Expanded Programme on Immunization (EPI)

Sri Lanka 217 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 216 Table 1 5 Immunization schedule 216 Table 2 5 National immunization coverage 198-216 Figure 1 6 Immunization system highlights Table 3 6 DTP3 coverage, diphtheria and pertussis cases 198-216 Figure 2 7 Reported cases of vaccine preventable diseases 211-216 Table 4 7 DTP-Hib-HepB3 coverage by district 215 Figure 3 7 DTP-Hib-HepB3 coverage by district 216 Figure 4 7 Maternal and neonatal tetanus elimination is sustained TT2+ coverage and NT cases 198-216 Figure 5 8 Polio-free status is maintained Page No. Page No. Page No. AFP surveillance indicators 211-216 Table 5 9 Non-polio AFP rate by district 215 Figure 6 9 Non-polio AFP rate by district 216 Figure 7 9 Adequate stool specimen collection percentage by district 215 Figure 8 1 Adequate stool specimen collection percentage by district 216 Figure 9 1 OPV supplementary immunization activities Table 6 1 Towards measles elimination and rubella/congenital rubella syndrome control Page No. MCV1 and MCV2 coverage, measles and rubella cases, 198-216 Figure 1 11 MCV supplementary immunization activities Table 7 11 MCV1 coverage by district 215 Figure 11 12 MCV1 coverage by district 216 Figure 12 12 MCV2 coverage by district 215 Figure 13 12 MCV1 coverage by district 216 Figure 14 12 Immunity against measles immunity profile by age in 216 Figure 15 12 Subnational risk assessment for measles and rubella Figure 16 12 Sporadic and outbreak associated measles cases by month 211-216 Figure 17 13 Immunization status of confirmed (laboratory and Epi linked) measles outbreak associated cases by age 211 216 Figure 18 13 Quality of field and laboratory surveillance for measles and rubella 212-216 Table 8 14 Performance of laboratory surveillance 212-216 Table 9 14 WHO supported laboratory network for VPD surveillance Figure 19 15

WHO South-East Asia Region Sri Lanka: province 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 1 216 EPI history EPI launched in 1978 Inactivated JE vaccine introduced in 1988 and live JE vaccine nationwide in 211 Rubella vaccine introduced in 1996 Vitamin A supplementation added in 2 MR vaccine and atd vaccine introduced in 21 HepB vaccine introduced in 23 DTP-Hib-HepB vaccine introduced in 28 Total population 21,164,458 Live births 331,73 Children <1 year 33,461 Children <5 years 1,82,143 Children <15 years 5,333,443 Pregnant women 331,73 WCBA (15-49 years) 4,939,621 Neonatal mortality rate 5.4 (per 1, LB) Infant mortality rate 8.4 (per 1, LB) Under-five mortality rate 9.8 (per 1, LB) Maternal mortality ratio 3 (per 1, LB) 1 SEAR annual EPI reporting form, 216 and WHO, World Health Statistics 216 Division/Province/State/Region 9 District 26 Medical officer of health (MOH) areas 337 Population density (per sq. km) 324 Population living in urban areas 18% Population using improved drinking-water sources 94% Population using improved sanitation 92% Total expenditure on health as % of GDP 3.1% Births attended by skilled health personnel 99% Neonates protected at birth against NT 95% MMR vaccine introduced in 211 IPV introduced in 215 Nationwide fipv introduced in 216 topv to bopv switched on 3 April 216. Source: cmyp 217-221 and EPI/MOH Table 2: Immunization schedule, 216 Vaccine Age of administration BCG Birth DTP-Hib-HepB 2 months, 4 months and 6 months OPV 2 months, 4 months, 6 months, 18 months and 5 years IPV (fipv) 2 months and 4 months JE_LiveAtd 1 year MMR 9 months and 3 years DTP 18 months DT 5 years atd 12 years TT Pregnant women (2 doses in 1st pregnancy and 1 dose in subsequent 3 pregnancies) Vitamin A 6 to 36 months Source: WHO/UNICEF JRF, 216 5

