Immunization

Immunization
State Institute of Health and Family Welfare, Jaipur

Immunization: Common Terms
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
SIHFW: An ISO:9001:2008 certified Institution 2

Vaccine:
A commercial preparation with shelf life of a
weakened or killed pathogen, 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

ØFull immunization:
 Beneficiary child receiving (12-23 months) 3
doses of DPT and OPV each, 1 dose of BCG
& measles each. Mothers -two doses or 1
booster dose of tetanus toxoid during her last

pregnancy.
ØPartial immunization:
 Child, who missed any vaccine or one or
more doses and for mother who received just
one dose of primary prenatal tetanus toxoid

during her last pregnancy.
ØNon immunization:
 Child or mother who did not receive even a
single dose of vaccine.

ØRing immunization:
Vaccination of people in close contact with
an isolated infected patient.
ØMop-up rounds:
When the final pockets of poliovirus
transmission have been identified through
standard surveillance, door-to-door
immunization in high-risk districts.
ØCatch up rounds:
An additional effort over and above the
normal routine immunization to cover those
who were left during Routine immunization.

Herd Immunity?
ØResistance to the spread of infectious
disease in a group because
susceptible members are few,
making transmission from an
infected member unlikely.

ØThe immunologic status of a

population, determined by the ratio
of resistant to susceptible members
and their distribution.

§
ØHerd Immunity works only when:
ØProbability of an infected person
encountering every other individual in
the population (random mixing) is the
same; this however, is not normal.

ØHerd Immunity Does not work when:

ØAn infected person interacts only with
people who are susceptible (no
random mixing); likely to transmit the
disease to those people


Estimated Herd Immunity Thresholds for
Vaccine Preventable Diseases
Disease Transmission R0 Herd immunity
threshold
Diphtheria Saliva 6-7 85%
Measles Airborne 12-18 83 - 94%
Mumps Airborne droplet 4-7 75 - 86%
Pertussis Airborne droplet 12-17 92 - 94%
Polio Fecal-oral route 5-7 80 - 86%
Rubella Airborne droplet 5-7 80 - 85%
Smallpox Social contact 6-7 83 - 85%
R0 is the Basic Reproduction number, or the average number of secondary infectious
cases that are produced by a single index case in completely susceptible population.
qThe herd immunity threshold value varies with the virulence of the disease, the
efficacy of the vaccine, and the contact parameter for the population.
Source- Fine P (1993). "Herd immunity: history, theory, practice". Epidemiology Rev 15 (2): 265–302. PMID 8174658.

Mile Stones in Immunization Program
in India
Ø 1978: EPI
Ø 1985: UIP, Measles vaccine added
Ø 1986: Technology mission
Ø 1990: Vitamin A
Ø 1992: CSSM
Ø 1995: Polio National Immunization days
Ø 1997: RCH-I
Ø 2005: RCH-II and NRHM


Why Immunization?
ØKey strategy to child survival

ØProtecting infants from VPDs
ØLowers morbidity and mortality rates in
children
ØCan lead to lower birth rates
ØIndicator of a strong primary health care
system

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

Ø47% of total children in India are malnourished.
ØDeveloped countries 26%
ØRest of south Asia 42%.
Child Mortality
Rank Country Under Five
1st Sierra Leone Mortality
262 rate
43rd Pakistan 90
49th India 72
58th Bangladesh 61
62nd Nepal 55
189th Sweden 3
Note : 5,700 infants die everyday in India.

Source: State of the World’s Children 2009 UNICEF

Impact of Various Interventions
Infant Mortality Rate :1971-2008
UIP
CSSM RCH
NRHM
Source::SRS Oct.2009
SIHFW: an ISO 9001: 2008 certified institution 13
Type of Vaccine
Type of antigen Vaccine type
Live bacteria, attenuated BCG,Typhoid 21
Live virus attenuated OPV, MMR
Killed bacteria Pertusis, S.Typhii
Killed virus IPV, Rabies, Hepatitis A Virus
Toxoid DT, TT
Capsular polysaccharide Typhoid VI, HIB,
Meningococcal &
Viral subunit Pneumococcal
HBsAg
Bacteria subunit Acellular Pertusis

