epi vaccines handouts

Lecture Notes on EPI (Expanded Program on Immunization)

Prepared By: Mark Fredderick R Abejo R.N, MAN

Clinical Instructor

1

E.P.I

Expanded Program on

Immunization

Objective: To reduce the morbidity and

mortality among infants and children

caused by the seven childhood

immunizable diseases.

Four Major Strategies Sustaining high routine FIC

coverage of at least 90% in all

provinces and cities.

Sustaining the polio free country for

global certification.

Eliminating measles by 2008

Eliminating neonatal tetanus by

2008

Elements of EPI Target Setting (main element)

Information, Education and

Communication

Cold chain logistic management

Assessment and Evaluation of

overall performance

Surveillance, Studies and Research

Seven (7) Childhood

Immunizable Diseases

Tuberculosis ( Primary Complex if

less than 3 years old )

Diphteria

Pertussis

Neonatal Tetanus

Poliomyelitis

Hepatitis B

Measles

PD 996 : “ Providing for

compulsory basic immunization for

infants and children below 8 years old

Concept and Importance of

Vaccination

Immunization – is the process by

which vaccines are introduced into the

body before infection sets in.

Vaccines are administered to

introduced immunity thereby

causing the recipient’s immune

system to react to the vaccine that

produces antibodies to fight

infection.

Vaccinations promote health and

protect children from disease –

causing agents.

Infants and newborn need to be

vaccinated at an early age since they

belong to vulnerable age group.

General Principles in

Vaccinating Children

It is safe and immunologically

effective to administer all EPI

vaccines on the same day at different

sites of the body.

The vaccination schedule should

not be restarted from the beginning

even if the interval between doses

exceeded the recommended interval

by months or year.

Giving doses of a vaccine at less

than the recommended 4 weeks

interval may lessen the antibody

response. Lengthening the interval

between doses of vaccines leads to

higher antibody levels.

No extra doses must be given to

children who missed a dose of

DPT/HB/OPV. The vaccination

must be continued as if no time had

elapsed between doses.



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2

Note:

If parent strongly objects to

an immunization for a sick infant,

do not give it. Ask the mother to

comeback when child is well.

Do not give more than one dose of

the same vaccine to a child in one

session. Give doses of the same

vaccine at the correct intervals.

Strictly follow the principle of

never, ever reconstituting the freeze

dried vaccine in anything other than

the diluent supplied with them.

If you are giving more than one

vaccine, do not use the same syringe

and do not use the same arm or leg

for more than one injection.

Contraindication to

Immunization

Anaphylaxis or severe

hypersensitivity reaction to a

previous dose of vaccine is an

absolute contraindication to

subsequent doses of vaccine

Person with a known allergy to a

vaccine component should not be

vaccinated.

DPT2 or DPT3 is not given to a

child who has convulsions or shock

within 3 days after DPT1. Vaccines

containing the whole cell pertussis

component should not be given to a

children with an evolving

neurological disease.

Do not give live vaccines like BCG

to a individuals who are

immunosuppressed due to malignant

disease ( child with AIDS) , going

therapy with immunosuppressive

agents or radiation.

A child with a sign and symptoms

of severe dehydration

Fever of 38.5 C and above

The following are NOT

contraindication. Infants with

these conditions SHOULD be

immunized:

Allergy or asthma ( except if there

is a known allergy to a specific

component of vaccine mentioned

above )

Minor respiratory tract infection

Diarrhea

Temp. below 38.5 C

Family history of adverse reaction

following immunization

Family history of convulsions,

seizures Known or suspected HIV infection

with no signs and symptoms of

AIDS

Child being breastfed

Chronic illness such as diseases of

heart, lung, kidney or liver

Stable neurological condition such

as cerebral palsy or Down’s

Syndrome

Premature or low birthweight (vaccination should not be

postponed )

Recent or imminent surgery

Malnutrition

History of jaundice at birth

EPI Routine Schedule Every Wednesday is

designated as immunization day and is

adopted in all part of the country

FIC “Fully Immunized Child” when

a child receives one dose of BCG, 3

doses of OPV, 3 doses of DPT, 3 doses

of HepB and one dose of measles

before a child’s first birthday.



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3

EPI COLD CHAIN and LOGISTICS

Cold Chain Manager = Public Health Nurse

Temperature monitoring of vaccines is done in all levels of health facilities to

monitor vaccine temperature.