Figure 1: National immunization coverage, 198-216 1 8 % Coverage 6 4 2 198 1985 199 1995 2 25 21 214 215 216 BCG 61 71 84 9 98 99 99 99 99 99 DTP3 46 7 86 93 99 99 99 99 99 99 OPV 46 71 86 92 99 99 99 99 99 99 MCV1 2 8 87 99 99 99 99 99 99 Source: WHO/UNICEF estimates of national immunization coverage, July 217 revision Table 3: Immunization system highlights cmyp for immunization 217-221 NTAGI fully functional Spending on vaccines financed by the government no data Spending on routine immunization programme financed by the government 74% Updated micro-plans that include activities to improve immunization coverage 26 districts (1%) National policy for health care waste management including waste from immunization activities in place National system to monitor AEFI in place Most recent EPI CES EPI coverage survey Nuwara Eliya district 216 >8% coverage for DTP-Hib-HepB3 26 districts (1%) >9% coverage for MCV1 26 districts (1%) >1% drop-out rate for DTP-Hib-HepB1 to DTP-Hib-HepB3 no district Source: WHO/UNICEF JRF, 216 6

Figure 2: DTP3 coverage 1, diphtheria and pertussis cases 2, 198-216 542 536 3 25 1 8 DTP-Hib-HepB3 coverage by district Figure 3: 215 No. of cases 2 15 1 6 4 % Coverage 5 2 198 1985 199 1995 2 25 21 211 212 213 214 215 216 Year Source: SEAR annual EPI reporting form, 215 (administrative data) Diphtheria Cases Pertussis Cases DTP3 Coverage 1 WHO/UNICEF estimates of national immunization coverage, July 217 revision 2 WHO vaccine-preventable diseases: monitoring system 216 Figure 4: 216 Table 4: Reported cases of vaccine preventable diseases, 211-216 Year Polio Diphtheria Pertussis NT (% of all tetanus) Measles Rubella Mumps JE CRS 211 23 6 416 1,129 3 3 212 61 51 54 3,558 6 12 213 67 2,17 24 1,274 7 4 214 38 1,686 1 383 21 4 215 17 1,568 9 ND 17 216 54 112 311 18 Source: WHO/UNICEF JRF, (multiple years) ND=No data Source: SEAR annual EPI reporting form, 216 (administrative data) <7% 7% - 79% 8% - 89% >9% 7

Maternal and neonatal tetanus elimination is sustained Figure 5: TT2+ coverage 1 and NT cases 2, 198-216 MNT elimination before 2 8 339 1 7 6 8 No. of cases 5 4 3 6 4 % Coverage 2 1 2 198 1985 199 1995 2 25 21 211 212 213 214 215 216 Year WHO/Sri Lanka/K Reidey NT Cases 1 WHO/UNICEF JRF, Country official estimates, 198-215 2 WHO vaccine-preventable diseases: monitoring system 215 & JRF 215 TT2+ Coverage 8

Polio-free status is maintained Table 5: AFP surveillance performance indicators, 211-216 The last laboratory confirmed polio case due to WPV was reported in November 1993. Indicator 211 212 213 214 215 216 AFP cases 88 75 13 84 7 65 Wild poliovirus confirmed cases Compatible cases Non-polio AFP rate 1 1.42 1.54 1.66 1.59 1.35 1.2 Adequate stool specimen collection percentage 2 86% 8% 82% 75% 77% 85% Total stool samples collected 175 156 168 134 137 14 % NPEV isolation 1 4 6 5.3 1 3.8 % Timeliness of primary result reported 3 99 89 98 98 89 81 1 Number of discarded AFP cases per 1, 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: 215 Figure 7: 216 WHO/Sri Lanka/K Reidey <1 1 1.99 >2 No non-polio AFP case 9

Adequate stool specimen collection % by district Figure 8: 215 Figure 9: 216 <6% 6% - 79% >8% No AFP Table 6: OPV SIAs Year Vaccine Geographic coverage Target age Target population Coverage (%) Round 1 Round 2 Round 1 Round 2 1997 OPV NID <5 years 1,838,465 97 95 1998 OPV NID <5 years 1,856,85 92 88 1999 OPV NID <5 years 2,32,556 93 93 2 OPV NID <5 years 634,999 93 93 21 OPV SNID <5 years 514,821 96 91 22 OPV SNID <5 years 272,559 98 97 23 OPV SNID <5 years 536,269 97 98 Source: NCCPE reports and WHO/UNICEF JRF 1

Towards measles elimination and rubella/crs control Figure 1: MCV1 and MCV2 coverage 1, measles and rubella cases 2, 198-216 Table 7: MCV SIAs 6 9398 16527 1 Year Antigen Geographic coverage Target group Target Coverage % 5 8 23 M 2 districts 1 to 15 years 1,987,847 95 No. of cases 4 3 2 6 4 % Coverage 24 MR nationwide 213 M nationwide 16 to 2 years 6 to 12 months 1,89,326 72 176,587 96 1 2 Source: WHO/UNICEF JRF, (multiple years) 198 1985 199 1995 2 25 21 211 212 213 214 215 216 Year Measles Cases Rubella MCV1 Coverage MCV2 Coverage 1 WHO/UNICEF estimates of national immunization coverage, July 217 revision 2 WHO vaccine-preventable diseases: monitoring system 216 11

