INTRODUCTION

‣ Universal Immunization Program is a vaccination program launched by the Government of

India in 1985.

‣ It became a part of Child Survival and Safe Motherhood Program in 1992 and is currently one
of the key areas under National Rural Health Mission (NRHM) since 2005.

Program consists of vaccination for 12 diseases -

 Tuberculosis
 Diphtheria
 Pertussis
 Tetanus,
 Poliomyelitis,
 Measles,
 Hepatitis B,
 Diarrhea,
 Japanese-Encephalitis,
 Rubella,
 Pneumonia
 Pneumococcal diseases

CONSTRAINTS

UNDER RCH I

The most common constraints of immunization success are

 Non uniform coverage

 Poor implementation
 Poor monitoring
 High dropouts
 Over reporting
 Poor injection safety
 Reorientation of staff being not carried out
 Cold chain replacement plan not made
 Vacancy of staff at field level not filled
 Poor surveillance of vaccine preventable dieses
 Poor vaccine logistics
 Poor maintenance of equipment
 Extra ordinary emphasis on polio vaccine

‣ Under RCH II

The six goals and their respective objectives with strategies to achieve these objectives are
summaries in following slides.

GOAL 1
  Districts will provide efficient and safe immunization to all infants and pregnant women.

Objectives

 Regular quality immunization sessions are planned and held.

 Adequate trained staff are empowered to provide quality immunization services.
 An annually upgraded cold chain inventory according to level of network, in order to
maintain a functional status of 90%.
 An efficient vaccine and injection equipment management and logistic system to forecast
and deliver adequate supplies of vaccines in timely manner.
 The implementation of safe injection practices and waste disposal.

Strategies

 Strategies include coordination between national and state level.

 Printing and supply of national operation guideline.
 Strengthening of supervision.
 Prioritization of under served population within districts.
 Strengthening & training of all categories of staff.
 Management of cold chain.
 Procurement installation of cold chain equipment.
 Proper inventory management.
 Cold chain maintenance and repair.
 Timely supply of vaccine.
 Phased introduction of auto disposal syringes and safety boxes.

GOAL 2

 Contribute to global polio eradication, measles mortality reduction and neonatal tetanus
elimination.

Objectives

 Polio eradication certification by 2007.

 Elimination of neonatal tetanus by 2009.
 Reduction measles mortality by 2/3 compared to 2000 estimates, by 2010.
 Achieve and maintain 70% coverage of two doses of vitamin A to children < 3 years.

Strategies

 Strategies include routine immunization for polio.

 Supplementary immunization campaigns.
 AFP virological surveillance.
 Strengthening service delivery.
 Increasing reporting and action on cases.
 Data analysis.
 Safe delivery practices.
 Targeting supplementary immunization activities.
  Strengthening measles vaccination and surveillance and response to the outbreaks.

GOAL 3

The UIP will have sufficient and sustainable funding with established adequate, accountable and
efficient fund flows.

Objectives

 Adequate and reliable financial resources and national, state and local levels for UIP to
achieve goals and objectives.
 Political commitments for adequate annual funding at all levels.

Strategies

 Strengthening national financial planning and building partnerships.

GOAL 4

Sustain demand and reduce social barriers to access immunization services.

Objectives

 Widespread support by families & communities.

 All eligible children and pregnant women are immunized.
 High level political and administrative support for immunization.

Strategies

Include coverage with print, electronic media and improve interpersonal communication.

GOAL 5

Accelerated introduction of licensed new and under utilized vaccines against diseases with
significant mortality and morbidity in India.

Objectives

‣ Institutional mechanisms in place to adequately obtained, review and utilize information for
deciding on introduction of new and under utilized vaccines.

‣ Review need for MMR or MR vaccine in India's immunization program.

▸ Review need for introduction of Japanese encephalitis vaccine.

