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Manual on Expanded Program on Immunization

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1. Signature 60 Annex 2 Monitoring of Adverse Events Following Immunisation List of Definitions All of the following adverse events should be reported if temporally related to immunisation Unless otherwise specified this includes all such events occurring within four weeks of a vaccine administration 1 Local Adverse Events A Injection site Abscess Occurrence of a fluctuant or draining fluid filled lesion at the site of injection with or without fever Bacterial Existence of purulence inflammatory signs fever positive Gram stain positive culture or finding of neutrophil predominance of content will support a bacterial site abscess but the absence of some of these signs will not rule it out Sterile There is no evidence of bacterial infection following investigation B Lymphadenitis includes suppurative lymphadenitis Occurrence of either e At least one lymph node 1 5 cm in size one adult finger width or larger OR e A draining sinus over a lymph node Almost exclusively caused by BCG and then occurring within 2 to 6 months after receipt of BCG vaccine on the same side as the site of inoculation mostly axillary C Severe Local Reaction Redness and or swelling centred at the site of injection and one or mote of the following e Swelling beyond the nearest joint e Pain redness and swelling of more than 3 days duration OR
2. Measles amp Yellow Fever DELSECS These vaccines may be used TT amp OT amp Hepatitis B Name Nom Date of dispatch Date d exp dition Vaccine Vaccin SUPPLIER FOURNISSEUR 15 JIL 3999 POLIO Activation of the monitor card oN PODEA iia IP Mpc BB ark ee E E ud PECETE A RISE Miyahara gd hema ie FEN Pu a i B G Fad tab back bo break sea ge mrt A B S Back Keep the Cold Chain Monitor with your vaccine When the Monitor arrives complete the top part of the card fill in the date fill in the index A B C and or D fill in the location When the Monitor leaves complete the top part of the card fill in the date fill in the index A B C and or D If windows A B C amp D are all white use vaccines normally If the windows A to C are completely blue but window D is still white it means that the vaccine has been exposed to a temperature above 10 C but below 34 C for the following number of days INDEX A AB ABC At a temperature of 12 C 3 days 8 days 14 days At a temperature of 21 C 2 days 6 days 11 days If window D is blue it means that there has been a break in the cold chain of atemperature higher than 34 C fora period of atleasttwo hours Check the cold chain The instruction use within three months should not be followed if either the expiry date or any local cold chain p
3. Locate the cause of the problem If it is simple e g the refrigerator was unplugged by the cleaning staff correct the problem if you can Replace the vaccines and cold chain monitors in the refrigerator after the problem has been solved and the temperature has returned to well within the safe range 2 C to 8 C If there is a cold chain failure the person responsible for the refrigerator should wtite a btief description of the problem amp what actions were undertaken Forward a copy of this report to regional EPI focal point as well as to DSDC for information amp record 28 DEPARTMENT OF SURVEILLANCE amp DISEASE CONTROL Fig 10 Cold Chain Refrigerator Graph B Begining of immunisation session Ramee 242 EUER ye tW sseak z sea je 10 pun INOA ur ajy e ui sudejo 10je1361j8H UIEYD pjo2 perejduioo je daay aseaig Au essaoeu p aded jo avad 8jejedas e uo nunuos veye eAeu no uoi 1eym pue wajqosd y jo uorduosap e m pinoys no ine uieu2 pio2 e s aay ji End of immunisation session day Begining of immunisation session RB pe gt YIUOW Sui j0jeJ8Duja 10 ejqisuodsa uosjad leog JE A 470 Won JO ON HEIS pue amp LUEN g 41 2 2 4a D N Jo 3 eine edway ojes uoz 1eBueg H ecd be 4c 8z 162 yde19 10ye19H yay UYD PIO rac aara A n HLIVIH JO AULSININ AIVIAIN AO ET VATV TING 29 EXPANDED PROGRAM ON IMMUNIZATION 4
4. chool S education in Oman has a high priority and is universally and socially Probably the most important part of the School Immunization Programme is the opportunity to immunize almost ALL girls in Oman This opportunity must not be lost to sustain the elimination of neo natal tetanus in Oman Every girl who leaves school MUST therefore be fully immunized with TT 10 2 Responsibilities e Immunizations in schools should be carried out by the School Health Visitor SHV and doctors but if there is no school health visitor for an area the programme must still be completed by the staff in the health facility within their school s catchment area e Recording All school immunization should be recorded in the School Health Student Record Additional details are available in the MoH manual on School Health 10 3 School Immunization Schedule See page 9 for details Note Those students who present without any documentary evidence of ptimaty immunization should be investigated thoroughly and the reasons for the same should be ascertained through interviewing the parents amp family This will give an opportunity to assess the immunization status of the mother amp other siblings 55 EXPANDED PROGRAM ON IMMUNIZATION TheSchool Health Student Record Boys Girls 56 Chapter Immunizations in Private Sector 11 1 Introduction against the 10 vaccine preventable diseases and to vaccinate all women of child bearing age
5. 3 1 2 AEFI to be included in surveillance The immunization programme will monitor the following AEFI e All cases of BCG lymphadenitis Allinjection site abscesses All deaths that are thought by health workers or the community to be related to immunization e All cases requiring hospitalizations that are thought by health workers or the community to be related to immunization Other severe or unusual medical incidents that are thought by health workers or the public to be related to immunization With respect to the third and fifth events health workers may relate the event to immunization because it occurred within a month of an immunization as its case definition indicates The above five categories of AEFI are sometimes called trigger events because their presence stimulates or triggers a response Investigation should begin as soon as possible ideally within 24 hours of detection by a health worker to identify any programmatic errors that might be present to correct them before other people are exposed to the same error and to show members of the community that their health and concerns are being taken seriously 3 1 3 AEFI investigation In most cases a preliminary investigation can be made by the health worker who detected the case i e a nurse and paediatrician physician in the hospital Serious AEFIs or clusters should be investigated by the Regional Epidemiologist wherever available ot the focal po
6. 3 1 Introduction he goal of immunization is to protect the individual and the community from vaccine preventable diseases Although modern vaccines are safe no vaccine is entirely without risk Some people expetience reactions after immunization ranging from mild side effects to life threatening but rare illnesses In some cases these reactions are caused by the vaccine in others they are caused by an error in the administration of the vaccine and in yet others there is no relationship To increase acceptance of immunization and to improve the quality of services the surveillance of AEFI must become an integral part of the immunization programme The benefits of immunizing against diseases like measles neonatal tetanus and polio far outweigh the risks of an incident caused by immunization Monitoring events related temporally to immunization will enable us to reduce those risks even further The formal AEFI surveillance system was launched in the country from January 1996 3 1 1 Reporting of AEFI An adverse event following immunization is a medical incident that takes place after an immunization and is believed to be caused by the immunization Although people often think that a medical incident after an immunization must be caused by the immunization many such incidents are coincidental Another belief that vaccine is the most common cause of AEFI is also mistaken Programme error which can be prevented is more often the cause
7. BAN Ic jad Dose 3 asl ic all Dose 2 old Re jal Dose 1 Vaccine padat Back a YELLOW FEVER FE aus ys TETANUS TOXOID Ta ZAUYI Tuanai RUBELLA Baka sagi DT Td M 300 14 2 6 Tetanus Toxoid in Wound Management Wound Management Algorhythm Surgical Toilet For ALL Fully immunized Wound Clean wound e g a clean ki knife Dirty Wound e g dirty sporting injuries accident injuries Puncture Wound e g stab wounds or rusty nail injuries Category Treatment No TT required only give TT if person has NOT had a course of TT ora TT Booster in last 10 ears No TT required only give TT if victim has NOT had a course of TT or a TT Booster in last FIVE years Antibiotic cut from a tchen Wound knife or dirty car Always give TT Antibiotic Wound NOT fully immunized Wound Category Clean minor e g a cut from a clean kitchen Dirty Puncture OR Status unknown Treatment Give 1 dose TT Recall the patient for 2 dose TT after 4 6 weeks and 3 dose 6 12 months after 2 dose Give a 4 dose with a minimum interval of one year after the 3 dose followed by a 5 dose after one year Subsequently give one booster every 10 years Antibiotic Give TT as above Give TT as below
8. Manual on Expanded Program on Immunization Third Edition 2002 Department of Surveillance amp Disease Control Directorate General of Health Affairs Edition DIRECTORATE GENERAL OF HEALTH AFFAIRS Department of Surveillance amp Disease Control Manual on Expanded Proeram on Immunization DEPARTMENT OF SURVEILLANCE amp DISEASE CONTROL Expanded Program on Immunization Ministry of Health Sultanate of Oman Directorate General of Health Affairs PO Box 393 PC 113 Phone 968 600808 Fax 968 600808 Constructive suggestions forimproving orupdating this Manual would always be gratefully received Contents Foreword Contributors Contents Acronyms CHAPTER 1 INRODUCTI ON 1 1 Global Scenario 1 2 EPI Progress in Oman 1 3 EPI Policy 1 4 Strategy 1 5 Objectives amp Service Targets CHAPTER 2 IMMUNI ZATI ON SCHEDULE 2 1 Schedule 2 2 School Immunization 2 3 TT Schedule CHAPTER 3 ADVERSE EVENTS FOLLOWI NG IMMUNIZATI ON 3 1 Introduction 3 2 AEFI Reporting 3 3 AEFI Monitoring CHAPTER 4 THE COLD CHAIN 4 1 Introduction 4 2 Purpose 4 3 Storage Requirements 4 4 Refrigeration Equipment 4 5 Monitoring Tools 4 6 Storage at EPI Units CHAPTER 5 STATIC UNITS 5 1 Introduction 5 2 Child Health Register 5 3 Transfer of Responsibility 5 4 Feed Back Report 5 5 Children Born at Home 5 6 Defaulter Retrieval 5 7 EPI reporting CHAPTER 6 OUTREACH TEAMS 6 1 Introduction 6 2 Defaulter Ret
9. Procedure for Inaccessible Population e Selection the following procedures should be followed to mark the Inaccessible areas distant villages in the Region e Consultation the selection should be made in consultation with the MOIC of the static unit s and Regional MCH Committee e Criteria the question to be asked is Are the inhabitants of a village so far or inaccessible from a health facility that they rarely if ever visit the facility and would be unlikely to do so for anything that was NOT a clear emergency i e not just to immunise their child Note It is impossible to lay down a hard and fast rule saying exactly how far from a MoH institution a distant village would be because an inaccessible village in Musandam may be only 5 kilometres away across a harsh terrain whereas a distant village in Jalaan might be over 20 kilometres away Planning a visit to a Distant Village PHS Outreach Teams should not visit distant villages randomly Visits must be rather planned and the community must be informed in advance Community involvement can be achieved by liaison with the local Wali and Sheikhs who should be requested to arrange for ALL children under 6 years to be gathered at the central location of the village on a mutually convenient day If the community can be mobilised in this way then it is not necessary to carry out house to house visits but instead use the age old collection point method Note Unless it is e
10. PRIMARY SCHOOL LEVEL 6 12 15 YEARS Vaccine Td Booster one dose Adult OR Td 2 doses Schedule For GIRLS and BOYS who have been fully immunized before with DPT and or DT Give a Booster dose one dose If NOT fully immunized as above or NO records available give 2 doses of Td at an interval of 4 6 weeks 12 SECONDARY SCHOOL LEVEL 2 17 18 YEARS Vaccine Schedule TT Booster one dose If the student is fully immunized in class 6 OR TT 2 doses Primary School give one dose If NOT fully immunized as above or NO recotd available give 2 doses of TT at an intetval of 4 6 weeks OPV Booster one dose To be given to All students at this level 2 5 Tetanus Toxoid for Adults Table 6 For Females in childbearing age 15 49 years amp Adult males 18 years and above Vaccination Status If immunized as per schedule in above and documentary evidence available If not immunized as per schedule above OR immunization status unknown Notes Action Give one Booster of TT every 10 years Give 2 doses of TT at an interval of 4 to 6 weeks apart Give 3 dose of TT with a minimum interval of 6 months after the 2 dose Give a 4 dose with a minimum interval of one year after the 3 dose followed by a 5 dose after one veat y y Subsequently give one booster dose evety ten years e After 2 doses of TT 4 to 6 weeks apart protective levels of anti toxin are reached but de
