of Health ‘HE SECRETARY Departr OFFICE OF September 24, 2019 DEPARTMENT MEMORANDUM No. 2019-_ 0347 FOR: ALL DEPARTMENT UNDERSECRETARIES AND ASSISTANT SECRETARIES; CENTERS FOR HEALTH DEVELOPMENT. (CHD) AND BUREAU DIRECTORS; SPECIAL & SPECIALTY HOSPITAL DIRECTORS: CHIEFS OF MEDICAL CENTERS, HOSPITALS AND SANITARIA; AND OTHER CONCERNED. SUBJECT: Interim Guidelines_in_the Implementation _of_a_Nati Epidemic Response Immunization in Mindanao Region I. BACKGROUND AND RATIONALE, ‘The Philippines, together with other countries in the Western Pacific Region, has been declared polio-free since October 2000. This progress has been achieved through a strong routine immunization coverage coupled with regular conduct of supplementary immunization activities known as “Patak Polio”, and complemented by highly sensitive surveillance system in the country. .al_Polio In recent years, vaccination coverage for the 3 doses of oral polio vaccine (OPV3) has been steadily declining below the target required to ensure population protection against polio. It is estimated that more than 4 million children who were born between 2013 to 2018 were missed for OPV3!. This gap in population immunity against polio continues to widen in the Philippines. In the 2019 Polio risk assessment, the whole country is at high risk for polio due to persistently low immunization coverage leading to significant accumulation of susceptible population coupled with persistently. low surveillance performance. The Acute Flaccid Paralysis (AFP) surveillance has an overall decreasing performance since 2016. In addition, the practice of open defecation, poor-and unhygieni tion practices still persist in urban and rural communities which put the country at high risk for polio re-circulation, Recently, the routine environmental surveillance detected the presence of vaccine- derived poliovirus (VDPV) in several sampling sites in Metro Manila and Davao. A vaccine derived poliovirus 2 has been isolated from two (2) human cases presenting with Acute Flaccid Paralysis (AFP). While the Philippines has been certified polio-free in 2000, the detection of poliovirus in both human and the environment raises the concem of re- circulation of polioviruses in the country. The Secretary of Health declared a polio epidemic in 19 September. To respond;-the Department of Health (DOH) together with the respective CHDs and LGUs will conduet three (3) rounds of polio outbreak response immunization which is a critical action, to. <2 guarantee high population immunity among under 5 years old children and protectthe = population from the consequences of polio virus recirculation ie = * Regional Commission for the Certification of Poliomyelitis Eradication in the Western Pacific, Novem 2018. ‘uring , San Cazaro Compound, Rial Avenue, St, Cri, 100K Wana = Tank ine 651-7800 Toca TOE TTA, 11, TTI Dinet Line: 711-9502; 711.9503 Pax: 743-1829 « URL: htp/ivvn doh gov ph; e-mail: Adugue@doh gov ph wenI, SCOPE AND COVERAGE This Order shall provide technical guidance to all CHDs, LGUs, all health care workers and other partners in the country regarding the implementation of a polio epidemic Tesponse immunization among children aged 0-59 months regardless of immunization status in sclected areas. I. OBJECTIVE To ensure a high QUALITY polio outbreak response immunization targeting at least 95% of children aged 0-59 months in each barangay, municipality ot city of selected areas to interrupt the transmission of poliovirus. IV. GENERAL GUIDELINES 1. A polio outbreak response immunization shall be conducted in 3 rounds in priority areas. Areas tobe | Vaccineto | Target Age Round | Date Covered Use Group. Davao del Sur__| monovalent October Davao City Oral Polio 0 14.27, Tanao del Sur | Vaceine es aaa, 2019 including Marawi Type 2 ” City (mOPV2) monovalent 1 | November | All Regions in | Oral Polio 25. Mindanao Vaccine fe bat December Type 2 years ol 7,2019 (mOPV2) ‘monovalent January 6- |All Regions in iin bid 0-59 months old 2 18, 2019 Mindanao (<5 years old) Type 2 (mOPV2) 2. All children aged 0-59 months regardless of immunization status will be vaccinated with monovalent Oral Polio Vaccine (mOPV2) 3. The activity will be synchronized across all targeted areas and should be completed within two weeks’ time, 4. All vaccines shall be sourced from WHO through UNICEF and will be distributed by the DOH central office and UNICEF. 5. 95% coverage should be targeted in order to attain herd immunity and address the current epidemic 6. The involved regions shall organize a Regional Polio Incident Management Team and activate its Emergency Operation Centers (EOC) (See Annex A: Incident Management Organizational Structure) 7. The Regional Polio Incident Management Team shall coordinate, monitor and report the progress of the implementation of the polio outbreak response immunization to the National Polio Technical Team. | CERTIFIED TRUE | |8. The involved provinces, cities and municipalities shall also organize its respective Incident Management Team and activate its emergency operation centers and regularly coordinate. VI. SPECIFIC GUIDELINES A. Preparatory Activities 1. 3. Social Preparation The Polio Incident Management Team at all levels shall be activated and conduct meetings and consultations with the Local Chief Executives (LCEs) and other partners. Orientation and Training The Polio Incident Management Team shall conduct orientation /re-orientation to concemed health staff of the Provincial / City Health Offices and other stakeholders on the polio outbreak response immunization, Microplanning As part of the orientation, the Regional Polio Incident Management Team shall conduct microplanning to LGUs which shall include the following ste a. Calculation of the eligible population at the component city and municipality to be given with mOPV2; b, Creation or updating of operational spot maps of the areas to be covered for immunization; ¢. Calculation and identification of the number of children to be vaccinated per day and the vaccination teams needed in order to prepare a daily immunization schedule for the vaccination team and the areas to be visited; d. Calculation of the vaccine and other logistics needed including the cold chain equipment; e. Filling-up of the Daily Immunization Session Plan (itinerary) of the