Expanded Program for Immunization (EPI)

Expanded Program for Immunization (EPI)

The Expanded Program on Immunization (EPI) in

the Philippines began in July 1979.

And, in 1986, made a response to the Universal Child Immunization

goal.

It aims to control the occurrence of preventable diseases especially of

the children.

Furthermore its original objective was to reduce the morbidity and

mortality among infants and children caused by the six childhood immunizable

diseases:Tuberculosis, Diptheria, Pertussis, Tetanus, Hepatitis B, and

Measles [Polio can also be added].

The four MAJOR STRATEGIES include:

Sustaining high routine Full Immunized Child (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.

PRINCIPLES of EPI include:

EPIDEMIOLOGICAL SITUATIONThe program is based on epidemiological situation;

schedules are drawn on the basis of the occurrence and characteristic epidemiological features of the disease.

MASS APPROACHThe whole community rather than just the individual is

to be protected, thus mass approached is utilized.

BASIC HEALTH SERVICEImmunization is a basic health service and such it is

integrated in to the health services being provided for by the Rural Health Unit

Elements of EPI

Target setting Cold chain logistic management Information, education and

communication Assessment and evaluation of the

program’s overall performance

Legal basis/ existing policies:

Presidental Decree No.996“ providing for compulsary basic

immunization for infants and children below eight years of age”

Presidential Proclamation No. 6“ implementing a United Nations goal on

Universal Child Immunization by 1990”

Presidential Proclamation No. 46“ reaffirming the commitment of the

Philippines to the Universal child and Mother Immunization Goal of the world health assembly

Presidential Proclamation No. 47“Declaring april 21 and may 19, 1993

and every third Wednesday of January and February thereafter, for 2 years, as National Immunization Days” (Nids)

Republic Act 7486“ an act requiring compulsary

immunization against Hepatitis B for infants and children below 8 yrs. Old”

Presidential Proclamation No.4“ Declaring the peroid from September

16 to October 14 1998 as the “Ligtas Tigdas Month” and launching the Philippines Measles Elimination Campaign.

The 7 IMMUNIZABLE diseases are:

1. Tuberculosis2. Diptheria3. Pertussis4. Measles5. Poliomyelitis6. Tetanus7. Hepatitis B

Diphtheria

is an acute infectious disease caused by the bacteria Corynebacterium diphtheriae.

http://www.ncbi.nlm.nih.gov/pubmedhealth/n/pmh_adam/A002215/

Causes, incidence, and risk factors

Diphtheria spreads through respiratory droplets (such as those produced by a cough or sneeze) of an infected person or someone who carries the bacteria but has no symptoms. Diphtheria can also be spread by contaminated objects or foods (such as contaminated milk).

The bacteria most commonly infects the nose and throat. The throat infection causes a gray to black, tough, fiber-like covering, which can block the airways. In some cases, diphtheria may first infect the skin, producing skin lesions.

Symptoms symptoms usually occur 2 to 5 days

after you have come in contact with the bacteria.

Bluish coloration of the skin Bloody, watery drainage from nose Breathing problems

› Difficulty breathing› Rapid breathing› Stridor

Chills Croup-like (barking) cough

Drooling (suggests airway blockage is about to occur)

Fever Hoarseness Painful swallowing Skin lesions (usually seen in

tropical areas) Sore throat (may range from

mild to severe) Note: There may be no

symptoms.

Risk factors include crowded environments, poor hygiene, and lack of immunization.

PertussisWhooping cough

Pertussis is a highly contagious bacterial disease that causes uncontrollable, violent coughing.

The coughing can make it hard to breathe. A deep "whooping" sound is often heard when the patient tries to take a breath.

Causes, incidence, and risk factors

Pertussis, or whooping cough, is an upper respiratory infection caused by the Bordetella pertussis or Bordetella parapertussisbacteria. It is a serious disease that can cause permanent disability in infants, and even death.

When an infected person sneezes or coughs, tiny droplets containing the bacteria move through the air, and the disease is easily spread from person to person.

