WHO initiated the extended program on immunization (EPI) in 1974 to provide countries with guidance and support to improve vaccine delivery and to help make vaccines available for all children. A standard immunization schedule was established in 1984 on the basis of a review of immunological data for the original EPI vaccines: BCG, diphtheria-tetanus-pertussis (DTP), oral polio, and measles vaccines.
Today, national immunization programs in developing countries are responsible for improving access to the traditional EPI antigens and introducing new vaccines. In 2002, the EPI introduced the Reaching Every District strategy, which focused on achieving an 80 percent coverage rate of DTP3 in 80 percent of districts and using immunization contacts to deliver other high-priority child health interventions. In addition to delivering vaccinations, national immunization programs are concerned with the quality and safety of immunization through the adoption of safe injection technologies (autodisabled syringes, storage boxes, and incinerators) and proper cold chain and vaccine stock maintenance.
In most developing countries, immunizations are provided through a system of fixed facilities at different levels of the health system. Immunization campaigns are discrete, time-limited efforts at national or subnational levels that usually focus on specific antigens (for example, polio). Mobile strategies rely on the use of specialized vehicles to transport health professionals and vaccines to deliver services to remote or migrating populations. Outreach is a strategy by which staff members from a health facility travel to villages and surrounding areas to administer vaccines. Extended outreach refers to more targeted and intensive efforts.
In 1999, the major international development partners involved in immunization (for example, WHO, UNICEF, the World Bank, and bilateral donors) joined the Bill & Melinda Gates and Rockefeller Foundations, the vaccine industry, and nongovernmental organizations to create GAVI (
GAVI | The Global Alliance for Vaccines and Immunization) to increase access to new and underused vaccines in the world's poorest countries, improve access to basic immunization services, and accelerate research and development pertaining to new vaccines and delivery technology. Through the Vaccine Fund, GAVI raised more than US$1.3 billion to strengthen immunization systems, introduce new vaccines, and support safe injection practices. More than US$3 billion has been pledged for the next 10 years. Between 2000 and 2003, an additional 4 million children were vaccinated with DTP3, 42 million with hepatitis B, nearly 5 million with Hib, and more than 3 million with yellow fever vaccine.
Nepal initiated the implementation of EPI in the fiscal year 1978/79. At the start, only three districts of the Kingdom of Nepal were taken for piloting of the EPI Programme in the first year, i.e. 1978/79. Then the number of districts included in the EPI programme were gradually increased. All the districts of the country were covered with EPI programme in 1987/88, when Universal Childhood Immunisation (UCI) was a priority.
The EPI remained as a project of Ministry of Health of Nepal from 1978 till 1988. The project hired its own human resources and was conducted in a "vertical" mode, with its inherent characters of financial autonomy and managerial flexibility.
However, after reorganization of EPI into a division at the central level as well as at the district level, these characters seem to be lost. Some characters were lost during the “integration phase also. Coming to the year 1992, the central structure of EPI totally collapsed. A unit called “child health” with just two personnel at the centre were allocated for EPI under the Family Health Division of Department of Health Services to run the whole EPI programme. However, due to programme related pressures and "observed" importance of EPI as an essential component of primary health care system, it was "upgraded" as a section of Child Health Division in 1995. With just three personnel at the central level, it tries to achieve the global goal.
However, grass root level health workers directly involved in EPI are allocated in eachvillage development committee (numbering 3914) of the country.
The shift in the internal structure of the EPI programme as such seems to be an important aspect in the legacy of immunization programme in Nepal. There seems to be very poor institutional memory pertaining to the changes and replacement of the human resources, though the functioning of the programme appears appropriate in the national context, because of the tireless effort of the grass root level health workers and volunteers.
Nepal expanded its EPI service to all the 75 districts of the country by 1988/89 (2). Initially only two antigens (BCG and DPT) were introduced in the programme with subsequent addition of other antigens: Polio vaccine was added in 1980 and the measles vaccine was added in the programme in 1982.
It was estimated in 1985/86 that about 42,600 deaths occurred due to vaccine preventable diseases (VPD) because of absence of immunisation. This number was estimated to be about 36,655 in 1991. There is no reference available what was the situation at the end of the millennium.
If we see retrospectively, the work plan developed by National Planning Commission in 1992 seems to be very ambitious: it planned to eradicate neonatal tetanus by 1995, reduce the mortality of measles by 95% by 1995 and aimed to eradicate polio by 2000. It seems that the target was too ambitious without focussing on the various aspects of the programme, when the program was virtually collapsed at the centre because it was minimized to "Child Health Unit" looking for nutrition, control of diarrhoeal diseases and acute respiratory infection and EPI. However, immunisation service at the grass root level survived because of the demand from the community and good acceptance of the programme.
Even if we shift the target for few more years, there are still many challenges ahead to reach the target. With the initiation of National Immunization Days, with lots of resources and human resources mobilization, Polio eradication seems virtually certain6. Nepal has had no case of laboratory confirmed wild poliovirus detected since November 2000.
Special activities were also carried out to eliminate maternal and neonatal tetanus (MNT) and has been recently completed. All the 75 districts of Nepal have carried out MNT elimination activities through campaign approach by providing three doses of tetanus toxoid vaccine to all women aged 10-39 years of age. The national coverage of the campaign stands at >90%, though some fluctuation has been observed.
Nepal also has recently initiated measles control activities. The target is to reduce measles mortality through vaccination of children aged 9 months to 14 years. The campaign intends to reduce measles mortality by 50% from the currently estimated 5000 deaths.
Starting 2002, Nepal has also introduced Hepatitis B vaccine in the routine immunisation programme in a phased manner, planning to cover all the 75 districts by 2005.
Expanded Program on Immunization (EPI) or National Programme on Immunization (NPI) for Nepal
A child has to be immunized as per the National Immunization schedule of Nepal as follows
BCG for Tuberculosis At birth or as soon as possible - -
DPT for Diphtheria, Whooping Cough, & Tetanus at 6 wks 10 wks 14 wks
POLIO for Poliomyelitis at 6 wks 10 wks 14 wks
MEASLES for Measles 9 month - -
HEPATITIS B for Hepatitis B at 6 wks 10wks 14wks
Resources:
Expanded Program on Immunization Immunisation programme of Nepal : an update
Twenty-five years of immunization program in Nepal Expanded program of Immunization (EPI) & Immunization in pregnat women Expanded program on immunization - WHO
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