CARE Booklet C

Published on January 2017 | Categories: Documents | Downloads: 40 | Comments: 0 | Views: 165
of 20
Download PDF   Embed   Report

Comments

Content

C. Immunization and Vaccine Preventable Diseases

1

UNICEF/Pirazzi

THE PROBLEM: A SIGNIFICANT PROPORTIONS OF DEATHS AMONG CHILDREN, LESS THAN FIVE YEARS OF AGE, ARE FROM VACCINE PREVENTABLE DISEASES

The Need for Immunization
Of global deaths among children, less than five years of age, a significant proportions die of vaccine preventable diseases. These include 770,000 deaths due to measles and 200,000 deaths due to neonatal tetanus. Many of these children are already otherwise compromised by malnutrition or other infectious diseases. In a country like India, by vaccinating 1000 infants we can prevent about 30 deaths from measles, 10 deaths from whooping cough, and five cases of lifelong disability from polio. Vaccinating 1000 women with tetanus toxoid (TT) prevents five deaths from neonatal tetanus. Immunization is one of the most costeffective public health interventions available. Yet, a large proportion of vulnerable infants and children in India are not receiving this simple intervention. Across India in 1998-99,

only 42% of children 12-23 months had received all six of their primary vaccines, with a wide variation among states. States with poorer immunization rates generally have higher child mortality rates (Figure 1). A successful immunization program is an indication of a strong and functioning public health system. The low immunization rates in India are a cause of great concern.

Why are we not achieving higher immunization coverage rates?
There are several reasons that have been put forward for poor immunization rates, both globally and in the Indian context. According to the Ministry of Health and Family Welfare, Government of India, the main reasons for the low immunization rates and poor vaccine effectiveness as identified by the National Family Health Survey 1998-99

FIGURE 1 Childhood Mortality and Immunization in Selected States 160 140 Vaccine Coverage % 120
Uttar Pradesh Madhya Pradesh

Under 5 Mortality Rate/1000 Births

100
Rajasthan

Orissa

Bihar

40 20 0

Vaccine coverage %
Source: National Family Health Survey 1998-99

U5MR

2

West Bengal

India

60

Andhra Pradesh

80

(NFHS-II) and the qualitative surveys are the following:* • Inadequate delivery of health services (supply shortages, vacant staff positions, lack of training) • • • • • • Poor maintenance of the cold chain Inadequate supervision and monitoring of the program Weak surveillance for all vaccinepreventable diseases except polio Injection safety not assured No provision made for medical waste disposal General lack of inter-sectoral coordination, resulting in missing opportunities to improve immunization coverage and quality • Date, place, and time of immunization sessions varied, making it difficult for parents to access services • Inadequate technical capacities among service providers, such as a lack of clarity on proper methods of reconstitution of vaccines, and the administration of intradermal injections • Complacency, for several reasons such as the belief that since some disease are not common they are not important, or a mistaken belief that measles is common and therefore not a dangerous disease • • Lack of support for ANMs from other staff at the health centers. Lack of updated information, education and communication(IEC) materials.

•

Parental non-acceptance of immunization due to various reasons: o Lack of information/ awareness of day/time/place of immunization sessions o Lack of awareness of the importance of/need for immunization o o o No one available to take a child to the sessions Lack of faith in immunization Doctors advising against immunization in some cases

A. The Immunological basis of Immunization
Basis of Immunization
Immunization is based on the principle that if the body is exposed in a controlled manner to infective agents, it develops the capacity to fight infections in future. This ability is the immunity status of the body against specific infection, and functions on the inherent ability of the body to recognise, fight and memorise its actions against an infective agent.

It is clear from the above list that the problem lies at various levels in the system, including planning, training, implementation and monitoring of the program. Some of these relate to inadequate resources; some to inadequate use of available resources; either due to poor knowledge and training or due to inadequate management systems. This section will attempt to fill the information gaps and to provide a rational basis for strengthening the operational aspects of the program.

How does a vaccine protect an individual child?
A vaccine contains an antigen, such as a bacteria or virus or part of the organism that is capable of provoking an immune response in the body. Upon administering the vaccine, there is an immune response in the body similar to that of the original microbe. The vaccine however, does not cause the disease, and the immune response to the antigen protects the body from any invasion by such a microbe in the future.

* Introduction of Hepatitis B Vaccine in the Universal Immunization Programme: A Handbook for Programme Managers and Medical Officers. Child Health Division, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India; July 2002.

Source: Immunization in Practice. WHO/EPI/ TRAM/98.12

A child being given an intramascular injection.

3

Infection: What is it?

We live in an environment full of millions of kinds of microorganisms — germs that are too small to see with the naked eye. These microorganisms are of different types — viruses, bacteria, fungi, single-celled parasites and a few others. Some of them live on and in us, coexisting happily on our skin, and in our mouths, noses, intestines and other surfaces. Most of them do not harm us in the normal course of life. Sometimes, however, we become unwell because one or another microorganism, capable of causing harm gets into the body. We say that the person has been infected by the microorganism. The manifestations of the infection, such as fever or pain or swelling are symptoms that tell us that the person has a disease. Some examples of common infections are: • • • • Caused by viruses, such as common cold, measles, hepatitis, rabies, AIDS Caused by bacteria, such as abscess, cholera, typhoid, tuberculosis, whooping cough Caused by fungi, such as candidiasis (or thrush), ringworm Caused by single-celled parasites, such as malaria, amebiasis

