epi vpd surveillance review report myanmar 2016

SEA-Immun-114
Distribution: General

Joint National/International Expanded
Programme on Immunization and
Vaccine Preventable Disease
Surveillance Review
Republic of the Union of Myanmar
25 September – 8 October 2016

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Joint National/International Expanded Programme on Immunization and Vaccine Preventable Disease Surveillance
Review, Republic of the Union of Myanmar, 25 September – 8 October 2016 (SEA-Immun-114)

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TABLE OF CONTENT
ACRONYMS ............................................................................................................................................... I
ACKNOWLEDGEMENTS ........................................................................................................................... IV
EXECUTIVE SUMMARY ......................................................................................................................... - 1 INTRODUCTION ..................................................................................................................................... 10
BACKGROUND ....................................................................................................................................... 12
REVIEW OBJECTIVES .............................................................................................................................. 21
METHODOLOGY ..................................................................................................................................... 22
LIMITATIONS ......................................................................................................................................... 23
FINDINGS AND KEY RECOMMENDATIONS BY TOPIC AREA ..................................................................... 24

GENERAL ..................................................................................................................................................... 24
GOVERNMENT SUPPORT ................................................................................................................................. 24
PROGRESS IN MEETING GLOBAL AND REGIONAL GOALS. ....................................................................................... 46
NUVI ......................................................................................................................................................... 60
CONCLUSION ......................................................................................................................................... 63
ANNEXES ............................................................................................................................................... 64
ANNEX 1.
ANNEX 2.
ANNEX 3.
ANNEX 4.

LIST OF PARTICIPANTS IN JOINT NATIONAL/INTERNATIONAL EPI REVIEW ............................................. 64
AFP SURVEILLANCE INDICATORS, MYANMAR, 2016 AS OF WEEK 42 ................................................ 67
QUALITY OF MEASLES PERFORMANCE INDICATORS, MYANMAR, 2011-2015 ...................................... 68
MYANMAR IN THE CONTEXT OF IMMUNIZATION GOALS & TARGETS ................................................... 69

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List of Tables
TABLE 1. EPI SCHEDULE, MYANMAR, 2016 ------------------------------------------------------------------------------------------ 17

TABLE 2. FINANCIAL INDICATORS REPORTED TO WHO, MYANMAR, 2013-2015 (ALL FUND AMOUNTS IN US$) --------------- 18
TABLE 3. VACCINATION COVERAGE: WHO AND UNICEF BEST ESTIMATES AND COUNTRY ESTIMATES. MYANMAR, 20122015. ----------------------------------------------------------------------------------------------------------------------------- 19
TABLE 4. DHS ESTIMATES OF VACCINATION COVERAGE. MYANMAR, 2015-2016 ------------------------------------------------ 20
TABLE 5. VPDS REPORTED TO WHO, 2013 – 2016 -------------------------------------------------------------------------------- 21
TABLE 6. BASELINE COST PROFILE OF IMMUNIZATION PROGRAMME IN 2015 ------------------------------------------------------ 26
TABLE 7. FUTURE IMMUNIZATION PROGRAMME RESOURCE REQUIREMENTS, 2017-2021---------------------------------------- 27
TABLE 8. SOURCES OF EPI VACCINE FUNDING IN MYANMAR AS OF AUGUST 2016 ----------------------------------------------- 33
TABLE 9. AFP AND FEVER/RASH SURVEILLANCE INDICATORS, MYANMAR, 2012 - 2015 ----------------------------------------- 43

List of Figures
FIGURE 1. MAP OF MYANMAR............................................................................................................................. 12
FIGURE 2. ORGANOGRAM OF THE MOHS, MYANMAR.............................................................................................. 14
FIGURE 3. ORGANOGRAM OF THE DOPH, MYANMAR .............................................................................................. 14
FIGURE 4. MAP OF MYANMAR SHOWING SITES VISITED BY THE REVIEW TEAM ............................................................... 23
FIGURE 5. REPORT ROUTING, TIMELINE AND MANDATED ACTIONS FOR AEFI ................................................................. 31
FIGURE 6. REPORTED SERIOUS AEFI CASES, MYANMAR, 2007 - 2015 ........................................................................ 32
FIGURE 7. PERFORMANCE OF ISC IN MYANMAR ...................................................................................................... 34
FIGURE 8. INTEGRATED WEEKLY VPD REPORTING .................................................................................................... 42
FIGURE 9. FIRST AND SECOND DOSE COVERAGE OF MCV, SIAS, AND CASE AND DEATH COUNT, MYANMAR, 1987 – MID2016 ..................................................................................................................................................... 51
FIGURE 10. PERCENTAGE OF TOWNSHIPS WITH AT EAST 95% COVERAGE WITH MCV1, BY YEAR. MYANMAR, 2010 - 2015. 51

FIGURE 11. SEROPREVALENCE OF CHRONIC HBV INFECTION IN 18 TOWNSHIPS ............................................................. 54
FIGURE 12. REPORTED DIPHTHERIA CASES BY AGE AND VACCINATION STATUS. MYANMAR, 2016 ..................................... 56

