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Auto-disable (syringes or prefilled injection devices)
AEFI
Adverse Event Following Immunization
AIDS
Acquired immune-deficiency syndrome
BCG
Bacille Calmette-Guérin vaccine that protects against tuberculosis
CRS
Congenital rubella syndrome
CTC
Controlled temperature chain
DOTS
Directly observed treatment schedule for tuberculosis
dT
Diphtheria-tetanus toxoids vaccine with lower concentration of diphtheria toxoid
DT
Diphtheria-tetanus toxoids vaccine
DTP
A combination vaccine containing diphtheria, tetanus toxoid, and pertussis vaccines
DTP+HepB
A combination vaccine containing DTP and hepatitis B vaccines
DTP+HepB+Hib
A combination vaccine containing DTP, HepB and
Haemophilus influenzae
type b vaccines
DTR
Electronic temperature logger
EPI
Expanded Programme on Immunization
GAPPD
Integrated Global Action Plan for Pneumonia and Diarrhoea
HC
Health centre
HepB
Hepatitis B
Hib
Haemophilus influenzae
type b
HIV
Human immunodeficiency virus
HPV
Human papillomavirus
ID
Intradermal
ILR
Ice-lined refrigerators
IM
Intramuscular
IPV
Inactivated polio vaccine
IU
International unit (unit in vitamin A supplements)
JE
Japanese encephalitis
M
Measles only vaccine
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Measles-containing vaccine
Men (as in MenA)
Meningitis
MM
A combination vaccine containing measles and mumps vaccines
MMR
A combination vaccine containing measles, mumps, and rubella vaccines
MMRV
A combination vaccine containing measles, mumps, rubella and varicella vaccines
MNT
Maternal and neonatal tetanus
MR
A combination vaccine containing measles and rubella vaccines
NGO
Nongovernmental organization
NIDs
National Immunization Days (for polio eradication)
OPV
Oral polio vaccine
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PATH
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SC
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TT
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TTCV
Tetanus toxoid-containing vaccine
UNFPA
United Nations Population Fund
UNICEF
United Nations Children’s Fund
USA
United States of America
VAD
Vitamin A deficiency
VAPP
Vaccine associated paralytic polio
VVM
Vaccine vial monitor
WHO
World Health Organization
WPV
Wild polioviruses
YF
Yellow fever
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"text": "Diphtheria is caused by the bacterium Corynebacterium diphtheriae . This bacterium produces a toxin that can harm or destroy human body tissues and organs. One type of diphtheria affects the throat and sometimes the tonsils. Another type, which is more common in the tropics, causes ulcers on the skin.",
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"text": "\n\n\n1.4 What are the complications of diphtheria?\nThe most severe complication of diphtheria is respiratory obstruction followed by death. During the early phase of the illness, or even weeks later, patients may develop abnormal heartbeats that can result in heart failure. Some patients with diphtheria experience inflammation of the heart muscle and valves, and this may lead to chronic heart disease and heart failure.",
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The most severe complication of diphtheria is respiratory obstruction followed by death. During the early phase of the illness, or even weeks later, patients may develop abnormal heartbeats that can result in heart failure. Some patients with diphtheria experience inflammation of the heart muscle and valves, and this may lead to chronic heart disease and heart failure.
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"text": "\n\n\n1.5 What is the treatment for diphtheria?\nChildren who develop diphtheria should be given diphtheria antitoxin and such antibiotics as erythromycin or penicillin. They should be isolated to avoid exposing others to the disease. About two days after starting antibiotic treatment, patients are no longer infectious.\nTarget diseases and vaccines\nTo confirm the diagnosis, health workers should obtain throat cultures from suspected cases. However, treatment should begin urgently without waiting for culture results.",
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Children who develop diphtheria should be given diphtheria antitoxin and such antibiotics as erythromycin or penicillin. They should be isolated to avoid exposing others to the disease. About two days after starting antibiotic treatment, patients are no longer infectious.
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"text": "\n\n\n1.6 How is diphtheria prevented?\nThe most effective way to prevent diphtheria is to maintain a high level of immunization in the community. In most countries, diphtheria vaccine is given in combination with tetanus and pertussis vaccines (DTP). Some countries now use pentavalent vaccine that combines DTP with hepatitis B (HepB) and Haemophilus influenzae type b (Hib) vaccines. Pentavalent (DTP+HepB+Hib) vaccine reduces the number of injections needed for infant immunization. Sections 1.7–1.9 and Table 1.1 below describe diphtheria-containing vaccines.",
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"text": "\n\n\n1.7 What are diphtheria-containing vaccines?\nDiphtheria-containing vaccines include: the combination with tetanus toxoid (DT/ dT); the combination with tetanus and pertussis (DTP); and the combination with tetanus, pertussis, hepatitis B and Haemophilus influenzae type b (pentavalent). They are supplied in single- and multi-dose presentations. Pentavalent vaccine with a freeze-dried (also called lyophilized) Hib component requires reconstitution: see Module 5 ( Managing an immunization session ), Section 4.2 for details. They must be stored between +2 °C and +8 °C without being frozen. Pentavalent vaccine is freeze-sensitive. If freezing is suspected, the “Shake Test” should be performed to determine whether a vial is safe to use (see Module 2 ( The vaccine cold chain ), Section 7). Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).\nDiphtheria-containing vaccines are administered as 0.5 ml doses given intramuscularly in the anterolateral (outer) thigh in infants and in the deltoid muscle (upper arm) of older children and adults.",
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Diphtheria-containing vaccines include: the combination with tetanus toxoid (DT/ dT); the combination with tetanus and pertussis (DTP); and the combination with tetanus, pertussis, hepatitis B and
Haemophilus influenzae
type b (pentavalent). They are supplied in single- and multi-dose presentations. Pentavalent vaccine with a freeze-dried (also called lyophilized) Hib component requires reconstitution: see Module 5 (
Managing an immunization session
), Section 4.2 for details. They must be stored between +2 °C and +8 °C without being frozen. Pentavalent vaccine is freeze-sensitive. If freezing is suspected, the “Shake Test” should be performed to determine whether a vial is safe to use (see Module 2 (
The vaccine cold chain
), Section 7). Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).
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"text": "\n\n\n1.9 When are diphtheria-containing vaccines administered?\nDiphtheria-containing vaccine should be included in infant immunization programmes. A three-dose primary series starting as early as six weeks of age, with an interval of four to six weeks between doses, is generally recommended. Unimmunized children aged one to seven years should receive three doses of DTP with an interval of two months between the first and second doses and an interval of six to 12 months between the second and third doses. For all children over seven years of age and for all adults, including pregnant women, dT should be used since it has a lower concentration of diphtheria toxoid. For unimmunized individuals over seven years of age, two doses of dT one to two months apart followed by a third dose after six to 12 months is recommended. When combined with tetanus vaccine, a total childhood schedule of five doses is required: three in infancy, another (DT) in early childhood (1–6 years) and another (dT) during adolescence (12–15 years). A further dose in adulthood is likely to provide lifelong protection.",
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Diphtheria-containing vaccine should be included in infant immunization programmes. A three-dose primary series starting as early as six weeks of age, with an interval of four to six weeks between doses, is generally recommended.
Unimmunized children aged one to seven years should receive three doses of DTP with an interval of two months between the first and second doses and an interval of six to 12 months between the second and third doses.
For all children over seven years of age and for all adults, including pregnant women, dT should be used since it has a lower concentration of diphtheria toxoid. For unimmunized individuals over seven years of age, two doses of dT one to two months apart followed by a third dose after six to 12 months is recommended.
When combined with tetanus vaccine, a total childhood schedule of five doses is required: three in infancy, another (DT) in early childhood (1–6 years) and another (dT) during adolescence (12–15 years). A further dose in adulthood is likely to provide lifelong protection.
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"text": "\n DESCRIPTION:\n Le vaccin contre la diphtérie, à base d'anatoxine, nécessite 3 à 5 doses selon l'âge et le statut vaccinal.\n :TABLE DATA:\n Table 1.1 Diphtheria-containing vaccine summary Type of vaccine Toxoid Total number of doses 3–5 – see schedules Schedule – Pentavalent or DTP for infants For infant immunization doses: pentavalent1/DTP1 starting at age 6 weeks (minimum) with pentavalent2/DTP2 and pentavalent3/DTP3 at intervals of 4 weeks (minimum) to 8 weeks after the previous dose Schedule – DTP for unimmunized ages 1–7 years For children aged 1–7 years who have not previously been immunized: 3 doses of DTP with an interval of 2 months between the first and second doses and an interval of 6–12 months between the second and third doses Schedule – dT for unimmunized ages over 7 years For previously unimmunized individuals 7 years of age and older: dT1 and dT2 should be given 1–2 months apart, and dT3 given 6–12 months after dT2 Booster When combined with tetanus vaccine, a total childhood schedule of 5 doses (3 in infancy), another (DT) in early childhood (1–6 years), and another (dT) during adolescence (12–15 years) is required. A further dose in adulthood is likely to provide lifelong protection. Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe adverse events due to diphtheria toxoid alone have not been reported Mild: injection site reactions, fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.1 Diphtheria-containing vaccine summary Type of vaccine Toxoid Total number of doses 3–5 – see schedules Schedule – Pentavalent or DTP for infants For infant immunization doses: pentavalent1/DTP1 starting at age 6 weeks (minimum) with pentavalent2/DTP2 and pentavalent3/DTP3 at intervals of 4 weeks (minimum) to 8 weeks after the previous dose Schedule – DTP for unimmunized ages 1–7 years For children aged 1–7 years who have not previously been immunized: 3 doses of DTP with an interval of 2 months between the first and second doses and an interval of 6–12 months between the second and third doses Schedule – dT for unimmunized ages over 7 years For previously unimmunized individuals 7 years of age and older: dT1 and dT2 should be given 1–2 months apart, and dT3 given 6–12 months after dT2 Booster When combined with tetanus vaccine, a total childhood schedule of 5 doses (3 in infancy), another (DT) in early childhood (1–6 years), and another (dT) during adolescence (12–15 years) is required. A further dose in adulthood is likely to provide lifelong protection. Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe adverse events due to diphtheria toxoid alone have not been reported Mild: injection site reactions, fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.1 Diphtheria-containing vaccine summary
Type of vaccine
Toxoid
Total number of doses
3–5 – see schedules
Schedule – Pentavalent or DTP for infants
For infant immunization doses:
pentavalent1/DTP1 starting at age 6 weeks (minimum) with pentavalent2/DTP2 and pentavalent3/DTP3 at intervals of 4 weeks (minimum) to 8 weeks after the previous dose
Schedule – DTP for unimmunized ages 1–7 years
For children aged 1–7 years who have not previously been immunized:
3 doses of DTP with an interval of 2 months between the first and second doses and an interval of 6–12 months between the second and third doses
Schedule – dT for unimmunized ages over 7 years
For previously unimmunized individuals 7 years of age and older:
dT1 and dT2 should be given 1–2 months apart, and dT3 given 6–12 months after dT2
Booster
When combined with tetanus vaccine, a total childhood schedule of 5 doses (3 in infancy), another (DT) in early childhood (1–6 years), and another (dT) during adolescence (12–15 years) is required. A further dose in adulthood is likely to provide lifelong protection.
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe adverse events due to diphtheria toxoid alone have not been reported
Mild: injection site reactions, fever
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
pentavalent1/DTP1 starting at age 6 weeks (minimum) with pentavalent2/DTP2 and pentavalent3/DTP3 at intervals of 4 weeks (minimum) to 8 weeks after the previous dose
Schedule – DTP for unimmunized ages 1–7 years
For children aged 1–7 years who have not previously been immunized:
3 doses of DTP with an interval of 2 months between the first and second doses and an interval of 6–12 months between the second and third doses
Schedule – dT for unimmunized ages over 7 years
For previously unimmunized individuals 7 years of age and older:
dT1 and dT2 should be given 1–2 months apart, and dT3 given 6–12 months after dT2
Booster
When combined with tetanus vaccine, a total childhood schedule of 5 doses (3 in infancy), another (DT) in early childhood (1–6 years), and another (dT) during adolescence (12–15 years) is required. A further dose in adulthood is likely to provide lifelong protection.
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe adverse events due to diphtheria toxoid alone have not been reported
Mild: injection site reactions, fever
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
Do not freeze
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"text": "\n\n\nKey points about diphtheria\nDiphtheria is spread from person to person in airborne droplets. Symptoms of the disease include sore throat, loss of appetite and mild fever. Patients with the disease can experience complications, such as abnormal heartbeat and inflammation of the heart muscle and valves, and this can lead to heart failure. Children with diphtheria should be treated with diphtheria antitoxin and antibiotics. The most effective way to prevent the disease is to maintain a high level of immunization within a community.\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.1 Diphtheria-containing vaccine summary Type of vaccine Toxoid Total number of doses 3–5 – see schedules Schedule – Pentavalent or DTP for infants For infant immunization doses: pentavalent1/DTP1 starting at age 6 weeks (minimum) with pentavalent2/DTP2 and pentavalent3/DTP3 at intervals of 4 weeks (minimum) to 8 weeks after the previous dose Schedule – DTP for unimmunized ages 1–7 years For children aged 1–7 years who have not previously been immunized: 3 doses of DTP with an interval of 2 months between the first and second doses and an interval of 6–12 months between the second and third doses Schedule – dT for unimmunized ages over 7 years For previously unimmunized individuals 7 years of age and older: dT1 and dT2 should be given 1–2 months apart, and dT3 given 6–12 months after dT2 Booster When combined with tetanus vaccine, a total childhood schedule of 5 doses (3 in infancy), another (DT) in early childhood (1–6 years), and another (dT) during adolescence (12–15 years) is required. A further dose in adulthood is likely to provide lifelong protection. Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe adverse events due to diphtheria toxoid alone have not been reported Mild: injection site reactions, fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Diphtheria is spread from person to person in airborne droplets.
Symptoms of the disease include sore throat, loss of appetite and mild fever.
Patients with the disease can experience complications, such as abnormal heartbeat and inflammation of the heart muscle and valves, and this can lead to heart failure.
Children with diphtheria should be treated with diphtheria antitoxin and antibiotics.
The most effective way to prevent the disease is to maintain a high level of immunization within a community.
pentavalent1/DTP1 starting at age 6 weeks (minimum) with pentavalent2/DTP2 and pentavalent3/DTP3 at intervals of 4 weeks (minimum) to 8 weeks after the previous dose
Schedule – DTP for unimmunized ages 1–7 years
For children aged 1–7 years who have not previously been immunized:
3 doses of DTP with an interval of 2 months between the first and second doses and an interval of 6–12 months between the second and third doses
Schedule – dT for unimmunized ages over 7 years
For previously unimmunized individuals 7 years of age and older:
dT1 and dT2 should be given 1–2 months apart, and dT3 given 6–12 months after dT2
Booster
When combined with tetanus vaccine, a total childhood schedule of 5 doses (3 in infancy), another (DT) in early childhood (1–6 years), and another (dT) during adolescence (12–15 years) is required. A further dose in adulthood is likely to provide lifelong protection.
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe adverse events due to diphtheria toxoid alone have not been reported
Mild: injection site reactions, fever
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
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"text": "\n\n\n2.8 What are Hib-containing vaccines?\nHib-containing vaccines prevent pneumonia, meningitis, epiglottitis, septicaemia and other Hib disease. They do not protect against other types of Haemophilus influenzae or other bacteria that cause similar diseases.\nHib-containing vaccines are available in stand-alone and combination forms. Hib combined with DTP and HepB vaccines, or pentavalent vaccine (DTP+HepB+Hib), reduces the number of injections an infant has to receive while completing the recommended immunization schedule.\nHib-containing vaccines are supplied in liquid or freeze-dried powder (also called lyophilized) formulations in single- and multi-dose presentations. Pentavalent vaccine is available in two- and 10-dose vials. Pentavalent vaccine with a freeze-dried Hib component requires reconstitution: see Module 5 ( Managing an immunization session ), Section 4.2 for details. The diluent for pentavalent vaccine is the DTP+HepB component. Hib-containing vaccines must be stored between +2 °C and +8 °C without being frozen. Freezing does not damage stand-alone freeze-dried Hib vaccine but does damage liquid Hib and pentavalent vaccines. If freezing is suspected, the Shake Test should be performed to determine whether a vial is safe to use (see Module 2 ( The vaccine cold chain ), Section 7). Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).\nModule 1: Target diseases and vaccines\nFor infants, Hib-containing vaccines are administered as 0.5 ml doses in the anterolateral (outer) thigh. For older children (12–24 months of age), they may be given in the deltoid muscle (upper arm).",
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Hib-containing vaccines prevent pneumonia, meningitis, epiglottitis, septicaemia and other Hib disease. They do not protect against other types of
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Hib-containing vaccines are available in stand-alone and combination forms. Hib combined with DTP and HepB vaccines, or pentavalent vaccine (DTP+HepB+Hib), reduces the number of injections an infant has to receive while completing the recommended immunization schedule.
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"text": "Hib-containing vaccines are supplied in liquid or freeze-dried powder (also called lyophilized) formulations in single- and multi-dose presentations. Pentavalent vaccine is available in two- and 10-dose vials. Pentavalent vaccine with a freeze-dried Hib component requires reconstitution: see Module 5 ( Managing an immunization session ), Section 4.2 for details. The diluent for pentavalent vaccine is the DTP+HepB component. Hib-containing vaccines must be stored between +2 °C and +8 °C without being frozen. Freezing does not damage stand-alone freeze-dried Hib vaccine but does damage liquid Hib and pentavalent vaccines. If freezing is suspected, the Shake Test should be performed to determine whether a vial is safe to use (see Module 2 ( The vaccine cold chain ), Section 7). Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).",
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Hib-containing vaccines are supplied in liquid or freeze-dried powder (also called lyophilized) formulations in single- and multi-dose presentations. Pentavalent vaccine is available in two- and 10-dose vials. Pentavalent vaccine with a freeze-dried Hib component requires reconstitution: see Module 5 (
Managing an immunization session
), Section 4.2 for details. The diluent for pentavalent vaccine is the DTP+HepB component. Hib-containing vaccines must be stored between +2 °C and +8 °C without being frozen. Freezing does not damage stand-alone freeze-dried Hib vaccine but does damage liquid Hib and pentavalent vaccines. If freezing is suspected, the Shake Test should be performed to determine whether a vial is safe to use (see Module 2 (
The vaccine cold chain
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For infants, Hib-containing vaccines are administered as 0.5 ml doses in the anterolateral (outer) thigh. For older children (12–24 months of age), they may be given in the deltoid muscle (upper arm).
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"text": "\n\n\n2.9 How safe is Hib vaccine and what are the potential adverse events following immunization?\nHib vaccine is one of the safest vaccines in current use. There are no known serious adverse events to date. Mild events include injection site pain, redness or swelling in approximately 10% of recipients and fever in 2%.\nWHO safety information summaries for Hib and combination vaccines are on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/ .",
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2.9 How safe is Hib vaccine and what are the potential adverse events following immunization?
Hib vaccine is one of the safest vaccines in current use. There are no known serious adverse events to date. Mild events include injection site pain, redness or swelling in approximately 10% of recipients and fever in 2%.
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"text": "\n\n\n2.10 When is Hib-containing vaccine administered?\nSince serious Hib disease occurs mainly before 24 months of age, and infants are most at risk at between four and 18 months of age, Hib-containing vaccines should be included in all infant immunization schedules. Any of three schedules may be followed: three primary doses without a booster (3p+0), two primary doses plus a booster (2p+1), and three primary doses with a booster (3p+1). The series should start from six weeks of age, or as early as possible thereafter. The interval between doses should be at least four weeks if three primary doses are given, and at least eight weeks if two primary doses are given. When given, the booster dose should be given at least six months after completion of the primary series. Children who start vaccination late, but are aged less than 12 months, should complete the schedule. When a first dose is given to a child over 12 months of age, only one dose is recommended. Hib vaccine is not required for healthy children after five years of age.",
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"text": "Since serious Hib disease occurs mainly before 24 months of age, and infants are most at risk at between four and 18 months of age, Hib-containing vaccines should be included in all infant immunization schedules. Any of three schedules may be followed: three primary doses without a booster (3p+0), two primary doses plus a booster (2p+1), and three primary doses with a booster (3p+1). The series should start from six weeks of age, or as early as possible thereafter. The interval between doses should be at least four weeks if three primary doses are given, and at least eight weeks if two primary doses are given. When given, the booster dose should be given at least six months after completion of the primary series. Children who start vaccination late, but are aged less than 12 months, should complete the schedule. When a first dose is given to a child over 12 months of age, only one dose is recommended. Hib vaccine is not required for healthy children after five years of age.",
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"text": "\n DESCRIPTION:\n Le tableau résume la vaccination Hib (conjugée, 3 doses) : schémas, contre-indications, effets indésirables, précautions, dosage, injection et stockage.\n :TABLE DATA:\n Table 1.2 Hib-containing vaccines (Hib, pentavalent (DTP+HepB+Hib) summary Type of vaccine Conjugate (capsular polysaccharide bound to a carrier protein) Number of doses 3 Schedules Given as pentavalent, or as a separate injection at the same time as DTP from age 6 weeks 3p+0: 3 primary doses given at minimum intervals of 4 weeks 2p+1: 2 primary doses given at minimum intervals of 8 weeks and booster given at least 6 months after 2nd primary dose 3p+1: 3 primary doses given at minimum intervals of 4 weeks and booster given at least 6 months after 3rd primary dose Children >12 months of age without a primary series may be given a single dose Booster As above Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: none reported to date Mild: injection site reactions, fever Special precautions For pentavalent: do not use pentavalent vaccine to provide a birth dose of hepatitis B vaccine Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.2 Hib-containing vaccines (Hib, pentavalent (DTP+HepB+Hib) summary Type of vaccine Conjugate (capsular polysaccharide bound to a carrier protein) Number of doses 3 Schedules Given as pentavalent, or as a separate injection at the same time as DTP from age 6 weeks 3p+0: 3 primary doses given at minimum intervals of 4 weeks 2p+1: 2 primary doses given at minimum intervals of 8 weeks and booster given at least 6 months after 2nd primary dose 3p+1: 3 primary doses given at minimum intervals of 4 weeks and booster given at least 6 months after 3rd primary dose Children >12 months of age without a primary series may be given a single dose Booster As above Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: none reported to date Mild: injection site reactions, fever Special precautions For pentavalent: do not use pentavalent vaccine to provide a birth dose of hepatitis B vaccine Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Conjugate (capsular polysaccharide bound to a carrier protein)
Number of doses
3
Schedules
Given as pentavalent, or as a separate injection at the same time as DTP from age 6 weeks
3p+0: 3 primary doses given at minimum intervals of 4 weeks
2p+1: 2 primary doses given at minimum intervals of 8 weeks and booster given at least 6 months after 2nd primary dose
3p+1: 3 primary doses given at minimum intervals of 4 weeks and booster given at least 6 months after 3rd primary dose
Children >12 months of age without a primary series may be given a single dose
Booster
As above
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe: none reported to date
Mild: injection site reactions, fever
Special precautions
For pentavalent: do not use pentavalent vaccine to provide a birth dose of hepatitis B vaccine
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
Do not freeze
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"text": "\n\n\nKey points about Hib disease\nHib disease primarily affects children under two years of age in developing countries. Healthy carriers as well as sick patients can spread Hib. Hib disease can affect different parts of the body. The most frequently seen serious diseases are pneumonia and meningitis. Hib conjugate vaccine protects only against the type b strain. The type b strain is found in 90% of serious Haemophilus influenzae cases. Hib vaccination should be given in infancy as part of a comprehensive package to reduce childhood pneumonia (see Section 19 of this module).\nTarget diseases and vaccines\n :TABLE DATA: \nTable 1.2 Hib-containing vaccines (Hib, pentavalent (DTP+HepB+Hib) summary Type of vaccine Conjugate (capsular polysaccharide bound to a carrier protein) Number of doses 3 Schedules Given as pentavalent, or as a separate injection at the same time as DTP from age 6 weeks 3p+0: 3 primary doses given at minimum intervals of 4 weeks 2p+1: 2 primary doses given at minimum intervals of 8 weeks and booster given at least 6 months after 2nd primary dose 3p+1: 3 primary doses given at minimum intervals of 4 weeks and booster given at least 6 months after 3rd primary dose Children >12 months of age without a primary series may be given a single dose Booster As above Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: none reported to date Mild: injection site reactions, fever Special precautions For pentavalent: do not use pentavalent vaccine to provide a birth dose of hepatitis B vaccine Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Hib disease primarily affects children under two years of age in developing countries.
Healthy carriers as well as sick patients can spread Hib.
Hib disease can affect different parts of the body. The most frequently seen serious diseases are pneumonia and meningitis.
Hib conjugate vaccine protects only against the type b strain. The type b strain is found in 90% of serious
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"text": "Table 1.2 Hib-containing vaccines (Hib, pentavalent (DTP+HepB+Hib) summary Type of vaccine Conjugate (capsular polysaccharide bound to a carrier protein) Number of doses 3 Schedules Given as pentavalent, or as a separate injection at the same time as DTP from age 6 weeks 3p+0: 3 primary doses given at minimum intervals of 4 weeks 2p+1: 2 primary doses given at minimum intervals of 8 weeks and booster given at least 6 months after 2nd primary dose 3p+1: 3 primary doses given at minimum intervals of 4 weeks and booster given at least 6 months after 3rd primary dose Children >12 months of age without a primary series may be given a single dose Booster As above Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: none reported to date Mild: injection site reactions, fever Special precautions For pentavalent: do not use pentavalent vaccine to provide a birth dose of hepatitis B vaccine Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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"text": "\n\n\n3.1 What is hepatitis B?\nHepatitis B is caused by a virus that infects the liver. Among adults who get hepatitis B, 90% recover completely. But among infants infected during birth or before one year of age, 90% develop chronic disease. Approximately 780,000 people die each year due to the consequences of hepatitis B such as cirrhosis or liver cancer.",
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Hepatitis B can be prevented by immunization. Since perinatal (around the time of birth) or postnatal (during the early days of life) transmission is an important cause of chronic infections globally, all infants should receive their first dose of HepB as soon as possible (less than 24 hours) after birth even in low-endemicity countries. After the birth dose, HepB vaccine should be administered with DTP and Hib, preferably in the form of pentavalent (DTP+HepB+Hib) vaccine. Sections 3.7–3.9 and Table 1.3 below describe HepB-containing vaccines.
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HepB vaccine has an excellent safety profile. Severe adverse events include anaphylaxis, which has been reported in about one per million vaccine doses administered. Mild events include injection site pain in 3–29% of those vaccinated, redness or swelling in about 3%, headache in about 3% and fever in 1–6%.
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A WHO safety information summary for hepatitis B vaccine is available on the website:
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"text": "\n\n\n3.9 When are HepB-containing vaccines administered?\nAll infants should receive HepB vaccine at birth, preferably within the first 24 hours. Only stand-alone HepB vaccine can be used for the birth dose. It can be given with BCG vaccine. HepB combinations such as pentavalent vaccine are recommended for subsequent doses. Two additional doses can be given in the form of pentavalent1 and 3. Alternatively, three additional doses can be given in the form of pentavalent1, 2 and 3. There should be a minimum interval of four weeks between doses. HepB vaccine may also be used for older age groups at risk of infection, including patients who require frequent transfusions, dialysis patients, injecting drug users, household members and sexual contacts of known chronic hepatitis B patients, and health care workers.",
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All infants should receive HepB vaccine at birth, preferably within the first 24 hours. Only stand-alone HepB vaccine can be used for the birth dose. It can be given with BCG vaccine. HepB combinations such as pentavalent vaccine are recommended for subsequent doses. Two additional doses can be given in the form of pentavalent1 and 3. Alternatively, three additional doses can be given in the form of pentavalent1, 2 and 3. There should be a minimum interval of four weeks between doses.
HepB vaccine may also be used for older age groups at risk of infection, including patients who require frequent transfusions, dialysis patients, injecting drug users, household members and sexual contacts of known chronic hepatitis B patients, and health care workers.
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"text": "\n DESCRIPTION:\n Ce tableau résume le vaccin contre l'hépatite B, incluant le nombre de doses, le calendrier vaccinal, les contre-indications et les effets secondaires.\n :TABLE DATA:\n Table 1.3 HepB-containing vaccine summary Type of vaccine Recombinant DNA or plasma-derived Total number of doses 3 or 4 (including birth dose) Schedule – HepB birth dose followed by pentavalent 3-dose primary series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent3 4-dose primary series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent2, pentavalent3 Minimum interval of 4 weeks between doses required for both series For the pentavalent schedule, see Table 1.2: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose Booster None Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: rare anaphylaxis Mild: injection site reactions (pain, redness, swelling); headache; fever Special precautions Use only stand-alone HepB vaccine for the birth dose (do not use pentavalent vaccine for the birth dose) Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.3 HepB-containing vaccine summary Type of vaccine Recombinant DNA or plasma-derived Total number of doses 3 or 4 (including birth dose) Schedule – HepB birth dose followed by pentavalent 3-dose primary series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent3 4-dose primary series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent2, pentavalent3 Minimum interval of 4 weeks between doses required for both series For the pentavalent schedule, see Table 1.2: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose Booster None Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: rare anaphylaxis Mild: injection site reactions (pain, redness, swelling); headache; fever Special precautions Use only stand-alone HepB vaccine for the birth dose (do not use pentavalent vaccine for the birth dose) Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.3 HepB-containing vaccine summary
Type of vaccine
Recombinant DNA or plasma-derived
Total number of doses
3 or 4 (including birth dose)
Schedule – HepB birth dose followed by pentavalent
3-dose primary
series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent3
4-dose primary
series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent2, pentavalent3
Minimum interval of 4 weeks between doses required for both series
For the pentavalent schedule, see Table 1.2: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose
Booster
None
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe: rare anaphylaxis
Mild: injection site reactions (pain, redness, swelling); headache; fever
Special precautions
Use only stand-alone HepB vaccine for the birth dose (do not use pentavalent vaccine for the birth dose)
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
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3-dose primary
series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent3
4-dose primary
series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent2, pentavalent3
Minimum interval of 4 weeks between doses required for both series
For the pentavalent schedule, see Table 1.2: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose
Booster
None
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe: rare anaphylaxis
Mild: injection site reactions (pain, redness, swelling); headache; fever
Special precautions
Use only stand-alone HepB vaccine for the birth dose (do not use pentavalent vaccine for the birth dose)
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
Do not freeze
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"text": "\n\n\nKey points about hepatitis B\n➢ 90% of infants infected develop chronic disease while 90% of healthy adults infected recover completely. Early vaccination at birth is important. ➢ The hepatitis B virus is spread through contact with blood or other body fluids from an infected person. It is 50 to 100 times more infectious than HIV. ➢ Chronic hepatitis B infection leads to cirrhosis, liver cancer, liver failure and death. ➢ All children should receive stand-alone hepatitis B vaccine at birth followed by two to three doses given with the DTP and Hib schedule, preferably as pentavalent vaccine.\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.3 HepB-containing vaccine summary Type of vaccine Recombinant DNA or plasma-derived Total number of doses 3 or 4 (including birth dose) Schedule – HepB birth dose followed by pentavalent 3-dose primary series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent3 4-dose primary series: stand-alone HepB as soon as possible after birth (<24h), pentavalent1, pentavalent2, pentavalent3 Minimum interval of 4 weeks between doses required for both series For the pentavalent schedule, see Table 1.2: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose Booster None Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: rare anaphylaxis Mild: injection site reactions (pain, redness, swelling); headache; fever Special precautions Use only stand-alone HepB vaccine for the birth dose (do not use pentavalent vaccine for the birth dose) Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants Deltoid muscle of upper arm in older children and adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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➢ 90% of infants infected develop chronic disease while 90% of healthy adults infected recover completely. Early vaccination at birth is important.
➢ The hepatitis B virus is spread through contact with blood or other body fluids from an infected person. It is 50 to 100 times more infectious than HIV.
➢ Chronic hepatitis B infection leads to cirrhosis, liver cancer, liver failure and death.
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4 Human papillomavirus infection and cervical cancer
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"text": "\n\n\n4.1 What is human papillomavirus?\nHuman papillomavirus (HPV) is a common sexually transmitted virus that causes genital warts and various cancers. There are more than 100 types of HPV. Some types cause only genital warts, but at least 13 different types cause cancer. While HPV does cause cancer of the anus, external genitalia and oral cavity in both sexes, it is of particular concern in women since it is now known to be the cause of 99% of cervical cancers. Cervical cancer is the leading cause of cancer death in adult women in the developing world and the second most common cancer among women worldwide. Approximately 85% of these deaths occur in developing countries.",
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"text": "Human papillomavirus (HPV) is a common sexually transmitted virus that causes genital warts and various cancers. There are more than 100 types of HPV. Some types cause only genital warts, but at least 13 different types cause cancer. While HPV does cause cancer of the anus, external genitalia and oral cavity in both sexes, it is of particular concern in women since it is now known to be the cause of 99% of cervical cancers. Cervical cancer is the leading cause of cancer death in adult women in the developing world and the second most common cancer among women worldwide. Approximately 85% of these deaths occur in developing countries.",
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Human papillomavirus (HPV) is a common sexually transmitted virus that causes genital warts and various cancers. There are more than 100 types of HPV. Some types cause only genital warts, but at least 13 different types cause cancer. While HPV does cause cancer of the anus, external genitalia and oral cavity in both sexes, it is of particular concern in women since it is now known to be the cause of 99% of cervical cancers.
Cervical cancer is the leading cause of cancer death in adult women in the developing world and the second most common cancer among women worldwide. Approximately 85% of these deaths occur in developing countries.
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Most HPV infections do not cause symptoms or disease and usually clear within a few months. About 90% of infections clear within two years, but some infections continue. Infection that continues can progress to cervical cancer with specific types of HPV (particularly types 16 and 18). This progression takes 20 years on average and tends to cause symptoms only after the cancer has reached an advanced stage.
Symptoms and signs of cervical cancer include abnormal vaginal bleeding (after sexual intercourse and/or between menstrual periods); pelvic, back and/or leg pain; vaginal discharge; fatigue and weight loss. Anaemia, renal failure and fistulae can also occur in advanced stages of cervical cancer.
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"text": "\n\n\n4.4 What is the treatment for cervical cancer?\nA comprehensive approach should be taken to prevent cervical cancer as described in Section 4.5. If cervical cancer is caught early by screening methods such as the Papanicolaou smear (Pap smear), HPV-DNA tests and/or visual inspection with acetic acid, then it can be\nTarget diseases and vaccines\nremoved and cured effectively with localized treatment (e.g. cryotherapy). Treatment of advanced cancer is complicated and usually involves combinations of surgery, radiotherapy and chemotherapy.",
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A comprehensive approach should be taken to prevent cervical cancer as described in Section 4.5.
If cervical cancer is caught early by screening methods such as the Papanicolaou smear (Pap smear), HPV-DNA tests and/or visual inspection with acetic acid, then it can be
removed and cured effectively with localized treatment (e.g. cryotherapy). Treatment of advanced cancer is complicated and usually involves combinations of surgery, radiotherapy and chemotherapy.
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"text": "\n\n\n4.5 What can be done to prevent and control cervical cancer?\nComprehensive cervical cancer prevention and control consists of: a) primary prevention by vaccination against HPV infection for girls nine to 13 years of age and, for both girls and boys, health education warning against tobacco use, sexuality education and promotion of condom use, and male circumcision; b) secondary prevention in women aged 30–49 years with a screen and treat approach, since vaccination does not protect against all cancer-causing HPV types; and c) tertiary prevention by treatment of invasive cancer at any age. Currently available HPV vaccines can prevent infection with the two HPV types, 16 and 18, which are known to cause 70% of cervical cancers. This is important particularly in countries that lack resources for effective screening programmes. Screening by Pap smear, HPV-DNA or visual inspection with acetic acid is recommended at least once for women between 30 and 49 years of age even after vaccination, since cervical cancer related to other HPV types may still occur. Condom use can also reduce the risk of infection with HPV. For an HIV-positive woman, screening should start when the HIV diagnosis is confirmed, regardless of her age. HPV vaccines should be introduced as part of a coordinated strategy to prevent cervical cancer. HPV vaccination of males is not recommended as a priority, especially in resource-constrained settings. The available evidence indicates that the first priority should be for cervical cancer reduction by timely and high-coverage vaccination of young females. Sections 4.6–4.8 and Table 1.4 describe available HPV vaccines.",
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"text": "Comprehensive cervical cancer prevention and control consists of: a) primary prevention by vaccination against HPV infection for girls nine to 13 years of age and, for both girls and boys, health education warning against tobacco use, sexuality education and promotion of condom use, and male circumcision; b) secondary prevention in women aged 30–49 years with a screen and treat approach, since vaccination does not protect against all cancer-causing HPV types; and c) tertiary prevention by treatment of invasive cancer at any age. Currently available HPV vaccines can prevent infection with the two HPV types, 16 and 18, which are known to cause 70% of cervical cancers. This is important particularly in countries that lack resources for effective screening programmes. Screening by Pap smear, HPV-DNA or visual inspection with acetic acid is recommended at least once for women between 30 and 49 years of age even after vaccination, since cervical cancer related to other HPV types may still occur. Condom use can also reduce the risk of infection with HPV. For an HIV-positive woman, screening should start when the HIV diagnosis is confirmed, regardless of her age. HPV vaccines should be introduced as part of a coordinated strategy to prevent cervical cancer. HPV vaccination of males is not recommended as a priority, especially in resource-constrained settings. The available evidence indicates that the first priority should be for cervical cancer reduction by timely and high-coverage vaccination of young females. Sections 4.6–4.8 and Table 1.4 describe available HPV vaccines.",
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Comprehensive cervical cancer prevention and control consists of: a) primary prevention by vaccination against HPV infection for girls nine to 13 years of age and, for both girls and boys, health education warning against tobacco use, sexuality education and promotion of condom use, and male circumcision; b) secondary prevention in women aged 30–49 years with a screen and treat approach, since vaccination does not protect against all cancer-causing HPV types; and c) tertiary prevention by treatment of invasive cancer at any age.
Currently available HPV vaccines can prevent infection with the two HPV types, 16 and 18, which are known to cause 70% of cervical cancers. This is important particularly in countries that lack resources for effective screening programmes. Screening by Pap smear, HPV-DNA or visual inspection with acetic acid is recommended at least once for women between 30 and 49 years of age even after vaccination, since cervical cancer related to other HPV types may still occur. Condom use can also reduce the risk of infection with HPV. For an HIV-positive woman, screening should start when the HIV diagnosis is confirmed, regardless of her age.
HPV vaccines should be introduced as part of a coordinated strategy to prevent cervical cancer.
HPV vaccination of males is not recommended as a priority, especially in resource-constrained settings. The available evidence indicates that the first priority should be for cervical cancer reduction by timely and high-coverage vaccination of young females.
Sections 4.6–4.8 and Table 1.4 describe available HPV vaccines.
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"text": "\n\n\n4.6 What is HPV vaccine?\nTwo HPV vaccines are currently available worldwide: a bivalent vaccine, Cervarix®, which protects against HPV types 16 and 18, and a quadrivalent vaccine, Gardasil®, which protects against four HPV types (6 and 11 (which cause genital warts), and 16 and 18). Both are available in single-use vials or prefilled syringes. The bivalent HPV vaccine (Cervarix®) also comes in two-dose vials. These vaccines do not require reconstitution. They must be stored between +2 °C and +8 °C. Opened multi-dose vials must be handled according to national policy (see Module 2, Section 5 for WHO multi-dose vial policy). Both vaccines are administered intramuscularly in two or three separate 0.5 ml doses.\nModule 1: Target diseases and vaccines",
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Two HPV vaccines are currently available worldwide: a bivalent vaccine, Cervarix®, which protects against HPV types 16 and 18, and a quadrivalent vaccine, Gardasil®, which protects against four HPV types (6 and 11 (which cause genital warts), and 16 and 18). Both are available in single-use vials or prefilled syringes. The bivalent HPV vaccine (Cervarix®) also comes in two-dose vials. These vaccines do not require reconstitution. They must be stored between +2 °C and +8 °C. Opened multi-dose vials must be handled according to national policy (see Module 2, Section 5 for WHO multi-dose vial policy).
Both vaccines are administered intramuscularly in two or three separate 0.5 ml doses.
4.7 How safe is HPV vaccine and what are the potential adverse events following immunization?
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"text": "Both HPV vaccines are well tolerated and have excellent safety profiles. Serious events include rare anaphylaxis with quadrivalent vaccine (1.7–2.6 per million doses). Mild events include local injection site reactions (pain, redness and swelling). These usually resolve without treatment. Other mild events reported following HPV vaccination include fever, dizziness and nausea. Adolescents are known to sometimes faint after any injection and should be seated during vaccination and for at least 15 minutes afterwards. WHO safety information summary for HPV vaccines is available on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/.",
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Both HPV vaccines are well tolerated and have excellent safety profiles. Serious events include rare anaphylaxis with quadrivalent vaccine (1.7–2.6 per million doses). Mild events include local injection site reactions (pain, redness and swelling). These usually resolve without treatment. Other mild events reported following HPV vaccination include fever, dizziness and nausea. Adolescents are known to sometimes faint after any injection and should be seated during vaccination and for at least 15 minutes afterwards.
WHO safety information summary for HPV vaccines is available on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/.
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"text": "\n\n\n4.8 When is HPV vaccine administered?\nThe recommended target population for the prevention of cervical cancer is females aged nine to 13 years, prior to becoming sexually active. For females younger than 15 years, a two-dose schedule with an interval of six months is recommended. Even those females who are over 15 years at the time of the second dose are adequately protected by two doses. There is no maximum recommended interval between doses. However, an interval of no greater than 12–15 months is suggested in order to complete the schedule promptly and before the start of sexual activity. If the interval between the two doses is less than five months, a third dose should be given at least six months after the first dose. For females over 15 years of age, or who are known to have a compromised immune system (that does not respond normally) and/or are HIV-infected, a three-dose schedule (at 0, 1 or 2 and 6 months) is recommended. HPV vaccines can be delivered through a healthcare facility-based strategy, or a school- and/or other community-based outreach service. If a girl gets pregnant before she has been fully immunized, the remaining dose(s) should be postponed since it is not licensed for use in pregnancy. To date, no health problems for mother or child have been observed following vaccination during pregnancy.\nTarget diseases and vaccines",
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The recommended target population for the prevention of cervical cancer is females aged nine to 13 years, prior to becoming sexually active. For females younger than 15 years, a two-dose schedule with an interval of six months is recommended. Even those females who are over 15 years at the time of the second dose are adequately protected by two doses. There is no maximum recommended interval between doses. However, an interval of no greater than 12–15 months is suggested in order to complete the schedule promptly and before the start of sexual activity. If the interval between the two doses is less than five months, a third dose should be given at least six months after the first dose. For females over 15 years of age, or who are known to have a compromised immune system (that does not respond normally) and/or are HIV-infected, a three-dose schedule (at 0, 1 or 2 and 6 months) is recommended.
HPV vaccines can be delivered through a healthcare facility-based strategy, or a school- and/or other community-based outreach service. If a girl gets pregnant before she has been fully immunized, the remaining dose(s) should be postponed since it is not licensed for use in pregnancy. To date, no health problems for mother or child have been observed following vaccination during pregnancy.
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"text": "\n DESCRIPTION:\n Le tableau résume les vaccins HPV (bivalent/quadrivalent) pour les filles de 9-13 ans, incluant doses, calendrier, contre-indications, et précautions.\n :TABLE DATA:\n Table 1.4 Summary of HPV vaccines for girls aged between 9 and 13 years Type of vaccine Recombinant protein capsid, liquid vaccine Total number of doses 2 Schedule – bivalent (HPV types 16 and 18; GSK Cervarix ® ) and quadrivalent (HPV types 6, 11, 16 and 18; Merck Gardasil ® ) 0 and 6 months There is no maximum interval between doses – as long as the girl is under 15 years of age at the time of the first dose, two doses are sufficient If the interval between doses is less than 5 months, a third dose should be given at least 6 months after the first dose. Note: For females ≥15 years of age, or who are known to have a compromised immune system and/or are HIV-infected, a 3-dose schedule (at 0, 1 or 2 and 6 months) is recommended Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: rare anaphylaxis Mild: injection site reactions; fever, dizziness, nausea Special precautions Postpone vaccination for pregnancy Adolescents should be seated during injections and for 15 minutes afterwards since they sometimes faint Dosage 0.5 ml Injection site Deltoid muscle of upper arm Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.4 Summary of HPV vaccines for girls aged between 9 and 13 years Type of vaccine Recombinant protein capsid, liquid vaccine Total number of doses 2 Schedule – bivalent (HPV types 16 and 18; GSK Cervarix ® ) and quadrivalent (HPV types 6, 11, 16 and 18; Merck Gardasil ® ) 0 and 6 months There is no maximum interval between doses – as long as the girl is under 15 years of age at the time of the first dose, two doses are sufficient If the interval between doses is less than 5 months, a third dose should be given at least 6 months after the first dose. Note: For females ≥15 years of age, or who are known to have a compromised immune system and/or are HIV-infected, a 3-dose schedule (at 0, 1 or 2 and 6 months) is recommended Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: rare anaphylaxis Mild: injection site reactions; fever, dizziness, nausea Special precautions Postpone vaccination for pregnancy Adolescents should be seated during injections and for 15 minutes afterwards since they sometimes faint Dosage 0.5 ml Injection site Deltoid muscle of upper arm Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.4
Summary of HPV vaccines for girls aged between 9 and 13 years
Type of vaccine
Recombinant protein capsid, liquid vaccine
Total number of doses
2
Schedule –
bivalent
(HPV types 16 and 18; GSK Cervarix
®
) and
quadrivalent
(HPV types 6, 11, 16 and 18; Merck Gardasil
®
)
0 and 6 months
There is no maximum interval between doses – as long as the girl is under 15 years of age at the time of the first dose, two doses are sufficient
If the interval between doses is less than 5 months, a third dose should be given at least 6 months after the first dose.
Note:
For females ≥15 years of age, or who are known to have a compromised immune system and/or are HIV-infected, a 3-dose schedule (at 0, 1 or 2 and 6 months) is recommended
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe: rare anaphylaxis
Mild: injection site reactions; fever, dizziness, nausea
Special precautions
Postpone vaccination for pregnancy
Adolescents should be seated during injections and for 15 minutes afterwards since they sometimes faint
Summary of HPV vaccines for girls aged between 9 and 13 years
Type of vaccine
Recombinant protein capsid, liquid vaccine
Total number of doses
2
Schedule –
bivalent
(HPV types 16 and 18; GSK Cervarix
®
) and
quadrivalent
(HPV types 6, 11, 16 and 18; Merck Gardasil
®
)
0 and 6 months
There is no maximum interval between doses – as long as the girl is under 15 years of age at the time of the first dose, two doses are sufficient
If the interval between doses is less than 5 months, a third dose should be given at least 6 months after the first dose.
Note:
For females ≥15 years of age, or who are known to have a compromised immune system and/or are HIV-infected, a 3-dose schedule (at 0, 1 or 2 and 6 months) is recommended
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe: rare anaphylaxis
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Dosage
0.5 ml
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Between +2 °C and +8 °C
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"text": "\n\n\nKey points about HPV and cervical cancer\nCervical cancer is the leading cause of cancer death among women in developing countries. Almost all cervical cancers are caused by HPV, a sexually transmitted virus. Two types of HPV (types 16 and 18) cause 70% of cervical cancer cases. Cervical cancer develops many years after initial HPV infection and does not usually show symptoms and signs until it is late stage and difficult to treat. HPV vaccination, condom use, prevention of tobacco use, and cervical cancer screening later in life are all needed to prevent cervical cancer. Screening to detect early changes that lead to cancer is needed at least once for all women aged 30–49 years, including those who were vaccinated, because the vaccine does not protect against all HPV types that cause cervical cancer. Two HPV vaccines, a bivalent and a quadrivalent, are currently available.\n :TABLE DATA: \nTable 1.4 Summary of HPV vaccines for girls aged between 9 and 13 years Type of vaccine Recombinant protein capsid, liquid vaccine Total number of doses 2 Schedule – bivalent (HPV types 16 and 18; GSK Cervarix ® ) and quadrivalent (HPV types 6, 11, 16 and 18; Merck Gardasil ® ) 0 and 6 months There is no maximum interval between doses – as long as the girl is under 15 years of age at the time of the first dose, two doses are sufficient If the interval between doses is less than 5 months, a third dose should be given at least 6 months after the first dose. Note: For females ≥15 years of age, or who are known to have a compromised immune system and/or are HIV-infected, a 3-dose schedule (at 0, 1 or 2 and 6 months) is recommended Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events Severe: rare anaphylaxis Mild: injection site reactions; fever, dizziness, nausea Special precautions Postpone vaccination for pregnancy Adolescents should be seated during injections and for 15 minutes afterwards since they sometimes faint Dosage 0.5 ml Injection site Deltoid muscle of upper arm Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Almost all cervical cancers are caused by HPV, a sexually transmitted virus. Two types of HPV (types 16 and 18) cause 70% of cervical cancer cases.
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Table 1.4
Summary of HPV vaccines for girls aged between 9 and 13 years
Type of vaccine
Recombinant protein capsid, liquid vaccine
Total number of doses
2
Schedule –
bivalent
(HPV types 16 and 18; GSK Cervarix
®
) and
quadrivalent
(HPV types 6, 11, 16 and 18; Merck Gardasil
®
)
0 and 6 months
There is no maximum interval between doses – as long as the girl is under 15 years of age at the time of the first dose, two doses are sufficient
If the interval between doses is less than 5 months, a third dose should be given at least 6 months after the first dose.
Note:
For females ≥15 years of age, or who are known to have a compromised immune system and/or are HIV-infected, a 3-dose schedule (at 0, 1 or 2 and 6 months) is recommended
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
Severe: rare anaphylaxis
Mild: injection site reactions; fever, dizziness, nausea
Special precautions
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"text": "\n\n\n5.1 What is Japanese encephalitis?\nJapanese encephalitis (JE) is an infection of the brain caused by a virus. It is found in nearly all Asian countries, some Pacific Islands and a small part of Northern Australia. Although traditionally considered a childhood disease, JE can occur in all ages, particularly when the virus is introduced into new areas where the population has no pre-existing immunity.",
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Japanese encephalitis (JE) is an infection of the brain caused by a virus. It is found in nearly all Asian countries, some Pacific Islands and a small part of Northern Australia. Although traditionally considered a childhood disease, JE can occur in all ages, particularly when the virus is introduced into new areas where the population has no pre-existing immunity.
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"text": "\n\n\n5.2 How is Japanese encephalitis spread?\nThe JE virus is spread by mosquitoes. It normally infects birds and domestic animals, especially wading birds and pigs, which serve as its reservoirs. Humans may contract the disease when a mosquito that has bitten an infected animal then bites a person. In temperate climate zones, JE occurs more frequently during the warm season. In subtropical and tropical areas, the disease occurs at the highest rate during and shortly after the rainy season, although where irrigation permits mosquito breeding, transmission can occur all year. People living in rural areas, especially where rice is grown, are most at risk although patterns of the disease are changing.",
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"text": "\n\n\n5.3 What are the symptoms and signs of Japanese encephalitis?\nThe majority of infections result in mild symptoms or no symptoms at all. On average, only one of every 250 people infected with the virus develops symptoms. Symptoms, which usually appear four to 14 days after infection, are flu-like, with sudden onset of fever, chills, headache, tiredness, nausea and vomiting. In children, stomach or abdominal pain may be the most prominent symptom during the early stage of the illness. Signs of confusion or coma occur after three to four days. Children often have seizures.",
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"text": "\n\n\n5.4 What are the complications of Japanese encephalitis?\nJE is fatal in about 20–30% of cases, with young children (less than 10 years of age) having a greater risk of severe disease and a higher case fatality rate. Of those who survive the disease, 30–50% will have brain damage and paralysis.\nTarget diseases and vaccines",
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"text": "\n\n\n5.6 How is Japanese encephalitis prevented?\nImmunization is the single most important measure to control JE. No effective method of environmental control of JE transmission is known. Socioeconomic improvements and changes in agricultural practices may reduce viral transmission in some places, but large-scale vaccination of affected populations with effective and affordable vaccines appears to be the logical control measure, at least in the short term. Sections 5.7–5.9 and Table 1.5 describe JE vaccine. Bed nets may help prevent JE in small children since mosquitoes carrying JE tend to bite in the twilight hours.",
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Immunization is the single most important measure to control JE. No effective method of environmental control of JE transmission is known. Socioeconomic improvements and changes in agricultural practices may reduce viral transmission in some places, but large-scale vaccination of affected populations with effective and affordable vaccines appears to be the logical control measure, at least in the short term. Sections 5.7–5.9 and Table 1.5 describe JE vaccine.
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"text": "\n\n\n5.7 What is Japanese encephalitis vaccine?\nThere are now four types of vaccines that protect against JE:\nInactivated Vero cell-derived vaccine (so called since the virus is grown in Vero cells) – the vaccine with the brand name JEEV ® has been WHO prequalified. Live attenuated (weakened) vaccine – single- and multi-dose vials of the vaccine are WHO prequalified. Live recombinant vaccine – this type of vaccine, which is also grown in Vero cells and is WHO prequalified, combines parts of an attenuated JE virus with an attenuated yellow fever vaccine virus (brand names include IMOJEV ® , JE-CV ® and ChimeriVax-JE ® ). Inactivated mouse brain-derived vaccine (so called because the virus is grown in mouse brains) – this is an older type of vaccine that is slowly being replaced with the newer ones above. No inactivated mouse brain-derived vaccines are WHO prequalified.\nSummaries of these vaccines are in Tables 1.5–1.8. WHO recommends the first three newer vaccine types over the older inactivated mouse brain-derived vaccines.\nTarget diseases and vaccines",
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There are now four types of vaccines that protect against JE:
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"text": "Inactivated Vero cell-derived vaccine (so called since the virus is grown in Vero cells) – the vaccine with the brand name JEEV ® has been WHO prequalified. Live attenuated (weakened) vaccine – single- and multi-dose vials of the vaccine are WHO prequalified. Live recombinant vaccine – this type of vaccine, which is also grown in Vero cells and is WHO prequalified, combines parts of an attenuated JE virus with an attenuated yellow fever vaccine virus (brand names include IMOJEV ® , JE-CV ® and ChimeriVax-JE ® ). Inactivated mouse brain-derived vaccine (so called because the virus is grown in mouse brains) – this is an older type of vaccine that is slowly being replaced with the newer ones above. No inactivated mouse brain-derived vaccines are WHO prequalified.",
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Inactivated Vero cell-derived vaccine (so called since the virus is grown in Vero cells) – the vaccine with the brand name JEEV
®
has been WHO prequalified.
Live attenuated (weakened) vaccine – single- and multi-dose vials of the vaccine are WHO prequalified.
Live recombinant vaccine – this type of vaccine, which is also grown in Vero cells and is WHO prequalified, combines parts of an attenuated JE virus with an attenuated yellow fever vaccine virus (brand names include IMOJEV
®
, JE-CV
®
and ChimeriVax-JE
®
).
Inactivated mouse brain-derived vaccine (so called because the virus is grown in mouse brains) – this is an older type of vaccine that is slowly being replaced with the newer ones above. No inactivated mouse brain-derived vaccines are WHO prequalified.
Summaries of these vaccines are in Tables 1.5–1.8.
WHO recommends the first three newer vaccine types over the older inactivated mouse brain-derived vaccines.
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"text": "\n\n\n5.8 How safe is Japanese encephalitis vaccine and what are the potential adverse events following immunization?\nJE vaccines have acceptable safety profiles. The tables in this section include adverse events noted for each type of JE vaccine. A WHO safety information summary for JE vaccines is available on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/.",
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5.8 How safe is Japanese encephalitis vaccine and what are the potential adverse events following immunization?
JE vaccines have acceptable safety profiles. The tables in this section include adverse events noted for each type of JE vaccine.
A WHO safety information summary for JE vaccines is available on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/.
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"text": "\n\n\n5.9 When is Japanese encephalitis vaccine administered?\nJE vaccine should be integrated into EPI programmes in all areas where JE constitutes a public health problem. The most effective immunization strategy in JE-endemic settings is one-time catch-up campaigns, including child health weeks or multi-antigen campaigns in the locally defined primary target population, followed by incorporation of the JE vaccine into the routine immunization programme.",
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JE vaccine should be integrated into EPI programmes in all areas where JE constitutes a public health problem. The most effective immunization strategy in JE-endemic settings is one-time catch-up campaigns, including child health weeks or multi-antigen campaigns in the locally defined primary target population, followed by incorporation of the JE vaccine into the routine immunization programme.
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"text": "\n DESCRIPTION:\n Le tableau décrit le vaccin inactivé contre l'encéphalite japonaise (JEEV), son schéma vaccinal, ses contre-indications, ses effets secondaires et son administration.\n :TABLE DATA:\n Table 1.5 Inactivated Vero cell-derived Japanese encephalitis vaccine summary Note: This table primarily addresses JEEV*, which is WHO prequalified. If other brands of inactivated Vero cell-derived vaccine are chosen, the manufacturer's instructions should be followed. Type of vaccine Inactivated Vero cell-derived Number of doses Two doses at 4-week intervals, with the primary series starting at ≥6 months of age in endemic settings Schedule As above Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or its components Adverse events Injection site reactions: pain, redness, swelling (in 4% of cases); hives (6%); headache and dizziness (less than 1%); fever (12%) Special precautions Postpone vaccination in persons with acute severe febrile conditions Dosage 0.25 ml for those aged <3 years, 0.5 ml for those aged ≥3 years Injection site Anterolateral (outer) thigh for children Deltoid muscle of upper arm for adults Injection type Intramuscular Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n\n ",
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"text": "Table 1.5 Inactivated Vero cell-derived Japanese encephalitis vaccine summary Note: This table primarily addresses JEEV*, which is WHO prequalified. If other brands of inactivated Vero cell-derived vaccine are chosen, the manufacturer's instructions should be followed. Type of vaccine Inactivated Vero cell-derived Number of doses Two doses at 4-week intervals, with the primary series starting at ≥6 months of age in endemic settings Schedule As above Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or its components Adverse events Injection site reactions: pain, redness, swelling (in 4% of cases); hives (6%); headache and dizziness (less than 1%); fever (12%) Special precautions Postpone vaccination in persons with acute severe febrile conditions Dosage 0.25 ml for those aged <3 years, 0.5 ml for those aged ≥3 years Injection site Anterolateral (outer) thigh for children Deltoid muscle of upper arm for adults Injection type Intramuscular Storage Between +2 °C and +8 °C",
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Table 1.5 Inactivated Vero cell-derived Japanese encephalitis vaccine summary
Note: This table primarily addresses JEEV*, which is WHO prequalified. If other brands of inactivated Vero cell-derived vaccine are chosen, the manufacturer's instructions should be followed.
Type of vaccine
Inactivated Vero cell-derived
Number of doses
Two doses at 4-week intervals, with the primary series starting at ≥6 months of age in endemic settings
Schedule
As above
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or its components
Adverse events
Injection site reactions: pain, redness, swelling (in 4% of cases); hives (6%); headache and dizziness (less than 1%); fever (12%)
Special precautions
Postpone vaccination in persons with acute severe febrile conditions
Dosage
0.25 ml for those aged <3 years, 0.5 ml for those aged ≥3 years
Injection site
Anterolateral (outer) thigh for children Deltoid muscle of upper arm for adults
Table 1.5 Inactivated Vero cell-derived Japanese encephalitis vaccine summary
Note: This table primarily addresses JEEV*, which is WHO prequalified. If other brands of inactivated Vero cell-derived vaccine are chosen, the manufacturer's instructions should be followed.
Type of vaccine
Inactivated Vero cell-derived
Number of doses
Two doses at 4-week intervals, with the primary series starting at ≥6 months of age in endemic settings
Schedule
As above
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or its components
Adverse events
Injection site reactions: pain, redness, swelling (in 4% of cases); hives (6%); headache and dizziness (less than 1%); fever (12%)
Special precautions
Postpone vaccination in persons with acute severe febrile conditions
Dosage
0.25 ml for those aged <3 years, 0.5 ml for those aged ≥3 years
Injection site
Anterolateral (outer) thigh for children Deltoid muscle of upper arm for adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
"
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"text": "\n DESCRIPTION:\n Le tableau décrit un vaccin vivant atténué contre l'encéphalite japonaise, administré en une dose unique dès 8 mois, avec des contre-indications et effets indésirables spécifiques.\n :TABLE DATA:\n Table 1.6 Live attenuated Japanese encephalitis vaccine summary Type of vaccine Live attenuated virus Number of doses 1 Schedule Single dose administered at >8 months of age Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or any of its components Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system Adverse events High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare) Special precautions Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating Postpone vaccination for at least 3 months if the person has been given immunoglobulin There should be at least a 1 month interval (either before or after) between JE and other live vaccines Women of childbearing age should avoid pregnancy for at least 3 months after immunization Live attenuated JE vaccine is not meant to be given during JE epidemic seasons Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n\n ",
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"text": "Table 1.6 Live attenuated Japanese encephalitis vaccine summary Type of vaccine Live attenuated virus Number of doses 1 Schedule Single dose administered at >8 months of age Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or any of its components Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system Adverse events High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare) Special precautions Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating Postpone vaccination for at least 3 months if the person has been given immunoglobulin There should be at least a 1 month interval (either before or after) between JE and other live vaccines Women of childbearing age should avoid pregnancy for at least 3 months after immunization Live attenuated JE vaccine is not meant to be given during JE epidemic seasons Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C",
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Table 1.6 Live attenuated Japanese encephalitis vaccine summary
Type of vaccine
Live attenuated virus
Number of doses
1
Schedule
Single dose administered at >8 months of age
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or any of its components
Pregnancy
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever
Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system
Adverse events
High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare)
Special precautions
Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating
Postpone vaccination for at least 3 months if the person has been given immunoglobulin
There should be at least a 1 month interval (either before or after) between JE and other live vaccines
Women of childbearing age should avoid pregnancy for at least 3 months after immunization
Live attenuated JE vaccine is not meant to be given during JE epidemic seasons
Table 1.6 Live attenuated Japanese encephalitis vaccine summary
Type of vaccine
Live attenuated virus
Number of doses
1
Schedule
Single dose administered at >8 months of age
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or any of its components
Pregnancy
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever
Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system
Adverse events
High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare)
Special precautions
Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating
Postpone vaccination for at least 3 months if the person has been given immunoglobulin
There should be at least a 1 month interval (either before or after) between JE and other live vaccines
Women of childbearing age should avoid pregnancy for at least 3 months after immunization
Live attenuated JE vaccine is not meant to be given during JE epidemic seasons
Dosage
0.5 ml
Injection site
Upper arm
Injection type
Subcutaneous
Storage
Between +2 °C and +8 °C
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"text": "\n DESCRIPTION:\n L'encéphalite japonaise, transmise par les moustiques, est prévenue par plusieurs vaccins, dont un vaccin recombinant vivant en une dose unique.\n :TABLE DATA:\n Table 1.7 Live recombinant Japanese encephalitis vaccine summary Type of vaccine Live recombinant virus vaccine Number of doses 1 Schedule Single dose at >9 months of age Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or any of its components Pregnancy Lactation Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Symptomatic HIV infection Adverse events Comparable to other vaccines; lower local reaction rates in adults (compared to mouse brain-derived JE vaccines); high fever, acute viral illness have been reported only twice Special precautions Postpone vaccination for acute febrile illness Dosage Per manufacturer’s instructions Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n\n ",
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Table 1.7
Live recombinant Japanese encephalitis vaccine summary
Type of vaccine
Live recombinant virus vaccine
Number of doses
1
Schedule
Single dose at >9 months of age
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or any of its components
Pregnancy
Lactation
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Symptomatic HIV infection
Adverse events
Comparable to other vaccines; lower local reaction rates in adults (compared to mouse brain-derived JE vaccines); high fever, acute viral illness have been reported only twice
Live recombinant Japanese encephalitis vaccine summary
Type of vaccine
Live recombinant virus vaccine
Number of doses
1
Schedule
Single dose at >9 months of age
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or any of its components
Pregnancy
Lactation
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Symptomatic HIV infection
Adverse events
Comparable to other vaccines; lower local reaction rates in adults (compared to mouse brain-derived JE vaccines); high fever, acute viral illness have been reported only twice
Special precautions
Postpone vaccination for acute febrile illness
Dosage
Per manufacturer’s instructions
Injection site
Upper arm
Injection type
Subcutaneous
Storage
Between +2 °C and +8 °C
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"text": "\n DESCRIPTION:\n L'encéphalite japonaise est une maladie virale transmise par les moustiques. La vaccination est la mesure de contrôle la plus importante. Il existe plusieurs types de vaccins contre l'encéphalite japonaise, chacun avec son propre schéma vaccinal, ses contre-indications et ses effets indésirables potentiels.\n :TABLE DATA:\n Table 1.8 Japanese encephalitis mouse brain-derived vaccine summary Type of vaccine Live attenuated vaccine Number of doses 1 (primary immunization) Schedule First dose at 9–12 months of age Booster After 1 year Contraindications Hypersensitivity (allergy) to gelatin, gentamycin, kanamycin Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Adverse events Severe: anaphylaxis in 1–2% of those vaccinated; hypersensitivity (allergy) reactions, sometimes up to 9 days after vaccination in 17%; nervous system complications in 1–2.3% Mild: fever, injection site swelling in about 20% of those vaccinated; headache, muscle aches, low-grade fever, nausea, vomiting, abdominal pain, rash, chills, dizziness in 5–30% Special precautions Not usually given before 9 months of age Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n\n ",
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"text": "Table 1.8 Japanese encephalitis mouse brain-derived vaccine summary Type of vaccine Live attenuated vaccine Number of doses 1 (primary immunization) Schedule First dose at 9–12 months of age Booster After 1 year Contraindications Hypersensitivity (allergy) to gelatin, gentamycin, kanamycin Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Adverse events Severe: anaphylaxis in 1–2% of those vaccinated; hypersensitivity (allergy) reactions, sometimes up to 9 days after vaccination in 17%; nervous system complications in 1–2.3% Mild: fever, injection site swelling in about 20% of those vaccinated; headache, muscle aches, low-grade fever, nausea, vomiting, abdominal pain, rash, chills, dizziness in 5–30% Special precautions Not usually given before 9 months of age Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C",
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Table 1.8
Japanese encephalitis mouse brain-derived vaccine summary
Type of vaccine
Live attenuated vaccine
Number of doses
1 (primary immunization)
Schedule
First dose at 9–12 months of age
Booster
After 1 year
Contraindications
Hypersensitivity (allergy) to gelatin, gentamycin, kanamycin
Pregnancy
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Adverse events
Severe: anaphylaxis in 1–2% of those vaccinated; hypersensitivity (allergy) reactions, sometimes up to 9 days after vaccination in 17%; nervous system complications in 1–2.3%
Mild: fever, injection site swelling in about 20% of those vaccinated; headache, muscle aches, low-grade fever, nausea, vomiting, abdominal pain, rash, chills, dizziness in 5–30%
Japanese encephalitis mouse brain-derived vaccine summary
Type of vaccine
Live attenuated vaccine
Number of doses
1 (primary immunization)
Schedule
First dose at 9–12 months of age
Booster
After 1 year
Contraindications
Hypersensitivity (allergy) to gelatin, gentamycin, kanamycin
Pregnancy
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Adverse events
Severe: anaphylaxis in 1–2% of those vaccinated; hypersensitivity (allergy) reactions, sometimes up to 9 days after vaccination in 17%; nervous system complications in 1–2.3%
Mild: fever, injection site swelling in about 20% of those vaccinated; headache, muscle aches, low-grade fever, nausea, vomiting, abdominal pain, rash, chills, dizziness in 5–30%
Special precautions
Not usually given before 9 months of age
Dosage
0.5 ml
Injection site
Upper arm
Injection type
Subcutaneous
Storage
Between +2 °C and +8 °C
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"text": "\n\n\nKey points about Japanese encephalitis\n➢ JE is found in nearly all Asian countries, some Pacific islands and a small part of northern Australia. ➢ The disease is spread by infected mosquitoes. ➢ In temperate zones, JE occurs more frequently during the warm season. In subtropical and tropical areas, the disease occurs with the rainy season, although transmission can occur all year. ➢ The illness can progress to encephalitis, a serious infection/inflammation of the brain that is fatal in 20–30% of cases. It can also cause paralysis and brain damage. ➢ There is no specific treatment for JE. ➢ Immunization with JE vaccine is the single most important control measure.\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.5 Inactivated Vero cell-derived Japanese encephalitis vaccine summary Note: This table primarily addresses JEEV*, which is WHO prequalified. If other brands of inactivated Vero cell-derived vaccine are chosen, the manufacturer's instructions should be followed. Type of vaccine Inactivated Vero cell-derived Number of doses Two doses at 4-week intervals, with the primary series starting at ≥6 months of age in endemic settings Schedule As above Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or its components Adverse events Injection site reactions: pain, redness, swelling (in 4% of cases); hives (6%); headache and dizziness (less than 1%); fever (12%) Special precautions Postpone vaccination in persons with acute severe febrile conditions Dosage 0.25 ml for those aged <3 years, 0.5 ml for those aged ≥3 years Injection site Anterolateral (outer) thigh for children Deltoid muscle of upper arm for adults Injection type Intramuscular Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n :TABLE DATA: \nTable 1.6 Live attenuated Japanese encephalitis vaccine summary Type of vaccine Live attenuated virus Number of doses 1 Schedule Single dose administered at >8 months of age Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or any of its components Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system Adverse events High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare) Special precautions Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating Postpone vaccination for at least 3 months if the person has been given immunoglobulin There should be at least a 1 month interval (either before or after) between JE and other live vaccines Women of childbearing age should avoid pregnancy for at least 3 months after immunization Live attenuated JE vaccine is not meant to be given during JE epidemic seasons Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\nTarget diseases and vaccines\n :TABLE DATA: \nTable 1.7 Live recombinant Japanese encephalitis vaccine summary Type of vaccine Live recombinant virus vaccine Number of doses 1 Schedule Single dose at >9 months of age Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or any of its components Pregnancy Lactation Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Symptomatic HIV infection Adverse events Comparable to other vaccines; lower local reaction rates in adults (compared to mouse brain-derived JE vaccines); high fever, acute viral illness have been reported only twice Special precautions Postpone vaccination for acute febrile illness Dosage Per manufacturer’s instructions Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n :TABLE DATA: \nTable 1.8 Japanese encephalitis mouse brain-derived vaccine summary Type of vaccine Live attenuated vaccine Number of doses 1 (primary immunization) Schedule First dose at 9–12 months of age Booster After 1 year Contraindications Hypersensitivity (allergy) to gelatin, gentamycin, kanamycin Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Adverse events Severe: anaphylaxis in 1–2% of those vaccinated; hypersensitivity (allergy) reactions, sometimes up to 9 days after vaccination in 17%; nervous system complications in 1–2.3% Mild: fever, injection site swelling in about 20% of those vaccinated; headache, muscle aches, low-grade fever, nausea, vomiting, abdominal pain, rash, chills, dizziness in 5–30% Special precautions Not usually given before 9 months of age Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Key points about Japanese encephalitis
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"text": "➢ JE is found in nearly all Asian countries, some Pacific islands and a small part of northern Australia. ➢ The disease is spread by infected mosquitoes. ➢ In temperate zones, JE occurs more frequently during the warm season. In subtropical and tropical areas, the disease occurs with the rainy season, although transmission can occur all year. ➢ The illness can progress to encephalitis, a serious infection/inflammation of the brain that is fatal in 20–30% of cases. It can also cause paralysis and brain damage. ➢ There is no specific treatment for JE. ➢ Immunization with JE vaccine is the single most important control measure.",
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➢ JE is found in nearly all Asian countries, some Pacific islands and a small part of northern Australia.
➢ The disease is spread by infected mosquitoes.
➢ In temperate zones, JE occurs more frequently during the warm season. In subtropical and tropical areas, the disease occurs with the rainy season, although transmission can occur all year.
➢ The illness can progress to encephalitis, a serious infection/inflammation of the brain that is fatal in 20–30% of cases. It can also cause paralysis and brain damage.
➢ There is no specific treatment for JE.
➢ Immunization with JE vaccine is the single most important control measure.
Table 1.5 Inactivated Vero cell-derived Japanese encephalitis vaccine summary
Note: This table primarily addresses JEEV*, which is WHO prequalified. If other brands of inactivated Vero cell-derived vaccine are chosen, the manufacturer's instructions should be followed.
Type of vaccine
Inactivated Vero cell-derived
Number of doses
Two doses at 4-week intervals, with the primary series starting at ≥6 months of age in endemic settings
Schedule
As above
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or its components
Adverse events
Injection site reactions: pain, redness, swelling (in 4% of cases); hives (6%); headache and dizziness (less than 1%); fever (12%)
Special precautions
Postpone vaccination in persons with acute severe febrile conditions
Dosage
0.25 ml for those aged <3 years, 0.5 ml for those aged ≥3 years
Injection site
Anterolateral (outer) thigh for children Deltoid muscle of upper arm for adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
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"text": "Table 1.6 Live attenuated Japanese encephalitis vaccine summary Type of vaccine Live attenuated virus Number of doses 1 Schedule Single dose administered at >8 months of age Booster WHO position states that the need for a booster in endemic settings has not been clearly established Contraindications Known allergy to the vaccine or any of its components Pregnancy Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth) Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system Adverse events High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare) Special precautions Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating Postpone vaccination for at least 3 months if the person has been given immunoglobulin There should be at least a 1 month interval (either before or after) between JE and other live vaccines Women of childbearing age should avoid pregnancy for at least 3 months after immunization Live attenuated JE vaccine is not meant to be given during JE epidemic seasons Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C",
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Table 1.6 Live attenuated Japanese encephalitis vaccine summary
Type of vaccine
Live attenuated virus
Number of doses
1
Schedule
Single dose administered at >8 months of age
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or any of its components
Pregnancy
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Acute diseases, severe chronic diseases, and chronic diseases with acute symptoms and/or fever
Encephalopathy (brain disease), uncontrolled epilepsy (seizures) or other diseases of the nervous system
Adverse events
High fever (5–7% of those vaccinated); injection site reactions (redness, swelling: in less than 1% with some types of vaccine); low-grade fever, irritability, nausea and dizziness (rare)
Special precautions
Review medical history – caution needed for family or individual history of seizures or other chronic diseases, allergies and for women who are lactating
Postpone vaccination for at least 3 months if the person has been given immunoglobulin
There should be at least a 1 month interval (either before or after) between JE and other live vaccines
Women of childbearing age should avoid pregnancy for at least 3 months after immunization
Live attenuated JE vaccine is not meant to be given during JE epidemic seasons
Live recombinant Japanese encephalitis vaccine summary
Type of vaccine
Live recombinant virus vaccine
Number of doses
1
Schedule
Single dose at >9 months of age
Booster
WHO position states that the need for a booster in endemic settings has not been clearly established
Contraindications
Known allergy to the vaccine or any of its components
Pregnancy
Lactation
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Symptomatic HIV infection
Adverse events
Comparable to other vaccines; lower local reaction rates in adults (compared to mouse brain-derived JE vaccines); high fever, acute viral illness have been reported only twice
Japanese encephalitis mouse brain-derived vaccine summary
Type of vaccine
Live attenuated vaccine
Number of doses
1 (primary immunization)
Schedule
First dose at 9–12 months of age
Booster
After 1 year
Contraindications
Hypersensitivity (allergy) to gelatin, gentamycin, kanamycin
Pregnancy
Any condition that results in a decreased or abnormal immune system response, including due to any infection (such as HIV), medication and/or congenital problems (since birth)
Adverse events
Severe: anaphylaxis in 1–2% of those vaccinated; hypersensitivity (allergy) reactions, sometimes up to 9 days after vaccination in 17%; nervous system complications in 1–2.3%
Mild: fever, injection site swelling in about 20% of those vaccinated; headache, muscle aches, low-grade fever, nausea, vomiting, abdominal pain, rash, chills, dizziness in 5–30%
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Because the disease is so infectious, it tends to occur as an epidemic with high death rates in settings such as refugee camps. Severe measles is particularly likely to occur in poorly nourished children, especially those who do not receive sufficient vitamin A, who live in crowded conditions, and whose immune systems have been weakened by HIV/AIDS or other diseases.
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"text": "\n\n\n6.4 What are the complications of measles?\nUnimmunized children under five years of age and, especially, infants are at the highest risk of contracting measles and suffering from its complications, which can include death. Infected infants may suffer from dehydration due to severe diarrhoea. Children may also develop malnutrition, inflammation of the middle ear, pneumonia and encephalitis (brain infection). Measles is a major cause of blindness among children in Africa and other areas of the world where it is endemic.\nModule 1: Target diseases and vaccines\nPneumonia is the most common cause of death associated with measles. The pneumonia may be caused by the measles virus itself or by a secondary bacterial infection.",
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"text": "\n\n\n6.6 How is measles prevented?\nMeasles is prevented by immunization with measles-containing vaccine (MCV). High coverage with a two-dose schedule is needed to prevent measles epidemics. Sections 6.8–6.10 and Table 1.9 below describe MCVs. Children who have recovered from measles are immune for the rest of their lives.",
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"text": "\n\n\n6.8 What are measles-containing vaccines?\nMeasles-containing vaccines (MCVs) include measles only (M) or a combination of measles with rubella (MR), mumps (MM, MMR) and varicella (MMRV) vaccines. MCVs can be used interchangeably in immunization programmes. MM and MMRV are not discussed in this module; national guidelines should be made available if either is used routinely in an immunization programme. M, MR and MMR are supplied as freeze-dried (also called lyophilized) powders with diluents in separate vials. They must be reconstituted before use with only the diluent supplied: see Module 5 (Managing an immunization session), Section 4.2 for details. Measles-containing vaccines must be stored between +2 °C and +8 °C and protected\nTarget diseases and vaccines\nfrom sunlight since they are sensitive to both heat and light. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy). MCVs are administered by subcutaneous injection. In countries where vitamin A deficiency is common, vitamin A supplements are often given at the same time as the vaccine (see Section 18 of this module).",
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"text": "from sunlight since they are sensitive to both heat and light. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy). MCVs are administered by subcutaneous injection. In countries where vitamin A deficiency is common, vitamin A supplements are often given at the same time as the vaccine (see Section 18 of this module).",
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from sunlight since they are sensitive to both heat and light. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).
MCVs are administered by subcutaneous injection.
In countries where vitamin A deficiency is common, vitamin A supplements are often given at the same time as the vaccine (see Section 18 of this module).
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All MCVs approved for immunization programmes are safe and effective. Serious events are rare and include anaphylaxis in 1–3.5 per one million doses administered, severe allergic reaction in one per 100 000 doses, and thrombocytopenia (decreased platelet count) in one per 30 000 doses. Encephalitis (brain infection) has been reported rarely but there is no definite proof that the vaccine was the cause. Mild events are more common and include local injection site pain and tenderness, fever (in 5–15%) and rash (in about 5%), which can occur five to 12 days after vaccination.
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"text": "\n\n\n6.10 When are measles-containing vaccines administered?\nAll children should receive two doses of MCV. Very high (90–95%) coverage with both doses is required to prevent measles outbreaks. The first dose (MCV1) should be given at nine or 12 months of age. Because many cases of measles occur in children over 12 months of age who have not been vaccinated, routine delivery of MCV1 should not be limited to infants ages nine to 12 months. All unvaccinated children over 12 months should be offered MCV1 using every opportunity when the child comes in contact with health services. MCV2 should be given between 15–18 months of age. Vaccinating in the second year of life reduces the number of unprotected children. This may be linked to the timing of other routine immunizations (for example, a DTP booster). Screening for measles vaccination at school entry helps to ensure that all children receive both doses. In measles outbreaks or in areas where there is a high rate of both HIV infection and measles, the first dose of MCV1 may be offered as early as age six months. Two additional doses of measles vaccine should be administered to these children according to the national immunization schedule.\nModule 1: Target diseases and vaccines",
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6.10 When are measles-containing vaccines administered?
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All children should receive two doses of MCV. Very high (90–95%) coverage with both doses is required to prevent measles outbreaks. The first dose (MCV1) should be given at nine or 12 months of age. Because many cases of measles occur in children over 12 months of age who have not been vaccinated, routine delivery of MCV1 should not be limited to infants ages nine to 12 months. All unvaccinated children over 12 months should be offered MCV1 using every opportunity when the child comes in contact with health services.
MCV2 should be given between 15–18 months of age. Vaccinating in the second year of life reduces the number of unprotected children. This may be linked to the timing of other routine immunizations (for example, a DTP booster). Screening for measles vaccination at school entry helps to ensure that all children receive both doses.
In measles outbreaks or in areas where there is a high rate of both HIV infection and measles, the first dose of MCV1 may be offered as early as age six months. Two additional doses of measles vaccine should be administered to these children according to the national immunization schedule.
Table 1.9 Measles-containing vaccines summary (MCV = M, MR, or MMR)
Type of vaccine
Live attenuated (weakened) viral
Total number of doses
2
Schedule
• MCV1: 9 or 12 months of age; minimum age 6 months (for infants at high risk, see text)
• MCV2: at least 1 month after MCV1
Contraindications
• Known allergy to vaccine components (including neomycin and gelatin)
• Pregnancy
• Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
• Serious: thrombocytopenia (decreased platelets), anaphylaxis, encephalitis (brain infection, though causal link not certain)
• Mild: fever, rash 5–12 days following administration
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral thigh or upper arm depending on the child’s age
Injection type
Subcutaneous
Storage
• Between +2 °C and +8 °C
• Keep all MCVs away from sunlight
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➢ Measles is a highly infectious viral disease that is spread from person to person through sneezing, coughing and close personal contact.
➢ The first sign of infection is a high fever lasting one to seven days. A generalized rash develops seven to 18 days after exposure to the virus.
➢ Pneumonia is the most common cause of death associated with measles.
➢ Severe complications can be avoided through proper case management, including vitamin A supplementation.
➢ Measles can be prevented by immunization. All children should receive two doses of measles vaccine. Very high coverage (90–95%) is needed with both doses.
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Table 1.9 Measles-containing vaccines summary (MCV = M, MR, or MMR)
Type of vaccine
Live attenuated (weakened) viral
Total number of doses
2
Schedule
• MCV1: 9 or 12 months of age; minimum age 6 months (for infants at high risk, see text)
• MCV2: at least 1 month after MCV1
Contraindications
• Known allergy to vaccine components (including neomycin and gelatin)
• Pregnancy
• Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
• Serious: thrombocytopenia (decreased platelets), anaphylaxis, encephalitis (brain infection, though causal link not certain)
• Mild: fever, rash 5–12 days following administration
Special precautions
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Injection site
Anterolateral thigh or upper arm depending on the child’s age
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"text": "Meningococcal meningitis is an infection of the meninges (membranes covering the brain and spinal cord) caused by the bacterium Neisseria meningitidis (also known as the meningococcus). Each Neisseria meningitidis bacterium has a capsule and, depending on the type of this capsule, it is put in a serogroup. Neisseria meningitidis serogroups A, B, C, X, W135 and Y cause most cases of meningococcal meningitis. It occurs globally, but in the sub-Saharan Africa meningitis belt, epidemics occur every two to three years. Since the 1980s, the intervals between major epidemics of meningococcal meningitis have become shorter and more irregular.",
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Meningococcal meningitis is an infection of the meninges (membranes covering the brain and spinal cord) caused by the bacterium
Neisseria meningitidis
(also known as the meningococcus). Each
Neisseria meningitidis
bacterium has a capsule and, depending on the type of this capsule, it is put in a serogroup.
Neisseria meningitidis
serogroups A, B, C, X, W135 and Y cause most cases of meningococcal meningitis. It occurs globally, but in the sub-Saharan Africa meningitis belt, epidemics occur every two to three years. Since the 1980s, the intervals between major epidemics of meningococcal meningitis have become shorter and more irregular.
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The meningococcus bacterium can also cause septicaemia (bloodstream infection), which is less common but more severe and often fatal.
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"text": "\n\n\n7.2 How is meningococcal disease spread?\nThe meningococcus is spread from person to person via airborne droplets emitted from the nose and throat of infected people. Meningococcal disease is most common in young children, but older children and young adults living in crowded conditions can also be at high risk.",
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"text": "\n\n\n7.3 What are the symptoms and signs of meningococcal disease?\nMeningococcal meningitis is marked by the sudden onset of intense headache, fever, nausea, vomiting, sensitivity to light and stiff neck. Other signs include lethargy, delirium, coma and convulsions. Infants may not have sudden-onset illness and a stiff neck; they may only appear to be slow, inactive, irritable or are feeding poorly and may be vomiting. A petechial rash (petechiae are small spots of bleeding into the skin) is the key sign of meningococcal septicaemia, which can be followed by rapid shock and death.",
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Meningococcal meningitis is marked by the sudden onset of intense headache, fever, nausea, vomiting, sensitivity to light and stiff neck. Other signs include lethargy, delirium, coma and convulsions. Infants may not have sudden-onset illness and a stiff neck; they may only appear to be slow, inactive, irritable or are feeding poorly and may be vomiting.
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"text": "\n\n\n7.4 What are the complications of meningococcal disease?\nDeath occurs in almost all untreated cases. Even with early treatment, up to 10% of patients die. About 10–20% of meningococcal meningitis survivors suffer from complications, such as mental retardation, deafness, paralysis and seizures.\nModule 1: Target diseases and vaccines",
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Death occurs in almost all untreated cases. Even with early treatment, up to 10% of patients die. About 10–20% of meningococcal meningitis survivors suffer from complications, such as mental retardation, deafness, paralysis and seizures.
7.5 What is the treatment for meningococcal disease?
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Because the meningococcus is a bacterium, antibiotics such as ceftriaxone, chloramphenicol and penicillin G are effective. Each case should be considered as a medical emergency and referred to a hospital to reduce the risk of death from rapidly progressing disease.
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"text": "\n\n\n7.6 How is meningococcal meningitis prevented?\nSeveral vaccines are available to protect against meningococcal serogroups A, C, W135 and Y. No vaccine protects against serogroup X at this time. Countries must choose a vaccine based on the meningococcal serogroups most often identified locally. Sections 7.8–7.10 and Tables 1.10–1.12 describe meningococcal vaccines.",
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"text": "\n\n\n7.7 What is needed for meningococcal disease control?\nEpidemic control relies on good surveillance with early detection and treatment of cases as well as immunization. A mass immunization campaign that reaches at least 80% of the entire population with vaccine against serogroups A and C can prevent an epidemic in areas where these serogroups are the cause of outbreaks.",
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Epidemic control relies on good surveillance with early detection and treatment of cases as well as immunization. A mass immunization campaign that reaches at least 80% of the entire population with vaccine against serogroups A and C can prevent an epidemic in areas where these serogroups are the cause of outbreaks.
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"text": "\n DESCRIPTION:\n Le tableau décrit les vaccins méningococciques : polysaccharidiques (bivalents, trivalents, quadrivalents, monovalents) et conjugués (quadrivalents, combinés), tous lyophilisés.\n :TABLE DATA:\n Table 1.10 Meningococcal vaccines Meningococcal vaccine category Serogroups (and other antigens) How supplied Polysaccharide bivalent A, C trivalent A, C, W135 quadrivalent A, C, W135, Y monovalent A or C Conjugate quadrivalent A, C, W135, Y combination C, Hib Freeze-dried powder requiring reconstitution Single- or multi-dose vials\n :END TABLE DATA:\n\n ",
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"text": "\n\n\n7.8 What is meningococcal vaccine?\nThere are two categories of meningococcal vaccine, as shown in Table 1.10 below: polysaccharide vaccines with specific capsule serogroup antigens and polysaccharide-protein conjugate vaccines, which have serogroup antigens bound to a protein that helps increase the immune system response to the vaccine. Conjugate vaccines are preferred over polysaccharide vaccines due to their potential for herd protection and their increased ability to generate immunity, particularly in children under two years of age (this is similar for pneumococcal conjugate vaccines, see Section 10 of this module). Meningococcal vaccines should be stored between +2 °C and +8 °C. Polysaccharide vaccines are generally given as a 0.5 ml dose subcutaneously. Conjugate vaccines are administered as a 0.5 ml dose intramuscularly.\n :TABLE DATA: \nTable 1.10 Meningococcal vaccines Meningococcal vaccine category Serogroups (and other antigens) How supplied Polysaccharide bivalent A, C trivalent A, C, W135 quadrivalent A, C, W135, Y monovalent A or C Conjugate quadrivalent A, C, W135, Y combination C, Hib Freeze-dried powder requiring reconstitution Single- or multi-dose vials\n :END TABLE DATA:\nTarget diseases and vaccines",
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There are two categories of meningococcal vaccine, as shown in Table 1.10 below: polysaccharide vaccines with specific capsule serogroup antigens and polysaccharide-protein conjugate vaccines, which have serogroup antigens bound to a protein that helps increase the immune system response to the vaccine. Conjugate vaccines are preferred over polysaccharide vaccines due to their potential for herd protection and their increased ability to generate immunity, particularly in children under two years of age (this is similar for pneumococcal conjugate vaccines, see Section 10 of this module).
