this ppt is intended to serve as a basic learning to medical officers ( & their staff )on quality aspects of immunization services offered at primary & secondary care facilities both in urban & rural india. Prepared based on my own personal experience as a former state immunization in-charge as well as director family welfare in a state government

1. Safe immunization practices
Basics for the primary level medical
officers
Prepared by Dr. D K Dewan ( slide# 4,5,10 taken from
other national/international sources being duly acknowledged)

2. Conduction of Safe Immunization
Session
• Safe Immunization means no harm :-
- To the beneficiary.
- To the service provider.
- To the environment.
• Most cost effective health care intervention
• Country declared Polio free since March 2014

3. Importance of Safe Immunization Session
• Through reducing the possibilities of
programmatic errors & consequent AEFIs
builds the Confidence of beneficiaries
• Boosts the confidence of service provider
• Vehicle to piggy-back other RMNCH+A services
• Improves IMR & <5 Mortality through:
decreasing vaccine preventable diseases load

4. Pre-requisites--Successful immunization
Vaccine
Trust in health
system
Info on vaccine
benefit
Access
Cultural
acceptance
AEFIs
satisfactorily
resolved
Vaccine supply
Cold chain storage
and transportation
Availability of quality
vaccines
Vaccine stock
management
Safe handling during
vaccine delivery
Pre-service
training
Supportive
supervision
Job satisfaction
and security
Ability to redirect
programme

6. Injection Administration
• Always use AD Syringes
• Always use fresh Syringe for reconstitution
• Open the Syringe from piston side.
• Use normal saline for BCG, double Distilled water for measles for MMR ( as supplied with vaccine
only )
• Always use the right dose- right route- and right site
• 0.05 ml of BCG for new born up to one month and 0.1 ml from one month to one year
• 0.5 ml use for DPT, Pentavalent vaccine, MMR, measles and Hepatitis B vaccine
• BCG on left arm, measles and MMR on right arm, DPT, Hepatitis B and Pentavalent Vaccine on thigh.
• Position the baby appropriately for vaccine administration
• Display the name of nearest AEFI centre
• Display the management of serious AEFI
• Never keep T-series vaccine on ice packs.

7. Features of Vaccine for Safe Immunization
• Should be potent i.e. VVM stage I or II
• Should be within the expiry date period ( valid )
• Take out only one vaccine vial at a time (Vaccine should not have been
taken out from cold chain equipment more than thrice )
• ‘T’ series vaccine should not have been frozen/Shake Test
• Vaccine to be reconstituted ONLY with the specific supplied diluents
and NO SUBSTITUTION
• Reconstituted vaccine should be used within 4hours at fix heath facility
an 2 hours in out reach sessions
• The vaccine vials batch no. and label should be visible and not damaged.

8. Basic Universal Screening of Beneficiaries
• Age should be appropriate for the due vaccine
• No contradiction for vaccination for e.g. history
of high fever, child seriously ill, on steroids on
anti-convulsion medication and history of allergy
to drug or egg etc
• No earlier history of side effect following
previous dose administration for e.g. Excessive
crying, convulsion, hospitalization etc.

9. prior screening of atleast those infants who have are
apparently looking not too well
• from high fever, vomiting,
• loose motions, dehydrated
• urticarial rash,
• facial puffiness,
• excessive crying,
• convulsion, previous history of convulsion
• lethargy,
• not eating for days on end following vaccine
• or not even eating that food /item which the infant /child used to eat with interest earlier(
only a few discerning mothers would notice & report )
• Vomiting
• rapid breathing,
• listless,
• extreme low weight at birth or even at the time of vaccination,
• is on some drugs say prednisolone/dexamethasone
• If due to any reason the MO is not available then in that case such
infants have to be called again and are NOT to be immunized before the
opinion of MO is clearly obtained.

10. All due vaccines can be
given at same time but
in different limbs (sites)
Remember
e.g. it is safe and effective to give
BCG, DPT, OPV, Hep.B,(
PENTAVALENT), Measles & Vit.A at
same time to a 9 month old child
who has never been immunized
earlier..
Vit A (oral)
BCG
(intradermal)
DPT
(intramuscular)
Hepatitis B
(intramuscular)
Measles
(subcutaneous)
OPV
(oral)

11. Injecting time precautions
• Please see that for live attenuated vaccines ( BCG,Measles, MMR)
NO Spirit swabbing is to be done . However appropriately boiled
cotton swab can be used to clean the injection site without rubbing
the swab vigorously but only gently
• However for the other T group of vaccines ( Typhoid, Hepataitis B,
Petntavalent, DPT,DT,TT ) spirit swab can be used to clean the
injection site but no vigorous rubbing to be done.
Vigorous rubbing induces hyperaemia ( increased circulation
which could result in the vaccine actually getting in the micro-
circulation as a bolus instead of its sub cutaneous/ intra-dermal
deposition for slower absorption/local action of antibody
formation

