Japanese Encephalitis Guideline SEARO 2006

e
Introduction of
Japanese Encephalitis
Vaccine in the
South-East Asia Region
(with focus on SA 14-14-2 JE Vaccine)
Operations Guidelines
SEA-Vaccines-136
Distribution: Limited
Introduction of
Japanese Encephalitis Vaccine
in the South-East Asia Region
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October 2006
ii Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Contents
1. Introduction ......................................................................................... 1
1.1 Background ...................................................................................................... 2
1.2 Recognizing the extent of the JE problem ......................................................... 2
1.3 Different approaches to control JE .................................................................... 3
2. Vaccines against Japanese Encephalitis .................................................. 7

2.1 Type of vaccines ............................................................................................... 7
3. Immunization strategy for the control of JE ............................................ 9

3.1 Mass campaign ................................................................................................. 9
3.2 Conducting the mass campaign ...................................................................... 11
3.3 Ensuring injection safety and adverse events following
immunization (AEFI) during a campaign ......................................................... 15
4. Routine immunization with JE vaccine and surveillance for JE .............. 17

4.1 Routine immunization .................................................................................... 17
5. Vaccine procurement ........................................................................ 19

5.1 Vaccine licensing or registration ...................................................................... 19
5.2 Vaccine procurement and management ......................................................... 19
5.3 Important considerations in the procurement and
management of JE vaccine are as follows ........................................................ 20
5.4 Considerations for vaccine supply and allowable wastage rates ....................... 20
5.5 Receiving vaccines and supplies ..................................................................... 21
5.6 Vaccine administration ................................................................................... 22
5.7 Cold chain requirements ................................................................................ 23
5.8 WHO opened-vial, multi-dose policy ............................................................. 23
Operations Guidelines iii

6. Surveillance for Janpanese encephalitis ............................................... 24
6.1 Clinical case definition of Acute Encephalitis Syndrome ................................. 24
6.2 Types of surveillance for JE .............................................................................. 25
6.3 JE outbreaks and outbreak response ............................................................... 26
6.4 Other aspects of JE surveillance ...................................................................... 29
7. Laboratory aspects of surveillance for JE .............................................. 31

7.1 Laboratory criteria for confirmation ................................................................ 31
7.2 The JE laboratory network .............................................................................. 33
7.3 Specimen collection ....................................................................................... 33
7.4 Transport of specimen .................................................................................... 34
8. References ......................................................................................... 36
Annexes
1. Checklist for planning a mass campaign with JE vaccine ...................... 37
2. Detecting and reporting AEFIs ............................................................. 40
3. SAMPLE: Japanese encephalitis virus laboratory
request and report form ...................................................................... 42
4. Stock management ............................................................................. 43
5. Packaging and shipping of vaccine ...................................................... 48
iv Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Introduction 1
What this guide is NOT

These guidelines are not meant to be a reference document on the epidemiology,
clinical features and the different control measures for Japanese Encephalitis
(JE). These are practical, hands-on operations guidelines for the introduction of
JE vaccine in a country.
The guidelines assume that the disease epidemiology has been defined,
appropriate national consultations have taken place, necessary funding and
other administrative and policy decisions for the introduction of JE vaccine
have been taken. The guidelines do not purport to provide the decision analysis
framework for the introduction of JE vaccine into national immunization
programmes.
The purpose of the guidelines is:

• To guide countries who wish to introduce JE vaccine to control and
prevent JE;
• To guide the planning of mass campaigns as well as routine immunization
with JE vaccine; and
• To ensure the establishment of a functioning routine reporting and
monitoring system, including laboratory surveillance and adverse events
following immunization with JE vaccine
The guidelines are for:

• The National Expanded Programme on Immunization (EPI) Programme
Manager;
• The District Medical Officer; and
• Field workers involved in immunization activities who may not need
the entire guidelines, but to whom appropriate sections may be
provided.
Operations Guidelines 1
1.1 Background
Japanese encephalitis (JE) is the leading viral cause of disability in many countries
of Asia. The virus is a Flavivirus transmitted by mosquitoes and is related to
dengue, yellow fever, and west nile virus. In endemic areas across Asia the
disease primarily infects children, leaving approximately 70% of those who
develop clinical illness either dead or neurologically disabled. Public health
authorities have long concluded that vaccination is a necessary tool to control
JE. While an effective vaccine has existed since 1941, and is recommended for
routine use in endemic countries, it has not reached the poorest countries in
Asia. Its value as a control tool has been proven by its successful use to control
JE in Japan, Korea, and Taiwan.
Control of JE in the Region has been limited by inadequate disease

surveillance, a limited and inconsistent vaccine supply, lack of guidance and
programmematic support for immunization, and limited advocacy. But recent
advances have increased the feasibility of effective JE control. There are new
efforts aimed at defining the disease burden and impact in JE-endemic countries
which include, inter alia, new WHO surveillance standards and new diagnostics.
More importantly, affordable, single-dose new vaccines compatible with routine
immunization have been developed.
1.2 Recognizing the extent of the JE problem

The endemic areas for JE have been defined for many years. However, the
actual JE disease burden has been poorly defined in many parts of Asia. Many
countries, although considered endemic, have had no data on disease
prevalence to demonstrate JE to be a public health issue. During the 60 years
that the vaccine has been available, JE virus has infected an estimated 10.5
million children, resulting in more than 3 million deaths and more than 4 million
children living with long-term disabilities.
Ecosystems alter with changing land use patterns and irrigation. A recent
review shows that 1.9 billion people live in JE-prone areas and the number of
people living in irrigated rice growing areas has continually increased since the
1960s. Outbreaks in peri-urban and urban settings are well documented and,
outbreaks not associated with the traditional pig-amplifying host clearly
demonstrate the importance of other multiple animal species in the transmission
and over-wintering of the JE virus. In addition, JE virus has been isolated from
no less than 16 different species of mosquito in India and from 19 species in
Indonesia.
2 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Some of the challenges of disease recognition have been lack of diagnostic
tools and no uniform guidelines for reporting of JE cases. Some measures put in
place to address some of these shortcomings are the release of the first
surveillance standards for JE by WHO in January 2006. In the SEA Region
encephalitis and JE are now reportable diseases. In addition, three new
commercial diagnostic kits, based on IgM ELISA technology, have been
developed and are undergoing field testing for integration into laboratory
networks. These laboratory networks will be built on the existing infrastructure
of measles and polio surveillance.
1.3 Different approaches to control JE

Control programmes for JE have focused on three major areas:
(1) mosquito control,
(2) amplifying host (pig) control, and
(3) vaccination.
However, neither mosquito control nor amplifying host (pig) control have
proven to be reliably effective public health measures to control JE disease in
humans.
Mosquito control
Mosquito control can include spraying, draining mosquito habitats, personal
protection and the use of bed nets. Spraying is both resource intensive, expensive
and frequently ineffective. To be effective the control measures must cover all
mosquito habitats, which include rice paddy fields, puddles and drainage areas.
This is difficult anytime, but especially difficult during the monsoon season and
in rural rice-growing areas where JE is most common. The time it takes a Culex
mosquito to develop from an egg to an adult is 10-12 days. Therefore, in addition
to the large area to be included in control programmes, spraying must also be
repeated very frequently (every 10-12 days) to control mosquito populations.
An average rice paddy field can produce 30,000 mosquitoes in one day which
presents an incredible challenge. Indoor residual spraying has not been shown
to be effective and fogging has only resulted in decreases of mosquito populations
for one day with complete recovery in four days.
With increasing resistance to pesticides, it is now recognized that chemical

control of JE mosquito populations for disease control is not effective. Similarly,
non-chemical options, including alternative wet/dry irrigation and biological
control measures, have shown temporary decreases in mosquito populations
but none have been linked to a decrease in JE cases. Regardless of its effectiveness
against JE, vector control is important for the control of many vector-borne
diseases and should be maintained for the control of those diseases.
Bed nets are only effective for young children who may be in bed in the
early evening as the Culex mosquito bites in the twilight hours. The population
at-risk for JE is 1-15 years of age, and usually this population is still active during
these peak hours. So a large portion of the at-risk population will still be exposed
despite the use of bed nets.
Amplifying host control

As the vector of JE is hard to control, additional efforts have been directed to
the main amplifying host, the pig. Pig control has been attempted in three
ways: segregation, slaughtering or vaccination. Segregation is not practical in
many settings. Slaughtering has a high economic impact and affects the livelihood
of many families. Vaccination of pigs is costly, difficult and very time consuming.
The window of opportunity for immunization is limited as pigs are often
slaughtered at 6-8 months of age and vaccination too early has interference
from maternal antibodies. Pig vaccination, therefore, has not been shown to
significantly impact human cases of JE. In addition to the challenges of controlling
pigs, multiple other animal hosts exist in the life cycle of JE virus. For example,
birds have been implicated in several outbreaks in different settings. So, even
with excellent control measures of pigs the risk of JE virus transmission is still
present.
Environmental control
It has been suggested that urbanization and economic development have led
to decreases in JE transmission but this has not been well documented. In
Singapore the urbanization of the entire country has stopped viral transmission.
However, this model is hard to replicate elsewhere. Recent viral transmission
in wild pigs on outlying islands has raised concern about the potential of human
exposure. Prior to the availability of vaccines, vector and environmental control
were the only options to control JE. Multiple reviews have shown that these
measures are neither sustainable, nor cost-effective and have a limited temporary
impact. As JE virus is a part of the ecosystem with multiple hosts and vectors,
eradication is not possible.

