IMMUNIZATION (WHO MEANING)

 Immunization is the process whereby person is made immune or resistant to an infectious disease,
typically by the administration of a vaccine.
 Immunization is a proven tool for controlling & eliminating life-threatening infectious diseases.
 Immunization is likewise known as vaccination or inoculation
IMMUNITY

 Condition of being secure against any particular disease.

 Ability of human body to tolerate the presence of material indigenous to body & to eliminate
foreign material.
TWO BASIC MECHANISMS FOR ACQUIRING IMMUNITY:
1. Active immunity
 protection produced by person’s own immune system.
 immunity lasts for many years, often lifetime
 Vaccine produces “Active Acquired Immunity” to specific infectious disease
2. Passive immunity
 protection by products produced by animal or human
 transferred to another human, usually by injection.
VACCINE

 vaccine helps body’s immune system to recognize & fight pathogens like viruses or bacteria
 keeps us safe from diseases they cause
TYPES OF VACCINES
1. Live-attenuated vaccines (LAV)
2. Inactivated vaccines (killed antigen)
3. Subunit (purified antigen)
a. Protein-based
b. Polysaccharide
c. Conjugate
4. Toxoid (inactivated toxins)

LIVE-ATTENUATED
 Live vaccines use a weakened (or attenuated) form of the germ that causes a disease.
 So similar to the natural infection, it creates a strong & long-lasting immune response.
 Just 1 or 2 doses of most live vaccines can give you a lifetime of protection
 Limitations: (live vaccines have limitations)
people with weakened immune systems, long- term health problems, or people who had an
organ transplant.
 need to be kept cool
 Examples
BACTERIA:
1. Tuberculosis
BCG (Bacille Calmette-Guerin)
 VIRUS
2. Oral polio vaccine,trivalent (OPV)
3. AMV – 1 (Anti-Measles Vaccine)
4. AMV – 2 (Measles-Munps-Rubella Vaccine)
5. rotavirus
6. yellow fever
INACTIVATED VACCINE

 use the killed version of germ that causes disease

 usually do not provide immunity (protection) as strong as live vaccines; need several doses
(booster shots) in order to get ongoing immunity against diseases.
 Examples
BACTERIA:
1. Whole-cell pertussis (wP)
VIRUS:
2. Inactivated polio virus (IPV)

SUB-UNIT: PROTEIN-BASED, POLYSACCHARIDE, CONJUGATE

 Subunit, recombinant, polysaccharide, and conjugate vaccines USE SPECIFIC PIECES of germ
— like its protein, sugar, or capsid (a casing).
 Use only specific pieces of the germ;
 Give a very strong immune response targeted to key parts of germ.
 Can be used by everyone who needs them, including people with weakened immune systems and
long-term health problems.
 Limitation of these vaccines is that you may need booster shots to get ongoing protection against
diseases
 Examples
BACTERIA
1. Acellular pertussis (aP)
VIRUS
2. Hepatitis B (HepB) Pneumococcal, Meningococcal,
3. Salmonella typhi
BACTERIA
4. Haemophilius influenzae type b (Hib)
5. Pneumococcal (PCV-7, PCV-10, PCV-13)

TOXOID VACCINE
 use a toxin (harmful product) made by germ that causes a disease.
 create immunity to parts of the germ that cause a disease instead of the germ itself.
 immune response is targeted to the toxin instead of the whole germ.
 need booster shots to get ongoing protection against diseases.
 Examples
BACTERIA
1. Tetanus toxoid (TT)
2. Diphtheria toxoid
ADJUVANTS are added to enhance the body’s immune response towards the antigen. Examples of
common adjuvants include aluminum hydroxide and aluminum phosphate.
STABILIZERS are primarily used to prevent separation of the vaccine components. The common
stabilizers used are human serum albumin, gelatin, lactose, sucrose and amino acids (most vaccines are
produced through freeze-drying of multi-component mixtures)
PRESERVATIVES In order to ensure the absence of microbial growth Examples of preservatives in
vaccine include thiomersal, phenol and phenoxyethanol
Also contain minute quantities of substances remaining from the manufacturing process known as
TRACE COMPONENTS These could be anything ranging from antibiotics, inactivating agents, cell
culture fluid, egg proteins to yeast.
INACTIVATING AGENTS Small amounts of formaldehyde and glutaraldehyde
Antibiotics are added into vaccines during manufacturing to prevent microbial contamination but are
mostly removed in subsequent purification.
EXPANDED PROGRAM ON IMMUNIZATION
RATIONALE

 Established in 1976
 Legal Basis Presidential Decree 996 (PD 996)
 to ensure that infants/children and mothers have access to routinely recommended
infant/childhood vaccines.
 Six vaccine preventable diseases were initially included in the EPI: TB, poliomyelitis, diphtheria,
tetanus, pertussis & measles
SUPPORTING LEGISLATIONS

 REPUBLIC ACT OF 7846 (RA 7846)

a. Provided for compulsory immunization against Hepatitis B for infants & children below
8 years old.
b. Provided for hepatitis B immunization within 24 hours after birth of babies of women
with hepatitis B.
 REPUBLIC ACT OF 10152 OR RA 10152
(Mandatory Infants and Children Health Immunization Act of 2011)
a. mandates basic immunization covering the vaccine- preventable diseases
GOALS OF THE PROGRAM
1. To immunize all infants/children against the most common vaccine-preventable diseases.
2. To sustain the polio-free status of the Philippines.
3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus.
5. To control diphtheria, pertussis, hepatitis B, & German measles.
6. To prevent extrapulmonary TB among children

EPI | DISEASES
1. Tuberculosis (TB)
2. Diphtheria
3. Poliomyelitis (polio)
4. Measles
5. Pertussis
6. Tetanus
7. Hepatitis B
8. Yellow fever
a. Pneumonia
b. Influenza

EPI – PREVENTABLE DISEASES

1. TUBERCULOSIS
CASE DEFINITION
 Child
with history of contact with a suspect or confirmed case of pulmonary tuberculosis
 who does not return to normal health AFTER measles or whooping cough
 Loss of weight, cough & wheeze which does not respond to antibiotic therapy for
acute respiratory disease.
 Abdominal swelling with a hard painless mass and free fluid
 Painful firm or soft swelling in a group of superficial lymph nodes
 Any bone or joint lesion or slow onset
 Signs suggesting meningitis or disease in the central nervous system
Agent
 Mycobacterium tuberculosis
Reservoir
 Man
 Diseased cattle
Sources of Infection
 Droplet infection, that is through inhalation of bacilli from patients
Occurrence
 Worldwide
 Mortality and morbidity higher in developing countries
Transmissible Period
 person who excretes tubercle bacilli is communicable
DEGREE OF COMMUNICABILITY DEPENDS:
 The number of bacilli in the air
 Virulence of bacilli
 Environmental conditions like overcrowding
Duration of Natural Immunity
 Not known
 Reactivation of old infection commonly causes disease
RISK FACTOR FOR INFECTION
 Low access to care
 Immunodeficiency
 Malnutrition
 Alcoholism
 Diabetes

2. DIPHTHERIA
Case Definition
 an acute pharyngitis, acute nasopharyngitis or acute laryngitis with a PSEUDO
MEMBRANE
Agent
 Corynebacterium diphtheriae
Reservoir
 Man
Sources of Infection
 By respiratory droplets from discharge of a case or carrier
 Occurrence
 Worldwide
 Endemic in developing countries with unimmunized populations
Transmissible Period
 May last for 2-3 weeks
 Maybe shortened in patients with antibiotics treatment
 Diphtheria transmission is increased in schools, hospitals, households and in crowded
areas
Duration of Natural Immunity
 lifelong
Risk Factor for Infection
 Crowding
 Low socio-economic status

