Making the most of every immunization contact Practical considerations for the successful introduction of Inactivated Polio Vaccine (IPV) June 2015 © 2012 IMG 1

What are the WHO recommendations? Contents What are the WHO recommendations? How to successfully introduce IPV? How to effectively prepare healthcare workers for IPV introduction? © 2012 IMG

Definitions Multiple injections: administering three or more injectable vaccines at the same immunization contact. Healthcare worker: professional health worker such as nurse, physician, professional midwife, etc., or can also be a community health worker or member. © 2012 IMG

What are the WHO recommendations? Contents What are the WHO recommendations? How to successfully introduce IPV? How to effectively prepare healthcare workers for IPV introduction? © 2012 IMG

What are the WHO recommendations for IPV? By 2015 All countries To add IPV into routine schedules At, or soon after, 14 weeks of age Vaccine schedule option # doses Age at each dose Interval between doses IPV 1 At 14 weeks, or soon after N/A WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: http://www.who.int/wer/2014/wer8909.pdf?ua=1 (PDF) © 2012 IMG

Considerations when adding IPV to the schedule WHO recommendations should always inform planning decisions, considered in the context of other programme factors: Other injectable new vaccines at the same visit, e.g. pentavalent, pneumococcal vaccine (PCV), others. Studies of health worker and caregiver attitudes indicating that multiple injections may affect acceptance of recommended vaccines (e.g. apprehension about pain or potential side effects). Understanding concerns can inform communication and training strategies to mitigate. Strength of routine services, e.g. if high number of drop outs, optimize existing earlier contacts to administer vaccines. 11/10/2018

What are the WHO recommendations for pneumococcal conjugate vaccine (PCV)? Now All countries To add PCV into routine schedules At, or soon after, 6 weeks of age Vaccine schedule options # doses Age at each dose (examples) Interval between primary doses PCV 3+0 6, 10, 14 weeks 2, 4, 6 months At least 4 weeks 2+1 6, 14 weeks + 9-12 months 2, 4 months + 9-12 months At least 8 weeks WHO recommendations for routine immunization: summary tables (May 2014) http://www.who.int/immunization/policy/immunization_tables/en/ © 2012 IMG

What are the WHO recommendations for rotavirus? Now All countries To add rotavirus into routine schedules At, or soon after, 6 weeks of age Vaccine schedule options # doses Age at each dose (examples) Interval between primary doses Rotarix 2, with DTP 6, 10 weeks 2, 4 months At least 4 weeks Rotateq 3, with DTP 6, 10, 14 weeks 2, 4, 6 months WHO recommendations for routine immunization: summary tables (May 2014) http://www.who.int/immunization/policy/immunization_tables/en/ © 2012 IMG

Example of a routine immunization schedule with IPV IPV can be co-administered with other vaccines including: OPV, DTP, Hib, hepatitis B, pentavalent, rotavirus or pneumococcal conjugate vaccines (PCV) 1. Co-administration of OPV and IPV has resulted in good immune responses to all 3 poliovirus types2. * Some countries use a 2-dose schedule for rotavirus vaccines and a 2+1 schedule for PCV. 1. Global Advisory Committee on Vaccine Safety (GACVS; December 2013). Weekly Epidemiological Record, 14 Feb 2014: http://www.who.int/wer/2014/wer8907.pdf?ua=1 (PDF) 2. WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: http://www.who.int/wer/2014/wer8909.pdf?ua=1 (PDF) 11/10/2018

Safety of IPV IPV and IPV-containing vaccines have an excellent safety profile1 When used in combination with other vaccines, IPV is very safe2 There is no proven causal relationship to any adverse events, other than minor local redness, induration, and tenderness 1. Global Advisory Committee on Vaccine Safety (GACVS; December 2013). Weekly Epidemiological Record, 14 Feb 2014: http://www.who.int/wer/2014/wer8907.pdf?ua=1 (PDF) 2. WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: http://www.who.int/wer/2014/wer8909.pdf?ua=1 (PDF) © 2012 IMG

Many countries have immunization schedules where children receive three or more injections at one visit Several countries (including high and low income) have been using immunization schedules that require three or more injectable vaccines at the same contact for over a decade with no problems. Data from these countries has reinforced the well-established record of safety and acceptance of multiple injections at the same visit. Studies are underway in some developing countries to compile further data on the perceptions and acceptance of multiple injections. Recent studies in Tanzania and South Africa reported very high rates of acceptance of multiple injections, despite some expressed caregiver concerns, demonstrating that concerns can be addressed with effective communication and immunization practices. © 2012 IMG

How to successfully introduce IPV? Contents What are the WHO recommendations? How to successfully introduce IPV? How to effectively prepare healthcare workers for IPV introduction? © 2012 IMG

Case study: Successful introduction of IPV in South Africa The South African immunization schedule is based on the available evidence and in line with WHO recommendations. Since 2009, South Africa has administered three vaccines per visit, at 6 and 14 weeks. Successful experience with good coverage and acceptability. The country is documenting its experience to share with others. Reference (schedule): WHO 2014 monitoring - global summary http://apps.who.int/immunization_monitoring/globalsummary/ © 2012 IMG

