1. Picture Box Training for rotavirus vaccine introduction

2. Training for rotavirus vaccine introduction | 2012 2 |2 | Countries are introducing the rotavirus vaccine. To ensure that this introduction is done in a safe way, the World Health Organization (WHO), through its Department of Immunization, Vaccines and Biologicals (IVB), developed a training package on rotavirus vaccine introduction for developing countries. The training package is composed of 7 modules. It is targeted at staff working in health facilities at district level such as medical officers, nurses, and medical assistants, as well as Expanded Program on Immunization (EPI) staff/vaccinators. This Picture Box was developed as an alternative to the training package for staff in resource-poor settings who do not have access to the learning materials for various reasons (e.g., lack of computer, projector, electricity, or computer skills). It provides the same content as the training package but in a picture format. Picture Box presentation: Side 1 (seen by trainees): Pictures or scenarios Side 2 (seen by facilitator): Key concepts and messages It is recommended that the Picture Box be used for training in small groups of no more than 5 people. It may also be used during supervisory visits to reinforce key concepts or train staff who did not attend the large group training. Foreword Trainees Facilitator

3. Training for rotavirus vaccine introduction | 2012 3 |3 | Module 1: Introduction to rotavirus disease and vaccine What is rotavirus disease?05 How to recognize rotavirus disease?07 How is rotavirus spread?09 What can be done to prevent rotavirus disease?11 Introduction to rotavirus vaccine13 Module 2: Rotavirus vaccine attributes and storage conditions What is the rotavirus vaccine?16 How to store the vaccine?18 Module 3: Rotavirus vaccine eligibility What is the rotavirus vaccine schedule?21 How to determine infant eligibility for rotavirus vaccine?23 What information do you need from the mother before vaccinating the child?33 Module 4: Rotavirus vaccine administration How to check vaccine quality before vaccinating the child?35 How to prepare for vaccination?37 Content (1/2)

4. Training for rotavirus vaccine introduction | 2012 4 |4 | Module 4: Rotavirus vaccine administration (continued) Can rotavirus vaccine be administered at the same time as other childhood vaccines?39 How to administer the vaccine?41 Module 5: Recording and monitoring uptake of rotavirus vaccine How to report rotavirus immunization? 45 How to track rotavirus immunization?47 Module 6: Rotavirus vaccine AEFI monitoring What are the AEFIs of rotavirus vaccine? 49 What about intussusception (IS)? 51 How to report an AEFI? 53 Module 7: Rotavirus vaccine communication with caretakers How to communicate with caretakers?55 How to inform caretakers about the disease?57 How to advise caretakers on rotavirus vaccine?59 How to alert caretakers of side effects and how to respond?61 How to arrange with caretakers for a follow-up appointment?63 Content (2/2)

5. Training for rotavirus vaccine introduction | 2012 5 |5 | What is rotavirus disease? Module 1: Introduction to rotavirus disease and vaccine

6. Training for rotavirus vaccine introduction | 2012 6 |6 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Rotavirus disease Rotavirus is a virus that causes diarrhea (sometimes severe), mostly in babies and young children. The name rotavirus is derived from the Latin Rota, meaning “wheel,” because the rotavirus has a wheel-like appearance when viewed by a microscope. Rotavirus infects and damages the cells that line the small intestine and causes gastroenteritis. WHO estimates that rotavirus is responsible for up to 500,000 diarrheal deaths, mostly infants in developing countries, and millions of admissions to hospital per year worldwide. Rotavirus is not the only cause of diarrhea, several other agents may also cause diarrhea. Key messages: 1) Rotavirus is a virus that causes diarrhea, 2) WHO estimates that rotavirus is responsible for up to 500,000 diarrheal deaths, mostly infants in developing countries, 3) Several other agents may also cause diarrhea. Module 1: Introduction to rotavirus disease and vaccine What is rotavirus disease?

7. Training for rotavirus vaccine introduction | 2012 7 |7 | How to recognize rotavirus disease? Module 1: Introduction to rotavirus disease and vaccine

8. Training for rotavirus vaccine introduction | 2012 8 |8 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Signs and symptoms of rotavirus infection The three main symptoms of rotavirus infection are fever, watery diarrhea, and vomiting. Abdominal pain may also occur. Diarrhea usually stops after 3 to 7 days. Young children can become dehydrated, requiring urgent treatment. Diagnosis of rotavirus disease The clinical features and stool characteristics of rotavirus diarrhea are nonspecific, and similar illness may be caused by other pathogens. As a result, confirmation of diarrheal illness caused by rotavirus requires laboratory testing. A sensitive test can be carried out on stool specimens, using a commercial test kit (enzyme immunoassay). Key messages: 1) Symptoms are fever, watery diarrhea, and vomiting, 2) Rotavirus is not the only cause of diarrhea, several other agents may also cause diarrhea, 3) Sensitive test can be carried out on stool specimens. How to recognize rotavirus disease? Module 1: Introduction to rotavirus disease and vaccine

9. Training for rotavirus vaccine introduction | 2012 9 |9 | How is rotavirus spread? Module 1: Introduction to rotavirus disease and vaccine

10. Training for rotavirus vaccine introduction | 2012 10 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Rotavirus cycle of transmission - Step 1: A child passes a stool. - Step 2: The child does not wash his/her hands. - Step 3: The child plays with a balloon together with another child, who touches the infected toy. - Step 4: The second child places his/her hand in the mouth by eating an apple and gets infected. Key messages: 1) Rotavirus infection is highly contagious, 2) Rotavirus disease spreads by the fecal-oral route, 3) People at risk are infants over the age of 3 months, because they have no immunity and are very vulnerable to dehydration, and older children if they are immuno- compromised. How is rotavirus spread? Module 1: Introduction to rotavirus disease and vaccine

11. Training for rotavirus vaccine introduction | 2012 11 |

12. Training for rotavirus vaccine introduction | 2012 12 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Prevention methods Prevention methods against rotavirus disease include breastfeeding, improvements in nutrition, hygiene, and water quality, and ORL/zinc (treatment) can reduce diarrheal disease and decrease child mortality where diarrheal disease is a serious burden. But enhancing sanitation and hygiene is not enough to prevent the disease and stop the spread. Currently, vaccination is the only way to prevent severe episodes of rotavirus infection. Key messages: 1) Good sanitation and hygiene, 2) Exclusive breastfeeding, 3) Improved water quality, 4) Treatment- ORL+ zinc, 5) Vaccination. Module 1: Introduction to rotavirus disease and vaccine What can be done to prevent rotavirus disease?

13. Training for rotavirus vaccine introduction | 2012 13 | Introduction to rotavirus vaccine Determine eligibility for the vaccine Administer the vaccine Communicate with caretakers about the vaccine Record immunization Store the vaccine Monitor AEFIs Module 1: Introduction to rotavirus disease and vaccine

14. Training for rotavirus vaccine introduction | 2012 14 | Facilitator instructions: After the briefing on rotavirus disease, which provides the rationale for rotavirus immunization, introduce the content of the training and its learning objectives. As we previously saw, rotavirus is very contagious, and spreads easily from infected children to other children. The best way to protect babies from rotavirus disease is through vaccination with rotavirus vaccine. Currently, there are 2 available vaccines, Rotarix TM and RotaTeq TM, which allow the prevention of rotavirus disease and save children. Your country is going to introduce Rotarix TM. The general objective of the training is to give you the required knowledge to ensure the safe introduction of the rotavirus vaccine at your level. After this training, you will be able to:  Store the vaccine  Determine eligibility for the vaccine  Administer the vaccine  Record immunization  Monitor AEFIs  Communicate with caretakers about the vaccine Introduction to rotavirus vaccine Module 1: Introduction to rotavirus disease and vaccine

