Universal Immunization Programme

Presentation outline

• 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

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Target infants : 26 millionFully immunized: 14.1 millionPartial immunized: 9.0 million

No immunized: 2.9 million

National Immunization Schedule (Jan., 2011)Age VaccinesPregnant 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

• 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

• 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

Cold

Why have the Cold Chain?

If vaccines are exposed to excessive

they may lose their potency or effectiveness.

Heat

Light

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

LEAST SENSITIVE

MOST SENSITIVE

Sensitivity from Freezing

• HepB

• DPT

• DT

• TTLEAST

SENSITIVE

MOST 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.

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.

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.

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

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)

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

Pack the Vaccine Carrier

1 2

3

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.

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.

4 Remember to..

Correct Packing of the Vaccine Carrier

OPV

DPT

DPTDPTDPT

DTDT

Diluent Diluent DiluentTT TT TT

TT

DPT

Measles MeaslesMeasles

OPVOPV OPV

Measles

Measles Measles

MeaslesMeasles Measles

OPV OPVOPV

BCG BCG BCG

TT

DPT

DPTDPT

Measles

DPT

Hep BHep B

DTT

DPTDPTDPT DPT DPT

DT

TTBCG

BCGBCG

TT TT TT

DTDTDT

Hep B Hep B

Hep B Hep B Hep B

BCG BCG

DPT Diluent

DiluentDiluent

Diluent

Keep thermometer hanging position in basket and maintain temperature

between +2O C to +8O C (monitor morning and evening)

Keep thermometer hanging position in basket and maintain temperature

between +2O C to +8O C (monitor morning and evening)

Arrange vaccines in order (top to

bottom)Hep B DPT, DT, TTBCGMeasles OPV

Follow Early Expiry First Out

(EEFO)

Arrange vaccines in order (top to

bottom)Hep B DPT, DT, TTBCGMeasles OPV

Follow Early Expiry First Out

(EEFO)

Discard any frozen Hep B, DPT, TT

and DT

Discard any frozen Hep B, DPT, TT

and DT

Store all vaccines in baskets

Store all vaccines in baskets

Store diluents in baskets,

for 24 hours before next

session

Store diluents in baskets,

for 24 hours before next

session

Keep space between

boxes

Keep space between

boxes

Storing vaccines in the Ice-Lined Refrigerator

Freezing Ice-packs in the Deep Freezer

Never store UIP

vaccines in the DF.

Use only for freezing icepacks

Never store UIP

vaccines in the DF.

Use only for freezing icepacks

Large compartmentWipe dry and arrange

20-25 unfrozen icepacks vertically

(never flat) in a crisscross pattern with space for air

circulation

Large compartmentWipe dry and arrange

20-25 unfrozen icepacks vertically

(never flat) in a crisscross pattern with space for air

circulation

Un-frozen icepacks for

freezing

Un-frozen icepacks for

freezing

Store frozen icepacks only up to half the height of the

large compartment

Store frozen icepacks only up to half the height of the

large compartment

Small compartment Arrange and store frozen

icepacks vertically, in

layers.Also store in cold

boxes

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)

AEFIsAEFI 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 Reaction

BCG Suppurative adenitis, BCG Osteitis, Disseminated BCG infection

Hib None knownHep B AnaphylaxisMeasles/MMR Febrile Seizures, Thrombocytopaenia,

anaphylaxisOPV Vaccine associated paralytic polioTetanus Brachial Neuritis, anaphylaxis, sterile abscessDPT Persistent (>3 hrs) inconsolable crying, seizures,

hypotonic hypo-responsive episode, anaphylaxis/shock

Japanese Encephalitis

Serious allergic reaction, neurological event

Reporting of AEFIsFor 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

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 mid-

thigh• 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

• 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

• 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

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