Annexure III

EPI and VPD Review Format – RDHS level

Year of evaluation 2016

Background information

1-RDHS area
2-Estimated Population for the year 2016
3-Actual Population for the year 2016
4-Reasons for differences in actual and estimated populations
5-Crude Birth Rate for District 2016
6-Crude Birth Rate for Province 2016
7-Estimated Number of Births in the year 2016
Based on the Actual Population / Based on the Estimated Population
District BR
Provincial BR
8-Number of Immunizations performed in the year 2016 (institutions and field)
(Sum of relevant data from four Q/ EPI returns, 2016) / PVV1 / PVV2 / PVV3
9-Number of pregnant mothers registered for the area in 2015
10-Number of actual births reported for the area in 2016
11-Number of infants registered for the area in 2015
12-The most probable number of births for the RDHS area*
Number
approved / Number
available / Average Population covered by each category / clinic / Population Range
13-PHMs
14-PHIs
15-SPHMs
16-PHNS
17-SPHI
18-MOHs/AMOHs
19-MCH Clinics

(*Choose the higher birth estimate close to the whatever the highest number of infant immunizations(PVV1, PVV2,PVV3) performed or the number of actual births reported during 2016

FORM 1 a

Calculation of No. of registered infants under care among infants born between1stof January 2016 to 31stof December 2016(eligible for BCG vaccination in year 2016)

MOH area / Number of pregnant mothers registered in year 2015
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of January 2016 to 31st of December 2016
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

Form1 bCoverage of BCG vaccination among infants born between 1stof January 2016 to 31stof December 2016 and protection of their mothers from Tetanus and Rubella vaccination at the time of delivery

MOH area / (AA)
Number of pregnant mothers registered in year 2015 / BCG** / Maternal TT / Maternal Rubella
(A)
Number of registered infants under care * / (B)
Number of estimated births for 2016 / (C)
Number of vaccinations according to BI registers / (D)
Number & % of age appropriate vaccinations according to BI registers**
(D/A)*100 / (E)
Number of vaccines given according to Q/ EPI return / (F)
Coverage
according to / (G)
Number of mothers protected from TT at the time of delivery according to pregnant mothers registers /mothers cards / (H)
Number of mothers protected from Rubella at the time of delivery according to pregnant mother registers /mothers cards
Registered infants under care *
(C/A)* 100 / Estimated births
(C/B)* 100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for BCG- 24 hours to date^^ -to the date of compilation of data for the review***TT & Rubella immunizations of pregnant mothers of children born between 01st January 2016 – 31st December 2016 should be obtained from Pregnant Mothers Registers/512b or mothers cards V & W **** -For the infants born to the mothers who were under care/ residing within the area at the time of delivery

FORM 2 a

Calculation of No. of registered infants under care among infants bornbetween1stof November 2015 to 31stof October 2016 (eligible for OPV1/ PVV1 vaccination in year 2016)

MOH area / Number of pregnant mothers registered in 2015
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of November 2015 to 31st of October 2016
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

Form 2b

Coverage of OPV1 /PVV 1 vaccination among infants born between 01st of November 2015 to 31st of October 2016

MOH area / (AA)
Number of pregnant mothers registered in 2015 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2016 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A)* 100 / (C/B) *100 / (D/A) *100 / (C/E) *100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for PVV 1 /OPV1- Two weeks

FORM 3 a

Calculation of No. of registered infants under care among infants born between 01st of March 2015 to 28th February 2016

(eligible for IPV(IM) vaccination in year 2015 3rd & 4th quarters & 2016 1st & 2nd quarters)

MOH area / Number of pregnant mothers registered in 2014
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 01st of March 2015 to 28th February 2016
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

Form 3b

Coverage of IPV(IM) vaccination among infants born between 01st of March 2015 to 28th February 2016

MOH area / (AA)
Number of pregnant mothers registered in 2014 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2015 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI returns(3rd & 4thq 2015 and 1st & 2nd q 2016) / Coverage according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A)* 100 / (C/B) *100 / (D/A) *100 / (C/E) *100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for IPV(IM)- Two weeks

FORM 4 a

Calculation of No. of registered infants under care among infants born between01st of July 2015 to 31stof June 2016(eligible for OPV3/ PVV3 vaccination in year 2016)

MOH area / Number of pregnant mothers registered in 2015
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of July 2015 to 31st of June 2016
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

Form 4b

Coverage of OPV3 /PVV 3 vaccination among infants born between 01st of July 2015 to 31stof June 2016

MOH area / (AA)
Number of pregnant mothers registered in 2015 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2016 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage
according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A)* 100 / (C/B) *100 / (D/A) *100 / (C/E) *100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for PVV 3 /OPV3- Two weeks

FORM 5a

Calculation of No. of registered infants under care among infants born between 01st of April 2015 to 31st of March 2016
(eligible for MMR 1 vaccination in year 2016)

MOH area / Number of pregnant mothers registered in 2014
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of April 2015 to 31st of March 2016
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

FORM 5b

Coverage of MMR1 vaccination among infants born between 01st of April 2015 to 31st of March 2016

