IMMUNIZATION

 
Presented by:

Dr. R. Ahmed.
 
 

Department of Pediatric
 OUTLINE
- INTRODUCTION
Definition
PHC
Immunization
Objectives of EPI
- WHAT COMPRISES IMMUNIZATION?
Immunization schedule
Types
Vaccine failure.
Care of the vaccines.
- ARE THERE SOME CONTRAINDICATIONS TO
IMMUNIZATION?
- CHALLENGES
Conclusion

 
 INTRODUCTION
In health care management, emphasis has
Shifted from curative and moved more towards
Preventive aspect since the ALMA ATA
declaration
of primary health care which is, first level of
contact
of individuals, the family and community with,
the
national health system, bringing heath care to
the
door steps of people with emphasis on the main
health problems in the community.
 Of the 5 levels of prevention, immunization
forms the centre of specific protection.
The prevention of diseases by immunization, a
conventional primary health care measure is today
the best known practical, low-cost community
based way of protecting children against the major
killer disease.
 WHAT IS IMMUNIZATION?
Immunization is the process of inducing
immunity
artificially by either vaccination or administration
of
antibody.
There are two types of immunization
1. Actively (active immunity) which involves
stimulating the immune system to produce
antibodies and cellular immune response
that
protects against the agent.
2. passive immunity-consists of
a. Providing temporary protection through
administration of exogenously produced
antibody such as immune globulin or
through trans-placental transmission of
antibodies to a fetus which provides protection

against many infectious disease for at least

the 1st 3 month of life.
EPI
In 1974 the world health organization formulated and launched the EPI which was adopted by over 60 countries, Nigeria inclusive, and is being used as
the building block for PHC.
The aim is to assist all nations to carry out immunization of their 0-2years child population against vaccine preventable diseases which will help in
reducing the morbidity and mortality from these infectious diseases and to promote the control of endemic diseases through assistance from WHO and
UNICEF
 
OBJECTIVES
The overall objectives of the Expanded Program on Immunization were:
1. To achieve 80% immunization coverage of the target population by the year 1990 and mid term goal of 60% by 1987.
2. To reduce, by 1990, by at least 50% the incidence of the target diseases i.e. tuberculosis, diphtheria, pertusis, tetanus, polio and measles through immunization and other preventive
measures.
3. To establish an efficient system of surveillance and program monitoring activities to ensure reliable systematic procurement of vaccine.
4. To foster inter-sectoral co-operation and community involvement and participation in these activities at all levels, and thus enhance the ability of the program to sustain it self effectively.
 

Launched in Nigeria in 1971, and revised in 1984, the EPI had successfully attained the universal child
immunization (UCI) target of 80% by 1990 in Nigeria as in many countries. Unfortunately, this coverage could
not be sustained and there was a decline in coverage and increase in the number of reported cases of the
target disease. As a way of reawakening national consciousness and demonstrating ownership of the
program, the Nigerian government in 1996 renamed the EPI as National Program on Immunization (NPI).  
Because of the importance of the program the new NPI was established as parastatal under the Federal
Ministry of Health under a degree 12 of August 1997 and became fully operational in 1998.
 Because of the importance of the program the new NPI was established as parastatal
under the Federal Ministry of Health under a degree 12 of August 1997 and became
fully operational in 1998. The NPI has the following specific objectives:
< To achieve polio eradication by the year 2005.
< To eliminate maternal and neonatal tetanus by the year 2005.
< To reduce measles morbidity by 90% and mortality by 95% compared to the
pre immunization era by the year 2005.
< To improve routine immunization service delivery in order to achieve 80% coverage
for all the antigens in all LGA’s by the year 2005.
• To eliminate maternal and neonatal tetanus by the
year 2005.

 
• To reduce measles morbidity by 90% and mortality
by 95% compared to the pre immunization era by the
year 2005.
• To improve routine immunization service delivery in
order to achieve 80% coverage for all the antigens
in all LGA’s by the year 2005.
• TO consolidate the integration of new vaccines such
as yellow fever, hepatitis B and haemophilus influenza
type B vaccines into the routine system in phased
manner by 2007.
• To strengthen the new district based social
mobilization structure such that 80% community
ownership is achieved by 2007.
 To conclude the cold chain rehabilitation plan
by 2007.
 To ensure financial sustainability of the
program through expansion of sources of
fund and increase internally generated fund to
60% by 2007.

