Update on the Implementation of Measles 2 nd Dose in India

1. Update on the Implementation of Measles 2nd Dose in India Ms. Anuradha Gupta Joint Secretary, Ministry of Health Govt. of India Global Measles and Rubella Management Meeting Salle B, WHO Headquarters, Geneva, Switzerland 15-17 March, 2011

2. Presentation outline • Context • Introducing 2nd dose of measles vaccine in India • MCV2 – Routine immunization • MCV2 – Catch-up campaigns • Road map and way forward

3. India Context • India steps up public investment in health • National Rural Health Mission (NRHM) provides augmented funding to states to the tune of over INR 550 billion (>$12 billion) during 2005-2010 • System strengthening • HR Augmentation: 2nd ANM*, 800 000 ASHAs#, additional doctors • Infrastructure, Ambulance networks • Communitization • Flexible financing * ANM: Auxiliary Nurse Midwife # ASHA: Accredited Social Health Activist

4. Global Context: Worldwide measles vaccination delivery strategies, mid-2010 India national immunization programmeintroduced second dose of measles in 2010 MCV1 & MCV2, no SIAs (40 member states or 21%) MCV1, MCV2 & one-time catch-up (36 member states or 19%) MCV1, MCV2 & regular SIAs (57 member states or 28%) MCV1 & regular SIAs (59 member states or 31%) Single dose (1 member state or 1%) Data source: WHO/IVB measles database as of 26 January 2010

5. Recommendations from expert Indian committees • National Technical Advisory Group on Immunization (NTAGI) recommended: • States with MCV1 coverage <80%: Second opportunity for measles vaccine through measles catch-up campaigns in 9 months - 10 years age • States with MCV1 coverage >80% MCV2 through routine immunization at 16-24 months of age • Ad hoc expert review committee reviewed above strategy in early 2010 and endorsed the NTAGI recommendation

6. MCV2 introduction: State-specific delivery strategies SIA: MCV1 <80%: 14 states RI: MCV1 > 80%: 21 states • SIA in 14 states: • Target population (9 mo-10 years): 134 million • Vaccine doses and AD syringes: 147 million • Mixing syringe : 29.5 million • MCV2 in routine immunization in 21 states: • Annual targets • 1-2 year population: ~10 million • Vaccine doses: ~12 million

7. Introduction of 2nd dose of Measles in RI, India Annual Target 1-2 year Ongoing: 4 states (0.4 million) 2010: 3 states (1.2 million) 2011: 11 states (5.9 million) To be decided: 3 states (2.2 mln)

8. Measles Catch-up campaigns

9. MCV2 introduction through catch-up vaccination campaign (MCUP) Phase 1 • In three phases • Target: 134 million in 351 districts • Phase 1: • 45 districts from 13 states with ~13 million target children • 9 district from Chhattisgarh • 5 districts from each of the 6 states (Bihar, Jharkhand, Rajasthan, Madhya Pradesh, Gujarat & Haryana) • 1 district from each of the North-East states • Phase 2 to take place from September 2011 • Phase 3 in 2012

10. Key operational strategies: MCUP-1 • Immunization from fixed posts to ensure safe injection practices • Routine immunization and outreach sites used • Additional sites added as needed • Schools with children under 10 years targeted • Specific plans for hard to reach areas and/or underserved populations • Average campaign duration: 3 weeks = 12 working days • 1st week: School based campaign (for 5-10 year children) • 2nd & 3rd weeks: Community based campaign for remaining children • Medical officers trained to establish AEFI management networks equipped with management kits • Regular weekly RI sessions continued without interruption • Measles catch-up campaign activities conducted during remaining days of week

11. Measles catch-up campaign budget • Vaccine/ADS, 33.2 million USD • Op cost 25.9 million USD • Total 59.1 million USD • Target 134 million • Per child cost 0.44 USD

12. Administrative coverage achieved in MCUP1@ 10.2 million children vaccinated so far (92% coverage) in 39 districts across 11 states State (No. of Districts covered in phase 1) * Provisional data @ From 39 districts where campaign completed

13. Reasons for non-vaccination in MCUP1 (from Monitoring data)* Communication related Operational * As reported by caregivers to monitors Source: MoHFW, RCA monitoring

14. Experiences from Phase 1 catch-up campaigns • GoI supported all logistic and operation costs of the activities • Budget committed for subsequent phases • Cold chain capacity and management met expectations • No major issues with vaccine and injection equipment management • Large scale campaigns with injectable vaccines can be conducted safely in India • Medical officers in all SIA districts trained in AEFI management, reporting • No instance of AEFI due to programme error detected • All reported AEFIs managed effectively • Administrative coverage variable across states: • 39 districts completed campaigns so far • 49% (19/39) with >= 90% coverage

15. Areas for improvement • Coordination and planning • Better coordination among the three primary departments of Health, Education and ICDS • Flexible approach with states for timeline; but stringent adherence to agreed upon timeline • Communication and advocacy • IEC and interpersonal communication at grass-root level • Civil society and professional bodies: Indian Academy of Pediatrics, Indian Medical Association, Others • Private schools • Vaccination in urban areas poses special challenges • Injection waste management needs strengthening • Supervision needs to be improved at all levels.

16. Way forward • MCV2 introduction • Routine Immunization (21 states): Started in 7 states; will start in all 21 by 2011 • Catch-up: Will complete in all 14 states by 2012 • State and national review meetings to compile best practices and lessons learned planned in April 2011 • Measles mortality reduction through immunization plus NRHM initiatives to improve access to health care at grassroots • Laboratory supported measles surveillance initially in states with higher burden • At least one state level laboratory in each state for measles serology • Build synergies of catch-up campaigns with Routine Immunization Thank You