POLIO ERADICATION STRATEGIES

ROUTINE IMMUNIZATION
NIDs (PPIs)
Acute Flaccid Paralysis (AFP) SURVEILLANCE
MOPPING-UP

What is AFP surveillance?
•Detect any case of AFP <>

Standard Case Definition Acute Flaccid Paralysis
Any patient under 15 years of age with acute, flaccid paralysis; or any person in whom a clinician suspects polio.
Onset of paralysis during last six months to be included as a case of AFP.
Plan for covering special population
•Same populations are often missed by the routine as well as SIAs
–Religious minority groups
–Multi-storied building (flats)
– Fishermen colonies
–Pavement dwellers
–Slum dwellers
–People with working hours that do not coincide with team visits
–People living in peri-urban areas
•Identify all such populations and ensure they are included in micro plans for coverage during each round.
Migrant Population

•Construction sites

»Factories
»IT Parks
»Railway gauge conversion
»Road construction
»Bridge construction
»Housing
•Brick kiln, quarry, etc
•Nomads – Narikuravas,

Migratory populations - Actions

•Identification of clusters with migratory populations from Bihar/ UP
•Mapping such areas
•Focus during PPI campaigns
•Plan for special polio campaign during March, 2008
•Plan for routine immunization.

Measles
• Highly infectious

• Transmitted through respiratory droplets or airborne

• Fever, rash, cough, conjunctivitis and coryza

• CFR 0.1% - 10%

• Vitamin A deficiency increases mortality

Clinical features
• Incubation period from exposure to onset of fever is usually 10 days.
• Initial symptoms and signs are high fever, runny nose, coryza, cough, red eyes and Koplik spots (small white spots on the buccal mucosa).
• Characteristic erythematous (red) maculopapular (blotchy) rash appears on the 3rd to 7th day, starting behind the ears and on the hairline and then spreading to the rest of the body.

Case Definition of Suspected Measles
Any person in whom clinician suspects measles infection during last one month(OR)
Any person with fever and rash and cough, coryza (running nose) or conjunctivitis (red eyes) during last one month.

For epidemiological investigation, clinical measles would be a case within last 3 months

Measles death definition
“A death which occurs within one month [30 days] of onset of measles”
– The Global Epidemiology of Infectious Diseases, WHO-2004

Objectives of Measles Surveillance
• Detect and investigate suspected measles outbreaks
• Improve case management of measles cases
• Identify high-risk populations/areas for measles
• Strengthening measles immunization coverage in these areas
• Monitor progress in reduction in measles mortality and morbidity

Operational criteria for conducting extensive outbreak investigation
• > 5 suspect cases of measles in a block in a week(OR)

• > 1 death due to measles in a block in a week(OR)

• > 5 suspect cases in an area bordering several blocks


• Outbreak Flag:
– 5 or more suspected measles cases are reported from one block or contiguous blocks in a week, OR
– 1 or more suspected measles deaths are reported from one block in a week
• Collate information at District level from
– weekly reports,
– AFP Informer network
– Other sources like IDSP/ICMR Measles network etc.

Sample Collection and Transport Kit
• 5ml syringe and needle or Vacutainer tube with 22 gauge needle and adapter
• 5ml externally threaded screw cap vials
• Tourniquet, sterile swabs & band aid
• Gloves
• Uricol disposable bottles
• Specimen labels
• Zip lock plastic bags
• Autoclavable disposal bags
• Cold box with ice packs
• Measles lab request form

Blood sample collection
• Apply tourniquet 2 - 3’’ above elbow, swab the cubital fossa.
• Draw 3-5 ml of blood by venipuncture using syringe
• Discard Needle into disposable bags / needle destroyer. Be careful of needle stick injury
• Push the blood gently into sterile labeled tube. (do not push blood through the needle). Discard the barrel of syringe into auto clavable disposal bags
• Leave the tube at RT for 30mins for clot formation.
• Clotted Blood can be stored at 4-8deg C for up to 24 hours. Do not freeze whole blood
• Fill up lab request: Three dates are important: Dates of last measles vaccination, of rash onset, & collection of sample

Factors responsible for increased rate/severity of complications & deaths in measles
• Young age
• Malnutrition
• Vitamin A deficiency
• Overcrowding
• Immune deficiency (~HIV)

MEASLES REPORTING
• Gross under reporting
v Perception of disease
v Workers perception vs. immunization
v Outbreak response immunization

REPORTING GUIDELINES
Ø All Block PHC will be a reporting unit

Ø All the additional PHCs will send weekly report to the Block PHC every Monday (Form VPD-H002) (2 copies)
Ø All the Block PHCs will send consolidated weekly report VPD-H002 (2 copies) based on additional PHC reports including block PHC area to DDHS office by Tuesday noon
Ø Weekly Hospital report VPD-H002

Global Strategy for sustainable measles mortality reduction
Strong routine immunization of > 90%
Reaching Every District strategy.

