immunization notes

1
The Expanded Program On Immunization(EPI)COLD
CHAIN EQUIPMENT

• Kenneth b miriti
• HND-MED

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Cold rooms

• It is a specially built thick walled room which
  are mechanically kept cold with temperature
  regulation to the required levels

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How to work safely in a cold room

• When more than one person is working in a cold
  room care should be taken to avoid locking them
  in the room
• The cold room door is made in such a way that it
  can be opened from inside, this mechanism should
  be checked often to avoid accidental locking in
  of any body

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Cont

• Minimum time should be spent working it the cold
  roomand warm clothes should be worn to avoid cold
  infections
• The amount of fuel in the generators should be
  checked regularly and reprenished as required
• A technician should always check on the equipment
  e.g the belts, drier and compressor

5
Packing vaccines

• Vaccines should be neatly packed on the shelves
• They should be packed in order of expiry dates to
  prevent expiries
• The cold room should never be overstocked,
  vaccines should be packed with adequate space
  between them to allow for adequate air circulation

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Daily care of the cold room

• The thermometer should be read on adaily basis
  and adjusted as appropriate
• The functioning of the temperature reading sheet
  fitted in the cold room shoud be checked always
• Any unusual noise should be investigated in case
  of malfunction
• At the ed of the day all lights should be
  switched off and the door closed securely

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Weekly care

• The temperature recording sheets should be
  changed
• The alarmthat indicate unfavourable temperature
  should be checked
• The standby generator must be checked by
  switching off the mains supply, letting it run
  for 5 minutes the switching back the mains

8
Monthly care

• A major check should be carried by the
  maintainace team
• Orders should be placed for any spares and for
  the proper functioning of the cold room

9
Refrigerators1. compression

• It uses electirvc motorcompressor to circulate a
  cooling fluid called a refrigerant
• The pump compresses the refregirant from gaseous
  form to liquid form giving off heat
• The compression system circulates the refrigerant
  very quickly hence it has a much greater cooling
  effect than the absorption system

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Compression cont

• The temperature in the storage area is controlled
  by a thermostat which switches the compressor
  motor on and off at the desired temperature
• The motor of the fridge uses a higher output to
  start then run, but it still requires a constant
  supply of electricity at a steady voltage this
  limits its use to centres with steady supply of
  power.

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Absorption type

• Uses heat prodused by electricity, gas or
  kerosene to drive a cooling cycle under pipes
  produces by hydrogen
• The heat causes ammonia and water to circulate in
  a sealed system of pipes
• The ammonia fluid turns into a gas absorbing heat
  from inside air and as agas it rises circulating
  to the outside of the fridge have it condensed
  into liquid releasing the heat to the outside of
  the fridge

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How to install a refregerator

• Place it on the coolest part of the buiding
• Should be placed at leat 16 inches from the
  ceiling and 12 inches from the wall respectively
• The room should be well ventilated away from
  direct sunlight
• Keep the fridge dry by rising it with a 1-2 inch
  wooden block

13
Packing vaccines in the fridge

• Polio, measles, and BCG are placed on the coolest
  part of the fridge
• Pentavalent, rota, and ipv are palced in the
  middle shelves away from the evapolatorto avoid
  freezing them

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Packing vaccines in the fridge

• Vaccines should be neatly packed in the fridge
  leaving spaces between them to allow fro air
  circulation
• The newest vaccines are plaved on the right side
  of the fridge and there fore it is advisable to
  use the vaccines on the left side first to ensure
  a first in first out rule application
• Ice packs are stored in the frezzer compartment
  filled with water for freezing

15
Caring for the refregerator

• Mke sure you do not operate the fridge with two
  sources of power at the same time
• Check the temperature inside the fridge twice in
  a day
• If its the absoerption type check the burner
  ensure the frame is blue
• If not blue it may be due to inadequate gas
  supply thererfore adjust the supply appropriately

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• Chck for ice formation on the evapolator
• If more than 10mm thick, plan to defrost the
  fridge because thick ice will rise the
  temperatures

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Defrosting the refregerator

• Transfer the vaccines from the fridge to a cold
  box with as many ice packs as possible
• Switch off the power and leave the fridge open
  until all the ice is melt
• Remove all the loose ice with handsand dry all
  the inner parts with a clean towel
• Desist from use of instruments or sharp items to
  scrub the ice

