Chapter

04 Child Health Programme

Chapter - 04

4.1 INTRODUCTION • Four States together contribute to 56% of

all child deaths in the country, namely-Uttar
The Child Health programme under the Reproductive, Pradesh (2.45 lakhs), Bihar (1.2 lakhs), Madhya
Maternal, Newborn, Child and Adolescent Pradesh (1.0 lakh) and Rajasthan (0.75 lakh).
(RMNCH+A) Strategy of the National Health Mission
(NHM) comprehensively integrates interventions that • About 46% of under-five deaths take place
improve child health and nutrition status and addresses within the first 7 days of birth, 62% within first
factors contributing to neonatal, infant, under-five one month of birth.
mortality and malnutrition. The National Population
4.2.2 Causes of Child Mortality in India
Policy (NPP) 2000, the National Health Policy
2002, Twelfth Five Year Plan (2007-12), National • The major causes of child mortality in India as
Health Mission (NRHM - 2005 – 2017), Sustainable per the SRS reports (2010-13) are: Prematurity
Development Goals (2016-2030) and New National & low birth weight (29.8%), pneumonia
Health Policy, 2017 have laid down the goals for (17.1%), diarrhoeal diseases (8.6%), other non-
Child Health. communicable diseases (8.3%), birth asphyxia
& birth trauma (8.2%), injuries (4.6%),
Child Health Goals under NHP-2025 and SDG-2030
congenital anomalies (4.4%), ill-defined or
Child Health Indicator Current NHP 2025 SDG
cause unknown (4.4%), acute bacterial sepsis
status 2030 and severe infections (3.6%), fever of unknown
origin (2.5%) & all other remaining causes
Neonatal Mortality rate 24 16 by 2025 <12
continue 8.4% of the total child mortality.
Infant Mortality Rate 34 28 by 2019 -
• Besides these, malnutrition is a contributory
Under 5Mortality Rate 39 23 by 2025 ≤25
factor in 45% child deaths.
Source: Sample Registration System (SRS) 2016
4.2.3 Interventions under Child Health
4.2 CHILD MORTALITY
Based on the identified causes of mortality, five major
4.2.1 Situation of Child Mortality in India strategic areas have been identified to improve child
health outcomes. These are:
• As per latest Sample Registration System, 2016
Report; the Under Five Mortality Rate in India
3. Interventions to
is 39/1000 live births, Infant Mortality Rate 1. Newborn health
Interventions
2. Nutrition related
interventions
address pneumonia and
diarrhoea
is 34/1000 live births and Neonatal Mortality
Rate is 24/1000 live births. This translates into
an estimated 9.6 lakh under-5 child deaths 4. Interventions to
address birth defects,
annually. disabilities, delays and 5. Immunization activities
deficiencies
• The U5MR has declined at a faster pace in the (4 Ds)

period 2008-2016, registering a compound

annual decline of 6.7% per year, compared to Besides the above mentioned, maternal health
3.3% compound annual decline observed over and family planning interventions are also linked
Congenital Diarrhoeal Causes of Neonatal Deaths (%)
1990-2007. inextricablyanomalies,
to child health
4 diseases, 3.1 outcomes. Therefore, the
Injuries, 0.9 All Other
Ill-defined or Remaining
cause unknown, 5 Causes, 1.4

Sepsis, 5.4
Other non- Annual Report | 2017-2018 35
communicable
diseases, 7.1
Prematurity &
low birth weight,
Neonatal 48.1
Chapter - 04

RMNCH+A strategic approach strategizes continuum ¾¾ Home Based Newborn Care (HBNC) is
of care across life stages of the over-arching umbrella for promotion of essential newborn care
under which these child health interventions have including breastfeeding practices, early
been built in. identification and referral of neonatal
3. Interventions to
1. Newborn health 2. Nutrition related
Interventions interventions
address pneumonia and illnesses by ASHAs. They are paid an
4.3 NEWBORN HEALTH diarrhoea
incentive for visiting each newborn and
• The Newborn Mortality Rate in India is 24/1000 post-partum mother in the first six weeks
4. Interventions to
live address
births birth(SRS
defects, 2015) which translates into of life as per the defined schedule. More
approximately
disabilities, delays6.3
deficiencies
and lakhs deaths, annually.
5. Immunization activities than 1.1 crore newborns were visited by
(4 Ds) ASHA in 2016-17 whereas, around 50
• Newborn deaths contribute to 61% of the
lakh newborns were visited during April-
Under-5 deaths in the country.
September, 2017.
Congenital Diarrhoeal Causes of Neonatal Deaths (%)
anomalies, 4 diseases, 3.1
Injuries, 0.9 All Other
¾¾ Facility Based Newborn Care (FBNC)
Ill-defined or
cause unknown, 5
Remaining
Causes, 1.4
is being scaled up for care of small or
Sepsis, 5.4 sick newborns. 712 Special Newborn
Other non-
communicable
Care Units (SNCUs) have been set up
diseases, 7.1
Prematurity & in district hospitals and medical colleges
low birth weight,
Neonatal 48.1 to provide round the clock services for
Pneumonia, 12
sick newborns. More than 8.5 lakh
Birth asphyxia &
birth trauma, 12.9 newborns are treated in the SNCUs each
year. SNCU Online Reporting System
4.3.1 India Newborn Action Plan (INAP) was has been established and more than 500
launched in 2014 to make concerted efforts towards facilities are reporting online. 2,321
attainment of the goals of “Single Digit Neonatal Newborn Stabilization Units (NBSUs) at
Mortality Rate” and “Single Digit Still Birth Rate”, the level of FRUs and 18,323 Newborn
by 2030. Care Corners (NBCCs) at delivery
• Strategic interventions under newborn health points have been operationalized in the
are as under: continuum of care.

¾¾ Promotion of Institutional Deliveries ¾¾ Newer interventions to reduce newborn

and Essential Newborn Care: Since mortality have also been implemented,
antenatal and intra-partum events have a including Vitamin K injection at birth,
bearing on newborn health, institutional Antenatal corticosteroids in preterm
deliveries are being promoted with cash labour, Kangaroo Mother Care (KMC)
incentives in the form of Janani Suraksha and empowering ANMs to provide
Yojana (JSY). Newborn Care Corners injection Gentamycin to young infants
(NBCCs) have been operationalized for possible serious bacterial infection.
at delivery points to provide essential
newborn care at the time of birth. In order ¾¾ Stillbirth Surveillance is being rolled
to reduce out of pocket expenses, Janani out. The guidelines for the same have
Shishu Swasthya Karyakram (JSSK) been issued.
entitlements have been provided to 4.4 NUTRITION RELATED INTERVENTIONS
ensure cashless diagnosis and treatment
of pregnant woman and her child till one • Malnutrition is considered to be the underlying
year of age in public health facilities. cause of 45% of child deaths.
This also includes free referral transport.