15. Training for rotavirus vaccine introduction | 2012 15 | What is rotavirus vaccine? Module 2: Rotavirus vaccine attributes and storage conditions

16. Training for rotavirus vaccine introduction | 2012 16 | What is rotavirus vaccine? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Rotavirus vaccine presentation Rotavirus vaccine is a solution for oral use. It comes in a tube specially designed for direct oral administration (1 tube = 1 dose; 1 tube has 1.5mL liquid). The rotavirus vaccine must be given to babies orally, which means swallowed and not injected. Information on vaccine safety Current rotavirus vaccines are generally well tolerated. They do not appear to cause any serious adverse events. Rotavirus vaccine may be given with other vaccines in the infant EPI schedule without interfering with their effectiveness. Very common side effects: irritability, loss of appetite Common side effects: fever, fatigue, diarrhea, vomiting, flatulence, abdominal pain, regurgitation of food Rotavirus vaccine may be given with other vaccines in the infant EPI schedule without interfering with their effectiveness Key messages: 1) Rotavirus vaccine has a liquid formulation, 2) Vaccine comes in a squeezable plastic tube, 3) Irritability and loss of appetite are very common side effects of rotavirus vaccine. Module 2: Rotavirus vaccine attributes and storage conditions

17. Training for rotavirus vaccine introduction | 2012 17 | How to store the vaccine? Module 2: Rotavirus vaccine attributes and storage conditions

18. Training for rotavirus vaccine introduction | 2012 18 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Vaccine storage The rotavirus vaccine should be stored in a refrigerator. Do not put rotavirus vaccine in the freezer. If the vaccines are frozen, they lose their potency and no longer provide protection against the disease. Vaccines with early expiration dates should be kept in the front of the refrigerator for first use. Keep a “use first box” containing vaccines with a Vaccine Vial Monitor (VVM) at stage 2 (and nearing stage 2) and vaccines that were taken out of the refrigerator and brought back unused. Vaccines in the “use first box” must be used first in the next session. Vaccine storage temperature Good temperature control during the storage and transport of vaccines is critical to ensure the potency and safety of vaccines. Rotavirus vaccines must be stored between +2°C and +8°C. Key messages: 1) Store vaccines between +2°C to +8°C, 2) Vaccines with early expiration dates and VVM in stage 2 (or nearing stage 2) should be kept in front of the refrigerator to be used first, 3) Do not open the refrigerator door often, 4) Regularly monitor the temperature of the refrigerator. How to store the vaccine? Module 2: Rotavirus vaccine attributes and storage conditions

19. Training for rotavirus vaccine introduction | 2012 19 | Scenario 1: What to do? The refrigerator stops functioning. Module 3: Rotavirus vaccine eligibility

20. Training for rotavirus vaccine introduction | 2012 20 | Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. The exercise will determine if participants know what to do if the refridgerator stops functioning. Situation The refrigerator stops functioning. What should you do? Response - Find another refrigerator or cold room to store vaccines (be sure that the temperature is maintained between +2°C and + 8°C). - If another refrigerator is unavailable, line ice packs or cold packs in cold box(es) or vaccine carrier(s) then put vaccines in the box(es) (Be careful not to put rotavirus vaccines or other freeze-sensitive vaccines near frozen ice packs, as it may affect vaccine potency). - Inform supervisor immediately. What should you do in this scenario? Module 3: Rotavirus vaccine eligibility

21. Training for rotavirus vaccine introduction | 2012 21 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Recommended schedule for rotavirus vaccine On-time vaccination is very important for rotavirus immunization. - Rotavirus vaccine is given in a 2-dose schedule: first dose at 6 weeks and second/last dose at 10 weeks of age. - An interval of 4 weeks between the doses is recommended. - Rotavirus vaccine doses can be given at the same time as pentavalent vaccine (i.e. Penta1 and Penta2). Key messages: 1) First dose of rotavirus has to be given at 6weeks, 2) Second (last) dose has to be given at 10 weeks. What is the rotavirus vaccine schedule? Module 3: Rotavirus vaccine eligibility