Case study: Successful introduction of IPV in Brazil Brazil’s routine immunization schedule involves multiple injections. IPV is given at the 2 and 4 month contacts, with pentavalent and pneumococcal vaccines. Reference (schedule): WHO 2014 monitoring - global summary http://apps.who.int/immunization_monitoring/globalsummary/ © 2012 IMG

Successful introductions of IPV in Brazil and South Africa How did they achieve this? Having communication strategies that educated health workers, community leaders and professionals about the safety, effectiveness and value of multiple vaccine injections at the same contact. Having messages from health workers to caregivers about: Disadvantages of extra visits and delayed vaccination The safety of multiple injections Their efforts to minimize pain As a result, health workers are able to understand the importance and address parent or caregiver concerns. © 2012 IMG

Other important lessons from successful introductions There has been good acceptance of multiple injections at the same visit Multiple injections were well tolerated, and help to avoid extra visits or risks of delayed vaccination When administered correctly, there was only minor discomfort Multiple injectable vaccines are not associated with severe or serious adverse events IPV coverage among infants after first year of introduction was high © 2012 IMG

How to effectively prepare healthcare workers for IPV introduction? Contents What are the WHO recommendations? How to successfully introduce IPV? How to effectively prepare healthcare workers for IPV introduction? © 2012 IMG

The critical role of health workers There are three things that health workers can do to reassure parents or caregivers: Be knowledgeable of all relevant data, including safety and effectiveness, and the value of providing multiple vaccines in the same visit Provide clear responses to any caregiver questions using the evidence and recommendations Administer the vaccines using the recommended technique, taking necessary steps to minimize pain © 2012 IMG

The critical role of health workers: Be knowledgeable of all relevant data Know when to give IPV: At 14 weeks or soon after If starting the routine schedule late, the IPV dose should be administered at the first immunization contact Give IPV with other life saving vaccines © 2012 IMG

The critical role of health workers: Provide clear responses Common questions Potential answers “Why does my child need to receive all of these vaccines today?” At this age, children are most vulnerable to polio, diphtheria, whooping cough (pertussis), Hib and pneumococcal disease. Scientific data indicates that this is the best time for these vaccines to be given. “Will my child experience more pain or discomfort?” No, the pain or discomfort from vaccination is very brief. Even one injection can cause pain or discomfort. However, if you need to come back for other injections, there will be more times when children will experience pain or discomfort. We don’t want your child to be unprotected from serious diseases until you come back. “Will vaccines given together be less effective?” No. These vaccines are equally effective when given alone or with other vaccines. “Will my child experience more or more severe adverse events?” No. The scientific data shows that multiple injections do not lead to an increase in the number or severity of adverse events. “Can multiple vaccines given at once “overwhelm” a child’s immune system?” No. Every day, children are naturally exposed to many bacteria and viruses on a daily basis. When given as recommended, vaccines do not add a significant burden to the immune system, and help the child to be protected. *United States Institute of Medicine, Adverse Events Associated with Childhood Vaccines, 1994. **Wheeler M, Buttenheim AM. Parental vaccine concerns, information source, and choice of alternative immunization schedules. Human vaccines & immunotherapeutics. 2013;9:1782-1789. © 2012 IMG

The critical role of health workers: Administer the vaccines using the recommended technique © 2012 IMG

How to successfully administer multiple injections? Pentavalent (or other) in the thigh IPV and PCV given in the outer aspect of the upper thigh. Injection sites separated by at least 2.5 cm -- about two fingers apart. http://www.who.int/vaccine_safety/initiative/tech_support/Vaccine-safety-E-course-manual.pdf © 2012 IMG

Recommendations for minimizing pain and distress for intramuscular injections Administer vaccines in order of increasing painfulness Proper positioning: Ask the caregiver to hold the baby in his/her lap Encourage breastfeeding (if feasible and culturally acceptable) during or just before injection Injection technique: Do not aspirate Gently stretch and support the skin between thumb and forefinger Push the entire needle in at a 90 degree angle with a quick, smooth action Depress the plunger slowly and smoothly, taking care not to move the syringe around Pull the needle out quickly and smoothly at the same angle that it went in. Discard syringe immediately in safety box. © 2012 IMG

Summary: Advantages of providing multiple vaccine injections during the same visit Protecting children when they are at greatest risk of disease and death: Young infants can be more vulnerable to severe illness. Fewer vaccination visits: Giving several vaccinations at the same time means caregivers do not need to make as many visits to the health center. More effective use of health resources and workers: Health workers are able to be more efficient in providing and delivering other health services. © 2012 IMG

Summary: Successful introduction of IPV Several countries have successfully administered multiple injections during the same contact. Parental concerns about multiple injections can be addressed through reassurance, clear communication and pain reducing techniques. © 2012 IMG

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