Epi L 4 MW 2013

1
Expanded Program
of
Immunization
(EPI)
By Niguas A. (BSC, MSC Fellow) 5/9/21

Objectives of the lecture
At the end of this topic, the students will be able to describe;
2
1- history of the program
2- Objectives of the EPI
3- Strategies of the program
4- The target population
5- Schedule of immunization in Ethiopia
6- Dose, route of administration & type of vaccine
.
7- Contraindications of vaccination
8- Records and reports
9- Cold chain
History of the EPI
Experience with smallpox eradication progr
3
am showed the world that immunization was

the most powerful and cost-effective weap
on against preventable diseases.
In 1974, the WHO launched its “ Expanded pr
ogram of immunization” (EPI) against six
most common vaccine-preventable diseases
(diphtheria, pertussis, tetanus, polio, t
uberculosis and measles.)
Cont.
4
In 1980GC, Ethiopia launched its national Expa

nded program of immunization” (EPI) in the 1 st t
ime against the six most common preventable d
iseases (diphtheria, pertussis, tetanus, polio, tub
erculosis and measles.) for children under two y
ears of age.

Cont.
5
 Ethiopia updated its policy governing the national

EPI in 2007, and the program targeted against eigh
t most common preventable diseases including He
patitis B and Haemophilus influenza type b vaccin
es were successfully added to the standard EPI sch
edule in 2007GC.

Health Facilities conducting Routine Immunization
◦ Health Posts
6
◦ Health Centers
◦ Hospitals
◦ (NGO/GO clinics – if appropriate)
◦ (Private Clinics – if appropriate)
EPI Staff
◦ All HEWs
◦ All HWs who have pre-service training on c
onducting EPI are responsible to conduct/lea
d EPI program in the assigned Health Facilit
y. By Niguas A. (BSC, MSC Fellow) 5/9/21
Current Organization of EPI service delivery:
7
◦ Health Facility EPI Focal Person

◦ Woreda Child Health Officer (EPI, Nutrition, IMNCI
◦ Zone Child Health Officer (EPI, Nutrition, IMNCI
◦ Zone Cold Chain Officer
◦ Region EPI Officer
Reporting line of monthly EPI data:
◦ HP to Health Center
◦ Health Center to Woreda Health Office
◦ Woreda Health Office to ZHD
◦ ZHD to Regional HB
◦ Regional HB to FMOH
◦ Feedback and supervision
By Niguas A.goes in the
(BSC, MSC 5/9/21 direction.
opposite
Fellow)
Main gaps and Challenges in EPI Program in t
he Region
8
Access to EPI service not 100%.

Unacceptably High Drop out rate.
Frequent cold chain break down.
Competency of Health Workers to conduct/lead EPI n
ot universally perfect.
Data quality problem/poor monitoring and supervisio
n.
Poor vaccine stock management/shortage of vaccines.
Adverse events following immunization not properly
managed.
Cont.
Currently, Ethiopia focuses on ten most common vaccine-pr
9
eventable Diseases;
Diphtheria,
Pertussis,
Hepatitis B
Haemophilus Influenza Type B
Tetanus,
Pneumonia,
Polio,
Tuberculosis and
Measles
Rotarix
Brainstorming

10
Define the following terms;
 Expanded,
 Immunity,
 Immunization,
 Vaccine,
 Vaccination
“Expanded” means:
11
 Expanding the number of diseases to be covered

 Expanding the number of children and target popu
lation to be covered
 Expanding coverage to all corners of the count
ry and spreading services to reach the less privi
leged sectors of the society

Immunity
12
 State of being protected against disease throu

gh the presence of antibodies either by previo
us infection or by vaccine.
 Antibodies are proteins produced by the body
to neutralize or destroy toxins or diseases carr

ying organisms.
 Antibodies are disease specific.

Cont.
13
There are two types of immunity:

1. Innate or non-specific immunity
 It is the natural resistance of body
2. Acquired or specific immunity
- it can be -Active Acquired
-Passive acquired
1. Active immunity
14
 I. ACQURIED - vaccine-induced immunity
 Attenuated organisms (live-weakened)
 E.g. BCG, Measles

Inactivated organisms(dead, e.g.Pcv10)
 Toxoid , e.g. TT
 II. NATURAL-
 Exposure to the diseased organism can occu

through infection with the actual disease. E
. measles
 Active immunity is long lasting/life long.

