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Universal Immunization Programme

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Title: Universal Immunization Programme


1
Universal Immunization Programme
2
Presentation outline
  • Background and overview
  • National Immunization Schedule (Jan. 2011)
  • Vaccines and Cold Chain
  • Safe injections, waste disposal
  • AEFIs
  • Desirable vaccines

3
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

4
Target infants 26 million Fully immunized 14.1
million Partial immunized 9.0 million No
immunized 2.9 million
5
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

6
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

7
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

8
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

9
Hepatitis B
  • 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

10
OPV
  • 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

11
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)

12
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

13
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

14
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

15
  • Vaccines and Cold Chain

16
Vaccines
  • Live attenuated BCG, Measles and OPV
  • Inactivated killed DPT, TT, wholecell
    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

17
Why have the Cold Chain?
  • If vaccines are exposed to excessive

Heat
Cold
they may lose their potency or effectiveness.
18
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

19
Heat sensitivity
MOST SENSITIVE
  • BCG (after reconstitution)
  • OPV
  • Measles (before and after reconstitution)
  • DPT
  • BCG (before reconstitution)
  • DT
  • TT
  • HepB

LEAST SENSITIVE
20
Sensitivity from Freezing
MOST SENSITIVE
  • HepB
  • DPT
  • DT
  • TT

LEAST SENSITIVE
21
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.

22
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.

23
Correct Packing of the Vaccine Carrier
2
1
  • Fill the Ice-Pack with water to mark. Check water
    level before every use. Do NOT add salt to this
    water.
  • Fit the stopper and screw on the cap tightly
  • Make sure the Ice-Pack does not leak
  • Wipe the Ice-Pack dry and place in the Deep
    Freezer

Prepare Ice-Packs for Freezing
  • Place frozen Ice-Packs in the open till they
    sweat, (some condensation or droplets of water)
  • Check if an Ice-Pack has been conditioned by
    shaking it and listening for water
  • Unconditioned Ice-Packs may damage freeze
    sensitive vaccines (DPT, DT,TT and Hepatitis B)

Condition Frozen Ice-Packs
3
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.

4
Remember to..
  • Collect vaccines in the carrier on the session
    day (Vaccine carriers may not store vaccines
    effectively beyond 12 hrs)
  • Do not drop or sit on the vaccine carrier.
  • Do not leave in sunlight. Keep in shade.
  • Do not leave the lid open once packed.

24
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
Arrange vaccines in order (top to bottom) Hep B
DPT, DT, TT BCG Measles OPV Follow Early Expiry
First Out (EEFO)
Diluent
Diluent
Diluent
Diluent
Store diluents in baskets, for 24 hours before
next session
Keep space between boxes
Discard any frozen Hep B, DPT, TT and DT
25
Freezing Ice-packs in the Deep Freezer
Never store UIP vaccines in the DF. Use only for
freezing icepacks
Small compartment Arrange and store frozen
icepacks vertically, in layers. Also store in
cold boxes
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
26
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

27
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

28
Usable and Unusable stages of VVM
29
Safe vaccines and waste disposal
30
Safe Injections
  • Cover any small cuts on the service providers
    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

31
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.

32
Adverse Events Following Immunization (AEFI)
33
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

34
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

35
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.

36
Rare Serious Adverse Events
Vaccine Reaction
BCG 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 (gt3 hrs) inconsolable crying, seizures, hypotonic hypo-responsive episode, anaphylaxis/shock
Japanese Encephalitis Serious allergic reaction, neurological event
37
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
  • Encephalopathy
  • Sepsis
  • Any event where vaccine quality is suspected
  • Events occurring in a cluster

38
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.

39
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

40
Desirable vaccines
Pentavalent (DPT HepB Hib) Hib Typhoid Chickenpox
41
Hib vaccine
  • Haemophilus influenzae b (pneumonia, meningitis)
  • 0.5 ml
  • Intramuscular at Antero-lateral side of mid-thigh
  • At 6, 10 and 14 weeks and a subsequent booster
    after age of one year (currently not included
    officially in GOIs Immunization Schedule)
  • Combination with DPT Hep B also available

42
Pentavalent vaccine
  • 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

43
Typhoid vaccine
  • Salmonella typhi
  • Vi polysaccharide vaccine
  • 0.5 ml dose
  • Intramuscular or subcutaneous
  • At two years of age (currently not included
    officially in GOIs Immunization Schedule)
  • Revaccination every 3-4 years

44
Chickenpox vaccine
  • Varicella vaccine
  • Any time after 15 months (currently not included
    officially in GOIs 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

45
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