A FIELD VISIT ON EXPANDED PROGRAM ON

IMMUNIZATION (EPI), HEAD QUARTER, MOHAKHALI, DHAKA

Submitted to:
Prof. Dr. Md. Ziaul Islam PhD
MBBS, MPH, PGD, MSc
Head of Dept. of Community Medicine
NIPSOM, Mohakhali, Dhaka.

Submitted by:
Dr. Samiha Kaisar
Program- MPH (Occupational and
Environmental Health)
Roll: 115
Session: 2017-2018

National Institute of Social and Preventive Medicine

(NIPSOM)
Table of Contents
1.0 Introduction .......................................................................................................................... 2
2.0 History of EPI in Bangladesh .............................................................................................. 2
3.0 Goal of EPI .......................................................................................................................... 3
4.0 Target population ................................................................................................................. 3
5.0 Objectives of EPI ................................................................................................................. 3
6.0 Strategies .............................................................................................................................. 4
7.0 Activities .............................................................................................................................. 4
8.0 Existing Resources ............................................................................................................... 5
9.0 EPI service-delivery along the health system ...................................................................... 5
10.0 Organogram ........................................................................................................................ 6
11.0 Vaccination Schedule for Children of <1 year and 15 months ........................................... 9
12.0 Vaccination schedule for 15-49 years woman ................................................................... 11
13.0 Cold Chain ........................................................................................................................ 11
14.0 Adverse event following immunization ............................................................................ 12
15.0 Disease Surveillance ......................................................................................................... 12
16.0 Major achievements .......................................................................................................... 12
17.0 Strength of EPI.................................................................................................................. 13
18.0 Constraints & challenges .................................................................................................. 13
19.0 Future Plan ........................................................................................................................ 14
20.0 Observation ....................................................................................................................... 14
21.0 Conclusion ........................................................................................................................ 14
22.0 Recommendation .............................................................................................................. 15

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1.0 Introduction

Field visit no.: 01

Name of the Organization: EPI Head Quarter for Expanded Program on Immunization
Date of Visit: 02 August, 2017
Location of the Organization: Mohakhali, Dhaka City, Adjacent to NIPSOM.
Type of Organization: Government organization under the control of Director General of Health
Service.
Background: As a part of field visit, we went to the EPI Head Quarter on 2nd August 2017. This
organization is just adjacent to NIPSOM premises. The EPI program is one of the major health
activities of the Government of Bangladesh. This global immunization program was officially
launched by the World Health Organization (WHO) in May 1974. In Bangladesh it was launched
on April 7, 1979 having the aim to protect all children against six vaccine preventable diseases.
The six diseases are as follows:
1. Tuberculosis
2. Diphtheria
3. Whooping cough
4. Tetanus
5. Poliomyelitis and
6. Measles.

2.0 History of EPI in Bangladesh

 EPI in Bangladesh was launched on April 7, 1979
 Intensified both in rural and urban areas as Universal Child Immunization (UCI) from
1985
 EPI service was made available to all target groups in phases by the year 1990
 Polio Eradication and Elimination of Maternal and Neonatal Tetanus (MNT) activities
started in 1995
 AFP and NT Surveillance started in 1997
 Introduce Hepatitis-B vaccination in 2003
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  2003- 7 district and 1 City Corporation
 2004- 25 district and 5 City Corporations
 2005- Rest 32 Districts
 Introduction of AD syringes from 2004
 Hib Vaccine introduced as pentavalent form in January 2009 and completed by July 2009
all over the country.
 In addition, EPI of Bangladesh is starting pilot project on HPV whose target population
will be the school going girls aging 9-18 years old and its future aim is to prevent cervical
cancer of women.

3.0 Goal of EPI

 To reduce child mortality and morbidity
 To reduce maternal mortality

4.0 Target population

 All the children below the age of 1 year

 All the children between the age 15-18 months
 All the adolescent girls at age of 15 years
 All the women between the age 15-49 years

5.0 Objectives of EPI

 At least 90% fully immunization coverage among under one year children at national
level and 85% in each district by 2016
 TT5 coverage among women of childbearing age to be reached at least 80% at national
level and 75% at each district level
 Maintain polio free status
 Maintain maternal and neonatal tetanus elimination status (<1 NT case per 1000 live
births)

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  Achieve 95% measles coverage at national level and reaching measles elimination status
by 2016
 Achieve 95% MR coverage among the girls of 15 years to prevent CRS by the year 2016
 Achieve 90% PCV coverage at national level by 2016
 Ensure safe injection practices and waste disposal

6.0 Strategies

 Establishment and implementation of EPI micro-plan by:

 Planning of regular vaccination session without compromising quality
 planning supportive supervision
 Involvement of people
 Introducing Evidence Based Planning and monitoring of effective
coverage of fully vaccinated children.
 Proper management of human and other resources
 Ensure injection safety and implementation of sharp waste disposal
 Strengthen AEFI surveillance system
 Disease surveillance
 Specialized vaccination programs

7.0 Activities

 Conduction of vaccination under EPI (DPT, OPV, BCG, Measles and Hepatitis B) to all
infants and TT to all mothers of respective age.
 Expanded program on Immunization throughout the whole country.
 TT and MR Campaign
 Activities of Surveillance of Acute Flaccid Paralysis(AFP)
 EPI plus vitamin-A capsule distribution to all children.
 Observation of National Immunization Day (NID)

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8.0 Existing Resources

 Manpower: Total 150 staffs are working

 Financial support: Financed by Government of Peoples Republic Bangladesh
 Other facilities
 Office: Government organization under control of Director General of Health Service.
 Logistic: GAVI Project provides extent this program. WHO/ UNICEF not delivered vaccine
only delivered consultancy.

