Immunization and vaccines

Immunization

1. IMMUNIZATION EXPANDED PROGRAMME ON IMMUNIZATION / UNIVERSAL IMMUNIZATION PROGRAMME AND COLD CHAIN Presented by: Mateena Maqbool M.Sc. Nsg 1 st Year

2. Immunization is the process of protecting an individual from a disease through introduction of live , killed or attenuated organisms . The immunization is essential to reduce child mortality, morbidity and handicapped conditions. It is a healthy choice that saves lives. Immunization has saved lives of children more than any other medical intervention in last 50 years. The recommended age for beginning primary immunization of infants is within 2 weeks of birth or at birth. Children born preterm should receive the full dose of each vaccine at appropriate chronologic age. Children who began primary immunization at recommended age but fail to receive all the doses do not need to begin the series again but instead receive only the missed doses. INTRODUCTION TO IMMUNIZATION

3. INTRODUCTION …… Contd: Immunization work by stimulating the immune system, the natural disease-fighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to prevent against a disease. To immunize against viral diseases, the virus used in the vaccine is weakened or killed (Attenuation). To immunize against bacterial diseases, small portion of the dead bacteria is used to stimulate the formation of antibodies against the whole bacteria. The effectiveness of immunizations can be improved by periodic repeat injections or "boosters."

4. DEFINITION Immunization is the process by which an individual's immune system becomes fortified against an agent (known as the immunogen ). “ WIKIPEDIA” (OR) Immunization is the process of inducing or providing active or passive immunity to a person just to prime his immune system against the infectious agent.

5. BACKGROUND OF IMMUNIZATION: In 2012, the WHO estimated that vaccination prevents 2.5 million deaths each year. With 100% immunization, and 100% efficacy of the vaccines, one out of seven deaths among young children could be prevented, mostly in developing countries, making this an important global health issue . Four diseases were responsible for 98% of vaccine-preventable deaths: measles, Haemophilus influenza serotype b, pertussis, and neonatal tetanus. The Immunization Surveillance, Assessment and Monitoring program of the WHO monitors and assesses the safety and effectiveness of programs and vaccines at reducing illness and deaths from diseases that could be prevented by vaccines.

6. World immunization week 21 st April ,2016 celebrated over the theme set by WHO as “close the immunization gap”, immunization for all through out life. Immunization averts 2-3 million deaths annually. However an additional 1.5 million deaths could be avoided , if global immunization improves. Today, nearly 1 in 5 children world wide are still missing routine immunizations for preventable diseases.

7. LIST OF VACCINE-PREVENTABLE DISEASES The WHO lists 25 diseases for which vaccines are available

8. 1. TUBERCULOSIS 2. DIPHTHERIA 3 PERTUSSIS 4. POLIOMYELITIS 5. HEPATITIS B 6. MEASLES 7 TETANUS 8 INFLUENZA 9 HEPATITIS E 10 HUMAN PAPILLOMA-VIRUS 11 RUBELLA 12 MUMPS 13 VARICELLA AND HERPES ZOSTER (SHINGLES) 14 TICK-BORN ENCEPHALITIS 15 ROTAVIRUS GASTROENTERITIS 16 CHOLERA 17 ANTHRAX 18 PNEUMOCCOCAL DISEASE 19 HAEMOPHILUS INFLUENZAE TYPE B 20 YELLOW FEVER 21 MENINGOCOCCAL DISEASE 22 HEPATITIS A 23 TYPHOID FEVER 24 RABIES 25 JAPANESE ENCEPHALITIS

9. NEED OF IMMUNIZATION: Immunizations are definitely less risky and an easier way to become immune to a particular disease than risking a milder form of the disease itself. Through the use of immunizations, some infections and diseases have almost completely been eradicated throughout the United States and the World. Polio in the U.S. is eradicated since 1979.

