Bhutan 2017 Expanded Programme on Immunization (EPI) FACT SHEET
Acronyms AD Auto disable MCV1 First dose measles containing vaccine AEFI Adverse events following immunization MCV2 Second dose measles containing vaccine AFP Acute flaccid paralysis MICS Multiple indicator cluster survey BCG Bacillus Calmette-Guérin vaccine MMR Measles mumps rubella vaccine CES Coverage evaluation survey MNT Maternal and neonatal tetanus cmyp Comprehensive multi-year plan MR Measles rubella vaccine CRS Congenital rubella syndrome NCIP National committee on immunization practices DHS Demographic health survey NID National immunization day DT Diphtheria tetanus toxoid, pediatric NTAGI National technical advisory group on immunization DTP Diphtheria tetanus pertussis vaccine NPEV Non-polio enterovirus DTP-Hib-HepB Pentavalent vaccine NT Neonatal tetanus DTP-Hib-HepB3 3rd dose pentavalent vaccine OPV Oral poliovirus vaccine EPI Expanded programme on immunization bopv Bivalent OPV GDP Gross domestic product topv Trivalent OPV HCW Health care worker PCV Pneumococcal conjugate vaccine HepB Hepatitis B vaccine SEAR WHO South-East Asia Region Hib Haemophilus influenzae type b SIA Supplementary immunization activities HPV Human papilloma virus SNID Subnational immunization day IgM Immunoglobulin M Td Tetanus diphtheria toxoid; older children, adults IPV Inactivated poliovirus vaccine TT Tetanus toxoid JE Japanese encephalitis TT2+ 2 or more doses TT JE_Live-Atd JE live attenuated vaccine VDPV Vaccine derived poliovirus JRF WHO UNICEF joint reporting form VPD Vaccine preventable diseases LB Live birth WCBA Women of child bearing age M Measles WPV Wild poliovirus
Contents Impact of routine immunization EPI history 5 Basic information 2016 Table 1 5 Immunization schedule 2016 Table 2 5 National immunization coverage 1980-2016 Figure 1 6 Immunization system highlights Table 3 6 DTP3 coverage, diphtheria and pertussis cases 1980-2016 Figure 2 7 Reported cases of vaccine preventable diseases 2011-2016 Table 4 7 DTP-Hib-HepB3 coverage by district 2015 Figure 3 7 DTP-Hib-HepB3 coverage by district 2016 Figure 4 7 Maternal and neonatal tetanus elimination is sustained TT2+ coverage and NT cases 1980-2016 Figure 5 8 Polio-free status is maintained Page No. Page No. Page No. AFP surveillance indicators 2011-2016 Table 5 9 Non-polio AFP rate by district 2015 Figure 6 9 Non-polio AFP rate by district 2016 Figure 7 9 Adequate stool specimen collection percentage by district 2015 Figure 8 10 Adequate stool specimen collection percentage by district 2016 Figure 9 10 OPV supplementary immunization activities Table 6 10 Towards measles elimination and rubella/congenital rubella syndrome control Page No. MCV1 and MCV2 coverage, measles and rubella cases, 1980-2016 Figure 10 11 MCV supplementary immunization activities Table 7 11 MCV1 coverage by district 2015 Figure 11 12 MCV1 coverage by district 2016 Figure 12 12 MCV2 coverage by district 2015 Figure 13 12 MCV1 coverage by district 2016 Figure 14 12 Immunity against measles immunity profile by age in 2016 Figure 15 12 Subnational risk assessment for measles and rubella Figure 16 12 Sporadic and outbreak associated measles cases by month 2011-2016 Figure 17 13 Immunization status of confirmed (laboratory and Epi linked) measles outbreak associated cases by age 2011 2016 Figure 18 13 Quality of field and laboratory surveillance for measles and rubella 2012-2016 Table 8 14 Performance of laboratory surveillance 2012-2016 Table 9 14 WHO supported laboratory network for VPD surveillance Figure 19 15
WHO South-East Asia Region Bhutan: district level map Disclaimer: The boundaries and names shown and the designations used on all the maps do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area of its authorities, or concerning the delimitation of its frontiers or boundaries. 4