MOH area / (AA)
Number of pregnant mothers registered in 2014 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2015 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage
according to
Registered infants
under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A) *100 / (C/B) *100 / (D/A)* 100 / (C/E) *100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for MMR1- one month

FORM 6a

Calculation of No. of registered infants under care among infants born between1st of January 2015 to 31st of December 2015(eligible for LJE vaccination in 2016)

MOH area / Number of pregnant mothers registered in 2014
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of January2015 to 31st of December 2015
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

Form 6b

Coverage of LJEV vaccination among infants born between 1st of January 2015 to 31st of December 2015

MOH area / (AA)
Number of pregnant mothers registered in 2014 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2015 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage
according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A) *100 / (C/B)* 100 / (D/A)* 100 / (C/E) *100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for LJEV- one month

FORM 7a

Calculation of No. of registered infants under care among infants born between1st of July2014 to 30th of June 2015 (eligible for DPT4/ OPV4 vaccination in year 2016)

MOH area / Number of pregnant mothers registered in 2013
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of July 2014 to 30st of June 2015
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

FORM 7b

Coverage of DPT4/OPV4 vaccination among infants born between 1st of July2014 to 30th of June 2015

MOH area / (AA)
Number of pregnant mothers registered in 2013 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2014 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage
according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A)* 100 / (C/B) *100 / (D/A)* 100 / (C/E) *100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for DPT4/ OPV4- one month

FORM 8a

Calculation of No. of registered infants under care among infants born between 1st of January 2013 to 31st of December 2013(eligible for MMR2 vaccination in year 2016)

MOH area / Number of pregnant mothers registered in 2012
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of January 2013 to 31st of December 2013
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

Form 8b

Coverage of MMR2 vaccination among infants born between1stof January 2013 to 31st of December 2013

MOH area / (AA)
Number of pregnant mothers registered in 2012 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2013 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A) *100 / (C/B) *100 / (D/A)* 100 / (C/E)* 100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for MMR2- one month

FORM 9a

Calculation of No. of registered infants under care among infants born between 1st of January 2011 to 31stof December 2011(eligible for DT/ OPV5 vaccination in year 2016)

MOH area / Number of pregnant mothers registered in 2010
(AA) / Number of registered infants under care*
(A)
A = (V+W+X) - (Y+-Z) / Number of infants born between 1st of January 2011 to 31st of December 2011
Registered within 3 months of birth
(V)**** / Registered after 3 months of birth to date^^
(W)**** / Came newly into the area & registered
to date^^
(X) / Left the area
to date^^
(Y) / Died
to date^^
(Z)

FORM 9b

Coverage of DT/OPV5 vaccination among infants born between 1st of January 2011to 31stof December 2011

MOH area / (AA)
Number of pregnant mothers registered in 2010 / (A)
Number of registered infants under care* / (B)
Number of estimated births
For 2011 / (C)
Number of vaccinations according to BI registers / (D)
Number of age appropriate vaccinations according to BI registers** / (E)
Number of vaccines given according to Q/ EPI return / Coverage
according to
Registered infants under care* / Estimated births / Age appropriateness / Number of vaccines given as per Q/ EPI returns
(C/A)* 100 / (C/B)* 100 / (D/A) *100 / (C/E)* 100
Total

*Number of registered infants under care = (Number registered within 3 months of birth + Number registered after 3 months of birth to date+ Number newly came into the area & registered to date ) – (Number left the area to date + number died to date )

**Age appropriate vaccination for DT/ OPV5 - one month

Form 10

Coverage of aTd vaccination among children in grade 7 during2016

No / MOH area / Number on roll in
grade 7 / Number of children immunized in
grade 7 / % of immunized children in
grade 7 / Number of children immunized in
other grades / Total number immunized in year2016
1
2
3
4
5
6
7
8
9
10
Total

Form 11a

Status of vaccine usage and wastage in the district for year 2016 by antigen

Antigen / Book balance at the all MOH officesas of 31st December2015
(A) / Total receipts at the all MOH offices during 2016
(B) / Book balance at the all MOH offices as of 31st of December2016
(C ) / No of doses discarded at the all MOH offices due to expiry or cold chain failure during 2016
(D) / Total number
of doses
utilized by all MOOH during 2016for vaccination
( E)=(A+B)-(C +D) / Highest book balance at the MOH offices
in a
given time during
the year 2016
(F) / Total No. of
Immunizations
Performed in year 2015
( Based on the4 EPI quarterly Returns sent by the MOOH for year2016)
( G ) / Usage
%
( I )=(G/E)*100 / Wastage
%
( J )=(100- I )
B.C.G
Penta
DPT
OPV
LJEV
DT
TT
aTd
MMR
Other

