol in place?

GEN

 Yes  No  Don’t know If yes: How many for the HPV vaccine? _______________ How many for a traditional vaccine? (specify) _____________ What were the AEFIs? ______________ How were they handled? __________________

Advocacy, Communication & Acceptance GEN 42. Did you have an official launch ceremony at this health facility at the time of the HPV vaccine introduction? Note: What did it involve, was it successful, did it get much media coverage?

Health-Facility Questionnaire  Yes  No  Don’t know If yes, describe ________________________

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GEN

43. Did this health facility provide any health education messages or materials to the community about the HPV vaccine at the time of introduction? Ask to see copies of materials.

Check all that apply  None provided  Posters  Brochures  Health education sessions  Public meetings  Other (specify)

GEN

44. Did you experience any resistance from the community regarding the HPV vaccine? 45. Do you remember any media focus (e.g. on radio, television or newspapers) on the HPV vaccine? Health-Care Worker Knowledge (ask HCW, not head of health facility)

 Yes  No  Don’t know

GEN

 Yes  No If yes, describe ______________________________ Health-Facility Questionnaire

GEN GEN

46. What is the immunization schedule for the HPV vaccine? 47. What disease(s) does the HPV vaccine prevent? Interviewer: HPV cervical precancer and cancer caused by serotypes included into vaccine (around 70% of all). For quadrivalent vaccine – anogenital warts. Interviewer: Write exact response given Key Finding: Percentage HCWs that knew what disease(s) the new vaccine prevents?

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GEN

48. What information do you provide to girls before and after vaccination with the HPV vaccine?

Check if mentioned — don’t prompt but can tell afterwards  Name of the vaccine  Diseases it protects against  Benefits to the girl  Vaccine schedule/when to return  Normal side effects?  Risk of synkopy (fainting)  What side effects they should return for  Bring vaccination card  Other health messages (specify) Two or more mentioned? Yes  No Key Finding: Percentage HCWs providing two or more accurate pieces of information to parents? Yes  No

General Impressions GEN 49. Were there any financial implications for the health facility involved in introduction of the HPV vaccine?

Health-Facility Questionnaire Ask about the financial implications of each of the following:  Don’t know Cold chain  Y  N If yes, specify____________________ Vaccine transport  Y  N If yes, specify______________ Wastage  Y  N If yes, specify________________ Communication materials/media  Y  N If yes, specify_______ Training  Y  N If yes, specify____________________ Other costs?  Y  N If yes, specify____________________

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GEN

50. What effect has the introduction of the HPV vaccine had on your EPI programme?

Please check one that best describes the introduction:  Improved the EPI programme. Please explain______________  Made the EPI programme worse. Please explain______________  No effect. Please explain______________ Key Finding: Percentage sites reporting that new vaccine improved the EPI programme?

GEN

51. In your opinion, was the introduction of the HPV vaccine a smooth process or problematic? Please explain.

Please check one that best describes the introduction:  Very smooth. No problems  Generally smooth, minor problems. Please explain______________  Somewhat smooth, some major problems. Please explain _____  Not smooth. Major problems. Please explain ______ Key Finding: Percentage sites reporting a smooth or very smooth introduction

GEN

52. Many other countries will be introducing this and other new vaccines soon. What have you learned from this experience and what advice do you have for other health facilities to ensure a smooth introduction? Observations at Vaccination Session Health-Facility Questionnaire  Y  N  Unknown (N = unsafe practice)  Y  N  Unknown (N = unsafe practice)

GEN

53. Are (all) vaccines reconstituted correctly (e.g. measles, BCG)? 54. Are vaccines stored/handled properly during the session, e.g. clean, organized, vaccine vials outside carrier are in foam pad?

GEN

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GEN

55. Are appropriate administration techniques observed (for Gardasil intramuscular injection in the deltoid region of upper arm or the higher anterolateral area of the thigh) 56. Are AD syringes used?

 Y  N  Not observed (N = unsafe practice)

GEN

Y N (N = unsafe practice)

GEN

57. Are needles recapped (look in safety box for capped needles)? 58. Are AD syringes disposed of in a safety box? 59. Is the policy on use of the open multi-dose vial observed?

 Y  N  Unknown (Y = unsafe practice)  Y  N  Unknown (N = unsafe practice) Date opened marked on vial  Y  N Open vial discarded at end of immunization session Y N  Other observation (specify) ___________________  Unknown (N = unsafe practice)

GEN

60. Summary: How many unsafe practices, based on questions above, were observed?

Number of unsafe practices _________ Key Finding: Percentage of sites with two or more unsafe practices observed  Y  N  Unknown

GEN

61. Are girls observed after vaccination approximately 15 minutes? Observation of Vaccine Storage Area

Health-Facility Questionnaire Y N Y N Y N

GEN GEN GEN GEN

62. Are all refrigerators clean and properly functioning? 63. Is there a thermometer outside the refrigerator? 64. Is there a thermometer inside the refrigerator? 65. Is the temperature inside the refrigerator currently between +2° and +8° C?

 Y  N What is the temperature? ________

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GEN GEN

66. Is there a log of refrigerator temperatures? 67. How often are temperatures recorded? 68. Are temperatures monitored and recorded on weekends and holidays? Note: Check specifically for holidays in ____________ (insert date of most recent holiday).

