Vaccination PDF - Semester 1 2024

HIGHER INSTITUTE OF SCIENCE, MICROFINANCE AND LOCAL GOVERNMENT School of Biomedical Sciences – BSc (NUS/MID/) VACCINATION Semester 1 – 2024 Course F...

HIGHER INSTITUTE OF SCIENCE, MICROFINANCE AND LOCAL GOVERNMENT School of Biomedical Sciences – BSc (NUS/MID/) VACCINATION Semester 1 – 2024 Course Facilitator: M. SHADRACK T. D. Samuel Class meets: Monday 10:00 am – 12:00 am Email: [email protected] Required resources: Computer, reliable internet connection, additional articles, supplemental materials, and URLs/website addresses will be supplied by the instructor during the course. Grading - Class Participation/In-class activities 15% of final CA mark - Class attendance 10% of the final CA mark - Quiz 55% of final CA mark - Assignments 20% of final CA mark - Continuous assessment (CA) 30% - Semester Exam 70% Aim: To equip the learner to become a nurse and midwife leader, manager, educator and an advocate for patients, quality health services and the contribution/role of nursing profession to the health agenda. Instructional Consideration and Methods: This course builds on fundamentals of nursing and professional ethical legal practice module. It is designed to equip the learner with knowledge and attitudes in health services management and leadership necessary for provision of health care. Emphasis is placed on utilization of management process, leadership theories, problem solving, clinical decision making, policy analysis and monitoring and evaluation. Lectures, Group work, Case study, Self-directed learning, Reflective diaries, Role plays Course will include a combination of lecture, online class discussion, and active participation. Computer-generated presentations will be used in the lecture portion of this course. Prior to each lecture, the student is encouraged to complete the recommended readings and actively participate in online class discussions. In this way, it is hoped that the learner will be better prepared to successfully accomplish the learning objective of each lecture experience. This course assumes substantial and informed student participation. General discussion of theory and practice is encouraged and expected of all students. At a minimum, being informed requires class engagement, completion of assigned readings and projects, and attention to health care news and world events. Thoughtful participation is important and will be reflected in part in the final grade. Failing to participate meaningfully in class discussions or project presentations will result in a lower grade. Make-up Exams and Late Assignments: Make-up exams are not provided, except in hardship cases which should be discussed in advance with the instructor. Any assignment turned in late will be lowered one letter grade for each day the assignment is late. There will be no scheduled make-up times for exams or paper presentations. If a student cannot take an exam within the scheduled time, they must consult with the terms of the administration for prior to the scheduled due date.  Vaccination VACCINATION GENERALITIES AND CLASSIFICATION OF VACCINES VACCINES A vaccine is an antigenic preparation of microorganisms such as bacteria, viruses or their products administered for prevention of infectious diseases. A vaccine for diseases is prepared from the microbes that causes disease. The vaccine is administered in advance so as to give the body time to set immunity, before the invasion of pathogens occurs. Vaccines improves the immunity to a particular disease. An injected vaccine induces the host to generate antibodies against the disease-causing organism; therefore, during the further exposures, the infectious agent is inactivated, its proliferation is prevented and disease state is not established. Effective vaccines stimulated the immune system by promoting the development of antibodies which quickly and effectively attack disease-causing microorganisms when it enters the body, preventing disease development. A vaccine contains live-attenuated or killed microorganisms or parts from them capable of stimulating a specific immune response comprised of protective antibodies and T cell immunity. A vaccine stimulates a sufficient number of memory T and B lymphocytes to yield effectors T cells and antibody-producing B cells from memory cells of neutralizing antibodies. Vaccination is injection of antigens into the body to produce immunity and to protect against diseases. It is a process of active immunization. The first injection of the vaccine is called as primary dose. The subsequent injection of the same vaccine is called booster dose. Vaccines are given orally or subcutaneous