Module 5 - Managing An Immunization Session

Module 5 Managing an
immunization session
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
5. 1 Preparing for the session
Plan the immunization session
Prepare the workplace
Prepare
supplementary
materials and
equipment
A basic list of supplementary items includes:
Adverse Events Following Immunization (AEFI) kit

water container, basin, soap, towel for hand washing and drying
metal file to open ampoules, if needed
immunization register
new immunization/child health cards
immunization tally sheets
cotton wool
container for rubbish that does not go into a safety box
paper, pencils and pens
table(s)
stool(s)/chair(s)
adhesive tape to repair vaccine carriers if needed.

Select vaccines from the refrigerator in the
order given below.
1. Opened vials kept in the USE FIRST box in the
fridge (if in agreement with national multi-dose vial
policy)
2. Unopened vaccine vials that have been returned from
outreach sessions or have been outside of the
refrigerator and returned (usually also in the USE FIRST
box).
3. Vaccine vials with vaccine vial monitors (VVMs) that
have started to change to a darker colour but have not
gone past the discard point
When selecting vials from the refrigerator, check
each vaccine and diluent vial/ ampoule and
remember to:
use only vials/ampoules in good condition; discard

vials/ampoules that are damaged and/or have no label
discard any vials/ampoules that have passed their expiry
date
discard any vials/ampoules with VVMs past the discard point
do not use any vials/ampoules with fluid that has changed
colour or contains particles: seek the advice of your

supervisor if any are found.
5. 2 Communicating with caregivers
understand their own attitude to immunization
maintain confidence in their ability to talk about the
vaccines and the diseases they prevent

develop skills for giving one or more injections quickly,
safely and with little discomfort

have a genuine interest in each individual
listen without judgement
look beyond what is being said
check that the caregiver understands the information
given, which should be accompanied by giving written

and other reminders as appropriate for the situation
remain patient and kind.
Communicating potential adverse events
Reassure the caregiver that reactions, such as fever,
pain or swelling at the injection site, and changes,
such as the child being irritable or off colour, are
common and indicate a good response to the
vaccine.
Instruct the caregiver to give extra fluids in the form of
breast milk or clean water.

Instruct the caregiver that paracetamol may be given
and specify the appropriate dose and timing for the

individual infant.
Communicating potential adverse events

Remind the caregiver to give extra hugs and attention,
but to avoid pressure to the injection site(s).
Explain that placing a clean, cold, damp cloth can help
to ease pain if there is a local injection site reaction.

Tell the caregiver to bring the infant to the health centre
if the infants condition worsens or the reaction

continues for more than a day or two, since the infant
may develop an illness, unrelated to immunization, that
needs treatment.
Communication during each encounter

At the start
Greet the caregiver in a friendly manner. Thank
them for coming for vaccination and

for their patience if they had to wait.
Ask the caregiver if they have any questions or
concerns and answer them politely.
During assessment
Write the date of the vaccination(s) being given on the
immunization card and explain the disease(s) against which

the vaccination(s) protect(s) in simple terms (in the local
language). If there is a poster or chart, use it to help your
explanation.
Mention possible adverse events and explain how to handle
them
Explain the need for the child to return for each contact in the
immunization schedule to be fully protected. Use the

immunization card as an instructional guide, and congratulate
the caretaker if the child has completed a series.
During assessment
Write the date for the next vaccination on the immunization
card and tell the caregiver. If appropriate, associate the date

with a well-known occurrence, such as a holiday or seasonal
event, that will help them remember to bring the child back.
Ask the caregiver to repeat the date to be sure it is
understood.
Explain to the caregiver that if the child cannot come on the
return date, they can obtain the next vaccination at another

location or another date close to the due date.
Remind the caregiver to bring the immunization card when
they bring the child back for the next vaccination.


After vaccination
Remind the caregiver when to return with the infant.
In the event of any out-of-stocks of vaccine at the
time of the session, inform the caregiver where and

when to return for the next doses.
Remind the caregiver about other services given
during immunization sessions, as per national

policy; for example, vitamin A supplementation or
tetanus toxoid for women.

