Instructions for users

1. Instructions for users • This slide presentation provides an overview of immunizing with the SA 14-14-2 JE vaccine. • This slide set should be used together with the manual “Immunizing Children Against Japanese Encephalitis using SA 14-14-2 Japanese Encephalitis Vaccine: A Training Module for Vaccinators”. • Below some of the slides, there are notes to explain the information in the slide. • You should adapt the presentation for your own use.

2. Immunizing Children Against Japanese Encephalitis with SA 14-14-2 JE Vaccine

3. Learning Objectives Participants will: • Be familiar with key facts on SA 14-14-2 JE vaccine. • Demonstrate correct vaccine administration techniques. • Describe appropriate JE vaccine storage. • Describe safe disposal of used needles and syringes. • Communicate more effectively with parents of children being vaccinated.

4. Facts about SA 14-14-2 JE vaccine • SA 14-14-2 is a live, attenuated vaccine. • Licensed in the People’s Republic of China in 1988. • Currently about 60 million doses are used annually in China. • Also licensed and used in South Korea and Nepal. • Produced in primary hamster kidney cell cultures.

5. Administering Japanese encephalitis vaccine Who should be given JE vaccine? Photo credit: Lisa Lundgren

6. The following two slides need to be adapted according to the strategy and immunization schedule in your area An example is given

7. For areas where JE vaccine is newly introduced • A one-time preventive or “catch-up”campaign will be conducted. • This will include children 1 to 15 years of age.

8. For routine immunization Standard immunization schedule All children who are 9 months of age should receive a dose of JE vaccine.

9. What if a dose is missed? • If a child misses the date for vaccination, the child should make up the dose as soon as possible. • There is no need to re-start the vaccination schedule. Photo credit: Lisa Lundgren

10. The SA 14-14-2 vaccine (1) • SA 14-14-2 is a lyophilized vaccine that needs to be reconstituted (mixed with diluent) before use. • Prior to reconstitution it is a milky-white caked powder. • After mixing with diluent it becomes a transparent pink liquid.

11. Photo credit: Chengdu Institute of Biological Products

12. The SA 14-14-2 vaccine (2) • Provided in a single-dose vial or a 5-dose ampoule. • Lyophilized vaccine comes with two separate vials or ampoules: • Lyophilized (freeze-dried) JE vaccine • Diluent

13. Single-dose vial Photo credit: Chengdu Institute of Biological Products 5-dose ampoule Photo credit: Chengdu Institute of Biological Products

14. Packaging of 5-dose ampoule Photo credit: Julie Jacobson

15. Dosage and administration • Dosage is 0.5 mL (all ages). • Subcutaneous injection. • Given in outer upper arm.

16. What are the steps to follow when immunizing a child against JE disease? • Initial assessment with parents and child. • Prepare the vaccine. • Give the injection.

17. Before preparing the vaccine (1) • Greet the parents. • Evaluate the child’s immunization card and check what vaccine(s) are needed. • Explain the vaccine to the parents, including possible side effects and how to manage them. • Ask if the parent has any questions. • Check to make sure the correct vaccine is available. • Discuss with parents when to return for the next vaccination.

18. Before preparing the vaccine (2) • Prepare your supplies. Photo credit: Lisa Lundgren

19. Prepare the vaccine (1) • Read the expiry date on the lyophilized vaccine vial or ampoule. • If the expiry date has passed, discard the vial. • If the label has fallen off, discard the vial. Photo credit: Lisa Lundgren

20. Prepare the vaccine (2) • Make sure you have the correct, manufacturer-supplied diluent. Check the vial or ampoule is in tact and read the expiry date. • If the correct diluent is not available, do not reconstitute the vaccine with anything else. • Discard the vial or ampoule if • the expiry date has passed. • the label has fallen off. • the vial or ampoule is cracked.

21. Prepare the vaccine (3) • Check that diluent and vaccine are the same temperature. • If the diluent is warmer than the vaccine, put it into the refrigerator or vaccine carrier ahead of time so that it cools to the same temperature as the vaccine. • If the diluent is frozen, thaw the diluent to the same temperature as the vaccine. Make sure steps are taken to avoid freezing in the future.

22. Prepare the vaccine (4) • Remove the plastic flip-off cap from the diluent vial and the vaccine vial. • Do not remove the rubber stopper. Photo credit: Lisa Lundgren

23. Prepare the vaccine (5) • Reconstitute only with the manufacturer-supplied diluent. • Using a sterile syringe with mixing needle, draw up the diluent. Photo credit: Lisa Lundgren

24. Prepare the vaccine (6) • Insert the needle into the lyophilized JE vaccine vial. Photo credit: Lisa Lundgren

25. Prepare the vaccine (7) • Inject the diluent into the lyophilized vaccine vial. Photo credit: Lisa Lundgren

26. Prepare the vaccine (8) • Discard the mixing needle and syringe. Photo credit: Lisa Lundgren

27. Prepare the vaccine (9) • Shake the vial with the diluent and lyophilized vaccine gently, but thoroughly. • The vaccine should be uniformly pink when completely mixed. • After reconstitution the vaccine should be stored between 2°C and 8°C and used within 2 hours. • Do not freeze reconstituted JE vaccine!

28. Giving the injection (1) • Draw up the reconstituted vaccine, using a new sterile needle and syringe for each injection. • The needle and syringe used for reconstitution should not be used for giving the injection. Photo credit: Lisa Lundgren

29. Giving the injection (2) • Give: • 0.5 ml of JE vaccine. • As a subcutaneous injection. • In the outer upper arm, avoiding the BCG scar.

