Introduction: Delivering effective and safe vaccines through an efficient delivery system is one of the most cost effective

public health interventions. Immunization

programmes aim to reduce mortality and morbidity due to vaccine preventable diseases (VPDs),thus contributing to saving millions of deaths a year . Following successful global eradication of smallpox in 1975 through the

effective vaccination

programmes and strengthened surveillance, the Expanded Programme on Immunization (EPI) was launched in India in 1978 to control other VPDs. Initially, six and

diseases were selected: diphtheria, pertussis, tetanus, poliomyelitis, typhoid childhood tuberculosis. The aim was to cover 80% the programme was universalized and renamed

of all infants. Subsequently, as Universal Immunization

Programme (UIP) in 1985. Measles vaccine was included in the programme and typhoid vaccine was discontinued. UIP also requires a reliable cold chain system for storing and transporting of all required vaccines, and attaining self-sufficiency in the production vaccines(1). Children age one to five at the time of the survey were

classified into three categories: not immunized, partially immunized and fully immunized. Fully immunization children were those children who had received one dose of BGG,three doses each of DPT and OPV one dose of measles vaccine (2). Immunization can significantly contribute to achieve the United Nation Millennium Development Goal-4(MDG-4)which aim to reduce under five mortality by two thirds by 2015.Vaccine preventable diseases are responsible for about 8.8 million deaths annually among children under five years of age. Multi Year Strategic Plan (2005-2010)suggested priority actions in the following areas ensuring regularity of sessions, safe injection, improved cold chain and vaccine logistics management and social mobilization(3).How ever ,in cognizance of this, initiatives had been outlined in Tenth Plan of Government of India.Health together with Immunization ,occupy one of the most important places as one of three core sectors of child development. The Immunization Strengthening project of MOHFW,Indisa is a step in that direction followed by nutrition ,and supply of safe drinking water. The Approach Paper to the Tenth Plan clearly emphasis on bring down the IMRfrom 70 to 28 by 2012.The Tenth Plan has laid down steps to improve the coverage levels through the Universal Immunization Programme ,which is implemented as part of RCH Programme(4). However national socio-demographic goals in National Population Policy 2000 set a target of achieving universal immunization of
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children by 2010 . In spite of Immunization Programme operating in India since 1978, approximately10 million infants and children remains unimmunized. Number is higher than any other country in the world Only 44% of infants receive full vaccination (all doses up to age of one year) and 5% of infants dont receive any vaccine in India(5).The present study I would like to find the factors facilitating and inhibiting the immunization services in District of Haryana.

Review of Literature Immunization describes the whole process of delivery of a vaccine and the immunity it generates in an individual and population. A vaccine is a special form of a disease-causing agent (e.g., virus or bacteria) that has been developed to protect against that disease. Edward Jenner demonstrated the value of immunization against smallpox in 1792. Nearly 200 years later, in 1977, smallpox was eradicated from the world through the widespread and targeted use of the vaccine. In 1974, based on the emerging success of smallpox, the World Health Organization (WHO) established the Expanded Programme on Immunization (EPI). Through the 1980s, UNICEF worked with WHO to achieve Universal Childhood Immunization of the six EPI vaccines (BCG, OPV, diphtheria, tetanus, pertussis, and measles). As a result a record 106 million children were vaccinated in 2008 and global immunization rates are at their highest level ever (82% in 2008). Coverage has been improving since the formation of the GAVI Alliance in 2000. Nearly 23.5 million children are still not fully immunized every year(6). The Expanded Programme on Immunization remains committed to its goal of universal access to all relevant vaccines for all at risk. The programme aims to expand the targeted groups to include older

children, adolescents and adults and work in synergy with other public health programmes populations, in order to the control disease and achieve better health is a for all

particularly

underserved populations. Immunization

proven

tool for controlling and even eradicating infectious diseases. An campaign

immunization

carried out by the World Health Organization (WHO) from 1967 to in the eradication of smallpox. When the programme began, the