Meningococcal vaccines should be stored between +2 °C and +8 °C. Polysaccharide vaccines are generally given as a 0.5 ml dose subcutaneously. Conjugate vaccines are administered as a 0.5 ml dose intramuscularly.
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Table 1.10 Meningococcal vaccines
Meningococcal vaccine category
Serogroups (and other antigens)
How supplied
Polysaccharide
bivalent
A, C
trivalent
A, C, W135
quadrivalent
A, C, W135, Y
monovalent
A or C
Conjugate
quadrivalent
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"text": "\n\n\n7.9 How safe are meningococcal vaccines and what are the potential adverse events following immunization?\nMeningococcal vaccines have an excellent safety record. Severe adverse events with polysaccharide vaccines include rare anaphylaxis (one per one million doses of vaccine administered) and infrequent neurologic reactions, such as seizures. Mild events include local injection site reactions in up to 56% and fever in less than 5% (most commonly in infants). Conjugate vaccines have excellent safety profiles. No severe adverse events have been associated with them. Mild events include local injection site reactions, and fever and irritability in children. Both conjugate and polysaccharide vaccines are safe and effective when used in pregnant women.",
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Meningococcal vaccines have an excellent safety record. Severe adverse events with polysaccharide vaccines include rare anaphylaxis (one per one million doses of vaccine administered) and infrequent neurologic reactions, such as seizures. Mild events include local injection site reactions in up to 56% and fever in less than 5% (most commonly in infants).
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"text": "\n\n\n7.10 When are meningococcal vaccines administered?\nFor MenA conjugate vaccine (5μg), a one-dose schedule is recommended at nine to 18 months of age based on local programme factors. The vaccine should be administered by deep intramuscular injection, preferably in the anterolateral (outer) aspect of the thigh. There is no reason to expect interference when co-administered with other vaccines. The need for a booster dose has not been established. If in a specific setting there is a strong reason to vaccinate infants younger than nine months, a two-dose schedule should be used starting at three months of age, with an interval of at least eight weeks between doses. For monovalent MenC conjugate vaccine, a single intramuscular dose is recommended for children aged over 12 months, teenagers and adults. Children aged two to 11 months require two doses administered at an interval of at least two months and a booster about one year after. If the primary series is interrupted, vaccination should be resumed without repeating the previous dose. Quadrivalent conjugate vaccines (A,C,W135,Y-D and A,C,W135,Y-CRM) should be administered as one single intramuscular dose to individuals aged over two years. A,C,W135,Y-D is also licensed for children nine to 23 months of age, and given as a two-dose series, three months apart beginning at age nine months. If the primary series is interrupted, vaccination should be resumed without repeating the previous dose. Meningococcal polysaccharide vaccines can be used for those over two years of age to control outbreaks in countries where limited economic resources or insufficient supply restrict the use of meningococcal conjugate vaccines. Polysaccharide vaccines should be administered to individuals over two years of age as one single dose. One booster three to five years after the primary dose may be given to persons considered to be at continued high risk of exposure, including some health workers.\nModule 1: Target diseases and vaccines",
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"text": "For MenA conjugate vaccine (5μg), a one-dose schedule is recommended at nine to 18 months of age based on local programme factors. The vaccine should be administered by deep intramuscular injection, preferably in the anterolateral (outer) aspect of the thigh. There is no reason to expect interference when co-administered with other vaccines. The need for a booster dose has not been established. If in a specific setting there is a strong reason to vaccinate infants younger than nine months, a two-dose schedule should be used starting at three months of age, with an interval of at least eight weeks between doses. For monovalent MenC conjugate vaccine, a single intramuscular dose is recommended for children aged over 12 months, teenagers and adults. Children aged two to 11 months require two doses administered at an interval of at least two months and a booster about one year after. If the primary series is interrupted, vaccination should be resumed without repeating the previous dose. Quadrivalent conjugate vaccines (A,C,W135,Y-D and A,C,W135,Y-CRM) should be administered as one single intramuscular dose to individuals aged over two years. A,C,W135,Y-D is also licensed for children nine to 23 months of age, and given as a two-dose series, three months apart beginning at age nine months. If the primary series is interrupted, vaccination should be resumed without repeating the previous dose. Meningococcal polysaccharide vaccines can be used for those over two years of age to control outbreaks in countries where limited economic resources or insufficient supply restrict the use of meningococcal conjugate vaccines. Polysaccharide vaccines should be administered to individuals over two years of age as one single dose. One booster three to five years after the primary dose may be given to persons considered to be at continued high risk of exposure, including some health workers.",
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For MenA conjugate vaccine (5μg), a one-dose schedule is recommended at nine to 18 months of age based on local programme factors. The vaccine should be administered by deep intramuscular injection, preferably in the anterolateral (outer) aspect of the thigh. There is no reason to expect interference when co-administered with other vaccines. The need for a booster dose has not been established. If in a specific setting there is a strong reason to vaccinate infants younger than nine months, a two-dose schedule should be used starting at three months of age, with an interval of at least eight weeks between doses.
For monovalent MenC conjugate vaccine, a single intramuscular dose is recommended for children aged over 12 months, teenagers and adults. Children aged two to 11 months require two doses administered at an interval of at least two months and a booster about one year after. If the primary series is interrupted, vaccination should be resumed without repeating the previous dose.
Quadrivalent conjugate vaccines (A,C,W135,Y-D and A,C,W135,Y-CRM) should be administered as one single intramuscular dose to individuals aged over two years. A,C,W135,Y-D is also licensed for children nine to 23 months of age, and given as a two-dose series, three months apart beginning at age nine months. If the primary series is interrupted, vaccination should be resumed without repeating the previous dose.
Meningococcal polysaccharide vaccines can be used for those over two years of age to control outbreaks in countries where limited economic resources or insufficient supply restrict the use of meningococcal conjugate vaccines. Polysaccharide vaccines should be administered to individuals over two years of age as one single dose. One booster three to five years after the primary dose may be given to persons considered to be at continued high risk of exposure, including some health workers.
Purified bacterial capsular polysaccharide; bivalent, trivalent or quadrivalent
Number of doses
1
Schedule
2 years of age and older
Booster
One dose after 3–5 years if still at risk
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: rare anaphylaxis
• Mild: injection site reaction, fever
Special precautions
Children under 2 years of age are not protected by the vaccine
Dosage
0.5 ml
Injection site
Upper arm
Injection type
Subcutaneous
Storage
Between +2 °C and +8 °C
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"text": "\n DESCRIPTION:\n Le tableau résume les vaccins conjugués antiméningococciques : type, doses, schémas vaccinaux, contre-indications, effets indésirables, précautions et administration.\n :TABLE DATA:\n Table 1.12 Meningococcal conjugate vaccines summary Type of vaccine Purified bacterial capsular polysaccharide bound to protein; monovalent, quadrivalent Number of doses 1 or 2 – see schedules below Schedule – monovalent MenA conjugate Single dose 9–18 months (5 µg) Schedule – monovalent MenC conjugate • Single dose 12 months and older • 2 doses (at least 8 weeks apart) 2–11 months of age Schedule – quadrivalent conjugate • [A,C,W135,Y-D] and [A,C,W135,Y-CRM] vaccines: single dose for all 2 years of age and older • [A,C,W135,Y-D] vaccine only: 2 doses (at least 12 weeks apart) for 9–23 months of age Booster MenC after 1 year if given to infants 2–11 months Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Serious: rare anaphylaxis • Mild: injection site reactions, fever Special precautions See schedules above for age restrictions Dosage 0.5 ml Injection site • Anterolateral (outer) thigh in infants • Deltoid muscle of upper arm in children and adults Injection type Intramuscular Storage • Between +2 °C and +8 °C • Do not freeze MenC\n :END TABLE DATA:\n\n ",
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"text": "Table 1.12 Meningococcal conjugate vaccines summary Type of vaccine Purified bacterial capsular polysaccharide bound to protein; monovalent, quadrivalent Number of doses 1 or 2 – see schedules below Schedule – monovalent MenA conjugate Single dose 9–18 months (5 µg) Schedule – monovalent MenC conjugate • Single dose 12 months and older • 2 doses (at least 8 weeks apart) 2–11 months of age Schedule – quadrivalent conjugate • [A,C,W135,Y-D] and [A,C,W135,Y-CRM] vaccines: single dose for all 2 years of age and older • [A,C,W135,Y-D] vaccine only: 2 doses (at least 12 weeks apart) for 9–23 months of age Booster MenC after 1 year if given to infants 2–11 months Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Serious: rare anaphylaxis • Mild: injection site reactions, fever Special precautions See schedules above for age restrictions Dosage 0.5 ml Injection site • Anterolateral (outer) thigh in infants • Deltoid muscle of upper arm in children and adults Injection type Intramuscular Storage • Between +2 °C and +8 °C • Do not freeze MenC",
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Table 1.12
Meningococcal conjugate vaccines summary
Type of vaccine
Purified bacterial capsular polysaccharide bound to protein; monovalent, quadrivalent
Number of doses
1 or 2 – see schedules below
Schedule – monovalent MenA conjugate
Single dose 9–18 months (5 µg)
Schedule – monovalent MenC conjugate
• Single dose 12 months and older
• 2 doses (at least 8 weeks apart) 2–11 months of age
Schedule – quadrivalent conjugate
• [A,C,W135,Y-D] and [A,C,W135,Y-CRM] vaccines: single dose for all 2 years of age and older
• [A,C,W135,Y-D] vaccine only: 2 doses (at least 12 weeks apart) for 9–23 months of age
Booster
MenC after 1 year if given to infants 2–11 months
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Serious: rare anaphylaxis
• Mild: injection site reactions, fever
Special precautions
See schedules above for age restrictions
Dosage
0.5 ml
Injection site
• Anterolateral (outer) thigh in infants
• Deltoid muscle of upper arm in children and adults
Purified bacterial capsular polysaccharide bound to protein; monovalent, quadrivalent
Number of doses
1 or 2 – see schedules below
Schedule – monovalent MenA conjugate
Single dose 9–18 months (5 µg)
Schedule – monovalent MenC conjugate
• Single dose 12 months and older
• 2 doses (at least 8 weeks apart) 2–11 months of age
Schedule – quadrivalent conjugate
• [A,C,W135,Y-D] and [A,C,W135,Y-CRM] vaccines: single dose for all 2 years of age and older
• [A,C,W135,Y-D] vaccine only: 2 doses (at least 12 weeks apart) for 9–23 months of age
Booster
MenC after 1 year if given to infants 2–11 months
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Serious: rare anaphylaxis
• Mild: injection site reactions, fever
Special precautions
See schedules above for age restrictions
Dosage
0.5 ml
Injection site
• Anterolateral (outer) thigh in infants
• Deltoid muscle of upper arm in children and adults
Injection type
Intramuscular
Storage
• Between +2 °C and +8 °C
• Do not freeze MenC
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"text": "\n\n\nKey points about meningococcal disease\nMeningococcal disease is caused by a bacterium, Neisseria meningitides , and most commonly affects young children. The meningococcus is spread by contact with respiratory droplets from the nose and throat of the infected person. Meningococcal meningitis typically presents with sudden-onset intense headache, fever, nausea, vomiting, light sensitivity and stiff neck. Infants may only be slow, irritable and feeding poorly. A petechial rash is the key sign of meningococcal septicaemia. Meningococcal disease can be rapidly fatal and should always be treated as a medical emergency. Conjugate vaccines are the preferred choice due to their better protection of children under two years of age and herd immunity.\n :TABLE DATA: \nTable 1.11 Meningococcal polysaccharide vaccines summary Type of vaccine Purified bacterial capsular polysaccharide; bivalent, trivalent or quadrivalent Number of doses 1 Schedule 2 years of age and older Booster One dose after 3–5 years if still at risk Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Severe: rare anaphylaxis • Mild: injection site reaction, fever Special precautions Children under 2 years of age are not protected by the vaccine Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C\n :END TABLE DATA:\nTarget diseases and vaccines\n :TABLE DATA: \nTable 1.12 Meningococcal conjugate vaccines summary Type of vaccine Purified bacterial capsular polysaccharide bound to protein; monovalent, quadrivalent Number of doses 1 or 2 – see schedules below Schedule – monovalent MenA conjugate Single dose 9–18 months (5 µg) Schedule – monovalent MenC conjugate • Single dose 12 months and older • 2 doses (at least 8 weeks apart) 2–11 months of age Schedule – quadrivalent conjugate • [A,C,W135,Y-D] and [A,C,W135,Y-CRM] vaccines: single dose for all 2 years of age and older • [A,C,W135,Y-D] vaccine only: 2 doses (at least 12 weeks apart) for 9–23 months of age Booster MenC after 1 year if given to infants 2–11 months Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Serious: rare anaphylaxis • Mild: injection site reactions, fever Special precautions See schedules above for age restrictions Dosage 0.5 ml Injection site • Anterolateral (outer) thigh in infants • Deltoid muscle of upper arm in children and adults Injection type Intramuscular Storage • Between +2 °C and +8 °C • Do not freeze MenC\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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"text": "Meningococcal disease is caused by a bacterium, Neisseria meningitides , and most commonly affects young children. The meningococcus is spread by contact with respiratory droplets from the nose and throat of the infected person. Meningococcal meningitis typically presents with sudden-onset intense headache, fever, nausea, vomiting, light sensitivity and stiff neck. Infants may only be slow, irritable and feeding poorly. A petechial rash is the key sign of meningococcal septicaemia. Meningococcal disease can be rapidly fatal and should always be treated as a medical emergency. Conjugate vaccines are the preferred choice due to their better protection of children under two years of age and herd immunity.",
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Meningococcal disease is caused by a bacterium,Neisseria meningitides, and most commonly affects young children.
The meningococcus is spread by contact with respiratory droplets from the nose and throat of the infected person.
Meningococcal meningitis typically presents with sudden-onset intense headache, fever, nausea, vomiting, light sensitivity and stiff neck. Infants may only be slow, irritable and feeding poorly.
A petechial rash is the key sign of meningococcal septicaemia.
Meningococcal disease can be rapidly fatal and should always be treated as a medical emergency.
Conjugate vaccines are the preferred choice due to their better protection of children under two years of age and herd immunity.
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"text": "Table 1.11 Meningococcal polysaccharide vaccines summary Type of vaccine Purified bacterial capsular polysaccharide; bivalent, trivalent or quadrivalent Number of doses 1 Schedule 2 years of age and older Booster One dose after 3–5 years if still at risk Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Severe: rare anaphylaxis • Mild: injection site reaction, fever Special precautions Children under 2 years of age are not protected by the vaccine Dosage 0.5 ml Injection site Upper arm Injection type Subcutaneous Storage Between +2 °C and +8 °C",
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Table 1.11
Meningococcal polysaccharide vaccines summary
Type of vaccine
Purified bacterial capsular polysaccharide; bivalent, trivalent or quadrivalent
Number of doses
1
Schedule
2 years of age and older
Booster
One dose after 3–5 years if still at risk
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: rare anaphylaxis
• Mild: injection site reaction, fever
Special precautions
Children under 2 years of age are not protected by the vaccine
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"text": "Mumps is an infection caused by a virus that is present throughout the world. It is also known as infectious parotitis since it most often involves the salivary glands. When the mumps virus infects the testicles, the disease is called mumps orchitis. Mumps most often affects children of between five and nine years of age. The mumps virus can also infect adults, in which case the complications are more likely to be serious.",
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Mumps is an infection caused by a virus that is present throughout the world. It is also known as infectious parotitis since it most often involves the salivary glands. When the mumps virus infects the testicles, the disease is called mumps orchitis.
Mumps most often affects children of between five and nine years of age. The mumps virus can also infect adults, in which case the complications are more likely to be serious.
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"text": "\n\n\n8.2 How is mumps spread?\nThe mumps virus is spread by airborne droplets released when an infected person sneezes or coughs, and by direct contact with an infected person. A person who has mumps can infect others from about six days before to about nine days after salivary gland infection.",
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The mumps virus is spread by airborne droplets released when an infected person sneezes or coughs, and by direct contact with an infected person. A person who has mumps can infect others from about six days before to about nine days after salivary gland infection.
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"text": "\n\n\n8.3 What are the symptoms and signs of mumps?\nAbout 33% of individuals infected with the mumps virus have no symptoms or signs. If they do appear, they usually begin 14–21 days after infection. Symptoms include pain on chewing or swallowing. Fever and weakness can occur. Swelling of the salivary glands, just below and in front of the ears, is the most prominent sign and may occur on one or both sides of the neck. If mumps orchitis develops, the testicles usually become tender and swollen.",
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8.3 What are the symptoms and signs of mumps?
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"text": "About 33% of individuals infected with the mumps virus have no symptoms or signs. If they do appear, they usually begin 14–21 days after infection. Symptoms include pain on chewing or swallowing. Fever and weakness can occur. Swelling of the salivary glands, just below and in front of the ears, is the most prominent sign and may occur on one or both sides of the neck. If mumps orchitis develops, the testicles usually become tender and swollen.",
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About 33% of individuals infected with the mumps virus have no symptoms or signs. If they do appear, they usually begin 14–21 days after infection. Symptoms include pain on chewing or swallowing. Fever and weakness can occur. Swelling of the salivary glands, just below and in front of the ears, is the most prominent sign and may occur on one or both sides of the neck.
If mumps orchitis develops, the testicles usually become tender and swollen.
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"text": "\n\n\n8.4 What are the complications of mumps?\nComplications from mumps are rare, but they can be serious. In men and teenage boys, mumps orchitis may cause sterility. Encephalitis (brain infection), meningitis (infection of the membranes covering the brain and spinal cord) and hearing loss are other rare complications that can occur with mumps at any age.",
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8.4 What are the complications of mumps?
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Complications from mumps are rare, but they can be serious. In men and teenage boys, mumps orchitis may cause sterility. Encephalitis (brain infection), meningitis (infection of the membranes covering the brain and spinal cord) and hearing loss are other rare complications that can occur with mumps at any age.
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"text": "\n\n\n8.5 What is the treatment for mumps?\nThere is no specific treatment for mumps. Since it is caused by a virus, antibiotics are not effective. Supportive treatment should be given to relieve symptoms.\nModule 1: Target diseases and vaccines",
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8.5 What is the treatment for mumps?
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"text": "Mumps is prevented by immunization with mumps-containing vaccine. In countries implementing mumps vaccine, MMR, the combination measles-, mumps- and rubella-containing vaccine, is recommended. Sections 8.8–8.10 and Table 1.13 below describe mumps vaccine. Measles and rubella vaccines are described in Sections 6 and 13 of this module respectively. People who recover from mumps are thought to have lifelong immunity against the virus.",
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Mumps is prevented by immunization with mumps-containing vaccine. In countries implementing mumps vaccine, MMR, the combination measles-, mumps- and rubella-containing vaccine, is recommended. Sections 8.8–8.10 and Table 1.13 below describe mumps vaccine. Measles and rubella vaccines are described in Sections 6 and 13 of this module respectively.
People who recover from mumps are thought to have lifelong immunity against the virus.
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"text": "\n\n\n8.7 What is needed for global mumps control?\nRoutine mumps vaccination is recommended in countries with well-established programmes that maintain measles and rubella coverage at over 80%. Measles and congenital rubella syndrome are considered priorities because of their higher mortality and disease burden. Like rubella, mumps may cause more serious disease burden in older age groups if childhood vaccination lapses. Two doses of mumps-containing vaccine are required to maintain the high level of immunization coverage needed for mumps control. Countries must decide on the addition of mumps-containing vaccine based on the burden of this disease and its public health priority.",
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8.7 What is needed for global mumps control?
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"text": "Routine mumps vaccination is recommended in countries with well-established programmes that maintain measles and rubella coverage at over 80%. Measles and congenital rubella syndrome are considered priorities because of their higher mortality and disease burden. Like rubella, mumps may cause more serious disease burden in older age groups if childhood vaccination lapses. Two doses of mumps-containing vaccine are required to maintain the high level of immunization coverage needed for mumps control. Countries must decide on the addition of mumps-containing vaccine based on the burden of this disease and its public health priority.",
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Routine mumps vaccination is recommended in countries with well-established programmes that maintain measles and rubella coverage at over 80%. Measles and congenital rubella syndrome are considered priorities because of their higher mortality and disease burden. Like rubella, mumps may cause more serious disease burden in older age groups if childhood vaccination lapses. Two doses of mumps-containing vaccine are required to maintain the high level of immunization coverage needed for mumps control. Countries must decide on the addition of mumps-containing vaccine based on the burden of this disease and its public health priority.
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"text": "\n\n\n8.8 What are mumps-containing vaccines?\nMumps-containing vaccines such as MMR are supplied as freeze-dried (also called lyophilized) powders. They must be reconstituted before use: see Module 5 (Managing an immunization session), Section 4.2 for details. They should be kept at a temperature of between +2 °C and +8 °C. They are sensitive to heat but are not damaged by freezing. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy). Mumps-containing vaccines are administered by subcutaneous injection.",
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"text": "Mumps-containing vaccines such as MMR are supplied as freeze-dried (also called lyophilized) powders. They must be reconstituted before use: see Module 5 (Managing an immunization session), Section 4.2 for details. They should be kept at a temperature of between +2 °C and +8 °C. They are sensitive to heat but are not damaged by freezing. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy). Mumps-containing vaccines are administered by subcutaneous injection.",
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Mumps-containing vaccines such as MMR are supplied as freeze-dried (also called lyophilized) powders. They must be reconstituted before use: see Module 5 (Managing an immunization session), Section 4.2 for details. They should be kept at a temperature of between +2 °C and +8 °C. They are sensitive to heat but are not damaged by freezing. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).
Mumps-containing vaccines are administered by subcutaneous injection.
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"text": "\n\n\n8.9 How safe is mumps vaccine and what are the potential adverse events following immunization?\nMumps vaccine is very safe to use. Infrequently, depending on the vaccine virus strain used, aseptic meningitis (inflammation of the membranes covering the brain and spinal cord) has been reported at different rates. Children recover from it without long-term problems, although some may need to be hospitalized. Mild events include pain at the injection site (in 17–30% of those vaccinated) and parotid swelling (in 1–2%). There is no evidence to support an association between MMR and autism.\nA WHO safety information summary for MMR vaccine is available on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/ .\nModule 1: Target diseases and vaccines",
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A WHO safety information summary for MMR vaccine is available on the website:
8.10 When are mumps-containing vaccines administered?
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"text": "Two doses of mumps-containing vaccines are required for long-term protection. The first dose should be given at the age of 12–18 months. The second should be given at least one month before school entry; the age may range from the second year of life to about six years. Countries should decide on optimal timing to maximize programme coverage. The required minimum interval between doses is one month.",
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Two doses of mumps-containing vaccines are required for long-term protection. The first dose should be given at the age of 12–18 months. The second should be given at least one month before school entry; the age may range from the second year of life to about six years. Countries should decide on optimal timing to maximize programme coverage. The required minimum interval between doses is one month.
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"text": "\n DESCRIPTION:\n Le vaccin contre les oreillons est vivant atténué, administré en 2 doses (12-18 mois puis avant l'entrée à l'école), avec des contre-indications spécifiques.\n :TABLE DATA:\n Table 1.13 Mumps-containing vaccines summary Type of vaccine Live attenuated (weakened) viral Total number of doses 2 Schedule Mumps1: 12–18 months of age with MCV Mumps2: in the second year of life to school entry with MCV Minimum 1-month interval required between doses Contraindications Known allergy to vaccine components (including neomycin and gelatin) Pregnancy Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS Adverse events Serious: aseptic meningitis (with some strains); orchitis (inflammation of the testicles); sensorineural deafness; acute myositis (inflammation of the muscles) Mild: injection site reactions; parotid swelling Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh or upper arm depending on the child’s age Injection type Subcutaneous Storage Between +2 °C and +8 °C If using combination vaccines, keep all measles-containing vaccines away from sunlight\n :END TABLE DATA:\n\n ",
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Table 1.13 Mumps-containing vaccines summary
Type of vaccine
Live attenuated (weakened) viral
Total number of doses
2
Schedule
Mumps1: 12–18 months of age with MCV
Mumps2: in the second year of life to school entry with MCV
Minimum 1-month interval required between doses
Contraindications
Known allergy to vaccine components (including neomycin and gelatin)
Pregnancy
Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
Serious: aseptic meningitis (with some strains); orchitis (inflammation of the testicles); sensorineural deafness; acute myositis (inflammation of the muscles)
Mild: injection site reactions; parotid swelling
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh or upper arm depending on the child’s age
Injection type
Subcutaneous
Storage
Between +2 °C and +8 °C
If using combination vaccines, keep all measles-containing vaccines away from sunlight
Mumps2: in the second year of life to school entry with MCV
Minimum 1-month interval required between doses
Contraindications
Known allergy to vaccine components (including neomycin and gelatin)
Pregnancy
Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
Serious: aseptic meningitis (with some strains); orchitis (inflammation of the testicles); sensorineural deafness; acute myositis (inflammation of the muscles)
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Special precautions
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Subcutaneous
Storage
Between +2 °C and +8 °C
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"text": "\n\n\nKey points about mumps\nMumps is transmitted in airborne droplets emitted by infected individuals when they cough or sneeze. About one-third of individuals infected with mumps have no symptoms. The most prominent sign is swelling in the salivary glands. Complications from mumps are rare but can be serious. Mumps vaccine should be given in combination with measles and rubella vaccines (MMR) in high-performing immunization programmes with coverage over 80%.\n :TABLE DATA: \nTable 1.13 Mumps-containing vaccines summary Type of vaccine Live attenuated (weakened) viral Total number of doses 2 Schedule Mumps1: 12–18 months of age with MCV Mumps2: in the second year of life to school entry with MCV Minimum 1-month interval required between doses Contraindications Known allergy to vaccine components (including neomycin and gelatin) Pregnancy Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS Adverse events Serious: aseptic meningitis (with some strains); orchitis (inflammation of the testicles); sensorineural deafness; acute myositis (inflammation of the muscles) Mild: injection site reactions; parotid swelling Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh or upper arm depending on the child’s age Injection type Subcutaneous Storage Between +2 °C and +8 °C If using combination vaccines, keep all measles-containing vaccines away from sunlight\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Mumps is transmitted in airborne droplets emitted by infected individuals when they cough or sneeze.
About one-third of individuals infected with mumps have no symptoms.
The most prominent sign is swelling in the salivary glands.
Complications from mumps are rare but can be serious.
Mumps vaccine should be given in combination with measles and rubella vaccines (MMR) in high-performing immunization programmes with coverage over 80%.
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"text": "Table 1.13 Mumps-containing vaccines summary Type of vaccine Live attenuated (weakened) viral Total number of doses 2 Schedule Mumps1: 12–18 months of age with MCV Mumps2: in the second year of life to school entry with MCV Minimum 1-month interval required between doses Contraindications Known allergy to vaccine components (including neomycin and gelatin) Pregnancy Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS Adverse events Serious: aseptic meningitis (with some strains); orchitis (inflammation of the testicles); sensorineural deafness; acute myositis (inflammation of the muscles) Mild: injection site reactions; parotid swelling Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh or upper arm depending on the child’s age Injection type Subcutaneous Storage Between +2 °C and +8 °C If using combination vaccines, keep all measles-containing vaccines away from sunlight",
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Table 1.13 Mumps-containing vaccines summary
Type of vaccine
Live attenuated (weakened) viral
Total number of doses
2
Schedule
Mumps1: 12–18 months of age with MCV
Mumps2: in the second year of life to school entry with MCV
Minimum 1-month interval required between doses
Contraindications
Known allergy to vaccine components (including neomycin and gelatin)
Pregnancy
Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
Serious: aseptic meningitis (with some strains); orchitis (inflammation of the testicles); sensorineural deafness; acute myositis (inflammation of the muscles)
Mild: injection site reactions; parotid swelling
Special precautions
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Injection type
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Storage
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If using combination vaccines, keep all measles-containing vaccines away from sunlight
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"text": "Pertussis, or whooping cough, is a disease of the respiratory tract caused by Bordetella pertussis bacteria that live in the mouth, nose and throat. Because it is highly communicable and affects unimmunized infants in particular, pertussis remains a public health concern globally, including in countries where vaccination coverage is high.",
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Pertussis, or whooping cough, is a disease of the respiratory tract caused by
Bordetella pertussis
bacteria that live in the mouth, nose and throat. Because it is highly communicable and affects unimmunized infants in particular, pertussis remains a public health concern globally, including in countries where vaccination coverage is high.
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"text": "\n\n\n9.2 How is pertussis spread?\nPertussis spreads very easily from person to person in droplets produced by coughing or sneezing. Untreated patients may be infectious and spread pertussis for up to three weeks after the typical cough starts. In many countries, the disease occurs in regular epidemic cycles of three to five years.",
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Pertussis spreads very easily from person to person in droplets produced by coughing or sneezing. Untreated patients may be infectious and spread pertussis for up to three weeks after the typical cough starts. In many countries, the disease occurs in regular epidemic cycles of three to five years.
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"text": "\n\n\n9.3 What are the symptoms and signs of pertussis?\nAbout 10 days after infection, symptoms similar to a common cold appear – runny nose, watery eyes, sneezing, fever and a mild cough. The cough worsens to many rapid bursts. At the end of these bursts, the typical patient takes in air with a high-pitched whoop. Children may turn blue because they do not get enough oxygen during a long burst of coughing. Vomiting and exhaustion often follow the coughing attacks, which are particularly frequent at night.",
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About 10 days after infection, symptoms similar to a common cold appear – runny nose, watery eyes, sneezing, fever and a mild cough. The cough worsens to many rapid bursts. At the end of these bursts, the typical patient takes in air with a high-pitched whoop. Children may turn blue because they do not get enough oxygen during a long burst of coughing. Vomiting and exhaustion often follow the coughing attacks, which are particularly frequent at night.
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Prevention involves immunization with pertussis vaccine, which has been given in combination with diphtheria and tetanus vaccines (as DTP) for many years, but is more recently being given in pentavalent vaccine that covers hepatitis B and
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"text": "\n\n\n9.7 What are pertussis-containing vaccines?\nPertussis vaccine is most often given in DTP or pentavalent combination form. Pertussis-containing vaccines are supplied in single- and multi-dose presentations. Pentavalent vaccine with a freeze-dried Hib component requires reconstitution: see Module 5 (Managing an immunization session) , Section 4.2 for details. Pertussis-containing vaccines must be stored between +2 °C and +8 °C without being frozen. They are freeze-sensitive: see Module 2 (The vaccine cold chain) , Section 7 for instructions on the Shake Test that determines whether a vial is safe to use if freezing is suspected. Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).\nPertussis-containing vaccines are administered as 0.5 ml doses given intramuscularly in the anterolateral (outer) thigh in infants and in the deltoid muscle (upper arm) of older children and adults.",
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at between one and six years of age, preferably between one to two years of age. The booster dose should be given at least six months after the last primary dose.
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Schedules for combination vaccines are shown in the diphtheria and
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"text": "\n DESCRIPTION:\n Le tableau résume la vaccination contre la coqueluche : type de vaccin, doses, calendrier, contre-indications, effets indésirables, dosage et administration.\n :TABLE DATA:\n Table 1.14 Pertussis-containing vaccine summary Type of vaccine Killed whole cell or acellular (without intact cells) Number of doses 3 Schedule Pentavalent or DTP or pertussis vaccine 3-dose primary series starting at age 6 weeks (minimum) with second and third doses at intervals of 4–8 weeks after the previous dose Booster • Children between 1 and 6 years: 1 booster dose at least 6 months after the 3-dose primary series, preferably in the second year of life • Each country should make its own decision on booster doses in adolescents and adults Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Severe: rare anaphylaxis, hypotonic–hyporesponsive episodes (loss of muscle tone and responsiveness/consciousness); febrile seizures; prolonged crying • Mild: injection site reactions (pain, redness, swelling); fever and agitation Special precautions None Dosage 0.5 ml Injection site • Anterolateral (outer) mid-thigh in infants • Outer deltoid muscle of upper arm in children and adults Injection type Intramuscular Storage • Between +2 °C and +8 °C • Do not freeze\n :END TABLE DATA:\n\n ",
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Table 1.14
Pertussis-containing vaccine summary
Type of vaccine
Killed whole cell or acellular (without intact cells)
Number of doses
3
Schedule
Pentavalent or DTP or pertussis vaccine 3-dose primary series starting at age 6 weeks (minimum) with second and third doses at intervals of 4–8 weeks after the previous dose
Booster
• Children between 1 and 6 years: 1 booster dose at least 6 months after the 3-dose primary series, preferably in the second year of life
• Each country should make its own decision on booster doses in adolescents and adults
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: rare anaphylaxis, hypotonic–hyporesponsive episodes (loss of muscle tone and responsiveness/consciousness); febrile seizures; prolonged crying
• Mild: injection site reactions (pain, redness, swelling); fever and agitation
Special precautions
None
Dosage
0.5 ml
Injection site
• Anterolateral (outer) mid-thigh in infants
• Outer deltoid muscle of upper arm in children and adults
Killed whole cell or acellular (without intact cells)
Number of doses
3
Schedule
Pentavalent or DTP or pertussis vaccine 3-dose primary series starting at age 6 weeks (minimum) with second and third doses at intervals of 4–8 weeks after the previous dose
Booster
• Children between 1 and 6 years: 1 booster dose at least 6 months after the 3-dose primary series, preferably in the second year of life
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Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: rare anaphylaxis, hypotonic–hyporesponsive episodes (loss of muscle tone and responsiveness/consciousness); febrile seizures; prolonged crying
• Mild: injection site reactions (pain, redness, swelling); fever and agitation
Special precautions
None
Dosage
0.5 ml
Injection site
• Anterolateral (outer) mid-thigh in infants
• Outer deltoid muscle of upper arm in children and adults
Injection type
Intramuscular
Storage
• Between +2 °C and +8 °C
• Do not freeze
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Pertussis, or whooping cough, is a disease of the respiratory tract.
Pertussis is a bacterial infection spread from person to person by sneezing and coughing.
Infants and young children are most likely to be infected, to have serious complications, and to die from the disease.
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Pertussis-containing vaccine summary
Type of vaccine
Killed whole cell or acellular (without intact cells)
Number of doses
3
Schedule
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Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: rare anaphylaxis, hypotonic–hyporesponsive episodes (loss of muscle tone and responsiveness/consciousness); febrile seizures; prolonged crying
• Mild: injection site reactions (pain, redness, swelling); fever and agitation
Special precautions
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• Outer deltoid muscle of upper arm in children and adults
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"text": "\n\n\n10.1 What is pneumococcal disease?\nPneumococcal disease is caused by infection with a bacterium called Streptococcus pneumoniae (also known as the pneumococcus) in different parts of the body. The pneumococcus is a common cause of serious diseases, such as pneumonia, meningitis (infection of the membranes covering the brain and spinal cord) and septicaemia (bloodstream infection) and milder ones, such as otitis media (middle ear infection) and sinusitis.\nPneumococcal diseases are a common cause of morbidity and mortality worldwide, although rates of disease and death are higher in developing countries, with the majority of deaths occurring in sub-Saharan Africa and Asia. It is most common in very young children and elderly people. For infants, risk factors for pneumococcal disease include lack of breastfeeding and exposure to indoor smoke. HIV infection, sickle cell disease, asplenia (lack of a functioning spleen), chronic kidney disease and previous influenza virus infection are risk factors for all ages.",
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Pneumococcal disease is caused by infection with a bacterium called
Streptococcus pneumoniae
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"text": "\n\n\n10.3 What are the symptoms and signs of pneumococcal disease?\nBecause the pneumococcus can affect many parts of the body, symptoms and signs vary, depending on the site of infection. Fever and shaking or chills can occur with all types of pneumococcal disease. Children with pneumonia can present with cough, rapid breathing and chest wall retractions; older patients may complain of shortness of breath and pain when breathing in and on coughing. Patients with meningitis can present with headaches, sensitivity to light, neck stiffness, convulsions and sometimes confusion or altered consciousness. Those with otitis or sinusitis may have pain, tenderness and/or discharge from the affected area.\nModule 1: Target diseases and vaccines",
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Because the pneumococcus can affect many parts of the body, symptoms and signs vary, depending on the site of infection. Fever and shaking or chills can occur with all types of pneumococcal disease. Children with pneumonia can present with cough, rapid breathing and chest wall retractions; older patients may complain of shortness of breath and pain when breathing in and on coughing. Patients with meningitis can present with headaches, sensitivity to light, neck stiffness, convulsions and sometimes confusion or altered consciousness. Those with otitis or sinusitis may have pain, tenderness and/or discharge from the affected area.
10.4 What are the complications of pneumococcal disease?
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Pneumococcal disease can be prevented by vaccination. While improved living conditions (e.g. reduced crowding and indoor air pollutants) and nutrition can reduce the risk of pneumococcal disease and death, they are less effective than vaccines for prevention. Sections 10.8–10.10 and Table 1.16 below describe pneumococcal conjugate vaccine.
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"text": "\n\n\n10.8 What is pneumococcal conjugate vaccine?\nThe pneumococcus is a bacterium with an outer polysaccharide (or sugar) capsule. Many different strains, or serotypes, of pneumococcus have been identified based on differences in this capsule. Pneumococcal vaccines have been developed based on the serotypes frequently found in severe pneumococcal disease patients. There are two categories of pneumococcal vaccines. Pneumococcal polysaccharide vaccines were used for many years; they contain the purified capsule of up to 23 serotypes of pneumococcus but only produce short-term protection and are not effective in infants and young children. Pneumococcal conjugate vaccines (PCV) overcome the limitations of polysaccharide vaccines by conjugating, or binding, the capsule with a protein; this results in longer-lasting protection and makes the vaccine more effective in children.\nTarget diseases and vaccines\nEach pneumococcal vaccine protects against disease caused by the pneumococcal serotypes that it contains; it is unlikely to protect against serotypes that it does not contain. It does not protect against other bacteria that cause the same types of infections (pneumonia, meningitis, etc.) as the pneumococcus. The fact that the vaccine cannot protect against all causes of pneumonia should be emphasized in health education so that it is not misunderstood as a failure of the vaccine. Available pneumococcal conjugate vaccines are listed in Table 1.15 below. The number indicates how many pneumococcal serotypes the vaccine contains (for example, PCV10 protects against 10 serotypes of pneumococcus).\nPCVs in these presentations do not require reconstitution. They must be stored at a temperature of between +2 °C and +8 °C without being frozen. They are freeze-sensitive. If freezing is suspected, the Shake Test should be performed to determine whether a vial is safe to use (see Module 2 ( The vaccine cold chain ) , Section 7). Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).\nFor infants and children, 0.5 ml of PCV is administered by intramuscular injection in the anterolateral thigh.\n :TABLE DATA: \nVaccine Formulation Presentation PCV10 Liquid Single-dose vial PCV10 Liquid 2-dose, preservative-free vial Prefilled syringe PCV13 Liquid Single-dose vial Prefilled syringe\n :END TABLE DATA:",
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There are two categories of pneumococcal vaccines. Pneumococcal polysaccharide vaccines were used for many years; they contain the purified capsule of up to 23 serotypes of pneumococcus but only produce short-term protection and are not effective in infants and young children. Pneumococcal conjugate vaccines (PCV) overcome the limitations of polysaccharide vaccines by conjugating, or binding, the capsule with a protein; this results in longer-lasting protection and makes the vaccine more effective in children.
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Pneumococcal conjugate vaccine is safe and well tolerated in all target groups. No severe adverse events have been proven with use of these vaccines to date. Mild events include soreness at the injection site in about 10% of those vaccinated; fever has been reported in less than 1%.
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"text": "\n\n\n10.10 When is pneumococcal conjugate vaccine administered?\nPCVs should be given priority in childhood immunization programmes, particularly in countries with high mortality in children under five years of age (more than 50/1000 live births). Three doses are required and can be given as a three-primary (3p+0) or, as an alternative, two-primary-plus-one booster (2p+1) schedule. The 3p+0 schedule can be started as early as six weeks of age, with a minimum interval of four weeks between doses. The 2p+1 schedule is shown in Table 1.16 below. In choosing between schedules factors such as the epidemiology of the disease, likely coverage, and the timeliness of vaccination should be considered. Once a series has been started, the same product should ideally be used for all three doses; for example, if PCV10 is used for the first dose, it should be used for the second and third doses also. If this is not possible, the schedule may be completed with the available PCV. Previously unvaccinated or incompletely vaccinated children, including those who recover from pneumococcal disease, should be vaccinated according to their age. Children 12–24 months require only two doses, with an interval of at least eight weeks.",
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"text": "PCVs should be given priority in childhood immunization programmes, particularly in countries with high mortality in children under five years of age (more than 50/1000 live births). Three doses are required and can be given as a three-primary (3p+0) or, as an alternative, two-primary-plus-one booster (2p+1) schedule. The 3p+0 schedule can be started as early as six weeks of age, with a minimum interval of four weeks between doses. The 2p+1 schedule is shown in Table 1.16 below. In choosing between schedules factors such as the epidemiology of the disease, likely coverage, and the timeliness of vaccination should be considered. Once a series has been started, the same product should ideally be used for all three doses; for example, if PCV10 is used for the first dose, it should be used for the second and third doses also. If this is not possible, the schedule may be completed with the available PCV. Previously unvaccinated or incompletely vaccinated children, including those who recover from pneumococcal disease, should be vaccinated according to their age. Children 12–24 months require only two doses, with an interval of at least eight weeks.",
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PCVs should be given priority in childhood immunization programmes, particularly in countries with high mortality in children under five years of age (more than 50/1000 live births). Three doses are required and can be given as a three-primary (3p+0) or, as an alternative, two-primary-plus-one booster (2p+1) schedule. The 3p+0 schedule can be started as early as six weeks of age, with a minimum interval of four weeks between doses. The 2p+1 schedule is shown in Table 1.16 below. In choosing between schedules factors such as the epidemiology of the disease, likely coverage, and the timeliness of vaccination should be considered.
Once a series has been started, the same product should ideally be used for all three doses; for example, if PCV10 is used for the first dose, it should be used for the second and third doses also. If this is not possible, the schedule may be completed with the available PCV.
Previously unvaccinated or incompletely vaccinated children, including those who recover from pneumococcal disease, should be vaccinated according to their age. Children 12–24 months require only two doses, with an interval of at least eight weeks.
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"text": "\n DESCRIPTION:\n Le vaccin pneumococcique conjugué (3 doses) est administré par voie intramusculaire aux nourrissons dès 6 semaines, avec un rappel possible.\n :TABLE DATA:\n Table 1.16 Pneumococcal conjugate vaccine summary Type of vaccine Conjugate (pneumococcal polysaccharide bound to a carrier protein; does not contain any live bacteria) Total number of doses 3 Schedule – 3p+0 First dose as early as 6 weeks of age with 4–8 weeks interval between doses Schedule – 2p+1 • 2 primary doses ideally completed by six months of age, starting as early as 6 weeks of age with an interval of 8 weeks or more between doses • For infants ≥7 months who started vaccination late: a minimum interval of 4 weeks between doses is possible Booster • With 2p+1 schedule: one booster dose between 9–15 months of age • HIV+ infants and preterm neonates who receive 3p doses before 12 months of age may benefit from a booster dose during the second year of life Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Severe: none known • Mild: injection site reactions and fever Special precautions Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C) Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants and children Injection type Intramuscular Storage • Between +2 °C and +8 °C • Do not freeze\n :END TABLE DATA:\n\n ",
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Table 1.16 Pneumococcal conjugate vaccine summary
Type of vaccine
Conjugate (pneumococcal polysaccharide bound to a carrier protein; does not contain any live bacteria)
Total number of doses
3
Schedule – 3p+0
First dose as early as 6 weeks of age with 4–8 weeks interval between doses
Schedule – 2p+1
• 2 primary doses ideally completed by six months of age, starting as early as 6 weeks of age with an interval of 8 weeks or more between doses
• For infants ≥7 months who started vaccination late: a minimum interval of 4 weeks between doses is possible
Booster
• With 2p+1 schedule: one booster dose between 9–15 months of age
• HIV+ infants and preterm neonates who receive 3p doses before 12 months of age may benefit from a booster dose during the second year of life
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: none known
• Mild: injection site reactions and fever
Special precautions
Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C)
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants and children
Conjugate (pneumococcal polysaccharide bound to a carrier protein; does not contain any live bacteria)
Total number of doses
3
Schedule – 3p+0
First dose as early as 6 weeks of age with 4–8 weeks interval between doses
Schedule – 2p+1
• 2 primary doses ideally completed by six months of age, starting as early as 6 weeks of age with an interval of 8 weeks or more between doses
• For infants ≥7 months who started vaccination late: a minimum interval of 4 weeks between doses is possible
Booster
• With 2p+1 schedule: one booster dose between 9–15 months of age
• HIV+ infants and preterm neonates who receive 3p doses before 12 months of age may benefit from a booster dose during the second year of life
Contraindications
Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse events
• Severe: none known
• Mild: injection site reactions and fever
Special precautions
Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C)
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants and children
Injection type
Intramuscular
Storage
• Between +2 °C and +8 °C
• Do not freeze
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"text": "\n\n\nKey points about pneumococcal disease\nPneumococcal disease is a leading cause of death in children under five years of age, especially in developing countries. The pneumococcus can cause infections in different parts of the body; the most common severe diseases are pneumonia, meningitis and septicaemia. Healthy carriers as well as patients can spread pneumococcus. Pneumococcal vaccination should be given as part of a comprehensive package to protect, prevent and treat and to reduce mortality and morbidity from childhood pneumonia. Each pneumococcal vaccine protects against disease caused only by the pneumococcal serotypes that it contains. It does not protect against other bacteria that cause the same types of infections (pneumonia, meningitis, etc.).\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.16 Pneumococcal conjugate vaccine summary Type of vaccine Conjugate (pneumococcal polysaccharide bound to a carrier protein; does not contain any live bacteria) Total number of doses 3 Schedule – 3p+0 First dose as early as 6 weeks of age with 4–8 weeks interval between doses Schedule – 2p+1 • 2 primary doses ideally completed by six months of age, starting as early as 6 weeks of age with an interval of 8 weeks or more between doses • For infants ≥7 months who started vaccination late: a minimum interval of 4 weeks between doses is possible Booster • With 2p+1 schedule: one booster dose between 9–15 months of age • HIV+ infants and preterm neonates who receive 3p doses before 12 months of age may benefit from a booster dose during the second year of life Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose Adverse events • Severe: none known • Mild: injection site reactions and fever Special precautions Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C) Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants and children Injection type Intramuscular Storage • Between +2 °C and +8 °C • Do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Pneumococcal disease is a leading cause of death in children under five years of age, especially in developing countries.
The pneumococcus can cause infections in different parts of the body; the most common severe diseases are pneumonia, meningitis and septicaemia.
Healthy carriers as well as patients can spread pneumococcus.
Pneumococcal vaccination should be given as part of a comprehensive package to protect, prevent and treat and to reduce mortality and morbidity from childhood pneumonia.
Each pneumococcal vaccine protects against disease caused only by the pneumococcal serotypes that it contains. It does not protect against other bacteria that cause the same types of infections (pneumonia, meningitis, etc.).
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"text": "Poliomyelitis, or polio, is a highly infectious disease caused by poliovirus types 1, 2 or 3. These are also called wild polioviruses (WPVs) since they are the naturally occurring types that circulate and infect people. Polio mainly affects children of less than five years of age. One in 200 infections causes irreversible paralysis when the virus attacks the spinal cord nerve cells that control the muscles. Due to the Global Polio Eradication Initiative, which was launched in 1988, the number of countries still reporting WPVs has been reduced from 125 to three in 2015.",
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Poliomyelitis, or polio, is a highly infectious disease caused by poliovirus types 1, 2 or 3. These are also called wild polioviruses (WPVs) since they are the naturally occurring types that circulate and infect people.
Polio mainly affects children of less than five years of age. One in 200 infections causes irreversible paralysis when the virus attacks the spinal cord nerve cells that control the muscles.
Due to the Global Polio Eradication Initiative, which was launched in 1988, the number of countries still reporting WPVs has been reduced from 125 to three in 2015.
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Poliovirus spreads by the faecal-to-oral route. In areas with poor sanitation, it is thought to more commonly enter the body through the mouth when people eat food or drink water that is contaminated with faeces. The majority of infected people do not show symptoms but can still spread the disease.
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"text": "\n\n\n11.3 What are the symptoms and signs of polio?\nFollowing infection with poliovirus, approximately 25% of those infected develop a minor illness, usually with fever, headache and sore throat. Paralysis occurs in approximately 1% of those infected. Death occurs in approximately 5–10% of those paralysed.",
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Following infection with poliovirus, approximately 25% of those infected develop a minor illness, usually with fever, headache and sore throat. Paralysis occurs in approximately 1% of those infected. Death occurs in approximately 5–10% of those paralysed.
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"text": "\n\n\n11.4 What is the treatment for polio?\nThere is no cure for polio. Treatment consists of supportive, symptomatic care. A ventilator can help patients who have difficulty breathing. Orthopedic treatment, regular physiotherapy and the use of braces can help reduce the long-term crippling effects.",
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"text": "\n\n\n11.6 What is polio vaccine?\nOPV is a live attenuated (weakened) poliovirus vaccine that contains types 1, 2 and 3 individually or in combination (types 1, 2 and 3, or 1 and 3). It is supplied in multi-dose vials. It is very heat-sensitive and must be kept frozen during long-term storage. After thawing, it can be kept at a temperature of between +2 °C and +8 °C for a maximum of six months or can be refrozen. IPV is an inactivated poliovirus vaccine available as a stand-alone product or in combination with diphtheria, tetanus, pertussis, hepatitis B and/or Hib. It is stable outside the cold chain but should be stored between +2 °C and +8 °C. It must not be frozen. It is supplied in one-, five- or ten-dose vials. OPV is given orally and IPV is injected intramuscularly as a 0.5 ml dose.",
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OPV is a live attenuated (weakened) poliovirus vaccine that contains types 1, 2 and 3 individually or in combination (types 1, 2 and 3, or 1 and 3). It is supplied in multi-dose vials. It is very heat-sensitive and must be kept frozen during long-term storage. After thawing, it can be kept at a temperature of between +2 °C and +8 °C for a maximum of six months or can be refrozen.
IPV is an inactivated poliovirus vaccine available as a stand-alone product or in combination with diphtheria, tetanus, pertussis, hepatitis B and/or Hib. It is stable outside the cold chain but should be stored between +2 °C and +8 °C. It must not be frozen. It is supplied in one-, five- or ten-dose vials.
OPV is given orally and IPV is injected intramuscularly as a 0.5 ml dose.
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Both OPV and IPV are extremely safe. With OPV, vaccine-associated paralytic polio (VAPP) can occur in approximately 1 in 2.7 million doses. VAPP usually occurs with the first dose of OPV, and this small risk declines further with subsequent doses. On rare occasions, over time, in areas of low vaccination coverage, the live attenuated (weakened) viruses contained in OPV can begin to circulate and regain the ability to cause paralytic cases. This is known as circulating vaccine-derived poliovirus.
IPV is one of the safest vaccines in routine use. No serious adverse events have been linked to it. Mild events include injection site redness in less than 1% of those vaccinated, swelling in 3–11% and soreness in 14–29%.
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"text": "\n\n\n11.8 When is polio vaccine administered?\nPolio vaccine schedules for countries no longer infected are shown in Table 1.17. Countries reporting infections should refer to guidance available on the WHO website: http://www.who.int/immunization/documents/positionpapers/en/ .\nModule 1: Target diseases and vaccines",
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Polio vaccine schedules for countries no longer infected are shown in Table 1.17. Countries reporting infections should refer to guidance available on the WHO website:
IPV – No known serious reactions; mild injection site reactions do occur
Special precautions
Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C)
Dosage
OPV – 2 drops into the mouth
IPV – 0.5 ml injection
Route of administration
OPV – Oral only
IPV – Intramuscular injection; anterolateral (outer) mid-thigh in infants and children
Storage
OPV – Keep frozen; very heat sensitive; storage in temperatures of between +2 °C and +8 °C is possible for a maximum of 6 months
IPV – between +2 °C and +8 °C; do not freeze
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"text": "\n\n\nKey points about polio\nPolio is caused by wild type polioviruses 1, 2 and 3 and is easily spread by the faecal-to-oral and oral-to-oral routes. The majority of individuals infected do not have symptoms but can still spread the disease. Approximately 1% of infections result in paralytic poliomyelitis; when paralysis occurs, it will lead to death in approximately 5–10% of cases. For countries using OPV only, WHO recommends that they introduce at least one dose of IPV to the routine immunization schedule.\n :TABLE DATA: \nTable 1.17 Polio vaccination summary Type of vaccine OPV – Live attenuated (weakened) viral; IPV – Inactivated viral Total number of doses 3–4 Schedule – OPV plus IPV 3 OPV doses initiated from 6 weeks of age with minimum interval of 4 weeks; an IPV dose should be given from 14 weeks of age (with OPV dose). Note: In areas where polio is endemic or there is high-risk for importation, an OPV birth dose (a zero dose) should be given Schedule – Sequential IPV-OPV 1–2 doses of IPV starting from 2 months of age, followed by at least 2 doses of OPV; an interval of 4–8 weeks is required between all doses Schedule – IPV-only 3 doses beginning at 2 months of age, with an interval of 4–8 weeks between doses Booster IPV-only schedule If the series begins before 2 months of age, then give booster ≥ 6 months after last dose Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose Adverse events OPV – Rare vaccine-associated paralytic polio (VAPP) IPV – No known serious reactions; mild injection site reactions do occur Special precautions Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C) Dosage OPV – 2 drops into the mouth IPV – 0.5 ml injection Route of administration OPV – Oral only IPV – Intramuscular injection; anterolateral (outer) mid-thigh in infants and children Storage OPV – Keep frozen; very heat sensitive; storage in temperatures of between +2 °C and +8 °C is possible for a maximum of 6 months IPV – between +2 °C and +8 °C; do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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The majority of individuals infected do not have symptoms but can still spread the disease.
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"text": "Table 1.17 Polio vaccination summary Type of vaccine OPV – Live attenuated (weakened) viral; IPV – Inactivated viral Total number of doses 3–4 Schedule – OPV plus IPV 3 OPV doses initiated from 6 weeks of age with minimum interval of 4 weeks; an IPV dose should be given from 14 weeks of age (with OPV dose). Note: In areas where polio is endemic or there is high-risk for importation, an OPV birth dose (a zero dose) should be given Schedule – Sequential IPV-OPV 1–2 doses of IPV starting from 2 months of age, followed by at least 2 doses of OPV; an interval of 4–8 weeks is required between all doses Schedule – IPV-only 3 doses beginning at 2 months of age, with an interval of 4–8 weeks between doses Booster IPV-only schedule If the series begins before 2 months of age, then give booster ≥ 6 months after last dose Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose Adverse events OPV – Rare vaccine-associated paralytic polio (VAPP) IPV – No known serious reactions; mild injection site reactions do occur Special precautions Postpone vaccination if the child has moderate to severe illness (with temperature ≥39 °C) Dosage OPV – 2 drops into the mouth IPV – 0.5 ml injection Route of administration OPV – Oral only IPV – Intramuscular injection; anterolateral (outer) mid-thigh in infants and children Storage OPV – Keep frozen; very heat sensitive; storage in temperatures of between +2 °C and +8 °C is possible for a maximum of 6 months IPV – between +2 °C and +8 °C; do not freeze",
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Table 1.17Polio vaccination summary
Type of vaccine
OPV – Live attenuated (weakened) viral; IPV – Inactivated viral
Total number of doses
3–4
Schedule – OPV plus IPV
3 OPV doses initiated from 6 weeks of age with minimum interval of 4 weeks; an IPV dose should be given from 14 weeks of age (with OPV dose).
Note: In areas where polio is endemic or there is high-risk for importation, an OPV birth dose (a zero dose) should be given
Schedule – Sequential IPV-OPV
1–2 doses of IPV starting from 2 months of age, followed by at least 2 doses of OPV; an interval of 4–8 weeks is required between all doses
Schedule – IPV-only
3 doses beginning at 2 months of age, with an interval of 4–8 weeks between doses
Booster IPV-only schedule
If the series begins before 2 months of age, then give booster ≥ 6 months after last dose
Contraindications
Known hypersensitivity (allergy) or anaphylaxis to a previous dose
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Rotavirus gastroenteritis is a highly infectious diarrhoeal disease caused by strains of rotavirus infecting the small intestine. Rotavirus gastroenteritis is the leading cause of severe diarrhoea in infants and young children worldwide. It occurs everywhere, including in countries where sanitation standards and access to safe water are good.
Deaths occur mainly in infants of between three and 12 months of age when they develop severe gastroenteritis following their first infection and are very vulnerable to the effects of dehydration.
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Rotavirus spreads by the faecal-to-oral route. Large quantities of virus can be shed in the faeces of an infected child. Shedding can occur from two days before to 10 days after the onset of symptoms. Rotavirus is stable in the environment and can spread via contaminated food, water and objects.
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Rotavirus gastroenteritis can range from mild loose stools to severe watery diarrhoea and vomiting leading to dehydration. Symptoms usually begin one to three days after infection. Fever and vomiting can occur before diarrhoea. The diarrhoea lasts for three to seven days on average.
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There is no specific antiviral treatment for rotavirus gastroenteritis. As with other causes of diarrhoea, key supportive measures are fluid replacement with oral rehydration solution (ORS) and treatment with zinc supplementation. Severe dehydration may require intravenous infusion in addition to ORS for the urgent replacement of fluid and electrolytes.
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"text": "\n\n\n12.6 How is rotavirus gastroenteritis prevented?\nOver the past 20 years, global deaths due to diarrhoea from other causes have decreased significantly due to improved nutrition, hygiene and sanitation and the availability of ORS and zinc. Improvements in sanitation and access to safe water are less effective for reducing rotavirus infections, and vaccination has become important for prevention of severe rotavirus disease in particular. Sections 12.8–12.10 and Table 1.18 describe rotavirus vaccines. The first infection will give some, but not complete, immunity. The severity of infection tends to become less with each repeat infection.",
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The first infection will give some, but not complete, immunity. The severity of infection tends to become less with each repeat infection.
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The currently available rotavirus vaccines (RV) contain one or more live attenuated (weakened) virus strains. They are given orally to protect against rotavirus gastroenteritis. They do not protect against other causes of diarrhoea, a fact that is important to emphasize in health education.
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"text": "\n\n\n12.9 How safe are rotavirus vaccines and what are the potential adverse reactions?\nThe available rotavirus vaccines are safe and well tolerated. There is a low risk of intussusception (about one to two per 100 000 infants vaccinated; see box on intussusception). Both are approved for administration with other vaccines in infant immunization programmes. Mild adverse reactions include irritability, runny nose, ear infection, vomiting and diarrhoea (in 5% or more of children vaccinated). Rotavirus vaccines are generally not recommended for infants with a history of intussusception. Studies show a much smaller increase in risk (five to 10 times lower) of intussusception after the first dose of Rotarix® or RotaTeq® than with an earlier vaccine called RotaShield® that was withdrawn from the market. The benefits of the currently available rotavirus vaccines are far greater than the potential risks.\nA WHO safety information summary for rotavirus vaccines is on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/ .",
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The available rotavirus vaccines are safe and well tolerated. There is a low risk of intussusception (about one to two per 100 000 infants vaccinated; see box on intussusception). Both are approved for administration with other vaccines in infant immunization programmes. Mild adverse reactions include irritability, runny nose, ear infection, vomiting and diarrhoea (in 5% or more of children vaccinated).
Rotavirus vaccines are generally not recommended for infants with a history of intussusception. Studies show a much smaller increase in risk (five to 10 times lower) of intussusception after the first dose of Rotarix® or RotaTeq® than with an earlier vaccine called RotaShield® that was withdrawn from the market. The benefits of the currently available rotavirus vaccines are far greater than the potential risks.
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A WHO safety information summary for rotavirus vaccines is on the website:
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"text": "\n\n\nWhat is intussusception?\nIntussusception is a folding or telescoping of one segment of the intestine within another. Intussusception usually results in a blockage of the intestine (bowel obstruction). Intussusception occurs primarily in infants; peak incidence is between four and 10 months of age. Symptoms and signs of intussusception include abdominal pain sometimes accompanied by a lump that can be felt on examination, vomiting, stools with blood and mucus, and lethargy. These are not specific and may be caused by other bowel diseases, but intussusception should be considered as one of the possible diagnoses in relevant cases. Early diagnosis and treatment of intussusception are essential to save the intestine and the child. A child that has any of the above symptoms should be taken immediately to the nearest hospital for urgent evaluation and appropriate treatment.\nModule 1: Target diseases and vaccines",
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"text": "Intussusception is a folding or telescoping of one segment of the intestine within another. Intussusception usually results in a blockage of the intestine (bowel obstruction). Intussusception occurs primarily in infants; peak incidence is between four and 10 months of age. Symptoms and signs of intussusception include abdominal pain sometimes accompanied by a lump that can be felt on examination, vomiting, stools with blood and mucus, and lethargy. These are not specific and may be caused by other bowel diseases, but intussusception should be considered as one of the possible diagnoses in relevant cases. Early diagnosis and treatment of intussusception are essential to save the intestine and the child. A child that has any of the above symptoms should be taken immediately to the nearest hospital for urgent evaluation and appropriate treatment.",
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Intussusception is a folding or telescoping of one segment of the intestine within another.
Intussusception usually results in a blockage of the intestine (bowel obstruction).
Intussusception occurs primarily in infants; peak incidence is between four and 10 months of age.
Symptoms and signs of intussusception include abdominal pain sometimes accompanied by a lump that can be felt on examination, vomiting, stools with blood and mucus, and lethargy.
These are not specific and may be caused by other bowel diseases, but intussusception should be considered as one of the possible diagnoses in relevant cases.
Early diagnosis and treatment of intussusception are essential to save the intestine and the child.
A child that has any of the above symptoms should be taken immediately to the nearest hospital for urgent evaluation and appropriate treatment.
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"text": "WHO recommendations encourage early vaccination (first dose of RV to be given as soon as possible after six weeks of age), but allow infants to receive rotavirus vaccine together with pentavalent vaccine (DTP4+HepB+Hib) regardless of the time of vaccination. Because rotavirus disease mainly affects very young children, vaccination after 24 months of age is not recommended. The duration of protection of RV is not yet known, but boosters are also not recommended.",
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WHO recommendations encourage early vaccination (first dose of RV to be given as soon as possible after six weeks of age), but allow infants to receive rotavirus vaccine together with pentavalent vaccine (DTP4+HepB+Hib) regardless of the time of vaccination.
Because rotavirus disease mainly affects very young children, vaccination after 24 months of age is not recommended. The duration of protection of RV is not yet known, but boosters are also not recommended.
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"text": "\n DESCRIPTION:\n Le tableau résume les vaccins contre le rotavirus (Rotarix et RotaTeq), leurs schémas vaccinaux, contre-indications, effets indésirables et précautions.\n :TABLE DATA:\n Table 1.18 Rotavirus vaccines summary Type of vaccine Live attenuated (weakened) viral Number of doses 2 for RV1 (monovalent RV, Rotarix ® ) 3 for RV5 (pentavalent RV, RotaTeq ® ) Schedule – Rotarix ® First dose with pentavalent1; second dose with pentavalent2, with a minimum interval of 4 weeks. Not recommended after 24 months of age Schedule – RotaTeq ® First dose with pentavalent1; second dose with pentavalent2; third dose with pentavalent3, with a minimum interval of 4 weeks. Not recommended after 24 months of age Booster Not recommended at this time Contraindications Severe allergic reaction to previous dose Severe immunodeficiency (but not HIV infection) Adverse events Severe: intussusception Mild: irritability, runny nose, ear infection, diarrhoea, vomiting Special precautions Should be postponed for acute gastroenteritis and/or fever with moderate to severe illness Not routinely recommended for history of intussusception or intestinal malformations that possibly predispose to intussusception Dosage Rotarix ® : 1.5 ml of liquid RotaTeq ® : 2 ml Route of administration Oral only Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.18 Rotavirus vaccines summary Type of vaccine Live attenuated (weakened) viral Number of doses 2 for RV1 (monovalent RV, Rotarix ® ) 3 for RV5 (pentavalent RV, RotaTeq ® ) Schedule – Rotarix ® First dose with pentavalent1; second dose with pentavalent2, with a minimum interval of 4 weeks. Not recommended after 24 months of age Schedule – RotaTeq ® First dose with pentavalent1; second dose with pentavalent2; third dose with pentavalent3, with a minimum interval of 4 weeks. Not recommended after 24 months of age Booster Not recommended at this time Contraindications Severe allergic reaction to previous dose Severe immunodeficiency (but not HIV infection) Adverse events Severe: intussusception Mild: irritability, runny nose, ear infection, diarrhoea, vomiting Special precautions Should be postponed for acute gastroenteritis and/or fever with moderate to severe illness Not routinely recommended for history of intussusception or intestinal malformations that possibly predispose to intussusception Dosage Rotarix ® : 1.5 ml of liquid RotaTeq ® : 2 ml Route of administration Oral only Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.18 Rotavirus vaccines summary
Type of vaccine
Live attenuated (weakened) viral
Number of doses
2 for RV1 (monovalent RV, Rotarix
®
)
3 for RV5 (pentavalent RV, RotaTeq
®
)
Schedule – Rotarix
®
First dose with pentavalent1; second dose with pentavalent2, with a minimum interval of 4 weeks.
Not recommended after 24 months of age
Schedule – RotaTeq
®
First dose with pentavalent1; second dose with pentavalent2; third dose with pentavalent3, with a minimum interval of 4 weeks.
Should be postponed for acute gastroenteritis and/or fever with moderate to severe illness
Not routinely recommended for history of intussusception or intestinal malformations that possibly predispose to intussusception
Dosage
Rotarix
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RotaTeq
®
: 2 ml
Route of administration
Oral only
Storage
Between +2 °C and +8 °C
Do not freeze
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"text": "\n\n\nKey points about rotavirus gastroenteritis\nRotavirus is a common cause of gastroenteritis in infants and young children. The disease spreads by the faecal-to-oral route and the virus is stable in the environment. Severe disease can lead to rapid dehydration resulting in shock and death if fluids are not replaced quickly by ORS and, if needed, intravenous infusion. Vaccination is the best prevention for rotavirus gastroenteritis since safe water and sanitation measures are less effective in preventing rotavirus infections than in preventing other causes of diarrhoea. Rotavirus vaccination prevents only rotavirus gastroenteritis and should be included as part of a comprehensive treatment and prevention strategy to control diarrhoea.\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.18 Rotavirus vaccines summary Type of vaccine Live attenuated (weakened) viral Number of doses 2 for RV1 (monovalent RV, Rotarix ® ) 3 for RV5 (pentavalent RV, RotaTeq ® ) Schedule – Rotarix ® First dose with pentavalent1; second dose with pentavalent2, with a minimum interval of 4 weeks. Not recommended after 24 months of age Schedule – RotaTeq ® First dose with pentavalent1; second dose with pentavalent2; third dose with pentavalent3, with a minimum interval of 4 weeks. Not recommended after 24 months of age Booster Not recommended at this time Contraindications Severe allergic reaction to previous dose Severe immunodeficiency (but not HIV infection) Adverse events Severe: intussusception Mild: irritability, runny nose, ear infection, diarrhoea, vomiting Special precautions Should be postponed for acute gastroenteritis and/or fever with moderate to severe illness Not routinely recommended for history of intussusception or intestinal malformations that possibly predispose to intussusception Dosage Rotarix ® : 1.5 ml of liquid RotaTeq ® : 2 ml Route of administration Oral only Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nTarget diseases and vaccines",
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Rotavirus is a common cause of gastroenteritis in infants and young children.
The disease spreads by the faecal-to-oral route and the virus is stable in the environment.
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"text": "\n\n\n13.1 What are rubella and congenital rubella syndrome?\nRubella is an infection caused by a virus and is usually mild in children and adults. Congenital rubella syndrome (CRS) is a group of birth defects that occur when the rubella virus infects a fetus. A woman infected with the rubella virus early in pregnancy has a 90% chance of passing the virus on to her fetus and this can lead to death of the fetus or to CRS. The most common birth defect is deafness, but CRS can also cause defects in the eyes, heart and brain.",
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13.1 What are rubella and congenital rubella syndrome?
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Rubella is an infection caused by a virus and is usually mild in children and adults. Congenital rubella syndrome (CRS) is a group of birth defects that occur when the rubella virus infects a fetus. A woman infected with the rubella virus early in pregnancy has a 90% chance of passing the virus on to her fetus and this can lead to death of the fetus or to CRS. The most common birth defect is deafness, but CRS can also cause defects in the eyes, heart and brain.
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"text": "\n\n\n13.2 How is rubella virus spread?\nRubella is spread in airborne droplets released when infected people sneeze or cough. The virus spreads throughout the body and, in a pregnant woman, to the fetus, about five to seven days after infection. Infected individuals are most likely to spread virus on days one to five of the rubella rash (see below), but they can spread it from seven days before to about 14 days after the rash appears. Infants with CRS can transmit the virus for a year or more.",
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13.2 How is rubella virus spread?
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Rubella is spread in airborne droplets released when infected people sneeze or cough. The virus spreads throughout the body and, in a pregnant woman, to the fetus, about five to seven days after infection.
Infected individuals are most likely to spread virus on days one to five of the rubella rash (see below), but they can spread it from seven days before to about 14 days after the rash appears. Infants with CRS can transmit the virus for a year or more.
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"text": "\n\n\n13.3 What are the symptoms and signs of rubella and CRS?\nAbout seven to 14 days after exposure to the virus, mild fever, conjunctivitis (more often in adults) and swollen neck lymph nodes may occur and then be followed by a rash five to 10 days later. The rash most often begins on the face and spreads towards the feet. It is an erythematous maculopapular rash, which means it is red and raised but usually fainter than a measles rash. The rash typically lasts for one to three days. Studies have shown that 20–50% of rubella infections occur without a rash. Up to 70% of adult women may have joint pain and stiffness. Children with CRS usually show birth defects, such as cataracts and loss of hearing in infancy, but some do not show signs for two to four years. Mental retardation can occur.",
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About seven to 14 days after exposure to the virus, mild fever, conjunctivitis (more often in adults) and swollen neck lymph nodes may occur and then be followed by a rash five to 10 days later. The rash most often begins on the face and spreads towards the feet. It is an erythematous maculopapular rash, which means it is red and raised but usually fainter than a measles rash. The rash typically lasts for one to three days. Studies have shown that 20–50% of rubella infections occur without a rash. Up to 70% of adult women may have joint pain and stiffness.
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"text": "\n\n\n13.4 What are the complications of rubella?\nComplications of rubella tend to occur more often in adults than in children. Encephalitis occurs in about one in 6000 cases and is most common in adult women. Problems with bleeding occur in about one in 3000 cases, usually among children. Guillain-Barré syndrome has been reported rarely.\nTarget diseases and vaccines",
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Complications of rubella tend to occur more often in adults than in children. Encephalitis occurs in about one in 6000 cases and is most common in adult women. Problems with bleeding occur in about one in 3000 cases, usually among children. Guillain-Barré syndrome has been reported rarely.
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"text": "\n\n\n13.6 How are rubella and CRS prevented?\nRubella and CRS are prevented with safe, effective rubella vaccines. For infant immunization, rubella vaccine is usually given in combination with measles and mumps vaccine (MR or MMR). In some countries, mostly in the industrialized world, rubella has been nearly eliminated through childhood immunization programmes. It is important to ensure that coverage in infants is sustained at over 80% to avoid shifting rubella transmission to older age groups. For prevention of CRS, women of childbearing age are the primary target group for rubella immunization. Sections 13.8–13.10 and Table 1.19 describe the rubella vaccine. Measles and mumps vaccines are described in Sections 6 and 8 of this module respectively.",
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"text": "\n\n\n13.8 What are rubella-containing vaccines?\nMR and MMR are supplied as freeze-dried (also called lyophilized) powders. They must be reconstituted before use: see Module 5 (Managing an immunization session), Section 4.2 for details. Rubella-containing vaccines must be stored between +2 °C and +8 °C. They are sensitive to heat but not damaged by freezing. Opened multi-dose vials must be handled according to national multi-dose vial policy: see Module 2 (The vaccine cold chain), Section 5 for WHO policy. Rubella-containing vaccines are administered in 0.5 ml doses by subcutaneous injection.",
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MR and MMR are supplied as freeze-dried (also called lyophilized) powders. They must be reconstituted before use: see Module 5 (Managing an immunization session), Section 4.2 for details. Rubella-containing vaccines must be stored between +2 °C and +8 °C. They are sensitive to heat but not damaged by freezing. Opened multi-dose vials must be handled according to national multi-dose vial policy: see Module 2 (The vaccine cold chain), Section 5 for WHO policy.
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"text": "\n\n\n13.10 When is rubella-containing vaccine administered?\nRubella-containing vaccine should be given at nine to 12 months of age. It can be introduced into childhood immunization programmes with the two-dose schedule for measles-containing vaccines. Countries should establish national schedules for older children, adolescents and adults as needed.",
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"text": "\n DESCRIPTION:\n La vaccination contre la rubéole utilise un vaccin vivant atténué administré par voie sous-cutanée, avec une dose à 9-12 mois (ou deux en combinaison ROR).\n :TABLE DATA:\n Table 1.19 Rubella-containing vaccines summary Type of vaccine Live attenuated (weakened) viral Total number of doses 1 (but when given in combination with measles/mumps, 2 doses are required for programmatic reasons) Schedule Rubella1: 9 or 12 months of age with MCV Refer to national schedules for older children, adolescents and adults Contraindications Known allergy to vaccine components (including neomycin and gelatin) Pregnancy Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS Adverse events In some adult women: serious arthritis (joint inflammation) and mild arthralgia (joint pain) Mild: injection site reactions Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh or upper arm depending on the child’s age Injection type Subcutaneous Storage Between +2 °C and +8 °C If using combination vaccines, keep all measles-containing vaccines away from sunlight\n :END TABLE DATA:\n\n ",
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Table 1.19 Rubella-containing vaccines summary
Type of vaccine
Live attenuated (weakened) viral
Total number of doses
1 (but when given in combination with measles/mumps, 2 doses are required for programmatic reasons)
Schedule
Rubella1: 9 or 12 months of age with MCV
Refer to national schedules for older children, adolescents and adults
Contraindications
Known allergy to vaccine components (including neomycin and gelatin)
Pregnancy
Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
In some adult women: serious arthritis (joint inflammation) and mild arthralgia (joint pain)
Mild: injection site reactions
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh or upper arm depending on the child’s age
Injection type
Subcutaneous
Storage
Between +2 °C and +8 °C
If using combination vaccines, keep all measles-containing vaccines away from sunlight
1 (but when given in combination with measles/mumps, 2 doses are required for programmatic reasons)
Schedule
Rubella1: 9 or 12 months of age with MCV
Refer to national schedules for older children, adolescents and adults
Contraindications
Known allergy to vaccine components (including neomycin and gelatin)
Pregnancy
Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS
Adverse events
In some adult women: serious arthritis (joint inflammation) and mild arthralgia (joint pain)
Mild: injection site reactions
Special precautions
None
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Subcutaneous
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Between +2 °C and +8 °C
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"text": "\n\n\nKey points about rubella and CRS\n➢ Rubella and CRS are infections caused by a virus. ➢ Rubella is normally a mild childhood disease, but women who contract rubella early in pregnancy can pass the virus on to their fetuses and this can lead to fetal death or CRS. ➢ The rash associated with rubella infection may not occur in 20–50% of cases. ➢ CRS includes birth defects of the ears, eyes, heart and brain. ➢ WHO currently recommends that countries use rubella vaccine in conjunction with measles vaccine (MR or MMR) for the goal of rubella and CRS elimination.\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.19 Rubella-containing vaccines summary Type of vaccine Live attenuated (weakened) viral Total number of doses 1 (but when given in combination with measles/mumps, 2 doses are required for programmatic reasons) Schedule Rubella1: 9 or 12 months of age with MCV Refer to national schedules for older children, adolescents and adults Contraindications Known allergy to vaccine components (including neomycin and gelatin) Pregnancy Severe congenital or acquired immune disorders, including advanced HIV infection/AIDS Adverse events In some adult women: serious arthritis (joint inflammation) and mild arthralgia (joint pain) Mild: injection site reactions Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh or upper arm depending on the child’s age Injection type Subcutaneous Storage Between +2 °C and +8 °C If using combination vaccines, keep all measles-containing vaccines away from sunlight\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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➢ Rubella and CRS are infections caused by a virus.
➢ Rubella is normally a mild childhood disease, but women who contract rubella early in pregnancy can pass the virus on to their fetuses and this can lead to fetal death or CRS.
➢ The rash associated with rubella infection may not occur in 20–50% of cases.
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"text": "\n\n\n14.1 What is seasonal influenza?\nSeasonal influenza is a respiratory disease caused by influenza viruses A and B. In temperate climates, it can occur primarily in winter epidemics. In tropical climates, it can occur year-round with high attack rates and deaths. Globally, seasonal influenza can affect 5–10% of adults and 20–30% of children each year. Children under five years of age, pregnant women, the elderly (over 65 years of age) and people with HIV/AIDS, asthma, and other chronic heart or lung conditions are at greater risk.",
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Seasonal influenza is a respiratory disease caused by influenza viruses A and B. In temperate climates, it can occur primarily in winter epidemics. In tropical climates, it can occur year-round with high attack rates and deaths. Globally, seasonal influenza can affect 5–10% of adults and 20–30% of children each year. Children under five years of age, pregnant women, the elderly (over 65 years of age) and people with HIV/AIDS, asthma, and other chronic heart or lung conditions are at greater risk.
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"text": "\n\n\n14.4 What are the complications of seasonal influenza?\nBacterial pneumonia is a frequent complication in the elderly and people with certain chronic diseases. Two of the bacteria that are often found, Streptococcus pneumoniae and Haemophilus influenzae, are discussed in previous sections of this module. Pregnant women are at increased risk of severe disease and death, and complications for their babies, such as stillbirth, preterm delivery, neonatal death and low birth weight. Elderly persons (age 65 years or over) have the highest risk of mortality from influenza.",
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Annual vaccination is recommended to prevent seasonal influenza, particularly for high-risk groups. WHO recommends that pregnant women should be the first priority for influenza vaccine. Children aged six to 59 months, the elderly (over 65 years of age), people with chronic conditions and health care workers may also be vaccinated based on the local burden of disease, available resources and competing health priorities. Sections 14.7–14.9 and Table 1.20 describe influenza vaccines.
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"text": "\n\n\n14.7 What is seasonal influenza vaccine?\nMost seasonal influenza vaccines are trivalent, containing two strains of influenza A and one strain of influenza B, which are chosen based on known circulating strains. Both inactivated and live attenuated (weakened) trivalent vaccines are available. A quadrivalent live attenuated (weakened) vaccine was licensed in the USA in 2012. Inactivated influenza vaccines are usually available in multi-dose vials that have preservative (thiomersal). Preservative-free, single-dose vials and prefilled syringes are in limited supply and more expensive. They do not require reconstitution and must be stored at a temperature of between +2°C and +8 °C without freezing. Inactivated influenza vaccines are administered intramuscularly in 0.5 ml doses. Live attenuated (weakened) vaccines are administered as nasal sprays and are generally used for healthy individuals between two and 49 years of age. The rest of this section focuses on inactivated influenza vaccines since they are recommended for pregnant women at any time, children six to 59 months of age and persons of 50 years of age and older.",
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"text": "Most seasonal influenza vaccines are trivalent, containing two strains of influenza A and one strain of influenza B, which are chosen based on known circulating strains. Both inactivated and live attenuated (weakened) trivalent vaccines are available. A quadrivalent live attenuated (weakened) vaccine was licensed in the USA in 2012. Inactivated influenza vaccines are usually available in multi-dose vials that have preservative (thiomersal). Preservative-free, single-dose vials and prefilled syringes are in limited supply and more expensive. They do not require reconstitution and must be stored at a temperature of between +2°C and +8 °C without freezing. Inactivated influenza vaccines are administered intramuscularly in 0.5 ml doses. Live attenuated (weakened) vaccines are administered as nasal sprays and are generally used for healthy individuals between two and 49 years of age. The rest of this section focuses on inactivated influenza vaccines since they are recommended for pregnant women at any time, children six to 59 months of age and persons of 50 years of age and older.",
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Most seasonal influenza vaccines are trivalent, containing two strains of influenza A and one strain of influenza B, which are chosen based on known circulating strains. Both inactivated and live attenuated (weakened) trivalent vaccines are available. A quadrivalent live attenuated (weakened) vaccine was licensed in the USA in 2012.
Inactivated influenza vaccines are usually available in multi-dose vials that have preservative (thiomersal). Preservative-free, single-dose vials and prefilled syringes are in limited supply and more expensive. They do not require reconstitution and must be stored at a temperature of between +2°C and +8 °C without freezing.
Inactivated influenza vaccines are administered intramuscularly in 0.5 ml doses.
Live attenuated (weakened) vaccines are administered as nasal sprays and are generally used for healthy individuals between two and 49 years of age.
The rest of this section focuses on inactivated influenza vaccines since they are recommended for pregnant women at any time, children six to 59 months of age and persons of 50 years of age and older.
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"text": "\n\n\n14.8 How safe are inactivated influenza vaccines and what are the potential adverse events following immunization?\nInactivated influenza vaccines are considered safe. Severe adverse events have included anaphylaxis in 0.7 per million vaccinations, Guillain-Barré syndrome in one to two per million (in older adults) and oculo (eye)-respiratory syndrome in 76 per million. Mild events include local injection site reactions in 10–64%, fever in 12% of children aged one to five years and fever in 5% of children aged six to 15 years. Inactivated influenza vaccines are contraindicated in cases of known allergic reaction to a previous dose or to a vaccine component, including egg protein.\nA WHO safety information summary on influenza vaccines is on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/ .\nTarget diseases and vaccines",
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"text": "Inactivated influenza vaccines are considered safe. Severe adverse events have included anaphylaxis in 0.7 per million vaccinations, Guillain-Barré syndrome in one to two per million (in older adults) and oculo (eye)-respiratory syndrome in 76 per million. Mild events include local injection site reactions in 10–64%, fever in 12% of children aged one to five years and fever in 5% of children aged six to 15 years. Inactivated influenza vaccines are contraindicated in cases of known allergic reaction to a previous dose or to a vaccine component, including egg protein.",
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Inactivated influenza vaccines are considered safe. Severe adverse events have included anaphylaxis in 0.7 per million vaccinations, Guillain-Barré syndrome in one to two per million (in older adults) and oculo (eye)-respiratory syndrome in 76 per million. Mild events include local injection site reactions in 10–64%, fever in 12% of children aged one to five years and fever in 5% of children aged six to 15 years.
Inactivated influenza vaccines are contraindicated in cases of known allergic reaction to a previous dose or to a vaccine component, including egg protein.
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"text": "\n\n\n14.9 When are inactivated influenza vaccines administered?\nAnnual vaccination for high-risk groups should be incorporated into immunization programmes following national policy. WHO recommends that pregnant women have the highest priority. Pregnant women can be vaccinated in any trimester. Ideally, influenza vaccine should be made available throughout the year and it may be given at the same time as tetanus vaccine. Immunizing pregnant women also benefits their babies after birth since the vaccine is not given to infants before six months of age. A single dose is recommended for those over nine years of age, including pregnant women. Children aged six to 59 months are at high risk of severe disease and should be given two doses at least four weeks apart. Children aged six to 35 months should receive a pediatric dose. For elderly persons (over 65 years of age) vaccination is the most effective public health intervention to reduce their risk of death from influenza. Health care workers are an important group to vaccinate to reduce the risk of transmission to patients. Annual vaccination (or re-vaccination, if the vaccine strains are identical) is recommended. Previously vaccinated children aged six to 59 months require only one dose.",
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"text": "Annual vaccination for high-risk groups should be incorporated into immunization programmes following national policy. WHO recommends that pregnant women have the highest priority. Pregnant women can be vaccinated in any trimester. Ideally, influenza vaccine should be made available throughout the year and it may be given at the same time as tetanus vaccine. Immunizing pregnant women also benefits their babies after birth since the vaccine is not given to infants before six months of age. A single dose is recommended for those over nine years of age, including pregnant women. Children aged six to 59 months are at high risk of severe disease and should be given two doses at least four weeks apart. Children aged six to 35 months should receive a pediatric dose. For elderly persons (over 65 years of age) vaccination is the most effective public health intervention to reduce their risk of death from influenza. Health care workers are an important group to vaccinate to reduce the risk of transmission to patients. Annual vaccination (or re-vaccination, if the vaccine strains are identical) is recommended. Previously vaccinated children aged six to 59 months require only one dose.",
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Annual vaccination for high-risk groups should be incorporated into immunization programmes following national policy. WHO recommends that pregnant women have the highest priority. Pregnant women can be vaccinated in any trimester. Ideally, influenza vaccine should be made available throughout the year and it may be given at the same time as tetanus vaccine. Immunizing pregnant women also benefits their babies after birth since the vaccine is not given to infants before six months of age.
A single dose is recommended for those over nine years of age, including pregnant women. Children aged six to 59 months are at high risk of severe disease and should be given two doses at least four weeks apart. Children aged six to 35 months should receive a pediatric dose. For elderly persons (over 65 years of age) vaccination is the most effective public health intervention to reduce their risk of death from influenza.
Health care workers are an important group to vaccinate to reduce the risk of transmission to patients.
Annual vaccination (or re-vaccination, if the vaccine strains are identical) is recommended. Previously vaccinated children aged six to 59 months require only one dose.
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"text": "\n DESCRIPTION:\n Le tableau résume les vaccins antigrippaux inactivés, tri- ou quadrivalents, administrés annuellement par voie intramusculaire. Deux doses sont nécessaires chez les enfants de 6 à 59 mois.\n :TABLE DATA:\n Table 1.20 Inactivated influenza vaccines summary Type of vaccine Inactivated viral: tri- or quadrivalent for 2 strains of influenza A and 1–2 strains of influenza B Total number of doses 1 for ≥ 9 years of age, including pregnant women and adults 2 for children 6–59 months of age (children 6–35 months should receive a pediatric dose) Schedule Annual For children 6–59 months of age, 2 doses with an interval of 4 weeks minimum. Previously vaccinated children aged 6–59 months require only 1 dose Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose or to a vaccine component such as egg protein Adverse events Severe: rare anaphylaxis, Guillain-Barré syndrome, oculo-respiratory syndrome Mild: injection site reactions and fever Special precautions May postpone vaccination in case of moderate to severe illness (with temperature ≥39 °C) Dosage 0.5 ml Injection site Outer (anterolateral) mid-thigh in infants and children; upper arm (deltoid) adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.20 Inactivated influenza vaccines summary Type of vaccine Inactivated viral: tri- or quadrivalent for 2 strains of influenza A and 1–2 strains of influenza B Total number of doses 1 for ≥ 9 years of age, including pregnant women and adults 2 for children 6–59 months of age (children 6–35 months should receive a pediatric dose) Schedule Annual For children 6–59 months of age, 2 doses with an interval of 4 weeks minimum. Previously vaccinated children aged 6–59 months require only 1 dose Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose or to a vaccine component such as egg protein Adverse events Severe: rare anaphylaxis, Guillain-Barré syndrome, oculo-respiratory syndrome Mild: injection site reactions and fever Special precautions May postpone vaccination in case of moderate to severe illness (with temperature ≥39 °C) Dosage 0.5 ml Injection site Outer (anterolateral) mid-thigh in infants and children; upper arm (deltoid) adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.20 Inactivated influenza vaccines summary
Type of vaccine
Inactivated viral: tri- or quadrivalent for 2 strains of influenza A and 1–2 strains of influenza B
Total number of doses
1 for ≥ 9 years of age, including pregnant women and adults
2 for children 6–59 months of age (children 6–35 months should receive a pediatric dose)
Schedule
Annual
For children 6–59 months of age, 2 doses with an interval of 4 weeks minimum. Previously vaccinated children aged 6–59 months require only 1 dose
Contraindications
Known hypersensitivity (allergy) or anaphylaxis to a previous dose or to a vaccine component such as egg protein
May postpone vaccination in case of moderate to severe illness (with temperature ≥39 °C)
Dosage
0.5 ml
Injection site
Outer (anterolateral) mid-thigh in infants and children; upper arm (deltoid) adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
Do not freeze
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"text": "\n\n\nKey points about seasonal influenza\n➢ Seasonal influenza due to influenza virus types A and B results in significant disease and economic burden each year. ➢ Pregnant women are the highest priority for vaccination in order to protect young infants (vaccine cannot be given to those under six months of age). ➢ Additional risk groups to be considered include children six to 59 months, as well as the elderly over age 65 years. The elderly are most at risk of death. ➢ The main complication is bacterial pneumonia, which can be fatal. ➢ Annual vaccination is recommended, particularly for high-risk groups.\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.20 Inactivated influenza vaccines summary Type of vaccine Inactivated viral: tri- or quadrivalent for 2 strains of influenza A and 1–2 strains of influenza B Total number of doses 1 for ≥ 9 years of age, including pregnant women and adults 2 for children 6–59 months of age (children 6–35 months should receive a pediatric dose) Schedule Annual For children 6–59 months of age, 2 doses with an interval of 4 weeks minimum. Previously vaccinated children aged 6–59 months require only 1 dose Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose or to a vaccine component such as egg protein Adverse events Severe: rare anaphylaxis, Guillain-Barré syndrome, oculo-respiratory syndrome Mild: injection site reactions and fever Special precautions May postpone vaccination in case of moderate to severe illness (with temperature ≥39 °C) Dosage 0.5 ml Injection site Outer (anterolateral) mid-thigh in infants and children; upper arm (deltoid) adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nTarget diseases and vaccines",
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➢ Seasonal influenza due to influenza virus types A and B results in significant disease and economic burden each year.
