EXPANDED PROGRAMME IN IMMUNIZATION (EPI).pptx

Study only

1. EXPANDED PROGRAMME IN IMMUNIZATION (EPI) MRS A.TEMBO

2. GENERAL OBJECTIVE At the end of the presentation, student midwives should be able to have an understanding on immunization

3. SPECIFIC OBJECTIVES At the end of the lesson, students should be able to: Define terms used in immunization. Review immunology Explain the EPI Discuss the immunization guidelines and schedule: Target groups for vaccination Vaccination schedule Administration of vaccines Side effects School health and nutrition programme

4. INTRODUCTION At birth, infants have immunity to certain diseases because antibodies have passed through the placenta from the mother to the unborn child. After birth, the breastfed baby gets the continued benefits of additional antibodies in breast milk. But in both cases, the immunity is only temporary.

5. Immunization (vaccination) is a way of creating immunity to certain diseases - by using small amounts of a killed or weakened microorganism that causes the particular disease. Microorganisms can be viruses, such as the measles virus, or they can be bacteria, such as Haemophilus Influenza

6. Vaccines stimulate the immune system to react as if there were a real infection - it fends off the "infection" and remembers the organism so that it can fight it quickly should it enter the body later.

7. DEFINITION OF TERMS Immunization: the process where by people are protected against illness caused by infection with microbes. (science.org 12:28), 06/02/17 Or the act of creating immunity by artificial means. Immune: Protected against infectious diseases, foreign tissue, and foreign non-toxic substances and other antigens. Immunity: The resistance possessed by the body to infectious diseases, foreign tissue, foreign non-toxic substances and other antigens.

8. Antigen: Any substance that, on introduction into the body, brings about immunity by stimulating antibody production. Antibodies: Specific substances formed in the body that counteracts the effects of antigens or bacterial toxins.

9. Vaccine: an antigenic substance prepared from the causative agents of a disease or a synthetic substitute , used to provide immunity against one or several diseases. Or a suspension of killed or attenuated organisms e.g. virus. Bacteria e.t.c administered for prevention, amelioration or treatment of infection diseases ( bailliers nurses dictionary)

10. Vaccination: introduction of the vaccine into the body to produce immunity to a specific disease. Cold chain: The cold chain system is a means for storing and transporting vaccines in a potent state from the manufacturer to the person being immunized (ICN, 2005).

11. REVIEW OF IMMUNOLOGY Has two components; these are: 1. Non-specific component or innate immunity . The non-specific components act either as barriers or as eliminators of wide range of pathogens irrespective of antigenic specificity.

12. 2 . Specific component or adaptive immunity or acquired immunity This component of the immune system adapt itself to each new disease encountered and is able to generate pathogen-specific immunity

13. Natural/Innate Immunity This type of immunity is non-specific response that does not require previous exposure to micro-organisms. This includes intact cellular barriers (skin, and mucous membranes), gastric acid, digestive enzymes, complement and lysozomes . These act as a first line of defence against infection in the neonate. Genetic factors, age, race, and hormonal levels affect the natural immunity.

14. 2. Acquired Immunity These are specific responses that develop and improve with on going exposure to a pathogen or organism. It involves a change in the behaviour of cells and in production of antibody

15. Active Immunity: This is when the body produces its own antibodies against a specific antigen. This can either be natural or artificial: Natural Active Immunity- this is when the body produces antibodies after suffering from an infectious disease.

16. Artificial Active Immunity- this is when the body produces antibodies after being injected by living or dead organisms or their products in form of toxins and toxoids .

17. Passive Immunity: In this immunity, the antibodies are given to an individual. This can either be natural or acquired:

18. Natural Passive Immunity - this is when the foetus obtains maternal immunoglobulin G ( IgG ) via the placenta. This protects the infant from various infections for a few months of life. The new-born also receives Immunoglobulin A ( IgA ) through the breast milk that protects the surfaces like mucous membranes.

19. Acquired Passive Immunity - this is when a person gets temporary immunity after being given an injection of antibodies of human (gamma globulin).