2. passive immunity
It is provided when a person is g

15

iven antibodies to a disease rath

er than producing them through hi
s/her own immune system.

ACQUIRED PASSIVE IMM.
16
Injection of immune globulin Performed prophyl

actically, either after diagnosis of exposure
to toxin/virus or as a short term preventive p
rocedure, e.g. if one is traveling to an endem
ic area. (chloroquine) 500mg 300mg
NATURAL PASSIVE IMM.
 Trans placental transfer of maternal IgG Abs
to developing fetus;
 Transfer of IgG + IgA Abs in milk during bre
ast-feeding of newborn
Immunization
It is a process or proc
17

edure designed to rende

r or increase the conc
entration of a human im
munity by active or pas
sive process
Vaccine
It is a Substance(one or more)
18

preparation used to stimulate t

he production of antibodies and
provide immunity against a dise
ase. e.g. OPV,PCV10 Vaccine,…

Vaccination
19
It is a process or wa
ys to put a vaccine in
the body to produce im
munity against a disea
se.

Objectives of the EPI
20
To achieve 100% coverage with all EPI vaccines .
Eradication of polio to maintain polio free

status
 Elimination of measles
 Reduce sero prevalence of (HBSAg)to <1% am
ong under five

 Elimination of Neonatal Tetanus
 To maintain zero level of diphtheria.
 Prevention ofBysevere forms of TB.
Niguas A. (BSC, MSC Fellow) 5/9/21
Cont…
21
 To reduce the incidence of whooping c

ough
 Reduce the incidence of Bacterial
Meningitis due to Haemophilus
influenza
 To maintain immunization safety
 To prepare for introduction of ne
w vaccines
Strategies of the EPI

22
Integrate vaccination sessions with P
HC services
 Appropriate measures to expand the va
ccination coverage of the eligible po
pulation
 Ensuring regular supply of potent vac
cine
 Strengthening the cold chain
 Training of health personnel
 Promotion of community participation
 Incorporating health education activi
 Ensuring logistic support ( supplies and equ
ipments)
 Introducing a system for continuous monitori
ng and periodic evaluation
 Undertaking operational research to find out
deficiencies and difficulties in the program
and suggest methods of improvement
 Insure prompt reporting and improve control of vaccine p
23
reventable diseases
Target populations
24
 Under 5-years children.
 Women in the child bearing
 age (15-45 years).

Determinants of the Immune
response to a vaccine includes
25
 Age--- The measles vaccine is given at 9 month

s of age
 Route of administration-- BCG is administere
d ID rather than IM
 Nature of vaccine Live attenuated vaccines
 Genetic Individuals genetically vary in their ability
to respond to the same vaccine
 Potency requires keeping the cold chain

TYPES OF VACCINE
26
Bacillus Calmette Guérin (BCG)

Oral Polio vaccine (OPV)
Pneumococcal Vaccine(PCV1O)
PENTAVALENT(Penta)
Measles
Rotarix

BCG
27  Bacillus Calmette Guérin
Target disease------Tuberculosis(TB)
Target population---age <2years
Nature of vaccine--- Live attenuated
Route of administration- intradermal
SITE---Right deltoid region of the arm
DOSE---Infants 0.05ml, 0.1ml for 1-2yrs
Storage temperature--- 2oC to 8oC
 Schedule--- at birth, if not till 2yrs only
 Number of dose--- single dose only

BCG (cont.)
 Preparation----
28
in powder form
Diluting with 1m
l
 One vial needed for a maximum of 20 infants.
 Contraindications –
 Symptomatic HIV infection

 Protection:
 variable, 90% only for disseminated disease
 Adverse reactions –
 Local abscess, regional lymphadenitis;
 rarely, distant spread to osteomyelitis, disseminated disea
se
Safety and side effects- BCG
29
 Most children will have :

◦ Small raised lump at site of injection- disapp
ear within 30 min
◦ Red sore appear after 2 weeks and last for two
weeks. Leaving a scar
 Generalized infection: 5/1,000,000 in immuno-com
promised

Special precautions –
30
 Correct intradermal administration is essential.