➢ Pregnant women are the highest priority for vaccination in order to protect young infants (vaccine cannot be given to those under six months of age).
➢ Additional risk groups to be considered include children six to 59 months, as well as the elderly over age 65 years. The elderly are most at risk of death.
➢ The main complication is bacterial pneumonia, which can be fatal.
➢ Annual vaccination is recommended, particularly for high-risk groups.
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"text": "\n\n\n15.2 How is tetanus spread?\nTetanus is not transmitted from person to person. In people of all ages, the bacterium can enter a wound or cut from items such as dirty nails, knives, tools, wood splinters, dirty tools used during childbirth, or deep puncture wounds from animal bites. It grows well in deep wounds, burns and crush injuries. In newborn babies, infection can occur when delivery occurs on dirty mats or floors, a dirty tool is used to cut the umbilical cord, dirty material is used to dress the cord or when the hands of the person delivering the baby are not clean. Infants and children may also contract tetanus when dirty tools are used for circumcision, scarification and skin piercing, and when dirt, charcoal or other unclean substances are rubbed into a wound.",
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"text": "\n\n\n15.3 What are the symptoms and signs of tetanus?\nThe incubation period (time between getting infected and showing symptoms) is usually three to 21 days, but can be as much as several months depending on the wound. The risk of death from the disease increases as the incubation period decreases. In children and adults, muscular stiffness in the jaw (trismus or lock-jaw) is a common first sign of tetanus. This is followed by stiffness in the neck, abdomen and/or back, difficulty swallowing, muscle spasms, sweating and fever. Newborns with tetanus are normal at birth but stop feeding at three to 28 days of age. They then become stiff and severe muscle spasms occur.\nTarget diseases and vaccines",
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The incubation period (time between getting infected and showing symptoms) is usually three to 21 days, but can be as much as several months depending on the wound. The risk of death from the disease increases as the incubation period decreases.
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"text": "\n\n\n15.4 What are the complications of tetanus?\nWhen muscles used in breathing are affected, respiratory failure and death can occur. Neonates and elderly patients are at highest risk. Pneumonia is also common. Fractures of the spine or other bones may occur as a result of muscle spasms and convulsions. Long-term neurologic impairment has been described in survivors of neonatal tetanus.",
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When muscles used in breathing are affected, respiratory failure and death can occur. Neonates and elderly patients are at highest risk. Pneumonia is also common. Fractures of the spine or other bones may occur as a result of muscle spasms and convulsions. Long-term neurologic impairment has been described in survivors of neonatal tetanus.
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"text": "\n\n\n15.6 How is tetanus prevented?\nTetanus toxoid-containing (TTCV) vaccine protects against tetanus. Infants and children may receive combination vaccines, such as DTP, pentavalent (DTP+HepB+Hib) or DT. Anyone older than seven years of age should receive dT, which contains tetanus toxoid and lower levels of diphtheria antigen. Sections 15.8–15.10 and Tables 1.21–1.23 describe tetanus toxoid-containing vaccines. Neonatal tetanus can be prevented by immunizing women of reproductive age with tetanus toxoid, either during or before pregnancy. Clean delivery procedures are needed even when the mother has been immunized. Clean umbilical cord care for the newborn is equally important. People who recover from tetanus do not have natural immunity and can be infected again. WHO recommends completion of a six-dose schedule.",
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"text": "\n\n\n15.7 What is needed for global tetanus disease control?\nWHO, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) have set 2015 as the target date for the worldwide elimination of neonatal tetanus, which means less than one case per 1000 live births per year in every district. Because the tetanus bacterium survives in the environment, eradication of tetanus is not feasible and high levels of immunization need to be maintained even after elimination. The strategies to achieve the maternal and neonatal tetanus (MNT) elimination goal are improved vaccination coverage of pregnant women with TT-containing vaccines, vaccination of all women of reproductive age in high-risk areas, promotion of clean delivery and cord care practices, and improved surveillance and reporting of neonatal tetanus cases. After MNT elimination, countries must maintain high coverage of pregnant women with TTCV through routine immunization, use all opportunities such as mother-and-\nTarget diseases and vaccines\nchild health days and periodic intensification of routine immunization to ensure high protection, promote school-based TTCV booster doses, promote clean delivery and cord care practices, and maintain surveillance of cases.",
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WHO, the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) have set 2015 as the target date for the worldwide elimination of neonatal tetanus, which means less than one case per 1000 live births per year in every district. Because the tetanus bacterium survives in the environment, eradication of tetanus is not feasible and high levels of immunization need to be maintained even after elimination.
The strategies to achieve the maternal and neonatal tetanus (MNT) elimination goal are improved vaccination coverage of pregnant women with TT-containing vaccines, vaccination of all women of reproductive age in high-risk areas, promotion of clean delivery and cord care practices, and improved surveillance and reporting of neonatal tetanus cases.
After MNT elimination, countries must maintain high coverage of pregnant women with TTCV through routine immunization, use all opportunities such as mother-and-
child health days and periodic intensification of routine immunization to ensure high protection, promote school-based TTCV booster doses, promote clean delivery and cord care practices, and maintain surveillance of cases.
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"text": "\n\n\n15.8 What are tetanus toxoid-containing vaccines?\nTetanus toxoid vaccine is available as TT, which protects only against tetanus and neonatal tetanus. It is also available in pentavalent, DTP and dT/DT combinations. TT vaccine is supplied as a liquid in single- and multi-dose vials and also in prefilled auto-disable syringes. Pentavalent vaccine with a freeze-dried Hib component requires reconstitution: see Module 5 ( Managing an immunization session ), Section 4.2 for details. Tetanus toxoid-containing vaccines must be stored between +2 °C and +8 °C without being frozen. They are freeze-sensitive. If freezing is suspected, the Shake Test should be performed to determine whether a vial is safe to use (see Module 2 ( The vaccine cold chain ), Section 7). Opened multi-dose vials must be handled according to national multi-dose vial policy (see Module 2, Section 5 for WHO policy).\nTetanus toxoid-containing vaccines are administered as 0.5 ml doses given intramuscularly in the anterolateral (outer) thigh in infants and in the deltoid muscle (upper arm) of older children and adults.",
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Tetanus toxoid vaccine is available as TT, which protects only against tetanus and neonatal tetanus. It is also available in pentavalent, DTP and dT/DT combinations. TT vaccine is supplied as a liquid in single- and multi-dose vials and also in prefilled auto-disable syringes. Pentavalent vaccine with a freeze-dried Hib component requires reconstitution: see Module 5 (
Managing an immunization session
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"text": "\n\n\n15.9 How safe is tetanus toxoid vaccine and what are the potential adverse events following immunization?\nTetanus toxoid is very safe. Severe events are rare and include anaphylaxis (1.6 per 1 million doses) and neurologic problems such as brachial neuritis (inflammation of arm nerves). Guillain-Barré syndrome has been reported but TTCV has not been established as the cause. Mild events include injection site pain, redness and/or swelling. These are more common after later doses than earlier ones, and may affect between 50% and 85% of people who receive TT booster doses. Fever may develop in 10% of those vaccinated.\nA WHO safety information summary for combination vaccines is on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/ .",
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Tetanus toxoid is very safe. Severe events are rare and include anaphylaxis (1.6 per 1 million doses) and neurologic problems such as brachial neuritis (inflammation of arm nerves). Guillain-Barré syndrome has been reported but TTCV has not been established as the cause. Mild events include injection site pain, redness and/or swelling. These are more common after later doses than earlier ones, and may affect between 50% and 85% of people who receive TT booster doses. Fever may develop in 10% of those vaccinated.
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"text": "\n\n\n15.10 When are tetanus toxoid-containing vaccines given?\nFor long-term immunity against tetanus in all individuals, five doses of TTCV are recommended in childhood: three doses in the primary series given in infancy by pentavalent vaccine, one booster dose between four and seven years of age using dT vaccine, and a second booster dose with dT between 12 and 15 years of age. For women, one additional dose of dT is recommended during pregnancy to ensure protection throughout reproductive age and probably for life.",
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For long-term immunity against tetanus in all individuals, five doses of TTCV are recommended in childhood: three doses in the primary series given in infancy by pentavalent vaccine, one booster dose between four and seven years of age using dT vaccine, and a second booster dose with dT between 12 and 15 years of age. For women, one additional dose of dT is recommended during pregnancy to ensure protection throughout reproductive age and probably for life.
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"text": "\n DESCRIPTION:\n Le vaccin antitétanique, un toxoïde, nécessite 5 doses initiales et des rappels, avec un schéma d'administration et des sites d'injection spécifiques.\n :TABLE DATA:\n Table 1.21 Tetanus-toxoid vaccine summary Type of vaccine Toxoid Total number of doses 5 Schedule With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2) For women, see Tables 1.22 and 1.23 Booster 4–7 years; and adolescence 12–15 years For women, see Tables 1.22 and 1.23 Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose Adverse events Severe: rare anaphylaxis, brachial neuritis Mild: injection site reactions and fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\n\n ",
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"text": "Table 1.21 Tetanus-toxoid vaccine summary Type of vaccine Toxoid Total number of doses 5 Schedule With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2) For women, see Tables 1.22 and 1.23 Booster 4–7 years; and adolescence 12–15 years For women, see Tables 1.22 and 1.23 Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose Adverse events Severe: rare anaphylaxis, brachial neuritis Mild: injection site reactions and fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.21
Tetanus-toxoid vaccine summary
Type of vaccine
Toxoid
Total number of doses
5
Schedule
With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2)
For women, see Tables 1.22 and 1.23
Booster
4–7 years; and adolescence 12–15 years
For women, see Tables 1.22 and 1.23
Contraindications
Known hypersensitivity (allergy) or anaphylaxis to a previous dose
Adverse events
Severe: rare anaphylaxis, brachial neuritis
Mild: injection site reactions and fever
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults
With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2)
For women, see Tables 1.22 and 1.23
Booster
4–7 years; and adolescence 12–15 years
For women, see Tables 1.22 and 1.23
Contraindications
Known hypersensitivity (allergy) or anaphylaxis to a previous dose
Adverse events
Severe: rare anaphylaxis, brachial neuritis
Mild: injection site reactions and fever
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults
Injection type
Intramuscular
Storage
Between +2 °C and +8 °C
Do not freeze
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"text": "\n DESCRIPTION:\n Ce tableau décrit le calendrier de vaccination antitétanique pour les femmes enceintes non vaccinées dans l'enfance, incluant doses, timing et durée de protection.\n :TABLE DATA:\n Table 1.22 Tetanus toxoid immunization schedule for routine immunization of pregnant women who were not previously vaccinated in childhood Dose of TT or Td Schedule Expected duration of protection* 1 At first contact or as early as possible in pregnancy None 2 At least 4 weeks after TT1 1–3 years 3 At least 6 months after TT2 or during subsequent pregnancy At least 5 years 4 At least 1 year after TT3 or during subsequent pregnancy At least 10 years 5 At least 1 year after TT4 or during subsequent pregnancy For all reproductive years and possibly longer\n :END TABLE DATA:\n\n ",
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"text": "Table 1.22 Tetanus toxoid immunization schedule for routine immunization of pregnant women who were not previously vaccinated in childhood Dose of TT or Td Schedule Expected duration of protection* 1 At first contact or as early as possible in pregnancy None 2 At least 4 weeks after TT1 1–3 years 3 At least 6 months after TT2 or during subsequent pregnancy At least 5 years 4 At least 1 year after TT3 or during subsequent pregnancy At least 10 years 5 At least 1 year after TT4 or during subsequent pregnancy For all reproductive years and possibly longer",
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Table 1.22 Tetanus toxoid immunization schedule for routine immunization of pregnant women who were not previously vaccinated in childhood
Dose of TT or Td
Schedule
Expected duration of protection*
1
At first contact or as early as possible in pregnancy
None
2
At least 4 weeks after TT1
1–3 years
3
At least 6 months after TT2 or during subsequent pregnancy
At least 5 years
4
At least 1 year after TT3 or during subsequent pregnancy
At least 10 years
5
At least 1 year after TT4 or during subsequent pregnancy
Table 1.22 Tetanus toxoid immunization schedule for routine immunization of pregnant women who were not previously vaccinated in childhood
Dose of TT or Td
Schedule
Expected duration of protection*
1
At first contact or as early as possible in pregnancy
None
2
At least 4 weeks after TT1
1–3 years
3
At least 6 months after TT2 or during subsequent pregnancy
At least 5 years
4
At least 1 year after TT3 or during subsequent pregnancy
At least 10 years
5
At least 1 year after TT4 or during subsequent pregnancy
For all reproductive years and possibly longer
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"text": "\n DESCRIPTION:\n Ce tableau guide la vaccination antitétanique des femmes ayant déjà été vaccinées, selon leur âge à la dernière vaccination et leurs antécédents.\n :TABLE DATA:\n Table 1.23 Guidelines for tetanus toxoid immunization of women who were immunized during infancy, childhood and adolescence Age at last vaccination Previous immunizations (based on written records) Recommended immunizations At present contact/ pregnancy Later (at intervals of at least one year) Infancy 3 DTP 2 doses of TT/Td (min 4 weeks interval between doses) 1 dose of TT/Td Childhood 4 DTP 1 dose of TT/Td 1 dose of TT/Td School age 3 DTP + 1 DT/Td 1 dose of TT/Td 1 dose of TT/Td School age 4 DTP + 1 DT/Td 1 dose of TT/Td None\n :END TABLE DATA:\n\n ",
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Table 1.23 Guidelines for tetanus toxoid immunization of women who were immunized during infancy, childhood and adolescence
Age at last vaccination
Previous immunizations (based on written records)
Recommended immunizations
At present contact/ pregnancy
Later (at intervals of at least one year)
Infancy
3 DTP
2 doses of TT/Td (min 4 weeks interval between doses)
Table 1.23 Guidelines for tetanus toxoid immunization of women who were immunized during infancy, childhood and adolescence
Age at last vaccination
Previous immunizations (based on written records)
Recommended immunizations
At present contact/ pregnancy
Later (at intervals of at least one year)
Infancy
3 DTP
2 doses of TT/Td (min 4 weeks interval between doses)
1 dose of TT/Td
Childhood
4 DTP
1 dose of TT/Td
1 dose of TT/Td
School age
3 DTP + 1 DT/Td
1 dose of TT/Td
1 dose of TT/Td
School age
4 DTP + 1 DT/Td
1 dose of TT/Td
None
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"text": "\n\n\nKey points about tetanus\nTetanus is caused by a bacterium found in the environment. Infection occurs during unclean delivery of babies, when contaminated objects are used to cut the umbilical cord, or whenever tetanus bacteria enter a wound or cut. Neonatal tetanus remains a serious problem in countries with poor immunization coverage and unsafe childbirth and cord care practices. Most newborns who contract tetanus will die. The best way to prevent maternal and neonatal tetanus is to give the WHO six-dose TTCV schedule of infant and booster doses, immunize pregnant women in all areas (and all women of reproductive age in high-risk areas), and ensure clean delivery and cord care practices.\n :TABLE DATA: \nTable 1.21 Tetanus-toxoid vaccine summary Type of vaccine Toxoid Total number of doses 5 Schedule With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2) For women, see Tables 1.22 and 1.23 Booster 4–7 years; and adolescence 12–15 years For women, see Tables 1.22 and 1.23 Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose Adverse events Severe: rare anaphylaxis, brachial neuritis Mild: injection site reactions and fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze\n :END TABLE DATA:\nModule 1: Target diseases and vaccines\n :TABLE DATA: \nTable 1.22 Tetanus toxoid immunization schedule for routine immunization of pregnant women who were not previously vaccinated in childhood Dose of TT or Td Schedule Expected duration of protection* 1 At first contact or as early as possible in pregnancy None 2 At least 4 weeks after TT1 1–3 years 3 At least 6 months after TT2 or during subsequent pregnancy At least 5 years 4 At least 1 year after TT3 or during subsequent pregnancy At least 10 years 5 At least 1 year after TT4 or during subsequent pregnancy For all reproductive years and possibly longer\n :END TABLE DATA:\n*Recent studies suggest that the duration of protection may be longer than indicated in the table. This matter is currently under review.\n :TABLE DATA: \nTable 1.23 Guidelines for tetanus toxoid immunization of women who were immunized during infancy, childhood and adolescence Age at last vaccination Previous immunizations (based on written records) Recommended immunizations At present contact/ pregnancy Later (at intervals of at least one year) Infancy 3 DTP 2 doses of TT/Td (min 4 weeks interval between doses) 1 dose of TT/Td Childhood 4 DTP 1 dose of TT/Td 1 dose of TT/Td School age 3 DTP + 1 DT/Td 1 dose of TT/Td 1 dose of TT/Td School age 4 DTP + 1 DT/Td 1 dose of TT/Td None\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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Tetanus is caused by a bacterium found in the environment.
Infection occurs during unclean delivery of babies, when contaminated objects are used to cut the umbilical cord, or whenever tetanus bacteria enter a wound or cut.
Neonatal tetanus remains a serious problem in countries with poor immunization coverage and unsafe childbirth and cord care practices.
Most newborns who contract tetanus will die.
The best way to prevent maternal and neonatal tetanus is to give the WHO six-dose TTCV schedule of infant and booster doses, immunize pregnant women in all areas (and all women of reproductive age in high-risk areas), and ensure clean delivery and cord care practices.
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"text": "Table 1.21 Tetanus-toxoid vaccine summary Type of vaccine Toxoid Total number of doses 5 Schedule With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2) For women, see Tables 1.22 and 1.23 Booster 4–7 years; and adolescence 12–15 years For women, see Tables 1.22 and 1.23 Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose Adverse events Severe: rare anaphylaxis, brachial neuritis Mild: injection site reactions and fever Special precautions None Dosage 0.5 ml Injection site Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults Injection type Intramuscular Storage Between +2 °C and +8 °C Do not freeze",
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Table 1.21
Tetanus-toxoid vaccine summary
Type of vaccine
Toxoid
Total number of doses
5
Schedule
With pentavalent: starting at age 6 weeks (minimum) with second and third doses at 4–8 week intervals after the previous dose (see Table 1.2)
For women, see Tables 1.22 and 1.23
Booster
4–7 years; and adolescence 12–15 years
For women, see Tables 1.22 and 1.23
Contraindications
Known hypersensitivity (allergy) or anaphylaxis to a previous dose
Adverse events
Severe: rare anaphylaxis, brachial neuritis
Mild: injection site reactions and fever
Special precautions
None
Dosage
0.5 ml
Injection site
Anterolateral (outer) thigh in infants and children; upper arm (deltoid) in adults
*Recent studies suggest that the duration of protection may be longer than indicated in the table. This matter is currently under review.
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Table 1.23 Guidelines for tetanus toxoid immunization of women who were immunized during infancy, childhood and adolescence
Age at last vaccination
Previous immunizations (based on written records)
Recommended immunizations
At present contact/ pregnancy
Later (at intervals of at least one year)
Infancy
3 DTP
2 doses of TT/Td (min 4 weeks interval between doses)
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Not everyone who is infected with TB bacteria develops the disease. People who are infected may not feel ill and may have no symptoms. The infection can last for a lifetime, but the infected person may never develop the disease itself. People who are infected and who do not develop the disease do not spread the infection to others.
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"text": "\n\n\n16.2 How is TB spread?\nTB is spread from one person to another through the air, often when an infected person coughs or sneezes. TB spreads rapidly, especially in areas where people are living in crowded conditions, have poor access to health care, and/or are malnourished. A person can contract bovine tuberculosis, another variety of TB, by consuming raw milk from infected cattle. People of all ages can develop TB, but the risk is highest in children younger than three years of age and in older people. People with TB infection who have weakened immune systems (for example, people with HIV/AIDS) are more likely to develop the disease.",
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TB is spread from one person to another through the air, often when an infected person coughs or sneezes. TB spreads rapidly, especially in areas where people are living in crowded conditions, have poor access to health care, and/or are malnourished. A person can contract bovine tuberculosis, another variety of TB, by consuming raw milk from infected cattle.
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"text": "\n\n\n16.3 What are the symptoms and signs of TB?\nThe period from infection to development of the first symptoms is usually four to 12 weeks, but the infection may persist for months or even years before the disease develops. A person with the disease can infect others for several weeks after he or she begins treatment. The symptoms of TB include general weakness, weight loss, fever and night sweats. In TB of the lungs, which is called pulmonary tuberculosis, the symptoms include persistent cough, coughing up of blood and chest pain. In young children, however, the only sign of pulmonary TB may be stunted growth or failure to thrive. Other symptoms and signs depend on the part of the body that is affected. For example, in tuberculosis of the bones and joints, there may be swelling, pain and crippling effects on the hips, knees or spine.\nTarget diseases and vaccines",
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The period from infection to development of the first symptoms is usually four to 12 weeks, but the infection may persist for months or even years before the disease develops. A person with the disease can infect others for several weeks after he or she begins treatment.
The symptoms of TB include general weakness, weight loss, fever and night sweats. In TB of the lungs, which is called pulmonary tuberculosis, the symptoms include persistent cough, coughing up of blood and chest pain. In young children, however, the only sign of pulmonary TB may be stunted growth or failure to thrive. Other symptoms and signs depend on the part of the body that is affected. For example, in tuberculosis of the bones and joints, there may be swelling, pain and crippling effects on the hips, knees or spine.
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"text": "\n\n\n16.8 How safe is BCG vaccine and what are the potential adverse events following immunization?\nSevere events following immunization with BCG include generalized infection in about one per 230 000–640 000 doses of vaccine given, primarily in HIV-infected persons or those with severe immune deficiencies. Known HIV infection or other immune deficiency is a contraindication for BCG (refer to Module 5, Section 3.1). Other severe events include swelling and abscesses in about one per 1000–10 000 doses. Swollen glands (in the armpit or near the elbow) and/or abscesses sometimes\nModule 1: Target diseases and vaccines\noccur because an unsterile needle or syringe was used, too much vaccine was injected or, most commonly, the vaccine was injected incorrectly under the skin instead of into the top layer (refer to Module 5, Section 4.7 for injection technique). A mild reaction at the site of injection occurs in almost all children. When BCG vaccine is injected, a small raised lump usually appears at the injection site and then disappears within 30 minutes. After about two weeks, a red sore (about the size of the end of an unsharpened pencil) forms. This sore usually lasts for another two weeks and then heals, leaving a small scar about 5 mm across – the scar is a sign that the child has been effectively immunized.\nA WHO safety information summary for BCG vaccine is available on the website: http://www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/ .",
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Severe events following immunization with BCG include generalized infection in about one per 230 000–640 000 doses of vaccine given, primarily in HIV-infected persons or those with severe immune deficiencies. Known HIV infection or other immune deficiency is a contraindication for BCG (refer to Module 5, Section 3.1). Other severe events include swelling and abscesses in about one per 1000–10 000 doses. Swollen glands (in the armpit or near the elbow) and/or abscesses sometimes
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"text": "\n\n\n16.9 When is BCG vaccine administered?\nBCG is recommended for infants living in countries with a high TB disease burden and high-risk children living in countries with a low disease burden. It should be given routinely at, or as soon as possible after, birth to all infants except those known to have HIV or any condition that results in a decreased or abnormal immune system response. In areas where TB is highly endemic but services are limited, BCG should be given at birth to all infants regardless of HIV exposure. Infants with known HIV-positive mothers should be followed closely to monitor for any BCG-related complications. If services are available, BCG should be postponed until HIV-exposed infants (born to known HIV-positive mothers) can be confirmed to be HIV negative. BCG vaccine is not recommended after 12 months of age because the protection provided is less certain.",
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In areas where TB is highly endemic but services are limited, BCG should be given at birth to all infants regardless of HIV exposure. Infants with known HIV-positive mothers should be followed closely to monitor for any BCG-related complications. If services are available, BCG should be postponed until HIV-exposed infants (born to known HIV-positive mothers) can be confirmed to be HIV negative.
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"text": "\n DESCRIPTION:\n Le vaccin BCG, bactérien vivant, est administré en une dose unique par voie intradermique aux nourrissons pour prévenir la tuberculose.\n :TABLE DATA:\n Table 1.24 BCG vaccine summary Type of vaccine Live bacterial Number of doses 1 Schedule At or as soon as possible after birth Booster None Contraindications Known HIV infection or other immune deficiency Adverse events • Severe: generalized disease or infections such as osteomyelitis (bone infection); abscess; regional lymphadenitis (lymph node inflammation) • Mild: injection site reactions Special precautions Correct intradermal administration is essential – a specific syringe and needle are used for BCG (see Module 5, Section 4.8) Dosage 0.05 ml Injection site Outer upper left arm or shoulder Injection type Intradermal Storage • Between +2 °C and +8 °C • Do not freeze\n :END TABLE DATA:\n\n ",
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Table 1.24
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Live bacterial
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1
Schedule
At or as soon as possible after birth
Booster
None
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Adverse events
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➢ TB usually affects the lungs but can affect other parts of the body, including the bones, joints and brain.
➢ TB is spread through the air.
➢ The symptoms of TB disease include general weakness, weight loss, fever and night sweats.
➢ People who develop TB disease must complete a course of drug therapy to cure it and to avoid spreading it to others.
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Table 1.24
BCG vaccine summary
Type of vaccine
Live bacterial
Number of doses
1
Schedule
At or as soon as possible after birth
Booster
None
Contraindications
Known HIV infection or other immune deficiency
Adverse events
• Severe: generalized disease or infections such as osteomyelitis (bone infection); abscess; regional lymphadenitis (lymph node inflammation) • Mild: injection site reactions
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YF is spread by several species of
Haemagogus
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Aedes
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"text": "\n\n\n17.7 What is yellow fever vaccine?\nLive attenuated (weakened) virus vaccines for preventing YF are currently in use. They are supplied in freeze-dried (also called lyophilized) form and must be reconstituted with the diluent supplied by the manufacturer before use: see Module 5 ( Managing an immunization session ), Section 4.2 for details. YF vaccine must be stored between +2 °C and +8 °C. It is not damaged if accidentally frozen. Opened multi-dose vials must be handled according to national multi-dose vial policy: see Module 2 ( The vaccine cold chain ), Section 5 for WHO policy.\nIt is administered as a single 0.5 ml dose either subcutaneously in the upper arm or intramuscularly in the anterolateral thigh.",
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Live attenuated (weakened) virus vaccines for preventing YF are currently in use. They are supplied in freeze-dried (also called lyophilized) form and must be reconstituted with the diluent supplied by the manufacturer before use: see Module 5 (
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"text": "\n\n\n17.8 How safe is yellow fever vaccine and what are the potential adverse events following immunization?\nSevere adverse events include hypersensitivity (allergy) or anaphylaxis (0.8 per 100,000 vaccinations) occurring most commonly in people with allergies to eggs or gelatin. YF vaccine-associated neurologic disease (inflammation of different parts of the nervous system, including the brain) and viscerotropic disease (affecting internal organs) have been reported; overall rates are low but older patients (over 60 years of age) receiving primary YF vaccine doses seem to be at higher risk. YF vaccine-associated viscerotropic disease (affecting internal organs with symptoms and signs similar to infection with YF) has been fatal in over 60% of cases. Mild adverse events, such as injection site pain, headache, muscle ache, low-grade fever, itching, hives and other rashes are reported in up to 25% of those vaccinated.\nTarget diseases and vaccines",
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Severe adverse events include hypersensitivity (allergy) or anaphylaxis (0.8 per 100,000 vaccinations) occurring most commonly in people with allergies to eggs or gelatin. YF vaccine-associated neurologic disease (inflammation of different parts of the nervous system, including the brain) and viscerotropic disease (affecting internal organs) have been reported; overall rates are low but older patients (over 60 years of age) receiving primary YF vaccine doses seem to be at higher risk. YF vaccine-associated viscerotropic disease (affecting internal organs with symptoms and signs similar to infection with YF) has been fatal in over 60% of cases.
Mild adverse events, such as injection site pain, headache, muscle ache, low-grade fever, itching, hives and other rashes are reported in up to 25% of those vaccinated.
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"text": "\n\n\n17.9 When is yellow fever vaccine administered?\nA single dose of YF vaccine is sufficient for life-long protection and, in endemic countries, should be integrated into routine immunization programmes, with children aged 9–12 months receiving the vaccine at the same time as measles-containing vaccine. Preventive mass immunization campaigns are recommended in endemic countries where YF vaccine coverage is low. It should be provided to everyone aged nine months or more in areas with reported cases. Unvaccinated travellers aged nine months or more going to and from high-risk areas should receive YF vaccine unless otherwise contraindicated. YF vaccine is contraindicated in children aged under six months and not recommended for children aged six to eight months, except during epidemics. It is contraindicated in anyone with allergies to egg antigens and in HIV-infected individuals with CD4 T-cell values of under 200 per mm³. See Table 1.25 for YF vaccination summary.",
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A single dose of YF vaccine is sufficient for life-long protection and, in endemic countries, should be integrated into routine immunization programmes, with children aged 9–12 months receiving the vaccine at the same time as measles-containing vaccine. Preventive mass immunization campaigns are recommended in endemic countries where YF vaccine coverage is low. It should be provided to everyone aged nine months or more in areas with reported cases. Unvaccinated travellers aged nine months or more going to and from high-risk areas should receive YF vaccine unless otherwise contraindicated.
YF vaccine is contraindicated in children aged under six months and not recommended for children aged six to eight months, except during epidemics. It is contraindicated in anyone with allergies to egg antigens and in HIV-infected individuals with CD4 T-cell values of under 200 per mm³.
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"text": "\n DESCRIPTION:\n Le tableau résume le vaccin contre la fièvre jaune : une dose unique à virus vivant atténué, avec précautions et contre-indications spécifiques.\n :TABLE DATA:\n Table 1.25 Yellow fever vaccine summary Type of vaccine Live attenuated (weakened) viral Number of doses 1 Schedule • In endemic areas: 9–12 months of age with MCV1 • In areas with reported cases: all persons aged ≥9 months • For travellers to high-risk areas: all persons aged ≥9 months Booster None Contraindications • Age <6 months; age 6–8 months except during epidemics • Known allergy to egg antigens or to a previous dose • HIV infection with CD4 T-cell values <200 per mm³ Adverse events • Severe: anaphylaxis; YF vaccine-associated neurologic (nerve) disease and viscerotropic (affecting internal organs) disease; encephalitis in infants aged <6 months • Mild: headache, muscle pain, fever Special precautions Carry out a risk–benefit assessment before administering to pregnant women or people aged >60 years Dosage 0.05 ml Injection site Outer upper left arm or shoulder (for subcutaneous); or anterolateral (outer) thigh in infants and children (for intramuscular) Injection type Subcutaneous or intramuscular Storage Between +2 °C and +8 °C\n :END TABLE DATA:\n\n ",
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Table 1.25 Yellow fever vaccine summary
Type of vaccine
Live attenuated (weakened) viral
Number of doses
1
Schedule
• In endemic areas: 9–12 months of age with MCV1
• In areas with reported cases: all persons aged ≥9 months
• For travellers to high-risk areas: all persons aged ≥9 months
Booster
None
Contraindications
• Age <6 months; age 6–8 months except during epidemics
• Known allergy to egg antigens or to a previous dose
• HIV infection with CD4 T-cell values <200 per mm³
Adverse events
• Severe: anaphylaxis; YF vaccine-associated neurologic (nerve) disease and viscerotropic (affecting internal organs) disease; encephalitis in infants aged <6 months
• Mild: headache, muscle pain, fever
Special precautions
Carry out a risk–benefit assessment before administering to pregnant women or people aged >60 years
Dosage
0.05 ml
Injection site
Outer upper left arm or shoulder (for subcutaneous); or anterolateral (outer) thigh in infants and children (for intramuscular)
• In areas with reported cases: all persons aged ≥9 months
• For travellers to high-risk areas: all persons aged ≥9 months
Booster
None
Contraindications
• Age <6 months; age 6–8 months except during epidemics
• Known allergy to egg antigens or to a previous dose
• HIV infection with CD4 T-cell values <200 per mm³
Adverse events
• Severe: anaphylaxis; YF vaccine-associated neurologic (nerve) disease and viscerotropic (affecting internal organs) disease; encephalitis in infants aged <6 months
• Mild: headache, muscle pain, fever
Special precautions
Carry out a risk–benefit assessment before administering to pregnant women or people aged >60 years
Dosage
0.05 ml
Injection site
Outer upper left arm or shoulder (for subcutaneous); or anterolateral (outer) thigh in infants and children (for intramuscular)
Injection type
Subcutaneous or intramuscular
Storage
Between +2 °C and +8 °C
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"text": "\n\n\nKey points about yellow fever\n➢ Yellow fever is a viral disease spread by infected mosquitoes primarily in tropical zones of Africa and South America. ➢ YF symptoms and signs can range from none to liver and kidney failure that leads to death; they can be easily confused with other diseases. ➢ No specific antiviral treatment is recommended at this time. ➢ YF vaccine is effective as a single dose and, if not contraindicated, should be given to all people aged nine months or more living in or travelling to high-risk areas.\nTarget diseases and vaccines\n :TABLE DATA: \nTable 1.25 Yellow fever vaccine summary Type of vaccine Live attenuated (weakened) viral Number of doses 1 Schedule • In endemic areas: 9–12 months of age with MCV1 • In areas with reported cases: all persons aged ≥9 months • For travellers to high-risk areas: all persons aged ≥9 months Booster None Contraindications • Age <6 months; age 6–8 months except during epidemics • Known allergy to egg antigens or to a previous dose • HIV infection with CD4 T-cell values <200 per mm³ Adverse events • Severe: anaphylaxis; YF vaccine-associated neurologic (nerve) disease and viscerotropic (affecting internal organs) disease; encephalitis in infants aged <6 months • Mild: headache, muscle pain, fever Special precautions Carry out a risk–benefit assessment before administering to pregnant women or people aged >60 years Dosage 0.05 ml Injection site Outer upper left arm or shoulder (for subcutaneous); or anterolateral (outer) thigh in infants and children (for intramuscular) Injection type Subcutaneous or intramuscular Storage Between +2 °C and +8 °C\n :END TABLE DATA:\nModule 1: Target diseases and vaccines",
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➢ Yellow fever is a viral disease spread by infected mosquitoes primarily in tropical zones of Africa and South America.
➢ YF symptoms and signs can range from none to liver and kidney failure that leads to death; they can be easily confused with other diseases.
➢ No specific antiviral treatment is recommended at this time.
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"text": "Table 1.25 Yellow fever vaccine summary Type of vaccine Live attenuated (weakened) viral Number of doses 1 Schedule • In endemic areas: 9–12 months of age with MCV1 • In areas with reported cases: all persons aged ≥9 months • For travellers to high-risk areas: all persons aged ≥9 months Booster None Contraindications • Age <6 months; age 6–8 months except during epidemics • Known allergy to egg antigens or to a previous dose • HIV infection with CD4 T-cell values <200 per mm³ Adverse events • Severe: anaphylaxis; YF vaccine-associated neurologic (nerve) disease and viscerotropic (affecting internal organs) disease; encephalitis in infants aged <6 months • Mild: headache, muscle pain, fever Special precautions Carry out a risk–benefit assessment before administering to pregnant women or people aged >60 years Dosage 0.05 ml Injection site Outer upper left arm or shoulder (for subcutaneous); or anterolateral (outer) thigh in infants and children (for intramuscular) Injection type Subcutaneous or intramuscular Storage Between +2 °C and +8 °C",
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Table 1.25 Yellow fever vaccine summary
Type of vaccine
Live attenuated (weakened) viral
Number of doses
1
Schedule
• In endemic areas: 9–12 months of age with MCV1
• In areas with reported cases: all persons aged ≥9 months
• For travellers to high-risk areas: all persons aged ≥9 months
Booster
None
Contraindications
• Age <6 months; age 6–8 months except during epidemics
• Known allergy to egg antigens or to a previous dose
• HIV infection with CD4 T-cell values <200 per mm³
Adverse events
• Severe: anaphylaxis; YF vaccine-associated neurologic (nerve) disease and viscerotropic (affecting internal organs) disease; encephalitis in infants aged <6 months
• Mild: headache, muscle pain, fever
Special precautions
Carry out a risk–benefit assessment before administering to pregnant women or people aged >60 years
Dosage
0.05 ml
Injection site
Outer upper left arm or shoulder (for subcutaneous); or anterolateral (outer) thigh in infants and children (for intramuscular)
Opportunities for integration of services: EPI Plus and vitamin A deficiency
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"text": "Immunization programmes provide an opportunity to deliver other essential health services such as vitamin A supplementation, de-worming, malaria prevention with insecticide-treated nets and Integrated Management of Childhood Illness. These additional services are part of EPI Plus programmes. Vitamin A deficiency is discussed further here.",
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"text": "\n\n\n18.2 What is vitamin A?\nVitamin A is a substance that is required by the human body. It strengthens resistance to infection, increases a child’s chances of surviving an infection, promotes growth and protects the cornea (the transparent part of the eye). Lack of vitamin A, or vitamin A deficiency, can result in poor vision in dim light. The human body cannot make vitamin A. So all the vitamin A it needs must come from food intake. Vitamin A is present in the following foods:\nVitamin A can be added to such foods as sugar, vegetable oil and wheat flour during processing. This is called food fortification.\nTarget diseases and vaccines",
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Vitamin A is a substance that is required by the human body. It strengthens resistance to infection, increases a child’s chances of surviving an infection, promotes growth and protects the cornea (the transparent part of the eye). Lack of vitamin A, or vitamin A deficiency, can result in poor vision in dim light.
The human body cannot make vitamin A. So all the vitamin A it needs must come from food intake. Vitamin A is present in the following foods:
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"text": "\n\n\n18.3 When does vitamin A deficiency occur?\nVitamin A deficiency occurs when a person does not eat enough food containing vitamin A or when the body uses it up too fast. This often happens during illness, during pregnancy and lactation, and when children’s growth is most rapid – from six months to five years of age.",
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"text": "\n\n\n18.4 What are symptoms and signs of vitamin A deficiency?\nVitamin A deficiency (VAD) reduces resistance to infections, leading to more severe and prolonged illnesses and increasing the risk of death. It can cause eye damage, such as corneal lesions and, when severe, can cause blindness. Generally, the first clinical sign of vitamin A deficiency is night blindness (impaired vision in dim light). Because vitamin A deficiency reduces the body’s resistance to infection, it is a threat even before any direct signs become apparent. Children suffering from vitamin A deficiency are more likely to get infections, such as measles, as well as diarrhoea and fevers. These infections are more likely to be severe, sometimes resulting in death.",
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Vitamin A deficiency (VAD) reduces resistance to infections, leading to more severe and prolonged illnesses and increasing the risk of death. It can cause eye damage, such as corneal lesions and, when severe, can cause blindness. Generally, the first clinical sign of vitamin A deficiency is night blindness (impaired vision in dim light). Because vitamin A deficiency reduces the body’s resistance to infection, it is a threat even before any direct signs become apparent.
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"text": "\n\n\n18.6 Are there any side effects of vitamin A supplements?\nThere are usually no side effects. On rare occasions, a child may experience headache, loss of appetite or vomiting. These symptoms pass in time, and no treatment is necessary. Parents should be advised that this is normal.\nTarget diseases and vaccines",
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Measles/yellow fever
Polio NIDs
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store vaccines and diluents within the required temperature range at all sites
pack and transport vaccines to and from outreach sites according to recommended procedures
keep vaccines and diluents within recommended cold chain conditions during immunization sessions.
Section 5 of this module describes how to store and pack vaccines at health facility level.
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"text": "\n\n\n1.1 Temperature requirements for vaccines\nVaccines are sensitive biological products. Some vaccines are sensitive to freezing, some to heat and others to light. Vaccine potency, meaning its ability to adequately protect the vaccinated patient, can diminish when the vaccine is exposed to inappropriate temperatures. Once lost, vaccine potency cannot be regained. To maintain quality, vaccines must be protected from temperature extremes. Vaccine quality is maintained using a cold chain that meets specific temperature requirements. Figure 2.2 shows recommended vaccine storage temperatures at each level of the cold chain. It is essential that all those who handle vaccines and diluents know the temperature sensitivities and the recommended storage temperatures for all the vaccines in the national schedule.\nFigure 2.3 shows the relative heat sensitivity of vaccines. These vaccines are grouped into six categories. Within each of these six categories, the vaccines are arranged in alphabetical order, not in order of sensitivity to heat within the group. The most heat sensitive vaccines are in Group A and the least heat sensitive vaccines are in Group F.\nNote that the heat stability information shown for freeze-dried vaccines applies only to unopened vials; most freeze-dried vaccines rapidly lose potency after reconstitution. In addition, it is important to keep opened multi-dose vaccine vials that do not contain preservative – whether lyophilized or liquid – cooled at temperatures between +2 °C and +8 °C during the immunization session, or within six hours after opening, whichever comes first.\nVaccines that are sensitive to freezing and should be protected from sub-zero temperatures are listed in Figure 2.4.\nModule 2: The vaccine cold chain\nThe vaccine cold chain\nAn increasing number of vaccines are being examined to determine their compatibility with a Controlled Temperature Chain (CTC), which would allow their use at ambient temperatures. WHO defines a CTC as the on-label use of a WHO-prequalified vaccine out of the traditional +2 °C to +8 °C cold chain for a limited period of time, at temperatures of up to 40 °C, just before administration. Vaccines licensed accordingly can be used in a CTC. The CTC approach can be adopted by countries for carefully chosen circumstances, such as for special strategies or mass vaccination campaigns.",
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"text": "\n\n\n1.2 The cold chain at health centre or peripheral health facility level\nAt the health facility level (usually health centres and health posts), health workers can adequately protect vaccines by doing the following:\nKeep vaccines in appropriate vaccine refrigeration equipment. Use a temperature monitoring device to ensure temperatures remain between +2 °C and +8 °C. Transport vaccines to immunization sessions in a vaccine carrier, correctly packed, using coolant packs that have been properly prepared, as described in Section 2.4 of this module. During immunization sessions, fit a foam pad (if available) at the top of the vaccine carrier, as described in Section 2.5 of this module.\nAt the health facility, one person must have overall responsibility for managing the vaccine cold chain. A second person can fill in when the primary person is absent. Their responsibilities should include:\nchecking and recording vaccine temperatures twice daily; typically in the morning and at the end of the session or day properly storing vaccines, diluents and water packs handling preventative maintenance of the cold chain equipment.\nAll health workers in a facility should know how to monitor the cold chain and what to do if temperatures are out of range, as described in Section 4.2 of this module.\nModule 2: The vaccine cold chain",
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"text": "\n DESCRIPTION:\n Le tableau décrit les trois catégories de réfrigérateurs vaccinaux (électriques, solaires, gaz/kérosène) et leurs avantages/inconvénients en fonction de la source d'énergie.\n :TABLE DATA:\n Categories of vaccine refrigerators Description Electric (also referred to as compression units) Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly. Solar energy (also referred to as photovoltaic units) Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels. Bottled gas (or kerosene) (also referred to as absorption units) Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.\n :END TABLE DATA:\n\n ",
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"text": "Categories of vaccine refrigerators Description Electric (also referred to as compression units) Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly. Solar energy (also referred to as photovoltaic units) Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels. Bottled gas (or kerosene) (also referred to as absorption units) Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.",
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Categories of vaccine refrigerators
Description
Electric (also referred to as compression units)
Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly.
Solar energy (also referred to as photovoltaic units)
Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels.
Bottled gas (or kerosene) (also referred to as absorption units)
Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.
Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly.
Solar energy (also referred to as photovoltaic units)
Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels.
Bottled gas (or kerosene) (also referred to as absorption units)
Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.
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"text": "\n\n\n2 Health facility cold chain equipment\nDifferent levels within the national cold chain system require different types of equipment for transporting and storing vaccines and diluents within the required temperature range.\nPrimary level (national): Depending on the capacity required, the primary level generally uses cold or freezer rooms, freezers, refrigerators, cold boxes and, in some cases, refrigerated trucks for transportation. Intermediate level (province or district): Depending on the capacity required, intermediate level generally uses cold and freezer rooms and/or freezers, refrigerators and cold boxes and, in some cases, refrigerated trucks for transportation. Peripheral level (health centre/facility or health post): Depending on the capacity required, health facilities generally need refrigerators (in certain instances with water pack freezing/cooling compartments), cold boxes and vaccine carriers. In some countries, cold boxes alone may be used for monthly or weekly immunization sessions.\nTo ensure optimal performance, cold chain equipment used for immunization programmes at any level must comply with relevant technical specifications, as defined under WHO prequalification standards or as determined by national regulatory authorities. This module focuses on cold chain equipment needed at peripheral-level health facilities.\nHealth facility refrigerators may be powered by electricity, solar energy or gas (or kerosene). A health facility refrigerator should be chosen based on the most reliable power supply available and the combined capacity needed for vaccine and water pack storage. Table 2.1 briefly describes the different refrigerator categories. Domestic refrigerators do not have good temperature control and they cannot keep vaccines cool during electricity cuts of more than one or two hours. These units are not specifically built or designed to store vaccines. For this reason, domestic refrigerators are not recommended by WHO for vaccine storage.\nModule 2: The vaccine cold chain\n :TABLE DATA: \nCategories of vaccine refrigerators Description Electric (also referred to as compression units) Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly. Solar energy (also referred to as photovoltaic units) Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels. Bottled gas (or kerosene) (also referred to as absorption units) Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.\n :END TABLE DATA:\nSince 2009, all WHO prequalified ice-lined, solar battery and solar direct-drive refrigerators have been fitted with thermostats that cannot be adjusted by the user. Provided power cuts are not excessive, the temperature in these refrigerators should always remain between +2°C and +8°C. If there is a recurring problem with the temperature control in these models, you must notify your supervisor and call the refrigerator technician. These newer refrigerators all carry a round red and blue sticker: the top red semi-circle shows the maximum allowable operating temperature and the bottom blue semi-circle shows the minimum operating temperature. For older ice-lined and solar equipment, domestic refrigerators, and all gas and kerosene refrigerators, proceed as follows:\nModule 2: The vaccine cold chain\nA health facility refrigerator must never be packed solid – always leave plenty of space around the vaccines and diluents to allow air to circulate freely, and to make vaccine handling easier. Typically, a health facility refrigerator should be chosen so that it is able to hold:\nat least one month’s supply of vaccines and diluents in the refrigerator compartment a one- or two-week reserve stock of vaccines and diluents (usually an additional 25–50% of the one-month supply) a minimum of four water packs in the freezer/cooling compartment. (Note: For technical reasons, some solar direct-drive refrigerators cannot freeze ice packs.)\nFigure 2.5 shows three commonly used types of refrigerators.\nModule 2: The vaccine cold chain\nModule 2: The vaccine cold chain",
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Primary level (national):
Depending on the capacity required, the primary level generally uses cold or freezer rooms, freezers, refrigerators, cold boxes and, in some cases, refrigerated trucks for transportation.
Intermediate level (province or district):
Depending on the capacity required, intermediate level generally uses cold and freezer rooms and/or freezers, refrigerators and cold boxes and, in some cases, refrigerated trucks for transportation.
Peripheral level (health centre/facility or health post):
Depending on the capacity required, health facilities generally need refrigerators (in certain instances with water pack freezing/cooling compartments), cold boxes and vaccine carriers. In some countries, cold boxes alone may be used for monthly or weekly immunization sessions.
To ensure optimal performance, cold chain equipment used for immunization programmes at any level must comply with relevant technical specifications, as defined under WHO prequalification standards or as determined by national regulatory authorities. This module focuses on cold chain equipment needed at peripheral-level health facilities.
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"text": "Health facility refrigerators may be powered by electricity, solar energy or gas (or kerosene). A health facility refrigerator should be chosen based on the most reliable power supply available and the combined capacity needed for vaccine and water pack storage. Table 2.1 briefly describes the different refrigerator categories. Domestic refrigerators do not have good temperature control and they cannot keep vaccines cool during electricity cuts of more than one or two hours. These units are not specifically built or designed to store vaccines. For this reason, domestic refrigerators are not recommended by WHO for vaccine storage.",
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Health facility refrigerators may be powered by electricity, solar energy or gas (or kerosene). A health facility refrigerator should be chosen based on the most reliable power supply available and the combined capacity needed for vaccine and water pack storage. Table 2.1 briefly describes the different refrigerator categories.
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"text": "Categories of vaccine refrigerators Description Electric (also referred to as compression units) Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly. Solar energy (also referred to as photovoltaic units) Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels. Bottled gas (or kerosene) (also referred to as absorption units) Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.",
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Categories of vaccine refrigerators
Description
Electric (also referred to as compression units)
Ice-lined refrigerators are the preferred option where there is reliable mains electricity for at least eight hours per day. Even with periodic breaks in electricity, the inner lining of the unit can preserve the +2°C to +8°C holdover time. A few models are available that can operate effectively on as little as four hours of electricity per day (see Figure 2.19). Ice-lined refrigerators can expose vaccines to freezing temperatures if vaccines are not loaded properly.
Solar energy (also referred to as photovoltaic units)
Solar refrigerators are more expensive to buy and install than electric refrigerators, but they have no running costs, apart from cleaning and preventative maintenance. The two types are: a) solar-battery units connected to a battery bank, which is charged by the solar panels and b) solar direct-drive units that are powered directly by the solar panels.
Bottled gas (or kerosene) (also referred to as absorption units)
Bottled gas (or kerosene) refrigerators may be necessary in places where there is insufficient sunshine for a solar-powered unit. Gas-powered units are better than kerosene models because they need less maintenance and have better temperature control. Bottled gas and kerosene refrigerators can expose vaccines to freezing temperatures. Keeping vaccines in the +2°C to +8°C range is particularly difficult with kerosene refrigerators.
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"text": "Since 2009, all WHO prequalified ice-lined, solar battery and solar direct-drive refrigerators have been fitted with thermostats that cannot be adjusted by the user. Provided power cuts are not excessive, the temperature in these refrigerators should always remain between +2°C and +8°C. If there is a recurring problem with the temperature control in these models, you must notify your supervisor and call the refrigerator technician. These newer refrigerators all carry a round red and blue sticker: the top red semi-circle shows the maximum allowable operating temperature and the bottom blue semi-circle shows the minimum operating temperature. For older ice-lined and solar equipment, domestic refrigerators, and all gas and kerosene refrigerators, proceed as follows:",
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Since 2009, all WHO prequalified ice-lined, solar battery and solar direct-drive refrigerators have been fitted with thermostats that cannot be adjusted by the user. Provided power cuts are not excessive, the temperature in these refrigerators should always remain between +2°C and +8°C. If there is a recurring problem with the temperature control in these models, you must notify your supervisor and call the refrigerator technician. These newer refrigerators all carry a round red and blue sticker: the top red semi-circle shows the maximum allowable operating temperature and the bottom blue semi-circle shows the minimum operating temperature.
For older ice-lined and solar equipment, domestic refrigerators, and all gas and kerosene refrigerators, proceed as follows:
A health facility refrigerator must never be packed solid – always leave plenty of space around the vaccines and diluents to allow air to circulate freely, and to make vaccine handling easier. Typically, a health facility refrigerator should be chosen so that it is able to hold:
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at least one month’s supply of vaccines and diluents in the refrigerator compartment
a one- or two-week reserve stock of vaccines and diluents (usually an additional 25–50% of the one-month supply)
a minimum of four water packs in the freezer/cooling compartment. (Note: For technical reasons, some solar direct-drive refrigerators cannot freeze ice packs.)
Figure 2.5 shows three commonly used types of refrigerators.
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"text": "\n\n\n2.2 Cold boxes\nA cold box is an insulated container that can be lined with water packs to keep vaccines and diluents in the required temperature range during transport or short-term storage – see Figure 2.6. Depending on the model, cold boxes can be used to store vaccines for periods of up to two days or more when there is no electricity available, when the health facility refrigerator is out of order, or when a passive container is needed while the refrigerator is being defrosted. Once packed, cold boxes should not be opened until the vaccine is needed. The “cold life” of a cold box is the maximum length of time that a closed cold box can maintain temperatures below +10 °C when it is lined with frozen ice packs. Current prequalified cold box models have a maximum cold life of two to seven days when tested at a constant +43 °C. The “cool life” of a cold box is the maximum length of time the closed cold box can maintain temperatures below +20 °C if lined with cool water packs that have been stored in a refrigerator. Current prequalified cold box models have a maximum cool life of 12 hours to two days when tested at a constant +43 °C. A cold box to be used at health facility level should be chosen based on the following factors:\nThe vaccine and diluent storage capacity needed for the supply period. The cold or cool life required, which depends on the maximum time vaccines will be stored in the box (including transport time). The type and number of water packs designed to be compatible with the size of the cold box.\nDifferent models of cold boxes have different vaccine storage capacities and need different numbers and sizes of water packs. It is important to use the correct number and size of water packs, exactly as specified by the container manufacturer, otherwise cold life or cool life will be affected. Cold boxes can be used to carry monthly vaccine supplies from district stores to the health facility and also from the health facility to outreach sessions if a vaccine carrier is too small (see Section 2.3). In general, a cold box in a health facility should be large enough to transport at least a one-month supply of vaccines.\nModule 2: The vaccine cold chain",
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"text": "\n\n\n2.3 Vaccine carriers\nVaccine carriers are smaller than cold boxes and easier to carry (see Figure 2.7). Current prequalified vaccine carriers have a cold life with frozen ice packs of between 18 and 50 hours at +43 °C and a cool life with cool water packs of between three and 18 hours. Vaccine carriers are generally used for the following purposes:\nTo transport vaccines and diluents to outreach sites and store them during health facility immunization sessions. To store vaccines temporarily when the health facility refrigerator is out of order or is being defrosted. To transport monthly vaccine supplies from the district store to small health facilities.\nVaccine carriers used at the health facility should be chosen based on the following factors:\nThe type and quantity of vaccines and diluents to be transported. The cold or cool life needed for the longest planned journeys. The transport method used (for example, the requirements for a vaccine carrier that will be carried for short distances on foot are not the same as those for one that will be transported for long distances on the back of a motorcycle).",
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To transport vaccines and diluents to outreach sites and store them during health facility immunization sessions.
To store vaccines temporarily when the health facility refrigerator is out of order or is being defrosted.
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"text": "\n\n\n2.4 Water packs\nWater packs are flat, leak-proof plastic containers that can be filled with tap water. They are used to line the inside of the cold box or vaccine carrier (see Figure 2.8). Water packs are used to keep vaccines at the required temperature range inside cold boxes and vaccine carriers. In order to protect the vaccines it is important to use the correct number and size of water packs and to follow the instructions printed inside the lid of the container. To ensure optimal performance, WHO recommends the use of pre-qualified water packs.\nModule 2: The vaccine cold chain\nHealth facilities must have a minimum of two complete sets of water packs for each of their cold boxes and vaccine carriers so that one set can be frozen or cooled in the freezer/refrigerator while the other set is being used in the cold box or vaccine carrier. The appropriate temperature of the water pack will depend on the type(s) of vaccines being transported, the ambient temperatures to which the cold box or vaccine carrier will be exposed, and the duration of transport. Water packs can be used in any of the following ways:\nfrozen ice packs , taken directly from a freezer at temperatures between -10 °C and -25 °C conditioned ice packs containing a mixture of water and ice at an initial temperature of about 0 °C cool water packs , containing liquid water at an initial temperature of +5 °C or less warm water packs , containing liquid water, initially at room temperature, between +18 °C and +24 °C.\nThe appropriate water pack strategy to use at health facility level, for transport or outreach operations, will be guided by national policy and practice. If cool water packs are used for outreach operations, there must be additional provision at the outreach session to keep both reconstituted lyophilized vaccines – and unpreserved multi-dose vaccines that have been opened – cool at between +2 °C and +8 °C. Exposure of reconstituted unpreserved vaccines and liquid vaccines that do not contain preservative to temperatures above +8 °C during immunization sessions can result in an increased risk of microbial growth in opened vials of vaccine. In practice, this means that one or more frozen or conditioned ice packs must also be available at the session. Note that taking frozen, conditioned or cool water packs out of the vaccine carrier will shorten their cold/cool life. Therefore, water packs should not be removed during immunization sessions to hold opened vials. Opened vials should be placed in the foam pad that is provided with the vaccine carrier, as described in Section 2.5. WHO strongly discourages the use of wet ice in plastic water bags as this may expose vaccines to freezing temperatures.\nModule 2: The vaccine cold chain",
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The appropriate water pack strategy to use at health facility level, for transport or outreach operations, will be guided by national policy and practice.
If cool water packs are used for outreach operations, there must be additional provision at the outreach session to keep both reconstituted lyophilized vaccines – and unpreserved multi-dose vaccines that have been opened – cool at between +2 °C and +8 °C. Exposure of reconstituted unpreserved vaccines and liquid vaccines that do not contain preservative to temperatures above +8 °C during immunization sessions can result in an increased risk of microbial growth in opened vials of vaccine. In practice, this means that one or more frozen or conditioned ice packs must also be available at the session.
Note that taking frozen, conditioned or cool water packs out of the vaccine carrier will shorten their cold/cool life. Therefore, water packs should not be removed during immunization sessions to hold opened vials. Opened vials should be placed in the foam pad that is provided with the vaccine carrier, as described in Section 2.5.
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"text": "\n\n\n2.5 Foam pads\nA foam pad is a piece of soft sponge-like material that fits precisely on top of the water packs inside a vaccine carrier (see Figure 2.9) while still permitting the lid of the vaccine carrier to fully close. The foam pad is provided by the manufacturer of the vaccine carrier. The foam pad usually has slits in which vaccine vials can be inserted snugly and protected. The foam pad should be used during an immunization session as a temporary lid to securely hold opened vials, while protecting unopened vials in the cool chamber below inside the carrier. Note that opened vials of heat-sensitive vaccines can be protected from heat damage for longer periods during immunization sessions if they are pushed into the foam pad. Even with a foam pad, however, it is important to keep the hard vaccine carrier lid closed whenever possible to conserve the inner temperature. WHO does not recommend the use of homemade foam pads. Health workers should use the pad supplied with the carrier and try to keep it clean and free from dirt or dust.\nModule 2: The vaccine cold chain",
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"text": "\n\n\n3.1 Monitoring heat exposure using vaccine vial monitors\nVaccine vial monitors (VVMs) are the only temperature monitoring devices that routinely accompany vaccines throughout the entire supply chain. A VVM is a chemical indicator label attached to the vaccine container (vial, ampoule or dropper) by the vaccine manufacturer. As the container moves through the supply chain, the VVM records its cumulative heat exposure through a gradual change in colour (see Figure 2.10). If the colour of the inner square is the same colour or darker than the outer circle, the vaccine has been exposed to too much heat and should be discarded. There are currently four types of VVM, chosen to match the heat sensitivity of the vaccine. These four types are VVM2, VVM7, VVM14 and VVM30. The VVM number is the time in days that it takes for the inner square to reach the colour indicating a discard point if the vial is exposed to a constant temperature of 37 °C. The main purpose of VVMs is to ensure that heat-damaged vaccines are not administered. The VVM status is also used to decide which vaccines can safely be kept after a cold chain break occurs thus minimizing unnecessary vaccine wastage. In addition, VVM status helps the user decide which vaccine should be used first – a batch of vaccine showing significant heat exposure should be distributed and used before a batch that shows lower heat exposure, even if its expiry date is longer.\nModule 2: The vaccine cold chain\nVVM status should always be checked and recorded manually on the arrival voucher when it first reaches the health facility. The vaccinator must also check the VVM before the vaccine is opened to see whether the vaccine has been damaged by heat. Only use the vial if the expiry date has not passed, and if the inner square of the VVM is lighter in colour than the outside circle. VVMs do not measure exposure to freezing temperatures. If the vaccine is freeze-sensitive and freezing is suspected, then the Shake Test must be conducted (see Section 7 of this module).\nModule 2: The vaccine cold chain",
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"text": "Vaccine vial monitors (VVMs) are the only temperature monitoring devices that routinely accompany vaccines throughout the entire supply chain. A VVM is a chemical indicator label attached to the vaccine container (vial, ampoule or dropper) by the vaccine manufacturer. As the container moves through the supply chain, the VVM records its cumulative heat exposure through a gradual change in colour (see Figure 2.10). If the colour of the inner square is the same colour or darker than the outer circle, the vaccine has been exposed to too much heat and should be discarded. There are currently four types of VVM, chosen to match the heat sensitivity of the vaccine. These four types are VVM2, VVM7, VVM14 and VVM30. The VVM number is the time in days that it takes for the inner square to reach the colour indicating a discard point if the vial is exposed to a constant temperature of 37 °C. The main purpose of VVMs is to ensure that heat-damaged vaccines are not administered. The VVM status is also used to decide which vaccines can safely be kept after a cold chain break occurs thus minimizing unnecessary vaccine wastage. In addition, VVM status helps the user decide which vaccine should be used first – a batch of vaccine showing significant heat exposure should be distributed and used before a batch that shows lower heat exposure, even if its expiry date is longer.",
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Vaccine vial monitors (VVMs) are the only temperature monitoring devices that routinely accompany vaccines throughout the entire supply chain. A VVM is a chemical indicator label attached to the vaccine container (vial, ampoule or dropper) by the vaccine manufacturer. As the container moves through the supply chain, the VVM records its cumulative heat exposure through a gradual change in colour (see Figure 2.10). If the colour of the inner square is the same colour or darker than the outer circle, the vaccine has been exposed to too much heat and should be discarded.
There are currently four types of VVM, chosen to match the heat sensitivity of the vaccine. These four types are VVM2, VVM7, VVM14 and VVM30. The VVM number is the time in days that it takes for the inner square to reach the colour indicating a discard point if the vial is exposed to a constant temperature of 37 °C.
The main purpose of VVMs is to ensure that heat-damaged vaccines are not administered. The VVM status is also used to decide which vaccines can safely be kept after a cold chain break occurs thus minimizing unnecessary vaccine wastage. In addition, VVM status helps the user decide which vaccine should be used first – a batch of vaccine showing significant heat exposure should be distributed and used before a batch that shows lower heat exposure, even if its expiry date is longer.
VVM status should always be checked and recorded manually on the arrival voucher when it first reaches the health facility. The vaccinator must also check the VVM before the vaccine is opened to see whether the vaccine has been damaged by heat. Only use the vial if the expiry date has not passed, and if the inner square of the VVM is lighter in colour than the outside circle. VVMs do not measure exposure to freezing temperatures. If the vaccine is freeze-sensitive and freezing is suspected, then the Shake Test must be conducted (see Section 7 of this module).
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"text": "\n\n\nWhere is the VVM?\nThere are two different locations for VVMs (see Figure 2.11) and each is associated with specific guidance for handling opened multi-dose vials of vaccine:\nWHO-prequalified vaccines, where the VVM, if attached, is on the label of the vaccine. The vaccine vial, once opened, can be kept for subsequent immunization sessions up to 28 days, regardless of the formulation of the product (liquid or freeze-dried). WHO-prequalified vaccines where the VVM is attached in a location other than on the label (e.g., cap or neck of ampoule). In this instance, the vaccine vial, once opened, must be discarded at the end of the immunization session or within six hours of opening, whichever comes first. This is regardless of the formulation of the product (liquid or freeze-dried). This would apply, for example, to a reconstituted product of which the vaccine vial cap, which has a VVM attached, has been discarded after opening.\nModule 2: The vaccine cold chain",
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WHO-prequalified vaccines where the VVM is attached in a location other than on the label (e.g., cap or neck of ampoule). In this instance, the vaccine vial, once opened, must be discarded at the end of the immunization session or within six hours of opening, whichever comes first. This is regardless of the formulation of the product (liquid or freeze-dried). This would apply, for example, to a reconstituted product of which the vaccine vial cap, which has a VVM attached, has been discarded after opening.
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"text": "\n\n\n3.2 Temperature monitoring devices\nThese devices are placed with the vaccine load in a vaccine refrigerator. They record the refrigerator temperature at no more than 10-minute intervals and show the temperature history for any day in the last 30 days. They also record and display a 30-day history of any heat and freeze alarms that have occurred. Alarms are triggered if the temperature of the refrigerator drops to –0.5 °C or below for 60 minutes or if it exceeds +10 °C for a continuous period of 10 hours. As long as the temperature has remained within the recommended range, the device displays “OK” or a tick symbol. Several types of 30 DTR are prequalified by WHO and Figure 2.12 shows two examples. On newer models, data can also be downloaded via a connection to a computer. 30 DTRs should not be used in vaccine freezers. Current models have built-in batteries with a battery alarm feature; the device must be discarded and replaced when the battery expires, which is typically every two or three years. 30 DTRs should be placed in an accessible position where they can be read easily and are unlikely to be damaged. This will vary depending on the type of refrigerator. Try to observe the following rules:\nIf the refrigerator is used to store vaccines that are not freeze-sensitive, place the device on top of the load, in the warmest part of the refrigerator. If the refrigerator is used to store any freeze-sensitive vaccines, the device should preferably be placed in the coldest part of the refrigerator that is being used to store these vaccines. This will be the bottom of a basket in chest refrigerators or nearest to the evaporator plate in front-opening models and absorption units.\nModule 2: The vaccine cold chain\nThese are small digital devices that are placed with freeze-sensitive vaccines during transport or storage. The devices have a visual indicator that shows whether the vaccine has been exposed to freezing temperatures. Once the alarm indicator is triggered, the device is no longer usable and should be discarded. Otherwise the device can be used until the built-in battery expires. Figure 2.13 shows two types. Note that electronic freeze indicators are not needed in refrigerators where a 30 DTR is used.",
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"text": "These devices are placed with the vaccine load in a vaccine refrigerator. They record the refrigerator temperature at no more than 10-minute intervals and show the temperature history for any day in the last 30 days. They also record and display a 30-day history of any heat and freeze alarms that have occurred. Alarms are triggered if the temperature of the refrigerator drops to –0.5 °C or below for 60 minutes or if it exceeds +10 °C for a continuous period of 10 hours. As long as the temperature has remained within the recommended range, the device displays “OK” or a tick symbol. Several types of 30 DTR are prequalified by WHO and Figure 2.12 shows two examples. On newer models, data can also be downloaded via a connection to a computer. 30 DTRs should not be used in vaccine freezers. Current models have built-in batteries with a battery alarm feature; the device must be discarded and replaced when the battery expires, which is typically every two or three years. 30 DTRs should be placed in an accessible position where they can be read easily and are unlikely to be damaged. This will vary depending on the type of refrigerator. Try to observe the following rules:",
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These devices are placed with the vaccine load in a vaccine refrigerator. They record the refrigerator temperature at no more than 10-minute intervals and show the temperature history for any day in the last 30 days. They also record and display a 30-day history of any heat and freeze alarms that have occurred. Alarms are triggered if the temperature of the refrigerator drops to –0.5 °C or below for 60 minutes or if it exceeds +10 °C for a continuous period of 10 hours. As long as the temperature has remained within the recommended range, the device displays “OK” or a tick symbol. Several types of 30 DTR are prequalified by WHO and Figure 2.12 shows two examples. On newer models, data can also be downloaded via a connection to a computer. 30 DTRs should not be used in vaccine freezers. Current models have built-in batteries with a battery alarm feature; the device must be discarded and replaced when the battery expires, which is typically every two or three years.
30 DTRs should be placed in an accessible position where they can be read easily and are unlikely to be damaged. This will vary depending on the type of refrigerator. Try to observe the following rules:
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If the refrigerator is used to store vaccines that are not freeze-sensitive, place the device on top of the load, in the warmest part of the refrigerator.
If the refrigerator is used to store any freeze-sensitive vaccines, the device should preferably be placed in the coldest part of the refrigerator that is being used to store these vaccines. This will be the bottom of a basket in chest refrigerators or nearest to the evaporator plate in front-opening models and absorption units.
These are small digital devices that are placed with freeze-sensitive vaccines during transport or storage. The devices have a visual indicator that shows whether the vaccine has been exposed to freezing temperatures. Once the alarm indicator is triggered, the device is no longer usable and should be discarded. Otherwise the device can be used until the built-in battery expires. Figure 2.13 shows two types.
Note that electronic freeze indicators are not needed in refrigerators where a 30 DTR is used.
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"text": "\n\n\n3.3 Recommended equipment\nTable 2.2 sets out the temperature monitoring options for health facility storage and transport, in order of preference.\n :TABLE DATA: \nVaccine refrigerator Cold boxes and vaccine carriers Best practice 30-day temperature logger Integrated digital thermometer Stem thermometer for back-up VVMs where supplied Conditioned ice packs Freeze indicator VVMs where supplied Cool water packs Stem thermometer VVMs where supplied Warm water packs Freeze indicator VVMs where supplied Minimum requirement Integrated digital thermometer Stem thermometer for back-up Electronic freeze indicator VVMs where supplied\n :END TABLE DATA:\nModule 2: The vaccine cold chain",
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"text": "Vaccine refrigerator Cold boxes and vaccine carriers Best practice 30-day temperature logger Integrated digital thermometer Stem thermometer for back-up VVMs where supplied Conditioned ice packs Freeze indicator VVMs where supplied Cool water packs Stem thermometer VVMs where supplied Warm water packs Freeze indicator VVMs where supplied Minimum requirement Integrated digital thermometer Stem thermometer for back-up Electronic freeze indicator VVMs where supplied",
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"text": "If conditioned ice packs are being used to transport freeze-sensitive vaccines, an electronic freeze indicator should be included with the load – the indicator shows if the vaccines have been exposed to freezing temperatures. Freeze indicators are not needed if cool water packs are used because there is no freezing risk. If warm water packs are used to protect freeze-sensitive vaccines in very cold climates it is also good practice to use freeze indicators, since the temperature of the load may drop below zero on a long journey.",
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If conditioned ice packs are being used to transport freeze-sensitive vaccines, an electronic freeze indicator should be included with the load – the indicator shows if the vaccines have been exposed to freezing temperatures. Freeze indicators are not needed if cool water packs are used because there is no freezing risk. If warm water packs are used to protect freeze-sensitive vaccines in very cold climates it is also good practice to use freeze indicators, since the temperature of the load may drop below zero on a long journey.
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"text": "The data gathered from temperature monitoring devices must be recorded and analysed on a regular basis to demonstrate that vaccines are being stored and transported at the correct temperatures. This section reviews temperature monitoring of vaccine refrigerators, cold boxes and vaccine carriers at the health facility level.",
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"text": "\n\n\n4.1 Monitoring vaccine refrigerator temperature\nA standard manual temperature-recording chart should be attached to the door or lid of every vaccine refrigerator. Readings should be taken twice a day at least five days per week and preferably every day, including weekends and holidays. Daily readings should be taken from the same temperature monitoring device each time. The health worker should read the 30 DTR and write the data on the chart. If there is no 30 DTR, you should check the integrated dial thermometer or, where necessary, the stem thermometer. Recording temperatures in this way provides evidence that the refrigerator is being monitored and that regular readings are being taken. This can help identify performance trends, sometimes even before automatic alarms are generated. Manual readings should be recorded on a temperature chart attached to the refrigerator door using the following procedure:\nCheck the refrigerator temperature first thing in the morning and at the end of the working day. Record the temperature by date and time on the temperature chart (an example specifically designed for 30 DTRs is shown in Figure 2.17). When a chart is completed, replace it with a new one. Keep completed charts together in a file for future reference. (Note: action should be taken when the temperature goes out of range; see Section 4.2 of this module.)",
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"text": "A standard manual temperature-recording chart should be attached to the door or lid of every vaccine refrigerator. Readings should be taken twice a day at least five days per week and preferably every day, including weekends and holidays. Daily readings should be taken from the same temperature monitoring device each time. The health worker should read the 30 DTR and write the data on the chart. If there is no 30 DTR, you should check the integrated dial thermometer or, where necessary, the stem thermometer. Recording temperatures in this way provides evidence that the refrigerator is being monitored and that regular readings are being taken. This can help identify performance trends, sometimes even before automatic alarms are generated. Manual readings should be recorded on a temperature chart attached to the refrigerator door using the following procedure:",
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A standard manual temperature-recording chart should be attached to the door or lid of every vaccine refrigerator. Readings should be taken twice a day at least five days per week and preferably every day, including weekends and holidays. Daily readings should be taken from the same temperature monitoring device each time. The health worker should read the 30 DTR and write the data on the chart. If there is no 30 DTR, you should check the integrated dial thermometer or, where necessary, the stem thermometer. Recording temperatures in this way provides evidence that the refrigerator is being monitored and that regular readings are being taken. This can help identify performance trends, sometimes even before automatic alarms are generated.
Manual readings should be recorded on a temperature chart attached to the refrigerator door using the following procedure:
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Check the refrigerator temperature first thing in the morning and at the end of the working day.
Record the temperature by date and time on the temperature chart (an example specifically designed for 30 DTRs is shown in Figure 2.17). When a chart is completed, replace it with a new one. Keep completed charts together in a file for future reference. (Note: action should be taken when the temperature goes out of range; see Section 4.2 of this module.)
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"text": "\n\n\n4.2 Taking action when a vaccine refrigerator’s temperature is out of range\nIf the temperature of the refrigerator is below +2 °C, which is too low, a report should be made to the supervisor. The corrective action includes the following procedure:\nTurn the thermostat knob so the arrow points to a higher number. This will make the refrigerator warmer. Check whether the door of the freezer closes properly. The seal may be damaged. If broken, a technician should be called to make repairs. If the temperature has fallen below 0 °C for any length of time, check freeze-sensitive vaccines to see if they have been damaged by freezing using the Shake Test (see Section 7 of this module).\nRemember: slight heat exposure is less damaging to most liquid vaccines and diluents than freezing exposure.\nIf the temperature is above +8 °C, which is too high, a report should be made to the supervisor. The corrective action includes the following procedure:\nMake sure that the refrigerator is working. If it is not working, check whether the power supply (electricity, gas, kerosene or solar) is adequate. Check whether the door of the refrigerator or the freezing compartment closes properly; if the seal is broken, the temperature will fluctuate. Call a technician to make repairs. Check whether frost is preventing cold air in the freezing compartment from entering the refrigerator compartment. Defrost if necessary. If the power supply, door seal and frost levels are all in working order, turn the thermostat knob so that the arrow points to a higher number. This will make the refrigerator cooler. If the temperature cannot be maintained between +2 °C and +8 °C, store vaccines in other cold chain equipment that can maintain this temperature range until the refrigerator is repaired.\nRemember: to avoid freezing vaccines, do not adjust the thermostat to a cooler (higher number) setting after a power cut or when vaccines arrive.\nModule 2: The vaccine cold chain",
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4.2 Taking action when a vaccine refrigerator’s temperature is out of range
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Turn the thermostat knob so the arrow points to a higher number. This will make the refrigerator warmer.
Check whether the door of the freezer closes properly. The seal may be damaged. If broken, a technician should be called to make repairs.
If the temperature has fallen below 0 °C for any length of time, check freeze-sensitive vaccines to see if they have been damaged by freezing using the Shake Test (see Section 7 of this module).
slight heat exposure is less damaging to most liquid vaccines and diluents than freezing exposure.
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Make sure that the refrigerator is working. If it is not working, check whether the power supply (electricity, gas, kerosene or solar) is adequate.
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If the temperature cannot be maintained between +2 °C and +8 °C, store vaccines in other cold chain equipment that can maintain this temperature range until the refrigerator is repaired.
To maintain the correct temperature in cold boxes and vaccine carriers, proceed as follows:
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Place the correct number and type of properly conditioned ice packs or cool water packs in the cold box or vaccine carrier.
If you are using conditioned ice packs you should preferably put an electronic freeze indicator in each cold box or vaccine carrier containing freeze-sensitive vaccines.
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Keep the lid tightly closed.
Use the foam pad to hold opened vials at the top of the vaccine carrier during an immunization session; keep the hard carrier lid closed whenever possible.
During the immunization session, vaccines must be kept at the recommended temperatures after opening. In particular, it is important to keep opened multi-dose vaccine vials that do not contain preservative – whether lyophilized or liquid – cooled at temperatures between +2 °C and +8 °C.
At the end of the immunization session, health workers should follow national policy in handling remaining vials. In general, this means:
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discarding all opened vials of vaccines that do not contain preservative; this includes all reconstituted vaccines and some liquid multi-dose vaccines
checking the VVMs of all unopened vials and returning the unopened vials with VVMs that are not past the discard point to a working refrigerator or appropriate cold box as soon as possible
where multi-dose vial policy is applied, check the VVMs of all opened vials that contain preservative and return those with VVMs that are not past the discard point to a working refrigerator or appropriate cold box as soon as possible. Use these vaccines first for the next immunization session.
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"text": "\n\n\n5.1 General rules for using vaccine refrigerators\nHealth facility refrigerators are used to store vaccines and diluents. Several types of refrigerator are available and the arrangement of items inside them varies according to the type. The following general rules (Do’s and Do Not’s) apply to all health facility refrigerators. DO arrange the vaccines in the health facility refrigerator like this:\nWherever possible, store vaccines and diluents in a refrigerator that is reserved for this purpose only. If other heat-sensitive supplies, such as drugs, ointments, sera and samples, have to be stored in the refrigerator, label them clearly and keep them completely separate from the vaccines and diluents. Always arrange vaccines and diluents so that air can circulate freely; this also makes it easier to handle the vaccines. If vaccines or diluents are supplied in their original cartons, arrange the boxes so that there is at least a two-centimetre space between stacks. Mark the cartons clearly and make sure the markings are visible when the door or lid is opened. If vaccines or diluents are supplied as individual containers (vials, ampoules or tubes), use a plastic tray, plastic box or other arrangement to store the vaccines in an orderly fashion. Figure 2.18 shows a good arrangement using local-made stacking boxes. If diluent is packaged with the vaccine, store the complete packaged product in the refrigerator. If diluents are supplied separately from the vaccine, store them in the refrigerator if there is adequate space. If there is not adequate space, move the diluents to the refrigerator at least 24 hours before they are needed so they are cooled.\nModule 2: The vaccine cold chain",
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If diluent is packaged with the vaccine, store the complete packaged product in the refrigerator. If diluents are supplied separately from the vaccine, store them in the refrigerator if there is adequate space. If there is not adequate space, move the diluents to the refrigerator at least 24 hours before they are needed so they are cooled.
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"text": "\n\n\nFigure 2.18 Purpose-made tray for vials and ampoules\nSource: Anthony Battersby\nPlace vaccines with VVMs that show the most heat exposure (darker squares) in a separate container in the refrigerator, clearly marked “Heat-exposed vials – use first”. If there are other vaccines of the same type in the refrigerator, the vaccines with the darkest squares should always be used first even if the expiry date is later than the vaccines with the lighter squares. If a multi-dose vial policy is in place, follow the instructions for handling opened multi-dose vials exactly as described in the national policy. If an opened multi-dose vial will be used for the next session, the vials must be placed in a separate container in the refrigerator, which is clearly marked “Opened vials – use first.” A summary of the WHO Multi-dose Vial Policy is outlined in the box below. The local policy may be different.\nDON’T arrange the vaccines in the health facility refrigerator like this:\nNever store food or drink in a vaccine refrigerator. Do not open the door or lid unless it is essential to do so. Frequent opening raises the temperature inside the refrigerator. If there is a freezer compartment, do not use it to store vaccines and diluents. Do not keep expired vaccines in the refrigerator. Do not keep vaccines with VVMs that have reached, or are beyond, their discard point. Do not keep reconstituted vaccines for more than six hours, or after the end of an immunization session. Discard all these items immediately according to your national guidelines. Refer any questions to your supervisor.\nModule 2: The vaccine cold chain\nSummary of WHO Multi-dose Vial Policy (MDVP), 2014 All opened WHO-prequalified multi-dose vials of vaccines should be discarded at the end of the immunization session, or within six hours of opening, whichever comes first, unless the vaccine meets all four of the criteria listed below. If the vaccine meets the four criteria, the opened vial can be kept and used for up to 28 days after opening. The criteria are as follows: The vaccine is currently prequalified by WHO. The vaccine is approved for use for up to 28 days after opening the vial, as determined by WHO. The expiry date of the vaccine has not passed. The vaccine vial has been, and will continue to be, stored at WHO- or manufacturer-recommended temperatures; furthermore, the vaccine vial monitor, if one is attached, is visible on the vaccine label and is not past its discard point, and the vaccine has not been damaged by freezing. If ALL of the criteria cited above are present, the vaccine vial may be kept and used for up to 28 days after opening, or until all the doses are administered.",
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"text": "Summary of WHO Multi-dose Vial Policy (MDVP), 2014 All opened WHO-prequalified multi-dose vials of vaccines should be discarded at the end of the immunization session, or within six hours of opening, whichever comes first, unless the vaccine meets all four of the criteria listed below. If the vaccine meets the four criteria, the opened vial can be kept and used for up to 28 days after opening. The criteria are as follows: The vaccine is currently prequalified by WHO. The vaccine is approved for use for up to 28 days after opening the vial, as determined by WHO. The expiry date of the vaccine has not passed. The vaccine vial has been, and will continue to be, stored at WHO- or manufacturer-recommended temperatures; furthermore, the vaccine vial monitor, if one is attached, is visible on the vaccine label and is not past its discard point, and the vaccine has not been damaged by freezing. If ALL of the criteria cited above are present, the vaccine vial may be kept and used for up to 28 days after opening, or until all the doses are administered.",
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Summary of WHO Multi-dose Vial Policy (MDVP), 2014
All opened WHO-prequalified multi-dose vials of vaccines should be discarded at the end of the immunization session, or within six hours of opening, whichever comes first, unless the vaccine meets all four of the criteria listed below. If the vaccine meets the four criteria, the opened vial can be kept and used for up to 28 days after opening. The criteria are as follows:
The vaccine is currently prequalified by WHO.
The vaccine is approved for use for up to 28 days after opening the vial, as determined by WHO.
The expiry date of the vaccine has not passed.
The vaccine vial has been, and will continue to be, stored at WHO- or manufacturer-recommended temperatures; furthermore, the vaccine vial monitor, if one is attached, is visible on the vaccine label and is not past its discard point, and the vaccine has not been damaged by freezing.
If ALL of the criteria cited above are present, the vaccine vial may be kept and used for up to 28 days after opening, or until all the doses are administered.
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"text": "\n DESCRIPTION:\n Le tableau décrit trois types de réfrigérateurs à ouverture frontale pour vaccins, en distinguant ceux avec ou sans compartiment de congélation.\n :TABLE DATA:\n Table 2.3 Types of front-opening vaccine refrigerators Types of front-opening vaccine refrigerators Description Type 1 Gas or kerosene models, with an ice pack freezing compartment: There are no recently prequalified models of this type, but large numbers remain in use. Type 2 Mains electric domestic models: Typically these have an ice pack freezing compartment. Type 3 Prequalified water-lined models powered by mains or solar electricity: These models do not have an ice pack freezing compartment.\n :END TABLE DATA:\n\n ",
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"text": "Table 2.3 Types of front-opening vaccine refrigerators Types of front-opening vaccine refrigerators Description Type 1 Gas or kerosene models, with an ice pack freezing compartment: There are no recently prequalified models of this type, but large numbers remain in use. Type 2 Mains electric domestic models: Typically these have an ice pack freezing compartment. Type 3 Prequalified water-lined models powered by mains or solar electricity: These models do not have an ice pack freezing compartment.",
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Table 2.3 Types of front-opening vaccine refrigerators
Types of front-opening vaccine refrigerators
Description
Type 1
Gas or kerosene models, with an ice pack freezing compartment: There are no recently prequalified models of this type, but large numbers remain in use.
Type 2
Mains electric domestic models: Typically these have an ice pack freezing compartment.
Type 3
Prequalified water-lined models powered by mains or solar electricity: These models do not have an ice pack freezing compartment.
Table 2.3 Types of front-opening vaccine refrigerators
Types of front-opening vaccine refrigerators
Description
Type 1
Gas or kerosene models, with an ice pack freezing compartment: There are no recently prequalified models of this type, but large numbers remain in use.
Type 2
Mains electric domestic models: Typically these have an ice pack freezing compartment.
Type 3
Prequalified water-lined models powered by mains or solar electricity: These models do not have an ice pack freezing compartment.
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"text": "\n\n\n5.2 Specific rules for using front-opening refrigerators\nTable 2.3 briefly describes the three types of front-opening vaccine refrigerators used for storing vaccines. Figure 2.19 shows how a gas or kerosene vaccine refrigerator or a domestic electric front-opening refrigerator should be organized.\n :TABLE DATA: \nTable 2.3 Types of front-opening vaccine refrigerators Types of front-opening vaccine refrigerators Description Type 1 Gas or kerosene models, with an ice pack freezing compartment: There are no recently prequalified models of this type, but large numbers remain in use. Type 2 Mains electric domestic models: Typically these have an ice pack freezing compartment. Type 3 Prequalified water-lined models powered by mains or solar electricity: These models do not have an ice pack freezing compartment.\n :END TABLE DATA:\nModule 2: The vaccine cold chain\nThe following rules apply for front-opening refrigerators:\nNever put vaccines or diluents in the door shelves. The temperature is too warm for vaccine storage and vaccines are exposed to room temperature each time the door is opened. Never put freeze-sensitive vaccines in contact with, or close to, the evaporator plate in the refrigerator. Put water packs or plastic bottles full of coloured water in the space below the bottom shelf. This helps to stabilize the temperature if there is a power cut. Do not use the water packs in vaccine carriers. Never drink the water.\nModule 2: The vaccine cold chain\nPut measles, MR, MMR, BCG, OPV, yellow fever, Japanese encephalitis, meningococcal A conjugate and/or any other vaccines not damaged by freezing on the top shelf. Put DTP, DT, Td, TT, HepB, DTP+HepB, DTP+HepB+Hib, Hib, HPV, rotavirus and/or any other freeze-sensitive vaccines on the middle or lower shelves. Store the diluents next to the freeze-dried vaccine with which they are supplied, on the appropriate shelf. If there is not enough space on the shelf, put the diluents on the bottom shelf, clearly labelled so they can be easily identified to their matching vaccine.\nFigure 2.20 shows the recommended arrangement for an upright ice-lined refrigerator. In these models there is very little variation in the temperature inside the refrigerator compartment, so vaccines and diluents can be placed safely on any of the shelves. However, in humid climates, there is a risk of condensation. Cartons and vials should be stored in plastic boxes with tightly fitting lids to reduce the risk of moisture damage. Never store vaccines below the bottom shelf – this area may be wet because it collects and drains the condensation from the roof and walls of the compartment.\nModule 2: The vaccine cold chain",
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5.2 Specific rules for using front-opening refrigerators
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Table 2.3 Types of front-opening vaccine refrigerators
Types of front-opening vaccine refrigerators
Description
Type 1
Gas or kerosene models, with an ice pack freezing compartment: There are no recently prequalified models of this type, but large numbers remain in use.
Type 2
Mains electric domestic models: Typically these have an ice pack freezing compartment.
Type 3
Prequalified water-lined models powered by mains or solar electricity: These models do not have an ice pack freezing compartment.
The following rules apply for front-opening refrigerators:
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Never put vaccines or diluents in the door shelves. The temperature is too warm for vaccine storage and vaccines are exposed to room temperature each time the door is opened.
Never put freeze-sensitive vaccines in contact with, or close to, the evaporator plate in the refrigerator.
Put water packs or plastic bottles full of coloured water in the space below the bottom shelf. This helps to stabilize the temperature if there is a power cut. Do not use the water packs in vaccine carriers. Never drink the water.
Put measles, MR, MMR, BCG, OPV, yellow fever, Japanese encephalitis, meningococcal A conjugate and/or any other vaccines not damaged by freezing on the top shelf.
Put DTP, DT, Td, TT, HepB, DTP+HepB, DTP+HepB+Hib, Hib, HPV, rotavirus and/or any other freeze-sensitive vaccines on the middle or lower shelves.
