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h e a l t h l i n e ISSN2229-337XVolume2Issue1January-June2011 17OriginalArticle

ProcessevaluationofroutineimmunizationinruralareasofAnandDistrictof

Gujarat

TusharPatel

1

,DevangRaval

2

NirajPandit

3

1AssistantProfessor,P.S.medicalCollege,Karamsad,2AssociateProfessor,CommunityMedicineDepartment,

Govtmedicalcollege,Bhavnagar;3AssociateProfessor,CommunityMedicineDepartment,SBKSMedicalCollege,

Waghodia

Correspondenceto:Tusharpatel,Email:[email protected]

Abstract:

Objective:To evaluate the process components of routine

immunization such as planning of immunization

sessions, cold-chain and logistic management,

communitymobilization,appropriatetechniqueof

vaccinationetc.indistrictAnand,Gujarat.

StudyDesign:Cross-sectionalobservationalstudy.

Studysetting:Sub-centre or Aanganwadi where immunization

sessions are conducted and Primary Health

Centres.

Methods:Total88immunizationsessionswereevaluatedin

44 PHCs.With the help of pre-tested structured

questionnaireinformationwasgathered.

Results:Almost46percentofsessionsitesdidnothavelist

of beneficiaries foractivemobilization. Innearly78.4% of sessions, number ofmobilizer present

duringimmunizationsessionwasoneand/ortwo.

Only 50percent ofsession siteshad allvaccines

available. 93.2% ofPrimaryHealthCentres had

no written plan for supervision of immunization

sessions. Out of 44 PHC, in 29.6 % of PHCs,

sessionswerenotconductedaspermicro-planon

thedateofvisit.

.

Conclusion:

AllASHA/Aanganwadiworkersshouldmobilize

infants from their respective area if village hasmore than one AWW/ASHA. There is need to

sendBCGvaccineatallsessionsitesirrespective

of wastage concerns. Problem ofVacant post of

FHWorFHWonleave/deputationshouldbedealt

with.

Key words: Routine Immunization, Process

evaluation

Introduction:Infectious diseases are one of the major

causesofmorbidityandmortalityinchildren.One

of the most cost effective and easy methods for

child survival is immunization. To reduce the

morbidityandmortalityduetovaccinepreventable

diseases World Health Organization (WHO)

launchedExpandedProgramme on Immunization

in 1974. As a member country Government of

India alsoaccepted the immunization programme

in1978whichwasre-introducedastheUniversal

Immunization programme in 1985. Initially the

targetwassettocoveratleast85%ofallinfants(1). However national socio-demographic goals in

National Population Policy 2000 set a target ofachievinguniversalimmunizationofchildrenby

2010(2).

InspiteofImmunizationProgrammeoperatingin

Indiasince1978,approximately10millioninfants

and children remains unimmunized. Number is

higherthananyothercountryintheworld(3).Only

44%of infants receive fullvaccination (alldoses

up to age of one year) and 5% of infants dont

receiveanyvaccineinIndia(4).

It was realized that merely providing

vaccine just to achieve targets without giving

adequate attention to quality of immunizationservicesdoesnt guarantee a reduction in disease

morbidity & mortality. Full course of potent

vaccine given at right age, at right interval, by

right technique with a valid documentation

constitutesqualitycriteriaofvaccinationservices.

For successful implementation of routine

immunization service all its components

planningofimmunizationsessions,cold-chainand

logistic management, community mobilization,

appropriate technique of vaccination etc. should

alsobecarefullylookedinto.Thisrequiresanin-

depth process evaluation. The present studywasconducted with an objective to evaluate the

processofroutineimmunizationindistrictAnand,

Gujaratwithspeciallyfocusonqualityofservices.

MaterialsandMethods:The present study was immunization

session based evaluation study. The study was

carriedoutduringtheyear2008inAnanddistrict

of Gujarat. The district is situated in central

Gujarat andpopularlyknown ascharotargreen

beltofagriculture,wheremainagricultureproduct

istobacco.AuthorofthestudyworkedasRoutine

Immunization Monitor and study was conducted

alongwithmonitoring.ThedistrictAnandhas44


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h e a l t h l i n e ISSN2229-337XVolume2Issue1January-June2011 18PrimaryHealthcentresin8Talukas,whichcovers

1.86millionpopulationsaccordingto2001census.

It was decided to cover all PHCs for evaluation

andatleasttwosessionsshouldbemonitoredfor

study.Thustotal88 sessionsindifferentvillages

were observed on Wednesdays (FixedImmunization day). The schedule of vaccination

programmewas takenfromChiefDistrictHealth

officer and Block Health officer. Two

sessions/sites in one PHC area were selected

randomly. The PHC staffs were informed about

visitofsupervisionandthesessionvisited.

