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IPV Vaccine India Intro - NHM
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Dated : 29th June, 2015
FOREWORD
IPV VACCINE IPV VACCINE India was certified polio free along with ten countries of WHO
IPV VACCINE IPV VACCINE South-East Asia Region on 27 March 2014. India has not reported
IPV VACCINE IPV VACCINE any polio case since 13 January 2011. This has been a hard won
IPV VACCINE IPV VACCINE
victory for the countrys health system. In 2013, the Executive
IPV VACCINE IPV VACCINE
Board of the World Health Organization (WHO) approved the
IPV
IPV VACCINE
VACCINE IPV VACCINE targets, goals, and timelines of the Polio Eradication and Endgame
Strategic Plan (PEESP) 2013-2018 which lays out the strategy for
achieving a world free from polio. India has endorsed this strategic
plan and is committed to its objectives. This strategy includes the
introduction of at least one dose of IPV into the routine
immunization schedule followed by a globally synchronized withdrawal of type 2 vaccine
viruses from immunization programmes in all OPV only using countries.
Based on recommendations of India Expert Advisory Group (IEAG) and National Technical
Advisory Group on Immunization (NTAGI), the Government of India (GoI) has decided to
introduce inactivated polio vaccine (IPV) into routine immunization schedule in October
2015 simultaneously across the entire country. The introduction of IPV is critical to achieving
high population immunity against type-2 poliovirus to protect our children and to prepare the
platform for the upcoming tOPV to bOPV switch.
These operational guidelines are the culmination of efforts of Ministry of Health and Family
Welfare (MoHFW) and the World Health Organization, India with excellent support from
other partner agencies notably UNICEF, BMGF, Rotary and CORE.
In addition to the introduction of IPV, these guidelines and the trainings, will also contribute
immensely to strengthening the routine immunization delivery mechanism.
It is expected that states will use the operational guidelines to disseminate uniform
understanding across all levels and conduct quality training of medical officers, health
workers including data managers and cold chain handlers.
The importance of training cannot be overemphasised and each state should ensure that all
the trainings are completed before the introduction of the vaccine. Quality trainings with
special attention to the Frequently Asked Questions (FAQs) will be the cornerstone that will
ensure a successful introduction of IPV across the country.
This document encompasses the key activities and timelines necessary to guide the
introduction of IPV in India. This document also provides relevant information and evidence
that is required for policy makers.
I wish this document would be fruitfully used by all concerned stakeholders to carry forward
the agenda of IPV introduction in India.
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
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TABLE OF CONTENTS
IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
Background 1
1.1 Brief epidemiology of polio 1
1.2 Global scenario 2
1.3 Indian scenario 2
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IPV Introduction Activities at State, District and Block Levels 29
7.1 State-level IPV introduction activities 29
7.2 District-level IPV introduction activities 32
7.3 Block-level IPV introduction activities 36
7.4 Role of partner agencies 39
Annexures 60
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LIST OF ACRONYMS
IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
AD auto-disable (syringe)
AEFI adverse events following immunization
AHS Annual Health Survey
ANM auxiliary nurse midwife
ASHA accredited social health activist
AWW anganwadi worker
BCG Bacillus Calmette-Guerin vaccine
bOPV bivalent oral poliovirus vaccine
cMYP comprehensive multi-year plan
CHC community health centre
CBOs community-based organizations
cVDPV circulating vaccine-derived poliovirus
DHS District Health Society
DIO district immunization officer
DLHS District Level Household Survey
DPT diphtheria-pertussis-tetanus
DTFI district task force for immunization
EPI Expanded Programme on Immunization
FAQs frequently asked questions
GPEI Global Polio Eradication Initiative
Hib Haemophilus influenzae type b
HMIS health management information system
IAP Indian Academy of Paediatrics
ICDS Integrated Child Development Services
ILR ice-lined refrigerator
IMA Indian Medical Association
IEC information, education and communication
IPHA Indian Public Health Association
IPV inactivated poliovirus vaccine
JE Japanese Encephalitis
LHV lady health visitor
M&E monitoring and evaluation
MCP mother-child protection (card)
MCTS mother and child tracking system
MO medical officer
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MoHFW Ministry of Health and Family Welfare
NHM National Health Mission
NGOs nongovernmental organizations
NPSP National Polio Surveillance Project
OPV oral polio vaccine
PHC primary health centre
RI routine immunization
SAGE Strategic Advisory Group of Experts on Immunization
SIA supplementary immunization activities
STFI state task force for immunization
tOPV trivalent oral poliovirus vaccine
ToT training of trainers
TT tetanus toxoid
UIP Universal Immunization Programme
VAPP vaccine-associated paralytic polio
VDPV vaccine derived poliovirus
VVM vaccine vial monitor
WHO World Health Organization
WPV wild poliovirus
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BACKGROUND
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The Global Polio Eradication Initiative (GPEI) was launched in 1988 when the forty-first
World Health Assembly adopted a resolution for the worldwide eradication of polio. The goal
of the GPEI is to complete the eradication and containment of all wild, vaccine-related and
Sabin polioviruses, such that no child ever again suffers paralytic poliomyelitis. Since then,
the global programme has developed evidence-based strategies and timely interventions
which resulted in significant reduction in the number of polio-endemic countries from more
than 125 in 1988 to 31 in 2015.
The poliovirus enters the body through the mouth, Figure 1: Image of wild poliovirus
often with food or drinking water that is
contaminated with faecal matter from a person who carries the poliovirus. The virus
multiplies at the site of implantation in the throat and gastrointestinal tract and is passed
through faeces. The virus is usually present in the throat and stool before the onset of
illness. The virus invades local lymphoid tissue, enters the bloodstream, and then may
infect cells of the central nervous system.
Polio is a crippling and potentially fatal infectious disease. There is no cure, but there are
safe and effective vaccines. Therefore, the strategy to eradicate polio is based on
preventing infection by immunizing every child to stop transmission and ultimately make the
world polio free. Type 2 wild poliovirus has been eliminated in the world the last wild type 2
poliovirus was detected in India in 1999. In this final stage of polio eradication, only type 1
and type 3 wild polioviruses continue to circulate in endemic areas. Both are highly
infectious and both cause paralytic polio. Type 1 is the most pervasive strain of poliovirus
and type 3 is at very low levels.
1
WHO data as of 2 June 2015; http://www.polioeradication.org/Portals/0/Wild_poliovirus_list_2010-2015_02JUN.pdf
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1.2 Global scenario
Since the launch of GPEI in 1988, polio cases have decreased by over 99%, from an
estimated 350 0002 cases then, to 263 reported cases in 2015 (as shown in Figure 2). The
reduction is the result of the global effort to eradicate the disease. In 2015, only 3 countries
(Afghanistan, Nigeria and Pakistan) remain polio-endemic, down from more than 125 in
1988.
As long as a single child remains infected, children in all countries are at risk of contracting polio.
Failure to eradicate polio from these last remaining countries could result in as many as 200 0004
new cases every year, within 10 years, all over the world. In most countries, the global effort has
expanded capacities to tackle other infectious diseases by building effective surveillance and
immunization systems.
Figure 2: GPEI accomplishment significant decline in wild polioviruses cases worldwide, 1988-2015
2
Global Polio Eradication Initiative; History of polio. Available from:http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx
3
WHO data as of 2 June 2015; http://www.polioeradication.org/Dataandmonitoring/Poliothisweek/Wildpolioviruslist.aspx
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http://www.searo.who.int/thailand/factsheets/fs0005/en/
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India accounted for nearly half of the world's total polio cases in 2009 when it reported 741
cases. The number of cases came down to 42 in 2010, a 94% reduction over the previous
year. No polio cases have been reported from the historic reservoir states of Uttar Pradesh
since April 2010 and Bihar since September 2010. The last case of paralytic polio due to wild
poliovirus (WPV) in the country was reported from Howrah district of West Bengal on 13
January 20115.
Having made unprecedented progress in stopping WPV transmission, India was removed
from the list of polio-endemic countries in 2012. India's successful interruption of poliovirus
for three years led to WHO South-East Asia Region being certified as polio free in March
2014. This was a historic milestone in the global effort to end polio and one of the greatest
public health achievements in India.
5
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734678/#ref51
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As India continues its efforts to raise population immunity against polio through continuing
polio campaigns and intensive routine immunization activities, enhanced poliovirus
surveillance and regular serosurveys against poliovirus in the highest risk areas since
20072012 help to identify areas at the risk of poliovirus importation and emergence of
circulating vaccine-derived poliovirus type 2 (cVDPV2).
At present, the Government of India is committed to sustaining its polio-free status until
global certification of polio is achieved and implementing the polio endgame strategy, which
involves risk-free withdrawal of oral polio vaccine from the programme in a phased manner.
The global polio endgame strategy entails introduction of inactivated poliovirus vaccine
(IPV) in the routine immunization schedule prior to switch from trivalent oral polio vaccine
(tOPV) to bivalent oral polio vaccine (bOPV) to boost population immunity against the risk of
cVDPV type 2 emergence. The Government of India plans to introduce IPV across the
country in October 2015.
The Government of India endorses the global polio endgame strategy and is moving
steadily towards implementing this strategy. The National Vaccine Policy 2011 and the
comprehensive Multi-Year Plan (cMYP) 20132017 have also envisioned the introduction
of new vaccines, including IPV.
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TYPES OF POLIO VACCINES
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The development of effective vaccines to prevent paralytic polio was one of the major
medical breakthroughs of the 20th century. Both orally administered, live attenuated oral
polio vaccines (OPV) and inactivated poliovirus vaccines (IPV) are being widely used
across the world to prevent poliomyelitis. These vaccines have stopped transmission of
polioviruses from most countries and have reduced the worldwide incidence of polio from
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350 000 cases in 1988 to just 26 cases in 2015 .
High levels of vaccination coverage must be maintained to stop poliovirus transmission and
prevent outbreaks from occurring. The GPEI is constantly assessing the optimal use of the
different vaccines to prevent paralytic polio and stop poliovirus transmission in different
areas of the world.
An Indian study showed that two doses of mOPV1 and mOPV2 protect about 90% of
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children and mOPV3 provides immunity to about 84% children .
6
WHO data as of 2 June 2015
7
Sutter RW, John TJ, Jain H, Agarkhedkar S, Ramanan PV, Verma H, et al. Immunogenicity of bivalent types 1 and 3 oral poliovirus vaccine: a
randomized, double-blind, controlled trial. Lancet. 2010;376:16245.[PubMed]
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A recent Indian study showed that bOPV given as per the EPI schedule protects about 99%
of children from both polioviruses type 1 and 38.
As per a recently conducted study in India, tOPV given as per the EPI schedule protects
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about 99%, 98% and 91% of children from polioviruses type 1, 2 and 3 respectively .
Vaccine Derived Poliovirus (VDPV): As we are aware that oral polio vaccine contains
a live, attenuated vaccine-virus. When a child is vaccinated, the weakened vaccine-
virus replicates in the intestine and enters into the bloodstream, triggering a protective
immune response in the child. Like wild poliovirus, the child excretes the vaccine-virus
for a period of six to eight weeks. Importantly, as it is excreted, some of the vaccine-
virus may no longer be the same as the original vaccine-virus as it has genetically
altered during replication. This is called a vaccine-derived poliovirus.
