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EPI
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The Expanded Program On
Immunization (EPI)
By
Prof. Drs
Asmaa ABelAziz Alaa Hassan
The Expanded Program On Immunization
(EPI)
The Objectives of the lecture:
State the objectives of EPI.
Outlines the schedule of compulsory immunization of KSA.
Recognize the scientific principles of immunization .
List the contraindications to vaccination.
Explain the four strategies for the vaccine delivery.
Define missed opportunity for immunization.
Mention the reasons for missed opportunity.
Define the cold chain.
Discuss the three components of the cold chain.
Interpret the tools for the cold chain monitoring.
The objectives of EPI: 1. To achieve 100% coverage with all EPI vaccines.
Example:
The coverage rate for measles vaccine by the year 2002 in a
city Y=
The No. of the infants received measles vaccine in the year 2002 in city Y X100 The total No. of the targeted infants during the same year & locality
2. Eradication of polio to maintain polio free status.
3. Elimination of measles.
4. Reduce
seroprevalence of
(HBsAg)to
5.Elimination of Neonatal Tetanus .
6. To maintain zero level of diphtheria.
7.Prevention of severe forms of TB ( TB meningitis
&military TB).
12 year old girl with TB meningitis
8. To reduce the incidence of whooping cough
.
9-Reduce the incidence of Bacteria Meningitis due to
haemophelus influenza
9. To maintain immunization safety.
10.To prepare for introduction of new vaccines
The Schedule of Compulsory Vaccination
in KSA
Diseases Type of vaccine Dose Rout of administration
1-BCG
2-HBV
TB
Hepatitis B
Live attenuated,
variant Recombinant, yeast
derived HBs antigen
0.01ml
0.5 ml
ID injection in left
deltoid IM thigh
At birth
Rout of
administration
Dose Type of vaccine Diseases
oral
2 drops
Live attenuated
Polio
1-OPV
IM thigh
0.5 ml
polysaccharide
conjugate
Hib disease
2-HiB
IM thigh
0.5 ml
Recombinant, yeast
derived HBs antigen
Hepatitis B
3-HBV
IM thigh
0.5 ml
Toxoid (D)
Toxoid (T)
Killed pertussis (P)
Diphtheria
Tetanus
Whooping
cough
4-DPT
2ndmonth
Rout of
administration
Dose Type of vaccine Diseases
oral
2 drops
Live attenuated
Polio
1-OPV
IM thigh
0.5 ml
polysaccharide
conjugate
Hib disease
2-HiB
IM thigh
0.5 ml
Toxoid (D)
Toxoid (T)
Killed pertussis (P)
Diphtheria
Tetanus
Whooping
cough
3-DPT
4th month
Rout of
administration
Dose Type of vaccine Diseases
oral
2 drops
Live attenuated
Polio
1-OPV
IM thigh
0.5 ml
polysaccharide
conjugate
Hib disease
2-HiB
IM thigh
0.5 ml
Recombinant, yeast
derived HBs antigen
Hepatitis B
3-HBV
IM thigh
0.5 ml
Toxoid (D)
Toxoid (T)
Killed pertussis (P)
Diphtheria
Tetanus
Whooping
cough
4-DPT
6 th month
Mode of
administration
Dose
Type of the
vaccine
The
disease
Subcutaneous
0.5 ml
All
Live attenuated
Measles, Mumps German Measles
1-MMR
12th month
Rout of
administration
Dose Type of vaccine Diseases
oral
2 drops
Live attenuated
Polio
1-OPV
IM thigh
0.5 ml
polysaccharide
conjugate
Hib disease
2-HiB
IM thigh
0.5 ml
Toxoid (D)
Toxoid (T)
Killed pertussis (P)
Diphtheria
Tetanus
Whooping
cough
3-DPT
18th month
Rout of
administration
Dose Type of vaccine Diseases
oral
2 drops
Live attenuated
Polio
1-OPV
IM thigh
0.5 ml
All
Live attenuated
- Measles
- Mumps
- German
Measles
2-MMR
IM thigh
0.5 ml
Toxoid (D)
Toxoid (T)
Killed pertussis (P)
Diphtheria
Tetanus
Whooping
cough
3-DPT
4- 6th years
BCG (At birth)
Live attenuated variant.