Vaccination Teams; f. Development of an Immunization Activity Plan for the Catchment Areas of a health facility; g. Crafting of a supervisory and monitoring schedule; h, Development of a Rapid Coverage Assessment (RCA) plan i, Development of a follow-up schedule and mop-up plans j. Human Resource Contingency Plan Contingency plans should be developed to re-deploy or re-distribute vaccinators in case of staff absence due to sickness, emergencies or other uncontrolled reasons in the area k. Health Care Waste and Vaccine Management Plans for mOPV2B. Campaign Strategies 1. Polio Immunization Round Schedule Each round of the polio outbreak response immunization shal] be conducted over a period of 2 weeks (14 continuous days), including weekends and holidays. This is to ensure that children can be at home during Saturdays or Sundays for immunization, The following table of activities is recommended for an effective campaigr Campaign Main Activity Remarks Day With intra-campaign monitoring : i and supportive supervision Intensive and simultaneous a i Day 1-5. | Vaccination in all barangays Strict tracking and recording of missed children Including weekends and holidays House to house teams do 2nd visit in assigned areas to cover all recorded missed children Follow-up and mop up based on : Day OT yeaa anita The fixed and special session teams continue to work in assigned areas and locations Including weekends and holidays } a Day 8-14 | Follow up and mop-up based on Follow-up and mop up after RCA uy RCA findings of missed children | Including weekends and holidays 2. Vaccine Administration and Target a. All children aged 0-59 months regardless of immunization status shall be vaccinated with monovalent oral polio vaccine (mOPV2), two (2) drops, directly into the mouth without touching the skin or mucosa of the oral cavity; and Note: Please ensure that the complete dose is completely swallowed. Repeat the full dose if vomited or spitted-out. , mOPV2 is presented in a 20-dose vial with a vaccine vial monitor (VVM) on the label. The vaccine is WHO-prequalified with the same operational characteristics as bOPV. Note: 1 dose =2 drops c. mOPV2 is safe to be administered to all targeted children irrespective of their current health condition 3. Immunization Service Delivery ‘The immunization service delivery strategy shall include a mix combination of: a Door to-Door (D2D) . = . The Door-to-door vaccination approach shall be the mr paraRWe C approach for the campaign;ii, It shall be considered in areas where demand for vaccination has decreased and in which there is prior evidence of refusal of vaccination; House-to- house vaccination provides the opportunity to engage families and convince them of its benefits, iii, It shall be the strategy in highly dense urban slums with complex multiple dwelling places, and rural areas where physical access to the health facility is difficult for parents and caregivers to avoid missed children; affluent populations, such as_— condominiums, gated communities, apartments/townhouses, and subdivisions; iv.In each houschold visited, one member of the team will tally the number of eligible children in the houschold, and will also tally the children who receive vaccine. v. All children vaccinated will be finger-marked vi. If eligible children cannot be vaccinated during the visit ~ the team will record and will conduct a follow-up visit to reach the missed child/children Fixed Post (FP) i. Fixed posts are located at permanent health facilities such as hospitals, health centers, rural health units or barangay health stations. ii, Immunization services shall be provided at the health facilities for the whole day and daily, including weekends and holidays, for the whole duration of the campaign, iii, Routine immunization services will continue at all fixed posts as per national immunization schedule iv, Each child of eligible age who receives mOPV2 vaccine will be recorded on the tally sheet and will get a finger-mark. Child visits the + Vaccinate with mOPV2 fixed post at Health J + Finger mark and tally Center for *+ Use the opportunity to track and vaccinate if campaign dose he/she is RI defaulter (except bOPV) * Cheek for mOPV2 administration through finger mark + Ifnot vaccinated yet, vaccinate with mOPV2 first, finger mark, and tally * Give all scheduled vaccines as usual (except OPV), and update the record in RI register and health card Child visits fixed post at health center for RIb, Special Vaccination (SV) Sessions i, Special Vaccination Sessions are required for areas with very small and/or disperse populations, hard-to-reach areas or Geographically Isolated and Disadvantaged Areas (GIDA), rural communities which are too remote or too small in size to have a health facility or fixed vaccination post; ii, The vaccination teams shall set up the temporary vaccination post for the time needed to complete the task before moving on to the next location; After completing the session they should move on foot in the area to ensure all children have been vaccinated iii, SV sessions can be done in the following locations: a, government establishments, such as barangay halls and public schools; b, transportation hubs, such as bus stations, seaports, and airports; . gathering areas, such as markets, churches, malls, basketball courts and playgrounds; 4. daycare centers, orphanages and other social service institutions where children are housed; ¢. in cemeteries, under the bridges, parks or open spaces where some families with eligible children are living; f. highly mobile group such as the urban poor, street children, indigenous people and the like; g- Gated communities and condominiums requiring permissions from authorities for entry of vaccination teams 4. Vaccination Team a, Vaccination teams shall be organized based on the target number of children (0-59 months old), the duration of vaccination (14 days) and the vaccination strategy to be employed; . The vaccination team should ensure that every child targeted is vaccinated following the microplan; and ©. The vaccination team shall be composed of at least i, One (1) vaccinator (health staff, trained health or civil society volunteers) ii, One (1) recorder (health staff or trained volunteer) iii, One (1) guide (barangay health worker / volunteer) C. Vaccine Storage, Transport and Disposal J. Storage and Transport a. Monovalent oral polio vaccine (mOPV2) is heat sensitive and shall be stored at #2%c to +8°C (body of refrigerator) at the Rural Health Units or Barangay Health Stations; b. During immunization sessions, mOPV2 vaccines shall be transported and stored using the recommended vaccine carriers with ice packs; ¢. All mOPV2 vaccines come with an attached “Vaccine Vial Monitor” (VVM).. ‘The VVM should be regularly checked before using the vaccine; 4. All mOPV? vaccines with VVM at discard point should not be used;WM Stage “eo —— E eamny e. The use of mOPV2 does not follow the multi-dose vial policy. 