1. Module 8 Safety and acceptability of multiple injections
Training for Inactivated Poliovirus Vaccine (IPV) introduction
Module 8
Safety and acceptability of multiple injections

2. Learning objectives At the end of the module, the participant will:
Know the benefits of multiple injections
Understand the safety of IPV when administered with other vaccines
Be able to respond to parental concerns regarding IPV and multiple injections
Duration
30 minutes

3. It is safe to give multiple vaccine injections at one visit.
Key issues
It is safe to give multiple vaccine injections at one visit. 1
Multiple injections are better than spacing injections because they protect children, increase efficiency and lead to fewer overall vaccination visits. 2
Parental concerns about multiple injections can be addressed through reassurance, clear communication and pain reducing techniques. 3
To the facilitator:
Explain to the participants the key issues raised in this module.

4. Multiple Injections
It is safe to give multiple vaccine injections during one single visit.
Many countries have immunization schedules where children receive multiple vaccine injections at one visit.
Globally, most middle and high-income countries have been safely using multiple injections for more than a decade.
To the facilitator: Explain to the participants that it is safe to give multiple vaccine injections during one single visit.
Many countries have immunization schedules where children receive multiple vaccine injections at one visit.
Globally, most middle and high-income countries have been safely using multiple injections for more than a decade. 4

5. Multiple Injections
Protect children against most common childhood illnesses
Lead to fewer vaccination visits for parents and caregivers
Increase the efficiency of immunization programs
To the facilitator: the following slides describe how multiple injections protect children, increase efficiency and lead to fewer vaccination visits for parents and caregivers. 5

6. Multiple vaccine injections
protect children
Giving a child two or more vaccinations during the same visit offers protection during the most vulnerable early months of life.
Spreading out vaccinations leaves babies unprotected from common childhood illnesses for a longer time.
Spreading out vaccinations means parents or caregivers will have to schedule additional visits and bring their children back. If children are not brought back, they will be unprotected from serious diseases and their lives may be threatened by illness.
To the facilitator:
Multiple vaccine injections protect children during their early months of life. Spreading out vaccinations leaves babies unprotected for a longer time and means that caregivers will have to schedule additional visits and bring their children back. If they do not bring their child back, their child will be unprotected from serious disease and their child's lives may be threatened by illness. 6

7. Multiple vaccine injections
are more convenient for caregivers
Spreading out vaccinations means parents or caregivers will have to schedule additional visits and bring their children back.
By reducing the number of visits that a caregiver has to make, multiple injections are more convenient for caregivers
To the facilitator:
Giving as many of the necessary vaccines as possible on one visit prevents caregivers from having to schedule additional visits. This is more convenient for caregivers, and saves them time and travel. 7

8. Multiple vaccine injections
increase efficiency
Giving a child two or more vaccinations during the same visit is more efficient for health care providers
Health providers are able to more efficiently provide and deliver other health services by reducing the time they need to spend providing vaccinations.
To the facilitator:
Giving a child multiple injections in one visit is more efficient for health care workers. They will not need to schedule the child for extra visits for additional vaccines. This reduces the amount of time they need to provide vaccinations and increase efficiency. 8

9. How should IPV be administered?
IPV is administered by intramuscular injection (IM) in a dose of 0.5 ml into the outer part of the thigh.
First, IPV and PCV injections should be given in one thigh, with injection sites separated by at least 2.5 centimetres (cm). The pentavalent injection should be given in the other thigh.
To the facilitator:
IPV is administered by intramuscular injection (IM) in a dose of 0.5 ml into the outer part of the thigh
First, IPV and PCV injections should be given in one thigh, with injection sites separated by at least 2.5 centimeters (cm). The pentavalent injection should be given in the other thigh.
IPV can be administered to prematurely born infants and children with immunodeficiencies. 9

10. How to minimize pain during vaccination
Wash skin that is dirty. Swabbing clean skin is not necessary.
For intramuscular injections (IM), 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.
Do not aspirate.
For all injections, 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.
The caregiver may hold a clean swab gently over the site if it is bleeding after injection.
Facilitator: Review the steps to minimizing pain during vaccination. 10

11. Other recommendations to minimize pain
Administer vaccines in order of increasing painfulness
Proper positioning: Ask caregiver to hold the infant on his/her lap
Encourage breastfeeding (if feasible and culturally acceptable) during or just before injection
Facilitator: Review the steps to minimizing pain during vaccination. 11

12. Importance of good communication
Health workers play important roles in parent and caregiver acceptance. Caregivers may not understand why their child needs an additional vaccine for polio and may be concerned about receiving multiple injections on the same visit Health workers need to explain the advantages of IPV and multiple injections, listen to caregiver’s concerns, and provide reassurance.
To the facilitator:
It is important for health workers to explain the advantages of IPV and multiple injections and listen to their concerns. This will reassure parents, who may be concerned about a new vaccine and receiving multiple injections on the same visit. 12

