Transcript Document

Universal Immunization
Programme
Presentation outline
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Background and overview
National Immunization Schedule (Jan. 2011)
Vaccines and Cold Chain
Safe injections, waste disposal
AEFIs
Desirable vaccines
Universal Immunization Programme
• Largest UIP program in the world.
• Targets include 27 million infants and 30.2
million pregnant women every year
• Protection against six Vaccine Preventable
Diseases (VPDs) - Tuberculosis, Diphtheria,
Tetanus, Pertussis, Polio and Measles
• Two new vaccines (JE and Hepatitis B)
introduced in select areas
%Infants (0-1 year)reached
120
100
100
86.9
80
69.6
66.2
63.6
54.1
60
40
20
11.3
Target infants :
Fully immunized:
Partial immunized:
26 million
14.1 million
9.0 million
No immunized:
2.9 million
No
immunization
Fully
immunize
DPT-3
OPV
Measles
BCG
Target infants
0
National Immunization Schedule (Jan., 2011)
Age
Vaccines
Pregnant Women
TT (2 doses/Booster)
Birth
BCG, OPV-O, Hep B
6 weeks
DPT -1, OPV -1, Hep B
10 weeks
DPT -2, OPV -2, Hep B
14 weeks
DPT -3, OPV-3, Hep B
9 months
Measles
16-24
months
DPT booster, OPV – Booster, MCV (Measles Containing
Vaccine), JE*
5 years
DPT Booster 2
10 years
TT
16 years
TT
If a dose is missed……..
• Give the dose at the next opportunity
irrespective of the time gap
• Do not start the schedule all over again
Tetanus toxoid
• Intramuscular – upper arm – 0.5 ml
• Pregnancy – 2 doses - 1st dose as early as possible
and second dose after 4 weeks of first dose and
before 36 weeks of pregnancy
• Pregnancy – booster dose (before 36 weeks of pregnancy) – If
received 2 TT doses in a pregnancy within last three
years. Give TT to woman in labour, if she has not
received TT previously
• TT booster for both boys and girls at 10 years and 16
years
• No TT required between two doses in case of injury
BCG
• At birth or as early as possible till one year of
age
• 0.1 ml (0.05ml until one month of age)
• Intra-dermal
• Left upper arm
Hepatitis B
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Birth dose – within 24 hours of birth
0.5 ml
Intramuscular
Antero-lateral side of mid-thigh
Rest three doses at 6 weeks, 10 weeks and 14
weeks
OPV
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Zero dose – within first 15 days of birth
2 drops
Oral
First, second and third doses at 6, 10 and 14
weeks with DPT-1, 2 and 3
• OPV booster with DPT booster at 16-24
months
DPT
• Three primary doses at 6, 10 and 14 weeks
with OPV-1, 2 and 3
• 0.5 ml
• Intra-muscular
• Antero-lateral side of mid-thigh
• One booster at 16-24 m with OPV booster
(antero-lateral side of mid-thigh) and second
booster at 5-6 years (upper arm)
Measles
• At 9 completed months to 12 months
• Give upto 5 years if not received at 9-12 months age
• Second dose at 16-24 months (select states after
catch-up campaign) – Measles Containing Vaccine
• 0.5 ml
• Sub-cutaneous
• Right upper arm
• Along with Vitamin A (1st dose) – 1ml (1 lakh IU) oral
Vitamin A
• 1st dose – 1 ml (1 IU) - along-with Measles
first dose - Oral
• Subsequent 8 doses (2 ml or 2 lakh IU) every
six months till 5 years of age starting with DPT
first booster at 16-24 months
• Use only plastic spoon provided with Vitamin
A solution
Japanese Encephalitis
• SA 14-14-2 vaccine in select endemic districts
after campaign in UP, Bihar, Assam, Haryana,
Andhra Pradesh, Goa, Karnataka, Manipur,
West Bengal, Tamil Nadu
• 16-24 months with DPT and OPV booster
• 0.5 ml
• Subcutaneous
• Left upper arm
Vaccines and Cold Chain
Vaccines
• Live attenuated – BCG, Measles and OPV
• Inactivated killed – DPT, TT, whole–cell pertussis, hepatitis B
• All vaccines should be stored at plus 2 to plus 8 degrees
ideally in Ice Lined Refrigerators/ Domestic Refrigerators
• All government supply vaccines come with Vaccine Vial
Monitors (VVMs)
• BCG and Measles vaccines are in powder form and come with
diluents. Reconstitution is needed before use.
