1. EPI
(Expanded Program of Immunization)
By: Habtamu K.
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2. Learning Objectives:
• Define immunization and vaccination
• List types of immunization and vaccination
• Discuses determinants of immune response
• Discussion of individual vaccines
– Preparations
– Precautions and contraindications
– Administration
– Side effects
– Contraindications
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3. Introduction
• Infectious diseases lead to high mortality and
morbidity in pediatric patients.
• These infectious diseases range from self limiting to
long term disability such as; blindness, deafness and
others.
• Magnitude of communicable disease could be
reduced by maintaining:
o Good nutrition and safe water
o Environmental and self hygiene
o Better living environment
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4. Cont…
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5. Cont….
 Presently Hepatitis B, H.Influenza B and pneumonia
are included under EPI target diseases nationally.
 The EPI of a give country is determined by:
• Epidemiology of the diseases
• Sustainable financial support
• Well organized infrastructure
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6. Immunization:
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7. Active immunization
• Active immunization entails the introduction of a
foreign molecule into the body, which causes the
body itself to generate immunity against the target.
• This immunity comes from the T cells and the B cells
with their antibodies
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8. Passive immunization
 This method of immunization begins to work very
quickly, but it is short lasting, because the antibodies
are naturally broken down, and if there are no B cells
to produce more antibodies, they will disappear.
 The antibodies can be produced in animals ("serum
therapy") although there is a high chance of
anaphylactic shock because of immunity against
animal serum itself.
Thus, humanized antibodies produced in vitro by cell
culture are used instead if available.
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9. importance of immunization
• Eradication of disease Eg: smallpox
• Elimination of disease Eg: polio
• Control of disease Eg: diphtheria
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10. Immunizing agent:
Vaccine :a protein, polysaccharide or nucleic acid
delivered to body to produce immunity
Toxoid :a modified bacterial toxin (not toxic but
capable of producing antitoxin)
 Antitoxin: antibodies derived from human or animal
serum after stimulation with specific antigen
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11. Determinants of immune response
1. Age –presence of high concentration of maternal
antibody.
-immature response in the 1st 4 months .
e.g. measles vaccine
2. Route of administration-
- Mucosal secretion of antibody ( ImA.) e.g. OPV
- Using an improper route to administer the vaccine
may reduce the immune response.
E.g. Subcutaneous hepatitis B at buttock less
immunogenic than IM at deltoid
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12. Dete….
3. Nature of vaccine-
- live attenuated vaccine s induce immunity with
single dose which lasts longer than inactivated
ones.
4. Genetic –individuals genetically vary in their ability
to respond to the same vaccines.
5. Potency of the vaccine- ensuring potency of the
vaccine , especially live attenuated, requires
keeping the cold chain.
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13. Strategies of immunization
I. Static : at health facilities
II. Out-reach: in the community level
III. Intensive : campaign/ immunization day
IV. Mop up: revision of campaign for those who are
not vaccinated
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14. Constituents of vaccine
 Vaccination - administration of any vaccine or toxoid
for prevention of disease that constitutes:
» Protein , polysaccharide ,nucleic acid
» Preservative/stabilizer/antibiotics
» Adjuvant (salts)
» Suspending fluid
» Component of organism: like influenza
vaccine
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15. Types of vaccines:
Live attenuated:
- Prepared from attenuated strains that render them
non-pathogenic .
- Usually effective with one dose as they replicate in the
host and provide antigenic stimulation for long time.
- The drawbacks of live attenuated vaccine are:
Reversion to wild type can lead to disease
They can cause severe disease in
immunocompromised children
Some people exhibit hypersensitivity to viral
antigen.
e.g. BCG, MMR, OPV, Varicella, Measles.
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16. Type cont…
• Inactivated or killed :
i. Inactivated whole organism :
e.g. Hepatitis A, whole cell pertussis
ii. Detoxified exotoxins :
e.g. Tetanus , Diphtheria
iii. Purified protein antigen:
e.g. Acelluar pertusses , Hepatitis B
iv. Polysaccharide:
e.g. Capsular Meningococcal
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17. Types Cont…
v. Conjoined Vaccines- polysaccharides are being
conjugated with protein b/c they have;
. Short-term antibody production
. Poor immunegenicity in infants and
. No memory for future antigens
- So they are conjoined with other proteins to improve
their immunological response
- E.g; Hib, meningococcal, pneumococcal
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18. Immune response to vaccine:
• In live attenuated vaccines ,the organisms
multiply in recipient so it is more like the
natural infection ,so it is likely to produce life
long protection after 1st dose of vaccine.
• Killed vaccines :less antigenic so usually need
booster doses.
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19. Types of vaccine
BCG (Bacille Calmette Guerin)vaccine
• There is evidence that BCG provides appreciable
protection against tuberculosis meningitis (50-80%)
and miliary disease.