11. s VQ status be withdrawn immediately Any Private Clinic which loses its VQ status will have to return all unused vaccine stocks to EPI DSDC and will lose its entitlement to draw free supplies of vaccines in the future Applications for reinstatement of VQ status will be dealt with on a case by case basis and are liable to be given very rarely Annex 1 Directorate General of Health Affairs Dept of Surveillance amp Disease Control AEFI Case Investigation Report Sultanate of Oman W Ministry of Health P A To Department of Surveillance amp Disease Control Institution Directorate General of Health Affairs Fax 601832 Region Date 1 Name 2 Name 3 Name Tribe DOB Age Sex Nationality OPD IPD No MR2 No M F Wilayat Village Tel No House No Land Mark I Name of the suspect vaccine No of doses per vial Batch No of vaccine Storage Temp Mfd Date Exp Date uem MEME ERES Mfd Date m mo ETE Exp Date Lot No of diluent if relevant Mfd by Syringe used company name Date of Injection Time Site of Injection secuti ee Denar LI Yes Injection given by name designation Institution Admission LI No If yes Date of admission Time of reactions onset of symptoms Time of recovery Outcome Il Immunization History Ill Lab
12. ATS 750 IU sensitivity test or TIG 250 IU if available e Antibiotic Note In the event that a child under 7 years of age requires TT for wound management purposes the child should be given DPT DT rather than TT unless there are any specific contraindications 2 7 Route Site and Dose of Vaccines Table 7 Route amp Site Vaccines Vaccinees Children under 2 years Children lt 7 yr Children gt 7 yr Women Pregnant amp in child bearing age XX XXX Note Vaccine BCG OPV DPT Hib Hep B Measles MMR DT Td TT Booster dose Sar I 3 ar le e ES iss bk Route ID Oral IM IM IM IM IM IM IM IM Site Left deltoid Mouth Left anterolateral thigh Left right anterolateral thigh Right anterolateral thigh Right anterolateral thigh Right anterolateral thigh Left deltoid Left deltoid Left deltoid Give two doses 4 to 6 weeks apart if not vaccinated previously Dose for children above one year is 0 1 mi Dose 0 05 ml 2 drops 0 5 ml 0 5 ml 0 5 ml 0 5 ml 0 5 ml 0 5 ml 0 5 ml 1 When two injections ate required to be administered together use different limbs 2 DPT conventionally should always be administered on the left anterolateral thigh 3 Measles MMR Hep B should preferably be administered on the right anterolateral thigh and Hib on either left or right 16 Chapter Adverse Events Following Immunization AEFI
13. The success of the programme is none the less also due to the active support of the community 1 3 The Milestones of EPI in Oman Expanded Programme on Immunization formally launched in Oman in 1981 Eatly 70s to 1989 1989 1990 August 1990 March 1994 August 1995 January 1996 September 1997 October 1997 January 1998 June 1998 June 1999 February 2001 October 2001 BCG OPV DPT amp Measles standard regime primaty amp boosters Booster doses of DPT DT amp OPV integrated into School Health Programme Introduction of birth dose of OPV Introduction of dose of OPV at 40 days AI Arbayeen dose Introduction of Hepatitis B vaccine 0 3 amp 7 months Introduction of Rubella amp second dose of Measles at 15 months as MR Introduction of Vitamin A supplementation as part of EPI along with Measles amp MR vaccine 9 amp 15 months New policy on the use of opened vials in subsequent immunisations Introduction of a national surveillance system for monitoring Adverse Events Following Immunisation AEFI Discontinuation of policy of BCG re vaccination in school MR at 15 months replaced by MMR DPT rescheduled at 1 1 2 3 amp 5 months DPT amp OPV boosters at 15 amp 19 months respectively Vaccine Vial Monitor VVM introduced Discontinuation of policy of BCG re vaccination at 3 months Introduction of Rubella vaccine for postpartum mothers Introduction of Hib vaccine Measles amp MMR reschedu
14. a national standard taking into account operational constraints in the field A Safe injection is that which does not harm the recipient does not expose the provider to any avoidable risk and does not result in any waste that is dangerous for other people National standards The injection safety should target the following three levels 1 The safety of the injection recipient 2 The safety of the health care worker 3 The safety of the community 82 Type of Equipment Single use syringes and needles disposable Single use syringes and needles are appropriate for all types of immunization strategies including use in static clinics and in outreach or during special campaigns A sterile packed syringe and a sterile packed needle must be used for each injection and they must be disposed off immediately after use Autodestruct auto disable or AD syringes are designed so that it is impossible to use them more than once Consequently they present the lowest risk of person to person transmission of blood borne infections These are 49 EXPANDED PROGRAM ON IMMUNIZATION preferred for administering vaccines particularly in mass immunization programmes The MoH is contemplating to introduce AD syringes for EPI in near future Table Sizes of syringes and needles Use Syringe size Needle size All other EPI vaccines for IM or SC injections 2ml Single use 23 gauge Parts of needle and syringe It is impo
15. and thus avoid giving heat damaged vaccines to patients WHO UNICEF and manufacturers of OPV decided in a meeting in Oct 94 that all vials of oral polio vaccine which meet WHO standards shall be fitted with vaccine vial monitors as of 1st January 1996 The benefits of using vaccine vial monitors include e The ability to keep opened vials of polio vaccine until fresh supplies arrive e A decrease of at least 30 in vaccine wastage rates e The flexibility to take vaccine beyond the cold chain where it is necessary in reaching difficult locations and above all e t gives the health worker confidence that he she is administering vaccine unharmed by exposure to heat Note Future shipments of all vaccines will contain individual vaccine vial monitots Fig 15 Vaccine Vial Monitor v v Fig 16 Vaccine Storage at EPI Unit Hospitals Health Centres Private Clinics and CDC ICE Packs loosely packed or will crack the freezer compartment Cold packs Cold packs xK Thermometer EA Cj P G v Ica y indicator H B V o x O S 3 p o o Cold packs Cold packs Cold packs Water Bottles Water dyed with potassium permanganate LA U 34 Vaccine Storage Precautions at the EPI Unit Who is responsible for the cold chain Many staff members wil use the vaccine refrigerator but ONE staff member must have overall responsible for it The MOIC must nominate one staff member by
16. area are fully immunised Postnatal staff must ask a child s mother the location of her nearest health institution in order to ascettain the child s Parent Institution Note normally children should be registered in the Master Register in the month they were born e g all children born in August 95 would be registered together under that month amp year Regarding children born at home or outside Oman these children should be registered under the month they were born Few pages should be left blank at the end of the every month to register such children 522 Child Health Card the pink card MR 224 53 522 Child s Registration Number The child s registration number also known as MR 374 number is made up of 3 parts See Annexure Note Registration Number should always be allocated by the child s parent institution and Not by the institution where the child was delivered unless that is the child s parent institution as well e g children born at Khoula hospital but residing at Seeb should be given their MR 374 number at Seeb Health Centre which represents child s parent institution Transfer of Responsibility Children who are not residing in the catchments area of parent institution should not be entered in its Master Register Instead the responsibility for that child should be transferred to their Parent Institution Therefore for example a child born in Tanam Hospital but living near Dhank Health Centre HC would not be regi
17. been recommending vaccination against Hepatitis B since 1993 yet it kills approximately one million people each year Against this background the World Health Assembly set the goal of immunising 80 of the world s children by the end of 1990 This goal was achieved by a majority of countties in the developing world and almost all countries ended in 1990 with immunisation levels close to the 80 target 75 for sub Saharan Africa Following a drop off in 1991 and three subsequent years of flat growth worldwide immunisation of children is now increasing again according to the newly released figures from the World Health Organisation WHO 1 2 Progress of EPI in Oman EPI in Oman was launched in 1981 with a substantial progress in the last two decades Reviews of the programme conducted by international agencies in 1983 1987 1989 1993 and 2000 Polio documented a well designed and implemented program with increasing rates of vaccination coverage Immunization coverage levels have increased substantially from 10 in 1981 to over 95 in 1995 The near 100 coverage has been maintained till 2001 resulting in corresponding impact on Vaccine Preventable Diseases VPD in Oman as evident in the Table 1 Table 1 Incidence of EPI Target diseases in Oman Diseases 1981 1990 1995 2000 Poliomyelitis 43 0 0 0 Neonatal Tetanus 10 0 1 0 Tetanus 36 3 7 0 Measles 40 679 1 262 68 9 Diphtheria 10 0 0 0 Pertussis 2 236 49 108 205 Rubella NA 2 46
18. box is full dispose it by burning The disposal box should be destroyed by incineration as close as possible to the point of use and as soon after the immunization session as is practical The compound in which incineration takes place must be secure Auto combustion incinerators achieving temperatures above 800 C are preferred although burning can also be performed in other types of incinerator for instance in a pit drum or constructed hearth Preventing injuries and infections You can reduce the risk of injuries and infections when handling injection equipment as follows 1 Take care to prevent injuries when using and handling needles during and after finishing the injection procedure as well as during the disposal 2 Do not recap used needles or do not remove used needles from syringes by hand 3 Place used syringes and needles in puncture proof containers for final disposal Keep a container as close as possible to the place where you give injections but it should be away from the reach of children 4 Immediately and thoroughly wash hands and other skin surfaces that have been contaminated with blood or other body fluids Safe Disposal Containers Supervision amp Evaluation Systematic supervision and periodic evaluation of injection practices are vital to ensure safety Supervisory visits should be made by the EPI focal point to each health centre at least twice in a year A standardised checklist should be utilise
19. e Requires hospitalization Local reactions of lesser intensity may occur commonly and are generally of little consequence For monitoring purposes priority should be given to severe local reactions as defined above 2 Central Nervous System Adverse Events Acute Paralysis e Vaccine Associated Paralytic Poliomyelitis Acute onset of flaccid paralysis within 4 to 30 days of receipt of oral poliovirus vaccine OPV or within 4 to 75 days after contact with a vaccine recipient with neurological deficits remaining 60 days after the onset or death e Guillain Barre Syndrome GBS Acute onset of rapidly progressive ascending symmetrical flaccid paralysis without fever at onset of paralysis and with sensory loss Cases are diagnosed by cerebrospinal fluid CSF investigation showing dissociation between cellular count and protein content GBS occurring within 30 days after immunisation should be reported Encephalopathy Encephalopathy is an acute onset of major illness temporally linked with immunization and characterized by any two of the following three conditions e Seizures e Severe alteration in level of consciousness lasting for one day or more and e Distinct change in behaviour lasting one day or more Cases occurting within 72 hours after vaccination should be reported Encephalitis Encephalitis is characterized by the above mentioned symptoms and signs of cerebral inflammation and in many cases CSF pleocytosis and or virus isolation An
20. health Programme The nursing staff working under the school health programme would be responsible to conduct the scheduled immunizations The records would be maintained in the appropriate documents 1 6 Objectives amp Service Targets 1 6 1 Immunisation Targets e To sustain and consolidate a level of near 100 immunisation coverage of all infants for all the ten antigens against the EPI target diseases e To maintain a level of near 100 immunisation coverage with 2 doses or more of TT and Rubella vaccine for women of child bearing age with an aim to sustain the elimination of Neo Natal Tetanus and Congenital Rubella Syndrome CRS e To coordinate with the Department of School Health to maintain full coverage of boosters included in the school immunization programme 1 6 2 Disease Reduction Targets To eliminate neonatal tetanus and to sustain elimination thereafter To sustain the polio free status last case in 1993 till the ultimate goal of global Poliomyelitis eradication by the year 2005 To sustain Measles elimination with an ultimate goal of regional measles elimination in WHO EMRO by 2010 To minimize the outbreaks of Whooping cough and to reduce its incidence to a level where it is no more a public health problem Maintenance of zero status for Diphtheria Reduction in the prevalence of Hepatitis B chronic carrier status in the population to low level 2 Elimination of Rubella amp CRS by 2005 Cha
