Immunization

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Dr. Prabir Kumar Das MD, DTCD, MPS,MIPHA, MA (Philosophy), MA (Public Administration). Strengthening of Routine Immunization

Topics to be Covered :

Topics to be Covered Milestones in Immunization Programme Introduction to Immunization Programme Objectives of Reviewing Immunization Programme Major Observations Immunization Schedule and FAQs Micro-planning

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Disease Surveillance Delivery of Immunization Services Adverse Events Following Immunization Cold Chain and Logistics Injection Safety Role of Behavioural Change Monitoring, Supervision, Information System and Evaluation

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MILESTONES IN VACCINE DEVELOPMENT

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ON MAY14, 1796: EDWARD JENNER, A BRITISH PHYSICIAN, DISCOVERED THAT INOCULATION OF A PERSON WITH RELATIVELY HARMLESS DISEASE MATERIAL COULD PROTECT THE PERSON FROM A MORE DANGEROUS DISEASE HE CALLED THIS PROCESS “VACCINATION” , DERIVED FROM THE LATIN NAME FOR COWPOX “VACCINIA” 6TH JULY, 1885: FIRST USE OF LIVE ATTENUATED LIVE VIRAL VACCINE (RABIES ) IN HUMANS BY JOSEPH MEISTER. 1885: CHOLERA LIVE VIBRIO CHOLERAE FERRAN 1885: RABIES NERVOUS TISSUE VACCINE PASTEUR 1892: CHOLERA ATTENUATED WHOLE CELL HAFFKINE

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1896:TYPHOID FEVER INACTIVATED WHOLE CELL WRIGHT, PFEIFFER & KOLLE 1897: PLAGUE INACTIVATED WHOLE CELL BEHRING 1911: RABIES NERVOUS TISSUE VACCINE SEMPLE 1913: DIPHTHERIA TOXIN-TOXOID BEHRING 1921:TUBERCULOSIS LIVE ATTENUATED CALMETTE BACTERIAL VAACCINE (BCG) GUERIN 1923: DIPHTHERIA PARTIALLY PURIFIED TOXOID RAMON, GLENNY 1926: WHOOPING INACTIVATED WHOLE CELL MADSEN COUGH

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1927: TETANUS TOXOID PARTIALLY PURIFIED TOXOID RAMON, ZOELLER 1932: YEOLLOW FEVER LIVE ATTENUATED SELLARD 1937: YELLOW FEVER LIVE ATTENUATED THEILER 1937:INFLUENZA INACTIVATED SALK 1938: SCRUB TYPHUS INACTIVATED WHOLE CELL ------- 1940s: D.P.T. COMBINATION -------- 1949: MUMPS LIVE ATTENUATED MORODINTSEV

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1955: POLIOMYELITIS INACTIVATED SALK 1956: RABIES INACTIVATED DUCK EMBRYO PECK 1968: MENINGOCOCCUS ‘C’ 1971: MENINGOCOCCUS ‘A’ 1961: POLIOMYELITIS LIVE ATTENUATED ORAL SABIN 1961: MEASLES LIVE ATTENUATED ENDERS, SCHWARZ 1962: RUBELLA LIVE ATTENUATED WELLER, NEVA, PARKINE

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1967: MUMPS LIVE ATTENUATED WEIBEL, BUYNACH, HILLEMAN 1974: J.E INACTIVATED -------- 1976: RABIES INACTIVATED & GROWN ON WIKTOR HUMAN DEPLOID CELL 1976: HEPATITIS “B” PLASMA DERIVED -------- 1980: PNEUMOCOCCAL VACCINE 1980: TYPHOID FEVER LIVE ATTENUATED WAHDAN

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1983: CHICKEN POX LIVE ATTENUATED -------- 1986: HEPATITIS ‘B ’ RECOMBINANT -------- 1986: CHOLERA ‘B’ SUBUNIT WHOLE CELL HOLMGREN, SVENNERHOLM 1990: HAEMOPHILIUS POLYSACCHARIDE -------- INFLUENZAE TYPE ‘B’

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INTRODUCTION

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EXPANDED PROGRAMME ON IMMUNISATION INITIATED IN INDIA IN 1978 UNIVERSAL IMMUNISATION PROGRAMME LAUNCHED ON 19 TH NOVEMBER 1985 CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME CAME INTO EXISTENCE IN 1993 REPRODUCTIVE AND CHILD HEATH PROGRAMME INTRODUCED DURING 1998 IMMUNISATION PROGRAMME IS ONE OF THE MAJOR COMPONENTS OF NATIONAL TECHNOLOGY MISSION

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OBJECTIVES OF REVIEWING VACCINATOION PROGRAMME

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REVIEW THE POLICIES, STRATEGIES AND PLANS OF ACTION MEASURE THE PROGRESS IDENTIFY THE BOTTLENECKS AND CONSTRAINTS MAKE RECOMMENDATIONS

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MAJOR OBSERVATIONS

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1. POLICY ASPECT: INCLUDED IN THE 20 POINT PROGRAMME A TECHNOLOGY MISSION FOR IMMUNISATION HAS BEEN CREATED STATES HAVE ACCEPTED TO CARRY OUT THE PROGRAMME AND FORMED TECHNOLOGY MISSION POLICY DECISION TO INTEGRATE IMMUNISATION PROGRAMME WITH PRIMARY HEALTH CARE PROVIDED THROUGH PHC AND SUBCENTRES GOVERNMENT OF INDIA PROVIDED 100 % FINANCIAL SUPPORT TO STATES CLEAR-CUT POLICIES FOR IMPLEMENTING IMMUNISATION PROGREAMME IN URBAN AREAS ALMOST NON-EXISTENCE

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2. ORGANISATIONAL AND OPERATIONAL ASPECTS PROGRAMME IS BEING IMPLEMENTED IN AN INTEGRATED MANNER D.I.O. FACED THE PROBLEMS OF LACK OF ADEQUATE ADMINISTRATIVE AUTHORITY, AMBIGUITY REGARDING RELATIONSHIP WITH OTHER DISTRICT HEALTH OFFICIAL 3. RESOURCE AVAILABILITY 30.95 % DISTRICTS WITH LESS NUMBER OF FUNCTIONAL SUB-CENTRES 24% OF SUBCENTRES WITH FEMALE STAFF RESIDING OUTSIDE AREA

