COMMUNITY BASED LEARNING AND EDUCATION

Seventh Community Posting at District Level

In depth study on BCG Vaccination Program of Nuwakot District

A Report Submitted by:

Anjit Phuyal

Submitted to:
Department of Community Health Sciences
School of Medicine
Patan Academy of Health Sciences
December, 2014

Acknowledgement
I would like to thank the entire PAHS faculties for an opportunity to perform an in-depth study
on BCG vaccination program. I am thankful to all our faculties of DCHS for their continuous
guidance on and off the field.
I would like to appreciate the cooperation and support of all the staffs of Nuwakot District health
office (DHO) especially immunization supervisor Mr. Amrit Maharjan, cold chain officer Mr.
Sanat Kumar Khadka and Statistical assistant Mr. Bishnu Rijal.
I am also thankful to the community people of Nuwakot district for their cordial cooperation and
kind information without which this report would never have been possible.
I would also like to thank all those people who have directly and indirectly helped me to fulfill
my objectives.
Thank You

Executive Summary
Tuberculosis (TB) continues to be a major public health problem around the world. For
preventive interventions, the only available and licensed vaccine thus far is BCG, which is
routinely administered to infants and young children. For high-incidence, developing countries,
the BCG vaccine was included in the Expanded Program on Immunization as of 1974. In Nepal,
EPI was introduced in the fiscal year 1978/79.
The objective of the study was in-depth analysis the BCG vaccine program in Nuwakot district.
Data on BCG vaccination was obtained from the HMIS section of Nuwakot DHO for the study
purpose. Qualitative information was obtained through key informant interviews with staffs of
district health office.
The National Immunization Program (NIP) is a high priority program of Government of Nepal.
The goal of National Immunization Program is to reduce child morbidity, mortality and disability
associated with vaccine preventable diseases. The main objective is Achieve and maintain at
least 90% vaccination coverage for all antigens at national and district level by 2016. BCG
coverage of Nuwakot district has increased from past year but still below national and regional
coverage. BCG vaccine wastage is higher than national target in both national and district level.
Vacant posts of vaccinators is the main hindrance in achieving the national target of BCG
vaccine coverage but no initiative has been taken at the district level to fulfill the sanctioned
posts of vaccinators. No effective measures have been taken at both national and district level to
decrease vaccine wastage rate. High vaccine wastage and inability to take any effective measures
shows the failure of management.

Acronyms
BCG

Bacillus Calmette Guerin

CHS

Community Health Sciences

DCHS

Department of Community Health Sciences

DHO

District Health Office/r

DoHS

Department of Health Services

EPI

Extended Program on Immunization

FCHV

Female Community Health Volunteer

FY

Fiscal Year

HP

Health Post

PAHS

Patan Academy of Health Sciences

SHP

Sub-Health Post

VDC

Village Development Committee

VPD

Vaccine Preventable Disease

Contents
1. Introduction............................................................................................................ 1
1.1.Background of study......................................................................................... 1
1.2. Objective of study............................................................................................ 1
2. Methodology........................................................................................................... 2
2.1.Methodology...................................................................................................... 2
2.2. Limitations........................................................................................................ 2
3. Findings.................................................................................................................. 3
3.1. National Policy.................................................................................................. 3
3.2. Goal.................................................................................................................. 3
3.3. Objectives........................................................................................................ 3
3.4. Strategies......................................................................................................... 4
3.5. Activities........................................................................................................... 4
3.6. Data Analysis................................................................................................... 5
3.6.1. Coverage.................................................................................................... 5
3.6.2. Wastage..................................................................................................... 6
4. Discussion.............................................................................................................. 7
5. Recommendations.................................................................................................. 8
6. Conclusion and Lesson Learnt................................................................................ 9
6.1. Conclusion........................................................................................................ 9
6.2. Lesson Learnt................................................................................................... 9
7. References............................................................................................................ 10
Appendix.................................................................................................................. 11
Appendix 1: Data of BCG Vaccination status.........................................................11

List of Tables
Table 1 Ilaka wise BCG coverage of Nuwakot district..............................................................................11
Table 2 Health Facility wise BCG coverage of Nuwakot District, 2070/71...............................................11

List of Figures
Figure 1. BCG coverage at different levels..................................................................................................5
Figure 2. BCG coverage at Ilaka levels.......................................................................................................5
Figure 3. BCG Wastage at different levels...................................................................................................6

