FMOH_lo_res
FMOH_lo_res
FMOH_lo_res
Ministry of Health
Immunization
Distance Learning Module for the
Health Extension Programme
HEAT
Health Education and Training
HEAT in Africa
Federal Democratic Republic of Ethiopia
Ministry of Health
The Ethiopian Federal Ministry of Health (FMOH) and the Regional Health Bureaus (RHBs)
have developed this innovative Blended Learning Programme in partnership with the HEAT
Team from The Open University UK and a range of medical experts and health science
specialists within Ethiopia. Together, we are producing 13 Modules to upgrade the theoretical
knowledge of the country’s 33,000 rural Health Extension Workers to that of Health Extension
Practitioners, and to train new entrants to the service. Every student learning from these
Modules is supported by a Tutor and a series of Practical Training Mentors who deliver the
parallel Practical Skills Training Programme. This blended approach to workplace learning
ensures that students achieve all the required theoretical and practical competencies while they
continue to provide health services for their communities.
These Blended Learning Modules cover the full range of health promotion, disease prevention,
basic management and essential treatment protocols to improve and protect the health of
rural communities in Ethiopia. A strong focus is on enabling Ethiopia to meet the Millennium
Development Goals to reduce maternal mortality by three-quarters and under-5 child mortality
by two-thirds by the year 2015. The Modules cover antenatal care, labour and delivery,
postnatal care, the integrated management of newborn and childhood illness, communicable
diseases (including HIV/AIDS, malaria, TB, leprosy and other common infectious diseases),
family planning, adolescent and youth reproductive health, nutrition and food safety, hygiene
and environmental health, non-communicable diseases, health education and community
mobilisation, and health planning and professional ethics.
In time, all the Modules will be accessible from the Ethiopian Federal Ministry of Health
website at www.moh.gov.et; online versions will also be available to download from the HEAT
(Health Education and Training) website at www.open.ac.uk/africa/heat as open educational
resources, free to other countries across Africa and anywhere in the world to download and
adapt for their own training programmes.
Dr Kesetebirhan Admasu
State Minister of Health
Ethiopian Federal Ministry of Health
i
Acknowledgements
Immunization is one of the 13 Blended Learning Modules for the Ethiopian Health Extension
Programme. Together with the practical skills training sessions that accompany each of the
supported self-study texts, this programme will upgrade the Health Extension Workers who
complete the curriculum to Health Extension Practitioners at Level-IV of the Ethiopian
Occupational Standards. The upgrading programme is sponsored by the Ethiopian Federal
Ministry of Health (FMOH) and the Regional Health Bureaus (RHBs). The FMOH gratefully
acknowledges the receipt of funding for this programme from the Ethiopian Office of UNICEF
(the United Nations Children’s Emergency Fund), The Open University UK, the Alan and Nesta
Ferguson Foundation Trust UK, and AMREF (the African Medical and Research Foundation).
Immunization was produced by a team of Ethiopian experts, who were trained and supported by
experts in blended learning pedagogy from the HEAT (Health Education and Training) Team for
Africa at The Open University UK. The contributors of original material are:
· Dr Kalid Asrat, FMOH, Ethiopia
· Dr Amha Mekasha (Module Academic Coordinator) Addis Ababa University
· Dr Gavin Grant, WHO/Ethiopia EPI
· Dr Basiro Davey, The Open University
· Dr Janet Haresnape, The Open University
The Academic Editors of Immunization are Dr Basiro Davey, Deputy Director (Ethiopia), HEAT
Team at The Open University UK, and Dr Janet Haresnape, in the Department of Life Sciences
at The Open University UK. The other members of the HEAT Team are:
· Ato Mohammed Hussein Abeseko, UNICEF Ethiopia and the Federal Ministry of Health
· Ato Tedla Mulatu, AMREF Ethiopia
The cover design for Immunization is by Chris Hough, Learning and Teaching Solutions, The
Open University UK. The cover photographs are with acknowledgement to hdptcar (large
image). This file is licensed under the Creative Commons Attribution Licence http://
creativecommons.org/licenses/by/2.0. Julien Harnels (small image). This file is licensed under
the Creative Commons Attribution-Share Alike Licence http://creativecommons.org/licenses/
by-sa/2.0
We particularly wish to acknowledge our use in this Module of extracts and illustrations from
the World Health Organization’s series Immunization in Practice: A practical resource guide
for health workers in its various editions (1998, 2001, 2004, 2009), particularly Module 2 ‘The
vaccines’, Module 3 ‘The cold chain’, Module 4 ‘Ensuring safe injections’, Module 5 ‘Planning
immunization sessions to reach every infant’, Module 6 ‘Holding an immunization session’, and
Module 7 ‘Monitoring and using your data’.
The opinions expressed in this Module are those of the authors and do not necessarily reflect
the views of any of the donor organisations whose generous support made the production of
Immunization possible.
ii
Contents
Study
Session
2 Antibacterial Vaccines
3 Antiviral Vaccines
7 Immunization Safety
iv
Introduction to the Immunization Module
Many serious communicable diseases are easily preventable by immunization. The World
Health Organization estimates that it saves between two to three million lives every year
— the majority in regions with low incomes, under-developed infrastructure and large rural
populations. Immunization (vaccination) can make an enormous difference to the health of
individuals, communities, and nations like Ethiopia. The vaccine-preventable diseases included
in the National Expanded Programme on Immunization (EPI) in Ethiopia are tuberculosis,
poliomyelitis, diphtheria, pertussis (whooping cough), tetanus, measles, pneumonia and
meningitis due to Haemophilus influenzae type b, pneumonia due to pneumococcal bacteria,
diarrhoeal disease due to rotavirus infection, and hepatitis B disease. An efficient and thorough
immunization programme, in which the vaccines are stored and administered correctly, can
prevent these diseases and hence save many lives — particularly of young children.
In this Module, you will learn how immunization can lead to the development of immunity
and is therefore able to protect individuals from many life-threatening communicable diseases.
You will also learn the correct route of administration for each vaccine, and about the rare
contraindications that mean you should not vaccinate a particular child. Immunization is only
effective if vaccine management is good, and if vaccines are administered safely, so we will tell
you how to reduce the risk of adverse effects following immunization (AEFIs), and what to do
if they occur. Vaccines must be kept at the correct temperature right from the time they leave the
factory until the time they are injected into a person, or they lose their potency. How to maintain
vaccines at the correct temperature is explained in the study session on the cold chain. We will
teach you how to predict your community’s requirements for each vaccine, so that you can
order enough doses and minimise wastage. Another important aspect you will learn is how to
dispose safely of potentially hazardous waste materials, such as needles and syringes, after your
immunization sessions.
Immunization campaigns are only successful if they are managed well, and if the community
understands their significance. The importance of communication with parents and community
leaders about the benefits of immunizing infants aged under one year and women of
childbearing age (15 to 49 years) is emphasised throughout this Module. You will also learn
about the effective organisation of immunization activities at your Health Post, in outreach sites,
and in mobile teams. The ability to deliver improved immunization coverage rates and reduced
levels of dropout from immunization programmes also requires excellent record-keeping, and
thorough monitoring and evaluation of the outcomes of your activities.
The ten study sessions in this Module contain clear guidelines on how to conduct all these
important activities. Through these methods, Ethiopia has already had much success in reducing
vaccine-preventable diseases. For example, the number of reported cases of measles was over
10,000 per year in 1980; although the total estimated population has more than doubled since
then, the number of reported cases of measles was less than 1,200 in 2009. There have also been
huge reductions in the reported cases of polio and neonatal tetanus since immunization against
these diseases was introduced. Successes such as these are due to the rapid increase in the
immunization coverage rate among target populations.
Much of the credit for successful immunization campaigns is due to the activities of health
professionals like you. This is why you have such a big part to play in protecting women and
children from vaccine-preventable diseases in your community. We hope that this Module will
help you in this effort.
v
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
Study Session 1
Immunity, Vaccines and the Expanded
Programme on Immunization
Introduction
In the Communicable Diseases Module, Part 1, Study Sessions 3 and 4, you
learned that some diseases are preventable by immunization with vaccines.
Many different types of vaccines are available, and these can be enormously
successful in preventing some of the major communicable diseases
particularly those that affect children if they are used correctly. This Module
teaches you about the concepts and procedures required to deliver an
effective immunization service in your community. In this first study session,
you will learn about how the immune system protects us from infection, the
general principles underlying immunization, the types of immunity and the
types of vaccines available.
We will also explain the main features of the Expanded Programme on
Immunization (EPI) in Ethiopia, and what you as a Health Extension
Practitioner can do to help to make it successful. Immunization benefits the
whole country because it has the following general outcomes:
. It prevents millions of people dying needlessly each year.
. It has led to some diseases being eradicated from the world altogether, for
example smallpox, and others are targets for elimination, e.g. polio and
neonatal tetanus.
. It promotes health and optimal growth and development in children.
. It releases resources for other health interventions.
. It is an investment for a healthy population and a stronger economy.
1
HEAT Ethiopia
protozoa and parasites. They are also often referred to as pathogens, which
means ‘disease-causing organisms’. We will use both terms in this Module.
■ Which of the following are infectious agents: the hepatitis B virus, polio
virus, Mycobacterium tuberculosis, Neisseria gonorrhoeae, Candida
albicans, Giardia intestinalis, and Plasmodium falciparum?
□ All of these are infectious agents. The list includes two viruses (causing
hepatitis and polio), two bacteria (causing tuberculosis and gonorrhoea),
a fungus (Candida causes oral and genital thrush), one protozoan
(Giardia causes diarrhoea), and one parasite (Plasmodium causes
malaria).
The immune system is the name given to the network of cells, proteins,
tissues and organs within the body (Figure 1.1), which act together to protect
us against infectious agents. In addition to the structures shown in Figure 1.1,
the cells of the immune system also circulate in the blood and some of them
migrate through the tissues. These cells are usually known as white blood
cells, which is a confusing name because they are found throughout the body
– not just in the blood. Wherever an infectious agent gets into the body, it
will soon be detected and attacked by the immune system.
Figure 1.1 The sites in the body (in addition to the blood) where the cells and
molecules of the human immune system are concentrated. (Source: The Open
University, SXR376 Preparatory Reading, Figure 1.2)
2
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
Non-specific immunity
Non-specific immunity (also known as innate immunity — ‘innate’ means
‘already formed at birth’) includes protection from infectious agents by
mechanical barriers, such as intact skin or the mucus membranes lining the
inside of our nose, mouth, lungs, reproductive system and gut. It also
includes the actions of some kinds of white blood cells that can engulf (‘eat’)
or kill a wide range of infectious agents, without distinguishing between
them.
Specific immunity
In this study session, we will focus on specific immunity, which is the type
generated by immunization. Specific immunity is produced when the immune
system reacts specifically against one particular type of infectious agent in
ways that we will now describe.
When bacteria, viruses or other pathogens get into the body, they are
identified as ‘foreign’ by special white blood cells in the immune system,
known as helper T lymphocytes or helper T cells (Figure 1.2 overleaf).
Infectious agents are recognised as foreign because they have unique proteins
— called antigens — on their surfaces, which the helper T cells can detect.
Each type of infectious agent has its own unique antigens, so the person’s
immune system can tell which type of infectious agent has got into the body,
and direct an attack specifically against that pathogen. Some infectious agents
release antigens into the body fluids of the organism and the helper T cells
detect these too. Thus, a simple definition of an antigen is any substance that
is foreign to the organism that is exposed to it, and which the organism’s
immune system can detect specifically and attack.
You learned about the family of white blood cells called lymphocytes
(pronounced ‘lim-foh-sites’) in the study sessions on HIV/AIDS in Part 3 of
the Communicable Diseases Module.
3
HEAT Ethiopia
Figure 1.2 Three types of lymphocytes involved in the immune response against
infectious agents in the human body. (Diagram: Dr Ignacio Romero)
The surface molecules labelled CD8 and CD4 are unique ‘markers’ of these
cells
The helper T cells activate (‘help’) the rest of the immune system to attack
the specific infectious agents they have detected in our bodies. In particular,
they help two other types of lymphocytes shown in Figure 1.2. The cytotoxic
T cells kill our own cells which have become damaged or infected by viruses.
The B lymphocytes or B cells make special proteins called antibodies in
response to infectious agents getting into the body. Antibodies are proteins
made by B cells, which circulate in the blood or body fluids and attach to the
antigens in (or released by) infectious agents. Infectious agents that have
antibodies attached to them are neutralised, or destroyed, by the person’s
immune system.
The helper T cells also cause the production of long-lived memory cells,
which circulate in the body for years, sometimes for the person’s whole life.
These cells ‘remember’ that they have met the infectious agent in the past —
either during an infection, or through immunization — and they direct a rapid
and effective immune attack against it if it ever gets into the body again.
4
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
5
HEAT Ethiopia
directed against the antigens in the vaccine. After the immunization, if the
living infectious agents with the same antigens that were in the vaccine get
into the person’s body, the correct antibodies are already present and they
bind to the infectious agents. The memory cells generate a rapid immune
response from the rest of the immune system, and the infectious agents are
quickly attacked and destroyed, often before symptoms of the disease can
develop.
Vaccine doses
Some vaccines are given as a single dose, but others are given as a course of
three doses at intervals of a few weeks. Some vaccines also require a ‘booster
dose’ five to ten years after the original immunization. This is necessary to
increase the immune response and ensure an adequate level of protection.
Once established, the protection provided by immunization usually lasts for
several years, or even for life. This makes immunization a highly effective
method of giving long-lasting immunity.
□ The child will develop artificially acquired active immunity. She was
deliberately exposed to polio antigens in the vaccine, so her immunity is
artificially acquired. She produced her own antibodies and memory cells
directed against the polio antigens, so her immunity is active.
6
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
Note that herd immunity is not relevant in communicable diseases where the
main reservoir of infectious agents is the environment (e.g. tetanus), or in
other animals (e.g. rabies). Susceptible people can still be exposed to these
infectious agents, even if herd immunity is very high, because they do not
usually spread from person to person.
7
HEAT Ethiopia
8
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
9
HEAT Ethiopia
10
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
Figure 1.4 Increasing immunization coverage rates achieved in one year at Fura
Health Post in the Southern Nations, Nationalities and Peoples Region (SNNPR)
of Ethiopia. (Photo: Janet Haresnape)
11
HEAT Ethiopia
Tracing defaulters
Have you come across children who started the immunization programme,
but have not completed the schedule? These children are still at risk of
vaccine-preventable diseases. It is therefore essential to keep a proper
registration system of vaccinations, and to establish a community network for
tracing defaulters — i.e. people who fail to complete a course of
immunization or treatment. You will learn about EPI registration and
defaulter tracing in Study Session 8 and a system for identifying them in
Study Session 10.
