Immunization Division at MoHFW

Universal Immunization Program

Immunization division is a part of the RCH program under National Health Mission
(NHM) and is placed at the Ministry Of Health and Family Welfare, Nirman Bhawan New
Delhi. This division provides all the technical assistance required to undertake the
activities under UIP. The division reviews the state Program implementation plans and
facilitates in its approval process as per norms and guidelines The key roles of this
division include activities related to Routine Immunization, Campaigns (SIAs) such as
Polio, Measles, and Japanese Encephalitis, Monitoring Adverse Events Following
Immunization (AEFI), Vaccine and Cold Chain Logistics, Strategic communication related
to immunization program and trainings related to Immunization Program. It facilitates
the National Technical Advisory Group on Immunization (NTAGI) to review and
recommend its views on various technical and programmatic issues related to
immunization such as new vaccine introduction etc. The division is engaged in
reviewing and sharing the learnings of the program with state and district program
officers. The division also works closely with all development partners and other stake
holders.

Organogram of Immunization Division:

Universal Immunization Programme (UIP)

Evolution of the programme:

1978: Expanded Programme of immunization (EPI).
 Limited reach - mostly urban
1985: Universal Immunization Programme (UIP).
 For reduction of mortality and morbidity due to 6 VPD’s.
 Indigenous vaccine production capacity enhanced
 Cold chain established
 Phased implementation - all districts covered by 1989-90.
 Monitoring and evaluation system implemented
1986: Technology Mission On Immunization
 Monitoring under PMO’s 20 point programme
 Coverage in infants (0 – 12 months) monitored
1992: Child Survival and Safe Motherhood (CSSM)
 Included both UIP and Safe motherhood program
1997: Reproductive Child Health (RCH 1)
2005: National Rural Health Mission
(NRHM)
2012: Government of India declared 2012 as “Year of Intensification of
Routine Immunization.

2013: India, along with other South-East Asia Region, declared

commitment towards measles elimination and rubella/congenital rubella
syndrome (CRS) control by 2020.

2014: No Wild Polio virus case was reported from the country for the
last three years and India had a historic achievement and was certified
as “polio free country” along with other South East Asia Region (SEAR)
countries of WHO.
Vaccines under UIP

 Under UIP, following vaccines are provided:

1. BCG (Bacillus Calmette Guerin)
2. DPT (Diphtheria, Pertussis and Tetanus Toxoid)
3. OPV (Oral Polio Vaccine)
4. Measles
5. Hepatitis B
6. TT (Tetanus Toxoid)
7. JE vaccination (in selected high disease burden districts)
8. Hib containing Pentavalent vaccine (DPT+HepB+Hib) (In selected
States)

Diseases Protected by Vaccination under UIP

1. Diphtheria
2. Pertussis.
3. Tetanus
4. Polio
5. Tuberculosis
6. Measles
7. Hepatitis B
8. Japanese Encephalitis ( commonly known as brain fever)
9. Meningitis and Pneumonia caused by Haemophilus Influenzae type b

VPD surveillance

 Vaccine Preventable Diseases (VPD) surveillance system is needed to

create evidence base to enable planning and deployment of effective
interventions.

 India has different surveillance models. Integrated Disease

Surveillance Project (IDSP) is one of those surveillance systems.

 IDSP is a case-based surveillance system for detection of early

 warning signals of outbreaks. There are other sentinel surveillance
systems which falls under different vertical national health programs
for diseases targeted for control, elimination or eradication.

 Another source is the National Polio Surveillance Project (NPSP),

which has done extremely well in acute flaccid paralysis (AFP) and
measles surveillance in India.

 WHO/NPSP provides needed technical and training support for AFP

and measles surveillance.

National Immunization Schedule (NIS)

S Vaccine& its Protection Rout Number Vaccination
No presentation e of Schedule
doses
1 BCG Tuberculosi Intra 1 at birth (upto 1
(Bacillus Calmette s - year if not given
Guerin)- der earlier)
Lyophilized mal
vaccine
2 OPV Poliomyeliti Oral 5 Birth dose for
(Oral Polio s institutional
Vaccine)- Liquid deliveries,
vaccine Primary three
doses at 6, 10 &
14 week and
one booster
dose at 16-24
month of age.
Given
orally
3 Hepatitis B – Hepatitis B Intra 4 Birth dose
Liquid Vaccine - (within 24
mus hours) for
cula institutional
r deliveries,
Primary three
doses at 6, 10 &
14 week.
4 DPT (Diphtheria, Diphtheria, Intra 5 Three doses at
Pertussis and Pertussis - 6, 10 & 14 week
Tetanus Toxoid) – and mus and two booster
Liquid vaccine Tetanus cula dose at 16-24
r month and 5-6
years of age
5 Measles - Measles Sub- 2 9-12 months of
Lyophilized cuta age and
vaccine neo 2nd dose at 16-
us 24 months.