36 Annual Report | 2017-2018

 Chapter - 04

• 35.7% of under-5 children are underweight, (SAM) children under 5 years of age who are
38.4% are stunted and 21% are acutely facing medical complications. In addition, the
malnourished (wasted). More importantly, mothers are also imparted skills on child care
7.5% of children are suffering from severe and feeding practices so that the child continues
acute malnutrition, as per the last available to receive adequate care at home.
national survey (NFHS 4, 2015-16).
¾¾ National Iron Plus Initiative (NIPI): To
• Only 41.6% newborns initiated on breastfeeding address anaemia, NIPI has been launched
within one hour of birth while, 54.9% children which includes provision of supervised
breastfed exclusively till 6 months of age biweekly iron folic acid (IFA) supplementation
(NFHS 4, 2015-16). by ASHA for all under-five children, weekly
IFA supplementation for 5-10 year old children
• Complementary feeding started for only 42.7% and annual/biannual deworming.
children on time (more than 6 months of age)
(NFHS 4, 2015-16). ¾¾ National Deworming Day (NDD):
Recognizing worm infestation as an important
• 58.4% of children in age group 6 months-59 cause of anaemia, National Deworming Day
months are anaemic (NFHS 4, 2015-16). (NDD) is being observed annually on 10th
The strategic nutrition related interventions are as February, targeting all children in the age group
under: of 1-19 years (both school enrolled and non-
enrolled). A total of 50 crore children received
¾¾ Promotion of Infant and Young Child feeding Deworming tablet (Albendazole) during the
practices (IYCF): Exclusive breastfeeding National Deworming Day 2017 (February and
for first six months, complementary feeding August, 2017).
beginning at six months and appropriate Infant
and Young Child Feeding practices (IYCF) are
being promoted. Mother’s Absolute Affection
(MAA) programme was launched in 2016
to promote breastfeeding and infant feeding
practices by building the capacity of frontline
health workers and comprehensive IEC
campaign.

National Deworming Day 2017 at New Delhi

on 9th February, 2017
¾¾ Biannual Vitamin A Supplementation is
being done for all children below five years of
age.
¾¾ Village Health and Nutrition Days (VHNDs)
are also being organized for imparting
nutritional counselling to mothers and to
Inauguration of Vatsalya Maatri Amrit Kosh by Former improve child care practices.
Secretary(HFW) at LHMC New Delhi on 7th June, 2017
4.5 PNEUMONIA & DIARRHOEA RELATED
¾¾ E
stablishment of Nutritional Rehabilitation INTERVENTIONS
Centres (NRCs): 1148 NRCs have been set
up at facility level to provide medical and a. Pneumonia and diarrhoea are leading childhood
nutritional care to Severe Acute Malnourished killers- responsible for 15% and 12% of child

Annual Report | 2017-2018 37

Chapter - 04

(0-5 years) deaths, respectively. distribute ORS packets to the families

with children under five years of age.
b. As per available survey data, only 54.4%
children with diarrhoea episode in preceding 2 4.6 INTERVENTIONS TO ADDRESS BIRTH
weeks received ORS. DEFECTS, DISEASES, DELAYS AND
DEFICIENCIES
c. As per available survey data, 8.6% children
reportedly suffered from an episode of Acute Birth defects account for 9.6% of all newborn deaths
Respiratory Illness in preceding two weeks and and 4% of under-five mortality.
only 76.9% sought treatment for this.
Development delays affect at least 10% children and
d. Integrated Action Plan for Pneumonia and these delays if not intercepted timely may lead to
Diarrhoea (IAPPD) has been formulated for permanent disabilities.
four States with highest child mortality (UP,
MP, Bihar and Rajasthan) to address the two Rashtriya Bal Swasthya Karyakram (RBSK)
biggest killers of children, viz. pneumonia and provides child health screening and early interventions
diarrhoea. services by expanding the reach of mobile health
teams at block level. These teams also carry out
e. The strategic interventions targeting pneumonia screening of all the children in the age group 0 – 6
and diarrhoea are as below: years enrolled at Anganwadi Centres twice a year.
RBSK covers 30 common health conditions. States/
¾¾ Promotion of Integrated Management UTs may incorporate a few more conditions based on
of Neonatal and Childhood Illnesses high prevalence/endemicity. An estimated 32.8 crore
(IMNCI) for early diagnosis and case children in the age group of zero to eighteen years are
management of common ailments expected to be covered in a phased manner.
of children with special emphasis on
pneumonia, diarrhoea and malnutrition
is being promoted for care of children at
community as well as facility level.
¾¾ Promotion of early detection and
prompt referral of children with
common ailments like pneumonia and
diarrhoea by ASHAs: ASHAs are being
trained in Modules 6 & 7 to aid them in
identifying common childhood illnesses
like diarrhoea, pneumonia and provide Screening of children in healthcare facilities under
first level of care and refer baby to an Rashtriya Bal Swasthya Karyakram
appropriate health facility. The strategic interventions to address birth defects,
¾¾ Increase awareness about use of ORS diseases, delays and deficiencies are:
and Zinc in diarrhoea: In order to ¾¾ Screening of children under RBSK: Child
increase awareness about the use of ORS health screening and early intervention services
and Zinc in diarrhoea, an Intensified with an aim to improve the overall quality of
Diarrhoea Control Fortnight (IDCF) is life of children through early detection of birth
being observed during July-August, with defects, diseases, deficiencies, development
the ultimate aim of ‘zero child deaths due delays (4 Ds) and reduce out of pocket
to childhood diarrhoea’. During fortnight expenditure for the families. Dedicated mobile
health workers visit the households of medical health teams (for screening purpose)
under five children, conduct community have been set up at block level, comprising of
level awareness generation activities and four health personnel viz. two AYUSH doctors