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VACANCY DIO 21.4% REFRIGERATOR MECHANIC 50.0% STATISTICAL ASSISTANT 35.7% DRIVERS 28.5% 30.9% OF DISTRICTS WITH MORE THAN 20% VACCANY OF MEDICAL OFFICERS 26.1% OF DISTRICTS WITH MORE THAN 20% VACCANY OF HEALTH ASSISTANT (FEMALE) 14.2% OF DISTRICTS WITH MORE THAN 20% VACCANY OF HEALTH WORKERS (FEMALE)

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VACCINES AND COLD CHAIN SYSTEM: THE REFRIGERATORS AND FREEZERS IN WORKING CONDITION DISTRICT 97.6 P.H.C 81.5 THERMOMETER IN ALL REFRIGERATOR DISTRICT 88.0 P.H.C 73.0 DAILY TEMPARATURE RECORD DISTRICT 78.57 P.H.C 67.20

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DISTRICT PHC % % THERMOMETER IN I.L.R 97.6 74.1 EXPIRY DATE VACCINE -- 3.7 FROZEN D.P.T / T.T. 2.4 4.8 OPEN VACCINE VIALS -- 6.3 RETURNED UNOPENED VIALS MARKED 76.1 49.2 F.I.F.O. PRINCIPLE OBSERVED 86.1 68.8

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DISTRICT PHC % % > THREE MONTHS SUPPLY 11.9 15.3 < 1 MONTH SUPPLY 7.2 52.1 FOOD / DRINKING WATER WITH VACCINES 2.6 6.9 FROZEN ICE PACKS 96.0 61.9 VACCINE STOCK REGISTER MAINTAINED 97.6 85.2

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4. TRAINING OF HEALTH PERSONNEL PROBLEMS OF BACK LOG IN TRAINING POOR QUALITY OF TRAINING PROCESSES IN ADEQUACY OF TRAINING AIDS 5. OPERATIONAL AND MANAGERIAL PROCESSES A. PLANNING ACTIVITIES: ACTION PLAN AVAILABLE 78.5 % ALLOCATTION OF TARGET USING SPECIFIC POPULATION CRITERIA 69.0% CORRECT INFORMATION USED FOR ESTIMATING VACCINE REQUIREMENT 78.5%

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B. SCHEDULED IMMUNISATION SESSION: 45.8% REASONS: SHORTAGE OF VACCINE 50.6% CALLED FOR OTHER DUTIES 37.3% ABSENCE OF WORKERS 28.8% LACK OF TRANSPORT 23.2% SHORTAGE OF SYRINGES 7.4% SHORTAGE OF NEEDLES 6.8% C. SPECIAL STRATGIES ADOPTED FOR IN ACCESSIBLE AREAS 46.5% D. MICROPLANNING DISTRICT A FEW E. MONITORING SOME STATES

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F. SUPERVISORY VISIT AS PER SCHEDULUED DATE 40.4% CHECKING COLD CHAIN, VACCINES, RECORDS 47.6% CHECKING DISEASE SURVEILLANCE 33.3% VISIT OBSERVATION RECORDED 26.2% RECORD OF MONTHLY MEETING MAINTAINED 76.19% REPORTS ON A.E.F.I. 90.4% DISTRICT HEALTH OFFICIALS SATISFED 57.1% AVERAGE NO. OF VISIT BY DISTRICT OFFICIAL 4 (1-10) USE OF SUPERVISORY CHECK LIST DID NOT EXIST

6. IMMUNISATION COVERAGE:

6. IMMUNISATION COVERAGE > 50% COVERAGE FOR DPT-III 83.7% > 50% COVERAGE FOR OPV-III 81.3% > 50% COVERAGE FOR BCG 67.4% > 50% COVERAGE FOR MEASLES 25.5%

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Vitamin A Give at 10 and 16 years TT Give at 5 yrs/ school entry DT Give at 16 months (wait at least 6 months after OPV3 & DPT3) DPT- OPV Booster Give at completion of 9 months/ as soon as possible after completion of 9 mths Measles Give at 3 ½ months/ as soon as possible after 3 ½ months (wait at least 1 month after DPT 2, Hep B 2 & OPV 2 to give DPT3, Hep B 3 & OPV 3) DPT 3 OPV 3 Hep B Give at 2 ½ months or as soon as possible after 2 ½ months (wait at least 1 month after DPT 1 , Hep B1 & OPV 1 to give DPT 2, HeB 2 & OPV 2) DPT 2 OPV 2 Hep B Give at 1 ½ months or as soon as possible after 1 ½ months DPT 1 OPV 1 Hep B Give as early as possible in the first 12 months BCG Give in first 15 days only OPV 0 10 & 16 years 5 th year 1- 2 years 9 - 12 months 1 ½ to 9 months ½ - 1 ½ months Doses For the Infant and Child Birth - 14 days If a child does not receive Measles by 1yr, give as soon as possible before 5 yrs ( 9 months with measles, 16 months with DPT booster. Thereafter every 6 month till 5 years of age) Immunization Schedule And FAQs

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Find out from Which vaccines should I give today? Immunization Card MCH Register Caregiver/beneficiary

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1. How many TT injections has she received till today? 2. When was the last TT injection received before today ? Pregnant Woman

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Infant and Child 1. How old is the child? 2. Which vaccines has the child already received till today? 3. Have at least 4 weeks passed since the last DPT, OPV, or Hep B was given?

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Tuberculosis Skin Subcutaneous Tissue Muscle 15 ° Angle Intra-dermal Injection Give at birth or as early as possible in the first 12 months. Left Upper Arm Gently pull skin under arm to stretch skin at injection site Dose: 0.1 ml (0.05ml for less than 1 month); Diluent: 1 ml sodium chloride; Vial: 10 doses Precaution Discard 4 hours after reconstitution BCG

Remember:

Remember BCG Do NOT repeat BCG if given once, even if the eschar /scar does not appear. Do NOT give BCG if child is over one year old.