Prevention of JE with vaccination
JE control through vaccination has been well established in many countries.
The success of this intervention is best illustrated through the experience of
Thailand. From 1973 until 1983, a vertical control programme for JE with vector
control, case detection and outbreak response was used without much effect
on disease burden. Since 1983 this programme has been integrated with the
primary health care system as a horizontal control programme which also had
little effect. However, when JE vaccine was introduced in a phased manner
and as coverage increased, the incidence of JE fell dramatically. At a bi-regional
consultation on JE, held in 2004 in Bangkok, control strategies were reviewed
for all countries from both the South-East Asia and Western Pacific Regions.
One of the main conclusions of this consultation was the general agreement
that preventive campaigns in high risk populations followed by introduction of
JE vaccine into the routine EPI in endemic regions are an appropriate strategy.
This strategy mirrors the approach used for yellow fever which is also a mosquito-
borne flavivirus. Recent work has shown that JE immunization is not only cost-
effective but also cost -saving. More cost effective and safe vaccines are now
available and technical support through WHO and partners can help countries
control JE throughout Asia. One vaccine, the live attenuated SA 14-14-2, now
has a specific public sector pricing available for the JE endemic countries of
Asia with GNP less than 1000USD to allow increased access. With the availability
Figure 1: Japanese encephalitis control in Thailand 1970-1997*
* Graph form Thai MOPH presentation at JE bi-regional meeting 2002
of safe, effective and affordable vaccines, JE control is now possible as an
integrated part of the public health system. Vaccination now provides an effective
and reliable public health intervention.
Treatment options
There is no specific therapy for JE so the care of JE patients though only
supportive, requires excellent critical care and careful attention to early
rehabilitation. By providing diligent care, case fatality rates can be greatly
reduced. In India in a retrospective study of 12,506 cases, the main causes of
death were aspiration, hypoxia, hypoglycemia and uncontrolled seizures.
Supportive care, therefore, focuses on airway management, seizure control,
decreasing cerebral edema, fluids and nutrition, fever control and managing
secondary infections.

Vaccines against Japanese encephalitis 2
2.1 Type of vaccines

Three types of JE vaccine are currently in use in several JE endemic countries
within the Asia-Pacific region. They are namely:
(1) mouse brain-derived inactivated vaccine;
(2) cell culture-derived live attenuated vaccine, and
(3) cell culture-derived inactivated vaccine.
Mouse brain-derived inactivated vaccine

The mouse brain-derived inactivated JE vaccine is produced in several Asian
countries. This is the only type of JE vaccine that is commercially available on
the international market. The commercially available mouse brain-derived JE
vaccine is based either on the Nakayama strain, which was isolated in Japan in
1935, or on the Beijing-1 strain. Currently, the mouse brain-derived vaccine is
used in China, India, Japan, South Korea, Sri Lanka, Thailand and Viet Nam.
The mouse brain-derived JE vaccine is given subcutaneously in doses of

0.5 ml or 1 ml, the lower dose being for children aged 1-3 years. Due to likely
interference of maternal antibodies, children are usually not vaccinated before
the age of 1 year. The manufacturers of the internationally marketed vaccine
recommend that primary childhood immunization involve 2 injections at an
interval of 1-2 weeks. In several Asian trials, primary immunization has a disease-
preventing efficacy of > 95%; 91% efficacy was achieved in a placebo-controlled
trial. There is no reduction in seroconversion rates when other childhood
vaccines are given simultaneously. However, the primary vaccination schedules
vary considerably among different Asian countries.
Cell culture-derived live attenuated vaccine

This Chinese vaccine is based on a stable neuro-attenuated strain of the JE virus
(SA-14-14-2). In non-endemic areas, a single dose of this vaccine induced an
antibody response in 83%-100% of children aged 6-7 years, and older children
when immunized twice at intervals of 1-3 months, 94%-100% showed a
serological response. Side-effects are reported to be minimal. Although at least
two doses are recommended, there is evidence that even a single dose can
stimulate adequate immune response in the recipient of the vaccine as
demonstrated more recently in Nepal. Apart from hundreds of millions of doses
used in China, India began introduction of this vaccine in 11 high endemic
districts in five states in 2006.
Cell culture-derived inactivated vaccine

This vaccine is manufactured in China and is based on the Beijing P-3 strain of
JE virus. Primary immunization of infants with this formalin-inactivated vaccine
results in about 85% protection. The vaccine is inexpensive, and 90 million
doses are distributed for internal use in China every year. However, in China
this vaccine will be gradually replaced by the cell culture-derived live attenuated
vaccine.
JE vaccines in development
Other vaccines are in development and in late stage clinical trials in adults. For
up to date information please see: http://www.who.int/vaccine_research/
diseases/japanese_encephalitis/en/

Immunization strategy for the control of JE 3
At the bi-regional meeting on JE held in Bangkok, (30 March to 1 April 2005),

after reviewing the experiences from all countries that have successfully
controlled JE with vaccination, the consensus statement on future strategies
stated: “A proven immunization strategy for JE control seems to be to initiate a
preventive campaign in high-risk areas and age groups followed by introduction
of vaccine into the routine EPI Programme.” Therefore, the strategy for JE
vaccination should include a combination of mass campaign followed by
introduction into routine, EPI programme or introduction into routine EPI
programme without mass campaign. The latter will be appropriate only in those
areas where the disease prevalence is low (or areas considered as low endemic)
and the likelihood of an outbreak minimal. For all JE endemic countries, it is
necessary to ‘develop a basic minimum data set that countries require for a
decision on vaccine introduction. Such information may include disease burden,
age, and geographic distribution of cases.
3.1 Mass campaign

Planning for mass campaign
(See Annex 1: Checklist for planning a mass campaign with JE vaccine)
It is important for countries to carefully review the criteria used to decide which
geographic areas to include in the campaign and what age group to consider;
not all areas need to be covered and age groups immunized. Some key
considerations that must be taken into account to guide a decision on the
selection of areas and age groups to be included in a mass campaign are:
• Review information from the past on cases, deaths, outbreaks reported
etc. to make a decision on which areas to include for the mass campaign.
• Identify reliable source of data to provide accurate population size
estimates for different age strata in defined geographic areas.
• Assess the cold chain space and equipment to ensure that the large
quantity of vaccines and injection equipment can be accommodated.
• Assess the health system delivery infrastructure, particularly logistics
such as transport, storage, and human resources needed to conduct
the campaign.
• Put in place a procurement plan that ensures there is sufficient vaccine
for the campaign.
• Ensure sufficient funds to meet the cost of vaccines, equipment, and
operations.
Defining high risk geographic areas for mass campaign

JE is a focal disease with seasonal patterns impacted by agricultural activities,
variation in rainfall, animal husbandry and bird-rearing practices of that locality.
Peak seasons may vary from state to state in large countries; for example, the
peak season for JE is the summer months July to September in Northern India
whereas, in the Southern parts, the JE season starts from about August to peak
during the winter months. Seasonality is an important consideration for the
vaccination campaign as vaccination must precede the onset of the JE season;
vaccination during an outbreak usually has minimal impact on the progress
and outcome of that outbreak.
While all places that report even one case of JE are at risk of future JE
outbreaks, due to the sheer cost and the logistics challenges of immunizing
everyone, particularly in large population countries, some prioritization is
necessary. There are no clear-cut rules for this decision and every country must
make that judgment based on the considerations as outlined above. Countries
have used different approaches based upon availability of data or pressure
brought on by outbreaks.
• Thailand initiated routine JE vaccination in children 18-24 months old

in eight Northern Provinces with a JE morbidity rate of more than
1.5/100,000 population. Catch-up campaigns were conducted for
children aged 7 to 9 years. Both routine immunization and catch-up
campaigns were expanded in a phased manner to reach 34 provinces
by 1999. JE vaccine is offered nationwide as of 2000 due to continued
risk and population migration.
• In the planning for JE vaccination in India, 10 years data on case reports
and outbreaks were reviewed. Due to the difficulty in establishing either
an incidence or a prevalence rate, the total cases reported during the

period 1993-2004 were compiled. Five states with the maximum
number of cases reported in this period were listed as priority. Further,
within the selected states, district-wise data were reviewed and 11
districts with the highest number of cases or outbreaks reported were
selected to be targeted in the first phase in 2006.
Defining age group for mass campaigns