21. next available number in the master register of Mutrah HC under the month and yeat of birth ALL Parent Institutions must register the child and issue the child health card as soon as the white copy of the MR 224 is received At times the mother would visit a health facility betore the white copy was received It is emphasized that NOT receiving the white copy of the card due to reasons such as postal delay should not be considered a valid 38 reason for NOT registering the child After ensuring the place of residence and birth details the child MUST be registered and issued the MR 224 number 5 3 1 Hospitals without Master Register M 374 In some of the secondary tertiaty referral Hospitals deliveries are conducted but they do not keep the master register MR 374 Such institutions do not represent a parent institution of that child for a certain catchment area However these institutions are obliged to comply on the following points These responsibilities should be carried out by a staff nurse specifically assigned to look after EPI e Issue the child health card M 224 e Record the birth vaccinations on MR 224 e Write the ANC number both on MR 224 card and the birth register e Transfer mother s TT card from the ANC card to the child health card e Write the complete address including telephone number village amp Wilayat e Write the name of the parent institution of the child based on the place of residence 5 4 EPI Feedb
22. of vaccine box not on a different shelf Refrigerator routine checks amp procedures e Correct Recording of Temperature In order to check that there has been no cold chain failure the temperature of the Refrigerator must be recorded on the Cold Chain refrigerator graph form MR 247 on page 29 at the same time every day i e usually at the beginning and end of the immunization session The graph should be displayed prominently on the refrigerator door At the end of the month the graph should be filed These records should be preserved for a period of two years e Correct Periodic Checks reference should be made to the User s Manual supplied by the manufacturer with the equipment for the frequency and type of checks that are to be carried out on each item of cold chain For this purpose a copy of the appropriate User s Manual should always be accessible 4 3 2 Deep freezer Deep freezers have been supplied for e Storage of polio measles and BCG vaccines at Central and Regional stores e Preparation of ice packs and storage of ice EXPANDED PROGRAM ON IMMUNIZATION Note DPT DT TT HBV e Hib vaccines should NEVER be kept in deep freezers 4 3 3 Vaccine camiers e Used for carrying small quantities of vaccines e Used for storing the vaccine vials during the immunisation sessions e Made of insulation material to preserve temperature e Vials of DPT DT TT Hib and HBV should not be in direct contact with the frozen ice packs e
23. with TT Hence in conformity of the policy it is imperative that the private health establishments catering to a certain proportion of the population must also follow these guidelines t is the policy of MoH to vaccinate all children under six years of age In order to ensure that the policies are followed in the private sector the Directorate General of Health Affairs DGHA would supply to the existing vaccine qualified private clinics in the country provided certain prerequisites outlined below are satisfied 11 2 Vaccine Qualified VQ Clinics A VQ clinic would be liable to periodic supervision and audit by National EPI supervisors from DSDC If a clinic fails to maintain the required standards it would be withdrawn from the VQ list and would automatically cease to be entitled to draw vaccines under the EPI programme e EPI Schedule Clinics must understand the EPI Schedule as practiced in the Sultanate of Oman and must comply with it in respect of doses dose interval and method of administration e Cold Chain Clinics must equip themselves with and then adequately maintain the necessary refrigeration equipment required to ensure that the vaccines they have remain potent e Recording Clinics must understand that once they embark on the immunization of a particular child they must follow up that child to ensure that the child is fully immunized as per the MoH policy 57 Reporting Clinics must make regular reports to EPI prog
24. 3 Mumps NA 115315 14 574 10 443 Hepatitis B NA NA 622 49 NA Not Available The marked achievement in immunization coverage has resulted from an expansion of EPI at to the grass root level EPI has been integrated into the Primary Health Care services provided by the Ministry of Health Other sister health organizations viz Sultan Qaboos University SQU hospital and health services provided by the Petroleum Development Organization PDO Armed Forces Royal Oman Police ROP Palace clinics as well as the private health establishments have also contributed to the programme s remarkable success in Oman The cold chain monitoring and supervision has also contributed to the achievements Similarly the unique system of child health card and institution based child health register was established at the outset Every child was born was assigned a unique identifier known popularly as the MR2 number The concept of catchment area of a health institution was evolved A child could receive immunization anywhere in the country but his records would be maintained at its parent health institution Every visit by the mother to the health institution was considered as an opportunity to check the immunization status of the child Thus this system proved to be an effective tool for defaulter retrieval More coverage was achieved by reliance on the static EPI units in the health institutions rather than a house to house visit by the outreach teams in the past
25. 4 3 Freeze watch Freeze watch is an irreversible temperature indicator to show if a package of vaccines was exposed to freezing temperature The colour changes from white or blue colour if exposed to temperature below 0 C blue for more than 1 hour This warns the recipient that the vaccine was probably frozen The vaccines like DPT TT DT Td Hib and HBV if frozen loose their potency Fig 12 Freeze Watch The indicator is NOT blue which The indicator has burst and has stained indicates that the temperature has not the background BLUE This shows that been too cold for HB DPT DT Td Hib the temperature has been below 0 C and or tetanus toxoid vaccines there is a strong possibility that the HB DPT DT Td Hib or tetanus toxoid vaccines have been frozen If you suspect that these vaccines have been frogen follow the instructions below e Select some vials you think may have been frozen e Select another vial of the same type of vaccine that you know for sure was not frozen e Perform the Shake test as described to confirm or to rule out whether the vaccine being tested was frozen or not 30 The Shake Test For vaccines which are sensitive to freezing DPT TT DT Td HB Hib Compare the vaccine that you suspect has been frozen and thawed with vaccine from the same manufacturer that you are sure was never frozen Shake the containers of vaccine Inspect the contents carefully Leave the vaccines to stand sid
26. Gio style 7 ice packs for Thermos style 4 ice packs and for RCW 25 22 ice packs required Do not over pack the freezer compartment Ice packs should be loosely packed and placed obliquely to avoid cracking the freezer compartment 4 34 Cold box RCW25 To collect large quantities of vaccine for health centres Regional store Transport large quantities of vaccine by vehicle to Regional Vaccine stores Carry vaccine for several days maximum of 156 hours or 6 days without opening the box Store vaccines when electricity fails 22 ice packs are required Type E5 04 Fig Cold Box RCW 25 23 Fig 7 Method of arrangement of ice packs in the RCW 25 4 4 Cold Chain Monitoring Equipment 4 4 1 Vaccine cold chain monitor The cold chain monitor is a card which helps supervisors and health workers to check on the standard of vaccine handling in the cold chain Monitor catds which are packed with shipments of EPI vaccines from manufacturers are also available for general use in the cold chain To retain potency all EPI vaccines must be kept at a temperature of 8 C or less at all points of the cold chain ie from the time the vaccines ate manufactured through their shipment to central warehouses and to their distribution at regional district and health centre levels The monitor cards available in Oman in two languages Arabic Green card English Yellow card Each monitor card has four windows for registe
27. ack Children who go to other institutions if at any time a child is brought to any MoH institution which is not his her Parent Institution for any reason and is screened and found to be due for next dose then the EPI staff nurse must ensure that he she is immunised and the dose given should be entered in the child health card NO OPPORTUNITY OF IMMUNIZING A CHILD MUST EVER BE LOST The details of the child and the past doses given should be written on an EPI Feedback Form M 246 immediately and the copy of the form should be sent to the child s Parent Institution as soon as possible The Parent Institute must then update its Master Register For example consider a five months old child from the Ras A Hadd village Sur Wilayat was brought to Sur Hospital for some minor ailment After screening in the OPD the EPI staff nurse finds that the second dose of DPT OPV is due She would immunise the child and then send details of the child and the vaccines given to Ras A Hadd HC through Ministry post The EPI staff nurse in Ras A Hadd HC after receiving the feedback must then update the immunization records of that child in the master register Note the institution giving an immunisation dose should report that dose along with all the other doses given that month on the normal Monthly Report Form Thus continuing with the example above Sur Hospital should report immunising this child NOT Ras Al Hadd HC 55 5 6 Children Born A
28. appearance floating particles etc B Rationale for changing EPI policy on opened vaccine vials Two issues dictate the EPI policy on the use of opened vaccine vials e The potency of the vaccine and e The safety of administration Since the original policy statement was issued research has been conducted to determine how these two factors are affected over time Potency The potency of vaccine over time is determined primarily by e The heat stability of that particular vaccine and e Whether or not the vaccine was reconstituted The potency of OPV TT DTP DT Td and hepatitis B is a function of heat stability and opened vials of these vaccines remain potent as long as they are stored under appropriate cold chain conditions 2 to 8 C Safety The safety of an opened vial of vaccine is primarily depends on 7 5 7 6 7 7 e The risk of contamination with a pathogenic organism and e The bacteriostatic or viricidal effect of preservatives in the vaccine MoH Revised Policy Opened Vaccine Vials BCG Measles amp MMR are reconstituted vaccines and hence must be discarded at the end of the immunisation session 8 houts MoH revised policy recommends that OPV can be used as long as the VVM does not show any colour changes DPT DT TT Td Hib and Hepatitis B can be kept up to 7 days 1 week subject to the conditions stated below The expiry date has not passed The vaccines are stored under appropria
29. cines IDR E 4 3 Vaccine Storage Equipment 4 3 1 Refrigerator All Refrigerators irrespective of the type of system must be placed in the coolest possible part of the Health Institution They must never be placed in direct sunlight Place the refrigerator close to an electric socket and in the coolest part of the building The room must be well ventilated and a good air circulation around the refrigerator is necessaty In very hot climates a fan should be used to blow air between the wall and the refrigerator Keep the refrigerator in the shade and away from sources of heat of any kind Clearance from wall and roof must be as shown in the figure 20 Fig Correct Positioning of Refrigerator 400 mm 16 inches 300 mm 12 inches VN Check that the plug fits into the electrical socket If it does not find a good plug that fits Do not use adopters or take multiple connections from the same electrical socket Correct Internal Arrangement of the Refrigerator The refrigerator must be organised internally according to the layout shown in the figure on page No 34 The following points are especially important Correct Arrangement of the ice packs These help to stabilize the temperature in the refrigerator and are used when storing vaccines in a cold box Thermometer ON the vaccines The thermometer should show the exact temperature of the vaccines and must therefore be placed on top