8,9
Comparative evaluation of immunogenicity and reactogenicity of bivalent oral poliovirus vaccine (bOPV) and trivalent oral poliovirus
vaccine (tOPV) in the standard EPI schedule, with or without inactivated poliovirus vaccine (IPV) administration at DTP3 contact: A
randomized controlled trial; Protocol No.: PBL/CR/2012/04/CT/bOPV (Unpublished)
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So on very rare occasions,
strain of poliovirus in OPV Types of VDPVs
may change and revert to a (a) cVDPVs (circulating VDPVs) are associated with sustained
form that may be able to person-to-person transmission and considered to be
cause paralysis (VDPV) in circulating in the community under conditions of low
humans. There are three population immunity
types of vaccine-derived (b) iVDPVs (immunodeficiency-related VDPVs ) reported in
polioviruses immunodeficient patients who have prolonged infections
after exposure to OPV
1. circulating vaccine- (c) aVDPVs (ambiguous VDPVs) currently have unclassifiable
derived poliovirus source (i.e., a single isolate from a healthy or non-
(cVDPV) immunodeficient person; environmental isolate without an
2. immunodeficiency- associated AFP case)So on very rare occasions, strain of
related vaccine- poliovirus in OPV may change and revert to a form that may
derived poliovirus
be able to cause paralysis (VDPV) in humans. There are
(iVDPV)
three types of vaccine-derived polioviruses:
3. ambiguous vaccine-
derived poliovirus
(aVDPV).
Among the three types, cVDPV causes the sustained circulation. cVDPVs occur where
there is low routine immunization or
supplementary immunization coverage. This Remember
is a major risk factor for cVDPV emergence Once polio has been eradicated, use of the
as there will be low population immunity in oral polio vaccine will need to be stopped to
the area. A fully immunized population will be prevent re-establishment of poliovirus
protected against both vaccine-derived and transmission due to vaccine-derived
wild polioviruses. cVDPV outbreaks have polioviruses. These vaccine-related cases
the ability to become endemic, can spread in
are big challenge for the scientific
any under-vaccinated communities, and can
community if the polio-eradication goal is to
be imported into other countries.
be achieved, and there is a need for prompt
action to combat the issue. Switching to IPV
Due to the risk of cVDPVs, OPV must be
is one option for this post-OPV era.
phased out to secure a lasting polio-free
world. This is because on very rare
occasions, if a population is under-immunized, there are enough susceptible children for the
excreted vaccine-derived polioviruses to begin circulating in the community. It is important
to start with the removal of type 2-containing OPV (the trivalent OPV to bivalent OPV switch)
because presently the type 2 component contained in trivalent OPV accounts for more than
90% of all cVDPV cases. There have been 43 cases of paralysis due to VDPVs since 2009
in India, of which 40 were due to type 2 VDPVs. The lower the population immunity, the
longer these viruses survive. The longer they survive, the more they replicate, change, and
exchange genetic material with other enteroviruses as they spread through a community.
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2.2 Inactivated poliovirus vaccine (IPV)
Inactivated poliovirus vaccine (IPV) was developed in 1955 by Dr Jonas Salk. IPV is given
by injection and is available only in trivalent form. IPV consists of inactivated (killed)
poliovirus strains of all three poliovirus types (poliovirus types 1, 2 and 3). IPV is given
intramuscularly using sterile injection equipment and procedures, and needs to be
administered by a trained health worker. The IPV produces antibodies in the blood to all
three types of poliovirus. It is highly effective in preventing paralytic disease caused by all
three types of poliovirus. In the event of infection, these antibodies prevent the spread of the
virus to the central nervous system and protect against paralysis. As IPV is not a live
vaccine, it carries no risk of VAPP and VDPV. IPV provides excellent humoral immunity but
does not provide mucosal intestinal immunity. However, studies in India shows that IPV
given to OPV primed children boosts the mucosal intestinal immunity. IPV is one of the
safest vaccines in use.
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THE POLIO ERADICATION
IPV VACCINE IPVSTRATEGY
VACCINE IPV VACCINE
3 ENDGAME
IPV VACCINEOF
RATIONALE IPV
AND
VACCINE IPV VACC
INTRODUCING
IPV INTO ROUTINE IMMUNIZATION
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On 26 May 2012, the World Health Assembly
declared the completion of poliovirus
eradication to be a programmatic emergency
for global public health and called for the
development of a comprehensive polio
endgame strategy. In response to this
directive, the Global Polio Eradication
Initiative (GPEI) developed this Endgame
Strategic Plan 2013-2018.
The timeline is based on the epidemiology of polio globally, the recent rate and trend in OPV
campaign quality improvements in the remaining polio-infected areas, new understanding
of the risks posed by vaccine-related polioviruses, and the recent development of new
strategies and tools for managing post-eradication risks.
The overall goal of this plan is to complete the eradication and containment of all wild,
vaccine-related and Sabin polioviruses, such that no child ever again suffers paralytic
poliomyelitis and also to plan for the backbone of the polio effort to be used for delivering
other health services to the world's most vulnerable children.
Under this endgame plan to achieve and sustain a polio-free world, the use of oral polio
vaccine must eventually be stopped worldwide, starting with OPV that contains type 2
poliovirus (OPV type 2). At least one dose of inactivated poliovirus vaccine (IPV) must be
introduced into the routine immunization schedule as a risk mitigation measure before the
proposed tOPV-bOPV switch.
The endgame planning document also frames the process for planning the polio 'legacy',
building on the polio programme's achievements and experience, to sustain a polio-free
world after programme closure and to ensure that the assets, learning, capacities and
workforces developed in the fight against polio are applied to other major public health
challenges.
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3.1 The polio endgame strategy
The plan addresses the endgame through three distinct steps (Figure 6):
Step 2. tOPV-bOPV
switch by April 2016:
From 2016, switch from
tOPV to bOPV (which Figure 6: Steps of the polio endgame strategy
does not contain type 2
Sabin virus) in routine immunization and polio campaigns.
Step 3. Withdrawal of routine OPV use: Plan for the eventual withdrawal of all OPV in
routine use by 20192020.
3.2 Rationale for the introduction of IPV The primary purpose of the IPV
into routine immunization programme dose is:
The primary purpose of introducing IPV into To maintain immunity against
routine immunization is to boost population type 2 poliovirus during and after
immunity against type 2 poliovirus during and after the planned global withdrawal of
the planned global withdrawal of OPV2 and switch OPV2 and switch from tOPV to
from tOPV to bOPV. The vaccine will also facilitate bOPV.
the interruption of transmission with the use of
To boost both humoral and
monovalent OPV type 2 in the case of outbreaks,
mucosal immunity against
hasten eradication by boosting immunity to
poliovirus types 1 and 3, which
poliovirus types 1 and 3, and mitigate the risk of
may also hasten the eradication
emergence and transmission of cVDPV2.
of these WPVs.
Evidence indicates that one dose of IPV may To reduce VAPP risks
reduce risk by protecting individuals against
paralytic polio should they be exposed to cVDPV2
or WPV2 or by enhancing the population immunity that can be achieved through use of
mOPV2 in the setting of an outbreak of type 2 poliovirus post OPV2 cessation. Because a
proportion of the population will already be immune as a result of having received IPV, the
immunity levels reached after a dose of mOPV2 will be higher than the immunity levels
reached with a single dose of mOPV2 in a completely susceptible population.
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3.3 Withdrawal of type 2 component of oral polio vaccines (OPVs):
Switch from trivalent OPV (tOPV) to bivalent OPV (bOPV)
The endgame strategy plan mandates that all countries must eventually stop use of OPV
beginning with removal of the type 2 component of tOPV through a globally synchronized
switch to bOPV (containing only types 1 and 3) for routine immunization and all
supplementary immunization activities. The global tOPV-bOPV switch, expected to occur in
April 2016, has to be a globally coordinated process because any use of tOPV after April
2016 could jeopardize polio eradication by generating circulating vaccine-derived
polioviruses from the type 2 component of the vaccine.
Although no wild poliovirus type 2 has been recorded Primary objectives of switch
over the past years, the risk of paralytic polio disease Successfully recall tOPV and
due to the type 2 component of OPV now outweighs introduce bOPV in April 2016
its benefits. This switch is necessary because Minimize tOPV wastage after
replacing tOPV with bOPV is the key to ensuring the switch
eradication of type 2 polio Sabin virus, which in turn Ensure all children are
will reduce the risk of new cVDPV type 2 outbreaks vaccinated (avoid tOPV
after OPV type 2 cessation, if a cVDPV2 appears. stock-outs before and bOPV
stock-outs after the switch)
Once the switch is made, tOPV will no longer be used Validate that the country is
anywhere in the world, and manufacturers will no free of tOPV
longer supply tOPV. Selected high risk countries will
conduct SIAs with tOPV in the months leading up to
the switch.
IPV will be introduced through routine immunization delivery systems. The use of
routine immunization as the primary way to deliver IPV will be critical to secure a polio-
free future and to help sustain the gains made by the eradication efforts.
This is an opportunity for the global polio eradication initiative to use its infrastructure to
contribute more systematically to strengthening routine immunization systems.
One of the goals is to improve infant routine immunization coverage in a group of focus
countries, which have some of the lowest routine immunization coverage levels in the
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INTRODUCTION OF IPV IN
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4 ROUTINE IMMUNIZATION
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PROGRAMME IN INDIA IPV VACCINE
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4.1 Global scenario
IPV was licensed in 1955 for use as a stand-alone and
combination vaccine and was the only polio vaccine available
until licensure of OPV in 19611962. IPV has been
successfully used in many European countries over many
years.
Routine vaccination with IPV alone should be used only in countries with high immunization
coverage (>90%) and at low risk of wild poliovirus
importation and spread. In the regions of the Remember
world where wild poliovirus has been eliminated, IPV is not replacing OPV, it is a pre-
moving to an IPV or IPV/OPV sequential requisite for tOPV-bOPV switch.
schedule will reduce or eliminate the risk of VAPP
and outbreaks of cVDPVs, as well as increase
the likelihood of countries agreeing to stop administering OPV after eradication is achieved.
New evidence now demonstrates that adding a dose of IPV is even more effective at
stopping the virus and protecting children, than using OPV alone. Introducing IPV is a key
element of the endgame plan and global readiness to manage risks associated with OPV
type 2 withdrawal. The endgame plan calls for the introduction of IPV in all OPV-only using
countries by the end of 2015. The primary role of IPV will be to maintain immunity against
type 2 poliovirus while removing OPV type 2 globally.
Solid evidence exists supporting closing of immunity gaps and substantial boosting of
antibody titres to types 1 and 3 (in addition to type 2 as described previously) when IPV is
administered after OPV. To complete eradication and get the benefits of both, IPV and OPV
should be used together. IPV should be used with OPV in routine schedules to increase
immune responses and to decrease the circulation of wild poliovirus in countries in which
transmission has not been stopped.
12
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
When IPV is administered after a few doses of OPV, the IPV not only enhances
protection against paralytic disease but also boosts intestinal immunity, even more
than an additional dose of OPV would provide. Thus, combining IPV with OPV
provides the advantages of both vaccines: strong intestinal immunity and antibody
protection against all three serotypes. This combination gives both the child and the
child's community the best protection.
India should work towards a withdrawal of OPV2 from the immunization programme
and comply with timelines of the globally synchronized tOPV to bOPV switch.
India should introduce a single, full dose of IPV into the routine immunization schedule
in all states, to be given at 14 weeks of age with DPT3-containing vaccines; and
Routine immunization needs to be strengthened to ensure high coverage with all
vaccines, including IPV.