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ACRONYMS
3MDG

Three Millennium Development Goal Fund

AEFI

adverse events following immunization

AES

acute encephalitis syndrome

AFP

acute flaccid paralysis

BCG

Bacille Calmette Guerin

bOPV

bivalent oral poliovirus vaccine

CEPI

Central Expanded Programme on Immunization

CEU

Central Epidemiology Unit

CIF

case investigation form

cMYP

comprehensive multi-year plan

CRS

congenital rubella syndrome

CTC

controlled temperature chain

cVDPV

circulating vaccine-derived poliovirus

cVDPV2

type 2 vaccine-derived poliovirus

DG

Director General (of Public Health)

DHS

Demographic Health Survey

DoPH

Department of Public Health

DoV

Decade of Vaccines

DTP

diphtheria–tetanus-pertussis

EPI

Expanded Programme on Immunization

EVM

Effective Vaccine Management

GAPIII

third edition of the Global Action Plan to minimize posteradication poliovirus facility-associated risk

Gavi

Gavi, the Vaccine Alliance

GDP

gross domestic product

GNI

gross national income

GVAP

Global Vaccine Action Plan

GSP

good supply practices

HBV

hepatitis B virus

HCW

health care worker

HBeAg

hepatitis B e antigen

HBsAg

hepatitis B surface antigen

HepB

hepatitis B vaccine

HepB-BD

hepatitis B vaccine birth dose
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Hib

Haemophilus influenzae type B

HPV

human papilloma virus

HSS2

second health system strengthening grant (from Gavi, the
Vaccine Alliance)

IEC

information, education and communication

INGO

international nongovernmental organization

IPAC

Immunization Practices Advisory Committee

IPV

inactivated poliovirus vaccine

iSC

immunization supply chain

JCV

Japan Committee "Vaccines for the World's Children"

JE

Japanese encephalitis

M

single antigen measles vaccine

M2

second dose of single antigen measles vaccine

MCV

measles antigen containing vaccine

MCV1

first dose of measles antigen containing vaccine

MCV2

second dose of measles antigen containing vaccine

MNTE

maternal and neonatal tetanus elimination

MoHS

Ministry of Health and

MoPF

Ministry of Planning and

MR

measles-rubella vaccine (MR)

MR1

first dose of measles–rubella vaccine

MR2

second dose of measles-rubella vaccine

MW

midwife

Myanmar

the Republic of the Union of Myanmar

NCCPE

National Certification Commission for Polio Eradication

NCIP

National Committee for Immunization Practices

NGO

non-governmental organization

NHL

National Health Laboratory

NHP

National Health Plan

NPERC

National Polio Expert Review Committee

NPLCC

National Polio Laboratory Containment Committee

NRA

National Regulatory Authority

NT

neonatal tetanus

NUVI

new and underutilized vaccine introduction

NVC

National
Verification
Committee
(for
measles
rubella/congenital rubella syndrome elimination)
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and

OBRA

(poliovirus) outbreak response assessment

OPV

oral polio vaccine

OPV3

third dose of oral polio vaccine

P1

poliovirus type 1

P2

poliovirus type 2

PCV

pneumococcal conjugate vaccine

Penta

pentavalent vaccine (diphtheria-pertussis-tetanus-hepatitis BHaemophilus influenzae type B)

Pol3

third dose of polio vaccine (either oral or inactivated)

PV2

Poliovirus type 2

RCV1

first dose of rubella antigen containing vaccine

RHC

rural health centre

RHSC

rural health sub-centre

RSO

regional surveillance officer

SEAR

World Health Organization South-East Asia Region

SEAR ITAG

South-East Asia
Immunization

SEARVAP

South-East Asia Region Vaccine Action Plan

SIA

supplementary immunization activity

SOP

standard operating procedure

THE

total health expenditure

tOPV

trivalent oral poliovirus vaccine

TT

tetanus toxoid

TT2

second dose of tetanus toxoid

UHC

universal health care

UNICEF

United Nations Children’s Fund

US CDC

United States Centres for Disease Control and Prevention

VDPV

vaccine-derived poliovirus

VDPV2

type 2 vaccine-derived poliovirus

VII

Vaccine Independence Initiative

VPD

vaccine preventable disease

VVM

vaccine vial monitor

WPV

wild poliovirus

WHO

World Health Organization

YCH

Yangon Children’s Hospital

Regional Technical Advisory Group on

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ACKNOWLEDGEMENTS
The review team would like to gratefully acknowledge the support provided by the
Ministry of Health and Sport, the Republic of the Union of Myanmar, the World
Health Organization Country Office in the Republic of the Union of Myanmar, and
the WHO Regional Office for South-East Asia. Their provision of administrative,
management

and

technical

assistance

was

critical

to

the

successful

implementation of the mission. The team would also like to acknowledge the long
list of persons throughout the Republic of the Union of Myanmar in multiple offices
and agencies who shared their time and gave insights into the status of the
Expanded Programme on Immunization and vaccine preventable disease
surveillance in Myanmar. The review team would particularly like to acknowledge
the commitment and interest of the Union Minister of Health and Sport who found
time in his busy schedule for a two hour meeting with the review team to discuss
findings and recommendations.