Diphtheria
Ø Agent-
ØCornyebacteriun diphtheriae-
Ø Reservoir-
ØMan-Case, or
 Carrier (Temporary/ Chronic,
Nasal/Throat)
Ø Transmission-
ØAir borne-Droplet/droplet nuclei
Ø Source of infection-
ØNaso-pharyngeal secretions
Ø Incubation period:
Ø3-4 days
Ø SIHFW: An ISO:9001:2008 certified Institution 15
ØPeriod of Communicability:
Ø14 days, longer with carriers
ØHost factors-
ØAge -Children 2-5 Yrs. (usually)
ØSex- Gender equity
ØMortality-10% untreated cases and 5% in
treated cases
ØEnvironmental factors-
ØSeasonal incidence-August to October
ØSymptoms
Ølaryngitis or pharyngitis or tonsillitis, plus
an adherent membrane of the tonsils,
pharynx and/or nose.

 SIHFW: An ISO:9001:2008 certified Institution 16

Diphtheria: Case Classification
Ø Probable:
 A case that meets the clinical description
Ø Confirmed:
 A probable case that is laboratory confirmed
or linked epidemiologically to a laboratory
confirmed case


Diphtheria Antitoxin
Type of diphtheria Dosage (units) Route

Nasal 10 000-20 000 IM
Tonsillar 15 000-25 000 IM/ IV
Pharyngeal or 20 000-40 000 IM/ IV
Laryngeal types Or
Combined 40 000-60 000 IM/ IV
delayed diagnosis

In case of an outbreak, if the epidemiological

situation demands;
ØThe whole adult population should be included in
mass immunization.
ØAdditionally, mass immunization in schools and
preschool institutions to ensure that
Øall children are well protected against the
disease
Øcompletion of the primary series in non-
immunized or incompletely immunized
children
Øadministration of a booster dose for fully
immunized children if the last injection was
given more than five years ago

Pertusis
ØBordetella pertussis
ØAirborne, droplets
ØMajor Signs and symptoms –
ØCatarrhal Stage (1- 2 weeks) -mild symptoms
-coughing, sneezing, or runny nose
ØParoxysmal Stage (2-8 weeks) -the coughing
develops into uncontrollable fits, each with five to
ten forceful coughs, followed by a high-pitched
"whoop" sound
ØConvalescent Stage (1-2 weeks)
ØCommon Complications- Pneumonia,
Encephalopathy, Earache or Seizures and severe
Pulmonary Hypertension
ØCase Fatality Rate - in developing countries range
from 4-15 percent in infants.

Ø
ØAgent-
ØBordetella pertusis
ØReservoir-
ØA case; evidence for sub clinical infection
does not exist
ØPeriod of Communicability-
Ø7 days after infection to 21 days after
appearance of paroxysmal stage;
Øthe secondary attack rate is 90% in
susceptible
ØIncubation Period-
Ø7-14 days

ØSource of infection-
ØNasopharyngeal secretions; f recently
contaminated omites.
ØTransmission-
ØAir borne-Droplet & droplet nuclei.
ØHost factors-
ØAge-infants and children below 5 years,
ØSex- more in females than males
ØEnvironmental factors-
Øperennial, majority during December to March.
ØOvercrowding & poor living conditions facilitate
spread
Ø
Ø Clinical features-
Ø3 stages-Catarrhal (10 days), Paroxysmal (2-4
weeks) and Convalescent (1-2 weeks)
ØComplications -Bronchopneumonia, Bronchiectasis,
Bronchitis, Conjunctival hemorrhage, epistaxis
Haemoptysis, and punctuate cerebral hemorrhage.
Ø Prevention & Control-
ØEarly diagnosis &Treatment of cases
ØContacts- Chemoprophylaxis with Erythromycin
ØActive immunization-
ØImmunity drops from 75% to 33 % after 4 years of
full course (reason to administer boosters at 3 year
interval)
ØVaccine does not provide immunity in more than
90% cases, a precondition for a disease to qualify
for elimination.
Tetanus
ØCausative Organism-
 Clostridium tetani
ØTransmission –
 Contaminated wounds
Tissue injury
ØMajor Signs and symptoms –
ØGeneralized tetanus: descending
symptoms of trismus (lockjaw), difficulty
swallowing, muscle rigidity, spasms
ØLocal tetanus is an uncommon form of the
disease, in which patients have persistent
contraction of muscles in the same anatomic
area as the injury
ØCephalic tetanus is a rare form of the disease;
occasionally occurring with otitis media (ear
infections) in which C. tetani is present in the
flora of the middle ear, or following injuries to
the head. There is involvement of the cranial
nerves, especially in the facial area
ØNeonatal tetanus is a form of generalized
tetanus that occurs in newborns .Infants who
have not acquired passive immunity because
the mother has never been immunized are at
risk
ØCase Fatality Rate – Neonatal tetanus is killer
disease in with case fatality rate 80-90%.