Ideally, anyone living in JE-endemic areas should be immunized. However,
mass campaigns are logistically complex and very expensive to carry out.
Therefore, it is essential to assess which age groups are to be targeted for
maximum impact on the epidemiology of the disease.
• Data from Thailand show that of the cases reported from 1993 to 1997,
60% were in children below 15 years of age, with maximum morbidity
in these below 10 years. The catch-up campaign was limited to only
those between 7 to 9 years of age.
• In a major outbreak in 1988 in the same area where the 2005 outbreak
occurred in Uttar Pradesh, 60.4% of the reported cases and deaths
were in children below 10 years of age, with only 10.3% reported in
those aged 19 years or above. In the years between 1978 to 2001,
60% to 80% of reported cases were in children below 15 years of age.
• In Sri Lanka, when JE vaccine was introduced into the routine
immunization programme, campaigns targeted at children aged 10
years or less were carried-out with a major impact on the disease in
the immunized districts.
Where JE is endemic, the vast proportion of cases occurs in children

aged 10 years or less. Although some countries have carried out campaigns
targeting children up to 15 years of age, most countries that have carried
out mass campaigns targeted children aged 10 years or less. The decision
on the age group to be included for campaigns should be based on local
epidemiological data and available resources.
3.2 Conducting the mass campaign

Conducting a mass campaign requires meticulous planning and careful
coordination to make it a success. An exercise of such a magnitude requires
the involvement of many sectors and the administrative authorities at different
levels. In order to guide the planning of a mass campaign, a ‘Checklist for
planning a mass campaign with JE vaccine’ as attached at Annex 1. Please
ensure that you go through the checklist before you hold your final preparatory
meeting on the day prior to the actual launch of the campaign.
Final preparatory meeting

The District Coordinating Team or District Task Force (DTF) must meet at least
24 to 48 hours prior to the actual launch of the campaign to assess the readiness
for the campaign. The DTF should check the following:
• District microplans have been developed and discussed in detail.
• Responsibilities have been defined with clear tasks assigned to
individuals and departments.
• Clear lines of communication established; clear command and control
structure in place.
• Vaccines, injection supplies and cold chain equipment (vaccine carriers,
cold box, freezers, refrigerators, icepacks) in place and in sufficient
quantities.
• Ice packs prepared; if insufficient, ice blocks requisitioned from private
ice factories.
• Information and communications (through banners, posters, radio, TV)
etc. commenced. Announcements being aired from mosques, temples,
and public address systems in villages, towns etc.
• Medical centres and medical officers identified to deal with AEFI should
any occur during the campaign.
• Daily reporting plans in place and instructions given on how to provide
daily feedback at the end of each day.
• T-shirts, caps, other advocacy materials (if available) distributed to health
workers and supervisors.
• District level, micro-planning map developed.
The immunization team

It is recommended that each team should ideally comprise of at least five
members; of these, at least two must be health workers or nurses who have
experience with giving injections. The team composition may be as follows:

• Two health workers/nurses;
• One assistant to manage the crowd;
• One assistant to do the registration and filling of forms, and
• Another one to mark tally sheets as the child receives the injection.
Setting up the immunization post

Since mass campaigns need to be conducted in the heart of the community to
get maximum coverage, it is essential to identify central locations such as schools,
mosques, temples, community halls etc. Once the place is identified, the
immunization centre can be established. The centre should be used in such a
way that children enter from one direction and leave for the opposite direction;
avoid entry and exit through the same door.
A long table should be set up. If this is not possible, at least two to three
small tables are needed. The first table should be used for issuing the
immunization card. The central table should have the vaccine, syringes and
safety boxes. The third and last place or table should have the tally sheets. Keep
unopened vaccine carriers or cold box under the table and not on top of the
table. (see figure 2)
Figure 2: A sample sketch of a typical layout of an immunization session
Source: WHO/IVB/04.06
Administering the vaccine
• Use common-sense to decide if the child seems to be in the age group
identified for the vaccination; DO NOT waste time trying to get proof
of age.
• Keep children in single file.
• The SA 14-14-2 vaccine comes as either a single dose or in 5-dose
vials. At present the vaccine does not come with vaccine vial monitors
(VVM).
• Reconstitute only one vaccine vial at a time. Once reconstituted, place
the vaccine vial on top of an ice pack, but make sure that the ice pack
is not frozen solid. Allow the ice pack to warm up, i.e. ‘conditioned.’ A
conditioned ice pack has water around the ice in the pack. Otherwise,
separate the reconstituted vial from the frozen ice pack either by a
piece of cardboard, or the foam often found in vaccine carriers.
• DO NOT expose the reconstituted vaccine to direct sunlight.
• DO NOT fill multiple syringes and keep them lying around; fill one
syringe at a time, use one before filling another.
• There is NO need to clean site of injection; DO NOT use alcohol to
clean the cap of the vial or injection site.
• Used needles should be disposed of in accordance with national
guidelines.
• Only after the child receives the injection should the tally sheet be
marked.
Ending the immunization session

• Make sure that the immunization team waits till the end of the stipulated
working time for the day so that late comers are not missed.
• Once the decision to close the immunization post is taken, several
things need to be done. These include:
− Checking the number of immunization cards issued against the
number ticked in the tally sheet; sort out if there are differences.
− Make sure that the tally sheet markings are complete, total the final
numbers and record it.
− Count the number of vials used, check the unused balance and
compare with the number of children immunized.

− If possible, note the wasted vials (in terms of doses of vaccine used
and wasted).
− If any unopened vials are left and if they have stayed in the vaccine
carrier or the cold box, return them to be used the next day. But
discard all reconstituted vaccines that are NOT used.
− Has there been any adverse event during the immunization session?
If any, make note of it after carefully checking the facts about the
event.
− Compile and communicate the day’s result to the supervisor on the
same day.
− Check for missing population and plan for reaching the unreached.
Do’s and Don’ts of vaccine management
• If the vaccine and diluent are not packed together, it does not matter
if the lyophilized vaccine vial is kept at sub-zero temperature. If the
vaccine and diluent are packed together, make sure that the icepacks
are conditioned prior to putting them in the vaccine carrier to avoid
freezing of the diluent. Wrap the diluent container in brown paper
before putting it in the vaccine carrier.
• If diluent containers are packed separately, ensure that an equal
number of diluent containers are packed as that of vaccine vials.
• To reconstitute the vaccine; the diluent should be stored at the same
temperature as the vaccine (+2 to + 8 degrees centigrade and not
frozen).
• Reconstituted vaccine should not be exposed to direct sunlight; it
also should not be placed directly on solid ice or frozen ice packs.
• Never use alcohol to clean the rubber stopper of the vial.
3.3 Ensuring injection safety and adverse events

following immunization (AEFI) during a campaign
(See Annex 2: Detecting and reporting AEFIs)
Countries must have an AEFI monitoring system even for routine immunization
programmes. This becomes even more important when a new vaccine is being
introduced. Many countries already have national guidelines which should be
followed. Although vaccines are safe, there is no vaccine that is entirely without
risks. It is important to have in place a monitoring system that includes early
detection, rapid investigation and appropriate and timely management of such
events. While AEFI should be integrated into the routine surveillance system in
the national EPI Programme, injection safety concerns must be addressed a
little differently when an injectable vaccine is used on a mass scale. Special
consideration with JE vaccine:
• It is essential to perform a lumbar puncture (LP) on any patient with a
neurological event following immunization and is especially important
within the 28 days following immunization.
• AEFI surveillance provides an opportunity to monitor for programme
errors as well as ensuring the safety of injections.

Routine immunization with JE vaccine
and surveillance for JE 4
4.1 Routine immunization

Following the mass campaign, JE vaccine needs to be introduced as part of
routine immunization to maintain immunity in the new birth cohort. Therefore,
JE vaccine should be treated like any other antigen with regard to forecasting,
procurement, distribution and management. As known endemic areas receive
immunization, JE cases will appear in adjacent or other areas. People in those
areas will demand vaccination. Therefore, a country introducing JE vaccine in
high-risk areas must be prepared to introduce progressively in other areas where
JE is known to be endemic or where JE may spread. Routine immunization is
a long-term investment and careful consideration must be given to its
sustainability.
Immunization schedule
Vaccination should be administered according to the national immunization
schedule with attention to contraindications and co-administration as
appropriate. The WHO recommended schedule for the inactivated vaccine is
three doses: one dose given at 6 months of age or later, followed by a second
dose 1-4 weeks later with the third dose given at one year of age. However, the
schedule of vaccination varies from country to country: in Thailand two doses
of the inactivated mouse-brain-derived vaccine are administered between 18
to 24 months, and a booster dose at 2.5 to 3 years of age. Sri Lanka currently
uses the inactivated mouse-brain-derived vaccine and three doses are
administered at 12, 13 and 24 months of age.
The live attenuated SA 14-14-2 vaccine is recommended to be given as a

single dose to children older than 8 months of age followed with a second
opportunity at 2 years of age. However, at present it is not recommended to
give the vaccine to children below one year of age till further evidence of its
safety in infants is available. Please follow package insert and national
recommendations for the most up-to-date information. The age at which the
first dose is to begin, should be based on local age distribution of cases and
immunization schedule. The live JE vaccine has no additional contraindications
to other live vaccines.
Cold chain and logistics

In the management of JE vaccines, given that both the inactivated and the live
vaccines are lyophilized, their management and logistics aspects should not be
any different from how measles vaccine is handled; all countries have extensive
experience with measles vaccine.
Should further specific information regarding management of the live

vaccine become available, adjustment to the guideline will be made as
appropriate.
Monitoring and reporting

The monitoring and reporting, be it on vaccine stock or immunization coverage,
should be integrated into routine EPI activities and JE should not be treated as
something different.
In addition, vaccine impact on disease transmission should be followed to

justify impact and follow programme effectiveness.

