Immunization is one of the best public health intervention to reduce mortality and morbidity caused by vaccine preventable diseases. in this part i am going to describe regarding cold chain ,frequently ask questions regarding vaccines and how to manage acute and life threatening adverse reactions at most peripheral level

1. IMMUNIZATION
DR HARIVANSH CHOPRA
DCH.,MD.
PROFESSOR
COMMUNITY MEDICINE
LLRM MEDICAL COLLEGE ,MEERUT
harichop@gmail.com

2. OBJECTIVES
To study
Cold chain
VVM
FAQs on immunization
Management of anaphylaxis
Vaccine coverage in NFHS

3. PRIMARY VACCINATION FAILURE
It is the inherent inability of the vaccine to produce immunity

4. SECONDARY VACCINATION FAILURE
It is reduction in the immunity after successful seroconversion

5. Cold chain
 The "cold chain" is a system of storage and transport of
vaccines at low temperature from the manufacturer to the
actual vaccination site.

7. Cold chain equipment
 Walk in cold rooms (WIC)
/ walk in freezer -They are
located at regional level,
meant to store vaccines up
to 3 months and serve 4-5
districts.

8. WALK IN FREEZER WALK IN COOLAR

9.  Deep freezers (300 Itr) and
Ice lined Refrigerators (ILRs
300/240 Itr capacity)-
Supplied to all districts and
theWIC locations to store
vaccines. Deep freezers are
used for making ice packs
and to store OPV and
measles vaccines.

10.  Small deep freezers and
ILR (140 Itr):
One set is provided to
PHCs, Urban Family
Planning Centres and Post-
partum Centres. Deep
freezers are to prepare
frozen ice packs which are
used in cold boxes, vaccine
carriers for transportation
of vaccines and during the
sessions.

11. HOW TO STORE VACCINES IN ILR

12. HOW TO STORE VACCINES IN REFRIGERATOR

13.  Cold boxes-
Cold boxes are supplied to
all peripheral centres .
These are used mainly for
transportation of the
vaccines. Before the
vaccines are placed in the
cold boxes, fully frozen ice
packs are placed at the
bottom and sides.The
vaccines are first kept in
cartons or polythene bags.

14.  Vaccine carriers:
Vaccine carriers are used to carry small quantities of vaccines
(16-20 vials) for the out of reach sessions. 4 fully frozen ice
packs are used for lining the sides.The carriers should be
closed tightly

15.  Day carriers-
Day carriers are used to carry small quantities of vaccines (6-8
vials) to a nearby session.Two fully frozen packs are to be
used. It is used only for few hours period.

16.  Ice packs-
The ice packs contain water.The water should be filled up to
the level marked on the side.

17. EQUIPMENT TEMPERATURE STORAGE CAPACITY HOLD OVERTIME
DEEP FREEZER
LARGE
-15-25 200 ice packs or 3 months
stock of OPV
(120,000-180,000 doses)
43°C for 18 hours
32°C for 22 hours
ILR (LARGE) +2°C - +8°C BCG, DPT, DT,TT,
Measles, Hep-B,Vaccine
stock for 3 months
(60000 doses)
At 43°C for 62 Hrs
At 32°C for 78Hrs
Deep Freezer -15°C - -25°C 100 ice packs At 43°C for 18 Hrs
At 32°C for 22Hrs
ILR (Small) +2°C - +8°C BCG, OPV, DT, DPT,TT,
Measles, Hep-B, vaccine
stocks for one
month(25,000 doses)
At 43°C for 62 Hrs
At 32°C for 78 Hrs

18. EQUIPMENT TEMPERATURE STORAGE CAPACITY HOLD OVERTIME
Cold Box (Large) +2°C - +8°C All vaccines stored for
transport or in case of
power failure (6000 doses
of mixed antigen with 50
ice-packs/72-96 icepacks)
At 43°C for 6.5 days
At 32°C for 10 days
Cold Box (Small) +2°C - +8°C All vaccines stored for
transport or in case of
power failure (1500 doses
of mixed antigen with 24
ice-packs/36 ice-packs)
At 43°C for 6.5 days
At 32°C for 10 days
Vaccine carrier (1.7 litres) +2°C - +8°C All vaccines carried for 12
hours (4 ice packs & 16-20
vials)
At 43°C for 34 Hrs
At 32°C for 51Hrs

19. Vaccine Vial Monitor
 VVM is a label containing a heat sensitive material which is
placed on a vaccine vial to register cumulative heat exposure
over time.
 The combined effect of time and temperature cause the VVM
to darken gradually and irreversibly.

