Chap 5

UNIT FIVE
EXPANDED PROGRAM ON
IMMUNIZATION
10/28/2021 Gizachew A (Bsc ,MPH) 1

 Immunization: - is the process of protecting a person from
infection by producing antibodies against antigens (micro-
organisms).
 Those antibodies kill that organism or prevent it from
growing in the body and a person has become immune
against that particular infection.
 Immunity: - is a state in which antibodies
(immunoglobulin) are capable of
• preventing a particular disease.
Cont.
 When an antibody is formed in response to a particular antigen, it
is specific to that antigen.
 For example, antibodies for the pertusis antigen take no
action against a tetanus antigen. Specific antibodies must be
formed that combat a tetanus antigen.
 Immunoglobulins that are involved in immunity are IgG, IgA,
and Ig M.
 Functions and characteristics of immunoglobulin

Cont.
1. IgG – only type to cross placenta Produced in
secondary response to a given antigen
2. IgA – protects mucous membrane from organisms

found in breast milk
3. IgM- produced in primary response to a given antigen

4. IgE – present in serum of allergic children, active in
hyper sensitivity reactions
5. IgD - little documentation of activity appears to direct
antigens to B-cell surface to establish immunizations.
Types of immunity
 Immunity may be either active or passive
1. Active immunity:-
It is immunity that the child body (person) makes its
own antibodies to an antigen.
It is long lasting immunity.

Cont.
a. Naturally acquired active immunity
 when children produced antibodies, after the natural
invasion of a pathogen (after exposure or an attack of
a disease)

Cont.
b. Artificial acquired active immunity
 Immunity that developed after administration of
vaccine (antigen or toxoid).OR ,
 When pathogens are artificially injected by
immunization, the body produces antibody against the
pathogen.

Cont.
1. Passive immunity
The child gets ready made antibodies.
 Short live immunity.
a. Naturally acquired passive immunity
Trans-placental transferred maternal antibodies in
the body of the child.

Cont.
 The IgG antibodies that a woman has formed through
either immunization or having had a disease are
transferred across the placenta to a fetus. Because the
fetus does not make these antibodies but merely
receives them, this is called passive immunity.
 It lasts only about 2 months. However measles
antibodies have been isolated up to 1 years of age,

Cont.
b. Artificial acquired passive immunity
 It is attained by administration of antibodies.
 When children are exposed to a disease against which
they have no antibodies (such as tetanus), antibodies
obtained from animal serum (ant tetanus serum) may be
injected to give them artificially acquired passive
immunity.
 Because the antibodies are not naturally in the children,
this form of immunityGizachew
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A (Bsc ,MPH) 1 to 6 wks. 10
Cont.
Objectives of EPI
 The main objective of national immunization is to
reduce morbidity and mortality caused by immunizable
diseases.
 To achieve this EPI uses the following principles:
 Integration in MCH program
 Health education
 Disease surveillance
 Monitoring and evaluation,
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Cont.
Delivery Strategies of EPI
 Static: at permanent health unit
 Outreach: scheduled sessions at outreach sites
 Mobile and intensive immunization activity E.g. polio
immunization day and campaign, AND mobile vaccine
teams to control epidemics such as measles and
meningitis

Cont.
Target diseases of EPI in Ethiopia
 Tuberculosis
 Measles
 Diphtheria
 Pertusis
 Poliomyelitis
 Tetanus
 Hepatitis B
 Homophiles InfluenzaGizachew
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A (Bsc ,MPH) 13
Cont.
Types of vaccines
1. Attenuated vaccines: -
Attenuated vaccines are made from live organisms
that have been reduced in virulence to a point at
which they do not cause active disease. But ensure a
good antibody response
E.g. Measles, rubella, polio(sabin), mumps, yellow
fever (virus), BCG and typhoid (bacteria)
Cont.
2. Killed (dead) or inactivated form.
Injections of dead organisms are disappointing in the
antibody response they produce. Because a dead
form does not multiply in the body, several spaced
doses of vaccine must be given.
E.g. - Salk polio vaccine.
E.g. Diphtheria, Tetanus

Cont.
3.Toxiodis:
 Since some bacteria cause disease by producing
toxin, the vaccine against it, called a toxoid, is
actually an extract of the toxin reduced in virulence.
4. Antitoxins: -
The antibodies for toxin – producing bacteria are
called antitoxins.
 E.g. diphtheria, Tetanus
Eight EPI targeted disease vaccine
1. BCG vaccination
 BCG (bacillus of calmette and Guerin) vaccine is an
attenuated live vaccine obtained from the boy is strain
of tubercle bacilli.
 It produces controlled primary tuberculosis infection.
 BCG is given at birth.
• BCG injection Site – The middle of deltoid over the

right upper arm.
Cont.
 Method- 0.1ml (0.05 ml in neonate) of BCG is injected
intradermally with a special tuberculin syringe.
 Reaction following vaccination
 A papule appears in 2 to3 weeks after vaccination. By
about the fourth week, it grows in size. Then it either
subsides or sheds in to a shallow ulcer. This ulcer heals
in nearly 8 to 12 weeks time.