6 TT (Tetanus Tetanus Intra 2 10 years and 16

Toxoid) – Liquid - years of
vaccine mus 2 Age.
cula For pregnant
r woman, two
doses given(one
dose if
previously
vaccinated
within 3 Year)
7 JE vaccination Japanese Sub- 2 9-12 months of
(in selected high Encephalitis cuta age and
disease burden (Brain neo 2nd dose at 16-
districts) fever) us 24 months.
Lyophilized
vaccine
8 Hib (given as Hib Intra 3 6, 10 & 14 week
pentavalent Pneumonia - of age
containing and Hib mus
Hib+DPT+Hep B) meningitis cula
(in selected r
states) – Liquid
vaccine
In addition,
 179 Japanese Encephalitis (JE) endemic districts across 20 states
have been identified. JE vaccination campaign has been completed
in 154 districts covering nearly 108 million children; remaining
districts will be covered till March 2015.

 Pentavalent vaccine has been introduced in 8 States/UTs i.e. Tamil

Nadu, Kerala, Haryana, J&K, Gujarat, Karnataka, Goa and
Puducherry. Pentavalent vaccine expansion is planned in 12
States/UTs i.e. Andhra Pradesh, Telangana, Assam, Bihar,
Chhattisgarh, Jharkhand, Madhya Pradesh, Punjab, Rajasthan, West
Bengal, Delhi, Uttarakhand by December 2014.

New vaccines to be introduced as per National Technical Advisory Group on

Immunization (NTAGI) recommendation

 Injectable Polio Vaccine (IPV): National Technical Advisory Group on

Immunization (NTAGI) recommended Injectable Polio Vaccine (IPV)
introduction as an additional dose along with 3rd dose of DPT in the
entire country in the first quarter of 2016.

 Rota virus vaccine: NTAGI recommended the introduction of rotavirus

vaccine in Universal Immunization Programme in a phased manner.

 Rubella vaccine is to be introduced as MR vaccine replacing the measles

containing vaccine first dose (MCV1) at 9 months and second dose (MCV2)
at 16-24 months.
 Implementation of Routine Immunization

 RI targets to vaccinate 27 million new born each year with all primary doses and
~100 million children of 1-5 year age with booster doses of UIP vaccines. In
addition, 30 million pregnant mothers are targeted for TT vaccination each year.
 To vaccinate this cohort of 157 million beneficiaries, ~10 million
immunization sessions are conducted, majority of these are at
village level.
 As per Coverage Evaluation Survey (2009), 89.8% of vaccination in India is
provided through Public sector (53% from outreach session held at Anganwadi
centre (25.6%), sub centre (18.9%) etc.) while private sector contributed to only
8.7%.
 ASHA and AWW support ANM by mobilizing eligible children to session site thus
try to ensure that no child is missed. ASHA is also provided an incentive of Rs.
150/session for this activity

 To ensure potent and safe vaccines are delivered to children, a network of

~27,000 cold chain points have been created across the country where vaccines
are stored at recommended temperatures.

Components:
 Strategy and policy:

National Health Policy (2002) is directed towards achieving an acceptable, affordable and
sustainable standard of health through an appropriate health system. Provision of universal
immunization of children against vaccine preventable diseases is one of the major goals
under this policy. Country’s five year plan also puts emphasis on reduction in maternal and
infant mortality rates as major maternal and child health indicators. Country developed a
comprehensive Multi Year Strategic Plan for Immunization in 2005, which has been revised
in 2013. This document is a national strategy document to guide development of UIP plans
at national and state levels. Ministry of Health and Family Welfare also revised the National
Vaccine Policy in 2011. The goal of this vaccine policy is to guide decision making in order to
develop a long term plan to strengthen the UIP. This policy addresses issues of vaccine
security, management, regulation guidelines, vaccine research and development and
product development. To ensure informed decision making for any modification in UIP
schedule or inclusion of new vaccines, there is a National Technical Advisory Group on
Immunization (NTAGI) which comprises of a number of technical experts, national program
leaders and managers, representatives from development partners and professional bodies.
All issues related to the program and vaccines are presented to this group for review and
discussions and final recommendations.