22. Training for rotavirus vaccine introduction | 2012 22 | What are some conditions under which child should not be vaccinated (contraindications)? Module 3: Rotavirus vaccine eligibility

23. Training for rotavirus vaccine introduction | 2012 23 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Absolute contraindications - Hypersensitivity after previous administration of rotavirus vaccines - Previous history of intussusception - Administration of Rotarix TM to asymptomatic HIV subjects is not recommended - The administration of Rotarix TM should be postponed in subjects suffering from diarrhea or vomiting and in need of rehydration therapy Note that mild illness such as an upper respiratory tract infection is not a contraindication. Key messages: 1) Rotavirus vaccine should not be given to individuals who experienced hypersensitivity after the first dose, to people with a history of intussusception, or to asymptomatic HIV subjects. Module 3: Rotavirus vaccine eligibility What are some conditions under which child should not be vaccinated (contraindications)?

24. Training for rotavirus vaccine introduction | 2012 24 | How to check vaccine quality before vaccinating the child? 1 1 2 2 3 3 4 4 Stage 1: Vaccine OK Stage 2: Vaccine OK (use first) Stage 3: Do not use the vaccine Stage 4: Do not use the vaccine Module 4: Rotavirus vaccine eligibility

25. Training for rotavirus vaccine introduction | 2012 25 | Facilitator instructions: Ask the participants to identify which vaccines need to be used first (and which ones need to be discarded). Then provide the information below and point out key messages. Checking vaccine quality Before administering the vaccine you need to: check and interpret the Vaccine Vial Monitor (VVM) on the tube cap; check the expiration date on the vaccine marked on the tube cap 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. By comparing the color of the inner square to the reference color, a health worker can determine whether the vaccine has been exposed to heat. Interpreting the Vaccine Vial Monitor (VVM) - Color of the small square remains white and the color of outer circle remains grey: Ok - Color of the small square changes to a light grey color: Ok - Color of the small square changes to grey and looks similar to the outer grey circle: Not ok - Color of the small square changes to a darker grey then the outer grey circle: Not ok Key messages: 1) Check expiration date, 2) Check and interpret vaccine vial monitor How to check vaccine quality before vaccinating the child? Module 4: Rotavirus vaccine eligibility

26. Training for rotavirus vaccine introduction | 2012 26 | How to prepare for vaccination? 1 1 3 3 2 2 4 4 Module 4: Rotavirus vaccine eligibility

27. Training for rotavirus vaccine introduction | 2012 27 | Facilitator instructions: Ask the participants to respond to the question above, then describe step-by- step how the vaccine should be prepared. Finally, point out key messages. Steps for preparing the vaccine - Step 1: Pull off the cap from the tube. Clear the fluid from the upper part of the tube by tapping the tube. - Step 2: Turn the cap upside-down and place the cap vertically onto the tip seal. Insert the tip seal into the small hole in the top of the cap. - Step 3: Twist the cap in the direction of the arrow (clockwise) to remove the tip seal. Do not snap off tip seal: It may fall into tube. - Step 4: Ensure that a hole clearly appears at the top of the tube and that the detached tip seal is inside the top of the cap. Very important to know that the vaccine must be discarded if the tip seal falls into the tube. Key messages: 1) Do not snap off tip seal: It may fall into tube, 2) The vaccine must be discarded if the tip seal falls into the tube. How to prepare for vaccination? Module 4: Rotavirus vaccine eligibility

28. Training for rotavirus vaccine introduction | 2012 28 | Can rotavirus vaccine be administered at the same time as other childhood vaccines? Module 4: Rotavirus vaccine eligibility