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Poliomyelitis Dose: 2 drops; Vial: 20 doses Put two drops directly in mouth of child Mouth Oral administration Birth till 15 days, 1 ½ mths (6 wks), 2 ½ mths (10 wks), 3 ½ mths (14 wks) OPV

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Stretch skin flat between finger & thumb on both sides of injection site DPT Muscle Subcutaneous Tissue Skin 90 °Angle Intramuscular Injection Dose: 0.5 ml; Vial: 10 doses Outer Mid-thigh (Antero-lateral side of mid-thigh) 1 ½ mths (6 wks), 2 ½ mths (10 wks), 3 ½ mths (14 wks) Outer Mid-thigh (Antero-lateral side of mid-thigh) Stretch skin flat between finger & thumb on both sides of injection site

Remember:

DPT Remember Always give DPT in outer mid thigh (Antero-lateral Thigh in vastus lateralis muscle) Giving DPT in buttocks (gluteal region) may injure the sciatic nerve and cause paralysis. Never give DPT in buttocks

Remember:

Remember Wait at least 4 weeks (one month) after previous dose of DPT-OPV before giving next dose. If child comes after gap of more than 4 weeks for its next dose of DPT-OPV, give next dose of series. Do NOT repeat previous dose , as there is no maximum interval between doses . DPT & OPV Give DPT and OPV Booster dose at 16 months till 24 months (Wait at least 6 months after OPV3 & DPT3) Give DPT at 5 years of age If no DPT / DT is given till 5 years, give 2 doses of TT one month apart as soon as possible

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Stretch skin flat between finger & thumb on both sides of injection site Muscle Subcutaneous Tissue Skin 90 °Angle Intramuscular Injection Dose: 0.5 ml; Vial: 10 doses Outer Mid-thigh (Antero-lateral side of mid-thigh) 1 ½ mths (6 wks), 2 ½ mths (10 wks), 3 ½ mths (14 wks) Hepatitis B

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Dose: 0.5ml; Diluent: 2.5 ml double distilled water; Vial: 5 doses Precaution Discard 4 hours after reconstitution Right Upper Arm 9 months completed - 12 months (39 – 52 weeks). If a child does not receive Measles before the 12th month, give a dose as soon as possible before 5 years of age. Subcutaneous Injection Skin Subcutaneous Tissue Muscle 45 ° Angle Pinch skin through left index finger & thumb Measles

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1 ml (9 months) or 2 ml ( 16 months, 24 months, 30 months & 36 months) Precaution Use within 6-8 weeks once opened Keratomalacia, Bitot Spots, Night Blindness. Other sub-clinical symptoms leading to increased severity of disease and mortality 9 months with measles, 16 months with DPT booster. Thereafter every 6 month till 5 years of age (Total 9 doses) Oral Administration (use only spoon provided observing marks for 1ml and 2ml) Vitamin A

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Tetanus Suck & cry in first 2 days of life, Illness between 3- 28 days of life, Inability to suck foll. by stiffness of neck & body &/or jerking of muscles Muscle Subcutaneous Tissue Skin 90 °Angle Intramuscular Injection Dose: 0.5 ml; Vial: 10 doses Stretch skin flat between finger and thumb on either side of injection site Early in pregnancy and at least 4 weeks later TT Deltoid Muscle

Remember:

Remember Give TT Booster only if already received at least two TT injections within last 3 years Try to give TT2 or TT Booster at least one month before Expected Date of Delivery. However, give even if less than 1 month remains. TT Give TT at 10 years and 16 years

Remember:

Remember All due vaccines can be given at same time but in different limbs (sites) e.g. it is safe and effective to give BCG, DPT, OPV, HepB , Measles & VitA at same time to a 9 month old child who has never been immunized Hepatitis B (intramuscular) Measles (subcutaneous) Vit A (oral) BCG ( intradermal ) DPT (intramuscular) OPV (oral)

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Vitamin A Give at 10 and 16 years TT Give at 5 yrs/ school entry DT Give at 16 months (wait at least 6 months after OPV3 & DPT3) DPT- OPV Booster Give at completion of 9 months/ as soon as possible after completion of 9 mths Measles Give at 3 ½ months/ as soon as possible after 3 ½ months (wait at least 1 month after DPT 2, Hep B 2 & OPV 2 to give DPT3, Hep B 3 & OPV 3) DPT 3 OPV 3 Hep B Give at 2 ½ months or as soon as possible after 2 ½ months (wait at least 1 month after DPT 1 , Hep B1 & OPV 1 to give DPT 2, HeB 2 & OPV 2) DPT 2 OPV 2 Hep B Give at 1 ½ months or as soon as possible after 1 ½ months DPT 1 OPV 1 Hep B Give as early as possible in the first 12 months BCG Give in first 15 days only OPV 0 10 & 16 years 5 th year 1- 2 years 9 - 12 months 1 ½ to 9 months ½ - 1 ½ months Doses For the Infant and Child Birth - 14 days If a child does not receive Measles by 1yr, give as soon as possible before 5 yrs ( 9 months with measles, 16 months with DPT booster. Thereafter every 6 month till 5 years of age)

Planning Immunization Services:

Planning Immunization Services

Immunization Microplan:

Immunization Microplan District 1 District 3 District 2 District Plan = Area map, Compiled PHC plans + supervision, budget, IEC, training etc. State Level State Plan = Compiled District Plans + state specific activities SC Plan = Area Map, estimation of beneficiaries, vaccine logistics and ANM work plan Sub-Centres PHC Plan = Area map, Compiled SC plans, supervision plan + alternate vaccine delivery, waste disposal Primary Health Cen tres

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Step 2 Write population of each village and hamlet based on actual headcount Step 1 List all villages and hamlets in SC area If hamlets have too small a population, tag these along with larger nearby villages.

