1. Fractional IPV (fIPV) vaccine administration
Training for the introduction of Inactivated Poliovirus Vaccine, Fractional Dose (fIPV)
Fractional IPV (fIPV) vaccine administration
- Using syringe adapters -

2. Learning objectives
At the end of the module, the participant will be able to:
Identify the necessary steps to assure good vaccine quality
Describe the method to administer Intradermal fractional dose (0.1 ml)
Duration
30 minutes

3. Key issues 1 2 3 4 How do I check vaccine quality?
How do I prepare for vaccination? 2
How do I administer the vaccine? 3
How do I administer IPV at the same time as mOPV2? 4
To the facilitator:
Explain to the participants the key issues raised in this module.
You have children to vaccinate, what are you going to do first?
We will provide you with answers to the following questions:
How to check the quality of the vaccine?
How to prepare for vaccination?
How to administer the vaccine?
What to do administer IPV at the same time as other routine immunizations?

4. IPV is heat and freeze sensitive
IPV loses potency when exposed to heat or when frozen
Store at +2°C to +8°C
IPV is freeze sensitive
Unlike OPV, which can be frozen
The “shake test” is ineffective in determining whether IPV has been frozen
If you suspect that IPV may have been frozen, the vial must be discarded
Do not use if vaccine has a cloudy appearance
Check the VVM and the expiration date (see next 2 slides)
Warming vaccines shortens shelf life
Aim for 4⁰-5⁰C
Freezing KILLS vaccines! Except OPV, Vaccines that have been frozen are ineffective
To the facilitator:
Explain to the participants at which temperature the vaccine should be stored.
Handling vaccines requires great care. Some vaccines are sensitive to heat and some to freezing.
Careful storage and transport conditions are needed to protect vaccines from becoming ineffective and unusable.
IPV is heat sensitive. Inactivated poliovirus vaccine (IPV) must be transported and stored at +2°C to +8°C.
IPV is also freeze sensitive (unlike OPV which can be frozen). It is important to ensure that the vaccine is not frozen.
If vaccines are frozen, they lose their potency and they would not provide adequate protection against the disease.
The “shake test” is ineffective in determining whether IPV has been frozen. If there is doubt or suspicion that IPV was frozen, the vial must be discarded.
Do not use if it has a cloudy appearance.
Do not use after the expiry date listed on the package. 4

5. Checking the Vaccine Vial Monitor (VVM)
IPV vial has a VVM on the vial label
The VVM registers cumulative heat exposure, and changes from light to dark
Check the VVM on each vaccine vial
If inside square is the same color, or darker than the circle, do not use the vaccine
To the facilitator:
Explain to the participants how to check and interpret the Vaccine Vial Monitor (VVM).
The vaccine vial monitor (VVM) is a round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat exposure.
The inner square is chemically active and changes color irreversibly from light to dark with exposed to heat over time.
By comparing the color of the inner square to the reference color, a health worker can determine whether or not the vaccine has been exposed to heat.
Thanks to the VVM, important decisions about which vaccines to use or to discard are now clear. If the inner square matches or is darker then the outer ring, discard the vaccine. 5

6. IPV has high heat sensitivity
IPV has increased susceptibility to heat than many existing heat sensitive vaccines.
VVM on IPV may change color faster than other vaccines
Proper temperature monitoring and stock management is required to avoid wasting IPV vials with VVM reaching the discard point
While the “earliest expiry, first out” principal usually applies in vaccine stock management, the status of a VVM overrules this, whereby any batch showing a darker VVM should be used sooner, regardless of a later expiry date
To the facilitator:
Explain to the participants at which temperature the vaccine should be stored.
Handling vaccines requires great care. Careful storage and transport conditions are needed to protect vaccines from becoming ineffective and unusable.
IPV is heat sensitive. Inactivated poliovirus vaccine (IPV) must be transported and stored at +2°C to +8°C. IPV has increased susceptibility to heat than some other heat sensitive vaccines therefore VVM on IPV may change color faster than other vaccines
It is important to monitor refrigerator temperature regularly and Check VVM status, use first vials with VVM that have started to change color
Proper stock management and temperature monitoring is required to avoid wasting IPV vials with VVM reaching the discard point.
While the “earliest expiry, first out” principal usually applies in vaccine stock management, the status of a VVM overrules this, whereby any batch showing a darker VVM should be used sooner, regardless of a later expiry date 6