10. Polio is still found in other parts of the world like Pakistan & Afghanistan so certain people could still be at risk of getting it This includes those people:

11. VACCINES: Active immunizing agents are known as vaccines. These are immuno biological substances which produce specific protection against a given disease. Vaccines stimulate active production of protective antibody and other immune mechanisms. Vaccines are of various types like:

12. TYPE OF VACCINE VACCINE AGAINST BACTERIA VACCINE AGAINST VIRUS LIVE ATTENUATED VACCINE BCG Cholera Typhoid oral Oral polio vaccine Mumps Measles Rubella Rotavirus. INACTIVATED OR KILLED VACCINE Diphtheria Pertusses Pneumococcal Typhoid. Rabies Polio H. Influenza Hepatitis B Measles. TOXOIDS Diphtheria tetanus

13. IMMUNOGLOBULIN: Passive immunizing agents obtained from humans. WHO “ Gamma globulin”  synonym for “immunoglobulin”. Human immunoglobulin consists of 5 major classes IgG, IgM, IgA, IgD AND IgE. IgG constitutes 85% of total serum immunoglobulin and is the only Ig which is transported across placenta. IgA constitutes approximately 15 % and in present in body secretions like saliva, tears, milk, colostrums, prostatic secretions and vaginal secretions. The available human Ig’s are: diphtheria, hepatitis A and B, Measels, mumps and tetanus. ANTISERA: passive immunizing agents obtained non human sources like horses e.g; Bacterial: diphtheria, tetanus, botulism Viral: Rabies.

14. NATIONAL IMMUNIZATION SCHEDULE OR EXPANDED PROGRAMME ON IMMUNIZATION (EPI) The WHO launched global immunization programme in 1974, known as Expanded Programme on Immunization (EPI) to protect all children of the world against six killer diseases. In India EPI was launched in January 1978. The EPI is now renamed as Universal Child Immunization, as per declaration by UNICEF. In India it is called Universal Immunization Programme (UIP) and was launched in1985, November, for the universal coverage of immunization to eligible population.

15. NOTE:

16. NATIONAL IMMUNIZATION SCHEDULE

17. BENEFICIARIES AGE VACCINE DOSE ROUTE AMOUNT I N F A N T At Birth (for Institutional deliveries) * BCG Single Intradermal 0.05ml * OPV Zero dose Oral 2 drops At 6 weeks BCG (if not given at birth) Single Intradermal 0.1 ml DPT-1 OPV-1 Hepatitis 1 st 1 st 1 st Intramuscular Oral Intramuscular 0.5 ml 2 drops 0.5 ml At 10 weeks DPT-2 OPV-2 Hepatitis B-2 2 nd 2 nd 2 nd Intramuscular Oral Intramuscular 0.5 ml 2 drops 0.5 ml At 14 weeks DPT-3 OPV-3 Hepatitis B-3 3 RD 3 RD 3 RD Intramuscular Oral Intramuscular 0.5ml 2 drops 0.5 ml At 9 months Measles Single Subcutaneous 0.5 ml C H I L D R E N At 16-24 months DP T Booster Intramuscular 0.5 ml OPV Booster Oral 2 drops At 5-6 Years DT Single Intramuscular 0.5 ml Second dose of DT should be given after 4 weeks, if not vaccinated previously with DPT At 10-16 years TT Single Intramuscular 0.5 ml second dose of TT should be given if not vaccinated previously PREGNANT WOMEN Early in pregnancy One month after TT-1 TT-2 1 ST 2 ND Intramuscular Intramuscular 0.5 ml 0.5 ml

18. OPTIONAL VACCINES

19. S. NO VACCINE DISEASE DOSE/ROUTE AGE 1 HIB Meningitis & pneumonia 1.5ml /IM 6,10,14 WEEKS 12-14MONTHS---BOOSTER 2 Varicella Chicken pox 0.5ml/ SC 12-24 MONTHS 2 DOSES FOR ADULTS 2-4 WEEKS APART 3 Typhoid Typhoid 0.5ml/ SC 0.25ml /SC >10year For younger kids > 1year( 2 doses at 4-6 weeks interval 4 RRV-TV(Rotavirus) Diarrhoeal diseases 1-1.5ml / PO 6-26weeks, 3-doses at 4weeks internal 5 MMR Measles, Mumps and Rubella 0.5ml /SC 16-24 Months 6 Rubella Congenital Rubella syndrome 0.5ml /SC Females 12-15 months and women of child bearing age

20. PENTAVALENT VACCINE: Pentavalent vaccine is given to those children who are coming for first dose of DPT. Infants who have already received either the first dose or the 2 nd dose of DPT and Hep B will complete the schedule with DPT and Hep B only. Pentavalent vaccine has been introduced in 8 states/ UTs. Tamil Nadu , Kerala, H aryana, J and K, Gujarat, Karnataka, Goa and Pondicherry

21. AGE CURRENT SCHEDULED VACCINE AFTER INTRODUCTION OF PENTAVALENT VACCINE. At Birth BCG, OPV-O, Hep B- Birth Dose. BCG, OPV-0, Hep B- Birth Dose. 6 weeks OPV-1, DPT-1, Hep B 1 ST Dose. OPV-1, Pentavalent-1. 10 Weeks OPV-2, DPT-2, Hep B 2 ND Dose. OPV-2, Pentavalent-2 14 Weeks OPV-3, DPT-3, Hep B 3 RD Dose OPV-3, Pentavalent-3 9 Months Measles – 1 st Dose Measles – 1st Dose 16-24 Months Measles – 2 nd Dose DPT- Booster, OPV Booster. Measles – 2nd Dose DPT- Booster, OPV Booster. 5 Years DPT Booster 2 DPT Booster 2 10 Years TT TT 16 Years TT TT

22. BCG: VACCINATION: BCG (Bacillus of Calmette and Guerin) is produced by “Dannish-1331” strain of tubercle bacilli. It is a live attenuated bacterial vaccine It produces active immunization to children to protect children against tuberculosis It is heat stable and available in freeze dried form It should be kept away from direct sunlight and stored at 2 o -8 o C Normal saline is recommended as its diluents for reconstituting the vaccine. Reconstituted vaccine is used upto 3 hours then the left over vaccine should be discarded Vaccine is given by a special tuberculin syringe in intradermal route

23. BCG ……Contd

24. COMPLICATIONS OF BCG:

25. CONTRAINDICATIONS of BCG It is contraindicated in children with Eczema. Infective dermatosis Hypogammaglobulinemia. Immunodefiency and HIV with symptoms of AIDS. DURATION OF PROTECTION: 15-20 years.

26. POLIO VACCINATION  Salk polio vaccine is administered in IM or SC route. It is expensive and produce short lived immunity. So, it is not recommended in National Immunization Schedule. Government of India conducted pulse polio immunization (PPI) campaign towards the goal of eradication of poliomyelitis by oral administration of polio vaccine (OPV). Oral polio vaccine was first described by Sabin in 1957. Vaccine potency can be monitored by Vaccine Vial Monitors (VVM)

27. OPV…… CONTD

28. CONTRAINDICATIONS OF OPV

29. DPT is a combined vaccine consists of diphtheria toxoid, tetanus toxoid and killed B Pertussis bacilli. The potency of Diphtheria toxoid is enhanced by Pertussis component of DPT vaccine. The WHO recommends that only adjuvant DPT vaccine to be utilized immunization programme. The plain DPT vaccine can be used as a booster. Stored at 4 – 8 C and should not be frozen. It loses potency if kept at room temperature for longer period of time. DPT (Diphtheria, Pertussis and Tetanus) VACCINATION:

30. DPT…..CONTD DPT vaccine is given lateral aspect of thigh (vastus lateralis muscle) in infant s and in older children it can be given in gluteal muscle.

