Making the most of every
immunization contact
Practical considerations for the successful
introduction of Inactivated Polio Vaccine (IPV)
June 2015
Contents
1. What are the WHO recommendations?
2. How to successfully introduce IPV?
3. How to effectively prepare healthcare workers for
IPV introduction?
2
Definitions
Multiple injections: administering three or more injectable vaccines at
the same immunization contact.
Healthcare worker: professional health worker such as nurse,
physician, professional midwife, etc., or can also be a community
health worker or member.
3
Contents
1.What are the WHO recommendations?
2. How to successfully introduce IPV?
3. How to effectively prepare healthcare workers for IPV
introduction?
4
What are the WHO recommendations for IPV?
By 2015
All countries
To add IPV into routine schedules
At, or soon after, 14 weeks of age
Vaccine
schedule
option
# doses
Age at each
dose
Interval between
doses
IPV
1
At 14 weeks,
or soon after
N/A
WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: http://www.who.int/wer/2014/wer8909.pdf?ua=1 (PDF)
5
Considerations when adding IPV to the schedule
WHO recommendations should always inform planning decisions,
considered in the context of other programme factors:
 Other injectable new vaccines at the same visit, e.g. pentavalent,
pneumococcal vaccine (PCV), others.
 Studies of health worker and caregiver attitudes indicating that multiple
injections may affect acceptance of recommended vaccines (e.g. apprehension
about pain or potential side effects). Understanding concerns can inform
communication and training strategies to mitigate.
 Strength of routine services, e.g. if high number of drop outs, optimize existing
earlier contacts to administer vaccines.
7/24/2016
6
What are the WHO recommendations for pneumococcal
conjugate vaccine (PCV)?
Now
All countries
To add PCV into routine schedules
At, or soon after, 6 weeks of age
Vaccine
schedule
options
# doses
Age at each dose
(examples)
Interval between
primary doses
PCV
3+0
6, 10, 14 weeks
2, 4, 6 months
At least 4 weeks
PCV
2+1
6, 14 weeks + 9-12 months
2, 4 months + 9-12 months
At least 8 weeks
WHO recommendations for routine immunization: summary tables (May 2014) http://www.who.int/immunization/policy/immunization_tables/en/
7
What are the WHO recommendations for rotavirus?
Now
All countries
To add rotavirus into routine schedules
At, or soon after, 6 weeks of age
Vaccine
schedule
options
# doses
Age at each dose
(examples)
Interval between
primary doses
Rotarix
2, with DTP
6, 10 weeks
2, 4 months
At least 4 weeks
Rotateq
3, with DTP
6, 10, 14 weeks
2, 4, 6 months
At least 4 weeks
WHO recommendations for routine immunization: summary tables (May 2014) http://www.who.int/immunization/policy/immunization_tables/en/
8
Example of a routine immunization schedule with IPV
 IPV can be co-administered with other vaccines including:
-
OPV, DTP, Hib, hepatitis B, pentavalent, rotavirus or pneumococcal
conjugate vaccines (PCV) 1.
 Co-administration of OPV and IPV has resulted in good immune
responses to all 3 poliovirus types2.
* Some countries use a 2-dose schedule for rotavirus vaccines and a 2+1 schedule for PCV.
1. Global Advisory Committee on Vaccine Safety (GACVS; December 2013). Weekly Epidemiological Record, 14 Feb 2014:
http://www.who.int/wer/2014/wer8907.pdf?ua=1 (PDF)
2. WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: http://www.who.int/wer/2014/wer8909.pdf?ua=1 (PDF)
7/24/2016
9
Safety of IPV
 IPV and IPV-containing
vaccines have an excellent
safety profile1
 When used in combination with
other vaccines, IPV is very safe2
 There is no proven causal
relationship to any adverse
events, other than minor local
redness, induration, and
tenderness
1. Global Advisory Committee on Vaccine Safety (GACVS; December 2013). Weekly Epidemiological Record, 14 Feb 2014:
http://www.who.int/wer/2014/wer8907.pdf?ua=1 (PDF)
2. WHO Polio Position Paper. Weekly Epidemiological Record. January 2014: http://www.who.int/wer/2014/wer8909.pdf?ua=1 (PDF)
10
Many countries have immunization schedules where children
receive three or more injections at one visit
 Several countries (including high and low income) have been using
immunization schedules that require three or more injectable vaccines
at the same contact for over a decade with no problems.
 Data from these countries has reinforced the well-established record of
safety and acceptance of multiple injections at the same visit.
 Studies are underway in some developing countries to compile further
data on the perceptions and acceptance of multiple injections.
- Recent studies in Tanzania and South Africa reported very high rates
of acceptance of multiple injections, despite some expressed
caregiver concerns, demonstrating that concerns can be addressed
with effective communication and immunization practices.
11
Contents
1. What are the WHO recommendations?
2.How to successfully introduce IPV?
3. How to effectively prepare healthcare workers for IPV
introduction?
12
Case study: Successful introduction of IPV in South Africa
The South African immunization schedule is
based on the available evidence and in line
with WHO recommendations.