7. Checking the expiration date
Vaccine loses potency over time
VVM provides information about storage conditions, but not about potency
VVM may be OK, but vaccine may be expired
Before administering any vaccine, always check the expiration date
Expiration date: 02NOV14
Use through November 2, 2014
Do NOT use on or after November 3, 2014
To the facilitator:
Explain to the participants how and where to check the expiration date.
It is important to understand that VVM does not provide information about vaccine potency.
The VVM may be ok (which means the inner square is lighter than the outer circle), but the vaccine may be beyond the expiration date.
The VVM may be ok but the vaccine may have been frozen
So always check the expiration date on the vaccine vial before using it.
The expiration date is mentioned clearly on the label. 7

8. Sequence and injection site for fractional doses of IPV
Give oral polio vaccines first if fIPV is co-administered with mOPV2
When giving fIPV:
Give fIPV by intradermal injection in the upper arm (opposite to BCG arm)
To the facilitator:
Explain to the participants that rotavirus vaccines can be given with routine childhood vaccines.
IPV can be given with mOPV2
As a general rule its better to give oral vaccines first when the child is still calm and then give injectable vaccines.
Give the mOPV2 vaccine first – the general rule is to give oral vaccines first while the child is still calm
Give IPV by intradermal injection in the upper arm - opposite arm in which BCG is given
Step 2: IPV - fractional
(upper arm)
Step 1: OPV 8

9. Intradermal (ID) injection
Fractional doses of IPV must be injected intradermally (into the layers of the skin) for slow absorption.
Intradermal injection is given in the upper arm (opposite to the arm where BCG was given).
To the facilitator:
Explain to the participants, how to prepare the vaccine.
IPV should never be mixed with other vaccines in the same vial or syringe 9

10. Syringes to use for fIPV
To measure and inject the very small dose accurately, special 0.1 mL syringes should be used

11. How to position the child for intradermal IPV vaccination
The child should be held in an upright position by the caregiver
The caregiver should hold the child’s arms and legs very firmly
The vaccine is injected intradermally into the upper arm at a 10-15°angle (see next slides for technique)
To the facilitator:
Explain to the participants how to position the child before administering the vaccine.
The child should be held in a upright position by the caregiver
The caregiver should hold the arms and legs very firmly
The vaccine is injected intradermally in the upper arm at a 10-15° angle 11

12. How to administer intradermal IPV
Location:
IPV fractional dose is administered in a dose of 0.1 mL, injected intradermally into the outer part of the upper arm
Technique:
Open the blister and remove the syringe
Push the plunger down completely
Remove the needle cover and dispose the needle cover into Safety Box. Check needle integrity.
Insert needle into vial and fill the syringe by gently pulling back the plunger. Withdraw needle from vial.
To the facilitator:
Explain to the participants, how to administer the vaccine.
IPV fractional dose is administered in a dose of 0.1 ml, injected intradermally into the outer part of the upper arm 12

13. How to administer intradermal IPV
Lay the syringe and needle almost flat along the skin with the bevel (hole) of the needle facing upwards
Insert the tip of the needle just under the surface of the skin, just past the bevel
Place thumb on lower end of syringe near needle to hold position (but do not touch the needle!)
Hold the plunger end of the syringe between index and middle fingers. Press the plunger slowly with the thumb. If you feel no resistance to the plunger, you are not in the right place and should reposition
A pale flat-topped swelling (a bleb) with small pits like an orange peel should appear on the skin
Remove needle slowly at same angle as it went in
Do not rub or massage the area
Discard the needle and syringe into safety box
To the facilitator:
Explain to the participants, how to administer the vaccine. 13