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EXECUTIVE SUMMARY
Background and Methodology
The Expanded Programme on Immunization (EPI) in the Republic of the Union of
Myanmar (Myanmar) has achieved considerable success in preventing and controlling
vaccine preventable diseases (VPD). The country has seen a recent increase in
government commitment to EPI. Since 2015 (inclusive), Myanmar has successfully
introduced four vaccines and intends to introduce three more by end-2019. However,
the country faces new challenges as it is forecast to transition from eligibility for funding
from Gavi, the Vaccine Alliance (Gavi) and must self-finance all vaccines by 2025.
Furthermore, as the country seeks to reach every child with vaccine, it faces unique
sociocultural and political challenges.
As part of systematic reviews scheduled to be carried out in all World Health
Organization (WHO) South-East Asia Region (SEAR) countries, WHO’s Regional
Office for South-East Asia and Myanmar’s Ministry of Health and Sport (MoHS)
collaborated to conduct a Joint National/International EPI and VPD Surveillance
Review in Myanmar from 25 September to 08 October 2016. In 2015, Myanmar had
also experienced an outbreak of circulating type 2 vaccine-derived poliovirus
(cVDPV2), to which the country responded in accordance with WHO guidelines. This
response was assessed concurrently with the EPI and VPD Surveillance Review; the
results of the assessment are reported elsewhere.1
The objectives of Myanmar’s Review were to:
 Understand which children in Myanmar are not being fully immunized and the
reasons that this is occurring. To the extent possible, efforts were made to assess
areas with limited access to government services and increased reliance on other
providers such as non-governmental organizations (NGOs) or local administrations;
 Determine if the VPD surveillance system meets national and global targets and is
currently able to detect any VPD outbreaks; this would include laboratory support
and data management systems;
 Determine if the strategies being implemented for measles and rubella objectives
are adequate to maintain or achieve targets;
 Assess how strategies and capacities of the immunization programme need to be
strengthened to sustain polio-free status and maternal and neonatal tetanus
elimination (MNTE), accelerate hepatitis B control and uniformly increase coverage
for all routine vaccines; this would include vaccine and supply management,

1

WHO. Regional Office for South-East Asia. Immunization. Documents and Publications.
External Second Assessment: Circulating Vaccine-Derived Poliovirus Type 2 (cVPDV2)
Outbreak Response, Myanmar, 25 September-8 October 2016. Available at
http://www.searo.who.int/entity/immunization/documents/en/ (Accessed Feb 1 2017)

-1-

adverse events following immunization (AEFI) management, financing and
sustainability.
Myanmar’s Central Epidemiology Unit (CEPI), and WHO’s Regional Office for SouthEast Asia and Country Office in Myanmar collaborated to assemble a review team of
Myanmar members drawn from national and state/regional levels as well as
internationals representing a variety of agencies. The team conducted a desk review of
relevant policies and guidelines; secondary analysis of available data; interviews with
key stakeholders, policy makers, and programme staff; and direct observation of
programme implementation at field sites throughout Myanmar.

Key Findings
Myanmar shows an increasing level of government support with increased funding in
2015 for EPI and the articulation of immunization as one of five health priorities in the
new government’s 100-day plan. Historically, Myanmar’s health budget has been low,
both in absolute terms and as a proportion of gross domestic product (GDP); this has in
turn been reflected in low government funding and a heavy dependency on external
funding for the EPI. Recent growth in GDP has translated into an increasing health
budget and a 2016 commitment to fund traditional vaccines and co-finance vaccines
supported by Gavi.
The programme benefits from a number of advisory and oversight bodies, several
chaired by the Director General (DG) of Public Health. Reporting of AEFI and response
to AEFI has been adequate to detect and mitigate the impact of several major events in
recent years. All vaccines used in the country must be licensed by Myanmar’s National
Regulatory Authority (NRA). Vaccine is procured annually through the United Nations
Children’s Fund (UNICEF). The country underwent an Effective Vaccine Management
(EVM) review in 2015 and has developed an improvement plan, in the process of
implementation, to respond to the findings of this review.2
Equitable and universal delivery of vaccination in Myanmar is challenged in several
different ways. The country’s sociocultural and political diversity requires flexible and
creative situation-specific approaches to reach as-yet unreached children. Unfilled
sanctioned posts, situations in which the population has grown but the number of
sanctioned posts has not expanded accordingly (especially in the growing urban
areas), a lack of sanctioned posts for the immunization supply chain (iSC) resulting in
cold chain key persons not holding sanctioned posts, and incomplete knowledge in
certain topic areas (for example, iSC, some aspects of surveillance) all pose human
resource challenges. The need for demand generation has led to a public
communications plan which is in the early stages of implementation. Many service
delivery challenges have been identified through and are scheduled to be addressed

2

Myanmar cEVM Improvement Plan. 2016-2021. 2015. Ministry of Health and Sport.
Republic of the Union of Myanmar