38 Annual Report | 2017-2018

 Chapter - 04

(One Male, One Female), ANM/SN and a Centres (DEICs) to be made operational
Pharmacist. in the districts of the country for providing
management of cases referred from the blocks
¾¾ Under this intervention, in 2016-17, 29.8 crore and link these children with tertiary level
children were screened, 1.35 crore children health services in case surgical management is
identified with any of 4Ds, 98.9 lakh children required. 92 DEICs have been established till
were referred to secondary/tertiary facilities, date.
59.5 lakh children had availed services in
secondary tertiary facilities. ¾¾ Birth Defects Surveillance System (BDSS) is
being established to serve as a tool for identifying
¾¾ During April-September, 2017, more than congenital anomalies. It is a collaborative effort
9 crore children were screened, 26.1 lakhs between the MoHFW, GoI, WHO and CDC. It
identified with any of 4D’s, 43.6 lakhs children is envisaged to establish at least one surveillance
refereed for 4D’s and 29.8 lakhs children centre per State, preferably in a medical college.
received secondary or tertiary treatment. Currently, 55 medical colleges are a part of the
¾¾ Establishment of District Early Intervention Birth Defects Surveillance System.

Child Health Programme: At a Glance

Sl. State/UTs U5MR IMR NMR No. of No. of No. of No. of No. of
No. (SRS (SRS (SRS SNCUs NBSUs NBCCs NRCs RBSK
2016) 2016) 2016) teams
A. Non-NE High Focus States
1 Bihar 43 38 27 25 40 860 38 815
2 Chhattisgarh 49 39 26 13 16 289 72 302
3 Himachal Pradesh 27 25 16 13 34 124 5 70
4 Jammu & Kashmir 26 24 18 33 76 40 4 230
5 Jharkhand 33 29 21 15 42 594 87 158
6 Madhya Pradesh 55 47 32 54 101 1303 315 602
7 Odisha 50 44 32 30 49 1190 54 687
8 Rajasthan 45 41 28 36 304 1665 147 446
9 Uttar Pradesh 47 43 30 73 160 1820 74 1573
10 Uttarakhand 41 38 30 5 29 140 2 148
B. NE States
11 Arunachal Pradesh - 36 - 5 10 106 1 42
12 Assam 52 44 23 26 192 730 19 299
13 Manipur - 11 - 1 2 47 0 36
14 Meghalaya - 39 - 3 7 147 5 72
15 Mizoram - 27 - 4 11 110 0 29
16 Nagaland - 12 - 1 12 130 0 22
17 Sikkim - 16 - 2 3 17 0 5
18 Tripura - 24 - 2 0 131 0 22

Annual Report | 2017-2018 39

Chapter - 04

Child Health Programme: At a Glance

Sl. State/UTs U5MR IMR NMR No. of No. of No. of No. of No. of
No. (SRS (SRS (SRS SNCUs NBSUs NBCCs NRCs RBSK
2016) 2016) 2016) teams
C. Non High Focus States
19 Andhra Pradesh 37 34 23 26 95 1232 18 0
20 Goa - 8 - 3 0 10 0 15
21 Gujarat 33 30 21 40 150 910 139 835
22 Haryana 37 33 22 23 66 318 11 211
23 Karnataka 29 24 18 40 169 1301 57 402
24 Kerala 11 10 6 14 49 88 3 1095
25 Maharashtra 21 19 13 34 130 1845 35 1088
26 Punjab 24 21 13 15 56 208 0 258
27 Tamil Nadu 19 17 12 64 156 1761 2 666
28 Telangana 34 31 21 19 61 510 12 190
29 West Bengal 27 25 17 66 303 561 35 670
D. Union Territories
30 A & N Islands - 16 - 1 3 25 0 4
31 Chandigarh - 14 - 3 2 23 1 13
32 Dadra & Nagar Haveli - 17 - 1 1 7 1 4
33 Daman & Diu - 19 - 1 0 6 0 3
34 Delhi 22 18 12 16 0 63 11 NA
35 Lakshadweep - 19 - 1 0 8 0 NA
36 Puducherry - 10 - 4 0 4 0 8
India 39 34 24 712 2329 18323 1148 11020

4.7 UNIVERSAL IMMUNIZATION Universal Immunization Programme in 1985

PROGRAMME (UIP) when its reach was expanded beyond urban
areas. In 1992, it became part of Child Survival
• The Universal Immunization Programme (UIP) and Safe Motherhood Programme and in 1997 it
in India is one of the largest public health came under the ambit of National Reproductive
programmes in the world. It targets 3 crore and Child Health Programme. Since the launch
pregnant women and 2.67 crore newborn of National Rural Health Mission in 2005,
annually. More than 9 million immunization Universal Immunization Programme is an
sessions are conducted annually. integral part of it.
• It is one of the most cost effective public • Under UIP, Government of India is providing
health interventions and largely responsible vaccination free of cost against twelve
for reduction of vaccine preventable under-5 vaccine preventable diseases, of which:
mortality rate.
¾¾ 8 are provided across the country against
• Launched in 1978 as expanded programme Diphtheria, Pertussis, Tetanus, Polio,
on immunization, it got its present name of Measles, severe form of Childhood

40 Annual Report | 2017-2018

 Chapter - 04

Tuberculosis, Hepatitis B and Meningitis data, the full immunization coverage in

& Pneumonia caused by Hemophilus the country stands at 79%.
Influenza type B
• The trends in Full Immunization coverage
¾¾ 4 are provided in selected States/ (FIC) over the past years is as follows:
endemic districts against Rota virus
diarrhea, Rubella, Pneumococcal Survey NFHS-3 DLHS-3 CES RSOC NFHS-4
Pneumonia and Japanese Encephalitis; Time 2005-06 2007-08 2009 2013-14 2015-16
of which Rotavirus vaccine, Measles-
FIC (%) 43.5 53.5 61.0 65.3 62.0
Rubella vaccine and Pneumococcal
Conjugate vaccine are in process of • A system of cold chain equipment is utilized
expansion while JE vaccine is provided to store vaccine and deliver the immunization
only in endemic districts. services from fix centers or out-reach sessions
• A child needs 7 contacts till the age of 5 years utilizing the following infrastructure:
to complete immunization due to him under ¾¾ Sub-centres: around 1.5 lakhs,
Universal Immunization Programme. The
detailed immunization schedule age-wise as ¾¾ Health facilities: approximately 29
well as vaccine-wise is given at Annexure-1 thousand (Hospital, CHC, PHC etc.),
and Annexure-2 respectively.
¾¾ Cold Chain Points: around 27 thousand –
• A child is said to be fully immunized if he/ vaccine storage point,
she receives all due vaccines as per national
immunization schedule within 1st year of age of ¾¾ ILRs & Deep Freezers: around 72
child. thousand equipment to store vaccine,