Impact of routine immunization Table 1: Basic information 1 2016 EPI history EPI launched on 15 November 1979 TT for pregnant women introduced in 1983 HepB vaccine introduced in 1997 DTP-HepB vaccine introduced in 2003 AD syringes introduced in 2003 MR vaccine introduced in 2006 DTP-Hib-HepB vaccine introduced in 2009 HPV vaccine introduced in 2010 HepB birth dose introduced in 2012 TT vaccine replaced by Td vaccine in 2012 IPV vaccine introduced in 2015 topv to bopv switched on 25 April 2016 MMR vaccine introduced in October 2016. Source: cmyp 2014-2018 and VPDP/MOH Total population 757,042 Live births 12,869 Children <1 year 11,227 Children <5 years 82,561 Children <15 years 229,796 Pregnant women 11,680 WCBA (15-49 years) 186,509 Neonatal mortality rate 18.3 (per 1,000 LB) Infant mortality rate 2 27.2 (per 1,000 LB) Under-five mortality rate 32.9 (per 1,000 LB) Maternal mortality ratio 2 148 (per 100,000 LB) 1 SEAR annual EPI reporting form, 2016 and WHO, World Health Statistics 2016 2 VPDP/MOH Table 2: Immunization schedule, 2016 Vaccine Age of administration BCG Birth HepB Birth OPV Birth, 6 weeks, 10 weeks and 14 weeks DTP-Hib-HepB 6 weeks, 10 weeks and 14 weeks IPV 14 weeks MMR 9 months and 24 months DTP 24 months HPV Females 12 years and grade VI girls Td 6 and 12 years Vitamin A 6 to 30 months (6 months interval) Source: WHO/UNICEF JRF,, 2016 5 Division/Province/State/Region - Dzongkhag/District 20 Gewog/Block 205 Sub-block/Ward 1,050 Village (approx.) 3,717 Population density (per sq. km) 18 Population living in urban areas 37% Population using improved drinkingwater sources 2 97.7% Population using improved sanitation 2 66.3% Total expenditure on health as % of GDP 3.6% Births attended by skilled health 74.6% personnel 2 Neonates protected at birth against NT 83%
Figure 1: National immunization coverage, 1980-2016 100 80 % Coverage 60 40 20 0 1980 1985 1990 1995 2000 2005 2010 2014 2015 2016 BCG 43 54 99 98 97 92 96 99 99 99 DTP3 6 41 96 87 92 95 91 99 99 98 OPV 4 41 96 86 98 95 92 98 98 97 MCV1 21 44 93 85 78 93 95 97 97 97 Source: WHO/UNICEF estimates of national immunization coverage, July 2017 revision Table 3: Immunization system highlights cmyp for immunization 2014-2018 NTAGI fully functional Spending on vaccines financed by the government 41% Spending on routine immunization programme financed by the government 24% Updated micro-plans that include activities to improve immunization coverage 20 districts (100%) National policy for health care waste management including waste from immunization activities National system to monitor AEFI in place in place Most recent EPI CES National Health Survey 2012 >80% coverage for DTP-Hib-HepB3 20 districts (100%) >90% coverage for MCV1 16 districts (80%) >10% drop-out rate for DTP-Hib-HepB1 to DTP-Hib-HepB3 1 district (5%) Source: WHO/UNICEF JRF, 2016 6
Figure 2: DTP3 coverage 1, diphtheria and pertussis cases 2, 1980-2016 DTP-Hib-HepB3 coverage by district 300 464 100 Figure 3: 2015 250 80 No. of cases 200 150 100 60 40 % Coverage 50 0 1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014 2015 2016 20 0 Source: SEAR annual EPI reporting form, 2015 (administrative data) Year Diphtheria Cases Pertussis Cases DTP3 Coverage 1 WHO/UNICEF estimates of national immunization coverage, July 2017 revision 2 WHO vaccine-preventable diseases: monitoring system 2016 Figure 4: 2016 Table 4: Reported cases of vaccine preventable diseases, 2011-2016 Year Polio Diphtheria Pertussis NT (% of all tetanus) Measles Rubella Mumps JE CRS 2011 0 0 0 0 10 3 262 3 ND 2012 0 0 0 0 1 2 198 0 0 2013 0 0 0 0 0 6 20 0 0 Source: SEAR annual EPI reporting form, 2016 (administrative data) 2014 0 0 0 0 0 0 206 2 0 2015 0 0 12 0 11 1 620 5 0 2016 0 0 4 0 45 3 795 5 0 Source: WHO/UNICEF JRF, (multiple years) ND=No data <70% 70% - 79% 80% - 89% > 90% 7