▸ A phased introduction of Hepatitis B vaccine. Strategies

▸ Strategies include improve coordination between MoHFW, research institute, NRI and
development partners, disease burden study, surveillance and training.

GOAL 6
To monitor and use accurate, complete and timely data on vaccine preventable disease, AEFIs,
antigen coverage and drop out rates by districts.

Objectives

▸ Institutionalize surveillance of VPD's and early detection of any outbreaks.

▸ Strengthened vaccine quality and injection safety by developing monitoring system.

▸ An effective, efficient, complete and timely immunization, local recording and area monitoring
system.

URBAN MEASLES CAMPAIGN

Measles is highly contagious viral disease, occur in over crowded area and coverage of measles
vaccine is poor.

▸ These areas needed special vaccination drive which was initiated by UNICEF in 1998 covering
13 cities and in 1999-2000, 50 more cities were also covered.

▸ Now the main focus is on covering all unprotected children upto 3 years.

Age of giving MMR vaccine is 15 months.

▸ MMR can be given till 5 years of age under UIP.

‣ Greece and Bulgaria indicates low coverage of vaccination in children due to change in national
immunization schedule.

▸ Study highlights that there is need of constant supervision of national immunization program
and repeat dose of MMR in adolescents or youth.

MMR VACCINE

▸ In some places like Delhi the measles, mumps and rubella (MMR) vaccine has been introduced
in the program.

‣ It is given at 15 month of age in a dose of 0.5ml IM/SC.

▸ If measles is not received by the child till 12 months of age MMR vaccine can be given.

▸ MMR can be given till 5 years of age under the program.

ELIMINATION OF NEONATAL TETANUS

› Neonatal tetanus is a common problem in many developing countries.

▸ In some instances NNT is responsible for >50% of neonatal deaths which, themselves, may
account for >50% of all infants deaths.

▸ It is estimated that about 3,00,000 cases NNT occurred worldwide each year, of which
approximately 2/3 died.
In 1990 neonatal tetanus accounted for almost 80,000 deaths. India was finally declared free of
maternal and neonatal tetanus on May 15, 2015 by WHO.

Scientifically this disease has been eliminated by immunizing all women in reproductive age
group with tetanus toxoid.

Elimination of NNT is done by-

 Coverage of all pregnant women with two doses of tetanus toxoid

 Extensive IEC efforts to promote clean deliveries;
 Five cleans-clean hands, clean surface, clean blade, clean stump, clean cord tie.
 Providing disposable delivery kits
 Community based surveillance of neonatal deaths and investigation and control measures
in case of neonatal deaths.

Neonatal tetanus elimination is defined as less than 1 case of neonatal tetanus per 1000 live
births in every district.

Recommendation after validation of NTT elimination;

 Maintain High TT vaccination coverage to pregnant women.

 Improve institutional delivery practices
 Strengthen surveillance of NNT.

HEPATITIS B VACCINE

 Hepatitis B is viral infection that attacks the liver and can cause both acute and chronic
liver disease.
 The virus is transmitted through contact with blood or other body Fluids of an infected
person.
 It is a major Global health problem and the most serious type of viral hepatitis.
 About 2 billion people worldwide have been infected with virus and about 350 million live
with chronic infection.
 Among the vaccines, Polio is the most sensitive to heat requiring storage at -20 degree
centigrade.
 Vaccines must be stored in the freezer compartment are; Polio and Measles.
 Vaccine which must be stored in cold part but never allowed to freeze are "T Series"
vaccines (DPT, Tetanus toxoid, DT) Hepatitis B, BCG and Diluents.
 An estimated 6 lakh persons die each year due to acute or chronic consequences of
Hepatitis B.
 The Hepatitis virus is 50 to 100 times more infectious than HIV.
 Hepatitis B virus is an important occupational hazard for health workers.
 India is in an intermediate endemic state with prevalence of 2-7 %.
 Hepatitis B is preventable with a safe and effective vaccine. A vaccine against Hepatitis B
have been available since 1982. Hepatitis B vaccine is 95 % effective in preventing HBV
infection and its chronic consequences.
  First dose of hepatitis B may be given at birth or within 48 hours of delivery in institutional
deliveries. Otherwise three doses are given together with OPV and DPT doses in the dose
of 0.5 ml intramuscularly.