20. TYPES OF VACCINES Four different types of vaccines are currently available: Attenuated Vaccines : these are live but weakened viruses and bacteria used as vaccines such as in the measles, polio, and BCG. Killed (inactivated) Vaccines: these are inactivated bacteria or viruses used as vaccines, such as in Pertussis .

21. Toxoid : these are vaccines, which contain toxins produced by bacterium; example diphtheria and tetanus are toxoid vaccines. Toxins are rendered non-toxic but retain its protective qualities. Biosynthetic vaccines (such as Hib ) contain synthetic substances.

22. N.B: Vaccines should be potent to make the child immune. Vaccines lose their potency after a certain time (expiry date). Heat and sunlight can damage live vaccines. Freezing damages the killed vaccines and toxoids . Disinfectants, soap, spirit, and antiseptics kill live vaccines

23. INTRODUCTION TO EPI The Expanded Program on Immunization is a World Health Organization program with the goal to make vaccines available to all children throughout the world. The World Health Organization (WHO) initiated the Expanded Program on Immunization (EPI) in May 1974 with the objective to vaccinate children throughout the world.

24. Ten years later, in 1984, the WHO established a standardized vaccination schedule for the original EPI vaccines: Bacillus Calmette-Guérin (BCG), diphtheria-tetanus- pertussis (DPT), oral polio , and measles . Increased knowledge of the immunologic factors of disease led to new vaccines being developed and added to the EPI’s list of recommended vaccines:

25. Hepatitis B ( HepB ), yellow fever in countries endemic for the disease, and Haemophilus influenza meningitis ( Hib ) conjugate vaccine in countries with high burden of disease. In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created with the sole purpose of improving child health in the poorest countries by extending the reach of the EPI.

26. The GAVI brought together a grand coalition, including the UN agencies and institutions (WHO, UNICEF , the World Bank ), public health institutes, donor and implementing countries, the Bill and Melinda Gates Foundation and The Rockefeller Foundation , the vaccine industry, non-governmental organizations (NGOs) and many more.

27. The creation of the GAVI has helped to renew interest and maintain the importance of immunizations in battling the world’s large burden of infectious diseases. The current goals of the EPI are: To ensure full immunization of children under one year of age in every district To globally eradicate poliomyelitis

28. MAIN GOAL OF IMMUNIZATION The goal of Expanded Programme on Immunization (EPI) in Zambia is to reduce morbidity and mortality from vaccine preventable diseases such as tuberculosis, measles, poliomyelitis, tetanus, diphtheria, pertussis , hepatitis B and haemophilus Influenza type b. doing no harm in the process. 

29. Attain and sustain coverage of 90% for each antigen. Control measles through high vaccine coverage of 95%.

30. Children up to about 9 months of age are targeted for routine EPI, although children above this age that have not completed their course may be eligible for vaccination.  A fully protected child is one who received 1 dose of BCG,4 doses of oral polio,3 doses of DPT+Hep B+Hib , 3 doses of PCV, 1 dose of IPV and 1 dose of measles by the age of 24 months.

31. GENERAL PRINCIPLES It is safe and immunologically effective to administer all EPI vaccines on the same day at different sites of the body. Minor illnesses such as low grade fever, mild respiratory infection, diarrhoea and vomiting are not contra-indicated to vaccinations .

32. All persons with asymptomatic HIV should be immunized with EPI vaccines. Persons with symptomatic HIV/AIDS infection should not receive BCG or yellow fever vaccine, but should receive all other EPI vaccines. Malnutrition is an indication to immunize. Live vaccines should not be given to pregnant women

33. TARGET GROUPS FOR VACCINATION Children under 5 years of age School age children Pregnant women Women of child bearing age (15-45yrs old) Special at risk groups (travellers)

34. THE TARGET DISEASES FOR IMMUNIZATION The following are the target diseases for immunization: Tuberculosis Poliomyelitis Tetanus Diphtheria