13. Responding to parental concerns
Provide reassurance: A strong health worker endorsement of IPV vaccine and multiple injections is essential to increase parent or caregiver acceptance. Health workers should also encourage and promote the importance of immunization generally
Provide clear responses to parent or caregiver questions: Health workers or providers need to be able to effectively answer or address questions and concerns related to the safety and value of multiple injections, the effectiveness of the vaccines, and child pain or discomfort.
Take steps to minimize pain during immunization: Healthcare workers should take appropriate steps to decrease pain during immunization.
To the facilitator: 13

14. Healthcare providers can say:
“Your child needs three shots/injections today: IPV vaccine, xxx and xxx.”
“IPV vaccine is very important because along with OPV it will provide your child with strong protection against polio. The additional dose of IPV will help protect your children against polio disease even more – and will give your child the benefits of both vaccines.”
“IPV provides immunity through the blood, while OPV provides immunity through the gut”
“Getting OPV and IPV is safe and strong protection against polio – a disease that is a threat to the health of your child and other children. Using both vaccines together provides the best form of protection – it protects your child and helps protect our community.”
To the facilitator: 14

15. Common questions from caregivers about multiple injections:
Module 8: Multiple Injections
Common questions from caregivers about multiple injections:
Why does my child need three injections on one visit?
Giving a child several vaccinations during the same visit allows your child to be fully immunized as soon as possible . This provides protection during the vulnerable early months of your child’s life. In addition, giving multiple vaccinations at one time means fewer vaccination visits for parents and caregivers.
Is it safe to give multiple vaccine injections at one visit?
It is safe for your child to receive multiple injections at once. Many countries have immunization schedules where children receive multiple vaccine injections at one visit.
To the facilitator: These are questions that parents may ask caregivers and a suggested response.

16. Common questions from caregivers about multiple injections:
Module 8: Multiple Injections
Common questions from caregivers about multiple injections:
Is there any evidence that multiple injections of vaccines may increase the risk for adverse events?
No. Numerous studies have shown that giving multiple vaccinations during the same visit does not result in higher incidence of adverse events.
Aren’t multiple injections painful for the child?
While receiving multiple injections at once is painful, having to return for additional vaccines forces the child to experience pain on two visits. It is better for the child to experience one brief moment of pain than pain on two separate days.
To the facilitator: These are questions that parents may ask caregivers and a suggested response.

17. Common questions from caregivers about multiple injections:
Module 8: Multiple Injections
Common questions from caregivers about multiple injections:
Wouldn’t it be safer to separate vaccine injections and spread them out?
No, it is safer for your child to receive all of his vaccinations at once. Spreading out vaccinations leaves babies unprotected for a longer time.
If my child receives multiple injections at the same visit, will the vaccines be as effective if given alone?
Yes. IPV does not interfere with other vaccines and IPV is equally effective when given alone or with other vaccines.
To the facilitator: These are questions that parents may ask caregivers and a suggested response.

18. Common questions from caregivers about multiple injections:
Module 8: Multiple Injections
Common questions from caregivers about multiple injections:
Can multiple vaccines given at once “overwhelm” a child’s immune system?
No. Children are exposed to numerous bacteria and viruses on a daily basis through eating and playing. Vaccines do not add a significant burden to the immune system.
Why did you not suggest this better injection when I came for immunization earlier?
WHO has recently recommended that countries add at least one dose of IPV to routine immunization programs, with a dose administered at 14 weeks of age or the closest immunization visit following that age. Children would receive both OPV and IPV at 14 weeks or 4 months. IPV does not replace any of the OPV doses.
To the facilitator: These are questions that parents may ask caregivers and a suggested response.

19. Key Messages
It is safe to give multiple vaccine injections at one visit. Many countries have successfully introduced multiple vaccine injections into their routine immunization schedule.
Multiple injections are better than spacing injections because they protect children, increase efficiency and lead to fewer overall vaccination visits.
Parental concerns about multiple injections can be addressed through reassurance, clear communication and pain reducing techniques.
Health workers need to listen, encourage and effectively communicate with caregivers to ensure that they receive their vaccines and return for future vaccinations.
To the facilitator: review the key messages related to IPV and multiple injections.
Multiple vaccine injections at one visit are safe.
They are better because they protect children, increase efficiency and are more convenient for caregivers.
Health workers can help caregivers by providing clear communication and reassurance, and taking steps to reduce pain during vaccination.
4. Caregiver concerns over multiple injections can be addressed by listening, providing encouragement and effective communication. 19

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