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by the second grant from Gavi for health system strengthening (HSS2) funding which
will cover 2017 -2019.3
VPD surveillance is an integral part of the evaluation process to ensure that a country
is delivering high quality vaccination services to the entire population. Elimination and
eradication goals require that countries raise their surveillance standards and their use
of surveillance data to levels beyond those needed for disease control alone. While
VPD surveillance in Myanmar is strong enough to detect large outbreaks, its
usefulness to the programme is hampered by limited sensitivity, resulting in part from
inadequate health worker awareness of surveillance protocols and specimen collection
for suspected cases, as well as by incomplete local ownership in terms of data analysis
and use. In addition, it is possible that the country’s sociocultural and political diversity
impact under-reporting of diseases. The National Health Laboratory (NHL) provides
excellent support to the programme, but at times confronts challenges in terms of
quality of specimens received and/or incomplete or no case investigation forms (CIF).
Myanmar was certified polio-free on 27 March 2014 with all other countries in the
region. The last case of indigenous wild poliovirus (WPV) was reported in 2000 and the
last imported WPV was identified in 2007. However, the country has experienced
cases of circulating vaccine-derived poliovirus (cVDPV), with the most recent cases
confirmed in 2015 in Rakhine State. Outbreak response assessments (OBRA) were
carried out twice as per the requirements of the Global Polio Eradication Initiative; the
second OBRA was conducted concurrently with this EPI and VPD surveillance review.
Reports
of
both
first
and
second
assessment
are
available
at:
http://www.searo.who.int/entity/immunization/documents/en/
The country achieved MNTE in 2010. Since that time, the country has made
continuous efforts to maintain MNTE with a particular focus on ensuring that women
receive at least two doses of tetanus toxoid (TT), conducting neonatal tetanus (NT)
surveillance, and promoting the presence of skilled attendants at births.
Myanmar administers the first dose of measles containing vaccine (MCV1) at 9 months
and the second dose (MCV2) at 18 months of age. MCV2 was introduced in 2012; in
2015, following a nationwide measles-rubella vaccine (MR) supplementary
immunization activity (SIA) targeting those aged 9 months – 15 years and achieving a
reported 94% coverage, Myanmar replaced single antigen measles vaccine (M) at 9
months with MR and plans to begin using MR as MCV2 in 2017. To achieve measles
elimination, at least 95% coverage with two doses of MCV must be reached in 100% of
districts. In 2015, only 19% of districts achieved at least 95% coverage with MCV1.
Measles surveillance indicators suggest substantial surveillance gaps while there is
relatively little awareness of rubella and congenital rubella syndrome (CRS). Sentinel
CRS surveillance is scheduled to begin in 2017.
3

Using HSS approach to address country priority areas of immunization: lessons learned
and challenges from Myanmar. Presentation made to the Seventh SEAR-ITAG Meeting, 710 June 2016. Ministry of Health and Sport. Republic of the Union of Myanmar.

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Myanmar has intermediate to high hepatitis B endemicity. A major intervention to
prevent mother-to-infant transmission of hepatitis B is administration of a dose of
hepatitis B vaccine within 24 hours of birth (HepB-BD). Hepatitis B vaccine (HepB) was
introduced in 2003, with HepB-BD supported by Gavi. The discontinuation of Gavi
support for HepB-BD resulted in discontinuation of HepB-BD as part of EPI. HepB-BD
will be (re)introduced in hospitals in the last quarter of 2016. However, reaching
regional 2020 hepatitis B control goals will require expansion of the use of HepB-BD
beyond hospitals.
Myanmar has a functional National Committee for Immunization Practices (NCIP) to
guide decisions on new and underutilized vaccine introduction (NUVI). Since 2012
(inclusive), Myanmar has successfully introduced MR, inactivated polio vaccine (IPV),
bivalent oral poliovirus vaccine (bOPV) and pneumococcal vaccine (PCV) and plans to
introduce Japanese encephalitis (JE) vaccine in 2017, rotavirus vaccine in 2018, and
human papilloma virus (HPV) vaccine in 2019. In terms of NUVI, a major challenge
faced by Myanmar is expansion of sentinel surveillance sites and generation of burden
of disease and economic data to adequately inform decision-making processes.

Key Recommendations
A.

Government Support

Advocacy


Look for opportunities to advocate at the highest level (for example, Cabinet) for the
EPI. Work with partners [US Centres for Disease Control and Prevention (CDC),
WHO and UNICEF] to develop a slide-set showcasing immunization as a ‘best-buy’
which can be used in advocacy.

Finance


Advocate at all levels and with all stakeholders for a comprehensive health
financing policy in the context of the universal health care (UHC) vision for
Myanmar as a pre-requisite for increasing health budget allocations.



Advocate for the CEPI to be an example of increasing national financial shares for
essential public health services and of high return on investments in the health
sector.



Operationalize the comprehensive Multi-Year Plan 2017-2021 (cMYP) financing
strategy options and explore innovative resource mobilization and financial
instruments (for example, community participation, an immunization trust fund4, and
efficiency gains in service delivery).

4

A detailed explanation of immunization trust funds is provided in Domestic trust funds. In
Immunization financing: A resource guide for advocates, policymakers and program
managers (website). http://www.immunizationfinancing.org/en/sources-offinancing/domestic-trust-funds# accessed 1 June 2017.

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

Reform and restructure financial management at the central and regional levels to
allow effective utilization of available resources, including greater flexibility in
funding allocation at peripheral levels and more rapid transfer of funds from central
to peripheral level.

