Abstract

This study investigated educational interventions for the prevention and management of adverse events following immunisation. This a systematic review was conducted by examining observational studies, with no restriction as to language or year, registered in PROSPERO with the identifier CRD42022313144 and by searching the MEDLINE, LILACS, Embase, CINAHL and Scopus databases. Two researchers selected the studies, extracted the data and assessed the risk of study bias; disagreements were resolved by a third researcher. A total of six articles met the inclusion criteria of the systematic review and the studies reported significant post-intervention improvements in staff conduct in relation to immunisation. It was concluded that educational strategies that lead to continued professional development in relation to vaccination in primary care were effective in reducing and/or eradicating immunisation errors and adverse events following immunisation.

Key words:
Continuing education; Nursing; Drug-related side effects and adverse reactions; Vaccination; Systematic review

Introduction

Adverse events following immunisation (AEFIs) are defined by the World Health Organisation (WHO) as “any untoward medical occurrence which follows immunisation and which does not necessarily have a causal relationship with the usage of the vaccine”¹1 World Health Organization (WHO). Global manual os surveillance of adverse events following immunization [Internet]. [cited 2022 jul 23]. Available from: https://apps.who.int/iris/bitstream/handle/10665 /206144/9789241507769_eng.pdf
https://apps.who.int/iris/bitstream/hand... .

Factors involved in such events include vaccine composition, the organism of the vaccinated individual and the vaccination application process. Staff conduct in non-compliance with standards and techniques may or may not cause harm to the client, leading to what are termed immunisation errors (IEs)²2 Brasil. Ministério da Saúde (MS). Manual de vigilância epidemiológica de eventos adversos pós-vacinação [Internet]. 2021. [acessado 2022 jul 8]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/vacinacao-imunizacao-pni/manual_eventos_adversos_pos_vacinacao_4ed_atualizada.pdf/view
https://www.gov.br/saude/pt-br/centrais-... .

A 2020 survey in 5 English-speaking countries found prevalence of IEs of 1.15 per 10,000 vaccine doses³3 Morse-Brady J, Marie Hart A. Prevalence and types of vaccination errors from 2009 to 2018: a systematic review of the medical literature. Vaccine 2020; 38(7):1623-1629.. In several countries then, IEs are responsible for AEFIs and are therefore the first to be examined in an investigation²2 Brasil. Ministério da Saúde (MS). Manual de vigilância epidemiológica de eventos adversos pós-vacinação [Internet]. 2021. [acessado 2022 jul 8]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/vacinacao-imunizacao-pni/manual_eventos_adversos_pos_vacinacao_4ed_atualizada.pdf/view
https://www.gov.br/saude/pt-br/centrais-... . Several authors state that vaccine hesitancy may be associated with the occurrence of IEs⁴4 Bisetto LHL, Ciosak SL. Análise da ocorrência de evento adverso pós-vacinação decorrente de erro de imunização. Rev Bras Enferm 2017; 70(1):87-95..

Nursing plays a fundamental role in the immunisation process, at the stages of reception, vaccination screening, the correct preparation, handling and administration of immunobiologicals, clarifying doubts and giving guidance on vaccines administered and possible AEFIs. Faced with a AEFI, nurses will report and investigate the event, thus contributing to improved quality and patient safety at the stages of the vaccination process⁵5 Moura ADA, Roubert ESC, Lima FET, Chaves CS, Canto SVE, Lima GG. Avaliação da vigilância dos eventos adversos pós-vacinação em um estado do nordeste brasileiro. Braz J Health Rev 2020; 3(6):16789-16793..

Nurses face difficulties in their work process, such as poor physical structure, organisational problems, as well as poor quality training. Most prominent among these difficulties are those relating to knowledge and attitudes to the day’s work⁶6 Barboza JSA, Sales MLH, Veras JDN, Nagliate PC, Rodrigues ARA, Oliveira AS, Fonseca ECM. Safe patient care in the vaccine room: a scoping review. Res Soc Dev 2022; 11(7):e42611729250..

