JOURNAL OF PUBLIC HEALTH IN AFRICA

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Please cite this article as:

Qanbar MA, Jasim AK, Mahmood AA. Assessment of immunization session practices in primary
health care centers in Al-Najaf province. J Public Health Afr doi:10.4081/jphia.2023.2754

Submitted: 19-06-2023
Accepted: 09-07-2023

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Assessment of immunization session practices in primary health care centers in Al-Najaf
province

Mustafa Ali Qanbar,1 Alaa Kadhim Jasim,2 Abdulkareem Abdullah Mahmood3

1
Department of Community Health Techniques, College of Health and Medical Technology, Basrah,
Southern Technical University; 2Department of Medical Laboratory Technologies, College of Health
and Medical Technology, Basrah, Southern Technical University; 3Department of Community and
Family Medicine, College of Medicine, University of Kufa, Iraq

Correspondence: Mustafa Ali Qanbar, Department of Community Health Techniques, College of

Health and Medical Technology, Basrah, Southern Technical University, Iraq.
Tel.: +9647830879436.
E-mail: mustafaalghanemi@gmail.com

Key words: primary health care, immunization, session, practices.

Conflict of interest: the authors declare no potential conflict of interest.

Funding: none.

Availability of data and materials: data and materials are available from the corresponding author
upon request.

Acknowledgments: the authors want to thank all the participants in the study and the staff in Al-
Najaf governorate primary healthcare centers who fully cooperated during the study.
Abstract
Background. Immunization has played a vital role in improving global health by reducing the
transmission of infectious diseases. To ensure the successful implementation of immunization
programs, it is crucial to thoroughly examine various elements within the Primary Health Care
Centers, including immunization session management, cold-chain and logistics management,
supervision, and reporting.
Objective. The study aims to assess the immunization session practices in selected primary healthcare
centers in Al-Najaf governorate
Methods. A descriptive cross-sectional study was conducted at 26 primary healthcare centers,
selected using simple random sampling, across six districts in Najaf governorate. A total of 143
healthcare workers, comprising 122 vaccinators and 21 doctors, were included in the study.
questionnaires were utilized to assess immunization session practices. Data collection commenced on
December 2, 2022, and concluded on March 2, 2023.
Results. Immunization session practices were evaluated as having poor vaccine and diluent
management, fair cold chain management, communication with clients and caregivers, vaccine
preparation and administration practices, and waste management practices. However, immunization
session equipment availability, as well as card review and registration during immunization, received
good evaluations. The overall assessment of immunization session practices was determined to be
fair. In addition, the study identified significant associations between immunization practices and the
number of non-vaccinators working in the immunization unit (P=0.035), and the average number of
daily vaccine recipients in primary healthcare centers (P=0.046).
Conclusion. The immunization session practices achieved a fair level of assessment, The increased
number of daily visitors to the immunization unit and the number of health workers who are non-
vaccinator in the unit affected negatively the immunization session practices.

Introduction
Immunization is a method for eradicating and controlling infectious diseases that threaten life,
affecting an estimated two to three million children deaths avoided each year. Routine vaccination is
cost-effective and the most important public health measure for children.1
The World Health Organization (WHO) has identified immunization as an essential health service
that protects the health and well-being of populations, making it critical for the successful functioning
of countries and economies. Immunization activities should be prioritized and protected to enable
optimum continuity in the event of a substantial disruption in service supply or consumption.2,3
Vaccinations have significantly enhanced world health by limiting the transmission of infectious
diseases. Worldwide health organizations such as the World Health Organization (WHO), place a high
value on developing and implementing effective immunization programs.4,5
The "Expanded Program of Immunization" (EPI) started in 1974 to gradually limit the transmission
of infectious diseases, resulting in decreased child mortality and morbidity rates.6
The goal of carrying out the "Expanded Immunization Program" is to avoid infection with illnesses
that can be prevented with vaccinations. Smallpox has been eradicated via the use of vaccinations,
and the world is now on the verge of eradicating a second disease, viral polio.7
The Primary Health Care Center (PHCC) is an important location for executing routine vaccination
programs and storing vaccines. For the successful implementation of regular vaccination services, all
of its elements - immunization session management, cold-chain and logistics management, reports,
supervision, and so on - must be thoroughly examined. The Primary Health Care Center (PHCC) is
an important location for executing routine vaccination programs and storing vaccines. For the
successful implementation of regular vaccination services, all of its elements - immunization session
management, cold-chain and logistics management, reports, supervision, and so on - must be
thoroughly examined.8,9
Despite evidence that immunizations are among the most successful public health strategies for
preventing mortality and morbidity from vaccine-preventable diseases in the world, vaccination rates
in many countries remain low due to a lack of accurate information, incorrect beliefs, concerns about
side effects, and vaccine hesitancy across the general public.10 The objective of this study is to assess
the immunization session practices in the primary healthcare centers in Al-Najaf Governorate.