injection or intracellular injection. Edward Jenner is called father of vaccination. The first vaccine used by Jenner is (cowpox) inoculation of humans confers immunity to smallpox but does not cause smallpox. Jenner took the blisters from milk maids who were suffering from cowpox and inoculated a 9- year-old healthy. Through life the boy did not develop small-pox through his life time and become immune. Recall- IMMUNITY Immunity is the ability of the body to resist to diseases and infectious agents. There are roughly different types of immunity from individuals to even community levels including: Lecturer: Shadrack Samuel – HISMIL  Vaccination - Innate immunity: inherited by the organism from the parents and protects it from birth throughout life. - Acquired Immunity: The immunity that an individual acquires after the birth is called acquired or adaptive or specific immunity. It is specific and mediated by antibodies or lymphocytes or both which make the antigen harmless. It not only relieves the victim of the infectious disease but also prevents its further attack in future, i.e. it entails memory cells. There are two types of acquired immunity, active immunity and passive immunity. The table below summarizes adaptive immunity: - Herd immunity: This develops when a high proportion of the target population in the community has been immunized with live vaccines, usually 80% and more in order to prevent the spread of infectious diseases. Mechanism of vaccination / immunization The immune system is a network of cells, tissues and organs that work together to help fight off infection from harmful bacteria or viruses. When a disease-causing agent, such as virus or bacteria, invades your body, your immune system recognizes it as harmful and will trigger a response to destroy it. One of the ways our immune system fights against infection is by creating large proteins known as antibodies. Each antibody is specific to the bacteria or virus that it has detected and will trigger a specific immune response. These specific antibodies will remain in the immune system after the infection has gone. If the same disease-causing bacteria is attacked again, our immune system has a ‘memory’ of the disease and is ready to quickly destroy it before we get sick and any symptoms can develop. Vaccination is the safest and most common way to gain immunity against a bacteria or virus that your body is yet to encounter. Lecturer: Shadrack Samuel – HISMIL  Vaccination Vaccines contain a very small amount/ non virulent or inactive form / hapten / of bacteria or virus that causes the disease. This is so because it will be just enough to trigger an immune response without making the body to develop disease. Our immune system recognizes the harmless form of bacteria or virus from the vaccine and will produce antibodies to fight it off. The immune system then keeps a memory of the disease, so if a vaccinated person encounters the disease years later, their immune system is ready to fight it off and prevent an infection from developing. Thus, the main aim of the vaccines is to stimulate the production of antibodies without the person actually having the to develop disease. The pathogen entering the cells produces cell mediated immune response and pathogen present in the intracellular space produces humoral immune response. Definition of terms Immunization: A process by which a person becomes protected against a disease through vaccination. This term is often used interchangeably with vaccination or inoculation. Antigen: Any substance, usually a protein that is capable of eliciting an immune response. The antigens that can cause a disease are called pathogens. Antibody: A protein produced by plasma cells in response to an antigen. Immunity: The ability of protection against infectious disease. Immunogenicity: The inherent ability of an antigen to induce an immune response. Seroconversion: When an individual following a disease or vaccination generates antigen- specific antibodies. Vaccination: The process of administering a vaccine or manipulation of the immune system to induce protective immunity. Vaccine adjuvant: Substance that is added to a vaccine to its immunogenicity without having any specific antigenic effect in itself. These may include mineral salts (aluminum and calcium phosphate), organic adjuvants, particulate adjuvants, virosomes, microbial derivatives, oil emulsions and surfactant-based formulations Incubation period: the interval between exposure to an infectious agent and onset of clinical symptoms. The incubation period varies for different diseases from a few hours to several months or even longer for some diseases, e.g. leprosy CLASSIFICATION OF VACCINES There are several different types of vaccines. Each type is designed to teach the immune system how to fight off certain kinds of germs—and the serious diseases they cause. - When vaccines are created the following are generally considered: - How the immune system reacts to the germ - Who needs to be vaccinated against the germ Lecturer: Shadrack Samuel – HISMIL  Vaccination - The best approach/technology to create the vaccine There are roughly 5 types of vaccines Live attenuated vaccines; Inactivated vaccines; Subunit vaccines, Recombinant, Polysaccharide, and Conjugate vaccine; Toxoid vaccine; mRNA vaccine and Viral vector vaccines. 