Oversight Bodies


Explore whether oversight and advisory bodies may wish to follow WHO ‘best
practices’ by having chairmanship independent from government.

AEFI Surveillance


Develop stringent regulations requiring proper supply regulatory inspection for
public and private sectors.



Allocate budget for enhancing AEFI surveillance.

Vaccine Licensing, Procurement and Management


Accelerate the approval of the Vaccine Independence Initiative (VII) and initiate its
implementation.



Accelerate the implementation of the EVM improvement plan with close monitoring
of progress against established milestones and timelines.



Strengthen human resource support for the iSC and management in following
ways:



Establish sanctioned posts for cold chain Key persons and supportive staff at all
levels;



Redefine necessary qualifications and terms of reference for iSC and management
posts particularly at the storage points where large quantities of vaccines are kept
(central and state/region sub-depot);



Provide routine training to staff, as well as on-the-job coaching through supportive
supervision.



Advocate for a national budget line to ensure stable and predictable funding for the
iSC once Gavi’s HSS2 to Myanmar is ended.

Demand Generation


Implement and evaluate the impact of the communication activities defined in
HSS2.



Conduct training at regional and township levels to improve interpersonal and risk
communication skills among basic health staff and volunteers.



Develop simplified materials on immunizations for communities and caregivers.
Materials should be tailored to local languages and cultures.

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Service Delivery
Short term


Implement HSS2.



Develop a quarterly implementation plan and set up a high-level mechanism of
oversight (DG or Minister).

Mid/long term


Create national and state/regional-level government budget lines for EPI to cover
both vaccine and operational costs (for example, field allowances for midwives
(MWs), vaccine transportation, outbreak response, supervision and monitoring).



Create positions and supportive funding for dedicated EPI staff (EPI and cold chain
key persons, data focal person) at state/region and township levels.



Allow flexibility and promote local approaches and language to encourage tailoring
of service delivery to special populations.

B.

VPD Surveillance


Focus Regional Surveillance Officer (RSO) responsibility on VPD surveillance and
EPI.



Increase frequency of active VPD surveillance in large hospitals.



Provide VPD surveillance-specific refresher training to clinicians and health staff
with a specific focus on case definitions, procedures for specimen collection and
transport.



Increase laboratory confirmation and genotyping of cases.



Encourage calculation of acute flaccid paralysis (AFP) and fever/rash surveillance
indicators at subnational levels to increase ownership.

C.

Progress in Meeting Global and Regional Goals
Polio


For recommendations related to polio, please see those contained in the report of
the OBRA conducted from 25 September to 08 October 2016, available at
http://www.searo.who.int/entity/immunization/documents/en/

MNTE


In highest-risk communities incompletely reached through routine immunization,
TT SIAs targeting women of child bearing age could be considered.



To improve the sensitivity of the existing case based NT surveillance system:
o

consider community based surveillance in high risk areas;

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





o

strengthen the maternal and infant death reporting and auditing system and
investigate all reported infant deaths;

o

establish a monitoring mechanism for community based surveillance,
comparable to that used for AFP surveillance;

o

ensure that the NT case investigation form allows supervisors and
surveillance personnel at all levels to have a complete understanding of the
history and symptoms of the case and to confirm diagnosis of the
suspected NT case; and

o

adapt the case response to the cause(s) of non-protection. If the mother
requires vaccination to protect further unborn children, other eligible women
in the same community should also be evaluated for TT vaccination status
and targeted for immunization based on eligibility.

To increase use of skilled delivery care in high-risk and hard-to-reach areas
consider:
o

strategic re-deployment of MWs to high-risk areas; and

o

strategic deployment of lady health visitors to fill gaps in skilled birth
attendance.

To expand the types of providers able to administer TT vaccine consider:
o

using auxiliary MWs as TT vaccinators to minimize missed opportunities for
TT protection; and

o

in hard-to-reach areas, partnering with qualified private or NGO sector
providers with success and local acceptability operating in those contexts.

To increase use of facility care by communities in close proximity to health centres,
consider:
o

an incentive scheme (for example, conditional cash transfers) for
accessible communities; and
o

vouchers for transport to rural health centres (RHCs).

Measles and Rubella


Increase commitment to measles and rubella elimination by:
o
o



gaining agreement to 2020 rubella elimination goal once the second dose of
MR (MR2) is added to the routine immunization schedule; and
finalizing the National Measles and Rubella Strategy, 2016-2020, ensuring it
reflects the rubella elimination goal.

Increase to at least 95% MCV2 coverage in all districts by:
o

developing costed sub-national measles/rubella elimination work plans with
clear designations of responsibility;
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



o

conducting village-level risk assessment and mitigation;

o

conducting school-based immunization record checks at school entry; and

o

conducting SIAs when the population immunity gap equals the size of the
birth cohort.

Move from “control” to “elimination” standard surveillance by:
o

increasing surveillance sites beyond AFP sites to include all health facilities,
and train relevant staff;

o

developing a clear implementation plan, with communication strategy, for
fever/rash surveillance, and a field guide with standard operating
procedures (SOPs) with clear designation of roles and responsibilities for
specimen collection and transport, and train relevant staff; and

o

finalizing CRS guidelines and establishing CRS sentinel sites in 2017 as
planned.