30. cline over the next year e The 3 dose of TT given i e minimum 6 months after the 2 dose provides excellent immunity which lasts for about 5 years e Subsequent booster doses given restore protective immunity and should provide protection during child bearing years All doses of TT given should be entered in the adult immunisation card M 311 to act as a record of TT immunisation status for future reference Sample of back side of the card is shown below Apart from TT immunisation of pregnant and child bearing age women every effort should be made to immunise males against tetanus as per prescribed sc hedule Every contact with the health services should be taken as an opportunity to check for TT immunisation status and vaccine should be given if due The adult immunisation card M 311 SULTANATE OF OMAN MINISTRY OF HEALTH IMMUNIZATION CARD LES Loo ul lina saf east fols foi Lili oid aiai pejal Liay Lile gan ol elias Lasy Glas dahl uu ALL 35159 Casi dills m S dasal dasu ex Name la Address Previous Immunizations Write date of vaccinations if available Others specify Jda AUI a Vi Rad Front Measles Lus EE Date Name of institution in bottom of box lid L aug el y ea US clot aa eG Jos Of vaccination in top of box CEU v IA UGH FILL IN TERT Booster AERE Dose 5 dal It dc ol Dose 4
31. d that includes points on injection safety An assessment of safe injection practices injection equipment and the equipment supply system is included in the EPI programme review and evaluation activities performed by the National EPI supervisors All injection related adverse events should be routinely monitored regionally and nationally and investigated with a view of improving the safety of injections 52 Chapter The Quality and Auditing System 9 1 Introduction most important components of the successful EPI programme On the the spot training of re training is an integral part of such supervision R supportive firm but sympathetic supervision is one of the most During the early implementation of EPI the national supervisors played a key role in ensuring uniform quality of the programme implementation in the country Gradually after the decentralization began the regional component of supervision was strengthened National training workshops as well as in service training were conducted Experienced health workers were nominated as the focal points for EPI in the regions 9 2 EPI Regional supervisors targets Supervision Each supervision team must aim to supervise ALL units in their area of responsibility on a periodic basis Weak units should be frequently supervised and re trained as much as is necessary to solve their problems Training the supervisors have a responsibility to train or re train as necessary all pers
32. destination However if he does not have enough monitor cards to do this he could do either of the following e Pack all of the available monitor cards with the shipment to one destination With the next despatch of vaccines he can then send the monitor card which is available at that time to another destination OR e Place a monitor card with shipments going to destinations where the cold chain is suspected to be weak Before the storekeeper puts the monitor card with the vaccine he has to ensure to e Write the date on which the vaccine leaves the store and 26 e Enter the index registered on the monitor e The health workers at regional sub regional amp health centre levels should follow the same steps when they pack their cold boxes and vaccine carriers Actions to take when there is some blue colour on the catd The RVS in charge and EPI focal point at regional and Wilayat levels must routinely check the monitor cards and take appropriate actions when there is some blue colour showing in any of the cards Fig Cold chain monitor card Front Vaccine Cold Chain Monitor Detein Index Dato out Index Im r 7 laa 27 9199 le QV S 2 AT Cin V4 LK d BAG 2 4 t INDEX INDICE dala 10 C MonitorMark irs NEM Da s e e SIS Indicator A B IfAall IfBall If Call DUM blue blue blue blue Polio TEST VACCINE BEFORE USE
33. distribution e Equipment To control and monitor the temperature of the vaccines e Procedures The actions carried out to ensure that this equipment is correctly installed and maintained The Cold Chain reaches from the Manufacturer to the Recipient Manufacturer Ash wh Request for supply P d a Ca eral bro M Te Annual statistics amp estimates Analysis n BE Monthly a Central Vaccine Stores report A gum Sua checking t P dd ka Ewes Regional Vaccine Stores Daily record ch P s Health Centre EJ Source WHO Ve B 19 4 2 Vaccine storage requirements General Requirements All vaccines must be stored at e Correct Temperature The temperature requirements for vaccines at different levels are shown in Table 7 e In darkness this requirement will usually be satisfied if the vaccines are stored in the correct refrigeration equipment and only becomes an important independent requirement when vaccines are held ready for an immunisation session by Static Units or Outreach Teams Hence vaccines must be kept in vaccine carriers when held ready for use and must NOT be exposed to light Table 8 Temperature requirements at different levels Unit Vaccine Temperature Keep frozen at OPV Measles BCG Central amp 20 to 30 C Regional Vaccine store 4 279 F P C All othet vaccines Do NOT freeze Sub Regional Vaccine All vaccines including A 2 store OPV Measles BCG MOS ere amp EPI units All other vac
34. e by side for 15 30 minutes for the sediment to settle Inspect the contents carefully again Always compate vials from the same manufacturer After some experience you should be able to recognise a frozen vial of vaccine in much less than 1 hour Fig 13 Shake test nowt DEBUT INMEDIATAMENTE AFTER 15 MINUTES T 15 MINUTES APRES 15 MINUTOS DESPUES Frozen Unfrozen amp Vaccine thawed Vaccine AFTER 30 MINUTES f 30 MINUTES APR S 30 MINUTOS DESPUES AFTER 1 HOURT 1 HEURE APR S 1 HORA DESPUES 4 5 Types of Vaccine Thermometers Strip Crystal Thermometer Dial type Thermometer SAFE SAFE nee d J UE ee Bar type Thermometer i en all a RR LR eeu 30 20 10 O 10 2 40 50 Sensor type Thermometer 32 4 6 The Vaccine Vial Monitor The Vaccine Vial Monitor VVM is one of the most significant developments in the history of cold chain technology Applied directly to a vaccine vial by the vaccine manufacturer it enables the health worker to verify at the time of use whether each vaccine is in useable condition and or has NOT lost its potency and efficacy due to temperature abuse Vaccine itself exhibits no visible change with heat exposure Prior to the development of the vaccine vial monitor there was no way for the health worker to see if a vaccine had been properly refrigerated Now with the vaccine vial monitor the health worker can easily see if a vial has had too much heat exposure
35. ed Al Ghobashy 830137 Al Wustah Mr Mahmood Salem Al Raqmi 436013 64 Annex 4
36. eeks before the delivery 5 For practical purposes it is assumed that the antibody levels in the mother and the umbilical cord are approximately the same Source WHO HIV infection amp immunisation WHO amp UNICEF have established guidelines for the immunisation of children and women of childbearing age with EPI recommended vaccines It is recommended that individuals with known or suspected asymptomatic HIV infection receive all EPI vaccines as early in life as possible according to the national recommended schedule Individuals with symptomatic HIV infection can receive all EPI vaccines except OPV BCG and Yellow Fever vaccines Table 4 WHO UNICEF recommendations for the Immunisation of HIV infected children and women of childbearing age TT HIV Infection Optimal timing ob Asymptomatic Symptomatic on BCG Yes No Birth DPT Yes Yes 6 12 amp 20 weeks IPV Yes Yes 6 12 amp 20 weeks Measles Yes Nes 6 amp 9 months Hepatitis B Yes Yes 6 10 amp 14 weeks Yellow fever Yes No Tetanus Yes Yes 5 doses In severely symptomatic case do not administer 2 4 School Immunization Schedule Table 5 School Immunization Schedule PRIMARY SCHOOL LEVEL 1 6 7 YEARS Vaccine OPV Booster DT Booster one dose OR DT 2 doses Schedule One dose Give One dose to ALL children OR Give TWO DOSES at an interval of 4 to 6 weeks if NOT vaccinated previously or if no documentary evidence available i e Immunization card
37. een exposed to temperatures above 10 C If there is some blue colour the storekeeper should inform his supervisor e The storekeeper should fill in the top part of the monitor card with the following information The date of arrival of shipment Name and location of the cold store e To check if the letter of any window is entirely blue the storekeeper should look at the strip and the disk and mark the index column For example e If there is no blue colour showing in any of the windows fill in a dash e If window A is entirely blue write A in the index column e If window A amp B are entirely blue write A amp B e If window A B amp C are entirely blue write A amp B amp C e If window A amp D are blue but the others are white write A amp D e If window A B C are white but D is blue write D e If any window is partly blue do not place any mark in the index column Importance of keeping the monitor card cool The monitor cards should always be kept in the cold room or refrigerator along with the vaccines with which they were originally packed The card should be checked periodically for any colour changes by the vaccine store in charge or the EPI staff nurse as applicable Placement of monitor catd when it leaves to other destinations The storekeeper may have to send vaccines to several destinations at the same time The ideal situation would be to have enough monitor cards for each
38. frozen vial to thaw MARK IT CAREFULLY so that you don t use it by mistake and use it as a sample to compare with all other vials of this batch of vaccine Learn to tell the difference between vials of DPT DT TT Td HBV Hib which have been frozen and those which have not The test to detect frozen vials is called the shake test the EPI supervisors or your knowledgeable colleagues will tell you how to perform the test Chapter The Recording System 5 1 Introduction operation in MoH institutions from 1st August 1986 With the inclusion of new vaccines in the schedule the Child Health Register MR 374 and Child Health Card MR 224 have been modified from time to time and are periodically updated whenever required system for recording immunisation in the static units was brought into The recording system requires detailed supervision and meticulous paper work The components of the recording system are elaborated below 5 2 System Components 5 2 1 Child Health Register MR 374 Each child should be registered in only one MR 374 Register in the country This Master Register would normally be in the Hospitals EHC Health Centres unit closest to the place where the child lives and or where the child will normally be brought for routine immunisation This institution is known as the child s Parent Institution The Parent Institution is responsible for ensuring that the children residing in their catchments
39. health register MR2 register was introduced As a result immunization coverage increased throughout the late 1980 s and early 1990 s and coverage of more than 95 has been maintained since the early 1990 s for all the vaccines in the EPI schedule In the early 1990 s there was a measles rubella epidemic in which more than 3000 cases were reported Most of those affected were children born before 1987 when immunization coverage was comparatively low Due to this outbreak a Measles Rubella MR vaccination campaign was held to vaccinate all children between the ages of 15 months and 18 years Subsequently a second MR dose was introduced into the EPI schedule The EPI programme has now initiated the Hepatitis B campaign targeting all children not covered by the EPI programme By the end of the Year 2004 everyone under the age of 20 years would have been vaccinated against Hepatitis B Thus the EPI schedule has been revised and expanded several times over the past 20 years and now includes immunizations for 10 antigens the latest was the introduction of the Hib vaccine this year This manual provides a comprehensive overview of the vaccines provided in the EPI programme the immunization schedule adverse events following immunization the vaccine cold chain and EPI disease surveillance follow up and reporting It is hoped through this revised Standard Operating Procedures Manual all staff of the Ministry of Health and sister inst
40. heir work are in accordance with this manual and that their cold chain and immunization techniques are correct e Outreach Teams Productivity Defaulter retrieval and visiting distant villages are resource intensive activities Teams spend a lot of time in travel to reach distant villages and searching for defaulters It is inevitable that only few doses ate administered in a day This is perfectly acceptable and should not be criticised as long as the teams are finding all the defaulters in the area 44 Chapter T he Immunization Session for conducting immunisation sessions will follow the Standard Operating Procedures mentioned below A ll Hospitals Health Centres and Public Health sections who are responsible 7 1 Information to Mother e Explain to mother which vaccine dose s you are offering to her child and what disease the vaccine s would prevent e Ensure that no mother leaves any immunisation session without a clear idea of exactly what disease s her child has just been protected against e Explain to the mother about the normal post immunisation reactions e g a fever after DPT or a fever and rash after Measles e Provide the mother with the due date of her child s next dose write the date on the child health card in pencil in the appropriate place and politely stress to the mother the importance of bringing her child back on or around the due date 7 2 Maintaining the cold chain during session e Vaccines for