Materials and Methods

Period of the study
Data collecting began on December 2, 2022, and continued until March 2, 2023. For each center, 3
days were provided for data collection, which took place on average 5 days per week.

Study design
A descriptive, cross-sectional study conducted at 26 randomly selected (simple sample) Primary
Health Centers in Najaf governorate. There are 52 primary health care centers in Najaf, distributed in
6 primary health care sectors. Take 26 centers (52% of the total) randomly (using a simple sampling
technique) from all sectors.

Population source
The source of this study was all healthcare workers in the immunization session at the selected
primary healthcare centers in Al-Najaf governorate.

Inclusion criteria
Firstly. At the time of research, All healthcare workers who work in the immunization unit in the
healthcare center in addition to the primary healthcare doctors who work in the healthcare center.
Secondly, both genders are represented and all age ranges.

Exclusion criteria
Staff who refused to interview them and all healthcare workers who did not have an administrative
order to work in the immunization unit.

Sample size and sampling techniques

Thompson's statistical equation was used to calculate the sample size considering the following
assumptions:11

n= The minimum sample size, N= Community size 258449, Z= Standard degree =1.96, P= Rate
of availability of property = 0.50, d= Error ration = 0.05.

The population includes all health workers (both gender) who work in immunization units, as well as
primary healthcare physicians. The sample size for healthcare workers was (143) persons, including
(122) vaccinators and (21) doctors. The sample size was selected Depending on the attached equation
to choose the appropriate sample size.
The governorate of Najaf has 50 primary healthcare centers dispersed throughout six primary
healthcare sectors. Twenty-six centers (52% of the total) were picked at random from all sectors using
the simple random approach from each sector based on the sector aggregation map.

Data collection technique

Data were collected by a questionnaire which is responsible for information about the healthcare
center and evaluating the practices of the immunization session in the healthcare center through direct
observation. Using a questionnaire prepared based on the information from the Expanded Guide to
Immunization Program of the Iraqi Ministry of Health and the World Health Organization as well as
the opinion and approval of experts and modified WHO immunization session practices checklist(12)
which consists of:
1-Primary healthcare center information which includes:-
(`Number of physicians in primary health care,Number of vaccinators working in the
immunization unit, Number of non-vaccinator persons working in the immunization unit, Number
of people receiving primary health care services according to population 2022 (or last available
year), Monthly target for children under one year of age for the health care rate Primary health
care, Number of people receiving vaccination in primary health care every day, Number of square
meters (m2) occupied by the immunization unit, Number of kilometers (km) between primary
health care centers and the administrative center of the health district, Number of supervisory visits
made by district staff to primary health care during the past three months
2-WHO modified checklist for the assessment of the immunization session practices that include five
domains: -
A. Vaccine and diluent management.
B. Cold chain management.
C. Communication with clients and caregivers.
D. Vaccine preparation and administration practices.
E. waste management practice.

Scoring system
The assessment of each domain in immunization session practices is calculated according to the
quartile status.13

Assessment of cold chain management practice

This section has 8 questions. (1 score) is calculated for replying (no) and (2 score) is calculated for
answering (yes), and it is computed based on the quartile status, which is classified as (good). If the
score is higher than the (80%) (≥14 scores), it is classified as (Fair) if it is higher than the second
quartile and lower than (80%) when (≥12 and <14 scores), and it is considered (bad) if it is lower than
the second quartile (<12).

Assessment of communication with clients and caregivers practice

This section has 6 questions. (1score) is calculated for replying (no) and (2score) is calculated for
answering (yes), and it is computed based on the quartile status, which is classified as (good). If the
score is higher than the (80%) (≥8 scores), it is classified as (Fair) if it is higher than the second
quartile and lower than (80%) when (≥7 and < 8 scores), and it is considered (bad) if it is lower than
the second quartile (<7 scores).

Assessment of waste management practice

This section has 5 questions. (1score) is calculated for replying (no) and (2score) is calculated for
answering (yes), and it is computed based on the quartile status, which is classified as (good). If the
score is higher than the (80%) (≥8 scores), it is classified as (Fair) if it is higher than the second
quartile and lower than (80%) when (≥7 and <8 scores), and it is considered (bad) if it is lower than
the second quartile (<7 scores).

