ROUTINE IMMUNIZATION MANUAL

FOR HEALTH WORKERS

2024
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Acknowledgments
We would like to extend heartfelt gratitude to Ms. Punya Salila Srivastava, Secretary
(Health) for her leadership and support provided in the process of development of Routine
Immunization (RI) Manual for Health Workers 2024. Special thanks to Ms. Aradhana Patnaik
(Additional Secretary & Mission Director -NHM) for her overall guidance for drafting this
essential document for Health Workers and Ms. Meera Srivastava, Joint Secretary (RCH)
for her contribution in providing valuable inputs and unwavering support to this initiative
are well acknowledged.

We deeply express sincere gratitude and thankfulness for the exceptional technical expertise,
guidance, support, and meticulous review provided under the stewardship of Dr. Pawan
Kumar, Additional Commissioner (UIP) throughout the development process of the revised
Routine Immunization Manual for Health Workers 2024. His vision for a high standard
technical manual is deeply appreciated, which would significantly improve the technical
skills of Health Workers to further strengthen Universal Immunization Programme in India.

We express appreciations for the commitment and valuable contributions of Dr. Ashish B
Chakraborty, (Public Health Specialist, MoHFW), Dr. Satishchandra Donkatti (Technical
Officer, WHO) and Ms. Visali Sekar (Technical officer, MoHFW) in conceptualization, content
development & editing of this revised RI Manual for Health Workers 2024.

Additionally, We express our sincere thanks for providing guidance by Dr. Veena Dhawan (Ex-
Additional Commissioner (UIP), Dr. Suhas Dhandore (Ex-Public Health Specialist, MoHFW)
and Dr. Tigran Avagyan (Team Leader-NPSN, WHO).

List of Contributors: Immunization Division (MoHFW)

Immunization Division (MoHFW)

1. Dr. Pawan Kumar
2. Dr. Ashish B Chakraborty
3. Ms. Visali Sekar
4. Dr. Kapil Singh
5. Dr. Sheen Job
6. Dr. Rajat Ranjan
7. Dr. Shipra Verma
8. Mr. Praveen Rajouria
9. Mr. Govind Singh
10. Mr. Nishant Shukla
11. Mr. Naushad Ansari
12. Mr. Satya Prakash

World Health Organization (WHO)

1. Dr. Tigran Avagyan
2. Dr. Satishchandra Donkatti
3. Dr. Vishesh Kumar

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4. Dr. Puneet Mishra
5. Dr. Ashutosh Aggarwal
6. Dr. Puttaraju A K
7. Dr. Ratnesh Murugan
8. Dr. Arun Kumar
9. Dr. Subramanya B P
10. Dr. P K Roy
11. Dr. Vineet Goyal
12. Dr. Mohammad Samiuddin
13. Dr. Rakesh Vishwakarma
14. Dr Preeti Nigam
15. Dr Nitasha Kaur (Former Urban Focal Person)

United Nations International Children’s Emergency Fund (UNICEF)

1. Dr. Mainak Chatterjee
2. Dr. Ashish Chauhan
3. Dr. Yashika Negi
4. Ms. Joshila Pallapati
5. Ms. Sukhpal Kaur Marwa

United Nations Development Programme (UNDP)

1. Mr. Abhimanyu Saxena
2. Dr. Pankaj Somani

Immunization Technical Support Unit (ITSU)

1. Dr. Pritu Dhalaria
2. Dr. Jaishri Jethwaney
3. Dr. Deepak Polpakara
4. Dr. Mona Chopra
5. Dr. Disha Aggarwal (Former Programme Lead)
6. Mr. Satish (Former Programme Communication Officer)

John Snow India Private Limited (JSI)

1. Dr. Pradeep Haldar
2. Dr. G K Soni
3. Dr. Parthasarathy Ganguli (Former Programme Lead)
4. Dr. Arup Deb Roy
5. Dr. Anshul Shukla

JHPIEGO
1. Dr. Prem Singh

National Cold Chain and Vaccine Management Resource Centre (NCCVMRC)

1. Mr. Shashi Kant Ray
2. Mr. Rakesh Kumar

We express sincere acknowledgment for the consolidated efforts of Immunization Division

Team (MoHFW) and Development Partners from WHO, UNICEF, UNDP, ITSU, JSI, JHPIEGO,
NCCVMRC in the entire process of manual development which is highly appreciated.

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Table of contents
Unit Topic Page

Messages i
Acknowledgements ix
Table of contents xi
Table of annexures xiii
Acronyms xv
Unit-1 Introduction 1
Unit-2 Roles and responsibilities of health workers in immunization 9
Unit-3 National Immunization Schedule 19
Unit-4 Diseases prevented by vaccination 29
Unit-5 Routine Immunization Microplanning 37
Unit-6 Cold-chain and vaccine management 85
Unit-7 Safe injection practices and Waste disposal 105
Unit-8 Conducting the routine immunization session 115
Unit-9 Adverse events following immunization (AEFI) 135
Unit-10 Records, reports and using data for action 155
Unit-11 Communication 167
Unit-12 Surveillance of vaccine preventable diseases 177
Unit-13 U-WIN-- Digital Platform for Data Recording & Reporting 183
Frequently asked questions 191
References 203
Annexures 207

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Table of annexures
1. National Immunization schedule beneficiary vaccine chart 209
2. Routine Immunization microplanning formats - Head count survey formats,
Subcenter/ANM area microplan formats, PHC/ UPHC microplan formats 210
3. Routine Immunization head count survey validation format 233
4. Checklists for Preventive Maintenance of cold-chain equipment 234
5. Formats for Vaccine stock and distribution registers 236
6. Flow chart of Initial management of Anaphylaxis by ANM 239
7. Formats used during Adverse Event Following Immunization (AEFI)
Case Reporting Form (CRF) and AEFI register 240
8. Routine Immunization Tally sheet 244
9. Routine Immunization Supervision and monitoring formats 245
10. HRA enlistment and validation formats 248
11. Agenda for two days RI training for Health workers 249

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Acronyms
ABDM Ayushman Bharat Digital Mission
AD Auto Disable Syringe
AEFI Adverse Events Following Immunization
AES Acute Encephalitis Syndrome
AFP Acute Flaccid Paralysis
AIDS Acquired Immuno Deficiency Syndrome
ANC Ante-Natal Care
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AVD Alternate Vaccine Delivery
AWC Anganwadi Centre
AWW Anganwadi Worker
BCG Bacillus Calmette-Guerin
bOPV Bivalent Oral Polio Vaccine
CBO Community Based Organization
CBWTF Common Biomedical Waste Treatment Facility
CHC Community Health Centre
CRS Congenital Rubella Syndrome
CPCB Central Pollution Control Board
DF Deep Freezer
DIO District Immunization Officer
DPT Diphtheria, Pertussis, Tetanus
DTF-I District Task Force – Immunization
EDD Expected Date of Delivery
EEFO Early Expiry First Out
e-VIN Electronic Vaccine Intelligence Network
FAQs Frequently Asked Questions
fIPV Fractional Inactivated Polio Vaccine
FLW Front Line Worker
GMP Good Manufacturing Practices
Hep B Hepatitis B
HHE Hypotonic, Hypo responsive Episode
Hib Haemophilus influenzae type b
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HRA High Risk Area
H-t-H House to House
HW Health Worker
ICDS Integrated Child Development Services
IEC Information, Education, Communication
ILR Ice Lined Refrigerator
IM Intra Muscular
IPC Inter Personal Communication

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IPV Inactivated Poliovirus Vaccine
JE Japanese Encephalitis
LGD Local Government Directory
LHV Lady Health Visitor
LMP Last Menstrual Period
LS Lady Supervisor
LW Link Worker
MCH Maternal and Child Health
MCP Mother and Child Protection
MCTS Mother and Child Tracking System
MO Medical Officer
MOIC Medical Officer In-Charge
MR Measles Rubella
NGO Non-Government Organization
NIN National Institute of Nutrition
NIS National Immunization Schedule
NPSN National Public Health Support Network
OPV Oral Polio Vaccine
OVP Open Vial Policy
Penta Pentavalent
PCV Pneumococcal Vaccine
PHC Primary Health Centre
PIP Project Implementation Plan
PRI Panchayat Raj Institution
PW Pregnant Women
RCH Reproductive and Child Health
RI Routine Immunization
RVV Rotavirus Vaccine
SC Sub Centre
SHG Self Help Group
SOP Standard Operating Procedure
Td Tetanus Diphtheria Toxoid
UHC Urban Health Centre
UIP Universal Immunization Programme
ULB Urban Local Body
VHSC Village Health and Sanitation Committee
VHND Village Health and Nutrition Day
VPD Vaccine Preventable Disease
VVM Vaccine Vial Monitor
WMF Wastage Multiplication Factor
WPV Wild Poliovirus
WHO World Health Organization

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 Unit 1
Introduction

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 Learning Objectives
At the end of the unit, Health worker should be able:
• To describe the importance of immunization
• To understand the objectives of Universal Immunization Programme
(UIP)
• To illustrate the milestones of immunization programme in India

Contents Page
1.1. Importance of immunization 3
1.2. The Universal Immunization Programme (UIP) in India 3
1.3. Immunization programme milestones – India 4
1.4. Impact of vaccination on vaccine preventable diseases in India 6

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Introduction

1.1. Importance of immunization

Vaccination is the process of providing safe and effective vaccines to the beneficiaries.
Immunization is the development of body’s protective response following vaccination.
Immunization is thus the outcome of vaccination.1

Vaccines are highly regulated, biological products designed to induce a protective immune
response effectively and safely. 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, several vaccines are administered to
children and women to protect them from vaccine-preventable diseases.

INTRODUCTION
Immunization is a proven tool for controlling and eliminating life-threatening infectious
diseases and globally it prevents 35-50 lakh deaths every year from diseases like diphtheria,
tetanus, pertussis, influenza and measles. It is one of the most cost-effective health
investments, with proven strategies that make it accessible to even the most hard-to reach
and vulnerable populations. It has clearly defined target groups; it can be delivered effectively
through outreach activities.

Target beneficiary: All eligible children and pregnant women in the catchment area of
Subcenter/ ANM area should receive the benefits of immunization. The health worker should
remember that all visitors (Eg. Pregnant woman coming to mother’s house, children visiting
grandparents, etc.), tenants eligible children and pregnant women should also be vaccinated.
All migrant population (nomads) or temporary settlements staying in sub-centre/ ANM area
should also be vaccinated.

1.2 The Universal Immunization Programme (UIP) in India:2

Universal Immunization programme of India is one of the world’s largest health programmes.
All vaccines provided under Universal Immunization Programme (UIP) are voluntary in
nature. However, it is emphasized and encouraged that all eligible beneficiaries must take
all vaccines, as prescribed in the UIP schedule. All caregivers are encouraged in larger
public interest and public good, to ensure that the eligible beneficiaries under their care are
vaccinated with all the vaccines provided under UIP in a timely manner. The society at large
is healthy, and the vaccine preventable diseases can be kept under control only, if all eligible
beneficiaries of UIP are vaccinated under UIP programme.

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 The Aim of UIP:

The aim of UIP is that eligible beneficiaries should get all UIP vaccines in India, so that they
may be protected from life threatening vaccine preventable diseases against which vaccines
are provided under UIP in India.

Objectives:
• To attain more than 90% full immunization coverage on a year-to-year basis and sustain
the gains
• To achieve MR elimination
• To maintain and sustain Polio free status and Maternal & Neonatal Tetanus elimination
• To sustain robust VPD and AEFI surveillance
• To ensure efficient supply chain, cold-chain and logistic system for UIP
• To provide regular supportive supervision to UIP
• To ensure accountability framework through regular task force meetings
• To expand digitization in UIP
• To introduce need based new vaccines

Universal Immunization Programme (UIP) of India has a target of nearly 2.6 crore newborns
and 3.0 crore pregnant women per year. About 1.3 crore routine immunization (RI) sessions
are planned annually.
INTRODUCTION

Figure. 1.1: Snapshot of facts about RI programme in India

Annual target Vaccine against VPDs
2.6 crore newborns 11 nation- wide
3.0 crore pregnant women 1 sub nationally (JE)

~1.3 crore sessions ~30,000 cold-chain points for

planned per year storage and distribution

UIP offers vaccines against twelve Vaccine Preventable Diseases (VPDs) of which eleven are
nationwide and one [Japanese Encephalitis (JE) in endemic districts] is sub-national. The
UIP has significantly contributed to reduction in morbidity and mortality due to Vaccine
preventable diseases (VPDs). The next major milestone to be achieved is Measles and Rubella
Elimination. For this achievement, it is necessary that, all children till the age of 5 years are
immunized with two doses of Measles Rubella containing vaccines (MRCV).

1.3 Immunization programme milestones – India3

The immunization programme milestones in India, starting from the year of Smallpox free
declaration in India in 1977 is shown in table no.1.1.

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Table 1.1. Immunization programme milestones – India3
1977 • India declared Smallpox free
1978 • Expanded Programme of Immunization (EPI) launched with BCG, DPT,
OPV, Typhoid (urban areas)
1983 • TT vaccine for pregnant women
1985 • EPI expanded nationwide as Universal Immunization Programme (UIP)
with addition of measles and removal of Typhoid vaccines; Focus on
children less than one year of age
1986 • Technology mission for expansion of UIP – Monitoring under PMO’s
20-point programme
1990 • Vitamin-A supplementation
1992 • UIP became a part of Child Survival and Safe Motherhood (CSSM)
included both UIP and Safe motherhood programme
1995 • Polio National Immunization Days
1997 • Vaccine Vial Monitor introduced in Polio vaccine for campaign. Later
expanded to all UIP vaccines in 2006
• UIP became a part of RCH-1 programme
2001 • National Technical Advisory Group on Immunization (NTAGI) in India was
formed

INTRODUCTION
2002 • Hepatitis B vaccine introduced as pilot in 33 districts & 16 cities of 10
states
2005 • Auto Disable (AD) Syringes introduced into UIP
2006 • Immunization week strategy was introduced to strengthen immunization
• Japanese Encephalitis (JE) vaccine introduced after campaigns in
endemic districts
2007-2008 • Hepatitis B vaccine expanded to all districts in 10 states
2010 • Measles 2nd dose introduced in RI (21 states) and after Measles vaccine
catch up campaign (MCUP) (14 states) covering 9 months-10 years over a
period of 3 years
• Hepatitis B vaccine scaled up nationwide
2011 • Pentavalent vaccine (DPT, Hepatitis B, Hib) introduction in phased
manner. However, the birth dose of Hepatitis B and booster dose of DPT
vaccines continued
2013 • Second dose of JE vaccine introduced
• Open Vial Policy for vaccines in UIP
• e-VIN introduced
2014 • India and Southeast Asia Region certified POLIO- FREE
• Launch of Mission Indradhanush for low immunization coverage pockets
2015 • Pentavalent vaccine expanded to all states
• Inactivated Polio Vaccine introduced in 5 states
• India validated for Maternal and Neonatal Tetanus elimination
2016 • Rotavirus vaccine introduced in 4 states in phased manner
• tOPV to bOPV Switch (25 April)
• Switch to fractional IPV nationwide

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 2017 • MR vaccine introduced through campaign in 9 months - 15 years replacing
measles vaccine, followed by its inclusion in NIS
• Pneumococcal Conjugate Vaccine (PCV) introduced (Phased manner)
• Use of adrenaline (intramuscular) at immunization session site by ANM
• Intensified Mission Indradhanush (IMI) campaign
2019 • Td vaccine introduced replacing TT vaccine
2019 • Rotavirus vaccine expanded nationwide
2021 • Pneumococcal Conjugate Vaccine nationwide expansion
• COVID-19 vaccine introduced using CoWIN platform
2022 • Rota virus vaccine formulation with VVM on Label introduced, which
becomes eligible for Open Vial Policy
2023 • Introduction of 3rd dose of fractional IPV at 9-11 months (fIPV 3)
• U-WIN introduced, as a pilot in 65 districts and rollout across the country
during Intensified Mission Indradhanush 5.0
Government of India is planning to introduce Typhoid Conjugate Vaccine (TCV) and Human
Papilloma Virus (HPV) vaccine in UIP.

Fig. 1.2 Vaccine introduction under Immunization Programme in India

INTRODUCTION

1985 2006 2011 2015 2017 2019 2022

Vaccines against JE vaccine Pentavalent IPV introduction MR, PCV Rotavirus vaccine RVV Product
6 VPDs-Measles, introduced (2011-2015) (2015-16) JE Adult expanded nation wide Switch
DPT, TB, Polio

2002 2010 2013 2016 2019 2021 2023

Hep. B pilot Measles 2 dose
nd
JE 2 dose
nd
Rotavirus vaccine Td replacing COVID-19 flPV 3rd dose
(2010-13) introduced TT Vaccination introduced
Hep. B scaled up Switch from tOPV to Campaign
nationwide bOPV PCV Nationwide

1.4 Impact of vaccination on vaccine preventable diseases in India

The vaccination in India under UIP has resulted in significant impact in bringing down
morbidity and mortality due to Vaccine Preventable Diseases (VPDs). Surveillance and other
data sources have shown the decline in the VPD burden over the years (ref. Fig.1.3). The
infographic below demonstrates the successes but also reminds us of the need to increase
our efforts to reach the unreached and sustain good coverage.

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Fig. 1.3: Impact of vaccines on vaccine preventable diseases in India

Est. cases at/around

Name of Year of introduction of IMPACT of VACCINES Decrease in
the time of vaccine
DISEASE vaccine in the country (Number of reported cases) disease burden
introduction

SMALLPOX 1973 1974 Eradicated in 1977 100%

(Mass Campaign) 1,88,000 cases ZERO CASE

POLIO 1978 1978 Polio-Free in 2014 100%

(EPI) 2,00,000 cases ZERO CASE

Eliminated in 2015
NEONATAL 1978 1980 (<1 case / 1000 live births) 99%
TETANUS (NNT) (EPI) 45,948 cases 81 cases 2021

INTRODUCTION
Smallpox: 1.88 lakh cases were affected in 1974. So, in 45 years after eradication 84.6 lakh
children are assumed to be protected.

Poliomyelitis: 2.0 lakh cases were affected in 1978. So, in 10 years after certified as polio free,
20.0 lakh children are assumed to be protected.

Neonatal Tetanus (NNT): 46 thousand cases were affected in 1980. So, in 10 years after
declaration of elimination in 2015, 4.6 lakh children are assumed to be protected.

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 Unit 2
Roles and responsibilities of health
workers in immunization

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 Learning objectives
At the end of the unit, Health worker should be able:
• To enlist the roles and responsibilities of Health Workers in Routine
Immunization.
• To understand the roles and responsibilities of Community Health
Officers in Routine Immunization.

Key contents Page

2.1 Roles and responsibilities of Health Workers in Routine Immunization 11
2.2 Roles and responsibilities of Community Health Officer 16
(CHO) in providing Routine Immunization services

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Roles and responsibilities
of health workers in
immunization

ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

2.1 Roles and responsibilities of Health Workers in Immunization1

Health care worker in the context of immunization: This handbook is primarily aimed
towards Auxiliary Nurse Mid-wife (ANM), however all those who are actively administering
vaccine in health care and community settings are also called as Health care worker in
context of immunization and they are advised to refer this handbook. Health care workers
include Health worker (Female) / ANM, Health worker (Male), CHO/ HWO, Nursing staff, etc.
Health workers play a major role in providing Immunization services to mothers & children.
They are expected to put all efforts to vaccinate all children and pregnant women as per the
National Immunization Schedule. Their roles and responsibilities are highlighted under the
following headings
a) Planning for Immunization
b) Managing the Cold-chain
c) Vaccine and logistics management at the immunization session site
d) Preparing and conducting the immunization session
e) Communicating with caregivers
f) Mobilizing the beneficiaries
g) AEFI Management
h) Recording, reporting of immunization data in U-WIN and relevant registers and tracking
of left outs and dropouts
i) Capacity building of ASHAs, AWWs, link workers, Mahila Arogya Samiti (MAS) and other
mobilizers to perform their roles in UIP
j) Sensitization of local influencers, CBOs, village elders, local religious leaders, faith
healers, etc.
k) Coordination with ICDS, panchayat raj and line departments

a) Planning for Immunization: Activities to be done

Once a year:
Actively participate in preparing and generating new RI microplans including house to
house survey and head counting
o to ensure that there is clear area demarcation between ANMs, ASHAs, so that there is
no missed areas between ANMs and ASHAs
o identify the AWW in the catchment area and liaise, coordinate, cooperate with the
AWWs to ensure all immunization related services are delivered
o at the beginning of the financial year, actual head count survey should be carried out
effectively to get the actual population and beneficiaries count to plan RI sessions
and estimate annual and monthly vaccine and logistics requirements

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 Every six months:
House to House (H to H survey) and Head counting needs to be repeated after six months
to update the beneficiary records. This activity should be preferably done in coordination
with ICDS, line departments and key stake holders which will help to
o identify any new sites for inclusion and update the beneficiary due lists for effective
mobilization
o all areas including migratory high-risk areas are included into the master list with map.
ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

Any new houses, settlements, habitations, etc. are to be included in the microplan as
and when needed. Update the beneficiary due lists for effective mobilization

Every three months:

Participate in RI microplan review at Block/ PHC/UPHC to help
o update the plans to address emerging situations Eg. new migratory HRAs, vacant
subcenters, changes in vaccine delivery, other issues based on monitoring results,
etc.
o ensure preregistration of new beneficiaries in the U-WIN if not done earlier through
ASHA. If there is no ASHA, preregistration should be done by Health worker and enter
of next quarter into U-WIN

Every month:
At Sub centre/ ANM area: with the involvement of ASHA/ AWW
o to review due lists of all the sessions held in the previous month
o track the beneficiaries by use of tracking bag and counterfoils
o ensure preregistration of new beneficiaries in the U-WIN if not done earlier through
ASHA. If there is no ASHA, preregistration should be done by Health worker
o discuss important issues related to RI services with the medical officer (MO) for their
support

After every RI session:

o Ensure that the session catchment area is clearly demarcated and ANM is aware of
their respective catchment area
o Review the session due list with the involvement of ASHA/AWW/ Link workers/other
mobilizers
o ensure that the beneficiary list is complete and updated in the U-WIN
o identify all the eligible beneficiary who were not vaccinated in the RI session. These
beneficiaries should be included in the due list of next RI session
o ensure follow-up visits to beneficiaries to identify any AEFIs. Inform medical officer
about AEFI and ensure it is recorded in the AEFI register and reported through SAFEVAC
o Guide ASHA/mobilizer to identify, newborns/pregnant women for inclusion in
beneficiary and due list
o guide ASHA/mobilizer to visit these houses during other field visits and remind
beneficiaries about importance of immunization and tell them about next date and
place of RI session

b) Managing the Cold-chain (if applicable)

As a vaccine and cold-chain handler at the cold-chain point, Health worker is responsible
for:
o Daily maintenance and cleanliness of cold-chain equipment
o Ensure that data loggers of e-VIN for that ILR is installed. If not installed, inform the
medical officer. All the electrical cold-chain equipments, should have functional data

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 loggers installed
o The temperature of the data logger should also be monitored twice daily along with
temperature recording from alcohol stem thermometer. However, the recording of
the temperature in the register should be from alcohol stem thermometer only
o Identify if the e-VIN sensors are working. If the health worker notices that the
temperature of data loggers is outside the recommended range for the particular
equipment or the temperature is not relayed to e-VIN web on a daily basis, they should

ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

immediately inform district VCCM and district cold-chain technician
o Monthly vaccine and logistics indenting, receipt and storage
o Timely issue of vaccine to the lower store/sessions as per microplan
o Timely update of stock and issue registers for vaccines and logistics
o Breakdown reporting of equipment including solar equipment immediately If the
facility has solar powered ILR then, it should be ensured that, the solar panels are
kept clean
o Monthly vaccine utilization including wastage reporting both in e-VIN and register;
o Refer and follow e-VIN and U-WIN guidelines

c) Vaccine and logistics management at the immunization session site

o Ensure that vaccines are carried in a vaccine carrier with 4 well-sealed conditioned
ice packs
o Ensure vaccine carriers are kept in shade and are not opened frequently
o Required number of vaccines, Auto disabled and reconstitution syringes are available
o Bundling: It is the procedure of vaccine and logistic packaging to ensure that the
vaccines are always supplied with corresponding diluents, droppers, AD syringes and
reconstitution syringes, in correct quantities to the session site
Examples of bundling are as follows:
 OPV, RVV vials should be equal to the number of droppers and or RVV dispenser
syringes
 MR and BCG vaccine vials and their respective supplied diluents (bundled diluent)*
and 5 ml reconstitution syringes should be equal in number
* Bundled diluents are the one’s which are supplied with the vaccine by the
manufacturer
o Wrap vaccine vials and diluent ampoules in thick paper (e.g. plain white paper)
before putting in polythene bag so as to prevent them from touching the icepacks.
Place some packing material between ‘T’ series vaccines (DPT, Td, Pentavalent and
Hepatitis B vaccines), fIPV, PCV, JE (inactivated) vaccines, and the icepacks to prevent
them from touching the icepacks
o After use ensure that the vaccine carrier is cleaned and dried appropriately
o Ensure that adequate amount of new blank MCP cards and functional hub cutters are
also taken
o Check the labels for expiry date and VVM of the vaccine vials before use
o Ensure Open Vial Policy applicable vaccine vials have readable labels with date and
time of opening
o Check that T-Series and Hep B, fIPV, PCV, JE (inactivated) vaccines are not frozen
o Follow the guidelines for use of open vaccine vials
o Check that required diluents are placed in cold-chain
o Ensure that the reconstitution guidelines are followed for BCG, MR vaccines
o Anaphylaxis kit contains all needed items as per checklist

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 d) Preparing and conducting the immunization session
o Prepare and conduct sessions at appropriate sites adhering to the guidelines. (Refer
Unit-9)
o Involve community influencers and leaders to support in conducting successful
immunization sessions. (Community influencer - any person from local area whose
words are respected and can help solve the problems in conducting successful sessions.)
ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

e) Communicating with caregivers

Soft communication skills are followed while communicating with the caregivers. Ensure
that the following four key messages are delivered during vaccination
o Explain what vaccine(s) will be given and the disease it prevents
o Mention possible adverse events (minor AEFIs) and explain how to handle them
o Explain the need for the child to return for each contact in the immunization schedule
to be fully protected. Write the date for the next vaccination on the immunization
card and tell the caregiver
o Remind the caregiver to bring the immunization card when they bring the child back
for the next vaccination

f) Recording, Reporting and tracking of dropouts

o All U-WIN related activities including ABHA generation (if ABHA of the beneficiary has
not been generated previously) are to be ensured
o Record all vaccinations in a due list cum tally sheet, immunization card and
immunization register
o Mark the date of vaccination and the next due date on the card, and ensure that the
caregiver understands when and where to return for the next dose(s) of vaccine(s)
o Keep the updated counter foil of the immunization card in tracking bag
o Share the list of dropouts with AWW and ASHA and ensure they are mobilized to the
session
o Maintain immunization coverage monitoring chart at the sub center
o Report all suspected cases of Tuberculosis, Diphtheria, Pertussis, Neonatal Tetanus,
Fever and Rash, Acute Flaccid Paralysis (AFP) and Acute Encephalitis Syndrome (AES)
to the medical officer
o Report all Adverse Event Following Immunization (AEFIs). Ensure recording of all
AEFIs is done in the PHC/ UPHC AEFI register followed by entry in SAFEVAC. These
data is to be updated in Block AEFI register also

g) Capacity building of ASHAs, AWWs, link workers and other mobilizers to perform
their roles in UIP

For Immunization planning - train them to:

o Describe the national immunization schedule and address FAQs
o Conduct the house-to-house survey to undertake head count and generate beneficiary
list (children upto 2 years, missed children between 2-5 years and pregnant women);
o Contribute to finalizing master list of villages/Urban areas, including HRAs and
underserved population
o Have clear area demarcation between ASHA, AWW /LW/ other mobilizers
o Help create working maps for each area
o Help in preparing the beneficiary due list

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 o Help in planning and selection of the site, day and time of the session in the village/
urban area
o Share the list of newborns in the area with the ANM every month
o Conduct community mobilization activities for each session site and sub centre/ ANM
area
o Visit households to inform the due beneficiaries for vaccination day and site
o Report all suspected VPDs

ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

o Help the ASHA for U-WIN related queries

For managing immunization session, train them to:

o Assist in setting up RI session site
o Ensure all beneficiaries are brought to the session site as per due beneficiary list.
There may be a need of repeated visits to bring the beneficiary for vaccination. There
also may be need to take help from local influencers for mobilizing the beneficiaries
o Assist in conducting the immunization session. (Control the crowd, assist in recording,
etc.)
o Remind caregivers of the 4 key messages about immunization
o Ensure beneficiaries wait for 30 minutes at the session site after immunization
o Help with preparing the due list for next session

For post immunization follow-up - train them to:

o Report any AEFI to the ANM or Medical officer and refer them to identified AEFI
management center
o Visit the houses of dropouts and leftouts to counsel the mothers to immunize their
children
o Contact you for any advise or questions pertaining to vaccination

h) Coordination with ICDS

Use the following sources of information in planning immunization:
o List and map of villages including hamlets /urban areas /wards/ mohallas
o 0-6 years registers, eligible couple register, etc. for total and beneficiary population
o VHSND/ UHND microplans
o AWW/Helper list
o Panchayath records or lists
Follow up for the participation of respective ICDS and line department staff in sectoral
review meetings held at PHC/ UPHC for good coordination.

Involve the ICDS, panchayat supervisors to:

o Visit field to monitor the house-to-house survey conducted by AWWs
o Supervise the filling of forms SC- 3, SC-4A, SC-4B and SC-4C
o Support in review of all survey forms and consolidation of sub centre microplans
during meeting at SC/ ANM area
o Be aware of Health and ICDS sector boundaries for joint planning, implementation
and monitoring of immunization activities
o Contribute to development of communication plan
o Ensure that the AWWs are regularly trained in immunization/mobilization

15
 2.2. Roles and responsibilities of Community Health Officer (CHO) in
providing Routine Immunization services

Community Health Officer (CHO) oversees and facilitates all aspects of routine immunization
(RI) services, playing a vital role in promoting immunization uptake and ensuring quality
service delivery in their communities through following activities:
ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

Service provision
o Ensure early registration of child at the nearest Ayushman Arogya Mandir (AAM) to
avail the immunization services
o Ensure immunization services at Routine Immunization (RI) sessions, VHNDs, health
campaigns, health promotion events, etc.
o Ensure quality head count survey for immunization services by supportive supervision
of activities of ANM and ASHA
o Ensure meticulous micro planning for routine immunization services, high- risk area
(HRA) tagging, mapping of areas under sub-health centre with areas demarcation for
each ANM, if more than 2 ANMs
o Supportive supervision of activities of ANM and ASHAs in preparation of line listing,
regular updating of list of eligible children, review of due list prepared and tracking
dropouts and left out children. Ensure reasons for dropouts are entered in the routine
immunization counterfoil in the MCP card by you or the ANM
o Ensure availability of vaccines and logistics at cold-chain points and session sites
(including anaphylaxis) in the AAM-SHC area
o Ensure cold-chain and equipment management
o Supportive supervision of immunization session site and ensure availability of
updated due list, proper vaccination technique, vaccine management is undertaken.
o Ensure observance of standard precautions to prevent infection and appropriate
waste segregation and disposal
o Ensure ANM is providing four key messages after child vaccination to their mother/
caregivers - what vaccine was given and what disease it prevents, when and where to
come for the next visit, what minor adverse events could occur and how to deal with
them and to keep the immunization card safe and bring it along for the next visit
o Submit monthly reports and ensure availability and quality of records-MCP, RCH/
Immunization register, RCH Portal, etc.
o Ensuring early identification, classification, recording, reporting and referral for
AEFI, if any. Management of minor AEFIs (like fever, pain, etc.) symptomatically and
establishing linkages with nearby health facility for management of serious AEFIs like
to the Medical Officer. Accompany the mother/caregiver of the child if needed to the
referral health facility
o Report all AEFIs to the Medical Officer at AAM-PHC immediately. The process of finding
out the reasons for the AEFI will help the MO and you to understand why the event
happened
o Ensure all AEFIs details are entered in the AEFI block register maintained at the Block
PHC
o Facilitation of any campaign/intensification activity including inter-sectoral
coordination. Organise inter-sectoral coordination meetings with ICDS/local village
administration/NGOs, etc.
o Monitor surveillance activities undertaken by ANM and ASHAs to ensure all cases are

16
 reported from health facility and community; regular review of sub-health centre
surveillance reports for completeness and accuracy (activities include surveillance
for diphtheria, pertussis, neonatal tetanus, measles, rubella and polio)

Demand generation
o Organise meetings to discuss and orient ASHA/ANM in their area for increasing
demand for immunization services, building vaccine confidence among caregivers

ROLES AND RESPONSIBILITIES OF HEALTH WORKERS IN IMMUNIZATION

and mobilising beneficiaries for timely vaccination
o Praise and encourage the family for ensuring their child’s immunization if all necessary
vaccines have been given
o Counsel beneficiaries, handhold ASHAs and ANMs and partner with community to
overcome social, economic, geographic barriers in improving immunization coverage.
o Active mobilisation of all beneficiaries by ASHAs and ANMs with focus on reaching
the marginalised and migrant population. Check the immunization status of the child
from the MCP card whether child has received age-appropriate vaccines
o Inform when and where the family can take the child for the next vaccination, for a
missed vaccine, or if a vaccine is due soon
o Allay fear of Adverse Event Following Immunization (AEFI)
o Coordination with community/religious/local leaders, teachers and volunteers on
regular basis; encourage them to discuss immunization in their meetings
o Ensure effective mobilisation of children by ASHA, ANM and VHSNC members for
immunization sessions during VHND session or at the health facilities

17
18
 Unit 3
National Immunization Schedule

19
 Learning objectives
At the end of the unit, Health worker should be able:
• To enlist vaccines administered in the National Immunization
Programme, due ages for vaccination, number of doses along with
site and route of administration.

Key contents Page

3.1. National Immunization Schedule (NIS) 21
3.2. Sequence of vaccines administered at different schedule in UIP 23
3.3. Definitions of vaccination status of beneficiaries in UIP 27

20
National Immunization
Schedule
3.1. National Immunization Schedule (NIS)

The aim of UIP is that eligible beneficiaries should get all UIP vaccines in a timely manner
as specified in UIP schedule, so that they may be protected from life threatening vaccine
preventable diseases against which vaccines are provided under the UIP in India.

NATIONAL IMMUNIZATION SCHEDULE

Vaccination of beneficiaries in Universal Immunization programme:
Pregnant women
• As early as possible during the First Antenatal visit- appropriate Td doses
Infants and children
• At birth - Hep B, bOPV, BCG
• Vaccines to be given to a child by first year of age
o 3 doses of bOPV, 3 doses of Rotavirus vaccine, 3 doses of Pentavalent, 3 doses of
fractional IPV, 3 doses of PCV, 1st dose of MR vaccine, 1st dose of JE vaccine (where
applicable)
• Vaccines to be given to a child by second year of age
o 2nd dose of MR vaccine, 1st dose of DPT booster, 1 dose of bOPV booster and 2nd
dose of JE vaccine (where applicable)
• Vaccines to be given to a child after 5 years – 2nd dose of DPT booster at 5 years, 1 dose
of Td vaccine at 10 years & 1 dose of Td vaccine at 16 years

Hep B – Hepatitis B; bOPV – Bi valent oral polio vaccine; BCG – Bacillus Calmette-Guerin; IPV – Inactivated Polio
Vaccine; PCV – Pneumococcal Conjugate Vaccine; MR- Measles Rubella vaccine; JE – Japanese Encephalitis; DPT –
Diphtheria–pertussis–tetanus; Td – Tetanus diphtheria

Different syringes and needle positions for vaccine administration:

Fig. No. 3.1: Different syringes and needle positions for vaccine administration

21
 Table 3.1. National Immunization Schedule (NIS) for Pregnant Women, Infants and
Children4, 5-9

Vaccine Age of administration Maximum age Dose Route Site

For Pregnant Women
Td-1 As early as possible 4 wks before 0.5 ml Intra-muscular Upper Arm in
during First Antenatal EDD* If not Deltoid region
visit received, any
time before
delivery
Td-2* 4 weeks after Td-1 Any time after 4 0.5 ml Intra-muscular Upper Arm in
wks from Td-1 Deltoid region
Td- Booster** If received two Td doses 4 wks before 0.5 ml Intra-muscular Upper Arm in
during pregnancy within EDD* If not Deltoid region
the last 3 years. #Give received, any
Td-2 or Booster doses time before
before 36 weeks of delivery
NATIONAL IMMUNIZATION SCHEDULE

pregnancy. However,
give these even if more
than 36 weeks have
passed. Give Td to a
woman in labour, if
she has not previously
recieved Td.
For Infants
BCG $ At birth one year of 0.05 ml Intra-dermal Upper Arm in
age, before 1st (upto 1 month Deltoid region
birthday of age) - LEFT
0.1ml
(1 month
to 1 year)
Hepatitis B At birth within 24 hours 0.5 ml Intra-muscular Antero- lateral
-Birth dose of birth side of mid-
thigh - LEFT
bOPV-0 At birth within the first 2 drops Oral Mouth
15 days of age
bOPV 1, 2 and 3 At 6, 10 and 14 weeks till 5 years of 2 drops Oral Mouth
of age age
Rotavirus At 6, 10 and 14 weeks 1 year of age 5 drops or 2ml Oral Mouth
vaccine 1, 2 and of age as per vaccine
3® formulations

f-IPV 1, 2 and 3 At 6, 14 weeks and at 9 1 year of age 0.1 ml Intra-dermal Upper Arm in
-11 months of age Deltoid region
-RIGHT for
fIPV-1 & fIPV-2
-LEFT for
fIPV-3
Pneumococcal At 6, 14 weeks for 1 year of age 0.5 ml Intra-muscular Antero-lateral
Conjugate primary doses, and 9-11 side of mid-
Vaccine (PCV) months for booster thigh -RIGHT
(2 Primary +1 dose
booster)
Pentavalent 1, At 6, 10 and 14 weeks 1 year of age 0.5 ml Intra-muscular Antero- lateral
2 and 3 of age side of mid-
thigh-LEFT

22
 Measles 9 to 11 months of age 5 years of age 0.5 ml Sub- cutaneous Upper arm in
Rubella vaccine Deltoid region
(MR) 1st dose# - RIGHT
Japanese 9 to 11 months of age 2 years of age 0.5 ml Killed Vaccine: Killed vaccine:
Encephalitis– 1¥ (Killed & live Intra-muscular Antero-lateral
(in selected vaccine) Or side of mid-
districts) Live thigh – LEFT
attenuated Or
Vaccine: Live
Subcutaneous attenuated
vaccine: Upper
arm in Deltoid
region – LEFT
Vitamin A 9 months with MR 5 years of age 1 ml (1 lakh IU) Oral Mouth
(1st dose) 1st dose
For Children
bOPV Booster 16 to 23 months 5 years of age 2 drops Oral Mouth
MR 2nd dose# 16 to 23 months of age 5 years of age 0.5 ml Sub-cutaneous Upper Arm-

NATIONAL IMMUNIZATION SCHEDULE

RIGHT
DPT Booster-1 16 to 23 months of age 7 years of age 0.5 ml Intra-muscular Antero- lateral
side of mid-
thigh–LEFT
JE vaccine 2nd 16 to 23 months of age 2 years of age 0.5 ml Killed Vaccine: Killed vaccine:
dose¥ Intra-muscular Antero-lateral
(in selected or side of mid-
districts) Live thigh – RIGHT
attenuated or
Vaccine: Live
Subcutaneous attenuated
vaccine: Upper
arm – LEFT
Vitamin A 16 to 23 months with 5 years of age 2 ml (2 lakh IU) Oral Mouth
(2nd to 9th dose) MR 2nd dose, subsequent
doses at an interval of
6 months, upto 5 years
of age
DPT Booster-2 5 to 6 years of age 7 years of age 0.5 ml Intra-muscular Upper Arm
-LEFT
Td 10 and 16 years of age 16 years of age 0.5 ml Intra-muscular Upper Arm
-LEFT

Note: Age mentioned in above table are in completed weeks/ months/ years
* EDD=Expected Date of delivery
$
BCG vaccine requires reconstitution with diluent which is supplied by the manufacturer
® Rotavirus vaccine – Open vial policy is applicable to RVV with VVM on the label; Not applicable to RVV with VVM on the cap
#
MR vaccine requires reconstitution with diluent which is supplied by the manufacturer
¥
JE Vaccine is provided in select districts in India. JE (Live) vaccine requires reconstitution with diluent which is supplied by the
manufacturer

3.2. Sequence of vaccines administered at different schedule in UIP:

The below mentioned pictures represent the sequence of different vaccines that are
administered at different schedule in UIP. It should be remembered that Oral vaccines have
to be given first followed by injections.

23
 Fig. no. 3.2: Pictorial representation of sequence of vaccination from birth up to 16-23 months

Sequence of vaccination at birth

Hep B
BCG
OPV Vaccine BCG Vaccine Hep B Vaccine
1 2 3

1 2 3

BCG

Hep B
Left Side
NATIONAL IMMUNIZATION SCHEDULE

Right Side

Sequence of vaccination at 6 weeks

Penta
PCV
IPV

OPV Vaccine Rota Vaccine fIPV Vaccine PCV Vaccine Penta Vaccine
1 2 3 4 5

3
IPV

5
Penta

4
PCV

Right Side Left Side

24
 Sequence of vaccination at 10 weeks

Penta
OPV Vaccine Rota Vaccine Penta Vaccine
1 2 3

Penta
PCV

NATIONAL IMMUNIZATION SCHEDULE

Right Side Left Side

Sequence of vaccination at 14 weeks

Penta
PCV
IPV

OPV Vaccine Rota Vaccine fIPV Vaccine PCV Vaccine Penta Vaccine
1 2 3 4 5

3
IPV

5
Penta

4
PCV

Right Side Left Side

25
 Sequence of vaccination at 9-11months

PCV
IPV

MR

JE
fIPV Vaccine MR Vaccine PCV Vaccine JE Vaccine*
1 2 3 4

fIPV
2
MR

JE
NATIONAL IMMUNIZATION SCHEDULE

3
PCV

*JE in endemic districts

Right Side Left Side

Sequence of vaccination at 16-23 months

DPT
MR

JE

OPV Vaccine MR Vaccine DPT Vaccine JE Vaccine*

1 2 3 4

2
MR

3
DPT

4
JE

*JE in endemic districts

Right Side Left Side

26
3.3 Definitions of vaccination status of beneficiaries in UIP:

Full Immunization: Child who has received BCG, 3 doses of bOPV, 3 doses of Pentavalent and
1 dose of MR by first year of age. This is the historical definition used for survey and evaluation
purposes and hence has been continued - Full Immunization coverage (FIC).
FIC plus: Child who has received all the vaccines given in the Universal Immunization
Programme (UIP) by one year of age.
Complete Immunization: Child who has received all the vaccines given in the Universal
Immunization Programme (UIP) by two years of age.
Left-out: Child who has not received any vaccine under UIP (unimmunized).
Drop-out: Child who has received one or more UIP vaccine/s but did not complete the schedule
as per the age (partially immunized).

NATIONAL IMMUNIZATION SCHEDULE

Zero-dose (operational & reporting purpose): Child who has not received first dose of
Pentavalent vaccine by one year of age.10

“Continuous tracking and vaccinating left-out, Zero dose and drop-out children are to be
ensured to achieve 100% full immunization coverage”.

Full Immunization coverage (FIC) plus:

Child who has received all the vaccines given nationally in the Universal Immunization
Programme (UIP) by one year of age. This is a new indicator for measuring the Universal
Immunization Programme.

Need for FIC Plus:

FIC as an indicator is well established and widely used. This indicator has been in use since
NFHS-1 survey of 1992-93, during that time only few vaccines (BCG, OPV, DPT, Measles) were
administered to a child till first birthday. However, as on January 2024 in addition to the
above-mentioned vaccines new vaccines have also been added in the UIP like IPV, PCV &
Rota). Therefore, there is a programmatic need to measure the administration of all of these
doses to the child. Hence the concept of FIC Plus has been introduced.

A child will be counted as FIC plus if the child has received all the doses of the following
vaccines – BCG, 3 doses of OPV, 3 doses of Penta, 3 doses of IPV, 3 doses of Rota, 3 doses of
PCV and one dose of MR before first birthday throughout the country.

It is reiterated that FIC will continue to be used as an indicator as it will facilitate national and
global compatibility with previous data.

India is targeting MR Elimination and therefore the missed dose of MR vaccine is to be

given to any child upto 5 years of age.

Zero Dose children:

For operational and reporting purposes, “zero-dose children” are defined as children who
have not received the first dose of Pentavalent vaccine by 1 year of age.10

27
 Fig. No. 3.3: Concept of Zero dose children

Left out children

Zero dose children
Dropout children but not received Penta-1
Dropout children
Dropout children but received Penta-1

Fully immunized children

NATIONAL IMMUNIZATION SCHEDULE

Calculation of Zero dose children: It is calculated as the difference between the estimated
number of surviving infants and the number of children vaccinated with Penta-1 dose.
• As shown in the figure below,
o All Left out/ unimmunized children of one year age are Zero Dose children
o Zero Dose children also include children, who received any other vaccines but not
received Penta-1

So, Zero Dose Children include​Left Out Children of one year age + Drop out children who
have not received Penta-1 dose (though may have received ​any other vaccine).

Table No. 3.1: Snapshot of vaccines administered in National Immunization schedule:

Beneficiary Age Vaccines given
Birth BCG, bOPV-0, Hepatitis B Birth dose
6 Weeks bOPV-1, Pentavalent-1, fIPV-1, RVV-1 & PCV-1
Infants 10 Weeks bOPV-2, Pentavalent-2 & RVV-2
14 Weeks bOPV-3, Pentavalent-3, fIPV-2, RVV-3 & PCV-2
9-11 months MR-1, JE-1* , PCV-B, fIPV-3 & Vitamin- A 1st dose
MR-2, JE-2*, DPT-B 1, bOPV-B and Vitamin-A
16-23 months nd th
(2 to 9 dose) one dose every 6 month up to 5 years
Children 5-6 years DPT-B 2
10 years Td
16 years Td
Pregnant Mother: Td 1, 2 or Td Booster**
*JE Vaccine in selected areas (endemic districts) only
**one dose if previously vaccinated by two doses of Td within last 3 years
bOPV – Bi valent oral polio vaccine; BCG – Bacillus Calmette-Guerin; fIPV –Fractional IPV
RVV – Rota virus vaccine; PCV – Pneumococcal Conjugate Vaccine; JE- Japanese Encephalitis;
DPT – Diphtheria–pertussis–tetanus; Td – Tetanus diphtheria

28
 Unit 4
Diseases prevented by vaccination

29
 Learning objectives
At the end of the unit, Health worker should be able:
• To enlist diseases that are preventable by immunization under the
Universal Immunization Programme (UIP).
• To describe their mode of spread and how they can be recognized
and prevented.

Key contents Page

4.1. Diseases prevented by Immunization under UIP Programme 31

30
Diseases prevented
by vaccination
4.1. Diseases prevented by Immunization under UIP Programme1, 11-15

The following are the targeted vaccine preventable diseases under Universal Immunization
Programme:
1. Severe form of childhood Tuberculosis 7. Haemophilus influenzae Type b related

DISEASES PREVENTED BY VACCINATION

2. Hepatitis B diseases
3. Poliomyelitis 8. Diarrhoea due to rotavirus
4. Diphtheria 9. Pneumococcus related diseases
5. Pertussis 10. Measles
6. Tetanus 11. Rubella
12. Japanese Encephalitis

1. Tuberculosis

Tuberculosis (TB) is caused by the bacterium (Mycobacterium

tuberculosis). It usually attacks the lungs but can also affect other
parts of the body including the bones, joints and brain. TB can
cause serious illness and death.

Recognition of the disease:

• A person 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
Figure. 4.1: Childhood
Mode of spread: TB is spread from one person to another through Tuberculosis case
the air, often when an infected person coughs or sneezes. TB
spreads rapidly, especially in areas where people are living in crowded conditions, have poor
access to health care and/or are malnourished. A person can contract bovine tuberculosis,
another variety of TB by consuming raw milk from infected cattle.

Disease prevention: Vaccination with Bacillus Calmette-Guerin (BCG) vaccine as per the
schedule will prevent serious forms of childhood tuberculosis.

2. Hepatitis B
Hepatitis B is caused by a virus that affects the liver. 90 percent of infants who get infected
during birth or before one year of age develop chronic disease. It is a highly infectious disease
(50-100 times more infectious than HIV) and is the leading cause of jaundice, chronic liver
disease or primary liver cancer.

31
 Recognition of the disease: An acute illness typically including yellowish discolouration of
eyes and skin, dark yellow colored urine, loss of appetite, generalized weakness, letharginess
and pain in right upper abdomen.

Mode of spread: The disease spreads through contact with infected blood or other body
fluids in various situations:
a) from mother to child during birth
b) through unsafe injections and/or transfusions, or needle stick accidents with infected blood
c) contact with infected person with cuts, scrapes, bites and/or scratches
d) from person to person during sexual intercourse

Disease prevention: By vaccinating children with Hepatitis B vaccine birth dose within 24
hrs of birth and completing the Pentavalent vaccine (which also contains Hep B vaccine) dose
schedule as per the immunization schedule.
DISEASES PREVENTED BY VACCINATION

3. Poliomyelitis

Poliomyelitis, or polio, is a highly infectious disease caused by

poliovirus types 1, 2 or 3. It mainly affects children of less than
five years of age. One in 100 to 1000 infections causes irreversible
paralysis when the virus attacks the spinal cord nerve cells that
control the muscles.

India continues to be polio free since 2011. It is important that

all eligible children receive polio vaccinations during routine
immunization and polio campaigns until the world is polio free.

Recognition of the disease: Sudden onset of weakness and

Figure. 4.2: Polio case
looseness in any part of the body in a child less than 15 years of age
or paralysis in a person of any age in whom polio is suspected.

Mode of spread: Polio is transmitted by faeco-oral route. In areas with poor sanitation, it
enters the body through the mouth when people eat food or drink water that is contaminated
with faeces.

Disease prevention: Vaccination with the oral polio vaccine (OPV) and inactivated polio
vaccine (IPV) administered as per the immunization schedule.

Importance of reporting AFP cases: As the world is not yet polio free, it is important that all
AFP cases be reported even though India is polio free. Surveillance for polio must continue to
ensure that we are able to detect cases if they occur.

4. Diphtheria

Diphtheria is caused by the toxin producing bacterium (Corynebacterium diphtheriae).

Diphtheria is an infectious disease that commonly affects the throat and the tonsils, forming
a membrane that can lead to obstructed breathing and death.

32
Recognition of the disease: An illness of the upper respiratory
tract characterized by the following:
laryngitis (hoarseness of voice, cough) or nasopharyngitis
(running nose, nasal congestion and sneezing) or pharyngitis
(fever with pain and redness of throat) or tonsillitis (fever, pain
and enlarged red tonsils) or neck swelling (bull-neck)
AND Figure. 4.3: Diphtheria case
adherent membranes of tonsils, pharynx and/or nose

Mode of spread: Diphtheria spreads easily between people by direct contact with an infected
person or through respiratory droplets in air, like from coughing or sneezing.

Disease prevention: Giving diphtheria containing vaccines - Pentavalent, DPT boosters and
Td boosters as per the immunization schedule is the most effective method of prevention.

DISEASES PREVENTED BY VACCINATION

5. Pertussis (whooping cough)

Pertussis or whooping cough is a disease of the respiratory

tract caused by Bordetella pertussis bacteria that live
in mouth, nose and throat. It is highly communicable
disease characterized by repeated cough that may lead
to pneumonia and other complications leading to death
especially in infants and young children.

Recognition of the disease: a person of any age with a

cough lasting for >=2 weeks, or of any duration in an infant
or any person in an outbreak setting, without a more
likely diagnosis and with at least one of the following on Figure. 4.4: Pertussis case
observation or parental report:
• paroxysms (fits of coughing)
• inspiratory whooping
• post-tussive vomiting (vomiting immediately after coughing) or vomiting without other
apparent causes
• Apnoea in infants (<1 year of age)
• clinician suspects pertussis

Mode of spread: Pertussis spreads very easily from person to person in droplets produced
from an infected person.

Disease prevention: Giving pertussis containing vaccines - Pentavalent and DPT boosters as
per the immunization schedule.

6. Tetanus

Tetanus: Tetanus is an acute infectious disease caused by the bacterium Clostridium tetani
spores. The spores are found everywhere in the environment, particularly in soil, ash,
intestinal tracts/ feces of animals and humans, and on the surfaces of skin and rusty tools like
nails, needles, barbed wire, etc.

33
 Anyone can get tetanus, but the disease is prevalent
and serious in newborn babies and pregnant women
who have not been sufficiently immunized with
tetanus-toxoid-containing vaccines. Tetanus during
pregnancy or within 6 weeks of the end of pregnancy
is called maternal tetanus, and tetanus within the
first 28 days of life is called neonatal tetanus.

Recognition of the disease: Any neonate with a

Figure. 4.5: Neonatal Tetanus case
normal ability to suck and cry during the first 2 days
of life, and who thereafter cannot suck normally from
3 to 28 days of age and becomes stiff or has convulsions/spasms (jerking of the muscles), or
both.
or
Any neonate who died of an unknown cause during the first month of life
DISEASES PREVENTED BY VACCINATION

Mode of spread: Tetanus is not transmitted from person to person. In people of all ages, the
spores of bacteria can enter a wound or cut from items such as dirty nails, dirty tools used
during childbirth, or deep puncture wounds from animal bites.

In newborn babies, infection can occur when delivery occurs on dirty mats or floors, a dirty
tool is used to cut the umbilical cord, dirty material is used to dress the cord or when the
hands of the person delivering the baby are not clean.

Disease prevention: By giving tetanus-containing Pentavalent vaccine, DPT booster and

Td to children and adolescents, and Td vaccine to pregnant women as per the National
Immunization Schedule.

7. Haemophilus infuenzae type b disease

Haemophilus influenzae is a bacterium found commonly in the nose and throat of children.
Hib can lead to severe pneumonia and meningitis in children aged less than 5 years.

Recognition of the disease: Clinical signs and symptoms of pneumonia include fever, chills,
cough, rapid breathing and chest wall retractions. Children with meningitis can have fever,
headache, avoidance and intolerance to bright light , neck stiffness and sometimes confusion
or disturbed consciousness.

Mode of spread: The disease spreads from person to person through the droplets released
from an infectious person during sneezing and coughing. Healthy children carrying the
bacteria in their noses and throats can also infect others.

Disease prevention: By vaccinating children with Hib vaccine (contained in Pentavalent

vaccine) as per the immunization schedule, we can prevent Hib infection and its complications.

8. Rotavirus diarrhea

Rotavirus diarrhea is a highly infectious diarrhoeal disease caused by rotavirus infecting the
small intestines. It causes severe diarrhoea in infants and young children. Infants between
three and 12 months of age may die due to severe dehydration.

34
Recognition of the disease: Clinical symptoms and signs range from mild loose stools to
large volume watery stools and vomiting leading to rapid dehydration.

Mode of spread: The disease spreads via contaminated food, water and objects through
faeco-oral route.

Disease prevention: By vaccinating children with Rotavirus vaccine as per the immunization
schedule. Remember to give oral rehydration solution (ORS) and ZINC during diarrhoea.

9. Pneumococcal disease

Pneumococcal disease is a group of diseases caused by a bacterium Streptococcus

pneumoniae (also known as pneumococcus). The most serious form of bacterial diseases
are pneumonia, meningitis, and blood stream infections. Streptococcus pneumoniae is the
leading cause of bacterial pneumonia in children under 5 years of age.

DISEASES PREVENTED BY VACCINATION

Diseases caused by pneumococcus: include:
• Bacterial 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-ear pain and discharge)
• Sinusitis, Bronchitis (chest infection)

Mode of spread: Pneumococcus spreads from person to person (coughing, sneezing or

close contact). Healthy carriers may harbour pneumococcus in their nasopharynx for days
or weeks.

Risk group for of pneumococcal disease: Young children and elderly individuals are most at
risk. The children most at risk of pneumococcal disease are:
• Children under 5 years of age, especially those under 2 years of age
• Immunocompromised children (children with reduced immunity to fight diseases)
• Those with influenza or other respiratory virus infections can get a secondary infection
with pneumococcus
• Malnutrition, lack of breastfeeding, exposure to indoor smoke and crowded living
conditions
• Poor and low-income group populations with poor access to health care

Disease prevention: By vaccinating children with PCV vaccine as per the immunization
schedule.

10. Measles and Rubella

Measles is a highly infectious disease caused by a virus. It is an important cause of death

among children who are poorly nourished, un- & partially vaccinated and living in crowded
conditions. Complications include dehydration due to severe diarrhoea, malnutrition, ear
pain/discharge, pneumonia/chest infection, blindness and encephalitis (brain infection).

Rubella is generally a mild disease in children but when infection occurs in early pregnancy,
it has the potential to cause spontaneous abortions, death of baby in womb, dead-born baby,

35
 and serious birth defects (congenital rubella syndrome – CRS) in
the child causing lifelong disabilities.

Recognition of the disease: Any person with fever and

maculopapular rash (flat or slightly raised from the skin).

Mode of spread: The virus is spread through nose and throat

secretions of infected people and in airborne droplets released
when an infected person sneezes or coughs.

Disease prevention: By vaccinating children with Measles/ Figure. 4.7: Measles case
Rubella vaccine as per the immunization schedule. Children
till 5 years of age, who missed any dose of MR vaccine should be
given the missed dose so as to complete two doses of MR vaccine.
DISEASES PREVENTED BY VACCINATION

11. Japanese Encephalitis

Japanese encephalitis (JE) is an infection of the brain caused by a virus. It is prevalent in

certain geographical areas in some of the states. JE
is fatal in 20-30% of cases, with young children (less
than 10 years) having a greater risk of severe disease
and death.

Recognition of the disease: A person of any age,

at any time of the year with acute onset of fever
not more than 5-7 days duration, associated with
change in mental status (may include irritability,
somnolence (excess sleeping) or abnormal behavior
greater than that seen with usual febrile illness) Figure. 4.8: Japanese Encephalitis case
and/ or
new onset of seizures (excluding simple febrile seizures).

Mode of spread: JE virus is spread by mosquitoes. The virus normally infects birds and
domestic animals, especially pigs, which serve as its reservoirs. Humans may contract the
disease when a mosquito that has bitten an infected animal then bites a person.

Disease prevention: By vaccinating children with JE vaccine as per the immunization

schedule. JE vaccine is being given only in identified JE endemic districts of the country.

36
 Unit 5
Routine Immunization
Microplanning

37
 Learning objectives
At the end of the unit, Health worker should be able:
• To list the components and steps involved in developing RI micro-
plans
• To describe the utility of formats in RI micro-planning
• To guide HWs to prepare SC or ANM area micro-plans including maps
of their catchment area
• To review and update the RI micro-plan to include all HRAs
• To understand the process of development of microplan for DPT
Booster-2, Td vaccination

Key contents Page

5.1. RI microplanning – Importance 39
5.2. Components of an RI microplan at subcenter or ANM area level 40
5.3. Frequency of major activities for RI microplanning process 40
5.4. Process/ steps of Microplanning 41
5.5. Overview and utility of RI microplanning formats
5.6. Alternate Vaccine Delivery
5.7. Coverage of DPT-booster 2 and Td 10 & Td 16 in schools and 80
community level
5.8. Planning in High Risk areas 81

38
Routine Immunization
Microplanning

5.1. RI microplanning – Importance

Routine Immunization (RI) microplanning is the basis for ensured delivery of RI services to a

ROUTINE IMMUNIZATION MICROPLANNING

community. The availability of updated and complete microplans at a subcenter/ ANM area
(urban/rural) demonstrates preparedness of the health institute and indicates the quality of
services provided.

Purpose of RI microplan:
• Define the catchment area and population covered by each SC / urban ANM Area
• Identify HRAs both migratory and settled HRAs
• Listing & Tracking of Beneficiaries to Reduce dropouts and left outs
• Ensuring rational workload distribution and session planning to cover the beneficiaries in
the catchment area to increase the RI coverage
• Plan and improve the supervision
• Better utilization of human resources as well as vaccine and logistics
• Strengthen capacity to use data for action

Levels of RI microplanning process:

Microplanning process should start at the Sub Centre (SC)/ Urban ANM area level. Microplans
from the subcentres are compiled to prepare the PHC/ UPHC microplan. Information from
PHCs/ UPHCs is consolidated at the district or may be at the block/ taluk/ zone and then to
the district level in some states. Fig 5.1 shows the RI microplanning from subcentre/ ANM
area to the district and to the state level.

State UT

District / City

Taluk / CHC / Block / Zone

Primary Health Centre / Urban Primary Health Centre

Sub-centre /Urban ANM area

Fig. 5.1. Levels of RI microplanning process

39
 5.2 Components of an RI microplan at subcenter or ANM area level

An RI microplan at the subcentre or ANM area level should have the following components:
a) Master list of the area– Includes names of all villages and urban areas (hamlets / tolas /
/wards/ sub-ward/ mohalla/ sector/ HRAs, etc.)
High Risk Areas (HRAs) both migratory and settled HRAs form an important
component of the master list of the areas for preparing RI-Microplan
b) Area map showing names of villages and urban areas (including all hamlets / tola,
sector, mohalla and hard to reach areas, HRAs)
c) Demarcation Map – Clearly define areas for each ANM and if more than 1 ANM are
posted, their area should be clearly demarcated. It should show the exact boundaries
and areas for each ASHAs/ AWWs/ other mobilizers
d) Estimation of beneficiaries (who has to be vaccinated and with which antigen)
e) Estimation of vaccines and logistics (for each planned session)
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f) ANM work / roster plan including mobilization plan

High Risk Areas (HRAs) and urban areas form an important component of the master
list of the areas for preparing RI-Microplan.

5.3 Frequency of major activities for RI microplanning process

Table no. 5.1. Frequency of major activities for RI microplanning process

Frequency Activity
Annually Prepare/ update RI microplan
• list all areas (all villages, hamlets (tola), sub villages, urban and peri
urban areas, mohalla, hard to reach areas, etc. ) including HRAs in the
master list and map them
• conduct house to house survey for head counting of beneficiaries –
pregnant women and children below 5 years (to be repeated every 6
months)
• plan RI sessions - community need based, and demand driven
• calculate vaccine and logistics
• preparation of Supervisory plan, AVD Plan, ANM Roster, communication,
BMW management and Contingency plan
Half yearly House to house survey for head counting of beneficiaries:
• repeat the house-to-house survey after six months to update the
beneficiaries
• identify new areas, validate HRAs by supervisors/ medical officers
Quarterly Review and update
• Review and update the microplans to address the emerging situations.
eg. community needs, vacant subcenters, new migratory HRAs
• preparation of Supervisory plan, AVD Plan and ANM Roster
Monthly Session due list review at SC /ANM area: ANM should
• Review due cum tally sheet of all the sessions held in the previous
month.
• Update coverage report & monitoring chart and list out the left outs,
dropouts
• Report the challenges in vaccination coverage to MO and plan to
address them

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Weekly Update session due list after every session
After every RI session with the help of ASHA/AWW/ MAS/ other mobilizers,
ANM should:
• Identify all the missed children by reviewing the previous session due
list tally sheet and include them in the next due list, including newborns
and pregnant women
• Plan to mobilize all eligible beneficiaries to the immunization session
sites

5.4 Process/ steps of RI Microplanning

RI Microplans should be prepared annually based on actual head count survey and it should
be reviewed every quarter. However, the process is dynamic, requiring regular reviews and

ROUTINE IMMUNIZATION MICROPLANNING

updation based on the community needs and available resources to plan for effective delivery
of immunization services to reach all the beneficiaries including HRAs.

The steps in the process of developing RI microplan are shown in Fig. no.5.2

Fig. 5.2. Snapshot of steps for RI micro-plan developing process

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

Sub-center/ ANM Head count Review & Finalization
Block PHC/UPHC
area planning survey in all urban consolidation of SC/ PHC/UPHC microplan
meeting
and rural area ANM area microplan

Review of field Review and

Sensitization finalization of SC/
Planning for head formats
meeting with ANMs/ ANM area microplan
count survey Conducting head Review SC/ ANM area
ASHAs
training of surveyors count survey in all master list SC/ ANM area final
Subcentre ANM RI
for head count areas including HRAs Develop draft SC/ due list
microplan review
survey ANM area RI Develop PHC/UPHC
meeting
microplan RI microplans

The activities for RI microplan preparation should preferably be initiated on 1st working day
of February and the Head count survey should be done meticulously and completed by end
of February. Head Count survey should not be done on RI days. The microplan updation at
PHC/UPHC level should be completed by mid of March. This should be followed by microplan
review at Block and District level before the submission of the plan from district to state. The
RI microplan are expected to be operational from 1st April of every year. Refer Gantt chart for
suggested timelines and steps involved (Fig. No. 5.3).

The microplanning formats are essential to enlist all the catchment areas and to plan adequate
immunization services. All the sessions planned for a month as per ANM rosters should be entered on
U-WIN. For example, if 38 sessions are planned on a RI day in a PHC/Block, then all these 38 sessions
should be scheduled and conducted on U-WIN. Ensure that all the sessions planned in HRAs including
hard to reach areas through RI microplanning process should be reflected in U-WIN. Eg. If 5 sessions are
planned in HRAs, the same has to be reflected in U-WIN.

41
 ROUTINE IMMUNIZATION MICROPLANNING

Fig 5.3: Proposed timeline of activities in RI microplanning –

February March
Activities for developing RI micro-plans (Urban/ Rural)
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

PHC / UPHC meeting - Sensitization meeting for ANMs and other

health staff (Step 1)

PHC/ UPHC meeting - ANM RI micro-plan review meeting and

area demarcation planning (Step 1)

SC/ ANM area planning meeting - for planning head count survey
and training of all surveyors for Head count survey (Step2)

Conducting house to house head count survey without leaving

42
any house (Step 3)

Field validation

SC/ ANM area meeting -review of all formats & preparing draft
RI micro-plan (Step 4)

PHC/ UPHC meeting - SC / Urban ANM area micro-plan

finalization with ANMs and submission of final plan (Step 5)

PHC / UPHC : Final review of consolidated plan and followed by

submission to block & district DIO (Step 5)

Note: This Gantt chart is indicative of average time needed for important activities in developing RI micro-plan. The Urban areas may require additional resources and time.
Step-1 Block/PHC/UPHC meeting – Sensitization and review of existing microplans

Step 1 involves two meetings:

A. Sensitization meeting of ANMs and other staff to plan for Head count survey
B. ANM wise RI microplan review meeting

A. Sensitization meeting chaired by MO to prepare master list of areas to plan for Head
count survey

Purpose: During this sensitization meeting, health workers are sensitized on:
• Microplan process and utilization of different RI forms (ref. table no.5.3 and Fig. no.5.26)
• Planning for head count survey (filling form SC-1 & SC-2)

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o preparation of master list of areas under each SC/ ANM area by including all
villages and their hamlets, tolas; Urban/peri-urban areas and their wards/sub wards/
mohallas; HRAs in the master list (Form SC-1). This is the most important activity.
o Area demarcation
o Details of HRAs must be shown in a separate row in Form SC-1
 Roles and responsibilities of health workers
At the end of this meeting, MO would schedule the date of ANM review meeting and finalize
training dates of surveyors

B. ANM RI micro-plan review meeting

This meeting would be conducted by MO PHC/ UPHC (in small batches of 2 or 3 ANMs) to
finalize the:
• Area demarcation for each subcentre and ANM area
• Master list of all areas for each sub centre in Form SC-1
• Plan for conducting house to house survey for each Sub centre/ ANM area
• Timeline for conducting the house-to-house survey / head counting

Preparation for the review meeting

The ANM should work with ASHAs and AWWs of her area to generate the village list for her
SC/ ANM area. Use the following sources of information for listing of areas and beneficiaries
(Medical officer has to ensure all the sources are available).

Table 5.2 Sources of information for listing of areas and beneficiaries

Information / Sources of information
Data
Geographic List and map of all villages including hamlets, all urban area, wards,
mohallas, HRAs, etc.
Sources: Health, Revenue, ICDS departments., Urban local bodies, slum
boards, Swachh Bharat Mission, etc.

43
 Demographic Total population (Census/ revenue records) and number of target
beneficiaries –head count survey, ANC registration, Expected Level of
Achievement (ELA), target given by district/ block
ICDS survey data of 0 -6 years children and pregnant women registers,
etc.
Programmatic Latest microplans of RI, Polio, MR campaign, Intensified Mission
Indradhanush, VHSND/ UHND microplans
Administrative Human resource available and vacancy status
Epidemiologic VPD surveillance and outbreak data
Stakeholders ICDS, Education and other line departments
Community representatives, Local Influencers, Local practitioners,
NGOs, Development partners, etc.
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Plan to address few important questions which are given below:

 Are all areas identified and included in  Where are the hard-to-reach populations?
the SC/ ANM area plan? o Low coverage areas
 Are there areas/villages with large o Accessibility compromised areas
population?  Are there problems with access to
 Border/peri-urban areas, new immunization services?
settlements, unauthorized colonies? o Catchment area with Penta 1 coverage
 Where are the unreached populations? of < 90%
o Areas with highest number of o Catchment areas with Penta 3 / MR 2 is
unimmunized children <90%
o Areas with mobile/migrant  Where is utilization of services low?
populations o Areas with dropouts >10%
o Construction sites o Areas needing flexible timing? (Eg.
o Areas with resistance, vaccine Urban areas, harvest season, etc.)
hesitancy, vaccine avoidance
behaviour
Overview of RI microplanning formats:
A set of formats for RI microplanning at SC/ ANM area level are explained in Table 5.3.
Table 5.3. RI microplanning formats and utility
RI Forms Form No. Utility
MASTER LIST AND SC-1 Master list of all villages and their hamlets, tolas;
MAPPING FORMS Urban/peri-urban areas and their wards/sub wards/
to be filled by ANM mohallas; HRAs (migratory and non-migratory
with support of ASHAs/ settlements in each sub centre / ANM area
AWWs/ other mobilizers SC-2 Sub centre / ANM area map

44
HEAD COUNT SURVEY SC-3 Provides total number of households and target
FORMS beneficiaries’ - pregnant women and all children in the
to be filled by surveyor age group of 0 to 2 years, 2-5 years (Children who have
(ASHA, AWWs, Link missed MR 1, MR2, DPT, OPV and JE vaccines) in the
worker, other surveyors area
SC-4A List of pregnant women - vaccination status and ANC
visits
SC-4B List of children upto 2 years including new borns with
vaccination status
SC-4C List of children b/w 2-5 missed for due vaccine doses
(Children who have missed MR 1, MR2, DPT, OPV and
JE vaccine)
SUB CENTRE SC-5 RI session beneficiary due list (which gets updated
PLANNING FORMS after each session)

ROUTINE IMMUNIZATION MICROPLANNING

to be filled by ANM SC-6 RI session plan
SC-7 Injection load and vaccine distribution plan
SC-8 Estimation of vaccines and logistics
SC-9 ANM work plan / roster
SC-10 Communication plan

1. Master list of all areas and head count survey planning in Sub-centre / ANM area (Form
SC-1)

Master list of Sub-centre / ANM area and head count survey planning is the most important
step in preparation of RI microplan. Form SC-1 is to be used by the ANM to list the areas in the
sub centre / ANM area including HRAs in separate rows. This activity needs coordination with
ASHA / AWW or Community representatives (Panchayat Raj Institution (PRI)/ ward members,
religious leaders, etc.) and local influencers and also by referring to the sources of information
available in table no.5.2. The names of local influencers with their phone number should be
noted down area wise. (Refer SOPs for details).

45
 ROUTINE IMMUNIZATION MICROPLANNING

Fig. no. 5.4: Sub-center/ANM Area Master List and Survey Planning Form: SC-1 (Refer Annexure 2.1)

46
SOP for filling Form SC-1(refer fig no. 5.4):
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/ ANM area. If the areas per sub-centre/ ANM
area need to be entered on more than one sheet, the numbering will continue until the last
area for that sub-centre/ ANM area.

Column B- Ensure all the Villages / Hamlets / Tolas / High Risk Areas (HRAs) details are
entered. The classification of the HRAs is mentioned at the bottom of format, relevant number
to be entered in brackets along with the name of HRA.

o 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

ROUTINE IMMUNIZATION MICROPLANNING

each sub centre/ ANM area. This is a critical step in preparation of microplan. Update
this format as information is received or every quarter

Column C – Enter the number of households 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 “Y”.

Column E, Mention the HRA code mentioned below the format. The different types of HRA
code: 1 = Slums with migration; 2 = Nomads; 3 - Brick kiln; 4 - Construction site; 5 - Other
migratory high-risk areas (fishermen villages, riverine areas with shifting populations,
migrants in tea/coffee estates, etc.); 6A- Settled Slums (notified & non-notified); 6B- Hard to
Reach Area; 6C- Areas under Vacant / temporarily vacant (More than 3 months) sub centres;
6D- Areas with Measles/Rubella outbreaks or cases of Diphtheria, Pertussis, Neonatal tetanus
in last 3 years; 6E-Areas with vaccine hesitancy/ refusal; 6F-Other settled high-risk areas.

Column F, Enter the name of the ASHA / AWW/ mobilizer responsible for the area.

Column G, 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 should be entered.

Column H, Designation of the surveyor has to be entered. Survey can be done by the
local AWW / link worker / others in consultation with the Medical Officer (MO) ONLY after
undergoing training.

Column I, Surveyor should complete 25-30 households in an ideal rural area; in urban and
densely populated areas the number may be more; fewer houses to be covered in remote
hard to reach areas. The area survey is to be completed as mentioned in Gantt chart (Refer
Fig. No. 5.3). 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 survey starts and end
dates are to be entered here.

Column J, mention the name and contact number of local influencers of each of the areas
enlisted

47
 Columns K-R, The last shaded columns are for use by the ANM incharge AFTER the survey
to enter total population, number of beneficiaries.

After survey, total number of all beneficiaries- pregnant women, children between 0-2
years and children between 2-5 years with missed MR1, MR2, DPT, JE & OPV doses are to
be documented in Form SC-1.

2. Sub-centre / ANM area map (Form SC-2)

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. The maps should be able to
show at least the following:

• Names of all the villages/hamlets/mohalla in the area

ROUTINE IMMUNIZATION MICROPLANNING

• Shading of parts of a village/area to demarcate the ASHAs areas

• Location of the SC/PHC/UPHC and cold-chain point
• Location of all RI session sites
• Location of cold-chain point
• Major roads
• Rivers streams/Hilly area
• High Risk areas
• AEFI management center
• Private health sector providing vaccination (in urban areas)

Purpose of maps is to
• understand the actual geography of the sub centre/ ANM area. Maps of all the subcentres/
ANM areas put together should reflect the entire catchment area of the PHC/ UPHC
• clearly demarcate the villages/ urban localities for implementing RI services and avoid
overlap/ confusion of areas
• guide health workers to reach all beneficiaries and type of session suitable for each village
or urban area

Preparation of maps:
To prepare good maps, the health worker may refer the already existing maps available from
the previous microplan. For this purpose, the health worker may also refer other sources of
information like:
• Polio, MR or other vaccination campaign microplan maps
• Maps from local administration, e.g. municipal corporation, land department, election
commission, local panchayat, etc.
• google maps (Ref. Fig no.5.7)
• Local area maps from any other sources

Plan for walk through of areas to ensure clear area demarcation to ensure the border areas
included in the respective subcenter/ ANM area

48
 Fig. No. 5.5: Sub Center / ANM Area Map Form SC-2 (refer annexure 2.2):
Sub centre / ANM area map Form SC-2

District/ Corporation: ________________ Block/Urban area: ________________ PHC/ UPHC: ______________ Sub-centre/ANM area:___________

SUB CENTRESub-centre
MAP Map showing Sub-Centers/ANM area, Session sites, AVD, High Risk areas & AEFI management center LEGEND
RI Form 2
PHC/UPHC

ASHA Y SUB CENTRE

VILLAGES HQ

ROAD
Village A
RAILWAY LINE

Village A RIVER

River LAKE / POND

Village C Village B
RI session site RI

Private RI Session P

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Religious place P
Village F
Village D School S
AEFI management centre

PHC HRAs 1-5 & 6A-6F

Village E
Tola E1
OTHERS

Tola E2
Signature of ANM_______________________ Signature of Medical Officer:_____________________

Signature of ANM Signature of MO

Fig.No.5.6: Sample map showing area demarcation in rural area:

49
 Fig.No.5.7: Sample map showing area demarcation in urban area:
ROUTINE IMMUNIZATION MICROPLANNING

Fig.No.5.8: Sample map showing area demarcation in urban area with mapping of
session sites – fixed, outreach and private vaccination centres

50
 Head count survey planning and training of surveyors
Step-2 (ASHA/AWW/Link worker/other surveyor)

Purpose: ANM to guide the ASHAs and AWWs of the area to conduct the head count survey to
effectively identify all beneficiaries in the community.

Fig. 5.9. Sub centre/ ANM area survey planning meeting– personnel and activities

ASHA
ACTIVITIES
AWW SC survey • Area listing
planning • Area demarcation
meeting • Training

ROUTINE IMMUNIZATION MICROPLANNING

Link
• Walk through
Worker/Surveyor
• Head count/survey

Key components of this training are:

• Review area demarcation and assign the areas from master list to carryout head count
survey
• create working maps for each area including map for vacant ANM areas also
• Training of surveyors to undertake head count and prepare beneficiary list

Venue:
• At PHC/UPHC for 2 to 3 Sub centres/ ANM areas in batches (about 15 to 20 ASHA/AWW/Link
workers in each batch), OR
• At the Sub centre/ ANM area

Responsibility: Medical officer or Health supervisor/ LHV

Participants for this training: ANM, ICDS supervisor, ASHAs, ASHA facilitator, AWWs, Link
Workers, other mobilizers

Preparations for head count survey-planning meeting

• Surveyors should bring the information on list of villages/ urban localities including HRAs
with number of households and population of their area
• Encourage surveyors to identify any new areas that may not have been included or any
new migratory HRAs
• Cross check and make corrections in the master list, if any
• plan logistics for survey – adequate number of formats (Forms SC-3,4A,4B, 4C); chalk for
house marking

On meeting day
The MO/ health supervisor needs to discuss the status of RI coverage and challenges in
their area and explain the importance of RI microplanning.

51
 Agenda/ Discussion points:
a) Area demarcation between ASHA, AWW, link worker:
o Ask each ASHA/link worker to readout the list of villages/urban areas in her area. Cross
check with the list available with AWWs. In urban areas, discuss with MAS, community
representatives, local influencers and others for listing of areas
ANM to identify areas requiring a walk-through to verify demarcation and inclusion of
all HRAs in the list
o ANM to finalize the surveyors (ASHAs, AWWs, Link workers and others) for head count
survey and fix the dates (exclude RI days) as per the workload for completing the
survey (25 to 30 households per day) for ensuring quality. Refer to Polio house to
house microplans for this survey
o Distribute copies of Forms SC-3, 4A ,4B and 4C to each ASHA/AWW/ Surveyor. Explain
the process (use SOPs of each form)
b) Create a simple map for each area before the head count survey: During the survey,
ROUTINE IMMUNIZATION MICROPLANNING

details may be added to this map

c) Plan for walk through of areas to ensure clear area demarcation/HRA identification:
o MO/Supervisor/ ANM should visit and walk-through high priory areas, urban, periurban
and border areas for demarcation with support from other line department officials,
community representatives, local influencers, etc.
d) Prepare a plan to monitor the head count survey

Outputs expected:
o Completeness of master list of areas and survey planning form (Form SC-1)
o Simple area maps for each survey area

Roles and responsibilities:

Personnel Activities to be performed Supervisor
ANM • Area demarcation for ASHAs/AWWs Sector
• Develop a reasonable timeline for survey MO/LHV/
• Will support the ASHA/AWW for survey designated
• Supervise the survey with field visits ANM/ CHO
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 most important step of RI microplanning
process. The objective of the headcount survey is to reach the entire population and list out
all target beneficiaries (pregnant women, children 0-2 years and children between 2-5 years
missed the due vaccines/ doses of MR, OPV, DPT including boosters). It has to be conducted
by trained ASHA/AWW/Link worker/surveyor. This activity should be monitored to ensure
quality and completeness.

52
Key activities to be conducted:
The key activities to be conducted are as follows:

Preparations for head count survey:

o ANM should ensure that the trained surveyors conduct the survey and necessary logistics
like forms, map, chalks etc are available
o All queries raised by surveyors must be answered clearly; they must be motivated to visit
all the areas and NOT to leave out any beneficiary during the HCS
o ANM should take support from community representatives (PRI/ ward members, etc.),
other influencers before the survey and support the surveyors

During the survey Target beneficiaries: pregnant women

o A maximum of 25 to 30 households should be and newborns (0-1 month); children 1

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covered per day in an ideal rural areas; in urban -11 months; 1-2 years; children between
and densely populated areas the number may be 2-5 years who have missed the due
more; fewer houses to be covered in remote hard vaccination doses
to reach areas
o cover all the households in the area in a “A household is defined on the basis of
systematic way. Refer Polio house to house “Kitchen“or “Chullah” (like if a family
microplan for assistance, if needed has brothers living in one house but
has separate chulla, then house hold
At each house: marking has to be based on chullas just
like in polio microplans)
o Greet the family and explain the purpose of visit
o document the details of first house owner and
last house owner for the day
o information of ALL households to be entered in house-to-house survey form (Form SC-3)
o If the team identifies target beneficiries, their details with vaccination status (as per
MCP/ RI card) is entered in the relevant form as per table 5.4.

Table. No. 5.4: House to house survey forms used by surveyor:

House to house Target beneficiary details & completeness of Head Count survey
survey forms
SC-4A List of pregnant women - vaccination status and ANC visits
SC-4B List of children upto 2 years including newborn with vaccination status
SC-4C List of children between 2-5 years who have missed due vaccine doses
of MR, DPT or booster doses

House marking should be done with chalk/geru indicating the serial No of the household and
date of survey, as shown in Fig. 5.10

53
 Fig. 5.10. House marking during house-to-house survey for RI

Household number
RI-15
Arrow indicating survey
12-02-2024 team movement
Date of head count
survey
This survey should not be done on RI days and may be completed in 7 to 10 days.

Fig.5.11. Flow chart of Head count survey documentation in formats

ROUTINE IMMUNIZATION MICROPLANNING

Pregnant women Pregnant women

(Full/partial/unvaccinated) Survey listing form-4A

Children 0-5 years

& Children 0-2 years Children Survey listing
Pregnant women in (Full/partial/unvaccinated) form-4B
form-3

Children b/w 2-5 years Children b/w 2-5 years with

(Partial/unvaccinated) missed vaccination Survey
listing form 4C

Supervision:
o ANM, supervisors, field monitor should visit 5 households in the area to ensure quality
and completeness of survey. (Ref. template for validation of head count survey)

Outputs expected:
o Completion of house-to-house survey in all the areas
o Enlisting all target beneficiaries residing in the area

Roles and responsibilities:

Personnel Activities to be performed Supervisor
ANM • Area demarcation for ASHAs/AWWs MO/LHV/
• Develop a timeline for survey Health
• Facilitate ASHA/AWW/ Link worker/ other surveyor for supervisor
survey
• Supervise and validate head count survey with field visits
ASHA, Link • Conduct survey and fill Forms SC-3, 4A, 4B, 4C ANM/ASHA
worker, MAS, • Identify beneficiaries/HRAs/missed areas/ dropouts/left facilitator
others outs
AWW • Conduct survey and fill Forms SC-3,4A, 4B, 4C ANM/
• Identify beneficiaries/HRAs/missed areas/ dropouts/left LHV/ ICDS
outs supervisor

54
 Fig.no. 5.12: House to house survey form: Form SC-3 (Refer Annexure 2.3)

Fig. no. 5.13: Head count survey of pregnant women: Form SC-4A (Refer Annexure 2.4)

55
ROUTINE IMMUNIZATION MICROPLANNING
 SOPs for filling Form SC-3:
Each household is to be identified by a number (Column A). This is the household
identification number.
o The numbering of households is to be continuous until the area is completed
o 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

o Restart of numbering will be done when a new area is being assessed by the same person.
o House marking should be done with chalk/geru indicating the serial No of the
household and date of survey, as shown in Fig. 5.10.
o Interview each household and gather information on the head of household (Column
B), name of father/ mother to be included in column C, any contact number in column
D and the total number of members in each household (Column E). This must include
all newborn children
ROUTINE IMMUNIZATION MICROPLANNING

o 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, mention number (Column F) and collect information on
the pregnant woman and enter in Form 4A

o Similarly for Columns G, H, I, J & K enquire if there is:

o Newborn child or child up to 1 month of age, mention the number in Column G
o Child/ children between 1 month and 1 year of age, mention the number in Column H
o Child/ children between 1 and 2 years of age, mention the number in Column I
o Child/ children between 2 and 5 years of age, mention the number in Column J
o Missed child/ children between 2 and 5 years of age, mention the number in Column K
o If a child/ children is identified in any of these columns, mention the number and
enter information on the newborn/infant/child in Form 4B and children who have
missed MR-1/ MR-2/ DPT/ OPV/ JE including boosters in SC-4C

SOP for filling RI Form SC-4A: Head Count Survey of Pregnant Women
Form SC-4A has to be filled when a pregnant woman is identified in Form SC-3 Column F.
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 pregnant woman in a house, the same number will have to be
entered for each of these Pregnant women in separate rows. 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 registered in U-WIN. If she has MCP card or U-WIN reference ID, enter card
number or U-WIN number in column F. 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. Also, if U-WIN
reference ID is not available with the beneficiary, efforts should be made to check for
U-WIN registration. If not registered, efforts should be made to register the pregnant
woman in U-WIN.

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

56
 can consult ANM who can refer to the EDD ready reckoner from RCH register/ training
manual).

The administration of Td 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 Td 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 Td injections and ANC check-ups should ideally be obtained

ROUTINE IMMUNIZATION MICROPLANNING

from the RI/MCP card.

SOP for filling form 4B:

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, E and F. These columns are used to collect identification information of

each child. Attempt to collect the latest mobile number from the parent/household.

Column G and H - Enquire if the infant/child has been issued an RI/MCP card. If the child has
MCP card or U-WIN reference ID, enter card number or U-WIN number in column G. If MCP
card not available, information should be shared with the ANM of the area to ensure
that a card is issued at the earliest. Also, if U-WIN reference ID is not available with the
beneficiary, efforts should be made to check for U-WIN registration. If not registered,
efforts should be made to register the child in U-WIN.

Column H- This records detail of vaccines administered at birth. Dates of administration of

BCG, bOPV birth dose and Hepatitis B (within 24 h) are to be mentioned

Column I- Dates of administration of Penta 1, Rotavirus 1 (where applicable), PCV 1 (where

applicable), fIPV 1 and bOPV 1

Column J- Dates of administration of Penta 2, Rotavirus 2 (where applicable) and bOPV 2

Column K- Dates of administration of Penta 3, Rotavirus 3 (where applicable), PCV 2 (where

applicable), fIPV 3, and bOPV3

Column L- Enter the dates of administration of vaccines due between the age of 9 – 11
months– MR first dose, Vitamin A, PCV Booster (where applicable), fIPV 3 and JE (where
applicable) vaccines

Column M- Record whether the child is fully immunized – encircle “Yes” or “No”. A child is to
be considered as fully immunized plus (FIC plus) if s/he has received all due vaccines up to 1
year of age.

57
 Column N- Dates of administration of vaccines due for a child between the ages of 1 and 2
years are to be entered in column O. This includes MR 2, DPT-1 booster, bOPV booster dose
and JE 2 vaccine (where applicable).

Column O- Record whether the child 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.

RI Form 4C–List of children between 2-5 years missed for MR/DPT/Penta/ OPV doses
This form collates the information of list of children between 2-5 years missed for MR/DPT/
Penta/ OPV doses identified during the house-to-house survey.

SOP for filling form 4C:

Column A. The number in Column A must be the same as that used to identify the household
ROUTINE IMMUNIZATION MICROPLANNING

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, E and F. These columns are used to collect identification information of

each missed child. Attempt to collect the latest mobile number from the parent/household.

Column G - Enquire if the infant/child has been issued an RI/MCP card or have U-WIN
reference ID. If the child has MCP card or U-WIN reference ID, enter card number or U-WIN
number in column G.

If MCP card not available, information should be shared with the ANM of the area to
ensure that a card is issued at the earliest. Also, if U-WIN reference ID is not available
with the beneficiary, efforts should be ensured to check for U-WIN registration. If not
registered, efforts should be made to register the child in U-WIN.

Columns H to Q - These columns are used to collect information on MISSED VACCINE

DOSE/ DOSES for MR/ OPV/Penta/ DPT doses. Encircle ‘Y’, if the child has MISSED the
vaccine and ‘N’, if the child has RECIEVED the vaccine.

Columns R to AA - These columns are used to TRACK THE VACCINATION STATUS OF

MISSED CHILDREN. The missed children found during head count survey are mobilized
to RI session for vaccination of missed dose/s. After vaccination, the date of vaccination
of the missed dose/s is/ are to be updated in the columns (R to AA) as per vaccine dose
received.

The details about registration of beneficiaries in U-WIN is mentioned in a separate unit no. 13.
Validation of head count survey:

58
 The assigned supervisor will cross check 5 houses and provide hands on training to rectify issues observed during head count survey. The
head count survey validation format is placed in annexure.

Fig. no. 5.14: Head count survey of children (0-2 years): Form SC-4B (Refer Annexure 2.5)
Booster and 2nd doses
Vaccines at 6 Vaccines at Vaccines at 14 Vaccines at 9 to 11
Vaccines at birth of vaccines at 16 to 23
weeks 10 weeks weeks months of age
MCP months of age
House Date of Age in Name of the Child is Child is
card
No as Name of Birth months Gender: mother/ father/ Fully completely
number bOP Hepat
in the child dd/mm (comple M / F Gaurdian with immunized immunize
/ UWIN V- itis B
Form 3 /yy ted) mobile number (FIC Plus) d

fIPV3
MR 1
MR 2

RVV1
PCV 1
PCV 2

f IPV1
RVV 2
RVV 3
fIPV 2
ref ID Birth BCG Birth

bOPV1
bOPV 2
bOPV 3
Penta 2
Penta 3

Penta-1
Vitamin A 1
Vitamin A 2

PCV Booster
dose dose
bOPV Booster
DPT Booster 1

JE 1 (elligible dists)
JE 2 (elligible dists)

A B C D E F G H I J K L M N O
Date / Y/N Date / Y/N Date / Y/N Date / Y/N Date / Y/N Y/N Date / Y/N Y/N
__ /__
M/F
/__

Fig. no. 5.15. Enlistment and tracking of children between 2-5 years missed for MR/DPT/OPV/ booster doses: Form SC-4C (refer
annexure 2.6)

59
ROUTINE IMMUNIZATION MICROPLANNING
 Fig. no. 5.16: Template for Validation of Head Count Survey (HCS) Routine Immunization
Template for Validation of Head Count Survey (HCS) Routine Immunization 2024
Date: _ _ / _ _ / _ _ State/UT: ……………….…….……. District: …………..……………….. Block/ Urban area: ………………….……..……… CHC/PHC/UPHC/Others: ……………………….……….
Name of Planning unit: ………………………….. Subcenter/ ANM area:……………………. Village/ Ward/ Mohalla: …………………… Setting: Urban / Rural, If Urban, NUHM City: Yes/ No;
Name of ANM/ Vaccinator…………..……………. Name of Monitor: …………………………………………….; Organization: Govt / WHO / UNICEF / JSI / CHAI / Others (specify): …………….…;
Designation: ……………………..……;
Is head count survey (HCS) conducted in this area (as per survey plan): Yes / No: if No - inform MoIC, proceed to another area as per validation plan.

Monitor to visit 5 households (HH) with at least one child due for at least one due vaccine and/or a pregnant woman and interact to elicit response. Select HH should
represent the area. Find out from caregivers if surveyor/team has visited for HCS. Meet surveyor and validate the data in HCS format. Ensure data entry in ODK tool same day.

No. Monitoring and validation details: HH-1 HH-2 HH-3 HH-4 HH-5
a. Ask family member if surveyor/team visited HH for HCS? Yes / No Yes / No Yes / No Yes / No Yes / No
1 b. If visited, date surveyor visited this HH (from wall / family member, else NA) __ / __/ __ / NA __ / __/ __; UM __ / __/ __; UM __ / __/ __; UM __ / __/ __; UM

c. No. marked for this HH (From wall of HH / else consider unmarked HH (UM) ______ / UM ______ / UM ______ / UM ______ / UM ______ / UM

a. Name of the head of family

2
b. Mobile/landline contact number
a. Is there a pregnant woman found in this HH? (Select only 1 if >1)? Y/N Y/N Y/N Y/N Y/N
Pregnant
woman
ROUTINE IMMUNIZATION MICROPLANNING

3 b. Name of the pregnant woman

c. Is this PW identified in HCS Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA
a. No. of children found in this HH by monitor as on day of HCS?
b. No. of children found due for any vaccine dose as on day of HCS
c. Name(s) of children due for any vaccine (b) to validate with HCS format
Children <1 year
(0-11 months)

d. No. of children due for any vaccine but missed (c) in HCS format

4 e. Name(s) of children due for any vaccine but missed (d) in HCS format
f. No. of children 2-11 months due for Penta-1 as on day of HCS
g. Name(s) of children (f) due for Penta-1 for validation with HCS format
h. No. of children due for Penta-1 but missed (g) in HCS format
i. Name(s) of children (h) due for Penta-1 missed in HCS format
No. Monitoring and validation details: HH-1 HH-2 HH-3 HH-4 HH-5
a. No. of children (12-23 months) in this HH as on day of HCS
b. No. of children who have not received Pentavalent-1 within 1st year of
age (Zero dose) as on day of HCS
Children 1-2 years (12-23 months)

(Even if the child

c. Name(s) has received
of ZERO DPT1) (b) to validate with HCS format
dose children
d. No. of children due (c) for DPT-1
e. Name(s) of children (d) due for DPT-1 to validate with HCS format

5 f. No. of children (e) due for DPT1 but missed in HCS format
g. Name(s) of children (f) due for DPT-1 but missed in HCS format
h. No. of children (16-23 M) found due for DPT booster-1 as on day of HCS
i. Name(s) of children due for DPT booster-1 (h) to validate with HCS
format
j. No. of children due for DPT booster-1 (i) but missed in HCS format
k. Name(s) of children due for DPT booster-1 (j) but missed in HCS format
a. No. of children found in this HH by monitor as on day of HCS
Children 2-5

MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2:
b. No. of children found due for MR-1/MR2 as on day of HCS
months)
(24-59
years

6 MR1: MR1: MR1: MR1: MR1:

c. Name(s) of children due (b) for MR1/MR2 MR2: MR2: MR2: MR2: MR2:

MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2:
d. No. of children due (c) for MR1/MR2 but missed in HCS
7 Refusal Has this child missed any due dose due to refusal / AEFI apprehension? Yes / No Yes / No Yes / No Yes / No Yes / No
Interaction with the surveyor/team: Met surveyor/team? Yes / No (If no – skip Q 8- a, b, c and d)
a. Who has done HCS? ASHA / AWW / ANM / Link worker / Others
b. Did the surveyor receive training prior to HCS? Yes / No
8
c. No. of houses planned by the team per day: i) less than 25 ii) 25-50 iii) 50 - 100 iv) ≥ 100
d. Has the surveyor (team)` used standardized HCS format? Yes / No

Assessment by the monitor:

a. Has surveyor missed children due for one or more vaccines in ≥2 HH? Y / N / NA (if not met with surveyor/team)
9
b. No. of cluster of ≥3 consecutive HH not visited by surveyor/team (within 5 HH monitored and in the area while walk through)? _______
Recommend repeat survey if: 1). ≥ 3 consecutive HH not visited for survey AND/OR 2). ≥ 2 HH have missed children due for any due vaccine dose(s) in survey

60
 Review of all survey forms and consolidation of sub
Step-4 centre/ ANM area microplans
2024:

Each ASHA/AWW/LW/surveyor should submit the complete list of beneficiaries in the relevant
forms (Forms SC-3, 4A, 4B and 4C) to the respective ANM after completing the head count
survey.

ANM should plan for a meeting of all the surveyors to review the forms. The meeting venue,
date and time should be communicated to all surveyors at least 2–3 days in advance so that
they attend the meeting with completed survey forms.

Facilitator: Sector MO/LHV/health supervisor/ CHO

Participants: ASHA/AWW/surveyor with ASHA facilitator, LHV/LS

ROUTINE IMMUNIZATION MICROPLANNING

Key activities to be conducted during this step:
• RI microplans are reviewed and updated as per actual head counts of target beneficiaries
and identification of any missed (migratory/ settled) pockets including HRAs in sub
centre/ ANM area
• Clearly demarcated maps with HRAs included
• RI sessions planned as per the injection load and community needs. All areas including
HRAs should be tagged to sessions
• Vaccine and logistic estimation and distribution plan should be finalized
• Communication plan should be finalized

During the meeting

• ANM should review the information collected during the house-to-house survey in Forms
SC-3, 4A, 4B, 4C with the ASHA/AWW/link workers/surveyor
• A simple map of the SC/ ANM area 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 update the RI session
plans to address the following issues:
• Are the number of sessions presently sufficient? In urban / periurban / slum areas, the
• Are all the areas covered? health workers should be vigilant for
• Are the migrants/HRAs identified? If so, are migrated population and enlist the
RI sessions being conducted for these mobile beneficiaries and if new settlements
populations? are found include in the microplan

Session due list (Form SC-5) –With the information gathered in Form 4A, 4B and 4C, it is
now possible to correctly quantify the number of beneficiaries.

Outputs expected
• Completed head count survey form (Form SC-3) for each area
• Completed Beneficiary list of pregnant women and children 0-2 years Forms SC-4A and
4B beneficiary list respectively and Form 4C –missed children 2-5 years as per ASHA/areas
identified
• Clearly demarcated maps with HRAs identified

After the review of all survey forms, ANM should

• plan for RI sessions as per the injection load and community needs

61
 • Vaccine and logistic estimation
• Vaccine distribution plan
• Communication plan

Roles and responsibilities

Personnel Activities to be performed Supervisor
ANM o Conduct the meeting at SC/ ANM area MOIC, Sector
o Finalize area listing and draft of plan for con-ducting RI MO
sessions in the areas
ASHA o Contribute to final forms SC ANM/ASHA
facilitator
AWW o Contribute to final forms SC ANM/LS
ROUTINE IMMUNIZATION MICROPLANNING

An overview of RI Forms 5 to 10 used in the SC/ ANM area RI microplan is given in Fig. 5.17.

Fig. 5.17. Overview of Sub Centre RI Microplan – Forms SC-5 to 10

RI Form SC-5 Per session due list Update after each RI session

Number of beneficiaries Calculation of Deciding number

RI Form SC-6
from actual head count injection load of RI sessions
Deciding location
RI Form SC-7 RI session plan of RI sessions Vaccine distribution plan

RI Form SC-8 Per session estimation of vaccines and logistics

RI Form SC-9 ANM workplan

RI Form SC-10 Communication plan

RI session beneficiary due list (Form SC-5)

Purpose:
• This form is prepared by ANM to enlist the beneficiaries due for vaccination and utilized by
ASHA/ mobilizers for mobilization of due beneficiaries to RI session/s
• This is also a record of payment of ASHA incentives for mobilization of beneficiaries – full
and complete immunization
• The visitors and guest children, pregnant women who have come to mother’s place and
are due for vaccine/s should be identified, included in the duelist and vaccinated. Health
workers should be very vigilant in urban / periurban areas for tenants and in slum areas for
the migrant beneficiaries to be included in the due list for vaccination

Responsibility: This format is to be prepared by the ANM with the support of ASHAs/AWWs/
LWs after the proposed microplan is approved by the medical officer.

62
 Fig. no. 5.18: RI session beneficiary due list: Form SC-5 (refer annexure 2.7)

63
Fig.5.19: Utilization of session due list for RI sessions:

ROUTINE IMMUNIZATION MICROPLANNING

 Utilization of session due list for RI sessions:
This format is to be used in triplicate (in different colours), one copy each for
• ASHA/ AWWs/ Link workers/ other mobilizer – for mobilization of beneficiaries to session
site
• ANM – to plan the session
• Pharmacist/ Cold-chain handler of PHC/UPHC – to plan for vaccine and logistics distribution.

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.

SOP for filling Form SC-5: RI session due list

Column A: The serial number for each beneficiary is to be entered here.
ROUTINE IMMUNIZATION MICROPLANNING

Column B: MCP 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. Enter U-WIN registration number if available.

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 completed months or age of pregnant woman in
completed years and months.

Column F: Enter the gender of the child.

Column G: Enter the name of the father or husband for easy identification at the village level
along with contact number.

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: If column I is “Yes”, vaccines administered on the day of vaccination to pregnant

woman / child should be mentioned in column J.

Column K: If column I is “No” i.e if the beneficiary has not received vaccine on the day of
vaccination, specify the reason (R1=Beneficiary out of Village/ House locked; R2= Beneficiary
sick; R3= Refusal; R4= Vaccinated outside; R5=AEFI apprehension; R6=Other reason) for not
vaccination in column K.

Column L & M: If the beneficiary receives the vaccine/s, the next due date and next due
vaccines are entered in column L & M respectively.

Column N, O & P: These are to be filled as and when ASHA receives her payments.

64
RI session planning (Form SC-6)

The area wise, actual number of pregnant women and children (infants, 1-2 years and children
2-5 years missed the RI dose) are obtained from Head count survey form (Form 3). From this,
the annual and monthly target beneficiaries of pregnant women and infants (0-1 years) are
utilized for planning RI sessions, estimation of vaccine and logistics as subsequent steps. The
calculations are as below

Calculation of target beneficiaries: annual and monthly target

Annual target:
Annual target of PW = Actual number of PW as per head count survey X 2
Annual target of infants = actual number of infants (0-1 yrs) as per head count survey

Monthly Target:

ROUTINE IMMUNIZATION MICROPLANNING

Monthly target of PW = Annual target pregnant women divided by 12
Monthly target of children = Annual infant target divided by 12

Calculating injection load (for determining the frequency of RI sessions)

This calculation is to be used only as a planning tool for session frequency and not for
estimation of vaccines or logistics.

Firstly, the total number of injections needed per beneficiary are determined. This gives a
multiplying factor of 14 for an infant and 2 for a pregnant woman.

For a child:
• BCG – 1 injection
• Pentavalent – 3 injections
• fIPV – 3 injections
• MR Vaccine – 2 injections
• PCV – 3 injections
• DPT – 2 booster injections

For a pregnant woman:

• Td– 2 injections (for pregnant women)

For districts where JE vaccine is included in the RI schedule add 2 to the above number,
giving the multiplying factor of 16 for an infant and 2 for a pregnant woman.

Injection load:
In non-JE district: Injection load = (Monthly PW x 2) + (Monthly infant x 14)
In JE district: Injection load = (Monthly PW x 2) + (Monthly infant x 16)

65
 Note:
Annual Target of Infants = Actual number of Infants as per head count
Annual target of PW = Actual number of PW as per head count x 2
Monthly target = Annual target/ 12 (Keep it as fraction)

Monthly Injection Load calculation:

• For JE districts = {{Monthly Infant target x 16) + (Monthly PW target x 2)}
• For Non-JE districts = {(Monthly infant target x 14) + (Monthly PW target x 2)}

Note: Round off all numbers in injection load to next higher I,umber

PW found in Head count survey are representative of almost half year pregnancy, as it usually
becomes visible during second trimester onwards, hence for annual target calculation, it must
be multiplied by 2.
ROUTINE IMMUNIZATION MICROPLANNING

Planning frequency of RI sessions based on injection load:

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 outreach 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 very hard-to-reach areas with small population, plan for at least one session every
quarter for a minimum of 4 sessions a year

In bigger institutes like medical colleges, ESI hospitals, CGHS hospitals, Railway, Army hospitals,
District hospitals or equivalent hospitals, etc. can have daily RI sessions based on footfall.

Fig. no. 5.20: Sub-center/ ANM area – RI sessions plan: SC-6 (Refer annexure 2.8)
Beneficiary Targets
Name of Villages / Wards /
Type of
Mohallas / Hamlets / Tolas Total Annual Target
area / Type of
/ HRAs# Population (PW = Actual
Monthly Name of the mobilizer terrain - Session -
(From form SC-1) of Area Head count X2 Number of Name and location of the
S.No Monthly Target Injection with designation and plain / Fixed /
New areas /identified (Total of , Infants ₤ Sessions $ Session site / sites
Load mob.no. hilly / outreach/
missed areas should be form 3 =Actual Head
riverine/ mobile
entered marking with Column E) count)
tribal area
asterisk(*)
PW Infants PW Infants

F G
A B C D E H I J K L M
(D/12) (E/12)

SOP for filling Form SC-6: RI session plan

Enter the serial number and name of the villages in Columns A and B, keeping the same
order as in Form SC-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 SC-3 Column E (Total), the individual areas actual population (from the survey)
should be entered into Column C.

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

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 area and house to house survey. Once the survey is completed, these figures will be available
from Form SC-3.

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 is of annual target of infants = actual number of infants
identified during the area assessment.
For columns F and G

Monthly target of PW = Annual target divided by 12

Monthly target of children = Annual target divided by 12

Column H: Enter the monthly injection load for each area. For calculation of injection load (only

ROUTINE IMMUNIZATION MICROPLANNING

for determining the number of sessions) refer above.

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 above.

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/ ANM area.
Mobilizers play an important role in mobilizing beneficiaries to the RI session site. The name
of the mobilizer with designation and contact number are 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/ UPHC/ 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.

Planning RI session site and timing:

Majority of the sessions are planned in the subcentre or Health and wellness centre. However,
it is crucial to identify other sites in an area to meet the following criteria:
• monthly injection load of the area,
• community needs and demands (Demand driven)
• easy access to the target beneficiaries
• acceptance to the community and as per their time and day
• visibility of the site to the people

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 Planning RI session based on community needs:

It is important to note that, the community needs, and demands are to be considered for
planning sessions. The steps to provide demand driven vaccination sessions are mentioned
below.

Vaccination on demand strategy:

The demand driven vaccination sessions can be planned in any area as per need of the
population.

Step-1: Identification of influencers:

Identify the influencers in the catchment area and arrange a meeting. Influencers will help
in identification of day, time and venue for vaccination. Influencers can be gram pradhan,
ROUTINE IMMUNIZATION MICROPLANNING

community or religious leaders, teachers, NGO members, Resident Welfare Association (RWA)
or ward members, counsellors, village elders in tribal areas, etc.

Step-2: Identify venue and time:

Identify suitable venue, day and time for conducting sessions. Efforts should be made to scale
up the community ownership for mobilization. If the sessions are already being conducted
and are not suitable/acceptable to the community, make required modifications.

It is important to ensure that services meet the needs of the population and should be offered
at the appropriate locations and times. Vaccination should be promoted with the help of
locally available communication means so as to reach all the families. UHND/VHSND forums
may be used to approach the influencers.

Step 3: Head count survey and Due list generation:

The Due list is to be generated based on head count survey. The due list is to be shared with
the leaders of community (elderly, religious leaders, gram Pradhan, etc.) to ensure all due
children are identified.

Step-4: Update micro plans to conduct sessions as per community needs:

Once immunization-session schedules are decided and agreed to with the communities, it is
imperative that they be adhered to. Micro plans should be modified to reflect new/ revised
session sites and plans. Changing and cancelling scheduled sessions can result in loss of
confidence in the service. A critical part of planning, therefore, is to ensure that sufficient
vaccines, injection supplies, and cold-chain equipment and all logistical needs are in place
well in advance of the session date.

Step-5: Engage community leaders for mobilization:

Take the support of community leaders and members in organizing sessions, mobilization
and any other support.

Well planned RI sessions, ensure reach of all the target beneficiaries, thereby leading to
successful implementation of the Universal immunization programme in the subcentre
or ANM area.

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Types of Routine Immunization sessions:
The different types of RI sessions is mentioned in fig.no.5.21

Fig.no.5.21: Types of Routine Immunization sessions:

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A well-planned RI session, ensure reach of all the target beneficiaries, thereby leading
to successful implementation of the Universal immunization program in the subcentre
or ANM area.

Ensuring “Same day, Same site, Same time” policy will help to increase community
acceptance and in turn the utilization of services provided.

Per session injection load and vaccine distribution plan (RI Microplan Form SC-7)
Once the frequency, type and location of RI sessions to cover all the areas are finalized, the
beneficiaries per session for each vaccine and Vitamin A should be calculated and accordingly
the vaccine distribution plan for each session is developed. Vaccine distribution plan should
mention the mode of transport and name of the responsible person with contact number. It
is very important to tag each session site with the designated AEFI management center.

Note: For fixed site use daily average of PW and children vaccinated (number vaccinated per
month/30)

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 ROUTINE IMMUNIZATION MICROPLANNING

Fig.no.5.22: Subcenter/ ANM area – Session wise injection load and vaccine distribution plan: Form SC-7 (Refer Annexure 2.9)

70
SOPs for using Form SC-7
In Column A, 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/ ANM area 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 B. 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 SC-1. For multiple areas, write the
names separated by commas into this column.
e.g – Village XYZ

Column C The frequency of sessions at this RI site is to be entered in Column D. It may be

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entered as:
o once in a quarter, i.e. once in three months
o once in two months
o twice a month
o daily.

Column D and E. The target of PW and infants per session is determined for each site. This is
obtained from monthly targets in Form SC-6 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 SC-6 columns F and G
Village XYZ has 3 PW and 5 infants similarly tola ABC has 1 PW and 2 infants for RI site no 1.
Thus, for RI site 1, monthly target will be 4 PW and 7 infants. Village XYZ has 8 PW and 12
infants with two RI sites 2 and 3. Thus, for RI site 2, monthly target will be 4 PW and 6 infants
and for RI site 3 also is 4 PW and 6 infants

Note: For fixed site use daily average of PW and children vaccinated (number vaccinated per
month/30)

Columns F to R. Injection load for each antigen is to be entered in Columns F to Q. Using the
target from Columns D and E the individual antigen dose requirement can be calculated
using the formula in the boxes.

Column S. The total injection load for each site is now available to enter into Column S. This
is calculated by adding the number of beneficiaries in Columns F, H, J, K, L, M, N, O, P (any
new injectable vaccines introduced). (Note that OPV, Rotavirus vaccine (where applicable)
and Vit A should not be considered as injections.)

Columns T to V. 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
Each column is for a month. The day is to be entered as follows:
E.g. If the session is held in month 1 on the fourth Wednesday, the entry will be “Wed 4” in

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 Column T.

Each state can customize this format for their own RI days and immunization schedule.
Method of vaccine distribution with details of responsible person to each site is to be entered
in the three Columns W.
o Information on the mode of transport – two-wheeler/three-wheeler/four-wheeler with
its registration number, if possible, needs to be mentioned.
o Name of the person transporting the vaccine and his contact number are to be entered.

Column X: Every RI session should be tagged with the nearest designated AEFI center (eg.
CHC, District hospital, Private hospital, etc.) which should be mentioned in column X with
contact number which should be contacted by ANM in the event of any adverse events.

Alternate Vaccine Delivery System

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Alternate Vaccine Delivery (AVD) System is an incentive-based vaccine and logistics delivery
system from the last CCP to session sites using locally hired people. Vaccine Delivery System
refers to the independent person who delivers the vaccine carrier from the PHC to the session
site. It allows for better community engagement with the immunization programme and
promote vaccine uptake.

Medical officer should review and finalize a route plan for the AVD at every CCP. The AVD
plan and route chart for alternate vaccine (and logistics) delivery (AVD) is prepared to the
session sites from the nearest cold-chain storage point for each session day. The plan should
be prepared keeping in mind – time-to-care approach of 1 hour. It implies that the AVD plan
should be prepared in a way that the distance between the CCP and the farthest session site
can be covered within one hour through any means of transportation.

AVD transports the vaccine carriers through bicycle, bike, boat, on foot or any other means of
transportation. AVD delivers the vaccine directly to the ANM at the session site, and it allows
for the session to begin on time. Similarly, at the end of the same day, AVD collects the vaccine
carrier from the ANM and returns the vaccine carrier along with biomedical waste generated
at the session site to the CCP after the session is over.

Per Session estimation of Vaccine and logistics (Form SC-8):

It is very important to calculate the vaccine and logistic requirement for each session site
considering the vaccine wastage. The wastage multiplication factor (WMF) for each vaccine
and logistics is utilized for calculating the exact requirement. The details about WMF is
mentioned below.

Wastage multiplication factor (WMF)–

It is calculated using the following equation:
100 divided by [100 – (Permissible wastage %)]
E.g. if wastage is 10%, 100/ [100-10] 100/90 = 1.11

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 Table No.5.5: Permissible wastage percentage

Vaccine Maximum permissible wastage % WMF

Hep B 10 1.11
BCG 50 2.0
OPV 10 1.11
Rotavirus 10 1.11
fIPV 10 1.11
PCV 10 1.11
Pentavalent 10 1.11
MR 25 1.33
JE 10 1.11
DPT 10 1.11
Td 10 1.11

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Syringes 10 1.11

Fig.no.5.23: Per Session estimation of Vaccine and logistics (Form SC-8) refer annexure 2.10

ROUTINE IMMUNIZATION MICROPLANNING

 SOPs for using Form SC-8
This format collates the exact requirement of vaccines and logistics (considering wastage)
for each session site. This information is calculated using data from Form SC-7.

Columns ‘a’ should be in the same as column A of Form SC-7.

Columns ‘b’ through ‘l’, 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 Wastage Multiplication Factor-WMF) ÷ no.
of doses per vial.

Column n – Calculation of number of Vitamin A bottles for sessions.

Columns ‘o’, ‘p’ and ‘q’ - Calculates the requirement of syringes including reconstitution
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syringes. Calculation is based on number of vials from Columns ‘b’ to d and g to l of this
format. Remember – only calculate reconstitution syringes for BCG, MR and JE (live
attenuated vaccine).

In the format wastage factors and dose per vial are given in the row below the names of
antigens. Columns r to w are to indicate the requirement of other logistics for each
session site.

ANM Work plan (Form SC-9):

Based on the planning of RI sessions, ANM should prepare a quarterly workplan mentioning
the RI session days with details of session location and timing. The RI days vary from state
to state and even from area to area. Eg. Some state has fixed RI sessions on Thursdays and
outreach RI sessions on Tuesdays.

Once the RI microplanning of SC/ ANM area is completed, the date of submission of final
workplan by ANM and also date of verification by MO I/C should be mentioned at the bottom
of the format SC-9.

74
 Fig. no. 5.24: ANM work plan: Form SC-9 (refer Annexure 2.11)

75
ROUTINE IMMUNIZATION MICROPLANNING
 Communication plan for SC/ ANM area (Form SC-10):

ANM should identify the IEC activities that can be conducted in her areas by preparing
communication plan (RI Form SC-10). 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/ UHNC, Mothers meetings, AWW meetings, MAS meetings are planned regularly,
and the tentative dates are fixed based on the availability of MO.

IEC material (Posters / banners): These should be displayed at prominent places in the
community.

Pamphlets / leaflets / counseling aids are material that can be placed at the AWC or other
locations and used during RI sessions / other meetings.
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PRI / Community influencers can play a key role in RI and it is essential to identify them in a
village or ward area in organizing IEC activities.

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 Fig.no.5.25: Communication plan for SC/ ANM area: Form SC-10 (refer annexure 2.12)

77
ROUTINE IMMUNIZATION MICROPLANNING
 Review and finalization of Sub Centre/ ANM area plans
Step-5 and finalization of session due lists area microplans

The final step in the RI microplanning exercise at the PHC consists of review and finalization
of the newly updated/ proposed SC RI microplans and finalization of formats and session due
lists.

Review of the updated / proposed RI plans

The outputs are now focused on the finalization of SC microplans and the development of
the PHC microplan. Each ANM presents her sub centre microplans focusing on the following
points:
1. Total number of areas identified – any increase or decrease? Form SC-1
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2. Total number of HRAs identified – any increase or decrease? Form SC-1

3. Demarcation of areas – who will be looking after which area? Form SC-1 and SC-2
4. Number of RI sessions planned? Form SC-6 and SC-7
5. Are the maps updated? RI Form SC-2
6. Is sub centre RI microplan now complete?

Finalization of SC/ ANM area microplan: Each ANM should compile all the forms of SC/ ANM
area and submit to PHC/UPHC. Plans from all sub centre/ ANM areas including the vacant
(permanent/ temporary) should be prepared and submitted to PHC/UPHC. The MO of PHC/
UPHC reviews the microplans as per the checklist for SC/ ANM area (Refer. Table 5.6) and
approves. Once approval is done, ANM should develop the RI session due lists (Form SC-5) as
per the RI sessions.

Responsibility: Medical officer

Expected participants for the meeting: ANMs, LHV, Health supervisors

Activities at the final PHC/ UPHC meeting

• Review and finalization of SC/ ANM area 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/ ANM areas to develop PHC/ UPHC plan
• Prepare vaccine delivery and supervision plan
Recalculate vaccine and logistics requirement.

Outputs expected
Availability of the following documents after Step 5:
• Forms SC-5, 6, 7, 8, 9 and10 for each SC/ ANM area

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Roles and responsibilities
Personnel Activities to be performed Supervisor
Coordination of the activity/reviewing each SC/
MOIC DIO
ANM area plan
Generate SC/ ANM area forms and suggest
ANM MO
changes to the reviewing officer
Data handler
Compilation of SC/ ANM area microplans.
(Supervisor, Data MO
Preparation of PHC/ UPHC microplan
entry operator, etc.)
Fig. 5.26. Flow diagram of RI microplanning process at subcenter/ ANM area level:

Master list of all areas and head count survey planning (SC-1)

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Area mapping (SC-2)

Conduct house to house survey

House to House survey form (SC-3)

Head count of pregnant Head count of infants and Children b/w 2-5 years with
women (SC-4A) children (SC-4B) missed due doses (SC-4C)

Prepare due beneficiary list

(SC-5)

Annual target of beneficiaries

Pregnant women = Actual head count of PW X 2
Infant = Actual head count of infants (0-1 years)

Monthly target of beneficiaries

Pregnant women = (Actual head count of PW X 2)/12 SC-6
Infant= rActual head count of infants (0-1 vearsll/12

calculation of monthly Injection Load for estimation

of number of sessions

Estimation of beneficiaries per Estimation of vaccines & logistics

session and vaccine distribution per session (SC-8)
plan (SC-7)

ANM workplan
(SC-9)

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 Table 5.6 Checklist for RI microplan components – at SC/ ANM area
Sl. Components of Routine Immunization Microplan Available
No. Yes No
1 Master list which includes all villages/areas/HRAs (SC-1)
2 Map of area -with name of village, urban area including all hamlets
(tola), sub-villages, sub-wards, sector, mohallas, hard to reach areas,
etc.) (SC-2)
3 Total number of households and target beneficiaries - pregnant women,
children below 2 years and children between 2-5 years missed for due
vaccine doses (SC-3)
4 Beneficiary list – pregnant women, children below 2 years and children
between 2-5 years missed for due vaccine doses (SC-4A, 4B, & 4C)
5 Session due list (SC-5)
ROUTINE IMMUNIZATION MICROPLANNING

6 Estimation of beneficiaries and injection load per area including HRAs

7 RI session plan (SC-6)
8 Session wise injection load and vaccine distribution plan (SC-7)

9 Estimation of vaccines and logistics (SC-8)

10 ANM work/ roster plan (SC-9)
11 Vaccine coverage chart of all antigens and doses

RI microplan for the PHC/ UPHC is prepared based on the subcenter/ ANM area microplan. For
details of preparation of PHC/ UPHC microplan, refer Routine Immunization manual for medical
officers.

5.7 Coverage of DPT-booster 2 and Td 10 & Td 16 in schools and community

level:4

Vaccination for DPT-booster 2 and Td 10 & 16 should be done primarily through school-based
activity. The out of school children should be identified, listed and mobilized to the RI session
at community level for vaccination. These plans should be available for in-school and out-of-
school children and should be reviewed quarterly.

Specific components of a RI microplan for DPT-booster 2 and Td immunization:

 Two types of microplans should be prepared:
o For School going –School immunization plan
o For out of school - Community based immunization plan
 For School going –School immunization plan
Village/ward/tola wise enlistment of all schools (government, government-aided, private,
religious/ faith-based schools, etc.) of the area
o Line listing of all students of class 1st (5-6 yrs), 5th (10 yrs) and 10th (16 yrs) of the
schools
o Vaccine and logistic estimates should be based on the listing of target beneficiaries
o Session planning should be based on the coordination between health and education
department

80
 For out of school - Community based immunization plan
o The health worker with support of AWW & ASHA should identify and enlist missed
beneficiaries of DPT booster 2, Td 10 & Td 16. These beneficiaries should be mobilized
to the nearest RI session for vaccination
 Coordination may be done with RBSK team and ICDS adolescent schemes. There are
three different strategies to strengthen school immunization. (Refer chapter)
 AEFI management plan: should be available
 Communication strategy: A very good communication strategy is needed for effective
implementation of school vaccination. The lessons learnt from MR campaigns should be
applied
 Supervision and monitoring plan: Ensure good supervision and monitoring of the
activities

Fig. no. 5.27: School immunization plan for DPT-Booster 2 and Td - Sub-center/ ANM

ROUTINE IMMUNIZATION MICROPLANNING

area: SC-11A (refer annexure 2.13)

Fig. no. 5.28: Community based immunization plan for DPT-Booster 2 and Td - Sub-
center/ ANM area: SC-11A (refer annexure 2.14)

For further details refer to Strengthening Td 10 and Td 16 Vaccine Implementation guidelines

5.8 Planning in High-Risk areas:

High Risk Areas (HRAs):

HRAs need special attention as they often miss routine and supplementary immunization
and pose a risk for polio, measles rubella and other VPDs. HRAs are categorized as migratory
and non-migratory (settled).

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 Migratory HRAs Non-Migratory HRAs
• Slums with migration • Slums (settled population)
• Nomads • Hard to reach areas
• Brick kilns • Unserved areas with shortage of health
• Construction sites workers (sub centers vacant for more than
• Other migratory areas eg. Char areas three months)
in river delta), riverine areas with • Areas with outbreaks of vaccine preventable
shifting populations, migrants in tea/ diseases (past 3 years)
coffee estates, etc. • Areas with vaccine hesitancy/refusal
• Others: Any area with a risk of disease
transmission or outbreak. Security
compromised areas, orphanage prisons,
brothels, red-light areas
ROUTINE IMMUNIZATION MICROPLANNING

Microplanning in HRAs:

Identification and validation of HRAs: During the head count survey,

• these areas should be identified and enlisted in the below mentioned format (Form HRA-1)
• updated every quarterly and accordingly RI sessions are planned
• enlisted HRAs should be validated by the supervisors (use Form HRA-2)

Format for HRA enlistment:

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 Fig. No. 5.29: Format to capture HRA data at Sub center/ ANM area:

Fig. no.5.30: Format for field validation of sites with migratory population:

Field Validation of Sites with Migratory populations Form: HRA-2

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Name of District/ Corporation:____________________Block/Urban area: _____________________________ PHC/ UPHC:_______________________________ Sub Centre:__________________________
Name of the person conducting Field Validation:_____________________________________ Designation:_______________________________________________
Whether RI services
Re-Estimated Whether planned using mobile Name of the Name of the
Sl. Type of Date Field Whether Re- Re- Beneficiaries reesimate Where are they Migrated
Name of the site & team / special team? ANM/CHO Mobilizer
No HRA Validation the site estimated Estimated approximately from?
Location If Yes then responsible responsible for
. (1-5) Done exists Population Households (0-1 (1-2 (2-5 match survey (area, block, district, State)
Y/N details (day, for area area
years) years) years) data
week)
A B C D E F G H I J K L M N O P
Y / N / Newly Y / N / Newly
1 Y/ N
identified identified
Y / N / Newly Y / N / Newly
2 Y/ N
identified identified

Migratory HRA 1 2 3 4 5 Total Migratory HRA: 1-Slum with migration;, 2-Nommads;, 3-Brick Kilns; 4-Constructions; 5-other
No. of sites / Areas migratory HRA;
Reestimated Population
Reestimated households
Reestimated 0-1 yr children
Reestimated 1-2 yr children
Reestimated 2-5 yr children
Total Reestimated 0-5 yr children Signature of validator:__________________________________

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 Session planning in High risk:
• In vaccine hesitant areas, community accepted sites can boost immunization coverage.
Sessions sites in the community run hospitals/schools/community owned halls, public/
private hospitals, schools and colleges, premises of local influencers, panchayat hall, etc.,
are more acceptable and convenient for all the beneficiaries
• In high-risk areas like brick kilns, nomadic sites, hamlets, etc., select a clean, convenient,
comfortable place in a shaded place making sure the vaccines are not exposed to direct
sunlight or explore use of mobile session for such areas with proper planning and
mobilization, the vaccine wastage is to be kept to the minimum during mobile sessions.
Wherever required, plan for mobile sessions for optimal use of resources. Support of CSOs
to create kiosks to attract residents for vaccination may be elicited

Planning in Urban areas:

Characteristics of urban areas – why they need special attention
ROUTINE IMMUNIZATION MICROPLANNING

Urban areas face a number of challenges and issues as follows:

• Poor demarcation of areas
• Large volume of transit / migrant population
• Expanding borders and peri-urban areas
• HRA with a higher number of construction and nomadic sites
• Manpower shortage
• Unrecognized slums

Provision of services to tackle challenges in urban areas:

a) Area demarcation: Prepare maps with clear demarcation of areas for AWW/ASHA/link
worker. Superimpose ANM area on the map. Plan for field verification where boundaries
are not well defined.

b) Accessibility: Identify local solutions based on the needs e.g.

• Use three or two wheelers to access narrow lanes
• Seek support from local key influencers and community leaders
• Get support from local civil service organizations – Rotary, Lions, professional bodies,
etc.

c) Infrastructure for providing RI services:

• “Same day, Same site, Same time” provision of services: This should include all
anganwadi centres, dispensaries, clinics and maternity homes in the public sector;
all NGOs, private institutions /practitioners engaged in providing health care in urban
areas
• Urban outreach: Expand the network of urban service provision points e.g. in every
urban slum. seek help from local bodies / shops / organizations
• Communication: Use various channels to inform the community about the timing of
local immunization services; local service delivery points; the vaccines and schedule
of immunization and the benefits of immunization

d) Multiple departments / NGOs / organizations / coordination: Support the medical

officer to identify and coordinate with the multiple agencies already working in the area.
Joint planning will help to reduce duplication and improve the coverage of immunization
services.

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 Unit 6
Cold-chain and vaccine management

85
 Learning objectives
At the end of the unit, Health worker should be able:
• To define and describe the importance of the cold-chain
• To describe which vaccines are sensitive to heat /light and freezing
• To demonstrate how to check vaccines for exposure to heat or
freezing
• To demonstrate how to condition frozen ice packs and how to pack a
vaccine carrier properly

Key contents Page

6.1. Cold-chain 87
6.2. Cold-chain equipments 87
6.3. Checking vaccines for correct maintenance of cold-chain 98
6.4. Guidelines for use of open vaccine vials in immunization programme 100

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Cold-chain and vaccine
management
6.1. 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.

COLD-CHAIN AND VACCINE MANAGEMENT

Fig. 6.1. Immunization cold-chain supply system

Vaccine Air Primary Store Refrigerated State Store Insulated Van

Transport (GMSD /State) / Insulated
Manufactur Van

Beneficiary Session Sites Vaccine Primary Health Insulated Van District Vaccine
Carrier Centre (+ 2° to 8°C) Store
All Vaccines in
ILR

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

6.2 Cold-chain equipments

Ice Lined Refrigerator (ILR):

Maintains a cabinet temperature between +2°C to +8°C; is used to store UIP vaccines at the
PHC and district level. Two types of ILR are present. One with top opening lid which prevents
loss of cold air during door opening and second with front opening lid. Both Type of ILR can
keep vaccines safe with as little as 8 hours continuous electricity supply in a 24-hour period.

All UIP vaccines must be stored in baskets in ILR. In case basket is not available with top
opening ILR, 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.

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 Fig. 6.2 Storing vaccines in the ILR
NEVER keep any vials
that are expired, frozen
or with VVMs beyond the
end point in the ILR as
they may be confused
with those containing
potent vaccines.

Keep them in the red

bag for disinfection and
disposal.

IDENTIFY A DRY SPACE

COLD-CHAIN AND VACCINE MANAGEMENT

FOR STORING EXPIRED/

UNUSABLE VACCINES
BEFORE FINAL DISPOSAL

Fig. 6.3. Front opening Ice Lined Refrigerator

88
Table 6.1. Dos and don’ts for ILR use
Dos Don’ts
• Keep all vaccines including those returned under • Do not store any other
open vial policy in a box marked as Open Vials in the drugs, serum, injections,
basket supplied along with the ILR diagnostic kits, /non-UIP
• Store diluents at +2°C to +8°C at least 24 hours before vaccines in the ILR
supplying for use in vaccination • Do not open the ILR
• Leave space in between the vaccine boxes frequently.
• Place a thermometer in between the baskets. • Do not keep food or drinking
• Keep freeze-sensitive vaccines at the top of the water in the ILR
basket • Do not keep vaccines which
• Keep heat-sensitive vaccines in the bottom of the have expired and have
basket crossed the discard point of
• Arrange vaccines as per their expiry dates. (Early VVM

COLD-CHAIN AND VACCINE MANAGEMENT

expiry should be kept above the later expiry ones). • Do not disturb the
• ILR should be placed on a wooden platform, each thermostat setting
ILR should be connected to a dedicated voltage frequently
stabilizer • Do not place heavy weight
• Each ILR should be connected to a functional Data on the ILR
Logger for remote monitoring of temperature • Do not store excess stock of
• Each ILR should have a separate logbook and vaccines, i.e. more than the
temperature should be recorded twice daily maximum stock

Temperature of the data logger should also be monitored twice daily along with
temperature recording from stem thermometer. However, the recording of the
temperature in the register should be from alcohol stem thermometer only

Deep Freezer (DF):

maintains cabinet temperature between -15°C to -25°C. Deep freezer at sub district level is
used only for preparation of icepacks.

Fig. 6.4 Preparing of icepacks in the Deep freezer

89
COLD-CHAIN AND VACCINE MANAGEMENT

Table 6.2. Dos and don’ts for DF use

Dos Don’ts
• Use DF only for preparation of ice packs • Do not keep any vaccine in the DF at
at PHC/ UPHC levels. But at the district sub-district level
level store, the bOPV, Measles Rubella • Never keep diluents in the deep
lyophilized vials can be stored in DF freezer
• Should be kept on wooden platform
• Defrost the deep freezer when the frost on
the wall is more than 5 mm

Voltage Stabilizer: is an electronic equipment to monitor and stabilize the range of

fluctuations in the main incoming voltage to safeguard equipment from excessive voltage
variation. Voltage stabilizers provide specified constant stabilized voltage to CCEs (ILRs &
DFs) for its desired optimum operation & in turn protect vaccines.
• There are predominantly three types of VS in the UIP:
1. Normal Voltage stabilizers: works in voltage range: 150 – 280 V
2. Low range voltage stabilizers: 90 – 280 V
• Every Cold-chain Equipment (ILR and DF) must be connected to an individual functional
voltage stabilizer. A low voltage stabilizer should be used in areas with low voltage
supply. Bypassing a voltage stabilizer can damage the CCE
• Proper earthing should be available and connected

Fig. 6.5: Voltage stabilizer

90
Cold Box: is an insulated box, used for transportation and emergency storage of vaccines
and icepacks. 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 five days, if necessary for outreach sessions or when
there is power cut
• Store vaccines in case of breakdown of ILR as a contingency measure
• Also used for storing frozen icepacks, e.g. during emergency and before campaigns

Packing a cold box:

• Ensure that the gasket of the cold box is intact and is not broken or damaged.
• Place conditioned icepacks 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 icepacks. Surround them
with OPV/BCG/JE (live) vaccines
• Keep a thermometer in the cold box

COLD-CHAIN AND VACCINE MANAGEMENT

• Place 2 rows of conditioned icepacks above the vaccine vials
• Place plastic sheet to cover the icepacks kept on top to ensure full hold over time
• Securely close the lid of the cold box
• Do not open the cold box unless needed

Fig. 6.6. Packing a cold box Fig.6.7. Picture of icepack

Icepacks: 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; also used in ILR as inside lining to improve & maintain holdover time during electricity
failure. About 20-25 icepacks (8-10 Kg Ice) and 35-40 icepacks (12-14 Kg Ice) can be frozen in
one day in small and large deep freezers respectively. Standard icepacks used in UIP for cold
box and vaccine carrier are of 0.4 litre capacity.

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 Table 6.3 Dos and Don’ts in using icepacks

Dos Dont’s
• Fill water only up to the level mark on the • Do not use ice packs that are
side to leave 10 mm room for expansion as cracked and/or are without cap
water freezes • Do not use ice packs with leakage;
• While filling, keep the ice pack vertically discard them
upwards under the tap • Never add salt to the water as it
• Fit the stopper and screw on the cap tight. lowers the temperature to sub-zero
• Check and ensure that ice pack does not leak level, which is not recommended as
• Clean the outer surface of ice packs with dry it may cause freeze damage to the
cloth before putting into the deep freezer vaccines
• Keep ice packs horizontally (not flat) in a • Do not refill an ice pack every time
criss-cross manner in the DF (brick layered before use; the same water can be
COLD-CHAIN AND VACCINE MANAGEMENT

pattern see Fig 6.4) used repeatedly

• Keep a gap/breathing space between ice • Do not fill the water into the icepack
packs for freezing to be faster and uniform. above the marking
• Ensure use of conditioned ice packs when • Do not use prefilled (coolant)
storing / transporting RI vaccines icepacks (supplied with other drugs)
in the vaccine carriers

Conditioning of frozen Icepacks: Icepacks 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 icepack to rise to 0°C. This takes at least 30-45 minutes in hot weather and
much longer in cooler conditions – from 90 to 120 minutes at +20°C. This process is called
‘conditioning’.
• Freeze sensitive vaccine like Hepatitis B, T series vaccines (DPT, Td, Penta), fIPV, PCV can
be damaged if it comes in direct contact with the frozen icepacks
• Conditioning of icepacks prevents freezing of vaccines during transport
• At start of session day, take all the frozen icepacks, you need from the freezer and close
the door. Lay out on a table leaving a 5 cm space all round each icepack
• Lay out icepacks, preferably in single rows but never in more than two rows
• Wait until there is liquid water inside the icepacks. The ice pack is conditioned as soon
as ice cores move inside the packs. An ice pack is adequately “conditioned” as soon as
beads of water cover its surface and the crackling sound of water is heard on shaking it

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Fig. 6.8 Conditioning of frozen icepacks

COLD-CHAIN AND VACCINE MANAGEMENT

Vaccine Carrier: Two type of vaccine carrier are available in the system. One is the normal
vaccine carrier and second is the freeze free vaccine carrier. It is an insulated box used for
carrying vaccines (16-20 vials) and diluents from 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 same day after the session for storage and subsequent use. Vaccine carrier (with 4
conditioned icepacks) maintains the inside temperature between +2°C to +8°C for 12 hours,
if not opened frequently.

Packing a vaccine carrier:

• Confirm that there are no cracks in the walls of the vaccine
carrier
• Take out the required number of icepacks from the deep
freezer

Keep them outside for conditioning and wiped them dry

before placing into carrier.
• Place four conditioned icepacks into the vaccine carrier
along the sides
• Bundling:
o It is the procedure of vaccine and logistic packaging Fig. 6.9 Packing icepacks
to ensure that the vaccines are always supplied with in Vaccine carrier
corresponding diluents, droppers, AD syringes and
reconstitution syringes, in correct quantities, to the session site. Examples of bundling
are as follows
 OPV, RVV vials should be equal to the number of droppers and or RVV dispenser
syringes
 MR and BCG vaccine vials and their respective supplied diluents (bundled diluent)*
and 5 ml reconstitution syringes should be equal in number
* Bundled diluents are the one’s which are supplied with the vaccine by the
manufacturer

93
 • Put the vaccines with diluents in polythene zipper bag, ensure the zipper bag is zipped
properly. Place some packing material between `T’ series vaccines (DPT, Td, Pentavalent
and Hepatitis B vaccines) and the icepacks to prevent them from touching the icepacks
• Place the plastic zipper bag in the centre away from the icepacks
• Place foam pad on top of the icepacks
• If more than one vaccine carrier is being carried, keep the whole range of the vaccines
required for the day’s use in each carrier so that only one carrier is opened at a time

Fig. 6.10 Correct packing of the Vaccine Carrier

COLD-CHAIN AND VACCINE MANAGEMENT

Table 6.4. Dos and don’ts in using a vaccine carrier

Dos Dont’s
• Place vaccines and diluents in cartons • Never use day carriers, which contain
or polythene bags to ensure labels are 2 ice packs or thermos flasks for
protected routine immunization
• Use only conditioned ice packs in the • Never use a screwdriver or any other
vaccine carrier sharp shaft to open the lid of vaccine
• Ensure that some ice is present in the ice carrier
packs while conducting the immunization • Do not drop, knock or sit on the
session vaccine carrier
• Ensure collection of vaccines in the vaccine • Do not leave the vaccine carrier in the
carrier on the session day itself sunlight
• Close the lid tightly and securely • Do not leave the lid open once
• Keep the interior of the vaccine carrier packed
clean and dry after every use

94
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.

Dos and don’ts in temperature monitoring of vaccines is given in Table 6.5.

Alcohol stem thermometer

Alcohol stem thermometers (Fig. 6.11) are very sensitive and more accurate than dial
thermometers. They can record temperatures from -30°C to +50°C and can be used for ILRs
or DFs.

COLD-CHAIN AND VACCINE MANAGEMENT

Fig.6.11. Alcohol stem thermometer

Functional alcohol stem

thermometer is the
most commonly used
temperature monitoring
device under UIP. Each CCE
should contain at least one
functional thermometer. The
thermometer should always
be placed along with the
vaccines.
• Twice-daily readings from
the stem thermometer
must be entered in the
individual temperature
logbooks on all days
including Sundays and
holidays. As a MO, you must
review the temperature
logbooks for all CCE every
month, including keeping
a track of alarm events (if
any)
• It must be ensured that the cold-chain technician validates the reading of thermometer
every year. Non-functional thermometers must be discarded using proper procedure

Temperature logbook
Temperature recording from the CCE should be entered twice daily (including Sundays and
holidays) by the cold-chain handler in the Temperature logbook (Fig 6.12).

Temperature logbook should be used to take action to shift vaccines to cold boxes or other
ILRs when the situation requires.

95
 COLD-CHAIN AND VACCINE MANAGEMENT

Fig. 6.12. Logbook for ILR

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 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 10 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 11 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 12 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 13 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
(+) 14 ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

96
(+) 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)
(* 1 = Major, 2 = Minor)
Electronic Vaccine Intelligence Network (e-VIN)
These devices are capable of transmitting temperature data from sensor placed inside Cold-
chain equipment to e-VIN server and subsequently programme managers and cold-chain
handlers can view temperature remotely and receive SMS and email alerts as and when there
is a temperature breach.

• Identify if the e-VIN sensors are working. If the cold chain handler notices that the
temperature of data loggers is outside the recommended range or shows temperature
of previous days/ months for the particular equipment then, they should immediately
inform district VCCM and district cold-chain technician through medical officer
• e-VIN temperature records should be monitored twice daily.

Fig.6.13: e-VIN equipments

COLD-CHAIN AND VACCINE MANAGEMENT

CTX

U2GW Cold Trace 5

Table No.6.5. Dos and don’ts in temperature monitoring of vaccines

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

97
 Vaccine sensitivities:
Vaccines lose their potency due to exposure to heat (temperature above +8°C), cold
(temperature below + 2°C) and light. The loss of potency due to either exposure to heat or
cold is permanent and cannot be regained.

Reconstituted BCG, MR and JE (Live) vaccines are the most heat and light sensitive. They
should be used within 4 hours of reconstitution. These light sensitive vaccines are supplied
in amber-coloured vials.

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.
COLD-CHAIN AND VACCINE MANAGEMENT

Open Vial Policy YES NO

Vaccines Hepatitis B, OPV, DPT, Pentavalent, Td, PCV, IPV, BCG, MR, RVV (Liquid
RVV (Liquid frozen 5 drops formulation), and JE 2ml formulation), JE
(killed) (live)

Sensitivity of vaccines to heat, light and freezing:

Vaccine Exposure to heat/light Exposure to cold
Heat & light sensitive vaccines
OPV & Rota with VVM on label Sensitive to heat Not damaged by freezing
MR & BCG Sensitive to heat & light Not damaged by freezing
Freeze sensitive vaccines
IPV, DPT, Pentavalent, JE & Rota
Sensitive to heat Damaged by freezing
with VVM on cap
Hepatitis B, PCV & Td Relatively heat stable Damaged by freezing
At the Sub district level, all vaccines are kept in the ILR at temperature of +2°C to +8°C
Vaccines sensitive to heat Most Vaccines sensitive to freezing Most
• OPV
• Rotavirus vaccine
• IPV • DTP/Pentavalent/HepB/PCV/Td
• DPT/Pentavalent/MR • IPV
• BCG/JE/Td
• PCV/HepB Least Least

Only those diluents that are provided with the vaccine by the manufacturer should be used.
Keep diluents in an ILR at +2°C to +8°C at least 24 hours before use to ensure that the
vaccine and diluent are at the same temperature when being reconstituted.

6.3. Checking vaccines for correct maintenance of cold-chain

A. Checking the vaccines for heat damage

Vaccine Vial Monitor:

A VVM attached to vaccine vials is also a temperature monitoring device that records
cumulative heat exposure over time. The combined effect of time and temperature cause

98
the inner square of the VVM to darken gradually and irreversibly. Before opening a vial, check
the status of the VVM. If the VVM shows change in colour to the end point, then discard the
vaccines.

Fig. No.6.14: Vaccine vial monitor:

COLD-CHAIN AND VACCINE MANAGEMENT

Procedure of checking VVM:
Hold the vial as shown in the picture. The background should be covered by palm and the
direction of light should fall on the VVM.

Fig. 6.15: Holding of vial for checking VVM:

99
 B. Checking vaccines for cold damage (freezing)
DPT, Td, IPV, HepB, PCV and Penta vaccines lose their potency if frozen. Moreover, the risk of
adverse events following immunization, such as sterile abscesses, may increase. Discard the
vial if it is frozen or it contains floccules after shaking. Shake Test is not applicable for IPV.
Details of shake test are given in MoHFW’s Handbook for Vaccine & Cold-chain Handlers.

Fig. 6.16: Procedure of Shake test

Shake Test Passed - Vaccine usable Shake Test Failed - Do not use Vaccine
COLD-CHAIN AND VACCINE MANAGEMENT

Table 6.6: Dos and don’ts in cold-chain and vaccine sensitivities

Do’s Don’ts
• Keep all vaccines in ILR at +2°C to +8°C at PHC • Do not keep in the cold-chain:
• Use diluent provided by the manufac turer with o Expired vials,
the vaccine o Frozen vials or
• Keep diluents in ILR at +2°C to +8°C atleast 24 o Vials with VVM beyond the
hours before use end point
• Use Rotavirus vaccine (RVV with VVM on cap/ • Do not use Rotavirus vaccines
stem), reconstituted BCG, JE (live) and MR (RVV with VVM on cap/ stem),
within 4 hours or re- constituted BCG, JE (live)
• Discard all damaged vials for disinfection and and MRvaccines after 4 hours
disposal

6.4. Guidelines for use of open vaccine vials in immunization programme:18

Implementation of Open Vial Policy allows reuse of partially used multi dose vials of applicable
vaccines under UIP in subsequent session (both fixed and outreach) up to four weeks (28
days) subject to meeting certain conditions and thus reduces vaccine wastage. Open Vial
Policy is applicable on DPT, Td, Hepatitis B, Oral Polio Vaccine (OPV), Pentavalent vaccine,
Injectable-Inactivated Poliovirus Vaccine (IPV), RVV (RVV with VVM on Label), JE- (Killed), and
PCV. Open Vial Policy does not apply to MR, RVV with VVM on cap/ stem, BCG and JE (live)
vaccines. As a basic principle open vial policy is not applicable to vaccines with VVM on cap
and on vaccine supplied in single-dose presentation.

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

100
at more than one immunization session up to four weeks (28 days) provided that:
• Date and Time of opening of the vial is visible on the vial
• The expiry date has not passed
• The Vaccine Vial Monitor (VVM) is in Usable stage
• The vaccines are stored under appropriate cold-chain conditions both during
transportation and storage in cold-chain storage points
• The vaccine vial septum has not been submerged in water from melted icepack or
contaminated in any way
• Aseptic technique has been used to withdraw vaccine doses. (That is needle/septum has
not been contaminated in any way)

Discard the vaccine vial in case any one of the following conditions is met:
• Expiry date has passed
• VVM reached/crossed discard point (for freeze-dried vaccine, before reconstitution only)

COLD-CHAIN AND VACCINE MANAGEMENT

or vaccine vials without VVM or disfigured / nonreadable VVM
• No label/partially torn label and/or writing on the label/ vial not legible
• 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
• If the vaccine vial contains floccules or any foreign body
• If there is a breakage in the continuity of the vials (crack/leaks)
• If there is any reported AEFI following use of any of the vaccine
vial, do not use it, and retain it safely in proper cold-chain and
properly sealed zipper bag earmarked “For AEFI Investigation”
in a separate Cold-chain Equipment (+2° to +8° C) under
special custody and in the knowledge of Medical Officer. This
vial should never be issued to anyone unless authorized by
DIO

Health workers must be able to distinguish between vials that can

be used in subsequent sessions and vials that must be discarded.

Cold-chain maintenance during vaccine distribution:

• Maintain temperature of ILR between +20 to +80C for storage of vaccines & diluents and
monitor temperature twice daily regularly including Sundays/holidays
• Note the name of the manufacturer, batch number and expiry date of the vaccine and
diluent in the stock register
• Always fill the injectable vaccine only immediately before giving vaccine. Never prefill the
injectable vaccine in anticipation of vaccination of next beneficiary
• Proper recording and reporting of vaccine distribution and usage has to be ensured
• Keep stock up to date, don’t over-stock or under-stock vaccines and diluent
• 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
• 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

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 • Contingency plan must be in place in case of any exigency like power failure, equipment
breakdown, etc.

Cold-chain maintenance during the immunization session:

• Inspect for and discard vaccine vial with visible contamination (i.e. checking for any
change in the appearance of vaccine or any floating particles) or breaches of integrity
(e.g. cracks, leaks)
• All vaccines vials must be marked (in permanent marker) with date & time of opening
on the cap of the vial at first use.
• Note the name of the manufacturer, batch number and expiry date of the vaccine and
diluent in the tally sheet
• Do not keep freeze sensitive vaccines like Hepatitis B, Pentavalent, DPT, Td, PCV and JE
(Inactivated) vaccines on the ice pack. BCG, OPV, MR, RVV and JE (live attenuated) vaccines
on the ice pack as shown in fig. 5.2.
COLD-CHAIN AND VACCINE MANAGEMENT

• Always pierce the septum with a sterile needle/adapter 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 icepack

Fig. 6.17. 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 vaccine vials before using!!!

Fig. 6.18. Placement of vaccines at the RI session site:

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Specific attention while implementing open vial policy:
• Open Vial Policy is NOT applicable to opened reconstituted vials of MR and BCG
• Open Vial Policy is NOT applicable to opened vials of Rotavirus vaccine with VVM on Cap
• All vaccine vials have VVM appropriately displayed on them. The vaccine has to be used
before reaching the end point
• If any AEFI occurred following use of any of the vial, do not use that vial, mark it and
retain safely for AEFI investigation

After immunization session is over:

• ANM should segregate all the vaccine vials (used and unused) and keep it inside in a
properly sealed zipper pouch/bag in the vaccine carrier under the cold-chain (reverse cold-
chain). All the vials used/unused/partially used including the empty vial must be returned
to tagged CCP

COLD-CHAIN AND VACCINE MANAGEMENT

• Under no circumstance, the vaccine carrier/vaccines will be kept at the session site
without cold-chain maintenance. It should also be ensured that under no circumstances,
the vaccine carrier or vaccine vial is kept in the house of health care worker. The vaccine
should never be stored in domestic refrigerator of any health care worker’s house. In such
an instance, the vials should be discarded and not 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:
1. If VVM is intact and in usable stage, retain the vial in ILR as per guideline, and issue
accordingly.
2. 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 a separate Cold-chain
Equipment (+20 to +80 C). Such vial should be discarded after 48 hours.
Opened vials:
1. Segregate the vials on which Open Vial Policy is not applicable such as BCG/MR/RVV
with VVM on the Cap/ stem, JE (live) vaccine to retain in a plastic box clearly marked
“Not to be used” in a separate Cold-chain Equipment (+20 to +80 C). These vials should
be discarded after 48 hours. In case of any reported AEFI they will not be discarded but
retain in proper cold-chain for investigation.
2. Segregate the vials for which Open Vial Policy is applicable such as OPV/Td/DPT/
Hepatitis-B/Pentavalent/IPV/PCV/JE(Killed)/RVV with VVM on Label as below:
a. If VVM is intact and is in usable stage, expiry date not passed, and the written date
& time of vial opening is readable then retain the vaccine vial in ILR as per guideline
subjected to condition that vial is within 28 days of opening and reissue in the next
session after ensuring that it has not passed 28 days of opening the vial.
b. If VVM is intact and is in usable stage, expiry date not passed, and the written
date & time of vial opening is readable but the vaccine vial has crossed 28 days of
opening. These vials should be discarded after ascertaining that these vials are not
required for AEFI investigation.
c. 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 a separate Cold-chain
Equipment (+20 to +80C). These vaccine vials should be discarded after 48 hours or
before the next session whichever is earlier.
3. If there is any vial which has been used and there is report of AEFI, that vial (even if it

103
 is in usable stage) has to be kept separately in proper cold-chain and properly sealed
zipper bag earmarked “For AEFI Investigation” in a separate Cold-chain Equipment
(+20 to +80C) under special custody and in the knowledge of Medical Officer. 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.
COLD-CHAIN AND VACCINE MANAGEMENT

104
 Unit 7
Safe injection practices and
Waste disposal

105
 Learning objectives
At the end of the unit, you should be able to:
• To describe the importance of safe injections and ways to improve
injection safety
• To demonstrate how to use AD Syringes correctly
• To explain the steps to ensure safe disposal of immunization waste
as per BMWM Guidelines 2021

Key contents Page

7.1. Importance of safe injection practices 107
7.2. Simple ways to improve injection safety 107
7.3. Correct use of Auto-Disable (AD) syringes 109
7.4. Immunization waste segregation guideline 111
7.5. Steps to ensure safe disposal of immunization waste 112

106
Safe injection practices
and Waste disposal
7.1. Importance of safe injection practices1

SAFE INJECTION PRACTICES AND WASTE DISPOSAL

A safe injection is one that –
(a) Does not harm the recipient
(b) Does not expose the health workers to any avoidable risks
(c) Does not result in waste, which is dangerous for the community

The most common, serious infections transmitted by unsafe injections are Hepatitis B,
Hepatitis C, and HIV (the virus that causes AIDS). 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 necessary to dispose
off used syringes and needles safely to prevent risks to the community at large.

The provision of auto disabled syringes by the Government of India and the implementation
of Central Pollution Control Board (CPCB) outlined waste management procedures are
attempts to improve injection safety in the immunization programme.

Fig. 7.1 Impacts of unsafe injections

7.2. Simple ways to improve injection safety 1, 20

• Keep hands clean before giving injections

• Wash hands prior to preparing injection material
• Hands should be washed for 40–60 seconds with soap and running water and dry
before start of session
• Not to use alcohol-based sanitizers

107
 • Before vaccination, inspect the area of injection. 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.

Fig. no. 7.2. Hand washing technique using soap

Use of soap and water Duration of entire procedure: 40-60 seconds

Wet hands with water & apply Rub hands palm to palm Right palm over back of left Palm to palm with fingers
SAFE INJECTION PRACTICES AND WASTE DISPOSAL

enough soap to cover all hand palm with interlaced fingers interlaced
surfaces and vice versa

Backs of fingers to opposing Rotational rubbing of left Rotational rubbing, backwards Rinse hands with water, dry
palms with fingers interlocked thumb clasped in right palm and forwards with clasped fingers hands thoroughly with a single
and vice versa of right hand in left palm and vice use towel.
versa

• Use sterile injection equipment, every time

• Always use Auto Disabled syringe for each
injection and a new disposable syringe to
reconstitute each vial of BCG, MR and JE (live).

• Prevent the contamination of vaccine and

injection equipment
• Prepare each injection in a designated clean
area where contamination from blood or body
fluid is unlikely
• Check if the vaccine vial has a usable Vaccine
Vial Monitor (VVM), has readable manufacturing details, is within the expiry date, and
has not crossed beyond 28 days from the date of first opening it (if under open vial
policy) and date of opening is clearly written on the vial
• Always pierce the rubber cap (septum) of the vial with a sterile needle
• DO NOT touch the needle or rubber cap (septum) of a vial with your finger
• Follow product-specific recommendations for the use, storage, and handling of a
vaccine
• Discard any needle that has touched any non-sterile surface
• Ensure and check that the diluent supplied by the manufacturer for the respective
vaccine is used at vaccination sites and is within the expiry period
• DO NOT use any vaccine vial or diluent with visible contamination or breaches of
integrity (e.g. cracks, leaks)
• DO NOT use a needle or syringe if the package has been punctured, torn, or exposed to
moisture, defaced, contaminated, etc.
• NEVER leave a needle in the septum of the vial
• Fill the vaccine in the syringe just before injecting the beneficiary. Do not keep syringes
prefilled
• Use separate and new syringe & needle for reconstitution of vaccine every time. Reuse
of the same syringe/needle for reconstitution is strictly forbidden

108
 • Cut the hub of the used syringe with hub cutter
immediately after use.
• If the injection site is dirty, clean it with clean dry swab
• Always pierce the rubber cap of the vial with a sterile
needle
• Ensure opened vial septum is covered to prevent
contamination
• Follow product-specific recommendations for use,
storage, and handling of a vaccine

• Assume all used equipment is contaminated

• Cut the used syringe at the hub immediately after use

SAFE INJECTION PRACTICES AND WASTE DISPOSAL

• Practice safe disposal of all medical sharps waste
• Used sharps (needles) must be collected in a hub cutter
and then carried for safe disposal

• Prevent needle-stick injuries

• Do not recap or bend needles
• Collect sharps in a puncture proof container (Hub cutter)
• Anticipate sudden movement of the child

7.3. Correct use of Auto-Disable (AD) syringes

AD syringes have a fixed needle and are pre-sterilized in a sealed pack. They can only be used
once. They are available in two sizes with vaccine drawing capacity of 0.1 ml and 0.5 ml.

Fig. 7.3. Correct use of AD syringes

Do not recap the needle

• Select the correct syringe for the vaccine to be administered: 0.1ml for BCG, fIPV and 0.5ml
for all others
• Check the packaging. Don’t use if the package is damaged, opened, or expired

109
 • 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
• Remove the needle cover/cap and discard it into the black plastic bag
• 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
• Take the appropriate vaccine vial, invert the vial, and insert the needle into the vial through
the septum at 90°. 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 is very difficult to expel
• Do not touch the needle or the rubber cap (septum) of the vial
• Pull the plunger back slowly to fill the syringe. The plunger will automatically stop
when the necessary dose of the vaccine has been drawn (0.1 ml or 0.5 ml). Follow the
manufacturer’s instruction
SAFE INJECTION PRACTICES AND WASTE DISPOSAL

• Do not draw air into the syringe. In case air accidentally enters the syringe, remove
the needle from the vial. Holding the syringe upright, tap the barrel to bring the bubbles
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
• Clean the injection site (if dirty) with a clean dry swab, no alcohol swab to be used
• Administer the vaccine as specified in the National Immunization Schedule (Refer Unit-3)
• Push the plunger completely to deliver the dose. Do not rub the injection site after
vaccine is given
• Do not re-cap the needle. Cut the hub of the syringe immediately after use with hub
cutter that collects the sharps in its puncture proof container
• 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

Fig. 7.4 Usage of Auto Disabled syringe

Hub

Needle Cap

Needle Syringe Plunger

After withdrawing the

Tear the package Remove the needle cap Invert the vial and vaccine, tap the barrel
from the plunger by holding the syringe insert the needle to bring the bubbles
side (not plunger) through the septum towards the tip

Using the hub cutter correctly:

• Hub cutter is used at the immunization session site (outreach/ mobile) for cutting hub
and needle of the used syringes immediately after use

110
• It segregates infected sharps into a puncture proof container and thus prevents injury to
service provider, beneficiary and community members
• Immediately after use, insert the syringe in the hub cutter and then cut it from the hub
• Other sharps such as broken vial diluent ampoules at the session site should also be
stored in Hub cutter. This should be done by collecting broken vials and ampoules on
paper and putting it in hub cutter after opening the lid
• Never touch any sharp (cut needles, broken vials or ampoules)
• Immediately after use, carefully insert the hub with needle of used syringe (and not just
the metal part of the needle) into the insertion hole
• If the functional hub cutter is not available, immediately inform vaccine storage point
cold-chain handler/ MOIC

SAFE INJECTION PRACTICES AND WASTE DISPOSAL

Fig. 7.5 Using the hub cutter correctly

Infection Prevention and control (IPC) practices: IPC practices are encouraged at all the
sessions to prevent spread of disease during vaccination.

7.4. Immunization waste segregation guideline21

The immunization waste needs to be correctly segregated right at the site of the generation.

111
 Table 7.1: Summary of the segregation guidelines
Logistics Particulars Type of Bag or Container to be used as
used during per CPCB UIP Guidelines, 2021
vaccination
AD Syringes Cut hub of AD and disposable WHITE
with packing syringes [White coloured translucent, puncture-
proof, leak-proof, tamper-proof
containers]
Plastic part of syringe RED
Vaccine parts Vaccine adaptor & dropper [Red coloured non-chlorinated plastic
Oral syringe bags (having thickness > 50 micron or
containers)]
SAFE INJECTION PRACTICES AND WASTE DISPOSAL

Gloves Used gloves

Ampoules Ampoules (plastic)
Ampoules (glass) BLUE
Vaccines Expired vaccine [Container / Cardboard boxes with
Or Discarded vaccine blue coloured marking or blue
Broken vials coloured puncture proof, temper proof
Empty unbroken vials containers]
Cotton Cotton contaminated with YELLOW
Blood or body fluid [Yellow coloured non-chlorinated plastic
Vitamins Expired Bottles of Vitamins bags (having thickness > 50 micron or
Paracetamol Expired tab/ Syrup containers)]
For outreach RI sessions, hub cutter may be used for broken vials.

7.5. Steps to ensure safe disposal of immunization waste

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 hub cutter This is to prevent needle stick injuries (NSI) associated with recapping and
any re-usage of needles.

Fig.7.6 Correct usage of hub cutter

Step 2: Segregate and store the plastic portion of the cut syringes and plastic ampoules/
plastic diluents into the red bag/container. At outreach session site, red bag to carry
plastic portion of the syringes, used cotton swabs contaminated with blood and used but

112
unbroken vials, discarded medicines, empty vit A bottles. The bags or containers should
bear the biohazard symbol.

Step 3: Store the broken vials/ diluents/ vitamin A bottles in a separate sturdy and puncture
proof container or in the same hub cutter, in case its capacity is also able to accommodate
broken vials.

Step 4: Packaging material, plastic wrappers of the syringe, empty paper/ cardboard boxes
and cap of the needle to go into black bag or container as a dry general waste. Dispose off
the black bag as general waste.

Step 5: From an outreach session send the red, black bag, and the hub cutter to designated

SAFE INJECTION PRACTICES AND WASTE DISPOSAL

Cold-chain Point (PHC/UPHC/DH/SDH/RH/CHC) OR Health Care Facility (HCF) for disinfection
and disposal by the designated person at the HCF or CCP following biomedical waste
guidelines.

Health facilities and workers (government and private) should follow the national
guidelines issued by MOHFW and Central Pollution Control Board (CPCB) 2021 for
treatment and disposal of Immunization Waste.

Step 6: Wash the hub cutters properly with freshly prepared 1% sodium hypochlorite before
reuse.

Step 7: Maintain a proper record of waste generation, treatment and disposal of waste at
the district hospital/CHC/PHC/UPHC to assess whether the waste (needles/syringes/vials)
reported back matches with the stock issued to health worker/ vaccinator at the beginning
of each session day.

Preparation of Bleaching Solutions

As chloride solutions gradually loose strength, it is highly advised that freshly prepared
solution with clean water should be used daily and use within 24 hours of prepartions.
Since these are caustic solutions, avoid direct contact with skin and eyes. Use ONLY plastic
containers for prepartion and storage, as metalic containers are corroded rapidly and also
affects the quality of bleach.

From bleaching powder:

To prepare 1% Hypochlorite solution, dissolve 10-15 gm OR 1 tablespoonful of beaching
powder in 1 litre of water in a well-ventilated area.

From liquid bleach solution:

• From commercially available 5% liquid bleaching solution – prepare 1% hypochlorite
solution, dissolve 200 ml bleaching solution (5% concentration) in 800 ml clean water in a
well ventilated area
• From commercially available 10% liquid bleaching solution – prepare 1% hypochlorite
solution, dissolve 100 ml bleaching solution (10% concentration) in 900 ml clean water in
a well ventilated area

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 Fig.7.7 Pictorial flow chart – disinfection and disposal sharps waste from RI session
SAFE INJECTION PRACTICES AND WASTE DISPOSAL

Record Maintenance

Maintain proper records of waste generation, transportation, treatment, and disposal at

CCP/ HCF. It should include:
• Log of all waste generated from the immunization activity (outreach sessions, fixed
sessions, Covid vaccination sessions & CCPs)
• All records of collection of waste from CBWTF
• Records of needle stick injuries
• Logbook of each cycle of treatment with all details such as time, date, weight, duration
and hours of treatment
• All records must be supervised and audited by MO in-charge on monthly basis

114
 Unit 8
Conducting the Routine
immunization session

115
 Learning objectives
At the end of the unit, health worker should be able:
• To make preparations for conducting the routine immunization
sessions
• To conduct Routine immunization session using correct
communication, assessment and vaccine administration techniques

Key contents Page

8.1. Steps in holding an immunization session 117
• Preparing for the session
• Communicating with caregivers
• Assessing infants & pregnant females for vaccination
• Giving safe vaccinations
• Closing the session
• Recording data
8.2. Using the immunization session checklist 132
8.3. Birth dose vaccination protocol 133

116
Conducting the Routine
immunization session

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

Health workers should follow the following important tasks to ensure the quality of an
immunization session1

8.1. Steps in managing an immunization session:

I. Preparing for the session:

a) Select an appropriate immunization site
Ideally, it should be:
• easily accessible, acceptable and identified - using the IEC posters / banner at a visible
point
• the place of session site in an area should be the same as per the microplan and
preferably it should not be changed
• in a clean area, out of exposure to sun and rain – No open-air sites
• space for registration and recording, should be available
• having adequate space:
o a waiting area for beneficiaries
o a separate area for vaccinators to vaccinate children – preferably out of view of
other beneficiaries and
o area for waiting after the vaccine is administered

Getting a good space for RI session site:

In most situations the Anganwadi centre or the Sub-centre or Health and wellness centre space
is used for immunization sessions. Wherever the session site is very small and unsuitable,
ANM should explore for better options.

During meetings with panchayat / ward members always discuss the requirement for a good
session site. Involve the ANMs, ASHA/AWW/Link worker to support.

Furniture like tables, chairs, benches and mats are to be sourced from local areas / neighbours.
This involves the community and creates a supportive environment.

117
 b) Arrange for the equipment and supplies required
Furniture Logistics:
o A table to keep vaccines and injection o AD syringes
equipment o Metal file to open ampoules
o A seat for a parent to sit while holding o 5 ml disposable syringes (mixing or
a child for vaccination and a seat for reconstitution syringes)
the HW o CD Marker for writing date and time on
o Bench for beneficiaries in waiting area vaccine vials
o Bench or mats for beneficiaries after o Dry Cotton swabs
vaccination – post vaccination area o Hub cutter
o Two small buckets for the red and o Black and Red bags for waste disposal and
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

black bags and blue puncture proof blue puncture proof container if hub cutter
container not available
o Water for drinking o Anaphylaxis management kit
o Area for washing hands o BP apparatus*
Immunization records: o Weighing machine*
o MCP card / immunization cards Vaccine carrier with 4 conditioned ice packs:
o Due list and head count survey records o Paracetamol syrup (125 mg / 5 ml strength)
o RCH register with measuring cap having markings for
o IEC material – poster or banner 2.5, 5.0, 7.5 and 10ml
o Immunization tally sheets o Vaccines and diluents
o ALWAYS CARRY THE MOBILE PHONE o Vitamin A, ORS, Zinc and IFA tablets*
WHICH IS REGISTERED ON U-WIN
*Items to be included when immunization session is part of Village Health and Nutrition Day (VHND)

c) Prepare due list of beneficiaries and share with AWW and ASHA for mobilizing
beneficiaries
Refer to the following documents:
• Counterfoils of immunization cards
• U-WIN duelist
• MCH / Immunization register
• Register of AWW and ASHA

Fig. 8.1. Ideal layout of vaccination site:

118
d) Arrange the vaccination session site
Place everything you need within reach. On the table you should keep
• Vaccine carrier
• Hub Cutter
• Immunization cards and records
• Dry Cotton swabs

Keep red and black bags, blue puncture proof container/ hub cutter for disposing immunization
waste. Also keep a bowl, water and soap for washing hands clean before beginning the
vaccination session and every time your hands come in contact with any un-sterile surface.

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

e) Cold-chain maintenance during immunization session:
• Inspect for and discard vaccine vial with visible contamination (i.e. checking for any
change in the appearance of vaccine e.g. Frozen or any floating particles which do not
dissolve after shaking gently) or breaches of integrity (e.g. cracks, leaks)
• All vaccines vials must be marked with date & 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
• Do not keep freeze sensitive vaccines like Hepatitis, Pentavalent, DPT, Td, IPV, PCV &
JE killed vaccines on the ice pack. BCG, OPV, MR, RVV and JE (live attenuated) vaccines
on the ice pack as shown in fig. 6.18.
• ALWAYS VERIFY that you are USING THE CORRECT VACCINE for administration
• Always pierce the septum with a sterile needle/adapter for drawing vaccine from
the multi-dose vials being used. “DO NOT TOUCH SEPTUM BEFORE OR AFTER
WITHDRAWING OF VACCINE”
• OPV vial dropper should be recapped with stopper (small cap) after each use and kept
on the icepack
NOTE:
• Well-sealed conditioned icepacks 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
• 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
• Proper recording and reporting of vaccine distribution and usage has to be ensured

119
 Fig. 8.2. Placement of vaccines at the RI session site:
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

Fig. 8.3. 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 vaccine vials before using!!!

Specific attention while implementing open vial policy:

• Open Vial Policy is NOT applicable to opened reconstituted vials of BCG, MR and JE-live
attenuated vaccine
• Open Vial Policy is NOT applicable to opened vials of Rotavirus vaccine with VVM on Cap/
stem
• All vaccine vials have VVM appropriately displayed on them. The vaccine has to be used
before reaching the end point (except reconstituted vials of BCG, MR, JE live, and RVV with
VVM on Cap/Stem, should be used within 4 hours of opening the vial or the session end,
whichever is earlier)
• If any AEFI occurred following use of any of the vial, do not use that vial, mark it and retain
safely for AEFI investigation

Bundling always ensure that Diluent and vaccine (BCG & MR) are supplied from the same
manufacturer. Do not use diluent & vaccine of different manufacturer

II. Communicating with caregivers:

Vaccinators should always have soft communication skills during vaccination of beneficiaries.
Communication involves giving information verbally (including the tone of voice) and non-

120
verbally (body language). Most communication is non-verbal. It is conveyed in many ways:
posture, facial expression, gestures, eye contact and attitude. For example, welcoming
families to an immunization session with a smile and a calm manner will reassure those who
may be afraid or worried of injections.

At the start
• Greet the caregiver or parent in a friendly manner. Thank them for coming for vaccination
and for their patience if they had to wait
• Ask the caregiver if they have any questions or concerns and answer them politely

During assessment

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

• Write the date of the vaccinations being given on the immunization card and complete
entries on U-WIN and explain the diseases against which the vaccination protects, use
simple terms (in the local language). If there is a poster or chart, use it to help your
explanation
• Mention possible adverse events and explain how to handle them
• Explain the need for the child/beneficiary to return as per the immunization schedule to
be fully protected. Use the immunization card as an instructional guide and congratulate
the caretaker if the child has completed a series
• Write the date for the next vaccination on the immunization card and tell the caregiver. If
appropriate, associate the date with a well-known day, such as a holiday or festival that
will help them remember to return to complete their immunization schedule
• Ask the caregiver to repeat the date to be sure it is understood
• Explain to the caregiver that if the child cannot come on the return date, they can obtain
the next vaccination at another location or another date close to the due date
• Remind the caregiver to bring the immunization card when they bring the child back for
the next vaccination
• Inform them to always carry the immunization card. If they are travelling to other places
during the next vaccination date, inform them that they can vaccinate their child /
pregnant woman anywhere in the country if they have the vaccination card with them

They should remind parents about four key messages which are as follows:

121
 Fig. no.8.4. Delivery of four key messages after vaccination
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

Proceed with vaccination, including explanation of positioning, as described later.

After vaccination
• Always ask the beneficiary to wait for 30 minutes to observe for any adverse reactions
• Remind the caregiver when to return with the infant. The date of next vaccination as per
UIP schedule will be auto filled in the e-vaccination certificate generated in U-WIN
• In the event of any out-of-stocks of vaccine at the time of the session, inform the caregiver
where and when to return for the next doses
• Remind the caregiver about other services given during immunization session; for
example, vitamin A supplementation or Td vaccine for women
• If immunization campaigns are planned in the coming months, inform the caregivers about
the date of the campaign, what vaccination is being given, and where the vaccination site
will be
• Offer relevant print information to caregivers who are literate
• Ask the caregiver if they have any questions or concerns and answer them politely

III. Assessing infants for vaccination:

a) Eligibility for immunization
• Verify the infant’s age on the immunization card or ask the caregiver in case the card
is not available
• Check due vaccines on U-WIN. If the beneficiary is not registered in U-WIN, then register
them on U-WIN
• Verify which vaccines the infant has received by reviewing the immunization card or
ask the caregiver in case the card is not available. Fill a new card

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 • Verify all vaccines the infant needs at this session to allow efficient preparation
o If the infant is eligible for more than one type of vaccine, it is safe to give ALL
the different vaccines to one child at different injection sites during the same
session
o If the baby has regurgitated the administered oral vaccines (OPV & Rota), the health
worker should repeat the complete dose in the same immunization session.
o If the vaccine is delayed, do not restart the schedule. Simply provide the next
needed dose in the series
• If there is a delay in starting the immunization schedule, give the due vaccine(s) and
an appointment for the next dose at the interval as recommended in the national
immunization schedule

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

b) Assess for the possible contraindications
All infants should be immunized except in these situations:
• Do not vaccinate severely sick child, ask the caregiver to come on next available
session after the child recovers
• Do not give a vaccine if the infant has had anaphylaxis (a serious allergic reaction) or
other severe reaction to a previous dose of the vaccine or a vaccine component
• Vaccination of a known immunocompromised (HIV/ on steroid/ chemotherapy, etc.)
child should be done in consultation with the treating physician
• High fever (>38.5°C). Do not give a vaccine if the caregiver objects to immunization
for a sick infant after explanation that mild illness is not a contraindication. Ask the
caregiver to come back when the infant is well
• Vaccinate malnourished children as per schedule as they are more prone for
vaccine preventable diseases

IV. Giving vaccinations:

Sequence of vaccines administered at different schedule in UIP is explained in unit 3.
a) Good oral administration technique: Administer oral vaccines before injectable vaccines
OPV and Rotavirus vaccines are the oral vaccines in the national immunization schedule.
Do not vaccinate child who is sleeping. Do not give oral vaccine to a crying baby. Wait
for baby to stop crying.