Accordingly, knowledge and safety in nursing staffs’ conduct and guidance are indispensable at all stages of vaccination in Primary Health Care (PHC), with a view to optimising health services in accordance with Brazil’s National Immunisation Programme (Programa Nacional de Imunização, PNI)⁷7 Porfirio TC, Moreira RL. Assistência de enfermagem nos eventos adversos pós-vacinação da BCG na infância. Braz J Hea Rev 2019; 22(6):1455-1470.. In this regard, specific conduct can be adopted to prevent AEFIs, from reception and screening, assessment for postponement or contraindication of vaccination through to vaccination safety and quality, and AEFI monitoring and management⁶6 Barboza JSA, Sales MLH, Veras JDN, Nagliate PC, Rodrigues ARA, Oliveira AS, Fonseca ECM. Safe patient care in the vaccine room: a scoping review. Res Soc Dev 2022; 11(7):e42611729250..

It is thus important and current to think about education strategies that promote meaningful learning⁸8 Martins JRT, Viegas SMF, Oliveira VC, Rennó HMS. A vacinação no cotidiano: vivências indicam a Educação Permanente. Esc Anna Nery 2019; 23(4):e20180365.. Studies indicate Continued Professional Development (CPD) for health personnel as a strategy for improving immunisation-related safety⁹9 Araújo TM, Souza FO, Pinho PS. Vaccination and associated factors among health workers. Cad Saude Publica 2019; 35(4):e00169618..

In 2004, the Ministry of Health introduced the National Policy of Continued Professional Development in Healthcare (Política Nacional de Educação Permanente em Saúde, PNEPS), which proposed to change and improve the training of health professionals, thus reinforcing the quality of nursing staffs’ vaccination training, by deploying active methodologies to encourage thinking and problem solving based on the realities of health service provision¹⁰10 Brasil. Ministério da Saúde (MS). Portaria GM/MS nº 198, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Diário Oficial da União 2004; 13 fev..

CPD in healthcare makes for meaningful learning, because it enables staffs to lead the process and offer proposals for reordering their work process on the basis of their thinking about their service practices. CPD is thus essential to building quality services¹¹11 Brasil. Ministério da Saúde (MS). Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília: MS; 2018..

According to Google Scholar and the Virtual Health Library (VHL), in the last ten years, studies of CPD for nurses in preventing and managing AEFIs have been insufficient. The scientific literature features, in Brazil, a 2015 experience report, which discusses AEFIs, and a 2021 qualitative, descriptive study using realistic simulation as a resource for training primary health care personnel in the immunisation process. Although studies endorse immunisation-related CPD, the effectiveness of any action taken has not been assessed¹²12 Ternopolski CA, Baratieri T, Lenstck MH. Eventos adversos pós-vacinação: educação permanente para a enfermagem. Espaç Saude 2015; 16(4):109-119.^,1313 Rodrigues SB, Assis GDP, Siva BS, Oliveira GCCF, Tavares LOM, Amaral GG, Oliveira VC, Guimarães EAA. Simulação realística na capacitação de profissionais de enfermagem em sala de vacinação. Res Soc Dev 2021; 10(3):e20810313314..

This study thus investigated education interventions in the prevention and management of adverse events following immunisation.

Methods

The protocol for this Systematic Review (SR) was based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P)¹⁴14 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA; PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4(1):1. and then registered with the International Prospective Register of Systematic Reviews (PROSPERO) under identifier CRD42022313144.

The manuscript was described by reference to the PRISMA 2020¹⁵15 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71. checklist and flowchart. The article selection, extraction and risk of bias assessment stages were carried out by two researchers and disagreements were resolved by a third researcher.

Using the acronym PICOS (P = population, I = intervention, C = comparison, O = outcome and S = study type) the following guiding question was asked: “Do education interventions for health professionals promote prevention and proper management of adverse events following immunisation?”

The inclusion criteria for article eligibility were that studies involve educational interventions with health professionals involved in vaccination with a view to preventing and managing AEFIs and observational studies, with no language restrictions. The exclusion criteria were studies duplicating reviews or data, lacking an abstract, with no full text available after communication with the author, not answering the guiding question and reviews, case reports, abstracts submitted to congresses and conferences, study protocols, letters to the editor, personal opinions, institutional analyses, manuals, dissertations, theses, books and chapters.

The databases chosen were MEDLINE, Embase, LILACS, CINAHL and Scopus. Search strategies were formulate using controlled terms allowed by each database and uncontrolled terms and Peer Review of Electronic Search Strategies (PRESS) was also implemented to achieve a high-quality search¹⁶16 McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol 2016; 75:40-64.. These strategies are available in Chart 1 through the DOI.