Assessment of vaccine preparation and administration practices

This section has 16 questions. (1score) is calculated for replying (no) and (2score) is calculated for
answering (yes), and it is computed based on the quartile status, which is classified as (good). If the
score is higher than the (80%) (≥29.6 scores), it is classified as (Fair) if it is higher than the second
quartile and lower than (80%) when (≥28.5 and <29.6 scores), and it is considered (bad) if it is lower
than the second quartile (<28.5 scores).
Assessment of vaccine and diluent management practices
This section has 10 questions. (1score) is calculated for replying (no) and (2 score) is calculated for
answering (yes), and it is computed based on the quartile status, which is classified as (good). If the
score is higher than the (80%) (≥16 scores), it is classified as (Fair) if it is higher than the second
quartile and lower than (80%) when (≥15 and <16 scores), and it is considered (bad) if it is lower than
the second quartile (<15 scores).

Results and Discussion

Table 1 presents an assessment of Cold Chain Management practices based on various criteria. The
table includes different practices related to the handling and storage of temperature-sensitive
products, such as vaccines. The assessment categorizes each practice as either "No" (indicating the
practice is not followed) or "Yes" (indicating the practice is followed).Icepacks are not to be used
until the sound of water can be heard on shaking (conditioned icepacks): In this case, 73.1% of the
PHCs that indicates that a significant number of PHCs understood the importance of conditioning
icepacks and adhered to this practice. Followed the practice of using conditioned icepacks, while
26.9% did not. That could be due to lack of awareness or oversight regarding the correct usage of
icepacks. Vaccine carrier contains Conditioned icepacks in a required number (according to vaccine
carrier type): Here, 34.6% of the PHCs used the required number of conditioned icepacks in their
vaccine carriers, while 65.4% did not. The lower percentage suggests a lack of compliance with the
recommended guidelines for icepack usage. This could be attributed to factors such as inadequate
training, resource limitations, or oversight during the supply chain process. Vaccine vials in the
middle of the vaccine carrier (not in contact with icepacks): the table shows that 26.9% of the PHCs
placed vaccine vials in the middle of the vaccine carrier as recommended, while 73.1% did not follow
this practice. The higher percentage indicates a lack of adherence to the proper positioning of vaccine
vials, potentially compromising the temperature stability of the products. Put the opening date on the
vaccine vial that is subject to the open-vial policy: In this case, 80.8% of the PHCs correctly marked
the opening date on vaccine vials subject to the open-vial policy, while 19.2% did not. The higher
percentage reflects a satisfactory level of compliance with this important practice, ensuring the safety
and efficacy of opened vaccine vials. Foam/sponge pad on top of vaccine carrier: The table shows
that 96.2% of the PHCs used a foam or sponge pad on top of the vaccine carrier, while only 3.8% did
not. This finding is consistent with a study conducted in the Southern part of Ethiopia.14 The higher
percentage indicates a widespread adoption of this practice, which helps provide additional insulation
and maintain temperature stability within the carrier. Unopened vaccine vials are placed in a plastic
bag inside the vaccine holder: Here, 26.9% of the PHCs followed the practice of placing unopened
vaccine vials in a plastic bag inside the vaccine holder, and 73.1% did not, while in India's Bijapur
district, 95.7% of immunization locations successfully practiced this issue, with vaccine vials
maintained in zipper bags within vaccine carriers.15 A higher percentage indicates non-compliance
with this practice, which poses a risk to vaccine safety. The sponge at the top of the vaccine carrier is
clean and tidy: The table shows that 57.7% of the PHCs maintained a clean and tidy sponge at the top
of the vaccine carrier, while 42.3% did not. The higher percentage suggests that a majority of the
PHCs were conscious of the importance of cleanliness in Cold Chain Management. The lower
percentage might be due to insufficient attention or oversight in maintaining the cleanliness of the
carrier's sponge. Opening vials held in foam (or sponge) pad of vaccine carrier (Multiple dose
vaccines): In this case, 73.1% of the PHCs held opening vials in the foam or sponge pad of the
vaccine. An evaluation of cold chain management in vaccine distribution reveals a fair level of
performance with room for improvement. The assessment considers different aspects, such as the use
of conditioned icepacks, proper placement of vaccine vials, labeling practices, foam/sponge pad
utilization, and the use of plastic bags for unopened vials. Reference to the study by Johnson et al.
(2022) demonstrates that while some aspects of cold chain management received positive evaluations,
certain areas fell short of optimal performance.16
Table 2 shows important point related to communication with clients and caregivers that include 6
items regarding Client and caregiver greeted, Contraindications and the four key message. Overall