 Cold Chain System, Vaccines and Logistics:

Cold Chain is a system of storing and transporting vaccine at the recommended

temperature range from the point of manufacture to point of use. India has built a vast cold
chain infrastructure to ensure that only potent and effective vaccines reach millions of
beneficiaries across the country. The vaccines are supplied by manufacturers directly to four
Government Medical Store Depots (at Karnal, Mumbai, Chennai and Kolkata) and state and
regional vaccine stores. The GMSDs supply to the states and regional vaccine stores; state
and regional vaccine stores supply vaccines to Divisional vaccine stores and district. The
vaccines are further supplied to last cold chain points which are usually situated in Primary
Health Centers (PHCs) and Community Health Centers. Transportation of vaccines from
States/Regional stores to divisions and districts is done in cold boxes using insulated vaccine
vans. Vaccines carriers with icepacks are used to transport vaccines from PHCs to the
outreach sessions in the village.

In addition to the equipment, there are different personnel deployed for cold chain and
vaccine handling. In the states, there are State Cold Chain Officers who are in charge to
ensure smooth functioning of all cold chain equipment in the state. At regional, divisional
and district levels, there are cold chain technicians whose responsibility is to maintain and
repair cold chain equipment for maintaining the recommended temperatures for storage of
vaccines. At the PHCs and CHCs, cold chain handlers, who are health personnel
(pharmacists, male and female multi-purpose health workers, etc) have been tasked with
proper storage and handling of vaccines and daily upkeep of Ice Lined Refrigerators (ILRs)
and Deep Freezers (DFs) including temperature charting. Cold chain technicians have been
provided with trainings and tool kits for performing installation, maintenance and repair
activities. For maintenance of cold chain equipment, Govt. of India provides funds to the
state under NRHM.

The performance and efficiency of the cold chain system at different levels is monitored
continuously, through supervisory visits, review meetings.
 The Government of India procures and supplies all UIP vaccines along with diluents to all
states. In addition to vaccines, syringes of different capacities, are also procured centrally
and supplied to states. The process involves vaccines and logistics forecasting, scheduling,
ensuring supplies as per need, and so on. It is important to ensure that the cold chain
system is not over burdened and there are no under supplies. Supplies are made to states
on a quarterly basis on receipt of indent. State Vaccine Stores can store vaccines for three
months and so can district vaccine stores. PHCs/CHCs send monthly indents to district
stores. PHCs can store vaccines for a maximum of one month only.

 Injection safety and waste disposal:

A large number of injection procedures are undertaken in lakhs of vaccination sessions

across the country every year. Unsafe injection practices can harm the recipient of the
injection, the health worker and the community resulting in potentially life threatening
infections such as HIV/AIDS, Hepatitis B and C, etc. To ensure safe injection practices,
Government of India endeavours to ensure continuous supply of injection safety
equipments (AD syringes, reconstitution syringes, hub cutters and waste disposal bags).
Trainings are conducted and supported by job-aids, on job training (supportive supervision).

Disposal of immunization waste is strictly as per Central Pollution Control Board (CPCB)
guidelines for biomedical waste disposal. The principles followed are segregation of waste
at source (at the session site), transportation to the PHC or CHC, treatment of sharps and
potentially biohazardous plastic waste, disposal of sharps in sharp pits and treated plastic
waste through proper recycling. The states are provided funds to procure hub cutters, black
and red plastic bags and construction of sharp pits in PHCs and CHCs construction of.

