Toxic Shock Syndrome

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Many thanks to Government of India, PATH, WHO, Immunization Basics for the slides. Comments from diseasesurveillance and mfriendcircle yahoogroup members helped to refine the presentation. It is also going to the Technet 21 group

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Toxic Shock Syndrome

  1. 1. What Happened- What to Do? Toxic Shock Syndrome
  2. 2. Problem of Measles <ul><li>Two suspended after measles epidemic in Maharashtra village </li></ul><ul><li>1 post - Last post: 23 Aug 2010 </li></ul><ul><li>Two local officials in Maharashtra have been suspended following the deaths of two children and 26 others affected by a measles epidemic in ... www.thaindian.com/.../two-suspended-after- measles -epidemic-in- maharashtra -village_100416915.html - United States - Cached Two kids die, measles epidemic hits Maharashtra village ‎ - 1 post - 21 Aug 2010 India jeopardising global measles death target ‎ - 1 post - 7 Dec 2009 </li></ul>
  3. 3. Only licensed vaccines ( by DCGI) are used in the Immunization Programme in India .•Every batch of vaccine manufactured undergoes various safety tests at Central Research Institute Kasauli. • Vaccines are transported at recommended temperatures from the manufacturers to the stores and beneficiaries in cold chain • At the end user level VVM Vaccine Vial Monitors is used to monitor exposure to temperatures. • Only trained Health workers Operational details on 2 nd Opportunity for Measles Vaccination Measles Media Workshop Gauhati Assam 2 nd November 2010 Remember:
  4. 4. • A medical event that takes place after immunization, causes concern in the community and is believed to be caused by the immunization. • Program errors account for more than 95% of the total AEFI. Adverse Event following immunization Operational details on 2 nd Opportunity for Measles Vaccination Measles Media Workshop Gauhati Assam 2 nd November 2010
  5. 5. Program Error : (>95%) Due to error in vaccine preparation, handling or administration . Examples : 􀂃 1.Use of wrong or expired vaccine. 􀂃 2.Incorrect reconstitution or using reconstituted vaccine after 4 hrs. 􀂃 3.Use of wrong injection technique 􀂃 4.Using frozen freeze sensitive vaccines AEFI 2 nd November 2010
  6. 6. • Emphasis in vaccinator training about safe injection practices for zero programme errors • All PHCs will work as AEFI management centres • Additional sites at private sector clinics also to work as AEFI management centres • AEFI trays provided down to PHC level • Doctors at above sites trained in AEFI management • VHSCs will be empowered to transport the serious AEFI cases to the nearest AEFI Management centre • Wherever required, private practitioners will be identified for AEFI management & will also be trained on AEFI • Involvement of professional bodies Immunization Handbook for Medical Officers 2008 Training for Medical Officers
  7. 7. Toxic Shock syndrome Immunization Handbook for Medical Officers 2008
  8. 8. 1. Programmatic error <ul><li>Event caused by error in vaccine selection, storage, preparation, handling, or administration (95% and Preventable)‏ </li></ul><ul><ul><li>Wrong vaccine used, </li></ul></ul><ul><ul><li>Vaccine reconstituted incorrectly </li></ul></ul><ul><ul><li>Needle left in vial </li></ul></ul><ul><ul><li>Wrong technique used </li></ul></ul><ul><ul><li>Expired vaccine used </li></ul></ul><ul><ul><li>Reconstituted vaccine not discarded after 4 hours. </li></ul></ul><ul><ul><li>Freezing of freeze-sensitive vaccines (DPT, DT, TT)‏ </li></ul></ul>BCG injection given sub-cutaneously instead of Intradermally: local lymphadenitis and abcess Adverse Events Following Immunization from PATH
  9. 9. <ul><li>Reconstitute vaccines only with diluents supplied by the manufacturer for that vaccine. </li></ul>How to minimize AEFIs? Adverse Events Following Immunization from PATH
  10. 10. <ul><li>Use Measles and BCG vaccine within 4 hours of reconstitution. If they could not be used with in 4 hours then reconstituted vials should be discarded, irrespective of number of doses remaining in the vials. </li></ul><ul><li>Keep diluents of BCG and measles vaccine separate from other potentially harmful liquids. </li></ul>How to minimize AEFIs? Adverse Events Following Immunization from PATH
  11. 11. • Use Measles and BCG vaccine within 4 hours of reconstitution. If they could not be used with in 4 hours then reconstituted vials should be discarded, irrespective of number of doses remaining in the vials. ……… .When a severe adverse event occurs, the health worker should immediately contact the Medical Officer and if needed should accompany the patient. Immunization Handbook for Health workers 2006 Training for Field Workers 2006
  12. 12. Training for Field Workers 2010 <ul><li>After reconstitution </li></ul><ul><li>Always keep reconstituted vaccine in the hole in the ice pack to </li></ul><ul><li>maintain temperature at +2 to +80 C. </li></ul><ul><li>Keep the reconstituted vaccine in shade. </li></ul><ul><li>NEVER USE RECONSTITUTED MEASLES VACCINE BEYOND 4 HOURS AFTER RECONSTITUTION. </li></ul><ul><li>Using measles vaccine beyond 4 hours after reconstitution may result in Toxic Shock Syndrome (TSS) leading to death. </li></ul><ul><li>NEVER CARRY AND USE RECONSTITUTED VACCINE FROM ONE SESSION SITE TO ANOTHER. </li></ul><ul><li>Injecting measles vaccine: </li></ul><ul><li>Use only AD syringes to inject vaccine. </li></ul><ul><li>Dose is 0.5 ml for all ages. </li></ul>Handbook for field workers: Measles catch-up campaign 2010