Articles were selected by exporting to the Mendeley reference manager to remove duplicates and then entered into Rayyan, where they were screened by reading the titles and abstracts and those selected, by a complete reading; the excluded studies were justified. Data were extracted using a form for overall study data, method, outcome and interventions.

Thus, as the studies can be classed as quasi-experimental, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies was used to assess risk of bias. The critical appraisal checklist specifies that the answer “Yes” relates to absence of bias. Thus, studies returning 49% or fewer “Yes” answers were considered to offer high risk of bias; those returning between 50 and 69%, moderate risk; and 70% or more, low risk¹⁷17 Joanna Briggs Institute (JBI). Critical appraisal checklist for quasi-experimental studies [Internet]. 2017. [cited 2022 jul 8]. Available from: https://jbi.global/sites/default/files/2019-05/JBI_Quasi-Experimental_Appraisal_Tool2017_0.pdf
https://jbi.global/sites/default/files/2... .

The data from this review were separated, tabulated and analysed by database, authors, year and journal of publication, title, country, language of publication, objective, study population, type of education interventions, educational intervention effectiveness assessment instrument and outcome and, thus, discussed descriptively.

Results

Selection of systematic review studies

Initially, 2,627 articles were found in the five databases. After excluding duplicate studies, 2230 remained, which were selected by titles and abstracts. After applying the inclusion and exclusion criteria, nine articles were considered eligible. However, the full text of one study could not be accessed. Thus, eight articles were evaluated by reading the full text and two were excluded for not answering the guiding question. Thus, after article selection differences were resolved by the third researcher, six articles, as shown in Figure 1, were included in the systematic review.

Characteristics of the systematic review studies

Chart 2 shows authors and year of publication, database, periodical, title, country, language of publication, objective and populations of the study. Four of the six articles¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2020 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133.^,2222 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89. are indexed in the MEDLINE database, one¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128. in Embase and one²³23 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564. in CINAHL. All studies included were published between 2006 and 2021.

The studies were conducted in India¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2020 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., Nigeria¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128., the United States²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178. and South Korea²²22 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89.. Sample populations ranged from 20 to 323 health personnel, including nurses, doctors, pharmacists, nursing and pharmacy assistants, health agents, midwives and cold chain handlers.

As in Table 3, the content taught regarding immunisation was vaccine administration¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,1919 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128.^,2121 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., waste disposal¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,1919 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128.^,2121 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., care for the cold chain¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2020 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., AEFIs¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., vaccination calendar²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., problems in the immunisation process¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128., dangers of unsafe injection practices¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128., immunisation recording²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178., basic concepts of immunisation²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178. and vaccination coverage²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178..

The education interventions ranged from four hours to three months and most studies used pre-test and post-test questionnaires to assess the effectiveness of these interventions, except for one study²⁰20 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133., which used only a post-intervention questionnaire. Other means of assessment used were visual inspection²⁰20 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133., checklist²²22 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89., supportive supervision²³23 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564., number of immunisations and staff AEFIs reports following training²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178., as shown in Chart 3.

As regards the interventions’ effectiveness, research showed significant improvements among staff in immunisation following the interventions, as shown in Chart 3. One study¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590. demonstrated that validated content transmitted by an educational module was effective in conveying knowledge at all the stages of the immunisation process.

Another study¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128. emphasised that content relating to safe administration of vaccines and waste disposal had significant effect on the health personnel’s knowledge, although no significant improvements were found in their practice, because of precarious working conditions. The study also reported that training should be provided to all personnel involved in vaccination activities, including cleaning staff.

One study²⁰20 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133. indicated that in-depth training in the cold chain with PowerPoint presentations and detailed discussion, followed by practical training with field visits, was appropriate, while another study²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178. showed that a pilot study should be conducted to adjust the duration of the intervention. As a result, in that study, live training went from 2 hours to 4 hours with a view to improving personnel’s practice time. The study also emphasised that a model combining online and live training was effective.

One study²²22 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89. considered that individual guidance and distribution of educational leaflets with content on care with vaccine storage was effective training. Lastly, another study²³23 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564. showed that supportive supervision was an appropriate manner for personnel to learn at all stages of the immunisation process, as the environment and routine belonged to the participants’ own workplace.

Some articles¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2020 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133.^,2222 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89. argued that interventions should not be occasional, but continuous, so one of the articles²⁰20 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133. took this issue as accounting for the positive, although unsatisfactory, results in identification of heat- and cold-sensitive vaccines, in preventive maintenance of cold chain equipment on a fixed monthly date, temperature maintenance on holidays and formulation of an appropriate emergency contingency plan, and alerted to the need for subsequent staff guidance.

