CME -ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI).pptx

Short protocol on how to manage the adverse events following immunisation happening in the peripheral level documentation and clinical workup explained

1. ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) Dr.M Silas District Epidemiologist ( i /c) District Health office Krishnagiri .

2. Agenda Introduction Types of AEFIs Managing AEFI when it occurs Responsibilities of health service providers Reporting of AEFIs Presentation Title ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 2

3. Definition An adverse event following immunization (AEFI) is any untoward medical occurrence which follows immunization and which does not necessarily have a causal relationship with the usage of the vaccine The adverse event may be any unfavorable or unintended sign (e.g. Abscess following vaccination), abnormal laboratory finding (e.g. Thrombocytopenia following measles vaccination) symptom or disease (e.g. Disseminated BCG infection following BCG vaccination). . ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 3

4. Cause Specific Categorization of AEFI 5

5. Cause Specific Categorization of AEFI Disseminate standardized metrics Coordinate e-business applications Foster holistically superior methodologies Deploy strategic networks with compelling e-business needs ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 5 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Immunization anxiety-related reaction Coincidental event

6. Cause Specific Categorization of AEFI An AEFI that is caused or precipitated by a vaccine due to one or more of the inherent properties of the vaccine product . Disseminate standardized metrics Coordinate e-business applications Foster holistically superior methodologies Deploy strategic networks with compelling e-business needs ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 6 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Immunization anxiety-related reaction Coincidental event

7. Cause Specific Categorization of AEFI An AEFI that is caused or precipitated by a vaccine due to one or more of the inherent properties of the vaccine product . An AEFI caused or precipitated by a vaccine that is due to one or more quality defects of the vaccine product including its administration device as provided by the manufacturer . An AEFI that is caused by Inappropriate vaccine handling, prescribing or administration. An AEFI arising from anxiety about the immunization. An AEFI that is caused by something other than the vaccine product, immunization error or immunization anxiety ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 7 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Immunization anxiety-related reaction Coincidental event

8. Cause Specific Categorization of AEFI An AEFI that is caused or precipitated by a vaccine due to one or more of the inherent properties of the vaccine product . caused or precipitated by a vaccine that is due to one or more quality defects of the vaccine product including its administration device as provided by the manufacturer . An AEFI that is caused by Inappropriate vaccine handling, prescribing or administration. An AEFI arising from anxiety about the immunization. An AEFI that is caused by something other than the vaccine product, immunization error or immunization anxiety ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 8 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Immunization anxiety-related reaction Coincidental event

9. Cause Specific Categorization of AEFI An AEFI that is caused or precipitated by a vaccine due to one or more of the inherent properties of the vaccine product . caused or precipitated by a vaccine that is due to one or more quality defects of the vaccine product including its administration device as provided by the manufacturer . An AEFI that is caused by Inappropriate vaccine handling, prescribing or administration. An AEFI arising from anxiety about the immunization. An AEFI that is caused by something other than the vaccine product, immunization error or immunization anxiety ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 9 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Immunization anxiety-related reaction Coincidental event

10. Immunization anxiety-related reaction Cause Specific Categorization of AEFI An AEFI that is caused or precipitated by a vaccine due to one or more of the inherent properties of the vaccine product . caused or precipitated by a vaccine that is due to one or more quality defects of the vaccine product including its administration device as provided by the manufacturer . An AEFI that is caused by Inappropriate vaccine handling, prescribing or administration. An AEFI arising from anxiety about the immunization. An AEFI that is caused by something other than the vaccine product, immunization error or immunization anxiety ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 10 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Coincidental event

11. Cause Specific Categorization of AEFI Disseminate standardized metrics Coordinate e-business applications Foster holistically superior methodologies Deploy strategic networks with compelling e-business needs ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 11 Vaccine product-related reaction Vaccine quality defect-related reaction Immunization error-related reaction Immunization anxiety-related reaction Coincidental event

12. Examples Vaccine product-related reaction Extensive limb swelling following DTP vaccination. Vaccine quality defect-related reaction Failure by the manufacturer to completely inactivate a lot of inactivated polio vaccine leads to cases of paralytic polio. Immunization error-related reaction Transmission of infection by contaminated multidose vial. Immunization anxiety-related reaction Vasovagal syncope in an adolescent following vaccination. Coincidental event A fever occurs at the time of the vaccination (temporal association) but is in fact caused by malaria. Presentation title 12