2. Disposal of Vaccination Waste See Annex B: Technical Guidance on mOPV2 Vaceine Management, Monitoring, Removal and Validation D. Co-administration with Other Vaccines and Contraindication 1, Monovalent oral polio vaccine (mOPV2) shall not be given simultaneously with the bivalent oral polio vaccine (bOPV) to avoid confusion; 2. For the whole duration of the campaign (Day 1-14) until a week (7 days) after each round, the administration of bivalent aral polio vaccine (bOPV) shall cease for the time being until all mOPV2 stocks have reverted or transported to the higher administrative level ; 3. However mOPV2 can be concurrently given with other routine vaccines in the health facility except bOPV. Bacillus Calmette-Guérin (BCG), diphtheria-pertussis-tetanus (DPT), hepatitis B, measles containing vaccine, Haemophilus influenzae type b (Hib), and pneumococcal conjugate vaccine shall continue to be administered in health facilities throughout the duration of each campaign round. 4, Defer giving OPV in those with primary immune deficiency disease or suppressed immune response from medication, leukemia, lymphoma or generalized malignancy. E. Recording and Reporting 1, Finger Marking: Every child vaccinated with polio vaccine will be marked with indelible ink on the left little (pinky) finger. This will help both the health workers and supervisors, monitors and RCA validators to determine the missed children and also to ascertain the completeness of vaccination in an arca, The mark should cover the entire nail and adjoining skin/cuticle. 2. Masterlisting of children is not recommended and should not be done during the campaign as basis for target. vet3. The vaccination team shall be provided with Daily Tally Sheets (Annex C). For every child vaccinated should be recorded (ticked) in the Daily Tally Sheet. List the nam age and address of those children deferredirefiised at the back of Daily Tally Sheet. It is important to note details of vaccine vials received on the tally sheet 4, The vaccination team should record the total children vaccinated for the day using the Daily Summary Reporting Form (Annex D) and submit to the supervisor at the end of the day 5. The consolidated daily summary reporting shall be submitted by the supervisor to the DOH-Central Office using the Data4Action app. 6. Recording of missed children by House to House teams + The house to house team will also record any children who ere missed from vaccination along with the reason missed and scheduled time for follow up + This information will help the team to track and vaccinate all missed children during follow up visits 7. Recording Routine Immunization at Fixed posts + First vaccinate with mOPV2 if not already vaccinated (check finger mark) + Then administer scheduled Routine Immunization vaccines + The routine immunization doses will be recorded on the health card of the child as per usual practice + No finger marking or tally recording will be done for the routine immunization Supervisors must ensure that house to house teams are recording missed children on the back of tally sheet and using this record for follow up visits F. Supervision of the Vaccination Team (See Annex E: Supervisor's Checklist for Vaccination Team) 1. Key activities ~ Precampaign © Oversee and follow up microplan development * Use checklists to review SIA readiness and take timely corrective measures * Review and validate supervisory plans and map * Ensure team geographical boundaries are clear * Make sure all team members have been trained and no untrained people on the team are used as substitutes + Logistics arrangements © Transportation for hard to reach areas © Cold chain arrangements: Functional refrigerators, Cold boxes, Vaccine carriers with ice packs © Vaccines © Dry logistics: Finger markers, recording and reporting formats, IEC material — flyers, banners © Community mobilization © Meetings with partners and stake holders for community mobilization © Arrangements for local announcements: radio/ television, schools and day care centers, churches! mosques © Atmunicipality and city levels, arrange meetings with mayors, © Schedule meetings with barangay officials,° Discuss the objectives of the campaign, specific date(s) of the actual vaccination, and specific assistance the teams require from the officials: information dissemination through “bandillos” reaching every household and every eligible child, mobilizing the “tanods” to provide security to the VTs, provision of transportation from one purok to another, etc. Ask the barangay official to identify a focal person in each purok to assist the teams in mobilizing the communities Key Pre-Campaign Activities Microplan All items included according to template with correct calculations _ All Barangays included in every plan Identify any supply shortfall. What action is needed Maps: shows catchment areas location of posts/ teams per day | Budget accurately calculated High risk areas High risk Barangays/puroks identified High risk area coverage plan available with supervisors/sites/dates High risk areas prioritized in supervision and monitoring plans Cold chain logisties supply ‘Adequate vaccine storage space for mopy2 vaccine in health facilities ‘Adequate vaccine carriers/ice packs/freezer capacity Logistics/supply transport plan available to supply all areas Contingeney plan for replenishment for health facility if stocks run low ‘Advocacy Mayors have been informed and ready to participate/contribute Local NGO meetings held to enlist their support for monitoring and transport of supervisors/teams Social mobilization Soc. Mob materials available Plan for Barangay