Symptoms initial symptoms, similar to

the common cold, usually develop about a week after exposure to the bacteria.

Severe episodes of coughing start about 10 to 12 days later. In children, the coughing often ends with a "whoop" noise. The sound is produced when the patient tries to take a breath. The whoop noise is rare in patients under 6 months of age and in adults.

The infection usually lasts 6 weeks.

Whooping cough can affect people of any age. Before vaccines were widely available, the disease was most common in infants and young children.

Now that most children are immunized before entering school, the higher percentage of cases is seen among adolescents and adults.

Coughing spells may lead to vomiting or a short loss of consciousness. Pertussis should always be considered when vomiting occurs with coughing. In infants, choking spells are common.

Other pertussis symptoms include: Runny nose Slight fever (102 °F or lower) Diarrhea

Poliomyelitis

a highly infectious viral disease, which mainly affects young children. The virus is transmitted through contaminated food and water, and multiplies in the intestine, from where it can invade the nervous system. Many infected people have no symptoms, but do excrete the virus in their faeces, hence transmitting infection to others.

Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. In a small proportion of cases, the disease causes paralysis, which is often permanent. Polio can only be prevented by immunization.

Routine Schedule of Immunization

Every Wednesday is designated as immunization day and is adopted in

all parts of the country.

Immunization is done monthly in barangay health stations, quarterly

in remote areas of the country.

Routine Immunization Schedule for Infants

The standard routine immunization schedule for infants in the Philippines is adopted to provide maximum immunity against the seven vaccine preventable diseases in the country before the child's first birthday.

The fully immunized child must have completed BCG 1, DPT 1, DPT 2, DPT 3, OPV 1, OPV 2, OPV 3, HB 1, HB 2, HB 3 and measles vaccines before the child is 12 months of age

Vaccine Minimum Age

at 1st Dose

Numberof Doses Dose

Minimum Interval

Between Doses

Route Site Reason

BACILLUS CALMETTE-GUÉRIN

Birth or anytime after

birth1 0.05

mL -- Intradermal

Right deltoid

region of the arm

BCG given at earliest possible age protects the possibility of TB meningitis and

other TB infections in which infants

are prone

Content: Form & Dosage

Live attenuated bacteria Freeze dried infant- 0.05ml

Vaccine Minimum Ageat 1st Dose

Numberof

DosesDose

Minimum Interval

Between Doses

Route Site Reason

DIPHTHERIA-PERTUSSIS-

TETANUS VACCINNE

6 weeks 3 0.5 mL 4 weeks

Intra

muscular

Upper outer

portion of the thigh

An early start with

DPT reduces the chance of severe pertussis.

Content: Form & Dosage

DT- weakened toxinP-killed bacteria

liquid-0.5ml


Numberof Doses Dose

Minimum Interval

Between Doses

Route Site Reason

ORAL POLIO

VACCINE

Content: weakened

virus

6 weeks 3 2-3 drops 4 weeks Oral Mouth

The extent of protection

against polio is increased the

earlier the OPV is given.

Keeps the Philippines polio-free.

Vaccine Minimum Age

at 1st Dose

Numberof

DosesDose Minimum Interval

Between Doses Route Site Reason

HEPATITIS B VACCINE

Content: plasma

derivative

6 weeks 3

0.5 mL

Liquid form

6 weeks interval from

1st dose to 2nd dose,

8 weeks interval from

2nd dose to third dose.

Intramuscular

Upper outer

portion of the thigh

An early start of Hepatitis B vaccine

reduces the chance of being infected and becoming a carrier.

Prevents liver cirrhosis and liver cancer which

are more likely to develop if infected with Hepatitis B early in life.

About 9,000 die of complications of

Hepatits B. 10% of Filipinos have Hepatitis

B infection


Numberof Doses Dose

Minimum Interval

Between Doses

Route Site Reason

MEASLES VACCINE

(not MMR)

Content:

Weakened virus

9 months 10.5 mL

Freeze dried

-- Subcutaneous

Upper outer

portion of the arms

At least 85% of measles

can be prevented by immunization

at this age.

