Therefore, when a child who has missed measles vaccine among other vaccines presents to a health facility; the catch-up process should ensure that whenever

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October 2020 Page 2 of 39 TABLE OF CONTENTS 1 ACRONYMS .. .. .. .. .. 5 1. BACKGROUND .. .. .. . 6 1.1 PURPOSE .. .. .. 7 1.2 SPECIFIC OBJECTIVE .. .. .. .. 7 1.3 SCOPE .. .. .. .. 7 2 IMMUNISATION CATCH – UP .. .. .. 8 2.1 BACKGROUND .. .. .. .. 8 2.2 IMMUNISATION CA TCH – UP .. .. . 8 2.2.1 CHECK FOR MISSED DOSES .. .. .. 8 2.2.2 ASSESSING FOR ELIGIBILITY OF CATCH – UP DOSES .. .. 9 2.2.3 RECORDING OF THE CATCH – UP DOSES .. .. 11 2.2.4 FOLLOW – UP APPOINTMENTS .. .. . 11 3 NUTRITIONAL ASSESSMENTS CATCH – UP .. .. 12 3.1 BACKGROUND .. .. .. 12 3.2 NUTRITIONAL ASSESSMENTS CATCH UP .. .. .. 13 3.2.1 CHECK FOR MISSED ASSESSMENTS .. .. .. 13 3.2.2 MISSED NUTRITIONAL ASSESSMENTS .. . 13 3.2.3 RECORDING OF THE MISSED NUTRITIONAL ASSESSMENT .. 14 3.2.4 FOLLOW – UP APPOINTMENTS .. .. . 15 4 VITAMIN A SUPPLEMENTATION CATCH – UP .. .. 16 4.1 BAC KGROUND .. .. .. 16 4.2 VITAMIN A CATCH UP .. .. .. 16 4.2.1 CHECK FOR MISSED VITAMIN A DOSES .. .. 16 4.2.2 ASSESSING FOR ELIGIBILITY .. .. . 17 4.2.3 RECORDING OF THE CATCH – UP .. .. .. 17 4.2.4 FOLLOW – UP APPOINTMENTS .. .. . 18 5 DEWORMING CATCH – UP .. .. .. .. 19 5.1 BACKGROUND .. .. .. 19 5.2 DEWORMING CATCH – UP .. .. .. . 19 5.2.1 CHECK FOR MISSED DEWORMING DOSES .. 19 5.2.2 ASSESSING FOR ELIGIBILITY .. .. . 19

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October 2020 Page 3 of 39 5.2.3 RECORDING OF THE CATCH – UP DOSES .. .. 20 5.2.4 FOLLOW – UP APPOINTMENTS .. .. . 21 6 PMTCT CATCH UP PROCEDURE .. .. .. 22 6.1 BACKGROUND .. .. .. 22 6.2 PMTCT CATCH – UP .. .. .. 23 6.2.1 CHECK FOR MISSED HIV TESTING AND EARLY INFANT TESTING 23 6.2.2 ASSESSING FOR ELIGIBILITY .. .. . 23 6.2.3 RECORDING OF THE CATCH – UP TESTING .. .. 24 6.2. 4 FOLLOW – UP APPOINTMENTS .. .. . 25 7 SAFETY & CO – ADMINISTERING CATCH – UP INTERVENTIONS .. . 26 7.1 FLOW OF INTERVENTIONS .. .. .. 27 ANNEXURE 1: IMMUNISATION CATCH UP SCHEDULE .. 28 ANNEXURE 2: VITAMIN A SUPPLEMENTATION CATCH – UP SCHEDULE .. 29 ANNEXURE 3: DEWORMING SCHEDULE .. .. .. 30 8 DATA MANAGEMENT .. .. .. .. 31 Annexure 5: .. .. .. .. . 35 Annexure 6: .. .. .. .. . 36 DAILY SUMMARY SHEET ROUTINE DOSES 2020 – 2021 .. . 36 Annexure 7: .. .. .. .. . 37 DAILY SUMMARY SHEET CATCH – UP DOSES 2020 – 2021 .. . 37

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October 2020 Page 5 of 39 1 ACRONYMS AEFI Adverse Event Following Immunisation ARV Anti – retro viral BANC Basic ante – natal care BCG Bacille Calmette Gue rin CHAI Clinton Health Access Initiative DOH Department of Health ECD Early Childhood Development EPI Expanded Program on Immunisation EPI – SA T he Expanded Programme on immunisation in South Africa HepB Hepatitis B Hib Hemophilus influenza type b H IV Human immunodeficiency virus IMCI Integrated Management of Childhood Illnesses (IMCI) MAM Moderate acute malnutrition MCV1 Measles Containing Vaccine 1 MCV2 Measles Containing Vaccine 2 OPV Oral Polio Vaccine PMTCT Prevention of Mother to Child t ransmission of HIV REC Reaching Every Child RI Routine Immunisation R t HB Road to Health booklet RV Rotavirus Vaccine SAM Severe acute malnutrition Td Tetanus and reduced strength diphtheria UNICEF VAS Vitam in A supplementation WHO World Health Organization