• Use reconstituted BCG and Measles vaccines within 4 hours of
reconstitution and JE within 2 hours of reconstitution if kept
at +2 to +8 degrees
• Use separate 5 ml syringes for each reconstitution
Why have the Cold Chain?
If vaccines are exposed to excessive
Heat
Cold
Light
they may lose their potency or effectiveness.
HEAT DAMAGE
• Heat damage is cumulative effect
• Reconstituted vaccine is most sensitive to
heat and light.
• Measles and BCG vaccines should not be
used 4 hrs after reconstitution and JE 2
hrs after reconstitution
• Temperature of diluents & vaccine must
be same during reconstitution
Heat sensitivity
• BCG (after reconstitution)
• OPV
• Measles (before and after
reconstitution)
• DPT
• BCG (before reconstitution)
• DT
• TT
• HepB
MOST SENSITIVE
LEAST SENSITIVE
Sensitivity from Freezing
MOST SENSITIVE
• HepB
• DPT
• DT
• TT
LEAST SENSITIVE
Remember
• All vaccines tend to lose potency on exposure
to heat above +80 C
• Some vaccines (Hep B, TT, DPT) lose potency when
exposed to freezing temperatures
• Some vaccines are sensitive to light (BCG, Measles).
• The damage is irreversible
• Physical appearance of the vaccine may remain
unchanged but potency might be lost.
Vaccine carriers
• Used for carrying vaccines (16-20
vials) and diluents from PHC to the
outreach session sites.
• With 4 conditioned icepacks
maintain inside temperature of 2-80C
for 12 hours.
• Close the lid of the carrier tightly.
• Never use any day carriers with 2
icepacks or thermos flask for
carrying vaccines.
Correct Packing of the Vaccine Carrier
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Prepare Ice-Packs for Freezing
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Condition Frozen Ice-Packs
Fill the Ice-Pack with water to mark. Check
water level before every use. Do NOT add
salt to this water.
Place frozen Ice-Packs in the open till they
“sweat,” (some condensation or droplets of water)
Fit the stopper and screw on the cap tightly
Check if an Ice-Pack has been conditioned by
shaking it and listening for water
Make sure the Ice-Pack does not leak
Wipe the Ice-Pack dry and place in the
Deep Freezer
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Pack the Vaccine Carrier
Place four conditioned Ice-Packs
against the sides of the carrier
Place the plastic bag containing all
vaccines and diluents in the centre of
the carrier.
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Remember to..
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Collect vaccines in the carrier on the session day
(Vaccine carriers may not store vaccines effectively
beyond 12 hrs)
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Do not drop or sit on the vaccine carrier.
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Do not leave in sunlight. Keep in shade.
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Do not leave the lid open once packed.
Unconditioned Ice-Packs may damage freeze
sensitive vaccines (DPT, DT,TT and Hepatitis B)
Storing vaccines in the Ice-Lined Refrigerator
Keep thermometer hanging
position in basket and maintain
temperature between
+2O C to +8O C (monitor
morning and evening)
Store all
vaccines in
baskets
Diluent
DPT
Diluent
DT
Diluent
DPT
DPTDPT
DPT
DPT
Diluent
DPT
DPT
DPT
DPT
TT
DT
Measles
Measles
Measles
Measles
Measles
TT
TT
TT
Diluent Diluent
Measles
Measles
Measles
Measles
Measles
Diluent
OPV
OPV
Store diluents
in baskets, for
24 hours
before next
session
OPV
Hep B Hep B
DPT
DPT
Hep B
DTT DT
TTBCG
DT
TT
BCG
OPV
OPV
Hep BHep B Hep B
DPT
DPT
DPT
Hep B
DT
DT
TT
TT
TT
BCG
BCGBCG
OPV
BCG
BCG
OPV
Arrange vaccines
in order (top to
bottom)
Hep B
DPT, DT, TT
BCG
Measles
OPV
Follow Early Expiry
First Out (EEFO)
Keep space
between
boxes
Discard any
frozen Hep
B, DPT, TT
and DT
Freezing Ice-packs in the Deep Freezer
Never store
UIP vaccines
in the DF.
