1. Update on the Implementation of Measles 2 nd 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 2 nd 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: 2 nd 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 MCV1 & MCV2, no SIAs (40 member states or 21%) MCV1 & regular SIAs (59 member states or 31%) MCV1, MCV2 & one-time catch-up (36 member states or 19%) MCV1, MCV2 & regular SIAs (57 member states or 28%) Single dose (1 member state or 1%) Data source: WHO/IVB measles database as of 26 January 2010 India national immunization programme introduced second dose of measles in 2010

5. Recommendations from expert Indian committees  National Technical Advisory Group on Immunization (NTAGI) recommended: 1.States with MCV1 coverage <80%: Second opportunity for measles vaccine through measles catch-up campaigns in 9 months - 10 years age 2.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 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 RI: MCV1 > 80%: 21 states SIA: MCV1 <80%: 14 states

7. Introduction of 2 nd 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 1.Vaccine/ADS, 33.2 million USD 2.Op cost 25.9 million USD 3.Total 59.1 million USD  Target 134 million  Per child cost 0.44 USD

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

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

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

17. Haryana: 22 Nov 2010 Rajasthan: 29 Nov 2010 Gujarat: 8 March 2011 Chhattisgarh: 14-15 Dec 2010 Madhya Pradesh: 6 Dec 2010 Bihar: 13 Dec 2010 Assam, Arunachel Pradesh: 8 Nov 2010 Phase 1 calendar of catch-up campaigns Jharkhand: 31 Jan 2011 Nagaland 7 Feb 2011 Uttar Pradesh: ??? Manipur: 29 Nov 2010 Tripura 31 Jan 2011 Meghalaya 7 March 2011