assessment of this domain was fair (7.46±1.30). Regarding (Client and caregiver greeted) our result
show the 69.2 % of selected PHCs do not greet parents properly. It is suggested that the reason is the
societal customs in the holy city of Najaf, especially when mothers bring their children to the
immunization unit and dealing with a male vaccinator. In relation to Contraindications checking
practices, our result showed that (96.2%) of selected PHCs do not verify or ask parents about
Contraindications to vaccination. Where the health workers were completely dependent on the doctor
in the health center in determining vaccine contraindications and considered that this issue is greater
than their responsibilities and capabilities. Similarly, in the study conducted in Wasit province, Iraq
By Amily, Ali, and F. Lami (2016) that found problem in greeting of clients and caregivers Some
difficulties may be observed in welcoming clients and carers, particularly when a male vaccinator is
dealing with a female client or caregiver and due to overcrowding and the result show only (7%) of
selected PHC did check Contraindications to vaccinations are health workers at the vaccination
session, because the vaccinators believed that this bigger duty should be carried out by doctors
themselves, and this choice, if made, may add another responsibility for them that they should not
attempt to undertake.17 The delivery of four critical messages following immunization proved
ineffective, as (61.5%) of selected PHCs do not give key messages about the day of the next visit ,
(76.9%) do not told about (Common adverse event following immunization (AEFI), (69.2%) do not
told parents about (What to do in case of AEFI) and (80.8%) do not give key messages about (Bring
the vaccination card to the next visit). This may be happens as a result of the health worker's lack of
knowledge of the importance of these matters, as well as due to the overcrowding of the health center.
these findings on the way with study conducted in Bahir Dar city, Northwest Ethiopia by Swarnkar,
Madhusudan et al. (2016) found that only 35% of workers delivered all four message, 42% delivered
three messages 47% delivered two message, and 75% delivered at least one message.18 Another study
conducted by Singh et al. (2015) in Ahmedabad District, India, found that Four key messages by
Healthcare worker were given in only 38.3% of session site.19
Table 3 shows the Assessment of Waste Management Practice in the 26 selected primary healthcare
centers which consist of 5 items. This domain has a fair assessment score. Our result shows that
(Used AD syringes disposed of into a safety box Immediately after injection) was 73.1 % of PHC
where applicable. These findings agree with a study conducted in Wassit province, Iraq by Amily,
A., & Lami, F (2018) that found sharps were immediately disposed into these boxes in 86% of these
PHCs.20 Regarding (the safety box is disposed of when it is 75% full) the result show that 84.6 % of
selected PHCs dispose safety box when it is filled with more than 75%. Where it is suggested that the
reason for this is the lack of attention due to the overcrowding. This finding dose not consistent with
previous study conducted by Jahangiri et al. (2016) in Iran that have shown Discharging the safety
box when it is filled at ¾ of its capacity in 71% of selected sample.21
Table 4 shows the practices assessment regarding vaccine preparation and administration, which
include hand washing, safe preparation of vaccines, using correct type of diluent, using new
disposable syringe for each injection and new syringe for each dissolve process, Rubber membrane
or opening as well as needle not touched and alcohol do not used , Fill syringes just before
administration, do not re-cap syringe after use and the right process for administration of routine
vaccines.This domain has an assessment score of fair (28.53±0.989). Regarding (Health care
worker/vaccinator washed hands with soap) and (Vaccines prepared safely on clean table) our result
showed that (69.2%) of selected PHCs vaccinators did not wash their hand before the injection of
vaccines and (50%) of selected PHCs did not use clean table for vaccine preparation . It is likely that
the reason is due to the health worker's lack of awareness of the importance of washing hands before
the vaccine injection process and their failure to use a clean table for preparing the vaccine, as they
prepare the vaccine on the vaccine-giving table. These results consist with that found in a study
conducted in 40 healthcare facilities of two districts of Kashmir valley, India by Allaqband et al. for
assessment of injection practices in various healthcare settings that found 95.6% of HCWs in selected
PHCs used unsafe methods, such as preparing injections on dirty surfaces or tables, and 99.8% did
not wash their hands before preparing injections.A nother study Tripoli, Libya (2015) about Cold
chain status and vaccination activities at vaccination centers by El-Hamadi et al. shows that only
66% of HCWs in selected PHCs washed their hands before vaccination due to absence of this habit
in HCWs practice.22 Our result disagree with a study condact in Darjeeling District, West
Bengal(2016) about Safe injection practices in primary health care settings that found (100%) of
vaccinator in selected PHCs wash their hands once before starting the vaccination session.23 The