Store the diluents next to the freeze-dried vaccine with which they are supplied, on the appropriate shelf. If there is not enough space on the shelf, put the diluents on the bottom shelf, clearly labelled so they can be easily identified to their matching vaccine.
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Figure 2.20 shows the recommended arrangement for an upright ice-lined refrigerator. In these models there is very little variation in the temperature inside the refrigerator compartment, so vaccines and diluents can be placed safely on any of the shelves. However, in humid climates, there is a risk of condensation. Cartons and vials should be stored in plastic boxes with tightly fitting lids to reduce the risk of moisture damage. Never store vaccines below the bottom shelf – this area may be wet because it collects and drains the condensation from the roof and walls of the compartment.
5.3 Specific rules for using top-opening refrigerators without baskets
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"text": "Table 2.4 briefly describes the two types of top-opening vaccine refrigerators used for storing vaccine. Some top opening refrigerators are supplied without baskets. Figure 2.21 shows the arrangement of vaccines and diluent in a top-opening refrigerator without baskets.",
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Table 2.4 briefly describes the two types of top-opening vaccine refrigerators used for storing vaccine. Some top opening refrigerators are supplied without baskets.
Figure 2.21 shows the arrangement of vaccines and diluent in a top-opening refrigerator without baskets.
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"text": "\n DESCRIPTION:\n Le tableau décrit deux types de réfrigérateurs à vaccin à ouverture par le haut : à gaz/kérosène (avec compartiment de congélation) et solaires PCM (sans congélateur).\n :TABLE DATA:\n Types of top-opening vaccine refrigerators Description Type 1 Gas or kerosene refrigerators: These have a small compartment for freezing ice packs. Type 2 Solar direct-drive models with a lining containing a phase-change material (PCM) to protect the vaccine overnight and during cloudy periods: The PCM freezes at around +5 °C so vaccine can be in contact with the lining without risk of damage. Current models do not have a freezer compartment.\n :END TABLE DATA:\n\n ",
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Types of top-opening vaccine refrigerators
Description
Type 1
Gas or kerosene refrigerators: These have a small compartment for freezing ice packs.
Type 2
Solar direct-drive models with a lining containing a phase-change material (PCM) to protect the vaccine overnight and during cloudy periods: The PCM freezes at around +5 °C so vaccine can be in contact with the lining without risk of damage. Current models do not have a freezer compartment.
Gas or kerosene refrigerators: These have a small compartment for freezing ice packs.
Type 2
Solar direct-drive models with a lining containing a phase-change material (PCM) to protect the vaccine overnight and during cloudy periods: The PCM freezes at around +5 °C so vaccine can be in contact with the lining without risk of damage. Current models do not have a freezer compartment.
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Table 2.4 Types of top-opening vaccine refrigerators
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Types of top-opening vaccine refrigerators
Description
Type 1
Gas or kerosene refrigerators: These have a small compartment for freezing ice packs.
Type 2
Solar direct-drive models with a lining containing a phase-change material (PCM) to protect the vaccine overnight and during cloudy periods: The PCM freezes at around +5 °C so vaccine can be in contact with the lining without risk of damage. Current models do not have a freezer compartment.
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"text": "\n\n\nFigure 2.21 Vaccine and diluent arrangement in a top-opening refrigerator without baskets\nModule 2: The vaccine cold chain\nThe following rules apply to these two types of refrigerator:\n• Never put freeze-sensitive vaccines in the bottom of gas and kerosene refrigerators or next to the freezer compartment. There is a risk of freezing in these areas. • Put measles, MR, MMR, BCG, OPV, yellow fever, Japanese encephalitis and/or any other vaccines not damaged by freezing in the bottom of the compartment. • Put diluents, DTP, DT, Td, TT, HepB, DTP+HepB, DTP+HepB+Hib, Hib, meningococcal, HPV, rotavirus and/or any other freeze-sensitive vaccines in the upper part of the compartment and well away from the freezing compartment in gas and kerosene models. • Store the diluents close to the freeze-dried vaccine with which they were supplied. If this is not possible, make sure the diluents are clearly labelled so they can be easily identified to their matching vaccine.",
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Figure 2.21 Vaccine and diluent arrangement in a top-opening refrigerator without baskets
The following rules apply to these two types of refrigerator:
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Never put freeze-sensitive vaccines in the bottom of gas and kerosene refrigerators or next to the freezer compartment. There is a risk of freezing in these areas.
•
Put measles, MR, MMR, BCG, OPV, yellow fever, Japanese encephalitis and/or any other vaccines not damaged by freezing in the bottom of the compartment.
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Put diluents, DTP, DT, Td, TT, HepB, DTP+HepB, DTP+HepB+Hib, Hib, meningococcal, HPV, rotavirus and/or any other freeze-sensitive vaccines in the upper part of the compartment and well away from the freezing compartment in gas and kerosene models.
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Store the diluents close to the freeze-dried vaccine with which they were supplied. If this is not possible, make sure the diluents are clearly labelled so they can be easily identified to their matching vaccine.
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"text": "\n\n\n5.4 Specific rules for using top-opening refrigerators with baskets\nMany top-opening ice-lined refrigerators are supplied with baskets for storing vaccines. There are also a few top-opening solar-battery models; typically, these models do not have an ice lining, but they generally have baskets. Figure 2.22 shows how these refrigerators should be organized. The following rules apply to these refrigerators:\n• Always store vaccines and diluents in the baskets provided. Never store them outside the baskets. • If there is an internal lid on the freezer compartment and/or the refrigerator compartment, always replace it before closing the main lid. • Some solar direct-drive refrigerators have an ice-bank at one end. Never remove ice packs from this area. • Some solar direct-drive refrigerators have a separate ice pack freezing compartment. Make sure to follow the manufacturer’s instruction on the use of this feature – instructions vary. • Use the bottom baskets to store measles, MR, MMR, BCG, OPV, yellow fever, Japanese encephalitis and/or any other vaccines not damaged by freezing.\nModule 2: The vaccine cold chain\nUse the top baskets to store products for immediate use and to store diluents, DTP, DT, Td, TT, HepB, DTP+HepB, DTP+HepB, DTP+HepB+Hib, Hib, HPV, rotavirus and/or any other freeze-sensitive vaccines. Never put freeze-sensitive vaccines in the bottom baskets. In some models there is a risk of freezing in these areas. Store the diluents close to the freeze-dried vaccine with which they were supplied. If this is not possible, make sure the diluents are clearly labelled so they can be easily identified to their matching vaccine.\nModule 2: The vaccine cold chain",
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5.4 Specific rules for using top-opening refrigerators with baskets
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Many top-opening ice-lined refrigerators are supplied with baskets for storing vaccines. There are also a few top-opening solar-battery models; typically, these models do not have an ice lining, but they generally have baskets.
Figure 2.22 shows how these refrigerators should be organized.
The following rules apply to these refrigerators:
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"text": "\n\n\n5.5 Preparing ice packs and cool water packs\nIf the vaccine refrigerator has a freezer compartment, this can be used to freeze and store ice packs. If cool water packs are used, these must be prepared and stored in a separate refrigerator, never in a refrigerator that is used to store vaccines. Every health facility should have at least two sets of water packs that correspond in size and number to its stock of cold boxes and vaccine carriers.\nNew empty water packs: Fill each pack with clean water, up to the fill line. Do not over-fill; leave a little air space at the top. Fix the cap on tightly. Used water packs: It is not necessary to empty and refill water packs unless they have leaked. If there is a leak, top up the water and make sure the cap is fixed securely. Before use: Hold each pack upside down and squeeze it to make sure it does not leak. If the pack has been damaged, discard it.\nDepending on a range of factors, it can take 24 hours or more to fully freeze a batch of ice packs. Most mains electric ice-lined refrigerators, domestic refrigerators, or larger gas refrigerators have a separate freezing compartment; these models can freeze up to six large or 12 small water packs every 24 hours. Small gas or kerosene models may be able to freeze only one or two packs per day. Some recent solar direct-drive refrigerators can also freeze ice packs. However, their freezing capacity depends on the amount of sunshine available, and in cloudy weather it may not be possible to freeze any ice packs. The ice packs will always melt slightly overnight when there is no power and there may well be some liquid water in the packs at the beginning of the day, but this is normal.\nOlder solar direct-drive models do not have an ice pack freezing compartment. The latest models do. Instead of an ice lining, the Vestfrost Solar Chill and Haier solar direct-drive models have a bank of standard water packs in a compartment that looks like a freezer compartment. These water packs must never be removed for use in vaccine carriers.\nModule 2: The vaccine cold chain\nAlways follow the manufacturer’s instructions and never overload the freezing compartment. Put packs in the freezer, arranged upright or on their sides so that the surface is touching the evaporator plate. If there is a door or lid to the compartment, make sure it is properly closed. The more packs placed in the freezing compartment, the longer they will take to freeze. If too many water packs are placed in the unit, they may not freeze at all. Keep extra, unfrozen water packs that do not fit into the freezer in the bottom part of the main refrigerator compartment to keep this section cold in case of a power failure. When these water packs are placed in the freezer, they will freeze relatively quickly because they are already cold. Never store frozen water packs in the refrigerator compartment; this will lower the temperature and increase the risk of freezing vaccines.\nFrozen ice packs, taken directly from the freezer, are not suitable for immediate use. If they are not correctly conditioned it is very likely that freeze-sensitive vaccines will be frozen and destroyed. Wrapping vaccines in newspaper or other materials does not protect against freezing. Except where cool water packs are used, WHO recommends the use of “conditioned” ice packs for transporting vaccines in cold boxes and vaccine carriers. An ice pack is correctly conditioned when it has melted enough to allow the ice to move inside the pack. Use the following procedure to achieve this:\nRemove the required number of frozen ice packs from the freezer compartment. The number and type of pack required is shown on the inside of the lid of the cold box or vaccine carrier. Lay the frozen ice packs on a work surface in a single layer leaving gaps of about 5 cm between packs. Wait until all packs are properly conditioned – there must be liquid water inside every pack and the ice-cores should move inside the packs when shaken (see Figure 2.23). This will take at least 30–45 minutes in hot weather and much longer in cooler conditions – from 90 to 120 minutes at +20 °C.\nModule 2: The vaccine cold chain\nNote: If a cool water pack strategy has been adopted for outreach operations, one or more frozen ice packs must be brought to the session to ensure that opened multi-dose vaccine vials are kept at recommended temperatures. It is particularly important that vaccines that do not contain preservative – whether lyophilized or liquid – are kept at temperatures between +2 °C and +8 °C during the session.",
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Lay the frozen ice packs on a work surface in a single layer leaving gaps of about 5 cm between packs.
Wait until all packs are properly conditioned – there must be liquid water inside every pack and the ice-cores should move inside the packs when shaken (see Figure 2.23). This will take at least 30–45 minutes in hot weather and much longer in cooler conditions – from 90 to 120 minutes at +20 °C.
Note: If a cool water pack strategy has been adopted for outreach operations, one or more frozen ice packs must be brought to the session to ensure that opened multi-dose vaccine vials are kept at recommended temperatures. It is particularly important that vaccines that do not contain preservative – whether lyophilized or liquid – are kept at temperatures between +2 °C and +8 °C during the session.
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"text": "\n\n\n6.1 Defrosting vaccine refrigerators\nA refrigerator only works well if it is properly installed and is then cleaned and defrosted regularly. Thick ice in the freezer compartment and on the evaporator plate does not keep a refrigerator cool. Instead, it makes the refrigerator work harder and uses more electricity, gas, kerosene or solar power. Refrigerators should be defrosted regularly, or when the ice is more than 0.5 cm thick, whichever comes first. To defrost and clean a refrigerator:\nRemove all the vaccines and transfer them to another refrigerator or to a cold box or vaccine carrier lined with conditioned ice packs. Switch off the electrical supply for a mains or solar-battery refrigerator. Turn off the gas supply for a gas refrigerator. Extinguish the flame for a kerosene refrigerator. Leave the door open and wait for the ice to melt. Never try to remove the ice with a knife or ice pick; this can permanently damage the refrigerator. A pan of boiling water can be placed inside and the door closed. Clean the inside of the refrigerator and door seal with a clean damp cloth. Re-start the refrigerator. Do not adjust the thermostat. When the temperature in the main section falls to +8 °C or lower (but not less than +2 °C), arrange the vaccines, diluents and water packs in their appropriate places.\nIf a refrigerator needs to be defrosted more than once a month, check for these common problems: Staff are opening the door too often (more than three times daily). The door is not closing properly. The door seal needs to be replaced.\nThe vaccine cold chain",
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"text": "\n\n\n6.2 Maintaining solar power systems\nSolar panels need to be cleaned and checked and the batteries of solar battery refrigerators must be inspected and maintained. Tasks can be divided into daily, periodic and annual.\nCheck the status of the control panel display. Take appropriate action as described in the instruction manual if status is not normal. For battery systems only: Check the indicator lights on the battery charge regulator every day. Do not freeze water packs if the low battery warning light is on. Move vaccine to a safe location if the load-disconnect warning light or alarm sounder are activated.\nDo not attempt to carry out this task unless you have the correct access and safety equipment and have received training in safe working at height. Make sure you have somebody to help you and to hold the ladder. Never stand on corrugated roof sheets or tiles – use a properly designed roof ladder. Clean the array in the early morning or evening when the sun is weak. Use a soft cloth dampened with water. Wipe gently, starting at the top and working downwards. Do not lean or stand on the array panels because you may damage them. Report any damage to wiring or hardware to your supervisor.\nMake sure the solar panels are not shaded by trees, plants, new buildings or overhead cables between 9.00 am and 3.00 pm. If there is shading from vegetation, arrange for the vegetation to be cut back. If there is shading from newly constructed buildings or new overhead cables, contact your supervisor. The solar array may have to be moved or increased in capacity. Check the electric cables between the solar array, the charge regulator, the batteries and the refrigerator. Inspect grounding/lightning protection. If you see any damage, contact your supervisor.\nModule 2: The vaccine cold chain\nSolar battery and solar direct-drive refrigerators should be defrosted only on a sunny day; they should never be defrosted in cloudy or rainy weather. A solar direct-drive refrigerator should generally be defrosted in the early morning. It will have partly defrosted overnight so this will speed up the process. Defrosting in the early morning will also allow the refrigerator to make best use of the day’s supply of solar power.",
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"text": "\n\n\n7.2 When is the Shake Test needed?\nIf a freeze indicator is activated, or temperature recordings show negative temperatures, freeze-sensitive vaccines may have been damaged. If this occurs, notify your supervisor. If they decide to proceed, carry out the Shake Test on a sample of the freeze-sensitive vaccines.",
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"text": "\n DESCRIPTION:\n Le test de secouage compare la sédimentation d'un vaccin suspect à un vaccin congelé. Si la sédimentation est plus lente, le vaccin est utilisable. Sinon, il est endommagé et doit être éliminé.\n :TABLE DATA:\n The TEST vial sediments slower than the FROZEN vial, THEN, Sedimentation is similar in both vials OR The TEST vial sediments faster than the FROZEN vial THEN, Use the vaccine batch. Vaccine damaged: Notify your supervisor. Set aside all affected vaccine in a container marked “DAMAGED VACCINE FOR DISPOSAL – DO NOT USE” Discard all affected vaccine once you have received permission to do so. Fill in the Loss/Adjustment Form.\n :END TABLE DATA:\n\n ",
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"text": "\n\n\nAbout this module…\nThis module discusses practices that health workers should follow to ensure that they deliver immunization injections in the safest manner. Injections are considered safe for:\nthe child , when health workers use sterile needles and syringes and appropriate injection techniques; the health worker , when he or she avoids needle-stick injuries; and waste handlers and the community , when used injection equipment is disposed of properly and does not cause injuries or pollution.\nModule 3: Ensuring safe injections\nModule 3: Ensuring safe injections",
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"text": "\n DESCRIPTION:\n Le tableau indique que les seringues auto-désactivables (AD) sont le choix privilégié pour la vaccination, les autres options étant déconseillées ou limitées.\n :TABLE DATA:\n Equipment Remarks Auto-disable (AD) syringes equipment of choice Prefilled AD injection devices available for some antigens only Reusable syringes and needles not recommended Hypodermic syringes with reuse prevention feature (RUP) and needles for mixing purposes only\n :END TABLE DATA:\n\n ",
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Auto-disable (AD) syringes
equipment of choice
Prefilled AD injection devices
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Remove the syringe from its plastic wrapping (peel the package open from the syringe plunger end), or detach the plastic cap.
Take off the needle cap without touching the needle.
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"text": "\n\n\nGeneral steps for using RUP syringes for reconstituting vaccines\nJust as with AD syringes, each type of RUP syringe requires a specific technique for its use. But for all types, the plunger can go back and forth only once and so health workers should take care not to move it unnecessarily. General steps to follow when using RUP syringes are given below. Note that they should be adapted depending on manufacturer’s instructions for the type of syringe being used.\nRemove the RUP syringe from its wrapping (peel the package open from the syringe plunger end) or detach the plastic caps. If there is a detachable needle, fit it onto the hub of the syringe and take off the cap without touching the needle. Insert the needle in the diluent vial and move the tip of the needle to the lowest part or bottom of the vial. Pull the plunger back to fill the syringe, making sure to empty the full contents of the vial. Remove the needle and syringe from the vial. If needed, remove air in the syringe by holding it upright and pushing the plunger slowly until the air goes out. Insert the needle and syringe into the vaccine vial. Push the plunger in completely to ensure that all the diluent goes into the vaccine vial. Remove the needle and syringe from the vial and ensure that the syringe is locked. Dispose of the needle and syringe directly in a safety box. Shake the vial to mix the diluent with the vaccine (see Module 5 (Managing an immunization session), Section 4 for details on reconstitution technique).\nModule 3: Ensuring safe injections\nare easy to use since no vaccine reconstitution is required prevent vaccine contamination make administering an accurate dose easy deliver vaccine and syringe in the same set (separate orders are not needed) reduce waste that can occur with multi-dose vials.",
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"text": "Remove the RUP syringe from its wrapping (peel the package open from the syringe plunger end) or detach the plastic caps. If there is a detachable needle, fit it onto the hub of the syringe and take off the cap without touching the needle. Insert the needle in the diluent vial and move the tip of the needle to the lowest part or bottom of the vial. Pull the plunger back to fill the syringe, making sure to empty the full contents of the vial. Remove the needle and syringe from the vial. If needed, remove air in the syringe by holding it upright and pushing the plunger slowly until the air goes out. Insert the needle and syringe into the vaccine vial. Push the plunger in completely to ensure that all the diluent goes into the vaccine vial. Remove the needle and syringe from the vial and ensure that the syringe is locked. Dispose of the needle and syringe directly in a safety box. Shake the vial to mix the diluent with the vaccine (see Module 5 (Managing an immunization session), Section 4 for details on reconstitution technique).",
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Remove the RUP syringe from its wrapping (peel the package open from the syringe plunger end) or detach the plastic caps.
If there is a detachable needle, fit it onto the hub of the syringe and take off the cap without touching the needle.
Insert the needle in the diluent vial and move the tip of the needle to the lowest part or bottom of the vial.
Pull the plunger back to fill the syringe, making sure to empty the full contents of the vial.
Remove the needle and syringe from the vial. If needed, remove air in the syringe by holding it upright and pushing the plunger slowly until the air goes out.
Insert the needle and syringe into the vaccine vial.
Push the plunger in completely to ensure that all the diluent goes into the vaccine vial.
Remove the needle and syringe from the vial and ensure that the syringe is locked.
Dispose of the needle and syringe directly in a safety box.
Shake the vial to mix the diluent with the vaccine
(see Module 5 (Managing an immunization session), Section 4 for details on reconstitution technique).
are easy to use since no vaccine reconstitution is required
prevent vaccine contamination
make administering an accurate dose easy
deliver vaccine and syringe in the same set (separate orders are not needed)
reduce waste that can occur with multi-dose vials.
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"text": "\n\n\nGeneral steps for using prefilled AD injection devices\nEvery prefilled AD injection device is sterilized and sealed in its own foil package by the manufacturer. The vaccine is contained in a sealed syringe or bubble-like reservoir that prevents it from coming in contact with the needle until its administration. Using it requires the steps below:\nPrepare or activate the prefilled bubble-like injection device by pushing the needle shield (or cap) into the port as shown in Figure 3.1. This opens the fluid path between the needle and the reservoir that contains the vaccine. Remove the needle shield. Insert the needle into the injection site (see Module 5 (Managing an immunization session) , Section 4 for details on injection technique). Deliver the dose by squeezing the reservoir until it is empty. Dispose of the used AD device directly in a safety box.\nModule 3: Ensuring safe injections\nDisposable single-use syringes and needles that could potentially be reused because they do not have RUP devices are also not recommended for immunization programmes. The reuse of syringes and needles carries a high risk of transmitting infections. This risk prompted the 1999 WHO, UNICEF and UNFPA joint policy statement (see Box 1). While RUP reconstitution injection devices are the equipment of choice for mixing vaccine with diluent, they may not always be available. If RUP devices are not available and disposable syringes and needles are used to reconstitute vaccine, they must never be reused for reconstitution or injection.\nEnsuring safe injections",
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Prepare or activate the prefilled bubble-like injection device by pushing the needle shield (or cap) into the port as shown in Figure 3.1. This opens the fluid path between the needle and the reservoir that contains the vaccine.
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"text": "\n\n\n1.3 Giving the right vaccine safely\nProper vaccine storage and handling as well as clinical assessment and administration at immunization sessions are essential. Module 2 ( The vaccine cold chain ) discusses how to handle vaccines to ensure that they are safe and effective at the time of use. Module 5 ( Managing an immunization session ) contains details on assessing which vaccines are needed for each child and the techniques for their reconstitution and administration. Table 3.2 introduces some examples of incorrect immunization practices, and adverse events following immunization are discussed further in Module 5 and Module 6 ( Monitoring and surveillance ).",
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The vaccine cold chain
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Managing an immunization session
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Monitoring and surveillance
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"text": "\n DESCRIPTION:\n Ce tableau décrit les pratiques d'immunisation incorrectes et leurs conséquences potentielles, incluant infections, réactions locales, inefficacité du vaccin et complications graves.\n :TABLE DATA:\n Incorrect practice Possible adverse events following immunization Non-sterile injection due to: reuse of disposable syringe or needle improperly sterilized syringe or needle contaminated vaccine or diluent Infections such as local abscess at injection site, sepsis, toxic shock syndrome, or death Transmission of bloodborne infections such as hepatitis or HIV Reconstitution error due to: inadequate mixing of vaccine reconstitution with incorrect diluent drug substituted for vaccine or diluent inappropriate reuse of reconstituted vaccine at subsequent session Local abscess at injection site Vaccine ineffective a Negative effect of drug (for example, insulin, oxytocin, muscle relaxants) Death Injection at incorrect site such as: BCG given subcutaneously DTP/DT/dT/TT too superficial injection into buttocks Local reaction or abscess Local reaction or abscess Sciatic nerve damage Vaccine transportation/storage incorrect such as: VVM changed colour clumping of adsorbed vaccine Local reaction Vaccine ineffective a Contraindications ignored Avoidable severe reaction\n :END TABLE DATA:\n\n ",
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"text": "Incorrect practice Possible adverse events following immunization Non-sterile injection due to: reuse of disposable syringe or needle improperly sterilized syringe or needle contaminated vaccine or diluent Infections such as local abscess at injection site, sepsis, toxic shock syndrome, or death Transmission of bloodborne infections such as hepatitis or HIV Reconstitution error due to: inadequate mixing of vaccine reconstitution with incorrect diluent drug substituted for vaccine or diluent inappropriate reuse of reconstituted vaccine at subsequent session Local abscess at injection site Vaccine ineffective a Negative effect of drug (for example, insulin, oxytocin, muscle relaxants) Death Injection at incorrect site such as: BCG given subcutaneously DTP/DT/dT/TT too superficial injection into buttocks Local reaction or abscess Local reaction or abscess Sciatic nerve damage Vaccine transportation/storage incorrect such as: VVM changed colour clumping of adsorbed vaccine Local reaction Vaccine ineffective a Contraindications ignored Avoidable severe reaction",
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Incorrect practice
Possible adverse events following immunization
Non-sterile injection due to:
reuse of disposable syringe or needle
improperly sterilized syringe or needle
contaminated vaccine or diluent
Infections such as local abscess at injection site, sepsis, toxic shock syndrome, or death
Transmission of bloodborne infections such as hepatitis or HIV
Reconstitution error due to:
inadequate mixing of vaccine
reconstitution with incorrect diluent
drug substituted for vaccine or diluent
inappropriate reuse of reconstituted vaccine at subsequent session
Local abscess at injection site
Vaccine ineffective
a
Negative effect of drug (for example, insulin, oxytocin, muscle relaxants)
Infections such as local abscess at injection site, sepsis, toxic shock syndrome, or death
Transmission of bloodborne infections such as hepatitis or HIV
Reconstitution error due to:
inadequate mixing of vaccine
reconstitution with incorrect diluent
drug substituted for vaccine or diluent
inappropriate reuse of reconstituted vaccine at subsequent session
Local abscess at injection site
Vaccine ineffective
a
Negative effect of drug (for example, insulin, oxytocin, muscle relaxants)
Death
Injection at incorrect site such as:
BCG given subcutaneously
DTP/DT/dT/TT too superficial
injection into buttocks
Local reaction or abscess
Local reaction or abscess
Sciatic nerve damage
Vaccine transportation/storage incorrect such as:
VVM changed colour
clumping of adsorbed vaccine
Local reaction
Vaccine ineffective
a
Contraindications ignored
Avoidable severe reaction
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"text": "\n\n\nTable 3.2 Examples of incorrect immunization practices and possible adverse events following immunization\n :TABLE DATA: \nIncorrect practice Possible adverse events following immunization Non-sterile injection due to: reuse of disposable syringe or needle improperly sterilized syringe or needle contaminated vaccine or diluent Infections such as local abscess at injection site, sepsis, toxic shock syndrome, or death Transmission of bloodborne infections such as hepatitis or HIV Reconstitution error due to: inadequate mixing of vaccine reconstitution with incorrect diluent drug substituted for vaccine or diluent inappropriate reuse of reconstituted vaccine at subsequent session Local abscess at injection site Vaccine ineffective a Negative effect of drug (for example, insulin, oxytocin, muscle relaxants) Death Injection at incorrect site such as: BCG given subcutaneously DTP/DT/dT/TT too superficial injection into buttocks Local reaction or abscess Local reaction or abscess Sciatic nerve damage Vaccine transportation/storage incorrect such as: VVM changed colour clumping of adsorbed vaccine Local reaction Vaccine ineffective a Contraindications ignored Avoidable severe reaction\n :END TABLE DATA:\na Strictly speaking, ineffective vaccine is considered to be an effect, not an adverse event.\nModule 3: Ensuring safe injections",
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Possible adverse events following immunization
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Transmission of bloodborne infections such as hepatitis or HIV
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drug substituted for vaccine or diluent
inappropriate reuse of reconstituted vaccine at subsequent session
Local abscess at injection site
Vaccine ineffective
a
Negative effect of drug (for example, insulin, oxytocin, muscle relaxants)
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"text": "\n\n\n1.4 Simple ways to improve injection safety\nThe following is a summary of points to improve injection safety that are discussed in more detail in Module 2 ( The vaccine cold chain ) and Module 5 ( Managing an immunization session ) and included here to emphasize their importance.\nPrepare injections in a clean, designated area that is free from blood and body fluid contamination. Prepare each dose immediately before its administration – do not prepare several syringes in advance. Never leave the needle in the top of the vaccine vial. Follow product-specific recommendations for storage, handling and use of vaccines. Follow safe procedures to reconstitute vaccines. The correct diluent must be used for reconstituting freeze-dried vaccines. Use only the diluent supplied by the manufacturer for each vaccine – check the labels. Diluents must be cooled before reconstitution. Dispose of used AD and RUP needles and syringes in a safety box. Follow national multi-dose vial policy for opened vials. Use a new AD needle and syringe for every child: Inspect the packaging very carefully. Discard the needle and syringe if the package has been punctured, torn or damaged in any way. Do not touch any part of the needle. Discard a needle that has touched any non-sterile surface. Position the child carefully to minimize risk of movement and injury.\nRefer to Annex 3.1 for unsafe immunization practices that must be avoided.\nModule 3: Ensuring safe injections",
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Prepare each dose immediately before its administration – do not prepare several syringes in advance.
Never leave the needle in the top of the vaccine vial.
Follow product-specific recommendations for storage, handling and use of vaccines.
Follow safe procedures to reconstitute vaccines. The correct diluent must be used for reconstituting freeze-dried vaccines.
Use only the diluent supplied by the manufacturer for each vaccine – check the labels.
Diluents must be cooled before reconstitution.
Dispose of used AD and RUP needles and syringes in a safety box.
Follow national multi-dose vial policy for opened vials.
Use a new AD needle and syringe for every child:
Inspect the packaging very carefully.
Discard the needle and syringe if the package has been punctured, torn or damaged in any way.
Do not touch any part of the needle.
Discard a needle that has touched any non-sterile surface.
Position the child carefully to minimize risk of movement and injury.
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Needles can be dangerous. They can injure health workers and, if contaminated with hepatitis B, hepatitis C, HIV or other infections, they can transmit diseases.
Needle-stick injuries can happen at any time, particularly during and immediately after an injection. This risk is increased when:
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"text": "\n\n\n2.1 Minimizing the need to handle needles and syringes\nPlace a safety box close to the person giving vaccinations so used needles and syringes can be disposed of immediately, easily and without walking to find a sharps container. Avoid recapping the needle. If recapping is absolutely necessary – for example, if the injection is delayed because the child is too agitated – use the one-hand technique of placing the cap on a table or tray and reinserting the needle by sliding it inside without using the other hand. Do not remove the used needle from the syringe with your hands. Do not carry used syringes and needles around the work site for any reason. When ready to administer, draw the vaccine into the syringe, give the injection and dispose of the syringe in the safety box without putting it down between steps. Close the safety box securely when it is three quarters full. Do not manually sort needles and syringes.\nEnsuring safe injections",
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Any part of the syringe that is touched becomes contaminated. Although the barrel and plunger of a syringe have to be touched to prepare and give an injection (see Figure 3.2), care should be taken to avoid touching parts that come into contact with the vaccine or the child (see Figure 3.3).
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"text": "\n\n\n3.3 Using safety boxes\nAll injection equipment should be destroyed by proper waste disposal methods (see Section 3.4). Collecting sharps waste in safety boxes or similar containers both decreases risk of injury during handling and helps ensure proper disposal.\nSafety boxes should be placed within reach of the staff administering injections (as described in Section 2.3 of this module and in in Module 5 ( Managing an immunization session )) so that needles and syringes can be disposed of immediately. If needle removers or needle cutters are available, used needles and syringes should be separated immediately after each injection. After removing the needle with one of these devices, the syringe should go in the safety box. Needles remain in a separate safe container, which, when almost full, should be closed and disposed of properly (see next section for disposal methods).\nSafety boxes should be closed when they are three quarters full. Used needles and syringes should never be transferred from safety boxes to other containers. A five-litre safety box can hold about 100 syringes and needles. For the best use of safety boxes, you should never dispose the following items in them:\nModule 3: Ensuring safe injections\nOnce three quarters full, safety boxes should be closed, treated and destroyed appropriately, preferably quickly at a nearby site to minimize handling.\nUsed needles and syringes must never be dumped in open areas where people might step on them or children might find them (inside safety boxes or loose). They should never be disposed of along with general non-sharps types of waste.",
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"text": "\n\n\n3.4 Disposing of filled safety boxes\nMethods commonly used to destroy or dispose of filled safety boxes are described below. Any selected method of waste disposal must comply with national and sub-national environmental and health regulations.\nIncineration Incineration can completely destroy needles and syringes. Fires burning at temperatures higher than 800 °C will kill microorganisms and reduce the volume of waste to a minimum. Properly functioning incinerators ensure the most complete destruction of needles and syringes. High temperature, dual-combustion incinerators with air filters produce less air pollution than incinerators burning at lower temperatures (see Figure 3.7). Some hospitals have on-site incinerators. Others transport the waste to cement factories to dispose of it in high-temperature kilns.\nThe compound in which incineration takes place must be secure. Staff members conducting the incineration should wear safety glasses, heavy gloves and any other personal protective equipment required by local and national guidelines.\nModule 3: Ensuring safe injections\nModule 3: Ensuring safe injections\nUsed injection equipment may be buried in a disposal pit. The site should be chosen carefully – there should be enough space for a pit large and deep enough for bulky boxes to be buried with minimum risk of contaminated sharps being released into the surroundings and doing harm (see Figure 3.10). If a disposal pit is to be used, several steps must be followed.\nChoose a site where people will not dig or build latrines in the future. Choose a qualified staff person to supervise the burn using appropriate equipment. Fence off and clear the area. Dig a pit at least two metres deep. Make sure that buried materials will not escape from the pit, for example, during the rainy season. When ready to bury them, take filled safety boxes to the pit site and place them in it. Do not open or empty the boxes. After placing the boxes in the pit, immediately cover them with at least 30 cm of soil. If possible, cover the site with concrete when the pit is full.\nOnly qualified staff should perform this task.\nModule 3: Ensuring safe injections\nIMPORTANT: The two options below are to be considered as last resort options since they are not in keeping with WHO policy for the treatment of waste.\nBurning in a metal drum This option should only be considered as a last resort, short-term emergency response since low-temperature burning produces toxic emissions and is a public health and environmental hazard.\nIf contaminated sharps must be destroyed by burning in a metal drum or container (see Figure 3.11), several steps must be followed:\nChoose a site in an unused area that is as far from buildings as possible. The area should be fenced and cleared. Choose a qualified staff person to supervise the burn using appropriate equipment.\nPlace four bricks on the ground in a square pattern. Put a metal screen or grate on top of the bricks. Remove both ends of a 210-litre steel drum. This will allow air to flow through the drum and the contents to burn better. If a metal drum is not available, build a cylinder from sheet metal, bricks or clay. A chimney may be added to the removable top of the drum or container. Place the drum on top of a metal screen or grate. Put filled safety boxes in the metal drum. Mix paper, leaves or other flammable material in among the safety boxes to help them burn. Sprinkle a small amount of kerosene, if available, on the boxes and other material in the drum. Place a fine metal screen over the top of the drum to reduce flying ashes.\nPut wood, paper or other flammable material under the drum and ignite the material. Warn people to stay away to avoid smoke, fumes and ash from the fire. Allow the fire to burn until all of the safety boxes have been destroyed. Once the fire is out, allow the residue at the bottom of the drum to cool and carefully collect it. Bury it in an unused location. Cover it with at least 30 cm of soil. If possible, seal the residue pit with cement once it is full.\nOnly qualified staff should perform this task.\nModule 3: Ensuring safe injections\nThis option should also only be considered as a last resort since it produces toxic emissions and is a public health and environmental hazard. It is always preferable to collect safety boxes for later disposal at a more appropriate treatment site. If burning waste in the open as shown in Figure 3.12 is the only option, several steps must be followed.\nChoose a site in an unused area that is as far from buildings as possible. The area should be fenced and cleared. Choose a qualified staff person to supervise the burn using appropriate equipment. 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IMPORTANT: The two options below are to be considered as last resort options since they are not in keeping with WHO policy for the treatment of waste.
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"text": "\n DESCRIPTION:\n Le tableau liste des pratiques dangereuses à éviter lors de vaccinations, incluant la manipulation et l'élimination incorrecte des aiguilles usagées.\n :TABLE DATA:\n Do not recap the needle Do not recap the needle Do not leave the needle inside the vial Do not leave the needle inside the vial Do not touch the needle Do not touch the needle Do not dispose of used needles in an open cardboard box Do not dispose of used needles in an open cardboard box Do not overfill the safety box Do not overfill the safety box\n :END TABLE DATA:\n\n ",
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Annex 3.1
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"text": "\n\n\n4 Microplanning for reaching every community\n4. Microplanning for reaching every community\nAbout this module… This module discusses the process of microplanning to ensure immunization services reach every community. It starts with maps at district and health centre level, which should be updated to include all population centres and groups in the catchment area and to flag high-risk areas. It next describes how to identify priority, high-risk health centres and communities based on numbers of unimmunized children. It then describes how to clarify barriers to service access and utilization in priority communities and to make a workplan for solutions. It concludes with making a session plan and following up on defaulters.\nModule 4: Microplanning for reaching every community\n1. Making or updating a map ................................................................. (4)3 1.1 District map .................................................................................................................. (4)3 1.2 Health centre map ....................................................................................................... (4)4 2. Identifying priority health centres and communities ................................. (4)7 2.1 Analysis of district immunization data ........................................................................ (4)7 2.2 Analysis of health centre data ..................................................................................... (4)9 3. Identifying barriers to access and utilization .............................................. (4)11 3.1 Household survey of immunization status ................................................................. (4)11 3.2 Community discussion ............................................................................................... (4)13 4. Identifying solutions and preparing a workplan ........................................ (4)14 4.1 Outline solutions ......................................................................................................... (4)14 4.2 Make a workplan to implement identified solutions .................................................. (4)15 5. Making a session plan .............................................................................. (4)17 5.1 Immunization session plan ......................................................................................... (4)17 5.2 Health centre outreach session plan ......................................................................... (4)19 5.3 Immunization session supplies .................................................................................. (4)21 5.4 Health centre monthly stock report .......................................................................... (4)22 6. Finding defaulters .................................................................................... (4)23 6.1 Defaulter tracking list .................................................................................................. (4)23 6.2 Other opportunities .................................................................................................... (4)23 Annex 4.1 Calculations used in determining needed session frequency ...... (4)24\nMicroplanning for reaching every community\nEvery district and every health centre should display a map that shows the current location and relative size of the population groups in their catchment areas. A catchment area is usually determined by national authorities to help ensure service delivery. Specific facilities are made responsible for specific catchment areas and the population living in them. District and health centre maps should include all eligible population groups in their catchments. A table listing these populations or communities should be displayed next to each map. The maps should be updated regularly to include any changes in the catchment areas, including new administrative divisions. Priority, high-risk areas, identified based on their high numbers of unimmunized children (see Section 2 of this module), should be clearly marked. All sources of updated maps should be used: polio eradication microplanning activities in particular may have current versions to offer. If online access is available, Internet-based tools, such as Google Maps with its Map Maker (www.google.com/maps), can be used to create updated catchment area maps. Community leaders and administrative officials should collaborate on creating and updating local maps, just as they should be involved in all microplanning steps.",
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"text": "About this module… This module discusses the process of microplanning to ensure immunization services reach every community. It starts with maps at district and health centre level, which should be updated to include all population centres and groups in the catchment area and to flag high-risk areas. It next describes how to identify priority, high-risk health centres and communities based on numbers of unimmunized children. It then describes how to clarify barriers to service access and utilization in priority communities and to make a workplan for solutions. It concludes with making a session plan and following up on defaulters.",
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About this module…
This module discusses the process of microplanning to ensure immunization services reach every community. It starts with maps at district and health centre level, which should be updated to include all population centres and groups in the catchment area and to flag high-risk areas. It next describes how to identify priority, high-risk health centres and communities based on numbers of unimmunized children. It then describes how to clarify barriers to service access and utilization in priority communities and to make a workplan for solutions. It concludes with making a session plan and following up on defaulters.
6.1 Defaulter tracking list .................................................................................................. (4)23
6.2 Other opportunities .................................................................................................... (4)23
Annex 4.1 Calculations used in determining needed session frequency ...... (4)24
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"text": "Every district and every health centre should display a map that shows the current location and relative size of the population groups in their catchment areas. A catchment area is usually determined by national authorities to help ensure service delivery. Specific facilities are made responsible for specific catchment areas and the population living in them. District and health centre maps should include all eligible population groups in their catchments. A table listing these populations or communities should be displayed next to each map. The maps should be updated regularly to include any changes in the catchment areas, including new administrative divisions. Priority, high-risk areas, identified based on their high numbers of unimmunized children (see Section 2 of this module), should be clearly marked. All sources of updated maps should be used: polio eradication microplanning activities in particular may have current versions to offer. If online access is available, Internet-based tools, such as Google Maps with its Map Maker (www.google.com/maps), can be used to create updated catchment area maps. Community leaders and administrative officials should collaborate on creating and updating local maps, just as they should be involved in all microplanning steps.",
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Every district and every health centre should display a map that shows the current location and relative size of the population groups in their catchment areas. A catchment area is usually determined by national authorities to help ensure service delivery. Specific facilities are made responsible for specific catchment areas and the population living in them.
District and health centre maps should include all eligible population groups in their catchments. A table listing these populations or communities should be displayed next to each map. The maps should be updated regularly to include any changes in the catchment areas, including new administrative divisions. Priority, high-risk areas, identified based on their high numbers of unimmunized children (see Section 2 of this module), should be clearly marked.
All sources of updated maps should be used: polio eradication microplanning activities in particular may have current versions to offer. If online access is available, Internet-based tools, such as Google Maps with its Map Maker (www.google.com/maps), can be used to create updated catchment area maps. Community leaders and administrative officials should collaborate on creating and updating local maps, just as they should be involved in all microplanning steps.
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Distance between health centre and main district facility (km and travel time)
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the total population and target population in the catchment area of each health centre
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"text": "\n\n\n1.2 Health centre map\nEach health centre should make a simple map of its catchment area (see Figure 4.1). The communities in the catchment area should be listed and the list updated regularly. Community boundaries should be confirmed with the help of community leaders (see Module 7 (Partnering with communities) for more details on how to involve communities in microplanning activities).\nThe health centre catchment area map should be an operational diagram with details that can help with planning. Maps created for polio or other mass vaccination and health intervention campaigns may serve as examples. The health centre map should include:\nlocations of every village and/or community in the catchment area, including those that are not reached and/or are new\nMicroplanning for reaching every community\nlandmarks and significant buildings, for example, religious centres, markets, schools, motor parks settlements of urban poor and migrants within towns and cities settlements of migrants and/or displaced persons in rural areas.\nThe table displayed next to the health centre map (see Table 4.2 for example) should include:\nthe total population and target populations in each community in the catchment area approximate distances and travel times to each community community volunteer names and their mobile phone numbers.\nInclude every community on the map even if accurate numbers are not available. This applies particularly to communities of migrant workers, urban poor, ethnic minorities, new rural settlements and groups in movement or unrest.\nModule 4: Microplanning for reaching every community",
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Each health centre should make a simple map of its catchment area (see Figure 4.1). The communities in the catchment area should be listed and the list updated regularly. Community boundaries should be confirmed with the help of community leaders (see Module 7
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locations of every village and/or community in the catchment area, including those that are not reached and/or are new
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Consider prioritizing health centres that have inaccurate data; for example, a health centre that shows negative values for unimmunized children due to inaccurate population data or negative vaccine wastage rates may need to be given priority.
Consider prioritizing health centres with known management problems.
Table 4.3 District immunization data analysis: example format
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"text": "\n\n\nHow to prioritize communities using health centre immunization data\nUse all available information to complete the analysis of health centre data – the input of community and administrative leaders is needed to best assemble all available information. List every community, including new ones and those that do not have regular access to services (for example, urban slums, distant rural communities). Rank communities by number of unimmunized infants; the one with the highest number of unimmunized children is ranked first (1) and so on. The community ranked 1 has the highest priority, and so on. Look for any monthly variation in immunizations given in a community when reviewing data from the preceding 12 months and note any seasonal changes in the last column (for example, decreases during the rainy season).\nMicroplanning for reaching every community\nModule 4: Microplanning for reaching every community",
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"text": "\n\n\n3.1 Household survey of immunization status\nTable 4.5 is a questionnaire format for evaluating the immunization status of children aged 12–23 months by household. In a small community, a sample of five partially immunized or unimmunized children may be sufficient; but in a larger community such as an urban slum, where there may be different subgroups of people, a sample of at least 10 may be needed. Vaccine information given by households can be checked against the immunization register. The questionnaire can be modified to meet local evaluation needs. How to complete the household questionnaire In the top section of the form:\ntally each household with eligible children visited tally the total number of children aged 12–23 months in the household tally the number of children with immunization cards.\nUnder “Immunization status of child”:\nfor each child with an available card, tally whether they are fully, partially or never immunized under “From card – tally” if the card is not available but the caregiver gives the immunization history (in response to prompting questions), tally whether the child is fully/partially/never immunized under “By recall – tally”.\nIn the lower part of the form:\nIf a child is partially or never immunized, write the name of the child and ask the caregiver the question, “Why was the child not fully immunized?” Mark the row with the choice that best matches the answer the caregiver gives.\nMicroplanning for reaching every community\nAfter noting the answer to the question about a child not being fully immunized, try to understand issues from the household’s point of view. For example, when a caregiver says she is “too busy”, you may need to find out whether she may be able to attend sessions at specific times, or whether there are additional problems such as cancelled sessions that discourage people from going to the next one. Understanding the situation will help in adding appropriate solutions to the workplan (this issue is discussed further in Section 4 of this module). Partially or never immunized children identified in this exercise should be added to defaulter tracking lists.",
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After noting the answer to the question about a child not being fully immunized, try to understand issues from the household’s point of view. For example, when a caregiver says she is “too busy”, you may need to find out whether she may be able to attend sessions at specific times, or whether there are additional problems such as cancelled sessions that discourage people from going to the next one. Understanding the situation will help in adding appropriate solutions to the workplan (this issue is discussed further in Section 4 of this module).
Partially or never immunized children identified in this exercise should be added to defaulter tracking lists.
Table 4.5 Household immunization status questionnaire assessing children aged 12–23 months
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"text": "\n DESCRIPTION:\n Le tableau 4.6 est un guide de discussion communautaire pour évaluer les obstacles à l'immunisation et améliorer les services de santé.\n :TABLE DATA:\n Table 4.6 Community discussion guide Community description Distance from health centre – km and time Total population from health centre data Total population from community leaders’ information Results of household immunization status questionnaire Number of children 12–23 months of age partially or never immunized Discussion with caregivers (done after completing the household survey) – suggested questions: Where do you get immunizations? (Outreach/HC fixed site/other) Where was your last child delivered? If at home, what was your main reason for not using a health facility? Where do you take sick children? (Traditional healer/HC/district/ private/other) How much does it cost to travel to the HC/district? Do you have to pay any fees at the HC/district facilities? When was the last outreach visit from the health centre to your community? What do you think the health facility can do to get children fully immunized? Discussion with community health worker(s) – suggested questions: What supplies of medicines do you have in the community? (ORS, antibiotics, paracetamol, antimalarials, etc.) In what health programmes do you work? (for example, ANC, nutrition, EPI, TB, malaria) Do you have a mobile phone? Give number(s). Are you informed in advance of outreach sessions? If so, how? How are the communities you work with informed about an outreach session before and on the day of the session? When did you last receive any training? Do you do defaulter follow up for the immunization programme? Discussion with community leader(s) – suggested questions: What do you see as the main health problems in your community? How can the health facility improve services for the community?\n :END TABLE DATA:\n\n ",
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"text": "Table 4.6 Community discussion guide Community description Distance from health centre – km and time Total population from health centre data Total population from community leaders’ information Results of household immunization status questionnaire Number of children 12–23 months of age partially or never immunized Discussion with caregivers (done after completing the household survey) – suggested questions: Where do you get immunizations? (Outreach/HC fixed site/other) Where was your last child delivered? If at home, what was your main reason for not using a health facility? Where do you take sick children? (Traditional healer/HC/district/ private/other) How much does it cost to travel to the HC/district? Do you have to pay any fees at the HC/district facilities? When was the last outreach visit from the health centre to your community? What do you think the health facility can do to get children fully immunized? Discussion with community health worker(s) – suggested questions: What supplies of medicines do you have in the community? (ORS, antibiotics, paracetamol, antimalarials, etc.) In what health programmes do you work? (for example, ANC, nutrition, EPI, TB, malaria) Do you have a mobile phone? Give number(s). Are you informed in advance of outreach sessions? If so, how? How are the communities you work with informed about an outreach session before and on the day of the session? When did you last receive any training? Do you do defaulter follow up for the immunization programme? Discussion with community leader(s) – suggested questions: What do you see as the main health problems in your community? How can the health facility improve services for the community?",
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Community description
Distance from health centre – km and time
Total population from health centre data
Total population from community leaders’ information
Results of household immunization status questionnaire
Number of children 12–23 months of age partially or never immunized
Discussion with caregivers (done after completing the household survey) – suggested questions:
Where do you get immunizations? (Outreach/HC fixed site/other)
Where was your last child delivered?
If at home, what was your main reason for not using a health facility?
Where do you take sick children? (Traditional healer/HC/district/private/other)
How much does it cost to travel to the HC/district?
Do you have to pay any fees at the HC/district facilities?
When was the last outreach visit from the health centre to your community?
What do you think the health facility can do to get children fully immunized?
Discussion with community health worker(s) – suggested questions:
What supplies of medicines do you have in the community? (ORS, antibiotics, paracetamol, antimalarials, etc.)
In what health programmes do you work? (For example, ANC, nutrition, EPI, TB, malaria)
Do you have a mobile phone? Give number(s).
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If so, how?
How are the communities you work with informed about an outreach session before and on the day of the session?
When did you last receive any training?
Do you do defaulter follow up for the immunization programme?
Discussion with community leader(s) – suggested questions:
What do you see as the main health problems in your community?
How can the health facility improve services for the community?
Total population from community leaders’ information
Results of household immunization status questionnaire
Number of children 12–23 months of age partially or never immunized
Discussion with caregivers (done after completing the household survey) – suggested questions:
Where do you get immunizations? (Outreach/HC fixed site/other)
Where was your last child delivered?
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What do you think the health facility can do to get children fully immunized?
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Do you have a mobile phone? Give number(s).
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How are the communities you work with informed about an outreach session before and on the day of the session?
When did you last receive any training?
Do you do defaulter follow up for the immunization programme?
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What do you see as the main health problems in your community?
How can the health facility improve services for the community?
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Table 4.6 is a guide to community discussions on barriers. It aims to gather information on community perceptions and ideas for improvement and is meant to complement the household survey. It requires the involvement of caregivers, community health workers and community leaders. Interviews may be done with individuals or groups separately or together as appropriate for the situation. The questions can be modified as needed and the exercise is intended to take about an hour.
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"text": "Table 4.6 Community discussion guide Community description Distance from health centre – km and time Total population from health centre data Total population from community leaders’ information Results of household immunization status questionnaire Number of children 12–23 months of age partially or never immunized Discussion with caregivers (done after completing the household survey) – suggested questions: Where do you get immunizations? (Outreach/HC fixed site/other) Where was your last child delivered? If at home, what was your main reason for not using a health facility? Where do you take sick children? (Traditional healer/HC/district/ private/other) How much does it cost to travel to the HC/district? Do you have to pay any fees at the HC/district facilities? When was the last outreach visit from the health centre to your community? What do you think the health facility can do to get children fully immunized? Discussion with community health worker(s) – suggested questions: What supplies of medicines do you have in the community? (ORS, antibiotics, paracetamol, antimalarials, etc.) In what health programmes do you work? (for example, ANC, nutrition, EPI, TB, malaria) Do you have a mobile phone? Give number(s). Are you informed in advance of outreach sessions? If so, how? How are the communities you work with informed about an outreach session before and on the day of the session? When did you last receive any training? Do you do defaulter follow up for the immunization programme? Discussion with community leader(s) – suggested questions: What do you see as the main health problems in your community? How can the health facility improve services for the community?",
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Community description
Distance from health centre – km and time
Total population from health centre data
Total population from community leaders’ information
Results of household immunization status questionnaire
Number of children 12–23 months of age partially or never immunized
Discussion with caregivers (done after completing the household survey) – suggested questions:
Where do you get immunizations? (Outreach/HC fixed site/other)
Where was your last child delivered?
If at home, what was your main reason for not using a health facility?
Where do you take sick children? (Traditional healer/HC/district/private/other)
How much does it cost to travel to the HC/district?
Do you have to pay any fees at the HC/district facilities?
When was the last outreach visit from the health centre to your community?
What do you think the health facility can do to get children fully immunized?
Discussion with community health worker(s) – suggested questions:
What supplies of medicines do you have in the community? (ORS, antibiotics, paracetamol, antimalarials, etc.)
In what health programmes do you work? (For example, ANC, nutrition, EPI, TB, malaria)
Do you have a mobile phone? Give number(s).
Are you informed in advance of outreach sessions?
If so, how?
How are the communities you work with informed about an outreach session before and on the day of the session?
When did you last receive any training?
Do you do defaulter follow up for the immunization programme?
Discussion with community leader(s) – suggested questions:
What do you see as the main health problems in your community?
How can the health facility improve services for the community?
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"text": "Some people do not live within reach of health services, whether they are in permanent shelter or mobile nomadic/seasonal migrant communities. In many countries, geographical barriers are not the only, or even the primary, reason that limits access and utilization of immunization services. Access is also made difficult by inconvenient scheduling, lack of information and/or lack of opportunities. All these problems can be solved relatively simply by improving scheduling, raising awareness and/or expanding outreach.",
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Some people do not live within reach of health services, whether they are in permanent shelter or mobile nomadic/seasonal migrant communities. In many countries, geographical barriers are not the only, or even the primary, reason that limits access and utilization of immunization services. Access is also made difficult by inconvenient scheduling, lack of information and/or lack of opportunities. All these problems can be solved relatively simply by improving scheduling, raising awareness and/or expanding outreach.
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"text": "This section is a guide to taking the information collected in Sections 1–3 and planning solutions to overcome the identified barriers to access and utilization. Solutions should be added to a workplan to guide a practical approach, and a workplan should be developed for each priority community. The table in Module 6 ( Monitoring and surveillance ), Annex 6.1 lists common problems and possible solutions. While not exhaustive, this may help to complete a workplan.",
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This section is a guide to taking the information collected in Sections 1–3 and planning solutions to overcome the identified barriers to access and utilization. Solutions should be added to a workplan to guide a practical approach, and a workplan should be developed for each priority community. The table in Module 6 (
Monitoring and surveillance
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"text": "\n DESCRIPTION:\n Le tableau 4.7 illustre une méthode pour lister des solutions aux problèmes de santé communautaires, en impliquant les centres de santé, la communauté et le district.\n :TABLE DATA:\n Table 4.7 Identified solutions list – example format Community name: Village One Main problems SOLUTIONS Description of the main problems identified for the community HEALTH CENTRE activities COMMUNITY activities DISTRICT activities Example: Poor community attendance at outreach sessions Call the community chief or community worker by mobile phone in advance of the session to confirm time and place Mobilize mothers and children by informing them in advance and encouraging attendance at session Ensure costs of outreach sessions are budgeted (transport and per diem) according to HC session plan\n :END TABLE DATA:\n\n ",
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Community name:
Village One
Main problems Description of the main problems identified for the community
SOLUTIONS
HEALTH CENTRE activities
COMMUNITY activities
DISTRICT activities
Example: Poor community attendance at outreach sessions
Call the community chief or community worker by mobile phone in advance of the session to confirm time and place
Mobilize mothers and children by informing them in advance and encouraging attendance at session
Ensure costs of outreach sessions are budgeted (transport and per diem) according to HC session plan
Main problems Description of the main problems identified for the community
SOLUTIONS
HEALTH CENTRE activities
COMMUNITY activities
DISTRICT activities
Example: Poor community attendance at outreach sessions
Call the community chief or community worker by mobile phone in advance of the session to confirm time and place
Mobilize mothers and children by informing them in advance and encouraging attendance at session
Ensure costs of outreach sessions are budgeted (transport and per diem) according to HC session plan
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"text": "\n\n\n4.1 Outline solutions\nTable 4.7 shows a format for outlining solutions at health centre, community and district levels. How to list identified solutions\nHold a brainstorming session with key people from the health centre, community and district to gather ideas. Be sure to include a session on how higher performing health centres and communities have been able to solve their problems and achieve improvements (this will give evidenced-based ideas). Get consensus on the main problems (not every problem) and list the priority ones. To address the problems, limit priority problems to about three. Working on a longer list of problems usually becomes too difficult for a practical approach. Choose practical and feasible activities to solve the prioritized problems, since:\nhealth centre problem-solving activities should be within existing capacity and resources community activities may be limited to the capacity of its volunteers since additional resources are often not available district-level activities may provide support to the health centre with extra technical or financial resources.\nMicroplanning for reaching every community\n :TABLE DATA: \nTable 4.7 Identified solutions list – example format Community name: Village One Main problems SOLUTIONS Description of the main problems identified for the community HEALTH CENTRE activities COMMUNITY activities DISTRICT activities Example: Poor community attendance at outreach sessions Call the community chief or community worker by mobile phone in advance of the session to confirm time and place Mobilize mothers and children by informing them in advance and encouraging attendance at session Ensure costs of outreach sessions are budgeted (transport and per diem) according to HC session plan\n :END TABLE DATA:",
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Community name:
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Main problems Description of the main problems identified for the community
SOLUTIONS
HEALTH CENTRE activities
COMMUNITY activities
DISTRICT activities
Example: Poor community attendance at outreach sessions
Call the community chief or community worker by mobile phone in advance of the session to confirm time and place
Mobilize mothers and children by informing them in advance and encouraging attendance at session
Ensure costs of outreach sessions are budgeted (transport and per diem) according to HC session plan
4.2 Make a workplan to implement identified solutions
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"text": "\n\n\nHow to complete the health centre workplan\nComplete one form for each person involved – the same form can be used for both health centre staff and community workers. List the main health centre and community-level problem-solving activities from the exercise given in Section 4.1, compiled on the form shown in Table 4.7. Activities should be defined as specific tasks for the person named on the form. Make a schedule for completing the activities over the next six months (see Table 4.8) – the person named on the form should track their progress as the activities/tasks are completed each month.\nMicroplanning for reaching every community\nMicroplanning for reaching every community",
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"text": "\n\n\n5 Making a session plan\nA session plan lists all communities served by the health centre and specifies how frequently each community will be reached based on such factors as distance, target population, workload and other relevant operational issues. This section provides an example format and gives a simple method for choosing session frequency, scheduling dates and organizing the supplies needed to complete a session plan that reaches every community in a health centre catchment area. It is based on a maximum workload of about 30 infants per vaccinator per session. It uses an immunization schedule that requires a minimum of four contacts during the first year of life. The aim is to plan sessions so that staff time is used efficiently.",
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"text": "\n\n\n5.1 Immunization session plan\nTable 4.9 shows an example immunization session plan format. It compiles a list of communities and the distances from the health centre that is responsible for their immunization services. The type of session needed – fixed (at the health centre) or outreach (at a site in the community) – for rural communities usually depends on the distance of the community from the health centre or on the travel time needed if the terrain is difficult. The type of session needed for urban communities may depend on social factors or convenience for the groups being served. The frequency of sessions needed depends on the number of infants expected at each session. The number of infants an immunization programme should expect to serve in a community depends on its total population. Table 4.10 is a simplified guide to choosing session frequency based on total population – it gives the end result of calculations based on total population and estimated proportions of infants in the total population (see Annex 4.1 for calculation details).",
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"text": "\n\n\nTable 4.9 Health centre overall session plan: example format\nNote that this includes all communities, some of which may be scheduled for fixed sessions (at the health centre) and some for outreach\n :TABLE DATA: \nCommunity name Distance from HC in km Type of session (fixed or outreach) Total population Session frequency \n :END TABLE DATA:\nMicroplanning for reaching every community\nTable 4.10 estimates the best use of staff time based on the number of vaccinators expected to be available for each session in a range of population sizes. Find the total population of the community to be served and choose the session frequency based on the number of vaccinators available for the immunization team. The following are some examples:\nfor a community with a total population of 6000 and an immunization team with two vaccinators per session, session frequency should be every two weeks for a community with a total population of 3000 and an immunization team with one vaccinator per session, session frequency should be monthly for a community with a total population of 500 and an immunization team with one vaccinator per session, session frequency should be quarterly.\nThis table states that a reasonable workload is about 30 infants per vaccinator per session. The maximum acceptable workload may vary depending on the national schedule and immunization policies and strategies; follow national guidelines.",
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Table 4.10 estimates the best use of staff time based on the number of vaccinators expected to be available for each session in a range of population sizes. Find the total population of the community to be served and choose the session frequency based on the number of vaccinators available for the immunization team. The following are some examples:
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"text": "for a community with a total population of 6000 and an immunization team with two vaccinators per session, session frequency should be every two weeks for a community with a total population of 3000 and an immunization team with one vaccinator per session, session frequency should be monthly for a community with a total population of 500 and an immunization team with one vaccinator per session, session frequency should be quarterly.",
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for a community with a total population of 6000 and an immunization team with two vaccinators per session, session frequency should be every two weeks
for a community with a total population of 3000 and an immunization team with one vaccinator per session, session frequency should be monthly
for a community with a total population of 500 and an immunization team with one vaccinator per session, session frequency should be quarterly.
This table states that a reasonable workload is about 30 infants per vaccinator per session. The maximum acceptable workload may vary depending on the national schedule and immunization policies and strategies; follow national guidelines.
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"text": "\n DESCRIPTION:\n Le tableau indique la fréquence des séances de vaccination en fonction de la population, avec 1 ou 2 vaccinateurs.\n :TABLE DATA:\n Total population of community Session frequency (30 infants per vaccinator per session) 1 vaccinator per session 2 vaccinators per session 4- or 5-contact schedule 5001–10 000 Weekly Every 2 weeks 3001–5000 Every 2 weeks Monthly 2001–3000 Monthly Monthly 1001–2000 Monthly Quarterly 0–1000 Quarterly Quarterly\n :END TABLE DATA:\n\n ",
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"text": "\n\n\nTable 4.10 Estimated immunization session frequency\n :TABLE DATA: \nTotal population of community Session frequency (30 infants per vaccinator per session) 1 vaccinator per session 2 vaccinators per session 4- or 5-contact schedule 5001–10 000 Weekly Every 2 weeks 3001–5000 Every 2 weeks Monthly 2001–3000 Monthly Monthly 1001–2000 Monthly Quarterly 0–1000 Quarterly Quarterly\n :END TABLE DATA:\nSession plans should be reviewed quarterly with corresponding monitoring data for communities served (see Module 6 (Monitoring and surveillance) , Section 4). Any missed or incomplete sessions should be rescheduled and adjustments should be made. The session frequency may need to change if population numbers change significantly.\nModule 4: Microplanning for reaching every community",
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Table 4.10 Estimated immunization session frequency
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Session plans should be reviewed quarterly with corresponding monitoring data for communities served (see Module 6
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"text": "\n\n\n5.2 Health centre outreach session plan\nEvery health centre should make, display and monitor an outreach schedule to show the date and place of each session, the means of transport and the person responsible for arranging it. It should also include a community contact person who will communicate session dates and other reminders to the wider community. An example format is shown in Table 4.11. Note that fixed sessions can be added to this if needed to keep all on one sheet (leave the transport column blank or write “fixed” there). Outreach sessions are often planned for rural communities that are 5–15 km from the health centre and for urban populations who use convenient locations such as markets, community centres and schools. Outreach sessions may also need to be planned to take place before and/or after seasonal rains or other factors that make populations hard to reach at certain times of the year. In some programmes, communities living more than 10 km away from the health centre may be served by mobile activities organized from district level, as shown in Figure 4.2. Follow national and district guidelines for microplanning. Other activities, such as EPI Plus and maternal–child health interventions, may be integrated in immunization sessions. Follow national guidelines on including additional staff, logistics and financial resources as needed.\nModule 4: Microplanning for reaching every community\nMicroplanning for reaching every community",
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"text": "Note that Table 4.12 is a rough estimate of needs; numbers include an average 10% excess and/or are rounded off to whole units. Each health centre should calculate its supply quantities based on the national immunization schedule and any known variations, such as increased numbers of infants in sessions where defaulters are expected to catch up even if a list of expected infants is not compiled. Health centre wastage rates and other similar factors should also be taken into account for both vaccine vial and AD syringe numbers. Quantities may be rounded off based on packaging and/or ease of dispensing from the pharmacy or stockroom. Supplies for EPI Plus or other activities integrated with immunization sessions should be added to the table and stock lists as directed by national guidelines.",
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Note that Table 4.12 is a rough estimate of needs; numbers include an average 10% excess and/or are rounded off to whole units. Each health centre should calculate its supply quantities based on the national immunization schedule and any known variations, such as increased numbers of infants in sessions where defaulters are expected to catch up even if a list of expected infants is not compiled. Health centre wastage rates and other similar factors should also be taken into account for both vaccine vial and AD syringe numbers. Quantities may be rounded off based on packaging and/or ease of dispensing from the pharmacy or stockroom.
Supplies for EPI Plus or other activities integrated with immunization sessions should be added to the table and stock lists as directed by national guidelines.
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"text": "Monthly stock reports are needed to ensure adequate supplies and avoid stock-outs. Table 4.13 shows an example format for a health centre stock report, giving an estimated monthly consumption requirement based on expected immunization service activities. The consumption figures should correlate with the total number of doses used at sessions held during the month. This example matches the schedule given in Table 4.12, but each health centre should report according to national guidelines. Stock report data may be added to the monthly summary report, as shown in Module 6 ( Monitoring and surveillance ), Section 3.",
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Monthly stock reports are needed to ensure adequate supplies and avoid stock-outs. Table 4.13 shows an example format for a health centre stock report, giving an estimated monthly consumption requirement based on expected immunization service activities. The consumption figures should correlate with the total number of doses used at sessions held during the month. This example matches the schedule given in Table 4.12, but each health centre should report according to national guidelines. Stock report data may be added to the monthly summary report, as shown in Module 6 (
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"text": "\n DESCRIPTION:\n Ce tableau est un rapport mensuel de stock d'un centre de santé, listant les vaccins, seringues et autres fournitures, ainsi que leur consommation et commandes.\n :TABLE DATA:\n Monthly stock report Health centre name: Date report completed: Stock month and year: Reported by: Monthly consumption Opening stock Order received Closing stock Order for next month RV – single dose OPV – 10-dose vial + dropper PCV – single-dose vial pentavalent – single-dose vial BCG – 20-dose vial + diluent Measles – 10-dose vial + diluent AD syringe – 0.5 ml BCG AD syringe – 0.05 ml RUP reconstitution syringe – 5 ml + needle RUP reconstitution syringe – 2 ml + needle Safety box Other\n :END TABLE DATA:\n\n ",
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"text": "Monthly stock report Health centre name: Date report completed: Stock month and year: Reported by: Monthly consumption Opening stock Order received Closing stock Order for next month RV – single dose OPV – 10-dose vial + dropper PCV – single-dose vial pentavalent – single-dose vial BCG – 20-dose vial + diluent Measles – 10-dose vial + diluent AD syringe – 0.5 ml BCG AD syringe – 0.05 ml RUP reconstitution syringe – 5 ml + needle RUP reconstitution syringe – 2 ml + needle Safety box Other",
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"text": "\n\n\nTable 4.13 Health centre monthly stock report – example format\n :TABLE DATA: \nMonthly stock report Health centre name: Date report completed: Stock month and year: Reported by: Monthly consumption Opening stock Order received Closing stock Order for next month RV – single dose OPV – 10-dose vial + dropper PCV – single-dose vial pentavalent – single-dose vial BCG – 20-dose vial + diluent Measles – 10-dose vial + diluent AD syringe – 0.5 ml BCG AD syringe – 0.05 ml RUP reconstitution syringe – 5 ml + needle RUP reconstitution syringe – 2 ml + needle Safety box Other\n :END TABLE DATA:\nModule 4: Microplanning for reaching every community\nEvery health centre needs to plan to follow up defaulters or infants who miss scheduled vaccinations, who thus fall into the unimmunized or underimmunized group. Refer to Module 6 ( Monitoring and surveillance ), Section 1.4 for details on defaulter tracking methods. This section is a brief reminder of how opportunities to complete vaccinations can be linked to regularly scheduled immunization services.",
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Table 4.13Health centre monthly stock report – example format
Every health centre needs to plan to follow up defaulters or infants who miss scheduled vaccinations, who thus fall into the unimmunized or underimmunized group. Refer to Module 6 (
Monitoring and surveillance
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"text": "\n\n\n6.1 Defaulter tracking list\nAn example defaulter tracking list is shown in Module 6 ( Monitoring and surveillance ). This list should be completed regularly at the end of each session or monthly, depending on health centre practice. A community worker or other staff should be assigned to find defaulters and give them appointments for the next immunization session. For outreach sessions, this list should be sent to the community at least a week in advance.",
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An example defaulter tracking list is shown in Module 6 (
Monitoring and surveillance
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"text": "\n\n\n6.2 Other opportunities\nImmunization status should be reviewed at all health care visits. Children who are due or overdue should be vaccinated immediately whenever possible. If vaccines are not immediately available for administration during the same visit, the infant should be referred to the earliest possible immunization session. The caregiver should be informed of the time, date and location of the immunization session, and the infant’s name should be added to the health centre defaulter tracking list to help ensure the follow-up visit is made.\nModule 4: Microplanning for reaching every community",
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Immunization status should be reviewed at all health care visits. Children who are due or overdue should be vaccinated immediately whenever possible. If vaccines are not immediately available for administration during the same visit, the infant should be referred to the earliest possible immunization session. The caregiver should be informed of the time, date and location of the immunization session, and the infant’s name should be added to the health centre defaulter tracking list to help ensure the follow-up visit is made.
Expected number of newborns and returning infants at each session (by session frequency for 4-contact minimum schedule)
Weekly session (= monthly newborn target)
Biweekly session (= monthly newborn target × 2)
Monthly session (= monthly newborn target × 4)
Quarterly session (= annual target population)
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"text": "\n\n\nCalculations used in determining needed session frequency\nThe following steps are needed to develop Table 4.10:\nCalculate the annual target population and monthly newborn target\nSince infants are the target population for immunization, calculating the number of newborns expected in a year gives the annual target population for a programme: Annual target population = (total population) x (% infants in population or expected birth rate)\nThe percentage of infants in the population, or the expected birth rate, should be obtained from local data. If a specific local percentage is not available, the suggestion here is to use 3% as an estimate for session planning. See Module 6 ( Monitoring and surveillance ), Section 4.1 for further discussion on calculating targets.\nDivide the annual target population by 12 to get the monthly newborn/infant target: Monthly newborn target = (annual target population)/12\nCalculate the expected number of infants per session\nIn order to choose the frequency of sessions, sessions, an estimate is needed of the expected number of infants per session for a given community. This includes the number of newborns presenting for first doses of vaccines and the number of infants returning for follow-up doses. The number of infants returning for follow-up doses depends on the number of contacts required by the national immunization schedule. For example, for a four-contact schedule, each newborn will be added to the schedule as a returning infant three times in later months during the year; this means that for a monthly session, there should be three returning infants for every newborn expected based on the monthly newborn target. Table 4.14 shows the results of calculations based on the annual target population and the monthly newborn target to determine the expected number of newborns plus returning infants at individual sessions. A four-contact (minimum) schedule is assumed. A choice among weekly, biweekly (every two weeks), monthly and quarterly (every three months) is also assumed. Both the number of contacts and the choice of sessions may vary in different programmes.\nMicroplanning for reaching every community\n! Note that the equations are:\nExpected number of newborns and returning infants at a weekly session = monthly newborn target Expected number of newborns and returning infants at a biweekly session = monthly newborn target x 2 Expected number of newborns and returning infants at a monthly session = monthly newborn target x 4 Expected number of newborns and returning infants at a quarterly session = annual target population\n :TABLE DATA: \nTotal population Annual target population (infants <1 year of age) Expected number of newborns and returning infants at each session (= total population x 3%) Monthly newborn target Weekly session (once every week) Biweekly session (once every two weeks) Monthly session (once every month) Quarterly session (once every 3 months) 10 000 300 25 25 50 100 300 5000 150 13 13 25 50 150 4000 120 10 10 20 40 120 3000 90 8 8 15 30 90 2000 60 5 5 10 20 60 1000 30 3 3 5 10 30 500 15 1 1 3 5 15 200 6 1 1 1 2 6\n :END TABLE DATA:\n3. Choose session frequency based on acceptable workload per vaccinator\nTable 4.10 uses 30 injections per session. Session frequency per immunization site can be decided based on number of vaccinators available and acceptable workload.",
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The percentage of infants in the population, or the expected birth rate, should be obtained from local data. If a specific local percentage is not available, the suggestion here is to use 3% as an estimate for session planning. See Module 6 (
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Calculate the expected number of infants per session
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In order to choose the frequency of sessions, sessions, an estimate is needed of the expected number of infants per session for a given community. This includes the number of newborns presenting for first doses of vaccines and the number of infants returning for follow-up doses. The number of infants returning for follow-up doses depends on the number of contacts required by the national immunization schedule. For example, for a four-contact schedule, each newborn will be added to the schedule as a returning infant three times in later months during the year; this means that for a monthly session, there should be three returning infants for every newborn expected based on the monthly newborn target.
Table 4.14 shows the results of calculations based on the annual target population and the monthly newborn target to determine the expected number of newborns plus returning infants at individual sessions. A four-contact (minimum) schedule is assumed. A choice among weekly, biweekly (every two weeks), monthly and quarterly (every three months) is also assumed. Both the number of contacts and the choice of sessions may vary in different programmes.
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Expected number of newborns and returning infants at a weekly session = monthly newborn target
Expected number of newborns and returning infants at a biweekly session = monthly newborn target x 2
Expected number of newborns and returning infants at a monthly session = monthly newborn target x 4
Expected number of newborns and returning infants at a quarterly session = annual target population
3. Choose session frequency based on acceptable workload per vaccinator
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"text": "\n\n\nAbout this module…\nThis module describes the tasks a health worker needs to perform to ensure the quality of an immunization session. It starts with the preparation required at the health centre and the immunization site before the infants arrive. It next discusses the communication needed throughout each encounter with caregivers during the session. It then proceeds with assessment of infants before vaccination, the correct technique for giving vaccines, and instructions for closing sessions and recording data. It concludes with a newly developed checklist that can serve as a reminder to ensure safety before, during and after immunization sessions. This module touches on topics that are covered in more detail in other modules with references given in the text. It focuses mainly on infant immunization, but the principles may be applied to older age groups.\nModule 5: Managing an immunization session\nModule 5: Managing an immunization session\nPreparation for sessions should be part of microplanning. This begins well before the day of the session and should continue throughout the session to include feedback for improving the planning of the next sessions. The main objectives are: a) to inform the community in advance: the community should be aware of the session and those who are due for immunization should know about the location and time; and b) to set up the site for safe immunization: staff should organize adequate quantities of vaccines, safe injection materials, safe disposal containers and reporting tools as well as an adequate cold chain for conserving vaccines. Some of the preparation steps given below are covered elsewhere in more detail; see references to other modules. The order of the steps may vary by site; for example, for outreach sessions, vaccines have to be packed for transport at the health centre before the workplace is prepared at the remote site. Community staff and/or volunteers should set up as much of the outreach site as possible before the vaccinators arrive.",
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"text": "Preparation for sessions should be part of microplanning. This begins well before the day of the session and should continue throughout the session to include feedback for improving the planning of the next sessions. The main objectives are: a) to inform the community in advance: the community should be aware of the session and those who are due for immunization should know about the location and time; and b) to set up the site for safe immunization: staff should organize adequate quantities of vaccines, safe injection materials, safe disposal containers and reporting tools as well as an adequate cold chain for conserving vaccines. Some of the preparation steps given below are covered elsewhere in more detail; see references to other modules. The order of the steps may vary by site; for example, for outreach sessions, vaccines have to be packed for transport at the health centre before the workplace is prepared at the remote site. Community staff and/or volunteers should set up as much of the outreach site as possible before the vaccinators arrive.",
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The main objectives are: a) to inform the community in advance: the community should be aware of the session and those who are due for immunization should know about the location and time; and b) to set up the site for safe immunization: staff should organize adequate quantities of vaccines, safe injection materials, safe disposal containers and reporting tools as well as an adequate cold chain for conserving vaccines.
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"text": "\n\n\n2.3 Communicating accurate information\nThe essential elements of every encounter are highlighted in Figure 5.4.\nModule 5: Managing an immunization session\nSome caregivers will want detailed information while others will be happy to trust that they are receiving appropriate care, and lengthy explanations may cause them anxiety. Use words that are readily understood rather than technical terms. The following issues may need to be covered, depending on individual needs and understanding:\nvaccine-preventable disease vaccines and their schedules, including the number of doses, their timing, the importance of completing the series and due date(s) for the next dose(s) route of vaccine administration: oral or injectable potential adverse events and what to do if they occur explanation and reassurance in response to inaccurate information (for example, contraceptive effect of vaccines) vitamin A, if needed and when importance of immunization cards and documents and what is written on them immunization session locations and times, especially for the next visit.",
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The essential elements of every encounter are highlighted in Figure 5.4.
Some caregivers will want detailed information while others will be happy to trust that they are receiving appropriate care, and lengthy explanations may cause them anxiety. Use words that are readily understood rather than technical terms. The following issues may need to be covered, depending on individual needs and understanding:
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vaccines and their schedules, including the number of doses, their timing, the importance of completing the series and due date(s) for the next dose(s)
route of vaccine administration: oral or injectable
potential adverse events and what to do if they occur
explanation and reassurance in response to inaccurate information (for example, contraceptive effect of vaccines)
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importance of immunization cards and documents and what is written on them
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"text": "\n\n\n2.4 Communicating potential adverse events\nThe following points are important when talking about the potential adverse events of any vaccine.\nReassure the caregiver that reactions, such as fever, pain or swelling at the injection site, and changes, such as the child being irritable or off colour, are common and indicate a good response to the vaccine. Instruct the caregiver to give extra fluids in the form of breast milk or clean water. Instruct the caregiver that paracetamol may be given and specify the appropriate dose and timing for the individual infant. Remind the caregiver to give extra hugs and attention, but to avoid pressure to the injection site(s). Explain that placing a clean, cold, damp cloth can help to ease pain if there is a local injection site reaction. Tell the caregiver to bring the infant to the health centre if the infant’s condition worsens or the reaction continues for more than a day or two, since the infant may develop an illness, unrelated to immunization, that needs treatment.\nModule 5: Managing an immunization session\nAfter BCG vaccine: Explain to the caregiver that the flat-topped swelling on the infant’s arm is normal and indicates that the vaccine is working. Ask the caregiver to return with the infant if the infant develops such signs as abscesses or enlarged glands.\nAfter measles vaccine: Explain to the caregiver that a rash or fever may develop after 6–12 days. Other people will not catch the rash and it will go away on its own. The caregiver should give the infant extra fluids and keep them cool.\nSee Module 1 ( Target diseases and vaccines ) for more details on vaccines and potential adverse events.",
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➢ In the event of any out-of-stocks of vaccine at the time of the session, inform the caregiver where and when to return for the next doses.
➢ Remind the caregiver about other services given during immunization sessions, as per national policy; for example, vitamin A supplementation or tetanus toxoid for women.
➢ If immunization campaigns are planned in the coming months, inform the caregiver about the date of the campaign, what vaccination is being given, and where the vaccination site will be.
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"text": "\n\n\n3.1 Assess eligibility for immunization\nWhenever an infant visits the health facility, they should be screened for immunization and given all the vaccines needed. If there is no immunization session that day, the earliest possible appointment should be made and explained to the caregiver. The steps below should be followed at any health care visit as well as at any immunization session.\nVerify the infant’s age on the immunization card If the infant does not have an immunization card, ask the caregiver for the infant’s age. If the caregiver does not know the infant’s age, estimate it by asking if the infant was born during/around a notable community event, for example during a certain season or celebration. A local events calendar can help with this. Verify which vaccines the infant has received by reviewing the immunization card If the infant does not have an immunization card but has come to the health facility before, check the register and fill out a new card. If the infant is new to the health facility, ask the caregiver questions to prompt recall of each vaccine the infant should have received and fill out a new card. Check for a BCG scar (usually on the left arm/shoulder) if there is no record or recall. Proceed to the next step with or without the card, recall or a scar. If immunization status is in doubt and there are no known contraindications (see Section 3.2 of this module), vaccinate the infant. Verify all vaccines the infant needs at this session to allow efficient preparation Follow the national schedule (see Module 1 ( Target diseases and vaccines ) for WHO recommendations on each vaccine) remembering these general points: If the infant is eligible for more than one type of vaccine, it is safe to give the different vaccines at different injection sites during the same session (see Section 4.10). Never give more than one dose of the same vaccine at one time. If the vaccine is overdue, do not restart the schedule. Simply provide the next needed dose in the series.\nModule 5: Managing an immunization session\nIf there is a delay in starting the immunization schedule, give the vaccine(s) and an appointment for the next dose at the interval recommended in the national schedule.",
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Verify the infant’s age on the immunization card
If the infant does not have an immunization card, ask the caregiver for the infant’s age.
If the caregiver does not know the infant’s age, estimate it by asking if the infant was born during/around a notable community event, for example during a certain season or celebration. A local events calendar can help with this.
Verify which vaccines the infant has received by reviewing the immunization card
If the infant does not have an immunization card but has come to the health facility before, check the register and fill out a new card. If the infant is new to the health facility, ask the caregiver questions to prompt recall of each vaccine the infant should have received and fill out a new card.
Check for a BCG scar (usually on the left arm/shoulder) if there is no record or recall.
Proceed to the next step with or without the card, recall or a scar. If immunization status is in doubt and there are no known contraindications (see Section 3.2 of this module), vaccinate the infant.
Verify all vaccines the infant needs at this session to allow efficient preparation
Follow the national schedule (see Module 1 (
Target diseases and vaccines
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If the infant is eligible for more than one type of vaccine, it is safe to give the different vaccines at different injection sites during the same session (see Section 4.10).
Never give more than one dose of the same vaccine at one time.
If the vaccine is overdue, do not restart the schedule. Simply provide the next needed dose in the series.
If there is a delay in starting the immunization schedule, give the vaccine(s) and an appointment for the next dose at the interval recommended in the national schedule.
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"text": "\n DESCRIPTION:\n Ce tableau indique les vaccins à administrer ou à éviter selon le statut VIH (asymptomatique/symptomatique) du nourrisson.\n :TABLE DATA:\n Vaccine Asymptomatic HIV infection/HIV+ Symptomatic HIV infection/AIDS RV Vaccinate Vaccinate OPV and/or IPV Vaccinate Vaccinate BCG Do not vaccinate Do not vaccinate Pneumococcal Vaccinate Vaccinate DTP-containing Vaccinate Vaccinate Hepatitis B-containing Vaccinate Vaccinate H. influenzae type b-containing Vaccinate Vaccinate Measles- and/or mumps- and/or rubella-containing Vaccinate Do not vaccinate Yellow fever Vaccinate Do not vaccinate* Japanese encephalitis Vaccinate Vaccinate Tetanus toxoid Vaccinate Vaccinate Meningococcal Vaccinate Vaccinate Influenza (inactivated) Vaccinate Vaccinate HPV Vaccinate (always 3 doses) Vaccinate (always 3 doses)\n :END TABLE DATA:\n\n ",
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"text": "\n\n\n3.2 Assess possible contraindications\nFor the first dose of a vaccine, assess the general status of the child to rule out signs of serious illness. For a subsequent dose in a vaccine series, ask the caregiver whether any adverse events, including anaphylaxis, occurred following the previous dose(s). All infants should be immunized except in these situations:\nDo not give a vaccine if the infant has had anaphylaxis (a serious allergic reaction) or other severe reaction to a previous dose of the vaccine or a vaccine component. Refer to Table 5.1 for guidance on vaccinating HIV-infected children. Do not give a vaccine if the caregiver objects to immunization for a sick infant after explanation that mild illness is not a contraindication. Ask the caregiver to come back when the infant is well.\n :TABLE DATA: \nVaccine Asymptomatic HIV infection/HIV+ Symptomatic HIV infection/AIDS RV Vaccinate Vaccinate OPV and/or IPV Vaccinate Vaccinate BCG Do not vaccinate Do not vaccinate Pneumococcal Vaccinate Vaccinate DTP-containing Vaccinate Vaccinate Hepatitis B-containing Vaccinate Vaccinate H. influenzae type b-containing Vaccinate Vaccinate Measles- and/or mumps- and/or rubella-containing Vaccinate Do not vaccinate Yellow fever Vaccinate Do not vaccinate* Japanese encephalitis Vaccinate Vaccinate Tetanus toxoid Vaccinate Vaccinate Meningococcal Vaccinate Vaccinate Influenza (inactivated) Vaccinate Vaccinate HPV Vaccinate (always 3 doses) Vaccinate (always 3 doses)\n :END TABLE DATA:\n* pending further studies\nManaging an immunization session\nFor infants with a minor illness and/or fever below 38.5 °C, vaccinate as usual. This includes respiratory tract infections, diarrhoea and similar mild infections without significant fever. For very ill infants who need to go to hospital, or infants who have a very high fever, vaccinate if possible. A senior health worker may have to decide in each case, but infants need protecting from diseases that could be transmissible in hospital (measles, for example). For malnourished infants, vaccinate as usual. Malnourished infants do develop immunity after vaccination, and when they do not receive vaccines, they are more likely than well-nourished children to die from vaccine-preventable diseases.\nallergies or asthma, with the exception of a known allergy to a specific component of the vaccine as mentioned ongoing treatment with antibiotics family history of adverse events following immunization prematurity or low birth weight history of jaundice at birth ongoing breastfeeding recent or upcoming surgery chronic noncommunicable diseases of the heart, lung, kidney or liver stable neurological conditions, such as cerebral palsy or Downs syndrome family history of convulsions, seizures or fits.\nModule 5: Managing an immunization session",
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"text": "\n\n\n4.1 Preparing to vaccinate\nInjectable vaccines can be ready to use or can require reconstitution (mixing) with diluent. Oral vaccines may require manipulation of the packaging to enable administration. With the increasing range of products and presentations available, the aim of this section is to cover general principles that can be adapted to specific vaccines in each programme. Firstly, use aseptic technique to prepare vaccines:\nWhenever possible, prepare the vaccine away from the child and caregiver; be aware that injection materials may cause anxiety. If this is not possible, turn away slightly to shield the preparation. Try to talk to the caregiver while preparing injections as showing interest in the caregiver is reassuring.",
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4.1 Preparing to vaccinate
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"text": "\n\n\nPoints to remember about diluents\nAlways use diluent from the same manufacturer as the vaccine. Diluent is not interchangeable, different vaccines have different diluents. Administering a vaccine with the wrong diluent has led to serious adverse events, including death. Diluent should be cooled before being mixed with the vaccine. Vaccines should be reconstituted with diluent immediately before use. Unused reconstituted vaccine must be handled according to national multi-dose vial policy; WHO policy is outlined in Module 2 (The vaccine cold chain) .\nFor vials with VVMs, double check that the vaccine can be used. Double check each vial/ampoule to make sure it is not past its expiry date, and read the label carefully. Open the vial. For a metal cap, use a file to lift the pre-cut centre and bend it back; for a plastic cap, flip it off with your thumb or slowly twist it depending on the specific instructions for the type of vial. Open the glass ampoule by holding the ampoule between the thumb and middle finger and supporting the top with the index finger; scratch the ampoule neck with a file, then gently break off the top, taking care to avoid injury from the sharp glass (see Figure 5.5) . If you injure yourself, discard the ampoule since the contents may have been contaminated. Cover the wound before opening a new ampoule. Draw all of the diluent out with a new disposable reconstitution needle and syringe. Insert the needle of the reconstitution syringe into the vaccine vial and empty all the diluent – depress the plunger slowly to avoid frothing inside the vaccine vial. Draw the fluid slowly and gently in and out of the vial several times to mix the diluent and vaccine or gently swirl the vial to mix the diluent and vaccine. Take care not to touch the rubber membrane or opening.\nManaging an immunization session",
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"text": "\n DESCRIPTION:\n Le tableau décrit l'ordre recommandé pour administrer les vaccins aux nourrissons, en commençant par les vaccins oraux puis les injectables.\n :TABLE DATA:\n Order in which to give the vaccine Route Vaccine 1 Oral Rotavirus 2 Oral Polio 3 Injectable/ID BCG 4 Injectable/IM Pneumococcal 5 Injectable/IM Pentavalent or Hib-containing 6 Injectable/IM DTP, if not using pentavalent 7 Injectable/IM HepB, if not using pentavalent 8 Injectable/SC Measles- and rubella-containing 9 Injectable/SC Yellow fever 10 Injectable/SC Japanese encephalitis 11 Injectable/IM Meningococcal\n :END TABLE DATA:\n\n ",
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help make administering them easier; in general, the suggestion is to give oral vaccines first, while the infant is still calm, and then follow with the injectable ones. The choice of whether to give a new vaccine first or last usually depends on local factors. Table 5.2 shows a suggested order based on the current WHO schedule. Note that rotavirus vaccine comes before polio since it has a larger volume and it may be better to give it when the infant is most calm. Also note that some programmes may not use all the vaccines listed in the table. Always refer to national guidelines.