20. Reading the stage of VVM
STAGE 1- inner square is lighter
than the outer circle.
STAGE 2- inner square is still lighter
than the outer circle.
STAGE 3- the color of inner square
matches that of outer circle.
STAGE 4- the color of the inner
square is darker than the outer
circle.

22. Frequently asked questions on immunization
 Q-If mother / caregiver permits administration
of only one injection during an infants first
visit at 9 months of age, which vaccine should
be given ?
A- at 9 m0nth of age , the priority is to give
measles vaccine with OPV & Vitamin A.

23. If a child who has never been vaccinated is brought in at 9
completed months but before 12 completed months of age, then, can
all the due vaccines be given to a child on the same day?
 Yes, all the due vaccines can be given during the same session but at
recommended injection sites, using separate AD syringes. It is safe
and effective to give BCG, penta, OPV, IPV, MR, RVV (where
applicable), PCV (where applicable) JE (where applicable) vaccines
andVitamin A at the same time to a 9-month-old child who has never
been vaccinated. If more than one injection has to be given in one
limb then ensure that the distance between the two injection sites is
at least 1 inch apart.

24. Q- Which vaccine can be given to a child between 1-5
years of age, whohas never been vaccinated ?
A- The child should be given DPT 1,
OPV-1, Measles & 2 ml of vitamin
A solution. It should then be given
second & third doses of DPT &
OPV at one month intervals.
Measles second dose is also to be
given as per the schedule. The
booster dose of OPV/ DPT can be
given at a minimum of 6 months
after administering OPV3/DPT3.

25. Q-which vaccine can be given to a childbetween 5-7
year of age , who never been vaccinated.
A- the child should be given
first, second & third doses
of DPT at one month
intervals. The booster dose
of DPT can be given at a
minimum of 6 months after
administering DPT3 upto 7
year of age.

26. Q- shouldone restart with the first dose of a vaccine if a
child is brought late for a dose.
A- do not start the
schedule all over
again even if the child
is brought late for a
dose. Pick up where
the schedule was left
off.

27. Q- why it is not advisable to clean the injectionsite with
a spirit swabbefore vaccination?
A- this is
because some
of the live
component of
the vaccine are
killed if they
come in contact
with spirit.

28. Q- if a child couldnot receive DPT1,2, 3 & OPV 1, 2 , 3
according to the schedule, upto what age can the
vaccine be given ?
A- the DPT vaccine
can be given upto 7
years of age & OPV
can be given upto 5
years of age.

29. Q- Why shouldthere be minimumgap of 4 week
between two doses of DPT ?
A- this is because
decreasing the interval
between two doses may
not obtain minimal
antibody production for
protection.

30. Why are the DPT, HepB (birth dose),
IPV and pentavalent vaccines given
in the anterolateral mid-thigh and
not the gluteal region (buttocks)?
- To prevent damage to
the sciatic nerve.
Moreover, the vaccine
deposited in the fat of
gluteal region does not
invoke the appropriate
immune response.

31. Q-What shouldone do if the childfound allergic to DPT
or develop encephalopathyafter DPT ?
A-Child should be given the
DTaP/DT vaccine instead of
DPT for remaining doses, as
it is usually the P ( whole
cell pertusis ) component of
vaccine which causes the
allergy / encephalopathy .

32. Q- Why DT is replaced by DPT vaccine for children
above two year of age ?
A- as pertussis cases
were reported in higher
age group children and
the risk of AEFIs were
not found to be more
after DPT vaccine as
compared to DT
vaccine.

33. Q-why give the measles vaccine only on the right
upper arm ?
A- to maintain the
uniformity and to
help surveyors in
verifying the receipt
of the vaccine.

34. Q- If the childreceive the measles vaccine before 9 monthof
age , is it necessary to repeat the vaccine later ?
A- yes, the measles vaccine need
to be administered , according to
NIS i.e. after the completion of 9
months until 12 months of age
and at 16-24 month. If not
administered in ideal age for
measles vaccine , it can be
administered upto 5 year of age.

35. Q- what is measles catch up campaign?
It is the special campaign to vaccinate all children in
a wide age group in a state or a district with one
dose of measles vaccine. The catch up campaign
dose is given to all children, both immunized and un
immunized , who belong to the target age group of 9
month to 15 years. The goal of a catch up campaign
is to quickly make the population immune from
measles and reduce death from measles. A catch up
campaign must immunize nearly 100 % of target age
group children.

36. Q- why 2nd dose of measles vaccine is introduced in NIP ?
A- one dose of measles
vaccine at 9 month of age
protect 85% of infant. With
second dose the aim is to
protect all children who
remain unprotected after first
dose.