9.0 EPI service-delivery along the health system

In Bangladesh, the EPI is run under two different systems: one for rural areas and the other one
for urban areas. The Ministry of Health and Family Welfare (MoHFW) is responsible for the EPI
in the rural areas. The EPI vaccines are delivered on a quarterly basis from the EPI headquarters
(EPI HQ) in Dhaka to the Civil Surgeon's Office.

EPI Structure of Rural Bangladesh

Stored in
Cold Room EPI HQ
Stored in ILR
or freezer District District
Stored in ILR Upazila

Union On day of
vaccination
Ward Ward Ward activities

Each site active

once a month Immunization Site

64 Districts, 461 Upazila, 140,000 Immunization Sites

Figure 1: EPI structure

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 EPI Service Delivery Strategy:
Union Level

EPI EPI
Sun
Wed

EPI EPI
Sun D2 A1 Wed
D1 A2

C2 B1
C1 B2
EPI EPI
Wed Sun

EPI
EPI
Sun Wed

Figure 2: EPI Service delivery

10.0 Organogram

Figure 3: Administrative Structure

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Figure 4: Organogram of MOH&FW

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Figure 5: Organogram of EPI

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 Figure 6: Organogram of MOLGRD&C

11.0 Vaccination Schedule for Children of <1 year and 15

months
 There is only minimum interval but no maximum interval in child immunization schedule
 Vaccinate your children and protect them against dreadful diseases

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Table 1: Vaccination Schedule for Children of <1 year and 15 months

Name of Name of Quantity Number Minimum Eligible Site Route

antigen vaccine per dose of dose interval age of of of
between vaccina administrat administration
doses tion ion

Tubercul BCG 0.05 ml 1 Just Upper outer Intradermal

osis vaccine after quadrant of
birth left arm
Diptheria Penta 0.5 ml 3 4 weeks 6,10,14 Midpoint of Intramuscular
Pertussis, vaccine weeks upper outer I/M
Tetanus, quadrant of
HepB, thigh(left)
Haemop-
hilus
Influenza
type b
(Hib)
Pneumo- PCV 0.5 ml 3 4 weeks 6,10,14 Midpoint of Intramuscular
coccal weeks upper outer I/M
quadrant of
thigh(right)
Polio OPV 2 drops 3 4 weeks 6 weeks mouth oral

IPV 0.5 ml 1 14 Midpoint of Intramuscular(I

weeks upper outer /M)
quadrant of
thigh(right)

Measles, MR 0.5 ml 1 After Midpoint of subcutaneous

Rubella vaccine completi upper outer
(1st dose) on of 9 quadrant of
months( thigh(right)
270
days)

MR 0.5 ml 1 At 15 Midpoint of subcutaneous

vaccine months upper outer
(2nd dose) quadrant of
thigh(left)

*3 doses of OPV with 3 doses of pentavalent

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12.0 Vaccination schedule for 15-49 years woman
 There is only minimum interval but no maximum interval in TT immunization schedule
 TT 5 doses contributes for reducing of maternal and neonatal mortality from tetanus
Table 2: Vaccination schedule for 15-49 years woman

Name of Name Quantity dose Eligible age of Site of Route of

antigen of per dose vaccination/minimum administ administration
vaccine interval between ration
doses
Tetanus Tetanus 0.5 ml TT1 15 years completed Midpoint Intramuscular
Toxoid TT2 At least 4 weeks after of upper (I/M)
TT3 TT1 outer
TT4 At least 6 months after quadrant
TT5 TT2 of arm
At least 1 year after
TT3
At least 1 year after
TT4

13.0 Cold Chain

Cold chain is a system to maintain the potency and efficacy of vaccines at every stage of storage
and transportation that is from the manufacturer to the actual vaccination site. Vaccines have
different storage requirements. A Table showing cold chain system in different level is given
below:
Table 3: Cold Chain

Location DPT, HepB ,BCG& TT Polio & Measles Duration

Central Store +20C to +80C -150C to -250C 6 months

District Store +20C to +80C -150C to -250C 3 months
Upazilla Store +20C to +80C +20C to +80C 1 months
During Transportation +20C to +80C +20C to +80C 4 days
(cold box)
Vaccine Carrier +20C to +80C +20C to +80C Up to 1 day

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14.0 Adverse event following immunization
An AEFI is any untoward medical occurrence which follows immunization and which does not
necessarily have a causal relationship with the usage of the vaccine. The adverse event may be
any unfavorable or unintended sign, abnormal finding, symptom or disease.