current assessment discovered that all selected PHCs received a complete assessment score (100%)
for (each vaccine provided using the proper route of administration practices,each vaccine
prepared using the appropriate vaccine diluents, needle and rubber not touched, do not re-cap the
syringe after use , alcohol is not used to disinfect the skin and Fill syringes just before administration).
These results agreed with the previous study findings done in Al- Diwanyia Governorate, Iraq for
evaluation of vaccination session that found All PHCCs received a complete assessment score (100%)
for (each vaccine delivered using the proper method of immunization, and each vaccine prepared
using the appropriate vaccine diluents). While 93.6% of the investigated sample was good in terms of
(vaccinator did not touch or recap the needle).24 Also our result agreed with another study in rural
areas of Ahmedabad district that found all session sites (100%) practice a correct site and route of
vaccination.25
Table 5 shows the Assessment of Vaccine and Diluent Management Practices in the 26 selected
primary healthcare centers which consist of 10 items. The assessment categorizes each practice as
either "No" (indicating the practice is not followed) or "Yes" (indicating the practice is followed).our
result about this domain has a poor assessment score of (14.88±1.24). Regarding (vaccines and
vaccination supplies are requested through the approved application form described in the vaccinators'
guide) and (Vaccine vials taken out of the refrigerator in Required quantities) found that (96.2% and
88.5% respectively) of selected PHCs do not use the form for requesting vaccines from the cold chain,
which is approved in the immunization guide and they do not take out the vaccines from the
refrigerator according to the required quantity Where the health worker takes the vaccine out of the
refrigerator as needed. this is similar to the finding of a study conducted in Amhara region that found
a gap in using requisition forms for reporting and ordering vaccines.26 92.3 % of selected PHCs do
not check the freeze indicator (or digital thermometer) when the vaccine was taken out of the storage
refrigerator. This suggested that the health worker's have lack of knowledge about the importance of
the freeze indicator for sensitive vaccines. This finding is likely to a study conduct by Zalyer et al. in
Wassit Governorate, Iraq for the evaluation of the application of effective vaccine Management that
found only 22% of sample reported use of freeze indicators.27 This differs from study conducted in
2018 in Oman that showed good performance about vaccine management.28 This domain also contains
important points related to examining the safety of the vaccine, which includes checking the label,
expiry date and vaccine vial monitor (VVM) . our result found that 73.1 % of PHCs did not check the
label on the vaccine vial , 80.8% did not check the expiry date and 50% did not check (VVM).This
finding disagrees with a study conducted in India by Parmar, Snehal, et al. (2020) that found most of
healthcare worker (96%) had checked VVM status, expiry dates of vaccine vials and vaccine label
before vaccination.29 Finally Unopened vaccine vials were returned to the refrigerator in 100% of
selected PHCs and opened vaccine vials that should no longer be used are discarded in 96.2 % of
selected PHCs. this finding agree with study conducted in Wasit Governorate, Iraq by Amily, A. S.,
Lami, F., & Khader, Y. (2019) that found unopened vaccine vials returned to the refrigerator in 100%
of PHCs and 90% of opened vaccine vial that should no longer be used are discarded.30
Table 6 show the assessment of overall immunization session practices which divided into seven
domains in 26 primary healthcare centers that included in the study. Regarding Vaccine and Diluent
Management only 8 (30.8%) of primary healthcare centers had a correct application of these practices
while 18 (69.2%) of PHCs had poor practices. The second domain include cold chain management
practices which had good application in only 9 (34.6%) of PHCs with poor application of these
practices in 9 (65.4%) of PHCs. Third domain which include the availability of immunization session
equipment we found that all PHCs (100%) had a fully assessment degree. Fourth domain which
include communication with clients and caregivers practices, as the results show, this domain received
the lowest assessment score in relation to the other domain with only 3 (11.5 %) PHCs had adequate
practices with inadequate practices in 23 (88.5 %) of PHCs. Full assessment degree regarded fifth
domain which include Card review and registration practices during immunization and sixth domain
which include vaccine preparation and administration practices. The last domain include waste
management practices, as the result we found 11 (42.3 %) of PHCs were applied correctly with
incorrect application in 15 (57.7%) of PHCs.The overall assessment of immunization session
practices was fair (96.34±3.35) according to quartile status. Our findings consist with another study
conducted in Northwest Ethiopia by Amarem et al. (2021) for vaccine safety practices and its
implementation barriers that found vaccination safety practices, including the cold chain system,
vaccination administration, and waste disposal and management, were suboptimal.31

