UIP: The Universal Immunisation Programme of India

by Rohin Kachroo

Background of the UIP in India

The Universal Immunisation Programme in India is one of the largest immunisation programmes in the word and plays a a major role in public health intervention for the country.

The UIP was originally introduced in 1978 under the title of Expanded Programme of Immunisation (EPI). By 1985, the programme had significantly increased and was therefore renamed the Universal Immunisation Programme (UIP). The main goal of the UIP at the times was to cover all 700 districts by 1989-90.

On the 13th of January 2011, India reported its last case of Polio. This was important because India was the only country from the South East Asia Region (SEAR) which was still actively reporting cases of Polio. WHO declared the South East Asia Region Polio free on the 27th of March 2014. This was a huge achievement for the whole programme, both for policy makers and the large team that worked tirelessly through years to finally achieve this.

  

The UIP - Present Day

The UIP’s annual target is to vaccinate 26 million newborns and 29 million pregnant women. Nationally, eight vaccines are provided however a further four vaccines are offered depending on factors such as location. The vaccines offered are as follows: BCG, OPV, RVV, IPV, Measles, MR, JE, DPT, TT, Pentavalent and Hepatitis B.

Each year, more than nine million vaccination sessions are planned all throughout the country with almost 27 thousand cold chain points used for the storage and distribution of vaccines.

On the 25th of December 2014, the UIP introduced Mission Indradhanush (MI). MI aimed to increase full immunisation coverage to 90% by 2018 across 528 districts in 35 states. WHO had recognised that underserved areas were in desperate need of full immunisation and this is what the main focus of MI was. The mission consisted of four rounds of immunisation drives which would help to try and catch those who had been left out or missed.

  

Cold Chain

The Cold Chain contains a collection of storage and transport links. These links are specifically designed to keep the vaccine at the recommended temperature.

Vaccines lose their potency due to exposure to three factors:

            Heat - When the temperature goes beyond 8°C, all vaccines under the UIP lose their                                                 potency.

            Cold - If the temperature goes below -20°C, Hep. B, Pentavalent, IPV, DPT and TT will all                           lose their potency.

            Light - Vaccines such as BCG, Measles and MR can lose their potency if exposed to light                             for a period of time.

This is why it is very important to make sure the links in the cold chain are kept intact. If even one of these links were to be broken, the results would almost certainly be catastrophic.

The cold chain begins with the vaccine manufacturer. From there, the vaccine is transported to the primary store in specifically designed planes which control the temperature required for each particular vaccine.

The primary store employs used Walk in Coolers (WIC) and Walk in Freezers (WIF). The WIC is used to store vaccines in the temperature range of 2°C to 8°C whereas the WIF is used to store vaccines in the temperature range of -25°C to -15°C.

The vaccines are then carried to the state store by either a refrigerated or insulated van. Usually, an insulated van is used as its is cheaper to run when compared to the refrigerated van.

Once the vaccines reach the primary health centre, they are all stored in an Ice Lined Refrigerator which only operates between 2°C and 8°C.

They are then transported in a vaccine carrier to the sub-centre session sites where the vaccine is finally administered.

  

Supply Chain

The UIP has a hugely streamlined process to make sure every part of the cold chain is maintained. The same can also be said about the supply chain. The Ministry of Health and Family Well Being (MoHFW), places an order for a certain amount of vaccines to the manufacturer.

The manufacturer then either sends the vaccines to the Government Medical Store Depot (GMSD) or to the State Vaccine Store (SVS). Both these stores are Primary Vaccine Stores. There are 4 GMSDs and 53 State Vaccine Stores in the country.

From there, the vaccines are transported to the Regional Vaccine Store or the District Vaccine Store. If vaccines are needed quickly, the Primary Vaccine Store is likely to directly send the vaccines to the District Vaccine Store and skip the Regional Vaccine Store because the Regional Vaccine Store sends the vaccines to the District Vaccine Store anyway.

The District Vaccine Store sends the vaccines to either a Primary Health Centre (PHC), Community Health Centre (CHC), Urban Health Centre (UHC) or Sub-Centre (SC). These are the last cold chain points. There are in excess of 25,000 of these.

My Experience - Programme Delivery

On my first day, I visited the Integrated Child Development Scheme (ICDS). The ICDS is based in the community and is where the vaccine is administered to the child/pregnant woman. There was an Auxiliary Nurse Midwife (ANM), Accredited Social Health Activist (ASHA) and a Surveillance Field Monitor (SFM) present.

The ANM is responsible for administering the vaccine to the child or pregnant mother. They are widely regarded as one of the grass-root workers in the programme. From what I could see, the ANM is a key member at the session site and they seemed fully trained to carry out the task that was required of them.

