Training for rotavirus vaccine introduction

Training for rotavirus vaccine introduction
Picture Box Training for rotavirus vaccine introduction

Foreword Countries are introducing the rotavirus vaccine. To ensure that this introduction is done in a safe way, the World Health Organization (WHO), through its Department of Immunization, Vaccines and Biologicals (IVB), developed a training package on rotavirus vaccine introduction for developing countries. The training package is composed of 7 modules. It is targeted at staff working in health facilities at district level such as medical officers, nurses, and medical assistants, as well as Expanded Program on Immunization (EPI) staff/vaccinators. This Picture Box was developed as an alternative to the training package for staff in resource-poor settings who do not have access to the learning materials for various reasons (e.g., lack of computer, projector, electricity, or computer skills). It provides the same content as the training package but in a picture format. Picture Box presentation: Side 1 (seen by trainees): Pictures or scenarios Side 2 (seen by facilitator): Key concepts and messages It is recommended that the Picture Box be used for training in small groups of no more than 5 people. It may also be used during supervisory visits to reinforce key concepts or train staff who did not attend the large group training. Trainees Facilitator

Content (1/2) Module 1: Introduction to rotavirus disease and vaccine
What is rotavirus disease? How to recognize rotavirus disease? How is rotavirus spread? What can be done to prevent and treat rotavirus disease? 11 Introduction to rotavirus vaccine Module 2: Rotavirus vaccine attributes and storage conditions What is rotavirus vaccine? How to store the vaccine? Module 3: Rotavirus vaccine eligibility What is the rotavirus vaccine schedule? How to determine infant eligibility for rotavirus vaccine? 23 What information do you need from the mother before vaccinating the child? 33 Module 4: Rotavirus vaccine administration How to check vaccine quality before vaccinating the child? 35 How to prepare for vaccination?

Content (2/2) Module 4: Rotavirus vaccine administration (continued)
Can rotavirus vaccine be administered at the same time as other childhood vaccines? 39 How to administer the vaccine? Module 5: Recording and monitoring uptake of rotavirus vaccine How to report rotavirus immunization? How to track rotavirus immunization? Module 6: Rotavirus vaccine AEFI monitoring What is an AEFI? What about intussusception (IS)? How to report an AEFI? Module 7: Rotavirus vaccine communication with caretakers How to communicate with caretakers? How to inform caretakers about the disease? 57 How to advise caretakers on rotavirus vaccine? 59 How to alert caretakers of side effects and how to respond? 61 How to arrange with caretakers for a follow-up appointment? 63

What is rotavirus disease?
Module 1: Introduction to rotavirus disease and vaccine What is rotavirus disease?

Module 1: Introduction to rotavirus disease and vaccine
What is rotavirus disease? Module 1: Introduction to rotavirus disease and vaccine Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Rotavirus disease Rotavirus is a virus that causes diarrhea (sometimes severe), mostly in babies and young children. The name rotavirus is derived from the Latin Rota, meaning “wheel,” because the rotavirus has a wheel-like appearance when viewed by a microscope. Rotavirus infects and damages the cells that line the small intestine and causes gastroenteritis. WHO estimates that rotavirus is responsible for up to 453,000 diarrheal deaths, mostly infants in developing countries, and over 2 millionof admissions to hospital per year worldwide. Rotavirus is not the only cause of diarrhea, several other agents may also cause diarrhea. Key messages: 1) Rotavirus is a virus that causes diarrhea, 2) WHO estimates that rotavirus is responsible for up to 453,000 diarrheal deaths, mostly infants in developing countries, 3) Several other agents may also cause diarrhea.

How to recognize rotavirus disease?
Module 1: Introduction to rotavirus disease and vaccine How to recognize rotavirus disease?