After vaccination
If immunization campaigns are planned in the
coming months, inform the caregiver about the date

of the campaign, what vaccination is being given,
and where the vaccination site will be.
Offer relevant print information to caregivers who
are literate.
Ask the caregiver if they have any questions or
concerns and answer them politely.
5. 3 Assessing infants for vaccination
Assess eligibility for immunization

1) Verify the infants age on the immunization card
2) Verify which vaccines the infant has received by
reviewing the immunization card
3) Verify all vaccines the infant needs at this session
to allow efficient preparation
Assess possible contraindications
Immunizing sick infants
1) For infants with a minor illness and/or fever below
38.5 C, vaccinate as usual.
2) For very ill infants who need to go to hospital, or
infants who have a very high fever, vaccinate if
possible. A senior health worker may have to
decide in each case, but infants need protecting
from diseases that could be transmissible in
hospital (measles, for example).
3) For malnourished infants, vaccinate as usual.
Other conditions when infants should be
immunized
allergies or asthma, with the exception of a known
allergy to a specific component of the vaccine as
mentioned
ongoing treatment with antibiotics
family history of adverse events following
immunization
prematurity or low birth weight
history of jaundice at birth
Other conditions when infants should be

immunized
ongoing breastfeeding
recent or upcoming surgery
chronic noncommunicable diseases of the heart,
lung, kidney or liver

stable neurological conditions, such as cerebral
palsy or Downs syndrome

family history of convulsions, seizures or fits.
5. 4 Giving vaccinations
Preparing to vaccinate
Reconstituting vaccines
Cluster of illness/deaths in rural Idleb, Northern Syria
Good general techniques

Welcome the family
Be prepared
Take time to position the infant with the caregiver
Follow a preset sequence for administering the
vaccines based on national guidelines
Positioning the infant for vaccination
Good oral administration technique

1. Position: Use the cuddle position on the
caregivers lap with the head supported and tilted
slightly back. Vaccinator stands to one side
2. Administration: Open the infants mouth by gently

squeezing the cheeks between your thumb and
index finger using gentle pressure. Firm squeezing
can cause distress.
Good oral administration technique

For rotavirus vaccine in tubes, angle the tube
towards the inner cheek.
Administer the entire contents by squeezing the tube
several times.
For OPV, let two drops of vaccine fall from the
dropper onto the tongue. Do not let the dropper touch
the infant.
3. Disposal: Discard the used oral vaccine tube into
the rubbish.
Good injection technique

Summary of injection steps
1. Wash skin that looks dirty with water. Swabbing
clean skin is not necessary.
Do not use alcohol to clean the skin before giving
vaccinations.
2. Hold the syringe barrel between the thumb, index

and middle fingers. Do not touch the needle.
3. For intradermal (ID) injections, gently stretch and
support the skin with the thumb and forefinger. Lay
the syringe and needle almost flat along the infants
skin. Gently insert the needle into the top layer of the
skin
4. For subcutaneous injections (SC), gently squeeze

the skin. Insert the entire needle at a 45 degree angle
(towards the shoulder) with a quick, smooth action
5. For intramuscular injections (IM), gently stretch and
support the skin between thumb and forefinger. Push
the entire needle in at a 90 degree angle with a quick,
smooth action
6. For all injections, depress the plunger slowly and
smoothly, taking care not to move the syringe around.
7. For all injections, pull the needle out quickly and
smoothly at the same angle that it went in.