Conclusions
Poor vaccine and diluent management especially in requesting the vaccine from the cold chain, as
well as not checking the freezing indicator when taking out the vaccines from the refrigerator.
Immunization session practices varied among the selected healthcare centers with the highest
evaluating percentage (100%) for the availability of immunization session equipment and card review
and registration during immunization. Healthcare workers who are not vaccinators and working in
immunization units have an effect on immunization session practices since they do not have any
information about vaccination practices. The number of people who visit the immunization unit in
the health care center has an impact on the practices of the immunization session, especially on the
days of Sunday and Wednesday of each week, due to the opening of the BCG vaccine on these days.

Recommendations
Continuous training of the primary health care worker on information about vaccines through the
comprehensive guide to the Expanded Program on Immunization. On-job training on the correct
practices of the immunization session, especially on the vaccine and diluent management. Immediate,
accurate, and for long-term planning to solve the problem of overcrowding in immunization units
during certain days of the week. Increasing supervisory visits to follow up the work of immunization
units, evaluate their performance and support their development.

References
1. Nadeem AY, Shehzad A, Islam SU, Al-Suhaimi EA, Lee YS. MosquirixTM RTS, S/AS01
vaccine development, immunogenicity, and efficacy. Vaccines (Basel). 2022;10(5):713.
2. Organization WH. Immunization as an essential health service: guiding principles for
immunization activities during the COVID-19 pandemic and other times of severe disruption,
1 November 2020.
3. Organization WH. Working for a brighter, healthier future: how WHO improves health and
promotes well-being for the world’s adolescents. 2021.
4. Karlsson LC, Lewandowsky S, Antfolk J, Salo P, Lindfelt M, Oksanen T, et al. The association
between vaccination confidence, vaccination behavior, and willingness to recommend vaccines
among Finnish healthcare workers. PLoS One. 2019;14(10):e0224330.
5. Excler JL, Saville M, Berkley S, Kim JH. Vaccine development for emerging infectious
diseases. Nat Med. 2021;27(4):591–600.
6. Nanayakkara S. Global Immunization Programs: A Summary and Consideration of Polio
Vaccine Programs. 2022.
7. Goodson JL, Alexander JP, Linkins RW, Orenstein WA. Measles and rubella elimination:
learning from polio eradication and moving forward with a diagonal approach. Expert Rev
Vaccines. 2017;16(12):1203–16.
8. Patel N, Unadkat S, Sarkar A, Rathod M, Dipesh P, Patel N. Assessment of cold chain
maintenance for routine immunization in Jamnagar district, Gujarat. Int J Med Sci Public
Health. 2018;7:1–5.
9. Oladeji O, Campbell P, Jaiswal C, Chamla D, Oladeji B, Ajumara CO, et al. Integrating
immunization services into nutrition sites to improve immunization status of internally
displaced persons’ children living in Bentiu protection of civilian site, South Sudan. Pan African
Medical Journal. 2019;32(1).
10. della Polla G, Napolitano F, Pelullo CP, de Simone C, Lambiase C, Angelillo IF. Investigating
knowledge, attitudes, and practices regarding vaccinations of community pharmacists in Italy.
Hum Vaccin Immunother. 2020;16(10):2422–8.
11. Thompson SK. Estimating Proportions, Ratios, and Subpopulation Means. In: Sampling Third
Edition. Hoboken, NJ, United States: Wiley; 2012. p. 59–60.
12. Organization WH, Immunization WHOrganizationD of. Immunization in practice: a practical
guide for health staff. World Health Organization; 2015.
13. Jasem FM, Al-Hafidh AH. Evaluation of Vaccination Session in Al-Diwanyia Governorate,
Iraq. Ann Rom Soc Cell Biol. 2021;25(6):12630–40.
14. Rogie B, Berhane Y, Bisrat F. Assessment of cold chain status for immunization in central
Ethiopia. Ethiop Med J. 2013;51(Suppl 1):21–9.
15. Biradar SM, Biradar MK. Session sites monitoring of routine immunization program in Bijapur
district. Int J Life Sci Biotechnol Pharma Res. 2013;2(4):232–6.
16. Johnson A, WK, & DL (2022). Assessment of cold chain management in vaccine distribution.
Vaccine Research Journal. 2022;47(3):215-230.
17. Amily A, Lami F. Assessment of Immunization Session Practices in Primary Healthcare
Centers-Wasit Province, Iraq, 2016-17. Iproceedings. 2018;4(1):e10622.
18. Swarnkar M, Baig VN, Soni SC, Shukla US, Ali J. Assessment of knowledge and practice about
immunization among health care providers. National Journal of Community Medicine.
2016;7(04):281–5.
19. Singh A, Chaudhari A, Mansuri S, Talsania N. Process evaluation of special immunization
weeks in rural areas of Ahmedabad district. Int J Sci Study. 2015;3(4):111–4.
20. Amily AS, Lami F, Khader Y. Impact of Training of Primary Health Care Centers’ Vaccinators
on Immunization Session Practices in Wasit Governorate, Iraq: Interventional Study. JMIR
Public Health Surveill. 2019;5(4):e14451.
21. Jahangiri M, Rostamabadi A, Hoboubi N, Tadayon N, Soleimani A. Needle stick injuries and
their related safety measures among nurses in a university hospital, Shiraz, Iran. Saf Health
Work. 2016;7(1):72–7.
22. El-Hamadi MR, Burshan NM, Abugalia MO, Abdel-Azeem AM, Lapez RM. COLD CHAIN
STATUS AND VACCINATION ACTIVITIES AT VACCINATION CENTERS IN TRIPOLI,
LIBYA 2015.
23. Chaudhuri SB, Ray K. Safe injection practices in primary health care settings of Naxalbari
Block, Darjeeling district, West Bengal. J Clin Diagn Res. 2016;10(1):LC21.
24. Jasem FM, Al-Hafidh AH. Evaluation of Vaccination Session in Al-Diwanyia Governorate,
Iraq. Ann Rom Soc Cell Biol. 2021;25(6):12630–40.
25. Singh A, Chaudhari A, Mansuri S, Talsania N. Process evaluation of special immunization
weeks in rural areas of Ahmedabad district. Int J Sci Study. 2015;3(4):111–4.
26. Bogale HA, Amhare AF, Bogale AA. Assessment of factors affecting vaccine cold chain
management practice in public health institutions in east Gojam zone of Amhara region. BMC
Public Health. 2019;19(1):1–6.
27. Zayer JAR, Chiad IA. Evaluation of Application of Effective Vaccine Management in Wassit
Governorate, Iraq.
28. Al-Abri SS, Al-Rawahi B, Abdelhady D, Al-Abaidani I. Effective vaccine management and
Oman’s healthcare system’s challenge to maintain high global standards. J Infect Public Health.
2018;11(5):742–4.
29. Parmar S, Puwar T, Saxena D, Shukla S, Pandya AK. Health Workers’ Approach Toward
Adverse Events following Immunization–An Insight From Madhya Pradesh. Indian J
Community Med. 2020;45(4):567.
30. Amily AS, Lami F, Khader Y. Impact of Training of Primary Health Care Centers’ Vaccinators
on Immunization Session Practices in Wasit Governorate, Iraq: Interventional Study. JMIR
Public Health Surveill. 2019;5(4):e14451.
31. Amare G, Seyoum T, Zayede T, Tazebew A, Teklu A, Mekonnen ZA, et al. Vaccine safety
practices and its implementation barriers in Northwest Ethiopia: A qualitative study. Vol. 35.
2021.
Table 1. Cold chain management practice.
Rating