6 months – earliest dose of measles given in case of outbreak

9months-11months- regular schedule of measles vaccine

15 months- latest dose of measles given

4-5 years old- catch up dose

Fully Immunized Child (FIC)- less than 12 months old child with complete immunizations of DPT, OPV, BCG, Anti Hepatitis, Anti measles.

General Principles in Infants/Children Immunization

Because measles kills, every infant needs to be vaccinated against measles at the age of 9 months or as soon as possible after 9 months as part of the routine infant vaccination schedule.

It is safe to vaccinate a sick child who is suffering from a minor illness (cough, cold, diarrhea, fever or malnutrition) or who has already been vaccinated against measles

If the vaccination schedule is interrupted, it is not necessary to restart. Instead, the schedule should be resumed using minimal intervals between doses to catch up as quickly as possible

Vaccine combinations (few exceptions), antibiotics, low-dose steroids (less than 20 mg per day), minor infections with low fever (below 38.5º Celsius), diarrhea, malnutrition, kidney or liver disease, heart or lung disease, non-progressive encephalopathy, well controlled epilepsy or advanced age, are not contraindications to vaccination. Contrary to what the majority of doctors may think, vaccines against hepatitis B and tetanus can be applied in any period of the pregnancy

There are very few true contraindication and precaution conditions.

Only two of these conditions are generally considered to be permanent: severe (anaphylactic) allergic reaction to a vaccine component or following a prior dose of a vaccine, and encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination

Only the diluent supplied by the manufacturer should be used to

reconstitute a freeze-dried vaccine.

A sterile needle and sterile syringe must be used for each vial for adding the diluent to the powder in a single

vial or ampoule of freeze-dried vaccine

The only way to be completely safe from exposure to blood-borne diseases from injections, particularly hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) is to use one sterile needle, one sterile syringe for each child

Tetanus Toxoid Immunization Schedule for Women

When given to women of childbearing age, vaccines that

contain tetanus toxoid (TT or Td) not only protect women against

tetanus, but also prevent neonatal tetanus in their newborn infants

VaccineMinimum

Age/IntervalPercent

ProtectedDuration of Protection

TT1 As early as possibleduring pregnancy -- --

TT2 At least 4 weeks later 80%

infants born to the mother will be protected from neonatal tetanus

gives 3 years protection for the mother

TT3 At least 6 months later 95%



TT4 At least 1 year later 99%



TT5 At least 1 year later 99%

gives lifetime protection for the mother

all infants born to that mother will be protected

There is no contraindication to immunization except when the child is immunosuppressed or is very, very ill (but not slight fever or cold). Or if the child experienced convulsions after a DPT or measles vaccine, report such to the doctor immediately.

Malnutrition is not a contraindication for immunizing children rather, it is an indication for immunization since common childhood diseases are often severe to malnourished children.

Cold Chain under EPI:

Cold Chain is a system used to maintain potency of a vaccine from that of manufacture to

the time it is given to child or pregnant woman

The allowable timeframes for the storage of vaccines at different levels are:

o 6months- Regional Level

o 3months- Provincial Level/District Level

o 1month-main health centers-with ref.

o Not more than 5days- Health centers using transport boxes.

Most sensitive to heat: Freezer (-15 to -25 degrees C)

o OPVo Measles

Sensitive to heat and freezing (body of ref. +2 to +8 degrees Celcius)

o BCGo DPTo Hepa Bo TT

Use those that will expire first, mark “X”/ exposure, 3rd- discard,

Transport-use cold bags, let it stand in room temperature for a while before storing DPT.

Half life packs: 4hours-BCG, DPT, Polio, 8 hours-measles, TT, Hepa B.

FEFO (“first expiry and first out”) – vaccine is

practiced to assure that all vaccines are utilized

before the expiry date.

Proper arrangement of vaccines and/or labeling of vaccines expiry date are done to identify those near to expire vaccines.