1977 resulted

disease still threatened 60% of the world's population and killed every fourth victim. Eradication of poliomyelitis is now within reach. Since the launch by WHO and its partners of the Global Polio Eradication Initiative in 1988,

infections have fallen by 99%, and some five million people have escaped. In DLHS-3 immunization course of children aged 12-23 months has been recorded either from vaccination card or by questioning the mothers in case the card was not available. The vaccination data from children aged 12-23 months who received specific vaccine, 38.8 percent was recorded from the vaccination card in Haryana. More than half (59.6 percent) of
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children aged 12-23 months received full immunization comprising BCG, three doses of DPT,three doses of Polio (excluding Polio 0) and measles. Only 1.9 percent of children have not received any vaccine Full immunization coverage would have been well above 80 percent, if immunization againstDPT did not drop down to 15.6 percent point for first (84.6 percent) to third (69 percent) dose and had vaccination against polio not dropped 29.2 percent point for first (97 percent) to third(67.8 percent) dose. The coverage of measles vaccine (69 percent) also (17.5 percent point)lower than the coverage of BCG vaccine (86.5 percent). The key to improvement in full immunization coverage is to monitor drop out at all stages of vaccination before completion of full course of immunization. Higher coverage of full vaccination is observed with boys (62.5 percent), the urban residents (70.9 percent), births of first order (68.5 percent) and children born to women educated up to 10 or more years (81.4 percent), children belong to women from other caste groups (69.5 percent) and children from households in the highest wealth quintile(74.4 percent) and it was lower for the girl children (56 percent), children have rural residence(55.9 percent), births of order four and above (31.7 percent), child On an average, 14%4 of infants in each state who come into contact with immunization services to receive their BCG do not receive their measles vaccine. This is as high as 37% in Andhra Pradesh and35% in West Bengal. Nationally, almost 6.55 million infants drop out betweenBCG and measles annually. Of these, 57% are in five states: Andhra Pradesh,Bihar, Rajasthan, Uttar Pradesh and West Bengal. Children of non-literate mother(34.9 percent), children whose mothers belong to scheduled tribe (43.8 percent) and children belong to households in lowest wealth quintile (28.5 percent). District-wise variation in coverage of full Immunization is depicted(7). Rapid household surveys performed in 260 districts in 1998/9 and again in 2002/3 showed that full immunization rates have decreased in 1761 (76%) of the districts(8). Infant Mortality Drops, but Full Immunization Coverage

ShowsLittleProgress Infant mortality continues to decline, dropping from 68 to 57 per thousand births. There were particularly notable drops in the infant mortality rate in Bihar, Goa, Haryana, Jammu and Kashmir, Meghalaya, Orissa, Punjab, Rajasthan, Tamil Nadu, and Uttar Pradesh. The situation regarding child immunization rates, however, is not as clear cut. By the time they are one year old, children are supposed to receive a BCG vaccination against tuberculosis, a measles vaccination, and three doses each of polio and DPT vaccine. Overall, there was only a small improvement in full vaccination coverage, with 44% of children ages 12-23 months receiving all recommended vaccinations, up from 42% seven years earlier. Substantial improvements in coverage have been made in all vaccinations
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except DPT, which did not change at all between NFHS 2 and NFHS-3. Gains are particularly evident for polio immunization coverage, but nearly one-quarter of children age 12-23 months have still not received the recommended number of polio doses(9). The coverage rates show a geographical trend; generally, the northern States perform poorer than the southern States. Even within better-performing States there are significant pockets of poorly performing districts or urban settings. Over time, the RCHRapid Household Surveys performed in 199899 and again in 200203 show a worrying decrease in the percentage of districts achieving >80% DTP3 coverage. In200102,17.9 million infants were not immunized in India. Of these infants, 40% live either in Uttar Pradeshor Bihar. Stagnating routine immunization rates, high drop-out rates and a declining trend in some of the districts in key States (UP, Bihar, Rajasthan, Jharkhand,West Bengal, AP and Assam) are issues of major concern. There are considerable geographical and social inequities(10).

General Objective To study the implementation status of Immunization services for children (aged 12-23 months) in District of Haryana. Specific Objective:

1. To find out the availability and functionality of the infrastructure available for immunization services in district of Haryana. 2. To assess the utilization of services as per provider perspective. 3. To identify the issues related to immunization services provision and utilization amongst mothers with children (aged 12-23 months). 4. To suggest interventions (if any) based on identified gaps.

