Mission Indradhanush

Introduction

Background / Rationale

Objective / Goal

Target Beneficiaries

• Children below 2 years of age who are unvaccinated or partially vaccinated
• Pregnant women who have not received tetanus toxoid

Vaccines Covered

High Focus Districts

Implementation Phases

• Phases 1-6 (April 2015 - December 2018): Covered 681 districts; 3.39 crore children reached; ~81.79 lakh children fully immunized; 87.18 lakh pregnant women vaccinated.
• First two phases alone achieved a 6.7% increase in full immunization coverage in one year (vs. 1%/year previously); rural areas improved more (7.9%) than urban (3.1%).

Intensified Mission Indradhanush (IMI)

• Launched in October 2017
• Covered 190 districts/urban areas across 24 states
• Special focus on urban slums and districts with slowest progress
• Used head-count surveys to generate due-lists of beneficiaries
• IMI 5.0 (latest phase): 18.5 percentage points increase in full immunization coverage compared to NFHS-4 (2015-16)
• Subsequent phases: IMI 2.0, 3.0, 4.0, 5.0 (2023) have progressively expanded coverage

Key Features / Strategies

1. Microplanning: Session-level planning using household surveys and due-list preparation
2. Social mobilization: ASHA workers, Anganwadi workers, and community leaders
3. Accountability frameworks: District and state task forces for immunization
4. Tracking: eVIN (Electronic Vaccine Intelligence Network) for cold chain and logistics
5. Leveraging polio eradication lessons: Block-level planning and supervision borrowed from pulse polio strategy
6. Multi-sectoral convergence: Involvement of Women & Child Development, Tribal Welfare, Panchayati Raj, ITBP, Railways

Significance in Pediatrics

• Reduces infant and child morbidity and mortality from vaccine-preventable diseases
• Reaches left-out and drop-out children - the most vulnerable groups
• Strengthened cold chain and vaccine logistics across India
• Foundation for introducing new vaccines (Rotavirus, PCV, MR, IPV) into routine immunization

Outcome

Mission Indradhanush

• Targets 528+ high-focus districts across 28 states with highest unimmunized burden
• Conducted as 7-day intensive monthly campaigns for 4 consecutive months
• Uses ASHA/AWW workers for mobilization and door-to-door surveys for due-lists

National Immunization Schedule (NIS) - India

Schedule Table

Key Points

• Pentavalent vaccine = DPT + Hepatitis B + Hib (5-in-1)
• fIPV = Fractional dose Inactivated Polio Vaccine (1/5th dose, given intradermally)
• Vitamin A supplementation: 1 lakh IU at 9 months; 2 lakh IU every 6 months from 16 months up to 5 years (total 9 doses)
• Td replaced TT for children at 10 and 16 years
• Diseases covered: TB, Diphtheria, Pertussis, Tetanus, Polio, Measles, Rubella, Hepatitis B, Hib disease, Rotavirus diarrhea, Pneumococcal disease, Japanese Encephalitis

Route & Site (important for exams)

Pulse Polio Immunization Programme

Definition & Launch

Objectives

• To eradicate poliomyelitis from India
• To rapidly raise herd immunity above the threshold needed to stop wild poliovirus transmission
• To reach every child, including those missed by routine immunization

Strategy / Components

AFP Surveillance

• Reporting of all AFP cases in children under 15 years is mandatory
• Every single case is treated as an outbreak - response within 48 hours
• Stool samples collected for virus isolation
• Follow-up of all AFP cases at 60 days to check for residual paralysis

Strategies for Polio Eradication (Park's)

1. Conduct Pulse Polio Immunization days every year
2. Sustain high routine immunization coverage
3. Monitor OPV coverage at district level
4. Strengthen AFP surveillance
5. Rapid case investigation with stool sample collection
6. Conduct mop-up operations for confirmed/suspected cases

Outcome / Achievement

• Last case of wild poliovirus in India: January 2011 (Howrah, West Bengal)
• India removed from polio-endemic countries list: 25 February 2012
• India certified polio-free by WHO: 27 March 2014
• The first two phases led to a 6.7% increase in immunization coverage

Current Status

• tOPV replaced by bOPV (bivalent OPV) in April 2016 (Polio Endgame Strategy)
• fIPV (fractional Inactivated Polio Vaccine) introduced from 30 November 2015 at 6 and 14 weeks - given intradermally (0.1 ml) to protect against type-2 poliovirus after removal of OPV type-2 component

Pentavalent Vaccine

Definition

Composition (5 Antigens)

Schedule (Under UIP / NIS)

• Replaces: DPT primary doses + Hepatitis B doses at 6, 10, 14 weeks
• Continued separately: Hepatitis B birth dose + DPT booster doses at 16-24 months and 5-6 years