3. POLIOMYELITIS (POLIO)
Case Definition
 SUSPECT CASES of polio is defined as ANY PATIENT BELOW 15 YEARS OF AGE
with acute flaccid paralysis (including those diagnosed to have Guillain-Barre Syndrome)
for which no other cause can be immediately identified.
Agent
 Poliovirus type 1,2 & 3
Reservoir
 Man. Mostly children
Sources of Infection
 Fecal-oral route
 Oral route through pharyngeal secretion
 contact with infected persons
Occurrence
 Cyclical
 Worldwide
 Morbidity and mortality higher in developing countries
Transmissible Period
 7 to 16 days before onset of symptoms
 first few days after onset of symptoms
Risk Factor for Infection
 Poor environmental hygiene
Duration of Natural Immunity
 Type specific immunity lifelong

4. MEASLES
Case Definition
 highly communicable disease with history of following:
a. Cough
b. Runny nose
 c. Red eyes/conjunctivitis
d. Fever (above 38⁰C or “hot” to touch and
e. Generalized blotchy rash, lasting for three of more days
Agent
 Rubeola virus
Sources of Infection
 Close respiratory contact and aerosolized droplets
Reservoir
 Humans
Occurrence
 Worldwide
 Mortality and morbidity higher in developing countries
Transmissible Period
 4 days before until 2 days after rash
Risk Factor of Infection
 Crowding
 Low socio-economic status
Duration of Natural Immunity
 Lifelong after attack

5. PERTUSSIS
Case Definition
 History of severe cough & history of any of the following:
a. Cough persisting 2 or more weeks
b. Fits of coughing &
c. Cough followed by vomiting
Agent
 Bordetella pertussis
Reservoir
 Man
Sources of Infection
 primarily by direct contact with discharges from respiratory mucous membranes of
infected persons
 Airborne route probably by droplets
 Indirect contact with articles freshly soiled with the discharges of infected persons
Occurrence
 Worldwide
 Morbidity higher in developing countries
Transmissible Period
 Highly communicable in early catarrhal stage, before paroxysmal cough
 Antibiotics may shorten the period of communicability from 7 days after exposure to 3
weeks after onset of typical paroxysms to only 5 to 7 days after onset of therapy
 Highly communicable in early catarrhal stage, before paroxysmal cough
 Antibiotics
 a. may SHORTEN THE PERIOD OF COMMUNICABILITY from 7 days after
exposure to 3 weeks after
 onset of typical paroxysms to only 5 to 7 days after onset ng therapy
Duration of Natural Immunity
 Usually lifelong
Risk Factors for Infection
 Young age crowding

6. NEONATAL TETANUS
Case Description
 A newborn with history with all three of the following:
1. Normal suck for the first two days of life
2. Onset of illness between 3 to 26 days
3. Inability to suck followed by stiffness of the body and/or convulsions
Agent
 lostridium Tetani
Reservoir
 soil
 intestinal canals of animals (esp horses)
 man
Sources of Infection
 Unhygienic cutting of umbilical cord, improper handling of cord stump esp when treated
with contaminated substance
Occurrence
 Worldwide
 Morbidity higher in developing countries more common in agricultural and
underdeveloped areas where contact with animal excreta is more likely
Transmissible Period
 Susceptibility is general
 immunity can be obtained after 2 primary doses of tetanus toxoid at 4 weeks interval in
mothers one month before delivery
 three booster doses increase antibody levels in mother
Duration of Natural Immunity
 No immunity induced by infection
Risk Factor for Infection
 Contamination of umbilical cord
 Agricultural work

7. HEPATITIS B
Case Definition
 It is the liver infection caused by type B of hepatitis virus. It attacks the liver often
resulting in inflammation.
Sources of Infection
 From child to child or mother to child after birth
 From mother to child during birth
  through sharing unsterilized needles, knives or razors
 through sexual intercourse
Agent
 Hepatitis B virus
Reservoir
 Man
Occurrence
 In the Philippines, approximately 12% of the population are chronic carriers
 Most Filipinos are infected before the age of 6 years
 Some infected infants are not able to develop immunity and become chronic carriers

 Hepatitis B is especially dangerous for children

Duration of Natural Immunity
 If develops, lifelong
Transmissible Period
 Infants born to immune mothers may be protected up to 5 months
 Recovery from clinical attack is not always followed by lasting immunity
 Immunity is often acquired through inapparent infection or complete immunization
series with diphtheria toxoid
Risk Factors for Infection
 HBeAG + mother
 Multiple sexual partners

8. YELLOW FEVER
 Yellow fever is an acute viral hemorrhagic disease transmitted by infected
mosquitoes.
 The "yellow" in the name refers to the jaundice that affects some patients.
 Symptoms of yellow fever include fever, headache, jaundice, muscle pain, nausea,
vomiting and fatigue
 A small proportion of patients who contract the virus develop severe symptoms and
approximately half of those die within 7 to 10 days.
 The virus is endemic in tropical areas of Africa and Central and South America.
 Large epidemics of yellow fever occur when infected people introduce the virus into
heavily populated areas with high mosquito density and where most people have
little or no immunity, due to lack of vaccination. In these conditions, infected
mosquitoes of the Aedes aegypti specie transmit the virus from person to person.
 Yellow fever is prevented by an extremely effective vaccine, which is safe and
affordable.
 A single dose of yellow fever vaccine is sufficient to confer sustained immunity and
life-long protection against yellow fever disease.
 A booster dose of the vaccine is not needed.
 The vaccine provides effective immunity within 10 days for 80- 100% of people
vaccinated, and within 30 days for more than 99% of people vaccinated.
EPI |Schedule and manner of administering infant immunizations
 Use only sterile syringe and needle per client
 There is no need to restart a vaccination series regardless of the time that has elapsed
between doses.
 All the EPI antigens are safe and effective when administered simultaneously
 same immunization session but at different sites
 NOT recommended:
a. to mix different vaccines in one syringe
b. to use a fluid vaccine for reconstitution of a freeze-dried vaccine.
 If more than one injection has to be given on the same limb: injection sites should be 2.5-
5cm apart
 Recommended sequence of coadministration:
OPV first followed by Rotavirus vaccine, then other appropriate vaccines.
 OPV administration:
a. drops of vaccine straight from the dropper onto the child’s tongue
b. DO NOT let the dropper touch the tongue.
 Only monovalent hepatitis B vaccine must be used for the birth dose.
 Pentavalent vaccine must not be used for the birth dose because DPT and Hib vaccine
should not be given at birth
 Shall be given:
AMV1 ASAP
a. Children who have not received AMV1 as scheduled
b. children whose parents/caregivers do not know whether they have received AMV1
AMV2 one month after the AMV1
 All children entering day care centers/ preschool and Grade I Shall be screened for measles
immunization
 First dose of Rotavirus vaccine:
a. administered only to infants aged 6 weeks to 15 weeks.
 The second dose
b. administered only to infants aged 10 weeks up to a maximum of 32 weeks
 Administer the entire dose of the Rotavirus vaccine slowly down one side of the mouth with
the tip of the applicator directed toward the back of the infant’s mouth.
 To prevent spitting or failed swallowing, stimulate the rooting or sucking reflex of the
young infant.
 For infants aged 5 months or older, lightly stroke the throat in a downward motion to
stimulate swallowing.

EPI | TARGET SETTING

Goal of EPI in the Philippines:
 100% immunization of infants/children against the most common vaccine- preventable
diseases
In RHU/health center level the public health nurse is responsible for:
 Preparing vaccine requirements
 Overseeing vaccine allocation
  “Vaccine requirement is calculated based on eligible population.”

 𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑖𝑛𝑓𝑎𝑛𝑡𝑠 = 𝑡𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑥 2.7%

 𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 12 𝑡𝑜 59 𝑚𝑜𝑛𝑡ℎ 𝑜𝑙𝑑 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 = 𝑡𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑥 10.8%

 𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑟𝑒𝑔𝑛𝑎𝑛𝑡 𝑤𝑜𝑚𝑒𝑛 = 𝑡𝑜𝑡𝑎𝑙 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑥 3.5%

EPI | COLD CHAIN

1. Vaccines buildsdes immunity when potent.
 To retain the potency, must be:
 properly stored
 handled
 transported.
2. Maintain the COLD CHAIN
 system for ensuring potency of vaccine from time of manufacture to time it is given to
eligible client.
3. Person responsible: Cold Chain Officer

COLD CHAIN
Equipment and Supplies:
1. Freezer/refrigerator
2. Transport box
3. Vaccine bags/carriers
4. Cold chain monitors*
5. Thermometers *Check temperature 2x in a day
6. Cold packs
 On a stem or bulb thermometer, coloured fluid in the bulb:
moves up the scale
a. warmer down the scale
b. colder.

COLD CHAIN
REQUIREMENTS
OPV = -15C to -25C, stored in freezer.
In vaccine bag= placed in contact with cold packs
All other vaccines including MEASLES, MMR, &ROTAVIRUS VACCINE = +2 ⁰C. to +8⁰C
stored the body/ compartment of refrigerator
All other vaccines including MEASLES vaccines, MMR and ROTAVIRUS vaccine Stocked neatly
on the shelves of refrigerator.
DO NOT stock vaccines at refrigerator door shelves.
Hepatitis B vaccine, Pentavalent vaccine, Rotavirus vaccine & TT damaged by freezing
Wrap containers of these vaccines with paper before putting them in the vaccine bag with cold packs.

Hepatitis B vaccine, Pentavalent vaccine, Rotavirus

vaccine & TT
 Keep diluents cold by storing them in the
refrigerator in the lower or door shelves.
Load front-loading refrigerator with freezer on top as follows:
1. Measles, MR, MMR, BCG and OPV on the top shelf
2. DTP, DT, Td, TT, HepB, DTP-HepB, Hib, DTP-HepB+Hib, meningococcal, yellow fever, and
JE vaccines on the middle shelves
3. Diluents next to the vaccine with which they were supplied
Loading ice-lined refrigerators (ILR)
All the vaccines should be stored in the basket provided with the refrigerator
1. Measles, MR, MMR, BCG and OPV in the bottom only
2. Freeze-sensitive vaccines (DTP, TT, hepB, DTP-hepB, Hib, DTP- hepB+Hib, meningococcal,
yellow fever, and JE vaccines) in the top only

OTHER CONSIDERATIONS TO MAINTAIN POTENCY

1. Observe the first expiry- first out (FEFO) policy.
2. Duration of storage & transport: health center/RHU with a refrigerator – storage should not
exceed one month
3. Duration of storage & transport: Transport boxes, vaccines can be kept only up to maximum
of 5 days.
Vaccine Carriers
 Smaller than cold boxes;
 Easier to carry if walking
 They do not stay cold as long as a cold box – maximum for 48 hours with the lid
closed.
4. VACCINE VIAL MONITOR (VVM) VVM is a round disc of heat-sensitive material placed
on a vaccine vial to register cumulative heat exposure.
 VVM
Direct relationship exists between rate of color change and temperature:
the lower the temperature, the slower the color change;
the higher the temperature, the faster the color change.

5. Reconstitute freeze-dried vaccines

 Discard reconstituted freeze-dried vaccines 6 hours after reconstitution OR at the end of
immunization session, whichever comes sooner.

6. OPEN-VIAL POLICY (DOH)/ MULTI – DOSE VIAL

Any vial of the applicable vaccines opened/used in a session (fixed or outreach) can be used at
more than one immunization session up to four weeks (28 days) provided ….
7. MULTI DOSE LIQUID VACCINES:
 OPV, Pentavalent vaccine, Hepatitis B vaccine, and TT from which one or more doses
have been taken following standard sterile procedures
 MULTI DOSE VIAL may be opened for 1 or 2 clients if the health worker feels that
a client cannot come back for the scheduled immunization session, following standard
sterile procedures …
 MULTI DOSE LIQUID VACCINES may be used in the next immunization sessions
for up to maximum of 4 weeks, provided …. that all conditions are met:
 MULTI DOSE LIQUID VACCINES if conditions are met:
a. expiry date has not passed. Vaccine not been contaminated
b. vials have been stored under appropriate cold chain conditions.
c. vaccine vial septum has not been submerged in water.
d. VVM on the vial, if attached, has not reached the discard point
8. Protect BCG from sunlight and Rotavirus vaccine from light
EXPOSURE TO ULTRAVIOLET LIGHT CAUSES LOSS OF POTENCY

 must always be protected against sunlight or fluorescent (neon) light.

 BCG, measles, MR, MMR and rubella vaccines
 These are equally sensitive to light (as well as to heat)
 Normally, these vaccines are supplied in vials made from dark brown glass
Procedure:

 Prepare a frozen control sample.

Take a vial of vaccine same
type /batch of vaccine you want
to test. FREEZE vial until the
contents are solid (at least 10
hours at -10°C). Then let it thaw.
This is the control sample. Mark
the vial clearly
 Choose a test sample Take a vial (s) of vaccine from the batch (es) that you suspect
has been frozen. This is the test sample.
 Shake the control and test samples. Hold the control sample and the test sample
together in one hand and shake vigorously for 10–15 seconds. Allow to rest Leave
both vials to rest by placing the vials on table and not moving them further.
 Compare the vials View both vials against the light to compare the sedimentation
rate. If the test sample shows a much slower sedimentation rate than the control
sample, the test sample has most probably not been frozen and can be used. If the
sedimentation rate is similar, the vial has probably been damaged by freezing and
should not be used
Table of Immunization Schedule

Measles-Containing Vaccine 1 (MCV1)

Recommended age of MCV1 depends on epidemiology and

programmatic considerations
Dose
1: 9 months where attack rates high and risk
of serious disease among infants-
Two (2) doses, at 6 and 9 months, for HIV-infected
infants
Dose 1: 12-15 months where risk of infant infection is
low

Measles-Containing Vaccine 2 (MCV 2)

MCV2 should be given early in the 2ndyear of life from

15-18 months of age.
The exact age of MCV2 contact depends on epidemiology and
programmatic considerations but should be selected to:
Maximize coverage and population immunity–Consider timing of boosters or other vaccines–Linkage with other health
interventions (vitamin A, deworming, etc).
 all children should be screened/checked at school entry. Those who have not already received a 2nd dose of measles or do not
have documentation should be vaccinated, and recorded on child's immunization card and registry.
National Tuberculosis TB Control Program
RA 10767 : Comprehensive TB Elimination Plan Act of 2016
March 24 - World TB Day Commemoration August - Lung Month Celebration
 In 2010, TB was the 6th leading cause of mortality with a rate of 26.3 deaths for every 100,000
population and accounts for 5.1% of total deaths
 More males died (17,103) compared to females (7,611); and among the 25 – 55 year old age
group
 It is also higher among the malnourished and diabetics
 In 2010, DOH issued the 2010 – 2016 Philippine Plan of Action to Control TB (PhilPACT)
as the roadmap for controlling TB.
 The Philippines subscribes to the Millennium Develop Goal (MDG) set by the United Nations
(UN) that must be achieved by 2015.
 According to the WHO, the Philippines is one of the seven countries that have already
achieved the MDGs in 2012.
CASE FINDING is the identification and diagnosis of TB cases among individuals with signs and
symptoms presumptive of tuberculosis
1. CXR chest radiograph - used to complement bacteriologic testing in making a
diagnosis. However, it has low specificity and does not differentiate drug- susceptible from
drug-resistant disease.
2. Tuberculin skin test (TST) - basic screening tool for TB infection among children
using purified protein derivative (PPD) tuberculin solution to trigger a delayed
hypersensitivity reaction among those previously infected.
- Also known as the PPD test or Mantoux test, it is one of the criteria used in
determining disease activity among children.
3. DSSM direct sputum smear microscopy - serves as one of the bases for categorizing TB
cases according to standard case definition. This is also used to: a) monitor progress of
patients with TB while they are on anti– TB treatment; and, b) confirm cure at the end of
treatment
- Direct sputum smear microscopy (DSSM) is fundamental to the detection of infectious
cases and is recommended for case finding among adults and children who can
expectorate
4. Xpert MTB/RIF assay - a rapid test that detects Mycobacterium tuberculosis and
rifampicin resistance

