Immunization Handbook For Medical Officers 2017

Reprint 2017
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Government of India
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B.P. SHARMA
Secretary
MESSAGE
Two monumental public health milestones have been achieved

recently with India completing five years of being Polio free and the
WHO certification of India having eliminated Maternal and Neonatal Tet-
anus. I commend the hard work and commitment of medical officers and
all health workers on achieving these commendable milestones.
The Universal Immunization Program has grown from strength

to strength over the years and has also responded to the public health
challenges across the country. With an attempt to bridge the gap in im-
munization, Mission Indradhanush has made tremendous gains towards this goal. This special coun-
trywide initiative has been successful mainly due the unstinted support and active involvement of
the state governments, health staff at all levels, partner agencies and other stakeholders.
While Mission Indradhanush has resulted in immediate gains, it is imperative that the rou-
tine immunization planning and delivery mechanism are also strengthened. This will build up sus-
tainable capacity to ensure that every single pregnant woman and child are immunized, thus pre-
venting the avoidable loss of precious lives and the burden of health care costs.
The Immunization Handbook 2016 will provide guidance to the officers in the field and
prove to be a source of reference to support their efforts to provide quality immunization services.
I congratulate the Immunization Division of the Ministry of Health and Family Welfare and the part-
ner agencies who have contributed to bringing out this important document.
(B.P. Sharma)
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Room No. 156, A-Wing, Nirman Bhawan, New Delhi-110011
Tele : (O) 011-23061863, Fax : 011-23061252, E-mail : [email protected]
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GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
C.K. Mishra NIRMAN BHAWAN, NEW DELHI-110011
Additional Secretary &
Mission Director, NHM
Telefax : 23061066, 23063809
E-mail : [email protected]
FOREWORD
Routine Immunization (RI) is a nation’s strategic investment in its future.

India’s routine immunization program is dynamic and over the years has
evolved to address the changing public health needs of the county.
Tremendous gains have been made in immunization coverage in a coun-
try where challenges reflect accessibility, acceptability and availability
issues. The medical officers and health workers of the health system
delivering the RI program continue to be the backbone and strength in
preventing morbidity and mortality from Vaccine Preventable Diseases
(VPDs).
Since the printing of the last edition of the RI medical officers handbook, India and South East Asia
have been certified Polio-Free and India has achieved the certification of having eliminated Ma-
ternal and Neonatal Tetanus. Both these achievements are the direct result of the RI program and
attributed to the hard work and commitment of the frontline health workers, medical officers and
program managers at all levels.
The Government of India continues to encourage and support all endeavours to strengthen and
improve the capacity of the health workers to help them improve the quality of their work. The RI
medical officer’s handbook has been the guiding force providing the necessary knowledge and skills
for the medical officers to be effective leaders of the immunization program.
With the introduction of newer vaccines, this revised Immunization handbook will play a critical
role in the coming years. Its renewed focus on microplanning will provide the platform necessary to
build a stronger base for ensuring immunization of all beneficiaries and prevent needless mortality
and morbidity due to VPDs.
(C.K.Mishra)
iv
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Government of India
Dr. RAKESH KUMAR, I.A.S Ministry of Health & Family Welfare
JOINT SECRETARY
Telefax : 23061723 Nirman Bhawan, New Delhi-110011
PREFACE
It gives me immense pleasure to present the revised Immunization
Handbook for Medical Officers, 2016. This unique handbook has been
the mainstay for Immunization-specific training of medical officers since
2006 and continues to contribute to improving the capacity of medical
officers to lead their teams in increasing the reach and quality of the
routine immunization program in the country.
Improving equity and quality of service is a goal that is achievable by us-
ing techniques to strengthen systems, build capacity of health staff and
ensure the confidence of the community in the services provided.
While the existing infrastructure of manpower and material continues to be effective, it is necessary
to focus on enhanced efficiency through systematic development of micro plans and management
of immunization services. Towards this aim, the unit on microplanning has been enhanced with a
detailed description of the process and formats needed for developing and maintaining high quality
RI microplans and beneficiary due lists. The unit on high risk populations and urban areas defines
such areas as well as describes area demarcation and identification of vulnerable populations with
the objective of ensuring that beneficiaries in such areas are less likely to be missed. This will make
medical officers and health workers to bring about equity of services.
The units on cold chain, supervision and monitoring, and use of data will improve the capacity of
medical officers to interpret data, better manage storage and handling of vaccines, and provide
supportive supervision to health staff at the field level. As team leaders, medical officers will benefit
from the unit on capacity building which provides agendas as well as the key messages to be dis-
seminated during trainings and review meetings. This will contribute to enhancing knowledge and
skill of frontline health workers, which in turn will improve the quality of services.
The success of the routine immunization program is also influenced by the confidence the commu-
nity holds in the services. Safety of injections administered as well as safety of health staff is detailed
v
in the unit on safe injections and waste management which will help to build staff and community
confidence. The unit on communication for behavior change focuses on how to strategically use
information as well as innovative methods to tackle vaccine hesitancy and bring in community sup-
port for the program.
Surveillance for Vaccine Preventable Diseases (VPD) and Adverse Events Following Immunization
(AEFI) are critical to the immunization program as timely investigation will provide information for
program managers and field staff to address community concerns. The units on VPDs and AEFI are
aimed to sensitize readers to the importance of timely reporting with reference to the operational
guidelines.
With the introduction of newer vaccines such as Inactivated Polio Vaccine (IPV), Rotavirus vaccine
and Pneumococcal vaccine (PCV), it is an opportune time to regularly review immunization services
in order to identify gaps and determine local actions necessary to address them. These activities
well ensure rational use of manpower and logistics thus strengthening systems and reducing avoid-
able wastage of valuable vaccines.
I am confident that this edition of the Handbook will continue to be an effective guide for immuni-
zation training and a reference book for medical officers to address immunization issues in the field.
I commend the efforts of all those who have contributed to making this a much valuable document.
(Dr. Rakesh Kumar)
vi
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Government of India
Dr. PRADEEP HALDAR Ministry of Health & Family Welfare
Deputy Commissioner (IMM) Nirman Bhawan, New Delhi-110011
Telefax : 23062728, 23062126
Message from Deputy Commissioner (Immunization)
With the success of Small Pox eradication, the Immunization programme was
implemented in a more organized manner as Expanded Programme of Immuni-
zation (EPI) in 1978 targeting under 5 year children only in urban areas. In 1985
Immunization programme expanded as Universal Immunization Programme
(UIP) with focus for under 1 year children, expansion of cold chain etc. The pro-
gram reached every corner of the country in 1990 and now the program has
become an integral part of India’s public health infrastructure.
The last five years has seen a dramatic change in the landscape of routine im-
munization with new vaccines being introduced, the vaccination schedule for
Measles and JE changed to 2 dose schedule, open vial policy implemented,
strengthening of AEFI system etc. Implementation has been strengthened with capacity building of personnel
as well as improvements in service delivery.
One of the key instruments for building capacity of medical officers has been the “Immunization handbook”
which provides essential information, guidelines and exercises for skill development of medical officers.
The 3rd edition has grown in both size and content. This edition has been redesigned to serve two purposes,
the first as the backbone for the three day MO immunization training and second as a reference for immu-
nization in the field. All the information has been updated to reflect recent changes in policy and guidelines.
The Unit on microplanning has been rewritten to explain the step by step process of microplan develop-
ment. This Unit includes GoI recommended RI formats at all levels from planning, head-counting and session
due-listing at the sub-centre to consolidated formats for the PHC to give an overview of critical RI information
on a single sheet. Efforts have been made to explain “how” each step is to be taken rather than what steps to
take. Each format has its SOP sheet which explains each variable and how it is to be collected.
Three new Units have been included to cover capacity building, high-risk & urban areas and financial man-
agement. These critical areas have been included in response to the changing dynamics in demography, man-
power and needs of the program.
References and links have been carefully selected from Government and WHO sites to enable the medical
officers to access relevant guidelines and information needed to strengthen existing processes and improve
outcomes.
I am certain that medical officers and the program will benefit from this edition of the immunization hand-
book.
(Dr. Pradeep Haldar)
vii
Table of Contents
UNIT TOPIC PAGE NO
Message iii
Foreword iv
Preface v
Message from DC (IMM) vii
Acknowledgements xi
Acronyms xiii
Unit-1 Introduction to immunization and role of

medical officers in immunization 1
Unit-2 National Immunization Schedule 17
Unit-3 Routine Immunization Microplanning 21
Unit-4 Cold chain and logistics management 83
Unit-5 Safe injections and Waste Disposal 133
Unit-6 Adverse events following immunization 145
Unit-7 Sources and use of data 169
Unit-8 Supervision and monitoring 179
Unit-9 Communication for behaviour change 197
Unit-10 Vaccine Preventable Diseases and

VPD surveillance 221
Unit-11 Capacity building of health functionaries

in immunization 229
Unit-12 High risk populations and Urban areas 247
Unit-13 Financial planning in Immunization 257
References and links 273
Frequently asked questions 279
ix
Acknowledgements
Compiled and Edited by:
Dr. M K Aggarwal, MoHFW
Dr. Leonard Machado, WHO India
Advisors:
Dr. Pradeep Haldar, MoHFW
Dr. Pankaj Bhatnagar, WHO India
List of Contributors:
Mr. Abhimanyu Saxena, UNDP
Dr. Bhawani Shankar Tripathy, UNICEF
Dr. Bhupendra Tripathi, BMGF
Dr. Leonard Machado, WHO India
Dr. Mainak Chatterjee, NCCVMRC, NIHFW
Mr. Nithiyananthan Muthusamy, ITSU
Ms. Monica Chaturvedi, ITSU
Mr. Paritosh Kumar P, NCCVMRC, NIHFW
Dr. Pradeep Haldar, MoHFW
Dr. Sheenu Chaudhary, ITSU
Dr. Sudhir Joshi, WHO India
Dr. Sujeet Jain, WHO India
Recognizing the suggestions and contributions of Dr. Renu Paruthi author of the 1st Edi-
tion of the MO Handbook.
Support in reviewing the manuscript:

BMGF: Dr. Gunjan Taneja
ITSU : Dr. Ajit B, Dr. Arup Debroy, Dr. Deepak Polpakara.
JSI : Dr. Bhrigu Kapuria
MoHFW : Dr. Manjari, ITSU & Dr. Priti Chaudhary, WHO India
UNICEF : Dr. Srihari Dutta, Dr. Satish Gupta, Dr. Gajendra Singh
WHO India : Dr. Balwinder Singh, Dr. Bindu Kalshan, Dr. Danish Ahmed,
Dr. Lucky Sangal, Dr. Mohammad Ahmad, Dr. Mohammad Samiuddin,
Dr. Sachin Rewaria, Dr. Sataybrata Routray.
xi
Acronyms
AD Auto-Disable
AEFI Adverse Event Following Immunization
AES Acute Encephalitis Syndrome
AFP Acute Flaccid Paralysis
AHS Annual Health Survey
ANM Auxiliary Nurse Midwife
ANMTC ANM Training Centre
ASHA Accredited Social Health Activist
AVD Alternate Vaccine Delivery
AWC Anganwadi Centre
AWW Anganwadi Worker
BCC Behaviour Change Communication
BCG Bacillus Calmette-Guerin
BDO Block Development Officer
BEE Block Extension Educator
BMO Block Medical Officer
CBHI Central Bureau Of Health Intelligence
CBO Community-Based Organization
CBWTF Common Biomedical Waste Treatment Facility
CCT Cold-Chain Technician
CDPO Community Development Project Officer
CES Coverage Evaluation Survey
CHC Community Health Centre
CMO Chief Medical Officer
CPCB Central Pollution Control Board
CPR Cardiopulmonary Resuscitation
CSO Civil Service Organization
CSSM Child Survival and Safe Motherhood
CSU Central Surveillance Unit
DF Deep Freezer
DGHS Directorate General Of Health Services
DIO District Immunization Officer
DLHS District Level Health Survey
DPT Diphtheria–Pertussis–Tetanus
DTFI District Task Force For Immunization
xiii
Dwpt Diphtheria, whole Cell Pertussis, Tetanus
EC Executive Committee
ECCVMC Effective Cold Chain Vaccine Management Course
EDD Expected Date Of Delivery
EEFO Early Expiry First Out
EPI Expanded Programme On Immunization
Evin Electronic Vaccine Intelligence Network
EVM Effective Vaccine Management
FAQ Frequently Asked Questions
FIFO First in First Out
fIPV Faractional Inactivated Polio Vaccine
FLW Field Level Worker
FMR Financial Management Report
GFR General Financial Rules
GMP Good Manufacturing Practice
GMSD Government Medical Store Depot
Goi Government of India
GVAP Global Vaccine Action Plan
Hep B Hepatitis B
HHE Hypotonic, Hyporesponsive Episode
Hib Haemophilus Influenzae Type B
HMIS Health Management Information System
HRA High-Risk Area
HRG High-Risk Group
HS Health Supervisor
HW Health Worker
IAP Indian Academy Of Paediatrics
ICDS Integrated Child Development Services
IDSP Integrated Disease Surveillance Project
IEC Information, Education And Communication
ILR Ice-Lined Refrigerator
IM Intramuscular
IPC Inter Personal Communication
IPV Inactivated Polio Vaccine
ISP Immunization Strengthening Project
ITSU Immunization Technical Support Unit
IV Intravenous
JE Japanese Encephalitis
xiv
LAV Live Attenuated Vaccine
LHV Lady Health Visitor
LMIS Logistics Management Information System
LMP Last Menstrual Period
LS Ladies Supervisor (ICDS)
MCH Maternal and Child Health
MCP Mother and Child Protection
MCTS Mother and Child Tracking System
MCUP Measles Catch-Up Programme
MCV Measles Containing Vaccine
MIS Management Information System
MO Medical Officer
Mohfw Ministry Of Health And Family Welfare
MOIC Medical Officer In-Charge
NCC National Cadet Corps
NCCMIS National Cold Chain Management Information System
NCCTC National Cold Chain Training Centre
NCCVMRC National Cold Chain and Vaccine Management Resource Centre
NFHS National Family Health Survey
NGO Non-governmental Organization
NHM National Health Mission
NIHFW National Institute Of Health And Family Welfare
NIS National Immunization Schedule
NPSP National Polio Surveillance Project
NRHM National Rural Health Mission
NSS National Social Service
NTAGI National Technical Advisory Group on Immunization
OPV Oral Polio Vaccine
Penta Pentavalent
PHC Primary Health Centre
PIP Program Implementation Plan
PRI Panchayati Raj Institution
PW Pregnant Woman
RCH Reproductive and Child Health
RI Routine Immunization
RIM Routine Immunization Monitoring
RIMS Routine Immunization Management System
SAGE Strategic Advisory Group of Experts
xv
SBCC Social and Behavioural Change Communication
SC Sub-Centre
SEPIO State EPI Officer
SHG Self-Help Group
SMnet Social Mobilization network
SMO Surveillance Medical Officer
SOP Standard Operating Procedure
SRS Sample Registration System
SSU State Surveillance Unit
STFI State Task Force For Immunization
TBA Trained Birth Attendant
TOT Training of Trainers
RRT Rapid Response Team
TSS Toxic Shock Syndrome
TT Tetanus Toxoid
UHC Urban Health Centre
UIP Universal Immunization Programme
UT Union Territory
VAPP Vaccine Associated Paralytic Poliomyelitis
VCCH Vaccine and Cold Chain Handler
VCCM Vaccine and Cold Chain Manager
VDPV Vaccine Derived Polio Virus
VHND Village Health and Nutrition Day
VHSC Village Health and Sanitation Committee
VPD Vaccine Preventable Disease
VVM Vaccine Vial Monitor
WCO India WHO Country Office for India
WHO World Health Organization
WIC Walk-In Cooler
WIF Walk-In Freezer
WMF Wastage Multiplication Factor
WPV Wild Polio Virus
xvi
Unit 1 : Introduction to immunization and role of medical officers in immunization
1
Introduction including
role of medical
officers in
immunizationn
One of the greatest impacts on the health of mankind has been the use of vaccines. From as
far back as 496 B.C. when the Greek historian Thucydides observed that those who survived
small pox would never get re-infected to 1796 with Edward Jenner’s historic cowpox
experiment, vaccination has played a major role in the battle on infectious diseases.
Since their acceptance as a public health intervention, vaccines have been instrumental in
bringing about a reduction of morbidity and mortality due to vaccine preventable diseases
globally. The eradication of smallpox was not only a global public health victory but also a
turning point in public health strategy. The power of vaccines and vaccination was proven
and thus began an all-out movement to target more diseases.
Vaccines in Routine Immunization (RI) are one of the most cost-effective health investments
a country can make. Over the years various strategies to make vaccines universally available,
including to the most hard-to-reach and vulnerable populations have saved countless lives.
The benefits to the individual include not only the prevention of disease and disabilities but
also the opportunity for a healthier and a more productive life.
The year 2014 marked 40 years since the launch of the Expanded Programme on
Immunization (EPI) in 1974. The 27th World Health Assembly (1974) recommended the
use of vaccines to protect against six diseases: tuberculosis, diphtheria, tetanus, pertussis
measles and poliomyelitis. This program was the starting point for a dramatic change in
world’s public health strategy.
Today, all countries have national immunization programs, and in most developing countries,
children under five years of age are immunized with the standard WHO recommended
vaccines that protect against– tuberculosis, diphtheria, tetanus (including neonatal tetanus
through immunization of mothers), pertussis, polio, measles, hepatitis B, Haemophilus
influenza type b (Hib), Rota Virus and Pneumococcal Vaccines. These vaccines prevent more
than 2.5 million child deaths each year.
Immunization handbook for Medical Officers 1

In May 2012 the 65th World Health Assembly endorsed The Global Vaccine Action Plan
(GVAP), which envisages provision of universal access to immunization. The mission goal is
to improve health by 2020 and beyond, by extending the full benefits of immunization to all
people, regardless of where they are born, who they are, or where they live.
The immunization programme in India – a chronology

The first vaccine to be introduced in India was BCG in 1962 as part of the National
Tuberculosis Programme. Over the years, various new vaccines have been introduced
and many milestones achieved. Table 1.1 gives a chronological listing of some important
milestones in India’s immunization programme.
Table 1.1. Immunization milestones – India
1978 Expanded Programme of immunization BCG,DPT,OPV, typhoid (urban areas)
1983 TT vaccine for pregnant women
1985 Universal Immunization Programme – measles added, typhoid removed,
Focus on children less than 1yr of age
1990 Vitamin-A supplementation
1995 Polio National Immunization Days
1997 VVM introduced on vaccines in UIP
2002 Hep B introduced as pilot in 33 districts & cities of 10 states
2005 • National Rural Health Mission Launched
• Auto Disable (AD) Syringes introduced into UIP
2006 JE vaccine introduced after campaigns in endemic districts
2007-8 Hep B expanded to all districts in 10 states & schedule revised to 4 doses
from 3 doses
2010 Measles 2nd dose introduced in RI and MCUP (14 states)
2011 • Hepatitis B universalized and Haemophilus influenza type b introduced
as pentavalent in 2 states
• Open Vial Policy for vaccines in UIP
2013 • Pentavalent expanded to 9 states
• Second dose of JE vaccine
2014 India and South East Asia Region certified POLIO- FREE
2015 • India validated for Maternal and Neonatal Tetanus elimination
• Pentavalent expanded to all states
• IPV Introduced
2016 • Rotavirus vaccine introduced in 4 states in Phase 1
• tOPV to bOPV Switch
• Switch to fractional IPV (Phased)
• Rotavirus vaccine introduced (Phased launch)
2017 • MR Vaccine introduced
• PCV (Phased launch)
• Use of adrenaline IM by ANM in AEFI
2 Immunization handbook for Medical Officers

In 1985 the program was changed to Universal Immunization Programme (UIP) and Measles
vaccine was added in the same year.
India’s UIP was given the status of one of the five ‘National Technology Missions’ in 1986
thus bringing it under the purview of the 20 point program of the Prime Minister’s Office.
In 1992, UIP and the Safe Motherhood program merged under the umbrella of the Child
Survival and Safe Motherhood (CSSM) program. Further in 1997 the program was renamed
as the Reproductive and Child Health (RCH) program.
In 2005, along with other programs the UIP became part of the National Rural Health
Mission. Below are some of the Initiatives undertaken by the government under NRHM
(2005) to strengthen the immunization program:
• introduction of Auto Disable (AD) syringes and hub cutters;
• financial support for alternate vaccine delivery to session sites from the last vaccine
storage point;
• mobility support to State and District Immunization Officers and other supervisory
staff;
• alternate vaccinators for sessions in urban slums and under-served areas, including
vacant SCs;
• mobilization of children and pregnant women by ASHAs;
• preparing microplans for SC, PHC/CHC and district;
• quarterly RI review meetings at state, district and block levels;
• training of HWs, MOs, cold chain and data handlers;
• computer assistants for every district and at state;
• decentralized printing of recording, reporting and monitoring tools (e.g. Immunization
cards, monitoring charts, tracking bags, temperature charts);
• injection safety (red and black bags, bleach solution and twin buckets);
• strengthening cold chain maintenance and expansion;
• strengthening vaccine delivery from state to district to the PHC/CHC.
GOI declared the year 2012-13 as the “Year of intensification of routine immunization”. During
this phase various strategic actions were initiated towards Health systems improvement
such as increased funding for supportive supervision and mobilization of beneficiaries.
Regular program reviews were conducted at all levels and Special Immunization weeks were
conducted in four rounds. The year also saw the introduction of the web based mother and
child tracking system (MCTS) with the objective of preventing left out and drop outs.

Towards strengthening Adverse Event Following Immunization (AEFI) surveillance

mechanism, activities such as establishing a national AEFI Secretariat, collaboration with
medical colleges for technical and research assistance, involvement of the WHO-NPSP SMO
network, revision of the guidelines in tune with global guidelines and capacity building
across the country were taken up.
To ensure vaccine safety and effective cold chain management, the National cold chain
management information system (NCCMIS) was established to track the functioning of
cold chain equipment across the country. A National Effective Vaccine Management (EVM)
assessment was also conducted to identify issues and provide solutions to strengthen cold
chain and vaccine management.
Mission Indradhanush Ministry of Health and Family Welfare

Government of India
As a strategic endeavor, the Ministry of Health & Family Zindagi Indradhanush Banayein!
Full Immunization keeps me healthy and I can

Welfare (MoHFW), Government of India, launched play with my friends and go to school everyday
THANK YOU MISSION INDRADHANUSH
Mission Indradhanush in December 2014. #FullyImmunizeEveryChild
The Mission focuses on interventions to improve full

immunization coverage for children in India from 65%
in 2014 to at least 90% over the next five years through
special catch-up drives.
Four states – Bihar, Madhya Pradesh, Rajasthan and
Uttar Pradesh – account for 82 of the 201 high-focus Join MISSION INDRADHANUSH
and help provide life-saving vaccines to all children
districts and nearly 25% of the unvaccinated or partially /Vaccinate4Life /Vaccinate4Life www.missionindradhanush.in
vaccinated children.
Based on prioritization, the country has been Figure 1.3- Map showing High/medium focus districts in
Mission Indradhanush
categorized into high, medium and low focus
districts. Phase I of Mission Indradhanush
targeted 201 high-focus districts, with four rounds
of activity between April and July 2015. Phase II
targeted 352 districts (73 districts repeated from
phase I) with four rounds of activity between
October 2015 and January 2016.
During these two phases of Mission Indradhanush
more than 3.7 million children were fully
immunized and about 3.7 million pregnant women. Phase III of MI in 2016 will reach out to
216 high focus districts across 27 states/union territories.

The broad strategy includes four basic elements: -

1. Ensure revision of micro plans in all blocks and urban areas in each district to ensure
availability of sufficient vaccinators and all vaccines during routine immunization
sessions. Develop special plans to reach the unreached children in more than 400,000
high risk pockets such as urban slums, construction sites, brick kilns, nomadic sites
and hard to reach areas.
2. I ncrease awareness and demand for immunization services by intensive
communication efforts to deliver improved community participation.
3. I ntensive training of the frontline workers to build the capacity of these workers for
quality immunization services.
4. E nsure engagement and accountability of district administrative and health
machinery for implementation of this operation by strengthening district task force
meetings.
Integration with the polio programme in the following areas:

• Approximately 400 000 high-risk areas identified as a part of emergency preparedness
and response plan for polio eradication, linked to RI session sites to ensure RI services;
• State Task Forces for Immunization (STFIs) and District Task Forces for Immunization
(DTFIs) constituted;
• Integrated communication with branding and logo for communication;
• Realigning monitoring strategy to generate actionable data and intensified RI
monitoring started by hiring and training external monitors in priority states at the
sub-district level;
• UIP reviews integrated with acute flaccid paralysis (AFP) surveillance reviews;
• Intensified and focused training of all ANMs, AWWs and ASHAs in 9 priority states to
track children missed for immunization with support by WHO Country Office for India
(WCO-India).
The immunization program in India – facts and impact
UIP is one of the largest immunization programs in the world on the basis of quantities
of vaccine used, number of beneficiaries, number of immunization sessions organized,
geographical spread and diversity of areas covered.
The Universal Immunization Program targets to vaccinate nearly 27 million newborn
each year with all primary doses and an additional ~100 million children of 1- 5 year age
with booster doses. In addition, nearly 30 million pregnant mothers are targeted for TT
vaccination each year.
• To vaccinate this cohort of 156 million beneficiaries, ~9 million immunization sessions

are conducted.
• To ensure potent and safe vaccines are delivered to children, a network of ~27000
cold chain points have been created across the country where vaccines are stored at
recommended temperatures
• As per Coverage Evaluation Survey (2009), 91% of vaccination in India was provided
through Public sector while the private sector accounted for 9%. The survey also
indentified the location of vaccination in the public sector at the following sites:
o Fixed sites PHC/CHC/Govt Hospital – 37%
o Sub center- 19%,
o Outreach session held at Anganwadi center–26%
o Outreach session at any place in the village – 9%
The frontline health workers i.e. ASHA’s, AWW and link workers play a critical role in the
process by mobilizing beneficiaries to the RI session sites.
The objectives of UIP are to:
• rapidly increase immunization coverage
• improve the quality of services
• establish a reliable cold chain system up to the health facility level
• introduce a district-wise system for monitoring of performance
• achieve self-sufficiency in vaccine production
INDIA-Public health landmarks

Impact of vaccines in India
The public health use of vaccines in India has had an impressive impact on the morbidity
and mortality of Vaccine Preventavle Diseases (VPDs). Various studies and surveys over the
years have quantified these changes. The infographic below demonstrates the successes
but also reminds us of the need to increase our efforts to further strengthen and sustain RI.
Adapted from Johns Hopkins IVAC.

Improving routine immunization coverage
Improving RI coverage involves an understanding of the factors that impact each process
or activity. Many opportunities arise to gather information or data that reflect the various
components of the immunization delivery mechanism, such as availability of manpower,
finances, communication or vaccine and logistics.
During the RI microplanning strengthening workshops, participants (MOs) were encouraged
to identify factors based on their field experiences. Some of the important issues identified
by them as having a direct bearing on RI coverage were:
• Health services– timely dispersal of funds, vacant SCs, weak tracking of children, fixed
timing of sessions, quality of service provided;
• Planning – weak or absent RI microplans, absence of validation of areas, difficulties in
urban areas planning;
• Health financing – delayed incentive payments, project implementation plan (PIP)
release and alternate vaccine delivery (AVD) payments;
• Programme leadership – supervision by MOs, involvement of MOs in RI microplanning,
involvement of other departments like Integrated Child Development Services (ICDS)
and urban bodies;
• Policy related – delays in receiving guidelines;
• Human Resources- vacancies of ANMs and doctors, irrational distribution of ANMs;
• Training – regular training of manpower, refresher training, quality of training,
availability of trainers;
• Vaccine and logistics – vaccine requirement calculations, vaccine shortages, vaccine
wastage, maintenance of stock register;
• Health information – availability of IEC material, session site communication,
interpersonal communication skills.
In addition to the above, geographical and social factors also play an important role.
Coverage evaluation surveys continue to identify differences as shown in Figs. 1.4 and 1.5.
Utilize opportunities such as block level meetings, review meetings and field visits to
discuss with your staff and identify similar factors.

Figure 1.4 – Differences in vaccine coverage across geography, caste and wealth status –
CES 2009
Percentage of children aged 12 – 23 months fully immunized

100
75.5
80
67.4 66.3
58.5 60.6 58.9
60 49.8
47.3
40
20
Figure 1.5- Gender differences in vaccine coverage – HMIS
Fully immunized children

2
1.8
1.6
CRORES
1.4
1.2
Male Female

The data in Fig 1.4 and 1.5 shows differences in coverage between rural/urban areas, within
socio-economic strata and even in gender. Why do these differences exist? Is it because of
accessibility, awareness, acceptability or health seeking behaviour? Analyzing the available
data at planning unit level can help to identify the issues and answers to these questions as
well as guide you to find practical local solutions through dialogue.
There is no “panacea” or “cure all” to address these differences. We must constantly be
aware that gaps exist and all attempts should be made to close these gaps by finding
practical local solutions which target the contributing factors.
If information or data to identify these differences is not readily available, you can explore
the utilization of information from other departments such as – census data, land records
information for list of areas, election department area listing, Department of social welfare
or women and child development, NGOs etc. Another important and real-time source of
data is RI monitoring (session and house to house) which can be used even though this
may not have a large sample size, it is indicative of issues and can be used locally to initiate
measures to close these gaps.
New vaccine introduction
The GoI is vigilant to the changing public health needs of the country and continues to be
responsive to the epidemiology of VPDs and actively spearheads introduction of newer
vaccines that will have an impact in reducing morbidity and mortality from these VPDs.
The commitment to introducing newer vaccines is stated under the key objective 4 of the
cMYP 2013-2017 - “Introduce and expand the use of new and underutilized vaccines and
technology in UIP”.
The successful elimination of polio and the polio free certification of India and SEARO
on 27th March, 2014 is a public health milestone which is a credit for the entire health
workforce. India’s commitment to a world free of polio is reiterated by the introduction of
IPV as an additional dose along with OPV on 30th November, 2016.
The globally synchronized switch from the use of tOPV to bOPV was done in April 2016 and
all activities to ensure a smooth switch across India were successful.
Rotavirus vaccine has been approved by the GoI for inclusion in to the UIP with the phase 1
launch of the vaccine in 4 states (Himachal Pradesh, Odisha, Andhra Pradesh and Haryana)
in February, 2016.
Rubella vaccine has been approved for introduction as MR vaccine, thus replacing the
measles containing vaccine first dose (MCV1) at 9 months and second dose (MCV2) at 16-
24 months.

To address the burden of pneumococcal diseases such as bacterial pneumonia, meningitis

and sepsis in children, Pneumococcal Conjugate Vaccine has been approved by the NTAGI
for introduction in UIP.
These introductions provide opportunities for strengthening systems and personnel through
the introduction preparedness evaluations and trainings which will be conducted prior to
the launching of each of these vaccines.
Responsibilities of medical officers in immunization programme management
Planning and review

• Develop comprehensive action plan to improve routine immunization.
• Conduct review of the immunization program at block level. (Refer Unit- 8)
• Prioritize sub centres/areas after data analysis (quantitative and qualitative) and
identify areas for additional support and interventions.
• Conduct Block Task Force – Immunization meetings with all stakeholders
• Prepare RI-Microplan for the next year including map, plan for alternate vaccine
delivery, supervision, social mobilization and waste disposal.(Refer- Unit 3)
• Prepare annual plan with budget corresponding to part C of PIP at block level in
consultation with other stakeholders including field personnel involved in immunization.
(Refer Unit- 13)
Implementation
• Guide the health workers to analyse their data, in order to observe coverage trends,
identify bottlenecks/constraints and prepare micro-plan.(Refer Unit-3 and 7)
• Regularly review and update of microplans, HRAs tagging in RI-microplans and
provision of immunization services. Regular feedback to health workers. (Refer Unit-3)
• Ensure updated technical and operational guidelines are available with all health
workers, including guidelines for use of adrenaline IM in AEFI.
• Respond to AFP/Measles/AEFI as per protocol.

Maintaining beneficiary linelist at block level

• Ensure that health workers conduct annual survey to list all immunization beneficiaries
and update this beneficiary list monthly. (Refer Unit-3)
• Validate during field visits sample lists to ensure completeness, correctness and regular
updating. Review ANMs RCH registers and guide them to ensure quality.
• Support the data handler in compiling and maintaining the line list of beneficiaries
with records of their successive vaccinations and analyze this list for program progress
and intervention.
Supervision, monitoring and surveillance
• Ensure planned outreach sessions are implemented even if HW is on leave by making
alternate arrangements.
• Conduct field visits as per the supervision plan; ensure visits of other supervisory
personnel. (Refer Unit-8)
• Analyze data from various reports to identify issues for discussion during review
meetings. (Refer Unit-7)
• Review monthly sub-center surveillance reports for completeness, accuracy, VPD and
AEFI cases including AEFI block register and take appropriate action
• Organize periodic review meetings at sector and block level to review program
performance and decide on course of action.
• Organize inter-sectoral coordination meetings at PHC to coordinate with ICDS, local
village administration and NGOs
• Facilitate capacity building of HWs including the use of adrenaline IM in AEFI and
support staff in immunization. (Refer Unit-11)
• Ensure use of coverage monitoring chart, supervision checklist, tracking tools, etc.
Cold chain and logistics management (refer Unit 4)
• Guide and supervise the Vaccine and Cold Chain Handler at the ILR point to effectively
manage the cold chain and logistics. Refer Cold Chain Handlers Manual.
• Monitor preventive maintenance of cold chain equipment
• Ensure availability and use of standard stock register for maintaining vaccine and
logistics
• Ensure that sufficient vaccines and supplies are available for all planned sessions
• Ensure regular distribution of vaccine and logistics to health workers at outreach
session sites through Alternate Vaccine Delivery (AVD) system

• Ensure practice of Open Vial Policy and supervise closely

• Ensure regular NCCMIS entries
• Ensure proper storage of returned vials to prevent errors in use
• Ensure availability and replenishment of AEFI kits. (Refer Unit-6)
• Ensure availability and use of job aids at cold chain point
Community involvementand communication (refer Unit 9)
• Guide the development of a communication plan
• Support health workers in establishing regular dialogue with community (IPC)
• Establish alliances with other programs (e.g. ICDS) and organizations (e.g., NGOs) with
community reach.
• Meet community/Panchayat leaders, teachers and volunteers on a regular basis;
encourage them to discuss immunization in their meetings; share hand-outs with
immunization information.
• In urban areas involve all Civil Service Organizations (CSOs) in RI. (Refer Unit-12)
• Get feedback from the community to ensure a high quality service.
• Use of RI invitation slips to mothers on the previous day to ensure attendance for RI
sessions.
• Monitor tracking of new-borns and dropouts and ensure that due list is shared with
ASHA and AWW. Check during field visits.
Financial management (refer Unit 13)
• Ensure the timely release of funds.
• Keep record of all funds received and expenditure incurred with vouchers under
various heads.
• Monitor timely dispersal of funds at grass root level.
• Send the statement of expenditure and utilization certificate to the district.

Responsibilities of District Immunization Officers in Immunization programme

management
Planning
• Guide medical officers in data analysis and attend meetings at block/PHC
• Oversee the quarterly review of RI microplans and provide feedback and solutions
• Ensure all identified HRAs (Including from Mission Indradhanush if applicable) are
tagged / incorporated into RI microplans
• Organize inter-sectoral coordination meetings at district to coordinate with ICDS,
local/Urban administration and NGOs
• Ensure tracking of newborns, dropouts and availability of session due lists.
Review
• Coordinate the RI review meetings at district level
• Participate in periodic review meetings at sector and block level to review program
performance and decide course of action
• Provide feedback to district administration of issues through meetings District Task
Force – Immunization and with state through state level meetings
• Review and respond to feedback on immunization activities from various agencies
• Provide regular feedback to CMO/DHO on immunization.
Supervision, monitoring and surveillance
• Develop a rational supervision plan for self and other district officials
• Conduct field visits as per the supervision plan; ensure visits of other supervisory
personnel
• Conduct RI session site and House to house monitoring
• Respond to AFP/Measles/AEFI or any other outbreaks as per protocol.
• Analyze data from all reports to identify issues for discussion with MOs during district
review meetings
• Review monthly block/PHC reports for completeness, accuracy, VPD and AEFI cases
and take appropriate action. Review AEFI data to identify issues.
• Ensure use of coverage monitoring chart, supervision checklist, tracking bag and other
tracking tools.

Cold chain and logistics management

• Regularly guide and supervise the Vaccine and Cold Chain Handler at the district
vaccine store
• Monitor preventive maintenance of cold chain equipment at district and during field
visits
• Ensure that sufficient vaccines and supplies are available for the district at all times
• Ensure regular distribution of vaccine and logistics to all blocks/PHCs and monitor use
of vaccine stock registers at all levels
• Ensure availability and timely replenishment of AEFI kits.
Community involvement and communication
• Guide the development the district communication plan
• Establish alliances with programs (e.g. ICDS), Civil Service Organizations (CSOs)/
organizations (e.g., NGOs) with community reach
• Meet community/Panchayat leaders on a regular basis; encourage them to discuss
immunization in their meetings; share immunization/monitoring information if
required
• In interactions with community seek feedback on quality of RI services.
Training
• Facilitate capacity building of MOs and support staff in immunization.
• Guide MOs in data analysis.
• Facilitate organization of training for ANMs and ASHAs.
• Participate in district level ICDS trainings to sensitize them for their role in RI.
Financial management (refer Unit 13)
• Ensure the timely release of funds to the blocks/PHCs.
• Keep record of all funds received and expenditure incurred with vouchers under
various heads.
• Effectively utilise mobility funds for monitoring and field visits
• Monitor timely dispersal of funds at grass root level.
• Send the statement of expenditure and utilization certificate to the state.

Notes:
Unit 2 : National immunization schedule
2
National
Immunization
Schedule
Under the UIP, vaccines are provided to prevent the following VPDs:
• Diphtheria • Haemophilus Influenzae Type B related diseas-
• Pertussis es (bacterial meningitis, pneumonia and others)
• Tetanus • Japanese Encephalitis
• Polio • Encephalitis
• Measles • Diarrhoeas due to rotavirus
• Tuberculosis • Rubella
• Hepatitis B • Pneumococcal disease
The goal of Universal Immunization Programme is to reach out to the following beneficiaries:
Pregnant women
• As early as possible - appropriate TT doses
Infants & children
• At birth - HepB, BCG, OPV
• Before age 1 year - for Full Immunization
3 doses of OPV, 3 doses of Rotavirus (where applicable), 3 doses of
Pentavalent, 2 doses of fractional IPV, 3 doses of PCV (where applicable),
MR vacccine -1st dose , JE 1st dose (where applicable)
• Before age 2 years - for Complete Immunization
MR vaccine - 2nd dose, DPT booster, Polio booster and JE 2nd dose (where
applicable)
OPV – oral polio vaccine; BCG – bacillus Calmette-Guerin; Hep B – hepatitis B;
PCV – Pneumococcal Conjugate Vaccine

DPT – diphtheria–pertussis–tetanus

Fig. 2.1. Different needle positions for vaccine administration
National Immunization Schedule

Table 2.1. National Immunization Schedule for infants, children and pregnant women
Vaccine Due age Max age Dose Diluent Route Site
For Pregnant Women
TT-1 Early in Give as early 0.5 ml NO Intra- Upper Arm
pregnancy as possible muscular
in pregnancy
TT-2* 4 weeks 0.5 ml NO Intra- Upper Arm
after TT-1* muscular
TT- Booster If received 2 0.5 ml NO Intra- Upper Arm
TT doses in muscular
a pregnancy
within
the last 3
years*

Vaccine Due age Max age Dose Diluent Route Site

For Infants
(0.05 ml until YES
1 month) Manufacturer
till one year Intra- Upper Arm
BCG At birth 0.1ml supplied diluent
of age dermal - LEFT
Beyond age (Sodium
1 month chloride)
Antero-
Hepatitis B - within 24 Intra- lateral side
At birth 0.5 ml NO
Birth dose hours muscular of mid-thigh
- LEFT
within the
OPV-0 At birth 2 drops - Oral Oral
first 15 days
At 6 weeks,
till 5 years of
OPV 1, 2 & 3 10 weeks & 2 drops - Oral Oral
age
14 weeks
Pentavalent
1, 2 & 3**
Antero-
(Diphtheria+ At 6 weeks,
Intra- lateral side
Pertussis + 10 weeks & 1 year of age 0.5 ml NO
muscular of mid-thigh
Tetanus + 14 weeks**
- LEFT
Hepatitis B +
Hib)
Fractional IPV
At 6 & 14 Intra- Upper Arm
(Inactivated 1 year of age 0.1 ml NO
weeks dermal - RIGHT
Polio Vaccine)
Rotavirus‡
At 6 weeks,
(Where
10 weeks & 1 year of age 5 drops NO Oral Oral
applicable)
14 weeks
At 6 weeks
Pneumococcal & 14 weeks Antero-
Conjugate
At 9 Intra- lateral side
Vaccine 1 year of age 0.5 ml NO
completed muscular of mid-thigh
(PCV) (Where
months - - RIGHT
applicable)
booster
At 9 YES
Measles /
completed 5 years of Manufacturer Sub- Upper Arm
Rubella 1st 0.5 ml
months-12 age supplied diluent cutaneous - RIGHT
dose ##
months. (Sterile water)
Japanese
YES -
Encephalitis –
At 9 Manufacturer
1 @ 15 years of Sub- Upper Arm
months-12 0.5 ml supplied diluent
(Where age cutaneous - LEFT
months@ (Phosphate
applicable)
Buffer Solution)
5 years of
Vitamin A
At 9 months age 1 ml - Oral Oral
(1st dose)
( 1 lakh IU)

When to
Vaccine Max age Dose Diluent Route Site
give
For Children
Antero-
16-24 7 years of Intra- lateral side
DPT Booster-1 0.5 ml NO
months age muscular of mid-thigh
– LEFT
YES
Measles / Manufacturer
16-24 5 years of Sub- Upper Arm
Rubella 2nd 0.5 ml supplied diluent
months age cutaneous - RIGHT
dose ## (Sterile water)
16-24
OPV Booster 5 Years 2 drops NO Oral Oral
months
Japanese
YES
Encephalitis –
Manufacturer
2@ 16-24 till 15 years Sub- Upper Arm
0.5 ml supplied diluent
(Where months @ of age cutaneous - LEFT
(Phosphate
applicable)
Buffer Solution)
At 16
Vitamin A $
months. up to the 2 ml
(2nd to 9th
Then, one age of 5 (2 lakh IU) - Oral Oral
dose)
dose every years
6 months.
7 Years of Intra-
DPT Booster-2 5-6 years 0.5 ml NO Upper Arm
age muscular
10 years & Intra-
TT 16 Years 0.5 ml NO Upper Arm
16 years muscular
* Give TT-2 or Booster doses before 36 weeks of pregnancy. However, give these even if more than 36 weeks have passed. Give TT to a
woman in labour, if she has not previously received TT.
** Pentavalent vaccine is introduced in place of DPT and HepB 1, 2 and 3.
‡ Rotavirus vaccine is being in troduced in phases.
## MR vaccine introduced in phases replacing measles vaccine in the UIP schedule. If first dose delayed beyond 12 months ensure
minimum 1 month gap between 2 MR doses.
@ JE Vaccine has been introduced in select endemic districts. If first dose delayed beyond 12 months ensure minimum 3 months gap
between 2 JE doses.
$ The 2nd to 9th doses of Vitamin A can be administered to children 1-5 years old during biannual rounds, in collaboration with ICDS.
¾¾ Human Papilloma Virus (HPV) Vaccine – presently not in schedule.
¾¾ Td - Tetanus diphtheria to replace TT - to be added in schedule
The goal of UIP is to provide every child and

pregnant woman protection from vaccine
preventable diseases

Unit 3 : Microplanning for immunization services
3
Microplanning
for immunization
services
RI microplanning is the basis for the delivery of RI services to a community. The availability
of updated and complete microplans at a planning unit (urban/rural) demonstrates
preparedness of a unit and directly affects the quality of services provided. Microplans are
prepared for a one year period but must be reviewed every quarter.
Common RI microplan issues found in the field
• NO microplan available, RI sessions conducted unplanned
• Not aware of the need for mapping and microplanning
• Formats / guidelines not received from district/state
• Microplans prepared by ANMs/health workers not reviewed
• Not aware about method of estimation of beneficiaries
• Logistics calculation was not based on due beneficiaries
• Available at the PHC but not in use.
• Vaccine distribution done on last minute estimation.
• Available but not updated with information on HRA sites
• Recently settled nomadic population not updated in RI microplan
• Not taking into consideration vacant SC
• One microplan is in the computer and a different microplan is used during RI days.
Improving the RI microplan helps to:
• Define the area and population covered by each SC
• Prevents/reduces dropouts
• Prevents left outs
• IdentifiesHRAs/HRGs including nomadic populations
• Increases the RI coverage
• Strengthens capacity to use data for action.

Levels of RI microplanning
The levels of the health system from the Sub Centre (SC) to the state level is shown in Fig. 3.1.
Microplans begin at the SC level and cascade to the district level through the Primary Health
Centre (PHC). A sub centre microplan must incorporate all the villages and areas under its
administrative area. The PHC microplan incorporates the SC information which is essential
for planning and logistics management . Information from PHCs is to be consolidated at the
next level which may be the taluk in some states and then to the district or directly to the
district in others. Fig 3.2 shows the RI microplanning from SC to district level.
Health system
Fig. 3.1. Levels of the health system
State
State
District
District
Taluk / CHC
Block / PHC
Primary Health Centre / Urban
UHC Planning
Health Centre Unit
Sub Centre / Urban health post

Sub-Centres/Urban Centre
Villages / hamlets / wards

Fig. 3.2. RI microplanning from SC to district

Components of an RI microplan
An RI microplan is an integrated set of components to:
• enlist and map all villages/wards/tolas/HRAs
• identifiy all beneficiaries for RI services through surveys
• estimate and plan the vaccine and logistic requirements including modes of delivery
• preparation of plans for a strong RI service delivery.
An RI microplan consists of a number of formats and documents at various levels. Availability
of all the components at the relevant levels will facilitate effective implementation. Table
3.1 lists the components for microplanning in RI at each level.
Table 3.1.List of components for microplanning in RI at each level
Level Components of RI microplan

SC/Urban Health Centre a) Map of area under SC with names of villages,
urban areas including all hamlets (tola), sub-vil-
5,000 population in rural and lages, sub-wards, sector, mohalla, hard to reach
10,000 – 12,000 population in areas, etc.)
urban areas b) Demarcation map – allocate areas for each ANM
if more than 2 ANMs are present in a SC. It can
(ANM to coordinate activities also show the exact boundaries and areas for
with ASHA & AWW at least 2 ASHAs and AWWs
days before session) c) Master list of the area– this list includes all villag-
es/tolas/HRAs/wards/mohalls
Responsible person : ANM d) An estimation of beneficiaries
e) An estimation of vaccines and logistics
f) ANM work plan including mobilization plan
PHC/Urban Planning unit a) Map of PHC showing the SC area demarcation
b) RI microplans from all SC
Responsible person : Medical c) Alternate Vaccine Delivery (AVD) plan and route
officer in-charge / RI nodal MO chart
d) Supervision plan
e) Cold chain contingency plan
f) Immunization waste disposal plan
g) IEC and social mobilization
h) Training plan (if applicable)
i) Budget

District a) Map of district showing all the blocks and PHCs

b) RI microplans from all PHCs – compiled forms
Review PHC plans including c) Supervision plan of district officials
utilization of funds d) Latest Penta 3 coverage chart for the district
e) Distribution and maintenance of vaccines, cold
Responsible person : District chain and logistics including contingency plan
Immunization Officer (DIO) f) District-specific activities for intensification of RI
g) IEC and social mobilization plan
h) Training plan
i) Budget
State a) Map showing the districts
Responsible person : State Ex- b) Compiled district plans
panded Programme on Immuni- c) State specific activities
zation Officer (SEPIO) d) Budget
An updated microplan ensures:

• All boundaries of the catchment area are identified
• Complete maps are in place to ensure that all personnel are aware of their areas and
that no villages or high-risk population pockets have been left out
• All beneficiaries have been identified and information is available on who has to be
vaccinated and with which antigen.
Process of microplanning
The RI microplan is a dynamic tool that requires regular conduction of reviews and surveys
in order to be effective. These activities provide opportunities for planning units, districts
and the state to modify RI microplans based on real-time manpower availability, movement
of beneficiaries and also respond to important coverage and monitoring indicators. Table
3.2 gives the frequency of major RI activities.
Frequency of major RI activities
Table 3.2. Frequency of major RI activities

Frequency Activity
Annually Preparing and generating new RI microplans
Half yearly House to house survey and head counting
Quarterly RI microplan review
Monthly Session due list review at sub centre
Weekly Session due list update after every session

Annually: Preparing and generating new RI microplans including house to house survey and
head counting
• Ensures that all areas are included into the list; confirm the master list of villages and
HRAs.
• Provides actual population and beneficiary counts through house to house survey and
head counting,
• Generates needed information for planning sessions, vaccine and logistic calculations.
This activity is large scale and needs to be synchronized with district.
Half yearly: Only conduct the house to house survey and head counting. This activity will:
• Help to identify any new sites for inclusion / mobilization
• Update the beneficiary due lists for effective mobilization
This activity needs to be supervised and planned in coordination with ICDS and partners
Quarterly: RI microplan review, helps to :
• Update the plans to incorporate information on sub centres where staff is on leave or
if it has become vacant.
• Respond to changes in vaccine delivery and inclusion of new areas - nomads / HRAs
and other issues based on monitoring results.
This activity takes time and requires planning.
Monthly: At Sub centre ANM should
• Review due lists of all the sessions held in the previous month.
• Update coverage monitoring chart to quantify left outs and dropouts.
ANM should share the salient points with the sector medical officer. MO can make plans to
visit Sub centre during this activity.
Weekly:
After every RI session ANM and ASHA/AWW workers should review the session due list,
identify drop-out / left-out beneficiaries and enter their names into the next session’s due
list for follow-up and mobilization.
The medical officer should try to attend a full RI session at least once in two weeks. This is
an opportunity to provide solutions to practical problems in the field.

