Immunization

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Immunization : 

Immunization State Institute of Health & Family Welfare, Jaipur

Why Immunization?: 

Why Immunization? Key strategy to child survival Protecting infants from VPDs Lowers morbidity and mortality rates in children Can lead to lower birth rates Indicator of a strong primary health care system 2 SIHFW: an ISO 9001: 2008 certified institution

Slide 3: 

Immunization: Process of inducing immunity by stimulating immune system through antigens. Immunity : Resistance of a host to a specific agent, characterized by measurable and protective surface or humoral antibody and by cell-mediated immune responses. Immunization: common terms 3 SIHFW: an ISO 9001: 2008 certified institution

Slide 4: 

Vaccine: A preparation of a weakened or killed pathogen, such as a bacterium or virus, or of a portion of the pathogen's structure that upon administration stimulates antibody production or cellular immunity against the pathogen but is incapable of causing severe infection. Vaccination: Administration of antigenic material (the vaccine) to produce immunity to a disease. 4 SIHFW: an ISO 9001: 2008 certified institution

Slide 5: 

Full immunization: Beneficiary child (12-23 months) - 3 doses of DPT and OPV each, 1 dose of BCG & measles each. Mother - two doses or 1 booster dose of tetanus toxoid during her last pregnancy. Partial immunization : Child- missed any vaccine or one or more doses Mother- received just one dose of primary tetanus toxoid during last pregnancy. Non immunization : Child and/or mother- not received a single dose of vaccine. 5 SIHFW: an ISO 9001: 2008 certified institution

Slide 6: 

Ring immunization: Vaccination of people in close contact with an isolated infected patient. Mop-up rounds: When the final pockets of poliovirus transmission have been identified through standard surveillance, door-to-door immunization in high-risk districts. Catch up rounds: Additional effort besides routine immunization to cover left outs 6 SIHFW: an ISO 9001: 2008 certified institution

Herd immunity? : 

Herd immunity? Resistance to spread of infectious disease in a group because of few susceptible members, making transmission unlikely. The immunologic status of a population, determined by the ratio of resistant to susceptible members and their distribution. 7 SIHFW: an ISO 9001: 2008 certified institution

Herd immunity : 

Herd immunity Works only when: Probability of an infected person encountering every other individual in the population (random mixing) is the same; (not likely to happen) Does not work when: An infected person interacts only with people who are susceptible (no random mixing) ; likely to transmit the disease to those people 8 SIHFW: an ISO 9001: 2008 certified institution

Mile Stones in immunization program in India: 

Mile Stones in immunization program in India 1978: EPI 1985: UIP, Measles vaccine added 1986: Technology mission 1990: Vitamin A 1992: CSSM 1995: Polio National Immunization days 1997: RCH-I 2005: RCH-II and NRHM 9 SIHFW: an ISO 9001: 2008 certified institution

Child health: 

Child health In World In India Under 5 mortality 9.7 million 2.1 million Under weight 156 million 54.6 million Neonatal mortality (first 28 days) 4 million 1 million Low birth weight (<2.5 kg) 19 million 8.3 million Source: State of the World’s Children 2009:UNICEF report 47% of total children in India are malnourished. Developed countries 26% Rest of south Asia 42%. 10 SIHFW: an ISO 9001: 2008 certified institution

Child Mortality: 

Child Mortality Rank Country Under Five Mortality rate 1 st Sierra Leone 262 43 rd Pakistan 90 49 th India 72 58 th Bangladesh 61 62 nd Nepal 55 189 th Sweden 3 Note : 5,700 infants die everyday in India. Source : State of the World’s Children 2009 UNICEF 11 SIHFW: an ISO 9001: 2008 certified institution

Slide 12: 

UIP CSSM RCH NRHM Impact of various interventions Infant Mortality Rate : 1971-2008 Source: SRS Oct.2009 12 SIHFW: an ISO 9001: 2008 certified institution

Slide 13: 

Reported Immunization Coverage 1985-2008 Source: WHO/UNICEF Review of National Immunization Coverage1980-2008 13 SIHFW: an ISO 9001: 2008 certified institution

National immunization schedule: 

National immunization schedule Vaccine When to give Dose Route Site For Pregnant Women TT-1 Early in pregnancy 0.5 ml Intra-muscular Upper Arm TT-2 4 weeks after TT-1* 0.5 ml Intra-muscular Upper Arm TT- Booster If pregnancy occur within three yrs of last TT vaccination* 0.5 ml Intra-muscular Upper Arm 14 SIHFW: an ISO 9001: 2008 certified institution

Slide 15: 

For infants Vaccine When to give Dose Route Site BCG At birth (for institutional deliveries ) or along with DPT-1 0.1 ml (0.05ml for infant up to 1 month) ID Left Upper Arm OPV-0 At birth if delivery is in institution 2 drops Oral Oral OPV- 1,2 & 3 At 6, 10 & 14 weeks 2 drops Oral Oral DPT- 1,2 & 3 At 6, 10 & 14 weeks 0.5 ml IM Antero-lateral side of mid-thigh Hep B 1,2 & 3 At 6, 10 & 14 weeks** 0.5 ml IM Antero-lateral side of mid-thigh Measles 9-12 months 0.5 ml SC Right upper Arm Vitamin-A (1 st Dose) At 9 months with measles 1 ml (1 lakh IU) Oral Oral 15 SIHFW: an ISO 9001: 2008 certified institution

National immunization schedule: 

National immunization schedule For children Vaccine When to give Dose Route Site DPT Booster 16-24 months 0.5 ml IM Outer Mid-thigh (Antero-lateral side of mid-thigh) OPV Booster Vitamin-A (2 nd to 9 th Dose) 16-24 months 16 months with DPT/OPV booster Then, one dose every 6 months up to the age of 5 years. 2 drops 2 ml (2 lakh IU) Oral Oral Oral Oral DPT Booster 5 years 0.5 ml IM Upper Arm TT 10 years & 16 years 0.5 ml IM Upper Arm * TT-2 or booster dose to be given before 36 weeks of pregnancy. ** For institutional deliveries, give at birth, 6 weeks and 14 weeks. 16 SIHFW: an ISO 9001: 2008 certified institution

Barriers to Immunization: 

Barriers to Immunization Physical barriers Waiting time Distance Discomfort Psychological barriers Discourtesy Endangered privacy 17 SIHFW: an ISO 9001: 2008 certified institution

Reasons for Low Immunization Coverage: 

Reasons for Low Immunization Coverage Failure to provide immunization Dropouts Un-reached populations:- Unawareness socio-economic barriers geographic access Resistant populations Missed Opportunities Improper logistics management 18 SIHFW: an ISO 9001: 2008 certified institution

Strategies for increasing coverage of immunization: 

Strategies for increasing coverage of immunization Record keeping Recommendations and reinforcement Reminder and recall to patients Reminder and recall to providers Reduction of missed opportunities 19 SIHFW: an ISO 9001: 2008 certified institution

Why focus on strategies to increase immunization?: 

Why focus on strategies to increase immunization? Immunization levels are not optimal Cost effectiveness is a concern Sustainability is a concern 20 SIHFW: an ISO 9001: 2008 certified institution

Strategies to minimize drop outs: 

Strategies to minimize drop outs Each planned immunization session to be held in spite of holiday/leave and Re-schedule session timings Maintaining list of children with partial/ no immunization. Reaching migrant populations in service delivery area. Informing parents about next immunization date. Taking help of community teams ( AWW/ASHA/NGOs etc .) Developing solutions based on the responses of parents. 21 SIHFW: an ISO 9001: 2008 certified institution

Settings where missed opportunities occur: 

Settings where missed opportunities occur Settings that traditionally offer immunizations (e.g., primary care offices or public health clinics) Settings that do not traditionally offer immunizations health care settings (e.g. Emergency dept.) public health settings (e.g., WIC) 22 SIHFW: an ISO 9001: 2008 certified institution

Causes of missed opportunities: 

Causes of missed opportunities Lack of simultaneous administration Unawareness about need for additional vaccines Invalid contraindications Avoidance of accelerated schedule Inappropriate clinic policies Reimbursement deficiencies 23 SIHFW: an ISO 9001: 2008 certified institution

Strategies for reducing missed opportunities: 