Poliomyelitis
ØCausative organism- enterovirus
(RNA) three serotypes: 1, 2, 3

ØTransmission – fecal-oral and

droplet infection
ØAsymptomatic polio- in about 95% of cases,
ØSymptomatic polio- in the 4% to 8% of cases
1.Abortive poliomild flu-like symptoms such as mild upper
respiratory infection, diarrhea, fever, sore throat, and a
general feeling of being ill
2.Nonparalytic polio- (1% to 5%)
3.Paralytic polio- (0.1% to 2% of cases)
ØCase fatality rate – the mortality rate varies by age: 2–5%
of children and up to 15–30% of adults die in paralytic polio

Measles
q

ØCausative organism- Paramyxovirus (RNA)
ØIncubation period-
Ø10 days, range 10-14 days
ØSecondary attack rate
Ø80-90% in susceptible household contacts.
ØHost
ØAge- 6 months-3 years, older up to 5 yrs.
ØTransmission
ØDroplet nuclei (Air borne)
ØPeriod of communicability-
Ø4 days before and 5 days after the appearance of
rash
ØMajor Signs and symptoms
ØFevers with cough, coryza ,conjunctivitis, koplik’s
spots
ØRash-maculopapular, erythematous rash
Ø
ØCase fatality rate
SIHFW–5
: An –
ISO30% depending
:9001:2008 certified Institution 27
Tuberculosis
Ø Causative organism- Mycobacterium Tuberculosis
ØTransmission –Respiratory (Droplet infection) and Airborne
Ø
ØMajor Signs and symptoms
Ø
ØPulmonary tuberculosis (75%) is symptoms include
chest pain, coughing up blood, and a productive,
prolonged cough for more than three weeks.
ØSystemic symptoms include fever, chills, night
sweats, appetite loss, weight loss, pallor, and often a
tendency to fatigue very easily
ØExtra pulmonary tuberculosis (25% )
ØCase fatality rate – 2.5 billion people are infected with
tuberculosis, 10% will develop disease over a lifetime, 15-
33% of AIDS patients die of TB and case fatality rate of
untreated tuberculosis is 50%.”

WHO/UNICEF Review of National Immunization Coverage1980-2008
Reported Immunization Coverage
1985-2008
Source: WHO/UNICEF Review of National Immunization Coverage1980-2008

Children between 12-23 Months
State Fully BCG 3 doses of 3 doses Measles
immunized polio of DPT
vaccine
India 43.5 78.1 78.2 55.3 58.8
Rajasthan 48.8 82.8 55.6 63.9 67.5
State Vitamin A in last 6 months
India 21
Rajasthan 13.2
Ø43.5% of children in India received all vaccinations as

per NFHS-III 2005-06 where as in Rajasthan 48.8%
children received all vaccinations
Source : NFHS-III 2005-06

National Immunization Schedule
Vaccine When to give Dose Route Site
For Pregnant Women
TT-1 Early in pregnancy 0.5 ml Intra- Upper Arm
muscular
TT-2 4 weeks after TT-1* 0.5 ml Intra- Upper Arm
muscular
TT- If pregnancy occur within 0.5 ml Intra- Upper Arm
Booster three yrs of last TT muscular
vaccination*
For infants
BCG At birth (for institutional 0.1 ml (0.05ml Intra- Left Upper Arm
deliveries) or along with for infant up to dermal
DPT-1 1 month)
OPV-0 At birth if delivery is in 2 drops Oral Oral
institution
OPV- 1,2 &At 6 weeks, 10 weeks & 14 2 drops Oral Oral
3 weeks
DPT- 1,2 & At 6 weeks, 10 weeks & 14 0.5 ml Intra- Outer Mid-thigh
3 weeks muscular (Antero-lateral
side of mid-thigh)