Microplanning process overview
Microplans should be prepared annually based on head count/survey and be reviewed every
quarter. The steps in the process of developing RI microplans are shown in Figs. 3.3 while
Fig. 3.4 gives an overview of the major activities to be conducted. The process to prepare
new microplans should be initiated when the state/district task force for immunization
decides to conduct this activity. Refer Gantt chart in Fig 3.5 for suggested timelines.
Fig. 3.3. Steps for developing RI microplans
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
Block PHC/UHC Sub Centre level Head count Review & Finalization at
meetings Planning survey at village / consolidation of PHC/UHC
ward SC microplan
 Planning for  Review of SC
 Sensitization head count  Review of formats
meeting with survey  Conducting field formats  Finalize the
MO / ANMs /  Training of the house to master list of
 Review SC
staff ASHA/ house survey areas in the SC
master list
 Sub centre AWW/survey / head
counting  Develop draft  Finalization of
ANM RI or for head SC RI microplan
SC RI
microplan count /
microplan in  SC final
review survey
formats for beneficiary due
meeting
finalization list and
relevant
formats
 Develop
PHC/UHC RI
microplans
Fig 3.4. Overview of major activities in RI microplan development process

Detailed list of activities at RI microplan development
To simplify the process of developing RI microplans, Table 3.3 below enlists in detail the
activities at each step. This table can also be used as a checklist to review the process and
guide the actions of medical officers and ANMs.
Table 3.3. Steps and activities for RI microplanning
Steps Activities
STEP 1 • Confirm area demarcation of subcentres
Block PHC/UHC meet- • Confirm area demarcation among ANMs, especially in subcen-
ing– tres where more than one ANM is posted.
¾¾ Orientation meeting • Generate a master list of villages/areas, Include ALL areas in RI
¾¾ ANM RI review meet- microplan
• Record sub centre wise information
ing- review of existing
microplans & inclu- • Use data on SC performance
sion of all areas • Conduct training of ANMs for area survey
• Prepare SC plan for head count / survey
STEP 2 MO to decide venue of meeting– at each SC or if at PHC then
Planning for SC level conduct with only 2 to 3 SC combined at a time
head count survey and • Confirm area demarcation between ASHA, AWW /LW/ surveyor
training of ASHA/AWW/ • Create working maps for each area
Link worker/Surveyor • Conduct training to undertake head count & generate benefi-
ciary list
• Plan to walk through areas to ensure clear area demarcation/
HRA identification
STEP 3 • As per the plan, the ASHA/AWW/LW/Surveyor with assistance
House to house sur- from mobilizers will conduct the area survey. This is NOT to be
vey village/ward level done on RI days.
-ASHA/AWW/Surveyor • During the survey
Maximum of 25 to 30 houses should be covered per day.
Collect information of pregnant women, infants and children.
Survey to be completed in 7 to 10 days
• Generate beneficiary list for the village/ward
• Ensure monitoring of the process by ANM , ICDS supervisors,
Sector Medical Officer, any other

STEP 4 Conduct review meeting at SC – involving AWW /ASHA / Link

Review & consolidation worker / surveyor. Sector MO oversight will be beneficial.
of the Sub centre mi- ANM to:
croplan • Review completeness of all formats of the area
• Review the master list of areas in the SC
• Review the area of demarcation
• Review the number of HRA in the SC
• Review lists of identified beneficiaries
• Develop SC RI microplan for finalization
• Develop community mobilization plan for each session site and
sub centre area
STEP 5 • Finalization of area demarcation of ANMs
Review and finalization • Finalization of areas and HRAs in all SC microplans
of SC plans and develop- • Review of all SC formats and approval of microplans
ment of final block PHC • ANM to complete filling of all SC formats and submit
plan • Develop the session due list for RI sessions
• Ensure availability of beneficiary due listing for all sessions
• SC Maps availability
• Development of PHC RI microplan

WORKING DAYS
Activities for developing RI microplans
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34
1 Decision in DTF-I on RI microplan revision
2 Meeting of district officials
3 Communication of dates and activities to PHCs
4 PHC meeting - Sensitization meeting for MOs and ANMs (Step 1)
Immunization handbook for Medical Officers

5 PHC meeting - ANM RI microplan review meeting (Step 1)
Subcentre planning meeting - for Survey - Plan finalization and

6
training of all surveyors (Step 2)
7 Conducting house to house survey (Step 3)

Fig. 3.5. Timeline of activities in RI microplanning
SC meeting - review of all formats & preparing of draft RI

8
microplan (Step 4)
9 PHC meeting - SC microplan finalization with ANMs (Step 5)
10 ANMs complete and submit Forms 6 to 11 (Step 5)
11 PHC Forms 12 to 18 followed by submission to DIO (Step 5)
This Gantt chart is indicative of average times needed for the major activities in developing the RI microplan. Variations are a
reality and reasonable timelines specific to your area can be decided in discussion with district/colleagues.
29
• Block PHC/UHC meeting – Sensitization and Review of existing

Step 1 microplans
Step 1 of the process for developing/updating the RI microplans involves 2 meetings:

1. A sensitisation meeting of all MOs, ANMs and other staff
2. ANM RI microplan review meeting
1. Sensitization meeting at PHC/Urban health center:
Call for a meeting at your PHC/ UHC to bring the focus on routine immunization and the
process.
This meeting will:
• Sensitize all the staff on the process and their roles in RI microplanning
• Delegate activities to specific personnel with timelines
• Encourage discussion on issues
• Train ANMs on use of formats and conduction of head count / survey
• Finalize dates and schedule for the meeting with ANMs at PHC
In setups with multiple medical officers (Block/PHC/UHC): Conduct a meeting of all the
MOs and ANMs to inform them of the plan for improving / updating the RI Microplan.
Demarcate area of the PHC into sectors and allot each to a MO for supervision and follow-
up. Sensitize them of the need for this activity and the process. Define roles; give specific
responsibilities with reasonable timelines. Give specific responsibilities with focus on “what
has to be done” “by whom” and “when”.
In setups with single Medical Officer (PHC/Additional PHC/UHC): Call for a meeting of all
staff and inform them of the plan for improving / updating the RI Microplan. Sensitize them
of the need, describe the contents of RI microplan forms and address any queries. Give
specific responsibilities with focus on “what has to be done” “by whom” and “when”.

During this sensitization meeting:

For ANMs -
• Distribute at least 2 blank Form 1 sheets to all ANMs. Using the SOP for RI form 1
(page 39) discuss the format with them and ensure they are clear on how to use it.
• In Form 1 explain that a key element is to confirm areas under each subcentre and this
form will become the master list. Ensure inclusion of:
All villages and their hamlets, tolas
Urban/peri-urban areas and their wards/sub wards/mohalla
Migratory and non migratory high risk settlements (slums, constructions sites,
nomads, brick kilns)
• Record each HRA/Brick Kiln etc. in a separate row in the master list of areas
• Train ANMs on the proccess of conducting headcount survey (refer SOP for RI form 3).
• Instruct them to come prepared for the ANM RI review meeting with any RI microplan
documentation available with them
• Finalize a schedule for meeting the ANMs.
2. ANM RI microplan review meeting - as per decided schedule:
This meeting should be conducted in small batches over 2 or 3 days to ensure that each
ANM gets enough time to discuss and bring out issues in the planning process for RI.
The agenda points for discussion with each ANM must include -
a. Clear area demarcation for each sub center and ANM area
b. Review of Form 1 – master list
c. Proposing plan for missed areas, vacant sub centers including plans for areas
without ANMs
d. Prepare maps (this will require a realistic timeline) also refer Unit 12
e. Assess adequacy of RI sessions
f. Proposing a communication plan
g. Any other issues related to RI microplanning
This step should not be completed in a SINGLE meeting – 2 to 3 days

will be required, which need not be consecutive days. Plan these days
taking into consideration all other activities and develop a schedule so
ANMs can plan well.

Participants :
• Sector MO, Health supervisors, LHV, ANMs, key persons assisting MO/IC, Block program
manager-National Health Mission, CDPO, ICDS supervisors etc.
• Immunization Field Monitor / WHO-Field monitor/SMNet partners where applicable
Preparations for the ANM RI microplan review :
The data manager of the PHC should generate the needed data for the PHC and each SC.
Data to be used: Review monitoring and coverage reports to identify issues in provision of
immunization services with special emphasis on HRAs. Some suggestions are given below:
a) Vacant sub-centre areas
b) Areas with no sessions planned
c) Areas with no mobilizer assigned
d) Sessions with poor mobilization
e) Where planned sessions were not held
f) Areas with low coverage
g) Status of due-list updating, especially for migrants and new-borns
h) Inadequate supply of vaccines and logistics
i) Any serious AEFI
j) Staff position of ANM, AWW, ASHA, Supervisor etc.
k) Status of AVD/transportation (vehicle breakdown etc.)
Calculation of drop-out figures for each subcenter will help in identification of issues.
However, this may not reflect specifically to each RI session site or village. Few suggested
differences to be calculated per subcentre are between BCG and MCV1; Penta1 and Penta
3; MCV1 and MCV2; Penta 1 and OPV1 and Penta 3 and OPV3. Refer Unit 7 for details.
Table 3.4 below provides some of the data sources that can be used to help in planning the
RI microplan . However, this is not an exhaustive list and if other data sources are available,
they may also be used to compare information.

Table 3.4 - Sources of information for listing of areas and beneficiaries

Information / MOIC ANM ICDS Super-
Data required visor
Geographic List & map
List & map of villages of villages
List & map of villages
including hamlets /urban including
including hamlets /
areas/wards (SC catchment hamlets /
urban areas/wards
area) urban areas/
wards
Demographic 0 -6 years
Total & beneficiary Total & beneficiary registers,
population (Census/ population (service records), eligible
revenue records) migrants couple
register, etc.
Programmatic Existing sub centre RI
Existing RI microplans,
microplans, Polio microplans,
Polio microplans,
monitoring feedback,
monitoring feedback, VHND
Mission Indradhanush
Mission Indradhanush microplans
microplans (where
microplans (where
applicable) List of HRAs,
applicable) List of HRAs
VHND microplans
Administrative Staff vacancy to ASHA/ Mobilisers list to AWW/ helper
identify vacant SC identify villages for focus list
Epidemiologic VPD outbreaks VPD data
Social mapping NGOs, Practitioners,
Influencers, Possible session
Community centres,
sites
schools
Suggested questions during ANM RI review meeting:
• Are all areas identified and included in the SC plan?

• Where are the unreached populations?
o Areas with highest number of unimmunized children
o Areas with mobile/migrant populations
• Where are the hard-to-reach populations?
o Low coverage areas
o Accessibility compromised areas

• Where is the population?

o Are there areas/villages with large population?
o Border/peri-urban areas?
• Are there problems with access to immunization services?
o Catchment areas with Penta or other antigen <80%
• Where is utilization of services low?
o Areas with high drop-outs
Outputs expected from this meeting:
• Master list of all areas for each sub centre in Form 1
• Plan for conducting house to house survey for each Sub centre
• Timeline for conducting the house to house survey / head counting
Roles and responsibilities:
Personnel Activities to perform Follow up by
• Preparing for and
conducting first meeting at
MO/Ic PHC DIO
• Conduct SC RI review with
few ANMs per day
• Actively participate in first
meeting at PHC
Sector MO Medical Officer in charge
• Review progress of SC areas
in allotted sector
Generate village list for each SC
Sector MO / LHV /
ANM in coordination with frontline
designated ANM
workers for the meeting
Sharing of village list and AWW
CDPO BPO
centre details
ICDS supervisors Provide information on any CDPO
areas / populations that may be
overlooked
DIO – District Immunization Officer; BDO – block development officer; LHV – lady health visitor
Each of the steps in the following pages includes detailed explanation

of the RI microplanning formats to be used for each activity

Overview and utility of the RI formats
A set of formats have been developed to collect and collate data to prepare RI microplans
for an area . The table 3.5 below enlists these formats and the information they collect.
Table 3.5. RI microplanning formats and utility
Level of use RI Form Utility
1 • Master list of all the villages in sub centre
PLANNING FORMS area
to be filled by ANM • Plan for conduction of survey
2 Sub centre map
3 Enlists all houses and occupants with focus on
SURVEY FORMS
pregnant women and children in the age group
Used In the Survey by of 0 to 2 years
4 Enlists details of identified pregnant women
ASHA / assessor area
5 Enlists details of infants / children identified
6 RI Session beneficiary due list (to be made after
SC microplan is approved by MO)
SUB CENTRE FORMS 7 RI session plan
8 RI Session injection load and vaccine distribution
To be filled by ANM
plan
9 Per session estimation of vaccines & logistics
10 ANM work plan / roster
11 Communication plan for SC
12 SC workload and Sessions plan
13 PHC vaccine delivery plan including alternate
vaccine delivery plan
14 PHC vaccine and logistics per sub centre
PHC FORMS
15 PHC – RI session supervision plan
16 Emergency plan for vaccine storage
17 Bio-medical waste management plan
18 Communication plan for PHC/UHC

Overview of RI Forms 1 and 2

Basis for
Area Survey
Village / area conducting
RI Form 1 Master list
planning
house to house
template
survey
Map of Sub
RI Form 2 centre area

SUB CENTRE AREA MASTER LIST and SURVEY PLANNING FORM RI Form 1
Sub centre name:__________________

ANM Name/Ph No.:________________________ PHC Name: ________________________ District:__________
FILL AFTER Survey - FOR ANM USE ONLY
Total
number of Name of ASHA Name and contact
Name of Villages / Hamlets / Tolas / HRA High Risk Designation (encircle Dates of Survey - Number of Number of
s.no households designated for this number of person doing Total Number of
# Area # applicable) From / To Total new born ( 0 of Infants(1
in this area? survey Pregnant children (1to
Population to 1 month) month to 1
area? Women 2 yr of age)
of age yr of age)
A B C D E F G H I

Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
Y/N ASHA/AWW/Other
TOTAL TOTAL
RI Microplan Form 1 – Sub-centre area survey planning form & Master List
Signature of ANM_______________________ Signature of Medical Officer:_____________________
# 1- Slums with migration; 2 - Nomads; 3 - Brick Kiln; 4 - Construction Site; 5 - Others (fisherman villages, riverine areas with shifting populations, etc.); 6 - Non migratory (settled population), hard to
reach areas
37
SOPs for using RI Form 1
This format is to be used by the ANM of a sub centre area. Each ANM should list the areas
in her sub centre including HRAs/nomadic sites in separate rows.
Column A - Serial numbers are to be allotted to each area. Numbers are not to be repeated
and must be in serial for one sub-centre area. If the areas per sub-centre need to be entered
on more than one sheet, the numbering will continue until the last area for that sub-centre.
Column B- Ensure all the Villages / Hamlets / Tolas / High Risk Areas (HRAs) details are
entered. The classification of the HRAs is given as footer and the relevant number to be
entered in brackets along with the name of HRA.
• For HRAs, (including brick kilns or nomadic/construction sites) each site must be
entered into a separate row. Refer to existing polio microplans, census lists, maps,
high risk area lists, and interactions with ASHA / AWW or Panchayat Raj Institution
(PRI) members to ensure the inclusion of all areas in the sub centre area. This will form
the master list for each sub centre. This is a critical activity. Update this format as
information is received or every quarter. (Refer Unit 12 for details on high risk areas)
Column C – enter the number of houses as per information available. If information is not
available an approximate number can be entered. For areas such as nomadic sites and brick
kilns household numbers are important or approximations must be entered.
Column D, if the entered area is an HRA then encircle “yes”.
Column E, Enter the name of the ASHA responsible for the area.
Column F, the name and contact number of the person who will conduct the survey should
be entered.If the area does not have an ASHA or the position is vacant then, name of the
person who will be delegated to conduct the area assessment should be entered.
Column G, The survey can be done by the local AWW / link worker / others in consultation
with the Medical Officer (MO) ONLY after undergoing training. Enter the relevant designation.
Column H, The area survey is to be completed in seven to 10 days (See Fig 3.5). The dates
for conducting this activity and the persons who will conduct the survey will be decided by
the ANM in consultation with the MO. The From and To dates are to be entered here.
Columns I, The last shaded columns are for use AFTER the survey.

RI Form 2– Sub-centre map
This form provides space for drawing a map of the SC area. A sample map is also given and
health workers are encouraged to put forward simple drawings (see Figs 3.6, 3.7 and 3.8).
The maps should be able to show at least the following:
• All the villages in the SC area, with names
• Shading of parts of a village to demonstrate the ASHA demarcation areas
• Location of the SC
• Location of all RI session sites
• Major roads
• Rivers streams.
• AEFI management centres
Each SC should have a map which helps to clearly demarcate the villages and areas to ensure
that the frontline workers have clarity in operations, and avoid overlap or loss of services
to the beneficiaries.
Encourage ANMs and ASHA to draw simple line diagrams of the areas; it is not necessary to
have elaborate maps. (see next section)
Form 2 – Sub centre area map (Sample)
SUB CENTRE MAP

RI Form 2
ASHA Y
Legends:
PHC
Village A
Sub Centre
RI Session site
AEFI Management
centre River
Village C Village B
Vaccine Delivery
Route
Vaccine delivery
with boat/on foot
Village F
Village D
Village E
Signature of ANM_______________________ Signature of Medical Officer:_____________________

Making maps: updating maps made simple
Maps help to identify borders and areas of administration. They also help to identify areas
that are in dispute or where workers have confusion.
In RI, simple maps are required (see Figs 3.6/3.7/3.8). The capacity to draw varies from
person to person. Encourage your ANMs by showing printouts of the maps given as examples
in this unit or demonstrate how simple line drawings can help them to be more sure and
confident of their areas. Convey this message also to the respective ASHAs and AWWs of
the area in subsequent meetings.
A good start for making maps begins with already existing maps. You should access the
following sources:
• Polio maps
• Maps from local administration, e.g. municipal corporation, land department, election
section, local panchayat
• Local area maps from other sources.
Ask the HWs
(Refer Unit 12 for map utilization)
SC/UHC microplan
microplans including maps.
Ask the HWs to come to PHC with all the required data and guide them to prepare the SC/
Prepare a map of the blo
block/PHC/Urban Planning Unit area,, i.e. map showing the
UHC microplans including maps.
boundaries of SC/UHC, session sites, HRAs and demarcation of areas by each
Prepare a map of the block/PHC/Urban Planning Unit area, i.e. map showing the boundaries
supervisor.
of SC/UHC, session sites, HRAs and demarcation of areas by each supervisor.
Fig. 3.6. Sample
Fig. 3.12.map showing
Sampl
Sample map area demarcation
showing area 1demarcation 1

Update the map of SC
SC/urban health centre showing:
Update the map of SC/urban health centre showing:

• the SC, villages, areas, hamlets and HRAs
• all Anganwadi centres, session sites and session days
• distance from the ILR point and the mode of transport
• landmarks such as panchayat bhavan, schools, roads,etc.
Fig. 3.7. Sample map showing area demarcation 2
Fig. 3.8. A simple line diagram map

• Sub Centre level Planning for head count survey and training of
Step 2 ASHA/AWW/Link worker/surveyor
The finalization of the head count survey plan and the training of the ASHAs/AWWs/Link
workers/surveyors is the second step in the process for developing RI microplans. The role
of Health
the ANMsystem
is to guide the ASHAs and AWWs of the area in order to conduct the survey
effectively and to use of their close ties with the community to identify all beneficiaries.
Fig. 3.9. Sub centre survey planning meeting– personnel and activities
State
District
Block / PHC
UHC Planning Unit
Sub-Centres/Urban Centre
Key components this activity should include:
• Review of area demarcation between ASHA, AWW & surveyors as per Form 1
• Sharing dates of survey and finalize withVillages / hamlets /workers
ASHAs/AWWs/link wards
• Creating working maps for each area
• Training ASHAs/AWWs/link workers to undertake head count & generate beneficiary
list
• If required, plan to walk through areas to ensure clear area demarcation/HRA
identification.
Medical Officer to decide on the venue for holding this meeting:
• At PHC for 2 to 3 Sub centres at a time– about 15 to 20 ASHA/AWW/Link workers in
each batch, OR
• At Additional PHC, OR
• At the Sub centre.
Participants for this meeting : Sector Medical Officers, sub centre ANM, ICDS- lady
supervisor, all ASHAs,AWWs,Link Workers, Mobilizers as well as ASHA facillitator of the
villages in the sub centre.

Preparations
On meeting day
• Share the information and requirements for the meeting with respective ASHAs/
AWWs/link workers at least a week in advance. Encourage them to identify any new
areas that may not have been included or any new nomadic or construction sites in
their areas.
• Each ASHA and AWW should prepare a list of villages/areas as per the available
information. This list should also include the HRAs and any other identified populations
that require special services. Cross check and make corrections in the master list, if any.
• Discuss and plan logistics for the survey – adequate number of formats (Forms 3,4,5) ;
chalk for house marking;
The MO/ANM need to share the status of RI in their area and explain the importance of the
RI microplanning. Aspects that should be covered during the discussions are listed below.
Area demarcation between ASHA, AWW, link worker and mobilizer: Ask each ASHA/link
worker to readout the list of villages/urban areas she visits/has been allocated. The AWWs
of these areas can refer to the list they have prepared and add to or clarify the list of the
ASHA. In some urban areas where AWW workers are not available, other key local persons
can be approached for listing of areas.
Identify areas in each SC requiring a walk-through to verify demarcation and that all HRAs
are included in the list of areas.
Using Form1 distributed during the PHC planing meeting, finalize the personnel who will
conduct the headcounting and the approximate dates for completing the survey (if not
already done). Allow for corrections of the master list at all times. Any information is
important and will benefit the area.
Training of ASHA/AWW to undertake head count and generate due beneficiary list:
Distribute copies of Forms 3, 4 and 5 to each ASHA/AWW. Explain the process (use SOPs of
each form) for conducting the house to house survey of the areas, the information they will
collect and the process for filling up these forms.
Develop a practical timeline considering that a maximum of 25 to 30 houses are to be
covered in one day. This will ensure quality and allow the workers to collect detailed
information on each family. Rushing this process will lead to a compromise in quality.

Creating working maps for each area: Working maps are simple maps (Figs 3.6/3.7/3.8)
which need not be to scale, but provide an overview of the areas with clear lines of
demarcations if there are more than one HW. These maps should be developed before
going out into the area. Finer details may be added to this map during or in the next part of
the process. Refer section on “Making maps” in this unit and also Unit 12.
Walk through of areas to ensure clear area demarcation/HRA identification: Once the
training is completed the MO/ANM along with the ICDS LS should visit some areas. Priority
should be given to those areas where confusion of demarcation exists and HRA areas. A
walk through will bring an agreement on the lines of demarcation and will verify all HRAs
are included in the list of areas. If there are a large number of areas, or the identified areas
are accessibility compromised, the field visit can be covered as per a practical timeline over
a few days.
Before closing the meeting, confirm the dates for the area survey by each person as per
Form 1 and clarifi any doubts of the participants. Coordinate with ICDS supervisors to ensure
monitoring and oversight. Working maps generated can be strengthened with additional
information during the survey. Any changes should be intimated to the concerned ANM and
ICDS supervisors.
Outputs expected
• Confirmed plan for area survey with timelines and names mentioned in Form 1.
• Refined master list of all areas in the SC
• Simple area maps for each ASHA area
Roles and responsibilities
Personnel Activities to be performed Supervisor
MO/Sector • Will support the SC personnel to finalize plan for MOIC
MO area survey
• Supervise the survey with field visits
ANM • Area demarcation for ASHAs/AWWs Sector MO/LHV/
• Develop a reasonable timeline for survey designated ANM
• Will support the ASHA/AWW for survey
• Supervise the survey with field visits
ASHA • Contribute to finalizing the master list SC ANM/ASHA
• Conduct the house-to-house survey facilitator
AWW • Conduct/assist in the house to house survey SC ANM/LS
• Identify beneficiaries/HRAs/missed areas/
dropouts/left-outs

Step 3
• Conducting head count survey at village /ward
The head count survey or house-to-house survey is the third step of the RI microplanning
process. The survey will ensure enrolment of all beneficiaries in an area. It is to be conducted
by the ASHA/AWW/Link worker/surveyor (after training) as specified in Form 1. No person
will conduct this activity without having undergone the training as mentioned in Step 2.
Each ANM will have a list of the SC areas and the dates for conducting the visits. This is to
be shared with the LHV/Ladies Supervisor (LS) of ICDS to enable field visits and monitoring.
Key activities to be conducted:
• ASHA/AWW/LW/surveyor will conduct the survey as per the plan in Form 1. Support
may be sought from local residents while conducting the survey. This survey is NOT to
be done on RI days.
• During the survey
A maximum of 25 to 30 houses should be covered per day.
Information of ALL households to be entered in Form 3.
On identifying a pregnant woman in a household, enter her information into Form 4
On identifying infants and children up to 2 years of age, enter information in Form 5.
Process to be completed in 7 to 10 days per area.
• Monitoring of the process by ANM/LHV/LS/Sector Medical Officer/Medical Officer In-
charge/DIO.
• Involve other departments (e.g. education, PRI, etc.) and block/district administration
in supervision of this activity.
The minimum activities to be conducted are as follows:
Participants
Designated ANM, ASHA, AWW, LW or identified person for conducting the survey, Sector
MO, ASHA supervisor, LS, others.
Preparations
The ANM should review the available lists and maps from Step 2 before beginning Step 3.
During the period of survey, ANM and LS (ICDS) will make coordinated visits to ensure that
the ASHAs/AWWs/LW/surveyors conduct the activity as per the training given.

ANM/ASHA facilitator/LS should verify at least 5 households. Adequate numbers of formats

need to be made available for this activity to make maximum use of the resources in the
field. All queries need to be addressed at the earliest. Upon completion of the activity and
after verification the ANM should sign the Forms 3, 4 and 5.
Use of local mobilizers
It is essential that the ANM interacts with the mobilizers and encourages other influencers
in the village to participate in the survey activity.
Supervision
Sector MOs will visit the areas and provide oversight during this important phase of the
microplanning exercise. An overview of Forms 3, 4 and 5 is given in Fig. 3.10.
Fig. 3.10. Overview of RI Forms 3 to 5
Area house -to-

Used by ASHA/AWW/LW
RI Form 3 house survey
format
during survey
Information on pregnant
RI Form 4 women
RI Form 5 Infant/child information
Outputs expected
• ASHA/AWW/LW/surveyor conducting the survey as per training
• Completion of house-to-house survey
• Forms 3 ,4 and 5 identifying all beneficiaries for each area.
Sector MO Supervise with field visits MOIC
ANM Supervise with field visits Sector MO/LHV/designated
ANM
ASHA Conduct survey and fill Forms 3,4,5 SC ANM/ASHA facilitator
AWW Conduct survey and fill Forms 3,4 and 5/ SC ANM/LS
assist in survey

House to House Survey form
ASHA/AWW-Assessor Name/Ph No.: ________ Sub-Centre name:________ Name of ANM: ____________ RI Form 3
ASHA/AWW-Facilitator Name/Ph No.:______________________
Area Name and No as per Form 1: ________ Date of Visit : dd/mm/yy
First house visited today - House No. :_________ Last house visited today - House No. :________
Name: _____________ Address with landmark:___________________ Name: _________________ Address with landmark:________________________
Family Details Pregnant Woman Children 0 to 2 years - (if YES , go to form 5)
Is there any child aged Is there any child
Is there any Newborn/child
How many family members are living Is there any woman pregnant between aged between
aged less than 1 month
Name of head of family Fathers name in this house? (Include All adults & in the family ? 1 month and 1 year 1 to 2 Years
in the family (if YES , go to
children including new borns) (If YES, go to form 4) in the family (if YES , in the family (if YES , go
form 5)
House number
go to form 5) to form 5)
(as per chullah)

A B C D E F G H
Yes / No Yes / No Yes / No Yes / No

TOTAL Total Yes Total Yes Total Yes Total Yes

RI Microplan Form 3 – Area survey/house to house survey form
Total
Signature of ASHA/assessor:______________________ Verified by ASHA Facilitator (Signature):___________________ Verified by ANM (Signature):________________

SHEET NUMBER :________
47

• Form 3 is to be used when conducting the house to house survey.
• Each sheet must have the area name and number as given in Form 1. The ANM must
instruct the surveyor to enter this.
• This assessment is not to be done on RI days.
• A household is defined based on “Kitchen“ or “Chullah”
• Each sheet has information for 15 households. Multiple sheets for each area will be
required and must be made available.
• A maximum of 25 to 30 houses should be covered per day. Calculations for the number
of days will depend on the timeline as per DTF-I decisions.
Details of the first house visited and the last house on each sheet must be entered in the
space provided. When multiple sheets are used in an area, each sheet must be numbered in
the space provided at the bottom right of the form. The working map of the area prepared
will help in identifying the roads and location of houses. Changes to this map can be made
during the survey.
All houses in the area must be visited and information entered into the form. Each
household is to be identified by a number (Column A). This is the household identification
number. The numbering of households is to be continuous until the area is completed.
The assessment of the area may take more than one day but the numbering of the houses
will be in serial order for the entire area. Restart of numbering will be done when a new
area is being assessed by the same person. House marking should be done with chalk/geru
indicating the serial No of the household and date of survey, as shown in Fig. 3.11.
Fig. 3.11. House marking during house-to-house survey for RI
Interview each household and gather information on the head of household (Column B)
and the total number of members in each household (Column C). This must include all
newborn children.

Next, enquire if there is any currently pregnant woman in this household. This does not
depend on if she is a resident / visitor to the area. Include all pregnant women as each is
a beneficiary. If yes, then encircle yes (Column D) and collect information on the pregnant
woman and enter in Form 4.
Similarly for Columns F, G and H enquire if there is:
• A newborn child
• A child up to 1 month of age
• A child between 1 month and 1 year of age
• A child between 1 and 2 years of age.
If a child is identified in any of these columns, encircle “Yes” and enter information on the
newborn/infant/child in Form 5.

50
VILLAGE/ AREA - Pregnant Women Survey Listing
Name of ASHA/AWW/ assessor: _____________ Area Name and No as IN Form 3: ______________ RI Form 4
Name of ANM:____________________________
Tetanus Toxoid Vaccination Ante Natal Check Up FOR ANM ONLY
Is MCP card Expected date

Name of the pregnant Age in
Husbands name Mobile / Telephone Number available: of delivery/ TT-Booster ANC
woman years (If 2 doses of TT have 1st 2nd 3rd 4th TT due -
Yes / No LMP TT-1 TT-2 due -
been given within 3 years ANC ANC ANC ANC Y/N
of the current pregnancy) Y/N
House No as in Form 3
A B C D E F G H I J
Date/Y/N/DNK Date/Y/N/DNK Date/Y/N/DNK Date Date Date Date
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
RI Form 4 – Pregnant woman information
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
TOTALS
Signature of ASHA____________________________ Verified by ASHA Facilitator (Signature):___________ Verified by ANM (Signature):__________

Form 4 has to be filled when a pregnant woman is identified in Form 3 Column E.

The number in Column A must be the same as that used to identify the household in Form 3.
This number is a unique number that will link the pregnant woman to the house details.
Columns B, C, D and E are for information which identifies the pregnant woman.
Column F. Enquire from the woman if she has been issued a mother and child protection
(MCP) card and accordingly encircle Yes or No. If she does not have a card, then information
should be shared with the ANM of the area to ensure that a card is issued to her during the
next visit.
Column G. Determine the expected date of delivery (EDD) of the child. This can be sourced
from the RI/MCP card if available or from the mother herself. If she is unaware, then
determine the EDD as best as possible by assessing her date of last menstrual period (LMP).
(Surveyor can consult ANM who can refer to the EDD ready reckoner from RCH register/
training manual).
The administration of TT vaccine to PW as per the UIP schedule prevents maternal and
neonatal tetanus; details of the same are to be entered in the three H Columns.
Antenatal check-ups help to identify a high-risk pregnancy and reduce chances of any
complications. Details of these checks are to be entered in the four (I Columns).
Column J. this is for the ANM to enter if the woman is due for any ANC or TT vaccination.
These two columns make it easier for the ANM to extract the information and develop the
beneficiary due list for each RI session.
The dates of administration of TT injections and ANC check-ups should ideally be obtained
from the RI/MCP card.

RI Form 5– list and details of infants / children identified
This form collates all the information of infants/children identified during the house to
house survey.
When filled correctly, this form provides information needed to develop the beneficiary list
of infants/children of the area. Accurate information on the number of children and the
vaccines that they are due for will help to identify which vaccines a child is to receive, and
when.
Column A. The number in Column A must be the same as that used to identify the household
in Form 3. If there is more than one child in a house, the same number will have to be
entered for each of these children.
Columns B, C, D and E. These columns are used to collect identification information of each
child. Attempt to collect the latest mobile number from the parent/household.
Column F - Enquire if the infant/child has been issued an RI/MCP card. If not, information
should be shared with the ANM of the area to ensure that a card is issued at the earliest.
Column G. This records detail of vaccines administered at birth. Dates are to be entered of
when BCG, OPV birth dose and Hepatitis B (within 24 h) were administered.

Column H. Dates of administration of Penta 1, Rotavirus 1 (where applicable), PCV 1 (where

applicable), fIPV 1 and OPV 1
Column I. Dates of administration of Penta 2, Rotavirus 2 (where applicable) and OPV 2
Column J. Dates of administration of Penta 3, Rotavirus 3 (where applicable), PCV 2 (where
applicable), fIPV 2, and OPV3
Column K. Enter the dates of administration of vaccines due between the age of 9 months
and 1 year – MR first dose, Vitamin A, PCV Booster (where applicable) and JE (where
applicable) vaccines
Column L. Record whether the ASHA has received the incentive for the child who is fully
immunized – encircle “Yes” or “No”. A child is to be considered as fully immunized if s/he
has received all the due vaccines up to 1 year of age.
Column M. Dates of administration of vaccines due for a child between the ages of 1 and 2
years are to be entered in column M. This includes MR second dose, OPV booster dose and
JE vaccine (where applicable).
Column N. Has ASHA has received the incentive for the child who is completely immunized–
encircle “Yes” or “No”. A child is to be considered as completely immunized if s/he has
received all the due vaccines up to 2 years of age.

• Review of all survey forms & consolidation of Sub Centre microplans

Step 4
Each ASHA/AWW/LW/surveyor submits Forms 3, 4 and 5 to the ANM after completing the
area survey. Step 4 is to review and collate this information.
ANM should plan for this meeting and inform all participants of the venue, date and time
at least 2–3 days in advance so that they attend the meeting with completed survey forms.
Facilitator: ANM/Sector MO
Participants: ASHA/AWW/surveyor with ASHA facilitator, LHV/LS to attend if possible
Key activities to be conducted:
• Area demarcation to be finalized on map
• Review and refine RI plans as per actual head counts & identification of any missed
(migratory/ settled) pocket in sub centre area
• Ensure functional tagging – areas tagged to existing RI sites should be practical
• Consolidation of Routine Immunization Microplan at sub centre – Form 6,7,8 & 9
• Develop mobilization plans
• Update the map of sub-centre/urban health centre showing:
All HRAs, villages with hamlets, urban areas with wards, sub wards & mohallas
All session sites and session days including Anganwadi centres
Distance from the ILR point and the mode of transport.
Landmarks as Panchayat Bhavan, school, roads etc.
Demarcate ASHA/mobilizer wise areas for social mobilization on map
Preparations
The Sector MO must review the plan of the ANM; timely oversight will ensure the
development of effective RI microplans. MO should guide the ANM and extend support
with visits and reviews.
During the meeting
ANM will review the information collected during the house to house survey in Forms 3, 4
and 5 with the ASHA/AWW/link workers/surveyor. A simple map of the SC can then be made
from the information and experiences of the workers who have completed the survey. This
map need not be to scale, but should include area demarcation for ASHA/AWW/mobilizers
and other information as mentioned above.

As the actual head counts and areas are now available, review and refine the RI session
plans to address the following issues:
• Are the number of sessions presently sufficient?
• Are all the areas covered?
• Are the migrants/HRAs identified? If so, are RI sessions being conducted for these
mobile populations?
Session due list (Form6) –With the information gathered in Form 4 and
Form 5, it is now possible to correctly quantify the number of beneficiaries.
The role of the ANM is crucial in this meeting. The focus must be on three points – beneficiary
list, area finalization and mapping. The ANM Should remember that these tasks require
investment in time and this meeting may take more than one day. RI Form 6 is the session
due list and is best to be filled in Step 5 after finalization of the SC micorplans. A draft may
be prepared but in discussion with MO Planning by the Sectoral MO should take this into
consideration to enable him to attend if possible.
Outputs expected
• Number of new areas identified
• Number of beneficiaries
• Consensus on listing of areas and HRA
• Consensus on demarcation of areas
• Formats collected after cross check and attestation
• Availability of maps.
List of documents after conduct of the SC meeting:
1. Completed RI Form 3 for each area
2. Completed RI Forms 4 and 5 –Beneficiary list – as per ASHA/areas identified
3. RI Form 7– proposed sessions planning for SC
4. Map of the SC – Form 2 showing demarcation of areas for ANMs (if applicable), ASHAs
and AWWs
An overview of RI Forms 6 to 11 used in the SC RI microplan is given in Fig. 3.12.


Sector MO Monitor surveys, review forms in the field MOIC , DIO
Oversee the meeting at SC where possible
ANM Conduct the meeting at SC MOIC ,Sector MO
Finalize area listing and draft of plan for con-
ducting RI sessions in the areas
ASHA Contribute to final forms SC ANM/ASHA facilitator
AWW Contribute to final forms SC ANM/LS
Fig. 3.12. Overview of Sub Centre RI Microplan – Forms 6 to 11
Update
Per session
RI Form 6 due list
after each
RI session
Number of
Calculation of Deciding number
RI Form 7 beneficiaries from
injection load of RI sessions
actual head count
Deciding Vaccine
RI session
RI Form 8 plan
location of distribution
RI sessions plan
Per session estimation of

RI Form 9 vaccines and logistics
RI Form 10 ANM workplan
RI Form 11 Communication plan

RI SESSION DUE LIST PHC: ________________________
Name of Sub-Centre : _____________________
Name Session Site : ______________________ Block : _______________
RI Form 6
Name & No of ANM :_______________________ Name & No of ASHA : ____________________________ Name & No of AWW :
Details of Pregnant Women / Children due for vaccination for RI session After the RI session
**Incentive money
*Incentive money Rs.
Did the pregnant Vaccines which were Rs. 50 will be
Date Of Birth / 100 will be payable
Sl. MCTS Registration Sex Vaccines due in this woman / child administered to pregnant payable to ASHA
Name of Child / Pregnant Woman Expected date of Age Name of Father/Husband to ASHA under Part
No. No. M/F session arrive today? woman / child (If not under Part C.5.B. for
Delivery C.5.A. for Full
(Yes/No) given mention reason) Complete
Immunization
Immunization
A B C D E F G H I J K L
1
2

3
4
5
6
7
8
9
10
11
12
13
RI Microplan Form 6 – Session beneficiary due list
14
15
16
17
18
Total amount received
Out of Village Sick Refused Vaccinated outside Other
Number of beneficiaries who did not attend
Have these beneficiaries been included in the next session? Y/N Y/N Y/N Y/N Y/N
This form is to be filled after finalization of SC microplans with medical officer

Total Number of Pregnant women as per the due list
Total women vaccinated
Signature of ANM Signature of ASHA Signature of AWW Total number of children as per due list
Total children vaccinated
57
This form is the session due list. It identifies the number of beneficiaries per session and
the vaccines for which they are eligible during the RI session. This is also the record of
payment of ASHA incentives.
This format is to be prepared by the ANM with support of the ASHA/AWW/LW after the
proposed microplan is approved by the medical officer.
This session due list will help the ASHA in mobilizing beneficiaries to the session/s. Use
a calendar and share the dates of upcoming sessions with ASHA/AWW/LW in advance to
allow for mobilization.
Form 6 – Note
• This is a session due list and incentive recording sheet
• To be filled after finalization of microplan with medical officer
• ANM to compile the session beneficiary due list from the information
• Where possible, the MCTS number of PW is to be entered
Column A: The serial number for each beneficiary is to be entered here.

Column B: MCTS registration number is to be entered where available. ANM can provide
this information from her RCH register. This unique number will help track the beneficiaries
for complete immunization.
Column C: Name of the child/pregnant woman identified for services during this session is
entered here.
Column D: For children enter the date of birth and for PW the expected date of delivery, if
known.
Column E: Enter the age of the child in months or age of pregnant woman in years and
months.
Column F: Enter the sex of the child.
Column G: Enter the name of the father or husband for easy identification at the village
level.
Column H: Enlist all the vaccines that the beneficiary is due for in the upcoming session.
The following columns are to be filled at the end of the RI session:
Column I: After the completion of the RI session, cross check that all beneficiaries had
arrived, answer as Yes or No

Column J: Enter all the vaccines were received by the beneficiary during this session. If not
received,mention reasons.
Columns K and L: These are to be filled as and when ASHA receives her payments.
Presentation of this form
This format is not to be used singly. Each sheet to be in triplicate (different colours) and
numbered. ANMs should use carbon sheets while filling the form. It is recommended that a
booklet containing enough sheets for one year be printed to enable continuous use of the
information and developing of a realistic RI session due list.
Maintaining the session due list after every RI session

• Who are the children who were due for vaccination today but did not turn up?
• Why did they not turn up?
• Who are the children we did not list for today’s session?
It is essential that the left-out and drop-out children be identified. These children are at
maximum risk as their immunization cover will not be complete and makes them susceptible
to VPDs. Incomplete immunization contributes to child deaths under the age of 2 years.
Therefore, after each session the ANM, ASHA and AWW must review the children who have
not come to the session. The reasons for not coming, once identified, must be addressed
by the team. Seek support from local influencers/key persons to identify any children or
beneficiaries before leaving the session site.
Enlist all children who had not come in for the session conducted, irrespective of the
reason. After these names, enter the names of children who will be due for any vaccine in
the next session. Share this list with the ASHA/AWW/LW so as to give them sufficient time
to visit these houses and use all possible methods to convince the parents or ensure that
the children are vaccinated at the fixed site at the PHC or in the next session.
As per the SC RI microplan, the ANM should remind the ASHA/AWW/LW on the next session
date before leaving the session site.

60
Subcenter / UHC - RI Sessions plan
District: ___________ Block/PHC/Urban Planning Unit: __________________ SC/UHC: _________________
RI Form 7
Name of IO / ICC: _________________________ Mobile no.: _______________ Name of Medical Officer I/C: ___________________ Mobile no.: _____________________
Name of ANM: _______________ Mobile no.: _____________________ Name & Designation of Supervisor: _________________________ Mobile no.: ___________
Beneficiary Targets
Total Population Annual Target (PW Type of area /

Monthly Type of Session -
Name of Villages / Hamlets / Tolas / of Area (Totals of = Actual Head count Monthly Target Number of Name and location of the Session site terrain - plain
S.No Injection Name of the mobilizer Fixed / outreach/
HRA # form 3 Column X2 , Infants =Actual Sessions / sites / hilly /
Head count) Load mobile / tagged
D) riverine
PW Infants PW Infants
A B C D E F G H I J K L M
D/12 E/12
RI Microplan Form 7 –RI session planning form
# 1- Slums with migration; 2 - Nomads; 3 - Brick Kiln; 4 - Construction Site; 5 - Others (fisherman villages, riverine areas with shifting populations, etc.); 6 - Non migratory (settled population), hard to reach areas
Less than 25 injections: One session every alternate month; 26-50 injections: one session per month; more than 50 injections: two sessions per month as per need; For hard to reach areas or less than 1000 population,
where not tagged, plan for sessions every quarter for a minimum of 4 sessions a year ; for a busy PHC/CHC/RH: plan daily sessions.

Enter the serial number and name of the villages in Columns A and B, keeping the same
order as in Form 1. New areas /identified missed areas should be entered towards the end
with clear marking that this is a new area, using an asterisk (*).
Using Form 3 Column D, the individual areas actual population (from the survey) should be
entered into Column C.
The information for Column D is of the annual target of PW in each area.
Annual target of PW = Number of PW identified in the area survey X 2
The information for Column E
Annual target of infants = actual number of infants identified during the area
assessment.
Calculating annual and monthly target population
Beneficiaries in the UIP are the PW and the children of an area who are eligible for any
vaccinations. The cardinal numbers of these beneficiaries is obtained by conducting the area
and house to house survey. Once the survey is completed, these figures will be available
from Form 3.
However, for calculation of the yearly and monthly number of beneficiaries it is necessary
to do the following:
• For pregnant women:
The survey will give the number of PW identified in an area at the time of conducting
the survey.
The annual target of PW = actual number of PW as per head count X2
• For children:
The house to house survey also identifies child beneficiaries. For the calculation of the
annual target the actual number identified is considered.
The annual target of children = actual number of children as per headcount
For columns F and G
Monthly target of PW = Annual target divided by 12
Monthly target of children = Annual target divided by 12

In column H
Enter the monthly injection load for each area.
Calculating injection load (only for determining the number of sessions)
This calculation is to be used only as a planning tool and not for estimation of vaccines or
logistics.
Firstly, determine the total number of injections needed per beneficiary.
This gives a multiplying factor of 15 injections.
• BCG – 1 injection
• DPT – 2 booster injection
• HiB containing Pentavalent – 3 injections
• fIPV – 2 injections
• MR Vaccine – 2 injections
• PCV – 3 injections (where applicable)
• TT– 2 injections (for pregnant women)
For districts where JE is included in the schedule add 2 to the above number, giving the
multiplying factor of 17 injections.
Injection load = Monthly target of children from Column G multiplied by the above factor
Column I
Based on the monthly injection load the number of RI sessions to be conducted for each
village/area is to be entered as per the guideline below.
Frequency of RI sessions depending on injection load –

• 1 to 25 injections – 1 session every alternate month
• 26 to 50 injections – 1 session every month
• 51 to 100 injections - 2 sessions every month
For hard to reach areas or less than 1000 population, where not tagged,
plan for sessions every quarter for a minimum of 4 sessions a year
Column J describes the location of the vaccination site. It is important that the exact location
be entered, preferably with a landmark. This helps to collate the information and makes it
easier to develop the overall plan for RI sessions under the SC area.
Mobilizers play an important role in mobilizing beneficiaries to the RI session site. The name
of the mobilizer is to be entered into Column K.
Column L. Describes the type of terrain as this is a factor that contributes to determining

the number of sessions in the area and the method of vaccine delivery. The areas may be
as follows:
• Plain – flat and accessible with no compromise in accessibility
• Hilly – hilly area
• Riverine – area divided by a river or rivulets making access difficult
• Inaccessible – hard to reach due to absence of roads or is approachable only by foot.
Column M. Describes the type of session. Sessions can be:
• Fixed. These sessions are held where vaccine storage is possible because of availability
of ILR and deep freezer (DF), i.e. the sessions conducted at PHC/CHC
• Outreach. All sessions conducted where vaccine has to be taken by vaccine carrier
• Mobile. Sessions conducted using a vehicle which moves from site to site along with
the immunization team and vaccine
• Tagged. Site/area which does not have a session but is linked to the nearest session
site.
Ensuring “Same day, Same site, Same time”policy will help to

increase community acceptance and in turn the utilization of
services provided.

RI Microplan Form 8 –Per session injection load and vaccine distribution plan

The form contains detailed information on each RI session site in the SC. It also contains
details on frequency of sessions, the villages/areas covered or tagged with each site, the
injection loads per antigen and the vaccine distribution plan for each session.
In Column A, enter the serial number.

In Column B, this is the name of the RI session site.
Enter each RI session site in a separate row. It is important that the exact site location be
entered. This will give the exact planning of sessions for the SC on a single page. If the site
is located in an Anganwadi centre, also include the centre number and location. If the site
is located in private premises, the house owner’s name should also be entered. Include a
landmark where possible.
Column C. This contains the names of areas to which a RI session site provides services.
Enter the names of the village/s or areas as per Form 1. For multiple areas, write the names
separated by commas into this column.
E.g – Village XYZ
The frequency of sessions at this RI site is to be entered in Column D. It may be entered as:
• once in a quarter, i.e. once in three months
• once in two months
• twice a month
• daily.
Column E and F. The target of PW and infants per session is determined for each site.This is
obtained from monthly targets in Form 7 Columns F and G. If the site caters to more than
one area, add the targets. If there are two RI sites in a large village, then the monthly target
is to be divided by 2.
Example – monthly target for each area from Form 7 columns F and G
Village XYZ has 3 PW & 5 infants and tola XYZ has 1 PW & 2 infants for RI site no 1.
Thus for RI site 1 monthly target will be 4 PW & 7 infants.
Village XYZ has 8 PW & 12 infants with two RI sites 2 and 3
Thus for RI site 2 monthly target will be 4 PW & 6 infants and for RI site 3 also is 4 PW & 6
infants
Note: For fixed site use daily average of PW and children vaccinated (number vaccinated
per month/30)

Columns G to Q. Injection load for each antigen is to be entered in Columns G to Q. Using

the target from Columns E and F the individual antigen dose requirement can be calculated
using the formula in the boxes.
Column R. The total injection load for each site is now available to enter into Column R.
This is calculated by adding the number of beneficiaries in Columns G, H, I, K, L, M, N, O, P
and Q. (Note that OPV, Rotavirus vaccine (where applicable) and Vit A should not be
considered as injections.)
Columns S, T and U. These columns show the exact time of RI site functioning for the next
3 months.
Each column is for a month. The day is to be entered as follows:
– Days – Mon, Tue, Wed, Thu, Fri, Sat
– Weeks – 1 to 5
Columns Q, R and S. Columns Q, R and S show the exact time of RI site functioning in the
next 3 months.
Each column is for a month. The day is to be entered as follows:
E.g. If the session is held in Month 2 on the fourth Wednesday, the entry will be “Wed 4” in
Column S.
Each state can customise this format for their own RI days and immunization schedule.
Method of vaccine distribution to each site is to be entered in the three Columns V.
• Information on the mode of transport – two wheeler/three wheeler/four wheeler with
its registration number, if possible
• Name of the person transporting the vaccine and his contact number are to be entered.

RI Form 9 – Per Session estimation of Vaccine and logistics

This format collates the exact requirement of vaccines and logistics (considering wastage)
for each session site. This information is calculated using data from Form 8.
Columns A and B should be in the same order as in Form 8.
Columns C through M, These columns, provide the number of vials/units of vaccine required
for each session site. For the calculations, use the information from columns mentioned
from Form 8 for each session site. (Number of doses x WMF) ÷ no. of doses per vial.
Columns N, O and P - Calculates the requirement of syringes including reconstitution
syringes. Calculation is based on number of vials from Columns C to M of this format.
Remember – only calculate reconstitution syringes for BCG, MR and JE.
In the format wastage factors are given in the row below the names of antigens.
Columns Q to V are to indicate the requirement of other logistics for each session site.
Wastage multiplication factor (WMF)–
This is for use in estimation of vaccine and logistics. It is calculated using the following
equation:
100 divided by [100 – (wastage %)]
E.g. if wastage is 15 %,
100/ [100-15]
100/85 = 1.18
Permissible wastage percentage
Number of doses Permissible wast- WMF

age %
Hep B 1 10 1.11
BCG 1 50 2
DPT 2 booster 10 1.11
OPV 3+2 booster 10 1.11
Rotavirus 3 25 1.33
IPV 1 10 1.11
Pentavalent 3 10 1.11
MR 2 25 1.33
PCV 3 10 1.11
TT 2 10 1.11
JE 2 25 1.33
Syringes As per requirement 10 1.11

Sub Centre - ANM's Workplan RI Form 10
District: ___________________________ Block/PHC/Urban Planning Unit: __________________ SC: _________________
Name & Mobile no. of Medical Officer I/C: __________________________________ Name & Mobile no. of IO / ICC:____________________________
Name & Mobile no. of ANM: _______________________________________ Name & Mobile no. of Sector Medical Officer:___________________________
Location of RI sessions with timing

Month Week Monday Tuesday Wednesday Thursday Friday Saturday

4
5
RIMP – Form 10 - ANM work plan
5
The day columns may be customized for each state or district.
2
Entry of the name of the site and time is to be made against each month.
3
This form is used by each ANM to plan her movement for the next 3 months.
Signature of ANM_______________________ Verified by Medical Officer (Signature):____________________________

69
70
Sub centre communication plan for RI Quarter- 1 / 2 / 3 / 4
RI Form 11
Name of Block:________________ Name of ANM:______________________________ Name of Subcentre:______________________
Name of Village
Nane of Session site 1- 2- 3- 4- 5- 6-
Activities
Miking / drum beating- Name and contact
number
Mosque announcement - Contact person and
number - announcement time
Meetings (Mothers meeting,AWW meeting,etc -
Contact person and number - Monthly / weekly )
VHSC meeting - contact person and number -
location - attended by ANM Monthly / weekly -
enter date
School Rallies - school name and contact person
with number (once a month in villages on
rotation)
Celebrations / Special Days (eg Mothers day,
health day etc) - contact person and number

Wall paintings - locations
Banners - identify 4 key locations - Ensure
display at least one day before RI day
Painting competition / Exihibition - (once a
quarter -school name and contact person with
RI Form 11 - Sub Centre Communication Plan
number
Posters - identify 5 key locations ( other than
Panchayat ghar, Ration store, AWWcentre, Sub
centre, Bus stand) - ensure display at least 2 days
before RI day
Pamphlets / Leaflets - available with - contact
person name and number - distribute before RI
session day
Counselling aids / job aids (flip books etc.,) -
available with - contact person name and number
Other
Manpower involvement - with contact number
Name of ASHA
Name of AWW
Name of Mobilizer / CMC
Name of community influencer
Name of PRI member
Date:____________ Sign of ANM:__________________ Sign of MO:________________________

Form 11 is the communication plan for a SC.
Information to be filled for up to 6 session sites under a SC. Multiple formats may be used
if needed.
A number of activities have been identified; the medical officer should guide the ANM to
identify the activities that can be conducted in her areas. It is important to firstly identify
the contact person who will coordinate the activity such as a school principal or community
leader. Meetings such as VHSC, Mothers meetings, AWW meetings are generally held
regularly and the tentative dates should be entered in the columns. Follow up on the dates
by ANM and if possible the medical officer can support the visits or include them in MO
plan.
With IEC material (Posters / banners) the common issue remains who and where the IEC is
to be displayed. When reviewing the SC RI microplan discuss the locations appropriateness
with ANM and enter the locations in the columns. MO can suggest changes when visiting
the area or during subsequent meetings.
Painting competitions / exhibitions require some planning but have a positive impact on
the community. Encourage the conduction of such activities.
Pamphlets / leaflets / counseling aids are material that can be placed at the AWC or other
locations and used during RI sessions / other meetings.
Having the names and contact numbers of frontline workers of each centre will help the
ANM to contact them in advance of RI session days. PRI / Community influencers can play a
key role in RI and it is essential to identify them in a village or ward area.

• Finalization of Sub Centre plans and development of final block PHC

Step 5 plan
The final step in the RI microplanning exercise at the PHC comprises of two components:
• Component 1 - Review and finalization of the newly updated/ proposed SC RI
microplans and finalization of formats and session due lists
• Component 2 - Development of the final block PHC/UHC RI microplan.
First component: Review of the updated / proposed RI plans
This meeting is to be conducted on the same lines as the first meeting as demonstrated
in step 1. The outputs are now focused on the finalization of SC microplans and the
development of the PHC microplan. Each ANM should present her sub centre microplans
focusing on the following points:
1. Total number of areas identified – any increase or decrease? Form 1
2. Total number of HRAs identified – any increase or decrease? Form 1
3. Demarcation of areas – who will be looking after which area? Form 1 and 2
4. Number of RI sessions planned? Form 7 and 8
5. Are the maps updated? RI Form 2
6. Is sub centre RI microplan now complete?
Each ANM after finalization of the information, plans and forms should compile the
information for her SC. Sector medical officers should review the information for their
respective areas. After review the MO should approve the ANMs microplans including the
number of sessions and the sites.
The ANM can now develop the RI session due lists (Form 6) as per the RI sessions.
Plans from all sub centre are required including those which are vacant and those where
ANM is on leave. It is advisable to review 2 to 3 ANMs per day to allow for other activities
and maintain quality.
The second component - development of the PHC plan comprises of forms 12 to 18 as
enlisted in figure 3.13. Form 12 is made by collating information from individual sub centre
plans (RI form 7 and 8). Remember to include the fixed site session at PHC/Block.
Facilitator: MOIC
Participants: Sector MO,ANM, LHV, Health supervisors

Minimum activities at the final PHC meeting

• Review and finalization of SC plans for
o inclusion of all HRAs
o special plans for difficult areas
o adequate deployment of mobilizers
o adequate session planning
• Compile plans from all SCs to develop block plan
• Prepare vaccine delivery and supervision plan
• Recalculate vaccine and logistics requirement.
Remember
• Every 6 months– Update the available list of all the HRAs in the
block/urban area
• During visits to RI sessions – review existing beneficiary and mobi-
lization lists
• Prioritize block/s having large number of HRAs
• Review monitoring reports and data to identify issues
• Facilitate block level review and revision under guidance of DIO in
priority blocks
• Follow-up the progress during weekly and monthly PHC meetings
Outputs expected
Availability of the following documents after Step 5:
• Forms 6, 7, 8, 9 ,10 and 11 for each SC
• Forms 12 to 18 for the PHC
MOIC Coordination of the activity/reviewing each SC plan DIO
Sector MO Oversee/review the microplans submitted by ANMs MOIC
Data manager Clarify and finalize the names of villages. Data entry for MOIC
generation of RIMP
ANM Generate SC forms and suggest changes to the review- Sector MO
ing officer

Preparation of a block/PHC/urban planning format
At a PHC or UHC, Seven formats provide overview of a PHC’s RI session planning.

Fig. 3.13. Overview of PHC RI Microplan – Forms 12 to 18
Block/PHC/UHC - SC
RI Form 12 workload and sessions
plan
RI Form 13 PHC vaccine delivery plan
RI Form 14 PHC vaccine and logistics
RI Form 15 MO supervision plan
Emergency plan for vaccine

RI Form 16 storage
Bio-medical waste
RI Form 17 management plan
RI Form 18 PHC communication plan
RI form 12 – Block workload and sessions plan per Sub Centre
This format is a one page listing of the SCs and the details of the number of beneficiaries,
injection load, number of sessions and HRAs. This information is a collation of totals of Form
8 of each SC. It gives the workload per SC and the details of number of sessions for the PHC.
For fixed sites – at PHC/CHC/UHC – Remember to include as a separate row entry. To
determine injection load of the fixed session, use monthly average from tally sheets /
register. In very busy centres daily sessions may be held. In form 12 write “Not Applicable”in
the columns for information that is not relevant for fixed site.

BLOCK / PHC - Population and injection load RIMP - FORM 10
BLOCK / PHC / UHC - Subcentre workload and Sessions plan
District: ___________________________ Block/PHC/Urban Planning Unit: __________________ RI Form 12
Name of IO / ICC: _________________________ Mobile no.: _____________ Name of Medical Officer I/C: _____________ Mobile no.: __________________
Estimation of beneficiaries
Annual Target
(Based on actual Monthly Number of
Monthly Target Number of Number of
S.No Name of Sub Centre Total Population headcount) by ASHA Injection sessions per Name of ANM Contact No
Session Sites polio HRAs
/ AWW / ANM etc. Load month
PW Infants PW Infants
A B C D E F G H I J
a/12 b/12

1
10
11
12
TOTAL
Signature of Nodal Medical Officer - Immunization - ________________ Signature of Medical Officer I/c- ________________
75
RI Form 13 - Vaccine Delivery Plan including Alternate Delivery.
Vaccine Delivery System refers to the independent person who delivers the vaccine carrier
from the PHC to the session site. The ANM has to directly reach the session site in order to
maximize the use of her time. It helps to start the session on time, and the HW does not have
to come to PHC to collect or return vaccine and other logistics to the PHC at the end of the
session. Prepare the AVD plan and route chart for alternate vaccine (and logistics) delivery
(AVD) to the session sites from the nearest cold chain storage point for each session day.
Site 5
RI Form 13
Mobile no.: _____________
Site 4
Signature of Cold chain handler - __________________

Block/PHC/Urban Planning Unit: __________________
Site 3
Name of Medical Officer I/C: _____________
Site 2
PHC - VACCINE DISTRIBUTION PLAN INCLUDING ALTERNATE VACCINE DELIVERY
Site 1
1/2/3/4/5
Week no -
Mobile no.: _____________
___/___/_
Day -
__
District: ___________________________
___/___/___
Month -
Signature of Nodal Medical Officer - Immunization - ________________

Contact number
Name of IO / ICC: _________________________
Name of person responsible
10
11
12
13
14
15
1

RI Form 14 - Block / PHC Monthly requirement of vaccines and logistics
This format provides a single sheet to view the requirement of vaccines and logistics for the
entire PHC.

78
Health Centre MO Supervision plan
District: ___________________________ Block/PHC/Urban Planning Unit: __________________ RI Form 15
Name & Mobile no. of Medical Officer I/C: __________________________________ Name & Mobile no. of IO / ICC:____________________________
RI session sites and Medical Officers assigned for supervisory visits
Month Week Monday Tuesday Wednesday Thursday Friday Saturday
4
5
RI Form 15 - Block medical officer supervision plan
Signature of Medical Officer_______________________ Verified by Medical Officer (Signature):____________________________

Prepare the supervision plan for a quarter at the Block/PHC/Urban planning unit level.

RI Form 16 - Emergency plan for vaccine storage
At your PHC/Urban Planning Unit, prepare a plan for safely storing vaccines during
equipment breakdown or electricity failure and display in the cold chain room.
RI Form 17 - PrepareWaste Management plan

BIO-MEDICAL WASTE MANAGEMENT PLAN
PHC / UHC:___________________________ Date: __/__/____ RIRIForm
Form 1717
Name of the outsourcing agency : _____________________________
Name and contact number of agency supervisor:_____________________________
Name and contact number of agency waste collection person:
At PHC/Urban planning unit:
Name and contact number of nodal medical officer :______________________________________________
Name and contact number of coordination personnel:____________________________________________
Name and contact number of ANM coordinator :__________________________________________________
BMW mechanisms at unit
Location
Identified RI session sharps recovery point Y/N
identified Disinfection corner/point Y/N
Sharps pit location Y/N
Y/N
Availability of IEC material on BMW :
Location
@ OPD Y/N EMERGENCY Contact:
@ Injection Room Y/N 1
@ OT (Minor / Major / Labour)
Labour) Y/N 2
@ lab (Liquid waste management) Y/N 3
@ Y/N
@ Y/N
Signature MO/IC :___________________________________ Signature Nodal Officer :______________________________________

RI Form 18 – Communication plan for PHC/UHC

PHC/UHC Block level communication plan for RI
RI Form 18
Name of Block:________________ Quarter- 1 / 2 / 3 / 4
Activities
Meetings with Block Panchayat / BDO
Local Press agency / journalist- Names and

contact numbers
Meetings with NGO/Community

groups/institutions
Other
IEC material and display plan dispatched for display
on:__/__/____
Received on: __/__/____ to:
Banners -
Quantity: ____
on:__/__/____
Posters -
Quantity: ____
on:__/__/____
Pamphlets / Leaflets
Quantity: ____
on:__/__/____
Counselling aids / job aids (flip books etc.,) - Received on: __/__/____ to:
available with - contact person name and number Quantity: ____
Received on: __/__/____

Other
Quantity: ____
Name & contact number of PRI Chairman
Name & contact number of BDO
Name & contact number of BEO

Date:____________ Signature of MO:________________________

This communication plan has been designed with the objective of collating the information
necessary at a PHC level to give an overview of the opportunities available to the MO and
staff to enhance immunization coverage. The plan can be made for each quarter with
tentative dates. At times it may not be possible to give exact dates however it may be
possible to identify a person or time when the dates could be confirmed.
Activities: the sub headings are indicative and medical officers are encouraged to identify
any other meetings that could be utilized for vaccination advocacy or enhance community
support for RI.
Meetings with Block Panchayat/BDO – the PRI is an important part of RI strengthening
and their meetings are held regularly. Interactions with the BDO are essential as they are
involved in community development and directly interact with community leaders.
Local press agency / journalist – this list will be useful to disseminate information through
channels of mass media. They can also be of help during emergencies or any AEFI. Discuss
with the CMO/DHO/DIO to ensure clear messages.
Meetings with NGO/community groups/institutions - wherever possible engage with
organizations working with communities or NGOs or institutions such as colleges , medical
colleges, industries in the area for support for RI.
Other – any other organizations or meetings
IEC material and display plan
Hoardings – identify points for display of hoardings and or banners – list main areas such as
bus stops , market places or prominent locations.
Banners – enter the number and date of receipt of any banners and who will be responsible
to ensure timely display. If banners are distributed to SC ensure entry of the same in Form
11 of each ANM.
Posters – enter the number and date of receipt of any banners and who will be responsible
to ensure timely display.
Pamphlets / leaflets – same as above
Counselling aids / job aids etc. Enter the number and date of receipt and ensure distribution
at the earliest.
Other – refers to other IEC material such as polio posters or other campaign posters.
Contact numbers of PRI Chairman, BDO and BEO - ensure numbers are up to date.

Table 3.7 Checklist for RI microplan components – all levels

Available
Level Components of Routine Immunization Microplan
Yes No
Sub-cen- Map of area -with name of village, urban area including all hamlets
tre (tola), sub-villages, sub-wards, sector, mohallas, hard to reach areas,
etc.)
Demarcation Map - This map allocates areas for each ANM if more than
2 ANMs are present in a SC. It can also show the exact boundaries and
areas for ASHA and AWW.
Master list which includes all villages/areas/HRAs
Estimation of beneficiaries and injection load per area
Estimation of beneficiaries and injection load per HRA
Estimation of beneficiaries, injection load and mobilizers per RI session
site
Estimation of vaccines and logistics
ANM work plan including mobilization plan
General information sheet
Beneficiary list - PW and children aged 0-2 years
Session due list
Vaccine coverage chart
PHC/ Map of PHC showing SCs area demarcation
Urban Master list of all areas
planning RI microplans from each SC
unit plan Vaccine delivery plan and route chart
Vaccine and logistics estimation per SC
Vaccine and logistics for entire PHC
MO Supervision plan
Cold chain contingency plan
Bio Medical Waste management plan
IEC and social mobilization plan
Training plan (if applicable)
Latest coverage chart
District Map of district showing blocks/PHCs in district
plan Compiled RI microplans from all PHCs
Supervision plan of district officials
Latest coverage chart for district
Vaccine and logistics estimation per block
Timeline for RI microplan update/beneficiary estimation
IEC and social mobilization plan
Training plan

Unit 4 : Cold chain and logistics management
Cold Chain and

logistics 4
management
Cold chain
Cold chain is a system of storing and transporting vaccines at recommended temperatures

from the point of manufacture to the point of use. The cold-chain system is depicted at Fig
4.1.
Fig. 4.1. Cold chain system
Vaccine Air Transport Primary Store Refrigerated / State Store Insulated Van
Manufacturer (+2° to 8°C (GMSD &/State) Insulated Van WIC (+2° to 8°C) & (+2° to 8°C &
& -15° to WIC (+2° to 8°C) (+2° to 8°C & WIF (-15° to -25°C) -15° to -25°C)
-25°C) & WIF (-15° to -15° to -25°C)
-25°C)
Mother & Sub-Centre/ Vaccine Primary Health Insulated Van District Vaccine
Child Session Sites Carrier (+2° Centre (+2° to 8°C) Store
to 8°C) ILR +2° to 8°C & ILR (+2° to 8°C) &
All Vaccines in ILR DF (-15° to -25°C)
Cold Chain - Key elements
The key elements of the cold chain are:

• Personnel: to manage vaccine storage and distribution (vaccine and cold-chain handler
at each cold-chain point)
• Equipment: to store and transport vaccine and monitor temperature
• Procedures: to ensure correct utilization of equipment and ensure vaccines are stored
and transported safely.

As MO, you need to ensure that cold-chain equipment is functional, storage temperatures
are correctly maintained and recorded and that adequate stock of vaccines and logistics are
available and issued. A vaccine and cold-chain handler (VCCH) is trained and designated to
maintain the cold chain. It is also necessary to look into the dry storage areas, i.e. storage of
syringes and diluents, and ensure that they are safely stored and accessible.
Personnel:
In case more than one MO is posted in the centre, designate one MO for RI, who can also
be the focal point for the cold chain.
Vaccine and cold-chain handler: At every ILR point, designate a senior male or female HW
(pharmacist/staff nurse/ANM/LHV/MPW/health supervisor) as the VCCH. He/she should
be responsible for forecasting, indenting, receiving, storing and distributing vaccines and
logistics, maintaining cold-chain equipment and related records. They will require training
or update of knowledge and skills in order to perform their roles effectively. (refer Handbook
for Vaccine & Cold Chain Handlers)
Equipment and procedures
Cold chain equipment: Cold chain equipment, both electrical and non-electrical, is used
for storing vaccines and/or transporting them at appropriate temperatures. Figure 4.2
summarizes the cold chain equipment supplied under the UIP. The NCCMIS (National Cold
Chain Management Information System) website is the platform where all information on
the cold chain equipment and management is being collated.
Fig. 4.2. Overview of cold-chain equipment
COLD CHAIN EQUIPMENT
TEMPERATURE
ASSOCIATED
STORAGE TRANSPORTATION MONITORING
EQUIPMENT
DEVICES
• REFRIGERATED VAN • THERMOMETER

• INSULATED VAN • STABILIZER • ELECTRONIC
ELECTRICAL SOLAR NON-
• COLD BOX • GENERATOR DATA LOGGER
ELECTRICAL • VACCINE CARRIER • INVERTER • FREEZE
• ICE-PACKS INDICATOR
• REALTIME
TEMP
• WIC SOLAR • COLD BOX MONITORING
• WIF REFRIGE • VACCINE DEVICE
• ILR RATOR CARRIER
• DF
WIC – walk-in cooler; WIF – walk-in freezer; ILR – ice-lined refrigerator; DF – deep freezer

Table 4.1 – Technical specifications of cold chain equipment
Equipment Temperature Storage Capacity Holdover time

Electrical
Deep Freezer -15°C to Ice packs or OPV stock for 3 months At 43°C for 2 hrs 30
(Large) -25°C (275 to 300 Litres) mins (minimum)
BCG, OPV, IPV, RVV, DPT, TT, Measles/
At 43°C for 20 hrs
ILR (Large) +2°C to +8°C MR, Hep-B , Penta, IPV, Vaccine stock
(minimum)
for 3 months (135 to 160 litres)
Deep Freezer -15°C to At 43°C for 2 hrs 30
Ice packs (105 to 125 litres)
(Small) -25°C mins (minimum)
BCG, OPV, IPV,RVV, DPT, TT, Measles/
At 43°C for 20 hrs
ILR (Small) +2°C to +8°C MR, Hep-B vaccine stocks for one
(minimum)
month (90-105 litres)
Non-electrical
Cold Box All vaccines stored for transport or in At 43°C for 96 hrs
+2°C to +8°C
(Large) case of power failure (20 to 25 litres) (minimum)
Cold Box All vaccines stored for transport or in At 43°C for 48 hrs
+2°C to +8°C
(Small) case of power failure. (5 to 8 litres) (minimum)
Vaccine
All vaccines carried for 12 hours At 43°C for 36 Hrs
carrier +2°C to +8°C
(4 conditioned Ice packs & 16-20 vials) (minimum)
(1.7 litres)
Holdover time
In the event of power failure, “holdover time” for any functional healthy cold-chain
equipment is defined as “the time taken by the equipment to raise the inside cabinet
temperature from its cut-off temperature to the maximum temperature limit of its
recommended range”, e.g. in the case of ILR, if the temperature is 4°C, then the time taken
to reach 8°C from 4°C will be the holdover time for that ILR.
Holdover time of ILR depends on the following factors:
• Ambient temperature – more the ambient temperature, less will be the holdover time;
• Frequency of opening of lid and use of basket;
• Quantity of vaccines kept inside with adequate space between the containers
(equipment empty/loaded);
• Condition of the ice pack lining (frozen/partially frozen/melted) inside electrical/non-
electrical cold-chain equipment.
Note: DF does not have holdover time like ILR as it does not have an ice lining inside its wall.
It is dependent on the number of frozen ice packs kept inside it.

ILR point or Cold Chain point:

An ILR point or cold chain point (CCP) is located at a health centre (usually PHC/UHC/CHC)
with an Ice Lined Refrigerator for storage of vaccines and a deep freezer for preparation of
frozen ice packs. The cold chain point must have a generator as power back up.
The function of the CCP point is to receive, store and further distribute vaccines, diluents
and other logistics to another ILR point or directly to the session sites.
Cold-chain room
Keep all electrical cold-chain equipment in a separate room (Fig. 4.3) with restricted entry
to keep the vaccines and cold-chain equipment safe and secure. During visits to the cold-
chain room and the weekly meetings, review the cold chain and vaccine distribution system
of your centre. Ensure proper display of all the cold chain related job aids and use them to
refresh knowledge and skills.
Fig. 4.3. Cold chain room
Fig. 4.3. Cold chain room
Fig. 4.4
4.4. Storing vaccines in ILR

Ice-lined refrigerator (ILR)

A diagrammatic representation of an ILR is given in Fig. 4.4. An ILR maintains a cabinet
temperature between +2°C and +8°C. It is used to store UIP vaccines at the PHC and district
levels. An ILR with a top-opening lid prevents loss of cold air during door opening and can
keep vaccines safe with as little as 8 hours electricity supply in a 24-hour period. ILRs are
available in two sizes – large (for districts) and small (for PHCs).
In case baskets are not available, two layers of empty ice packs can be laid flat on the
bottom of the ILR to avoid contact with the inside floor of the cabinet. Vaccines should
never be kept on the floor of the ILR. Other dos and dont’s for ILR use are given in Table 4.2.
Fig. 4.4. Storing vaccines in ILR
NEVER keep any vials that are expired, frozen or with VVMs beyond the
end point in the cold chain, as they may be confused with those contain-
ing potent vaccines. Keep them in the red bag for disinfection and dispos-
al.
IDENTIFY A DRY SPACE FOR STORING
EXPIRED/UNUSABLE VACCINES BEFORE FINAL DISPOSAL

Table 4.2. Dos and dont’s for ILR use

Dos Dont’s
99 Keep all vaccines including those ¾¾ Do not store any other drugs/non-UIP
returned under open vial policy in the vaccines in the ILR.
basket supplied along with the ILR. ¾¾ Do not open the ILR frequently.
99 Store diluents at +2°C to +8°C at least ¾¾ Do not keep food or drinking water in
24 hours before use. the ILR.
99 Leave space in between the vaccine ¾¾ Do not keep vaccines which have
boxes. expired and have crossed the discard
99 Place a thermometer in the basket in point of VVM.
between the vaccines. ¾¾ Do not disturb the thermostat setting
99 Keep freeze-sensitive vaccines at the frequently.
top of the basket. ¾¾ Do not place heavy weight on the ILR.
99 Keep heat-sensitive vaccines in the ¾¾ Do not store excess stock of vaccines,
bottom of the basket. i.e. more than the maximum stock.
99 Arrange vaccines as per their expiry
dates. (Early expiry should be kept
above the later expiry ones).
Deep freezer (DF)
Freezing ice packs in the DF maintains the cabinet temperature between -15°C and -25°C.
Unlike the ILR, the DF has little or limited holdover time, which is dependent on the number
of frozen ice packs in it (See Fig. 4.5 and 4.6 for correct placement of ice-packs in the DF)
and the frequency of opening (See Table 4.3 for Dos and dont’s on use of DFs).
• At the PHC level, DF is used only for preparation of ice packs.
• At the district headquarters, DFs have been supplied for storage of recommended
vaccines such as OPV and preparation of ice packs.
Table 4.3.Dos and dont’s for DF use
Dos Dont’s
99 Use DF only for preparation of ice ¾¾ Do not keep any vaccine in the DF at
packs at the sub-district level cold- sub-district level
chain points(PHC/CHC/SC) ¾¾ Never keep diluents in the deep
99 Use DF to store OPV at district level freezer
99 Keep frozen ice packs in the vaccine ¾¾ At district level do not use the same
storing DF to increase the holdover DF for simultaneously storing vaccines
time and preparing ice packs

Fig. 4.5. Freezing ice packs in the deep freezer
Freezing Ice-packs in the Deep Freezer
Small
compartment
Arrange and
store frozen
icepacks
horizontally, in
Un-frozen layers.
icepacks
Also store in
for
cold boxes
freezing
Large compartment
Store frozen
Wipe dry and
icepacks only
arrange 20-25
up to half the
unfrozen icepacks
height of the
horizontally (never
large
flat) in a crisscross
compartment
pattern with space
for air circulation
Fig.and
Dos 4.6. don’ts for use ice
Brick layered packs
of DFs in deep
is given infreezer
Table 4.3.Brick-layered ice packs in a DF is

Domestic refrigerators
Domestic refrigerators also maintain a cabinet temperature between +2°C and +8°C with a
holdover time of only 4 hours. Therefore, they are not recommended for common use in
the UIP. However, they are used in urban dispensaries and by private practitioners in urban
areas due to more assured power supply and non-availability of ILRs and DFs.
The refrigerator if used must be:
• Used exclusively for vaccines
• No vaccine should be kept in the compartments of the freezer, chiller, door or basket
of the refrigerator
• Follow the guidelines to store vaccines on the shelves of the refrigerator in the same
order as used for ILR.
Voltage stabilizer
A voltage stabilizer is electronic equipment that ensures a constant output voltage of 220
volts whatever be the variation in input voltage, and thus safeguards equipment from
excessive voltage variation. This is suitable for the working of the ILR and DF. Each ILR or
DF should be connected to the mains through its own independent voltage stabilizer with
proper earthing.
ILR/DF Control panel Remember:

• Glowing of green light
A control panel monitors the temperature/supply voltage and does not ensure that the
operates the cold-chain equipment. It is placed at the front equipment is in running
right bottom side of the ILR and DF. The control panel may condition. Always keep a
close watch on the inside
differ as per the make/model of the cold-chain equipment.
temperature of the vac-
The functions of various components of the control panel are cines stored in the equip-
as follows: ment.
• The temperature indicat-
• Green light: This is an indicator lamp, which shows that ed by the panel thermom-
electric power is available up to the equipment from the eter is not the tempera-
stabilizer. ture of the vaccine.
• Record the temperature
• Red light (in DF control panel only): It indicates that the of alcohol stem thermom-
temperature inside the equipment is not in safe range. eter kept inside the basket
of the ILR.

• Yellow switch (In ILR control panel only): It is a thermostat bypass switch used when
the ambient temperature is more than 45°C or when it requires lowering down inside
temperature quickly.
• Thermometer: Shows the inside temperature of the equipment.
• Thermostat: A thermostat is a component which senses the temperature of inside the
cabinet of the cold-chain equipment so that the system’s temperature is maintained
near a desired set point. The thermostat does this by switching the compressor on or
off to maintain the correct temperature.
Vaccine van
A vaccine van is an insulated van used for transporting of vaccines in bulk. Vaccines should
be transported only in cold boxes with the desired number of conditioned ice packs. These
cold boxes should be loaded in the vaccine van immediately after packing with vaccines and
unloaded at the destination as soon it is reached. Vaccines should be removed from the
cold boxes and placed in the ILR immediately after reaching the destination.
Cold box
A cold box is an insulated box used for transportation and emergency storage of vaccines
and ice packs. It is available in two sizes, large and small. It is used to:
• collect and transport large quantities of vaccines;
• store vaccines for transfer up to 5 days, if necessary for outreach sessions or when
there is a power cut;
• store vaccines in case of breakdown of ILR, as a contingency measure;
• also used for storing frozen ice packs, e.g. during emergencies and before campaigns.
Packing a cold box (See Fig 4.7)
• Place conditioned ice packs at the bottom and sides of the cold box.
• Load the vaccines in cardboard cartons or polythene bags.
• Never place freeze-sensitive vaccines in direct contact with the ice packs. Surround
them with OPV/BCG/JE vaccines.
• Keep a thermometer in the cold box.
• Place two rows of conditioned ice packs above the vaccine vials.
• Place a plastic sheet to cover the ice packs kept on top to ensure full holdover time.
• Securely close the lid of the cold box.

Fig. 4.7.Packing a cold box
Packing a cold box
Ice packs
Ice packs are plastic containers filled with water. These are hard frozen in the deep freezer.
They are placed inside a vaccine carrier and cold box to improve and maintain the holdover
time. They are also used in ILRs as inside lining to improve and maintain holdover time
during electricity failure. Dos and dont’s for use of ice packs is given in Table 4.7.
About 20–25 ice packs (8–10 kg of ice) and 35–40 ice packs (12–14 kg of ice) can be frozen
in one day in small and large deep freezers, respectively. Standard ice packs used in UIP for
cold box and vaccine carrier are of 0.4 litre capacity.
Note: The personnel involved in preparing the vaccine carriers and “conditioned” ice
packs may include other staff of the health centre.
It is essential to train these staff as well on the importance and method of condi-
tioning ice packs

Table 4.4.Dos and dont’s in using ice packs

Dos Dont’s
99 Fill water only up to the level mark ¾¾ Do not use ice packs that are cracked
on the side to leave 10 mm room for and/or are without cap or cork.
expansion as water freezes. ¾¾ Do not use ice packs with leakage;
99 While filling, keep the ice pack vertically discard them.
upwards under the tap so that it will ¾¾ Never add salt to the water as it
overflow after reaching the desired lowers the temperature to sub-zero
level. level, which is not recommended.
99 Fit the stopper and screw on the cap ¾¾ Do not refill an ice pack every time
tight. before use; the same water can be
Space for air
99 Check and ensure that ice pack does not used repeatedly.
Max water level
leak. Cap & Cork
99 Clean the outer surface of ice packs
with dry cloth before putting into the
deep freezer.
99 Keep ice packs horizontally (not flat)
in a criss-cross manner in the DF (brick
layered pattern see Fig 4.7).
99 Keep a gap/breathing space between
ice packs for freezing to be faster and
uniform.
99 Ensure use of conditioned ice packs
Reconstituted BCG and
when storing / transporting RI vaccines. Measles vial
Conditioning of ice packs
Ice packs come out of the freezer at a temperature of about -20°C. They need to be kept at
room temperature for a period of time to allow the ice at the core of the ice pack to rise to
0°C. This takes up to one hour at +20°C and rather less at higher temperatures. This process
is called “conditioning” (Fig. 4.8).
• Conditioning of ice packs prevents freezing of vaccines (freeze-sensitive vaccines such
as Hep B and T series) during transportation.
• Freeze-sensitive vaccines can be damaged if they come in direct contact with the frozen
ice packs.
• At the start of session day, take all the frozen ice packs that you need from the freezer
and close the door. Lay these out on a table leaving a 5 cm space all round each ice
pack.

• Lay out ice packs preferably in single rows but never in more than two rows.
• Wait until there is a small amount of liquid water inside the ice packs.
• Shake one of the ice packs every few minutes. The ice is conditioned as soon as it
begins to move about slightly inside its container.
Fig. 4.8.Conditioning of ice packs
Vaccine sensitivities
Vaccines lose their potency due to exposure to heat (temperatures above +8°C) ,cold
(temperatures below + 2°C) and light .
Reconstituted BCG, measles/MR and JE vaccines are the most heat and light sensitive.
Since these live vaccines do not contain preservatives, there is risk of contamination with
Staphylococcus aureus leading to toxic shock syndrome and, therefore, they should be
used within 4 hours of reconstitution. These light-sensitive vaccines are supplied in amber-
coloured vials.
Under the open vial policy (OVP), any open vaccine vial returned from the field has to be
used within 4 weeks (28 days) from the date of opening, provided the vaccine vial monitor
(VVM) is in usable condition, vaccine has not been frozen and is within expiry date. The

vaccines that come under this policy are Hep B, OPV, DPT, pentavalent, TT and IPV.
Only those diluents that are provided with the vaccine by the manufacturer should be
used. Keep diluents in an ILR at between +2°C and +8°C at least 24 hours before use to
ensure that the vaccine and diluent are at the same temperature when being reconstituted.
Keep diluents with the vaccines in a plastic zipper bag inside the vaccine carrier during
transportation.
Sensitivity of various vaccines to heat, light and freezing is given in Table 4.5.
Table 4.5: Sensitivity of vaccines to heat, light and freezing
Vaccine Exposure to heat/light Exposure to cold
Heat and light sensitive vaccines
OPV Sensitive to heat Not damaged by freezing
Measles/MR Sensitive to heat and light Not damaged by freezing
BCG, RVV and JE Relatively heat stable, but Not damaged by freezing.
sensitive to light
Freeze sensitive vaccines
HepB/Penta/PCV Relatively heat stable Freezes at -0.5°C
(Should not be frozen)
IPV, DPT and TT Relatively heat stable Freezes at -3°C
(Should not be frozen)
At the PHC level, all vaccines are kept in the ILR for a period of one month at tempera-
ture of +2°C to +8°C
Vaccines sensitive to heat
Vaccines sensitive to heat
Vaccines sensitive to freezing
BCG sensitive
Vaccines (after reconstitution)
to heat Most Most
 BCG (after reconstitution) Most Most
 BCG
OPV, sensitive Most sensitive
 Rota
(after
OPVreconstitution) Most
 OPV Vaccines sensitive to heat Vaccines
 HepB sensitive to freezing
IPV IPV
 IPV  BCG Measles, MR
 HepB HepB
 Penta
(after reconstitution) Most Most
 Measles,
MR MR
Rotavirus
 OPV
 Penta
 PCV
IPV
 Rotavirus
Rotavirus  IPV  DPT
HepB
 JEIPV  Penta
 JE  DPT  DPT TT
Penta
JE Measles, MR 
 DPT  Rotavirus
BCG (before reconstitution)
TT  IPV
IPV
 BCG
DPT(before
 JETT, reconstitution)  DPT
DPT
Least
 TT,
BCG (before reconstitution)
Penta,HepB
DPT  TT
Least TT
 Penta,HepB Least
TT,LeastBCG (before reconstitution) Least
Least  TT, sensitive Least
Penta, HepB, PCV
 Penta,HepB sensitive
How to check vaccines for correct maintenance of cold chain
Least vaccines for correct maintenance of cold chain
How to check
Do not keep any vials that are expired, frozen or with VVM beyond the
end
Howpoint in thevaccines
to check cold chain,
forascorrect
they may be confused with
maintenance those
of cold contain-
chain
ing potent vaccines.

How to check vaccines for correct maintenance of cold chain
Vaccines need to be checked both for damage from excessive heat as well as from freezing.
However, the physical appearance of a vaccine may remain unchanged even after it is
damaged.
Checking vaccines for heat damage
VVM is a label containing a heat-sensitive material to record cumulative heat exposure over
time. The combined effect of time and temperature causes the inner square of the VVM
to darken gradually and irreversibly. Before opening a vial, check the status of the VVM
(Fig. 4.9). If the VVM shows change in colour to the end point, then discard the vaccines.
Fig. 4.9. Different stages of vaccine vial monitor
Checking vaccines for cold damage (freezing)
DPT, TT, IPV, HepB and penta vaccines lose their potency if frozen. Moreover, the
risk of adverse events following immunization (AEFIs) such as sterile abscesses may
increase. Freezing can occur at any level in the cold chain. Discard the vial if it is
frozen or it contains floccules after shaking. Conduct the shake test (as given below)
if you suspect that a large number of vials at the cold-chain point could have been frozen.
Information on vaccine sensitivities is given in Table 4.5, Dos and dont’s in cold chain are
given in Table 4.6. (Shake test NOT applicable for IPV)

Shake test - Test vial

• Take a vaccine vial you suspect that may have been frozen – This is “TEST” vial.
Shake test - Control vial
• Take a vaccine vial of the same antigen, same manufacturer, and same batch number
as the suspect vaccine vial you want to test.
• Freeze solid this vial at -20°C overnight in the DF, and this is the ‘CONTROL’ vial and
label accordingly to avoid its usage.
• Let it thaw. Do NOT heat it.
• Hold the Control and the Test vials together between thumb and forefinger, and
vigorously shake the vials for 10-15 seconds.
• Place both vials to rest on a flat surface, side-by-side and observe them for 30 minutes.
• Compare for rate of sedimentation.
• If the sedimentation rate in the ‘Test vial” is slower than in the “Frozen vial”, the
vaccine has not been damaged, it has passed the shake test. Use the vaccine batch – it
is not damaged.
• If the sedimentation rate is similar in both vials or if sedimentation is faster in the
“Test” vial than in the “Frozen” vial, the vaccine is damaged, it failed in shake test. Do
NOT use. Notify your supervisor.
Fig. 4.10: Shake Test Passed - Fig. 4.11: Shake Test Failed -
Vaccine usable Do not use Vaccine
Control Vial Test Vial Control Vial Test Vial
Sedimentation
Information: Types of VVM

VVMs are unique to each vaccine.
There are four types of VVM - VVM 30, VVM 14, VVM 7 and VVM 2. The
number corresponds to the number of days the vaccine remains potent with
exposure at + 37°C. In combined vaccines the VVM corresponds to the most
heat sensitive component of the vaccines, e.g. in DPT vaccine the VVM
corresponds to the Pertussis component of the vaccine.

Preventing freezing of vaccines in extreme cold climates:
• Keep cold chain equipment in heated rooms.

• Do not leave cold boxes outdoors or in unheated rooms.
• Use room temperature water packs for vaccine transport. Fill ice-packs with ordinary
tap water; do not freeze or chill them. In extremely cold conditions, use ice packs filled
with warm water at 20°C.
• Use freeze indicators in all refrigerators and cold boxes, if possible.
• Use a heated vehicle. Never leave cold boxes in an unheated vehicle, especially
overnight.
Storage and Use of Diluents
Only use the diluents supplied/packaged by the manufacturer with the vaccine, since the
diluents are specifically designed for the needs of that vaccine, with respect to volume, pH
level and chemical properties.
The diluents should be stored in the ILR at the last cold chain point. If the ILR has space
constraints then the diluents may be stored outside the cold chain. However diluents must
be kept in ILR at least 24 hours before use or issuing to sessions to ensure that vaccines
and diluents are at same temperature (i.e. +2°C to +8°C) during reconstitution. Otherwise,
it can lead to thermal shock that is, the death of some or all the essential live organisms in
the vaccine. Store the diluents and droppers with the vaccines in the vaccine carrier during
transportation.
Table 4.6: Dos and dont’s in cold chain and vaccine sensitivities
Do’s Dont’s
99 Keep all vaccines in ILR at +2°C to +8°C ¾¾ Do not keep in the cold chain:
at PHC o Expired vials,
99 Use diluent provided by the manufac- o Frozen vials or
turer with the vaccine o Vials with VVM beyond the end
99 Keep diluents in ILR at +2°C to +8°C point
atleast 24 hours before use ¾¾ Do not use Rotavirus vaccines or re-
99 Use Rotavirus vaccine, reconstituted constituted BCG, JE and Measles/MR
BCG, JE and measles/MR within 4 vaccines after 4 hours
hours
99 Discard all damaged vials for disinfec-
tion and disposal

Vaccine carrier
It is an insulated box used for carrying vaccines (16–20 vials) and diluents from the PHC/
cold-chain point to session sites and to bring back the open vials (under the open vial policy)
from the session sites to the cold-chain point on the same day after the session for storage
and subsequent use. Vaccine carrier (with 4 conditioned ice packs) maintains the inside
temperature between +2°C and +8°C for 12 hours, if not opened frequently.
Packing a vaccine carrier
99 Confirm that there are no cracks in the walls of the vaccine carrier.
99 Take out the required number of ice packs from the deep freezer and wipe them dry.
99 Keep them outside for conditioning before placing into the carrier.
99 Place four conditioned ice packs into the vaccine carrier along the sides.
99 Wrap vaccine vials and ampoules in thick paper, e.g. plain white paper before putting
in a polythene bag so as to prevent them from touching the ice packs. Place some
packing material between “T” series vaccine and the ice packs to prevent them from
touching the ice packs.
99 Place the plastic bag in the centre, away from the ice packs. This will prevent labels
from peeling off from the vials.
99 Place foam pad on top of the ice packs.
99 If more than one vaccine carrier is being carried, keep the whole range of vaccines
required for the day’s use in each carrier so that only one carrier is opened at a time.
Correct
Fig 4.12. Correct Packing
packing of of the
a vaccine carrier Vaccine Carrier
1 Prepare Ice-Packs for Freezing 2 Condi on Frozen Ice-Packs
• Fill the Ice-Pack with water to mark. Check
water level before every use. Do NOT add salt • Place frozen Ice-Packs in the open till there is
to this water. liquid water inside the ice packs
• Fit the stopper and screw on the cap tightly • Check if an Ice-Pack has been conditioned by
shaking it and listening for movement of ice inside
• Make sure the Ice-Pack does not leak the ice pack
• Wipe the Ice-Pack dry and place in the Deep • Unconditioned Ice-Packs may damage freeze
Freezer sensitive vaccines (DPT, TT, IPV, Penta and HepB)
3
Pack the Vaccine Carrier
•Place four conditioned Ice- packs against the
sides of the carrier
•Place the plastic bag containing all vaccines

and diluents in the centre of the carrier.
•Place foam pad at the top of ice packs

Table 4.7. Dos and dont’s in using a vaccine carrier

Dos Dont’s
99 Place vaccines and diluents in cartons ¾¾ Never use day carriers, which contain
or polythene bags to ensure labels are 2 ice packs or thermos flasks for
protected. routine immunization.
99 Use only conditioned ice packs in the ¾¾ Never use a screwdriver or any other
vaccine carrier. sharp shaft to open the lid of vaccine
99 Ensure that some ice is present in carrier.
the ice packs while conducting the ¾¾ Do not drop, knock or sit on the
immunization session. vaccine carrier.
99 Ensure collection of vaccines in the ¾¾ Do not leave the vaccine carrier in the
vaccine carrier on the session day sunlight.
itself. ¾¾ Do not leave the lid open once
99 Close the lid tightly and securely. packed.
99 Keep the interior of the vaccine carrier
clean and dry after every use.
Fig 4.13. Placement of vaccines when at RI session site
PCV
Temperature monitoring
Temperature recording is done in order to ensure that the vaccines are kept at recommended
temperatures and the cold-chain equipment is working properly. A break in the cold chain
is indicated if the temperature rises above +8°C or falls below +2°C in the ILR and above
-15°C in the DF. Different type of thermometers and instruments are used to measure the
temperature during storage and transport of vaccines as given below.
Dos and dont’s in temperature monitoring of vaccines is given in Table 4.8.

Alcohol stem thermometer Fig. 4.14. Alcohol stem thermometer
Alcohol thermometers (Fig. 4.14) are very sensitive

and more accurate than dial thermometers. They +500C
can record temperatures from -40°C to +50°C and

can be used for ILRs or DFs. Numbers Numbers
in RED are in BLUE are
Temperature logbook for below

zero (-)
for above
zero (+)
temperature temperature
Temperature logbook (Table 4.8) should be used
to take action to shift vaccines to cold boxes or
other ILRs when the situation requires.
ILR: +2°C to
VVM +8°C
A VVM attached to vaccine vials is also a DF: -15°C to

temperature monitoring device which records -25°C
cumulative heat exposure over time.

-400C
Electronic data logger (30DTR – 30 days
temperature recorder) Do not hold here
Electronic data loggers are being introduced to

monitor the temperature of ILR. An electronic logger is an electronic device placed with
the vaccines; it records the vaccine temperature for 30 days. It has an alarm that alerts the
handlers as soon as the temperature of the equipment Fig. 4.15. Fridge indicator
storing the vaccines crosses the safe range.
Fridge indicator
The fridge indicator (Fig. 4.15) is placed in between
freeze sensitive vaccines (Hep B, DPT, TT, IPV, penta,
etc.)
Freeze indicator Fig. 4.16. Freeze indi-
cator
A Freeze indicator is an electronic device to monitor vaccines
exposed to temperatures less than 0°C. It contains an electronic
temperature measuring circuit with associated LCD display. If the
indicator is exposed to a temperature below 0°C for more than
60 minutes, the display will change from the “good” status “ü” to
the “alarm” status “X”. Once it changes to X, it cannot be re-used
or reset and will need to be discarded. Its shelf life is five years.
Vaccines should never be used without conducting the shake test
when freeze tag shows the “X” mark.

102
Comprehensive Log book for ILR Month & Year:_________________ /_____
Temperature/Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E
-2 and below ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
-1 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
0 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 1 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 2 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 3 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 4 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 5 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 6 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 7 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 8 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 9 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Table 4.8. Temperature log book for ILR
(+) 10 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 11 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 12 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 13 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 14 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 15 and above ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Power failure (in Hrs)
Defrosting & Cleaning Done (√)
Defect Reported to CCT (√)
CCT reported for repair (√)
Type of defect noticed (1 or 2)*
Equipment repaired (√)
Signature of VCCH
PPM Visit by CCT (Signature)
Supervisory visit (Signature)
MOI/C or DIO should review the temp. log book and assess the following parameters once monthly and do stock verification of atleast one vaccine, diluent and syringes
Paremeters Y N Y N Y N
Is the CCE levelled Is the CCE Locked Vaccine are stacked neatly
Is the CCE away from sunlight Is the CCE connected with independent functional stabilizer Vaccine are placed in basket
Is the CCE placed on wooden platform Is the CCE plugged permanently to the socket Vaccine are arranged in FIFO order
Is the CCE atleast 10 cm away from wall Is the CCE has a functional thermometer available Any unusable vaccine (Expired / VVM with Discard point) found?
Is there atleast 10 cm gap between CCE Frost less than 5 mm
Reviewed & Verified by Facility Incharge (Signature/ Inspected during PPM Visit by CCT (Signature/Date) Supervisory visit (Signature/Date)

date)
(* 1 = Major, 2 = Minor)
Real time temperature monitoring device

A real time monitoring device will allow time–temperature monitoring for the recorded
period. Temperature monitoring is done at the device level using a digital display and LED
indicators/buzzer for audio/visual indication that will help local action immediately.
With this type of temperature monitoring data logger having a number of sensors as per
requirement (placed at the top/middle/bottom location in the ILR cabinet), real time
temperature mapping is possible and it will give an alarm at the local level and SMS alerts
to the users in case of temperature excursion.
Table 4.9. Dos and dont’s in temperature monitoring of vaccines

Dos Dont’s
99 Keep one thermometer in each ILR and each DF. ¾¾ Do not take the alcohol
99 Designate VCCH to record the temperature twice stem thermometer out of
daily for ILR/freezer used for storage of vaccines. ILR while taking reading,
99 Keep the booklet of 12 monthly temperature as it is very sensitive.
recording forms on the top of each unit.
99 Write the serial number of ILR/deep freezer on
the top of the temperature record book.
99 Keep the thermometer in between the freeze
sensitive vaccines inside the basket of the ILR.
99 VCCH should sign on the temperature record book
after recording temperature reading.
99 MOIC to record the temperature and sign on the
log book once every week.
99 Preserve the temperature logbook of cold-chain
equipment for a minimum period of three years.
99 Adjust the thermostat switch in different seasons
to maintain the inside temperature of the
equipment well within the prescribed range.
99 Do the shake test for T-series vaccines if
temperature falls below +2°C.

Making an inventory of equipment
An inventory or equipment stock register should have details of cold-chain equipment

such as model number, serial number, company, capacity (volume), date or month of
manufacture, received on, received from and by, document of receipt, bill and details of
warranty. The dates of installation, repair and condemnation should also be mentioned for
individual equipment according to their condition.
Condemnation of cold-chain equipment
Cold-chain equipment which is obsolete or unserviceable should be condemned according

to state government rules by state/district level committees. In the absence of state-specific
rules for condemnation, follow Rule 124 of General Financial Rules (GFR) and GoI decisions
read with Schedule VII of Delegation of Financial Power Rules.
Cold-chain maintenance
Cold-chain handlers are responsible for the day-to-day component of preventive

maintenance, while the cold-chain technician (CCT) is responsible for undertaking minor/
major repairs. Each cold-chain point should keep a logbook to record all the maintenance
and repair tasks undertaken. Some terminologies related to cold-chain maintenance are
discussed below.
Downtime
Downtime means the time period for which the equipment remains out of service. For
example, if an ILR goes out of order on 10 Sept and is functional again on 15 Sept, the
downtime is 5 days. Downtime of cold-chain equipment should be less than 7 days in case
of minor repairs and 21 days in case of major repairs.
Response time
Response time is the time between sending information regarding breakdown to actually
attending. For example, if an ILR goes out of order on 10 Oct and information about the
breakdown is also sent on 10 Oct and a CCT attends to it on 12 Oct to check the defect, the
response time is 2 days.The aim is to maintain a response time of 2 days.
Sickness reporting
An efficient reporting system contributes greatly to reduce the downtime of the equipment.
The reporting should be direct from “who wants the service” to “who will provide the
service” (with intimation to the other officers concerned) using the most reliable means of
communication (telephone, email, etc.), whichever is the fastest for reporting on breakdown
of CCE.

Cold-chain sickness rate
This is the proportion of cold-chain equipment out of order at any point of time.
For example, if there are 100 ILRs/DFs in a district and 5 are out of order (equipment
declared condemned should not be counted), the cold-chain sickness rate on that day is
5%.
The Cold Chain Sickness Rate should always be less than 2% at any given point of time.
Cold Chain sickness rate
= No. of cold-chain equipment (ILR + DF)
non-functional but repairable x 100
No. of cold-chain equipment (ILR + DF)
functional plus non-functional but repairable
Float assembly
A float assembly is a stock of spare ILR/DF units kept at district/state headquarters for
immediate replacement of defective units brought from cold-chain points, similar to a
spare wheel in a car. The defective units, once repaired, go into the float assembly to meet
any future emergency. At district level, following stock should be available in float assembly
to ensure timely replacement:
• 5% of total ILR and DF installed in the district
• 20% of voltage stabilizers (1KVA)
• 20% of stem alcohol thermometers.
Repair
When cold chain equipment breaks down, immediately inform the CCT (Cold Chain
Technician) at the district headquarters directly by telephone, followed by written
communication with copy to the DIO as soon as posible.
Preventive maintenance tasks for cold-chain equipment is given in Table 4.10. A checklist of
preventive maintenance tasks is given in Table 4.11. Suggested alternatives to be followed
in emergency situations is given in Table 4.12.

Table 4.10. Preventive maintenance tasks

For ILR/DF For cold box and vaccine carrier
Daily checkup After every use
99 Outside of equipment is neat and • Clean and dry the equipment
clean • Examine the inside and outside
99 Equipment is level with wooden surface for cracks
planks or wooden stand below each • Check that the rubber seal around the
CCE lid is not broken
99 Temperature recording is done twice • Adjust the tension on the latches (if
daily provided) so that the lid closes tightly
Weekly checkup • Lubricate hinges and locks routinely
99 MOIC signs on the temperature log • Never keep the lid in locked condition
book while not in use
99 Rubber seal (gasket) of the lid/door • Do not leave in sunlight. Keep in shade
fits tightly. If a piece of paper is placed • Do not leave the lid open once packed
below the lid/door, it does not come • Never drop or sit on the vaccine
out easily (paper test). carrier/cold box
99 Defrost if necessary
Monthly checkup
99 Defrost the equipment
CCE – cold-chain equipment
Defrosting and cleaning

Frost formation is a sign of malfunctioning of the equipment, either due to incorrect setting
of the thermostat or incorrect operation of the equipment. Frost increases electricity
consumption and also makes the refrigerator less efficient. The accumulated frost must
be removed, i.e.the equipment must be “defrosted”. This requires technical intervention
as the vaccines are put to risk. It is recommended that the appliance be defrosted every
month or earlier if the frost thickness on the inner wall is Rubber seal
more than 5 mm. (Gasket) ILR/DF
Frost formation increases if:

99 Equipment is opened too frequently
99 Door is not closing properly
No gap.
99 Door seal is defective Should be airtight
99 There is a high level of humidity.
Defrosting requires planning and support with MO oversight.

Troubleshooting
When the inside temperature of an equipment rises above 8°C or falls below 2°C, it requires
to be checked immediately. Please check the following :
¾¾ Is power supply on?
¾¾ Plug placed correctly in the socket?
¾¾ Has the fuse blown?
¾¾ Is there a power failure?
¾¾ Is the setting of the thermostat correct?
¾¾ Is the appliance placed too close to a heat source?
¾¾ Is stabilizer supplying the rated output voltage or has its MCB tripped?

Table 4.11. Checklist for preventive maintenance of ILR/DF

A. External
1 The exterior is clean Yes □ No □
2 It is firm on the floor Yes □ No □
3 It is properly levelled Yes □ No □
4 Its sides are a minimum of 10 cm away from any wall or object Yes □ No □
5 It is away from direct sunlight Yes □ No □
6 The room is well ventilated Yes □ No □
7 Lid is kept locked Yes □ No □
8 Keys are kept at an easily accessible place Yes □ No □
B. Internal
1 Lid seals properly without gap on all sides Yes □ No □
2 Lid seal is clean on all sides Yes □ No □
3 Ice packs are in proper position (for DF only) Yes □ No □
4 Ice packs are filled to the proper level (no leak) Yes □ No □
5 Thickness of frost formation is not more than 5 mm Yes □ No □
6 Vaccines are preserved in neat rows Yes □ No □
7 There is space between rows for air circulation Yes □ No □
8 Freeze sensitive vaccines are kept in basket and not touching any cooling Yes □ No □
surface (for ILRs only)
9 Separate dial/stem thermometer is kept among the vaccines Yes □ No □
10 Reading of dial/stem thermometer is within desired temperature range Yes □ No □
C. Technical
1 Reading on the built-in thermometer of the equipment is within desired Yes □ No □
temperature range
2 Thermostat setting is correct for the desired cut-in/cut-off temperature Yes □ No □
3 Temperature indicated is within specified range. (If not, adjust thermostat to
obtain steady temperature within specified limits (only if user is fully aware about
the setting procedure, otherwise contact the cold-chain technician)
4 One voltage stabilizer connected for each CCE Yes □ No □
5 Input voltage reading ……………….volts Yes □ No □
6 Output voltage reading……………….volts Yes □ No □
7 Plug of voltage stabilizer fits properly and is not loose in the power socket Yes □ No □
8 Connections of equipment to voltage stabilizer are proper and not loose Yes □ No □
9 Compressor compartment and the components inside are clean Yes □ No □
10 Electrical connections are proper (visual checks) Yes □ No □
11 No abnormal sound Yes □ No □
12 Cooling fan (if any) and fan in compressor compartment (if any) works properly Yes □ No □
13 Compressor and fan mounting bolts are tight Yes □ No □
14 Pipe of components are not out of position and not touching others Yes □ No □
15 Temperature is recorded minimum twice a day Yes □ No □

Table 4.12. Suggested alternatives to be followed in emergency situations

Type of Alternatives at Alternatives
Equipment
failure Primary Health Centre at District Level
Power failure ILR • Use alternate source of power Same as recommended for
of longer supply for at least 8 hours in a day. PHC
duration • If it is not possible, then transfer
(more than the vaccines to cold box, which
16 hours in a can hold the vaccines for 72 hours
day) if not opened. At district level, if vaccines
• After 72 hours, if still alternate are stored in freezer,
source could not be arranged, transfer them to cold box
then shift the vaccines to the and store with frozen ice
nearest cold-chain point. packs or commercial ice in
Freezer If vaccines are not preserved in freezer, polythene bags.
no action is required, otherwise
transfer them to cold box.
Equipment ILR • Store vaccines in cold boxes with • Store in cold box with
breakdown conditioned ice packs. conditioned ice packs
(Select • Transfer to domestic refrigerator if • Transfer to other ILR or
suitable available in the vicinity. refrigerator available.
alternative • Transfer to any nearby PHC or • Transfer to any
as indicated) other department’s vaccine other storage facility
storage facility, if available. available.
Equipment Freezer • Freeze ice packs in domestic • Store vaccines in ILR or
breakdown refrigerator/s or in commercial ice refrigerator available
(select factory, if available. • Dispatch vaccines for
suitable • Collect required quantity of frozen PHC using commercial
alternative ice packs from nearby PHC in cold ice.
as indicated) boxes on the day or a day before • Ask CCP recipient
vaccine distribution. of vaccines to bring
• Distribute vaccine using frozen ice packs while
commercial ice. coming for collection.
Voltage Replace from float
Stabilizer • Disconnect the stabilizer and assemblies immediately
obtain replacement immediately from district/regional HQ
from district/regional HQ and stock
reconnect.

Guidelines for use of open vaccine vials in immunization programme
Implementation of Open Vial Policy (OVP) allows reuse of partially used multi-dose vials
of applicable vaccines under the UIP in subsequent sessions (both fixed and outreach) up
to 4 weeks (28 days) subject to meeting certain conditions. This policy contributes to the
reduction of vaccine wastage.
Open Vial Policy is only applicable to DPT, TT, Hep B, OPV, PCV, Hib containing pentavalent
vaccine (Penta) and injectable inactivated poliovirus vaccine (IPV).
Conditions that must be fulfilled for the use of open vial policy
Any vial of the applicable vaccines opened/used in a session (fixed or outreach) can be used
at more than one immunization session up to 4 weeks (28 days) provided that:
• The expiry date has not passed;
• The vaccines are stored under appropriate cold-chain conditions both during
transportation and storage in cold-chain storage point;
• The vaccine vial septum has not been submerged in water or contaminated in any way;
• Aseptic technique has been used to withdraw vaccine doses, i.e. needle/septum has
not been contaminated in anyway;
• The VVM has not reached/crossed the discard point;
• Date and time is written on vial.
DO NOT USE vaccine vial in case any one of the following conditions are met:
• expiry date has passed;
• VVM has reached/crossed discard point (for freeze-dried vaccine, before reconstitution
only) or vaccine vials without VVM or disfigured VVM;
• no label/partially torn label and/or writing on label not legible;
• If date and time is not mentioned on vial;
• any vial thought to be exposed to non-sterile procedure for withdrawal;
• open vials that have been under water or vials removed from a vaccine carrier that has
water;
• vaccine vial is frozen or contains floccules or any foreign body;
• there is breakage in the continuity of the vials (cracks/leaks);
• there is any AEFI from any of the vials; if so, do not use it, and retain it safely and
seperately. Inform MO and/or supervisor.
Open Vial Policy does not apply to measles/MR, Rotavirus, BCG and JE vaccines.

Cold-chain maintenance during vaccine distribution
• Maintain temperature of ILR between +2°C and +8°C for storage of vaccines and
diluents. Monitor temperature twice daily regularly including on Sundays/holidays.
• Note the name of the manufacturer, batch number and expiry date of the vaccine and
diluent in the stock register.
• Ensure proper recording and reporting of vaccine distribution and usage.
• Keep stock upto date, do not over-stock or under-stock vaccines and diluents.
• Multi-dose vials from which at least one dose has been removed may be at risk of
contamination of the vial septum. These vials should therefore never be allowed to
be submerged in water (from melted ice for example) and the septum should remain
clean and dry.
Note: Well-sealed conditioned ice packs should be used in vaccine carriers and water should
not be allowed to accumulate where the vials are stored. Vaccine vials must be transported
in properly locked plastic zipper bag.
Fig. 4.17. Magnifying glass for reading vaccine vial labels
Field tip: Small handheld magnifying glasses were

distributed to all ANMs in a district to enable them to read
the small print of the vaccines vials. This has made it easier
to see the small print and encouraged them to check the
vials before using!!!
• Keep the “returned, partially used” vials in a separate box and label these accordingly.
• Observe early expiry first out (EEFO) policy for issuing vaccines. If the vaccines are of
same expiry date, the partially used vaccine vials should be re-issued. The vial opened
earlier, as recorded on the label of the vial, should be issued first.
• Contingency plan (RI Form 16) has to be in place in case of any exigency like power
failure, equipment breakdown, etc.
Cold chain maintenance during the immunization session
• Inspect vaccine vials for visible contamination, i.e. check for any change in the
appearance of vaccine, any floating particles or breaches of integrity such as cracks
and leaks. If found DO NOT USE.
• All vaccine vials must be marked with date and time of opening at first use.

• Note the name of the manufacturer, batch number and expiry date of the vaccine and
diluent in the tally sheet.
• Always pierce the septum with a sterile needle for drawing vaccine from the multi-
dose vials being used. OPV vial dropper should be recapped with stopper (small cap)
after each use, and kept on the ice pack. Vials of DPT, HepB, pentavalent, IPV, PCV and
TT should not be kept on the ice pack (see Fig 4.13).
Specific attention while implementing open vial policy

• OVP is not applicable to vials of Measles/MR, Rotavirus, BCG and JE vaccine.
• Measles/MR, Rotavirus, BCG, and JE vaccine should not be used beyond 4 hours of
reconstitution/opening under any circumstances.
• Rotavirus vaccine does not require reconstitution but must not be used beyond 4
hours of opening.
• ANM must NOT USE such vials after 4 hours of reconstitution or at the end of the
session, whichever is earlier.
• These OVP vaccines will be used as per following instructions:
– Before reconstitution check that the vaccine is within the expiry date and that
VVM has not reached/crossed the discard point. When reconstituting, do so only
with the diluent provided by manufacturer for that batch of vaccine.
– Date and time of reconstitution must be mentioned on the label of the vial
immediately following reconstitution. ANM needs to reconstitute the required
vaccine vial even if there is a single beneficiary.
– Reconstituted vials will only be used for a single session; they will not be carried
from one session to another, even if the session is close by.
– All vaccine vials have VVM appropriately displayed on them. The vaccine has to be
used before reaching the end point.
– If any AEFI occurs following use of any vial, do not use that vial; mark it and retain
safely and seperately for AEFI investigation.
After immunization session is over

• ANM should segregate the vaccine vials (used and unused) and keep these inside
in a properly sealed and marked zipper pouch/bag in the vaccine carrier under the
cold chain and ensure carrier is picked up by the AVD mechanism to deliver at the
designated vaccine/cold storage point.
• Under no circumstances will the vaccine carrier/vaccines be kept in the field at places
other than the designated cold-chain point such as ANM/LHV/other HW/ASHA/AWW’s
house, etc. In such an instance, the vials should not be used for subsequent sessions.

At the vaccine storage/cold-chain point at the end of immunization day
• Cold chain handler should ensure appropriate segregation of the vaccines into opened
and unopened vials, and follow the instructions as below:
Unopened vials
o If VVM is intact and in usable stage, retain the vial in ILR as per guideline, and issue
accordingly.
o If VVM is not in usable stage or there is partial/complete defacement of the label,
retain the vial in a plastic box clearly marked “Not to be used” in ILR. Such vial
should be discarded after 48 hours or before the next session, whichever is earlier.
Opened vials
o Segregate the vials on which OVP is not applicable such as Measles/MR/ Rotavirus
/BCG/JE and retain in a plastic box clearly marked “NOT TO BE USED” in ILR. These
vials should be discarded after 48 hours or before the next session, whichever
is earlier. In case of any reported AEFI, they will not be discarded but retained
seperately for investigation.
o Segregate the vials for which OVP is applicable such as OPV/DPT/HepB/pentavalent/
IPV as below:
If VVM is intact and is in usable stage, retain the vaccine vial in ILR as per
guideline, subject to the condition that the vial is within 28 days of opening
(as found from date marked on the vial) and re-issue in the next session after
ensuring that it has not exceeded 28 days after opening the vial.
If VVM is intact and is in usable stage, but the vaccine vial has exceeded 28
days after opening (as found from date marked on the vial), the vials should
be discarded after ascertaining that these vials are not required for AEFI
investigation.
If VVM is not in usable stage or there is partial/complete defacement of the
label, retain in a plastic box clearly marked “Not to be used” in ILR. These
vaccine vials should be discarded after 48 hours or before the next session,
whichever is earlier (after ascertaining that these vials are not required for
AEFI investigation).
o If there is any vial which has been used and there is a report of an AEFI, that
vial (even if it is in usable stage) has to be kept separately in a properly sealed
zipper bag earmarked “For AEFI investigation” in ILR under special custody and
in the knowledge of the MO. This vial should never be issued to anyone unless
authorized by DIO.
• The cold-chain handler should document the return of used (complete/partial) and
unused vials in the vaccine distribution register.

properly sealed zipper bag earmarked “For AEFI investigation”
i in ILR
under special custody and in the knowledge of the MO.
M . This vial should
never be issued to anyone unless authorized by DIO.
 The cold-
and unused vials in the vaccine distribution register.
Managing logistics
Managingof vaccines
logistics ofand otherand
vaccines supplies
other supplies
Vaccine and logistics

Vaccinemanagement is a cyclic process
and logistics management (Fig.
is a cyclical 4.18) (Fig.
process and 4.14)
involves several steps,
and involves several
veral
steps,
namely demand estimation, indenting, receipt, storage and distribution of vaccines and
other supplies to health facilities in a timely fashion and at optimum cost.
Fig 4.18.
Fig 4.14. Logistics Logistics
management management cycle
cycle
Estimate
requirements
and indent
Issue and use Receive
Store
Commonly encountered problems in vaccines and logistics management
Stock out: A condition when no stock of a vaccine or114

other supplies are available.
Inadequate stock: Stock which is less than the buffer stock, i.e. less than 25% for vaccines
and syringes.
Excess stock: Stock which is more than the requirement for one month including the buffer
stock, i.e. more than 125% for vaccines and syringes.
Steps in logistics management
Following are the steps involved in logistics management related to vaccines, diluents and
AD syringes.
Step 1 – Estimating requirements of vaccines
Compile the microplans of all the SCs at the PHC level and estimate the requirement of
vaccines and other supplies (Refer Unit 3 for formats and details). Furthermore, ensure that
the overall estimate includes a buffer stock and wastage as per acceptable wastage rates
(Refer Unit 3 RI format 9). This allows maximum stock of vaccines at the:
• PHC level – for 1.5 months
• District level – for 2.75 months.

The GoI has laid down recommended stock levels for various levels as given in Table 4.13.
Table 4.13: GoI recommendations for storage of vaccines
Level Working Buffer Lead time Stocks
stock stock stock Max Min
Months Months
Months Months (Working stock + (Buffer stock + lead
buffer stock) time)
District 2 0.5 0.25 2.75 0.75
PHC/UHC 1 0.25 0.25 1.5 0.50
The problems of stock-out, inadequate or excess stock can be avoided if a minimum/

maximum inventory control system is implemented. This system ensures that the quantity
in hand is always more than the buffer stock and less than the maximum stock.
Relationship between minimum, maximum and buffer stocks is given in Fig 4.19.
Fig. 4.19. Relationship between minimum, maximum and buffer stocks
Maximum
Stock
Amount used
between receiving
Re-order
Re-order
Level
Level
supplies and
placing re-order
Amount used
Lead Time Lead Time
between placing
Minimum
and receiving an
Stock
order
Buffer Stock
Lead time
The time between ordering of new stock and its receipt. Leadtime varies depending upon
the speed of delivery, availability and reliability of transport and sometimes the weather.
Buffer stock
It serves as a cushion or buffer against emergencies, major fluctuations in vaccine demands

or unexpected transport delays. It is 25% extra for vaccines and syringes.

Minimum stock level
This is also known as the re-order level. It implies the least amount that you should have in
your stock, or the level which, when reached initiates a re-order; usually expressed as the
number of weeks/months of supply. It is the amount of stock which will be used in the time
between placing and receiving the order, plus the buffer stock. The minimum stock level is
the level below which stock should never drop without having placed an order.
Maximum stock level (peak stock)
It implies the largest amount of the stock that one should have, usually expressed as the
numbers of weeks/months of supply. It is the minimum stock plus amount of the stock used
between orders. The maximum stock level is set to guard against excess stock, which results
in losing vaccines to expiration before use.
Working stock
Amount of stock used between two orders. It will be 4 weeks in case of a PHC.
Example: For a PHC with monthly requirement of Pentavalent of 280 doses, the buffer stock
will be 70 doses (25% or one week’s supply). Additionally, if the lead time is one week, then
the maximum stock level, therefore, will be the Minimum stock and the stock between
used between orders (140 doses + 4 weeks stock of 280 doses = 420 doses).
If the stock level falls to the re-order level, inform the district vaccine stores for replenishment
and place an indent to avoid any shortage or stock-out.
Step 2 – Indenting, receipt and issue of vaccines at PHC
For indenting vaccines and supplies, you must check the following:
• Requirements of the PHC (session-wise)
• Utilization during the previous months. Get this information from monthly progress
reports
• Find out balance in hand.
On arrival of vaccine:
• Check that type and amount of vaccine and diluents are the same as per the indent
• Check VVM and expiry date on each vial of vaccine
• Transfer vaccines to the ILR immediately after delivery

• Keep separate date-wise records of receipts, distribution and balance for each type of
vaccine, logistics and each size of vial
• Keep record of vaccines distributed and utilized at the centres to assess the wastage
of vaccine.
Before issuing vaccines, ensure the following:
• Requirement for each RI session
• Adequate number of diluents for the next day’s use are kept in the ILR and sent to the
session sites in vaccine carriers
• Ice packs in the vaccine carriers are conditioned
• Vaccines and diluents are at the same temperature and from the same manufacturer
(Bundling)
• Open vial policy applicable vaccines are issued after carefully checking date of opening.
Step 3 – Update records on vaccine use
• Keep a record of the vaccines you administer
• Keep a record of the batch numbers and expiry dates of vaccine used
• Keep a record of vaccines returned to PHC
• Update eVIN (where applicable).
And then re-start with Step 1: Estimation of requirements.
Before you indent the next batch of vaccine, conduct a physical inventory to make sure that
the ledger is accurate, i.e. all supplies issued to sessions are accounted for. Before indenting
additional supplies for the next month, subtract your end balance from next month’s stock
requirements and include a 25% buffer stock.
Dos and dont’s for vaccine storage and use are given in Table 4.14.

Vaccine storage and use
Table 4.14. Dos and dont’s on vaccine storage and use

Dos Dont’s
• Keep all vaccine in ILR in PHC between • Do not use any vaccine after expiry
+2°C and +8°C • Do not keep vaccines for more than
• Ensure that vaccine with earlier expiry 2.75 months at the district stores and
date is used first (EEFO) if VVM is in 1.5 months at PHC
usable stage • Do not store any vaccines at SCs or
• If two shipments of vaccines have outside the cold chain
the same expiry date, select the one • Do not allow DPT, TT, IPV, HepB and
which has remained longer in the penta vaccines to freeze
store to be used first – first in first out • Do not freeze the diluents, as the
(FIFO) ampoules are likely to crack when
• Transport vaccines in cold boxes or frozen
vaccine carriers only • Do not keep any expired vials, freeze-
• Check ice packs for conditioning damaged vials or vials with VVMs
before packing vaccines beyond the discard point in the cold
• Ensure that the stocks are rotated so chain. These should also not appear in
that no vaccine is kept for more than 1 the available stock balance.
month in PHC
• Select the shortest route for
distributing vaccines on session day
• Conduct a physical inventory of all
vaccines with diluents once every
month and other supplies at least
once every 3 months
Since provision of immunization services depends on the simultaneous availability of a

number of related supplies, shortage or stock-out of any of these negatively impact the
programme.
“Bundling” ensures that vaccines are always supplied with diluents, droppers, AD syringes
and reconstitution syringes, in corresponding quantities, at each level of the supply chain.
Other related items such as tablet IFA and ORS required for the conduct of Village Health
and Nutrition Day also need to be supplied simultaneously.

National Cold Chain and Vaccine Management Resource Centre (NCCVMRC),

NIHFW, Delhi
National Cold Chain and Vaccine Management Resource Centre (NCCVMRC) is a joint
initiative of the Ministry of Health & Family Welfare, National Institute of Health and
Family Welfare (NIHFW)& UNICEF (GAVI) and was established in 2015 at NIHFW, Delhi. It
coordinates with the National Cold Chain Training Centre (NCCTC), Pune to conduct Cold
Chain Technicians’ training and also coordinates and supports CCTs’ training in other cold
chain training centres.
Objectives of the NCCVMRC
• To plan, design, conduct, monitor and evaluate cold-chain training courses;
• To act as a resource centre for updated programmes and technical guidelines in
immunization;
• To conduct need-based research to achieve an impact in quality and reach of
immunization coverage in the country;
• To provide technical inputs to MoHFW for policy level decisions.
Activities
• Standardization of training for CCTs and vaccine logistics managers
• Operationalization, administration and monitoring of National Cold Chain Management
Information System (NCCMIS)
• Maintaining training database for CCTs
• Knowledge/information management for cold chain and vaccine management
• Temperature monitoring (online) of State Vaccine Stores in ten states
• Conducting Effective Cold Chain and Vaccine Management Course (ECCVMC) for
programme managers at state and district levels
• Support to states to conduct EVM assessments.

National Cold Chain Management Information System (NCCMIS)
Considering the usefulness in managing and monitoring the cold-chain equipment and for
taking management decisions for the Immunization Programme, a centralized MIS was
developed in 2010 by Ministry of Health and Family Welfare (MoHFW), GoI with technical
and financial support from UNICEF India, and was coined as the National Cold Chain
Management Information System (NCCMIS). Valuable inputs were taken from all the state
EPI officers (SEPIOs) and cold-chain officers while developing this MIS.
NCCMIS serves as a comprehensive web-based database for various cold chain equipment
and their related information across the country used in the UIP.
This is a dynamic database, which provides a wide range of information on:
• Cold chain situation of the country;
• Cold-chain points at various levels – Government Medical Stores Depot (GMSD), state,
region, district and sub-district;
• Human resource, capacity building;
• Inventory of electrical and non-electrical cold-chain equipment, spare parts and
toolkits;
• Analysis of various performance indicators for cold chain;
• Space analysis, etc.
Data collection
Data for this MIS is usually captured in two ways. A set of data which is required to be filled
while opening a particular cold-chain point in a district is collected and entered as one-time
data. The state-level cold-chain points (state vaccine stores) are created at national level.
Cold-chain points up to district level (regional/divisional/district level stores) are created at
state level and sub-district level cold chain points are created at district level.
Besides this, there are certain fields which are dynamic and need to be updated as and
when there is a change such as breakdowns, repair of any equipment, change in staff, etc.
The data entry is limited to GMSD, state and district level users. The CCTs placed at the
respective levels along with the immunization computer assistants are responsible for data
collection and entry in the MIS under the supervision of cold-chain officers of the respective
states.
State-wise trainings were conducted at the national level for training of trainers, who in
turn have trained the district level users (CCTs/immunization computer assistants/stores
managers/data entry operators) in a cascading manner for making the NCCMIS operational
and updating it regularly.

NIHFW, through the NCCVMRC, is responsible for the overall maintenance, implementation
and monitoring of the NCCMIS across the country including providing helpline support to
end-users.
Features of NCCMIS
• Common portal for data retrieving (site: www.nccvmtc.org; login ID: national;
password: national)
• NCCMIS dashboard (state/district-wise status of cold-chain points, cold-chain
equipment)
• Generates around 70 reports at all levels (national, state, district, block and down to
PHC) on key cold-chain indicators.
Electronic Vaccine Intelligence Network (eVIN)
Electronic Vaccine Intelligence Network (eVIN) is India’s solution for ensuring effective
management of the immunization supply chain. It answers three crucial questions for cold-
chain handlers:
¾¾ Where are my vaccines?
¾¾ Are they available in adequate quantities?
¾¾ Are they being stored in appropriate conditions?
With data answering these questions, cold-chain handlers will be able to make effective
vaccine storage and stock management decisions. eVIN was conceptualized and piloted by
the Immunisation Technical Support Unit (ITSU), MoHFW.
eVIN is made up of three components—processes, technology, and human resources,
which are all required to ensure vaccine stock, temperature data visibility and improved
immunization supply chain performance. Data flow chart of eVIN is shown in Fig. 4.20.
How do cold-chain handlers interact with eVIN?
eVIN supports cold-chain handlers in their routine vaccine handling activities. The
interactions between cold-chain handlers and eVIN are simple and clearly defined.
Interaction 1: eVIN’s registers
There are two types of registers, one for recording detailed distribution data on every
immunisation session day, and another for recording changes in total stock levels.

Fig. 4.20. eVIN – Data flow chart
Vaccine Distribution Register

The number of doses distributed and returned for each vaccine to each session site is
recorded in this register. Transactions for open vials and syringes are also similarly recorded.
At the end of the session day, cold-chain handlers calculate the net utilization for each
vaccine (total distributed - total returned).
Vaccine Stock Register
At the end of a session day, the net utilisation for a vaccine is deducted from the day’s
opening stock balance to create a closing balance. Vaccines received from higher level
stores are recorded as receipts and are added to opening balances. In addition, important
information such as batch number, expiry date, name of manufacturer and VVM status is
recorded for every transaction.

Interaction 2: eVIN’s technology
Mobile phone alerts are sent to cold-chain handlers in case storage temperatures or stock
levels are too high or too low.
Mobile Logistics Management Information System (LMIS) application
Cold chain handlers enter the net utilization numbers for each vaccine (from the Vaccine
Distribution Register) into the LMIS application on their mobile phones, and the updated
stock levels are automatically calculated by the LMIS software.
In case the stock levels are inaccurate or need to be updated due to vaccine expiry or
damage, then updated stock levels can be entered into the mobile application. If stock levels
are too low (below buffer level), or too high (above maximum level), cold-chain handlers
will be alerted on their mobile phones.
Temperature loggers
eVIN’s automated temperature loggers monitor and record the storage temperatures of
ILRs, DFs, WICs and WIFs and report their temperature data to the LMIS. Instances of low or
high temperatures are instantly alerted to cold-chain handlers and refrigerator mechanics
through their mobile phones.
Automated temperature monitoring helps cold-chain handlers in ensuring appropriate
storage conditions for vaccines.
Interaction 3: Training of cold-chain handlers and VCCMs
The third interaction of cold-chain handlers with eVIN involves training sessions to improve
their knowledge and skills.
Training for using eVIN’s registers, mobile LMIS and temperature maintenance
Cold chain handlers are trained to ensure effective record keeping in eVIN’s registers
and quality data reporting into the mobile LMIS. Emphasis on learning the basic steps of
operating the mobile LMIS is particularly important among handlers who have had limited
prior experience in using mobile phones. A visual guidebook on using the mobile LMIS is
provided to cold-chain handlers for referral.
Responses to these alerts are guided by detailed guidelines, which are provided to cold-
chain handlers.

Vaccine and Cold Chain Managers (VCCMs)

VCCMs are at the district level and support cold-chain handlers in recordkeeping, stock
management and temperature maintenance. They help handlers get comfortable with the
LMIS mobile application and are available to answer questions or handle any problems that
handlers face with the mobile application. VCCMs also supportively supervise cold-chain
handlers in their use of eVIN’s registers to help ensure complete data recording.
Additionally, VCCMs work with cold-chain handlers to ensure that their vaccine stock levels
are appropriate and that storage temperatures are maintained within the recommended
ranges. VCCMs use LMIS data to plan stock distribution to cold-chain points. They also
monitor temperature data from the temperature loggers to help cold-chain handlers and
refrigerator mechanics maintain the cold-chain equipment.

Stock and distribution registers
Following are the formats required for indent, supply, stock and distribution of vaccines
and logistics:
• Stock register formats
• Indent and supply formats
• Vaccine distribution register
• Vaccinator’s logistics diary
Stock register formats
A
L HE LTH M
NA IS
IO
SI
NAT
ON
Vaccine Stock Register - Issue and Receipt
Name of the CHC/PHP/SC/UHC/PPC/Others:
Name of the Block:
Name of the District:
Name of the State:
Year:

126
Vaccine Stock Register - Issue and Receipt
Name of the Vaccine Store:
Name of the Vaccine/Diluent/AD Syringe:
Serial Date Opening Received Received Issued (Dose/ Issued to Challan VVM Name of the Batch Expiry Closing
No. Balance (Dose/ From Piece) (Name of Cold Chain No. Status Manufacturer No. Date Balance
(Dose/Piece) Piece) Point/RI Sessions/ (Usable/ (Dose/Piece)
Discarded-Reason) Non-
Usable)


Name of the CHC/PHC/PPC: Name of the person distributing the vaccines: Name of the person receiving return vaccines:
Issue and Return of Un-opened Vaccine Vials (VVM Status-Usable)
BCG BCG OPV OPV Doses Diluent JE JE DPT Hep-B TT Pentavalent
Doses Diluent Doses Dropper Doses Doses Diluent Doses Doses Doses Doses
Doses Doses
Name of the
Sub-centre/
UHP/HF-
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Issue
Return
Session site
1
2
3

Vaccine and logistics indent and supply formats

(Copy for Record for Requester) (Copy for Record for Receiver)
Indent No.: Date: Indent No.: Date:
From: From:
To: To:
Item Total Balance Amount Item Total amount Balance Amount
amount available requested received in available requested
received on date of current year on date of
in current indent indent
year
BCG (doses) BCG (doses)
bOPV (doses) bOPV (doses)
DPT (doses) DPT (doses)
Hep B Hep B
Pentavalent Pentavalent
IPV (doses) IPV (doses)
JE JE
TT (doses) TT (doses)
BCG Diluent BCG Diluent
0.1ml AD Syringes 0.1ml AD Syringes
0.5 ml AD Syringes 0.5 ml AD Syringes
5 ml Disp. Syringes 5 ml Disp.Syringes
VitA Syrup VitA Syrup
Signature of Receiver: Signature of Requester: Signature of Requester: Signature of Requester:
Name: Name: Name: Name:
Designation: Designation: Designation: Designation:
(Copy for Record for Supplier) (Copy for Record for Receiver)
Supply Voucher No.: Date: Indent No.: Date:
Reference Indent No Dated: Received on: Reference Indent No Date: Received on:
To: To:
Item Amount Batch Expiry Remarks Item Amount Batch Expiry Remarks
Released No. VVM Released No. VVM
Date Date
Status Status
1 BCG (doses) 1 BCG (doses)
2 bOPV (doses) 2 bOPV (doses)
3 DPT (doses) 3 DPT (doses)
4 Hep B 4 Hep B
5 Pentavalent 5 Pentavalent
6 IPV (doses) 6 IPV (doses)
7 JE 7 JE
8 TT (doses) 8 TT (doses)
9 BCG Diluent 9 BCG Diluent
(amp) (amp)
10 Diluent 10 Diluent
(amp) (amp)
11 0.1ml AD 11 0.1ml AD
Syringes Syringes
12 0.5 ml AD 12 0.5 ml AD
Syringes Syringes
13 5 ml Disp. 13 5 ml Disp.
Syringes Syringes
14 VitA Syrup 14 VitA Syrup
Received above vaccines and logistics in quantity mentioned Received above vaccines and logistics in quantity mentioned and
and in good condition. in good condition.
Signature of Receiver: Signature of Store in Charge: Signature of Receiver: Signature of Receiver:
Name: Name: Name: Name:
Designation: Designation: Designation: Designation:


Vaccine Distribution Register for Immunization Session
Type of the session (RI/ SIW/Campaign/Others): Date:

Syringes Red and Issue and Return of Open Vaccine Vials (VVM Status-Usable)
0.1ml 0.5 ml 5 ml Black DPT vials OPV vials TT vials Hep-B vials Pentavalent
Plastic vials
Bags (Yes/
Issue Return Issue Return Issue Return No) Issue Return Issue Return Issue Return Issue Return Issue Return
(un- (un- (un-
used) used) used)

Net Utilised = (Issued BCG BCG OPV OPV Doses Diluent JE JE DPT Hep B TT Pentavalent 0.1ml 0.5 5
Doses - Returned doses Diluent doses dropper doses doses Diluent doses doses doses doses ml ml
Doses) doses doses

129
VACCINATOR'S LOGISTICS DIARY

VACCINATOR'S LOGISTICS DIARY
1. This diary is to be maintained by the vaccinator and should be available at the session site.
1.
2. This
This diary
diary isshould
to be maintained
be used for by the vaccinator
maintaining and should
the records be available
of Received andatReturned
the session site. Syringes and
Vaccines,
2. This diary
Diluents should
at the be used
session site.for maintaining the records of Received and Returned Vaccines, Syringes and
3. The name
Diluents at theofsession
the Vaccinator,
site. Health Facility, Session Site and Session Date should be written in the upper
part of the diary in the space provided.
3. The name of the Vaccinator, Health Facility, Session Site and Session Date should be written in the upper
4. The
part of details
the diaryforin'Un-Opened Vials & Syringes', and 'Open Vaccine Vials' should be recorded separately
the space provided.
under the separate headings
4. The details for 'Un-Opened Vials as provided in the
& Syringes', dairy.
and 'Open Vaccine Vials' should be recorded separately under
the separate headings as provided in the dairy.
An example on how to record in the Vaccinator's Logistics Diary is shown below:
On a routine immunisation day, Nyara PHC distributes the following amount of vaccines, syringes to the session site - Rithora. The
Vaccinator should fill up the details regarding the name and designation of the person, mode of delivery of the vaccines and the
time when it is delivered to the session as follows:
At the time of Receiving Vaccines/Diluents/Syringes and Other Logistics
Vaccinator's Logistics Diary

Name of Vaccinator………………………………………………………………………………
Name of Health Facility:…………………………………………………..
Session Site: …………………………………………………………………………………………..
Date of session:……………………………………………………………………..
Un-Opened Vials & Syringes

Received Returned
Item
(In Doses) (In Doses)
Manufactur
Sl. No. Name of the Items Quantity Manufacturer Batch No. Exp.Date VVM Quantity Batch No. Exp.Date VVM
er
1 OPV
tOPV
2 DPT
Item
3 Hep-B
4 TT
5 Pentavalent
6 BCG
7 Measles
8 JE
9 BCG Diluent
10 Measles Diluent
11 JE Diluent
Other Logistics
(in pieces)
Items Received Returned Items Received Returned Items Received Returned
0.1ml 0.5 ml 5 ml
OPV Dropper Black Bag Red Bag
Open Vaccine Vials

Received Returned
Date of
Quantity in Quantity in Date of
Batch No. Exp.Date VVM Opening of Batch No. Exp.Date VVM
Vials Vials Opening of vial
vial
1 DPT vials
2 OPV vials
tOPV vials
3 TT vials
4 Hep-B vials
5 Pentavalent vials
Receiving Details Returning Details

Name and designation Name and designation of Person
Transport modality Transport modality (AVD/self
Date & Time Date & Time
1. At the end of the session, the vaccinator should fill the details of all logistics being returned and the mode of
130 return of vaccine carrier. Immunization handbook for Medical Officers
2. The vaccinator should sign after the complete details are filled. Any supervisor visiting the session site should
check the details and verify by counter signing.
An example is shown below:
1. At the end of the session, the vaccinator should fill the details of all logistics being returned and the mode of
return of vaccine carrier.
2. The vaccinator should sign after the complete details are filled. Any supervisor visiting the session site should
check the details and verify by counter signing.
At the time of Returning the Vaccines/Diluents/Syringes/and other Logistics
Un-Opened Vials & Syringes

Item Received Returned
Manufactu
Sl. No. Name of the Items Quantity Manufacturer Batch No. Exp.Date VVM Quantity Batch No. Exp.Date VVM
rer
1 OPV
tOPV
2 DPT
3 Hep-B
4 TT
5 Pentavalent
6 BCG
7 Measles
8 JE
9 BCG Diluent
10 Measles Diluent
11 JE Diluent
Other Logistics
(in pieces)
Items Received Returned Items Received Returned Items Received Returned
0.1ml 0.5 ml 5 ml
OPV Dropper Black Bag Red Bag
Open Vaccine Vials

Received Returned
Date of
Quantity in Quantity in Date of
Batch No. Exp.Date VVM Opening of Batch No. Exp.Date VVM
Vials Vials Opening of vial
vial
1 DPT vials
2 OPV
tOPV vials
vials
3 TT vials
4 Hep-B vials
5 Pentavalent vials
Receiving Details Returning Details

Name and designation of Person
Name and designation
collecting the stock from the
of Person delivering the
session and return to cold Chain
stock to session site:
Point:
Transport modality
Transport modality (AVD/self
(AVD/self
collection/other-specify)
collection/other-specify)
Date & Time Date & Time
Signature of Vaccinator:

Notes:

Unit 5 : Safe injections and Waste Disposal
5
Safe injections
and waste
disposal
Safe injections
A safe injection is one that:

• does not harm the recipient
• does not expose the HWs to any avoidable risks
• does not result in waste, which is dangerous for the community.
The most common, serious infections transmitted by unsafe injections are Hep B, Hep C,
and HIV. Poorly administered injections can also cause injuries or drug toxicity when the
wrong injection site, vaccine, diluent, or dose is used. It is important to prevent the risks
of accidental needle-stick injury, and it is also necessary to dispose of used syringes and
needles safely to prevent risks to the community at large.
Impacts of unsafe injections are illustrated in Fig. 5.1.
Fig. 5.1. Impacts of unsafe injections
Reused Unsafe Unsafe

needles and/or collection of disposal of
syringes sharps waste sharps waste
Beneficiary Health worker Community
The provision of AD syringes by the GoI and the implementation of the Central Pollution
Control Board (CPCB) waste management guidelines improves injection safety in the
immunization programme.

Simple ways to improve injection safety
Keep hands clean before giving injections

o Wash or disinfect hands prior to preparing injection
material.
o Cover any small cuts on the service provider’s skin.
o Avoid giving injections if the skin at the site of injection is
compromised by any local infection such as a skin lesion,
cut, or weeping dermatitis.
Use sterile injection equipment, every time
o Always use AD syringes for each injection and a new
disposable syringe to reconstitute each vial of BCG,
measles/MR and JE.
Prevent the contamination of vaccine and injection equipment
o Prepare each injection in a designated clean area where
contamination from blood or body fluid is unlikely.
o If the injection site is dirty, clean it with clean swab.
o Always pierce the rubber cap (septum) of the vial with a
sterile needle.
o Do not touch the needle or rubber cap (septum) of a vial
with your finger.
o Follow product-specific recommendations for use, storage and
handling of a vaccine.
o Discard any needle that has touched any non-sterile surface.
Assume all used equipment is contaminated
o Cut the used syringe with the hub cutter immediately after use.
Practice safe disposal of all medical sharps waste
o Used sharps (needles) must be collected in a hub cutter and
then carried to the PHC for safe disposal.
Prevent needle-stick injuries
o Do not re-cap or bend needles.
o Anticipate sudden movement of the child.
o Collect sharps in a puncture-proof container (hub cutter).

Correct use of AD syringes (Fig 5.2)
Fig. 5.2. Correct use of AD syringes

1. Select the correct syringe for the vaccine to be administered
– 0.1ml for BCG, fIPV and 0.5ml for all others.
2. Check the packaging. Don’t use if the package is damaged,
opened, or expired.
3. Peel open or tear the package from the plunger side and
remove the syringe by holding the barrel. Discard the
packaging into a black plastic bag.
4. Remove the needle cover/cap and discard it into the black
plastic bag.
5. Do not move the plunger until you are ready to fill the
syringe with the vaccine and do not inject air into the vial as
this will lock the syringe.
6. Take the appropriate vaccine vial, invert the vial, and insert
the needle into the vial through the septum. Insert the
needle such that the tip is within the level of the vaccine. If
inserted beyond that, you may draw an air bubble which
inserted is that, you may draw an air bubble which is
beyond
very difficult
ficult to expel. very difficult to expel.
7. 7. Do not touch the needle or the rubber cap (septum) of the vial.
8. Pull the plunger back slowly to fill the syringe. The plunger
the vial..
will automatically stop when the necessary dose of the
vaccine has been drawn (0.1 ml or 0.5 ml).
9. Do not draw air into the syringe. In case air accidentally
has been drawn (0.1 ml or 0.5 ml). enters the syringe, remove the needle from the vial. Holding
9. Do not draw air into the syringe. In casetheair syringe upright, tap the barrel to bring the bubbles
accidentally
towards the tip of syringe. Then carefully push the plunger
to the dose mark (0.5 or 0.1 ml) thus expelling the air
bubble.
10. Clean the injection site (if dirty) with a clean swab.
the dose mark (0.5 or 0.1 ml) thus expelling the air bubble.
11. Administer the vaccine,, as follows:

 BCG: upper arm LEFT
 B Anterolateral aspect (outer side) of
DPT and Hep B:
mid-thigh LEFT
 Pentavalent Anterolateral aspect of mid-thigh
Pentavalent: -thigh LEFT
 IPV: Anterolateral
Immunization aspect
handbook of mid-thigh
for Medical Officers RIGHT 135
 Measles/MR: Upper arm RIGHT
11. Administer the vaccine, as follows:

• BCG: upper arm LEFT
• DPT and Hep B: Anterolateral aspect (outer side) of mid-
thigh LEFT
• Pentavalent: Anterolateral aspect of mid-thigh LEFT
• fractional IPV: Upper arm RIGHT
• PCV: Anterolateral aspect of mid-thigh RIGHT
• MR: Upper arm RIGHT
• TT: Upper arm RIGHT
• JE: upper arm LEFT.
12. Push the plunger completely to deliver the dose. Do not
rub the injection site after vaccine is given.
13. Do not re-cap the needle. Cut the hub of the syringe
immediately after use with hubcutter that collects the
sharps in its puncture proof container.
14. Then collect the plastic portion of the cut syringes in a red
plastic bag.
Follow the guidelines for waste disposal as given in next section.
Steps to ensure safe disposal of immunization waste
The CPCB outlines guidelines for disposal of biomedical waste generated during immunization
under the UIP. The concerned CMO/DHO or the officer responsible for implementation of
UIP in the respective area, as decided by the MoHFW, will obtain authorization from the
“Prescribed authority” notified under the Biomedical Waste (Management & Handling)
Rules for generating, collecting, receiving, storing, transporting, treating, disposing and/or
handling biomedical waste in any other manner.
Biohazard and cytotoxic symbols are given in Fig. 5.3.
Fig. 5.3. Biohazard and cytotoxic symbols

Disposal of biomedical waste generated at outreach points/PHCs/CHCs/

district hospitals, etc. (refer Fig. 5.6)
Step 1: At the session site, ANMs to cut the needle of the AD syringe immediately after
administering the injection using the hub cutter that cuts the plastic hub of the syringe
and not the metal part of needle. The cut needles will get collected in the puncture-proof
container of the hubcutter (Fig. 5.4).
Step 2: Store the broken vials in a separate white sturdy and puncture proof container or in
the same hubcutter, in case its capacity is also able to accommodate broken vials.
Step 3: Segregate and store the plastic portion of the cut syringes and unbroken (but
discarded) vials in the red bag or container. Both the containers should bear the biohazard
symbol as stipulated in Schedule III of the Bio-Medical Waste (BMW) Rules (Fig. 5.3).
Step 4: Send the red, black bag and the hub cutter to PHC for disinfection (see fig. 5.5) and
disposal by the designated person at the PHC. Dispose of the black bag as general waste.
PHC may send the collected materials to the Common Biomedical Waste Treatment Facility
(CBWTF). If the CBWTF doesn’t exist, go to Step 5.
Step 5: Treat the collected material in an autoclave. If unable to impart autoclaving, boil
the waste in water for at least 10 minutes or provide chemical treatment using sodium
hypochlorite for 30 minutes to ensure that this results in disinfection. However, the district
hospital/CHC/PHC will ultimately make the necessary arrangements to autoclave on a
regular basis.
Step 6: Dispose the autoclaved (or boiled/chemically disinfected) waste as follows:
Dispose the needles and broken vials in a safety pit/tank
Send the syringes and unbroken vials for recycling or to a landfill.
Step 7: Wash the hub cutters properly with sodium hypochlorite before reuse.
Step 8: Maintain a proper record of generation, treatment and disposal of waste at the
district hospital/CHC/PHC in order to assess that waste (needles/syringes/vials) reported
back matches with the stock issued to HWs at the beginning of the session day. Match
by weighing rather than counting to avoid occupational and safety hazards. This helps to
prepare annual reports, submitted to the prescribed authority by 31 January of every year.

Fig. 5.4. Using the hub cutter correctly
CUT HERE
Handle Hub
Needle
Insertion
Hole
Puncture
proof
container
• Cut needles and hub

• Broken vials and ampoules

Disinfec on Corner Instruc ons at disinfec on corner Sharps in Hub cu er

Using Sodium Hypochlorite
Disinfec on using double bucket method At the sharps pit
Fig. 5.5. Pictorial flow chart – disinfection and disposal sharps waste from RI session
Disposing disinfected sharps into sharps pit Securing sharps pit with lock
139
Fig. 5.6.Pictorial guide – segregation and safe disposal methods for immunization
waste
Fig. 5.6. Pictorial guide – segregation and safe disposal methods for immunization waste
Waste from Immunization Session
Cut hub of AD and disposable

syringes Plastic part of Syringe,
Needle Cap/ Wrappers
broken vials and ampoules Empty unbroken Vials
Bio
Send to Health Facility
haz at end of Session
ard
B
Disinfect in Sodium Disinfect
Disinfect in Sodium
in Bleach solution i
Disinfect in Bleach solution
Hypochlorite for 30Solution
/1% Hypochlorite minutes. Hypochlorite for 30Solution
/1% Hypochlorite minutes.
(for 30 minutes)
o
(for 30 minutes)
h
Dispose in Recycle a Dispose as
Safety Pit Municipal
z Waste
a
r
d
141

Red/black plastic bags
30 Liters (24’’ x 28’’) (biodegradable) HDPE/LLDPE/PP bags made with virgin, non-chlorinated
polymer material with minimum thickness of 55 micron, with easy to hold collar tie/knot
arrangement and preprinted as per requirements of Bio Medical Waste Management Rules
are to be used.
Final disposal at PHC/UHC/CHC of treated needles and broken vials (sharps)
Treated needles/broken vials should be disposed of in a circular or rectangular pit as shown

in Fig. 5.7. Such a rectangular or circular pit can be dug and lined with brick, masonry or
concrete rings. The pit should be covered with a heavy concrete slab, which is penetrated
by a galvanized steel pipe projecting for about 1 m above the slab, with an internal diameter
of up to 50 mm or 1.5 times the length of vials, whichever is more. The top opening of
the steel pipe shall have a provision for locking after the treated waste sharps have been
disposed.
When the pit is full, it can be sealed completely after another one has been prepared. For
high water-table regions where the water table is less than 6 meters beneath the bottom of
the pit, a tank with above mentioned arrangements shall be made above the ground.
Fig. 5.7. Design of the pit/tank for disposal of treated needles and broken vials (sharps)

Your role in safe injections, safety of staff and waste management
Medical Officer’s Activity How

role
Ensuring safe 1. Ensuring availability and maintenance Use the opportunity
injections by of logistics needed for safe injections during field visits to RI
health workers 2. Ensuring all ANMs both in the field and session sites
in health centre are aware and practice
injection safety
Further develop 1. Review of waste segregation and Discuss during
and guide safe management with all staff to identify meetings and involve
practices issues all staff
2. Involvement of waste handlers
Ensure 1. Is at source segregation of waste being When on rounds of
existing waste practiced at all levels? hospital or visiting any
management 2. Ensuring availability of proper logistics other department in
is adequate 3. Making sure the injection pit and waste your centre
and in line with storage areas are as per guidelines
guidelines
Ensuring safe 1. Ensure timely collection of segregated Discuss issues during
final disposal of waste from your health centre. Report district level meetings
waste delays to district. or contact district
2. Ensure safe storage of segregated immediately when
waste before final disposal issues arise
3. Review functioning of sharps pit /
landfill
Global research in new vaccine delivery methods
 Intra dermal delivery – Jet injectors, Micro needles,

 Needle free vaccines delivery – Needle free patch,
inhaled vaccines
 Transcutaneous route

Notes...

Notes...

Unit 6 : Adverse events following immunization
Adverse events
following
immunization
6
Adverse event following immunization (AEFI) is defined as any untoward medical
occurrence which follows immunization and which does not necessarily have a causal
relationship with the usage of the vaccine.
The adverse event may be any unfavourable or unintended sign, abnormal laboratory
finding, symptom or disease.
Reported adverse events can either be true adverse events, i.e. actually a result of the
vaccine or immunization process, or coincidental events that are not due to the vaccine or
immunization process, but are temporally associated with immunization.
In 2015, revised classification relevant to cause-specific categorization of AEFIs has been
introduced (Table 6.1).
Table 6.1. Cause-specific categorization of AEFIs
Cause-specific type of AEFI Definition
An AEFI that is caused or precipitated by a
1 Vaccine product-related reaction vaccine due to one or more of the inherent
properties of the vaccine product
An AEFI that is caused or precipitated by a vaccine
Vaccine quality defect-related reaction
that is due to one or more quality defects of the
2 (Both 1 & 2 were earlier categorised in
vaccine product, including its administration
Vaccine Reaction)
device as provided by the manufacturer
An AEFI that is caused by inappropriate vaccine
Immunization error-related reaction
3 handling, prescribing or administration and
(formerly “programme error”)
thus by its nature is preventable
Immunization anxiety-related reaction An AEFI arising from anxiety about the
4
(formerly “injection reaction”) immunization
An AEFI that is caused by something other than
5 Coincidental event the vaccine product, immunization error or
immunization anxiety

Vaccine reactions
There are two types of possible vaccine reactions. First - a vaccine product-related reaction;
this is a reaction (an individual’s response) to the inherent properties of the vaccine,
even when the vaccine has been prepared, handled and administered correctly. Second
- vaccine quality defect-related reaction; this is a defect in a vaccine that occurred during
the manufacturing process. Due to introduction of improved good manufacturing practices
(GMP), such defects are now extremely rare.
Vaccine reactions may be classified into common, minor reactions; severe reactions; or
serious reactions. Most vaccine reactions are minor and settle on their own. More severe
and serious reactions are very rare and in general do not result in long-term problems.
Common, minor vaccine reactions
A vaccine induces immunity by causing the recipient’s immune system to react to the
vaccine. Therefore, local reaction, fever and systemic symptoms can result as part of the
immune response. In addition, some of the vaccine’s components (e.g. aluminium adjuvant,
stabilizers or preservatives) can lead to reactions. The proportion of reaction occurrences
likely to be observed with the UIP vaccines are listed in Table 6.2.
Table 6.2. Common, minor vaccine reactions and treatment
Local adverse Irritability, malaise

Fever
Vaccine events (pain, swell- and systemic symp-
(> 38°C)
ing, redness) toms
BCG 90-95% - -
OPV None Less than 1% Less than 1%
Hepatitis B Adults: up to 15% 1-6% -
Children: up to 5%
Hib 5-15% 2-10% -
Pertussis (DwPT) up to 50% up to 50% up to 55%
Tetanus ~ 10% ~ 10% ~ 25%
Measles/MR/MMR ~10% 5-15% 5% (Rash)
JE live-attenuated <1% - -
Local reactions include pain, swelling and/or redness at the injection site and can be expected
in about 10% of vaccinees, except for those injected with DwPT (whole cell DPT), or tetanus
boosters, where up to 50% can be affected. BCG causes a specific local reaction that starts
as a papule (lump) two or more weeks after immunization, which becomes ulcerated and
heals after several months, leaving a scar.

Systemic reactions include fever and occur in about 10% or less of vaccinees, except for
DwPT where the reactions are about half. Other common systemic reactions such as
irritability, malaise, “off-colour” and loss of appetite can also occur after DwPT. For Live
Attenuated Vaccines (LAV) such as measles/MR and OPV, the systemic reactions arise from
vaccine virus infection. Measles/MR vaccine causes fever, rash and/or conjunctivitis, and
affects 5–15% of vaccinees. It is very mild compared to “wild” measles.
Paracetamol, at a dose of up to 15mg/kg every 6–8 hours with a maximum of four doses
in 24 hours is useful for the common minor reactions. It eases pain and reduces fever.
However, it is important to advise not to overuse paracetamol as overdosing may harm the
vaccinee. A feverish child can be cooled with a tepid sponge or bath, and by wearing cool
clothing. Extra fluids need to be given to feverish children. For a local reaction, a cold cloth
applied to the site may ease the pain.
Serious and severe vaccine reactions
An AEFI will be considered serious if it results in death, requires hospitalization, results in

persistent or significant disability/incapacity or a cluster (two or more cases) of AEFIs occur
in a geographical area.
AEFIs that are not minor but do not result in death, hospitalization or disability are categorized
as severe. Examples include non-hospitalized cases of seizures, hypotonic hyporesponsive
episodes (HHEs), persistent screaming, anaphylaxis, severe local reaction, injection site
abscesses, intussusception, etc. Table 6.3 details these rare vaccine reactions. Most of the
rare and more serious vaccine reactions such as seizures, thrombocytopenia, HHEs and
persistent inconsolable screaming do not lead to long-term problems. Anaphylaxis, while
potentially fatal, is treatable without leaving any long-term effects. Although encephalopathy
is included as a rare reaction to measles or DPT vaccine, it is not certain that these vaccines
in fact cause encephalopathy.
Table 6.3. Rare vaccine reactions, onset interval and rates
Vaccine Reaction Onset interval Rate/doses
Suppurative lymphadenitis 2-6 months 1 to 10 /10,000
BCG osteitis 1-12 months 1 to 700/1,000,000
BCG
Disseminated BCG infec- 1-12 months 0.19 to
tion 1.56/1,000,000
Oral poliomyelitis VAPP† 4-30 days 2 to 4 /1,000,000†
Hepatitis B Anaphylaxis 0-1 hour 1.1/1,000,000
Hib None

Persistent (>3 hours) incon- 0-24 hours <1 /100

solable screaming <1 /100
Pertussis (DwPT)/ Seizures†† 0-3 days
Pentavalent vac- Hypotonic, hypo respon- 0-48 hours 1 to 2 /1000
cine sive episode(HHE)
Anaphylaxis 0-1 hour 20/1,000,000
Encephalopathy§ 0-2 days 0 to 1 /1,000,000
Brachial neuritis 2-28 days 5 to 10 /1,000,000
Tetanus toxoid
Anaphylaxis 0-1 hour 1 to 6 /1,000,000
Febrile seizures 6-12 days 3 /1000
Measles/MMR/ Thrombocytopenia 15-35 days 3 /10,000
MR* Anaphylaxis 0-1 hour ~1 /1,000,000
Encephalopathy § 6-12 days < 1 /1,000,000
Rotavirus Intussusception 3-14 days 1 to 2/100,000
Notes:
† VAPP Risk is higher following the first dose (1 in 750 000 compared to 1 in 5.1 million for subsequent doses), and for
adults and immunocompromised.
†† Seizures are mostly febrile and the risk depends on age, with much lower risk in infants under the age of four months.
* Reactions (except anaphylaxis) do not occur if already immune (~90% of those receiving a second dose are immune):
children over six years unlikely to have febrile seizures.
§ Although encephalopathy is included as a rare possible reaction to measles or DPT vaccines, it is not certain that these
vaccines in fact cause encephalopathy. Hence, further scientific evaluation is necessary.
Though vaccines are very rarely contraindicated, it is important to check for contraindications
to avoid serious reactions. For example, vaccines are contraindicated if there is a possibility
of serious allergy to a vaccine or its components. Live vaccines should not be given to
immune deficient children.
Advice on managing the common reactions should be given to parents, in addition to
instructions to return if there are more serious symptoms. Such action will help to reassure
parents about immunization and prepare them for common reactions.
It is recommended that facilities be available at all clinic settings to provide initial emergency
care. All immunization providers need to have these skills and competence to manage
anaphylaxis. Availability of adrenaline (within expiry date) and other basic items in the
emergency tray (AEFI kit) is vital.
Administration of one dose of Intra Muscular (IM) adrenaline by ANM as

first line management in the field - See annex on Page 294.

Immunization error-related reactions (formerly “programme error”)

An adverse event can occur as a result of inappropriate handling, prescribing or administration
of a vaccine. It is very important to identify and correct these errors as they are preventable
(Table 6.4); otherwise they may derail the benefits of the immunization programme.
An immunization error-related reaction may lead to a cluster of events associated with
immunization. These clusters are usually associated with a particular provider, health facility,
or even a single vial of vaccine that has been inappropriately prepared or contaminated.
Immunization error-related reactions can also affect many vials. For example, freezing
vaccine during transport may lead to an increase in local reactions.
Table 6.4. Immunization error-related reactions
Immunization Examples Related reaction
error
Exposure to excess heat or cold Systemic or local reactions due to
(using hard frozen ice packs in RI) as changes in the physical nature of
Error in a result of inappropriate transport, the vaccine, such as agglutination
vaccine (and storage or handling of the vaccine of aluminium-based excipients in
diluent) (and its diluent) where applicable. freeze-sensitive vaccines.
handling Use of a product after the expiry Failure to vaccinate as a result of
date. loss of potency or non-viability of
an attenuated product.
Error in Failure to adhere to a Anaphylaxis, disseminated infection
vaccine contraindication. with an attenuated live vaccine.
prescribing Failure to adhere to vaccine Systemic and/or local reactions,
or non- indications or prescription (dose or neurological, muscular, vascular
adherence to schedule). or bony injury due to incorrect
recommen- injection site, equipment or
dations for use technique.
Use of an incorrect diluent or Failure to vaccinate due to incorrect
injection of a product other than diluent. Reaction due to the
the intended vaccine. inherent properties of whatever
Error in was administered other than the
adminis- intended vaccine or diluent.
tration
Incorrect sterile technique or Infection at the site of injection/
inappropriate procedure with a beyond the site of injection.
multidose vial.

With the introduction of AD syringes, infections due to non-sterile injections have reduced
significantly. Such an infection could manifest as a local reaction (e.g. suppuration, abscess),
systemic effect (e.g. sepsis or toxic shock syndrome), or blood borne-virus infection (e.g.
HIV, Hep B or Hep C).
Use of reconstituted vaccine beyond the recommended period can lead to contamination
of the vaccine (usually with bacterium Staphylococcus aureus). Within a few hours after
administration, there may be local tenderness and tissue infiltration, vomiting, diarrhoea,
cyanosis, high temperature leading to dehydration and death if not managed in time.
Inadequate shaking of the vaccine before use, superficial injection and use of frozen vaccine
increases the risk of sterile abscesses which are rare (~1 per 100 000 doses) and local
reactions from aluminium containing vaccines, especially DPT. Contamination of vaccine or
injection equipment can also lead to a bacterial abscess. For BCG vaccine, injection abscess
can arise from improper injection (subcutaneous rather than intradermal injection).
Immunization anxiety-related reactions (formerly “injection reactions”)
Immunization anxiety-related reactions are common in children over 5 years of age, resulting
from fear or pain of injection rather than the vaccine. Vaccinated children or adults can
react in anticipation to, and as a result of, an injection of any kind. This reaction is unrelated
to the content of the vaccine.
These are common in mass vaccination campaigns. Examples include fainting, light-
headedness, and dizziness, tingling around the mouth and in the hands. Younger children
may react with vomiting, breath-holding, which in some cases can lead to a brief period of
unconsciousness and convulsions.
Minimize overcrowding by proper planning of the immunization sessions to reduce waiting
time. Prepare vaccine out of recipient’s view and ensure privacy during the procedure to
prevent anxiety.
Coincidental events
Coincidental events have only a temporal association, i.e. event happening after
immunization, and are not causally related.
Vaccines are normally scheduled early in life when infections and other illnesses are
common, including manifestations of an underlying congenital or neurological condition. It
is, therefore, possible to encounter many events, including deaths, to be falsely attributed
to vaccine through chance association.

A coincidental event is more likely if the same or similar events also affected others in the
same age group around the same time but who did not receive the suspect vaccine(s).
There may also be evidence showing that the event is not related to immunization.
Immediate investigation is critical as a response to the community’s concern about vaccine
safety and to maintain public confidence in immunization.
Ensure appropriate follow-up communication with the affected group or community to
avoid misunderstanding or negative rumours.
Responsibilities of health service providers in preventing, managing and

reporting AEFIs
Community level
Anganwadi and ASHA/volunteers/frontline workers
– Follow up with beneficiaries to identify AEFIs after the vaccination session, using the
beneficiaries list provided by the ANM.
– Inform the adverse event immediately by telephone to concerned ANM, MO, etc.
– Assist in referral of any suspected cases
– Assist the team investigating the event
– Support in building community confidence.
Sub Centre level
ANM
– Follow best immunization practices. Prior to starting vaccination at the RI site, the
ANM must note down (in vaccinator’s logistics diary) the following particulars. This will
help mitigate AEFIs at session site level:
o manufacturer’s name
o expiry date
o batch number
o VVM status (for new and partially used vaccines)
o Date on the label of partially used vaccine (in case of OVP)
o In case of reconstituted vaccines, date and time of opening on the label.

– Ensure that vaccine vial septum has not been submerged in water or contaminated in
any way.
– Provide a list of children vaccinated during the session to the AWW/ASHA and request
them to be alert, follow up and report AEFIs (if any) to her and the concerned MO.
– Ensure reasons for dropouts are entered in the immunization card counterfoils.
– Treat minor/non-serious AEFIs (mild symptoms like fever, pain,etc.) symptomatically.
– For all other cases (serious/severe) provide immediate first aid and refer AEFI to
MO(PHC) or to appropriate health facility for prompt treatment and report. Inform the
MO(PHC) at the health centre immediately by the fastest means possible.
– Share details of all AEFIs (serious/severe and minor) with the MOIC in the weekly block
level meeting. Ensure details of all serious/severe and minor cases are entered in the
AEFI case register maintained at the block PHC (see Annexure 1 for suggested format
for AEFI Case Register).
– Assist in investigation of AEFIs and take corrective action in response to the guidance
from the MO (PHC).
Health supervisors (HSs)
– Supervise and provide hands-on training to the ANMs/vaccinators in the field. This
includes provision of information on referral transport and concerned officials in case
of crisis.
– Monitor the community for adverse events during supervisory visits to immunization
sites or SCs. Also monitor and ensure follow-up of beneficiaries by HWs. Ensure reasons
for dropouts are entered in the counterfoils.
– Encourage the HWs to report AEFIs. Serious/severe AEFIs should be notified immediately
by the fastest means possible.
– Analyze the reported AEFIs in the SC monthly reports and keep track of HWs who have
not reported any AEFI over a period of time.
– Assist the investigation team in conducting the investigation.
Block PHC/CHC/corporation/ward/urban health post
MO In-Charge
Detection of AEFIs
– Train staff in detecting, managing and reporting of AEFIs and differentiating between
minor and serious/severe events. Encourage the staff to report AEFIs.
– During case visits, enquire about any recent outbreak of disease/illness or any death in
the community which may or may not have been related to vaccination.

Management of AEFIs
– Ensure clinical case management of AEFIs and referral to the next level if required.
– Ensure availability of emergency drugs and medical equipment to deal with an adverse
event. Regularly check the emergency kits (functional status of equipment and expiry
of drugs)
– Ensure ANM is familiar with and that the anaphylaxis kit is certified every quarter.
Reporting of AEFIs (Fig. 6.1)
– Ensure timely notification of AEFIs from SC to PHC. Besides immediately informing all
serious/severe AEFIs by telephone / in person, ensure that ANMs provide details of all
AEFIs in their area on a weekly basis. A weekly NIL report from ANM gets submitted
only after an effort has been made to look for these events in the children recently
vaccinated.
– Detailed information of all serious, severe and minor AEFIs notified by HWs should be
recorded in the block AEFI register.
– Ensure weekly submission of information of the number of serious/severe AEFI cases
to the district in the VPD H-002 form. Assessment of Minor AEFI at the BLOCK PHC/PHC
level - see page no 168.
– Conduct timely visits when cases are notified. Completely fill up Section A of CRF
(Annexure 2) and submit the same to the DIO within 24 hours of case notification.
– Maintain quality (e.g. good clinical history, pre- and post-vaccination health status,
community investigation, etc.) during interview and documentation.
Fig. 6.1. Reporting of AEFIs

– Ensure followup and collection of all relevant records including hospital records,
laboratory records, other reports for all AEFI hospitalization cases which have been
reported and investigated and submit the same to DIO.
– In AEFI death cases where postmortem has been conducted, track and collect
postmortem, histo-pathological, toxicology and final cause of death reports and submit
them to the DIO.
– Ensure adequate supervision and monitoring in the field.
– Communicate and share the results of investigation with HWs and the community
wherever warranted.
– For any query from the media, refer the media person/s to the district authorities and
abstain from giving any statements
(Please refer to the AEFI Surveillance and Response Operational Guidelines 2015 for further
details and the activities to be conduced at district, state and national level)
The line list of serious, severe and minor AEFI should be main-
tained at the Block PHC/CHC in the block AEFI register.
Number of serious and severe AEFI should be submitted to DIO as
part of weekly reporting in the H002 form.

Recognition and treatment of anaphylaxis
Anaphylaxis is a very rare but severe and potentially fatal allergic reaction. Train HWs to
distinguish anaphylaxis from fainting (vasovagal syncope), anxiety and breath-holding
spells, which are common benign reactions (Table 6.5).
Table 6.5. Distinguish anaphylaxis from fainting (vasovagal reaction)
Fainting Anaphylaxis
Onset Usually at the time or soon after the Usually some delay, be-
injection tween 5 to 30 mins, after
injection
Systemic
Skin Pale, sweaty, cold and clammy Red, raised and itchy rash;
swollen eyes, face, general-
ized rash
Respiratory Normal to deep breaths Noisy breathing from air-
ways obstruction (wheeze
or stridor)
Cardiovascular Bradycardia, transient hypotension Tachycardia, hypotension
Gastrointestinal Nausea, vomiting Abdominal cramps
Neurological Transient loss of consciousness, relieved Loss of consciousness, not
by supine posture relieved by supine posture
Before immunization, check for contraindications to immunization by asking about known
allergies and previous adverse reactions to vaccines.
Recognition of anaphylaxis
Signs and symptoms of anaphylaxis are given in Table 6.6. In general, the more severe the
reaction, the more rapid is the onset. Most life-threatening reactions begin within 10 mins
of immunization. That is why it is advised that the beneficiary be kept under observation
for at least 30 mins after the injection.
Unconsciousness is rarely the sole manifestation of anaphylaxis – it only occurs as a late
event in severe cases. A strong central pulse (e.g. carotid) is maintained during a faint,
but not in anaphylaxis. Anaphylaxis usually involves multiple body systems. However,
symptoms limited to only one body system (e.g. skin itching) can occur, leading to delay
in diagnosis. Occasional reports have described reactions where symptoms recur 8 to 12
hours after onset of the original attack and prolonged attacks lasting up to 48 hours.

Table 6.6. Signs and symptoms of anaphylaxis

Clinical progression Progression of signs and symptoms of anaphylaxis
Mild, early warning Itching of the skin, rash and swelling around injection site.
signs Dizziness, general feeling of warmth.
Painless swellings in parts of the body e.g. face or mouth.
Flushed, itching skin, nasal congestion, sneezing, tears.
Hoarseness, nausea, vomiting
Swelling in the throat, difficult breathing, abdominal pain.
Late, life-threatening Wheezing, noisy and difficult breathing, collapse, low blood
symptoms pressure, irregular weak pulse.
Treatment of anaphylaxis
Once the diagnosis is made, consider the patient as being in a potentially fatal condition,
regardless of the severity of the current symptoms. Begin treatment immediately; and at
the same time, make plans to transfer the patient immediately to the hospital (if not already
in a hospital setting).
Role of adrenaline
Adrenaline (epinephrine) stimulates the heart, reverses the spasm in the lung passages and
reduces edema and urticaria, thus countering the anaphylaxis. But this very potent agent
can cause irregular heartbeat, heart failure, severe hypertension and tissue necrosis if used
in inappropriate doses.
Every health facility should have health staff trained in treatment of anaphylaxis and should
have rapid access to an emergency kit with adrenaline. They should be familiar with its
dosage and administration. The expiry date of the adrenaline should be written on the
outside of the emergency kit and the whole kit should be checked three or four times a
year. Adrenaline that has a brown tinge must be discarded. Adrenaline has a short expiry
life, so monitor the expiry date on a regular basis.
Steps in initial management
– If already unconscious, place the patient in the recovery position (pronate) and ensure
that the airway is clear.
– Assess heart rate and respiratory rate (if the patient has a strong carotid pulse, he/she
is probably not suffering from anaphylaxis).
– If appropriate, begin cardiopulmonary resuscitation (CPR).
– Give adrenaline 1:1000 (See Table 6.7 for correct dose for age) by deep intramuscular
injection into the opposite limb to that in which the vaccine was given. Subcutaneous
administration is acceptable in mild cases. Also, give an additional half dose around the
injection site (deep intramuscular injection) to delay antigen absorption.

– If the patient is conscious after the adrenaline is given, place his/her head lower than
the feet and keep the patient warm.
– Give Inj. Hydrocortisone IM or slow IV as per dosage chart below (Table 6.8).
– Give oxygen by facemask, if available.
– Call for professional assistance but never leave the patient alone. Call an ambulance
(or arrange other means of transport, after the first injection of adrenaline, or sooner
if there are sufficient people available to help you).
– If there is no improvement in the patient’s condition within 10–20 mins of the first
injection, repeat the dose of adrenaline up to a maximum of three doses in total.
Recovery from anaphylactic shock is usually rapid after adrenaline.
– Record, or get someone to record, vital signs (pulse rate, respiratory rate and blood
pressure), as well as time and exact dose of any medication given. Make sure the
medical and treatment details accompany the patient when s/he is transferred.
– Mark the immunization card clearly so that the individual never gets a repeat dose
of the offending vaccine. At a suitable moment, explain to parents or relatives the
importance of avoiding the vaccine in future.
– Report the occurrence of anaphylaxis to the appropriate officer by phone followed by
the reporting form.
Adrenaline dosage: 1:1000 adrenaline (epinephrine) at a dose of 0.01ml/kg up to a
maximum of 0.5 ml injected intramuscularly (or subcutaneously in very mild cases). If the
weight of the patient is unknown an approximate guide is given in Table 6.7.
Table 6.7. Injection adrenaline (1:1000 solution) dosage chart IM
Age group (in One inch Dosage (in mL) using 1 Dosage (in units) using 40
years) needle gauge mL tuberculin syringe units insulin syringe
0-1 0.05 2
1-6 0.1 4
6-12 24G/ 25G 0.2 8
12-18 0.3 12
Adults 0.5 20
Table 6.8. Injection hydrocortisone (IM or slow IV): dosage chart

Age Dosage
Less than 6 months 25 mg
6 months to 6 years 50 mg
6–12 years 100 mg
>12 years 200 mg

AEFI management centres
Each health facility staffed with a MO in the government as well as the private sector
should be designated as an AEFI management centre. Each block should prepare a list of
such centres dispersed geographically so that in the event of an AEFI, the beneficiary can
be quickly managed. The RI microplan of each HW should include the name, address and
phone number of the MO of the AEFI management centre. All the MOs of the designated
AEFI management centres should be trained in standard AEFI management and reporting
procedures. All AEFI management centres should be provided with AEFI treatment kits
(Fig.6.2, Table 6.9) and standard AEFI reporting forms. Treatment protocol for anaphylaxis
is given in Fig 6.3.
Fig. 6.2.Contents of AEFI kit
Table 6.9.Contents of an AEFI treatment kit

1. Injection adrenalin (1:1000) solution – 8. IV fluids (5% dextrose): 1 unit in plastic
2 ampoules bottle
2. Injection hydrocortisone (100 mg) – 1 9. IV drip set: 1 set
vial 10. Cotton wool, adhesive tape – 1 each
3. Disposable syringe - Tuberculin 11. AEFI Case Reporting Form (CRF)
syringes (1mL) OR insulin syringe 12. Label showing date of inspection,
(without fixed needle of 40 units) 3 expiry date of Inj. adrenaline and
Nos shortest expiry date of any of the
4. Disposable syringe (5 ml) and 24/25G components
IM needle – 2 sets 13. Drug dosage tables for Inj.adrenaline
5. Scalp vein set – 2 sets and hydrocortisone
6. Tab paracetamol (500 mg) – 10 tabs 14. In hospital settings, oxygen support
7. IV fluids (Ringer lactate/normal and airway intubation facility should
saline): 1 unit in plastic bottle be available
IV – intravenous

Fig. 6.3. Treatment protocol for anaphylaxis
Anaphylaxis?
Assess ABC: Airway/breathing/circulation
Diagnosis: Look for acute onset of illness/life threatening

problems with A-B-C/skin changes
Call for help/lay patient flat/raise patient’s legs/keep airway

clear/if necessary give CPR
Inj. adrenaline IM (1:1000 solution) (see dosage Inj hydrocortisone (see dosage chart Table
chart Table 6.7) 6.8)
If no improvement, refer to next level
In hospital settings: establish airway/high flow oxygen/IV fluids
Anaphylaxis kit for ANM

1. Job aid for recognizing anaphylaxis; dose chart for adrenaline as
per age
2. 1 ml ampoule of adrenaline (1:1000 aqueous solution) - 3 nos.
(adrenaline ampoules may also labeled as
epinephrine)
3. Tuberculin syringes (1ml) or insulin syringe
(without fixed needle of 40 units)-3 nos.
4. 24G/25G needles (1 inch) - 3 Nos.
5. Swabs - 3 nos.
6. Updated contact information of DIO, Medical
167
Officer(s) of PHC/CHC, referral centre and
local ambulance services.
7. Adrenaline administration record slips.

Difference between AEFI kit and Anaphylaxis kit

Anaphylaxis
AEFI kit
kit
At health
Outreach
Location facilities with
session
Medical Officer
For use by Medical Officer ANM
Contents
Equipment for intubation and resuscitation Yes No
Ringer lactate, normal saline, 5% dextrose, IV drip
Yes No
set, scalp vein sets(2)
Inj. Hydrocortisone and Tab. Hydrocortisone Yes No
Cotton wool Yes Yes
Inj. Adrenaline ampoules Yes Yes
24G/25G needles 1 inch length Yes Yes
Tuberculin syringes (1ml) or Insulin syringes (40 units,
Yes Yes
without fixed needles)
Fig. 6.4
Age group mL UNITS

0-1 years 0.05 2.0
1-6 years 0.1
4.0
6-12 years 0.2 8.0
12-18 years 0.3 12.0
Adults 0.5 20.0
TUBERCULIN INSULIN
SYRINGE – 1.0 mL SYRINGE –
40 UNITS
1.0 40.0

Role of Medical Officer in Anaphylaxis management
• Encourage staff to insist on caregivers waiting for at least half hour

Detection following vaccination
of AEFIs • Train staff in suspecting, detecting and reporting of AEFIs
• Encourage staff to report AEFIs
• AEFI management centres in health facilities to be identified in

microplans
• Ensure availability of emergency drugs and medical equipment to
Management
deal with an adverse event
of AEFI
• Regularly check to emergency tray (Functional status of equipment
and expiry of drugs) and AEFI kits
• Provide apporpriate treatment to AEFI cases and refer if needed
Quarterly certification of ANM anaphylaxis kit by Medical Officer

• Medical officer will ensure availability of anaphylaxis kit with all ANMs at session sites/
sub centre during field visits.
• He will examine contents of the anaphylaxis kit at least once a quarter
• He will ensure injection adrenaline and other logistics do not have expiry dates within
the next three months of the visit
• If the expiry date of any logistics is within three months of visit, this will be replaced
during the next visit of the ANM to the PHC and signed by the Medical Officer in the
following format which will be part of the kit
Name and contact number of
Name of subcenter: Name of ANM:
MO
Date of Action required Action taken,
Expiry date Signature
Check- Contents (replace am- signature of
of contents of MO
ing poule /syringe) MO, date
1 ml ampoule of
adrenaline (1:1000
aqueous solution)-3 Nos.
1 ml syringes-3 nos.
1 ml ampoule of
adrenaline (1:1000
1 ml ampoule of
adrenaline (1:1000

162
Annexure 1 – Format for block AEFI register
Week Name of Name of Father’s Age Date of Name of Batch AEFI noted Category Case Entered
No sub- vaccinee name vaccination vaccines given number of (symptoms) (serious/ seen in case
centre vaccines severe/ by reporting
given minor) MOIC form
(Yes/ (Yes/No)
No)
1. Kindly follow the AFP Surveillance Calendar to identify week no.

2. Information on serious and severe AEFI should be shared weekly with the district along with the H-002 form
3. The details of Minor AEFI are to be maintained at Block Level and monthly cumulative data to be entered in HMIS report

Annexure 2 – AEFI Case Reporting Form


Annexure 3 – AEFI case definitions and treatment

Adverse event Case definition Treatment Vaccines
Acute flaccid • Acute onset of flaccid paralysis within 4 No specific treatment Oral polio
paralysis (AFP) to 30 days of receipt of OPV, or within 4 available; supportive vaccine
to 75 days after contact with a vaccine care (OPV)
recipient
• Neurological deficits remaining 60 days
after onset
• Death
Anaphylactic • Exaggerated acute allergic reaction Self-limiting; anti- All
reaction (acute occurring within 2 hours after histamines may be
hypersensitivity immunization, characterized by one or helpful
reaction) more the following:
• wheezing and shortness of breath due
to bronchospasm
• one or more skin manifestations, e.g.
hives, facial oedema, or generalized
oedema. Less severe allergic reactions
do not need to be reported
• laryngospasm, laryngeal oedema
Anaphylaxis • Severe and immediate allergic reaction Adrenaline injection All
(within 1 hour) leading to circulatory
failure with or without bronchospasm
and/or laryngospasm/laryngeal oedema
Arthralgia • Joint pain, usually including the small Self-limiting; analgesics Rubella;
peripheral joints. Persistent if lasting MMR
longer than 10 days; transient if lasting
up to 10 days
Brachial neuritis • Dysfunction of nerves supplying the Symptomatic only; Tetanus
arm/shoulder without any other analgesics
involvement of the nervous system
• A deep, steady, often severe aching
pain in the shoulder and upper arm,
followed in days or weeks by weakness
and wasting in arm/shoulder muscles
• Sensory loss may be present, but is less
prominent. May present on the same or
the opposite side to the injections and
sometimes affects both arms
Disseminated • Widespread infections occurring Should be treated BCG
BCG infections within 1 to 12 months after BCG with anti-tuberculous
vaccination and confirmed by isolation regimens including
of mycobacterium bovis BCG strain. isoniazid and rifampicin
Usually in immunocompromised
individuals

Encephalopathy • Acute onset of major illness No specific treatment Measles,

characterized by any two of the available; supportive pertussis
following three conditions: care
• Seizures
• Severe alteration in level of
consciousness lasting for one day or more
• Distinct change in behaviour lasting 1
day or more
• Needs to occur within 48 hours of
DTP vaccine or from 7 to 12 days after
measles or MMR vaccine to be related
to immunization
Fever • The fever can be classified (based on Symptomatic; All
rectal temperature) as: paracetamol
• Mild: 100.4°F to 102°F (38 to 38.9°C),
• High: >102°F to 104.7°F (39 to 40.4°C) and
• Extreme: 104.8°F or higher (40.5°C or
higher).
• High/extreme fever should be reported.
Hypotonic • Event of sudden onset occurring within The episode is transient Mainly
hyporesponsive 48 (usually less than 12 hours) of and self-limiting, DTP,
episode (HHE) or vaccination and lasting from 1 min to and does not require rarely
shock-collapse several hours, in children younger than specific treatment. It is others
10 years of age. All of the following not a contraindication
must be present: to further doses of the
• Limpness (hypotonic) vaccine
• Reduced responsiveness
(hyporesponsive)
• Pallor or cyanosis, or failure to observe/
recall
Injection site • Fluctuant or draining fluid-filled lesion Incise and drain; All
abscess at the site of injection antibiotics if bacterial
• If evidence of infection (purulent,
inflammatory signs, fever, culture) then
consider as bacterial if not consider as
sterile abscess
Lymphadenitis • At least one lymph node enlarged to Heals spontaneously BCG
(includes >1.5 cm in size (one adult finger width), (over months) and
suppurative or a draining sinus over a lymph node best not to treat
lymphadenitis) • Almost exclusively caused by BCG and unless lesion is sticking
occurring within 2 to 6 months after to the skin. If so, or
receipt of BCG vaccine, on the same if already draining,
side as inoculation (mostly axillary) surgical drainage and
local instillation of
anti-tuberculosis drug.
Systemic treatment
with anti-tuberculosis
drugs is ineffective

Osteitis/ • Inflammation of the bone with isolation Should be treated BCG

osteomyelitis of mycobacterium bovis, BCG strain with anti-tuberculosis
regimens including
isoniazid and rifampicin
Persistent • Inconsolable continuous crying lasting Settles within a day or DTP,
inconsolable 3 hours or longer accompanied by high- so; analgesics may help pertussis
screaming pitched screaming
Seizures • Occurrence of generalized convulsions Self-limiting; supportive All,
that are not accompanied by focal care; paracetamol and especially
neurological signs or symptoms. cooling if febrile; rarely pertussis,
Febrile seizures if temperature anticonvulsants measles
elevated >100.4°F (rectal); afebrile
seizures if temperature normal
Sepsis • Acute onset of severe generalized Critical to recognize All
illness due to bacterial infection and and treat early. Urgent
confirmed (if possible) by positive transfer to hospital for
blood culture. Needs to be reported parenteral antibiotics
as possible indicator of immunization and fluids
error
Severe local • Redness and/or swelling centered at Settles spontaneously All
reaction the site of injection and one or more of within a few days to
the following: a week. Symptomatic
• Swelling beyond the nearest joint treatment with
• Pain, redness, and swelling of more analgesics. Antibiotics
than 3 days duration are inappropriate
• Requires hospitalization
• Local reactions of lesser intensity occur
commonly; these are trivial and do not
need to be reported
Thrombocy- • Serum platelet count of less than 50 Usually mild and self- MMR
topaenia 000/ml leading to bruising and/or limiting; occasionally,
bleeding may need steroid or
platelets
Toxic shock • Abrupt onset of fever, vomiting and Critical to recognize All
syndrome (TSS) watery diarrhoea within a few hours and treat early. Urgent
of immunization. Often leading to transfer to hospital for
death within 24 to 48 hours. Needs to parenteral antibiotics
be reported as possible indicator of and fluids
immunization error.
Note: Brighton Collaboration has developed case definitions for many vaccines reactions that are available
at www.brightoncollaboration.org.
For further details refer to the AEFI Surveillance and Response Operational Guidelines 2015.

168
Assessment of Minor AEFI at the BLOCK PHC/PHC level
(Format to be shared in the first week of every month to DIO)
To be filled by inchrge Block Medical officer
Month Year:
Name of the BLOCK PHC/PHC in charge: Block Name: Date:
Phone Number: District:
Following table need to be filled up after reviewing block AEFI register of respective month. Tabulate the data for minor AEFIs listed in
respective month.
Name of Distribution of Minor AEFIs line listed in block AEFI register as per their clinical presentation
PHC Fever <39 Local Localised Localised Irritability Malaise Systemic symptoms Any other unusu-
/SubCenter degree Swelling Pain Redness ( ex. Fatigue etc ) al MINOR events
Total
Any Aggregation or Clustering ( Tick on appropriate ) Possible reason Action proposed

A) Antigenwise and Batch wise If antigenwise , does it ex-
ceed expected reaction rate. Refer Table No. 1 ( Yes /No )
B) Subcenterwise/Vaccinator wise
C) Dose wise (First, Second, Booster Etc.)
D) Any other ( ex. Unusual minor event )
Name of Incharge Medical officer- Signature-

Unit 7 : Sources and use of data
7
Sources and use
of data
In every situation and/or meeting, there is usually a direct or an indirect reference to
“data”. As MOs, you are constantly reminded to review your data, analyse your data and to
decide your actions based on data. However, many times this is not as straight forward as
it appears. Data has to be carefully utilized and interpreted; and when done, should enable
you to make very appropriate and confident decisions. Data handling is not limited to the
data manager, even the ANM in the field can use the data to better understand how her RI
sessions are performing; an ANM in the PHC can look at the immunization records in the
labour room and better understand how to ensure all newborns are vaccinated.
Data management process
A flowchart of the data management process is given in Fig 7.1.

Fig. 7.1. Data management process
Collect Collate Represent Interpret Decide
Collect
This refers to the data collection instruments or sources of information in the raw form.
This includes all registers such as OPD Register, Vaccine Stock Register and OT Register, tally
sheets (e.g. Polio, RI session) and supervisory formats. All these contain information that
can be made useful.
Collate
Collation means entering the data into the system or into a reporting format. Thus, data
normally at a block level can be used in making reports when called for by the district or
the state. Data can be collated to better understand how your block is functioning, e.g.
extracting information on only number of Hep B birth doses administered at your PHC over
the last 3 months.

Represent
Presenting data has been made very simple with easily accessible software such as
PowerPoint and Excel. It is important to decide which data to present based on which forum
it is required for. For example, showing the number of births versus the number of HepB
birth doses given at your PHC (Fig 7.2) during a weekly meeting can help to drive home the
point to ANMs and staff.
Fig. 7.2. Sample graph – births and Hep B vaccinations
Interpret
Interpret
What does my data say? Continuing with the above example,the graph in Fig. 7.2 shows
that there is a difference between the number of births and HepB birth doses given. The
possible reasons are:
o children born on Sunday do not receive the dose
o children are vaccinated during the daytime only
o Some mothers refuse to be admitted for 2 days.
This example demonstrates that when data is presented,you can interpret to an extent; but
if discussed with the staff, more reasons can be brought out and solutions identified.
Decide
Based on the above example, the MO can identify an issue, and following discussions with
staff or during meetings, can then take decisions on correcting or restructuring systems in
the PHC. For example, to increase the HepB birth dose, a decision could be – “one vaccine
carrier with RI vaccines will be issued to the labour room to ensure administration of birth
doses to all newborns at the PHC”.

Sources of immunization data

Fig. 7.3. Sources of immunization data
HMIS – Health Management Information System; MCTS- Mother and Child Tracking System; DLHS - District
Level Health Survey; AHS – Annual Health Survey; CES- Coverage Evaluvation Survey; NFHS – National
Family Health Survey; IDSP – Integrated Disease Surveillance Project; NPSP – National Polio Surveillance
Project; CBHI– Central Bureau of Health Intelligence; SRS– Sample Registration System; MIS – Management
Information System;
Monthly Progress Report
The Monthly Progress Report is a report of the SC submitted by the ANM at the end of
each month. This report is based on correctly filled tally sheets, Maternal and Child Health
(MCH)/ Reproductive and Child Health (RCH) registers and other records. Data must be
recorded completely and correctly as follows:
• Yearly target of infants must be based on actual head count.
• Immunization with each antigen dose needs to be filled in correctly.
• All VPDs and AEFIs should be reported to the PHC for followup.
The cumulative coverage will enable you to calculate the coverage of each antigen and the
dropout rates. Since this is the basis of obtaining all coverage and epidemiological data at
state and national levels, the data must be recorded accurately.

Coverage Monitoring Chart
Coverage monitoring chart is a useful tool which provides information at a glance on target
figures and the immunization coverage, particularly in terms of left-outs and dropouts. The
supervisor should plot the immunization data on the chart during visits to the SC (as given
in Fig.7.4). It should be updated every month.
Here is an example for calculating coverage, dropouts and left-outs for Penta1 and Penta3.
A similar chart can be prepared for other vaccines.
Fig 7.4. Coverage Monitoring Chart
The coverage monitoring chart has a vertical and a horizontal axis. Vertical axis is divided
into 12 equal parts, each representing the monthly target. Write cumulative target against
each month. If the yearly target of infants in a Sub-centre is 360 children, then the monthly
target is 360/12 = 30 children. Therefore, the cumulative target for April will be 30; for May
it will be 60 (30 + 30); for June it will be 90 (30 + 30 + 30); for July it will be 120 (30 + 30 +
30 + 30), etc.
On the horizontal axis, the months of the year are given starting from April to March. In
the rows below each month, write the total number of children immunized with Penta 1
and Penta 3 during that month and also cumulative till that month. On the graph, plot the
cumulative total of Penta 1 for each month (on the right side of the column). Similarly, plot
for Penta 3 in a different colour in the same column.

Calculating coverage for an antigen at any time

= Total Antigen administered X 100
Yearly target
Eg- Coverage for Penta 1 from Apr till July is:

104 / 360 X 100 = 28.8% rounded off = 29%
Calculate the total number of dropouts and the Dropout Rate (%) as follows:
= (Penta 1 cumulative total - Penta 3 cumulative total) x100
Penta 1 Cumulative total
Using routine data for action
As a first step to data analysis, you should:

• Ensure that the vaccination coverage report is received from all ANMs through alternate
vaccine delivery system after each session;
• Check the data from the monthly progress reports (HMIS/MCTS) for timeliness and
completeness.
Steps in using routine data for action (refer data in table 7.1 on page 176)
There are three major steps in using routine data.
Step 1. Quantitative data analysis to identify priority health centres for improving coverage
• Compile the population and coverage data for last quarter / full financial year.
• Calculate the immunization coverage of BCG, Penta 1, Penta 3 and Measles/MR first
dose.
• Calculate the number of unimmunized with Penta 3.
• Calculate drop-out rates (BCG- Penta 3, Penta 1- Penta 3 and BCG-MCV1).
• Identify problems of access and utilization as follows:
o Access is good if Penta 1 coverage is >80% and poor if <80%.
o Utilization is good if dropout rate is <10% and poor if >10%.
• Prioritize the centres based on number of unimmunized children e.g. UHC Dolatpara
with highest number of immunized children is given priority 1 followed by UHC
Ganeshnagar, Timbawadi etc.

Step 2. Qualitative data analysis to identify problems (based on local wisdom and
observations from the RI monitoring/supervision)
This involves collection, compilation and analysis of data from monitoring checklists.
– After the supervisory visits, collect the session and house-to-house monitoring
checklists to compile the data on the following key indicators:
• Percentage of polio HRAs visited;
• Percentage of sessions held;
• Percentage of sessions where beneficiaries were found mobilized to session sites
by ASHA/AWW;
• Percentage of sessions where vaccines and logistics found brought to session site
by AVD system;
• Percentage of sessions with any reconstituted vial in use after the specified time
has lapsed;
• Percentage of sessions where due list of beneficiaries found available with ANM;
• Percentage of sessions where due list of beneficiaries found available with ASHA/
AWW;
• Percentage of sessions where ANM found cutting each syringe with hubcutter
immediately after use;
• Percentage of sessions where session site waste is segregated in red and black
bags;
• Percentage of sessions where four key messages are found given to the parents;
• Percentage of sessions where caregiver is advised to wait for 30 mins after
vaccination.
– Check for ANM area-wise indicators from the house-to-house monitoring checklists,
such as:
• Percentage of households where RI/MCP card is available;
• Percentage of fully immunized children;
• Percentage of partially immunized children;
• Percentage of unimmunized children;
• Drop-out rates (BCG and measles/MR ,Penta1 and Penta3 , Penta3 and DPT
booster, MCV1 and MCV2 etc.)
– Identify areas with large number of left-outs and dropouts; conduct the reason
analysis to identify issues.

– Correlate the house-to-house monitoring data with data from session site monitoring
to identify the root causes of the problems. For example, if the problem is a high
dropout rate, then the causes could be:
• poor social mobilization as due list not prepared, ASHA not working
• key messages not given at the session site
• session not held, etc.
– Initiate actions. For example, plan to involve volunteers/link workers
– Identify root causes of the major problems such as:
o vacant positions of HWs and social mobilizers
o cold chain capacity and stock availability
o sessions held versus planned
o hard-to-reach or HRAs
o training issues, behaviour of HWs and community
o IEC and IPC issues.
Step 3. Prepare action plan
• Identify interventions to improve coverage in terms of
o short-term and long-term activities;
o activities that can be done with limited resources (more supervisory visits, training,
better use of data tools) and those that need extra resources (mobility support);
• Develop an action plan for implementing the activities with expected timeline, name
of responsible person and funds required;
• Identify additional requirements and budget them in the next PIP with appropriate
justification.
Table 7.1 gives the steps involved in identifying priority health centres for improving
coverage while a sample action plan is given in Table 7.2.

176
Table 7.1 gives the steps involved in identifying priority health centres for improving coverage.
Table 7.1.Data analysis to identify priority health centres for improving coverage (UHCs Of Junagadh)
Step 5:
Step1: Compile population and immunization coverage Step 4:
Step 2: Calculate coverage Step 3: Analyse the problem Prioritize
data of last financial year (Apr 14–Mar 15) Identify problem
area
a b c d e f
UHC Name Infant BCG Penta 1 Penta 3 MCV1 BCG Penta 1 Penta 3 MCV1 Unimm BCG- Penta 1 – BCG- Access Utilization Priority
populati doses Doses Doses cover Coverage Coverage Coverage unized Penta 3 Penta 3 MCV1 (1,2,3.)
on adminis adminis admini age (%) (%) (%) with Drop- Drop- out Drop-out
tered tered stered (%) Penta 3 out rate rates (%) rate
(No.) (%) (%)
Ambedkar Nagar 354 273 211 102 29 77 60 29 8 252 63 52 89 Poor Poor 4

Dolatpara 1076 614 511 342 389 57 47 32 36 734 44 33 37 Poor Poor 1
Ganeshnagar 963 591 497 370 233 61 52 38 24 593 37 26 61 Poor Poor 2
Shanteshwar 632 450 455 441 298 71 72 70 47 191 2 3 34 Poor Good 5
Timbawadi 801 483 431 226 98 60 54 28 12 575 53 48 80 Poor Poor 3
Total 3826 2411 2105 1481 1047 63 55 39 27 2345 39 30 57 Poor Poor
182

Table 7.2 – Action plan for improving RI coverage

Your role as an MO in data management and use

Table 7.3. Role of MO in data management

Medical Officer’s Activity How
role
Understanding • Explore the sources of data • Allocation of time with data
sources of data available at your centre handler/data operator/
• Understand the types of personnel involved in
reports generated reporting
• Build capacity of data
manager to generate data
output
Improving quality • Cross check data randomly • While signing documents/
of data • Timeliness and reports, cross check the data
completeness of reports with original formats
• Quality of data capture • During field visits, discuss the
tally sheets being used with
ANMs/personnel
• Involvement of data manager
in meetings to identify and
solve data issues
Using data for • Produce graphs from data • Encourage the data manager
action • Coverage monitoring charts to produce graphs and
at PHC/SC represent data
• Data interpretation • Insist on the use of the
coverage monitoring chart
both at your PHC and by
ANMs at SC to track coverage
of various antigens
• Use these charts in meetings
for tracking progress

 To describe the importance of supervision and monitoring
 To list the steps for conducting supportive supervision
 To explain the steps for conducting effective review meetings Unit 8 : Supervision and monitoring
 To list common issues observed during monitoring and supervision of the

immunization programme me
8
plan for improving immunization coverage
 Supervision and d children”.
monitoring
upervision and monitoring
Supportive supervision is a process of guiding and assisting staff to continuously

- improve
their aown
uthoritarian way with work
focus performance.
on using It is carried
supervisory visits asout
an in a respectfultoand
opportunity non-authoritarian way
improve
with a focus on using supervisory visits as an opportunity to improve the knowledge and
-way
skills of health staff. Supervision encourages open, two-way communication and builds
team approaches that facilitate problem solving.
aspects of
Monitoring involves regular collection and analysis of data on various aspects of programme
activities. Monitoring can be done through desk review of reports, providing feedback on
roviding feedbackphone
on phone
or byor by e--mail/letter
e-mail/letter during during the meetings
the review review meetings
as well asasduring
well as
supervisory visits.
uring supervisory visits.
Fig. 8.1.Supervision matrix
g. 8.1.S
8.1.Supervision matrix
Step 1: Prepare for supportive supervision
Right supervisors Right tools Right resources
Step 2: Plan regular supervisory visits

Where to conduct visits When to conduct visits What to do during visits
Step 3: Conduct supportive supervision visits

Problem solve and Provide on-the-job Record results of
Collect information
provide feedback training supervision
Step 4: Follow up
Follow up on Analyse data Provide feedback Conduct follow-up
agreed actions regularly to all stakeholders visits
Supervision must involve interaction

188 with staff and usually also has an element of monitoring.
During the supervisory visit, the supervisor can monitor the quality of service delivery, find
out the reasons for unimmunized and under-immunized children and plan interventions
to reach and sustain them. It can be done at session site and house-to-house (community)
using the monitoring formats at the end of this Unit.

Unit 8 : Supervision and monitoring
Steps for conducting supportive supervision
Step 1: Prepare for effective supportive supervision

Ensure the following three main “Rights” as follows:
• Right supervisors
Identify and prepare a pool from the available staff, i.e. MOs (including AYUSH), health
supervisors, ICDS supervisors, block programme managers, immunization field volunteers,
etc. Train them on the immunization schedule, the process and the information to be
collected.
• Right tools
Use monitoring formats and SOPs for session, house-to-house and block (for recording
observations) , also use training materials and job aids (to update skills of HWs during the
visits).
• Right resources
Ensure that sufficient mobility and time is allocated for the visits and followup.
Step 2: Plan regular supervisory visits
Plan regular supervisory visits as per the microplan, considering three “Ws”:
• Where to conduct visits (priority areas)
• When to conduct visits (on immunization session days after informing the HWs)
• What to do during visits (review data and previous supervision and monitoring reports)
Prioritization of areas
An updated RI microplan is a prerequisite for monitoring, as it helps to prioritize the areas
for monitoring visits. The priority should be to visit:
• listed HRAs in the microplan
• areas missed in the microplans
• villages with vacant SCs
• peri-urban underserved areas
• ANM with large catchment population
• area with reported measles outbreak, wild polio virus (WPV) or vaccine derived polio
virus (VDPV)
• migrant and mobile populations
• areas with low RI coverage/resistance.

Step 3: Conduct supportive supervision visits

Session site visit
After deciding the area to be visited, plan to visit the nearest session site catering to that
area. Visit the session site on the scheduled day and time and collect information using the
session monitoring format. If the session is held, do the following:
o observe the ongoing session, e.g. who is mobilizing the children, how the HW is
vaccinating each child, messages provided by HWs, etc.
o interview the HWs for additional information, e.g. supervisor visits made, Measles/
MR2 dose, RCH register, ASHA incentives, etc.
o interview any three caregivers to know who has mobilized them.
House-to-house visit
• If the session is not being held, (find out the reason for the same) proceed for house-
to-house monitoring. House-to-house monitoring helps in rapid assessment of RI
coverage in the community. Visit 10 households with children aged 0–35 months (<3
years) and collect data on the house-to-house monitoring format through RI/MCP card
and interviews of caregivers.
Before leaving the field
• Provide feedback to the health staff concerned. Start with positive feedback followed
by the specific weaknesses
• Identify problems, discuss the causes of the problem with health staff and plan the
solutions
• When required, provide on the job training as an immediate solution. First explain and
demonstrate the skill, then allow the HWs to practice the skill, providing feedback till
they learn.
Step 4: Followup
After the supervisory visit, you should:
• followup on the agreed actions in the implementation plan;
• discuss with other block officials (MOIC, etc.) the issues of RI implementation in the
block , if related to their department – e.g. departments of education, women and
child development (ICDS), power supply , etc.
• provide a feedback to higher levels for support in problem solving;
• conduct follow-up visits to see if the recommendations are being implemented and if
there is improvement in the performance of the HWs.
• Record results of supervision and prepare the report.

Common issues observed during monitoring and supervision of the

immunization programme
The following issues have been identified during regular monitoring in the field. This is
not an all inclusive list but helps to categorize issues to enable corrective actions.
Human resource issues
• Vacant SCs
• Inadequate hiring of alternate vaccinators for vacant urban and rural areas
• Irrational distribution of the workload/areas among the HWs within a block
• Absenteeism of HWs
• Lack of designated cold chain handlers at cold chain points
• Lack of regular capacity building of knowledge and skills of health staff.
Microplanning issues
• Microplan not prepared or incomplete with only roster of the HW
• Missed areas and population groups, e.g. migratory and mobile population, urban
slums, hamlets and geographically distant population not included
• Microplans not based on head count survey
• Map of the SC and PHC not prepared/displayed
• Area demarcation of SC with two ANMs is not done to clarify their individual roles
• Microplans are not reviewed at regular intervals.
Operational issues
• List of due beneficiaries for the sessions is not prepared
• All the planned sessions are not held by ANM due to leave, post being vacant,
ANM not going to the site
• Poor attendance at outreach sessions due to poor mobilization by ASHA and AWW
• Late start of session and early closing of session site
• Non-availability of all vaccines and logistics at the session site
• Incorrect route/site/technique used for vaccine administration
• Date and time not recorded on reconstituted vaccine vials
• 4 key messages not conveyed to the beneficiary/caregiver
• Coverage monitoring chart and tracking bags not available at PHC or SC

Cold chain and logistics management issues

• No dedicated trained person in charge of cold chain at PHC level
• Job aids for cold chain maintenance not displayed at cold chain point
• Guidelines for correct storage of vaccines and diluents in ILR not followed
• Temperature not recorded twice a day; recording by cold chain handler not
monitored
• Contingency plan for emergencies not prepared/followed
• Preventive maintenance of cold chain equipment not in place
• Presence of snake anti venom/other drugs/eatables in ILR along with vaccines
• Stock registers not updated and supervised for record of issue and balance of
vaccines and other logistics
• Timely indenting of vaccines and logistics not done resulting in stock-outs being
reported.
Recording and reporting system issues
• RCH/MCTS register not updated regularly and not used in preparation of
beneficiary due list.
• Careless recording in immunization/MCP card; counterfoils not maintained
• Due list-cum-tally sheets not used for session-wise recording
• No system for identification and tracking of dropouts and left outs
• Monthly reports – incomplete and not analyzed for feedback and action
• AEFI and VPD cases not being reported or being underreported
• Block AEFI registers not being used.
Injection safety and waste disposal issues
• Hub cutter not available/not being used immediately after vaccination/
reconstitution
• Red and black bags not available/not being used
• Disinfection of immunization waste not practiced before disposal
• Sharps pits for needles not constructed/functional at PHCs.
Monitoring and supervision issues
• Supervisory visits not planned/conducted by health and ICDS supervisors in
priority areas
• Review meetings not used for providing feedback of monitoring and use of data
for action.

Issues in community involvement and communication

• Weak coordination with other related agencies and sectors such as private and
NGO sectors
• Lack of information, education and communication (IEC) and social mobilization
activities contributing to poor utilization of services
• Four key messages not being given to beneficiaries at sessions.
Steps for conducting effective RI review meetings
Meetings are regular event at a PHC, use each meeting as an opportunity to identify,
solve issues with service delivery.
Prepare for the meeting
• Determine the objectives of the meeting based on review of the minutes of
previous meetings, monitoring reports and any new guidelines/topics to be
discussed
• Prepare the agenda including objectives, list of topics to be covered, name of the
facilitator for each topic and the time duration
• Assign logistic arrangements to the members of the team
• Assign talks on specific technical topics to concerned supervisors and colleagues
• Inform the date, time and place of the meeting to all participants.
Conduct the meeting
• Start the meeting on time
• Enquire if participants are comfortable. Make changes if needed.
• Follow the agenda closely during the meeting to ensure that set objectives are
met
• Ensure that the meeting is focused and participatory
• Keep listening and summarizing the key points raised at regular intervals
• Ensure that minutes are taken with actionable points and timelines
• Summarize the action points, including persons responsible and deadlines
• Agree upon date of next meeting
• Thank participants.
Followup
• Forward unresolved issues to the district level for necessary action
• Examine the meeting process. Assess and make a plan to improve the next meeting
• Followup in writing to document key action points.
A sample agenda for a PHC review meeting of ANMs is given in Table 8.1.

Table 8.1: Sample agenda for PHC review meeting of ANMs

Time Activities Facilitators
10:00–10:15 Welcome & objectives of the meeting MOIC
10:15–11:15 Feedback on supervisory visits and MO/health supervisor/
monitoring data partner
11:15–11:45 Feedback on data analysis from the monthly health supervisor
reports for left-outs and dropouts
11:45–12:30 Review of microplans, immunization records/ MOIC
reports, any other issues such as ASHA/AWWs
involvement in mobilization of beneficiaries
12:30 –13:00 Action plan to improve coverage and track MOIC/health
missed children supervisor
13:00–13:15 Summary and conclusion MOIC
Quarterly review meetings
Under National Health Mission, there is a provision to conducting quarterly review meetings
for RI at block level under part C, FMR code c.1.f (refer Unit 13) for ASHAs. As per norms,
Rs. 50/ per person as honorarium for ASHA (Travel) and Rs. 25/person at the disposal of
MO-IC for meeting expenses (refreshment, stationary and misc. expenses) is available for
conducting review meeting four times in a year.
These funds should be utilized for improved planning and supervision of front line health
workers for Routine Immunization activities.
Tracking tools to track ‘dropouts’

Various tracking tools are as follows:
• MCP Card with counterfoil
• Tracking bag
• Immunization/RCH/MCTS Registers
• Name-based list of due beneficiaries (refer SOP RI form 6 - Unit 3)
Mother and Child Protection (MCP) card with counterfoil

The MCP Card is a tool for families to learn, understand and follow positive practices for
achieving good health of pregnant women, young mothers and children.
The card gives information on the immunization schedule and the doses of Vitamin A to be
given to the child during the first five years. Boxes in the chart indicate each type of vaccine,
date to be given, date when it was given and age.

Details that would be available from MCP Card are:

• the date in the pink box when the child is expected to come for next immunization
• the date in the white box when the child came for immunization.
How to use the card
• During the first visit, fill the information on the cover page on “Family Identification
and Birth Record”.
• Record the date, month and year of all entries clearly.
• Explain the section on immunization by explaining which vaccines have been given
and which vaccines are due, with dates.
• Do not leave any cells or columns blank.
• After filling up all the columns, retain the smaller portion of the card (counterfoil).
• Give the rest of the filled-in card to the parent of the child after immunization and
ask her to bring the same card during her subsequent visits to the health centre.
• Advise families to keep the card in a safe place to prevent it from damage.
• Advise families to bring the card along when they visit the Anganwadi Centre
(AWC), SC, health centre, private doctor or a hospital.
• At the end of each session, the counterfoils should be placed in the appropriate
pocket of the tracking bag.
• Each month, look at the counterfoils in the tracking bag and make sure those
children come for immunization. If they miss the session, ask the ASHA/AWW to
follow up with those families and ensure that they attend the next session.

Fig 8.2 – Infant RI card and counterfoil
Tracking bag
Keeping counterfoils in tracking bag helps in:

• preparing a session-wise name-based list of due beneficiaries for sharing with the
ASHA/AWW/mobilizer
• estimating the vaccine requirement for the next session
• tracking the dropouts
• providing information, if the beneficiary/parent has lost the immunization card.

The counterfoils need to be filed separately for each Figure 8.3: Immunization tracking
session site. A cloth tracking bag with 15 pockets is a
simple, easy to use tool for filing the counterfoils (Fig.
8.3 and 8.4). The first 12 pockets indicate each of the 12
months of the year. The thirteenth pocket is for those
who left/died during the period, the fourteenth pocket
is for fully immunized children and the fifteenth pocket
is to store blank MCP cards.
Once a beneficiary is immunized, the counterfoil would
be placed in the month (pocket) due for the next dose
(see Fig 8.4). For example, if a child comes for Penta 1
in January, Penta 2 is due in February. Update and place
the counterfoil in the February pocket.
When the Penta 2 dose is given in February, update the
counterfoil and move to the pocket for March. When the
Penta 3 dose is given in March, then update and place
the counterfoil in the September/October pocket since
the child has to return for measles/MR vaccine.
• If some cards are left in the pocket at the end of the month, it indicates that the
beneficiaries are the dropouts.
• Move these cards to the next month’s pocket and track them.
Fig 8.4 How to use tracking bag
Fig 8.4 How to use tracking bag
188 Immunization
Fig 8.4 How tohandbook for Medical
use tracking bag Officers
In case no tracking bag is available, counterfoils for each month can be separately tied with
different rubber bands and labelled. File counterfoils for each session site separately and do
not forget to carry them to the session.
Immunization/RCH/MCTS Registers
Immunization / RCH / MCTS registers help to record and track each pregnancy and
immunization. It should be:
• updated to include new pregnancies and births from the records of AWWs and ASHAs
before each immunization session;
• updated after each session on the basis of counterfoils filled during the session;
• if the beneficiary is from outside the catchment area, the HW should issue a new
card and give appropriate vaccination. Record should be entered in the non-resident
column of the register;
• if the beneficiary receives vaccination from a private practitioner, the HW should record
the same in the MCH register and the immunization card and write “P” after the date.
Conducting an effective RI session
For an RI session to be effective, there are some points that need to be addressed. These
are enlisted below:
• Appropriateness of location
• Setting up the site for safe injections:
o Basic furnishings and spacing
o IEC display
• Advance information to community
• Information on arrival.
Field Tip: “SAME DAY, SAME SITE, SAME TIME”

Ensuring the RI session is conducted on the same day, at the same site and at
the same time builds community confidence and faith in the system and health
worker.

Appropriateness of location
The RI session site should be:

• easily accessible and identifiable – using the IEC posters/banners at a visible point;
• located in the same place each and every time;
• in a clean area, out of the sun and rain – avoid open-air sites;
• having space either within the premises or near a sheltered/shaded area where those
needing vaccination can wait;
• large enough to provide space to have separate stations for—registration and
assessment; immunization and record keeping; and screening/education on other
health issues;
• quiet enough for HWs to be able to explain what they are doing and to give advice.
All these parameters may not be possible at all places. However, in many instances it is
possible with community support to ensure the best resources in the available circumstances.
The MOs must visit all the RI session sites over the course of a few months and ascertain
their appropriateness.
All communities are very proactive and supportive towards immunization services if they
are involved in the planning process. It is necessary at times to reach out to the community
through key influencers and local leaders in areas where ground realities make it difficult to
identify or locate the site.
An ideal set-up for an RI session is shown in Fig. 8.5.
Setting up the site
Displaying IEC material, i.e. either the poster or banner or even both outside the session
site informs the community of the arrival of the ANM and that the RI session site is now
functional. The IEC display should be visible from the approach road and clearly identify the
session site. The ANM should spend time after arriving at the session site to arrange the site
to make it as convenient as possible for her and her supporting ASHA/AWW and also for the
community that comes for services.
Sourcing furniture or requesting support from the community reflects the rapport of
HWs and community involvement. In places where there is less support, it is necessary to
address the issue with the community leaders at the earliest. Though this may seem an
unimportant or minor issue, lack of community involvement is a factor that has a negative
impact on RI coverage and mobilization of beneficiaries. A well setup RI session helps to
build community confidence and also contributes to providing a quality experience for the
HWs and beneficiaries.

Fig. 8.5. Ideal.Set-up for an RI session
Advance information to the community
Providing advance information of the upcoming RI session in an area has many advantages.
Various examples exist across the country, e.g. issuing invitation cards to beneficiaries,
house-to-house visits by ASHA/AWW workers 2 days before the session, using mothers’
meetings to announce the upcoming date and the beneficiaries. These are some of the
innovative ways of informing beneficiaries. Explore what could work in your area.
Information on arrival of ANM
While the ASHA/AWW/mobilizer will visit the beneficiaries to come for immunization, word
of the arrival of the ANM can also be spread through using any public address system at
a religious or community centre. With support from local leaders, information can also be
passed through students or local shopkeepers. The intention is to announce the starting of
the session and any other local methodologies should be explored and encouraged.

The four key messages the HW should give to the caregiver are:
Using RI monitoring formats
Monitoring in routine immunization is an essential tool for a medical officer. It provides an

opportunity to:
• observe service delivery and practices
• identify issues and provide solutions at field level
• identify training needs of staff
• interact directly with the community
• interact and motivate frontline health care workers at field level
Using RI• monitoring

build confidence in health workers and community
formats
• increase understanding of the RI delivery mechanism
Monitoring in types
Two routine
of immunization
formats are in useis an essential
– RI session tool for aHouse
site and medical officer.
to house It provides
monitoring formats.
an opportunity to:
1. The RI session format focuses on the following: Microplanning, session due list & its
 observequality,
servicesafe
delivery andpractices,
injection practicesvaccine availability at session site, implementation of
 identifyopen vialand
issues policy, logistics,
provide IEC and
solutions atASHA incentives.
field level
 2. The
identify houseneeds
training to house format focuses on collecting information from at least 10 children
of staff
 interactbelow thewith
directly age of
the35community
months in an area. Information on the child’s vaccination status
 interactincluding the dates
and motivate of administration
frontline health careisworkers
to be collected,
at fieldthe source of information being
level
the MCP card. However in the absence of the card, parent recall by identifying the sites
 build confidence in health workers and community
of injection may be utilized. The rear of the format has a ready reckoner to easily identify
 increaseif understanding of the
a child has received RI vaccine
due deliveryasmechanism
per age. When a child is found unimmunized or
partially immunized information 202on the reason should also be collected.





Unit 9 : Communication for behaviour change
9
Communication for
reducing vaccine
hesitancy and
increasing demand for
immunization
Role of MOs in reducing vaccine hesitancy
MOs at the block and PHCs have a critical role to play in ensuring that all children in the
population under their PHCs are fully vaccinated. MOs are already working very hard to
ensure that the quality of health services for mothers and children in their PHCs and SCs
and are well recognized by the communities living in their areas. This also means that their
first responsibility will be to ensure that RI services are not only available but that these
services are also of the best quality.
Vaccine hesitancy is the behaviour of parents, caregivers, or the community in hesitating
to get their children vaccinated in spite of immunization services being available and
accessible to them. Inadequate immunization services due to non-availability of vaccines,
absenteeism of vaccinators and long distances to vaccination centres contribute to this
hesitancy. Hesitation also comes from a number of other reasons (let’s call them barriers),
such as low perception of the benefits of vaccines, loss of wages, social beliefs, fear of AEFIs,
demotivation owing to inadequate IPC skills of HW, to sometimes geographical barriers
such as inaccessible terrain.
This section looks at low immunization coverage from the behavioural perspective, i.e.
the reasons behind vaccine hesitancy and the interventions that can be initiated by MOs to
achieve the communication objectives of increasing demand for vaccination services.
On the other hand, vaccine confidence is when parents, caregivers or the community
understand the value of vaccination and voluntarily demand vaccination services as a right,
whether these vaccinations are part of the RI schedule for their children or part of adult
vaccinations such as TT for pregnant women. Vaccine confidence comes from adequate
awareness about the benefits of vaccines, both to the individual and the community, and the
trust in the immunization service delivery system to be able to provide quality vaccination.

Left-outs and dropouts
From a service delivery perspective:

• left-outs are those children who have never been vaccinated or reached (thus remaining
unimmunized);
• dropouts are those children who started vaccination but did not complete the schedule
(thus remaining partially immunized).
Fig. 9.1. Three types of behaviour groups
Left-outs/unreached
Dropouts
Fully immunized
The immunization-targeted community can be divided into three groups as shown in Fig.
9.1. The aim of the health system (including MOs, HWs and mobilizers) should be to expand
the inner circle to cover the entire universe of eligible children in its catchment area.
From a behavioural perspective, a large percentage of dropouts is a serious problem
because it reflects the poor perception of parents/caregivers’ about the benefits of
vaccination or of the immunization service delivery system, or both, combined with other
barriers that forces them to place immunization on a low priority.
People who “drop out” of the immunization system are the easiest to reach and be
convinced to return for full immunization.

Fig. 9.2. Reasons for partial or no immunization (multiple responses) (n=10 542)
Fig. 9.2. Reasons for partial or no immunization (multiple responses) (n = 10 542)
Did not feel need 28.2
Not Knowing about vaccines 26.3
Demand side issues
Not knowing where to immunize 10.8

Time not convenient 8.9
Fear of side effects 8.1
Do not have time 6
Wrong advice by someone 3
Cannot afford the cost 1.2
Supply side issues
Vaccine not available 6.2

Place not convenient 3.8
ANM absent 3.9
Long waiting time 2.1
Place too far 2.1
Service not available 2.1
Others 11.8
0 5 10 15 20 25 30
PERCENTAGE
Why children do not get vaccinated: behavioural barriers
The Coverage Evaluation Survey (2009) identified the reasons for not accessing immunization
services as cited by the community. A majority had demand-side issues, e.g. did not feel the
need for vaccination; did not know about vaccines or where to go for vaccination; time not
convenient; fear of side-effects; or did not have time.
Recent data from house-to-house RI monitoring in UP also highlighted lack of awareness
and fear of AEFIs as majorWhy arefor
reasons children being missed?
missed children as shown India, 2015
in Fig.9.3.
Fig.9.3. Reasons for missed children
No immunization
100%
3%
90% Child travelling

22% 13% Awareness &
80% Partial information
Immunization
Gap
70%
Others 34%
60%
10%
50%
40% Operational
75%
Full
Gap
30%
immunization 11%
20%
10%
AEFI
0%
apprehension
Total
32%
Number of children monitored (12-23m) = 418,139 N = 101,220
* Jan15 – Dec15
Source : RI house to house monitoring data

The table below enlists reasons and possible interventions for tackling vaccine hesitancy.
Medical officers are encouraged to review/discuss this table with staff during meetings.
Table 9.1: Reasons for missed children and possible interventions
Possible reasons Possible interventions
Demand-side issues
Parents not motivated to • Engage with community leaders, school teachers,
immunize children because of faith/religious leaders, youth networks, women’s
their poor understanding of self-help groups (SHGs) and encourage them to talk
its purpose and importance to parents about the benefits of immunization.
• Build capacities of HWs to counsel and effectively
communicate with parents and the community on
the importance of immunization.
• Disseminate information on the benefits of
immunization at health fairs and other events and
make people aware of immunization services.
• Use other communication channels such as local
cable television, wall paintings and posters, mosque
and temple announcements, traditional and folk
media.
Cultural or religious reasons • Find out the reasons for reluctance by talking
for refusal of vaccination directly to communities/leaders. Try to address
(myths, rumours and their misconceptions, doubts and fears by listening
misconceptions) to them and offering support.
• Involve community leaders (particularly the ones
favourable to immunization) and other staff
working within that particular community in order
to encourage their fellow members to have their
children immunized.
• Arrange for an interaction between resistant groups
and satisfied beneficiaries in the area to promote
immunization.

Fear of side-effects or AEFI in • Involve religious leaders, village elders, school

the community discourages teachers and panchayati raj institution (PRI)
parents to immunize their members to accompany the field level workers
children (FLWs) during their house-to-house mobilization
visits, organize folk shows to educate parents and
communities on the importance of RI for children
and dispel myths and misconceptions.
• Remind HWs to always tell parents/caregivers
about common side-effects that may occur and
what to do should they occur.
• Investigate any AEFI and apprise the community of
the details of the case, possible causes and actions
taken.
Financial or gender barriers to • Counsel opinion leaders and influential persons
immunization, e.g. husbands about the dangers of VPDs and the benefits of
disallowing wives to attend immunization.
sessions because of time/lost • Encourage peer counselling by fathers of children
labour, expense and/or fear of who accept immunization.
side-effects • Publicize that immunization services are entirely
free.
Refugees/families that fear • Determine where these populations reside.
contact with government, e.g. • Visit the communities and work with local
those who lack documents/ mobilizers/educators/community groups/leaders
scheduled castes or tribes/ to discuss reasons why they are not accessing
nomadic groups/homeless immunization services.
families/urban slums/street • Provide information on the importance of
children vaccination and date, time and place of the next
nearest session.
• Develop a list of children who have never accessed
immunization services in the area and share it
with HWs of the area for immunization and ensure
follow-up.

Supply-side issues
All newborns and infants not • Involve AWWs/ASHAs to identify and share lists of
identified and listed newborns and children with the HWs.
Sessions too infrequent • Plan sessions after consulting the community, e.g.
or timings and days not early in the morning/late evening.
convenient/not understood
Session site too far away, e.g. • Include all the areas in the microplan.
border populations • Reorganize the catchment area so that remote sites
are visited at least once every 2 or 3 months (plan
at least 4 immunization sessions a year).
• Work with neighbouring health facilities to
coordinate services for border areas.
• Improve outreach to communities through
appropriate transport, additional staff and publicize
outreach services.
Parents do not return because • In case of HW being on leave, deploy alternate
sessions are not held as vaccinators.
planned or vaccines are • Ensure alternate delivery of vaccines to session
unavailable sites.
• Encourage community groups to report problems
regarding HWs’ attendance on session days to the
PHC.
• Conduct session monitoring and make real
improvements; then publicize the improvements to
communities.
• Ensure adequate supplies of vaccines and logistics.
HWs do not clearly explain • Remind HWs/AWWs/ASHAs to always convey
to parents what vaccines are the 4 key messages to parents in a simple and
due, when they are due and understandable language.
why they are needed • Train HWs to provide filled-in MCP cards to all
beneficiaries and to write the next due date on the
card.
• Ask caregivers to repeat the information given to
them in order to increase the chances that they will
remember when to return. Praise correct answers.
• Thank the parents for bringing the child.
• Publicize the immunization schedule.

HWs do not show respect • Sensitize and train HWs, ASHAs and AWWs to
towards parents or interest communicate with and treat parents with respect,
in the child’s health, e.g. warmth, friendliness and should empathize
long waits, HWs shouting at with the parents’ situation. Encourage and
mothers for forgetting the praise the parents for bringing their children for
card or bringing the baby in immunization. Encourage parents to ask questions.
late • Guide HWs to visit dropouts before the next
session to find out the reasons why they missed the
session.
HWs do not know which • Organize tracking of children using RI Cards,
children are due and what immunization registers, counterfoils and tracking
vaccines are due bags.
• HWs can involve community teams (NGOs,
community based organizations (CBOs), youth
clubs, school teachers, volunteers, etc.) to identify
children who are left-outs and dropouts
• remind parents about the importance of full
immunization; inform them about the date and
time of the next session and mobilize parents for
immunization sessions.
HWs do not understand/ • Orient HWs that immunization can be safely
explain to caregivers that provided to mildly ill children and that they should
immunization may be given convince parents about this fact.
to mildly ill children (false
contraindication)
Children and mothers are • When providing other services, always keep an
not immunized when coming eye on eligible children visiting the session with a
to the HWs for curative care parent or sibling. Enquire about their immunization
(missed opportunities) status or refer to the list of due beneficiaries and
provide services, as appropriate.
• Put a reminder about immunization in the facility’s
waiting area.

MO as facilitator and enabler: 10 key roles
All medical officers must take a few simple steps for improving vaccine demand. The primary
role of MO is to act as a facilitator and enabler for demand generation activities in order to
be effective within their respective PHCs. Given below are some of the initiatives MOs must
take:
1. Collect evidence for vaccine hesitancy/refusal
2. Undergo professionally-organized orientation in social and behavioural change
communication (SBCC)
3. Ensure front-line workers and community mobilizers are well-trained in interpersonal
communication skills
4. Strengthen or innovate supportive supervision for communication
5. Target populations through communication microplanning
6. Develop a communication plan using mapping and communication tools
7. Develop partnerships at local level
8. Generate resources for communication activities
9. Ensure the right communication tools (IEC) are available and used
10. Monitor communications interventions.
Changing behaviour
Behaviour change is not a one-time effort but a continuous, well-planned endeavour. To

mobilize parents and communities for immunization, we need to ensure that the community
understands our message, taking care to keep our message simple and straight forward,
avoiding too much information too fast. It is equally important that as health-care providers,
we have complete information on the issue and take time to understand the community’s
perspective, establish and maintain credibility and also clarify misconceptions.
One of the most popular theories of behaviour change communication is called the “Stages
of Change,” proposed by F. Prochaska. It states that individuals are at various stages in the
behaviour change cycle. Knowing at what stage of change an individual is – or a group of
individuals are – will help create the appropriate change intervention (Fig. 9.4).

Fig. 9.4. Behaviour change cycle
For the RI programme to create an impact, behaviour change has to happen both at the
parents/caregivers as well as service providers level. Behaviour change cannot be achieved
in isolation; it is important to engage with key stakeholders in the community. This will help
to create an enabling environment and motivate people to immunize their children.
For example, a mother who is aware of immunization but does not get her children routinely
vaccinated could be in Step 4 of the stages of behaviour change (Trial). She might be aware of
the benefits of immunization and also have accessed services, but needs to be encouraged
further to continue getting her children vaccinated. The HW needs to discuss the benefits
of immunization with the mother to motivate her further. Community networks and peer
support groups can help in stimulating community dialogue to adopt immunization, thus
helping the mother sustain this positive behaviour.

Involving the community to support immunization
Sharing responsibilities for increasing demand

Community participation is the key to increasing demand for services. An informed
community has confidence in the immunization programme, ensures that provision of
immunization services is tailored to the community’s context (time, place and convenience)
and therefore supports and demands immunization services.
You may not have much time to directly interact with the various community groups and
leaders. However, encourage and support HWs and supervisors in establishing strong
links with the community.
The community should be involved in the immunization programme from the planning
phase.
Planning
HWs should:
• consult communities about service locations and timings to ensure a convenient
service, e.g. shifting vaccination hours from mornings to afternoons in areas where
mothers are busy in the fields in the morning;
• involve village elders, religious leaders and village youth to motivate the community to
access the immunization sessions, dispel myths and misconceptions.
Implementation
Communities can assist with:

• arranging a clean outreach site such as a school, club, panchayat bhawan, community
meeting room;
• informing families initially of scheduled outreach, and again when the HW has actually
arrived;
• educating the community regarding free availability of these services;
• registering patients, controlling crowds, and making waiting areas more comfortable
(by providing shade and organizing space and seating);
• disseminating appropriate messages and answering questions (health education);
• identifying and referring newborns and/or infants who have recently arrived in the
community and sharing the list with the HW to include in the immunization register;

• facilitate transporting vaccines and HWs in some hard to reach areas ;

• motivating fellow community members to use immunization services and helping
bridge cultural or educational gaps between HWs and caregivers;
• identifying dropouts and left-outs. Making home visits when children are behind
schedule to explain the importance of adherence to the immunization schedule and to
motivate caregivers;
• communicating with local people and informing HWs about suspected VPDs
Evaluation
Community leaders can contribute by responding to questions about the quality of services,
including counselling provided by front-line workers.
Steps for involving the community
Step 1: Identify key stakeholders in the PHC area/community and also ways to engage
with them
These could be:
• governmental departments and staff (Health, ICDS, Education, District/Block
Administration, PRI);
• NGOs, local organizations and youth bodies such as Nehru Yuva Kendra, National Social
Service (NSS), National Cadet Corps (NCC);
• professional associations (Indian Medical Association, Indian Association of Paediatrics);
• community (parents, village health and sanitation committee(VHSC), faith-based
organizations, SHGs);
• private and traditional health practitioners.
Meet the key stakeholders on a regular basis, establish a rapport with them and seek their
support for the immunization programme. Encourage them to talk to parents/caregivers
about the benefits of immunization; give them some IEC material such as posters and
handouts with messages on immunization which can be displayed at their offices/premises
or during their meetings and also be disseminated in the community. Motivate religious
leaders, particularly the ones favourable to immunization, to endorse and encourage their
fellow members to have their children immunized; get temple/mosque/religious places
announcements made giving out details about the next immunization session and calling
on parents to get their children vaccinated.

Step 2: Conduct a situation analysis

• Hold community meetings, small group discussions or discussions with opinion leaders
to assess the current extent of the community’s involvement with immunization
services, by finding out:
o what the community already knows about VPDs and immunization;
o community awareness and perceptions about immunization services;
o perceived barriers to immunization (related to quality of immunization services
and the community’s knowledge, attitudes and practices);
o issues affecting physical access to services (location, frequency, schedule);
o issues on access to services by special groups (minorities, migrants etc.);
• Identify problems and reasons for left-outs and dropouts. Jointly seek possible
solutions;
• Provide information, using basic language and non-scientific terminology, on the
importance of immunization, and where and when services are available. Dispel
misinformation and doubts that sometimes surround immunization;
• Encourage questions so that everyone can be better informed;
• Use stories, short plays, songs and visual aids to hold the group’s attention and make
meetings interesting;
• Discuss possible community support.
If required, re-align Health and ICDS sector boundaries for joint planning,
implementation and monitoring of immunization activities.
Step 3: Establish mechanisms for coordination

Establish a consultative mechanism at the block/PHC level, or use existing forums such as
the Rogi Kalyan Samitis to ensure regular coordination between departments and to enlist
community support for immunization services.
• Establish alliances with programmes such as ICDS and organizations such as NGOs with
community reach;
• Involve representatives of the key stakeholder groups listed in Step 1;

• Inform the members well in advance and prepare a clear agenda for the meeting
including:
o state and district immunization goals
o current status of immunization in the district and block
o key challenges and areas requiring support, with suggestions on possible
interventions
o possible roles of stakeholders
o preparing and implementing a communication plan.
Step 4: Develop a comprehensive communication plan for community mobilization
A communication plan helps to organize actions to target our communication accurately,
leading to the fulfilment of a goal. It gives a structure to determine whom we need to reach,
and how. It can be longterm as well as short term, making our communication efforts more
efficient, effective and lasting. This saves a great deal of time, as we know exactly what we
should be doing at any point in the process. (See also Unit 3 - Forms 11 and 18)
The steps given in Fig 9.5 will help you and your team members to prepare a comprehensive
communication plan for your area.
Fig. 9.5.Communication plan development
To develop a plan for communication, you need to consider some basic questions:
• Why do you want to communicate with the community? (What is your purpose?)
• Who do you want to communicate it to? (Who is your target audience?)
• What do you want to communicate? (What is your message?)
• How do you want to communicate it? (What communication channels will you use?)
• Whom should you contact and what should you do in order to use these channels?
(How are you going to disseminate your message?)

Sample communication action plan

A sample communication action plan is outlined in Table 9.2.
Table 9.2. Developing a communication action plan
Communication objective: By……….(month and date), parents and caregivers of children
under 2 years of age in village………….., to be aware of the benefits of immunization and
agree to get their children immunized as per schedule
Behaviour anal- Primary target group (Individ- Secondary target group
ysis ual/household level) (community/service provider level)
Who is the Mothers/caregivers of children HWs, community members
target group?
What is Parents not motivated to ANMs may write the next due date
the current immunize children in the immunization card, but few
behaviour? give mothers the four key messages
or any other information, or invite
questions
What is the Mothers/caregivers to access ANMs give mothers/caregivers four
recommended immunization services and get key messages, including when and
key behaviour? their children fully immunized where to go for next vaccination,
what side-effects can occur and how
to deal with them
What are the key Lack of information on ANM/AWW lack skills or
barriers to the immunization focus on importance of
recommended Poor understanding of its communicating with mothers
behaviour? purpose and importance There are real or perceived
Fear of AEFIs social, economic, class and
Cultural and religious possibly ethnic differences
reasons (myths and between ANM/AWW and
misconceptions) caregivers/community
Long waiting time; days ANMs/AWWs lack time to give
and time not convenient good counselling (because so
Time/lost labour, expense many people are waiting for
and/or fear of side-effects care)
Lack of money

Communication Primary target group Secondary target group

strategy
Which Demand side issues can be addressed through communication (refer
barriers can Table 9.1 on possible reasons for left-outs and dropouts)
be addressed
through
communication?
What is the Immunization is important and Communicate four key messages to
key message beneficial for your child. Get mothers/caregivers
for each target your child fully immunized
group?
What are the Use posters, community Plan sessions after consulting
suggested meetings,radio, TV the community (e.g. early in the
communication (where appropriate), morning/late evening)
activities? and other channels Visit the communities and work
to create awareness with local mobilizers/educators
on the importance of and community groups/leaders
immunization and inform to discuss reasons for not
parents/caregivers about accessing immunization services
the next immunization Provide information on the
session. importance of vaccination and
Orient community the date, time and place of the
volunteers and school nearest session.
children on immunization Improve talks and counselling
and encourage them by reminding HW/AWW/ASHA
to discuss the benefits to always communicate thefour
of immunization with key messages to the caregivers
parents/caregivers. Train/orient HWs to provide
filled-in immunization cards to
all beneficiaries and to write
the next due date on the card.
Ask caregivers to repeat the
information given to them in
order to increase the chances
of their remembering when to
return
Encourage ANMs/HWs to do
more one-on-one counsellings.

Monitoring Primary target group Secondary target group

What are the Number of mothers caregivers who can tell the vaccine schedule
monitoring Number of mothers who can recall the four key messages
indicators? Number of ASHAs/AWWs/HWs with updated duelist
How will you RI monitoring data; rapid surveys; in-depth interviews
measure these? Monthly HMIS reports
Who will collect HWs and supervisors
information/
data?
Communicating messages
The Immunization Programme uses different communication methods to reach parents and
other target audiences with messages on RI such as radio, television, folk media, community
meetings and interpersonal communication during sessions.
It is important to identify which communication methods or channels are the most
appropriate for our target audiences, liked and used by them and can most effectively reach
them with immunization messages. For example, while using mass media, it is important
to know which radio stations and TV programmes are popular with the target population.
A mix of different communication channels is usually employed to reach different target
groups, as each channel serves a specific purpose as outlined in Table 9.3.
Table 9.3: Benefits of communication channels
Mass media (radio, TV, Mid media (reminder media) Interpersonal
etc.) Communication (IPC)
Triggers thought and Reinforces and expands Involves direct
acts as a “hook” upon mass media interaction with the
Reaches many people messages audience
very quickly and Builds on messages Allows discussion and
repeatedly delivered through dispels myths and
Reinforces messages IPC and serves as misconceptions
delivered through “reminders” or “message Encourages, motivates
other channels takeaways” and reinforces action
Thus, no single channel is the “best channel”. Multiple, mutually reinforcing channels/
messages integrating all these channels together has a greater impact in stimulating
behaviour change.

At the PHC level, you can effectively use the channels and tools for involving and informing
the community about immunization services (Table 9.4).
Table 9.4. Channels and tools for communicating information on immunization
Communication channel or Settings Activities
tool
Discussions between HWs Immunization sessions Inform parents (using
and small groups of parents storyboards or flip charts) about
importance of immunization, the
immunization schedule and clarify
individual concerns
Community mobilizers Immunization Identify target beneficiaries and
(ASHAs and AWWs) sessions, home visits share lists with HWs. Make home
visits to mobilize beneficiaries,
inform about session dates and
times and follow up dropouts
Local leaders such as PRI Work places or Advocate for increasing
members, political/religious community events immunization coverage and seek
leaders, teachers, private their support in mobilizing the
medical practitioners community
Community groups, NGOs, Work places or Advocate for increasing
CBOs, SHGs community events immunization coverage and seek
their support in mobilizing the
community
Public/street Town criers, Provide basic information in
announcements community events support of immunization and
publicize date and time of session
Drama and songs As a precursor Counter rumours, misconceptions
to discussion in and other barriers to
community meetings understanding. Provide basic
information, e.g. on RI schedule
Poster, banner, tinplate and Well-frequented Display information related
wall writing places such as AWC, to the session site, date and
markets, bus stops, immunization schedule
ration shops, schools,
panchayat bhawan
AWW home visits with AWC, panchayat Motivate and remind families to
shared session due list bhawan, school get their children immunized
RI form 11 for a SC communication plan is given at the end of this unit.

Learning objectives for MOs
Unit 9 : Communication
 Recognize forthe
behaviour changeof integrating social and behaviour change
importance
communication (BCC) in immunization services to reduce vaccine hesitancy
Identify the reasons for children missing vaccinations (dropouts or left outs) and
Increasing visibility
possible and awareness of immunization services
interventions
 Learn about different communication tools, channels and opportunities to

Increasing the visibility and awareness of immunization and outreach health services to the
reduce vaccine hesitancy.
general public, and particularly to beneficiaries, is the initial and perhaps the easiest step
 Learn to develop a simple communication plan for the PHC/CHC using
of communication. The designs for posters and hoardings on RI have been developed at
communication planning tools
the national level and the states/districts may use the prototypes to customize it according
to their local needs. For example, banners and posters should preferably be in the local
language.
Role of MOsYou in
should read the
reducing contenthesitancy
vaccine and see the pictures of the material available to
you before arranging for their placements. Make sure that what is written or shown is
MOs at the block
consistent andguidelines
with the PHCs haveofa critical role to play
the programme. As in ensuring that
programme all children
managers, in the
you will have
to plan when and how to use these communication materials.
population under their PHCs are fully vaccinated. MOs are already working very hard to
ensure that the quality of health services for mothers and children in their PHCs and
Fig. 9.6. Posters and banners used in RI
SCsand are wellrecognized by the communities living in their areas. This also means
that their first responsibility will be to ensure that RI services are not only available but
that these services are also of the best quality.
Vaccine hesitancy is the behaviour of parents, caregivers, or the community in

hesitating to get their children vaccinated or immunized in spite of immunization
services being available and accessible to them. Inadequate immunization services such
as non-availability of vaccines, absence of vaccinators and long distances between
vaccination centre and home contribute to this hesitancy. Hesitation also comes from a
number of other reasons (let’s call them barriers), such as low perception of the benefits
of vaccines, its affordability, social beliefs, fear of AEFIs, demotivation owing to HW
behaviour, to sometimes
For example, geographical
if a poster stresses barriers
on birth such as inaccessible
dose vaccination followingterrain.
institutional deliveries,
it should ideally be put up at institutional delivery points. If another poster encourages
beneficiaries to ensure that their child completes the vaccine doses as per the immunization
schedule, it could be put up at outreach sites as well as delivery points.
208

Strengthening interpersonal communication skills of front-line workers
ANMs/ASHAs/AWWs are a critical interpersonal link between health providers and

community members. They carry out door-to-door visits
and are actively involved with the community.For them
How and when to
to be able to effectively communicate with parents/
communicate key messages?
caregivers and mobilize them to get their children
Messages need to be
vaccinated, it is important that their interpersonal
appropriately timed:
communication skills be strengthened. They also need to
neither too early, lest they
be equipped with appropriate knowledge about vaccines
be forgotten nor too late
and their benefits, and how to counter prevailing myths
for the behaviour to be
and misconceptions on immunization with facts. Details
practiced
on training of front-line workers are given in Unit 11 on
training.
Tips for effective IPC skills for communicating with caregivers
Speak clearly
• Use encouraging/helpful non-verbal communication.
• Posture – keep your head level.
• Spend enough time; do not be in a hurry.
• Use responses and gestures to show interest.
• Listen carefully and repeat what the mother says.
Greet
• Smile.Speak in a pleasant voice and tone.
• Maintain eye contact.
• Introduce yourself and your organization.
Ask
• Ask open-ended questions—What? When? Where? Why? How? Who?
o How many children do you have?
o Why did you not vaccinate your child?
o How did you know about the immunization session?
Tell
• What diseases are prevented by vaccination.
• Where and when will the session be held.
• What minor side-effects can occur after vaccination and how these can be managed.

Help: Encourage the parents to come for vaccination by telling them about how to manage
AEFIs.
Explain: Use info-kits to explain the importance of immunization and the immunization
schedule.
Repeat: Use your visit to find out reasons for left-outs and dropouts.
Four key messages to be given to caregivers
• What vaccine was given and what disease it prevents

• What minor adverse events could occur and how to deal with them
• When and where to come for the next visit
• To keep the immunization card safe and to bring it along for the next visit

Holding an effective community meeting
• Identify local community representatives who would participate in the meeting;

• Hold the meeting at a convenient time and place, e.g. on market days, close to places
of worship;
• Be prepared with data on the coverage and dropout rates and a map of the health
areas with low coverage;
• Provide a comfortable and welcoming environment for the discussion;
• Listen to the community; find out what the community already knows about VPDs and
immunization;
• Provide information, using basic language and non-scientific terminology, on the
importance of immunization, the status of the immunization programme and where
and when services are available. Dispel misinformation and doubts that sometimes
surround immunization;
• Encourage the participants to ask questions so that everyone can be better informed;
• Use stories, short plays, songs and visual aids to hold the group’s attention and make
meetings interesting;
• Involve as many group members as possible in the discussion and ask them to suggest
solutions to problems;
• Help mobilize resources for immunization.
Exploring new media and digital communication
The reach of digital media is expanding exponentially and you should exploit every potential
communication media. The digital media, either mobile or internet-based, is inexpensive and
requires minimal effort. During planning for communication, whether it is for strengthening
routine RI programmes or for campaigns, remember to identify media behaviour of the
population in your block/under your PHC. As MOs, you have the potential and opportunity
to be innovative. There are a number of ways to achieve impactful communication using
new digital technologies, as follows:
1. Social media such as Facebook, Twitter, and YouTube are becoming highly popular
as preferred modes of communication among the new millennia (young, educated
generation).
2. Mobile phones have not only reached every village but also almost every villager,
including into women’s hands. The potential of reaching the targeted stakeholders is
thus enormous. SMS messaging, voiceover messages using celebrities and reminder
calls are some simple, direct and affordable ways of reaching the stakeholders with
messages.

3. iPads and Notebooks: Digital tools such as iPads or digital Notebooks have now become
very powerful tools for IPC sessions to be conducted by front-line workers with the
communities. RI counselling using multimedia formats during household visits can be
made not only educative but also entertaining.
4. Digitized PHCs: Visitors to PHCs, whether they are patients or their families, can be
effectively counselled and exposed to key messages on RI using these digital tools
innovatively. A MO who is innovative can make their PHC a model on the use of new
media and digital technologies.
5. Data collection and analysis: These digital tools can also be used for purposes of data
collection and monitoring and evaluation of different communication interventions for
instant results.
6. Training before using: Innovative require capacity building of health service providers
to enable effective use.

Sub centre communication plan for RI Quarter- 1 / 2 / 3 / 4
RI Form 11
Name of Block:________________ Name of ANM:______________________________ Name of Subcentre:______________________
Name of Village
Nane of Session site 1- 2- 3- 4- 5- 6-
Activities
Miking / drum beating- Name and contact number
Mosque announcement - Contact person and number -

announcement time
Meetings (Mothers meeting,AWW meeting,etc -Contact person and

number - Monthly / weekly )
VHSC meeting - contact person and number - location - attended by

ANM Monthly / weekly - enter date
School Rallies - school name and contact person with number (once a

month in villages on rotation)
Celebrations / Special Days (eg Mothers day, health day etc) -

contact person and number
Wall paintings - locations
Banners - identify 4 key locations - Ensure display at least one day

before RI day
Painting competition / Exihibition - (once a quarter -school name

and contact person with number
Posters - identify 5 key locations ( other than Panchayat ghar, Ration

store, AWWcentre, Sub centre, Bus stand) - ensure display at least 2 days
before RI day
Pamphlets / Leaflets - available with - contact person name and

number - distribute before RI session day
Counselling aids / job aids (flip books etc.,) - available with -

contact person name and number
Other
Manpower involvement - with contact number
Appendix: RI form 11: Communication plan for a SC (See Unit 3 for details)
Name of ASHA
Name of AWW
Name of Mobilizer / CMC
Name of community influencer
Name of PRI member

Date:____________ Sign of ANM:__________________ Sign of MO:________________________
219
Notes:

Unit 10 : Vaccine Preventable Diseases and VPD surveillance
10
Surveillance for
vaccine preventable
diseases
Surveillance is data collection for action. It is defined as the ongoing systematic collection,
analysis, interpretation and dissemination of data about cases of a disease and factors
influencing disease behaviour, which is used as a basis for planning, implementing and
evaluating disease prevention and control activities, including immunization. Surveillance
is the basic tool for understanding the epidemiology of a disease. Its key objectives are to
trigger public health control measures, identify outbreaks and assess the effectiveness of
prevention programmes.
Key elements of an effective surveillance system
These are:
• detection and notification of disease conditions
• investigation and confirmation (epidemiological, clinical and lab) of VPD cases
• collection, analysis and interpretation of data
• feedback and dissemination of results
• prevention and control responses.
Surveillance data on VPDs can monitor the impact of vaccination on disease incidence,
identify HRAs and identify outbreaks.
Uses of VPD surveillance
Disease surveillance enables the following:

• predicting or detecting disease outbreaks for containment (what disease is occurring)
• identifying high-risk populations (who gets the disease)
• identification of HRAs requiring special attention, and where system performance is
poor (where the disease is occurring)

• determining the frequency of occurrence of a disease in the community and magnitude

of the problem (when the disease is occurring and how many get the disease)
• identifying underlying causes (or risk factors) of the disease (why the disease is
occurring)
• guiding response activities, including immunization (how the disease can be prevented,
controlled or eliminated).
Prerequisites for effective surveillance
• Standard case definitions (to ensure uniformity in reporting)
• Recording and reporting system (to ensure regularity in reporting)
• List of all the reporting units (to ensure completeness in reporting)
The quality of surveillance data depends upon correct diagnostic criteria, timeliness and
completeness of reports.
Case definitions of VPDs
The case definitions of VPDs are as follows:

• Polio: Acute flaccid paralysis (AFP) is defined as sudden onset of weakness and
floppiness in any part of the body in a child < 15 years of age, or paralysis in a person
of any age in whom polio is suspected. (WHO)
•
Measles: Any person in whom a clinician suspects measles infection,
or
Any person with fever and maculopapular rash, i.e. non-vesicular
and
cough, coryza (runny nose), or conjunctivitis (red eyes). (WHO)
• Diphtheria: A suspected case of diphtheria is defined as an illness of the upper
respiratory tract characterized by the following:
laryngitis or pharyngitis or tonsillitis,
and
adherent membranes of tonsils, pharynx and/or nose. (WHO)
• Pertussis: A suspected case of pertussis is defined as a person with a cough lasting for
at least 2 weeks, with at least one of the following:
paroxysms (fits of coughing)
inspiratory whooping
post-tussive vomiting (vomiting immediately after coughing)
without other apparent causes. (WHO)

• Neonatal tetanus: Any neonate with a normal ability to suck and cry during the first
2 days of life, and who thereafter cannot suck normally between 3 and 28 days of age
and becomes stiff or has convulsions/spasms (jerking of the muscles), or both. (WHO)
• Tuberculosis: A child with fever and/or cough for more than 2 weeks, with loss of
weight/no weight gain and history of contact with a suspected or diagnosed case of
active TB disease within the last 2 years. (WHO)
• Bacterial meningitis: Any person with sudden onset of fever (> 38.5 °C rectal or 38.0 °C
axillary)
and
one of the following signs: neck stiffness, altered consciousness or other meningeal
sign (IDSP).
• Hepatitis B: An acute illness typically including acute jaundice, dark urine, anorexia,
malaise, extreme fatigue and right upper quadrant tenderness.
Biological signs include increased urine urobilinogen and >2.5 times the upper
limit of serum alanine aminotransferase.
Note: Most infections occur during early childhood. A variable proportion of adult
infections are asymptomatic. (IDSP)
• Japanese Encephalitis: A person of any age, at any time of the year with acute
onset of fever and change in mental status (including symptoms such as confusion,
disorientation, coma or inability to talk)
and/or
new onset of seizures (excluding simple febrile seizures).
Other early clinical findings may include an increase in irritability, somnolence or
abnormal behaviour greater than that seen with usual febrile illness. (IDSP)
Reporting network: the backbone of a surveillance system
Efficient and reliable reporting network and notification systems are vital for any disease
surveillance. In many developing countries, the number of cases that are reported into the
system is an underestimation of the actual disease burden, for the following main reasons:
• Community level: Not all cases seek healthcare at the designated reporting sites (this
is called under ascertainment).
• Health facility level: Failure of the reporting site to adequately report suspected cases
that have sought medical advice (under-reporting). The common reasons for under-
reporting include lack of knowledge of case definitions , lack of appreciation of the
importance of reporting , lack of motivation, competing priorities and complexity of
the reporting procedure.