2. Provide second opportunity for measles immunization
• One time only “catch-up” campaign (< 15)
• “Follow-up” campaigns every 3-4 years (< 5)
• Integration of campaigns with other priority health interventions
(Vit A, polio, TT, bed nets)
3. Surveillance

4. Improved case management Vitamin A - antibiotics

Cold Chain Maintanance

Cold chain and vaccine logistics
DEFINITION
Cold Chain is a system of transporting vaccine at recommended temperature from
the point of manufacturing to the point of use

ESSENTIALS OF COLD CHAIN
• Equipment
• Power
• Maintenance of Equipment
• Monitoring
EQUIPMENT - ELECTRICAL
• Walk-in-Freezer ( WIF ):. Stores bulk quantity of OPV/Measles & freezes Ice Packs at -20°C.
• Walk-in-Cooler ( WIC ): storage of bulk vaccine at State & Regional stores. Storage Temp. is + 2°C to + 8°C
• Deep Freezers ( DF )
• Ice Lined Refrigerators ( ILR )
In general,
• All Vaccines tend to lose potency on exposure to heat above +80 C
• Some Vaccines lose potency when exposed to freezing temperatures
• The damage is irreversible

Vaccines vulnerable to heat
BCG
OPV
Measles
HepB
DPT
DT
TT
Vaccines vulnerable to Freezing
Hep- B
DPT
DT
TT
Ice cream principle
Colder the better does not hold good for all vaccines
Ice lined refrigerators (ILRs)
• Capacity: 300 & 140 ltrs
• Ideal Temperature: +2°C to 8°C
• Vaccine Storage capacity:
– 300 ltrs stores 60000 doses of mixed antigen
– 140 ltrs stores 25000 doses of mixed antigen
• Safe Storage: Always in the basket section
Deep freezers (DF)
• Capacity: 300 & 140 ltrs
• Ideal Temperature: -18°C to -20°C
• Ice Pack Freezing Capacity:
300 ltrs freezes 40 packs every 24 hours.
140 ltrs freezes 25 packs every 24 hours.

Equipment – non electrical
• Cold Boxes: Placed at State/Region/ DHQ/PHC
• Vaccine Carrier: Placed at DHQ/PHC & sub centres.
• Ice Packs: Placed at State WIF /DHQ/PHC & sub centres.

Cold Boxes
• Type: Insulated boxes of 20 ltrs & 5 ltr capacity

• Usage: Stores & Transports vaccine. Also stores frozen Ice Packs

• Vaccine Layout: Direct contact of frozen Ice packs spoil the vaccine. Give carton spacers/surround vaccine by OPV vials.

• Label Protection: Place vaccine in cartons or polythene bags.

Vaccine Carrier
• Type: Insulated boxes used for carrying small quantities of vaccine.
• Capacity: 16-20 vials
• Ice packs: A maximum of 4 frozen packs
• Vaccine Layout: Keep vaccine clear off direct touch with the Ice Packs

Ice Packs
Water Fill: Do not fill 100%. Leave 10mm room for expansion as water freezes. Condition before use. Do fill the Ice packs up to the marked line.
• Usage: Lowers Temp range for safe vaccine storage. Placed in side lining of ILR to improve & maintain holdover time during electrical failure.
• Best Frozen: In WIF, DF & Ice factories.
Supplies
• Base supplies as per demand & utilization.
• Supply to Districts/PHC after assessing monthly usage & balance stock in hand.
• Districts need to maintain some buffer stock for any unforeseen demand.
• Transport the vaccine in strict cold chain.
• Rotate stocks – “vaccine in first out first”
• Check early expiry date vials & use first.

Vaccine Distribution
• Follow first-in-first - out rule (FIFO)
• Also: first to expire - first out. (FEFO)
• Vaccines are not stored at the sub-centre level and must be supplied on the day of use
• Note manufacturer, batch no., VVM status
• Use VVM stage-II vaccine near the cold chain point (do not distribute to remote areas)
Potency
• T series, Hep B and Hib and diluents should never be frozen.
• BCG, OPV & Measles (light) are sensitive to heat & lose potency fast.
• Potency lost due to heat exposure does not change the appearance of the vaccine.
• VVM is an effective tool in monitoring OPV (and measles) potency.
• Damage to vaccine cannot be reversed by re-freezing.
• Discard frozen vaccine.

Conditioning
• On the session day, take the frozen ice-packs you need from the freezer and place on a table
• Allow ice-packs to sweat at room temperature for some time
• Shake the ice pack to listen to melted for water.

Shake test
• Hold the Control and the Test sample together in hand and vigorously shake the samples
• Place both vials to rest on a flat surface, side-by-side observe them for 30 minutes.
• Compare for rate of sedimentation

Ensure Protection - Protocol
•Searching for undernourished, underweight children among poorer socio economic groups and families.
•Monitoring their growth.
•Underweight, undernourished children to receive measles vaccine at 6-8 months.
•Provide another dose after completion of 9 months of age.
•Asses nutritional status of children infected with Measles.
•Counsel the parents about nutritional inputs, Measles complications, growth monitoring and growth faltering.
•Take follow up visits and ensure protection and proper growth of these children.
Average Height and Weight at different Ages (ICMR (Boys) ).