  13. 13. For serious AEFI e.g. convulsions or anaphylaxis <ul><li>o Give primary care: lay child flat; ensure airway is clear. If child is </li></ul><ul><li>unconscious, put in semi-prone position. </li></ul><ul><li>Refer immediately to the nearest AEFI management centre </li></ul><ul><li>Call (telephone) the AEFI management centre and inform them of the </li></ul><ul><li>referral. </li></ul><ul><li>Inform immediate supervisor </li></ul>Handbook for field workers: Measles catch-up campaign 2010
  14. 14. <ul><li>AEFI Management Centres </li></ul><ul><li>During the catch-up campaign, every Govt. health facility from the PHC level and </li></ul><ul><li>upwards which has at least one Medical officer posted will function as an AEFI </li></ul><ul><li>management site. </li></ul><ul><li>In addition BMO, in consultation with CMO will explore the possibility of setting up </li></ul><ul><li>AEFI management centres in the clinics of physicians in the private sector or other </li></ul><ul><li>Govt. Departments. Such AEFI management sites should be geographically </li></ul><ul><li>dispersed within the Block so that in the event of an AEFI the child can be taken to </li></ul><ul><li>the nearest AEFI management centre quickly. </li></ul><ul><li>All such AEFI management centres should be listed out in the micro-plan with </li></ul><ul><li>telephone number and addresses and all vaccinators and supervisors must know </li></ul><ul><li>the contact details of the nearest AEFI centre from their area of activity for that </li></ul><ul><li>day. </li></ul><ul><li>All clinicians at the block level (Block PHC and PHC), district level (District hospitals </li></ul><ul><li>and sub-divisional hospitals) and the designated clinicians in the AEFI management </li></ul><ul><li>centres in the private sector will be trained in standard AEFI management and </li></ul><ul><li>reporting procedures. </li></ul><ul><li>All medical officers acting as supervisors will carry an emergency AEFI management </li></ul><ul><li>kit. </li></ul><ul><li>All AEFI management centres will be provided with AEFI treatment kits and AEFI </li></ul><ul><li>reporting forms. The private sector management centres will be reimbursed for </li></ul><ul><li>treatment costs of AEFI cases per standard protocol. </li></ul><ul><li>BMO and PHC MOI/C will be provided mobility support to quickly respond to reported AEFI. </li></ul><ul><li>The AEFI management centres will report the AEFI per laid out procedures in the national </li></ul><ul><li>guidelines. </li></ul>Measles catch-up campaign planning and implementation guidelines 2010
  15. 15. Contents of an AEFI Treatment kit <ul><li>Injection adrenalin (1:1000) solution – 2 ampoules </li></ul><ul><li>Injection Hydrocortisone (100 mg) – 1 vial </li></ul><ul><li>Disposable Syringe (insulin type) having 0.01 ml graduations and 26G IM needle – 2 sets </li></ul><ul><li>Disposable Syringe (5 ml) and 24/26G IM needle – 2 sets </li></ul><ul><li>Scalp vein set – 2 sets </li></ul><ul><li>Tab Paracetamol (500 mg) - 10 tabs </li></ul><ul><li>I/V fluids (Ringer lactate/Normal Saline): 1 unit in plastic bottle </li></ul><ul><li>I/V fluids (5% Dextrose): 1 unit in plastic bottle </li></ul><ul><li>IV drip set: 1 set </li></ul><ul><li>Cotton wool + adhesive tape : 1 each </li></ul><ul><li>AEFI reporting form (FIR) </li></ul><ul><li>Label showing: Date of inspection, Expiry date of Inj. Adrenaline and shortest expiry date of any of the components </li></ul><ul><li>Drug dosage tables for Inj Adrenaline and Hydrocortisone </li></ul><ul><li>At hospital setting, Oxygen support and airway intubation facility should be available. </li></ul>Measles catch-up campaign planning and implementation guidelines 2010
  16. 16. Contents of an AEFI Treatment kit
  17. 17. If already unconscious, place the patient in the recovery position and ensure that airway is clear. Assess heart rate and respiratory rate (if the patient has a strong carotid pulse, he/she is probably not suffering from anaphylaxis). If appropriate, begin cardiopulmonary resuscitation (CPR). Give adrenaline 1:1000 (See below for correct dose for age or weight) by deep intramuscular injection into the opposite limb to that in which the vaccine was given. (Subcutaneous administration is acceptable in mild cases) and give an additional half dose around the injection site (to delay antigen absorption). If the patient is conscious after the adrenaline is given, place his/her head lower than the feet and keep the patient warm. Give Inj. Hydrocortisone IM or slow IV per dosage chart below. Give oxygen by face mask, if available. Call for professional assistance but never leave the patient alone. Call an ambulance (or arrange other means of transport, after the first injection of adrenaline, or sooner if there are sufficient people available to help you. Measles catch-up campaign planning and implementation guidelines 2010
  18. 18. Immunization Handbook for Medical Officers 2008 If there is no improvement in the patient’s condition within 10-20 minutes, of the first injection, repeat the dose of adrenaline up to a maximum of three doses in total. Recovery from anaphylactic shock is usually rapid after adrenaline.
  19. 20. Measles catch-up campaign planning and implementation guidelines 2010
  20. 21. WHO 1997
  21. 22. WHO 1997
  22. 23. WHO 1997

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