Position: Use the cuddle position on the caregiver’s lap with the head supported and
tilted slightly back. Vaccinator stands to one side (see Table 8.1).

Administration: Open the infant’s mouth by gently squeezing the cheeks between your
thumb and index finger using gentle pressure. Firm squeezing can cause distress. NEVER
pinch the nose to open the mouth of child.
• Ensure that, two drops of OPV and five drops/2ml of rotavirus vaccine fall from the
dropper onto the tongue. Do not let the dropper touch mouth of the infant

Disposal: Discard the used oral vaccine vial into the red bag

b) Preparing to vaccinate
Use aseptic technique to prepare vaccines:
• Start with handwashing – use soap and water and dry your hands thoroughly
• Work on a clean table
• Prepare vaccines individually for each child; NEVER prefill syringes in anticipation of
the next beneficiary

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 c) Reconstitution of vaccines
Vaccines that need to be mixed with diluent before use are BCG, MR and JE (Live
attenuated) vaccine. Use these vaccines 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
 Reconstitute the vaccine with entire amount of diluent immediately before use
 Reconstitute the vaccine even when only one eligible child is present
 Write the date and time of reconstitution on the label of the vial immediately
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

following reconstitution. Use the reconstituted vials only for a single session; do not
carry them for another session
 If any AEFI occurs following use of any vial, do not use that vial; mark it and retain
safely for AEFI investigation

Steps for reconstitution

 Check for VVM on the vial. The VVM indicates whether the vaccine is usable or not.
Once reconstituted, VVM is of no use, as these vaccines has to be used within 4 hours of
reconstitution
 Double check each vial/ampoule for the expiry date and ensure that it is used within
expiry date
 Open the vaccine vial. For a metal cap, use a vial opener to lift the pre-cut centre and bend
it back; for a plastic cap, flip it off with your thumb or slowly twist it depending on the
specific instructions for the type of vial
 Open the glass ampoule (with diluent) by holding the ampoule between the thumb and
middle finger and supporting the top with the index finger; scratch the ampoule neck with
a file, then gently break off the top, taking care to avoid injury from the sharp glass (see
Figure 8.5). If vaccinator gets injury, the ampoule should be discarded since the contents
may have been contaminated. Cover the wound before opening a new ampoule
 Draw the entire diluent out with a new disposable reconstitution (mixing) syringe and
needle
 Insert the needle of the reconstitution (mixing) syringe into the vaccine vial and empty all
the diluent – depress the plunger slowly to avoid frothing inside the vaccine vial
 Remove the reconstitution needle and cut the mixing syringe at the hub with a hub-cutter
 To mix the diluent and vaccine, shake the vial gently by holding at the neck. Take care
not to touch the rubber septum or rub the vial between palms for mixing
 Write the date and time of reconstitution on the vial label
 Put the reconstituted vaccine vial on the ice pack of your vaccine carrier
 Use the reconstituted vaccine, within four hours of reconstitution. At the end of four
hours, Discard the vaccine vial. DO NOT USE the vaccine. Do not carry them for another
session. Reconstitute a new one if needed

Never touch the needle of the syringe. Ensure that the needle should not touch any part of
finger of the vaccinator during the entire process of vaccination.

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Fig. 8.5: Procedure of reconstitution

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

d) Positioning the child for vaccination
The aim of positioning is to keep the child still and the caregiver and vaccinator
comfortable. The choice of position will depend on the number of vaccines to be given,
the age of the child and the materials available. Explain to the caregiver how to hold the
child and that it is important to keep the child steady in order to reduce any pain.

Table 8.1 Different positions for vaccinating

Position Illustration Directions for caregiver
Cuddle position: 1. Sit on a chair holding the infant
Semi-recumbent on sideways on lap with one arm
caregiver’s lap behind infant’s back.
2. Tuck the infant’s inside arm
around their own back to hug
the shoulders and upper body
close to their body.
3. Bring their arm around the
infant’s back to hug the
shoulders and upper body
close to their body.
4. Tuck the infant’s legs between
their own to hold them with
their other arm.
5. Vaccinators should position
themselves to avoid strain
while giving vaccines at the
correct angle.

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 Bed position: 1. Lay the infant, with both legs
Lying on back on flat bare on a flat surface.
surface 2. Stand on the other side of the
bed and hold the infant’s hands
and arms.
3. Vaccinator should stand at
the infant’s feet and use non-
injecting hand to gently cup the
slightly bent knee of the leg to
receive the vaccine.
Upright position: 1. Sit on a chair holding the infant
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

Sitting upright on sitting facing straight outwards

the caregiver’s on their lap.
lap, facing straight 2. Rest the infant’s back against
outwards their chest.
3. Encircle (hug) the infant’s upper
body and arms with one arm
and use the other arm to hold
the infant’s lower legs (lower
legs and feet on behind the
other between the caregiver’s
knees.
4. Vaccinator should stand on the
side of the first injection and at
the level where it can be given
at 90 degree angle.

Straddle position: 1. Sit on a chair holding the child

Child>12 months facing them and sitting astride
of age vaccinated their knees.
sitting upright on 2. Encircle (hug) the child’s upper
caregiver’s lap, body and arms with their arms.
facing towards them 3. If necessary, use one arm to
with straddling over secure the child’s leg.
theirs 4. Vaccinator should stand on the
side of the injection.
Independent Adolescent/adult vaccinated
position: sitting on a chair
Adolescent/adult
vaccinated sitting on
a chair

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 e) Good injection technique
Good injection technique includes administering all injectable vaccines with an auto-
disable (AD) syringe. To use AD syringes correctly, remember that the plunger of an
AD syringe can only go back and forth once; so do not draw up air to inject into the
vaccine vial when filling the AD syringe.

Summary of injection steps

• Wash skin that looks dirty with Fig. 8.6 Needle positions for ID, SC and IM
water. Swabbing clean skin is not injections
necessary. Do not use alcohol
to clean the skin before giving

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

vaccinations
• Hold the syringe barrel between the
thumb, index and middle fingers.
Do not touch the needle
• For intradermal (ID) injections,
gently stretch and support the skin
with the thumb and forefinger. Lay
the syringe and needle almost flat
along the infant’s skin. Gently insert the needle into the top layer of the skin (see Fig. 8.7)
• For subcutaneous injections (SC), gently squeeze the skin. Insert the entire needle at a
45-degree angle (towards the shoulder) with a quick, smooth action (see Fig. 8.8)
• For intramuscular injections (IM), gently stretch and support the skin between thumb and
forefinger. Push the entire needle in at a 90-degree angle with a quick, smooth action
• For all injections, depress the plunger slowly and smoothly, taking care not to move the
syringe around
• For all injections, pull the needle out quickly and smoothly at the same angle that it went
in
• For all injections, the caregiver may hold a clean swab gently over the site if it bleeds after
injection
• For all injections, cut the hub of the syringe with hub cutter and put the plastic part of the
syringe into the red bag immediately after each vaccination
• For all injections, soothe and distract the child when all the vaccines have been given

f) Intradermal (ID) injection

BCG and IPV are injected intradermally (into the layers of the skin) for slow absorption.
BCG - left upper arm and IPV - right upper arm (1st and 2nd dose) & left upper arm (3rd dose).
To measure and inject the very small dose Fig.8.7. Administration of intra-
(0.05ml/ 0.1 ml) accurately, a special syringe dermal injection
and needle are used.

How to give BCG/IPV intradermally

1. Position: Cuddle position on caregiver’s lap

2. Administration technique:
Gently stretch and support the skin with the
thumb and forefinger. Lay the syringe and needle
almost flat along the infant’s skin. Gently insert
the needle into the top layer of the skin.

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 • Hold the syringe barrel with the bevel (hole) of the
needle facing upwards

Place the syringe and needle almost flat (10 to 15

degrees) along the infant’s skin.
• Place your other thumb on the lower end of the
syringe near the needle to hold the needle in position, but do
not touch the needle
• Insert the tip of the needle under the surface of the skin just
past the bevel
• Hold the plunger end of the syringe between the index and
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

middle fingers. Press the plunger with the thumb

• Push the plunger slowly; there will be some resistance while the
bleb forms. If you feel no resistance to the plunger, you are not
in the right place and should reposition
• A pale flat-topped swelling with small pits like an orange peel
should appear on the skin
• After administration do not rub the area or allow the caregiver
to rub the area
• Remove the needle smoothly at the same angle as it went in
• The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or
massage the area
• Care to be taken to avoid child from rubbing the area after the injection is given.
• Soothe the infant

If the vaccine is administered incorrectly, the risk of side effects, such as abscesses or
enlarged glands is greater specially for BCG vaccine, so the technique is very important.
It is better to ask for help from a supervisor or other colleague than to continue giving
intradermal injections incorrectly.

3. Disposal: Cut the hub of the syringe with hub cutter and put the plastic part of the syringe
into the red bag immediately after each vaccination.

Fig. 8.8 Subcutaneous injection

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g) Subcutaneous (SC) injection in the upper arm
The injection is given into the layer below the skin. Right arm is used for MR vaccine and
left arm is used for JE Live attenuated vaccine.

How to give a subcutaneous injection

1. Position: The position depends on the age of the child, the number of vaccinations to be
given and what is easiest and most convenient for the vaccinator.

2. Administration:
• Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the
bevel (hole) of the needle facing upwards

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

• Quickly push the needle into pinched-up skin; the needle should point towards the
shoulder at a 45-degree angle. (See fig. 8.8)
• Depress the plunger smoothly, taking care not to move the needle under the skin.
• Pull the needle out quickly and smoothly at the same angle as it went in
• The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or
massage the area
• Soothe and distract the infant

3. Disposal: Cut the hub of the syringe with hub cutter and put the plastic part of the syringe
into the red bag immediately after each vaccination.

h) Intramuscular (IM) injection in infants

The muscle on the Anterolateral aspect of Mid-Thigh (upper outer part of the thigh) is
large and safe for intramuscular injections. (See Fig. 8.9)

In children aged less than 5 years the deltoid muscle of the upper arm is not safe to use
since it is not developed enough to absorb the vaccine and the radial nerve is close to the
surface. The deltoid muscle may be used in older children, adolescents and adults.

Fig. no. 8.9: Showing appropriate site (x mark) Fig. no. 8.10: Showing 90º
for IM Injection in infants placement of needle

Intramuscular
injection site

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 Fig. no. 8.11: Showing site for IM Injection in older children
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

Intramuscular
injection site

How to give an intramuscular injection to an infant

1. Position: The position depends on the age of the child, the number of vaccinations to be
given and what is easiest and most convenient for the vaccinator.

2. Administration:
• Hold the syringe barrel with fingers and thumb on the sides of the barrel and with the
bevel (hole) of the needle facing upwards
• Gently stretch and support the skin on the upper, outer thigh with the other hand and
quickly push the needle at a 90-degree angle down through the skin into the muscle
• Depress the plunger smoothly, taking care not to move the needle under the skin
• Pull the needle out quickly and smoothly at the same angle as it went in
• The caregiver may hold a clean swab gently over the site if it is bleeding. Do not rub or
massage the area
• Soothe and distract the infant

3. Disposal: Cut the hub of the syringe with hub cutter and put the plastic part of the syringe
into the red bag immediately after each vaccination.

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Advantages of multiple injections

UIP schedule is designed to provide a child several vaccinations during the same visit as this
offers three major advantages:

• Protecting children: Immunizing children as soon as possible provides protection during

the vulnerable early months of their lives. Often, diseases are more severe in babies.
• Fewer vaccination visits: Giving several vaccinations at the same time means parents and
caregivers do not need to make as many vaccination visits.
• Increasing efficiency: It means that you will be able to more efficiently provide and deliver
other health services by reducing the time they need to spend providing vaccinations.

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

Two injections can be given at one site, three fingers apart.
This may be needed only in few drop out/late vaccination cases

V. Closing the session:

1. After immunization session is over

Segregate the vaccine vials (used and unused) and keep these inside in separate
properly sealed 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. Leave the site clean and tidy.

Specifically, after using an outreach site:

o Do not leave anything behind that might be a health threat to the community
o Clean and return tables, chairs and other equipment to their owners
o Thank the local people who have helped to organize the session and remind them
of the date of the next session

2. At the vaccine storage/cold-chain point at the end of immunization day

Cold-chain handler should ensure appropriate segregation of the vaccines as explained
below:

Unopened vials:
1. If VVM is intact and in usable stage, retain the vial in ILR as per guideline, and issue
accordingly
2. 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 a separate Cold-
chain Equipment (+2° to +8° C). Such vial should be discarded after 48 hours.

Opened vials:
1. Segregate the vials on which Open Vial Policy is not applicable such as BCG/MR/
RVV with VVM on the Cap/ stem, JE (live) vaccine to retain in a plastic box clearly
marked “Not to be used” in a separate Cold-chain Equipment (+2° to +8° C). These
vials should be discarded after 48 hours. In case of any reported AEFI they will not
be discarded but retain in proper cold-chain for investigation.
2. Segregate the vials for which Open Vial Policy is applicable such as OPV/Td/DPT/
Hepatitis-B/Pentavalent/IPV/PCV/JE(Killed)/RVV with VVM on Label as below:
a. If VVM is intact and is in usable stage, expiry date not passed and the written

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 date & time of vial opening is readable then retain the vaccine vial in ILR as
per guideline subjected to condition that vial is within 28 days of opening
and reissue in the next session after ensuring that it has not passed 28 days of
opening the vial.
b. If VVM is intact and is in usable stage, expiry date not passed and the written date
& time of vial opening is readable but the vaccine vial has crossed 28 days of
opening. These vials should be discarded after ascertaining that these vials are
not required for AEFI investigation.
c. 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 a separate Cold-chain
Equipment (+20 to +80C). These vaccine vials should be discarded after 48 hours
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

or before the next session whichever is earlier.

3. If there is any vial which has been used and there is report of AEFI, that vial (even
if it is in usable stage) has to be kept separately in proper cold-chain and properly
sealed zipper bag earmarked “For AEFI Investigation” in a separate Cold-chain
Equipment (+20 to +80C) under special custody and in the knowledge of Medical
Officer. 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.

Wipe the carrier with a damp cloth and check it for cracks. Repair any cracks with adhesive
tape and leave the carrier open to dry.

Recording data
Accurate and reliable records are vital, not only for the individual child but also to track the
immunization status through monthly and annual reporting.

During a session, individual immunization cards and health centre records – such as registers,
counter foils and tally sheets – have to be completed. It is to be ensured that all data for the
immunization done on the day are entered in U-WIN at the time of same session.

Analyze the session due list and tally sheet

After every RI session:
• Enlist all beneficiaries who did not turn up for vaccination for any reason.
• After listing such names, enter the names of beneficiaries 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 mobilize the beneficiaries for vaccination
• The reasons for not turning up for vaccination, must be addressed by the team. Seek
support from local influencers/key persons to identify any children or beneficiaries before
leaving the session site
• Remind the ASHA/AWW/LW on the next session date before leaving the session site

8.2. Using the immunization session checklist

Immunization session checklist (Table 8.2) can help ensure safety before, during and after
immunization. This checklist is a reminder of key points in preparation, vaccination and

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closure of sessions that are described above, and is meant to reinforce positive actions.
A printed copy of this checklist can be posted on a wall in the immunization area for easy
viewing throughout sessions.

Table 8.2. Immunization session checklist

Before the Immunization During the immunization After the Immunization
session session session
DID YOU: DID YOU: DID YOU:
1. CHECK if sufficient quantities 1. GREET the beneficiary and 1. CORRECTLY ASSESS if open
of vaccines and diluents are caregiver? Y/N vials can be used in the next
available for the session? Y/N 2. REVIEW the beneficiary’s session in accordance with
2. CHECK vials for the following and immunization card? Y/N open vial policy? Y/N

CONDUCTING THE ROUTINE IMMUNIZATION SESSION

take appropriate action: 3. DETERMINE eligible 2. DISCARD open vials that
• Expiry dates? Y/N vaccinations based on should not be used? Y/N
• Open vial date/time? Y/N the national schedule, 3. RECORD date and time of
• VVM status? Y/N beneficiary’s age and possible opening on vials that can be
• Freezing status? Y/N contraindications? Y/N Used and PLACE them in the
3. PLACE vials in the appropriate 4. RECONSTITUTE each vaccine use first” box in the ILR? Y/N
place in the immunization area? with its matched diluent (for 4. RETURN unopened vials to
Y/N lyophilized vaccines)? Y/N the cold-chain point ? Y/N
4. ENSURE sufficient supplies are 5. FILL syringes just before 5. COMPLETE Session due-list
available for the session including: administration using aseptic cum Tally sheet? Y/N
• Auto-disable (AD) syringes? Y/N technique? Y/N 6. LIST the names of children
• Reconstitution syringes? Y/N 6. ADMINISTER each vaccine who missed vaccination and
• Hub cutter? Y/N according to recommended require follow up? Y/N
• Black, red and blue bags? Y/N technique and correct injection 7. HANDLE immunization
• Immunization register? Y/N site? Y/N waste correctly? Y/N
• Immunization tally sheets? Y/N 7. IMMEDIATELY cut syringes with 8. TAKE appropriate action to
• Blank immunization cards? Y/N hub cutter after each injection? ensure sufficient vaccine
5. WASH your hands with soap? Y/N Y/N stock for the next session?
8. RECORD all vaccinations Y/N
in register, tally sheet and 9. INFORM COMMUNITY of date
immunization card? Y/N and time of next session? Y/N
9. COMMUNICATE key messages,
including potential AEFls and
date of next visit? Y/N
10. Did the U-WIN data entry for all
those were vaccinated? Y/N

8.3. Birth dose vaccination protocol22

Birth dose vaccination of the child is an integral component of Universal Immunization

Programme (UIP) and is provided against three vaccine preventable diseases (hepatitis B,
poliomyelitis and severe form of childhood tuberculosis).

These vaccinations should be provided SOON after child’s birth and certainly before the
mother is discharged from the health facility. Particular care has to be taken for the hepatitis
В vaccination which needs to be administered AS SOON AS POSSIBLE and certainly within
24 hours of birth to prevent transmission of infection from mother to infants. The risk
of acquiring hepatitis В infection for a neonate can be as high as 85-90%, if the mother is
hepatitis В positive.

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 The following protocol for administering birth dose vaccination is to be followed-
1. Hepatitis B, BCG including diluent and Oral Polio Vaccine (OPV) should be stored in a
vaccine carrier with four conditioned ice packs (if it’s a cold-chain point)
2. Birth dose vaccines should preferably be available in post-partum area where the
mothers with babies are shifted immediately after delivery. Immunization session/
administration of the Birth dose is to be organized in that area.
3. Designated staff nurses/ANMs posted in the labour room should be responsible for the
administration of the birth dose vaccination to the newborn. They should be trained/
oriented for the same.
4. Hepatitis В and OPV vaccine should be opened even if there is a single newborn for
CONDUCTING THE ROUTINE IMMUNIZATION SESSION

vaccination and open vial policy should be followed. The open vial policy guidelines are
attached as annexure for ready reference.
5. Hepatitis В and OPV birth dose should be given to all the newborns immediately after
birth and definitely within 24 hours of birth.
6. BCG needs to be reconstituted before administration of the vaccine to the newborn
and to be used within four hours after reconstitution. Efforts should be made that every
newborn should be vaccinated before discharge with BCG. Therefore, a new vial of BCG
vaccine should be opened and reconstituted if need be, thereby ensuring availability of
BCG vaccine at all times. If the newborn misses the birth dose for some totally unavoidable
reasons, the dose of BCG to be administered at the next earliest opportunity or next
vaccination i.e. at 1.5 months/6 weeks when the infant is due for Pentavalent 1/OPV 1
vaccination.
7. Date and time to be recorded for all the open vials.
8. Hepatitis В should be administered intramuscular in the anterolateral aspect of the left
thigh, while vitamin К should be administered intramuscular on the anterolateral aspect
of the right thigh at the same time.
9. The birth dose of vaccines should be recorded both on MCP card/baby case sheet as well
as the discharge slip, while the Vitamin К administration to be recorded on the discharge
slip.
10. In case mother is discharged before 24 hours, ensure that infant has received all three-
birth dose vaccination.
11. If the child after delivery is shifted to NICU, the birth doses should be given in consultation
with pediatrician /neonatologist.
12. If the institutions are also getting newborns delivered outside the institution who have
not been immunized with birth doses, the same should be given as early as possible.
13. At the time of discharge advice should be given to parent to bring the child for next doses
of vaccination at 1.5 month/6 week of age of the child.
14. Ensure availability of all logistics like vaccines, diluents, syringes, hub cutter, etc.
15. Regular supervision and monitoring of the above processes to be ensured.

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 Unit 9
Adverse Events Following
Immunization (AEFI)

135
 Learning objectives
At the end of the unit, health worker should be able:
• To list and identify adverse events following immunization
• To manage adverse events (fever, local reactions, suspected
anaphylaxis at the session site)
• To explain the steps in recording and reporting adverse events
following immunization
• To list the responsibilities of health service providers in minimizing
AEFIs

Key contents Page

9.1. Adverse events following Immunization (AEFIs) 137
9.2. Types of AEFIs 137
9.3. Reporting of AEFIs 142
9.4. Managing AEFIs 143
9.5. Use of syrup Paracetamol following vaccinations 145
9.6. First line Management of Anaphylaxis in Field Settings 146
9.7. Role of ANM/ vaccinator in initial management of anaphylaxis 146
9.8. Responsibilities of health service providers in AEFI surveillance 152

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Adverse Events Following
Immunization (AEFI)

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

9.1. Adverse events following immunization1, 23, 24, 25

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 unfavorable or unintended sign, symptom or disease. Reported
adverse events can either be truly associated with vaccine or result of immunization process;
or coincidental events that are not due to the vaccine or immunization process but are
temporally associated with immunization.

AEFIs may not necessarily be causally related to vaccine/vaccination. Therefore, adverse

events generating parental, community or media concerns should also be reported as AEFIs.

9.2. Types of AEFIs:

Based specifically on the severity, cause and frequency, vaccine reactions or AEFIs may be
broadly grouped as under:
I. AEFIs by severity of the event:
a) Minor reactions (common)
b) Severe vaccine reactions (uncommon)
c) Serious vaccine reactions (rare)

II. Cause-specific AEFIs:

a) Vaccine product-related reactions
b) Vaccine quality defect-related reactions
c) Immunization error-related reactions
d) Immunization-triggered stress response (ITSR)
e) Coincidental events

I. AEFIs by severity of the event:

For the purpose of reporting, AEFIs can be minor, severe and serious. Most vaccine reactions
are minor and settle on their own. Severe and serious reactions are rare.

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ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

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.

Local reactions (pain, swelling and/or redness at the injection site) and fever can be expected
in about 10% of vaccinees, except for those injected with DPT, or tetanus-adult diphtheria
(Td) 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. Measles/MR vaccine causes fever, rash and/or
conjunctivitis, and affects 5–15% of recipients.

Serious and severe vaccine reactions:

Serious AEFI: An AEFI will be considered serious if it results in death, requires hospitalization,
results in persistent or significant disability/incapacity or congenital anomaly/birth defect
or a cluster (two or more cases) of AEFIs occur in a geographical area or the AEFI evokes
community concern.

SERIOUS AEFI
• Death • Hospitalization • Clusters • Disability • Congenital anomaly/birth defect
• Media reports/ community or parental concern

Severe AEFI: AEFIs that are clinically more severe than minor AEFIs but do not have
characteristics of serious category (events resulting in death, inpatient hospitalization or
disability) are reported as severe AEFIs. This category includes cases that are clinically severe,
but do not need admission in hospital and/or are treated in OPD/daycare or could not be
admitted due to any reason.

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SEVERE AEFI
• Can be disabling and, rarely, life threatening
• Most do not lead to long-term problems
• Must also be reported
• Examples: seizures, hypotonic hypo responsive episodes (HHE), prolonged crying,
thrombocytopenia

Examples include non-hospitalized cases of seizures, hypotonic hyporesponsive episodes

(HHEs), persistent screaming, anaphylaxis, severe local reaction, injection site abscesses,
etc. Anaphylaxis, while potentially fatal, is treatable without leaving any long-term effects.

Fig. 9.1. Minor, serious and severe vaccine reactions:

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Severe Reactions
• Are clinically more severe than minor
Minor Reactions reactions, may or may not be life
• Common and self limiting threatening

• Occurs within a few hours of • Most do not lead to long-term problems

vaccination • Examples - high grade fever (102° F) treated
without hospitalization, allergic reactions
• Resolves over a short period of time
managed without admission on OPD basis

Serious reactions
Death
Inpatient hospitalization
Persistent or significant
disability
AEFI cluster
Congenital anomaly
Parental / community /
media concern

II. Cause-specific AEFIs:

Following is the cause-specific categorization of serious/severe AEFIs

Table 9.1. Cause-specific type of AEFI

Sl. No. Cause-specific type of AEFI Definition
1. Immunization error-related An event that is caused by inappropriate vaccine
reaction handling, prescribing or administration and thus by
its nature is preventable.
2. Vaccine product-related Vaccine product-related reaction is an event that
reaction is caused or precipitated by a vaccine due to one
or more of the inherent properties of the vaccine
product.

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 3. Vaccine quality defect- An event that is caused or precipitated by a vaccine
related reaction that is due to one or more quality defects of the
vaccine product, including its administration device
as provided by the manufacturer.
4. Immunization triggered An event arising from anxiety about the
stress response (earlier immunization.
Immunization anxiety-
related reaction)
5. Coincidental event An event that is caused by something other
than the vaccine product, immunization error or
immunization anxiety.
ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Reference: CIOMS/WHO 2018

Note: “Immunization” as used in these definitions means the usage of a vaccine for the purpose
of immunizing individuals. “Usage” includes all processes that occur after a vaccine product
has left the manufacturing/ packaging site, i.e. handling, prescribing and administration of
the vaccine.

Immunization error-related reactions

An adverse event can occur as a result of inappropriate handling/ prescribing/ administration
of a vaccine. It is very important to prevent, identify and rectify these errors. (Table 9.2).
Programme errors may impact the confidence vaccine beneficiaries have in vaccines in the
area and will require special advocacy and communication activities to get the immunization
programme back on track.

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 9.2 : Immunization error-related reactions

Immunization Examples Related reaction

Error
Error in vaccine Exposure to excess heat or cold Systemic or local reactions due to
(and diluent) (using hard frozen ice packs in changes in the physical nature of
handling RI) as a result of inappropriate the vaccine, such as agglutination
transport, storage or handling of aluminium-based excipients in
of the vaccine (and its diluent) freeze-sensitive vaccines.
where applicable. Besides AEFI, there is possibility of
failure to vaccinate as a result of
Use of a product after the expiry loss of potency or non-viability of
date. an attenuated product.

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Error in vaccine Failure to adhere to a Anaphylaxis, disseminated
prescribing or contraindication. infection with an attenuated live
non-adherence to vaccine.
recommendations Failure to adhere to vaccine Systemic and/or local reactions,
for use indications or prescription (dose neurological, muscular, vascular
or schedule). or bony injury due to incorrect
injection site, equipment or
Use of reconstituted vaccine technique.
beyond the recommended Contamination of the vaccine
period. (usually with bacterium
Staphylococcus aureus), leading
to local tenderness and tissue

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

infiltration, vomiting, diarrhea,
cyanosis, high temperature,
dehydration and death within a few
hours after administration, if not
managed in time.
Error in Use of an incorrect diluent or Reaction due to the inherent
administration injection of a product other than properties of whatever was
the intended vaccine. administered other than the
Incorrect sterile technique or intended vaccine or diluent.
inappropriate procedure with a Infection at the site of injection
multidose vial. / beyond the site of injection,
local reaction (e.g., suppuration,
Inadequate shaking of the abscess), systemic effect (e.g.,
vaccine before use, superficial sepsis or toxic shock syndrome), or
injection and use of frozen blood borne-virus infection (e.g.,
vaccine HIV, Hep B or Hep C).
Sterile abscesses and local
reactions from aluminum
containing vaccines.

With the introduction of AD syringes, infections due to non-sterile injections have reduced
significantly.

Vaccine product-related reaction

This is a reaction (an individual body’s response) to the inherent properties of the administered
vaccine, even when the vaccine has been prepared, handled and administered correctly.
Examples of common minor reactions are fever, pain, etc. and severe/serious reactions are
anaphylaxis, etc.

Vaccine quality defect-related reaction

This is a defect in a vaccine that occurred during the manufacturing process.

Immunization triggered stress response (earlier Immunization anxiety-related reaction)

It is a response to the stress some individuals may feel about getting an injection and
encompasses a spectrum of manifestations ranging from a vasovagal reaction (fainting),
hyperventilation to a dissociative neurological symptom reaction which includes non-
epileptic seizures (formerly known as a conversion reaction). Clinical presentations include

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 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.

Immunization stress-related response are common in adults, adolescents and children over
5 years of age, resulting from pain of injection and is unrelated to the content of the vaccine.
These are common in mass vaccination campaigns.

To minimize this anxiety response, it is advisable that the beneficiaries and caregivers are
explained about the vaccine and its process before vaccination. If possible, the vaccinator
needs to segregate potential recipients from those who received the vaccine. For management
of such events, please refer to the paragraph on managing AEFI.
ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Coincidental events
Coincidental event– this means that the event has occurred after immunization and is not
caused due to the vaccine or process of administration. These 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, or when
underlying congenital or neurological conditions are manifested. It is, therefore, possible to
encounter many events, including deaths, which may be falsely attributed to vaccine through
chance association. Immediate investigation as a response is critical to the community’s
concern about vaccine safety and to maintain public confidence in immunization.

9.3. Reporting of AEFIs

If the health worker comes across an adverse event following vaccination, it should be
reported. AEFI can be reported after any vaccine whether
o Given in UIP schedule or not
o Given in government or private setting
o Beneficiary is a child or adult

AEFI registers at PHCs, CHCs, etc.

• All ANMs should notify all AEFIs (serious, severe and minor) of their respective areas
immediately and document the details in an AEFI register (see Annexure D) to be
maintained at all centers from PHC upward. Medical Officer In-charge of the center should
analyze the information regularly to look for any pattern or preventable programme
errors
• A serious or severe AEFI case needs to be reported immediately to the concerned Medical
Officer or to DIO
• The medical officer will fill a hard copy of CRF, sign it and forward it to DIO, who will verify,
countersign and upload the information and scanned copy of CRF in SAFE-VAC

Reporting of AEFIs in U-WIN: The vaccinators can report the AEFIs through U-WIN. The
details about the reporting in U-WIN in mentioned in unit 13

Reporting in Health Management Information System (HMIS)

In the current HMIS system, there are formats for reporting of various data primarily related
to RCH from facilities specifically sub-centers, PHCs/wellness centres, CHCs, sub-divisional
hospitals, district hospitals and medical colleges. In case of sub-centres (HWC-Sub-centre),

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the number of AEFI cases reported during the month is recorded under section 8.6 Adverse
Event Following Immunization (AEFI). There are four rows under this section as follows:

Fig. 9.2. HMIS Monthly service delivery reporting format

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Please note that deaths (reported under 8.6.3a) will also be reported under 8.6.3.

ANMs should enter “0” in the relevant row in the formats, if no AEFI has been reported. The
numbers need to be entered separately for “In facility” and “Outreach” as may be the case.

9.4. Managing AEFIs

Health workers must have a humane, sensitive and empathetic approach in dealing with AEFI
cases. Timely attention and management of AEFIs can prevent serious clinical consequences
and helps in maintaining confidence of the caregiver.

At the session site

Health workers must be vigilant so that AEFIs can be prevented, detected timely and
managed.

Preparedness: At the session site, health worker or vaccinator should follow the guidelines
as mentioned below:
 Ensure recipients wait for 30 minutes at session site after vaccination and monitor the
health condition of the recipient
 To reduce chances of occurrence of Immunization stress related responses, minimize
overcrowding by proper planning of immunization sessions and reduce waiting time.
Prepare vaccines out of recipient’s view, ensure privacy during the procedure and keep
the beneficiaries engaged during the observation period
 After vaccination, inform the vaccine recipient
i. About any minor events which may occur
ii. Adverse events such as mild to moderate fever, local pain and swelling at injection
site, malaise, etc.:
a. Syrup Paracetamol-125mg/5ml (for infants and children) or tablet Paracetamol
(for adults) SOS with a minimum interval of 4-6 hours between two doses
b. Ask the beneficiary to visit the nearest health facility, if minor adverse events

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 persist beyond 2-3 days
iii. In case of adverse event/discomfort/illness, other than minor events, the beneficiary
should visit the nearest health facility
 Anaphylaxis kit with inj. adrenaline within expiry date must be available at outreach
session site
 Inform Medical Officer immediately by telephone about serious/severe AEFIs
 Emergency numbers (102, 108, etc.) for transporting case to AEFI management center /
higher health facility with vaccinator team

Fig. 9.3: Contents of Anaphylaxis kit Fig. 9.4 Contents of an AEFI treatment kit
ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

The differences in anaphylaxis kit and AEFI kit are mentioned in table 6.12 below.

Table 9.2: Difference between AEFI kit and Anaphylaxis kit

Anaphylaxis kit AEFI kit
At immunization session site At health facility well equipped to manage
anaphylaxis (PHC/CHC/district hospital, etc.)
For use by ANM/ Health worker/vaccinator For use by medical officer
Contains adrenaline, tuberculin/insulin In addition to contents of the Anaphylaxis
syringes, 24/25 G one-inch needles, swabs, kit, contains intubation and resuscitation
guidelines/job aid with dose calculation equipment, hydrocortisone (injection and
tablet), ringer lactate, normal saline, 5 %
dextrose, IV drip set, scalp vein sets.

Managing AEFI when it occurs

When a serious or severe adverse event occurs, you should immediately:
o Provide immediate first aid: lay child flat; ensure airway is clear. If child is unconscious,
put in semi-prone position
o Refer to the MO (PHC) or nearest AEFI management centre for prompt treatment.
Accompany the patient if needed
o Inform the MO (PHC) at the health centre immediately by the fastest means possible e.g.
telephonically
o Report and assist in investigation of AEFIs

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Treat minor/non-serious AEFIs symptomatically as per Table below:

Table no 9.4. Minor reactions due to vaccines

Minor vaccine reactions Treatment When to report
Local reaction (pain, • Cold cloth at injection site • In case of an abscess
swelling, redness) • Give Paracetamol
Fever > 38.5°C • Give extra fluids • When accompanied by
• Give tepid sponging other symptoms
• Give Paracetamol
Irritability, malaise and • Give extra fluids • When severe or unusual
systemic symptoms • Give Paracetamol

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

9.5. Use of syrup Paracetamol following vaccinations24

Some common minor adverse events following immunization are local reactions, pain
at injection site and fever. High-grade fever following vaccination may precipitate febrile
seizure in susceptible infants. The ANM should give age-appropriate dose to all children who
have got Pentavalent vaccine or DPT with an instruction to give Paracetamol in case of fever
or pain in injection site. The recommended dose of Paracetamol is 10-15mg/kg body weight
every 4-6 hours with a maximum dose of four doses in 24 hours. The recommended doses
and frequency of administration of Paracetamol syrup (125 mg/5 ml) as per age is as follows:

Table 9.5: Age wise dose of Paracetamol syrup (125 mg/5 ml) in infants
Age group Dose How often (in 24 hours)
6 weeks-6 months 2.5 ml
6-24 months 5 ml SOS or 4-6 hourly following vac-
2-4 years 7.5 ml cination#
4-6 years 10 ml
* Paracetamol is not recommended in children weighing <2 kg.
# Maximum four doses in 24 hours with a gap of at least four hours between two doses.

Note:
1. Dispense one bottle of 60 ml syrup Paracetamol 125 mg/5 ml after every dose of
Pentavalent and DPT.
2. Use the dosage chart to choose volume of single dose of Paracetamol required to be
given as per age group.
3. Show the mark on the cap till which the syrup has to be filled to the caregiver and instruct
to:
• Administer age-appropriate dose of syrup Paracetamol ONLY WHEN THERE IS FEVER.
• Not administer more than four doses a day
• USE only the cap supplied with the Paracetamol syrup bottle to measure and
administer syrup Paracetamol to the child
• Shake the bottle for 10 seconds before use if suspension is supplied in place of syrup.
• Refer the child to a doctor if the fever is >38° C (100.4° Fahrenheit)

Caregivers should be informed and encouraged to practice non-pharmacological methods

like breastfeeding before, during and after immunization for relieving pain and crying. Other

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 methods like sponging, skin to skin contact and keeping with mother are also helpful in
reducing pain, fever and crying after immunization. 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.

Refer the child to the hospital, if a child develops fever indicated by;
• An axillary temperature of 38°C or 100.4°Fahrenheit or higher
• Or feels hot to touch

For more information, please refer to “Guidelines on use of syrup Paracetamol following
vaccinations” by Ministry of Health and Family Welfare, Govt of India.
ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

9.6. First line Management of Anaphylaxis in Field Settings

Anaphylaxis and its manifestation:

Anaphylaxis is a very rare but severe and potentially fatal allergic reaction.

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.

Recognition 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.

9.7. Role of ANM/ vaccinator in initial management of anaphylaxis

ANMs are in continuous contact with the community and are responsible for delivery of
multiple health services, including immunization, antenatal care, reproductive and child
health. They are trained on safe injection practices. In order to initiate the process of timely
management of anaphylaxis cases by ANMs, they need to be trained for:
1) Early recognition of a case of anaphylaxis
2) Immediate administration of a single age-appropriate dose of injection adrenaline
intramuscularly. This injection is to be given using 1 ml syringe with 24/25 gauge 1 inch
detachable needle.
3) Arranging immediate transportation of patient to the nearest health facility/ center (well
equipped to manage anaphylaxis)

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4) Providing details of the patient to medical officer for follow up and proper documentation
in records and reports

Fig. 9.5 Steps for Initial Management of Anaphylaxis

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Steps to be taken by an ANM
a) Assess case and suspect anaphylaxis
b) Initial management of suspected anaphylaxis case with one time use of injection
adrenaline
c) Transporting suspected anaphylaxis case to the nearest health facility
d) Inform medical officer and documentation

a) Assess case and suspect anaphylaxis

A case of anaphylaxis is suspected if the following criteria are met:

Usually respiratory, dermatological and cardiovascular systems are involved in anaphylaxis.

The signs and symptoms under each of the three systems are listed in table below.

Table 9.6. Signs and symptoms of Anaphylaxis

System Signs and Symptoms
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)

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 Dermatological • Generalized urticaria (raised red skin lesion, rash with itching)
or 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
*Modified from The Brighton Collaboration Anaphylaxis Working Group; Anaphylaxis: Case Definition and Guidelines
for data collection, analysis, and presentation of immunization safety data; Vaccine; Vol. 25, (2007); 5675-5684

In most cases of anaphylaxis, skin and mucous membrane are affected. In addition to the
signs and symptoms given above, following features may also be observed: anxiety, diarrhea,
abdominal cramps, nausea, vomiting and sneezing or rhinorrhea.
ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Fig.9.6 Signs and symptoms of anaphylaxis – Cyanosis, Angioedema & Urticaria

Cyanosis

Angioedema

Urticaria

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Fig.9.7 Signs and symptoms of anaphylaxis

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

b) Initial management of suspected anaphylaxis case
Following vaccination, a case of anaphylaxis can be suspected if there is early onset of
symptoms (within minutes to 6 hours) with rapid progression. In such a case,
o The ANM should reassure the patient, parents and relatives
o The suspected case should never be left alone
o If the patient is conscious, he/she should be kept in a supine position with lower limbs
raised higher than head level
o If the patient is unconscious, he/she should be kept in left lateral position
o As per the age of patient (see table 9.7), ANM must administer one dose of injection
adrenaline by deep intramuscular route
o ANM should seek help to immediately arrange for an ambulance/vehicle to transport the
patient to the nearest health facility (PHC/CHC/District Hospital/Civil Hospital)

Steps for administration of injection adrenaline by ANM

o Take one ampoule of adrenaline (1:1000 dilution) solution from Anaphylaxis Kit (Fig. 9.3)
and check name, dilution and expiry date on label of vial (not from kit label). Remember
that adrenaline ampoules are also labelled as epinephrine. Epinephrine is another name
for adrenaline
o Take a 1 ml tuberculin syringe or a 40-unit insulin syringe and a 24/25 G one-inch-long
needle
o Using the “age specific dosing chart” available in the anaphylaxis kit, load the syringe
with the appropriate dose of adrenaline. [Table 9.7]

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 o Use swab to clean the middle 1/3rd of anterolateral aspect of the thigh of the opposite
limb to that in which vaccine was given
o Give deep intramuscular injection at 90° angle to skin in middle 1/3rd of anterolateral
aspect of thigh

Fig.9.8 Administration of intramuscular injection

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Table 9.7. Chart listing age-specific dose of adrenaline (1:1000) to be administered

intramuscularly using tuberculin / insulin syringes
Age group Dose in mL (tuberculin syringe)# Equivalent volume in insulin syringe#
0-1 ·year 0.05 2
1-6 years 0.1 4
6-12 years 0.2 8
12-18 years 0.3 12
Adults 0.5 20
# Based on type of syringe available (tuberculin 1mL/insulin), choose relevant volume of
adrenaline for administration

Anaphylaxis kit for ANM

In order to ensure availability of adrenaline and the required syringes and needles for
administration at the session site, an anaphylaxis kit should be available with the ANM at
every session. The contents of the anaphylaxis kit is mentioned in Fig. 9.3.

The anaphylaxis kit may have either tuberculin syringe or insulin syringe (without fixed
needles). Usually, insulin syringes are more easily available as compared to tuberculin
syringes. The needle to be used should be of 24G or 25G with length of one inch for IM
administration. Based on the availability of tuberculin or insulin syringe and considering

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the age of the patient, the appropriate dose of adrenaline should be loaded in the syringe.
A comparison of the markings on tuberculin (in mL) and insulin (in units) syringes for
corresponding volumes is shown in figure below.
Fig. 9.9. Tuberculin (in mL) and Insulin (in Fig. 9.10 Markings of age-appropriate
units) syringes with detachable needles dosage of adrenaline in mL (tuberculin
syringes) and in units insulin syringes

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

The following details of the patient should be conveyed to the medical officer of the health
facility well equipped to manage anaphylaxis: Name, age, date, time, site, route and dose
of adrenaline administered. The same should be available as a record with the ANM after
transferring the patient.

c) Transporting suspected anaphylaxis case to the nearest health facility

As soon as the ANM suspects anaphylaxis, she should administer injection adrenaline
intramuscular and call for the ambulance. The ANM should ensure that the patient is
transferred to the ambulance/ vehicle without delay and refer the case to nearest health
facility well equipped to manage anaphylaxis for further management.
o The ANM should keep contact details of an alternate vehicle owner/driver always. If an
ambulance is not available or it is delayed, the ANM should contact the owner/driver of
the alternate vehicle to transport the case to nearest health facility equipped to manage
anaphylaxis
o The untied sub centre funds may be used to reimburse cost of transportation

d) Informing the medical officer and documentation

o As the child is being transferred, the ANM will inform the medical officer about the case
with necessary details (name, age, date, time, site, route and dose of adrenaline
administered) for further management at the health facility well equipped to manage
anaphylaxis and for follow up
o The anaphylaxis reaction (suspected or confirmed) should be recorded in the
immunization card in block letters and further vaccinations should be given only as
per prescription of a medical officer in hospital settings with availability of adrenaline
and other resuscitation equipment
o The case details should also be recorded in the AEFI register and reported as a serious/
severe AEFI case by the MO in the CRF to the DIO

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 ANM/ staff nurses must ensure 30 minutes post vaccination observation for each beneficiary
and identify suspected case of anaphylaxis and administer one dose of Intramuscular
injection Adrenaline (age-appropriate dose) to these suspected cases at RI session site
before referring to the AEFI management center.