Temperature checking is done twice a day early in the morning and in the

afternoon before going home.

Temperature is plotted every day in monitoring chart to monitor break in cold

chain.

Type of Vaccine Storage Temp. Hours of

Life after

opening

Most Sensitive to OPV -15 to -25 C

Heat Measles At the freezer

Hepa B 8 hours

Most Sensitive to DPT 2 to 8 C

Cold Tetox Body of

Sensitive to Sunlight

and Fluorescent light

BCG refrigerator 4 hours

Vaccine can be stored in Refrigerator:

Regional – 6 months

Municipal / City – 3 months

Main Health Center – 1 months

Transport Box : 5 days

Note: 3 trip in transport box with the same vaccine discard it

FEFO ( first expiry and first out ) vaccine is practiced to ensure that all

vaccines are utilized before its expiry date.

Proper arrangement of vaccines and labeling of vaccines expiry date are done to

identify those near to expire vaccines

Vaccine Wastage Wastage is defined as loss by use, decay, erosion or leakage or through

wastefulness

Wastage rate = Doses supplied – doses administered x 100

Doses supplied



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Types of Vaccine Wastage

Vaccine wastage in unopened vials

Expiry

Heat exposure

Freezing

Breakage

Missing inventory

Theft

Discarding unused vials returned from

an outreach session

Vaccine wastage in opened vials

Discarding remaining doses at end of

session

Not being able to draw the number of

doses indicated on the label of a vial

Poor reconstitution practices

Submergence of opened vials in water

Suspected contamination

Patient reaction requiring more than

one dose

Wastage Factor: ( constant ) DPT = 1.67

OPV = 1.67

Measles = 2

BCG = 2.5

HepB = 1.10

Tetox = 1.67



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5

Target Setting

Steps and examples in calculating vaccine requirements

Steps Formula Infant Mothers

BCG DPT Hep B Tetox

Total Population

( TP )

e.g 3,000

3,000

3,000

3,000

3,000

Determine the

Eligible Population

( EP )

EP = TP x 3%

(Infants/Children)

EP = TP x 3.5 %

( Mothers )

90

90

90

105

Required number of

doses to immunize a

child/ mother

1

3

3

2

Determine the total

vaccine required

( TVR )

TVR = EP x number

of doses

90

270

270

210

Wastage Factor

( WF )

Given wastage factor

(constant )

2.5 1.67 1.1 1.67

Calculate the

Annual Vaccine

doses required

( AVR )

AVR = TVR x WF

225

451

297

351

Number of doses per

ampule/vial

20 10 or

20

1 or 10 10 or 20

Determine Annual

Vaccine

Ampule/Vial

required ( AVA )

AVA = AVR / # of

doses per

ampule/vial

12

46 or

23

297 or

30

36 or 18

Caculate the

Monthly Vaccine

doses Required

( MVR )

MVR = AVR / 12

months

19

38

25

29

Determine Monthly

Vaccine

Ampule/Vial

required ( MVA)

MVA = AVA / 12

1

4 or 2

25 or

2.5

3 or 1.5



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6

EPI VACCINES

BCG ( Bacille Calmette-Guerin ) Vaccine

Type of Vaccine Live Bacterial

Form of Vaccine Freeze dried

Minimum Age at 1st Dose Birth or anytime at birth

Number of Doses to

Complete the Immunization

1st dose : at birth

2nd

dose: school entrance

Reason BCG given at earliest possible age protects the

possibility of TB meningitis and other TB infectious in

which infants are prone.

Number of Doses per

Ampule

20 ( 20 children )

Dosage At birth : 0.05 ml

At school entrance : 0.10 ml

Route of Administration Intradermal ( a special syringe and needle is used for

the administration of BCG vaccine )

Site of Administration Right deltoid region of the arm

Storage Temperature 2 C to 8 C ( in the body or refrigerator )

Note: Freezing does not damage it but ampules may

break.

Diluents should also be kept cold before using

Special Precautions Correct ID administration is essential. A special

syringe and needle is used for the administration of

BCG vaccine

Side Effect A wheal formation

Koch phenomenon ( inflammatory reaction 2-4 days )

Undesired Effect Indolent ulceration

Abscess on the injection site

Enlarged lymph nodes

Note: Swollen glands or abscesses occur because an

unsterile needle or syringe was used, too much vaccine

was injected or most commonly, the vaccine was

injected incorrectly under the skin instead of its top

layer.