Vaccine procurement 5
5.1 Vaccine licensing or registration

Currently, no JE vaccines are WHO pre-qualified. However, WHO pre-
qualification is not required for use of vaccines in countries as long as the
vaccines are known to be of assured quality. Such an assurance comes when a
country has a functional National Regulatory Authority (NRA). Countries should
consider and license JE vaccine through their NRA. The WHO document,
Regulation of vaccines: building on existing drug regulatory authorities
(WHO/B&B/99.10) is available on the web at http://www.who.int/vaccines-
documents/DocsPDF/www9846.pdf.
5.2 Vaccine procurement and management

(See also Annex 4: Stock Management)
The WHO document, ‘Guidelines for the international procurement of
vaccines and sera,’ (WHO/VSQ/98.05) is also accessible on the web at http:/
/www.who.int/vaccines-documents/DocsPDF/www9846.pdf.
The general guidelines for vaccine supply and stock management are
provided in Annex X. In general, vaccine management has several important
issues that are not specific to JE vaccine but are important to highlight as many
countries may not have extensive experience in vaccine procurement. Some
of these include:
• Manufacturers require significant lead time to produce vaccines. In
general, vaccines are produced after they are ordered so programmes
need to be planned early allowing approximately six months for
production and quality testing of the vaccine.
• Multi-year contracts can help with the stability of vaccine supply and
can be considered an important tool where available. For example,
UNICEF engages in three year contracts with manufacturers.
• In the management of vaccine supply, particularly for routine
administration, countries could consider setting a value for minimum
stock levels that trigger re-ordering.
5.3 Important considerations in the procurement and

management of JE vaccine are as follows:
• Seasonality of epidemics of JE frequently results in attempts to order
vaccine just prior to the JE season. This frequently does not allow
enough lead time for the manufacturer. It also does not account for
the production process that occurs year round and, therefore, cannot
have the surge capacity to meet demands for vaccine for all countries
at the same time. In addition to planning ahead, countries should
consider phased delivery of the vaccine supply round the year.
• Specifically with the SA 14-14-2 live attenuated vaccine, the shelf life
of the vaccine needs to be considered in programme planning and
while ordering the vaccine. The shelf life of the vaccine upon delivery
to the country is 10-12 months. This may have implications for stock
management.
5.4 Considerations for vaccine supply and allowable

wastage rates:
• Wastage rates will differ depending on the number of doses per vial
and on the settings in which the vaccine is used, i.e. either in campaign
or in routine infant immunization.
• In outreach clinics where the number of children attending the clinic
is small, a higher wastage may be expected. Use of single dose vials
should be considered for routine programme, but this will have a
major impact on the cold chain space requirement.
• Currently, the manufacturer of live JE vaccine produces both single
dose and five-dose vials. Therefore, at times single dose vials or a
combination of single and multi-dose vials may be the only formulations
available.
• Estimating vaccine needs should be based on the target population
for campaigns plus the birth cohort in areas previously covered with
preventive campaigns.

Allowable maximum wastage rates for vaccines
For multi dose vials, eg. DTP or HepB in 10-dose vials, wastage can be
high. In the past, WHO used a 40% wastage for multi dose vials. However,
with the launch of the Global Alliance for Vaccines and Immunization
(GAVI), the target for reduction of vaccine wastage rates were set at 25%
for multi dose vials such as HepB or HepB-DTP combination vaccine,
and at 10% for the two-dose pentavalent (DTP+HepB-Hib).
Since the SA14-14-2 vaccine is shipped in single-dose and five dose
vials, the allowable wastage should be 10% for the single-dose vials, and
at least 20% for the five dose vials. In a campaign setting, it may be
possible to reduce the wastage to around 5% for the single-dose, and
15% for the five-dose vial.
5.5 Receiving vaccines and supplies

At all levels, qualified personnel should receive the vaccines and supplies. The
following steps are recommended to be followed:
• Check all accompanying documents to ensure they are properly filled.

• Check the delivery address and external marking indicating the contents
of the box.
• Check the condition of packaging (to see if opened, damaged or
otherwise tampered with).
• Once the boxes are opened, check if the content is the same as labeled
and as written on the delivery slips.
• Check if the diluents are correct for the vaccines; ensure that equal
quantities of diluents are shipped along with the vaccine.
• Check the shipping indicators/temperature monitors in all boxes.
• Check the date of expiry.
For all vaccines supplied through UNICEF or other UN Procured systems,

a Vaccine Arrival Report (VAR), designed to monitor international shipment of
vaccines and to ensure that shipping guidelines are followed, is required to be
filled in and distributed as appropriate.
5.6 Vaccine administration
The administration of the SA 14-14-2 vaccine is no different from that of measles
vaccine.
Although there is data that the live attenuated vaccine can be safely given
to children as young as 8 months, the current recommendation is NOT to use
it in children younger than one year. Also, it is recommended NOT to
administer measles and the SA 14-14-2 vaccines together or on the same
day (co-administration). Data may be available by the end of 2006 to
demonstrate if co-administration is appropriate.
The characteristics of the inactivated and the live attenuated vaccines are
given in Table 1.
Table 1: Characteristics of mouse-brain-derived and SA 14-14-2 vaccines
For both vaccines, age of first immunization should be based on epidemiological data on transmission
and the local immunization schedule.

5.7 Cold chain requirements
The general cold chain rule is to store all vaccines at +2°C to +8°C. A lyophilized
vaccine can be stored at low temperatures for long periods, but diluents are
not recommended to be frozen. Further, once the vaccine is reconstituted it
should NOT be frozen. At the central and regional vaccine stores, if the vaccines
and diluents are packaged separately, the lyophilized vaccine can be stored in
freezers or a walk-in freezer room, but not the diluent. At the district level,
vaccine can be stored at +2°C to +8°C.
5.8 WHO opened-vial, multi-dose policy

WHO’s policy for reconstituted vaccine is to discard the reconstituted vaccine
at the end of the session or after six hours, whichever comes first. However,
currently the SA 14-14-2 vaccine is recommended to be used within one to
two hours once it is reconstituted. Therefore, it is important that this special
requirement for the SA14-14-2 is kept in mind, particularly if a programme
uses the 5-dose vial for their routine immunization programme.
6 Surveillance for Janpanese encephalitis
6.1 Clinical case definition of Acute Encephalitis

Syndrome
Clinically, a case of Acute Encephalitis Syndrome (AES) is defined as a person of
any age, at any time of year with the acute onset of fever and a change in
mental status (including symptoms such as confusion, disorientation, coma, or
inability to talk1) AND/OR new onset of seizures (excluding simple febrile
seizures2).
Case classification
Suspected Case: A case that meets the clinical case definition for AES. Suspected
cases should be classified in one of the following four ways:
Laboratory-confirmed JE: A suspected case that has been laboratory-

confirmed as JE.
Probable JE: A suspected case that occurs in close geographic and temporal
relationship to a laboratory-confirmed case of JE, in the context of an outbreak.
“Acute encephalitis syndrome” – other agent: A suspected case in which

diagnostic testing is performed and an etiologic agent other than JE virus is
identified.
“Acute encephalitis syndrome” – unknown: A suspected case in which

no diagnostic testing is performed or in which testing was performed but no
etiologic agent was identified or in which the test results were indeterminate.
1
Other early clinical findings may include an increase in irritability, somnolence or abnormal behaviour
greater than that seen with usual febrile illness.
2
A simple febrile seizure is defined as a seizure that occurs in a child aged 6 months to less than 6 years
old, whose only finding is fever and a single generalized convulsion lasting less than 15 minutes, and
who recovers consciousness within 60 minutes of the seizure.

