Bhutan 2017

FACT SHEET

Expanded Programme on Immunization (EPI)

Acronyms

AD Auto disable

AEFI Adverse events following immunization

AFP Acute flaccid paralysis

BCG Bacillus Calmette-Guérin vaccine

CES Coverage evaluation survey

cMYP Comprehensive multi-year plan

CRS Congenital rubella syndrome

DHS Demographic health survey

DT Diphtheria tetanus toxoid, pediatric

DTP Diphtheria – tetanus – pertussis vaccine

DTP-Hib-HepB Pentavalent vaccine

DTP-Hib-HepB3 3rd dose pentavalent vaccine

EPI Expanded programme on immunization

GDP Gross domestic product

HCW Health care worker

HepB Hepatitis B vaccine

Hib Haemophilus influenzae type b

HPV Human papilloma virus

IgM Immunoglobulin M

IPV Inactivated poliovirus vaccine

JE Japanese encephalitis

JE_Live-Atd JE live attenuated vaccine

JRF WHO UNICEF joint reporting form

LB Live birth

M Measles

MCV1 First dose measles containing vaccine

MCV2 Second dose measles containing vaccine

MICS Multiple indicator cluster survey

MMR Measles mumps rubella vaccine

MNT Maternal and neonatal tetanus

MR Measles rubella vaccine

NCIP National committee on immunization practices

NID National immunization day

NTAGI National technical advisory group on immunization

NPEV Non-polio enterovirus

NT Neonatal tetanus

OPV Oral poliovirus vaccine

bOPV Bivalent OPV

tOPV Trivalent OPV

PCV Pneumococcal conjugate vaccine

SEAR WHO South-East Asia Region

SIA Supplementary immunization activities

SNID Subnational immunization day

Td Tetanus diphtheria toxoid; older children, adults

TT Tetanus toxoid

TT2+ 2 or more doses TT

VDPV Vaccine derived poliovirus

VPD Vaccine preventable diseases

WCBA Women of child bearing age

WPV Wild poliovirus

Contents

Impact of routine immunization Page No.

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

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

Maternal and neonatal tetanus elimination is sustained Page No.

TT2+ coverage and NT cases 1980 - 2016 Figure 5 8

Polio-free status is maintained 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

WHO South-East Asia Region

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.

Bhutan: district level map

4

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

Table 1: Basic information1 2016

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 rate2 27.2 (per 1,000 LB)

Under-five mortality rate 32.9 (per 1,000 LB)

Maternal mortality ratio2 148 (per 100,000 LB)

1SEAR annual EPI reporting form, 2016 and WHO, World Health Statistics 20162VPDP/MOH

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 drinking-water sources2

97.7%

Population using improved sanitation2 66.3%

Total expenditure on health as % of GDP 3.6%

Births attended by skilled health personnel2

74.6%

Neonates protected at birth against NT 83%

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

Impact of routine immunization

5

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 in place

National system to monitor AEFI 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

Figure 1: National immunization coverage, 1980-2016

% C

over

age

0

20

40

60

80

100

Source: WHO/UNICEF estimates of national immunization coverage, July 2017 revision

1980 1985 1990 1995 2000 2005 2010 2014 2015 2016BCG 43 54 99 98 97 92 96 99 99 99DTP3 6 41 96 87 92 95 91 99 99 98OPV 4 41 96 86 98 95 92 98 98 97MCV1 21 44 93 85 78 93 95 97 97 97

6

Figure 3: 2015

Figure 4: 2016

Source: SEAR annual EPI reporting form, 2016 (administrative data)

Source: SEAR annual EPI reporting form, 2015 (administrative data)

Figure 2: DTP3 coverage1, diphtheria and pertussis cases2, 1980-2016

Year

Diphtheria Cases Pertussis Cases DTP3 Coverage

% C

over

age

No.

of c

ases

201620152014201320122011201020052000199519901980 1985

464

0

20

40

60

80

100

0

50

100

150

200

250

300

1WHO/UNICEF estimates of national immunization coverage, July 2017 revision 2WHO vaccine-preventable diseases: monitoring system 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