 A special syringe and needle is used for the admi
nistration of BCG vaccine
 Notice
 Do not used a prepared BCG vaccine afte
r six hours.

OPV
31
Oral polio vaccine (OPV) gives protection ag

ainst the three types (types 1, 2 and 3) of viru
ses that cause poliomyelitis or polio which l
ead to crippling disease of the brain and spinal
cord called acute flaccid paralysis.
OPV is a light red or light yellow liquid suppl
ied in vials which either have droppers as cap
s, or they come with separate glass droppers.

Summary
32
 Oral Polio vaccine
Target disease------polio
Nature of vaccine--- Live attenuated
Route of administration- oral
SITE---mouth
DOSE---2 drops
Storage temperature--- -15oC to – 25oC
 Schedule--- at birth, 6, 10, 14wks
 Number of dose--- 4 (opv0,opv1,opv2,pov3)

Con…
33
 Contraindications- None
 Adverse reactions –
 Headache , diarrhea muscle pain- <1%
 VAPP very rare (approximately 2 to 4 cases per mill
ion children vaccinated)
 Special precautions –
 Children known to have rare congenital immune de
ficiency syndromes should receive IPV rather than
OPV.
 Storage - Store between 2°C–8°C ( maybe frozen for
long-term storage)

PENTAVALENT(Penta)/DTP-HepB-Hib combination vaccine
34
Pentavalent vaccine: - vaccine which contains five different antige

ns is called Pentavalent
Target disease---Diphtheria, Pertussis,
Hepatitis B, Haemophilus Influenza Type B, an
d Tetanus
Nature of vaccine---
Dead------Hepatitis B, Pertussis, HIB
Toxoids---Tetanus, diphtheria

Penta(cont.)
35
Route of administration- IM
SITE---Upper, outer portion of the left thigh
DOSE---0.5ml
 Schedule--- 6wks, 10wks, 14wks
 Number of dose--- 3(pent1, Penta 2, penta3)
 Found in liquid form and use one vial

for one child in a single time.
 Don’t forget to check 3x before you give the
vaccine .
SAFETY AND SIDE EFFECT- Pentavalent vaccine
(DPT-HepB-HIB)
36
95% effective for HepB, Hib, Diphtheria, 80% for

Pertussis
Mild reactions following immunization are common
◦ Pain and swelling at the site of injection,
◦ fever, irritability, malaise
◦ Self- limiting, hardly requiring even symptomatic
treatment
Reassure parents about such events so that they know
about it
Side effects are not contraindications for vaccination

36
Diphtheria
37
 Diphtheria is caused by bacteria called Corynebacterium
diphtheria.
 The bacteria produce a toxin that can harm or destroy human
body tissues and organs.
 One type of the disease affects the pharynx and other parts of
the throat.
 Diphtheria affects mostly non-immunized children under 15
years of age but it can affect people of all age‘s groups.
 When diphtheria affects the throat and tonsils, the early sign
and symptoms are: sore throat, loss of appetite and fever.
 The most effective way of preventing diphtheria is to maintain
a high level of immunization in the community.

37
Pertussis
38
Pertussis,or whooping cough, is a disease of the

respiratory tract caused by inactivated (killed)
bacteria called Bordetella pertussis.
The germ lives in the mouth, nose and throat.
The disease is common in non-immunized
children all over the world.
Severe epidemics can occur where immunization
coverage is low.
The disease is most dangerous in children less than
12 months old.
38
Tetanus toxoid for neonatal tetanus (TT)
39
Tetanus or lockjaw is caused be a bacteria Clostridium

tetani.
Tetanus toxoid is a sub unit antibacterial vaccine.
Tetanus affects person‘s muscles all contract, making
the body stiff.
The disease is particularly common and serious in
newborn babies, when it is called neonatal tetanus
(NNT).