12
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
13
HEAT Ethiopia
The diagram on the left of Figure 1.5 summarises the five operational
components listed in Box 1.2, and the diagram on the right reminds you that
in order to achieve them there must also be:
. sustainable financing
. management
. strengthening human and institutional resources.
Figure 1.5 (left) The five key immunization operations, and (right) the three
additional requirements for achieving an effective immunization service.
In the next two study sessions, you will learn the details of the antibacterial
and antiviral vaccines used in the EPI in Ethiopia.
14
Study Session 1 Immunity, Vaccines and the Expanded Programme on Immunization
15
HEAT Ethiopia
16
Study Session 2 Antibacterial Vaccines
17
HEAT Ethiopia
usually attacks the lungs, but can also affect other parts of the body,
including the bones, joints and brain. The letters, B, C and G stand for
Bacillus of Calmette and Guerin.
Bacillus describes the rod shape of the tuberculosis bacteria; Calmette and
Guerin are the names of the people who developed the vaccine.
■ What does a live-attenuated antibacterial vaccine mean?
□ Bacteria in the vaccine are alive, but they have been weakened
(attenuated) in the laboratory so that they cannot cause the disease.
BCG storage
BCG vaccine can be also affected and damaged by heat and light, so it
should be stored between +2°C and +8°C. The vaccine powder may be frozen
for long-term storage, but the diluent and the reconstituted vaccine must
never be frozen. Since BCG vaccine is easily destroyed by sunlight, the vials
containing the vaccine powder are mostly made from black or brown glass.
Some other vaccines which are supplied as powders can stay in good
condition for a long time in a refrigerator and are not spoiled as long as they
remain dry. But BCG vaccine can be spoiled and lose its strength in a very
short time. Also, since other harmful bacteria can grow in the reconstituted
BCG vaccine, it should be used within six hours of mixing the powder with
the diluent. If there is any leftover reconstituted BCG vaccine, it should be
thrown away in the correct medical waste container at the end of the
immunization session.
18
Study Session 2 Antibacterial Vaccines
For children aged over one year, the dose is twice this amount — 0.1 ml
containing 0.1 mg of BCG vaccine powder.
How to give an intradermal injection and other vaccination routes are
described in detail in Study Session 4 of this Module.
BCG vaccine is given at birth or as soon as possible thereafter. The vaccine
is given intradermally (into the top layer of the skin) in the right upper arm
in Ethiopia. This is so the injection site can be inspected later.
Table 2.1 summarises the characteristics of the BCG vaccine. The only
reason for not giving the BCG vaccine is if the newborn has symptoms of
HIV-disease, which may include a high-grade fever. You will learn more
about routes of administration and cold storage of all the common vaccines,
including BCG, in Study Sessions 4 and 6 of this Module.
Table 2.1 Summary of BCG vaccine characteristics.
Category Description
Type of vaccine Live-attenuated antibacterial vaccine
Number of doses One
Schedule At birth, or as soon as possible after birth. If not given at birth, it is
better to give within the first three months, when the infant is at greatest
risk of developing the most severe forms of TB, such as TB meningitis.
Immunization is generally ineffective at older ages.
Booster (additional dose) None
Contraindications Babies or infants showing symptoms of HIV infection
Adverse events Study Session 7 discusses AEFIs, adverse events following immunization,
more generally.
Infants aged under one year, give 0.05 mg of BCG vaccine powder
reconstituted in 0.05 ml of diluent; over one year, give 0.1 mg in 0.1 ml
of diluent
Injection site Outer upper right arm or shoulder. Routes of administration are described
in Study Session 4
Injection type Intradermal (into the top layer of skin). Types of injection are described
in Study Session 4
Storage Store between +2°C and +8°C. BCG vaccine powder may be frozen for
long-term storage, but the diluent and reconstituted vaccine must never be
frozen. Discard any reconstituted vaccine after no more than six hours.
Vaccine storage is described in Study Session 6
19
HEAT Ethiopia
Figure 2.2 A small raised swelling can be seen at the site of an intradermal
BCG injection. (Photo: AMREF Ethiopia/Demissew Bizuwork)
After approximately two weeks, a small red sore normally develops at the
injection site, which is about 10 mm in diameter (the size of the unsharpened
end of a pencil). The sore remains for about another two weeks and then
heals, leaving a small scar about 5 mm across (Figure 2.3). This is a sign that
the child has been effectively immunized. If there is no scar at the injection
site six weeks after a BCG immunization, the injection must be repeated. If
there is still no skin reaction to the second injection, the child should be
referred to a higher-level health facility.
Figure 2.3 (a) The small sore at the injection site is a sign that the child has
been effectively immunized with BCG vaccine. (b) A healed BCG vaccination
scar on the arm of an adult. (Photos: supplied by Dr Kalid Asrat and Dr Basiro
Davey)
Occasionally, there is an abnormal adverse event following BCG
immunization, such as swelling of glands in the armpit, or rarely the
formation of an abscess at the injection site (Figure 2.4).
An abscess is a collection of pus and inflamed tissue at the site of bacterial
infection. It can be due to bacterial causes other than BCG.
20
Study Session 2 Antibacterial Vaccines
21
HEAT Ethiopia
□ It consists of bacteria that have been killed so that they cannot cause the
disease.
■ What is a toxoid?
Diphtheria toxoid
Diphtheria toxoid is a sub-unit antibacterial vaccine, made from the modified
toxin (poison) produced by the bacteria Corynebacterium diphtheriae. The
vaccine protects against diphtheria, a serious bacterial infection causing a
sore throat, high fever and serious complications which can be fatal. It has
become rare in Ethiopia and most other countries where infants are routinely
vaccinated against it.
Pertussis vaccine
Pertussis vaccine is an inactivated antibacterial vaccine, which contains killed
whole bacterial cells. It protects against pertussis (also known as whooping
cough), a highly contagious, acute respiratory infection caused by the bacteria
Bordetella pertussis.
22
Study Session 2 Antibacterial Vaccines
23
HEAT Ethiopia
Category Description
Type of vaccine Five different antigens combined, including one inactivated whole-cell
vaccine, two sub-unit vaccines (toxoids), one conjugate vaccine and one
recombinant vaccine
Number of doses Three (referred to as Penta1, Penta2 and Penta3)
Schedule At 6, 10 and 14 weeks of age
Booster None in males; boosters of tetanus toxoid vaccine are given to women of
(additional doses) childbearing age
Contraindications Severe allergic reaction or encephalopathy to a previous pentavalent
immunization (see Section 2.2.5)
Adverse events Mild local reactions are common (see Section 2.2.5); rarely, injection-site
abscess
Special precautions Usually not given after six years of age because of the increased risk of
serious adverse reactions
Dosage 0.5 ml
Injection site Upper outer left thigh. Injection sites are described in Study Session 4
Injection type Intramuscular (IM). Types of injection are described in Study Session 4
Storage Store between +2°C and +8°C. Never freeze. Storage of vaccines is
described in Study Session 6
24
Study Session 2 Antibacterial Vaccines
25
HEAT Ethiopia
Vaccination status if infant aged less than At first contact Subsequent contact – Subsequent contact –
one year at time of PCV10 introduction after 4 weeks after 4 more weeks
Never received any Penta Penta1 + PCV1 Penta2 + PCV2 Penta3 + PCV3
Already received Penta1 Penta2 + PCV1 Penta3 + PCV2 PCV3
Already received Penta2 Penta3 + PCV1 PCV2 PCV3
Already received Penta3 PCV1 PCV2 PCV3
26
Study Session 2 Antibacterial Vaccines
Figure 2.6 These women are of childbearing age and should be immunized with
TT vaccine to protect them and their babies from tetanus. (Photo: AMREF
Ethiopia)
■ From your reading of Study Session 1, how do you think immunizing
women against tetanus also prevents tetanus in their newborn babies?
Figure 2.7 Make sure all pregnant women are immunized against tetanus.
Category Description
Type of vaccine Toxoid (sub-unit vaccine)
27
HEAT Ethiopia
28
Study Session 2 Antibacterial Vaccines
2.6 In conclusion
Table 2.8 summarises the antibacterial vaccines in the Expanded Programme
on Immunization (EPI) in Ethiopia. In Study Session 3, we will turn our
attention to the antiviral vaccines in the EPI.
Table 2.8 Summary of antibacterial vaccines in the current EPI in Ethiopia.
29
HEAT Ethiopia
3 At least two doses of TT vaccine (and ideally five) should also be given
to pregnant women and women of childbearing age to protect them and
their newborns from tetanus.
4 A meningococcal vaccine is available to control outbreaks of meningitis
caused by Neisseria meningitides bacteria; it is not a routine EPI vaccine.
5 To guarantee long-term protection, all doses of the routine antibacterial
vaccines in the EPI should be given. A child who misses a vaccination
should be given the missed dose as soon as possible and complete any
remaining doses at the scheduled time.
6 The EPI antibacterial vaccines are very effective and safe for infants, and
TT vaccine is safe for women of childbearing age and during pregnancy.
Adverse events following immunization are usually mild, e.g. low-grade
fever and soreness at the injection site, which can easily be managed;
serious adverse events are extremely rare.
7 Infants with minor illnesses may be immunized safely. But if they are
suffering from a high fever (38.5oC or above), they should be referred to
a health centre; delay the immunization until after they recover. Other
contraindications are HIV disease, severe allergic reaction or
encephalopathy following a previous dose of a vaccine.
30
Study Session 2 Antibacterial Vaccines
31
HEAT Ethiopia
32
Study Session 3 Antiviral Vaccines
33
HEAT Ethiopia
HepB vaccine is also available on its own as a single vaccine, which may be
given to healthworkers as a ‘booster’ to increase their protection against
infection by bloodborne hepatitis B viruses from patients. The vaccination
schedule in adults is not the same as the schedule you already know for
infants, who receive HepB vaccine as part of the pentavalent vaccine in the
Ethiopian EPI.
■ How many doses and at what ages should infants receive pentavalent
vaccine containing HepB vaccine? What is the route of administration?
The HepB component of the pentavalent vaccine is very safe and effective:
up to 95% of infants who receive all three doses of pentavalent vaccine are
protected against hepatitis B virus infection. The contraindications are the
same as already described for pentavalent vaccine: infants with a high-grade
fever should not be vaccinated until they recover. An infant who develops a
severe allergic reaction, swollen lymph glands or encephalopathy to a
previous dose of pentavalent vaccine should not be given another dose.
■ Do you remember the storage conditions for pentavalent vaccine
containing HepB vaccine and the four antibacterial vaccines?
34
Study Session 3 Antiviral Vaccines
35
HEAT Ethiopia
Category Description
Type of vaccine Live-attenuated antiviral vaccine
Number of doses Four (referred to as OPV0, OPV1, OPV2 and
OPV3), plus campaign doses
Schedule At birth, 6, 10 and 14 weeks
Additional dose If the child spits or vomits after OPV, repeat the
dose immediately; if the child has diarrhoea, give a
fifth dose at least 4 weeks after the scheduled fourth
dose
Contraindications None
Adverse events Very rarely AFP; refer immediately to a health
centre
Special precautions None
Dosage 2 drops
Administration route Into the mouth (oral)
Storage Store between +2°C and +8°C (may be frozen for
long-term storage)
■ What should you do if a baby vomits immediately after being given the
oral polio vaccine?
□ You should repeat the dose immediately; it is quite safe to give the baby
an extra dose of OPV.
Figure 3.2 (a) Measles rash covering the whole body of a child; (b)
Conjunctivitis (red, watery eyes) caused by measles. (Photos: WHO and
Ethiopian Federal Ministry of Health, 2005, Case Definition of Measles)
36
Study Session 3 Antiviral Vaccines
37
HEAT Ethiopia
Table 3.3 summarises what you should know about measles vaccine.
Table 3.3 Summary of measles vaccine immunization characteristics.
Category Description
Type of vaccine Live-attenuated antiviral vaccine
Number of doses One in routine EPI schedule, plus one in
supplementary campaigns
Schedule At 9 months in the EPI; after 12 months in
campaigns
Additional early dose At 6 months in some circumstances (see
Section 3.3.2)
Contraindications Severe allergic reaction to previous dose
Adverse events Fever, rash and (rarely) severe allergic reaction or
abscess (see Section 3.3.4)
Special precautions None
Dosage 0.5 ml
Injection site Outer upper arm
Injection type Subcutaneous
Storage Store between +2°C and +8°C (Note: the vaccine
powder may be frozen for long-term storage, but not
the diluent or the reconstituted vaccine)
38
Study Session 3 Antiviral Vaccines
The routine dose of vitamin A for a child aged 6–11 months is the drops
from one capsule (100,000 IU); the drops from two capsules (200,000 IU) are
given to children aged 12–59 months at regular intervals, every six months.
This ensures that all children are fully protected from the harmful effects of
vitamin A deficiency.
39
HEAT Ethiopia
Table 3.4 Vitamin A treatment dosages for children with measles in different age-
groups.
40
Study Session 3 Antiviral Vaccines
3.6 In conclusion
Table 3.5 summarises the current and forthcoming antiviral EPI vaccines in
Ethiopia.
Table 3.5 Summary of antiviral vaccines in the EPI in Ethiopia.
41
HEAT Ethiopia
42
Study Session 3 Antiviral Vaccines
OPV
Measles
Measles
43
HEAT Ethiopia
44
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
45
HEAT Ethiopia
□ You should:
. Wash your hands thoroughly with soap and water, and allow them to ‘air
dry’.
. Prepare all the equipment you need and lay it out on a clean tray that has
been swabbed with antiseptic solution.
. Organise your equipment to minimise the risk of injury from needles and
broken glass.
. Make sure there is a safety box nearby for the safe disposal of used
syringes and needles (Figure 4.1).
Figure 4.1 A standard safety . Make sure that children are securely held by someone they know and
box. (Photo: Basiro Davey) trust, in the correct position to enable you to give the injection
(Figure 4.2). You cannot hold the child because you need both hands to
give the injection.
Figure 4.2 The mother or another caregiver should hold the child securely like
this. (Source: WHO, 2004, Immunization in Practice, Manual 4, Ensuring Safe
Injections, Figure 4-D)
. The skin at the site of the injection should be swabbed clean with an
appropriate antiseptic solution. After giving the injection, press a clean
cotton swab onto the site until all bleeding stops.
You will learn about these and other immunization safety issues in more
detail in Study Session 7.
Syringe selection
A separate syringe should be used for each injection. BCG vaccine should be
injected using a 0.1 ml syringe; for all other EPI vaccines, use a 1 ml
syringe. Disposable syringes are supplied in sterile plastic packages and are
46
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
designed to be used once only and then put into a safety box. The safest type
recommended by the World Health Organization is the auto-disable (AD)
syringe (Figure 4.3). This has the needle already attached and a plunger
mechanism that prevents the syringe from being used a second time. If the
syringe and needle are supplied separately, when you remove a syringe from
its package, take care not to touch the syringe adapter shown in Figure 4.4.