Form 11b

Status of IPV (IM)vaccine wastage in the MOH areaduring1st of July2015 to 30th June 2016
Antigen / Book balance*
as of
30th of June 2015
(A) / Total receipts* during
1st of July2015
to
30th June 2016
(B) / Book balance* as of
30th June 2016
(C ) / No of doses* discarded due to expiry or cold chain failure during
1st of July2015
to
30thJune 2016
(D) / Total number
of doses*
used during
1st of July2015
to
30th June 2016
for vaccination
( E)=
(A+B)-(C +D) / Highest & Lowest book balances*
in a
given time during
1st of July2015
to
30th June 2016 / No. of
Immunizations
Performed by clinics/ estates/GPs
( Based on 4^ EPI quarterly Returns)during
1st of July2015
to
30th June 2016
( G ) / No. of doses*
Distributed to Clinics/
Estates/
GPs
(Based on the MOH Office vaccine movement register during
1st of July2015
to
30th June 2016
( H ) / Usage
%
( I )=
G/E * 100 / Wastage
%
( J )=
(100- I )
Highest
(F1) / Lowest
(F2)
IPV
(IM dose)
*For IM vaccination 1dose=0.5ml 4 ^EPI quarterly returns=3rd & 4th Q 2015 and 1st & 2nd Q 2016 EPI quarterly returns

Form 12 a: Adverse events following immunization (A.E.F.I.) in year2016

MOH area / No. of
Monthly AEFI Returns received / No. of
Monthly AEFI Returns received in time / No. of
“Nil” Monthly AEFI returns received / Total No. of AEFI** reported / Total No. of AEFI investigated( %)
Total

**Injection site abscess,BCG lymphadenitis,Severe local reactions,Encephalitis/Encephalopathy,MeningitisSeizures (Febrile + Afebrile)Anaphylaxis,Persistent Screaming,HHE

Form 12 b : Rates of AEFIs reported in the district during 2016

Antigen / Type of AEFI / Number of AEFI
reported
(A) / No of doses
administered†
(B) / AEFI Rate
( C )
(C ) =(A)/(B)*100000 / National Rates for
2016
BCG / BCG lymphadenitis
Penta / Seizures (Febrile + Afebrile)
Anaphylaxis
Persistent Screaming
HHE
Allergic reaction
Measles / Seizures (Febrile + Afebrile)
Anaphylaxis
Allergic reaction
MMR / Seizures (Febrile + Afebrile)
Anaphylaxis
Allergic reaction
Parotitis
JE / Seizures (Febrile + Afebrile)
Anaphylaxis
Allergic reaction
Encephalitis/Encephalopathy

Form 14a

Incidence of infant deaths, neo natal deaths and their causes in the district – 2016

**Please use national Infant mortality rate (9.9 per 1000 live births) and national neonatal mortality rate (7.0 per 1000 live births) to calculate the estimated number of infant/ neonatal deaths for year 2016

MOH area / Estimated No. of live births / Estimated No. of infant deaths / Estimated No. of neonatal deaths / No of infant deaths reported / No. of infant deaths investigated / % of infant deaths investigated
Total

14b

Causes / No. reported / %
1. Prematurity
2. Congenital Abnormalities
3.
4.
5.
6.
Total

Form 15

Notification and investigation of VPD- 2016

Disease / No. Reported
(A) / No. Investigated*
(B) / No, confirmed
(C) / % Investigated
(D)
(D)=(B)/(A)*100 / No. of special investigation forms sent
(E) / % of special investigation forms sent
(F)
(F)=(E)/(C)*100
Whooping Cough
Tetanus
NNT
Measles
Rubella
CRS
AFP
Encephalitis
Meningitis
Mumps
Total

Data have to be obtained from the Notification Register to fill the columns (A) & (B) and from the Infectious Disease (ID) register to fill the column (C)

*No. investigated =(Number confirmed+ Number identified as anon notifiable disease+ Number unable to trace+ Number belongs to other MOH areas+ Number re notified)OR *No. Investigated =No. reported - No. not attended by a MOH/PHI

District and Provincial Birth Rates to be used for calculation of estimated number of births for year 2017

( Source- Registrar General ‘s Department )

Districts / District Birth Rate 2015
per 1000 population / Provincial Birth Rate 2015
per 1000 population
Colombo / 14.4 / 13.9
Gampaha / 13.1 / 13.9
Kalutara / 14.2 / 13.9
Kandy / 17.5 / 17.1
Matale / 17.4 / 17.1
Nuwara Eliya / 16.5 / 17.1
Galle / 16.4 / 16.8
Matara / 14.2 / 16.8
Hambantota / 19.7 / 16.8
Jaffna / 13.6 / 15.7
Kilinochchi / 16.9 / 15.7
Mannar / 18.1 / 15.7
Vavuniya / 17.6 / 15.7
Mulativu / 12.2 / 15.7
Batticaloa / 17.3 / 19.7
Ampara / 20.5 / 19.7
Trincomalee / 20.5 / 19.7
Kalmunai / 20.5 / 19.7
Kurunegala / 15.4 / 16.9
Puttalam / 18.4 / 16.9
Anuradhapura / 17.3 / 17.1
Polonnaruwa / 16.9 / 17.1
Badulla / 16.2 / 17.3
Moneragala / 18.4 / 17.3
Ratnapura / 16.7 / 15.8
Kegalle / 14.9 / 15.8
Sri Lanka / 16.0 / 16.01 16.011111116