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Defrosting continued

• When the cabinet is dry and clean close it and
  restart the fridge
• Wait till when the thermostat, shows that the
  inside temperature is 2-8
• Return all the vaccines from the cold box
• Close the door firmly

19
How to keep the vaccines cold in the fridge

• Place the vaccins in the correct compartment
• Avoid unneceesary opening of the fridge
• Ensure the mentainance of ideal temperatures of
  2-8 degrees based on twice daily temperature
  reading
• Defrost the fridge regularly
• Pack vaccines leaving air spaces inbetween, avoid
  contact with the evapolator

20
Cold boxes and vaccine carriers

• Used for keeping vaccines cool during
  trsnsportation
• Avoid opening them as much as possible, during
  transportation and distribution of vaccines
• Frozen icepacks are linned inside the wall of the
  cold box to keep the vaccines cold, they should
  be exposed for 5-10 minutes (thawing) to avoid
  freezing pentavalent, tetanus, pcv 10 and rota
  vaccines

21
Ice packs

• They are plastics filled with jerry or water
• They should be placed in the freezer compartment
  for freezing
• Ensure that the caps are well placed to avoid
  water spillage and leaks

22
thermometers

• Liquid crystal thermometer not expensive , used
  mostly for transportation and in epi fridges
• They do not operate at temperatures below the
  freezing point
• Dial thermometers they are of two types
• Used at the central, regional and district stores
• They have an alarm and can record minimum and
  amaximum temperatures

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• Can also be used during transportation of
  vaccines
• They do not have an alarm
• They do not have capacity to record minimum and
  maximum temperatures

24
Dial thermo digital

• Mainly used by ingineers during evaluation to
  determine functioning of cold chain equipment
• Thermographics they are large thermometers and
  are inbult on the walls of the cold rooms they
  graphically record the temperatures in the cold
  room on a regular basis

25
Cold chain monitoring systemtemperature recording

• Done twice dailys occur
• Cold chain monitor cardits a rectangular card
  with four windowsand a stabilizing stripnat the
  end.
• The monitor is activated when the stripe is
  removed and colour change corresponding to the
  temperature rise
• Freeze Watchit is a sealed glass ampoule which
  is filled with a coloured substance. If the
  temperature falls below -3 degrees the watch will
  burst and stain the background

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shake test

• The shake test is designed to determine whether
  adsorbed vaccines have been affected by freezing.
  After freezing, the lattice (made up of bonds
  between the adsorbent and the antigen) in a
  vaccine is broken
• Separated adsorbent tends to form larger, heavier
  granules that gradually settle at the bottom of
  the vial when this is shaken. When freezing and
  thawing cycles are repeated, the granules appear
  to increase in size and weight

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Visual difference in sedimentation rates after
shake test for detecting freeze damage to
adsorbed vaccines
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•  In a typical demonstration of the shake test,
  two identical vials of a vaccine (i.e. from the
  same batch and the same manufacturer) that is
  suspected of having been exposed to freezing
  temperatures are selected
• one of the two vials is purposely frozen and then
  thawed as the negative control, while the second
  vial serves as the vial to be tested against
  this negative control.

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SHAKE TEST CONT

• The two vials are held together in one hand and
  shaken they are then placed side by side on a
  flat surface.
• Provided the test vial has not been frozen,
  sedimentation is slower in the test vial than in
  the control vial that has been frozen and thawed
•  If the test vial has been frozen, the test and
  control vials will have similar sedimentation
  rates
• (WHO, 2017)

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VACCINE VIAL MONITOR

•  vaccine vial monitor (VVM) is a thermochromic lab
  el put on vials containing vaccines which gives a
  visual indication of whether the vaccine has been
  kept at a temperature which preserves its
  potency.

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• The labels were designed in response to the
  problem of delivering vaccines to developing
  countries where the cold chain is difficult to
  preserve, and where formerly vaccines were being
  rendered inactive and administered ineffectively
  due to their having been denatured by exposure to
  ambient temperature

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VVM ILLUSTRATION
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REFERENCES

• Milstien J, Kartoglu U, Zaffran M.(2006)
  Temperature sensitivity of vaccines. Geneva
  World Health Organization (unpublished document
  WHO/IVB/06.10)
• Burgess MA, McIntyre PB. (1999 )Vaccines and the
  cold chain is it too hot...or too cold? Med J
  Aust  171 82- pmid 10474582.
• Milhomme P. (1993)Cold chain study danger of
  freezing vaccines. Can Commun Dis Rep 1993 19
  33-8 pmid 8467304.