41. hild care plan Oral poliomyelitis vaccine Petroleum development organization Public health section Royal Oman police Regional vaccine stores Sultan Qaboos University Tetanus immune Globulin human Tetanus diphtheria toxoid adult type Tetanus toxoid United Nations Children s Fund Vaccine and Biologicals Vaccine preventable diseases Vaccine qualified clinic Vaccine vial monitor World Health Organization Forward EPI program was one of the first health programme launched in Oman In the last 30 years Oman has transformed from an isolated undeveloped country to a modern welfare state The dramatic decreases in mortality rates and other positive indicators of health and well being in conjunction with other political and economic transformations are due to the dedication and commitment of the Sultanate s leader H M Sultan Qaboos One of the most significant features is the dramatic drop in the infant mortality rate from around 125 per 1000 live births in the 1970 s to less than 16 2 per 1000 by the year 2001 and this can be attributed in part to the Expanded Programme on Immunization EPI Childhood immunization was one of the components of health services in Oman in the 1970 s But it was not until 1981 that the EPI Programme was launched with the establishment of an office and recruitment of staff for the programme A comprehensive childcare programme was launched nationally in 1987 and the child health card and child
42. hould take steps to retrieve that child as follows e Passive Defaulter Retrieval The Parent Institution attempts to retrieve the child through its own resources ie the EPI nurse would send messages directly to the family through the health workers from the village the local Sheikh Community Support groups and the school teachers or anyone else who has influence in the community This is community s involvement and has been shown to work in most areas A Parent Institution would normally begin passive defaulter retrieval after the child has not come for immunisation within 1 to 2 weeks from the due date e Active Defaulter Retrieval once a child has not come for immunisation within 4 weeks from the due date the EPI staff nurse should pass the responsibility for retrieving the defaulter to the nearest EPI Outreach Team Defaulter Retrieval by EPI Outreach Teams is described later 5 7 EPI Reporting The following EPI reporting forms have been introduced since August 1990 40 annexure 5 7 1 EPI Feedback Form Purpose to inform a child s Parent Institution that one or more of their children have been immunised in another place so that they can update their Master Register Used by any static unit or outreach team Sent to the Parent Institution as soon as possible by Ministry post 5 7 2 EPI Defaulter Retrieval Form Purpose to inform a PHS Outreach team that certain children are overdue fot their next immunisat
43. in 24 48 hours Any death of a vaccine recipient temporally linked within 4 weeks to immunization where no other clear cause of death can be established should be reported In addition any other severe and unusual events occurting within 4 weeks after immunization and not specified in the above description should be reported Annexure 3 Important Phone Numbers 2002 National EPI Program Name of Supervisor Designation Telephone Office 968 601921 607524 Dr Salah Al Awaidy Programme Manager Res 968 545489 GSM Office 968 601921 607524 Dr Shyam Bawikar Epidemiologist Res 968 683695 GSM 9368327 Pharmacist I C Central Office 968 Mr Abraham Vaccine Stores Darsait Pager National EPI Supervisor Head Quarters Name of Supervisor Regions Office Telephone Wik Tam Al Botush South Batinah Office 968 607524 North Batinah Muscat Dhofar Dakhliyah Mr Bader Saif Al Rawahi Dhahira Al Wustah amp Muscat South Sharqiyah North Sharqiyah Musandam Muscat Mr Hussamuddin Nawar EPI Regional Supervisor focal point Region Name of Supervisor Office Telephone Muscat Mt 782110 Dhofar Mr Bakheet Ali Safrar 210130 North Batinah Ms Khadija Hassan Al Balushi 842545 South Batinah Mr Waleed Khamis Al Hadebi 875434 Dakhliyah Mr Nasserulla Khalaf Al Tobi 411159 Dhahirah Mr Said Nasser Al Kalbani 491870 North Shargiyah Mr Dawood Dudin Al Balushi 470534 Musandam Dr Mohamm
44. ines for a maximum of FOUR WEEKS Regional stores level store vaccines for a maximum of THREE MONTHS depending on vaccine storage capacity Control the temperature By using the Thermostat to keep the temperature between 2 to 8 C at ALL times Monitor the temperature By placing the thermometer within the vaccines box By placing Vaccine Monitors with the vaccines By Placing the freeze watch indicator with in the vaccines box Record the temperature Use the new Cold Chain Refrigerator Graph see fig 10 amp 11 to plot the temperature twice a day Plot the temperature at the B egining of the immunization session and at the E nd of the session If you have two sessions per day for example a morning and afternoon session plot the temperature at the B egining of the first session and at the E nd of the second session Keep these temperature records in a file for 2 years Vaccine Storage Precautions at the EPI Unit Cold Chain failure If the Cold Chain fails or if you have any reason to suspect it may have failed you should not use the affected vaccines Report the problem to your regional supervisors and DSDC and order more vaccines immediately There is NO shame or blame attached to reporting cold chain failure although you should obviously do your best to avoid it Staff will only be blamed if they attempt to hide or fail to report cold chain failure if in doubt repor
45. int of communicable diseases in the region in consultation with the Department of Surveillance amp Disease Control For the data to be collected for case or cluster investigation refer to AEFI investigation form in the annexure 1 The list definitions for monitoring AEFI are given in annexure 2 3 1 4 AEFI Reporting After completing the AEFI report form see annexure a copy should be sent to the Director DSDC on Fax No 601832 and to the Department of Health Affairs of the region Regional EPI focal point within 24 hours of the event Any death severe AEFI or unusual medical incident must also be notified immediately during the same immunization session by phone or fax to the Director DSDC and the Superintendent of Health Affairs of the region AEFI reporting form should be duly filled by the EPI nurse taking care that all relevant details are entered The attending doctor should enter the clinical details sign and dispatch 18 Chapter The Cold Chain 4 1 Introduction he Cold Chain is the system which ensures that vaccines remain potent from the from the moment of manufacture to the time of immunisation Vaccines deteriorate quickly when exposed to HEAT and or LIGHT If a child is immunised with a vaccine which has deteriorated i e a vaccine which has been rendered impotent then it is as if that child had not been immunised at all The Cold Chain has three components e People To organise and manage the vaccine
46. ion dose and are to be located and immunised as soon as possible Used by any PHS and or Outreach team Filled out by EPI Static unit Outreach team staff Returned to the parent institution of the defaulting children before the end of the month or earlier to update their Master Register 5 7 3 EPI Monthly Report A monthly report form is to be completed by all units involved in EPI and sent to the DSDC through the Regional Directorate by not later than 10th of the following month The form serves following purposes Self assessment of the immunisation coverage of children for the institution s catchment area Summary of vaccine doses given to children in the reporting month Summary of Tetanus Toxoid doses given in the reporting month Information on the number of vials used for vaccine procurement and monitoring vaccine wastage Surveillance of Vaccine preventable diseases VPD Monitoring of adverse events following immunisation Note All units must ensure that they report only those immunisations that ate actually administered by them They must NEVER report immunisation cattied out by another unit 5 8 Vaccine Stock Form amp Forms for Record of Cleaning amp Maintenance of Cold Chain Equipment These forms are maintained by the in charge staff of RVS sub RVS amp static units according to the guidelines See Annexure Chapter The Outreach Strategy 6 1 Introduction he EPI outreach immunization teams ha
47. itutions will feel responsible for sustaining the universal acceptance by the community that immunization is vital to the life health and well being of the children of this country and the resulting high immunization coverage Dr Ali Jafer M Suleiman Director General of Health Affairs Ministry of Health Oman vi Chapter Introduction 1 1 Global Scenario otld Health Assembly in 1974 adopted a resolution and launched the Expanded Program on Immunisation EPI Since the 1980s considerable progress in immunization worldwide has helped to decrease mortality in young children As a result of immunization almost 3 million lives have been saved each year and 750 000 children are saved from disability In 1999 the worldwide average vaccination coverage of children under five was 74 One in every four children in the world remains without immunization against the six diseases initially covered by EPI Measles Polio Pertussis Diphtheria Tetanus and tuberculosis Access to immunization varies greatly across the world A child in a developing country is ten times more likely to die of a vaccine preventable disease than a child from an industrialized one In some countries up to 70 of children do not receive the full set of vaccines the lowest coverage is found in sub Saharan Africa In Africa as a whole over 40 of children are not immunized against Measles a major cause of infant mortality that kills one child every minute WHO has
48. led at 12 amp 18 months respectively DPT amp OPV Booster at 18 months Vitamin A supplementation at 7 amp 12 months Introduction of IPV for immunocompromised amp their contacts National Immunization Campaigns March 1994 1995 to 1999 5 2001 to 2004 Future Plans Catch up campaign with MR vaccine Target 15 m to 18 yrs Polio National Immunization Days NIDs Target lt 5 yrs Hepatitis B Catch up school campaign Introduction of combined vaccine as Tetra Penta DT P Hib Hep B Introduction of Hepatitis A vaccine Introduction of Auto Disable AD syringes 14 Immunization Policy Ministerial Decree No 127 92 and Article 14 of Royal Decree No 73 92 act as background legislation documents on EPI policy in Oman It is the Policy of the Ministry of Health e To immunize ALL children under one year against the 10 vaccine preventable childhood diseases primary immunization amp boosters and also to immunize all women in child bearing age with Tetanus Toxoid in order to eliminate Neo Natal Tetanus All these vaccines would be offered at all the MoH institutions sister health organizations and vaccine qualified private clinics without incurring any cost to the beneficiaries Note The 10 vaccine preventable diseases are Tuberculosis Diphtheria Pertussis Tetanus Poliomyelitis Measles Hepatitis B Rubella Mumps amp Haemophilus influenzae type b e To offer specified boosters to the children u
49. months form January 1998 Mumps The MR vaccine was replaced by MMR from October 1997 Haemophilus influenzae type b Following the estimation of disease burden of Haemophilus influenzae type b year 2000 the Hib vaccine was introduced from October 2001in EPI on the basis of the findings of its cost effectiveness 2 4 3 School Immunizations The second dose of BCG was omitted at school entry as recommended by WHO Similarly DT booster was replaced by Td adult formulation Table 2 The current EPI Schedule Last revision in October 2001 FIRST YEAR OF LIFE Due Age Vaccine dose order At Birth BCG 1 dose OPV Birth HBV 1 dose 6 weeks OPV 40 Al Arbayeen dose DPT 1 dose HBV 2 dose 3 months OPV 1 dose DPT 2 dose Hib 1 dose 5 months OPV 2 dose DPT 3 dose Hib 2 dose 7 months OPV 3 dose HBV 3 dose Hib 3 dose Vitamin A 100 000 IU 12 months Measles 1 dose Vitamin A 200 000 IU SECOND YEAR OF LIFE 18 months MMR Measles 2 dose DPT Booster OPV Booster 2 2 Contraindications to Vaccination Given the success of reduction in the incidence of the vaccine preventable diseases in the Sultanate of Oman and the consequent decline in levels of avoidable sickness disability and death it is important that every opportunity should be taken to immunize the target population in order to sustain the gains made so far General contra indications include prior allergic reactions to
