Training of Trainers Guide to

Transcription

1 Training the Trainers Guide Training of Trainers Guide to Immunization Training Workshops Timor-Leste,

2 Training the Trainers Guide Introduction Purpose of the TOT course The purpose of this Training of Trainers (TOT) Guide is to introduce potential facilitators to the training course for peripheral health care workers who administer vaccines in health facilities and in the community. Because the purpose of the training course is not to simply impart information, but rather to improve relevant skills and practices, the teaching techniques used in the training course may not be familiar to all trainers. The basic thinking is that adults tend to learn best by seeing, doing and talking about issues. In this way they will become better equipped to return to their work place with improved levels of skills and practices. The TOT workshop takes facilitators through the elements of training methodology in day 1. The subsequent days are taken up with conducting the actual training course with each other so they will be practiced in it by the time they have to conduct a course themselves. 2

3 Training the Trainers Guide Course Details - Daily Timetable Day am Introductions Welcome by hosts (MOH/UNICEF) Introductions Purpose and description of workshop (Dr Clements) Coffee Facilitating What does it mean to be a facilitator? Presentation (Dr Clements) Active listening. Presentation (Dr Clements) Practice by participants pm pm pm pm pm Training Components of a training programme. Presentation (Dr Clements) Transferring teaching. Presentation (Dr Clements) Plenary discussion of morning s topics (Dr Clements) Lunch Motivation. Passive to active learning. Presentation (Dr Clements) Teaching strategies. Presentation (Dr Clements) Small group discussion and report back Tea Methods of working Training manual and work book (Dr Clements) Immunization in Practice Course (Dr Clements) Method of working in TOT course (Dr Clements) Review of day 1 Preparation for Day 2 and field visits (Dr Clements) Day am Field visit Coffee pm pm pm pm pm Field visit summarizing Lunch Sessions 1, 2 and 3: Introductions Tea Session 4: The national immunization schedule. Review of day 2. Preparation for Day 3 3

4 Training the Trainers Guide Day am Session 5: Holding immunization sessions Coffee pm pm pm pm pm Session 6. How to load cold chain equipment Lunch Session 7: Cold chain equipment Tea Session 8: Cold chain monitoring equipment Review of day 3 Preparation for Day 4 and field visits Day am Field visit Coffee pm pm pm pm pm Field visit summarizing Lunch Session 9: Vaccine supply and calculation of stock. Tea Session 10: How to maintain cold chain equipment Review of Day 4 Preparation for Day 5 Day am Session 11: Correct handling of vaccines Coffee pm pm pm pm pm Session 12: Building community support Lunch Session 13: Monitoring basic tools Tea Session 14: Monitoring your performance Review of Day 5 Preparation for Day 6 4

5 Training the Trainers Guide Day am Field visit Coffee pm pm pm pm pm Field visit summarizing Lunch Session 16: Practice in using monitoring charts Tea Session 17: Monitoring summary reports Review of Day 6 Preparation for Day 7 Day am Session 17: Ensuring safe injections Coffee pm pm pm pm pm Session 18: adverse events and contraindications Lunch Session 19: Planning an immunization session Tea Session 20: Reaching every district Review of Day 7 Preparation for Day 8 Day am Session 21: Stock management Coffee pm pm pm pm pm Session 22: Micro-planning Lunch Session 23: Improve vaccine coverage Tea Session 24: Problem solving Review of Day 8 Preparation for Day 9 5

6 Training the Trainers Guide Day am Session 25: New vaccines Coffee pm pm pm pm pm Session 26: New vaccines Lunch Session 27: NIDs Tea Session 28: Integration Review of Day 9 Preparation for Day 10 Day am Session 29: Global issues and national priorities Coffee pm pm pm pm pm Review of field visit findings Lunch Session 30: Evaluation Tea Wrap-up and closing ceremony Presentation of certificates (MOH/UNICEF) 6

7 Training the Trainers Guide Notes for Course Organizer 1. Dates and location You will need to choose a five-day working week for the course. It will be held either in Dili or in a town chosen by the Region as suitable. Criteria for selection of the location include: Reliable electricity supply including a stand-by generator Adequate hotel accommodate in numbers and quality Ability to provide meals to participants Accessibility by all participants Venue for the course e.g. community hall, health centre, church building Avoid dates that will be difficult in the wet season 2. Selection of facilitators Assuming 25 participants, five facilitators is ideal, allowing for five small working groups supervised by one facilitator each. At least one facilitator should be selected from Dili and at least one from the Region. One facilitator should be designated to lead the course (principal facilitator). Invitations and letter of explanation should be sent out as early as possible. Facilitators should have prior experience in training and supervision. 3. Selection of participants The course is planned for around 25 participants. A class larger than 25 is difficult to handle from facilitation point of view. A class mush less than that makes it less economical and slows the process of national dissemination of learning. If the decision to train all staff is made, then it is relatively easy to select around 25 at a time. If not all staff are to be trained, selection should be made at regional level. Ultimately it is up to the Regional authorities to make the final selection. But guidance to the Region should come from the Course Organizer. Invitations and a letter of explanation should be sent out as early as possible. 4. Budget A budget should be submitted by the course organizer to the Ministry of Health well in advance of the course. All funding for the course will be provided by the Ministry, supported by external donors. Items in the budget should include line items for: Transportation of facilitators and participants to and from course Lunch (if the course agrees to provide them) Tea and coffee Per diem and hotel costs Rent of hall for the course Printing cost of training material Drinking water for classrooms Petrol for vehicle 7

