The “unchecked” box-Identifying reasons for non- or under -vaccination A variety of structural and behavioral obstacles can lead to non- and under- vaccination. Effective interventions require proper diagnosis.Target group for use- First line health workers doing routine checks for any health problemIdentify whether obstacle relates to:Opportunity (costs, supply availability, etc) Ability (information, social networks) Motivation – (self-interest, hesitancy etc) ,This can serve as an individual and system diagnostic tool Could trigger health worker action /referrals Possible m-Health application for data collection and transmitting to EPI managerPersona profilingCan identify cause of hesitencies?Can be linked with communications training and delivertySupply focusStock Management Improved stock management is vital for vaccine delivery Targeted to EPI Managers; LogisticiansQuarterly reviewVaccine supply; transport; cold chain storage; distribution; utilization; data collection, interpretation and management; regular reviewsReduced stock-outs of vaccines; increased acceptability of the immunization programme Supply inventory – quality checks Rationale- Inconsistent availability of supplies, lack of proper cold chain undermines vaccination capacities Target - Community clinics-PHC centres- Supply and quality managers/ Daily checks – refrigerator Weekly supply inventory 10 key vaccines and delivery supplies
Checklists for Vaccines and Immunization
Checklists for Vaccines and Immunization Dr. Carsten Mantel WHO/FWC/IVB/EPI
Why immunization?One of the most successful 2 to 3 million deaths averted and cost-effective health annually by vaccination interventions . Excellent immunization19.3 million infants not fully services can increase immunized in 2010 confidence in the health care system overall
Immunization accelerates child mortality reduction “Over half of the (30%) drop in child mortality since 1990 is attributable to immunization.” Dr Margaret Chan, Director-General, World Health Organization Source: Levels & Trends in Child Mortality Report 2011. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation.
Why immunization session checklist? Checklist for health care worker / vaccinator, supported by m-Health tool for caregiver to: – increase quality of vaccination services; – ensure completion of vaccine schedules; – increase vaccine effectiveness; – reduce threats to programme from adverse events (AEFI); – improve client confidence in the health care system overall.
Checklist to improve programme performance Embedded in package of increasing quality and safety awareness, behavior change for health-care workers and empowerment of clients Checklist programme may include: SMS Information on Broader disease reminders to vaccines prevention clients when the given, alerts on messages Feedback from next vaccination adverse events e.g., for clients on is due based on and connection rotavirus, pneu service quality electronic to health facility mococcal, HPV- vaccination if these should related diseases schedule occur
Checklist to improve vaccine effectiveness Loss of vaccine effectiveness due to exposures to adverse conditions is cumulative, permanent and irreversible "A study of vaccine potency and efficacy in Nigeria found only 1 of 14 vials used for measles vaccination had virus titer at or above minimum WHO standard, potentially leading to inadequate seroconversion and vaccine failure. This usually has to do with cold chain management at lower levels."
Checklist to reduce adverse eventsTamil NaduFour deaths in children following inoculationwith measles vaccine due to re-constitutionerror (not related to vaccine quality)All vaccination sites instructed to stop use ofmeasles vaccine from this manufacturerSeveral million doses of vaccine recalled andState EPI programme interrupted for months
Checklist to reduce adverse events Ukraine Death after MR vaccine in 2009 fuelled vaccine scares and anti- vaccination movement (death was unrelated to vaccine) MoH stopped vaccination campaign Severe measles outbreaks since and now threatening visitors of European Soccer Championship
Activities conducted to dateWHO working group establishedComprehensive checklist prepared on basis of WHOpolicy document “Immunization in Practice” (32 items)AFRO EPI mangers surveyed on common and criticalerrors; Preliminary literature review conductedChecklist revised and condensed (18 items)
Guidance for setting up the immunization session Icepack taken from freezer for conditioning Vaccine carrier prepared (conditioned ice at least 30 minutes before session packs, vaccine vials in middle, foam pad on top) and lid closed tightly Required quantities of vaccine vials taken out of refrigerator in specific order Equipment for immunization session collected (auto-disable syringes, register, cards, tally sheets) Diluents taken out and matched (quantity and type) with appropriate vaccines List of clients due for vaccination and defaulters prepared and reviewed with Checked if vaccines are safe to use (label, community volunteer expiry date, vaccine vial monitor) Health care worker / vaccinator washed Checked freeze indicator (if freezing hands with soap warning appears, perform shake test)
Guidance for conduct of the immunization session Caretaker and vaccinee greeted and Contraindications checked seated Vaccinee’s date of birth and age Immunization register completed determined Determined which vaccine(s) have Vaccines prepared safely previously been received (reconstituted with correct diluent, not contaminated during preparation vaccine, in correct quantity) Determined all vaccines the client is eligible for according to national schedule
Guidance for conduct of the immunization session All vaccines administered safely (aseptic Key messages given (diseases technique with no breach of sterility) explained, common adverse events and what to do in case of an AEFI) Used syringes disposed of immediately into safety box Other health interventions provided as appropriate Each vaccine dose recorded in tally sheet Community volunteers informed about next immunization session Immunization card completed with vaccines given and date of next immunization marked
Guidance for concluding the immunization session Immunization tally sheet completed Unused syringes returned to safe location Unopened vaccine vials returned to refrigerator Safety box placed in a safe location Opened vaccine vials to which multi-dose vial policy does apply returned to "use Full safety boxes handled according to first" box in refrigerator national waste management guidelines Opened vials to which multi-dose vial policy does not apply discarded
Survey of EPI managers Survey among EPI managers meetings in Africa: 29 country responses Questions asked: What are most frequent errors (commonly overlooked, forgotten or poorly executed) and What are the most critical or consequential errors by health care workers / vaccinators before, during and after an immunization session
Feedback from EPI managers Before session: Common errors After session: common errors 1. Prefilling syringes 1. Waste management policy not 2. Not verifying VVM status and expiry date respected 3. Poor estimation of vaccination materials 2. Vaccinees not advised of next visit 4. Not washing hands 3. Registration and data management 5. Poor target population estimates not properly done 4. No information on potential adverse eventsDuring session: Common errors 5. No follow-up on unvaccinated and1. Not using aseptic technique defaulters2. Recapping of needle3. Wrong injection technique4. Not explaining to the client which vaccine is being administered5. Safety box not used
Next steps Literature review on key issues related to vaccine administration and preparation of background document Usability testing in 10 to 15 sites Pilot testing and evaluation in 2 to 3 countries (SEA countries showing interest) Presentation to WHO Immunization Practices Advisory Committee in October 2012 for comments and subsequent endorsement Review potential for setting up databases to link local immunization registries with vaccination schedules and m-Health SMS messages to health care workers, clients and caregivers
Other vaccine checklist ideas The ‘unchecked’ box Identifying non- and under- immunizedUptake focus Opportunity Ability Motivation Persona profiling Hesitancies Stock managementSupply focus Inventory quality
Acknowledgements Jhilmil Bahl Hemanthi Dassanayake-Nicolas Angela Lashoher Rudi Eggers Thomas Cherian Diana Chang-Blanc Franklin Apfel Thank You