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October 2020 Page 6 of 39 1. BACKGROUND Targeted child health interventions may be missed due to a number of reasons. It is the responsibility of all health care providers who encounter children who have missed essential child hea lth interventions such as immunisation , growth monitoring, vitamin A supplementation, deworming among other preventive interventions to ensure that these children receive eligible interventions in an age – appropriate, safe manner. This applies to both the p ublic sector as well as the private sector health providers. The impact of missed interventions is adverse. For example, missed vaccine doses during routine immunisation result in immunity gaps that makes the population susceptible to vaccine preventable disease outbreaks with the resultant morbidity and mortality. When a child misses routine growth monitoring interventions such as weight, height and mid – upper arm circumference measurements as well assessments for bilateral pedal oedema, there is the miss ed opportunity for early detection and intervention in children with moderate acute and severe acute malnutrition (MAM/SAM) that increases their risk of vulnerability to diseases including VPDs. Care – givers are advised to i ntegrate growth and development monitoring, counselling and support for nutrition (including special attention to support for breastfeeding and complementary feeding), at every contact with health services, including during immunisation visits . Missed doses of Vitamin A may result in Vit amin A deficiency. Vitamin A deficiency cause s visual impairment (night blindness), increase s the risk of illness and mortality from childhood infections such as measles and diarrhoea . Improving the vitamin A status of deficient children through supplemen tation enhances their resistance to disease and can reduce mortality from all causes by approximately 23%. Missed doses of deworming tablets may result in intestinal worm infestation, which can tion of growth and anaemia. South Africa like other parts of the world has a high prevalence of Soil Transmitted Helminthes, particularly amongst disadvantaged children who live in densely populated rural and under serviced areas such as informal settlemen ts. Worm infestation, if left health, nutrition, cognitive development, learning and educational access and achievement. Deworming therefore represents a cost – effective intervention. Because of the high risk of death before the age of 2 years among HIV – infected infants and given the increasing availability of paediatric antiretroviral treatment in the country , e arly virological diagnosis of HIV infection in infants is i mportant as it enables early identification of children who have HIV – infection, as a first step in securing their treatment and care and enables the identification of those who are HIV – exposed but uninfected, facilitating follow – up care and prevention meas ures that will help to ensure that they remain uninfected. The South African PMTCT guidelines recommends that an HIV PCR

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October 2020 Page 8 of 39 2 IMMUNISATION CATCH – UP 2.1 BACKGROUND EPI – SA was launched in 1994. There are currently eleven antigens in the vacci nation schedule. Immuni sation is offered free of charge at all government health care facilities. The government of SA provides 100% of routine vaccine expenditure. There are over 3000 government facilities offering immunisation in SA. There are also a number of private provider s of immunisation (hospital groups , private pharmacies as well as individual private nurse and doctors) . The public sector routine immunisation schedule is shown below: TABLE 1 : SA IMMUNISATION SCHEDULE Age Antigens Birth OPV 0 , BCG 6 weeks OPV 1, DTaP – IPV – Hib – HBV 1, , RV 1, PCV 1 10 weeks DTaP – IPV – Hib – HBV 2, 14 weeks DTaP – IPV – Hib – HBV 3, , RV 2, PCV 2 6 months Measles 1 9 months PCV3 12 months Measles 2 18 months DTaP – IPV – Hib – HBV 3, PCV3 6 years Td 12 years Td Grade 4 girls, aged 9 years and older HPV 2.2 IMMUNIS ATION CATCH – UP 2.2.1 CHECK FOR MISSED DOSES Missed vaccination doses should be checked upon encounter with any child up to 5 years of age: All children who present to all health facilities for any curative services incl ud ing hospitalized children or children presenting for elective procedures All children attending Early Childhood Development ( ECD ) centres All children of school – going age at schools All children seeking care in the private sector health facilities Al l children residing in long term care facilities Street children and other vulnerable children (in informal settlements, children of immigrants, in prisons etc)