1- Inactivated vaccines Inactivated vaccines use the killed version of the germ that causes a disease. Inactivated vaccines usually don’t provide immunity (protection) that is as strong as live vaccines. So, several doses may be needed over time (booster shots) in order to get ongoing immunity against diseases. Inactivated vaccines are used to protect against: Hepatitis A Flu (shot only) Polio (shot only) Rabies 2- Live Attenuated vaccines Live vaccines use a weakened (or attenuated) form of the germ that causes a disease. Because these vaccines are so similar to the natural infection that they help prevent, they create a strong and long-lasting immune response. Just 1 or 2 doses of most live vaccines can give a lifetime of protection against a germ and the disease it causes. But live vaccines also have some limitations. For example: Because they contain a small amount of the weakened live virus, some people should talk to their health care provider before receiving them, such as people with weakened immune systems, long-term health problems, or people who’ve had an organ transplant. Live vaccines are used to protect against: Measles, mumps, rubella (MMR combined vaccine) Rotavirus Smallpox Chickenpox Yellow fever 3- Messenger RNA vaccines – mRNA vaccine Researchers have been studying and working with mRNA vaccines for decades and this technology was used to make some of the COVID-19 vaccines. mRNA vaccines make proteins in order to trigger an immune response. mRNA vaccines have several benefits compared to other types of vaccines, including shorter manufacturing times and, because they do not contain a live virus, no risk of causing disease in the person getting vaccinated. Lecturer: Shadrack Samuel – HISMIL  Vaccination mRNA vaccines are used to protect against: COVID-19 Rabies 4- Subunit, recombinant, polysaccharide, and conjugate vaccines Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of the germ— like its protein, sugar, or capsid (a casing around the germ). Because these vaccines use only specific pieces of the germ, they give a very strong immune response that’s targeted to key parts of the germ. They can also be used on almost everyone who needs them, including people with weakened immune systems and long-term health problems. One limitation of these vaccines is that a booster shot may be needed to get ongoing protection against diseases. These vaccines are used to protect against: Hib (Haemophilus influenzae type b) disease Hepatitis B HPV (Human papillomavirus) Whooping cough (part of the DTaP combined vaccine) Pneumococcal disease Meningococcal disease Shingles 5- Toxoid vaccines Toxoid vaccines use a toxin (harmful product) made by the germ that causes a disease. They create immunity to the parts of the germ that cause a disease instead of the germ itself. That means the immune response is targeted to the toxin instead of the whole germ. Like some other types of vaccines, you may need booster shots to get ongoing protection against diseases. Toxoid vaccines are used to protect against: Diphtheria Tetanus VACCINE CONSTITUENTS / COMPONENTS - Active material(s) Antigens or molecules that react with specific receptors on T and B cells and activate these cells to induce antigen-specific T and B immune responses. Lecturer: Shadrack Samuel – HISMIL  Vaccination - Inactive materials Adjuvants (aluminum salts, mono-phosphoryl lipid A or MPL, etc.). Enhances immune responses of vaccine antigens - Preservatives (phenoxyethanol, formaldehyde, thiomersal / thimerosal, or antibiotics) They prevent bacterial growth especially in multi-dose vaccines - Stabilizers (proteins or other organic compounds) They extend the shelf-life of the vaccine - Salts and acidic solutions (sodium hydroxide, sodium chloride, sodium borate and acetic acid) For maintain pH - Solvents such as calcium carbonate, xanthan gum and sterile water - Diluents for reconstituting lyophilised or freeze-dried vaccines CHARACTERISTICS OF AN IDEAL VACCINE An ideal vaccine should; 1. Be immunogenic, provoking a good immune response; but not pathogenic. 2. Provide long-lasting immunity; 3. Be safe, with no or very rare adverse event following immunization (AEFIs); Vaccination is only of benefit if it provides a significant degree of protection against a disease with minimum side effects 4. Be stable in field conditions and can be stored reasonably long without or with minimum cold chain requirements (heat stable); 5. Be combined with several antigens producing immunity against a number of diseases; 6. Be effective after a single dose hence requires few immunizations to induce protection 7. Be administered preferably by non-injectable routes (oral or through inhalation); 8. Be affordable cost and accessible to all. 9. Suitable for administration early and late in life (Effective in the old & very young) 10. Give life-long immunity 11. Be broadly protective against all variants of organism 12. Prevent disease transmission 13. Rapidly induce immunity 14. Transmit maternal protection to the baby Lecturer: Shadrack Samuel – HISMIL  Vaccination VACCINE STORAGE AND HANDLING GUIDELINES Immunizations help save lives, prevent serious illnesses, and are recognized as one of the most effective public health interventions available today. Immunization programs are among the most cost-effective ways to prevent disease. The success of these programs depends heavily upon the high immunization coverage of the target group and vaccine inventory management, including proper storage and handling of vaccines. By understanding and implementing proper vaccine storage and handling practices, staff in health care provider premises can play a critical role in improving the health of Ontarians by ensuring that the administered vaccines retain their potency and that vaccine wastage is reduced. The Cold Chain The “cold chain” includes all of the materials, equipment and procedures used to maintain vaccines in the required temperature range of 2 ºC to +8 ºC from the time of manufacture until the vaccines are administered to individuals. The cold chain incident occurs when vaccine is exposed to a temperature outside the required temperature range of +2 ºC to +8 ºC for any period of time and the potency of the vaccine is potentially compromised. Cold chain incident inspection investigates the cause of the cold chain incident, determine whether vaccine can be used by the health care provider or returned to the public health unit, provide follow-up education in order to prevent the occurrence of future incidents and ensure that adequate cold chain conditions can be maintained prior to continuing the vaccine supply to the health care provider. An exposed vaccine is that which is stored or handled at temperatures below +2 ºC and/or above +8 ºC for any period of time, or that is not stored according to the manufacturer’s recommendations, is considered to be “exposed.” Depending on the length and type of exposure some vaccines may still be viable. Your public health unit will assist you in determining the vaccines that remain suitable for use. An insulated container is a solid walled container with a tight lid. The container must be able to store and transport vaccines at the required temperatures for the necessary duration of time. Spoiled vaccine is vaccine that cannot be used because of exposure to temperatures below +2 ºC and/or above +8 ºC for a specific period of time. This will depend on the specific vaccine. The public health unit assesses all provincially funded vaccines that have been exposed to determine whether they can be used. Lecturer: Shadrack Samuel – HISMIL  Vaccination THE EXPANDED PROGRAM ON IMMUNIZATION (EPI) The expanded Program on Immunization (EPI) was launched in 1974 by the World Health Organization (WHO). In 1977 EPI set the following three long-term objectives: To reduce morbidity and mortality from six major childhood diseases, i.e. measles, tuberculosis, tetanus, pertussis, poliomyelitis and diphtheria by immunizing all children throughout the world by 1990. To promote national self-reliance in delivering immunization services within the comprehensive health service, and To promote regional self-reliance in vaccine production and quality control. Despite various initiatives and campaigns over the years, immunization coverage in most parts of Cameroon remains low, and this contributes to high morbidity and mortality among children. Some of the factors accounting for under immunization service are: lack of transportation ineffective cold chain shortages of trained health personnel poor inter-sectoral collaboration inadequate community involvement and participation. EPI