National immunization schedule
Hep B 1,2 & At 6 weeks, 10 weeks & 14 0.5 ml Intra- Outer Mid-thigh
3 weeks** muscular (Antero-lateral side
of mid-thigh)
Measles 9-12 months 0.5 ml Sub- Right upper Arm
cutaneous
Vitamin-A At 9 months with measles 1 ml (1 lakh IU) Oral Oral
(1st Dose)
For children
DPT 16-24 months 0.5 ml Intra- Outer Mid-thigh
Booster muscular (Antero-lateral side
of mid-thigh)
OPV 16-24 months 2 drops Oral Oral
Booster 16 months with DPT/OPV 2 ml Oral Oral
Vitamin-A booster (2 lakh IU)
Then, one dose every 6
(2nd to 9th
Dose) months up to the age of 5
years.
DPT 5 years 0.5 ml Intra- Upper Arm
Booster muscular
TT 10 years & 16 years 0.5 ml Intra- Upper Arm
muscular
* TT-2 or booster dose to be given before 36 weeks of pregnancy.
** For institutional deliveries, give at birth, 6 weeks and 14 weeks.

Reasons for Low Immunization
Coverage
ØFailure to provide immunization
ØDropouts
ØUn-reached populations:
ØUnawareness about immunization
Øsocio-economic barriers
ØLack of geographic access
ØResistant populations
ØMissed Opportunities
ØImproper logistics management leading to
unmet need
Strategies for Increasing Coverage of
Immunization
ØRecord keeping
ØRecommendations and reinforcement
ØReminder and recall to patients
ØReminder and recall to providers
ØReduction of missed opportunities

Why Focus on Strategies to Increase
Immunization?
ØImmunization levels are not optimal

Ø
ØCost effectiveness is a concern
Ø
ØSustainability is a concern

Reduction to Barriers to Immunization
ØPhysical barriers
ØWaiting time
ØDistance
ØDiscomfort
Ø
ØPsychological barriers
ØDiscourtesy
ØEndangered privacy

Contraindications and Precautions
Condition Live Inactivated
Allergy to component C C
Encephalopathy --- C
Pregnancy C V
Immunosuppression C V
Severe illness P P
Recent blood product P V
C=contraindication P=precaution
V=vaccinate if indicated

These are not Contraindications to
Routine Immunization
ØMinor illnesses such as upper respiratory

infections or diarrhea, mild fever (<
38.5°c)
ØAllergy, asthma
ØPrematurity, underweight newborn child
ØMalnutrition
ØChild being breastfed
ØFamily history of convulsions

ØTreatment with antibiotics
ØDermatosis, eczema or localized skin
infection
ØChronic diseases of the heart, lung,
kidney and liver
ØStable neurological conditions, such as
cerebral palsy and down's syndrome
ØHistory of jaundice after birth

Micro planning for Routine
Immunization

What is a Micro plan?
Helps you identify

ØWhat needs to be provided

ØWho will provide
ØWhere to provide (including hard to reach)
ØWhen to provide
ØHow to provide
ØHow many to provide for (beneficiaries)
ØHow much to provide (vaccines & logistics)
Estimating Beneficiaries In a
Sub-Centre Area
1.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.ofage =13% of total population

=13/100x5000=650

Calculating Beneficiaries for each
Vaccine
ØTT = No. PW X 2
ØBC = No. infants X 1
ØOP = No. infants X 4
ØDP = No. infants X 4
ØMeasles = infants X 1
ØDT = No. children at 5 yrs X 1

Estimation of Vaccine Vials
Ø Each session should have one vial of BCG

 No. beneficiaries / session * 1.33

Ø TT = ------------------------------------------
 10
Ø BCG = ------------------------------------------
 10
Ø OPV = -----------------------------------------
20


Ø DPT = --------------------------------------------
 10
 No. beneficiaries/ session * 1.33
Ø Measles = ------------------------------------------
 5
 No. beneficiaries/ session * 1.33
Ø DT = ---------------------------------------------
 10
Ø Vitamin A Solution
ØChildren below 1 year of age (1 dose of 1lakh unit) =
141
ØChildren between 1-5 yrs. (8 doses of 2 lakh units) =
509x2 = 1018

Estimation of ADS and Disposable
Syringes and Diluents with Vaccines
Ø0.1 ml = (No. of beneficiaries for BCG) + 10 %
Ø0.5 ml = (Beneficiaries of DPT + Measles + DT +
TT ) + 10 %
Ø5 ml reconstitution = (No. of BCG vials + No. of
Measles vials )+ 10 %
ØNo. of Sodium chloride ampoules = No. of BCG
vials
ØNo. of Double distilled water ampoule = No. of
Measles vials
Ø
How to Plan Number of Sessions
Fixed Sites (PHC / CHC etc.)