Strategies for reducing missed opportunities Standing orders Provider education with feedback Provider reminder and recall systems 24 SIHFW: an ISO 9001: 2008 certified institution

Slide 25: 

Minor illnesses such as upper respiratory infections or diarrhea, mild fever (< 38.5°c) Allergy, asthma Prematurity, underweight newborn child Malnutrition Child being breastfed Family history of convulsions Treatment with antibiotics Dermatosis, eczema or localized skin infection Chronic diseases of the heart, lung, kidney and liver Stable neurological conditions, such as cerebral palsy and Down's syndrome History of jaundice after birth What should not hold Routine Immunization 25 SIHFW: an ISO 9001: 2008 certified institution

Micro planning for Routine Immunization: 

Micro planning for Routine Immunization 26 SIHFW: an ISO 9001: 2008 certified institution

What is a Micro plan?: 

What is a Micro plan? Helps to identify What needs to be provided Who will provide Where to provide (including hard to reach) When to provide How to provide How many to provide for (beneficiaries) How much to provide (vaccines & logistics) 27 SIHFW: an ISO 9001: 2008 certified institution

Estimating Beneficiaries In a Sub-centre Area: 

Estimating Beneficiaries In a Sub-centre Area No. of Live Births = Birth Rate x Population of the Area 30/1000x5000=150 2. No. of Pregnant Women = No. of Live Births + 10% 150+15=165 3. No. of Infants alive at 1yr. = 150-{150x60/1000=9} =141 4. No. of Children <3 yrs. of age =8% of population =8/100x5000=400 5. No. of Children <5 yrs.of age =13% of total population =13/100x5000=650 28 SIHFW: an ISO 9001: 2008 certified institution

Calculating beneficiaries for each Vaccine: 

Calculating beneficiaries for each Vaccine TT = No . PW x 2 BCG = No . infants x 1 OPV = No . infants x 4 DPT = No . infants x 4 Measles = No. infants x 1 DT = No . children at 5 yrs x 1 29 SIHFW: an ISO 9001: 2008 certified institution

Estimation of Vaccine Vials: 

Estimation of Vaccine Vials Each session should have one vial of BCG No. beneficiaries / session TT = ---------------------------------------* 1.33 10 No. beneficiaries / session BCG = --------------------------------------* 1.33 10 No. beneficiaries / session OPV = --------------------------------------* 1.33 10 30 SIHFW: an ISO 9001: 2008 certified institution

Estimation of Vaccine Vials: 

No. beneficiaries / session DPT = ---------------------------------------* 1.33 10 No. beneficiaries/ session Measles = ----------------------------------------* 1.33 5 No. beneficiaries/ session DT = -----------------------------------------* 1.33 10 Vitamin A Solution Children below 1 year of age (1 dose of 1lakh unit) = 141 Children between 1-5 yrs. (8 doses of 2 lakh units) = 509x2 = 1018 Estimation of Vaccine Vials 31 SIHFW: an ISO 9001: 2008 certified institution

Estimation of ADS and Disposable Syringes and Diluents with Vaccines: 

Estimation of ADS and Disposable Syringes and Diluents with Vaccines 0.1 ml = (No. of beneficiaries for BCG) + 10 % 0.5 ml = (Beneficiaries of DPT + Measles + DT + TT ) + 10 % 5 ml reconstitution = (No. of BCG vials + No. of Measles vials ) + 10 % No. of Sodium chloride ampoules = No. of BCG vials No. of Double distilled water ampoule = No. of Measles vials 32 SIHFW: an ISO 9001: 2008 certified institution

How to Plan Number of Sessions: 

How to Plan Number of Sessions Fixed Sites (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 33 SIHFW: an ISO 9001: 2008 certified institution

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 34 SIHFW: an ISO 9001: 2008 certified institution

Preparation of Micro Plans at PHC and District: 

Preparation of Micro Plans at PHC and District PHC- Compile micro plans from all SC; Add components of alternate vaccine delivery; plan for supervision; plan for immunization waste disposal etc. District- Compile plans from PHC and additional components of plans for deployment of human resources, supplies and logistics, training, IEC, monitoring, supervision, surveillance, Inter-sectoral coordination etc added to prepare District micro plan. Don’t : Cancel any planned session Leave any community meeting without communication about next immunization session days. 35 SIHFW: an ISO 9001: 2008 certified institution

