Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
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
1
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.
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
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
2
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
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.
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.
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
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.
Most Sensitive to
Heat
Most Sensitive to
Cold
Sensitive to Sunlight
and Fluorescent light
Type of Vaccine
Storage Temp.
OPV
Measles
Hepa B
DPT
Tetox
BCG
-15 to -25 C
At the freezer
Hours of
Life after
opening
8 hours
2 to 8 C
Body of
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
Doses supplied
x 100
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
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
OPV
Measles
BCG
HepB
Tetox
=
=
=
=
=
=
1.67
1.67
2
2.5
1.10
1.67
4
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
5
Target Setting
Steps and examples in calculating vaccine requirements
Steps
BCG
Infant
DPT Hep B
3,000
3,000
3,000
3,000
90
90
90
105
1
3
3
2
TVR = EP x number
of doses
90
270
270
210
Given wastage factor
(constant )
2.5
1.67
1.1
1.67
AVR = TVR x WF
225
451
297
351
20
10 or
20
1 or 10 10 or 20
12
46 or
23
297 or
30
36 or 18
MVR = AVR / 12
months
19
38
25
29
MVA = AVA / 12
1
4 or 2
25 or
2.5
3 or 1.5
Formula
Total Population
( TP )
e.g 3,000
Determine the
Eligible Population
( EP )
EP = TP x 3%
(Infants/Children)
Mothers
Tetox
EP = TP x 3.5 %
( Mothers )
Required number of
doses to immunize a
child/ mother
Determine the total
vaccine required
( TVR )
Wastage Factor
( WF )
Calculate the
Annual Vaccine
doses required
( AVR )
Number of doses per
ampule/vial
Determine Annual
Vaccine
Ampule/Vial
required ( AVA )
Caculate the
Monthly Vaccine
doses Required
( MVR )
Determine Monthly
Vaccine
Ampule/Vial
required ( MVA)
AVA = AVR / # of
doses per
ampule/vial
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
6
EPI VACCINES
BCG ( Bacille Calmette-Guerin ) Vaccine
Type of Vaccine
Form of Vaccine
Minimum Age at 1st Dose
Number of Doses to
Complete the Immunization
Reason
Number of Doses per
Ampule
Dosage
Route of Administration
Site of Administration
Storage Temperature
Special Precautions
Side Effect
Undesired Effect
Contraindication
Health Teaching
Live Bacterial
Freeze dried
Birth or anytime at birth
1st dose : at birth
2nd dose: school entrance
BCG given at earliest possible age protects the
possibility of TB meningitis and other TB infectious in
which infants are prone.
20 ( 20 children )
At birth : 0.05 ml
At school entrance : 0.10 ml
Intradermal ( a special syringe and needle is used for
the administration of BCG vaccine )
Right deltoid region of the arm
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
Correct ID administration is essential. A special
syringe and needle is used for the administration of
BCG vaccine
A wheal formation
Koch phenomenon ( inflammatory reaction 2-4 days )
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.
Immunosuppressed indvidual due to malignant disease
( child with clinical AIDS ) ; therapy with
immunosuppressive agent or radiation.
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
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
7
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
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
8
DPT ( Diphteria-Pertussis-Tetanus ) Vaccine
Type of Vaccine
Diphteria and Tetanus as “toxiods” which is a
weakened toxin
Pertussis as killed whole-cell bacterium
Liquid vaccine
6 weeks
3
Form of Vaccine
Minimum Age at 1st Dose
Number of Doses to
Complete the Immunization
4 weeks / minimum of 28 days
Interval
An early start with DPT reduces the chance of severe
Reason
pertussis
20 or 10
Number of Doses per
Ampule
0.5 ml
Dosage
Intramuscular
Route of Administration
Upper outer portion of the thigh ( Vastus lateralis ) in
Site of Administration
infant ( R – L – R )
Outer upper arm if older
2 C to 8 C ( in the body of refrigerator )
Storage Temperature
Note: “DT” component is damage by freezing
“P” component is damage by heat
DPT not usually given over 6 years of age
Special Precautions
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.
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
9
OPV ( Oral Polio Vaccine )
Type of Vaccine
Form of Vaccine
Minimum Age at 1st Dose
Number of Doses to
Complete the Immunization
Interval
Reason
Number of Doses per
Ampule
Dosage
Route of Administration
Site of Administration
Storage Temperature
Special Precautions
Side Effect
Contraindication
Health Teaching
Live attenuated vaccine
Liquid vaccine
6 weeks
3
4 weeks / minimum of 28 days
The extent of protection against polio is increased the
earlier the OPV is given
20 ( 10 children )
2 drop
Oral
Mouth
-15 C to -25 C ( at the freezer )
Note: It is easily damaged by heat but is not harmed
by freezing.