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Steps 3 and 4 Write the annual target of pregnant women and infants Steps 5 and 6 Write the monthly target of pregnant women and infants

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Step 7 Calculate the beneficiaries per month for each vaccine and Vitamin A TT = Monthly target of pregnant women x 2 doses BCG = Monthly target of infants x 1 dose DPT = Monthly target of infants x 4 doses OPV = Monthly target of infants x 4 doses HepB = Monthly target of infants x 3 doses Measles = Monthly target of infants x 1 dose DT = Monthly target of infants x 1 dose Vit.A = Monthly target of infants x 9 doses

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Step 8 Calculate the requirement of vaccine vials and Vitamin A per month TT/BCG/DPT/HepB/DT = Beneficiaries per month X 1.33* 10 OPV = Beneficiaries per month X 1.33 20 Measles = Beneficiaries per month X 1.33* 5 VitA = {(monthly target of infants x 1 ml) + (monthly target of infants x 2 ml x 8)} x 1.11** * Vaccines = 25% wastage rate or 1.33 WMF (Wastage Multiplication Factor) * * VitA= 10% wastage rate or 1.11 WMF

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Step 9 Calculate the requirement of Syringes per month 0.1 ml ADS = Beneficiaries for BCG x 1.1* 0.5 ml ADS = Beneficiaries for (TT+DPT+HepB+Measles+DT) x 1.1* Reconstitution Syringes = (BCG + Measles vials) X 1.1* * Syringes = 10% wastage rate or 1.11 WMF (Wastage Multiplication Factor)

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Steps 10 to 13 List all villages & hamlets in Sub-Center area in the same order as Step 1 Write distance of village from the closest ILR List names of the AWW and ASHA Write the monthly injection load per village

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Step 14 to 15 Calculate the number of sessions required per month (in column sessions required per month) Write day of immunization session in village Outreach sites Fixed sites 1-24 injections = 1 session every alternate month 25-50 injections= 1 session per month 51-100 injections = 2 sessions per month, etc For hard-to-reach areas with popn . less than 1000 = minimum of 4 sessions a year 1-39 injections = 1 session every alternate month 40-70 injections= 1 session per month 71-140 injections = 2 sessions per month, etc For a busy CHC/RH, plan daily sessions.

Area Map:

Area Map Step 16 Prepare a map of the Sub-Center area including all villages and hamlets with their: Total population and annual target infants Anganwadi Centers and session sites Distance from the ILR point and transport mode Landmarks e.g. Panchayat, school, roads etc. Sessions days

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Step 17 Prepare a quarterly supervision plan at the PHC level. Health Facility: PHC Garhi Month: May Sub-Center Supervisor Post Session Site Planned visit Conducted (Y/N) Remarks Kushalgarh Kashinath Soni HA(M) Piplod 11 May Yes Talwara Dr B Singh MO Sailana 18 May Yes Arthuna Rita Matthew LHV Arthuna 25 May No SIA, visit next wed. Jhalod Dr Geeta Joshi MOIC Jhalod 31 May No SIA, visit next wed.

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DISEASE SURVEILLANCE

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SURVEILLANCE SYSTEM FOUND TO BE POOR POOR TRAINING OF STAFF INADEQUATE RECORD MAINTENANCE INSUFFICIENT INVESTIGATION OF REPORTED DISEASE OUT-BREAKS WERE COMMON IN MANY STATES POLIO AND N.N.T SURVEY WERE CONDUCTED

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history of contact with suspected/confirmed case of pulmonary TB Weight loss, cough and wheeze not responding to ARI antibiotics Tuberculosis Skin Subcutaneous Tissue Muscle 15 ° Angle Intra-dermal Injection Give at birth or as early as possible in the first 12 months. Left Upper Arm Gently pull skin under arm to stretch skin at injection site Dose: 0.1 ml (0.05ml for less than 1 month); Diluent: 1 ml sodium chloride; Vial: 10 doses Precaution Discard 4 hours after reconstitution Childhood TB

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Poliomyelitis Sudden weakness & paralysis of leg(s), &/ or arm(s) &/or trunk Paralysis not present at birth or due to serious injury/mental retardation Dose: 2 drops; Vial: 20 doses Put two drops directly in mouth of child Mouth Oral administration Birth till 15 days, 1 ½ mths (6 wks), 2 ½ mths (10 wks), 3 ½ mths (14 wks) Poliomyelitis

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Stretch skin flat between finger & thumb on both sides of injection site Diphtheria, Pertussis & Tetanus Muscle Subcutaneous Tissue Skin 90 °Angle Intramuscular Injection Dose: 0.5 ml; Vial: 10 doses Outer Mid-thigh (Antero-lateral side of mid-thigh) 1 ½ mths (6 wks), 2 ½ mths (10 wks), 3 ½ mths (14 wks) Outer Mid-thigh (Antero-lateral side of mid-thigh) Stretch skin flat between finger & thumb on both sides of injection site

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Diphtheria : Sore throat with gray patch(es) in throat Pertussis (whooping cough ): Repeated & violent coughing, with: Cough persisting for 2+ weeks, fits of coughing, Cough followed by vomiting, typical whoop in older infants. Tetanus : Suck & cry in first 2 days of life, Illness between 3- 28 days of life, Inability to suck foll. by stiffness of neck & body &/or muscle jerking

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Stretch skin flat between finger & thumb on both sides of injection site Muscle Subcutaneous Tissue Skin 90 °Angle Intramuscular Injection Dose: 0.5 ml; Vial: 10 doses Outer Mid-thigh (Antero-lateral side of mid-thigh) 1 ½ mths (6 wks), 2 ½ mths (10 wks), 3 ½ mths (14 wks) Hepatitis B Fever, headache, nausea, vomiting, jaundice (yellowish eyes) and light or gray stools. Finally confirmed by laboratory tests

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Dose: 0.5ml; Diluent: 2.5 ml double distilled water; Vial: 5 doses Precaution Discard 4 hours after reconstitution Right Upper Arm 9 months completed - 12 months (39 – 52 weeks). If a child does not receive Measles before the 12th month, give a dose as soon as possible before 5 years of age. Subcutaneous Injection Skin Subcutaneous Tissue Muscle 45 ° Angle Pinch skin through left index finger & thumb Measles Measles fever with rash with cough or running nose or red eyes.