29. Training for rotavirus vaccine introduction | 2012 29 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Vaccines that can be administered concomitantly with rotavirus vaccine Rotavirus vaccine can be given with any of the following routine childhood vaccines without interfering with their effectiveness: - Diphtheria–tetanus–acellular pertussis vaccine (DTPa) - Haemophilus influenzae type b vaccine (Hib) - Inactivated polio vaccine (IPV) - Hepatitis B vaccine - Pneumococcal vaccine - Oral polio vaccine (OPV) Give the rotavirus vaccine at the beginning of the visit, when the baby is still calm. Key messages: 1) Give the rotavirus vaccine first, then administer other childhood vaccines. Can rotavirus vaccine be administered at the same time as other childhood vaccines? Module 4: Rotavirus vaccine eligibility

30. Training for rotavirus vaccine introduction | 2012 30 | How to administer the vaccine? 1 1 3 3 4 4 2 2 Module 4: Rotavirus vaccine eligibility

31. Training for rotavirus vaccine introduction | 2012 31 | Facilitator instructions: Ask the participants to respond to the question above, then describe step-by- step how the vaccine should be administered. Finally, point out key messages. How to position the child for rotavirus vaccination The child should be seated in a semi-reclining position (i.e. normal feeding position). How to position the vaccine - Step 1: Gently squeeze the child's cheeks to open the mouth. - Step 2: Put the tube towards the inner cheek. Make every effort to aim the tube containing the vaccine down one side and toward the back of the child's mouth. Do not put the tube too far back in the mouth. Never place the tube into the center of the mouth to prevent the risk of choking. How to administer the vaccine - Step 3: Administer the entire content of the tube by gently squeezing it several times. Make sure the child is swallowing the vaccine to prevent buildup in the mouth. - Step 4: Gently hold the cheeks together and stroke the child under the chin to help with swallowing. Key messages: 1) The rotavirus vaccine dose quantity is larger than that of oral polio vaccine (Rotarix™1.5 mL) and infants might not take the full dose all at once, 2) To prevent spitting, slowly administer the vaccine in small amounts and properly place the tip of the tube towards the inside of the child's cheek. How to administer the vaccine? Module 4: Rotavirus vaccine eligibility

32. Training for rotavirus vaccine introduction | 2012 32 | Scenario 6: What to do? 1 1 2 2 Module 4: Rotavirus vaccine eligibility

33. Training for rotavirus vaccine introduction | 2012 33 | Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. Situation 1 The child is 8 weeks old. You vaccinate him/her with rotavirus vaccine. Is the child in the good position to be vaccinated? Response Yes. The child should be seated in a semi reclining position (i.e. normal feeding position). Situation 2 During vaccination, the child regurgitates the vaccine. In this scenario do you give the child a replacement dose? Response Replacement dose is not needed if, for any reason, an incomplete dose is administered (e.g. infant spits or regurgitates the vaccine). Module 4: Rotavirus vaccine eligibility What should you do in this scenario?

34. Training for rotavirus vaccine introduction | 2012 34 | How to report rotavirus immunization? Immunization card Tally sheet Rota1 = 1 st dose Rota2 = 2 nd dose Monthly report Module 5: Recording and monitoring uptake of rotavirus vaccine

35. Training for rotavirus vaccine introduction | 2012 35 | How to report rotavirus immunization? Facilitator instructions: Describe each document used for rotavirus immunization reporting. Then point out key messages. Immunization card description Each time a vaccine is administered, health workers should complete the immunization card outlining which vaccines have been given. Health workers should also note the date of the next appointment on the immunization card and remind the caretaker to return on that date with the card. Then, parents should be reminded to bring the immunization card at each visit. Health workers should use the abbreviation “Rota” when recording the vaccine they administered. Tally sheet description Tally sheets were updated to reflect the inclusion of rotavirus vaccine in the national immunization program. Health workers should keep a tally of each vaccine dose given. At the end of an immunization session, they should count the tally sheets to identify the total number of vaccinations given (for each dose). Monthly report description Reporting forms were updated to reflect the inclusion of rotavirus vaccine in the national immunization program. Report Rota1 and Rota2 doses given each month, along with other vaccine doses. Use tally sheets to prepare monthly reports to send to supervisors. Key messages: 1) Complete immunization card, 2) Update tally sheet, 3) Compile monthly report Module 5: Recording and monitoring uptake of rotavirus vaccine