Ø40 – 70 injections = one session per month

Ø> 70 injections = two sessions per month

Outreach:

Ø25-50 injections = one session per month

Ø> 50 injections = two sessions per month
Ø< 25 injections = one session in alternate month

Steps in Preparation of Micro Plan
ØStep1 – List all villages and hamlets

ØStep2 – Write the population of each village
ØStep3 – Write the number of beneficiaries
ØStep4 – Prepare a map of the sub
center/PHC

Preparation of Micro Plans at PHC
and District
ØPreparation of Micro Plans at PHC and District
ØMicro plans from all sub-centres are
complied. Add components of alternate
vaccine delivery, plan for supervision, plan
for immunization waste disposal etc.
ØSimilarly the PHC plans are compiled 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.
Preparation of Micro Plans at PHC
and District
ØDon’ts of Micro Plans at PHC and District:

ØCancel any schedule plan. Ensure that each
planned session is held, even in case of
holiday or leave.
ØLeave any community meeting without
communication about next immunization
session days.


Urban Micro Plan
ØDemarcation of areas
ØSite for immunization session
ØSlums/Aanganwadi
centers
ØDistrict Hospital
ØPrivate Hospital
ØDispensary
ØHuman resources
ØVaccine delivery
ØTracking beneficiaries
ØIEC and Social mobilization
Regular Monitoring and Review of
Micro Plan
Ø Monthly reports Monitoring Chart
Ø coverage monitoring
chart
Ø Quarterly Review meeting
Ø review missed sessions
Ø other problems
Ø revise session plan and
work plan (if needed)
Ø Supportive supervisory
visits
Ø monitoring the work in
the field,
Ø providing on-the-job
training,
Ø taking notes for future
discussion at review
meetings . : An ISO:9001:2008
SIHFW certified Institution 52
Tracking Bag and Tickler Box

Dropouts
ØDefinition:-children who receive one or more
vaccination, but do not return for subsequent

immunization.
ØCommon reasons for Dropout are:
Ø Anaphylaxis or a severe allergic reaction
Ø Parents are not aware of the reason of
following an immunization schedule
Ø Parents do not know that immunization is
important

Ø Parents develop misconceptions about
immunization
Ø Families move to a new village
Ø
ØWhy bother about dropouts?
ØPeople who “drop-out” of the immunization
system are the easiest to reach and
convince to return for full immunization.


Strategies for Minimize Drop outs
ØEach planned immunization session should be held in
spite of holiday or leave and Re-schedule immunization

session timings
ØMaintain a list of children who have not completed full
immunization
ØLook for migrant populations travelling through your
service delivery area and reach out to them
ØInform and advise to the parents about next date for
immunization
ØTake the help of your community teams
(AWW, ASHA, NGOs etc.)
ØDevelop your own solutions based on the responses of
parents
Suitable Methods for Mobilize the
Community
Ø Communication with community
Ø Involvement of community and community leaders for
education
Ø Gather information regarding misconception and its
resolution
Ø Arrange for an interaction between resistant groups and
satisfied beneficiaries in the area to promote
immunization
Ø Use of Loudspeaker, Discussion sessions at farmers’
meetings ad at religious places, Radio and TV spots,
Newspaper articles and drama shows.
Ø Always provide prompt and quality services

Dealing with Rumours and
Misinformation
ØRumours and misinformation about immunization are
amongst the most serious threats to the success of your
immunization programme
ØSome examples of rumours:
Ø“Vaccine are a contraceptive to control population or
to limit the size of a certain ethnic group”
Ø“Vaccines are contaminated by the AIDS virus or
mad cow disease”
Ø“Children are dying after receiving vaccines”
ØRefer the matter to your supervisors
ØAction may even need to be taken at the national level

