Immunization

Universal Programme Immunization as per World Health Organisation in India with Cold Chain and Vaccine Storage in Overall Health Management for Children under 5 years of age

1. Immunization RN Ankita Ashok Kadam (Registered Nurse) Basic B.Sc. Nursing, Post Graduation Diploma in Hospital Administration

2. Introduction Immunity Immunity is the security against a particular disease & no susceptibility to the invasive or pathogenic effects of foreign micro-organisms or to the toxic effect of antigenic substances.

3. Immunization Immunization is a process of protecting an individual from a disease through introduction of live, or killed or attenuated organisms in the individual system. Immunization against vaccine-preventable diseases is essential to reduce the child mortality, morbidity & handicapped conditions. It is mass means of protecting the largest number of people from various diseases as it gives resistance to an infectious disease by producing or augmenting the immunity. Artificially acquired immunity is developed by the immunization

4. Immunizing agents These agents are mainly classified as Vaccines Immunoglobulin Antisera

5. Vaccines It is an immune biological substance, designed to produce specific protection against a given disease. It stimulates the production of protective antibodies & other immune mechanisms. Live Vaccines : These types of vaccines are prepared from live organisms. These organisms lost their capacity to produce a full blown disease but retain their immunogenicity. Inactivated or Killed Vaccines : Organisms killed by heat or chemical when infected into the body stimulate immunity. They are usually safe but are less effective than live vaccines. Toxoids : Certain organisms produce exotoxins. The toxins produced by these organisms are detoxified & used in the preparation of vaccines. Cellular Fractions : In certain instance vaccines are prepared from extracted cellular fractions. Combination Vaccines : If more than one immunizing agent is included in a single dose vaccine they are called as combination vaccines. The aim of combination vaccine is to simplify administration, reduce cost and minimize the number of contact of patients with health system .

6. Types of Vaccines Examples Live attenuated Mumps Yellow fever Rubella Oral Polio, Oral Typhoid Measles Endemic Typhus BCG (TB vaccine) Inactivated/Killed Typhoid Cholera Pertussis CS meningitis Rabies Salk (Polio Vaccine) Hepatitis A & B Japanese Encephalitis Toxoids Diphtheria Tetanus Cellular Fractions Meningococcal Pneumococcal Combination DPT (Diphtheria, Pertussis, Tetanus) MMR (Measles, Mumps, Rubella) Pentavalent (Diphtheria, Pertussis, Tetanus, Hep. B, HiB )

7. Immunoglobulin The Human immunoglobulin system composed of five major immunoglobulin ( IgG , IgM , IgA, IgD and IgE ). Two types of immunoglobulin preparations are available for passive immunization. These are Normal Human Immunoglobulin & Specific (hyper immune) Human Immunoglobulin. They are used in Prophylaxis of viral and bacterial infections & in replacement of antibodies in immunodeficient patients .

8. Antisera The term ‘Antisera’ is applied to the materials prepared in animals or non-human immunoglobulin. Originally passive immunity was achieved by the administration of antisera or antitoxins prepared from nonhuman resources like horses . Human Ig preparations exist only for a small number of diseases. Administration of antisera may have adverse effects like serum sickness & anaphylactic shock due to abnormal sensitivity of the recipient.

9. Immunoglobulin Examples Human Immunoglobulin Hepatitis A & B Rabies Tetanus Diphtheria Measles Mumps Varicella Non- human Diphtheria Tetanus Gas Gangrene Botulism

10. National immunization programme The World Health Organisation (WHO) launched Global Immunization Programme in 1974 known as Expanded Programme on Immunization (EPI ). The EPI is now renamed as Universal Child Immunization, as per declaration sponsored by UNICEF .

11. National Immunization Programme in India In India , the EPI was launched in January 1978 with the objective of increasing immunization coverage in children below 2 years of age, with 3 doses of DPT & 1 dose of BCG vaccine & in Pregnant women with 2 doses of TT. Oral Polio Vaccine was added to the programme in 1979 . In 1985 , the objectives of National Immunization Programme were revised & it was renamed as Universal immunization Programme (UIP) for attaining universal immunization coverage of infants & pregnant women. Measles Vaccine was added to the programme in 1985. The Programme covered whole of India by 1990 . UIP became a part of Child Survival & Safe Motherhood Programme (CSSM) in 1992 & Reproductive & Child Health Programme (RCH) in 1997 .

