

A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY

EXPANDED PROGRAM ON IMMUNIZATION RA 10152
Prepared by: Orlan D. Balano

INTRODUCTION/EPI Milestones
1976 - Launching of EPI
1986 - UCI Goal Acceleration
1989 – Adoption of Wed. as Immunization Day
1992 – integration of Hep B
(target : 40% of 0-11 months old)

INTRODUCTION
Major Strategies
1. Sustaining high routine FIC coverage at least 95% in all provinces and cities
2. Sustaining polio-free country for global eradication ( NIDs- 1993-1996)
3. Eliminating measles by 2008
1998 – catch up campaign (Ligtas Tigdas)
2004- follow-up campaign
2007- 2ND follow-up campaign (KOT)
4. Eliminating neonatal tetanus
5. Control diphtheria,pertusis, Hep B and extra pulmonary TB
 April –May 2012 - Iiigta sa Tignas ng Pinas
MR SIA (Measles Rubella Supplemental Activity – Door to Door Strategy to eliminate measles by 2012.
May 21, 2012 Dept. Mmemorandum Administration of Rotavirus Vaccine for Infants in National House Targeting
System
CONCEPT and IMPORTANCE of VACCINATION
IMMUNIZATION – promote health and protect children from disease causing agents
> PASSIVE Immunity
> ACTIVE Immunity

OBJECTIVES OF EPI:
 To reduce the morbidity and mortality rates of the following immunizable diseases :
 TB,tetanus,diphtheria, pertussis, measles, poliomyelitis, hepatitis B,influenza, rubella, and mumps
1.Active Immunization – antibodies are produced by the body in response to infection
Natural – antibodies are formed in the presence of active infection in the body. It is a lifelong immunity. e.g.
recovery from mumps, chickenpox
Artificial – antigens (vaccines or toxoids) are administered to stimulate antibody production. Requires
booster inoculation after many years. e.g. tetanus toxoid, oral polio vaccine, etc.
Passive Immunization – antibodies are produced by another source such as animal or human
Natural – antibodies are transferred from the mother to her newborn through the placental or in the
colostrums
Artificial –immune serum (antibody) from an animal or another human is injected to a person e.g. tetanus
immunoglobulin human, rabies immunoglobuli

CONCEPT and IMPORTANCE of VACCINATION

GENERAL PRINCIPLES IN VACCINATION
- It is safe and immunologically effective to administer on same session but at different sites
- Measles should be given at 9 months
Vaccine efficacy :
9 months old – 85%
> 1 year old – 95%
- Vaccination schedule should not be restarted from the beginning even if the interval between doses
exceeded by the recommended interval by months or years
- One should immunize unless the child is so sick that he needs to be hospitalized
Not Contraindication : moderate fever, malnutrition,
mild ARI, diarrhea, vomiting
Absolute Contraindications :
- DPT2/DPT3 to a child who had convulsion/shock w/in 3 days the previous day
- Live vaccines (BCG) must not be given to immunopressed
- Local reaction, fever and systematic symptoms can result as part of the normal immune response
- Giving doses of vaccine < recommended 4 weeks interval may lessen the antibody response
Lengthening the interval between doses of vaccines leads to higher Ab levels
- No extra doses must be given to children/mother who missed a dose of DPT/HB/OPV/TT
- Diluents are not interchangeable
- Diarrhea – NOT contraindication to OPV imz
- Repeat BCG if there is no scar after 1st injection
- 1 syringe- 1 needle – 1 child/mother
PRINCIPLES AND ELEMENTS OF EPI
Principles:
1.The program is based on epidemiological situation.
2.The whole community rather than just the individual must be protected( mass approach).
3.Immunization is a basic health service
Elements of EPI:
1.Target setting
2.Cold chain logistic management
3.Assessment and evaluation
4.Surveillance, research and studies

LEGAL BASIS/POLICIES ON IMMUNIZATION

P.D. 996 – compulsory basic immunization for infants and children below 8 years old.
R.A. 7846- compulsory immunization against hepatitis B for infants and children below 8 years old
P.D. No. 1066 – neonatal tetanus elimination campaign
R.A. 10152- An act providing for mandatory Basic Immunization Services for Infants and Children repealing P.D.
No. 996

WHO POLICY STATEMENT (OPENED MULTI-DOSE VIALS OF VACCINE)