TARGET DISEASES 1. PERTUSSIS / WHOOPING COUGH This is an acute bacterial disease of the respiratory tract characterized by intense cough in paroxysms and sometimes with forceful inspiratory gasp and absence of fever, tachypnea, sore throat, hoarseness, sneezing, night cough, anorexia, etc. It is caused by a gram-negative bacterium called Bordetella pertussis. The organism produces exotoxin and affects the pharynx, larynx, trachea, bronchi, bronchioles and sometimes the alveoli. It spread from person to person by droplets, i.e. through coughing or sneezing etc. Risk factors will include: - Not being immunized - Overcrowding - Poor ventilation - Malnutrition. Lecturer: Shadrack Samuel – HISMIL  Vaccination Incubation period is 7 – 17 days. The symptoms of classical pertussis last about 6 weeks and are divided into 3 stages – Catarrhal (lasts 1-2 weeks), Paroxysmal (lasts 2 – 4 weeks), Convalescent (after 4 weeks) stage. Diagnosis (laboratory) - WBC 15000 - 20000/mm3 (rarely to 50,000/mm3) - 60 - 80% Lymphocytes - Microscopy; Gram stain - Culture to isolate the organism 2. TETANUS This is a neurological disease characterized by generalized increased rigidity and convulsive spasms of skeletal muscles from the bacterial toxin. This disease is caused by the metabolic activity (tetanus toxin release) of a gram-positive anaerobic bacterium called Clostridium tetani. A person may become infected if contaminated soil or dung enters a wound or cut. Neonatal tetanus mainly occurs as a result of umbilical cord contamination at birth. Risk factors - Cutting umbilical cord with non-sterile instrument. - Lack of adequate tetanus toxoid (TT) immunization of mothers. - Applying cow dung, mud and other contaminated materials on the umbilical stump. - Home deliveries attended by untrained traditional birth attendants. - Harmful traditional health practices like uvulectomy, tonsillectomy. Tetanus occurs in several clinical forms. One of the most important manifestations is neonatal tetanus (NNT). Diagnosis of neonatal tetanus is mainly by clinical features. Its incubation period is from 1-14 days (in 90% of the cases) but it can last up to 54 days. The period of onset (the time between the first symptom and start of the spasm) ranges from hours today. Tetanus manifests itself in two clinical forms: Local tetanus - pain around the umbilicus - dirt and clotted blood are usually present Generalized tetanus - It is the most common form of the disease and presents with early symptoms. - Progressive difficulty in feeding (sucking and swallowing) - Hunger and crying. This is followed by paralysis or diminished movement Lecturer: Shadrack Samuel – HISMIL  Vaccination - Lock jaw (clenched) - Stiffness to the touch and spasms with or without opisthotonus. - Board like abdomen. - Hyper extended extremities. Prevention is by: - Immunization of children and women. - Health information on harmful practices - Training of Traditional Birth Attendants (TTBA). 3. POLIOMYELITIS This is an acute viral disease with severity ranging from in apparent infection to paralytic disease. It is caused by polioviruses type I, II and III. The virus affects the anterior horn cells of the spinal cord and several areas of the brain. Damage may be reversible with recovery, but it may go on to irreversible nuclear destruction where muscle paralysis results. It is a crippling disease that can occur in adults but it is mainly commoner in children. Risk factors - Not being immunized - Poor sanitation and hygienic practices - Overcrowding - Poverty Signs and symptoms - Incubation period is 6 – 14 days - Fever, malaise, headache and muscle pain - Nausea, vomiting, sore throat and stiffness of the neck and back with or without paralysis. - Paralysis usually affects the legs, more often one. Diagnosis is mainly by clinical features Management Early phase - Keep the limbs position with cushions - Apply warm packs - Provide analgesics Active and passive movements are assisted by physiotherapist after the acute phase ended. Lecturer: Shadrack Samuel – HISMIL  Vaccination Recovery phase - Continue with full range of passive/active movement of the affected limb every day. Residual phase - Regular outpatient supervision of physical, social and economic problems if needed. 