OPV/Measles Ice packs Measles BCG, DPT TT, Hep B Water not for drinking

 Six vaccines are used to combat seven immunizable diseases:  OPV - must be kept frozen at -15°C to -25°C  Measles vaccines - can be stored at either -15°C to -25°C or at +2°C to +8°C  BCG, DPT, TT, and Hep B vaccines - should be stored at +2°C to +8°C

 All Vaccines can be stored at +2°C to +8°C (presence of solid ice) during SUPPLEMENTAL IMMUNIZATION ACTIVITIES

AntigenScheduleStorageRemarks BCG Anytime after birth +2°C to +8°CFreezing DOES NOT damage it but ampoules may break Diluents should be kept cold before using

OPV 1 st dose - 6wks 2 nd dose - 10 wks 3 rd dose - 14 wks -15°C to -25°C Easily damaged by heat NOT harmed by freezing DPT 1 st dose - 6wks 2 nd dose - 10 wks 3 rd dose - 14 wks +2°C to+8°C“DT” is damaged by freezing “P” is damaged by heat Dose Schedule and Recommended Storage Temperature

Hep B 1 st dose - at birth 2 nd dose - 6 wks 3 rd dose -14 wks +2°C to +8°C Both heat and freezing damages vaccine Measles 9 months -15°C to -25°C Diluents should also be kept cold before using Dose Schedule and Recommended Storage Temperature

Tetanus Toxoid 1 st dose - as early as possible during first pregnancy 2 nd dose - 4 weeks after first dose within the same pregnancy 3 rd dose - 6 months after TT2 4 th dose - 1 yr after TT3 5 th dose - 1 yr after TT4 +2°C to +8°CShould never be frozen Dose Schedule and Recommended Storage Temperature

B1. Sensitivity to Heat Most sensitive  OPV  Measles  DTP, yellow fever  BCG  Hib, DT  Td, TT, Hepatitis B Least sensitive

Most sensitive  Hepatitis B  Hib (liquid)  DTP  DT  Td  TT Least sensitive

 BCG and MEASLES vaccines  sensitive to light and fluorescent light (as well as heat) B4. Expiry Date  All vaccines including diluents have an expiry date

B4. Expiry Date  End of the month - the last date by which the vaccines can be used (if not specified)  Expired vials, heat or frozen damaged vaccines or vials with VVMs beyond the discard point should be disposed immediately or labeled ‘Damaged/ expired vaccine – do not use’ and stored outside the cold chain to avoid confusion with good quality vaccines

C. Diluents  contain chemicals and additives to stabilize a specific vaccine after reconstitution  each vaccine requires a specific diluent  are not interchangeable

 Diluent vials/ampoules must never be frozen or allowed to be in contact with any frozen surface to avoid breakage and contamination  Freeze dried vaccines and correct diluents from the same manufacturer should be distributed and receive in matching quantities

Vaccine requirement = Total population x 2.7% (Eligible Pop) x no. of doses of the particular vaccine required x wastage factor

Antigen No. of doses to complete immunization Wastage allowance Wastage factor No. of doses per vial/amp. DPT340% or 10 OPV340% MEASLES 150% BCG160% Hep. B310% or 10 TETANUS TOXOID 2 40% or 20

1. Eligible Population = Total Pop. x 2.7% = 3,000 x 2.7% = Annual Vaccine Doses Required = EP x 1 (total # of doses to immunize a child with BCG) x 2.50 (WF of BCG) = 81 x 1 x 2.50 = No. of Annual Vials Required = Annual vaccine dose required = 202 = (No. of doses/vial ) 10

VaccinesEligible Pop. No. of doses / person Estimated Wastage Total No. of Doses Total No. of Vials Total No. of AD Syringes Total No. of Mixing Syringes Total No. of Safety Boxes (col. A)(col. B)(col. C)(col. D)(col. E)(col. F)(col. G)(col. H)(col. I) BCG (10 or 20 dose) DPT (10 or 20 dose) OPV (10 or 20-dose) Measles (10-dose) Hepatitis B (10-dose) TT (10 dose) LOGISTICS REQUIREMENTS Municipality/Barangay: _____________________________ Total Population: 10,000

 Quantity of vaccine that can be used for delayed supplies or sudden increases in demand  Typically 25% of the amount expected to be used during a given supply period  To avoid overstocking, this should be reviewed and adjusted for each order