0.01ml .
ID injection in left deltoid (Why)
HB Vaccine: at birth,2nd,6th month
Recombinant, yeast derived HBs antigen
0.5 ml IM anterolateral of the thigh
OPV : (Sabin)
2nd , 4th, 6th, 18th& 4- 6th years
OPV live attenuated ,2drops
,Oral
Haemophilus influenzae type b
Severe bacterial infection,
particularly among infants
During late 19th century believed
to cause influenza
Immunology and microbiology
clarified in 1930s
Hib Vaccine
Haemophilus influenzae type b
Pathogenesis
Organism colonizes nasopharynx
In some persons organism invades
bloodstream and cause infection at distant site
Antecedent upper respiratory tract infection
may be a contributing factor
Cellulitis
6%
Arthritis
8% Bacteremia
2%
Meningitis
50%
Epiglottitis
17%
Pneumonia
15%
Osteomyelitis
2%
Haemophilus influenzae type b Clinical Features*
*prevaccination era
The Type of Hib vaccine inactivated polysaccharide
conjugate vaccine,
It is made by joining a piece of the polysaccharide capsule
that surrounds the Hib bacterium to a protein carrier.
This joining process is called conjugation.
Haemophilus influenzae type b
Meningitis Accounted for approximately
50%-65% of cases in the prevaccine era
Hearing impairment or neurologic sequelae in 15%-
30%
Case-fatality rate 2%-5% despite of effective
antimicrobial therapy
05
10
15
20
25
1990 1992 1994 1996 1998 2000 2002 2004
Inc
ide
nc
eIncidence*of Invasive Hib Disease,
1990-2004 *Rate per 100,000 in
children
After a Hib primary series of two or three doses,95% of
infants develop protective antibodies
Although Hib vaccines provide long lasting immunity the
duration of immunity is not known
The recommended dose for all is 0.5 mL.
Always administer by the IM injection in the thigh.
The preferred injection site in older children and adults is
the deltoid muscle in the upper arm.
Small child receiving Hib
vaccine into the muscles of
the thigh.
Adolescent receiving Hib
vaccine into the deltoid muscle
of the arm.
Storage of the vaccine
The vaccine should not kept frozen or exposed to
freezing
Store at 2 to 8C
Shake vial vigorously before withdrawal and use.
Do not use if resuspension does not occur with vigorous
shaking.
The vaccine should be administered shortly after
withdrawal from the vial.
Give all infants, including premature infants,
a primary series of Hib vaccine beginning at 2
months of age.
Do not administer Hib vaccine to infants
younger than 6 weeks of age because this
may induce immunologic tolerance to further
doses of Hib vaccine.
The most common adverse reactions after Hib
vaccination are
1-local reactions: swelling, redness, or pain
at the injection site.
2-Fever also can occur in as many as 5% of
recipients.
Fever usually starts within the 1st 24 hours of
vaccination and may last for 2 to 3 days.
These reactions can be treated with
a non-aspirin pain reliever, if needed.
local reactions: swelling, redness, or pain at the injection site.
The main contraindication to Hib vaccine :
Severe allergic reaction Do not give Hib-containing
vaccine to anyone who has had a prior severe allergic
reaction to a dose of Hib vaccine or to a component
in the vaccine.
Persons who are severely allergic to diphtheria
toxoid, meningococcal vaccine, or tetanus toxoid
also may be sensitive to a particular Hib vaccine
because of the protein carriers used to create the
conjugate vaccines.
DPT vaccine: 2nd, 4th ,6th, 18th months& 4-6 years
(D ,T) Toxoid & Diphtheria , (P) Killed pertussis
0.5 ml ,IM thigh
DPT:
2nd, 4th ,6th, 18th months& 4-6 years
DT: No pertussis component
It is given as subsequent doses to an infant who showed severe adverse effects
due to pertussis component.
dT: No pertussis component.
A small dose of diphtheria toxoid is given at school entry or after the age of six years.
