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ORIENTATION ON THE ROTAVIRUS VACCINATION
I. WHAT IS ROTAVIRUS DISEASE?
• Rotavirus disease is a diarrheal disease caused by a virus called rotavirus
• The name rotavirus comes from a Latin word “rota” the wheel-like appearance of the virus under the
microscope
• Rotavirus is a virus that infects the intestines
• Rotavirus is the most common cause of severe
diarrheal disease in infants and young children worldwide
• Rotavirus is not the only cause of diarrhea, several other agents may also cause diarrhea
• Rotavirus infection is highly contagious• Rotavirus spread by fecal-oral route
• The primary mode of transmission of rotavirus is the passage of the virus in stool to the mouth of another child
How does rotavirus spread?How does rotavirus spread?
WHAT ARE THE THE SIGNS AND SYMPTOMS OF ROTAVIRUS INFECTION?
• Three main symptoms of rotavirus infection:• Fever• Vomiting• Watery diarrhea
• Abdominal pain may also occur
• Diarrhea usually stops after 3 to 7 days
• Young children can become dehydrated, requiring urgent treatment
HOW IS ROTAVIRUS DISEASE DIAGNOSED?
• Confirmation of a diarrheal illness such as rotavirus requires laboratory testing
• Strains of rotavirus may be further characterized by special testing with enzyme immunoassay or polymerase chain reaction
• Such testing is not commonly available or necessary
WHO IS MOST AT RISK IN THE POPULATION?
• Infants after the age of 3 months• Low to no immunity• Vulnerable to dehydration
• Older children if they are immunocompromised
Baby> 3 months
Ris
k o
f d
isea
se
Immuno-compromised
Children
Adults Older people
Population
High level of rotavirus morbidity continues to occur in the world
What can be done to prevent rotavirus and diarrheal disease?
What can be done to prevent rotavirus and diarrheal disease?
PREVENTION
Good sanitation and hygiene
Exclusive breastfeeding
Improved water quality
Vaccination
What can be done to treat rotavirus and diarrheal disease?
What can be done to treat rotavirus and diarrheal disease?
TREATMENT
Zinc
Oral rehydration therapy (ORT)
ROTAVIRUS VACCINE
IS THERE A VACCINE AGAINST ROTAVIRUS?
• Currently there are 2 rotavirus vaccines:• RotaTeqTM
• RotarixTM
• Main characteristics• Both are highly effective and safe• Both protect against severe forms of rotavirus disease• Both do not protect against diarrhea caused by other
agents than rotavirus
WHAT IS ROTAVIRUS VACCINE PRESENTATION?
• Rotavirus vaccine is a ready-to-use, oral vaccine in a liquid formulation • Specially designed tube for direct oral
administration
• 1 tube = 1 dose• 1 tube has 1.5mL liquid
ROTAVIRUS VACCINE
ROTAVIRUS VACCINE
Plunger Barrel Oral
applicator tip cap
Rotavirus vaccines should be stored between +2°C to +8°C
At which temperature must the vaccine be stored?
At which temperature must the vaccine be stored?
The rotavirus vaccine should be stored in a refrigerator
Where do you store the vaccine?Where do you store the vaccine?
• Vaccines with early expiration dates should be kept in front to be used first
Closer expiry date in front
Further expiry date in back
WHICH VACCINE SHOULD BE STORED IN FRONT?
ROTAVIRUS VACCINE TARGETS AND SCHEDULE
POPULATION TARGETS
• All 6 weeks up to 15 weeks old infants identified in the list of NHTS for poverty reduction
• Nationwide implementation
WHAT IS THE ROTAVIRUS VACCINE SCHEDULE? (1/2)
• Rotavirus vaccine is given in a 2-dose schedule at 6 and 10 weeks of age
• Rotavirus vaccine can be given at the same time as first and second dose of DTP-HepB-Hib (i.e. Penta1 & Penta2, OPV1 & OPV2)
• Maintain an interval of 4 weeks between doses
6Birth 10 15
32 weeksRota 1 Rota 2
WHAT IS THE ROTAVIRUS VACCINE SCHEDULE? (2/2)
• First dose of vaccine should be given before 15 weeks
• Second dose has to be given before 32 weeks• 16 weeks is too late for 1st dose and 33 weeks is
too late for 2nd dose
Rota 1
Rota 2
6Birth 10 15 32
weeks
NO ‘CATCH-UP’ FOR ROTAVIRUS VACCINE
• If a child is late for vaccination:• He/she cannot get rotavirus vaccine• He/she can get all other vaccines in the schedule
Older than 32 weeks
No rotavirus vaccine
Other vaccines in the schedule
Older than 15 weeks
HOW TO DETERMINE ELIGIBILITY OF INFANT TO RECEIVE ROTAVIRUS
VACCINE?