8 Training the Trainers Guide (Salaries for staff and facilitators is assumed to be provided as part of normal employment) 5. Per Diem Standard government per diem should be paid. 6. Accommodation Selection of the accommodation should be based on value for money (you can usually negotiate a good price for 30 or more persons for 4-5 nights. The hotel should provide electricity (for reading) at night with a stand-by generator). As a minimum, breakfast should be included. 7. Meals/tea/coffee Drinking water should be provided constantly. A generous amount of time is allowed for tea and coffee breaks. These should be provided for everyone free. Such times are very useful for informal discussions and networking. It is recommended that lunch be provided in a nearby location and that it be served promptly. If the session ends at 12.15pm, lunch should be served for everyone by 12.30pm. Participants must be back promptly at 1.15pm. If a per diem is provided, participants may prefer to choose their own location for the evening meal. 8. Training materials and extras The following materials should be ordered well in advance and be ready by the first day of the course: Training manuals, one per participant and facilitator (around 30 per course) Participant work book, one per participant and facilitator (around 30 per course) Facilitator Guide, one per facilitator (around 5 per course) Computer Data projector and screen Overhead projector (OHP) Acetates and pens for OHP Electric extension leads for projector etc Flip charts at least 5, plus paper and pens Pens for participants in case they have none Extras for teaching sessions as required e.g. cold chain equipment, A-D syringes, vaccine vials Pointer or infra-red spot torch for p0inting on screen 8

9 Training the Trainers Guide 9. Other teaching aids Specific sessions need certain teaching aids and these are indicated at the start of each day. 10. Classroom set-up If only one room is available, a large hall is needed that seats 30 persons. Even better is a hall that seats 30 persons and has several classrooms adjacent that can be used for small group work. Seating should be an informal arrangement where everyone can see the presenter and the screen, but can move chairs into small working groups as needed. Small tables can be useful though not essential) allowing participants to write on them. Fixed seating arrangements should be avoided as they suggest formal teaching (as in school classes) and do not encourage the flow of discussion. For using a projector, it is useful if the light can be dimmed near the screen. Avoid any situation where all natural light is blocked out (as participants go to sleep!). Ventilation is essential, whether through open windows or by air-conditioning. No-one learns if they are too hot. Have water available at several locations throughout the classroom all the time. Hotel/hall staff should constantly refill jugs or replace water bottles. 11. Transport There should be an easy re-imbursement system for participants to get their money back for transport to and from the course and receipt of per diem. If transport from outlying districts is a problem in the wet season, make allowances for this. It is useful (not essential) to have at least one vehicle dedicated for use at the discretion of the principal facilitator to run errands etc. 12. Planning follow-up The course organizer will identify appropriate supervisors to follow up each participant over the next three months after completing the course. 13. Special guests for opening/closing You may choose to have a senior member of the Ministry of Health, UNICEF, WHO or another partner to open the proceedings or to present the certificates at the closing ceremony. Arrange this well in advance. You can also make it a time of raising the profile of immunization work in the community by inviting members of the press (local or national as appropriate) to the opening or closing ceremony. Explain to them what is happening on the course and offer to give them an interview. It would be wise to clear contact with the press with a senior official in the Ministry beforehand. 9

10 Training the Trainers Guide 14. Certificates Certificates will be available from the Ministry of Health, but you will need to order the correct number beforehand. 15. End-of-day debrief Because such workshops always have their own peculiarities of personalities, environment and personal skills, it is a valuable exercise for the facilitators to meet for 10 minutes after the last session of the day and de-brief. In this way the course can be finetuned ready for the next day. A longer de-brief should be carried out at the end of the last day. Layout of each session In the facilitators guide, each session is numbered (1-30) and in the heading box are details of who should be the lead facilitator for the session, how the session is broken up in time slots, the teaching objective, and the reference to the appropriate section of the Training Manual. The philosophy of repetition is applied in that within each session, the facilitator: Provides a brief overview of the subject for the session Tells the participants what they will have to do in the session Participants do the exercise The facilitator reminds them what they have just done and its significance. During the training of the trainers course, each participant will be assigned some of the above tasks in advance and will have to present them to the group. Field Visits for trainers Two health centres in the training location will be identified and participation sought from the heads of the facilities. Participants will be divided into 6 groups of 3-4 persons (total 23). They will each undertake three activities on successive field visits: Observing the process of immunization Talking with health staff Talking with parents They will report back to a facilitator on their findings during the second half of the morning. Generally, it is a good idea to appoint one person per group as a note-taker for the morning, but the entire group must take responsibility for the report. Their brief will be to learn about the reality of trying to immunize every child. It will include determining the problems associated with the process of immunizing, the problems reported by the staff concerning running the service, and the problems from the perspective of the parents in getting babies immunized. The participants will be asked to assemble ideas in three areas: 10