Slide 36: 

Demarcation of areas Site for immunization session Slums/Aanganwadi centers District Hospital Private Hospital Dispensary Human resources Vaccine delivery Tracking beneficiaries IEC and Social mobilization Urban Micro Plan 36 SIHFW: an ISO 9001: 2008 certified institution

Regular Monitoring and Review of Micro Plan: 

Regular Monitoring and Review of Micro Plan Monthly reports coverage monitoring chart Quarterly Review meeting 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 . Monitoring Chart 37 SIHFW: an ISO 9001: 2008 certified institution

Community Mobilization: 

Community Mobilization Communication with community. Involvement of community and community leaders for education. Gathering information regarding misconception and its resolution. Arranging for interaction between resistant groups and satisfied beneficiaries for promoting immunization. Using loudspeakers, discussion sessions at farmers’ meetings, ad at religious places , radio and TV spots , newspaper articles and drama shows. Providing prompt and quality services. 38 SIHFW: an ISO 9001: 2008 certified institution

Dealing with Rumours and Misinformation: 

Dealing with Rumours and Misinformation Serious threats to success of immunization program. Some examples of rumours: “Vaccine are a contraceptive to control population or to limit the size of a certain ethnic group.” “Vaccines are contaminated by the AIDS virus or mad cow disease.” “Children are dying after receiving vaccines.” Refer the matter to supervisors Action may even need to be taken at the national level . 39 SIHFW: an ISO 9001: 2008 certified institution

Records: 

Records Must be easy to write, compile & read Must be available at the time of the visit Must be accurate reflect all vaccines given 40 SIHFW: an ISO 9001: 2008 certified institution

Cold Chain: 

Cold Chain A system of transporting and storing vaccines at recommended temperature from the point of manufacture to the point of use. Essential Elements: Personnel to organize and manage vaccine distribution Equipment for storage and transport of vaccines Transport facilities Maintenance of equipment and Monitoring Responsibility – District/ Block Managers Cold chain equipment installation, operation and maintenance 41 SIHFW: an ISO 9001: 2008 certified institution

Slide 42: 

Cold Chain Equipment Name of Equipment Place of Installation Temperature Utilization ILR MK 300 Regional & district HQ +2 C to +8 C BCG, DPT, DT, TT, Measles, Hep-B Vaccine Deep Freezer 300 Regional & district HQ -18 C to -20 C Preparation of ice packs, and storing OPV vaccines ILR MK 140 litres PHC +2 C to +8 C BCG, OPV, DT, DPT, TT, Measles, Hep-B Vaccine Deep Freezer 140 litres PHC -18 C to -20 C Preparation of ice packs No Cold Chain Equipment should be installed without a voltage stabilizer 42 SIHFW: an ISO 9001: 2008 certified institution

Slide 43: 

Name of Equipment Place of Installation Temperature Utilization Cold Box 20 litres State, Regional, district HQ & PHC +2 C to +8 C Vaccines can be stored for transpiration or in case of power failure Cold Box 5 litres District HQ & PH C +2 C to +8 C Vaccines can be stored for transportation or in case of power failure Vaccine carrier (1.7 litres) PHC/Sub Centre +2 C to +8 C Vaccines can be carried in small quantity for vaccination sessions

Maintenance of Equipment : 

Maintenance of Equipment Defrosting/Cleaning: Periodic defrosting & cleaning Cold boxes/Vaccine Carriers: Replace or repair locally Ice Packs: Fill clean water Leave 10mm room for expansion Cap tightly Keep pack clean & dry 44 SIHFW: an ISO 9001: 2008 certified institution

Slide 45: 

Vaccine’s Sensitivity Vaccine Exposure to heat/light Exposure to cold Temperature at PHC Heat and light sensitive vaccines BCG Relatively heat stable, but sensitive to light Not damaged by freezing. +2°C to + 8°C OPV Sensitive to heat and light Not damaged by freezing +2°C to + 8°C Measles Sensitive to heat and light Not damaged by freezing +2°C to + 8°C At PHC level, all vaccines are kept in ILR in which temperature is maintained at + +2°C to + 8°C 45 SIHFW: an ISO 9001: 2008 certified institution