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Order in which to give the vaccine
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1
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Oral
Polio
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BCG
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Japanese encephalitis
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Meningococcal
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"text": "\n DESCRIPTION:\n Le tableau décrit différentes positions de vaccination (câlin, lit, etc.) avec leurs instructions, avantages et inconvénients pour assurer la sécurité et le confort.\n :TABLE DATA:\n Table 5.3 Vaccination positions, their advantages and disadvantages Position Illustration Directions for caregiver Advantages Disadvantages Cuddle position: Semi-recumbent on caregiver’s lap Illustration of cuddle position Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle. Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change. Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change. Bed position: Lying on back on flat surface Illustration of bed position Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine. Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant. Vaccinator responsible for restraint of the legs.\n :END TABLE DATA:\n\n ",
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"text": "Table 5.3 Vaccination positions, their advantages and disadvantages Position Illustration Directions for caregiver Advantages Disadvantages Cuddle position: Semi-recumbent on caregiver’s lap Illustration of cuddle position Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle. Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change. Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change. Bed position: Lying on back on flat surface Illustration of bed position Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine. Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant. Vaccinator responsible for restraint of the legs.",
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Table 5.3 Vaccination positions, their advantages and disadvantages
Position
Illustration
Directions for caregiver
Advantages
Disadvantages
Cuddle position: Semi-recumbent on caregiver’s lap
Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle.
Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change.
Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change.
Bed position: Lying on back on flat surface
Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine.
Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant.
Table 5.3 Vaccination positions, their advantages and disadvantages
Position
Illustration
Directions for caregiver
Advantages
Disadvantages
Cuddle position: Semi-recumbent on caregiver’s lap
Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle.
Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change.
Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change.
Bed position: Lying on back on flat surface
Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine.
Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant.
Vaccinator responsible for restraint of the legs.
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"text": "\n DESCRIPTION:\n Le tableau décrit différentes positions pour vacciner les nourrissons, enfants et adultes, avec leurs avantages et inconvénients respectifs.\n :TABLE DATA:\n Position Illustration Directions for caregiver Advantages Disadvantages Upright position: Sitting upright on caregiver’s lap, facing straight outwards Illustration of upright position Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle. Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position. Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver. Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs Illustration of straddle position Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection. Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position. Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps). Independent position: Adolescent/adult vaccinated sitting on chair Illustration of independent position See Section 4.11 of this module. Good access to deltoid. Restraint, if required, dependent on vaccinator.\n :END TABLE DATA:\n\n ",
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"text": "Position Illustration Directions for caregiver Advantages Disadvantages Upright position: Sitting upright on caregiver’s lap, facing straight outwards Illustration of upright position Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle. Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position. Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver. Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs Illustration of straddle position Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection. Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position. Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps). Independent position: Adolescent/adult vaccinated sitting on chair Illustration of independent position See Section 4.11 of this module. Good access to deltoid. Restraint, if required, dependent on vaccinator.",
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Position
Illustration
Directions for caregiver
Advantages
Disadvantages
Upright position: Sitting upright on caregiver’s lap, facing straight outwards
Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle.
Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position.
Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver.
Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs
Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection.
Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position.
Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps).
Independent position: Adolescent/adult vaccinated sitting on chair
Upright position: Sitting upright on caregiver’s lap, facing straight outwards
Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle.
Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position.
Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver.
Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs
Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection.
Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position.
Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps).
Independent position: Adolescent/adult vaccinated sitting on chair
See Section 4.11 of this module.
Good access to deltoid.
Restraint, if required, dependent on vaccinator.
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"text": "\n\n\n4.5 Positioning the infant for vaccination\nThe choice of position will depend on the number of vaccines to be given, the age of the child and the materials available. The aim of positioning is to keep the child still and the caregiver and vaccinator comfortable. Table 5.3 shows different positions for vaccinating. The first three are for infants and the fourth and fifth are for children aged 12 months or older and adolescents/adults respectively. Reviewing the positions and picturing movements to give vaccinations will help you be more confident during the actual immunization encounter. You should try different positions to find the one that suits you best. Check that the caregiver is willing to hold the child while the injection/s is/are given. If they are not willing, ask someone else to help.\nModule 5: Managing an immunization session\n :TABLE DATA: \nTable 5.3 Vaccination positions, their advantages and disadvantages Position Illustration Directions for caregiver Advantages Disadvantages Cuddle position: Semi-recumbent on caregiver’s lap Illustration of cuddle position Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle. Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change. Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change. Bed position: Lying on back on flat surface Illustration of bed position Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine. Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant. Vaccinator responsible for restraint of the legs.\n :END TABLE DATA:\nModule 5: Managing an immunization session\n :TABLE DATA: \nPosition Illustration Directions for caregiver Advantages Disadvantages Upright position: Sitting upright on caregiver’s lap, facing straight outwards Illustration of upright position Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle. Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position. Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver. Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs Illustration of straddle position Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection. Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position. Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps). Independent position: Adolescent/adult vaccinated sitting on chair Illustration of independent position See Section 4.11 of this module. Good access to deltoid. Restraint, if required, dependent on vaccinator.\n :END TABLE DATA:\nModule 5: Managing an immunization session",
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The choice of position will depend on the number of vaccines to be given, the age of the child and the materials available. The aim of positioning is to keep the child still and the caregiver and vaccinator comfortable. Table 5.3 shows different positions for vaccinating. The first three are for infants and the fourth and fifth are for children aged 12 months or older and adolescents/adults respectively. Reviewing the positions and picturing movements to give vaccinations will help you be more confident during the actual immunization encounter. You should try different positions to find the one that suits you best.
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"text": "Table 5.3 Vaccination positions, their advantages and disadvantages Position Illustration Directions for caregiver Advantages Disadvantages Cuddle position: Semi-recumbent on caregiver’s lap Illustration of cuddle position Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle. Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change. Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change. Bed position: Lying on back on flat surface Illustration of bed position Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine. Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant. Vaccinator responsible for restraint of the legs.",
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Table 5.3 Vaccination positions, their advantages and disadvantages
Position
Illustration
Directions for caregiver
Advantages
Disadvantages
Cuddle position: Semi-recumbent on caregiver’s lap
Sit on a chair holding the infant sideways on lap with one arm behind infant’s back. Tuck the infant’s inside arm around their own back or against their body. Bring their arm around the infant’s back to hug the shoulders and upper body close to their body. Tuck the infant’s legs between their own to secure them or hold them with their other arm. Vaccinator should position themself to avoid strain while giving vaccines at the correct angle.
Infant’s arm and legs securely held by caregiver. Infant comforted by close contact and eye contact with caregiver. Leg and arm injections possible without position change.
Delay between injections if 2 IM injections given. Possibility that secure restraint may not occur after position change.
Bed position: Lying on back on flat surface
Lay the infant, with both legs bare, on a flat surface. Stand on the other side of the bed and hold the infant’s hands and arms. Vaccinator should stand at the infant’s feet and use non-injecting hand to gently cup the slightly bent knee of the leg to receive the vaccine.
Infant’s arms held securely by caregiver. Infant comforted by close contact and eye contact with caregiver. Injection in both legs possible without change in position of infant.
Vaccinator responsible for restraint of the legs.
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"text": "Position Illustration Directions for caregiver Advantages Disadvantages Upright position: Sitting upright on caregiver’s lap, facing straight outwards Illustration of upright position Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle. Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position. Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver. Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs Illustration of straddle position Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection. Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position. Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps). Independent position: Adolescent/adult vaccinated sitting on chair Illustration of independent position See Section 4.11 of this module. Good access to deltoid. Restraint, if required, dependent on vaccinator.",
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Position
Illustration
Directions for caregiver
Advantages
Disadvantages
Upright position: Sitting upright on caregiver’s lap, facing straight outwards
Sit on a chair holding the infant sitting facing straight outwards on their lap. Rest the infant’s back against their chest. Encircle (hug) the infant’s upper body and arms with one arm and use the other arm or their knees to hold the infant’s lower legs (lower legs and feet one behind the other between the caregiver’s knees). Vaccinator should stand on the side of the first injection and at the level where it can be given at a 90 degree angle.
Infant’s arms and legs held securely by caregiver. Multiple injections possible without change in position.
Security of leg restraint dependent on caregiver – if too tight, muscles tense, if too loose leg may jerk out of restraint. No eye contact with caregiver.
Straddle position: Child >12 months of age vaccinated sitting upright on caregiver’s lap, facing towards them with legs straddling over theirs
Sit on a chair holding the child facing them and sitting astride their knees. Encircle (hug) the child’s upper body and arms with their arms. If necessary, use one arm to secure the child’s leg. Vaccinator should stand on the side of the injection.
Child’s arms tucked securely under caregiver’s arms. Child comforted by close contact with caregiver. Multiple injections possible without change in position.
Thigh muscles may be tense. Vaccinator responsible for restraint of legs (unless caregiver helps).
Independent position: Adolescent/adult vaccinated sitting on chair
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Position: Use the cuddle position on the caregiver’s lap with the head supported and tilted slightly back. Vaccinator stands to one side (see Table 5.3).
Administration: Open the infant’s mouth by gently squeezing the cheeks between your thumb and index finger using gentle pressure. Firm squeezing can cause distress.
For rotavirus vaccine in tubes, angle the tube towards the inner cheek. Administer the entire contents by squeezing the tube several times.
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"text": "\n\n\n4.7 Good injection technique\ndo not draw up air to inject into the vaccine vial when filling the AD syringe;\nWash skin that looks dirty with water. Swabbing clean skin is not necessary.\n\n Do not use alcohol to clean the skin before giving vaccinations. Hold the syringe barrel between the thumb, index and middle fingers. Do not touch the needle. For intradermal (ID) injections, gently stretch and support the skin with the thumb and forefinger. Lay the syringe and needle almost flat along the infant’s skin. Gently insert the needle into the top layer of the skin (see Figure 5.6). For subcutaneous injections (SC), gently squeeze the skin. Insert the entire needle at a 45 degree angle (towards the shoulder) with a quick, smooth action (see Figure 5.6).\nManaging an immunization session\nFor intramuscular injections (IM), gently stretch and support the skin between thumb and forefinger. Push the entire needle in at a 90 degree angle with a quick, smooth action (see Figure 5.6). For all injections, depress the plunger slowly and smoothly, taking care not to move the syringe around. For all injections, pull the needle out quickly and smoothly at the same angle that it went in. For all injections, the caregiver may hold a clean swab gently over the site if it bleeds after injection. For all injections, dispose of the needle and syringe immediately in the safety box. For all injections, soothe and distract the child when all the vaccines have been given.\nModule 5: Managing an immunization session",
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Wash skin that looks dirty with water. Swabbing clean skin is not necessary.\n\n Do not use alcohol to clean the skin before giving vaccinations.\n
Hold the syringe barrel between the thumb, index and middle fingers. Do not touch the needle.
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For intramuscular injections (IM), gently stretch and support the skin between thumb and forefinger. Push the entire needle in at a 90 degree angle with a quick, smooth action (see Figure 5.6).
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"text": "\n\n\n4.8 Intradermal (ID) injection\nBCG is the only vaccine that is injected intradermally (into the layers of the skin) for slow absorption. It is usually given in the left upper arm. To measure and inject the very small dose (0.05 ml) accurately, a special syringe and needle are used (see Figure 5.7).\nPosition: Cuddle position on caregiver’s lap (BCG recommended for infants only). Administration: Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the bevel (hole) of the needle facing upwards. Lay the syringe and needle almost flat along the infant’s skin. Insert the tip of the needle under the surface of the skin just past the bevel. Keep the needle close to the skin at the same angle as you inserted it. Place your other thumb on the lower end of the syringe near the needle to hold the needle in position, but do not touch the needle. Hold the plunger end of the syringe between the index and middle fingers. Press the plunger in slowly with the thumb. If you feel no resistance to the plunger, you are not in the right place and should reposition (see below). A pale flat-topped swelling with small pits like an orange peel should appear on the skin. Remove the needle smoothly at the same angle as it went in. The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or massage the area. Soothe the infant. Disposal: Discard the needle and syringe straight into the safety box.\nManaging an immunization session\nWhen an intradermal injection is given correctly, the syringe plunger is hard to push. If the plunger goes in too easily, the injection may be too deep. Stop injecting immediately, correct the position of the needle, and give the remainder of the dose, but no more. If the whole dose has already gone in, count the infant as having received a dose of vaccine, even though it was given subcutaneously rather than intradermally. Do not repeat the dose.\nThe risk of side effects, such as abscesses or enlarged glands, is greater if the vaccine is given incorrectly, so the technique is very important. It is better to ask for help from a supervisor or other colleague than to continue giving BCG incorrectly.",
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BCG is the only vaccine that is injected intradermally (into the layers of the skin) for slow absorption. It is usually given in the left upper arm. To measure and inject the very small dose (0.05 ml) accurately, a special syringe and needle are used (see Figure 5.7).
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Position: Cuddle position on caregiver’s lap (BCG recommended for infants only).
Administration:
Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the bevel (hole) of the needle facing upwards.
Lay the syringe and needle almost flat along the infant’s skin.
Insert the tip of the needle under the surface of the skin just past the bevel.
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Hold the plunger end of the syringe between the index and middle fingers. Press the plunger in slowly with the thumb. If you feel no resistance to the plunger, you are not in the right place and should reposition (see below).
A pale flat-topped swelling with small pits like an orange peel should appear on the skin.
Remove the needle smoothly at the same angle as it went in.
The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or massage the area.
Soothe the infant.
Disposal: Discard the needle and syringe straight into the safety box.
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"text": "\n\n\n4.9 Subcutaneous (SC) injection in the upper arm\nThe injection is given into the layer below the skin on the upper arm. The exact injection site (right arm or left arm) used for particular vaccines may be specified in your country. Be sure to check and always use the side specified (see Figure 5.8).\nPosition: The position depends on the age of the child, the number of vaccinations to be given and what is easiest and most convenient for the vaccinator. Administration: Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the bevel (hole) of the needle facing upwards. Quickly push the needle into pinched-up skin; the needle should point towards the shoulder at a 45 degree angle. Depress the plunger smoothly, taking care not to move the needle under the skin. Pull the needle out quickly and smoothly at the same angle as it went in. The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or massage the area. Soothe and distract the infant. Disposal: Discard the syringe and needle straight into the safety box.\nModule 5: Managing an immunization session",
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Position:
The position depends on the age of the child, the number of vaccinations to be given and what is easiest and most convenient for the vaccinator.
Administration:
Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the bevel (hole) of the needle facing upwards.
Quickly push the needle into pinched-up skin; the needle should point towards the shoulder at a 45 degree angle.
Depress the plunger smoothly, taking care not to move the needle under the skin.
Pull the needle out quickly and smoothly at the same angle as it went in.
The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or massage the area.
Soothe and distract the infant.
Disposal:
Discard the syringe and needle straight into the safety box.
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"text": "\n\n\n4.10 Intramuscular (IM) injection in infants\nThe muscle on the upper outer part of the thigh is large and safe for intramuscular injections. See Figures 5.9 and 5.10. In children aged less than 15 months the deltoid muscle of the upper arm is not safe to use since it is not developed enough to absorb the vaccine and the radial nerve is close to the surface. The deltoid muscle may be used in older children, adolescents and adults (see Section 4.11).\nPosition: The position depends on the age of the child, the number of vaccinations to be given and what is easiest and most convenient for the vaccinator.\nAdministration: Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the bevel (hole) of the needle facing upwards. Gently stretch and support the skin on the upper, outer thigh with the other hand and quickly push the needle at a 90 degree angle down through the skin into the muscle. Depress the plunger smoothly, taking care not to move the needle under the skin. Pull the needle out quickly and smoothly at the same angle as it went in. The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or massage the area. Soothe and distract the infant.",
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In children aged less than 15 months the deltoid muscle of the upper arm is not safe to use since it is not developed enough to absorb the vaccine and the radial nerve is close to the surface. The deltoid muscle may be used in older children, adolescents and adults (see Section 4.11).
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Position: Most will be comfortable sitting on a chair (see Table 5.3). Those who are known to be prone to fainting may feel better lying down.
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"text": "\n DESCRIPTION:\n Ce diagramme représente une liste de contrôle pour les sessions de vaccination, divisée en trois phases: avant, pendant et après la session.\n :TABLE DATA:\n graph TD;\n A[Before the immunization session] --> B[For selected clients attending the immunization session];\n B --> C[After the immunization session];\n A --> D[CHECK if sufficient quantities of vaccines and diluents are available for the session?];\n D --> E[Y];\n D --> F[N];\n A --> G[CHECK if all equipment is in place and functioning correctly?];\n G --> H[Y];\n G --> I[N];\n A --> J[CHECK if all supplies are available for the session?];\n J --> K[Y];\n J --> L[N];\n A --> M[CHECK if all staff are present and ready?];\n M --> N[Y];\n M --> O[N];\n A --> P[CHECK if the session site is prepared and ready?];\n P --> Q[Y];\n P --> R[N];\n A --> S[CHECK if the session schedule is available and correct?];\n S --> T[Y];\n S --> U[N];\n A --> V[CHECK if the session plan is available and correct?];\n V --> W[Y];\n V --> X[N];\n A --> Y[CHECK if the session register is available and correct?];\n Y --> Z[Y];\n Y --> AA[N];\n A --> AB[CHECK if the session tally sheets are available and correct?];\n AB --> AC[Y];\n AB --> AD[N];\n A --> AE[CHECK if the session AEFI kit is available and correct?];\n AE --> AF[Y];\n AE --> AG[N];\n A --> AH[CHECK if the session communication materials are available and correct?];\n AH --> AI[Y];\n AH --> AJ[N];\n A --> AK[CHECK if the session waste management materials are available and correct?];\n AK --> AL[Y];\n AK --> AM[N];\n A --> AN[CHECK if the session cold chain materials are available and correct?];\n AN --> AO[Y];\n AN --> AP[N];\n A --> AQ[CHECK if the session transport materials are available and correct?];\n AQ --> AR[Y];\n AQ --> AS[N];\n A --> AT[CHECK if the session security materials are available and correct?];\n AT --> AU[Y];\n AT --> AV[N];\n A --> AW[CHECK if the session communication plan is available and correct?];\n AW --> AX[Y];\n AW --> AY[N];\n A --> AZ[CHECK if the session waste management plan is available and correct?];\n AZ --> BA[Y];\n AZ --> BB[N];\n A --> BC[CHECK if the session cold chain plan is available and correct?];\n BC --> BD[Y];\n BC --> BE[N];\n A --> BF[CHECK if the session transport plan is available and correct?];\n BF --> BG[Y];\n BF --> BH[N];\n A --> BI[CHECK if the session security plan is available and correct?];\n BI --> BJ[Y];\n BI --> BK[N];\n A --> BL[CHECK if the session communication materials are available and correct?];\n BL --> BM[Y];\n BL --> BN[N];\n A --> BO[CHECK if the session waste management materials are available and correct?];\n BO --> BP[Y];\n BO --> BQ[N];\n A --> BR[CHECK if the session cold chain materials are available and correct?];\n BR --> BS[Y];\n BR --> BT[N];\n A --> BU[CHECK if the session transport materials are available and correct?];\n BU --> BV[Y];\n BU --> BW[N];\n A --> BX[CHECK if the session security materials are available and correct?];\n BX --> BY[Y];\n BX --> BZ[N];\n A --> CA[CHECK if the session communication plan is available and correct?];\n CA --> CB[Y];\n CA --> CC[N];\n A --> CD[CHECK if the session waste management plan is available and correct?];\n CD --> CE[Y];\n CD --> CF[N];\n A --> CG[CHECK if the session cold chain plan is available and correct?];\n CG --> CH[Y];\n CG --> CI[N];\n A --> CJ[CHECK if the session transport plan is available and correct?];\n CJ --> CK[Y];\n CJ --> CL[N];\n A --> CM[CHECK if the session security plan is available and correct?];\n CM --> CN[Y];\n CM --> CO[N];\n A --> CP[CHECK if the session communication materials are available and correct?];\n CP --> CQ[Y];\n CP --> CR[N];\n A --> CS[CHECK if the session waste management materials are available and correct?];\n CS --> CT[Y];\n CS --> CU[N];\n A --> CV[CHECK if the session cold chain materials are available and correct?];\n CV --> CW[Y];\n CV --> CX[N];\n A --> CY[CHECK if the session transport materials are available and correct?];\n CY --> CZ[Y];\n CY --> DA[N];\n A --> DB[CHECK if the session security materials are available and correct?];\n DB --> DC[Y];\n DB --> DD[N];\n A --> DE[CHECK if the session communication plan is available and correct?];\n DE --> DF[Y];\n DE --> DG[N];\n A --> DH[CHECK if the session waste management plan is available and correct?];\n DH --> DI[Y];\n DH --> DJ[N];\n A --> DK[CHECK if the session cold chain plan is available and correct?];\n DK --> DL[Y];\n DK --> DM[N];\n A --> DN[CHECK if the session transport plan is available and correct?];\n DN --> DO[Y];\n DN --> DP[N];\n A --> DQ[CHECK if the session security plan is available and correct?];\n DQ --> DR[Y];\n DQ --> DS[N];\n A --> DT[CHECK if the session communication materials are available and correct?];\n DT --> DU[Y];\n DT --> DV[N];\n A --> DW[CHECK if the session waste management materials are available and correct?];\n DW --> DX[Y];\n DW --> DY[N];\n A --> DZ[CHECK if the session cold chain materials are available and correct?];\n DZ --> EA[Y];\n DZ --> EB[N];\n A --> EC[CHECK if the session transport materials are available and correct?];\n EC --> ED[Y];\n EC --> EE[N];\n A --> EF[CHECK if the session security materials are available and correct?];\n EF --> EG[Y];\n EF --> EH[N];\n A --> EI[CHECK if the session communication plan is available and correct?];\n EI --> EJ[Y];\n EI --> EK[N];\n A --> EL[CHECK if the session waste management plan is available and correct?];\n EL --> EM[Y];\n EL --> EN[N];\n A --> EO[CHECK if the session cold chain plan is available and correct?];\n EO --> EP[Y];\n EO --> EQ[N];\n A --> ER[CHECK if the session transport plan is available and correct?];\n ER --> ES[Y];\n ER --> ET[N];\n A --> EU[CHECK if the session security plan is available and correct?];\n EU --> EV[Y];\n EU --> EW[N];\n A --> EX[CHECK if the session communication materials are available and correct?];\n EX --> EY[Y];\n EX --> EZ[N];\n A --> FA[CHECK if the session waste management materials are available and correct?];\n FA --> FB[Y];\n FA --> FC[N];\n A --> FD[CHECK if the session cold chain materials are available and correct?];\n FD --> FE[Y];\n FD --> FF[N];\n A --> FG[CHECK if the session transport materials are available and correct?];\n FG --> FH[Y];\n FG --> FI[N];\n A --> FJ[CHECK if the session security materials are available and correct?];\n FJ --> FK[Y];\n FJ --> FL[N];\n A --> FM[CHECK if the session communication plan is available and correct?];\n FM --> FN[Y];\n FM --> FO[N];\n A --> FP[CHECK if the session waste management plan is available and correct?];\n FP --> FQ[Y];\n FP --> FR[N];\n A --> FS[CHECK if the session cold chain plan is available and correct?];\n FS --> FT[Y];\n FS --> FU[N];\n A --> FV[CHECK if the session transport plan is available and correct?];\n FV --> FW[Y];\n FV --> FX[N];\n A --> FY[CHECK if the session security plan is available and correct?];\n FY --> FZ[Y];\n FY --> GA[N];\n A --> GB[CHECK if the session communication materials are available and correct?];\n GB --> GC[Y];\n GB --> GD[N];\n A --> GE[CHECK if the session waste management materials are available and correct?];\n GE --> GF[Y];\n GE --> GG[N];\n A --> GH[CHECK if the session cold chain materials are available and correct?];\n GH --> GI[Y];\n GH --> GJ[N];\n A --> GK[CHECK if the session transport materials are available and correct?];\n GK --> GL[Y];\n GK --> GM[N];\n A --> GN[CHECK if the session security materials are available and correct?];\n GN --> GO[Y];\n GN --> GP[N];\n A --> GQ[CHECK if the session communication plan is available and correct?];\n GQ --> GR[Y];\n GQ --> GS[N];\n A --> GT[CHECK if the session waste management plan is available and correct?];\n GT --> GU[Y];\n GT --> GV[N];\n A --> GW[CHECK if the session cold chain plan is available and correct?];\n GW --> GX[Y];\n GW --> GY[N];\n A --> GZ[CHECK if the session transport plan is available and correct?];\n GZ --> HA[Y];\n GZ --> HB[N];\n A --> HC[CHECK if the session security plan is available and correct?];\n HC --> HD[Y];\n HC --> HE[N];\n A --> HF[CHECK if the session communication materials are available and correct?];\n HF --> HG[Y];\n HF --> HH[N];\n A --> HI[CHECK if the session waste management materials are available and correct?];\n HI --> HJ[Y];\n HI --> HK[N];\n A --> HL[CHECK if the session cold chain materials are available and correct?];\n HL --> HM[Y];\n HL --> HN[N];\n A --> HO[CHECK if the session transport materials are available and correct?];\n HO --> HP[Y];\n HO --> HQ[N];\n A --> HR[CHECK if the session security materials are available and correct?];\n HR --> HS[Y];\n HR --> HT[N];\n A --> HU[CHECK if the session communication plan is available and correct?];\n HU --> HV[Y];\n HU --> HW[N];\n A --> HX[CHECK if the session waste management plan is available and correct?];\n HX --> HY[Y];\n HX --> HZ[N];\n A --> IA[CHECK if the session cold chain plan is available and correct?];\n IA --> IB[Y];\n IA --> IC[N];\n A --> ID[CHECK if the session transport plan is available and correct?];\n ID --> IE[Y];\n ID --> IF[N];\n A --> IG[CHECK if the session security plan is available and correct?];\n IG --> IH[Y];\n IG --> II[N];\n A --> IJ[CHECK if the session communication materials are available and correct?];\n IJ --> IK[Y];\n IJ --> IL[N];\n A --> IM[CHECK if the session waste management materials are available and correct?];\n IM --> IN[Y];\n IM --> IO[N];\n A --> IP[CHECK if the session cold chain materials are available and correct?];\n IP --> IQ[Y];\n IP --> IR[N];\n A --> IS[CHECK if the session transport materials are available and correct?];\n IS --> IT[Y];\n IS --> IU[N];\n A --> IV[CHECK if the session security materials are available and correct?];\n IV --> IW[Y];\n IV --> IX[N];\n A --> IY[CHECK if the session communication plan is available and correct?];\n IY --> IZ[Y];\n IY --> JA[N];\n A --> JB[CHECK if the session waste management plan is available and correct?];\n JB --> JC[Y];\n JB --> JD[N];\n A --> JE[CHECK if the session cold chain plan is available and correct?];\n JE --> JF[Y];\n JE --> JG[N];\n A --> JH[CHECK if the session transport plan is available and correct?];\n JH --> JI[Y];\n JH --> JJ[N];\n A --> JK[CHECK if the session security plan is available and correct?];\n JK --> JL[Y];\n JK --> JM[N];\n A --> JN[CHECK if the session communication materials are available and correct?];\n JN --> JO[Y];\n JN --> JP[N];\n A --> JQ[CHECK if the session waste management materials are available and correct?];\n JQ --> JR[Y];\n JQ --> JS[N];\n A --> JT[CHECK if the session cold chain materials are available and correct?];\n JT --> JU[Y];\n JT --> JV[N];\n A --> JW[CHECK if the session transport materials are available and correct?];\n JW --> JX[Y];\n JW --> JY[N];\n A --> JZ[CHECK if the session security materials are available and correct?];\n JZ --> KA[Y];\n JZ --> KB[N];\n A --> KC[CHECK if the session communication plan is available and correct?];\n KC --> KD[Y];\n KC --> KE[N];\n A --> KF[CHECK if the session waste management plan is available and correct?];\n KF --> KG[Y];\n KF --> KH[N];\n A --> KI[CHECK if the session cold chain plan is available and correct?];\n KI --> KJ[Y];\n KI --> KK[N];\n A --> KL[CHECK if the session transport plan is available and correct?];\n KL --> KM[Y];\n KL --> KN[N];\n A --> KO[CHECK if the session security plan is available and correct?];\n KO --> KP[Y];\n KO --> KQ[N];\n A --> KR[CHECK if the session communication materials are available and correct?];\n KR --> KS[Y];\n KR --> KT[N];\n A --> KU[CHECK if the session waste management materials are available and correct?];\n KU --> KV[Y];\n KU --> KW[N];\n A --> KX[CHECK if the session cold chain materials are available and correct?];\n KX --> KY[Y];\n KX --> KZ[N];\n A --> LA[CHECK if the session transport materials are available and correct?];\n LA --> LB[Y];\n LA --> LC[N];\n A --> LD[CHECK if the session security materials are available and correct?];\n LD --> LE[Y];\n LD --> LF[N];\n A --> LG[CHECK if the session communication plan is available and correct?];\n LG --> LH[Y];\n LG --> LI[N];\n A --> LJ[CHECK if the session waste management plan is available and correct?];\n LJ --> LK[Y];\n LJ --> LL[N];\n A --> LM[CHECK if the session cold chain plan is available and correct?];\n LM --> LN[Y];\n LM --> LO[N];\n A --> LP[CHECK if the session transport plan is available and correct?];\n LP --> LQ[Y];\n LP --> LR[N];\n A --> LS[CHECK if the session security plan is available and correct?];\n LS --> LT[Y];\n LS --> LU[N];\n A --> LV[CHECK if the session communication materials are available and correct?];\n LV --> LW[Y];\n LV --> LX[N];\n A --> LY[CHECK if the session waste management materials are available and correct?];\n LY --> LZ[Y];\n LY --> MA[N];\n A --> MB[CHECK if the session cold chain materials are available and correct?];\n MB --> MC[Y];\n MB --> MD[N];\n A --> ME[CHECK if the session transport materials are available and correct?];\n ME --> MF[Y];\n ME --> MG[N];\n A --> MH[CHECK if the session security materials are available and correct?];\n MH --> MI[Y];\n MH --> MJ[N];\n A --> MK[CHECK if the session communication plan is available and correct?];\n MK --> ML[Y];\n MK --> MM[N];\n A --> MN[CHECK if the session waste management plan is available and correct?];\n MN --> MO[Y];\n MN --> MP[N];\n A --> MQ[CHECK if the session cold chain plan is available and correct?];\n MQ --> MR[Y];\n MQ --> MS[N];\n A --> MT[CHECK if the session transport plan is available and correct?];\n MT --> MU[Y];\n MT --> MV[N];\n A --> MW[CHECK if the session security plan is available and correct?];\n MW --> MX[Y];\n MW --> MY[N];\n A --> MZ[CHECK if the session communication materials are available and correct?];\n MZ --> NA[Y];\n MZ --> NB[N];\n A --> NC[CHECK if the session waste management materials are available and correct?];\n NC --> ND[Y];\n NC --> NE[N];\n A --> NF[CHECK if the session cold chain materials are available and correct?];\n NF --> NG[Y];\n NF --> NH[N];\n A --> NI[CHECK if the session transport materials are available and correct?];\n NI --> NJ[Y];\n NI --> NK[N];\n A --> NL[CHECK if the session security materials are available and correct?];\n NL --> NM[Y];\n NL --> NN[N];\n A --> NO[CHECK if the session communication plan is available and correct?];\n NO --> NP[Y];\n NO --> NQ[N];\n A --> NR[CHECK if the session waste management plan is available and correct?];\n NR --> NS[Y];\n NR --> NT[N];\n A --> NU[CHECK if the session cold chain plan is available and correct?];\n NU --> NV[Y];\n NU --> NW[N];\n A --> NX[CHECK if the session transport plan is available and correct?];\n NX --> NY[Y];\n NX --> NZ[N];\n A --> OA[CHECK if the session security plan is available and correct?];\n OA --> OB[Y];\n OA --> OC[N];\n A --> OD[CHECK if the session communication materials are available and correct?];\n OD --> OE[Y];\n OD --> OF[N];\n A --> OG[CHECK if the session waste management materials are available and correct?];\n OG --> OH[Y];\n OG --> OI[N];\n A --> OJ[CHECK if the session cold chain materials are available and correct?];\n OJ --> OK[Y];\n OJ --> OL[N];\n A --> OM[CHECK if the session transport materials are available and correct?];\n OM --> ON[Y];\n OM --> OO[N];\n A --> OP[CHECK if the session security materials are available and correct?];\n OP --> OQ[Y];\n OP --> OR[N];\n A --> OS[CHECK if the session communication plan is available and correct?];\n OS --> OT[Y];\n OS --> OU[N];\n A --> OV[CHECK if the session waste management plan is available and correct?];\n OV --> OW[Y];\n OV --> OX[N];\n A --> OY[CHECK if the session cold chain plan is available and correct?];\n OY --> OZ[Y];\n OY --> PA[N];\n A --> PB[CHECK if the session transport plan is available and correct?];\n PB --> PC[Y];\n PB --> PD[N];\n A --> PE[CHECK if the session security plan is available and correct?];\n PE --> PF[Y];\n PE --> PG[N];\n A --> PH[CHECK if the session communication materials are available and correct?];\n PH --> PI[Y];\n PH --> PJ[N];\n A --> PK[CHECK if the session waste management materials are available and correct?];\n PK --> PL[Y];\n PK --> PM[N];\n A --> PN[CHECK if the session cold chain materials are available and correct?];\n PN --> PO[Y];\n PN --> PP[N];\n A --> PQ[CHECK if the session transport materials are available and correct?];\n PQ --> PR[Y];\n PQ --> PS[N];\n A --> PT[CHECK if the session security materials are available and correct?];\n PT --> PU[Y];\n PT --> PV[N];\n A --> PW[CHECK if the session communication plan is available and correct?];\n PW --> PX[Y];\n PW --> PY[N];\n A --> PZ[CHECK if the session waste management plan is available and correct?];\n PZ --> QA[Y];\n PZ --> QB[N];\n A --> QC[CHECK if the session cold chain plan is available and correct?];\n QC --> QD[Y];\n QC --> QE[N];\n A --> QF[CHECK if the session transport plan is available and correct?];\n QF --> QG[Y];\n QF --> QH[N];\n A --> QI[CHECK if the session security plan is available and correct?];\n QI --> QJ[Y];\n QI --> QK[N];\n A --> QL[CHECK if the session communication materials are available and correct?];\n QL --> QM[Y];\n QL --> QN[N];\n A --> QO[CHECK if the session waste management materials are available and correct?];\n QO --> QP[Y];\n QO --> QQ[N];\n A --> QR[CHECK if the session cold chain materials are available and correct?];\n QR --> QS[Y];\n QR --> QT[N];\n A --> QU[CHECK if the session transport materials are available and correct?];\n QU --> QV[Y];\n QU --> QW[N];\n A --> QX[CHECK if the session security materials are available and correct?];\n QX --> QY[Y];\n QX --> QZ[N];\n A --> RA[CHECK if the session communication plan is available and correct?];\n RA --> RB[Y];\n RA --> RC[N];\n A --> RD[CHECK if the session waste management plan is available and correct?];\n RD --> RE[Y];\n RD --> RF[N];\n A --> RG[CHECK if the session cold chain plan is available and correct?];\n RG --> RH[Y];\n RG --> RI[N];\n A --> RJ[CHECK if the session transport plan is available and correct?];\n RJ --> RK[Y];\n RJ --> RL[N];\n A --> RM[CHECK if the session security plan is available and correct?];\n RM --> RN[Y];\n RM --> RO[N];\n A --> RP[CHECK if the session communication materials are available and correct?];\n RP --> RQ[Y];\n RP --> RR[N];\n A --> RS[CHECK if the session waste management materials are available and correct?];\n RS --> RT[Y];\n RS --> RU[N];\n A --> RV[CHECK if the session cold chain materials are available and correct?];\n RV --> RW[Y];\n RV --> RX[N];\n A --> RY[CHECK if the session transport materials are available and correct?];\n RY --> RZ[Y];\n RY --> SA[N];\n A --> SB[CHECK if the session security materials are available and correct?];\n SB --> SC[Y];\n SB --> SD[N];\n A --> SE[CHECK if the session communication plan is available and correct?];\n SE --> SF[Y];\n SE --> SG[N];\n A --> SH[CHECK if the session waste management plan is available and correct?];\n SH --> SI[Y];\n SH --> SJ[N];\n A --> SK[CHECK if the session cold chain plan is available and correct?];\n SK --> SL[Y];\n SK --> SM[N];\n A --> SN[CHECK if the session transport plan is available and correct?];\n SN --> SO[Y];\n SN --> SP[N];\n A --> SQ[CHECK if the session security plan is available and correct?];\n SQ --> SR[Y];\n SQ --> SS[N];\n A --> ST[CHECK if the session communication materials are available and correct?];\n ST --> SU[Y];\n ST --> SV[N];\n A --> SW[CHECK if the session waste management materials are available and correct?];\n SW --> SX[Y];\n SW --> SY[N];\n A --> SZ[CHECK if the session cold chain materials are available and correct?];\n SZ --> TA[Y];\n SZ --> TB[N];\n A --> TC[CHECK if the session transport materials are available and correct?];\n TC --> TD[Y];\n TC --> TE[N];\n A --> TF[CHECK if the session security materials are available and correct?];\n TF --> TG[Y];\n TF --> TH[N];\n A --> TI[CHECK if the session communication plan is available and correct?];\n TI --> TJ[Y];\n TI --> TK[N];\n A --> TL[CHECK if the session waste management plan is available and correct?];\n TL --> TM[Y];\n TL --> TN[N];\n A --> TO[CHECK if the session cold chain plan is available and correct?];\n TO --> TP[Y];\n TO --> TQ[N];\n A --> TR[CHECK if the session transport plan is available and correct?];\n TR --> TS[Y];\n TR --> TT[N];\n A --> TU[CHECK if the session security plan is available and correct?];\n TU --> TV[Y];\n TU --> TW[N];\n A --> TX[CHECK if the session communication materials are available and correct?];\n TX --> TY[Y];\n TX --> TZ[N];\n A --> UA[CHECK if the session waste management materials are available and correct?];\n UA --> UB[Y];\n UA --> UC[N];\n A --> UD[CHECK if the session cold chain materials are available and correct?];\n UD --> UE[Y];\n UD --> UF[N];\n A --> UG[CHECK if the session transport materials are available and correct?];\n UG --> UH[Y];\n UG --> UI[N];\n A --> UJ[CHECK if the session security materials are available and correct?];\n UJ --> UK[Y];\n UJ --> UL[N];\n A --> UM[CHECK if the session communication plan is available and correct?];\n UM --> UN[Y];\n UM --> UO[N];\n A --> UP[CHECK if the session waste management plan is available and correct?];\n UP --> UQ[Y];\n UP --> UR[N];\n A --> US[CHECK if the session cold chain plan is available and correct?];\n US --> UT[Y];\n US --> UU[N];\n A --> UV[CHECK if the session transport plan is available and correct?];\n UV --> UW[Y];\n UV --> UX[N];\n A --> UY[CHECK if the session security plan is available and correct?];\n UY --> UZ[Y];\n UY --> VA[N];\n A --> VB[CHECK if the session communication materials are available and correct?];\n VB --> VC[Y];\n VB --> VD[N];\n A --> VE[CHECK if the session waste management materials are available and correct?];\n VE --> VF[Y];\n VE --> VG[N];\n A --> VH[CHECK if the session cold chain materials are available and correct?];\n VH --> VI[Y];\n VH --> VJ[N];\n A --> VK[CHECK if the session transport materials are available and correct?];\n VK --> VL[Y];\n VK --> VM[N];\n A --> VN[CHECK if the session security materials are available and correct?];\n VN --> VO[Y];\n VN --> VP[N];\n A --> VQ[CHECK if the session communication plan is available and correct?];\n VQ --> VR[Y];\n VQ --> VS[N];\n A --> VT[CHECK if the session waste management plan is available and correct?];\n VT --> VU[Y];\n VT --> VV[N];\n A --> VW[CHECK if the session cold chain plan is available and correct?];\n VW --> VX[Y];\n VW --> VY[N];\n A --> VZ[CHECK if the session transport plan is available and correct?];\n VZ --> WA[Y];\n VZ --> WB[N];\n A --> WC[CHECK if the session security plan is available and correct?];\n WC --> WD[Y];\n WC --> WE[N];\n A --> WF[CHECK if the session communication materials are available and correct?];\n WF --> WG[Y];\n WF --> WH[N];\n A --> WI[CHECK if the session waste management materials are available and correct?];\n WI --> WJ[Y];\n WI --> WK[N];\n A --> WL[CHECK if the session cold chain materials are available and correct?];\n WL --> WM[Y];\n WL --> WN[N];\n A --> WO[CHECK if the session transport materials are available and correct?];\n WO --> WP[Y];\n WO --> WQ[N];\n A --> WR[CHECK if the session security materials are available and correct?];\n WR --> WS[Y];\n WR --> WT[N];\n A --> WU[CHECK if the session communication plan is available and correct?];\n WU --> WV[Y];\n WU --> WW[N];\n A --> WX[CHECK if the session waste management plan is available and correct?];\n WX --> WY[Y];\n WX --> WZ[N];\n A --> XA[CHECK if the session cold chain plan is available and correct?];\n XA --> XB[Y];\n XA --> XC[N];\n A --> XD[CHECK if the session transport plan is available and correct?];\n XD --> XE[Y];\n XD --> XF[N];\n A --> XG[CHECK if the session security plan is available and correct?];\n XG --> XH[Y];\n XG --> XI[N];\n A --> XJ[CHECK if the session communication materials are available and correct?];\n XJ --> XK[Y];\n XJ --> XL[N];\n A --> XM[CHECK if the session waste management materials are available and correct?];\n XM --> XN[Y];\n XM --> XO[N];\n A --> XP[CHECK if the session cold chain materials are available and correct?];\n XP --> XQ[Y];\n XP --> XR[N];\n A --> XS[CHECK if the session transport materials are available and correct?];\n XS --> XT[Y];\n XS --> XU[N];\n A --> XV[CHECK if the session security materials are available and correct?];\n XV --> XW[Y];\n XV --> XX[N];\n A --> XY[CHECK if the session communication plan is available and correct?];\n XY --> XZ[Y];\n XY --> YA[N];\n A --> YB[CHECK if the session waste management plan is available and correct?];\n YB --> YC[Y];\n YB --> YD[N];\n A --> YE[CHECK if the session cold chain plan is available and correct?];\n YE --> YF[Y];\n YE --> YG[N];\n A --> YH[CHECK if the session transport plan is available and correct?];\n YH --> YI[Y];\n YH --> YJ[N];\n A --> YK[CHECK if the session security plan is available and correct?];\n YK --> YL[Y];\n YK --> YM[N];\n A --> YN[CHECK if the session communication materials are available and correct?];\n YN --> YO[Y];\n YN --> YP[N];\n A --> YQ[CHECK if the session waste management materials are available and correct?];\n YQ --> YR[Y];\n YQ --> YS[N];\n A --> YT[CHECK if the session cold chain materials are available and correct?];\n YT --> YU[Y];\n YT --> YV[N];\n A --> YW[CHECK if the session transport materials are available and correct?];\n YW --> YX[Y];\n YW --> YY[N];\n A --> YZ[CHECK if the session security materials are available and correct?];\n YZ --> ZA[Y];\n YZ --> ZB[N];\n A --> ZC[CHECK if the session communication plan is available and correct?];\n ZC --> ZD[Y];\n ZC --> ZE[N];\n A --> ZF[CHECK if the session waste management plan is available and correct?];\n ZF --> ZG[Y];\n ZF --> ZH[N];\n A --> ZI[CHECK if the session cold chain plan is available and correct?];\n ZI --> ZJ[Y];\n ZI --> ZK[N];\n A --> ZL[CHECK if the session transport plan is available and correct?];\n ZL --> ZM[Y];\n ZL --> ZN[N];\n A --> ZO[CHECK if the session security plan is available and correct?];\n ZO --> ZP[Y];\n ZO --> ZQ[N];\n A --> ZR[CHECK if the session communication materials are available and correct?];\n ZR --> ZS[Y];\n ZR --> ZT[N];\n A --> ZU[CHECK if the session waste management materials are available and correct?];\n ZU --> ZV[Y];\n ZU --> ZW[N];\n A --> ZX[CHECK if the session cold chain materials are available and correct?];\n ZX --> ZY[Y];\n ZX --> ZZ[N];\n A --> AAA[CHECK if the session transport materials are available and correct?];\n AAA --> AAB[Y];\n AAA --> AAC[N];\n A --> AAD[CHECK if the session security materials are available and correct?];\n AAD --> AAE[Y];\n AAD --> AAF[N];\n A --> AAG[CHECK if the session communication plan is available and correct?];\n AAG --> AAH[Y];\n AAG --> AAI[N];\n A --> AAJ[CHECK if the session waste management plan is available and correct?];\n AAJ --> AAK[Y];\n AAJ --> AAL[N];\n A --> AAM[CHECK if the session cold chain plan is available and correct?];\n AAM --> AAN[Y];\n AAM --> AAO[N];\n A --> AAP[CHECK if the session transport plan is available and correct?];\n AAP --> AAQ[Y];\n AAP --> AAR[N];\n A --> AAS[CHECK if the session security plan is available and correct?];\n AAS --> AAT[Y];\n AAS --> AAU[N];\n A --> AAV[CHECK if the session communication materials are available and correct?];\n AAV --> AAW[Y];\n AAV --> AAX[N];\n A --> AAY[CHECK if the session waste management materials are available and correct?];\n AAY --> AAZ[Y];\n AAY --> ABA[N];\n A --> ABB[CHECK if the session cold chain materials are available and correct?];\n ABB --> ABC[Y];\n ABB --> ABD[N];\n A --> ABE[CHECK if the session transport materials are available and correct?];\n ABE --> ABF[Y];\n ABE --> ABG[N];\n A --> ABH[CHECK if the session security materials are available and correct?];\n ABH --> ABI[Y];\n ABH --> ABJ[N];\n A --> ABK[CHECK if the session communication plan is available and correct?];\n ABK --> ABL[Y];\n ABK --> ABM[N];\n A --> ABN[CHECK if the session waste management plan is available and correct?];\n ABN --> ABO[Y];\n ABN --> ABP[N];\n A --> ABQ[CHECK if the session cold chain plan is available and correct?];\n ABQ --> ABR[Y];\n ABQ --> ABS[N];\n A --> ABT[CHECK if the session transport plan is available and correct?];\n ABT --> ABU[Y];\n ABT --> ABV[N];\n A --> ABW[CHECK if the session security plan is available and correct?];\n ABW --> ABX[Y];\n ABW --> ABY[N];\n A --> ABZ[CHECK if the session communication materials are available and correct?];\n ABZ --> ACA[Y];\n ABZ --> ACB[N];\n A --> ACC[CHECK if the session waste management materials are available and correct?];\n ACC --> ACD[Y];\n ACC --> ACE[N];\n A --> ACF[CHECK if the session cold chain materials are available and correct?];\n ACF --> ACG[Y];\n ACF --> ACH[N];\n A --> ACI[CHECK if the session transport materials are available and correct?];\n ACI --> ACJ[Y];\n ACI --> ACK[N];\n A --> ACL[CHECK if the session security materials are available and correct?];\n ACL --> ACM[Y];\n ACL --> ACN[N];\n A --> ACO[CHECK if the session communication plan is available and correct?];\n ACO --> ACP[Y];\n ACO --> ACQ[N];\n A --> ACR[CHECK if the session waste management plan is available and correct?];\n ACR --> ACS[Y];\n ACR --> ACT[N];\n A --> ACU[CHECK if the session cold chain plan is available and correct?];\n ACU --> ACV[Y];\n ACU --> ACW[N];\n A --> ACX[CHECK if the session transport plan is available and correct?];\n ACX --> ACY[Y];\n ACX --> ACZ[N];\n A --> ADA[CHECK if the session security plan is available and correct?];\n ADA --> ADB[Y];\n ADA --> ADC[N];\n A --> ADD[CHECK if the session communication materials are available and correct?];\n ADD --> ADE[Y];\n ADD --> ADF[N];\n A --> ADG[CHECK if the session waste management materials are available and correct?];\n ADG --> ADH[Y];\n ADG --> ADI[N];\n A --> ADJ[CHECK if the session cold chain materials are available and correct?];\n ADJ --> ADK[Y];\n ADJ --> ADL[N];\n A --> ADM[CHECK if the session transport materials are available and correct?];\n ADM --> ADN[Y];\n ADM --> ADO[N];\n A --> ADP[CHECK if the session security materials are available and correct?];\n ADP --> ADQ[Y];\n ADP --> ADR[N];\n A --> ADS[CHECK if the session communication plan is available and correct?];\n ADS --> ADT[Y];\n ADS --> ADU[N];\n A --> ADV[CHECK if the session waste management plan is available and correct?];\n ADV --> ADW[Y];\n ADV --> ADX[N];\n A --> ADY[CHECK if the session cold chain plan is available and correct?];\n ADY --> ADZ[Y];\n ADY --> AEA[N];\n A --> AEB[CHECK if the session transport plan is available and correct?];\n AEB --> AEC[Y];\n AEB --> AED[N];\n A --> AEE[CHECK if the session security plan is available and correct?];\n AEE --> AEF[Y];\n AEE --> AEG[N];\n A --> AEH[CHECK if the session communication materials are available and correct?];\n AEH --> AEI[Y];\n AEH --> AEJ[N];\n A --> AEK[CHECK if the session waste management materials are available and correct?];\n AEK --> AEL[Y];\n AEK --> AEM[N];\n A --> AEN[CHECK if the session cold chain materials are available and correct?];\n AEN --> AEO[Y];\n AEN --> AEP[N];\n A --> AEQ[CHECK if the session transport materials are available and correct?];\n AEQ --> AER[Y];\n AEQ --> AES[N];\n A --> AET[CHECK if the session security materials are available and correct?];\n AET --> AEU[Y];\n AET --> AEV[N];\n A --> AEW[CHECK if the session communication plan is available and correct?];\n AEW --> AEX[Y];\n AEW --> AEY[N];\n A --> AEZ[CHECK if the session waste management plan is available and correct?];\n AEZ --> AFA[Y];\n AEZ --> AFB[N];\n A --> AFC[CHECK if the session cold chain plan is available and correct?];\n AFC --> AFD[Y];\n AFC --> AFE[N];\n A --> AFF[CHECK if the session transport plan is available and correct?];\n AFF --> AFG[Y];\n AFF --> AFH[N];\n A --> AFI[CHECK if the session security plan is available and correct?];\n AFI --> AFJ[Y];\n AFI --> AFK[N];\n A --> AFL[CHECK if the session communication materials are available and correct?];\n AFL --> AFM[Y];\n AFL --> AFN[N];\n A --> AFO[CHECK if the session waste management materials are available and correct?];\n AFO --> AFP[Y];\n AFO --> AFQ[N];\n A --> AFR[CHECK if the session cold chain materials are available and correct?];\n AFR --> AFS[Y];\n AFR --> AFT[N];\n A --> AFU[CHECK if the session transport materials are available and correct?];\n AFU --> AFV[Y];\n AFU --> AFW[N];\n A --> AFX[CHECK if the session security materials are available and correct?];\n AFX --> AFY[Y];\n AFX --> AFZ[N];\n A --> AGA[CHECK if the session communication plan is available and correct?];\n AGA --> AGB[Y];\n AGA --> AGC[N];\n A --> AGD[CHECK if the session waste management plan is available and correct?];\n AGD --> AGE[Y];\n AGD --> AGF[N];\n A --> AGG[CHECK if the session cold chain plan is available and correct?];\n AGG --> AGH[Y];\n AGG --> AGI[N];\n A --> AGJ[CHECK if the session transport plan is available and correct?];\n AGJ --> AGK[Y];\n AGJ --> AGL[N];\n A --> AGM[CHECK if the session security plan is available and correct?];\n AGM --> AGN[Y];\n AGM --> AGO[N];\n A --> AGP[CHECK if the session communication materials are available and correct?];\n AGP --> AGQ[Y];\n AGP --> AGR[N];\n A --> AGS[CHECK if the session waste management materials are available and correct?];\n AGS --> AGT[Y];\n AGS --> AGU[N];\n A --> AGV[CHECK if the session cold chain materials are available and correct?];\n AGV --> AGW[Y];\n AGV --> AGX[N];\n A --> AGY[CHECK if the session transport materials are available and correct?];\n AGY --> AGZ[Y];\n AGY --> AHA[N];\n A --> AHB[CHECK if the session security materials are available and correct?];\n AHB --> AHC[Y];\n AHB --> AHD[N];\n A --> AHE[CHECK if the session communication plan is available and correct?];\n AHE --> AHF[Y];\n AHE --> AHG[N];\n A --> AHH[CHECK if the session waste management plan is available and correct?];\n AHH --> AHI[Y];\n AHH --> AHJ[N];\n A --> AHK[CHECK if the session cold chain plan is available and correct?];\n AHK --> AHL[Y];\n AHK --> AHM[N];\n A --> AHN[CHECK if the session transport plan is available and correct?];\n AHN --> AHO[Y];\n AHN --> AHP[N];\n A --> AHQ[CHECK if the session security plan is available and correct?];\n AHQ --> AHR[Y];\n AHQ --> AHS[N];\n A --> AHT[CHECK if the session communication materials are available and correct?];\n AHT --> AHU[Y];\n AHT --> AHV[N];\n A --> AHW[CHECK if the session waste management materials are available and correct?];\n AHW --> AHX[Y];\n AHW --> AHY[N];\n A --> AHZ[CHECK if the session cold chain materials are available and correct?];\n AHZ --> AIA[Y];\n AHZ --> AIB[N];\n A --> AIC[CHECK if the session transport materials are available and correct?];\n AIC --> AID[Y];\n AIC --> AIE[N];\n A --> AIF[CHECK if the session security materials are available and correct?];\n AIF --> AIG[Y];\n AIF --> AIH[N];\n A --> AII[CHECK if the session communication plan is available and correct?];\n AII --> AIJ[Y];\n AII --> AIK[N];\n A --> AIL[CHECK if the session waste management plan is available and correct?];\n AIL --> AIM[Y];\n AIL --> AIN[N];\n A --> AIO[CHECK if the session cold chain plan is available and correct?];\n AIO --> AIP[Y];\n AIO --> AIQ[N];\n A --> AIR[CHECK if the session transport plan is available and correct?];\n AIR --> AIS[Y];\n AIR --> AIT[N];\n A --> AIU[CHECK if the session security plan is available and correct?];\n AIU --> AIV[Y];\n AIU --> AIW[N];\n A --> AIX[CHECK if the session communication materials are available and correct?];\n AIX --> AIY[Y];\n AIX --> AIZ[N];\n A --> AJA[CHECK if the session waste management materials are available and correct?];\n AJA --> AJB[Y];\n AJA --> AJC[N];\n A --> AJD[CHECK if the session cold chain materials are available and correct?];\n AJD --> AJE[Y];\n AJD --> AJF[N];\n A --> AJG[CHECK if the session transport materials are available and correct?];\n AJG --> AJH[Y];\n AJG --> AJI[N];\n A --> AJJ[CHECK if the session security materials are available and correct?];\n AJJ --> AJK[Y];\n AJJ --> AJL[N];\n A --> AJM[CHECK if the session communication plan is available and correct?];\n AJM --> AJN[Y];\n AJM --> AJO[N];\n A --> AJP[CHECK if the session waste management plan is available and correct?];\n AJP --> AJQ[Y];\n AJP --> AJR[N];\n A --> AJS[CHECK if the session cold chain plan is available and correct?];\n AJS --> AJT[Y];\n AJS --> AJU[N];\n A --> AJV[CHECK if the session transport plan is available and correct?];\n AJV --> AJW[Y];\n AJV --> AJX[N];\n A --> AJY[CHECK if the session security plan is available and correct?];\n AJY --> AJZ[Y];\n AJY --> AKA[N];\n A --> AKB[CHECK if the session communication materials are available and correct?];\n AKB --> AKC[Y];\n AKB --> AKD[N];\n A --> AKE[CHECK if the session waste management materials are available and correct?];\n AKE --> AKF[Y];\n AKE --> AKG[N];\n A --> AKH[CHECK if the session cold chain materials are available and correct?];\n AKH --> AKI[Y];\n AKH --> AKJ[N];\n A --> AKK[CHECK if the session transport materials are available and correct?];\n AKK --> AKL[Y];\n AKK --> AKM[N];\n A --> AKN[CHECK if the session security materials are available and correct?];\n AKN --> AKO[Y];\n AKN --> AKP[N];\n A --> AKQ[CHECK if the session communication plan is available and correct?];\n AKQ --> AKR[Y];\n AKQ --> AKS[N];\n A --> AKT[CHECK if the session waste management plan is available and correct?];\n AKT --> AKU[Y];\n AKT --> AKV[N];\n A --> AKW[CHECK if the session cold chain plan is available and correct?];\n AKW --> AKX[Y];\n AKW --> AKY[N];\n A --> AKZ[CHECK if the session transport plan is available and correct?];\n AKZ --> ALA[Y];\n AKZ --> ALB[N];\n A --> ALC[CHECK if the session security plan is available and correct?];\n ALC --> ALD[Y];\n ALC --> ALE[N];\n A --> ALF[CHECK if the session communication materials are available and correct?];\n ALF --> ALG[Y];\n ALF --> ALH[N];\n A --> ALI[CHECK if the session waste management materials are available and correct?];\n ALI --> ALJ[Y];\n ALI --> ALK[N];\n A --> ALL[CHECK if the session cold chain materials are available and correct?];\n ALL --> ALM[Y];\n ALL --> ALN[N];\n A --> ALO[CHECK if the session transport materials are available and correct?];\n ALO --> ALP[Y];\n ALO --> ALQ[N];\n A --> ALR[CHECK if the session security materials are available and correct?];\n ALR --> ALS[Y];\n ALR --> ALT[N];\n A --> ALU[CHECK if the session communication plan is available and correct?];\n ALU --> ALV[Y];\n ALU --> ALW[N];\n A --> ALX[CHECK if the session waste management plan is available and correct?];\n ALX --> ALY[Y];\n ALX --> ALZ[N];\n A --> AMA[CHECK if the session cold chain plan is available and correct?];\n AMA --> AMB[Y];\n AMA --> AMC[N];\n A --> AMD[CHECK if the session transport plan is available and correct?];\n AMD --> AME[Y];\n AMD --> AMF[N];\n A --> AMG[CHECK if the session security plan is available and correct?];\n AMG --> AMH[Y];\n AMG --> AMI[N];\n A --> AMJ[CHECK if the session communication materials are available and correct?];\n AMJ --> AMK[Y];\n AMJ --> AML[N];\n A --> AMM[CHECK if the session waste management materials are available and correct?];\n AMM --> AMN[Y];\n AMM --> AMO[N];\n A --> AMP[CHECK if the session cold chain materials are available and correct?];\n AMP --> AMQ[Y];\n AMP --> AMR[N];\n A --> AMS[CHECK if the session transport materials are available and correct?];\n AMS --> AMT[Y];\n AMS --> AMU[N];\n A --> AMV[CHECK if the session security materials are available and correct?];\n AMV --> AMW[Y];\n AMV --> AMX[N];\n A --> AMY[CHECK if the session communication plan is available and correct?];\n AMY --> AMZ[Y];\n AMY --> ANA[N];\n A --> ANB[CHECK if the session waste management plan is available and correct?];\n ANB --> ANC[Y];\n ANB --> AND[N];\n A --> ANE[CHECK if the session cold chain plan is available and correct?];\n ANE --> ANF[Y];\n ANE --> ANG[N];\n A --> ANH[CHECK if the session transport plan is available and correct?];\n ANH --> ANI[Y];\n ANH --> ANJ[N];\n A --> ANK[CHECK if the session security plan is available and correct?];\n ANK --> ANL[Y];\n ANK --> ANM[N];\n A --> ANN[CHECK if the session communication materials are available and correct?];\n ANN --> ANO[Y];\n ANN --> ANP[N];\n A --> ANQ[CHECK if the session waste management materials are available and correct?];\n ANQ --> ANR[Y];\n ANQ --> ANS[N];\n A --> ANT[CHECK if the session cold chain materials are available and correct?];\n ANT --> ANU[Y];\n ANT --> ANV[N];\n A --> ANW[CHECK if the session transport materials are available and correct?];\n ANW --> ANX[Y];\n ANW --> ANY[N];\n A --> ANZ[CHECK if the session security materials are available and correct?];\n ANZ --> AOA[Y];\n ANZ --> AOB[N];\n A --> AOC[CHECK if the session communication plan is available and correct?];\n AOC --> AOD[Y];\n AOC --> AOE[N];\n A --> AOF[CHECK if the session waste management plan is available and correct?];\n AOF --> AOG[Y];\n AOF --> AOH[N];\n A --> AOI[CHECK if the session cold chain plan is available and correct?];\n AOI --> AOJ[Y];\n AOI --> AOK[N];\n A --> AOL[CHECK if the session transport plan is available and correct?];\n AOL --> AOM[Y];\n AOL --> AON[N];\n A --> AOO[CHECK if the session security plan is available and correct?];\n AOO --> AOP[Y];\n AOO --> AOQ[N];\n A --> AOR[CHECK if the session communication materials are available and correct?];\n AOR --> AOS[Y];\n AOR --> AOT[N];\n A --> AOU[CHECK if the session waste management materials are available and correct?];\n AOU --> AOV[Y];\n AOU --> AOW[N];\n A --> AOX[CHECK if the session cold chain materials are available and correct?];\n AOX --> AOY[Y];\n AOX --> AOZ[N];\n A --> APA[CHECK if the session transport materials are available and correct?];\n APA --> APB[Y];\n APA --> APC[N];\n A --> APD[CHECK if the session security materials are available and correct?];\n APD --> APE[Y];\n APD --> APF[N];\n A --> APG[CHECK if the session communication plan is available and correct?];\n APG --> APH[Y];\n APG --> API[N];\n A --> APJ[CHECK if the session waste management plan is available and correct?];\n APJ --> APK[Y];\n APJ --> APL[N];\n A --> APM[CHECK if the session cold chain plan is available and correct?];\n APM --> APN[Y];\n APM --> APO[N];\n A --> APP[CHECK if the session transport plan is available and correct?];\n APP --> APQ[Y];\n APP --> APR[N];\n A --> APS[CHECK if the session security plan is available and correct?];\n APS --> APT[Y];\n APS --> APU[N];\n A --> APV[CHECK if the session communication materials are available and correct?];\n APV --> APW[Y];\n APV --> APX[N];\n A --> APY[CHECK if the session waste management materials are available and correct?];\n APY --> APZ[Y];\n APY --> AQA[N];\n A --> AQB[CHECK if the session cold chain materials are available and correct?];\n AQB --> AQC[Y];\n AQB --> AQD[N];\n A --> AQE[CHECK if the session transport materials are available and correct?];\n AQE --> AQF[Y];\n AQE --> AQG[N];\n A --> AQH[CHECK if the session security materials are available and correct?];\n AQH --> AQI[Y];\n AQH --> AQJ[N];\n A --> AQK[CHECK if the session communication plan is available and correct?];\n AQK --> AQL[Y];\n AQK --> AQM[N];\n A --> AQN[CHECK if the session waste management plan is available and correct?];\n AQN --> AQO[Y];\n AQN --> AQP[N];\n A --> AQQ[CHECK if the session cold chain plan is available and correct?];\n AQQ --> AQR[Y];\n AQQ --> AQS[N];\n A --> AQT[CHECK if the session transport plan is available and correct?];\n AQT --> AQU[Y];\n AQT --> AQV[N];\n A --> AQW[CHECK if the session security plan is available and correct?];\n AQW --> AQX[Y];\n AQW --> AQY[N];\n A --> AQZ[CHECK if the session communication materials are available and correct?];\n AQZ --> ARA[Y];\n AQZ --> ARB[N];\n A --> ARC[CHECK if the session waste management materials are available and correct?];\n ARC --> ARD[Y];\n ARC --> ARE[N];\n A --> ARF[CHECK if the session cold chain materials are available and correct?];\n ARF --> ARG[Y];\n ARF --> ARH[N];\n A --> ARI[CHECK if the session transport materials are available and correct?];\n ARI --> ARJ[Y];\n ARI --> ARK[N];\n A --> ARL[CHECK if the session security materials are available and correct?];\n ARL --> ARM[Y];\n ARL --> ARN[N];\n A --> ARO[CHECK if the session communication plan is available and correct?];\n ARO --> ARP[Y];\n ARO --> ARQ[N];\n A --> ARR[CHECK if the session waste management plan is available and correct?];\n ARR --> ARS[Y];\n ARR --> ART[N];\n A --> ARU[CHECK if the session cold chain plan is available and correct?];\n ARU --> ARV[Y];\n ARU --> ARW[N];\n A --> ARX[CHECK if the session transport plan is available and correct?];\n ARX --> ARY[Y];\n ARX --> ARZ[N];\n A --> ASA[CHECK if the session security plan is available and correct?];\n ASA --> ASB[Y];\n ASA --> ASC[N];\n A --> ASD[CHECK if the session communication materials are available and correct?];\n ASD --> ASE[Y];\n ASD --> ASF[N];\n A --> ASG[CHECK if the session waste management materials are available and correct?];\n ASG --> ASH[Y];\n ASG --> ASI[N];\n A --> ASJ[CHECK if the session cold chain materials are available and correct?];\n ASJ --> ASK[Y];\n ASJ --> ASL[N];\n A --> ASM[CHECK if the session transport materials are available and correct?];\n ASM --> ASN[Y];\n ASM --> ASO[N];\n A --> ASP[CHECK if the session security materials are available and correct?];\n ASP --> ASQ[Y];\n ASP --> ASR[N];\n A --> ASS[CHECK if the session communication plan is available and correct?];\n ASS --> AST[Y];\n ASS --> ASU[N];\n A --> ASV[CHECK if the session waste management plan is available and correct?];\n ASV --> ASW[Y];\n ASV --> ASX[N];\n A --> ASY[CHECK if the session cold chain plan is available and correct?];\n ASY --> ASZ[Y];\n ASY --> ATA[N];\n A --> ATB[CHECK if the session transport plan is available and correct?];\n ATB --> ATC[Y];\n ATB --> ATD[N];\n A --> ATE[CHECK if the session security plan is available and correct?];\n ATE --> ATF[Y];\n ATE --> ATG[N];\n A --> ATH[CHECK if the session communication materials are available and correct?];\n ATH --> ATI[Y];\n ATH --> ATJ[N];\n A --> ATK[CHECK if the session waste management materials are available and correct?];\n ATK --> ATL[Y];\n ATK --> ATM[N];\n A --> ATN[CHECK if the session cold chain materials are available and correct?];\n ATN --> ATO[Y];\n ATN --> ATP[N];\n A --> ATQ[CHECK if the session transport materials are available and correct?];\n ATQ --> ATR[Y];\n ATQ --> ATS[N];\n A --> ATT[CHECK if the session security materials are available and correct?];\n ATT --> ATU[Y];\n ATT --> ATV[N];\n A --> ATW[CHECK if the session communication plan is available and correct?];\n ATW --> ATX[Y];\n ATW --> ATY[N];\n A --> ATZ[CHECK if the session waste management plan is available and correct?];\n ATZ --> AUA[Y];\n ATZ --> AUB[N];\n A --> AUC[CHECK if the session cold chain plan is available and correct?];\n AUC --> AUD[Y];\n AUC --> AUE[N];\n A --> AUF[CHECK if the session transport plan is available and correct?];\n AUF --> AUG[Y];\n AUF --> AUH[N];\n A --> AUI[CHECK if the session security materials are available and correct?];\n AUI --> AUJ[Y];\n AUI --> AUK[N];\n A --> AUL[CHECK if the session communication materials are available and correct?];\n AUL --> AUM[Y];\n AUL --> AUN[N];\n A --> AUO[CHECK if the session waste management materials are available and correct?];\n AUO --> AUP[Y];\n AUO --> AUQ[N];\n A --> AUR[CHECK if the session cold chain materials are available and correct?];\n AUR --> AUS[Y];\n AUR --> AUT[N];\n A --> AUU[CHECK if the session transport materials are available and correct?];\n AUU --> AUV[Y];\n AUU --> AUW[N];\n A --> AUX[CHECK if the session security materials are available and correct?];\n AUX --> AUY[Y];\n AUX --> AUZ[N];\n A --> AVA[CHECK if the session communication plan is available and correct?];\n AVA --> AVB[Y];\n AVA --> AVC[N];\n A --> AVD[CHECK if the session waste management plan is available and correct?];\n AVD --> AVE[Y];\n AVD --> AVF[N];\n A --> AVG[CHECK if the session cold chain plan is available and correct?];\n AVG --> AVH[Y];\n AVG --> AVI[N];\n A --> AVJ[CHECK if the session transport plan is available and correct?];\n AVJ --> AVK[Y];\n AVJ --> AVL[N];\n A --> AVM[CHECK if the session security plan is available and correct?];\n AVM --> AVN[Y];\n AVM --> AVO[N];\n A --> AVP[CHECK if the session communication materials are available and correct?];\n AVP --> AVQ[Y];\n AVP --> AVR[N];\n A --> AVS[CHECK if the session waste management materials are available and correct?];\n AVS --> AVT[Y];\n AVS --> AVU[N];\n A --> AVV[CHECK if the session cold chain materials are available and correct?];\n AVV --> AVW[Y];\n AVV --> AVX[N];\n A --> AVY[CHECK if the session transport materials are available and correct?];\n AVY --> AVZ[Y];\n AVY --> AWA[N];\n A --> AWB[CHECK if the session security materials are available and correct?];\n AWB --> AWC[Y];\n AWB --> AWD[N];\n A --> AWE[CHECK if the session communication plan is available and correct?];\n AWE --> AWF[Y];\n AWE --> AWG[N];\n A --> AWH[CHECK if the session waste management plan is available and correct?];\n AWH --> AWI[Y];\n AWH --> AWJ[N];\n A --> AWK[CHECK if the session cold chain plan is available and correct?];\n AWK --> AWL[Y];\n AWK --> AWM[N];\n A --> AWN[CHECK if the session transport plan is available and correct?];\n AWN --> AWO[Y];\n AWN --> AWP[N];\n A --> AWQ[CHECK if the session security plan is available and correct?];\n AWQ --> AWR[Y];\n AWQ --> AWS[N];\n A --> AWT[CHECK if the session communication materials are available and correct?];\n AWT --> AWU[Y];\n AWT --> AWV[N];\n A --> AWW[CHECK if the session waste management materials are available and correct?];\n AWW --> AWX[Y];\n AWW --> AWY[N];\n A --> AWZ[CHECK if the session cold chain materials are available and correct?];\n AWZ --> AXA[Y];\n AWZ --> AXB[N];\n A --> AXC[CHECK if the session transport materials are available and correct?];\n AXC --> AXD[Y];\n AXC --> AXE[N];\n A --> AXF[CHECK if the session security materials are available and correct?];\n AXF --> AXG[Y];\n AXF --> AXH[N];\n A --> AXI[CHECK if the session communication plan is available and correct?];\n AXI --> AXJ[Y];\n AXI --> AXK[N];\n A --> AXL[CHECK if the session waste management plan is available and correct?];\n AXL --> AXM[Y];\n AXL --> AXN[N];\n A --> AXO[CHECK if the session cold chain plan is available and correct?];\n AXO --> AXP[Y];\n AXO --> AXQ[N];\n A --> AXR[CHECK if the session transport plan is available and correct?];\n AXR --> AXS[Y];\n AXR --> AXT[N];\n A --> AXU[CHECK if the session security plan is available and correct?];\n AXU --> AXV[Y];\n AXU --> AXW[N];\n A --> AXX[CHECK if the session communication materials are available and correct?];\n AXX --> AXY[Y];\n AXX --> AXZ[N];\n A --> AYA[CHECK if the session waste management materials are available and correct?];\n AYA --> AYB[Y];\n AYA --> AYC[N];\n A --> AYD[CHECK if the session cold chain materials are available and correct?];\n AYD --> AYE[Y];\n AYD --> AYF[N];\n A --> AYG[CHECK if the session transport materials are available and correct?];\n AYG --> AYH[Y];\n AYG --> AYI[N];\n A --> AYJ[CHECK if the session security materials are available and correct?];\n AYJ --> AYK[Y];\n AYJ --> AYL[N];\n A --> AYM[CHECK if the session communication plan is available and correct?];\n AYM --> AYN[Y];\n AYM --> AYO[N];\n A --> AYP[CHECK if the session waste management plan is available and correct?];\n AYP --> AYQ[Y];\n AYP --> AYR[N];\n A --> AYS[CHECK if the session cold chain plan is available and correct?];\n AYS --> AYT[Y];\n AYS --> AYU[N];\n A --> AYV[CHECK if the session transport plan is available and correct?];\n AYV --> AYW[Y];\n AYV --> AYX[N];\n A --> AYY[CHECK if the session security plan is available and correct?];\n AYY --> AYZ[Y];\n AYY --> AZA[N];\n A --> AZB[CHECK if the session communication materials are available and correct?];\n AZB --> AZC[Y];\n AZB --> AZD[N];\n A --> AZE[CHECK if the session waste management materials are available and correct?];\n AZE --> AZF[Y];\n AZE --> AZG[N];\n A --> AZH[CHECK if the session cold chain materials are available and correct?];\n AZH --> AZI[Y];\n AZH --> AZJ[N];\n A --> AZK[CHECK if the session transport materials are available and correct?];\n AZK --> AZL[Y];\n AZK --> AZM[N];\n A --> AZN[CHECK if the session security materials are available and correct?];\n AZN --> AZO[Y];\n AZN --> AZP[N];\n A --> AZQ[CHECK if the session communication plan is available and correct?];\n AZQ --> AZR[Y];\n AZQ --> AZS[N];\n A --> AZT[CHECK if the session waste management plan is available and correct?];\n AZT --> AZU[Y];\n AZT --> AZV[N];\n A --> AZW[CHECK if the session cold chain plan is available and correct?];\n AZW --> AZX[Y];\n AZW --> AZY[N];\n A --> AZZ[CHECK if the session transport plan is available and correct?];\n AZZ --> BAA[Y];\n AZZ --> BAB[N];\n A --> BAC[CHECK if the session security materials are available and correct?];\n BAC --> BAD[Y];\n BAC --> BAE[N];\n A --> BAF[CHECK if the session communication materials are available and correct?];\n BAF --> BAG[Y];\n BAF --> BAH[N];\n A --> BAI[CHECK if the session waste management materials are available and correct?];\n BAI --> BAJ[Y];\n BAI --> BAK[N];\n A --> BAL[CHECK if the session cold chain materials are available and correct?];\n BAL --> BAM[Y];\n BAL --> BAN[N];\n A --> BAO[CHECK if the session transport materials are available and correct?];\n BAO --> BAP[Y];\n BAO --> BAQ[N];\n A --> BAR[CHECK if the session security materials are available and correct?];\n BAR --> BAS[Y];\n BAR --> BAT[N];\n A --> BAU[CHECK if the session communication plan is available and correct?];\n BAU --> BAV[Y];\n BAU --> BAW[N];\n A --> BAX[CHECK if the session waste management plan is available and correct?];\n BAX --> BAY[Y];\n BAX --> BAZ[N];\n A --> BBA[CHECK if the session cold chain plan is available and correct?];\n BBA --> BBB[Y];\n BBA --> BBC[N];\n A --> BBD[CHECK if the session transport plan is available and correct?];\n BBD --> BBE[Y];\n BBD --> BBF[N];\n A --> BBG[CHECK if the session security plan is available and correct?];\n BBG --> BBH[Y];\n BBG --> BBI[N];\n A --> BBJ[CHECK if the session communication materials are available and correct?];\n BBJ --> BBK[Y];\n BBJ --> BBL[N];\n A --> BBM[CHECK if the session waste management materials are available and correct?];\n BBM --> BBN[Y];\n BBM --> BBO[N];\n A --> BBP[CHECK if the session cold chain materials are available and correct?];\n BBP --> BBQ[Y];\n BBP --> BBR[N];\n A --> BBS[CHECK if the session transport materials are available and correct?];\n BBS --> BBT[Y];\n BBS --> BBU[N];\n A --> BBV[CHECK if the session security materials are available and correct?];\n BBV --> BBW[Y];\n BBV --> BBX[N];\n A --> BBY[CHECK if the session communication plan is available and correct?];\n BBY --> BBZ[Y];\n BBY --> BCA[N];\n A --> BCB[CHECK if the session waste management plan is available and correct?];\n BCB --> BCC[Y];\n BCB --> BCD[N];\n A --> BCE[CHECK if the session cold chain plan is available and correct?];\n BCE --> BCF[Y];\n BCE --> BCG[N];\n A --> BCH[CHECK if the session transport plan is available and correct?];\n BCH --> BCI[Y];\n BCH --> BCJ[N];\n A --> BCK[CHECK if the session security plan is available and correct?];\n BCK --> BCL[Y];\n BCK --> BCM[N];\n A --> BCN[CHECK if the session communication materials are available and correct?];\n BCN --> BCO[Y];\n BCN --> BCP[N];\n A --> BCQ[CHECK if the session waste management materials are available and correct?];\n BCQ --> BCR[Y];\n BCQ --> BCS[N];\n A --> BCT[CHECK if the session cold chain materials are available and correct?];\n BCT --> BCU[Y];\n BCT --> BCV[N];\n A --> BCW[CHECK if the session transport materials are available and correct?];\n BCW --> BCX[Y];\n BCW --> BCY[N];\n A --> BCZ[CHECK if the session security materials are available and correct?];\n BCZ --> BDA[Y];\n BCZ --> BDB[N];\n A --> BDC[CHECK if the session communication plan is available and correct?];\n BDC --> BDD[Y];\n BDC --> BDE[N];\n A --> BDF[CHECK if the session waste management plan is available and correct?];\n BDF --> BDG[Y];\n BDF --> BDH[N];\n A --> BDI[CHECK if the session cold chain plan is available and correct?];\n BDI --> BDJ[Y];\n BDI --> BDK[N];\n A --> BDL[CHECK if the session transport plan is available and correct?];\n BDL --> BDM[Y];\n BDL --> BDN[N];\n A --> BDO[CHECK if the session security materials are available and correct?];\n BDO --> BDP[Y];\n BDO --> BDQ[N];\n A --> BDR[CHECK if the session communication materials are available and correct?];\n BDR --> BDS[Y];\n BDR --> BDT[N];\n A --> BDU[CHECK if the session waste management materials are available and correct?];\n BDU --> BDV[Y];\n BDU --> BDW[N];\n A --> BDX[CHECK if the session cold chain materials are available and correct?];\n BDX --> BDY[Y];\n BDX --> BDZ[N];\n A --> BEA[CHECK if the session transport materials are available and correct?];\n BEA --> BEB[Y];\n BEA --> BEC[N];\n A --> BED[CHECK if the session security materials are available and correct?];\n BED --> BEE[Y];\n BED --> BEF[N];\n A --> BEG[CHECK if the session communication plan is available and correct?];\n BEG --> BEH[Y];\n BEG --> BEI[N];\n A --> BEJ[CHECK if the session waste management plan is available and correct?];\n BEJ --> BEK[Y];\n BEJ --> BEL[N];\n A --> BEM[CHECK if the session cold chain plan is available and correct?];\n BEM --> BEN[Y];\n BEM --> BEO[N];\n A --> BEP[CHECK if the session transport plan is available and correct?];\n BEP --> BEQ[Y];\n BEP --> BER[N];\n A --> BES[CHECK if the session security materials are available and correct?];\n BES --> BET[Y];\n BES --> BEU[N];\n A --> BEV[CHECK if the session communication materials are available and correct?];\n BEV --> BEW[Y];\n BEV --> BEX[N];\n A --> BEY[CHECK if the session waste management materials are available and correct?];\n BEY --> BEZ[Y];\n BEY --> BFA[N];\n A --> BFB[CHECK if the session cold chain materials are available and correct?];\n BFB --> BFC[Y];\n BFB --> BFD[N];\n A --> BFE[CHECK if the session transport materials are available and correct?];\n BFE --> BFF[Y];\n BFE --> BFG[N];\n A --> BFH[CHECK if the session security materials are available and correct?];\n BFH --> BFI[Y];\n BFH --> BFJ[N];\n A --> BFK[CHECK if the session communication plan is available and correct?];\n BFK --> BFL[Y];\n BFK --> BFM[N];\n A --> BFN[CHECK if the session waste management plan is available and correct?];\n BFN --> BFO[Y];\n BFN --> BFP[N];\n A --> BFQ[CHECK if the session cold chain plan is available and correct?];\n BFQ --> BFR[Y];\n BFQ --> BFS[N];\n A --> BFT[CHECK if the session transport plan is available and correct?];\n BFT -->\n :END TABLE DATA:\n\n ",
"filename": "Immunization in Practice_WHO_eng_2015.pdf",
"filetype": "application/pdf",
"elements": {
"type": "Table",
"element_id": "a5c84e64a0c1e7b3f688514537935dca",