37. Q- if a child comelate for the first dose , then can it get
the second dose of measles vaccine ?
A- all effort should be made
to immunize the children at
the right age i.e. first dose
at completed 9 month to 12
month of age and second
dose at 16 – 24 month .
However if a child comes
late then give two doses of
measles vaccine at one
month of interval until 5
year of age.

38. Q- if a child receive one dose of measles vaccineduring
an SIA campaign,shouldit receive the routine doseof
measles vaccine ?
A- yes, child should
receive should vaccine
routine dose according
to NIS.

39. Q- why give BCG vaccine only on left upper arm ?
A- to maintain
uniformity and for
helping surveyor in
verifying the receipt
of the vaccine.

40. Q- why do give 0.05 ml dose of vaccine to newborn?
A- because skin of
newborns is thin and an
intra-dermal injection of
0.01 ml may break the
skin or penetrate into
the deeper tissue and
cause local abscess and
enlarge axillary lymph
node. Dose of 0.05 ml is
sufficient to elicit
adequate protection.

41. Q- Why BCG is givenonly up to one yearof age?
A- most children acquire
natural clinical / sub
clinical tuberculosis
infection by the age of
one year. This too
protect against severe
form of childhood
tuberculosis e.g. TB
meningitis & miliary
disease.

42. Q- if no scar appears after administering BCG vaccine ,
shouldone revaccinate the child?
A- there is no
need to
revaccinate
the child.

43. Q- till what age can a child be given OPV ?
A- OPV can given
to children till 5
years of age.

44. Q- can OPV and vitamin A be given together with DPT
booster dose ?
A- yes

45. Q- Can an infant be breast fed Immediately after OPV?
A- yes

46. Q- If a girl has received all doses of DPT and TT as per
NIS till 16 years of age & she get pregnant at 20 years of
age, shouldshe get one dose of TT during pregnancy ?
A- give two doses
of TT during the
pregnancy as
per the
schedule.

47. Q- is TT at 10 years and 16 years meant only for
girls ?
A- NO it is
to be
given to
both boys
and girls .

48. Q- Can TT given in the first trimester of pregnancy ?
A- Yes, it should be
given as soon as
pregnancy is
diagnosed.

49. What is the “birth dose” of hepatitis
B?
This refers to the
dose given within
24 hours of birth.
A child vaccinated
with Hep B after
more than 24
hours of birth is
not considered to
have received the
birth dose.

50.  Why is hepatitis B vaccine given only till 1 year of age?
 Hepatitis B vaccine is given till 1 year of age because
infections during first year of age have a 90% chance of
becoming chronic as compared to 30% during 1–5 years
and 6% after 5 years. Persons with chronic infection
have 15–25% risk of dying prematurely due to HBV
related liver cirrhosis and cancer.

51. Q- Upto what age can hepatitis B vaccine be given?
A- according to NIS ,hepatitis B vaccine should
be given with the 1st ,2nd, & 3rd dose of DPT till
one year of age .

52. Q- why give the birth dose of hepatitis B vaccine
only within24 hours of birth ?
A- the birth dose of vaccine is effective to
prevent perinatal transmission of hepatitis B if
given within the first 24 hours.

53. Q- if a child 16-24 months of age has been
immunizedwith JE vaccine during SIA , can it
receive the JE vaccine again,as part of routine
immunization ?
A- No, currently this is a single dose vaccine and
should not repeated.

54. Q- if a child above 2 years of age has not
received the JE vaccine througheither RI or SIA .
Should s/he be given the JE vaccine ?
A- yes , the child is eligible to receive a dose of
JE vaccine , through RI, till the age of 15 years.

55. Can Hepatitis B vaccine be mixed in the same
syringe with DPT and given as one injection?
No, DPT and Hepatitis B vaccine (if supplied separately)
cannot be mixed or administered through the same
syringe.

56. What is pentavalent vaccine?
Pentavalent vaccine
is a vaccine that contains five antigens
(diphtheria + pertussis + tetanus+ hepatitis B +
Haemophilusinfluenzae type b).

57. How is pentavalent vaccine more
advantageous?
The addition of Hib vaccine provides protection against
Haemophilus InfluenzaeType b related diseases (bacterial
meningitis, pneumonia and others)
•The number of injections administered under UIP during the first
year of life reduces from ten to seven (not including IPV).
• It does not require reconstitution.