Slide 46: 

Freeze Sensitive Vaccines DPT Relatively heat stable Freezes at -3°C should not be frozen +2°C to + 8°C Hepatitis B Relatively heat stable Freezes at -5°C Should not be frozen +2°C to + 8°C DT Relatively heat stable Freezes at -3°C Should not be frozen +2°C to + 8°C TT Relatively heat stable Freezes at -3°C Should not be frozen +2°C to + 8°C 46 SIHFW: an ISO 9001: 2008 certified institution

Slide 47: 

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 A label that changes colour when vaccine vial is exposed to heat over a period of time. 47 SIHFW: an ISO 9001: 2008 certified institution

Checking for Cold Damage (Freezing): 

Checking for Cold Damage (Freezing) Test Control Test Control Discard Shake Test :- designed to determine whether adsorbed vaccines (DPT, DT, TT or Hepatitis B) have been frozen. 48 SIHFW: an ISO 9001: 2008 certified institution

Programmatic Errors causing AEFIs: 

Programmatic Errors causing AEFIs Programmatic Errors Possible Adverse event that may occur Non-Sterile injection: Improperly sterilizing syringe Contaminated vaccine or diluents 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 Heb B, HIV, Hep C Reconstitution Error/ Wrong vaccine preparation Reconstitution with incorrect diluents Drug substituted for vaccine diluents Inadequate shaking for T-series vaccines Vaccine ineffective Negative effect of drug, e.g. insulin causing death Local abscess 49 SIHFW: an ISO 9001: 2008 certified institution

Slide 50: 

Programmatic Errors Possible Adverse event that may occur 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 Local reaction from frozen vaccine Vaccine ineffective Contraindications ignored Avoidable serious reaction 50 SIHFW: an ISO 9001: 2008 certified institution

AEFI---- Rare, more severe reactions: 

AEFI---- Rare, more severe reactions Seizures, Thrombocytopenia, Hypotonic-hypo responsive episodes, Persistent inconsolable screaming -in most cases they are self-limiting and lead to no long-term problems Anaphylaxis, while potentially fatal, is treatable without any long-term effects 51 SIHFW: an ISO 9001: 2008 certified institution

Minimizing AEFIs: 

Minimizing AEFIs Instruction for the health workers Selection of separate site One syringe & one needle/AD syringe Ensure sterilization Reconstitute vaccines only with diluents Use Reconstituted vaccines within 4 hours Keep diluents of BCG and measles vaccine separate Do not keep needles in the rubber cap (stopper) of vaccine vials. Do not store other drugs or substances in the ILR or deep freezer. What to do if an AEFI Occurs? immediately inform MO and accompany if needed. 52 SIHFW: an ISO 9001: 2008 certified institution

Minor reactions due to vaccines (normal and not required to be reported): 

Minor reactions due to vaccines (normal and not required to be reported) Mild vaccine reactions Treatment When to report Local reaction (pain, selling, redness) Cold cloth at injection site Give Paracetamol In case of an abscess Fever > 38.5°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 53 SIHFW: an ISO 9001: 2008 certified institution

Vaccine Preventable Disease Outbreak: 

Vaccine Preventable Disease Outbreak During outbreak Ensure the following :- Adequate supply Adequate staff Pertusis :- Prophylactic antibiotic (erythromycin or ampicillin ) for 10 days and booster dose of DPT or DT Measles :- Ring immunization within 2 days of exposure Polio :- Ring immunization with use of Oral(Sabin) Polio vaccine 54 SIHFW: an ISO 9001: 2008 certified institution

Slide 55: 

In case of diphtheria outbreak , if the epidemiological situation demands; Mass immunization- Entire adult population Mass immunization in schools and preschool institutions to ensure- all children are protected against the disease completion of primary series in non-immunized or incompletely immunized children booster dose for fully immunized children if the last injection was given >five years ago. 55 SIHFW: an ISO 9001: 2008 certified institution

Thank You : 

Thank You For more details log on to www. Sihfwrajasthan.com or contact : Director-SIHFW on sihfwraj@yahoo.co.in