Biology of under nutrition
•Under nutrition is widely prevalent among socially and economically deprived population groups around the world. Cluster of factors responsible:
-Inadequate income level
-Diets quantitatively and qualitatively deficient
-Poor environment, poor access to safe water
and poor sanitation
-Poor access to health care
-High levels of female illiteracy.

•Nutritional status depends on nutrition's availability at cellular level. Diets providing essential nutrients, Absorptions, utilisation and activity level and environmental factors like infections and stress situations.
•Under 5 constitutes the most sensitive segment of the population from the point of view of nutritional vulnerability.
Growth Retardation
•The minimal role of genetic factor.
•The differences in growth patterns are mostly attributable to differences in their socioeconomic status and not to genetic differences.
•The genetic potential for growth and development is nearly similar among most peoples of the world.
•There is often a linear relationship between the degree of growth retardation and the degree of physical and mental functional impairment.
•In Japan between 1957 and 1977 average mature height increased by 4.3 cm in males and 2.7cm in females. Practically all the height increase was due to increase in leg length, not in sitting height, with the result that within 20 years of economic advancement the entire body proportions of the Japanese had changed.
Child survival
• Regular nutritional assessment of mothers and under 5 is a must on the part of MCH workers.
• If under nourished status of a child is not corrected within 5 years, the child will get stunted.
• It can never be intervened and corrected beyond that age.
• MCH supervisors must become skilled in nutritional assessment and counseling so that they train their workers in the field.
• Child survival will be ensured only when you care to provide all the inputs:
Immunisation
Nutritional inputs
Health care
Female literacy
But where do we stand now?

Strengthening Immunisation (Devices and Desires)

Strengthening Immunisation (Devices and Desires)

Universal Immunisation Programme
•Need for sustaining UIP.
•Require a stronger programme.
•UIP as the most important input for child survival.
•Extensive – 100% fully immunised children
•The above demands fully aware, well informed mothers.
•Commitment on the part of the workers and supervisors.

FACTORS Behind The SUCCESS
• Our Alliance with women nutrition workers
• Energetic, enthusiastic, Free India’s women work force. Workers and supervisors.
• Well designed monitoring and review system.
• Must rededicate ourselves to strengthen the above facets of reality.

STATUS
• Polio free for the past 3 years.
• Indigenous polio transmission free for the past 7 years.
• Neonatal Tetanus Elimination status certification based on:
Ø Immunisation level assessment
Ø District with poor performance identified.
Ø Designed survey
Ø Trained personnel involved.
Ø Certification by WHO

Measles
•Classical childhood communicable disease- High transmission potential.
•Complications – Otitis media, pneumonia,
Diarrhea, post infectious encephalitis, corneal ulceration, ketatitis.
•85% alone among immunised offered protection.
•Undernourished do not develop optimum antibodies and hence may be infected with Measle

Measles and the undernourished
•Measles tends to be very severe in the under nourished child. Complications and mortality chances. Many times more than in well nourished child.
•Measles infection is the single most important factor in faltering in growth of children.
•Undernourished – poor cell – mediated immunity – Measles infection inspite of immunisation – complications of Measles – faltering in growth – cycle.

Medical Audit

1. Medical Audit
   AUDIT
   Official Examination and Verification of Accounts or Dealings
   
   Medical Audit
   Evaluation of Medical Care through retrospective analysis of Medical Records or prospective follow up of patients suffering from a particular disease by treating doctors and his team.
   
   Pre Requisites of Medical Audit
   To be carried out by fair and impartial clinicians who are thoroughly conversant with the current practice of medicine. The impetus must come from the Medical staff themselves, realising the benefits to the patients and themselves. A good system of Medical Record keeping preferably with a trained medical record Librarian. Well defined disease related criteria.
   
   Process of Medical Audit
   Retrospective
   Analysis of the records of the discharged patients
   Finding out the deficiencies, errors, omissions and commissions on these.
   
   Prospective
   To Ensure that the management of individual case on a particular diagnosis conforms to the prescribed standards.
   A group of patients suffering from a disease is followed up by treating doctors and his team.
   Criteria Development
   Step 1.
   Selection of the Diagnosis to be studied by audit or utilisation committee.
   Step 2.
   Develop the criteria
   i) Indicators for admission
   ii) Hospital services recommended for optimal care
   iii) Range of length of stay and indicators for discharge
   iv) Complications as a result of treatment procedures.
   
   Medical Audit of Infant Death
   Line listing of all cases
   Case investigation from against medical advice (AMA) discharge cases should also be investigated.
   u Verbal Autopsy at field level
   u Verbal determination of the non-clinical causes of death.
   u Verbal reporting of background characteristics
   u Medical Audit at institutional Level
   Analyse the information collected
   Find out the Medico Social cause
   Discuss with staff and community members to prevent such deaths in future.