Children known to have rare congenital immune
deficiency syndrome should receive IPV ( injectable
polio vaccine ) rather OPV
Causes almost no side-effects. Less than 1% of the
people who receive the vaccine develop a headache,
diarrhea or muscle pain.
None
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
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
10
Hepatitis B Vaccine
Type of Vaccine
Form of Vaccine
Minimum Age at 1st Dose
Number of Doses to
Complete the Immunization
Interval
Reason
Number of Doses per
Ampule
Dosage
Route of Administration
Site of Administration
Storage Temperature
Special Precautions
Side Effect
Contraindication
Health Teaching
“Monovalent vaccine” contain only one antigen
Cloudy liquid vaccine
At birth
3
6 weeks interval from 1st dose to 2nd dose
8 weeks interval from 2nd dose to 3rd dose
An early start of Hep B vaccine reduces the chance of
being infected and becoming a carrier. Prevent liver
cirrhosis and liver cancer
1 for single dose vial
10 for multi dose vial ( 10 children )
0.5 ml
Intramuscular
Upper outer portion of the thigh ( Vastus lateralis ) in
infant ( with DPT: L – R – L )
2 C to 8 C ( in the body of refrigerator )
Note: Both heat and freezing damages the vaccine )
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
Mild fever that lasts one to two days after injection
Soreness, children may have pain, redness or
swelling at the injection site.
Anaphylactic reaction such as severe rashes,
difficulty in breathing and choking to a previous
dose.
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 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.
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.
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
11
Measles Vaccine
Type of Vaccine
Form of Vaccine
Minimum Age at 1st Dose
Attenuated Measles Virus
Freeze dried
9 months
6 months: if there is an epidemic
1
Number of Doses to
Complete the Immunization
Measles vaccine given at 9 months provide at least
Reason
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
10 ( 10 children )
Number of Doses per
Ampule
0.5 ml
Dosage
Subcutaneous
Route of Administration
Outer part of the upper arm
Site of Administration
-15 C to -25 C ( at the freezer )
Storage Temperature
Note: But can also be safely stored between 0 C to 8C
until its expiry date.
Diluents should also be kept cold before using.
Birth dose must be given if there is a risk of perinatal
Special Precautions
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
Soreness, children may have pain, redness or
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
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 .
It also prevent diarrhea
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
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
OPV
X
X
X
DPT
X
X
X
BCG
HepB
X
Option B
Option A
Measles
9 months
X
X
X
X
X
X
X
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
13
Tetanus Toxoid (TeTox) Vaccine
Type of Vaccine
Form of Vaccine
Minimum Age at 1st Dose
Number of Doses to
Complete the Immunization
Number of Doses per
Ampule
Dosage
Route of Administration
Site of Administration
Storage Temperature
Side Effect
Contraindication
Health Teaching
Weakened toxin
Liquid vaccine
As early as possible during pregnancy
5 doses ( TeTox 1 – TeTox 5 )
TeTox 2 is the minimum required immunization
during pregnancy
10 or 20
0.5 ml
Intramuscular
Outer upper arm
2 C to 8 C ( in the body of refrigerator )
Note: Never freeze
Fever in the evening after receiving the injection.
Soreness, woman may have pain, redness or
swelling and warmth at the injection site.
Anaphylactic reaction to previous dose
NO MEDICATION FOR PREGNANT
For Pain cold compress 24 hrs to warm compress
Tetox Routine Immunization of Pregnant Women
Vaccine
Minimum
Interval
As early as
possible during
pregnancy
4 weeks after
TeTox 1
Percent
Protected
TeTox 3
6 months after
TeTox 2
95 %
TeTox 4
1 year after TeTox
3
99 %
TeTox 5
1 year after TeTox
4
99 %
TeTox 1
TeTox 2
80%
Duration of Protection
infant will be protected by
neonatal tetanus
3 years protection for the mother
infant will be protected by
neonatal tetanus
5 years protection for the mother
infant will be protected by
neonatal tetanus
10 years protection for the mother
all infant born to that mother will
be protected
lifetime protection for the mother
Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
14
Giving Tetanus Toxoid ( TeTox ) Vaccine
Shake the vial.
Clean the skin with a cotton ball, moistened with water and let skin dry.
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.
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.
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.