MCV1 coverage by district Figure 15: Immunity against measles - immunity profile by age in 216* 1% Figure 11: 215 Figure 12: 216 Percent of population 8% 6% 4% 2% Source: SEAR annual EPI reporting form, 215 (administrative data) MCV2 coverage by district Source: SEAR annual EPI reporting form, 216 (administrative data) % 1 2 3 4 5 6 7 8 9 1 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 in 216. Figure 16: Sub-national risk assessment - measles and rubella Figure 13: 215 Figure 14: 216 Very high risk High risk Medium risk Low risk Not available Source: SEAR annual EPI reporting form, 215 (administrative data) Source: SEAR annual EPI reporting form, 216 (administrative data) <8% 8% - 89% 9% - 94% >95% 12 Source: developed using WHO risk assessment tool based on JRF & ARF data base

Figure 17: Sporadic and outbreak associated measles cases* by month, 211-216 35 3 No of cases 25 2 15 Sporadic measles Outbreak associated measles 1 5 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 *Includes laboratory confirmed and epidemiologically linked cases Source: SEAR Monthly VPD reports Mar-13 Figure 18: Immunization status of confirmed (laboratory and EPI linked) measles outbreak associated cases, by age, 211-216 8 May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 7 6 5 4 3 2 1 WHO/Sri Lanka/K Reidey < 1 year 1-4 years 5-9 years 1-14 years > 15 years < 1 year 1-4 years 5-9 years 1-14 years > 15 years < 1 year 1-4 years 5-9 years 1-14 years > 15 years < 1 year 1-4 years 5-9 years 1-14 years > 15 years < 1 year 1-4 years 5-9 years 1-14 years > 15 years < 1 year 1-4 years 5-9 years 1-14 years > 15 years 211 212 213 214 215 216 Immunized Not immunized/ unknown Source: SEAR annual EPI reporting form (211-216) 13

Table 8: Surveillance performance indicators for measles and rubella, 212-216 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 1, total population Proportion of subnational administrative units reporting at least two discarded nonmeasles non-rubella cases per 1, total population Proportion of sub-national surveillance units reporting to the national level on time Target - - 8% 2 8% 8% 212 147 7 ND 117 23 ND 54 2.5 2.7 ND.27 ND 1% 213 4,8 1,759 ND 966 2 ND 598 22 1.2 ND 2.99 ND 1% 214 3,117 1,593 958 11 555 76.5 ND 2.7 ND 1% 215 2,432 1,297 271 9 855 62.4 ND 4 ND 1% 216 339 76 43 263 3.5 87 1.21 12 1% Source: SEAR annual EPI reporting form (212-216) ND=No data Table 9: Performance of laboratory surveillance, 212-216 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 % Confirmed cases tested for viral detection No (%) No (%) No. % No. % Measles Rubella 212 84 (57%) ND 7 8 23 5 68 ND ND 2B 213 2,377 (58%) ND 1,759 74 2 4 46 ND ND ND 214 2,159 (69%) ND 1,593 74 11 5 75 ND B3 ND 215 2,161 (89%) 1,42 (65%) 1,297 72 9 2 75 ND B3 ND 216 296 (87%) 296 (1%) 76 25.7 6* 2 94 ND ND ND *this includes 5 rubella Igm positive samples that were subsequently excluded as they are post vaccination and one sample that was a repeat sample Source: SEAR annual EPI reporting form (212-216) ND=No data Genotypes detected 14

Figure 19: WHO supported laboratory network for VPD surveillance Medical Research Institute, Colombo National polio laboratory National measles and rubella laboratory National Japanese encephalitis laboratory Rotavirus laboratory Lady Ridgeway Hospital, Colombo Invasive bacterial disease laboratory 15

For contact or feedback: Expanded Programme on Immunization Ministry of Health, Colombo, Sri Lanka Tel: +94 11 2695112; Fax: +94-11-2696583 Email: samithag@hotmail.com www.health.gov.lk Immunization and Vaccine Development (IVD) WHO-SEARO, IP Estate, MG Marg, New Delhi 112, India Tel: +91 11 233784, Fax: +91 11 2337251 Email: SearEpidata@who.int www.searo.who.int/entity/immunization