The vaccine in opened vials of OPV, TT, DTP, DT, Hepatitis B, and liquid formulations of Hib, from which
one or more doses of vaccine have been removed during an immunization session maybe used in subsequent
immunization sessions for up to a maximum of 4 weeks, provided that all of the following conditions are met:
The expiry date has not pass
The vaccine are stored under appropriate cold chain conditions
The vaccine vial septum has not been submerged in water
Aseptic technique has been used to withdraw all doses
The vaccine vial monitor (VVM) if attached has not reached the discard point
Most freeze-dried (lyophilized vaccines) do not contain preservatives and consequently must not be kept
more than the manufacturer’s recommended limit and never longer than six hours after they are reconstituted, such
as BCG,Measles

EPI VACCINE, TYPES. CONTENTS AND FORM

1.BCG- live attenuated, bacterial vaccine, freeze-dried and reconstituted with a special diluent ,20 doses per ampule
2.OPV (Oral Polio -live attenuated vaccine,liquid,20 doses per vial
3. Hepatitis B-plasma derived, RNA recombinant, 10 doses per vial
4.MMR (Measles, Mump, Rubella )
5. Measles – live attenuated, freeze dried and reconstituted with a special diluent, 10 doses per vial.
6. Pentavalent ( DPT,Hepa B,Hemophylus Influenza type B
Antigen Schedule of Vaccination How it is stored? Remarks
BCG Anytime after birth +2°C to +8°C BCG – protects from TB
meningitis and other forms
of TB
OPV st
1 dose- at least 6 wks old -15°C to -25°C Extent of protection
against polio is increased
2nd dose- at least 10 wks old the earlier OPV is given
rd
3 dose- at least 14 wks old
DPT 1st dose- at least 6 wks old +2°C to +8°C Early startà ↓ severe
pertusis
2nd dose- at least 10 wks old
3rd dose- at least 14 wks old
Hepatitis B 1st dose- within 24H after birth +2°C to +8°C Early start
à↓inection/carrier
2nd dose- at least 6 wks old Prevent liver cirrhosis/liver
3rd dose- at least 14 wks old CA
Eliminate HB before 2012
Measles At least 9 months old -15°C to -25°C Prevents death 2 to
+2°C to +8°C complications
Tetanus Toxoid 1st dose- as early as possible +2°C to +8°C It should never be frozen
during pregnancy
nd
2 dose- at least 4 weeks after
TT1
rd
3 dose- at least 6 months after
TT2
th
4 dose- at least 1 year after
TT3
th
5 dose- at least 1year after
TT4
Pentavalent - 6wks-11 months old – 3 doses
1st dose at 6 weeks old
2nd dose at least 10 wks
3rd dose at least14 weeks
Given deep IM 0.5 ml deep IM at mid upper thigh

NEW VACCINES
Anti-measles vaccine should be given at least 9-11 months old before MMR will be injected at 12-15months old
.There shall be at 4 weeks interval between measles vaccine-MMR.Anti-Measles vaccine given at 9 -11 months
shall be called AMV 1 and MMR shall be called AMV2
“Rotarix” vaccines rotavirus Immunizatiion – given among infants of families identified to the NHTS provided by the
DSWD)
 Given in 2 doses, administered orally to infants the first dose given to age 6 weeks age to 15 weeks
Second dose given to infants age 6 weeks ged 10 weeks up to maximum of 32 weeks.

SCHEDULE OFTT IMMUNIZATION

When Protection
TT 1 As early as possible during
pregnancy
TT 2 4 weeks 80%
3 years
TT3 6 months 95%
5 years
TT4 1 year 99%
10 years
TT5 1 year 99%
Reproductive Life Time

TT IMMUNIZATION FOR PREGNANT WOMEN AND MOTHERS OF 0-4 CHILDREN

 Primary Series of TT immunization includes 2 doses of 0.5 per dose administered IM with one month
interval between doses. Primary series can be given anytime during the pregnancy and up to 3
months post partum.
 All mothers who bring the child to an immunization session will be screened for TT immunization
and be given a dose of TT if not yet given.
 3 booster doses shall be given to mothers of children underfive who have completed the 2 tetanus
toxoid primary series.
 TT 3 – during the measles immunization of the baby at 9 months old
 TT 4 – at the baby’s second birthday
 TT 5 – at the baby’s third birthday
 Mothers who have completed 5 TT shall be called Mothers fully immunized for life of “FIL”.
Non-pregnant mothers of under five childen (mothers protected for life (TT5) – age between 15-45
years old shall also be recorded.
 Use 3.5 % of the total population in calculating EP for mothers to be given vaccine and assessing
accomplishment.
 Fully Immunized Child – mean a child who has 1BCG,Hepa B, .3 Pentavalent Hib, 3 OPV and 1 MV