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DELIVERY OF IMMUNISATION SERVICES

REASONS FOR FAILURE OF IMMUNISATION:

REASONS FOR FAILURE OF IMMUNISATION UNAWARE OF NEED 19-53% UNAWARE OF NEED TO RETURN 0.5-27% PLACE AND TIME UNKNOWN 0.9-26% FEAR OF SIDE REACTION 0.6-30% WRONG IDEAS ABOUT CONTRAINDICATIONS 0.9- 8.8% PLACE TOO FAR TO GO 0.5-49%

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INCONVENIENT TIME 0.8-13 % VACCINATOR ABSENT 0.8-23% MOTHERS TOO BUSY 3- 19% CHILD ILL 2-32% POSTPONED 10-24% NO FAITH 0.5-29% RUMOURS 0.5-13%

RESULTS OF OBSERVATION OF IMMUNISATION SESSION:

RESULTS OF OBSERVATION OF IMMUNISATION SESSION IMMUNISATION WITH M.C.H 77 IMMUNISATION CARDS CORRECTLY FILLED 70 IMMUNISATION CARDS GIVEN TO MOTHERS 60 AGE SCREENING DONE CORRECTLY 82

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ALL VACCINES GIVEN < 84 VACCINES WITH EXPIRY DATE 79 VACCINE KEPT ON ICE 80 DILUENT KEPT IN VACCINE CARRIER 85

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DOSAGES CORRECT 94 IMMUNISATION SITE CORRECT 92 IMMUNISATION TECHNIQUE CORRECT 88 ADEQUATE NO. OF SYRINGES / NEEDLES 70 SEPARATE SYRINGE AND NEEDLE USED 73

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ADEQUATE NO. FROZEN ICE PACKS 72 PARTIALLY USED VIALS DISCARDED 83 MOTHERS PROPERLY INFORMED PURPOSE OF IMMUNISATION 77 NUMBER OF DOSES 89 RIGHT AGE FOR IMMUNISATION 81 POSSIBILITY OF SIDE EFFECTS 79 WHEN TO COME BACK FOR NEXT DOSE 90 SAFE KEEPING OF IMMUNISATION CARD 74

WHY PEOPLE USE ROUTINE IMMUNISATION SERVICES:

WHY PEOPLE USE ROUTINE IMMUNISATION SERVICES STUDIES IN MANY DEVELOPING COUNTRIES SHOW THAT: THEY KNOW WHEN TO COME BACK THEY HAVE BEEN TREATED RESPECTFULLY THEY HAVE CONFIDENCE THAT THEY WILL RECEIVE THE VACCINATIONS THAT THEY COME FOR

WHY FAMILIES DO NOT USE IMMUNISATION SERVICES :

WHY FAMILIES DO NOT USE IMMUNISATION SERVICES LACK OF INFORMATION POOR SERVICES LONG WAIT RUDENESS OR INSENSITIVITY UNAUTHORIZED FEES CHARGED UNSCHEDULED FACILITY CLOSURES SHORTAGE OF PERSONNEL, VACCINES, DRUGS OR OTHER SUPPLIES

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TIME CONSTRAINTS NOT BE THE FIRST PRIORITY FOR A MOTHER SOCIAL, CULTURAL OR POLITICAL BARRIERS MISINFORMATION DISTANCE

STRATEGIES FOR INCREASING THE USE OF ROUTINE IMMUNISATION SERVICES :

STRATEGIES FOR INCREASING THE USE OF ROUTINE IMMUNISATION SERVICES (A) REACHING THE UNREACHED IMPROVEMENT IN SCHEDULING RAISING AWARENESS IMPROVING AND EXPANDING OUTREACH TARGETING SERVICES TO MEET URBAN NEEDS

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(B) REDUCING DROP-OUTS: EXAMPLE: DISTRICT ‘A’ 50% OF CHILDREN HAVE ACCESS TO IMMUNIZATION SERVICES USING D.P.T. - 1 COVERAGE AS AN INDICATOR. 42% COMPLETE THE THREE - DOSE SERIES OF D.P.T. CALCULATE THE DROP-OUT RATE (50% -42%) * 100 ---------------------- = 16% 50% DISTRICT ‘B’ 85% OF CHILDREN HAVE RECEIVED D.P.T.-1 AND 58% COMPLETED THE THREE DOSE SERIES OF D.P.T. CALCULATE THE DROP-OUT RATE (85%-58%)*100 -------------------- = 32% 85%

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(C) LIMITING MISSED OPPORTUNITIES IMPROVE SCREENING GIVE ALL VACCINES DUE ELIMINATE FALSE CONTRAINDICATIONS CLARIFY POLICY ON MULTI-DOSE VIALS CLARIFY OPEN VIAL POLICY SUPPLIMENTAL IMMUNIZATION STRATEGIES ACCELERATED DISEASE CONTROL CATCH-UP CAMPAIGNS DOOR-TO-DOOR VACCINATION MOP-UP STRATEGIES OUT-BREAK RESPONSE SPECIAL POPULATION

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Remember Give these 4 Key Messages to the Care-giver: 1. What vaccine was given and what disease it prevents (e.g. BCG for preventing TB) 2. When to come for the next visit. 3. What are the minor side-effects and how to deal with them. 4. To keep the vaccination card safe and to bring it along for the next visit Even if the child is suffering from diarrhea, mild fever or malnutrition, it should be vaccinated. Unless a child is so sick that it has to be taken to hospital, do not stop its vaccination. The goal is to fully immunise each child before its first birthday

Adverse Events Following Immunization (AEFI):

Adverse Events Following Immunization (AEFI)

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Is it really safe? No vaccine is 100% safe and without any risks. Prepare parents for side effects

What is an AEFI ?:

What is an AEFI ? A medical event that takes place after an immunization causes concern is believed to be caused by immunization ranges from mild side effects to life-threatening, but rare, illnesses

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DEALING WITH RUMOURS “P” PREDICT “P” PREPARE “P” POSITIVE RESPONSE (FAST) “P” PROFESSIONAL SUPPORT “P” POLITICAL SUPPORT

Types of AEFIs :

Types of AEFIs Programmatic error Vaccine reaction LOCAL REACTION SYSTEMATIC REACTION ALLERGIC REACTION Coincidence Injection reaction Unknown