31. COMPLICATIONS OF DPT Severe complications of DPT ARE : Encephalitis, Encephalopathy, prolonged convulsions, infantile spasms and Reyes syndrome. These problems are thought to be due to Pertussis component of DPT

32. CONTRAINDICATIONS OF DPT

33. MEASLES VACCINATION: Measles vaccine is available as freeze dried powder. Heat stable measles and its diluting fluid should be stored at 2 o -8 o C to maintain their potency. The freeze dried vaccine after reconstitution with diluting fluid must be kept on ice and then used within one hour. Left out vaccine should be discarded and never used after 4 hours of opening the vial.

34. COMPLICATIONS OF MEASELS Severe complications can developed if recommended temperature is not maintained and necessary precautions are not followed like Toxic shock syndrome.

35. CONTRAINDICATIONS OF MEASELS

36. HEPATITIS B VACCINE

37. HEPATITIS B….CONTD Hepatitis B vaccine is available in two forms: plasma derived vaccine (HBsAg) and yeast derived vaccine. Plasma derived Hep B vaccine gives protection for about 3-5 years Hep B vaccine is used in pre- exposure or post-exposure prophylaxis. Booster immunizations are required Stored at 2 o -8 o C and should not be frozen It is recommended the dose be doubled in patients on haemolysis, immuno-compromised individuals and those with malignancies. Recommended DNA (RDNA) Yeast derived vaccine is alternative to plasma derived vaccine but it is costly RDNA gives protection for 9 years Booster immunization is not recommended.

38. TYPHOID VACCINATION: It does not give 100% protection but it reduces incidence and severity of infection. It can be given at any age after one year Stored at 2 o -8 o C temperature and should not be frozen Oral typhoid vaccine (Typhoral ) induces the local gut immunity. It is recommended for children above 6 years of age.

39. T Y P E S The efficacy of all types of typhoid vaccines ranges from 50-70% Primary immunization with anti-typhoid vaccine develops immunity in 10-21 days after inoculation and gives protection for about 3 years. So, booster dose in every 3 years.

40. TYPHOID ….CONTD COMPLICATIONS: It includes fever, local pain, malaise and swelling CONTRAINDICATIONS: Antibiotics are contraindicated in case of oral typhoid vaccines between 3 days before to 7 days after the vaccine administration as their use may compromise the vaccine “take”. Immunodeficiency states and immunosuppressive therapy Febrile illness Acute intestinal infections Anti-malarial therapy

41. COLD CHAIN: Cold Chain is a system of storing and transporting vaccine at the recommended temperature range from the point of manufacture to point of use. This cold chain is needed because vaccines are very sensitive to heat and may lose their potency if not stored and transported at optimum temperature. Among all vaccines the oral polio vaccine is the most sensitive vaccine requiring storage at -20 o C

42. India has built a vast cold chain infrastructure to ensure that only potent and effective vaccines reach millions of beneficiaries across the country.

43. Transportation of vaccines from States/Regional stores to divisions and districts is done in cold boxes using insulated vaccine vans. Vaccines carriers with icepacks are used to transport vaccines from PHCs to the outreach sessions in the village.

44. COLD CHAIN…..CONTD At regional, divisional and district levels, there are cold chain technicians whose responsibility is to maintain and repair cold chain equipment for maintaining the recommended temperatures for storage of vaccines. At the PHCs and CHCs, cold chain handlers, who are health personnel maintain Ice Lined Refrigerators (ILRs) and Deep Freezers (DFs) including temperature charting. Cold chain technicians have been provided with trainings and tool kits for performing installation, maintenance and repair activities. For maintenance of cold chain equipment, Govt. of India provides funds to the state under NRHM.