The data was collected on structured

pretested questionnaire, which was prepared by

WHO/Government of India and modified as per

requirementofstudy(3).Thequestionnaireconsists

of interview and observations of various aspects

like programme management, cold chainmanagement, injection technique and safety,

quality of record keeping and reporting, IEC,

microplanand communitymobilization. Allthe

datacollectedwasthencodedandanalyzedusing

MicrosoftExcel. Co-Authorassisted indesigning

thestudyandanalysisofdata.

Results:Total 88 immunization sessions were

observed during 2008. It also showed that only

13.6%ofFemaleHealthWorkershaveregistered

90-100% of expected number of births. Birth

registration is essential for mobilizing

beneficiaries.The poorregistrationwas observed

atmajorityofsub-centres(Table1).

Almost46%ofsessionsitesdidnothave

listofbeneficiariesforactivemobilization.Infant

mobilizerplaysan important role invaccination

coverage. In immunization programme,

Aanganwadi worker, ASHA worker, Village

volunteersareworkingasmobilizer.In 78.4%of

sessions, number of mobilizers present during

immunizationwasoneand/ortwo.(Table-1)Mostof the Female Health workers (92.1%) were

correctly filling immunization register. IEC

materialsweredisplayed at97%ofsessionsites.

Only 62% of ANMs were giving four key

messagestobegivenaftervaccinationviz.nameof

vaccine that has been given, side effects of

vaccination,whentocomefornextvaccineandto

bringimmunizationcardalongduringnextvisit.

Table2depictsthatonly50%ofsession

siteshadallvaccinesavailable.Inrespecttocold

chainmaintenance,98.8%ofsitesshowsVVM

stageIorIIand98.8%ofsiteshadfreezesensitivevaccinesinliquidform.Thiswasquitepositive

forthedistrict.However,at28.5%sites,timeof

reconstitutionwasnotwrittenonvialafter

reconstitutionoffreezedriedvaccine.

TableI:Statusofrecordkeepingandinfant

mobilizationduringimmunizationsession

DIFFERENTASPECTSN=88ADEQUATE(%)

Numberofbirthsregistered

(%oftotaltarget):

90100%

12 13.6

70-90% 59 67.1

Lessthan70% 17 19.3

Listofduebeneficiaries

prepared

Yes

48 54.5

No 40 45.5

Numberof

AWW/ASHA/other

mobilizerpresent


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h e a l t h l i n e ISSN2229-337XVolume2Issue1January-June2011 19threemonths.AllANMswereusingauto-disable

syringesforvaccination.

Table2:Coldchain,logistics,safetyissuesetc.

atsessionsite


Allvaccinesalongwithdiluents

availableYes44 50.0

No 44 50.0

Freezesensitivevaccineinliquid

formandshaketestOKYes

87 98.8

No 01 01.2

VVMstageIorIIonOPV

Yes

54 98.8

No 01 01.2

Timeofreconstitutionwrittenon

vialYes

64 61.4

No 34 28.6

CorrectselectionofInjectionsite

androuteYes

84 95.4

No 04 04.6

Correctdoseofvaccinegiven

Yes

76 86.4

No 12 13.6

Correctageofadministration

Yes

81 92.0

No 07 08.0

NumberofANMsaskingtowait

forhalfanhouraftervaccination

Yes

86 97.2

No 02 02.8

Useofseparatesyringeandneedle

foreachinjection

Yes

88 100.0

No 00 0

NeedlesstickinjurytoANM

duringlastthreemonths

Yes

02 02.8

No 86 97.2

Programme management and cold chain

aspectsatPrimaryHealthCentre(Table-3)shows

that 93.2% of Primary Health Centres had no

written plan for supervision of immunization

sessions. Out of 44 PHCs, in 29.6% of PHCs

sessions were not conducted as per micro-plan,

due tovarious reasonslikevacant post,FHWon

leave or in training etc. Temperature of ILR (in90.9%ofPHCs)andstorageofvaccinesinILR(in

93.2%ofPHCs)wereappropriate.

Table3:Programmemanagementandcold

chainissuesatPHClevel


Planforsupervisionavailable

atPHCYes03 06.8

No 41 93.2

PercentageofsessionsConductedagainstplannedon

thedateofvisit

100%

31 77.0

80-100% 08 18.2


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h e a l t h l i n e ISSN2229-337XVolume2Issue1January-June2011 20mobilization. Only one or two mobilizer was

present in session at 78% sessions and at 10%

session sites therewere nomobilizers. Even if a

village had more than one Anganwadi, only one

Anganwadi worker remained present during

sessionsasperrotation.Workersfromotherareasneither mobilize infants nor remain present at

session.

