National Immunization Program

Routine Immunization

The National Immunization Programme (at the time known as the Expanded Programme on Immunization - EPI) was initiated in 1979 in three districts with only two antigens (BCG and DPT) and was rapidly expanded to include all 75 districts with all six recommended antigens (BCG, DTP, OPV, and measles) by 1988. In 2003, with the support of the GAVI Alliance, monovalent Hepatitis B (HepB) vaccine was introduced, which was later administered as a single tetravalent (DPT-HepB) injection. In 2009, vaccination against Haemophilus influenzae type b was introduced through out the nation in a phase wise manner starting in Far Western (FWDR) and Western (WDR) Development Regions. Also in 2009, Japanese encephalitis (JE) vaccine was introduced into the routine immunization programme in 16 JE endemic districts following JE mass vaccination campaigns.

Routine immunization Schedule for children and pregnant women

Vaccine Disease(s) prevented	Number of Doses	Recommended Age
BCG tuberculosis	1	At birth or on first contact
OPV Polio	3	6, 10, and 14 weeks of age
DPT-HepB-Hib Diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type b	3	6, 10, and 14 weeks of age
Measles	1	9 months of age
TT tetanus	2	All Pregnant women Note – 5 doses of TT vaccine during a woman’s reproductive life
JE Japanese encephalitis	1	12 to 23 months

All children should receive the suggested number of doses of BCG, DPT-HepB-Hib, OPV, and measles vaccines during their first year of life. Similarly, all women of childbearing age should complete 5 doses of TT vaccine during their reproductive life. JE vaccine is available in the routine immunization programme only in districts with high risk of Japanese encephalitis transmission. All of the vaccines in the routine immunization schedule are provided free of cost in all public health facilities in Nepal.

Goal

The goal of NIP is to reduce morbidity and mortality associated with vaccine preventable diseases.

Objectives

1. Achieve and sustain 90% coverage of DPT3 by 2008 and all antigens in all district by 2010;

2. Maintain polio free status;

3. Sustain MNT elimination status;

4. Initiate measles elimination initiatives from 2010;

5. Expand vaccine preventable diseases (VPD) surveillance;

6. Accelerate control of other VPD through introduction of new vaccines;

7. Improve and sustain immunization quality;

8. Expand immunization service beyond infancy.

Source: cMYP 2007-2011, MoHP

Service delivery

Nepal is geographically divided into five ecological regions which are Far-western, Mid-western, Western, Central and Eastern Regions. These regions are further divided into 75 administrative districts. In each district, there are hospitals (at least one), primary health care centers (PHC), health posts (HP) and sub health posts (SHP) through which health care services are delivered. Immunization services are provided through the fixed (health facilities) as well as out reach sessions. Hospitals, PHCs, HPs and SHPs provide immunization services through established clinics. In addition there are 3 to 5 outreach sessions conducted monthly in each VDC or Village Development Committee. Village health workers are primarily responsible for providing immunization services. Female community health volunteers (FCHVs) are the key link between the community and service providers. Their role has been crucial toward achieving and sustaining high immunization coverage through routine or supplemental services.

Go to top é

Achievements

Objective 1: Achieve and sustain 90% coverage for all antigens

The coverage status of immunization for all antigens in Nepal remains satisfactory. The reported coverage status of the country is around 80% for all antigens. The drop-out rate for all antigens is decreasing. However, the immunization coverage is not uniform throughout and within the districts. Intensified monitoring of VDC coverage (by categorizing the VDCs as per their performance) has been implemented at district level since 2002 in order to promote universal coverage at all VDCs for all antigens.

Trends in immunization coverage among children 12-23 months

All antigens

Objective 2: Maintain polio free status

In 1996, Nepal initiated polio eradication efforts by holding the first Nepal National Immunization Days (NIDs) in all 75 districts. Since then, the polio eradication efforts have continued and expanded. Nepal has achieved and maintained global certification-standard AFP surveillance since 2001.

Indicators	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010
Non-polio AFP rate per 100,000 children less than 15 years	1.95	2.00	1.90	2.16	2.25	3.50	3.24	3.94	4.14	5.15
Stool adequacy	83%	87%	86%	84%	84%	86%	83%	88%	88%	89%
Polio cases	0	0	0	0	4	5	5	6	0	6
Polio compatible	0	1	1	0	2	2	0	0	0	0

Polio3 coverage, 1988 to 2010

Go to top é

Objective 3: Sustain MNT elimination status

In 2000, Nepal began concerted efforts to meet the goal of maternal and neonatal tetanus elimination (MNTE) with the initiation of 3-doses of tetanus toxoid (TT) supplemental immunization activities (SIAs). All 75 districts completed the SIAs to achieve MNTE by the end of 2004.

In 2005, WHO & UNICEF validated that Nepal had eliminated neonatal tetanus (NT), i.e., achieved an NT incidence of less than one case per 1,000 live births in every district of the country. Results from the 2006 Nepal Demographic and Health Survey (NDHS) provided further evidence of NT elimination. School-based immunizations for grade one students in 12 districts and immunization of pregnant women with TT is ongoing. Through VPD surveillance, eighteen neonatal tetanus cases were investigated and confirmed in 2009.