"text": "graph TD;\n A[Before the immunization session] --> B[For selected clients attending the immunization session];\n B --> C[After the immunization session];\n A --> D[CHECK if sufficient quantities of vaccines and diluents are available for the session?];\n D --> E[Y];\n D --> F[N];\n A --> G[CHECK if all equipment is in place and functioning correctly?];\n G --> H[Y];\n G --> I[N];\n A --> J[CHECK if all supplies are available for the session?];\n J --> K[Y];\n J --> L[N];\n A --> M[CHECK if all staff are present and ready?];\n M --> N[Y];\n M --> O[N];\n A --> P[CHECK if the session site is prepared and ready?];\n P --> Q[Y];\n P --> R[N];\n A --> S[CHECK if the session schedule is available and correct?];\n S --> T[Y];\n S --> U[N];\n A --> V[CHECK if the session plan is available and correct?];\n V --> W[Y];\n V --> X[N];\n A --> Y[CHECK if the session register is available and correct?];\n Y --> Z[Y];\n Y --> AA[N];\n A --> AB[CHECK if the session tally sheets are available and correct?];\n AB --> AC[Y];\n AB --> AD[N];\n A --> AE[CHECK if the session AEFI kit is available and correct?];\n AE --> AF[Y];\n AE --> AG[N];\n A --> AH[CHECK if the session communication materials are available and correct?];\n AH --> AI[Y];\n AH --> AJ[N];\n A --> AK[CHECK if the session waste management materials are available and correct?];\n AK --> AL[Y];\n AK --> AM[N];\n A --> AN[CHECK if the session cold chain materials are available and correct?];\n AN --> AO[Y];\n AN --> AP[N];\n A --> AQ[CHECK if the session transport materials are available and correct?];\n AQ --> AR[Y];\n AQ --> AS[N];\n A --> AT[CHECK if the session security materials are available and correct?];\n AT --> AU[Y];\n AT --> AV[N];\n A --> AW[CHECK if the session communication plan is available and correct?];\n AW --> AX[Y];\n AW --> AY[N];\n A --> AZ[CHECK if the session waste management plan is available and correct?];\n AZ --> BA[Y];\n AZ --> BB[N];\n A --> BC[CHECK if the session cold chain plan is available and correct?];\n BC --> BD[Y];\n BC --> BE[N];\n A --> BF[CHECK if the session transport plan is available and correct?];\n BF --> BG[Y];\n BF --> BH[N];\n A --> BI[CHECK if the session security plan is available and correct?];\n BI --> BJ[Y];\n BI --> BK[N];\n A --> BL[CHECK if the session communication materials are available and correct?];\n BL --> BM[Y];\n BL --> BN[N];\n A --> BO[CHECK if the session waste management materials are available and correct?];\n BO --> BP[Y];\n BO --> BQ[N];\n A --> BR[CHECK if the session cold chain materials are available and correct?];\n BR --> BS[Y];\n BR --> BT[N];\n A --> BU[CHECK if the session transport materials are available and correct?];\n BU --> BV[Y];\n BU --> BW[N];\n A --> BX[CHECK if the session security materials are available and correct?];\n BX --> BY[Y];\n BX --> BZ[N];\n A --> CA[CHECK if the session communication plan is available and correct?];\n CA --> CB[Y];\n CA --> CC[N];\n A --> CD[CHECK if the session waste management plan is available and correct?];\n CD --> CE[Y];\n CD --> CF[N];\n A --> CG[CHECK if the session cold chain plan is available and correct?];\n CG --> CH[Y];\n CG --> CI[N];\n A --> CJ[CHECK if the session transport plan is available and correct?];\n CJ --> CK[Y];\n CJ --> CL[N];\n A --> CM[CHECK if the session security plan is available and correct?];\n CM --> CN[Y];\n CM --> CO[N];\n A --> CP[CHECK if the session communication materials are available and correct?];\n CP --> CQ[Y];\n CP --> CR[N];\n A --> CS[CHECK if the session waste management materials are available and correct?];\n CS --> CT[Y];\n CS --> CU[N];\n A --> CV[CHECK if the session cold chain materials are available and correct?];\n CV --> CW[Y];\n CV --> CX[N];\n A --> CY[CHECK if the session transport materials are available and correct?];\n CY --> CZ[Y];\n CY --> DA[N];\n A --> DB[CHECK if the session security materials are available and correct?];\n DB --> DC[Y];\n DB --> DD[N];\n A --> DE[CHECK if the session communication plan is available and correct?];\n DE --> DF[Y];\n DE --> DG[N];\n A --> DH[CHECK if the session waste management plan is available and correct?];\n DH --> DI[Y];\n DH --> DJ[N];\n A --> DK[CHECK if the session cold chain plan is available and correct?];\n DK --> DL[Y];\n DK --> DM[N];\n A --> DN[CHECK if the session transport plan is available and correct?];\n DN --> DO[Y];\n DN --> DP[N];\n A --> DQ[CHECK if the session security plan is available and correct?];\n DQ --> DR[Y];\n DQ --> DS[N];\n A --> DT[CHECK if the session communication materials are available and correct?];\n DT --> DU[Y];\n DT --> DV[N];\n A --> DW[CHECK if the session waste management materials are available and correct?];\n DW --> DX[Y];\n DW --> DY[N];\n A --> DZ[CHECK if the session cold chain materials are available and correct?];\n DZ --> EA[Y];\n DZ --> EB[N];\n A --> EC[CHECK if the session transport materials are available and correct?];\n EC --> ED[Y];\n EC --> EE[N];\n A --> EF[CHECK if the session security materials are available and correct?];\n EF --> EG[Y];\n EF --> EH[N];\n A --> EI[CHECK if the session communication plan is available and correct?];\n EI --> EJ[Y];\n EI --> EK[N];\n A --> EL[CHECK if the session waste management plan is available and correct?];\n EL --> EM[Y];\n EL --> EN[N];\n A --> EO[CHECK if the session cold chain plan is available and correct?];\n EO --> EP[Y];\n EO --> EQ[N];\n A --> ER[CHECK if the session transport plan is available and correct?];\n ER --> ES[Y];\n ER --> ET[N];\n A --> EU[CHECK if the session security plan is available and correct?];\n EU --> EV[Y];\n EU --> EW[N];\n A --> EX[CHECK if the session communication materials are available and correct?];\n EX --> EY[Y];\n EX --> EZ[N];\n A --> FA[CHECK if the session waste management materials are available and correct?];\n FA --> FB[Y];\n FA --> FC[N];\n A --> FD[CHECK if the session cold chain materials are available and correct?];\n FD --> FE[Y];\n FD --> FF[N];\n A --> FG[CHECK if the session transport materials are available and correct?];\n FG --> FH[Y];\n FG --> FI[N];\n A --> FJ[CHECK if the session security materials are available and correct?];\n FJ --> FK[Y];\n FJ --> FL[N];\n A --> FM[CHECK if the session communication plan is available and correct?];\n FM --> FN[Y];\n FM --> FO[N];\n A --> FP[CHECK if the session waste management plan is available and correct?];\n FP --> FQ[Y];\n FP --> FR[N];\n A --> FS[CHECK if the session cold chain plan is available and correct?];\n FS --> FT[Y];\n FS --> FU[N];\n A --> FV[CHECK if the session transport plan is available and correct?];\n FV --> FW[Y];\n FV --> FX[N];\n A --> FY[CHECK if the session security plan is available and correct?];\n FY --> FZ[Y];\n FY --> GA[N];\n A --> GB[CHECK if the session communication materials are available and correct?];\n GB --> GC[Y];\n GB --> GD[N];\n A --> GE[CHECK if the session waste management materials are available and correct?];\n GE --> GF[Y];\n GE --> GG[N];\n A --> GH[CHECK if the session cold chain materials are available and correct?];\n GH --> GI[Y];\n GH --> GJ[N];\n A --> GK[CHECK if the session transport materials are available and correct?];\n GK --> GL[Y];\n GK --> GM[N];\n A --> GN[CHECK if the session security materials are available and correct?];\n GN --> GO[Y];\n GN --> GP[N];\n A --> GQ[CHECK if the session communication plan is available and correct?];\n GQ --> GR[Y];\n GQ --> GS[N];\n A --> GT[CHECK if the session waste management plan is available and correct?];\n GT --> GU[Y];\n GT --> GV[N];\n A --> GW[CHECK if the session cold chain plan is available and correct?];\n GW --> GX[Y];\n GW --> GY[N];\n A --> GZ[CHECK if the session transport plan is available and correct?];\n GZ --> HA[Y];\n GZ --> HB[N];\n A --> HC[CHECK if the session security plan is available and correct?];\n HC --> HD[Y];\n HC --> HE[N];\n A --> HF[CHECK if the session communication materials are available and correct?];\n HF --> HG[Y];\n HF --> HH[N];\n A --> HI[CHECK if the session waste management materials are available and correct?];\n HI --> HJ[Y];\n HI --> HK[N];\n A --> HL[CHECK if the session cold chain materials are available and correct?];\n HL --> HM[Y];\n HL --> HN[N];\n A --> HO[CHECK if the session transport materials are available and correct?];\n HO --> HP[Y];\n HO --> HQ[N];\n A --> HR[CHECK if the session security materials are available and correct?];\n HR --> HS[Y];\n HR --> HT[N];\n A --> HU[CHECK if the session communication plan is available and correct?];\n HU --> HV[Y];\n HU --> HW[N];\n A --> HX[CHECK if the session waste management plan is available and correct?];\n HX --> HY[Y];\n HX --> HZ[N];\n A --> IA[CHECK if the session cold chain plan is available and correct?];\n IA --> IB[Y];\n IA --> IC[N];\n A --> ID[CHECK if the session transport plan is available and correct?];\n ID --> IE[Y];\n ID --> IF[N];\n A --> IG[CHECK if the session security plan is available and correct?];\n IG --> IH[Y];\n IG --> II[N];\n A --> IJ[CHECK if the session communication materials are available and correct?];\n IJ --> IK[Y];\n IJ --> IL[N];\n A --> IM[CHECK if the session waste management materials are available and correct?];\n IM --> IN[Y];\n IM --> IO[N];\n A --> IP[CHECK if the session cold chain materials are available and correct?];\n IP --> IQ[Y];\n IP --> IR[N];\n A --> IS[CHECK if the session transport materials are available and correct?];\n IS --> IT[Y];\n IS --> IU[N];\n A --> IV[CHECK if the session security materials are available and correct?];\n IV --> IW[Y];\n IV --> IX[N];\n A --> IY[CHECK if the session communication plan is available and correct?];\n IY --> IZ[Y];\n IY --> JA[N];\n A --> JB[CHECK if the session waste management plan is available and correct?];\n JB --> JC[Y];\n JB --> JD[N];\n A --> JE[CHECK if the session cold chain plan is available and correct?];\n JE --> JF[Y];\n JE --> JG[N];\n A --> JH[CHECK if the session transport plan is available and correct?];\n JH --> JI[Y];\n JH --> JJ[N];\n A --> JK[CHECK if the session security plan is available and correct?];\n JK --> JL[Y];\n JK --> JM[N];\n A --> JN[CHECK if the session communication materials are available and correct?];\n JN --> JO[Y];\n JN --> JP[N];\n A --> JQ[CHECK if the session waste management materials are available and correct?];\n JQ --> JR[Y];\n JQ --> JS[N];\n A --> JT[CHECK if the session cold chain materials are available and correct?];\n JT --> JU[Y];\n JT --> JV[N];\n A --> JW[CHECK if the session transport materials are available and correct?];\n JW --> JX[Y];\n JW --> JY[N];\n A --> JZ[CHECK if the session security materials are available and correct?];\n JZ --> KA[Y];\n JZ --> KB[N];\n A --> KC[CHECK if the session communication plan is available and correct?];\n KC --> KD[Y];\n KC --> KE[N];\n A --> KF[CHECK if the session waste management plan is available and correct?];\n KF --> KG[Y];\n KF --> KH[N];\n A --> KI[CHECK if the session cold chain plan is available and correct?];\n KI --> KJ[Y];\n KI --> KK[N];\n A --> KL[CHECK if the session transport plan is available and correct?];\n KL --> KM[Y];\n KL --> KN[N];\n A --> KO[CHECK if the session security plan is available and correct?];\n KO --> KP[Y];\n KO --> KQ[N];\n A --> KR[CHECK if the session communication materials are available and correct?];\n KR --> KS[Y];\n KR --> KT[N];\n A --> KU[CHECK if the session waste management materials are available and correct?];\n KU --> KV[Y];\n KU --> KW[N];\n A --> KX[CHECK if the session cold chain materials are available and correct?];\n KX --> KY[Y];\n KX --> KZ[N];\n A --> LA[CHECK if the session transport materials are available and correct?];\n LA --> LB[Y];\n LA --> LC[N];\n A --> LD[CHECK if the session security materials are available and correct?];\n LD --> LE[Y];\n LD --> LF[N];\n A --> LG[CHECK if the session communication plan is available and correct?];\n LG --> LH[Y];\n LG --> LI[N];\n A --> LJ[CHECK if the session waste management plan is available and correct?];\n LJ --> LK[Y];\n LJ --> LL[N];\n A --> LM[CHECK if the session cold chain plan is available and correct?];\n LM --> LN[Y];\n LM --> LO[N];\n A --> LP[CHECK if the session transport plan is available and correct?];\n LP --> LQ[Y];\n LP --> LR[N];\n A --> LS[CHECK if the session security plan is available and correct?];\n LS --> LT[Y];\n LS --> LU[N];\n A --> LV[CHECK if the session communication materials are available and correct?];\n LV --> LW[Y];\n LV --> LX[N];\n A --> LY[CHECK if the session waste management materials are available and correct?];\n LY --> LZ[Y];\n LY --> MA[N];\n A --> MB[CHECK if the session cold chain materials are available and correct?];\n MB --> MC[Y];\n MB --> MD[N];\n A --> ME[CHECK if the session transport materials are available and correct?];\n ME --> MF[Y];\n ME --> MG[N];\n A --> MH[CHECK if the session security materials are available and correct?];\n MH --> MI[Y];\n MH --> MJ[N];\n A --> MK[CHECK if the session communication plan is available and correct?];\n MK --> ML[Y];\n MK --> MM[N];\n A --> MN[CHECK if the session waste management plan is available and correct?];\n MN --> MO[Y];\n MN --> MP[N];\n A --> MQ[CHECK if the session cold chain plan is available and correct?];\n MQ --> MR[Y];\n MQ --> MS[N];\n A --> MT[CHECK if the session transport plan is available and correct?];\n MT --> MU[Y];\n MT --> MV[N];\n A --> MW[CHECK if the session security plan is available and correct?];\n MW --> MX[Y];\n MW --> MY[N];\n A --> MZ[CHECK if the session communication materials are available and correct?];\n MZ --> NA[Y];\n MZ --> NB[N];\n A --> NC[CHECK if the session waste management materials are available and correct?];\n NC --> ND[Y];\n NC --> NE[N];\n A --> NF[CHECK if the session cold chain materials are available and correct?];\n NF --> NG[Y];\n NF --> NH[N];\n A --> NI[CHECK if the session transport materials are available and correct?];\n NI --> NJ[Y];\n NI --> NK[N];\n A --> NL[CHECK if the session security materials are available and correct?];\n NL --> NM[Y];\n NL --> NN[N];\n A --> NO[CHECK if the session communication plan is available and correct?];\n NO --> NP[Y];\n NO --> NQ[N];\n A --> NR[CHECK if the session waste management plan is available and correct?];\n NR --> NS[Y];\n NR --> NT[N];\n A --> NU[CHECK if the session cold chain plan is available and correct?];\n NU --> NV[Y];\n NU --> NW[N];\n A --> NX[CHECK if the session transport plan is available and correct?];\n NX --> NY[Y];\n NX --> NZ[N];\n A --> OA[CHECK if the session security plan is available and correct?];\n OA --> OB[Y];\n OA --> OC[N];\n A --> OD[CHECK if the session communication materials are available and correct?];\n OD --> OE[Y];\n OD --> OF[N];\n A --> OG[CHECK if the session waste management materials are available and correct?];\n OG --> OH[Y];\n OG --> OI[N];\n A --> OJ[CHECK if the session cold chain materials are available and correct?];\n OJ --> OK[Y];\n OJ --> OL[N];\n A --> OM[CHECK if the session transport materials are available and correct?];\n OM --> ON[Y];\n OM --> OO[N];\n A --> OP[CHECK if the session security materials are available and correct?];\n OP --> OQ[Y];\n OP --> OR[N];\n A --> OS[CHECK if the session communication plan is available and correct?];\n OS --> OT[Y];\n OS --> OU[N];\n A --> OV[CHECK if the session waste management plan is available and correct?];\n OV --> OW[Y];\n OV --> OX[N];\n A --> OY[CHECK if the session cold chain plan is available and correct?];\n OY --> OZ[Y];\n OY --> PA[N];\n A --> PB[CHECK if the session transport plan is available and correct?];\n PB --> PC[Y];\n PB --> PD[N];\n A --> PE[CHECK if the session security plan is available and correct?];\n PE --> PF[Y];\n PE --> PG[N];\n A --> PH[CHECK if the session communication materials are available and correct?];\n PH --> PI[Y];\n PH --> PJ[N];\n A --> PK[CHECK if the session waste management materials are available and correct?];\n PK --> PL[Y];\n PK --> PM[N];\n A --> PN[CHECK if the session cold chain materials are available and correct?];\n PN --> PO[Y];\n PN --> PP[N];\n A --> PQ[CHECK if the session transport materials are available and correct?];\n PQ --> PR[Y];\n PQ --> PS[N];\n A --> PT[CHECK if the session security materials are available and correct?];\n PT --> PU[Y];\n PT --> PV[N];\n A --> PW[CHECK if the session communication plan is available and correct?];\n PW --> PX[Y];\n PW --> PY[N];\n A --> PZ[CHECK if the session waste management plan is available and correct?];\n PZ --> QA[Y];\n PZ --> QB[N];\n A --> QC[CHECK if the session cold chain plan is available and correct?];\n QC --> QD[Y];\n QC --> QE[N];\n A --> QF[CHECK if the session transport plan is available and correct?];\n QF --> QG[Y];\n QF --> QH[N];\n A --> QI[CHECK if the session security plan is available and correct?];\n QI --> QJ[Y];\n QI --> QK[N];\n A --> QL[CHECK if the session communication materials are available and correct?];\n QL --> QM[Y];\n QL --> QN[N];\n A --> QO[CHECK if the session waste management materials are available and correct?];\n QO --> QP[Y];\n QO --> QQ[N];\n A --> QR[CHECK if the session cold chain materials are available and correct?];\n QR --> QS[Y];\n QR --> QT[N];\n A --> QU[CHECK if the session transport materials are available and correct?];\n QU --> QV[Y];\n QU --> QW[N];\n A --> QX[CHECK if the session security materials are available and correct?];\n QX --> QY[Y];\n QX --> QZ[N];\n A --> RA[CHECK if the session communication plan is available and correct?];\n RA --> RB[Y];\n RA --> RC[N];\n A --> RD[CHECK if the session waste management plan is available and correct?];\n RD --> RE[Y];\n RD --> RF[N];\n A --> RG[CHECK if the session cold chain plan is available and correct?];\n RG --> RH[Y];\n RG --> RI[N];\n A --> RJ[CHECK if the session transport plan is available and correct?];\n RJ --> RK[Y];\n RJ --> RL[N];\n A --> RM[CHECK if the session security plan is available and correct?];\n RM --> RN[Y];\n RM --> RO[N];\n A --> RP[CHECK if the session communication materials are available and correct?];\n RP --> RQ[Y];\n RP --> RR[N];\n A --> RS[CHECK if the session waste management materials are available and correct?];\n RS --> RT[Y];\n RS --> RU[N];\n A --> RV[CHECK if the session cold chain materials are available and correct?];\n RV --> RW[Y];\n RV --> RX[N];\n A --> RY[CHECK if the session transport materials are available and correct?];\n RY --> RZ[Y];\n RY --> SA[N];\n A --> SB[CHECK if the session security materials are available and correct?];\n SB --> SC[Y];\n SB --> SD[N];\n A --> SE[CHECK if the session communication plan is available and correct?];\n SE --> SF[Y];\n SE --> SG[N];\n A --> SH[CHECK if the session waste management plan is available and correct?];\n SH --> SI[Y];\n SH --> SJ[N];\n A --> SK[CHECK if the session cold chain plan is available and correct?];\n SK --> SL[Y];\n SK --> SM[N];\n A --> SN[CHECK if the session transport plan is available and correct?];\n SN --> SO[Y];\n SN --> SP[N];\n A --> SQ[CHECK if the session security plan is available and correct?];\n SQ --> SR[Y];\n SQ --> SS[N];\n A --> ST[CHECK if the session communication materials are available and correct?];\n ST --> SU[Y];\n ST --> SV[N];\n A --> SW[CHECK if the session waste management materials are available and correct?];\n SW --> SX[Y];\n SW --> SY[N];\n A --> SZ[CHECK if the session cold chain materials are available and correct?];\n SZ --> TA[Y];\n SZ --> TB[N];\n A --> TC[CHECK if the session transport materials are available and correct?];\n TC --> TD[Y];\n TC --> TE[N];\n A --> TF[CHECK if the session security materials are available and correct?];\n TF --> TG[Y];\n TF --> TH[N];\n A --> TI[CHECK if the session communication plan is available and correct?];\n TI --> TJ[Y];\n TI --> TK[N];\n A --> TL[CHECK if the session waste management plan is available and correct?];\n TL --> TM[Y];\n TL --> TN[N];\n A --> TO[CHECK if the session cold chain plan is available and correct?];\n TO --> TP[Y];\n TO --> TQ[N];\n A --> TR[CHECK if the session transport plan is available and correct?];\n TR --> TS[Y];\n TR --> TT[N];\n A --> TU[CHECK if the session security plan is available and correct?];\n TU --> TV[Y];\n TU --> TW[N];\n A --> TX[CHECK if the session communication materials are available and correct?];\n TX --> TY[Y];\n TX --> TZ[N];\n A --> UA[CHECK if the session waste management materials are available and correct?];\n UA --> UB[Y];\n UA --> UC[N];\n A --> UD[CHECK if the session cold chain materials are available and correct?];\n UD --> UE[Y];\n UD --> UF[N];\n A --> UG[CHECK if the session transport materials are available and correct?];\n UG --> UH[Y];\n UG --> UI[N];\n A --> UJ[CHECK if the session security materials are available and correct?];\n UJ --> UK[Y];\n UJ --> UL[N];\n A --> UM[CHECK if the session communication plan is available and correct?];\n UM --> UN[Y];\n UM --> UO[N];\n A --> UP[CHECK if the session waste management plan is available and correct?];\n UP --> UQ[Y];\n UP --> UR[N];\n A --> US[CHECK if the session cold chain plan is available and correct?];\n US --> UT[Y];\n US --> UU[N];\n A --> UV[CHECK if the session transport plan is available and correct?];\n UV --> UW[Y];\n UV --> UX[N];\n A --> UY[CHECK if the session security plan is available and correct?];\n UY --> UZ[Y];\n UY --> VA[N];\n A --> VB[CHECK if the session communication materials are available and correct?];\n VB --> VC[Y];\n VB --> VD[N];\n A --> VE[CHECK if the session waste management materials are available and correct?];\n VE --> VF[Y];\n VE --> VG[N];\n A --> VH[CHECK if the session cold chain materials are available and correct?];\n VH --> VI[Y];\n VH --> VJ[N];\n A --> VK[CHECK if the session transport materials are available and correct?];\n VK --> VL[Y];\n VK --> VM[N];\n A --> VN[CHECK if the session security materials are available and correct?];\n VN --> VO[Y];\n VN --> VP[N];\n A --> VQ[CHECK if the session communication plan is available and correct?];\n VQ --> VR[Y];\n VQ --> VS[N];\n A --> VT[CHECK if the session waste management plan is available and correct?];\n VT --> VU[Y];\n VT --> VV[N];\n A --> VW[CHECK if the session cold chain plan is available and correct?];\n VW --> VX[Y];\n VW --> VY[N];\n A --> VZ[CHECK if the session transport plan is available and correct?];\n VZ --> WA[Y];\n VZ --> WB[N];\n A --> WC[CHECK if the session security plan is available and correct?];\n WC --> WD[Y];\n WC --> WE[N];\n A --> WF[CHECK if the session communication materials are available and correct?];\n WF --> WG[Y];\n WF --> WH[N];\n A --> WI[CHECK if the session waste management materials are available and correct?];\n WI --> WJ[Y];\n WI --> WK[N];\n A --> WL[CHECK if the session cold chain materials are available and correct?];\n WL --> WM[Y];\n WL --> WN[N];\n A --> WO[CHECK if the session transport materials are available and correct?];\n WO --> WP[Y];\n WO --> WQ[N];\n A --> WR[CHECK if the session security materials are available and correct?];\n WR --> WS[Y];\n WR --> WT[N];\n A --> WU[CHECK if the session communication plan is available and correct?];\n WU --> WV[Y];\n WU --> WW[N];\n A --> WX[CHECK if the session waste management plan is available and correct?];\n WX --> WY[Y];\n WX --> WZ[N];\n A --> XA[CHECK if the session cold chain plan is available and correct?];\n XA --> XB[Y];\n XA --> XC[N];\n A --> XD[CHECK if the session transport plan is available and correct?];\n XD --> XE[Y];\n XD --> XF[N];\n A --> XG[CHECK if the session security plan is available and correct?];\n XG --> XH[Y];\n XG --> XI[N];\n A --> XJ[CHECK if the session communication materials are available and correct?];\n XJ --> XK[Y];\n XJ --> XL[N];\n A --> XM[CHECK if the session waste management materials are available and correct?];\n XM --> XN[Y];\n XM --> XO[N];\n A --> XP[CHECK if the session cold chain materials are available and correct?];\n XP --> XQ[Y];\n XP --> XR[N];\n A --> XS[CHECK if the session transport materials are available and correct?];\n XS --> XT[Y];\n XS --> XU[N];\n A --> XV[CHECK if the session security materials are available and correct?];\n XV --> XW[Y];\n XV --> XX[N];\n A --> XY[CHECK if the session communication plan is available and correct?];\n XY --> XZ[Y];\n XY --> YA[N];\n A --> YB[CHECK if the session waste management plan is available and correct?];\n YB --> YC[Y];\n YB --> YD[N];\n A --> YE[CHECK if the session cold chain plan is available and correct?];\n YE --> YF[Y];\n YE --> YG[N];\n A --> YH[CHECK if the session transport plan is available and correct?];\n YH --> YI[Y];\n YH --> YJ[N];\n A --> YK[CHECK if the session security plan is available and correct?];\n YK --> YL[Y];\n YK --> YM[N];\n A --> YN[CHECK if the session communication materials are available and correct?];\n YN --> YO[Y];\n YN --> YP[N];\n A --> YQ[CHECK if the session waste management materials are available and correct?];\n YQ --> YR[Y];\n YQ --> YS[N];\n A --> YT[CHECK if the session cold chain materials are available and correct?];\n YT --> YU[Y];\n YT --> YV[N];\n A --> YW[CHECK if the session transport materials are available and correct?];\n YW --> YX[Y];\n YW --> YY[N];\n A --> YZ[CHECK if the session security materials are available and correct?];\n YZ --> ZA[Y];\n YZ --> ZB[N];\n A --> ZC[CHECK if the session communication plan is available and correct?];\n ZC --> ZD[Y];\n ZC --> ZE[N];\n A --> ZF[CHECK if the session waste management plan is available and correct?];\n ZF --> ZG[Y];\n ZF --> ZH[N];\n A --> ZI[CHECK if the session cold chain plan is available and correct?];\n ZI --> ZJ[Y];\n ZI --> ZK[N];\n A --> ZL[CHECK if the session transport plan is available and correct?];\n ZL --> ZM[Y];\n ZL --> ZN[N];\n A --> ZO[CHECK if the session security plan is available and correct?];\n ZO --> ZP[Y];\n ZO --> ZQ[N];\n A --> ZR[CHECK if the session communication materials are available and correct?];\n ZR --> ZS[Y];\n ZR --> ZT[N];\n A --> ZU[CHECK if the session waste management materials are available and correct?];\n ZU --> ZV[Y];\n ZU --> ZW[N];\n A --> ZX[CHECK if the session cold chain materials are available and correct?];\n ZX --> ZY[Y];\n ZX --> ZZ[N];\n A --> AAA[CHECK if the session transport materials are available and correct?];\n AAA --> AAB[Y];\n AAA --> AAC[N];\n A --> AAD[CHECK if the session security materials are available and correct?];\n AAD --> AAE[Y];\n AAD --> AAF[N];\n A --> AAG[CHECK if the session communication plan is available and correct?];\n AAG --> AAH[Y];\n AAG --> AAI[N];\n A --> AAJ[CHECK if the session waste management plan is available and correct?];\n AAJ --> AAK[Y];\n AAJ --> AAL[N];\n A --> AAM[CHECK if the session cold chain plan is available and correct?];\n AAM --> AAN[Y];\n AAM --> AAO[N];\n A --> AAP[CHECK if the session transport plan is available and correct?];\n AAP --> AAQ[Y];\n AAP --> AAR[N];\n A --> AAS[CHECK if the session security plan is available and correct?];\n AAS --> AAT[Y];\n AAS --> AAU[N];\n A --> AAV[CHECK if the session communication materials are available and correct?];\n AAV --> AAW[Y];\n AAV --> AAX[N];\n A --> AAY[CHECK if the session waste management materials are available and correct?];\n AAY --> AAZ[Y];\n AAY --> ABA[N];\n A --> ABB[CHECK if the session cold chain materials are available and correct?];\n ABB --> ABC[Y];\n ABB --> ABD[N];\n A --> ABE[CHECK if the session transport materials are available and correct?];\n ABE --> ABF[Y];\n ABE --> ABG[N];\n A --> ABH[CHECK if the session security materials are available and correct?];\n ABH --> ABI[Y];\n ABH --> ABJ[N];\n A --> ABK[CHECK if the session communication plan is available and correct?];\n ABK --> ABL[Y];\n ABK --> ABM[N];\n A --> ABN[CHECK if the session waste management plan is available and correct?];\n ABN --> ABO[Y];\n ABN --> ABP[N];\n A --> ABQ[CHECK if the session cold chain plan is available and correct?];\n ABQ --> ABR[Y];\n ABQ --> ABS[N];\n A --> ABT[CHECK if the session transport plan is available and correct?];\n ABT --> ABU[Y];\n ABT --> ABV[N];\n A --> ABW[CHECK if the session security plan is available and correct?];\n ABW --> ABX[Y];\n ABW --> ABY[N];\n A --> ABZ[CHECK if the session communication materials are available and correct?];\n ABZ --> ACA[Y];\n ABZ --> ACB[N];\n A --> ACC[CHECK if the session waste management materials are available and correct?];\n ACC --> ACD[Y];\n ACC --> ACE[N];\n A --> ACF[CHECK if the session cold chain materials are available and correct?];\n ACF --> ACG[Y];\n ACF --> ACH[N];\n A --> ACI[CHECK if the session transport materials are available and correct?];\n ACI --> ACJ[Y];\n ACI --> ACK[N];\n A --> ACL[CHECK if the session security materials are available and correct?];\n ACL --> ACM[Y];\n ACL --> ACN[N];\n A --> ACO[CHECK if the session communication plan is available and correct?];\n ACO --> ACP[Y];\n ACO --> ACQ[N];\n A --> ACR[CHECK if the session waste management plan is available and correct?];\n ACR --> ACS[Y];\n ACR --> ACT[N];\n A --> ACU[CHECK if the session cold chain plan is available and correct?];\n ACU --> ACV[Y];\n ACU --> ACW[N];\n A --> ACX[CHECK if the session transport plan is available and correct?];\n ACX --> ACY[Y];\n ACX --> ACZ[N];\n A --> ADA[CHECK if the session security plan is available and correct?];\n ADA --> ADB[Y];\n ADA --> ADC[N];\n A --> ADD[CHECK if the session communication materials are available and correct?];\n ADD --> ADE[Y];\n ADD --> ADF[N];\n A --> ADG[CHECK if the session waste management materials are available and correct?];\n ADG --> ADH[Y];\n ADG --> ADI[N];\n A --> ADJ[CHECK if the session cold chain materials are available and correct?];\n ADJ --> ADK[Y];\n ADJ --> ADL[N];\n A --> ADM[CHECK if the session transport materials are available and correct?];\n ADM --> ADN[Y];\n ADM --> ADO[N];\n A --> ADP[CHECK if the session security materials are available and correct?];\n ADP --> ADQ[Y];\n ADP --> ADR[N];\n A --> ADS[CHECK if the session communication plan is available and correct?];\n ADS --> ADT[Y];\n ADS --> ADU[N];\n A --> ADV[CHECK if the session waste management plan is available and correct?];\n ADV --> ADW[Y];\n ADV --> ADX[N];\n A --> ADY[CHECK if the session cold chain plan is available and correct?];\n ADY --> ADZ[Y];\n ADY --> AEA[N];\n A --> AEB[CHECK if the session transport plan is available and correct?];\n AEB --> AEC[Y];\n AEB --> AED[N];\n A --> AEE[CHECK if the session security plan is available and correct?];\n AEE --> AEF[Y];\n AEE --> AEG[N];\n A --> AEH[CHECK if the session communication materials are available and correct?];\n AEH --> AEI[Y];\n AEH --> AEJ[N];\n A --> AEK[CHECK if the session waste management materials are available and correct?];\n AEK --> AEL[Y];\n AEK --> AEM[N];\n A --> AEN[CHECK if the session cold chain materials are available and correct?];\n AEN --> AEO[Y];\n AEN --> AEP[N];\n A --> AEQ[CHECK if the session transport materials are available and correct?];\n AEQ --> AER[Y];\n AEQ --> AES[N];\n A --> AET[CHECK if the session security materials are available and correct?];\n AET --> AEU[Y];\n AET --> AEV[N];\n A --> AEW[CHECK if the session communication plan is available and correct?];\n AEW --> AEX[Y];\n AEW --> AEY[N];\n A --> AEZ[CHECK if the session waste management plan is available and correct?];\n AEZ --> AFA[Y];\n AEZ --> AFB[N];\n A --> AFC[CHECK if the session cold chain plan is available and correct?];\n AFC --> AFD[Y];\n AFC --> AFE[N];\n A --> AFF[CHECK if the session transport plan is available and correct?];\n AFF --> AFG[Y];\n AFF --> AFH[N];\n A --> AFI[CHECK if the session security plan is available and correct?];\n AFI --> AFJ[Y];\n AFI --> AFK[N];\n A --> AFL[CHECK if the session communication materials are available and correct?];\n AFL --> AFM[Y];\n AFL --> AFN[N];\n A --> AFO[CHECK if the session waste management materials are available and correct?];\n AFO --> AFP[Y];\n AFO --> AFQ[N];\n A --> AFR[CHECK if the session cold chain materials are available and correct?];\n AFR --> AFS[Y];\n AFR --> AFT[N];\n A --> AFU[CHECK if the session transport materials are available and correct?];\n AFU --> AFV[Y];\n AFU --> AFW[N];\n A --> AFX[CHECK if the session security materials are available and correct?];\n AFX --> AFY[Y];\n AFX --> AFZ[N];\n A --> AGA[CHECK if the session communication plan is available and correct?];\n AGA --> AGB[Y];\n AGA --> AGC[N];\n A --> AGD[CHECK if the session waste management plan is available and correct?];\n AGD --> AGE[Y];\n AGD --> AGF[N];\n A --> AGG[CHECK if the session cold chain plan is available and correct?];\n AGG --> AGH[Y];\n AGG --> AGI[N];\n A --> AGJ[CHECK if the session transport plan is available and correct?];\n AGJ --> AGK[Y];\n AGJ --> AGL[N];\n A --> AGM[CHECK if the session security plan is available and correct?];\n AGM --> AGN[Y];\n AGM --> AGO[N];\n A --> AGP[CHECK if the session communication materials are available and correct?];\n AGP --> AGQ[Y];\n AGP --> AGR[N];\n A --> AGS[CHECK if the session waste management materials are available and correct?];\n AGS --> AGT[Y];\n AGS --> AGU[N];\n A --> AGV[CHECK if the session cold chain materials are available and correct?];\n AGV --> AGW[Y];\n AGV --> AGX[N];\n A --> AGY[CHECK if the session transport materials are available and correct?];\n AGY --> AGZ[Y];\n AGY --> AHA[N];\n A --> AHB[CHECK if the session security materials are available and correct?];\n AHB --> AHC[Y];\n AHB --> AHD[N];\n A --> AHE[CHECK if the session communication plan is available and correct?];\n AHE --> AHF[Y];\n AHE --> AHG[N];\n A --> AHH[CHECK if the session waste management plan is available and correct?];\n AHH --> AHI[Y];\n AHH --> AHJ[N];\n A --> AHK[CHECK if the session cold chain plan is available and correct?];\n AHK --> AHL[Y];\n AHK --> AHM[N];\n A --> AHN[CHECK if the session transport plan is available and correct?];\n AHN --> AHO[Y];\n AHN --> AHP[N];\n A --> AHQ[CHECK if the session security plan is available and correct?];\n AHQ --> AHR[Y];\n AHQ --> AHS[N];\n A --> AHT[CHECK if the session communication materials are available and correct?];\n AHT --> AHU[Y];\n AHT --> AHV[N];\n A --> AHW[CHECK if the session waste management materials are available and correct?];\n AHW --> AHX[Y];\n AHW --> AHY[N];\n A --> AHZ[CHECK if the session cold chain materials are available and correct?];\n AHZ --> AIA[Y];\n AHZ --> AIB[N];\n A --> AIC[CHECK if the session transport materials are available and correct?];\n AIC --> AID[Y];\n AIC --> AIE[N];\n A --> AIF[CHECK if the session security materials are available and correct?];\n AIF --> AIG[Y];\n AIF --> AIH[N];\n A --> AII[CHECK if the session communication plan is available and correct?];\n AII --> AIJ[Y];\n AII --> AIK[N];\n A --> AIL[CHECK if the session waste management plan is available and correct?];\n AIL --> AIM[Y];\n AIL --> AIN[N];\n A --> AIO[CHECK if the session cold chain plan is available and correct?];\n AIO --> AIP[Y];\n AIO --> AIQ[N];\n A --> AIR[CHECK if the session transport plan is available and correct?];\n AIR --> AIS[Y];\n AIR --> AIT[N];\n A --> AIU[CHECK if the session security plan is available and correct?];\n AIU --> AIV[Y];\n AIU --> AIW[N];\n A --> AIX[CHECK if the session communication materials are available and correct?];\n AIX --> AIY[Y];\n AIX --> AIZ[N];\n A --> AJA[CHECK if the session waste management materials are available and correct?];\n AJA --> AJB[Y];\n AJA --> AJC[N];\n A --> AJD[CHECK if the session cold chain materials are available and correct?];\n AJD --> AJE[Y];\n AJD --> AJF[N];\n A --> AJG[CHECK if the session transport materials are available and correct?];\n AJG --> AJH[Y];\n AJG --> AJI[N];\n A --> AJJ[CHECK if the session security materials are available and correct?];\n AJJ --> AJK[Y];\n AJJ --> AJL[N];\n A --> AJM[CHECK if the session communication plan is available and correct?];\n AJM --> AJN[Y];\n AJM --> AJO[N];\n A --> AJP[CHECK if the session waste management plan is available and correct?];\n AJP --> AJQ[Y];\n AJP --> AJR[N];\n A --> AJS[CHECK if the session cold chain plan is available and correct?];\n AJS --> AJT[Y];\n AJS --> AJU[N];\n A --> AJV[CHECK if the session transport plan is available and correct?];\n AJV --> AJW[Y];\n AJV --> AJX[N];\n A --> AJY[CHECK if the session security plan is available and correct?];\n AJY --> AJZ[Y];\n AJY --> AKA[N];\n A --> AKB[CHECK if the session communication materials are available and correct?];\n AKB --> AKC[Y];\n AKB --> AKD[N];\n A --> AKE[CHECK if the session waste management materials are available and correct?];\n AKE --> AKF[Y];\n AKE --> AKG[N];\n A --> AKH[CHECK if the session cold chain materials are available and correct?];\n AKH --> AKI[Y];\n AKH --> AKJ[N];\n A --> AKK[CHECK if the session transport materials are available and correct?];\n AKK --> AKL[Y];\n AKK --> AKM[N];\n A --> AKN[CHECK if the session security materials are available and correct?];\n AKN --> AKO[Y];\n AKN --> AKP[N];\n A --> AKQ[CHECK if the session communication plan is available and correct?];\n AKQ --> AKR[Y];\n AKQ --> AKS[N];\n A --> AKT[CHECK if the session waste management plan is available and correct?];\n AKT --> AKU[Y];\n AKT --> AKV[N];\n A --> AKW[CHECK if the session cold chain plan is available and correct?];\n AKW --> AKX[Y];\n AKW --> AKY[N];\n A --> AKZ[CHECK if the session transport plan is available and correct?];\n AKZ --> ALA[Y];\n AKZ --> ALB[N];\n A --> ALC[CHECK if the session security plan is available and correct?];\n ALC --> ALD[Y];\n ALC --> ALE[N];\n A --> ALF[CHECK if the session communication materials are available and correct?];\n ALF --> ALG[Y];\n ALF --> ALH[N];\n A --> ALI[CHECK if the session waste management materials are available and correct?];\n ALI --> ALJ[Y];\n ALI --> ALK[N];\n A --> ALL[CHECK if the session cold chain materials are available and correct?];\n ALL --> ALM[Y];\n ALL --> ALN[N];\n A --> ALO[CHECK if the session transport materials are available and correct?];\n ALO --> ALP[Y];\n ALO --> ALQ[N];\n A --> ALR[CHECK if the session security materials are available and correct?];\n ALR --> ALS[Y];\n ALR --> ALT[N];\n A --> ALU[CHECK if the session communication plan is available and correct?];\n ALU --> ALV[Y];\n ALU --> ALW[N];\n A --> ALX[CHECK if the session waste management plan is available and correct?];\n ALX --> ALY[Y];\n ALX --> ALZ[N];\n A --> AMA[CHECK if the session cold chain plan is available and correct?];\n AMA --> AMB[Y];\n AMA --> AMC[N];\n A --> AMD[CHECK if the session transport plan is available and correct?];\n AMD --> AME[Y];\n AMD --> AMF[N];\n A --> AMG[CHECK if the session security plan is available and correct?];\n AMG --> AMH[Y];\n AMG --> AMI[N];\n A --> AMJ[CHECK if the session communication materials are available and correct?];\n AMJ --> AMK[Y];\n AMJ --> AML[N];\n A --> AMM[CHECK if the session waste management materials are available and correct?];\n AMM --> AMN[Y];\n AMM --> AMO[N];\n A --> AMP[CHECK if the session cold chain materials are available and correct?];\n AMP --> AMQ[Y];\n AMP --> AMR[N];\n A --> AMS[CHECK if the session transport materials are available and correct?];\n AMS --> AMT[Y];\n AMS --> AMU[N];\n A --> AMV[CHECK if the session security materials are available and correct?];\n AMV --> AMW[Y];\n AMV --> AMX[N];\n A --> AMY[CHECK if the session communication plan is available and correct?];\n AMY --> AMZ[Y];\n AMY --> ANA[N];\n A --> ANB[CHECK if the session waste management plan is available and correct?];\n ANB --> ANC[Y];\n ANB --> AND[N];\n A --> ANE[CHECK if the session cold chain plan is available and correct?];\n ANE --> ANF[Y];\n ANE --> ANG[N];\n A --> ANH[CHECK if the session transport plan is available and correct?];\n ANH --> ANI[Y];\n ANH --> ANJ[N];\n A --> ANK[CHECK if the session security plan is available and correct?];\n ANK --> ANL[Y];\n ANK --> ANM[N];\n A --> ANN[CHECK if the session communication materials are available and correct?];\n ANN --> ANO[Y];\n ANN --> ANP[N];\n A --> ANQ[CHECK if the session waste management materials are available and correct?];\n ANQ --> ANR[Y];\n ANQ --> ANS[N];\n A --> ANT[CHECK if the session cold chain materials are available and correct?];\n ANT --> ANU[Y];\n ANT --> ANV[N];\n A --> ANW[CHECK if the session transport materials are available and correct?];\n ANW --> ANX[Y];\n ANW --> ANY[N];\n A --> ANZ[CHECK if the session security materials are available and correct?];\n ANZ --> AOA[Y];\n ANZ --> AOB[N];\n A --> AOC[CHECK if the session communication plan is available and correct?];\n AOC --> AOD[Y];\n AOC --> AOE[N];\n A --> AOF[CHECK if the session waste management plan is available and correct?];\n AOF --> AOG[Y];\n AOF --> AOH[N];\n A --> AOI[CHECK if the session cold chain plan is available and correct?];\n AOI --> AOJ[Y];\n AOI --> AOK[N];\n A --> AOL[CHECK if the session transport plan is available and correct?];\n AOL --> AOM[Y];\n AOL --> AON[N];\n A --> AOO[CHECK if the session security plan is available and correct?];\n AOO --> AOP[Y];\n AOO --> AOQ[N];\n A --> AOR[CHECK if the session communication materials are available and correct?];\n AOR --> AOS[Y];\n AOR --> AOT[N];\n A --> AOU[CHECK if the session waste management materials are available and correct?];\n AOU --> AOV[Y];\n AOU --> AOW[N];\n A --> AOX[CHECK if the session cold chain materials are available and correct?];\n AOX --> AOY[Y];\n AOX --> AOZ[N];\n A --> APA[CHECK if the session transport materials are available and correct?];\n APA --> APB[Y];\n APA --> APC[N];\n A --> APD[CHECK if the session security materials are available and correct?];\n APD --> APE[Y];\n APD --> APF[N];\n A --> APG[CHECK if the session communication plan is available and correct?];\n APG --> APH[Y];\n APG --> API[N];\n A --> APJ[CHECK if the session waste management plan is available and correct?];\n APJ --> APK[Y];\n APJ --> APL[N];\n A --> APM[CHECK if the session cold chain plan is available and correct?];\n APM --> APN[Y];\n APM --> APO[N];\n A --> APP[CHECK if the session transport plan is available and correct?];\n APP --> APQ[Y];\n APP --> APR[N];\n A --> APS[CHECK if the session security plan is available and correct?];\n APS --> APT[Y];\n APS --> APU[N];\n A --> APV[CHECK if the session communication materials are available and correct?];\n APV --> APW[Y];\n APV --> APX[N];\n A --> APY[CHECK if the session waste management materials are available and correct?];\n APY --> APZ[Y];\n APY --> AQA[N];\n A --> AQB[CHECK if the session cold chain materials are available and correct?];\n AQB --> AQC[Y];\n AQB --> AQD[N];\n A --> AQE[CHECK if the session transport materials are available and correct?];\n AQE --> AQF[Y];\n AQE --> AQG[N];\n A --> AQH[CHECK if the session security materials are available and correct?];\n AQH --> AQI[Y];\n AQH --> AQJ[N];\n A --> AQK[CHECK if the session communication plan is available and correct?];\n AQK --> AQL[Y];\n AQK --> AQM[N];\n A --> AQN[CHECK if the session waste management plan is available and correct?];\n AQN --> AQO[Y];\n AQN --> AQP[N];\n A --> AQQ[CHECK if the session cold chain plan is available and correct?];\n AQQ --> AQR[Y];\n AQQ --> AQS[N];\n A --> AQT[CHECK if the session transport plan is available and correct?];\n AQT --> AQU[Y];\n AQT --> AQV[N];\n A --> AQW[CHECK if the session security plan is available and correct?];\n AQW --> AQX[Y];\n AQW --> AQY[N];\n A --> AQZ[CHECK if the session communication materials are available and correct?];\n AQZ --> ARA[Y];\n AQZ --> ARB[N];\n A --> ARC[CHECK if the session waste management materials are available and correct?];\n ARC --> ARD[Y];\n ARC --> ARE[N];\n A --> ARF[CHECK if the session cold chain materials are available and correct?];\n ARF --> ARG[Y];\n ARF --> ARH[N];\n A --> ARI[CHECK if the session transport materials are available and correct?];\n ARI --> ARJ[Y];\n ARI --> ARK[N];\n A --> ARL[CHECK if the session security materials are available and correct?];\n ARL --> ARM[Y];\n ARL --> ARN[N];\n A --> ARO[CHECK if the session communication plan is available and correct?];\n ARO --> ARP[Y];\n ARO --> ARQ[N];\n A --> ARR[CHECK if the session waste management plan is available and correct?];\n ARR --> ARS[Y];\n ARR --> ART[N];\n A --> ARU[CHECK if the session cold chain plan is available and correct?];\n ARU --> ARV[Y];\n ARU --> ARW[N];\n A --> ARX[CHECK if the session transport plan is available and correct?];\n ARX --> ARY[Y];\n ARX --> ARZ[N];\n A --> ASA[CHECK if the session security plan is available and correct?];\n ASA --> ASB[Y];\n ASA --> ASC[N];\n A --> ASD[CHECK if the session communication materials are available and correct?];\n ASD --> ASE[Y];\n ASD --> ASF[N];\n A --> ASG[CHECK if the session waste management materials are available and correct?];\n ASG --> ASH[Y];\n ASG --> ASI[N];\n A --> ASJ[CHECK if the session cold chain materials are available and correct?];\n ASJ --> ASK[Y];\n ASJ --> ASL[N];\n A --> ASM[CHECK if the session transport materials are available and correct?];\n ASM --> ASN[Y];\n ASM --> ASO[N];\n A --> ASP[CHECK if the session security materials are available and correct?];\n ASP --> ASQ[Y];\n ASP --> ASR[N];\n A --> ASS[CHECK if the session communication plan is available and correct?];\n ASS --> AST[Y];\n ASS --> ASU[N];\n A --> ASV[CHECK if the session waste management plan is available and correct?];\n ASV --> ASW[Y];\n ASV --> ASX[N];\n A --> ASY[CHECK if the session cold chain plan is available and correct?];\n ASY --> ASZ[Y];\n ASY --> ATA[N];\n A --> ATB[CHECK if the session transport plan is available and correct?];\n ATB --> ATC[Y];\n ATB --> ATD[N];\n A --> ATE[CHECK if the session security plan is available and correct?];\n ATE --> ATF[Y];\n ATE --> ATG[N];\n A --> ATH[CHECK if the session communication materials are available and correct?];\n ATH --> ATI[Y];\n ATH --> ATJ[N];\n A --> ATK[CHECK if the session waste management materials are available and correct?];\n ATK --> ATL[Y];\n ATK --> ATM[N];\n A --> ATN[CHECK if the session cold chain materials are available and correct?];\n ATN --> ATO[Y];\n ATN --> ATP[N];\n A --> ATQ[CHECK if the session transport materials are available and correct?];\n ATQ --> ATR[Y];\n ATQ --> ATS[N];\n A --> ATT[CHECK if the session security materials are available and correct?];\n ATT --> ATU[Y];\n ATT --> ATV[N];\n A --> ATW[CHECK if the session communication plan is available and correct?];\n ATW --> ATX[Y];\n ATW --> ATY[N];\n A --> ATZ[CHECK if the session waste management plan is available and correct?];\n ATZ --> AUA[Y];\n ATZ --> AUB[N];\n A --> AUC[CHECK if the session cold chain plan is available and correct?];\n AUC --> AUD[Y];\n AUC --> AUE[N];\n A --> AUF[CHECK if the session transport plan is available and correct?];\n AUF --> AUG[Y];\n AUF --> AUH[N];\n A --> AUI[CHECK if the session security materials are available and correct?];\n AUI --> AUJ[Y];\n AUI --> AUK[N];\n A --> AUL[CHECK if the session communication materials are available and correct?];\n AUL --> AUM[Y];\n AUL --> AUN[N];\n A --> AUO[CHECK if the session waste management materials are available and correct?];\n AUO --> AUP[Y];\n AUO --> AUQ[N];\n A --> AUR[CHECK if the session cold chain materials are available and correct?];\n AUR --> AUS[Y];\n AUR --> AUT[N];\n A --> AUU[CHECK if the session transport materials are available and correct?];\n AUU --> AUV[Y];\n AUU --> AUW[N];\n A --> AUX[CHECK if the session security materials are available and correct?];\n AUX --> AUY[Y];\n AUX --> AUZ[N];\n A --> AVA[CHECK if the session communication plan is available and correct?];\n AVA --> AVB[Y];\n AVA --> AVC[N];\n A --> AVD[CHECK if the session waste management plan is available and correct?];\n AVD --> AVE[Y];\n AVD --> AVF[N];\n A --> AVG[CHECK if the session cold chain plan is available and correct?];\n AVG --> AVH[Y];\n AVG --> AVI[N];\n A --> AVJ[CHECK if the session transport plan is available and correct?];\n AVJ --> AVK[Y];\n AVJ --> AVL[N];\n A --> AVM[CHECK if the session security plan is available and correct?];\n AVM --> AVN[Y];\n AVM --> AVO[N];\n A --> AVP[CHECK if the session communication materials are available and correct?];\n AVP --> AVQ[Y];\n AVP --> AVR[N];\n A --> AVS[CHECK if the session waste management materials are available and correct?];\n AVS --> AVT[Y];\n AVS --> AVU[N];\n A --> AVV[CHECK if the session cold chain materials are available and correct?];\n AVV --> AVW[Y];\n AVV --> AVX[N];\n A --> AVY[CHECK if the session transport materials are available and correct?];\n AVY --> AVZ[Y];\n AVY --> AWA[N];\n A --> AWB[CHECK if the session security materials are available and correct?];\n AWB --> AWC[Y];\n AWB --> AWD[N];\n A --> AWE[CHECK if the session communication plan is available and correct?];\n AWE --> AWF[Y];\n AWE --> AWG[N];\n A --> AWH[CHECK if the session waste management plan is available and correct?];\n AWH --> AWI[Y];\n AWH --> AWJ[N];\n A --> AWK[CHECK if the session cold chain plan is available and correct?];\n AWK --> AWL[Y];\n AWK --> AWM[N];\n A --> AWN[CHECK if the session transport plan is available and correct?];\n AWN --> AWO[Y];\n AWN --> AWP[N];\n A --> AWQ[CHECK if the session security plan is available and correct?];\n AWQ --> AWR[Y];\n AWQ --> AWS[N];\n A --> AWT[CHECK if the session communication materials are available and correct?];\n AWT --> AWU[Y];\n AWT --> AWV[N];\n A --> AWW[CHECK if the session waste management materials are available and correct?];\n AWW --> AWX[Y];\n AWW --> AWY[N];\n A --> AWZ[CHECK if the session cold chain materials are available and correct?];\n AWZ --> AXA[Y];\n AWZ --> AXB[N];\n A --> AXC[CHECK if the session transport materials are available and correct?];\n AXC --> AXD[Y];\n AXC --> AXE[N];\n A --> AXF[CHECK if the session security materials are available and correct?];\n AXF --> AXG[Y];\n AXF --> AXH[N];\n A --> AXI[CHECK if the session communication plan is available and correct?];\n AXI --> AXJ[Y];\n AXI --> AXK[N];\n A --> AXL[CHECK if the session waste management plan is available and correct?];\n AXL --> AXM[Y];\n AXL --> AXN[N];\n A --> AXO[CHECK if the session cold chain plan is available and correct?];\n AXO --> AXP[Y];\n AXO --> AXQ[N];\n A --> AXR[CHECK if the session transport plan is available and correct?];\n AXR --> AXS[Y];\n AXR --> AXT[N];\n A --> AXU[CHECK if the session security plan is available and correct?];\n AXU --> AXV[Y];\n AXU --> AXW[N];\n A --> AXX[CHECK if the session communication materials are available and correct?];\n AXX --> AXY[Y];\n AXX --> AXZ[N];\n A --> AYA[CHECK if the session waste management materials are available and correct?];\n AYA --> AYB[Y];\n AYA --> AYC[N];\n A --> AYD[CHECK if the session cold chain materials are available and correct?];\n AYD --> AYE[Y];\n AYD --> AYF[N];\n A --> AYG[CHECK if the session transport materials are available and correct?];\n AYG --> AYH[Y];\n AYG --> AYI[N];\n A --> AYJ[CHECK if the session security materials are available and correct?];\n AYJ --> AYK[Y];\n AYJ --> AYL[N];\n A --> AYM[CHECK if the session communication plan is available and correct?];\n AYM --> AYN[Y];\n AYM --> AYO[N];\n A --> AYP[CHECK if the session waste management plan is available and correct?];\n AYP --> AYQ[Y];\n AYP --> AYR[N];\n A --> AYS[CHECK if the session cold chain plan is available and correct?];\n AYS --> AYT[Y];\n AYS --> AYU[N];\n A --> AYV[CHECK if the session transport plan is available and correct?];\n AYV --> AYW[Y];\n AYV --> AYX[N];\n A --> AYY[CHECK if the session security plan is available and correct?];\n AYY --> AYZ[Y];\n AYY --> AZA[N];\n A --> AZB[CHECK if the session communication materials are available and correct?];\n AZB --> AZC[Y];\n AZB --> AZD[N];\n A --> AZE[CHECK if the session waste management materials are available and correct?];\n AZE --> AZF[Y];\n AZE --> AZG[N];\n A --> AZH[CHECK if the session cold chain materials are available and correct?];\n AZH --> AZI[Y];\n AZH --> AZJ[N];\n A --> AZK[CHECK if the session transport materials are available and correct?];\n AZK --> AZL[Y];\n AZK --> AZM[N];\n A --> AZN[CHECK if the session security materials are available and correct?];\n AZN --> AZO[Y];\n AZN --> AZP[N];\n A --> AZQ[CHECK if the session communication plan is available and correct?];\n AZQ --> AZR[Y];\n AZQ --> AZS[N];\n A --> AZT[CHECK if the session waste management plan is available and correct?];\n AZT --> AZU[Y];\n AZT --> AZV[N];\n A --> AZW[CHECK if the session cold chain plan is available and correct?];\n AZW --> AZX[Y];\n AZW --> AZY[N];\n A --> AZZ[CHECK if the session transport plan is available and correct?];\n AZZ --> BAA[Y];\n AZZ --> BAB[N];\n A --> BAC[CHECK if the session security materials are available and correct?];\n BAC --> BAD[Y];\n BAC --> BAE[N];\n A --> BAF[CHECK if the session communication materials are available and correct?];\n BAF --> BAG[Y];\n BAF --> BAH[N];\n A --> BAI[CHECK if the session waste management materials are available and correct?];\n BAI --> BAJ[Y];\n BAI --> BAK[N];\n A --> BAL[CHECK if the session cold chain materials are available and correct?];\n BAL --> BAM[Y];\n BAL --> BAN[N];\n A --> BAO[CHECK if the session transport materials are available and correct?];\n BAO --> BAP[Y];\n BAO --> BAQ[N];\n A --> BAR[CHECK if the session security materials are available and correct?];\n BAR --> BAS[Y];\n BAR --> BAT[N];\n A --> BAU[CHECK if the session communication plan is available and correct?];\n BAU --> BAV[Y];\n BAU --> BAW[N];\n A --> BAX[CHECK if the session waste management plan is available and correct?];\n BAX --> BAY[Y];\n BAX --> BAZ[N];\n A --> BBA[CHECK if the session cold chain plan is available and correct?];\n BBA --> BBB[Y];\n BBA --> BBC[N];\n A --> BBD[CHECK if the session transport plan is available and correct?];\n BBD --> BBE[Y];\n BBD --> BBF[N];\n A --> BBG[CHECK if the session security plan is available and correct?];\n BBG --> BBH[Y];\n BBG --> BBI[N];\n A --> BBJ[CHECK if the session communication materials are available and correct?];\n BBJ --> BBK[Y];\n BBJ --> BBL[N];\n A --> BBM[CHECK if the session waste management materials are available and correct?];\n BBM --> BBN[Y];\n BBM --> BBO[N];\n A --> BBP[CHECK if the session cold chain materials are available and correct?];\n BBP --> BBQ[Y];\n BBP --> BBR[N];\n A --> BBS[CHECK if the session transport materials are available and correct?];\n BBS --> BBT[Y];\n BBS --> BBU[N];\n A --> BBV[CHECK if the session security materials are available and correct?];\n BBV --> BBW[Y];\n BBV --> BBX[N];\n A --> BBY[CHECK if the session communication plan is available and correct?];\n BBY --> BBZ[Y];\n BBY --> BCA[N];\n A --> BCB[CHECK if the session waste management plan is available and correct?];\n BCB --> BCC[Y];\n BCB --> BCD[N];\n A --> BCE[CHECK if the session cold chain plan is available and correct?];\n BCE --> BCF[Y];\n BCE --> BCG[N];\n A --> BCH[CHECK if the session transport plan is available and correct?];\n BCH --> BCI[Y];\n BCH --> BCJ[N];\n A --> BCK[CHECK if the session security plan is available and correct?];\n BCK --> BCL[Y];\n BCK --> BCM[N];\n A --> BCN[CHECK if the session communication materials are available and correct?];\n BCN --> BCO[Y];\n BCN --> BCP[N];\n A --> BCQ[CHECK if the session waste management materials are available and correct?];\n BCQ --> BCR[Y];\n BCQ --> BCS[N];\n A --> BCT[CHECK if the session cold chain materials are available and correct?];\n BCT --> BCU[Y];\n BCT --> BCV[N];\n A --> BCW[CHECK if the session transport materials are available and correct?];\n BCW --> BCX[Y];\n BCW --> BCY[N];\n A --> BCZ[CHECK if the session security materials are available and correct?];\n BCZ --> BDA[Y];\n BCZ --> BDB[N];\n A --> BDC[CHECK if the session communication plan is available and correct?];\n BDC --> BDD[Y];\n BDC --> BDE[N];\n A --> BDF[CHECK if the session waste management plan is available and correct?];\n BDF --> BDG[Y];\n BDF --> BDH[N];\n A --> BDI[CHECK if the session cold chain plan is available and correct?];\n BDI --> BDJ[Y];\n BDI --> BDK[N];\n A --> BDL[CHECK if the session transport plan is available and correct?];\n BDL --> BDM[Y];\n BDL --> BDN[N];\n A --> BDO[CHECK if the session security materials are available and correct?];\n BDO --> BDP[Y];\n BDO --> BDQ[N];\n A --> BDR[CHECK if the session communication materials are available and correct?];\n BDR --> BDS[Y];\n BDR --> BDT[N];\n A --> BDU[CHECK if the session waste management materials are available and correct?];\n BDU --> BDV[Y];\n BDU --> BDW[N];\n A --> BDX[CHECK if the session cold chain materials are available and correct?];\n BDX --> BDY[Y];\n BDX --> BDZ[N];\n A --> BEA[CHECK if the session transport materials are available and correct?];\n BEA --> BEB[Y];\n BEA --> BEC[N];\n A --> BED[CHECK if the session security materials are available and correct?];\n BED --> BEE[Y];\n BED --> BEF[N];\n A --> BEG[CHECK if the session communication plan is available and correct?];\n BEG --> BEH[Y];\n BEG --> BEI[N];\n A --> BEJ[CHECK if the session waste management plan is available and correct?];\n BEJ --> BEK[Y];\n BEJ --> BEL[N];\n A --> BEM[CHECK if the session cold chain plan is available and correct?];\n BEM --> BEN[Y];\n BEM --> BEO[N];\n A --> BEP[CHECK if the session transport plan is available and correct?];\n BEP --> BEQ[Y];\n BEP --> BER[N];\n A --> BES[CHECK if the session security materials are available and correct?];\n BES --> BET[Y];\n BES --> BEU[N];\n A --> BEV[CHECK if the session communication materials are available and correct?];\n BEV --> BEW[Y];\n BEV --> BEX[N];\n A --> BEY[CHECK if the session waste management materials are available and correct?];\n BEY --> BEZ[Y];\n BEY --> BFA[N];\n A --> BFB[CHECK if the session cold chain materials are available and correct?];\n BFB --> BFC[Y];\n BFB --> BFD[N];\n A --> BFE[CHECK if the session transport materials are available and correct?];\n BFE --> BFF[Y];\n BFE --> BFG[N];\n A --> BFH[CHECK if the session security materials are available and correct?];\n BFH --> BFI[Y];\n BFH --> BFJ[N];\n A --> BFK[CHECK if the session communication plan is available and correct?];\n BFK --> BFL[Y];\n BFK --> BFM[N];\n A --> BFN[CHECK if the session waste management plan is available and correct?];\n BFN --> BFO[Y];\n BFN --> BFP[N];\n A --> BFQ[CHECK if the session cold chain plan is available and correct?];\n BFQ --> BFR[Y];\n BFQ --> BFS[N];\n A --> BFT[CHECK if the session transport plan is available and correct?];\n BFT -->",
"metadata": {
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"parent_id": "d4d58bc3bbc1410c8e2c48903285d09b",
"text_as_html": "
Figure 5.11 Immunization session checklist
Before the immunization session
DO YOU:
□
CHECK if sufficient quantities of vaccines and diuretics are available for the session?
□
CHECK visits for the following and take up two weeks to visit:
H Opservical doses?
N Opservical doses?
N VVVA status?
N Freezing status?
□
PLACE visits in the appropriate places in the clinic.
□
DISCUSS whether or not there are available for the session including:
N Auto-disable M2D syringes?
N Recombination syringes?
N Safety food
N ASTI kit?
N Immunization registers?
N Immunization fully sheets?
N Black immunization cards?
□
WASH your hands with soap?
For selected clients attending the immunization session
DO YOU:
□
GREET the client and caregiver?
□
REFUSE the client's immunization card?
□
DETERMINE eligible vaccinations based on the common standard, client's age and possible medical schedule?
□
RECONSTRUITE each vaccine with its matched diuretic RID (type/attack vaccine)?
□
FILL syringes and follow administration using as-path techniques?
□
ADMINISTER each vaccine according to recommended techniques and correct injection rate?
□
IMMEDIATELY DISPOSE needle/M2D syringes in safety boxes after each injection?
□
RECORD all vaccinations in register, fully sheet and immunization card?
□
COMMUNICATE key messages, including potential ASTIs and dates of new visit?
After the immunization session
DO YOU:
□
CONNECTLY ASSESS if open visit can be used in the next session in accordance with national multi-task viral policy?
□
DISCARD open visits that should not be used?
□
RECORD date of opening on visit that can be used and PLACE them in the \"use first\" box in the refrigerator?
□
RETURN unopened visits to the refrigerator?
□
COUPLE LTE fixation summary report?
□
LIST the names of children who missed vaccination and require follow up?
□
MARCILL full safety boxes correctly?
□
TAKE appropriate action to ensure sufficient vaccine stock for the next session?
□
INFORM COMMUNITY of data and time of next session?
CHECK if sufficient quantities of vaccines and diuretics are available for the session?
□
CHECK visits for the following and take up two weeks to visit:
H Opservical doses?
N Opservical doses?
N VVVA status?
N Freezing status?
□
PLACE visits in the appropriate places in the clinic.
□
DISCUSS whether or not there are available for the session including:
N Auto-disable M2D syringes?
N Recombination syringes?
N Safety food
N ASTI kit?
N Immunization registers?
N Immunization fully sheets?
N Black immunization cards?
□
WASH your hands with soap?
For selected clients attending the immunization session
DO YOU:
□
GREET the client and caregiver?
□
REFUSE the client's immunization card?
□
DETERMINE eligible vaccinations based on the common standard, client's age and possible medical schedule?
□
RECONSTRUITE each vaccine with its matched diuretic RID (type/attack vaccine)?
□
FILL syringes and follow administration using as-path techniques?
□
ADMINISTER each vaccine according to recommended techniques and correct injection rate?
□
IMMEDIATELY DISPOSE needle/M2D syringes in safety boxes after each injection?
□
RECORD all vaccinations in register, fully sheet and immunization card?
□
COMMUNICATE key messages, including potential ASTIs and dates of new visit?
After the immunization session
DO YOU:
□
CONNECTLY ASSESS if open visit can be used in the next session in accordance with national multi-task viral policy?
□
DISCARD open visits that should not be used?
□
RECORD date of opening on visit that can be used and PLACE them in the \"use first\" box in the refrigerator?
□
RETURN unopened visits to the refrigerator?
□
COUPLE LTE fixation summary report?
□
LIST the names of children who missed vaccination and require follow up?
□
MARCILL full safety boxes correctly?
□
TAKE appropriate action to ensure sufficient vaccine stock for the next session?
□
INFORM COMMUNITY of data and time of next session?
"
},
{
"type": "CompositeElement",
"element_id": "chunk-336",
"text": "\n\n\nUsing the immunization session checklist\nFigure 5.11 shows a checklist that can help ensure safety before, during and after immunization. This checklist is a reminder of key points in preparation, vaccination and closure of sessions that are described above, and is meant to reinforce positive actions. Health workers should be familiar with national immunization schedules, vaccine administration, waste disposal, data collection and other details of standard operating procedure from relevant national programme documents and be able to quickly recognize and complete the checklist items. A printed copy of this checklist can be posted on a wall in the immunization area for easy viewing throughout sessions.\nModule 5: Managing an immunization session\n :TABLE DATA: \ngraph TD;\n A[Before the immunization session] --> B[For selected clients attending the immunization session];\n B --> C[After the immunization session];\n A --> D[CHECK if sufficient quantities of vaccines and diluents are available for the session?];\n D --> E[Y];\n D --> F[N];\n A --> G[CHECK if all equipment is in place and functioning correctly?];\n G --> H[Y];\n G --> I[N];\n A --> J[CHECK if all supplies are available for the session?];\n J --> K[Y];\n J --> L[N];\n A --> M[CHECK if all staff are present and ready?];\n M --> N[Y];\n M --> O[N];\n A --> P[CHECK if the session site is prepared and ready?];\n P --> Q[Y];\n P --> R[N];\n A --> S[CHECK if the session schedule is available and correct?];\n S --> T[Y];\n S --> U[N];\n A --> V[CHECK if the session plan is available and correct?];\n V --> W[Y];\n V --> X[N];\n A --> Y[CHECK if the session register is available and correct?];\n Y --> Z[Y];\n Y --> AA[N];\n A --> AB[CHECK if the session tally sheets are available and correct?];\n AB --> AC[Y];\n AB --> AD[N];\n A --> AE[CHECK if the session AEFI kit is available and correct?];\n AE --> AF[Y];\n AE --> AG[N];\n A --> AH[CHECK if the session communication materials are available and correct?];\n AH --> AI[Y];\n AH --> AJ[N];\n A --> AK[CHECK if the session waste management materials are available and correct?];\n AK --> AL[Y];\n AK --> AM[N];\n A --> AN[CHECK if the session cold chain materials are available and correct?];\n AN --> AO[Y];\n AN --> AP[N];\n A --> AQ[CHECK if the session transport materials are available and correct?];\n AQ --> AR[Y];\n AQ --> AS[N];\n A --> AT[CHECK if the session security materials are available and correct?];\n AT --> AU[Y];\n AT --> AV[N];\n A --> AW[CHECK if the session communication plan is available and correct?];\n AW --> AX[Y];\n AW --> AY[N];\n A --> AZ[CHECK if the session waste management plan is available and correct?];\n AZ --> BA[Y];\n AZ --> BB[N];\n A --> BC[CHECK if the session cold chain plan is available and correct?];\n BC --> BD[Y];\n BC --> BE[N];\n A --> BF[CHECK if the session transport plan is available and correct?];\n BF --> BG[Y];\n BF --> BH[N];\n A --> BI[CHECK if the session security plan is available and correct?];\n BI --> BJ[Y];\n BI --> BK[N];\n A --> BL[CHECK if the session communication materials are available and correct?];\n BL --> BM[Y];\n BL --> BN[N];\n A --> BO[CHECK if the session waste management materials are available and correct?];\n BO --> BP[Y];\n BO --> BQ[N];\n A --> BR[CHECK if the session cold chain materials are available and correct?];\n BR --> BS[Y];\n BR --> BT[N];\n A --> BU[CHECK if the session transport materials are available and correct?];\n BU --> BV[Y];\n BU --> BW[N];\n A --> BX[CHECK if the session security materials are available and correct?];\n BX --> BY[Y];\n BX --> BZ[N];\n A --> CA[CHECK if the session communication plan is available and correct?];\n CA --> CB[Y];\n CA --> CC[N];\n A --> CD[CHECK if the session waste management plan is available and correct?];\n CD --> CE[Y];\n CD --> CF[N];\n A --> CG[CHECK if the session cold chain plan is available and correct?];\n CG --> CH[Y];\n CG --> CI[N];\n A --> CJ[CHECK if the session transport plan is available and correct?];\n CJ --> CK[Y];\n CJ --> CL[N];\n A --> CM[CHECK if the session security plan is available and correct?];\n CM --> CN[Y];\n CM --> CO[N];\n A --> CP[CHECK if the session communication materials are available and correct?];\n CP --> CQ[Y];\n CP --> CR[N];\n A --> CS[CHECK if the session waste management materials are available and correct?];\n CS --> CT[Y];\n CS --> CU[N];\n A --> CV[CHECK if the session cold chain materials are available and correct?];\n CV --> CW[Y];\n CV --> CX[N];\n A --> CY[CHECK if the session transport materials are available and correct?];\n CY --> CZ[Y];\n CY --> DA[N];\n A --> DB[CHECK if the session security materials are available and correct?];\n DB --> DC[Y];\n DB --> DD[N];\n A --> DE[CHECK if the session communication plan is available and correct?];\n DE --> DF[Y];\n DE --> DG[N];\n A --> DH[CHECK if the session waste management plan is available and correct?];\n DH --> DI[Y];\n DH --> DJ[N];\n A --> DK[CHECK if the session cold chain plan is available and correct?];\n DK --> DL[Y];\n DK --> DM[N];\n A --> DN[CHECK if the session transport plan is available and correct?];\n DN --> DO[Y];\n DN --> DP[N];\n A --> DQ[CHECK if the session security plan is available and correct?];\n DQ --> DR[Y];\n DQ --> DS[N];\n A --> DT[CHECK if the session communication materials are available and correct?];\n DT --> DU[Y];\n DT --> DV[N];\n A --> DW[CHECK if the session waste management materials are available and correct?];\n DW --> DX[Y];\n DW --> DY[N];\n A --> DZ[CHECK if the session cold chain materials are available and correct?];\n DZ --> EA[Y];\n DZ --> EB[N];\n A --> EC[CHECK if the session transport materials are available and correct?];\n EC --> ED[Y];\n EC --> EE[N];\n A --> EF[CHECK if the session security materials are available and correct?];\n EF --> EG[Y];\n EF --> EH[N];\n A --> EI[CHECK if the session communication plan is available and correct?];\n EI --> EJ[Y];\n EI --> EK[N];\n A --> EL[CHECK if the session waste management plan is available and correct?];\n EL --> EM[Y];\n EL --> EN[N];\n A --> EO[CHECK if the session cold chain plan is available and correct?];\n EO --> EP[Y];\n EO --> EQ[N];\n A --> ER[CHECK if the session transport plan is available and correct?];\n ER --> ES[Y];\n ER --> ET[N];\n A --> EU[CHECK if the session security plan is available and correct?];\n EU --> EV[Y];\n EU --> EW[N];\n A --> EX[CHECK if the session communication materials are available and correct?];\n EX --> EY[Y];\n EX --> EZ[N];\n A --> FA[CHECK if the session waste management materials are available and correct?];\n FA --> FB[Y];\n FA --> FC[N];\n A --> FD[CHECK if the session cold chain materials are available and correct?];\n FD --> FE[Y];\n FD --> FF[N];\n A --> FG[CHECK if the session transport materials are available and correct?];\n FG --> FH[Y];\n FG --> FI[N];\n A --> FJ[CHECK if the session security materials are available and correct?];\n FJ --> FK[Y];\n FJ --> FL[N];\n A --> FM[CHECK if the session communication plan is available and correct?];\n FM --> FN[Y];\n FM --> FO[N];\n A --> FP[CHECK if the session waste management plan is available and correct?];\n FP --> FQ[Y];\n FP --> FR[N];\n A --> FS[CHECK if the session cold chain plan is available and correct?];\n FS --> FT[Y];\n FS --> FU[N];\n A --> FV[CHECK if the session transport plan is available and correct?];\n FV --> FW[Y];\n FV --> FX[N];\n A --> FY[CHECK if the session security plan is available and correct?];\n FY --> FZ[Y];\n FY --> GA[N];\n A --> GB[CHECK if the session communication materials are available and correct?];\n GB --> GC[Y];\n GB --> GD[N];\n A --> GE[CHECK if the session waste management materials are available and correct?];\n GE --> GF[Y];\n GE --> GG[N];\n A --> GH[CHECK if the session cold chain materials are available and correct?];\n GH --> GI[Y];\n GH --> GJ[N];\n A --> GK[CHECK if the session transport materials are available and correct?];\n GK --> GL[Y];\n GK --> GM[N];\n A --> GN[CHECK if the session security materials are available and correct?];\n GN --> GO[Y];\n GN --> GP[N];\n A --> GQ[CHECK if the session communication plan is available and correct?];\n GQ --> GR[Y];\n GQ --> GS[N];\n A --> GT[CHECK if the session waste management plan is available and correct?];\n GT --> GU[Y];\n GT --> GV[N];\n A --> GW[CHECK if the session cold chain plan is available and correct?];\n GW --> GX[Y];\n GW --> GY[N];\n A --> GZ[CHECK if the session transport plan is available and correct?];\n GZ --> HA[Y];\n GZ --> HB[N];\n A --> HC[CHECK if the session security plan is available and correct?];\n HC --> HD[Y];\n HC --> HE[N];\n A --> HF[CHECK if the session communication materials are available and correct?];\n HF --> HG[Y];\n HF --> HH[N];\n A --> HI[CHECK if the session waste management materials are available and correct?];\n HI --> HJ[Y];\n HI --> HK[N];\n A --> HL[CHECK if the session cold chain materials are available and correct?];\n HL --> HM[Y];\n HL --> HN[N];\n A --> HO[CHECK if the session transport materials are available and correct?];\n HO --> HP[Y];\n HO --> HQ[N];\n A --> HR[CHECK if the session security materials are available and correct?];\n HR --> HS[Y];\n HR --> HT[N];\n A --> HU[CHECK if the session communication plan is available and correct?];\n HU --> HV[Y];\n HU --> HW[N];\n A --> HX[CHECK if the session waste management plan is available and correct?];\n HX --> HY[Y];\n HX --> HZ[N];\n A --> IA[CHECK if the session cold chain plan is available and correct?];\n IA --> IB[Y];\n IA --> IC[N];\n A --> ID[CHECK if the session transport plan is available and correct?];\n ID --> IE[Y];\n ID --> IF[N];\n A --> IG[CHECK if the session security plan is available and correct?];\n IG --> IH[Y];\n IG --> II[N];\n A --> IJ[CHECK if the session communication materials are available and correct?];\n IJ --> IK[Y];\n IJ --> IL[N];\n A --> IM[CHECK if the session waste management materials are available and correct?];\n IM --> IN[Y];\n IM --> IO[N];\n A --> IP[CHECK if the session cold chain materials are available and correct?];\n IP --> IQ[Y];\n IP --> IR[N];\n A --> IS[CHECK if the session transport materials are available and correct?];\n IS --> IT[Y];\n IS --> IU[N];\n A --> IV[CHECK if the session security materials are available and correct?];\n IV --> IW[Y];\n IV --> IX[N];\n A --> IY[CHECK if the session communication plan is available and correct?];\n IY --> IZ[Y];\n IY --> JA[N];\n A --> JB[CHECK if the session waste management plan is available and correct?];\n JB --> JC[Y];\n JB --> JD[N];\n A --> JE[CHECK if the session cold chain plan is available and correct?];\n JE --> JF[Y];\n JE --> JG[N];\n A --> JH[CHECK if the session transport plan is available and correct?];\n JH --> JI[Y];\n JH --> JJ[N];\n A --> JK[CHECK if the session security plan is available and correct?];\n JK --> JL[Y];\n JK --> JM[N];\n A --> JN[CHECK if the session communication materials are available and correct?];\n JN --> JO[Y];\n JN --> JP[N];\n A --> JQ[CHECK if the session waste management materials are available and correct?];\n JQ --> JR[Y];\n JQ --> JS[N];\n A --> JT[CHECK if the session cold chain materials are available and correct?];\n JT --> JU[Y];\n JT --> JV[N];\n A --> JW[CHECK if the session transport materials are available and correct?];\n JW --> JX[Y];\n JW --> JY[N];\n A --> JZ[CHECK if the session security materials are available and correct?];\n JZ --> KA[Y];\n JZ --> KB[N];\n A --> KC[CHECK if the session communication plan is available and correct?];\n KC --> KD[Y];\n KC --> KE[N];\n A --> KF[CHECK if the session waste management plan is available and correct?];\n KF --> KG[Y];\n KF --> KH[N];\n A --> KI[CHECK if the session cold chain plan is available and correct?];\n KI --> KJ[Y];\n KI --> KK[N];\n A --> KL[CHECK if the session transport plan is available and correct?];\n KL --> KM[Y];\n KL --> KN[N];\n A --> KO[CHECK if the session security plan is available and correct?];\n KO --> KP[Y];\n KO --> KQ[N];\n A --> KR[CHECK if the session communication materials are available and correct?];\n KR --> KS[Y];\n KR --> KT[N];\n A --> KU[CHECK if the session waste management materials are available and correct?];\n KU --> KV[Y];\n KU --> KW[N];\n A --> KX[CHECK if the session cold chain materials are available and correct?];\n KX --> KY[Y];\n KX --> KZ[N];\n A --> LA[CHECK if the session transport materials are available and correct?];\n LA --> LB[Y];\n LA --> LC[N];\n A --> LD[CHECK if the session security materials are available and correct?];\n LD --> LE[Y];\n LD --> LF[N];\n A --> LG[CHECK if the session communication plan is available and correct?];\n LG --> LH[Y];\n LG --> LI[N];\n A --> LJ[CHECK if the session waste management plan is available and correct?];\n LJ --> LK[Y];\n LJ --> LL[N];\n A --> LM[CHECK if the session cold chain plan is available and correct?];\n LM --> LN[Y];\n LM --> LO[N];\n A --> LP[CHECK if the session transport plan is available and correct?];\n LP --> LQ[Y];\n LP --> LR[N];\n A --> LS[CHECK if the session security plan is available and correct?];\n LS --> LT[Y];\n LS --> LU[N];\n A --> LV[CHECK if the session communication materials are available and correct?];\n LV --> LW[Y];\n LV --> LX[N];\n A --> LY[CHECK if the session waste management materials are available and correct?];\n LY --> LZ[Y];\n LY --> MA[N];\n A --> MB[CHECK if the session cold chain materials are available and correct?];\n MB --> MC[Y];\n MB --> MD[N];\n A --> ME[CHECK if the session transport materials are available and correct?];\n ME --> MF[Y];\n ME --> MG[N];\n A --> MH[CHECK if the session security materials are available and correct?];\n MH --> MI[Y];\n MH --> MJ[N];\n A --> MK[CHECK if the session communication plan is available and correct?];\n MK --> ML[Y];\n MK --> MM[N];\n A --> MN[CHECK if the session waste management plan is available and correct?];\n MN --> MO[Y];\n MN --> MP[N];\n A --> MQ[CHECK if the session cold chain plan is available and correct?];\n MQ --> MR[Y];\n MQ --> MS[N];\n A --> MT[CHECK if the session transport plan is available and correct?];\n MT --> MU[Y];\n MT --> MV[N];\n A --> MW[CHECK if the session security plan is available and correct?];\n MW --> MX[Y];\n MW --> MY[N];\n A --> MZ[CHECK if the session communication materials are available and correct?];\n MZ --> NA[Y];\n MZ --> NB[N];\n A --> NC[CHECK if the session waste management materials are available and correct?];\n NC --> ND[Y];\n NC --> NE[N];\n A --> NF[CHECK if the session cold chain materials are available and correct?];\n NF --> NG[Y];\n NF --> NH[N];\n A --> NI[CHECK if the session transport materials are available and correct?];\n NI --> NJ[Y];\n NI --> NK[N];\n A --> NL[CHECK if the session security materials are available and correct?];\n NL --> NM[Y];\n NL --> NN[N];\n A --> NO[CHECK if the session communication plan is available and correct?];\n NO --> NP[Y];\n NO --> NQ[N];\n A --> NR[CHECK if the session waste management plan is available and correct?];\n NR --> NS[Y];\n NR --> NT[N];\n A --> NU[CHECK if the session cold chain plan is available and correct?];\n NU --> NV[Y];\n NU --> NW[N];\n A --> NX[CHECK if the session transport plan is available and correct?];\n NX --> NY[Y];\n NX --> NZ[N];\n A --> OA[CHECK if the session security plan is available and correct?];\n OA --> OB[Y];\n OA --> OC[N];\n A --> OD[CHECK if the session communication materials are available and correct?];\n OD --> OE[Y];\n OD --> OF[N];\n A --> OG[CHECK if the session waste management materials are available and correct?];\n OG --> OH[Y];\n OG --> OI[N];\n A --> OJ[CHECK if the session cold chain materials are available and correct?];\n OJ --> OK[Y];\n OJ --> OL[N];\n A --> OM[CHECK if the session transport materials are available and correct?];\n OM --> ON[Y];\n OM --> OO[N];\n A --> OP[CHECK if the session security materials are available and correct?];\n OP --> OQ[Y];\n OP --> OR[N];\n A --> OS[CHECK if the session communication plan is available and correct?];\n OS --> OT[Y];\n OS --> OU[N];\n A --> OV[CHECK if the session waste management plan is available and correct?];\n OV --> OW[Y];\n OV --> OX[N];\n A --> OY[CHECK if the session cold chain plan is available and correct?];\n OY --> OZ[Y];\n OY --> PA[N];\n A --> PB[CHECK if the session transport plan is available and correct?];\n PB --> PC[Y];\n PB --> PD[N];\n A --> PE[CHECK if the session security plan is available and correct?];\n PE --> PF[Y];\n PE --> PG[N];\n A --> PH[CHECK if the session communication materials are available and correct?];\n PH --> PI[Y];\n PH --> PJ[N];\n A --> PK[CHECK if the session waste management materials are available and correct?];\n PK --> PL[Y];\n PK --> PM[N];\n A --> PN[CHECK if the session cold chain materials are available and correct?];\n PN --> PO[Y];\n PN --> PP[N];\n A --> PQ[CHECK if the session transport materials are available and correct?];\n PQ --> PR[Y];\n PQ --> PS[N];\n A --> PT[CHECK if the session security materials are available and correct?];\n PT --> PU[Y];\n PT --> PV[N];\n A --> PW[CHECK if the session communication plan is available and correct?];\n PW --> PX[Y];\n PW --> PY[N];\n A --> PZ[CHECK if the session waste management plan is available and correct?];\n PZ --> QA[Y];\n PZ --> QB[N];\n A --> QC[CHECK if the session cold chain plan is available and correct?];\n QC --> QD[Y];\n QC --> QE[N];\n A --> QF[CHECK if the session transport plan is available and correct?];\n QF --> QG[Y];\n QF --> QH[N];\n A --> QI[CHECK if the session security plan is available and correct?];\n QI --> QJ[Y];\n QI --> QK[N];\n A --> QL[CHECK if the session communication materials are available and correct?];\n QL --> QM[Y];\n QL --> QN[N];\n A --> QO[CHECK if the session waste management materials are available and correct?];\n QO --> QP[Y];\n QO --> QQ[N];\n A --> QR[CHECK if the session cold chain materials are available and correct?];\n QR --> QS[Y];\n QR --> QT[N];\n A --> QU[CHECK if the session transport materials are available and correct?];\n QU --> QV[Y];\n QU --> QW[N];\n A --> QX[CHECK if the session security materials are available and correct?];\n QX --> QY[Y];\n QX --> QZ[N];\n A --> RA[CHECK if the session communication plan is available and correct?];\n RA --> RB[Y];\n RA --> RC[N];\n A --> RD[CHECK if the session waste management plan is available and correct?];\n RD --> RE[Y];\n RD --> RF[N];\n A --> RG[CHECK if the session cold chain plan is available and correct?];\n RG --> RH[Y];\n RG --> RI[N];\n A --> RJ[CHECK if the session transport plan is available and correct?];\n RJ --> RK[Y];\n RJ --> RL[N];\n A --> RM[CHECK if the session security plan is available and correct?];\n RM --> RN[Y];\n RM --> RO[N];\n A --> RP[CHECK if the session communication materials are available and correct?];\n RP --> RQ[Y];\n RP --> RR[N];\n A --> RS[CHECK if the session waste management materials are available and correct?];\n RS --> RT[Y];\n RS --> RU[N];\n A --> RV[CHECK if the session cold chain materials are available and correct?];\n RV --> RW[Y];\n RV --> RX[N];\n A --> RY[CHECK if the session transport materials are available and correct?];\n RY --> RZ[Y];\n RY --> SA[N];\n A --> SB[CHECK if the session security materials are available and correct?];\n SB --> SC[Y];\n SB --> SD[N];\n A --> SE[CHECK if the session communication plan is available and correct?];\n SE --> SF[Y];\n SE --> SG[N];\n A --> SH[CHECK if the session waste management plan is available and correct?];\n SH --> SI[Y];\n SH --> SJ[N];\n A --> SK[CHECK if the session cold chain plan is available and correct?];\n SK --> SL[Y];\n SK --> SM[N];\n A --> SN[CHECK if the session transport plan is available and correct?];\n SN --> SO[Y];\n SN --> SP[N];\n A --> SQ[CHECK if the session security plan is available and correct?];\n SQ --> SR[Y];\n SQ --> SS[N];\n A --> ST[CHECK if the session communication materials are available and correct?];\n ST --> SU[Y];\n ST --> SV[N];\n A --> SW[CHECK if the session waste management materials are available and correct?];\n SW --> SX[Y];\n SW --> SY[N];\n A --> SZ[CHECK if the session cold chain materials are available and correct?];\n SZ --> TA[Y];\n SZ --> TB[N];\n A --> TC[CHECK if the session transport materials are available and correct?];\n TC --> TD[Y];\n TC --> TE[N];\n A --> TF[CHECK if the session security materials are available and correct?];\n TF --> TG[Y];\n TF --> TH[N];\n A --> TI[CHECK if the session communication plan is available and correct?];\n TI --> TJ[Y];\n TI --> TK[N];\n A --> TL[CHECK if the session waste management plan is available and correct?];\n TL --> TM[Y];\n TL --> TN[N];\n A --> TO[CHECK if the session cold chain plan is available and correct?];\n TO --> TP[Y];\n TO --> TQ[N];\n A --> TR[CHECK if the session transport plan is available and correct?];\n TR --> TS[Y];\n TR --> TT[N];\n A --> TU[CHECK if the session security plan is available and correct?];\n TU --> TV[Y];\n TU --> TW[N];\n A --> TX[CHECK if the session communication materials are available and correct?];\n TX --> TY[Y];\n TX --> TZ[N];\n A --> UA[CHECK if the session waste management materials are available and correct?];\n UA --> UB[Y];\n UA --> UC[N];\n A --> UD[CHECK if the session cold chain materials are available and correct?];\n UD --> UE[Y];\n UD --> UF[N];\n A --> UG[CHECK if the session transport materials are available and correct?];\n UG --> UH[Y];\n UG --> UI[N];\n A --> UJ[CHECK if the session security materials are available and correct?];\n UJ --> UK[Y];\n UJ --> UL[N];\n A --> UM[CHECK if the session communication plan is available and correct?];\n UM --> UN[Y];\n UM --> UO[N];\n A --> UP[CHECK if the session waste management plan is available and correct?];\n UP --> UQ[Y];\n UP --> UR[N];\n A --> US[CHECK if the session cold chain plan is available and correct?];\n US --> UT[Y];\n US --> UU[N];\n A --> UV[CHECK if the session transport plan is available and correct?];\n UV --> UW[Y];\n UV --> UX[N];\n A --> UY[CHECK if the session security plan is available and correct?];\n UY --> UZ[Y];\n UY --> VA[N];\n A --> VB[CHECK if the session communication materials are available and correct?];\n VB --> VC[Y];\n VB --> VD[N];\n A --> VE[CHECK if the session waste management materials are available and correct?];\n VE --> VF[Y];\n VE --> VG[N];\n A --> VH[CHECK if the session cold chain materials are available and correct?];\n VH --> VI[Y];\n VH --> VJ[N];\n A --> VK[CHECK if the session transport materials are available and correct?];\n VK --> VL[Y];\n VK --> VM[N];\n A --> VN[CHECK if the session security materials are available and correct?];\n VN --> VO[Y];\n VN --> VP[N];\n A --> VQ[CHECK if the session communication plan is available and correct?];\n VQ --> VR[Y];\n VQ --> VS[N];\n A --> VT[CHECK if the session waste management plan is available and correct?];\n VT --> VU[Y];\n VT --> VV[N];\n A --> VW[CHECK if the session cold chain plan is available and correct?];\n VW --> VX[Y];\n VW --> VY[N];\n A --> VZ[CHECK if the session transport plan is available and correct?];\n VZ --> WA[Y];\n VZ --> WB[N];\n A --> WC[CHECK if the session security plan is available and correct?];\n WC --> WD[Y];\n WC --> WE[N];\n A --> WF[CHECK if the session communication materials are available and correct?];\n WF --> WG[Y];\n WF --> WH[N];\n A --> WI[CHECK if the session waste management materials are available and correct?];\n WI --> WJ[Y];\n WI --> WK[N];\n A --> WL[CHECK if the session cold chain materials are available and correct?];\n WL --> WM[Y];\n WL --> WN[N];\n A --> WO[CHECK if the session transport materials are available and correct?];\n WO --> WP[Y];\n WO --> WQ[N];\n A --> WR[CHECK if the session security materials are available and correct?];\n WR --> WS[Y];\n WR --> WT[N];\n A --> WU[CHECK if the session communication plan is available and correct?];\n WU --> WV[Y];\n WU --> WW[N];\n A --> WX[CHECK if the session waste management plan is available and correct?];\n WX --> WY[Y];\n WX --> WZ[N];\n A --> XA[CHECK if the session cold chain plan is available and correct?];\n XA --> XB[Y];\n XA --> XC[N];\n A --> XD[CHECK if the session transport plan is available and correct?];\n XD --> XE[Y];\n XD --> XF[N];\n A --> XG[CHECK if the session security plan is available and correct?];\n XG --> XH[Y];\n XG --> XI[N];\n A --> XJ[CHECK if the session communication materials are available and correct?];\n XJ --> XK[Y];\n XJ --> XL[N];\n A --> XM[CHECK if the session waste management materials are available and correct?];\n XM --> XN[Y];\n XM --> XO[N];\n A --> XP[CHECK if the session cold chain materials are available and correct?];\n XP --> XQ[Y];\n XP --> XR[N];\n A --> XS[CHECK if the session transport materials are available and correct?];\n XS --> XT[Y];\n XS --> XU[N];\n A --> XV[CHECK if the session security materials are available and correct?];\n XV --> XW[Y];\n XV --> XX[N];\n A --> XY[CHECK if the session communication plan is available and correct?];\n XY --> XZ[Y];\n XY --> YA[N];\n A --> YB[CHECK if the session waste management plan is available and correct?];\n YB --> YC[Y];\n YB --> YD[N];\n A --> YE[CHECK if the session cold chain plan is available and correct?];\n YE --> YF[Y];\n YE --> YG[N];\n A --> YH[CHECK if the session transport plan is available and correct?];\n YH --> YI[Y];\n YH --> YJ[N];\n A --> YK[CHECK if the session security plan is available and correct?];\n YK --> YL[Y];\n YK --> YM[N];\n A --> YN[CHECK if the session communication materials are available and correct?];\n YN --> YO[Y];\n YN --> YP[N];\n A --> YQ[CHECK if the session waste management materials are available and correct?];\n YQ --> YR[Y];\n YQ --> YS[N];\n A --> YT[CHECK if the session cold chain materials are available and correct?];\n YT --> YU[Y];\n YT --> YV[N];\n A --> YW[CHECK if the session transport materials are available and correct?];\n YW --> YX[Y];\n YW --> YY[N];\n A --> YZ[CHECK if the session security materials are available and correct?];\n YZ --> ZA[Y];\n YZ --> ZB[N];\n A --> ZC[CHECK if the session communication plan is available and correct?];\n ZC --> ZD[Y];\n ZC --> ZE[N];\n A --> ZF[CHECK if the session waste management plan is available and correct?];\n ZF --> ZG[Y];\n ZF --> ZH[N];\n A --> ZI[CHECK if the session cold chain plan is available and correct?];\n ZI --> ZJ[Y];\n ZI --> ZK[N];\n A --> ZL[CHECK if the session transport plan is available and correct?];\n ZL --> ZM[Y];\n ZL --> ZN[N];\n A --> ZO[CHECK if the session security plan is available and correct?];\n ZO --> ZP[Y];\n ZO --> ZQ[N];\n A --> ZR[CHECK if the session communication materials are available and correct?];\n ZR --> ZS[Y];\n ZR --> ZT[N];\n A --> ZU[CHECK if the session waste management materials are available and correct?];\n ZU --> ZV[Y];\n ZU --> ZW[N];\n A --> ZX[CHECK if the session cold chain materials are available and correct?];\n ZX --> ZY[Y];\n ZX --> ZZ[N];\n A --> AAA[CHECK if the session transport materials are available and correct?];\n AAA --> AAB[Y];\n AAA --> AAC[N];\n A --> AAD[CHECK if the session security materials are available and correct?];\n AAD --> AAE[Y];\n AAD --> AAF[N];\n A --> AAG[CHECK if the session communication plan is available and correct?];\n AAG --> AAH[Y];\n AAG --> AAI[N];\n A --> AAJ[CHECK if the session waste management plan is available and correct?];\n AAJ --> AAK[Y];\n AAJ --> AAL[N];\n A --> AAM[CHECK if the session cold chain plan is available and correct?];\n AAM --> AAN[Y];\n AAM --> AAO[N];\n A --> AAP[CHECK if the session transport plan is available and correct?];\n AAP --> AAQ[Y];\n AAP --> AAR[N];\n A --> AAS[CHECK if the session security plan is available and correct?];\n AAS --> AAT[Y];\n AAS --> AAU[N];\n A --> AAV[CHECK if the session communication materials are available and correct?];\n AAV --> AAW[Y];\n AAV --> AAX[N];\n A --> AAY[CHECK if the session waste management materials are available and correct?];\n AAY --> AAZ[Y];\n AAY --> ABA[N];\n A --> ABB[CHECK if the session cold chain materials are available and correct?];\n ABB --> ABC[Y];\n ABB --> ABD[N];\n A --> ABE[CHECK if the session transport materials are available and correct?];\n ABE --> ABF[Y];\n ABE --> ABG[N];\n A --> ABH[CHECK if the session security materials are available and correct?];\n ABH --> ABI[Y];\n ABH --> ABJ[N];\n A --> ABK[CHECK if the session communication plan is available and correct?];\n ABK --> ABL[Y];\n ABK --> ABM[N];\n A --> ABN[CHECK if the session waste management plan is available and correct?];\n ABN --> ABO[Y];\n ABN --> ABP[N];\n A --> ABQ[CHECK if the session cold chain plan is available and correct?];\n ABQ --> ABR[Y];\n ABQ --> ABS[N];\n A --> ABT[CHECK if the session transport plan is available and correct?];\n ABT --> ABU[Y];\n ABT --> ABV[N];\n A --> ABW[CHECK if the session security plan is available and correct?];\n ABW --> ABX[Y];\n ABW --> ABY[N];\n A --> ABZ[CHECK if the session communication materials are available and correct?];\n ABZ --> ACA[Y];\n ABZ --> ACB[N];\n A --> ACC[CHECK if the session waste management materials are available and correct?];\n ACC --> ACD[Y];\n ACC --> ACE[N];\n A --> ACF[CHECK if the session cold chain materials are available and correct?];\n ACF --> ACG[Y];\n ACF --> ACH[N];\n A --> ACI[CHECK if the session transport materials are available and correct?];\n ACI --> ACJ[Y];\n ACI --> ACK[N];\n A --> ACL[CHECK if the session security materials are available and correct?];\n ACL --> ACM[Y];\n ACL --> ACN[N];\n A --> ACO[CHECK if the session communication plan is available and correct?];\n ACO --> ACP[Y];\n ACO --> ACQ[N];\n A --> ACR[CHECK if the session waste management plan is available and correct?];\n ACR --> ACS[Y];\n ACR --> ACT[N];\n A --> ACU[CHECK if the session cold chain plan is available and correct?];\n ACU --> ACV[Y];\n ACU --> ACW[N];\n A --> ACX[CHECK if the session transport plan is available and correct?];\n ACX --> ACY[Y];\n ACX --> ACZ[N];\n A --> ADA[CHECK if the session security plan is available and correct?];\n ADA --> ADB[Y];\n ADA --> ADC[N];\n A --> ADD[CHECK if the session communication materials are available and correct?];\n ADD --> ADE[Y];\n ADD --> ADF[N];\n A --> ADG[CHECK if the session waste management materials are available and correct?];\n ADG --> ADH[Y];\n ADG --> ADI[N];\n A --> ADJ[CHECK if the session cold chain materials are available and correct?];\n ADJ --> ADK[Y];\n ADJ --> ADL[N];\n A --> ADM[CHECK if the session transport materials are available and correct?];\n ADM --> ADN[Y];\n ADM --> ADO[N];\n A --> ADP[CHECK if the session security materials are available and correct?];\n ADP --> ADQ[Y];\n ADP --> ADR[N];\n A --> ADS[CHECK if the session communication plan is available and correct?];\n ADS --> ADT[Y];\n ADS --> ADU[N];\n A --> ADV[CHECK if the session waste management plan is available and correct?];\n ADV --> ADW[Y];\n ADV --> ADX[N];\n A --> ADY[CHECK if the session cold chain plan is available and correct?];\n ADY --> ADZ[Y];\n ADY --> AEA[N];\n A --> AEB[CHECK if the session transport plan is available and correct?];\n