N Cold Chain Management No Yes

F % F %
1 Icepacks are not to be used until the sound of water can be heard on
7 26.9 19 73.1
shaking (conditioned icepacks)
2 Vaccine carrier contain Conditioned icepacks in a required number
17 65.4 9 34.6
(according to vaccine carrier type).
3 Vaccine vials in the middle of the vaccine carrier (not in contact with
19 73.1 7 26.9
icepacks).
4 Put the opening date on the vaccine vial that is subject to the open-vial
21 80.8 5 19.2
policy
5 Foam/sponge pad on top of vaccine carrier. 1 3.8 25 96.2
6 Unopened vaccine vials are placed in a plastic bag inside the vaccine
19 73.1 7 26.9
holder.
7 The sponge at the top of the vaccine carrier is clean and tidy. 11 42.3 15 57.7
8 opening vials held in foam (or sponge) pad of vaccine carrier. (Multiple
7 26.9 19 73.1
dose vaccines)
Overall 12.07±1.49 (9-15)
*Quartile status {(≥14 good) , (≥12 & <14 fair) ,(<12 poor) (N= 8 items) (Total score =16)}

Table 2. Communication with clients and caregivers practice

Rating

Communication with Clients and Caregivers

N No Yes

F % F %
1 The client and caregiver greeted. 18 69.2 8 30.8
2 Contraindications checked 25 96.2 1 3.8
3 Key messages are given (Date of next visit) 16 61.5 10 38.5
key messages are given (Common adverse event following
4 20 76.9 6 23.1
immunization (AEFI)
5 key messages are given (What to do in case of AEFI). 18 69.2 8 30.8
6 key messages are given (Bring the vaccination card to the next visit 21 80.8 5 19.2
Overall 7.46±1.30 (6-10)
*Quartile status {(≥8.6 good) , (≥7 & <8.6 fair) ,(<7 poor) (N= 6 items) (Total score =12)
Table 3. Waste management practice.
Rating