NT cases and TT2+ coverage, 1998-2009

Objective 4: Measles elimination initiatives

Measles was endemic in Nepal and was a major cause of child hood morbidity and mortality. However, the burden of measles disease and its associated mortality has decreased sharply after the introduction of measles vaccine through catch-up and follow-up measles campaigns in 2004/05 and 2008/09.

Measles cases and MCV1 coverage, 1980-2009

MCV1

The government of Nepal is committed to reduce the mortality and morbidity related to measles. The commitment has been reflected in the “Comprehensive Immunization Multi Year Plan of Action” (cMYPA) 2007-2011, which sets a target to reduce measles mortality by 90% by 2009 compared to 2003 estimates, to achieve at least 90% MCV1 coverage at national and district level by 2010 and to initiate measles elimination by 2010.

Go to top é

Objective 5 and 6: Accelerate, control and sustain of other vaccine preventable diseases

Other vaccine preventable diseases for which vaccines are included in the routine immunization schedule are hepatitis B, Haemophilus influenzae type b (Hib), and Japanese encephalitis (JE). Vaccinations for hepatitis B and Hib are included along with diphtheria, pertussis and tetanus in a pentavalent vaccine where protection against all five diseases is provided in each injection of the three-dose series. In Nepal, the estimated annual incidence of Hib among children less than five years of age is 5.4 cases per 100,000. However, low lumbar puncture rates and low rates of Hib isolation from cerebral spinal fluid (CSF) indicate that available data may underestimate the true disease burden. According to WHO estimates, the Hib meningitis incidence in Nepal is approximately 19/100,000 among children under five years of age. Sentinel sites for the surveillance of Hib diseases as well as other types of invasive bacterial diseases are functional in selected hospitals in Nepal.

JE was first confirmed in Nepal in 1978 after an outbreak in the western part of the country (Rupendehi district) along the border with India. Since then, JE infection has been reported in humans throughout the terai region, which borders India, during and after the annual monsoon season from May to October. JE vaccination has been included into routine immunization in the JE endemic districts (where JE campaigns have been conducted). Surveillance for acute encephalitis syndrome (clinical syndrome present for JE cases) is ongoing through out the country.

WHO is providing technical and financial support for burden of disease studies for other VPDs in order to support the Government of Nepal in its decision making process to introduce other vaccinations in the routine immunization schedule.

Objective 7: Improve and sustain immunization quality

All immunizations provided during infancy are WHO-prequalified.

Objective 8: Expand immunization service beyond infancy

JE vaccine, which was introduced into the routine immunization program in 16 districts in 2009, is the first vaccine to be routinely administered for all children after the first year of life.

A demonstration project is ongoing in 12 districts where TT vaccine is provided to grade one students. It is likely that additional vaccines will be added targeting toddlers or school aged children.

NIP history at a glance

Go to top é

Year	Activity
1979	Started immunization program with BCG and OPV in three districts.
1988	Nationwide immunization program with BCG, OPV, DTP, Measles.
1996	First nationwide polio immunization campaign.
1998	Polio Eradication Nepal (PEN) was established with four surveillance field offices. Nepal National Certification Committee was formed. Surveillance Medical Officers hired by WHO to support polio eradication activities. International and national review for polio eradication initiatives
2000	Last reported indigenous case of poliomyelitis in Nepal.
2001	Program expands to 14 surveillance field offices (10 in 2005). National Expert Review Committee starts virological classification of AFP cases. AFP surveillance achieves internationally accepted standards.
2002	National Task Force for Laboratory Containment of wild poliovirus formed. TT campaign was initiated (2002-2004, for age 11 to 39 and 15 to 45 years)
2003	Measles and tetanus surveillance integrated into AFP surveillance network. National Public Health Laboratory accredited by WHO as a National Laboratory for Measles surveillance. National immunization injection safety policy Hepatitis B included in the routine immunization schedule.
2004	Surveillance for acute encephalitis syndrome (AES) for Japanese encephalitis (JE) integrated into AFP surveillance. Nationwide Measles catch up immunization campaign initiated (2004-2005, in three phases).
2005	Neonatal tetanus elimination achieved. Sentinel surveillance for Haemophilus Influenzae type b initiated. Immunization Officers hired to support routine immunization. School immunization was initiated with TT for student (grade 1, 2 and 3) in 8 districts
2006	Japanese encephalitis catch up campaigns initiated in high risk districts. International and national AFP surveillance review.
2007	Measles case-based surveillance initiated.
2008	Measles follow up campaign integrated with OPV nationwide (in two phases). Rubella burden of disease studies initiated. National Committee for Immunization Practice Formed.
2009	Hib vaccine included in the routine immunization schedule. JE vaccine included in the routine immunization schedule in 17 districts that completed catch up campaigns. EPI coverage survey. Sentinel surveillance site for rotavirus initiated. Sentinel sites for Hib disease expanded to include pneumococcal disease. Initiated pneumonia surveillance to support H5N1, H1N1 influenza through AFP surveillance network. Provided technical support for cholera outbreak in Mid West Development Region.
2010	International and national review of vaccine preventable diseases and EPI.