1. Module 4 HPV vaccine administration GardasilTM
Essential Training Package for HPV Vaccine Introduction
Module 4
HPV vaccine administration
GardasilTM

2. Learning Objectives
At the end of this module, you will have learned to:
Describe activities carried out before, during and after an immunization session.
Describe how to ensure that vaccine is of good quality
Describe the technique to administer the vaccine
Describe considerations for conducting immunization session in school setting
Duration
45 ’

3. Key issues 1 2 3 4 How to ensure that the vaccine is of good quality?
How to prepare for vaccination? 2
How to administer the vaccine? 3
What to do after completing the immunization session? 4
Explain to the participants the key issues that are raised in this module:
You have many girls to vaccinate, what are you going to do first?
We will provide you with the answers to the following questions:
How do you ensure that vaccine is of good quality ?
How do you prepare for vaccination?
How do you administer the vaccine?
What to do after completing the immunization session?

4. Immunization sessions: phases & critical activities
Phase 1 Before girls come for immunization
Phase 2 When girls come for immunization
Phase 3 After all girls leave immunization AREA
Now let’s look at the key phases and critical activities of an immunization session, consisting of 3 parts:
Phase 1: Before girls come for immunization, health workers need to ensure that all equipment is ready for the immunization session. They can use a checklist to prepare for immunization session
Phase 2: During an immunization session, key activities include assessing and registering girls, preparing for vaccination and giving immunization. After vaccinating each girl, key activities include observing the girl to make sure no AEFIs occur, identifying date for next vaccine dose, and updating vaccination card
Phase 3: After all girls leave immunization AREA, key activities include data reporting, waste management and safety, and communication about next session and catch up activities
In the following slides, each phase will be described with key activities and tools to be checked.

5. Phase 1: Before girls come for immunization
1. Take vaccines and vials out of the refrigerator
2. Check expiry date and VVM status for each vial
3. Collect & arrange supplies and monitoring tools for immunization session
Let’s go through each phase with key activities together:
Before girls come for immunization:
Required quantities of vaccines vials should be taken out of refrigerator
When the immunization session is carried out as outreach or in schools – the number of vials calculated for that day will be prepared and taken in a cold box to the vaccination site - or various sites
Expiry date and VVM status should be checked for each vial
Supplies and monitoring tools for the immunization session should be collected and arranged
AD syringes
Safety box
Immunization register, Immunization tally sheets, Blank immunization cards
Rubbish container, paper, pencils and pens
Prepare an AEFI kit
4. Prepare an AEFI Kit

6. How to ensure that vaccine is of good quality?
Check the temperature inside the refrigerator, if vaccine freezing is suspected perform the Shake test to confirm
Check VVM status
Check the expiry date on the vials
Explain to the participants how and where to check the expiration date:
As HPV vaccine is freeze sensitive, check the temperature inside the refrigerator to ensure that HPV vaccine was not frozen
Check VVM status. Do not use a vial with VVM that has reached the discard point
It is important to understand that VVM does not provide information about vaccine potency
Check the expiration date on the vaccine vial before using it. The VVM may be ok (which means the inner square is lighter than the outer circle), but the vaccine may have passed the expiration date. The expiration date is mentioned clearly on the vial

7. How to check VVM status?
Before administering the vaccine, you need to check the Vaccine Vial Monitor (VVM) on the vaccine vial
The vaccine vial monitor (VVM) is a round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat exposure
The inner square is chemically active and changes color irreversibly from light to dark when exposed to heat over time
By comparing the color of the inner square to the reference color of the outer ring, a health worker can determine whether or not the vaccine has been exposed to heat
Thanks to the VVM, important decisions about which vaccines to use or to discard are now clear. If the inner square matches, or is darker than the outer ring, discard the vaccine

8. What should you do in this scenario?
The vaccine vial monitor shows that the inner square is lighter than
the outer circle?
What should you do?
Read the situation and question to the participants.
This question will test if the participants understand what to do if the vaccine vial monitor shows that the inner square is still lighter than the ring.
Response: Use these vaccines first, as their VVM has already started to change. 8

9. Checklist of supplies and monitoring tools needed for HPV vaccination
Vaccine and syringes
IEC materials (e.g. flyers, pamphlets, posters)
Chair and table
Water and soap for cleaning hands
Trays
Safety box
Containers for used vials
Drugs to manage allergic reactions- 'AEFI kit'
Chairs to rest after vaccination (15 mins)
Pen, pencil
Monitoring tools
Vaccination register
Tally sheets
Vaccination cards
Calendar
The organization of an HPV vaccination session required specific supplies and monitoring tools
The use of a checklist as displayed on the slide is helpful for preparing the immunization session