Maternal and neonatal tetanus elimination is sustained Figure 5: TT2+ coverage 1 and NT cases 2, 1980-2016 MNT elimination before 2000 No. of cases 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 No data 1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014 2015 2016 Year 100 80 60 40 20 0 % Coverage NT Cases TT2+ Coverage 1 WHO/UNICEF JRF, Country official estimates, 1980-2016 2 WHO vaccine-preventable diseases: monitoring system 2016 8
Polio-free status is maintained Table 5: AFP surveillance performance indicators, 2011-2016 Last clinically-confirmed polio case was reported in 1986. Indicator 2011 2012 2013 2014 2015 2016 AFP cases 6 10 10 11 9 11 Wild poliovirus confirmed cases 0 0 0 0 0 0 Compatible cases 0 0 0 0 0 0 Non-polio AFP rate 1 2.74 5.14 4.52 4.84 4.18 5.11 Adequate stool specimen collection percentage 2 83% 70% 80% 73% 67% 73% Total stool samples collected 7 21 11 22 16 20 % NPEV isolation 0 0 0 9 0 0 % Timeliness of primary result reported 3 71 100 100 100 100 100 1 Number of discarded AFP cases per 100,000 children under 15 years of age. 2 Percent with 2 specimens, at least 24 hours apart and within 14 days of paralysis onset. 3 Results reported within 14 days of sample received at laboratory. Non-polio AFP rate by district Figure 6: 2015 Figure 7: 2016 WHO/Bhutan/S Bahadur <1 1 1.99 >2 No non-polio AFP case 9
Adequate stool specimen collection % by district Figure 8: 2015 Figure 9: 2016 <60% 60% - 79% >80% No AFP Table 6: OPV SIAs Year Vaccine Geographic coverage Target age Target population Coverage (%) Round 1 Round 2 Round 1 Round 2 1995 OPV NID <5 years 80,336 99 100 1996-1997 OPV SNID <5 years 37,107 100 100 1997-1998 OPV SNID <5 years 37,465 100 100 1998-1999 OPV SNID <5 years 36,006 100 100 1999-2000 OPV SNID <5 years 36,541 100 100 2000-2001 OPV SNID <5 years 38,604 100 100 2001 OPV SNID <5 years 36,753 100 100 2002 OPV SNID <5 years 37,665 96 100 Source: WHO/UNICEF JRF, (multiple years) 10
Towards measles elimination and rubella/crs control Figure 10: MCV1 and MCV2 coverage 1, measles and rubella cases 2, 1980-2016 Table 7: MCV SIAs 500 1642 819 100 Year Antigen Geographic coverage Target group Target Coverage % 400 80 1995 M nationwide 9 months to 15 years 69,285 100% No. of cases 300 200 100 60 40 20 % Coverage 2000 M nationwide 2006 MR nationwide 9 months to 15 years 9 months to 14 years children and 15 years to 44 years women 214,128 100% 338,040 98% 0 1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014 2015 2016 0 Year Measles Cases Rubella MCV1 Coverage MCV2 Coverage 2016 MR subnational 418 100% Source: WHO/UNICEF (multiple years) 1 WHO/UNICEF estimates of national immunization coverage, July 2017 revision 2 WHO vaccine-preventable diseases: monitoring system 2016 11
MCV1 coverage by district MCV2 coverage by district Figure 11: 2015 Figure 12: 2016 Figure 13: 2015 Figure 14: 2016 Source: SEAR annual EPI reporting form, 2015 (administrative data) Source: SEAR annual EPI reporting form, 2016 (administrative data) Source: SEAR annual EPI reporting form, 2015 (administrative data) Source: SEAR annual EPI reporting form, 2016 (administrative data) <80% 80% - 89% 90% - 94% >95% Figure 15: Immunity against measles - immunity profile by age in 2016 Figure 16: Sub-national risk assessment - measles and rubella Percent of population 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Age (in years) Protected by maternal antibodies Protected by routine vaccination with 1st dose Protected by routine vaccination with 2nd dose Protected by SIAs Immune due to past infection Susceptible * Modeled using MSP tool ver 2 assuming the schedule and MCV coverage remain unchanged and no SIAs between 2009 & 2016. 12 Very high risk High risk Medium risk Low risk Not available Source: developed using WHO risk assessment tool based on JRF & ARF data base
