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Introduction
Immunization is one of the most cost-effective ways to decrease the disease burden
of the vaccine preventable disease (1). There is a high demand of vaccines
providers in India. You can start an immunization clinic as a part of regular pediatric
OPD or even have a separate immunization clinic, working at specific times/ days.
This chapter summarizes the basics necessities to set up an immunization clinic
under the following headings.
Conclusion
1. Plan workspace
Designated vaccination space will be needed to vaccinate and to draw and prepare
the vaccine. Along with there should be an adequate waiting area. It should have
proper ventilation, good lightening, drinking water facility, restroom, toys for
distracting children, preferably with lights and sound, magazine and newspaper for
the caregivers and a seating area are recommended (2). Space for the proper
disposal of the sharp needles will be needed near the place of vaccination.
Vaccination area should also have space for placing refrigerator, cupboard for
storing the needles, alcohol wipes, and other essentials like emergency medicines.
An area that can be considered private should be available if clothing needs to be
removed to access immunization site, especially for adolescents. Space for storing
vaccination record will be needed if physical records are kept. A computer could be
used successfully for this purpose, as it helps in decreasing the space requirement
and time needed to store and retrieve the records. Finally, using computerized
records vaccination reminders can be sent easily to patients via calls/ SMS/ emails/
whatsapp messages, to ensure better compliance with appropriate vaccination
schedule. IAP has partnered with Immunize India to setup a free SMS service for this
purpose as well. The reminder service will be available free of cost for parents
across the country and they can opt for the service by sending a text message to the
national code 566778 from any mobile network in India. The parents will receive
immediate confirmation through a text message and will be reminded for 12 years,
the prescribed immunization schedule for their child. A total of three reminders would
be sent, at two-day intervals, for each vaccination due (3).
For your clinic, you should have sufficient staff to handle the personnel registration,
payment collection, vaccination assistant, vaccination administration, and for
handling emergency situations, including security. Staff should be polite and
conversant with the local language. You should orient your staff regarding the basic
training in overall need, purpose, and flow of vaccination clinic. Each staff should
understand their responsibilities clearly. Cross-train staff members, it would help in
handling the situation of absenteeism of any staff, and meeting the fluctuating
demands of your clinic. Take care of the staff by providing adequate rest breaks and
snacks in a designated area (4). Counsel the staff regarding the importance of cold
chain, so that they do not open the refrigerator unnecessarily and for long durations.
A dedicated refrigerator cum freezer will be needed to store the vaccine. This
refrigerator should be used only for storing the biological and pharmaceuticals. Care
should be taken to avoid the frequent opening, to avoid the temperature to go out of
the desired range. While purchasing the refrigerator care should be taken to
purchase the unit with a double door. Single door refrigerators are generally not able
to maintain the temperature. A good quality thermometer will be needed to keep
track on the temperature in refrigerator and freezer. A dial thermometer is
recommended and the temperature should be taken at least twice a day. Continuous
monitoring thermometers with alarms are preferred. For more details refer to the
chapter on “Cold Chain and Storage of Vaccines” in this guidebook.
Hydrocortisone and chlorpheniramine are not the first line drugs; however, these
drugs could be used in the further management of anaphylaxis by trained staff.
Hydrocortisone should only be given after a severe anaphylactic attack to prevent
any late symptoms (7).
If further skills and equipment are available, patients ECG and pulse oximetry should
be done. Blood pressure should be measured regularly (7). It is preferable to have
oxygen supplies in the premises as well for managing severe anaphylactic reactions.
For standalone outpatient (OPD) clinics, a tie up with a nearby hospital is essential
for possible transport of a sick child that requires admission.
You should have someone who will be responsible for ordering vaccine, maintaining
vaccine stock register, and storing the vaccine after the receipt from the vendor.
Vaccines have known shelf lives, are expensive, and fragile, therefore they need to
be ordered in last after your clinic is setup. Always order vaccines from an
authorized distributor of the company, as this will ensure proper documentation in
case of any rare side-effects from any vaccine. Vaccines can be ordered as per the
need of the clinic, either daily or weekly. Vaccines should be stored in the fridge
immediately after delivery without breaking the cold chain. Delivery should be
checked for any leakage or breakage. A stock register should be maintained to keep
a track of the expiring vaccine. A policy of FIFO (First In, First Out) should be
followed so that the vaccines with shorter expiry are consumed first. A proper
inventory will ensure adequate stock of all vaccine all the time in the clinic.
You should try to accept all possible methods of payment including cash, credit card,
debit card, and e-payments via net banking or e-wallets. Insurance providers help in
cashless immunization if you have tied up with the insurance providers that will be an
additional advantage for the customers who are insured.
9. AEFI reporting
Waste disposal including used syringes, needles, damaged vials, and other
biological waste at the immunization site should be disposed of according to
recommended guideline (13). In India, Central Pollution Control Board (CPCB)
guideline for biomedical waste disposal should be followed for the disposal of
immunization waste. Improper disposal could harm the injection recipient, health
care providers, and the community. It could lead to spread of life-threatening
infections like HIV/AIDS, Hepatitis B and C, and others (14).
Needle caps and wrappers should be disposed of in the black color bag. This bag
could be disposed of as municipal waste. Syringes plastic part and unbroken empty
vials should be disposed of in the red color bag. Content needs to be disinfected
before sending for recycling. Broken vials, ampules, and AD syringes should be
disposed of in safety pits post disinfection treatment (15).
Nowadays, specialized medical waste disposal agencies provide you with the bags,
chemicals, and recording sheets needed to dispose of the vaccination related
consummables. Ensure that your staff takes all precautions and follows instructions
as specified by the waste disposal company.
1. WHO, UNICEF, World Bank. State of World Vaccines and Immunizaion. 3rd
Ed, Geneva: World Health Organization; 2009.
3. Immunize India. The Indian Academy of Pediatrics. [cited 2016 Dec 30];
Available from: http://www.immunizeindia.org/.
5. WHO. Category E003 Refrigerators and freezers for storing vaccines and
freezing waterpacks. World Health Organization [cited 2016 Dec 28]; Available from:
http://apps.who.int/immunization_standards/vaccine_quality/pqs_catalogue/category
page.aspx?id_cat=17.
12. Chitkara AJ, Thacker N, Vashishtha VM, Bansal CP, Gupta SG. Adverse
event following immunization (AEFI) surveillance in India, position paper of Indian
Academy of Pediatrics,2013. Indian Pediatr. 2013;50(8):739-41.
13. Immunization hanbook for health workers. Ministry of health and family
welfare. Governemnt of India. 2011 [cited 2016 Dec 27]; Available from:
http://www.pbhealth.gov.in/Immunization/Immunization_Handbook.pdf.