12. Open Vial – some basics
• Open vials of pentavalent vaccine are to be
discarded after 14 days even if some doses are
still left ( maximum 4 sessions in primary facility
–first in first out, while in hospitals it could mean
theoretically 12 sessions-- if the hospital has a 6
all working days sessions activity, though the
chances of such open vials getting exhausted in
even 2-3 days are very high due to larger
turnover of children in hospitals OPDs)

13. Safe Practices– Standard Practices expected-1
• A vial once opened date, time must be
mentioned on it alongside entries must also
be made in the immunization registers
including the name of the health worker who
has opened the vial & BATCH NUMBER, DATE
OF EXPIRY. It is preferable that the same ANM
uses the same vial over the next sessions till it
is exhausted ( 10 doses)

14. Safe Practices– Standard Practices expected--2
• Each time minimal external handling of the vial is
prescribed and the hands are to be clean washed
before starting the immunization session. Cold
chain as prescribed ( NO FREEZING of ant T group
vaccine) must be adhered to through replacing
the half used/partially used vial at the end of
session and stored in the cold chain (
ILR/Refrizerator) marked clearly. NO Needle is to
be left in the septum /stopper of the vial and the
septum is to be dry BUT NOT TO BE WIPED WITH
COTTON !

15. Open Vial Policy only for non-reconstituted vaccine– (DPT,
Hepatitis B, TT and Pentavalent)
• Do not wet the rubber septum of the vial
• Do not keep the septum of the vial pierced
• Do not wipe the septum with cotton
• Do not use the vaccine beyond the expiry date
• Do not use the vaccine beyond stage-II of the VVM
• Label of the vaccine vial should be intact and legible

16. Communication with mothers--Four key messages
• Name of the Vaccine administered to the child
• The diseases likely to be prevented
• Likely side effects & what is to be done
• When to come next
• Keep the card safe for child admission to the
school.

17. Post vaccination advice
• Keep the mother with the baby in health
facility for 30 minutes in normal baby after
vaccination
• Utilize this time for nutritional and family
planning advice.

18. Bio Medical Waste Disposal
• Wrappers of the Syringe in the black bag
• Swabs in yellow bag
• Cauterize the needle with hub cutter
• Put the sharp in puncture proof container
• Put the Syringes in the blue/red bag
• Give biomedical waste to authorize biomedical waste
agency.

19. Pre-Emergency Response Preparation
• Linkages with nearest hospital MUST be
established for emergency treatment of any
such infant who suffers some serious adverse
event and the Contact details of the MO In-
charge should/ could also be written as stamp
on the Immunization cards & explained to
family in case any clarification is required
subsequently or that if any event happens
what is to be done by the mother

20. Emergency Handling preparation
• ANMs must be fully trained in use of emergency drugs
and Injection Dexamethasone, Hydrocortisone,
Diazepam, Adrenalin, Phenergan, Pheneramine
maleate (Avil ) should invariably be available and kept
handy during immunization sessions
• Oxygen cylinders if available at some facilities must be
ensured to be functional and stocked with oxygen ( and
not empty ) with its key on its head always available.
ANM should know how it is to operated Mask must
also be available. Ambu bag must be kept ready &
ANM must know how it is to be used & when.

22. Summary of Rare Serious Adverse Events
(onset interval and rate) source: Imm handbook For MO 2008
Vaccine Reaction
Interval between
vaccination
and onset
No. of events
per million
doses
BCG Suppurative adenitis 2-6 months 100-1000
BCG Osteitis Up to several
years
-
Disseminated BCG infection 1-12 months -
Hib None known - -
Hep B Anaphylaxis 0-1 hour 1-2
Measles/
MMRa
Febrile seizures 5-12 days 330
Thrombocytopenia (low platelets) 60 days 30
Anaphylaxis 0-1 hour 1
OPV Vaccine-Associated Paralytic Poliomyelitis 4-30 days Up to o.4 b
Tetanus Brachial Neuritis 2-28 days 5-10
Anaphylaxis 0-1 hour 1-6
Sterile abscess 1-6 weeks 6-10
DPT Persistent (>3hours) inconsolable screaming 0-48 hours 1,000-60,000
Seizures 0-3 days 600c
Hypotonic Hypo Responsive Episode (HHE) 0-24 hours 30 – 990
Anaphylaxis/Shock 0-1 hour 1 -6
JE Serious allergic reaction 0 – 2 weeks 10 – 1000
Neurological event 0 – 2 weeks 1 – 2.3