0 doses received
Older than 15 weeks
Make an appointment for second dose of rotavirus vaccine in 4 weeks time,
and before child is 32
weeks old.
Explain to the caregiver that the child could not get
rotavirus vaccine because he/she is too old.
Doses of RotarixTM vaccine already given?
Give other vaccines as appropriate given the infant's age and schedule the next appointment according to the national immunization schedule.
Between 6 and 15 weeks
Infant's age?
Infant's age?
Between 10 and 32 weeks Older than 32 weeks
Explain to the caregiver that the child has completed
his/her rotavirus immunization.
Explain to the caregiver that the child could not get the second dose of rotavirus
vaccine because he/she is too old.
1 dose received
Give first dose of RotarixTM
Give second dose of RotarixTM vaccine if first dose was received 4 weeks ago or
more
No longer eligible for RotarixTM
vaccination
No longer eligible for RotarixTM
vaccination
ABSOLUTE CONTRAINDICATIONS
Hypersensitivity after previous administration of rotavirus vaccines
Previous history of intussusception
Administration of RotarixTM should be postponed in subjects suffering from diarrhea or vomiting and in need of rehydration therapy
Mild illness such as an upper respiratory tract infection or mild diarrhea is not a contraindication
IMMUNIZATION SCHEDULE FOR INFANTSAntigen AGE
At birth 6 W 10W 14W 9M 12M
BCG √
HepB-BD
√
OPV1 √
Rota1 √
Penta1 √
OPV2 √
Rota2 √
Penta2 √
OPV3 √
Penta3 √
AMV1 √
AMV2 √
ROTAVIRUS VIRUS VACCINE ADMINISTRATION
HOW TO CHECK THE QUALITY OF THE VACCINE? (1/2)
• Before administering the vaccine, you need to check the Vaccine Vial Monitor (VVM)
Stage 1: Vaccine OK
Stage 2: Vaccine OK but use first
Stage 3: Do not use the vaccine
Stage 4: Do not use the vaccine
How to check the quality of the vaccine? (2/2)
Before administering the vaccine, always check the expiration date on the box
• Pull off the oral applicator tip cap
How to prepare for vaccination? (1/4)
Oral applicator tip cap
The child should be seated in a semi reclining position to take the vaccine orally
How to position the child for rotavirus vaccination?
How to position the vaccine?
Open the child’s mouth by gently pressing the cheeks together
Angle the tube towards the inner cheek
NEVER Place the tube into the center of the mouth to prevent risk of choking!
How to administer the vaccine?
Administer the entire content of the tube by pressing the tube– Squeeze the tube slowly
Make sure the child is swallowing the vaccine to prevent buildup in the mouth– Hold the cheeks together and
stroke him/her under the chin to help with swallowing
CAN ROTAVIRUS VACCINE BE GIVEN AT THE SAME TIME AS OTHER CHILDHOOD VACCINES?
Rotavirus vaccine can be administered with any of the following routine childhood vaccines without interfering with their effectiveness:
– Diphtheria–tetanus–pertussis vaccine (DTP)– Haemophilus influenzae type b vaccine (Hib)– Pentavalent (DPT-HepB-HiB)– Inactivated polio vaccine (IPV)– Hepatitis B vaccine– Pneumococcal vaccine– Oral polio vaccine (OPV)
Give the OPV first, Rotavirus, then administer other childhood vaccines
ROTAVIRUS VACCINE EFFECTIVENESS
CONDITION EFFECTIVENESS
Any rotavirus gastroenteritis
74% - 87%
Severe gastroenteritis 85% - 98%
Both vaccines significantly reduced physician visits for diarrhea, and reduced rotavirus related hospitalization.