Needle selection
The needle used should be of the appropriate diameter for the vaccine.
Typically, vaccines are not very thick liquids, and therefore a fine needle size
of 22–26 gauge (outer diameter) can be used. A new needle and syringe is
used for each injection. Note that for vaccines that need to be reconstituted
with diluent before use, you should use a separate ‘mixing’ syringe and
needle (like those shown in Figure 4.4) for reconstitution. Use a new auto-
disable (AD) syringe and needle to inject the client.
Figure 4.4 Parts of a syringe and a hollow needle, showing the areas that should
not be touched. (Source: Adapted from WHO, 2004, Immunization in Practice,
Module 4, Ensuring Safe Injections, Figures 4-B and 4-C)
Figure 4.4 shows the parts of a needle — none of which should be touched.
Open the protective wrapping around the needle and remove it without
touching the adaptor. The needle is inside a plastic outer case. Holding the
needle by the outer case, push the needle adapter onto the syringe adapter
until they ‘lock’ together firmly.
Vaccine reconstitution is taught in the next section. Diluents were introduced
in Study Session 2.
47
HEAT Ethiopia
Figure 4.5 (a) Vials. (b) Ampoules, with a metal file to ‘scratch and break’ the
neck of the ampoule. (Source: WHO, 1998, Immunization in Practice, Module 7,
During a Session: Preparing Vaccines, Figures 7-M and 7-I)
Vials and ampoules should be carefully inspected for damage or
contamination prior to use. The expiry date printed on the vial or ampoule,
or the box they came in, should be checked. The expiry date gives the last
day of the month that the vaccine or diluent can be used, unless otherwise
stated on the package labelling. Expired vaccines and diluents should never
be used. You will learn more about stock control to avoid wastage in Study
Session 5.
Check the vaccine vial monitor (VVM), which is a label that changes colour
when the vaccine vial has been exposed to heat over a period of time. The
VVM enables you to check if the vaccine has not passed the discard point
due to heat exposure. It cannot tell you if the vaccine has been damaged by
freezing. You will learn more about this, and other components of the ‘cold
chain’ for preserving vaccines, in Study Session 6.
■ What is the correct temperature for storing vaccines supplied as liquids?
48
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
49
HEAT Ethiopia
Figure 4.7 (a) Scratching and (b) breaking the neck of an ampoule.
(Source: WHO, 2004, Immunization in Practice, Module 6, Holding an
Immunization Session, p.16)
50
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
Figure 4.10 The foam pad on top of the ice-packs in a vaccine carrier.
(Photo: Janet Haresnape)
51
HEAT Ethiopia
Figure 4.12 The 0.1 ml syringe and 26 gauge needle used for BCG
immunizations. (Source: WHO, 1998, Immunization in Practice, Module 8,
During a Session: Giving Immunizations, Figure 8-A)
Ideally you should use auto-disable (AD) syringes with needles attached.
■ Why should you use a 0.1 ml syringe to inject BCG vaccine and a 1 ml
syringe for all other injected EPI vaccines?
□ The dose of BCG vaccine is very small – only 0.05 ml. In order to
measure and inject such a small dose accurately you must use a 0.1 ml
syringe. All other injected vaccines are given in doses of 0.5 ml, so you
should use a 1 ml syringe.
Figure 4.13 Needle position for intradermal injection of BCG vaccine. (Source:
WHO, 2001, Immunization in Practice, Module 2, EPI Vaccines, Figure 2-A)
52
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
Figure 4.14 Correct position of the 0.1 ml syringe and needle for BCG
immunization. (Photo: AMREF Ethiopia/Demissew Bizuwork)
The reason for injecting the vaccine in the same place (upper right arm) for
each child is to make it easy to find the BCG scar subsequently. This enables
you to check that the immunization has been effective. If the child does not
develop a sore at the injection site, which heals to form a small scar (see
Figure 2.3a in Study Session 2), the BCG vaccination should be repeated.
53
HEAT Ethiopia
Figure 4.16 Needle position for subcutaneous injection of measles and yellow
fever vaccines. (Source: WHO, 2001, as Figure 4.13, but Figure 2-B)
54
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
Figure 4.18 Holding a child for immunization by intramuscular injection into the
outer upper thigh. (Photo: Dr Kalid Asrat)
55
HEAT Ethiopia
Figure 4.20 (a) Removing a dropper from its plastic bag, and (b) fitting it on top
of a vial of OPV. (Source: WHO, 1998, Immunization in Practice, Module 8,
During a Session: Giving Immunizations, Figure 8-E)
Ask the parent or carer to hold the child firmly with the child lying on its
back. Then open the child’s mouth by squeezing the cheeks gently between
your fingers to make the child’s lips point outward. Hold the dropper over the
child’s mouth at an angle of 45 degrees (Figure 4.21) and let two drops of
the vaccine fall from the dropper onto the child’s tongue. If the child spits
out the vaccine or vomits, give another dose immediately.
Figure 4.21 OPV drops being administered to a newborn baby. (Photo: Dr Kalid
Asrat)
56
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
4.4 In conclusion
Table 4.1 summarises what you should know about the routes and sites of
administration of the EPI antibacterial and antiviral vaccines.
Table 4.1 Summary of routes of administration and injection sites of the EPI
vaccines.
57
HEAT Ethiopia
4 The injectable EPI vaccines are each given by a specific route and site:
BCG vaccine is injected intradermally into the upper right arm; measles
vaccine is injected subcutaneously into the upper arm; pentavalent vaccine
and pneumococcal vaccine (PCV10) are injected intramuscularly into
opposite upper thigh muscles; tetanus toxoid vaccine is injected
intramuscularly into the woman’s upper arm.
5 Oral polio vaccine (OPV) is given by two drops into the infant’s mouth.
Rotavirus vaccine (RotarixTM) is given as 1.5 ml of drops into the infant’s
mouth.
58
Study Session 4 Vaccine Preparation and Administration Routes of the EPI Vaccines
(a) What is the swelling in the thighs of the three sick babies, and what
could have caused it?
(b) What should Bekelech do about this problem?
SAQ 4.3 (tests Learning Outcomes 4.1, 4.2, 4.3 and 4.4)
Read Case Study 4.2 and then answer the question that follows it.
. What two things has Fatuma forgotten to do? In each case, explain
why this is important and what could happen as a result of it being
forgotten.
59
HEAT Ethiopia
60
Study Session 5 Vaccine Supply and Stock Management
61
HEAT Ethiopia
Figure 5.1 Fura kebele Health Post, in the Southern Nations, Nationalities and
Peoples Region (SNNPR) of Ethiopia, has been commended for meeting high
performance targets. (Photo: Janet Haresnape)
Before we move on, remind yourself of the meaning of some key terms from
previous study sessions.
■ What is the expiry date?
■ What is a diluent?
□ There is the risk that the vaccines will pass their expiry date before you
need to use them, so they will be wasted.
We now consider how you can determine the vaccine needs for your Health
Post. There are three methods based on:
. size of the target population for immunization
. previous vaccine consumption data
. size of the scheduled immunization sessions.
You will learn about each of these methods in the sections that follow. But
you should note that vaccine requirements are likely to vary a lot from one
62
Study Session 5 Vaccine Supply and Stock Management
kebele to another; the stocks required for your immunization programme may
be very different from the examples used in this study session.
Figure 5.2 Annual activity plan performance for immunizations in Fura kebele
with a total population of 6,348 people in 2003 E.C. (Ethiopian calendar, or 2010
in the European calendar). (Photo: Janet Haresnape)
In Figure 5.2, the column headed ‘eligible’ gives the number in the target
population for each vaccine. You can see that the health workers in this
Health Post planned to immunize 100% of the eligible children and 100% of
the pregnant women (TT+2 PW, pregnant women receiving more than 2
doses of TT vaccine). Columns headed P refer to ‘planned’ numbers for
immunization, and A are the ‘actual’ numbers immunized — in the first
quarter of the year, they exceeded their targets for all categories except
63
HEAT Ethiopia
You estimate the target population by multiplying the total population by the
percentage in a particular category; for example in Table 5.1:
Expressing a percentage as a decimal number is easy, e.g.
90% is the same as 0.9; 23% is the same as 0.23, and 4% is the same as
0.04.
. The estimated number of women eligible for TT vaccination (Figure 5.3)
is 5,000 × 23% (or 0.23) = 1,150
. The estimated number of children eligible for all other EPI vaccines is
5,000 × 4% (or 0.04) = 200, if you take the simple average of 4%. If you
use the Ministry of Health indicators of live births (3.6%) and surviving
infants (3.4%), the numbers will be 170 and 180 respectively.
Figure 5.3 About 23% of the Ethiopian population are women of childbearing
age (pregnant and non-pregnant combined). (Photo: Ali Wyllie)
64
Study Session 5 Vaccine Supply and Stock Management
■ Look back at Figure 5.2. What was the estimated target population
eligible for TT immunization in Fura kebele in the year shown?
■ If you have an estimated 200 surviving infants in your kebele, how many
doses of pentavalent vaccine would be needed to complete the EPI
schedule for all these children? Use the data on % of total population in
Table 5.1.
□ The target population is 170 surviving infants, so you would need 510
doses to complete the EPI schedule for all of them, because each
surviving infant should have three doses of pentavalent vaccine.
65
HEAT Ethiopia
If the annual target is less than 100% for a particular vaccine, you can
estimate the number of vaccine doses you will actually need as follows. Start
with the number of doses required to immunize everyone in the target
population (i.e. total coverage), and multiply that number by the agreed
(lower) percentage target for immunization coverage in your setting. We use
the letters ‘ic’ to represent the percentage target for immunization coverage in
calculations. Now look at the example in Table 5.3. (Your targets will be
different.)
Table 5.3 Estimate of actual vaccine doses needed for various percentage targets for immunization coverage in an
imaginary population of 5,000. (ic stands for immunization coverage target)
Vaccine Number of doses for 100% % coverage target Actual number of doses
coverage (ic) needed
BCG (1 dose) 200 90 180
Polio (4 doses) 800 90 720
Pentavalent (3 doses) 600 100 600
PCV10 (3 doses) 600 90 540
Measles (1 dose) 200 80 160
Tetanus toxoid (2 doses) 2,300 65 1,495
□ Total 100% coverage with three doses would require 3,450 doses. If the
coverage target is 70%, the actual doses required would be
3,450 × 0.7 = 2,415 doses.
Note that you can use the same method of calculation to estimate the number
of ampoules of specific diluents required to reconstitute the freeze-dried
vaccines (BCG and measles), and your requirement for injection equipment.
66
Study Session 5 Vaccine Supply and Stock Management
□
Wastage factor = 100 ÷ (100 – 30)
= 100 ÷ 70
= 1.43
Therefore, if 30% of the doses are wasted, the wastage factor will be
1.43.
Now you have learned how to calculate the basic values you need to estimate
your vaccine needs for the target population. These values are the target
population (pt), the number of doses in the schedule (dn), the immunization
coverage target (ic) and the wastage factor (wf).
67
HEAT Ethiopia
68
Study Session 5 Vaccine Supply and Stock Management
Figure 5.4 EPI coverage for infants aged under one year during a five year
period at Fura kebele, SNNPR, Ethiopia; years are in the Ethiopian
calendar (E.C.). (Photo: Janet Haresnape)
69
HEAT Ethiopia
■ Use the above equation to calculate the annual vaccine needs (in doses)
for pentavalent vaccine in a particular kebele, in which the initial stock
at the beginning of the year was 250 doses, and the quantity received
during the year was 1,250 doses. At the end of the year there were 500
doses remaining in stock. The quantity lost during the year was 125
doses.
□ Clearly the Health Post staff used more vaccine doses (750) in the
previous year than was predicted from the size of the target population
(718). There are several possible reasons for this, including:
. There were more surviving infants in the kebele than the 200
estimated from calculating 4% of the total population size
of 5,000.
. The Health Post staff achieved a higher immunization coverage rate
in the previous year than the 80% target they were asked to deliver.
. They wasted more doses of vaccine than expected.
70
Study Session 5 Vaccine Supply and Stock Management
Table 5.4 shows how to calculate vaccine needs based on the size of
immunization sessions in an imaginary example, using a vaccine supplied in
multi-dose vials containing 10 doses per vial.
Table 5.4 Calculation of annual vaccine needs based on the size of immunization sessions.
So the vaccine needs for this particular multi-dose vaccine, based on the size
and number of vaccination sessions = 960 doses per year.
■ Why do you think an estimate based on the size of the immunization
sessions is likely to be higher than one based on previous consumption?
Health facility staff should always use an EPI Vaccine and Injection
Materials Stock Record (see Figure 5.5 on the next page) to help them
to:
. Avoid stock shortages, especially when mass immunization
campaigns are planned.
. Avoid stock excesses, by not ordering excess stock, or exceeding the
recommended storage periods.
. Avoid situations where vaccines expire during their storage period.
. Ensure that the other necessary stocks (e.g. diluents, syringes,
needles; wick and paraffin or kerosene for refrigerators, etc.) are
ordered at the same time as the vaccines.
. Organise stock using the principle of ‘bundling’ for all supplies
required delivering an immunization session.
. Ensure that there are adequate cold chain storage facilities (both in
capacity and temperature; see Study Session 6).
71
HEAT Ethiopia
Figure 5.5 This stock record should be kept up to date at all times to ensure that
stock shortages and stock excesses are avoided.
Bundling refers to the practise of organising related stock all together in
‘bundles’ consisting of the correct numbers of all the items you need during
an immunization session:
. good quality vaccines and diluents
. auto-disable (AD) syringes (or single-use disposable syringes and needles,
if these are still used)
. safety boxes, etc.
Auto-disable (AD) syringes were mentioned in Study Session 4, and are
specially modified disposable syringes with a fixed needle; an AD syringe is
automatically disabled after it has been used once, because the plunger
cannot be pulled back a second time. The WHO recommends that
immunization programmes use AD syringes for all vaccinations, to prevent
re-use of contaminated injection equipment.
The cold chain is fully described in Study Session 6, and refers to the
network of refrigerators, cold stores, freezers, cold boxes and vaccine
carriers, and their efficient organisation and maintenance, so that vaccines are
kept at the right temperature at all times. This ensures that vaccines keep
their potency during their transportation and storage at all stages, from
leaving the factory to the point of administration to the target population.