Records
ØMust be easy to write, compile & read

Ø
ØMust be available at the time of the visit
Ø
ØMust be accurate
Øreflect who is in the practice
Øreflect all vaccines given

Matching Strategies to Existing
Problems
ØValue of a strategy depends on:

Øimplementation
Øpotential effectiveness
Øhow well it is matched to
existing problems

AFIX
Ø Assessment
Ø Feedback
Ø Incentives
Ø Exchange

Special Characteristics of AFIX
ØFocus on outcomes
Ø
ØFocus on providers
Ø
ØBoth personal and technological

Assessment
ØEvaluation of medical records to ascertain

the immunization coverage for a defined
group
Ø
ØDiagnosis of potential service delivery

problems
Ø
ØAssessment increases awareness

Feedback
ØInforming immunization providers about
their performance
Ø
ØAssessment with feedback creates the
awareness necessary for behavior
change

How to Provide Feedback
ØTo all who can make a change

ØWith feeling and precision
ØWithout judgment
ØWith confidentiality as appropriate
ØAs a challenge

Settings Where Missed Opportunities
Occur
ØSettings that traditionally offer
immunizations (e.g., primary care offices
or public health clinics)
Ø
ØSettings that do not traditionally offer

immunizations
Øhealth care settings (e.g. Emergency
dept.)
Øpublic health settings (e.g., WIC)

Causes of Missed Opportunities
ØLack of simultaneous administration

ØUnaware child needs additional vaccines
ØInvalid contraindications
ØAvoidance of accelerated schedule
ØInappropriate clinic policies
ØReimbursement deficiencies

Strategies for Reducing Missed
Opportunities
ØStanding orders
Ø
ØProvider education with feedback
Ø
ØProvider reminder and recall systems

Cold Chain
Ø Definition- system of transporting and storing vaccines at
recommended temperature from the point of
manufacture to the point of use.
Ø Essential Elements:-
Ø Personnel to organize and manage vaccine
distribution
Ø Equipment for storage and transport of vaccines.
Ø Transport facilities
Ø Maintenance of equipment and Monitoring
Ø It is the responsibility of district block managers to
ensure the cold chain equipment are installed
operated and maintained properly so as to keep it
continuously functioning equipment.

Cold Chain Equipment Supplied
Under the Immunization Programme
Name of Place of Installation Temperature Utilization
Equipment
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 PHC -18 C to -20 C Preparation of ice packs
litres
Cold Box 20 litres State, Regional, +2 C to +8 C All vaccines can be stored for transpiration
district HQ & PHC or in case of power failure
Cold Box 5 litres District HQ & PHC +2 C to +8 C All vaccines can be stored for
transportation or in case of power failure
Vaccine carrier (1.7 PHC/Sub Centre +2 C to +8 C All vaccines can be carried in small quantity
litres) for vaccination sessions
No Cold Chain Equipment should be installed without a voltage stabilizer

Maintenance of Equipment
ØDefrosting/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.
ØCold 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
ØIce Packs: Fill clean water for freezing & leave
10mm room for expansion as water freezes.
Cap tightly to avoid leakage. Keep pack clean &
dry.
Vaccine’s Sensitivity
Vaccine Exposure to heat/light Exposure to cold Temperature
at PHC
Heat and light sensitive vaccines
BCG Relatively heat stable, but Not damaged by freezing. +2°C to + 8°C
sensitive to light
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
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
At PHC level, all vaccines are kept in ILR in which temperature is maintained at + +2°C to + 8°C
ØAll Vaccines tend to lose potency on exposure to heat above +80 C

ØSome Vaccines lose potency when exposed to freezing temperatures
ØThe damage is irreversible
Potency
ØDPT series, Hep-B and diluents should never be
frozen
ØBCG, OPV & Measles are sensitive to heat and
light & lose potency fast
ØPotency lost due to heat exposure does not
change the appearance of the vaccine
ØDamage to vaccine cannot be reversed by re-
freezing
ØDiscard frozen vaccine
ØVaccines need to be checked both for damage
from excessive heat as well as from freezing by
:-
ØVVM for Heat Damage
ØShake test for Cold Damage
 Vaccine Vial Monitor
ØDefinition of Vaccine Vial Monitor:- A vaccine vial
monitor (VVM) is a label that changes colour when the
vaccine vial has been exposed to heat over a period of time.
1 = good:
Utilize 3 = bad:
Don’t Utilize
X
2 = good:
Utilize
4 = bad:
Don’t Utilize
X
The central square is lighter The central square is equal to, or
than the surrounding circle darker than the surrounding circle