• There are three main systems to measure full ¾¾ District Vaccine Stores: around 666,
immunization coverage: ¾¾ WIC & WIF: 269 – cold room to store
1. Online web-based Health Management vaccine.
Information System (HMIS) portal 4.7.1 Routine Immunization Strengthening
wherein administrative coverage is
being reported through health facilities 1. Mission Indradhanush
across the country. As per HMIS data for
• To increase the rate of increase of full
2016-17, the full immunization coverage
immunization coverage, Government of
of the country stands at 88.05%.
India launched Mission Indradhanush in
2. Periodic surveys like National Family December 2014 with an aim to increase the
Health Survey (NFHS), District Level full immunization coverage to at least 90% by
Household Survey (DLHS), Rapid 2020, which has now been pre-poned to 2018.
Survey on Children (RSOC), Integrated
• Mission Indradhanush is a targeted approach
Child Health and Immunization Survey
focused on pockets of low immunization
(INCHIS) etc. As per the latest available
coverage (like hard to reach areas, vacant sub-
survey, which is NFHS-4 conducted in
centres, areas with recent outbreaks of vaccine
2015-16, the full immunization coverage
preventable diseases, resistance pockets etc.).
in the country stands at 62%.
• Mission Indradhanush has completed four
3. Concurrent monitoring of the
phases (from April 2015 to July 2017) covering
Universal Immunization Programme
528 districts wherein:
through session as well as community
monitoring. As per concurrent monitoring ¾¾ 2.55 crore children were reached,

Annual Report | 2017-2018 41

Chapter - 04

¾¾ 66.57 lakh children fully immunized,

¾¾ 68.79 lakh pregnant females immunized.
• The detailed phase-wise coverage of Mission
Indradhanush is given at Annexure - 3.
• As per the report of Integrated Child Health and
Immunization Survey (INCHIS), the first two
phases of Mission Indradhanush have led to an
increase of 6.7% in full immunization coverage MoU with Rotary, India in presence of Hon'ble Health
in one year as compared to 1% increase/year in Minister Shri J.P. Nadda, AS&MD Shri Manoj Jhalani,
the past. This increase was more in rural areas JS Smt. Vandana Gurnani and Sr. Officers of Rotary
(7.9%) as compared to urban areas (3.1%) thus
shifting the focus of the programme towards
urban areas.

MoU with Rotary, India on 6th December 2017

• Focus is on urban slum areas and districts with
slowest progress, completion of due-list of
beneficiaries on the basis of head-count surveys
Vaccination of children under Mission Indradhanush
& greater convergence with other ministries/
2. Intensified Mission Indradhanush: departments with defined roles.

• During the review of Mission Indradhanush • As on 15th January, 2018, under Intensified
in PRAGATI meeting on 26th April 2017, Mission Indradhanush:
directions were received to achieve the goal - No. of children vaccinated - 49.80 lakh
under the mission by December, 2018. - No. of children fully immunized - 12.02 lakh
- No. of pregnant women vaccinated - 10.05 lakh
• Accordingly, MoHFW has identified 121
districts, 17 urban areas and 52 districts of NE 4.7.2 New Vaccines
States (total 190 districts/urban areas across 24
a) Measles-Rubella (MR) vaccine
States) where Intensified Mission Indradhanush
has started. The list of districts and urban areas • WHO’s regional goal for South-East Asia
is given at Annexure-4. It was launched by region is measles elimination and rubella/
Hon’ble Prime Minister of India on 8th October, Congenital Rubella Syndrome control by 2020.
2017 at Vadnagar, Gujarat.
• The goal of measles elimination was also
• The activity is being monitored closely by reiterated by Hon’ble Union Minister of
Prime Minister of India and Cabinet Secretary. Finance during the budget speech of 2017-18
along with reduction in Under-5 Mortality.
• Intensified Mission Indradhanush will involve
intensive preparation, implementation and • MR vaccine is being introduced through
integration of IMI sessions into RI microplans. campaign, targeting around 41 crore children

42 Annual Report | 2017-2018

 Chapter - 04

in the age group of 9 months to 15 years in • The remaining States/UTs are planned for MR
a phased manner (covering ⅓ of the total campaign subsequently.
population of the country), followed by 2 doses
in routine immunization at 9-12 months and 16- Group of Secretaries (GoS) have also recommended
24 months, replacing the measles vaccine. for introduction of Rotavirus vaccine (RVV)
and Pneumococcal Conjugate vaccine (PCV) for
• MR campaign started in February, 2017 from reduction in mortality and morbidity due to diarrhea
5 States/UTs (Karnataka, Tamil Nadu, Goa, and pneumonia. Further, the budget speech of Union
Lakshadweep and Puducherry), where 3.34 Finance Minister for 2017-18 also mentions about
crore children were vaccinated against the reduction in under-five mortality rate. Accordingly,
target of 3.43 crore with a coverage of 97%. following two vaccines have been introduced in
Universal Immunization Programme:
• The next phase started for 8 States/UTs
from August, 2017 namely Andhra Pradesh, i) Pneumococcal Vaccine (PCV)
Chandigarh, Daman & Diu, Dadra & Nagar
Haveli, Telangana, Kerala, Himachal Pradesh & • PCV was launched in May, 2017 for reducing
Uttarakhand where around 3.21 crore children Infant mortality and morbidity caused by
have been vaccinated by December, 2017. pneumococcal pneumonia.

National PCV launch on 13th May, 2017 in presence of Union Health Minister Shri J.P. Nadda

• The vaccine has been introduced in Himachal • Presently, the vaccine has been introduced in
Pradesh, 6 districts of Uttar Pradesh and 17 9 States, namely, Andhra Pradesh, Haryana,
districts of Bihar. Himachal Pradesh, Odisha, Assam, Tripura,
Rajasthan, Tamil Nadu & Madhya Pradesh
• Till December, 2017, around 11.20 lakh doses
through domestic funds.
of PCV have been administered to children in
the above mentioned areas. • Till November, 2017, around 1.29 crore doses
of Rotavirus vaccine have been administered
ii) Rotavirus vaccine (RVV)
to children in above mentioned States since its
• RVV has been introduced to reduce mortality introduction.
and morbidity caused by Rotavirus diarrhea.