11 Training the Trainers Guide Problems generated by the technical difficulties of administering vaccines Problems in running an immunization service Problems generated by the difference in perspective of health staff and parents. Each problem identified should generate a set of solutions. The results will be tabulated on return to the course with the help of the facilitator as follows: Technical Problem Solutions Service-related Parent-related Notes for organizers: The participants will need to be divided up into six groups of 3 or 4 at the end of the first day. Collaboration with the head of each health facility will be needed well in advance. Enough transportation must be arranged to get everyone to the health facilities by the start of the working day. Transport will be needed only until midmorning when the participants return to the course. Three participants should be chosen to facilitate three debriefing sessions from 10.45am until lunch time. One facilitator will be allocated to each of the three subject areas and will report back to the plenary on Friday. So, for instance, one facilitator will debrief the two groups dealing with technical issues on each day and will synthesize the findings of all six groups on this subject. It is suggested they use flip charts to develop the grid (above) that identifies problems and solutions. They will then summarize the three days discussions ready for the report back in plenary on day

12 Facilitators Guide Day 1 Draft March 2007 Facilitators Guide to Immunization Training Workshops Timor-Leste,

13 Facilitators Guide Day 1 Introduction The purpose of this Facilitators Guide is to assist facilitators to conduct the training course for peripheral health care workers who administer vaccines in health facilities and in the community. It enables the facilitator to work along side the participants as they progress through the course. Because the purpose of the training course is not to simply impart information, but rather to improve relevant skills and practices, the teaching technique used in the training course may not be familiar to all trainers and participants. The basic thinking is that adults tend to learn best by seeing, doing and talking about issues. In this way they will become better equipped to return to their work place with improved levels of skills and practices. The workshop takes facilitators through the five-day course, session by session. Even if they are not fully involved in immunization but have a teaching background, facilitators will be able to function fully in the course with the support provided by the facilitators guide. All the paragraphs are cross-referenced to the participant work book and the EPI Training Manual. Each session is numbered and in the heading box are details of who should be the lead facilitator for the session, how the session is broken up in time slots, the teaching objective, and the reference to the appropriate section of the Training Manual. The philosophy of repetition is applied in that within each session, the facilitator: Tells the participants what they will have to do in the session They do the exercise The facilitator reminds them what they have just done and its significance. 2

14 Facilitators Guide Day 1 1. Dates and location Notes for Course Organizer You will need to choose a five-day working week for the course. It will be held either in Dili or in a town chosen by the Region as suitable. Criteria for selection of the location include: Reliable electricity supply including a stand-by generator Adequate hotel accommodate in numbers and quality Ability to provide meals to participants Accessibility by all participants Venue for the course e.g. community hall, health centre, church building Avoid dates that will be difficult in the wet season 2. Selection of facilitators Assuming 25 participants, five facilitators is ideal, allowing for five small working groups supervised by one facilitator each. At least one facilitator should be selected from Dili and at least one from the Region. One facilitator should be designated to lead the course (principal facilitator). Invitations and letter of explanation should be sent out as early as possible. Facilitators should have prior experience in training and supervision. 3. Selection of participants The course is planned for around 25 participants. A class larger than 25 is difficult to handle from facilitation point of view. A class mush smaller than that makes it less economical and slows the process of national dissemination of learning. Choosing the 25 is not easy. In principle, at least one staff member from each health facility in the region is ideal. Ultimately it is up to the Regional authorities to make the final selection. But guidance to the Region should come from the Course Organizer. Invitations and a letter of explanation should be sent out as early as possible. 4. Budget A budget should be submitted by the course director to the Ministry of Health well in advance of the course. All funding for the course will be provided by the Ministry, supported by external donors. Items in the budget should include: Transportation of facilitators and participants to and from course Lunches (if the course agrees to provide them) Tea and coffee Per diem and hotel costs Rent of hall for the course Printing cost of training material Drinking water for classrooms Petrol for vehicle 3

15 Facilitators Guide Day 1 (Salaries for staff and facilitators is assumed to be provided as part of normal employment) 5. Per Diem Standard government per diem should be paid. 6. Accommodation Selection of the accommodation should be based on value for money (you can usually negotiate a good price for 30 or more persons for 4-5 nights. The hotel should provide electricity (for reading) at night with a stand-by generator). As a minimum, breakfast should be included. 7. Meals/tea/coffee Drinking water should be provided constantly. A generous amount of time is allowed for tea and coffee breaks. These should be provided for everyone free. Such times are very useful for informal discussions and networking. It is recommended that lunch be provided in a nearby location and that it be served promptly. If the session ends at 12.15pm, lunch should be served for everyone by 12.30pm. Participants must be back promptly at 1.15pm. If a per diem is provided, participants may prefer to choose their own location for the evening meal. 8. Training materials and extras The following materials should be ordered well in advance and be ready by the first day of the course: Training manuals, one per participant and facilitator (around 30 per course) Participant work book, one per participant and facilitator (around 30 per course) Facilitator Guide, one per facilitator (around 5 per course) Computer Data projector and screen Overhead projector (OHP) Acetates and pens for OHP Electric extension leads for projector etc Flip charts at least 5, plus paper and pens Regular pens for participants in case they have none Pens for drawing graphs of various colours Rulers Sheets of large graph paper Sticky tape to fix graphs to walls Pointer or infra-red spot torch for pointing on screen 9. Other teaching aids 4