36. Training for rotavirus vaccine introduction | 2012 36 | How to track rotavirus immunization? Rotavirus vaccine monitoring chart Year 2012 Module 5: Recording and monitoring uptake of rotavirus vaccine

37. Training for rotavirus vaccine introduction | 2012 37 | How to track for rotavirus immunization? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. How to track infants for first dose of rotavirus vaccine Unlike other vaccines that can even be started late, rotavirus vaccination has to start on time. This should be communicated to parents and the community at large. Use volunteers to inform and motivate parents of newborns to bring their children for vaccination on time. Parents of infants who are due for vaccination, but have not yet come to the health center, should be reminded and followed up with. How to track infants for second dose of rotavirus vaccine A copy of the infant immunization card may be filed under the month the infant should return for a second dose. Every month, review the reminder cards and follow up with those who did not attend when due. Involve community volunteers to bring children who are eligible for the second dose. How to monitor uptake of rotavirus vaccine Use a monitoring chart to track the number of infants who received first and second doses of rotavirus vaccine. If the gap between Rota1 and Rota2 is large, this means that several children received the first dose but not the second. Thus, follow-up systems need to be strengthened. A big gap between monthly targets and infants getting Rota1 means newborns need to be followed up with regularly. Key messages: 1) It is very important to find all newborns and ensure they receive their two doses of Rotavirus vaccines. Module 5: Recording and monitoring uptake of rotavirus vaccine

38. Training for rotavirus vaccine introduction | 2012 38 | What are the AEFIs of rotavirus vaccine? Potential serious adverse events Intussusception (IS) Gastrointestinal symptoms and signs Hospitalization for unexplained medical events following vaccination Unexplained death following vaccination Rare events thought to be related to rotavirus vaccination Module 6: Rotavirus vaccine AEFI monitoring

39. Training for rotavirus vaccine introduction | 2012 39 | Facilitator instructions: Ask the participants to respond to the question above, then describe the adverse events following immunization (AEFIs) of rotavirus vaccine outlined below. Finally, point out key messages. Non serious adverse events Most infants who get the rotavirus vaccine do not experience any side effects. However, a small proportion of infants may suffer short episodes of vaccine-induced fever, diarrhea, or vomiting in the first week following vaccination. These side effects are classified as “safe and common side effects.” Potential serious adverse events Potential serious adverse events of special relevance for rotavirus vaccines include: - Intussusception (IS) - Gastrointestinal symptoms and signs - Hospitalization for unexplained medical events following vaccination - Unexplained death following vaccination - Rare events thought to be related to rotavirus vaccination or otherwise causing concern, including pneumonia or central nervous system signs and symptoms (source: WHO manual Post-marketing surveillance of rotavirus vaccine safety, 2009.) Key messages: 1) The current safety profile of rotavirus vaccines is good, 2) Most infants who get the rotavirus vaccine do not experience any side effects. What are the AEFIs of rotavirus vaccine? Module 6: Rotavirus vaccine AEFI monitoring

40. Training for rotavirus vaccine introduction | 2012 40 | What about intussusception (IS)? Module 6: Rotavirus vaccine AEFI monitoring