TYPHOID VACCINE

 Typhoid is a major public health problem in India.

 Causes heavy morbidity and mortality.
 Typhoid vaccine has been introduced in Delhi by the Directorate of safeguards all children
below 5 years of age.
 Vaccine can be given to the children above 2 years of age till 5 years of age IM.

PENTAVALENT VACCINE

 Approximately 410000 of under 5 deaths in India are due to pneumonia out of which an
estimated 70000 are caused by Haemophilus Influenzae Type B.
 Data from some developing countries such as Bangladesh, Chile and Malawi suggested
that it is a cause of over 20% of life threatening childhood pneumonia.
 Small scale studies from India have documented case fatality rate of HIB Meningitis as 11
%, and about 30% of survivors suffer from major disabilities.
 This is why HIB vaccine introduction in National immunization Program (NIP) of India has
been done.
 The Pentavalent vaccine combines 5 different vaccine in one injection to protect at least
five diseases;

I. Haemophilus Influenzae Type B diseases

II. Diphtheria

III. Pertussis

IV. Tetanus

V.Hepatitis B.

 Children immunized with the 5-in-1 vaccine don't need to be vaccinated separately with
the DPT or Hepatitis B vaccine
 All children during their first year of age should receive 3 doses of pentavalent vaccine
with an interval of at least 4 weeks between the doses.
 However children who have already started immunization with DPT and hepatitis B have
to complete their vaccination with DPT and hepatitis B only, they are not to be given
pentavalent vaccine.
 Vaccination with pentavalent must be completed within 2 years of age if the child starts
before one year of age.
 Children under 6 weeks of age, over 5 years, teenagers and adults should not be given
pentavalent vaccine because of the DPT component.

COLD CHAIN SYSTEM

  The "cold-chain" is a system of storage and transport of vaccine at low temperature from
the manufacturer to the actual vaccination site.
 In other words the success of national immunization program is highly dependant on
supply chain system for delivery of vaccines and equipments, with a functional system
that meets 6 rights of supply chain;
 The right vaccine in right quantity at the right place at the right time in the right condition
and at the right cost.
 Among the vaccines, Polio is the most sensitive to heat requiring storage at -20 degree
centigrade.
 Vaccines must be stored in the freezer compartment are; Polio and Measles.
 Vaccine which must be stored in cold part but never allowed to freeze are "T Series"
vaccines (DPT, Tetanus toxoid, DT) Hepatitis B, BCG and Diluents.
 In general all vaccine must be stored under the conditions recommended by the
manufacturer in the literature accompanying the vaccine, otherwise they may become
denatured and totally ineffective.
 Vaccine must be protected from sunlight and antiseptics.
 At the health centre, most vaccines can be stored up to 5 weeks if the refrigerator
temperature is strictly kept between 2 to 8 centigrade.
 Do not keep any used vials in the cold chain.
 Return the unused vaccine vial from the session site to the PHC on the same day in the
cold chain through alternative vaccine delivery.
 Keep the box labeled "returned unused" in the ILR for all unused vaccines that can be
used in the subsequent session, but discard vaccines that have been returned unopened
more than 3 times.

COLD-CHAIN EQUIPMENTS

 Walk in cold room (WIC): located at regional level.