1. Programmatic error:

1. Programmatic error Event caused by error in vaccine selection, storage, preparation, handling, or administration (95% and Preventable) Wrong vaccine used, Vaccine reconstituted incorrectly Needle left in vial Wrong technique used Expired vaccine used Reconstituted vaccine not discarded after 4 hours. Freezing of freeze-sensitive vaccines (DPT, DT, TT) BCG injection given sub-cutaneously instead of Intradermally: local lymphadenitis and abcess

Types of Programmatic Errors:

Types of Programmatic Errors Programmatic Errors Possible Adverse event that may occur Non-sterile injection: Improperly sterilizing syringe and needle Contaminated vaccine or diluent Re-use of reconstituted vaccine at subsequent sessions Wiping the needle with a swab Administering injection over clothes Infection such as local abscess at site of injection, sepsis, toxic shock syndrome or death. Re-use of disposable syringe and needle Transmission of blood-borne infections such as Hep B, HIV, Hep C Reconstitution Error/ Wrong vaccine preparation Reconstitution with incorrect diluent Drug substituted for vaccine diluent Inadequate shaking for T- series vaccines Vaccine ineffective Negative effect of drug, e.g. insulin causing death Local abscess Injection at incorrect site BCG given sub-cutaneously DPT/DT/TT given superficially Injection into buttocks Local reaction or abscess Local reaction or abscess Sciatic nerve damage Vaccine transportation/storage incorrect Local reaction from frozen vaccine Vaccine ineffective Contraindications ignored Avoidable serious reaction

2. Vaccine Reaction :

2. Vaccine Reaction Rare event caused by inherent properties of vaccine, not by Programmatic error. Child has an allergic reaction to Vaccine.

True AEFIs:

True AEFIs Mild Reactions Common Pain & swelling Fever Irritability & malaise Self-limiting, hardly requiring even symptomatic treatment Important to reassure parents Severe reactions Rare Include seizures, thrombocyto-paenia, hypotonic hypo-responsive episodes, persistent inconsolable screaming Largely self-limiting and do not lead to long-term problems Anaphylaxis, while potentially fatal, is treatable without any long-term effect

3. Coincidence :

3. Coincidence Event not caused by the vaccine (a chance association) Child shows signs of measles a few days/ weeks after DPT vaccine is given.

4. Injection reaction :

4. Injection reaction Event is caused by pain from (or fear about) the injection itself. Child screams and faints at the sight of the needle.

5. Unknown :

5. Unknown Cause of event cannot be determined. Child develops respiratory infection or fever a few days after Injection.

Elicit past history of AEFIs :

Elicit past history of AEFIs Ask parents about history of any adverse reaction following earlier vaccinations, such as convulsion after DPT vaccination.

How to minimize AEFIs?:

How to minimize AEFIs? Use separate site for each vaccine. Hepatitis B (intramuscular) Measles (subcutaneous) Vit A (oral) BCG ( intradermal ) DPT (intramuscular) OPV (oral)

How to minimize AEFIs?:

How to minimize AEFIs? Use one syringe and one needle for each injection. Use auto-disable syringes for all immunization injections.

How to minimize AEFIs?:

How to minimize AEFIs? Reconstitute vaccines only with diluents supplied by the manufacturer for that vaccine.

How to minimize AEFIs?:

How to minimize AEFIs? Use Measles and BCG vaccine within 4 hours of reconstitution. Keep diluents of BCG and measles vaccine separate from other potentially harmful liquids.

How to minimize AEFIs?:

How to minimize AEFIs? Do not keep needles in the rubber cap (stopper) of vaccine vials. This can cause toxic shock syndrome, a deadly and completely avoidable adverse event .

How to minimize AEFIs?:

How to minimize AEFIs? Do not store other drugs or substances in the ice-lined refrigerator or deep freezer.

What to Report?:

What to Report? All abscesses Serious events requiring hospitalizations Deaths Clustering of Cases

What not to Report? :

What not to Report? Minor Reactions due to vaccines Mild vaccine reactions Treatment When to report Local reaction (pain, swelling, redness) Cold cloth at injection site Give Paracetamol In case of an abscess Fever > 38.5 0 C Give extra fluids Wear cool clothing Give tepid sponging Give Paracetamol When accompanied by other symptoms Irritability, malaise and systemic Symptoms Give extra fluids Give Paracetamol When severe or unusual

Slide 100:

Investigate every AEFI

Slide 101:

COLD CHAIN AND LOGISTICS

Slide 102:

Cold Chain is a system of transporting and storing vaccines at recommended temperature from the point of manufacture to the point of use Definition

Essential Elements of Cold Chain:

Essential Elements of Cold Chain PERSONNEL to organize and manage vaccine distribution EQUIPMENT for storage and transport of vaccines. Transport facilities Maintenance of equipment Monitoring

In general :

In general All Vaccines tend to lose potency on exposure to heat above +8 0 C Some Vaccines lose potency when exposed to freezing temperatures The damage is irreversible

Vaccines sensitive to heat:

Vaccines sensitive to heat OPV Measles BCG

Vaccines sensitive to freezing :

Vaccines sensitive to freezing Hep- B DPT DT TT

Ice lined refridgerators (ILRs):

Ice lined refridgerators (ILRs) Capacity: 140 litres at PHC level(1200 vials) Ideal Temperature: +2°C to 8°C (Effective with electricity supply of 8/24 hrs) Safe Storage: Always in the basket section (Always T series, Hepatitis-B and Diluents) (OPV/Measles/BCG may be kept below basket in case space is not available) Thermometer: Place in the ILR-basket

Right way of keeping vaccines in ILR:

Right way of keeping vaccines in ILR Keep all vaccines in baskets Place a thermometer in the center of the ILR. Avoid placing vaccines at bottom of ILR. ( never diluents, freeze sensitive) Leave space between the vaccine boxes Same vaccines in same area. Diluent / freeze sensitive/ Closer expiry date vaccines on top Heat sensitive / Further expiry date vaccines in the bottom of basket

Deep freezers (DF):

Deep freezers (DF) Capacity: 140 litres at PHC level Ideal Temperature: -18°C to -20°C (In case of power failure - maintain temperature for 18-20 hrs) Ice Pack Freezing Capacity: freezes 20 ice packs every 24 hours.