Use only for
freezing
icepacks
Un-frozen
icepacks for
freezing
Store frozen
icepacks only
up to half the
height of the
large
compartment
Large compartment
Wipe dry and arrange
20-25 unfrozen
icepacks vertically
(never flat) in a
crisscross pattern with
space for air circulation
Small compartment
Arrange and store
frozen icepacks
vertically, in layers.
Also store in cold
boxes
Domestic Refrigerators
• Only in urban areas with assured electric
supply
• Hold over time (time taken in absence of
power to raise temperature from minimum
i.e. +2 degrees to maximum i.e. +8 degrees for
an equipment) for a domestic refrigerator is
only four hours
• Specific order of storing ice packs and vaccines
in domestic refrigerator
Storing vaccines in Domestic
Refrigerator
• Ice packs and OPV in freezer
• Block door panels (where bottles are stored)
and vegetable tray at the bottom with
thermocol
• Measles vaccine may be stored in the chiller
tray below the freezer followed by T – series
vaccines in the shelves below
• Hepatitis B should be stored below all
vaccines
Usable and Unusable stages of
VVM
Safe vaccines and waste disposal
Safe Injections
• Cover any small cuts on the service provider’s skin.
• Wash or disinfect hands prior to preparing injection material.
• Always use an Auto Disable Syringe (ADS) for each injection
and a new disposable syringe to reconstitute each vial of BCG
and measles
• Avoid giving injections if the skin of the recipient is infected or
compromised by local infection (such as a skin lesion, cut, or
weeping dermatitis)
• Check expiry date and VVM before use
• If the injection site is dirty, wash with clean water
• Use only diluent supplied with vaccine for reconstitution
• Write time of reconstitution on label - Use reconstituted
vaccines within 4 hours
• Use hub cutters immediately after injection has been
administered to separate needle from syringe
• Disinfect sharps and non-sharps before disposal
Simple ways to improve injection safety
• Follow product-specific recommendations for use, storage,
and handling of a vaccine.
• Discard any needle that has touched any non-sterile surface.
• Discard a syringe that has been punctured, torn or damaged
by exposure to moisture
• Consider all used equipment as contaminated
• Cut the used syringe at the hub immediately after use.
Practice safe disposal of all sharps
• Deposit used sharps (needles) in a hub cutter and disinfect
before safe disposal.
• Prevent needle-stick injuries. Do not recap or bend needles.
• Anticipate sudden movement of child.
Adverse Events Following
Immunization (AEFI)
AEFIs
AEFI is any medical incident that takes
place after an immunization, causes
concern, and is believed to be caused by
immunization
AEFIs need to be detected, properly
managed clinically, reported,
investigated, monitored and promptly
responded to for corrective interventions
AEFI…..types
• Vaccine reactions (high grade fever following DPT) –
caused/precipitated by active component or one of
the other components of vaccine such as adjuvant/
preservative/ stabilizer
• Program error (bacterial abscess due to unsterile
injections) – caused by vaccine preparation, handling
or administration
• Injection reaction (fainting spell in teenager after
immunization) – caused by anxiety or pain from
injection rather than due to vaccine
• Coincidental (pneumonia after pulse polio NID during
winters) - event occurs after immunization but is not
caused by vaccine – chance temporal association
• Unknown – cause of event cannot be determined
Common minor vaccine reactions
• Local reaction (pain, swelling and/or redness), fever and
systemic symptoms (e.g. vomiting, diarrhea, malaise) can
result as a part of the immune response.
• Local reactions and fever should be anticipated in only
10% of the vaccine recipients, except in the case of whole
cell DPT which produces fever in nearly half of those
vaccinated.
• Fever and minor local and systemic reactions usually
occur within a day or two of immunization (except for
those produced by measles/MMR vaccine which occurs 6
to 12 days after immunization) and only last for few days.
• Fever and minor local reactions can usually be treated
symptomatically with paracetamol.
Rare Serious Adverse Events
Vaccine
BCG
Reaction
Suppurative adenitis, BCG Osteitis,
Disseminated BCG infection
Hib
None known
Hep B
Anaphylaxis
Measles/MMR Febrile Seizures, Thrombocytopaenia,
anaphylaxis
OPV
Vaccine associated paralytic polio
Tetanus
Brachial Neuritis, anaphylaxis, sterile abscess
DPT
Persistent (>3 hrs) inconsolable crying, seizures,
hypotonic hypo-responsive episode,
anaphylaxis/shock
Japanese
Serious allergic reaction, neurological event
Encephalitis
Reporting of AEFIs
For Immediate Reporting and Investigation
• Death, hospitalization, disability or other serious and unusual
events that are thought by the public to be related to
immunization
• Anaphylaxis
• Toxic shock syndrome (TSS)
• Anaphylactoid (acute hypersensitivity) reaction
• Acute Flaccid Paralysis (AFP) - Any case of AFP will be reported through the
current system for AFP surveillance and reporting
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Encephalopathy
Sepsis
Any event where vaccine quality is suspected
Events occurring in a cluster
Reporting of AEFIs
• Report immediately by telephone/ fax/ messenger to
PHC doctor/District Immunization Officer or Chief
Medical Officer
• First Information Report format for AEFI reporting to
be used
• Keep vaccines, diluents and syringes (including that
used for reconstitution) for investigation
• Be vigilant for other cases
• Do not use multi dose vials further if AEFI occurs. If
available use single dose vials.
Single dose vs multi dose vials
• Single dose vaccines are
more costly
• Per dose cold chain space
occupied is more
• Less wastage of doses if
number of beneficiaries are
less
• Lesser chance of AEFIs
occurring due to incorrect
handling
• More immunization waste
generation
• Multi dose vaccines cheaper
• Reduced per dose cold
chain space required
• Wastage is more if number
of beneficiaries are less
• More chances of AEFI
(cluster) occurring due to
incorrect handling
• Less generation of
immunization waste
Desirable vaccines
• Pentavalent (DPT + HepB + Hib)
• Hib
•Typhoid
•Chickenpox
Hib vaccine
• Haemophilus influenzae b (pneumonia,
meningitis)
• 0.5 ml
• Intramuscular at Antero-lateral side of midthigh
• At 6, 10 and 14 weeks and a subsequent
booster after age of one year (currently not included
officially in GOI’s Immunization Schedule)
• Combination with DPT + Hep B also available
Pentavalent vaccine
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DPT + Hep B + Haemophilus influenzae b
Intramuscular
Antero-lateral side of mid-thigh
0.5 ml dose
At 6, 10 and 14 weeks with booster at 16-24
months
• Proposed to be piloted in Kerala and Tamil Nadu – pending ICMR study
completion
Typhoid vaccine
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Salmonella typhi
Vi polysaccharide vaccine
0.5 ml dose
Intramuscular or subcutaneous
At two years of age (currently not included officially in GOI’s
Immunization Schedule)
• Revaccination every 3-4 years
Chickenpox vaccine
• Varicella vaccine
• Any time after 15 months (currently not included officially in
GOI’s Immunization Schedule)
• One dose if less than 13 years of age
• Two doses (gap of four to eight weeks) if more
than 13 years of age
• 0.5 ml
• Subcutaneous
• Upper arm
THANK YOU