Immunity: Our defence against infections

Every animal, including human beings, have a natural defence against infections, without which survival would be impossible. This natural defence comes from a system in the bodies of animals called the immune system. “Immunity” is the protection that the immune system provides us. The immune system: The immune system consists of various kinds of cells, including mostly white blood cells. The basis for immunity is the ability of some of the cells of the immune system to recognize any other cells or parts of cells that they come in contact with as “self” or “not-self” — as “part of my own body” or “something foreign”, and the ability of the immune system to capture and destroy what is foreign, while leaving alone what belongs to the body. The Antigen: Identification markers that enable immune cells to say whether a substance is its own or foreign, are molecules, usually made of protein, that are present on the surface of (or sometimes inside) every cell. The shapes of these molecules are unique for every organism, and the immune cells can recognize shapes that are different from those of similar molecules on the body’s own cells. Molecules that are recognized by the immune system as foreign are called “antigens”. Antibodies: Once an antigen is recognized as foreign, the immune system begins a process of capturing, isolating and destroying the foreign material. For doing this, it may use other molecules that combine with the antigen and make it easy to destroy. These molecules produced by the immune system (to match in shape with part of the foreign molecule, much like a key fitting into a lock) are called “antibodies”. At the same time, the immune system may also produce special cells capable of capturing and destroying that particular antigen. For some infections, the antibodies produced are the main defence (such as against measles), and in the case of other infections, the special cells are the main defence (such as against tuberculosis). Immunity is specific: Since antigenic molecules are usually unique to a particular organism, the antibodies and cells that the immune system produces are helpful against only that organism. Usually, the immune system is able to memorize the characteristics of the antigen, and respond very rapidly when the same antigen enters the body at a later date. This is why we generally do not get second attacks of some of the infectious diseases, such as measles or tuberculosis. In some cases, the body produces large amounts of antibodies that last a long time, and in other cases, just remembers the antigen and produces cells or antibodies only when the antigen enters the body again. As a child gets older, she gets exposed to more and more organisms in the environment, and her immune system learns to recognize and destroy each of them. This is why children suffer so many common infections when young, but later become immune to the same infections. We use this ability of the immune system to recognize and destroy an antigen to protect ourselves against certain infections with the use of vaccines. A vaccine contains antigens of a particular organism and provokes the immune system to recognize, remember and produce antibodies and cells that can destroy that antigen, if and when the organism enters the body at a later date. Types of immune response: When the immune system learns to recognize and respond to an antigen, we call it active immunity; when readymade antibodies are injected from outside, such as for the treatment of diphtheria or tetanus, we call it passive immunity. Another example is the way a newborn baby is born with a number of different kinds of antibodies acquired from the mother from across the placenta, or the way it later gets antibodies from the breast milk of the mother. While active immunity is the ability to remember an antigen for a long time, passive administered antibodies have a short life span of a few weeks or months, since they themselves are destroyed over a period of time. Abberations of the immune sytem: The immune system is not perfect, however, and immunity acquired may be partial (such as against malaria). In some cases, the immune system may itself be the target of the infection, such as in the case of the Human Immunodeficiency Virus (HIV) that causes AIDS. Here, the body’s ability to fight other infections becomes badly affected, and the person gets infected by organisms that normally would not be able to cause disease.

4

Types of Vaccines
• Live attenuated vaccines are derived from disease-causing viruses or bacteria that have been weakened under laboratory conditions. They will grow in vaccinated individuals, but because they are weak, they will cause either no disease or only a mild form. Examples: BCG, OPV, Measles vaccines. Inactivated vaccines are produced by growing virus or bacteria and then inactivating them with heat or chemicals. Because they are not alive, they cannot grow in a vaccinated individual. Inactivated vaccines may be whole-cell or part of a cell, or they can be an inactivated toxin (toxoid). Examples: Inactivated Polio vaccine (IPV), DPT vaccine.

•

Both types of vaccines are difficult to “purify” completely, that is, to ensure that they contain only those antigens that are completely safe and effective. Vaccines that are not pure tend to produce more undesirable effects, which are difficult to predict. In order to make vaccines safer, it is desirable to include only that antigen which is needed. This can be achieved using recombinant DNA technology, where DNA molecules from unrelated cells are used to produce the specific antigenic protein. Such vaccines are called recombinant vaccines. Hepatitis B vaccine is an example of a recombinant vaccine. It is possible that in the future, most vaccines will be recombinant vaccines, and the existing live and inactivated vaccines will be phased out.

How does an immunization program protect a whole community?
Many infections pass from person to person, either by direct contact or through breathing in organisms breathed or coughed out by an infected individual. This chain of infection can continue as long as there are non-immune, vulnerable individuals in the community to catch and pass on the infection. When a few individuals are vaccinated, they are protected from the infection, while the non-immune individuals continue to catch and pass on the infection among themselves. As more and more individuals are vaccinated, it is possible to reach a stage where the remaining non-immune individuals are also protected, as long as there are enough immune individuals in the chain of infection between the person who brings in the disease into the community and the non-immune individuals in the community. While this does not provide perfect individual protection (since the nonimmune may at times chance to come in contact with a diseased person), it is

rare to see epidemics in communities where a large proportion of individuals are immunized. This phenomenon is called herd immunity, just as a herd of animals provides protection to weak individuals within. Herd immunity works best where close contact is necessary for transmission of the infection, such as in measles. It does not work where all individuals are equally exposed to a common source of infection, such as an epidemic of typhoid or hepatitis from a contaminated drinking water source.

It also does not work where the transmission of infection does not involve another case, such as tetanus.

Variance of the Schedule
Women who have received three doses of DPT during childhood or additional doses of tetanus toxoid-containing vaccine during their school years do not need all five doses of tetanus toxoid (TT) in adulthood for protection. They must retain their vaccination cards for health workers to determine the number of additional doses they need.
Continued on page 9...

TABLE 1 Vaccines Used in Immunization Programs in Developing Countries
Vaccine BCG OPV Diphtheria Pertussis Tetanus Measles Type Live attenuated bacteria Live attenuated viruses Toxoid Killed bacteria Toxoid Live attenuated viruses Supplied As A dry powder in a glass vial, reconstituted in normal saline (the supplied diluent) before use* A liquid form in a plastic dropper bottle DPT/DT, a liquid in an injection vial DPT, a liquid in an injection vial DPT/DT/TT, a liquid in an injection vial Dry powder in a glass vial, reconstituted in double distilled water (the supplied diluent) before use*

DPT: A mix of toxoid of Diphtheria, Pertussis bacteria and toxoid of Tetanus DT: Diphtheria and Tetanus toxoids TT: Tetanus toxoid OPV: Oral Polio Virus *The diluents for BCG and measles are not interchangeable

5

The Vaccine Preventable Diseases
Vaccines are available against a number of diseases, but as per the national immunization schedule, six diseases have been identified as the ones which are vaccine preventable and as the ones which contribute significantly to infant mortality and morbidity. The diseases are tuberculosis, diphtheria, pertussis (whopping cough), tetanus, poliomyelitis (polio) and measles.