16 Facilitators Guide Day 1 Specific sessions need certain teaching aids and these are indicated at the start of each day session. 10. Classroom set-up If only one room is available, a large hall is needed that seats 30 persons. Even better is a hall that seats 30 persons and has several classrooms adjacent that can be used for small group work. Seating should be an informal arrangement where everyone can see the presenter and the screen, but can move chairs into small working groups as needed. Small tables can be useful though not essential) allowing participants to write on them. Fixed seating arrangements should be avoided as they suggest formal teaching (as in school classes) and do not encourage the flow of discussion. For using a projector, it is useful if the light can be dimmed near the screen. Avoid any situation where all natural light is blocked out (as participants go to sleep!). Ventilation is essential, whether through open windows or by air-conditioning. No-one learns if they are too hot. Have water available at several locations throughout the classroom all the time. Hotel/hall staff should constantly refill jugs or replace water bottles. 11. Transport There should be an easy re-imbursement system for participants to get their money back for transport to and from the course and receipt of per diem. If transport from outlying districts is a problem in the wet season, make allowances for this. It is useful (not essential) to have at least one vehicle dedicated for use at the discretion of the course director to run errands etc. 12. Planning follow-up The course director will identify appropriate supervisors to follow up each participant over the next three months after completing the course. 13. Special guests for opening/closing You may choose to have a senior member of the Ministry of Health, UNICEF, WHO or another partner to open the proceedings or to present the certificates at the closing ceremony. Arrange this well in advance. You can also make it a time of raising the profile of immunization work in the community by inviting members of the press (local or national as appropriate) to the opening or closing ceremony. Explain to them what is happening on the course and offer to give them an interview. It would be wise to clear contact with the press with a senior official in the Ministry beforehand. 5

17 Facilitators Guide Day Certificates Certificates will be available from the Ministry of Health, but you will need to order the correct number beforehand. 15. End-of-day debrief Because such workshops always have their own mixture of personalities, environment and personal skills, it is a valuable exercise for the facilitators to meet for 10 minutes after the last session of the day and de-brief. In this way, the course can be fine-tuned ready for the next day. A longer de-brief should be carried out at the end of the last day. 6

18 Facilitators Guide Day 1 Materials for the day Day 1 Training Flip charts and pens Registration material Pre-test sheets A copy of the timetable for everyone Cold chain equipment for the afternoon: one upright refrigerator, one chest refrigerator, a vaccine carrier, various boxes of vaccines, diluents, ice packs and vitamin A. Try and get a selection of all vaccines used. The boxes do not need to contain vaccines, but must be marked clearly with the name of the vaccine and the expiry date. There should be two sets of boxes, one for the upright refrigerator session and one for the chest freezer. For the vaccine carrier, there should be ice packs and vaccine vials. Staff allocation Allocate an administrator to be available for session 1. The course director (senior facilitator) will take all the morning sessions. Session am Registration Participants will be asked to sign various forms relating to administration and receiving of per diem allowance. If they have problems with accommodation, travel etc, now is the time to talk to the staff. Session am Welcome. Who: Course director He/she will welcome participants officially. They will be introduced to facilitators and each other. A general description of the course and its purpose will be provided. If there is a course photograph, now would be a good time to take it. Natural break for coffee. Session am Pre-Test Who: Course director Participants will be asked to complete a questionnaire concerning their general knowledge about immunization. You should explain what is required, and that it is not a test in the normal sense. It is for the benefit of the course designers to know whether the information on the course is useful. Be sure they name their paper so it can be compared with later tests. 7

19 Facilitators Guide Day 1 Collect the completed forms and delegate another facilitator to check each form has been completed properly. Ensure the completed forms get back to Dili. Introduction Who: Course director Teaching objective: To familiarize participants with the methods of working during the 5 day course. Points to make are: Method of working doing not listening. 30 sessions in all, 6 per day. Homework at night. Distribute the timetable. Each session will consists of Brief introduction 5 minutes Brief explanation of activity 5 minutes Activity (various) 45 minutes Summing up of lesson 5 minutes Materials: Training manual Work book Hand-outs Allocation of individuals into small groups Explanation of small group work Explanation of flip chart for unanswered questions Explanation of daily summary by the facilitator of the day Go over the 5 days briefly. Questions and clarification 8