These recommendations are far reaching
in their vision as they give a new direction
to India's polio eradication programme
Infant
and reemphasize the importance and IPV injection
need to strengthen the routine immunization along with third dose of OPV in
service delivery mechanism. routine immunization at 14 weeks
13
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Based on recommendations of the Indian Academy of Paediatrics (IAP), IPV is being used
in the private sector, in addition to OPV schedules for a decade.
4.3 Rationale for introducing at least one dose of IPV with OPV schedule prior
to OPV2 cessation
Introduction of at least one dose of
inactivated poliovirus vaccine (IPV) into
routine immunization schedule is a A WHO Position Paper on polio vaccines
strategy to mitigate the potential risk of re- (published on 28 February 2014)
emergence of type 2 poliovirus following c o n f i r m s t h a t W H O n o l o n g e r
the withdrawal of Sabin type 2 strain from recommends an OPV-only vaccination
oral polio vaccine (OPV). Combined and schedule. For all countries using OPV
sequential schedules of OPV and one only, at least one dose of IPV should be
dose of IPV have generated high added to the schedule
seroconversion rates, and a number of
studies have shown use of both vaccines
10
simultaneously induces better immune responses than either vaccine alone .
One dose of IPV closes the immunity gap against type 2 poliovirus: A study conducted
in Cote d'Ivore demonstrated that in previously tOPV vaccinated infants who were
seronegative had seroconversion rates against type 2 poliovirus of 100% after one dose of
IPV versus 53% after tOPV11. A similar study in Moradabad, India demonstrated that a single
dose of IPV among children who had previously been immunized with tOPV but were
seronegative substantially improved seropositivity rates against types 2 and 3 wild
poliovirus (100% and 91% seroconversion, respectively)12.
One dose of IPV and OPV result in additive immunity: Studies in Baltimore and Buffalo in
the United States showed that equivalent serologic responses were seen after two doses of
13
IPV, two doses of OPV, and a dose of IPV followed by a dose of OPV .
One dose of IPV boosts intestinal immunity: A recent study conducted in India found that
in infants and children (aged 611 months, 5 and 10 years) with a history of multiple doses of
OPV, a single dose of IPV boosted intestinal mucosal immunity and reduced the prevalence
of poliovirus excretion (depending on age group) by 3976% after an OPV challenge,
14
compared to no polio vaccination .
10
http://www.who.int/wer/2014/wer8909.pdf
11
Moriniere BJ, Van Loon FPL, Rhodes PH, Patriarca PA, Moriniere BJ, Klein-Zabban M-L, et al. Immunogenicity of a supplemental
dose of oral versus inactivated poliovirus vaccine. The Lancet. 1993;341(8860):154550.
12
Estivariz CF, Jafari H, Sutter RW, John TJ, Jain V, Agarwal A, et al. Immunogenicity of supplemental doses of poliovirus vaccine
for children aged 6-9 months in Moradabad, India: a community-based, randomised controlled trial. Lancet Infect Dis. 2012
Feb;12(2):12835.
13
Faden H. Results of a clinical study of polio vaccine: the Buffalo experience. Pediatr Infect Dis J. 1991 Dec;10(12):9735.
14
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
4.4 Rationale for introducing single
dose of IPV at 14 weeks SAGE Recommendation:
In November 2013, the SAGE made a
IPV administration is recommended at 14
weeks of age because it provides the formal recommendation on the
optimal balance between vaccine efficacy immunization schedule. Based on a
and early protection. If one dose of IPV is detailed review of evidence, one dose of
used, it should be given from 14 weeks of IPV be added when the third dose of DPT3
age because this is the age point when is given, i.e., at 14 weeks or at a contact
maternal antibodies have diminished and soon thereafter.
immunogenicity is significantly higher.
4.4.1 Administering IPV earlier than 14 weeks of age is not recommended because
14
World Health Organization, unpublished data, presented [Internet]. [cited 2014 Apr 21]. Available from:
http://www.who.int/immunization/sage/meetings/2012/november/3__SAGE_WG_Scientific_Evidence22Oct2012.pdf
15
Estivariz CF, Pallansch MA, Anand A, Wassilak SG, Sutter RW, Wenger JD, et al. Poliovirus vaccination options for achieving eradication and
securing the endgame. Curr Opin Virol. 2013 Jun;3(3):30915.
16
Sutter RW, Kew OM, Cochi SL, Aylward RB. 28 - Poliovirus vaccinelive. In: Plotkin SA, Orenstein WA, Offit PA, editors. Vaccines (Sixth
Edition) [Internet]. London: W.B. Saunders; 2013. p. 598645. Available from:
http://www.sciencedirect.com/science/article/pii/B9781455700905000355
15
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
4.4.2 Risks associated with introducing IPV later than 14 weeks include
Administering IPV at later immunization visits (e.g., 9 months measles visit) is not
recommended because it leaves children unprotected for a longer period of time.
Children entering the routine immunization programme late should be given IPV at the
first immunization contact after 14 weeks of age.
The purpose of IPV is to give infants protection against type 2 vaccine-derived
polioviruses (VDPVs) after the switch from tOPV to bOPV. This IPV dose will be the only
protection an infant will receive against type 2 poliovirus. The child is therefore
vulnerable until vaccinated. Waiting until 9 months to administer IPV would mean
leaving a large pool of susceptible hosts (all children aged 08 months) to be infected
by or to transmit type 2 VDPV.
Reaching fewer children due to significant dropout rates between the 14 weeks visit and 9
months of age.
DPT
IPV
IPV
administration of a 0.5 ml of
IPV by intramuscular route
IP
The vaccine shall also be administered to all children of more than 14 weeks of age who are
still eligible for third dose of OPV and pentavalent or third dose of OPV, DPT and HepB. This
will ensure that children who are brought late for the third dose of OPV and pentavalent or
third dose of OPV, DPT and HepB also get an opportunity to receive the IPV dose maximum
up to 1 year of age.
16
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Table 1: Comparison of immunization schedule before and after IPV introduction
Vaccination schedule
Age After IPV introduction Remarks
before IPV introduction
At birth BCG, OPV-0, Hep B-birth dose BCG, OPV-0, Hep B-birth dose (1) BCG vaccine can be given
up to 1 year of age.
OPV1/Pentavalent1 or OPV1/Pentavalent1 or (2) DPT vaccine can be given
6 weeks OPV1/DPT1/HepB1 OPV1/DPT1/HepB1 up to 5-6 years (not beyond 7
years) of age
(3) Pentavalent vaccine
OPV2/Pentavalent2 or OPV2/Pentavalent2 or should be given under 1 year
10 weeks OPV2/DPT2/HepB2 OPV2/DPT2/HepB2 of age. In delayed cases , due
doses above 1 year of age
OPV3/Pentavalent3 or IPV, OPV3/Pentavalent3 or can be given to a child only if a
14 weeks OPV3/DPT3/HepB3 IPV/OPV3/DPT3/HepB3 child has received at least
one dose of pentavalent
vaccine before his/her first
MCV1; JE-1 (where MCV1; JE-1 (where birthday. Due doses should
9 months applicable) applicable) be given at a minimum
interval of four weeks, at the
earliest available
MCV2, DPT first booster dose; MCV2; DPT first booster dose; opportunity.
1624 OPV booster dose OPV booster dose;
months (4) Measles vaccine can be
JE-2 (where applicable) JE-2 (where applicable)
given up to 5 years of age
(5) JE vaccine can be given
5-6 years DPT second booster dose DPT second booster dose up to 15 years of age.
(6) IPV vaccine should be
given at 14 weeks along with
10 years TT TT other due vaccines. In
delayed cases, IPV can be
16 years TT TT given maximum up to 1 year
of age.
17
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Presentation IPV is a liquid vaccine.
and dosage form No reconstitution is required.
In UIP, IPV will be available in 5-dose or 10-dose vials.
Age group for The IPV in UIP is recommended for infants along with third dose of OPV at
vaccination 14 weeks (3 1/2 months) to maximum upto 1 year of age.
Dosageand
androute 0.5 ml using auto-disable (AD) syringe available in programme.
Dosage
route Intramuscular in anterolateral aspect of mid-thigh (right thigh)
Instructions to parents for correctly holding the baby for an intramuscular injection
18
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
IPV can be administered at the same time as the other vaccines in
the programme. However, different syringes and different sites
(minimum distance of 2.5 cm between injection sites) should be used.
IPV can be administered to prematurely born infants (i.e., <37 weeks
gestation) at the recommended age concurrent with other routine
vaccinations.
At 14 weeks contact, vaccinate child in the following sequence:
Co-administration
with other
vaccines
19
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
IPV should not be administered to children with a documented/known
Contraindications allergy to streptomycin, neomycin or polymyxin B, or with a history of
an allergic reaction following a previous injection of IPV.
4.8 Challenges
The introduction of a new vaccine
into any routine immunization
schedule poses challenges at
various levels. In India, the health
system provides a strong
infrastructure for delivering these
services to all parts of the country.
20
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINE OF IPVIPV VACC
IPV VACCINE
5 OPERATIONALIZATION
IPV VACCINE IPV VACCINE
INTRODUCTION IN INDIAIPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
5.1 Preparedness assessment for IPV introduction in India
The introduction of IPV vaccine should be viewed as an opportunity to strengthen the overall
RI service delivery in the states and districts. Introduction of any new vaccine in the
programme requires meticulous planning at all levels. This initially involves top-down
macroplanning at the state level, followed by bottom-up microplanning and detailing precise
logistic and financial needs for each district and sub-district, starting from the more
peripheral levels and moving towards the higher levels. Timely trainings/orientation/media
briefing and information sharing with community helps in smooth launch at the level of
health care service providers, mobilizers and community settings.
developed to support
the state and district
programme managers
in assessing critical
information prior to
introduction of the new Figure 9: State and district preparedness assessment checklists to
vaccine. strengthen routine immunization coverage
These checklists help in assessing and identifying strengths and weaknesses at state,
district and block levels to take corrective actions for effective and successful introduction of
any new vaccine such as Hib-containing pentavalent vaccine or IPV in the UIP in respective
states. WHO and UNICEF assisted MoHFW in reviewing the preparedness based on
information provided by the states in the checklist. Table 1 lists the 14 components
incorporated in the checklists.
21
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Table 2: Components of state & district preparedness assessment checklists
Every beneficiary will require just one dose at 14 weeks or in delayed cases maximum up to
1 year of age. Considering the standard vaccine wastage rate of 10% for 5-dose vials and
10-dose vials and buffer stock of 25%, the annual vaccine requirement in the first year can
be calculated as follows:
Vaccine stores at all levels (state, regional, district, primary health centers (PHCs),
community health centers, other cold chain storage points) need to forecast their vaccine
needs for the stipulated time period to ensure that the right amount of vaccines, logistics
and cold chain equipment are available to vaccinate all eligible infants at a given time in a
given area. Each of these levels should monitor the stock of vaccine and syringes in order to
assess the lead-time and re-ordering levels.
22
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Summary: Wastage permissible for all vaccines in routine immunization
In states that have introduced the pentavalent vaccine, cold chain space availability has
increased due to the reduced requirement of DPT and hepatitis B vaccines. With this freed
capacity, there is no constraint envisaged on the cold chain capacity for storage of IPV.
The cold chain inventory should be regularly reviewed and status of the same should be
updated in the National Cold Chain Management Information System (NCCMIS).