Health Worker training available Plan for involving Barangay officials and volunteers Plan for identification of community focal points in Barangays Immunization safety All supervisors know how to report AEFI AEFI Investigation forms and SOPs available to supervisors Plan for waste disposal available Team management Plan for team training available with simple training materials/tally sheets “Team strategy: fixed post, house to house team, special session used in teams' activity plans ‘Teams available for mop-up if RCA fails, ‘Team/post distribution plan is available Reporting system System for daily collection and consolidation of tally sheets into. | reports | Mechanism in place for submission of reports and sending todistrict/provincelregion HC has system to react on a daily basis to failed RCA by ordering Limmediate mop-up Z 2. Key activities ~ Intracampaign * Preparing logistics and transportation for the teams before deployment in field * Morning briefing to teams before deployment © Timely deployment of all teams © Manage any absentees * Supervisory visits of team and implementation of corrective actions immediately ‘* Support monitors for conducting RCAs in areas which are covered as per daily activity plan of the teams * Daily evening review meetings with teams; Major challenges and observation, RCA findings, decisions for corrective action, follow up on last days pending actions ‘* Daily compilation of data and reporting to city/ district concemed focal persons + Ensure special attention for high risk areas, special sessions at busy congregation points, and security compromised or conflict affected areas * During second week of the campaign, ensure mop up activities in all poorly covered areas * Pay special attention on mOPV2 vaccine management and accountability for each vial © Dedicated focal person available to manage vaccine storage, distribution, and return at end of each day © Two vaccine carriers for fixed posts at health facilities: one for Routine Immunization, Another for mOPV2 © Teams record all details about vaccine vials issued, used, and returned on tally sheet © Each vial distributed is well accounted for, and is tracked for proper use and return 3. Team supervision in field Main objectives: + To make onsite corrections in the field + To educate and train concemed health functionaries on job * To provide feedback & recommend measures for improvement/mid-course corrections 4. Key activities — Postcampaign * Coverage report compilation and submission © Final report of coverage must be compiled at the end of the campaign and shared with ditric¥/ city administration focal person 5y | E COPY) * Waste management © All guidelines detailed in waste management plan should be folloWbdjt9 2919 ensure proper waste management |* mOPV2 vaccine management of used and unused vials as per shared DoH guideline © Conduct campaign review meeting with all stake holders to share updates about coverage achieved, strengths, challenges, lessons identified and plan ahead for corrective action before next round of campaign G. Rapid Coverage Assessment (RCA) of the Areas Visited for Vaccination (See Annex F Rapid Coverage Assessment (RCA) Form) 1. Main objectives © To search and rapidly identify areas with missed children (who have not received mOPV2 in current campaign) Identify reasons for missed vaccination Identify sources of information on the vaccination campaign Provide data to inform corrective action BEFORE the campaign ends Provide data for improvements/corrective actions in planning of next campaign 2. Area selection for RCA * All High Risk Puroks should be prioritized for RCA selection, The criteria may include: Polio outbreak infected and neighbouring areas hard to reach areas, conflict affected areas areas with dense populations (urban slums) areas with heightened vaccine hesitancy/ refusals (Dengvaxia) When: RCA can be done after the teams have completed their work in that area as per daily activity plan in Microplan (next day onwards) ° ° o o ° ° 3, Eligible households and children © In the selected area, all households with at least one child aged 0 to 59 months (physically present at the time of RCA) are eligible to be selected for RCA © All children aged 0 to 59 months in the selected household will be included in the RCA Method for RCA. Monitors select an area to go for RCM Meet with concerned officials in the area to inform about purpose of visit The area officials/Health Center manager should provide local guide for facilitation Complete the mOPV2 management assessment All monitors should carry vaccine carriers to vaccinate any missed child found Select a starting point Go to eligible households (at least one eligible child aged 0-59 months resides in that household, and is physically present at the time of RCA) © Check each child aged 0 to 59 months in the selected household and record their mOPV? vaccination status, * Skip 3 or 5 houses after each surveyed house (depending on population density) to ensure that a bigger area is assessed * Each RCA should include 20 households * In selected household, only those children will become part of the survey who are _ physically present to be verified for mOPV2 vaccination at the time of'si * Finger mark will be used to confirm mOPV2 vaccination status© Monitors may choose to do more than 20 households if they find no unvaccinated children 4, Mop up Decision No child found missed No mop up required No more children found missed Do RCA in 20 more house holds The monitor must complete RCA in 20 households, even if >2 missed children are found before reaching the 20" house. 