35. Pertussis Hepatitis B Haemophilus Influenza type B Measles. Diarrhoea pneumonia

36. VACCINE AGE FOR VACINATION diseases Number of doses BCG At birth if no scar at 12 weeks tuberculosis 1 OPV 0, At birth -13 days Poliomyelitis in the GIT 1 OPV 1,2,3 At 6weeks 10 and 14 OPV 4 at 9months if OPV 0 wasn’t given at birth Poliomyelitis in the GIT 3 DPT, HEPB AND HIB 1,2,3 At 6 weeks 10 and 14 Tetanus and diphtheria, hepatitis B and hemophils influenza B 3 PCV 10-1,2,3 At 6 weeks 10 and 14 Meningitis, pneumonia ,bacteremia 3 Vaccination Schedule

37. VACCINE AGE DISEASE NUMBER Of DOSES ROTA 1,2 6 weeks 10 diarrhea 2 Measles –rubella 1,2 9months and 18 month booster Measles and rubella 2 (IPV ) Ipv at 14weeks with opv 3 Prevents polio in the blood 1 SHEDULE

38. VACCINE DOSE SITE/ROUTE AE BCG 0.05ML less 1yr 0.1ml more than 1year Intra dermal in the lower aspect of the left arm Pain, redness, swelling OPV0, 1,2,3,4 2-3 DROPS ORAL Rare close to none. 1% fever, malaise DPT,HEB,HIPB 0.5MLS Deep IM in the left thigh Pain, redness, Swelling, fever, malaise, irritability PCV 10 0.5mls Deep IM in the right thigh Pain irritability, swelling, malaise fever ROTA 1.5mls oral Close to none Measles rubbella 0.5mls Subcuteneously on let deltoid muscle Pain,fever,redness,malaise TD O.5MLS Left deltoid arm IM Numbness,pain,redness IPV 0.5 MLS Deep IM in the right thigh Pain, swelling ADMINISTRATION OF VACCINE.

39. Vaccine Time for administration Duration of protecton Td 1 At first contact or as early as possible in pregnancy NO protection TD2 At least 4 weeks after TD 1 3 years TD3 At least 6 months after TD2 or during subsequent pregnancy 5 years TD4 At least 1 year after TD3 10 years TD5 At least 1 year after TD 4 Up to 30 years and throughout a woman's reproductive age. TATENUS DIPHTHERIA VACCINATION

40. BCG BCG is a live attenuated mycobacterium, which protects against Tuberculosis. It was developed by Calmette and Guerin, hence the name BCG. It is frozen then dried and comes as a powder in a vial. It is reconstituted with sterile diluent before it can be injected.

41. Only the particular diluent that comes with the particular brand of the vaccine should be used. Storage: BCG can be safely stored and transported between -15 to -25ºC. And +2 to +8 at the centre

42. The diluents should not be frozen but cooled immediately prior to use. BCG should never be exposed to sunlight. Reconstituted BCG must be used within six hours or be disposed of.

43. Age: At birth or any time after. Dose: 0.05 mls for children under one year. 0.1 ml for children above one year. Route: Intra-dermal injection in the left fore arm. Number of Doses: One

44. If there is no scar at the injection site 12 weeks after a BCG immunization, the vaccine injection must be repeated. Normal Reaction: After BCG injection there should be a flat-topped swelling (wheel) in the skin at the injection site looking like a mosquito bite.

45. This usually disappears within 30- 40 minutes. After approximately two weeks, a red sore develops which is about 10 mm in diameter. The sore remains for another two weeks and then heals. A small scar, about 5mm remains. This is a sign that the child has been effectively immunized with BCG

46. DPT+Hep B+Hib VACCINE The DPT vaccine contains weakened Diphtheria and Tetanus Toxoids and killed Pertussis (whooping Cough) bacteria. ( i ) Diphtheria Toxoid : This is the 'D' part of DPT vaccine. Bacteria that produce toxin cause diphtheria. The vaccine is toxiod , that is, inactivated diphtheria toxin. Freezing damages it. It is also damaged by heat but not as quickly as the live vaccines

47. (ii) Pertussis : This is the 'P' part of DPT vaccine. The microorganisms that cause pertussis are bacteria. The vaccine is made from killed bacteria.