Cold Boxes:

Cold Boxes Type: Insulated boxes of 5 litre capacity Usage: Stores & transports vaccine. Also stores frozen Ice Packs Capacity: 1500 doses (mixed antigen) or 5000 doses (only OPV) with 24 ice packs. Holdover Time: 3 days (Keep thermometer inside) Vaccine Layout: Direct contact of frozen Ice packs spoil the vaccine. Give carton spacers/surround vaccine by OPV vials. Label Protection: Place vaccine in cartons or polythene bags.

Vaccine Carrier:

Vaccine Carrier Type: Insulated boxes used for carrying small quantities of vaccine. Capacity: 16-20 vials Holdover Time: Maintain +2 to+8 0 C for about 24 hours (one day) Ice packs: A maximum of 4 frozen packs Vaccine Layout: Keep vaccines in a plastic bag (not in direct touch with the Ice packs)

Ice Packs:

Ice Packs Water Fill: Do not fill 100%. Leave 10 mm room for expansion as water freezes. Close the cap tightly Clean the outer surface dry before freezing

Ice Pack Freezing:

Ice Pack Freezing Ice Packs to be frozen ROCK Solid Freezing is faster & uniform if gap /breathing space is left between ice packs Ice Packs are best frozen in Deep Freezers Condition before use

Preparing icepacks for use: Conditioning :

Preparing icepacks for use: Conditioning A Conditioned ice-pack On the session day, take the frozen ice-packs you need from the freezer and place on a table A llow ice-packs to sweat (droplets of water) at room temperature Shake the ice pack to listen to sound of water.

Maintenance of Equipment :

Maintenance of Equipment Defrosting/Cleaning: Ice deposit 5mm & over in freezer or at the bottom of ILR results in rise in temperature. Periodic defrosting & cleaning ensures trouble free performance for a long period. Cold boxes/Vaccine Carriers: Cold box hinges, lid knobs & chains are often damaged. Replace or repair locally. Minor insulation casing cracks/gaps can also be repaired with fresh PUF insulation Ice Packs: Fill clean water for freezing & leave 10mm room for expansion as water freezes. Cap tightly to avoid leakage. Keep pack clean & dry.

Vaccine Distribution:

Vaccine Distribution Follow first-in-first - out rule (FIFO) Also: first to expire - first out. (FEFO) Vaccines are not stored at the sub-centre level and must be supplied on the day of use Note manufacturer, batch no, VVM status Use VVM stage-II vaccine near the cold chain point (do not distribute to remote areas)

Storage Temperature:

Storage Temperature Monitor temperature twice daily. All vaccines at PHC are stored between +2 to +8°C

Shake Test: Summary:

Shake Test: Summary

Slide 128:

Vaccine Vial Monitor 3 = bad: Don’t Utilize 4 = bad: Don’t Utilize The central square is equal to, or darker than the surrounding circle X X 1 = good: Utilize 2 = good: Utilize The central square is lighter than the surrounding circle

Slide 129:

INJECTION SAFETY

Safety of the:

Safety of the Client Service Provider Community Environment

Slide 145:

SAFE INJECTION POLICIES Hand Wash REDUCTION OF UNNECESSARY INJECTIONS PROMOTION OF SAFE INJECTION PRACTICES SUFFICIENT QUANTITIES OF INJECTION EQUIPMENTS MANAGEMENT OF SHARP WASTE

Slide 146:

USE OF STERILE INJECTOIN EQUIPMENTS SAFE COLLECTION OF SHARPS SAFE MANAGEMENT OF WASTE USE OF AUTO- DISABLE (AD) SYRINGES

Slide 152:

THE ROLE BEHAVIOUR CHANGES

Slide 153:

“ KNOWING IS NOT ENOUGH, WE MUST APPLY, WILLING IS NOT ENOUGH, WE MUST DO” TARGET GROUP: UNINFORMED DISSATISFIED TOO BUSY POOR AND POWERLESS DISTANT MOTHERS AND OTHER PRIMARY CARE TAKER, FATHERS, HEALTH WORKERS, POLITICAL AND PUBLIC HEALTH LEADERS,COMMUNITY LEADERS

Slide 154:

IDENTIFYING BARRIERS TO DESIRED BEHAVIOURS QUALITATIVE METHODS LIKE FOCUS GROUP DISCUSSION QUANTITATIVE METHODS LIKE K.A.P. SURVEY, BEHVIOURAL ANALYSIS LIKE “SWOT” (STRENGTH, WEAKNESS, OPPORTUNITY AND THREAT)

Slide 155:

BEHAVIOUR CHANGE STRATEGIES COMMUNICATION STRATEGIES B.C.C. SOCIAL MOBILISATION ADVOCACY

Slide 156:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 157:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 158:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 159:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 160:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 161:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 162:

sn Steps for achieving behaviour change 7 . Success & Reinforcement 6 Advocate (Its worthwhile & easy) 5 Practice (I can, I am joining/adopting) 4 Intention, Desire to change (I want to) 3 Approval (I know, I should) 2 New knowledge 1 Old behaviour

Slide 163:

MONITARING, EVALUATION & INFORMATION MANAGEMENT

What is a Micro plan?:

What is a Micro plan? Work-plan and estimate of requirements Helps you identify What services need to be provided Who will provide When to provide Where to provide (including hard to reach) How to provide How many to provide for (beneficiaries) How much to provide (vaccines & logistics) Microplanning for Routine Immunization

Process of Microplanning: Bottom Up:

State Plan = Aggregation of District Plans + state specific activities District Plans = Aggregation of PHC plans + mobile strategy, supervision, monitoring, IEC, Trg. and coordination etc. State Level District 1 District 2 District 3 Primary Health Centres PHCs =Compilation of detailed operational plans of subcentres and add alternate vaccine delivery, waste disposal plan etc. HSC = ANM with AWW, ASHA, PRIs etc Health Sub-Centres Process of Microplanning: Bottom Up

How to plan number of sessions:

How to plan number of sessions Fixed Sites (SC / PHC / CHC etc.) 40 – 70 injections = one session per month > 70 injections = two sessions per month Outreach: 25-50 injections = one session per month > 50 injections = two sessions per month < 25 injections = one session in alternate month

Steps in preparation of Micro plan:

Steps in preparation of Micro plan Step 1 – List all villages and hamlets Step 2 – Write the population of each village Step 3 – Write the number of beneficiaries Step 4 - Prepare a map of the sub center / PHC

Slide 168:

BASIC MONITORING TOOLS MAPS PATIENT REGISTERS VACCINATION CARDS TICKLER FILES TALLY SHEETS IMMUNISATION MONITORING CHARTS

Map of Sub-center:

Map of Sub-center 1 st & 3 rd Wed 2 nd Wed 4 th Wed 1 st Sat 2 nd Sat

Slide 172:

Prepare the Sub Centre Map, Session Plan & Work Plan S. No. Village Name Distance from SC ANM AWW ASHA/Social Mobiliser Vaccination Population Annual Target Monthly Target Beneficiaries per session Vaccine Vials per session Injections per session AD Syringes Day Ste PW Infants PW Infants TT BCG DPT OPV HepB Measles DT TT BCG DPT OPV HepB Measles DT 1 Khusalpur (SC Village) 0 1800 2 Sahaspur 3.5km 1500 3 Rampur 2km 1200 4 Hasanpur 1km 1500 5 Majra 6km 1000

Monitoring chart:

Monitoring chart

Slide 175:

Tracking Bag and Tickler Box

MONITARING & EVALUATION:

MONITARING & EVALUATION INDICATORS : WHAT IT MAY INDICATE D.P.T. -1 COVERAGE AVAILABILITY OF, ACCESS TO, AND INITIAL USE OF IMMUNIZATION SERVICES D.P.T. -3 COVERAGE CONTINUITY OF USE, CLIENT SATISFACTION, CAPABILITY OF THE SYSTEM MEASLES COVERAGE PROTECTION AGAINST DISEASE A MAJOR PUBLIC HEALTH IMPORTANCE

Slide 178:

INDICATOR WHAT IT MAY INDICATE D.P.T. -1 TO D.P.T. -3 QUALITY OF SERVICES, QUALITY OF COMMUNICATION T.T. -1 COVERAGE AVAILABILITY OF, ACCESS TO, AND USE OF IMMUNIZATION SERVICES BY A.N.C. T.T. -2 CONTINUITY OF USE, CLIENT SATISFACTION, CAPABILITY OF THE SYSTEM FULLY IMMUNIZED CAPABILITY OF THE CHILD SYSTEM

Slide 179:

QUALITY AND OTHER INDICATORS: INDICATOR WHAT IT MAY INDICATE NUMBER OF IMMUNIZATION QUALITY OF PROGRAM SESSIONS HELD COMPARED MANAGEMENT TO NUMBER PLANNED SUPPLY OF UN-EXPIRED EFFECTIVENESS OF VACCINE VACCINES PROCUREMENT, DELIVARY, MANAGEMENT VACCINE USES / WASTE EFFECTIVENESS OF FIXED AND OUTREACH SESSION SCHEDULING, VACCINATION ADMINISTRATION AND VACCINE HANDLING

Slide 180:

INDICATOR WHAT IT MAY INDICATE TEMPARATURE OF COLD QUALITY OF COLD CHAIN CHAIN EQUIPMENT MANAGEMENT UPDATED INVENTORY QUALITY OF COLD CHAIN MANAGEMENT USE OF STRELILE SYRINGES QUALITY OF INJECTION AND NEEDLE PRACTICES DISEASE INCIDENCE IMPACT OF IMMUNISATION ERVICES PARENTS KNOWLEDGE OF QUALITY OF COMMON SIDE EFFECTS COMMUNICATION AND WHEN TO RETURN FOR ADDITIONAL VACCINATION

Using Routine Data for Action:

Using Routine Data for Action DPT1 Doses administered DPT3 Doses administered DPT1 Coverage (%) DPT3 Coverage (%) Unimmunized with DPT3 (No.) DPT1 DPT3 Drop- out rates (%) Access High ( 80%) Good access Low (<80%) Poor access Utilization Low ( 10%) Good utilization High (>10%) Poor utilization Priority

ANALYSIS AND USE OF ROUTINE DATA:

ANALYSIS AND USE OF ROUTINE DATA IMMUNISATION COVERAGE: DPT-3 COVERAGE: NO. IMMUNISIED BY DPT-3 IN A YEAR *100 ---------------------------------------------------------------------- NO. OF SURVIVING INFANTS < 12 MONTHS OF AGE IN THE SAME YEAR MEASLES COVERAGE: NO. IMMUNISED BY 12 MONTHS WITH MEASLES IN A YEAR * 100 -------------------------------------------------------------------------------------------------NO. OF SURVIVING INFANTS < 12 MONTHS OF AGE IN THE SAME YEAR

Slide 183:

DROP-OUT RATES: DROP-OUT OF DPT-1 AND DPT-3: DPT. 1 CUMULATIVE TOTAL - DPT. 3 CUMULATIVE TOTAL * 100 = ---------------------------------------------------------------------------------------------- DPT .1 CUMULATIVE TOTAL DPT-1 =176 DPT-3= 134 DROP-OUT RATE: 176 --134 * 100 --------------------- = 23.86 % 176

Slide 184:

DROP-OUT OF HIGHEST -LOWEST COVERAGE VACCINE DOSES OF HIGHEST COVERAGE - DOSES OF LOWEST COVERAGE *100 = -------------------------------------------------------------------------------------------------- DOSES OF HIGHEST COVERAGE DPT-3: 336 OPV-3: 360 MEASLES: 286 B.C.G: 442 DROP-OUT RATE: 442 - 286 * 100 ------------------- 442 35.29 %

Regular monitoring and review of Micro plan:

Regular monitoring and review of Micro plan Analysis of Monthly reports Sessions held vs planned coverage and drop outs Regular Review meeting coverage monitoring chart Review missed sessions other problems revise session plan and work plan (if needed) Supportive supervisory visits monitoring the work in the field, providing on-the-job training, taking notes for future discussion at review meetings.

Slide 186:

“ THE BEST WAY TO ESCAPE FROM A PROBLEM IS TO SOLVE IT” “ THIS IS SKILL, NOT STRENGTH, THAT GOVERNS THE SHIP”

Slide 187:

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