50. name to be in charge of the vaccine refrigerator Prepare your vaccine refrigerator Fill pac By removing all door shelves drawers glass shelves etc Fig 16 vegetable No water bottles must be kept in the door These items will be on the inventory of your hospital or health centre so please keep them safely in a cardboard box in your store room freezer To store cold i e To stabilise the refrigerator temperature and thus to increase the time that the refrigerator will maintain a safe temperature if the electricity or gas fails compartment with ice To protect vaccines in an emergency i e To store the vaccines in a vaccine carrier immunization unit or cold box regional store To protect vaccines in transit e g for outreach teams Use your vaccine refrigerator properly Use for vaccines only Other drugs etc should be kept in another refrigerator Do not even think of keeping cold drinks or food in your vaccine refrigerator What to do if the electricity or gas fails If the power is cut for more than TWO HOURS you should remove all the vaccines AND cold chain monitors from the refrigerator and put them in your vaccine carrier or in a vaccine cold box along with the appropriate ice packs and a vaccine thermometer You can keep vaccines in a vaccine carrier for up to 24 hours or in a vaccine cold box for 3 to 5 days Vaccine storage time At static unit or sub stores level store vacc
51. nder the school health programme e To use every contact of a child mother and females in child bearing age with the health delivery system as an opportunity to check the immunization status e To strive to sustain a universal acceptance by the community that immunization is vital to the life health and well being of the children e To strive to make ALL MoH and sister institution employees feel responsible for increasing and sustaining the immunization coverage in the area in which they work so as to reach near 100 coverage e To offer Vitamin A supplementation of 100 000 IU along with measles dose at 12 months and 200 000 IU with MMR dose at 18 months e To maintain the immunization records in the o Child Health Card MR 224 Boys Girls The card acts as the child s immunisation health and developmental record for the first 6 years of life o Child Health Register MR 374 The health institution based child health register acts as a comprehensive record of information related to child health e EPI Quality Assurance Policy o The EPI is committed to provide services fulfilling following quality dimensions accessibility equity continuity safety effectiveness and efficiency o Establishing an ongoing supervisory and auditing system o Continually improving the quality of EPI services 1 5 Immunization Strategy Department of Surveillance amp Disease Control Directorate General of Health Affairs MoH is
52. nsured that ALL eligible children can gather at one location and the community would take its responsibility then only the house to house method may be abandoned Procedure for new children whenever an outreach team finds a new child that is a child under 2 years of age who has not been immunised before they must ensure that they report the child s full details to the parent institution so that the child can be properly registered and then followed to full immunisation in the way described e Supervision and monitoring The defaulter retrieval activities described above would only be successful if the teams are adequately supervised The Director of Health Services of the Wilayat must therefore monitor and supervise these activities with firmness and sympathy This include o Planning Help the Outreach team to plan the programme so that they achieve an optimum balance between defaulter retrieval activities with the visits to the distant villages o Community involvement Accompany the Outreach team when they visit the Wali and Sheikhs Oo Supervision in the institution The EPI staff nurse should ensure that the Outreach team leaves in time with the list of defaulters Ensure that the team takes the required vaccines and equipment with them Ensure that the team fills out various reports correctly o Supervision in the field Accompany the outreach team to the field at least once every month in order to see that all aspects of t
53. olicy require a shor ter period before use or disposal of the vaccine Assembled amp distributed by Berlinger Ganterschwil Switzerland aH ie EDT 4 Pull tab Straight cul and remowe 4 4 2 Cold Chain Refrigerator and Freezer graph The purpose of the graph is to monitor the refrigerator and freezer temperature and to identify any impending problem of cold chain failure Ensure that at least one cold chain monitor amp freeze watch is available in each refrigerator to monitor such failures Scenarios and appropriate responses e Ifthe temperature rises steadily over a few days it may probably mean that the compressor is failing Immediately inform the MOIC to take approptiate action for repairs e If the temperature chart shows wide variations between the B egining of the session and the E nd of the session you may be opening the refrigerator door too often In this case minimize door opening and perhaps to increase the temperature stability increase the number of cold packs in the refrigerator e If when you monitor the temperature in the morning i e at the B egining of the immunisation session you find the temperature say 14 C you have a cold chain failure In case ofa Cold chain failure y y Transfer the vaccines and cold chain monitors to a vaccine carrier or vaccine cold box Contact your regional EPI focal point as well as the national EPI Supervisor in DSDC give them the facts and ask for guidance
54. onnel involved in EPI in their area 9 3 Supervisory responsibilities 1 The EPI supervision teams must maintain the following records for their area e List of units All static units and outreach teams and their areas of responsibility e g Wilayat villages static units served by each Outreach team e List of personnel In each unit team e List of doctors who supervise EPI i e the doctors who in institutions with more than 2 doctors have been nominated to supervise their EPI 53 activities 2 Supervise the Cold Chain to ensure the integrity of the Cold chain particularly in their area Table The Regional amp Sub regional Vaccine Stores in Oman 2002 Region Muscat Dhofar North Batinah South Batinah Dakhliyah Dhahira North Sharqiyah South Sharqiyah Musandam Al Wustah Regional Vaccine Store Darseit SQ Hospital Salalah Sohar EHC Rustaq Hospital Nizwa PHS Tanam Hospital Ibra Hospital BBB Hassan PHS Khasab Hospital Haima Hospital 54 Sub Regional TE Vaccine Store Besponsibiluy Pharmacist Shinas HC Suwaiq HC Khaburah HC Saham Hospital Sumail Hospital Bahla Hospital Buraimi Hospital Sinaw Hospital Sur Hospital BBB Ali Hospital Diba Hospital Chapter The School Immunizations 10 1 Introduction accepted Almost the entire population of children between the ages of 6 to 12 years attend the school and hence are accessible for immunization and follow up
55. oratory Findings if relevant IV Management Attach photocopy of child health card V Medical history H O reactions to previous doses drug allergies etc Vl Event summary VII Symptoms of AEFI Check only the appropriate box L Yes LINo BCG adenitis gt 1 5mm Injection site abscess requiring drainage Lymphadenitis Suppurative lymphadenitis LI Local Adverse Reactions L Pain swelling and redness at the site of injection Redness amp or swelling centred at the site of injection AND one of the following Swelling beyond the nearest joint Pain redness and swelling of more than three days duration L Requires hospitalization Systemic Adverse Reactions Non specific symptoms e g fever above 39 C malaise headache persistent screaming etc Specify iiini nada a Sa inari a Ada nana L CNS adverse events L Acute paralysis L Seizures febrile or afebrile Oo Meningitis Encephalitis OO Encephalopathy O Other specify L Allergic Reactions O Generalized urticaria L Toxic shock syndrome O Breathing difficulty O Disseminated BCG adenitis C Anaphylactic shock L Hypotension L Acute hypersensitivity reaction Oo Other specify anaphylactoid reaction LI Other Adverse Reactions Specify e g Osteitis Osteomylitis Arthralgia etc Investigated by Name
56. pter Immunization Schedule 2 1 The EPI Schedule S ince the introduction of EPI in Oman the schedule was changed on vatious occasions based either on the evidence of the changing incidence of vaccine preventable diseases or on the recommendations of WHO 2 1 1 The rationale for changes in EPI Schedule OPV The birth dose and AJ Arbayeen Day 40 dose was added to the earlier 3 dose schedule due to the outbreak of poliomyelitis in Oman in 1988 89 Thus currently five dose schedule of OPV is being followed for the primary immunization Measles Rubella Second dose of Measles was added in 1994 along with Rubella as MR vaccine at 15 months after a mass catch up campaign in the same year The Measles vaccine was rescheduled to 12 and 18 months recently based on the specific recommendations by WHO for countries in the phase of measles elimination Vitamin A supplementation Two doses of Vitamin A 100 000 at 7 months and 200 000 at 12 months are being offered based on the evidence of sub clinical Vitamin A deficiency amongst the children Hepatitis B Hepatitis B vaccine was added in August 1990 due to the concerns about the moderate endemicity of the disease in Oman and with the purpose of reducing its burden Pertussis During an outbreak in one of the regions of Oman in 1997 high incidence of cases in the children under 3 months of age was observed Hence the three doses of DPT were rescheduled at 175 3 and 5
57. ramme manager in DSDC on the progress of the immunization activities according to the laid down schedule The VQ clinics can administer other vaccines not included in the EPI schedule but licensed by MoH viz Hepatitis A Varicella Influenza Tetra Penta etc These vaccines are available in private pharmacies Examination In order to establish beyond any doubt that a private clinic is fully conversant with the EPI programme the management of the Cold Chain and the DSDC EPI Recording and Reporting requirements i e before a Private Clinic can be judged VQ the MOIC of that clinic must pass an examination in all these subjects 11 3 Recording amp Reporting All private clinics must maintain an immunisation record register as per the format recommended by EPI DSDC This register must be kept updated and would be inspected during routine visits by the national EPI supervisors Accurate and timely reporting is a major component of a satisfactory vaccination programme For this reason VQ clinics must understand and comply with the following reporting schedule Monthly Vaccination and consumption summary to be completed each month and submitted to EPI DSDC by not later than 10th of the following month EPI monthly report form should be utilised for this purpose Feed back summary Details of immunisation given are to be filled out in the Feed back form and immediately dispatched to the parent institution for updating the MR 237 regi
58. rieval 6 3 Inaccessible Population NA N P e N W we e UJ UJ H3 e U UJ e e CHAPTER 7 IMMUNI ZATI ON SESSI ON 7 1 Information to Mother 7 2 Maintaining Cold Chain 7 3 Session 7 4 Opened Vial Policy 7 5 Disposal of Sharps 7 6 Golden Rules CHAPTER 8 INJ ECTI ON SAFETY 8 1 Introduction 8 2 Equipment Handling 8 3 Safe Disposals 8 4 Golden Rule CHAPTER 9 SUPERVI SI ON 9 1 Objectives 9 2 Targets for Supervision 9 3 Responsibilities CHAPTER 10 SCHOOL I MMUNI ZATION 10 1 Introduction 10 2 Responsibilities 10 3 Schedule CHAPTER 11 PRIVATE CLI NI CS 11 1 Introduction 11 2 Vaccine Qualification 11 3 Schedule 11 4 Recording amp Reporting 11 5 Training 11 6 Supervision amp Audit ANNEXURES AEFI Case Investigation Form Child Health Register MR374 EPI Feed Back Report Form Vaccine Stock Form Maintenance of Cold Chain Equipment Telephone amp Fax Numbers Index mn UJ WP d UJ we n UJ UJ QJ F3 Hn UJ UJ HE d List of Contributors Chief Contributors e Dr Salah Al Awaidy Director DSDC e Dr Shyam Bawikar Epidemiologist DSDC Other Contributors e Mr Islam Al Balushi National Supervisor DSDC e Mr Hussamuddin Nawar National Supervisor DSDC e Mr Bader Al Rawahi National Supervisor DSDC e Mr Salem Al Mahroogi National Supervisor DSDC Reviewed by e Mr Philips Duclose V amp B WHO Geneva e Dr Saleh Al Khusaiby Sr Consultant Child Health Services e Dr Mohammed Al Hosni Con
59. ring temperature changes The instructions for interpreting the readings are printed on the monitor card fig How does the Monitor catd works The monitor card has a heat sensitive indicator in the form of a strip with 4 windows This indicator operates at two different temperatures To activate the card pull out a small tab on the left hand side of the strip e When the strip is exposed to temperatures above 10 C it functions as follows o A blue colour begins to appear in the first window marked A If the temperature then drops below 10 C the blue colour stops spreading to other windows o Each time the strip is exposed to temperatures over 10 C the blue colour will spread further across the monitor from A to C The colour change is irreversible The colour may stop spreading but will NEVER RETURN down the scale When the window labelled D is exposed to temperatures above 34 C it functions as follows o It turns blue within 2 houts o Once the colour has changed to blue it will never change back to white What to do with the monitor card when it attives There is usually one monitor card packed with each 3 000 doses of vaccine When the vaccine arrives at each level central regional sub regional and health centre levels the storekeeper should check the monitor card e To see if there is any blue colour on the strip If there is no blue colour it means that this shipment of vaccine has never b