Not administering adrenaline can be fatal for the beneficiary suffering from anaphylaxis. One
dose of IM injection adrenaline is safe.

9.8. Responsibilities of healthcare service providers in AEFI surveillance

Community level
ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

Anganwadi and ASHA/volunteers/frontline workers

o Regular follow up with beneficiaries to identify AEFIs after the vaccination session, using
the beneficiaries’ list provided by the ANM.
o Inform the adverse event immediately by telephone to concerned ANM, MO, etc.
o Assist in referral of any suspected cases
o Assist the team investigating the event
o Support in building community confidence

Sub Centre level

ANM and CHO

• Follow best immunization practices. Prior to starting vaccination at the RI site, the ANM
must note down the following particulars:
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 the vaccines and diluents are supplied by the same vaccine manufacturer
• Ensure that vaccine vial septum has not been submerged in water or contaminated in any
way
• Ensure an anaphylaxis kit with adrenaline within expiry date is available at the session
site
• Ensure four key messages are delivered after vaccination
• Provide a list of children vaccinated during the session to the AWW/ASHA and request
them to be alert 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 the case to
MO(PHC) or to the appropriate health facility for prompt treatment and report. Inform
the MO(PHC) at the health center 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 6.2 for suggested format for
AEFI Case Register)

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• Assist in investigation of AEFIs and take corrective action in response to the guidance
from the MO (PHC)

Health supervisors (HSs)

o 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
o Monitor the community for adverse events during supervisory visits to immunization sites
or sub centres. Also monitor and ensure follow-up of beneficiaries by HWs. Ensure reasons
for dropouts are entered in the counterfoils
o Encourage the HWs to report AEFIs. Serious/severe AEFIs should be notified immediately
by the fastest means possible

ADVERSE EVENTS FOLLOWING IMMUNIZATION (AEFI)

o 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
o Assist the investigation team in conducting the investigation

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154
 Unit 10
Records, reports and
using data for action

155
 Learning objectives
At the end of the unit, health worker should be able:
• To list the records and reports to be maintained at the subcentre
• To explain the correct use of the Mother and Child Protection (MCP)
card
• To demonstrate correct use of tracking bag to keep the counterfoils
• To record the information accurately in the registers and reporting
formats
• To use coverage monitoring chart to track the progress

Key contents Page

10.1. Importance of record-keeping 157
10.2. Data tools for recording and reporting 157
• Mother and Child Protection (MCP) card with counterfoil
• Tracking Bag
• Immunization/RCH Registers
• Name based list of due beneficiaries and Tally Sheet
• U-WIN
• Monthly Progress Report
• Coverage Monitoring Chart

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Records, reports and using
data for action

RECORDS, REPORTS AND USING DATA FOR ACTION

10.1. Importance of Record-Keeping

Systematic and regular recording of the vaccinations given at each session ensures that the
immunization services reach all beneficiaries, identifies dropouts and leftouts and helps to
actively follow up all those who need to complete their vaccinations.

10.2. Data tools for recording and reporting

The following records and reports are the basis of all the information generated at the sub-
center and higher levels:
o Mother and Child Protection (MCP) card with counterfoil
o Mother and Child Register / Immunization Register
o Session Tally Sheet
o Name based due list to track dropouts and left outs
o Monthly progress report for uploading on the HMIS portal
o U-WIN

I. Mother and Child Protection (MCP) card with counterfoil

The MCP Card is a tool for families to learn, understand and follow positive practices for
achie-VINg 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:

o Next vaccination date - top box - when the child is expected to come for next immunization
o Date of vaccination - against vaccine name - when the child was immunized

How to use the card

o During the first visit, fill the information on the cover page on “Family Identification and
Birth Record”
o Record the date, month and year of all entries clearly
o Explain the section on immunization by explaining which vaccines have been given and
which vaccines are due, with dates

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 o Do not leave any cells or columns blank
o After filling up all the columns, retain the smaller portion of the card (counterfoil)
o Give the rest of the filled-in card to the parent of the child after immunization and ask her
/him to bring the same card during her / his subsequent visits to the health centre
o Advise families to keep the card in a safe place to prevent it from damage
o Advise families to bring the card along when they visit the Anganwadi Centre (AWC), SC,
health centre, private doctor or a hospital
o At the end of each session, the counterfoils should be placed in the appropriate pocket of
the tracking bag
o Each month, look at the counterfoils in the tracking bag and make sure those children
come for immunization. If the expected children based on session duelist and/or from the
MCP card (next vaccination date from the tracking bag), ANM can guide ASHA/mobilizer
RECORDS, REPORTS AND USING DATA FOR ACTION

to proactively seek reach out to such families to mobilize the caregiver with beneficiaries

Fig 10.1 Mother and Child protection (MCP) card and counterfoil (English)

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Fig 10.2 Mother and Child protection (MCP) card and counterfoil (Hindi)

IPV-

RECORDS, REPORTS AND USING DATA FOR ACTION

IPV

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

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 The counterfoils need to be filed separately for each session site. A cloth-tracking bag with 15
pockets is a simple, easy to use tool for filing the counterfoils (Fig.10.3). 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 10.3). 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 MR vaccine at nine completed months.
• If some cards are left in the pocket at the end of the month, it indicates that the beneficiaries
RECORDS, REPORTS AND USING DATA FOR ACTION

are the dropouts

• Move these cards to the next month’s pocket and track them

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.

Fig. 10.3 Immunization tracking with the help of tracking bag

Fill the counterfoil and place it in the month pocket due for
next dose

Before due immunization session ASHA/AWW/ mobilizer

should track the child and invite for the due vaccine dose.

If the child happens to miss the due dose in that given

month, then this counterfoil is filled again with reason for
missing the dose and thereafter put in the pocket due for
next session.
Completely
Immunized Children
Counterfoils of all children successfully completing 2nd
year immunization will end up in green pocket.

Counterfoil of children that have died or left area

permanently will end up in red pocket

II. Mother and child register / Immunization Register/ RCH register

Immunization / RCH 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/ link workers 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

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 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 RCH register and the immunization card and write “P” after
the date

Ask the AWW/ASHA for the name of the newborns and record them in the register so that
they are not leftout.

III. Session Tally sheets:

Tally sheets are the formats that are marked every time a health worker administers a dose of
vaccine. They are used to monitor performance and complete monthly reporting. New tally

RECORDS, REPORTS AND USING DATA FOR ACTION

sheet should be used for each session.

Tally sheet records vaccinations given, by marking them after beneficiary receives a dose.
The dose is recorded in the immunization register and on the immunization card and the
caregiver is informed of which vaccinations were given.

IV. Name based due list to track due beneficiaries for RI session: (explained in microplan
chapter)
• This form is prepared by ANM to enlist the beneficiaries due for vaccination. This is
prepared prior to RI session and utilized by ASHA/ mobilizers for mobilization of due
beneficiaries to RI session/s
• After the RI session, the reason for due beneficiaries not turning up to RI session
is documented by ANM with the support of ASHAs, AWWs, link worker and other
mobilizers. Different reasons could be child out of house/ house locked (R1); Sick
child (R2); Refusal (R3); Already vaccinated in other RI session/ in private (R4); AEFI
apprehension (R5); Others (R6). These beneficiaries should be tracked and if not
vaccinated, their names should be included in the due list prepared for subsequent
session
• Due list is not only helpful in tracking the beneficiaries who did not turn up for the
current vaccination session, but also to track those who would become due for the
upcoming RI session

V. Monthly progress report for uploading on the HMIS portal

The Monthly Progress Report is a report of the SC/ ANM area submitted by the ANM at the end
of each month. This report is based on correctly filled tally sheets. 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.

The Medical officer should review the appropriate section of immunization data and diseases
under surveillance (AFP, Diphtheria, Pertussis, Neonatal Tetanus, MR) including AEFIs in the
HMIS portal for PHC/UPHC and Subcenter.

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 Table. No.10.1: HMIS formats – Sections for RI, VPD surveillance
Sl. Topics Sections in PHC/ UPHC Sections in SC
No. format format
1 Pregnant women immunization M 1.2.1 – 1.2.3 M 1.2.1 – 1.2.3
2 Child immunization including AEFIs M9 M8
3 VPD surveillance M 10.1.4 – 10.1.9 -

VI. Recording and Reporting on U-WIN:

Vaccinator Module: Real-time data entry will be done by Vaccinators at the RI session
sites updating all the vaccine doses administered to each beneficiary. The Vaccinator
module will be used to register and record the services which are being delivered on the
day of the session for Children and Pregnant Women.
RECORDS, REPORTS AND USING DATA FOR ACTION

U-WIN Registration:

At home registration of beneficiaries by Vaccinators - Based on the information collected by

the ASHAs/other mobilizers during the headcount survey, there will be a provision where the
Vaccinators (mainly ANMs) can collect this data from the ASHAs/ other mobilizers in the hard
copy format and pre-register the beneficiaries and update their previous vaccination history
in the Vaccinator module. Additionally, a provision for ASHAs to pre-register beneficiaries at
time of head count survey is also available.

Onsite registration of beneficiaries: Vaccinator will register the beneficiaries who are
coming to the RI session sites as walk-in beneficiaries

Steps of recording of beneficiaries at RI session site:

Key steps at the session site level would include –
1. Identity verification
2. Update previous Vaccination History
3. Record vaccine administered in present visit
4. Generate digital e-Vaccination certificate

AEFI Reporting
• There is a provision for reporting of AEFIs from U-WIN and sharing of data and information
between U-WIN and SAFE-VAC
• Vaccinators can view the list of beneficiaries in vaccinator module of the U-WIN. From the
list, vaccinator can report AEFI of identified beneficiary through a button “Report AEFI”
against each beneficiary. Some of the data points in the AEFI reporting form will be auto
populated by system and others will have to be filled in by the vaccinator
• After completing the form and filling information in all mandatory data field, the vaccinator
can click “Submit” button to submit the form. A confirmation message will appear on
the screen. After confirmation, the data will be submitted and transported to SAFE-VAC
through APIs and an AEFI ID will be reverted to U-WIN from SAFE-VAC for reference

For detailed information on accessing and navigating the various modules U-WIN, the
staff members may refer to the U-WIN SOP Document

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VII. 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 leftouts and
dropouts. The supervisor should plot the immunization data on the chart during visits to
the SC (as given in Fig. 10.4). It should be updated every month.

Here is an example for calculating coverage, dropouts and leftouts for Penta1 and Penta3. A
similar chart can be prepared for other vaccines.

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 120 children, then the monthly

RECORDS, REPORTS AND USING DATA FOR ACTION

target is 120 /12 = 10 children. Therefore, the cumulative target for April will be 10; for May it
will be 20 (10 + 10); for June it will be 30 (10 + 10 + 10); for July it will be 40 (10 + 10 + 10 + 10),
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.

Fig. no. 10.4: Coverage monitoring chart

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 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%

ANM should ensure that coverage of ALL ANTIGENS and DOSES are more than 90%.
RECORDS, REPORTS AND USING DATA FOR ACTION

Every dose should be recorded in U-WIN.

Reasons for low immunization coverage

Low immunization coverage puts the entire community and area at risk of vaccine preventable
diseases. This low coverage can be because of dropouts or left outs including zero dose
children.
• Left-outs – Children who have never received any vaccination as per UIP
• Drop-outs – Children who have received one or more vaccines but did not complete the
vaccination as per the age
• Zero-dose children- are those who have not received first dose of Pentavalent vaccine by
one year of age

There are many factors that influence the immunization coverage. Listed in the table below
are some of the issues identified by the health service providers across many states.

Table 10.1 Common issues affecting the immunization coverage Leftout, Dropout,
Zerodose
Immunization • vacant SCs (some areas remain without immunization services)
services • weak tracking of children (large number of dropout and leftout
children)
• fixed timing of sessions (not suitable for the some communities)
• stock out of vaccines, diluents, AD syringes, hubcutters,
immunization cards, etc.
Staffing • vacancies of ANMs and doctors
• irrational distribution of ANMs
Training • lack of supervision and guidance by MOs
• absence of regular training and refresher training
• poor availability of trainers and quality of training
Planning • weak or absent RI microplans, absence of validation of areas
• lack of involvement of MOs in RI microplanning
• lack of involvement of other departments like Integrated Child
Development Services (ICDS) and urban bodies
• difficulties in urban areas planning

164
Community • poor understanding and misconceptions about immunization in
involvement and the community (weak interpersonal communication skills or lack of
communication efforts to meet the community members)
• four key messages not delivered (fear of minor reactions and AEFls
not addressed)
• IEC material not displayed at session site
Leadership • poor supervision and review mechanism
Financial support • delayed incentive payments for RI activities like alternate vaccine
delivery (AVD) payments, ASHA incentives
• delay in preparation of statement of expenditures for the released
funds

RECORDS, REPORTS AND USING DATA FOR ACTION

In addition to the above, geographical, cultural and social factors also have an impact on
the community’s faith in immunization which affects the immunization coverage. Health
workers should have the capacity to identify the reasons for low immunization coverage and
appraise the issues to medical officer for corrective actions.

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166
 Unit 11
Communication

167
 Learning objectives
At the end of the unit, health worker should be able:
• To identify the reasons for children missing vaccinations (dropouts or
left outs) and possible interventions
• To involve community to support immunization
• To use effective IPC skills for communicating with caregivers
• To conduct an effective community meeting

Key contents Page

11.1. Reasons for missed children and possible interventions 169
11.2. Community engagement 173
11.3. Interpersonal communication 173
11.4. Risk/ crisis communication 175

168
Communication
Introduction

The goal of health workers is to ensure that all children in SC/ ANM area are fully immunized
before their first birthday. The immunization-targeted community can be divided into three
groups as shown in Fig.11.1. The aim is to expand the inner circle to cover the entire universe
of eligible children in the catchment area.
Fig.no.11.1. Pictorial representation of Fully
From a service delivery perspective: immunized, Dropouts and left out children
• Left outs are those children who have
not received any vaccine under UIP
(unimmunized)
• Zero-dosers are those children who
have not received first dose of
Pentavalent vaccine by one year of age.

COMMUNICATION
• Dropouts are those children who
started vaccination and received one
or more UIP vaccine/s but did not
complete the schedule as per the age
(partially immunized)

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 “dropout” of the immunization system are the easiest to reach and be convinced
to return for full immunization.

11.1 Reasons for missed children and possible interventions

Table 11.1 below gives the common reasons for missed children (left outs, dropouts and Zero
dose children) and the possible interventions to reach them.

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 Table 11.1 Reasons for missed children and possible interventions
Possible reasons Possible interventions
Demand-side issues
Parents not motivated • Engage with community leaders, school teachers, faith/
to immunize children religious leaders, youth networks, women’s self-help
because of their poor groups (SHGs) CSOs, and encourage them to talk to
understanding of its parents about the benefits of immunization
purpose and importance • 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
• Specific Demand Generation Engagement of Male
Individuals / Fathers
• Use of various communication channels including Cable
TV, Radio ( both All India Radio and Community Radio);
social media platforms ( Facebook, Whats App,/SMS, X,
Instagram, outdoor media ( bill-boards, posters, digital
screens), IEC materials, Traditional folk media and
COMMUNICATION

religious place announcements by faith leaders)

Cultural or religious • Find out the reasons for reluctance by talking
reasons for refusal directly to communities/leaders. Try to address their
of vaccination misconceptions, doubts and fears by listening to them and
(myths, rumours and offering support
misconceptions) • 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 • Involve religious leaders, village elders, school teachers
AEFI in the community and Panchayati raj institution (PRI) members to
discourages parents to accompany the field level workers (FLWs) during their
immunize their children 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 if
they occur
• Investigate any AEFI and appraise the community of the
details of the case, possible causes and actions taken
Fear of Multiple injections • Inform that it is safe to give multiple injections to the baby
to the baby (caregivers) • Counsel that, if the baby misses out any injection, then the
child is vulnerable to that particular vaccine preventable
disease

170
Financial or gender • Counsel opinion leaders and influential persons about the
barriers to immunization, dangers of VPDs and the benefits of immunization
e.g., husbands disallowing • Encourage peer counselling by fathers of children who
wives to attend sessions accepts immunization
because of time/loss of • Publicize that immunization services are entirely free
daily wages/expenses
Refugees/families that fear • Determine where these populations reside
contact with government, • Visit the communities and work with local mobilizers/
e.g., those who lack educators/community groups/leaders to discuss reasons
documents/ scheduled why they are not accessing immunization services
castes or tribes/ nomadic • Provide information through appropriate communication
groups/homeless families/ channels on the importance of vaccination and date, time
urban slums/street and place of the next nearest session
children • 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 • Involve AWWs/ASHAs to identify and share lists of all
infants not newborns and children with the ANMs

COMMUNICATION
identified and listed • Explain the AHSA/ AWW about the importance of mobilizing
all beneficiaries
• Ensure that all the beneficiaries including beneficiaries
amongst visitors, relatives, new tenants, nomads, etc. are
mobilized
Sessions too infrequent • Plan sessions after consulting the community, e.g. early
or timings and days morning, holidays, Sundays, etc.
not convenient/not • Plan for “On demand Vaccination” – engaging with
understood the communities to plan the day, time and venue of the
immunization sessions, particularly for the vulnerable missed
communities
Session site too far • Include all the areas in the microplan
away, e.g. • Reorganize the catchment area so that remote sites are
border populations 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 • In case of HW being on leave or the health facility is vacant,
because sessions are deploy alternate vaccinators
not held as planned • Ensure alternate delivery of vaccines to session sites.
or vaccines are • Encourage community groups to share the feedback
unavailable regarding HWs presence on session day to health center
• Conduct session monitoring and make real improvements,
then publicize the improvements to communities
• Ensure adequate supplies of vaccines and logistics

171
 HWs do not clearly • Remind HWs/AWWs/ASHAs to always convey the 4 key
explain to parents what messages to parents in a simple and understandable
vaccines are due, when language
they are due and why • Train HWs to provide filled-in MCP cards to all beneficiaries
they are needed and to write the next due date on the card
• HWs to update U-WIN and inform about the same to the
beneficiaries
• 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
• Appreciate parent/caregivers for bringing their child for
vaccination
• Ensure that IEC materials are prominently displayed at the
session site
HWs do not show • Sensitize and train HWs, ASHAs and AWWs to treat parents
respect towards with respect, communicate with politeness, warmth,
parents or interest friendliness and should empathize with the parents’ situation
in the child’s health, • Encourage and praise the parents for bringing their children
e.g.- long waits, HWs for immunization. Encourage parents to ask questions
shouting at mothers for • Guide HWs to visit dropouts before the next session to find
forgetting the card or out the reasons why they missed the session
COMMUNICATION

bringing the baby late

HWs do not know • Organize tracking of children using head count survey and
which children are due due list
and what vaccines are • HWs to use the headcount survey to estimate the due
due children/ pregnant women.
• HWs can involve community teams (NGOs, community based
organizations (CBOs), community leaders, PRI member,
women/youth clubs, schoolteachers, 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 • Orient HWs that vaccines can be safely provided to a child
understand/ explain having mild illness, they should explain this fact to parents/
to caregivers that caregivers
immunization may • Vaccination is to be deferred in seriously ill beneficiaries
be given to mildly ill
children (false
contraindication)
Children and mothers • When providing other services, always keep an eye on eligible
are not seeking children visiting the session with a parent or sibling. Enquire
immunization when about their immunization status or refer to the list of due
coming to the HWs for beneficiaries and provide services, as appropriate
curative care (missed • Put a reminder about immunization in the facility’s waiting
opportunities) area

172
Health workers are • Health workers to be trained on the fact that it is safe to give
afraid to give multiple multiple injectable vaccines to the baby
injections on the same
visit

11.2 Community engagement

Community engagement and accountability brings together community members, leaders,
influencers and institutions to work together to identify and respond to the community
challenges to immunization.

The frontline workers play the pivotal role in community engagement, and it is important to
ensure that ANMs, ASHAs, AWWs and community volunteers are well trained to engage with
the households and communities.

Some activities include:

1. Sensitize and engage with PRIs/ religious leaders / teachers/ Ration shop dealers/ influencers
2. Community meetings with caregivers
3. Fathers/ mothers meetings
4. Rallies, announcements through Mosques

COMMUNICATION
5. Interpersonal communication (IPC) with the caregivers
6. Mid media activities like nukkad natak, cycle prachar, miking, etc.
7. Maximizing the community platforms for convergence
8. Engage Immunization Champions/Role Models

11.3 Interpersonal communication

Interpersonal communication at the households/ individual

level is the core communication strategy which informs,
clarifies and empowers individuals to make changes in the
immunization behaviours. Establishing trust relationship is
imperative between the providers and the communities. It calls
for specific skills and values for IPC sessions to be effective.
IPC sessions provide an opportunity for the caregivers/
communities to engage in an open dialogue/ discussion on
immunization, importance of immunization, details of age
specific vaccinations that are due for the child, where, when
the immunization sessions are conducted in the community
help them make decisions on vaccinating their children. Front
line workers are expected to engage with communities in
IPC sessions, provide useful information in a socio-culturally
acceptable manner, use tools to engage with the caregiver and link them to the services.

IPC sessions are conducted during the home visits and conduct the community meetings to
mobilize the caregivers and communities to accept the vaccination.

ANMs/ASHAs/AWWs are critical link between health services and communities. FLWs need to
be trained from time to time to be able to effectively communicate with parents/ caregivers

173
 and mobilize them to get their children vaccinated, it is important that their interpersonal
communication skills be strengthened. They also need to be equipped with appropriate
knowledge about vaccines and their benefits, and how to counter prevailing myths and
misconceptions on immunization with facts. A simple IPC approach, GATHER (Greet, Ask,
Tell, Help, Explain and Return) to help the FLWs to follow during IPC sessions is explained to
the FLWs. BRIDGE (Boosting Routine Immunization Demand Generation) training package
was rolled out by the MoHFW for the FLWs. A refresher training needs to be conducted through
the sector meetings, use opportunities during monitoring and mentoring visits to hone their
IPC skills.

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
COMMUNICATION

• Maintain eye contact

• Introduce yourself and your organization

Ask
• Ask open-ended questions—What? When? Where? Why? How? Who?
• How many children do you have?
• Why did you not vaccinate your child?
• 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 leftouts and dropouts.

IEC materials display: Increasing visibility and awareness of immunization. Display of

IEC materials such as poster/ banners/ hoarding/ wall paintings increase the visibility of
immunization programme. MOHFW shares the creatives on RI which needs to be printed,
distributed and ensure its appropriate use. If needed, customize to the local context (change
of language or visual as necessary).

174
For example, banners and posters should preferably be in the local language. Make sure that
what is written or shown is consistent with the guidelines of the programme.

11.4 Risk/ Crisis communication

Communicating with Frontline Health Workers

ANMs, ASHAs, and Anganwadi workers are the first point of contact between the health system
and the community. It is essential to orient and empower the frontline workers to handle
basic queries from the community, such as why vaccines are necessary, which all diseases
can be prevented by vaccination, and what is the potential risk of an adverse event that can
occur post-vaccination. It is critical to encourage and support health workers to report AEFI,
especially in case of programme errors.

Communicating with Families and Communities

An effective Information Education and Communication (IEC) strategy helps create awareness
among the masses to benefit the immunization programme. Also, it sensitizes them about
the potential risk of an adverse event that may occur post-vaccination. However, if an AEFI
is reported, immediate steps must be taken to verify the facts and determine what has
happened. Promptly visiting the affected family and community, mainly if a severe/ serious
AEFI has occurred, is part of a good response.

COMMUNICATION
Meeting and listening to affected families and community representatives is critical for
understanding their concerns and fears and demonstrating the commitment to addressing
the event. If an AEFI investigation is initiated, communities must be informed of the actions
that have been taken. Furthermore, providing communities with regular updates on the
investigation status will go a long way toward dispelling potential fears and myths about
immunization in general. Disseminate a consistent set of easy-to-understand key messages
to concerned families and communities. Prompt feedback has to be given to the parents
regarding the results of the causality assessment for AEFI.

Communicating with the Media

Negative media coverage of adverse events following immunization can significantly impact
public trust in vaccines. Health workers should follow some do’s and don’ts to address as
mentioned below
Do’s Don’ts
• Notify appropriate authority in • Do not speculate on the cause of AEFI
cases where the attention of the
community/media has garnered
• Reiterate that reporting AEFI does not • Do not assign blame before the proper and
mean the vaccine has caused it complete investigation is done
• To the community, inform that the • Do not COMMENT on causality unless it is
case is being investigated as per the finalized (the actual cause cannot be known
national guidelines immediately)

175
 • Keep the Medical officer/ District • Do not loose temper and stop
Immunization Officer informed about communication with the community
the developments in the community
about AEFI apprehension, vaccine
hesitancy
• Support the ASHA/ mobilizer/ link • Do not engage with media
worker when cases are reported and
boost their confidence
COMMUNICATION

176
 Unit 12
Surveillance of vaccine
preventable diseases

177
 Learning objectives
At the end of the unit, you should be able
• To understand the importance of surveillance in Immunization
Programme.
• To describe how to conduct surveillance for the VPDs.

Key contents Page

12.1. The role of surveillance in the immunization programme 179
12.2. Conducting disease surveillance 179
12.3. Recording and reporting of suspected vaccine preventable diseases 181

178
Surveillance of
vaccine preventable
diseases

SURVEILLANCE OF VACCINE PREVENTABLE DISEASES

12.1. The role of surveillance in the Immunization Programme

Surveillance means data collection for action. Disease surveillance is a regular system of
collecting, analyzing and interpreting data and then using it to guide disease-control and
immunization strategies. It helps in the following ways:
• To find out What disease is occurring
• To find out Who gets the disease – e.g., in a particular population or group of people
• To find out Where the disease is occurring - this helps to identify areas requiring special
attention and where system performance is poor
• To understand When the disease is occurring and how many get the disease
• To understand Why the disease is occurring – e.g., due to less vaccination
• To decide How the disease can be prevented, controlled or eliminated

12.2. Conducting disease surveillance

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 sites (to ensure completeness in reporting)

The quality of surveillance data depends upon correct diagnostic criteria, timeliness and
completeness of reports.

Step 1: Recognition of the disease

A set of standard case definitions are used to recognize the disease in the community for
quick response. Health worker should be aware of all the case definitions of the diseases. The
standard case definitions of VPD cases are mentioned in the table below.

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 Table 12.1 VPD case definitions:
Disease Case definition
Polio (Acute Flaccid Acute flaccid paralysis is defined as sudden onset of weakness
Paralysis) 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 by
clinician.
Measles-Rubella (Fe- Any person with fever and maculopapular rash OR
ver-rash)
Any person in whom a clinician or health worker suspects
measles or rubella infection.
SURVEILLANCE OF VACCINE PREVENTABLE DISEASES

Diphtheria A suspected case of diphtheria is defined as an illness of the

upper respiratory tract characterized by the following: laryngitis
or pharyngitis or nasopharyngitis or tonsillitis, and adherent
membranes of tonsils, pharynx and/or nose.
Pertussis A person of any age with a cough lasting ≥ 2 weeks (of any
duration in an infant), with at least one of the following
symptoms: a) paroxysms (fits of coughing); b) inspiratory
whooping; c) post tussive vomiting (vomiting immediately
after coughing); d) apnoea in infants; OR clinician suspicion of
pertussis.
Neonatal Tetanus Any neonate who could suck and cry normally during the first
2 days of life and who cannot suck normally between 3 and
28 days of age, and becomes stiff or has convulsions/spasms
(jerking of the muscles) OR
Any neonate who dies of an unknown cause during the first
month of life.
Tuberculosis A person w i t h 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.
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 with one
or more of the following (a) Headache, vomiting, (b) altered
consciousness (c) other meningeal signs (d) Petechial or purpuric
rash.
In patients <2-year, suspect meningitis when fever accompanied by
bulging fontanelle.
Hepatitis B An acute illness typically including acute jaundice, dark urine,
anorexia, malaise, extreme fatigue and right upper quadrant
tenderness.
Japanese Encephalitis A person of any age, at any time of the year with acute onset of
(Acute Encephalitis fever and change in mental status (including symptoms such as
Syndrome - AES) confusion, disorientation, coma or inability to talk) AND/OR new
onset of seizures (excluding simple febrile seizures).

ASHAs, mobilizers and link workers should also be sensitized on identification of vaccine
preventable diseases.

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Step 2: Ensure all cases are reported and recorded for public health action
Ensure that, all cases (based on the standard case definition mentioned in the table) are
reported to the Medical Officer. The types of cases that should be included in Health worker’s
monthly report are:
• Cases that come to the health facilities (both government and private) for treatment
• All cases seen and diagnosed by health workers at outreach sessions
• Cases that the health worker hear about in the community. In such instance, verify the
case in person

12.3. Recording and reporting of suspected Vaccine preventable diseases

SURVEILLANCE OF VACCINE PREVENTABLE DISEASES

To ensure completeness in reporting, the health worker should document the VPDs in the
VPD surveillance register and report these cases to the medical officer immediately. The
reports of these cases should be sent through S form at the subcenter level. Weekly VPD H002
form from planning unit or block PHC should be shared to block or district. Also on monthly
basis, the number of VPD cases should be reported in the HMIS report.

In order to use data effectively, it must be as reliable and accurate as possible. It is important
that each case is counted only once.

Step 3: Public health action in the form of Active case search (ACS) in community:

Searching for additional cases of similar VPDs in the community helps in identifying clustering
of cases. This can prevent an impending outbreak by early identification and public health
interventions.

Attempts should be made to conduct active case search soon after identification of a
suspected case preferably within seven days of case investigation.

• Besides conducting the active case search in household and neighbourhood, the workplace
or school contacts should also be actively assessed for the illness
• ACS has to be conducted after proper microplanning and training. Logistics of sample
collection and shipment should be arranged beforehand by the medical officer
• While conducting ACS look for additional cases according to the case definition that has
been communicated during training
• During ACS usually the case definitions are simplified and made more sensitive e.g. for
diphtheria, screening of recent sore throat in all age groups may be required. Standardized
forms are to be used to facilitate ACS in the community
• On identification of a suspected case, the detailed information of the illness has to be
captured in the ACS form of the respective disease outbreaks
• These suspected cases are then investigated by a medical officer who would also clinically
manage the cases and suggest interventions

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 Table No. 12.2. Roles and responsibilities of different staff in VPD surveillance:
Staff Roles & responsibilities
ANM • Should be aware of case definitions of VPDs and promptly notify VPDs to
medical officer
• Conduct additional active case search in the community in response to
reporting of VPD case
• Prepare line list of all the suspected cases
• Include all the left out and drop out children upto 16 years of age in the due list
and ensure age appropriate vaccination
• Ensure case management and referral service
• Generate awareness of local transmission of VPDs and its control measures
SURVEILLANCE OF VACCINE PREVENTABLE DISEASES

among the local community and stakeholders

• To sensitize ASHAs, mobilizers, link workers on identification of VPDs
ASHA • Should be aware of case definitions of VPDs and promptly notify VPDs to ANM/
Medical officer
• Generate awareness of local transmission of VPDs and its control measures
among the local community and stakeholders
• Conduct head count survey of unvaccinated/under vaccinated children
in < 5yrs in the community and ensure vaccination of left out and dropout
beneficiaries
• Identify children missed for 2nd booster of DPT, Td 10 and Td 16 years doses
during head count survey and mobilize these for vaccination

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 Unit 13
U-WIN: Digital Platform for
Data Recording & Reporting

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 Learning objectives
• To understand the concept of U-WIN and modules for effective
implementation of U-WIN for capturing immunization data

Key contents Page

13.1. Introduction on U-WIN 185
13.2. U-WIN modules 185

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U-WIN: Digital Platform for
Data Recording
& Reporting

U-WIN: DIGITAL PLATFORM FOR DATA RECORDING& REPORTING

13.1. Introduction on U-WIN

MoHFW has rolled out Electronic Vaccine Intelligence Network called e-VIN to provide real
time information on vaccine stock & storage temperature across all cold-chain points in the
country. Based on e-VIN, Co-WIN was rolled out for beneficiary management, recording and
reporting of COVID-19 vaccination. After the success of Co-WIN Platform, it was decided to
have similar software-based tool named “U-WIN” (Winning with Universal Immunization
Programme) for recording & reporting of each and every vaccination provided under Universal
Immunization Programme (UIP). All efforts should be made to identify and register all the
beneficiaries who are not registered in U-WIN.

Key features of U-WIN: -

• Establishing single source of truth for immunization data
• Near real time availability of vaccination data
• QR code-based e-Vaccination certificates
• Individualized antigen and dose wise tracking of beneficiaries
• Automated reminders through SMS for due vaccine doses
• Universal search - mitigating inter-state and intra-state migration issue
• All planned vaccination sessions to be published in U-WIN
• Citizen interface for self-registration, booking online vaccination appointment along with
provision for walk in registration
• Creation of ABHA and Child ABHA can also be done through U-WIN
• Engagement of private sector immunization service providers

13.2. Modules of U-WIN

U-WIN is a web and mobile based application. It has the following modules which are accessed
through OTP based text SMS authentication.

A. Registration and Scheduling Module

• This is the only module which is available in public domain to be used by the beneficiaries
• Registration can be done online for pregnant women and children
• Pregnant women can do self-registration and they can also be registered by tagging
Co-WIN data base
• Children/infant can be registered through linkage with Mother/Father/Guardian
• Beneficiary can book an appointment for vaccination and generate appointment slips
• Download Vaccination Acknowledgement/ QR based vaccination certificate

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 Registration Administrator Newborn
& Scheduling Module & Vaccinator Vaccination Mobilizer
Module Session Planning Module Module Module
U-WIN: DIGITAL PLATFORM FOR DATA RECORDING& REPORTING

Programme Healthcare Workers Frontline Workers

Beneficiaries Managers Vaccinators at Delivery Point like ASHAs

U-WIN Modules

B. Administrator Module
• This module will be used by state, district, subdistrict and health facility user
• Creation of all Health Facilities, Sub-Centers and RI Session Sites
o Mapping of Block/Village/ULB/Ward (LGD and non-LGD*)
o Tag as newborn vaccination site, whether has SCs/ ANM area under it
• Integration with other portals to ensure inter-operability and unified database – e-VIN,
ABDM, NiN, RCH, POSHAN tracker
• U-WIN is compliant with ABDM under which health facility registry (HFR) ID for health
facilities and Health Professional Registry (HPR) ID for health workers are to be made
and linked with U-WIN
• Adding and tagging of Human Resource involved in Immunization service delivery
(U-WIN users) – State/District/Sub-district Administrators, Health Facilities and
Newborn vaccination site managers, Vaccinators, Mobilizers
• Session Planning & Management – Creation and publishing of RI Sessions
*non-LGD areas include health blocks, health villages, wards, etc.

Session Planning and Management by Health Facility Manager:

• Health Facility Manager will be responsible for the Creation and publishing of RI Sessions.
• The UIP Vaccination Session Sites tab will be used for creating sessions while the UIP
Vaccination Sessions tab will be used for viewing the ongoing, scheduled, canceled, and
completed vaccination sessions. Session type to be selected as RI session, select the
Dates from the calendar for the planned upcoming sessions - dates can be entered for up
to next 3 months. The dates on which session have already been created and published
will be highlighted and non-selectable in the calendar menu. Next select the Start time
and End time for the session and the Total Beneficiary Capacity for the planned session.

All sessions that were planned through microplanning process needs to be created and
published in U-WIN.

Sessions once created and published in U-WIN can be rescheduled but cannot be cancelled.

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C. Vaccinator Module
• The Vaccinator module will be used to register and record the vaccination services
provided at the session for beneficiaries
· Conducting Vaccination Sessions
o Once the health care worker starts the session s/he will be able to see the list of
the beneficiaries who have booked online appointments and will also be able to
do on-site registration of beneficiaries (walk-in).
o Key steps would include –
1. Identity verification

U-WIN: DIGITAL PLATFORM FOR DATA RECORDING& REPORTING

2. Update previous Vaccination History based on available vaccination records
3. Record vaccine administered in the present visit
4. Generate digital e-Vaccination certificate
5. Reporting of AEFI
· ASHA Management – ANM should add ASHA workers or mobilizers and map the
villages/wards/ mohalla, etc. with them
· ANM will be able to see the list of all beneficiaries (both vaccinated and due) for her
catchment area
· Pre-registration of beneficiaries by Vaccinators - based on the information
collected by the ASHAs/Other mobilizers during the headcount survey, there will
be a provision where the Vaccinators (mainly ANMs) to collect this data from the
ASHAs/other mobilizers in the hard copy format and pre-register the beneficiaries
and update their previous vaccination history in the Vaccinator module

D. Newborn vaccination module

All birth dose vaccination details will be recorded in this module by staff nurse/ANM of the
delivery point.

The details of the pregnant woman with regards to ANC and pregnancy outcome, registration
of newborn will be primarily recorded through RCH 2.0. Till the time RCH 2.0 is rolled out
U-WIN will be capturing these data.

E. Mobilizer Module
This module will be used by ASHA/ mobilisers/ link worker, etc. Once the session has been
created in U-WIN, the mobilisers will be able to see the detail of the sessions through this
module.
• The mobilizer will be able to view the list of vaccinated and due beneficiaries in their
catchment area
• For the eligible beneficiaries not registered (as per paper-based duelist), mobiliser can
preregister the beneficiary or facilitate registration on session site by ANM or guiding
beneficiary to register by self-registration portal
• ASHA/ mobilizer can also download e-vaccination certificate for the vaccinated
beneficiaries

F. Reports Module
There will be a drill down option (National<State<District<Sub-district<Health Facility<Session
Site) at each level based on the level of login. These reports can be downloaded in excel
format.

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 There will be an option in the reports to get data of following duration – Today (present date),
Cumulative and Date Range.

Some of the important reports are as follows:

1. Coverage Report
The real-time data entry will be done by Vaccinators updating all the vaccine doses
administered to each beneficiary.
They will get aggregated in the Coverage report which can be accessed at all levels from the
U-WIN: DIGITAL PLATFORM FOR DATA RECORDING& REPORTING

National Administrator to the Health Facility level.

The coverage report will have the following key data elements -
1. Sessions Planned and Sessions Held
2. Number of Pregnant women, infants (0-1 years), children (1-5 years) and adolescent
vaccinated (10 & 16 years)
3. Vaccine and dose wise coverage data

2. Registration Report
This report on the Registrations done will be available to programme managers. It has the
data of the fresh registrations done (online and on-site) in 3 categories - Pregnant women,
infants (0-1 years), children (1-5 years) and adolescents (10 & 16 years).

3. RI Session sites & Sessions Status

Session Sites - has data points entered by Health Facility Manager (State, district, sub-
district, Health facility, e-VIN CCP).
Session Status - The created sessions could be categorized under 3 groups – completed,
ongoing and scheduled. This report will have line-list of all published sessions with timing
of planned session, actual time when the session was started by vaccinator and name of the
vaccinator assigned for the session.
Upcoming sessions - this report will have details of future, upcoming sessions created and
published by the Health Facility Managers as per the micro-plan.
There are various other reports available like details of users, health facilities, etc. in report
section.

AEFI Reporting
There will be a provision for reporting of Adverse Events Following Immunization (AEFIs) from
U-WIN and sharing of data and information between U-WIN and SAFE-VAC.

With integration with U-WIN, SAFE-VAC can be used by Vaccinators and District Immunization
Officers (DIO) to report cases. Following major advancements can be seen in SAFE-VAC after
integration with U-WIN:
1. Besides DIO, vaccinator can also report AEFIs through U-WIN.
2. All types of AEFIs – minor, severe and serious can be reported in this version.
3. Vaccinator/health worker/ANM will have access to the beneficiary list of his/her jurisdiction
for the purpose of reporting AEFI

General guidelines
1. ANM / vaccinator who has user ID and password for U-WIN can also report AEFI through
U-WIN.
2. A vaccinator can report an AEFI to anyone of her/his beneficiary through U-WIN if

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 vaccination details have been entered into U-WIN.
3. A vaccinator can report AEFI multiple times for a beneficiary, but only once after each
date of vaccination. Therefore, vaccinator can report AEFI after each date of vaccination in
U-WIN.
4. It is date of vaccination in U-WIN against which AEFI is reported, and not against individual
vaccine/antigen.
5. All cases, whether reported by vaccinator, will appear in AEFI line-list in district
administrator module and can be viewed by DIO and higher-level users.

U-WIN: DIGITAL PLATFORM FOR DATA RECORDING& REPORTING

Process of reporting of AEFI
1. To report the AEFI cases, Vaccinators need to login in UWIN using their credentials. After
login, the “Report AEFI” tab will be visible on the left side of the screen.
2. Vaccinators can search the beneficiaries for whom AEFI has to be reported using
beneficiary/mother/father/guardian’s registered mobile number or list of IDs as given in
the list in UWIN.
3. After searching, all beneficiaries associated with the mobile number or ID will be auto
populated. Vaccinator then need to click on “Report AEFI” for which he/she/they want to
report the AEFI associated with the beneficiary.
4. Vaccinator will follow step-by-step process to complete the information in AEFI notification
form and will submit it.

Vaccination data of beneficiary should be uploaded on the same day of vaccination on real time
basis by vaccinator. If due to any reason it is not possible for the vaccinator to upload data in
U-WIN on the same day of vaccination, it can be uploaded next day till 5 PM only if the session
is not closed in U-WIN. In all cases efforts should be made to upload vaccination data in U-WIN
on the same day of vaccination.

For detailed information on accessing and navigating the various modules U-WIN, health
workers may refer to the U-WIN user manuals.

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190
 Unit 14
Frequently Asked Questions

191
192
Frequently Asked Questions

General queries on immunization

1. 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 particular vaccine. e.g., BCG is administered on
the left upper arm.

FREQUENTLY ASKED QUESTIONS

2. 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.

3. 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. Please refer to the
latest guideline provided by the Child Health division for the same. Guidance on Vitamin
A administration is revised and updated from time to time. In routine immunization,
Vitamin A is administered at 9 months, 16-18 months and then at the interval of 6 months
till the age of 5 years. A total of 9 doses are given under routine immunization.

4. 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. Guidance on Zinc administration is revised and updated from time
to time. Please refer to the latest guideline provided by the Child Health division for the
same.

Queries on immunization schedule

1. If a child is brought late for a subsequent dose, should one restart 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, Penta 1 and bOPV 1 at 5 months of age returns
at 11 months of age, then vaccinate the child with Penta 2, bOPV 2, MR 1, fIPV1, Rotavirus
vaccine 1, PCV 1 and JE 1 (where applicable).

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 2. 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, Pentavalent,
bOPV, IPV, MR, RVV, PCV, JE (where applicable) vaccines and Vitamin A at the same time to
the 9-month-old child, who has never been vaccinated. NEVER MIX TWO VACCINES IN ONE
SYRINGE. Always use separate syringe for one vaccine.