1 chi found missed| 1 or more children found missed vaccination status 2 or more children found missed Children checked for mOPV2 Mop up implementation If RCA has failed, mop-up must be done * The RCA monitor informs the supervisor of the FAIL result immediately * The supervisor organizes a vaccination team to visit the area together with BHW and volunteers. * The BHW and volunteers mobilize the community visited and the vaccination team conducts a mop up in the area * If the mop up decision is made during day 2 ~ 5, the supervisors may also decide to continue the daily activity plan, and do mop up during planned day 8 - 14. These decisions are purely based on local situations. Scope of mop up (area to be covered) Defining the area to be mopped up is very critical to ensure that all missed children are covered. Supervisor must revisit the daily activity plan for that arca. All area that was covered by the assigned team on that particular day of work in daily activity plan should be mopped up. RCA fail results indicate an unacceptable number of missed children in that area (and not only in the selected 20 households). It is necessary that the whole area should be revisited by the team to do mop up. Mop up does not mean that only the identified missed children in the RCA of 20 households will be vaccinated.5. Reporting for RCA All reports of RCAS, Market surveys will be compiled in RCA format and shared with assigned focal person at regional and national level for analysis Once the mop up activity is completed, the supervisor will also update the mop up report in RCA report (see attached reporting format for RCA and mop up report) HL Surveillance of Adverse Events Following Immunization (AEEI) 1. All detected AEFls both minor and serious, shall be reported to the nearest health facility. The existing DOH guidelines on AEFI surveillance and response (Administrative Order No. 2016-2006) shall be observed for this purpose. 2. AEFI cases needing hospitalization shall be managed and referred to the appropriate health facility following A.O. 2016-0025: Guidelines on the Referral System for Adverse Events. 1. Community Surveillance for Acute Flaccid Paralysis (AFP) 1. House to house teams must utilize the opportunity for AFP active case search in the community. In case a suspected case is identified, they must immediately report to supervisor with complete details about name, address, and contact number of the child. 2. Simple AFP case definition: Any child below 15 years of age with sudden onset of paralysis or weakness 3. Help the parents/ caregivers with pointers to identify AFP cases: + Paralysis/ weakness: Inability/ difficulty to move a limb * Sudden onset: Rapid progression within few hours/ days + Recent: Onset within last 6 months Key questions for vaceinators to avoid missing children a. At the houschold door: “How many mothers are in this house?” b. Then ask each mother: “How many children do you have?” c. Then ask: “How many of your children are below 5 years of age?” 4. To make sure all children, especially young infants, are included, ask each mother: * Do you have an infant? * Do you have a new born baby? * Do you have any sick children? * Do you have any visiting children? * Are any children sleeping? * Any children away from the house at this time (school, market, visiting, playing outside)© If there are any eligible children who are not available for vaccination right now, then ask about their name, and set follow up visit time and date. Note details in the tally sheet (back side) of e. Do you know about any child below 15 years of age who had sudden ons: paralysis or muscle weakness due to any cause? For your guidance and striet compliance. ae, 0 'Y/ SUQUE I, MD, MSC i; fecretary Y Department of Health uelAnnex A Incident Management Organizational Structure HOC GHDIEEN) $5, DPC KICTS HAS MR sarin DS 3 AG B BH BQ ms 17) m6 aM BRB HY ims Dee BLESD NBS? Operations Logstss STAD earns) B ras erLwz0 ner sux H sao aS pL] 2 Luc ag 4 DRE LU moANNEX B: Technical Guidelines on mOPV2 Vaccine Management, Monitoring, Removal and Validation Characteristics of the mOPV2 vaccine © mOPV2is NOT a hazardous material and should never be referred to as such. + Itisa safe and effective vaccine which ‘must be used with the strictest vaccine management protocols * Special attention is needed to reduce risk of further circulation of vaccine virus + WHO-prequalified and licensed by the National Regulatory Authority (NRA) in the producing country. ‘+ Administered orally, 1 dose = 2 drops Presented in 20-dose vials with a vaccine Vial monitor (VVM type 2) on the label. + Canbe kept at -20 °Celsius or between +2and +8 °Celsius, if freezer is not available. ‘Managing deployment of mOPV2 in a country © When a VDPV2 event or outbreaks notified, WHO and UNICEF support the provision of mOPV since there are no mOPV2 stocks in countries © The National warehouse shall complete the Vaccine Arrival Report (VAR) within 24 hours of the arrival of the moPv © Store and transport mOPV separately from other vaccines in the cold chain. Deploy mOPV2 only to the outbreak-affected areas as per the immunization plan Supply mOPV2 to outbreak areas in separate, clearly identified cold chain containers prepared with frozen icepacks. © Atthe end of each Sif round, return all open (fully or partially used) and unopened vials to the Region > All open vials (fully or partially used) should be promptly inactivated and safely destroyed at the Region, All unopened vials should be safely stored until the next planned round separately in the Region. > Vaccine Utilization Report (Form B-1) should be submitted to UNICEF at the end of each roundHandling of mopv2 + Stringent monitoring of the storage, distribution, usage and destruction of mOPV2 Is critical for ensuring that the vaccine is not mixed up with or mistaken for another vaccine (or vaccines) and that no vials are left within the country once the SIA rounds are completed. '* The Outbreak Response Assessment team (OBRA) recommends mOPV? destruction, |* All mOPV2 vials should be kept together in the same cold chain equipment at all levels, le _ Label the vaccine clearly (mOPV2 for campaign use only) to be easily identifiable A Tracking System Must Be Put In Place To: 1. The National warehouse will manage deployment of mOPV2 to the outbreak-affected area; 2. Monitor utilization patterns and stack balances at each level and daily report on stock using Form B-2 3. Ensure that all empty and opened (fully or partially used) vials are returned from immunization sites to health facilities to the Municipality then to the Province/City then to the Region based on proximity for safe disposal. 