Features of Vaccine Preventable Diseases Tuberculosis (TB)
disease and gives them some protection against recurrence at a later age. BCG does not prevent TB itself and provides little protection against the pulmonary forms. It is not recommended for adults. Prevention: The most effective way is through immunization of children in their first year of life with three doses of diphtheria toxoid (available in the form DPT), which provides over 95% protection against diphtheria for at least 10 years.

Diphtheria Pertussis (Whooping Cough)

A bacterial illness causing chronic disease that affects people of all ages, it is one of the most important public health problems worldwide. TB usually attacks the lungs, but almost every organ of the body can be affected, including the bones, joints, and brain. Case Definition*: A patient in whom TB has been bacteriologically confirmed, or has been diagnosed by a clinician. Transmission: Spread through the air when an infected person coughs, spits, or sneezes. Spreads rapidly where people live in crowded situations, are poorly nourished, and cannot obtain treatment. Morbidity and Mortality: Nearly two million people die from TB each year. Nearly 1% of the world’s population is newly infected with TB each year. Prevention: BCG vaccine protects infants with TB from progressing to a more dangerous form of the Morbidity and Mortality: In 1999, according to the World Health Organization (WHO), approximately 5,000 cases of diphtheria were reported worldwide. Between 5% and 10% of patients die, even with treatment. Morbidity and Mortality: Eight percent or more of unprotected children get pertussis, and 1% percent of those who get the disease Transmission: Spreads easily through the air by droplets (from sneezing and coughing) and secretions from the nose, throat, and eyes of an infected individual. Transmission: Spread by droplets from the nose and throat of an infected person; spreads easily among susceptible people who live in crowded conditions. Case definition*: An illness characterized by laryngitis or pharyngitis or tonsillitis and the presence of adherent membrane of the tonsils, pharynx and/or nose. • A bacterial infection, mainly of the upper respiratory tract, where the major symptoms are produced by a toxin released by the organism. Case Definition*: A person with cough lasting at least two weeks with at least one of the following: • • Fits of coughing Intake of breath accompanied by a whooping sound Vomiting immediately after coughing and without any other apparent cause. A bacterial infection of the lower respiratory tract.

6

die. It causes an estimated 300,000 deaths per year. Newborns get very little protective antibodies from the mother, and even very young infants can get infected. A third of all cases are less than 6 months old, and half of all deaths from pertussis are infant deaths. Prevention: The most effective way is to immunize children with three doses of DPT within the first year of life. Immunization against pertussis is not fully protective in all children, but helps reduce severity of the disease, and thus to prevent malnutrition. It also helps prevent epidemics by inducing herd immunity. Antibiotics may be given to shorten the period of communicability.

stiff or has spasms (i.e. jerking of the muscles), or both. Transmission: Organism enters the body of a newborn by the traditional practice of applying dung, mud, dirt, plant powders or ash on the umbilical cord stump or when unclean instruments are used for cutting the umbilical cord. It is not spread from person to person.

Case Definition*: Any child under fifteen years of age with acute flaccid paralysis (AFP) or any person with paralytic illness at any age when polio is suspected. Transmission: Highly communicable, transmitted through person to person contact with infected feces or secretions from nose and mouth. Morbidity and Mortality: All non-

Morbidity and Mortality: Every year, 200,000 infants die from tetanus in their first month of life. The case fatality is approximately 80%. Only 5% of cases are reported. Prevention: Elimination of neonatal tetanus (reducing incidence to less than 1 case per 1000 live births). • Giving 3 doses of tetanus toxoid (TT) to at least 80% of all women of childbearing age at the highest risk, preferably to all women. • Health education and promotion of clean delivery practices focusing on the “five cleans”: clean hands, clean delivery surface, clean thread and clean blade to tie and cut the umbilical cord, and a clean cord, to which nothing is applied.

vaccinated individuals will acquire the infection if the virus is in the environment. • 95% infections are silent (show no effect), 4% have mild flu-like illness. • 1% become paralyzed or lame, 0.5% will be lame for life. • 0.1% will die during the acute phase. There has been a 99% decrease in the number of confirmed polio cases due to the worldwide Polio Eradication Initiative (PEI). Wild poliovirus is only present in 7 countries, of which three nations (India, Nigeria and Pakistan) account for 99% of cases. Prevention: Polio Eradication Strategies • Routine immunization — all countries should immunize at least 90% of infants in the first year of life with four doses of Oral Polio Vaccine (OPV). This should continue regardless of other immunization drives. • Supplementary immunization — through national immunization days (NIDs) all children less than five years of age should receive OPV, regardless of their previous immunization status.

Tetanus

A bacterial illness usually following contamination of wounds by soil or feces, where the damage is done by a toxin released by the organism. While any unimmunized child can be infected, the commonest incidence in developing countries is in the neonatal period following unsafe childbirth. Case Definition of neonatal tetanus*: Any neonate with a normal ability to suck and cry during the first two days of life, and who, between three and 28 days of age, cannot suck normally and becomes A viral illness, introduced through the gastrointestinal tract, affecting mainly the central nervous system.

Poliomyelitis (Polio)

• Acute flaccid paralysis surveillance and laboratory investigation — to ensure that

7

all cases are detected and to investigate stool samples for identification of wild poliovirus. • Campaign approach — to eradicate polio the system of all or non is followed. It is based on the fact that if all children are immunized together at the same point the replacement of the wild virus by vaccine virus will take place simultaneously leaving no point source of remaining wild virus. The campaign approach is done through: o o National immunization days Mop-up campaign. Mop up rounds in areas that have reported polio cases or for difficult to reach children in areas where wild polio virus transmission is occurring.

Rapidly transmitted in large families, crowded homes, urban areas and schools. Morbidity and Mortality: Kills an estimated 770,000 children each year. The high risk of death is related to young age, crowding, malnutrition, pneumonia, acute and chronic diarrhea, dysentery, blindness due to concurrent vitamin A deficiency, and lowered resistance to other infections, including TB. The risk of death is very high in large epidemics, and these are common where immunization coverage is low. Infection with measles depresses the immune system, depletes the body’s store of vitamin A, and leaves children susceptible to diseases like pneumonia and diarrhea. Prolonged and severe illness can lead to severe malnutrition.