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.

3. What are the upper age limits for various vaccines?

According to National Immunization Schedule, some vaccines have an upper age limit
for administration and these vaccines should not be administered once that age limit
is crossed. The vaccines should not be administered once that age limit is crossed. The
vaccines should be given to the following ages as per UIP guidelines:
FREQUENTLY ASKED QUESTIONS

• BCG: up to one year of age for childhood vaccination

• Hepatitis B (Birth dose): till 24 hours of birth
• bOPV-0: till 15 days of birth
• bOPV: upto five years of age
• IPV: Till 1 year of age
• Pentavalent: Till 1 year of age
• RVV: Till 1 year of age
• PCV: Till 1 year of age
• MR: up to five years in UIP and in MR campaigns, the vaccine is given upto 15 years age
group
• DPT: up to 7 years, beyond this age administer the Td vaccine
• JE (both live & killed): up to 2 years

Only the above-mentioned vaccines have upper age limits for starting the first dose.
Efforts should be made to ensure that all vaccines are given at the recommended ages, or
closer to it.

For Pentavalent, IPV and PCV, if at least one dose is given before one year of age, then
remaining doses can be administered, and the schedule must be completed at the earliest.

If the first dose is not administered before one year of age, then these vaccines cannot be
administered to the child under UIP.

4. If a child who has never been vaccinated is brought in after completing 12 months of
age, (beyond one year) what vaccines would you give?
While vaccinating this child, keep the aforementioned upper age limits for each vaccine in
mind.

This child should be administered DPT 1, bOPV 1, MR-1, JE-1 (if applicable) and also
Vitamin A solution. The subsequent doses of DPT (2 and 3), bOPV (2and 3), MR-2, and
JE-2 should be given at an interval of 4 weeks. Give booster dose of bOPV and DPT at a
minimum of 6 months after administering bOPV 3/DPT 3.

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As per the national immunization schedule this child need not be given – BCG, Rotavirus,
Penta and IPV, PCV.

5. Which vaccines can be given to a child between 1 and 5 years of age who has never
been vaccinated?
This child should be administered 3 doses of DPT, 3 doses of bOPV, 2 doses of MR and 2
doses of JE (where applicable) and 2ml of Vitamin A solution. These doses should be given
at an interval of 4 weeks. Such a child will not receive BCG, Hepatitis B, Rotavirus, Penta,
PCV and IPV.

Give booster dose of bOPV/DPT at a minimum of 6 months after administering bOPV 3/

DPT 3.
*Note: If an unvaccinated child is more than 16 months of age remember the interval between MR 1 and MR 2
is 4 weeks and for JE 1 and JE 2 (where applicable) the interval is also 4 weeks.

6. Which vaccines can be given to a child between 5 and 7 years of age who has never
been vaccinated?

FREQUENTLY ASKED QUESTIONS

Give of DPT 1, 2 and 3 at 4 weeks intervals. Give booster dose of DPT at a minimum of 6
months after administering DPT 3 up to the age of 7 years.

In case the child is near to the 7th year, start with DPT. Once this child crosses 7 years, Td
vaccine should be used in place of DPT for the remaining doses. Thereafter, this child
continues to receive the Td vaccine at 10 years and 16 years as per the NIS.

7. Why are the DPT, Hep B (birth dose), IPV and Pentavalent vaccines given in the
anterolateral mid-thigh and not the gluteal region (buttocks)?
The gluteal muscles are not well developed in less than one year of age. Therefore, giving
injection in the gluteal region can damage the sciatic nerve. Moreover, vaccine deposited
in the fat of the gluteal region does not invoke the appropriate immune response.

Vaccine-specific FAQs2

BCG

1. Why is BCG given only up to 1 year age of the child in UIP?

Most children acquire natural clinical/sub-clinical tuberculosis infection by the age
of 1 year. This protects them against severe forms of childhood tuberculosis, e.g., TB
meningitis and miliary disease. Hence as per the current NIS, BCG is given only up to 1
year of age of child. Any change in the schedule shall be intimated appropriately by a
Government Order.

2. 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.

3. Why do we give 0.05 ml dose of BCG to newborns (below 1 month of age)?

Dose of 0.05 ml is sufficient to elicit adequate protection in newborn under 1 month of
age.

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 Hepatitis B

4. 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.

5. Why is the birth dose of the Hepatitis B vaccine given only within 24 hours of birth?
The birth dose of the Hepatitis B vaccine is effective in preventing perinatal transmission
of hepatitis B only if given within the first 24 hours.

6. Why is Hepatitis B vaccine in combination with Pentavalent vaccine given only till 1
year of age?
Hepatitis B in combination with Pentavalent vaccine if given after 6 weeks and upto 1
year of age because infections during the 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.
FREQUENTLY ASKED QUESTIONS

Pentavalent Vaccine
1. What is Pentavalent vaccine?
Pentavalent vaccine is a vaccine that contains five antigens (Diphtheria + Pertussis +
Tetanus+ Hepatitis B + Haemophilus influenzae type b).

2. 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 benefit of the Hepatitis B combination in Pentavalent is explained as below
• Operationally, the Pentavalent vaccine per se shall reduce injection load from 9
(3 for DPT, 3 for Hep B & 3 for Hib) to 3 (reduction of 6 injections). However, other
vaccines will be given as per the NIS and their injection load is not affected
• With introduction of Pentavalent, 1 antigen was added, while number of injections
reduced to 3

3. 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.

4. For what reasons should a child not be given Pentavalent vaccine?

• A child below 6 weeks of age should not be given the Pentavalent vaccine
• Severe allergic reactions – although serious side effects have not been reported, a
child who has had a severe reaction to the Pentavalent vaccine earlier should not be
given another dose
• Children with moderate or severe acute illness should not be administered a
Pentavalent vaccine until their condition improves. Minor illnesses, however, such as
upper respiratory infections (URI) are not a contraindication to vaccination

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5. 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.

6. 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 a fever for a short time after immunization. The child
should be given syrup Paracetamol (125 mg per 5ml) to relieve pain.

7. Why is the Haemophilus Influenzae Type b (Hib) vaccine in combination with

Pentavalent vaccine given only till 1 year of age?
Hib B is one of the leading causes of meningitis and pneumonia in children aged less
than 5 years. Hib most commonly occurs in less than 5 years (4mths-18mths are at the

FREQUENTLY ASKED QUESTIONS

highest risk). It is important to prevent disease and immunize very early in life. Beyond
1 year, the child is assumed to have been affected with natural infection, hence the
vaccination shall have no role.

Rotavirus vaccine

1. How effective is the Rotavirus vaccine?

Sanitation and hygiene improvements have less impact on the transmission of Rotavirus
diarrhea which is thought to be due to person-to-person contact. The only specific
intervention strategy is immunization.

The available Rotavirus Vaccines are observed to be effective in preventing severe rotavirus
diarrhoea by 54-60%. The protective effect of the Rotavirus vaccine lasts through 2nd year
of life.

2. Will vaccination with Rotavirus vaccine prevent all diarrheas?

No, it does not prevent all diarrheas. Diarrhea is caused by many organisms of which
Rotavirus is one of the leading causes for diarrhoea in children. Rotavirus vaccine is
effective in preventing diarrhoea due to Rotavirus only. So, the child may still get diarrhea
due to other germs and causes even after receiving Rotavirus vaccine.

The Rotavirus vaccine along with other interventions for prevention and management
of diarrhea including exclusive breastfeeding for 6 months and continued breastfeeding
with appropriate complementary feeding, vitamin A supplementation in children
9-59 months, early detection and appropriate case management of diarrhea with oral
rehydration solution (ORS) and zinc (for 14 days), access to safe drinking Water, Sanitation
and Hygiene interventions (WASH), will help in reducing under-five mortality due to
diarrhea.

3. 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

197
 two doses of Rotavirus vaccine in a private facility, the remaining doses may be provided
as per the NIS. Under the UIP, interchangeability between different Rotavirus vaccines is
permitted.

4. What If the child spits out the Rotavirus vaccine or vomits immediately after having
it?
Repeat the dose (2ml). In case an incomplete dose is administered (the infant spits out or
regurgitates most of the vaccine), repeat the dose in the same vaccination visit. To prevent
spitting, please position the tip (nozzle) of the 3ml oral syringe towards the inner cheek
(buccal cavity). Administer the vaccine slowly. Avoid administering the vaccine over the
tongue. It should also be ensured that the tip of the syringe (nozzle) is not touched with
finger before administration.

Inactivated Poliovirus vaccine

1. What is IPV?
IPV refers to Inactivated Poliovirus Vaccine administered by injection and it contains all
FREQUENTLY ASKED QUESTIONS

3 types of polioviruses. Evidence suggests that IPV vaccine, when used along with bOPV
(which contains only Type 1 and Type 3 live attenuated vaccine viruses), increases the
protection of the individual as well as the community. IPV together with OPV prevents
re-emergence and reinfection of wild poliovirus (WPV). Trivalent OPV (tOPV) has been
withdrawn globally in 2016 from all countries and only bOPV is in use in its place.

2. Will IPV (injection) replace OPV (drops)?

No, IPV (injection) will not replace bOPV (polio drops), since IPV is recommended to be
administered in addition to bOPV.

3. What is the benefit of IPV?

IPV is the only available vaccine which gives protection against Polio virus type 2 apart
from Polio virus type 1 and 3. It 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 bOPV, it builds better mucosal (intestinal) immunity
than when bOPV is used alone; it thereby increases both the protection of the individual
and the community. To maximize childhood immunity and move towards global polio
eradication, it is recommended that both vaccines be used together.

4. Is IPV safe?
Yes, IPV is considered very safe, whether given alone or in combination with other vaccines.

5. Are there any contraindications for use of IPV?

IPV should not be administered to children with a documented or known allergy to the
following antibiotics - streptomycin, neomycin or polymyxin B, or with a history of a
previous allergic reaction after IPV injection.

6. Is it safe to give IPV and bOPV together?

Yes, it is absolutely safe to give IPV and bOPV 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 bOPV
(bOPV1, and bOPV 3) should be completed as per schedule.

198
7. How and when is IPV to be administered?
fIPV is to be given as a fractional dose (0.1 ml) intradermally in the Right arm of the child.
Fractional IPV (fIPV) is given in 3 doses at 6 and 14 weeks along with bOPV 1 and bOPV 3
and third dose of fIPV is to be given at 9-11 months on Left upper arm.

Measles and Rubella vaccine

1. Does a child need to be vaccinated if she or he has history of any fever-rash illness
including measles or rubella disease?
Yes. There are multiple causes of fever rash like illness. Therefore, every child must be
vaccinated with two doses of MR vaccine, as per the national immunization schedule at
the recommended ages, irrespective of any past fever-rash illness.

2. If a child has received the Measles-Rubella (MR) vaccine before 9 months of age, is it
necessary to repeat the vaccine later?
If it is given before 9 months, it has to be repeated as per the National Immunization
Schedule, i.e after the completion of 9 months until 11 months of age as 1st dose and at

FREQUENTLY ASKED QUESTIONS

16-23 months as 2nd dose in RI.

3. If a child comes after 2 years for the first dose of MR vaccine, then can he/she get the
second dose?
All efforts should be made to immunize all children at the right age i.e. the first dose at
completed 9 months to 11 months and the second dose at 16-24 months. However, if a
child has missed one dose or both the doses, these need to be given to the child up to the
age of 5 years at one month interval.

4. If a child has received all vaccines as per the national immunization schedule, does
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.

5. As MR 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.

Japanese Encephalitis

1. What is the schedule of JE vaccine in the UIP?

Indigenously manufactured killed JE vaccines are being used under the NIS. And as per
the interim recommendation from the NTAGI, JE vaccines from various manufacturers
are programmatically interchanged.

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 9–11months along with the first dose
of MR vaccine and the second dose is given along with DPT booster dose and MR vaccine
second dose.

199
 2. 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 at an
interval of 1month following the first dose. Remember, that the upper age limit for JE
vaccine is 2 years.

Pneumococcal Conjugate Vaccine (PCV)

1. What should be done if a PCV dose is delayed?

The two primary doses and one booster dose of PCV should be given during the first year
of life. If the doses are delayed within the first year, Doses (both primary and booster)
must be separated by a minimum interval of at least 2 months, to be given at the next
scheduled immunization visit. In delayed cases beyond 1 year of age, due doses can be
given to a child only if a child has received at least one dose of PCV before his/her first
birthday. For those with at least one previous PCV dose, the series should be completed
at the earliest available opportunity.
FREQUENTLY ASKED QUESTIONS

Common health care provider and parent/caregiver questions about multiple injections

2. Will my child experience more pain or discomfort during vaccination when there are
multiple injections?
Children may experience slightly more pain or discomfort when there are multiple
injections. However, you should remind parents the pain or discomfort from vaccination
is very brief – and that even one injection can cause pain or discomfort, with children
often not noticing the pain or discomfort caused by subsequent injections.

If more immunization visits are used to provide children with need vaccinations that
means there will be more times when children will experience pain or discomfort from
vaccinations.
• Confidence in vaccine effectiveness, such as “Will the vaccines be as effective as if
given alone?”
• Concern about adverse events, such as “Is there a greater likelihood of a child
experiencing an adverse event?”

It is important to remember that giving all the eligible vaccines during the visit is essential.
It is safe to give multiple injections and you should inform the parents of the safety and
importance to vaccinate fully. Parents and caregivers will be willing to have their children
receive multiple injections during the same visit if you answer their questions and
concerns about the safety and effectiveness of multiple vaccinations.

3. How can you decrease or minimize the pain from multiple vaccine injections?
There are things that you can do when providing multiple injections to minimize pain.
Pain during immunization can be decreased by:
1. Properly restraining the child in cuddle, or straddle position, sudden and unexpected
movements can be prevented.
2. Stroking the skin or applying pressure close to the injection site before and during
injection.
3. Injecting the least painful vaccine first when two vaccines are being administered
sequentially during a single office visit.
4. Performing a rapid intramuscular injection without aspiration.

200
4. Is it safe for children to receive two or three injections of vaccines at one time?
Yes. Children are given vaccines at a young age because this is when they are most
vulnerable to polio, diphtheria, whooping cough (pertussis), Hib and pneumococcal
disease. Vaccination schedules that involve multiple vaccine injections during the same
visit are based on many years of safety and effectiveness information. An infant’s immune
system is more than ready to respond to the very small number of weakened and killed
antigens (bacteria and viruses) in vaccines. However, these same children, if exposed to
a disease without having been vaccinated, an infant’s immune system may not be strong
enough to fight the disease.

5. Is it safe for children to receive three vaccine injections at one time?

Yes. An infant’s immune system is more than ready to respond to the very small number
of weakened and killed antigens (bacteria and viruses) in vaccines. From the time they are
born, babies are exposed to thousands of germs and other antigens in the environment
and their immune systems are readily able to respond to these large numbers of antigenic
stimuli.

FREQUENTLY ASKED QUESTIONS

6. Is there any evidence that some multiple injections of vaccines may increase the risk
for adverse events?
In most cases, multiple injections carry no greater risk for adverse events. However, these
risks must be balanced against the risk of disease if one of the vaccinations is not given.

Tetanus and adult Diphtheria (Td) vaccine

1. What is Td vaccine?
Tetanus and adult diphtheria (Td) vaccine is a combination of tetanus and diphtheria
with lower concentration of Diphtheria antigen (d) as recommended for older children
and adults.

2. Why Td vaccine needed for pregnant women?

The use of Td is recommended during pregnancy to protect against maternal and
neonatal tetanus & Diphtheria during prenatal care. Vaccination during pregnancy also
serves to boost immunity and increase the duration of protection in those pregnant
women who had not received the full set of recommended booster doses. Td also boost
decreasing diphtheria immunity in addition to assuring tetanus protection and help to
curtail diphtheria outbreaks.

3. What is the sensitivity, storage procedure & handling process, wastage rate for Td
vaccine?
• Td is a freeze sensitive vaccine. No reconstitution required for Td vaccine
• Td vaccine to be stored between +2 to +8 degree Celsius in ILR
• Shake test is applicable to Td vaccine, to check freezing of Td vaccine. If you find any
frozen vial of Td vaccine in ILR, do not use the vial.
• The wastage rate for Td vaccine is 10 %.

201
202
 References

203
204
References
1. Ministry of Health and Family welfare, Government of India Immunization Handbook for
Health Workers 2018.
2. Ministry of Health and Family welfare, Government of India. Intensified Mission
Indradhanush 4.0. Operational Guidelines 2022.
3. Ministry of Health and Family welfare, Government of India. Immunization handbook for
medical officers. Reprint 2017.
4. Ministry of Health and Family welfare, Government of India. Field Guide Surveillance of
Acute Flaccid Paralysis, 3rd edition, September 2005.
5. Ministry of Health and Family welfare, Government of India. Measles Rubella surveillance
field guide 2020.
6. Ministry of Health and Family welfare, Government of India. Surveillance for Diphtheria,
Pertussis and Neonatal Tetanus, India Field Guide, 1st Edition 2020.
7. Ministry of Health and Family Welfare Government of India. Handbook for Vaccine & Cold-
chain Handlers 2nd edition India 2016.
8. Ministry of Health & Family Welfare, Government of India. Guideline on Open Vial Policy
for using multi-dose vials in Universal Immunization Program with inclusion of RVV, letter
dated 22 March 2023.

REFERENCES
9. Immunization Division, Ministry of Health & Family Welfare, Government of India. Birth
dose vaccination protocol, letter dated 16 October 2019.
10. Ministry of Health and Family welfare, Government of India. Guidance Document
on Strategic Approach for Reaching Zero Dose Children in India. India’s Zero Dose
Implementation Plan. 2024.
11. Ministry of Health and Family welfare, Government of India. Integrated Disease
Surveillance Programme. Available at: https://idsp.mohfw.gov.in/
12. Child Health Division. Department of Family Welfare Ministry of Health & Family Welfare,
New Delhi. Field Guide. Surveillance of Acute Flaccid Paralysis. Third edition. 2005.
13. Ministry of Health and Family welfare, Government of India. Measles and Rubella
Surveillance Field Guide 2020. 2020.
14. Ministry of Health and Family welfare, Government of India. Surveillance of Diphtheria,
Pertussis and Neonatal Tetanus, Field Guide, India. First Edition. 2020.
15. Ministry of Health and Family welfare, Government of India. National Viral Hepatitis
Control Program. Operational Guidelines. 2018
16. World Health Organization (WHO) Immunization in Practice. A practical guide for health
staff. WHO; 2015.
17. World Health Organization. Microplanning for immunization service delivery using the
Reaching Every District (RED) strategy [Internet]. WHO; 2009. Available from: https://
www.who.int/publications/i/item/microplanning-for-immunization-service-delivery-
using-the-reaching-every-district-(-red)-strategy
18. Immunization Division, Ministry of Health and Family welfare, Government of India.
Handbook for Vaccine & Cold-chain Handlers. 2nd Edition. 2016.
19. Government of India Ministry of Health & Family Welfare Immunization Division.
Guideline on Open Vial Policy for using multi-dose vials in Universal Immunisation
Program with inclusion of RVV, 22 March 2023

205
 20. Ministry of Health & Family Welfare, Government of India. Covid 19 vaccine operational
guidelines, 20th December 2020.
21. Guidelines on Management of Biomedical Waste under Universal lmmunization Program
(As Per Guidance Document issued by MoH&FW), Central Pollution Control Board, 2021
22. Government of India Ministry of Health & Family Welfare Immunization Division. Birth
dose protocol. 16 October 2019.
23. Ministry of Health and Family welfare, Government of India. AEFI Adverse Event Following
Immunization Surveillance and Response. Operational Guidelines. 2024.
24. Ministry of Health & Family Welfare, Government of India. Guidelines on use of Syrup
Paracetamol Following Vaccinations, 2020.
25. Ministry of Health & Family Welfare, Government of India. Operational Guidelines, Initial
management of Anaphylaxis using Injection Adrenaline by ANMs, 2018.
26. World Health Organization, WHO Position paper Recommendations for Routine
Immunization, March 2023.
REFERENCES

206
 Annexures

207
208
 National Immunization Schedule
Td 1, Td 2 or
1 January 2023 Onwards Td Booster
Td
Td
DPT-Booster-2

OPV-Booster
MR-2
MR-I DPT-Booster-1
fIPV-3 JE-2
PCV-Booster
OPV-3 *
RVV-3
JE-I
fIPV-2
Pentavalent-3
PCV-2
OPV-2
RVV-2
OPV-I Pentavalent-2
RVV-I
Annexures

fIPV-I
Pentavalent-1
OPV-Zero PCV-I
BCG
Birth
Hep B Dose

209
At Birth 6 weeks 10 weeks 14 weeks 9-12 months 16-24 months 5-6 years 10 years 16 years Pregnant Women
in selected states/districts*
Annexure 1. National Immunization schedule beneficiary vaccine chart

ANNEXURES
 ANNEXURES

2. Routine Immunization microplanning formats-Head count survey formats, Subcenter/ ANM area microplan formats,
PHC/ UPHC microplan formats

Annexure 2.1

SUB CENTER / ANM AREA MASTER LIST and Head COUNT SURVEY PLANNING FORM Form SC-1
District/ Corporation:_____________________ Block/urban area:________________________ PHC/ UPHC:______________________________ Sub center/ ANM area:_______________________________
ANM Name with Ph no.:_____________________________________________; No. of ASHAs working in Subcenter/ ANM area:___________; Medical offcier's naame with ph no.:_______________________________________
Sl. Name of Villages / Hamlets / Estimated High HRA Name of ASHA Name and Designation Dates of Name & contact FILL AFTER Survey - FOR ANM USE ONLY
No Tolas / Ward / Mohalla / no. of Risk code / AWW / contact number of Surveyor Survey number of local
HRAs households Area# (i f Mobilizer of person doing (ASHA/ AWW/ From / To influencer Total Total Number of children below 1 year Number Children 2 to 5 years
HRA) Population Pregnant of
in the area designated for survey Link worker/ Total
this area Other) Women Number Number children 1 Number of Number of children
of new of of children to 2 yr of children 2 2 to 5 years -
born Infants below 1 age to 5 years missed doses
(birth upto b/w 1 year (MR-1/ MR-2 doses/
1 month) month to (K+L) OPV/DPT/ booster
1 year doses)

A B C D E F G H I J K L M N O P Q R

210
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
TOTAL TOTAL

Signature of ANM_______________________ Signature of Supervisor:_____________________ Signature of Medical Officer:_____________________

# Type of HRA code: Migratory HRA: 1 = Slums with migration; 2 = Nomads; 3 - Brick kiln; 4 - Construction site; 5 - Other migratory high-risk areas (fishermen villages, riverine areas with shifting populations, migrants in tea/coffee estates etc); Non-Migratory (Settled) HRA:
6A- Settled Slums (notified & non-notified); 6B- Hard to Reach Area; 6C- Areas under Vacant / temporarily vacant (More than 3 months) sub centres; 6D- Areas with Measles/Rubella outbreaks or cases of Diphtheria, Pertussis, Neonatal tetanus in last 3 years; 6E-Areas with
vaccine hesitancy/ refusal; 6F-Other settled high-risk areas.
 Annexure 2.2

Sub centre / ANM area map Form SC-2

District/ Corporation: _______________________ Block/Urban area: ____________________ PHC/ UPHC: ______________________ Sub-centre/ANM area:_____________________
Sub-centre Map showing Sub-Centers/ANM area, Session sites, AVD, High Risk areas & AEFI management center LEGEND

PHC/UPHC

SUB CENTRE

VILLAGES HQ

ROAD

RAILWAY LINE

Village
VillageAA RIVER

LAKE / POND

211
RI session site RI

Private RI Session P

Religious place P
School S
AEFI management centre

HRAs 1-5 & 6A-6F

OTHERS

Signature of ANM Signature of MO

ANNEXURES
 ANNEXURES

Annexure 2.3

House to House Survey form Form SC-3

District/ Corporation::____________________ Block/urban area:_________________________________ PHC/ UPHC:___________________________________ Sub center/ ANM area:__________________________

Village/Urban area/Ward (as per form SC-1):______________________________________________ ANM name and phone no.:______________________________Supervisor's name and phone no.:_________________________

ASHA/ AWW/ Surveyor Name and Ph No.: _______________________; _________________________ ASHA facilitator's name and ph No.:________________________________________ Date of Visit : ___ /____ /____
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 Children 2 to 5 years
No. of children
No. of children
Total number of No. of children aged between No. of children
No. of Pregnant No. of children 2 to 5 Years
HH no. family members aged less than 1 1 month upto 1 aged between
Name of Husband (for PW) / Woman aged between MISSED MR-1/ MR-2
(as per Name of head of family Contact Number living in this month year 1 to 2 Years
(if present mention dose /DPT/ OPV/
Father (for child) / Gaurdian household? (Include details in form SC- (if present mention (if present mention (if present 2 to 5 Years
chullah) boosters
All adults & children details in form SC- details in form SC- mention details in
4A) (if present mention details
including new borns) 4B) 4B) form SC-4B)
in form SC-4C)
A B C D E F G H I J K

212
Total
Total
houses
Signature of ASHA / AWW / Surveyor:______________________ Verified by ASHA Facilitator (Signature):___________________ Verified by ANM (Signature):________________

SHEET NUMBER :________

 Annexure 2.4
Head Count Survey of Pregnant Women Form SC-4A
District/ Corporation::_________________________ Block/Urban area:____________________ Sub Centre/ANM area________________________ Village/Urban area/Ward:_______________________________
Name of ASHA/AWW/ surveyor with ph.no.: __________________________ Name of ANM:_______________________ Area Name and No as per Form SC-1: ______________________ Date of Visit : __
/__/__
For ANM
Td Vaccination Ante Natal Check Up
only
HH no. MCP card Expected Td-Booster
(as per Name of the pregnant Year of Age in number/ date of (If 2 doses of
Husband's name Mobile Number Td ANC
form woman birth years UWIN ref delivery / Td given within 1st 2nd 3rd 4th
Td-1 Td-2 due - due -
SC 3) ID LMP 3 years of the ANC ANC ANC ANC
Y/N Y/N
current
pregnancy)
A B C D E F G H I J
Date/Y/N Date/Y/N Date/Y/N Date Date Date Date

213
TOTAL
TOTAL
PW

Signature of ASHA/AWW/ Link worker/ Other surveyor _____________ Verified by ASHA Facilitator (Signature):___________ Verified by ANM (Signature):___________

ANNEXURES
 ANNEXURES

Annexure 2.5
Head count survey of Children (0-2 years) Form SC-4B
District/Corporation:______________________ Block/Urban area:______________________ Sub Centre/ANM area____________________________ Village/Urban area/Ward:_____________________________________

Name of ASHA/AWW/ surveyor with ph.no: _______________________________________________________________ Name of ANM:___________________________________________ Area Name and No as per Form SC-1: ____________________________________ Date of Visit : __/__/__

Vaccines at 10 Booster and 2nd doses of vaccines at 16

Vaccines at birth Vaccines at 6 weeks Vaccines at 14 weeks Vaccines at 9 to 11 months of age
weeks to 23 months of age
Child is
House No Age in Name of the mother/ father/ MCP card Fully Child is
Date of Birth Gender:
as in Name of the child months Gaurdian with mobile number/ immuni completely
dd/mm/yy M/F bOPV- Hepatitis
Form 3 (completed) number UWIN ref ID zed (FIC immunized
Birth BCG B Birth

MR 1
MR 2

RVV1
fIPV3

PCV 1
PCV 2

f IPV1
RVV 2
RVV 3
fIPV 2
Plus)

bOPV1
bOPV 2
bOPV 3

Penta 2
Penta 3

Penta-1
dose dose

Vitamin A 1
Vitamin A 2

PCV Booster
DPT Booster 1

bOPV Booster

JE 1 (elligible dists)
JE 2 (elligible dists)

A B C D E F G H I J K L M N O
Date / Y/N Date / Y/N Date / Y/N Date / Y/N Date / Y/N Y/N Date / Y/N Y/N

__ /__ /__ M/ F

__ /__ /__ M/ F

__ /__ /__ M/ F

__ /__ /__ M/ F

214
__ /__ /__ M/ F

__ /__ /__ M/ F

__ /__ /__ M/ F

__ /__ /__ M/ F

__ /__ /__ M/ F

__ /__ /__ M/ F

Name of ASHA/AWW/ Surveyor: _____________ Verified by ASHA Facilitator (Signature):___________ Verified by ANM (Signature):___________
 Annexure 2.6

Enlistment and tracking of children between 2-5 years missed for MR/DPT/OPV/ booster doses Form SC-4C
District/ Corporation::__________________________ Block/Urban area:______________________ Sub Centre/ANM area_______________________________ Village/Urban area/Ward:_____________________________________________________
Name of ASHA/AWW/ surveyor with ph.no.: ____________________________________________________________ Name of ANM:______________________________________ Area Name and No as per Form SC- 1:
______________________________________________Date of Visit : __ /__ /__
House Name of the child Date of Birth Age in years Gender: Name of the father and MCP card/ Missed vaccine dose/s Date of vaccination
No as in dd/mm/yy and months M / F mobile number UWIN ref ID (Encircle Y/N) (to be filled after vaccination)
Form 3 (completed) MR OPV DPT/ Penta OPV DPT
OPV DPT-1 OPV DPT-1
MR-1 MR-2
1 2 1 2 3 1 2 3 booster booster 1 2 3 1 2 3 booster booster
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

215
M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

M/F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__ __ /__ /__

Total No. of children missed for MR, OPV, DPT/

children Penta vaccines
missed

Name of ASHA/AWW/ Surveyor: ____________________ Verified by ASHA Facilitator (Signature): _______________________ Verified by ANM (Signature): Verified by Supervisor (Signature): _________________________________

Note: This format is used to document and track children between 2-5 years missed for MR/DPT/ Penta/OPV doses. If missed child/ children found, then encircle "Y" and mobilize the child to RI session. After vaccination, the date of vaccination of the missed dose/s are to be updated in the
columns (R to AA) as per vaccine dose received.

ANNEXURES
 ANNEXURES

Annexure 2.7

RI SESSION DUE LIST (for ASHAs/ mobilizers)

Form SC-5
(Prepared by ANM)
Block / Urban : _______________ PHC / UPHC Planning Unit: __________________ Name of Sub-Centre / ANM area: __________________________________ Name of Session Site : ________________________________
Name and Ph no of ASHA:_____________________________________________________ Name and Ph no of AWW / Mobilizer:______________________________ Name and Ph no of Influencer:_________________________
Name and Ph no of ANM :_____________________________________________________ Date of Session: ______________________________ Date of next session at this site: _______________________

Details of Pregnant Women / Children upto 5 years due for vaccination for RI session After the RI session
Sl. MCP Card No. Name of Child / Pregnant Woman Date of Birth Age in years Gender Name of Father / Mother/ Husband Vaccines due in this Did the If yes, vaccines If not When to What vaccines *Incentive money **Incentive money **Incentive money
No. (for Chi l d) / and months (M / F) with contact number session pregnant administered today vaccinated come for is/are due next Rs. 100/- payable to Rs. 75/- payable to Rs. 50/- payable to
Expected (completed) (menti on na me of woman / child to pregnant woman / then reason next session? ASHA for Full ASHA for Complete ASHA for DPT-2
date of ALL due va cci nes ) arrive today? child (R1/R2/R3/R vaccination? Immunization Immunization booster
Delivery (Yes / No) 4/R5/R6) (date) (Yes / No) (Yes / No) (Yes / No)
(for PW)

A B C D E F G H I J K L M N O P

1 Y/N
__/__ /__ __/__ /__
2 Y/N
__/__ /__ __/__ /__
3 Y/N
__/__ /__ __/__ /__

216
4 Y/N
__/__ /__ __/__ /__
5 Y/N
__/__ /__ __/__ /__
6 Y/N
__/__ /__ __/__ /__
7 Y/N
__/__ /__ __/__ /__
8 Y/N
__/__ /__ __/__ /__
9 Y/N
__/__ /__ __/__ /__

10 Y/N
__/__ /__ __/__ /__
Total amount payable
Vaccination coverage of due beneficiaries Tracking of missed beneficiaries of the RI session
R1: Out of Village/ R4: Vaccinated R5: AEFI
Total Number of Pregnant women as per the due list Reason for beneficiaries who did not attend Reason - R2: Sick R3: Refused R6: Other
House locked outside Apprehension
this session
Total Preganant women vaccinated Number -

Total number of children as per due list Have these beneficiaries been included in
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Total children vaccinated the due list of next session?

Signature of ANM:__________________________________ Signature of ASHA:______________________________________ Signature of AWW: __________________________________

 Annexure 2.8
Subcenter / ANM Area: RI Sessions plan Form SC-6
(MO IC to ensure this format is filled for all sub-centres/ ANM areas, including vacant sub-centres/ANM area)

District/ Corporation: ____________________ Block / Urban: ______________ PHC / UPHC: _____________________________ SC / ANM area: _________________________

Name of Medical Officer I/C: ______________ Mobile no.: _______________ Name of IO / ICC: _________________________ Mobile no.: _____________________________

Name of ANM: __________________________ Mobile no.: _______________ Name & Designation of Supervisor: _________________ Mobile no.: _____________________________

Beneficiary Targets

Name of Villages / Wards / Type of area /

Total Annual Target
Mohallas / Hamlets / Tolas / HRAs# Monthly terrain - plain Type of Session -
Population (PW = Actual Head Number of Name and location of the Session Name of the mobilizer with
(From form SC-1) Injection
S.No of Area count X2 , Infants Monthly Target / hilly / Fixed / outreach/
New areas /identified missed areas Sessions $ site / sites designation and mob.no.
(Total of form 3 =Actual Head Load ₤ riverine/ mobile
should be entered marking with count)
Column E) tribal area
asterisk(*)

PW Infants PW Infants
F G
A B C D E H I J K L M
(D/12) (E/12)

217
# Type of HRA code: Migratory HRA: 1 = Slums with migration; 2 = Nomads; 3 - Brick kiln; 4 - Construction site; 5 - Other migratory high-risk areas (fishermen villages, riverine areas with shifting populations, migrants in tea/coffee estates etc); Non-Migratory (Settled) HRA: 6A- Settled
Slums (notified & non-notified); 6B- Hard to Reach Area; 6C- Areas under Vacant / temporarily vacant (More than 3 months) sub centres; 6D- Areas with Measles/Rubella outbreaks or cases of Diphtheria, Pertussis, Neonatal tetanus in last 3 years; 6E-Areas with vaccine hesitancy/
refusal; 6F-Other settled high-risk areas
₤ Injection load for children-in non JE districts= {14 injections x monthly infant target (Col G); in JE districts= 16 injections x monthly infant target (Col G)}
For Pregnant woment: 2 injections x monthly PW target (Col D); Add Td 10 and Td 16 if being given at outreach RI session sites
$ 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; more than 100 injections: daily sessions. 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 PHC/CHC/RH: plan daily sessions.

Signature of ANM:__________________________________ Signature of Supervisor:__________________________________

ANNEXURES
 ANNEXURES

Annexure 2.9
Subcenter / ANM Area: Session wise injection load and vaccine distribution plan Form SC-7

District/ Corporation: ____________________________________ Block/ Urban: _________________________________________ PHC/ UPHC: ______________________________________________________________ SC / ANM area: _____________________________

Name of Medical Officer I/C: _______________________________ Mobile no.: ___________________________________________ Name of IO / ICC: __________________________________________________________ Mobile no.: ________________________________

Name of ANM: ____________________________________________ Mobile no.: ___________________________________________ Name of Supervisor with designation: _______________________________________ Mobile no.: ________________________________
Target for the THESE COLUMNS TO BE FILLED AFTER APPROVAL OF PROPOSED PLAN BY MEDICAL OFFICER
Beneficiaries per session for each vaccine & vitamin A
Name and location of Name/s of village/sub Frequency of session (add if (Updated every 3 months/ quarterly)
session site (exact village area /hamlet/ Sessions multiple areas /
Injection Load Month 1
location) urban ward/ mohalla/ (Once a tolas are clubbed Month 2 Month 3
__ Vit A for the session Vaccine Distribution
Sl. If >1 session sites in a big tola covered by the quarter / or divide in case Td Hep B BCG OPV RVV fIPV PCV Penta MR JE DPT ______ ______
(Td+BCG+ _____
No village / urban area, site with its sl no. from once in 2 of big village) Designated AEFI
fIPV+PCV+Penta management center
mention separately Form SC-1 months /
+MR+JE+DPT) Name of person with contact no.
(Ref. column J of format SC- (all areas in one cell number per Mode of
PW Infants D x 2 E x 1 E x 1 E x 5 E x 3 E x 3 E x 3 E x 3 E x 2 E x 2 E x 2 Ex9 Day / Week no. responsible with
6) separated by comma) month) Transport
contact no.

A B C D E F G H I J K L M N O P Q R S T U V W X

218
# Type of HRA code: Migratory HRA: 1 = Slums with migration; 2 = Nomads; 3 - Brick kiln; 4 - Construction site; 5 - Other migratory high-risk areas (fishermen villages, riverine areas with shifting populations, migrants in tea/coffee estates etc); Non-Migratory (Settled) HRA: 6A- Settled Slums (notified & non-notified); 6B- Hard to Reach Area; 6C- Areas under
Vacant / temporarily vacant (More than 3 months) sub centres; 6D- Areas with Measles/Rubella outbreaks or cases of Diphtheria, Pertussis, Neonatal tetanus in last 3 years; 6E-Areas with vaccine hesitancy/ refusal; 6F-Other settled high-risk areas
 Annexure 2.10
Sub Centre / ANM area: Estimation of vaccines & logistics per session
Form SC-8
(To be used with format SC-7)
District/ Corporation: ______________________________________
Block/ Urban: __________________________________ PHC/ UPHC - Planning Unit: __________________ SC/ANM area: _________________________

Name of Medical Officer I/C: ________________________________

Mobile no.: ____________________________________ Name of IO / ICC:____________________________ Mobile No.____________________________

Name of ANM: _______________________________________

Mobile no.: ____________________________________ Name of Supervisor:___________________________ Mobile No.____________________________
Location Estimation of vaccine vials and logistics for each session (At least one vial of each vaccine in each session) This should be filled with the help of Form SC-7
of Reconstitu Paracet Zinc ORS RI /
S.No Hep ADS ADS 0.5 IFA Other
session Td BCG OPV RVV fIPV PCV Penta MR JE DPT __ Vitamin A tion amol tablet / packe MCP
B 0.1 ml ml tablets logistics
site syringes syrup syrup t card
Calculations
F G I Kx L Mx NX Ox PX (Ex 1ml) + (F+G+L+ No. of
with help of Hx2 JX (H+K)
x1.11 x1.11 x1.11 1.11 x1.11 1.11 1.33 1.11 1.11 {(E x 8) x M+N+O+ BCG+ MR
columns in /10 1.11 x 1.11
/10 /10 /20 /25 /5 /10 /5 /10 /10 2ml)} x 1.11 P) x 1.11 vials x 1.11
Format SC-7
a b c d e f g h i j k l m n o p q r s t u v w

219
2

10

Signature of ANM_______________________ Verified by Medical Officer (Signature):____________________________

ANNEXURES
 ANNEXURES

Annexure 2.11

ANM Workplan/ roster plan Form SC-9

District/ Corporation: ___________________________
Block/ Urban: ___________________________________ PHC/ UPHC : ______________________________ SC/ ANM area: ________________________
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
Location : Location : Location : Location : Location : Location :

1 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

2 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

3 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

4 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

5 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

220
1 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

2 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

3 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

4 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

5 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

1 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

2 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

3 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

4 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......
Location : Location : Location : Location : Location : Location :

5 Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …...... Time: …....... to …......