The ASHA worker keeps a record of all the children in their designated area. This record is then cross checked against a central database to draw up lists for who needs a vaccination. The ASHA worker I met had maintained an accurate record and I was amazed to see how well kept everything was, despite the stressful conditions.

Everyone was doing a very good job despite slightly demoralising conditions.

I found that facilities were not consistent, some had a small room to carry out their work whereas some only had a table and two chairs.

Everyone was following strict infection prevention measures such as wearing gloves, ensuring that needles and gloves are not reused and using a hub cutter to cut each needle after the vaccination.

However, upon asking the members of the team whether there was anything that could be improved, they unanimously replied that stairs to reach the Anganwaadi were too steep. This meant that pregnant women were not able to reach the Anganwaadi in order for them to receive their vaccination.

I then visited a sub-centre. This centre was manned by a Lady Health Visitor (LHV) and a fresh qualified ANM. The sub-centre diagnoses and treats minor illnesses as well as administering vaccinations. The also keep an accurate record to ensure all vaccinations are given at the appropriate time. The sub-centre is located in a more urban setting and the facility had a dedicated room with easy access.

However, they were storing vaccines in an average domestic refrigerator. This is not unusual but I was surprised considering the size of the building would lead me to believe that facilities would be available for them to use (ILR).

After visiting the sub-centre, I went to see the MCD Dispensary, which is an Urban Primary Health Centre (UPHC). This was a much larger health facility with bigger rooms and an Ice Lined Refrigerator (ILR). As well as distributing vaccines to the local ANMs, the Dispensary also conducts its own vaccination sessions. There is also an in-house technician to make sure that the ILR is maintained properly and the vaccines are stored at the correct temperature.

Monitoring of the Programme

The whole programme is tightly monitored and there are Surveillance Field Monitors (SFM) that ensure accurate lists are maintained for children who are due to be vaccinated. They also oversee the work done by Angaanwadi workers and ANMs.

They conduct Immunisation Session Site Monitoring and keep a track of vaccine availability, compliance with established methods for administering the vaccine and safety procedures. All this data is recorded and fed back centrally. 

I also accompanied the Surveillance Field Monitor for house to house monitoring for immunisation. We collected data from thirty consecutive households with children under two years old. We made a record of all the vaccines that they had received so far and which vaccines they were due to receive in the future. We also collected information on reasons for why they had missed any doses.

The Electronic Database and RCH numbers allows the data to be collected across a large geographical area. Information from this database is then fed back to session site personnel like ANMs and Anganwadi Workers who use this to update their lists

Summary

At the start of this project, I had no idea what it was going to be like. I had some understanding of how vaccinations work, however, I had no previous knowledge of how the whole programme for a country is organised, how the cold chain is maintained and who else is involved to make this programme work for so many children.

This was a great opportunity for me to see how the largest immunisation programme in the world works from within. I have seen various levels of the cold chain and the stringent temperature control across thousands of miles. I was very impressed at how everything is so tight knit, especially considering most of the records are on paper! It was most amazing to see how each and every child is tracked through the system and how this elaborate network feeds through into a central office that coordinates this programme. I was also amazed to see how such large organisations like the WHO, Government of India, UNICEF, local State Governments and all the health professionals work together seamlessly to deliver this programme to such a high standard.

As I have gone through this project, I have realised not only how important it is to have every child immunised in the country, but also how much effort and dedication each member of the programme puts in to make sure this is achieved keeping children safe in the community at such a large scale. No child should die from a vaccine preventable disease and programmes like this one make such dreams possible! Achieving a polio free India is just one milestone and I feel this remarkable programme is capable of much more in the years to come, thanks to the wonderful dedicated staff that keep it going.

Acknowledgement

I would like to express my sincere gratitude and thanks to Dr Danish Ahmed, WHO India who took time to organise this project for me despite his very busy schedule. I would also like to thank Dr Summet Juneja, Consultant Immunisation Training at the National Cold Chain and vaccine Management Resource Centre, who showed me round the training centre for Cold Chain maintenance and explained how vaccines are stored at the correct temperature across a large country like India. I am grateful to Dr Qaiser Nizami, NPSP-WHO who arranged for me to do all the field visits. I am indebted to Mr Shekhar, Surveillance and Field Monitoring Officer who accompanied me on all immunisation site session and home monitoring visits, explained the working of various professionals in details and helped me interact with other health professionals involved with the delivery of this wonderful programme. I am thankful to all the ANMs, ANWs and ASHA workers who showed me round their areas of work and took time to explain how the programme is executed.

This project has been a wonderful opportunity for me to enhance my understanding of this huge Immunisation Programme and I have been amazed at the dedication and hard work I have seen along the way. I am sure this programme will reach new heights day by day, making it safer for the children of this country and keeping them disease free. I wish them all the best in their endeavour.