Supporting the EPI:

Let us boost up the

immunization
Pakistan Pediatric Association
World Wide Immunization Status
INTRODUCTION:
WHO estimates that 2.5 million children under 5 die from
vaccine preventable diseases every year in the world.
Immunization is most cost effective intervention
ever.
Eradicated incidence of Polio by 99% since 1988 and
achieved dramatic reduction in diseases such as measles,
diphtheria, pertusis, tetanus and hepatitis B.
Improvement in coverage of current vaccines and
inclusion of newer vaccines like Rota Virus and
Pneumococcal disease will reduce the infant mortality for
the achievement of the MDG4.



Types of Immunity
Immunity
Natural immunity
Acquired immunity

1. Active



2. Passive

Non-susceptibility(resistance)
Without external stimulation
By external stimulation

Body immune cells are stimulated to
produce antibodies by infection or
vaccination

Antibodies from outside e.g.
Maternal antibodies to fetus by placenta
/baby by breast milk
Human immune globulins, ATG, HBIG
Serum from animals immunized eg. ATS,
ADS
Types of vaccines
Toxoid

Killed
Organisms

Live
attenuated

Antigen

Conjugated

Tetanus toxoid, diphtheria toxoid

Pertusis


BCG,OPV,Measles


Hepatitis B, Hib

Pnemococcal
Expanded Program of Immunization
(EPI)
1974 WHO launched EPI to address inequities in global
vaccine coverage.
1977 The World Health Assembly proposed the goal of
universal childhood immunization against 6 antigens
(TB, Polio, Diphtheria, Pertusis, Tetanus and
Measles)
EPI Landmarks in Pakistan
1978
2002
2009
2012
EPI initiated
Hepatitis B
HiB
2
nd
Dose Measles
Pneumococal
EPI in Pakistan
1978 Nationwide
survey revealed 6
EPI diseases as
major health
problems under 5
1979 EPI initiated
0
50
100
1982
1984
1988
1991
1993
5
70
81
86
62
% coverage
% coverage
EPI in Pakistan
Pakistan demographic and health survey 2009:
96% of children aged 12-23months received at least 1 vaccine.
However, coverage of subsequent doses of all antigens
declined.
47% children received all recommended doses of BCG, OPV,
DPT and Measles.
Vaccination coverage ranged from 35% in Balochistan to 54%
in Punjab.
Reasons for Low Routine Coverage
Dropouts
Parental misconception due to polio days
Missed opportunities
Children not brought to health facilities or due to any
reason, parents dont vaccinate their children
Children in areas difficult to reach
Poor governance
Poor access to vaccination centre
Lack of available staff
Irregular vaccine supply
Poor monitoring


EPI Vaccines
BCG (TB)
OPV (Polio)
Pentavalent (Diphtheria, Tetanus, Pertussis
Hepatitis B,Hemophilus influenza B (Hib)
Pneumococcal
Measles

Proposed: Rota virus


EPI Vaccination schedule
Birth BCG+OPV
6 weeks 1
st
PENTA+ OPV + Pneumococcal
10 weeks 2
nd
PENTA+OPV + Pneumococcal
14 weeks 3
rd
PENTA+OPV + Pneumococcal
9 months 1
st
Measles
15 months 2
nd
Measles

PENTAVALENT (DPT+Hep B+HiB)
EPI Vaccines: Dose, Route and Sites
Vaccine Dose Route Site
BCG < 1 yr 0.05ml
> 1yr 0.10ml
I/D Rt deltoid
OPV 2-3 drops oral
Pentavalent 0.5 ml I/M Thigh, Anterolateral ,junction
of upper1/3& lower 2/3
Pnemococcal 0.5 ml I/M Thigh, Anterolateral
Measles 0.5 ml S/C Lt. deltoid
Needle size BCG-26 g All others 24-23 g

Schedule for children not immunized at
early infancy and age of child is<2 years
1
st
visit If > 6 weeks BCG+OPV
1
st
PENTA+OPV+Pneumo
If > 9 months 1
st
Measles

2
nd
visit 2
nd
PENTA + OPV + Pneumo
(after 4-8 weeks)

3
rd
visit 3
rd
PENTA + OPV + Pneumo
(after 4-8 weeks)

2
nd
Measles in 2nd year of life ,at least 4 weeks after 1
st

dose

TT for Women of child bearing age
(15-45 years)
Dose Time scedule Protection
1
st
At first contact Nil
2 4 weeks after 1
st
dose 3 years
3 6 months after 2
nd
dose 5 years
4 1 year after 3
rd
dose, or
next pregnancy
10 years
5 1 year after 4
th
dose, or
next pregnacy
Life time
Tetanus protection starts 15 days after TT 2 (give TT 2
at least 15 days before delivery but at least after 4
weeks of TT 1)
5 doses Tetanus Toxoid 0.5ml,I/M in Deltoid

Site of Injection
Few facts
Minor ailments and minor infections are not a
contraindication for vaccination
Minimum interval of 4 weeks is required
between 2 doses of OPV, Pentavalent,Pneumo,
TT, but subsequent dose may be given if
defaulter turns within 1 year of last dose
Measles vaccines should be given at 9months of
age ,even if history of measles is given
In children any vaccine given in campaigns like
OPV, Measles etc. should not be counted in
routine doses.