Cont.
 Contraindication
o Children with clinical AIDS
o Known mantoux positives
 Complication of BCG vaccinations
o local abscess formation or ulceration
o Regional lymphadenitis
o Local granulomatous lesions
o Hypertrophied scars/ keloids
Cont.
2. Polio vaccination:-
 Oral polio vaccine (Sabin vaccine} is a live but
attenuated virus containing all the three strains
(Lansing, Leon, brunhide),
 The killed poliovirus, the so called Salk vaccine is
required to administered parenterally (IM, Sc)

Cont.
 In grown up children (beyond 5 years of age) polio
vaccine may not be given. This is because the older
children are more or less immune to natural infection
with polio virus.
 How OPV behaves in the body?
On entry in the gut, strains of OPV multiply. As a
result there is production of local and systemic
immunity. The vaccine also leads to production of
antibodies like IgG,Gizachew
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,MPH) IgA. 21
Cont.
 IgA contribute to the local immunity, and IgG and IgM
limit spread of the poliovirus to the CNS and protect
against paralysis.
 Contraindication
o It should be avoided in children suffering from
severe diarrhea and an acute illness.
 Complication - none

Cont.
2. Pentavalent (PV)
 Offers combined prophylaxis against diphtheria,
pertusis (whooping cough), tetanus, homophiles
influenza B{Hib} and Hepatitis virus B{HBV}
 Administrations – A dose of 0.5ml of the penta vaccine
is given deep intramuscular over anterior lateral thigh.

Cont.
 Contraindication
 progressive neurological disease
 Child who has had convulsions or shock with in days of
the previous dose
 Complications – various degrees of reaction can occur
following PV injection. These are:
 Minor local swelling and tenderness at the site of
injection, slight fever and irritability.
 Excessive sleepiness,
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crying lasting 4 or more hours
Gizachew A (Bsc ,MPH) 24
Cont.
 Neurological reactions, such as convulsions and frank
encephalopathy, which may lead to brain damage or
death.
o Of these symptoms, the ones that contraindicated
further use of PV include a fever over 40.50c (1050F),
shock like syndrome, and the appearance of any
neurological reaction.

Cont.
2. Measles vaccination
measles vaccine is a live, attenuated measles vaccine
(Schwartz vaccine), given in a dose of 0.5ml by ID,
IM or Sc route, has a definite protective value of as
high a magnitude as 95 to 100%.
A single dose produces antibodies for an indefinitely
prolonged period.

Cont.
 Indication for measles vaccination
 All children in measles endemic area
 To interrupt measles out break, the incubation period
for the vaccine is shorter than that of the natural
disease. Measles vaccine given with in days of contact
stops the spread of the disease.

Cont.
 Contraindication to measles vaccine
 Sensitivity to vaccine content
 Personal and family history of convulsions
 Immunodeficiency diseases
 Acute tuberculosis
 Infants under 6 months of age
 Active tuberculosis
 Gross malnutrition
 During course of immunosuppressive drugs like steroids

Cont.
 Adverse reaction to measles vaccine
 10 to 20% of children get a mild illness 7-14 days after
the vaccine (fever, cough, occasionally rash)
 Convulsion in association with fever, encephalitis and
encephalopathy (rare)

Summary on Side effects of vaccines:
Vaccine Side effects Treatments
BCG  Local skin lesion (red and - Advice not to put any medicine on the
tender swelling, 10mm) sore (it heals in 2 – 3 months & leaves a
after 2 weeks scar)
* If deep injection abscess or enlarged - INH may be required
glands
PV  Fever, local tenderness - Reassure the mother
* Absences a week or more after the - Warm compress, systemic antibiotics,
injection (if the injection was not deep, - If the resolved it may require incision &
or with un- sterile needle) drainage
* Convulsion or shock in 3 days (rare) - Don’t give the subsequent DPT does
OPV -No - NO
Measles  Fever and mild rash about a - Reassurance
week after the injection for
1 -3 days.
TT  Local pain, redness and - Reassurance
swelling for some days.
•Normal reaction
* Severe reactions
Cont.
Storage of vaccines/ Cold chain system/
 "The cold chain is a system of storing and transporting
vaccines at low temperature from the manufacturer to
the actual vaccination location, so that their potency and
efficacy are preserved.
 Three vital elements in successful cold chain are cold
chain equipment; transportation motivated and trained
manpower for maintaining the link.
 The cold chain equipment
10/28/2021 Gizachew A consists
(Bsc ,MPH) of: 31
Cont.
a. Cold box:
 This can transport large quantities of vaccines by
vehicle to out reach sites, preserving the vaccine for
up to one week with out any power supply at all.
b. Vaccine carrier:
 This is designed to transport small quantities of
vaccine by a vehicle, bicycles or on foot to out reach
sites, preserving the vaccine for up to 3 days.
Cont.
c. Ice packs
 These are employed for use in box, carrier
d. Refrigerator (freezer)
 This is vital for storing vaccines for prolonged periods.
 PV,TT, and typhoid vaccines, as also dilutes (Which stored in the
cold part having a temperature of 4 to 10 0c on the other hand,
OPV, measles, MMR and rabies vaccines, which are highly heat
liable, need to be stored in the freezer compartment having a
temperature of 0 to 40c.

Cont.
Summary of correct storage of vaccines in a
refrigerator
• Freezing compartment
o Ice cubes
o OPV

Cont.
 Middle compartment
o PV/TT
 Lower compartment
o Diluent

Cont.
Target population for expanded program of
immunization (EPI)
Children under one year of age
Women in child bearing age (15-49
Immunization scheduled
Immunization schedules are determined by the
immunogenecity of the vaccine.

Cont.
 Good immunogenic vaccines (measles and BCG) need
only one injection to produce long lasting immunity.
 Weak immuogens (PV, OPV) requires several injections
to establish protective antibody levels and ensure
protection against the disease.
 Doses of TT versus duration of protection against
tetanus of the mother and her neonate.

Cont.
Dose Minimum interval Duration of
protection
TT1 0
TT2 4 wks after TT1 3 years
TT3 6 month after TT2 5 years
TT4 5 years after TT3 10 years
TT5 1 year after TT4 life long

Cont.
Table – The immunization schedules for the eight "EPI"
antigens
Contact Age of child Vaccination
1 At birth BCG, OPV zero
2 6 wks Penta 1, OPV 1
5 9 months Measles

Cont.
•N.B
 The immunization schedules for the eight EPI antigens
are given in the tables above. These tables reflect the
ideal situation for immunization. Often mothers bring
their children at less frequent intervals than those
suggested here.

Cont.
If the child is first seen at a later stage than indicated
in the immunization scheme, the immunization is
started with vaccines 1, 2, 3 and 4, given with four
weeks interval.
If the child is 9 months or older, the 5th injection,
measles is given four weeks after PV 3.

Cont.
The vaccination scheme should be started on all
children’s under 2 months.
BCG and measles should be given to all under 5.
BCG and measles may then be given at the same
time.
Tetanus vaccination: some women have certificate
that they had PVs. They need only one injection at
each of their two first pregnancies.
Cont.
 Interrupted immunization should not be restarted since
there is no maximum interval for the PV, TT, and polio
vaccines. Hence continue the remaining dose.
 Besides this, if a woman was given 3 doses of PV
vaccine when she was a child, provided that a written
document of her immunization is available, and the
doses were given at the right intervals, the 3 doses of
PV can continue as two doses of TT.
Guidelines on injection safety
 Use of a single sterile syringe and needle for each dose of

vaccine
 Use of AD syringes preferably
 Provision of safety boxes for disposal of used syringes
 Incineration of full safety boxes
 Removal and proper burial of residue from the incinerator
 No disposal of used syringe, needle or full safety boxes in open
dumped randomly

Cont.
Factors that contribution of unsafe injection is:-
 Reuse of a single syringe and needle
 Inadequate supply of injection material
 Inadequate disposal of used syringes and needles

Calculation of target population and EPI coverage
 Target population (children under one year old, their
proportion depends on the available recent demographic
data of the area district or region. for instance let us
take it as 3%): hence,
a. Year target children= total population X
b. Monthly target children= yearly target children
12

Cont.
 Immunization coverage with a specific vaccine (e.g.PV3)

Cont.
 Drop out
 It is defined as a child or a woman who failed to return for
subsequent doses for which he or she is eligible.
 Find out the causes drop out in your area by asking yourself,
other workers including cleaners in the clinic, people and
community leaders:
Examples of its possible causes are:
o Unsure of dates of return
o Long waiting time for vaccination
o Vaccination centers open at inconvenient date and hours
Cont.
 Drop out rate calculation
1.
2.
• N.B: drop out rate should always be less than 10, if >
10%, determine why the failure occurred.