13. “Life or Death for a young child too often depends on whether he or she is born in a country where vaccine are available or not” Nelson Mandela Presentation title 13

14. Areas of focus – Vaccine reactions Common minor vaccine reactions Caused when recipient’s immune system reacts to antigens contained in the vaccine. Immune response to the vaccine's antigen can cause local and systemic reactions: E.g. Local: Pain, Redness, swelling, Systemic: fever irritablilty , Malaise, Other vaccine components can also trigger reactions E.g. adjuvants, stabilizers, preservatives Serious vaccine reactions An AEFI will be considered serious if it results in death, requires hospitalization, results in persistent or significant disability/incapacity or a cluster (two or more cases) of AEFIs occur in a geographical area. 14 Severe vaccine reactions Usually do not result in long-term problems. Can be disabling. Are rarely life threatening. include non-hospitalized cases of seizures, hypotonic hyporesponsive episodes (HHEs), persistent screaming, anaphylaxis, Treated on time severe local reaction, injection site abscesses, intussusception,

15. Areas of focus – Vaccine reactions Common minor vaccine reactions Caused when recipient’s immune system reacts to antigens contained in the vaccine. Immune response to the vaccine's antigen can cause local and systemic reactions: E.g. Local: Pain, Redness, swelling, Systemic: fever irritablilty , Malaise, Other vaccine components can also trigger reactions E.g. adjuvants, stabilizers, preservatives Serious vaccine reactions An AEFI will be considered serious if it results in death, requires hospitalization, results in persistent or significant disability/incapacity or a cluster (two or more cases) of AEFIs occur in a geographical area. 15 Severe vaccine reactions Usually do not result in long-term problems. Can be disabling. Are rarely life threatening. include non-hospitalized cases of seizures, hypotonic hyporesponsive episodes (HHEs), persistent screaming, anaphylaxis, Treated on time severe local reaction, injection site abscesses, intussusception,

16. Areas of focus – Vaccine reactions Common minor vaccine reactions Caused when recipient’s immune system reacts to antigens contained in the vaccine. Immune response to the vaccine's antigen can cause local and systemic reactions: E.g. Local: Pain, Redness, swelling, Systemic: fever irritablilty , Malaise, Other vaccine components can also trigger reactions E.g. adjuvants, stabilizers, preservatives Serious vaccine reactions An AEFI will be considered serious if it results in death, requires hospitalization, results in persistent or significant disability/incapacity or a cluster (two or more cases) of AEFIs occur in a geographical area. 16 Severe vaccine reactions Usually do not result in long-term problems. Can be disabling. Are rarely life threatening. include non-hospitalized cases of seizures, hypotonic hyporesponsive episodes (HHEs), persistent screaming, Anaphylaxis treated on time and non hospitalised severe local reaction, injection site abscesses, intussusception

17. Leads to “ CLUSTER OF EVENTS “ ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 17 Immunization Error Non sterile injection Reconstitution error Incorrect injection site cold chain error contraindications ignored and the list goes on….

18. Leads to “ CLUSTER OF EVENTS “ ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 18 Immunization Error Non sterile injection Reconstitution error Incorrect injection site cold chain error contraindications ignored and the list goes on….

19. Leads to “ CLUSTER OF EVENTS “ ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 19 CLUSTER OF EVENTS cluster of events is defined as two or more cases of the same adverse event related in time, place or vaccine administered. These clusters are usually associated with: a particular provider or health facility, a vial of vaccine that has been inappropriately prepared (or) stored (or) contaminated.

20. Immunization anxiety-related reaction Fainting Is relatively common, but usually only affects older children and adults. Does not require any management beyond giving the injection while patients are seated (to avoid injury caused by falling) and placing the patient in a recumbent position after the injection. Hyperventilation Can cause light-headedness, dizziness, tingling around the mouth and in the hands. Vomiting Younger children tend to react differently, with vomiting a common anxiety symptom. Breath-holding may occur, which can end in a brief period of unconsciousness, during which breathing resumes. They may also scream to prevent the injection or run away. Convulsions In rare cases. These children do not need to be investigated but should be reassured. ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 20

21. Immunization anxiety-related reaction Fainting Fainting Is relatively common, but usually only affects older children and adults. Does not require any management beyond giving the injection while patients are seated (to avoid injury caused by falling) and placing the patient in a recumbent position after the injection. Hyperventilation Can cause light-headedness, dizziness, tingling around the mouth and in the hands. Vomiting Younger children tend to react differently, with vomiting a common anxiety symptom. Breath-holding may occur, which can end in a brief period of unconsciousness, during which breathing resumes. They may also scream to prevent the injection or run away. Convulsions In rare cases. These children do not need to be investigated but should be reassured. 21