Transmission: Child-to-child transmission through open wounds or shared implements that contain blood or body fluids, accounts for the majority of infections world wide. Exposure of babies to maternal blood or other fluids during delivery if she is a carrier, use of contaminated needles and syringes for injections and transfusions and transmission through sexual activity are other methods. Prevention: Hepatitis B vaccine is due to be phased in under the GAVI initiative. WHO recommends that hepatitis B vaccine be offered to all children under one year of age in all countries. Hepatitis B vaccine is usually given as a 3-dose series, with each dose at least 4 weeks apart.

Hepatitis B is currently not on the Prevention: Measles vaccination is primary immunization schedule in India, but is being introduced in a phased manner. one of the most effective preventive measures available. All children should be immunized with a dose of measles vaccine within first year of life. Maternal anti-measles antibodies, passed while in the womb, provide immunity to infants against measles infection until they are at least 6 months of age. With the mother’s antibody still present, the vaccine virus may be unable to multiply to produce enough

Measles

A viral illness, mainly of the respiratory tract. Case Definition*: Any person in whom a clinician suspects measles infection, or any person with fever and maculopapular rash and cough, runny nose or conjunctivitis (i.e. red eyes). Transmission: Extremely infectious, transmitted by respiratory droplets expelled by infected individuals.

antibodies in the system, leaving the child still susceptible. The recommended age for measles vaccination in developing countries is therefore nine months.

* Case definitions given here are the WHO clinical case definitions used by public health systems to monitor the occurrence of these diseases. The definitions are broad, allowing all likely cases to be accounted for or suspected. Many cases suspected on the basis of these definitions will turn out to be some other disease when examined and tested individually. These are not necessarily criteria used by doctors to definitively diagnose and treat individual patients.

Hepatitis B
Hepatitis B is a viral infection of the liver. If not fatal, acute infection either resolves or progresses to chronic infection, which may lead to cirrhosis or liver cancer several decades later.

8

TABLE 2: Immunization Schedule for Children Followed in India
Age Birth Vaccine BCG OPV0 6 weeks DPT1 OPV1 10 weeks DPT2* OPV2* 14 weeks DPT3* OPV3* 9 months Measles Vit A 18-24 months DPT OPV 5 years DT Dose 0.05 ml 2 drops 0.5 ml 2 drops 0.5 ml 2 drops 0.5 ml 2 drops 0.5 ml 100000 IU 0.5 ml 2 drops 0.5 ml Route Intra-dermal (within skin) Oral Intra-muscular (in the muscle) Oral Intra-muscular (in the muscle) Oral Intra-muscular (in the muscle) Oral Sub-cutaneous (under the skin) Oral Intra-muscular (in the muscle) Oral Intra-muscular (in the muscle) Site Left upper arm Mouth Outer part of mid-thigh Mouth Outer part of mid-thigh Mouth Outer part of mid-thigh Mouth Outer part of mid-thigh Mouth Outer part of mid-thigh Mouth Outer part of mid-thigh

Source: Adapted from Handbook for Vaccine Administrators, Child Health Division, MoHFW, GOI * The minimal interval between doses should be 28 days (4 weeks).

TABLE 3 Tetanus Toxoid Immunization Schedule (Women of Child Bearing Age)
Dose TT1 TT2 TT3 TT4 TT5 When to give As early as possible in pregnancy, or at first contact when a girl reaches childbearing age At least 4 weeks after TT1 At least six months after TT2 or in next pregnancy At least one year after TT3 or in next pregnancy At least one year after TT4 or in next pregnancy Expected Duration of Protection None One to three years Five years 10 years All child bearing years

Are vaccines safe? Does immunization produce any adverse effects?
Vaccines for childhood diseases are very safe — serious adverse effects are extremely rare. However, adverse events following immunization can occur even in the safest of programs. There is an active surveillance program monitoring adverse effects of vaccines. Childhood infectious diseases are a far

Source: WHO Continued from page 5...

vaccine on the same visit. Similarly, it is important that pregnant women be given TT immunization whenever they present for a health visit, regardless of trimester. The vaccination schedule should not be restarted from the beginning even if the interval between doses has exceeded the recommended interval by months or years.
9

greater health risk to children than adverse effects of vaccines. Causes of adverse events are classified under the following categories: 1. Program error: An error in vaccine preparation, handling or administration such as injecting in the wrong place, using unsterile equipment or giving the wrong vaccine.

It is safe and effective to administer all EPI vaccines on the same day at different sites of the body. It is also a health priority for the individual child and the community, for health services to maximize opportunistic immunization. A previously unimmunized child presenting at 9 months of age, would therefore receive BCG, DPT, OPV and measles

2.

Vaccine reaction: The reaction of a particular individual to the properties of the vaccine. These can be: a) Local reactions such as pain, swelling at the site of the injection; b) Systemic or generalized reactions such as fever, headache, loss of appetite; or c) Allergic reactions which are the most serious and most rare reactions.
DPT OPV Vaccine BCG

TABLE 4: Vaccines and their Adverse Effects
Normal reaction After injection a small raised lump appears which disappears in 30 minutes. It is followed by a small red sore in 2 weeks, which heals in the next few weeks leaving a small scar None Adverse effects1 Swelling of the glands in the armpit or near the neck, or a sterile abscess2

No common side effect. Vaccine associated paralysis occurs very rarely — in approximately 1 in 2400000 doses administered Local swelling and pain4 Rarely, high fever and prolonged crying. Very rarely neurological complications, including convulsions 5 Mild fever and rash lasting for 2-3 days appear a week after immunization in 10-15% of vaccinated children

— Mild fever3 — Soreness

3.

Coincidental: The adverse event occurs after immunization has been given but is not caused by the vaccine or its administration.
Measles None

4.

Unknown: The adverse event cannot be directly related to the vaccine, its administration, or any identifiable cause.

Table 4 alongside lists the adverse effects of vaccines.

In addition to the mentioned adverse effects, any injection given with an unsterile syringe or needle can cause a local infection, including an abscess. Similarly, any vaccine (just as any medicine or even food item) can in rare cases cause severe allergic reactions. 2 This is either due to an excess dose or because it is injected subcutaneously and not intra-dermally 3 Fever beginning after 24 hours is unlikely to be due to vaccination 4 This may be because the vaccine was not injected into the muscle, or due to the use of frozen vaccine. 5 This is due to the whole-cell pertussis component in the currently used vaccine. Acellular vaccine has far milder side effects, but the vaccine is expensive.