INFANT MORTALITY RATE

Interventions

p Promotion of institutional deliveries
p Establishment of CEmONC centres
p Establishment of BEmONC centres
p Establishment of 24 hours delivery care services
p Adolescent girls anaemia control programme
p Inroduction of emergency newborn care protocols
p Birth companion scheme
Proposed new interventions
p Formation of state task force for IMR reduction
p Infection control protocols
p Quality audit
p Incident reporting
p One delivery one sterile delivery kit policy
p Use of partographs
p Posting of additional nurses for obstetrics and paediatrics departments in Medical colleges
p Still birth audit
p IMNCI training
p Formation of separate nursing cadre for obstetrics and paediatrics
p BEmONC training
p Skilled birth attendant training
p Anaemia control
p Women link volunteers for every village panchayat


Maternal Mortality Ratio

Maternal Mortality Ratio represents the obstetric risk associated with each pregnancy, It is calculated as the number of maternal deaths during a given year per 1000 live births during the same period, though the measure has traditionally been referred to as a ‘rate’ it is actually a ‘ratio’.


Maternal Death
The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental cause.

Maternal Mortality Rate
Maternal Mortality Rate measures both the obstetric risk and the frequency with women are exposed to this risk. It is calculated as the number of maternal deaths in a given period per 1000 women of reproductive age (Usually 15 – 49 years).

Direct Obstetric Deaths
Those resulting from obstetric complications of the pregnant state (Pregnancy, Labour and the puerperium), from interventions, omissions or incorrect treatment or from a chain of events resulting from any of the above.




Indirect Obstetric Deaths
Those resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy.

Life Time Risk of Maternal Death
Life time risk of maternal death in to account both the probability of becoming pregnant and the probability of dying as a result of the pregnancy cumulated across a woman’s reproductive years.

CAUSES OF MMR
p HAEMORRHAGE -38%
p SEPSIS -11%
p ABORTION -8%
p PIH -5%
p OBSTRUCTED LABOUR -5%
p OTHERS -34%
SOURCE-SRS 2003
Effective Interventions to Reduce Maternal Death.
Vision
All women enjoy pregnancy and its outcome with equity, respect, dignity and social justice through better access to quality health services especially during pregnancy, child birth and the post partum.

A. Puerperal Infections

n Delivery by Qualified. (Not less than an ANM/VHN)
n Institutional deliveries.
n Antibiotics for Preterm (before 36 weeks )
n Clean delivery practices
n Rupture of membranes.
n Parenteral antibiotics for sepcis.

n Blood Transfusion & surgical intervention.
n Pregnancy counsellling for recognizing danger signs.
n Family Planning.
EXPECTED REDUCTION IN MMR 11%

B. PIH

p Family Planning
p Early detection and management of cases at HSC/PHC level.
p Antihypertensive drug therapy for mild to moderate.
p Mag sulphate & other anticonvulsants for women with Eclampsia.
p Calcium supplementation during pregnancy for preventing Hypertensive disorders and related problems.
p Pregnancy counselling for recognizing danger signs.
p Blood Transfusion & surgical intervention.
ECXPECTED REDUCTION IN MMR 5%
C. HAEMORRHAGE

p Family Planning.

p Skilled attendant providing active management of III Stage.

p Management of Primary PPH with rectal Mesoprestol.

p Treatment of Primary PPH.

p Blood Transfusion & surgical intervention.

p Promotion of voluntary blood donation.
p EXPECTED REDUCTION IN MMR 32.5%

D. OBSTRUCTED LABOUR
p Family Planning.
p Blood Transfution & surgical intervention.
p Use of Partographs.
EXPECTED REDUCTION IN MMR 5%

E. Complication of abortion

p Family Planning.
p MTP services at PHC level.
p Early registration and pregnancy counselling.
EXPECTED REDUCTION IN MMR 8%





E. Anaemia
p Iron and folate supplementation in pregnancy,
p Treatment for iron deficiency in pregnancy.
p Adolesent Anaemia control.
p Nutrition promotion.
p Blood Transfusion.
p Family Planning.
EXPECTED REDUCTION:20%
G. Others
p Community based MCH services.
p Balanced protein energy supplements in pregnancy.
p Continuity of care given during pregnancy & child birth.
p Pregnancy counselling.

INTERVENTIONS
p Establishment of CEmONC Centres
p 24 hours delivery services with three staff nurses
p Establishment of BEmONC PHCs
p Community Blood Donation camps
p RCH outreach camps
p Birth Companion Scheme
p Operationalising PHC FW operation theatres
p Upgrading of PHCs
p Hiring of Anesthetists and obstetricians

Gestational Diabetes Mellitus

Gestational Diabetes Mellitus
Awareness Creation Screening procedures & Management
(Guidelines)

Aim:
• Gestational Diabetes mellitus – awareness creation
• Screening for glucose intolerance during pregnancy
• Prevention and control in the community

Screening procedure
• Project Co-ordinator/ Project Medical Officers will be in constant touch with the Maternity centres/PHC/HSC

• Medical officers of PHC/Corporation Health Post (FW centres), PHN, MPHW/VHN will identify the pregnant women

• The pregnant women will be asked to come on her convenient day or Ante-natal clinic day on empty stomach (she can take water)

• She will be given 75gm of glucose in 300ml of clean water. She can drink the glucose water in 5 to 10 minutes.