48. Pertussis is damaged by heat about as quickly as BCG. It is the most easily damaged part of DPT. (iii) Tetanus: This is the 'T' part of DPT vaccine. It is also available as a separate vaccine. Tetanus is caused by bacteria, which produce toxins.

49. The vaccine is called a toxiod , that is, inactivated tetanus toxin. Freezing damages tetanus toxiod . It is also damaged by heat but more slowly than other vaccines

50. (iv). Hepatitis B (Hep B): This is a virus that infects the liver. Those who are infected can become lifelong carriers of the virus and may develop long-term problems such as cirrhosis (liver disease) or cancer of the liver.

51. The hepatitis B vaccine probably creates lifelong immunity. Infants who receive the HBV series should be protected from hepatitis B infection not only throughout their childhood but also into the adult years

52. Eliminating the risk of HBV infections also decreases risk for cirrhosis of the liver, chronic liver disease, and liver cancer. Young adults and adolescents should also receive the vaccine if they did not as infants.

53. (v ). Haemophilus Influenza ( Hib ): Haemophilus influenza type B bacteria were the leading cause of meningitis in children until the Hib vaccine became available. Long-term protection from Haemophilus influenzae type B occurs in more than 90% of infants who receive three doses of the vaccine.

54. Those immunized have protection against meningitis, pneumonia, pericarditis (an infection of the membrane covering the heart), and infections of the blood, bones, and joints caused by the bacteria. DPT+Hep B+Hib and TD are both liquid vaccines, which you can give by injection

55. DPT should not be given to a child who is over 5 years old. Children older than 5 years should be given TD instead. Age: Start at 6 weeks, then 10 weeks and 14 weeks. Dose: 0.5mls Route: Intra-muscular injection into the lateral middle side of the Left thigh.

56. Number of Doses: Three with minimum interval between doses of 4 weeks. Storage: DPT+Hep B+Hib should be stored and transported between +2 and +8ºC. NEVER FREEZE DPT+Hep B+Hib

57. Side Effects: Fever: Warn the mother that many children have fever and are irritable after DPT+Hep B+Hib vaccine and that it stops within a day. The child can be given paracetamol at the time of vaccination to reduce the fever.

58. (ii ) Local Soreness: Reassure the mother that some children may get a red, tender lump at the site of the injection, tell her that it is not serious and needs no treatment. However if pus appears at the site of injection, she should report to the nearest health facility.

59. (iii ) Abscess: If the pain and the swelling begin late (a week or more after the injection) it may be due to an abscess. If the child develops an abscess, put warm compresses on the swelling and give antibiotics (e.g. cloxacillin 50mg/kg/day for 5 days). If the swelling does not resolve refer for incision and drainage

60. (iv ) Convulsions: This is a rare complication and is often related to fever. This is due to pertussis part of DPT+Hep B+ Hib . Note: If the child who received DPT vaccination has convulsions or shock in the following three days, that child should not receive more doses of DPT+Hep B+Hib . He/she can be given TD instead.

61. PNEUMOCOCCO CONJUGATE VACCINE (PCV) PCV gives a long lasting and effective protection to children. It protects against severe forms of pneumococcal diseases such as meningitis , pneumonia and bacteraemia. It will not protect against these conditions if they are caused by agents other than pneumococcal bacteria.

62. STORAGE OF THE VACCINE. PCV should be stored at a temperature between +2 degrees Celsius and +8 degrees Celsius without being frozen. They are freeze sensitive, if freezing is suspected the shake test should be performed to determine whether a vial is safe to use.

63. ADVERSE EFFECTS FOLLOWIN IMMUNISATION Swelling, hotness and redness on the side of injection

64. OPV (Oral Polio Vaccine) This vaccine contains a live attenuated virus. It is damaged more easily by heat than the other vaccines. It should be stored and transported frozen up to health facility level. OPV comes either in a plastic dropper or in a glass vial with a dropper in a separate pack. It is important to use the right dropper with the right vaccine in order to avoid leakage

65. Storage: It should be kept between -15 and -25 ºC at the district and at +2 to +8 at the health centres -Vaccine Vial Monitors (VVMs) on the OPV vials indicate if the vaccine has been damaged by heat. If the square is lighter than the surrounding circle the vaccine can be used.