Annual Report | 2017-2018 43

Chapter - 04

Expansion of Rotovirus vaccine in Immunization Programme on 18th February, 2017

• In the next phase, Rotavirus vaccine will be • Currently, two dose fractional schedule is being
introduced in Jharkhand. followed in the country with vaccination at 6
weeks and 14 weeks of age.
b) Inactivated Polio Vaccine (IPV)
• Till December, 2017, around 3.45 crore doses
• There are three types of Polio viruses namely of IPV have been administered to children
type-1, 2 and 3 for which the vaccine was across the country since its introduction.
provided under Universal Immunization
Programme as trivalent oral polio vaccine. 4.7.3 Japanese Encephalitis (JE) vaccine
• Since last case of wild polio virus type-2 • Japanese Encephalitis (JE) vaccination under
was reported in 1999, therefore, Global Polio UIP was started in India in 2006.
Eradication Initiative (GPEI) has recommended
switch from trivalent OPV to bivalent OPV • NVBDCP carries out Acute Encephalitis
(containing only type-1 & 3). Syndrome (AES) surveillance including JE
burden and based on this surveillance they
• The tOPV to bOPV switch happened in India identify endemic districts and communicate
on 25th April, 2016. the same to immunization division which plays
limited role of providing JE vaccination in these
• As part of Global Polio end-game strategy, to districts.
mitigate the risk associated with tOPV to bOPV
switch, MoHFW has introduced Inactivated • Campaign: In the newly identified districts,
Polio Vaccine (IPV) in UIP in November, 2015, one-time JE vaccination campaign is carried
which was expanded across the country by out in children aged 1-15 years to knock out the
June, 2016. susceptible cohort.

44 Annual Report | 2017-2018

 Chapter - 04

• Routine Immunization: Subsequent to real time view of the vaccine stock position
completion of the campaign, JE vaccine and their storage temperature across all
is introduced in Universal Immunization the cold chain points providing a detailed
Programme as two doses provided at 9-12 overview of the vaccine cold chain logistics
months and 16-24 months. system across the entire country.
• A total of 231 JE endemic districts have been • eVIN system has been rolled out across
identified of which JE vaccination campaign all the 370 districts in 12 States – UP,
has been completed in 229 districts. A total of MP, Rajasthan, Odisha, Bihar, Jharkhand,
15.16 crore children were vaccinated against Chhattisgarh, Assam, Manipur, Nagaland,
JE in vaccination campaign carried out in these Gujarat and Himachal Pradesh.
districts.
¾¾ National Cold Chain Management
• Adult JE vaccination: Endemic districts Information System (NCCMIS) to track the
are also identified by NVBDCP where high cold chain equipment inventory, availability
numbers of JE cases are reported in people and functionality.
aged 15-65 years. In these districts, one time
campaign for JE vaccination is carried out in ¾¾ To augment the cold chain space & strengthen
adults to knock out the susceptible cohort. the cold chain system in the country, in 2017,
16 Walk in coolers (WICs), 6 Walk in freezers
• Till August 2017, 31 districts have been (WIFs), 13250 ILRs, 10567 DFs, 40 SDDs &
identified for JE vaccination in adults in which 150 tool-kits have been procured & supplied to
the campaign activity has been completed. A the States.
total of 3.3 crore people aged 15-65 years were
vaccinated for JE in these campaigns. 4.7.5 Adverse Events Following Immunization
(AEFI) System
4.7.4 New Initiatives in Vaccine Logistics & Cold
Chain Management 1. The AEFI surveillance programme of the
Immunization Division was assessed by the
a) Capacity building WHO as part of the Indian National Regulatory
Authority (NRA) Assessment in 2017. The
• National Cold Chain Training Centre (NCCTC), pharmacovigilance function of NRA which
Pune and National Cold Chain & Vaccine includes vaccine safety and AEFI surveillance
Management Resource Centre (NCCVMRC), received the maximum possible maturity level
New Delhi have been established to provide rating of 4.
technical training to cold chain technicians in
repair & maintenance of cold chain equipment. 2. The AEFI surveillance programme has been
quality certified for its national level processes
b) System strengthening as per National Quality Assurance Standards
¾¾ Electronic Vaccine Intelligence Network for AEFI Surveillance Programme. Scoping for
(eVIN) rollout : State level implementation is in progress in two
States.
• The Government of India has rolled out an
Electronic Vaccine Intelligence Network 3. Vaccine Adverse Event Management
(eVIN) system that digitizes the entire Information System (VAEMIS), the online
vaccine stock management, their logistics reporting software for reporting severe and
and temperature tracking at all levels of serious AEFI was developed in collaboration
vaccine storage – from national to the sub- with WHO has been piloted in two States (MP
district. and WB) and is being scaled across the country
in the coming year.
• This enables programme managers to have

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Chapter - 04

4. State level training on revised AEFI guidelines 10. Three research studies were conducted by
is completed in most States and UTs except INCLEN and ITSU. These are (a) Inter-
Tamil Nadu and few North-Eastern States. rater reliability of the WHO AEFI causality
District level training for medical officer and assessment methodology and the utility of the
health workers is completed in all major States new WHO AEFI causality assessment software,
and is in progress in remaining States. (b) Multi-site Active AEFI Surveillance Study,
(c) Factors affecting reporting of AEFI cases in
5. Reporting of serious and severe AEFIs has the field.
significantly increased from 961 cases (April
2015 – March 2016) to about 1589 cases (April 11. To reduce mortality and morbidity due to
2016 - March 2017). anaphylaxis following vaccination, a policy
has been approved wherein Health worker/
6. As a step to further improve vaccine safety, ANM is authorized to use a single injection
the line-listing of minor AEFIs in PHC AEFI of age appropriate Injection Adrenaline for
registers has been initiated in all States. management of suspected Anaphylaxis in field
settings. Development of training plans and its
7. AEFI surveillance job aids for HWs and MOs
operationalization with monitoring is underway.
have been developed in English and Hindi and
shared with some States for dissemination. 4.8 PULSE POLIO IMMUNIZATION (PPI)
Some States e.g. Maharashtra, Gujarat, etc.
have translated job aids in local languages too. With the global initiative of eradication of polio
following World Health Assembly resolution in 1988,
8. While 33 State AEFI committee meetings Pulse Polio Immunization programme was launched
were conducted by 25 States in 2015-16, 48 in India in 1995. Children in the age group of 0-5 years
State AEFI committee meeting were held in 27 were administered polio drops during National and
States in 2016-17. Sub-national immunization rounds (in high risk areas)
every year. There are 24 lakh vaccinators and 1.5 lakh
9. For the first time, four National AEFI
supervisors involved in the successful implementation
Committee meetings were held in the 2016-17
of the Pulse Polio Programme across the country.
as calendared and more than 783 AEFI cases
About 172 million children are immunized across
were causally assessed and have been uploaded
the country during each National Immunization Day
on the Ministry’s website by December, 2017.
(NID) and 77 million in SNIDs.