How to recognize rotavirus disease? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Signs and symptoms of rotavirus infection The three main symptoms of rotavirus infection are fever, watery diarrhea, and vomiting. Abdominal pain may also occur. Diarrhea usually stops after 3 to 7 days. Young children can become dehydrated, requiring urgent treatment. Diagnosis of rotavirus disease The clinical features and stool characteristics of rotavirus diarrhea are nonspecific, and similar illness may be caused by other pathogens. As a result, confirmation of diarrheal illness caused by rotavirus requires laboratory testing. A sensitive test can be carried out on stool specimens, using a commercial test kit (enzyme immunoassay). Key messages: 1) Symptoms are fever, watery diarrhea, and vomiting, 2) Rotavirus is not the only cause of diarrhea, several other agents may also cause diarrhea, 3) Sensitive test can be carried out on stool specimens.

How is rotavirus spread?
Module 1: Introduction to rotavirus disease and vaccine How is rotavirus spread?

How is rotavirus spread? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Rotavirus cycle of transmission - Step 1: A child passes a stool. - Step 2: The child does not wash his/her hands. - Step 3: The child plays with a balloon together with another child, who touches the infected toy. - Step 4: The second child places his/her hand in the mouth by eating an apple and gets infected. Key messages: 1) Rotavirus infection is highly contagious, 2) Rotavirus disease spreads by the fecal-oral route, 3) People at risk are infants over the age of 3 months, because they have no immunity and are very vulnerable to dehydration, and older children if they are immuno-compromised.

What can be done to prevent and treat rotavirus disease?
Module 1: Introduction to rotavirus disease and vaccine What can be done to prevent and treat rotavirus disease? Vaccination Good sanitation and hygiene Zinc PREVENTION TREATMENT Exclusive breastfeeding Improved water quality Oral rehydration therapy (ORT)

What can be done to prevent and treat rotavirus disease? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Prevention methods Prevention methods against rotavirus disease include breastfeeding, improvements in nutrition, hygiene, and water quality can reduce diarrheal disease and decrease child mortality where diarrheal disease is a serious burden. But enhancing sanitation and hygiene is not enough to prevent the disease and stop the spread. Currently, vaccination is the only way to prevent severe episodes of rotavirus infection. Treatment Treatment against rotavirus disease include zinc and oral rehydration therapy. ORT consists of a solution of salts and sugars that is taken by mouth. Key messages: 1) Prevention- Good sanitation and hygiene, Exclusive breastfeeding, Improved water quality, and Vaccination, 2)Treatment- oral rehydration therapy (ORT) and zinc.

Introduction to rotavirus vaccine Module 1: Introduction to rotavirus disease and vaccine Communicate with caretakers about the vaccine Determine eligibility for the vaccine Store the vaccine Administer the vaccine Monitor AEFIs Record immunization

Introduction to rotavirus vaccine Module 1: Introduction to rotavirus disease and vaccine Facilitator instructions: After the briefing on rotavirus disease, which provides the rationale for rotavirus immunization, introduce the content of the training and its learning objectives. As we previously saw, rotavirus is very contagious, and spreads easily from infected children to other children. The best way to protect babies from rotavirus disease is through vaccination with rotavirus vaccine. Currently, there are 2 available vaccines, RotarixTM and RotaTeqTM, which allow the prevention of rotavirus disease and save children. Your country is going to introduce RotarixTM. The general objective of the training is to give you the required knowledge to ensure the safe introduction of the rotavirus vaccine at your level. After this training, you will be able to: Store the vaccine Determine eligibility for the vaccine Administer the vaccine Record immunization Monitor AEFIs Communicate with caretakers about the vaccine

Module 2: Rotavirus vaccine attributes and storage conditions
What is rotavirus vaccine?

What is rotavirus vaccine? Module 2: Rotavirus vaccine attributes and storage conditions Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Rotavirus vaccine presentation Rotavirus vaccine is a solution for oral use. It comes in a tube specially designed for direct oral administration (1 tube = 1 dose; 1 tube has 1.5mL liquid). The rotavirus vaccine must be given to babies orally, which means swallowed and not injected. Information on vaccine safety Current rotavirus vaccines are generally well tolerated. They do not appear to cause any serious adverse events. Rotavirus vaccine may be given with other vaccines in the infant EPI schedule without interfering with their effectiveness. Very common side effects: irritability, loss of appetite Common side effects: fever, fatigue, diarrhea, vomiting, flatulence, abdominal pain, regurgitation of food Rotavirus vaccine may be given with other vaccines in the infant EPI schedule without interfering with their effectiveness Key messages: 1) Rotavirus vaccine has a liquid formulation, 2) Vaccine comes in a squeezable plastic tube, 3) Irritability and loss of appetite are very common side effects of rotavirus vaccine.