58. What is the schedule for pentavalent
vaccine?
As per the National Immunization Schedule, three doses of
pentavalent vaccine are to be administered. The first dose is given
only after a child is 6 weeks old.The second and third doses are
given at 10 and 14 weeks of age, respectively. There is no booster
dose recommended under UIP
Note: Pentavalent vaccine should be started for any child aged
more than 6 weeks and can be started upto 1 year of age

59. For what reasons should a child not be
given pentavalent vaccine?
Age – a child below 6 weeks of age should not be given
pentavalent vaccine.
•Vaccination history – a child whose vaccination schedule has
been initiated with DPT/hepatitis B vaccine will continue to
receive subsequent doses of DPT/hepatitis B and not pentavalent
vaccine.

60. For what reasons should a child not be
given pentavalent vaccine?
Severe allergic reactions – although serious side effects have not
been reported, a child who has had a severe reaction to
pentavalent vaccine earlier should not be given another dose.
• Children with moderate or severe acute illness should not be
administered pentavalent vaccine until their condition improves.
Minor illnesses, however, such as upper respiratory infections
(URI) are not a contraindication to vaccination.

61. What vaccine will be given to a child who has received
at least one dose of pentavalent vaccine before his/her
first birthday?
If a child has received at least one dose of pentavalent
vaccine before his/her first birthday, the child should be
administered the due pentavalent doses at a minimum
interval of 4 weeks, at the earliest available opportunity.

62. What are the common side-effects of
pentavalent vaccine?
Pentavalent vaccine has not been associated with any serious
side-effects. However, redness, swelling and pain may occur at
the site where the injection was given.These symptoms may
appear the day after the injection is given and last from 1 to 3
days. Less commonly, children may develop fever for a short time
after immunization.

63. After introduction of pentavalent vaccine,
will DPT and Hep B be required?
Yes, Hep B birth dose (within 24 hours) for institutional
deliveries and DPT boosters at 16– 24 months and 5–7
years will continue as before.

64. What is Rotavirus?
Rotavirus is a highly contagious virus. It is the most
common organism that causes diarrhea among children
which may lead to hospitalization and death.

65. What are the clinical features of
Rotavirus diarrhea?
Rotavirus diarrhea has an incubation period 1-3 days. It presents
usually with sudden onset of watery stools, often accompanied
by fever and vomiting. Sometimes accompanied with abdominal
pain.The diarrhea and associated symptoms may last for 3-7
days.

66. How effective is the Rotavirus
vaccine?
The available RotavirusVaccines are observed to be
effective in preventing severe rotavirus diarrhea by 54-
60%.The protective effect of Rotavirus vaccine lasts
through 2nd year of life.

67. Is Rotavirus vaccine being used in any
other country in the world?
Rotavirus vaccine is being used in national immunization
program more than 80 countries. Rotavirus vaccine has also
been in use by private practitioners in India for several years.

68. How and when is the Rotavirus vaccine
given?
Rotavirus vaccine is an oral vaccine.The dose of Rotavirus vaccine
varies from manufacturer to manufacturer. The dose and route for
Rotavirus vaccine currently being supplied under UIP is 5 drops to be
administered to all infants at 6, 10 and 14 weeks along with other
vaccines in routine immunization .

69. What is the maximum age limit for giving
the first dose of Rotavirus vaccine?
The upper age limit for the first dose of Rotavirus vaccine is one
year of age. If a child has received only the first dose of Rotavirus
vaccine by 12 months of age, two more doses of the vaccine
should be given at an interval of 4 weeks between the two doses
to complete the course.

70. Should Rotavirus vaccine be given to children who have
already received first dose of OPV
and Pentavalent vaccine?
No, during the initial period of Rotavirus vaccine introduction, only
the infants coming for the first dose of OPV and pentavalent vaccine
will be administered Rotavirus vaccine. These children will be given
2nd and 3rd doses in subsequent visits as per the schedule.
Infants who are coming for their second or third dose of OPV and
pentavalent vaccine, will complete the schedule with OPV and
pentavalent vaccine only. Rotavirus vaccine is not to be started with
second or third dose of OPV and Pentavalent vaccine.

71. What should be done if a child has received one or two
doses of Rotavirus vaccine in a
private facility?
If the parents want to vaccinate their child from the public sector
after receiving one or two doses of Rotavirus vaccine in a private
facility, a new course of Rotavirus vaccine must be started with all
three doses at one month intervals provided the child is less than
one year old

72. What is IPV?
IPV refers to Inactivated Poliovirus Vaccine administered by
injection. Evidence suggests that this vaccine, when used along
with OPV, increases the protection to the individual as
well as the community. IPV together with OPV prevents re-
emergence and reinfection of wild poliovirus (WPV).