Dose, Route & Site

Storage

• Cold chain: 2-8°C
• Freeze sensitive - must NOT be frozen (freezing destroys the vaccine)
• Discard if frozen or exposed to temperature above 8°C

Contraindications

• Previous severe allergic reaction (anaphylaxis) to a prior dose
• Encephalopathy within 7 days of previous pertussis vaccine
• Progressive neurological disorder

Advantages

1. Reduces number of injections (3 separate vaccines replaced by 1)
2. Improves compliance and immunization coverage
3. Adds Hib protection - a previously unvaccinated disease in India's UIP
4. Simplifies the immunization schedule for health workers

Side Effects

• Common: Pain, redness, swelling at injection site; fever, irritability, vomiting
• Rare: High fever (>39.5°C), febrile seizures
• Very rare: Severe allergic reaction (anaphylaxis)

Introduction in India

• First introduced in Kerala and Tamil Nadu
• Now expanded to whole country under UIP

Measles Vaccine & MR (Measles-Rubella) Vaccine

PART A: MEASLES VACCINE

Nature of Vaccine

• Live attenuated virus vaccine - the only type recommended by WHO
• Presented as freeze-dried (lyophilized) powder; reconstituted with sterile diluent before use
• Each dose (0.5 ml) contains ≥1000 viral infective units
• Contains stabilizers: sorbitol + hydrolysed gelatin; small amount of neomycin
• Does NOT contain thiomersal

Available Forms

Schedule (India - NIS)

• Minimum interval between MCV1 and MCV2: 4 weeks
• In high-transmission countries: MCV1 at 9 months, MCV2 at 15-18 months

Storage

• Freeze-dried vaccine: 2-8°C, protected from sunlight (kept in coloured vials)
• Diluent: must NOT be frozen but cooled before use
• After reconstitution: use within 4 hours, store at 2-8°C in the dark
• Reconstituted vaccine loses 50% potency after 1 hour at 20°C and almost all potency after 1 hour at 37°C

Contraindications

• Severe immunodeficiency (advanced HIV, leukaemia, lymphoma)
• Pregnancy
• Previous anaphylaxis to vaccine components (neomycin, gelatin)
• High-dose immunosuppressive therapy

PART B: MR (MEASLES-RUBELLA) VACCINE

Background

• WHO regional goal for SEAR: Measles elimination + Rubella/CRS (Congenital Rubella Syndrome) control by 2020
• MR vaccine replaced the standalone measles vaccine in India's UIP

MR Campaign

• Launched: February 2017, starting from 5 States/UTs - Karnataka, Tamil Nadu, Goa, Lakshadweep and Puducherry
• Target: ~41 crore children aged 9 months to 15 years in phased manner
• MR campaign completed in 33 states; 32.36 crore children immunized (97.04% of target)

MR in Routine Immunization

• MR-1 at 9-12 months (replaces measles vaccine dose 1)
• MR-2 at 16-24 months (replaces measles vaccine dose 2)
• As per NTAGI (National Technical Advisory Group on Immunization) recommendations

Rubella Component Significance

• Rubella is a mild illness in children but causes Congenital Rubella Syndrome (CRS) when infection occurs in pregnant women - leading to:
  • Congenital heart defects
  • Cataracts / deafness
  • Microcephaly / intellectual disability

Key Differences: Measles vs MR Vaccine

Hepatitis B Vaccine

Type of Vaccine

• Active substance: HBsAg (Hepatitis B surface antigen) produced by recombinant DNA technology in yeast
• Available as:
  • Monovalent (Hepatitis B alone)
  • Combination - with DPT, Hib (as Pentavalent), Hepatitis A, IPV

Schedule in India (NIS)

• India follows a 4-dose schedule (birth + 3 doses at 6, 10, 14 weeks)
• Minimum interval between doses: 4 weeks
• Only monovalent Hep B to be used at birth - combination vaccine not recommended at birth

Dose, Route & Site

• Gluteal injection avoided - risk of fat deposition, poor seroconversion
• Intradermal route not recommended - immune response less reliable
• Birth dose can be given together with BCG but at different sites

Why Give Birth Dose Within 24 Hours?

Efficacy & Duration of Protection

• Duration of protection: at least 15 years, possibly lifelong
• No routine booster recommended for immunocompetent individuals

Special Situations

Storage

• Store at 2-8°C
• Do NOT freeze (freeze-sensitive vaccine)
• Does NOT interfere with immune response to other vaccines

Contraindications

• Previous anaphylactic reaction to the vaccine
• No contraindication in pregnancy - safe to give to pregnant women