• The blood sample will be taken after 2 hrs.

• For the women who has diabetes before pregnancy, she will be tested for fasting and 2 hrs after food instead of 2 hrs after glucose
The blood test will be done by capillary method by using ‘Accucheck’ glucometer.
The amount of blood required will be less than a drop. Disposable needle will be used for each patient.

Diagnosis
• 2 hr ≥ 140mg%

• If GDM is diagnosed, she will be given meal plan and asked to come after two weeks.
Screening
• To start with all pregnant women will be screened if they are meeting the criteria of 16th,24th and 32nd week of pregnancy.

• If screening is done around 16th week and if the test is negative for GDM, she will be asked to come again around 24th week.

• If the test is negative for GDM at 24th week, it will be repeated around 32nd week.
The blood testing, recording the case sheet and follow up will be done by the medical officer concerned.

• The gestational diabetes woman would be advised regarding the importance of maintaining the blood sugar at normal level.

Follow Up
• The blood glucose of the GDM woman will be monitored periodically once in 15 days / 1 month and advise would be given.
• After delivery, the new born weight and Apgar score will be recorded.

After the delivery-
• Many women may not require any treatment for diabetes as most of them return to normal glucose tolerance. If required they will be advised accordingly.

• Two months after delivery, Women who had GDM will be given 75g of glucose orally and blood tested after 2 hours.
• The same procedure will be repeated after Six months, one year and there after every year.

• In case, she conceives within this period, the same procedure that has been performed in their earlier pregnancy will be followed.

Mobile RCH outreach Programme (Rural Area)

Mobile RCH outreach Programme (Rural Area)

Why ?
• To provide medical out reach services at village level
• Attempting to redefine the AN care
- at least 5 check ups by doctor
- at least three ultrasonogram examinations
- Hb, Blood grouping, Rh typing,
VDRL, urine albumin, sugar examination
-clinical parameters monitored by doctor
- TT immunization
- IFA

Objectives of out reach programme

• To provide MCH coverage by Medical Officer at village level
• To provide medical supervision for immunization at the identified locations
• To enhance the quality of home care of newborns and infants
• To provide the listed services in the camp

Objectives
To plan and implement holistic health care strategy covering the key areas of primary health care components.

Outreach services
• antenatal care
• postnatal care
• newborn screening
• under five care
• RTI / STI management
• adolescent care
• health checkup for ICDS children
• treatment of minor ailments particularly for women and children
• family welfare counseling including NSV
• lab services
• fever surveillance
• TB, leprosy case detection , review , follow up
• copper T insertion , removal and follow up
• IEC activities
• high risk family counselling and surveillance to prevent female infanticide / foeticide
• inspection of village drinking water supply system
• convening of health and nutrition village committee மீட்டிங்
Laboratory Services
• urine albumin
• urine sugar
• sputum for AFB
• PS for MP

Principles for planning
• Listed locations to be covered once in a month cycle
• Fixed programme policy to be followed
Example: First Monday fore noon
First Monday after noon
• Listed locations should not be more than 35 per block
• Areas around the Government Hospitals, PHC Headquarters village and immediate surrounding villages need not be provided Mobile services

• On Tuesday afternoon, the Mobile MO and team should attend PHC review meeting in their block on rotation.

• On Wednesdays mobile out reach camp should be conducted in only one village in view of immunization programme
• Total number of camps for the mobile out reach teams per month

Monday camps(2 camps) - 8
Tuesday camps(1 camp) - 4
Wednesday camp(1 camp) - 4
Thursday camp(2 camp) - 8
Friday(2 camp) - 8
Saturday(1 camp) -3

Total -35
• For a particular location beneficiaries can come from all around the location irrespective of the jurisdiction of the HSC or PHC.
• All the concerned field staff from the surrounding areas should participate in the camp

Dedicated Mobile Outreach Team
• Medical Officer
• Staff nurse
• Worker
• Driver
Outreach Support Team
• VHN
• SHN
• HSC health inspector
• PHC health inspector
• Block level staff shall attend in turn in all PHC Areas.
• ICDS staff and other community partners like FHLVs, adolescent girl volunteers should be encouraged to attend the camp

IEC
• Board informing the fixed out reach session day and time should be displayed at the camp site
• Banner to be displayed at the camp site
• Banner to be displayed on the outreach vehicle also
• Fixed outreach plan to be printed and distributed to all elected representatives, SHGs, NGOs, ICDS and other stakeholders.

WHAT IS MONITORING?

WHAT IS MONITORING?

Watching the work or action or performance of an activity for its progress over a period to the expected level Regularly

WHY MONITORING?

To find out any deviation from the strategy or functioning of an activity or performance level of expectation and to take remedial measures for its achivement.

USES OF Monitoring

•Manpower and Material wastage avoided•Bad result at the end avoided•Revised planning done if necessary•Additional inputs planned•Guide the programme officer for correction.