All IPV vaccine vials have a vaccine vial monitor (VVM). The VVM registers cumulative heat
exposure, and changes from light to dark. Before use, check the VVM on each vaccine vial.
If inside square is the same colour, or darker than the outer circle (stage 3 or 4), do not use
the vaccine. The colour of VVM on IPV vial changes faster than the other vaccines.
23
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
5.2.6 Vaccine storage
To ensure efficacy of the vaccines, proper storage and packing are essential. The following
are recommended for vaccine storage:
In top-opening refrigerators (ice-lined): store IPV and other freeze-sensitive vaccines
on top.
IPV could be damaged if placed in direct contact with frozen ice packs that were
inadequately conditioned, therefore water ice packs should be conditioned before use.
24
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
5.2.7 Conditioning of water ice packs
In order to ensure correct storage of vaccines, the following procedure should be followed
Ensure that the insulated vaccine carriers are clean before use and at end of the day.
Use a packing table, and remove water ice packs from freezer and place on table to
defrost. Packs are ready to use when there are physical signs of thawing; no ice and
drops of water on surface, and liquid is observed inside.
Dry the packs and line the walls of the insulated vaccine carrier with them.
Place the vaccines inside and ensure that the container is properly closed.
Allowing ice packs to thaw means that the initial freezing temperature is lost, so the
temperature in the insulated carrier does not drop below 0C.
Properly conditioned water ice packs constitute the best method to maintain the
temperature of the insulated carriers and cold boxes.
There should be sufficient ice packs to ensure that the vaccines are totally surrounded
during transportation.
25
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
6TRAINING FOR
HEALTHIPV
IPV VACCINE VACCINE
CARE STAFF IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
The successful introduction of IPV vaccine will
largely depend upon the training conducted for all Remember
levels of health functionaries. Health-care IPV introduction sensitization
providers are not only responsible for handling training should be conducted as per
and administering the vaccine but are also a guidelines.
major source of information for parents and the The trainings on IPV introduction
community. A good training gives confidence to should not be clubbed/tagged with
the health workers to introduce new vaccines other ongoing training or review
meetings.
All sessions must be interactive. Methodology All trainings will have some common
should include PowerPoint presentations, role and some cadre-specific messages.
plays, exercises and interactive discussions. Key tips/messages for participants
Each batch should not have more than 40 have been incorporated into
participants. In large states/districts more than respective agendas.without any
one batch may have to be planned. Trainers apprehension and ambiguity.
should be patient listeners to any feedback from
the trainees.
Health-care personnel who require training include district immunization officers (DIOs),
medical officers (MOs), cold chain handlers, supervisors, data managers and frontline
health workers. The officials and staff of the Department of Women and Child Development
such as child development project officers (CDPOs), integrated child development services
(ICDS) supervisors and anganwadi workers also need to be trained at the same time. In
addition, plans should be drawn up to orient the faculty of paediatrics and preventive and
social medicine departments in medical colleges as well as professional bodies (IAP, IMA)
involved in immunization service delivery.
workshops (one-day to
half-day duration each). This excludes IPV advocacy and launch workshop.
Subsequently, these state level officers will conduct trainings in their respective states,
beginning with a state level training for district level officials. Further, the district level officers
will conduct district-level training for block medical officers of their district. These medical
26
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
officers will, in-turn, be responsible for training health workers, including ANMs, supervisors
and cold chain handlers.
Step 1: Check and write the following details of IPV before opening the vial.
Date and time of opening the vial as per open vial policy
Manufacturer name
Manufacturing date
Expiry date
Batch number
VVM status
Step 2: Before administration of IPV, check the age of the beneficiary.
Single dose of IPV should be given alongwith third dose of OPV and
Pentavalent or third dose of OPV, DPT and HepB. In delayed cases IPV
can be given maximum up to 1 year of age.
Step 3: Administer 0.5 ml of the vaccine with AD syringe.
Remember IPV is a liquid vaccine so no reconstitution is required.
Step 4: Administer the vaccine as an intramuscular injection in the anterolateral aspect
of the mid-thigh (right side).
Step 5: Immediately cut the used AD syringe using the hub cutter.
Step 6: Dispose of the cut syringe and other immunization waste as per waste disposal
guidelines.
Step 7: Record the IPV dose in the revised MCP/immunization card, tally sheets,
registers, etc.
27
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
6.2 Reporting and recording of IPV in routine immunization programme
All recording and reporting formats should be revised to include IPV. These revised formats
should be distributed before introduction and ensure that during health workers' training, an
exercise for filling the MCP card should be conducted.
Inclusion of IPV will be required in vaccine stock forms, immunization cards, due lists, tally
sheets, monthly progress reports at all levels, maternal and child health (MCH)/immunization
register, coverage monitoring charts, supervisory checklists, computer databases,
immunization coverage surveys and evaluation formats as well as AEFI reporting formats.
The reporting of IPV vaccination will be done through existing reporting mechanisms such
as the health management information system (HMIS) and the mother and child tracking
system (MCTS). MoHFW is in process of updating the HMIS and MCTS portal to include
IPV coverage reporting.
In HMIS, IPV will find its place under the heading Child Immunization (M6) number of infants
from 0 to 11 months subhead. Position of IPV in this format will be under the DPT3
coverage. Do not record IPV under any other heading.
OPV- OPV-
JE-1
28
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
IPV INTRODUCTION
7 ACTIVITIES AT STATE,
IPV VACCINE IPV
DISTRICT ANDVACCINE IPV VACCINE
BLOCK LEVELS
IPV VACCINE IPV VACCINE IPV VACC
7.1 State-level IPV introduction activities
The following activities should be undertaken
at the state level for the successful Key messages
introduction of IPV in the national programme. IPV supply shall either be in 10 dose or 5
dose vials.
7.1.1 State task force for immunization Assess cold chain space accordingly.
(STFI) IPV is a freeze-sensitive vaccine and is
STFI should be convened periodically to to be stored in ILR (+2C and +8C).
steer key messages for all activities for As of now, introduction of IPV does not
introduction of IPV vaccine in the state, mean that OPV is to be stopped.
including commitment and support from One dose administration of IPV at 14
various departments and stakeholders. weeks of age and in delayed cases
Issues identified for smooth introduction of maximum up to one year only.
the vaccine should be addressed during Vaccine should only be introduced in the
meetings of the STFI and the State Health districts that have completed the
Society (SHS). recommended trainings.
Refrigerator mechanics to visit all
States should make best use of lessons
vaccine storage points at least once
learnt from the polio programme to
before IPV introduction.
strengthen routine immunization.
State and district task forces to monitor
Opportunity like new vaccine introduction
open vial policy implementation.
should be used to highlight issues that
need attention for corrective action.
WHO (National Polio Surveillance Project (NPSP), UNICEF and other key routine
immunization partners involved in immunization at state and district levels are expected
to proactively support the authorities in providing quality information/monitoring data at
STFI and district task force for immunization (DTFI) levels for appropriate actions.
29
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
7.1.4 Strengthening routine immunization micro-plans
All high-risk areas (HRAs) identified in polio microplans and all additional sessions
planned under mission Indradhanush should be incorporated into the RI microplans.
Ensure all vulnerable sections are provided an equal opportunity to avail services.
Monitor completeness of all components of microplanning.
30
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Table 3: State-level training workshops/TOTs
S.No. Trainees Trainers Duration Timeline
1 Medical ofcers SIO with support from
DIO and 2 MOs per district (3 persons per state cold chain handler,
district). Also include surveillance medical HMIS and MCTS
ofcers (SMOs) of WHO-NPSP, UNICEF coordinators , IEC
district coordinators, and others such as consultant and partners
state programme manager (NHM), state WHO NPSP, UNICEF,
information education and communication others
(IEC) consultant, state ASHA coordinator,
state cold chain ofcer, state data manager,
state monitoring and evaluation (M&E)
coordinator (NHM), state nance and
accounts manager (NHM)
(1-2 ofcials per organization dealing with
cold chain to be invited from agencies such
as WHO, UNICEF, UNDP, CORE, CARE,
others).
Notes: 1. Refer to related annexures for agendas and tips for trainers.
2. Submit district-wise fortnightly progress on training status to the GoI on the rst and fteenth of each month.
31
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
7.1.7 Dissemination of guidelines/revised formats/IEC materials
Disseminate relevant guidelines and training material during training to each category of
staff for introduction of pentavalent vaccine
Ensure printing of IEC materials (as per prototypes) in local languages in adequate
numbers
Ensure that all the updated reporting and recording tools including immunization
component in mother-child protection (MCP) card, registers, due lists, etc. are printed
and disseminated in time. Appropriate translation in local languages should be
undertaken if required. Ensure use of this updated material in the sensitization
workshops at all levels.
7.1.8 Tracking beneciaries (leftouts and dropouts)
Undertake headcount for estimation of beneciaries by ANMs/ ASHAs/AWWs for
improved micro planning and tracking.
Use standardized tools for microplanning and estimation of beneciaries. Ensure it is a
time-bound activity and gets completed in 12 weeks
State health authorities and partners should intensively monitor this activity and share
ndings at all relevant platforms
Implementation of immunization tracking bag (one per session site). ASHA or AWW of
that area to be made responsible for this. ANM to provide oversight and cross check
counterfoils to ascertain reasons for dropouts.
7.1.9 Intensify monitoring and supervision
Intensify supervision and monitoring of programme at district, block, session and house-
to-house levels through government functionaries and partners. Use standardized RI
monitoring formats provided by MoHFW.
32
IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Ensure district cold chain vaccine storekeeper and refrigerator mechanic attend the
DTFI meeting.
Representatives of urban local bodies should be invited in DTFI.
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Vaccine should only be introduced in the districts that have completed recommended
trainings. To ensure smooth launch and merger of IPV in routine immunization, all cold
chain handlers and frontline health workers should be trained before IPV introduction.
IPV is a freeze-sensitive vaccine. To avoid freezing of vaccine ensure that all vaccine
storage (cold chain) points are visited by refrigerator mechanics at least once prior to the
introduction so that necessary repairs or maintenance can be undertaken well in time.
Monitor the frequency and outcomes of visits and share the feedback in DTFI. DHS and
DTFI are responsible for providing support to issues requiring attention.
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Table 4: Summary of district training workshops/TOTs
S.No. Trainees Trainers Duration Timeline
1 Medical ofcers Master trainers: DIO Within 2
Blocks to identify and nominate the and 2 MOs trained at weeks
names of at least 4 ofcials (2 MOs + 2 state level after
others as nominated by block MO) per completion
block/urban planning unit. Nominations of state-
to be forwarded to DIO. Other level
participants to be invited include district workshop
programme manager NHM, district IEC
consultant, district ASHA coordinator,
district cold chain handler, district data
manager, district M&E coordinator
(NHM), district accounts manager
(NHM)
3 Vaccine and cold chain handlers Master trainers: DIO One day
Block/planning unit to identify and and 2 MOs trained at for each
nominate at least 2 persons per state level along with workshop
vaccine storage point. Nominations to district cold chain
be forwarded to DIO handler, refrigerator
mechanic trained at
state level
5
NHM nance ofcers SIO with support from Preferably,
District-level workshop to orient the WHO, UNICEF and before the
block-level NHM nance ofcials (BPM other partners start of
and BAM) on the guidelines related to any district
funding support for the introduction, workshops
especially launch, media sensitization, in the
block-level frontline health worker and district.
mobilizer training, IEC materials, ASHA
incentives, etc.
Notes: 1. Refer to related annexures for agenda and tips for trainers.
2. Submit fortnightly progress on training status of each level of functionaries to the State Immunization Ofcer.
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
7.2.7 Dissemination of guidelines/revised formats/IEC material
Disseminate relevant guidelines and training material to the participants in the
workshops
Ensure that the district has an adequate number of printed IEC materials (as per
prototypes)
Ensure that all the updated reporting and recording tools such as MCP cards, registers,
due lists, etc. are printed and disseminated to blocks/planning units in time. Ensure that
these materials are discussed and used in the sensitization workshops.
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Undertake head count for
estimation of beneciaries by Key messages
ANMs/ASHAs/AWWs for Cold chain handlers and ANMs should be made
improved microplanning. Use
aware that IPV supply from GoI will either be in
standardized tools. Ensure that
this is a time bound activity (12 10 dose or 5 dose vials.
weeks) and that it is intensively MOIC to ensure that cold chain storage points
monitored by government in block should have adequate cold chain
functionaries and partners. MO in space for IPV introduction.
charge to monitor and provide IPV is a freeze-sensitive vaccine and is to be
oversight to this activity. stored in ILR (+2C and +8C).
DTFI to monitor progress. As of now, introduction of IPV does not mean
that OPV is to be stopped.
7.3.2 Indenting and delivery of
One dose administration of IPV at 14
vaccines and logistics
Ensure availability of required weeks of age and in delayed cases
doses of IPV vaccine and other maximum up to one year only.
logistics. Ofcial communications Do not introduce IPV vaccine until all blocks
from the Block Medical Ofcer in have completed the recommended trainings.
charge should include the Refrigerator mechanics to visit all vaccine
following key messages and the storage points in the block at least once before
same should be reiterated in ANM IPV introduction.
monthly review meetings.
Ensure timely release of funds through Block
IPV supply from Government of Programme Manager and Block Accounts
India will either be in 10 dose or 5
dose vials, Manager (NHM)
Medical officer in-charge to strictly
Introduction of IPV does not mean
that OPV is to be stopped. implement and monitor open vial
policy.
One dose administration of IPV at
14 weeks of age and in delayed
cases maximum up to one year
only.
For smooth launch and merging IPV in routine immunization programme ensure 100
percent training of cold chain handlers and front line health workers are trained before
IPV introduction.
IPV is freeze sensitive vaccine; to avoid freezing of vaccine ensure that all vaccine
storage (cold chain) points in the block are visited by refrigerator mechanic at least once
prior to the introduction so that necessary repairs or maintenance can be undertaken well
in time. Monitor the frequency and outcomes of visits and share the feedback in DTFI.
DHS and DTFI are responsible to provide support for issues requiring attention
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
Table 5: Block-level training workshops/TOTs
S.No. Trainees Trainers Duration Timeline
1 Health workers District and block master trainers One day
(ANMs, LHVs, (DIO and 2 MOs trained at state level + 2 block level for each
health MOs trained at district level). workshop
supervisors They will be supported by other trained ofcials such Within 3
as district/block level data handlers, district vaccine weeks of
and cold chain completion
of the
2 Mobilizers District and block master trainers Half day district-level
(ASHAs and DIO and 2 MOs trained at state level + 2 block level for each workshop
AWWs) MOs trained at district level. workshop
They will be supported by other trained ofcials such
ASHA coordinators at the district level and others
Notes: 1. Refer to related annexures for agenda and tips for trainers.
2. Submit fortnightly progress on training status of each level of functionary to DIO.
7.4.1 WHO
Shall provide technical expertise in the development of plans for IPV introduction at
national and state levels;
Provide recommendations on customization of the preparedness checklists and support
the district and state governments in completion of these checklists;
Assist in the review of information derived at the state and national level;
Monitor training activities and implementation at the block/district levels with feedback to
DTFI and STFI;
Track the progress in implementation of actions in strengthening RI and sharing of the
ndings at district, state and national levels; and
Share feedback and recommendations to guide further strategies in IPV introduction.
7.4.2 UNICEF
Shall develop a communications strategy and its timeline for IPV introduction at both the
national and state levels;
Provide assistance in information dissemination through its network;
Provide regular feedback and recommendations; and
Assist in the development of behavioural change communication (BCC) for IPV
introduction.
7.4.3 Rotary International
Will support advocacy at state and district level;
Assist with IEC activities; and
Support activities for mobilization of religious groups in support of IPV.
7.4.4 State and local organizations
Other organizations such as IMA, IAP and civil society bodies will be identied as per
state requirements. These organizations can play an important role in information
dissemination and advocacy at various levels.
Their involvement at district and state task force meetings can be encouraged based on
decisions by state and district health department needs.
Their capacities and roles can be reviewed at local level.
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IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINE ADVOCACYIPV VACC
IPV VACCINE
8 COMMUNICATION,
IPV VACCINE IPV VACCINE
AND SOCIAL IPV VACCINE
MOBILIZATION
IPV VACCINE IPV VACCINE IPV VACC
8.1 Communication strategy and plan Key Communication Tasks
The launch of IPV vaccine is a critical step Raise awareness of all
forward in the global eradication of polio and stakeholders on the importance of
transitioning from oral polio vaccines. This is the IPV use.
first time after 1985 that a single vaccine is being Promote confidence in the
introduced across the entire country at the same vaccination schedule, its safety
time. It is therefore very important for all and effectiveness.
stakeholders the public and policy makers
Address rumours and misinformation.
alike to understand the value addition of
Improve vaccination coverage.
improving children's immunity against polio that
Enhance detection and reporting of
IPV in addition to OPV will bring.
possible AEFI.
A well planned communication strategy has
been developed to ensure that launch of IPV
builds upon the gains of India's long drawn out battle against polio and the country continues
to remain polio free.
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5. Ensuring visibility for the IPV introduction through an IEC/IPC package:
Posters for IPV introduction
Banners/hoardings
FAQs for health work force including ANM, ASHA, AWW, social mobilization network, etc.
6. AEFI communication plan
1. Preparatory phase:
Identify and brief key guests and invitees including public representatives,
government, professional bodies, media, NGO partners, religious leaders, etc.
Identify suitable venue and date in consultation with officials concerned.
Prepare materials for launch event from prototypes provided.
Prepare talking points for key speakers.
Prepare agenda for the event from the prototype provided.
Identify photographer and equipment required for the launch.
2. Event:
Check event venue prior to the event and ensure equipment is in working order.
Ensure orderly and timely conduct of the event.
Ensure folders with materials are available for all participants.
Ensure release of IEC materials for IPV launch.
Prepare press release based on the draft provided.
LAUNCH KIT: A standardized launch kit has been developed for the IPV introduction
which will be provided to the state government containing the following:
1. Prototypes for backdrop/banner
2. Prototypes for standee
3. Draft agenda for event
4. PowerPoint slides/other materials for use
5. Operational guidelines for IPV
6. Frequently asked questions on IPV
7. Draft press release
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
8.3 Briefing media
It is important to ensure that the media is well briefed about the IPV launch and has access
to the correct information so that wrong or incorrect reporting in mass media is minimized.
These simple steps can be followed at the state and district level for briefing of media:
1. Preparatory phase
Identify spokespersons at state and district levels. These can be the
SIO/CMO/District Magistrate. Ensure the spokespersons have the requisite media
skills. Organize media skills training for spokespersons if necessary on IPV facts.
Prepare list of state and district media staff covering health issues, with the latest
contact numbers, emails and official addresses; editors of major newspapers and
TV channels, radio; district-wise list of local cable operators.
Prepare key message sheets on immunization and share with spokespersons.
Prepare a press release from the prototype press release that has been provided in
the media kit.
2. Implementation phase
Organize media briefing with key reporters on IPV introduction using PowerPoint
slides and media kit that is provided
Hold media collaboration workshops; include state-level journalists.
Keep them regularly informed of all immunization related developments through
faxes and emails.
Media toolkit: A standardized media kit has been for the IPV introduction, which will
be provided to the state government for dissemination containing the following:
1. Background note on IPV introduction
2. Frequently asked questions on IPV
3. Draft press release
4. Compendium of radio messages for local FM channels on IPV
5. Format for maintaining media reports on IPV
8.4 Advocacy
Advocacy is a well-defined process based on demonstrated evidence to influence decision
makers, stakeholders and audiences to support and/or implement policies or actions
related to the advocacy goal which in this case is to ensure that IPV is introduced smoothly
into the routine immunization schedule and is accepted well by the community.
Advocacy with these groups is important for promoting immunization and IPV introduction.
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
1. Local public representatives (MPs, MLAs, members of legislative councils, zila
panchayat chairman and members, ward members for urban areas)
2. Key officials of the government and medical fraternity at the state, district and block
levels:
State level: Chief secretary, principal secretary health, Mission Director, National
Health Mission, directorate of health and family welfare, state immunization officers,
medical colleges, eminent private pediatricians/experts, medical institutions and
networks (such as the IAP Indian Academy of Pediatrics; IMA Indian Medical
Association; IAPSM Indian Association of Preventive and Social Medicine)
District and block level: district magistrates, chief development officers, block
development officers, chief medical officers, district immunization officers, medical
officers, private practitioners, etc.
3. Influencers such as religious leaders, teachers, self-help groups
4. NGOs and CBOs
5. Media
Prepare an advocacy plan to reach out to the relevant groups using tools and materials.
Assess your existing resources and adapt them with IPV related messages. Document the
proceedings with action points for the future. Keep IMA informed and prepare and share
PowerPoint/IEC materials on IPV with IAP/IMA members.
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
ADVOCACY TOOLKIT: You need to develop your own toolkit using the materials that
have been provided in the launch and media toolkits. Make sure that you adapt the IPV
materials to the audience that you are advocating with so that correct information reaches
the audience in the correct format.
Social mobilization can make a huge difference in reaching out to all the left outs (children
not vaccinated at all) and dropouts (children that started the vaccination but missed
subsequent doses).
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IPV VACCINEIPV VACCINE IPV VACCINE IPV VACCINEIPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
3. Service delivery
Mobilization of beneficiaries for RI session.
Ensuring of IPV along with OPV3/Pentavalent3 or with OPV3/DPT3/HepB3 for infants
14 weeks (3 months) of age.
Ensuring updating of Immunization card with IPV information.
Ensuring delivery of the four key messages including 30 minute waiting after the
immunization.
1. IEC/IPC package
Booth / Session site Posters for IPV introduction
Banners / hoardings
Brochure- FAQs for community / mothers / care-givers
Booklet: FAQs for frontline workers (SMNet, ASHAs)
2. Training resources
Media kit for training of media personnel
Training curriculum for training of frontline workers
Set up a communication plan between the AEFI committee members and those
working on the ground.
All ANMs/ASHAs/AWWs and MOs must:
o Be sensitized to recognize and report AEFI promptly.
o Know what to do in the event of an AEFI and the location of the nearest AEFI
treatment centre.
Develop single-page reference material for ANMs/ASHAs on what to do during an
AEFI, who to contact, etc.
Organize infection prevention and control training for ANMs and ASHAs on what to
say to parents about AEFI, during vaccination sessions, or during door-to-door IPC.
Ensure district AEFI committee is functional and involved .
If an AEFI occurs, get information out as quickly as possible. The public needs to know
that you share their concerns, that the situation is being investigated and that you will
keep them informed.
Have a trusted spokesperson identified in advance to deliver messages during an
AEFI. This spokesperson may not necessarily be the senior-most person in the
district.
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Ensure that this spokesperson has been trained in media handling during AEFI. If not
organize media-handling skills training in advance.
Call partners meetings and discuss how messaging must be communicated during an
unfortunate AEFI.
Demand for information increases from many quarters be prepared with
information!
Coordination is crucial take charge! Prepare a coordination plan. Constantly update
it when people move out of the system and new people come in.
Workload increases keep advances resources ready to quickly access the
resources!
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IPV VACCINE IPV VACCINEIPV VACCINE
IPV VACCINE AND VACCINE IPV VACC
MONITORING IPV
9
IPV VACCINE IPV VACCINE IPV VACCINE
SUPERVISION
IPV VACCINE IPV VACCINE IPV VACC
A team of national and state observers shall supervise and monitor all activities in the pre-
launch period across the country. Special focus states (where routine immunization
coverage requires to be strengthened), pre-identified high-focus districts (Mission
Indradhanush) and polio high-risk districts shall be prioritised. These teams shall guide and
evaluate the progress and share their findings with the state task force and national task
force (Immunization division, MoHFW) at the national level for further action. It is
recommended that introduction activities should start 36 months prior to the scheduled
introduction of the vaccine.
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9.2.1 Session site monitoring
This captures information on vaccine supply and the availability of logistics, functioning of
alternate vaccine delivery (AVD) system, injection practices of ANMs, injection safety and
waste disposal, record keeping and inter-personal communication of service providers.
If the following are found, there is a need to explore and address the reasons:
The utilization of the vaccine and AD syringes shows a pattern of rapid increase or
decrease week after week;
Doses consumed for vaccines that are provided at the same time (IPV,
OPV3/Pentavalent3 or IPV, OPV3/DPT3/HepB3) differ widely from each other for the
same period.
If there is any mismatch between the reported number of doses and AD syringes used, the
vaccinators, doctors, store in-charge and supervising authorities concerned must be consulted
to determine the reason for the variation or mismatch. If their reply is found convincing and
realistic, no action is required other than appreciating them. If the reply points towards
problems or irregularities in work/management, solutions need to be discussed with the
persons concerned. The senior authorities should be informed well in time.
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9.6 Lessons learnt from the introduction of injectable pentavalent vaccine
Post introduction evaluation (PIE)
The introduction of any new vaccine into the immunization programme is an opportunity to
strengthen health systems and improve the reach of immunization services to
disadvantaged populations. WHO recommends that a post introduction evaluation (PIE) of
new vaccines be conducted within 612 months of introduction of a new vaccine. The aim of
such evaluation is to assess community acceptance and its impact on the existing
immunization system, to derive lessons for necessary corrective measures. Although a PIE
is done in the context of new vaccine introduction, the exercise provides a broad overview of
the performance of the immunization programme and thus boosts the confidence to further
scale up and introduce new and underutilized vaccines in the programme.
A PIE of pentavalent vaccine was conducted in Tamil Nadu and Kerala in 2012, and a similar
PIE was conducted in Goa, Gujarat, Haryana, Jammu & Kashmir, Karnataka and
Puducherry in 2013 to evaluate the status of pentavalent vaccine and measles-containing
vaccine second dose.
The detailed findings of PIE in these eight states have been given in the annexure 1. The
national and state governments should plan to conduct PIE of IPV within 612 months of
vaccine introduction.
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IPV VACCINE IPV VACCINE IPV VACCINE IPV VACCINE
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FREQUENTLY ASKED QUESTIONS
10 (FAQs) FOR INACTIVATED
IPV VACCINE IPV VACCINE
POLIOVIRUS VACCINE
IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
1. What is IPV?
IPV refers to the inactivated poliovirus vaccine. IPV consists of inactivated (killed)
poliovirus strains of all three poliovirus types and is given as an injectable vaccine.
2. What is OPV?
OPV refers to oral polio vaccine. OPV is a live vaccine and is orally administered.
8. Why is IPV now being introduced when India has already eradicated polio?
Although polio has been eradicated in India, the threat of re-emergence and reinfection due to
poliovirus remains at large. For completing polio eradication and elimination of all polio disease
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in the world, a strategic plan has been developed by the global experts to secure a lasting polio-
free world. This plan includes use of IPV in combination with OPV. Using IPV and OPV together
will provide additional protection to the child and the community against polio.
As part of the global polio eradication plan, 126 countries, including India, are introducing at
least one dose of IPV along with OPV in the national immunization schedule.
11. After receiving IPV and OPV through routine immunization, does the child still
need to take OPV doses through Pulse Polio campaigns?
Yes, even after receiving IPV and OPV doses in routine immunization, the child must be
given OPV doses during Pulse Polio campaigns also. This will boost the child's immunity
and will continue to protect the child against Polio.
12. After receiving IPV and OPV through routine immunization, does the child still
need to take OPV booster doses as per routine immunization schedule?
Yes, even after receiving IPV and OPV doses in routine immunization, the child must be
given OPV booster doses as per RI schedule.
13. Which government health facilities in our country will provide IPV?
IPV is an injectable vaccine and will be provided free of cost through routine immunization
sessions. IPV will be provided in all government hospitals, dispensaries, PHCs, CHCs, sub-
centres and outreach session sites. IPV will not be given in a house-to-house campaign mode.
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17. Will Open Vial Policy be applicable to IPV? Open Vial Policy
Yes, Open Vial Policy is applicable to IPV. Do not
forget to write the date and time of opening of vial on Vaccines opened in a xed or outreach
the label. As per guidelines, IPV may be used up to session can be used at more than one
immunization session up to 4 weeks
28 days after opening, provided that the criteria for
provided:
the multi-dose vial policy are fully met. Expiry date has not passed
VVM has not reached discard point
18. What is the eligible age for IPV? Vaccines stored at appropriate cold
chain conditions: both during
The child between 14 weeks (3 months) and one transport & storage in cold chain
year of age coming to RI session site to receive third storage point
dose of OPV will be eligible for IPV. Vaccine septum has not been
submerged in water or
contaminated in any way
19. When should IPV be administered as per
Aseptic technique used to withdraw
routine immunization schedule? all doses
In states that have introduced pentavalent vaccine, If any adverse event happens Do
IPV should be administered to a child along with not use the opened vial, retain the
vial for investigation.
third dose of OPV and pentavalent vaccine. States
that have not yet introduced pentavalent vaccine
will provide IPV along with third dose of OPV, DPT and HepB as part of routine
immunization.
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20. What are the route, dose and site of IPV injection?
IPV is to be administered intramuscularly (I/M) as a single dose (0.5 ml) in the anterolateral
aspect of right mid-thigh. IPV will be administered using AD syringe.
If child requires more than one injection, for example Penta or DPT/HepB then these
have to be administered in the anterolateral aspect of left mid-thigh.
If two vaccines are to be administered simultaneously then ensure that the distance
between two sites is at least 2.5 cm (1 inch). Sites of other intramuscular vaccination
are mentioned below.
21. What should be the site for administration of Penta or HepB and DPT following
introduction of IPV in the programme?
As per revised RI schedule, only IPV will be administered in the anterolateral aspect of right
mid-thigh where in all doses of Penta or HepB and DPT will be administered in the
anterolateral aspect of left mid-thigh.
Penta
HepB
DPT
IPV
IPV
IP
V
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22. Why should IPV be given in the right side Remember
in anterolateral aspect of mid-thigh only? Pentavalent vaccine has already been
Site for an injection is fixed to maintain uniformity introduced in 20 states/UTs. This
across the country. Uniformity helps ANMs to vaccine will shortly be introduced in the
remaining 16 states/UTs.
remember and safely provide multiple DPT and HepB will continued to be
vaccinations. It also helps ANM in seeking given intramuscularly at 6, 10 and 14
vaccination history in case of loss of MCP card. weeks in states that have not yet
Fixing the sites for vaccination helps in better introduced pentavalent vaccine. This
means that the child coming for the third
recall by the caregiver during follow up visits, dose of OPV in such states will receive
evaluation surveys and adverse events, etc. three injections (IPV in the right thigh,
We are already practicing such kind of DPT and HepB in the left thigh).
uniformity for administering other UIP vaccines Following pentavalent vaccine
introduction, the number of injections at
such as BCG (left upper arm); Measles (right 6, 10 and 14 weeks will reduce.
upper arm) and JE (left upper arm). The child coming for third dose of OPV
IPV will be given in anterolateral aspect of right in pentavalent introduced states will
mid-thigh and pentavalent or HepB and DPT will then receive only two injections (IPV
and Penta) instead of three (IPV, DPT
be given in the anterolateral aspect of left mid-
and HepB).
thigh.
23. Will IPV injection be given to a child coming earlier than 14 weeks?
No, IPV injection will not be administered to a child coming earlier than 14 weeks. As per RI
schedule third dose of OPV is provided at 14 weeks of age hence IPV cannot be given
before 14 weeks of age.
24. Why is IPV administered with third dose of OPV at 14 weeks (3 months)?
IPV administration is recommended at 14 weeks of age because the protection response of
the IPV vaccine is significantly higher after 14 weeks than at an earlier age.
25. What should be the vaccination schedule for a child coming later than 14 weeks
of age (delayed cases)?
As per the national immunization schedule the child Remember
In delayed cases (beyond 14
should get one dose of IPV at 14 weeks along with weeks), one dose of IPV should be
third dose of OPV and Pentavalent or HepB/DPT. In given as soon as possible up to
case of those children where vaccination is delayed m a x i m u m o n e y e a r o f a g e .
beyond 14 weeks the child should be administered the Remember vaccination results are
the best when given at the
due dose as soon as possible but not later than one recommended age.
year.
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26. What sequence should be adopted for administering vaccines to a child coming
for third dose of OPV?
Please refer to the following sequence for administering all vaccines at 14 weeks contact.
29. What is the benefit of giving multiple vaccinations to a child in one visit?
There are several benefits of giving multiple vaccinations to a child in one visit.
There is no contraindication for giving multiple vaccination (if due) in one visit
The caregiver does not have to come repeatedly for vaccination
Better compliance at the level of caregiver.
Reduces ANM workload
30. Does the child need some special care after IPV injection?
No, the child does not need any special care after IPV vaccination. As per RI guidelines,
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after administering any vaccine, the health worker should observe the child for at least half
an hour at the session site. In case of fever, paracetamol can be given in recommended
doses.
34. Can IPV be given to a premature infant (born before 37 weeks gestation)?
Yes, IPV can be administered at 14 weeks after the birth of the premature child.
36. Where will the IPV dose be recorded in the MCP card?
IPV has to be recorded separately in the MCP card along with the other vaccines due at 14
weeks (3 months). The new MCP card has provision for recording the IPV vaccination.
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37. What should you do if you find a frozen IPV Remember
vial? IPV is a freeze sensitive vaccine.
IPV is a freeze sensitive vaccine. If you find a All vaccines come with VVM
frozen vial of IPV do not use the vaccine. Check the VVM before the use.
Remember freeze thawed IPV vaccine cannot be As part of open vial policy, all
tested for freezing. Shake test is not applicable to partially used vaccines should be
sent back to the vaccine storage
IPV.
point the same day.IPV is an
Suspected frozen vials of DPT, Pentavalent, TT,
expensive vaccine. Each dose of
Hep-B vaccines can be tested for freezing IPV costs more than Rs. 120. A 5-
through Shake Test procedure. dose vial costs Rs. 600 and a 10-
dose vial costs Rs. 1200.
38. Which all vaccines should be kept on an ice
pack at the immunization site?
As per RI guidelines, the health worker is expected to take out one ice pack at the session
site and use the same after opening the heat sensitive vaccine.
On Ice Pack- BCG and Measles (place them in the holes on ice pack), OPV and JE
vaccine should be placed on the surface of the ice pack.
Remember IPV, HepB, TT, DPT and Penta should never be kept on the ice pack.
39. What are the four key messages that every health worker must give to the
caregiver after vaccination?
Remember that a vaccinator's task is not complete till she delivers the four key messages to
caregiver (refer to the picture).
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40. Let us assume if one of the two vaccines OPV or IPV is not available at session
site, and a child due for third dose of OPV comes to the session site for vaccination?
In such a condition, the health worker should give all vaccines that are available and advice
the caregiver to come back in the next session for receiving the dose missed today due to
non-availability.
Remember
41. Will IPV be a part of ASHA's full immunization ASHA is eligible for the full
incentive? immunization incentive only if
Yes, IPV will be a part of the national immunization child has received all vaccines
schedule. The ASHA will be eligible for the full due in the first year as per the
national immunization schedule
immunization incentive only if the child has received all
and this now includes IPV.
vaccinations (within one year) as per the schedule
2. Child coming at 14 weeks of Verify that the child has not received any vaccinations
age is completely unimmunized Give vaccination as below
(has not received any ) - Give first dose of OPV
vaccinations - Give BCG (left upper arm)
- First dose of Penta in left thigh (Pentavalent States)
- First dose HepB and DPT in left thigh (States where
Pentavalent vaccine has not been introduced)
Give four key messages
3. Child coming is more than 14 weeks Verify if the child is more than 14 weeks of age and has
of age but less than one year of received all due vaccines at 6 weeks of age.
age and has received birth dose and As per RI schedule third dose of OPV is provided at 14
all vaccinations due at 6 weeks. weeks of age hence IPV can be given.
In such case give second dose of OPV along with
second dose of penta or HepB and DPT
If the child is 9-12 months of age then give Measles
and JE (if applicable).
The caregiver should be given four key messages.
4. Child coming at 14 weeks of age Verify if the child is more than 14 weeks of age and has
has received birth dose and all received all due vaccines at 6 and 10 weeks of age
vaccinations due at 6 and 10 weeks. In such cases give third dose of OPV with IPV
followed by
- third dose of Penta (Pentavalent States)
- third dose of HepB and DPT (States where
Pentavalent vaccine has not been introduced)
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5. Child coming is more than 14 weeks Verify if the child is more than 14 weeks and less than
but is less than one year of age one year of age and has received all due vaccines at
and has received birth dose and all 6, 10 and 14 weeks of age
vaccinations due at 6, 10 and 14 In such cases where third dose of OPV has already
weeks been given then do not give IPV.
Remember that we do not give IPV to a child that has
already received OPV3 earlier.
If the child is 9-12 months of age then give Measles
and JE (if applicable).
The caregiver should be given four key messages.
6. Child coming is more than Verify all doses of OPV have been given as per
14 weeks of age and less than one immunization schedule
year of age has received all due In such cases do not give IPV.
doses of OPV as per RI schedule. Remember IPV should be given only with third dose of
The child has also received OPV OPV.
through all campaigns. The child In such cases give BCG followed by
however has not received any - first dose of Penta (Pentavalent States)
injectable vaccine so far. - first dose of HepB and DPT (States where
Pentavalent vaccine has not been introduced)
- If the child is 9-12 months of age then give Measles
and JE (if applicable).
The caregiver should be given four key messages.
7. Child coming has received IPV Verify if the child has actually received IPV through
vaccination by a private practitioner. private practitioner.
Verify the age at which IPV was given:
- If IPV has been given before 14 weeks then give one
dose of IPV along with OPV.
- If IPV has been given at 14 weeks or later then do
not give IPV.
Utilize this opportunity to provide other due
vaccination (if any)
Give four key messages.
Children are still at risk of polio till such time as it is not eradicated from the world.
Just one dose of IPV with third dose of OPV to your child in routine immunization at 14
weeks of age gives additional protection against polio
IPV is available free of cost at the RI session site
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ANNEXURES
VACCINE IPV VACC
IPV VACCINE IPV VACCINE IPV VACCINE
IPV VACCINE IPV VACCINE IPV VACC
Annexure 1
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Annexure 2
Activity Person/s
responsible*
Registration
Role of participants attending the training workshop for IPV introduction (10 minutes)
Explain the objectives of the workshop to participants (why they have been called and what is
expected from them).
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Revised National Immunization Schedule
Discuss the existing vaccination schedule.
Emphasize as to how ANM will convince the parents for one dose of IPV at 14 weeks.
Keep watch on third dose of OPV, Penta or DPT and HepB coverage since IPV will be given
as just one dose with third dose of OPV, at 14 weeks.
Remember IPV introduction should not lead in drop of coverage of any other vaccine
(Penta, DPT, HepB) at 14 weeks.
National Immunization schedule with IPV inclusion; FAQs related to scenarios (20
minutes)
Discuss the existing vaccination schedule.
Emphasize on third dose of OPV, Penta or third dose of DPT and HepB coverage since IPV
will be given as just one dose with third dose of OPV at 14 weeks.
Make them understand the revised schedule.
Reporting of coverage: Do not forget to explain the IPV related scenarios that ANM is
expected to face in immunization session.
Reiterate as to when to give and when not to give IPV vaccination. Discuss how ANM has to
deal with children coming for vaccination later or earlier than recommended age.
Vaccine and cold chain management of freeze and heat sensitive IPV (15 minutes)
Demonstrate to participants where to report IPV coverage in HMIS. Also, make them
understand the fields in HMIS where AEFI data and vaccine stock positions are to be
entered.
Storage of IPV vaccine in ILRs should be between +2 8C. Explain how the space required
in ILRs will be used for IPV in view of IPV replacing Hep B and DPT vaccines. Explain about
the freeze sensitive nature of the injectable IPV. Explain them that these are heat sensitive as well.
Emphasize the need for the open vial policy. This will not be possible without the back up of a
strong alternate vaccine delivery (AVD) plan.
Emphasize on minimizing vaccine wastage. Explain to them that the state should review
vaccine wastage on a monthly basis and districts should review wastage session wise/on a
monthly basis.
Review the existing alternate vaccine delivery mechanism. Participants should bring the AVD
microplan of their district. Two well performing and two poor-performing districts should
share the AVD plans with their SWOT (strengths, weakness, opportunities and threats)
analysis.
This is a freeze-sensitive vaccine. Explain to the participants that the shake test will not be
applicable to IPV.
Are they aware of the National Cold Chain Management Information System (NCCMIS)
software?
Explain to them the value of this tool and indicators generated. Review the status of NCCMIS
and provide the password if required. NCCMIS will help them know inventory as well as
break down status of cold chain equipment.
Review the status of the NCCMIS. The cold chain handlers should be aware about the cold
chain inventory including the equipment that stands broken down. Is district or the cold chain
point in the district prepared for storage of this new vaccine? This is more important in states
that have not yet introduced IPV vaccine.
They should understand the appropriate time to reorder vaccines (lead time).
Ensure that vaccine handlers in the district are aware of the contact details of the refrigerator
mechanic/person/agency responsible for cold chain repair and preventive maintenance.
Details of visit and job undertaken related to cold chain equipment must be documented in
the temperature logbook for that particular equipment (when visited date and time, what
was found, what was repaired, outcome of visit and any other instructions given to the
vaccine handler of that cold chain point).
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Dealing with health workers: IPV related FAQs (30 minutes)
Coverage trends after IPV vaccine introduction: participants must ensure that ANMs are fully
aware of IPV and are comfortable administering IPV along with third dose of OPV, Penta or
third dose of DPT and HepB vaccination at 14 weeks.
They should know the value of giving IPV with OPV.
Introduction to the revised immunization component of the MCP card and counterfoil (20
minutes)
Update participants on IPV specific modifications in reporting and recording tools - MCP
cards, tally sheets, MCH registers, HMIS/MCTS formats.
Introduce them to the revised MCP cards with emphasis on counterfoil use. Sensitize them to
revisions done in the reporting and tracking tools (registers/MCP cards/vaccine distribution
registers/vaccine stock registers/due list registers, tools, etc.).
Emphasize the usefulness of tracking tools: estimation of beneficiaries, due list registers,
tally sheets, tracking bags and counterfoils, etc.
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Understanding evaluated, administrative and monitoring coverage trends of third dose of
OPV and Penta or third dose of DPT, HepB in view of IPV introduction (30 minutes)
Importance of due list preparation for tracking beneficiaries (drop outs and left outs)
The 'tOPV to bOPV' switch in April 2016 and other calendar events (20 minutes)
What to do after this workshop: role in sensitizing the health workforce, timelines for
completing IPV trainings (30 minutes)
Ask them to bring out possible issues that they visualize that they might face during the new
vaccine introduction.
Explain to them what they have to do when they go back to their districts.
These officials must know that as master trainers they will have to further conduct training at
block/planning unit level.
The master trainers will have to take the help of other officials that have been trained at the
state level such as NHM finance officials, data handlers (HMIS and MCTS coordinators,
district computer assistants to DIOs, district M&E focal person/coordinators (NHM), focal
person responsible for immunization reports in CMO office), cold chain handlers (district
vaccine store keeper, district cold chain handlers) and district IEC focal persons.
Ensure there is a plan to monitor IPV planning, trainings, introduction and implementation of
IPV vaccine.
Wrap up
Let participants know that partner agencies have been requested to monitor planning and
implementation of IPV introduction activities.
Also they should ensure that no district/block should introduce IPV until all their health
workers have been trained.
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Annexure 3
Agenda: IPV vaccine training workshop for data handlers at state/district level
Person/s
Activity
responsible*
Registration
Each batch should not have more than 40 participants. In large states/districts, more than
one batch may have to be planned.
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session for mobilization to session site, ` 100 for each fully immunized child, and ` 50 per for
each completely immunized child). Remember to mention that now IPV is included as part of
full immunization incentive.
Explain them about the evaluation survey.
Discuss the Full Immunization and complete immunization status at national, state and
district level such as Annual Health survey, District level household survey, any other
evaluated coverage if available.
They should know how important is to analyze physical and financial progress.
Analyzing trends of third dose of Penta, OPV, DPT and Hep B coverage in view of IPV
introduction (20 minutes)
Understanding importance of session-wise coverage reports: this will help programme
managers at all levels and also vaccine and data handlers at vaccine storage points to
understand vaccine coverage, utilization, wastage, etc.
Ask them to explain as to what analysis they would like to present in ANM meeting and MO
meeting.
Update on revised data entry tools and logistic requirements (30 minutes)
Introduce them to the revised MCP cards with emphasis on counterfoil use.
Sensitize them to revisions done in the reporting and tracking tools (registers/MCP
cards/vaccine distribution registers/vaccine stock registers/due list registers, tools, etc.).
Emphasize the usefulness of tracking tools: estimation of beneficiaries, due list registers,
tally sheets, tracking bags and counterfoils, etc.
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NCCMIS status (15 minutes)
Are they aware of NCCMIS software? Explain to them the value of this tool and the indicators
generated. Review the status of NCCMIS and provide the password if required.
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Annexure 4
IPV training workshop for vaccine and cold chain handlers at state/district level
Agenda: IPV training workshop for vaccine and cold chain handlers at state/district level
Person/s
Activity
responsible*
Registration
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Storage of vaccines in ILRs and; explain freeze sensitivity of IPV vaccine (30 minutes)
Storage of IPV vaccine in ILRs should be between +2 8C.
