Immunization & cold chain

Current programme & national immunization programme is arranged with cold chain.

1. IMMUNIZATION & COLD CHAIN GAJJAR PRASHANT ROLL NO.-36

2. IMMUNIZATION Immunization is defined as the procedure by which the body is prepared to fight against a specific disease . Immunization is of two types : 1. Passive immunization 2. Active immunization .

3. „ PASSIVE IMMUNIZATION Passive immunization or immunity is produced without challenging the immune system of the body. done by administration of serum or gamma globulins from a person who is already immunized (affected by the disease ) to a non-immune person. Passive immunization is acquired either naturally or artificially.

4. It is developed by injecting previously prepared antibodies using serum from humans or animals . This type of immunity is useful for providing immediate protection against acute infections like tetanus, measles, etc.

5. ACTIVE IMMUNIZATION Active immunization or immunity is acquired by activating immune system of the body . Body develops resistance against disease by producing antibodies following the exposure to antigens . Active immunity is acquire N aturally A rtificially

6. Active Natural Immunization Naturally acquired active immunity involves activation of immune system in the body to produce antibodies against microorganism. It is achieved in both clinical and subclinical infections Active Artificial Immunization It is achieved by the administration of vaccines or toxoids.

7. Herd Immunity It is a type of immunity that occurs when the vaccination of a portion of population provides protection to unprotected individual. The higher the number of immune individuals, the lower the like hood that a susceptible people will come in contact with an infectious agent. Resistance to spread of infectious disease in a group because of few susceptible members, making transmission unlikely.

8. Vaccine 9 Vaccine is a substance that is introduced into the body to prevent the disease produced by certain pathogens . It consists of dead pathogens or live but attenuated (artificially weakened) organisms. The vaccine induces immunity against the pathogen, either by production of antibodies or by activation of T lymphocytes.

9. Types of vaccine A. Live-attenuated ( weakened) vaccines: contain modified strains of a pathogen (bacteria or viruses) that have been weakened but are able to multiply within the body and remain antigenic enough to induce a strong immune response . B.Killed -inactivated vaccines: To produce this type of vaccines, bacteria or viruses are killed or inactivated by a chemical treatment or heat. 10

10. C.Sub -unit vaccines S ubunit vaccines include only the antigens that best stimulate the immune system . In some cases, epitopes are used—the very specific parts of the antigen that antibodies or T cells recognize and bind to . Subunit vaccines contain only the essential antigens and not all the other molecules that make up the microbe, the chances of adverse reactions to the vaccine are lower. 11

11. Types of subunit vaccines;- 1.toxoids 2.protein vaccine 3.recombinant protein vaccine 4.polysaccharide based vaccine 5.conjugated vaccine

12. D. Combination If more than one kind of immunising agent is included in the vaccine it is called a mixed or combined vaccine. The advantage of combined vaccine is as below: 1.simplify administration 2.reduce cost 3.improving timeline of vaccination 4.reducing the storage 13

13. Example of mixed vaccines are DPT,DT,DP,MMR,etc . POLYVALENT: It is prepared from 2 or more strain of the same species

14. vaccine Example Live, attenuated Measles, mumps, rubella (MMR combined vaccine) Varicella (chickenpox) Influenza (nasal spray) Rotavirus Inactivated/Killed Polio (IPV) Hepatitis A 15

15. Combined DPT,TT Subunit/conjugate Hepatitis B Influenza (injection) Homophiles influenza  type b ( Hib ) Pertussis , Diphtheria, tetanus

16. Why Immunization ? Key strategy to child survival Protecting infants from diseases. Lowers morbidity and mortality rates in children. Indicator of a strong primary health care system. 17

17. History of Immunization 18

18. Edward Jenner Vaccinating 19

19. Beginning of Vaccination. Vaccination (Latin ; Vacca - Cow ) Edward Jenner used the term Vaccination Cow pox virus provided immunity in prevention of Small pox 20

20. 14 May 1796 - Jenner inoculated James Phipps, an 8 yr old boy. Boy recovered after a brief illness Jenner inoculated pus taken from a small pox patient. Boy showed no reaction. Jenner recommended vaccination for prevention of smallpox Small pox eradicated in 1977. WHO certified India to be free of smallpox in march 1977. 21

21. SMALL POX 22

22. 1978: Expanded Program of Immunization (EPI) introduced after smallpox eradication: BCG, DPT, OPV, Typhoid. Limited to mainly urban areas 23

23. 1985 : Universal Immunization Program (UIP) introduced; Expanded to entire country; Measles added. 1990 : Vitamin-A supplementation. 1992: Child Survival and Safe Motherhood Program. 1995: Polio National Immunization Days. 1997: Reproductive and Child Health Program (RCH I). 2005 : RCH-II and the National Rural Health Mission (NRHM).  