Figure 17: Sporadic and outbreak associated measles cases* by month 2011-2016 25 20 15 Sporadic measles Outbreak associated measles 10 5 0 an-11 ar-11 ay-11 ul-11 ep-11 ov-11 an-12 ar-12 ay-12 ul-12 ep-12 ov-12 an-13 *Includes laboratory confirmed and epidemiologically linked cases Source: SEAR Monthly VPD reports. ar-13 Figure 18: Immunization status of confirmed (laboratory and EPI linked) measles outbreak associated cases, by age, 2011-2016 ay-13 ul-13 ep-13 ov-13 an-14 ar-14 ay-14 ul-14 ep-14 ov-14 an-15 ar-15 ay-15 ul-15 ep-15 ov-15 an-16 ar-16 ay-16 ul-16 ep-16 ov-16 18 16 14 12 10 8 6 4 WHO/Bhutan/S Bahadur 2 0 < 1 year 1-4 years 5-9 years 10-14 years > 15 years < 1 year 1-4 years 5-9 years 10-14 years > 15 years < 1 year 1-4 years 5-9 years 10-14 years > 15 years < 1 year 1-4 years 5-9 years 10-14 years > 15 years < 1 year 1-4 years 5-9 years 10-14 years > 15 years < 1 year 1-4 years 5-9 years 10-14 years > 15 years 2011 2012 2013 2014 2015 2016 Immunized Not immunized/ Unknown Source: SEAR annual EPI reporting form (2011-2016) 13
Table 8: Surveillance performance indicators for measles and rubella, 2012-2016 Case classification (number) Indicators Year No. of suspected measles Lab-confirmed Measles EPI-linked Clinically-confirmed Lab-confirmed Rubella EPI-linked Discarded non-measles non-rubella cases Annual incidence of confirmed measles cases per million total population Annual incidence of confirmed rubella cases per million total population Proportion of all suspected measles and rubella cases that have had an adequate investigation initiated within 48 hours of notification Discarded non-measles non-rubella incidence per 100,000 total population Proportion of districts reporting at least two discarded non-measles non-rubella cases per 100,000 total population Proportion of sub-national surveillance units reporting to the national level on time Target - - 80% 2 80% 80% 2012 82 1 0 0 2 0 80 0.7 1.4 0 11.4 ND ND 2013 99 0 0 0 6 0 93 0 4.2 0 13.3 ND ND 2014 69 0 0 0 4 0 65 0 2.8 0 9.3 ND ND 2015 120 11 0 0 1 0 108 16 0.13 0 0 0 0 2016 146 45 ND ND 3 ND 106 53 4 ND 14 ND ND Source: SEAR annual EPI reporting form, 2011-2016 ND=No data Table 9: Performance of laboratory surveillance, 2012-2016 Year Serum specimen collected from suspected measles cases Serum specimen received in laboratory within 5 days of collection Specimen positive for measles IgM Specimen positive for rubella IgM % Results within 4 days of receipt % Positive cases tested for viral detection No (%) No (%) No. % No. % Measles Rubella 2012 82 (100) 50 (81) 1 1% 2 2% 37 0 - - 2013 99 (100) 57 (69) 0 0% 6 6% 52 0 - - 2014 69 (100) 30 (43) 0 0% 4 6% 100 0 - - 2015 120 (100) 120 (100) 11 9% 1 1% 100 0 - - 2016 146 (100) 146 (100) 40 27% 3 2% ND ND ND ND Source: SEAR annual EPI reporting form, 2012-2016 ND=No data Genotypes detected 14
Figure 19: WHO supported laboratory network for VPD surveillance Public Health Laboratory National measles/rubella laboratory National Japanese encephalitis laboratory 15
For contact or feedback: Expanded Programme on Immunization Ministry of Health, Thimphu, Bhutan Tel: +975-2-332296, Fax: +975-2-332296 Email: ttamang@health.gov.bt www.health.gov.bt Immunization and Vaccine Development (IVD) WHO-SEARO, IP Estate, MG Marg, New Delhi 110002, India Tel: +91 11 23370804, Fax: +91 11 23370251 Email: SearEpidata@who.int www.searo.who.int/entity/immunization