 Should be determined before ordering a new stock  The following should be ensured:  Adequate amounts are available  Space is available to store the stock  Vaccine is used before the expiry date  Storage duration is consistent with recommendation

Health Facility LevelMinimum delivery period National6 months Regional3 months Provincial/City/Mun.3 months Health Center1 month Vaccination PostPer session

 OPV, DPT, TT and Hepatitis B - may be used in subsequent sessions for 4 weeks provided the following conditions are met: 1. Expiry date has not passed; 2. Vaccines are stored under appropriate cold chain conditions;

3. Vaccine vial septum has not been submerged in water ; 4. Aseptic technique has been used to withdraw all doses; 5. The VVM, if attached, has not reached its discard point

 one of the cold chain monitoring tools  a label that changes colour when the vaccine vial has been exposed to heat over a period of time  DO NOT measure exposure to freezing temperatures (for freeze-sensitive vaccines)

HOWTO READ A VACCINE VIAL MONITOR

 Defined as loss by use, decay, erosion or leakage or through wastefulness  Vaccine usage – defined as the proportion of vaccine issued which is administered Vaccine usage rate = No. of doses administered x 100 No. of doses supplied

Wastage rate = Doses supplied - doses admin. x 100 Doses supplied  Wastage rate higher than 20% may indicate problems such as: 1. Repeated instances of lower than planned attendance at session 2. Poor stock management

3. Cold chain failure 4. Incorrect mixing of freeze dried vaccine 5. Incorrect dosage 6. Failure to comply with multi-dose vial policy

Vaccine wastage in UNOPENED vials Vaccine wastage in OPENED vials  Expiry  VVM indication  Heat exposure  Freezing  Breakage  Discarding remaining doses at end of session  Not being able to draw the number of doses indicated on the label of a vial  Poor reconstitution practices

Vaccine wastage in UNOPENED vials Vaccine wastage in OPENED vials  Missing inventory  Theft  Discarding unused vials returned from an outreach session  Submergence of opened vials in water  Suspected contamination  Patient reaction requiring more than one dose

 Ensure compliance on MDVP  Use Vaccine Vial Monitor  Ensure vital information is recorded when vaccines are received, stored & distributed  Monitor temperature of stored vaccines 2x a day including weekends and holidays  Ensure the Earliest-Expiry-First-Out (EEFO) principle is maintained except where vaccine is nearing its VVM discard point

 Ensure vaccines are transported following standard operating procedure  Ensure a functional contingency plan on cold chain failure exists  Monitor, maintain a routinely repair cold chain equipment  Perform SHAKE TEST

 Determines whether DPT, TT or Hep B has been frozen  After freezing, the vaccine is no longer a uniform cloudy liquid. It forms flakes which gradually settle to the bottom after the vial has been shaken  Sedimentations occurs faster in a previously frozen vaccine vial than a never frozen vaccine from the same manufacturer

Step 1 Prepare a frozen control sample:  Take a vial of vaccine of the same type, batch number and manufacturer as the vaccine you want to test.  Freeze the vial until all the contents are solid ( at least 10 hours at -10°C).  Let it thaw.  This vial is the control sample.

 Clearly mark the vial so that it cannot later be used by mistake. Step 2 Choose a test sample:  Take a vial of vaccine from the same batch that you suspect has been frozen. This is the test sample.

Step 3 Shake the control and the test sample:  Hold the control sample and the test sample together in one hand and shake vigorously for seconds. Step 4 Allow to rest:  Place the vials on a stable surface and do not move for minutes.

Step 5 Compare the vials: 1. View both vials against the light to compare the sedimentation rate. 2. If the test sample shows a much slower sedimentation rate than the control sample, the test sample is probably potent and may be used.

3. If the sedimentation rate is similar and the test sample contains flakes, the vial under test has probably been damaged and should not be used. 4. Some vials have large labels which conceal the vial contents. This makes it difficult to see the sedimentation process.

In such cases, turn the control and reference test upside down and observe sedimentation taking place in the neck of the vial.  Frozen samples can be used for Shake Tests only when testing the same vaccine from the same manufacturers and the same lot number.  A new sample is needed for each manu- facturer and lot number.

1. Opened vials kept in the “use first” box in the refrigerator (multi-dose vial policy). 2. Unopened vaccine ampoules/vials that have been taken to outreach sessions and have been outside of the refrigerator, then returned (but not opened) to the refrigerator. 3. Vaccines with VVMs that have started to change. 4. The oldest vaccines that have not yet passed their expiry dates.