12. Vaccine Due Age Max. age Dose Route Site BCG** At Birth Till 1yr of age (0.05 ml until 1 month) 0.1ml beyond 1 month Intra Dermal Upper Arm Left Hepatitis ‘B’** At Birth Within 24 hours 0.5 ml Intra muscular Anterolateral side of mid-thigh (Left) Oral Polio 0** At Birth Within the first 15 days 2 Drops Oral Oral Oral Polio 1,2 & 3 6wk 10wk 14wk Till 5yrs of age 2 Drops Oral Oral Pentavalent 1,2 & 3 6wk 10wk 14wk 1yr of age 0.5 ml Intra muscular Anterolateral side of mid-thigh (Left) Rotavirus 1,2 & 3 6wk 10wk 14wk 1yr of age 2.5ml (5 drops) Oral Oral National immunization Schedule

13. Pneumococcal Conjugate vaccine 6wk 14wk 1yr of age 0.5ml Intra muscular Anterolateral side of mid-thigh (Right) Inactivated Polio vaccine 6wk 14wk Till 1yr of age 0.1ml Inter dermal Upper Arm (Right) Measles 1 9-12 month 5yrs of age 0.5ml Sub- cutaneous Upper Arm (Right) Vitamin A (1 st dose) 9 month 5yrs of age 1ml (1 lakh IU) Oral Oral   Japanese Encephalitis 9-12 month Till 5yr of age 0.5ml Sub- cutaneous Upper Arm (Left) MMR 15-16 month 5yrs of age 0.5ml Sub- cutaneous Upper Arm (Right) DPT Booster I 16-24 month 7yrs of age 0.5 ml Intra muscular Anterolateral side of mid-thigh (Left) OPV Booster I 16-24 month 5yrs of age 0.5 ml Intra muscular Anterolateral side of mid-thigh (Left) Vitamin A (2 nd – 9 th dose) 16mn. (Then once every 6mn.) 5yrs of age 2ml (2 lakh IU) Oral Oral DPT Booster II 5-6yrs 7yrs of age 0.5 ml Intra muscular Upper Arm TT 10 & 16yrs 16yrs of age 0.5 ml Intra muscular Upper Arm

14. TT – 1 Early in pregnancy As early as possible 0.5ml Intra muscular Upper Arm TT – 2* 4wks after TT 1     0.5ml Intra muscular Upper Arm TT Booster If Received 2TT in a pregnancy within last 3 years   0.5ml   Intra muscular Upper Arm For Pregnant Women

15. * Give TT-2 or booster doses before 36 weeks of pregnancy. However, give these even if more than 36 weeks have passed. Give TT to a women in Labour, if she has not previously received TT. ** At Birth in all institutional deliveries . Note : Interval between 2doses should not be less than 1 month. Minor cough, cold & mild fever or diarrhea are not a contraindication to vaccination. In some states Hepatitis B Vaccine is given as routine immunization. Interruption of the schedule with a delay between doses not interfere with the final immunity achieved. If the child missed a dose, the whole schedule need not to be repeated again.

16. Type of Reaction Explanation Vaccine reaction Event caused or precipitated by the vaccine when given correctly, caused by inherent properties of vaccine. Program error Event caused by an error in the vaccine preparation, handling or administration. Coincidental Events that happens after immunization but not caused by the vaccine- a chance of association. Injection Reaction Events from anxiety about or pain from the injection itself rather than the vaccine. Unknown Events cause cannot be determined. Adverse reactions following immunization

17. Vaccine Contraindications All An anaphylactic reaction following previous dose of vaccine is a true contraindication to further immunization with the antigen concerned. Live vaccines (MMR, BCG, Yellow fever) Pregnancy, total body reaction. Yellow Fever Egg allergy, immunodeficiency. BCG Symptomatic HIV infection. Influenza, Yellow fever History of anaphylaxis reaction following egg allergy. Pertussis Anaphylactic reaction to previous dose. Contraindications to Vaccination