While the above classifications are useful for clearer definitions of AES
cases, for practical purposes, the two key definitions to use are “suspected
JE cases” for those that meet the criteria for AES, and “confirmed JE
cases” for those AES cases which have laboratory confirmation for JE.
6.2 Types of surveillance for JE

At the peripheral and district level health facilities where diagnostic capacity
for JE does not exist, JE surveillance takes the form of surveillance for acute
encephalitis syndrome (AES). Such surveillance should be conducted through-
out the year. Where feasible, surveillance for and reporting of JE should be
performed within the context of integrated disease surveillance, supported
by synergistic linkages with similar on-going surveillance activities such as those
for acute flaccid paralysis (AFP) or meningitis. In such situations, reporting of JE
cases and deaths should be part of the national health management information
system (HMIS) or integrated into communicable diseases reporting systems.
However, in many countries it may not be possible to conduct a nationwide

surveillance system for JE; it may not even be necessary as JE is often localized
to specific geographic areas. Further, JE is a virulent agent resulting in severe
illness leading to self-referral. The need for active case detection is, therefore,
unlikely to be beneficial. In such a situation, it may be reasonable or more
practical to consider passive health facility-based sentinel surveillance for
the detection and reporting of AES on a routine basis. Sentinel surveillance
may aim to include all hospitals in JE-endemic areas or select the ones where
most cases are usually seen. Thus, such a system cannot be expected to provide
information on AES from all JE-endemic areas. However, sentinel surveillance
systems when used systematically over time will be able to provide information
on the trend of the disease; such a system can also provide early warning
systems for potential outbreaks of JE. On the other hand, given the nature of
the disease, an AES case would ultimately turn up in a health facility sooner or
later. Thus, a sentinel surveillance system may, in fact, pick up most AES cases
that may be occurring in that area.
Based on the endemicity and the current control status for JE, and in
accordance with WHO surveillance standards, surveillance systems may be
broadly considered as follows:
(1) In all Asian countries
Comprehensive syndromic surveillance for acute encephalitis syndrome (AES)
with aggregate reporting is recommended where feasible. In sentinel hospitals,
surveillance should be case-based with specimens collected for laboratory
confirmation3. The number of sentinel hospitals can be gradually increased if
feasible logistically.
(2) In Asian countries where a high level of JE control has been

achieved.
Surveillance should be case-based throughout the country and include laboratory
confirmation of all suspect cases.
Regardless of the type of surveillance, reporting should be weekly or

monthly and include “zero-reporting” (i.e. no blanks should be left in the
reporting forms, a zero should be indicated when there are no cases detected).
Outbreak investigations should be initiated if there is a sudden increase in
cases or if cases reported are different from historical information, in terms of
season, geographic area, age group, or case fatality.
6.3 JE outbreaks and outbreak response

Japanese Encephalitis outbreaks are serious as lives are lost and severe disability
caused to those that survive the disease. Any outbreak should be investigated
thoroughly and an intersectoral approach adopted in the response to an outbreak
of suspected JE.
Defining an outbreak
There is no single definition. In areas where JE endemicity is low, every case
may trigger an investigation. Where JE is endemic, the term outbreak is
misleading, unless this applies to an abnormal increase in suspected JE cases as
compared with normal transmission. It is difficult to define “abnormal increase”-
it should be defined as an increase above and beyond the “normal range” of
seasonal variation in reported cases, along the lines of the epidemiological
analysis of influenza outbreaks. The “normal range” will differ for different
countries.
3
During epidemics, laboratory testing can be limited to confirmation of the first 5-10 cases per geographic
area per epidemic.

Outbreak response
Once an outbreak is deemed to have occurred, immediate steps need to be
taken to conduct a rapid investigation of the outbreak and appropriate control
measures effected in time. In most countries, communicable diseases
departments have outbreak response teams. The immunization programme
must link closely with such teams and have established routes of communication
and agreed rules of procedure in responding to such events.
An outbreak response should include the following steps/actions

• Assessment to confirm the outbreak.
• Information, education and communication (IEC).
• Options for response.
Assessment to confirm the outbreak

• Establish that the ‘suspect’ cases actually fit the definition of JE. Obtain
information with regard to onset of illness, place of residence of the
patient, recent travel history, etc.
• Send a team to the locality from where the ‘suspect’ cases have come
and conduct a rapid search for similar cases that may have occurred
but not reported to the health facility. To what extent such a rapid
assessment should be expanded will depend on the population density
and the nature of settlements.
• Determine if there have been any deaths that have not been reported
or deaths for which no cause has been established.
Information, education and communication (IEC)

• Launch an IEC campaign for the general public so that all cases with
AES symptoms are taken to the nearest health facility for supportive
care.
• Explain to the community leaders of the outbreak and the potential
threat of the disease.
• Encourage the separation of human dwellings from close proximity to
animals such as pigs and wading birds.
• Establish a line of communication with the local media, appoint a focal
person for the media to refer to, and release information as regularly
and as accurately as possible.
• Encourage people to sleep under mosquito nets, preferably under
insecticide-treated nets.
• Encourage people to bring the patient early to the nearest health facility.
Options for response

• Reinforce local physicians’ capacity to provide supportive care for cases
with AES symptoms; provide physicians with simple ‘do’s’ and ‘don’ts’
and quick reference materials for clinical care. Emphasize that all
treatable should be ruled out prior to labeling a case as AES.
• Conduct a quick survey of the environment- rice fields, other likely
places where water can collect, presence of pigs or other likely
amplifying hosts for the virus.
• Link up with the integrated vector-borne diseases unit or malaria control
programme to explore possibilities of studying vectors known for
transmitting the disease.
• Get malaria or vector-borne diseases departments to conduct fogging
using space sprays.
• Conducting larviciding in areas with stagnant surface water and periodic
draining of rice fields may be possible, but requires a high degree of
sophistication in agricultural practices to be effective without risk of
damage to crops.
• It is an excellent opportunity to review immunization coverage if JE
vaccine is already being used, and if not, it is also an opportunity to
advocate for introduction of JE vaccine.
Data collection, analysis and reporting during a JE outbreak

When an outbreak occurs, there is usually tremendous pressure to start
immunizing. It is generally agreed that once an outbreak starts, immunizing the
population only has a limited impact. However, outbreaks provide excellent
opportunities to impress on national policy makers the importance of introducing
JE vaccine as part of routine immunization if it is not already integrated into the
National Immunization Programme (NIP). In countries where JE vaccine is
already a part of the routine programme, a thorough review of the immunization
coverage with the aim to improve access in subsequent months is an important
and necessary exercise.
During an outbreak investigation, the data collection tools must be simple,

data collected minimal and most relevant, and rapid analysis and transmission

of information made central to the purpose of the investigation. A few key
things to keep in mind include:
• Two basic forms need to be developed: a case investigation form and
a line list. A case investigation form will have more detailed information
with regard to the patient’s personal history, the onset and progress of
the disease and its outcome, and other related information. The line
list should have only the minimal information necessary: eg. age, sex,
locality (address), time of onset and outcome.
• Case investigation should be limited to establish an outbreak of JE; at
least 5 to 10 samples from suspect JE cases need to be collected for
laboratory confirmation in order to limit wastage of laboratory reagents.
Once confirmed, if there are many cases in the locality, it is essential
only to line list the suspect cases as no further resources and energy
should be expended to conduct case-based investigation of all suspect
cases.
• The minimum data to be collected in the line list are age, gender,
vaccination status, and address.
• In the analysis of the data, age should be grouped as 0-11 months,
12-59 months, 10-14 years, and >15 years.
Polio surveillance network and its relevance to JE surveillance

Several countries already have well established polio surveillance networks that
carry out on integrated vaccine preventable disease surveillance including
measles, rubella, neonatal tetanus and, more recently, JE. The regular surveillance
work for the surveillance medical officers (SMO) for acute flaccid paralysis (AFP)
requires them to visit health facilities on a regular basis to check if any AFP
cases have been seen. Therefore, adding AES surveillance does not require any
additional visits to heath facilities, as search for AES can be conducted during
the same visit for AFP cases.
In Nepal the polio SMO network is already reporting JE and the

Government of India has requested the National Polio Surveillance Unit (NPSU)
of India to assist in JE surveillance in the states of Uttar Pradesh and Bihar.
6.4 Other aspects of JE surveillance

Japanese Encephalitis virus is transmitted to humans by a mosquito bite. The
main transmission cycle involves animals and mosquitoes, with humans only
infected incidentally. Humans are also “dead end” hosts, meaning the virus
cannot be spread from human to human. The principal vector is Culex
tritaeniorhynchus, but a large number of other mosquitoes are known to carry
the virus including C. pipiens-pallens and C.quinquefasciatus in urban areas.
Pigs are known to be the key amplifying host, but aquatic birds also play an
important role in the transmission of the disease. Although other domestic
animals such as cattle, dogs, sheep, cows, chicken and peridomestic rodents
get infected, they do not achieve sufficient viremia to support further viral
amplification.
Surveillance can include entomological activities such as vector density

monitoring, larval density and breeding site surveys. In most cases, it is difficult
even for the malaria programme or the vector borne diseases control programme
to conduct such activities in a meaningful way, despite having an infrastructure
for entomological services as well as trained entomologists. It would be almost
impossible for an immunization programme to carry out such activities without
strong support from entomological units. Assessment of pig density in relation
to human habitation and evaluating rearing practices of aquatic birds may
provide some interesting information, but with minimal utility for control
activities.
Serological surveillance, where feasible, in domestic pigs might provide

useful information with regard to continuing viral activity, particularly in countries
where JE vaccination may have reduced the prevalence of JE in humans to
insignificant levels.
Serological surveillance of immunized cohorts of children over successive

years may provide useful information on the rate at which protective immunity
wanes following primary immunization. Such information may help national
programmes to determine the need for booster doses. However, in most
programmes this would be difficult to implement due to cost and logistics
reasons.