60. rtant to know that parts of the needle and the syringe in order to handle the equipment safely 2ml Syringe AD Syringe 50 8 2 Handling syringes and needles safely The following procedures and rules should be adopted Do not touch EVER e The shaft of the needle e The bevel of the needle e The adaptor of the needle e The adaptor of the syringe e The plunger seal of the syringe e The plunger shaft of the syringe If you touch any of these parts accidentally discard the syringe and needle You may however touch e The barrel e The plunger top All syringes and needles must be safely disposed off after single use 8 3 Procedures for disposing of injection equipment Before disposal syringes and needles should be placed in a puncture proof container Special boxes for collection and destruction by burning may be purchased These are water proof and tamper proof and needles cannot pierce them Alternatively you may use containers made of thick plastic or metal cans for collecting syringes and needles and transporting them to an incinerator or other site where they can be burned Follow these steps to dispose off injection equipment safely Place disposable syringes and needles after use directly in the disposal box To avoid needle stick injuries DO NOT attempt to recap the needle or to separate the syringe and needle Contaminated sharps should not be transferred from container to container When the
61. sely those risks of mortality and morbidity from the target diseases that immunisation is designed to avoid Therefore the note above about what to do in the case of an interrupted series should NOT be interpreted as an excuse to delay the subsequent doses Administration of Tetanus Immune Globulin TIG to newborn TIG must be administered only to babies born outside the hospital and 10 o Seen within 10 days of delivery o Born to mother who does not have at least 2 documented doses of Tetanus Toxoid o Born to a mother who has not received prescribed TT schedule ot born beyond the duration of protection refer to table 3 o Dose of TIG is 250 IU Table 3 Tetanus toxoid doses amp duration of Immunity Dose nma Percent Interval protected TT1 TIZ 4 weeks 80 60 90 TT3 6 months 95 TT4 1 year og TT5 1 year 99 1 For practical purposes Duration of protection 3 years 5 years 10 years life long There are NO contraindications to the administration of tetanus toxoid The risk of adverse reactions is negligible Only well documented immunizations should be counted If in doubt give an extra dose 2 There is NO maximum interval between doses 3 If the previous dose of tetanus toxoid was given during a pregnancy this dose could coincide with one of the immunization of the child 4 Optimal protection of the infant can only be expected if the woman receives the vaccine at least two w
62. specially during transportation and immunisation session This can be ensured by packing these vials in cardboard boxes or plastic bags e Lid of the carrier should be shut tightly Note Vaccine cartier should be used for vaccines only and not for any other purposes Fig Vaccine Carriers Geostyle amp Thermos Ice packs e Used for lining the walls of cold boxes and vaccine carriers to keep them cold and in refrigerator to help stabilise temperature at required level e They are flat plastic bottles filled with water Gel e Prepared by keeping in deep freezer or freezer compartment of a compression refrigerator e Ice packs should stand with their edges in contact with the evaporator and not flat on one another in the freezer compartment of refrigerator e Do not add salt to the water as it lowers the temperature to subzero temperature which is not recommended for DPT DT TT Hib and HBV 22 DEPARTMENT OF SURVEILLANCE amp DISEASE CONTROL While filling water in the ice pack do not fill it to the brim Leave some air space to allow for ice expansion Ice packs are also used as cold packs to stabilise the temperature inside the refriperator and to increase the time the refrigerator will maintain a safe temperature if electricity fails Do not use leaking ice packs Any damaged ice packs should be replaced Use only the correct type amp number of ice packs for each type of vaccine carrier amp cold box For
63. spital then he she is well enough to receive BCG OPVand HBV prior to discharge Infants born to mothers who are sputum positive for AFB should be given primary prophylaxis with INH 5 mg Kg body weight for a minimum period of 3 months and then vaccinated with BCG if tuberculin negative at 3 months not at birth as in normal infants If tuberculin positive then treat for 6 months in all for details refer to TB Manual 3 edition 1998 Hepatitis B vaccination The schedule for Hepatitis B vaccination is initiated soon after birth in the present EPI schedule to prevent perinatal transmission Mothers are NOT routinely screened for Hepatitis B surface antigen HBsAg during antenatal period hence it is vital that the newborn receives the first birth dose of Hepatitis B vaccine within 12 hours after delivery This also applies to sick and low birth weight babies The above time frame is required to be followed strictly to reduce the risk of perinatal transmission Booster Dose of DPT vaccination In the EPI schedule a booster dose of DPT is given at 18 months of age i e 1 year after the 3 dose of DPT It is clarified that the interval between the 3 dose of DPT and booster dose could vary from 6 to 12 months minimum interval is 6 months Hence children should be given the booster dose at 18 months of age even if their primary schedule is delayed provided the minimum interval is respected Minimum interval between doses should be at lea
64. st 4 weeks for OPV Measles Hib and DPT vaccines The recommended course of each vaccine must be completed as scheduled However in actual practice children may sometimes present for immunisation later than the exact intervals and times specified In such instances the child must be given the missed doses immediately irrespective of the gap between doses The immunisation series need NOT be re started but must be continued Few examples are cited below A child who on screening is found to have had DPT OPV first dose 6 or may be 12 months ago This child should be given DPT OPV second dose and any other vaccine for which he she is due or overdue The series should then be continued according to the minimum time interval A child is detected as a defaulter at 18 months with no measles at 12 months It would therefore be ideal to give MMR vaccine to protect the child with 3 antigens and advise the mother to bring the child for measles vaccine after one month A woman who on screening is found to have had TT first dose one year previously should be given the second dose without restarting the series There is NO maximum interval between TT doses Only minimum intervals between doses should be adhered to Every attempt must be made to immunise children on time i e as per the national immunisation EPI schedule Any delay in completing the schedule exposes that child and all others in the community who are not fully immunised to preci
65. ster 11 4 Training It is the responsibility of Private Clinics to become VQ and not the responsibility of EPI DSDC to qualify them The MOIC of any private Clinic seeking VQ status must study and learn and pass an examination in the EPI the Cold Chain management procedures and the recording and reporting protocols EPI DSDC will be available to advise assist or to clarify any points which are not clear in the above documents However such advice can only be given on an as available basis i e when the EPI DSDC supervisors have time to spate from their responsibilities In short although EPI DSDC will do its best to help Private Clinics whenever required Private Clinics do not have the right to demand such services at a time of their own convenience 58 11 Supervision amp Audit EPI DSDC has a responsibility to supetvise and audit all immunization activities in the Sultanate of Oman For this reason and because the DGHA would be supplying vaccines to Private Clinics under the terms of this Protocol EPI DSDC will exercise strict supervision over VQ Clinics This supervision will take the form of unannounced spot checks whose aim would be to see that Private Clinics are following the terms of this Protocol Any Private Clinic found in serious violation of the terms of this Protocol will be reported immediately to the Director General of Health Affairs of the Ministry of Health HQ with the recommendation that the Clinic
66. stered in the Tanam Hospital Master Register but in the Dhank HC Master Register This Transfer of Responsibility for the child children will be carried out at the end of every week by despatching the duplicate white part of the child health card duly filled to the parent institution These transferred children should then be entered into their Parent Institution Master Register under the month amp year they were born All static units should leave 2 to 3 blank pages at the end of each month entries so that the space is available to register children transferred in from other institutions Write the name of the child s Parent Institution in his Child Health Card to make it easy to tell which is child s Parent Institution The name of the institution should be written on the child s health card when it is issued For example a baby girl born in Khowla Hospital whose parents live in Suwaiq area would have Swwaiq EHC written in her child health card 5 3 1 Transferred in amp Out Sometimes the family moves out of the catchment area of the parent institution where the child was registered In such situation the previous MR 374 number should be cancelled and a new number should be issued by the parent institution as if it s a new registration For example a child was registered in Seeb health centre s master register and the family moved out to Murah The old MR 374 number issued by Seb HC would be replaced with a new number based on the
67. sultant Infectious Diseases Royal Hospital e Dr Amr M Taman Advisor Quality Assurance DGHA e Dr M V Joseph National IMCI Coordinator DGHA Acronyms A AFB AEFI AFP ARI ATS BCG CSF DGHA DPT DSDC DT DTaP EHC EMRO EPI GBS HBsAg HBV HC Hib HIV ID IM IPV ISO IU MCH MMR MoD MoE MoH MOIC MR NID NWCCP OPV PDO PHS ROP RVS SQU TIG Td TT UNICEF V amp B VPD VQ VVM WHO Alcohol acid fast bacilli Acute events following immunization Acute flaccid paralysis Acute respiratory tract infections Anti tetanus serum equine Bacille Calmette Guerin Cerebrospinal fluid Directorate General of Health Affairs Diphtheria pertussis tetanus Department of Surveillance amp Disease Control Diphtheria tetanus child type Diphtheria tetanus acellular pertussis Extended health centre WHO Regional Office for the Eastern Mediterranean Expanded Programme on Immunization Gullian Barre syndrome Hepatitis B surface antigen Hepatitis B virus Health centre Haemophilus influenzae type b Human immunodeficiency virus Intradermal route Intramuscular route Injectable poliomyelitis vaccine killed International standards organization International units Maternal and child health Measles Mumps amp Rubella vaccine Ministry of Defence Ministry of Education Ministry of Health Medical officer in charge Measles Rubella vaccine National Immunization Day Polio campaign National women and c
68. t Home It is estimated that less than 10 of all Omani children are born at home However ALL of these children must be registered in the Master Register at their Parent Institution If they are not registered then the chance of ensuring that they are fully immunised may be lost forever All health workers should be aware of their responsibility to ensure that the names and other details of these children are entered in the Master Register As with so many aspects of EPI community involvement is of vital importance here Evety attempt should be made to involve the community support group members to report the names and addresses of any babies born at home directly to the static unit Note The Director General of Health Services in the Region or the MOIC should ensure that a child born at home has been issued a child health card before issuing a Birth Certificate EPI Defaulters Once a child is registered in the Master Register in his Parent Institution it will be a simple matter to see that he she progresses towards full immunisation on time For example all the children registered in the month of January would be due for their next doses in February March They would be considered as EPI defaulters if they are not immunised within one month from the due date Defaulters are to be retrieved by a combination of passive and active means 5 6 1 Defaulter Retrieval As soon as a child is known to be an EPI defaulter the Parent Institution s
69. t it Stabilize the refrigerator temperature By keeping the door closed as much as possible Cold air drops out of the refrigerator each time you open the door By leaving space inside refrigerator for air to circulate do this by keeping your vaccines cold packs and water bottles one hands width from sides and back of your refrigerator If you have a small amount of vaccine i e most health centres amp smaller hospitals then put extra cold packs water bottles in fridge to help stabilise the temperature Please note that the purpose of the extra cold packs is to store cold if you have a lot of vaccines in your refrigerator they will store cold and providing the air can circulate you have achieved the same aim 36 Protect the vaccines from freezing By keeping vaccines an arms width away from the evaporator plate If vaccines touch the evaporator plate they will freeze and this will damage the vaccines especially HBV DPT DT Td Hib and TT Frozen DPT TT DT Td Hib or HBV Freezing destroys DPT TT DT Td HBV amp Hib vaccine It is a complete waste of every ones time to immunize with vaccine which has been destroyed Because the visible results of freezing these vaccines varies from batch to batch you should freeze one vial of any new batch of these vaccines you receive we only get 2 or 3 new batches of each vaccine per year you are NOT supplied with a new batch every month Allow the