Educational interventions in the immunisation process are thus essential to preventing and managing AEFIs. The educational strategy for this purpose should maintain close contact with the concrete realities of health personnel’s work and a pilot study should be conducted in order to prepare the intervention. It is also necessary to combine educational resources, provide periodic interventions for all employees involved in the immunisation process and assure appropriate conditions for vaccination-related activities.

Risk of bias in systematic review studies

As shown in Chart 4, four of the six studies included in the review¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2020 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133.^,2121 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564. returned moderate risk of bias and two¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128.^,2222 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89., low risk. All articles addressed questions 1, 2, 3 and 7, but questions 4 and 5 were not addressed in most studies. Only three studies¹⁹19 Musa OI, Parakoyi DB, Akanbi AA. Evaluation of health education intervention on safe immunization injection among health workers in Ilorin, Nigeria. Ann Afr Med 2006; 5(3):122-128.^,2121 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178.^,2222 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89. met the criteria for question 6 and only one study²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178. failed to satisfy items 8 and 9 of the risk of bias assessment instrument.

Discussion

In this study, India was notable for studies to assess the effectiveness of educational interventions in the vaccination process to improve prevention and proper management of AEFIs. The Serum Institute in India is the largest producer of vaccines, which is believed to account for its prominence in scientific production²⁴24 Guimarães R. Vacinas: da saúde pública ao big business. Cien Saude Colet 2021; 26(5):1847-1852.. A literature review addressing vaccination waste as a topic also showed India to be most prevalent in studies^25.

This SR also found the largest number of participants to be doctors, but nurses appear to participate in half the studies, even if in small numbers. In the countries where the studies took place, other groups were also involved in vaccination activities; this differs from Brazil, where nurses are responsible the vaccination room, where a nurse supervises the work and arranges CPD for the team²⁶26 Brasil. Ministério da Saúde (MS). Manual de normas e procedimentos para vacinação. Brasília: Ministério da Saúde [Internet]. 2014. [acessado 2022 out 22]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_procedimentos_vacinacao.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

Review studies have shown vaccination activities lacking supervision¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2222 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564.. In Brazil, nurses perform a number of duties in PHC and this work overload is known to limit nurses’ activities in vaccination. This finding corroborates an integrative review of Brazilian studies that questioned the absence or limited participation of nurses in the vaccination room and how nurses’ duties end up being performed by nursing technicians. This resulted in errors in the immunisation process for lack of the guidance, supervision and continued professional development fostered by nurses²⁷27 Barbosa FS, Barbosa R, Lima MCV. Atuação do enfermeiro em sala de vacina na Atenção Primária. Rev Acad FACOTTUR-RAF 2021; 2(1):89-100..

This SR found educational interventions with differing resources and durations. These considerations should be sufficient for CPD to be supported. In other words, they should provide health personnel with food for thought as regards their work process, with a view to improving patient care²⁸28 Assad SGB, Corvino MPF, Santos SCP, Cortez EA, Souza FL. Educação permanente em saúde e atividades de vacinação: revisão integrativa. Rev Enferm UFPE 2017; 11(1):410-421..

As regards content, the review found educational interventions at all stages of the immunisation process. It is important that the intervention address care for the cold chain, patient reception and screening, preparation, handling and administration of vaccines, as well as AEFI surveillance²⁹29 Batista EC, Ferreira AP, Oliveira VC, Amaral GG, Jesus RF, Quintino ND, Viegas SM, Guimarães EA. Vigilância ativa de eventos adversos pós-vacinação na atenção primária à saúde. Acta Paul Enferm 2021; 34:eAPE002335.. Accordingly, the content analysis of the studies in this review will be discussed below, by stages of the immunisation process.

Studies in this review found that lack of cold chain equipment was an hindrance¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2020 Mallik S, Mandal PK, Chatterjee C, Ghosh P, Manna N, Chakrabarty D, Bagchi SN, Dasgupta S. Assessing cold chain status in a metro city of India: an intervention study. Afr Health Sci 2011; 11(1):128-133.. Also, one SR study stated that vaccine packaging had been neglected and that all attention focused on vaccination coverage²²22 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89..