Storage of vaccines is a major challenge. Vaccines are easily damaged during
storage if the cold chain is not maintained. Therefore it is important to divide
the vaccine supply into manageable periods for the purpose of ordering
stocks. A Health Post will usually have a shorter supply period (four weeks)
than a health centre. The next section explains how to calculate the quantities
of vaccine needed for a specific supply period.
72
Study Session 5 Vaccine Supply and Stock Management
where:
qperiod = vaccine needs for the period
qyear = annual vaccine needs
psupply = supply period (in months or weeks).
You can see an example of vaccine needs calculated in weeks in the
following question.
■ If the number of doses of vaccine required for one year in an imaginary
kebele is 2,000, how many doses would be needed for a two-week
period?
□ In this example, the annual vaccine needs qyear = 2,000 and the supply
period psupply is 2 weeks.
The vaccine needs for one week would be 2,000 doses ÷ 48 working
weeks.
So the vaccine needs for the period (qperiod) of 2 weeks is
(2,000 ÷ 48) × 2 = 83 doses.
Therefore, 83 doses would be required for a two-week period in this
example.
73
HEAT Ethiopia
□ The number of OPV doses needed at this Health Post for a 2-week
period is 80, and the minimum stock level is 20 doses, so the maximum
stock level is (80 + 20) = 100 doses. So there should be no more than
100 doses of OPV in stock when the next supply of this vaccine is
collected.
If your supplies of vaccine exceed your maximum stock level, it may be wise
to consider returning some vials to the higher level facility.
74
Study Session 5 Vaccine Supply and Stock Management
The critical stock level can be calculated using the following equation:
scritical = qdelivery + smini , where:
. scritical is the critical stock level
. qdelivery is the number of doses needed during the delivery time, and
. smini is the minimum stock level.
qdelivery = (qperiod × tdelivery) ÷ n , where:
The number of doses required during the delivery time (qdelivery) can be
calculated using the following equation:
. tdelivery is the number of days between placing the order and collecting
new vaccines
. n is the number of days in the supply period (i.e. the period that the
health facility maintains its vaccine stocks at, or above, the minimum
level).
Now attempt Activity 5.1 to calculate the critical stock level for an imaginary
Health Post. You will need paper and a pen or pencil to help you make the
calculations.
Answer
The calculation of the critical stock (or ‘time to order’) level can be done
using the equations given above Activity 5.1. First, calculate the number of
doses you will need during the delivery time (qdelivery) by using the equation:
qdelivery = (qperiod × tdelivery) ÷ n
In this Health Post, qperiod is 80 doses of OPV, tdelivery is 2 days, and the
supply period is 10 working days (2 weeks) so n is 10.
qdelivery = (80 × 2) ÷ 10 = 16 doses
The minimum stock level (smini) is 25% of 80 doses, which is 20 doses. The
critical stock level (scritical) is calculated using the equation:
scritical = qdelivery + smini
In this Health Post, qdelivery is 16 doses and smini is 20 doses, so:
scritical = (16 + 20) = 36 doses.
So the staff at this Health Post should place an order for OPV when the
critical stock level is reached at 36 doses.
75
HEAT Ethiopia
In the next study session you will learn about keeping vaccines and diluents
safe and effective by maintaining the cold chain. This is vitally important in
reducing wastage, as well as maintaining the potency of the vaccines.
76
Study Session 5 Vaccine Supply and Stock Management
77
HEAT Ethiopia
78
Study Session 6 The Cold Chain
79
HEAT Ethiopia
Vaccine Manufacturer
Figure 6.1 The cold chain. (Adapted from: WHO, 2004, Immunization in
Practice, Module 3, The Cold Chain, Figure 3A, p.2)
6.2.1 Refrigerators
A refrigerator is a cooling apparatus. Health facility refrigerators may be
powered by electricity, kerosene, paraffin, bottled gas or solar energy. Electric
refrigerators are usually the least costly to run and the easiest to maintain, but
they must have a reliable electricity supply, which is not often possible in
rural Health Posts in Ethiopia. Different refrigerators have different capacities
for storing vaccines and for freezing and storing ice-packs (Figure 6.2).
80
Study Session 6 The Cold Chain
Figure 6.3 These unfrozen (chilled water) ice-packs help to keep the refrigerator
cold during a power failure. They should always be stored vertically to avoid
possible leaks. (Photo: Basiro Davey)
81
HEAT Ethiopia
Cold boxes are quite large. At Health Post level you may instead use a
smaller insulated container called a vaccine carrier (Figure 6.4). Vaccine
carriers are also lined with conditioned ice-packs to keep vaccines and
diluents cold during transportation from the collection store at the health
centre, or on journeys to outreach sites, and for temporary storage during
Health Post immunization sessions. They are smaller than cold boxes and are
easier to carry if walking, but they do not stay cold for as long — at most
36–48 hours with the lid closed (depending on the type).
Figure 6.4 (a) A vaccine carrier lined with conditioned ice-packs. (b) This type of
vaccine carrier stays cold for a maximum of 36 hours if the lid remains closed.
(Photo: Basiro Davey)
6.2.3 Ice-packs
Ice-packs are flat, rectangular plastic bottles filled with water and then either
kept at refrigerator temperature (Figure 6.3 on the previous page), or frozen
and then conditioned for use in vaccine carriers and cold boxes (Figure 6.4a).
The number of ice-packs required for a cold box or vaccine carrier varies.
Every Health Post should have a minimum of two sets of ice-packs for each
of their cold boxes and vaccine carriers, one in the process of being frozen or
refrigerated, and the other conditioned for use in a cold box or vaccine
carrier.
Freezing ice-packs
The proper freezing and conditioning of ice-packs is essential for maintaining
the potency of vaccines. To freeze ice-packs, follow the steps in Box 6.1.
82
Study Session 6 The Cold Chain
. Fill the ice-packs with water, leaving about 20% air space at the top,
and put the cap on tightly.
. Hold each ice-pack upside down and squeeze it to make sure it does
not leak.
. Put the ice-packs upright in the freezer compartment of the
refrigerator, so that the surface of each ice-pack is touching the
evaporator plate, and close the door.
. Leave ice-packs in the freezer for at least 24 hours to freeze solid.
After 24 hours they should be ready to use.
. After each vaccination session put the melted ice-packs back in the
freezer as soon as possible.
Keep extra unfrozen ice-packs that do not fit in the freezer in the bottom part
of the main refrigerator compartment (look back at Figure 6.3). This helps
the water in these chilled ice-packs to freeze relatively quickly when you put
them into the freezer, and it also helps to keep this section of the refrigerator
cold in case of a power failure.
83
HEAT Ethiopia
During immunization sessions, the foam pad can be used as a temporary lid
to keep unopened vaccines inside the carrier cool, while providing a surface
to hold and protect opened vaccine vials and keep them cool (Figure 6.6).
Vaccines are protected from heat damage during an immunization session if
they are inserted in the foam pad above the ice-packs in the vaccine carrier.
Figure 6.5 The foam pad in a vaccine carrier has cuts to hold vials and vaccines
during an immunization session. (Photo: Janet Haresnape)
Figure 6.6 Foam pad with vaccine vials inserted. (Source: WHO, 2004, as in
Figure 6.1, p.8)
84
Study Session 6 The Cold Chain
Figure 6.7 (a) Vaccine Vial Monitors (VVMs) on the neck of an ampoule, or on
the label or cap of a vaccine vial (Source: WHO, 2004, as in Figure 6.1, p.10).
(b) A vial of liquid PCV10 vaccine (Synflorix) with the VVM on the cap (Photo:
WHO).
You should only use vaccines where the inner square in the VVM is lighter
in colour than the outside circle (Figure 6.8, top row). Vials with VVMs in
which the inner square has begun to darken, but is still lighter than the outer
circle (Figure 6.8, second row), should be used first, i.e. before vials where
the VVM square has not begun to darken. Vials with VVMs in which the Do not use vaccines that have
inner square matches the colour of the outer square, or in which the inner reached the discard point, even if
square is darker than the outer circle, have reached or gone beyond the they have not passed their expiry
date!
discard point and should not be used (Figure 6.8, bottom two rows).
Figure 6.8 How to read a vaccine vial monitor (VVM). (Source: WHO, 2004, as
in Figure 6.1, p.11)
85
HEAT Ethiopia
Figure 6.9 Freeze-tags showing: (a) ‘good status’ display; (b) ‘alarm status’
display. (Photo: WHO)
If the freeze-tag is exposed to a temperature below 0oC (with a range
between +0.3 oC and –0.3 oC) for more than 60 minutes (with a range of
between 57 to 63 minutes), the display will change from the ‘good status’
(Figure 6.9a) to the ‘alarm status’ (Figure 6.9b).
Vaccines that have been exposed to freezing may have been damaged and
should be checked by using the shake test, as described below.
86
Study Session 6 The Cold Chain
Step 2 — Choose a test vial: Take a vial (or vials) of vaccine from the batch
that you suspect has been frozen. This is the suspected frozen test vial (on
the left in Figure 6.10).
Step 3 — Shake the control and test vials: Hold the frozen control vial and
the suspected frozen test vial together in one hand and shake them vigorously
for 10–15 seconds.
Step 4 — Allow the vials to rest: Leave both vials to rest by placing them on
a table side by side and not moving them further. A freeze-sensitive vaccine
(see the vial on the right in Figure 6.10) that has not been frozen appears as a
uniformly cloudy liquid. After freezing, the vaccine tends to form flakes that
quickly settle at the bottom of the vial to form a sediment when you leave it
to rest after vigorous shaking. The speed at which the flakes settle is called
the sedimentation rate. Note that some vials have large labels that conceal the
vial contents. This makes it difficult to see the sedimentation process. In such
cases, turn the control and test vials upside down and observe sedimentation
taking place in the neck of the vials.
Step 5 — Compare the vials: Observe the difference in sedimentation rates in
the frozen control and suspected frozen test vials for a maximum of 30
minutes. View both vials against the light to compare the sedimentation rate.
If the vaccine in the suspected test vial shows a much slower sedimentation
rate than the vaccine in the frozen control vial, you can conclude that the test
vaccine has most probably not been frozen and can be used.
■ What should you conclude if the sedimentation rate is similar in the
suspected test vial and the frozen control vial?
□ You should conclude that the test vial has probably been damaged by
freezing and the vaccine should not be used.
Figure 6.10 Three vials of liquid freeze-sensitive vaccine viewed with the light
behind them: (left) frozen test vial in which a sediment has settled to the bottom
of the vial after vigorous shaking; (centre) frozen control vial in which the
sedimentation rate can be compared with the rate in a suspected frozen test vial;
(right) non-frozen test vial showing the uniformly cloudy appearance of a vaccine
that has not been damaged by freezing. (Photo: WHO)
The shake test should be conducted for all vaccines with the following
characteristics:
. Vaccines packed in boxes that have a freeze indicator (e.g. freeze tag, see
Figure 6.9), which is found to be activated.
. Refrigerator temperature records that show the temperature has fallen
below +2ºC.
87
HEAT Ethiopia
. Where you suspect that the vaccines may have been frozen by mistake,
for example by placing too close to the freezer plate in the refrigerator, or
touching frozen ice-packs.
If the vaccine fails the ‘shake test’ it must be discarded. There is no need to
conduct a shake test if a liquid vaccine vial is already frozen solid — simply
discard it. Also discard any vials that develop white lumps of sediment
attached to the glass, which cannot be dispersed despite vigorous shaking.
This can happen if pentavalent vaccine is exposed to freezing below 0ºC.
6.3.4 Thermometers
A thermometer is an instrument for monitoring the temperature of your cold
chain equipment — refrigerator, cold box or vaccine carrier. It enables you to
adjust the temperature to the correct range for the storage and transport of
vaccines.
At a Health Post, either a dial or a stem (bulb) thermometer may be used to
monitor the equipment temperature. On a dial thermometer, the needle moves
around the scale, pointing to plus (+) numbers when it is warmer, and to
minus (–) numbers when it is colder (Figure 6.11a). On a stem (or bulb)
thermometer, coloured fluid in the bulb moves up the scale as it becomes
warmer, and down the scale as it becomes colder (Figure 6.11b).
■ What temperature is showing on the thermometers in Figure 6.11? Is this
a safe temperature for the storage of liquid vaccines?
88
Study Session 6 The Cold Chain
. Do not keep opening and closing the refrigerator door, since this
raises the temperature inside the refrigerator.
. Do not put vaccines on the door shelves. The temperature in this part
of the refrigerator is too warm to store vaccines, and when the door
is opened the door shelves are instantly exposed to room
temperature.
. Discard all expired vaccines (past their expiry date), or vaccines with
VVMs that have reached or are beyond their discard point, or
vaccines that have been reconstituted for more than six hours.
. Do not return reconstituted vaccines (BCG, measles) or opened
PCV10 vials to the refrigerator. They should be discarded at the end
of the immunization session or after six hours, whichever comes
soonest.
. The refrigerator should not be packed too full. Approximately half of
the total space inside should be left empty to allow air to circulate
around the vaccines and diluents and keep them cool.
. Vaccines, diluents and ice-packs should ideally be kept in a separate
refrigerator from other items. However, if your Health Post has only
one refrigerator and you need to store other heat-sensitive supplies in
it, such as drugs, ointments, serum and blood samples, be sure to
label them clearly and keep them on a separate shelf from the
vaccines and diluents.
. Food and drinks should NEVER be stored in a vaccine refrigerator.
89
HEAT Ethiopia
90
Study Session 6 The Cold Chain
91
HEAT Ethiopia
. At the beginning of the day of the immunization session, take all the
frozen ice-packs you need from the freezer compartment of the
refrigerator and close the door.
. Allow the frozen ice-packs to sit at room temperature until the ice
begins to melt and water starts to form. This is important because if
the ice packs are too cold, freeze-sensitive vaccines may be damaged
by freezing.
. Check to see if each ice-pack has been prepared properly by shaking
it and listening for the sound of water moving around the ice inside.
Ice-packs in which the ice has begun to melt are called conditioned
ice-packs.
. Put conditioned ice-packs against each of the four sides of the cold
box or vaccine carrier, and also on the bottom of the cold box.
Ordinary plastic bottles of chilled water can also be used.
. Put the vaccines and diluents in the middle of the cold box or
carrier.
. In vaccine carriers, place a foam pad on top of the conditioned ice-
packs. In cold boxes, place conditioned ice-packs on top of the
vaccines.
. Close the lid of the cold box or vaccine carrier tightly. It is then
ready to be taken to the immunization session.
92
Study Session 6 The Cold Chain
Figure 6.14 Temperature chart, showing the safe temperature range and unsafe
temperatures that require adjustment of the thermostat, or checking that the
refrigerator is working properly. (Source: WHO, 2004, as in Figure 6.1, p.23)
93
HEAT Ethiopia
. Set the refrigerator thermostat during the coldest part of the day to
around +2ºC to +4ºC.