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

DTP-Hib-HepB3 coverage by district

<70% 70% - 79% 80% - 89% > 90%

7

Figure 5: TT2+ coverage1 and NT cases2, 1980-2016

1WHO/UNICEF JRF, Country official estimates, 1980-20162WHO vaccine-preventable diseases: monitoring system 2016

Maternal and neonatal tetanus elimination is sustained

1980 1985 1990 1995 2000 2005 2010 2011 2012 2013 2014 2015 2016

% C

over

age

No.

of c

ases

Year

NT Cases TT2+ Coverage

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

0

20

40

60

80

100

No data

MNT elimination before 2000

8

Table 5: AFP surveillance performance indicators, 2011-2016

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 rate1 2.74 5.14 4.52 4.84 4.18 5.11

Adequate stool specimen collection percentage2 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 reported3 71 100 100 100 100 1001Number of discarded AFP cases per 100,000 children under 15 years of age.2Percent with 2 specimens, at least 24 hours apart and within 14 days of paralysis onset.3Results reported within 14 days of sample received at laboratory.

Figure 6: 2015 Figure 7: 2016

Polio-free status is maintained

Last clinically-confirmed polio case was reported in 1986.

Non-polio AFP rate by district

<1 1 – 1.99

>2 No non-polio AFP case

© WHO/Bhutan/S Bahadur

9

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)

Figure 9: 2016Figure 8: 2015

Adequate stool specimen collection % by district

<60% 60% - 79%

>80% No AFP

10

Towards measles elimination and rubella/CRS control

Figure 10: MCV1 and MCV2 coverage1, measles and rubella cases2, 1980-2016

Measles Cases Rubella MCV1 Coverage MCV2 Coverage

2016201520142013201220112010200520001995199019851980

1642 819

% C

over

age

No.

of c

ases

Year

0

100

200

300

400

500

0

20

40

60

80

100

1WHO/UNICEF estimates of national immunization coverage, July 2017 revision 2WHO vaccine-preventable diseases: monitoring system 2016

Table 7: MCV SIAs

Year Antigen Geographic coverage Target group Target Coverage %

1995 M nationwide 9 months to 15 years 69,285 100%

2000 M nationwide 9 months to 15 years 214,128 100%

2006 MR nationwide

9 months to 14 years

children and 15 years

to 44 years women

338,040 98%

2016 MR subnational 418 100%

Source: WHO/UNICEF (multiple years)

11

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Per

cent

of p

opul

atio

n

Age (in years)Protected by maternal antibodies Protected by routine vaccination with 1st doseProtected by routine vaccination with 2nd dose Protected by SIAsImmune due to past infection Susceptible

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Figure 15: Immunity against measles - immunity profile by age in 2016

* Modeled using MSP tool ver 2 assuming the schedule and MCV coverage remain unchanged and no SIAs between 2009 & 2016.

<80% 80% - 89% 90% - 94% >95%

Figure 12: 2016 Figure 13: 2015 Figure 14: 2016

Source: SEAR annual EPI reporting form, 2016 (administrative data)

Source: SEAR annual EPI reporting form, 2016 (administrative data)

Figure 11: 2015

Source: SEAR annual EPI reporting form, 2015 (administrative data)

Source: SEAR annual EPI reporting form, 2015 (administrative data)

Figure 16: Sub-national risk assessment - measles and rubella

MCV1 coverage by district MCV2 coverage by district

Source: developed using WHO risk assessment tool based on JRF & ARF data base

Very high riskHigh riskMedium riskLow riskNot available

12

Figure 17: Sporadic and outbreak associated measles cases* by month 2011-2016

Nov-

16Se

p-16

Jul-1

6M

ay-1

6M

ar-1

6Ja

n-16

Nov-

15Se

p-15

Jul-1

5M

ay-1

5M

ar-1

5Ja

n-15

Nov-

14Se

p-14

Jul-1

4M

ay-1

4M

ar-1

4Ja

n-14

Nov-

13Se

p-13

Jul-1

3M

ay-1

3M

ar-1

3Ja

n-13

Nov-

12Se

p-12

Jul-1

2M

ay-1

2M

ar-1

2Ja

n-12

Nov-

11Se

p-11

Jul-1

1M

ay-1

1M

ar-1

1Ja

n-11

Sporadic measles

Outbreak associated measles

0

5

10

15

20

25

*Includes laboratory confirmed and epidemiologically linked casesSource: SEAR Monthly VPD reports.