MMR Vaccination:
12th month& 4-6 years
Live attenuated ( Three : measles, German
measles& Mumps)
0.5 ml
Subcutaneous arm
Basic Principles to be considered in immunization
schedule:
1-All EPI antigens are safe and effective if administered
simultaneously.
2-The recommended interval between two doses of
- Live attenuated vaccine .
- Inactivated vaccines.
3-The only live attenuated vaccine given to HIV child is
measles
4-Tetanus immunoglobulin (250 IU) must be given to
babies :
i) Born outside hospital in unsanitary home
conditions
ii) Seen within 10 days after birth.
ii) Whose mothers are not given two documented
doses of TT.
5- Introduction of HB vaccine in 1990.
6-MMR vaccine is given not before the 12months not to
be neutralized by maternal antibodies
Contraindications to vaccinations:
Absolute
Temporary
Contraindications to live attenuated vaccines: Absolute: 1- History of anaphylactic reactions.
2- Subsequent doses of pertussis vaccines are absolutely
contraindicated if the child gets (within 48 hours of vaccination )
Fever (40.5) ,
Collapse or shock .
Persistent crying for 3 hours without apparent cause.
Convulsion with or without fever within 3 hours after
vaccination.
3- HIV infection is an absolute contraindication to administration of
live attenuated vaccines ( OPV & BCG).
Temporary:
1- Pregnancy.
2- Severe illness that needs hospitalization.
3- Immunosuppression.
4- Recent receipt of blood.
The strategy for the vaccine delivery:
(I) The static immunization strategy.
(II) The National Immunization Days (NIDs).
(III) Mopping up Immunization.
(IV) Outreach immunization.
I) The static immunization strategy:
Advantages of integration of immunization services through (MCH):
1-Available resources.
2- Cold Chain maintenance.
3- Save ,time, effort and money.
(II) The National Immunization Days (NIDs):
It is periodic immunization of all the eligible targets in a defined
group over a large geographic areas within a short period of time. It
is one of the strategy for polio eradication and tetanus elimination.
For successful NIDs for polio:
Two doses of OPV are given to all children in the age group
0-59 months within 1-3 days.
It is conducted in two rounds (4-6weeks apart).
The doses of OPV given are extradoses and do not replace the
routine doses given during infancy.
The NIDs are conducted during low season of polio transmission
Most countries conduct NIDs annually for at least three years
and until polio is reduced from being an endemic disease to a
disease that occurs only in focal areas. Then the Mopping Up
Immunization is conducted.
(III) Mopping up Immunization:
It is house-to-house immunization with OPV in high risk districts.
It consists of two to three rounds 4-6 weeks apart .
Each round should be completed within a short period of time (3days).
High risk districts are those:
Where the wild polio virus is still circulating
( polio case in the last 36 months) .
With low immunization coverage.
Transient population, with overcrowding poor sanitary
environment and low access to health services.
(IV) Outreach immunization:
What is the difference between the NIDs and the out reach
Strategy?
The outreach is carried for routine immuniation that is compusory
for the targets in certain areas where:
- immunization services are not accessible.
- vaccination coverage is Low.
The outreach is carried during any time without specific duration.
Limitations:
(i) Expensive
(ii) Cold chain failure.
(iii) Difficulty to arrange the immunization schedule.
Missed opportunity :
It occurs when a child or a woman in child bearing period comes to
the health facility or outreach site and does not receive any of the
vaccine doses for which he or she is eligible.
The reasons for missed opportunity are:
Health workers` practices.
Logistical problems.
Failure to administer simultaneously all the vaccines for which the child is eligible.
False contraindications to immunization.
False contraindications to immunization:
Conditions that are wrongly considered as contraindications:
Minor illness( respiratory tract infections ,diarrhea, fever < 38.5C).
Prematurely or small for date infants.
Child being breast-fed.
Family history of convulsion.
History of jaundice at birth
Chronic health problems: Malnutrition ,allergy, asthma, other atopic
manifestations, hay fever ,chronic diseases of heart, lungs, kidney or
liver, cerebral palsy & Down syndrome ,dermatoses, local skin lesion.
Treatment with antibiotics, low dose corticosteroids( local or inhaled)
The cold chain:
It is the system of storage and transportation of the vaccine at
low temperature (cold condition) from the manufacture till it is
consumed.