Pulse Polio Immunization with Hon’ble President of India on 22nd January, 2017

46 Annual Report | 2017-2018

 Chapter - 04

4.8.1 Progress
On 24th February, 2012 WHO removed India from the
list of countries with active endemic wild polio virus
transmission after reporting of last case of poliovirus
in country in January, 2011. Subsequently, on 27th
March, 2014, India along with 10 other countries of
South East Asia Region was declared polio-free by the
Regional Certification Commission (RCC) of WHO.
The issued certificate stated that “The Commission Health workers in the field during Pulse Polio Campaign
concludes, from the evidence provided by the National
Certificate Committees of the 11 Member States, that 4.8.2 Steps to maintain polio free status
the transmission of indigenous wild poliovirus has To maintain the polio free status, country is
been interrupted in all countries of the Region” implementing the following strategies:
India has maintained polio-free status as no wild
poliovirus case has been reported for more than 6 • Maintaining community immunity through
years after last case reported on 13th January, 2011. high quality of National and Sub National
polio rounds each year, apart from routine
Last Reported Polio Case immunization.
Polio Date of last case Location • Polio vaccination is provided to all eligible
Virus Type children round the clock through special
P1 13 January, 2011 Howrah (Panchla), booths set up at international borders (both
West Bengal Rail and Road routes) those shares with India
P2 24 October, 1999 Aligarh, Uttar Pradesh
i.e. Pakistan, Bangladesh, Bhutan, Nepal and
Myanmar. In these border posts 1.15 crore
P3 22 October, 2010 Pakur (Pakur), children were vaccinated as on December, 2017.
Jharkhand
• Travel advisory has been issued for Polio
The total number of cases and number of affected vaccination of international travelers travelling
districts during past 10 years is as below: between India and 8 other countries i.e.
Pakistan, Afghanistan, Nigeria, Kenya,
Year Cases of Polio Number of districts
Ethiopia, Somalia, Syria and Cameroon. Till
2006 676 114 November, 2017, more than 2.15 lakh travellers
2007 874 99 have been vaccinated with OPV.
2008 559 90 • An Emergency Preparedness and Response
2009 741 56 Plan (EPRP) have been put in place under
2010 42 17 which Rapid Response Teams (RRT) are set up
in every State/UTs for timely action in case of
2011 01 01
any occurrence of a polio case in the country.
2012 00 00
• As a part of Polio Endgame Strategy, India has
2013 00 00
introduced Inactivated Polio Vaccine (IPV)
2014 00 00 across the country to provide double protection
2015 00 00 against polio.
2016 00 00 • Strengthening Acute Flaccid Surveillance
2017 00 00 (AFP) across the country and Environmental
Surveillance at Mumbai, Delhi, Patna, Kolkata,
As on 7th October 2017

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Chapter - 04

Punjab, Hyderabad, Lucknow, West Bengal and were done timely (against the global minimum
Gujarat which acts as surrogate indicator for recommendation of 80%) (data till 7th October,
polio virus transmission. 2017).
• The lessons learnt from polio programme is • To supplement AFP surveillance, environmental
being implemented for strengthening of routine surveillance is established at 35 sites spread
immunization by carrying out Immunization over in 8 States.
weeks and also the same learnings are being
used for implementing “Mission Indradhanush” Measles-Rubella (MR) Surveillance:
and recently Intensified Mission Indradhanush– • The ‘suspected measles case with fever and
A drive toward 90% full immunization coverage rash’ surveillance was initiated in 2005 based
of India by year 2018. on the AFP network, which has been existent
4.8.3
Vaccine Preventable Diseases (VPDs) in the country since 1995. This laboratory
Surveillance supported measles-rubella surveillance system
was expanded across the country by 2015.
Currently, the following surveillance systems are
present in India for VPD surveillance: • At present, it is an outbreak based, aggregate
surveillance and involves investigation of
Polio Surveillance: suspected outbreaks (not every suspected case)
and generating case line-list through outbreak
• AFP (Acute Flaccid Paralysis) surveillance investigation. Active case search and case
is the gold standard for detecting cases of management is integrated as part of outbreak
poliomyelitis. This is done to identify all investigation. There are >40,000 reporting sites
reservoirs of wild poliovirus and vaccine across the country in the reporting network,
derived polio virus transmission. This includes includes private sector, non-formal sector,
reporting of all AFP cases, investigating them temples in addition to government health
and laboratory testing of all stool specimens facilities.
collected from such cases for polioviruses in
specialized laboratories. Nearly 40,000 health • MR Lab Network comprises 13 WHO
facilities report children with paralysis to the accredited, AFP linked laboratories in the
AFP surveillance system and 50,000 paralysed network, which classify outbreaks and cases
children are investigated annually in the based on serological confirmation. Annual
country. accreditation of labs in the network is done by
WHO to ensure quality results. The surveillance
• There are 8 WHO accredited laboratories in guidelines have been regularly revised, last in
India for primary isolation of polio virus (wild 2015, to increase the sensitivity of the system.
poliovirus and vaccine derived polio virus),
• Starting from 2016, country is moving to case
followed by Intratypic Differentiation (ITD) of
based measles- rubella surveillance system in a
isolates from AFP cases, if indicated.
phased manner.
• These laboratories are: BJMC Ahmedabad, • Summary of measles & rubella outbreaks in the
NIV Bengaluru, ERC Mumbai, IoS Kolkata, country:
NCDC Delhi, CRI Kasauli, KIPM Chennai,
and SGPGI Lucknow. Measles Rubella Mixed
outbreak outbreaks outbreaks
• Currently, India is maintaining highest standards
2016 802 274 67
as indicated by AFP rate of 10.60 (against the
global minimum recommendation of 2) and for 2017 (upto 436 115 15
total of 87% of AFP cases two stool collections October, 2017)