• All health-care delivery sectors not included in the reporting network (e.g. private
sector not involved, ISM practitioners not involved, etc.)
It is difficult to address under-ascertainment. However, under-reporting can be addressed
by diligently selecting the reporting sites, creating awareness of the importance of case
reporting and regular monitoring to verify the quality and completeness of reporting. The
health facility selected for VPD surveillance should:
• be adequately motivated to participate in the surveillance with the understanding of
its importance
• serve the population of interest
• have medical staff sufficiently specialised to diagnose, treat and report cases of the
diseases under surveillance.
Various types of surveillance systems functioning in India
Surveillance system for polio and other VPDs

The country has established an efficient surveillance system for polio with technical,
operational and monitoring support from WHO-NPSP. This support for countrywide AFP
surveillance is made through its strong field presence and a well-distributed network of
reporting sites.
The reporting network for AFP involves both public and private sector health facilities and
has established mechanisms for case investigation, reporting and data management. AFP
surveillance has proved to be one of the best surveillance systems globally and functions
beyond the globally accepted quality standards. Details of operational protocols are
available in the AFP surveillance field guide, also popularly known as Red Book.
Utilizing the AFP surveillance system for surveillance of other VPDs
To capitalize on the existing infrastructure and investments already made in the Polio
Eradication Initiative, the platform of the AFP surveillance system is being modified to
generate valuable epidemiological information for other VPDs. A laboratory-supported
surveillance system for VPDs has been designed to capture epidemiological data on measles,
rubella, diphtheria, pertussis and neonatal tetanus.
A measles-rubella surveillance system has been established across the country with
14 laboratories in the network. National Institute of Virology, Pune and King Institute
of Preventive Medicine (KIPM), Chennai are designated as reference laboratories. The
operational protocols for measles-rubella surveillance are available in the “Measles
Surveillance and Outbreak Investigation– Field Guide”.

A laboratory network for surveillance of other VPDs is being established. The Christian
Medical College at Vellore has been designated to serve as the reference laboratory for the
VPD surveillance laboratory network and state-specific laboratories functioning under the
supervision of the reference laboratory are expected to test the samples collected from
suspect cases. Technical and operational details of the laboratory-supported case-based
VPD surveillance system are available in “Surveillance for Vaccine Preventable Diseases –
Field Guide” developed by WHO in coordination with the GoI.
Integrated Disease Surveillance Project
IDSP is a surveillance system wherein data generation, compilation, analysis and
feedback to actions take place at district level and flow upwards to the state surveillance
unit (SSU) and central surveillance unit (CSU). IDSP has an administrative mechanism in
the form of surveillance committees and surveillance units at district and state levels
headed by a surveillance officer and supported by an epidemiologist, microbiologist,
data entry operator and data managers. Implementation is intended to uncover the
burden of infectious diseases and detect early warning signals for outbreaks based on
syndromic reporting right from the population level. Gaps exist in capturing of data
from the private sector.
Laboratory confirmation of cases and outbreaks is another important component of IDSP
that feeds into Form L at the district level. In addition, a reference laboratory network
has been established in nine states by utilizing the existing functional laboratories in
the medical colleges and other facilities which provide diagnostic services.
Central Bureau of Health Intelligence (CBHI)
CBHI, under the Directorate General of Health Services (DGHS), is an agency involved in
collection, compilation, analysis and dissemination of information on a broad range of
indicators related to health status and health services in the country. It is the national
nodal institution for health intelligence. CBHI has a web-based data entry portal for
collation of data at the national level. It regularly brings outs an annual publication in
the form of National Health Profile based on the health data collected from all health
directorates of states and union territories.

A sensitive and reliable VPD surveillance system can become an important tool for generating
valuable epidemiological data which provides guidance to national policy-makers to
identify specific national challenges and formulate evidence-based recommendations on
immunization.
Awareness and skills of health staff are major factors for high sensitivity and quality of
a surveillance system. All these systems are dependent on the district and sub-district
level health staff. The states have to ensure capacity building of the health-care providers/
surveillance staff, monitoring and evaluation of the key components of surveillance, data
analysis and providing feedback.
Outbreak investigation, response and control
An outbreak is defined as the occurrence of an illness in a community, clearly in excess

of the expected numbers. Usually, an outbreak is limited to a small focal area. When an
outbreak covers a larger geographic area and has more than one focal point, it is termed as
an epidemic.
Outbreaks are defined differently for different VPDs. For diphtheria, polio, neonatal tetanus
or JE, even a single case is defined as an outbreak, whereas for measles and pertussis, a
sudden increase in the number of cases is considered to be an outbreak.
Steps in outbreak investigation
Prompt and timely action during an outbreak is critical for minimizing the damage and
maintaining public trust in health and immunization services. The emphasis should be on
saving lives. Do not wait for confirmation of a suspected outbreak, immediately provide
logistic support to the field teams. Once the cause of the outbreak is confirmed, do not
further waste laboratory support for diagnosing every case, since standard case management
for epidemiologically-linked cases does not require laboratory confirmation.
Step 1: Confirm the outbreak
Confirmation of an outbreak is done through two related steps. Firstly, you have to visit the
area concerned and confirm the diagnosis of as many reported cases as possible. Next, you
should ascertain its geographical spread through a preliminary search.
Confirm the diagnosis by:
– Clinical criteria: According to the standard case definition using information
obtained by history and examination.

– Epidemiological association: If an outbreak has been confirmed, and similar

cases in the same area in the same period of time are reported by HWs but
not investigated individually, they may be confirmed by epidemiologically-
linked association with confirmed cases.
– Laboratory tests: For VPDs subject to eradication or elimination, collect
laboratory specimens from every suspect case (e.g. stool sample from each
AFP case). For VPDs subject to control, collect specimens from a sufficient
number of cases (e.g. five blood samples in case of a measles outbreak) to
confirm the outbreak. However, no laboratory specimens are required for
neonatal tetanus.
Ascertain the geographical extent of the outbreak to the surrounding villages/
blocks. The search for additional cases must include visits to:
Health facilities: Talk to the doctors and nurses to see if they are seeing suspected
cases of the VPD. Visit hospital wards and outpatient departments and search all
patient registers for cases that fit the standard case definition.
The community: Visit the area from where cases have been identified. Talk to
volunteers and other influential persons in the community. If feasible, organize
a rapid house-to-house search of the affected area(s) to search for similar cases.
Identify key informants in each village/ward for prompt information about any
cases.
Step 2: Conduct house-to-house searches to find additional cases and provide case
management
Train and assign HWs to conduct house-to-house searches to find the cases in the designated
area. Ensure all are aware of the case definitions and ensure monitoring of this activity.
Step 3: Line list and notify the cases
Enlisting all cases is important as it collates all relevant information.
Step 4: Describe the outbreak
Describe the outbreak in terms of time, place and person.
Step 5: Analyze the data to:
• Confirm the outbreak:
Are the number of cases reported greater than the number expected for this
period (e.g. threshold)?
What proportion of cases fulfill the case definition?

• Define the extent of the outbreak (time, place and person).

• Measure the severity of the outbreak (what proportion of confirmed cases were
hospitalized, suffered complications or died).
Step 6: Use the data for action
Use data on the various components of the immunization system such as coverage, status
of the cold chain, training and availability of personnel to determine the probable causes
of the outbreak.
Step 7: Write the report
After conducting the outbreak investigation, prepare a short comprehensive report.
Step 8: Give feedback
Provide feedback to all levels (community/SC/PHC/CHC/district) on the outcomes of the
VPD outbreak investigation, in order to ensure that all stake holders are aware of the
reasons for the outbreak, the actions initiated and the plan to prevent future outbreaks.
Step 9: Initiate action
In all VPD outbreaks, effective case management and followup of cases is a priority.
Thereafter, conduct activities for strengthening and raising awareness of RI.
For further details refer to operational manuals / guidelines of VPD surveillance, measles
and AFP.

Unit 11 : Capacity building of health functionaries in immunization
11
Capacity building
of health functionaries
in immunization
Regular capacity building of health functionaries at the village and SC level is essential
to ensure sustained utilization of quality immunization services by the community. As an
MO, it is your duty to ensure that all the health functionaries in your PHC have adequate
knowledge and skills to provide quality immunization services, including social mobilization
functions.
The following health functionaries need to be regularly trained in immunization at the
block/PHC level:
• HWs or vaccinators
• HSs
• Social mobilizers such as ASHAs and AWWs
• Vaccine and Cold-chain handlers
• Data handlers.
Training mechanisms
Different mechanisms which can be used to train the health functionaries are as follows:
• Half day training of front-line workers at PHC/block level once every 6 months
• Review meeting at the block/PHC held every fortnight/month/quarter
• Supervisory visits to the health centres, session sites and the community.
These are in addition to the regular training courses imparted by the district or state.
Overview of the regular training courses available under the immunization programme is
given in Table 11.1.

Table 11.1.Overview of regular training courses available under the immunization

programme
Category Duration Venue Training materials
Immunization
District/regional/state Handbook for MOs,
MOs – Immunization 3 days
training centre Facilitators’ Guide and
Training kit
State level TOT followed
MOs –RI by cascaded training at Material shared during
2 days
microplanning district and sub-district state-level workshops
level
Immunization
District training centre/
HWs 2 days Handbook for HWs and
ANMTC
Facilitators’ Guide
Info-kits for HWs
and ASHAs/
Frontline Workers – AWWs,Facilitators
Half day Block/PHC level
Immunization Guide for Intensified
Immunization Training
of Frontline Workers
Handbook for Vaccine
District training centre/
Cold-chain handlers 2 days and Cold-chain
ANM Training Centre
Handlers
Intensified immunization training of frontline workers: an overview
This training course was provided by GoI with WHO-India (NPSP) support to the frontline
workers in nine priority states during 2013. It is recommended that MOs of all blocks/
PHCs should use these guidelines, curricula and methodologies to regularly train frontline
workers, i.e. ANMs, LHVs, HSs, ASHAs, AWWs,HWs (male), urban HWs, link persons, etc. An
overview of the training is at Table 11.2.

Table 11.2 .Overview of immunization training for ANMs and LHVs

Participants Block level facilitators ANMs, LHVs, health ASHAs, AWWs and
(MO/BMC) supervisors others*
Venue of training District level Block level Block level
Duration One day TOT 4 hours 3 hours
Batch size 20–25 25–30 30–40 (ASHAs and
AWWs under the
same SC area should
be called together
along with the
concerned ANM)
Facilitators DIO, SMO (WHO), Block level MO (2 Block level (2 per
other partners, RRT per batch) batch) MO/LHV/
members BMC
Contents of Role of facilitator Immunization Immunization
training and types of training, schedule and FAQs, schedule and
immunization social mobilization FAQs, role and
schedule and FAQs, and IPC, planning responsibilities,
social mobilization and managing improving reach
and IPC, planning immunization of immunization
and managing session, injection services and IPC
immunization safety, AEFIs, records skills required
sessions, injection and reports
safety, AEFIs, records
and reports
Training material Facilitators’ guide Info-kit for HWs Info-kit for ASHAs,
AWWs
Training methods Discussions, roleplays, group exercises, films on immunization and
IPC
* Others include HW (male), urban HW, link person, etc.
TOT – training of trainers; RRT – rapid response team; FAQ – frequently asked questions

Roles and responsibilities of MOIC block/PHC as immunization manager
• Assess training load and prepare a training calendar for the year, marking the dates of
the meetings and other opportunities that can be used for training.
• Select topics from the training material which are relevant for the health functionaries
based on assessments through data analysis of routine reports and RI monitoring/
supervision.
• Prepare an agenda and allocate sessions to the facilitators at PHC/block level.
• Inform the participants in advance so that they can come prepared with their questions.
• Arrange for all equipment and supplies required during the training.
• Organize the venue and logistics.
• Conduct training as per the calendar.
• Submit a report of the training conducted with muster roll to DIO.
• Plan and conduct catch-up training for absentees.
• Continue to provide follow-up and on the job training to front-line workers during
supervisory visits and review meetings.
Role and responsibilities of MO as the facilitator
• Positive attitude is required at all times to effectively carry out your roles.
• Encourage participants to ask questions and make comments.
• Use examples from your own experience and ask participants for examples from their
experience.
• Model good communication skills, speak clearly and vary the pitch and speed of your
voice.
• Use interactive training methods for training such as demonstration and hands-on
practice, brainstorming, group discussions, role plays, films on immunization and IPC,
question and answer technique, posters and presentations and flip charts or black/
white board.
• Praise/compliment each participant for comments, participation and contributions.
• Always summarize, or ask a participant to summarize what was discussed in the session.
• Keep the group on track.
• Encourage participants to explore how the skills they are learning can help them to
improve immunization coverage.
Note: Various planning (annxure 1) and reporting formats (annxure 2) used for this training
are annexed in this unit.

Training programme for immunization training of ANMs and LHVs
Learning objectives
At the end of the training, the participants should be able to:
• explain National Immunization Schedule and the frequently asked questions (FAQs);
• list the reasons and solutions for left-outs and dropouts, and key IPC messages;
• plan and conduct immunization sessions using injection safety measures;
• use recording and reporting forms correctly.
The agenda for this training is given in Table 11.3.
Table 11.3. Agenda for immunization training of HWs (ANMs and LHVs)
Session
Time Session
No.
10:00–10:15 • Welcome, introduction of participants and pre-test
1.
• Sharing of RI issues from the RI monitoring reports
10:15–10:45 • National Immunization schedule
2.
• Frequently asked questions
10:45–11:30 Social mobilization and IPC:
3. • Tracking left-outs and dropouts with emphasis on HRAs
• Key IPC messages
11:30–12:30 Planning and managing immunization sessions:
• Planning and preparing for immunization session
• Arranging immunization session
4.
• Conducting immunization session
• Injection safety
• AEFIs - including the use of Adrenaline in AEFI
12:30 -13:20 Records and reports (10 minutes each):
• MCP card,counterfoils and tracking bag
5. • MCH/Immunization/MCTS register
• Name-based list of due beneficiaries and Tally Sheet
• Monthly Progress Report (HMIS report)
6. 13:20–13:40 Film on RI
7. 13:40–14:00 Open discussion, post-test, feedback and wrap-up

List of items required for the training

• Info-kit for HWs and stationary for all participants
• White board with marker pens/flip charts with tripod stand
• TV, DVD player/LCD projector and screen
• Vaccine carrier with 4 conditioned ice packs and vaccine vials in the zipper polythene
pack
• AD disposable syringes – 0.1 ml and 0.5 ml
• Functional hub cutters – 4
• Waste baskets with Red Plastic Bag – at least 1
• Waste basket with Black Plastic Bag- at least 1
• MCP/RI cards – filled
• Tracking bag
• RCH/Immunization/MCTS registers –filled
• Due list cum tally sheets –filled
• HMIS reporting format for SC–filled.
• Use of adrenaline in AEFI
Detailed guidelines for conducting HW training

Session 1: Welcome, introduction and sharing of key RI issues
Time: Registration:
10:00–10:15 • Register all participants by asking them to sign in Muster roll
Method: (Annex2).
Interaction and • Give info-kit and other stationary to each participant.
discussion • Make a note of the number of expected participants who did
not attend.
• Plan to train them during catch-up sessions.
Introduction and pre-test:
• Ask each participant to introduce herself/himself briefly by
giving her/his name, place of work and years of experience.
Also, one personal detail such as a hobby or interest they
have outside of work.
• Ask pre-test questions.
Sharing of RI issues from monitoring reports:
• Share key RI issues identified during monitoring visits. Ensure
that these issues are addressed during the training.

Session 2: National Immunization Schedule and frequently asked questions

Time: Steps:
10:15–10:45 • Discuss the National Immunization Schedule by asking
Method: participants and later ask them to check from info-kit.
Discussion • Discuss FAQs by asking each participant to read one question
and answer by taking turns.
• Explain to clarify their doubts.
Session 3: Social mobilization and interpersonal communication

Time: Steps:
10:45 – 11:30 • Discuss definition of dropouts and left-outs (5 mins).
Method: • Ask participants about the common reasons and solutions for
Group dropouts and left-outs based on their experience. List them
discussion and on the flip chart (15 mins).
role plays • Divide the participants into two groups to discuss the
following (20 mins):
Ask Group 1 to move to the far corner of the room to
represent that they are living in a remote hamlet without
any SC in their village. Outreach sessions are rarely held
in their village. Explain that their children are one type of
“left-outs”, i.e. they are hard to reach geographically and
have difficult access to services. Ask them to discuss the
reasons why their children do not get vaccinated and also
suggest some possible solutions.
Now turn to Group 2 and explain that their children
started the vaccination schedule but have not completed
it and no longer go to the session. Explain that their
children are “dropouts.” Ask them to discuss the reasons
why their children dropped out and to also suggest some
possible solutions.
• Ask each group to present/role play in the plenary (15 mins).
• Summarize the session by reminding participants of the 4 key
IPC messages (5 mins).

Session 4: Planning and managing an immunization session

Time: Steps:
11:30–12:30 • Discuss components of the Microplan by asking participants
Method: (5 mins).
Discussion, • Discuss what all preparations are required before an
role plays, immunization session (5 mins).
demonstration • Ask for volunteers to play the role of ANM and caregiver with
of injection beneficiary.
safety • Ask them to present a roleplay on conducting an
equipment immunization session (by using the session site equipment
and logistics) (10 mins).
• Ask all participants to observe the role play and check from
the info-kit whether all steps are being followed. Make a note
of missed steps to be discussed after the roleplay (15 mins).
• Demonstrate the use of AD syringe, hubcutter and waste
disposal guidelines (10 mins).
• Discuss definition of AEFIs and their types; common
programme errors and how to prevent them; how to manage
and report AEFIs (15 mins) and ensure entry in the block AEFI
register.
Session 5: Records and reports

Time: Steps:
12:30–13:20 • Ask participants what are the various records and reports
Method: related to the immunization programme (5 mins).
Brain • To each group of 4–5 participants, distribute filled in:
storming, o MCP card
group work, o RCH/Immunization/MCTS register
discussion, o Due list and Tally sheet
demonstration o Monthly Progress Report (HMIS report).
• Ask them to identify the gaps and discuss any issues faced.
• Demonstrate use of tracking bag for keeping counterfoils.

Session 6: Film on Routine Immunization

Time: Steps:
13:20–13:40 • Ask participants to note key messages from the film for
Method: improving quality of immunization services.
Film • Show the film.
Session 7: Open discussion, post-test, feedback and wrap-up

Time: Steps:
13:40–14:00 • Ask post-test (same as pre-test) and feedback questions from
Method: the participants.
DIscussion • Ask participants to enumerate key actions they would take to
improve coverage and quality of services after training.
• Clarify any doubts of the participants and close the session.
Training programme for immunization training of ASHAs and AWWs
Learning objectives:
At the end of the training, the participants should be able to:
• Describe the importance of immunization and the role of ASHA and AWW in the
• List the vaccines available under National Immunization Schedule
• List the reasons for left-outs and dropouts and how to deal with them
• Keyinterpersonal messages and skills to communicate with the caregivers.
Agenda for this training is given in Table 11.4.

Table 11.4. Agenda for immunization training for ASHAs and AWWs
S No Time Session
1. 10:00–10:15 Welcome,introduction of participants and pre-test
2. 10:15–10:30 Importance of immunization and National Immunization Schedule
3. 10:30–10:45 Role of ASHA/AWW in immunization programme
4. 10:45–12:00 Social mobilization and IPC:
• What and why are dropouts and left-outs? How to reach
them?
• IPC skills required
• Preparing/updating due lists
• Tracking left-outs and 0dropouts
• Key IPC messages during
o house-to-house visits
o immunization sessions
5. 12:00 –12:20 Film on IPC in RI
6. 12:20–12:40 FAQs regarding immunization
7. 12:40–13:00 Open discussion, post-test, feedback and wrap-up
List of items required for the training

• Info-kit for ASHA/AWW and stationary for all participants
• White board with marker pens/flip charts with tripod stand
• TV, DVD player/LCD projector and screen
• Due-list cum tally sheet – filled.
Detailed guidelines for conducting ASHAs and AWWs training
Session 1: Welcome and introduction of participants

Time: Registration:
10:00–10:15 • Register all participants by asking them to sign in Muster roll
Method: (Annex2).
Interaction • Give info-kit and other stationary to each participant.
and • Make a note of the number of expected participants who did
discussion. not attend
• Plan to train them during catch-up sessions.
Introduction and pre-test:
• Welcome and ask each participant to introduce herself briefly
by giving her name, place of work and years of experience.
Ask pre-test questions.

Session 2: Importance of immunization and National Immunization Schedule

Time: Steps:
10:15–10:30 • Explain the importance of immunization and the VPDs
Method: prevented.
Discussion • Discuss the National Immunization Schedule by asking
participants and later ask them to check from info-kit.
Session 3: Role of ASHAs/AWWs in the immunization programme

Time: Steps:
10:30–10:45 • Ask each participant to tell one responsibility of an ASHA/
Method: AWW in immunization and write their responses on a flip
Brainstorming chart.
• Group them into groups for enumerating their responsibilities
before, during and after immunization session and check from
info-kit for any missed points.
Session 4: Social mobilization and interpersonal communication

Time: Steps:
10:45–12:00 • Discuss the definition of dropouts and left-outs (5 mins).
Method: • Ask participants about the common reasons for dropouts and
Brainstorming, left-outs based on their experience. List them on the flip chart
discussion, (15 mins).
roleplays, • Check from info-kit to see if any reason is missed.
exercises • For each reason, ask and discuss the solutions and cross check
from info-kit (15 mins).
• Discuss IPC skills required for the social mobilizers by referring
to the info-kit (5 mins).
• For roleplays, ask for 8–10 volunteers, 4–5 to act as caregivers
and other 4–5 to act as ASHAs/AWWs.
• Ask other participants to observe the IPC skills used during
roleplays and comment on the same after the role plays.
• Call a pair of one caregiver and one ASHA/AWW to the front.
Ask them to enact the IPC related to RI issue/s (dropouts and
left-outs) during house-to-house visits and at session sites.
• Then ask other pairs to come one by one and discuss different
issues not covered by earlier groups (25 mins).
• Summarize the session by revising the key IPC messages.
• Discuss tools for tracking left-outs and dropouts.
• Give an exercise on filling due lists and Tally sheet (10 mins).

Session 5: Film on interpersonal communication in routine immunization

Time: Steps:
12:00–12:20 • Ask participants to note key messages from the film for
Method: improving coverage.
Film • Show the film.
Session 6: Frequently asked questions on immunization

Time: Steps:
12:20–12:40 • Ask participants to read the FAQs and answers one by one.
Method: • Explain and clarify their doubts.
Discussion
Session 7: Open discussion, post-test, feedback and wrap-up

Time: Steps:
12:40–13:00 • Ask post-test (same as pre-test) and feedback questions from
Method: the participants.
Discussion • Ask participants to enumerate key actions they would take to
improve coverage and quality of services after training.
• Clarify any doubts of the participants and close the session.
Pre and Post test questions
For HWs:
1. Name the VPDs under the UIP.
2. What all vaccines should be given to a child for full immunization by 1 year of age and
by 2 years of age?
3. What tools are available for tracking dropouts and left-outs?
4. What are the four key IPC messages that should be given to the caregivers?
5. What are minor AEFIs and how to manage them?
For ASHAs and AWWs:
1. Name the VPDs under the UIP.
2. What all vaccines should be given to a child for full immunization by 1 year of age and
by 2 years of age?
3. What tools are available for tracking dropouts and left-outs?
4. What are the four key IPC messages that should be given to the caregivers?

Role of ASHA, AWW and social mobilizers in the immunization programme
Planning for immunization

• Enumerate all the pregnant women and children and their immunization status.
• Help the ANM to identify hard to reach areas and underserved populations.
• Help in planning the site, day and time of the session in the village.
• Share the list of newborns in the area with the ANM every month.
• Help in preparing the due list of beneficiaries for your area/village.
• Visit households to inform the due beneficiaries of the vaccination date, time and site.
During the immunization session
• Ensure that all due beneficiaries are brought to the session site for immunization.
• Assist the ANM in conducting the immunization session(control the crowd, assist in
recording, etc.).
• Deliver the four key messages about immunization to the caregivers.
• Ask the beneficiaries to wait for 30 minutes at the session site after immunization.
• Prepare the due list for the next session.
After the immunization session
• Report any case of high fever, any allergic reaction or convulsions after immunization
to the ANM and ensure the treatment.
• Visit the houses of dropouts and left-outs to counsel the mothers to immunize their
children.
“How to conduct a roleplay” with a sample illustration
• Select a group of six volunteers and take them out of the hall.
• Share with them the story plot given below.
• Instruct them to prepare a roleplay based on the situation.
• Give them 10 minutes to present the roleplay.
• Before the roleplay begins, ensure the following:
o Participants are seated and attentive;
o Ask everyone to observe the roleplay closely so that it could be discussed later;
o Take note of the HW’s role.
• Ask them to enact out the roleplay.

A sample role play is given below (please note that in the case study below, the example
of a female child has been deliberately given to reinforce the point that a female chid is
equally important and needs equal care as a male child).
Rani is a HW. She goes to Phalguni’s house. She wants to remind the family about the
immunization session the next day and the visit of the ANM. Also, she has to explain the
importance of vaccinating a child and the benefits of immunization. Phalguni’s 5-month-
old daughter is suffering from diarrhoea and fever. The entire family is under great stress.
Rani is trying to draw their attention. She fails and the discussion could not start.
Rani: (Knock knock – she is knocking at the door of Phalguni’s house). Phalguni’s sister
Phoolwati opens the door.
Rani: (Comes in through the door.) “Phoolwati, listen, the ANM behenji is coming to the
village tomorrow and she will give vaccines to the children. I want to talk to you all about
this”.
Phoolwati: “Dekho Rani, we all are very tense and busy now”.
There is loud crying from inside. Phalguni is crying. The others in the house are trying
to pacify her. Rekha, her sister-in-law, is running around to get a clean cloth to wipe the
baby. Someone else is running to fetch a wiping mop.
Rani: “Listen, I have come to tell you something very important. The ANM will vaccinate
children of the village tomorrow. You have so many little children in the house. You all
must definitely come.”
Nobody is listening to Rani. She is looking around at all of them.
Rekha: “Bhabhi, don’t cry. Munni will be alright. Bhaiyya,why don’t you run and get the
nurse behenji”.
Rani: “Phoolwati, if you don’t want to listen it is really your headache. How does it matter
to me? I will tell the Pradhanji, and I have to visit other houses too. Had you taken the
advice of nurse behenji seriously your child would not have been so sick in the first place.”
The father of the child is running out and Rani leaves.
Some questions after the role play:
What did you see?
What mistakes did Rani make?
What should she have done?

Discuss and brief the HWs on the various attributes and skills a communicator should
possess and use when dealing with families and the community at large. Now ask them to
enact the same role play (with a changed scenario).
Rani: (Knock knock – she is knocking at the door of Phalguni’s house). Phalguni’s sister
Phoolwati opens the door.
Rani: (Comes in through the door.) “Phoolwati, listen, the ANM behenji is coming to
the village tomorrow and she will give vaccines to the children. I want to talk to you all
about this”.
Phoolwati: “Dekho Rani, we all are very tense and busy now”.
There is loud crying from inside. Phalguni is crying. The others in the house are trying
to pacify her. Rekha, her sister-in-law, is running around to get a clean cloth to wipe the
baby. Someone else is running for fetching a wiping mop.
Rani: “Oh! What happened? Why is the baby crying? Is everything all right?”
Phoolwati: “Rani, Phalguni’s baby is very sick. She has been having watery stools for the
last 3 days and also has fever. We all are very worried for her”.
Rani: “Don’t worry, she will be fine. May I have a look at her?”
Phoolwati: “Surely.She is in the room. Phalguni has been crying, we have tried
everything….don’t know what to do. Come in”.
Rani: (Goes into the room, and consoles and comforts Phalguni) “Don’t worry, she will
be fine. Have you given her ORS?”
Phalguni: “No Rani, she has become so weak. She is not even taking my milk”.
Rani: “ORS is very safe. Please give it to her. It will help her recover fast”. (Rani takes
out an ORS sachet from her bag and gives it to Phalguni. She tells her how to prepare
the ORS solution and how to feed the baby). “Also continue to breastfeed the baby,
there is no substitute for mother’s milk. But you should get her vaccinated tomorrow.
The fever is mild and vaccination will not harm her; rather, it will protect her from life-
threatening diseases. Bhaiyya, please come along with me. We need to call in the doctor
immediately”.
Both of them leave to call the doctor.
Some questions after the role play:
What did you see?
What did Rani do differently this time?
What do we learn from this?

Annexures –Planning and reporting formats
Annexure 1

Annexure 2

Annexure 3

Unit 12 : High risk populations and Urban areas
12
High-risk areas and
urban services
High risk areas/populations
HRAs are special sites/areas which may be one or more of the following types of areas:
• Hard-to-reach areas
• Unserved or underserved areas or areas with shortage of health workers
• Urban areas, especially slums
• Migratory populations including temporary harvesters, brick kiln workers and
construction labourers in large construction sites
• Security compromised areas.
The polio programme has identified population groups/areas that often
miss routine and supplementary immunization and pose a risk for polio and
other VPDs. HRAs are categorized as migratory and non-migratory (settled).
(Other high risk populations could include those living in prisons, brothels and redlight
areas)
Migratory HRAs
Migratory HRAs have been characterized as follows:
• Slums with migration: These are settlements in urban/periurban areas, or slums
situated close to industrial areas including mining/stone-crushing sites or agricultural
fields. These slums are typically found listed as such with urban development or district
authorities. These areas are densely populated with substandard housing, which may
be pucca or kaccha (jhuggies) and invariably have poor sanitation. Some of these areas
are unauthorized and/or are not recognized by urban development authorities. The
socioeconomic status of the residents in these areas is low.
• Nomads: Populations such as Mangteys, Kanjars, Fakirs, Natts, Banjaras, Shahs,
Shahbalis, Albis, GadhiaLuhars, Ghumantus, etc. often move from place to place for
livelihood, usually setting up “dera” wherever they stop. They are normally found in
between or at the end of big colonies, railway stations, along the rail tracks, open
fields, market places and in urban/periurban slums.

• Brick kilns: Migrant labour camping in brick kilns and the “pather” fields where raw
bricks are prepared.
• Construction sites: Migrant families live in jhuggies or brick sheds in and around the
under-construction buildings. The number of families and children present in these
sites varies according to the size of the construction site.
• Others: These are fishermen villages, riverine areas with shifting populations, etc.
Non-migratory HRAs
These are areas with settled population with no migration and poor immunization coverage.
These include hard-to-reach areas and misinformed communities that refuse vaccination
due to misplaced beliefs.
Hard to reach areas
Accessibility compromised areas i.e. due to geographical / topographical reasons and in
areas where security is a concern poses a different challenge to delivering RI or any other
services.
Provision of services
Despite these challenges frontline workers and health staff are committed to providing
services even in such areas. Therefore it is important for RI microplanning to be flexible and
respond specifically to local situations and needs.
As MO you can review situations and in consultation with the district be innovative to
overcome some of these obstacles.
For areas with multiple pockets of nomads or construction sites:
• Ensure identification of each area or pocket
• Identify a key person in each
• Explore use of mobile session for such areas
For hilly regions:
• Due to the vertical spread and terrain microplanning including maps should be made
to reflect the ground realities
• Mobilization of beneficiaries will benefit from innovation. E.g. using available
telecommunication /sending messages through school children returning home or
through other agencies
• The use of alternate vaccine delivery options which may include pack animals or other
modes of transport

• ANMs / health workers may have to stay overnight is some areas this will require extra
vaccine carriers with extra ice packs to ensure maintenance of cold chain
• Immunization waste management – all waste will have to return to the centre for
further management.
Steps to be followed by block/urban area MOs
1. Update the available list of all HRAs in the block/urban area every 3 months.
2. HRAs that are not included in the microplan should be immediately added, with
appropriate revisions.
3. Review monitoring and coverage reports to identify issues in provision of immunization
services with special emphasis on HRAs to include:
a. Planned sessions not held
b. Areas with low coverage
c. Sessions with poor mobilization
d. Status of due-list updating, especially for migrants and newborns
4. Revise session sites and timings, wherever required, in consultation with the ANM,
ASHA, LW,AWW and community members.
5. Followup the progress regularly.
Steps to be followed by DIO
1. Review the maps and microplans from each block to check that all the HRAs are
included in the ANM work-plan;
2. Review monitoring reports to identify issues;
3. Prioritize block/s with large number of HRAs;
4. Facilitate block level review and revision in priority blocks.
Any area with a risk for disease transmission or outbreak

can be included as an HRA by MO.

Urban services
Virtually all population growth over

the next 30 years will be in urban
areas. By 2030, six out of every 10
people will be city dwellers, rising
to seven out of 10 people by 2050.
The trend for the past 50 years is
for cities to grow horizontally in the
form of urban sprawls, whether as
suburbs or as peri-urban expansion.
Urbanization and its health impacts
are not just an issue for with over 10
million residents. In fact, much of the urban population growth will occur in small and mid-
sized cities. While large cities of developing countries will account for 20% of the increase
in the world’s population between 2000 and 2015, small and mid-size cities (less than 5
million) will account for 45% of this increase.
India is on the brink of an urban revolution with nearly 30% (about 300 million people)
of the total population living in towns and cities. As per the United Nations projections,
if urbanization continues at the present rate, 46% (about 500 million people) of the total
population will be concentrated in urban regions of India by 2030. Migration is a major
driving force for this rise in urban population. This exponential growth in urban population
is leading to many problems such as increasing slums, decrease in standard of living in
urban areas and contributes to environmental damage.
The definition of urban area as per the 2011 Census is as follows:
(a) All statutory places with a municipality, corporation, cantonment board or notified
town area committee, etc.
(b) A place satisfying the following three criteria simultaneously:
i) a minimum population of 5000;
ii) at least 75% of the male working population engaged in non-agricultural pursuits;
iii) a density of population of at least 400 per sq km (1000 per sq mile).
An urban agglomeration is a continuous urban spread constituting of a town and its
adjoining urban outgrowths, or two or more physically contiguous towns together and
any adjoining urban outgrowths of such towns.

Characteristics of urban areas
• Ever expanding borders and peri-urban areas

• HRAs - higher number of construction and nomadic sites
• Manpower shortages.
• Large volume of transit / migrant population
• Unrecognized slums
Challenges to providing immunization in urban areas
Providing immunization services in urban areas have the following challenges:

1. Area demarcation
2. Accessibility
3. Inadequate infrastructure to support RI sessions
4. Multiple agencies / bodies for coordination
1. Area demarcation
Most of the urban areas in cities and towns are defined clearly with local urban bodies and
infrastructure. However, the demarcation of areas among health workers is a challenge due
to either overlapping administrative areas or expanding areas.
Area demarcation in urban areas is an investment that will be beneficial to all and is worth
the effort. Except for the periphery or peri-urban parts, for the rest of the area it will be a
onetime activity to develop maps and demarcate areas.
Source of maps in urban areas:
• Local urban bodies such as municipality / corporation / Dept. of urban development
(see Unit 3, Fig 3.7)
• Simple hand drawn maps made by health workers (see Unit 3 Fig 3.8)
• Using google maps (Fig 12.3 and 12.4)
• Upgrading existing maps to clearly demarcate (Fig 12.2)
To clear up issues of area demarcation:
o Have copies of maps of each urban SC area prepared / copies made if already available
o Call for an ANM meeting and/or coordinated meeting with ICDS (if available)
o Bring out discussion on areas of confusion
o Clarify and if needed take decisions based on ease of access / rationality and finalize
o Plan for field verifications where boundaries are not well defined.
If there is an existing AWW/ASHA/link worker network, areas can be demarcated on the
same lines. This makes it simpler to identify areas. Once this is done, ANM areas can be
superimposed on the maps.

Fig 12.2 Urban PHC area polio map showing landmarks and upgraded to include migrant
population mapping
Fig 12.3 Urban PHC area map – screen grab from google maps
using Goolge Maps

Fig 12.4 Urban SC area map – screen grab from google maps – with areas demarcated for
ASHA/LW
1
2
3
7
4 Area 1
5 Area 2
Area 3
Area 4
Area 5
6 Area 6
Area 7
Steps to use google maps

Using google maps may seem to be very complicated but for the purpose of getting a birds
eye view of your area it is as simple as viewing a photograph on your computer.
Step 1 – go to www.googlemaps.com (generally the map identifies your IP address and
shows the area you are located automatically)
Step 2 – at the bottom left of the screen click on the “earth” square so this will
show you a satellite image rather than line map.
Step 3 –at the top left of the screen in the
“search google maps”enter the name of your area.
Step 4 – using the scroll button on the mouse or the + and – icons on the map
zoom into any area on the map.
Step 5 – once you have identified the area you wish to use as a map, either use the
“snipping tool” from “ACCESSORIES folder” from Windows Menu to cut out the
area you need OR press “PrtScn” to get an screen image of the map. (For Mac
computers use Command-control-shift-3)

Step 6 – paste the image on a PowerPoint slide or in a word document.

Step 7 – using the “insert shapes” option you can draw around an area using
the “scribble” option (see Fig 12.4) OR take a print out and draw directly on the
print out to demarcate areas.
Step 8 – save the file with area name and take a print out of the final map.
2. Accessibility
One of the challenges facing urban HWs is the large number of high-rise buildings, industrial
areas and apartment complexes. Other challenges include narrow lanes, distance from
local public transportation, high density and also access to flats and families living in
them. The local solutions to providing services include:
• Using three or two wheelers to access narrow lanes;
• Involvement of industries – individually or through their organizations;
• Involvement of the apartment associations in planning and support to the HWs during
visits;
• Involvement of local municipalities or corporations to issue instructions to all
apartments or other associations in an area;
• Seeking support from local key influencers and community leaders;
• Support from local civil service organizations – Rotary, Lions, professional bodies, etc.
The MO with support from the local workers can discuss and develop locally specific
solutions in such areas.
3. Infrastructure for providing RI services
Urban immunization services to be operationalized in the following way:

1. “Same day, Same site, Same time” provision of services: This should include:
• All sites including Anganwadi centres, dispensaries, clinics and maternity homes
in the public sector;
• All NGOs engaged in providing health care in urban areas;
• Any private institution /practitioner willing to support RI services.

2. Urban outreach: Expand the network of urban service provision points from the health
facility:
• Estimate size of population and frequency of sessions (same as with rural areas);
• Set up a site in every urban slum, with one or two trained vaccinators, to provide
immunization services on a regular (weekly or monthly) basis;
• Use the same principles for creating a session plan and work plan (described in
Unit 3) for the expanded network of urban outreach;
• Plan location of sites, frequency and timing of service to suit the local population;
• Establish contact with the local leader and obtain support;
• Communicate time and dates of sessions to the community (using existing
channels in the community like loudspeakers, religious or mothers’ groups, etc.);
• Ensure a regular uninterrupted service to gain the trust and cooperation of the
community
3. Communication: Communication through ICDS workers, LWs,HWs, NGOs active in the
area, print media, television and radio about the following:
• The timing of local immunization services;
• Local service delivery points;
• The vaccines and schedule of immunization;
• The benefits of immunization.
4. Multiple agencies / bodies for coordination
In addition to the Municipalities and Corporations there are many other departments that
can be approached for support. E.g. Department of Telecommunications can be approached
for help to send SMSs through government mobile network or from private sector under
Corporate Social Responsibility / local FM radio stations to be involved or conduct special
programs for immunization or Department of Transport can be approached to display
banners or posters on government vehicles or to facilitate support from private transport
companies.
Urban areas have the advantage of many non-governmental organisations working in the
peripheries or in slums. These organizations can be approached for support or for active
involvement in some areas where they have a strong presence.

Educational institutions can be approached directly or through the Department of

Education for support. Nursing colleges can be approached for support during campaigns
or in areas where there are vacancies in the urban health infrastructure. Involving multiple
organisations requires careful planning and inter-sectoral coordination, consult with CMO/
DHO and DIO for guidance and support.
Refer to frame work for implementation of National Urban Health Mission for urban
specific guidelines.
Notes:

Unit 13 : Financial planning in Immunization
13
Financial planning
in immunization
Financial management is an essential part of organizational management and comprises
of more than just keeping accounting records. Financial management involves planning,
organizing, controlling and monitoring financial resources in order to achieve organizational
objectives.This unit will give you an overview of sources of funding and focuses on the
detials of the program implementation plan and its norms.
Sources of funding:
The state financial resource for health is made up from three sources:
• State Budget
• State Exchequer
• Program Implementation Plan (PIP)
The state budget is the finances allocated by the state in its annual budget and reflects
the state’s contribution. The state exchequer source refers to funds received by the state
from the centre through the Ministry of Fig. 13.1. Source of funds
Finance. These are amounts disbursed
for regular activities and represent the
National share -
centres contribution. The PIP source State Exchequer
refers to the flexible funds proposed
National share -
by the states as per the states PIP Program State share -
Implementation State Budget
reflecting the states proposed needs Plan (PIP)
for funds from the centre in addition
to those committed. These funds are
Immunization
committed to the state by the centre expenditure
through the Recording of Proceedings

(ROP).
State Programme Implementation Plans (PIPs) are a proposal of the overall annual activities
and budgetary requirements based on which the state health system will function (Including
immunization expenditure).

PIPs are made up of five parts, namely: PART I: NRHM plus RMNCH+A (including
immunization), PART II: NUHM; PART III: Disease Control Programmes; PART IV: Non-
communicable diseases including injury and trauma; and PART V: Infrastructure
Maintenance. The MoHFW supports the states immunization programme through the
National Health Mission under Part I as mentioned above.
Process of PIP:
The purpose of the PIPs is to make budgetary proposals for both regular as well as need
based activities.
The block medical officer with support from the Block Program Management Unit provides
inputs for the DHAP in consultation with the District Program Management Unit and district
health officials. The DHAPs are a complete action plan which includes budgeting of all health
programs including immunization. The DPMU will review the district action plan before
submitting it to the District Health Society which under the chairmanship of the District
Magistrate will review and finalize it for submission to the state.
The State Program Management Unit (SPMU) with officials from the Directorate and
Mission Director review the action plans which are then sent to the State Health Society
where, under the chairmanship of the Principal Secretary they are finalized. The Executive
Committee (EC) of the State Health Society can examine this plan and make appropriate
modifications based on the states priorities and resource envelope. The State’s PIP is
consolidated from DHAPs.
The states submit their draft PIPs to the centre where the MoHFW conducts pre-appraisal
meetings with the states. The PIP is then appraised by the National Programme Coordination
Committee (NPCC), chaired by the Mission Director with officials from various program
divisions in MOHFW and with state participation.
Once approved the states are issued with a Record of Proceedings (ROP). Funds from the
centre are disdursed to the states in a phased manner.
The State Health Society implements the approved plan, with governance and oversight
exercised by the Governing Board and the State Health Mission, in association with District
Health Society (DHS). All expenditures should be made using FMR codes and followed by
issuance of SOE. See fig. 13.2 for proccess flow of PIP.

Fig. 13.2. Process flow of PIP
PIP Guidelines and resource

envelopes communicated to
states
Expenditure Action plans –

through FMR & Village to Districts
SOE to State
States submit draft PIP

Funds disbursement in
based on state priorities
phased manner
and PIP guidelines
MoHFW holds pre

ROPs for states issued appraisal meeting with
states
PIPs approved by NPCC

as per the Resource
Envelope of States
The role of the Medical Officer is crucial for the preparation of village & block health action
plans, which form the basis for making DHAPs which are finally merged into the state PIPs.
Programme Implementation Plan - Immunization
(Part C, Financial Management Report (FMR) C.1 to C.6)

Under the National Health Mission (NHM), financial support for various components of
immunization is given to all states at all levels to strengthen the Immunization Programme
under part C. These are further budgeted under FMR C.1 to C.6 of the PIP.
C.1 Routine Immunization strengthening project (Review meetings, mobility support,
printing, outreach services, innovations, etc.)
C.2 Salary of contractual staff
C.3 Training under Immunization
C.4 Cold chain maintenance
C.5 ASHA incentive for full immunization
C.6 Pulse polio operational cost

Most of the activities are covered under C.1 component, which is further sub classified into
FMR c.1.a to c.1.v.
There are certain activities which may not fit into part C like additional human resources or
budget for IEC/ BCC etc. These can be budgeted under part A/ part B of PIP.
Others (Part A and B) – support for HR and IEC/BCC:
• For other HR related to immunization (technical staff), e.g. refrigerator mechanics
• For IEC/BCC activities related to immunization.
New Activity
The State should provide a brief description, rationale, data/ background information
required to appraise the proposal and budget break-up for each new activity
Innovation
Up to a maximum of 10 % of the health systems strengthening budget (Mission Flexi pool
and NUHM) may be proposed for innovations which is a part of the overall budget envelope.
Budget Envelope:
As per 2016-17 guidelines, the NHM funding between the Centre and States would be in the
ratio of 60:40 (for all states except NE and 3 Himalayan States), 60 from Central government
and 40 from State.
States are requested to estimate the resource envelope accordingly. However, FMG
communicates the resource envelope separately.
Note:
Budgetary : this refers to norms to be used as guidance for preparing PIP.
Expenditure : this refers to norms to be used while spending as per GoI norms.