AREAS OF MONITORING

•Supply of forms to B&D Registrars•Receipt of Forms 11,12,13•Receipt of Forms 4 &4A•Receipt of Statistical data in CRS•MCH- AN Regn, Inst.Del., Detection of GDM prevalence, STI/RTI cases,•Immunisation- Supply of Vaccine, logistics, performance, coverage•Vital events- LBs, SBs, ID, MD,Deaths .

WHAT TYPE OF INDICATORS HELP IN MONITORING?

•Input indicators•Performance Indicators

HEALTH POLICY INDICATORS

•High level political commitment to health for all•Allocation of adequate resources for primary health care.•Level of community involvement in attaining health for all.

SOCIAL AND ECONOMIC INDICATORS

•Rate of population increase•Gross national product or Gross domestic products•Income distribution•Work availability•Adult literacy rate•Adequacy of housing expressed as number of persons per room.

INDICATORS OF THE PROVISION OF HEALTH CARE

•Availability•Physical accessibility•Economic and cultural accessibility•Indicators for assessing
quality of care•Indicators of coverage by primary health care-level of health literacy-availability of safe water in the home or within short walking distance-birth attendance by skilled personnel-avilability of essential drugs through out the year.

HEALTH STATUS INDICATORS

•Percentage of newborn infants with birth weight of at least 2500 g.•Percentage of children that have a weight for age that corresponds to a specified norm.•Infant mortality rate, child mortality rate, under-5 year mortality rate.•Life expectancy at a given age.•Maternal mortality rate.•Disease – specific mortality rate.•Disability rate.

INDICATORS FOR MONITORING HEALTH SERVICES

•Indicators of mortalityIndicators of childhood nutrition•Indicators of water and sanitation•Indicators of disability•Indicators of health & nutrition of the female child, pregnant and lactating women.•Indicators of child spacing•Indicators of immunisation Coverage.

THE REPRODUCTIVE HEALTH INDICATORSIndicators

•Total Fertility Rate
•Contraceptive prevalence
•Maternal Mortality Ratio
•Antenatal Care Coverage
•Births attended by skilled health personnel
•Availability of Basic essential Obstetric care
•Perinatal Mortality Rate•Prevalence of Low Birth weight
•Prevalence of positive syphilis serology in pregnant women
•Prevalence of Anaemia in women
•Percentage of Obstetric and Gynaecological admission to owing to abortion.
•Reported prevalence of women with mutilation
•Prevalence of Infertility in women
•Reported incidence of Urethritis in men•Prevalence of HIV infection in pregnant women•Knowledge of HIV related preventive practices.
Total Fertility Rate
•Availability of comprehensive essential Obstetric care ASFR= Births in year to women aged XNo. of women aged X at mid yearAnd TFR= Sum of ASFRs x 5/1000.

Contraceptive prevalence.

Numerator: Number of women of reproductive age at risk of pregnancy who are using (or whose partner is using) a contraceptive method at a given point of time .

Immunization – Mandatory Safety Protocols

Adverse Events Following Immunization (AEFI) lead to Crisis
•It hits unexpectedly
•Events quickly spin out of control
•The outcome seems uncertain
•The whole programme is at risk!
Possible risks in Immunisation

ØToxic shock syndrome
ØAnaphylactic shock
ØAccidental use of another drug
ØInjection abscess
ØTraumatic neuritis
ØLymphadenitis following BCG vaccination
ØCNS complications due to pertussis vaccine
ØDeliberate contamination with criminal intention

REPORTING(To be reported immediately)

•Death / Hospitalization
•Anaphylaxis
•Toxic Shock Syndrome
•AFP
•Encephalopathy
•Sepsis
•Clustering of events
•Persistent screaming

•Hypotonic Hypo responsive episodes
•Injection site abscess
•Severe local reaction
•Seizures
•Brachial neuritis
•Thrombocytopenia
•Lymphadenitis
•Disseminated BCG infection
•Osteitis
Classification
•Vaccine reactions -True
•Program Errors - > 95% and easily Preventable
•Coincidental – Child getting Measles after DPT injection
•Injection reaction- Among older children
•Unknown
Program Errors - >95%
Practice AEFI
Un-sterile injection Abscess
Using reconstituted vaccine beyond 4 hours TSS
Wrong diluent Effect of the diluent
Wrong Medicine Effect of the Medicine
Frozen vaccine Sterile abscess
Do’s during immunisation sessions

ØGive BCG to infants less than 1 yr of age(never give
BCG to children above 1 year of age)
Ø If a child is brought late for a dose, pick up where the
schedule was left off. For example, if a child left with
DPT-2 and comes at 13 months give DPT-3, OPV-3
and Measles
Ø Check VVM label of OPV vial and Hepatitis B before
immunizing every child

ØWelcome beneficiaries
ØProvide adequate space and seating arrangements
Ø Verify the age of the child
Ø Check label of the vial and expiry date
Ø Lightly shake the vial of T-series vaccine before
drawing the dose
Ø Screen for contra-indications for vaccination

Don’ts during immunisation sessions

ØDo not vaccinate in case of severe illness and
hospitalized children
Ø Do not Leave vaccine carrier in sunlight
Ø Do not Keep the DPT,DT,TT and Hep. B vaccines on
direct contact with Ice packs

ØDo not draw air into AD syringes
Ø Do not touch any part of the needle
Ø Do not recap the needle
Ø Do not leave the needle inside the vial
Ø Never give IM injections in the gluteal area
ØDo not massage the vaccination site after vaccination
Ø DO not use OPV / Hep . B vaccine with VVM stage 3 or 4
Ø Do not use expired vaccines.