v
he
 Ex
0°C

Inside the Cold

Room

Cold Room
ICE PACK
FREEZERS

ICE-LINED FREEZER
Modified
Vaccine
Refrigerator

THERMOMETER
HOW TO MONITOR THE REFRIGERATOR TEMPERATURE

TRANSPORT BOX
VACCINE CARRIERS

COLD LIFE : MAX. 48H

NORMAL COURSE AND SIDE EFFECTS OF VACCINATIONS
BCG
Normal Course: The wheel raised by the injection disappears after about half an hour. A small red tender
swelling, about 10 mm. across, appears at the place of immunization after approximately two weeks. After 2-
3 weeks, the swelling may become a small abscess, which then ulcerates. The ulcer will heal by itself and
leaves a scar. The course from vaccination to scar takes about 12 weeks.

Side Effects:
1.Koch’s phenomenon- an acute inflammatory reaction appearing within two to four days of vaccination. It
is not serious and disappears rapidly. No management is needed.
2. Deep Abscess at vaccination site/glandular enlargement. – Incision and drainage of the abscess is
necessary. Apply powdered INH.
3.Indolent ulceration – an ulcer, which persists after 12 weeks from, date of vaccination an ulcer more than
10 mm deep. This is due to deep injection or secondary infection. Treat with INH powder.
4.Glandular enlargement – the glands draining the injection site may become enlarged. If suppuration
occurs, treat as deep abscess.

DTP
Side effects:
1.Fever – if fever lasts more than 24 hours after a dose of DTP is not due to the vaccine but to other causes.
Advise mother to give anti-pyretic to the child.
2.Local soreness – pain or swelling in the area where injections was given. If this starts early after the
injection, then it is only due to the vaccine. Reassure mothers that it needs no treatment and will disappear
within 3-4 days
3.Abscess – that appear a week or more after the injection is due to wrong technique, either the vaccine
was not injected deep enough or the needle was not sterile
 Incision and drainage is necessary.
4. Convulsions – are very rare and occur more in children about three months of age. This is due to the
Pertussis component of the vaccine.
 If this occurs, do not continue the normal course of DTP.
Polio Vaccine
Side effect – usually none
Measles Vaccine

Side effects:
1. Fever, and rash – usually fever after five to seven days from the time of vaccination. Fever may last
from 1-3 days. Sometimes, there is a mild measles rash. Give anti-pyretics.
 Reassure the mother and advise her to give antipyretics to the child.
Tetanus Toxoid
Side effects:
1. Pain
2. Redness swelling for a few days at the site of the injection.
 Reassure the mother.
 No treatment needed

Hepatitis B
Side effects – local soreness; apply warm compress
Rotarix – No serious adverse reaction
“LIGTAS SA TIGDAS ANG PINAS”
A Door-to-Door Measles-Rubella (MR SIA)
Supplemental Immunization Campaign
Eligible Children:
9 months to 95 months old whether the child received measles- containing vaccine

WHAT ARE THE “DOORS” REFERRED TO IN THIS CAMPAIGN?

It includes all doors of houses, condominiums, apartments, tenements, orphanages and halfway homes as
well as non-conventional doors in the community.
Non-conventional doors include the following:
 Informal settlements such families/persons living under the bridge; inside the parks, cemeteries and
open spaces; in tents, carts, abandoned buildings, old vehicles/trans/motorboats, under the trees, in
islands on the middle of the street, etc.
 All eligible children found in the parks, playgrounds, streets, markets, and other public
places shall be directed to go home to be vaccinated.
 Areas like day care centers, schools, malls, groceries, or churches shall not be visited
anymore (if and only if no family resides).
OBJECTIVES OF THE CAMPAIGN:
 To reduce the number or pool of children at risk of getting measles or being susceptible to measles.
  To achieve at least 95% measles-rubella immunization coverage of all children 9-95 months old
 Ultimate Goal: To eliminate measles by 2012.
 To accelerate the control of rubella

HOW TO HANDLE M/RUBELLA VACCINE

 MR should be kept at +2°C to +8°C.
 Any remaining reconstituted vaccine must be discarded after 6 hours or at the end of the immunization,
whichever comes first.
 Child aged 8 years old at time of the vaccination team may GIVE MR but do not record in the Recording
Form
REACTIONS TO MEASLES, MMR,MR
“Common” . The majorities of vaccine reactions are “common”, mild, settle without treatment, and have no long-
term consequences:
 Fever (irritability, malaise and non-specific symptoms
 Local swelling (pain, swelling, redness
These common reactions occur within a day or two of immunization, except for fever and systemic
symptoms for measles/MMR which occur from 5 to 12 days after immunization. Although fever and/or
rash only 3% are attributable to vaccine.