• live-attenuated strain of M.bovis
• It is frozen dried vaccine in powder form (needs
diluents 1 ml)
• Dose/route - Id 0.05ml for neonates
- 0.1ml for older child
• Given intra dermal at Rt deltoid muscle
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20. BCG cont…
• Vaccine efficacy - 0-80% for pulmonary
- 75-90% for severe TBC
• Use diluted vaccine only for one session
• Keep between 2oc- 8oc even as low as -20 oc
• Stand in/on ice pack
• Keep away from sun light and cover with black paper
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21. BCG cont…
Side effects:
1. Koch phenomenon/small red tender swelling/
2. Indolent ulcer- local lesion, papule, 2 weeks after
vaccination. At 6 weeks (crust, detaches, ulcerates)
,then a 5mm scar (typically round and slightly
depressed) remains
3. Deep abscess- secondary to deep injection
- Small abscess might develop, 4-6 wks.
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22. BCG cont….
4. Lymphadenitis- Involvement of lymph node /
- Serious Lymphadenitis :Persistent, recurrent or
multiple
5. BCG osteitis- disseminated BCGosis in immune
compromised children ( 1: 1,000,000)
Contraindications:
 Only “Symptomatic HIV infection (i.e. AIDS)” is
a contraindication for BCG according to WHO
 Sever immunodeficiency
Precaution-moderate or severe illness
with/without fever
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23. Polio Vaccine
• Vaccines-live-attenuated virus (OPV, Sabin)
-killed, injectable (IPV, Salk)
• OPV -Given orally 2 drop
 Advantages of OPV over IPV
- Easy to administer
- superior antibody response
- Provides rapid immunity within 1wk
- Provides Herd Immunity
• Easily damaged by heat, store /keep at 0-8 oc at
health facilities & -15 to -25oc at central, regional and
zonal level
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24. Polio…
• Can be frozed and refrozen without damage
• Start at birth to 14 days OPV 0, then at 6, 10, 14wks
• Wait at least for 4wks between the doses
• Repeat it if the child spit it out
• Do not count the dose if the child has diarrhea during
vaccination & repeat week later.
 Contraindication
- sever immuno-suppression
 Precaution- chock of children
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25. Penta valent (DPT,HiB &HBvAg)
• Diphtheria and tetanus- are toxoids
• Pertussis- killed bacteria
• H/Influenza- conjugate vaccine
• Hepatitis BV- surface antigen
• Start at six weeks of age then at 10wk and 14wks
• 0.5ml I/m at outer middle of thigh
• Is liquid vaccine, shake it well before use
• Easily damaged by heat & freezing
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26. Tetanus
 Prepared by inactivating the toxin by formaldehyde
 Even if there was previous disease, the child should
be vaccinated since disease doesn’t confer immunity
 Neonatal tetanus is prevented by maternal
immunization(3doses before & 2doses during
pregnancy at 6wks interval, 2nd dose at least 4-6wks
before delivery)
 Efficacy= 85-95%
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27. Diphtheria
• Prepared from toxin by formaldehyde
• Almost always given with tetanus & pertussis as DPT
• Efficacy= 80-90%
Pertussis Vaccine
• Whole cell vaccines prevent serious illness
• Do not protect completely against infection
• Efficacy & antibody levels wane with time
• Efficacy= 80%
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28. Hepatitis B Virus vaccine
• Consists of purified inactive sub-unit of the virus, not
infectious, is a very safe vaccine
• Not contraindicated in immunodeficiency
• HBV is very effective in perinatally acqired
infection(85%) and 80-95% effective in postnatally
acquired infection
• Routine vaccination is given to all infants, children
and adolescents
• Infants of HBsAg-positive= Ig and vaccine within
12hrs of birth at separate site,2nd dose at 1-2mo and
3rd dose at 6th month of age
• Infants born to HBsAg-positive mothers
should receive the vaccine and HBIG within
12hr of birth.
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29. Haemopholus Influenza-type B
• Hib- common cause of;
. meningitis . pneumonia . epiglottitis
. sepsis . arthritis
• Conjugated vaccine
• Safe (almost free of side effects) and effective
• Can be given combined with other vaccines(DPT)
• If a child presents after 1yr of age;
- age 12-15months= 1st dose(today), 2nd after 2mo
and 3rd after 6mo
- 15-59mo= 1st and 2nd dose only
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30. Side effect of pentav.
• Majority are of pertussis
 Encephalopthy
 Convulsion
 Collapse /shok(hypotonic-hyporesponsive)
 Abscess (treat with antibiotics, warm compress)
• Mild Problems (Common):
- Fever, Redness, swelling, Soreness (1 in 4)
Fussiness ,Tiredness or poor appetite and
Vomiting (1 in 50)
- These problems occur more often after the 4th
and 5th doses of the DTP series than after earlier
doses.