39
Haemophilusinfluenzae type b (Hib)
40
Haemophilus influenzae type b(Hib) is one of the
six sero types of haemophilus bacteria That
causes about 95% of morbidity and mortality among
under five children where Hib vaccine is not
routinely given to all infants.
This bacteria causes majority of the serious
childhood illnesses like pneumonia, bacterial
meningitis, parotitis, and septicemia.
Hib vaccine is a conjugate antibacterial vaccine,
which protects against pneumonia and meningitis
caused by the bacteria Haemophilus influenza type b
40
Hepatitis B vaccine (HepB)
41
Hepatitis B viruses which cause Hepatitis B

diseases are protected by a recombinant
vaccine called Hepatitis B (HepB) vaccine.
If a child is infected with hepatitis B
viruses, liver disease may develop many
years later in adult life.

41
Pneumococcal vaccines (PCV10)
42

42
Con…
43
 Pneumococcal vaccines (PCVs) protect against pneu
monia and other pneumococcal infections caused by
Streptococcus pneumonia bacteria.
 These bacteria can attack different parts of the body, c
ausing serious infections in the lungs (pneumonia), the
inner ear (acute otitis media), the
bloodstream (bacteremia), and the membranes covering
the brain and spinal cord (meningitis).
 Ethiopia, pneumonia is the leading cause
of death among children under five years, accounting for
28% of all deaths in this age group.
Pneumococcal Vaccin
44
e(PCV)
Target disease--- Pneumonia
Nature of vaccine-(Dead)
Route of administration- IM
SITE--Upper, outer portion of the right thigh
DOSE---0.5ml
PCV(cont.)
45
 Schedule--- 6wks, 10wks, 14wks

 Number of dose--- 3 (pcv(1), pcv(2), pcv(3)
 Found in liquid form and use one
vial for two child after shaking
the vial effectively.
 Don’t forget to check 3x before you giv
e the vaccine .Don’t use the opened vac
cine after 6 hours, you must discard it.
Con…
46
Contra-indications - same as for pentavalent vaccine

Adverse effect -Mild local reactions (redness, pain an
d slight swelling at the injection site),
Rare severe reactions like convulsions, severe allergi
c reaction (anaphylaxis), swollen lymph glands, and e
ncephalitis
Management of AEFIs -For mild cases Keep dry and
clean (do not put any ointment or medicine on it)
-For severe reaction Refer or try antibiotic if bacterial i
nfection is suspected
Measles vaccine
47
Measles is caused by the measles virus and is highly
infectious, i.e. very easily spread from person to
persons.
It kills more children than any other of the EPI target
diseases.
In the absence of immunization, all children eventually
develop measles and about 3 of every 100 will die.
Unimmunized children under 5 years of age, and
especially infants, are at highest risk for measles and
its complications like Encephalitis, a dangerous
swelling of the brain, Blindness even lead to death.
By: Atsede G. 47
Measles…
48
Target disease---measles
Nature of vaccine-(Live attenuated)
Route of administration- Subcutaneous
SITE--Outer ,upper part of left arm
DOSE---0.5ml
 Storage temperature--- -15oC to – 25oC (vaccine w
l not be damaged by freezing but the diluent should never be frozen).

Measles(cont.)
49
 Schedule---at 9month, 13month

 Number of dose--- 2
 Preparation- found in powder form &
Diluting with 5ml
 One vial needed for a maximum of 10 infants.
 Notice
 Do not used a prepared measles vaccine after si
hours.
Con…
50
 Contraindications
 Severe reaction to previous dose; pregnancy; congenital or acquired im
mune disorders (not HIV infection)
Adverse reactions
 Malaise, fever, rash 5–12 days later; idiopathic thrombocytopenic purp 85
% Efficacy
 Soreness and pain at injection site- 24 hours
 5% - fever 5-12 days after injection
 5% mild rash 5-12 days after injection –last 2 days
 Severe reactions are rare:
 Anaphylaxis 1/1,000,000 doses
 Encephalitis :1/1,000,000 doses
 uric; rarely, encephalitis, anaphylaxis
Schedule summary
51
Age
Vaccine Birth 6 wks 10 wks 14 wks 9 mths 13 mths
BCG ×
OPV × × × ×
PCV × × ×
Penta/ × × ×
DPT-HepB-HIB
Rota × ×
Measles × ×