24. EPI Adding more disease controlling antigens to vaccination schedules. Extending coverage to all corners of a country. Spreading services to reach the less privileged sectors of the society

25. EPI is developed to protect all children of the world against 6 vaccine preventable diseases Diphtheria Tetanus Polio Tuberculosis Measles Pertussis (whooping cough)

26. 1985 – UNICEF re named it as “UNIVERSAL IMMUNIZATION PROGRAMME”. There is no difference between both the programme .

27. Universal immunization programme & National immunization programme

28. EPI IN INDIA 1978 The Govt. of India launched it’s EPI in 1978. The objective was to reducing mortality, morbidity resulting from VPDs. To achieve a self sufficiency in vaccine production.

29. COMPONENTS OF UIP 1. Immunization of pregnant women against tetanus. 2.Immunization of children in their first year of life against 6 VPDs . 3. The aim was to achieve 100 % coverage of pregnant women with 2 doses of TT & at least 85% coverage of children under one year (with 3 doses of DPT, OPV & one dose of BCG , One dose of MMR ) by 1990

30. TWO COMPONENTS OF UIP

31. OBJECTIVES To increase immunization coverage. To improve quality of service. To achieve self sufficiency in vaccine production To train health personnel To supply cold chain equipment and establish a good surveillance network. To ensure district wise monitoring

32. “NO CHILD SHOULD BE DENIED OF IMMUNIZATION.”

33. STATUS OF VPD -INDIA Disease 1987 2011 % decline POLIMYELITIS 28,257 1 100 DIPTHERIA 12,952 4,233 62.3 PERTUSIS 163,786 3,909 76.13 MEASLES 247,519 33,634 86.41

34. NATIONAL IMMUNIZAION SCHEDULE VACCINE When to give Does Route Site TT-1 Early in pregnancy 0.5ml Intra-muscular Upper arm TT-2 4 weeks after TT-1 0.5ml Intra-muscular Upper arm TT-booster If received 2 TT doses in a pregnancy within the last 3 years 0.5ml Intra-muscular Upper arm

35. FOR INFANT VACCINE When to give Does Route Site BCG At birth or early as possible till 1 year of age 0.1 ml Intra-dermal Left upper arm Hepatitis B At birth or early as possible within 24 hour 0.5ml IM Antero-lateral side of mid thigh OPV-0 At birth or early as possible within the 1 st 15 days 2 drops Oral Oral OPV-1,2&3 At 6,10,&14 weeks 2 drops Oral Oral DPT-1,2&3 At 6,10,&14 weeks 0.5ml IM Antero-lateral side of mid thigh Hepatitis B 1,2&3 At 6,10,&14 weeks 0.5ml IM Antero-lateral side of mid thigh Measles 9 completed months-12 months 0.5ml Sub- cutaneous Right upper arm Vitamin A (1 st does) At 9 months with measles 1ml (1 lakh IU) oral Oral

36. For children DPT booster 16-24 months 0.5ml IM Antero-lateral side of mid thigh OPV booster 16-24 months 2 drops ORAL ORAL Measles 16-24 months 0.5ml Sub - cutaneous Right upper arm JE 16-24 months with DPT/OPV booster 0.5 ml Sub - cutaneous Left upper arm Vitamin A 16 months with DPT/OPV booster. Than 1 does every 6 months up to age of 5 years 2ml(2 lakh IU) Oral Oral DPT BOOSTER 5-6 years 0.5ml IM Upper arm TT 10 year &16 year 0.5ml IM Upper arm

37. Vaccines under UIP Under UIP, following vaccines are provided: BCG (Bacillus Calmette Guerin) DPT (Diphtheria, Pertussis and Tetanus Toxoid) OPV (Oral Polio Vaccine) Measles

38. Hepatitis B TT (Tetanus Toxoid ) JE vaccination (in selected high disease burden districts) Hib containing Pentavalent vaccine ( DPT+HepB+Hib ) (In selected States)

39. Diseases covered under UIP Diphtheria Pertussis. Tetanus Polio Tuberculosis

40. Measles Hepatitis B Japanese Encephalitis ( commonly known as brain fever) Meningitis and Pneumonia caused by Haemophilus Influenzae type b

41. Barriers to Immunization Physical barriers -Waiting time -Distance -Discomfort Psychological barriers - Discourtesy - Endangered privacy

42. Reasons for Low Immunization Coverage Failure to provide immunization Un-reached populations:- - Unawareness - socio-economic barriers - geographic access Resistant populations Missed Opportunities Improper logistics management

43. What Should not Hold Routine Immunization Minor illnesses such as upper respiratory infections or diarrhea , mild fever (< 38.5°c) Allergy, asthma Prematurity, underweight newborn child Family history of convulsions

44. Treatment with antibiotics Dermatosis , eczema or localized skin infection Chronic diseases of the heart, lung, kidney and liver. Stable neurological conditions, such as cerebral palsy and Down's syndrome History of jaundice after birth

45. COLD CHAIN

46. Cold Chain The ‘cold chain’ is the system of transporting and storing vaccines at recommended temperature from the point of manufacture to the point of use.