Since 2009, South Africa has administered
three vaccines per visit, at 6 and 14 weeks.
Successful experience with good coverage
and acceptability.
The country is documenting its experience
to share with others.
Reference (schedule): WHO 2014 monitoring - global summary
http://apps.who.int/immunization_monitoring/globalsummary/
13
Case study: Successful introduction of IPV in Brazil
Brazil’s routine immunization
schedule involves multiple injections.
IPV is given at the 2 and 4 month
contacts, with pentavalent and
pneumococcal vaccines.
Reference (schedule): WHO 2014 monitoring - global summary
http://apps.who.int/immunization_monitoring/globalsummary/
14
Successful introductions of IPV in Brazil and South Africa
How did they achieve this?
 Having communication strategies that educated health workers, community
leaders and professionals about the safety, effectiveness and value of multiple
vaccine injections at the same contact.
 Having messages from health workers to caregivers about:
-
Disadvantages of extra visits and delayed vaccination
The safety of multiple injections
Their efforts to minimize pain
As a result, health workers are able to understand the importance and
address parent or caregiver concerns.
15
Other important lessons from successful introductions
 There has been good acceptance of multiple injections at the same visit
 Multiple injections were well tolerated, and help to avoid extra visits or risks of
delayed vaccination
 When administered correctly, there was only minor discomfort
 Multiple injectable vaccines are not associated with severe or serious adverse
events
 IPV coverage among infants after first year of introduction was high
16
Contents
1. What are the WHO recommendations?
2. How to successfully introduce IPV?
3.How to effectively prepare healthcare
workers for IPV introduction?
17
The critical role of health workers
There are three things that health workers can do to reassure parents or
caregivers:
1. Be knowledgeable of all relevant data, including safety and effectiveness,
and the value of providing multiple vaccines in the same visit
2. Provide clear responses to any caregiver questions using the evidence and
recommendations
3. Administer the vaccines using the recommended technique, taking
necessary steps to minimize pain
18
The critical role of health workers:
Be knowledgeable of all relevant data
Know when to give IPV:
 At 14 weeks or soon after
 If starting the routine schedule late, the IPV dose should be
administered at the first immunization contact
Give IPV with other
life saving vaccines
19
The critical role of health workers:
Provide clear responses
Common questions
Potential answers
“Why does my child need to
receive all of these vaccines
today?”
At this age, children are most vulnerable to polio, diphtheria, whooping cough
(pertussis), Hib and pneumococcal disease. Scientific data indicates that this is
the best time for these vaccines to be given.
“Will my child experience more
pain or discomfort?”
No, the pain or discomfort from vaccination is very brief. Even one injection can
cause pain or discomfort.
However, if you need to come back for other injections, there will be more times
when children will experience pain or discomfort.
We don’t want your child to be unprotected from serious diseases until you
come back.
“Will vaccines given together
be less effective?”
No. These vaccines are equally effective when given alone or with other
vaccines.
“Will my child experience more
or more severe adverse
events?”
No. The scientific data shows that multiple injections do not lead to an increase
in the number or severity of adverse events.
“Can multiple vaccines given at
once “overwhelm” a child’s
immune system?”
No. Every day, children are naturally exposed to many bacteria and viruses on
a daily basis. When given as recommended, vaccines do not add a significant
burden to the immune system, and help the child to be protected.
*United States Institute of Medicine, Adverse Events Associated with Childhood Vaccines, 1994.
**Wheeler M, Buttenheim AM. Parental vaccine concerns, information source, and choice of alternative immunization schedules. Human
vaccines & immunotherapeutics. 2013;9:1782-1789.
20
The critical role of health workers:
Administer the vaccines using the recommended technique
21
How to successfully administer multiple injections?
Pentavalent
(or other)
in the thigh
IPV and PCV
given in the outer
aspect of the
upper thigh.
Injection sites
separated by at
least 2.5 cm -about two fingers
apart.
http://www.who.int/vaccine_safety/initiative/tech_support/Vaccine-safety-E-course-manual.pdf
22
Recommendations for minimizing pain and distress for
intramuscular injections
1. Administer vaccines in order of increasing painfulness
2. Proper positioning: Ask the caregiver to hold the baby in his/her lap
3. Encourage breastfeeding (if feasible and culturally acceptable) during or just
before injection
4. Injection technique:
-
Do not aspirate
-
Push the entire needle in at a 90 degree angle with a
quick, smooth action
-
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.
Gently stretch and support the skin between thumb and
forefinger
Discard syringe immediately in safety box.
23
Summary: Advantages of providing multiple vaccine
injections during the same visit
1. Protecting children when they are at greatest risk of
disease and death: Young infants can be more vulnerable
to severe illness.
2. Fewer vaccination visits: Giving several vaccinations at
the same time means caregivers do not need to make as
many visits to the health center.
3. More effective use of health resources and workers:
Health workers are able to be more efficient in providing and
delivering other health services.
24
Summary: Successful introduction of IPV
1. Several countries have successfully administered
multiple injections during the same contact.
2. Parental concerns about multiple injections can be
addressed through reassurance, clear
communication and pain reducing techniques.
25
Thank you!
26