22. Immunization anxiety-related reaction Fainting Is relatively common, but usually only affects older children and adults. Does not require any management beyond giving the injection while patients are seated (to avoid injury caused by falling) and placing the patient in a recumbent position after the injection. Hyperventilation Can cause light-headedness, dizziness, tingling around the mouth and in the hands. Vomiting Younger children tend to react differently, with vomiting a common anxiety symptom. Breath-holding may occur, which can end in a brief period of unconsciousness, during which breathing resumes. They may also scream to prevent the injection or run away. Convulsions In rare cases. These children do not need to be investigated but should be reassured. 22

23. Immunization anxiety-related reaction Fainting Is relatively common, but usually only affects older children and adults. Does not require any management beyond giving the injection while patients are seated (to avoid injury caused by falling) and placing the patient in a recumbent position after the injection. Hyperventilation Can cause light-headedness, dizziness, tingling around the mouth and in the hands. Vomiting Younger children tend to react differently, with vomiting a common anxiety symptom. Breath-holding may occur, which can end in a brief period of unconsciousness, during which breathing resumes. They may also scream to prevent the injection or run away. Convulsions In rare cases. These children do not need to be investigated but should be reassured. ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 23

24. Immunization anxiety-related reaction Fainting Is relatively common, but usually only affects older children and adults. Does not require any management beyond giving the injection while patients are seated (to avoid injury caused by falling) and placing the patient in a recumbent position after the injection. Hyperventilation Can cause light-headedness, dizziness, tingling around the mouth and in the hands. Vomiting Younger children tend to react differently, with vomiting a common anxiety symptom. Breath-holding may occur, which can end in a brief period of unconsciousness, during which breathing resumes. They may also scream to prevent the injection or run away. Convulsions Pccurs In rare cases. These children do not need to be investigated but should be reassured. ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 24

25. Leads to “ CLUSTER OF EVENTS “ ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 25 Coincidental Event Coincidental events are inevitable when vaccinating children, especially during a mass campaign. Vaccinations are normally scheduled in infancy and early childhood, when illnesses are common and congenital or early neurological conditions become apparent.

26. Leads to “ CLUSTER OF EVENTS “ ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 26 Coincidental Event Expected number of coincidental events after immunization can be estimated by: Applying the normal incidence of disease and death in these age groups Calculation of the expected background rate of that event may be helpful in the investigation of an AEFI Understanding background mortality in the context of deaths that coincidentally follow vaccination is key when responding to AEFI reports. The coverage and timing of immunizations Immediate investigation of a severe adverse event attributed to a vaccine, but not causally related to it, is critical: To respond to a community's concerns about vaccine safety and Maintain public confidence in immunization

27. “Who owns the patent on this vaccine’ ‘well, the people I would say, There is no patent. Could you patent the sun ?” Dr. Jonas Salk ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 27

28. How Do we Manage? Provide Immediate First AID Treat minor/non-serious AEFIs symptomatically When a serious or severe adverse event occurs ensure airway is clear. If child is unconscious, put in semi-prone position. Refer to PHC and Inform PHC MO Inform PHC MO by the fastest means possible by Telephone Refer to the MO (PHC) or nearest AEFI management centre for prompt treatment. Accompany the patient if needed Report and assist in investigation of AEFIs. Cultivate one-to-one customer service with robust ideas Maximize timely deliverables for real-time schemas 28

29. Management of Minor AEFI Minor vaccine reactions Treatment When to report Local reaction (pain, swelling, redness) Cold cloth at injection site Give Paracetamol In case of an abscess Fever > 38.5°C Give extra fluids Give tepid sponging Give Paracetamol When accompanied by other symptoms Irritability, malaise and systemic symptoms Give extra fluids Give Paracetamol When severe or unusual ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 29

30. ANAPHYLAXIS How Do we Manage? DEFINITION Anaphylaxis is an extreme and severe allergic reaction, that is potentially life threatening. The whole body is affected, often within minutes of exposure to the allergen (substance causing the allergic reaction), but sometimes after hours. It occurs because the immune system overreacts to an allergen, and causes secretion of chemical substances that cause swelling of blood vessels. Observation Post Vaccination T he more severe the reaction the more rapid is the onset. Most life-threatening reactions begin within 10 mins of immunization. That is why it is advised that the beneficiary be kept under observation for at least 30 mins after the injection . 30