Duration of protection in women following 1–5
doses of TT vaccine.
52

52
Contraindications to vaccin
53
ations:
Absolut
Temporary

Absolut
54
 History of anaphylactic reactions.(all

eregic rxn)
Loss of consiosiness,skin color change,diff
icuit breathing,….epinephrine
 Subsequent doses of pertussis vaccine
s are absolutely contraindicated if t
he child gets convulsion (within 48 h
Absolut(cont.)
55
 Collapse or shock .
 Persistent crying for 3 hours without appare
nt cause.
 Convulsion with or without fever within 3 hour
s after vaccination.
 HIV infection is an absolute contraindication to admini
stration of live attenuated vaccines ( OPV & BCG).
Temporary
56
1. Severe illness that ne

eds hospitalization.
2. Immunosuppression.
3. Recent receipt of blood

Basic Principles to be considered in immunization s
chedule:
57
1. All EPI antigens are safe and effective if administ

ered simultaneously.
2. The only live attenuated vaccine given to HIV chi

ld is measles

The strategy for the vaccine
58 elivery:
1. The static immunization strategy.
2. The National Immunization Days (NIDs)
.
3. Mopping up Immunization.
4. Outreach immunization.

The static immunization strategy:
59
 Advantages of integration of immuniza

tion services through (MCH):
1-Available resources.
2- Cold Chain maintenance.
3- Save ,time, effort and money.

(II) The National Immunization Days (NIDs):
60
 It is periodic immunization of all the eligibl

e targets in a defined group over a large geo
graphic areas within a short period of time. I
t is one of the strategy for polio eradicatio
n and tetanus elimination.

(III) Mopping up Immunization:
61
 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).
(IV) Outreach immunization:
62
 The outreach is carried for routine i

mmunization that is compulsory for t
he targets in certain areas where:
- immunization services are not accessible.
- vaccination coverage is Low.

Outreach(cont.)
63
 The outreach is carried during any time with

out specific duration.
 Limitations:
(i) Expensive
(ii) Cold chain failure.
(iii) Difficulty to arrange the immunization

schedule. By Niguas A. (BSC, MSC Fellow) 5/9/21
Missed opportunity :
64
 It occurs when a child or a wo

man in child bearing period co
mes to the health facility or
outreach site and does not rec
eive any of the vaccine doses
for which he or she is eligibl
e.
The reasons for missed opportunity are:
65
Health workers` practices.

 Logistical problems.
 Failure to administer simultaneously
all the vaccines for which the child

is eligible.
 False contraindications to immunizat
ion
66
The cold chain

The cold chain
67
 It is the system of storage and

transportation of the vaccine a
t low temperature (cold conditi
on) from the manufacture till i
t is consumed.

Notice!!!
68
 Polio vaccine is the most sensitive v

accine to heat.
 Live attenuated vaccines are allowed
to be frozen (OPV, Measles, & BCG).
 Inactivated vaccines must not be froz
en ( Penta, PCV10 and TT) .
Heat, sun light and freezing
69
Heat and sunlight damage all vaccine, but

(live vaccine) most sensitive
Freezing damage DPT and TT vaccine.
Keep all vaccine at the correct cold
temperature
Chemicals (disinfectant, soap) e.t.c can
damage the vaccine.

69
70

Vaccines sensitive to heat
71

71
72

The components of the cold chain :
73
The health staff

The equipment & tools
The procedures

Refrigeration equipment :
74
 Refrigerator
 Cold boxes
 Vaccine carriers
 The ice packs retained in the free
er;
 -To stabilize the temperature of the
 refrigerator at the optimum level.

1-The refrigerator
75
 Placed in the coolest place of the health cen
ters away from sunlight.
 Well ventilated and adequate air circulation a
round it .
 Kept locked and open only when necessary .
 Ice packs are kept in the freezer.
 Its temperature is recorded twice daily.

Refrigerator(cont.)
Drugs, drinks or food must not be st
76

ored in the refrigerator.

 Both the monitor and thermometer ar
e placed in the refrigerator.
 The temperature chart is stuck on th
e door outside the refrigerator.

 The diluents should be kept on the l
owest shelf
77
ice packs
OPV, Measles, & BCG
Penta, PCV10 & TT
Diluent

Question
78
 What is the optimum Temperature o

f the refrigerator in the health
facilities?