These findings agree with a survey to assess the situation of the vaccination room in a town in Paraíba state, which highlighted improper conditions of refrigeration, a lack of thermometers and improper thermal boxes in insufficient quantity. The same study also found weaknesses in staffs’ knowledge as to correct checking of vaccine temperatures³⁰30 França KTG. Avaliação das salas de vacinas na perspectiva de enfermeiros da atenção primária à saúde [dissertação]. Campina Grande: Universidade Estadual da Paraíba; 2021.. These deficits led to IEs and, as a result, can cause AEFIs, besides impairing immunobiologicals’ effectiveness³¹31 Cunha JO, Bispo MM, Farias LHS, Silva GM, Menezes AF, Santos AD. Análise das unidades de vacinação públicas do município de Aracaju/SE. Enferm Foco 2020; 11(3):136-143..

One article in this review stressed that intervention after training significantly improved the staff’s awareness as to recording immunobiological storage refrigerator temperatures²²22 Lee S, Lim HS, Kim O, Nam J, Kim Y, Woo H, Noh W, Kim K. Vaccine storage practices and the effects of education in some private medical institutions. J Prev Med Public Health 2012; 45(2):78-89.. In order to yield quality results in improved staff training, educational strategies must be based on problematising work processes as experienced by nursing teams, thence to generate changes in the environment by engaging the facility’s staff and management³²32 Oliveira VC, Tavares LOM, Maforte NTP, Silva LNLR, Rennó HMS, Amaral GG, Viegas SMF. A percepção da equipe de enfermagem sobre a segurança do paciente em sala de vacinação. Rev Cuid 2018; 10(1):e590..

In the vaccination process, screening is carried out jointly with reception and seeks to ascertain needs and priorities as regards vaccination status, as well as guiding clients about the vaccines to be administered. Reception, meanwhile, aims to produce active listening and convey confidence to the patient⁴4 Bisetto LHL, Ciosak SL. Análise da ocorrência de evento adverso pós-vacinação decorrente de erro de imunização. Rev Bras Enferm 2017; 70(1):87-95.^,2626 Brasil. Ministério da Saúde (MS). Manual de normas e procedimentos para vacinação. Brasília: Ministério da Saúde [Internet]. 2014. [acessado 2022 out 22]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/manual_procedimentos_vacinacao.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

Studies in this review highlighted weaknesses in communication between health personnel and parents or guardians of children to be vaccinated, underlining that this relationship is necessary to ensure the confidence that results in vaccination adherence¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.^,2323 Holla N, Borker S, Bahat S. Vaccination sessions; challenges and opportunities for improvement: experiences from Karnataka. Ann Trop Med Public Health 2013; 6(5):559-564.. The reception, screening and guidance stages are intended to engage patients by communicating that the immunisation process is reliable, so as to combat vaccine hesitancy³³33 Souto EP, Kabad J. Hesitação vacinal e os desafios para enfrentamento da pandemia de COVID-19 em idosos no Brasil. Rev Bras Geriatr Gerontol 2020; 23(5):e210032..

Donnini et al. (2022)³⁴34 Donnini DA, Silva CMB, Gusmão JD, Matozinhos FP, Silva RB, Amaral GG, Guimarães EAA, Oliveira VC. Incidence of immunization errors in the state of Minas Gerais, Brazil: a cross-sectional study, 2015-2019. Epidemiol Serv Saude 2022; 31(3):e2022055. found that the most frequent error was administering vaccines at other than the recommended age. Health personnel’s weak knowledge and training as regards the vaccination schedule and the similarity of vaccine labels may be factors in this type of IE, which constitutes a failure in the stages of vaccine screening, preparation, handling and administration.

Manufacturers are thus advised to change immunobiologicals’ labelling so as to facilitate correct identification of vials at time of vaccination³⁵35 Samad F, Burton SJ, Kwan D, Porter N, Smetzer J, Cohen MR, Tuttle J, Baker D, Doherty DE. Strategies to reduce errors associated with 2-component vaccines. Pharmaceut Med 2021; 35(1):1-9.. Other manners of reducing occurrences of IE are by improving staff training, client participation, nurse supervision of vaccinations, as well as management that works to reduce these risks³⁶36 Barboza TC, Guimarães RA, Gimenes FRE, Silva AEBC. Retrospective study of immunization errors reported in an online Information System. Rev Lat Am Enferm 2020; 28:e3303..