Checking for Cold Damage
(Freezing)
ØShake Test :- The SHAKE TEST is designed to
determine whether adsorbed vaccines (DPT, DT, TT or
Hepatitis B) have been frozen.
Contro Test
l
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Auto-Disable Syringes
ØAdvantages of the AD syringes:
Øprevent the re-use of non-sterile
syringes.
Øreduces the dead space in the syringe
Øeliminates the chances of air bubble
entry into the syringe due to loose
fitting of the needle
Ødose specific (0.5 ml & 0.1 ML)
Øeliminating the need to carry bulky
equipment
ØSave time for sterilization
ØLowest risk of person to person
transmission of blood borne infections

Injection Safety
Ø What are the Risks Associated with Unsafe Injections?
ØTransmission of infection-Hepatitis B, Hepatitis C
and HIV (the virus that causes AIDS).
ØInjury or Drug Toxicity due to wrong injection site,
vaccine, diluents, or dose is used.
Ørisks of accidental needle-stick injury
Ø Simple Ways to Improve Injection Safety
ØHands Washing
Østerile injection equipment
ØPrevent the contamination of vaccine and injection
equipment
Øsafe disposal of all medical sharps waste
ØPrevent needle-stick injuries
Ø
Types of Programmatic Errors
causing AEFIs
Programmatic Errors Possible Adverse event that may occur
Non-Sterile injection:
Improperly sterilizing syringe Infection such as local abscess at site of
Contaminated vaccine or diluents injection sepsis, toxic shock syndrome or death.
Re-use of reconstituted vaccine at subsequent
sessions
Wiping the needle with a swab
Administering injection over clothes
Re-use of disposable syringe and needle Transmission of blood-borne infections such as


Heb B, HIV, Hep C

Reconstitution Error/ Wrong vaccine
preparation Vaccine ineffective
Reconstitution with incorrect diluents Negative effect of drug, e.g. insulin causing
Drug substituted for vaccine diluents death
Inadequate shaking for T-series vaccines Local abscess
Injection at incorrect site

BCG given sub-cutaneously Local reaction or abscess
DPT/DT/TT given superficially Local reaction or abscess
Injection into buttocks Sciatic nerve damage
Vaccine transportation/storage Local reaction from frozen vaccine
Vaccine ineffective
Contraindications ignored Avoidable serious reaction

AEFI---- Rare, more severe reactions
ØSeizures
ØThrombocytopenia
ØHypotonic-hypo responsive episodes
ØPersistent inconsolable screaming -In most
cases they are self-limiting and lead to no long-
term problems
ØAnaphylaxis, while potentially fatal, is treatable
without any long-term effects
Ø

How
Ø to Minimize AEFIs in your Area?
Ø Instruction for the health workers
Ø Selection of separate site
Ø One syringe & one needle should be used
Ø Use auto-disable syringes
Ø Follow correct sterilization procedures
Ø Use of Reconstitute vaccines only with diluents
Ø Use Measles and BCG vaccine within 4 hours of
reconstitution
Ø Keep diluents of BCG and measles vaccine separate from
other potentially harmful liquids.
Ø Do not keep needles in the rubber cap (stopper) of vaccine
vials.
Ø Do not store other drugs or substances in the ice-lined
refrigerator or deep freezer.
Ø What to do if an AEFI Occurs?
Ø the health worker should immediately contact the Medical
Officer and if needed should accompany the patient.
Minor Reactions Due to Vaccines (Normal
and not Required to be Reported)
Mild vaccine reactions Treatment When to report
Local reaction (pain, Cold cloth at injection  In case of an abscess

selling, redness) site
Give Paracetamol
Fever > 38.5°C Give extra fluids When accompanied by


Wear cool clothing other symptoms

Give tepid sponging
Give Paracetamol
Irritability, malaise and Give extra fluids When severe or


systemic symptoms Give Paracetamol unusual

Waste Generation
ØAD syringes to be used where safe disposal


possible
[
ØWaste consist of :
ØPackaging material
ØSyringes
ØNeedles
ØBroken / discarded vials