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 Chapter - 04

• Congenital rubella syndrome (CRS) and strengthening of laboratories across nation

surveillance is being conducted by ICMR. for diagnosis of Diphtheria, Pertussis and
Neonatal Tetanus.
Laboratory supported vaccine preventable diseases
(VPD) surveillance • For this purpose CMC Vellore has been
designated as reference laboratory for VPD
• WHO is establishing a case based laboratory surveillance. In addition, 6 network laboratories
supported VPD surveillance system based on have been established. These are SPHL
the operational knowledge acquired from AFP Chennai, KMC Kozhikode, KGMC Lucknow,
surveillance system in country which would IDH Delhi, NCDC Delhi and PGI Chandigarh.
be in collaboration with other surveillance
systems like Integrated Disease Surveillance • Integration of WHO and IDSP surveillance
Programme (IDSP) and Central Bureau of system is being done:
Health Intelligence (CBHI).
¾¾ Information of cases is shared on weekly
• VPD surveillance started from three States basis,
(Haryana, Kerala and Bihar) in 2015 and has
been rolled out in 4 more States, namely Uttar ¾¾ Lab reports are also shared,
Pradesh, Madhya Pradesh, Himachal Pradesh ¾¾ Joint VPD outbreak investigations by
& Punjab. WHO and IDSP,
• WHO has established a national reference ¾¾ Preparation of joint outbreak report for
laboratory for standardization of laboratory VPDs to be shared to both the systems.
procedures and quality assurance, identification

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Chapter - 04

Annexure-1
National Immunization Schedule (Age-wise)

Age Vaccines given

Birth BCG, Oral Polio vaccine (OPV)-0 dose, Hepatitis B birth dose
6 Weeks OPV-1, Pentavalent-1, Rotavirus vaccine (RVV)-1^, fIPV-1, PCV-1#
10 weeks OPV-2, Pentavalent-2, RVV-2^
14 weeks OPV-3, Pentavalent-3, fIPV-2, RVV-3^, PCV-2#
9-12 months Measles-1 or MR-1$, JE-1* , PCV-B#
16-24 months Measles-2 or MR-2$, JE-2*, DPT-Booster-1, OPV–Booster
5-6 years DPT-Booster-2
10 years TT
16 years TT
Pregnant Mother TT1, 2 or TT Booster**

1. * In endemic districts only (at present in 216 out of 231 districts).

2. ** One dose if previously vaccinated within 3 years.
3. ^Rotavirus vaccine is provided in Andhra Pradesh, Haryana, Himachal Pradesh, Odisha, Assam, Madhya
Pradesh, Rajasthan, Tamil Nadu & Tripura.
4. $ MR vaccine has been introduced in 13 States namely Karnataka, Tamil Nadu, Goa, Lakshadweep &
Puducherry, Andhra Pradesh, Chandigarh, Daman & Diu, Dadra & Nagar Haveli, Telangana, Himachal
Pradesh & Uttarakhand. Planned to cover entire country.
5. # PCV in Himachal Pradesh and parts of UP & Bihar.
6. Adult JE vaccination as one time vaccination to adults aged 15-65 years in 31 endemic districts of Assam,
West Bengal & UP.
Being introduced/scaled up.

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Annexure-2
National Immunization Schedule (NIS) for Infants, Children and Pregnant Women (Vaccine-wise)

Vaccine When to give Dose Route Site

For Pregnant Women
TT-1 Early in pregnancy 0.5 ml Intra-muscular Upper Arm
TT-2 4 weeks after TT-1* 0.5 ml Intra-muscular Upper Arm
TT- Booster If received 2 TT doses in a 0.5 ml Intra-muscular Upper Arm
pregnancy within the last 3 yrs*
For Infants
BCG At birth or as early as possible till 0.1ml (0.05ml Intra-dermal Left Upper Arm
one year of age until 1 month
age)
Hepatitis B - Birth dose At birth or as early as possible 0.5 ml Intra-muscular Antero-lateral
within 24 hours side of mid-thigh
OPV-0 At birth or as early as possible 2 drops Oral Oral
within the first 15 days
OPV 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeks 2 drops Oral Oral
(OPV can be given till 5 years of
age)
Pentavalent 1, 2 & 3 At 6 weeks, 10 weeks & 14 weeks 0.5 ml Intra-muscular Antero-lateral
(can be given till one year of age) side of mid-thigh
Pneumococcal Conjugate Two primary doses at 6 weeks and 0.5 ml Intra-muscular Antero-lateral
Vaccine (PCV)^ 14 weeks. Booster dose at 9-12 side of mid-thigh
months of age.
Rotavirus# At 6 weeks, 10 weeks & 14 weeks 3 Oral Oral
(can be given till one year of age)
IPV Two fractional dose at 6 and 14 0.1 ml ID Intra dermal Intra-dermal:
weeks of age two fractional Right upper arm
dose
Measles 1st dose / MR 9 completed months-12 months. 0.5 ml Sub-cutaneous Right upper Arm
1st dose (Measles can be given till 5 years of
age)
JE - 1** 9 completed months-12 months. 0.5 ml Sub-cutaneous Left upper Arm
Vitamin A At 9 completed months with 1 ml Oral Oral
(1st dose) measles-Rubella (1 lakh IU)
For Children
DPT booster-1 16-24 months 0.5 ml Intra-muscular Antero-lateral
side of mid-thigh
Measles 2nd dose / MR 16-24 months 0.5 ml Sub-cutaneous Right upper Arm
2nd dose
OPV Booster 16-24 months 2 drops Oral Oral

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Chapter - 04

JE-2 16-24 months 0.5 ml Sub-cutaneous Left Upper Arm

Vitamin A*** 16-18 months. Then one dose every 2 ml Oral Oral
(2nd to 9th dose) 6 months up to the age of 5 years. (2 lakh IU)
DPT Booster-2 5-6 years 0.5 ml. Intra-muscular Upper Arm
TT 10 years & 16 years 0.5 ml Intra-muscular Upper Arm

• *Give TT-2 or Booster doses before 36 weeks of pregnancy. However, give these even if more than 36
weeks have passed. Give TT to a woman in labour, if she has not previously received TT.
• **JE Vaccine is introduced in 229 endemic districts after the campaign.
• *** The 2nd to 9th doses of Vitamin A can be administered to children 1-5 years old during biannual
rounds, in collaboration with ICDS.
• #Phased introduction, at present in Andhra Pradesh, Haryana, Himachal Pradesh, Odisha, Madhya
Pradesh, Assam, Rajasthan, Tripura and Tamil Nadu.
• ^PCV vaccine in Himachal Pradesh and select districts of UP and Bihar.
• MR vaccine has been introduced in 13 States/UTs.