CLOSE CONTACT – A person who shared an enclosed space, such as the household, a social
gathering place, workplace or facility, for extended periods within the day with the index case during the
3 months before commencement of the current treatment episode
HIGH-RISK CLINICAL GROUPS – Individuals with clinical conditions that put them at risk of
contracting TB disease, particularly those with immune-compromised states (e.g., HIV/AIDS, diabetes,
end-stage renal disease, cancer, connective tissue diseases, autoimmune diseases, silicosis, patients
who underwent gastrectomy or solid organ transplantation and patients on prolonged systemic
steroids)
HIGH-RISK POPULATIONS – Persons with known high incidence of TB, particularly those in closed
environments or living in congregate settings that promote easy disease transmission (e.g., inmates,
elderly, Indigenous Peoples, urban/rural poor)

SPUTUM
 produced when a person’s lungs are diseased or damaged
 not saliva but the thick mucus – sometimes called phlegm – which is coughed up from the
lungs.
Pulmonary Tuberculosis (PTB)
 an infectious disease caused by the bacteria called Mycobacterium tuberculae
 Lungs are commonly affected but it could also affect other organs such as the kidney, bones,
liver and others.
 TB is curable and preventable

TB exposure – A condition in which an individual is in close contact with an active adult TB case, but
without any signs and symptoms of TB, with negative TST reaction, and no radiologic and laboratory
findings suggestive of TB
Presumptive TB – Any person whether adult or child with signs and/or symptoms suggestive of TB
whether pulmonary or extra-pulmonary, or those with CXR findings suggestive of active TB.
Children – Any person who is less than 15 years old

TB infection or latent TB infection (LTBI):

 A condition in which an individual has no signs and symptoms presumptive of TB nor
radiologic or laboratory evidence, but has a positive TST reaction
TB disease:
 A presumptive TB who after clinical and diagnostic evaluation is confirmed to have TB.

CLASSIFICATIONS OF TB DISEASE:
1. Classification based on bacteriological status
a. Bacteriologically-confirmed – A TB patient from whom a biological specimen is positive by
smear microscopy, culture or rapid diagnostic tests (such as Xpert MTB/RIF).
 b. Clinically-diagnosed – A PTB patient who does not fulfill the criteria for bacteriological
confirmation but has been diagnosed with active TB by a clinician or other medical
practitioner who has decided to give the patient a full course of TB treatment.
 This definition includes cases diagnosed on the basis of CXR abnormalities or suggestive
histology, and extra-pulmonary cases without laboratory confirmation.
 Two sputum specimens of good quality shall be collected, either as frontloading (i.e., spot-spot
one-hour apart) or spot-early morning specimens, based on the patient’s preference
 The two specimens should be collected at most within 3 days
 Tuberculin skin test (TST) shall not be used as the sole basis for TB diagnosis. It shall be used
as a screening tool for children
 A 10mm induration is considered a positive TST reaction. Only trained health worker shall do
the testing and reading.
2. Classification based on anatomical site:
a. Pulmonary TB (PTB) – Refers to a case of tuberculosis involving the lung parenchyma. A
patient with both pulmonary and extra-pulmonary TB should be classified as a case of
pulmonary TB.
b. Extra-pulmonary TB (EPTB) – Refers to a case of tuberculosis involving organs other than
the lungs (e.g., larynx, pleura, lymph nodes, abdomen, genito- urinary tract, skin, joints and
bones, meninges). Histologically-diagnosed EPTB through biopsy of appropriate sites will be
considered clinically- diagnosed TB. Laryngeal TB, though likely sputum smear-positive, is
considered an extra-pulmonary case in the absence of lung infiltrates on CXR.
3.Classification based on history of previous treatment
1. New case – A patient who has never had treatment for TB or who has taken anti-TB
drugs for less than one (<1) month. Isoniazid preventive therapy or other preventive
regimens are not considered as previous TB treatment.
2. Retreatment case – A patient who has been previously treated with anti-TB drugs for
at least one (1) month in the past.
4.Classification based on drug-susceptibility testing
a. Monoresistant-TB – Resistance to one first-line anti-TB drug only.
b. Polydrug-resistant TB – Resistance to more than one first-line anti-TB drug (other than both
Isoniazid and Rifampicin).
c. Multidrug-resistant TB(MDR-TB) – Resistance to at least both Isoniazid and Rifampicin.
d. Extensively drug-resistant TB(XDR-TB) – Resistance to any fluoroquinolone and to at least
one of three second-line injectable drugs (Capreomycin, Kanamycin and Amikacin), in addition
to multidrug resistance.
e. Rifampicin-resistant TB (RR-TB) – Resistance to Rifampicin detected using phenotypic or
genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance
to Rifampicin, whether monoresistance, multidrug resistance, polydrug resistance or extensive
drug resistance
 Directly Observed Treatment, short- course (DOTS) - a method developed to ensure
treatment compliance by providing constant and motivational supervision to TB patients.

 DOT works by having a responsible person, referred to as treatment partner, watch the TB
patient take anti-TB drugs every day during the whole course of treatment.
 TB/HIV co-infection In patients with HIV-related TB, the priority is to treat TB, especially
bacteriologically-confirmed PTB to stop transmission.
 However, patients with HIV-related TB can have Anti-Retroviral Therapy (ART) and anti-TB
treatment at the same time, if managed carefully. Careful evaluation is necessary in judging
when to start ART. For example, in a patient with a high risk of death during the period of
TB treatment (i.e., disseminated TB and/or CD4count <200/mm3), it may be necessary to
start ART concomitantly with TB treatment.
 On the other hand, for a patient with bacteriologically-confirmed PTB as the first manifestation
of HIV infection and who does not appear to be at risk of dying, it may be safer to defer ART
until the initial phase of TB treatment has been completed.
 This decreases the risk of immune reconstitution syndrome and avoids the risk of drug
interaction between Rifampicin and a Protease Inhibitor (PI).
 Possible options include the following
1. Defer ART until completion of TB treatment.•
2. Defer ART until the completion of the intensive phase of TB treatment and then use
Ethambutol and Isoniazid in the continuation phase.
3. Treat TB with a Rifampicin-containing regimen and use efavirenz + two Nucleoside
Reverse Transcriptase Inhibitors (NsRTIs).
4. Patients with TB/HIV co-infection should also receive
5. Co-Trimoxazole as prophylaxis for other infections.
6. Persons with HIV infection who, after careful evaluation, do not have active tuberculosis
should be treated for presumed latent tuberculosis infection with Isoniazid preventive
therapy
 Drug Interactions During TB Treatment:
1. Drug interactions can occur during TB treatment and potentially change the
pharmacologic effects of another drug that is given concomitantly.
2. Clinically significant drug interactions are seen mostly with Rifamficin, Isoniazid, and
Fluoroquinolones. Elderly individuals with significant co-morbidities, as well as the
immune-compromised patients (e.g., HIV/AIDS patients) are at higher risk of
developing drug interactions during TB treatment.
3. To minimize drug interactions, it is advisable that drugs be administered 12 hours
apart.
 Breastfeeding
1. A breastfeeding woman afflicted with TB should receive a full course of TB
treatment.
2. Timely and properly applied chemotherapy is the best way to prevent transmission of
tubercle bacilli to the baby. In lactating mothers on treatment, most anti- tuberculosis
drugs will be found in the breast milk in concentrations equal to only a small fraction of
the therapeutic dose used in infants.
3. However, effects of such exposure on infants have not been established. It is
recommended that lactating mothers feed their infants before taking medications.
Supplemental Pyridoxine (i.e., Vitamin B6) should be given at 5-10 mg/day to the
infant who is taking INH or whose breastfeeding mother is taking INH.
 Oral Contraceptives:
Rifampicin interacts with oral contraceptive medications with a risk of decreased protective
efficacy against pregnancy. Advise a woman receiving oral contraceptives while on Rifampicin
treatment that she has the following options:
 1. take an oral contraceptive pill containing a higher dose of estrogen (50u), following
consultation with a clinician; or
2. use another form of contraception
 Pregnancy:
1. Ascertain whether or not a woman is pregnant before she starts TB treatment.
2. Most anti-tuberculosis drugs are safe for pregnant women, except Streptomycin, which is
ototoxic to the fetus.
3. Advise a pregnant woman that successful treatment of TB with the recommended
standardized treatment regimen (i.e., 2HRZE/4HR) is important for a successful
outcome of pregnancy.
4. Pregnant women taking Isoniazid should be given Pyridoxine (Vitamin B6) at 25
mg/day.