Contraindication Immunosuppressed indvidual due to malignant disease

( child with clinical AIDS ) ; therapy with

immunosuppressive agent or radiation.

Health Teaching Do not massage the area of injection

A scar will formed 12 weeks after injection

Repeat BCG vaccination if the child does not

develop a scar after first injection



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Reconstituting the freeze dried BCG Vaccine:

Always keep the diluent cold

Using a 5ml. syringe fitted with along needle, aspirate 2 ml. of saline solution from

the opened ampule of diluent.

Inject the 2ml. saline into the ampule of freeze dried BCG.

Thoroughly mix the diluent and vaccine by drawing the mixture back into the

syringe and expel it slowly into the ampule several times.

Return the reconstituted vaccine on the slit of the foam provided in the vaccine

carrier.

Giving BCG Vaccine:

Clean the skin with a cotton ball moistened with water and let skin dry.

Hold the child’s arm with your left hand so that your hand is under and your thumb

and finger come around the arm and stretch the skin.

Hold the syringe in your right hand with the bevel and the scale pointing up

towards you.

Lay the syringe and needle almost flat along the child’s arm.

Insert the tip of the needle into skin – just the bevel. Keep the needle flat along the

skin and the bevel facing upwards, so the vaccine only goes into the upper layers of

the skin.

Put your left thumb over the needle end to hold it in position. Hold the plunger e

between the index and middle fingers of the right hand and press the plunger in

with your right thumb.

If the vaccine is injected correctly into the skin, a flat wheal with the surface pitted

like an orange peel will appear at the injection site.

Withdraw needle gently.

Note:

Any remaining reconstituted vaccine must be discarded after 6 hours or at the end

of the immunization sessions, whichever comes first.

The small raised lump appears at the injection site, usually disappears within 30

minutes.

After 2 weeks, a red sore forms that is about the size of the end of an unsharpened

pencil.

The sore remains for another two weeks and then heals, a small scar, about 5mm

across remains. This is a sign that the child has been effectively immunized.

Repeat BCG vaccination if the child does not develop a scar after the 1st injection

BCG vaccine is moderately effective. It has a protective efficacy of:

50 % against any TB disease

64 % against TB meningitis

74 % against death from TB



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DPT ( Diphteria-Pertussis-Tetanus ) Vaccine Type of Vaccine Diphteria and Tetanus as “toxiods” which is a

weakened toxin

Pertussis as killed whole-cell bacterium

Form of Vaccine Liquid vaccine

Minimum Age at 1st Dose 6 weeks

Number of Doses to


3

Interval 4 weeks / minimum of 28 days

Reason An early start with DPT reduces the chance of severe

pertussis

Number of Doses per

Ampule

20 or 10

Dosage 0.5 ml

Route of Administration Intramuscular

Site of Administration Upper outer portion of the thigh ( Vastus lateralis ) in

infant ( R – L – R )

Outer upper arm if older

Storage Temperature 2 C to 8 C ( in the body of refrigerator )

Note: “DT” component is damage by freezing

“P” component is damage by heat

Special Precautions DPT not usually given over 6 years of age

Side Effect Fever in the evening after receiving the injection.

Soreness, children may have pain, redness or

swelling at the injection site.

Contraindication DPT2 or DPT3 is not given to a child who has

convulsions or shock within 3 days after DPT1.

Vaccines containing the whole cell pertussis

component should not be given to a children with an

evolving neurological disease.

Health Teaching If the child has fever give paracetamol or any

appropriate antipyretic at the time and at four and

eight hours after immunization.

Alternating cold compress for 24 hours to warm

compress if there is pain and soreness .

Giving DPT Vaccine

Ask mother to hold the child across her knees so that her thigh is facing upwards.

Ask her to hold child’s leg.

Clean the skin with a cotton ball, moistened with water and let skin dry.

Grasp the injection site with your thumb and index finger.

Quickly push the needle, going deep in to the muscle.

Slightly pull the needle back to be sure it is not into a vein.

Inject the vaccine, withdraw the needle and press the injection spot quickly with a

piece of cotton.