Surveillance
Ø WHO definition:- “The continuous scrutiny of the
factors that determine the occurrence of disease
and other conditions of ill health. Surveillance is
essential for effective control and prevention and
includes the collection, analysis, interpretation and
distribution of relevant data for action”
Ø “Data collection for Action“
Ø Five steps in Surveillance
ØCollection of data
ØCompilation of data
ØAnalysis and interpretation
ØFollow up action
ØFeed back
 SIHFW: An ISO:9001:2008 certified Institution 83
Prerequisites for Effective
Surveillance
ØUse of Standard Case Definitions
ØEnsuring Regularity of the Reports
ØAction on Reports
ØMedical Officer must be clear about:
ØWhat information to gather
ØHow often to compile & analyze the
data
ØHow often & to whom to report
ØWhat Performa or formats to use
ØWhat action to take
Vaccine Preventable Disease
Outbreak
ØDuring outbreak we have to Ensure the following:-
1.Adequate supply of vaccines, syringes and
needles
2.Adequate staff who are able to administer the
vaccines
3.Ring immunization wherever applicable
ØRing vaccination: Ring vaccination controls an

outbreak by vaccinating and monitoring a ring of
people around each infected individual. The idea is to
form a buffer of immune individuals to prevent the
spread of the disease

Vaccination during outbreak
ØIn the event of a suspected or confirmed
outbreak, only close contacts are considered to
be at risk. For close contacts, treatment
includes:
ØDiphtheria:-
ØPrimary immunization or booster dose
was received with in previous 2 yrs-no
further action would be needed
ØPrimary course or booster dose was
received more than 2 yrs only a
booster dose of diphtheria toxoid need
be given
ØGetting a dose right away if primary
course was received fewer than three
doses
ØGetting a booster dose if have not had a
dose in five year
ØFor non-immunized contact-
prophylactic penicillin or erythromycin
and 1000-2000 units of diphtheria
antitoxin and actively immunized

against diphtheria
ØPertusis:- Prophylactic antibiotic (erythromycin
or ampicillin) for 10 days and booster dose of
DPT or DT
Vaccination During Outbreak
ØMeasles:- Ring immunization with in 2 days of
exposure
ØPolio :- Ring immunization with use of

Oral(Sabin) Polio vaccine
ØRecommendation for prevention of Tetanus in
Wounded :-
ØCategory 1 – Had a complete course of Toxoid
or a Booster dose with in past 5 yrs – nothing
more required
ØCategory 2 – had a complete course of Toxoid
or a booster dose more than 5 years ago and
less than 10 years ago – Toxoid 1 dose

ØCategory 3 – had a complete course of
Toxoid or a booster dose more than 10
years ago
Øif wound less than 6 hours old- toxoid 1
dose
ØIf wound more than 6 hours old – toxoid
1 dose + human Tet.Ig
ØCategory 4 – has not completed course of
 toxoid or immunity status is unknown –
Øif wound less than 6 hours old - Toxoid
complete course
ØIf wound more than 6 hours old - Toxoid
complete course + Human Tet.Ig

Thank You

Immunization

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Immunization

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Immunization

State Institute of Health and Family Welfare, Jaipur

SIHFW: An ISO:9001:2008 certified Institution 2

weakened or killed pathogen, 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.

vaccine) to produce immunity to a disease

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ØThe immunologic status of a

ØHerd Immunity Does not work when:

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ØKey strategy to child survival

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Source: state of the world’s children 2009:UNICEF report

Note : 5,700 infants die everyday in India.

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Type of diphtheria Dosage (units) Route

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ØTransmission – fecal-oral and

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Source: WHO/UNICEF Review of National Immunization Coverage1980-2008

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State Vitamin A in last 6 months

Ø43.5% of children in India received all vaccinations as

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ØImmunization levels are not optimal

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ØMinor illnesses such as upper respiratory

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ØWhat needs to be provided

2. No. of Pregnant Women = No. of Live Births + 10%

3. No. of Infants alive at 1yr. = 150-{150x60/1000=9}

4. No. of Children <3 yrs.of age =8% of population

5. No. of Children <5 yrs.ofage =13% of total population

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 No. beneficiaries / session * 1.33

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Ø40 – 70 injections = one session per month

Ø25-50 injections = one session per month

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ØStep1 – List all villages and hamlets

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