20 Facilitators Guide Day 1 Session pm Issues relating to the immunization schedule Who: Course director with four other facilitators for small group work Overview: Powerpoint 4. 5 minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: To familiarize participants with the immunization schedule so that they can rapidly and accurately assess what vaccines need to be given to any given infant. Reference: Modules 1 and 2. Participants will familiarize themselves with the themes of Manual module 1 and 2. There is not time to read every word but they should be encouraged to read it all through thoroughly tonight on their own. They should answer the questions E1-E3 below: E1. List all the vaccines used in your health facility and name the disease that each protects against. Say whether you have seen a case of each of the diseases, and if yes, describe the signs and symptoms of a case you remember. Vaccine BCG DTP DTP DTP OPV Measles HepB Disease(s) protected against Tuberculosis Diphtheria Tetanus (neonatal and maternal) Pertussis (whooping cough) Poliomyelitis Measles Hepatitis B Have you seen a case of this disease? If so, describe it briefly E2. List the vaccines/doses used in the Timor-Leste immunization schedule in the order in which they are given, indicating the age the child should be when given the vaccine. Also list the vaccines given to adult women and when they should be given. 9

21 Facilitators Guide Day 1 Antigen At Birth 6 Weeks 10 Weeks 14 Weeks 9 Months BCG Polio DTP Hep B Measles x x x x x x x x x x x x Discuss the rules below with participants as the opportunity arises: OPV0 should be given only within 2 weeks of birth. OPV1, DPT1, HepB1 should be given at 6 weeks of age or as soon as possible after 6 weeks of age. The interval between doses of DPT, HepB and OPV should be at least 4 weeks. In cases where the subsequent doses of DPT, HepB and OPV are delayed; there is no need to repeat the (previous) dose. All EPI antigens are safe, even if administered simultaneously at the same day, but should be in different injection sites. BCG should be given as soon after birth as possible, but may be given till 12 months of age. Measles vaccine should be given at 9 months or as soon as possible after 9 months of age. All child immunizations should be recorded in the register and reported in two age groups (under 1 year of age and above 1 year of age). If a child fails to come back for his/her subsequent doses of DPT, HepB or OPV or does not take measles immunization as scheduled, it is the responsibility of the health staff to follow up and complete the full course of primary immunization before one year of age or as soon as possible thereafter before the child reaches two years of age. E3. There are three different injection routes and sites for injecting vaccine into infants. Name them and the vaccines that use each route. Injection site/route Intradermal into Left upper arm Intramuscular into outer mid thigh Subcutaneous upper Left arm Vaccines using this site BCG DTP, HepB, Hib Measles (measles can also be given i.m.) CHECK>>>> JE. Intramuscular injections of e.g. tetanus toxoid in adults is given into the outer thigh. Wrap-up: 5 minutes 10

22 Facilitators Guide Day 1 Session pm Holding immunization sessions Who: Facilitator 2 Overview: Powerpoint 5. 5 minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: To familiarize participants with practical details of running an immunization session. Reference: This session is based on Training Manual module 6. E1. What is a vaccine vial monitor? It is a label that changes colour when the vaccine vial has been exposed to heat over a period of time. Every vial with a VVM on it should be checked before every time it is used to be sure the vaccine has not exceeded its safe exposure to heat. This would damage the vaccine potency. The vaccine vial you are about to use has a vaccine vial monitor sticker on it that looks like this: Should you use the vaccine, or not? Explain your answer. The inner circle is lighter than the outer circle. The vaccine can be used. Explain the VVM does not demonstrate whether or not a vaccine vial has been frozen. E2. List five important points about vaccine diluents. See Module 6 section Diluent are not interchangeable, different vaccines have different diluents; mixing and administering the wrong diluent has led to serious adverse events including death. 2. Always use diluent from the same manufacturer as the vaccine. 3. Diluents should be cooled before being mixed with the vaccine 4. Do not reconstitute vaccines until you are ready to immunize. 5. You must discard reconstituted vaccine after six hours or at the end of the immunization session, whichever comes first. 11

23 Facilitators Guide Day 1 E3. A mother comes to you in the health centre saying her baby is six months old and needs vaccinating. You look at the card and see the baby has only had DTP-1 and DTP-2 so far. What vaccines do you administer today? What instructions do you give her for the next visit? Explain your answer to the facilitator. If there has been at least 28 days since DTP-2, give DTP-3. If less than 28 days, tell the mother DTP-3 must be given at the next visit. As well the baby needs missing doses: BCG, OPV-1, (HepB if it has been introduced by then). Most important, the mother must be told when to come back i.e. in one month. As she has already failed to keep to the baby s schedule, she should be followed up enthusiastically. Do not give more than one injection per limb. E4. An 11 month old baby is seen at the clinic. Should you give him a vitamin A supplement today? If yes, what dose? If no, when should he have the next dose and at what dose? If the baby had a 6 month dose, he is NOT due one today. If the baby did not have a dose previously, he should have a dose today. If he gets a dose today, he only gets half a capsule 100,000 International Units (IU). He must not get the full dose of 200,000 IU until he is 12 months old or older. If he gets a dose today, a repeat dose should not be before 4 weeks from now unless it is part of an emergency treatment regime for a case of measles. Invite the participants to read Module 6 section 2.2 and 3.11 for more information. E5. A mother is 8 months pregnant in her first pregnancy. What vaccine should she be given? She should have had 2 doses of TT by the time she delivers her first baby. Check the antenatal card and see if she has had two doses already. If she has had two already she does not need any more today. The baby and she are fully protected. If she has had one already, she should have another today, so long as it is at least 28 days since the previous one. If she has only just had one dose a few days ago, it is too late to give the second. Encourage the participant to read Module 2 section 5. E 6. Name as many tasks as you can think of that need to be done at the end of a vaccination session. Complete an immunization tally sheet Take care of vaccines, return them to refrigerator, label opened vials for re-use. Take care of the vitamin A capsules Dispose of used injection equipment Pack vaccine carrier Leave outreach site tidy 12