1. Check the labels of the vaccine and diluent.  If the label is not attached, discard the vial or diluent. 2. Check the expiry date.  You must discard vials and diluents if the expiry date has already passed.

3. Check the vaccine vial monitor (VVM).  If it indicates the vaccine has passed the discard point, you must discard it immediately. 4. Check the freeze indicator in the refrigerator.  If it warns of freezing or you suspect that a freeze-sensitive vaccine has been frozen, you should perform the shake test.

 Regular physical check ensures stock records and running balances are accurate and complete  Count vaccines and diluent stocks and compare to the running balance in the stock records  Spot check VVM, CCM and freeze indicator status

A safe injection is defined by the WHO as an injection that:  Does not harm the recipient  Does not expose the health staff to any avoidable risks  Does not result in waste that is dangerous to the community

 Advantages of AD syringes:  can only be used once  eliminate the patient-to-patient disease transmission caused by the use of contaminated needles and syringes  save time for health workers from the heavy work of sterilization

WHO — UNICEF — UNFPA joint statement on the use of auto-disable syringes in immunization services. “The auto-disable syringe which is now widely available at low cost presents the lowest risk of person-to-person transmission of blood-borne pathogens (such as HepB or HIV) because it cannot be reused. The auto-disable syringe is the equipment of choice for administering vaccines, both in routine immunization and mass campaigns.”

Disposable needles and syringe  No longer recommended for injections in EPI  Reuse carries a high risk of infections  In 1999 WHO, UNICEF, and UNFPA issued a joint policy statement recommending against their use for immunization  Can be used to reconstitute a vaccine if AD syringe is not available  Do not reuse for reconstitution

AntigenWastage factor BCG1.1 DPT1.1 Measles1.1 Hepatitis B1.1 TT1.1

EXAMPLE: BCG Total Population = 3, Eligible population (EP) = 3,000 x 2.7% = Annual vaccine dose required = 81 x 1 x 2.5 = Annual AD Syringes = Annual vaccine dose required x 1.1 (wastage factor) = 202 x 1.1 = 222

AntigenWastage factor BCG1.1 Measles1.1

EXAMPLE : BCG TP = 3, Eligible population (EP) = 3,000 x 2.7% = Annual vaccine dose required = 81 x 1 x 2.5 = Annual no. of vials required = 202/10 = Annual Mixing Syringe = Annual no. of vials required x 1.1 (wf) = 20 x 1.1 = 22

 Used sharps must be placed in a safety box and then disposed of in a safe manner

Why is it important to handle sharps waste properly?  Dangers to health  Leaving used syringes and needles in the open or on the ground puts the community at risk  Most frequently, children are the unfortunate victims of needle-stick injuries from haphazard disposal of needles

Why is it important to handle sharps waste properly?  Dangers to the environment  throwing in a river spoils the water used for drinking and washing

 All used injection equipment except reusable syringes and needles should be placed in a safety box.  Safety boxes are:  water-proof  tamper-proof  puncture-resistant

What to do if safety boxes are not available:  Use strong cardboard boxes, thick plastic containers, or metal cans to collect syringes and needles and transport them to a site where they can be buried or burned.  Do not reuse the same can or container after filling it once.  Destroy the container when it is three- quarters full and find a new container for your next session.

How to ensure safe handling of the box  Don’t handle or shake the safety box more than necessary.  Never squeeze, sit, or stand on safety boxes.  Take extra care when carrying safety boxes to the disposal site. Hold the box by the top (by the handle provided) above the level of the needles and syringes.

How to ensure safe handling of the box  Keep safety boxes in a dry, safe place out of the reach of the general public, specially children until they have been safely disposed of.  Train everyone who will handle the box how to do it safely. Do not ask untrained staff to handle the box.

Never put the following material in a safety box. Discard them with other medical waste:  empty vials;  discarded vaccine vials;  cotton pads;  compressors;  dressing material;  IV bags or extension tubes;  latex gloves or any kind of plastic materials or waste products.

Annual Safety Collector Box Required = Total annual ADS + Mixing syringe 100* 100* -capacity of 5 liter SCB

Three most recommended methods of disposal of safety boxes filled with used syringes and needles:  Use of septic vault  Pit burial  Waste treatment and final disposal to land fill