30. Giving the injection (3) • To give a subcutaneous injection: • Position child sideways on mother’s lap. • Ask the parent to hold the child’s legs. • Reach fingers around child’s arm and pinch up the skin. • Push the needle into the fatty layer between the skin and the muscle on the child’s upper, outer arm. • The direction of the needle is towards the shoulder. • Do not push the needle too far in. Photo credit: WHO, Immunization in Practice

31. Giving the injection (4) • Dispose of the needle and syringe immediately in the safety box. • Needles shouldnot be recapped due to the danger of needle-stick injury. Photo credit: Lisa Lundgren

32. Giving the injection (5) • Record the date of vaccination on the child’s vaccination card. • Remind parents about when to bring the child back for the next vaccination.

33. What are the possible side effects of JE vaccine? (1) • Some children may experience mild symptoms such as tenderness or swelling at the injection site, rash, mild fever, nausea, or dizziness. • These side effects are not serious and will not last more than a few days. • No severe adverse events have ever been reported for SA 14-14-2 vaccine.

34. What are the possible side effects of JE vaccine? (2) • JE vaccine does not cause JE disease. • If a child becomes unusually ill in the days following the immunization, the parents should bring the child to a hospital or clinic as soon as possible.

35. What are the contra-indications to SA 14-14-2 JE vaccine? • A very severe adverse reaction (anaphylaxis) to a prior dose of SA 14-14-2 JE vaccine. • Known allergy to any vaccine component. • Individuals who show the signs and symptoms of AIDS or immunosuppressive illness. Note: if a child has a fever higher than 38.5°C, vaccination should be postponed. An appointment should be made for vaccination as soon as possible after the fever settles.

36. How do you store JE vaccine? • Both powdered, lyophilized JE vaccine and reconstituted JE vaccine should be stored between 2°C and 8°C. • The vaccine can be used for 2 hours after reconstitution as long as it is kept between 2°C and 8°C. • The vaccine should be discarded after 2 hours or at the end of the immunization session, whichever comes first. • Do not freeze reconstituted JE vaccine!

37. To avoid freezing vaccines (1) • Store freeze-sensitive vaccines in the warmest part of the refrigerator • In top-loading refrigerators, load freeze-sensitive vaccines near the top, not in the bottom or middle of the refrigerator. • In front-loading refrigerators, load freeze-sensitive vaccines in the middle or near the bottom. • Do not store freeze-sensitive vaccines on the top shelf because the top shelf is directly under the freezer and can be very cold.

38. To avoid freezing vaccines (2) • Condition ice packs properly before loading vaccine carriers. • To condition an ice pack, remove the ice pack from the freezer and wait until you can shake the ice pack and hear sloshing.

39. How can you safely dispose of used syringes and needles? (1) • Keep a safety box within reach whenever you give injections. Photo credit: Lisa Lundgren

40. How can you safely dispose of used syringes and needles? (2) • Immediately after giving an injection, place the used needle and syringe in the safety box. Photo credit: Lisa Lundgren

41. How can you safely dispose of used syringes and needles? • If no official safety box is available, use a hard plastic container for disposing of used syringes and needles. • Clearly mark the container “SHARPS” so others will know to dispose of it properly. • When the box is ¾ full, seal the box and burn it in an incinerator. • If there is no incinerator, burn the safety box in a metal drum or shallow pit. • After burning, bury all remaining ashes and debris (including burned needles and melted plastic).

42. Monitoring use of JE vaccine • Record JE vaccine doses given on the child’s immunization card and clinic record. • Record doses of JE vaccine used on the routine reporting form. • Think about ways to reduce wastage.

43. How can you help ensure that parents bring their children for all needed immunizations? (1) • Be friendly and courteous in all interactions with parents. • Listen respectfully to parents’ questions and concerns. • Answer questions and explain things simply and clearly. • Be patient with people who cannot read or who have not attended school.

44. How can you help ensure that parents bring their children for all needed immunizations? (2) • Speak the local language and use words the parents can understand. • Find out when it is convenient for parents to bring their children for immunization and offer immunizations at those times. • Maintain a regular immunization schedule so that parents know when to come. • Clearly post the schedule where parents will see it.

45. How can you help ensure that parents bring their children for all needed immunizations? (3) • Explain to parents when and why the child should return for future vaccinations. • Remind them to bring the child’s vaccination card. • Assure them that the child should be vaccinated even if he or she has a slight fever or cold. • Ensure a smooth patient flow so that children are seen in the order they arrive, and without unnecessary delay. • Allow only one family at a time in the immunization area.

46. How can you help ensure that parents bring their children for all needed immunizations? (4) • Help parents understand possible common side effects and how they can treat the symptoms. • Explain what to do in case of uncommon allergic reactions. • Before the parent leaves the clinic, be sure he or she knows when the child’s next vaccine is due. • Guide the parents and child to the exit after giving the immunization and thank them for coming.

47. How can you help ensure that parents bring their children for all needed immunizations? (5) • Ask community leaders and community organizations to help educate parents about full immunization and motivate or assist them to bring their children on time. Photo credit: Lisa Lundgren Photo credit: Lisa Lundgren

48. Acknowledgements Please include the following acknowledgement if you use this slide set: This slide set was adapted from a slide set prepared by Lisa Lundgren, Northrop Grumman Contractor with the U.S. Centers for Disease Control and Prevention, and PATH’s Japanese Encephalitis Project. For information: www.JEproject.org