66. Age: Within 13 days of birth, then at 6weeks, 10 weeks and 14 weeks. Dose: 2-3 drops. Route: Oral.

67. Number of doses: Four with minimum interval between doses of 4 weeks. Contra-indication: There is none. If the child has diarrhoea, give the vaccine, but give an extra dose four weeks after you finish the normal course. Do not record the dose given during diarrhoeal episode. Side Effects: None.

68. MEASLES This is a live attenuated virus that protects against measles. -It is freezing dried and has to be reconstituted before injection. Only use the diluent that comes from the vaccine manufacturer to reconstitute the vaccine. Storage: At central and district stores, measles vaccine should be kept between -15 and -25 ºC. -At health centre, it is stored between +2 and +8 ºC.

69. The diluents should not be frozen, but cooled immediately prior to use so that it does not over heat the vaccine Age: 9 months & 1 year 6 months Dose: 0.5mls Route: Subcutaneous injection into the left upper deltoid muscle (arm). Number of doses: two doses

70. TETANUS DIPTHERIA (TD) This vaccine consists of toxoids . Immunization schedules for protection against Tetanus begin in the newborn period. In addition, every woman of childbearing age (15-49 years) should receive 5 doses of TT to prevent neonatal tetanus. It is the same tetanus toxoid as contained in the DPT+ Hep B + Hib vaccine.

71. Storage: It should be stored and transported between +2 and +8 ºC. TD vaccine is destroyed by freezing. Age: School entry, during pregnancy and 15-45 years. Dose: 0.5 mls Route: Intra-muscular injection into the left detoid muscles of upper arm. Number of doses: Five

72. Side Effects: Mild pain, redness and swelling are common for a couple of days at the site of injection. Reassure the woman that this goes away by itself and needs no treatment.

73. VITAMIN A SUPPLEMENTATION Vitamin A supplementation means to give Vitamin A capsules to increase the amount of Vitamin A in the body. The periodic high dose supplementation is intended to protect against Vitamin A deficiency and its consequences by building up reserve of the Vitamin for periods of reduced dietary intake or increased need.

74. Administration of Vitamin A Supplementation: Children 6-11 months, give once : 100,000 iu Children 15-59 months, give every 6 months: 200,000 iu

75. Ten critical steps to reconstitute vaccines safely Read the label on the diluent to make sure that it is the correct diluent Check the expiry date to make sure that it has not passed. Check the status of the vaccine vial monitor (VVM) to make sure that it is not , or beyond the discard point. Cool the diluent to between +2°C and +8°C, preferably a day prior to its use.

76. Draw the entire contents of the diluent into a new sterile reconstitution syringe and empty the entire contents of the diluent into the vaccine vial. Discard the used reconstitution syringe and needle into a safety box without recapping Do not leave the reconstitution needle in the vaccine vial. After reconstitution, insert the vial in the foam pad of a vaccine carrier. Never allow the vial to become immersed in water.

77. Discard all reconstituted vaccine at the end of the session, or within six hours, whichever comes first. Use a new auto-disable (AD) syringe and needle to withdraw each dose of the vaccine, and use the same needle and syringe for injecting the vaccine. After giving the injection, drop the used syringe and needle into the safety box without recapping.

78. Multi-dose Vial Policy Applies only to OPV, TD, vaccines from which one or more doses of vaccine have been removed during an immunization session, may be used in subsequent immunization sessions for up to a maximum of four weeks, provided that all the following conditions are met. The expiry date has not passed. The vaccines are stored under appropriate cold-chain conditions (+2°C to +8°C).

79. The vaccine vial septum has not been submerged in water. Aseptic technique has been used to withdraw all doses. The VVM, if attached, has not reached the discard point.

80. Some vaccines to which MDVP does not apply Use within six hours of reconstitution or by the end of the immunization session, whichever comes first, and then discard. BCG vaccine. DTP-HepB+Hib vaccine. Yellow fever vaccine. Meningitis vaccine. Measles vaccine.