4. Ensure that all opened vials are inactivated and safely destroyed following the recommended regulation for medical waste management 5. Monitor mOPV2 stock at regional pending recommendation from the Outbreak Response Assessment (OBRA) team on further strategic use and destruction 6. Validate the removal of all mOPV2 vials from the cold chain following completion of all Polio outbreak response rounds 7. Wait for the recommendation from OBRA to destroy rem ing unopened mOPV2 vials Following completion of all Polio outbreak Inactivation and safe disposal of mOPV2 ‘once recommended by the Outbreak Response Assessment (OBRA) team will take place at all levels of the country health infrastructure. The following factors are critical for proper handling of mOPV2 across the supply chain, from its arrival to its administration: © clear labelling and marking of vaccine containers at each level of the cold chain; ‘© separate storage/packaging of mOPV2 from other vaccines; ‘* clear reporting and tracking, at each level, of all doses and vials used, with unopened and partially used vials returned to the region after each SIA round and all unopened vials, returned to the national store after completing all SIA rounds.Good Practice: mOPV2 vials are labeled, boxed for separation or stored in different freezers Subnational (Region) vaccine stores At the regional level, the vaccines should be unpacked from insulated containers and the vaccine cartons placed preferably in a freezer room (if available) or in a dedicated refrigerator. The vaccine boxes must be clearly labelled, for example: ‘mOPU2 FOR POLIO OUTBREAK ONLY’, If separate dedicated cold chain equipment is available, a similar notice should be placed on the refrigerator door, and additional steps may be taken to make the MOPV2 stocks easily identifiable and thus minimize the risk of confusion. In all cases, the vaccine and the box that contains the vaccine vials must be clearly and visibly marked as ‘mOPV2 FOR POLIO OUTBREAK ONLY’. The quantity of mOPV2 and all other required information about the vaccine should be recorded in the vaccine stock book at regional and district levels, including the date when the vaccines were quantities dispatched and received and the location or source that the vaccines were dispatched in Form B-1 The region should retrieve all mOPV2 vials within 5 days of completion of each SIA round, and report to the national level within 7 days. At the end of all SIA rounds, the region should report the completed Form B-1 to the central level within 7 days.Health facility (vaccination site) Because the vaccine is taken out of the manufacturer's packaging, there is a greater risk of inadvertently administering mOPV2. The person responsible for administering the vaccine must prepare the vaccine carriers or any WHO recommended containers to keep all mOPV2 vials together in the refrigerator with a label clearly bearing the marking ‘mOPV2 FOR POLIO OUTBREAK ONLY’. The person preparing the vaccine cartier should record for each vaccinator the number of vials provided, the SIA round and the date. The vaccinators must return all unopened Vials as well as fully or partially used vials to the Supervisory at the end of each day using Form B-1 reporting form All empty vials should be retrieved and accounted for on daily basis The number of all opened vials (partially or fully used) and the remaining stock balance (unopened vials) should be reported to the Supervisory within 2 days following completion of each SIA rounds. Form B-1 should be used for each level of the cold chain infrastructure to report to the Province/City the number of vials used and in stock. Vaccine Accountability Monitors (VAM) to monitor vaccine used Vaccine accountability monitors (VAM) are the new members of the vaccination teams during mOPV2 campaigns. One VAM is recommended for every 2-5 vaccination teams working in the same Municipality, Below are the activities expected from VAM during mOPV2 campaigns: > The VAM should liaise with the store manager (or local campaign manager) to understand the daily vaccine distribution plan. > At the beginning of each day, the VAM records details of all vials given to each team {number of vials, batch number of each vial, team number, and the name and phone number of the team supervisor) in the vaccine accountability monitoring forms. Both VAM and store manager keep a copy of the vaccine accountability monitoring form. > During the day each VAM visits at least 2-3 of the assigned teams and fills in the supervisory check list. ‘At the end of the day, team supervisors return all used and unused vials to the VAM and store manager. The VAM together with the store manager checks and compares all vials returned with the recorded details. if details match, team supervisor signs off for the day and the VAM reconciles the data with the store manager. The summary is then returned to the district and presented during the evening review meeting The store manager and VAM must also reconcile children immunized with the number of doses/vials used before transmitting data to the district. If there are missing vials, vaccinator and the team supervisor search for the missing vials together,‘¢ After each SIA round, the remaining opened vials (partially or fully used) of mOPV2 must be taken out of the cold chain, inactivated and securely destroyed at the Region in accordance with the guidelines issued for vaccine destruction and disposal and reported Form B-2. * If the health facilities do not have the capacity to inactivate and safely destroy partially and fully used mOPV2 vials, the vials should be sent to the Region or province level Retrieval of vials from the field Retrieval of vials from the field cnt shoal eta Al emg ‘ROP iin pepe a. Empty vial retrieval tothe Province store should be wel documented store managers cuperirs sou ceunt ‘olecedempty set endo echcampai oy Its inpoantn document ior lege The reverse cold chain © The balance of unused vials with mOPV2 may be used for mop up activities in poorly covered areas, or for another SIA. itis therefore critical to maintain the highest quality. Storage and transport of mOPV2 through the reverse cold chain should meet the same standards applied to the distribution of tOPV or bOPV. * Because mOPV2 is not damaged by repeated freezing and thawing, storage in @ freezer will extend its life time. Upon return of the vaccine at central level, the store manager needs to check the vials: > WM status; > Are the labels still readable; > Any sign of damage that may have compromised the quality of the vaccine inside. Any vial not