Waste Management Practice No Yes

N

F % F %
Used AD syringes disposed of into a safety box Immediately after
1 7 26.9 19 73.1
injection.
Do not dispose of the following items in the safe box: (Cotton,
2 2 7.7 24 92.3
bandages, gloves, and any other plastic materials)
3 The safety box is disposed of when it is 75% full 22 84.6 4 15.4
Safety boxes used and handled according to national waste management
4 guidelines (Placed within reach of staff administering injections, Closed 25 96.2 1 3.8
,Kept in a dry place out of reach of children and others)
Reconstituted needles and auto syringes were disposed of immediately
5 12 46.2 14 53.8
into a safety box.
Overall 7.38±0.94 (6-10)
*Quartile status {(≥8 good) , (≥7 & <8 fair) ,(<7 poor) (N= 5 items) (Total score =10)}

Table 4. Vaccine preparation and administration practices.

Rating

Vaccine Preparation and Administration Practices No Yes

N

F % F %
1 Health care worker / vaccinator washed hands with soap. 18 69.2 8 30.8
2 Vaccines are prepared safely on a clean table. 13 50 13 50
3 vaccine dissolves with the correct quantity and type of diluent. 0 0 26 100.0
4 New disposable needles were used. 0 0 26 100.0
5 use a new syringe for each dissolving process 0 0 26 100.0
6 Rubber membrane or opening not touched. 3 11.5 23 88.5
7 Fill syringes just before administration . 0 0 26 100
8 Never leave the needle on top of the vaccine vial. 4 15.4 22 84.6
9 Alcohol is not used to disinfect the skin. 0 0 26 100
10 Needle not touched. 0 0 26 100
11 Oral Polio vaccine and rotavirus vaccine are given orally 0 0 26 100
Pentavalent and triple vaccines are given in the muscle of the left thigh
12 0 0 26 100
at an angle of 90 degrees
The injectable polio and pneumococcal vaccines are given in the
13 0 0 26 100
muscle of the right thigh at an angle of 90 degrees.
BCG vaccine is given in the In the dermis of the left arm at an angle
14 0 0 26 100
of 15 degrees.
 MMR and measles vaccines are given in the muscle of left arm at an
15 0 0 26 100
angle of 45 degrees.
16 Do not re-cap the syringe after use. 0 0 26 100
Overall 28.53±0.989(27-30)
*Quartile status {(≥29.6 good) , (≥28.5 & <29.6 fair) ,(<28.5 poor) (N= 16 items) (Total score =32)}

Table 5. Vaccine and diluent management practice.

Rating

Vaccine and Diluent Management No Yes

N

F % F %
Vaccines and vaccination supplies are requested through the approved
1 25 96.2 1 3.8
application form described in the vaccinators' guide.
Checked freeze indicator (or digital thermometer). when the vaccine
2 24 92.3 2 7.7
was taken out of the storage refrigerator.
3 Vaccine vials taken out of refrigerator in Required quantities. 23 88.5 3 11.5
4 Vaccine vials taken out of refrigerator in Specific order. 6 23.1 20 76.9
Diluents taken out of the refrigerator are matched with the appropriate
5 1 3.8 25 96.2
vaccine in quantity and type.
6 Checked if the vaccine is safe to use by checking label. 19 73.1 7 26.9
7 Checked if the vaccine is safe to use by checking the Expiry date. 21 80.8 5 19.2
Checked if the vaccine is safe to use by checking the Vaccine vial
8 13 50.0 13 50.0
monitor.
9 Unopened vaccine vials were returned to the Refrigerator. 0 0 26 100.0
10 Opened vaccine vials that should no longer be used are discarded. 1 3.8 25 96.2
Total Score 14.88±1.24 (12-18)
*Quartile status {(≥16 good) , (≥15 & <16 fair) ,(<15 poor) (N= 10 items) (Total score=20)}

Table 6. Overall domains practices.

Rating
No Yes
Domains
F % F %
N
1 Vaccine and Diluent Management 18 69.2 8 30.8
2 Cold Chain Management 17 65.4 9 34.6
3 Availability of Immunization Session Equipment 0 0 26 100
4 Communication with Clients and Caregivers 23 88.5 3 11.5
5 Card Review and Registration During Immunization 0 0 26 100
6 Vaccine Preparation and Administration Practices 0 0 26 100
7 Waste Management Practice 15 57.7 11 42.3
Overall 0 0 26 100
Total Score 96.34±3.35(89-103)