1

TABLE 5: Common Mistakes in the Immunization Program
Health Worker Practice Screening: Lack of proper screening of children and women for immunization status Possible improvements Improve screening. Check children’s and woman’s immunization status every time a client visits a health facility or outreach site, regardless of the reason for the visit. Encourage mothers to bring immunization cards every time they visit a health facility. This will help determine eligibility for immunization and avoid missed opportunities. Train vaccinators to give all vaccines due at the time of client’s visit. For example, a nine-month old child may be given DPT and OPV and measles vaccine. Vaccines are as safe and effective in combination as they are individually Eliminate false contraindication. Children with low-grade fever, a cold, diarrhea, vomiting, or other mild illness can safely be vaccinated. Prematurity, LBW, and breast-feeding are not reasons to withhold immunization. Malnourished children must be immunized because they are much more likely to die from a vaccine preventable disease.* Clarify policy on multi-dose vials. Governments (central or state) need to set out policies on when to open multi-dose vials and when to continue using them on following days.

False beliefs: Sometimes, there is a belief on the part of health workers or parents that giving too many vaccines at once will harm a child. Some health workers mistakenly delay the measles immunization because they believe that it must be the last immunization given to the child False contraindication: Both health workers and parents may hesitate to immunize a sick child, though there are few true contraindications to immunization.

Multi-dose vials: Health workers often hesitate before opening vaccine for one or a few clients for fear of running out of vaccines before the next delivery.

* It is only ethical that severely malnourished or sick children contacted during an immunization session be referred and/or treated appropriately.

10

Immunization in the Presence of HIV
Children with HIV infection have compromised or weakened immune systems. Live attenuated vaccines are a risk because the vaccines can cause a form of the disease. Children with weakened immune systems may not be able to fight off even a mild infection. The disease that the vaccine is intended to prevent may be very severe in HIV-infected children. The risk of the disease must be balanced against the risk of the effects of the vaccine. In addition, most infants and children with HIV do not show symptoms, so it is difficult to know if they should be excluded from a particular vaccine injection. Taking these factors into account, the WHO recommends the following with respect to the vaccines that present the greatest threat to HIV-infected children: BCG: Should be given to all infants, even if their mothers have HIV, unless the infant shows HIV/AIDS symptoms, which is highly unlikely. This practice will protect HIV-positive and negative children who are at high risk of exposure to tuberculosis because their mothers are HIV-infected, and so are likely to have tuberculosis as well. OPV: Children without HIV/AIDS symptoms should be immunized with OPV according to standard schedules. Measles: As measles infection can be very severe in HIV-infected children, an early dose at six months is recommended, followed by the scheduled dose at nine months for those who are known to be infected with HIV. The overall risk of adverse events from the vaccine is relatively low compared with the risk of measles infection in HIV-infected children. Children should not be screened for HIV antibody status before receiving measles vaccine.

Note: These are current recommendations at the time of preparing this guide and may be subject to change.

Reconstitution of vaccine
Use a sterile syringe and needle to remove diluent from its ampoule to reconstitute freeze-dried vaccine. Always use the diluent provided by the manufacturer for that same vaccine for reconstitution, and maintain at a temperature of +20 to +80 C. Take the whole amount of diluent for reconstitution. Once reconstituted, wrap the vaccine vial in the foam pad from a vaccine carrier, in paper, or in foil to protect it from direct sunlight. Keep the wrapped vials on ice. Appropriately dispose reconstituted vaccines (i.e. vaccines should not be preserved for re-use, 6 hours after reconstitution).

Injection Sites for immunizations
Subcutaneous Intramucular

Intradermal

Dermis (skin) Subcutaneous layer Muscle

Delivery of vaccines
All vaccines, except polio (OPV) which is delivered orally, are delivered by injection. For the delivery of the vaccine the site of the injection varies. • • • BCG vaccine for TB is given intradermally i.e. within the skin. DPT is given intramascularly i.e. within the muscle. Measles is given subcutaneously.

A combination of vaccines can be given together but only the site of the vaccine and the needle and the syringe used should be different.

11

B. Operational Guidelines and their Basis: Improving Immunization Coverage and Quality I Improving Immunization Coverage
What approaches improve the use of immunization services?
1. Reaching the unreached by: Ensuring no one is left out: It should be possible to account for every family and child in the catchment area of a program, especially where preventive health services are universally available without a fee. This has been achieved in programs through meticulous periodic surveys and the use of area maps owned by communities (social maps). Improved scheduling: Immunization sessions should be scheduled to be convenient for parents. Session schedules for any facility should be reviewed at least once in a year and changed (if necessary) to reflect the current needs of the community.

use individual volunteers (e.g. Change Agents) and community-based groups (e.g. Self Help Groups) to assist in this effort. Improving and expanding outreach: Outreach must be well planned, organized and supported. Vaccines, sterile syringes and needles, vaccine carriers, ice packs, and other supplies must be available in the right amount, in the right place, and at the right time. To maximize utilization of limited resources and to assure continuity of outreach services strategies must merge other services with immunization on a single fixed day at a fixed site known to the community in advance (e.g. Vitamin A supplementation, antenatal care and other health services). Targeting services to meet urban needs: Vaccination coverage is usually lower in high-risk urban areas. Reaching the unreached urban slum population is very important because: a. b. Population density increases the intensity of disease transmission Measles and pertussis often begin in cities and towns and then spread to rural areas c. The poor sanitation and poor nutrition found in densely populated slums increases their risk of severe illness.

2. Reducing Drop-Outs If a child does not receive all the doses required for full protection, the resources that have been used to partially vaccinate that child are mostly wasted. Program Mangers should regularly monitor the dropout rate of their area, find out causes and take measures to solve the problem. The causes may be related to vaccine and other essential supplies (e.g. vaccine stocks), or to communication and community awareness (e.g. unaware of the need to return), or some other obstacles (e.g. timing of the session). 3. Improving a community’s participation to receive primary immunization services People usually use immunization services if they know what services are offered and where and when they are available. Discuss immunization services with communities in each service delivery area. If people are not coming to sessions, or if too many people are attending, the days or times of the immunization sessions may need to change. Immunization sessions can be held conjointly with other health events such as fixed-service days to improve access. Families will return to receive immunization if they know when to come back, have been treated respectfully, and have confidence that they will receive the immunizations that they come for. Table 6, page 13 lists obstacles to routine immunization and potential solutions.

