OPV/Measles

Ice packs

Measles

BCG, DPT

TT, Hep B

Water not for drinking

Six vaccines are used to combat seven immunizable diseases: OPV - must be kept frozen at -15°C

to -25°C Measles vaccines

- can be stored at either -15°C to -25°C or at +2°C to +8°C

BCG, DPT, TT, and Hep B vaccines - should be stored at +2°C to +8°C

All Vaccines can be stored at +2°C to +8°C (presence of solid ice) during SUPPLEMENTAL IMMUNIZATION ACTIVITIES

Antigen Schedule Storage Remarks

BCG Anytime after birth

+2°C to +8°C • Freezing DOES NOT damage it but ampoules may break

• Diluents should be kept cold before using

OPV •1st dose - 6wks•2nd dose - 10 wks•3rd dose - 14 wks

-15°C to -25°C • Easily damaged by heat

• NOT harmed by freezing

DPT •1st dose - 6wks•2nd dose - 10 wks•3rd dose - 14 wks

+2°C to+8°C • “DT” is damaged by freezing

• “P” is damaged by heat

Dose Schedule and Recommended Storage Temperature

Hep B •1st dose - at birth•2nd dose - 6 wks•3rd dose -14 wks

+2°C to +8°C Both heat and freezing damages vaccine

Measles 9 months -15°C to -25°C Diluents should also be kept cold before using

Dose Schedule and Recommended Storage Temperature

Tetanus Toxoid

• 1st dose - as early as possible during first pregnancy

• 2nd dose - 4 weeks after first dose within the same pregnancy

• 3rd dose - 6 months after TT2

• 4th dose - 1 yr after TT3

• 5thdose - 1 yr after TT4

+2°C to +8°C Should never be frozen

Dose Schedule and Recommended Storage Temperature

B1. Sensitivity to Heat

Most sensitiveOPVMeaslesDTP, yellow feverBCGHib, DTTd, TT, Hepatitis B

Least sensitive

Most sensitive Hepatitis B Hib (liquid) DTP DT Td TT

Least sensitive

BCG and MEASLES vaccines sensitive to light and fluorescent

light (as well as heat)

B4. Expiry Date All vaccines including diluents

have an expiry date

B4. Expiry Date End of the month - the last date by

which the vaccines can be used (if not specified)

Expired vials, heat or frozen damaged vaccines or vials with VVMs beyond the discard point should be disposed immediately or labeled ‘Damaged/ expired vaccine – do not use’ and stored outside the cold chain to avoid confusion with good quality vaccines

C. Diluents

contain chemicals and additives to stabilize a specific vaccine after reconstitution

each vaccine requires a specific diluent

are not interchangeable

Diluent vials/ampoules must never be frozen or allowed to be in

contact with any frozen surface to avoid breakage and contamination

Freeze dried vaccines and correct diluents from the same

manufacturer should be distributed and receive in matching quantities

Vaccine requirement = Total population x 2.7% (Eligible

Pop) x no. of doses of the particular vaccine required x wastage factor

Antigen No. of doses to complete immunization

Wastage allowance

Wastage factor

No. of doses per vial/amp.

DPT 3 40% 1.67 20 or 10

OPV 3 40% 1.67 20

MEASLES 1 50% 2.00 10

BCG 1 60% 2.50 10

Hep. B 3 10% 1.10 1 or 10

TETANUS TOXOID

2 40% 1.67 10 or 20

1. Eligible Population = Total Pop. x 2.7% = 3,000 x 2.7% = 81

2. Annual Vaccine Doses Required = EP x 1 (total # of doses to immunize a child with BCG) x 2.50 (WF of BCG)

= 81 x 1 x 2.50 = 202

3. No. of Annual Vials Required = Annual vaccine dose required = 202 = 20

10 (No. of doses/vial) 10

Vaccines Eligible Pop.

No. of doses / person

Estimated Wastage

Total No. of Doses

Total No. of Vials

Total No. of AD Syringes

Total No. of Mixing Syringes

Total No. of Safety Boxes

(col. A) (col. B) (col. C) (col. D) (col. E) (col. F) (col. G) (col. H) (col. I)

BCG

(10 or 20 dose)

DPT

(10 or 20 dose)

OPV (10 or 20-dose)

Measles (10-dose)

Hepatitis B (10-dose)

TT (10 dose)

LOGISTICS REQUIREMENTSMunicipality/Barangay: _____________________________Total Population: 10,000

Quantity of vaccine that can be used for delayed supplies or sudden increases in demand