Laboratory aspects of surveillance for JE 7
7.1 Laboratory criteria for confirmation

Clinical signs of JE are indistinguishable from other causes of AES. Epidemiological
data can provide supporting information for the diagnosis. However, laboratory
confirmation is essential for accurate diagnosis of JE.
Laboratory confirmation of a JE virus infection includes:

Presence of JE virus-specific IgM antibody in a single sample of cerebrospinal
fluid (CSF) or serum, as detected by an IgM-capture ELISA4 .
OR ANY ONE OF THE FOLLOWING which may be done in specialized
laboratories:
(1) Detection of a four-fold or greater rise in JE virus-specific antibody as
measured by hemagglutination inhibition (HI) or plaque reduction
neutralization assay (PRNT) in serum collected during the acute and
convalescent-phase of illness. For these tests the two specimens
should be collected at least 14 days apart; OR
(2) Detection of JE virus genome in CSF5, serum, plasma, blood, or tissue
by reverse transcriptase PCR or an equally sensitive and specific
nucleic acid amplification test; OR
(3) Isolation of JE virus in CSF5, serum, plasma, blood or tissue; OR
(4) Detection of JE virus antigens in tissue e.g. by immunofluorescence
assay (IFA) or by immunohistochemistry.
4
Further confirmatory tests (e.g. looking for cross-reactivity with other flaviviruses circulating in the
geographical area) should be carried out: (a) when there is an ongoing dengue or other flavivirus outbreak;
(b) when vaccination coverage is very high; or (c) in cases in areas where there are no epidemiological
and entomological data supportive of JE transmission.
5
Detection of virus genome or virus isolation in serum, plasma or blood is very specific for JE diagnosis;
however, it is not sensitive as virus levels are usually undetectable in a clinically ill JE case. Therefore a
negative result by these methods should not be used to rule out JE in a suspected case. Similarly detection
of virus genome or virus isolation in CSF is usually only found in fatal cases and therefore not very
sensitive and should not be used for ruling out a diagnosis of JE.
The large majority of JE infections are asymptomatic. Therefore, in JE
endemic areas it is possible to have AES due to a cause other than JE
virus and have JE virus-specific IgM antibody present in serum. To avoid
implicating asymptomatic JE as the cause of other AES illnesses, sterile
collection and testing of a CSF sample from all persons with AES is
recommended when feasible.
Because a serum sample collected on admission may not yet be positive

in a JE-infected person, a second serum sample should be collected at
discharge or on the 10th day onset or of illness of the time of death and
tested for presence of JE virus specific IgM by ELISA.
Note:
• For persons vaccinated with Japanese encephalitis vaccine within six
months of illness onset, testing a single serum sample for Japanese
encephalitis IgM may not be diagnostic because it may give a false
positive result. In such cases, a diagnosis can only be confirmed by
demonstrating JE IgM in the CSF, JE virus isolation, a positive nucleic
acid amplification test, immunohistochemistry, IFA, or a four-fold or
greater rise in antibody titre in acute and convalescent phase serum
samples.
• To confirm if a seasonal outbreak is due to JE, suspected cases should
be tested until 5-10 are laboratory-confirmed as JE. If the outbreak is
not an expected seasonal outbreak, or there are unusual epidemiological
features (e.g. age distribution of cases not consistent with pattern of JE
infection), testing of CSF is especially important, as an encephalitis
outbreak could be due to other aetiologies (eg. Nipah virus). In a non-
JE outbreak, sporadic cases of JE are still likely to occur, so the percentage
of specimens confirmed as JE positive also should be considered. For
example, in previous large JE outbreaks, typically about 30% cases have
been JE positive, so confirmation of a much smaller percentage of cases
may prompt further investigations into the aetiology of the outbreak.
As a JE outbreak continues, all samples may not need to be tested. For
example, 5%-10% could be tested on an ongoing basis.

7.2 The JE laboratory network
Samples should be sent for JE testing to designated first level laboratories. At
these laboratories the preferred test for JE diagnosis is the IgM-capture ELISA
(enzyme linked immunosorbent assay). These laboratories may also carry out
other investigations or send the specimens to other levels as necessary. In some
cases, the hospital laboratory may be a designated JE laboratory. For laboratories
in the JE network, systematic and regular supervision and quality control should
be ensured.
7.3 Specimen collection

Cerebrospinal fluid and blood (serum) are the specimens to be collected for JE
diagnosis. These samples should be collected on admission. If it is a serum
sample, it is important that a second serum sample is collected at discharge or
on the 10th day of onset or of illness at the time of death.
Initial processing of samples should be in hospital laboratories. Samples

for subsequent virological testing should then be sent to designated laboratories.
Patient information should be recorded on a laboratory request and report

form (see Annex x) that must accompany the specimen when it is referred to
the laboratory. Information should include: patient name, age (or date of birth),
province/district/town of residence, JE vaccination history (and date of last JE
vaccination), date of onset of symptoms, types of specimen and date of specimen
collection. In the case of an outbreak, a laboratory request and report form in
the form of a line list may be prepared (Annex 3 ).
All specimen tubes should be labeled with the patient’s name or identifier
number, date of collection and specimen type.
Cerebrospinal fluid (CSF) collection

• The collection of CSF should be a routine procedure when a patient is
suspected of having meningitis or encephalitis. However, it is an invasive
technique that should only be performed by experienced personnel
under aseptic conditions.
• CSF should be collected into separate aliquots for examination for cells,
biochemistry, microbiology and virology. It should be collected in a
dry, sterile, screw cap container. For virological investigations, 0.5 to
1.0 ml of CSF is required.
• CSF should be transported to the local hospital laboratory as soon as
possible (ideally within 1 hour). Before arrival at the laboratory, the
CSF specimens for routine investigations should not be refrigerated or
exposed to extreme cold, excessive heat or sunlight. However, if there
is likely to be a delay beyond 1 hour, specimens for virology should be
refrigerated. In the laboratory priority should be given to ruling out
treatable (usually bacterial) aetiological agents.
• CSF samples for virological testing should be sent to the designated
laboratory as soon as possible. Before transport, in the hospital
laboratory, they should be kept at +4oC for short term storage (1 to 3
days) or at or below –20oC for longer term storage. If a –20oC freezer is
not available, they should be stored in the freezer section of the
refrigerator. If specimens have been frozen, they should be transported
frozen. Repeated freezing and thawing of CSF should be avoided as
this may lead to instability of IgM antibodies.
Blood specimen collection

• Blood should be collected by venepuncture and placed in a dry, sterile
vial. The volume of specimen should be approximately 5 ml for older
children and adults and 1 ml for infants and younger children.
• Blood should be allowed to clot at room temperature and then should
be stored in a cold box or refrigerator and maintained at +4oC to
+8oC and not frozen. It should be transported to the hospital laboratory
within 24 hours.
• In the hospital laboratory, serum will be separated for subsequent
transfer to a designated laboratory. For serum, shorter term storage (1-
3 days) should be at +4oC, but longer term storage should be at -20oC.
If a –20oC freezer is not available, samples should be stored in the
freezer section of the refrigerator If specimens have been frozen, they
should be transported frozen. Repeated freezing and thawing of serum
should be avoided as this may lead to instability of IgM antibodies.
7.4 Transport of specimen

• Ensure the availability of specimen collection containers, laboratory
request forms and secondary transport containers at health care
facilities.

• A designated person (or persons) should be responsible for storage,
packing and transport of samples according to national or international
guidelines.
• In principle a “triple packaging system” (refer to laboratory manual
for details) should be used when transporting samples from place to
place.
Transport planning
Successful shipment of materials requires advanced planning, appropriate
packaging, labelling, and documentation. Coordination and communication
are required between all parties involved – the sender, carrier, and receiver. It
is the responsibility of the sender to ensure the correct designation, packaging,
labelling and documentation of all shipped materials to ensure that the material
is transported safely and arrives on time and in good condition. The basic steps
to follow are as follows:
• Make advance arrangement with the receiver.
• Make advance arrangement with the carrier.
• Label the package to be shipped as Category B, “Patient’s Specimen”.
Documentation and sending the package

The documentation required to be completed for shipping materials is
determined by the nature of the materials being sent. In general, each shipment
should be accompanied with the following documents:
• Shipper’s Declaration of Dangerous Goods (only those goods classified
as infectious substances, see Figure 3).
• A packing list / proforma invoice / customs declaration / commercial
invoice which includes the receiver’s address.
• Number of packages, detail of contents, weight, value (a minimal value
should be indicated for customs purposes if the items are supplied free
of charge).
• Airway bill if shipped by air.
• Export / import permit if required.
8 References
(1) WHO Position Paper on Japanese Encephalitis. WER, 1998;73:337-343.

(2) Core information for development of immunization policy, 2002 Update.
WHO/V&B/02.28.
(3) Immunization in Practice, A Practical guide for health staff, 2004 update.
WHO&UN Foundation.
(4) Mid-Level Management Course for EPI Managers, Module 9, Block III-
Logistics. WHO/AFRO. March 2004.
(5) Introduction of hepatitis B vaccine into childhood immunization services.
Management Guidelines, including information for health workers and
parents. WHO/V&B/01.31 November 2001.
(6) Surveillance of adverse events following immunization. Field guide for
managers of immunization programmes.
(7) http://aim-e-learning.stanford.edu/en/vaccines/je/index.html.
(8) WHO recommended standards for surveillance. Japanese Encephalitis,
pages 46-51. WHO/V&B/03.01.
(9) WHO. Surveillance of adverse events following immunization. Field guide
for managers of immunization programmes. WHO/EPI/TRAM/93.02.REV.1.