Contra indications
There are no contra indications except
1) The child is very ill and his condition warrants
admission to hospital
2) Child has previously experienced severe
reaction to Pentavalent, TT is recommended
instead of DPT where as HB and HIB should be
given separately.
3) BCG should not be given to baby of mother
suffering from AIDS.
4) Dont give Pneumococcal vaccine with H/O
severe reaction to previous dose or to a child
with moderate to severe illness

Adverse events following immunization
Vaccine reaction

Program error

Coincidental

Injection reaction


Common minor reactions
Vaccine Local
reaction
Fever>
38C
Systemic
Symptoms
BCG 90%-95% _ _
OPV _ <1% <1%
Hep. B Adult 15%
Child 5%
1%-6% _

Penta(Pertussis) 50% 50% 55%
Measles 10% 5%-15% 5% (Rash)
TT 10% 10% 25%
Pneumo 50% 5% Very common
Treatments Cold cloth
paracetamol
Extra fluids
paracetamol
Extra fluids
paracetamol
Rare vaccine reactions
Vaccine Reaction On set
interval
Reaction
per million
doses
Hep. B Anaphylaxis 0-1 hour 1-2
BCG Lymphadenitis 2-6 months 100-1000
BCG Osteitis 1-12
months
0.01-300
Disseminated
TB
1-12
months
0.19-1.56
Rare vaccine reactions
Pneumo Severe allergic
reaction
.01
OPV VAPP 4-30 days 0.4
Measles Febrile fits 6-12 days 330
Thrombocytopaenia 15-35 days 30
Anaphylaxis 0-1 hour 1
Encephalopathy 6-12 days >1
Rare vaccine reactions
TT Brachial neuritis 2-28
days
5-10
Anaphylaxis 0-1 hr 0.4-10
Penta
(pertusis)
Excessive cry >3
hr
0-24 hrs 1000-
60000
seizures 0-2 days 80-570
Hypotonic Hypo
responsive
0-24hrs 30-990
Anaphylaxis 0-1hr 20
Encephalopathy 0-2 days 0-1
Neonate of HepB positive mother
Hepatitis B immune globulin human 0.5ml I/M
within 12 hours of birth
HepB vaccine at the same time(at different site),
and then at 6,10 & 14 weeks as part of routine EPI
vaccination.

Post Exposure HepB Prevention
HBIG 0.06ml/kg (max 5ml) within 24 hours
First dose HB vaccine, then HB at one month and
6months
Management of Anaphylaxis
Things to be available

Immediate management steps

Practical points
Maintain cold chain
Store vaccines
between +2 to + 8C
Observe vaccine vial
monitor ( VVM)
After reconstitution,
BCG,Measles and
Pneumococcal
vaccines be
discarded in six hrs,as
there is chance of
Toxic shock Syndrom
























Practical points
Safe from sunlight (protect from heat)
Dont let Pneumococcal/ Pentavalent/TT freeze
Dont use disinfectants to clean syringes or needles
Once seal of vaccine vial is opened the rubber cap should not
come in contact of hand or any other surface
Dont store vaccines in refrigerator door
Defrost if ice layer is more than 5 millimeter
First use the vaccine which came first

Practical points
In preterm babies vaccinate according to chronological
age
Malnutrition is not contraindication to vaccination
Give OPV in Diarrhea but repeat the dose after 4 weeks of
completing OPV course

Local reaction to Pentavalent/TT increases if it is not given
deep I/M or is very cold
Two or more killed vaccines or killed and live vaccines can
be given simultaneously or at any interval
Two or more live vaccines should be given simultaneously
or should be given at least at 4 weeks interval

Other than EPI vaccines
Vaccine Type No of
doses
Recommended
Age
Schedule
MMR Live 2 After1 year 15 mo, 4.5yr
Hepatitis A Inactivated 2 After 1 year 6 months apart
Chickenpox Live 2 After 1 year 6 weeks apart
Typhoid Polysacchar
ide
Multiple After 2 year Single shot,
repeat 3 yearly
Meningococcal
vaccine
Polysacchar
ide
1 After 2 year Single shot
Flu Multiple At 6 months 4 weeks apart
than every year
Cervical Cancer Recombina
nt
3 > 9 years 2
nd
after 4 weeks
& 3
rd
after 6 mon
Role of Doctors
Ask Vaccination status of every child and mother seen at the
facility
Provide guidance for Immunization
Establish vaccination facility at your clinic/center
Alleviate any misconceptions regarding immunization
Support and participate in activities related to immunization
at public forums, print and electronic media
Help health authorities in surveillance and vaccination
promotion activities



Let us beat the menace of low
immunization coverage together
Thank you