 Store vaccine for 3 months. Serve 4 to 5 districts.
 Deep freezer: supplied to all districts (large) and PHC (small) to store vaccines.
 Temperature maintain between -15 degree centigrade to -25 degree centigrade.
 In case of power failure these freezers can maintain the cabinet temperature for 18 to 22
hours.
 Ice Lined Refrigerator (ILR): ILR are kept at the PHC (small) and District level (large).
 The cabinet temperature is maintained at + 2 degree centigrade to + 8 degree centigrade.
At the PHC level, ILR are used for storing all UIP vaccine. ILR are lined with tubes or Ice
packs filled with water which freezes and keeps the internal temperature at a safe level.
 All vaccines must be kept in the basket of the ILR along with the diluents.
 A Dial thermometer should be kept in the ILR and temperature recorded twice a day. At
the time of defrosting the vaccines are shifted to the cold boxes containing required
number of frozen ice packs.

COLD BOXES: Cold boxes are supplied to all peripheral centres.

 These are used mainly for transportation of the vaccines.

Vaccine Carrier: Vaccine Carriers are used to carry small quantities of vaccines (16 to 20 vials)
for the out of reach session.

 4 fully frozen ice packs are used for lining the sides, and the vials of DPT, DT, TT and
diluents should not be placed in direct contact with the frozen ice packs.
 The carriers should be closed tightly.

Day Carriers: Day Carriers are used to carry small quantities of vaccines (6 to 8) vials to a
nearby session.

 It is only used for few hours period.

Ice Packs: The ice pack contain water and no salt should be added to it. The water should be
filled up to the level mark on the side.

 If there is any leakage such ice pack should be discarded.

SHAKE TEST

The shake test to determine whether vaccine has been frozen

 DPT, hepatitis B and Tetanus toxoid vaccines can be damaged by freezing. You can find
out whether this has occurred by using the shake test.

1. Take two DPT vials, one that you think might have been frozen and another from the same
manufacturer which you KNOW has never been frozen.

2. Shake both vials.

3. Look at the vaccine inside the two vials.

4. Let the sediment settle for 15-30 minutes.

5. Again look at the vaccine inside the two vials.

POINTS TO BE NOTED DURING IMMUNIZATION

 Vaccines are not stored at the sub-centre level and must be supplied on the day of use.
 PHC must not hold more than 1 month's stock.
 Immunization must be carried out in a shade.
 The vaccines (OPV and Measles) must be kept on an ice pack or in a cup of ice during the
vaccination session.
 No direct sunlight should fall on them.
 OPV sample should be sent with fully frozen ice packs and rush to the assign laboratory
for the potency test.
 Measles vaccine should be used within 4 hours of reconstitution. Similarly BCG should not
be used after 3 hours of reconstitution.

FACTORS FOR SUCCESS OF IMMUNIZATION PROGRAM

 Good disease surveillance.

 No pathogen variations.
 Potent vaccine.
 Adequate development and/or procurement of vaccines.
 Appropriate and acceptable choice of Technologies.
 Universal vaccination (even among childhood vaccines).
 Adequate logistics, cost benefit analyses and resource mobilization.
FACTORS FOR THE FAILURE OF IMMUNIZATION PROGRAM

 Immunization sessions are not being held regularly in the community.

 Inadequate mobility of the health worker and the supervisory staff at district and state
level.
 Problem of delivery of vaccines and drugs to outreach session's site.
 In urban areas lack of adequate health infrastructure.
 Lack of trained manpower for vaccination.
 Impact of rumors of vaccine adverse event or deaths

POLIO ERADICATION PROGRAM

 Pulse Polio is an immunization campaign established by the government of India to

eliminate poliomyelitis (polio) in India by vaccinating all children under the age of five
years against the polio virus. The project fights poliomyelitis through a large-scale pulse
vaccination program and monitoring for polio cases.
 In India, vaccination against polio started in 1978 with Expanded Program on
Immunization (EPI). By 1984, it covered around 40% of infants, giving three doses of OPV
to each.
 In 1985, the UIP was launched to cover all the districts of the country. UIP became a part
of child survival and safe motherhood program (CSSM) in 1992 and Reproductive and
 Child Health Program (RCH) in 1997. This program led to a significant increase in
coverage, up to 95%.
 In 1995, following the Global Polio Eradication Initiative of the World Health Organization
(1988), India launched Pulse Polio immunization program with Universal Immunization
Program which aimed at 100% coverage.