24 Facilitators Guide Day 1 Clean surfaces in health facility and empty rubbish Clean all equipment e.g. vaccine carrier Encourage participants to read Module 6 section 6. Wrap-up: 5 minutes 13

25 Facilitators Guide Day 1 Session pm How to load cold chain equipment Who: Facilitator 2 in charge plus Facilitators 3, 4 and 5 to lead small groups. Overview: Powerpoint 6. 5 minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: To practice loading cold chain equipment correctly. Reference: This session is based on Training Manual Module 3, section 4. Divided the participants into 3 small groups. Allocate one facilitator to each group. Group 1: upright refrigerator. Group 2: Chest refrigerator. Group 3: Vaccine carrier. Ask for a volunteer. Instruct the volunteer to load up the refrigerator or vaccine carrier with the items provided. The others in the group must remain silent. But the one loading the items must explain his choice and position for each item. When he has finished, the group is asked to comment on how well he has done. Do not reveal whether he was correct. Ask a second volunteer to do the same. Ask for comments. This time say whether they were correct or not. E1. After the exercise, write down the main rules that guide you on how to load the equipment: First in, first out Freeze-sensitive vaccines away from ice Ice packs at the bottom of the refrigerator BCG - top OPV - top DTP - middle Hepatitis B - middle Measles - top Tetanus toxoid - middle Diluents - next to the vaccines they are supplied with Other e.g. those in Module 3, paragraph 4.1. Wrap-up: 5 minutes. Ask for the main rules people have written down. Summing up the day: As long as it takes. Course director sums up main points of the day. Asks for points that may need clarification. 14

26 Facilitators Guide Day 2 Day 2 Training Materials for the day: Doll for role play Flip charts and pens Registration material Pre-test sheets Cold chain equipment for the first session: thermometers etc Materials for the Shake Test. The vials of DTP that are frozen must be really well frozen to make a good demonstration. It is advisable to freeze them for several days before the demonstration. Staff allocation: Facilitator 2 for morning, Facilitator 3 for afternoon. 1

27 Facilitators Guide Day 2 Session am Cold Chain Equipment Who: Facilitator 2 Overview: Powerpoint 7. 5 minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: To familiarize participants with all cold chain equipment in use in Timor-Leste. Reference: Training Manual Module 3, section 1. E1. What cold chain equipment is used to keep vaccines cold in the cold chain in Timor-Leste? Explain the function and purpose of each. a) In the central vaccine store in Dili. Cold room (2-8 0 C) and freezer room (-15 to C) b) In the District Health Centre. Cold room (2-8 0 C) and cold boxes c) In the Community Health Centre. Refrigerator (2-8 0 C) and cold boxes d) In the Health Post. Some have refrigerator (2-8 0 C) and/or cold boxes/vaccine carriers E2. Where should each of the following vaccines be stored on the top shelf or the middle shelf? Give reasons for your answers: First in, first out Freeze-sensitive vaccines away from ice Ice packs at the bottom of the refrigerator BCG - top OPV - top DTP - middle Hepatitis B - middle Measles - top Tetanus toxoid - middle Diluents - next to the vaccines they are supplied with Other e.g. those in Module 3, paragraph 4.1. What else determines where vaccine boxes are stored in the refrigerator? Their expiry date and whether they have already been opened and stored under the open vial policy. Wrap-up: 5 minutes 2

28 Facilitators Guide Day 2 Session am Cold Chain monitoring equipment Who: Facilitator 2 Overview: Powerpoint 8. 5 minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: To practice techniques that monitor the proper functioning of cold chain equipment. Reference: Training Module 3. E1. In the picture below of a refrigerator temperature chart, the shaded area shows the safe temperature range. What temperature is shown at the top of the safe temperature range? What temperature is shown at the bottom? Plus 8 degrees C and plus 2 degrees C (the chart looks like it is zero but it should be plus 2 degrees.) A refrigerator temperature chart What do you notice about the temperature on the - morning of day 3? It is within acceptable range. - evening of day 5? It is within acceptable range. - morning of day 8? It dropped overnight to below freezing, placing the liquid vaccines at risk of loosing potency from cold damage. - evening of day 12? It rose to plus 16 degrees, way higher than is acceptable for very long. It would be fine for a short time while vaccines are on the way to an outreach clinic, but for a refrigerator to show this temperature suggests either a fault in the machine or a failure of power 3

29 Facilitators Guide Day 2 the day previously when the temperature started to rise. Urgent action is needed to prevent heat damage. Participants should remark on checking the VVM on every vial in the refrigerator. E2. What temperatures are shown in the thermometers below? Do they show a safe temperature for storing vaccines? Plus 5 degrees C. It is safe for all vaccines in the national schedule. Wrap-up: 5 minutes 4

