Health strategy and policy institude

The Expanded Program of Immunization (EPI) started implementation in Vietnam in 1981. In 1985, EPI was strengthened and carried out throughout the country. Since 1986, EPI has been considered as one of the priority national health program. In 1990, 87% of infant nationwide were fully vaccinated against 6 diseases (tuberculosis, diphtheria, whooping cough, tetanus, polio and measles). To date Vietnam has eliminated polio and newborn tetanus. Whooping cough morbidity falls by 183 times, diphtheria 82 times and measles by 572 times. With result achieved by EPI, Vietnam has been recognized as one of the most successful country in this area.

However, EPI stills has limitations and is confronting challenges. The quality of immunization has been recently paid special attention by the health sector. Many comments on immunization quality and safety, and causes have been mentioned after some recent post-vaccination complications. The workshop ”Improving the immunization quality and practice” was organized in Hochiminh city on 15 June 2007 to discuss immunization safety. Of the causes mentioned, human resources, namely the staff directly involved in delivering immunization services at commune level is considered as one of the key factors in immunization safety. Therefore, information on knowledge and skills of immunization personnel is essential to the training on EPI knowledge and skills, thereby improving the program quality. However to date there is no study on EPI personnel and the association of immunization quality and immunization service providers. From the above fact, the National Institute of Hygiene and Epidemiology (NIHE) and Health Strategy and Policy Institute (HSPI) jointly carry out the study on Current situation assessment of human resources in Expanded Program of Immunization (EPI).

The target group is limited to the health professionals directly or indirectly participating in EPI activities at grassroots level, including staff at district preventive centers performing EPI monitoring, health workers at commune health center and VHWs.

• To fill-in questionnaires for staff taking part in EPI at district preventive centers/hygiene and epidemic prevention teams and staff at commune health centers. Questionnaire sample size: all people present at facility at study time.

• Multiple choice tests on immunization knowledge of commune health center’s staffs: developed based on the regulations on immunization safety steps by the National EPI. Multiple choice tests include 25 questions, divided in 4 groups of i) knowledge of dose – administration – injection spot, ii) knowledge of vaccination time, iii) knowledge of cold chain and vaccine storage, and iv) knowledge of vaccination techniques.

Evaluate immunization skills via analyzing injection movement, videotapes of immunization sessions by commune health centers, including 3 contents: practical skills of cold chain and vaccine storage; organization of immunization session (14 assessment criteria) and immunization practical skills (14 assessment criteria). Each commune has 3-5 injection cases analyzed.

• The percentage of program officers and immunization supervisors at district level trained by the preventive/public health network is very low (12.5%). 17.3% staff have not been trained on EPI and EPI monitoring in 2002-2007 period, of which the majority have newly taken part in monitoring. Therefore 59% have expectation to be trained with EPI monitoring skills. 56% expect to have training on EPI knowledge and practice.

• Due to staff shortage at district preventive centers, each monitoring staff must integrate several contents on their trip to commune level. In addition there is a lack of monitoring budget and the monitoring activities have not been regularly carried out at immunization day at commune health centers. Moreover monitoring is mainly formality (monitoring staff often do not use checklist and only present in the first session), leading to limited monitoring effectiveness.

• At present, all staff of commune health stations (CHS) take part in all stages in regular immunization sessions. Therefore participants to annual training and retraining on EPI, normally the head and responsible staff are not appropriate.

• 74% of CHS staffs have good knowledge of immunization. This figure among EPI responsible staff is 83.3%. The two provinces in the northern mountainous, Bac Kan and Dien Bien have lower scores. There are differences in EPI knowledge scores by ethnic minority, especially only 16% of ethnic minority staff getting pass-score on dose – administration – injection spot while this figure among the Kinh is 84% 84% (P< 0,001).

• Knowledge of EPI areas among staff are uneven: knowledge of dose – administration – injection sport at excellent score among 3 groups while scores of immunization schedule, cold chain and vaccine storage at good level, and scores of immunization at average levels.

• CHS staff still have some errors in vaccine storage practice and organization for an immunization session (no thermometer to monitor vaccine temperature, no organizing for one-way immunization table, often with messy crowd, no child classification before vaccination, etc.)

• Injection practicing skills have yet to meet standards (52.8% do not shake vaccine vial before taking vaccines; 33.3% apply skin sterilization not in accordance with regulated techniques; 69.4% use cotton and alcohol to wipe injection sport; 84.7% write in immunization sheet before injecting; 83.3% do not communicate on vaccine when giving injection; 76.4% do not make next appointment). Errors in these two areas and low knowledge scores have proven that inappropriate attention were paid.

• Subjective causes: Sense of compliance with immunization regulation is not high. Some wrong movement are intentional (writing in immunization sheet before injecting, no vial shaking before vaccinating); limited capacities, qualification.

• Objective causes: 1) Some EPI responsible staff and CHS heads have not been trained on EPI due to staff appointment policy in some localities, making technical managing institutions untimely or lack budget to provide supplementary training. Other CHS staff are verbally trained on EPI by CHS heads and responsible staff, leading to limited EPI knowledge; 2) Equipment are insufficient, old or broken or inappropriate, causing difficulties to CHS staff to correctly comply with regulation on immunization safety; 3) CHS staff suffer from psychological pressure and stress at regular immunization day: they have to ensure immunization safety after a series of post-vaccination complication and time pressure in a context of crowded people and difficult patient – small children; 4) some regulations are hard to carry out in regular immunization sessions such as pre-vaccination counseling, post-vaccination advice for families.

• VHWs play important role in communication, management and advocating families to bring their children to immunization. Besides, due to unique features VHWs in some localities are mobilized to take part in immunization together with CHS staff with good results.

• Most VHWs are not content with current government incentives due to extremely low norms and late in changing. In many provinces, VHWs quit their job or neglect duties as their allowances are too low and not enough to pay for work expenses. VHWs actively participate in community health care activities are mainly from the love for the community.

• It is needed to train, retrain EPI monitoring skills for health professionals to participate in immunization activities more regularly and fully. General monitoring procedures and uniform checklist should be developed for all monitoring staffs to create favorable conditions for monitoring, supporting and training for CHS staff on immunization knowledge, skills and organization for immunization session.

• Review tasks regulated in sub-items a of item 1 and sub-item b of item 3, Article 13, Chapter IV or Regulation on use of vaccine and biological products in prevention and treatment according to Decision 23/2008/QD-BYT dated 7 July 2008 for CHS staff on regular immunization day because these duties are hard to implement and if yes, it may distract immunization task.

• In communes with difficulties in organizing for immunizations, it is possible to train VHWs to fully meet technical requirements so that they can participate in immunization activities with CHS staffs. This is to meet immunization needs in populous areas as well as mountainous, remote and disadvantaged areas.

• The Government should review some polices for VHWs to encourage them to actively take part in primary health care activities at grassroots levels, including increasing monthly allowance norm, and issuing free or partially subsidized premium health insurance cards.

To improve the responsibilities and obligations of family toward immunization, the immunization sheet should be re-designed into immunization journal, in which there are some basic EPI knowledge, consisting of immunization significance, names of free vaccines, schedule, administration, side effects, rights and obligations of families in cooperation with EPI. This journal is distributed to mothers right after birth delivery.