47. Why is the cold chain important ? Vaccines are: Biological products lose potency with time Process irreversible and accelerated if proper storage conditions are not adhered to. 2 . Assurance in potent product and vaccine programmes Professional responsibility Confident the vaccines you give will be effective Public Health responsibility Public confidence in immunisation programmes 3. Ensuring maximum benefit from immunisations Responsibility not to waste scarce NHS resources Reduce wastage from errors 4.Compliance with SPC/Manufacturer Any vaccine that has not been stored at a temperature of 2-8ºC as per its licensing conditions is no longer a licensed product

48. A. Walk in cold rooms(WIC) At regional level Storage up to 3 months Serve 4-5 districts

49. B. Deep freezers At district & PHC levels Temp :- -15 o c to -25 o c At PHC, used only for the preparation of ice packs In case of power failure these freezers can maintain the cabinet temp. for 18-22 hours 20-25 icepack can be prepared by a 140L in deep freezers with continuous electric supply of 8 hours.

50. C. Ice Lined Refrigerators(ILR) Both at district and PHC levels Temp :- +2 o c to +8 o c ILR’s are top opening, can hold cold air inside better than front opening refrigerators It can keep vaccine safe with 8 hours of continuous electric supply in a 24 hours period.

51. Arrangement of vaccine order top to bottom: Hepatitis B DPT & TT BCG Measles OPV Discard any frozen hep.b , DPT, & TT. Keep spaces between boxes Measles & OPV can be kept over 2 rows of empty ice-packs on the floor of the ILR.

52. Vaccine Stability Sensitivity to HEAT OPV Measles BCG MMR Hepatitis B DT Sensitivity to COLD HepB and combination Influenza * BCG (*Freeze dried) MOST SENSITIVE Temperature must be recorded twice in a day with dial thermometer LEAST SENSITIVE

53. Light Sensitive Sensitive to strong light, sunlight, ultraviolet, fluorescents (neon) OPV Measles MMR Varicella Meningococcal C Conjugate Most DTaP containing vaccines Vaccines should always be stored in their original packaging until point of use to protect them from light

54. Vaccine Storage Use a dedicated vaccine fridge Safeguard electricity supply No more than 50% full Place vaccines in clearly labelled plastic mesh baskets Group vaccines by type (Paediatric, Adult, Adolescent) Defrost/calibrate fridge regularly Ensure back up facilities are available in the event of fridge failing X No food or medical specimens X Do not place fridge in direct sunlight or near heat source X Do not store vaccines for more than 1 month at PHC. X Do not store vaccines in fridge doors or in solid plastic trays/containers within the fridge X Keep vaccines away from fridge walls and cold air vents Picture taken from www.medisave.co.uk DO’s DON’T’s

55. Used for transport of vaccines Fully frozen ice packs placed at the bottom and sides DPT, TT, DT should not be kept in direct contact 1.Cold boxes Used to carry small quantity of vaccines(16 to 20 vials) For out of reach sessions 4 icepacks are used 2.Vaccine carriers

56. 3.Day carriers Used to carry very small quantities of vaccines(6 to 8 vials) For a near by session 2 icepacks are used For only 2 hours period

57. ICE PACKS It contains water & no salt shold be added to it. The water should be filled upto the level marked on the side. If there is leakage such icepack should be discarded.

58. Vaccine Vial Monitor(VVM) VVM is a label containing heat sensitive material that is placed on a vaccine vial to register heat exposure over time Vaccine vial monitor

59. Combined effects of time and temperature cause the inner square to darken gradually and irreversibly VVM does not directly measure the vaccine potency but gives info about the main factor that affects potency

60. Mission Indradhanush

61. Mission Indradhanush was launched by Ministry of Health and Family Welfare (MOHFW) Government of India on 25th December, 2014. The objective of this mission is to ensure that all children under the age of two years as well as pregnant women are fully immunized with seven vaccine preventable diseases.

62. The Mission Indradhanush , depicting seven colours of the rainbow, targets to immunize all children against seven vaccine preventable diseases.

63. Science Hopes a Vaccine for every Disease

64. Vaccination created HOPE in Humanity

65. THANK YOU