Records and Reports

ØCards and counterfoils filled correctly
Ø Proper filling of immunization cards and counterfoils
of beneficiaries on the day of immunization
Ø Correct recording in the immunization register
Behavior of the People

•If people have no fear of vaccines, but have fear of disease, they vaccinate their children.
• If people have no fear of vaccines, but no fear disease either, there is inertia.
• But if people have no fear of disease, but fear of vaccines, they refuse vaccinations.

Vitamin. A deficiency How and Why ?

•Low dietary intake of Vitamin A rich foods
•Interference with absorption, transport and rapid loss
- absorption is impaired and the
metabolic demands increase during
diarrhoea, respiratory infections,
measles and other diseases
Ocular signs and symptoms
Classification of Xerophthalmia by eye (ocular) signs
•Night blindness (XN)
•Conjunctival xerosis (XIA)
•Bitot’s spots (XIB)
•Corneal xerosis (X2)
•Corneal ulceration / keratomalacia < 1/3
corneal surface (X3A)
•Corneal ulceration/keratomalacia ≥ 1/3
corneal surface (X3B)
•Corneal scar (XS)
•Xerophthalmic fundus (XF)

Prevalence criteria (in percentage of preschool-age population, 6 months to 6 years old, at risk) for determining the public health significance of Xerophthalmia and Vitamin A தேபிசிஎன்சி

CRITERIA
•Night blindness (XN) in > 1.0%
•Bitot’s spots (XIB) in > 0.5%
•Corneal xerosis / Corneal ulceration /
keratomalacia (X2/X3A/X3B) in > 0.01 %
•Corneal scar (XS) in > 0.05 %
•Plasma vitamin A of <0.35> 5.0%
Programme guidelines
•HSC wise 6 -60 months children to be listed.
•Meetings to be conducted for ICDS workers and field health functionaries
•PHC MOs should be thoroughly ஒரிஎண்டேது

•Vitamin A solution should be administered by preparing a schedule spread over two weeks
Camp I - May
Camp II - November
•Mothers should be educated about malnutrition, Vitamin. A deficiency, night blindness and consumption of Vit. A rich foods.
Oral dosage of Vitamin.A
•6 - 12 months - 100,000 IU ( 1 ml )
•1 - 5 years - 200,000 IU ( 2ml )
Programme guidelines

•One dose of Vitamin A solution(1 ml) should be administered to 6-12 months child.
•One dose of Vitamin A solution (2 ml) should be administered to 12-60 months children once in 6 months.
•One dose of Vitamin A solution (2 ml) should be administered to the postnatal mothers two weeks after delivery to cover the children in the age group of under 6 months
•Ensure 100 % administration of Vitamin A solution.
Treatment of Vitamin A deficiency கசெஸ்
•All children suffering from vitamin A deficiency must be administered a single oral dose of 200, 000 IU of vitamin .A immediately on diagnoses
•Repeat the dose one month later
Measles
Children suffering from measles should be given one dose of Vitamin A and repeated with another dose after 24 hours
Risk Mangement
•Sick children should not be administered Vitamin . A. Such children can be given Vitamin .A after recovery from illness
•Opened bottle should be used within one month time
•Vitamin. A should be stored in cool and dark place
•Used bottles should not be reused for storing or dispensing any other item

Corneal scar

Keratomalacia

Corneal xerosis / ulceration

Bitot’s spots

Vitamin A Deficiency Disorder

Vitamin A Deficiency Disorder

Childhood anaemia Control Programme

Programme guidelines
•HSC wise 1-5 years children to be listed and identify the children with visible signs of anaemia
•Mothers should be educated about malnutrition, childhood anaemia, consuming iron rich foods, avoiding coffee, tea, consequences of anaemia on child health and regular consumption of IFA tablets.
•All 1-5 years children, who show visible signs of anaemia should be given 100 IFA small tablets every year.
•Consumption of IFA Small tablet to be ensured.
Supply Management.

Anaemia Control Programme

Anaemia Control programme
Structure of Presentation
•Maternal Anaemia Control Programme
•Adolescent Anaemia Control Programme
•Childhood Anaemia Control Programme

Maternal Anaemia Control programme.
Programme guidelines

•All AN mothers should be registered at 12 weeks of pregnancy.
•Haemoglobin level should be tested and recorded for all AN mothers during the 1st , 2nd and 3rd trimester.
•Mothers should be educated about maternal anaemia, the need for consuming iron rich foods, avoiding coffee, tea, consequences of anaemia on maternal and child health and regular consumption of IFA tablets.