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31. Side eff. Cont…
• Moderate Problems (Uncommon):
Seizure (1 in 14,000), Non-stop crying for 3 hours
or more (1 in 1,000), High fever (1in 16,000)
• Severe Problems (Very Rare) :
- Serious allergic reaction (1 in a million dose)
- Long-term seizures, coma, or lowered
consciousness , Permanent brain damage.
so RARE that it is hard to tell if they are caused
by the vaccine.
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32.  Precautions
- fever >40.5 within 48hrs
- collapse or shock-like effect within 48hrs
-seizure in 3days
- persistent, inconsolable cry >3hrs within
- 48hrs during the previous dose
- moderate or severe illness with/without fever
 Contraindications:
1. Encephalopathy (coma ,altered level of
consciousness ,prolonged seizures ) within 7 days of
previous dose of DPT.
2. Progressive neurological disorder till
neurological state is clarified.
3. Severe allergic reaction after a previous dose
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33. Measles vaccine
• Live-attenuated, frozen dried vaccine
• Efficacy=85%
• Needs dilutes of 5ml for reconstitution
• 0.5ml subcutaneously at outer upper arm
• Given at 9 month after birth
• May be given in case of malnutrition, refuges,
hospital admission & affected by disaster
• Easily damaged by heat
• Store b/n 2-8 oc at health facilities &
• -15- -25oc at central, regional and zonal level
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34. Measles cont…
Side effect:
Contraindication:
 Fever & rushes 1-3  Anaphylactic shock
days  Moderate-sever illness
 Encephalopathy
 Prematurity
 Convulsion( rare)
 Sever malnutrition
 Penicillin allergy
 Immunodeficiency
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35. Tetanus toxoid
 A weak toxin ( toxoid)
 A liquid injectable vaccine
 Store & transport at 2-8oc
 Never frozen TT
 Target groups are 15-45 yrs of aged women
 0.5ml IM at upper arm
 5 doses are recommended
 Pain, redness & swelling for few days
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36. TT cont…
Dose Schedule Duration of protection in years
TT1 Starting dose Initiation of immunity
TT2 4wks after TT1 3 years protection
TT3 6 months after TT2 5 years protection
TT4 1 year after TT3 10 year protection
TT5 1year after TT4 Life long protection
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37. Vitamin A
• Administer with measles vaccine
• Children--< 6 month are recommended
-- 6- 12 months=100000IU
--12-59months 200000IU
• Not given for child with edema
• Indicated for:
– Measles case (90%)
- Immunodeficiency
- Evidence of vit. A deficiency
- Impaired intestinal absorption
- Moderate to sever malnutrition
- Immigration
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38. Vaccine schedules:
• Generally a vaccine is recommended at the youngest
age at which significant risk of a disease and
complication exist and at which protective immune
response is expected.
• Either universal schedules or for selected
populations e.g. :
Specific diseases (nephrotic syndrome…)
Travel (yellow fever vaccine…)
Post exposure (rabies…)
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39. Contact Age of child Vaccines
1 At birth BCG and OPV zero
2 6weeks DPT1-HepB1- HIB1 and OPV1
3 10weeks DPT2-HepB2-HIB2 and OPV2
4 14weeks DPT3-HEPB3-Hib3 and OPV3
5 9th month Measles and Vitamin A
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40. Schedule cont…
• No need of restart interrupted vaccination
• There is no maximal interval b/n doses of penta,
polio & TT
• The minimal interval is 4wks
• Acceptable proof for immunization are presence of
scar for BCG & immunization card
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41. How we keep potency of vaccine?
• Vaccines are sensitive to heat and freezing and must
be kept at the correct temperature
• Vaccines potency cannot be regained once it is lost
• The system used for keeping and distributing
vaccines in good conditions called cold chain.
• Cold chain- method of keeping vaccines cold to
insure its potency
• Cold chain consists of a series of storage and
transport links, all designed to keep vaccines with in
an acceptable range of temperature until it reach the
user.
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42. Potency cont…
• Maintenance of cold chain requires vaccines and
diluents to be:
– Collected from the manufacturer or an airport as
soon as they are available.
– Transported between 2oc and 8oc from the air port
and from one store to another.
– Transported between2oc and 8oc range during
immunization sessions and
– Kept between 2oc and 8oc range during
immunization sessions and return to health facility
from out reach.
– Check temperature 2 times daily
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43. Cold chain equipment used in heath facilities
1. Refrigerators:
– used for storing vaccines at the right temperature
– May be powered by electricity , gas or kerosene
– Electric refrigerators are least costly and easiest to
maintain
2. Cold boxes:
– Helps to store vaccines for several days (from 2 to 7
days)
– Are insulated containers that, when lined with frozen
ice packs, are used for collecting large quantities of
vaccines, and transporting large quantities of vaccine.