How to store the vaccine? Module 2: Rotavirus vaccine attributes and storage conditions

How to store the vaccine? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Vaccine storage The rotavirus vaccine should be stored in a refrigerator. Do not put rotavirus vaccine in the freezer. If the vaccines are frozen, they lose their potency and no longer provide protection against the disease. Vaccines with early expiration dates should be kept in the front of the refrigerator for first use. Keep a “use first box” containing vaccines with a Vaccine Vial Monitor (VVM) at stage 2 (and nearing stage 2) and vaccines that were taken out of the refrigerator and brought back unused. Vaccines in the “use first box” must be used first in the next session. Vaccine storage temperature Good temperature control during the storage and transport of vaccines is critical to ensure the potency and safety of vaccines. Rotavirus vaccines must be stored between +2°C and +8°C. Key messages: 1) Store vaccines between +2°C to +8°C, 2) Vaccines with early expiration dates and VVM in stage 2 (or nearing stage 2) should be kept in front of the refrigerator to be used first, 3) Do not open the refrigerator door often, 4) Regularly monitor the temperature of the refrigerator.

What should you do in this scenario?
Module 3: Rotavirus vaccine eligibility The refrigerator stops functioning. 19

Module 3: Rotavirus vaccine eligibility
Scenario 1 Module 3: Rotavirus vaccine eligibility Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. The exercise will determine if participants know what to do if the refridgerator stops functioning. Situation The refrigerator stops functioning. What should you do? Response - Find another refrigerator or cold room to store vaccines (be sure that the temperature is maintained between +2°C and + 8°C). - If another refrigerator is unavailable, line ice packs or cold packs in cold box(es) or vaccine carrier(s) then put vaccines in the box(es) (Be careful not to put rotavirus vaccines or other freeze-sensitive vaccines near frozen ice packs, as it may affect vaccine potency). - Inform supervisor immediately. 20

What is the rotavirus vaccine schedule? Module 3: Rotavirus vaccine eligibility Rota 1 Rota 2 6 Birth 10 15 32 weeks

What is the rotavirus vaccine schedule? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Recommended schedule for rotavirus vaccine On-time vaccination is very important for rotavirus immunization. - Rotavirus vaccine is given in a 2-dose schedule: first dose at 6 weeks and second/last dose at 10 weeks of age. - Remember that the first dose of vaccine must be given before 15 weeks and second dose before 32 weeks. - Maintain an interval of 4 weeks between doses. No ‘catch-up’ for rotavirus vaccine In the past it has been said, “Never miss an opportunity to immunize an infant, even if the infant is late (older) for vaccination.” This is NOT valid for rotavirus vaccine. This vaccine cannot be given to children who come late for vaccination and are therefore older. Infants coming late for vaccination can, however, get other vaccines in the schedule. Key messages: 1) First dose of rotavirus should be given at 6weeks, 2) Second (last) dose should be given at 10 weeks, 3) Children older than 15 weeks are not eligible to receive the first dose of rotavirus vaccine, 4) Children older than 32 weeks are not eligible to receive the second dose of rotavirus vaccine, 5) Rotavirus vaccine doses can be given at the same time as first and second dose of DTP-HepB-Hib (i.e. Penta1 and Penta2).

How to determine infant eligibility for rotavirus vaccine?
Module 3: Rotavirus vaccine eligibility Doses of RotarixTM vaccine already given? 0 doses received 1 dose received Infant's age? Infant's age? Between 6 and 15 weeks Older than 15 weeks Between 10 and 32 weeks Older than 32 weeks 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 Give first dose of RotarixTM Make an appointment for second dose of RotarixTM 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. 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. Give other vaccines as appropriate given the infant's age and schedule the next appointment according to the national immunization schedule.