AEB --> AEC[Y];\n AEB --> AED[N];\n A --> AEE[CHECK if the session security plan is available and correct?];\n AEE --> AEF[Y];\n AEE --> AEG[N];\n A --> AEH[CHECK if the session communication materials are available and correct?];\n AEH --> AEI[Y];\n AEH --> AEJ[N];\n A --> AEK[CHECK if the session waste management materials are available and correct?];\n AEK --> AEL[Y];\n AEK --> AEM[N];\n A --> AEN[CHECK if the session cold chain materials are available and correct?];\n AEN --> AEO[Y];\n AEN --> AEP[N];\n A --> AEQ[CHECK if the session transport materials are available and correct?];\n AEQ --> AER[Y];\n AEQ --> AES[N];\n A --> AET[CHECK if the session security materials are available and correct?];\n AET --> AEU[Y];\n AET --> AEV[N];\n A --> AEW[CHECK if the session communication plan is available and correct?];\n AEW --> AEX[Y];\n AEW --> AEY[N];\n A --> AEZ[CHECK if the session waste management plan is available and correct?];\n AEZ --> AFA[Y];\n AEZ --> AFB[N];\n A --> AFC[CHECK if the session cold chain plan is available and correct?];\n AFC --> AFD[Y];\n AFC --> AFE[N];\n A --> AFF[CHECK if the session transport plan is available and correct?];\n AFF --> AFG[Y];\n AFF --> AFH[N];\n A --> AFI[CHECK if the session security plan is available and correct?];\n AFI --> AFJ[Y];\n AFI --> AFK[N];\n A --> AFL[CHECK if the session communication materials are available and correct?];\n AFL --> AFM[Y];\n AFL --> AFN[N];\n A --> AFO[CHECK if the session waste management materials are available and correct?];\n AFO --> AFP[Y];\n AFO --> AFQ[N];\n A --> AFR[CHECK if the session cold chain materials are available and correct?];\n AFR --> AFS[Y];\n AFR --> AFT[N];\n A --> AFU[CHECK if the session transport materials are available and correct?];\n AFU --> AFV[Y];\n AFU --> AFW[N];\n A --> AFX[CHECK if the session security materials are available and correct?];\n AFX --> AFY[Y];\n AFX --> AFZ[N];\n A --> AGA[CHECK if the session communication plan is available and correct?];\n AGA --> AGB[Y];\n AGA --> AGC[N];\n A --> AGD[CHECK if the session waste management plan is available and correct?];\n AGD --> AGE[Y];\n AGD --> AGF[N];\n A --> AGG[CHECK if the session cold chain plan is available and correct?];\n AGG --> AGH[Y];\n AGG --> AGI[N];\n A --> AGJ[CHECK if the session transport plan is available and correct?];\n AGJ --> AGK[Y];\n AGJ --> AGL[N];\n A --> AGM[CHECK if the session security plan is available and correct?];\n AGM --> AGN[Y];\n AGM --> AGO[N];\n A --> AGP[CHECK if the session communication materials are available and correct?];\n AGP --> AGQ[Y];\n AGP --> AGR[N];\n A --> AGS[CHECK if the session waste management materials are available and correct?];\n AGS --> AGT[Y];\n AGS --> AGU[N];\n A --> AGV[CHECK if the session cold chain materials are available and correct?];\n AGV --> AGW[Y];\n AGV --> AGX[N];\n A --> AGY[CHECK if the session transport materials are available and correct?];\n AGY --> AGZ[Y];\n AGY --> AHA[N];\n A --> AHB[CHECK if the session security materials are available and correct?];\n AHB --> AHC[Y];\n AHB --> AHD[N];\n A --> AHE[CHECK if the session communication plan is available and correct?];\n AHE --> AHF[Y];\n AHE --> AHG[N];\n A --> AHH[CHECK if the session waste management plan is available and correct?];\n AHH --> AHI[Y];\n AHH --> AHJ[N];\n A --> AHK[CHECK if the session cold chain plan is available and correct?];\n AHK --> AHL[Y];\n AHK --> AHM[N];\n A --> AHN[CHECK if the session transport plan is available and correct?];\n AHN --> AHO[Y];\n AHN --> AHP[N];\n A --> AHQ[CHECK if the session security plan is available and correct?];\n AHQ --> AHR[Y];\n AHQ --> AHS[N];\n A --> AHT[CHECK if the session communication materials are available and correct?];\n AHT --> AHU[Y];\n AHT --> AHV[N];\n A --> AHW[CHECK if the session waste management materials are available and correct?];\n AHW --> AHX[Y];\n AHW --> AHY[N];\n A --> AHZ[CHECK if the session cold chain materials are available and correct?];\n AHZ --> AIA[Y];\n AHZ --> AIB[N];\n A --> AIC[CHECK if the session transport materials are available and correct?];\n AIC --> AID[Y];\n AIC --> AIE[N];\n A --> AIF[CHECK if the session security materials are available and correct?];\n AIF --> AIG[Y];\n AIF --> AIH[N];\n A --> AII[CHECK if the session communication plan is available and correct?];\n AII --> AIJ[Y];\n AII --> AIK[N];\n A --> AIL[CHECK if the session waste management plan is available and correct?];\n AIL --> AIM[Y];\n AIL --> AIN[N];\n A --> AIO[CHECK if the session cold chain plan is available and correct?];\n AIO --> AIP[Y];\n AIO --> AIQ[N];\n A --> AIR[CHECK if the session transport plan is available and correct?];\n AIR --> AIS[Y];\n AIR --> AIT[N];\n A --> AIU[CHECK if the session security plan is available and correct?];\n AIU --> AIV[Y];\n AIU --> AIW[N];\n A --> AIX[CHECK if the session communication materials are available and correct?];\n AIX --> AIY[Y];\n AIX --> AIZ[N];\n A --> AJA[CHECK if the session waste management materials are available and correct?];\n AJA --> AJB[Y];\n AJA --> AJC[N];\n A --> AJD[CHECK if the session cold chain materials are available and correct?];\n AJD --> AJE[Y];\n AJD --> AJF[N];\n A --> AJG[CHECK if the session transport materials are available and correct?];\n AJG --> AJH[Y];\n AJG --> AJI[N];\n A --> AJJ[CHECK if the session security materials are available and correct?];\n AJJ --> AJK[Y];\n AJJ --> AJL[N];\n A --> AJM[CHECK if the session communication plan is available and correct?];\n AJM --> AJN[Y];\n AJM --> AJO[N];\n A --> AJP[CHECK if the session waste management plan is available and correct?];\n AJP --> AJQ[Y];\n AJP --> AJR[N];\n A --> AJS[CHECK if the session cold chain plan is available and correct?];\n AJS --> AJT[Y];\n AJS --> AJU[N];\n A --> AJV[CHECK if the session transport plan is available and correct?];\n AJV --> AJW[Y];\n AJV --> AJX[N];\n A --> AJY[CHECK if the session security plan is available and correct?];\n AJY --> AJZ[Y];\n AJY --> AKA[N];\n A --> AKB[CHECK if the session communication materials are available and correct?];\n AKB --> AKC[Y];\n AKB --> AKD[N];\n A --> AKE[CHECK if the session waste management materials are available and correct?];\n AKE --> AKF[Y];\n AKE --> AKG[N];\n A --> AKH[CHECK if the session cold chain materials are available and correct?];\n AKH --> AKI[Y];\n AKH --> AKJ[N];\n A --> AKK[CHECK if the session transport materials are available and correct?];\n AKK --> AKL[Y];\n AKK --> AKM[N];\n A --> AKN[CHECK if the session security materials are available and correct?];\n AKN --> AKO[Y];\n AKN --> AKP[N];\n A --> AKQ[CHECK if the session communication plan is available and correct?];\n AKQ --> AKR[Y];\n AKQ --> AKS[N];\n A --> AKT[CHECK if the session waste management plan is available and correct?];\n AKT --> AKU[Y];\n AKT --> AKV[N];\n A --> AKW[CHECK if the session cold chain plan is available and correct?];\n AKW --> AKX[Y];\n AKW --> AKY[N];\n A --> AKZ[CHECK if the session transport plan is available and correct?];\n AKZ --> ALA[Y];\n AKZ --> ALB[N];\n A --> ALC[CHECK if the session security plan is available and correct?];\n ALC --> ALD[Y];\n ALC --> ALE[N];\n A --> ALF[CHECK if the session communication materials are available and correct?];\n ALF --> ALG[Y];\n ALF --> ALH[N];\n A --> ALI[CHECK if the session waste management materials are available and correct?];\n ALI --> ALJ[Y];\n ALI --> ALK[N];\n A --> ALL[CHECK if the session cold chain materials are available and correct?];\n ALL --> ALM[Y];\n ALL --> ALN[N];\n A --> ALO[CHECK if the session transport materials are available and correct?];\n ALO --> ALP[Y];\n ALO --> ALQ[N];\n A --> ALR[CHECK if the session security materials are available and correct?];\n ALR --> ALS[Y];\n ALR --> ALT[N];\n A --> ALU[CHECK if the session communication plan is available and correct?];\n ALU --> ALV[Y];\n ALU --> ALW[N];\n A --> ALX[CHECK if the session waste management plan is available and correct?];\n ALX --> ALY[Y];\n ALX --> ALZ[N];\n A --> AMA[CHECK if the session cold chain plan is available and correct?];\n AMA --> AMB[Y];\n AMA --> AMC[N];\n A --> AMD[CHECK if the session transport plan is available and correct?];\n AMD --> AME[Y];\n AMD --> AMF[N];\n A --> AMG[CHECK if the session security plan is available and correct?];\n AMG --> AMH[Y];\n AMG --> AMI[N];\n A --> AMJ[CHECK if the session communication materials are available and correct?];\n AMJ --> AMK[Y];\n AMJ --> AML[N];\n A --> AMM[CHECK if the session waste management materials are available and correct?];\n AMM --> AMN[Y];\n AMM --> AMO[N];\n A --> AMP[CHECK if the session cold chain materials are available and correct?];\n AMP --> AMQ[Y];\n AMP --> AMR[N];\n A --> AMS[CHECK if the session transport materials are available and correct?];\n AMS --> AMT[Y];\n AMS --> AMU[N];\n A --> AMV[CHECK if the session security materials are available and correct?];\n AMV --> AMW[Y];\n AMV --> AMX[N];\n A --> AMY[CHECK if the session communication plan is available and correct?];\n AMY --> AMZ[Y];\n AMY --> ANA[N];\n A --> ANB[CHECK if the session waste management plan is available and correct?];\n ANB --> ANC[Y];\n ANB --> AND[N];\n A --> ANE[CHECK if the session cold chain plan is available and correct?];\n ANE --> ANF[Y];\n ANE --> ANG[N];\n A --> ANH[CHECK if the session transport plan is available and correct?];\n ANH --> ANI[Y];\n ANH --> ANJ[N];\n A --> ANK[CHECK if the session security plan is available and correct?];\n ANK --> ANL[Y];\n ANK --> ANM[N];\n A --> ANN[CHECK if the session communication materials are available and correct?];\n ANN --> ANO[Y];\n ANN --> ANP[N];\n A --> ANQ[CHECK if the session waste management materials are available and correct?];\n ANQ --> ANR[Y];\n ANQ --> ANS[N];\n A --> ANT[CHECK if the session cold chain materials are available and correct?];\n ANT --> ANU[Y];\n ANT --> ANV[N];\n A --> ANW[CHECK if the session transport materials are available and correct?];\n ANW --> ANX[Y];\n ANW --> ANY[N];\n A --> ANZ[CHECK if the session security materials are available and correct?];\n ANZ --> AOA[Y];\n ANZ --> AOB[N];\n A --> AOC[CHECK if the session communication plan is available and correct?];\n AOC --> AOD[Y];\n AOC --> AOE[N];\n A --> AOF[CHECK if the session waste management plan is available and correct?];\n AOF --> AOG[Y];\n AOF --> AOH[N];\n A --> AOI[CHECK if the session cold chain plan is available and correct?];\n AOI --> AOJ[Y];\n AOI --> AOK[N];\n A --> AOL[CHECK if the session transport plan is available and correct?];\n AOL --> AOM[Y];\n AOL --> AON[N];\n A --> AOO[CHECK if the session security plan is available and correct?];\n AOO --> AOP[Y];\n AOO --> AOQ[N];\n A --> AOR[CHECK if the session communication materials are available and correct?];\n AOR --> AOS[Y];\n AOR --> AOT[N];\n A --> AOU[CHECK if the session waste management materials are available and correct?];\n AOU --> AOV[Y];\n AOU --> AOW[N];\n A --> AOX[CHECK if the session cold chain materials are available and correct?];\n AOX --> AOY[Y];\n AOX --> AOZ[N];\n A --> APA[CHECK if the session transport materials are available and correct?];\n APA --> APB[Y];\n APA --> APC[N];\n A --> APD[CHECK if the session security materials are available and correct?];\n APD --> APE[Y];\n APD --> APF[N];\n A --> APG[CHECK if the session communication plan is available and correct?];\n APG --> APH[Y];\n APG --> API[N];\n A --> APJ[CHECK if the session waste management plan is available and correct?];\n APJ --> APK[Y];\n APJ --> APL[N];\n A --> APM[CHECK if the session cold chain plan is available and correct?];\n APM --> APN[Y];\n APM --> APO[N];\n A --> APP[CHECK if the session transport plan is available and correct?];\n APP --> APQ[Y];\n APP --> APR[N];\n A --> APS[CHECK if the session security plan is available and correct?];\n APS --> APT[Y];\n APS --> APU[N];\n A --> APV[CHECK if the session communication materials are available and correct?];\n APV --> APW[Y];\n APV --> APX[N];\n A --> APY[CHECK if the session waste management materials are available and correct?];\n APY --> APZ[Y];\n APY --> AQA[N];\n A --> AQB[CHECK if the session cold chain materials are available and correct?];\n AQB --> AQC[Y];\n AQB --> AQD[N];\n A --> AQE[CHECK if the session transport materials are available and correct?];\n AQE --> AQF[Y];\n AQE --> AQG[N];\n A --> AQH[CHECK if the session security materials are available and correct?];\n AQH --> AQI[Y];\n AQH --> AQJ[N];\n A --> AQK[CHECK if the session communication plan is available and correct?];\n AQK --> AQL[Y];\n AQK --> AQM[N];\n A --> AQN[CHECK if the session waste management plan is available and correct?];\n AQN --> AQO[Y];\n AQN --> AQP[N];\n A --> AQQ[CHECK if the session cold chain plan is available and correct?];\n AQQ --> AQR[Y];\n AQQ --> AQS[N];\n A --> AQT[CHECK if the session transport plan is available and correct?];\n AQT --> AQU[Y];\n AQT --> AQV[N];\n A --> AQW[CHECK if the session security plan is available and correct?];\n AQW --> AQX[Y];\n AQW --> AQY[N];\n A --> AQZ[CHECK if the session communication materials are available and correct?];\n AQZ --> ARA[Y];\n AQZ --> ARB[N];\n A --> ARC[CHECK if the session waste management materials are available and correct?];\n ARC --> ARD[Y];\n ARC --> ARE[N];\n A --> ARF[CHECK if the session cold chain materials are available and correct?];\n ARF --> ARG[Y];\n ARF --> ARH[N];\n A --> ARI[CHECK if the session transport materials are available and correct?];\n ARI --> ARJ[Y];\n ARI --> ARK[N];\n A --> ARL[CHECK if the session security materials are available and correct?];\n ARL --> ARM[Y];\n ARL --> ARN[N];\n A --> ARO[CHECK if the session communication plan is available and correct?];\n ARO --> ARP[Y];\n ARO --> ARQ[N];\n A --> ARR[CHECK if the session waste management plan is available and correct?];\n ARR --> ARS[Y];\n ARR --> ART[N];\n A --> ARU[CHECK if the session cold chain plan is available and correct?];\n ARU --> ARV[Y];\n ARU --> ARW[N];\n A --> ARX[CHECK if the session transport plan is available and correct?];\n ARX --> ARY[Y];\n ARX --> ARZ[N];\n A --> ASA[CHECK if the session security plan is available and correct?];\n ASA --> ASB[Y];\n ASA --> ASC[N];\n A --> ASD[CHECK if the session communication materials are available and correct?];\n ASD --> ASE[Y];\n ASD --> ASF[N];\n A --> ASG[CHECK if the session waste management materials are available and correct?];\n ASG --> ASH[Y];\n ASG --> ASI[N];\n A --> ASJ[CHECK if the session cold chain materials are available and correct?];\n ASJ --> ASK[Y];\n ASJ --> ASL[N];\n A --> ASM[CHECK if the session transport materials are available and correct?];\n ASM --> ASN[Y];\n ASM --> ASO[N];\n A --> ASP[CHECK if the session security materials are available and correct?];\n ASP --> ASQ[Y];\n ASP --> ASR[N];\n A --> ASS[CHECK if the session communication plan is available and correct?];\n ASS --> AST[Y];\n ASS --> ASU[N];\n A --> ASV[CHECK if the session waste management plan is available and correct?];\n ASV --> ASW[Y];\n ASV --> ASX[N];\n A --> ASY[CHECK if the session cold chain plan is available and correct?];\n ASY --> ASZ[Y];\n ASY --> ATA[N];\n A --> ATB[CHECK if the session transport plan is available and correct?];\n ATB --> ATC[Y];\n ATB --> ATD[N];\n A --> ATE[CHECK if the session security plan is available and correct?];\n ATE --> ATF[Y];\n ATE --> ATG[N];\n A --> ATH[CHECK if the session communication materials are available and correct?];\n ATH --> ATI[Y];\n ATH --> ATJ[N];\n A --> ATK[CHECK if the session waste management materials are available and correct?];\n ATK --> ATL[Y];\n ATK --> ATM[N];\n A --> ATN[CHECK if the session cold chain materials are available and correct?];\n ATN --> ATO[Y];\n ATN --> ATP[N];\n A --> ATQ[CHECK if the session transport materials are available and correct?];\n ATQ --> ATR[Y];\n ATQ --> ATS[N];\n A --> ATT[CHECK if the session security materials are available and correct?];\n ATT --> ATU[Y];\n ATT --> ATV[N];\n A --> ATW[CHECK if the session communication plan is available and correct?];\n ATW --> ATX[Y];\n ATW --> ATY[N];\n A --> ATZ[CHECK if the session waste management plan is available and correct?];\n ATZ --> AUA[Y];\n ATZ --> AUB[N];\n A --> AUC[CHECK if the session cold chain plan is available and correct?];\n AUC --> AUD[Y];\n AUC --> AUE[N];\n A --> AUF[CHECK if the session transport plan is available and correct?];\n AUF --> AUG[Y];\n AUF --> AUH[N];\n A --> AUI[CHECK if the session security materials are available and correct?];\n AUI --> AUJ[Y];\n AUI --> AUK[N];\n A --> AUL[CHECK if the session communication materials are available and correct?];\n AUL --> AUM[Y];\n AUL --> AUN[N];\n A --> AUO[CHECK if the session waste management materials are available and correct?];\n AUO --> AUP[Y];\n AUO --> AUQ[N];\n A --> AUR[CHECK if the session cold chain materials are available and correct?];\n AUR --> AUS[Y];\n AUR --> AUT[N];\n A --> AUU[CHECK if the session transport materials are available and correct?];\n AUU --> AUV[Y];\n AUU --> AUW[N];\n A --> AUX[CHECK if the session security materials are available and correct?];\n AUX --> AUY[Y];\n AUX --> AUZ[N];\n A --> AVA[CHECK if the session communication plan is available and correct?];\n AVA --> AVB[Y];\n AVA --> AVC[N];\n A --> AVD[CHECK if the session waste management plan is available and correct?];\n AVD --> AVE[Y];\n AVD --> AVF[N];\n A --> AVG[CHECK if the session cold chain plan is available and correct?];\n AVG --> AVH[Y];\n AVG --> AVI[N];\n A --> AVJ[CHECK if the session transport plan is available and correct?];\n AVJ --> AVK[Y];\n AVJ --> AVL[N];\n A --> AVM[CHECK if the session security plan is available and correct?];\n AVM --> AVN[Y];\n AVM --> AVO[N];\n A --> AVP[CHECK if the session communication materials are available and correct?];\n AVP --> AVQ[Y];\n AVP --> AVR[N];\n A --> AVS[CHECK if the session waste management materials are available and correct?];\n AVS --> AVT[Y];\n AVS --> AVU[N];\n A --> AVV[CHECK if the session cold chain materials are available and correct?];\n AVV --> AVW[Y];\n AVV --> AVX[N];\n A --> AVY[CHECK if the session transport materials are available and correct?];\n AVY --> AVZ[Y];\n AVY --> AWA[N];\n A --> AWB[CHECK if the session security materials are available and correct?];\n AWB --> AWC[Y];\n AWB --> AWD[N];\n A --> AWE[CHECK if the session communication plan is available and correct?];\n AWE --> AWF[Y];\n AWE --> AWG[N];\n A --> AWH[CHECK if the session waste management plan is available and correct?];\n AWH --> AWI[Y];\n AWH --> AWJ[N];\n A --> AWK[CHECK if the session cold chain plan is available and correct?];\n AWK --> AWL[Y];\n AWK --> AWM[N];\n A --> AWN[CHECK if the session transport plan is available and correct?];\n AWN --> AWO[Y];\n AWN --> AWP[N];\n A --> AWQ[CHECK if the session security plan is available and correct?];\n AWQ --> AWR[Y];\n AWQ --> AWS[N];\n A --> AWT[CHECK if the session communication materials are available and correct?];\n AWT --> AWU[Y];\n AWT --> AWV[N];\n A --> AWW[CHECK if the session waste management materials are available and correct?];\n AWW --> AWX[Y];\n AWW --> AWY[N];\n A --> AWZ[CHECK if the session cold chain materials are available and correct?];\n AWZ --> AXA[Y];\n AWZ --> AXB[N];\n A --> AXC[CHECK if the session transport materials are available and correct?];\n AXC --> AXD[Y];\n AXC --> AXE[N];\n A --> AXF[CHECK if the session security materials are available and correct?];\n AXF --> AXG[Y];\n AXF --> AXH[N];\n A --> AXI[CHECK if the session communication plan is available and correct?];\n AXI --> AXJ[Y];\n AXI --> AXK[N];\n A --> AXL[CHECK if the session waste management plan is available and correct?];\n AXL --> AXM[Y];\n AXL --> AXN[N];\n A --> AXO[CHECK if the session cold chain plan is available and correct?];\n AXO --> AXP[Y];\n AXO --> AXQ[N];\n A --> AXR[CHECK if the session transport plan is available and correct?];\n AXR --> AXS[Y];\n AXR --> AXT[N];\n A --> AXU[CHECK if the session security plan is available and correct?];\n AXU --> AXV[Y];\n AXU --> AXW[N];\n A --> AXX[CHECK if the session communication materials are available and correct?];\n AXX --> AXY[Y];\n AXX --> AXZ[N];\n A --> AYA[CHECK if the session waste management materials are available and correct?];\n AYA --> AYB[Y];\n AYA --> AYC[N];\n A --> AYD[CHECK if the session cold chain materials are available and correct?];\n AYD --> AYE[Y];\n AYD --> AYF[N];\n A --> AYG[CHECK if the session transport materials are available and correct?];\n AYG --> AYH[Y];\n AYG --> AYI[N];\n A --> AYJ[CHECK if the session security materials are available and correct?];\n AYJ --> AYK[Y];\n AYJ --> AYL[N];\n A --> AYM[CHECK if the session communication plan is available and correct?];\n AYM --> AYN[Y];\n AYM --> AYO[N];\n A --> AYP[CHECK if the session waste management plan is available and correct?];\n AYP --> AYQ[Y];\n AYP --> AYR[N];\n A --> AYS[CHECK if the session cold chain plan is available and correct?];\n AYS --> AYT[Y];\n AYS --> AYU[N];\n A --> AYV[CHECK if the session transport plan is available and correct?];\n AYV --> AYW[Y];\n AYV --> AYX[N];\n A --> AYY[CHECK if the session security plan is available and correct?];\n AYY --> AYZ[Y];\n AYY --> AZA[N];\n A --> AZB[CHECK if the session communication materials are available and correct?];\n AZB --> AZC[Y];\n AZB --> AZD[N];\n A --> AZE[CHECK if the session waste management materials are available and correct?];\n AZE --> AZF[Y];\n AZE --> AZG[N];\n A --> AZH[CHECK if the session cold chain materials are available and correct?];\n AZH --> AZI[Y];\n AZH --> AZJ[N];\n A --> AZK[CHECK if the session transport materials are available and correct?];\n AZK --> AZL[Y];\n AZK --> AZM[N];\n A --> AZN[CHECK if the session security materials are available and correct?];\n AZN --> AZO[Y];\n AZN --> AZP[N];\n A --> AZQ[CHECK if the session communication plan is available and correct?];\n AZQ --> AZR[Y];\n AZQ --> AZS[N];\n A --> AZT[CHECK if the session waste management plan is available and correct?];\n AZT --> AZU[Y];\n AZT --> AZV[N];\n A --> AZW[CHECK if the session cold chain plan is available and correct?];\n AZW --> AZX[Y];\n AZW --> AZY[N];\n A --> AZZ[CHECK if the session transport plan is available and correct?];\n AZZ --> BAA[Y];\n AZZ --> BAB[N];\n A --> BAC[CHECK if the session security materials are available and correct?];\n BAC --> BAD[Y];\n BAC --> BAE[N];\n A --> BAF[CHECK if the session communication materials are available and correct?];\n BAF --> BAG[Y];\n BAF --> BAH[N];\n A --> BAI[CHECK if the session waste management materials are available and correct?];\n BAI --> BAJ[Y];\n BAI --> BAK[N];\n A --> BAL[CHECK if the session cold chain materials are available and correct?];\n BAL --> BAM[Y];\n BAL --> BAN[N];\n A --> BAO[CHECK if the session transport materials are available and correct?];\n BAO --> BAP[Y];\n BAO --> BAQ[N];\n A --> BAR[CHECK if the session security materials are available and correct?];\n BAR --> BAS[Y];\n BAR --> BAT[N];\n A --> BAU[CHECK if the session communication plan is available and correct?];\n BAU --> BAV[Y];\n BAU --> BAW[N];\n A --> BAX[CHECK if the session waste management plan is available and correct?];\n BAX --> BAY[Y];\n BAX --> BAZ[N];\n A --> BBA[CHECK if the session cold chain plan is available and correct?];\n BBA --> BBB[Y];\n BBA --> BBC[N];\n A --> BBD[CHECK if the session transport plan is available and correct?];\n BBD --> BBE[Y];\n BBD --> BBF[N];\n A --> BBG[CHECK if the session security plan is available and correct?];\n BBG --> BBH[Y];\n BBG --> BBI[N];\n A --> BBJ[CHECK if the session communication materials are available and correct?];\n BBJ --> BBK[Y];\n BBJ --> BBL[N];\n A --> BBM[CHECK if the session waste management materials are available and correct?];\n BBM --> BBN[Y];\n BBM --> BBO[N];\n A --> BBP[CHECK if the session cold chain materials are available and correct?];\n BBP --> BBQ[Y];\n BBP --> BBR[N];\n A --> BBS[CHECK if the session transport materials are available and correct?];\n BBS --> BBT[Y];\n BBS --> BBU[N];\n A --> BBV[CHECK if the session security materials are available and correct?];\n BBV --> BBW[Y];\n BBV --> BBX[N];\n A --> BBY[CHECK if the session communication plan is available and correct?];\n BBY --> BBZ[Y];\n BBY --> BCA[N];\n A --> BCB[CHECK if the session waste management plan is available and correct?];\n BCB --> BCC[Y];\n BCB --> BCD[N];\n A --> BCE[CHECK if the session cold chain plan is available and correct?];\n BCE --> BCF[Y];\n BCE --> BCG[N];\n A --> BCH[CHECK if the session transport plan is available and correct?];\n BCH --> BCI[Y];\n BCH --> BCJ[N];\n A --> BCK[CHECK if the session security plan is available and correct?];\n BCK --> BCL[Y];\n BCK --> BCM[N];\n A --> BCN[CHECK if the session communication materials are available and correct?];\n BCN --> BCO[Y];\n BCN --> BCP[N];\n A --> BCQ[CHECK if the session waste management materials are available and correct?];\n BCQ --> BCR[Y];\n BCQ --> BCS[N];\n A --> BCT[CHECK if the session cold chain materials are available and correct?];\n BCT --> BCU[Y];\n BCT --> BCV[N];\n A --> BCW[CHECK if the session transport materials are available and correct?];\n BCW --> BCX[Y];\n BCW --> BCY[N];\n A --> BCZ[CHECK if the session security materials are available and correct?];\n BCZ --> BDA[Y];\n BCZ --> BDB[N];\n A --> BDC[CHECK if the session communication plan is available and correct?];\n BDC --> BDD[Y];\n BDC --> BDE[N];\n A --> BDF[CHECK if the session waste management plan is available and correct?];\n BDF --> BDG[Y];\n BDF --> BDH[N];\n A --> BDI[CHECK if the session cold chain plan is available and correct?];\n BDI --> BDJ[Y];\n BDI --> BDK[N];\n A --> BDL[CHECK if the session transport plan is available and correct?];\n BDL --> BDM[Y];\n BDL --> BDN[N];\n A --> BDO[CHECK if the session security materials are available and correct?];\n BDO --> BDP[Y];\n BDO --> BDQ[N];\n A --> BDR[CHECK if the session communication materials are available and correct?];\n BDR --> BDS[Y];\n BDR --> BDT[N];\n A --> BDU[CHECK if the session waste management materials are available and correct?];\n BDU --> BDV[Y];\n BDU --> BDW[N];\n A --> BDX[CHECK if the session cold chain materials are available and correct?];\n BDX --> BDY[Y];\n BDX --> BDZ[N];\n A --> BEA[CHECK if the session transport materials are available and correct?];\n BEA --> BEB[Y];\n BEA --> BEC[N];\n A --> BED[CHECK if the session security materials are available and correct?];\n BED --> BEE[Y];\n BED --> BEF[N];\n A --> BEG[CHECK if the session communication plan is available and correct?];\n BEG --> BEH[Y];\n BEG --> BEI[N];\n A --> BEJ[CHECK if the session waste management plan is available and correct?];\n BEJ --> BEK[Y];\n BEJ --> BEL[N];\n A --> BEM[CHECK if the session cold chain plan is available and correct?];\n BEM --> BEN[Y];\n BEM --> BEO[N];\n A --> BEP[CHECK if the session transport plan is available and correct?];\n BEP --> BEQ[Y];\n BEP --> BER[N];\n A --> BES[CHECK if the session security materials are available and correct?];\n BES --> BET[Y];\n BES --> BEU[N];\n A --> BEV[CHECK if the session communication materials are available and correct?];\n BEV --> BEW[Y];\n BEV --> BEX[N];\n A --> BEY[CHECK if the session waste management materials are available and correct?];\n BEY --> BEZ[Y];\n BEY --> BFA[N];\n A --> BFB[CHECK if the session cold chain materials are available and correct?];\n BFB --> BFC[Y];\n BFB --> BFD[N];\n A --> BFE[CHECK if the session transport materials are available and correct?];\n BFE --> BFF[Y];\n BFE --> BFG[N];\n A --> BFH[CHECK if the session security materials are available and correct?];\n BFH --> BFI[Y];\n BFH --> BFJ[N];\n A --> BFK[CHECK if the session communication plan is available and correct?];\n BFK --> BFL[Y];\n BFK --> BFM[N];\n A --> BFN[CHECK if the session waste management plan is available and correct?];\n BFN --> BFO[Y];\n BFN --> BFP[N];\n A --> BFQ[CHECK if the session cold chain plan is available and correct?];\n BFQ --> BFR[Y];\n BFQ --> BFS[N];\n A --> BFT[CHECK if the session transport plan is available and correct?];\n BFT -->\n :END TABLE DATA:",
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Using the immunization session checklist
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"text": "Figure 5.11 shows a checklist that can help ensure safety before, during and after immunization. This checklist is a reminder of key points in preparation, vaccination and closure of sessions that are described above, and is meant to reinforce positive actions. Health workers should be familiar with national immunization schedules, vaccine administration, waste disposal, data collection and other details of standard operating procedure from relevant national programme documents and be able to quickly recognize and complete the checklist items. A printed copy of this checklist can be posted on a wall in the immunization area for easy viewing throughout sessions.",
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Figure 5.11 shows a checklist that can help ensure safety before, during and after immunization. This checklist is a reminder of key points in preparation, vaccination and closure of sessions that are described above, and is meant to reinforce positive actions. Health workers should be familiar with national immunization schedules, vaccine administration, waste disposal, data collection and other details of standard operating procedure from relevant national programme documents and be able to quickly recognize and complete the checklist items. A printed copy of this checklist can be posted on a wall in the immunization area for easy viewing throughout sessions.
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"text": "graph TD;\n A[Before the immunization session] --> B[For selected clients attending the immunization session];\n B --> C[After the immunization session];\n A --> D[CHECK if sufficient quantities of vaccines and diluents are available for the session?];\n D --> E[Y];\n D --> F[N];\n A --> G[CHECK if all equipment is in place and functioning correctly?];\n G --> H[Y];\n G --> I[N];\n A --> J[CHECK if all supplies are available for the session?];\n J --> K[Y];\n J --> L[N];\n A --> M[CHECK if all staff are present and ready?];\n M --> N[Y];\n M --> O[N];\n A --> P[CHECK if the session site is prepared and ready?];\n P --> Q[Y];\n P --> R[N];\n A --> S[CHECK if the session schedule is available and correct?];\n S --> T[Y];\n S --> U[N];\n A --> V[CHECK if the session plan is available and correct?];\n V --> W[Y];\n V --> X[N];\n A --> Y[CHECK if the session register is available and correct?];\n Y --> Z[Y];\n Y --> AA[N];\n A --> AB[CHECK if the session tally sheets are available and correct?];\n AB --> AC[Y];\n AB --> AD[N];\n A --> AE[CHECK if the session AEFI kit is available and correct?];\n AE --> AF[Y];\n AE --> AG[N];\n A --> AH[CHECK if the session communication materials are available and correct?];\n AH --> AI[Y];\n AH --> AJ[N];\n A --> AK[CHECK if the session waste management materials are available and correct?];\n AK --> AL[Y];\n AK --> AM[N];\n A --> AN[CHECK if the session cold chain materials are available and correct?];\n AN --> AO[Y];\n AN --> AP[N];\n A --> AQ[CHECK if the session transport materials are available and correct?];\n AQ --> AR[Y];\n AQ --> AS[N];\n A --> AT[CHECK if the session security materials are available and correct?];\n AT --> AU[Y];\n AT --> AV[N];\n A --> AW[CHECK if the session communication plan is available and correct?];\n AW --> AX[Y];\n AW --> AY[N];\n A --> AZ[CHECK if the session waste management plan is available and correct?];\n AZ --> BA[Y];\n AZ --> BB[N];\n A --> BC[CHECK if the session cold chain plan is available and correct?];\n BC --> BD[Y];\n BC --> BE[N];\n A --> BF[CHECK if the session transport plan is available and correct?];\n BF --> BG[Y];\n BF --> BH[N];\n A --> BI[CHECK if the session security plan is available and correct?];\n BI --> BJ[Y];\n BI --> BK[N];\n A --> BL[CHECK if the session communication materials are available and correct?];\n BL --> BM[Y];\n BL --> BN[N];\n A --> BO[CHECK if the session waste management materials are available and correct?];\n BO --> BP[Y];\n BO --> BQ[N];\n A --> BR[CHECK if the session cold chain materials are available and correct?];\n BR --> BS[Y];\n BR --> BT[N];\n A --> BU[CHECK if the session transport materials are available and correct?];\n BU --> BV[Y];\n BU --> BW[N];\n A --> BX[CHECK if the session security materials are available and correct?];\n BX --> BY[Y];\n BX --> BZ[N];\n A --> CA[CHECK if the session communication plan is available and correct?];\n CA --> CB[Y];\n CA --> CC[N];\n A --> CD[CHECK if the session waste management plan is available and correct?];\n CD --> CE[Y];\n CD --> CF[N];\n A --> CG[CHECK if the session cold chain plan is available and correct?];\n CG --> CH[Y];\n CG --> CI[N];\n A --> CJ[CHECK if the session transport plan is available and correct?];\n CJ --> CK[Y];\n CJ --> CL[N];\n A --> CM[CHECK if the session security plan is available and correct?];\n CM --> CN[Y];\n CM --> CO[N];\n A --> CP[CHECK if the session communication materials are available and correct?];\n CP --> CQ[Y];\n CP --> CR[N];\n A --> CS[CHECK if the session waste management materials are available and correct?];\n CS --> CT[Y];\n CS --> CU[N];\n A --> CV[CHECK if the session cold chain materials are available and correct?];\n CV --> CW[Y];\n CV --> CX[N];\n A --> CY[CHECK if the session transport materials are available and correct?];\n CY --> CZ[Y];\n CY --> DA[N];\n A --> DB[CHECK if the session security materials are available and correct?];\n DB --> DC[Y];\n DB --> DD[N];\n A --> DE[CHECK if the session communication plan is available and correct?];\n DE --> DF[Y];\n DE --> DG[N];\n A --> DH[CHECK if the session waste management plan is available and correct?];\n DH --> DI[Y];\n DH --> DJ[N];\n A --> DK[CHECK if the session cold chain plan is available and correct?];\n DK --> DL[Y];\n DK --> DM[N];\n A --> DN[CHECK if the session transport plan is available and correct?];\n DN --> DO[Y];\n DN --> DP[N];\n A --> DQ[CHECK if the session security plan is available and correct?];\n DQ --> DR[Y];\n DQ --> DS[N];\n A --> DT[CHECK if the session communication materials are available and correct?];\n DT --> DU[Y];\n DT --> DV[N];\n A --> DW[CHECK if the session waste management materials are available and correct?];\n DW --> DX[Y];\n DW --> DY[N];\n A --> DZ[CHECK if the session cold chain materials are available and correct?];\n DZ --> EA[Y];\n DZ --> EB[N];\n A --> EC[CHECK if the session transport materials are available and correct?];\n EC --> ED[Y];\n EC --> EE[N];\n A --> EF[CHECK if the session security materials are available and correct?];\n EF --> EG[Y];\n EF --> EH[N];\n A --> EI[CHECK if the session communication plan is available and correct?];\n EI --> EJ[Y];\n EI --> EK[N];\n A --> EL[CHECK if the session waste management plan is available and correct?];\n EL --> EM[Y];\n EL --> EN[N];\n A --> EO[CHECK if the session cold chain plan is available and correct?];\n EO --> EP[Y];\n EO --> EQ[N];\n A --> ER[CHECK if the session transport plan is available and correct?];\n ER --> ES[Y];\n ER --> ET[N];\n A --> EU[CHECK if the session security plan is available and correct?];\n EU --> EV[Y];\n EU --> EW[N];\n A --> EX[CHECK if the session communication materials are available and correct?];\n EX --> EY[Y];\n EX --> EZ[N];\n A --> FA[CHECK if the session waste management materials are available and correct?];\n FA --> FB[Y];\n FA --> FC[N];\n A --> FD[CHECK if the session cold chain materials are available and correct?];\n FD --> FE[Y];\n FD --> FF[N];\n A --> FG[CHECK if the session transport materials are available and correct?];\n FG --> FH[Y];\n FG --> FI[N];\n A --> FJ[CHECK if the session security materials are available and correct?];\n FJ --> FK[Y];\n FJ --> FL[N];\n A --> FM[CHECK if the session communication plan is available and correct?];\n FM --> FN[Y];\n FM --> FO[N];\n A --> FP[CHECK if the session waste management plan is available and correct?];\n FP --> FQ[Y];\n FP --> FR[N];\n A --> FS[CHECK if the session cold chain plan is available and correct?];\n FS --> FT[Y];\n FS --> FU[N];\n A --> FV[CHECK if the session transport plan is available and correct?];\n FV --> FW[Y];\n FV --> FX[N];\n A --> FY[CHECK if the session security plan is available and correct?];\n FY --> FZ[Y];\n FY --> GA[N];\n A --> GB[CHECK if the session communication materials are available and correct?];\n GB --> GC[Y];\n GB --> GD[N];\n A --> GE[CHECK if the session waste management materials are available and correct?];\n GE --> GF[Y];\n GE --> GG[N];\n A --> GH[CHECK if the session cold chain materials are available and correct?];\n GH --> GI[Y];\n GH --> GJ[N];\n A --> GK[CHECK if the session transport materials are available and correct?];\n GK --> GL[Y];\n GK --> GM[N];\n A --> GN[CHECK if the session security materials are available and correct?];\n GN --> GO[Y];\n GN --> GP[N];\n A --> GQ[CHECK if the session communication plan is available and correct?];\n GQ --> GR[Y];\n GQ --> GS[N];\n A --> GT[CHECK if the session waste management plan is available and correct?];\n GT --> GU[Y];\n GT --> GV[N];\n A --> GW[CHECK if the session cold chain plan is available and correct?];\n GW --> GX[Y];\n GW --> GY[N];\n A --> GZ[CHECK if the session transport plan is available and correct?];\n GZ --> HA[Y];\n GZ --> HB[N];\n A --> HC[CHECK if the session security plan is available and correct?];\n HC --> HD[Y];\n HC --> HE[N];\n A --> HF[CHECK if the session communication materials are available and correct?];\n HF --> HG[Y];\n HF --> HH[N];\n A --> HI[CHECK if the session waste management materials are available and correct?];\n HI --> HJ[Y];\n HI --> HK[N];\n A --> HL[CHECK if the session cold chain materials are available and correct?];\n HL --> HM[Y];\n HL --> HN[N];\n A --> HO[CHECK if the session transport materials are available and correct?];\n HO --> HP[Y];\n HO --> HQ[N];\n A --> HR[CHECK if the session security materials are available and correct?];\n HR --> HS[Y];\n HR --> HT[N];\n A --> HU[CHECK if the session communication plan is available and correct?];\n HU --> HV[Y];\n HU --> HW[N];\n A --> HX[CHECK if the session waste management plan is available and correct?];\n HX --> HY[Y];\n HX --> HZ[N];\n A --> IA[CHECK if the session cold chain plan is available and correct?];\n IA --> IB[Y];\n IA --> IC[N];\n A --> ID[CHECK if the session transport plan is available and correct?];\n ID --> IE[Y];\n ID --> IF[N];\n A --> IG[CHECK if the session security plan is available and correct?];\n IG --> IH[Y];\n IG --> II[N];\n A --> IJ[CHECK if the session communication materials are available and correct?];\n IJ --> IK[Y];\n IJ --> IL[N];\n A --> IM[CHECK if the session waste management materials are available and correct?];\n IM --> IN[Y];\n IM --> IO[N];\n A --> IP[CHECK if the session cold chain materials are available and correct?];\n IP --> IQ[Y];\n IP --> IR[N];\n A --> IS[CHECK if the session transport materials are available and correct?];\n IS --> IT[Y];\n IS --> IU[N];\n A --> IV[CHECK if the session security materials are available and correct?];\n IV --> IW[Y];\n IV --> IX[N];\n A --> IY[CHECK if the session communication plan is available and correct?];\n IY --> IZ[Y];\n IY --> JA[N];\n A --> JB[CHECK if the session waste management plan is available and correct?];\n JB --> JC[Y];\n JB --> JD[N];\n A --> JE[CHECK if the session cold chain plan is available and correct?];\n JE --> JF[Y];\n JE --> JG[N];\n A --> JH[CHECK if the session transport plan is available and correct?];\n JH --> JI[Y];\n JH --> JJ[N];\n A --> JK[CHECK if the session security plan is available and correct?];\n JK --> JL[Y];\n JK --> JM[N];\n A --> JN[CHECK if the session communication materials are available and correct?];\n JN --> JO[Y];\n JN --> JP[N];\n A --> JQ[CHECK if the session waste management materials are available and correct?];\n JQ --> JR[Y];\n JQ --> JS[N];\n A --> JT[CHECK if the session cold chain materials are available and correct?];\n JT --> JU[Y];\n JT --> JV[N];\n A --> JW[CHECK if the session transport materials are available and correct?];\n JW --> JX[Y];\n JW --> JY[N];\n A --> JZ[CHECK if the session security materials are available and correct?];\n JZ --> KA[Y];\n JZ --> KB[N];\n A --> KC[CHECK if the session communication plan is available and correct?];\n KC --> KD[Y];\n KC --> KE[N];\n A --> KF[CHECK if the session waste management plan is available and correct?];\n KF --> KG[Y];\n KF --> KH[N];\n A --> KI[CHECK if the session cold chain plan is available and correct?];\n KI --> KJ[Y];\n KI --> KK[N];\n A --> KL[CHECK if the session transport plan is available and correct?];\n KL --> KM[Y];\n KL --> KN[N];\n A --> KO[CHECK if the session security plan is available and correct?];\n KO --> KP[Y];\n KO --> KQ[N];\n A --> KR[CHECK if the session communication materials are available and correct?];\n KR --> KS[Y];\n KR --> KT[N];\n A --> KU[CHECK if the session waste management materials are available and correct?];\n KU --> KV[Y];\n KU --> KW[N];\n A --> KX[CHECK if the session cold chain materials are available and correct?];\n KX --> KY[Y];\n KX --> KZ[N];\n A --> LA[CHECK if the session transport materials are available and correct?];\n LA --> LB[Y];\n LA --> LC[N];\n A --> LD[CHECK if the session security materials are available and correct?];\n LD --> LE[Y];\n LD --> LF[N];\n A --> LG[CHECK if the session communication plan is available and correct?];\n LG --> LH[Y];\n LG --> LI[N];\n A --> LJ[CHECK if the session waste management plan is available and correct?];\n LJ --> LK[Y];\n LJ --> LL[N];\n A --> LM[CHECK if the session cold chain plan is available and correct?];\n LM --> LN[Y];\n LM --> LO[N];\n A --> LP[CHECK if the session transport plan is available and correct?];\n LP --> LQ[Y];\n LP --> LR[N];\n A --> LS[CHECK if the session security plan is available and correct?];\n LS --> LT[Y];\n LS --> LU[N];\n A --> LV[CHECK if the session communication materials are available and correct?];\n LV --> LW[Y];\n LV --> LX[N];\n A --> LY[CHECK if the session waste management materials are available and correct?];\n LY --> LZ[Y];\n LY --> MA[N];\n A --> MB[CHECK if the session cold chain materials are available and correct?];\n MB --> MC[Y];\n MB --> MD[N];\n A --> ME[CHECK if the session transport materials are available and correct?];\n ME --> MF[Y];\n ME --> MG[N];\n A --> MH[CHECK if the session security materials are available and correct?];\n MH --> MI[Y];\n MH --> MJ[N];\n A --> MK[CHECK if the session communication plan is available and correct?];\n MK --> ML[Y];\n MK --> MM[N];\n A --> MN[CHECK if the session waste management plan is available and correct?];\n MN --> MO[Y];\n MN --> MP[N];\n A --> MQ[CHECK if the session cold chain plan is available and correct?];\n MQ --> MR[Y];\n MQ --> MS[N];\n A --> MT[CHECK if the session transport plan is available and correct?];\n MT --> MU[Y];\n MT --> MV[N];\n A --> MW[CHECK if the session security plan is available and correct?];\n MW --> MX[Y];\n MW --> MY[N];\n A --> MZ[CHECK if the session communication materials are available and correct?];\n MZ --> NA[Y];\n MZ --> NB[N];\n A --> NC[CHECK if the session waste management materials are available and correct?];\n NC --> ND[Y];\n NC --> NE[N];\n A --> NF[CHECK if the session cold chain materials are available and correct?];\n NF --> NG[Y];\n NF --> NH[N];\n A --> NI[CHECK if the session transport materials are available and correct?];\n NI --> NJ[Y];\n NI --> NK[N];\n A --> NL[CHECK if the session security materials are available and correct?];\n NL --> NM[Y];\n NL --> NN[N];\n A --> NO[CHECK if the session communication plan is available and correct?];\n NO --> NP[Y];\n NO --> NQ[N];\n A --> NR[CHECK if the session waste management plan is available and correct?];\n NR --> NS[Y];\n NR --> NT[N];\n A --> NU[CHECK if the session cold chain plan is available and correct?];\n NU --> NV[Y];\n NU --> NW[N];\n A --> NX[CHECK if the session transport plan is available and correct?];\n NX --> NY[Y];\n NX --> NZ[N];\n A --> OA[CHECK if the session security plan is available and correct?];\n OA --> OB[Y];\n OA --> OC[N];\n A --> OD[CHECK if the session communication materials are available and correct?];\n OD --> OE[Y];\n OD --> OF[N];\n A --> OG[CHECK if the session waste management materials are available and correct?];\n OG --> OH[Y];\n OG --> OI[N];\n A --> OJ[CHECK if the session cold chain materials are available and correct?];\n OJ --> OK[Y];\n OJ --> OL[N];\n A --> OM[CHECK if the session transport materials are available and correct?];\n OM --> ON[Y];\n OM --> OO[N];\n A --> OP[CHECK if the session security materials are available and correct?];\n OP --> OQ[Y];\n OP --> OR[N];\n A --> OS[CHECK if the session communication plan is available and correct?];\n OS --> OT[Y];\n OS --> OU[N];\n A --> OV[CHECK if the session waste management plan is available and correct?];\n OV --> OW[Y];\n OV --> OX[N];\n A --> OY[CHECK if the session cold chain plan is available and correct?];\n OY --> OZ[Y];\n OY --> PA[N];\n A --> PB[CHECK if the session transport plan is available and correct?];\n PB --> PC[Y];\n PB --> PD[N];\n A --> PE[CHECK if the session security plan is available and correct?];\n PE --> PF[Y];\n PE --> PG[N];\n A --> PH[CHECK if the session communication materials are available and correct?];\n PH --> PI[Y];\n PH --> PJ[N];\n A --> PK[CHECK if the session waste management materials are available and correct?];\n PK --> PL[Y];\n PK --> PM[N];\n A --> PN[CHECK if the session cold chain materials are available and correct?];\n PN --> PO[Y];\n PN --> PP[N];\n A --> PQ[CHECK if the session transport materials are available and correct?];\n PQ --> PR[Y];\n PQ --> PS[N];\n A --> PT[CHECK if the session security materials are available and correct?];\n PT --> PU[Y];\n PT --> PV[N];\n A --> PW[CHECK if the session communication plan is available and correct?];\n PW --> PX[Y];\n PW --> PY[N];\n A --> PZ[CHECK if the session waste management plan is available and correct?];\n PZ --> QA[Y];\n PZ --> QB[N];\n A --> QC[CHECK if the session cold chain plan is available and correct?];\n QC --> QD[Y];\n QC --> QE[N];\n A --> QF[CHECK if the session transport plan is available and correct?];\n QF --> QG[Y];\n QF --> QH[N];\n A --> QI[CHECK if the session security plan is available and correct?];\n QI --> QJ[Y];\n QI --> QK[N];\n A --> QL[CHECK if the session communication materials are available and correct?];\n QL --> QM[Y];\n QL --> QN[N];\n A --> QO[CHECK if the session waste management materials are available and correct?];\n QO --> QP[Y];\n QO --> QQ[N];\n A --> QR[CHECK if the session cold chain materials are available and correct?];\n QR --> QS[Y];\n QR --> QT[N];\n A --> QU[CHECK if the session transport materials are available and correct?];\n QU --> QV[Y];\n QU --> QW[N];\n A --> QX[CHECK if the session security materials are available and correct?];\n QX --> QY[Y];\n QX --> QZ[N];\n A --> RA[CHECK if the session communication plan is available and correct?];\n RA --> RB[Y];\n RA --> RC[N];\n A --> RD[CHECK if the session waste management plan is available and correct?];\n RD --> RE[Y];\n RD --> RF[N];\n A --> RG[CHECK if the session cold chain plan is available and correct?];\n RG --> RH[Y];\n RG --> RI[N];\n A --> RJ[CHECK if the session transport plan is available and correct?];\n RJ --> RK[Y];\n RJ --> RL[N];\n A --> RM[CHECK if the session security plan is available and correct?];\n RM --> RN[Y];\n RM --> RO[N];\n A --> RP[CHECK if the session communication materials are available and correct?];\n RP --> RQ[Y];\n RP --> RR[N];\n A --> RS[CHECK if the session waste management materials are available and correct?];\n RS --> RT[Y];\n RS --> RU[N];\n A --> RV[CHECK if the session cold chain materials are available and correct?];\n RV --> RW[Y];\n RV --> RX[N];\n A --> RY[CHECK if the session transport materials are available and correct?];\n RY --> RZ[Y];\n RY --> SA[N];\n A --> SB[CHECK if the session security materials are available and correct?];\n SB --> SC[Y];\n SB --> SD[N];\n A --> SE[CHECK if the session communication plan is available and correct?];\n SE --> SF[Y];\n SE --> SG[N];\n A --> SH[CHECK if the session waste management plan is available and correct?];\n SH --> SI[Y];\n SH --> SJ[N];\n A --> SK[CHECK if the session cold chain plan is available and correct?];\n SK --> SL[Y];\n SK --> SM[N];\n A --> SN[CHECK if the session transport plan is available and correct?];\n SN --> SO[Y];\n SN --> SP[N];\n A --> SQ[CHECK if the session security plan is available and correct?];\n SQ --> SR[Y];\n SQ --> SS[N];\n A --> ST[CHECK if the session communication materials are available and correct?];\n ST --> SU[Y];\n ST --> SV[N];\n A --> SW[CHECK if the session waste management materials are available and correct?];\n SW --> SX[Y];\n SW --> SY[N];\n A --> SZ[CHECK if the session cold chain materials are available and correct?];\n SZ --> TA[Y];\n SZ --> TB[N];\n A --> TC[CHECK if the session transport materials are available and correct?];\n TC --> TD[Y];\n TC --> TE[N];\n A --> TF[CHECK if the session security materials are available and correct?];\n TF --> TG[Y];\n TF --> TH[N];\n A --> TI[CHECK if the session communication plan is available and correct?];\n TI --> TJ[Y];\n TI --> TK[N];\n A --> TL[CHECK if the session waste management plan is available and correct?];\n TL --> TM[Y];\n TL --> TN[N];\n A --> TO[CHECK if the session cold chain plan is available and correct?];\n TO --> TP[Y];\n TO --> TQ[N];\n A --> TR[CHECK if the session transport plan is available and correct?];\n TR --> TS[Y];\n TR --> TT[N];\n A --> TU[CHECK if the session security plan is available and correct?];\n TU --> TV[Y];\n TU --> TW[N];\n A --> TX[CHECK if the session communication materials are available and correct?];\n TX --> TY[Y];\n TX --> TZ[N];\n A --> UA[CHECK if the session waste management materials are available and correct?];\n UA --> UB[Y];\n UA --> UC[N];\n A --> UD[CHECK if the session cold chain materials are available and correct?];\n UD --> UE[Y];\n UD --> UF[N];\n A --> UG[CHECK if the session transport materials are available and correct?];\n UG --> UH[Y];\n UG --> UI[N];\n A --> UJ[CHECK if the session security materials are available and correct?];\n UJ --> UK[Y];\n UJ --> UL[N];\n A --> UM[CHECK if the session communication plan is available and correct?];\n UM --> UN[Y];\n UM --> UO[N];\n A --> UP[CHECK if the session waste management plan is available and correct?];\n UP --> UQ[Y];\n UP --> UR[N];\n A --> US[CHECK if the session cold chain plan is available and correct?];\n US --> UT[Y];\n US --> UU[N];\n A --> UV[CHECK if the session transport plan is available and correct?];\n UV --> UW[Y];\n UV --> UX[N];\n A --> UY[CHECK if the session security plan is available and correct?];\n UY --> UZ[Y];\n UY --> VA[N];\n A --> VB[CHECK if the session communication materials are available and correct?];\n VB --> VC[Y];\n VB --> VD[N];\n A --> VE[CHECK if the session waste management materials are available and correct?];\n VE --> VF[Y];\n VE --> VG[N];\n A --> VH[CHECK if the session cold chain materials are available and correct?];\n VH --> VI[Y];\n VH --> VJ[N];\n A --> VK[CHECK if the session transport materials are available and correct?];\n VK --> VL[Y];\n VK --> VM[N];\n A --> VN[CHECK if the session security materials are available and correct?];\n VN --> VO[Y];\n VN --> VP[N];\n A --> VQ[CHECK if the session communication plan is available and correct?];\n VQ --> VR[Y];\n VQ --> VS[N];\n A --> VT[CHECK if the session waste management plan is available and correct?];\n VT --> VU[Y];\n VT --> VV[N];\n A --> VW[CHECK if the session cold chain plan is available and correct?];\n VW --> VX[Y];\n VW --> VY[N];\n A --> VZ[CHECK if the session transport plan is available and correct?];\n VZ --> WA[Y];\n VZ --> WB[N];\n A --> WC[CHECK if the session security plan is available and correct?];\n WC --> WD[Y];\n WC --> WE[N];\n A --> WF[CHECK if the session communication materials are available and correct?];\n WF --> WG[Y];\n WF --> WH[N];\n A --> WI[CHECK if the session waste management materials are available and correct?];\n WI --> WJ[Y];\n WI --> WK[N];\n A --> WL[CHECK if the session cold chain materials are available and correct?];\n WL --> WM[Y];\n WL --> WN[N];\n A --> WO[CHECK if the session transport materials are available and correct?];\n WO --> WP[Y];\n WO --> WQ[N];\n A --> WR[CHECK if the session security materials are available and correct?];\n WR --> WS[Y];\n WR --> WT[N];\n A --> WU[CHECK if the session communication plan is available and correct?];\n WU --> WV[Y];\n WU --> WW[N];\n A --> WX[CHECK if the session waste management plan is available and correct?];\n WX --> WY[Y];\n WX --> WZ[N];\n A --> XA[CHECK if the session cold chain plan is available and correct?];\n XA --> XB[Y];\n XA --> XC[N];\n A --> XD[CHECK if the session transport plan is available and correct?];\n XD --> XE[Y];\n XD --> XF[N];\n A --> XG[CHECK if the session security plan is available and correct?];\n XG --> XH[Y];\n XG --> XI[N];\n A --> XJ[CHECK if the session communication materials are available and correct?];\n XJ --> XK[Y];\n XJ --> XL[N];\n A --> XM[CHECK if the session waste management materials are available and correct?];\n XM --> XN[Y];\n XM --> XO[N];\n A --> XP[CHECK if the session cold chain materials are available and correct?];\n XP --> XQ[Y];\n XP --> XR[N];\n A --> XS[CHECK if the session transport materials are available and correct?];\n XS --> XT[Y];\n XS --> XU[N];\n A --> XV[CHECK if the session security materials are available and correct?];\n XV --> XW[Y];\n XV --> XX[N];\n A --> XY[CHECK if the session communication plan is available and correct?];\n XY --> XZ[Y];\n XY --> YA[N];\n A --> YB[CHECK if the session waste management plan is available and correct?];\n YB --> YC[Y];\n YB --> YD[N];\n A --> YE[CHECK if the session cold chain plan is available and correct?];\n YE --> YF[Y];\n YE --> YG[N];\n A --> YH[CHECK if the session transport plan is available and correct?];\n YH --> YI[Y];\n YH --> YJ[N];\n A --> YK[CHECK if the session security plan is available and correct?];\n YK --> YL[Y];\n YK --> YM[N];\n A --> YN[CHECK if the session communication materials are available and correct?];\n YN --> YO[Y];\n YN --> YP[N];\n A --> YQ[CHECK if the session waste management materials are available and correct?];\n YQ --> YR[Y];\n YQ --> YS[N];\n A --> YT[CHECK if the session cold chain materials are available and correct?];\n YT --> YU[Y];\n YT --> YV[N];\n A --> YW[CHECK if the session transport materials are available and correct?];\n YW --> YX[Y];\n YW --> YY[N];\n A --> YZ[CHECK if the session security materials are available and correct?];\n YZ --> ZA[Y];\n YZ --> ZB[N];\n A --> ZC[CHECK if the session communication plan is available and correct?];\n ZC --> ZD[Y];\n ZC --> ZE[N];\n A --> ZF[CHECK if the session waste management plan is available and correct?];\n ZF --> ZG[Y];\n ZF --> ZH[N];\n A --> ZI[CHECK if the session cold chain plan is available and correct?];\n ZI --> ZJ[Y];\n ZI --> ZK[N];\n A --> ZL[CHECK if the session transport plan is available and correct?];\n ZL --> ZM[Y];\n ZL --> ZN[N];\n A --> ZO[CHECK if the session security plan is available and correct?];\n ZO --> ZP[Y];\n ZO --> ZQ[N];\n A --> ZR[CHECK if the session communication materials are available and correct?];\n ZR --> ZS[Y];\n ZR --> ZT[N];\n A --> ZU[CHECK if the session waste management materials are available and correct?];\n ZU --> ZV[Y];\n ZU --> ZW[N];\n A --> ZX[CHECK if the session cold chain materials are available and correct?];\n ZX --> ZY[Y];\n ZX --> ZZ[N];\n A --> AAA[CHECK if the session transport materials are available and correct?];\n AAA --> AAB[Y];\n AAA --> AAC[N];\n A --> AAD[CHECK if the session security materials are available and correct?];\n AAD --> AAE[Y];\n AAD --> AAF[N];\n A --> AAG[CHECK if the session communication plan is available and correct?];\n AAG --> AAH[Y];\n AAG --> AAI[N];\n A --> AAJ[CHECK if the session waste management plan is available and correct?];\n AAJ --> AAK[Y];\n AAJ --> AAL[N];\n A --> AAM[CHECK if the session cold chain plan is available and correct?];\n AAM --> AAN[Y];\n AAM --> AAO[N];\n A --> AAP[CHECK if the session transport plan is available and correct?];\n AAP --> AAQ[Y];\n AAP --> AAR[N];\n A --> AAS[CHECK if the session security plan is available and correct?];\n AAS --> AAT[Y];\n AAS --> AAU[N];\n A --> AAV[CHECK if the session communication materials are available and correct?];\n AAV --> AAW[Y];\n AAV --> AAX[N];\n A --> AAY[CHECK if the session waste management materials are available and correct?];\n AAY --> AAZ[Y];\n AAY --> ABA[N];\n A --> ABB[CHECK if the session cold chain materials are available and correct?];\n ABB --> ABC[Y];\n ABB --> ABD[N];\n A --> ABE[CHECK if the session transport materials are available and correct?];\n ABE --> ABF[Y];\n ABE --> ABG[N];\n A --> ABH[CHECK if the session security materials are available and correct?];\n ABH --> ABI[Y];\n ABH --> ABJ[N];\n A --> ABK[CHECK if the session communication plan is available and correct?];\n ABK --> ABL[Y];\n ABK --> ABM[N];\n A --> ABN[CHECK if the session waste management plan is available and correct?];\n ABN --> ABO[Y];\n ABN --> ABP[N];\n A --> ABQ[CHECK if the session cold chain plan is available and correct?];\n ABQ --> ABR[Y];\n ABQ --> ABS[N];\n A --> ABT[CHECK if the session transport plan is available and correct?];\n ABT --> ABU[Y];\n ABT --> ABV[N];\n A --> ABW[CHECK if the session security plan is available and correct?];\n ABW --> ABX[Y];\n ABW --> ABY[N];\n A --> ABZ[CHECK if the session communication materials are available and correct?];\n ABZ --> ACA[Y];\n ABZ --> ACB[N];\n A --> ACC[CHECK if the session waste management materials are available and correct?];\n ACC --> ACD[Y];\n ACC --> ACE[N];\n A --> ACF[CHECK if the session cold chain materials are available and correct?];\n ACF --> ACG[Y];\n ACF --> ACH[N];\n A --> ACI[CHECK if the session transport materials are available and correct?];\n ACI --> ACJ[Y];\n ACI --> ACK[N];\n A --> ACL[CHECK if the session security materials are available and correct?];\n ACL --> ACM[Y];\n ACL --> ACN[N];\n A --> ACO[CHECK if the session communication plan is available and correct?];\n ACO --> ACP[Y];\n ACO --> ACQ[N];\n A --> ACR[CHECK if the session waste management plan is available and correct?];\n ACR --> ACS[Y];\n ACR --> ACT[N];\n A --> ACU[CHECK if the session cold chain plan is available and correct?];\n ACU --> ACV[Y];\n ACU --> ACW[N];\n A --> ACX[CHECK if the session transport plan is available and correct?];\n ACX --> ACY[Y];\n ACX --> ACZ[N];\n A --> ADA[CHECK if the session security plan is available and correct?];\n ADA --> ADB[Y];\n ADA --> ADC[N];\n A --> ADD[CHECK if the session communication materials are available and correct?];\n ADD --> ADE[Y];\n ADD --> ADF[N];\n A --> ADG[CHECK if the session waste management materials are available and correct?];\n ADG --> ADH[Y];\n ADG --> ADI[N];\n A --> ADJ[CHECK if the session cold chain materials are available and correct?];\n ADJ --> ADK[Y];\n ADJ --> ADL[N];\n A --> ADM[CHECK if the session transport materials are available and correct?];\n ADM --> ADN[Y];\n ADM --> ADO[N];\n A --> ADP[CHECK if the session security materials are available and correct?];\n ADP --> ADQ[Y];\n ADP --> ADR[N];\n A --> ADS[CHECK if the session communication plan is available and correct?];\n ADS --> ADT[Y];\n ADS --> ADU[N];\n A --> ADV[CHECK if the session waste management plan is available and correct?];\n ADV --> ADW[Y];\n ADV --> ADX[N];\n A --> ADY[CHECK if the session cold chain plan is available and correct?];\n ADY --> ADZ[Y];\n ADY --> AEA[N];\n A --> AEB[CHECK if the session transport plan is available and correct?];\n AEB --> AEC[Y];\n AEB --> AED[N];\n A --> AEE[CHECK if the session security plan is available and correct?];\n AEE --> AEF[Y];\n AEE --> AEG[N];\n A --> AEH[CHECK if the session communication materials are available and correct?];\n AEH --> AEI[Y];\n AEH --> AEJ[N];\n A --> AEK[CHECK if the session waste management materials are available and correct?];\n AEK --> AEL[Y];\n AEK --> AEM[N];\n A --> AEN[CHECK if the session cold chain materials are available and correct?];\n AEN --> AEO[Y];\n AEN --> AEP[N];\n A --> AEQ[CHECK if the session transport materials are available and correct?];\n AEQ --> AER[Y];\n AEQ --> AES[N];\n A --> AET[CHECK if the session security materials are available and correct?];\n AET --> AEU[Y];\n AET --> AEV[N];\n A --> AEW[CHECK if the session communication plan is available and correct?];\n AEW --> AEX[Y];\n AEW --> AEY[N];\n A --> AEZ[CHECK if the session waste management plan is available and correct?];\n AEZ --> AFA[Y];\n AEZ --> AFB[N];\n A --> AFC[CHECK if the session cold chain plan is available and correct?];\n AFC --> AFD[Y];\n AFC --> AFE[N];\n A --> AFF[CHECK if the session transport plan is available and correct?];\n AFF --> AFG[Y];\n AFF --> AFH[N];\n A --> AFI[CHECK if the session security plan is available and correct?];\n AFI --> AFJ[Y];\n AFI --> AFK[N];\n A --> AFL[CHECK if the session communication materials are available and correct?];\n AFL --> AFM[Y];\n AFL --> AFN[N];\n A --> AFO[CHECK if the session waste management materials are available and correct?];\n AFO --> AFP[Y];\n AFO --> AFQ[N];\n A --> AFR[CHECK if the session cold chain materials are available and correct?];\n AFR --> AFS[Y];\n AFR --> AFT[N];\n A --> AFU[CHECK if the session transport materials are available and correct?];\n AFU --> AFV[Y];\n AFU --> AFW[N];\n A --> AFX[CHECK if the session security materials are available and correct?];\n AFX --> AFY[Y];\n AFX --> AFZ[N];\n A --> AGA[CHECK if the session communication plan is available and correct?];\n AGA --> AGB[Y];\n AGA --> AGC[N];\n A --> AGD[CHECK if the session waste management plan is available and correct?];\n AGD --> AGE[Y];\n AGD --> AGF[N];\n A --> AGG[CHECK if the session cold chain plan is available and correct?];\n AGG --> AGH[Y];\n AGG --> AGI[N];\n A --> AGJ[CHECK if the session transport plan is available and correct?];\n AGJ --> AGK[Y];\n AGJ --> AGL[N];\n A --> AGM[CHECK if the session security plan is available and correct?];\n AGM --> AGN[Y];\n AGM --> AGO[N];\n A --> AGP[CHECK if the session communication materials are available and correct?];\n AGP --> AGQ[Y];\n AGP --> AGR[N];\n A --> AGS[CHECK if the session waste management materials are available and correct?];\n AGS --> AGT[Y];\n AGS --> AGU[N];\n A --> AGV[CHECK if the session cold chain materials are available and correct?];\n AGV --> AGW[Y];\n AGV --> AGX[N];\n A --> AGY[CHECK if the session transport materials are available and correct?];\n AGY --> AGZ[Y];\n AGY --> AHA[N];\n A --> AHB[CHECK if the session security materials are available and correct?];\n AHB --> AHC[Y];\n AHB --> AHD[N];\n A --> AHE[CHECK if the session communication plan is available and correct?];\n AHE --> AHF[Y];\n AHE --> AHG[N];\n A --> AHH[CHECK if the session waste management plan is available and correct?];\n AHH --> AHI[Y];\n AHH --> AHJ[N];\n A --> AHK[CHECK if the session cold chain plan is available and correct?];\n AHK --> AHL[Y];\n AHK --> AHM[N];\n A --> AHN[CHECK if the session transport plan is available and correct?];\n AHN --> AHO[Y];\n AHN --> AHP[N];\n A --> AHQ[CHECK if the session security plan is available and correct?];\n AHQ --> AHR[Y];\n AHQ --> AHS[N];\n A --> AHT[CHECK if the session communication materials are available and correct?];\n AHT --> AHU[Y];\n AHT --> AHV[N];\n A --> AHW[CHECK if the session waste management materials are available and correct?];\n AHW --> AHX[Y];\n AHW --> AHY[N];\n A --> AHZ[CHECK if the session cold chain materials are available and correct?];\n AHZ --> AIA[Y];\n AHZ --> AIB[N];\n A --> AIC[CHECK if the session transport materials are available and correct?];\n AIC --> AID[Y];\n AIC --> AIE[N];\n A --> AIF[CHECK if the session security materials are available and correct?];\n AIF --> AIG[Y];\n AIF --> AIH[N];\n A --> AII[CHECK if the session communication plan is available and correct?];\n AII --> AIJ[Y];\n AII --> AIK[N];\n A --> AIL[CHECK if the session waste management plan is available and correct?];\n AIL --> AIM[Y];\n AIL --> AIN[N];\n A --> AIO[CHECK if the session cold chain plan is available and correct?];\n AIO --> AIP[Y];\n AIO --> AIQ[N];\n A --> AIR[CHECK if the session transport plan is available and correct?];\n AIR --> AIS[Y];\n AIR --> AIT[N];\n A --> AIU[CHECK if the session security plan is available and correct?];\n AIU --> AIV[Y];\n AIU --> AIW[N];\n A --> AIX[CHECK if the session communication materials are available and correct?];\n AIX --> AIY[Y];\n AIX --> AIZ[N];\n A --> AJA[CHECK if the session waste management materials are available and correct?];\n AJA --> AJB[Y];\n AJA --> AJC[N];\n A --> AJD[CHECK if the session cold chain materials are available and correct?];\n AJD --> AJE[Y];\n AJD --> AJF[N];\n A --> AJG[CHECK if the session transport materials are available and correct?];\n AJG --> AJH[Y];\n AJG --> AJI[N];\n A --> AJJ[CHECK if the session security materials are available and correct?];\n AJJ --> AJK[Y];\n AJJ --> AJL[N];\n A --> AJM[CHECK if the session communication plan is available and correct?];\n AJM --> AJN[Y];\n AJM --> AJO[N];\n A --> AJP[CHECK if the session waste management plan is available and correct?];\n AJP --> AJQ[Y];\n AJP --> AJR[N];\n A --> AJS[CHECK if the session cold chain plan is available and correct?];\n AJS --> AJT[Y];\n AJS --> AJU[N];\n A --> AJV[CHECK if the session transport plan is available and correct?];\n AJV --> AJW[Y];\n AJV --> AJX[N];\n A --> AJY[CHECK if the session security plan is available and correct?];\n AJY --> AJZ[Y];\n AJY --> AKA[N];\n A --> AKB[CHECK if the session communication materials are available and correct?];\n AKB --> AKC[Y];\n AKB --> AKD[N];\n A --> AKE[CHECK if the session waste management materials are available and correct?];\n AKE --> AKF[Y];\n AKE --> AKG[N];\n A --> AKH[CHECK if the session cold chain materials are available and correct?];\n AKH --> AKI[Y];\n AKH --> AKJ[N];\n A --> AKK[CHECK if the session transport materials are available and correct?];\n AKK --> AKL[Y];\n AKK --> AKM[N];\n A --> AKN[CHECK if the session security materials are available and correct?];\n AKN --> AKO[Y];\n AKN --> AKP[N];\n A --> AKQ[CHECK if the session communication plan is available and correct?];\n AKQ --> AKR[Y];\n AKQ --> AKS[N];\n A --> AKT[CHECK if the session waste management plan is available and correct?];\n AKT --> AKU[Y];\n AKT --> AKV[N];\n A --> AKW[CHECK if the session cold chain plan is available and correct?];\n AKW --> AKX[Y];\n AKW --> AKY[N];\n A --> AKZ[CHECK if the session transport plan is available and correct?];\n AKZ --> ALA[Y];\n AKZ --> ALB[N];\n A --> ALC[CHECK if the session security plan is available and correct?];\n ALC --> ALD[Y];\n ALC --> ALE[N];\n A --> ALF[CHECK if the session communication materials are available and correct?];\n ALF --> ALG[Y];\n ALF --> ALH[N];\n A --> ALI[CHECK if the session waste management materials are available and correct?];\n ALI --> ALJ[Y];\n ALI --> ALK[N];\n A --> ALL[CHECK if the session cold chain materials are available and correct?];\n ALL --> ALM[Y];\n ALL --> ALN[N];\n A --> ALO[CHECK if the session transport materials are available and correct?];\n ALO --> ALP[Y];\n ALO --> ALQ[N];\n A --> ALR[CHECK if the session security materials are available and correct?];\n ALR --> ALS[Y];\n ALR --> ALT[N];\n A --> ALU[CHECK if the session communication plan is available and correct?];\n ALU --> ALV[Y];\n ALU --> ALW[N];\n A --> ALX[CHECK if the session waste management plan is available and correct?];\n ALX --> ALY[Y];\n ALX --> ALZ[N];\n A --> AMA[CHECK if the session cold chain plan is available and correct?];\n AMA --> AMB[Y];\n AMA --> AMC[N];\n A --> AMD[CHECK if the session transport plan is available and correct?];\n AMD --> AME[Y];\n AMD --> AMF[N];\n A --> AMG[CHECK if the session security plan is available and correct?];\n AMG --> AMH[Y];\n AMG --> AMI[N];\n A --> AMJ[CHECK if the session communication materials are available and correct?];\n AMJ --> AMK[Y];\n AMJ --> AML[N];\n A --> AMM[CHECK if the session waste management materials are available and correct?];\n AMM --> AMN[Y];\n AMM --> AMO[N];\n A --> AMP[CHECK if the session cold chain materials are available and correct?];\n AMP --> AMQ[Y];\n AMP --> AMR[N];\n A --> AMS[CHECK if the session transport materials are available and correct?];\n AMS --> AMT[Y];\n AMS --> AMU[N];\n A --> AMV[CHECK if the session security materials are available and correct?];\n AMV --> AMW[Y];\n AMV --> AMX[N];\n A --> AMY[CHECK if the session communication plan is available and correct?];\n AMY --> AMZ[Y];\n AMY --> ANA[N];\n A --> ANB[CHECK if the session waste management plan is available and correct?];\n ANB --> ANC[Y];\n ANB --> AND[N];\n A --> ANE[CHECK if the session cold chain plan is available and correct?];\n ANE --> ANF[Y];\n ANE --> ANG[N];\n A --> ANH[CHECK if the session transport plan is available and correct?];\n ANH --> ANI[Y];\n ANH --> ANJ[N];\n A --> ANK[CHECK if the session security plan is available and correct?];\n ANK --> ANL[Y];\n ANK --> ANM[N];\n A --> ANN[CHECK if the session communication materials are available and correct?];\n ANN --> ANO[Y];\n ANN --> ANP[N];\n A --> ANQ[CHECK if the session waste management materials are available and correct?];\n ANQ --> ANR[Y];\n ANQ --> ANS[N];\n A --> ANT[CHECK if the session cold chain materials are available and correct?];\n ANT --> ANU[Y];\n ANT --> ANV[N];\n A --> ANW[CHECK if the session transport materials are available and correct?];\n ANW --> ANX[Y];\n ANW --> ANY[N];\n A --> ANZ[CHECK if the session security materials are available and correct?];\n ANZ --> AOA[Y];\n ANZ --> AOB[N];\n A --> AOC[CHECK if the session communication plan is available and correct?];\n AOC --> AOD[Y];\n AOC --> AOE[N];\n A --> AOF[CHECK if the session waste management plan is available and correct?];\n AOF --> AOG[Y];\n AOF --> AOH[N];\n A --> AOI[CHECK if the session cold chain plan is available and correct?];\n AOI --> AOJ[Y];\n AOI --> AOK[N];\n A --> AOL[CHECK if the session transport plan is available and correct?];\n AOL --> AOM[Y];\n AOL --> AON[N];\n A --> AOO[CHECK if the session security plan is available and correct?];\n AOO --> AOP[Y];\n AOO --> AOQ[N];\n A --> AOR[CHECK if the session communication materials are available and correct?];\n AOR --> AOS[Y];\n AOR --> AOT[N];\n A --> AOU[CHECK if the session waste management materials are available and correct?];\n AOU --> AOV[Y];\n AOU --> AOW[N];\n A --> AOX[CHECK if the session cold chain materials are available and correct?];\n AOX --> AOY[Y];\n AOX --> AOZ[N];\n A --> APA[CHECK if the session transport materials are available and correct?];\n APA --> APB[Y];\n APA --> APC[N];\n A --> APD[CHECK if the session security materials are available and correct?];\n APD --> APE[Y];\n APD --> APF[N];\n A --> APG[CHECK if the session communication plan is available and correct?];\n APG --> APH[Y];\n APG --> API[N];\n A --> APJ[CHECK if the session waste management plan is available and correct?];\n APJ --> APK[Y];\n APJ --> APL[N];\n A --> APM[CHECK if the session cold chain plan is available and correct?];\n APM --> APN[Y];\n APM --> APO[N];\n A --> APP[CHECK if the session transport plan is available and correct?];\n APP --> APQ[Y];\n APP --> APR[N];\n A --> APS[CHECK if the session security plan is available and correct?];\n APS --> APT[Y];\n APS --> APU[N];\n A --> APV[CHECK if the session communication materials are available and correct?];\n APV --> APW[Y];\n APV --> APX[N];\n A --> APY[CHECK if the session waste management materials are available and correct?];\n APY --> APZ[Y];\n APY --> AQA[N];\n A --> AQB[CHECK if the session cold chain materials are available and correct?];\n AQB --> AQC[Y];\n AQB --> AQD[N];\n A --> AQE[CHECK if the session transport materials are available and correct?];\n AQE --> AQF[Y];\n AQE --> AQG[N];\n A --> AQH[CHECK if the session security materials are available and correct?];\n AQH --> AQI[Y];\n AQH --> AQJ[N];\n A --> AQK[CHECK if the session communication plan is available and correct?];\n AQK --> AQL[Y];\n AQK --> AQM[N];\n A --> AQN[CHECK if the session waste management plan is available and correct?];\n AQN --> AQO[Y];\n AQN --> AQP[N];\n A --> AQQ[CHECK if the session cold chain plan is available and correct?];\n AQQ --> AQR[Y];\n AQQ --> AQS[N];\n A --> AQT[CHECK if the session transport plan is available and correct?];\n AQT --> AQU[Y];\n AQT --> AQV[N];\n A --> AQW[CHECK if the session security plan is available and correct?];\n AQW --> AQX[Y];\n AQW --> AQY[N];\n A --> AQZ[CHECK if the session communication materials are available and correct?];\n AQZ --> ARA[Y];\n AQZ --> ARB[N];\n A --> ARC[CHECK if the session waste management materials are available and correct?];\n ARC --> ARD[Y];\n ARC --> ARE[N];\n A --> ARF[CHECK if the session cold chain materials are available and correct?];\n ARF --> ARG[Y];\n ARF --> ARH[N];\n A --> ARI[CHECK if the session transport materials are available and correct?];\n ARI --> ARJ[Y];\n ARI --> ARK[N];\n A --> ARL[CHECK if the session security materials are available and correct?];\n ARL --> ARM[Y];\n ARL --> ARN[N];\n A --> ARO[CHECK if the session communication plan is available and correct?];\n ARO --> ARP[Y];\n ARO --> ARQ[N];\n A --> ARR[CHECK if the session waste management plan is available and correct?];\n ARR --> ARS[Y];\n ARR --> ART[N];\n A --> ARU[CHECK if the session cold chain plan is available and correct?];\n ARU --> ARV[Y];\n ARU --> ARW[N];\n A --> ARX[CHECK if the session transport plan is available and correct?];\n ARX --> ARY[Y];\n ARX --> ARZ[N];\n A --> ASA[CHECK if the session security plan is available and correct?];\n ASA --> ASB[Y];\n ASA --> ASC[N];\n A --> ASD[CHECK if the session communication materials are available and correct?];\n ASD --> ASE[Y];\n ASD --> ASF[N];\n A --> ASG[CHECK if the session waste management materials are available and correct?];\n ASG --> ASH[Y];\n ASG --> ASI[N];\n A --> ASJ[CHECK if the session cold chain materials are available and correct?];\n ASJ --> ASK[Y];\n ASJ --> ASL[N];\n A --> ASM[CHECK if the session transport materials are available and correct?];\n ASM --> ASN[Y];\n ASM --> ASO[N];\n A --> ASP[CHECK if the session security materials are available and correct?];\n ASP --> ASQ[Y];\n ASP --> ASR[N];\n A --> ASS[CHECK if the session communication plan is available and correct?];\n ASS --> AST[Y];\n ASS --> ASU[N];\n A --> ASV[CHECK if the session waste management plan is available and correct?];\n ASV --> ASW[Y];\n ASV --> ASX[N];\n A --> ASY[CHECK if the session cold chain plan is available and correct?];\n ASY --> ASZ[Y];\n ASY --> ATA[N];\n A --> ATB[CHECK if the session transport plan is available and correct?];\n ATB --> ATC[Y];\n ATB --> ATD[N];\n A --> ATE[CHECK if the session security plan is available and correct?];\n ATE --> ATF[Y];\n ATE --> ATG[N];\n A --> ATH[CHECK if the session communication materials are available and correct?];\n ATH --> ATI[Y];\n ATH --> ATJ[N];\n A --> ATK[CHECK if the session waste management materials are available and correct?];\n ATK --> ATL[Y];\n ATK --> ATM[N];\n A --> ATN[CHECK if the session cold chain materials are available and correct?];\n ATN --> ATO[Y];\n ATN --> ATP[N];\n A --> ATQ[CHECK if the session transport materials are available and correct?];\n ATQ --> ATR[Y];\n ATQ --> ATS[N];\n A --> ATT[CHECK if the session security materials are available and correct?];\n ATT --> ATU[Y];\n ATT --> ATV[N];\n A --> ATW[CHECK if the session communication plan is available and correct?];\n ATW --> ATX[Y];\n ATW --> ATY[N];\n A --> ATZ[CHECK if the session waste management plan is available and correct?];\n ATZ --> AUA[Y];\n ATZ --> AUB[N];\n A --> AUC[CHECK if the session cold chain plan is available and correct?];\n AUC --> AUD[Y];\n AUC --> AUE[N];\n A --> AUF[CHECK if the session transport plan is available and correct?];\n AUF --> AUG[Y];\n AUF --> AUH[N];\n A --> AUI[CHECK if the session security materials are available and correct?];\n AUI --> AUJ[Y];\n AUI --> AUK[N];\n A --> AUL[CHECK if the session communication materials are available and correct?];\n AUL --> AUM[Y];\n AUL --> AUN[N];\n A --> AUO[CHECK if the session waste management materials are available and correct?];\n AUO --> AUP[Y];\n AUO --> AUQ[N];\n A --> AUR[CHECK if the session cold chain materials are available and correct?];\n AUR --> AUS[Y];\n AUR --> AUT[N];\n A --> AUU[CHECK if the session transport materials are available and correct?];\n AUU --> AUV[Y];\n AUU --> AUW[N];\n A --> AUX[CHECK if the session security materials are available and correct?];\n AUX --> AUY[Y];\n AUX --> AUZ[N];\n A --> AVA[CHECK if the session communication plan is available and correct?];\n AVA --> AVB[Y];\n AVA --> AVC[N];\n A --> AVD[CHECK if the session waste management plan is available and correct?];\n AVD --> AVE[Y];\n AVD --> AVF[N];\n A --> AVG[CHECK if the session cold chain plan is available and correct?];\n AVG --> AVH[Y];\n AVG --> AVI[N];\n A --> AVJ[CHECK if the session transport plan is available and correct?];\n AVJ --> AVK[Y];\n AVJ --> AVL[N];\n A --> AVM[CHECK if the session security plan is available and correct?];\n AVM --> AVN[Y];\n AVM --> AVO[N];\n A --> AVP[CHECK if the session communication materials are available and correct?];\n AVP --> AVQ[Y];\n AVP --> AVR[N];\n A --> AVS[CHECK if the session waste management materials are available and correct?];\n AVS --> AVT[Y];\n AVS --> AVU[N];\n A --> AVV[CHECK if the session cold chain materials are available and correct?];\n AVV --> AVW[Y];\n AVV --> AVX[N];\n A --> AVY[CHECK if the session transport materials are available and correct?];\n AVY --> AVZ[Y];\n AVY --> AWA[N];\n A --> AWB[CHECK if the session security materials are available and correct?];\n AWB --> AWC[Y];\n AWB --> AWD[N];\n A --> AWE[CHECK if the session communication plan is available and correct?];\n AWE --> AWF[Y];\n AWE --> AWG[N];\n A --> AWH[CHECK if the session waste management plan is available and correct?];\n AWH --> AWI[Y];\n AWH --> AWJ[N];\n A --> AWK[CHECK if the session cold chain plan is available and correct?];\n AWK --> AWL[Y];\n AWK --> AWM[N];\n A --> AWN[CHECK if the session transport plan is available and correct?];\n AWN --> AWO[Y];\n AWN --> AWP[N];\n A --> AWQ[CHECK if the session security plan is available and correct?];\n AWQ --> AWR[Y];\n AWQ --> AWS[N];\n A --> AWT[CHECK if the session communication materials are available and correct?];\n AWT --> AWU[Y];\n AWT --> AWV[N];\n A --> AWW[CHECK if the session waste management materials are available and correct?];\n AWW --> AWX[Y];\n AWW --> AWY[N];\n A --> AWZ[CHECK if the session cold chain materials are available and correct?];\n AWZ --> AXA[Y];\n AWZ --> AXB[N];\n A --> AXC[CHECK if the session transport materials are available and correct?];\n AXC --> AXD[Y];\n AXC --> AXE[N];\n A --> AXF[CHECK if the session security materials are available and correct?];\n AXF --> AXG[Y];\n AXF --> AXH[N];\n A --> AXI[CHECK if the session communication plan is available and correct?];\n AXI --> AXJ[Y];\n AXI --> AXK[N];\n A --> AXL[CHECK if the session waste management plan is available and correct?];\n AXL --> AXM[Y];\n AXL --> AXN[N];\n A --> AXO[CHECK if the session cold chain plan is available and correct?];\n AXO --> AXP[Y];\n AXO --> AXQ[N];\n A --> AXR[CHECK if the session transport plan is available and correct?];\n AXR --> AXS[Y];\n AXR --> AXT[N];\n A --> AXU[CHECK if the session security plan is available and correct?];\n AXU --> AXV[Y];\n AXU --> AXW[N];\n A --> AXX[CHECK if the session communication materials are available and correct?];\n AXX --> AXY[Y];\n AXX --> AXZ[N];\n A --> AYA[CHECK if the session waste management materials are available and correct?];\n AYA --> AYB[Y];\n AYA --> AYC[N];\n A --> AYD[CHECK if the session cold chain materials are available and correct?];\n AYD --> AYE[Y];\n AYD --> AYF[N];\n A --> AYG[CHECK if the session transport materials are available and correct?];\n AYG --> AYH[Y];\n AYG --> AYI[N];\n A --> AYJ[CHECK if the session security materials are available and correct?];\n AYJ --> AYK[Y];\n AYJ --> AYL[N];\n A --> AYM[CHECK if the session communication plan is available and correct?];\n AYM --> AYN[Y];\n AYM --> AYO[N];\n A --> AYP[CHECK if the session waste management plan is available and correct?];\n AYP --> AYQ[Y];\n AYP --> AYR[N];\n A --> AYS[CHECK if the session cold chain plan is available and correct?];\n AYS --> AYT[Y];\n AYS --> AYU[N];\n A --> AYV[CHECK if the session transport plan is available and correct?];\n AYV --> AYW[Y];\n AYV --> AYX[N];\n A --> AYY[CHECK if the session security plan is available and correct?];\n AYY --> AYZ[Y];\n AYY --> AZA[N];\n A --> AZB[CHECK if the session communication materials are available and correct?];\n AZB --> AZC[Y];\n AZB --> AZD[N];\n A --> AZE[CHECK if the session waste management materials are available and correct?];\n AZE --> AZF[Y];\n AZE --> AZG[N];\n A --> AZH[CHECK if the session cold chain materials are available and correct?];\n AZH --> AZI[Y];\n AZH --> AZJ[N];\n A --> AZK[CHECK if the session transport materials are available and correct?];\n AZK --> AZL[Y];\n AZK --> AZM[N];\n A --> AZN[CHECK if the session security materials are available and correct?];\n AZN --> AZO[Y];\n AZN --> AZP[N];\n A --> AZQ[CHECK if the session communication plan is available and correct?];\n AZQ --> AZR[Y];\n AZQ --> AZS[N];\n A --> AZT[CHECK if the session waste management plan is available and correct?];\n AZT --> AZU[Y];\n AZT --> AZV[N];\n A --> AZW[CHECK if the session cold chain plan is available and correct?];\n AZW --> AZX[Y];\n AZW --> AZY[N];\n A --> AZZ[CHECK if the session transport plan is available and correct?];\n AZZ --> BAA[Y];\n AZZ --> BAB[N];\n A --> BAC[CHECK if the session security materials are available and correct?];\n BAC --> BAD[Y];\n BAC --> BAE[N];\n A --> BAF[CHECK if the session communication materials are available and correct?];\n BAF --> BAG[Y];\n BAF --> BAH[N];\n A --> BAI[CHECK if the session waste management materials are available and correct?];\n BAI --> BAJ[Y];\n BAI --> BAK[N];\n A --> BAL[CHECK if the session cold chain materials are available and correct?];\n BAL --> BAM[Y];\n BAL --> BAN[N];\n A --> BAO[CHECK if the session transport materials are available and correct?];\n BAO --> BAP[Y];\n BAO --> BAQ[N];\n A --> BAR[CHECK if the session security materials are available and correct?];\n BAR --> BAS[Y];\n BAR --> BAT[N];\n A --> BAU[CHECK if the session communication plan is available and correct?];\n BAU --> BAV[Y];\n BAU --> BAW[N];\n A --> BAX[CHECK if the session waste management plan is available and correct?];\n BAX --> BAY[Y];\n BAX --> BAZ[N];\n A --> BBA[CHECK if the session cold chain plan is available and correct?];\n BBA --> BBB[Y];\n BBA --> BBC[N];\n A --> BBD[CHECK if the session transport plan is available and correct?];\n BBD --> BBE[Y];\n BBD --> BBF[N];\n A --> BBG[CHECK if the session security plan is available and correct?];\n BBG --> BBH[Y];\n BBG --> BBI[N];\n A --> BBJ[CHECK if the session communication materials are available and correct?];\n BBJ --> BBK[Y];\n BBJ --> BBL[N];\n A --> BBM[CHECK if the session waste management materials are available and correct?];\n BBM --> BBN[Y];\n BBM --> BBO[N];\n A --> BBP[CHECK if the session cold chain materials are available and correct?];\n BBP --> BBQ[Y];\n BBP --> BBR[N];\n A --> BBS[CHECK if the session transport materials are available and correct?];\n BBS --> BBT[Y];\n BBS --> BBU[N];\n A --> BBV[CHECK if the session security materials are available and correct?];\n BBV --> BBW[Y];\n BBV --> BBX[N];\n A --> BBY[CHECK if the session communication plan is available and correct?];\n BBY --> BBZ[Y];\n BBY --> BCA[N];\n A --> BCB[CHECK if the session waste management plan is available and correct?];\n BCB --> BCC[Y];\n BCB --> BCD[N];\n A --> BCE[CHECK if the session cold chain plan is available and correct?];\n BCE --> BCF[Y];\n BCE --> BCG[N];\n A --> BCH[CHECK if the session transport plan is available and correct?];\n BCH --> BCI[Y];\n BCH --> BCJ[N];\n A --> BCK[CHECK if the session security plan is available and correct?];\n BCK --> BCL[Y];\n BCK --> BCM[N];\n A --> BCN[CHECK if the session communication materials are available and correct?];\n BCN --> BCO[Y];\n BCN --> BCP[N];\n A --> BCQ[CHECK if the session waste management materials are available and correct?];\n BCQ --> BCR[Y];\n BCQ --> BCS[N];\n A --> BCT[CHECK if the session cold chain materials are available and correct?];\n BCT --> BCU[Y];\n BCT --> BCV[N];\n A --> BCW[CHECK if the session transport materials are available and correct?];\n BCW --> BCX[Y];\n BCW --> BCY[N];\n A --> BCZ[CHECK if the session security materials are available and correct?];\n BCZ --> BDA[Y];\n BCZ --> BDB[N];\n A --> BDC[CHECK if the session communication plan is available and correct?];\n BDC --> BDD[Y];\n BDC --> BDE[N];\n A --> BDF[CHECK if the session waste management plan is available and correct?];\n BDF --> BDG[Y];\n BDF --> BDH[N];\n A --> BDI[CHECK if the session cold chain plan is available and correct?];\n BDI --> BDJ[Y];\n BDI --> BDK[N];\n A --> BDL[CHECK if the session transport plan is available and correct?];\n BDL --> BDM[Y];\n BDL --> BDN[N];\n A --> BDO[CHECK if the session security materials are available and correct?];\n BDO --> BDP[Y];\n BDO --> BDQ[N];\n A --> BDR[CHECK if the session communication materials are available and correct?];\n BDR --> BDS[Y];\n BDR --> BDT[N];\n A --> BDU[CHECK if the session waste management materials are available and correct?];\n BDU --> BDV[Y];\n BDU --> BDW[N];\n A --> BDX[CHECK if the session cold chain materials are available and correct?];\n BDX --> BDY[Y];\n BDX --> BDZ[N];\n A --> BEA[CHECK if the session transport materials are available and correct?];\n BEA --> BEB[Y];\n BEA --> BEC[N];\n A --> BED[CHECK if the session security materials are available and correct?];\n BED --> BEE[Y];\n BED --> BEF[N];\n A --> BEG[CHECK if the session communication plan is available and correct?];\n BEG --> BEH[Y];\n BEG --> BEI[N];\n A --> BEJ[CHECK if the session waste management plan is available and correct?];\n BEJ --> BEK[Y];\n BEJ --> BEL[N];\n A --> BEM[CHECK if the session cold chain plan is available and correct?];\n BEM --> BEN[Y];\n BEM --> BEO[N];\n A --> BEP[CHECK if the session transport plan is available and correct?];\n BEP --> BEQ[Y];\n BEP --> BER[N];\n A --> BES[CHECK if the session security materials are available and correct?];\n BES --> BET[Y];\n BES --> BEU[N];\n A --> BEV[CHECK if the session communication materials are available and correct?];\n BEV --> BEW[Y];\n BEV --> BEX[N];\n A --> BEY[CHECK if the session waste management materials are available and correct?];\n BEY --> BEZ[Y];\n BEY --> BFA[N];\n A --> BFB[CHECK if the session cold chain materials are available and correct?];\n BFB --> BFC[Y];\n BFB --> BFD[N];\n A --> BFE[CHECK if the session transport materials are available and correct?];\n BFE --> BFF[Y];\n BFE --> BFG[N];\n A --> BFH[CHECK if the session security materials are available and correct?];\n BFH --> BFI[Y];\n BFH --> BFJ[N];\n A --> BFK[CHECK if the session communication plan is available and correct?];\n BFK --> BFL[Y];\n BFK --> BFM[N];\n A --> BFN[CHECK if the session waste management plan is available and correct?];\n BFN --> BFO[Y];\n BFN --> BFP[N];\n A --> BFQ[CHECK if the session cold chain plan is available and correct?];\n BFQ --> BFR[Y];\n BFQ --> BFS[N];\n A --> BFT[CHECK if the session transport plan is available and correct?];\n BFT -->",
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Figure 5.11 Immunization session checklist
Before the immunization session
DO YOU:
□
CHECK if sufficient quantities of vaccines and diuretics are available for the session?