18. Vaccine Possible Minor Reactions BCG Local reaction(pain, redness& swelling) Cholera Oral presentation-none. DTP Local reaction(pain, redness& swelling), fever. Hepatitis A Local reaction(pain, redness& swelling Hepatitis B Local reaction(pain, redness& swelling), fever. Hib Local reaction(pain, redness& swelling), fever. Japanese Encephalitis Local reactions, low grade fever, myalgia, GI upset. Measles/MMR Local reaction(pain, redness& swelling), irritability, malaise & nonspecific symptoms, fever. Common Minor Vaccine Reactions

19. Pneumococcal Local reaction(pain, redness& swelling) OPV None IPV None Rabies Local or general reaction Meningococcal disease Mild local reaction TT Local reaction(pain, redness& swelling), malaise, nonspecific symptoms Tick borne Encephalitis Local reaction(pain, redness& swelling) Yellow fever Headache, influenza like symptoms, Local reaction(pain, redness& swelling)

20. Vaccine Reaction BCG Suppurative Lymphadenities, BCG osteitis, disseminated BCG infection Hib None Hepatitis B Anaphylaxis Measles/MMR Febrile seizure, thrombocytopenia, severe allergic reaction, encephalopathy OPV Vaccine associated Poliomyelitis TT Brachial Neuritis, Anaphylaxis DT Brachial Neuritis, Anaphylaxis Pertussis/DPT Inconsolable screaming, seizure, Hypotonic or Hypo responsive episode, anaphylaxis, encephalopathy Rare Vaccine Reactions

21. Vaccine storage

22. Do’s Don’ts Keep the equipment in cool room away from direct sunlight & a least 10cm away from wall. Keep the equipment through Voltage stabilizer. Keep vaccines neatly with space between stacks for circulation of air. Keep the equipment locked & pen it when necessary. Defrost periodically. Supervise the temperature record. If vaccines are in carton make holes on side of the carton for cold air circulations. Do not keep any other things other than vaccine in these boxes. Do not store any other drug. Do not keep drinking water or food in them. Do not keep more than 1 month requirements in PHC. Do not keep expired date vaccines.

23. Cold chain Cold chain is a system of storage & transport of vaccines at low temperature from the manufacturer to the actual vaccination site. The cold chain system is necessary because vaccine failure may occur due to failure of storage & transport under strict temperature controls.   Vaccine stored in the freezer compartment are Polio & Measles. Vaccine which must be stored in the cold compartment & never allowed to freeze are BCG, DPT, DT, TT, Typhoid & diluents. Vaccines must be protected from sunlight & prevented from contact with antiseptics. At health centres most of the vaccine (except polio) can be stored upto 5 weeks, if refrigerators temperature is strictly keep between 4°C & 8 °C Storage of Opened Vial: With preservatives: Upto 3 hours. Without preservatives: Upto 1 hour.  

24. The Cold Chain Equipments Walk in Cold Rooms Deep Freezer Small Deep Freezer Cold Boxes Vaccine Carrier Day Carrier Ice packs

25. Walk in Cold Rooms : It is located at regional levels & are meant to store vaccine supplies for upto 3 months. They are used to store vaccne supply of 4-5 districts.   Deep Freezers(300 litres) & Ice Lined Refrigerators (300/240 litres): Deep freezers & ILR are supplied at all districts & walk in Cold rooms to store vaccines. Deep freezers are used for making Ice packs & for storing OPV & measles vaccine.   Cold Boxes : Cold Boxes are supplied to peripheral vaccination centres & are of different sizes. The vaccines are first wrapped in Polythene bags & then kept inside cold boxes.

26. Vaccine Carriers : They are used to carry small quantity of vaccines (16-20 vials) for outreach sessions. It is a square box made up of insulated material. Four fully frozen ice packs are used to line the sides. The vaccine carrier should be closed tightly & has working capacity of 48 hours.   Day Carrier : These are square boxes containing 2 ice packs, one at bottom & one on top. Use to carry for small quantity (6-8 vials) with a 12 hours working capacity.   Ice packs : The ice packs contains water & no salt is added to it. Water is filled upto the marked level & it is allowed to freeze

27. Vaccine Vial Monitor VVM It is the label containing a heat sensitive material to check the status of vaccine durability .

28. Thank you