RECORDING AND REPORTING
WHAT ARE THE MAIN USES OF THE IMMUNIZATION CARD?
• Provides the date of birth of the child
• Informs health worker and caretaker of:• Vaccines already received and those needed in the future• Next appointment for vaccination
• Can help with identifying infants who do return for vaccination on time
• Useful to conduct coverage surveys
HOW TO USE THE IMMUNIZATION CARD?
Health worker checks the card, administer the
vaccine(s), and writes the date the
vaccine(s) were given in the card
Immunization cards are being updated to include boxes for indicating first and second rotavirus vaccine doses immunization card
How to record vaccination on the card?
= 1st dose of rotavirus vaccine
= 2nd dose of rotavirus vaccine
HOW TO RECORD THE VACCINATION ON THE TARGET CLIENT LIST ?
On the “REMARKS” column, draw 2 columns and write “ROTA1” in the 1st drawn column and “ROTA2” in the 2nd drawn column
Indicate the date Rota vaccine was administered
Put an asterisk (*) in the space before the registration number/date of the infant
An asterisk indicates member of NHTS family
Tally sheets, stock management forms, and monthly reporting forms are also being updated to include the new rotavirus vaccine
• Report Rota1 and Rota2 doses given each month, along with other vaccine doses
HOW TO RECORD ROTAVIRUS VACCINE ON THE MONTHLY REPORT?
HOW SAFE IS THE VACCINE?
• Rotavirus vaccines are safe and do not cause any serious adverse events
• Irritability and loss of appetite are very common side effects of rotavirus vaccine
• Rotavirus vaccine may be given with other vaccines in the infant Expanded Program on Immunization (EPI) schedule without interfering with their effectiveness
What is an AEFI? What is an AEFI?
At the end AEFI = Adverse event following immunization– A medical incident– Takes place after an immunization– Causes concern– Is believed to be caused by immunization
AEFI can be categorized into – Vaccine reaction– Programme error– Coincidental– Injection reaction– Unknown
IS is a rare type of bowel obstruction that occurs when one portion of the bowel slides into an immediately adjacent segment (also known as telescoping or prolapse).
Symptoms of IS include stomach pain with severe crying (which may be brief); several episodes of vomiting; blood in the stool; weakness, or irritability.
The increased risk appears to occur mainly in the first 1- 7 days following the first dose of rotavirus vaccine
What about Intussusception (IS)? (1/2)
In the past, the first rotavirus vaccines (RotashieldTM) caused IS, a serious but very rare bowel obstruction
With the new rotavirus vaccines, there seems to be a very small increased risk of IS in infants following rotavirus vaccination
The increased risk appears to occur mainly in the first 1- 7 days following the first dose of rotavirus vaccine
What about Intussusception (IS)? (2/2)
Whether the new rotavirus vaccine affects the overall incidence of IS has not yet been established
The risk of IS after rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children!
Risk of IS against risk of rotavirus infection
HOW TO REPORT AN AEFI? (2/2)
AEFI report should contain– Client information– Immunization event(s) description– Adverse event(s) description– Relevant medical and treatment
history– Associated event(s)– Reporter details
Report the identified AEFI through existing AEFI reporting systems established by NEC/RESU
National authorities
Communit/yprovince/city, and
regional levels
Suspected signs or
symptoms
How to report a AEFI? (1/2) How to report a AEFI? (1/2)
How to communicate with caretakers?
Be respectful
Use simple words and avoid technical terms
Listen to caretaker's concerns
Make sure the caretaker has understood your key messages
What is “triple A” communicationwith parents?
Arrangefor whento return
Alerton side effects and
how to respond
Adviceon what is
given
ADVICE: HOW TO INFORM ABOUT THE DISEASE?
Rotavirus causes severe diarrhea, vomiting, and fever leading to rapid dehydration
Rotavirus is found everywhere– Almost every child in the world will suffer from at least one
infection by the time he or she is three years old
Rotavirus is not the only cause of diarrhea, but it is one of the most serious
Rotavirus infection spreads very quickly
What can be done to treat rotavirus diarrhea?