8. For all injections, the caregiver may hold a clean
swab gently over the site if it bleeds after injection.
9. For all injections, dispose of the needle and syringe
immediately in the safety box.
10. For all injections, soothe and distract the child
when all the vaccines have been
given.
Intradermal (ID) injection
1. Position: Cuddle position on caregivers lap (BCG
recommended for infants only).
2. Administration:
Hold the syringe barrel with fingers and thumb on
the sides of the barrel and with the bevel (hole) of the
needle facing upwards.
Lay the syringe and needle almost flat along the
infants skin.
Insert the tip of the needle under the surface of the
skin just past the bevel.
Keep the needle close to the skin at the same angle
as you inserted it.
Place your other thumb on the lower end of the
syringe near the needle to hold the needle in position,
but do not touch the needle.
Hold the plunger end of the syringe between the
index and middle fingers. Press the plunger in slowly
with the thumb. If you feel no resistance to the
plunger, you are not in the right place and should
reposition
A pale flat-topped swelling with small pits like an
orange peel should appear on the skin.
Remove the needle smoothly at the same angle as
it went in.
The caregiver may hold a clean swab gently over
the site if it is bleeding. Do not rub or massage the
area.
Soothe the infant.
3. Disposal: Discard the needle and syringe straight
into the safety box.
Subcutaneous (SC) injection in the upper
arm
Subcutaneous (SC) injection in the upper arm
1. Position: The position depends on the age of the child,
the number of vaccinations to be given and what is easiest
and most convenient for the vaccinator.
2. Administration:
Hold the syringe barrel with fingers and thumb on the
sides of the barrel and with the bevel (hole) of the needle
facing upwards.
Quickly push the needle into pinched-up skin; the needle
should point towards the shoulder at a 45 degree angle.
Depress the plunger smoothly, taking care not to move the
needle under the skin.
Subcutaneous (SC) injection in the upper
arm
Pull the needle out quickly and smoothly at the
same angle as it went in.
area.
Soothe and distract the infant.
3. Disposal: Discard the syringe and needle straight
Intramuscular (IM) injection in infants
1. Position: The position depends on the age of the
child, the number of vaccinations to be given and what
is easiest and most convenient for the vaccinator.
2. Administration:
Hold the syringe barrel with fingers and thumb on the
sides of the barrel and with the bevel (hole) of the
needle facing upwards.
Gently stretch and support the skin on the upper,
outer thigh with the other hand and quickly push the
needle at a 90 degree angle down through the skin into
the muscle.
Depress the plunger smoothly, taking care not to
move the needle under the skin.
Pull the needle out quickly and smoothly at the
same angle as it went in.
area.
Soothe and distract the infant.
3. Disposal: Discard the needle and syringe straight
Intramuscular injection in adolescents and
adults
1. Position: Most will be comfortable sitting on a chair.
Those who are known to be prone to fainting may feel
better lying down.
2. Administration:
With your palm resting on their shoulder, hold the
injection site gently with thumb and forefinger. This touch is
comforting to the person and it will alert you of any potential
movement. Talk about how important it is for them to
remain still and then distract them by chatting about non-
related subjects like their favourite school subject or hobby.
Intramuscular injection in adolescents and adults
Holding the barrel of the syringe and, using a dart-like (quick,
smooth) action, insert the needle at a 90 degree angle all the way
down through the skin to the muscle. Keep chatting while you do
this. Distraction is an important aid to reduce injection discomfort.
Depress the plunger smoothly and steadily, taking care not to
move the needle.
Pull the needle out, quickly and smoothly, at the same angle as it
went in.
Do not rub the arm. A clean swab may be held over the site.
Give comfort, reassurance and distraction.
3. Disposal: Discard the needle and syringe straight into the safety
box.
5. 5 Closing the session
Discard or store opened vials depending

on vaccine type
1. Pack the vaccine carrier
2. Return vaccines to the refrigerator
3. Clean the vaccine carrier
4. Return other supplies
Dispose of used vaccine vials and

injection equipment safely
Leave the site clean and tidy
Recording data
Complete the infant immunization and reminder
cards
Prepare a summary of the session
Prepare a defaulter tracking list
Using the immunization session Checklist

Module 5 - Managing An Immunization Session

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Module 5 Managing an

Plan the immunization session

Prepare the workplace

Adverse Events Following Immunization (AEFI) kit

metal file to open ampoules, if needed

new immunization/child health cards

immunization tally sheets

container for rubbish that does not go into a safety box

paper, pencils and pens

adhesive tape to repair vaccine carriers if needed.

use only vials/ampoules in good condition; discard

do not use any vials/ampoules with fluid that has changed

colour or contains particles: seek the advice of your

vaccines and the diseases they prevent

safely and with little discomfort

listen without judgement

look beyond what is being said

check that the caregiver understands the information

given, which should be accompanied by giving written

breast milk or clean water.

and specify the appropriate dose and timing for the

Communicating potential adverse events

to ease pain if there is a local injection site reaction.

if the infants condition worsens or the reaction

Communication during each encounter

them for coming for vaccination and

concerns and answer them politely.

immunization card and explain the disease(s) against which

immunization schedule to be fully protected. Use the

card and tell the caregiver. If appropriate, associate the date

return date, they can obtain the next vaccination at another

they bring the child back for the next vaccination.

Communication during each encounter

In the event of any out-of-stocks of vaccine at the

time of the session, inform the caregiver where and

during immunization sessions, as per national

Communication during each encounter

coming months, inform the caregiver about the date

concerns and answer them politely.

Assess eligibility for immunization

family history of adverse events following

history of jaundice at birth

Other conditions when infants should be

chronic noncommunicable diseases of the heart,

lung, kidney or liver

palsy or Downs syndrome

Good general techniques

Take time to position the infant with the caregiver

Follow a preset sequence for administering the

vaccines based on national guidelines

Good oral administration technique

2. Administration: Open the infants mouth by gently

Good oral administration technique

Good injection technique

2. Hold the syringe barrel between the thumb, index

4. For subcutaneous injections (SC), gently squeeze

Good injection technique

Discard or store opened vials depending

Dispose of used vaccine vials and

Leave the site clean and tidy

Prepare a defaulter tracking list

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