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44. Equipments. Cont…
3. Vaccine carriers:
– Are insulated containers that when lined with
frozen ice packs are used for collecting small
quantities of vaccines (diluents for health facility ,
and transporting small quantities of vaccine by
vehicle or motorcycles or mule back)
4. Foam pads:
– It is a piece of soft foam that fits on top of ice
packs in vaccine carriers.
– Are some incisions on it to allow vaccines to be
inserted in the foam
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45. Equip. cont…
5. Ice packs:
– Are flat, square plastic bottles that are filled with
water and frozen ice packs are used to keep
vaccines cool inside the vaccine carriers.
– Helps to store vaccines for only one day.
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46. Cold chain monitoring equipments
1) Vaccine vial monitors (VVM)
– Is a label that changes color when the vaccine vial
has been exposed to heat over a period of time.
– As the vaccine exposed to heat a color which looks
like a square inside a circle becomes darken
– Note: Use only vials with inner square that are
lighter in color than the outside circle.
– Vials with VVM in which the inner surface has begun
to darken but is still lighter than the outer circle
should be used before the vials with a lighter inner
square.
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47. Cold chain mon. cont…
2) Vaccines cold chain monitoring card
(VCCMC)
– Is a card (different color back ground cards exist
for different language versions) with an indicator
strip that changes color when vaccines are
exposed to temperature that is too high.
– It is used to estimate the length of time that
vaccine has been exposed to high temperatures.
3) Thermometers:(dial or stem)
– On the dial thermometer, the needle moves
around the scale, pointing to plus (+) numbers
when it is warmer and to minus (-) numbers when
it is colder.
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48. Cold chain mon. cont…
– On stem thermometer, colored fluid in the bulb
moves up the scale as it become warmer and
down as it becomes colder.
4) Freeze indicators(freeze watch and freeze –
tag)
– Are sued to warn of freezing and are packed with
vaccines that are sensitive to freezing
temperature (<0oc): DPT, T, DT or HepB and Hib
vaccines.
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49. Cold chain mon. cont…
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50. Immunization monitoring chart
• Shows the progress in raising immunization
• Done by comparing the number of people you
actually immunize each month with your coverage
targets.
• The direction of the monitor line is interpreted as:
o Very successful=monitor line is 75 - 100% target line.
o Moderately successful= monitor line (50% -75%)
o Not very successful= ( 25% -50% )
o Not successful= monitor line <25% of target line
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51. Causes of low immunization coverage
1. Dropout: a child or a woman who failed to return for
subsequent doses for which he/she is eligible.
• Possible causes :
– Unsure of date of return
– Failure to explain the need of completing vaccination
and possible side effects
– Negative attitudes to HW
– Mothers usually busy
– Long wait at vaccination center
– Vaccination centers are opened at inconvenient dates
or hours
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52. Causes of low imm. cont…
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53. Causes of low imm. cont…
2. Missed opportunity
• Current policy states that all children and mothers at
health facility for any reasons should be screened for
immunization status and vaccinated if eligible
 Causes:
– Health workers do not know the policy
– False C/I to immunization. E.g, not giving polio vaccine
to child with diarrhea.
– Logistic problem
– HW vaccinate women with TT only if they are Px
– Acceptability: culture, rumors, belief etc
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54. Causes of low imm. cont…
3. Culture and belief:
4. Lack of geographic access
5. Problems associated with vaccines
6. Fail to know the target population
7. Low/ lack of community involvement and inter
spectral collaboration
8. Ineffective management:
9. Problem related to supplies, cold chain and
maintenance
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55. Tasks at immunization session
• Mobilization of population
• Keeping orders of the clients
• Weighting
• Screening and treating
• Registration
• Health education/information
• immunization
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56. Loading of Vaccines in a refrigerator
• Freezing compartment = ice packs
• Top shelf= OPV and measles vaccines
• Middle compartment=BCG vaccines
• Lower compartment= Penta & TT
• Don’t put dilutes out side
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57. Special conditions:
• Most vaccines can be given simultaneously without
impairment of vaccines effectiveness or safety
• Breast feeding is not a contraindication to any
vaccine ,although most live attenuated vaccines
replicate in mother they are not excreted in human
milk.
• Lapsed immunizations:
If interval between vaccine doses exceed those
recommended ,this does not adversely affect the
immune response provided the series is completed,
so no need to restart the series or to give extra
doses.
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58. Preterm infants:
• Immune response to vaccination is a function of
postnatal age rather than gestational age
• Prematurity does not increase the incidence of
vaccine related adverse effects
• Doses are same as those for term infants (NOT
reduced)
• Should be vaccinated at same chronological age as
full term ,according to schedule .
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