30 Facilitators Guide Day 2 Session am Vaccine supply and calculation of stock Who: Facilitator 2 Overview: Powerpoint 9. 5 minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: Practice calculating stock needs. Reference: Training Manual Module 5, section 3. E1. Tomorrow you will run an immunization session at your health facility (a fixed site ). Last week you saw 25 infants who needed vaccine and 3 mothers who needed tetanus toxoid. You expect about the same number tomorrow. Use Table 5.5 as your model and draw a chart that will help you calculate how many vials of vaccine, syringes and other equipment you will need to prepare. Assume it requires 7 injections to fully immunize one mother and one child. The numbers below are rounded up (for instance the first box is 25/7=3.57, that is 4 when rounded up) BCG (20 dose vials) OPV (10 dose vials) DTP- HepB (10 dose vials) Measles (10 dose vials) TT women (10 dose vials) AD BCG AD regular Mixing syringes 5ml: 1 BCG, 1 measles Safety box Number of doses Session needs 1 vial + 1 diluent 2 vials 2 vials 1 vial + diluent 1 vial E2. The following day you will have to run a mobile immunization session that visits a distant village ( outreach session ). Last week you saw 11 infants who needed vaccine and 2 mothers who needed tetanus toxoid. You expect about the same number tomorrow. Use Table 5.6 as your model and draw a chart that will help you calculate how many vials of vaccine, syringes and other equipment you will need to prepare. BCG (20 dose vials) OPV (10 dose vials) DTP- HepB (10 dose vials) Measles (10 dose vials) TT women (10 dose vials) AD BCG AD regular Mixing syringes 5ml: 1 BCG, 1 measles Safety box 5

31 Facilitators Guide Day 2 Number of doses Session needs 1 vial + 1 diluent 2 vials 2 vials 2 vial s+ 2 diluent 2 vials Note that the number of vials needed in this small outreach session have been increased by approximately two-fold to allow for situations where you cannot go to the refrigerator and get more supplies. There is no right answer; it is a matter of judgement. E3. Calculate how much hepatitis B vaccine you will require in the first month after hepatitis B vaccine is introduced at a health facility in the following circumstance: The target number of children under 1 year to vaccinate is 200. Assume you will use DTP-HepB (tetravalent) vaccine in 10-dose vials. Your DTP-3 coverage last year was 75%. You need 25% buffer stock. Your wastage for DTP was previously 20% Step 1. Number of infants x number of doses 200x 3 = 600 doses Step 2. Add the quantity required as your buffer stock. Usually this is estimated to be 25% of your total requirement and it is done only once with your first order. Therefore, the total vaccine requirement is (600 x 0.25) = ( ) = 750 doses. Step 3. Consider your wastage rate. Suppose your wastage is known to be 20% for your DTP. To estimate the quantity of vaccine needed to adjust for the wastage, first calculate the wastage factor by 100/100-20= 1.25 Next, the total vaccine calculated in step 3 should be multiplied by the wastage factor, i.e. 750 x 1.25 = 938 doses. This is the total number of doses of the DTP-HepB vaccine that is needed for the year. The number of vials needed is calculated by dividing the total doses by the vial size, 10 in this case. Therefore, the number of vials needed is 938/10 = 94 vials Step 4. Take into account your projected coverage rate. For example, if you judge that the best that you can do is attain only 75% coverage, then you need only 75% of the total doses estimated above, i.e. 94 x 0.75 = 71 ten-dose vials of vaccines for the year. 6

32 Facilitators Guide Day 2 Remember you do not need to include buffer stock in the order after the first month. Divide by 12 if you order by the month. Wrap-up: 5 minutes 7

33 Facilitators Guide Day 2 Session pm How to maintain cold chain equipment Who: Facilitator 2 Overview: Powerpoint minutes Description of Activity: 5 minutes Activity: 30 minutes. Report back: 15 minutes Teaching objective: To improve practical techniques which maintain cold chain equipment. Reference: Training Manual Module 3, section 7 Small group work Divide into small groups with a facilitator assigned to each. Work through Module 3 Section 7 of the manual with the group. Encourage the participants to describe any problems they have encountered in maintaining the cold chain equipment in their own health facility. From their experience, do they have advice to others in the group about maintaining cold chain equipment? Report back by each group rapporteur 15 minutes Wrap-up: 5 minutes 8

34 Facilitators Guide Day 2 Session pm Correct handling of vaccines Who: Facilitator 3 Overview: Powerpoint minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: Reference: Training Manual Module 3. Allow 15 minutes to answer E1-E3 E1. Which vaccines can be frozen? OPV, BCG, measles vaccines Which vaccines must not be frozen? Liquid vaccines DTP, HepB What effect does freezing have on liquid vaccines? It destroys the binding between the adjuvant and the antigen. Simply, it reduces potency. E2. Describe how you freeze ice packs. (Module 3, section 5.) Fill with water leaving a little air space at the top, and put the cap on tightly. Hold each ice-pack upside down and squeeze it to make sure it does not leak. Put the ice-packs upright or on their sides in the freezer so that the surface of each ice- pack is touching the evaporator plate, and close the door. Gas refrigerators or ice-lined refrigerators with a freezing compartment can freeze up to six large or 12 small ice packs per day. More packs will take longer to freeze. Leave ice-packs in the freezer for at least 24 hours to freeze solid. After the session put the ice-packs back in the freezer. E3. Explain how you load a vaccine carrier to ensure vaccines reach the outreach session at the correct temperature. Explain also what you do to keep vaccines at the correct temperature once the outreach session has started. Module 3, section 2 and 4.2. Be sure the participant describes the vaccine carrier itself, the ice packs and the foam pad. Stress the importance of conditioning the ice packs first. 9

