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

2. 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

3. 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

4. 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

5. 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: (PDF)
© 2012 IMG

6. 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

7. 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 months
2, 4 months months
At least 8 weeks
WHO recommendations for routine immunization: summary tables (May 2014)
© 2012 IMG

8. 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)
© 2012 IMG

9. 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: (PDF)
2. WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: (PDF)
11/10/2018

10. 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: (PDF)
2. WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: (PDF)
© 2012 IMG

11. 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

12. 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

13. 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
© 2012 IMG

14. 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
© 2012 IMG

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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:
© 2012 IMG

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

22. 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.
© 2012 IMG

23. 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

24. 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

25. 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

26. Thank you!
© 2012 IMG