70. te cold chain conditions 2 to 8 Celsius and Opened vials of vaccine which have been taken out of the health institution for immunisation activities e g outreach NIDs are discarded at the end of the day e Always write the date amp time on the vial after opening it Potential benefit of the above revised policy is that wastage would be cut down with NO compromise on the safety and the potency Disposal of Used Vials It is unwise to dispose off used vials of vaccine in an unsafe manner ALL immunisation used vials of vaccine must be disposed off in sealed containers These containers MUST NOT be thrown into the Municipality drums but should be handed over to the Municipality worker personally or to be incinerated on site if facilities are available Golden Rules e Look directly into the mother s eyes e Smile at the mother and child e Congratulate the mother for bringing her child for immunisation 48 Chapter The Injection Safety 8 1 Introduction here are three levels of definitions for a safe injection The first level is an ideal reference definition The second level represents international best practices that are a translation of the reference definition into an explicit list of critical steps for which best practices are recommended on the basis of a best available evidence or b expert consensus in the absence of evidence The third level is the adaptation of international best practices into
71. the apex body at the national level responsible for formulating policies planning organisation supervision and evaluation of the EPI programme The implementations of the EPI policies are carried out by a combination of the static units and the out reach teams However the major emphasis in EPI service delivery is through the static units located within the health institutions 1 5 1 Static Immunisation Units EPI sections of all hospitals health centres and extended health centres designated public health sections of Ministry of Health other non MoH sister institutions e g ROP MoD PDO Palace clinic SQU Hospital and Internal Security Services etc as well as vaccine qualified private clinics 1 5 2 Outreach Immunisation The designated health staff would conduct specified immunization tasks outside the health institutions e g defaulter retrieval special immunization campaigns in schools community or in remote and or inaccessible areas whenever such needs arise 1 5 3 Supervision amp Auditing The regional headquarters provincial are responsible for supervision and auditing of EPI in their respective regions One EPI focal point has been trained by year 2000 in each of the administrative regions for routine monitoring of the EPI The epidemiologist or the designated focal point of communicable diseases in the Directorate would provide technical assistance as well as supetvise vatious activities related to EPI 1 5 4 School
72. the diseases that are prevented and stress that they should bring their child to the Parent Institution when the next dose is due write the due date in pencil on the card e Report fill in the action taken section of Defaulter Retrieval Form M 246 and make sure that the Parent Institution Master Register is amended with the dose given Procedures if the child cannot be found on the available address If after a thorough search a child cannot be found the following procedures should be adopted o Visit the Sheikh and ask his advice on ways and means of locating the child o Report and discuss write not found and the date in the action taken section of Defaulter Retrieval Form and then discuss the possible reasons for this with the static unit e g was the address not sufficient etc and follow up Procedure if the child is found to be already immunised If the child has been immunised by the time he she is located by the Outreach team the team should o Congratulate the parents for getting their child immunised and politely ask them to try to bring their child to the static unit on time in future o Report and Discuss write already immunised and the date in the action taken section of Defaulter Retrieval Form and then discuss the possible reasons for this with the static unit e g did the outreach team started the action too eatly etc o Update the MR 374 Register by checking the defaulter retrieval form
73. the same or related vaccine However it s not an absolute contraindication and the decision should be taken on case to case basis What conditions should NOT be taken as Contta indications Mild or Moderately ill children unless they fall under any of the Specific Contra indications below should be immunized in order to increase individual and community protection Malnutrition low grade fever mild ARI or Diarrhoea and other minor illnesses are NOT contra indications for vaccination The general rule is to immunise all children who are not sick enough to be hospitalised Table 2 Specific Contraindications to Vaccines Vaccines Specific Contra indications BCG Clinical Symptomatic HIV infection or known immunodeficiency Any past history of seizures other than febrile convulsions LEE especially if these occurred after a previous dose of DPT OPV Immunocompromised patients Hib None Measles MMR None TT None DI None Hepatitis B None In these children DPT should be deferred until evaluated by a Neurologist amp progressive encephalopathy is ruled out In severely symptomatic case do not administer 2 3 Immunization Policies for specific situations e BCG OPV and HBV must be given to all newborns regardless of birth weight provided the baby is well enough to be discharged from hospital This includes premature and low birth weight babies The rule of thumb is ifthe baby is well enough to be discharged from ho
74. to use one needle to draw the vaccine and another new needle to inject the child The quality of modern stainless steel needles will not be affected by piercing the cap Therefore the staff should use the same syringe and needle to draw and also to administer the vaccine 46 Placing the Vaccines in the Carrier foam insert 7 4 WHO Policy on use of Opened Vaccine Vials Sufficient data has been collected by WHO on the safety and potency of EPI recommended vaccines to endorse a change in the global policy on the use of opened vials of vaccine The revised policy has the potential to reduce vaccine wastage rates by 30 resulting in annual savings worldwide of US 40 million in vaccine costs A Revised WHO EPI policy The revised policy applies only to vaccines which e Meet WHO requirements for potency and temperature stability e Are packaged according to ISO standards e Contain an appropriate concentration of preservative such as thiomersal for injectable vaccines only Note Vaccines supplied by UNICEF also meet these requirements Opened vials of Measles MMR amp BCG vaccines must be discatded at the end of each immunisation session 8 hours An opened vial must be discarded immediately if any of the following conditions apply e If sterile procedures were not fully observed OR e If there is a suspicion that the opened vial has been contaminated OR e If there is visible evidence of contamination such as a change in
75. use during an immunisation session should be kept in a vaccine catriet and not in a metal tray e Do NOT put frozen ice packs in the vaccine carrier directly Keep the packs outside the freezer for 10 15 minutes before placing them in the vaccine carrier This procedure would ensure that the vaccines like DPT TT DT Td Hib amp HBV are not frozen during the session e A thermometer kept with the in use vaccines helps to monitor vaccine temperature during the session 45 7 3 Immunisation Session Open a vial of vaccine for even a SINGLE child to immunise Vaccines are cheap children s lives are precious Write the date and the time when you opened the vial Do not use spirit or alcohol to clean the skin at the injection site or the vial cap The alcohol can kill the live vaccines if the mother insists you to clean the injection site then use clean cotton wool only Explain politely to the mother that it is no longer considered necessary to clean the injection site Contaminating the vaccine Never insert a needle through the rubber CAP of the vaccine vial and then leave it in place to allow you to draw the vaccine throughout the immunisation session Contaminated air can pass down the needle and damage the vaccine Also never re inject the excess withdrawn vaccine back into the vial to avoid contamination Use the same syringe amp needle to draw amp administer the vaccine It is unnecessary and a waste of resources
76. ve made a major contribution towards the high immunisation coverage of the target children by covering the defaulters These teams have been functional in specific problem areas identified in some administrative units Routine procedures followed for the defaulter retrieval would not be applicable essentially due to absence of communication This chapter of the manual desctibes the outreach strategy a combination of defaulter retrieval procedures and visiting inaccessible villages 6 2 Defaulter Retrieval 6 2 1 Detection amp Active Passive Defaulter Retrieval Described in the Chapter 5 6 2 2 The Defaulter Retrieval Procedure MOIC of the Health Institution would be responsible to arrange to collect the names and addresses of the EPI defaulters from the local EPI static unit Following standard procedures should be brought into operation by the Outreach Team e Record confirmation Counter check the child s immunisation records in the MR 374 as well as duplicate white card to confirm the status e Locate Find the child using the names and addresses written on the Defaulter Retrieval Form e Explain Inform the parents that their child is overdue for his her next dose and that it is important for the child to recetve vaccines according to schedule for the full benefit e Immunize Give the child the appropriate immunisation dose e Educate Remind the parents of the importance of having their child 42 6 3 immunized and
77. y after immunization Arthralgia Joint pain usually including the small peripheral joints Persistent Joint pain lasting longer than 10 days 62 Transient Joint pain lasting up to approximately 10 days Disseminated BCG itis Disseminated infection occurring within 1 to 12 months after BCG vaccination and confirmed by isolation of Mycobacterium bovis BCG strain Fever e Fever mild Temperature 38 9 C rectal e Fever high Temperature 39 C to 40 4 C rectal e Fever extreme hyperpyrexia Temperature higher than or equal to 40 5 C rectal e Fever unspecified Temperature presumed to be high but not measured Only high and extreme fever should be reported Hypotensive Hyporesponsive Episode shock collapse Sudden onset of paleness decreased level or loss of responsiveness decreased level or loss of muscles tone occurring within 24 hours of vaccination The episode is transient and self limiting Ostitis Osteomyelitis Inflammation of the bone either due to BCG immunisation occurring within 8 to 16 months after immunisation or caused by other bacterial infection Persistent Screaming Inconsolable continuous crying lasting at least 3 hours accompanied by high pitched screaming Sepsis Acute onset of severe generalised illness due to bacterial infection and confirmed by positive blood culture Toxic Shock Syndtome Abrupt onset of fever vomiting and watery diarrhoea within a few hours of immunization often leading to death with
78. y encephalitis occurring within 1 4 weeks following immunization should be reported Meningitis Acute onset of major illness with fever neck stiffness positive meningeal signs Kernig Brudzinski Symptoms may be subtle and similar to those of encephalitis CSF examination is the most important diagnostic measure CSF pleocytosis and or detection of microorganism Gram stain or isolation Seizures Seizures lasting from several minutes to more than 15 minutes and not accompanied by focal neurological signs or symptoms Febrile Seizures OR e Afebrile Seizures Other Adverse Events Allergic Reaction Characterized by one or more of the following 1 skin manifestations e g hives eczema 2 wheezing 3 facial or generalized oedema Anaphylactoid Reaction acute hypersensitivity reaction Exaggerated acute reaction occurring within 2 hours after immunization characterized by one or more of the following e Wheezing and shortness of breath due to bronchospasm e Latyngospasm laryngeal oedema e One or more skin manifestations e g hives facial or generalized oedema Anaphylactic Shock Circulatory failure e g alteration of the level of consciousness low arterial blood pressure weakness or absence of peripheral pulses cold extremities secondary to reduced peripheral circulation flushed face and increased perspiration with or without bronchospasm and or laryngospasm laryngeal oedema leading to respiratory distress occurring immediatel

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