Improve rapid outbreak control and response by:
o

implementing hospital infection control;

o

vaccinating high risk adults, including health care workers (HCW), at no
cost; and

o

vaccinating at-risk populations, such as orphaned children cared for within
monasteries.

Hepatitis B


Develop an immunization specific national hepatitis B operational plan to achieve
the 2020 hepatitis B control goal and expand HepB-BD to reach deliveries that
occur outside hospitals.



Explore using vaccine for HepB-BD outside the cold chain in RHCs, sub-centres,
and home births. This would require using a single dose HepB-BD with vaccine vial
monitors and approval by the National Immunization Technical Advisory Group and
relevant national regulatory body.



Train HCW on birth dose storage, vaccination, and recording.

NUVI


Develop a sustainable immunization financing plan and periodically update it to
ensure predictable funding for sustaining routine immunization and NUVI.



Foster partnerships with national/international technical partners (including
academia) to generate reliable evidence for decision making on NUVI and related
technologies.

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

Implement the cold chain improvement plan with the Gavi HSS2 to expand the cold
chain capacity to accommodate JE, rotavirus and HPV vaccine introduction, as
well as provide expansion of the cold chain to cover more service delivery points.

Conclusion
In conclusion, Myanmar has a rapidly evolving EPI which shows evidence of recentlyincreased government commitment and a high level of engagement from the
international community. The programme has successfully introduced a number of new
and underutilized vaccines and is supported by a dedicated and hard-working staff.
However, Myanmar faces complex social, cultural and political factors leading to
pockets of unimmunized children; these factors may also contribute to under-reporting
of disease. Reaching these children may require context-tailored approaches. This
situation is compounded by service delivery challenges, many of which have been
identified and seek to be addressed through Gavi’s HSS2 funding. Service delivery is
also challenged by human resource limitations, in particular vacant (but sanctioned)
posts. While VPD surveillance is adequate to detect outbreaks, sensitivity of
surveillance, specimen collection and laboratory confirmation, and local analysis and
use of data will need to be bolstered in order for disease surveillance to optimally
inform and guide the EPI. As the programme looks to the future, plans to sustain the
gains made through HSS2 and ensure vaccine self-sufficiency by 2025 are critical.

-9-

INTRODUCTION
The Expanded Programme on Immunization (EPI) in the Republic of the Union of
Myanmar (Myanmar) has achieved considerable success in preventing and controlling
vaccine preventable diseases (VPDs). The country has seen a reduction of > 90% in
cases of diphtheria, pertussis and tetanus when compared to the period prior to the
implementation of the EPI in 1978. Myanmar achieved maternal and neonatal tetanus
elimination (MNTE) in 2010 and was certified polio-free in 2014. Recent years have
seen the successful introduction of measles-rubella vaccine (MR), inactivated
poliovirus vaccine (IPV), bivalent oral poliovirus vaccine (bOPV) and pneumococcal
conjugate vaccine (PCV). Reporting of the EPI target diseases (polio, measles, rubella,
diphtheria, pertussis, neonatal tetanus (NT)) and Japanese encephalitis (JE) (for which
the vaccine is not yet part of the country’s EPI) are mandatory and is based on clinical
and/or laboratory evidence; reporting for some diseases is based on syndromic
surveillance.
In spite of impressive decreases in the overall morbidity and mortality due to VPDs in
Myanmar, gaps in coverage in certain populations have led to disease outbreaks. In
2012 and 2015, Myanmar experienced outbreaks of circulating vaccine-derived
poliovirus (cVDPV). Sporadic cases of diphtheria, many based on clinical diagnosis,
have been reported annually, with numbers varying from 19 to 87 in the past five years.
Myanmar subscribes to the key strategic objectives of the Global Vaccine Action Plan
(GVAP) and the global goals of the Decade of Vaccines (DoV) (2011-2020)5 (1)
achieve a world free of polio, (2) meet vaccination coverage targets, (3) reduce child
mortality, (4) meet global and regional elimination targets, and (5) develop and
introduce new vaccines. Myanmar also subscribes to regional goals of eliminating
measles and controlling6 rubella and congenital rubella syndrome (CRS) by 2020, as
well as accelerating the control of hepatitis B and JE. In line with the World Health
Organization (WHO) South-East Asia Region (SEAR) Vaccine Action Plan (VAP), the
country also seeks to strengthen routine immunization systems and services, and
accelerate the introduction of new vaccines.7
The South-East Asia Regional Technical Advisory Group on Immunization (SEARITAG) recommends that each country should conduct periodic joint nationalinternational programme reviews in addition to its own regular internal programme
monitoring. The last international EPI review in Myanmar was conducted in 2008.

5

Global Vaccine Action Plan. World Health Organization. 2013.
http://www.who.int/immunization/global_vaccine_action_plan/en/ . Accessed 15 November
2016
6
Defined as a 95% reduction of rubella and CRS as compared with the 2008 baseline
nationally and for the Region
7
South-East Asia Regional Vaccine Action Plan 2016-2020. World Health Organization
Regional Office for South-East Asia. 2016 (draft)

10

Joint national/international EPI reviews conducted in SEAR, including this one, have
three broad objectives, which are to:


provide a snapshot to public health programme directors and public health policy
makers on the status of the EPI and VPD surveillance;



assess progress in meeting key national, regional and global goals; and



provide an opportunity to share lessons learned with other countries which share
the same goals for preventing and controlling VPDs.