Tools for monitoring the cold chain
79
:
 1- Cold Chain Monitor Card.
 2- Freeze Watch Indicator
 3- Cold Chain Refrigerator Grap
 4- Vaccine Vial Monitors
 5- Shake Test

Cold Chain Refrigerator Graph
80

81

82

83
3-Vaccine
vial monit
ors:
84

85

86

What damage the Vaccines?
87
1. Any defect in the cold chain.

2. Out date expiry.
3. Using the reconstituted vaccine (pcv10, mea
sles, BCG) after the recommended period ( 6 h
ours).
4. Exposure of the vaccine to unacceptable tem
perature during the vaccination.
5. Exposure ofBy Niguas
theA. vaccine to direct sunlight
(BSC, MSC Fellow) 5/9/21
Con…
88
Vaccine can easily damage if not handle prop

erly.
If the vaccine is in good condition, and able t
o make a child immune is potent.

If vaccine is damaged, and not able to make a
child immune, then it has lost its potency

Types of records:
89
1. Yearly vaccination register- by age, sex,

nationality and dosage numbers.
2. Daily vaccination register- with identifyi
ng family register number.
3. Follow up register.
4. Immunization card ( details of immunizatio
n and the date of next visit).

90
Reports
 Monthly immunization report showing t
otal number of doses, age, sex, natio
nality are sent in the first week of
each month.
 This information would form a strong
base for the development of a surveil

lance system for EPI and EPI related
diseases.
91

05/09/2021 91

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1

By Niguas A. (BSC, MSC Fellow) 5/9/21

am showed the world that immunization was

In 1980GC, Ethiopia launched its national Expa

By Niguas A. (BSC, MSC Fellow) 5/9/21

 Ethiopia updated its policy governing the national

By Niguas A. (BSC, MSC Fellow) 5/9/21

◦ Health Facility EPI Focal Person

Access to EPI service not 100%.

 Expanding the number of diseases to be covered

By Niguas A. (BSC, MSC Fellow) 5/9/21

 State of being protected against disease throu

to neutralize or destroy toxins or diseases carr

By Niguas A. (BSC, MSC Fellow) 5/9/21

There are two types of immunity:

 E.g. BCG, Measles

 Exposure to the diseased organism can occu

By Niguas A. (BSC, MSC Fellow) 5/9/21

It is provided when a person is g

iven antibodies to a disease rath

By Niguas A. (BSC, MSC Fellow) 5/9/21

Injection of immune globulin Performed prophyl

edure designed to rende

preparation used to stimulate t

By Niguas A. (BSC, MSC Fellow) 5/9/21

By Niguas A. (BSC, MSC Fellow) 5/9/21

To achieve 100% coverage with all EPI vaccines .

Eradication of polio to maintain polio free

 Reduce sero prevalence of (HBSAg)to <1% am

ong under five

 To reduce the incidence of whooping c

 To prepare for introduction of ne

 Under 5-years children.

 Women in the child bearing

 age (15-45 years).

By Niguas A. (BSC, MSC Fellow) 5/9/21

 Age--- The measles vaccine is given at 9 month

By Niguas A. (BSC, MSC Fellow) 5/9/21

Bacillus Calmette Guérin (BCG)

By Niguas A. (BSC, MSC Fellow) 5/9/21

 Number of dose--- single dose only

 Symptomatic HIV infection

 Most children will have :

By Niguas A. (BSC, MSC Fellow) 5/9/21

 Correct intradermal administration is essential.

By Niguas A. (BSC, MSC Fellow) 5/9/21

Oral polio vaccine (OPV) gives protection ag

By Niguas A. (BSC, MSC Fellow) 5/9/21

 Number of dose--- 4 (opv0,opv1,opv2,pov3)

By Niguas A. (BSC, MSC Fellow) 5/9/21

Pentavalent vaccine: - vaccine which contains five different antige

By Niguas A. (BSC, MSC Fellow) 5/9/21

 Number of dose--- 3(pent1, Penta 2, penta3)

 Found in liquid form and use one vial

95% effective for HepB, Hib, Diphtheria, 80% for

By Niguas A. (BSC, MSC Fellow) 5/9/21

a high level of immunization in the community.

Pertussis,or whooping cough, is a disease of the