5 Vaccination

5.1 Helpful general information

Priority should be given to protection against easily transmitted and/or serious infectious diseases such as measles, rubella, diphtheria, tetanus, pertussis, polio, Hib (<6 years unless otherwise indicated in country-specific recommendations) and hepatitis B (with or without screening, according to national guidelines). When possible, combination vaccines should be used to facilitate vaccination. If there is a vaccine shortage, prioritise children but aim for at least one dose of dT-IPV-containing vaccine in adults.

Additional vaccinations should be considered for protection against the following diseases depending on living conditions, season and epidemiological situation:

Invasive meningococcal disease (disease common in densely-populated settings such as refugee camps or reception centres, vaccine included in many EU routine programmes);

Varicella (disease) common in crowded settings and refugees/migrants/asylum seekers are highly susceptible – vaccine included in some EU routine programmes.

In the ECDC table specific recommendations are provided regarding vaccinations to be offered in the absence of documented evidence of prior vaccination [http://ecdc.europa.eu/en/publications/Publications/Infectious-diseases-of-specific-relevance-to-newly-arrived-migrants-in-EU-EEA.pdf]

Another important resource is the vaccine information statements (VIS) in many languages for 30 vaccines in more than 40 languages [http://immunize.org/vis/]

Also the Robert-Koch Institute in Germany provides a website with vaccine information statements (VIS) in many languages [http://www.rki.de/DE/Content/Infekt/Impfen/Stichwortliste/A/Asylsuchende_und_Impfen.html]

Particularly helpful is also the Immunization Action Coalition website with pictures of 20 vaccine preventable diseases since they are rarely diagnosed in Austria nowadays like Polio or Diphtheria:

[http://immunize.org/photos/] For further information on Child Health please see Module 7 [Link to Module 7, Child Health]

5.1.1 Resource with special focus on refugees and other migrants

This sub-chapter is taken from deliverable 4.2 of the project EUR-HUMAN: Set of guidelines, guidance, training and health promotion materials for primary care for newly arrived migrants including refugees.

Toolkit for health care workers: [http://www.promovax.eu/toolkits/HCW_english_web.pdf]

This toolkit will give insight and knowledge about migrant immunization needs. It is designed to help health care providers assess the immunization needs of migrant patients. The information is available in English, Croatian, German, Greek, Hungarian, Italian, Norwegian and Polish. The following information can be found:

Who should be offered vaccinations
How to deal with missing or incomplete vaccination records
Assessing a migrants risk of exposure to vaccine preventable diseases and immunization needs
Schedules for paediatric and adult vaccinations
How to increase vaccination rates among migrants
Several case examples
Vaccination recommendation in addition to those recommended by age for workers at rick of occupationally acquired vaccine preventable diseases

Immunization record:

The project provides a clear assessment form for migrant’s risk of exposure to vaccine preventable diseases and a practical immunization record for adults and children. This information is also available in English, Croatian, German, Greek, Hungarian, Italian, Norwegian and Polish. [http://www.promovax.eu/toolkits/HCW_english_forms_web.pdf]

Toolkit for refugees/migrants

The toolkit also provides information for refugees on why vaccinations are necessary, which diseases to prevent, securing the safety of vaccinations, some myths and facts and information on where to get vaccinated. It also includes a copy of the immunization record. The information is available in English, Albanian, Arabic, Bosnian, Bulgarian, Chinese, Nepali, Polish, Romanian, Russian, Somali, and Ukrainian. [http://www.promovax.eu/index.php/promovax/toolkits/too2]

For Austria, of course, the Austrian Vaccination-Schedule is most relevant. For refugees are at least the same vaccinations schemes relevant than for Austrian citizens:

Vaccination schedule for Austria 2016 [http://bmg.gv.at/cms/home/attachments/2/8/1/CH1100/CMS1452867487477/impfplan.pdf]

5.2 Vaccine storage and handling

Vaccines must be stored properly from the time they are manufactured until they are administered. Assuring vaccine quality and maintaining the cold chain is a shared responsibility among manufacturers, distributors, public health staff, and health-care providers. A proper cold chain is a temperature-controlled supply chain that includes all equipment and procedures used in the transport and storage and handling of vaccines from the time of manufacture to administration of the vaccine.