meeting the standards should be disposed of after correction of the stock records. ‘To estimate the storage space at this level, a volume of 0.48 cm* per dose will be used, For example, 10.000 vials will represent a volume of 96 000 crn3 or 100 litres (10 000 vials x 20 doses each x 0.48 m3 per dose = 96 000 cm3 or 96 liters).Disposal of mOPV2 between Polio Outbreak Response Rounds ‘a. The regional EPI Coordinator shall submit to the Regional Director cc: Director of the Disease Prevention and Control Bureau, the final inventory report of all partially or fully used mOPV2 collected from the province/city levels b. The Regional Director shall submit a report to the Resident Auditor at the regional DoH Office including the schedule for the final disposal of the mOPV2 ¢. The Regional Sanitary Engineer shall lead the disposal of all remaining mOPV2 vaccines to be witnessed by Representative from the DoH Regional Management Committee, COA, EPI Coordinator, Cold Chain Managers, Supply Officers and development partners d. The mOPV2 destruction and disposal shall follow the WHO recommended country appropriate method which is encapsulation, (sequestration and destruction): Encapsulation destroy mOPV2 without immediate inactivation (and without opening the vials) but makes it inaccessible and unusable. The steps of encapsulation are: © Place the vials in a clean chemical free plastic container or steel drum * Fill the bottom of the container with cement approximately one quarter of the capacity and drop the mOPV2 up to three-quarters of the container capacity. Fill the remaining space capacity with cement and seal * Place the sealed container/steel drum in the sanitary landfill and cover with other waste and soil @. The regional EPI Coordinator shall submit a Report on Disposal of mOPV to the DoH central office using Form B-2 * The OBRA has the responsibility to formulate clear recommendations as to what should happen with the balance of mOPV2 after the last planned round, ‘* Each successive OBRA refreshes the recommendations on basis of an assessment of the current situation. © This may include the recommendation, not to wait until close of outbreak for the destruction of the mOPV2 balance. "Instructions to report on utilization of mOPV2 vials at the end of each SIA round Vaccine: * mOPV2 isa vaccine used exclusively to respond to an outbreak of type 2 vaccine-derived poliovirus (VOPV2). This vaccine should not be available in the country before SiA. '* Type 2 poliovirus is an eradicated pathogen and so itis critical to have very precise counts of mOPV2 vaccine vials at each level of the health infrastructure. ‘+ Once all SIA rounds are completed, all unopened vials must be returned to the national vaccine store and no mOPV2 vial should remain at any level of the health infrastructure. Stock reporting: Form B-1 should be used to report on mOPV2 stock levels from all administrative areas conducting mOPV2 Outbreak Response.Vaccine quantities should be recorded as vials rather than doses. The vaccine cold chain responsible should fill he form to be reviewed by the immunization programme manager. The VAM responsible at the facility level should report to the Province/City within 2 days following completion of each SIA round. ‘The VAM responsible at the municipality level should retrieve all mOPV2 vials (opened and unopened) within 5 days following the completion of each SIA round and report to the upper level within 7 days. All unopened vials at the end of each round should be physically counted and their VM status checked B-1: mOPV Vaccine Distribution and Collection "We ion and Galion Foe a ey ver || ve |Destruction and disposal: © Atthe end of each round, all opened vials of mOPV2 (partially or fully used) should be inactivated by boiling, chemical inactivation (by soaking in bleach) or autoclaving (if there is a dedicated autoclave for hospital waste). ‘© Methods for destruction and final disposal include encapsulation, crushing and burying in compliance with national regulations for hospital waste disposal. To inactivate opened vials and safely destroy them, the vials can be packed in sealed plastic bags and sent to the Regional level where such facilities are available. Form B-2: mOPV2 Disposal Report Date of Disposal: /__j__ Site/Location of Disposal Method of Destruction Inactivation Destruction [[) autoctaving [[) Incineration [_] Bolling [| Encapsulation Chemical inactivation () Burying [Other (please exp [1 other (please explain) Number of mOPV2 vials disposed of _ Opened Vials Unopened Vials, Total Comments Disposal Team Name Title SignatureWaste ‘Treatment and Disposal The purpose of treating vaccination waste isto insetivate the vaccine virus to minimize/prevent its potential impact on health and the environment. The vaccine virus can be inactivated by autoclaving, boiling, chemical inactivation/disinfection, encapsulation or through thermal destruction i.e. incineration, kiln process or pyrolysis. + Autoclaving: Autoclaving uses high-temperature steam. It is the most environmentally friendly method. Unopened glass vials full of liquid should be loosened before autoclaving to avoid rupture unless the autoclave has an integrated shredder. However, glass vials that contain little liquid do not need to be opened. After autoclaving, vials will be sterile but must still be destroyed in accordance with national or local waste management guidelines for municipal waste. + Boiling: Boiling involves immersing vials in boiling water for approximately 30 minutes, which destroys pathogenic microorganisms. Glass vials can be safely boiled, and do not need to be opened before boiling. After boiling, the inactivated vials should be destroyed in accordance with national or local waste management guidelines. ‘+ Chemical inactivation: Chemical inactivation of mOPV2 involves opening and immersing mOPV2 vials in a 0.5% chlorine solution for atleast 30 minutes. The solution should be nine parts clear water to one-part household bleach. immersing 20 vials in 4 liters of solution will safely inactivate mOPV2. After this treatment, vials and lefiover chlorine solution must both be destroyed in accordance with the existing national or local waste management guidelines. ‘* Incineration (inactivation and destruction): Incineration should