What can be done to treat rotavirusdiarrhea?
TREATMENT
Zinc
Oral rehydration therapy
Vaccination as part of a comprehensive approach to diarrheal disease control offers the best hope for protecting children from rotavirus
What can be done to prevent rotavirus diarrhea?
What can be done to prevent rotavirusdiarrhea?
PREVENTION
Good sanitation and hygiene
Exclusive breastfeeding
Improved water quality
Vaccination
Millions of children have received rotavirus vaccine in the last 8 years and the vaccine is considered very safe and effective
This vaccine will be given at the same time as pentavalent vaccine, therefore no extra visit is required for this vaccine
Rotavirus vaccine will not prevent diarrhea or vomiting caused by other germs, but it is very good at preventing diarrhea and vomiting caused by rotavirus.
Advice: What is the new rotavirus vaccine?
Advice: Rotavirus vaccine schedule?
Getting vaccinated on time is important2 doses of rotavirus vaccine
– First dose between 6 weeks and 15 weeks – Second dose between 10 weeks and 32 weeks– Interval of 4 weeks between the 2 doses
Rota 1
Rota 2
6Birth 10 15 32
weeks
ALERT: HOW TO RESPOND TO SIDE EFFECTS?
Infants may be more irritable. Some infants may also experience loss of appetite, fever, fatigue, diarrhea, and vomiting
After immunization, if your infant has fever (>39˚C), give paracetamol
If your infant shows unusual signs- persistent crying, vomiting, blood in bowel motion take him/her directly to the hospital
ARRANGE: WHEN TO RETURN?
Make an appointment for the next dose of rotavirus vaccine and other vaccines according to the immunization schedule
Wait at least 4 weeks before next appointment and make sure the child is less than 32 weeks old
Ensure that there is a session on the attributed date – i.e., no public holiday, weekend, or other event
Write the date of the next visit on the immunization card
Remind the caretaker to come on the specified date and to bring the card
HOW TO TRACK INFANTS FOR THE FIRST DOSE OF ROTAVIRUS VACCINE?
It is critical to ensure that all infants get the first dose of rotavirus vaccine by 15 weeks of age
Identify newborns – Review the birth registry or other records for newborns– Use volunteers/CHTs to inform about new births
Inform parents of vaccination sessions
Use volunteers/CHTs to follow up with newborns that are due for rotavirus vaccination
HOW TO TRACK INFANTS FOR THE SECOND DOSE OF ROTAVIRUS VACCINE?
Ensure that all children get the last dose of rotavirus vaccine before 32 weeks of age
Follow up with infants who have received the first dose and have not come back for the second dose
Reminder cards or immunization registries could be used follow up with defaulters
Use volunteers/CHTs to follow up with families of infants who will soon become ineligible for rotavirus vaccine
Year: 2012
HOW TO MONITOR UPTAKE OF ROTAVIRUS VACCINE?
• Use a monitoring chart to track the number of infants who received first and second doses of rotavirus vaccine
KEY MESSAGES
Fill in the immunization card once the vaccines have been administered to the infant
The child immunization card, tally sheet, and monthly report are being updated to include rotavirus vaccine doses
It is very important that all infants receive their first dose of rotavirus vaccine between 6 and 15 weeks
Follow up with infants to ensure they receive the second dose of Rotavirus vaccine by 32 weeks of age
KEY MESSAGESThe current safety profile of rotavirus vaccines is good
Many infants who get the rotavirus vaccine do not experience any side effects
The risk of IS after rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children
AEFIs should be reported through the existing AEFI reporting systems/forms
Reassure the caretaker- Admit uncertainty, investigate fully, and keep the community informed
Key messages (1/4) Key messages (1/4)
Triple A communication - Be respectful - Listen to caretaker's concerns
Use simple phrases and avoid technical terms to make sure the caretaker understands your key messages
Ongoing dialogue may successfully reassure vaccine-hesitant parents that immunization is the best and safest option for their child
Key messages (2/4) Key messages (2/4)
Rotavirus infection is highly contagious
Vaccination is the only way to prevent the severe episodes of rotavirus infection
A child immunized with rotavirus vaccine can still get diarrhea from other agents– Follow all steps to prevent and control diarrhea
Key messages (3/4) Key messages (3/4)
On-time vaccination is very important– If children come late they will get other vaccines but will lose out on
getting the important rotavirus vaccine
Current rotavirus vaccines are generally well tolerated– Parents have to understand that the risk of side effects after
rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children
– If your child shows any serious symptoms such as blood in the stool, take him/her immediately to the nearest hospital
Keep the immunization card safe and remember to bring it next time
Key messages (4/4) Key messages (4/4)
A coordinated approach that combines rotavirus vaccines with other prevention and treatment methods should be practiced to reduce death and illness from diarrhea, such as: – Rotavirus and measles vaccination– Promotion of exclusive breastfeeding and Vitamin A
supplementation– Promotion of hand washing with soap – Improved water supply including treatment and safe storage of
household water– Community-wide sanitation promotion– Fluid replacement (ORT) – Zinc treatment
Thank youfor your attention !