Raising awareness: Families need to know about the immunization services before they can use them. Local health workers play an important role in increasing community awareness and creating demand for services. They can

For outreach, when there is a shortage of staff, scheduling visits to individual villages every two months instead of every month permits health workers to reach twice as many villages, provided high coverage is achieved at each visit. The prolongation of the interval between two doses of DPT/OPV vaccines or delay in measles vaccine by a month in all villages under such circumstances is far less harmful than reaching only some of the villages regularly and the rest not at all or very infrequently.

12

TABLE 6: Obstacles to Routine Immunization and Potential Solutions
Obstacles to Immunization Lack of information Potential Solutions • • • • • • • • • • • • • • • • • • • Health education sessions Home visits by health workers Regularly updates and reconciliation of records/registers used by health workers Use of community volunteers Use of community based organizations Better planning of sessions Training of vaccinators Accurate ordering of vaccine and improvements in logistics Health education for parents Better session scheduling Better planning Health education Use of Community Based Organizations/ NGOs Use of Change Agents Health education Use of Community Based Organizations/ NGOs Use of Change Agents Planning immunization services to cover all families in the catchment area Better scheduling of sessions

Poor services

Time constraints Social, cultural or political barriers

Misinformation

Distance

II Improving the quality of immunization services
Cold Chain, Vaccine Storage and Supply
What is a Cold Chain? The equipment, people and procedures that keep the vaccines cold enough to remain viable during their journey from the site of manufacturing to the point of use is called a “cold chain”. Some vaccines are more sensitive to heat and light and some are more sensitive to cold. If a vaccine is exposed to too much heat, light, or cold, it can be damaged and lose its potency or effectiveness. See Tables 7 and 8 for details.
Vaccine BCG OPV Measles DPT Hepatitis B TT

TABLE 7: Vaccine Vulnerability
Exposure to heat/light Relatively heat stable but sensitive to light Sensitive to heat and light Sensitive to heat and light Relatively heat stable Relatively heat stable Relatively heat stable Exposure to cold Okay to freeze Okay to freeze Okay to freeze Freezes at -3°C Should not be frozen Freezes at - 0.5°C Should not be frozen Freezes at - 3°C Should not be frozen Temperature +2°C to +8°C +2°C to +8°C +2°C to +8°C +2°C to +8°C +2°C to +8°C +2°C to +8°C

What is Injection Safety?
A safe injection is defined by the WHO as one that: • • • Does not harm the recipient Does not expose the health care worker to any avoidable risk Does not result in waste that is dangerous to the community.
Continued on page 15...

Source: Handbook for Vaccine Administrators, Child Health Division, MoHFW, GOI If DPT, TT, DT and Hepatitis B vaccines are frozen they lose their potency and, therefore, should be discarded. The “Shake Test” can determine whether DPT, DT, TT or Hepatitis B vials have been frozen.

13

Shake Test

Take a vaccine vial of the same type, manufacturer and batch number as the vaccine vial you want to test. Freeze the vial for at least 10 hours at –10°C until the contents are solid, and then let it melt. This is the “control” sample and should be labeled as “frozen” to avoid its use for vaccination. Then take a vaccine vial from the batch that you suspect has been frozen. This is the “test” sample. Vigorously shake the control and test samples for 10 seconds, place both vials on a flat surface to rest, and continuously observe them over the following 30 minutes. View both vials against the light to compare the rate of sedimentation. If the test sample shows a much slower sedimentation rate than the control sample, the test sample has probably not frozen and may be used. However, if the sedimentation rate is higher and the test sample contains flakes, the test sample has probably been damaged by freezing and should be withdrawn from use. The health worker must notify the supervisor immediately to ensure that any other damaged vials are also identified and withdrawn from use.

Shake vials vigorously for 10 seconds and place them on a flat surface. Continuously observe their rate of sedimentation for 20 minutes.
Compare the deliberately frozen vial next to the suspect vial Deliberately Frozen Control Vial Suspect Test Vials USE THIS VACCINE

Almost Clear Thick Sediment

If the sendiments in the suspect vial settles more slowly, the suspect vaccine may be used

DO NOT USE THIS VACCINE

If the sendiments in the suspect vial settles at the same rate and contain flakes, the suspect vaccine may NOT be used

TABLE 8: Basic Features of Cold Chain Equipment
Equipment Ice Lined Refrigerator (ILR) 300 Liters ILR 140 Liters Place Regional Store & District H.Q. Temperature +2°C to +8°C Utilization BCG, DPT, TT, Hep-B vaccine Holdover time* At 43°C 62 hrs after 8 hrs continuous power supply At 43°C 62 hrs after 8 hrs continuous power supply 4 hours Storage capacity 60,000 doses (mixed antigen) & 20,000 doses of OPV 25,000 doses (mixed antigen) & 18,000 doses of OPV 150,000-200,000 doses Approximately 20 Ice Packs

PHC

+2°C to +8°C

BCG, DPT, TT, Hep-B vaccine

Deep Freezer 300 Liters Deep Freezer 140 Liters

Regional Store & District H.Q. PHC

-20°C

Preparation of ice packs, OPV & Measles vaccine Preparation of ice packs

-20°C

At 43°C 62 hrs after 8 hrs continuous power supply 5 days

Cold Box 20 Liters

State, Regional and District H.Q. District H.Q.& PHC

+2°C to +8°C

All vaccines can be stored for transportation or in case of power failure All vaccines can be stored for transportation or in case of power failure All vaccines can be carried in small quantity for vaccination sessions All vaccines can be carried in small quantity for vaccination sessions

52 Ice Packs & 6000 doses of mixed antigens 20 Ice Packs & 1500 doses of mixed antigens 4 Ice Packs &15-20 vials of mixed antigens 2 Ice Packs & 6-8 vials of mixed antigens

Cold Box 5 Liters

+2°C to +8°C

3 days

Vaccine Carrier (1.7 Liters)