35 Facilitators Guide Day 2 E4. Small group discussion. Case study: Maria is a vaccinator who conducts mobile clinics on Tuesday and Thursday each week. On Tuesday she returns from the clinic late. She leaves her vaccine carrier and other equipment at the community health centre and rushes home. On Wednesday she prepares all the equipment for the next day s mobile clinic and places the melted ice packs in the freezer. On Thursday Maria packs all the equipment and leaves for the mobile clinic early in the morning. It is already hot. When she arrives at the site, people are waiting for her. She opens the vaccine carrier and finds that the ice packs have melted. The thermometer in the carrier reads +16 degrees C. It is a very hot day at the clinic. 1. What should she do now? 2. What should she do in future to avoid this problem? Allow approximately 10 minutes for small group discussion and 5 minutes for reporting back. What should she do now? The vaccines have only been exposed to temperatures slightly above recommended storage temperate range (+2 to +8 degrees C) for a short time. They were in the refrigerator before being packed in the vaccine carrier). So BCG and measles vaccines that have not yet been reconstituted (and are very heat-stable) and DTP-HepB can last very well for hours at room temperature. Maria should first check each vial to make sure the VVM shows the vaccine is safe to use. If the VVMs all show safe colours, she should then go ahead and give all the vaccines at the clinic. But because the ice packs have melted, the temperature on the foam pad is probably not as cold as it should be. She should keep the reconstituted vaccine as cold as possible by exposing it to outside temperatures as little as possible. Best of all, she should try and give BCG and measles vaccines as soon as possible after reconstitution. She should discard after 6 hours anyway. What should she do in future to avoid this problem? She should make sure ice packs are in the refrigerator for at least 24 hours before use. 10

36 Facilitators Guide Day 2 E5. Shake Test Demonstration (module 3 chapter 8). Allow 10 minutes for this. Be sure to practice it before the demonstration. Wrap-up: 5 minutes 11

37 Facilitators Guide Day 2 Session pm Building community support Who: Facilitator 2 Overview: Powerpoint minutes Description of Activity: 5 minutes Activity: 45 minutes. Teaching objective: To improve ways of building contacts between health staff and the community they serve. To help health staff see immunization from the community s perspective. Reference: Training Manual Module 5 section 5 and Module 6, section 5. Instruct participants to do the exercises E1-E4 individually and discuss their answers with their facilitator. Allow 30 minutes. Then do E5 as the whole class. Allow as long as it takes. E1. What are five essential messages to give to parents about immunization? 1. Vaccines save lives by protecting against disease. Describe target diseases and the vaccines 2. Vaccines are safe. Describe possible side-effects 3. Needs more than one visit. Explain the schedule and concept of multiple doses 4. Date of next visit 5. Bring immunization card 6. Other.. E2. What decisions can local community leaders help you decide about immunization sessions? when to hold immunization sessions; where to hold outreach sessions; who can help you mobilize the community; and who can help you during sessions. E3. How can local volunteers be involved in immunization activities? remind mothers when to bring their children for vaccines; alert mothers that the vaccination session will take place on the following day; spread the word in the village that the outreach team has arrived; encourage women to obtain their tetanus toxoid injections; organize sessions beyond the health facility, and 12

38 Facilitators Guide Day 2 help set up an immunization session, administer oral polio vaccine (OPV) and vitamin A supplements after being trained to do these tasks. E4. What have you done to try and involve the local community in immunization activities? Mention any problems you have had a possible solutions. Discuss the responses of the participants with them. E5. Role play Role play 1. As facilitator, you ask for two volunteers to role-play. Volunteer A is a vaccinator, volunteer B is a community leader. Instruct the volunteers in the part they should play. The vaccinator comes to tell the community leader about impending vaccination sessions coming to his village and tries to tell him how good it will be for them. However the community leader is skeptical on all levels and needs a lot of convincing. Discuss the points raised. Role play 2. Ask for two more volunteers. One plays a vaccinator. The other plays a reluctant mother with a baby in her arms (find a baby substitute for her to hold), The scene is at a vaccination session and the vaccinator is about to give an injection but wants to tell the reluctant mother what she is giving and why. She gives the second dose of DTP to the baby and tells the mother about the vaccine and what to do next. The mother is not too happy about her baby being injected, and certainly not pleased he is now crying loudly. Discuss the points raised. Wrap-up: 5 minutes Summing up the day: Course director sums up main points of the day. Asks for points that may need clarification. Read Module 7 tonight. 13