Annex 1
Checklist for planning a mass campaign

with JE vaccine
While planning for a mass campaign, the following aspects of planning

should be kept in mind:
Coordination/planning
• Is there need to establish a national committee for the planning
and conduct of the mass campaign? If Yes, has it been formed?
• Is there need to establish a district coordinating committee?
• Is there need to develop a national guideline that defines geographic
areas and age groups to be included, along with time line for
activities, including overall strategy and policy for the campaign?
Has a team leader to coordinate national activities been identified?
• Has funding been secured? Has discussion with the Ministry of
Finance taken place and approval from relevant ministries sought?
• Has district level micro-planning been completed? If not, is there a
time frame within which it will be finalized?
Vaccine procurement
• Which vaccine will be used- inactivated mouse-brain-derived or
live attenuated SA 14-14-2 vaccine?
• Have you checked vaccine availability? For example, a letter of
intent is especially important where there is a sole supplier.
• What size vials (number of vaccine doses) of the vaccine will be
used?
• Has the procurement process been completed? When is the first
shipment expected to be delivered? Is there a plan of distribution
from the central level to provinces and districts?
• Have appropriate quantities of auto-disable syringes, re-constitution
syringes, safety boxes and diluents for the vaccine been accounted
for and ordered?
Cold chain
• Is there adequate space at the central and provincial cold stores to
accommodate the large quantities of vaccines likely to arrive soon?
• Has transport been organized and a distribution plan, along with
time lines, developed?
• Is there sufficient cold chain space and cold chain equipment at
the district level? Has an assessment been carried out or is there a
need to conduct a quick review?
• Is there need to develop a DO’s and DON’Ts list for cold store
managers and field workers who will handle the vaccine?
Injection safety
• Is there an injection safety plan?
• Is there a guideline on the use and disposal of auto disable syringes
at different levels of health facilities?
• Is there a plan for monitoring injection safety during the campaign?
• Does the country have an Adverse Events Following Immunization
(AEFI) monitoring system in place? If not, has a plan been developed
for AEFI monitoring during and after the campaign?
EPI forms and materials

• Will the recipients of vaccine be given a card? If Yes, have the cards
been printed?
• Have tally sheets been printed?
• Has a supervisory checklist been developed and printed?
Training
• Which staff needs to be trained? How will the training be carried
out?
• Who will provide the training?
• Is there a training plan or training schedule?
• Has any training material been developed? If Not, what plans are
there to start doing it?

Advocacy, communication and information
• Is there any need for advocacy targeted at decision makers,
influential community members and religious groups?
• What sort of advocacy materials need to be developed? What
messages need to be developed and communicated?
• Who will develop them?
• Is there a comprehensive plan on the use of existing media (TV,
radio, etc.) and community channels for communication (eg public
address system, religious gathering and festivals)?
• Have banners, posters, T-shirts etc. been ordered?
Supervision
• Have supervisors been identified at all levels?
• Has a supervisory checklist been developed and tested?
• Has a supervision plan been developed as an integral part of the
overall plan for the mass campaign?
Microplans
• Does the microplan map out accurately the distribution of dwellings,
and likely centres where immunization sessions are to take place?
• Is there accurate population data and is the estimated number of
target group for vaccination reflected on the activity map in the
microplan?
• Does the microplan contain details of vaccination sites, vaccination
teams, social mobilization plans and team, time table for activities
etc?
• Does the microplan clearly indicate the various supplies needed
for each of the planned session posts?
Annex 2
Detecting and reporting AEFIs
Which AEFIs should be reported?

During a campaign, the period up to which the system will monitor for adverse
events should be specified. Generally, it should be less than 48 hours after the
immunization session; anything occurring later than that should be part of the
regular AEFI system of the programme and not really that of the campaign.
The events, therefore, are also of immediate and sudden nature. They
include all deaths that are thought by health workers or the public to be related
to immunization, all cases requiring hospitalization that are thought to be related
to immunization, and any other severe or unusual medical events that are
thought to be linked to immunization.
Reporting the AEFI

As soon as a suspected adverse event is reported, the health worker must contact
the focal person identified for investigating AEFIs. If the health worker is not
sure, the information must be relayed immediately to the next level supervisor.
Immediate investigation must be initiated at the local level without waiting for
the AEFI Investigation Team to arrive.
Responding to the AEFI

The health worker must provide all supportive care as long as the child remains
within his area of influence. Every attempt must be made to shift the child to a
hospital and contact immediately the doctor identified as the focal person for
managing AEFI cases.
The health workers must collect all information regarding the suspect case
and make sure that the parents are kept well informed of the status and progress
in the management of the case. The health worker must be prepared to face
questions from local media or the community. Communicate the facts clearly,
honestly and as calmly as possible. Establish a line of communication and

information flow and let the parents and the community know who to contact
and how to contact for further information.
Investigating AEFIs
As soon as a suspected AEFI is reported, the investigation team must proceed
to the locality where the event occurred. Collect relevant information on the
patient data, time and activities immediately prior and after the immunization.
Obtain patient’s past history, history of any similar events in the past or any
known reaction to any drugs or other antigens. Review the child’s immunization
history and obtain results of laboratory investigation done, if any.
Review the vaccine (lot number, expiry, manufacture date) and the injection
equipment (for possible contamination, poor handling practices, re-use etc.).
Establish the circumstance and the persons who administered the injection.
Review the vaccine handling and storage practices, particularly reconstitution,
duration left unused after reconstitution, diluent (whether it was the right one
or not).
Have similar illness reports been received from the same locality or the
community? If any, investigate further. Collect samples of whatever is available
of the vaccine, syringes and needles (usually not available as they would have
been discarded).
Communicating the results of the investigation and

taking corrective action
Once the investigation is completed and all facts have been collected and
verified, a conclusion must be reached as to the nature of the adverse events.
A report must be made with the conclusions and communicated to all
concerned.
If the event is related to immunization, be it programme errors or quality

of vaccine, all possible corrective measures must be taken. The health worker
should not wait for the final conclusions of the investigation for taking corrective
action at the local level should such corrective actions be warranted.
Annex 3
SAMPLE: Japanese encephalitis virus

laboratory request and report form
*Sample is good if: If sample is bad specify

• There is no leakage Add in the following information:
• Of adequate quantity Fever at onset: Yes [ ] No [ ] Duration: ___________
• Brought in cold chain Seizures: Yes [ ] No [ ]
• Documentation is complete Altered level of consciousness: Yes [ ] No [ ]
Neck rigidity: Yes [ ] No [ ]
Any other information:_______________
Results of any laboratory investigations:_________________

Annex 4
Stock management
Defining vaccine supply period

It is important to plan vaccine procurement well in advance to ensure timely
arrival of vaccine supply. Most manufacturers need at least six months lead
time to prepare for supplies, and this is even more important if a large-scale
mass campaign is planned in a country. The general principles for vaccine stocks
and their period of storage at different administrative levels in the country are
as shown in Table 1. The main idea is to ensure that there is no overstocking or
stock-out at any administrative level.
Table 1: Generally recommended standard periods for vaccine supply
Location of store Supply period
Central store Six months
Regional/provincial store Three months
District store One month
Health centre One month
Health post/dispensary level* One week
*In many places, no vaccine is actually stored at the health post or dispensary level, and even at the
health centre level vaccine may be stored only for a week. The final determinant for a decision to store
or not to is the availability of electricity at that level.
There are sophisticated methods to calculate vaccine requirements based

on supply periods. However, for most programmes the vaccine supplies are
made either half yearly or on a quarterly basis, at least at the national and
provincial levels. More frequent supplies, for example, on a monthly basis may
be made from the provincial to district levels. The important thing to keep in
mind is the concept of minimum stock.
Minimum stock
The ‘minimum stock’ represents the minimum vaccine doses (or vials) that
should be in the store till the arrival of the next supply. For practical purposes,
this is fixed at 25% of the total estimated vaccines required for the given supply
period. The ‘minimum stock’ concept helps ensure that vaccine supplies are
estimated and supply planned so that there is no risk of a stock-out at any time.
Maximum stock
Sometimes stores also run the risk of overstocking. The “maximum stock” that
should be in the store is equivalent to the total vaccine doses required for that
period plus the “minimum stock.” If we take the above example, the “maximum
stock” is (36,000+9,000) = 45,000. Overstocking runs the risks of vaccine
expiring on the shelf.
For example, if say, 144,000 doses of vaccines are required for a place “X”
for the whole year and supplies are made on a quarterly basis, then the
“minimum stock” level should be;
Total vaccine doses required for the whole year 144,000
Number of times supplies are made 4
Quantity of vaccine needed during each supply period 36,000
Minimum stock level needed to be maintained (36,000 X 0.25) or
9,000 doses
Critical stock
At the district level, the vaccine stocks may be replenished every month. Also,
the time required for supply from the provincial store to the district store may
not be long enough to worry about. However, when supply delivery time is an
important consideration, another concept to keep in mind is the “critical stock
or time to order” notion. Mathematically, this can be expressed as,
Scritical = Sminimum + (QperiodxLeadtime)/Psupply
where Qperiod is the quantity required for that period,
Leadtime is the time required for delivery, and
Psupply is the supply frequency. Using the above figures, the calculations are
as follows if the supply delivery time is, say, 2 weeks:
Scritical = 9,000 +[36,000x(2/52)]/4
= 9,000+ [1,440/4]
= 9,000+360
= 9,360
Estimating vaccine needs

There are several methods to estimate vaccine need and different countries
use different methods as appropriate to their settings and practices.