Vaccine temperature is monitored twice a day (early in the morning and in the afternoon) in all health facilities and plotted to monitor break in the cold chain.

Each level of health facilities has cold chain equipment for use in the storage vaccines which included cold room, freezer, refrigerator, transport box, vaccine carriers, thermometers, cold chain monitors, ice packs, temperature monitoring chart and safety collector boxes.

Review Questions:

In immunizing school entrants with BCG, you are not obliged to secure parental consent. This is because of which legal document? A. P.D. 996 B. R.A. 7846 C. Presidential Proclamation No. 6 D. Presidential Proclamation No. 46

Answer: (A) P.D. 996 Presidential Decree 996, enacted in 1976, made immunization in the EPI compulsory for children under 8 years of age. Hepatitis B vaccination was made compulsory for the same age group by R.A. 7846.

Which immunization produces a permanent scar?

A. DPT B. BCG C. Measles vaccination D. Hepatitis B vaccination

Answer: (B) BCG BCG causes the formation of a superficial abscess, which begins 2 weeks after immunization. The abscess heals without treatment, with the formation of a permanent scar.

A 4-week old baby was brought to the health center for his first immunization. Which can be given to him?

A. DPT1 B. OPV1 C. Infant BCG D. Hepatitis B vaccine 1

Answer: (C) Infant BCG Infant BCG may be given at birth. All the other immunizations mentioned can be given at 6 weeks of age.

. You will not give DPT 2 if the mother says that the infant had

A. Seizures a day after DPT 1. B. Fever for 3 days after DPT 1. C. Abscess formation after DPT 1. D. Local tenderness for 3 days after DPT 1

Answer: (A) Seizures a day after DPT 1. Seizures within 3 days after administration of DPT is an indication of hypersensitivity to pertussis vaccine, a component of DPT. This is considered a specific contraindication to subsequent doses of DPT.

A 2-month old infant was brought to the health center for immunization. During assessment, the infant’s temperature registered at 38.1°C. Which is the best course of action that you will take?

A. Go on with the infant’s immunizations. B. Give Paracetamol and wait for his fever to subside. C. Refer the infant to the physician for further assessment. D. Advise the infant’s mother to bring him back for immunization when he is well.

Answer: (A) Go on with the infant’s immunizations. In the EPI, fever up to 38.5°C is not a contraindication to immunization. Mild acute respiratory tract infection, simple diarrhea and malnutrition are not contraindications either.

A pregnant woman had just received her 4th dose of tetanus toxoid. Subsequently, her baby will have protection against tetanus for how long? A. 1 year B. 3 years C. 10 years D. Lifetime

Answer: (A) 1 year The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection.

Unused BCG should be discarded how many hours after reconstitution? A. 2 B. 4 C. 6 D. At the end of the day

Answer: (B) 4 While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning.

. Which biological used in Expanded Program on Immunization (EPI) is stored in the freezer? A. DPT B. Tetanus toxoid C. Measles vaccine D. Hepatitis B vaccine

Answer: (C) Measles vaccine Among the biologicals used in the Expanded Program on Immunization, measles vaccine and OPV are highly sensitive to heat, requiring storage in the freezer.

. Which disease was declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines? A. Poliomyelitis B. Measles C. Rabies D. Neonatal tetanus

Answer: (B) Measles Presidential Proclamation No. 4 is on the Ligtas Tigdas Program.

Management of a child with measles includes the administration of which of the following? A. Gentian violet on mouth lesions B. Antibiotics to prevent pneumonia C. Tetracycline eye ointment for corneal opacity D. Retinol capsule regardless of when the last dose was given

Answer: (D) Retinol capsule regardless of when the last dose was given An infant 6 to 12 months classified as a case of measles is given Retinol 100,000 IU; a child is given 200,000 IU regardless of when the last dose was given.

Which biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer? A. DPT B. Oral polio vaccine C. Measles vaccine D. MMR

Answer: (A) DPT DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on Immunization.

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Expanded Program for Immunization (EPI)