ADDITIONAL SLIDES
What should you do in this scenario?
The parents of a child provide you with an old immunization card. The rotavirus vaccine is not included in this card .
How should you record the vaccination given ?
What should you do in this scenario?What should you do in this scenario?
A child's vaccination card shows that he/she received the first dose of rotavirus vaccine and pentavalent vaccine at 10 weeks of age .
The child is now 35 weeks of age.
What vaccines should you give to this child ?
A child's immunization card shows that he/she is now 17 weeks old and has only received BCG and OPV 1 vaccines.
What should you do ?
What should you do in this scenario?What should you do in this scenario?
A child's immunization card shows that he/she is now 13 weeks old and has only received BCG, OPV 1 ,Penta 1 vaccines.
What should you do ?
What should you do in this scenario?What should you do in this scenario?
What should you do in this scenario?
A caretaker brings a child to the health center for the first time and comes without any written documentation.
The caretaker does not remember the exact date of birth (DOB) of the infant.
What are some possible ways of determining DOB?
What should you do?
The refrigerator stops functioning.
What should you do ?
What should you do in this scenario?
A caretaker comes to the health center without an immunization card .
The caretaker says the child is 20 weeks old and is not sure if a first dose of rotavirus vaccine was administered.
What should you do?
What should you do in this scenario?
The vaccine vial monitor shows that the inner square is lighter than the ring (= stage 2) .
What should you do?
While opening the RotarixTM tube to administer the vaccine, the tip seal is accidentally pushed into the tube solution.
What should you do?
What should you do in this scenario?
The child is 6 weeks old. You give him/her OPV, rotavirus and pentavalent vaccines.
In which order should you give the vaccines?
What should you do in this scenario?
WHAT TO DO WHEN EXACT DOB IS UNKNOWN?
• Possible ways of determining the DOB• Question the caretaker to see if he/she can recall the child's
birth based on a cultural, religious or national/local event• Look for DOB record in other documents kept in the health
center or other local registries• Antenatal Care record• Birth registry
• Look for development indicators• If the child is able to sit unsupported and reaches out with
one hand, he/she is probably too old to get rotavirus vaccination
WHAT TO DO WHEN IMMUNIZATION CARD IS MISSING?
• Possible ways of determining when the child received the first dose:
• Look for a record within the health center like Target Client List (TCL), Family Health Record, ITR
• Try to contact another health center if the child has moved recently to get his/her record
• Show the caretaker the rotavirus tube and ask if he/she can remember if such a tube was used to orally administer a large amount of liquid during the child’s last immunization visit
KEY MESSAGES
On-time vaccination is very important for rotavirus vaccine
First dose of rotavirus should be given at 6 weeks of age
Children older than 15 weeks are not eligible to receive the first dose of rotavirus vaccine
Second dose should be given at 10 weeks of age
Children older than 32 weeks are not eligible to receive the second dose of rotavirus vaccine
“Never miss an opportunity to immunize an infant, even if the infant is late (older) for vaccination” is NOT valid for rotavirus vaccine
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