4. DIPHTHERIA An acute bacteria disease of tonsils, pharynx, larynx, and nose. It occasionally affects the conjunctiva, genitalia and can damage the heart. It is caused by A Gram-positive bacterium called Corynebacterium diphtheriae. The bacterium produces exotoxin which causes local tissue inflammation and necrosis. In cases where the pharynx is involved, there are patches of a grayish membrane with a surrounding dull red inflammatory zone, which may cause pharyngeal obstruction. Risk factors - Over crowding - Poor living conditions - Not being immunized - Malnutrition The incubation period is usually 2 - 5 days. Signs and Symptoms - Sore throat which may be followed by stridor. - Grayish white membrane seen in oropharynx. - Upper airway obstruction by the membrane. Diagnosis - Microscopy – gram staining - Clinical features Management A. Specific - Diphtheria antitoxin if the diagnosis is strongly suspected clinically. - Antimicrobial therapy with penicillin or erythromycin. B. General - Strict bed rest and sedation - Intubations if needed. Lecturer: Shadrack Samuel – HISMIL  Vaccination 5. MEASLES This is a highly contagious acute viral disease characterized by fever, runny nose, cough, irritability, conjunctivitis, lacrimation, enanthema (Koplik’s spots) on the buccal and labial mucosa, and maculopapular rash appearing in a shower distribution over a period of 3 days. It is caused by Measles Virus. Its transmission is by droplet spread or direct contact with noise/throat secretions of infected persons. Also spread by indirect contact with articles soiled by secretions Risk factors - Not being immunized - Overcrowding - Malnutrition Clinical features - The incubation period ranged from 7 - 18 days. - The initial stage (catarrhal stage) starts with fever, cough, sneezing, running nose and red, runny eyes. Koplik’s spots in the mouth occur before the rash. - A characteristic red blotchy rash appears on the third to 7th day, beginning on the face becoming generalized, lasting 4 – 7 days. Diagnosis - It is made mainly by clinical features epidemiological grounds. Management - Only severe cases are admitted and treated in hospitals. - Mothers are advised about care at home which includes – reducing fever, maintaining hydration and nutrition Complications - Pneumonia - Otitis media - Malnutrition - Encephalitis - Eye problems and blindness (abscised with Vitamin A deficiency) Lecturer: Shadrack Samuel – HISMIL  Vaccination 6. TUBERCULOSIS It is a chronic mycobacterial disease with a wide variety of clinical forms, pulmonary tuberculosis being the predominant form. Pulmonary tuberculosis is caused by Mycobacterium tuberculosis. Tuberculosis of the gastrointestinal tract is caused by Mycobacterium bovis. It is transmitted by; - Respiratory route Airborne droplet from sputum of person with infectious tuberculosis - Alimentary route Alimentary route: Ingestion of infected raw or non-pasteurized milk. The bacilli infect the lung forming a tubercle (lesion). The tubercle may heal, leaving scar-tissue or may continue as a granuloma or eventually proceed to necrosis, liquefaction, sloughing, and cavitations. The initial lesion may disseminate the bacilli by extension to adjacent tissue or via bloodstream and lymphatic system. Predisposing factors - Poor nutritional status - Not being immunized - Infection with HIV/AIDS - Habit of drinking non boiled/non-pasteurized milk - Overcrowding - Contact with pulmonary tuberculosis cases Clinical features and signs/symptoms - The incubation period ranged is 4 – 12 weeks but the infection may persist for months or years before the disease develops. - The signs and symptoms of pulmonary tuberculosis are: Persistent cough for more than 3 weeks. Sputum production, which may or may not be blood stained. Weight loss Chest pain Shortness of breath Intermittent fever, night sweats Less of appetite Fatigue and malaise Lecturer: Shadrack Samuel – HISMIL  Vaccination Diagnosis - Clinical features - Laboratory diagnosis Sputum smear microscopy using Ziehl Neelson Acid-Fast Staining technique-this is the commonly used laboratory technique Culture - Chest Xray Management - Chemotherapy: There are two phases of treatment; a. Intensive or initial phase - the first two or three months of treatment. b. Continuation phase - the remaining duration of treatment. - Drug Regimens There are two recommended standard tuberculosis drug regimens: i. Directly observed Treatment short course (DOTS), which is for 8 months; in DOTS the patients are given the drugs under observation by health worker for the first two months. ii. Long course chemotherapy (LCC); which is given for 12 months. Side effects of vaccines BCG - Bacillus Calmette-Guérin 1- Normal reaction: - A small red, tender swelling about 10 mm across appears at the place of immunization after about 2 weeks. - Abscess: due to injection errors - Ulcer - Scar 2- Severe reaction - Sometimes there is severe local inflammation or deeper abscess. - Sometimes the lymphatic glands near the elbow or in the axilla swell. This may