Signature of ANM_______________________ Verified by Medical Officer (Signature):____________________________

Date of submission Date of verification
 Annexure 2.12
Sub-Center/ ANM area level Quarterly Routine Immunization Communication Plan Form SC-10
Year: _______ Q1/2/3/4
Name of the district/ corporation: Name of the facility-CHC/ PHC/ UPHC: Name of sub-center/health center: Name of ANM:

Na me of Vi l l a ge/ Ha ml et/ Urba n a rea

Na me of ASHA
Na me of AWW
Na me of Infl uencers
Na me of PRI/ULB repres enta ti ve
Activities M1 M2 M3 M1 M2 M3 M1 M2 M3 M1 M2 M3 M1 M2 M3 M1 M2 M3
Mothers '/Fa thers ' Meeti ngs
Communi ty/ MAS/ SHG Meeti ng
Infl uencers Meeti ng
VHSNC/UHSNC Meeti ng
IPC s es s i ons /couns el l i ng
Mi ki ng/Drum bea ti ng
Ra l l i es
Cel ebra ti ons /competi ti ons /s peci a l da ys
Ba nners
Pos ters
Lea fl ets
Informa ti on ca rd/Bul a wa pa rchi for
pa rents

221
Wa l l pa i nti ngs
School Tea chers ' ori enta ti on/
coordi na ti on
(Provi de na me of s chool &/or tea cher
wi th mobi l e no.)
Mos que/Templ e/Church/Rel i gi ous
Ins ti tuti ons a nnouncement
(Provi de na me of rel i gi ous l ea der wi th
mobi l e no.)
Others

Si gna ture of ANM: Si gna ture of MO:

ANNEXURES
 ANNEXURES

Annexure 2.13

School immunization plan for DPT-2 and Td - Sub-center/ ANM area Form-SC-11A
District/ Corporation:_____________________________ Block/ Urban:___________________________ Sub center/ ANM area:____________________________
PHC/UPHC:____________________________
Target beneficiaries per year Vaccine vials required Session day,
Contact no. of Name of
Sl. Village / Urban Name of Principal 5-6 yrs (DPT week &
Name of School Affiliation School / Principal 5-6 yrs (DPT 10 yrs (Td) 16 yrs (Td) Td ASHA/Mobilizer
No. area / Head Master Booster2) Booster2) month /
/ Head master 5th std 10th std [(h+i)X1.11] / 10 mention date supporting session
1st std (g X 1.11 / 10)
a b c d e f g h i k l m n
Govt / Aided / Pvt

Govt / Aided / Pvt

Govt / Aided / Pvt

Govt / Aided / Pvt

Govt / Aided / Pvt

222
Govt / Aided / Pvt

Govt / Aided / Pvt

Govt / Aided / Pvt

TOTAL
 Annexure 2.14

Community based immunization plan for DPT Booster -2 and Td for school dropout children - Sub-center/ ANM area Form-SC-11 B

District/ Corporation:____________________ Block/ Urban:_____________________ Sub center/ ANM area:____________________ PHC/UPHC:________________

AD syringes
Target beneficiaries per year Vaccine vials required
required
Contact no. Name of
Address of Name of 5-6 yrs Session day,
Sl. Village / of 10 -16 yrs ASHA/Mobilizer
Anganwadi Anganwadi (DPT Booster2) 5-6 yrs (DPT week & month
No. Urban area Anganwadi (Td) Td supporting
centre worker (Anganwadi Booster2) / mention date
worker (for school [gX1.11] / 10 [(f+g) X 1.11] / 10) session
children & School (f X 1.11 / 10)
drop-outs)
dropouts)
a b c d e f g h i j k l

223
TOTAL

ANNEXURES
 ANNEXURES

Annexure 2.15

Subcentre / ANM area wise workload and sessions' plan Form - PHC-1
District/ Corporation: ___________________________
Block/ Urban: _______________________ PHC/ UPHC: _________________________________
Name of IO / ICC: ______________________________
Mobile no.: _________________________ Name of Medical Officer I/C: ___________________ Mobile no.: __________________
Estimation of beneficiaries Session sites Type of RI Sessions
Annual Target No. of No. of sessions
(Based on actual No. of No. of
Monthly Target Monthly Number of sessions at Very/Hard to Name of ANM/s Contact no./s
Total headcount) by Number of Fixed Outreach
S.No Name of Sub Centre Injection sessions per through reach area,
Population ASHA / AWW / Session Sites session session
Load month mobile Tribal, Nomads
sites sites
PW Infants PW Infants team etc.
A B C D E F G H I J
a/12 b/12
1
2
3
4
5
6

224
7
8
9
10
TOTAL

Signature of Nodal Medical Officer - Immunization - ________________ Signature of Medical Officer I/C- ________________
 Annexure 2.16
Vaccine distribution plan (including alternate vaccine delivery) for PHC/ Urban PHC Form - PHC-2
District/ Corporation: _______________________________ Block/ Urban: ______________ PHC/ UPHC: __________________
Name of IO / ICC: _________________________ Mobile no.: _____________ Name of Medical Officer I/C: _______________ Mobile no.: _____________

Week no -
S.No Name of person responsible Contact number Month Day Site 1 Site 2 Site 3 Site 4 Site 5
1/2/3/4/5
1
2
3
4
5
6
7
8
9
10

225
11
12
13
14
15

Signature of Nodal Medical Officer - Immunization - ________________ Signature of Cold chain handler - __________________ Signature of Medical Officer I/C- ________________

ANNEXURES
 ANNEXURES

Annexure 2.17

Monthly requirement of vaccines and logistics for PHC / Urban- PHC Form - PHC-3
District/ Corporation: _______________________________ Block/ Urban: _______________________________ PHC/ UPHC - Planning Unit: _______________________________

Name of Medical Officer I/C: __________________________________

Mobile no.: __________________________ Name of IO / ICC:____________________________ Mobile No.____________________________________

Estimation of vaccine vials and logistics for each Subcenter

S.No Name of Subcenter

JE

Td
__

MR

PCV
DPT

BCG
OPV
RVV
fIPV
ADS
ADS

Hep B
Penta
0.1 ml
0.5 ml

Vitamin A
IFA tablets
Hub Cutter

Zinc tablets
Yelllow, Black)

ORS packets
RI / MCP cards
Other logistics

Anaphylaxis Kits

Reconstitution syringes
Waste Disp Bags (Red, Blue,

Paracetamol tablet/ syrup

Source figures from column totals from FORM 9 of each sub centre
1
2

226
3
4
5
6
7
8
9
10
Total requirement

Signature of Suprervisor_______________________ Verified by Medical Officer (Signature):____________________________

 Annexure 2.18

Supervision plan for PHC / Urban- PHC (Update every quarter) Form -PHC-4
District/ Corporation: _____________________________________
Block/ Urban: ________________________________________
PHC/ UPHC - Planning Unit: ______________________________________

Name & Mobile no. of Medical Officer I/C: ______________________________________________ Name & Mobile no. of IO / ICC:____________________________________

RI session sites, subcenter / ANM area name assigned for supervisory visits
Week Supervisor name
Monday Tuesday Wednesday Thursday Friday Saturday

227
3

Verified by Medical Officer Incharge (Signature with date):____________________________

ANNEXURES
 ANNEXURES

Annexure 2.19

CONTINGENCY PLAN FOR VACCINE STORAGE Form - PHC-5

PHC / UPHC:__________________________________ Date: __/__/____
When to act: ILR/Deep Freezer breaks down OR Electricty failure for more than 18 hours
Who will act: : Name and number of Cold Chain
Handler/s:______________________________________________________
What to do (Recommended actions)
1-Shift vaccines in cold boxes with conditioned icepacks. Place thermometer inside the cold box.
ILR 2- Arrange shifting of vaccines to nearby PHC or other vaccine storage facility.
3-Contact DISTRTICT FOCAL PONIT for arranging cold chain space and arrange shifting.
Deep 1- Shift ice-packs into cold boxes, if extra cold box is available after shifting of vaccines from the ILR.
Freezer 2- Contact ice-factory:____________________________ , Mr __________________________ to freeze ice-packs.

228
In case of ILR /DF breakdown, IMMEDIATELY INFORM:
Designation Name Contact no E-mail Alternate contact no
Medical Officer :
DIO:
Discrict CC mechanic:
State Cold chain Officer
Company direct:

Record details of breakdown in inventory register , UIP monthly PHC performance report, NCCMIS

Signature of Medical Officer Signature of Cold Chain Handler

 Annexure 2.20

BIO-MEDICAL WASTE MANAGEMENT PLAN Form - PHC-6

PHC / UPHC___________________________ Date: __/__/____

Name of the outsourced 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:_____________________________________

229
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

Signature MO/IC :___________________________________ Signature Nodal Officer :______________________________________

ANNEXURES
 ANNEXURES

Annexure 2.21

PHC/UPHC Level Quarterly Routine Immunization Communication Plan Form PHC-7

Year Q1/2/3/4
Name of the district/
Name of Block: Name of PHC/UPHC: Name of MO I/C:
corporation:
COMPILATION OF SUBCENTRE LEVEL PLANS (Total for PHC/UPHC)
Activities
M1 M2 M3
Mothers’s/Fathers' meeting No. & C ategory

Community/ Influencers/ MAS/ SHG Meeting No. & C ategory

VHSNC/UHSNC Meeting No. & C ategory

IPC sessions/counselling No. & thematic area

Miking/Drum Beating No. & C ategory

Social Mobilization
Rallies No.
activities
Celebrations/competitions/special days No. & C ategory

Mosque/Temple/Church/Religious Institutions announcements No.

230
Information card/Bulawa parchi for parents
School Teachers' orientation/coordination
Others (Specify)
Banners
Posters
Mid media
Leaflets
activities
Wall Paintings
Others (Specify)

Note: This template is to be filled by the Medical Officer of the PHC/UPHC and submitted at Block level to the MOI/C for compilation at Block level.
The individual Sub-Centre level Quarterly RI Communication Plans are to be annexed with this Plan.
 Annexure 2.22

Block Level Quarterly Routine Immunization Communication Plan

Year Q1/2/3/4
Name of the District: Name of CHC:
Name of MO I/C: Name of BEE/BCM:
Activities at Block level M1 M2 M3
Sensitization meeting with Block-level Officers (Panchayat,
No. & Category
BDO, Ward Members, CDPO etc.)
Coordination meeting with CSO/ NGOs/Religious leaders/
Advocacy Meetings No. & Category
influencers at block level
Sensitization of media Responsible person
Any other (Specify) Date
No. of official groups
WhatsApp messages (members' category- CDPO, Education,
Member category
Social Media IEC, PRI, Ward Members, MOs, ANM, ASHA etc.)
Plan
Other (Specify)
COMPILATION OF PHC/UPHC LEVEL PLANS (Total for Block)
M1 M2 M3

231
Mothers’s/Fathers' meeting No. & Category
Community/ Influencers/ MAS/ SHG Meeting No. & Category
VHSNC/UHSNC Meeting No. & Category
IPC sessions/counselling No. & thematic area
Miking/Drum Beating No. & Category
Social Mobilization
Rallies No.
activities
Celebrations/competitions/special days No. & Category
Mosque/Temple/Church/Religious Institutions announcement No.
Information card/Bulawa parchi for parents
School Teachers' orientation/coordination
Others (Specify)
Banners Block l
Posters
Mid media activities Leaflets
Wall Paintings
Others (Specify)
Note: This template is to be filled by BEE/IEC focal at the Block level, reviewed by MOI/C and submitted to the person in-charge for IEC at the District for
compilation at District level.
The individual PHC/UPHC level Quarterly RI Communication Plans are to be annexed with this Plan.

ANNEXURES
 ANNEXURES

Annexure 2.23

Distrct Level Quarterly Routine Immunization Communication Plan

Year Q1/2/3/4
Name of State: Name of the District:
Name of DIO: Name of IEC I/C:
Activities at District level M1 M2 M3
Sensitization meeting with Block-level Officers (Panchayat, BDO,
No. & C ategory
Ward Members, CDPO etc.)
Coordination meeting with CSO/NGOs/Religious leaders/
No. & C ategory
influencers at block level
Orientation of IMA/IAP/FOGSI members No. & C ategory
Advocacy Meetings
Sensitization of media Responsible person
Identified local celebrity/brand ambassador for RI
Orientation of School principal/ Nodal persons No. & C ategory
Any other (Specify)
No. of official groups
WhatsApp messages (members' category- CDPO, Education, IEC,
Member category
Social Media PRI, Ward Members, MOs, ANM, ASHA etc.)
Plan
Other (Specify)
COMPILATION OF BLOCK LEVEL PLANS (Total for District)
M1 M2 M3
Sensitization meeting with Block-level Officers (Panchayat, BDO,
No. & C ategory
Ward Members, CDPO etc.)

Coordination meeting with CSO/ NGOs/Religious leaders/

232
Advocacy Meetings No. & C ategory
influencers at block level
Sensitization of media Responsible person
Any other (Specify) Date

No. of official groups

WhatsApp messages (members' category- CDPO, Education, IEC,
Member category
Social Media PRI, Ward Members, MOs, ANM, ASHA etc.)
Plan
Other (Specify)
Mothers’/Fathers' meeting No. & C ategory
Community/ Influencers/ MAS/ SHG Meeting No. & C ategory
VHSNC/UHSNC Meeting No. & C ategory
IPC sessions/counselling No. & thematic area
Miking/Drum Beating No. & C ategory
Social Mobilization
Rallies No.
activities
Celebrations/competitions/special days No. & C ategory
Mosque/Temple/Church/Religious Institutions announcement No.
Information card/Bulawa parchi for parents
School Teachers' orientation/coordination
Others (Specify)
Banners
Posters
Mid media activities Leaflets
Wall Paintings
Others (Specify)
Note: This tem plate is to be filled by BEE/IEC focal at the District lev el, rev iewed by DIO and subm itted to the person in- charge for IEC at the State for
com pilation at State lev el.
Annexure 3: Routine Immunization head count survey validation format
Template for Validation of Head Count Survey (HCS) Routine Immunization 2024
Date: _ _ / _ _ / _ _ State/UT: ……………….…….……. District: …………..……………….. Block/ Urban area: ………………….……..……… CHC/PHC/UPHC/Others: ……………………….……….
Name of Planning unit: ………………………….. Subcenter/ ANM area:……………………. Village/ Ward/ Mohalla: …………………… Setting: Urban / Rural, If Urban, NUHM City: Yes/ No;
Name of ANM/ Vaccinator…………..……………. Name of Monitor: …………………………………………….; Organization: Govt / WHO / UNICEF / JSI / CHAI / Others (specify): …………….…;
Designation: ……………………..……;
Is head count survey (HCS) conducted in this area (as per survey plan): Yes / No: if No - inform MoIC, proceed to another area as per validation plan.

Monitor to visit 5 households (HH) with at least one child due for at least one due vaccine and/or a pregnant woman and interact to elicit response. Select HH should
represent the area. Find out from caregivers if surveyor/team has visited for HCS. Meet surveyor and validate the data in HCS format. Ensure data entry in ODK tool same day.

No. Monitoring and validation details: HH-1 HH-2 HH-3 HH-4 HH-5
a. Ask family member if surveyor/team visited HH for HCS? Yes / No Yes / No Yes / No Yes / No Yes / No
1 b. If visited, date surveyor visited this HH (from wall / family member, else NA) __ / __/ __ / NA __ / __/ __; UM __ / __/ __; UM __ / __/ __; UM __ / __/ __; UM

c. No. marked for this HH (From wall of HH / else consider unmarked HH (UM) ______ / UM ______ / UM ______ / UM ______ / UM ______ / UM

a. Name of the head of family

2
b. Mobile/landline contact number
a. Is there a pregnant woman found in this HH? (Select only 1 if >1)? Y/N Y/N Y/N Y/N Y/N
Pregnant
woman

3 b. Name of the pregnant woman

c. Is this PW identified in HCS Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA
a. No. of children found in this HH by monitor as on day of HCS?
b. No. of children found due for any vaccine dose as on day of HCS
c. Name(s) of children due for any vaccine (b) to validate with HCS format
Children <1 year
(0-11 months)

d. No. of children due for any vaccine but missed (c) in HCS format

4 e. Name(s) of children due for any vaccine but missed (d) in HCS format
f. No. of children 2-11 months due for Penta-1 as on day of HCS
g. Name(s) of children (f) due for Penta-1 for validation with HCS format
h. No. of children due for Penta-1 but missed (g) in HCS format

ANNEXURES
i. Name(s) of children (h) due for Penta-1 missed in HCS format
No. Monitoring and validation details: HH-1 HH-2 HH-3 HH-4 HH-5
a. No. of children (12-23 months) in this HH as on day of HCS
b. No. of children who have not received Pentavalent-1 within 1st year of
age (Zero dose) as on day of HCS
Children 1-2 years (12-23 months)

(Even if the child

c. Name(s) has received
of ZERO DPT1) (b) to validate with HCS format
dose children
d. No. of children due (c) for DPT-1
e. Name(s) of children (d) due for DPT-1 to validate with HCS format

5 f. No. of children (e) due for DPT1 but missed in HCS format
g. Name(s) of children (f) due for DPT-1 but missed in HCS format
h. No. of children (16-23 M) found due for DPT booster-1 as on day of HCS
i. Name(s) of children due for DPT booster-1 (h) to validate with HCS
format
j. No. of children due for DPT booster-1 (i) but missed in HCS format
k. Name(s) of children due for DPT booster-1 (j) but missed in HCS format
a. No. of children found in this HH by monitor as on day of HCS
Children 2-5

MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2:
b. No. of children found due for MR-1/MR2 as on day of HCS
months)
(24-59
years

6 MR1: MR1: MR1: MR1: MR1:

c. Name(s) of children due (b) for MR1/MR2 MR2: MR2: MR2: MR2: MR2:

MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2: MR1: MR2:
d. No. of children due (c) for MR1/MR2 but missed in HCS
7 Refusal Has this child missed any due dose due to refusal / AEFI apprehension? Yes / No Yes / No Yes / No Yes / No Yes / No
Interaction with the surveyor/team: Met surveyor/team? Yes / No (If no – skip Q 8- a, b, c and d)
a. Who has done HCS? ASHA / AWW / ANM / Link worker / Others
b. Did the surveyor receive training prior to HCS? Yes / No
8
c. No. of houses planned by the team per day: i) less than 25 ii) 25-50 iii) 50 - 100 iv) ≥ 100
d. Has the surveyor (team)` used standardized HCS format? Yes / No

Assessment by the monitor:

a. Has surveyor missed children due for one or more vaccines in ≥2 HH? Y / N / NA (if not met with surveyor/team)
9
b. No. of cluster of ≥3 consecutive HH not visited by surveyor/team (within 5 HH monitored and in the area while walk through)? _______
Recommend repeat survey if: 1). ≥ 3 consecutive HH not visited for survey AND/OR 2). ≥ 2 HH have missed children due for any due vaccine dose(s) in survey

233
 ANNEXURES

Annexure 4: Checklists for Preventive Maintenance of cold-chain equipment

Daily Preventive Maintenenace checklist for ILR and DF/Date
1 Exterior of CCE is clean
2 CCE are placed firmly on the floor
3 CCE are properly leveled
4 Sides are atleast 10cm away from any wall or object
5 CCE are away from direct sunlight
6 The room is well ventilated
7 Lid is kept locked
8 Keys kept at easily available place
9 Lid seals properly without gap
10 Lid seal is clean
11 Ice packs are in proper position (for DF only)
12 Ice packs filled to proper level (no leak)
13 Thickness of frost formation is not more than 5 mm
14 Vaccines preserved in neat rows

234
15 There is space between rows of vaccine for air circulation
16 Freeze sensitive vaccines are kept in upper part basket and not touching any cooling surface (for ILRs only)
17 Separate thermometer kept among the vaccine
33 Temperature recorded is minimum twice a day
18 Reading of thermometer is within desire temp. range.
22 Voltage stabilizer connected
23 Input voltage reading........................................ volts
24 Output voltage reading…....................................volts
25 Plug of voltage stabilizer fits properly and not loose on the power socket
26 Connections to voltage stabilizer proper and not loose
27 Electrical connections are proper (visual checks)
28 No abnormal voice

Signature of Vaccine & Cold-chain Handler

Signature of MOI/C
*(If not, adjust thermostat to obtain steady temperature within specified limits, (Only if user is fully aware of setting procedure & confident about), or otherwise contact cold-chain Technician.)
 Preventive Maintenance checklist for ILR and DF (Weekly)
Weekly Preventive Maintenenace checklist for ILR and DF 1st week 2nd week 3rd week 4th week
1 Open the unit and wipe the area over the rubber gasket on the cover of the unit
and the area where it meets the main body when the cover is closed – with a
clean wet cloth. (If done put tick √ )
2 Check door seal, door fitting, position of the equipment on the floor, and clean
the gasket and adjust position if required (If done put tick √ )
3 Check lock and key operation (If done put tick √ )
4 Visual inspection of Electrical wiring appearance (If done put tick √ )
5 Condition of the cord & plug (If done put tick √ )
6 Stabilizer is working properly & giving proper output voltage (If done put tick √ )
7 Power supply is available up to CCE (If done put tick √ )
8 Check the units for level of frost around the inner side of the walls and especially
on the top where the cover meets the body of equipment. (If done put tick √ )

Signature of Vaccine & Cold-chain Handler

235
Signature of MOI/C
(If the frost is more than 5 mm thick on the walls or 1mm thick on the top area than the unit needs to be defrosted. See process for defrosting below)

ANNEXURES
 ANNEXURES

Annexure 5: Formats for Vaccine stock and distribution registers

Annexure 5.1: Vaccine Stock register formats

236
 Annexure 5.2 Vaccine distribution register formats
Vaccine Distribution Register for Immunisation Session
Name of the CHC/PHC/PPC: Name of the person distributing the vaccines: Name of the person receiving return vaccines: Type of the session (RI/ SIW/Campaign/Others): Date:

Issue and Return of Un-opened Vaccine Vials (VVM Status-Usable) Syringes Issue and Return of Open Vaccine Vials (VVM Status-Usable)
Red and
bOPV Pentavalent BCG Diluent MR Diluent Black Pentavalent
bOPV Doses fIPV Doses DPT Doses Hep-B Doses Td Doses BCG Doses MR Doses RVV Doses RVV Dropper JE Doses PCV Doses 0.1ml 0.5 ml 5 ml Plastic bOPV vials fIPV vials DPT vials Hep-B vials Td vials PCV vials JenVac vials
Name of the Sub- Dropper Doses Doses Doses vials
Bags
S.No
centre/UHP/HF- Session site Return Return Return (Yes/No)
Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue (un- Issue (un- Issue (un- Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return Issue Return
used) used) used)

10

11

12

13

14

15

237
16

17

18

19

20

21

22

23

24

25

26

27

28

Total

bOPV Pentavalent BCG Diluent MR Diluent

bOPV Doses fIPV Doses DPT Doses Hep-B Doses Td Doses BCG Doses MR Doses RVV Doses RVV Dropper JenVac Doses PCV doses 0.1ml 0.5 ml 5 ml
Dropper Doses Doses Doses
Net Utilised = (Total Issued Doses -
Total Returned Doses)

ANNEXURES
 ANNEXURES

Annexure 5.3 Indent and supply formats

238
Annexure 6

Flow Chart: Initial management of Anaphylaxis by ANM

AFTER IMMUNIZATION LET THE PARENTS OR GUARDIANS WAIT FOR 30 MINUTES.
Suspect* Anaphylaxis in a case with following symptoms and signs.

Eariy onset (within few minutes to 6 hours) & rapid progression of > =1 signs &
symptoms of any of the two systems (Respiratory, cardiovascular and dermatological
/ mucosal)
Respiratory:
• Swelling of tongue, lip, throat, uvula, larynx
• Difficulty in breathing
• 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.)
• Grunting (noisy breathing)
Step 1: Cardiovascular:
Assess Case • Decreased level/loss of consciousness (fainting, dizziness)
• Law 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 subcutaneous tissues
such as upper eyelids, lips, tongue, face, etc.

ANNEXURES
• Generalized pruritus (itching) with skin rash
Other signs/ symptoms: anxiety, diarrhea, abdominal cramps, nausea, vomiting and
sneezing or rhinorrhea.

Manage anaphylaxis

• Reassure patient, parents / relatives

Step 2: • Immediately administer one dose of injection Adrenaline by deep IM route
Administer • Seek help to inuuediately arrange for ambulance to transport the patient to
one dose of the nearest health facility (PHC/ CHC/ District Hospital/ Civil Hospital)
adrenaline • Do not leave the patient alone
deep IM • If patient is conscious, he/ she should be kept in supine position with lower
Iimbs raised higher than head
• If patient is unconscious he/ she sbould be kept in left lateral position
Step 3: Refer Refer to higher center
immediately
• Call for ambulance
• Inform MO about the case before arriving at the health facility for timely management
Step 4:
Docoment • Document suspected anapbylazis on immunization card in block letters against
suspected vaccines administered
anaphylaxis

*Many of the initial signs and symptoms are similar in both mild allergic reactions / anaphylaxis. AMN may administer a single dose of
adrenaline injection at the first sign or symptom suggestive of allergy or anaphylaxis.

239
 Annexure 7: Formats used during Adverse Event Following Immunization
(AEFI)– Case Reporting Form (CRF) and AEFI register

Annexure 7.1: Case Reporting Form (CRF)

ANNEXURES

240
241
ANNEXURES
 Annexure 7.2: AEFI Register (to be kept at PHC/cold-chain point/sector or block PHC/facility
conducting vaccination) (to be filled by ANMs once a week)
ANNEXURES

242
Annexure 7.3: Assessment of AEFIs recorded at the Planning unit level (Format to be shared
in the first week of every month to DIO) To be filled by MO in charge

ANNEXURES

243
 ANNEXURES
Tally sheet for Routine Immunization session For ANM
Date of session: Session site address: _______________ Village: ________________________________
Setting: Urban/ Rural HRA (Y/N)__________ If yes, specify code __________________________
Block/ Urban area: __________________________________________ Planning unit (PHC/UPHC/CHC): __________________________________________ Sub center: ________________________________
Name of ANM: ________________________________________________ Name of mobilizer(s): ________________________________________________________

Pregnant TICK (√) THE BOX FOR EACH VACCINE

TICK (√) THE BOX FOR EACH VACCINE GIVEN TO THE BENEFICIARY
Women GIVEN TO THE BENEFICIARY

Father/ husband
Name of beneficiary

Sex

S. No
Age*
(Y/N)
name
Tab. Zinc
(5-6 years)
ORS packets

BCG

Td-1
Td-2
JE-1#
JE-2#

PCV-1
PCV-2

RVV-1
fIPV-1
RVV-3

RVV-2
fIPV-2
fIPV-3

OPV-1

OPV-0
OPV-3
Vit A-2

OPV -2
Vit A-1
●DPT-1
●DPT-2
●DPT-3

Penta 1
Penta 2
Penta-3
DPT-2nd Booster
(mention the code)

first time in life (Y/N)

Td- Booster
PCV-Booster
OPV-Booster
If not vaccinated reason

DPT- 1st Booster

Hep. B birth dose

Vaccines due for this session

MR-1 (9-11 months)

MCP Card no. / U-WIN ref. no.

MR-2 (16-24 months)

Whether child vaccinated for the

Full immunization achieved (Y/N)
Complete immunization achieved

MR-1 (>12 months- 5 yrs)

MR-2 (>24 months - 5yrs)

(If not registered in UWIN register)

Total < 1 year Male
< 1 year Female
Total > 1 year Male
> 1 year Female
Total

244
Summary Age of child Up to 1 Year 1 to 2 Years 2 to 5 Years Grand Total
Full immunization Achieved Sex of child M F T M F T M F T M F T
No. of target children for the session
Age Male Female Total
(as per due list)
9 months to <12 months Total Children vaccinated
Annexure 8: Routine Immunization Tally sheet

No. of target Pregnant Women for the session

1 to <2 Years
(as per due list)
Children vaccinated for the first time in life Total Pregnant Women vaccinated
Up to 2 Year Reason for beneficiaries not vaccinated

2 to 5 Years Total no of beneficiaries that

could not be vaccinated R1 - House locked/ Out of R4 - Already Vaccinated in
R2 - Sick R3 - Refused R5 - Fear of AEFI Others
village/ Ward other RI session/ in private
AEFI Reporting
Pregnant Pregnant Pregnant Pregnant Pregnant Pregnant
No. of Adrenaline doses used (if any) Children Children Children Children Children Children Children Pregnant Women
Women Women Women Women Women Women
No. of hospitalized AEFI cases (if any)

Details of vaccine and logistic BCG BCG Diluent MR MR Diluent IPV PCV Pentavalent DPT Td JE# OPV RVV 0.1 ML Syringe 0.5 ML Syringe Mixing Syringe 5 ML

Received
Utilized
Returned
Prepare three copies of this form (1 for ANM, 1 for mobilizer (ASHA/ Link worker) and other for the Block/ Planning unit)
● Children less than 1 year should not be given DPT, start schedule with pentavalent vaccine only.
● As per guidelines, subsequent doses of the Pentavalent vaccine can be given to a child with more than one year of age only if the child has started with the Pentavalent vaccination within one year. Give subsequent dose in the next possible contact. Do not start Pentavalent
vaccination beyond one year of age.
● Children more than 1 year of age coming to the session site for the first time (without any vaccination) should be given DPT and not the pentavalent vaccine. Other missed vaccination should be given as per guidelines.
* Age of child should be documented in completed months; age of pregnant woman should be documented in completed years
# Record vaccination wherever is applicable (as JE vaccine is applicable in JE endemic districts only)

Signature of ANM/ Vaccinator Signature of Supervisor/ Medical Officer

 Annexure 9: Routine Immunization Supervision and monitoring formats

Annexure 9.1

Routine Immunization Session Site Monitoring Format - 2023

Encircle applicable options. For (*) marked questions multiple responses may be applicable

State/UT: …………………..…..…….……. District: …………..……………….. Date: _ _ / _ _ / _ _ Type of monitoring: RI / SIW / Others (specify) ……………. ………………. Monitoring time: _ _ : _ _ to _ _ : _ _
Block/ Urban area:……………………..……… CHC/PHC/UPHC/Others: ……………………. Planning unit: ……………………… Subcenter/ ANM area:…………………………. Village/ Ward/ Mohalla:……………….…………
Setting: Urban/ Rural, If Urban, NUHM City: Yes/ No ; Name of ANM/ Vaccinator…………..…………………. Name of Session site: …………………..……….
Session type: a. Fixed / Outreach / Mobile/ Vaccination on demand; b.. Govt./ Pvt; c. *HRA#: Yes/ No, If Yes, mention code :…… , ……., ……… Is there an ongoing measles outbreak in this area? Yes / No
Name of Monitor(s): …………………………………………………………….; Organization: Govt / WHO / UNICEF / JSI / CHAI / Others (specify): ……………….…………; Designation: ……………………..……;
Name of Monitor(s): …………………………………………………………….; Organization: Govt / WHO / UNICEF / JSI / CHAI / Others (specify): ……………….…………; Designation: ……………………..……;

# Codes for HRA*: 1: Slum with migration 2: Nomads 3: Brick kiln 4: Construction site 5: Other migratory sites 6A: Settled Slum 6B: Hard to Reach areas 6C: Vacant Subcenter 6D: VPD outbreak areas 6E: Vaccine hesitancy 6F: Others (Specify): …………………..
* If no-reason(s) a. Session closed early b. ANM didn’t report at the session c. Vaccine / logistics not available d. ANM and Vaccine/ logistics not available e. Others………………..…
Is planned
1 session found Yes / No If session found ‘not held’ skip to Q 31-33 as applicable, and plan to conduct house-to-house monitoring in this area after the stipulated session closure time same day /at the earliest
held at the time
of visit? If yes a. Is the session being held at same location as per micro-plan? Yes / No b. Is the vaccinator same as per micro-plan? Yes / No

UWIN portal use: Yes / No / NA – Not yet started in the state/district

a. Is this session site registered on UWIN? Yes / No / NA b. Is vaccinator registered on UWIN? Yes / No / NA c. Is the current session registered and conducted on UWIN Yes / No / NA

245
2
d. Whether e-Vaccination certificate is generated after administering vaccine? Yes / No / NA

Monitor observed ANM vaccinating at least 1 child? Yes / No [If no, skip to Q 11]
3 Is ANM administering vaccines in correct sequence per operational guidelines? Yes / No (6-14 weeks: bOPV, RVV, BCG, fIPV, PCV, Penta); (≥9 months: Vit-A, fIPV, MR, PCV, JE); (≥16 months: Vit-A, OPV, MR, DPT, JE)
4* Are safe injection practices followed? Yes / No; If No, select: a. not cutting syringe hub immediately after use b. recapping of needle c. touching the needle during preparation /administration d. pre-filling of syringe
5 Is ANM providing 4 key messages [Vaccine given for protecting which disease; their side effects & how to manage, safe keep of the card, & when and where is next visit] All 4 messages / Some messages / None
6 6A: ANM asking caregivers to wait with child for 30 min after vaccination? Y/ N 6B: Is paracetamol syrup provided, to be used if child develops fever following vaccination? Y / N / Paracetamol not available
7 Is ANM updating MCP/ RI card /UWIN after vaccinating each child? a. MCP/ RI card: Yes / No b. UWIN portal: Yes / No / NA – Not yet started in the state/district c. State initiated portal: Yes / No / NA

8 Who delivered vaccine/logistics at the session site? a. Alternate Vaccine Delivery (AVD) b. ANM / Vaccinator c. ASHA d. AWW e. Supervisor f. others g. Not applicable as session site is a CCP
9 a. Name of cold chain point (CCP) supplying vaccines/ logistics to this session site: ……………………………; b. Is the travel time from CCP to this session site more than 1 hour: Yes / No
10A. Is Mahila Arogya Samiti (MAS) 10B. Mobilizer/s found working at the session 10C. Any local Influencer identified and supporting RI in ongoing MR
10 for NUHM City constituted? Yes / No / NA a. ASHA: Yes / No / NA b. AWW: Yes / No / NA c. Link worker: Yes / No / NA outbreak area? Yes / No / NA; If Yes, Influencer is/are:
(Check with ANM / ASHA / mobilizer) d. MAS: Yes / No / NA e. Others (specify): _____________ a. religious influencer b. PRI member c. Local doctor d. Others……...…

Is the session being held at District hospital, Medical College, Block HQ PHC, CHC etc. [Which has no well-defined catchment area] Yes / No;
If yes, SKIP Q11 and 12, If “No” – continue with Q11 onwards
11 Is Head Count Survey (HCS) done for this session area? Y / N If yes, HCS record available? Y / N If yes, when was HCS done? a. within 6 months b. within 6-12 months c. More than 1 year back
12 Is updated due list available with mobilizers? Yes / No If yes, does the list have beneficiaries from: 0 to <2 Years: Y / N 2 – 5 years children missed MR1/MR2: Y / N Pregnant woman: Y / N

ANNEXURES
 ANNEXURES

13 Status of ice packs in the vaccine carrier (regular or freeze free vaccine carrier) a. Hard frozen b. Ice-packs have Ice and water c. Ice-packs have only water
14* Encircle vaccine/ diluent available at session : BCG / BCG Diluent / bOPV / IPV / RVV - VVM on Cap / RVV - VVM on Label / Pentavalent / DPT / PCV / MR / MR Diluent / JE /Td
15* Does ALL opened vials have date and time mentioned on them? Yes / No / NA; If no, mention vaccine(s): ……………..……; ………………; …….……….……………; ………………………..
16* Whether ALL reconstituted vaccines (BCG / MR) are within 4 hours of reconstitution? Yes / No / NA: If no, mention vaccine(s) ………………………………; ……………………………….………;

Any issue with condition of Yes / No ; If yes, select option a. Frozen ……..……………; b. VVM in unusable stage ………..……….; c. Damaged label: .. ……..………..; d. Damaged glass/septum…………..…...;
17*
vaccine/ diluent identified? and *mention vaccine(s) e. Beyond expiry date ……….; f. Beyond 28 days of opening (for vaccines under open vial policy) …………; g. Other conditions (specify) .……….….;

18* Which logistics are NOT available? AD syringes : a. 0.1 ml ; b. 0.5 ml; c. Sufficient 5 ml reconstitution. d. Vit-A solution; e. Spoon for Vit-A; f. ORS; g. Zinc tab/syr; h. Blank MCP cards; i. All logistics are available
Bio-medical waste and AEFI management [If Red/Black bag not available then NA for 19C and 19D]
19A. Is working hub-cutter with white/blue puncture & tamper proof container available? Yes / No; 19B: Hub cutter with cut hubs + needle and broken vial/ampoule being sent for disposal? Yes / No
19
19C. ANM segregating i). plastic portion of syringe /used empty vial into red bag – Y / N / NA; ii). Wrapper/ needle cap into black bag: Y / N / NA 19D. Red/ Black bags with contents sent for disposal? Yes / No/ NA
20 Is Anaphylaxis kit available? Yes / No if yes, a. Adrenaline within expiry date: Y / N b. Adrenaline dose chart: Y / N c. Tuberculin/Insulin syringe with detachable needle: Y / N
21 Any AEFI management center tagged with this session: Yes / No / Not aware; If yes, mention details: …………………………………………………………………………

Interaction with ANM / mobilizers

22* Did any supervisor visit the session today? Yes / No, If yes; select option(s): a. Medical Officer b. Health Supervisor c. Community Health Officer (CHO) d. District level Officials e. Others: ………..……
23 Training status of ANM on Immunization Handbook for Health Workers a. Trained more than 3 years back b. Trained within last 3 years c. never trained
24 24A. BRIDGE training received by a. ANM b. ASHA c. AWW d. None 24B. ANM trained on RISE module Yes / No / Not applicable (RISE training not started in the state/district)

Number of caregivers interviewed: 1 / 2 / None [If “None” SKIP Q 25- 27] Caregiver 1 Caregiver 2
25* Who asked to bring child to this session? a. ASHA b. AWW c. ANM d. MAS e. Link worker f. ULB/PRI g. Religious leader h. Influencer i. Self j.Others.…..... a/b/c/d/e/f/g/h/I/j a/b/c/d/e/f/g/h/I/j

246
26* What would you do if the vaccinated child develops fever / pain? a. Give Paracetamol b. contact Health worker c. Other (specify)…….… d. Not aware a / b / c……………… / d a / b / c……………… / d
27 When should you bring the child for next vaccination? (Monitor to assess and select whether the caregiver’s response is Correct / Incorrect) Correct / Incorrect Correct / Incorrect

Interview with ASHA / LINK worker: ASHA interviewed - Yes / No / NA [If No or NA, skip Q28]
ASHA aware of which of the following a. Line listing (HCS) of HH & beneficiaries b. Due list preparation and monthly updation c. Mobilization of children d. Full Immunization with 1st year vaccines
28*
incentives in RI programme? e. Complete Immunization with 2nd year vaccines f. For DPT booster dose-II at five years g. Not aware of any incentive
29 Is the LINK worker aware of incentive for mobilization of children Yes / No / Not applicable / Not met

30* Any RI related IEC material displayed at session site? Yes / No If yes; select a. Poster b. Banner c. Wall painting d. National Immunization schedule in local language e. Others (Specify): …………

Meet Medical Officer to ascertain reason(s) for session not held [SKIP Q31-33 if session was held]
31 Why ANM was not available at session site? a. On leave b. Vacant post c. Assigned other work d. Others (specify) ………..……
32 Are you aware of hired vaccinator and their incentives? Yes / No
33 Reason for non-availability of vaccines/logistics? a. Not issued b. Not picked up c. Not delivered d. Others (specify) …………….
Notes:
 Annexure 9.2
Routine Immunization House to House Monitoring Format - 2023
Monitor to follow “Standard Operating Procedure” (SOP) and refer “Ready Reckoner” during monitoring. Encircle appropriate options. For (*) marked questions multiple responses are allowed

State/UT: …………………..…………..…….…….… District: …………..……………….. Date: _ _ / _ _ / _ _ Type of monitoring: RI / SIW / Others (specify) …………………….. Monitoring time: _ _ : _ _ to _ _ : _ _
Block/ Urban area: ……………………… CHC/PHC/UPHC/Others:………………….……… Planning unit: ……………..…….. Subcenter/ ANM area:…………………..………… Session site/s for this area:……………………..
Village/ Ward/ Mohalla:……………………… Setting: Urban / Rural; HRA: Yes/ No; $If Yes, mention code: $ 1/ 2/ 3 / 4/ 5 / 6A / 6B / 6C / 6D / 6E / 6F; Is there an ongoing measles outbreak in this area? Yes / No
Name of Monitor(s): 1) ……………… ……..…………; 2) ………………………… Organization: Govt/ WHO / UNICEF/ JSI / CHAI / Others (specify): ………………; ……….…… Designation(s): ……………………; ……………..…
# Codes for HRA: 1: Slum with migration 2: Nomads 3: Brick kiln 4: Construction site 5: Other migratory sites 6A: Settled Slum 6B: Hard to Reach areas 6C:Vacant Subcenter 6D: VPD outbreak areas 6E: Vaccine hesitancy 6F: Others
Monitor to visit 10 households (HH) 7 HH for 7 children 0-23 months (up to 2 years) 3 HH for 3 children 24-59 months (2 to 5 years)
Details of child and vaccination status in monitored Households HH-1 HH- 2 HH-3 HH-4 HH-5 HH-6 HH-7 HH-1 HH-2 HH-3
1a Name of the selected child

1b Name of the Father/Mother of the child

Person providing information
1c M/F/G/O M/F/G/O M/F/G/O M/F/G/O M/F/G/O M/F/G/O M/F/G/O M/F/G/O M/F/G/O M/F/G/O
[Mother = M; Father = F, Grandparents = G , Others = O]
1d Religion (H=Hindu, M=Muslim, C= Christian, O=Others) H /M/C/O H /M/C/O H /M/C/O H /M/C/O H /M/C/O H /M/C/O H /M/C/O H /M/C/O H /M/C/O H /M/C/O
1e Gender of the child: M=Male, F=Female, O= Other M/F/O M/F/O M/F/O M/F/O M/F/O M/F/O M/F/O M/F/O M/F/O M/F/O
1f Place of delivery: G = Govt Hospital, P = Private Hospital, H = Home G/P/H G/P/H G/P/H G/P/H G/P/H G/P/H G/P/H G/P/H G/P/H G/P/H
1g Date of birth (dd/mm/yy). [if not known, write NA]

Details of sleeted child

1h Age in completed months
$1i Source of information on vaccination status C / R / eVC C / R / eVC C / R / eVC C / R / eVC C / R / eVC C / R / eVC C / R / eVC C / R / eVC C / R / eVC C / R / eVC
MCP/RI Card = C, Recall = R ; e-Vaccination certificate = eVC

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Write dates (dd/mm/yy) for each vaccine received if MCP /RI / eVC is available. In case of recall write Yes / No. Mention “NA” for vaccine if child is not due for vaccine in view of age or the vaccine has not been/was not introduced in the district or the child was not eligible
2a Hep-B birth dose Administered within 24 hours of birth
2b bOPV-0 dose as early as possible, within 15 days of birth

At birth
2c BCG at birth, within 1 year of age
3a bOPV-1 at 6 weeks, can be given up to 5 years of age
3b RVV-1 at 6 weeks, not to start after 1 year of age
3c fIPV-1 at 6 weeks, not to start after 1 year of age
3d PCV 1 at 6 weeks, not to start after 1 year of age

At 6 weeks
3e Pentavalent-1 at 6 weeks (not to start after 1 year of age)
3f DPT-1 (can be given if Penta-1 not started within 1 year of age)
4a bOPV-2 at 10 weeks
4b RVV-2 at 10 weeks
4c Pentavalent-2 at 10 weeks

At 10 weeks
4d DPT-2 (If DPT is initiated, else NA)
5a bOPV-3 at 14 weeks
5b RVV-3 at 14 weeks
5c fIPV-2 at 14 weeks
5d PCV2 at 14 weeks

At 14 weeks
5e Pentavalent-3 at 14 weeks
5f DPT-3 (If DPT is initiated, else NA)

ANNEXURES
 ANNEXURES

Annexure 10.1: Format to capture HRA data at Sub center/ ANM area/ PHC/ UPHC/ Block/ Urban area/ District

Annexure 10.2: Format for field validation of sites with migratory population
Field Validation of Sites with Migratory populations Form: HRA-2

Name of District/ Corporation:____________________Block/Urban area: _____________________________ PHC/ UPHC:_______________________________ Sub Centre:__________________________

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Name of the person conducting Field Validation:_____________________________________ Designation:_______________________________________________
Whether RI services
Re-Estimated Whether planned using mobile Name of the Name of the
Sl. Type of Date Field Whether Re- Re- Beneficiaries reesimate Where are they Migrated
Name of the site & team / special team? ANM/CHO Mobilizer
No HRA Validation the site estimated Estimated approximately from?
Location If Yes then responsible responsible for
. (1-5) Done exists Population Households (0-1 (1-2 (2-5 match survey (area, block, district, State)
Y/N details (day, for area area
years) years) years) data
week)
A B C D E F G H I J K L M N O P
Y / N / Newly Y / N / Newly
1 Y/ N
identified identified
Y / N / Newly Y / N / Newly
2 Y/ N
identified identified

Migratory HRA 1 2 3 4 5 Total Migratory HRA: 1-Slum with migration;, 2-Nommads;, 3-Brick Kilns; 4-Constructions; 5-other
No. of sites / Areas migratory HRA;
Reestimated Population
Reestimated households
Reestimated 0-1 yr children
Reestimated 1-2 yr children
Reestimated 2-5 yr children
Total Reestimated 0-5 yr children Signature of validator:__________________________________
Annexure 11. Agenda for two days RI training for Health workers

Time Topic
Day 1
09:00-09:15 Registration
09:15-09:30 Welcome and introduction of participants
09.30- 09:45 Pre-test
09.45-10:05 Introduction
10:05-10:30 Responsibilities of HWs in RI
10:30-10:50 Diseases prevented by vaccination
10:50-11:20 National Immunization Schedule and FAQs
11:20-11:30 TEA BREAK
11:30-13:15 Microplanning for immunization
13:15-14:00 LUNCH
14:00-15:00 Managing the cold-chain and the vaccine carrier
15:00-15:30 Safe injections and waste disposal
15:30-16:00 Adverse events following immunization
16.00-17:00 Conducting RI session
17:00–17:30 Preparation for the field visit and evaluation of the day
Day 2
Field visit to immunization session site followed by discussion on

ANNEXURES
08:00-12:00
observations
12:30-13:15 Records, reports and use of data for action
13:15-14:00 LUNCH
14:00-15:00 U-WIN
15:00-16:00 Communication
16:00–16:30 Surveillance of VPDs
16:30-16:45 Post test
16:30-17:15 Distribution of certificates and conclusion

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Notes

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