The Center for Disease Control and Prevention (CDC) provided a comprehensive Vaccine Storage and Handling Toolkit [http://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html]

As well as other resources like a list with recommendations and guidelines regarding this topic

[http://www.cdc.gov/vaccines/hcp/admin/storage/]

Here an excerpt with the most important topics:

Most important is that the refrigerator temperature for vaccine storage is always between +2°C and + 8°C.
Do not place the vaccine in the refrigerators door or use a combination refrigerator/freezer unit with one exterior door and an evaporator plate (cooling coil), which is usually located inside an icemaker compartment (freezer) within the refrigerator. These units have been shown to pose a significant risk of freezing vaccines, even when used for temporary storage! In addition, if the refrigerator has thawing cycles do not place the vaccine directly adhering to the back wall.
Please monitor temperature at least twice daily, if not automatically monitored.
Vaccines: follow the principle first in first out.
Immediately before use please control the expiry date of the vaccine. Also examine expiry dates of disinfectant and injection needles, if not ready to use vaccines are used

In the case of vaccine donations the WHO guideline for donations should be followed for donors and recipients. [http://apps.who.int/iris/bitstream/10665/44647/1/9789241501989_eng.pdf]

Medicinal products should have a residual shelf-life of at least one year. This may be difficult to achieve for vaccine donations but vaccines should have at least a residual shelf-life of 6 month, otherwise one has an unwanted donation.

Do not accept donations of medicinal products which are not licensed in the EU.

Do not accept donations with less shelf-life as above.

If unwanted donations arrived and cannot be sent back, see WHO guideline for safe disposal of pharmaceuticals [http://apps.who.int/iris/bitstream/10665/42238/1/WHO_EDM_PAR_99.2.pdf]

5.3 Documentation of vaccination

A uniform vaccination certificate should be used. Preferably the WHO certificate of immunisation (yellow international vaccination certificate).

However, there are different versions of this certificate. The correct version is the version where the front page include: [http://www.who.int/ihr/IVC200_06_26.pdf?ua=1]

given name
family name
birthdate (month should be given in Latin letters to avoid confusion due to different formats, e.g. 3. June 2002 instead of 03/06/2002 or 06/03/2002)
registration number or insurance number

! This document should be written in English with Latin letters, a second language may be used in addition. English language is important since health care providers from different countries have to read and understand the document.

Here you can find an index of pharmaceutical/medical terms available from the European Pharmacopoeia (Council of Europe) in many languages including a definition

[www.edqm.eu] (you have to register free of charge)

5.3.1 Name of vaccines

Vaccines are neither generics nor biosimilars. Each vaccines stands alone with its efficacy and adverse events following immunisation (AEFI).

Trade names of the same vaccine may be different in EU countries. For example: Hexavalent vaccines licensed in EU: Infanrix-hexa (GSK), Hexyon (SPMSD) distributed in Germany, Hexacim = 2nd Tradename of Hexyon, Vaxelis (MSD) – three of this vaccines have a different manufacture and different antigens on a molecular level. The INN name can`t be printed on the adhesive label, because it is too long.

To avoid medication errors resulting from the confusion of vaccine names a three letter code should be used for correct identification of the components in a combined vaccine in the vaccination certificate. So a tetravalent vaccine can be identified as DTaP-IPV or DTaP-HBV or MMR-VAR independent of its trade name. A hexavalent vaccine can be identified as DTaP-HBV-HIB-IPV.

5.4 Injection technique

Vaccinees should sit to avoid severe injuries due to fainting.

This risk may be higher in vaccinees with trauma or foreign setting with language problems.

How to administer vaccines i.m. or s.c. Find a short instruction on Administration by the Intramuscular (IM Route) [http://www.immunize.org/catg.d/p2020.pdf]

Vaccines containing adjuvants (e.g. aluminium-adsorbed antigen)

Must be injected deep into the muscle mass
Should not be adminitered s.c. or i.c.
Because they can cause local irritation, inflammation, granuloma formation and tissue necrosis (Red Book, 2003, 18)

Air (steril, about 200 µl) in the ready to use syringe should be injected with the vaccine. Injection needles should be dry at the outside, to reduce the possibility of sensitization against vaccine ingredients.

5.5 (Paediatric) pain reduction

A guideline of reducing pain during vaccine injections (Sept 2015) can be found here

[http://www.cmaj.ca/content/187/13/975.full.pdf]

For infants breastfeeding during immunization, or using sucrose solutions (20%) is helpful.

Recommendations for all ages are given.

How to hold an infant?

Pictures regarding this topic can be found here [http://www.eziz.org/assets/docs/IMM-720ES.pdf] free access English and Spain

Gloves are not required for immunization according to CDC [http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5102a1.htm]