Typically 25% of the amount expected to be used during a given supply period

To avoid overstocking, this should be reviewed and adjusted for each order

Should be determined before ordering a new stock

The following should be ensured: Adequate amounts are available Space is available to store the stock Vaccine is used before the expiry date Storage duration is consistent with

recommendation

Health Facility Level Minimum delivery period

National 6 months

Regional 3 months

Provincial/City/Mun. 3 months

Health Center 1 month

Vaccination Post Per session

OPV, DPT, TT and Hepatitis B - may be used in subsequent

sessions for 4 weeks provided the following conditions are met:

1. Expiry date has not passed;2. Vaccines are stored under

appropriate cold chain conditions;

3. Vaccine vial septum has not been submerged in water;

4. Aseptic technique has been used to withdraw all doses;

5. The VVM, if attached, has not reached its discard point

one of the cold chain monitoring tools

a label that changes colour when the vaccine vial has been exposed to

heat over a period of time

DO NOT measure exposure to freezing temperatures (for

freeze- sensitive vaccines)

The vaccine vial monitor says…

The inner square is lighter than the outer

circle. If the expiry date has not passed, USE

At a later time the inner square is still lighter

than the outer circle. If the expiry date has not

passed, USE the vaccine.

Discard point: the colour of the inner square

matches that of the outer circle.

DO NOT use the vaccine.

Beyond the discard point: the inner square is

darker than the outer circle.

DO NOT use the vaccine.

the vaccine.

HOW TO READ A VACCINE VIAL MONITOR

Defined as loss by use, decay, erosion or leakage or through

wastefulness

Vaccine usage – defined as the proportion of vaccine issued

which is administered

Vaccine usage rate =

No. of doses administered x 100

No. of doses supplied

Wastage rate =

Doses supplied - doses admin. x 100 Doses supplied

Wastage rate higher than 20% may indicate problems such as:

1. Repeated instances of lower than planned attendance at session

2. Poor stock management

3. Cold chain failure4. Incorrect mixing of freeze dried

vaccine5. Incorrect dosage6. Failure to comply with multi-dose

vial policy

Vaccine wastage in UNOPENED vials

Vaccine wastage in OPENED vials

Expiry VVM indication Heat exposure Freezing Breakage

Discarding remaining doses at end of session

Not being able to draw the number of doses indicated on the label of a vial

Poor reconstitution practices

Vaccine wastage in UNOPENED vials

Vaccine wastage in OPENED vials

Missing inventoryTheftDiscarding unused

vials returned from an outreach session

Submergence of opened vials in water

Suspected contamination Patient reaction

requiring more than one dose

Ensure compliance on MDVP Use Vaccine Vial Monitor Ensure vital information is recorded when vaccines

are received, stored & distributed Monitor temperature of stored vaccines 2x a day

including weekends and holidays Ensure the Earliest-Expiry-First-Out (EEFO)

principle is maintained except where vaccine is nearing its VVM discard point

Ensure vaccines are transported following standard operating procedure

Ensure a functional contingency plan on cold chain failure exists

Monitor, maintain a routinely repair cold chain equipment

Perform SHAKE TEST

Determines whether DPT, TT or Hep B has been frozen

After freezing, the vaccine is no longer a uniform cloudy liquid. It forms flakes which gradually settle to the bottom

after the vial has been shaken Sedimentations occurs faster in a

previously frozen vaccine vial than a never frozen vaccine from the same manufacturer

Step 1 Prepare a frozen control sample: Take a vial of vaccine of the same type,

batch number and manufacturer as the vaccine you want to test.

Freeze the vial until all the contents are solid ( at least 10 hours at -10°C).

Let it thaw. This vial is the control sample.

Clearly mark the vial so that it cannot later be used by mistake.

Step 2 Choose a test sample: Take a vial of vaccine from the

same batch that you suspect has been frozen. This is the test sample.

Step 3 Shake the control and the test sample: Hold the control sample and the test

sample together in one hand and shake vigorously for 10-15 seconds.

Step 4 Allow to rest: Place the vials on a stable surface

and do not move for 15-30 minutes.

Step 5 Compare the vials:1. View both vials against the light to

compare the sedimentation rate.

2. If the test sample shows a much slower sedimentation rate than the control sample, the test sample is probably potent and may be used.

3. If the sedimentation rate is similar and the test sample contains flakes, the vial under test has probably been damaged and should not be used.

4. Some vials have large labels which conceal the vial contents. This makes it difficult to see the sedimentation process.

In such cases, turn the control and reference test upside down and observe sedimentation taking place in the neck of the vial.

Frozen samples can be used for Shake Tests only when testing the same vaccine from the same manufacturers and the same lot number.

A new sample is needed for each manu-facturer and lot number.