Figure 18: Immunization status of confirmed (laboratory and EPI linked) measles outbreak associated cases, by age, 2011-2016

> 1

5 ye

ars

10-1

4 ye

ars

5-9

year

s1-

4 ye

ars

< 1

yea

r>

15

year

s10

-14

year

s5-

9 ye

ars

1-4

year

s<

1 y

ear

> 1

5 ye

ars

10-1

4 ye

ars

5-9

year

s1-

4 ye

ars

< 1

yea

r>

15

year

s10

-14

year

s5-

9 ye

ars

1-4

year

s<

1 y

ear

> 1

5 ye

ars

10-1

4 ye

ars

5-9

year

s1-

4 ye

ars

< 1

yea

r>

15

year

s10

-14

year

s5-

9 ye

ars

1-4

year

s<

1 y

ear

2011 2012 2013 2014 2015 2016Immunized Not immunized/ Unknown

0

2

4

6

8

10

12

14

16

18

Source: SEAR annual EPI reporting form (2011-2016)

© WHO/Bhutan/S Bahadur

13

Table 8: Surveillance performance indicators for measles and rubella, 2012-2016

Year

No.

of s

uspe

cted

mea

sles

Case classification (number) Indicators

Measles Rubella

Disc

arde

d no

n-m

easle

s no

n-ru

bella

cas

es

Annu

al in

cide

nce

of

confi

rmed

mea

sles c

ases

per

m

illio

n to

tal p

opul

ation

Annu

al in

cide

nce

of

confi

rmed

rube

lla c

ases

per

m

illio

n to

tal p

opul

ation

Prop

ortio

n of

all

susp

ecte

d m

easle

s and

rube

lla c

ases

th

at h

ave

had

an a

dequ

ate

inve

stiga

tion

initi

ated

with

in

48 h

ours

of n

otific

ation

Disc

arde

d no

n-m

easle

s no

n-ru

bella

inci

denc

e pe

r 10

0,00

0 to

tal p

opul

ation

Prop

ortio

n of

dist

ricts

re

porti

ng a

t lea

st tw

o di

scar

ded

non-

mea

sles

non-

rube

lla c

ases

per

10

0,00

0 to

tal p

opul

ation

Prop

ortio

n of

sub-

natio

nal

surv

eilla

nce

units

repo

rting

to

the

natio

nal l

evel

on

time

Lab-

confi

rmed

EPI-l

inke

d

Clin

ical

ly-c

onfir

med

Lab-

confi

rmed

EPI-l

inke

d

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 NDSource: SEAR annual EPI reporting form, 2011-2016 ND=No data

Year

Seru

m sp

ecim

en

colle

cted

from

su

spec

ted

mea

sles c

ases

Seru

m sp

ecim

en

rece

ived

in

labo

rato

ry

with

in 5

day

s of

colle

ction

Spec

imen

po

sitive

for

mea

sles I

gM

Spec

imen

po

sitive

for

rube

lla Ig

M

% R

esul

ts w

ithin

4

days

of r

ecei

pt

% P

ositi

ve c

ases

te

sted

for v

iral

dete

ction

Geno

type

s de

tect

ed

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 NDSource: SEAR annual EPI reporting form, 2012-2016 ND=No data

Table 9: Performance of laboratory surveillance, 2012-2016

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 ImmunizationMinistry of Health, Thimphu, BhutanTel: +975-2-332296, Fax: +975-2-332296Email: ttamang@health.gov.btwww.health.gov.bt

Immunization and Vaccine Development (IVD)WHO-SEARO, IP Estate, MG Marg, New Delhi 110002, IndiaTel: +91 11 23370804, Fax: +91 11 23370251Email: SearEpidata@who.intwww.searo.who.int/entity/immunization