31. Signs and Symptoms of Anaphylaxis System Involved Signs and Symptoms 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) 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 31

32. Initial management of Anaphylaxis by VHN Assess case and suspect anaphylaxis Early onset and rapid progression of ≥ ONE sign/s and symptom/s of any two of the following three systems Initial management of suspected anaphylaxis case with one time use of injection adrenaline zz Reassure patient, parents/ relatives zz Immediately administer one dose of injection Adrenaline by deep IM route zz Seek help to immediately arrange for ambulance to transport the patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital) zz Do not leave the patient alone zz If patient is conscious, he/she should be kept in supine position with lower limbs raised higher than head zz If patient is unconscious , he/she should be kept in left lateral position Transporting suspected anaphylaxis case to the nearest health facility The ANM should ensure that the patient is transferred to the ambulance / vehicle without delay and refer the case to nearest health facility well equipped to manage anaphylaxis for further management. zz The ANM should keep contact details of an alternate vehicle owner/driver always. If an ambulance is not available or it is delayed, the ANM should contact the owner/driver of the alternate vehicle to transport the case to nearest health facility equipped to manage anaphylaxis. Informing the medical officer and documentation zz As the child is being transferred, the ANM will inform the medical officer about the case with necessary details (name, age, date, time, site, route and dose of adrenaline administered) for further management at the health facility well equipped to manage anaphylaxis and for follow up. zz The anaphylaxis reaction (suspected or confirmed) should be recorded in the immunization card in block letters and further vaccinations should be given only as per prescription of a medical officer in hospital settings with availability of adrenaline and other resuscitation equipment. zz The case details should also be recorded in the AEFI register and reported as a serious/severe AEFI case by the MO in the CRF to the DIO. 32

33. Initial management of Anaphylaxis by VHN Assess case and suspect anaphylaxis Early onset and rapid progression of ≥ ONE sign/s and symptom/s of any two of the following three systems Respiratory Cardiac Dermal and Mucosal Initial management of suspected anaphylaxis case with one time use of injection adrenaline zz Reassure patient, parents/ relatives zz Immediately administer one dose of injection Adrenaline by deep IM route zz Seek help to immediately arrange for ambulance to transport the patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital) zz Do not leave the patient alone zz If patient is conscious, he/she should be kept in supine position with lower limbs raised higher than head zz If patient is unconscious , he/she should be kept in left lateral position Transporting suspected anaphylaxis case to the nearest health facility The ANM should ensure that the patient is transferred to the ambulance / vehicle without delay and refer the case to nearest health facility well equipped to manage anaphylaxis for further management. zz The ANM should keep contact details of an alternate vehicle owner/driver always. If an ambulance is not available or it is delayed, the ANM should contact the owner/driver of the alternate vehicle to transport the case to nearest health facility equipped to manage anaphylaxis. Informing the medical officer and documentation zz As the child is being transferred, the ANM will inform the medical officer about the case with necessary details (name, age, date, time, site, route and dose of adrenaline administered) for further management at the health facility well equipped to manage anaphylaxis and for follow up. zz The anaphylaxis reaction (suspected or confirmed) should be recorded in the immunization card in block letters and further vaccinations should be given only as per prescription of a medical officer in hospital settings with availability of adrenaline and other resuscitation equipment. zz The case details should also be recorded in the AEFI register and reported as a serious/severe AEFI case by the MO in the CRF to the DIO. 33

34. Initial management of Anaphylaxis by VHN Assess case and suspect anaphylaxis Early onset and rapid progression of ≥ ONE sign/s and symptom/s of any two of the following three systems Respiratory Cardiac Dermal and Mucosal Initial management of suspected anaphylaxis case with one time use of injection adrenaline Reassure patient, parents/ relatives Immediately administer one dose of injection Adrenaline by deep IM route Seek help to immediately arrange for ambulance to transport the patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital) Do not leave the patient alone If patient is conscious, he/she should be kept in supine position with lower limbs raised higher than head If patient is unconscious , he/she should be kept in left lateral position Transporting suspected anaphylaxis case to the nearest health facility The ANM should ensure that the patient is transferred to the ambulance / vehicle without delay and refer the case to nearest health facility well equipped to manage anaphylaxis for further management. zz The ANM should keep contact details of an alternate vehicle owner/driver always. If an ambulance is not available or it is delayed, the ANM should contact the owner/driver of the alternate vehicle to transport the case to nearest health facility equipped to manage anaphylaxis. Informing the medical officer and documentation zz As the child is being transferred, the ANM will inform the medical officer about the case with necessary details (name, age, date, time, site, route and dose of adrenaline administered) for further management at the health facility well equipped to manage anaphylaxis and for follow up. zz The anaphylaxis reaction (suspected or confirmed) should be recorded in the immunization card in block letters and further vaccinations should be given only as per prescription of a medical officer in hospital settings with availability of adrenaline and other resuscitation equipment. zz The case details should also be recorded in the AEFI register and reported as a serious/severe AEFI case by the MO in the CRF to the DIO. 34