41. Training for rotavirus vaccine introduction | 2012 41 | Facilitator instructions: Explain what intussusception is and its potential as a serious adverse event. Then, point out key messages. Description of intussusception (IS) IS is a rare type of bowel obstruction that occurs when one portion of the bowel slides into an immediately adjacent segment (also known as telescoping or prolapse).. Symptoms of IS include stomach pain with severe crying (which may be brief), several episodes of vomiting, blood in the stool, weakness, or irritability. IS as a potential serious adverse events In the past, the first rotavirus vaccines (Rotashield TM ) caused IS. With the new rotavirus vaccines, there seems to be a very small increased risk of IS in infants following rotavirus vaccination. The increased risk appears to occur mainly in the first 1- 7 days following the first dose of rotavirus vaccine. Key messages: 1)The risk of IS after rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children What about intussusception (IS)? Module 6: Rotavirus vaccine AEFI monitoring

42. Training for rotavirus vaccine introduction | 2012 42 | How to report an AEFI? National authorities Community, district & regional levels Suspected signs or symptoms Module 6: Rotavirus vaccine AEFI monitoring

43. Training for rotavirus vaccine introduction | 2012 43 | Facilitator instructions: Describe the process of reporting an AEFI. Then, point out key messages. How to recognize signs Health workers ask parents to immediately report any reaction that may be related to the vaccine. Report the identified AEFI through the existing AEFI reporting systems established by national immunization programs. The National Authorities will then decide if further investigation is needed. Information to include in an AEFI report An AEFI report should contain: - Client – unique identifier, date of birth and gender - Immunization event(s) – province where given, date, all vaccines given including name, manufacturer, lot number, administration site and route, as well as the number in series of vaccine doses if relevant - Adverse event(s) – description, including time of first onset following immunization, duration, health care utilization, treatment and outcome - Relevant medical and treatment history – underlying disease, known allergies, prior AEFIs, concomitant medication - Associated event(s) – acute illness, injury, exposure to environmental toxins - Reporter details Key messages: AEFI should be reported through the existing AEFI reporting systems/forms How to report an AEFI? Module 6: Rotavirus vaccine AEFI monitoring

44. Training for rotavirus vaccine introduction | 2012 44 | How to communicate with caretakers? A rrange for when to return A lert on side effects and how to respond A dvice on what is given Module 7: Rotavirus vaccine communication with caretakers

45. Training for rotavirus vaccine introduction | 2012 45 | How to communicate with caretakers? Facilitator instructions: Ask the participants to respond to the question above, then explain triple A communication and how to communicate effectively. Finally, point out key messages. Triple A communication Triple A communication is a mnemonic system that allows health workers to remember the three ways of communicating with parents. - Advice parents on what is given (disease prevented, vaccine used, etc.) - Alert on side effects after immunization and how to respond to that possible side effects - Arrange and fix with parents the next appointment for administering the second dose of the vaccine How to communicate effectively with caretakers Healthcare workers should establish an open, non confrontational dialogue with vaccine-hesitant parents at an early stage and provide clear, easily understandable answers about known vaccine adverse events and provide accurate information about vaccination. Key messages: 1) Triple A communication - Be respectful - Listen to caretaker's concerns - Use simple words to make sure the caretaker understands your key messages, 2) Ongoing dialogue may successfully reassure vaccine-hesitant parents that immunization is the best and safest option for their child. Module 7: Rotavirus vaccine communication with caretakers

46. Training for rotavirus vaccine introduction | 2012 46 | How to inform caretakers about the disease? Rotavirus Module 7: Rotavirus vaccine communication with caretakers