. Measure the temperature of the refrigerator first thing in the morning
and before you leave the Health Post in the evening. If the
temperature is between +2ºC to +8ºC, do not adjust the thermostat.
. Record the temperature at least twice every day (every morning and
every evening, seven days a week) on the refrigerator temperature
chart, as shown in Figure 6.14.
□ Based on the temperature chart in Figure 6.14, you should have noticed
that:
(a) In the morning of the 7th day of the month, the temperature of the
refrigerator was about +2ºC, which is within the acceptable
temperature range. No adjustment was needed.
(b) In the evening, the temperature had dropped to below +1ºC, which is
below the acceptable range. The thermostat should have been
adjusted to ‘warmer’, as described in the next section.
94
Study Session 6 The Cold Chain
95
HEAT Ethiopia
96
Study Session 6 The Cold Chain
Figure 6.15 A Health Extension Worker checks the kerosene tank of a kerosene
refrigerator. (Photo: Janet Haresnape)
97
HEAT Ethiopia
98
Study Session 6 The Cold Chain
SAQ 6.5 (tests Learning Outcomes 6.2, 6.3, 6.4 and 6.6)
Figure 6.17 shows a dial thermometer used to measure the temperature
of a vaccine refrigerator. Is this temperature safe for storing vaccines?
What actions should be taken?
99
HEAT Ethiopia
100
Study Session 6 The Cold Chain
101
HEAT Ethiopia
102
Study Session 7 Immunization Safety
Figure 7.1 The confidence of mothers in the safety and quality of the
immunization programme is crucial to its success. (Photo: Steve Evans, accessed
from Wikimedia Commons)
The first check on the quality of vaccines supplied to health facilities in
Ethiopia is made by a national body authorised for this purpose. Other checks
follow on their condition at every stage in the transport to health facilities
around the nation. However, once vaccines are in your care, you are
responsible for maintaining their quality by storing them at an appropriate
temperature until they are used. All vaccines are sensitive to heat, most
cannot be frozen, and some are damaged by bright light; so it is crucially
important to ensure that they are not exposed to heating or freezing, and are
kept out of direct sunlight. Therefore, as you learned in Study Session 6, the
cold chain should be maintained at all times, from the original manufacturer
of the vaccine until the moment of administration to your clients.
103
HEAT Ethiopia
□ The only EPI vaccines in Ethiopia that can be frozen are the freeze-dried
powder vaccines (BCG and measles) before reconstitution. Normally, all
vaccines should be stored at between +2ºC and +8 ºC in the main
(chilled) compartment of the vaccine refrigerator.
Expiry dates are written in the European calendar (not the Ethiopian
calendar).
. The expiry date has not been passed, i.e. the date after which the
vaccine should not be used for immunization.
. The vaccines have been stored between +2oC and +8oC under
appropriate cold chain conditions at all times.
. The vaccine vial has not been submerged in water (e.g. from leaking
ice-packs in a vaccine carrier).
. The vaccine vial monitor (VVM), if attached, has not reached its
discard point (look back at Figure 6.8 in Study Session 6).
. A new sterile needle and syringe and standard infection-control
procedures have been followed to prevent contamination of vials
when vaccine doses were withdrawn previously.
Standard procedures to reduce the risk of infection, contamination and
injuries were taught in Study Session 4.
(Source: Adapted from WHO, 2004, Immunization in Practice,
Module 3, The Cold Chain, p.16)
104
Study Session 7 Immunization Safety
□ The rubber membrane protecting the top of an opened vial has been
pierced by needles whenever previous doses were withdrawn, so water
could get into the vial if it becomes submerged.
If the conditions in Box 7.1 have been maintained, opened vials of OPV and
TT vaccines may be returned to your refrigerator at a temperature between
+2oC and +8oC after an immunization session. Put them in the ‘use first’ box
to remind you that they should be used first (before unopened vials) the next
time you give immunizations with these vaccines. (Look back at Figure 6.12
and note the position of the ‘use first’ box in the front-loaded refrigerator.)
Vaccines that should not be returned to the refrigerator after an immunization
session are:
. opened vials of reconstituted BCG and measles vaccines
. opened vials of PCV10 vaccine (which does not contain a preservative).
These vaccines must be discarded 6 hours after reconstitution, or at the end
of each immunization session — whichever comes first.
If a PCV10 vial is opened for one child and another is not immediately
available to be vaccinated with the remaining dose in the two-dose vial, you
should:
. write the time that the vial was opened on the vial so you can discard it
after 6 hours if it has not been used
. ensure that the vial is kept cool in the foam pad of the vaccine carrier
. ensure that the vial is kept away from potential contamination.
Any unopened vials of vaccine – including unopened pentavalent vaccine,
which is supplied in single-dose vials – can be returned to the refrigerator at
the end of an immunization session, providing that the expiry date has not
passed, storage under cold chain conditions has been maintained at all times,
and the VVM has not reached the discard point.
However, if the VVM indicates that the vaccine has reached its discard point,
then it should of course be thrown away and not used. Any vaccine which
has passed its expiry date should also be discarded. You will learn how to do
this safely later in this study session.
105
HEAT Ethiopia
You learned in detail about the equipment for giving safe injections in Study
Session 4. Here we will remind you of the main types that may be available
at your Health Post:
. Disposable, sterile, single-use syringes and needles, which are used once
only and then disposed of safely. They are commonly used for mixing
freeze-dried vaccines (BCG and measles) with their diluents and should
never be re-used.
. Auto-disable (AD) syringes, which are the preferred type of injection
equipment for administering vaccines and should replace all other
injection equipment if possible. These are used once and cannot be re-
used, because the plunger of the syringe cannot be pulled back again once
it has been pushed forward to inject the vaccine.
. Pre-filled, single-use syringes, which already contain a single dose of the
vaccine, and are made by the manufacturer in such a way that they can
only be used once.
All types of injection equipment must be disposed of safely after use, as
described later in this study session. But first, we remind you of the
circumstances in which immunizations should not be given.
106
Study Session 7 Immunization Safety
107
HEAT Ethiopia
108
Study Session 7 Immunization Safety
□
The reason is because the herd immunity in the population will be too You learnt about herd immunity
low to prevent the measles viruses from spreading; it can pass from in Study Session 1.
infected children to the many susceptible children who have not be
immunized.
Programme errors
A programme error is the term given to an error caused by improper use of
safety procedures or injection techniques. Common programme errors are
summarized in Box 7.3.
109
HEAT Ethiopia
Programme errors are mostly related to mistakes made by the health worker,
which can be prevented through proper training. They may also be due to
faulty equipment (e.g. a badly functioning refrigerator), or inadequate
supplies of sterile injection equipment and other essential materials.
Coincidental events
An adverse event that follows an immunization may not have any association
with the vaccine or the vaccination procedure – it may simply be due to
coincidence. For example, a child may already be in the latent period of an
infection, i.e. already infected but not yet showing any symptoms. When the
symptoms appear a day or two after the immunization, the parents may
conclude — incorrectly — that the vaccine has caused the infection. It is
important that you investigate all AEFIs and explain to parents and the
community why and how adverse events may follow an immunization simply
as a chance effect.
110
Study Session 7 Immunization Safety
Injection reactions
Sometimes the fear of being injected with a needle or the pain from the
injection may cause a child to become very upset, perhaps even fainting or
vomiting. This may also occur occasionally in women given TT vaccine.
Take care to reassure the vaccinated person and any caregiver who is with
them that the vaccine itself is harmless and their symptoms are due to
anxiety, which will rapidly disappear.
111
HEAT Ethiopia
□ Keep the site of the abscess clean. Give amoxicillin syrup three times
daily and refer the child urgently to a higher health facility.
All AEFIs, including those reported immediately during the month, should be
counted in routine, written, monthly surveillance reports. (You will learn how
to do this in Study Session 10.)
□ There will also be contaminated cotton swabs for cleaning the skin with
alcohol or antiseptic before giving an injection, and pressed onto the
injection site afterwards.
In this final section, you will learn about possible methods of disposing of
waste safely. You may not have access to the best waste disposal method, so
you may need to think about what innovations could be made to ensure that
112
Study Session 7 Immunization Safety
you keep the environment safe for the local community. You will need to
select the most appropriate disposal method and site for the particular
circumstances in your area.
Figure 7.2 (a) Safety box in an immunization clinic. (Photo: Basiro Davey); (b)
Do not overfill the safety box!
A five-litre safety box can hold about 100 needles and syringes. It is
important not to wait until the safety box is completely full before disposing
of it. It should be closed when it is about three-quarters full.
■ Can you explain why safety boxes should not be overfilled?
□ If the safety box is full, you could injure yourself on something sharp
near the top of the box when you try to add more injection equipment.
113
HEAT Ethiopia
available). Put paper under the drum, between the bricks, and set light to it so
the flames rise through the metal screen.
When the waste has completely burned and everything has cooled, put on
heavy protective gloves and carefully scrape out any tiny pieces remaining in
the bottom of the drum. Put them in a box and carry it to the Health Post
waste pit for burial (see below).
Figure 7.5 Open pit burning of healthcare waste. Note the fence around the area.
(Photo: Muluken Azage)
114
Study Session 7 Immunization Safety
SAQ 7.2 (tests Learning Outcomes 7.1, 7.2, 7.3 and 7.5)
Which of the following actions could result in an infection being
transmitted to your clients when you inject them with a vaccine? In each
case, explain why or why not.
A Allowing a freeze-sensitive vaccine to become colder than +1oC
for a short time.
B Allowing opened multi-dose vials of vaccine to become
submerged in melted water in a vaccine carrier.
115
HEAT Ethiopia
116
Study Session 7 Immunization Safety
117
HEAT Ethiopia
118
Study Session 8 Immunization Programme Management
Figure 8.1 Map of a rural kebele around Fura Health Post in the Southern
Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia. (Photo: Basiro
Davey)
. The distances (in kilometres, or travel time by walking) between the
health centre and your Health Post, and between the Health Post and the
furthest members of the community (Figure 8.2).
Figure 8.2 Routes that local people can take to reach the Health Post are visible
in this map from a rural kebele near Butajira in the Oromia region of Ethiopia.
(Photo: Ali Wyllie)
119
HEAT Ethiopia
Figure 8.3 Six steps in planning health interventions. (Diagram: Henk von
Stokkom)
120
Study Session 8 Immunization Programme Management
Step 1 Assess need: identify the problems and clarify the situation you
want to improve.
Step 2 Identify and prioritise: select your priorities for action — what
are the most important issues to tackle?
Step 3 Set goals and objectives: what is the overall goal of your
activities, what are your specific objectives (targets) and in what
timescale do you aim to achieve them?
Step 4 Develop strategy: What is your action plan? What activities,
resources (people, equipment) and finances will be needed to achieve
your objectives? How will you explain your action plan and gain
community support for it?
Step 5 Implementation: How will you deliver your plan? Do you have
everything you need to make it successful?
Step 6 Monitor and evaluate: What data will you collect and how will
you evaluate the impact and outcomes of your activities? How will you
measure progress towards meeting your objectives? Notice that in
Figure 8.3, the results of Step 6 help you improve the next cycle of
planning, beginning at Step 1.
Resource Management at Health Post level is covered in detail in the
Health Management, Ethics and Research Module.
121
HEAT Ethiopia
122
Study Session 8 Immunization Programme Management
□ The number of people who suffer from a common cold is much higher
than the number with pneumonia, but pneumonia is a much more serious
disease than the common cold. So the magnitude of the problem is
greater for the common cold, but the severity of the problem is greater
for pneumonia.
A simple scoring chart, like the one in Table 8.1, can help you to rank
priorities for each of the health problems identified in your needs assessment.
For each problem, you decide on a score from 1 to 5 for each column, where:
1 = concern about this criterion is very low
5 = concern about this criterion is very high.
Table 8.1 A simple chart for scoring and ranking priorities for health problems.
Problem Magnitude Severity Impact Feasibility Affordability Acceptability Total score Rank
Neonatal tetanus
Measles
■ In the example in Table 8.1, neonatal tetanus and measles are listed as
health problems that can be reduced by immunization. How would you
score each of these conditions based on your knowledge of these
diseases and their impact in your community?
□ We can’t guess what scores you wrote in Table 8.1, because local
circumstances will vary in different communities. But you should have
123
HEAT Ethiopia
When you have given a score to each problem in your priority chart, you add
up the scores and enter this figure in the ‘Total score’ column. You then
assign a rank to each problem according to its total score. The highest
scoring problem has a rank of 1; the next highest scoring problem has a rank
of 2, etc. Conducting an assessment like this will help to clarify your
thinking about which problems to tackle first. This will also enable you to
explain the reasons for your priorities to community members, so they
understand why you have prioritised certain activities.
□ You may have thought of other objectives, but one might be to increase
by 20% the number of women of childbearing age who receive more
than two doses of TT this year (Figure 8.4).
Notice that in all the examples above, a timescale is given for achieving the
objective, and the outcome (success or failure to meet the objective) can
easily be measured if accurate records are kept. Record keeping is covered in
Study Session 10.
Figure 8.4 Immunizing all 8.1.6 Developing strategies and activities in your action plan
women of childbearing age
After agreeing your objectives, the next task is to decide on the strategies and
with more than two doses of
activities for achieving them. This means working out the methods you will
TT vaccine protects them and
their babies. (Photo: Basiro use and the activities you will undertake, and writing a clearly stated action
Davey) plan. The action plan should include every activity to be performed during
the year, the time when that activity is to be done, who will do it, how that
124
Study Session 8 Immunization Programme Management
person (or people) will do it, and what resources will be needed. In
developing your action plan, you should ensure that your strategy and
activities are relevant to resolving the identified problems, and that they are
technically feasible, financially affordable and acceptable to the community.
■ What activities might you undertake in order to meet the objective of
updating registration of newborns in your community every month?
You can then determine the resources required (vaccines, diluents, infection
equipment, etc.) for delivering an effective immunization programme for this
target population. The next step in the action plan is to allocate people
(e.g. community volunteers), materials, time and finance to each of the
activities in your plan.
125
HEAT Ethiopia
Figure 8.5 Discuss your action plan with local officials and community leaders
to ensure community support.
Figure 8.6 Chart showing immunization coverage rates during five years at Fura
kebele, SNNPR, Ethiopia. The black bar to the right of each year shows the
number of fully immunized children. Years are given in the Ethiopian calendar
(E.C.), and correspond to 2005–2010 in the European calendar. (Photo: Basiro
Davey)
126
Study Session 8 Immunization Programme Management
Figure 8.7 Percent of babies protected at birth from neonatal tetanus, and the
pentavalent 3 and measles vaccine coverage rates in Shera Dibandibe kebele,
Oromia region, Ethiopia. (Photo: Basiro Davey)
. Dropout rates: the percentage of children and mothers not completing all
the scheduled EPI immunizations.