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immunization

• Ken B HND-MED

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MAIN OBJECTIVE

• By the end of the session the students will be
  able to define common terms used in immunization
  and describe all the vaccines in the national
  immunization schedule

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Defination of terms

• Vaccine
• It is a substance in nature dead ot attenuated
  material which is introduced into the body with
  the objective of inducing immunity againist
  diseases
• Vaccination
• Involves administration of a vaccine to the body

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What is a Vaccine?

• A vaccine is a non-pathogenic antigen that mimics
  a particular pathogen in order to elicit an
  immune response as if that actual pathogen were
  in the body.

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Types of vaccines

• Live, Attenuated Vaccines
• -Viral such as measles, mumps, rubella, oral
  polio and rota virus
• -Bacterial such as BCG
• 2. Inactivated Vaccines

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Types of vaccines

• 2. Inactivated Vaccines
• A. Whole cell vaccine
• -Viral
• -Bacterial
• B. Fractional
• 1-Protein based
• Toxoid
• Subunit
• 2-Polysaccharide based
• Pure
• conjugate

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Types of vaccines

• 2. Inactivated Vaccines
• Whole cell vaccine
• -Viral such as Hepatitis A, polio and rabies
• -Bacterial such as Pertussis

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Types of vaccines

• 2. Inactivated Vaccines
• A. Whole cell vaccine
• -Viral
• -Bacterial
• B. Fractional
• 1-Protein based
• Toxoid such as diphtheria, tetanus
• Subunit such as hepatitis B
• 2-Polysaccharide based
• Pure such as pneumococcal and meningococcal
  vaccines
• conjugate such as Haemophilus influenzae type B
  vaccine.

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Inactivated Vaccines Attenuated vaccine
High Low Vaccine dose
Short Long Antibody persistence
Frequently Infrequently Booster needed
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Types of vaccines

• Live, Attenuated Vaccines
• Live, attenuated vaccines contain a version of
  the living microbe that has been weakened in the
  lab so it cant cause disease.
• They elicit strong immune system response and
  often confer lifelong immunity with only one or
  two doses.

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Types of vaccines

• Live, Attenuated Vaccines
• live, attenuated vaccines usually need to be
  refrigerated to stay potent.
• Live, attenuated vaccines are relatively easy to
  create for certain viruses. Viruses are simple
  microbes containing a small number of genes,
• Live, attenuated vaccines are more difficult to
  create for bacteria. Bacteria have thousands of
  genes and thus are much harder to
• people who have damaged or weakened immune
  systems, such as people who undergone
  chemotherapy or have HIV, can not be given live
  vaccines..

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Types of vaccines

• Inactivated Vaccines
• Scientists produce inactivated vaccines by
  killing the disease-causing microbe with
  chemicals, heat, or radiation.
• Inactivated vaccines usually dont require
  freezing, and they can be easily stored and
  transported in a freeze-dried form, which makes
  them accessible to people in developing
  countries.

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Types of vaccines

• Inactivated Vaccines
• Most inactivated vaccines, however, stimulate a
  weaker immune system response than do live
  vaccines.
• So it would likely take several additional
  doses, or booster shots, to maintain a persons
  immunity.

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Types of vaccines

• Protein based
• Subunit Vaccines
• Instead of the entire microbe, subunit vaccines
  include only the antigens that best stimulate the
  immune system.
• This make the chances of adverse reactions to the
  vaccine lower. .

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Types of vaccines

• subunit vaccines can be made in one of two ways
• They can grow the microbe in the laboratory and
  then use chemicals to break it apart and gather
  the important antigens.
• 2.They can manufacture the antigen molecules from
  the microbe using recombinant DNA technology.
• Vaccines produced this way are called
  recombinant subunit vaccines. such as
  hepatitis B virus vaccine..

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Types of vaccines

• Scientists inserted hepatitis B genes that code
  for important antigens into common bakers yeast.
  The yeast then produced the antigens, which the
  scientists collected use in the vaccine

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Types of vaccines

• Protein based Vaccines
• Toxoid Vaccines
• These vaccines are used when a bacterial toxin
  is the main cause of illness.
• Toxins are inactivate by treating them with
  formalin.
• Vaccines against diphtheria and tetanus are
  examples of toxoid vaccines.

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Types of vaccines

• Pure polysaccharides. Vaccines
• Some bacterium possess an outer coating of sugar
  molecules called polysaccharides.
• vaccine is made up of long chain of sugar
  molecules
• infants immune system can not recognize the
  polysaccharides.