Regarding availability of all vaccines at

session sites, only 50% of sites were having all

vaccines. This was mainly because of BCG

vaccinewhichFHWgivesonlyonceinamonthto

avoidwastage.Notrackingofdrop-outsandleft-

outs and missing opportunities due to wastage

concernswere also identified by National

ImmunizationProgrammeReview(6).

Cold chain issues at vaccine sites, like

VVMfor poliovaccine and shake test for freezesensitive vaccine were satisfactory. But

reconstitution time was not written on vial for

almost28%ofsessionsitewhichisimportantfor

preventionof toxic shock syndrome followed by

measlesvaccine.Othervaccinesafetyaspectslike

correct site for vaccination, correct dose, and

correctageweresatisfactory.Injectionsafetyissue

wasalsogoodindistrict.Only3%ANMreported

needle stick injury in last three months. This is

much lower than reportedbyPanditNB(7) in his

study from the same district in 2004. He has

reported more than 19% of annual needle stick

injuriesamongserviceprovidersindistrictAnand,

India. The reason for lower needle stick injury

amongvaccinatormaybedue touniversaluseof

ADsyringe.

ArunAggarwal etal inhis evaluation of

cold chain system has identified that storage of

vaccine and packingwas proper,most ILRs had

temperaturewithinprescribedrange(4to80C)

(8).

The present study also supports the Arun et al

study. Similarly Sokhy J et al has also reported

satisfactory immunization session organization,cold chain maintenance and injection techniques(9).Micro-planshavebeenpreparedbyPHCs.But

all sessions are not conducted as per micro-plan

due to various reasons like vacant post, staff

deputed for training, staff on leave etc. Lack of

staff and resources for service delivery has also

been reported by National Immunization

Programme Review by World Health

Organization(6).

Recommendations:Thoughcoldchainmaintenanceisappropriate,to

achieve 100% target of immunization coveragethere is need to improve birth registration and

activemobilizationofinfants.AllASHAworkers/

Aanganwadiworkersshouldmobilizeinfantsfrom

their respectivearea ifvillagehasmore thanone

AWW/ASHA.Nameofmobilizershould alsobe

mentioned in micro-plan. Some incentive to

mother can improve attendance during routine

immunizationsession.BCGVaccine isgiven only once in amonth by

FHWs to avoid wastage. However different

sessions inonemonth are for different areas. So

there isneed tosendBCGvaccine at all session

sitesirrespectiveofwastageconcerns.

VacantpostsofFHWsshouldbefilledso

thatallplannedsessionscanbeconducted.There

should be alternate plan available in case ofany

unforeseen condition like leave and training of

ANM/FHW. It isalsorecommended thatconcept

ofmobileimmunizationteamcouldbeconsidered

which could fill the gap of staff on leave ordeputedfortrainingandotherreasons

OtheractivitieslikeOrientationtrainingof

ANM, Waste management. Review Meetings,

StrengtheningtheColdChainSystems,organizing

immunization week, etc. could be carried out to

improve the coverage and effectiveness of the

programme.

References:1.Park K. Parks Textbook of Preventive and SocialMedicine. M/S Banarsidas Bhanot Publishers. 20th

Edition2009:112

2. Government Of India. National PopulationPolicy2000.Dept.ofFamilyWelfare.MinistryOfHealth

&FamilyWelfare.GOINewDelhi.

3. GovernmentofIndia.ImmunizationHandbookforMedical Officers. Dept. of Family Welfare.

Ministry Of Health & Family Welfare. Edition

2008:15,130-131.

4. International institute of population sciences.NationalFamilyHealthSurvey-3.NationalReport.

Volume 1: 228 (accessible fromwww.nfhsindia.org)

5. UManjunath,R.P.PareekhMaternalKnowledgeand perceptions about routine immunization

programme. Indian Journal OfMedical Sciences,2003:57:4:158-163.

6. WorldHealthOrganization.NationalImmunizationProgrammeReview-India.2004:

7. Pandit NB, Choudhary SK; Unsafe injectionpracticesinGujarat,India;SingaporeMedJ2008;

49(11):936

8. ArunAggarwal,AmarjeetSinghEvaluationofcoldchain system in rural areas of Haryana. Indian

PediatricsJan1995:32:31-34.

9. Sokhey J. Country Overview A report of theinternational evaluation of the immunization

programme in India. Indian Pediatrics 1993:30:

2:153-174.

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