What are the rare, serious vaccine reaction rates?

Reaction Onset Interval Rates
 Febrile seizures 5 – 12 days
 Thrombocytopenia
(low platelets) 15 -35 Anaphylaxis
0 – 1 hour

HOW TO MANAGE PAIN /FEVER

 Avoid touching or hitting the swollen area;
 May give Paracetamol until fever subsides
 A cold cloth applied to the site may ease the pain.
 Extra fluids need to he given to feverish children.
 Rash –occurs in 5-15 children
 Infections (e.g. cellulitis) –Refer
 Give Paracetamol every 6 hours for pain, swelling and fever

Vaccine Vial Monitor

How to read a VVM

MULTI-DOSE VIAL POLICY/ OPEN VIAL POLICY

C – vaccines are stored under appropriate Cold Chain at all times

A – Aseptic /sterile technique has been used to withdraw all doses
V – Vaccine Vial Monitor (VVM) has not reached the discard point
E – Expiry date has not passed
S – vaccine Vial has not submerged in water

ROLE OF NURSE IN IMPROVING DELIVERY OF IMZN IN COMMUNITY

- Active masterlist à infants/mothers
- Immunize infants/mothers
- Observe aseptic technique
- Proper disposal of used S/N
à SCB/Hub cutter à septic vault
- Inform, educate and communicate with parents
- Conduct health visits
- Identify cases of EPI target diseases – standard case definition
- Correct management of vaccines
- Update of TCL/ECCD card/GMC
- Submit report/record children vaccinated, cases and deaths on
 EPI dses, EPI related report

BAKUNA ang UNA

Sa

SANGGOL

at

INA

NEWBORN SCREENING PROGRAM

WHAT IS NEWBORN SCREENING?

An essential public health program that prevents catastrophic health consequences from inborn disorders through:

 Early detection

 Early diagnosis
  Early treatment

HOW IS NEWBORN SCREENING PERFORMED?

Blood sample collection

(2 – 5 days of life in
term newborns)

Analysis for the presence

of the 5 disorders
screened (NIH
laboratory/NSC-WV)

Positive

Confirmatory Test

Positive

COMPONENTS OF NEWBORN SCREENING

No
Y
E
IT
 RA
AS UQ
SU
 WHICH DISORDERS ARE SCREENED?
 Inborn, but without obvious signs at birth
 Significantly prevalent in the population
 Life threatening or cause severe mental and physical disability if not detected and treated early
 Known cure:
 Supplementation
 Avoidance
 WHICH DISORDERS ARE SCREENED?
In the Philippines:
 Congenital Adrenal Hyperplasia (CAH)
 21 hydroxylase deficiency
 Congenital Hypothyroidism (CH)
 Primary Congenital Hypothyroidism
 Glucose 6-Phosphate Dehydrogenase (G6PD) deficiency
 Galactosemia
 Phenylketonuria (PKU)

Congenital Adrenal Hyperplasia

NON – SALT LOSSERS
- Simple Virilizing

Cong
Adren
Hyper
 Losse
CONGENITAL ADRENAL
HYPERPLASIA

CONGENITAL HYPOTHYROIDISM

SALT LOSSERS
Large Fontanel

Large Tongue

Thick dry cold skin

Abdominal Distention
Umbilical Hernia

GOOD Hypo
BABIES
 Inac

CRETINISM

Hollow empty Eyes-Far Apart

Swollen Eyelids

Open mouth w/ thick broad

tongue

Umbilical
Hernia
Disproport
short

Broad nose w/
depressed bridge
GALACTOSEMIA
CLINICAL MANIFESTATIONS Narrow chest w/
 Edema curved back
 Ascites

 Hepatomegaly

 Cataracts

 Mental retardation

 Cirrhosis of the liver

 Growth failure
RBC’S UNDERGO HEMOLYSIS WITHOUT G6PD!

No
G6PD

Oxidative
Oxidative

N
substance
substance
ss

TH A
Y OU
K
HEMO

INTACT RED BLOOD

CELL