DOH PROGRAMS
Integrated Management of Childhood Illness

 The WHO/UNICEF guidelines for Integrated Management of Childhood Illness (IMCI) offer
simple and effective methods to prevent and manage the leading causes of serious illness and
mortality in young children. The clinical guidelines promote evidence-based assessment and
treatment, using a syndromic approach that supports the rational, effective and affordable use of
drugs. The guidelines include methods for checking a child’s immunization and nutrition status;
teaching parents how to give treatments at home; assessing a child’s feeding and counselling to
solve feeding problems; and advising parents about when to return to a health facility. The
approach is designed for use in outpatient clinical settings with limited diagnostic tools, limited
medications and limited opportunities to practice complicated clinical procedures.
 In each country, the IMCI clinical guidelines are adapted:
a. To cover the most serious childhood illnesses typically seen at first-level health
facilities
b. To make the guidelines consistent with national treatment guidelines and other
policies
c. To make the guidelines feasible to implement through the health system and by
families caring for their children at home.
 Since the 1970s, the estimated annual number of deaths among children less than 5 years old has
decreased by almost a third. This reduction, however,
has been very uneven. And in some countries rates of
childhood mortality are increasing. In 1998, more than
50 countries still had childhood mortality rates of over
100 per 1000 live births.1 Altogether more than 10
million children die each year in developing countries
before they reach their fifth birthday. Seven in ten of
these deaths are due to acute respiratory infections
(mostly pneumonia), diarrhoea, measles, malaria, or
malnutrition—and often to a combination of these
conditions (figure
What is IMCI?
  A strategy for reducing mortality and morbidity associated with major causes of childhood illness
 A joint WHO/UNICEF initiative since 1992
 Currently focused on first level health facilities
 Comes as a generic guidelines for management which been adapted to each country.
 Pneumonia, diarrhea, dengue hemorrhagic fever, malaria, measles and malnutrition cause more
than 70% of the deaths in children under 5 years of age. All these are preventable diseases in
which when managed and treated early could have prevented these deaths. There are feasible and
effective ways that health worker in health centers can care for children with these illnesses and
prevent most of these deaths. WHO and UNICEF used updated technical findings to describe
management of these illnesses in a set of integrated guidelines for each illness. They then
developed this protocol to teach the integrated case management process to health worker who
see sick children and know which problems are most important to treat. Therefore, effective case
management needs to consider all of a child’s symptoms.
OBJECTIVES OF IMCI

 To reduce significantly global morbidity and mortality associated with the major causes of
illnesses in children
 To contribute to healthy growth and development of children.
The CASE MANAGEMENT PROCESS is used to assess and classify two age groups:

 age 1 week up to 2 months

 age 2 months up to 5 years
 And how to use the process shown on the chart will help us to identify signs of serious disease
such pneumonia, diarrhea, malaria, measles, DHF, meningitis, malnutrition and anemia.
 The charts describes the following steps;
1. assess the child or young infant
2. classify the illness
3. identify the treatment
4. treat the child
5. counsel the mother
6. give follow up care
 The classification tables on the assess and classify have 3 ROWS .
- COLOR of the row helps to IDENTIFY RAPIDLY whether the child has a SERIOUS
DISEASE requiring URGENT ATTENTION.
 Each row is colored either –
a. PINK – means the child has a severe classification and needs urgent attention and referral
or admission for inpatient care.
b. YELLOW – means the child needs a spec eds a specific medical treatment such as an
appropriate antibiotic, an oral anti-malarial or other treat other treatment; also teaches the
mother how to give oral drugs l drugs or to treat local infections at home. The health
worker teaches the mother how to care for her child at home and when she should return.
c. GREEN – not given a specific medical treatment such as t such as antibiotics or
treatments. The health worker h worker teaches the mother how her how to care for her
child at home.
- Always start at the top of the classification table. If the child has signs from more than 1
row always select the more serious classification
WHY NOT USE THE PROCESS FOR CHILDREN AGE 5 YEARS OR MORE?

 The case he case management process is designed for children < 5yrs of age, although. Much of
the advise on treatment of pneumonia, diarrhea, malaria, measles and malnutrition, is also
applicable to older children, the ASSESSMENT AND CLASSIF D CLASSIFICATION of older
children would differ. For example, the cut off rate for determining fast breathing would be d
would be different because normal breathing rates are slower in older chi older children. Chest
indrawing is no indrawing is not a reliable sign of severe pneumonia as children get older and the
bones of the chest become more firm.
 In addition, certain treatment recommendations or advice to mothers on hers on feeding would
differ for >5yrs r >5yrs old. The drug dosing he drug dosing tables only apply to chi ply to
children up to 5yrs old. The feeding advice for older children may differ and they may have ay
have different feeding problems.
 Because of differences in the clinical signs of older and younger children who have th ldren who
have these illnesses, the assessment and classification process using these clinical signs is not
recommended for older children.
WHY NOT USE THIS PROCESS FOR YOUNG INFANTS AGE < 1 WEEK OLD?

 The process on young infant chart is designed for infants age 1 week up to 2 months. It greatly
differs from older infants and young children. In the first week of life, newborn infants are often
sick from conditions related to labor and delivery. Their conditions require special treatment.
IDENTIFICATION AND PROVISION OF TREATMENT

 Curative component adapted to address the most common life-threatening conditions in each
country
 Rehydration (diarrhea, DHF)
 Antibiotics (pneumonia, “severe disease”)
 Antimalarial treatment
 Vitamin A (measles, severe malnutrition)
PROMOTIVE AND PREVENTIVE ELEMENTS

 Reducing missed opportunities for immunization (vaccination given if needed)

 Breastfeeding and other nutritional counseling
 Vitamin A and iron supplementation
 Treatment of helminth infections

The Integrated Case Management Process

Overall Case Management Process
  Outpatient
1. Assessment
2. classification and identification of treatment
3. referral, treatment or counseling of the child’s caretaker (depending on the classification
identified)
4. follow-up care
 Referral Health Facility
1. emergency triage assessment and treatment
2. diagnosis, treatment and monitoring of patient’s progress
Summary of the Integrated case Management Process

 For all sick children age 1 week up to 5 years who are brought to a firstlevel health facility
1. Classify the child’s illness:
- Use a color-coded triage system to classify the child’s main symptoms and his or her
nutrition or feeding status.
A. IF URGENT REFERRAL is needed and possible
1. IDENTIFY URGENT PRE-REFERRAL TREATMENT(S)
Needed prior to referral of the child according to classification
2. TREAT THE CHILD: Give urgent prereferral treatment(s) needed.
3. REFER THE CHILD:
a. Explain to the child’s caretaker the need for referral.
b. Calm the caretaker’s fears and help resolve any problems. Write
a referral note.
c. Give instructions and supplies needed to care for the child on the
way to the hospital
B. IF NO URGENT REFERRAL is needed or Possible
1. IDENTIFY TREATMENT needed for the child’s classifications:
identify specific medical treatments and/or advice
2. TREAT THE CHILD:
a. Give the first dose of oral drugs in the clinic and/or advice the
child’s caretaker.
b. Teach the caretaker how to give oral drugs and how to treat local
infections at home.
c. If needed, give immunizations.
3. COUNSEL THE MOTHER:
a. Assess the child’s feeding, including breastfeeding practices, and
solve feeding problems, if present.
b. Advise about feeding and fluids during illness and about when to
return to a health facility.
c. Counsel the mother about her own health.
4. FOLLOW-UP CARE: Give follow-up care when the child returns to
the clinic and, if necessary, reasses the child for new problems.
SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS

 THE SICK CHILD AGE 2 MONTHS TO 5 YEARS:

1. Ask the mother or caretaker about the 4 main symptoms:
a. cough or difficult breathing
b. diarrhea
c. fever, and
d. ear problem
2. When a main symptom is present:
a. Assess the child further for signs related to the main symptom, and
b. Classify the illness according to the signs which are present or absent
 When a child is brought to the clinic
3. Use Good Communication Skills:
a. Listen carefully to what the mother tells you
b. Use words the mother understands
c. Give mother time to answer questions
d. Ask additional questions when mother not sure of answer
- Record important information
 When a child is brought to the clinic check for GENERAL DANGER SIGNS
ASK:
a. Is the child able to drink or breastfeed?
b. Does the child vomit everything?
c. Has the child had convulsions?
LOOK:
a. See if the child is lethargic or unconscious

COUGH OR DIFFICULT BREATHING?

IF YES, ASK:
• For how long?
LOOK, LISTEN, FEEL:
• Count the breaths in one minute.
2-12 mos = fast breathing >/= 50/min
12 mos-5yrs = fast breathing >/= 40/min
• Look for chest indrawing
• Look and listen for stridor
Classify COUGH or DIFFICULT BREATHING
DIARRHEA
Child with dehydration
Does the child have diarrhea?
IF YES, ASK:
• For how long?
• Is there blood in the stool?
LOOK, LISTEN, FEEL:
Look at the child’s general condition, is the child: Lethargic or unconscious? Restless or irritable?
Look for sunken eyes Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?

CLASSIFICATION TABLE FOR DEHYDRATION

CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

CLASSIFICATION TABLE FOR DYSENTERY

FEVER
Does the child have FEVER?
IF YES, decide the malaria risk: high or low THEN ASK:
• For how long?
• If more than 7 days, has fever been present every day?
• Has the child had measles within the last 3 months?
If the child LOOK AND FEEL:
• Look for runny nose
• Look or feel for stiff neck
LOOK FOR SIGNS OF MEASLES
has measles now or within the last 3 months
-Rash -Mouth ulcers
-Cough -Pus from eyes
-Runny nose -Clouding of cornea
-Red eyes

CLASSIFICATION TABLE FOR NO MALARIA RISK AND NO TRAVEL TO A MALARIA

RISK AREA

CLASSIFICATION TABLE FOR MEASLES (IF MEASLES NOW OR WITHIN THE LAST 3
MONTHS)
FEVER WITH RASHES

Ear Problem
Does the child have an EAR PROBLEM?
IF YES, ASK
• Is there ear pain?
• Is there ear discharge? If yes, for how long?
LOOK AND FEEL:
• Look and pus draining from the ear
• Feel for tender swelling behind the ear.

CLASSIFICATION TABLE FOR EAR PROBLEM

MALNUTRITION AND ANEMIA

CHECK FOR MALNUTRITION AND ANEMIA

LOOK AND FEEL:
• Look for visible severe wasting
• Look for palmar pallor. Is it:
• Severe palmar pallor?
• Some palmar pallor?
• Look for edema of both feet
• Determine weight for age
CLASSIFY NUTRITIONAL STATUS

IMMUNIZATION STATUS

CHECK IMMUNIZATION STATUS: IMMUNIZATION SCHEDULE

 Birth - BCG, HepB1
 6 weeks - DPT1, OPV1, HepB2
 10 weeks - DPT2, OPV2, HepB3
 14 weeks - DPT3, OPV3, HepBbooster
 9 mos – measles
How to check the Immunization Status
  If an infant has not received any immunization, then give
–BCG
–DPT 1 , OPV 1
–Hepatitis B 1

THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS: ASSESS AND

CLASSIFY
CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION

How to assess and classify a young infant

for diarrhea?

CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT

Communicate and Counsel

GIVE FOLLOW-UP CARE

Follow-up care for the sick young infant

 When to return immediately immediately

b. –Signs of any of the following:
c. –Breastfeeding feeding or drinking poorly
d. –Becomes sicker
e. –Develops a fever
f. –Fast breathing
 g. –Difficult breathing
h. –Blood in the stool

 Follow-up in 2 days – on antibiotics for local bacterial infection or dysentery

 Follow-up in 2 days - with a feeding problem or oral thrush
 Follow-up in 14 days – with low weight for age

FOLLOW-UP VISIT TABLE IN THE COUNSEL THE MOTHER CHART

ESSENTIAL
INTRAPARTAL
NEWBORN CARE

 An evidence based
standards for safe
quality care of
 birthing mothers and their newborns within 48 hours of intrapartum period and a week of life for
the newborn.
 Purposes:
a. Assess and evaluate the newborn as he or she transitions from intrauterine life to
extrauterine life.
b. Evaluate and monitor the newborn, system-by-system for normal versus abnormal
functioning, providing maintenance of normal and potential treatment of abnormal
findings.
c. Foster bonding between infant and parent/s.
d. Provide a safe environment at all times.
EINC practices during Intrapartum period
1. Continuous maternal support, by a companion of her choice, during labor and delivery
2. Mobility during labor – the mother is still mobile, within reason, during this stage
3. Position of choice during labor and delivery
4. Non-drug pain relief, before offering labor anesthesia
5. Spontaneous pushing in a semi-upright position
6. Episiotomy will not be done, unless necessary
7. Active management of third stage of labor (AMTSL)
8. Monitoring the progress of labor with the use of partograph

 December 2009, the Secretary of the Department of Health Francisco Duque signed
Administrative Order 2009-0025, which mandates implementation of the EINC Protocol in
both public and private hospitals
 Unang Yakap campaign was launched.

FORMER NEWBORN CARE VS. UPDATED NEWBORN CARE

Immediate and Routine NBC

 A- Airway
 T-Thermoregulation
 A- APGAR scoring
 I- Initial Identification
 B- Bathing
 A- Anthropometric Measurement
 C- Crede’s Prophylaxis
 K- Vit. K Administration
 U- Umbilical Cord Care
 P- Prints

Time Bound and Non-immediate NBC

  Immediate and Thorough Drying
 Early Skin-to-Skin Contact
 Properly Timed Cord Clamping
 Non-separation of Newborn from Mother for Early Breastfeeding

1. Immediate and Thorough Drying

Within 1st 30 secs
(Immediate Thorough Drying)
a. Call out the time of birth
b. Dry the newborn thoroughly for at least 30seconds
a. Wipe the eyes, face, head, front and back, arms
c. Remove the wet cloth
d. Do a quick check of breathing while drying.
i. (do not suction unless the mouth or nose is blocked

“WHEN TO DO THE APGAR SCORING?”

 1st Minute – to assess the general condition of the Newborn
 5th Minute - to assess Newborn’s adaptation
 10th Minute - if the 5th minute APGAR is score is less than 4

Appearance( skin color)

Pulse heart rate
Grimace reflexes
Activity muscle tone
Respiration breathing and effort
Acrocyanosis

 Acrocyanosis is a functional peripheral vascular disorder characterised by dusky mottled

discolouration, or cyanosis, of the hands, feet, and sometimes the face. Acrocyanosis is caused by
vasospasm of the small vessels of the skin in response to cold.
2. Early Skin-to-Skin Contact
(after 30secs of Drying)
a. Position the newborn prone on the mother’s abdomen or chest.
b. Cover the newborn’s back with a dry blanket.
c. Cover the newborn’s head with a bonnet.
d. Avoid any manipulation, e.g. routine suctioning that may cause trauma or infection
e. Place identification band on ankle.
 Provide warmth/prevent hypothermia
 improves bonding
 provides protection from infection by exposure of the baby to good bacteria of
the mother
 increases the blood sugar of the baby
 contributes to the over all success of breastfeeding

3. Properly Timed Cord Clamping(1-3 mins)

a. Remove the first set of gloves.
b. After the umbilical pulsations have stopped, clamp the cord using a sterile plastic
clamp or tie at 2 cm from the umbilical base.
c. Clamp again at 5 cm from the base.
d. After clamping, provide 10 IU oxytocin IM to the mother
e. Cut the cord close to the plastic clamp.
o Points to Remember:
 Do not milk the cord towards the baby
 Cut the cord close to the plastic clamp so that there is no need for a 2 nd
“trim”
 Do not apply any substance onto the cord
 Check for two arteries and one vein (AVA)

4. Non-separation of Newborn from Mother for Early Breastfeeding

a. Within 90 mins
b. Leave the newborn in skin-to-skin contact (SSC)
c. Observe for feeding cues, including tonguing, licking, rooting
d. Point these out to the mother and encourage her to nudge the newborn towards the
breast.
e. P.T.R
 Minimize handling by health workers
 Do not throw away colostrum

f. Weighing, bathing, eye care, examinations, injections (hepatitis B, BCG) should be

done after the first full breastfeed is completed.
g. Postpone washing until at least 6 hours.
Medications
 Administer erythromycin, tetracycline or 2.5% povidone drops (to
prevent ophthalmia neonatorum)
 Give Vitamin K Prophylaxis, Vit K 1mg IM
  Inject Hepatitis B and BCG vaccination. (Hep B
IM and BCG intradermally)

h. Examine newborn for, Birth injuries, malformations or defects.

i. Do cord care
 Wash Hands
 Fold diaper below stump, keep cord stump open to keep it dry.
 Explain to the mother that she should seek medical attention if umbilicus is red or
draining pus.
 Teach the mother to treat local umbilical infections as per doctor's order

4 Newborn Protocol
1st 30sec. (Dry) Hypothermia
nd
2 30sec. (SSC) Hypoglycemia/Infection
1-3mins. (CCC) Anemia
90mins. (SSC) Promote Breast Feeding

Latch refers to how the baby fastens onto the breast while breastfeeding. A good latch promotes high
milk flow and minimizes nipple discomfort for the mother, whereas poor latch results in poor milk
transfer to the baby and can quickly lead to sore and cracked nipples.

Unnecessary Procedures
a. Routine Suctioning – Suctioning has no benefit if the amniotic fluid is clear. A dirty bulb can
be a source of infection.
b. Early bathing – WHO recommends to perform bathing after 6 hours after delivery.
c. Footprinting – is proven inadequate for newborn identification purposes.
d. Giving sugar water, formula or other prelacteals and the other use of bottles or pacicier.
e. Application of alcohol, medicine and other subtances on the cord stump.

Intraventricular hemorrhage (IVH) of the newborn is bleeding into the fluid-filled areas (ventricles) inside
the brain. The condition occurs most often in babies that are born early (premature)
MEDICATIONS

 CREDE'S PROPHYLAXIS
– ERYTROMYCIN/ TERAMYCIN OPTHALMIC OINTMENT
– TO PREVENT OPTHALMIA NEONATORUM
– applied from inner to outer canthus of the eyes

 VITAMIN K
PURPOSE:
 Promote blood clothing
 Prevent bleeding
 Prevent Hypofibrenogenimea
 DRUG OF CHOICE: PHYTOMENADIONE, AQUAMEPHYTON
 ROUTE: IM (90%)
 SITE: Left-Vastus lateralis (common)
Rectus Femoris (alternative site)
 DOSSAGE:
PRE TERM - 0.05 CC
FULLTERM - 0.1 CC
POST TERM – 0.1 CC
 HEPA B
 0.5ML INTRAMUSCULAR INJECTION
 VASTUS LATERALIS

BCG (BACILLUS CALMETTE GUERINE)

 ML INTRADERMAL DELTOID (LEFT)
 TO PREVENT FROM LUNG PROBLEM

ANTHROPOMETRIC
MEASUREMENT(cm)

Vital Signs
Check patency of the anus
Weight: 2.5kg-3.5kg
Check vital signs
Temperature: 37.2
Pulse rate: intrauterine: 120-160 beats per min
right after birth: 180
1 hour after birth: 120-140
Respiration: at birth: 80 cycles per min
at rest: 30-60 cycles per min
BP 80/46-100/50
TIME BAND: AT PERINEAL BULGING, WITH PRESENTING PART VISIBLE

Prepare for the Delivery

1. Check temperature of the delivery room ( 25-28 ºC)
2. Notify appropriate staff
3. Arrange needed supplies in linear sequence
4. Check resuscitation equipment
5. Wash hands with clean water and soap
6. Double glove just before delivery

TIME BAND: WITHIN 1ST 30 SECONDS IMMEDIATE THOROUGH DRYING

1. Dry the newborn thoroughly for at
least 30 seconds.
2. Wipe the eyes, face, head, front and
back, arms and legs.
3. Remove the wet cloth
4. Do a quick check of breathing while
Drying

 NOTES:
1. Do not wipe off vernix , bathe the newborn
2. Do not do foot printing
3. No hanging upside-down, no slapping
4. No squeezing of chest

TIME BAND: AFTER 30 SECONDS OF DRYING EARLY SKIN-TO-SKIN CONTACT

1. Position the newborn prone on the mother’s abdomen or chest
2. Cover the newborn’s back with dry blanket.
3. Cover the newborn’s head with bonnet

TIME BAND: 1-3 MINUTES PROPERLY- TIMED CORD CLAMPING

1. Remove the first set of gloves
2. After umbilical pulsations stopped, clamp the cord at 2 cm. from the umbilical base, clamp
again at 5 cm. from the base.
3. Cut the cord close to the plastic clamp

TIME BAND: 1-3 MINUTES PROPERLY- TIMED CORD CLAMPING

 Delay cutting until pulsation stop
a. Allows as much as 100 ml of blood to pass from the
placenta into the fetus
a. Ensures adequate RBC and WBC count in newborn

TIME BAND: WITHIN 90 MINS.

NON-SEPARATION OF NEWBORN FROM MOTHER EARLY BREASTFEEDING
1. Leave the newborn in skin-to-skin contact
2. Observe for feeding cues (tonguing, licking, rooting)
3. Encourage the mother to nudge the newborn towards the breast
 4. Counsel on attachment and sucking
a. Mouth wide open, lower lip turned outwards
a. Baby’s chin touching breast
c. Weighing, bathing,eye care, examinations, injections
(hepatitis B, BCG, Vit. K) should be done after the first full breastfeed is completed
d. Postpone washing until 6 hours

NEWBORN SCREENING
HISTORY OF NBS IN THE PHILIPPINES

NEWBORN

 A simple procedure to find if a baby has a congenital metabolic disorder even before clinical
signs and symptoms are present
PURPOSE:
1. To know the metabolic disorder that may occur to newborn that may lead to mental
retardation or even death if left untreated
2. To be able to identify newborn with metabolic disorders because they look normal at
birth
3. To treat genetic metabolic disorder as early as after birth
OBJECTIVE OF NEWBORN SCREEN
1. Newborn has access to newborn screening
2. Sustainable newborn screening system
3. All health practitioners are aware of the advantages
4. Parents recognize their responsibility
RA 9288: NEWBORN SCREENING ACT OF 2004

 Protect the rights of children to survival and full and healthy development as normal individuals
 Provide for a comprehensive, integrative and sustainable national newborn screening system to
ensure that every baby born in the Philippines is offered the opportunity to undergo newborn
screening and be spared from heritable conditions

NEWBORN SCREENING REFERENCE CENTER (NSRC)

 They are responsible for the national testing database and case registries, training, technical
assistance and continuing education for laboratory staff in all newborn screening centers
NBS PROCEDURE

 Law provides that NBS be done after 24 hours of life, but not later than three days from
complete delivery of the newborn
 Specimen for NBS is obtained through a heel prick
  A few drops of blood are taken from the baby’s heel blotted on a special absorbent filter card
and then sent to a newborn screening center
 Sample for NBS may be obtained by a physician, nurse, medical technologist or trained midwife
 Normal (negative) NBS Results are available by 7-14 working days from the time samples are
received at NSC

PULSE OXIMETRY

 This is a test that measures the amount of oxygen in the newborn’s blood and can detect some
heart problems called Critical Congenital Heart Disease (CCHD)
NEWBORN HEARING SCREENING

 Is designed to identify hearing loss in infants shortly after birth

 Done prior to discharge from the hospital or birth clinics
 Methods
1. Auditory brainstem response (ABR) evaluation
2. Otoacoustic emission (OAE)
- two different test can used to
screen for hearing loss in newborns
- both tests are quick (5-10minutes),
safe and comfortable with no activity required from newborn
RA 9709 UNIVERSAL NEWBORN HEARING AND INTERVENTION ACT OF 2009

 An act establishing a universal newborn hearing screening program for the prevention,
early diagnosis and intervention of hearing loss
UNIVERSAL NEWBORN HEARING SCREENING PROGRAM (UNHSP)

 Ensure all newborns have access to hearing loss screening

 Establish network among pertinent government and private sector stakeholders for policy
development, implementation monitoring, and evaluation to promote UNHSP
 Provide continuing capacity building
 Establish and maintain a newborn hearing screening database
 Ensures linkages to diagnosis and the community system of early
intervention services
 Develop public policy in early hearing detection
 Develop models which ensure effective screening, referral and linkage with appropriate
diagnostic, medical and qualified early intervention services, providers, and programs within
the community

OTOACOUSTIC EMISSIONS TEST (OAE)

 Used to determine if certain parts of the newborn’s ear respond to sound

 During the test, a miniature earphone and microphone are placed in the ear and sounds are
played. When a newborn has normal hearing, an echo is reflected back into the ear canal, which
can be measured by the microphone. If no echo is detected, it can indicate hearing loss

AUDITORY BRAIN STEM RESPONSE TEST (ABR)

 Used to evaluate the auditory brain stem and the brain’s response to sound.
 During the test, miniature earphones are placed in the ear and sounds are played. Band-Aid-
like electrodes are placed along the newborn’s head to detect the brain’s response to the
sounds. If the newborn’s brain does not respond consistently to the sounds, there may be a
hearing problem

DISORDERS TESTED FOR NBS

 CONGENITAL HYPOTHYROIDISM
 CONGENITAL ADRENAL HYPERPLASIA
 GALACTOSEMIA
 PHENYLKETONURIA
 GLUCOSE-6-PHOSPHATE- DEHYDROGENASE DEFICIENCY (G6PD)
 MAPLE SYRUP URINE DISEASE

1. CONGENITAL HYPOTHYROIDISM
 Occurs when a newborn or infant is born without the ability to make normal
amounts of thyroid hormone
 It usually occurs about 1 in 3000 – 4000 children
 CAUSES
1. Impaired neurological function
2. Stunted growth
3. Physical deformities
4.
  Signs and symptoms
1. less active
2. sleep more than normal
3. difficulty in feeding
4. constipation
 NURSING INTERVENTIONS
1. Maintain a stable weight
2. Educate the client and family regarding body weight changes
3. Collaborate with dietician to determine client’s caloric needs
4. Encourage the intake of foods rich in fiber
5. Encourage a low cholesterol, low calorie and low saturated fat diet
6. Reduce fatigue

2. CONGENITAL ADRENAL HYPERPLASIA

 Refers to a group of genetic disorder that affect the adrenal glands and a high level
of male hormones
 Hormones:
1.Cortisol – regulates the body’s response to illness, stress or injury
2.Mineralocorticoids – (aldosterone) which regulate sodium and
potassium levels
3.Androgens – (testosterone) male sex hormones

TYPES OF CONGENITAL ADRENAL HYPERPLASIA

1. Classic CHA – can be detected usually in infancy
2. Non-classic CAH – milder and more common, and may not become evident
until childhood or early adulthood

 Signs and Symptoms

1. A fetus affected by congenital adrenal hyperplasia will produce excessive
male hormones during development
2. If the fetus is female, this will result in virilization of the external genitalia
3. Female baby may be born with ambiguous genitalia
4. Adrenal crisis
5. if the infant has untreated, they will produce excessive levels of male
hormones such as testosterone

 NURSING INTERVENTIONS
1. Allow the parents to grief
2. Provide emotional support
3. Allow the parents to understand about the disease
4. Provide education for parents and child about the said condition
 3. GALACTOSEMIA
 Is a recessive hereditary metabolic disorder in which the enzyme necessary to convert
galactose into glucose is missing
 Clinical Manifestations
1. Poor growth
2. Jaundice
3. Bleeding
4. Feeding difficulties
5. Cataracts
6. Liver and spleen damage
 NURSING INTERVENTIONS
1. Milk substitution
2. Dietary restrictions
3. Read food labels
4. Client education
4. PHENYLKETONURIA

 Is an inborn error of metabolism that results in decreased metabolism of the amino

acid phenylalanine
 If untreated
1. Intellectual disability
2. Seizures
3. Behavioral problems
4. Mental disorders

 SIGNS AND SYMPTOMS

1. A musty odor in the breath, skin, urine
2. Seizures
3. Skin rashes (eczema)
4. Fair skin and blue eyes
5. Abnormally small head
 NURSING INTERVENTIONS
1. Diet
2. Emotional support
3. Health education
4. Guidance from a dietitian
5. Safety
5. GLUCOSE-6-PHOSPHATE- DEHYDROGENASE DEFICIENCY (G6PD)

 Is a genetic metabolic abnormality caused by deficiency of the enzyme glucose -6-

phosphate dehydrogenase
 SIGNS AND SYMPTOMS
1. Rapid heart rate
2. Shortness of breath
3. Urine that is dark or yellow-orange
4. Fever
 5. Fatigue
6. Dizziness
7. Paleness
8. Jaundice
 NURSING INTERVENTIONS
1. If the client is sick like cough, colds or other bacterial or viral infection, tell the doctor
that the client has G6PD
2. Keep the list of oxidative substances in a handy place and check food, beverage and
medicine against the list
3. Memorize the signs and symptoms of hemolytic anemia
4. Do not ignore infections
5. As the child gets older, tell him/her condition and educate the child to be careful about
what to eat
6. If you ingested or were exposed to any medication and your urine became tea colored,
inform the doctor immediately
7. If you have yellowish discoloration in the skin, sclera or any part of the body, consult
the doctor immediately
8. Avoid foods contraindicated to G6PD
Fava beans
Red wine
Legumes (bitsuelas, garbansos, monggo beans)
Soya foods(taho, tokwa, soy sauce), tonic water
6. MAPLE SYRUP URINE DISEASE

 Is an inherited disorder in which the body is unable to process certain protein building
blocks(amino acid) properly.
1. Leucine - contributes to regulation of blood- sugar levels; growth and repair of muscle
and bone tissue; growth hormone production; and wound healing.
2. Isoleucine - This is the oxygen-carrying pigment inside of red blood cells. It may help
control blood sugar. It may also boost energy and endurance.
3. Valine - is an α-amino acid that is used in the biosynthesis of proteins.
 SIGNS AND SYMPTOMS
1. Poor appetite
2. Trouble sucking during feeding
3. Weight loss
4. High pitched cry
5. Urine that smells sweet like maple syrup or burnt sugar
6. Sleeping longer or more often
7. Tiredness
8. Irritability
9. Vomiting
10. Development delay
 NURSING INTERVENTIONS
1. Dietary therapy
2. No restrictions in Activity
3. Hemodialysis/peritoneal dialysis
4. Medication