Materials and Methods: Study Type-Descriptive/Observational Study Area- Selected Districts of Haryana Study PopulationIt will comprise of Sampling Design Two Districts shall be Chosen based on Immunization coverage and trained personnel. District with >60% coverage >> Two PHC >> one Sub Centre from each PHC >> 100 children per Sub Centre. District with <60% coverage >> Two PHC >> one Sub Centre from each PHC >> 100 children per Sub Centre. Sample size
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State Immunization Officer Civil Surgeon District Immunization Officer Trainers for Immunization at District/Block Medical Officers of PHCs ANM in PHCs LHVs in PHCs ASHA and AWW in PHCs Mothers with (12-23months) children

State Immunization Officer Civil Surgeon District Immunization Officer Trainers for Immunization at District/Block Medical Officers I/C of four PHC ANM in 4 PHC All LHVs in four PHC ASHA and AWW (each PHC 10) Mothers with (12-23months) 100/subcenter The total sample size would be in the district as below: S.N Category 1 2 3 State Immunization Officer Civil Surgeon District Officer 4 Medical Officers PHCs 5 Trainers for Immunization four at District Block 6 All PHCs 7 All the LHVs in four PHCs 8 ASHAs and AWW each 8--12
8

1 2 2 4 4 25

40
400

Number one two

Total number one two two

Immunization two

of four four

four

four

the ANMs in four Approx:25

four FGDs

PHC 9 Mothers with 1223 100 centre per Sub 400 children

months child

Data collection Techniques and Tools: Techniques of interview, observation, desk review of records and focus group discussion (with ASHA & AWW) will be used to collect data. The following tools would be developed to meet the objectives of the study. N 1 Objective Tools/Techniques

To assess the performance (level of Interview schedule for the medical officers to knowledge officers and skill) PHCand of medical assess their knowledge and skills . in ANMs

immunization. 2 To note the manpower, equipment, Checklist for records review at PHC and budget and facilities for Immunization subcentre .Study of microplans.

To identify other performance issues related provision to immunization service

Interview schedule for State Immunization Officer ,Civil surgeon and DIO Checklist for Focus Group Discussion of ASHAs to know about the issues related to drop out etc.

Observation checklist for a vaccination session and microplan implementation

To identify the issues related to Interview schedule and record review. immunization services provision and utilization amongst mothers with

children (aged 12-23 months).

Data Analysis-Appropriate statistical tool will be applied to analyze the data generated from the study.

References: 1. Core Programme Cluster Family and Community Health Routine Immunization (internet) {last visited on 10/10/11Avialable from http://whoindia.org/en/Section6/Section284/Section286 506.htm 2.Gaudin S,Yazbeck.SAbdo Immunization in India1993-1999:Wealth,Gender,and Regional inequalities revisited . Journal Social Science and Medicine62(2006)694-706.last visited on3/9/11. 3.Routine Immunization :opportunities ,challenges.Dasgupta S.Indian Journal of Public Health,Volume 54,Issue1, January-March2010 4. Government of India,2002:Tenth Five year plan document, Women and children section : Health and Immunization.Tenth Five year Plan,MOH&FW:2002-2007. 5. Patel T, Raval D, Pandit N . Process evaluation of routine immunization in rural areas of Anand District of Gujarat e a l t h l i n e ISSN 2229-337X Volume 2 Issue 1 January-

June 2011. 6.Immunization Introduction (internet){last visited on 7/10/11}Available fromhttp://www.unicef.org/immunization/ 7. International Institute for Population Sciences(IIPS),2010.District level Household and Facility Survey(DLHS-3),2007-2008:india.Haryana:Mumbai:IIPS 8. WHO Strategic plan for Strengthening Routine Immunization in India April2004-March 2007{last visited on 8/10/11} Available fromhttp://203.90.70.117/PDSDOCS/B0009.pdf 9.Report of Data base that strengthen Indias dermographic and health policies and programmes. Summary of key Findings \india Fact Sheet.NFHS-3,2005-2006 {last visited on 1/10/11}Available from http:// www.nfhsindia.org/summary.html 10.Report Of Multi Year Strategic Plan 20052010Universal Immunization Programme (Internet) {Last Visited On
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9/10/11)

Available

From

http://whoindia.org/Linkfiles/Routine_Immunization_MYP_PDF_%28o5_July_05%29__Fin al.pdf

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