be carried out at a temperature of 21100 °C for the safe destruction of glass vials containing mOPV2 (for example, using rotary-kiln incinerators and industrial furnaces). ‘+ Encapsulation (sequestration and destruction): Encapsulation destroys mOPV2 without immediate inactivation (and without opening the vials) but makes it inaccessible and unusable. This method involves filling containers three-quarters full with mOPV2 vials, adding an immobilizing material (such as sand, cement or clay) and sealing and burying the containers, The encapsulated waste must be destroyed in accordance with national or local waste management guidelines. ‘Treatment of vaccination wastes can be done onsite at the PHO or can be treated to the DENR accredited Treatment, Storage and Disposal (TSD) facilities available within the area. ‘The level of inactivation and destruction of mOPV2 vaccines shall be in compliance with the Level IV treatment (Inactivation of vegetative bacteria, fungi, lipophilic/hydrophilic viruses, parasites and mycobacteria and B. Stearothermophilus spores at a 6logio reduction or greater) as stipulated in the DOH Health Care Waste Management Manual (2012) and DENR-DOH Joint Administrative Order No. 2- 5.2005. After treatment, the treated vaccination wastes can be transported for final disposal at the DENR approved waste disposal facility i.e. Sanitary Landfill and/or to the LGUs designated disposal of health care waste i.e, concrete vault or can be through burying in a cemetery.‘The flow of vaccination waste management is shown in Figure J (Waste Management Flow Diagram). WASTE GENERATOR SEGREGATION AND STORAGE COLLECTION AND/OR ONSITE ‘TREATMENT | COLLECTION AND OFFSITE k ‘TREATMENT FINAL | DISPOSAL. “eps ecg >) H sebbieee Note: MOBILE ONSITE OFFSITE DISPOSAL VACCINATION TREATMENT: TREATMENT: — METHOD: TEAM to deliver = Chemical * Sanitary Land all wastes Disinfection DENR accredited Fill generated toa * Boiling Treatment, * Concrete Vault designated Storage and * Burying in VACCINATION COLLECTION: Disposal (TSD) Cemetery FIXED "Daily collection facilities POST/BHS within by designated the day. collection vehicle PHO to submit report to CHD on the number of vaccination waste retrieved, treated and disposed(e6eg yuos3) 5P8110}9q ‘ON [2}0L ———_:pasnyay ‘ON [2301 +(Sou 6$-21) CAZINAWIAI ‘ON IV.LOL is eae +(Sour 11-0) GAZINOINIAI “ON TV.LOL TAdOW HLA GAZINOWINI NUCH AO Waa WAN (sou T1-0) ‘a60 s,pjy> ay) 40f ayouidosdde xog 4208 uy (/) sow yoay 0 ang ‘sueponaysuy snp aujsoe,A Jo s9quIN (IPA W) pos aurD0¥4 jo sDquMNy ——“S]etA ut) panroooy autDoe, Jo 12quINN, sz nau 303 (Sour 66-9) tonemndog 91qA11a Jo roGunN sowujsoey = sae, 2jomng ~~ :kvuexog, —— sonnsicyatedioruny iQyeoutaaig orto NAYCTIHS GALVNIDOWA 4O LA3HS ATIVL ATIVG :WHO4 DNIGHOD3Y ‘9 xouuyAnnex D REPORTING FORM DAILY SUMMARY REPORTING FORM Daily Consolidated Sheet for City/Municipal HCs or RHUs (To be reported to the Province/City) Region: Province: City/Municipality: Health Center/RHU: Date Total No. of mOPV2 Coverage Vaccine Utilization ParukBarangay | Elstle | umber of Children mmunized (in Vials) {059 mos) 12-59 | Grand o-ttmos| 159 | Grand | 9 | Received | Used | Unused TOTAL Submitted By: Noted: Reporting Date:ANNEX E. Supervisor’s Checklist for Vaccination Teams Region: Province'City: Date of Visit: City/ Municipality: Barangay: Name of Health Center: __Name of Monitors Target ‘Vaccinated: No. missed: Write Yes or No in each column. Key points for team supervision in field Is the team using proper vaccine carrier with frozen ice packs Are the vaccine vials kept inside a zip lock bag to prevent damage of label and VVM from moisture Does the team have adequate number of vaccine vials Are the vaccine vials in usable stage of VVM Does the team have all other required logistics: finger marker, tally sheets, daily activity plan Is the team administering vaccine correctl; Is the team following correct order of tasks: vaccinate, finger mark, tal Is the team doing correct finger marking Is the tally recorder filling tally sheet properly (including details about vaccine vials) Did the team members attend training before campaign Did the team start today’s work on time Does the team have proper workload (consider area geography, population density) General questions for all types of teams Vaccine management mOPV2: Have the teams properly recorded details about vaccine vials management on tally sheet Are the teams securing each empty, discarded, opened vial to return back to health facility at the end of the day’s work Is the team following daily activity plan for today’s assigned area of work Is the team asking proper questions at each household to ensure all children are reached House to house teams Is the team recording missed children details on the back of tally sheet for follow up visit Js the team also providing services of Routine Immunization ‘Are the mOPV?2 vials kept in a separate vaccine carrier which is properly labelled: mOPV? vaceine for outbreak use only Fixed Posts Is the post visible with banners Has the team selected appropriate location for the post: community accessibility Is the post visible with banners Were the community informed about team’s arrival schedule prior to the session Special sessionsAnnex F MOPV2 Rapid Coverage Assessment (RCA) FORM. REGION: PROVINCE/ CITY: DATE/TIME OF RCA: DISTRICT: MUNICIPALITY: ELIGIBLE POPULATION (0-59 MONTHS OLD}: HEALTH CENTER BARANGAY: ‘TOTAL NUMBER OF CHILDREN VACCINATED: PUROK: = Polio vaccination status Total # of eae SHn | Totals ofenaren | THN et iaren who Mranwaceinated, Het F23500 | mmunization (elt to the nna | children | \orocelved mopve (refer to thelist below) pa aged mopva *record only the codes - eas wean record only the codes o11 | 1259 | oat 1259 months | months | months | months z z = z z if a 2 3 4 5 6 7 2 a = 10 an 2 2B 4 5 16 v7. 8 19 20 Pass (0 oF 1 missed) 'REASONS FOR BONG UNVACOINATED (Selecta that apply forthe HH) Gade Reasons 1 Chi was beent/ away from hme Unaware of he campsien Vaccine post to faraway Vactine ported not have vaclng Fear ot vcrine Chis areadyvaccnates hid was set Do notknow/ declines to respond Relgous beets Respondent doesnot make that decion NAME OF RCA TEAM 1 2 SOURCE OF INFORMATION (ode Source fae al Msi (F, Twat, et) raneay offs estes neghooure others pees)