How to determine infant eligibility for rotavirus vaccine? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below. Describe the flow chart as a tool, which can help the health worker to determine if an infant is eligible or not to receive the rotavirus vaccine. Then point out the key messages. Required information to determine the eligibility of an infant to receive the rotavirus vaccine - The age of the infant - If he/she already received the first dose or not For each case, the flowchart helps you to determine if the infant is eligible and what to do after vaccination (or not). Key messages: 1) 16 weeks is too late for first dose, 2) 33 weeks is too late for second dose.

What should you do in this scenario? Module 3: Rotavirus vaccine eligibility 10 weeks = Rota1 and Penta1 35 weeks = ?

Scenario 2 Module 3: Rotavirus vaccine eligibility Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. The exercise will determine if participants understand that the second dose of vaccine cannot be given after 32 weeks. Other vaccines can be given as appropriate. Situation 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. What vaccines should you give the child? Response - The child will not get rotavirus vaccine as the second dose of rotavirus vaccine cannot be given after 32 weeks. - Explain to the caretaker that second dose of rotavirus vaccine cannot be given, as the child came late for vaccination. - Give a second dose of pentavalent vaccine. - Make an appointment for the next doses according to the schedule.

What should you do in this scenario? Module 3: Rotavirus vaccine eligibility  BCG and OPV 17 weeks = ? 27

Scenario 3 Module 3: Rotavirus vaccine eligibility Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. The exercise will determine if participants understand that the first rotavirus vaccine cannot be given after 15 weeks of age. Other vaccines can be given as appropriate. Situation A child's immunization card shows that he/she is now 17 weeks and has only received BCG and OPV vaccines. What should you do? Response - The child will not get rotavirus vaccine. The first dose of rotavirus vaccine cannot be given after 15 weeks. - Explain to the caretaker that rotavirus vaccine cannot be given, as the child came late for vaccination. - Give the first dose of pentavalent vaccine and other vaccines according to national schedule. - Make an appointment for the next doses according to the schedule. - Explain to the caretaker the importance of coming for vaccination on time and completing the immunization schedule.

What should you do in this scenario? Module 3: Rotavirus vaccine eligibility Date of birth unkown 29

Scenario 4 Module 3: Rotavirus vaccine eligibility Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. The exercise will determine if participants know how to determine if the first dose of rotavirus vaccine was given when the immunization card is unavailable. Situation 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? Response There are possible ways of determining the DOB for the first rotavirus vaccination: - 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 (ANC record, birth registry) - Look for development indicators (e.g. 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 should you do in this scenario? Module 3: Rotavirus vaccine eligibility No immunization card 31

Scenario 5 Module 3: Rotavirus vaccine eligibility Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. The exercise will determine if participants know what to do if immunization card is unavailable to determine whether the first dose of Rotavirus vaccine was given. Situation A caretaker comes without a immunization card to the health center. She states that child is 20 weeks old and is not sure if first dose of rotavirus vaccine was received. What should you do? Response Possible ways of determining when the child received the first dose: Look for a record within the health center like immunization registry 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 device was used to orally administer a large amount of liquid during the child’s last immunization visit

What information do you need from the mother before vaccinating the child?

What information do you need from the mother before vaccinating the child? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Absolute contraindications - Hypersensitivity after previous administration of rotavirus vaccines - Previous history of intussusception - The administration of RotarixTM should be postponed in subjects suffering from diarrhea or vomiting and in need of rehydration therapy Note that mild illness such as an upper respiratory tract infection is not a contraindication. Key messages: 1) Rotavirus vaccine should not be given to individuals who experienced hypersensitivity after the first dose or to people with a history of intussusception

How to check vaccine quality before vaccinating the child? Stage 1: Vaccine OK Stage 2: Vaccine OK (use first) Stage 3: Do not use the vaccine Stage 4: Do not use the vaccine