Sub-center

+2°C to +8°C

24-36 hours

Day carrier (0.85 Liter)

Sub-center

+2°C to +8°C

6-8 hours

* Holdover time in case of power failure Source: Operations Guide for Program Managers, Child Health Division, MoHFW, GOI

14

BCG, OPV and Measles vaccines will lose their potency when exposed to too much heat or light. The damage of heat and light is cumulative and cannot be reversed by re-freezing the vaccine. It is important therefore to maintain the proper temperature for all vaccines when carrying them from the PHC to the immunization site.
What is a Vaccine Vial Monitor (VVM)?
A VVM is a small colored disk printed on a vial label or for freeze-dried vaccine placed on the vial cap. A square inside the disk darkens irreversibly when exposed to heat over time. By comparing the color of the inner square to that of the outer ring, users can determine the extent to which the vaccine inside has been exposed to heat. VVMs have been available on all vials of OPV. When health workers use VVMs correctly, they can: • Identify heat-damaged vaccine and discard it • Avoid unnecessarily discarding vaccine because of suspected heat exposure • Extend accessibility to vaccinations in remote areas beyond the reach of the cold chain • Monitor the amount of vaccine discarded due to excessive heat exposure • Identify cold chain problems

How to pack vaccines in the Vaccine Carrier
• Remove ice packs from the freezer and keep them outside for 15 minutes until they begin to “sweat”. This prevents accidental freezing of vaccines that may come in contact with the ice packs. Place ice packs into the vaccine carrier along the sides Place OPV and BCG vaccine inside the vaccine carrier near the ice packs along the walls Wrap DPT, DT, TT and Hepatitis B in thick paper and then place them in the vaccine carrier, away from the ice packs Close lid securely

• • •

•

Dos and Don’ts to maintain proper temperature of vaccine in the field
Dos
• • • • Keep the Vaccine Carrier in the shade Keep opened vials of Measles, OPV, and BCG on an ice pack Keep the lid of the Vaccine Carrier always closed during the session Keep the lid of the Vaccine Carrier on in transit • • • • • Don’ts Don’t leave the Vaccine Carrier in sunlight Don’t leave the lid open Don’t drop or sit on the Vaccine Carrier Don’t carry vaccine in handbags Don’t keep DPT, DT, TT, and Hepatitis B vaccines on the ice pack during the session

Continued from page 13...

Types of syringes and needles used for immunization Sterilizable (reusable) syringes and needles: These syringes are usually made of glass (or plastic) and the needles all-steel. After use, they should be immersed in an antiseptic solution, before being thoroughly rinsed and cleaned in water and sterilized in a steam sterilizer. After many rounds of use, reusable syringes and needles are also disposed off in the same manner as single-use ones.

reuse them without adequate sterilization. Since they cannot be properly sterilized, they are a potential public health hazard, and WHO recommends that they not be used by public health programs for immunization. Auto-disable (A-D) syringes: A presterilized and pre-packed syringe with a fixed needle and plastic cap, designed to get locked after a single use. These cannot be reused, and so are safer, but more expensive. Pre-filled, single dose, non-reusable devices: Similar to the A-D, but prefilled with vaccine, maintained in a cold chain, ready for use. The most expensive, and least appropriate for large immunization programs. See Table 10 on page 16.

In developing countries, 16 billion injections are given annually; of which 50% are unsafe causing dangerous health risks to recipients, health workers and the public. Why is injection safety important? The first rule of health care is “First do not harm”* . Unsafe injection practices can cause transmission of serious infections like HIV, hepatitis B and C. How can safe injection be ensured? There are different methods of ensuring safe injection practices, the most important of them are by changing the practices of health care providers. See Table 9 on page 16.
* A part of the Hippocratic oath that doctors are expected to take on graduation

Single use syringes and needles: Standard disposables: Plastic syringes with steel needles (often with plastic hubs) that are pre-sterilized and packed in a sealed package. These syringes have a potential for abuse, since unscrupulous practitioners may

15

TABLE 9: How Safe Injection Practices Can be Ensured
Methods Keep hands clean and the injection site clean Use sterile injection equipment every time Safe Practices • • • • • Wash hands before preparing injection materials Wash injection site with clean swabs and clean water Always use a sterile syringe and needle for each injection and during reconstitution If auto-disabled syringes are not available, sterilize equipment using steam sterilizer Document the quality of the sterilization process using time, steam, and temperature (TST) spot indicators Designate a clean area for preparation of injection Always prick the cap of the vial with a sterile needle and syringe Do not leave the needle in the cap of the vial Discard any needle that has touched any non-sterile surface Do not touch the needle while pushing it into the injection site Assume that all used equipment is contaminated with body fluid of any form Re-sterilize equipment before re-use Deposit used sharps (e.g. needles) in a safety box or a hard-board box or other puncture proof and leak proof containers Dispose safely/handle the box/container containing used sharps carefully Never re-cap a used syringe to avoid accidental needle-stick injury Place in a puncture and leak proof sharp container within reach of the vaccine administrator Put used syringes and needles in the sharp container immediately after giving an injection Seal the container when it is three-quarter full Seal the sharp container before carrying to the designated area for disposal Dispose off syringes and sharp waste, under close supervision of managers, in an efficient, safe, and environmentally friendly way to protect the community from intentional and accidental exposure to used injection equipment

Prevent contamination of vaccine and injection equipment

• • • • • • • • •

Sterilise equipment before re-use

Safe disposal of all sharps

Prevent needle stick injuries

• • • • • •

Prevent public access to used needles

Single-use syringes and needles generate a large volume of potentially dangerous waste, which is difficult to dispose of, particularly in developing country settings.