•All pregnant women should be given 100 IFA Large tablets during 2nd trimester and continued till delivery
•Pregnant women with Hb level less than 11 grams should be given 200 IFA Large tablets during 2nd trimester. One in the morning after breakfast and one during night after dinner.
•Consumption of IFA tablets to be ensured.
•All postnatal mothers should be given 50 IFA tablets and ensure the consumption

•Annual estimation of IFA Large for HSC, PHC, municipality and HUD.
•Supply from HSC kit, PHC supply and supplies through other programmes like VKT, School Health, Mobile RCH Outreach etc
•At all times availability of IFA Large should be ensured in the field and institutions.

•Expiry of IFA tablets should be meticulously monitored.
•First In First Out principle to be followed strictly.
•Consumption of IFA tablets only after meals.
•IFA tablets should be kept safely at home.
Children should not have access to IFA tablets so as to preventing iron poisoning.
Risk Management
Albendazole administration guidelines for AN Mothers.
•All girls immediately before marriage should be given one albendazole tablet as marriage gift by the VHN.
•Pregnant women with the history of passing worms in stools should be given one albendazole tablet during 2nd or 3rd
trimester.

Monitoring.
•Supply monitoring.
•Stock monitoring through reports, inspection and field visits.
•Distribution monitoring through reports, inspection and field visits.
•Consumption monitoring through interaction with mothers and Community.
Adolescent Anaemia Control programme.
Programme guidelines
•All adolescent girls(11-19 yrs) should be listed, village wise / ward wise by the VHN and ICDS worker
•A self monitoring adolescent health card to be provided to each adolescent girl.
•A Link Volunteer (local adolescent girl) to be identified for each street / ward and trained and motivated for the distribution of the IFA
•Each Link Volunteer should have the list of her friends for distributing the IFA Large tablets.
•All adolescent girls should be given one IFA Large tablet on every Thursday by the Link Volunteer
•It should be recorded in the list by the Link volunteer and by the adolescent girl in the card

•Haemoglobin level should be tested before entering into the scheme and once in 6 months after consumption of the tablets • It should be recorded in the
Adolescent girls self monitoring health card.

•All teachers, mothers, SHG women and
adolescent girls should be educated about
anaemia, the need for consuming iron rich
foods, regular menstrual cycle, personality
development and improvement in studies,
avoiding coffee, tea and consequences of
anaemia and regular consumption of IFA
tablets.
• Consumption of IFA tablets to be ensured.

•Annual estimation of IFA Large for HSC, PHC, municipality and HUD.
•ICDS worker should be given one month requirement of IFA tablets.
•Link Volunteer should be provided with the required number of IFA tablets by the ICDS worker on every Thursday.

•Supply from HSC kit, PHC supply, Adolescent anaemia control programme and supplies through other programmes like VKT, School Health, Mobile RCH outreach etc.
•At all times availability of IFA Large should be ensured in the field

Risk management
•Expiry of IFA tablets should be meticulously monitored.
•First In First Out principle to be followed strictly.
•Consumption of IFA tablets only after dinner.
•IFA tablets should be kept safely at home.
Children should not have access to IFA tablets for preventing iron poisoning.

Albendazole administration guidelines
All adolescent girls should be given one albendazole tablet before entering into the scheme and once in 6 months.

Monitoring
•Supply monitoring
•Stock monitoring through reports, inspection and field visits.
•Distribution monitoring through reports, inspection and field visits.
•Consumption monitoring through interaction with adolescent girls, teachers and mothers.

Routine Immunization
The IEAG reinforces that the continued, rapid improvements in routine immunization are fundamental to sustaining the progress to date in eradicating wild poliovirus, preventing the emergence of cVDPVs, and ensuring long-term protection from polio

Steps in conducting the immunization session

¨Welcome the beneficiaries.
¨Verify beneficiaries’ record and age and check that the beneficiary is due for
vaccination today.
¨Explain what vaccine(s) will be given and the route of administration.
¨Screen for contraindications.
¨Check vial expiry date and double check vial label. Do not use if there is no label on vaccine vial. For OPV, check VVM.

¨Wash hands before reconstituting vaccine and conducting the session. Write the
time of reconstitution on the vial (BCG,Measles).
¨Maintain aseptic technique throughout.
¨For T-Series Vaccines, lightly shake the vials before withdrawing the dose.
¨Use only diluent supplied with the vaccine (Double distilled water (2.5 ml) for Measles & normal saline (1 ml) for BCG.

¨Inject the vaccine at the correct site and follow the correct route of administration of the vaccine e.g. intra-dermal; sub-cutaneous; intramuscular.
¨Inject the vaccine using steady pressure.
¨Withdraw the needle at the angle of insertion.
¨Do not massage the injection site after giving the injection.

¨Explain potential minor side-effects/ problems that may occur due to the vaccine and how to deal with them.
¨Ask beneficiaries to wait there for some time (15-30 minutes) after giving the injection
¨Fully document each immunization in the immunization card and relevant immunization register

¨Remind beneficiaries /parents about the next visit and ask them to bring the card on next visit .
¨Retain the counter foil
¨Ensure disinfection of the needles and syringes before disposal.
¨Disposal of syringes and needles should be done as per guidelines.

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