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Evaluation report

2000 BHG: Expanded Programme on Immunization UNICEF/WHO Assessment Report

Author: Benesh, O.; Zemokhol, R.; Popova Doytcheva, S.; Larsen, G.; Maire, D.

Executive summary


Bosnia and Herzegovina (BiH) was one of the six autonomous republics of the former Yugoslavia. It became independent in early 1992. Pre-war BiH, according to all indicators, was a country with a well-developed infrastructure and good public health services capacity. The four year long war (1992-1995) ended with the signing of the Dayton Peace Agreement. This agreement divided the country into two “Entities:” the Federation of Bosnia and Herzegovina (FBiH) and Republica Srpska (RS), each with its own government, constitution and administrative divisions. The State level of BiH (Council of Ministers) has no practical influence in areas of immediate administrative concern – health, education etc. There are no sectoral ministries at the State level, but each entity has it’s own Ministry of Health. In 1992, the two ministries initiated the Expanded Programme of Immunization (EPI) in their respective territories, and UNICEF supplied the basic vaccines and equipment. Since the end of the war, UNICEF and WHO have been working in close collaboration with the two Health Ministries (HMs) to strengthen EPI throughout the country and have funded all EPI antigens and immunization supplies, upgraded the cold-chain system, and provided , training and technical assistance. A comprehensive assessment of the BiH EPI was needed at this point of time as none had been carried out since the restarting of the programme. In addition, BiH has expressed interest in applying to the Global Alliance for Vaccines and Immunization (GAVI) fund in order to introduce universal immunization of children against hepatitis B and Hib infection.

Purpose / Objective

In preparation for this application, the 2 ministries requested UNICEF and WHO to organize an assessment mission in November/December 2000. It was agreed that the mission team would include three medical epidemiologists and two specialists on cold chain and logistics. 

Specific objectives: 
- To review the present epidemiological situation of Vaccine Preventable Diseases (VPDs) 
-  To review major EPI components and provide recommendations on:
Management, co-ordination and implementation of the EPI         
Policies and standards in the field of:             
Immunization service delivery             
VPDs surveillance             
Cold chain, logistics and safety of immunization        
Advocacy and communications
– To assess feasibility of introduction of universal immunization against Hepatitis B and Hib infection


- Data review of legislation, official reporting and surveillance forms, stock inventories and other relevant documents concerning immunization activities
- Personal interviews with EPI management staff and immunization providers including UNICEF BiH and WHO BiH staff
- Field visits to thirteen public health institutes (PHI) and two health facilities
- Data collection using a preset questionnaire about immunization services, vaccine coverage and VPDs surveillance

As a result of the large number of refugees and Internally Displaced Persons in many parts of the country, much of the basic data needed to plan immunization services, set targets and measure performance are either unknown or uncertain.

Key Findings and Conclusions

Incidence of Disease
Data supplied by the Public Health Institutes in each entity suggests that there is no dramatic increase of disease-incidence rate of major public health concern, with the exception of stress-related disorders and tuberculosis. However, it could not be determined how accurate this data was.

No cases of diphtheria have been reported in BiH during the last 5 years and according to RPHI. Single cases of tetanus are reported almost yearly in both FBiH and RS, most cases occurring in older people. However, one of 3 tetanus cases reported in FBiH in 1999 was a pre-school child. During the last 7 years, the pertussis incidence rate in RS varied from 1.1 per 100,000 to 7.2 per 100,000 (in 1994). FBiH statistics show a greater fluctuation in pertussis incidence rate for that entity (Annex 2, Table 2). Despite the problems in calculating incidence rates due to the uncertainty of population figures, it is clear that measles outbreaks occur in both FBiH and RS. No Wild Polio case has been reported in BiH since 1974. AFP surveillance is not yet sufficiently sensitive to confirm the absence of circulating wild virus however, and reported AFP rates were 0.9 per 100,000 children under 15 years in 1999 and 0.3 per 100,000 in 2000. The disease surveillance systems of FBiH and RS do not have yet the capabi

lity to reveal the real burden of HBV-infection. No serological surveys have been carried out, and reported VHB incidence rates in FBiH of between 1.9 and 8.1/100,000 and around 40 reported cases per year in RS probably represent only a fraction of the actual number of cases.

Vaccination Coverage
Reported vaccination coverage in pre-war BiH was high. In 1990, coverage rates were reported as over 91% for all EPI antigens (BCG 91.1, DPT3 92.7, OPV3 93.8, and MMR 93.6). During the war, immunization was conducted mainly in vaccination centers while for security reason, lack of vehicles, fuel, staff etc., outreach activities were rarely conducted and vaccination coverage of children dropped to an estimated 30%. Post-war, coverage returned to pre-war levels except for measles. Reported figures for coverage of 1-year-old children with basic EPI antigens in 1997-1999 are: BCG 100%, DPT3 and OPV3 90% and measles 83% (Source: The State of the World's Children 2001, UNICEF).

The design of the monthly and annual reporting forms on immunization does not permit calculation of timely immunization coverage. Consequently, overall vaccination numbers are artificially boosted while, in reality, some children included in the plan are missed and others not planned are included. Coverage reporting becomes a real dilemma for health staff when the number of vaccinated children exceeds 100%.