Details of PIP Norms
FMR
Activities Purpose Norms * Level
Code
C.1
c.1.a Mobility Support Budgetary: Rs.2,50,000/ Year / District
for supervision Mobility budget for the district level officers.
for district level entire year is provided
officers. to the districts for
undertaking monitoring
and supervision of Routine
in the district. The mobility
support is provided only for
the district level officers.
c.1.b Mobility support Budgetary: Rs. 1, 50,000 per State
for supervision at Mobility budget for year.
state level the entire year is
provided for undertaking
monitoring and supervision
of Routine immunization
programme in State Level.
c.1.c Printing and Budgetary: Rs. 10 / beneficiary State/
dissemination The funds allocated under district
of Immunization this head are for printing
cards, tally sheets, and dissemination of
monitoring forms Immunization cards, etc.
etc.
c.1.d Support for Budgetary: Rs. 1250/ per District
Quarterly State Funds allocated for participant/day for
level review conducting quarterly State 3 persons (CMO/
meetings of district level review meetings DIO/Dist. Cold Chain
officer of district officer for Officer)
maximum of 3 persons per
meeting

FMR
Code
c.1.e Quarterly review Budgetary: Rs. 100/per Block
meetings exclusive Funds allocated for participant for
for RI at district conducting quarterly meeting expenses
level with one Block review meetings at district for 5 persons
MOs, CDPO, and level for maximum of 5 (lunch, Organization
other stake holders persons per meeting expenses)
c.1.f Quarterly review Budgetary: Rs. 50/ per person Block

meetings exclusive Funds allocated for as honorarium for
for RI at block level conducting quarterly ASHA (Travel) and
review meetings at block Rs. 25/person at the
level wherein honorarium disposal of MO-IC for
is paid to ASHA meeting expenses
(refreshment,
stationary and misc.
expenses)
c.1.g Focus on slum Expenditure: Hiring of ANM@ District/
& underserved In case the ANM is not Rs 450/session for Block
areas in urban available or appointed, an four session/month/
areas/alternative alternate vaccinator can slum of 10000
vaccinator for slums be hired for these session population and Rs.
sites. 300/- per month as
contingency per slum
i.e. Rs. 2100/- per
month per slum of
10000 population
c.1.h Mobilization of Expenditure: Rs. 150 per session District/
children through Funds @ 150/- per Block
ASHA or other session for mobilization
mobilizers of Pregnant Women and
targeted children for
immunization as per the
micro-plan are to be paid
preferably to ASHA.

c.1.i Alternative vaccine Expenditure: Rs. 150 per session District/

delivery in hard to Rs. 150 per session for Block
reach areas Hilly terrains and
geographically hard to
reach areas
c.1.j Alternative Vaccine Budgetary: Rs. 75 per session District/
Delivery in other Rs. 75 per session for RI Block
areas session in other areas
c.1.k To develop micro Budgetary: @ Rs 100/- per Block
plan at sub-centre Rs. 100/- paid per subcentre
level subcentre to familiarize
the health managers with
the steps in developing
a comprehensive and
equitable micro plan
c.1.l For consolidation Budgetary: Rs. 1000 per block/ District/
of micro plans at Rs.2000/- for each district PHC and Rs. 2000 per Block
block level and Rs.1000/- for each district
block or PHC for the
purpose of consolidation of
micro plans
c.1.m POL for vaccine Budgetary: Rs1,50,000/ district/ State/
delivery from State The POL is provided for year District
to district and from transport and distribution
district to PHC/CHCs of vaccine from State to
district and then from
district to PHC/CHCs
c.1.n Consumables for Budgetary: @ 400/ - month/ District
computer including The funds is earmarked for district
provision for petty consumable items for
internet access for each district
RIMs

FMR
Code
c.1.o Red/Black plastic Budgetary: Rs. 3/bags/session District/
bags etc. Fund allocated for Block
procurement of red and
black plastic bags for
containment of medical
waste after post RI
immunization session
c.1.p Hub Cutter/ Budgetary: Rs. 1200 per PHC/ District/
Bleach/Hypochlorite For cutting the AD syringe CHC per year Block
solution/ Twin at the hub immediately
bucket after administering the
injection at the session site.
Similarly other items are
required for disinfecting
medical/bio waste
c.1.q Safety Pits Budgetary: Rs. 5250/pit District/
Funds allocated for the Block
disposal of used needles
and syringes that are loose
c.1.r State specific Expenditure: At all
requirement This head is for any levels
innovation under
Immunization. Normally it
should not exceed 10% of
the total resource envelope
under Part C.
c.1.s Teeka Express Expenditure: State (as
Operational Cost Funds allocated for a pilot
providing operational cost in only 5
for Teeka Express. states)
c.1.t Measles SIA Expenditure: Allocat-
operational Cost Funds allocated for ed by
providing operational cost GOI
for Measles SIA

c.1.u JE Campaign Expenditure: Allocat-

Operational Cost Funds allocated for ed by
providing operational cost GOI
for JE SIA
c.1.v Others Expenditure: At all
This head is basically for levels
any other Immunization
activity which could not be
covered under any other
head. Alternatively, this
head can also be used for
innovation in the field of
Immunization
C.1-Sub Total
C.2 Expenditure:
C.2.1 Computer Funds allocated for State
Assistants support payment of salary to
for State level Computer Assistant at
State level
C.2.2 Computer Funds allocated for District
Assistants support payment of salaries to
for District level Computer Assistants at
District level
C.2.3 Others(service Funds allocated for At any
delivery staff) payment of salaries to level
service delivery staff , if any
C.2-Sub Total

FMR
Code
C.3
C.3.1 District level Expenditure: As per revised norms
Orientation Fund allocated for for trainings under
training including conducting 2 days training RCH** (See page
Hep B, Measles for ANM, Multi-Purpose 286)
& JE(wherever Health Worker (Male), LHV,
required) for 2 Health Assistant (Male/
days ANM, Multi- Female), Nurse Midwives,
Purpose Health BEEs & other staff
Worker (Male), LHV,
Health Assistant
(Male/Female),
Nurse Midwives,
BEEs & other staff
C.3.2 Three day Expenditure:
training including Fund allocated for
Hep B, Measles conducting 3 days training
& JE(wherever for Medical Officers of RI
required) of Medical
Officers of RI using
revised MO training
module)
C.3.3 One day refresher Expenditure:
training of district Fund allocated for
Computer assistants conducting 1 day refresher
on HIMS and training of Computer
immunization assistants on RIMS/HIMS
formats and immunization formats
C.3.4 Two days cold chain Expenditure:
handlers training Fund allocated for
for block level cold conducting 2 days training
chain handlers by of cold chain handlers at
State and district block level and district level
cold chain officers

C.3.5 One day training Expenditure:

of block level data Fund allocated for
handlers by DIOs conducting 1 day training
and District cold of block level data handlers
chain officer by DIOs and District cold
chain officer
C.3.6 Others Expenditure: At all
Head reserved for levels
any other training to
be conducted under
Immunization which could
not be covered under the
above mentioned training
heads
C.3-Sub Total
C.4
C.4 Cold chain Budgetary: Rs.750/PHC/CHCs State/
maintenance Funds are allocated for per year District district
cold chain maintenance at Rs.15000/year
District Level, PHC and CHC
C.5
C.5 ASHA incentive for Expenditure: Rs 100 per child for District/
full Immunization The ASHAs will receive full immunization in block
performance-based first year
incentives for full
Immunization of Rs.150/-
which is paid in two years.
Rs 50 per child for
ensuring complete
immunization up to
2nd year of age
Total ROUTINE
IMMUNIZATION

FMR
Code
C.6 Pulse Polio Expenditure: Allocated by GOI National
Operational Cost Funds allocated for level
(Tentative) providing operational
cost for Pulse Polio
Immunization Programme
Total
A.8 Human Resources Expenditure: Any new or ongoing State/
Funds allocated for positions district
payment of salary to
technical staff e.g.
refrigerator mechanics
A.10 Program Expenditure: Any new or ongoing State/
Management Funds allocated for positions district
payment of salary to
other staff related to
Immunization
B.10 IEC-BCC NHM Expenditure: State /
Funds allocated for IEC / district
BCC activities related to
Immunization
Other incentives for ASHAs under NHM

c.1.r/ ASHA incentive for Expenditure: Rs 100/month District
c.1.v due list preparation For monthly updating of
due list of beneficiaries
under immunization
ASHA incentive Expenditure: Rs 100 twice in a year District
for house to house For conducting house to
survey house survey bi-annually
*Please note that under Immunization most of the activities are normatic, and is to be budgeted as the
multiplication factor of the mentioned norm. However, there is flexibility provided to the state under
innovations head (c.1.r & c.1.v). States should also refer to the conditionality mentioned in the ROP. These
conditionalities are provided for C.4 under cold chain maintenance funds, wherein the state may propose
for re-appropriation of funds within part C from MoHFW, in case the funds are exhausted as per the actual
expenditure. Also, the norms for alternate vaccine delivery are for budgetary purpose only and need based
support should be provided for vaccine delivery as per local situation.

** Revised training norms under RCH (as per GOI letter D.O.No. A-11033/101/07- Trg, dated
28th Jan, 2015)
S No. Budget Head Final Proposed Norms
1. DA to Group A equivalent Participants Rs 700/- per day
2. DA to Group B, C & D or equivalent Rs 400/- per day
participants
3. Honorarium/ per diem to Group A & B Rs 500/-
equivalent participants
4. Honorarium/ per diem to Group C & D or Rs 300/-
equivalent participants
5. TA to Group A,B,C & D or equivalent TA rules of Central/ State Govt.
participants (whichever applicable)
6. Hiring of Vehicle by Trainer State norms of hiring of vehicle will
apply
7. Honorarium to Guest faculty at District Rs 600 (district) Rs 1000 (State) &
and sub-district, State/Regional/National 1500 (National Level) per day^
level (Experts/Specialists of area, faculty
of medical college, centre of excellence,
program officer dealing with program)
8. Honorarium to professional/ Faculty/ District to Block- Rs 500/-, State to
Trainers from Medical Colleges^^^ District/Block 1000/- and National
for monitoring of trainings in field as to State/ District/ Block level –
Observer 1500/- (one training in a day with
• Checklist complete observer report) Report
• Handholding the training to be copied to respective concern
• Action taken decision division, State headquarters/ SIHFW
and in Ministry (MOHFW)
9. Food to participants (breakfast, working Rs 250/- participants/day at district
tea & lunch & Dinner for residential level and 350 at State and 400 at
trainings) National level (subject to actual)
10. Accommodation for Trainers where Up to Rs 3000 (district level)
residential facility is not available Rs 4000 (at state level), & 5000
(National Level) per day (subject to
actual). Above are the maximum
limits and subject to receipt.

11. Accommodation for participants where Up to Rs 1000 (district level)

hostel facility is not available Rs 2000 (at state level), & 3500
(National Level) per day (subject to
actual). Above are the maximum
limits and subject to receipt.
12. Incidental expenses (Photocopy, job aids, Rs 300/- participants/day (subject
flip charts etc) to actual)^^
13. Venue hiring (in absence of training Rs 5000/- per day at district/block
institute) level per day
Rs 10,000 per day at State level
per day and Rs 20,000 per day at
National level per day^^
14. Institutional overhead for the use of 15% of total training expense
institutional facilities
^ Subject to two lectures/Guest faculty/per day
^^Subject to keeping it minimum
^^^In principle, honorarium to impart training/taking sessions is not to be paid to any type of in-house
faculty from NIHFW/SIHFW/ DTC/ HFWTC/ ANMTC/ DTT/ HTT or similar institute of training since training
is their defined job.

The Medical Officer may refer to the link http://nhm.gov.in/nrhm-in-state/state-program-implementation-

plans-pips.html, for updated guidelines and ROPs of all states/ UTs at MoHFW National Health Mission
website.
Medical Officer’s role Activity How

1. Ensuring all activities related to
routine immunization are included
During preparation of
in BHAP (Block Health Action
Providing inputs during BHAP for PIPs, interact
Plans) of PIPs.
preparation of the block with BPMs (Block
2. MOIC can share his ideas with
& district health action Programme Manager),
the District Immunization Officer
plans. NHM & DPMs (District
(DIO) during preparation of District
Programme Manager)
Health Action Plans for adding any
need based innovation.
1. A Medical officer can view
activities under state ROP which
has been approved for his state ROP can be viewed at
Utilization of Budget
in a particular financial year and NHM website of GOI
provided to the state as
accordingly incur expenditure on or can be taken from
per ROP
various activities. SPMU/ DPMU.
2. The utilization is to be shared
with the district regularly.
Are all activities covered under
ROP? If not, you may propose
Any additional
a new activity within your
requirement can Any time after the issue
budget envelope, explaining in
be projected in the of final ROP.
a short write-up, why you need
Supplementary PIP.
this and may propose under
supplementary PIP.

Notes:

References and links
Further reading and links

This unit contains a list of links to some of the information that supports this module. Some
of the links provided are technical information which may not have been mentioned in this
manual but will be useful if you wish to read further on some topics or if you need a broader
perspective. Happy reading!!
Unit 1 – Introduction
• Comprehensive Multiyear Plan 2013–2017
https://www.itsu.org.in/Comprehensive-Multi-year-Plan
• Understanding global evolution of EPI
http://www.who.int/immunization/programmes_systems/en/
• Information on global immunization policies and strategies
http://www.who.int/immunization/programmes_systems/policies_strategies/en/
• Global Vaccine Action Plan
http://www.who.int/immunization/global_vaccine_action_plan/GVAP_foreword.
pdf?ua=1
• Sampling methods in estimating immunization coverage
o http://www.who.int/immunization/monitoring_surveillance/routine/coverage/
en/index1.html
o http://www.who.int/immunization/monitoring_surveillance/routine/coverage/
en/index2.html
Unit 2 – National Immunization Schedule
• How vaccines are introduced in India – National Vaccine Policy
http://mohfw.nic.in/showfile.php?lid=900
• Detailed technical information on vaccines – WHO: Vaccine Position Papers
http://www.who.int/immunization/documents/positionpapers/en/
• For National Technical Advisory Group on immunization recommendations
visit www.mohfw.nic.in. Use search function on webpage; key in NTAGI. Meeting
minutes and recommendations are available.

Unit 4 – Cold chain and logistics management

• National effective vaccine management assessment 2013
http://unicef.in/Uploads/Publications/Resources/pub_doc86.pdf
• Article on best practices in intradermal, subcutaneous and intramuscular
injections –http://www.who.int/bulletin/volumes/81/7/Hutin0703.pdf?ua=1
• Validation of the shake test for detecting freeze damage to adsorbed vaccines
http://www.who.int/bulletin/volumes/88/8/08-056879/en/
Unit 5 – Safe injections and waste disposal
• Central Pollution Control Board for details on BMW rules
http://www.cpcb.nic.in/Bio_medical.php
• Biomedical Waste Management and Handling Draft Rules 2015 amendments
http://www.moef.nic.in/sites/default/files/Final_vetted_BMW%20Rules%202015.pdf
• Injection safety information
http://www.who.int/injection_safety/en/
Unit 6 – Adverse events following immunization
• Information sheets on reaction rates of selected vaccines
www.who.int/vaccine_safety/initiative/tools/vaccinfosheets/en/
Unit 7 – Sources and use of data
• Immunization coverage estimation
http://www.who.int/immunization/monitoring_surveillance/routine/coverage/en/
• Using data to improve immunization – global learning
http://www.who.int/management/UsingDataToImproveServiceDeliveryImmunizati
on.pdf
Unit 8 – Supervision and monitoring
• NIHFW module on supervision and monitoring
http://www.nihfw.org/pdf/nchrc-publications/module%20-%204.pdf
Unit 9 – Communication for behaviour change
• Information on vaccine hesitancy
http://www.who.int/mediacentre/news/releases/2015/vaccine-hesitancy/en/

Unit 10 – Vaccine Preventable Diseases and VPD surveillance

• Epidemiology and Prevention of Vaccine-Preventable Diseases; The Pink Book: Course
Textbook– 13th Edition (2015) available at:
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html
• WHO – recommended standards for surveillance of selected vaccine-preventable
diseases available at:
http://apps.who.int/iris/bitstream/10665/68334/1/WHO_V-B_03.01_eng.pdf?ua=1
• Field guide for AFP surveillance
http://www.searo.who.int/entity/india/topics/poliomyelitis/Field_guide_for_
Surveillance_of_Acute_Flaccid_Paralysis_3rd_edition.pdf
• Measles outbreak investigation field guide
http://www.searo.who.int/india/topics/measles/Measles_surveillance_and_
outbreak_investigation_field_guide_2005.pdf
Unit 11 – Capacity building of health functionaries in immunization
• Module on ASHA guidelines including roles and responsibilities
http://nrhm.gov.in/images/pdf/communitisation/asha/Orders-Guidelines/
Guidelines_for_Community_Processes_2014_English.pdf
Unit 12
• National Framework for NUHM implementation
http://www.nrhm.gov.in/images/pdf/NUHM/Implementation_Framework_NUHM.
pdf
• PIP guidelines for NUHM
http://www.nrhm.gov.in/images/pdf/NUHM/NUHM_PIP_Guidelines_2013-14.pdf
Unit 13– Budgeting and finance
• E-Training Module on “PIP/Budget preparation”
http://mohfw.nic.in/WriteReadData/l892s/8514370340PIP-%20Budget%20%20
Module.pdf

Frequently asked questions
Notes:

FAQ Contents
General 279
Queries on Immunization schedule 281
BCG 282
HepB 283
Pentavalent 284
Rotavirus 285
IPV 287
Measles/Rubella 288
JE 290
Pneumococcal 291
Microplanning 293

Notes:


General queries on immunization
What is immunization?
Immunization is the process of administering vaccines for the development of the body’s
protective response.
How do vaccines work?
Vaccines contain either weakened or killed versions of viruses or bacteria. These are
also called “antigens”. Once introduced, they stimulate the immune system in the body
to produce “antibodies” against the disease causing organisms. Each vaccine provides
immunity against a particular disease; therefore, a number of vaccines are administered to
children and women to protect them from many vaccine-preventable diseases.
Vaccines also vary in efficacy, according to the age at which the vaccine is administered
and the number of doses given. Presence of maternal antibodies in early infancy interferes
with the antibody production. For example, measles vaccine is 85% effective at the age of
9 months and 95% at 1 year.
What are the different types of vaccines?
There are four main types of vaccines:
Live attenuated vaccines (LAV), inactivated or killedvaccines, Subunit or Recombinant and
Toxoid (Inactivated toxins).
Live attenuated vaccines are derived from disease-causing viruses or bacteria that
have been weakened under laboratory conditions. They replicate in a vaccinated
individual, but because they are weak, they cause either no disease or only a mild
form of the disease. Examples of live vaccines are BCG, measles, Rotavirus, JE and oral
polio vaccine.
Inactivated or killed vaccines are produced by viruses or bacteria which are inactivated
with heat or chemicals. They cannot grow in a vaccinated individual and so cannot
cause the disease. They may not always induce an immune response, requiring
multiple doses for full protection as well as booster doses to maintain immunity. Use of
adjuvants enhances response to non-live vaccines. Examples are whole-cell (pertussis),
fractional polysaccharide-based conjugate (Haemophilusinfluenzae type b or Hib) and
IPV.

Subunit or Recombinant vaccines are produced by inserting genetic material from

a disease-causing organism into a harmless cell, which replicates the proteins of the
disease-causing organism. The proteins are then purified and used as vaccine. Example
is hepatitis B vaccine.
Toxoid vaccines are made from a toxin that has been made harmless but which elicits
an immune response against the toxin. Toxoid vaccines are safe because they cannot
cause the disease they prevent and there is no possibility of reversion to virulence.
The vaccine antigens are not actively multiplying and do not spread to unimmunized
individuals. Examples are Tetanus toxoid and diphtheria toxoid.
What is Herd immunity or population immunity?
A population with a high number of members with immunity to a particular disease or
pathogen may give protection from that infection to the small number of its non-immune
members. This is as a result of there being too few susceptible persons in the “herd” for the
infection to circulate. This is known as “herd immunity or population immunity.”
Immunization of children can go well beyond saving individual lives. It can also help in
preventing large-scale outbreaks of diseases as well as keeping a disease under control (or
sometimes even eliminated or eradicated e.g. polio) in the area. You should always strive to
achieve the highest percentage of coveragepossible for all doses of the vaccines for disease
control to be effective.
How are vaccines introduced in UIP and how are immunization schedules decided?
The decision on inclusion of vaccines and the schedules is taken by the National Technical
Advisory Group on Immunization (NTAGI). It is based on recommendations of the Strategic
Advisory Group of Experts (SAGE)as well as WHO-recommended schedules and vaccine
position papers.
Why are vaccines administered at specific sites?
Vaccines are administered at specific sites to maintain uniformity and for helping surveyors
in verifying the receipt of the vaccine. e.g BCG on left upper arm.
Why should there be a minimum gap of 4 weeks between two doses of a vaccine?
There should be a minimum of 4 weeks gap between two doses because decreasing
the interval between doses may not achieve optimal antibody production required for
protection.
How long can a bottle of Vitamin A be used, once opened?
A Vitamin A bottle, once opened, should be used within 8 weeks. Write the date of opening
on the bottle. It must be kept away from direct sunlight.

What is the dose of Zinc to be used along with ORS in the treatment of diarrhea?
The dose of zinc for infants aged 2–6 months is 10 mg of dispersible tablet in expressed
breast milk for 14 days. For children 6 months to 5 years of age, it is 20 mg of dispersible
tablet for 14 days.
Queries on immunization schedule
If a child is brought late for a subsequent dose, should one re-start with the first dose of
a vaccine?
No, do not restart the schedule again; pick up where the schedule was left off. For example,
If a child who has received BCG, penta1 and OPV1 at 5 months of age returns at 11 months
of age, then vaccinate the child with penta2, OPV2 , measles, Rotavirus vaccine (where
applicable) and JE (where applicable).
If a child who has never been vaccinated is brought in at 9 completed months but before
12 completed months of age, then, can all the due vaccines be given to a child on the
same day?
Yes, all the due vaccines can be given during the same session but at recommended injection
sites, using separate AD syringes. It is safe and effective to give BCG, penta, OPV,IPV, measles
,RVV (where applicable), JE (where applicable) vaccines and Vitamin A at the same time to a
9-month-old child who has never been vaccinated.
If more than one injection has to be given in one limb then ensure that the distance between
the two injection sites is at least 1 inch apart.
If a child who has never been vaccinated is brought in immediately after completing 12
months of age, (beyond one year) what vaccines would you give?
As per the national immunization schedule this child need not be given – BCG, Hepatitis B,
Rotavirus, Penta and IPV.
This child should be administered DPT 1, OPV 1, Measles 1, JE 1(if applicable) and also
Vitamin A solution.
The subsequent doses of DPT and OPV should be given at an interval of 4 weeks. Administer
Measles 2, JE 2 (If applicable), Vitamin A and a booster dose of DPT at recommended age as
per national immunization schedule.

Which vaccines can be given to a child between 1 and 5 years of age who has never been
vaccinated?
Such a child will not receive BCG, Hepatitis B, Rotavirus, Penta and IPV.
Give DPT1, OPV1, measles 1, JE 1 (where applicable) and 2ml of Vitamin A solution.
Then follow with the second and third doses of DPT and OPV at 1 month intervals. Give
measles 2 as per the schedule/1 month later*. Give booster dose of OPV/DPT at a minimum
of 6 months after administering OPV 3/DPT 3. Also give Vit A at 6 months interval till 5 years
of age.
*Note: In an unvaccinated child more than 16 months of age remember the interval
between Measles 1 and Measles 2 is 4 weeks and for JE 1 and JE 2 (where applicable) the
interval is 3 months.
Which vaccines can be given to a child between 5 and 7 years of age who has never been
vaccinated?
Give of DPT 1, 2 and 3 at 1 month intervals. Give booster dose of DPT at a minimum of 6
months after administering DPT 3 up to the age of 7 years.
Why are the DPT, HepB (birth dose), IPV and pentavalent vaccines given in the anterolateral
mid-thigh and not the gluteal region (buttocks)?
This is done to prevent damage to the sciatic nerve. Moreover, vaccine deposited in the fat
of the gluteal region does not invoke the appropriate immune response.
Vaccine-specific FAQs
BCG
Why is BCG given only up to 1 year of age?

Most children acquire natural clinical/sub-clinical tuberculosis infection by the age of 1
year. This protects against severe forms of childhood tuberculosis, e.g. TB meningitis and
miliary disease.
If no scar appears after administering BCG, should one re-vaccinate the child?
There is no need to re-vaccinate the child even if there is no scar.
Why do we give 0.05 ml dose of BCG to new borns (below 1 month of age)?
This is because the skin of newborns is thin and an intra-dermal injection of 0.1 ml may
break the skin or penetrate into the deeper tissue and cause local abscess and enlarged
axillary lymph nodes. Dose of 0.05 ml is sufficient to elicit adequate protection.

Hepatitis B
What is hepatitis?
Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There
are five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are
of the greatest concern because of the burden of illness and death they cause and the
potential for spread of outbreaks and epidemics. In particular, types B and C lead to chronic
disease in hundreds of millions of people and, together, are the most common cause of liver
cirrhosis and liver cancer.
Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis
B, C and D usually occur as a result of parenteral contact with infected body fluids. Common
modes of transmission for these viruses include receipt of contaminated blood or blood
products and using contaminated equipment in invasive medical procedures. For hepatitis
B, the causes are transmission from mother to baby at birth, from family member to child
and also by sexual contact.
Acute infection may occur with limited or no symptoms, or may include symptoms such as
jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and
abdominal pain.
What is the “birth dose” of hepatitis B?
This refers to the dose given within 24 hours of birth. A child vaccinated with Hep B after
more than 24 hours of birth is not considered to have received the birth dose.
Why is the birth dose of hepatitis B vaccine given only within 24 hours of birth?
The birth dose of hepatitis B vaccine is effective in preventing peri-natal transmission of
hepatitis B only if given within the first 24 hours.
Why is hepatitis B vaccine given only till 1 year of age?
Hepatitis B vaccine is given till 1 year of age because infections during first year of age have
a 90% chance of becoming chronic as compared to 30% during 1–5 years and 6% after 5
years. Persons with chronic infection have 15–25% risk of dying prematurely due to HBV-
related liver cirrhosis and cancer.

Pentavalent Vaccine
What is pentavalent vaccine?

Pentavalent vaccine is a vaccine that contains five antigens (diphtheria + pertussis + tetanus+
hepatitis B + Haemophilusinfluenzae type b).
How is pentavalent vaccine more advantageous?
• The addition of Hib vaccine provides protection against Haemophilus Influenzae
Type b related diseases (bacterial meningitis, pneumonia and others)
• The number of injections administered under UIP during the first year of life
reduces from ten to seven (not including IPV).
• It does not require reconstitution.
What is the schedule for pentavalent vaccine?
As per the National Immunization Schedule, three doses of pentavalent vaccine are to
be administered. The first dose is given only after a child is 6 weeks old. The second and
third doses are given at 10 and 14 weeks of age, respectively. There is no booster dose
recommended under UIP
Note: Pentavalent vaccine should be started for any child aged more than 6 weeks and can
be started upto 1 year of age.
For what reasons should a child not be given pentavalent vaccine?
• Age – a child below 6 weeks of age should not be given pentavalent vaccine.
• Vaccination history – a child whose vaccination schedule has been initiated with
DPT/hepatitis B vaccine will continue to receive subsequent doses of DPT/hepatitis
B and not pentavalent vaccine.
• Severe allergic reactions – although serious side effects have not been reported, a
child who has had a severe reaction to pentavalent vaccine earlier should not be
given another dose.
• Children with moderate or severe acute illness should not be administered
pentavalent vaccine until their condition improves. Minor illnesses, however, such
as upper respiratory infections (URI) are not a contraindication to vaccination.

What vaccine will be given to a child who has received at least one dose of pentavalent
vaccine before his/her first birthday?
If a child has received at least one dose of pentavalent vaccine before his/her first birthday,
the child should be administered the due pentavalent doses at a minimum interval of 4
weeks, at the earliest available opportunity.
What are the common side-effects of pentavalent vaccine?
Pentavalent vaccine has not been associated with any serious side-effects. However, redness,
swelling and pain may occur at the site where the injection was given. These symptoms
may appear the day after the injection is given and last from 1 to 3 days. Less commonly,
children may develop fever for a short time after immunization.
After introduction of pentavalent vaccine, will DPT and Hep B be required?
Yes, Hep B birth dose (within 24 hours) for institutional deliveries and DPT boosters at 16–
24 months and 5–7 years will continue as before.– Introduced
Rotavirus vaccine – Introduced in Feb 2016 - in phases
What is Rotavirus?
Rotavirus is a highly contagious virus. It is the most common organism that causes diarrhea
among children which may lead to hospitalization and death.
What are the clinical features of Rotavirus diarrhea?
Rotavirus diarrhea has an incubation period 1-3 days. It presents usually with sudden onset
of watery stools, often accompanied by fever and vomiting. Sometimes accompanied with
abdominal pain. The diarrhea and associated symptoms may last for 3-7 days.
How effective is the Rotavirus vaccine?
The available Rotavirus Vaccines are observed to be effective in preventing severe rotavirus
diarrhea by 54-60%. The protective effect of Rotavirus vaccine lasts through 2nd year of life.
Is Rotavirus vaccine being used in any other country in the world?
Rotavirus vaccine is being used in national immunization program more than 80 countries.
Rotavirus vaccine has also been in use by private practitioners in India for several years.
Will vaccination with Rotavirus vaccine prevent all diarrheas?
No it does not prevent all diarrheas. Diarrhea is caused by many organismsof which
Rotavirus is one of the leading causes for diarrheain children. Rotavirus vaccine is effective
in preventing diarrhea due to Rotavirus only. So the child may still get diarrhea due to other
germs and causes even after receiving Rotavirus vaccine.

How and when is the Rotavirus vaccine given?

Rotavirus vaccine is an oral vaccine. The dose of Rotavirus vaccine varies from manufacturer
to manufacturer.
The dose and route for Rotavirus vaccine currently being supplied under UIP is 5 drops to
be administered to all infants at 6, 10 and 14 weeks along with other vaccines in routine
immunization .
What is the maximum age limit for giving the first dose of Rotavirus vaccine?
The upper age limit for the first dose of Rotavirus vaccine is one year of age. If a child has
received only the first dose of Rotavirus vaccine by 12 months of age, two more doses of
the vaccine should be given at an interval of 4 weeks between the two doses to complete
the course.
Is a booster dose required for Rotavirus vaccine?
No booster dose of Rotavirus vaccine is recommended. Only three doses at 6, 10 and 14
weeks are required to complete the schedule of vaccination for a child.
Should Rotavirus vaccine be given to children who have already received first dose of OPV
and Pentavalent vaccine?
No, during the initial period of Rotavirus vaccine introduction, only the infants coming for
the first dose of OPV and pentavalent vaccine will be administered Rotavirus vaccine. These
children will be given 2nd and 3rd doses in subsequent visits as per the schedule.
Infants who are coming for their second or third dose of OPV and pentavalent vaccine, will
complete the schedule with OPV and pentavalent vaccine only. Rotavirus vaccine is not to
be started with second or third dose of OPV and Pentavalent vaccine.
What should be done if a child has received one or two doses of Rotavirus vaccine in a
private facility?
If the parents want to vaccinate their child from the public sector after receiving one or two
doses of Rotavirus vaccine in a private facility, a new course of Rotavirus vaccine must be
started with all three doses at one month intervals provided the child is less than one year
old.

Inactivated Poliovirus Vaccine
What is IPV?
IPV refers to Inactivated Poliovirus Vaccine administered by injection. Evidence suggests
that this vaccine, when used along with OPV, increases the protection to the individual as
well as the community. IPV together with OPV prevents re-emergence and reinfection of
wild poliovirus (WPV).
Will IPV (injection) replace OPV (drops)?
No, IPV (injection) will not replace OPV (polio drops), since IPV is recommended to be
administered in addition to OPV.
Is IPV a new vaccine?
No, IPV is not a new vaccine. It is being used in many countries. IPV was licensed in 1955 for
use in United States, Canada, and Western Europe.
IPV was licensed for use in India in 2006. Based on recommendations of the Indian Academy
of Paediatrics (IAP), IPV is being used in the private sector in addition to OPV schedules
since 2007.
What is the benefit of IPV?
IPV provides much needed additional protection against polio and protects a child as well
as other children in our community. Evidence shows that when IPV is used along with OPV,
it builds better mucosal (intestinal) immunity than when OPV is used alone; it thereby
increases both the protection to the individual and the community. To maximize childhood
immunity and move towards global polio eradication, it is recommended that both vaccines
be used together.
Is IPV safe?
Yes, IPV is considered very safe, whether given alone or in combination with other vaccines.
Are there any contraindications for use of IPV?
IPV should not be administered to children with a documented or known allergy to
streptomycin, neomycin or polymyxin B, or with a history of a previous allergic reaction
after IPV injection.

Is it safe to give IPV and OPV together?

Yes, it is absolutely safe to give IPV and OPV together. It is also important – and best – for
a child to receive both IPV and OPV. Together, these two vaccines provide safe and strong
protection against polio. If a child only receives one of the vaccines they will not be as well
protected as the child that has received both the vaccines. Primary doses of OPV (OPV1,
OPV2 and OPV 3) should be completed as per schedule.
How and when is IPV to be administered?
IPV is to be given as a fractional dose (0.1 ml) intradermally in the Right arm of the child.
Fractional IPV is given in two doses at 6 and 14 weeks along with OPV 1 and OPV 3
Measles / Rubella
What are Measles / Rubella diseases?

Measles is a highly infectious disease causing illness and death due to complications in
the form of diarrhea, pneumonia or brain infection mostly among the children less than
five years of age. Rubella is a mild disease but when infection occurs in early pregnancy,
it has the potential to cause spontaneous abortions, fetal deaths, still births and serious
congenital defects in the child causing lifelong disabilities.
What is CRS?
CRS, (Congenital Rubella syndrome) is a set of serious congenital defects a child may be born
with when a pregnant women gets Rubella infection in early pregnancy , causing blindness,
deafness, heart defects, mental retardation, liver disorders and other hematological
disorder, incompatible with normal living.
Why is Measles-Rubella vaccine given?
This Measles –Rubella vaccine is given for preventing both measles and rubella disease in
the child, as these diseases can be only prevented by vaccination.
What is the efficacy of Measles-Rubella vaccine?
The efficacy of measles component in the vaccine is 85% when given below 12 months of
age in a child and >95% efficacy when given above 12 months of age. While the efficacy
of the Rubella component in the vaccine is more than 95% below 12 months and > 99% if
given above 12 months of age.

Does a child need to be vaccinated if she or he has history of any fever-rash illness including
measles or rubella disease?
Yes, every child must be vaccinated with two doses, as per the national immunization
schedule with MR vaccine at the recommended ages, irrespective of any past fever-rash
illness or measles/rubella disease.
If a child has received the Measles Rubella vaccine before 9 months of age, is it necessary
to repeat the vaccine later?
Yes, the Measles Rubella vaccine needs to be administered, according to the National
Immunization Schedule, after the completion of 9 months until 12 months of age as 1st
dose and at 16-24 months as 2nd dose in RI.
If a child comes after 2 years for the first dose, then can he/she get the second dose?
All efforts should be made to immunize all children at the right age i.e. first dose at completed
9 months to 12 months and second dose at 16-24 months. However if a child comes late
(beyond 2 years),then two doses of the vaccine can be given at one month interval until 5
years of age under UIP.
If a child has received all vaccines as per the national immunization schedule, dose she or
he need to be vaccinated during supplementary MR campaigns?
Yes, in addition to the recommended national immunization schedule the child (if eligible
as per age group targeted) must be vaccinated with supplementary MR vaccines during
campaigns.
As measles and JE vaccine doses are recommended for the same age group, can they be
given together?
Yes, two live injectable vaccines can be administered simultaneously at different sites,
otherwise at a minimum interval of 28 days.Japan

Japanese Encephalitis
What is Japanese encephalitis and what is acute encephalitis syndrome (AES)?
Japanese encephalitis (JE) is a severe, disabling viral disease spread by infected mosquitoes,
primarily in the agricultural regions of Asia. The disease affects the central nervous system
and can cause severe complications, seizures, and even death.
Clinically, a case of acute encephalitis syndrome (AES) is defined as a person of any age,
at any time of the year with acute onset of fever and a change in mental status (including
symptoms such as confusion, disorientation, coma, or inability to talk) and/or new onset
of seizures (excluding simple febrile seizures). Other early clinical findings may include an
increase in irritability, somnolence or abnormal behaviour greater than that seen with usual
febrile illness (WHO).
AES including JE is a group of clinically similar neurological manifestations caused by several
different viruses, bacteria, fungus, parasites, spirochetes, chemical/toxins, etc. Some other
causes of AES could be tuberculosis, meningitis, viral encephalitis, cerebral malaria, etc.
How common is JE?
JE is the leading cause of viral encephalitis in Asia. Though 30,000 to 50,000 cases and 15,000
deaths are reported each year, a lack of diagnostic capability and reliable data suggest that
the actual number of cases is much higher.
Where is JE endemic in India?
JE is endemic in 202 districts in 12 states across
the country. JE vaccination campaigns have
been completed in 193 districts and with the
remaining nine scheduled to be completed in
2016.
Who is at risk for JE?
People living in rural rice-growing and pig-
farming regions face increased risk. Cases are also found in the peri-urban parts of cities.
In areas where JE has been present for many years, the disease is most frequently seen in
children between the ages of 1 and 15 years; however, it can affect adults also.
Which vaccine is used in JE?
Live attenuated SA-14-14-2 JE vaccine manufactured by Chengdu Institute of Biological
Products, China is used by the GoI.

What is the schedule of JE vaccine in the UIP?

Two doses of JE vaccine are administered in UIP in all JE endemic districts of the country.
The first dose of JE vaccine is given to infants aged 9–12months along with the first dose
of measles vaccine and the second dose is given along with DPT booster dose and measles
vaccine second dose.
What is the side-effect of SA 14-14-2 JE vaccine?
JE vaccine is as safe as any other immunization vaccines given in India. Rare serious adverse
events may be reported, such as transient fever amongst 5–10% vaccine recipients and
local reactions such as injection site tenderness, rash or irritability in 1–3% of cases.
What if someone misses receiving JE vaccine during catch-up campaigns?
Those children aged 1–15 years who have missed receiving JE vaccine during the catch-up
campaigns can receive it at the nearest PHC/CHC or district hospital.
If a child more than 9 months but less than 24 months who has never received any JE
vaccine comes for immunization, how should JE vaccine be administered?
The first dose should be given at first contact and the second dose should be given with an
interval of 3 months following the first dose.
Pneumococcal
What is pneumococcal disease?
• Pneumococcal disease is a group of diseases caused by a bacterium Streptococcus
pneumoniae (also known as pneumococcus).
• The most serious of these diseases are pneumonia, meningitis, and blood stream
infections.
• Streptococcus pneumoniae is the leading cause of bacterial pneumonia in children
under 5 years of age.
How common is pneumococcal disease?
• Pneumococcal disease constitutes a major public health problem.
• In India, pneumococcal pneumonia was estimated to have caused 105,000 deaths in
2010.
• Beyond the pneumonia cases there are other serious pneumococcal cases and deaths
from blood stream infections (sepsis) and meningitis.

How is pneumococcal disease spread?

• Pneumococcus spreads from person to person (coughing, sneezing or close contact).
Many people have pneumococcus in their nasopharynx for days or weeks at a time. In
most cases the pneumococcus disappears from the nasopharynx without causing any
symptoms, but sometimes disease develops.
What diseases does pneumococcus cause?
Diseases that are often caused by pneumococci include:
• Pneumonia,
• Bacteraemia, sepsis: bloodstream infection,
• Bacterial meningitis: infection of the membranes and fluid that covers and protects the
spinal cord and brain
• Middle ear infection (otitis media)
• Sinusitis, Bronchitis
Who is at increased risk of pneumococcal disease?
• Young children and elderly individuals are most at risk.
• The children most at risk of pneumococcal disease are:
o Children under 5 years of age, especially those under 2 years of age
o Immunocompromised children
o Those with influenza or other respiratory virus infections can get a second infection
with pneumococcus.
o Malnutrition, lack of breastfeeding, exposure to indoor smoke and crowded living
conditions.
o Poor and marginalized populations with poor access to health care.
What is the vaccination schedule for PCV?
PCV is to be administered in three doses (2 primary doses and 1 booster) at 6 weeks, 14
weeks and 9 months of age.
Other scheduled vaccines
Age PCV schedule to be given along with
PCV
6 weeks PCV-1* OPV-1, Pentavalent-1,
Rota-1*, fIPV-1
14 weeks PCV-2* OPV-3, Pentavalent-3,
Rota-3*, fIPV-2
9 months PCV booster dose* Measles-1/MR-1, JE-1*
* Where applicable

Microplanning
RI microplans already exist in my PHC/UHC. Do I need to review them?

Yes, RI microplans require to be reviewed every quarter. This ensures that all areas and all
beneficiaries are included in the RI session due lists.
Why should we do the house-to-house survey?
The house-to-house survey is the most important activity in RI microplanning. It gives the
exact count of pregnant women and eligible children, and is the basis for calculation of
injection loads. This injection load estimation determines the number of sessions to be
conducted in an area.
Why is head counting important for microplanning?
• Head counting identifies all beneficiaries (children and pregnant women) for
immunization;
• When done correctly, it makes sure that no beneficiary is missed;
• It provides an opportunity to build community confidence in the programme;
• Due list preparation is based on head count;
• The head count is important for estimation of injection loads ,vaccines and
logistics.
What should an ANM do if there is no ASHA in her area?
• After discussing with the sector MO or MOIC, she should plan for an ASHA from
nearby to cover this area.
• With support from the ICDS supervisor, an AWW can also be deputed to help with
the head counting.
OR
• After discussion with the MOIC, a local person who is involved with the polio
programme, or who supports mobilization, can be called in to conduct the head
counting after receiving training from the MO.
Is there any incentive for ASHAs under NHM for conducting house to house survey?
Yes, an ASHA is to receive Rs 100 twice in a year for conducting the house-to-house survey.
(refer Unit 12)
Who is expected to conduct immunization at vacant sub-centres?
Any ANMof the adjoining area / SC with more than one ANM/ who has no planned sessions
on the day should be delegated to conduct RI sessions in vacant sub-centres. In some cases,
ANMs from other blocks can be deployed by block/district officials to conduct sessions for
such vacant areas.

First line Management of Anaphylaxis in Field Settings

SOP for administration of one dose of Intra-muscular Adrenaline by ANM
Q 1. What is Anaphylaxis? How does it manifest?
Anaphylaxis is an extreme and severe allergic reaction, that is potentially life threatening.
The whole body is affected, often within minutes of exposure to the allergen (substance
causing the allergic reaction), but sometimes after hours. It occurs because the immune
system overreacts to an allergen, and causes secretion of chemical substances that cause
swelling of blood vessels. Common allergens include foods such as peanuts, dairy products,
eggs etc. and non-foods such as wasp or bee sting, medications, vaccines, latex etc. The
symptoms of an anaphylactic reaction include generalized flushing of the skin, nettle rash
(hives) anywhere on the body, swelling of throat and mouth, difficulty in swallowing or
speaking, alterations in heart rate, severe asthma, abdominal pain, nausea and vomiting,
sudden feeling of weakness (drop in blood pressure), collapse and unconsciousness.
Q2. How will you suspect a case of anaphylaxis?
In anaphylaxis, there is sudden onset of symptoms which rapidly worsens. Individual may
complain of difficulty in breathing and/or giddiness/loss of consciousness, hypotension,
skin changes such as generalized rashes, swelling of the lips and tongue (angioedema), hives
(urticaria) and flushing.The person may have had a severe allergic reaction or anaphylaxis in
the past. However, this may be the first time. Sudden onset and rapid progression of ≥ 1 signs
and symptoms of any of the two systems (respiratory, cardiovascular and dermatological/
mucosal) should be suspected as a case of anaphylaxis.
Recognition of anaphylaxis case in field setting
Usually respiratory, dermatological and cardiovascular systems are involved in anaphylaxis.
In most cases of anaphylaxis, skin and mucous membrane are affected. The case of
anaphylaxis is suspected if the following criteria are met:
Rapid onset and progression of ≥ 1 signs and symptoms of any of the two systems (respiratory,
cardiovascular and dermatological/mucosal) as illustrated in Figure 3 (clinical features).
In addition to the signs and symptoms given in Table 1, following features could also
be observed: anxiety, diarrhea, abdominal cramps, nausea, vomiting and sneezing or
rhinorrhea.

Table 1: Signs and symptoms of Anaphylaxis

System Sign and Symptom
Respiratory • Swelling in tongue, lip, throat, uvula or larynx
• Difficulty in breathing
• Stridor (Harsh vibrating sounds during breathing)
• Wheezing (breath with whistling or rattling sound in the chest)
• Cyanosis (bluish discoloration of arms and legs, tongue, ears,
lips etc.)
• Grunting (noisy breathing)
Cardiovascular • Decreased level /loss of consciousness (fainting, dizziness)
• Low blood pressure ( measured hypotension)
• Tachycardia (increased heart rate, palpitation)
Dermatological or • Generalized urticaria (raised red skin lesion, rash with itching)
mucosal • Generalized erythema (redness of skin)
• Local or generalized Angioedema- itchy/ painful swelling of
subcutaneous tissues such as upper eyelids, lips, tongue, face
etc.
• Generalized pruritus (itching) with skin rash
Figure 3: Clinical features

Figure 3: Clinical features
Picture 1: Angioedema Picture 2: Cyanosis
Picture 3: Urticaria

Respiratory Cardiovascular Dermatological /

• Swelling of tongue, lip,
• Decreased level /loss of Mucosal
throat, uvula, larynx
consciousness (fainting, • Generalized urticaria
dizziness) (raised red skin lesion,
• Stridor (harsh vibrating
• Low blood pressure ( rash with itching)
sounds during
measured hypotension) • Generalized erythema
breathing)
• Tachycardia (redness of skin)
• Wheezing (breathing
(increased heart rate, • Local or generalized
with whistling or rattling
palpitation) Angioedema- itchy/
sound in the chest)
painful swelling of
• Cyanosis ((bluish
subcutaneous tissues
discoloration of arms
such as upper eyelids,
and legs, tongue, ears,
lips, tongue, face etc.
lips etc.)
• Generalized pruritus
• Grunting (noisy
(itching) with skin rash
breathing)
The ANM should follow four steps for initial management of anaphylaxis
cases.
Steps in Initial management of an Anaphylaxis
Recognize inform Medical
If anaphylaxis Give one dose Document
and Assess Officer and refer to
is suspected pf adrenaline anaphylaxis
Case Nearest PHC/CHC
1 2 3 4

Suspect Anaphylaxis in a case with following symptoms and signs
Rapid onset & progression of >= 1 signs & symptoms of any of the two
systems (Respiratory, cardiovascular and dermatological / mucosal)
Respiratory:
• Swelling of tongue, lip, throat, uvula, larynx
• Stridor (harsh vibrating sounds during breathing)
• Wheezing (breathing with whistling or rattling sound in the chest)
• Cyanosis ((bluish discoloration of arms and legs, tongue, ears, lips
etc.)
Assess • Grunting (noisy breathing)
Case Cardiovascular:
• Decreased level /loss of consciousness (fainting, dizziness)
• Low blood pressure ( measured hypotension)
• Tachycardia (increased heart rate, palpitation)
Dermatological or mucosal:
• Generalized urticaria (raised red skin lesion, rash with itching)
• Generalized erythema (redness of skin)
• Local or generalized Angioedema- itchy/ painful swelling of subcuta-
neous tissues such as upper eyelids, lips, tongue, face etc.
• Generalized pruritus (itching) with skin rash
Manage anaphylaxis
• Reassure patient, parents/ relatives

• Immediately administer one dose of injection Adrenaline by deep IM
route
Give one • Seek help to immediately arrange for ambulance to transport the
dose of patient to the nearest health facility (PHC/CHC/District Hospital/Civil
adrenaline Hospital)
deep IM • Do not leave patient alone
• If patient is conscious, he/she should be kept in supine position with
lower limbs raised higher than head
• If patient is unconscious, he/she should be kept in left lateral position
Referrals Refer to higher center
• Call for ambulance

• Inform MO about the case for timely management
Document
Document suspected anaphylaxis on immunization card in block letters
suspected
against vaccines administered
anaphylaxis

Steps for administration of injection Adrenaline by ANM
• Take one ampoule of adrenaline (1:1000) solution from the Anaphylaxis Kit and check
name, dilution and expiry date on label of vial (not from kit label).
• Take a 1 ml syringe and 24/25 G needle of length 1 inch and load the required dose of
adrenaline as per the age of the patient. [Table 2]
• Adrenaline ampoules are also labelled as Epinephrine. Epinephrine is another name
for adrenaline.
Table 2: Age specific dosing chart of adrenaline (1:1000) for management of anaphylaxis
Age group (in One inch Dosage (in mL) using 1 Dosage (in units) using 40
years) needle gauge mL tuberculin syringe units insulin syringe
0-1 0.05 2
1-6 0.1 4
6-12 24G/ 25G 0.2 8
12-18 0.3 12
Adults 0.5 20
• Use alcohol swab to clean the middle 1/3rd of anterolateral aspect of the thigh of the
opposite limb to that in which vaccine is given.
• Hold the muscle mass on the anterolateral aspect of thigh with hands, stretch the skin
(do not bunch) with fingers.
• Give deep intramuscular injection at 90 degree angle to skin in middle 1/3rd of anter-
olateral aspect of thigh.
Source: Smith et al., 2000, p. 394

Ensure appropriate syringes and Needle availability at sub centre

• States/districts should procure and supply anaphylaxis kits with
the following syringes and needles:
Tuberculin syringe (1 ml) OR
Insulin syringe (40 units) (without attached needle) – 3 nos./ANM
* 1ml tuberculin syringe comes with a detachable 0.5 inch needle. Procure 1 inch 24/25G
needles separately and supply in anaphylaxis kit.
Age group mL UNITS

0-1 years 0.05 2.0
1-6 years 0.1
4.0
6-12 years 0.2 8.0
12-18 years 0.3 12.0
Adults 0.5 20.0
TUBERCULIN INSULIN
SYRINGE – 1.0 mL SYRINGE –
40 UNITS
1.0 40.0
Anaphylaxis kit for ANM

Anaphylaxis Kit – Each kit should contain the following items:
• Annexure 2 of these guidelines to be taped to the inside of the box lid – 1 no.
• 1 mL ampoule of adrenaline (1:1000 aqueous solution) – 3 nos.
• 1 mL syringes – 3 nos.
• 24/25 G needles of 1 inch length – 3 nos.
• Alcohol swabs – 3 nos.
• Up to date contact information for the DIO and Medical Officer(s) of PHC/CHC and
local ambulance services.
The kits can be stored in an air tight container. Ensure the drugs are not exposed to
light which can cause deterioration. Ensure the contents of Anaphylaxis kits are verified
in advance of every session so as to replace drugs before the expiry date.
Adrenaline Administration record

Name of Patient: ______________________________________ Age: _________
Date:______________
Adrenaline (1:1000 dilution) dose administered:
dose Amount: _______________ mL
(if given)Time:________________ Site:________________

Anaphylaxis Kit
ANM should administer only one dose of adrenaline and refer the patient to referral
center. Record of the administration of Adrenaline should be entered in the card above,
which must be provided with the patient when he/she referred to medical officer. These
details must also be recorded in immunization session summary and available with the
ANM after transferring the patient.
About Adrenaline Injection
Adrenaline ampoules should not be exposed to temperature above 25 degree Celsius.

Key features of adrenaline are as follows:
• Description of drug: Adrenaline is a naturally occurring catecholamine.
• Dosage: 0.01ml/Kg body weight
• Route of administration: Intramuscular
• Site of injection: middle 1/3rd of anterolateral aspect of thigh in children and deltoid
region of arm in case of adults.
• Preparation: injection adrenaline is available in 1 mg/ml preparation.
• Storage: Store in airtight containers, protected from light.
• Shelf life: 1 year

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Two monumental public health milestones have been achieved

The Universal Immunization Program has grown from strength

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Routine Immunization (RI) is a nation’s strategic investment in its future.

(Dr. Rakesh Kumar)

Message from Deputy Commissioner (Immunization)

(Dr. Pradeep Haldar)

Unit-1 Introduction to immunization and role of

Unit-2 National Immunization Schedule 17

Unit-3 Routine Immunization Microplanning 21

Unit-4 Cold chain and logistics management 83

Unit-5 Safe injections and Waste Disposal 133

Unit-6 Adverse events following immunization 145

Unit-7 Sources and use of data 169

Unit-8 Supervision and monitoring 179

Unit-9 Communication for behaviour change 197

Unit-10 Vaccine Preventable Diseases and

Unit-11 Capacity building of health functionaries

Unit-12 High risk populations and Urban areas 247

Unit-13 Financial planning in Immunization 257

References and links 273

Frequently asked questions 279

Support in reviewing the manuscript:

Immunization handbook for Medical Officers 1

The immunization programme in India – a chronology

2 Immunization handbook for Medical Officers

Immunization handbook for Medical Officers 3

Towards strengthening Adverse Event Following Immunization (AEFI) surveillance

Mission Indradhanush Ministry of Health and Family Welfare

Full Immunization keeps me healthy and I can

The Mission focuses on interventions to improve full

4 Immunization handbook for Medical Officers

The broad strategy includes four basic elements: -

Integration with the polio programme in the following areas:

The immunization program in India – facts and impact

• To vaccinate this cohort of 156 million beneficiaries, ~9 million immunization sessions

6 Immunization handbook for Medical Officers

Impact of vaccines in India

Adapted from Johns Hopkins IVAC.

Immunization handbook for Medical Officers 7

Improving routine immunization coverage

8 Immunization handbook for Medical Officers

Percentage of children aged 12 – 23 months fully immunized

Figure 1.5- Gender differences in vaccine coverage – HMIS

Fully immunized children

Immunization handbook for Medical Officers 9

New vaccine introduction

10 Immunization handbook for Medical Officers

To address the burden of pneumococcal diseases such as bacterial pneumonia, meningitis

Responsibilities of medical officers in immunization programme management

Planning and review

Immunization handbook for Medical Officers 11

Maintaining beneficiary linelist at block level

12 Immunization handbook for Medical Officers

• Ensure practice of Open Vial Policy and supervise closely

Immunization handbook for Medical Officers 13

Signature of ANM___ Signature of Medical Officer:_