 AEFI Surveillance System in India:

HISTORY

o 1988: AEFI surveillance started India

o 2005: National AEFI guidelines developed and disseminated

o 2007 Onwards: State & District Level AEFI Committees formed

o 2008: National AEFI Committee constituted.

o 2010: Guidelines revised, printed and widely circulated.

o 2011: SOPs printed and disseminated

o 2012: AEFI Secretariat establishment

o Over the years: improved trends of reporting.

o The WHO defines AEFI as “a medical incident that takes place after an
immunization, causes concern, and believed to be caused by
immunization”.

o AEFI surveillance in country monitors immunization safety, detects and

responds to adverse events following immunization; corrects unsafe
immunization practices, reduces the negative impact of the event on
health and contributes to the quality of immunization activities.

o Special focus is being provided by Government of India to strengthen the

system for reporting and responding to any Adverse Event Following
Immunization (AEFI)

o Operational Guidelines for AEFI surveillance and response first published

in 2005 and revised in 2010. These have been disseminated to medical
officers all over the country. Subsequent revision of these guidelines is
under process.

o An AEFI secretariat has been established under ITSU (Immunization

Technical Support Unit) to strengthen &coordinate all issues related to
AEFI.

o India National Regulatory Authority (NRA) assessment has passed

successfully in Dec 2012.

o The National AEFI committee has been revised in 2013 and broader range
of expertise has been added to the National AEFI committee such as
Pharmacology, Forensic Medicine, Pathology, Immunology,
Epidemiology, Communication etc besides Paediatrics and Immunization
program related experts.

o Workshops have been conducted at national level and for the

pentavalent using states (Gujarat, Goa, Jammu and Kashmir, Haryana,
 Tamil Nadu, Kerala, Karnataka and Puducherry) for capacity building
through latest WHO AEFI Causality Assessment guidelines and developing
an effective AEFI monitoring system.

o To strengthen collaboration between stakeholders of vaccine pharmaco

vigilance program at state level, participants from the regulator (DCGI)
and In charges from the network of ADR monitoring centres of the
Pharmacovigilance program of India (PvPI) have also been included from
each state in these trainings.

o The National AEFI guidelines are being currently revised to include the
new WHO causality assessment methodology and add verbal autopsy and
forensic autopsy protocols for investigating AEFI deaths along with SOPs
for AEFI case related sample collections.

 Strategic communication:

Strategic Communication refers to policy-making and guidance for consistent information

activity through coherent messaging. The issue of media advocacy, proactive planning and
effective media response is emerging as one of the key elements of strategic
communication support to achieving full Routine Immunization coverage in the country.
Demand generation gains critical importance in raising immunization coverage in the
country, especially when India is poised to sustain polio eradication, increase visibility and
coverage of RI by motivating people to demand immunization services, sustain and report
vaccine related features, timely completion of routine immunization schedules of their
children, and build grounds for new vaccines.

Development of RI Logo

The new logo of the baby holding the syringe, indicating RI as his right, has been developed
in purple color. This will give RI a distinct identity. Deliberate efforts have been made to stay
away from the Polio brand colors of yellow and pink.
  Immunization Trainings

The Immunization Programme runs due to the coordinated efforts of different cadres of
health staff working in the states at different levels (states, districts, PHCs and CHCs). The
following immunization training programmes are conducted in the country:

No Name of Dura Level Participants Training module Evaluation

. training tion /venu
e
1. Immunization 3 State/ All contractual and Immunization Conducte
training for days Region regular Medical Handbook for in 2012-1
Medical al/dist Officers including Medical Officers
Officers (since rict AYUSH (revised 2011),
2009-10) Department of
Health and Family
Welfare, MOHFW,
GOI
2. Immunization 2 Distric All female and male Immunization Conducte
training of days t level Multi Purpose Handbook for in 2009
Health Health workers and Health Workers
Workers their supervisors (revised 2011),
(since 2006 Department of
and from Health and Family
2012 using Welfare, MOHFW,
revised GOI
version)
3. Training of 2 Distric All health workers Handbook for Conducte
Vaccine and days t level (Pharmacists /staff Vaccine and Cold in 2012-1
Cold Chain nurses/ANMs/LHVs Chain Handlers
Handlers /Male MPWs/etc.) (revised 2011),
(since 2010- in charge of Department of
11) handling vaccines & Health and Family
cold chain Welfare, MOHFW,
equipments at all GOI
vaccine stores
(state/region/
districts/
hospitals/PHCs
/CHCs)
4. Training of 1 day State Immunization - -
 state, district level programme data
and block entry operators at
data entry state, district and
operators block levels.
(ongoing)
In the year of Intensification of Routine Immunization (2012-13), the Government of India
has supported the training of approximately 12,50,000 frontline workers (ANMs, LHVs,
Anganwadi workers and ASHAs) in 9 high priority states – UP, MP, Rajasthan, Bihar,
Chhattisgarh, Jharkhand, Haryana, Gujarat and West Bengal. The objective is to motivate
and strengthen the capacity of frontline workers to reduce dropouts and left outs and
improve the quality of services. The process followed is a cascade model.