. Reported new cases in the community of:
◦ neonatal tetanus
◦ acute flaccid paralysis (AFP)
◦ measles in children under five years of age
◦ all vaccine-preventable diseases.
. Number of reports of adverse events following immunization (AEFIs).
. Vaccine wastage factors
. Reporting completeness, accuracy and timeliness.
You learned how to calculate vaccine wastage factors in Study Session 5.
Monitoring and reporting procedures are taught in Study Session 10.
The collection of data on your EPI progress indicators during the year will
help you to assess how well you are meeting the objectives of your action
plan. You may need to revise your activities if monitoring and evaluation
suggests that more needs to be done in order to achieve your objectives.
127
HEAT Ethiopia
Figure 8.8 The workplace flow through a Health Post (walls and roof not
shown) during an immunization session.
You need a table for registration and recording and another table to put
vaccines and accessories on. Ideally, there should be enough seats for carers
to sit on while waiting for their turn. While they are waiting, this area can
also be used to deliver information about immunization and to check the
infant immunization record cards (Figure 8.9).
128
Study Session 8 Immunization Programme Management
Figure 8.9 Women and babies waiting for immunizations; the health worker is
showing the vaccination certificate they will receive when their babies have been
immunized. (Photo: UNICEF Ethiopia)
129
HEAT Ethiopia
130
Study Session 8 Immunization Programme Management
Figure 8.10 A large shady tree can be a good place for people to wait for an
outreach session. (Photo: Basiro Davey)
Training, assistance and supportive supervision should be provided regularly
for you and the community volunteers in outreach sites, to ensure the
delivery of safe and high-quality immunization services for the local
community. Monitoring and evaluation of the outreach service, with
community input, is crucially important for its success. Regular meetings
should be organised to discuss ways of increasing the immunization coverage
locally, for example by changing the location to a more convenient site or
adding new outreach sites.
131
HEAT Ethiopia
□ You will need to pack all your equipment safely to transport it over the
required distance, while maintaining the vaccines and diluents under cold
chain conditions at all times. This may mean that you need a cold box,
which stays cold for longer than a vaccine carrier.
When you leave the outreach site, you should collect all the safety boxes and
any other waste, and take them back to your Health Post, where you can
dispose of them in a safe way (see Study Session 7). Do not leave any waste
at the site. You started your work in a clean area and it is important to leave
the site as clean as when you began. Make sure that you thank all the
community volunteers who helped you deliver a successful immunization
session that day.
132
Study Session 8 Immunization Programme Management
133
HEAT Ethiopia
SAQ 8.3 (tests Learning Outcomes 8.1, 8.2, 8.3 and 8.4)
Which of the following statements is false? In each case, explain what
is incorrect.
A Community discussion and approval is essential during the
development of your annual immunization action plan.
B If a mother has lost the immunization card for her child, you
should send her home to find it before you agree to immunize the
child.
C The percent of newborns protected at birth from neonatal tetanus
is a good indicator of progress towards achieving adequate TT doses
for their mothers during pregnancy.
D A fully immunized child has received all doses of all the EPI
vaccines scheduled for routine immunization by the age of 14 weeks.
E Accurate entries in your EPI Registration Book during each
immunization session will help you to estimate the number of doses
of vaccine needed for future sessions.
134
Study Session 8 Immunization Programme Management
135
HEAT Ethiopia
136
Study Session 9 Communication for an Effective Immunization Programme
137
HEAT Ethiopia
138
Study Session 9 Communication for an Effective Immunization Programme
Table 9.1 Top ten reasons reported by caregivers to explain why their children were
not fully immunized in Ethiopia. (Source: WHO, 2006, EPI National Survey in
Ethiopia)
Reason why child not fully immunized Caregivers giving this as the main
reason (%)
Unaware of need for immunization 22.8
Unaware of need to return for next dose 12.8
Vaccine not available 12.5
Mother too busy 6.3
Vaccinator absent 6.1
Place and time of immunization 6.0
unknown
Immunization site too far away 5.7
Family problems and/or mother ill 5.3
Fear of adverse effects following 4.0
immunization
Time of session not convenient 2.6
Stop reading for a moment and think about which of the reasons in
Table 9.1 are the most likely reasons for children not being brought for
immunization in your catchment area.
These are the issues that you should concentrate your communication
efforts on, and that should form the basis of your communication
objectives.
■ Which of the reasons listed in Table 9.1 do you think could be best
addressed by improved communication? How might you hope to address
these barriers to an effective immunization service?
139
HEAT Ethiopia
Setting objectives
You will recall from Study Session 8 that objectives always have to be
specific and the outcomes must be measurable. A well-constructed objective
identifies what will be done in order to achieve it, who will do it and where,
what resources will be used, and the timescale in which the target should be
achieved. You will also need to work out what resources are available in the
community that can be used for the communication activities that you may
wish to organise.
Having set your communication objectives, you next need to decide what
activities would be the most appropriate to help you to achieve them. You
should address the following questions:
. What message is it that you want to communicate?
. What media will be most suitable for communicating it?
. Will you be able to get the resources required?
140
Study Session 9 Communication for an Effective Immunization Programme
■ How could you evaluate whether your message was understood and
whether it has made a difference to people’s behaviour?
□ There are many possible ways you might try to evaluate the
effectiveness of your activities. Here are some suggestions (you might
have thought of others):
. You could record how many people attended the meeting or
community conversation, and who they were. You could then monitor
how many of these people have shown a change in behaviour. You
could see if these people brought their children for immunization, or
brought them more regularly than before.
. If someone who is not known to you brings their children for
immunization for the first time, you could ask how they knew the
immunization was available. This might help you to establish
whether those who were present at the meeting or community
conversation spread the message to others.
If you look back at Figure 9.1, you will see that the five key operators are
connected to one another. This is because the results of your monitoring and
evaluation help you to determine which strategies and activities are making
progress towards achieving your objectives. This information should be fed
back into your next communication analysis (Figure 9.2), so communication
improves when you find out about people’s attitudes and behaviour next time.
141
HEAT Ethiopia
■ Suppose the message you want to communicate is that there are many
diseases that are serious and may lead to death, but they can be
prevented by immunization; therefore, bringing babies and children for
immunization from an early age is beneficial. Who would your target
audience be? (Who would you want to communicate this message to?)
Figure 9.4 Mothers and other caregivers are the main target audience for
behaviour change communication about immunizing babies. (Photo: Basiro
Davey)
Once you have identified your target audience, the next step is to think about
your objective. What change in behaviour do you want your target audience
to make? This could be based on the problems you have identified in your
communication needs analysis. There are several strategies and activities that
you can use, including advocacy, community mobilisation, community
conversations and interpersonal communication — all of which are explained
in detail in the Health Education, Advocacy and Community Mobilisation
Module, Part 2. We will remind you of the main points below.
9.3.2 Advocacy
Advocacy is a process or activity that aims to influences politicians, policy-
makers and opinion leaders. In the context of EPI activities, this could refer
to an activity that aims to gain the support of stakeholders, community
leaders and local politicians, and to encourage community acceptance of and
commitment to the EPI. There are many activities and strategies that can be
used in advocacy. Here are some of them:
. lobbying
. meetings
. negotiation
. project visits
. use of information and education resources.
142
Study Session 9 Communication for an Effective Immunization Programme
■ Imagine that a new vaccine is being added to the routine EPI schedule,
but no decision has yet been reached about when it will be available for
your kebele. You may need to undertake some advocacy activities in
order to speed up the decision to make it available locally. What do you
think the most appropriate activities might be in this situation?
□ You may not have remembered all of the advantages, but your answer
should have included some of the following.
Community mobilisation:
. helps motivate the people in the community through participation and
involvement of everyone in a shared goal
. builds community capacity to identify and address community needs
. helps mobilise and release local resources
. promotes long-term commitment to sustained behaviour change and
hence sustainability of health improvements
. motivates communities to campaign for policy changes to respond
better to their health needs
. links members of the community to the available health services
. leads to a feeling of local ownership, which ultimately leads to a
more sustainable immunization programme.
In the EPI, mobilising the community is likely to enhance the programme and
hence make it much more effective. In order to mobilise the community you
will need to interact with your target audience members in person. You
should prepare your message in a clear and simple way. You can have the
interaction in community meetings, in religious places, market places, etc.
Loudspeaker messages for large community meetings may be appropriate.
You may need to use written materials — for example, you could put up
posters and distribute leaflets. Drama shows and local community radio
broadcasts may also help your communication messages to be heard and
understood.
143
HEAT Ethiopia
144
Study Session 9 Communication for an Effective Immunization Programme
. Telling the caregivers about the next immunization(s) that the child will
need.
Figure 9.6 Active listening encourages the client to trust you and express her
concerns. (Photo: Basiro Davey)
. Use appropriate visual aids. The pictures you use should be relevant to
the message you want to transmit, and appropriate to the local customs.
. Summarise what has been discussed at the end of the conversation. You
should check and confirm areas of agreement and disagreement.
□ There are many questions you might ask, for example the ones suggested
below. You may have thought of others.
145
HEAT Ethiopia
□ You could ask ‘Which immunizations has your child been given, and
what age was she when she got them?’
When asking questions, always give time for the client to think and answer.
Let the client answer freely and do not interrupt while the client is
answering.
146
Study Session 9 Communication for an Effective Immunization Programme
□ Some possible issues are listed below. You may have thought of others:
. any concerns the leaders and families may have about immunization
. any religious or traditional beliefs about disease or immunization
. barriers that may prevent people from accessing immunization
services, e.g. distance, seasonal work commitments, traditional
festivals or customs, lack of money for transport, and inconvenient
days, times or sites for immunization sessions
. the most appropriate times and locations for immunization sessions
. possible ways of reaching more children in the community
. whether immunization could be promoted by being mentioned
regularly at religious or other gatherings.
□ There are many things you might want to find out from parents, but here
are some things you may have suggested:
. what they already know about immunization
. what concerns they may have about immunization
. their traditional beliefs about disease or immunization
. any barriers to accessing existing services
. if the times and locations of immunization sessions are appropriate
. what they think about the quality of the service provided
. how they think the service could be improved.
147
HEAT Ethiopia
What can you do about negative rumours? Any negative rumours about
immunization that you hear are circulating should be communicated to your
supervisor as soon as possible. The following suggested actions cannot be
carried out by you alone, as the local Health Extension Practitioner; you will
need the full involvement of health centre officials and the district Health
Office. Immediate reporting is important and advice should be sought before
you take action.
With their approval, these are the steps you should take if you come across a
potentially damaging rumour about immunization:
148
Study Session 9 Communication for an Effective Immunization Programme
. First, try to find out what the rumour is, who was the original source of
the rumour and who is spreading the rumour now. Try to establish
whether there is any reason for the rumour spreading — there might be a
political or religious reason, or it might simply have arisen from lack of
information or incorrect information about the immunization programme.
. Once you have gathered this information, arrange a meeting with opinion
leaders such as local government officials, traditional and religious
leaders, community leaders and other health workers. In the meeting,
begin by providing information about the immunization programme and
the diseases it can prevent. Try to ensure that those present are free to ask
questions and express concerns. Discuss and reach agreement on
collective ways to correct the negative rumour and the wrong information
about the immunization service.
. Train your community volunteers on how to give the correct information
about vaccines and how to deal with the rumour.
. Distribute posters and printed materials which give correct information
about immunization to the public. Such materials may be made available
by your local health centre or to support regional or national campaigns.
In the final study session in this Module, we turn to a crucial aspect of your
immunization programme — monitoring and evaluating the outcomes.
149
HEAT Ethiopia
150
Study Session 10 Monitoring your Immunization Programme
151
HEAT Ethiopia
152
Study Session 10 Monitoring your Immunization Programme
Figure 10.2 Sample infant immunization card used in some parts of Ethiopia. Note that DPT-HepB-Hib vaccine is
referred to as pentavalent vaccine on some cards. (Federal Ministry of Health, supplied by Dr Amha Mekasha)
We now consider how you should complete the infant immunization card.
You should write down the date for each vaccine administered, or vitamin A
supplement given. Include doses of TT given to the mother if she is eligible
for a dose. Mark the next appointment date on the card and tell the mother
when and where to return for the next dose of the vaccine. Make sure that
the appointment date corresponds to a planned immunization session. Remind
the mother verbally as well as by writing on the card. Always return the card
to the mother or caregiver.
153
HEAT Ethiopia
Figure 10.3 All women of childbearing age should be entered in your EPI
Registration Book the first time they come to your Health Post, or outreach site.
Their records should also be entered in the Family Folder. (Photo: Basiro Davey)
154
Study Session 10 Monitoring your Immunization Programme
available, ask the mother the age of her infant and details of the first
immunization to help you locate the infant’s entry in the Registration Book.
For every new infant who has never been immunized, create a new entry in
the register and complete a new immunization card. For an infant who has
come to your Health Post for the first time, but has received immunizations
in another health facility, create a new entry in the register, ask for the
immunization card and mark on the register the immunizations that the infant
has already received.
Remember to record the vaccine dose and lot number in your Vaccine Stock
Register (see Study Session 5).
Figure 10.4 Sample tally sheet for recording immunizations. (Source: as in Figure 10.2)
After immunizing any woman, whether she is pregnant or not, record the
immunization in the EPI Registration Book and on the woman’s
immunization card, and mark it in the correct column of the tally sheet and
the Vaccine Stock Register. If no card is available, rely on the woman’s
history to tally the dose. For example, if a woman says she has received three
doses in the past, tally the new dose as TT4, issue a new card for the woman
and mark the card with the date.
Check that the tally sheet is complete at the end of a session. Add up the
number of doses of each vaccine that you have given during the session, and
check that the number of doses given ‘tallies’ (matches) the number recorded
in your EPI Registration Book. You will use this information to monitor your
performance and to prepare your monthly Summary Report (described in
Section 10.6) to your supervisor and the woreda health office. Keep the tally
sheets so that your supervisor can check the data quality (accuracy of
reporting).
155
HEAT Ethiopia
156
Study Session 10 Monitoring your Immunization Programme
total number of eligible infants in this age group was 205, what was the
immunization coverage rate in that period?
□ The target population data may be incorrect; there could have been more
surviving infants aged under one year than the number counted. The
number of fully immunized infants recorded may include some children
aged over one year. Children from other areas (not counted in your
target population) may have come to your Health Post for immunization.
157
HEAT Ethiopia
■ Imagine that 156 infants received the first dose of pentavalent vaccine at
your Health Post last year. The number brought back for the second dose
was 140 and the number who received the third dose was 132. What was
the Penta1 to Penta3 dropout rate for your Health Post last year?