This document reports on the findings and recommendations of the Joint NationalInternational EPI and VPD Surveillance Review held in Myanmar from 25 September to
8 October 2016. Recommendations are found at the end of each topic area.

11

BACKGROUND
General
Myanmar, a South-East Asian country, shares boundaries with the People's Republic of
Bangladesh, the Republic of India, and the People’s Republic of China, the Lao People’s
Democratic Republic and the Kingdom of Thailand. The country covers approximately
676 000 km2. It is administratively divided into one territory and 14 states or regions with
a total of 74 districts.
Figure 1. Map of Myanmar

In 2014, the population of Myanmar was estimated at 51.5 million. Approximately 28% of
the population was aged 0-14 years, 6% was aged more than 65 years and the median
age in the country was 27.1 years. The population growth rate was 0.89% with a total
fertility rate per woman of 2.29. Life expectancy at birth was 67 years. Under-five
mortality per 1000 live births was 72. From 2008 to 2012, the male literacy percentage in
those aged >15 years was 92.6% and the female literacy percentage for the same age
group was 86.9%. Approximately 28% of households are urban.8 Myanmar has >130
ethnic groups speaking more than 100 languages and dialects. There are eight major
8

The 2014 Myanmar Population and Housing Census. The Union Report. Census Report
Volume 2. Department of Population. Ministry of Immigration and Population. Republic of
the Union of Myanmar. 2015.

12

ethnic groups: Bamar, Shan, Kayin, Rakhine, Mon, Chin, Kachin and Kayah.
Approximately 90% of the population is Buddhist, 5% is Christian, and 4% Muslim.
Myanmar is considered a lower middle income country with a gross domestic product
(GDP) in 2014 of US$ 64.33 billion and an annual GDP growth rate that year of 8.5%.9 In
November 2015, general elections were held resulting in the National League for
Democracy forming the national government. Priority areas within health for the
government include the strengthening of the immunization programme and health
information systems, standardization of working procedures across health sectors, the
development of a code of ethics for all health personnel, fostering cooperation between
private and public sectors, and responding to outbreaks in a timely and appropriate
fashion.

Health Services and EPI in Myanmar
Health Services
In 1993, the National Health Policy was developed which places ‘Health for All’ as a
primary objective. The National Comprehensive Development Plan (Health Sector)
covers the period from 2010/2011 to 2030/2031. Short-to-medium-term planning is
provided through a series of five-year health plans, with the most recent covering the
period from 2011/2012 to 2015/2016.10
The Ministry of Health and Sport (MoHS), previously known as the Ministry of
Health, is responsible for planning, financing, administrating, regulating and
providing health care. The Department of Public Health (DoPH) is one of six
departments within the Ministry, and is responsible for immunization which is
managed by Central Expanded Programme on Immunization (CEPI) as well as
disease surveillance activities; both of these fall under the Central Epidemiology
Unit (CEU) (Figures 2 & 3).

9

The World Bank data base (online database). Washington: World Bank; 2016
(http://data.worldbank.org/country/myanmar, accessed 31 July 2016)
10
Myanmar Healthcare. 2014. Ministry of Health. The Republic of the Union of Myanmar.
(http://www.moh.gov.mm/file/MYANMAR%20HEALTH%20CARE%20SYSTEM.pdf, accessed 15
November 2016)

13

Figure 2. Organogram of the MoHS, Myanmar

Source: Ministry of Health Restructuring, 2015. Ministry of Health and Sport. The Republic of the Union of
Myanmar.

Figure 3. Organogram of the DoPH, Myanmar

Source: Ministry of Health and Sport. The Republic of the Union of Myanmar.

14

In Myanmar, both public and private sectors provide health care, with the private sector
providing primarily ambulatory care. The strengthening of community-based health
services is considered critical to improving health care in Myanmar. The importance of
building national capacity in field epidemiology is also recognized and Myanmar
participates in the Association of South-East Asian Nations Plus Three Field
Epidemiology Training Network.11
EPI
The EPI was launched in Myanmar in 1978. Partner support for the EPI is received from
Gavi, the Vaccine Alliance (Gavi) (new vaccine introduction, cold chain expansion,
health system strengthening), United Nations Children’s Fund (UNICEF) (procurement of
traditional vaccines, education and communication materials and cold chain expansion),
WHO (surveillance, capacity building, review meetings, etc.) and the Three Millennium
Development Goal Fund (3MDG)12 (operational support to targeted townships, cold
chain support). The role of the local community, nongovernmental organizations (NGOs)
and women’s organizations is limited to advocacy and social mobilization. A recent focus
of immunization services has been the border and hard-to-reach areas which have
displaced and vulnerable populations, as well as areas of previous conflict and periurban areas. Few NGOs work in these settings. Difficulties in reaching populations have
been linked to inadequate staff for immunization; as a result, the MoHS plans to increase
the number of staff trained to give vaccinations. 13 The government which came to power
in 2016 has articulated immunizations as being one of its top five health priorities.
A comprehensive multiyear plan (cMYP) for immunization covers 2017-2021. This plan
has the following programme objectives:


To strengthen immunization programme management, human resources, financing
and service delivery to provide equitable service to all target populations including
special strategies for peri-urban, slum, migratory populations, geographically and
socially hard- to-reach and conflict areas;



To improve demand creation and ownership of immunization through community
participation and communication;



To strengthen immunization supply chain (iSC), vaccine management and build
stronger cold chain systems at all levels;



To achieve the goals of eradication, elimination and control of VPDs: and



To maintain zero polio cases (both wild poliovirus (WPV) and VDPV);

11

Health in Myanmar. 2014. Ministry of Health. The Republic of the Union of Myanmar.
The 3MDG project is funded by a consortium of agencies – Australian Agency for
International Development (AusAID), Danish International Development Agency (Danida),
European Union, Swiss Confederation, Sweden, Department for International Development
(DFID), and United States Agency for International Development (USAID)
13
Health in Myanmar. 2014. Ministry of Health. The Republic of the Union of Myanmar.

12

15



To maintain MNTE status;



To achieve elimination of measles and control of rubella and CRS by 2020;



To strengthen and maintain strong surveillance systems for AEFI and other priority
VPDs;



To introduce new and underused vaccines and new technology into routine
immunization, supported by evidence of disease burden.14

Myanmar has recently seen a number of initiatives to perform in-depth evaluations of
and strengthen aspects of its EPI. In 2015, the country conducted an Effective Vaccine
Management (EVM) assessment. Key recommendations from this assessment included
increasing vaccine storage significantly, assuring temperature control during storage and
transport, and strengthening data and programme management.15 In response to this, a
cold chain expansion and replacement plan was developed16 and has been partially
implemented with funding from 3MDG. In 2016, the country also underwent an
evaluation, supported by UNICEF,17 with the development of a Supply Chain Data Use
Manual.18 The Joint Appraisal coordinated by Gavi in 2016 noted the following
bottlenecks and impediments to the EPI: immunization equities; data quality with specific
concerns around denominators; service delivery; cold chain and vaccine management;
management of vaccine and injection materials; community participation; and human
resource capacity.19 Through Gavi, Myanmar has also received funding for health
system strengthening from 2017 to 2019. Although this funding is not EPI-specific, many
of the bottlenecks that it seeks to address were noted in the Joint Appraisal and are
directly linked to EPI performance. In terms of EPI, the funding will target demand
creation, cold chain and vaccine supply management, leadership, management and
coordination, service delivery, and data and health information systems.20
Finally, as a lower middle income country, Myanmar is expected to reach full selfsufficiency in terms of vaccine purchase by 2025. A first step is self-sufficiency with
regard to the traditional EPI vaccines by 2017. This goal is supported by the proposal for

14

Comprehensive Multi-Year Plan 2017 – 2021. Ministry of Health and Sport. The Republic
of the Union of Myanmar.
15
Dissemination of Effective Vaccine Management Assessment (EVMA)
Findings. 25 May 2015. UNICEF. Presentation made at Partner Meeting.
16
Myanmar cEVM Improvement Plan. 2016-2021. 2015. Ministry of Health and Sport.
Republic of the Union of Myanmar.
17
Immunization Supply Chain Data Use in Myanmar. Situational Report. 201. UNICEF
18
Myanmar Immunization Supply Chain Data Use Manual. Generation, collection, analysis
and use of supply chain data. 2016. Ministry of Health and Sport. Republic of the Union of
Myanmar.
19
Joint appraisal report. Myanmar. 2016. Gavi, the Vaccine Alliance
20
Using HSS approach to address country priority areas of immunization: lessons learned
and challenges from Myanmar. Presentation made to the Seventh SEAR-ITAG Meeting, 710 June 2016. Ministry of Health and Sport. Republic of the Union of Myanmar.

16

subscription to the VII,21 developed by the MoHS and submitted to the Ministry of
Planning and Finance (MoPF) for approval.22 Given the depth and robustness of these
assessments, the EPI review team has focused its energies on other aspects of the
immunization programme while still touching on such critical facets as programme
financing and iSC.

National EPI Schedule
In 2016, the EPI schedule in Myanmar is as summarized below.
Table 1. EPI schedule, Myanmar, 2016
Vaccine

Age of Administration

Bacille Calmette Guerin (BCG)

Birth to 2 months

DTP-Hib-HepB

2, 4, 6 months

Oral Polio Vaccine (OPV)

2, 4, 6 months

PCV

2, 4, 6 months

IPV

4 months

MR

9 months

Measles

18 month

TT

During pregnancy (at first contact and 1
month later)

As of 2015, IPV is offered with the second dose of pentavalent vaccine and the second
dose of OPV, at the age of four months. PCV has been added to the vaccine schedule
as of July 2016.
EPI Service Delivery
Vaccines in Myanmar are delivered through four different approaches: fixed, outreach,
mobile and ‘crash’. Fixed immunization sites are loc