14. How to administer intradermal IPV
When an intradermal injection is given correctly, the syringe plunger is hard to push. If the plunger goes in too easily, the injection may be too deep.
Stop injecting immediately, correct the position of the needle, and give the remainder of the dose, but no more.
If the whole dose has already gone in, count the infant as having received a dose of vaccine, even though it was given subcutaneously rather than intradermally.
Do not repeat the dose.
To the facilitator:
Explain to the participants, how to administer the vaccine. 14

15. How to administer intradermal fractional of IPV using the syringe adapter
Attach the adapter to the syringe. Push the syringe upwards to ensure proper fitting. Visually confirm correct positioning of the needle as shown below:

16. How to administer intradermal fractional of IPV using the syringe adapter
Ensure that the bevel is upright
Slightly tauten the skin at the injection site with one hand and place the tip of the adapter against patient’s skin. With slight downward pressure slowly push the syringe until the needle disappears beneath skin.
Slowly administer dose. A bleb should be visible, confirming successful delivery of the vaccine. Wait 3-5 seconds before removal.
Dispose syringe with the attached adapter into a Safety Box.
To the facilitator:
Explain to the participants, how to administer the vaccine. 16

17. Multi-dose vials of IPV
Preservatives in multi-dose vials of IPV meet WHO requirements to preserve the vaccine for 28 days
At the end of the session:
VVM on LABEL
28 day discard
Provided the expiry date has not passed and the vaccine is appropriately handled and stored, opened IPV multi-dose vials with VVM on the label can be kept and used in subsequent sessions for up to 28 days after opening.
To the facilitator:
Explain to the participants how to deal with multi-dose vials of IPV after they are opened.
Provided the expiry date has not passed and the vaccine is appropriately handled and stored, opened multi-dose vials of IPV with VVM on the label can be kept and used in subsequent sessions for up to 28 days after opening.

18. Factors associated with vaccine wastage
Unavoidable
Requirement to discard opened multi-dose vials 28 days after opening
 Avoidable
Poor stock management
Over-supply
Vaccine reaches expiry before use (recall the EEFO principle)
Lost, broken, stolen vials
Cold chain failure
Loss of potency (high temperatures)
Inactivated vaccine (freezing)
Poor vaccination technique
Administration of more than recommended dose (0.1 mL for fractional doses) for each injection
To the facilitator:
Explain to the participants unavoidable and avoidable forms of vaccine wastage
 Avoidable wastage factors (Steps should be taken to minimize such wastage):
Poor stock management can result in over-supply and vaccine reaching expiry before use (recall the EEFO (Earliest Expiry First Out) principle)
Exposure to unacceptably high or low temperatures due to cold chain failure
Administration of excess vaccine dosage beyond the recommended 0.5 mL for each IPV injection
Lost, broken, or stolen vials

19. After vaccination? After injection, insert syringe into a safety box
When safety box is full, close tab to ensure box is closed
Dispose of safety box appropriately in compliance with national policy for infectious sharp waste
Opened vials of IPV with (some remaining doses) must be returned to the refrigerator and used first in the next session.
To the facilitator:
Explain to the participants how to discard injection syringes.
After injection, insert syringe into a safety box
When safety box is full, close tab to ensure box is closed
Dispose of safety box appropriately (incineration, burning, burial)
Opened vials of IPV with (some remaining doses) must be returned to the refrigerator and put in 'use first box' and used first in the next session 19

20. Key messages
Check and interpret VVM and expiration date on the vaccine vial before giving the vaccine
MDVP for IPV stipulate that the vaccine can be kept open for 28 days given that VVM did not past the discard point and the expiry date has not passed.
IPV fractional dose is prepared and administered similarly to BCG (and other intradermal injections)
Prepare and dispose of IPV as you do other injectable vaccines
The adapter mounted on the syringe facilitates the right position of the needle to deliver ID injection
Have the caregiver comfortably hold the child upright while inserting the needle intradermally into the upper arm at a 10-15⁰ angle
If fIPV is coadministered with OPV then give OPV first, then the intradermal injection (IPV).
To the facilitator:
Explain to the participants that this is the main information to keep in mind. 20

21. End of module
Thank you
for your attention!
To the facilitator: