Objectives

At the end of the presentation the students ◼

will/can:
have an in depth knowledge on what EPI or ◼
expanded program on immunization is.
be able to discuss all routine immunizations given ◼
by the Department of Health in a wider aspect.
define clearly what cold chain management is in ◼
related to EPI
 Immunization
Immunization is the a process where by a
person is made immune or resistant to an
infection, typically by administration of
vaccines

Immunization is a proven tool for controlling

and elimination life-threatening infectious
disease .
The Expanded Program On Immunization
(EPI)
The Expanded Programme on Immunization
(EPI) was established in 1974 through a World
Health Assembly resolution to build on the
success of the global smallpox eradication
programme, and to ensure that all children in
all countries benefited from life-saving
vaccines
◼ Objectives
The expanded immunization program, the who's initiative
to improve immunization coverage, focuses on the
following four items:4
◼ Standardizing immunization schedules
◼ Promoting safe injection technologies
◼ Improving the stocking and availability of vaccines
◼ Protecting vaccines' potency through cold chain
management
 The objectives of EPI:
1. To increase coverage of immunization
for eligible children.

2. To reduce the incidence of immunizable

diseases among children below five years of
age.

6
Eradication of polio to maintain polio free status.
Elimination of measles.
Reduce Incidence of

hepatitis B

among under five.

HBV
Elimination of Neonatal Tetanus .
Maintain zero level of diphtheria.
Prevention of severe forms of TB ( TB meningitis &military
TB).

12 year old girl with TB meningitis

 reduce the incidence of whooping cough
.

Reduce the incidence of Bacteria Meningitis due to

haemophelus influenza
3. Promoting safe injection techniques
4. Improve the stocking and availability of vaccines
5.Protecting vaccine potency through cold chain management
6.To prepare for introduction of new vaccines
 What is Immunity?
Immunity is the ability of the human body to ◼

recognize and dispose of substances which it

interprets as foreign and harmful to its well-
being
It provides protection from infectious ◼
diseases usually indicated by the presence of
antibody to that organism.
2 Basic Mechanisms for Acquiring
Immunity
Importance of Immunization Programs
Vaccines prevent more than ◼

2.5 million child deaths

globally each year.

An additional 2 million child ◼

deaths could be prevented
each year through
immunization with currently
available vaccines.
Child with smallpox.
Smallpox was certified
eradicated in 1979 …
thanks to effective vaccination.
 What is a vaccine?

A biological preparation intended to

produce immunity to a disease by
stimulating the production of antibodies
3 Essential Qualities of a Vaccine
Safety – vaccines are generally safe but .1

it is unlikely that it will be 100% safe

Immunonogenicity – must cause a strong .2

and measurable immune response and

induce the right type of immunity
Potency – it must remain at a high level .3

for the vaccine to evoke an immune

response
Types of vaccine

Live attenuated (LAV)

− Tuberculosis (BCG)
− Oral polio vaccine (OPV)
− Measles
− Rotavirus
− Yellow fever

Inactivated (killed antigen)

Whole-cell pertussis (wP) −
Inactivated polio virus (IPV) −

Subunit (purified antigen)

Acellular pertussis (aP), −
Haemophilus influenzae type b (Hib), −
Pneumococcal (PCV-7, PCV-10, PCV-13) −
Hepatitis B (HepB) −

Toxoid (inactivated toxins)

Tetanus toxoid (TT), −
Diphteria toxoid −
Vaccine Contraindication and Precaution
• Contraindication to vaccination is a rare condition in a
recipient that increases the risk for a serious adverse
reaction. The 2 types of contraindications are:
1. absolute – history of severe allergic reaction
2. relative – temporary reaction, the vaccine
can be administrated later

• Precaution are events or conditions to be considered in

determining if the if the benefits of the vaccine
outweigh the risks

DOH - Regional Epidemiology & Surveillance Unit 3

TT vaccination schedule for pregnant
and childbearing-aged women
TT or Optimal Dosing Interval Minimum Acceptable Estimated Duration
Td Dose Dosing of Protection

1 At first contact or as early as At first contact or as early as None

possible in pregnancy possible in pregnancy

2 6-8 weeks after TT1* At least 4 weeks after TT1 1-3 years

3 6-12 months after TT2* At least 6months after TT2 or At least 5 years
during subsequent
4 5 years after TT3* At least one year after TT3 or At least 10 years
during subsequent pregnancy

5 10 years after TT4* At least one year after TT4 or All childbearing age
during subsequent pregnancy years; possibly longer

*optimally given at least several weeks before due date if administered during pregnancy
 Target diseases
and vaccines

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Diphtheria

Type of vaccine Toxoid

Total number of doses 3

Schedule – For infant immunization doses:

Pentavalent or DTP for pentavalent1 starting at age 6 weeks (minimum) with pentavalent2 and
infants pentavalent3 at intervals of 4 weeks after the previous dose

Booster When combined with tetanus vaccine, a total childhood schedule of 5

doses (3 in infancy), another (DT) in early childhood (1–6 years), and
another (dT) during adolescence (12–15 years) is required. A further
dose in adulthood is likely to provide lifelong protection.
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Diphtheria

Adverse events Severe adverse events due to diphtheria toxoid alone have not
been reported
Mild: injection site reactions, fever
Special precautions None
Dosage 0.5 ml
Injection site Right Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adult
Injection type Intramuscular
Storage Between +2 °C and +8 °C
Do not freeze
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Haemophilus influenzae type b disease
Type of vaccine Conjugate (capsular polysaccharide bound to a carrier protein)
Total number of doses 3

Schedules Given as pentavalent, or as a separate injection at the same time as DTP

from age 6 weeks
3 primary doses given at minimum intervals of 4 weeks
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose

Adverse events Severe: none reported to date

Mild: injection site reactions, fever
Special precautions For pentavalent: do not use pentavalent vaccine to provide a birth dose of
hepatitis B vaccine
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Haemophilus influenzae type b disease

Dosage 0.5 ml
Injection site Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
Injection type Intramuscular

Storage Between +2 °C and +8 °C

Do not freeze

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Hepatitis B
Type of vaccine Recombinant DNA or plasma-derived
Total number of doses 3

Schedule – 4-dose primary series: stand-alone HepB as soon as possible after birth
HepB birth dose followed by (<24h), pentavalent1, pentavalent2, pentavalent3
pentavalent • Minimum interval of 4 weeks between doses required for both series
Booster None

Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose

Adverse events Severe: rare anaphylaxis

Mild: injection site reactions (pain, redness, swelling); headache; fever

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Hepatitis B

Special precautions Use only stand-alone HepB vaccine for the birth dose (do not use
pentavalent vaccine for the birth dose)
Dosage 0.5 ml
Injection site Anterolateral (outer) thigh in infants
Deltoid muscle of upper arm in older children and adults
Injection type Intramuscular
Storage Between +2 °C and +8 °C
Do not freeze
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Human papillomavirus infection
and cervical cancer
Type of vaccine Recombinant protein capsid, liquid vaccine
Total number of doses 2

Schedule – 0 and 6 months

bivalent (HPV types 16 and There is no maximum interval between doses – as long as the girl is
18; GSK Cervarix®) and under 15 years of age at the time of the first dose, two doses are
quadrivalent (HPV types 6, sufficient
11, 16 and 18; Merck If the interval between doses is less than 5 months, a third dose should
Gardasil® be given at least 6 months after the first dose.

Note: For females >15 years of age, or who are known to have a
compromised immune system and/or are HIV-infected, a 3-dose
schedule (at 0, 1 or 2 and 6 months) is recommended
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Human papillomavirus infection and
cervical cancer

Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose

Adverse events Severe: rare anaphylaxis
Mild: injection site reactions; fever, dizziness, nausea
Special precautions Postpone vaccination for pregnancy
Adolescents should be seated during injections and for 15 minutes
afterwards since they sometimes faint
Dosage 0.5 ml
Injection site Deltoid muscle of upper arm
Injection type Intramuscular
Storage Between +2 °C and +8 °C
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)

Do not freeze
 Measles
Type of vaccine Live attenuated (weakened) viral
Total number of doses 2

Schedule MCV1: 9 months of age

MCV2: 12 months of age

Contraindications • Known allergy to vaccine components (including neomycin and

gelatin)
• Pregnancy
• Severe congenital or acquired immune disorders, including advanced
HIV infection/AIDS
Adverse events • Serious: thrombocytopenia (decreased platelets), anaphylaxis,
encephalitis (brain infection, though causal link not certain)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)

• Mild: fever, rash 5–12 days following administration

 Measles
Special precautions None
Dosage 0.5 ml
Injection site upper arm
Injection type Subcutaneous
Storage Between +2 °C and +8 °C
Keep all MCVs away from sunlight

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Mumps
Type of vaccine Live attenuated (weakened) viral

Total number of doses 2

Schedule • Mumps1: 12 months of age with MCV

• Minimum 1-month interval required between doses

Contraindications • Known allergy to vaccine components (including neomycin and

gelatin)
• Pregnancy
• Severe congenital or acquired immune disorders, including
advanced HIV infection/AIDS
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Mumps
Adverse events • Serious: aseptic meningitis (with some strains); orchitis
(inflammation of the testicles); sensorineural deafness; acute
myositis (inflammation of the muscles)
• Mild: injection site reactions; parotid swelling
Special precautions None
Dosage 0.5 ml
Injection site upper arm
Injection type Subcutaneous
Storage Between +2 °C and +8 °C
If using combination vaccines, keep all measles-containing vaccines
away from sunlight
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Pertussis
Type of vaccine Killed whole cell or acellular (without intact cells)

Total number of doses 3

Schedule Pentavalent or DTP or pertussis vaccine 3-dose primary series starting

at age 6 weeks (minimum) with second and third doses at intervals of
4 weeks after the previous dose
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Pertussis
Adverse events • Severe: rare anaphylaxis, hypotonic–hyporesponsive episodes (loss of
muscle tone and responsiveness/consciousness); febrile seizures; prolonged
crying
• Mild: injection site reactions (pain, redness, swelling); fever and agitation
Special precautions None

Dosage 0.5 ml
Injection site Right Anterolateral (outer) mid-thigh in infants

Injection type Intramuscular

Storage Between +2 °C and +8 °C

Do not freeze
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Pneumococcal disease
Type of vaccine Conjugate (pneumococcal polysaccharide bound to a carrier protein;
does not contain any live bacteria)

Total number of doses 3

Schedule First dose as early as 6 weeks of age with 4 weeks interval between
doses
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose

Adverse events Severe: none known

Mild: injection site reactions and fever

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Pneumococcal disease
Special precautions Postpone vaccination if the child has moderate to severe illness (with
temperature ≥39 °C)
Dosage 0.5 ml
Injection site Left Anterolateral (outer) thigh in infants and children
Injection type Intramuscular
Storage Between +2 °C and +8 °C
Do not freeze

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Poliomyelitis
Type of vaccine OPV – Live attenuated (weakened) viral; IPV – Inactivated viral

Total number of doses 3–4

Schedule – • 3 OPV doses initiated from 6 weeks of age with minimum interval of 4
OPV plus IPV weeks; an IPV dose should be given from 14 weeks of age (with OPV
dose).
• Note: In areas where polio is endemic or there is high-risk for
importation, an OPV birth dose (a zero dose) should be given
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose

Adverse events OPV – Rare vaccine-associated paralytic polio (VAPP)

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
IPV – No known serious reactions; mild injection site reactions do occur
 Poliomyelitis
Special precautions Postpone vaccination if the child has moderate to severe illness (with
temperature ≥39 °C)

Dosage OPV – 2 drops into the mouth

IPV – 0.5 ml injection
Route of administration • OPV – Oral only
• IPV – Intramuscular injection; Left anterolateral (outer) mid-thigh
in infants and children 2 cm below PCV

Storage • OPV – Keep frozen; very heat sensitive;

storage in temperatures of between +2 °C and +8 °C is possible for a
maximum of 6 months
• IPV – between +2 °C and +8 °C; do not freeze
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Rotavirus gastroenteritis
Type of vaccine Live attenuated (weakened) viral
Total number of doses 2 for RV1 (monovalent RV, Rotarix®)

Schedule – • First dose with pentavalent1; second dose with pentavalent2, with
Rotarix® a minimum interval of 4 weeks.
• Not recommended after 24 months of age
Contraindications • Severe allergic reaction to previous dose
• Severe immunodeficiency (but not HIV infection)
Adverse events • Severe: intussusception
• Mild: irritability, runny nose, ear infection, diarrhea, vomiting

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Rotavirus gastroenteritis
Special precautions Should be postponed for acute gastroenteritis and/or fever with
moderate to severe illness
Not routinely recommended for history of intussusception or intestinal
malformations that possibly predispose to intussusception
Dosage Rotarix®: 1.5 ml of liquid
Route of administration Oral only
Storage • Between +2 °C and +8 °C
• Do not freeze

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Rubella and congenital rubella
syndrome
Type of vaccine Live attenuated (weakened) viral

Total number of doses 1 (but when given in combination with measles/mumps, 2 doses are
required for programmatic reasons)

Schedule • Rubella1: 9 or 12 months of age with MCV

• Refer to national schedules for older children, adolescents and
adults
Contraindications • Known allergy to vaccine components (including neomycin and
gelatin)
• Pregnancy
• Severe congenital or acquired immune disorders, including
advanced HIV infection/AIDS
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Rubella and congenital rubella
syndrome
Adverse events • In some adult women: serious arthritis (joint inflammation) and
mild arthralgia (joint pain)
• Mild: injection site reactions
Special precautions None

Dosage 0.5 ml

Injection Site Anterolateral (outer) thigh or upper arm depending on the child’s age

Injection Type Subcutaneous

Storage • Between +2 °C and +8 °C

• If using combination vaccines, keep all measles-containing
vaccines away from sunlight
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Tetanus
Type of vaccine Toxoid
Total number of doses 5

Schedule – • With pentavalent: starting at age 6 weeks (minimum) with second

and third doses at 4 intervals after the previous dose
• For women, see next table

Booster • 4–7 years; and adolescence 12–15 years

• For women, see next table
Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Tetanus
Adverse events • Severe: rare anaphylaxis, brachial neuritis
• Mild: injection site reactions and fever
Special precautions None
Dosage 0.5 ml
Injection Site Anterolateral (outer) thigh in infants and children; upper arm (deltoid)
in adults
Injection Type Intramuscular
Storage • Between +2 °C and +8 °C
• Do not freeze

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Tetanus
Dose of TT or Td
Schedule Expected durationof protection*

At first contact or as early as possible in

1 None
pregnancy
2 At least 4 weeks after TT1 1–3 years

At least 6 months after TT2 or during

3 At least 5 years
subsequent pregnancy
At least 1 year after TT3 or during
4 At least 10 years
subsequent pregnancy
For all reproductive years and possibly
At least 1 year after TT4 or during
5 longer
*Recent studies suggest that the duration of protection may be longer than indicated in the table. This matter is currently under review.

subsequent pregnancy
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Tuberculosis
Type of vaccine Live bacterial
Total number of doses 1

Schedule At or as soon as possible after birth

Booster None

Contraindications Known HIV infection or other immune deficiency

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Tuberculosis
Adverse events • Severe: generalized disease or infections such as osteomyelitis
(bone infection); abscess; regional lymphadenitis (lymph node
inflammation)
• Mild: injection site reactions
Special precautions Correct intradermal administration is essential – a specific syringe and
needle are used for BCG
Dosage 0.05 ml
Injection Site Outer upper left arm or shoulder
Injection Type Intradermal
Storage • Between +2 °C and +8 °C
• Do not freeze
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Opportunities for integration of services: EPI
Plus and vitamin A deficiency

Linking vitamin A and routine immunization ◼

Target for vitamin A Immunization contact Vitamin A dose

• Measles 100 000 IU
Infants 6–11 months
• Polio NIDs
Children 12 months and older Other EPI campaigns
200 000 IU
Boosters
Children 12–59 months • Booster doses 200 000 IU
• Delayed primary immunization

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Communicating with caregivers

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 AEFIs Five Categories
1 2 4 5
3
Vaccine Vaccine Immunization
Immunization
product- quality defect- anxiety-
error-related Coincidental
related related related
reaction event
reaction reaction reaction

An AEFI that is
caused or An AEFI that
precipitated by An AEFI is caused by
An AEFI that is
a vaccine that is An AEFI that is something
caused or
due to one or caused by arising from
precipitated by anxiety about other than the
more quality Inappropriate
a vaccine due to
defects of the vaccine the vaccine
one or more of
vaccine product handling, immunization product,
the inherent immunization
properties of the
including its prescribing or .
administration administration. error or
vaccine product. immunization
device as
provided by the anxiety
manufacturer.

RO - Regional Epidemiology and Surveillance Unit 3

 Examples of AEFIs Five Categories
1 2 3 4 5
Vaccine Vaccine quality Immunization Immunization
product- defect-related error-related anxiety-related Coincidental
related reaction reaction reaction event
reaction

EXAMPLE
Failure by the EXAMPLE
EXAMPLE manufacturer EXAMPLE A fever after
Extensive EXAMPLE
to completely Transmission vaccination
limb Vasovagal (temporal
inactivate a of infection
swelling syncope in an association)
lot of by
following adolescent and malarial
inactivated contaminated
following parasite
DTP polio vaccine multidose
vaccination.
vaccination. leads to cases vial. isolated from
of paralytic blood.
polio.

RO - Regional Epidemiology and Surveillance Unit 3

 MINOR REACTIONS SEVERE REACTIONS

Local reactions Systemic reactions

Vaccine Irritability, malaise and
(pain, swelling, redness) Fever > 38°C
systemic symptoms
BCG1 90% – 95% – –

Adults up to 15%, Children up to

Hepatitis B 1 – 6% –
5%

Hib 5 – 15% 2% – 10%

Measles/MR/MMR ~ 10% 5% – 15% 5% (Rash)

OPV None Less than 1% Less than 1%2

Pertussis (DTwP) 3 up to 50% up to 50% up to 55%

Pnemucoccal
~ 20% ~ 20% ~ 20%
conjugate5

Tetanus/DT/aTd ~ 10%4 ~ 10% ~ 25

Treatment • Cold cloth at injection site • Give extra oral fluids • Give extra oral fluids
• Paracetamol6 • Wear cool clothing • Paracetamol6
• Tepid sponge or bath
• Paracetamol6

RO - Regional Epidemiology and Surveillance Unit 3

 Vaccine Reactions

Severe vaccine reactions, treatments and rates associated with childhood

*
vaccines Frequency per
Vaccine Reaction Onset interval
doses given
BCG Fatal dissemination of BCG infection 1 – 12 months 0.19 – 1.56/1.000.000
Vaccine associated paralytic
OPV 4 – 30 days 2 – 4/1.000.000
poliomyelitis (VAPP)**
Prolonged crying and seizures*** 0 – 24 hours < 1/100
DTwP
HHE 0 – 24 hours < 1/1.000 – 2/1.000

Febrile seizures 6 – 12 days 1/3.000

Measles Thrombocytopenia 15 – 35 days 1/30.000

Anaphylaxis 1 hour 1/100.000

* Reactions (except anaphylaxis) do not occur if already immune (90% of those receiving a second dose); children >6 years unlikely to have febrile seizures.
** VAPP risk higher for first dose (1 in 750 000 compared with 1 in 5.1 million for subsequent doses), and for adults and immunocompromised clients.
*** Seizures are mostly febrile. The risk of having a seizure depends on the persons age. The risk is much lower in infants <4 months of age.

RO - Regional Epidemiology and Surveillance Unit 3

 EPI Accomplishment as of
August 2017
BCG Penta OPV3 Hepa FIC CIC PCV 3 IPV TT 2+ CPAB
PROVINCE
/ City / Mun 0-11 Total Total Total 0-11 12-23 0-11 Total NO. NO.

21,096 27,538 28,527 14,066 23,772 12,155 17,054 21,467 18,994 11,424
BULACAN
2,365 2,520 2,433 1,805 1,996 384 1,521 2,318 1,955 1,540
Malolos City
Meycauayan 3,127 2,805 2,862 2,575 3,052 2,303 1,516 2,012 2,758 1,985
City
San Jose del 5,862 9,166 9,043 900 9,217 6,523 4,485 7,604 9,115 1,683
Monte
Province of 32,450 42,029 42,865 19,346 38,037 21,365 24,576 33,401 32,822 16,632
Bulacan

FIC Fully Immunized Child = 42 %

 The vaccine
cold chain

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 The Cold Chain
The system used for storing vaccines in good condition. ❑

It is sometimes referred to as the vaccine supply chain, or the ❑

immunization supply chain.

The cold chain consists of a series of links that are designed to ❑

keep vaccines within WHO recommended temperature ranges,

from the point of manufacture to the point of administration.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Temperature Requirements for
Vaccines
Vaccine potency, meaning its ability to adequately protect the ❑

vaccinated patient, can diminish when the vaccine is exposed to

inappropriate temperatures.

Once lost, vaccine potency cannot be regained. To maintain ❑

quality, vaccines must be protected from temperature extremes.

Vaccine quality is maintained using a cold chain that meets
specific temperature requirements.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Sensitivity to Heat and Freezing

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Sensitivity to Heat and Freezing

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Sensitivity to Light
Vaccines that are as sensitive to light as they are to heat include BCG, ❑

measles, measles-rubella, measles-mumps-rubella and rubella.

These vaccines are often supplied in dark glass vials that give them ❑

some protection from light damage; but they should be kept in their
secondary packaging for as long as possible to protect them during
storage and transportation.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Cold boxes

A cold box is an insulated container that ❑

can be lined with water packs to keep

vaccines and diluents in the required
temperature range during transport or
short-term storage

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Vaccine carriers

Vaccine carriers are smaller than cold ❑

boxes and easier to carry

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Water packs

Water packs are flat, leak-proof plastic ❑

containers that can be filled with tap

water. They are used to line the inside of
the cold box or vaccine carrier

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Water packs can be used
in any of the following ways:

frozen ice packs, taken directly from a freezer at temperatures between −10 °C and ❑

−25 °C
conditioned ice packs containing a mixture of water and ice at an initial temperature ❑

of about 0 °C
cool water packs, containing liquid water at an initial temperature of +5 °C or less ❑

warm water packs, containing liquid water, initially at room temperature, between ❑

+18 °C and +24 °C.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Foam pads

A foam pad is a piece of soft spongelike ❑

material that fits precisely on top of the

water packs inside a vaccine carrier
while still permitting the lid of the
vaccine carrier to fully close.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Temperature monitoring devices
Vaccine vial monitors (VVMs) are the only temperature monitoring ❑

devices that routinely accompany vaccines throughout the entire supply

chain. A VVM is a chemical indicator label attached to the vaccine
container (vial, ampoule or dropper) by the vaccine manufacturer. As the
container moves through the supply chain, the VVM records its
cumulative heat exposure through a gradual change in colour.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 2.3 Temperature monitoring devices

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Electronic freeze indicators

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Integrated digital thermometers

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Stem thermometers

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Monitoring cold chain temperatures

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Arranging vaccines inside cold chain equipment

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Arranging vaccines inside cold chain equipment

Never store food or drink in a vaccine refrigerator. ❑

Do not open the door or lid unless it is essential to do so. Frequent opening ❑

raises the temperature inside the refrigerator.

If there is a freezer compartment, do not use it to store vaccines and diluents. ❑

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Arranging vaccines inside cold chain equipment

Do not keep expired vaccines in the refrigerator. Do not keep vaccines with ❑

VVMs that have reached, or are beyond, their discard point. Do not keep
reconstituted vaccines for more than six hours, or after the end of an
immunization session. Discard all these items immediately according to your
national guidelines. Refer any questions to your supervisor.

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Packing vaccines in cold boxes and
vaccine carriers

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 AEFIs Five Categories
1 2 4 5
3
Vaccine Vaccine Immunization
Immunization
product- quality defect- anxiety-
error-related Coincidental
related related related
reaction event
reaction reaction reaction

An AEFI that is
caused or An AEFI that
precipitated by An AEFI is caused by
An AEFI that is
a vaccine that is An AEFI that is something
caused or
due to one or caused by arising from
precipitated by anxiety about other than the
more quality Inappropriate
a vaccine due to
defects of the vaccine the vaccine
one or more of
vaccine product handling, immunization product,
the inherent immunization
properties of the
including its prescribing or .
administration administration. error or
vaccine product. immunization
device as
provided by the anxiety
manufacturer.

RO - Regional Epidemiology and Surveillance Unit 3

 Examples of AEFIs Five Categories
1 2 3 4 5
Vaccine Vaccine quality Immunization Immunization
product- defect-related error-related anxiety-related Coincidental
related reaction reaction reaction event
reaction

EXAMPLE
Failure by the EXAMPLE
EXAMPLE manufacturer EXAMPLE A fever after
Extensive EXAMPLE
to completely Transmission vaccination
limb Vasovagal (temporal
inactivate a of infection
swelling syncope in an association)
lot of by
following adolescent and malarial
inactivated contaminated
following parasite
DTP polio vaccine multidose
vaccination.
vaccination. leads to cases vial. isolated from
of paralytic blood.
polio.

RO - Regional Epidemiology and Surveillance Unit 3

 Tools for monitoring

Immunization in Practice: A practical guide for health staff- 2015 update (WHO)
 Tools for monitoring
The defaulter tracking list ◼
 Diseases Type of vaccine Dose Rout of administration

1-BCG TB Live attenuated, 0.05ml ID injection in left

variant forearm

2-HBV Hepatitis B Recombinant, yeast IM thigh

derived HBs antigen 0.5 ml
 Rout of Dose Type of vaccine Diseases
administration

oral 2 drops Live attenuated Polio 3-OPV

 Pentavalent Vaccine

Rout of Dose Type of vaccine Diseases

administration

IM thigh 0.5 ml polysaccharide Hib disease HiB

conjugate

Recombinant, yeast Hepatitis B HBV

derived HBs antigen

Toxoid (D) Diphtheria DPT

Toxoid (T) Tetanus
Killed pertussis (P) Whooping
cough
 Mode of Type of the The
administration Dose vaccine disease

Subcutaneous 0.5 ml Live attenuated Measles

BCG (At birth)
Live attenuated variant.

0.05ml .

ID injection in left forearm

 Monthly EPI Vaccine
Requirement Calculation
Why inventory control
 To avoid various issues such as
Expiry ◼

Plan ahead if vaccine is going to expire ◼

Don’t store more than what you need ◼

Storage space ◼
Temperature maintenance ◼
During typhoon/other calamities ◼

Missing inventory ◼
Theft ◼
 Vaccine Stock Level
Minimum Maximum
Facility
(months) (months)

Region (CHD) 3 6

Province/City 1 4
Municipality
1 2
(RHU)
BHS
1 2
(with refrigerator)
 Monthly BCG
Vial needs

Eligible Pop:
= ________ x ___
= Total Pop x 2.7%

Monthly needs:
= ___ x ___ x ___ / ___ /___

Dose
EP = # of x Wast x per / # of /
doses age fx mos
vial
Essential Information in Calculating Vaccine Needs
Antigen Number of Wastage Wastage Number
doses to Allowance Factor of doses
complete per
immunization vial/amp
BCG 1 60% 2.5 20

Rota 2 10% 1.1 1

OPV 3 40% 1.67 20

MEASLES 1 50% 2.0 10

HEP B 1 10% 1.1 10

TT 2 40% 1.67 20
 Essential Information in Calculating Vaccine Needs
Antigen Number of Wastage Wastage Number
doses to Allowance Factor of doses
complete per
immunization vial/amp
MMR 1 10% 1.1 5

PENTAVALENT 3 10% 1.1 1

PCV 3 10% 1.1 1

IPV 1 1.25 10
Vaccine Stocks:

No. of actual vaccines

No. of Monthly needs
Optimum (O): 1-2mos
Overstock(OS): >2mos
Understock(US):<1mo
Stockout (SO): Zero
 EXPANDED PROGRAM ON IM M UNIZAT ION

VACCINE CONTROL CARD

Name of Facility: Antigen:

To whom issued No. of No. of

Lot/Batch Expiry VVM
Date or from whom items items Balance Remarks
Number Date Status
received received issued

Name: Des ignation:

 EPI Vaccine and other Logistics Inventory Form
CHD's - Quarterly
Provinces/Cities - Quarterly Municipal/RHU level - Monthly
Expanded Program on Immunization
Deparment of Health

INVENTORY OF VACCINES AND OTHER LOGISTICS

For the month or quarter of ____________________ Year ____________

Beginning Received Lot or Expiry VVM Status Total Stock on

Balance during the Batch Dates (1,2,3,4) available Issuances Hand as of
ITEM
period Number __________
(Vials/pcs.) (Vials/pcs.) (Vials/pcs.) (Vials/pcs.) (Vials/pcs.) (Vials/pcs.)
(a) (b) © (d) (e) (f) (g) (h)
BCG, 20-dose
DPT, 20-dose
DPT, 10-dose
OPV, 20 -dose
Measles, 10-dose
Hepatitis B, 10-dose
Tetanus Toxoid, 20-dose
Tetanus Toxoid, 10-dose
BCG diluent, 5ml
Measles diluent, 5ml
Auto-Disable Syringe with needle
(0.5ml, G23 x 25 mm)
Tuberculin Syringe with needle
(0.05ml, G27 x 10 mm)
Mixing Syringe, 5ml G18 x 50mm
Safety Collector Box, 5 liter or 10 liter
mar807
Prepared by: ________________________________ Approved: ____________________________________
Designation: _________________________________ Designation: __________________________________
No Inventory Card
No Vaccine!
 Concerns over vaccine wastage
SHOULD NOT
prevent health staff from vaccinating
a child.
References:
Family Health Cluster Division ◼
(Expanded Program on Immunization)
Immunization in Practice: A practical guide for ◼
health staff- 2015 update (WHO)
RO - Regional Epidemiology and Surveillance Unit 3 ◼