Another way of analysing dropout rates is to start with the percentage of the
target population that attends for pentavalent 1, and compare this with the
percentage that attends for pentavalent 3. For example, imagine that 70% of
the eligible infants in a kebele are brought to you for pentavalent 1
immunization. However, you find that only 61% of the target population
complete the three-dose series of pentavalent vaccine.
■ What is the Penta1 to Penta3 dropout rate in the above example?
Figure 10.5 All children in Ethiopia should be fully immunized according to the
EPI schedule before their first birthday. (Photo: Lesley-Anne Long)
The pentavalent 1 to measles vaccine dropout rate is calculated using the
following equation:
Penta1 to measles vaccine dropout rate =
(Penta1 – measles) ÷ Penta1 × 100%, where:
. Penta1 is the number (or percentage) of infants receiving the first
pentavalent 1 dose
. measles is the number (or percentage) of infants receiving the measles
vaccine.
158
Study Session 10 Monitoring your Immunization Programme
If there is a high dropout rate between Penta1 and the measles immunization,
it suggests that there is a problem for parents of utilising (making use of) the
health services generally. A dropout rate of more than 10% indicates that the
particular Health Post has a utilisation problem — i.e. many people are not
using the services on offer.
159
HEAT Ethiopia
For continuous self-monitoring at Health Post level, we suggest you use wall
charts to record such indicators as actual immunization coverage rates for
each quarter of the year, compared with the planned targets for that period
(Figure 10.6).
Figure 10.6 Wall chart showing actual immunization coverage (number and
percentage) for the first quarter of the year, and the planned targets for the
remaining quarters at Fura Health Post in SNNPR. (Photo: Janet Haresnape)
Figure 10.7 illustrates how to enter data into an immunization monitoring
chart, in order to assess your monthly progress in meeting a 100%
immunization coverage target.
Figure 10.7 Immunization monitoring chart with examples of data for a Health
Post with a monthly target of 13 eligible infants (out of the total of 156)
immunized with Penta1 and Penta3. The bottom two rows calculate the number
and the percentage who dropped out between Penta1 and Penta3.
160
Study Session 10 Monitoring your Immunization Programme
Every Health Post should display a chart like Figure 10.7 where it can be
seen by all staff every day. The diagonal line from zero to the top right-hand
corner (labelled 100%) shows the ideal rate of progress if every eligible
infant is immunized on time.
■ What is your evaluation of the progress in meeting the Penta1 and
Penta3 immunization targets in the (fictional) Health Post in Figure 10.7?
161
HEAT Ethiopia
Table 10.3 shows you how to assess whether low immunization coverage or
high dropout rates are due to a problem of access (coming to the
immunization services) or to a problem of utilisation (usage of immunization
services). You should use the results of your assessment to identify and
prioritise problems in your immunization programme, and work out possible
solutions, as described in Section 10.4.
162
Study Session 10 Monitoring your Immunization Programme
163
HEAT Ethiopia
Figure 10.8 Box for storing immunization reminder cards. (Source: WHO 2001,
Immunization in Practice, Module 7, Monitoring and Using your Data,
Figure 7F, p.11)
164
Study Session 10 Monitoring your Immunization Programme
165
HEAT Ethiopia
This helps you to evaluate the accuracy of your recorded data and identify
and resolve any discrepancies. The district, provincial and national levels
should keep track of the completeness and timeliness of reporting at your
level, and remind you about any missing or late reports.
10.7 In conclusion
Now that you have completed this Module, you should be well prepared for
the practical skills training that accompanies it. Be proud that you have the
opportunity to improve the health of your community and save many young
lives by delivering a well-managed and effective immunization service.
166
Study Session 10 Monitoring your Immunization Programme
(b) Do the dropout rates suggest that access or utilisation is the major
problem for the immunization service in each district? Explain how
you reached your answer.
(c) What are the possible solutions for the problems in each district?
167
HEAT Ethiopia
168
Study Session 10 Monitoring your Immunization Programme
169
HEAT Ethiopia
170
Notes on the Self-Assessment Questions (SAQs) for Immunization
SAQ 1.2
Some immunity can be acquired without vaccination. This infant has
become temporarily immune to measles because he has received
maternal antibodies in his mother’s breastmilk (and possibly also across
the placenta before he was born). This type of immunity is called
naturally acquired passive immunity (‘passive’ because the antibodies
protecting the baby were made by his mother, not by his own immune
system).
SAQ 1.3
(a) The diphtheria component of the pentavalent vaccine is made from
the toxin (poison) produced by the bacteria that cause the disease;
the modified toxin is called diphtheria toxoid. This is an example of
a sub-unit vaccine.
(b) The diphtheria toxoid in the vaccine has antigens in its structure
which are unique to the diphtheria bacteria. Helper T cells in the
immune system of the immunized person recognise these antigens as
foreign. They activate other parts of the immune system to make
antibodies and memory cells, which remain circulating in the body
for a long time. If live diphtheria bacteria get into the body, the
person’s immune system is already prepared to attack them and
prevent the disease from developing.
(c) This type of immunity is called artificially acquired active immunity,
where a vaccine is used to develop active immunity against an
infection (‘active’ because the antibodies and memory cells were
made by the person’s own immune system).
171
HEAT Ethiopia
SAQ 1.4
There are many ways in which you can help to implement the EPI
services. You may have thought of the following:
. Help to increase immunization coverage rates by using every
opportunity to immunize eligible children, for example, when they
are brought to the Health Post for another reason; and by making
immunization routinely available at convenient times, preferably on a
daily basis.
. Ensuring the community is made aware of when immunizations are
available. Use any strategies you can to sustain high immunization
coverage, e.g. reminders, posters, meetings, etc.
. Increase the quality of immunization services through good
management, stock control and safe storage of vaccines and other
supplies, and using safe injection practices and disposal of waste.
. Help to reduce missed opportunities for immunization by checking if
all eligible children that you see are immunized, and tracing
defaulters (children who have not completed all the vaccinations in
the schedule).
. Help to improve public awareness and community participation in
the immunization service by involving community leaders and
groups in planning outreach sessions, so as to cover as much of the
target population as possible.
. Keep an accurate register of immunizations and report any cases of
vaccine-preventable diseases to the District Health Office.
Study Session 2
SAQ 2.1 (tests Learning Outcomes 2.1, 2.2 and 2.3)
A is false. BCG is injected intradermally (into the top layer of the
skin). The other antibacterial vaccines in the EPI are injected
intramuscularly, but only BCG and TT vaccine are injected in the
upper arm. Pentavalent vaccine and PCV10 are injected in the upper
outer thigh.
B is false. BCG vaccine is a powder which can be frozen before it is
reconstituted with diluent. The BCG diluent and all the other
antibacterial EPI vaccines will not be effective if they become
frozen.
C is true. If five doses of TT vaccine are given to a woman of
childbearing age at the correct intervals, she will receive the fifth
dose at least 2 years and 7 months after the first dose. The intervals
are TT1, then at least 4 weeks to TT2, then at least 6 months to TT3,
then at least 1 year to TT4, and then at least one more year to TT5.
D is true. Between 78% and 95% of infants who are immunized with
three doses of pentavalent vaccine at the correct intervals will be
protected against pertussis, diphtheria and tetanus. (They will also be
protected against hepatitis B and Hib diseases.)
E is true. BCG vaccine is supplied as a powder which has to be
mixed with a special diluent to activate the vaccine before use.
F is false. If a vial of pentavalent vaccine has a deposit like fine sand
at the bottom, it does not need to be thrown away; you should shake
the vial to mix the vaccine with the liquid before use.
172
Notes on the Self-Assessment Questions (SAQs) for Immunization
SAQ 2.2
The health workers in Dembi Health Post are correct. TT vaccine should
be given to all pregnant women during their first contact with a health
facility, regardless of the gestational age of their pregnancy. So Nurse
Ayele should give Birke the TT immunization.
SAQ 2.3
The completed version of Table 2.9 appears below.
Table 2.9 Adverse events following immunization with antibacterial vaccines and
their management at Health Post level.
SAQ 2.4
You should tell the mother that the sore is a result of BCG vaccination,
which will protect her baby from tuberculosis. Reassure her that this is a
normal reaction to the vaccine and that the small sore is a good sign
that the vaccine is working effectively. Tell her the sore will heal in
about two weeks and leave a small scar, which is harmless.
SAQ 2.5
This child has a high-grade fever. Give paracetamol syrup (5 ml) and
refer the child to a health centre; do not vaccinate until the child
recovers.
173
HEAT Ethiopia
Study Session 3
SAQ 3.1
The completed version of Table 3.6 appears below.
Table 3.7 Antibacterial and antiviral vaccine characteristics.
SAQ 3.2
The completed version of Table 3.7 appears below.
Table 3.7 Summary of dosage, route and schedule for the antiviral EPI vaccines.
SAQ 3.3
The completed version of Table 3.8 appears below.
Table 3.8 Adverse events following OPV and measles immunization, and their
management
174
Notes on the Self-Assessment Questions (SAQs) for Immunization
SAQ 3.4
The immunizations (if any) that these individuals should receive are as
follows:
(a) A newborn baby should be given BCG and OPV0.
(b) A ten-month-old child who has had BCG, OPV3, PCV3 and Penta3
should be given measles vaccine.
(c) An eight-month-old child who has had BCG, OPV3, PCV3 and
Penta3 should not be given any further vaccinations until he or she
is 9 months old, when measles vaccine should be given.
(d) A six-week-old child who has had BCG and OPV0 should be given
OPV1, PCV1 and Penta1.
SAQ 3.5
(a) Immunize Fatima with OPV3; it is safe to give this vaccine even
though she has mild diarrhoea. But do not give her PCV3 or Penta3
because she developed a severe allergic reaction three days after the
earlier immunization, which may have been an adverse vaccine
reaction following immunization with one of these vaccines. It is
very unlikely to have been due to the previous dose of OPV.
(b) Explain to the grandmother that it is safe for Fatima to have another
dose of OPV, and why you are not giving the child another dose of
the other two vaccines. Tell the grandmother to come back after
another four weeks; because of the diarrhoea Fatima has today, she
will need an extra (fifth) dose of OPV in four weeks’ time.
Study Session 4
SAQ 4.1
Table 4.2 Completed vaccine administration and reconstitution summary.
SAQ 4.2
(a) The red and tender swelling on the babies’ left thighs is likely to be
an abscess at the site where they received the pentavalent vaccine by
intramuscular injection the previous week. An abscess at an injection
site is usually caused by a contaminated needle or syringe, or incorrect
vaccine preparation, or incorrect injection technique. The fact that
Bekelech was so busy that day last week may have resulted in poor
adherence to standard procedures when she immunized the babies. For
example, she may have:
. used the same needle and syringe for more than one injection
175
HEAT Ethiopia
. touched the needle with unclean hands before giving the injection
. placed the needle and syringe on a table top or other unclean surface
. failed to keep the vaccine cold during the long immunization session.
(b) Bekelech should:
. Treat the abscesses by giving the babies amoxicillin syrup three
times daily and placing clean, warm compresses on the affected area.
She should ensure that the mothers take their babies to a health
centre urgently for further assessment.
. Take care in future to ensure that standard procedures are followed
when giving immunizations.
SAQ 4.3
Fatuma forgot to check the VVM on the vaccine ampoule. She checked
the expiry date of the vaccine, but this will not tell her if the vaccine
has been exposed to heat and lost its potency. She should check the
VVM and if it has passed the discard point she should discard it.
Fatuma also forgot to clean the injection site. She should clean the skin
with antiseptic solution and leave it to dry before giving the vaccination.
Pushing a needle through dirty skin could introduce an infection into the
baby’s body.
SAQ 4.4
OPV is never given to babies using a syringe as a substitute for the
glass dropper supplied with the vaccine or the dropper incorporated into
the vaccine vial. Using the correct dropper ensures that the correct dose
of OPV is given in two drops of vaccine.
Study Session 5
SAQ 5.1
The equation for calculating the annual vaccine needs, based on the size
of the target population, is:
Annual vaccine needs = pt × dn × ic × wf where:
. pt is the target population – for pentavalent vaccine this is the
number of children aged 0–11 months (calculated below)
. dn is the number of doses of vaccine in the recommended schedule
— this is 3 for pentavalent vaccine
. ic is the target immunization coverage rate — in this example it is
90%
. wf is the wastage factor (calculated below)
The number of children aged between 0–11 months is 5% (0.05) of the
total population of 5,700, which is:
5,700 × 0.05 = 285 children in this age group (5% expressed as a
decimal number is 0.05)
The wastage factor is calculated from the wastage rate of 5% using the
equation:
Wastage factor (wf) = 100 ÷ (100 – % wastage rate)
So for a wastage rate of 5%:
wf = 100 ÷ (100 – 5) = 100 ÷ 95 = 1.05
176
Notes on the Self-Assessment Questions (SAQs) for Immunization
Using the equation below to calculate the annual vaccine needs based on
the target population size:
pt × dn × ic × wf = 285 × 3 × 0.9 × 1.05 = 808 doses
So the annual pentavalent vaccine needs, based on the size of the target
population in this kebele, is 808 doses.
SAQ 5.2
The equation for calculating annual vaccine needs based on the size of
the immunization sessions is as follows:
Annual vaccine needs = posts × weeks × sessions × vials × doses;
where (for PCV10 vaccine in this example):
. posts is the number of immunization sites, which is 1
. weeks is how many weeks the immunization site operates, which is
45 in this example
. sessions is the number of sessions per week, which is 2
. vials is the number of vials used per session, which is 5
. doses is the number of doses per vial, which is 2.
So the annual vaccine needs for DPT in this example is:
1 × 45 × 2 × 5 × 2 = 900 doses.
SAQ 5.3
The wastage factor (expressed as a decimal number) is calculated from
the wastage rate (expressed as a percentage), using the following
equation:
Wastage factor (wf) = 100 ÷ (100 – % wastage rate)
In this example, the wastage rate for OPV has been set at 10%. So the
wastage factor is:
wf = 100 ÷ (100 – 10) = 100 ÷ 90 = 1.11
Therefore, the wastage factor is 1.11.
SAQ 5.4
(a) In the example given in SAQ 5.2, there are two immunization
sessions per week. Five multi-dose vials of PCV10 each containing
2 doses are used per session, so 20 doses are needed per week.
Therefore the number of doses required for a 2-week supply period
in this kebele is 40 doses.
(b) The minimum stock level is generally taken to be 25% (or 0.25) of
the requirement for the supply period, which in this example is 2
weeks. The equation needed to calculate the minimum stock level
for a 2-week period is:
smini = qperiod × 0.25 (25% expressed as a decimal number is 0.25)
where qperiod is the number of doses required for the supply period,
which in this example is 40 doses.
smini = 40 × 0.25 = 10 doses.
