immunization dr. deoki nandan (nihfw)

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. %Infants (0-1 year)reached
120
100
100
86.9
80 69.6 66.2 63.6
60 54.1
40
20 11.3
0
immunize
Target infants
DPT-3
BCG
immunization
Measles
OPV
Fully
No
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 DPT booster, OPV – Booster, MCV (Measles Containing
months 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, 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

17. Why have the Cold Chain?
If vaccines are exposed to excessive
Heat Cold
Light
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
• BCG (after reconstitution) MOST SENSITIVE
• 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
1 Prepare Ice-Packs for Freezing 2
Condition Frozen Ice-Packs
Fill the Ice-Pack with water to mark. Check
water level before every use. Do NOT add Place frozen Ice-Packs in the open till they
salt to this water. “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
Unconditioned Ice-Packs may damage freeze
Wipe the Ice-Pack dry and place in the sensitive vaccines (DPT, DT,TT and Hepatitis B)
Deep Freezer
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
Diluent
Diluent Hep B Hep B Hep BHep B Hep B
DPT DPT DPT Arrange vaccines
DPT DPT DPT
Diluent DPT
Diluent
DPT Hep B Hep B in order (top to
DPT DPT
DPT DT bottom)
DPT DTT DT DT DT Hep B
DPT DPT DPT TT
DT TT DT DPT, DT, TT
Measles Measles Measles
Measles TT
BCG TT TT TT
Measles
TT TT TT BCG
BCG
Measles Measles Diluent Measles
Diluent MeaslesDiluent
Measles BCG BCGBCG BCG
BCG
Measles
OPV
OPV OPV OPV OPV
OPV OPV OPV
Follow Early Expiry
First Out (EEFO)
Store diluents
in baskets, for Keep space
24 hours between
before next boxes
session Discard any
frozen Hep
B, DPT, TT
and DT

25. Freezing Ice-packs in the Deep Freezer
Never store
UIP vaccines
in the DF. Small compartment
Use only for Arrange and store
freezing frozen icepacks
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 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

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 (>3 hrs) inconsolable crying, seizures,
hypotonic hypo-responsive episode,
anaphylaxis/shock
Japanese Serious allergic reaction, neurological event
Encephalitis

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 • Multi dose vaccines cheaper
more costly • Reduced per dose cold
• Per dose cold chain space chain space required
occupied is more • Wastage is more if number
• Less wastage of doses if of beneficiaries are less
number of beneficiaries are • More chances of AEFI
less (cluster) occurring due to
• Lesser chance of AEFIs incorrect handling
occurring due to incorrect • Less generation of
handling immunization waste
• More immunization waste
generation

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 GOI’s 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 GOI’s
Immunization Schedule)
• Revaccination every 3-4 years

44. 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

45. THANK YOU