• Vaccine Product related reaction: An AEFI that is caused or precipitated by a vaccine

due to one or more of the inherent properties of the vaccine product.
• Vaccine quality defect - related reaction: An AEFI that is caused or precipitated by a
vaccine that is due to one or more quality defects of the vaccine product including its
administration device as provided by the manufacturer.
• Immunization error-related reaction: An AEFI that is caused by Inappropriate vaccine
handling, prescribing or administration and thus by its nature is preventable.
• Immunization anxiety-related reaction: An AEFI arising from anxiety about the
immunization.
• Coincidental event: An AEFI that is caused by something other than the vaccine product,
immunization error or immunization anxiety.

15.0 Disease Surveillance

 AFP: Children below the age of 15 years
 NT: 3rd day after birth to 28 days of age
 Measles: Any age
 Tuberculosis: Children below the age of 5 years
 Diphtheria: Any age
 Whooping cough: Any age
 Tetanus: Any age
16.0 Major achievements

 Bangladesh is achieving Millennium Development Goal by reducing child mortality and

morbidity through routine immunization.

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  Bangladesh achieved GAVI Alliance Award in 2009 and 2012 for the outstanding
performance in improving the child immunization status
 On 27th march 2014, WHO certified 11 countries of SEAR region including Bangladesh
are polio free.

17.0 Strength of EPI

 EPI is most readily available health service in Bangladesh. Almost every child gets their
vaccination under these programs.
 So many Govt. & private organizations provide facilities so that EPI supply all vaccination
& logistic free of cost.
 Consensus among all stakeholders to improve EPI performance.
 Sustained commitment & support of
 GOB & Partners
 Professional societies and bodies
 NGOs and Civil Society

18.0 Constraints & challenges

 Improving the coverage & quality of routine EPI
 Drop out of clients.
 All vaccines are imported from foreign countries
 Lacking of research activities
 Inadequate information about vaccine doses & interval among people
 Inadequate health worker.
 There is some remote area with poor transportation service.
 Importation of wild poliovirus through border of neighboring countries
 High rate of invalid doses
 Vaccination coverage process in urban area massively depends upon NGO which results
in massive pay for the vaccination

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19.0 Future Plan
 EPI plans to add two new vaccines to its routine immunization program in 2018.
 They would introduce Rota virus vaccine to prevent a common childhood Diarrhea and
Human Papillomavirus (HPV) vaccine to prevent cervical cancer.
 They also plan to introduce HBV at birth which is included now within pentavalent at 4
weeks of age.
 Vaccine against Japanese Encephalitis is included in planning list.

20.0 Observation

EPI center is located at Mohakhali, Dhaka City, which is very adjacent to NIPSOM. Considering
the communication medium, this place is quite convenient for all people considering public and
private transport. But when I first come to visit EPI center, I found the parking lot is very
crowded where most of the vehicles were not parked in a proper way. Cleanliness of the EPI
center is my next concern as the drainage system is not sufficient enough to drain out the rain
water. As a result, water used to get clogged in rainy season which may lead to further
difficulties and many water-borne diseases. Though, I have found some interesting and positive
features of the EPI center. Ventilation, power supply and lighting system of this center are well-
enough. On the other hand, cleanliness of the public toilet in each floor is not satisfactory
considering hygiene. I found the administration, medical officer and other staffs very friendly
and cooperative. They have been supportive during our visit and responded to our queries
regarding their center and operation. They are knowledgeable about their activities and I found
their openness towards sharing information to us very interesting. Client satisfaction is the key
indicator of the performance of EPI center. This EPI program is increased the global image of
Bangladesh in case of medical science.

21.0 Conclusion

Our visit to EPI Headquarter is totally successful. It has enriched our knowledge particularly in
relation to field application of a national immunization program which is nearly on its way to
achieve the target. The knowledge which we gathered will be helpful for our future carrier. We
express our gratitude and give sincere thanks to the concerned authority of EPI.

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22.0 Recommendation

 Proper care is needed for those who have been suffering after five years of age
 Awareness should be developed among people to complete vaccination to complete the
schedule
 Following recommendations can be made to achieve 100% coverage in vaccination in
Bangladesh Overall infrastructure needs to be improved
 New vaccines which has public health demand in context of Bangladesh
such as Rota Virus Vaccines should include in National EPI schedule as
early as possible
 Accommodation to be made for more vaccines and AD syringes.
 Newly scheduled vaccines need to be promoted through mass media
 Cleanliness should be hygienic and standardized

Signature of Supervisor Signature of student

Dr. Md. Noor Ashad –Uz-Zaman Dr. Samiha Kaisar

MBBS, BCS (Health), MPH Program- MPH (Occupational and
Medical Officer, Dept. of Public Health & Environmental Health)
Hospital Management Roll: 115
NIPSOM, Mohakhali, Dhaka. Session: 2017-2018

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