Polio vaccine is the most sensitive vaccine to heat.
Live attenuated vaccines are allowed to be frozen
(OPV, Measles, MMR and BCG).
Inactivated vaccines must not be frozen ( DPT, DT, dT
, TT and HB) .
The levels of cold chain
The administrative
level
Storage
period
Temperature
The vaccines
Central & regional
stores
Maximum
three months
- 20 to- 30C
OPV, Measles,
MMR,BCG
+2 to +8C DPT, DT, dT,
TT& HB,Hib
Districts stores&
local immunization
centers
Maximum
one month
0C to+8C
OPV, Measles,
MMR, BCG
+2 to +8C
DPT, DT, dT,
TT& HB,Hib
The administrative levels of cold chain according to the
duration of the storage and the temperature required to keep
the vaccine potent
The equipment and tools
The procedures The health staff
The components of the cold chain :
Refrigeration equipment:
Refrigerator
Cold boxes
Vaccine carriers
The ice packs retained in the freezer
-To stabilize the temperature of the refrigerator at the
optimum level.
- Fully frozen ice-packs are used for lining the vaccines
carriers and the cold boxes during storing the vaccines
1-The refrigerator :
Placed in the coolest place of the health centers away from sunlight
Well ventilated and adequate air circulation around it .
Kept locked and open only when necessary.
Defrosted regularly .
Ice packs are kept in the freezer.
Its temperature is recorded twice daily.
Drugs, drinks or food must not be stored in the refrigerator.
Both the monitor and thermometer are placed in the refrigerator.
The temperature chart is stuck on the door outside the refrigerator.
The diluents should be kept on the lowest shelf.
Question:
What is the optimum Temperature of the
refrigerator in the health center?
+2 C to +8C
Cold box
ice Packs
Vaccine carrier
Vaccine carrier
Tools for monitoring the cold chain:
1- Cold Chain Monitor Card.
2- Freeze Watch Indicator
3- Cold Chain Refrigerator Graph
4- Vaccine Vial Monitors
5- Shake Test
Cold Chain Refrigerator Graph The vaccines are stored in refrigerators, they are monitored twice a day
and readings are recorded on a chart to ensure a safe temperature is
maintained. Emergency provisions made. Vaccines moved to cold
storage for 48 hours.
+2C
+8C
2-Cold Chain Monitor
Card: is used to show
cumulative exposure to
Temp. above the safe
range during storage&
transportation . It has an
indicator that responds
to two different Temps:
the first part marked as
ABC, responds to Temp
above +10C; the 2nd
part marked as D
responds to Temps.
above +34C.
2-Cold Chain Monitor Card:
The front of the cold chain monitor has:
(1)A record form that health workers fill in to show when vaccines
are received.
(2) An indicator that is a heat-sensitive strip with four windows,
marked A, B, C and D.
(3) An interpretation guide explaining what to do with vaccines that
have been exposed to high temperatures.
(4) A space for filling in the following information: name of
supplier/manufacturer, type of vaccine.
The back of the cold chain monitor has:
Instructions on use.
A table giving information on the time and
temperature characteristics of the Monitor.
3-Vaccine vial monitors:
Every vial is also shipped with a
temperature-sensitive label, that health
workers monitor during vaccination
sessions.
SAFE
If the inner square is
lighter than the outer
ring and the expiration
date is valid, the
vaccine is
usable
SPOILED
If the inner square
matches or is darker
than the outer ring,
the vaccine must be
discarded.
4-The shake test
DPT, hepatitis B and
tetanus toxoid vaccines
can all be damaged by
freezing. By shaking two
vials, side-by-side, one
that might have been
frozen and one that has
never been frozen, health
workers can determine if a
vaccine has spoiled.
What damage the Vaccines?
1. Any defect in the cold chain.
2. Out date expiry.
3. Using skin antiseptic at the site of injection (e.g. BCG).
4. Using the reconstituted vaccine (MMR, measles, BCG)
after the recommended period ( 6 hours).
5. Exposure of the vaccine to unacceptable temperature
during the immunization session.
6. Exposure of the vaccine to direct sunlight (BCG)