Explain with pictures on positioning of IPV in ILR along with other UIP vaccines and make
them understand the freeze and heat sensitivity of vaccines.
IPV is both freeze and heat sensitive.
Repeat that shake test is not applicable on IPV.
Make sure alternate-back up CCHs are attentive and interact and make sure he/she is well
abreast on the handling of all vaccines including IPV.
Update on revised data entry tools and logistic requirements (30 minutes)
(MCP cards/counterfoil, tally sheets, MCH registers, HMIS/MCTS formats)
Identify cold chain handler who is aware of the contents of revised MCP cards/counterfoil,
tally sheets.
Show the revised MCP cards/counterfoil, tally sheets and pass it through the group and make
them aware.
Show them the contents of MCH registers and HMIS/MCTS formats.
Identify the space/column for filling information on IPV.
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- Temperature recording twice daily in recommended logbook.
- Remind MO to cross check recording of temperature physically and countersign the logbook
weekly.
- Door should not be opened frequently.
- Defrost monthly and/or as required.
- Must prepare to keep the vaccine in alternate arrangement when ILR is taken up for
defrosting and recorded accordingly in temperature lob book.
- Position the vaccines as per recommended guidelines.
- Diluent should be kept in ILR 24 hours prior to use (for reconstitution vaccines).
- Only conditioned ice packs have to be used (ask one cold chain handler to
explain/demonstrate).
Strengthening reporting and recording of vaccine and cold chain equipment (NCCMIS)
(15 minutes)
Review mechanism of monitoring and supervision
Ensure that vaccine handlers in the district are aware of the contact details of the refrigerator
mechanic/person/agency responsible for cold chain repair and preventive maintenance.
Details of visit and job undertaken related to cold chain equipment must be documented in
the temperature logbook for that particular equipment (when visited date and time, what
was found, what was repaired, outcome of visit and any other instructions given to the
vaccine handler of that cold chain point).
Reiterate the remember messages.
Initiatives taken by state to strengthen cold chain supervision and monitoring (15
minutes)
Wrap up
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Annexure 5
Person/s
Activity
responsible*
Registration
Understanding immunization status at national, state and district levels (20 minutes)
Situational analysis:
Global and national polio eradication status.
Explain full immunization and complete immunization.
Current RI status (evaluated/ reported coverage.
Brief about where and why we are missing children.
Current strengths and challenges in immunization program at state and district level.
Explain about national and state level efforts to increase immunization coverage in high
focus areas/districts Mission Indradhanush, etc.
Mobilization efforts, incentives available for ASHA.
Brief on preparedness for IPV introduction, State efforts to improve the gaps (10 minutes)
Explain about state preparedness plan for IPV introduction.
Trainings from state to block level staff.
Basic facts related to polio endgame strategy (20 minutes) including introduction of IPV
in national immunization programme
Briefly explain polio endgame strategy and forthcoming events.
How would current vaccination schedule change after introduction of IPV introduction?
Rationale for IPV introduction.
Increasing visibility of the RI program in state with a focus on IPV introduction (20
minutes)
Demonstrate the new IEC prototypes developed for IPV introductions.
Share state specific instructions on IEC and communication including budget guidelines (if any).
Role of media, (print, electronic and social) in IPV introduction (20 minutes)
Disseminate state specific instructions.
Plans for advocacy through print, electronic media (FM radio, TV, etc.) and social media.
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Risk communication (15 minutes)
Explain that IPV is a safe vaccine; it is in use in many countries and in India it has been in use
for more than a decade.
Most of the queries are answered in FAQs.
Handling an AEFI crisis refer MoH communication guidelines for building vaccine
confidence around AEFI)
Wrap up
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Annexure 6
IPV training workshop for National Health Mission (NHM) programme and
finance officers at state/district/block level
Agenda: IPV training workshop for National Health Mission (NHM) programme and
finance officers at state/district/block level
Person/s
Activity
responsible*
Registration
Objectives of the workshop and opening remarks (15 minutes)
Make the participants feel special and important since they are master trainers for training for
finance managers at district and block level.
Will help in informing the policy and decision makers.
With clarity on project implementation plan matters their support will be critical for smooth
introduction of trainings and other activities with NHM funding support.
They must understand that they their contribution will be instrumental in strengthening of the
health systems at state/district level.
Role of attending participants in IPV introduction activities at state/district and block level
(15 minutes)
Role of NHM programme and finance officers in state and district task forces will be critical to
the programme.
Support from state and district health society will be critical in areas needing attention
especially budgetary needs.
Understanding and supporting cascade-training plan from state to district to blocks by NHM
will be the key to introduction.
Global and National update on polio eradication and overview of Polio Endgame Strategy
(15 minutes)
The 'tOPV to bOPV' switch in April 2016 and other calendar events.
Inform about national and global implications/repercussions in case of missing/delaying
timelines.
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to `150. Each 10-dose vial approximately costs `1200 and a 5-dose vial is `600.
Participants should understand the implications of reporting inflated/incorrect coverage.
They should know that IPV is both freeze as well as heat sensitive vaccine. Open vial policy is
applicable to IPV.
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Status of available funds under Part C Immunization project implementation plan fund
utilization and status of utilization of Part A and Part B of funds identified for supporting
immunization activities (30 minutes)
Update on any state specific immunization initiative being supported by NHM (Immunization
field volunteer, etc.).
Issues and challenges for action by state/district task force and/or state/district health
society.
Understanding coverage trends of third dose of OPV and Penta or DPT, HepB in view of
IPV introduction (15 minutes)
Inform them about how to measure progress of IPV introduction in relation to coverage of
third dose of Penta/OPV or DPT/HepB/OPV.
Reiterate again that their role timely disbursement of immunization incentives will be very
important and hence they must review the utilization district wise at state level and block wise
at district level and subcentre wise at block level.
Wrap up
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Annexure 7
IPV training workshop for ANMs, LHVs and health supervisors at block level
Agenda: IPV training workshop for ANMs, LHVs and health supervisors at block level
Person/s
Activity
responsible*
Registration
Objectives of workshop and opening remarks (10 minutes)
Explain participants why they have been called, and what is expected from them.
Ask them to bring out possible issues that they visualize that they might face during the new
vaccine introduction.
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ANMS should be fully aware of IPV and are should be comfortable to give IPV along with third
dose of OPV, Penta or DPT and HepB vaccination at 14 weeks. They should know the value
of giving IPV with third dose of OPV.
Explain the IPV related scenarios that ANM is expected to face in immunization session.
- Reiterate as to when to give and when not to give IPV vaccination.
Discuss how ANM has to deal in children coming for vaccination later or earlier than
recommended age.
Do not forget to explain that all children younger than 1 year who have already received a
third dose of OPV will not be given IPV however any child who is coming for third dose of OPV
dose should not be denied a dose of IPV.
A child more than one year of age that has not earlier been vaccinated at 14 weeks or later
(before one year) is not eligible for the IPV vaccine. Go through with different scenarios that
the ANMs may face following IPV in their immunization sessions.
Use of immunization tracking bag and due list for tracking (30 minutes)
Use of immunization tracking bag.
Exercise on placing immunization card in tracking bag after IPV vaccination.
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Where does an ANM enter data for IPV vaccination in the HMIS and MCTS
registers/formats? (15 minutes)
Demonstrate where to report IPV coverage in HMIS format.
- Also, make them understand the fields in HMIS where AEFI data and vaccine stock
positions are to be entered.
Emphasize the usefulness of tracking tools: estimation of beneficiaries, due list registers,
tally sheets, tracking bags and counterfoils, etc.
Discuss about how coverage of DPT, hepatitis B and IPV vaccine will change when IPV
vaccine is introduced (20 minutes)
Importance of ensuring open vial policy for DPT, TT, hepatitis B and IPV vaccine is in
place through alternate vaccine delivery (15 minutes)
Open vial policy applicable to IPV. Emphasize on minimizing vaccine wastage. Explain them
that the vaccine storage points will be closely watching the IPV implementation including
vaccine wastage.
Explain how monitoring will intensify for vaccines distribution and return of unused/partial
vaccines on the day of immunization
What to do after this workshop: their role in sensitizing the social mobilizers: ASHAs and
AWWs (30 minutes)
Provide clarity on the terms full immunization and complete immunization. Ensure that all
entitlements of ASHA specific to Immunization are clearly explained to participants (`100 for
estimation of beneficiaries once in 6 months, `100 for updating due list per month, `150 per
session for mobilization to session site, `100 for each fully immunized child, and `50 per for each
completely immunized child). Remember to mention that now IPV is included as part of full
immunization incentive.
Wrap up
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Annexure 8
IPV training workshop for ASHA, AWW and link workers at block level
Agenda: IPV training workshop for ASHA, AWW and link workers at block level
Activity Person/s
responsible*
Registration
Introduction to the immunization component of the MCP card; filling and using the
counterfoil and its use through tracking bag; understanding full immunization and
complete immunization (30 minutes)
Introduce them to the revised MCP cards with emphasis on counterfoil use.
Ask all ANMs to make one entry in the card and counterfoil.
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Improving microplanning, emphasizing on estimation of beneficiaries by ASHAs/AWWs
in their catchment area (10 minutes)
Emphasize on including polio HRA as part of the microplan and estimation of
beneficiaries concept.
o Discuss process to undertake field survey.
o Preparation and updating of beneficiary due list.
Let them know that they have to undertake a very important and critical survey related to
estimation of beneficiaries for improving the microplans.
Ask them about the possible issues that they visualize that they might experience in the
estimation of beneficiaries (survey).
Use of immunization tracking bag and helping to prepare due lists for tracking (30
minutes)
Use of immunization tracking bag.
Exercise on placing immunization card in tracking bag after IPV vaccination.
New IEC materials related to IPV vaccine and how to display them (10 minutes)
Show the IPV vaccine/RI related material available.
Discuss how effectively these can be used.
Key messages regarding IPV vaccine that ASHAs/AWWs must understand for
improving vaccine coverage in the field. Emphasize on IPV vaccine messages (30
minutes)
Make ASHAs know what important messages need to be percolated in the community
regarding IPV
Critical messages related to IPV should be provided in addition to the four key messages.
o Explain their role in case any minor event or an AEFI case is reported.
o Reiterate the remember messages.
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Concept of full immunization and complete immunization & mobilizers incentive
for immunization (10 minutes)
Remember to mention that now IPV is included as part of full immunization incentive.
Interaction about way forward (15 minutes)
Explain to them what they have to do when they go back to their village/area of work.
Wrap up
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Annexure 9
Waste management
The existing immunization Central Pollution Control Board (CPCB) guidelines for biomedical waste
disposal will be applicable to IPV, including segregation of immunization waste at source and its
treatment and disposal.
The principles followed are segregation of waste at source (at the session site), transportation to the
PHC or CHC, treatment of sharps and potentially biohazardous plastic waste, disposal of sharps and
treated plastic waste through proper recycling.
Use black bag to put Use Hub Cutter to put Use red bag to put
sharps
(a) Needle caps
(b) Syringe packaging (a) Cut hub and needle of (a) Cut plastic part of syringes
(wrapper) Syringes (b) Used empty or discarded
(c) Cotton swab (b) Broken vials & ampoules unbroken vials
Dispose as
Municipal Waste
Dispose in
Recycle
Safety Pit
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