□
CHECK visits for the following and take up two weeks to visit:
H Opservical doses?
N Opservical doses?
N VVVA status?
N Freezing status?
□
PLACE visits in the appropriate places in the clinic.
□
DISCUSS whether or not there are available for the session including:
N Auto-disable M2D syringes?
N Recombination syringes?
N Safety food
N ASTI kit?
N Immunization registers?
N Immunization fully sheets?
N Black immunization cards?
□
WASH your hands with soap?
For selected clients attending the immunization session
DO YOU:
□
GREET the client and caregiver?
□
REFUSE the client's immunization card?
□
DETERMINE eligible vaccinations based on the common standard, client's age and possible medical schedule?
□
RECONSTRUITE each vaccine with its matched diuretic RID (type/attack vaccine)?
□
FILL syringes and follow administration using as-path techniques?
□
ADMINISTER each vaccine according to recommended techniques and correct injection rate?
□
IMMEDIATELY DISPOSE needle/M2D syringes in safety boxes after each injection?
□
RECORD all vaccinations in register, fully sheet and immunization card?
□
COMMUNICATE key messages, including potential ASTIs and dates of new visit?
After the immunization session
DO YOU:
□
CONNECTLY ASSESS if open visit can be used in the next session in accordance with national multi-task viral policy?
□
DISCARD open visits that should not be used?
□
RECORD date of opening on visit that can be used and PLACE them in the \"use first\" box in the refrigerator?
□
RETURN unopened visits to the refrigerator?
□
COUPLE LTE fixation summary report?
□
LIST the names of children who missed vaccination and require follow up?
□
MARCILL full safety boxes correctly?
□
TAKE appropriate action to ensure sufficient vaccine stock for the next session?
□
INFORM COMMUNITY of data and time of next session?
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"text": "\n\n\nAbout this module…\nThis module explains how to collect and report data for the monitoring of immunization services and the surveillance of vaccine-preventable diseases and adverse events following immunization (AEFI). Monitoring and surveillance are included together since data from both are usually reported in a summary form forwarded to central levels. The process of recording the data is described first. This is followed by a description of the summary reporting process and the ways in which these data can be analysed and used. Monitoring of immunization services helps to improve performance and identify and solve any problems of access and utilization detected in communities with high numbers of unimmunized children. Surveillance of vaccine-preventable diseases helps guide disease control activities by detecting outbreaks, identifying high-risk groups or areas and monitoring the impact of immunization services. Surveillance of AEFI cases helps to identify the causes of adverse events and, if needed, triggers a review of proper vaccine handling and administration. Examples in this module focus on infants, but the methods can be applied to older age groups. The examples show paper-based recording and reporting, but data collection principles apply to other modalities. While the use of electronic tools for district data monitoring is encouraged by WHO, their implementation and instructions for use will depend on national or central authorities and objectives.\nModule 6: Monitoring and surveillance\nModule 6: Monitoring and surveillance",
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This module explains how to collect and report data for the monitoring of immunization services and the surveillance of vaccine-preventable diseases and adverse events following immunization (AEFI). Monitoring and surveillance are included together since data from both are usually reported in a summary form forwarded to central levels. The process of recording the data is described first. This is followed by a description of the summary reporting process and the ways in which these data can be analysed and used.
Monitoring of immunization services helps to improve performance and identify and solve any problems of access and utilization detected in communities with high numbers of unimmunized children. Surveillance of vaccine-preventable diseases helps guide disease control activities by detecting outbreaks, identifying high-risk groups or areas and monitoring the impact of immunization services. Surveillance of AEFI cases helps to identify the causes of adverse events and, if needed, triggers a review of proper vaccine handling and administration.
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Every health facility needs a system of recording data for monitoring immunization services. Systematically and regularly recording the vaccinations given at each session ensures that services meet coverage targets (see Section 3 of this module), identifies defaulters and helps to actively follow up all those who need to complete their vaccinations.
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The tools required for effective monitoring were introduced in Modules 4 (
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Managing an immunization session
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"text": "\n\n\n1.1 The immunization register\nThe immunization register is used to record the immunizations received by each child. It is a book or a form that stays in the health facility. Its main purpose is to keep track of the immunization services provided to each infant over time. It lists each infant on a separate line and is important for several reasons:\nIt is the health facility’s primary source of information on a child’s immunization status and needed vaccinations. This information is particularly helpful if an infant attends for a follow-up visit without their immunization card. It helps identify infants who miss scheduled vaccinations and who need to be added to the defaulter tracking list. It is a source of data for monthly and other reports.\nHealth facilities may keep separate registers for each community that they serve; they may also use specific registers for outreach activities and/or children who present from outside their catchment area.\nMonitoring and surveillance\nunique identification number registration date (usually the date of the first visit) name of infant infant’s birth date infant’s sex name, address and phone/mobile number of caregiver(s) dates and doses of vaccinations and vitamin A supplementation given (if applicable) protected at birth (PAB) status, which indicates whether or not the infant was protected for neonatal tetanus.\nThe immunization register can also be used as a birth register. As soon as an infant is born in the community, their name can be entered in the register even before receiving any vaccinations. This will help to follow up new infants along with older ones on the defaulter tracking list. Two different infant immunization register examples are shown in Figure 6.1.\nWith both examples, a new month can be started at the top of the next page even if there are some lines left on the current page. For example, on 31 January there may be five lines blank on the current page but on 1 February registration of new infants should start at the top of the next page. This will make it easier to find infants returning without their immunization cards and to compile defaulter tracking lists (see Section 1.4 of this module). The first example (A) is organized by vaccine and the doses required for the series. With this format, it is easy to see whether an infant is fully immunized with each antigen. The second example (B) is organized by vaccines that are usually given in the same visit when following the example immunization schedule. With this format, it is easy to see which doses are needed each time an infant comes to a session. It is also easy to see which infants have missed vaccinations and need to be included in the defaulter tracking list (see Section 1.4 of this module).\nThese are suggestions. Any format used should match national guidelines and be coordinated with the method used to track defaulters, as described in Section 1.4 of this module.\nModule 6: Monitoring and surveillance\nNote: these examples feature 4-dose DTP, 2-dose RV and 3-dose PCV schedule. The register format always depends on the vaccines that are included in the national immunization schedule.\nA. Format organized by vaccine series\nB. Format organized by immunization contact and doses of all vaccines required at each contact\nModule 6: Monitoring and surveillance\nInfants should be registered as soon as they arrive at the health facility or outreach site. Fill in all information except the space provided for vaccinations. Vaccinations should be marked only after being administered. Use a unique identification number on the register for each infant and write the same number on the immunization card. A unique identification number is easier to locate in the register if the immunization card is available during follow-up appointments. Do not create a new entry in the register each time the mother brings the infant for immunization. Ask the caregiver for the immunization card and look for a corresponding entry in the register. If the immunization card is not available, ask the caregiver for the child’s name, age and the month and/or other details of the first immunization, then locate their line in the register. For every new infant (never immunized), create a new entry in the register and a new immunization card. For an infant who has come to the health facility for the first time but has received immunizations in another facility, create a new entry in the register, ask for the immunization card and write immunizations that the infant has already received in the register. If there is no immunization card, review the vaccines the child should have received (by age according to the national immunization schedule) with the caregiver and record the ones they can recall being given. If the caregiver is not able to recall the vaccines given, the immunization schedule should be started again (see Module 5, Section 3 on assessing eligibility for immunization).\n➢ Fill in all information on the register line for each infant. ➢ Mark vaccinations in the register only after they are given to the infant. ➢ When an infant returns for a follow-up visit, find the register line for the infant using the immunization card (or the infant’s name and age and/or month of first vaccination if the card is not available).",
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name of infant
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Infants should be registered as soon as they arrive at the health facility or outreach site. Fill in all information except the space provided for vaccinations. Vaccinations should be marked only after being administered.
Use a unique identification number on the register for each infant and write the same number on the immunization card. A unique identification number is easier to locate in the register if the immunization card is available during follow-up appointments.
Do not create a new entry in the register each time the mother brings the infant for immunization. Ask the caregiver for the immunization card and look for a corresponding entry in the register. If the immunization card is not available, ask the caregiver for the child’s name, age and the month and/or other details of the first immunization, then locate their line in the register.
For every new infant (never immunized), create a new entry in the register and a new immunization card. For an infant who has come to the health facility for the first time but has received immunizations in another facility, create a new entry in the register, ask for the immunization card and write immunizations that the infant has already received in the register. If there is no immunization card, review the vaccines the child should have received (by age according to the national immunization schedule) with the caregiver and record the ones they can recall being given. If the caregiver is not able to recall the vaccines given, the immunization schedule should be started again (see Module 5, Section 3 on assessing eligibility for immunization).
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➢ Fill in all information on the register line for each infant.
➢ Mark vaccinations in the register only after they are given to the infant.
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"text": "\n\n\n1.2 The immunization card\n• it serves to remind caregivers to return to the clinic for the next dose(s) of vaccine(s) • it helps the health worker determine an infant’s immunization status\nMonitoring and surveillance\nThe specific format of the immunization card depends on the vaccines that are included in the national immunization schedule. Examples of immunization cards are available from the vaccination card repository at www.immunizationcards.org .\nRemember that the immunization card may be the only record of immunization status available for health workers if registers are not well maintained or if families move from one health facility to another. Each infant should have a card with vaccinations marked correctly. Review Module 5 for the process of filling and explaining the card to caregivers during the immunization encounter.\nunique identification number (which is the same number written in the immunization register as shown in Figure 6.1) infant’s name infant’s birth date infant’s sex name and address of caregiver(s), including mobile/phone number if available date, dose and lot number of each vaccine given date and dose of vitamin A supplementation given, if applicable PAB status (infant protection at birth from neonatal tetanus) date, dose and lot number of each TT vaccine given to the mother (optional; see Annex 6.1) due date for next immunization(s) country immunization schedule (optional) growth monitoring chart (optional).\nMonitoring and surveillance\nThe infant’s caregiver should be reminded to keep the immunization card in a safe place and to take it to all immunization and other health care visits.\nComplete the card by writing down the date for each vaccine administered or vitamin A supplement given. Include doses of TT given to the mother if she is eligible and the card has space to enter it (this will depend on national protocol and there may be a separate women’s immunization card). Mark the next appointment date on the card and tell the caregiver when and where to return for the next vaccination.\n➢ Remember to mark the next appointment date on the immunization card. Make sure that the appointment corresponds to a planned immunization session. ➢ Inform the caregiver of the next appointment verbally as well as in writing on the card. ➢ Always return the immunization card to the caregiver. ➢ Remind the caregiver to keep the immunization card in a safe place and to take it to all health care and immunization visits.",
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unique identification number (which is the same number written in the immunization register as shown in Figure 6.1)
infant’s name
infant’s birth date
infant’s sex
name and address of caregiver(s), including mobile/phone number if available
date, dose and lot number of each vaccine given
date and dose of vitamin A supplementation given, if applicable
PAB status (infant protection at birth from neonatal tetanus)
date, dose and lot number of each TT vaccine given to the mother (optional; see Annex 6.1)
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➢
Remember to mark the next appointment date on the immunization card. Make sure that the appointment corresponds to a planned immunization session.
➢
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➢
Always return the immunization card to the caregiver.
➢
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"text": "\n DESCRIPTION:\n Le tableau liste les erreurs courantes de pointage des vaccins, leurs conséquences potentielles et les pratiques correctes à adopter.\n :TABLE DATA:\n Table 6.1 Common mistakes in tallying | Mistake in tallying: Tallying before the vaccination is given - Possible problem that may occur: The child may not receive the vaccination - Correct practice: Give the dose first then mark it on the tally sheet | Mistake in tallying: Tallying at the end of a session according to number of doses contained in the used vials - Possible problem that may occur: Wasted doses may be counted - Correct practice: Tally each dose given (as above) | Mistake in tallying: Tallying all vaccines under one age group (to include those outside the targeted age) - Possible problem that may occur: Will result in inaccurate coverage data - Correct practice: Separate tally for under 1 and over 1 year old\n :END TABLE DATA:\n\n ",
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"text": "Table 6.1 Common mistakes in tallying | Mistake in tallying: Tallying before the vaccination is given - Possible problem that may occur: The child may not receive the vaccination - Correct practice: Give the dose first then mark it on the tally sheet | Mistake in tallying: Tallying at the end of a session according to number of doses contained in the used vials - Possible problem that may occur: Wasted doses may be counted - Correct practice: Tally each dose given (as above) | Mistake in tallying: Tallying all vaccines under one age group (to include those outside the targeted age) - Possible problem that may occur: Will result in inaccurate coverage data - Correct practice: Separate tally for under 1 and over 1 year old",
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Mistake in tallying
Possible problem that may occur
Correct practice
Tallying before the vaccination is given
The child may not receive the vaccination
Give the dose first then mark it on the tally sheet
Tallying at the end of a session according to number of doses contained in the used vials
Wasted doses may be counted
Tally each dose given (as above)
Tallying all vaccines under one age group (to include those outside the targeted age)
Give the dose first then mark it on the tally sheet
Tallying at the end of a session according to number of doses contained in the used vials
Wasted doses may be counted
Tally each dose given (as above)
Tallying all vaccines under one age group (to include those outside the targeted age)
Will result in inaccurate coverage data
Separate tally for under 1 and over 1 year old
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"text": "\n\n\n1.3 The tally sheet\nTally sheets are forms that are marked every time a health worker administers a dose of vaccine. They are used to monitor performance and complete monthly reporting. Ideally, a new tally sheet should be used for each session, but weekly or monthly sheets are also found in some programmes. An example is shown in Figure 6.2.\nTally sheets record vaccinations actually given by marking them after an infant receives a dose. The dose is recorded in the immunization register and on the immunization card and the caregiver is informed of which vaccinations were given (see Module 5, Section 2 for more on communicating with caregivers).\nMark the tally sheet next to the dose received (there are various ways of making tally marks, for example: ▢ or ▢ ). Tally sheets with preprinted symbols that can be marked through may help to ensure more accurate counting of totals for reports (for example, a line can be drawn through each “0” in Figure 6.2 after each dose given). If\nMonitoring and surveillance\npreprinted sheets are not used, all vaccinators in a health facility should use the same type of tally marks to make it easier to count the totals. In Figure 6.2, after vaccinating an infant (who is by definition less than one year of age), place the mark in the column headed “Age <1 year”. After vaccinating an older child, place the mark under “Age >1 year”.\n :TABLE DATA: \nTable 6.1 Common mistakes in tallying | Mistake in tallying: Tallying before the vaccination is given - Possible problem that may occur: The child may not receive the vaccination - Correct practice: Give the dose first then mark it on the tally sheet | Mistake in tallying: Tallying at the end of a session according to number of doses contained in the used vials - Possible problem that may occur: Wasted doses may be counted - Correct practice: Tally each dose given (as above) | Mistake in tallying: Tallying all vaccines under one age group (to include those outside the targeted age) - Possible problem that may occur: Will result in inaccurate coverage data - Correct practice: Separate tally for under 1 and over 1 year old\n :END TABLE DATA:\nModule 6: Monitoring and surveillance\nMonitoring and surveillance",
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"text": "Table 6.1 Common mistakes in tallying | Mistake in tallying: Tallying before the vaccination is given - Possible problem that may occur: The child may not receive the vaccination - Correct practice: Give the dose first then mark it on the tally sheet | Mistake in tallying: Tallying at the end of a session according to number of doses contained in the used vials - Possible problem that may occur: Wasted doses may be counted - Correct practice: Tally each dose given (as above) | Mistake in tallying: Tallying all vaccines under one age group (to include those outside the targeted age) - Possible problem that may occur: Will result in inaccurate coverage data - Correct practice: Separate tally for under 1 and over 1 year old",
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Mistake in tallying
Possible problem that may occur
Correct practice
Tallying before the vaccination is given
The child may not receive the vaccination
Give the dose first then mark it on the tally sheet
Tallying at the end of a session according to number of doses contained in the used vials
Wasted doses may be counted
Tally each dose given (as above)
Tallying all vaccines under one age group (to include those outside the targeted age)
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"text": "\n\n\n1.4 The defaulter tracking list\nThe term “defaulter” refers to individuals who miss scheduled vaccinations for any reason, including health facility problems, such as cancelled sessions or vaccine stock outs. Defaulters need to be followed up and mobilized to attend the earliest available session, since the goal is to complete any missed vaccinations. A tracking list, such as the one shown in Figure 6.3, should be filled in after each immunization session or at least monthly as described below. It should be given to the person(s) tasked with finding defaulters.\nWhat information is commonly included on a defaulter list? A defaulter tracking list usually includes the following information:\ninfant’s name caregiver’s name caregiver’s contact information, including phone/mobile number(s) infant’s age in months vaccinations needed.\nDate: Health centre name: Community name:\n :TABLE DATA: \nInfant’s name Caregiver’s name Caregiver’s contact information (include phone/mobile number if available) Infant’s age in months Vaccinations needed 1 2 3 4 5 6 7 8 9\n :END TABLE DATA:\nMonitoring and surveillance\nDefaulters can be listed by reviewing different immunization records. Two suggested methods are:\nListing defaulters using the immunization register At the end of each month, review the immunization register to identify infants who may have failed to receive vaccinations when due. For example, in March check to see that any infant who received a pentavalent1 dose in February returned for pentavalent2 (in March) when it was due. Add the names of any infants who missed vaccinations to the defaulter tracking list. Names should be listed for tracking and follow-up as soon as possible after a missed appointment.\nFigure 6.4 shows a completed example of the register shown in Figure 6.1 (A). Note that looking at each line helps visualize which infants have missed vaccinations and so should be added to the defaulter tracking list.\nModule 6: Monitoring and surveillance\nThis example is typed for clarity. A handwritten register may be used. This is a register for a single village. Addresses may need to be written in more detail if more than one village is included in the same register. It shows the first page for a specific month: January 2013. The identification numbers are continued from the previous year and this is why the ID No column starts with the number 511. ID No 511 was born on 1/1/13 but added to the register on 3/1. ID No 512 did not return after receiving his second doses. He was added to the defaulter tracking list and found to have moved out of the catchment area. ID No 515 has not received a dose of the measles vaccine (MCV1) and is still under defaulter tracking. ID No 516 was born at home and registered after the health worker was notified by a community volunteer. Defaulter tracking found that the family subsequently left the catchment area. ID No 517 received birth doses in the hospital on 5/11/12 but then presented at irregular intervals for follow-up. She is now up-to-date. ID No 513, 514 and 518 are up to date according to the example immunization schedule used in this module. ID No 519 did not return after his first doses. Defaulter tracking found that the family declined any further immunizations. The last line is blank since the next infant was added in February, which starts on a new page (not shown).\nReminder cards are copies of infants’ immunization cards that can be filed in a box by the month when the next vaccination is due (see Figure 6.5). For example, when an infant receives pentavalent1 in January, mark it on the reminder card and place the card behind the February divider, since this is when pentavalent2 is due. In February, if the infant receives pentavalent2, update the reminder card and place it in the March section when pentavalent3 is due. If the infant does not come for pentavalent2 in February, or does come but does not get vaccinated (due to stock-outs or other reasons), the card will remain in February. At the end of each month, review all the reminder cards remaining and add the names of the infants who have missed vaccinations to the defaulter tracking list.\nMonitoring and surveillance\nThe defaulter tracking list will be effective only if every infant receives vaccinations that are overdue. Listing defaulters regularly every month makes it easier to find them and follow them up. To follow up defaulters, caregivers may be contacted directly (for example by phone or text messaging) or with the help of other community members. Module 7 ( Partnering with communities ) gives more detail on working with communities.\nModule 6: Monitoring and surveillance",
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What information is commonly included on a defaulter list?
A defaulter tracking list usually includes the following information:
Defaulters can be listed by reviewing different immunization records. Two suggested methods are:
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Listing defaulters using the immunization register
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This example is typed for clarity. A handwritten register may be used.
This is a register for a single village. Addresses may need to be written in more detail if more than one village is included in the same register.
It shows the first page for a specific month: January 2013. The identification numbers are continued from the previous year and this is why the ID No column starts with the number 511.
ID No 511 was born on 1/1/13 but added to the register on 3/1.
ID No 512 did not return after receiving his second doses. He was added to the defaulter tracking list and found to have moved out of the catchment area.
ID No 515 has not received a dose of the measles vaccine (MCV1) and is still under defaulter tracking.
ID No 516 was born at home and registered after the health worker was notified by a community volunteer. Defaulter tracking found that the family subsequently left the catchment area.
ID No 517 received birth doses in the hospital on 5/11/12 but then presented at irregular intervals for follow-up. She is now up-to-date.
ID No 513, 514 and 518 are up to date according to the example immunization schedule used in this module.
ID No 519 did not return after his first doses. Defaulter tracking found that the family declined any further immunizations.
The last line is blank since the next infant was added in February, which starts on a new page (not shown).
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patient’s name, date of birth, age and sex
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patient’s immunization status with dates of relevant vaccine doses
mother’s immunization status, if relevant (for example, in suspected cases of neonatal tetanus)
other risk factors for the suspected disease, if relevant
description and start date of symptoms of suspected disease
Figure 6.6WHO neonatal tetanus case investigation report form
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An AEFI that is caused or precipitated by a vaccine due to one or more of the properties of the vaccine product itself.
Example:
Extensive limb swelling following DTP vaccination.
Vaccine quality defect-related reaction:
An AEFI that is caused or precipitated by a vaccine that is due to one or more quality defects of the vaccine product, including its administration device as provided by the manufacturer.
Example:
Failure by the manufacturer to completely inactivate a batch of inactivated polio vaccine leads to cases of paralytic polio.
Immunization error-related reaction:
An AEFI that is caused by inappropriate vaccine handling, prescribing or administration and thus by its nature is preventable.
Example:
Transmission of infection by contaminated multi-dose vial.
Immunization anxiety-related reaction:
An AEFI arising from anxiety about the immunization.
Example:
Vasovagal syncope (fainting) in an adolescent during/following vaccination.
Coincidental event:
An AEFI that is caused by something other than the vaccine product, immunization error or immunization anxiety.
Example:
A fever occurs at the time of the vaccination (temporal association) but is in fact caused by malaria. Coincidental events reflect the natural occurrence of health problems in the community with common problems being frequently reported.
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"text": "\n\n\n4.1 Vaccination coverage charts\nCreating a chart showing doses administered and dropout rates is a simple, effective way to monitor immunization service progress. This type of chart tracks monthly progress towards immunization service goals. The number of doses administered can be compared to the number of infants eligible to receive them, and target population dropout rates can be calculated. The dropout rate compares the number of infants who completed the immunization schedule for a selected vaccine to the total number who failed to finish the course. Every health facility should display a current monitoring chart on a wall where all staff can see it. Charts can be produced at every level of the health system by combining data manually or electronically. Figure 6.11 shows a completed monitoring chart.\nHow to make a monitoring chart showing doses administered and dropouts Vaccine doses administered and dropout rates can be charted using the following steps (refer to Figure 6.10 and note that some of these calculations are shown in Module 4).\nCalculate the annual and monthly target population who should receive immunization services Annual target population = total population × % infants in population Aim to vaccinate every infant in the catchment area, including those who are hard to reach. Use existing population data for infants obtained from national statistics offices, ministry of health planning sections or community censuses. If data are not available, estimate the number of infants by multiplying the total population by 3% (or the percentage of infants in the population suggested by national/central authorities, if applicable). Always use the most precise percentage available: a measured, specific percentage for calculating the number of infants is preferred. Data for peripheral health facility calculations are often difficult to find and more accurate targets can be set by: a) immunization staff and district supervisors, who may need to discuss and agree on target population adjustments based on local knowledge and past experience; and b) drawing the past year’s results on the current year’s chart in order to follow progress from year to year.\nMonitoring and surveillance\nThe monthly target population is the annual target population number of infants calculated above divided by 12.\nMonthly target = annual target population/12\nExample calculation: If the total population is 3900, then the annual target population of infants is 3900 × 3/100 = 117; and the monthly target is 117/12 = 10.\nLabel the chart and draw the ideal monthly target line Complete the information on the top of the chart by adding the area and year. Label the left (and/or right) side of the chart with the monthly target numbers. Label the boxes at the bottom with the selected vaccine. Draw a diagonal line from zero to the top right-hand corner to show the ideal rate of progress from month to month using the cumulative monthly target numbers. Plot immunization data on the chart Locate the space for the month being recorded in the row of boxes underneath the graph and enter the monthly total of vaccine given. Calculate the cumulative total for the current month as shown: Current cumulative total = current month’s total doses + previous month’s cumulative total doses\nNote that cumulative means the total number of doses of vaccines given in the current month plus the monthly totals for the current calendar year; for example, the cumulative number of penta3 doses given by the end of March is the total number of doses given in January plus the total number given in February plus the total number given in March.\nEnter the current cumulative total on the right side of the month being recorded Make a dot on the graph corresponding to the cumulative total recorded on the right side of the month being recorded; the dot should line up with the correct monthly number on the left side of the chart. Connect the new dot to the previous month’s dot with a straight line. Repeat every month until the end of the year. Plot other immunizations given on the same chart, as needed.\nMonitoring and surveillance\nCalculate the total number of dropouts between the first and last dose of the same vaccine series.\nNumber of dropouts = (cumulative total for the first dose) – (cumulative total for the last dose of the vaccine series)\nDropout rate (%) = (number of dropouts/cumulative total for the first dose) × 100\nThe dropout rate can be seen easily in the doses administered chart: it is the gap between the lines for the first and last dose of a vaccine.\nExample calculation: If all 117 infants in the annual target population received penta1, but only 100 finished all three doses during the year, then:\nNumber of dropouts = (117) – (100) = 17\nDropout rate = [17/117] × 100 = 14.5%\nModule 6: Monitoring and surveillance",
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4.1 Vaccination coverage charts
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"text": "Creating a chart showing doses administered and dropout rates is a simple, effective way to monitor immunization service progress. This type of chart tracks monthly progress towards immunization service goals. The number of doses administered can be compared to the number of infants eligible to receive them, and target population dropout rates can be calculated. The dropout rate compares the number of infants who completed the immunization schedule for a selected vaccine to the total number who failed to finish the course. Every health facility should display a current monitoring chart on a wall where all staff can see it. Charts can be produced at every level of the health system by combining data manually or electronically. Figure 6.11 shows a completed monitoring chart.",
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Creating a chart showing doses administered and dropout rates is a simple, effective way to monitor immunization service progress. This type of chart tracks monthly progress towards immunization service goals. The number of doses administered can be compared to the number of infants eligible to receive them, and target population dropout rates can be calculated. The dropout rate compares the number of infants who completed the immunization schedule for a selected vaccine to the total number who failed to finish the course.
Every health facility should display a current monitoring chart on a wall where all staff can see it. Charts can be produced at every level of the health system by combining data manually or electronically. Figure 6.11 shows a completed monitoring chart.
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"text": "How to make a monitoring chart showing doses administered and dropouts Vaccine doses administered and dropout rates can be charted using the following steps (refer to Figure 6.10 and note that some of these calculations are shown in Module 4).",
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How to make a monitoring chart showing doses administered and dropouts
Vaccine doses administered and dropout rates can be charted using the following steps (refer to Figure 6.10 and note that some of these calculations are shown in Module 4).
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"text": "Calculate the annual and monthly target population who should receive immunization services Annual target population = total population × % infants in population Aim to vaccinate every infant in the catchment area, including those who are hard to reach. Use existing population data for infants obtained from national statistics offices, ministry of health planning sections or community censuses. If data are not available, estimate the number of infants by multiplying the total population by 3% (or the percentage of infants in the population suggested by national/central authorities, if applicable). Always use the most precise percentage available: a measured, specific percentage for calculating the number of infants is preferred. Data for peripheral health facility calculations are often difficult to find and more accurate targets can be set by: a) immunization staff and district supervisors, who may need to discuss and agree on target population adjustments based on local knowledge and past experience; and b) drawing the past year’s results on the current year’s chart in order to follow progress from year to year.",
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Calculate the annual and monthly target population who should receive immunization services
Annual target population = total population × % infants in population
Aim to vaccinate every infant in the catchment area, including those who are hard to reach. Use existing population data for infants obtained from national statistics offices, ministry of health planning sections or community censuses. If data are not available, estimate the number of infants by multiplying the total population by 3% (or the percentage of infants in the population suggested by national/central authorities, if applicable). Always use the most precise percentage available: a measured, specific percentage for calculating the number of infants is preferred.
Data for peripheral health facility calculations are often difficult to find and more accurate targets can be set by: a) immunization staff and district supervisors, who may need to discuss and agree on target population adjustments based on local knowledge and past experience; and b) drawing the past year’s results on the current year’s chart in order to follow progress from year to year.
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"text": "Example calculation: If the total population is 3900, then the annual target population of infants is 3900 × 3/100 = 117; and the monthly target is 117/12 = 10.",
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Example calculation: If the total population is 3900, then the annual target population of infants is 3900 × 3/100 = 117; and the monthly target is 117/12 = 10.
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"text": "Label the chart and draw the ideal monthly target line Complete the information on the top of the chart by adding the area and year. Label the left (and/or right) side of the chart with the monthly target numbers. Label the boxes at the bottom with the selected vaccine. Draw a diagonal line from zero to the top right-hand corner to show the ideal rate of progress from month to month using the cumulative monthly target numbers. Plot immunization data on the chart Locate the space for the month being recorded in the row of boxes underneath the graph and enter the monthly total of vaccine given. Calculate the cumulative total for the current month as shown: Current cumulative total = current month’s total doses + previous month’s cumulative total doses",
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Label the chart and draw the ideal monthly target line
Complete the information on the top of the chart by adding the area and year.
Label the left (and/or right) side of the chart with the monthly target numbers.
Label the boxes at the bottom with the selected vaccine.
Draw a diagonal line from zero to the top right-hand corner to show the ideal rate of progress from month to month using the cumulative monthly target numbers.
Plot immunization data on the chart
Locate the space for the month being recorded in the row of boxes underneath the graph and enter the monthly total of vaccine given.
Calculate the cumulative total for the current month as shown:
Current cumulative total = current month’s total doses + previous month’s cumulative total doses
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"text": "Note that cumulative means the total number of doses of vaccines given in the current month plus the monthly totals for the current calendar year; for example, the cumulative number of penta3 doses given by the end of March is the total number of doses given in January plus the total number given in February plus the total number given in March.",
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Note that cumulative means the total number of doses of vaccines given in the current month plus the monthly totals for the current calendar year; for example, the cumulative number of penta3 doses given by the end of March is the total number of doses given in January plus the total number given in February plus the total number given in March.
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"text": "Enter the current cumulative total on the right side of the month being recorded Make a dot on the graph corresponding to the cumulative total recorded on the right side of the month being recorded; the dot should line up with the correct monthly number on the left side of the chart. Connect the new dot to the previous month’s dot with a straight line. Repeat every month until the end of the year. Plot other immunizations given on the same chart, as needed.",
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Enter the current cumulative total on the right side of the month being recorded
Make a dot on the graph corresponding to the cumulative total recorded on the right side of the month being recorded; the dot should line up with the correct monthly number on the left side of the chart.
Connect the new dot to the previous month’s dot with a straight line.
Repeat every month until the end of the year.
Plot other immunizations given on the same chart, as needed.
Dropout rate (%) = (number of dropouts/cumulative total for the first dose) × 100
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"text": "The dropout rate can be seen easily in the doses administered chart: it is the gap between the lines for the first and last dose of a vaccine.",
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The dropout rate can be seen easily in the doses administered chart: it is the gap between the lines for the first and last dose of a vaccine.
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"text": "Example calculation: If all 117 infants in the annual target population received penta1, but only 100 finished all three doses during the year, then:",
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Example calculation: If all 117 infants in the annual target population received penta1, but only 100 finished all three doses during the year, then:
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"text": "\n\n\n4.2 Vaccination coverage data analysis\nFull analysis requires data to be compiled by area. Figures 6.12, 6.13 and 6.14 suggest how to compile and analyse vaccination coverage data. The first part of the process shown below is also shown in Module 4, which focuses on prioritizing areas by the number of unimmunized children during microplanning. The additional calculations given in Figures 6.12 and 6.13 are included here to help define problems that cause children to remain unimmunized. Defining problems in detail helps identify potential solutions (see also Annex 3). How to complete the compilation and analysis table\nList each geographic area or community served in Column a. List the target population numbers for infants less than one year of age in Column b. Enter the number of doses of each vaccine type administered to the target group during the preceding 12-month period in Columns c, d and e. The vaccines used for analysis will vary by programme. Calculate immunization coverage as follows: Immunization coverage is the total number of infants who have received all required doses of a selected vaccine in the preceding 12 months divided by the annual target population.\nMonitoring and surveillance\nImmunization coverage (%) = (number of infants with all required doses of the selected vaccine during the last 12 months)/(annual target population) × 100\nExample calculation for the table in Figure 6.12: immunization coverage (%) in Column g = (infants with all required doses of pentavalent in the last 12 months in Column d)/(annual target population in Column b) × 100 = (100)/(117) × 100 = 85%\nCalculate the number of unimmunized:\nUnimmunized number = (annual target population) – (doses of vaccine administered)\nExample calculation for the table in Figure 6.12: unimmunized pentavalent3 in Column i = annual target population in Column b – doses of pentavalent3 administered in Column d = (117) – (85) = 32\nThe dropout calculation for any vaccine is shown in Section 4.1.\nIn Column m, enter the quality of access (good = coverage 80% or better; poor = coverage less than 80%) based on pentavalent1 coverage in Column f. Note that the 80% cut-off is suggested here as a general indicator and programmes may use different cut-offs to define good and poor coverage based on national policy. In Column n, enter the quality of utilization (good = dropout rate less than 10%; poor = dropout rate 10% or more) based on the pentavalent1–pentavalent3 dropout rate given in Column k. Note that the 10% cut-off is suggested here as a general indicator and programmes may use different cut-offs to define good and poor dropout rates based on national policy. In Column o, use your data to prioritize communities for problem solving. Rank the community that has the most unimmunized infants (not necessarily the lowest coverage) as the highest priority (#1) Figure 6.14 illustrates this principle.\nModule 6: Monitoring and surveillance\n :TABLE DATA: \nFigure 6.14 Prioritizing districts according to total unimmunized infants (completed example using measles vaccine coverage) District name | Population | Population under 1 year | Measles coverage under 1 year | Unimmunized infants | Priority | A | 100 000 | 4 000 | 50% | 2 000 | 2 | B | 75 000 | 3 000 | 60% | 1 200 | 4 | C | 120 000 | 4 800 | 70% | 1 440 | 3 | D | 10 000 | 400 | 20% | 320 | 5 | E | 250 000 | 10 000 | 75% | 2 500 | 1\n :END TABLE DATA:\nMonitoring and surveillance",
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"text": "Full analysis requires data to be compiled by area. Figures 6.12, 6.13 and 6.14 suggest how to compile and analyse vaccination coverage data. The first part of the process shown below is also shown in Module 4, which focuses on prioritizing areas by the number of unimmunized children during microplanning. The additional calculations given in Figures 6.12 and 6.13 are included here to help define problems that cause children to remain unimmunized. Defining problems in detail helps identify potential solutions (see also Annex 3). How to complete the compilation and analysis table",
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Full analysis requires data to be compiled by area. Figures 6.12, 6.13 and 6.14 suggest how to compile and analyse vaccination coverage data. The first part of the process shown below is also shown in Module 4, which focuses on prioritizing areas by the number of unimmunized children during microplanning. The additional calculations given in Figures 6.12 and 6.13 are included here to help define problems that cause children to remain unimmunized. Defining problems in detail helps identify potential solutions (see also Annex 3).
How to complete the compilation and analysis table
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"text": "List each geographic area or community served in Column a. List the target population numbers for infants less than one year of age in Column b. Enter the number of doses of each vaccine type administered to the target group during the preceding 12-month period in Columns c, d and e. The vaccines used for analysis will vary by programme. Calculate immunization coverage as follows: Immunization coverage is the total number of infants who have received all required doses of a selected vaccine in the preceding 12 months divided by the annual target population.",
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List each geographic area or community served in Column a.
List the target population numbers for infants less than one year of age in Column b.
Enter the number of doses of each vaccine type administered to the target group during the preceding 12-month period in Columns c, d and e. The vaccines used for analysis will vary by programme.
Calculate immunization coverage as follows: Immunization coverage is the total number of infants who have received all required doses of a selected vaccine in the preceding 12 months divided by the annual target population.
Immunization coverage (%) = (number of infants with all required doses of the selected vaccine during the last 12 months)/(annual target population) × 100
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"text": "Example calculation for the table in Figure 6.12: immunization coverage (%) in Column g = (infants with all required doses of pentavalent in the last 12 months in Column d)/(annual target population in Column b) × 100 = (100)/(117) × 100 = 85%",
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Example calculation for the table in Figure 6.12:
immunization coverage (%) in Column g = (infants with all required doses of pentavalent in the last 12 months in Column d)/(annual target population in Column b) × 100 = (100)/(117) × 100 = 85%
The dropout calculation for any vaccine is shown in Section 4.1.
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"text": "In Column m, enter the quality of access (good = coverage 80% or better; poor = coverage less than 80%) based on pentavalent1 coverage in Column f. Note that the 80% cut-off is suggested here as a general indicator and programmes may use different cut-offs to define good and poor coverage based on national policy. In Column n, enter the quality of utilization (good = dropout rate less than 10%; poor = dropout rate 10% or more) based on the pentavalent1–pentavalent3 dropout rate given in Column k. Note that the 10% cut-off is suggested here as a general indicator and programmes may use different cut-offs to define good and poor dropout rates based on national policy. In Column o, use your data to prioritize communities for problem solving. Rank the community that has the most unimmunized infants (not necessarily the lowest coverage) as the highest priority (#1) Figure 6.14 illustrates this principle.",
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In Column m, enter the quality of access (good = coverage 80% or better; poor = coverage less than 80%) based on pentavalent1 coverage in Column f. Note that the 80% cut-off is suggested here as a general indicator and programmes may use different cut-offs to define good and poor coverage based on national policy.
In Column n, enter the quality of utilization (good = dropout rate less than 10%; poor = dropout rate 10% or more) based on the pentavalent1–pentavalent3 dropout rate given in Column k. Note that the 10% cut-off is suggested here as a general indicator and programmes may use different cut-offs to define good and poor dropout rates based on national policy.
In Column o, use your data to prioritize communities for problem solving. Rank the community that has the most unimmunized infants (not necessarily the lowest coverage) as the highest priority (#1) Figure 6.14 illustrates this principle.
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"text": "\n\n\n4.3 Improvement of services\nProblems can be broadly associated with access and utilization and the categories in Figure 6.13 indicate the different combinations of the two issues. Problems may be related to one or more communities or areas or may apply to the entire district. Access problems result in infants missing immunization sessions and may be due to:\nsessions not being held as planned session site and times being inconvenient or not advertised cultural, financial, racial, gender or other barriers preventing access to and use of immunization services.\nUtilization problems result in infants not coming back to complete the full series of immunizations and may be caused by:\ncaregivers’ lack of information about the complete immunization schedule missed opportunities for vaccination other problems leading to caregivers not returning due to vaccinations not being given as expected; for example supply shortages, delayed doses due to incorrect assessment of contraindications or other problems in the relationship between health workers and the community.\nThe table in Annex 6.1 lists commonly encountered problems. It is not exhaustive but can serve as a guide to finding solutions. The microplanning process includes identifying possible solutions as described in Module 4. Discussion should occur at community and health facility level, and also at district or more central levels as needed. Solutions should be prioritized for implementation. Those that affect the district level should generally come before those that affect more local levels. At any level, changes are likely to be more feasible when implemented with available resources. Supervisory visits from more central levels can also be helpful in identifying problems and solutions. Annex 6.2 shows an example checklist for such visits. Like the table in Annex 6.1, it is not exhaustive but can serve as a guide for health workers and supervisors.\nModule 6: Monitoring and surveillance",
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Problems can be broadly associated with access and utilization and the categories in Figure 6.13 indicate the different combinations of the two issues. Problems may be related to one or more communities or areas or may apply to the entire district.
Access problems result in infants missing immunization sessions and may be due to:
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session site and times being inconvenient or not advertised
cultural, financial, racial, gender or other barriers preventing access to and use of immunization services.
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caregivers’ lack of information about the complete immunization schedule
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"text": "The table in Annex 6.1 lists commonly encountered problems. It is not exhaustive but can serve as a guide to finding solutions. The microplanning process includes identifying possible solutions as described in Module 4. Discussion should occur at community and health facility level, and also at district or more central levels as needed. Solutions should be prioritized for implementation. Those that affect the district level should generally come before those that affect more local levels. At any level, changes are likely to be more feasible when implemented with available resources. Supervisory visits from more central levels can also be helpful in identifying problems and solutions. Annex 6.2 shows an example checklist for such visits. Like the table in Annex 6.1, it is not exhaustive but can serve as a guide for health workers and supervisors.",
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The table in Annex 6.1 lists commonly encountered problems. It is not exhaustive but can serve as a guide to finding solutions.
The microplanning process includes identifying possible solutions as described in Module 4. Discussion should occur at community and health facility level, and also at district or more central levels as needed. Solutions should be prioritized for implementation. Those that affect the district level should generally come before those that affect more local levels. At any level, changes are likely to be more feasible when implemented with available resources.
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"text": "\n\n\n5.1 Vaccine-preventable disease case number charts\nThe objective of surveillance is to:\nreport vaccine-preventable diseases according to national protocol; reports may be required monthly, weekly or as needed for outbreak response understand the data collected as a guide for response.\nIn addition to predicting or detecting outbreaks, identifying high-risk populations or areas and monitoring the impact of immunization services, surveillance data can highlight system weaknesses, determine disease burden in a community and document circulating strains of pathogens. Case numbers can be presented in graphs for display in the health facility. Trends in disease occurrence (usually incidence) are easy to visualize and compare to immunization data in this format. Graphs of trends that become outbreaks are also called “epidemic curves”. Keeping updated graphs will allow comparisons between seasons and years and alert to any increases in the number of cases or other relevant trends.",
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"text": "\n\n\n5.2 Analysis of vaccine-preventable disease data\nSurveillance data can be used to show trends and alert to possible outbreaks, as in the example above. Further analysis of the trends may include a breakdown of cases by area or by age and sex to better identify those at high risk and to define a targeted response. This type of analysis is often conducted at district or more central levels, but can begin with individual health facility data. High-risk or most-affected areas in the health facility catchment can be analysed simply by tracking cases on a map, as shown in Figure 6.16. Cases can be marked on the district and health centre catchment area maps prepared for microplanning, as described in Module 4.\nTable 6.2 shows the age and sex distribution of cases during an outbreak in a certain area. This is useful for evaluating an unidentified disease or an unusual pattern of a familiar disease, for example, measles cases occurring in older age groups.\nMonitoring and surveillance\n :TABLE DATA: \nAge 0–5m 6–11m 1–4y 5–9y 10–14y 15–34y 35–64y 65+y Total Male 1 1 0 0 5 26 15 3 51 Female 2 2 0 0 6 35 15 5 65 Total 3 3 0 0 11 61 30 8 116\n :END TABLE DATA:\nCase data can be compared with immunization data to illustrate disease patterns or evaluate the impact of control activities. This is usually done over a longer time frame and from district or higher levels using population-level measures, such as incidence. Accurately reported peripheral health facility-level data is needed throughout. Figure 6.17 compares measles case numbers (charted as incidence per 100 000 people) after immunization services were improved in a district and high coverage was maintained.\nMonitoring and surveillance",
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"text": "\n DESCRIPTION:\n Le tableau identifie des problèmes fréquents d'immunisation (ruptures de stock, personnel insuffisant, faible fréquentation) et propose des solutions pour améliorer la situation.\n :TABLE DATA:\n Examples of common problems Examples of solutions: activities to be included in health facility workplans Supply quantity Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards Request immediate supplies from district level. Review stock recording system (Module 4, Section 5). Review vaccine usage and wastage rates and take action (Module 6, Section 3). Review method of estimating needs (Module 4, Section 5). Supply quality Expired vaccine(s) VVMs show that vaccine has reached the discard point Frozen DTP- and HepB-containing vaccines in refrigerator Review stock recording system (Module 4, Section 5). Review method of estimating needs (Module 4, Section 5). Review management of cold chain equipment (Module 2). Staffing quality Some staff are not using correct protocols/procedures Inform supervisor and select subjects for on-the-job training/supportive supervision, for example: using AD syringes (Module 5) new vaccines (Module 1) reading vaccine vial monitors (Modules 2 and 5) implementing multi-dose vial policy (Module 2) interpersonal communication skills. Irregular supervisory visits Include supervisory visit schedule in district workplans. Staffing quantity Vacant positions; general staff shortage Inform supervisor and district authorities and take steps for recruitment. Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim. Ensure staff are available for each session (Module 4). Service quality and demand Poor attendance at sessions and poor utilization in some areas Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7). Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7). Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4). Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3). Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3). Consider conducting a missed opportunities study to understand the reasons for low utilization. Mothers lose or do not bring the immunization cards Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1). Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1). Parents fear adverse events and/or there are rumours that injection practices are not 100% safe Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1). Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3). Meet community to discuss rumours (Module 7, Section 4). Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2). Arrange information brief sessions with media, leaders, community influencers (Module 7).\n :END TABLE DATA:\n\n ",
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"text": "Examples of common problems Examples of solutions: activities to be included in health facility workplans Supply quantity Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards Request immediate supplies from district level. Review stock recording system (Module 4, Section 5). Review vaccine usage and wastage rates and take action (Module 6, Section 3). Review method of estimating needs (Module 4, Section 5). Supply quality Expired vaccine(s) VVMs show that vaccine has reached the discard point Frozen DTP- and HepB-containing vaccines in refrigerator Review stock recording system (Module 4, Section 5). Review method of estimating needs (Module 4, Section 5). Review management of cold chain equipment (Module 2). Staffing quality Some staff are not using correct protocols/procedures Inform supervisor and select subjects for on-the-job training/supportive supervision, for example: using AD syringes (Module 5) new vaccines (Module 1) reading vaccine vial monitors (Modules 2 and 5) implementing multi-dose vial policy (Module 2) interpersonal communication skills. Irregular supervisory visits Include supervisory visit schedule in district workplans. Staffing quantity Vacant positions; general staff shortage Inform supervisor and district authorities and take steps for recruitment. Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim. Ensure staff are available for each session (Module 4). Service quality and demand Poor attendance at sessions and poor utilization in some areas Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7). Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7). Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4). Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3). Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3). Consider conducting a missed opportunities study to understand the reasons for low utilization. Mothers lose or do not bring the immunization cards Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1). Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1). Parents fear adverse events and/or there are rumours that injection practices are not 100% safe Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1). Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3). Meet community to discuss rumours (Module 7, Section 4). Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2). Arrange information brief sessions with media, leaders, community influencers (Module 7).",
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Examples of common problems
Examples of solutions: activities to be included in health facility workplans
Supply quantity
Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards
Request immediate supplies from district level.
Review stock recording system (Module 4, Section 5).
Review vaccine usage and wastage rates and take action (Module 6, Section 3).
Review method of estimating needs (Module 4, Section 5).
Supply quality
Expired vaccine(s)
VVMs show that vaccine has reached the discard point
Frozen DTP- and HepB-containing vaccines in refrigerator
Review stock recording system (Module 4, Section 5).
Review method of estimating needs (Module 4, Section 5).
Review management of cold chain equipment (Module 2).
Staffing quality
Some staff are not using correct protocols/procedures
Inform supervisor and select subjects for on-the-job training/supportive supervision, for example:
using AD syringes (Module 5)
new vaccines (Module 1)
reading vaccine vial monitors (Modules 2 and 5)
implementing multi-dose vial policy (Module 2)
interpersonal communication skills.
Irregular supervisory visits
Include supervisory visit schedule in district workplans.
Staffing quantity
Vacant positions; general staff shortage
Inform supervisor and district authorities and take steps for recruitment.
Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim.
Ensure staff are available for each session (Module 4).
Service quality and demand
Poor attendance at sessions and poor utilization in some areas
Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7).
Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7).
Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4).
Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3).
Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3).
Consider conducting a missed opportunities study to understand the reasons for low utilization.
Mothers lose or do not bring the immunization cards
Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1).
Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1).
Parents fear adverse events and/or there are rumours that injection practices are not 100% safe
Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1).
Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3).
Meet community to discuss rumours (Module 7, Section 4).
Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2).
Arrange information brief sessions with media, leaders, community influencers (Module 7).
Examples of solutions: activities to be included in health facility workplans
Supply quantity
Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards
Request immediate supplies from district level.
Review stock recording system (Module 4, Section 5).
Review vaccine usage and wastage rates and take action (Module 6, Section 3).
Review method of estimating needs (Module 4, Section 5).
Supply quality
Expired vaccine(s)
VVMs show that vaccine has reached the discard point
Frozen DTP- and HepB-containing vaccines in refrigerator
Review stock recording system (Module 4, Section 5).
Review method of estimating needs (Module 4, Section 5).
Review management of cold chain equipment (Module 2).
Staffing quality
Some staff are not using correct protocols/procedures
Inform supervisor and select subjects for on-the-job training/supportive supervision, for example:
using AD syringes (Module 5)
new vaccines (Module 1)
reading vaccine vial monitors (Modules 2 and 5)
implementing multi-dose vial policy (Module 2)
interpersonal communication skills.
Irregular supervisory visits
Include supervisory visit schedule in district workplans.
Staffing quantity
Vacant positions; general staff shortage
Inform supervisor and district authorities and take steps for recruitment.
Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim.
Ensure staff are available for each session (Module 4).
Service quality and demand
Poor attendance at sessions and poor utilization in some areas
Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7).
Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7).
Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4).
Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3).
Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3).
Consider conducting a missed opportunities study to understand the reasons for low utilization.
Mothers lose or do not bring the immunization cards
Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1).
Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1).
Parents fear adverse events and/or there are rumours that injection practices are not 100% safe
Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1).
Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3).
Meet community to discuss rumours (Module 7, Section 4).
Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2).
Arrange information brief sessions with media, leaders, community influencers (Module 7).
"
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"text": "\n DESCRIPTION:\n Le tableau liste les problèmes courants liés à la surveillance de la vaccination et propose des solutions pour améliorer la couverture vaccinale.\n :TABLE DATA:\n Examples of common problems Examples of solutions: activities to be included in health facility workplans Unreliable information about catchment population - Request a list of all households, families and newborns from each community (Module 7). - Map the catchment area to include all populations (Module 4, Section 1). - Compare population data from various sources including data from National Immunization Days (NID) or polio activities (use the NID < 5 years population and divide by 5 for infant target). - Take the newborn register during house-to-house campaigns — register all newborns found and give them an immunization card. Inaccurate coverage data - Check record keeping and reporting systems for completeness (Module 6, Sections 1–3). - Review all tally sheets and reports (Module 6, Sections 1–3) — does the numerator include all areas? - Organize and complete refresher training for staff. Some areas are distant and underserved - Discuss with supervisor and organize mobile team approach from district/province — minimum 4 sessions per year (Module 4). - Discuss service with the communities and arrange adequate sessions, dates and times (Module 7). Transport not available for some outreach sessions - Identify sessions that were not held due to lack of transport. - Look for alternative means of transport, such as public transport, sharing with other programmes and/or taxis. - Request a vehicle from the district/next higher level. Poor attendance at antenatal care (ANC) clinics and/or poor TT2+ coverage - Promote the value of antenatal care, including TT immunization, during any contact with pregnant women. - Inform the community about dates of ANC clinics. Find out if session timing or location is inconvenient. If so, make appropriate changes in next quarter’s workplan. - Use all opportunities to give TT immunization including when mothers accompany infants for childhood immunizations.\n :END TABLE DATA:\n\n ",
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"text": "Examples of common problems Examples of solutions: activities to be included in health facility workplans Unreliable information about catchment population - Request a list of all households, families and newborns from each community (Module 7). - Map the catchment area to include all populations (Module 4, Section 1). - Compare population data from various sources including data from National Immunization Days (NID) or polio activities (use the NID < 5 years population and divide by 5 for infant target). - Take the newborn register during house-to-house campaigns — register all newborns found and give them an immunization card. Inaccurate coverage data - Check record keeping and reporting systems for completeness (Module 6, Sections 1–3). - Review all tally sheets and reports (Module 6, Sections 1–3) — does the numerator include all areas? - Organize and complete refresher training for staff. Some areas are distant and underserved - Discuss with supervisor and organize mobile team approach from district/province — minimum 4 sessions per year (Module 4). - Discuss service with the communities and arrange adequate sessions, dates and times (Module 7). Transport not available for some outreach sessions - Identify sessions that were not held due to lack of transport. - Look for alternative means of transport, such as public transport, sharing with other programmes and/or taxis. - Request a vehicle from the district/next higher level. Poor attendance at antenatal care (ANC) clinics and/or poor TT2+ coverage - Promote the value of antenatal care, including TT immunization, during any contact with pregnant women. - Inform the community about dates of ANC clinics. Find out if session timing or location is inconvenient. If so, make appropriate changes in next quarter’s workplan. - Use all opportunities to give TT immunization including when mothers accompany infants for childhood immunizations.",
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Examples of common problems
Examples of solutions: activities to be included in health facility workplans
Unreliable information about catchment population
- Request a list of all households, families and newborns from each community (Module 7).
- Map the catchment area to include all populations (Module 4, Section 1).
- Compare population data from various sources including data from National Immunization Days (NID) or polio activities (use the NID < 5 years population and divide by 5 for infant target).
- Take the newborn register during house-to-house campaigns — register all newborns found and give them an immunization card.
Inaccurate coverage data
- Check record keeping and reporting systems for completeness (Module 6, Sections 1–3).
- Review all tally sheets and reports (Module 6, Sections 1–3) — does the numerator include all areas?
- Organize and complete refresher training for staff.
Some areas are distant and underserved
- Discuss with supervisor and organize mobile team approach from district/province — minimum 4 sessions per year (Module 4).
- Discuss service with the communities and arrange adequate sessions, dates and times (Module 7).
Transport not available for some outreach sessions
- Identify sessions that were not held due to lack of transport.
- Look for alternative means of transport, such as public transport, sharing with other programmes and/or taxis.
- Request a vehicle from the district/next higher level.
Poor attendance at antenatal care (ANC) clinics and/or poor TT2+ coverage
- Promote the value of antenatal care, including TT immunization, during any contact with pregnant women.
- Inform the community about dates of ANC clinics. Find out if session timing or location is inconvenient. If so, make appropriate changes in next quarter’s workplan.
- Use all opportunities to give TT immunization including when mothers accompany infants for childhood immunizations.
Examples of solutions: activities to be included in health facility workplans
Unreliable information about catchment population
- Request a list of all households, families and newborns from each community (Module 7).
- Map the catchment area to include all populations (Module 4, Section 1).
- Compare population data from various sources including data from National Immunization Days (NID) or polio activities (use the NID < 5 years population and divide by 5 for infant target).
- Take the newborn register during house-to-house campaigns — register all newborns found and give them an immunization card.
Inaccurate coverage data
- Check record keeping and reporting systems for completeness (Module 6, Sections 1–3).
- Review all tally sheets and reports (Module 6, Sections 1–3) — does the numerator include all areas?
- Organize and complete refresher training for staff.
Some areas are distant and underserved
- Discuss with supervisor and organize mobile team approach from district/province — minimum 4 sessions per year (Module 4).
- Discuss service with the communities and arrange adequate sessions, dates and times (Module 7).
Transport not available for some outreach sessions
- Identify sessions that were not held due to lack of transport.
- Look for alternative means of transport, such as public transport, sharing with other programmes and/or taxis.
- Request a vehicle from the district/next higher level.
Poor attendance at antenatal care (ANC) clinics and/or poor TT2+ coverage
- Promote the value of antenatal care, including TT immunization, during any contact with pregnant women.
- Inform the community about dates of ANC clinics. Find out if session timing or location is inconvenient. If so, make appropriate changes in next quarter’s workplan.
- Use all opportunities to give TT immunization including when mothers accompany infants for childhood immunizations.
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"text": "\n\n\nCommon problems associated with poor access and utilization, and possible solutions\n :TABLE DATA: \nExamples of common problems Examples of solutions: activities to be included in health facility workplans Supply quantity Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards Request immediate supplies from district level. Review stock recording system (Module 4, Section 5). Review vaccine usage and wastage rates and take action (Module 6, Section 3). Review method of estimating needs (Module 4, Section 5). Supply quality Expired vaccine(s) VVMs show that vaccine has reached the discard point Frozen DTP- and HepB-containing vaccines in refrigerator Review stock recording system (Module 4, Section 5). Review method of estimating needs (Module 4, Section 5). Review management of cold chain equipment (Module 2). Staffing quality Some staff are not using correct protocols/procedures Inform supervisor and select subjects for on-the-job training/supportive supervision, for example: using AD syringes (Module 5) new vaccines (Module 1) reading vaccine vial monitors (Modules 2 and 5) implementing multi-dose vial policy (Module 2) interpersonal communication skills. Irregular supervisory visits Include supervisory visit schedule in district workplans. Staffing quantity Vacant positions; general staff shortage Inform supervisor and district authorities and take steps for recruitment. Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim. Ensure staff are available for each session (Module 4). Service quality and demand Poor attendance at sessions and poor utilization in some areas Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7). Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7). Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4). Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3). Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3). Consider conducting a missed opportunities study to understand the reasons for low utilization. Mothers lose or do not bring the immunization cards Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1). Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1). Parents fear adverse events and/or there are rumours that injection practices are not 100% safe Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1). Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3). Meet community to discuss rumours (Module 7, Section 4). Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2). Arrange information brief sessions with media, leaders, community influencers (Module 7).\n :END TABLE DATA:\nModule 6: Monitoring and surveillance\n :TABLE DATA: \nExamples of common problems Examples of solutions: activities to be included in health facility workplans Unreliable information about catchment population - Request a list of all households, families and newborns from each community (Module 7). - Map the catchment area to include all populations (Module 4, Section 1). - Compare population data from various sources including data from National Immunization Days (NID) or polio activities (use the NID < 5 years population and divide by 5 for infant target). - Take the newborn register during house-to-house campaigns — register all newborns found and give them an immunization card. Inaccurate coverage data - Check record keeping and reporting systems for completeness (Module 6, Sections 1–3). - Review all tally sheets and reports (Module 6, Sections 1–3) — does the numerator include all areas? - Organize and complete refresher training for staff. Some areas are distant and underserved - Discuss with supervisor and organize mobile team approach from district/province — minimum 4 sessions per year (Module 4). - Discuss service with the communities and arrange adequate sessions, dates and times (Module 7). Transport not available for some outreach sessions - Identify sessions that were not held due to lack of transport. - Look for alternative means of transport, such as public transport, sharing with other programmes and/or taxis. - Request a vehicle from the district/next higher level. Poor attendance at antenatal care (ANC) clinics and/or poor TT2+ coverage - Promote the value of antenatal care, including TT immunization, during any contact with pregnant women. - Inform the community about dates of ANC clinics. Find out if session timing or location is inconvenient. If so, make appropriate changes in next quarter’s workplan. - Use all opportunities to give TT immunization including when mothers accompany infants for childhood immunizations.\n :END TABLE DATA:\nModule 6: Monitoring and surveillance",
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"text": "Examples of common problems Examples of solutions: activities to be included in health facility workplans Supply quantity Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards Request immediate supplies from district level. Review stock recording system (Module 4, Section 5). Review vaccine usage and wastage rates and take action (Module 6, Section 3). Review method of estimating needs (Module 4, Section 5). Supply quality Expired vaccine(s) VVMs show that vaccine has reached the discard point Frozen DTP- and HepB-containing vaccines in refrigerator Review stock recording system (Module 4, Section 5). Review method of estimating needs (Module 4, Section 5). Review management of cold chain equipment (Module 2). Staffing quality Some staff are not using correct protocols/procedures Inform supervisor and select subjects for on-the-job training/supportive supervision, for example: using AD syringes (Module 5) new vaccines (Module 1) reading vaccine vial monitors (Modules 2 and 5) implementing multi-dose vial policy (Module 2) interpersonal communication skills. Irregular supervisory visits Include supervisory visit schedule in district workplans. Staffing quantity Vacant positions; general staff shortage Inform supervisor and district authorities and take steps for recruitment. Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim. Ensure staff are available for each session (Module 4). Service quality and demand Poor attendance at sessions and poor utilization in some areas Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7). Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7). Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4). Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3). Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3). Consider conducting a missed opportunities study to understand the reasons for low utilization. Mothers lose or do not bring the immunization cards Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1). Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1). Parents fear adverse events and/or there are rumours that injection practices are not 100% safe Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1). Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3). Meet community to discuss rumours (Module 7, Section 4). Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2). Arrange information brief sessions with media, leaders, community influencers (Module 7).",
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Examples of common problems
Examples of solutions: activities to be included in health facility workplans
Supply quantity
Stock-outs of vaccine(s), AD syringes, diluents, safety boxes, immunization cards
Request immediate supplies from district level.
Review stock recording system (Module 4, Section 5).
Review vaccine usage and wastage rates and take action (Module 6, Section 3).
Review method of estimating needs (Module 4, Section 5).
Supply quality
Expired vaccine(s)
VVMs show that vaccine has reached the discard point
Frozen DTP- and HepB-containing vaccines in refrigerator
Review stock recording system (Module 4, Section 5).
Review method of estimating needs (Module 4, Section 5).
Review management of cold chain equipment (Module 2).
Staffing quality
Some staff are not using correct protocols/procedures
Inform supervisor and select subjects for on-the-job training/supportive supervision, for example:
using AD syringes (Module 5)
new vaccines (Module 1)
reading vaccine vial monitors (Modules 2 and 5)
implementing multi-dose vial policy (Module 2)
interpersonal communication skills.
Irregular supervisory visits
Include supervisory visit schedule in district workplans.
Staffing quantity
Vacant positions; general staff shortage
Inform supervisor and district authorities and take steps for recruitment.
Request temporary assignment from district level and consider volunteers for some duties. Schedule rotation of staff in the interim.
Ensure staff are available for each session (Module 4).
Service quality and demand
Poor attendance at sessions and poor utilization in some areas
Meet with the community to discuss possible reasons for low attendance and suggested solutions (Module 7).
Consult the community and change the schedule to make sessions more convenient (Module 4, Section 5 and Module 7).
Check whether all planned sessions have been held. Aim to improve reliability by holding all planned sessions (Module 4).
Screen all infants for immunization whenever they visit the health facility and give all of the vaccines they are eligible to receive (Module 5, Section 3).
Review use of true contraindications to ensure that infants are not missed (Module 5, Section 3).
Consider conducting a missed opportunities study to understand the reasons for low utilization.
Mothers lose or do not bring the immunization cards
Set up a defaulter tracking system to keep complete records (register, reminder cards) at the health facility and take these along during outreach sessions (Module 6, Section 1).
Provide new cards and update from other records – do not restart schedule because of lost cards if the vaccinations given are recorded in the register (Module 6, Section 1).
Parents fear adverse events and/or there are rumours that injection practices are not 100% safe
Inform parents about benefits of immunization and reassure them about vaccine safety (Module 1).
Review safe injection practices: ensure AD syringes supply and use safety boxes and safe disposal practices (Module 3).
Meet community to discuss rumours (Module 7, Section 4).
Review information on AEFI (Modules 1 and 6) and how to report AEFI cases (Module 6, Section 2).
Arrange information brief sessions with media, leaders, community influencers (Module 7).
Examples of solutions: activities to be included in health facility workplans
Unreliable information about catchment population
- Request a list of all households, families and newborns from each community (Module 7).
- Map the catchment area to include all populations (Module 4, Section 1).
- Compare population data from various sources including data from National Immunization Days (NID) or polio activities (use the NID < 5 years population and divide by 5 for infant target).
- Take the newborn register during house-to-house campaigns — register all newborns found and give them an immunization card.
Inaccurate coverage data
- Check record keeping and reporting systems for completeness (Module 6, Sections 1–3).
- Review all tally sheets and reports (Module 6, Sections 1–3) — does the numerator include all areas?
- Organize and complete refresher training for staff.
Some areas are distant and underserved
- Discuss with supervisor and organize mobile team approach from district/province — minimum 4 sessions per year (Module 4).
- Discuss service with the communities and arrange adequate sessions, dates and times (Module 7).
Transport not available for some outreach sessions
- Identify sessions that were not held due to lack of transport.
- Look for alternative means of transport, such as public transport, sharing with other programmes and/or taxis.
- Request a vehicle from the district/next higher level.
Poor attendance at antenatal care (ANC) clinics and/or poor TT2+ coverage
- Promote the value of antenatal care, including TT immunization, during any contact with pregnant women.
- Inform the community about dates of ANC clinics. Find out if session timing or location is inconvenient. If so, make appropriate changes in next quarter’s workplan.
- Use all opportunities to give TT immunization including when mothers accompany infants for childhood immunizations.
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"text": "\n DESCRIPTION:\n Le tableau est une liste de contrôle pour une visite de supervision des services de vaccination, évaluant l'organisation, le suivi et la surveillance.\n :TABLE DATA:\n Question Yes/ No Problem observed and/or comments Corrective action on-site Corrective action longer term Is the session organized efficiently? Are immunization cards in use for every infant and pregnant woman? Is the register used for recording information on each child/mother/ pregnant woman? Are caregivers advised on when to return? Does the health facility have a monitoring chart displayed? Does the health facility have a map of the catchment area displayed? Does the health facility have a workplan for the quarter? Are planned sessions monitored for completeness/timeliness? Is there a system for tracking defaulters? Does the health facility display a spot map of measles cases? Is a temperature monitoring chart in use? Are the vaccines stacked properly inside the refrigerator? Are there any expired vaccines inside the refrigerator? Are there any vaccines with VVM reaching the discard point? Do the health workers know how to read and interpret the VVM? (Ask them to describe VVM changes and what they mean)\n :END TABLE DATA:\n\n ",
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Question
Yes/ No
Problem observed and/or comments
Corrective action on-site
Corrective action longer term
Is the session organized efficiently?
Are immunization cards in use for every infant and pregnant woman?
Is the register used for recording information on each child/mother/ pregnant woman?
Are caregivers advised on when to return?
Does the health facility have a monitoring chart displayed?
Does the health facility have a map of the catchment area displayed?
Does the health facility have a workplan for the quarter?
Are planned sessions monitored for completeness/timeliness?
Is there a system for tracking defaulters?
Does the health facility display a spot map of measles cases?
Is a temperature monitoring chart in use?
Are the vaccines stacked properly inside the refrigerator?
Are there any expired vaccines inside the refrigerator?
Are there any vaccines with VVM reaching the discard point?
Do the health workers know how to read and interpret the VVM? (Ask them to describe VVM changes and what they mean)
Are immunization cards in use for every infant and pregnant woman?
Is the register used for recording information on each child/mother/ pregnant woman?
Are caregivers advised on when to return?
Does the health facility have a monitoring chart displayed?
Does the health facility have a map of the catchment area displayed?
Does the health facility have a workplan for the quarter?
Are planned sessions monitored for completeness/timeliness?
Is there a system for tracking defaulters?
Does the health facility display a spot map of measles cases?
Is a temperature monitoring chart in use?
Are the vaccines stacked properly inside the refrigerator?
Are there any expired vaccines inside the refrigerator?
Are there any vaccines with VVM reaching the discard point?
Do the health workers know how to read and interpret the VVM? (Ask them to describe VVM changes and what they mean)
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"text": "\n DESCRIPTION:\n L'évaluation porte sur les connaissances des agents de santé, la gestion des stocks, la sécurité des injections et l'implication communautaire dans la vaccination.\n :TABLE DATA:\n Question Yes/ No Problem observed and/or comments Corrective action on-site Corrective action longer term Do the health workers know when and how to perform the Shake Test? (Ask them to demonstrate how to do it) Is there an adequate supply of AD syringes for the planned sessions? Are AD syringes used for every immunization? Is the injection technique appropriate? Is each used AD syringe and needle disposed of in a safety box? Are immunization posters displayed on the health facility wall(s)? Is there a schedule of community meetings? Are community volunteer(s) involved with immunization services? Is there a stock register? Does the stock register show adequate vaccines and supplies?\n :END TABLE DATA:\n\n ",
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knowledge and understanding of immunization, diseases and public health
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Review your programme’s immunization coverage.
Complete the exercise in Module 4, Section 2 (Table 4.3) to identify priority communities based on the number of unimmunized children.
Analyse service accessibility, reliability and client orientation.
This will help better define whether children remain under- or unimmunized due to poor access and/or utilization and gives a starting point for the community partnering discussions given in Step 4 below. Refer to Module 4, Sections 2 (Table 4.3) and 3, and Module 6, Section 4 (Figure 6.12).
Prepare an inventory of your potential community partners.
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community-based traditional health providers
religious leaders and groups affiliated with religious institutions (mother’s groups, youth groups)
other organized health groups (health committees)
teachers, parent–teacher groups, school health programmes
local staff or groups associated with other areas of social and economic development, such as agricultural extension workers
NGOs.
Share immunization programme information.
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"text": "\n\n\n4.1 Invite participation in microplanning\nExplain the purpose and importance of microplanning to community partners and invite representative caregivers, leaders, NGOs and others from the inventory given in Section 2 to participate. For better microplanning, health workers should consult with communities on the location, schedule and services offered in fixed and outreach sites. Communities should be encouraged to give input on the following:\nShould outreach sites be moved to reach more children? Are special sessions (evenings/weekends) needed if caregivers are unable to attend during routine vaccination times? Do any seasonal changes (heavy rains/mud, high water, snow) need to be kept in mind for scheduling? Can convenient gathering points and times (such as market days) be used to maximize attendance at immunization sessions?\nMicroplanning should include budgeted activities to promote partnering; for example:\ninformation exchange with communities mobilizing families for immunization obtaining community feedback on immunization services providing non-financial incentives for community volunteers to assist in service provision and monitoring.\nPartnering with communities\nMicroplans may integrate other high-priority services with immunization according to national guidelines and/or community needs (see Module 1 ( Target diseases and vaccines ) , Section 18). These might include:",
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5 Involve communities in monitoring and surveillance
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identifying community volunteers
defining their responsibilities (in collaboration with them)
training them and providing the required tracking or teaching materials
providing supportive supervision and mentoring, as needed
giving them feedback on the impact of their efforts
This section describes the monitoring and surveillance activities that can be part of efforts to partner with communities.
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collaborate with health workers to keep track of new and defaulter infants who need to complete immunization series (see Module 6
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"text": "\n\n\nThe importance of respect\nTreatment of and communication with caregivers at the time of vaccination can significantly affect their willingness to return for subsequent doses. Some points on encouraging caregivers are mentioned in Module 5 (Managing an immunization session), and are worth reviewing here. Health centre staff can help improve immunization coverage by:\nBe careful to avoid criticism of the caregiver verbally and/or with body language. Treating people respectfully and kindly can be difficult if a health worker:\nfeels overworked, underpaid and/or underappreciated perceives her/himself as different from the community, perhaps because of professional or educational status and/or being from another ethnic group considers some caregivers to be ignorant, lazy and/or illiterate.\nPartnering with communities",
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"text": "\n\n\nHow to respond to rumours and misconceptions about immunization\n➢ Act swiftly to identify the source of the rumours and understand their contents. Listen to what they are saying. Try to understand their starting point. ➢ Identify the people and organizations responsible for fabricating and spreading the rumours and design strategies to interact with them. ➢ Collect good data and facts about immunization to prepare responses to rumours. ➢ Determine the reasons behind the creation of these rumours (for example, is it lack of information, religious/cultural opposition, specific beliefs or mere propaganda?). ➢ Turn the rumour around by going to the source and asking the people what solution they can offer to dispel the rumour. ➢ Target key and credible opinion leaders in the affected area (community leaders, religious leaders, elders, clan leaders), inform them about immunization and seek their support for the promotion of services. ➢ Identify appropriate occasions on which to disseminate facts about immunization (for example, village meetings, religious gatherings, cultural and social functions such as fundraising). ➢ Involve NGOs, civil society organizations and respected leaders to disseminate accurate information on immunization. ➢ Coordinate with the district health authority to conduct a mass media campaign to spread accurate information on immunization (via radio, for example). In particular, seek out media that have already misinformed the public and involve them in an accurate campaign. ➢ Train community members who can support the dissemination of accurate information at various places/events.\nModule 7: Partnering with communities\nIn addition to involving community leaders, volunteers and others regularly, health centre staff should meet at least once a year with as many catchment area communities as possible. Work with local leaders to invite everyone with an interest in child health and to ensure that women and religious and ethnic minorities attend. The purpose of these meetings is to exchange information. This includes providing updates on the immunization programme and the importance of using its services, ask for honest feedback and suggestions, and invite any questions or concerns about immunization. Discuss ways to strengthen partnering for immunization. Adapt the advice below as needed based on local factors.\nPropose a meeting and explain its purpose to different community leaders and groups. If they agree, ask them to suggest the best time and place. Try to ensure that different community subgroups (for example, men or women or particular political parties, religions, social classes or ethnic groups) are represented, either in combined or separate meetings, as appropriate. Discuss and reach agreement on the objectives of the meeting. For example: to get their feedback on health services; to inform people about immunization and what it takes to protect their children; and/or to discuss how they might assist with promoting, providing or evaluating immunization services. Invite their suggestions. Ask the community representatives to inform others about the meeting and let them know what you will provide (for example, health education materials on immunization and drinks or snacks).\nHave everyone sit in a circle or in a similar arrangement that allows participants to see each other. The group can sit on chairs, benches, the ground or any appropriate seating. The facilitators should sit in similar seating and on the same level as the community participants. If culturally acceptable, encourage women not to stand at the back of the crowd but to come forward and participate actively. While men’s opinions are important, women are likely to have greater experience with immunization services. In some settings, separate meetings with men and women may be necessary.\nPartnering with communities\nOpen the meeting by thanking people for organizing it and attending. Explain the objectives clearly. 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➢ Act swiftly to identify the source of the rumours and understand their contents. Listen to what they are saying. Try to understand their starting point.
➢ Identify the people and organizations responsible for fabricating and spreading the rumours and design strategies to interact with them.
➢ Collect good data and facts about immunization to prepare responses to rumours.
➢ Determine the reasons behind the creation of these rumours (for example, is it lack of information, religious/cultural opposition, specific beliefs or mere propaganda?).
➢ Turn the rumour around by going to the source and asking the people what solution they can offer to dispel the rumour.
➢ Target key and credible opinion leaders in the affected area (community leaders, religious leaders, elders, clan leaders), inform them about immunization and seek their support for the promotion of services.
➢ Identify appropriate occasions on which to disseminate facts about immunization (for example, village meetings, religious gatherings, cultural and social functions such as fundraising).
➢ Involve NGOs, civil society organizations and respected leaders to disseminate accurate information on immunization.
➢ Coordinate with the district health authority to conduct a mass media campaign to spread accurate information on immunization (via radio, for example). In particular, seek out media that have already misinformed the public and involve them in an accurate campaign.
➢ Train community members who can support the dissemination of accurate information at various places/events.
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Review the specific commitments made by both the health services and the community.
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