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October 2020 Page 9 of 39 Within the community by ward – based outreach teams pro – actively requesting to review the RtHB o f all children in visited households The most objective method to verify missed doses is by checking the R t HB. In the absence of the R t HB history of vaccination from the care – giver is essential. Where the caregiver account is contrary to what is recorde d in the R t HB; the record in the RTHB takes precedence i.e. if it is not written in the R t HB; it means that it was not administered. If the caregiver cannot recall; and there is no R t HB then judge the doses as missed and assess eligibility for catch – up. N B: In the absence of the RTHB, the caregiver may not recall the exact names of vaccines; but may remember the diseases the vaccines prevent, the age at which the vaccines were administered and the route of administration. This therefore; requires skillful interviewing. If the RTHB is missing; ascertain the reason why and if it cannot be located for various reasons (e.g. lost; burnt etc.) a new R t HB should be issued to all children under 5. Upon checking the RTHB ; note the vaccines that were not recorded i .e. the missed doses for age. Noting the missed doses requires systematically reviewing all the vaccines age by age and dose by dose; chronologically from birth doses to the current age appropriate dose. After the missed doses are noted proceed to determin e eligibility for catch up NB: Some children may present with R t HBs or vaccination cards from the private sector or from other countries. Despite this, the process of systematically checking for missed doses should be followed for every child. If there are challenges in the translation of the vaccination cards , the vaccinators should inform the district/province who will get assistance from the NDOH via various means e.g. WHO . 2.2.2 ASSESSING FOR ELIGIBILITY OF CATCH – UP DOSES Once missed doses are identified per 2.2.1 above ; the next step is to assess which vaccines the child is eligible for catch – up. Eligibility is determined by the upper age limit of the vaccine as well as the direction from the national immunisation schedule . It is important to note that if a child missed a dose they are eligible to receive that dose on the manufacture r recommendations as well as the national catch – up schedule (Annexure 1)

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October 2020 Page 10 of 39 Below is the upper age limit of the vaccines in the public sector EPI schedule per the manufacturer recommendations. TABLE 2 : VACCINE UPPER AGE LIMITS Vaccine Upper age limit (per manufacturer) Upper limit per national schedule guideline BCG 12 months 12 mon ths OPV birth dose No upper age limit 6 months DTaP – IPV – Hib – HBV 59 months 59 months RV 24 weeks Measles No upper age limit No upper age limit PCV 72 months 72 months Td No upper age limit 15 years HPV In many cases the child may have missed multiple antigens and therefore may need multiple vaccines to be administered on the same first catch up visit. Vaccines can be safely administered at the same time (always different sites and different syringes and needles for the injectable vaccines ) N B. The measles vaccine that is currently being used in SA should not be co – administered with other vaccines per the advice from the regulatory authorities. Therefore, whe n a child who has missed measles vaccine among other vaccines presents to a health fac ility; the catch – up process should ensure that whenever the measles vaccine is administered; no other vaccines are administered on the same visit and in the preceding or next 4 – week interval. NB: For a child who has missed measles among other antigens; al ways administer measles vaccine first then the other vaccines after the 4 – week interval. Annexure 1 indicates the SA immunis ation catch – up schedule Some key principles to note are the following: The minimum interval between doses for vaccines that requir e multiple doses is 4 weeks. This interval should not be less than 4 weeks but can be more than 4 weeks Even if a long time has passed between doses of the same vaccine; it is not necessary to restart the series from the beginning (if a child gets the Hex axim © 1 at the correct age at 6 weeks and misses all other Hexaxim© doses at 10 and 14 weeks and returns to the facility at the age of 5 months; the vaccinator should continue to administer Hexaxim © and record it as a seco nd dose o f the series even thou gh the interval between the two doses is longer than 4 weeks

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October 2020 Page 11 of 39 Multiple vaccines may be given at the same time (exception: measles). In all situations the site of administration should be according to the national schedule (right /left) 2.2.3 RECORDING OF THE CATC H – UP DOSES All vaccine doses administered should be recorded appropriately. Recording should be done post administration. All vaccine catch – up doses should be recorded in the Rt HB/ vaccination card. Within the R t HB/vaccination card, the administered dose s should be recorded based on the dose number (the first eligible dose is dose 1) regardless of age of the child. For example if a child missed all the Hexaxim © doses and attends the health facility for catch – up vaccination at 14 weeks; at that age the ch ild receives the first Hexaxim © dose and it should be recorded as Hexaxim © 1; even though the child is 14 weeks old . Subsequent doses of the same antigen are then recorded chronologically based on dose number If a child missed some doses and is no longer eligible based on a number of factors e.g. age; the space of that vaccine should not be left blank in the R t HB but should be noted as (ineligible due to age) In addition to recording the catch – up doses in the RtHB; these doses should be recorded in the f acility PHC register All catch – up doses of children below the age of one year should be recorded by dose (as explained above) in the facility PHC register All first – year doses administered to children over 12 months of age should not be recorded in the fac ility PHC register but should be recorded in the appropriate tools/ tally sheets as directed by the NDOH. 2.2.4 FOLLOW – UP APPOINTMENTS Post the first catch up visit there may be need for additional visits for additional doses of the series or for booster doses Communicate with the caregiver the catch – up schedule so that they understand why and when they need to return Write the return date clearly in the RTHB and make sure the care giver understands and has noted this date Ensure the date is also recorded using the Ideal Clinic appointment system

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