Clinical Instructor

9

OPV ( Oral Polio Vaccine )

Type of Vaccine Live attenuated vaccine


Minimum Age at 1st Dose 6 weeks

Number of Doses to


3

Interval 4 weeks / minimum of 28 days

Reason The extent of protection against polio is increased the

earlier the OPV is given

Number of Doses per

Ampule

20 ( 10 children )

Dosage 2 drop

Route of Administration Oral

Site of Administration Mouth

Storage Temperature -15 C to -25 C ( at the freezer )

Note: It is easily damaged by heat but is not harmed

by freezing.

Special Precautions Children known to have rare congenital immune

deficiency syndrome should receive IPV ( injectable

polio vaccine ) rather OPV

Side Effect Causes almost no side-effects. Less than 1% of the

people who receive the vaccine develop a headache,

diarrhea or muscle pain.

Contraindication None

Health Teaching Nothing by mouth (NPO) 30 minutes before and

after OPV.

Do not touch the tip dropper bottle to the tongue.

Giving Oral Polio Vaccine

Read the manufacturer’s instructions to determine number of drops to be given.

Use the dropper provided for.

Two types of OPV containers:

- small plastic dropper bottles

- glass vials with dropper in a separate plastic bag

Let the mother hold the child lying firmly on his back.

If necessary open the child’s mouth by squeezing the cheeks gently between your

fingers to make his lips point upwards.

Put drops of vaccine straight from the dropper into the child’s tongue but do not let

the dropper touch the child’s tongue.

Make sure that the child swallows the vaccine. If he spits it out, give another dose.

If a child has diarrhea when you give OPV, administer an extra dose – that is, a

fourth dose at least four weeks after he or she has received the last dose in the

schedule



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10

Hepatitis B Vaccine Type of Vaccine “Monovalent vaccine” contain only one antigen

Form of Vaccine Cloudy liquid vaccine

Minimum Age at 1st Dose At birth

Number of Doses to


3

Interval 6 weeks interval from 1st dose to 2

nd dose

8 weeks interval from 2nd

dose to 3rd

dose

Reason An early start of Hep B vaccine reduces the chance of

being infected and becoming a carrier. Prevent liver

cirrhosis and liver cancer

Number of Doses per

Ampule

1 for single dose vial

10 for multi dose vial ( 10 children )

Dosage 0.5 ml


Site of Administration Upper outer portion of the thigh ( Vastus lateralis ) in

infant ( with DPT: L – R – L )


Note: Both heat and freezing damages the vaccine )

Special Precautions Birth dose must be given if there is a risk of perinatal

transmission.

Note : Combination vaccines should not be given at

birth, only monovalent HepB vaccine

Side Effect Mild fever that lasts one to two days after injection


swelling at the injection site.

Contraindication Anaphylactic reaction such as severe rashes,

difficulty in breathing and choking to a previous

dose.






Giving Hepatitis B Vaccine

Ask mother to hold the child across her knees so that her thigh is facing upwards.

Ask her to hold child’s leg.


Grasp the injection site with your thumb and index finger.




piece of cotton.



Clinical Instructor

11

Measles Vaccine

Type of Vaccine Attenuated Measles Virus

Form of Vaccine Freeze dried

Minimum Age at 1st Dose 9 months

6 months: if there is an epidemic

Number of Doses to


1

Reason Measles vaccine given at 9 months provide at least

85% protection against measles infection.

When given at one year and older provides 95%

protection.

Note: An infant with known or suspected HIV infection

should receive measles vaccine at 6 months and then

again at 9 months

Number of Doses per

Ampule

10 ( 10 children )

Dosage 0.5 ml

Route of Administration Subcutaneous

Site of Administration Outer part of the upper arm

Storage Temperature -15 C to -25 C ( at the freezer )

Note: But can also be safely stored between 0 C to 8C

until its expiry date.

Diluents should also be kept cold before using.

Special Precautions Birth dose must be given if there is a risk of perinatal

transmission.

Note : Combination vaccines should not be given at

birth, only monovalent HepB vaccine

Side Effect Fever that lasts one to two days after injection


swelling at the injection site within 24 hours of

immunization. It usually resolve within two to three

days.

About 1 in 20 children develop a mild rash five to

12 days after receiving the vaccine. The rash usually

lasts about two days.