Nursing teams often suffer from weaknesses in vaccine preparation, handling and administration. Teixeira et al. (2021)³⁷37 Teixeira TBC, Raponi MBG, Felix MMS, Ferreira LA, Barichello E, Barbosa MH. Avaliação da segurança do paciente na sala de vacinação. Texto Contexto Enferm 2021; 30:e20200126. found that the most frequent errors were preparing several vaccine doses at the same time, inappropriate needle positioning, aspiration before vaccine administration and inserting needles into the rubber of multi-dose vials. Barboza et al. (2020)³⁶36 Barboza TC, Guimarães RA, Gimenes FRE, Silva AEBC. Retrospective study of immunization errors reported in an online Information System. Rev Lat Am Enferm 2020; 28:e3303. showed that errors in vaccine administration technique were responsible for most AEFIs.

Solid healthcare waste (SHW) disposal at the vaccine preparation, handling and administration stages also requires training, as failures in this activity are considered IEs and can spread diseases to workers, public and environment³⁸38 Reis CAB, Sousa FLL, Sousa ASS, Filho PAM, Teixeira AB. Resíduos biológicos e descarte de vacinas [Internet]. 2019. [acessado 2023 jan 10]. Disponível em: https://www.doity.com.br/anais/conexaounifametro 2019/trabalho/124548
https://www.doity.com.br/anais/conexaoun... .

Preparation for appropriate SHW management requires implementing a solid healthcare waste management programme, although ignored by management and health service professionals, this is what defines and details the stages of SHW management in line with current rules. It thus helps in training health workers in this activity³⁹39 Agência Nacional de Vigilância Sanitária (Anvisa). RDC nº 222, de 28 de março de 2018. Regulamenta as boas práticas de gerenciamento dos resíduos de serviços de saúde e dá outras providências. Diário Oficial da União 2018; 29 de mar..

As regards client guidance following administration of a vaccine, one study in this SR found that health staff did not advise parents to wait up to 30 minutes at the health service to check for adverse reactions and discovered that they omitted to do so for lack of waiting room space¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590.. Batista et al. (2021)²⁹29 Batista EC, Ferreira AP, Oliveira VC, Amaral GG, Jesus RF, Quintino ND, Viegas SM, Guimarães EA. Vigilância ativa de eventos adversos pós-vacinação na atenção primária à saúde. Acta Paul Enferm 2021; 34:eAPE002335. agreed, pointing out that most users received no guidance on the vaccines administered, possible AEFIs or what to do should these arise.

This kind of guidance contributes to surveillance of adverse events following immunisation and is necessary in order to assure safe vaccination practices. Recommendations provided by health personnel are known to increase vaccination adherence, but for this to happen staffs must be ready to answer questions and concerns⁴⁰40 Centers for Disease Control and Prevention (CDC). Pinkbook: vaccine administration [Internet]. [cited 2023 jan 15]. Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html
https://www.cdc.gov/vaccines/pubs/pinkbo... .

One article in this review showed that, following an educational intervention on vaccine administration, health personnel felt more confident in administering the immunobiological, recording the vaccination and providing guidance²¹21 McKeirnan KC, Frazier KR, Nguyen M, MacLean LG. Training pharmacy technicians to administer immunizations. J Am Pharm Assoc 2018; 58(2):174-178..

As a contribution to continued professional development, a visual protocol was developed to assure safe vaccination of children under 1 year old. This tool covered the stages of reception, screening, vaccine preparation and administration and guidance. It was concluded that the technology helped to minimise IEs and thus AEFIs at these stages⁴¹41 Farias ERG. Construção e validação de protocolo gráfico para o cuidado seguro na vacinação em criança menor de 1 ano de idade [dissertação]. Natal: Universidade Federal do Rio Grande do Norte; 2021..

From content analysis, a review study demonstrated that inadequate knowledge of the process for reporting AEFIs and lack of time led to low reporting of these events¹⁸18 Sebastian J, Parthasarathi G, Ravi MD. Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city. Ther Adv Vaccines Immunother 2021; 9:25151355211032590..

In Brazil, however, under- or incomplete reporting of AEFIs and/or IEs is a reality, which in most cases can be explained by health personnel’s fear, lack of knowledge about reporting, lack of commitment and overwork. Although AEFIs are associated with IEs, physical environments inappropriate for professional practice have also contributed to the occurrence of these events⁴²42 Alves MD, Carvalho DS, Albuquerque GS. Motivos para a não notificação de incidentes de segurança do paciente por profissionais de saúde: revisão integrativa. Cien Saude Colet 2019; 24(8):2895-2908.^,4343 Mascarenhas FAS, Anders JC, Gelbcke FL, Lanzoni GMM, Ilha P. Facilidades e dificuldades dos profissionais de saúde frente ao processo de notificação de eventos adversos. Texto Contexto Enferm 2019; 28:e20180040..