be because needle used was not sterile, injection was too deep under the skin by mistake or a too large a dose of vaccine was administered. DPT - Fever - Soreness at the injection site - Abscess Lecturer: Shadrack Samuel – HISMIL  Vaccination - Convulsion (rare) Polio - Usually none Tetanus Toxoid (TT) - Pain, redness and swelling at the infection site. Measles - Fever 5 – 8 days late - Occasional rash Contraindications of vaccines A. DPT should not be given if the child has developed severe reactions like shock, convulsions, anaphylactic reaction, etc. to the previous dose of DPT. This is a rare side effect due to the pertussis component of DPT vaccine. B. Infants with clinical AIDS should not receive BCG vaccine and oral polio, but should be given the other EPI vaccines. Vaccination Schedule Lecturer: Shadrack Samuel – HISMIL  Vaccination Prevention and Control of EPI target diseases - Health Information about the importance of immunization. - Proper management and inspection of vaccines. - Early diagnosis and treatment. - Ensuring a clean and safe environment. - Avoid harmful traditional health practices. - Training of community health workers (CHW) and traditional birth attendants (TBA) - Integration of immunization into all aspects of primary health care - Mass mobilization. - Integration of nutrition education with health services. - Provision of services and expansion of outreach sites. - Integrated package of school health interventions. Delivery Strategies Static: Immunization performed as part of routine activity of the health units. Outreach: An immunization approach in which the staffs of health unit go out and administer vaccine to mothers and children in their communities. Mobile: An immunization approach only a single dose vaccination (measles, BCG) in nomadic, settlement areas and mostly used for controlling epidemics of measles. Campaign: an immunization approach conducted by mobilizing the community, example polio and measles vaccination Vaccination Indicators The following are some indicators that show a successful immunization: - BCG scar on the right shoulder. - Completed immunization card. - Vaccine storage times and temperatures at health center and outreach level. Immunization Problems A. Drop Out A drop out is defined as a child or a woman who failed to return for subsequent doses for which he or she is eligible. The possible causes of dropout rates are: - Unsure of dates of return - Long wait at the vaccination center. Lecturer: Shadrack Samuel – HISMIL  Vaccination - Vaccination centers open at inconvenient hours - Negative attitude of some health workers towards the program. - Mothers usually busy on other engagements. - Family left the place for a while. - Being sick on the appointed date. - Some health workers do not explain the need of completing vaccination. - Child develops side effects or was sick on the appointed date. A child or a woman who discontinued the immunization program should not have to restart the immunization. There is no maximum interval between two immunizations. B. Missed opportunities Current policy is that all children and mothers at the health facility for any reason should be screened for immunization status and vaccinated if eligible. Common causes of missed opportunities are: - Health workers do not know the policy - Health workers screen but tell patients to return later - Health workers only vaccinate women with TT if they are pregnant - Health workers only vaccinate the index child, miss the siblings. - Health workers only open a vial if there are enough clients who need it - False contraindications to immunization, example not giving polio vaccine to a child with diarrhea. - Logistical problems, such as vaccine shortages, poor clinic organization, and inefficient clinic scheduling - The failure to administer simultaneously all vaccines for which a child was eligible - Accessibility; time (women carry household responsibilities), distance, cost of transportation - Acceptability: culture, rumors, beliefs, etc. Dropouts and missed opportunities are causes of low vaccination coverage, and have potential solutions. These are: - Social mobilization - Dropout tracing mechanisms. - In service training to community health workers and utilization of other motivation mechanisms. - High level advocacy. - Get commitment by the local leaders. - Monitoring and supervision the program Ensure financial and logistics support for the health institutions. Lecturer: Shadrack Samuel – HISMIL  Vaccination - Monitor coverage periodically. - Daily integrated health service for all women and children attending the health units. Lecturer: Shadrack Samuel – HISMIL