47. Training for rotavirus vaccine introduction | 2012 47 | Facilitator instructions: Explain to the participants how they should inform caretakers about the disease. Then, point out key messages. What to communicate about the disease - Rotavirus is a virus that causes diarrhea, sometimes severe, mostly in babies and young children. It is often accompanied by vomiting and fever and can lead to dehydration. - Rotavirus is not the only cause of diarrhea, but it is one of the most serious. Almost every child in the world will suffer from at least one infection by the time he or she is three years old. - The primary mode of transmission of rotavirus is the passage of the virus in stool to the mouth of another child. How to communicate about diarrhea prevention methods The use of rotavirus vaccine needs to be part of a comprehensive strategy to control diarrhoeal diseases with the scaling up of both prevention (promotion of early and exclusive breastfeeding for six months, vitamin A supplementation, safe drinking water, hygiene, especially hand-washing with soap, and sanitation) and treatment packages (ORS, zinc, and continued feeding). Currently, vaccination is the only way to prevent the severe episodes of rotavirus infection. Key messages: 1) Rotavirus infection is highly contagious, 2) Vaccination is the only way to prevent the severe episodes of rotavirus infection. How to inform caretakers about the disease? Module 7: Rotavirus vaccine communication with caretakers

48. Training for rotavirus vaccine introduction | 2012 48 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. How to communicate about the new rotavirus vaccine Millions of children have received rotavirus vaccine in the last 8 years and the vaccine is considered very safe and effective The rotavirus vaccine must be given to babies orally, which means swallowed and not injected. This vaccine will be given at the same time as pentavalent vaccine, therefore no extra visit is required for this vaccine. Your child can still get diarrhea due to other agents. How to advice on the rotavirus vaccine schedule Explain to the caretakers that it is important to get vaccinated on time. Rotavirus vaccine is given orally in 2 doses at ages 6 and 10 weeks. There should be an interval of at least 4 weeks between the 2 doses. Key messages: 1) Vaccination is the only way to prevent the severe episodes of rotavirus infection, 2) A child immunized with rotavirus vaccine can still get diarrhea from other agents, 3) On-time vaccination is very important. How to advise caretakers on rotavirus vaccine? Module 7: Rotavirus vaccine communication with caretakers

49. Training for rotavirus vaccine introduction | 2012 49 | How to alert caretakers of side effects and how to respond ? >39˚C Unusual symptoms Module 7: Rotavirus vaccine communication with caretakers

50. Training for rotavirus vaccine introduction | 2012 50 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. How caretakers should respond to side effects Following vaccination, children may be more irritable and have loss of appetite. Some children may also experience fever, fatigue, diarrhea, and vomiting - If the child has a fever (>39˚C), caretakers can give him/her paracetamol - If the child shows any unusual symptoms, caretakers should take him/her directly to the hospital Key messages: 1) Current rotavirus vaccines are generally well tolerated, 2) Parents have to understand that the risk of side effects after rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children. How to alert caretakers of side effects and how to respond ? Module 7: Rotavirus vaccine communication with caretakers

51. Training for rotavirus vaccine introduction | 2012 51 | How to arrange with caretakers for a follow-up appointment? Module 7: Rotavirus vaccine communication with caretakers

52. Training for rotavirus vaccine introduction | 2012 52 | Facilitator instructions: Ask the participants to respond to the question above, then provide the information below on scheduling a follow-up appointment. Then, point out key messages. When to return Make an appointment for the next dose of rotavirus vaccine and other vaccines according to the immunization schedule. Make sure a minimum interval of 4 weeks is maintained. Ensure that there is a session on the given date (no public holiday, weekend, etc.). Write the date of the next visit on the immunization card and remind the caretaker to come on the specified date and to bring the card. Key messages: 1) If children come late they will get other vaccines but will lose out on getting the important rotavirus vaccine, 2) Keep the immunization card safe and remember to bring it next time, 3) If the card is not available, it is very difficult for the health worker to know if the child can get the vaccine. How to arrange with caretakers for a follow-up appointment? Module 7: Rotavirus vaccine communication with caretakers

53. Training for rotavirus vaccine introduction | 2012 53 | Thank you for your attention! End of training

54. Training for rotavirus vaccine introduction | 2012 54 | Special thanks to the Agence de Médecine Préventive (AMP) for its input in the instructional design of the training package to enhance the concepts and enrich the understanding and learning experience. © World Health Organization 2012 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.