Note, in this connection, that these factors have their origin in the training given to these health personnel and the continuance of this educational process, as well as the support they receive from job managers. However, it should be stressed that health personnel recognise their need for, and the importance of, training on this topic⁴²42 Alves MD, Carvalho DS, Albuquerque GS. Motivos para a não notificação de incidentes de segurança do paciente por profissionais de saúde: revisão integrativa. Cien Saude Colet 2019; 24(8):2895-2908.^,4343 Mascarenhas FAS, Anders JC, Gelbcke FL, Lanzoni GMM, Ilha P. Facilidades e dificuldades dos profissionais de saúde frente ao processo de notificação de eventos adversos. Texto Contexto Enferm 2019; 28:e20180040..

In this regard, failure to recognise an AEFI and take appropriate action is reflected in vaccination adherence, as it contributes to refusal in vaccination rooms and, consequently, amplifies myths and taboos, all of which, together with anti-vaccine movements, is leading to the re-emergence of vaccine-preventable diseases that once were eradicated or controlled⁴⁴44 Santos LB. A notificação de evento adverso pós-vacinação como instrumento para tomada de decisão do profissional enfermeiro [tcc]. Ariquemes: Faculdade de Educação e Meio Ambiente; 2019..

In view of the foregoing, there is a need for CPD to alleviate healthcare staffs’ - and especially nursing teams’ - fear of reporting and foster the recognition, proper management and prevention of AEFIs and/or IEs⁴⁵45 Ascari RA, Heinrichs BC, Weihermann AM. Eventos adversos e o cuidado seguro de enfermagem na atenção primária à saúde. Rev Enferm Atual Derme 2021; 95(34):e-021048..

The pre-test and post-test method, used to evaluate the interventions in this review, serves to assess intentional interventions before and after, without a control group⁴⁶46 Polit DF, Beck CT. Fundamentos de pesquisa em enfermagem: avaliação de evidências para a prática da enfermagem. Porto Alegre: Artmed; 2018.. Even in the absence of a comparison group, this method is an effective means of assessing the progress of interventions, because it makes it possible to judge whether the intervention was effective or not and whether changes are needed. It thus enables settings to be modified and contributes to improving a given group’s training⁴⁷47 Brousselle A, Champagne F, Contandriopoulos AP, Hartz Z, direction. L'évaluation: concepts et méthodes. Montréal: Presses de l'Université de Montréal; 2011..

This study found that educational interventions for AEFI prevention and management were effective in improving the training of health personnel working in vaccination. For this to happen, however, they have to maintain close contact with the realities of health staffs’ experience, that is, be grounded in problematisation, and they must be tested previously and assessed periodically to adjust content, resources and duration. Interventions can guarantee improvements only if associated with good working conditions. Martins et al. (2018)⁴⁸48 Martins JRT, Alexandre BGP, Oliveira VC, Viegas SMF. Permanent education in the vaccination room: what is the reality? Rev Bras Enferm 2018; 71(Suppl. 1):668-676. noted that they are still incipient and scarce and have been carried out using traditional methodologies contrary to what is recommended by Brazil’s National Policy of Continued Professional Development in Healthcare (PNEPS).

The limitations to this review included the absence of a search of the grey literature and meta-analysis, because of the heterogeneity of the studies. Also, only observational studies were evaluated.

Note that management must improve working conditions for vaccination by ensuring appropriate environment and equipment, as well as staff to meet vaccination demand safely, particularly nurses to supervise the work. Attention is also drawn to the need to train staffs by CPD to conduct activities pursuant to National Immunisation Programme recommendations.

It is hoped that this review will contribute to other scientific studies with a view to improving the immunisation process by reducing and/or eradicating IEs and AEFIs by means of educational interventions that contribute to CPD in vaccination in primary health care.

Acknowledgements

Our sincere acknowledgement and thanks to Kent Murnaghan of Canadian Memorial Chiropractic College, who collaborated in improving the search strategy through Peer Review of Electronic Search Strategies.

References

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