So the minimum stock level for PCV10 vaccine for a 2-week
period in this kebele is 10 doses.
177
HEAT Ethiopia
(c)
The maximum stock level for PCV10 for a 2-week period in this
kebele is calculated from the following equation:
smaxi = qperiod + smini
smaxi = 40 + 10 = 50 doses
(d) So the maximum stock level for PCV10 vaccine for a 2-week period
in this kebele is 50 doses.
Study Session 6
SAQ 6.1
A is false. The VVM records exposure of vaccines to heat over a
period of time, but it does not record exposure to freezing
temperatures.
B is false. Even if the expiry date has not passed, it is unsafe to use
vaccines that have reached the discard point indicated by the VVM.
C is true. A thermometer measures the temperature in a refrigerator.
D is false. Diluents can be kept at room temperature if there is not
enough space in the refrigerator, but should be chilled thoroughly
before use.
SAQ 6.2
(a) The vaccine can be used because the inner square of the VVM is
lighter than the outer circle. This means that the vaccine has not
been damaged by excessive heat.
(b) This vaccine should not be used because the inner square of the
VVM is almost as dark as the outer circle. This means that the
vaccine has been damaged by excessive heat and should be
discarded.
SAQ 6.3
The completed version of Table 6.1 appears below, with the correct
shelf for storing each vaccine marked with a cross.
Table 6.1 Storage of vaccines in a front-loading refrigerator.
SAQ 6.4
(a) Abeba must not reconstitute the vaccine using the diluent which has
been on the window ledge for several days because it will be warm.
Warm diluent damages the vaccine.
(b) Abeba should put the diluent back into the refrigerator and only use
it when it is cold again (between +2ºC and +8 ºC). She should
apologise to the parents and explain that they can either wait for
178
Notes on the Self-Assessment Questions (SAQs) for Immunization
SAQ 6.5
The thermometer shows a temperature of +22oC. This is much too high
a temperature for storing vaccines! They have to be stored between
+2oC and +8oC. This refrigerator is not working at all and must be
repaired, or the power may have been cut off. Check the gas, electricity
or kerosene supply, and call your supervisor to report the problem.
Move the vaccines and diluents into cold boxes and transport them
quickly to the nearest health centre for cold storage.
SAQ 6.6
(a) Opened vials that you are using should be put on the foam pad that
rests above the conditioned ice-packs on top of the vaccine carrier.
Make sure that the vaccine carrier is in a shady place, not in
sunshine.
(b) Unopened vials should be put inside the vaccine carrier with
conditioned ice-packs or chilled water bottles and the lid closed
until you need them.
SAQ 6.7
(a) On the morning of the 11th day of the month, the temperature of the
refrigerator had risen to above +8ºC, which is above the acceptable
temperature range. The refrigerator should have been checked on
that day. The thermostat should have been adjusted to ‘colder’. If
this action was taken, and the temperature still continued to rise, the
vaccines should have been moved into a vaccine carrier and
attempts made to repair the refrigerator or restore the power supply
(e.g. the kerosene may have run out).
(b) Figure 6.14 shows that the temperature continued to rise, and
reached about +18ºC by the morning of the 12th of the month. This
is much too high for safe storage of vaccines. It would be important
to check the VVM on any vaccines which had remained in the
refrigerator during this time, and throw away any which had reached
their discard point.
Study Session 7
SAQ 7.1
(a) A safe injection is one that does not harm the client, does not
expose the provider to any avoidable risk and does not result in
dangerous waste.
(b) Look back at Box 7.3 for descriptions of programme errors, i.e. due
to incorrect immunization practices.
SAQ 7.2
The actions that could expose your clients to infection when you
immunize them are:
B Allowing opened multi-dose vials of vaccine to become
submerged in melted water in a vaccine carrier. Contaminated water
can infect the vaccine if it leaks into the vial through the tiny holes
made by the needles used to withdraw vaccine previously.
179
HEAT Ethiopia
SAQ 7.3
(a) These are the symptoms of a severe acute allergic reaction, with
signs of shock (fast pulse and low blood pressure).
(b) You should refer the child immediately to the nearest health facility
– this is a potentially life-threatening reaction to the vaccine. As you
should know from earlier Modules, you should keep the baby warm
at all times, tell the mother to continue breastfeeding if the child
will suckle and go with them if you can. If you cannot go you
should send a clearly written referral note listing all the relevant
details.
SAQ 7.4
(a) This HIV-positive infant is well, so she can receive the birth dose of
BCG vaccine and all the routine EPI immunizations according to the
normal schedule at the age of 6 weeks.
(b) Immunization with pentavalent vaccine can result in low-grade
fever, which usually resolves within 24 hours. This is not a
contraindication, so the child should be immunized with the second
dose of pentavalent and the other routine EPI vaccines scheduled at
10 weeks.
(c) This child should not be given another pentavalent immunization.
Convulsions soon after immunization are an absolute
contraindication to further immunization with the same vaccine.
SAQ 7.5
The potential disadvantages of disposing of a safety box containing used
needles and syringes after an immunization session, using one of the
following methods, are:
(a) An incinerator at a health centre may be too far away to be a
realistic method of regular waste disposal.
(b) Burning in a metal container will leave fragments of waste that must
be scraped out of the drum and buried safely.
(c) Burning in an open pit may result in fragments being blown about
by the wind and scattered around the pit, or not being completely
burnt if the fire goes out too soon.
(d) Burying without burning in a sharps pit could result in waste being
exposed by soil being washed away, or children or animals digging
it up.
180
Notes on the Self-Assessment Questions (SAQs) for Immunization
Study Session 8
SAQ 8.1
The six planning steps in the correct sequence are:
1 assessing the community’s health needs
2 identifying and prioritising problems to be addressed
3 setting goals and objectives
4 agreeing strategies and activities in the annual action plan, including
resource requirements
5 implementing the service
6 monitoring and evaluating progress towards meeting the targets.
SAQ 8.2
You should also consider the socioeconomic impact of reducing each
problem, the feasibility of available solutions to each problem (are the
required actions realistically deliverable, and do you have adequate
resources?), and whether they are likely to be affordable within existing
budgets. Another consideration in prioritising your activities is whether
the beneficiaries in the community will find your solutions acceptable,
and whether they meet local and government concerns.
SAQ 8.3
A is true. Community discussion and approval is essential during the
development of your annual immunization action plan.
B is false. If a mother has lost the immunization card for her child,
you should not send her home. You should question her carefully to
see if she remembers what vaccines her child has received and the
date of the last immunization. Check your EPI Registration Book to
see if you can find an entry for her child’s previous immunizations
and give the next dose accordingly. If there are no available records
and there are no contraindications, give the child the appropriate EPI
vaccines based on its age.
C is true. The percentage of newborns protected at birth (PAB) from
neonatal tetanus is a good indicator of progress towards achieving
adequate TT doses for their mothers during pregnancy. The maternal
antibodies developed by women who have had TT2+ within 2 weeks
of delivery will protect their newborns from tetanus.
D is false. A fully immunized child has received all doses of all the
EPI vaccines scheduled for routine immunization — including
measles vaccine — by its first birthday.
E is true. Accurate entries in your EPI Registration Book during each
immunization session will help you to estimate the number of doses
of vaccine needed for future sessions.
SAQ 8.4
You should also tell her to bring her baby for her next dose of these
vaccines in 4 weeks’ time, at 10 weeks old, and explain that possible
side-effects of the vaccines her baby received are mild swelling and
soreness at the sites of vaccination and a slight fever, but these are
nothing to worry about.
181
HEAT Ethiopia
SAQ 8.5
(a) Before you arrive at an outreach site, the community volunteers
should prepare the area for the immunization session by setting out
a registration table and a table at which immunizations can be given,
and some chairs or other places for clients to wait for their turn. The
tables should be clean and the area should be tidy and well shaded,
so that everyone is protected from sun and rain, and the vaccines are
not exposed to heat or sunlight.
(b) Support for the community volunteers at the outreach site should be
provided in the form of adequate training and supportive
supervision, to enable you to deliver a safe and effective
immunization service with their help.
(c) Before leaving the site at the end of the outreach session you should
collect all waste and safety boxes for safe disposal back at your
Health Post, and leave the area clean and tidy — just as you found
it. Don’t forget to thank all the volunteers!
Study Session 9
SAQ 9.1
(a) A community conversation is a process of discussion with a
community group. It looks into an issue that is causing problems
locally and seeks to find collective solutions to these problems.
(b) There are many situations where you might decide to arrange a
community conversation about your immunization programme; for
example:
◦ If you have large numbers of families who do not bring their
children for immunization
◦ If you have a high dropout rate from the immunization
programme in parts of your kebele
◦ If children have had serious adverse reactions after
immunization
◦ If you believe there are negative rumours circulating in the
community about immunization.
(c) The appropriate people to invite will depend on the situation:
◦ If you have large numbers of families who do not bring their
children for immunization, you could invite representatives
of those families and also any of their neighbours who do
bring their children for immunization.
◦ If you have a high dropout rate from the immunization
programme in parts of your kebele, you could invite parents
from families whose children started their vaccinations, but
did not complete them.
◦ If children have had serious adverse reactions after
immunization, you might invite the parents of those
particular children, together with other parents whose
children were not adversely affected.
◦ If you believe there are negative rumours circulating in the
community about immunization, you might invite those who
you believe are being influenced by the rumours, together
with community leaders and other influential people in your
local community who support immunization.
182
Notes on the Self-Assessment Questions (SAQs) for Immunization
SAQ 9.2
The steps you should undertake in planning your strategy are:
1 Communication needs assessment — try to find out which parents
are not accessing the immunization programme and why this might
be.
2 Set specific and measurable objectives — identify what barriers need
to be removed in order to improve coverage rates, and what
communication activities might support this goal. Establish what
community resources you might have available to address the
problem.
3 Plan appropriate strategies or activities, e.g. a focus group with
parents, a community conversation, a meeting with opinion leaders,
etc.
4 Prepare your action plan — decide when and where the
communication activities will take place, who will lead them, who
will be invited, how you will advertise the event and ensure the right
people attend it.
5 Implement your plan.
6 Monitor and evaluate the outcomes of your communication activity
— record how many people took part, and whether they changed
their behaviour afterwards and brought their children for
immunization.
SAQ 9.3
Lack of accurate knowledge about the immunization service could be
improved by better communication. You should make sure that you
communicate the times and places for the immunization sessions
effectively, so that they are known to everyone. You could do this by
posting notices where they will easily be seen, telling all your clients
when you see them at the Health Post, or in their homes, at the market,
etc., and asking your community volunteers to tell everyone they visit.
You could ask community or religious leaders to announce the dates and
locations of immunization sessions during their own meetings.
SAQ 9.4
If you discover such a rumour, you should do the following:
. Report the rumour and seek advice from your supervisor and health
centre officials about how to deal with it.
. Collect information about the rumour — who has started it? Why do
they think that measles vaccination causes deafness? Has the rumour
started because of incorrect information, or is there some other
reason?
. Meet with opinion leaders — give them an opportunity to ask
questions, and provide clear information about the dangers of
measles and how vaccination can prevent it.
. Train community volunteers to give correct information about the
measles vaccine and how to deal with the rumour.
. Arrange meetings with concerned parents to communicate correct
information about measles vaccination.
183
HEAT Ethiopia
. Prepare posters and print materials and distribute them around your
kebele explaining in simple local language about the benefits of
measles vaccination and that it very rarely causes any bad effects.
Study Session 10
SAQ 10.1
Tally sheets should also be used to record the number of doses and the
lot number of each vaccine given during each immunization session.
This enables you to check that the number of doses given tallies
(matches) the number recorded in your Registration Book. It also acts as
a way of monitoring the number of doses given, and enables you to
complete your monthly Summary Report to the higher level. You may
also have mentioned your Vaccine Stock Register (see Study Session 5).
SAQ 10.2
The percentage of children in the target population who receive the third
dose of pentavalent vaccine (Penta3) is particularly useful, because it
indicates the continuity of use of the immunization service by parents
and caregivers. A low dropout between Penta1 and Penta3 indicates that
parents and caregivers are able to access the service.
The percentage of fully immunized children (FIC) is another particularly
useful indicator, as it demonstrates the capability of the system to
provide all the vaccines in the schedule at the appropriate times. It also
gives an indication of the public demand for the service. Low dropout
between Penta1 and measles immunization demonstrates satisfaction
with the perceived quality of the service in the community, and also that
there is not a general problem of utilisation of health services locally.
SAQ 10.3
(a) Calculation of dropout rates.
District A:
Figure 10.10 shows that 50% of infants received pentavalent 1 vaccine,
and 42% completed the three-dose schedule (using pentavalent 3
coverage as the indicator). The dropout rate is calculated using the
equation:
Penta1 to Penta3 dropout rate = (Penta1 – Penta3) ÷ Penta1 × 100%
The dropout rate in District A is therefore (50 – 42) ÷ 50 × 100 % =
16%.
District B:
Figure 10.10 shows that 85% of infants received pentavalent 1 vaccine,
but only 58% completed the three-dose schedule (received
pentavalent 3). The dropout rate in District B is therefore:
(85 – 58) ÷ 85 × 100% = 32%.
(b) In District A, the major problem is low coverage, as only 50% of
children received the first pentavalent dose, which indicates an access
problem for parents or caregivers. In District B, the major problem is
the high dropout rate of 32%, which indicates a general problem of
utilisation of health services.
184
Notes on the Self-Assessment Questions (SAQs) for Immunization
SAQ 10.4
(a) An estimated 3.6% of the population of 5,000 in the catchment area
are under one year of age and therefore eligible for measles
immunization. The total eligible population of infants in this age-
group is calculated as follows:
(b) The measles immunization coverage rate of only 60% is low, and
indicates a problem with utilisation of health services for parents or
caregivers.
(c) Possible actions you could take to try to reach more infants in the
target age group could include:
. more house-to-house visits in remote areas (using mobile teams)
. more outreach immunization sessions
. ensuring that no opportunities are missed to immunize eligible
infants with measles vaccine, e.g. if they are brought to the Health
Post for another reason, or when you are visiting the family
. more effective tracing of defaulters by checking entries in the EPI
Registration Book every month, and using reminder cards to tell you
which infants are due for their next immunization in which month.
SAQ 10.5
(a) Meseret’s mistake was leaving the Summary Report blank where she
should have recorded ‘zero’ for cases of vaccine-preventable
diseases and any serious adverse events following immunization.
(b) Meseret’s Summary Report should also have included:
. the number of vaccine vials she received as new stock during the
month
. any specific problems encountered during the reporting period,
e.g. stock shortages, transportation problems, cold chain failures, etc.
185