35. Initial management of Anaphylaxis by VHN Assess case and suspect anaphylaxis Early onset and rapid progression of ≥ ONE sign/s and symptom/s of any two of the following three systems Respiratory Cardiac Dermal and Mucosal Initial management of suspected anaphylaxis case with one time use of injection adrenaline Reassure patient, parents/ relatives Immediately administer one dose of injection Adrenaline by deep IM route Seek help to immediately arrange for ambulance to transport the patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital) Do not leave the patient alone If patient is conscious, he/she should be kept in supine position with lower limbs raised higher than head If patient is unconscious , he/she should be kept in left lateral position Transporting suspected anaphylaxis case to the nearest health facility The VHN should ensure that the patient is transferred to the ambulance/ vehicle without delay and refer the case to nearest health facilitywell equipped to manage anaphylaxis for further management. The VHN should keep contact details of an alternate vehicle owner/driver always. If an ambulance is not available or it is delayed, the VHN should contact the owner/driver of the alternate vehicle to transport the case to nearest health facility equipped to manage anaphylaxis. Informing the medical officer and documentation zz As the child is being transferred, the ANM will inform the medical officer about the case with necessary details (name, age, date, time, site, route and dose of adrenaline administered) for further management at the health facility well equipped to manage anaphylaxis and for follow up. zz The anaphylaxis reaction (suspected or confirmed) should be recorded in the immunization card in block letters and further vaccinations should be given only as per prescription of a medical officer in hospital settings with availability of adrenaline and other resuscitation equipment. zz The case details should also be recorded in the AEFI register and reported as a serious/severe AEFI case by the MO in the CRF to the DIO. 35

36. Initial management of Anaphylaxis by VHN Assess case and suspect anaphylaxis Early onset and rapid progression of ≥ ONE sign/s and symptom/s of any two of the following three systems Respiratory Cardiac Dermal and Mucosal Initial management of suspected anaphylaxis case with one time use of injection adrenaline Reassure patient, parents/ relatives Immediately administer one dose of injection Adrenaline by deep IM route Seek help to immediately arrange for ambulance to transport the patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital) Do not leave the patient alone If patient is conscious, he/she should be kept in supine position with lower limbs raised higher than head If patient is unconscious , he/she should be kept in left lateral position Transporting suspected anaphylaxis case to the nearest health facility The ANM should ensure that the patient is transferred to the ambulance/ vehicle without delay and refer the case to nearest health facilitywell equipped to manage anaphylaxis for further management. The ANM should keep contact details of an alternate vehicle owner/driver always. If an ambulance is not available or it is delayed, the ANM should contact the owner/driver of the alternate vehicle to transport the case to nearest health facility equipped to manage anaphylaxis. Informing the medical officer and documentation As the child is being transferred, the VHN will inform the medical officer about the case with necessary details (name, age, date, time, site, route and dose of adrenaline administered) for further management at the health facility well equipped to manage anaphylaxis and for follow up. The anaphylaxis reaction (suspected or confirmed) should be recorded in the immunization card in block letters and further vaccinations should be given only as per prescription of a medical officer in hospital settings with availability of adrenaline and other resuscitation equipment. The case details should also be recorded in the AEFI register and reported as a serious/severe AEFI case by the MO in the CRF to the DIO. 36