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Annexure-3
Mission Indradhanush Cumulative Coverage Report
(As on 15th January, 2018)
(Figures in lakhs)
S. No Indicator Ph-1 Ph-2 Ph-3 Ph-4 IMI* Total
1 No. of sessions held 9.61 11.55 7.44 6.3 5.01 39.91
2 No. of antigen administered 190.09 172.84 151.56 118.46 132.13 765.08
3 No. of pregnant women immunized 20.95 16.83 17.83 13.18 10.05 78.84
4 No. of pregnant women completely 11.13 8.94 9.56 7.13 5.65 42.41
immunized
5 No. of children immunized 75.75 70.3 62.08 46.65 49.80 304.58
6 No. of children fully immunized 19.81 18.17 16.34 12.25 12.02 78.59
7 No. of children vaccinated for the first time NA 9.31 12.06 6.84 7.38 35.59
8 No. of Vit A doses administered 19.85 20.53 17.98 15.13 15.76 89.25
9 No. of ORS packets distributed 16.93 13.62 21.38 16.64 9.71 78.28
10 No. of zinc tablets distributed 57.03 44.85 80.7 52.1 33.91 268.59
* Data is provisional

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Chapter - 04

Annexure-4
List of districts and urban areas identified for Intensified Mission Indradhanush
A. List of Districts identified in States other than NE States

Sl. No. State No. of Districts Name of Districts

1 Andhra Pradesh 2 East Godavari Nellore
2 Bihar 15 Champaran East Darbhanga
Champaran West Madhubani
Muzaffarpur Sheohar
Kishanganj Gaya
Sitamarhi Araria
Saran Nawada
Lakhisarai Katihar
Sheikhpura
3 Delhi 3 North South-East
Shahdara -
4 Gujarat 3 Banaskantha Bhavnagar
Kutch -
5 Haryana 3 Mewat Palwal
Faridabad -
6 Jammu & Kashmir 1 Jammu -
7 Jharkhand 2 Giridih Pakur
8 Karnataka 3 Yadgir Kalburgi
Bagalkote -
9 Kerala 1 Malappuram -
10 Madhya Pradesh 13 Tikamgarh Jhabua
Chhatarpur Vidisha
Sagar Sidhi
Rewa Panna
Raisen Shadol
Singrauli Sheopur
Alirajpur
11 Maharashtra 9 Nasik Beed
Ahmednagar Solapur
Nanded Yavatmal
Jalgaon Gadchiroli
Nandurbar -
12 Odisha 1 Ganjam -

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 Chapter - 04

13 Rajasthan 11 Alwar Jalor

Barmer Karauli
Partapgarh Udaipur
Jodhpur Sawai Madhopur
Bikaner Dhaulpur
Pali -
14 Uttar Pradesh 52 Bahraich Unnao
Sitapur Shahjahanpur
Moradabad Kaushambi
Badaun Banda
Hardoi Farrukhabad
Gonda Gorakhpur
Barabanki Mau
Jaunpur Kannauj
Azamgarh Sant Kabir Nagar
Muzaffarnagar Deoria
Balrampur Raebareli
Kheri Rampur
Aligarh Mirzapur
Siddharthnagar Srawasti
Mathura Kasganj
Ghazipur Sonbhadra
Kushinagar Ferozabad
Sultanpur Etah
Ballia Mainpuri
Pratapgarh Ambedkar Nagar
Maharajganj Badohi
Bulandshahar Lalitpur
Bijnor Auraiya
Fatehpur Chitrakoot
Basti Sambhal
Saharanpur Hapur
15 Uttarakhand 1 Hardwar -
16 West Bengal 1 24-Parganas North -
Total 121

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Chapter - 04

B. List of Urban Areas identified:

Sl. No. State No. of Urban Areas Name of Urban Areas

1 Bihar 1 Patna -
2 Haryana 1 Gurgaon -
3 Karnataka 2 Belgaum Bengaluru (U)
4 Madhya Pradesh 1 Indore -
5 Maharashtra 2 Thane Gr. Mumbai
6 Odisha 1 Bhubaneshwar Urban (Khurda) -
7 Rajasthan 1 Jaipur -
8 Uttar Pradesh 8 Allahabad Meerut
Bareilly Lucknow
Ghaziabad Kanpur(Nagar)
Agra Varanasi
Total 17

C. List of Districts in NE States

Sl. No. State No. of Districts Name of Districts

1 Arunachal Pradesh 13 Anjaw Papum Pare
Changlang Tirap
East Kameng Upper Siang
East Siang Upper Subansiri
Lohit Kurung Kumey
Namsai Kra Daadi
Longding -
2 Assam 7 Nagaon Karbi Anglong
Dhubri Kokrajhar
Goalpara Chirang
Darrang -
3 Manipur 4 Chandel Tamenglong
Churachandpur Ukhrul
4 Meghalaya 7 West Garo Hills West Jaintia Hills
South-west Garo Hills South-west Khasi Hills
East Khasi Hills North Garo Hills
East Jaintia Hills -

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5 Mizoram 3 Lawngtlai Mamit

Lunglei -
6 Nagaland 11 Dimapur Phek
Kohima Peren
Kiphere Tuensang
Longleng Wokha
Mokokchung Zunheboto
Mon -
7 Sikkim 2 East West
8 Tripura 5 Dhalai Unakoti
North Tripura West Tripura
South Tripura -
Total 52

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