ORIENTATION ON THE ROTAVIRUS VACCINATION. I.WHAT IS ROTAVIRUS DISEASE? Rotavirus disease is a...

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


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


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


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 ?


A child's immunization card shows that he/she is now 13 weeks old and has only received BCG, OPV 1 ,Penta 1 vaccines.




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.



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?


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?


The child is 6 weeks old. You give him/her OPV, rotavirus and pentavalent vaccines.

In which order should you give the vaccines?


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

ORIENTATION ON THE ROTAVIRUS VACCINATION. I.WHAT IS ROTAVIRUS DISEASE? Rotavirus disease is a...

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