Cold chain technicians posted at district, divisional, regional and state levels are given
trainings as follows:
 Training on repair and maintenance of ILRs / DFs
 Training on repair and maintenance of WICs / WIFs and generator sets.

 Training on installation, maintenance and repair of Solar Refrigerators

 Training on repair of voltage stabilizers.

Some of the new training courses under development for specific personnel are as follows:
 Induction training for State Immunization Officers
 Training on Effective Cold Chain and Vaccine Management (ECCVMC) for
immunization and cold chain programme managers at state and district levels
The Government of India has enhanced the training capacity for cold chain technicians by
setting up the National Cold Chain and Vaccine Management Resource Centre (NCCVMRC)
at National Institute of Health and Family Welfare (NIHFW), New Delhi and also the National
Cold Chain Training Centre (NCCTC) at State Health Transport Organization (SHTO), Pune,
Maharashtra.

 Monitoring and evaluation:

Universal Immunization Program has a set of indicators to monitor progress under different
components of the program and evaluate the coverage of immunization amongst the target
population. In the country, UIP performs monitoring and evaluation at three levels. 1) There
is a regular reporting system from the health sub-centre to PHC, district, state and national
level. This reporting has been computerized in the country as a part of Health Management
Information System (HMIS), and the data is available from health facility level and above
every month. Recently MOHFW has also implemented Mother and Child Tracking System
(MCTS) to track every pregnant woman, mother and child up to 5 years of age to ensure
delivery of health services. 2) To evaluate immunization coverage, country conducts period
population based surveys. These include National Family Health Survey (NFHS), District
Level Health Survey (DLHS), Annual Health Survey (AHS) and UNICEF Coverage Evaluation
Survey (CES). 3) In between periodic surveys and administrative reporting, country also
plans targeted studies and surveys to evaluate the performance of various components
under UIP. Some of the examples are VMAT/EVSM, PIE, MCTS Field Assessment etc.

A review mechanism is established at all levels of the program implementation in the

country. Though there are variations in the timings, but PHCs and districts usually conduct
program review at monthly intervals. However, at the state and national level, it is less
frequent. MOHFW has recommended constitution of task forces at the state and district
level for critical review of the program at monthly interval involving various stakeholders at
the particular level. At national level also, immunization division has constituted
Immunization Action Group (IAG) to review the program, discuss issues and suggest
solutions.

The State wise indicators are detailed in the national routine immunization dashboards (annexure
2).

Schemes:

 Routine Immunization:

 Objectives:
o The stated objectives of UIP are:
 To rapidly increase immunization coverage.
 To improve the quality of services.
 To establish a reliable cold chain system to the health facility
level.
 Monitoring of performance.
 To achieve self sufficiency in vaccine production.
 Scope and eligibility:
o India has one of the largest Universal Immunization Programs (UIP) in the
world in terms of the quantities of vaccines used, number of beneficiaries
covered, geographical spread and human resources involved.
 o Under the UIP, all vaccines are given free of cost to the beneficiaries as
per the National Immunization Schedule.
o All beneficiaries’ namely pregnant women and children can get
themselves vaccinated at the nearest Government/Private health facility
or at an immunization post (Anganwadi centres/ other identified sites)
near to their village/urban locality on fixed days.
o The UIP covers all sections of the society across the country with the
same high quality vaccines.

 Achievements:
o The biggest achievement of the immunization program is the eradication
of small pox.
o One more significant milestone is that India is free of Poliomyelitis caused
by Wild Polio Virus (WPV) for more than 33 months.
o Besides, vaccination has contributed significantly to the decline in the
cases and deaths due to the Vaccine Preventable Diseases (VPDs).

 Coverage: As per the Coverage Evaluation Survey (CES-2009), 61% of children in

the country are Fully Immunized with all vaccines. The comparative national
figures for the District Level Household Survey (DLHS) 3 (2007-08) and CES 2009
are summarised in the table below:

Evaluated Coverage (%)

District Level Household Coverage
Survey (DLHS) 3 (2007-08) Evaluation Survey
(CES) (2009)
Full Immunization 53.5 61.0
BCG 86.7 86.9
OPV3 65.6 70.4
DPT3 63.4 71.5
Measles 69.1 74.1
No Immunization 4.6 7.6