1. Introduction
1.1.Background of study
Tuberculosis (TB) continues to be a major public health problem around the world 1.One third of
the global population is estimated to be infected with TB bacillus. 9 million people fell ill with
TB in 2013, including 1.1 million cases among people living with HIV. In 2013, 1.5 million
people died from TB, including 360,000 among people who were HIV-positive. 510.000 women
died from TB in 2013, including 180,000 among women who were HIV-positive 2.Tuberculosis is
one of the most prevalent infectious disease and significant public health problem in Nepal and
continues to pose serious threat to the health of the population and development of the country.
Currently nearly 80,000 people have tuberculosis in Nepal, with more than 40,000 new cases
arising every year3.
Different measures are available for TB control. Curative interventions include the early
detection of the disease by purified protein derivative (PPD) skin test, followed by isoniazid
preventive therapy for positive cases or chemotherapy treatment. For preventive interventions,
the only available and licensed vaccine thus far is BCG, which is routinely administered to
infants and young children. More than 4 billion people have been vaccinated with BCG, since its
first use in 1921. For high-incidence, developing countries, the BCG vaccine was included in the
Expanded Program on Immunization as of 1974 4. In Nepal, EPI was introduced in the fiscal year
1978/79.
The mechanism of protection from BCG vaccination involves a reduction of the haematogenous
spread of bacilli from the site of primary infection. It protects against the acute manifestations of
the disease, and reduces the lifelong risk of endogenous reactivation and dissemination
associated with foci acquired from prior infection1.
1.2. Objective of study
1. To analyze BCG vaccine coverage wastage of Nuwakot district for last
three years.
2. To know the National plans, policies and strategies on BCG vaccination
3. To compare the findings with the national average

2. Methodology
2.1.Methodology
For in-depth study, topic was selected by the group and was allocated individually according to
the interest of the students. These topics were further reviewed by the faculties. Data on BCG
vaccination was obtained from the HMIS section of Nuwakot DHO for the study purpose. Data
was analyzed using Microsoft excel. Qualitative information was obtained through key informant
interviews with staffs of district health office.
2.2. Limitations
1. This study might not reflect the true vaccination coverage of the district as secondary data
from HMIS has been used and the children vaccinated outside the district are not
included in the data.
2. I could not talk to the village health system In-charges, so a lot of reasons for the low
coverage and high drop-out could not be identified.

3. Findings
3.1. National Policy
The National Immunization Program (NIP) is a high priority program of Government of Nepal.
The comprehensive multi-year plan (cMYP 2011- 2016) is the guiding document for national
immunization program. The cMYP aims to achieve the immunization related goals expressed by
the Government of Nepal in various policy documents, the Millennium Development Goals
(MDGs), Global Immunization Vision and Strategy (GIVS) and World health assembly (WHAs)
resolutions5.All immunization costs are included in the national work plan and budget. All
routine vaccines are procured using Government funds5.
3.2. Goal
The goal of National Immunization Program is to reduce child morbidity, mortality and disability
associated with vaccine preventable diseases5.
3.3. Objectives
The objectives of the National Immunization Program as per cMYP: 2011/122015/16 is as
follows5

Achieve and maintain at least 90% vaccination coverage for all antigens at national and

district level by 2016

Ensure access to vaccines of assured quality and with appropriate waste management
Achieve and maintain polio free status
Maintain maternal and neonatal tetanus elimination status
Achieve measles elimination status by 2016
Accelerate control of vaccinepreventable diseases through introduction of new and

underused vaccines
Strengthen and expand VPD surveillance
Continue to expand immunization beyond infancy

3.4. Strategies
The strategies of the National Immunization Program as per cMYP: 2011/122015/16 is as
follows5

Increase access and utilization to vaccination by implementing RED strategies in every

district
Enhance human resources capacity for immunization management
Strengthen immunization monitoring system at all levels
Strengthen communication, social mobilization, and advocacy activities
Strengthen immunization services in the municipalities
Strengthen the vaccine management system at all levels
Expand VPD surveillance to include vaccine preventable diseases of public health

concern.
Strengthen and expand laboratory support for surveillance.

3.5. Activities
Following activities are being conducted at the Nuwakot district to achieve national target of
BCG coverage6

With exception of Dashain and Tihar Immunization clinics are running regularly even on

public holidays.
Conduction of awareness programs.
Establishment of Cold-chain sub center.
Regular supervision of Immunization clinics and timely feedback
Timely supply of vaccine
Review of immunization status at VDC, Ilaka and District levels.

3.6. Data Analysis

3.6.1. Coverage
BCG coverage has increased from past year but still below national and regional coverage.

Three years BCG Coverage Comparision

120
100
80

87

97 91 92

96 90 93

CDR

Nepal

2067
2068
2069

70 67

60
40
20
0

Nuwakot

Figure 1. BCG coverage at different levels

Ilaka wise BCG coverage analysis showed that the BCG coverage is highest in Rautbesi HP and
lowest in Nuwakot HP.