10. Phase 2: When girls come for immunization
1. Check eligibility of girls
2. Prepare injection using aseptic techniques
3. Administer vaccine according to the recommended techniques and injection site
4. Dispose used syringes immediately into the safety box after each injection
5. Complete immunization card and tally sheet
When girls come for immunization:
Determine eligibility of girls and register them
Each injection prepared using aseptic techniques. Do not prefill syringes.
Each vaccine administered according to the recommended techniques and injection site
Used syringes disposed immediately into the safety box after each injection
Immunization card, tally sheet, register completed with vaccines given and date of next immunization marked
Key messages given to caregiver/parent: vaccines given, side effects, and date of return
6. Give key messages to girl/caregiver/parent: inform about vaccines given, side effects, and date of return

11. What to do when girls come for immunization ?
3.Prepare for vaccine
2.Verify, register, explain HPV vaccine benefits
4.Inject in the upper arm
1.Greet the girl
Let’s explain activities carried out when girls come for immunization:
Picture 1 illustrates the following steps:
Before administering vaccine, the health worker should determine that the girl is eligible for HPV vaccination, that the girl understands what is about to be done
Health worker greets the girl, explains the purpose and benefits of HPV vaccination, discusses potential risks and side-effects of vaccination, and discusses risks of not receiving the vaccine
Picture 2 illustrates the following steps:
Health worker verifies girl’s vaccination card and documents the following information in the vaccination register and on the vaccination card if available: Name of girl, Address, Date of birth and age (if unknown, determine age based on educated guess and document), Date of vaccination, HPV dose number (1,2,or 3)
Health worker verifies eligibility of the girl by checking that the girl: Is within the target age; Is not pregnant; Is not allergic to any component of the vaccine
- Health worker answers any question the girl may have about the vaccine and its effects to ensure she has proper understanding of the vaccine.
Collect written consent of parent if applicable and ensures girl agrees to be vaccinated (this is also called "assent")
Picture 3: Health worker prepares for vaccination. We will discuss details on how to prepare for vaccination in next slide
Picture 4 : Health worker gives the injection. We will discuss details on the site and route of administration
Picture 5 : Determine date for next vaccine dose and record on vaccination card and remind her that she must receive 3 doses and the date for her next scheduled vaccination. Write the date of the next dose on vaccination card
Picture 6: Return updated vaccination card to the girl and ask her to bring it back on her next scheduled vaccination day (note that in some places card maybe kept at the school)
Picture 7: Observe the girl for 15 minutes after administration, manage and document any adverse reaction
5.Determine date for next vaccine dose
6.Return the updated card
7.Observe the girl for 15’

12. How to prepare for vaccination ? (1/3)
Shake the vial well
Open AD syringe package and remove the syringe and needle from plastic wrapping
Ensure that you do not touch any part of the needle
Step 1/3 :
Mix the vaccine suspension by shaking the vial
Open the AD syringe package and remove the syringe and needle from package

13. How to prepare for vaccination ? (2/3)
Take off the needle cap when you are ready to give the vaccine
Insert the needle into the vaccine vial
Draw vaccine from the vial into the 0.5mL syringe
Step 2/3: Take off the needle cap and do not touch any part of the needle

14. Route and site of administration
Injection route: Intramuscular
Injection site: the upper arm, check national policy on which arm (left or right)
The injection angle- 90 degree angle
The deltoid muscle of the upper arm is the recommended location for HPV injection. HPV vaccine is given as an intramuscular injection
Hold the syringe like a pen and then push the needle straight down at 90˚ through the skin between the forefingers and thumb. Inject entire content of the syringe into the deltoid muscle of the upper arm

15. Phase 3: After all girls leave immunization site
1. Complete Immunization tally sheet by
counting the number of doses given
2. Return unopened vaccine vials to the
refrigerator
3. Put safety box in a safe location
4. Inform community of the next session and
activities planned to reach unvaccinated girls
After all girls leave the immunization site:
Complete Immunization tally sheet by counting the number of doses given
Unopened vaccine vials should be returned to the refrigerator
Safety box placed in a safe location. Full safety box handled according to national guidelines
Community informed of next session and activities planned to reach unvaccinated girls. In the case of school based vaccination the teacher of the relevant grade and the head master should be informed of the next session

16. Key messages
HPV vaccine session requires planning of activities before girls come, when girls arrive and after all girls leave
The quality of vaccine should be checked before giving the vaccine
The HPV vaccine is given as an intramuscular injection in the deltoid muscle of the upper arm
Explain to the participants that this is the main information to keep in mind. 16

17. End of module for your attention! Thank you
This is the end of the module, thank you for your attention!

18. References
Comprehensive Cervical Cancer Control. A guide to essential practice (C4 GEP). WHO 2013
HPV vaccine introduction into national immunization programmes: Information for programme managers and health workers. WHO 2013
Global update on HPV vaccine introduction