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Types of vaccines

• Conjugate Vaccines
• Some bacterium possess an outer coating of sugar
  molecules called polysaccharides.
• When making a conjugate vaccine, scientists link
  antigens or toxoids from a microbe that an
  infants immune system can recognize to the
  polysaccharides.

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• The vaccine that protects against Haemophilus
  influenzae type B (Hib) is a conjugate vaccine.
• It is made by joining a piece of the
  polysaccharide capsule that surrounds the Hib
  bacterium to a protein carrier.
• This joining process is called conjugation.

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• BCG (At birth)
• Live attenuated variant.
• 0.05ml .
• ID injection in left forearm

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local reactions swelling,
redness, or pain at the injection site.
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General policy on immunization in kenya

• Immunize all healthy children, sick children
  should be immunized when they are well
• A correct record of vaccines given should be
  indicated on the childs clinic card and the
  permanent immunization register
• Great care should be taken to maintain the cold
  chain
• All immunization should be done as a strile
  procedure, equipment should be kept clean.
• Always read the manufacturers instructions before
  administering vaccines

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• Never administer expired vaccines
• Immunization services should be integrated into
  the mch/fp clinic and the primary health care
  framework
• Vaccination sessions should be held daily in
  fixed points between 8.00am-5.00pm and
  supplemented by outreach services as approppriate

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KEPI VACCINESAND TECHNIQUE OFADMINISTRATION
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objectives

• Main objectivesDescribe the EPI vaccines and
  their administration.Learning objectives
  Identify the EPI vaccines. Discuss the
  rationale for giving each vaccine. State the
  storage temperature of each vaccine. Explain
  the National Immunization Schedule.

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• List requirements for each vaccine. Explain
  preparation of each vaccine to be administered.
  State the site for administration with the dosage
  used. Describe possible expected reactions
  after vaccination Educate the parents/guardians
  on what to do in case of a reaction.The
  following are the EPI vaccines currently in
  use BCG Oral Polio DPT/HepB-Hib
  (Pentavalent) PCV Measles Tetanus Toxoid

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Currently used vaccines

• The following are the EPI vaccines currently in
  use BCG Oral Polio DPT/HepB-Hib
  (Pentavalent) PCV Measles Tetanus Toxoid

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BcG -Bacilli calmette-Guerin vaccine

• BCG is a freeze-dried live attenuated vaccine
  prepared from Mycobacterium Bovis. It has a
  lifespan of up to 12 months from the date of
  preparation, when kept under the right
  temperature of2C to 8C.

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When should be BcG given?

• BCG vaccine should be given at birth or at
  frst contact. BCG vaccine is usually given to
  children up to the age of 5 years, if no BCG scar
  is present. Contacts of persons above 15 years
  who are not su?ering from TB and have a negative
  mantoux test, should be immunized with BCG
  immediately.

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When not to give BCG

• There are no absolute contraindications
  besides symptomatic HIV/AIDS and other known
  immune-suppression diseases e.g. cancers. BCG
  should also be withheld in cases of acute illness
  needing hospitalisation but be given ondischarge

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how to give BCG, Route and dose

• BCG is given through intradermal route, which is
  found to be the most efficient in immune
  conversion. It produces a lasting scar as an
  indicator for immunization The dose is 0.05 ml
  for children less than 1 year or 0.1 ml for
  children above 1 year.
• f) What are the requirements for administering
  BCG vaccine? Sterile AD BCG syringes with
  needles gauge 26. Sterile 2ml reconstituting
  syringe and needles gauge 21 Safety box A
  vaccine carrier with ice packs and a sponge
  Refuse bin

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How to prepare the BCG vaccine

• Always open ampoules of BCG vaccine with great
  care, because sometimes a vacuum is maintained
  inside the ampoule. Wash your hands Dilute
  the vaccine under sterile conditions with a cold
  diluent. Transfer the diluent with a dry
  sterile 2 ml syringe using gauge 21 long needle
  into the ampoule/vial containing thevaccine.
  Gently mix the vaccine well before flling the
  syringe. Withdraw the vaccine with needle and
  syringe, and then discharge it back into the
  ampouletwice or thrice to give a homogenous
  solution. If the vaccine comes in a vial, use
  non-touch technique and withdraw the diluent and
  mix

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• how to give BCG, Route and dose