Ilaka wise BCG Coverage 2070/71

120
100
80
60
40
20
0

89

86
66

106
77

86

73

82

103
65

85

75
48

64
Coverage

Figure 2. BCG coverage at Ilaka levels

6

Health facility wise analysis of data showed that Barsunchet SHP has highest BCG coverage
(288.89%) and Nuwakot HP has lowest coverage (5.45%). 21 health facilities has BCG coverage
above 90% in fiscal year 2071/70. (See Appendix 1).
3.6.2. Wastage
BCG vaccine wastage is higher than national target in both national and district level.

Vaccine Wastage by Region

100
90
80

88

88
79

88
80

79

70

Nuwakot

60

Nepal

50
40
30
20
10
0

2067

2068

2069

Figure 3. BCG Wastage at different levels

Ilaka wise analysis showed that the wastage is least in Rautbesi HP (87.59%) and highest in
Sallemaidan HP (93.90%) in the fiscal year 2070/71.

4. Discussion
Nepal has already achieved 98.9% coverage of BCG vaccine5 but despite the rising trend of the
vaccine coverage in past three years Nuwakot has not yet achieved the national target of >90%
BCG vaccine coverage. According to the EPI supervisor 22 posts of vaccinators are vacant but
no initiative has been taken at the district level to fulfill the sanctioned posts of vaccinators. The
target is set at the national level but the local factors like migration also affects the target.
Inappropriate target might be another reason for the lower coverage of BCG vaccine. Nuwakot is
connected to Kathmandu and a lot of people visit hospitals in Kathmandu for delivery that might
also show lower coverage of BCG vaccine at Nuwakot as HMIS data only gives the information
about the services provided by the health facility. During our previous posting we have also seen
the health facility staffs reporting wrong data which might be another reason for lower coverage
of the vaccine.
The vaccine wastage rate is high in both national level and at Nuwakot. No effective measures
have been taken at both national and district level to decrease vaccine wastage rate. A vial of
BCG contains 20 doses and once opened all doses should be given within 6 hours. Since, only
one to two children are immunized at one immunization clinic the wastage of BCG and Measles
is high. Lack of proper mechanism to return the vaccines to the cold chain centers or to store
them at the immunization clinics also increases the rate of vaccine wastage. High vaccine
wastage and inability to take any effective measures shows the failure of management.

5. Recommendations
The quality of the HMIS data should be improved by strengthening the supervision at all level,
periodic review of reported data and increasing the supervisory visit to the health facilities where
under and over reporting has been a problem. The vacant posts of vaccinators should be fulfilled.
Alternatively, local resources can be mobilized and vaccinators appointed from the VDC.
Available health staffs should be used in the immunization clinics. Target should be set at the
local level.
If possible cold chain sub centers should be established at all health facilities so that unopened
vials can be used in next sessions. Government should try to provide vaccines in smaller vials.
Any change in vaccine vial size, or formulation should be complimented with revised microplans and training of frontline workers. Wastage of vaccine at the supply chain is not being
analyzed. Analysis of the vaccine wastage at the supply chain should be carried out. Maximum
vaccine wastage occurs at the outreach session sites, optimization of outreach session
(Weekly/Monthly/Quarterly based on injection load) will greatly influence overall vaccine
wastage7.

6. Conclusion and Lesson Learnt

6.1. Conclusion
The coverage of BCG vaccine is low at the district level than that of national level. Vaccine
wastage is high in both national and district level. The problems with reporting, inadequate
supervision and feedback and inadequate manpower are the major reasons for low coverage and
higher wastage of the vaccine. Despite its extensive use, the BCG vaccine lacks the ability to
fully control the TB-endemic and -pandemic situations 4. At the current level of efficacy, the
MVA85A vaccine is neither effective nor cost-effective and, therefore, not a good use of limited
resources8. And with such a high wastage rate, the cost effectiveness of BCG vaccine in the
context of Nepal needs to be further analyzed through appropriate studies. Proper and timely
assessment of vaccine wastage and timely implementation of plans to reduce vaccine wastage is
necessary at the national level.
6.2. Lesson Learnt
District health system is responsible for immediate control, monitoring, supervision and
feedback of the peripheral level health centers. Timely and proper supervision and feedback can
play vital role to improve the overall health system. In the absence of adequate manpower, the
supply of adequate logistic does not ensure the quality of service. Inadequate manpower
increases the wastage and adds economic burden to the health system. So there should be balance
in manpower and supply of logistics to provide quality health services.

10

7. References
1. Aebelaez MP, Nelson KE, Munoz A. BCG vaccine effectiveness in preventing
tuberculosis and its interaction with human immunodeficiency virus infection, Int. J.
Epidemiol[Internet]. 2000 [cited 2014 Nov 10]; 29 (6): 1085-109. Available from:
http://ije.oxfordjournals.org/content/29/6/1085.full.pdf+html
2. Tuberculosis (TB) [Internet] 2014 [cited 2014 Nov

10].