Strategies to eradicate polio

 Routine immunization: Immunize every child age <1 year with at least 4 doses of OPV
through UIP.
 National immunization days (NIDs)/Pulse Polio Immunization (PPI) program/Sub-National
Immunization days(SNIDs): Conducted by giving additional doses of OPV, 4 to 6 weeks
apart to every child age less than 5 years.
 Intensification of the pulse polio immunization program has been done by adding
additional rounds at fixed booths followed by house to house "search and vaccinate"
component.

► National immunization day: In India transmission of polio has been fluctuating so it has been
decided that there is a need to make extra efforts to reach the unreached during pulse polio
immunization days. for that reason intensified pulse polio immunization was proposed and just
after the national immunization day (Polio Ravivaar).

 Immunization team would visit house to house with a vaccine to check whether the child
has received pulse polio vaccine and if not then child must be given a dose of that time
only.

► Surveillance of acute flaccid paralysis AFP: to identify all reservoirs of wild polio virus
transmission surveillance of AFP has been started. AFP is now defined as "any child is less than
15 years of age who have sudden onset of flaccid paralysis or paralytic illness in a person of any
age when polio suspected."

Steps involved

 Setting up of booths in all parts of the country.

 Initializing walk-in cold rooms, freezer rooms, deep freezers, ice-lined refrigerators and
cold boxes for a steady supply of vaccine to booths.
 Arranging employees, volunteers, and vaccines.
 Ensuring vaccine vial monitor on each vaccine vial.
 Immunizing children with OPV on national immunization days.
 Identifying missing children from immunization process.
 Surveillance of efficacy.

▸ Publicity was extensive and included replacing the national telecoms' authority ringtone with a
vaccination day awareness message, posters, TV and cinema spots, parades, rallies, and one-
to-one communication from volunteers.

Vaccination booths were set up, with a house-to- house campaign for remote communities.
  On 27 March 2014, the World Health Organization (WHO) declared India a polio free
country

Role of nurse in immunization

Nurses strive to make sure that all parents are up to date on their children's routine vaccination
schedule. Nurses have a fantastic opportunity to spread the word about the advantages of
immunization and inspire people to keep their immunization records up to date in order to
safeguard themselves against infectious diseases. Let's examine the critical function that nurses
play in the immunization process and how they can motivate parents to get their kids ready for
the start of the new school year.

Communication

According to recent surveys, more than 74% of parents believe the vaccination recommendations
made to them by pediatric healthcare professionals. Nurses play a crucial role in giving that
advice and assisting parents in making decisions regarding their child's vaccinations because
they are the first line of communication and care for the patient. It's critical for nursing
professionals to stay up to date on immunization news, safety concerns, and new research
showing the advantages of following vaccination schedules.

Health Education

A scientific education that emphasizes prevention and combines treatment is health education.
Its goals are to give the audience a correct and thorough understanding of the illness, enhance
people's capacity for self-defense, and make it possible for them to receive efficient care in social
situations. To establish a correct, uplifting, and self-improving ideology, people's physical and
psychological characteristics are comprehensively and methodically shaped through health
education. Health education plays a crucial role in vaccination care.

Safety

Safe handling and administration of vaccinations is a crucial additional role for nursing
professionals in the immunization process. The effectiveness of vaccines is maintained in large
part by using proper storage techniques. It is necessary to adhere to the expiration dates and
storage temperatures. Additionally, it's critical for nurses to keep up with developments in vaccine
administration. The need for intramuscular administration as opposed to subcutaneous
administration, etc., must be taken into consideration in order to prevent any potential adverse
reaction to a vaccine.