Causes of low immunization coverage
1. Drop out:
 It is defined as a child or a woman who failed to return
for subsequent doses for which he or she is eligible.
2. Missed opportunities:
 Current policy: The current policy states that all
children and mothers at health for any reason should be
screened for immunization status and vaccinated if
eligible.
Cont.
 The common causes of missed opportunity are:
 Health workers do not know the policy
 Health workers vaccinate women with TT only if they
are pregnant.
 Health workers vaccinate only the index child, miss the
siblings.
 Health workers open a vial only if there are enough
clients who need it.
Cont.
• False contraindications to immunization, for example,
not giving polio vaccine to child with diarrhea. Logistic
problems, such as vaccine shortages, poor clinic child
was eligible.
• Inconvenience of time (women carry house hold
responsibilities), distance, cost of transportation
• Acceptability: culture, rumors, beliefs, etc

Cont.
3. Culture & beliefs: though the service is accessible, it
hinders utilization
4. Lack of geographic access: includes lack of
transportation and sore parts for vehicles.
5. Problems associated with the vaccines: side effects,
the efficacy of BCG is uncertain
6. Problems of knowing the target population lead to
failure of early preparation of logistics
Cont.
7. Problems related to the suppliers, cold chain and maintenance.
 Shortage of suppliers (syringes, vaccines, iceboxes, vaccine
carriers, etc.)
 Maintenance of cold chain equipment is costly & unavailability
of spare parts
8. Problem of community involvement and intersectoral
collaboration may lead of failure of the EPI program. Involvement
of the community and intersectoral collaboration should be ensured
during the palming, implantation, and evaluation process of the EPI
program
Cont.
8. Ineffective management:
 Poor scheduling and allocation of resources
 Poor information system leads to inadequate recording
and reporting.
Possible solutions:
 Developing dropout (defaulters) tracing mechanisms
like using community health workers (front line health
workers to trace defaulters).
Cont.
 Sensitizing the population though health education and
discussion about the program
 In service training to community health workers (CHW)
and utilization of other motivation mechanism.
 Get commitment by the local leaders
 Ensure financial and logistics support of the health
institutions.
 Monitor coverage periodically
Management of EPI
 Procedures to follow in conducting EPI include:

 Know the catchments area
 Know the target population though survey
 Organize and conduct in service training for the staff
 Allocate resources such as
 Assign staff,
 Procure the required amount of vaccines, refrigerator
and other suppliers,
 The necessary financial
10/28/2021 support
Gizachew A (Bsc ,MPH) (budget) 57
Cont.
 Manage the cold chain
 Arrangement of vaccines in the refrigerator
 Use different mechanism of ensuring the cold chain
 Identify the strategy to be used and their frequencies
 Prepare and organize immunization schedule /session
(e.g. how many out reach sites?)

Cont.
 Give appropriate information for the clients such as:
 Be specific on the date and time of the next
immunization
 Give the client a written note of the date and time
 The place of the next immunization, particularly if
you change the previous site
 Number of visits a child and mother still need in
order to be fully immunized
 Side effects may occur
Cont.
 Collect and distribute materials for recording and
reporting
 Social mobilization (the clients, community, other
sector members, etc.) to create awareness
 Devise means of monitoring, supervising, and
evaluation, such as
 Prepare and use monitoring chart
 Calculate immunization coverage, drop out rate, etc
Cont.
 Identify problems and give solutions
 Identify those illegible who are not vaccinated and are
listed as dropouts.

Cont.
Thank you

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UNIT FIVE

10/28/2021 Gizachew A (Bsc ,MPH) 1

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2. IgA – protects mucous membrane from organisms

3. IgM- produced in primary response to a given antigen

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the body of the child.

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• BCG injection Site – The middle of deltoid over the

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TT3 6 month after TT2 5 years

TT4 5 years after TT3 10 years

TT5 1 year after TT4 life long

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 Use of a single sterile syringe and needle for each dose of

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 Procedures to follow in conducting EPI include:

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