TABLE 10: When to use these syringes?
Single use syringes Appropriate for all immunization sessions but most useful during campaigns to avoid repeated sterilization of syringes and needles Safe for recipient of the vaccine Reusable syringes Used for routine immunization. Appropriate for fixed site immunization, but not for campaigns Safe when proper cleaning and sterilization can be ensured If not properly cleaned and sterilized can pose serious risk to the vaccine recipient Need replenishment only after certain period of time (may be used for an average of 50 sterilizations)

If not properly disposed can pose high risk to the population as they may be reused Use disposable syringes only where they can be safely disposed after use Auto-disposable (A-D) syringe

16

Safe Handling and Disposal of Sharps
To prevent needlesticks during transport or storage, sharps disposal containers should be: • Puncture proof and leak proof, • Labeled with a warning that can be understood by local people, and • Sealed so they remain closed when stacked Do not fill sharps disposal containers completely full When only three-quarters full, sharps disposal containers should be sealed and discarded to prevent needlesticks that occur when the lid is pushed down against an overly-full box, or when people must put their hands too close to the points of contaminated needles. Sharps disposal containers should be filled only once and discarded immediately to minimize risk of needlesticks by workers who empty them.

How are used syringes and needles disposed off?

Syringe safety box.

Safety Boxes: A safety box is a puncture proof sharp container where used syringes and needles are placed immediately after injection. If a safety box is not available, health workers may use an alternative puncture proof container, such as a pitcher or jug made of mud (burned) or plastic, which should not be re-used. After a session, the entire box can be
Filling sharps disposal containers more than three-quarters full may cause needlesticks.

Too Full Unsafe
Needle Disposal Needle Disposal

3/4 Full Safe

incinerated, or disinfected by burning and buried.

Transporting contaminated waste Transporting contaminated waste can expose others to disease and injury. Consider the following points when transporting waste: • Delays in the disposal of contaminated needles may increase the occurrence of accidents. Containers should be collected for incineration or other forms of destruction (burn and bury) as soon as possible at the end of the immunization session. • Contaminated needles should not be transferred from container to container. Disposal Methods for syringes and needles Incineration: Burning by heating to very high temperatures, this is considered the best method that reduces everything to ash. However, incinerators are expensive to establish and maintain, and are not generally available to public health programs in developing countries.
17

Incineration can completely destroy needles and syringes by burning at temperatures above 800 C. The high
0

How to Build an Infectious Waste Burial Pit
An infectious waste burial pit is easy to use and maintain, but there are some disadvantages. A pit of this size can be difficult to dig if the ground is hard, and waste pits are not appropriate where heavy rains or floods are
5m

temperatures kill microorganisms and reduce the volume of waste to a minimum. Properly functioning incinerators ensure the most complete destruction of syringes and needles, and produce less air pollution than burning at lower temperatures. Some hospitals have on-site incineration, while others use incinerators at other facilities, such as cement factories.

common or where the water table is near the surface. And unlike incineration or burning, burying safety boxes in a pit does not reduce the volume of waste. However, if a burial pit is the best solution for your situation, this is the best way to construct the pit:

2m

Materials needed for construction • • • Tools (shovels, pickaxe) Concrete or corrugated on rings. Cement or nuts and bolts.

Building the pit (this pit has a capacity of 20 m3) •
Source: MOH, Cambodia

Select a proper site for the pit — — Do not dig the pit close to water sources such as wells or spring water. The ground should be of low permeability. Insert rings if necessary to reinforce the hole. A fence should be put round the burial pit to avoid accidents and unauthorized access by humans or scavengers.

•

Dig a hole approximately 2 m x 2 m x 5 m — —

Incinerator — different incinerators work in different ways.

• •

The walls should have a negative slope (narrow at the top, wider at the bottom). Line the bottom of the pit with a material of low permeability, such as clay.

Burying after disinfection: Less desirable, but more practical, the used instruments are first disinfected by burning, and then buried in a deep pit. This method can usually be used by immunization service providers in the field, with some training and support. See adjoining Box for details on how to build an infectious waste burial pit.

Using the pit • • • Dump only non-anatomical waste in the pit. Seal the pit with soil and concrete before it is full of waste. Leave approximately 50 cm to properly seal off the pit. The abandoned pit must be marked with a warning so that it is not used in the future. Source: World Health Organization, www.healthcarewaste.org

18

A summary of lessons from the global experience in immunization programs
• In immunization, past accomplishment is no guarantee of future performance: Annual investment and sustained commitment are required to protect each cohort of children, in each year, in each district. A strong primary (or “routine”) immunization program is recognized as a prerequisite to achieving equitable and timely protection, to achieve disease reduction and elimination goals, and to prepare the ground for the introduction of new vaccines. Immunization needs to be viewed as an essential component of primary health care, maternal and child health, infectious disease control, emergency humanitarian assistance, social transition and health reform. • Immunization program caught in a ‘Development Dilemma’: Under-funded, bottom-up, long-term strategies in delivering the Expanded Program of Immunization (EPI) have had to compete with well-funded, top-down, disease-specific initiatives. • False perceptions that the job of immunizing the population has been completed and that diseases have been controlled: Reports from several countries have noted health-worker and government complacency regarding routine immunization. • A primary immunization program requires a systems approach: That is staff training, development of supply chains, systems of management and monitoring, communications and behavior change, engagement of communities and adequate finances. Solving just one aspect of the program, e.g. vaccine supply, is insufficient. Several developing countries have attempted to get 100% of vaccine supplies, at the expense of paying or training staff to deliver the program. • Coordination is critical: No one partner can single-handedly deliver the immunization program. Successful immunization programs have largely been where adequate public health resources and political commitment have gone hand in hand.

Further Reading
1. 2. 3. 4. 5. 6. 7. Black RE, Morris SS, Bryce J; Where and why are 10 million children dying each year? Lancet 2003; 361: 2226-2234. Expanded Programme On Immunization; Module 1–8, WHO, Geneva; 1998. GAVI Progress Report; The Global Alliance for Vaccines and Immunization; November 2002. Immunization Essentials: A Practical Field Guide. BASICS II; October 2003. Increasing Immunization Coverage at the Health Facility Level; UNICEF. Keeping global immunization a critical priority, Just the Basics; BASICS II. Introduction of Hepatitis B Vaccine in the Universal Immunization Programme: A Handbook for Programme Managers & Medical Officers, Child Health Division, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India; July 2002. National Family Health Survey (NFHS-2), 1998-99, International Institute of Population Sciences. Measure DHS, ORC Macro, pp 202-229. National Health Programs of India, National Policies and Legislation Related to Health, J Kishore, 3rd Edition.

8. 9.

10. Steinglass Fields R, BASICS II, Immunization: Challenges and Opportunities, Global Healthlink 2000; 103: pp 15 and 22.

19

20

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close