Universal Immunization Programme

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Universal Immunization Programme
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Presentation outline

• Background and overview
• National Immunization Schedule (Jan. 2011)
• Vaccines and Cold Chain
• Safe injections, waste disposal
• AEFIs
• Desirable vaccines

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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 million Fully immunized 14.1
million Partial immunized 9.0 million No
immunized 2.9 million
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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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• Vaccines and Cold Chain

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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

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Why have the Cold Chain?

• If vaccines are exposed to excessive

Heat
Cold
they may lose their potency or effectiveness.
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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

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Heat sensitivity
MOST SENSITIVE

• BCG (after reconstitution)
• OPV
• Measles (before and after reconstitution)
• DPT
• BCG (before reconstitution)
• DT
• TT
• HepB

LEAST SENSITIVE
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Sensitivity from Freezing
MOST SENSITIVE

• HepB
• DPT
• DT
• TT

LEAST SENSITIVE
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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.

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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.

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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
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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..

• 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.

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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
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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
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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

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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

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Usable and Unusable stages of VVM
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Safe vaccines and waste disposal
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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

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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.

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Adverse Events Following Immunization (AEFI)
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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

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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

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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.

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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
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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

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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.

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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

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Desirable vaccines
Pentavalent (DPT HepB Hib) Hib Typhoid Chickenpox
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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

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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

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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

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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

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THANK YOU