• Estimating vaccine needs based on target population
• Estimating vaccine needs based on past consumption
• Estimating vaccine needs based on the size and number of immunization
sessions.
Estimating vaccine needs based on target population

The important parameters required for estimating vaccine needs based on target
population are:
• Target population
• Estimated coverage to be achieved
• Number of doses in the immunization schedule, and
• Wastage rate
Wastage rate need to be converted to wastage factor in order to account

for vaccine that may be “wasted.” Such wasting could occur due to:
• Discarding of opened vials at the end of the session
• Discarding of unused vaccine in a multidose vial where WHO’s opened
vial policy is not followed
• Accidental breakage of vaccine vials during immunization session
• Damage in the vaccine carrier during transport
• Discarding of un-opened vials returned from an outreach session
• Theft or loss of vaccine vials
The way to calculate the wastage factor is as follows: for a 25% wastage
rate, the wastage factor is calculated as 100/(100-25) or 100/75 or 1.33 To ease
the need for such calculations, the following tables provide equivalent wastage
factor for estimated wastage rates
Wastage rate in % 10% 15% 20% 25% 30% 35% 40% 50%
Equivalent wastage factor 1.11 1.18 1.25 1.33 1.43 1.54 1.67 2
Estimating vaccine needs based on past consumption

The important parameters required for estimating vaccine needs based on past
consumption are:
Estimating vaccine needs by target method
Example, vaccine needed for a target population of 12,000 with a vaccine
administered in three doses, at a wastage rate of 25% and a projected
coverage of 85%
Vaccine needed = 12,000 x 3 doses x 1.33x 0.85
= 40,698 doses
The main drawback of the population target based method is that in

most countries it is hard to get accurate population figures on the different
target age groups. For smaller countries and rural settings, it may be
relatively easy to estimate the target population, but in large metropolitan
cities it is difficult to get accurate estimates. Depending on fertility and
mortality patterns in a specific country, the proportions can either be
higher or lower than what is given below as an example.
Example of population estimates for different age groups
Age group Percent of total population
0 - 11 months 2.5%
12 - 59 months 13.0%
5 – 9 years 14.5%
10 – 14 years 12.1%
Source: Statistical Yearbook of Bhutan 2003. National Statistical Bureau, Royal Government of Bhutan,
Thimphu. March 2004
• Stock available at the beginning of the supply period

• Stock received during the supply period
• Stock available at the end of the supply period
• Stock known or considered ‘wasted’ (for example, destroyed, frozen,
expired etc.)
Mathematically it can be represented as follows:

Vneeded = [(Sbeginning + Sreceived) – (Send + Swasted)]
Where, Vneeded is vaccine stock needed for the period of supply,
Sbeginning is stock available at beginning
Sreceived is stock received
Send is stock available at end of year
Swasted is stock wasted

Appropriate adjustments will be needed to account for the natural increase
in the birth cohort based on growth rate for that population, as well as if there
is either immigration or emigration of a large number of people in that area.
This method is useful where stock management is good and reliable

stock management data are available. However, this method does not
provide information on immunization objectives and targets to be
achieved in the given period.
Estimating vaccine needs based on the size and

number of immunization sessions
Sometimes the nature of the programme delivery infrastructure is such that the
only appropriate way to estimate is to base it on the size and number of
immunization sessions. In general this entails a higher rate of wastage, particularly
if an opened-vial policy is not or cannot be adopted. This is primarily due to
the small number of target children at each session in a programme where
multidose vials are in use. A vial needs to be opened even if there is only one
child at that session.
An example of vaccines needed/estimated, based on size and number of

immunization sessions, Bangladesh
No. of wards in the country 14,027
No. of sessions in each ward 8 (fixed)
Total number of sessions in a year (14027x8x12) 1,346,592
Average number of new children per session 3
Minimum number of vials (multidose) to be opened 1
Total number of vials needed for the whole year 1,346,592
At 30% wastage and 25% buffer, the total vials needed
for the year is 2,390,200
With a 10-dose vial, the doses of vaccines needed 23,902,001
The projected surviving infants for Bangladesh for 2005 are 3,865,070. If
the target population method is used with the same wastage rate and buffer,
the number of doses (3 doses/child) of vaccines required, (3,865,070 x3
x1.42)+25% buffer = 20,581,497 doses. Therefore, this would result in
vaccine stock-outs.
Annex 5
Packaging and shipping of vaccine
Packaging volume information for the SA 14-14-2

live attenuated JE vaccine
1. The packaging of JE vaccine with diluent is below:

One dose vial vaccine packaged with diluent.
Small box:72mm X55mm X21mm
Middle box:215mm X75mm X58mm
2. Vaccines and diluent packaged separately.

2.1 The packing size for 1dose vial and 5 doses vial vaccine is the same
because the same size vial is used.
Small box: 83 mm X40 mm X 35 mm
Middle box: 185 mmX 85 mm X 83 mm
Each small box contains 10 vials and one package insert. Ten small boxes
are put into a middle box. Twenty middle boxes are put into one plastic
bag with quality certifications. The plastic bags are placed into a foam
box with ice pack and then put into one big box.
2.2 The following is the packing size for diluents.

The diluent for one dose vaccine is water for injection
WFI small box for 10 vials: 83mm x 35mm x 40mm
WFI middle box for 10 small boxes: 185mm x 85mm x 83mm
The diluent for five dose vaccine is PBS
PBS small box for 10 vials: 83mm x 35mm x 51mm
PBS middle box for 10 small boxes: 185mm x 85mm x 104mm
Each small box contains 10 vials and one package insert. Ten small boxes
are put into a middle box. Twenty middle boxes are put into one plastic
bag with quality certifications. The plastic bags are placed into a foam
box and then put into one big box.
Source: Chengdu Institute of Biological Products, Chengdu, China

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Introduction of
Japanese Encephalitis
Vaccine in the
South-East Asia Region

Japanese Encephalitis Guideline SEARO 2006

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ii Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

2. Vaccines against Japanese Encephalitis .................................................. 7

3. Immunization strategy for the control of JE ............................................ 9

4. Routine immunization with JE vaccine and surveillance for JE .............. 17

5. Vaccine procurement ........................................................................ 19

Operations Guidelines iii

7. Laboratory aspects of surveillance for JE .............................................. 31

iv Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

What this guide is NOT

The purpose of the guidelines is:

The guidelines are for:

Control of JE in the Region has been limited by inadequate disease

1.2 Recognizing the extent of the JE problem

2 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

1.3 Different approaches to control JE

With increasing resistance to pesticides, it is now recognized that chemical

Amplifying host control

4 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Figure 1: Japanese encephalitis control in Thailand 1970-1997*

* Graph form Thai MOPH presentation at JE bi-regional meeting 2002

6 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

2.1 Type of vaccines

Mouse brain-derived inactivated vaccine

The mouse brain-derived JE vaccine is given subcutaneously in doses of

Cell culture-derived live attenuated vaccine

Cell culture-derived inactivated vaccine

8 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

At the bi-regional meeting on JE held in Bangkok, (30 March to 1 April 2005),

3.1 Mass campaign

Defining high risk geographic areas for mass campaign

• Thailand initiated routine JE vaccination in children 18-24 months old

10 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Defining age group for mass campaigns

Where JE is endemic, the vast proportion of cases occurs in children

3.2 Conducting the mass campaign

Final preparatory meeting

The immunization team

12 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Setting up the immunization post

Figure 2: A sample sketch of a typical layout of an immunization session

Ending the immunization session

14 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

Do’s and Don’ts of vaccine management

3.3 Ensuring injection safety and adverse events

16 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

4.1 Routine immunization

The live attenuated SA 14-14-2 vaccine is recommended to be given as a

Cold chain and logistics

Should further specific information regarding management of the live

Monitoring and reporting

In addition, vaccine impact on disease transmission should be followed to

18 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

5.1 Vaccine licensing or registration

5.2 Vaccine procurement and management

5.3 Important considerations in the procurement and

5.4 Considerations for vaccine supply and allowable

20 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

5.5 Receiving vaccines and supplies

• Check all accompanying documents to ensure they are properly filled.

For all vaccines supplied through UNICEF or other UN Procured systems,

Table 1: Characteristics of mouse-brain-derived and SA 14-14-2 vaccines

22 Introduction of Japanese Encephalitis Vaccine in the South-East Asia Region

5.8 WHO opened-vial, multi-dose policy