37. Initial management of Anaphylaxis by VHN Assess case and suspect anaphylaxis Early onset and rapid progression of ≥ ONE sign/s and symptom/s of any two of the following three systems Initial management of suspected anaphylaxis case with one time use of injection adrenaline zz Reassure patient, parents/ relatives zz Immediately administer one dose of injection Adrenaline by deep IM route zz Seek help to immediately arrange for ambulance to transport the patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital) zz Do not leave the patient alone zz If patient is conscious, he/she should be kept in supine position with lower limbs raised higher than head zz If patient is unconscious , he/she should be kept in left lateral position Transporting suspected anaphylaxis case to the nearest health facility The ANM should ensure that the patient is transferred to the ambulance / vehicle without delay and refer the case to nearest health facility well equipped to manage anaphylaxis for further management. zz The ANM should keep contact details of an alternate vehicle owner/driver always. If an ambulance is not available or it is delayed, the ANM should contact the owner/driver of the alternate vehicle to transport the case to nearest health facility equipped to manage anaphylaxis. Informing the medical officer and documentation zz As the child is being transferred, the ANM will inform the medical officer about the case with necessary details (name, age, date, time, site, route and dose of adrenaline administered) for further management at the health facility well equipped to manage anaphylaxis and for follow up. zz The anaphylaxis reaction (suspected or confirmed) should be recorded in the immunization card in block letters and further vaccinations should be given only as per prescription of a medical officer in hospital settings with availability of adrenaline and other resuscitation equipment. zz The case details should also be recorded in the AEFI register and reported as a serious/severe AEFI case by the MO in the CRF to the DIO. 37

38. A ge-specific dose of Adrenaline (1:1000) to be administered intramuscularly Age group Dose in mL (tuberculin syringe Equivalent volume in insulin syringe 0-1 year 0.05 2 1-6 yrs 0.1 4 6-12 yrs 0.2 8 12-18 years 0.3 12 Adults 0.5 20 ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 38

39. Anaphylaxis kit for VHN 39 Annexure 1 of these guidelines translated into local language taped to inside of the box lid – 1 no. 1 mL ampoule of adrenaline (1:1000) – 3 nos. 1 mL tuberculin syringes / 40 unit insulin syringes without fixed needles – 3 nos. 24/25 G needles of 1 inch length – 3 nos. Swabs – 3 nos. Up to date contact information of Medical Officer(s) of PHC/CHC and local ambulance services. Format for quarterly certification of anaphylaxis kit by Medical Officer of PHC Store the contents in a plastic air tight container away from light. Ensure the contents of Anaphylaxis kits are verified every three months. Adrenaline has a short expiry date.

40. Plan Of Reporting EVENT MOIC CASE REPORTING FORM (CRF) DIO CASE REPORTING FORM (CRF) DIO CASE INVESTIGATION FORM(CIF) PRELIMINARY AEFI investigation Team CASE INVESTIGATION FORM ( CIF) FINAL ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 40 CASE DETAILS AND IMMUNISATION DETAILS

41. Timeline IMMEDIATE AEFI register in the PHC 24 HRS CASE REPORTING FORM (CRF) 48 HRS CASE REPORTING FORM (CRF) 10 DAYS CASE INVESTIGATION FORM(CIF) PRELIMINARY 70 DAYS CASE INVESTIGATION FORM ( CIF) FINAL ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 41

42. Presentation title 42 ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI)

43. PLAN OF REPORTING Presentation title 43 District Immunization Officer Preliminary CIF State Immunization Officer DC Immunization Division MoHFW , Govt.of India   Final CIF 10 days of Notification State National District

44. Areas of focus 44 Identify & address immunization error Causality assessment Decision-making Communication Research

45. How DO We investigate? ROI Envision multimedia-based expertise and cross-media growth strategies Visualize quality intellectual capital Engage worldwide methodologies with web-enabled technologies Niche markets Pursue scalable customer service through sustainable strategies Engage top-line web services with cutting-edge deliverables Supply chains Cultivate one-to-one customer service with robust ideas Maximize timely deliverables for real-time schemas 45

46. How Long does it take to investigate? ROI Envision multimedia-based expertise and cross-media growth strategies Visualize quality intellectual capital Engage worldwide methodologies with web-enabled technologies Niche markets Pursue scalable customer service through sustainable strategies Engage top-line web services with cutting-edge deliverables Supply chains Cultivate one-to-one customer service with robust ideas Maximize timely deliverables for real-time schemas 46 Following receipt of documents the State AEFI Committee would assess the AEFI case for causality with in the next 30 days. It is thus expected that the causality assessment of AEFI cases would be completed within maximum of 100 days of notification from the field

47. “VACCINE – Tiny Shot HUGEEEEeee …. Impact” Dept of Community Medicine, GMCH Krishnagiri ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) 47

48. Thank you Dr.SILAS.M [email protected] 8870470721