Contraindication Severe reaction to previous dose

Pregnancy

Congenital or acquired immune disorder






It also prevent diarrhea



Clinical Instructor

12

Reconstituting the Freeze Dried Measles Vaccine

Using a 10 ml. syringe fitted with a long needle, aspirate 5 ml of special diluent,

from the ampule.

Empty the diluent from the syringe into the vial with the vaccine.

Thoroughly mix the diluent and vaccine by drawing the mixture back into the

syringe and expelling it slowly into the vial several times. Do not shake the vial.

Protect reconstituted measles vaccine from sunlight. Wrap vial in foil.

Place the reconstituted vaccine in the slit of the foam provided in the vaccine

carrier.

Giving Measles Vaccine

Ask the mother to hold the child firmly.

Clean the skin with a cotton ball, moistened with water and let the skin dry.

With the finger of one hand, pinch up the skin on the outer side of the upper arm.

Without touching the needle, push the needle into the pinched-up skin so that it is

not pointing.

Slightly pull the plunger back to make sure that the vaccine is not injected into a

vein.

Press the plunger gently and inject.

Withdraw the needle and press the injection spot quickly with a piece of cotton.

Immunization Schedule For Infants Recommended By The EPI

AGE

Birth 6 weeks 10 weeks 14 weeks 9 months

BCG X

OPV X X X

DPT X X X

HepB Option B X X X

Option A X X X

Measles X



Clinical Instructor

13

Tetanus Toxoid (TeTox) Vaccine

Type of Vaccine Weakened toxin


Minimum Age at 1st Dose As early as possible during pregnancy

Number of Doses to


5 doses ( TeTox 1 – TeTox 5 )

TeTox 2 is the minimum required immunization

during pregnancy

Number of Doses per

Ampule

10 or 20

Dosage 0.5 ml


Site of Administration Outer upper arm


Note: Never freeze

Side Effect Fever in the evening after receiving the injection.

Soreness, woman may have pain, redness or

swelling and warmth at the injection site.

Contraindication Anaphylactic reaction to previous dose

Health Teaching NO MEDICATION FOR PREGNANT

For Pain cold compress 24 hrs to warm compress

Tetox Routine Immunization of Pregnant Women

Vaccine Minimum

Interval

Percent

Protected

Duration of Protection

TeTox 1 As early as

possible during

pregnancy

TeTox 2 4 weeks after

TeTox 1

80% infant will be protected by

neonatal tetanus

3 years protection for the mother

TeTox 3 6 months after

TeTox 2

95 % infant will be protected by

neonatal tetanus


TeTox 4 1 year after TeTox

3

99 % infant will be protected by

neonatal tetanus


TeTox 5 1 year after TeTox

4

99 % all infant born to that mother will

be protected

lifetime protection for the mother



Clinical Instructor

14

Giving Tetanus Toxoid ( TeTox ) Vaccine

Shake the vial.


Place your thumb and index finger on each side of the injection site and grasp the

muscles slightly. The best injection site for a woman is outer side of the upper arm.




piece of cotton.

Role of A Nurse In Improving the Delivery of Immunization

in the Community.

As a nurse you need to:

Actively master list infants eligible for vaccination in the community.

Immunize infants following the recommended immunization schedule, route of

administration, correct dosage and following the proper cold chain storage of

vaccines.

Observe aseptic technique on immunization and use one syringe and one needle

per child. This reduces blood-borne diseases and promote safety injection practices.

Dispose used syringes and needles properly by using collector box and disposing it

in the septic vault to prevent health hazard.

Inform, educate and communicate with the parents

to create awareness and motivate to submit their child for vaccination.

to provide health teachings on the importance and benefits of

immunization, importance of follow up dose to avoid defaulters and

normal course of vaccine.

to inform immunization schedule as adopted by local units.

Conduct health visits in the community to assess other health needs of the

community and be able to provide package of health services to targets.

Identify cases of EPI target diseases per standard case definition.

Manage vaccines properly by following the recommended storage of vaccines.

Record the children given with vaccination in the Target Client list and

GECD/GMC or any standard recording form utilized.

Submit report and record of children vaccinated, cases and deaths on EPI diseases,

vaccine received and utilized and any other EPI related reports.

Identify and actively search cases and deaths of EPI target diseases following

standard case definition.

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