73. Will IPV (injection) replace OPV (drops)?
No, IPV (injection) will not replace OPV (polio drops), since
IPV is recommended to be administered in addition to
OPV.

74. Are there any contraindications for use of
IPV?
IPV should not be administered to children with a documented or
known allergy to streptomycin, neomycin or polymyxin B, or with a
history of a previous allergic reaction after IPV injection.

75. How and when is IPV to be administered?
IPV is to be given as a fractional dose (0.1 ml) intradermally
in the Right arm of the child.
Fractional IPV is given in two doses at 6 and 14 weeks
along with OPV 1 and OPV 3

76. First line Management of Anaphylaxis in Field Settings
SOP for administration of one dose of Intra-muscular
Adrenaline by ANM
Respiratory • Swelling in tongue, lip, throat,
uvula or larynx
• Difficulty in breathing
• Stridor (Harsh vibrating sounds during
breathing)
• Wheezing (breath with whistling or rattling
sound in the chest)
• Cyanosis (bluish discoloration of arms and
legs, tongue, ears,
lips etc.)
• Grunting (noisy breathing) CYANOSIS

77. Cardiovascular •
Decreased level /loss of consciousness (fainting,
dizziness)
• Low blood pressure ( measured hypotension)
• Tachycardia (increased heart rate, palpitation)
Dermatological or mucosal
• Generalized urticaria (raised red skin lesion,
rash with itching)
• Generalized erythema (redness of skin)
• Local or generalized Angioedema- itchy/ painful
swelling of
subcutaneous tissues such as upper eyelids, lips,
tongue, face
etc.
• Generalized pruritus (itching) with skin rash
URTICARIA
ANGIOEDEMA

78. Steps for administration of injection Adrenaline by
ANM
• Take one ampoule of adrenaline (1:1000) solution from
the Anaphylaxis Kit and check name, dilution and
expiry date on label of vial (not from kit label).
• Take a 1 ml syringe and 24/25 G needle of length 1
inch and load the required dose of adrenaline as per the
age of the patient. [Table ]
• Adrenaline ampoules are also labelled as Epinephrine.
Epinephrine is another name for adrenaline.

79. • Use alcohol swab to clean the middle 1/3rd of
anterolateral aspect of the thigh of the opposite
limb to that in which vaccine is given.
• Hold the muscle mass on the anterolateral aspect
of thigh with hands, stretch the skin (do not bunch)
with fingers.
• Give deep intramuscular injection at 90 degree
angle to skin in middle 1/3rd of anterolateral aspect
of thigh.

80. Table : Age specific dosing chart of adrenaline (1:1000) for
management of anaphylaxis

82. Immunization Coverage
62.2
71.6
51.7
65.1
53.6
62.8
42.2
50.7
35.5
42
0
10
20
30
40
50
60
70
80
Percentage
BCG DPT 3
doses
OPV 3
doses
Measles All
Vaccines
NFHS I
NFHS II

83. Immunization Coverage
71.6
78.2
55.1 55.3
62.8
78.2
50.7
58.8
42 43.5
0
10
20
30
40
50
60
70
80
Percentage
BCG DPT 3
doses
OPV 3
doses
Measles All
Vaccines
NFHS II
NFHS III

84. CONCLUSION
Immunization is the second best cost effective public health
intervention.
It is important to remember the national immunization schedule
As well as exception associated with it.
Maintenance of cold chain is essential to produce desired
immunity
Each one of us must practice immunization for the benefit of the
community and country.
6/19/2019 85harichop@gmail.com

85. MCQ
Q1-Which of the following statements regarding
live vaccine is false-
(a) two live vaccine cannot be given
simultaneously.
(b) Booster doses are not required when live
vaccines are administered.
(c) single dose gives life long immunity.
(d) live vaccine contain both major and minor
antigen.
Ans -a

86. Q2- Most heat sensitive vaccine is –
( a)- BCG
(b)- Polio
(c)- Measles
(d)-DPT.
Ans - b

87.  Q 3- the efficacy of cold chain system for oral polio vaccine as
monitored byVVM depends on-
(a) change in color of vaccine.
(b) temperature indicator of the system
(c)Viral potency test.
(d) change in color of monitor.
Ans - d

88.  Q 4-Which is true about BCG-
(a)- Distilled water is used as diluent.
(b)- site of injection is cleaned with spirit.
(c)- mantoux test positive in 6 weeks
(d)WHO recommends Danish 1331 for vaccine production.
ANS- D

89.  Q5- In national immunisation programme, total number of
OPV dose is-
 (a)-3 (b)-4
 (c)- 5 (d)-6
Ans - c