45. For successful cold chain system, three elements are essential, i.e Cold chain equipment. Transportation system and Motivation and training of workers for maintenance of cold chain link

46. Vaccines to be stored in freezer ( -15 TO -25 C) OPV Measles B. Vaccines to be stored in cold part of refrigerator and never allowed to freeze (2-8 C) DPT DT BCG TT TYPHOID All vaccine diluents C. Vaccines stored at room temperature (25C) TT

47. VACCINE HEAT LIGHT FREEZING OPV Live attenuated Sensitive Sensitive. OK to freeze BCG Live attenuated Sensitive Sensitive OK to freeze before reconstitution Measles Live attenuated Sensitive Sensitive OK to freeze before reconstitution DPT Toxoid, Killed Relatively stables -- Freezes at -3 o C Discard if frozen HEPATITIS B recombinant Relatively stables -- Freezes at -5 o C Discard if frozen TETANUS Toxoid Relatively stables -- Freezes at -3 o C Discard if frozen

48. COLD CHAIN EQUIPMENTS:

49. LIST OF COLD CHAIN EQUIPMENTS Walk in cold rooms: Deep freezers: Ice Lined Refrigerators (ILR): Cold boxes: Vaccine carriers: Day carrier: Ice packs:

50. Walk in cold rooms: They are located at regional level and are meant to store vaccines for up to 3 months. They are used to store vaccines of 4-5 districts.

51. D E E P . F R E E Z E R S:

52. Two types of ILR are available, one with ice tubes (Electrolux) and others with ice packs (vest frost) as the ice lining.

53. ……

54. Available at all peripheral health centres.Fully frozen ice packs are placed at bottom and walls of it before placing vaccines in it. The vaccines are first placed in polythene bags then to be kept in cold boxes. DPT, DT, TT and all diluents should not placed in direct contact with the frozen ice packs.

55. It is used to carry 16- 20 vials of vaccines to out-reach sites to the sub centres, village, vaccination clinic or camp.

56. Day carrier: It is used for nearby areas and only for few hours period with two fully frozen ice packs. It is used to carry 6-8 vials only  

57. Ice pack is prepared in deep freezers and contains water, filled up to the level marked on the side. No salt is added to it. Leaking ice pack should not be used.

58. NURSES RESPONSIBILITIES FOR CHILD IMMUNIZATION Nursing personal is mostly responsible for administration of immunization Motivation of general public regarding the immunization and its benefits. Estimation of beneficiaries of area and identification of non-participants and drop- outs of immunization. Assessment of problems and reasons for non acceptance of immunization and intervening to solve problem. Information, health education and communication about immunization session, time, place and available vaccines Organization of immunization clinics at different health institutions, immunization camps and home based services. Arrangement and maintenance of required amount of vaccines and other necessary equipments for particular immunization centre.

59. 7. Maintenance of cold chain at centre or during transportation of vaccines to home or clinics with necessary precautions to preserve efficacy and potency of vaccines. 8. Care of cold chain equipments and Maintenance of optimum temperature of vaccines. 9. Administration of vaccine with basic skill of aseptic techniques and check checking the vaccine vials or ampoules. Selection of proper site, position of child, maintenance of six rights and steps of medication should be followed. 10. Observation of possible reaction after vaccination and providing necessary instructions about the care of child to parents and family after immunization. 11. Nurses give information about the next dose of immunization as per the schedule. 12. Maintenance of immunization card with required information and date of next visit 13. Maintenance of clinical records, registers, stocks and vaccines used 14. Reporting about immunization coverage and problems of particular area 15. Participation in research activities and new approaches related to immunization programme 16. Updating own knowledge and developing skill regarding advancement of immunization practices and changing attitudes

60. CONCLUSION Prevention of disease is one of the most important goals in child care. Immunization is less risky and better way to immune the body against some disease. It is a healthy choice that saves lives. As we know prevention is better than cure, so, complete immunization as per the universal immunization schedule prevents and protects us from various vaccine preventable diseases. Nurses play a vital role in immunization and in maintaining cold chain. Cold chain plays a key role in making the immunization effective

61. THANK YOU END