Immunization Schedules
Both schedules of the two regions call for numerous re-vaccinations spread over many years and extend routine childhood immunization far into adolescence. This inevitably requires additional resources and may affect coverage with primary immunizations when sufficient supplies are not ensured. There is little epidemiological evidence to justify such an extensive and expensive schedule.

Logistics & Cold Chain
UNICEF has donated many new cold chain equipment in recent years, and vaccine storage facilities at central and regional/cantonal levels in each entity appear to be generally adequate. Health centers are somewhat less well provided for, and some may require additional equipment or replacement of older items to ensure secure vaccine storage. No detailed central inventory of cold chain equipment at health facilities is available however, and actual needs were not quantified.

At most facilities visited, staff did not maintain the vaccine cold chain during immunization sessions, and opened vials were mostly kept on the vaccination table without either a vaccine carrier or the use of ice packs. The necessary vaccine carriers and ice packs were generally available at health facilities, but were simply not used. Many health staff had incorrect or insufficient understanding of the use and interpretation of Vaccine Vial Monitors (VVMs) for assessing vaccine quality, and vials with serious heat exposure were observed in several places visited. Date-expired vials were also found in some facilities and, in general, staff paid insufficient attention to vaccine quality (e.g. VVM status, expiry date, shake tests, etc). An urgent need for training of health staff on vaccine handling procedures and maintaining vaccine quality was thus identified.

Some basic vaccine stock management was undertaken at the FBiH store in Zenica, but there were no schedules for supplies to cantonal/ regional stores, no annual summaries of receipts and deliveries, no use of maximum/minimum stock indicators and no monitoring or projections of central vaccine needs. Vaccine wastage rates were not known or monitored and, due to the limited records, rates could not be determined. Vaccine stock management at cantonal/regional level was also limited, with few records or systems of any kind, and a widespread reliance on ad hoc collection of supplies as and when required. There was confusion over the policy for keeping some vaccines frozen at cantonal/regional or heath center level and, again, there were apparently no clear instructions from the PHIs on the issue.

Safety of Injections
Updated policies on injection practices were not yet adopted, and observations showed a number of procedures that are now considered as unnecessary and potentially damaging for the vaccine as well as harmful for the child. These included needles left permanently inserted in the vaccine vial, recapping needles of used syringes, and use of 90% alcohol to clean the skin before injection.

Neither of the entities used safety disposal boxes for containing used syringes and needles from immunization services, and there were apparently no specific guidelines from either PHI on how to deal with used injection equipment. Waste incinerators were not available at any of the health facilities visited, so final disposal of used syringes and needles (and most other medical waste) were usually by discarding into the regular public waste system. Health staff reported that used syringes and needles may sometimes be collected from waste containers or rubbish areas for re-use or re-sale, but no direct evidence of this practice was seen. Reportedly, the public waste system also lacks incinerators for final disposal, and dumping on open ground or in landfill sites is the common practice.

Advocacy and Training
Advocacy has not been closely studied during this mission, but there is evidence of some political support for EPI activities in country. This was noted especially at both entity and local levels during polio vaccination campaigns through participation of officials during the preparation and implementation of activities. A number of communication activities were carried out in 1996-1997 when the "Accelerated Immunization Programme" was initiated, aiming at restoring routine immunization coverage and updating the immunization schedule. EPI managers and PHIs worked in close collaboration with UNICEF in carrying out the following main activities. However, very few PHIs, HCs and ambulantas had posters, leaflets, or educational materials visibly available.

Monitoring, Evaluation, and Supervision
Almost all Public Health Institutes and health centers responded positively when asked about the implementation of supervision, monitoring and evaluation activities at different levels. However, when questioned more specifically about reported findings, measures taken and future plans, most of them were unable to remember specific, weekly/monthly or even yearly visits to a given site. These answers highlighted the serious lack of effectiveness of such activities.


A State-level Expanded Programme on Immunization (EPI) to be established with common disease reduction/elimination targets, vaccination coverage objectives, vaccine and injection supplies management, and a cold chain system serving all parts of BiH. This programme is to form the basis of immunization services in both entities and replace the 2 separate, non-coordinated services currently operating. A detailed 5-year plan for immunization services to be developed in each entity that reflects the objectives, strategies, targets of the State plan, and includes activities and a detailed budget for all components.

Adopt a common, simplified immunization schedule for both entities, which focuses on completing the basic course by the child's first birthday. The policy on contraindications to be revised according to WHO recommendations to reduce missed opportunities and increase immunization coverage. Simultaneous use of vaccines and reduction in the number of visits for immunization to be emphasized in the simplified schedule.

A monthly reporting system for immunization coverage to be introduced at all vaccination sites, at cantonal/regional and at entity levels. Existing procedures of disease surveillance to be revised; time limits on reporting to be introduced. The list of notifiable diseases to be simplified and shortened. Surveillance investigation teams to receive additional training, and equipment and supplies to be made available to enable rapid and efficient intervention in the field.

The ICC to decide on the most appropriate methodology for estimating population, and to agree on goals and targets for EPI that include all IDPs and returnees. If state registry information is to be used, urgent legislative amendments to be made, allowing health providers easy access to this data.

Refresher and upgrading training of all health staff providing immunization to be planned in a phased manner. A programme for refresher and upgrading training for all health staff on ensuring safety of injections to be planned as a matter of urgency. An investigation to be carried out to identify the reasons why knowledge and practices of health staff are not in accordance with efforts made through various training activities.

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