Care for vaccinations

Vaccination care is the routine education of healthy patients about the disease, how to treat it,
and how to develop positive coping mechanisms. Physical examinations on a regular basis help
identify issues and solve them quickly. A good vaccination care example is hydration. Both before
and after your vaccination, staying hydrated is crucial. Muscle aches, exhaustion, headaches,
and fever are some of the most typical adverse reactions to vaccinations. Not only will staying
hydrated keep you from getting sick, but it may also lessen the severity and length of any side
effects.

Follow-Up
The identification and treatment of anaphylaxis should be a routine practice for any nurse who
administers vaccines. In the busy clinical setting of today, it might be tempting to let volume and
efficiency dictate how recommended vaccinations are administered. For the patient receiving the
vaccination, this level of effectiveness may present challenges. The CDC suggests keeping an
eye on the patient for at least 15 minutes following vaccination.

For the sake of safeguarding the public's health, nurses must have access to the most recent
information and research on a variety of health issues. It is crucial that nurses are aware of the
new vaccines that are on the market because there is a wealth of important information about
them that has been published by medical professionals, researchers, and other experts from
around the world.

References

1) Immunization Handbook for Health Workers, New Delhi, Government of India, 2006,
(http://www.whoindia.org/LinkFiles/Routine_Immunization_Immunization_Handbook_for_Health_
W orkers_2006.zip),

2) Immunization In Practice: A Practical Resource Guide for Health Workers, Geneva, World
Health Organization, 2004, (WHO/IVB/04.06),
(http://www.who.int/vaccines-documents/DoxTrng/h4iip.htm)

3) India National Universal Immunization Programme Review, New Delhi,

B(http://www.whoindia.org/LinkFiles/Routine_Immunization_Acknowledgements_contents.pdf)

4) Integrated Disease Surveillance Project:, Training Manual for State & District Surveillance
Officers, Module 5, New Delhi, Government of India, 2005,
(http://nicd.nic.in/IDSP_docs/TRAINING%20MANUAL/District%20Surveillance%20Team
%20Training% 20Manual/Module5.pdf)

5) Measles Mortality Reduction: India Strategic Plan 2005-2010, New Delhi, Government of India,
2005, (http://www.whoindia.org/LinkFiles/Measles_Measlespdf.pdf)

6) National Child Survival and Safe Motherhood Programme: Surveillance, New Delhi,
Government of India, 1994

7) Field Guide: Measles Surveillance, &, Outbreak Investigation, New Delhi, Government of India,
2006, (http://www.npsuindia.org/download/Measles%20Guide.pdf)

8) Field Guide: Surveillance of Acute Flaccid Paralysis, New Delhi, Government of India, 2005,
(http://www.npspindia.org/download/Redbook.pdf)

9) Guidelines for Disposal of Bio-medical Waste Generated during Universal Immunization

Programme, Delhi, Central Pollution Control Board, 2004, (http://www.solution exchange-
un.net.in/environment/cr/res21040602.doc)

10) Guidelines for Reporting & Management of Adverse Events Following Immunization: India,
New Delhi, Government of India, 2005,
(http://www.whoindia.org/LinkFiles/Routine_Immunization_AEFIguidelines_for_reporting.pdf)
11) Guidelines for Surveillance of Acute Encephalitis Syndrome, New Delhi, Government of India,
2006, (http://nvbdcp.gov.in/Doc/AES%20guidelines.pdf)

12) Immunization Essentials: A Practical Field Guide, Washington, D.C., United States Agency
for International Development, 2003, (http://www.dec.org/pdf_docs/PNACU960.pdf)

13) Multi Year Strategic Plan 2005-2010: Universal Immunization Programme, New Delhi,
Government

of India, 2005,
(http://www.whoindia.org/LinkFiles/Routine_Immunization_MYP_PDF_(05_July_05)__Final.pdf)

14) National Family Health Survey (NFHS-3), 2005-06: India, Mumbai, International Institute of
Population Sciences and Macro International, 2007,
(http://nfhsindia.org/nfhs3_national_report.html)