How to check vaccine quality before vaccinating the child? Facilitator instructions: Ask the participants to identify which vaccines need to be used first (and which ones need to be discarded). Then provide the information below and point out key messages. Checking vaccine quality Before administering the vaccine you need to: check and interpret the Vaccine Vial Monitor (VVM) on the tube cap; check the expiration date on the vaccine marked on the tube cap Vaccine Vial Monitor (VVM) The vaccine vial monitor (VVM) is a round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat exposure. By comparing the color of the inner square to the reference color, a health worker can determine whether the vaccine has been exposed to heat. Interpreting the Vaccine Vial Monitor (VVM) - Color of the small square remains white: Ok - Color of the small square looks lighter than the outer circle: Ok - Color of the small square looks similar to the outer grey circle: Not ok - Color of the small square looks darker than the outer circle: Not ok Key messages: 1) Check expiration date, 2) Check and interpret vaccine vial monitor

How to prepare for vaccination? Module 4: Rotavirus vaccine eligibility 1 2 3 4

How to prepare for vaccination? Module 4: Rotavirus vaccine eligibility Facilitator instructions: Ask the participants to respond to the question above, then describe step-by-step how the vaccine should be prepared. Finally, point out key messages. Steps for preparing the vaccine - Step 1: Pull off the cap from the tube. Clear the fluid from the upper part of the tube by tapping the tube. - Step 2: Turn the cap upside-down and place the cap vertically onto the tip seal. Insert the tip seal into the small hole in the top of the cap. - Step 3: Twist the cap in the direction of the arrow (clockwise) to remove the tip seal. Do not snap off tip seal: It may fall into tube. - Step 4: Ensure that a hole clearly appears at the top of the tube and that the detached tip seal is inside the top of the cap. Before administration of the vaccine, make a final visual inspection to ensure that the tip has not fallen inside the tube Very important to know that the vaccine must be discarded if the tip seal falls into the tube. Key messages: 1) Do not snap off tip seal: It may fall into tube, 2) The vaccine must be discarded if the tip seal falls into the tube.

Can rotavirus vaccine be administered at the same time as other childhood vaccines? OPV + Rotavirus + Pentavalent vaccines ?

Can rotavirus vaccine be administered at the same time as other childhood vaccines? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. Vaccines that can be administered concomitantly with rotavirus vaccine Rotavirus vaccine can be given at the same time as first and second dose of the following routine childhood vaccines without interfering with their effectiveness: - Diphtheria–tetanus–acellular pertussis vaccine (DTPa) - Haemophilus influenzae type b vaccine (Hib) - Inactivated polio vaccine (IPV) - Hepatitis B vaccine - Pneumococcal vaccine Oral polio vaccine (OPV) Give the rotavirus vaccine at the beginning of the visit, when the baby is still calm. Key messages: 1) Give the rotavirus vaccine first, then administer other childhood vaccines. 40

How to administer the vaccine? Module 4: Rotavirus vaccine eligibility 1 2 3 4

How to administer the vaccine? Module 4: Rotavirus vaccine eligibility Facilitator instructions: Ask the participants to respond to the question above, then describe step-by-step how the vaccine should be administered. Finally, point out key messages. How to position the child for rotavirus vaccination The child should be seated in a semi-reclining position (i.e. normal feeding position). How to position the vaccine - Step 1: Gently squeeze the child's cheeks to open the mouth. - Step 2: Put the tube towards the inner cheek. Make every effort to aim the tube containing the vaccine down one side and toward the back of the child's mouth. Do not put the tube too far back in the mouth. Never place the tube into the center of the mouth to prevent the risk of choking. How to administer the vaccine - Step 3: Administer the entire content of the tube by gently squeezing it several times. Make sure the child is swallowing the vaccine to prevent buildup in the mouth. - Step 4: Gently hold the cheeks together and stroke the child under the chin to help with swallowing. Key messages: 1) The rotavirus vaccine dose quantity is larger than that of oral polio vaccine (Rotarix™1.5 mL) and infants might not take the full dose all at once, 2) To prevent spitting, slowly administer the vaccine in small amounts and properly place the tip of the tube towards the inside of the child's cheek.