Y N  Twice daily  Daily  No records  Other (specify)  Y  N  Sometimes

GEN

69. Are vaccines arranged as “First expiry, First out”?

Y  N If no, why not? ____________________  Not applicable. Why? ____________________

GEN

70. Did you observe any expired vaccines?

Y N If yes, which vaccine and how many? __________________

GEN

For vaccines with a VVM 71. Did the VVMs that you observed indicate that vaccine is usable, i.e. Stage 1 or 2

 Yes, all vaccines usable  No, some vaccines Stage 3 or 4 (unusable) Specify vaccine and proportion unusable ___________________ Key Finding: Percentage of health facilities reporting with any VVM in Stage 3 or 4.

GEN

For vaccines with a VVM 72. Are vaccines with VVM in Stage 2 arranged so that they are used first?

 Y  N  Not applicable, no Stage 2

GEN

73. Are there spaces between the vaccine boxes/trays to allow air circulation? Health Communication

Y N

Health-Facility Questionnaire Y N

GEN

74. Are any posters or other literature about the new vaccine noted in the health facility?

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Stock Room GEN 75. Is injection equipment stored in good condition

Health-Facility Questionnaire Adequate space  Y  N Clean and dry conditions  Y  N Well organized (i.e. easily accessible)  Y  N  Other observation (specify) _________________

Waste Disposal GEN 76. How are used AD syringes being disposed of? (If not observed, ask how boxes are disposed). GEN 77. How are used safety boxes disposed of? (If not observed, ask how boxes are disposed). Note: Specify whether box is emptied and reused or destroyed with contents inside.

Health-Facility Questionnaire  Safety box  Open bucket  Other  Other observations  Incinerator  Pit-burned  Pit-exposed  Pit-buried  Above-ground area  Box reused  Other observation

GEN

78. Were discarded needles and syringes observed on the ground outside the facility? 79. Is waste-disposal site closed off?

Y N

GEN

YN Key Finding: Percentage of health facilities with clean, closed-off disposal sites

GEN

80. Describe any other observation of the disposal site. Notes and Comments If you were unable to visit the cold store or dry store area, please mention reason. Record any interesting positive or negative anecdotes or comments by health-care workers.

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Questionnaire 1.3: — Interview with girls Optional

Date of interview: ______________________ Name of interviewer: _________________ Region: _________________District: _____________________Health-facility name school name where the girl was interviewed : ______________________________________ Interview girls who have just received the HPV vaccine (can also talk to a group of girls waiting to be vaccinated to get their impressions). Begin the interview by saying the following “I would like to ask you a few questions about the vaccines you received today. The answers you give will help us learn more about how to introduce a new vaccine.” (N.B. You may need someone conversant in the local language to ask the questions). 1. Do you have your Health card with you today? If yes: May I please see it? Use health card to answer the following Health card present  Yes  No Vaccines received today  HPV I the health card updated?  Old health card (not updated to include new vaccine)  Old health card (with new vaccine written in by hand)  New health card (updated to include new vaccine) 2. What vaccine(s) did you receive today? Check one box  Names all vaccines (answer correct)  Names some vaccines (partially correct)  Does not know  Mentions specific health benefit of vaccine (e.g. for HPV vaccine says, “got vaccine to prevent cervical cancer”)  Mentions general beneficial effects of vaccines, e.g. ”I got vaccines to be healthy”  Other (specify) _____________________

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3. Do you know about the HPV vaccine?

Yes  No If yes, which disease(s) do they prevent?  Does not know  Answer correct  Answer incorrect

4. If yes to question 3. How did you receive the message about the HPV vaccine? Note: Radio, newspaper, television, healthcare worker, friend, public meeting. 5. Do you know when to come for your next vaccination? Note: If answer is no or yes but incorrect, please advise girl when next vaccination is due. 6. Do you know what reaction you may get following your vaccination today? Note: This question is trying to differentiate between baseline knowledge and knowledge received at current vaccination session.  Yes (answer correct)  Yes (answer incorrect)  No  Yes (answer correct)  Yes (answer incorrect)  No Interviewer: If answer is no or yes but incorrect, please advise mother of potential injection side adverse experiences, e.g. mild redness, pain, mild swelling at injection site, mild fever.

7. Other comments or observations. Record any interesting positive or negative anecdotes or comments by girls.

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WHO assists Member states of the South-East Asia Region to periodically review their surveillance systems and national immunization programmes. These reviews provide an insight into the programme strengths and limitations. Additionally, WHO encourages countries to identify strategies to harness strengths and utilize the available resources to improve the quality of surveillance and immunization. In March 2011, national and international experts reviewed the Expanded Programme on Immunization (EPI) and conducted a post introduction evaluation for HPV vaccine in Bhutan. This report summarizes the progress made in vaccine preventable disease surveillance, immunization service delivery and coverage, injection safety, vaccine supply, cold chain management, and advocacy and communications. It also provides recommendations for the consideration of the Government of Bhutan and development partners in their efforts to achieve the national goals for immunization.

Regional Office for South-East Asia World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Publications

Дата принятия 31 декабря 2012 г.

Источник Всемирная организация здравоохранения