1. Opened vials kept in the “use first” box in the refrigerator (multi-dose vial policy).

2. Unopened vaccine ampoules/vials that have been taken to outreach sessions and have been outside of the refrigerator, then returned (but not opened) to the refrigerator.

3. Vaccines with VVMs that have started to change.

4. The oldest vaccines that have not yet passed their expiry dates.

1. Check the labels of the vaccine and diluent. If the label is not attached, discard the

vial or diluent.

2. Check the expiry date. You must discard vials and diluents if

the expiry date has already passed.

3. Check the vaccine vial monitor (VVM). If it indicates the vaccine has passed the

discard point, you must discard it immediately .

4. Check the freeze indicator in the refrigerator. If it warns of freezing or you suspect that

a freeze-sensitive vaccine has been frozen, you should perform the shake test.

Regular physical check ensures stock records and running balances

are accurate and complete

Count vaccines and diluent stocks and compare to the running

balance in the stock records

Spot check VVM, CCM and freeze indicator status

A safe injection is defined by the WHO as an injection that:

Does not harm the recipient Does not expose the health staff

to any avoidable risks Does not result in waste that is dangerous to the community

Advantages of AD syringes: can only be used once eliminate the patient-to-patient

disease transmission caused by the use of contaminated needles and syringes

save time for health workers from the heavy work of sterilization

WHO — UNICEF — UNFPA joint statement on the use of auto-disable syringes in immunization services.

“The auto-disable syringe which is now widely available at low cost presents the lowest risk of person-to-person transmission of blood-borne pathogens (such as HepB or HIV) because it cannot be reused. The auto-disable syringe is the equipment of choice for administering vaccines, both in routine immunization and mass campaigns.”

Disposable needles and syringe No longer recommended for injections in EPI

Reuse carries a high risk of infections In 1999 WHO, UNICEF, and UNFPA

issued a joint policy statement recommending against their use for immunization

Can be used to reconstitute a vaccine if AD syringe is not available

Do not reuse for reconstitution

Antigen Wastage factorBCG 1.1

DPT 1.1

Measles 1.1

Hepatitis B 1.1

TT 1.1

EXAMPLE: BCG Total Population = 3,000

1. Eligible population (EP)

= 3,000 x 2.7% = 81

2. Annual vaccine dose required

= 81 x 1 x 2.5 = 202

2. Annual AD Syringes

= Annual vaccine dose required x 1.1 (wastage factor) = 202 x 1.1 = 222

Antigen Wastage factor

BCG 1.1

Measles 1.1

EXAMPLE : BCG TP = 3,0001. Eligible population (EP) = 3,000 x 2.7% = 812. Annual vaccine dose required

= 81 x 1 x 2.5 = 2023. Annual no. of vials required = 202/10 = 204. Annual Mixing Syringe = Annual no. of vials required x 1.1 (wf) = 20 x 1.1 = 22

Used sharps must be placed in a safety box and then disposed of in a safe manner

Why is it important to handle sharps waste properly?

Dangers to health Leaving used syringes and needles in the

open or on the ground puts the community at risk

Most frequently, children are the unfortunate victims of needle-stick injuries from haphazard disposal of needles

Why is it important to handle sharps waste properly?

Dangers to the environment throwing in a river spoils the water

used for drinking and washing

All used injection equipment except reusable syringes and needles should be placed in a safety box.

Safety boxes are:

water-proof tamper-proof puncture-resistant

What to do if safety boxes are not available: Use strong cardboard boxes, thick plastic

containers, or metal cans to collect syringes and needles and transport them

to a site where they can be buried or burned.

Do not reuse the same can or container after filling it once.

Destroy the container when it is three- quarters full and find a new container

for your next session.

How to ensure safe handling of the box Don’t handle or shake the safety box

more than necessary. Never squeeze, sit, or stand on safety

boxes. Take extra care when carrying safety

boxes to the disposal site. Hold the box by the top (by the handle provided) above the level of the needles and syringes.

How to ensure safe handling of the box Keep safety boxes in a dry, safe place out

of the reach of the general public, specially children until they have

been safely disposed of. Train everyone who will handle the box how

to do it safely. Do not ask untrained staff to handle the box.

Never put the following material in a safety box. Discard them with other medical waste:

empty vials; discarded vaccine vials; cotton pads; compressors; dressing material; IV bags or extension tubes; latex gloves or any kind of plastic materials

or waste products.

Annual Safety Collector Box Required

= Total annual ADS + Mixing syringe 100*

100* -capacity of 5 liter SCB

Three most recommended methods of disposal of safety boxes filled with used syringes and needles:

Use of septic vault Pit burial Waste treatment and final disposal to

land fill