What should you do in this scenario? Module 4: Rotavirus vaccine eligibility 1 2

Scenario 6 Module 4: Rotavirus vaccine eligibility Facilitator instructions: Read the situation to the participants and have them discuss. Then provide the answer below. Situation 1 The child is 8 weeks old. You vaccinate him/her with rotavirus vaccine. Is the child in the good position to be vaccinated? Response Yes. The child should be seated in a semi reclining position (i.e. normal feeding position). Situation 2 During vaccination, the child regurgitates the vaccine. In this scenario do you give the child a replacement dose? A replacement dose maybe given if, for any reason, an incomplete dose is administered (e.g. infant spits or regurgitates the vaccine).

Module 5: Recording and monitoring uptake of rotavirus vaccine
How to report rotavirus immunization? Module 5: Recording and monitoring uptake of rotavirus vaccine Immunization card Tally sheet Rota1 = 1st dose Rota2 = 2nd dose Monthly report

How to report rotavirus immunization? Module 5: Recording and monitoring uptake of rotavirus vaccine Facilitator instructions: Describe each document used for rotavirus immunization reporting. Then point out key messages. Immunization card description Each time a vaccine is administered, health workers should complete the immunization card outlining which vaccines have been given. Health workers should also note the date of the next appointment on the immunization card and remind the caretaker to return on that date with the card. Then, parents should be reminded to bring the immunization card at each visit. Health workers should use the abbreviation “Rota” when recording the vaccine they administered. Tally sheet description Tally sheets were updated to reflect the inclusion of rotavirus vaccine in the national immunization program. Health workers should keep a tally of each vaccine dose given. At the end of an immunization session, they should count the tally sheets to identify the total number of vaccinations given (for each dose). If you have old tally sheet, include a lines for Rota1 and Rota2. Monthly report description Reporting forms have been updated to reflect the inclusion of rotavirus vaccine in the national immunization program. Report Rota1 and Rota2 doses given each month, along with other vaccine doses. Use tally sheets to prepare monthly reports to send to supervisors. If you have the old reporting forms, add lines to report Rota1 and Rota2 doses given. Key messages: 1) Complete immunization card, 2) Update tally sheet, 3) Compile monthly report.

How to track rotavirus immunization?
Module 5: Recording and monitoring uptake of rotavirus vaccine Rotavirus vaccine monitoring chart Year 2012 47

How to track for rotavirus immunization? Module 5: Recording and monitoring uptake of rotavirus vaccine Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. How to track infants for first dose of rotavirus vaccine Unlike other vaccines that can even be started late, rotavirus vaccination has to start on time. This should be communicated to parents and the community at large. Use volunteers to inform and motivate parents of newborns to bring their children for vaccination on time. Parents of infants who are due for vaccination, but have not yet come to the health center, should be reminded and followed up with. How to track infants for second dose of rotavirus vaccine A copy of the infant immunization card may be filed under the month the infant should return for a second dose. Every month, review the reminder cards and follow up with those who did not attend when due. Involve community volunteers to bring children who are eligible for the second dose. 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. If the gap between Rota1 and Rota2 is large, this means that several children received the first dose but not the second. Thus, follow-up systems need to be strengthened. A big gap between monthly targets and infants getting Rota1 means newborns need to be followed up with regularly. Key messages: 1) It is very important to find all newborns and ensure they receive their first dose of rotavirus vaccine before 15 weeks, 2) Follow up with infants for the second dose before 32 weeks. 48

What is an AEFI? Adverse event following immunization
Module 6: Rotavirus vaccine AEFI monitoring Adverse event following immunization A medical incident that takes place after an immunization, causes concern, and is believed to be caused by immunization AEFI can be categorized into Vaccine reaction Programme error Coincidental Injection reaction Unknown

Module 6: Rotavirus vaccine AEFI monitoring
What is an AEFI? Facilitator instructions: Ask the participants to respond to the question above, then describe the adverse events following immunization (AEFIs) of rotavirus vaccine outlined below. Finally, point out key messages. AEFI A medical incident that takes place after an immunization, causes concern, and is believed to be caused by immunization Types of AEFI AEFI can be categorized into: Vaccine reaction Programme error Coincidental Injection reaction Unknown Key messages: 1) The current safety profile of rotavirus vaccines is good, 2) Most infants who get the rotavirus vaccine do not experience any side effects, 3) Intussusception has been associated with Rotavirus vaccine and can result in severe illness or death.