Available

from:

http://www.who.int/gho/tb/en
3. Government of Nepal, Ministry of Health and Population, Department of Health
Services, National Tuberculosis Center. National Tuberculosis Program, General Manual.
Bhaktapur: National Tuberculosis Center; 2012.p.9
4. Tu HT, Vu HD, Rozenbaum MH, Woerdenbag HJ, Postma MJ, A Review of the
Literature on the Economics of Vaccination Against TB, Expert Rev Vaccines
[Internet].. 2012

[cited

2014

Nov

10];

11(3):303-317.

Available

from:

http://www.medscape.com/viewarticle/760578
5. Government of Nepal, Ministry of Health and Population. Department of Health and
Services. Annual Report 2012/2013. Kathmandu: Ministry of Health; 2014.p. 24-35
6. Nuwakot District Health Office. District Health Profile 2012/2013. Nuwakot, Nepal;
2071. p.12-15
7. Unicef, National rural health mission. Vaccine wastage assessment. India; 2010. p.41
8. Channing L, Sinanovic. Modelling the cost-effectiveness of a new infant vaccine to
prevent tuberculosis disease in children in South Africa. Cost Effectiveness and Resource
Allocation

[Internet].

2014

[cited

2014

Nov

http://www.resource-allocation.com/content/12/1/20

11

10],

12:20.

Available

from:

Appendix

Appendix 1: Data of BCG Vaccination status

Table 1Ilaka wise BCG coverage of Nuwakot distric

Ilaka

Deurali PHC
Kakani PHC
Kharanitar

(Year 68/69)
71.2
51.19
80.85

(Year 69/70)
74
63.58
100.17

(Year 70/71)
85.84
66.29
88.95

PHC
Bhadratar HP
Chaturale HP
Kaule HP
KhadagBhanjy

47.60
81.73
56.46
70.23

56.25
96.99
66.9
78.31

77.33
85.91
73.26
82.4

ang HP
Rautbesi HP
Samari HP
Samundratar

96.10
46.06
62.46

125
52.01
88.66

106.05
65.13
75.42

HP
Shikharbesi HP
Nuwakot HP
Sallemaidan

100.62
49.79
49.88

132.03
54.94
59.57

102.67
47.95
63.7

87.34

84.97

HP
District Total

Total

Coverage %

66.61

Total

Coverage %

Total

Table 2 Health Facility wise BCG coverage of Nuwakot District, 2070/71

Health Facility
Barsunchet SHP
Samundratar HP
Urleni HP
Kharanitar PHC

% Coverage
288.89
134.09
125.56
119.44
12

Coverage

Beteni SHP
Sunkhani SHP
Kabilas HP
Rautbesi HP
Shikharbesi HP
Ghyangphedi HP
Taruka HP
Gaunkharka SHP
Lachyang HP
Chaturale HP
Bageswori SHP
Ratmate SHP
Dangsing SHP
KholegaunKhanigaun

113.13
111.54
105.81
105.19
103.80
101.41
99.12
97.22
96.08
95.71
95.41
95.24
94.74
93.16

SHP
Ganeshthan SHP
Gorsyang HP
Sallemaidan HP
Kintang SHP
Chaughada SHP
Bhalche SHP
Panchkanya SHP
Samundradevi SHP
Thansing SHP
Gerkhu SHP
Kumari HP
Charghare SHP
Deurali PHC
KhadagBhanjyang HP
Kaule HP
Suryamati SHP
Kalikahalde HP
Talakhu SHP
Balkumari SHP
Belkot HP
Bungtang SHP
Mahakali HP
Tupche SHP
Salme SHP
Okharpauwa SHP
Ralukadevi SHP
Bhadratar HP

92.68
91.89
90.57
88.37
88.33
88.31
87.93
87.50
86.15
86.13
84.18
83.05
82.28
80.74
80.00
77.22
77.22
76.19
74.55
72.35
71.11
66.67
66.07
66.00
64.44
64.29
62.32
13

Sundaradevi SHP
Kakani PHC
Fikuri HP
Thaprek SHP
Jiling SHP
Narjamandap SHP
Madanpur SHP
Kalyanpur SHP
ThapDuipipal SHP
Samari HP
Chauthe SHP
Budhasing HP
Manakamana SHP
Chhap SHP
ThapSamari SHP
Thanapati SHP
Duipipal HP
ThapBudhasing SHP
Sikre SHP
Sisdol HP
Nuwakot HP

59.26
58.02
57.14
56.32
56.12
54.24
52.04
46.72
46.59
46.55
44.87
44.44
43.06
39.13
37.93
35.00
34.09
33.33
24.24
8.89
5.45

14