What about intussusception (IS)? Module 6: Rotavirus vaccine AEFI monitoring 51

What about intussusception (IS)? Facilitator instructions: Explain what intussusception is and its potential as a serious adverse event. Then, point out key messages. Description of intussusception (IS) 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). Complications of this can lead to intestinal swelling, inflammation, and decreased blood flow to the part of the intestines involved. Symptoms of IS include stomach pain with severe crying (which may be brief), several episodes of vomiting, blood in the stool, weakness, or irritability. Risk of IS against risk of rotavirus infection Whether the new rotavirus affects the overall incidence of IS has not yet been established. The rotavirus vaccine offers tremendous benefits by protecting infants and children from rotavirus disease. According to the U.S. Centers for Disease Control and Prevention, the risk of IS after rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children. Hence, rotavirus vaccine is strongly recommended to prevent rotavirus disease in infants and young children. Key messages: 1) Whether the new rotavirus vaccine affects the overall incidence of IS has not yet been established, 2) The risk of IS after rotavirus vaccination is much lower than the risk of severe rotavirus disease in unvaccinated children. 52

How to report an AEFI? Community, district & regional levels National
Module 6: Rotavirus vaccine AEFI monitoring How to report an AEFI? Community, district & regional levels National authorities Suspected signs or symptoms

How to report an AEFI? Facilitator instructions: Describe the process of reporting an AEFI. Then, point out key messages. How to recognize signs Health agents who administer the vaccine should ask parents to immediately report any reaction that may be related to the vaccine. Report the identified AEFI through the existing AEFI reporting systems established by national immunization programs. The National Authorities will then decide about the need for further investigation. Other problems related to the vaccines, such as administering the vaccines to infants who should not be vaccinated, or errors in vaccine administration, should also be reported. Information to include in an AEFI report - Client – unique identifier, date of birth and gender - Immunization event(s) – province where given, date, all vaccines given including name, manufacturer, lot number, administration site and route, as well as the number in series of vaccine doses if relevant - Adverse event(s) – description, including time of first onset following immunization, duration, health care utilization, treatment and outcome - Relevant medical and treatment history – underlying disease, known allergies, prior AEFIs, concomitant medication - Associated event(s) – acute illness, injury, exposure to environmental toxins - Reporter details Key messages: 1) AEFI should be reported through the existing AEFI reporting systems/forms , 2) Reassure the caretaker- Admit uncertainty, investigate fully, and keep the community informed.

Module 7: Rotavirus vaccine communication with caretakers
How to communicate with caretakers? Alert on side effects and how to respond Arrange for when to return Advice on what is given

How to communicate with caretakers? Module 7: Rotavirus vaccine communication with caretakers Facilitator instructions: Ask the participants to respond to the question above, then explain triple A communication and how to communicate effectively. Finally, point out key messages. Triple A communication Triple A communication is a mnemonic system that allows health workers to remember the three ways of communicating with parents. - Advice parents on what is given (disease prevented, vaccine used, etc.) - Alert on side effects after immunization and how to respond to that possible side effects - Arrange and fix with parents the next appointment for administering the second dose of the vaccine How to communicate effectively with caretakers Healthcare workers should establish an open, non confrontational dialogue with vaccine-hesitant parents at an early stage and provide unambiguous, easily comprehensible answers about known vaccine adverse events and provide accurate information about vaccination. Key messages: 1) Triple A communication - Be respectful - Listen to caretaker's concerns - Use simple words to make sure the caretaker understands your key messages, 2) Ongoing dialogue may successfully reassure vaccine-hesitant parents that immunization is the best and safest option for their child.

How to inform caretakers about the disease?
Module 7: Rotavirus vaccine communication with caretakers Rotavirus Good sanitation and hygiene Vaccination Zinc PREVENTION TREATMENT Improved water quality Exclusive breastfeeding Oral rehydration therapy

How to inform caretakers about the disease? Facilitator instructions: Explain to the participants how they should inform caretakers about the disease. Then, point out key messages. What to communicate about the disease - Rotavirus is a virus that causes diarrhea, sometimes severe, mostly in babies and young children. It is often accompanied by vomiting and fever and can lead to dehydration. - Rotavirus is not the only cause of diarrhea, but it is one of the most serious. Almost every child in the world will suffer from at least one infection by the time he or she is three years old. - The primary mode of transmission of rotavirus is the passage of the virus in stool to the mouth of another child. How to communicate about diarrhea prevention methods and treatment Prevention methods against rotavirus disease include breastfeeding, improvements in nutrition, hygiene, and water quality; they can reduce diarrheal disease and child mortality where diarrheal disease is a serious burden. But enhancing sanitation and hygiene is not enough to prevent the disease and stop the spread. Currently, vaccination is the only way to prevent the severe episodes of rotavirus infection. Treatment against rotavirus disease include zinc and oral rehydration therapy. Key messages: 1) Rotavirus infection is highly contagious, 2) Vaccination is the only way to prevent the severe episodes of rotavirus infection.

How to advise caretakers on rotavirus vaccine? Rota 1 Rota 2 6 Birth 10 15 32 weeks

How to advise caretakers on rotavirus vaccine? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. How to communicate about the new rotavirus vaccine Millions of children have received rotavirus vaccine in the last 8 years and the vaccine is considered very safe and effective The rotavirus vaccine must be given to babies orally, which means swallowed and not injected. This vaccine will be given at the same time as pentavalent vaccine, therefore no extra visit is required for this vaccine. Your child can still get diarrhea due to other agents. How to advice on the rotavirus vaccine schedule Explain to the caretakers that it is important to get vaccinated on time. If the infant is brought in late for vaccination, he/she may not get rotavirus vaccine. Rotavirus vaccine is given orally in 2 doses at ages 6 and 10 weeks. Children should be vaccinated with the first dose of rotavirus by 15 weeks and the second (last) dose by 32 weeks. There should be an interval of at least 4 weeks between the 2 doses. Key messages: 1) Vaccination is the only way to prevent the severe episodes of rotavirus infection, 2) A child immunized with rotavirus vaccine can still get diarrhea from other agents, 3) On-time vaccination is very important.

How to alert caretakers of side effects and how to respond ? >39˚C Unusual symptoms

How to alert caretakers of side effects and how to respond ? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below and point out key messages. How caretakers should respond to side effects Following vaccination, children may be more irritable and have loss of appetite. Some children may also experience fever, fatigue, diarrhea, and vomiting - If the child has a fever (>39˚C), caretakers can give him/her paracetamol - If the child shows any unusual symptoms, caretakers should take him/her directly to the hospital Key messages: 1) Current rotavirus vaccines are generally well tolerated, 2) 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.

How to arrange with caretakers for a follow-up appointment?

How to arrange with caretakers for a follow-up appointment? Facilitator instructions: Ask the participants to respond to the question above, then provide the information below on scheduling a follow-up appointment. Then, point out key messages. When to return Make an appointment for the next dose of rotavirus vaccine and other vaccines according to the immunization schedule. Make sure a minimum interval of 4 weeks is maintained but before the child is 32 weeks of age. Ensure that there is a session on the given date (no public holiday, weekend, etc.). Write the date of the next visit on the immunization card and remind the caretaker to come on the specified date and to bring the card. Key messages: 1) If children come late they will get other vaccines but will lose out on getting the important rotavirus vaccine, 2) Keep the immunization card safe and remember to bring it next time, 3) If the card is not available, it is very difficult for the health worker to know if the child can get the vaccine.

End of training Thank you for your attention! 65

© World Health Organization 2012
Special thanks to the Agence de Médecine Préventive (AMP) for its input in the instructional design of the training package to enhance the concepts and enrich the understanding and learning experience. © World Health Organization 2012 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: ; fax: ; Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: ; The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of speciﬁc companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. 66

Training for rotavirus vaccine introduction

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