To pursue knowledge and skills development

among all categories of health workers involved in
immunization activities (both public and private) by
ensuring that by 2007, 100% of all health institutes
providing immunization services are manned by
adequately trained personnel.
 COMPONENTS OF IMMUNIZATION.
Immunization Schedule.
Suggested schedule of immunization and that currently in use in Nigeria (JUTH inclusive) is as shown below .

TIME (AGE) VACCINE DOSE ROUTE OF SITE

ADMINISTRATION
Birth BCG 0.05cc Intra-dermal Upper Lt arm,
OPVo 2 drops Oral By mouth.
Hep B1 0.5 cc i-m. APT

6 weeks DPT2 0.5 cc i-m APT

OPV2 2 drops oral MOUTH
Hep B 2 0.5 cc i-m APT
10 weeks DPT2 0.5cc i-m APT
OPV2 2 drops oral MOUTH
14 weeks DPT3 0.5cc i-m APT
OPV3 2 drops oral MOUTH
Hep B3 0.5c i-m APT
9 month Measles 0.5 cc Subcute. ULA
Yellow fever 0.5cc i-m URA
Vit. A. 100,000iu oral MOUTH
12 months CSM 0.5cc i-m URA
15 months Vit. A 200,000IU ORAL MOUTH

Woman of child Tetanus 0. 5 m I. M UPPER ARM

bearing age Toxoid
1st contact
4 weeks
6 months
1 years
1 years
 Tetanus toxoid (TT) immunization for women
of child being age
TIME (AGE) VACCINE DOSE ROUTE OF SITE
ADMINISTRATION
Birth BCG 0.05cc Intra-dermal Upper LE arm,
OPVo 2 drops Oral ULA, by mouth.
Hep B1 0.5 cc i-m Mouth Ant. Part of
thigh APT

6 weeks DPT2 0.5 cc i-m APT

OPV2 2 drops oral MOUTH
Hep B 2 0.5 cc i-m APT
10 weeks DPT2 0.5cc i-m APT
OPV2 2 drops oral MOUTH
14 weeks DPT3 0.5cc i-m APT
OPV3 2 drops oral MOUTH
Hep B3 0.5c i-m APT
9 month Measles 0.5 cc i-m ULA
Yellow fever 0.5cc subcutaneous
12 months CSM 0.5cc i-m URA
Woman of Tetanus 0.5cc x 5 doses at intervals of 4 ORAL MOUTH
Childbearing age (16 – Toxoid (TT) weeks, 6 months 1 year and
44 years) another 1 year (see figure 2.4)
 9 month Measles 100, 000 iu ORAL Mouth
Yellow fever
Vit. A
15 months Vit A 200, 00 iu I/M Upper arm
Woman of child Tetanus 0. 5 m
bearing age Toxoid
1st contact
4 weeks
6 months
1 years
1 years

NOTE: Some centers

CSM 0.5cc i/m upper arm.
Other vaccines available include Hib, Mumps, Rubella, (MMR), typhoid, preumococcal,
a virus.

Dose When to give Percentage protection Duration of

protection
TTI At first contact or as early as Nil None
possible in pregnancy

TT2 At least four weeks after TTI 80 3 years

TT3 At least 6 months after TT2 95 5 years
TT4 At least 1 year after TT3 99 10 years
TT5 At least one year after TT4 or 99 For life
subsequent pregnancy
Since most developing countries have yet to establish an objective child immunization “Recall
system”, to ensure the follow up and immunization of defaulters, the general recommendation
is to immunize all age- appropriate eligible children at every opportunity.
Denying immunization may even constitute a greater risk where access to health services is
limited and the morbidity and mortality from vaccine preventable diseases are high.
NOTES ON THE DIFFERENT VACCINE
OPV: Trivalent, protect against the three types of the polio virus.
NB: No cross immunity between the three types of polio virus thus effective vaccines must contain all the three.
Two types – Salk – (killed IPV) injection
Sabin- (Live attenuated)
OPV must be given before two weeks age. Confers Herd immunity: The intestinal immunity confers protection to un-immunized individuals exposed to it through fecal contamination and as such lowers the rate of polio
transmission in areas where the majority of people are immunized.
Three doses required to provide protection
Four doses for full immunity
For IPV- two doses, but more costly and less simple to administer.
If child is having diarrhea, give OPV as usual but give an extra dose when child is better, at least four weeks after last dose.
Efficacy of vaccine = 95%.
BCG: Should not be given to children who have clinical HIV/AIDS
- If there is no nodule, six week after the second vaccination refer to a doctor.
- TST should be positive, six weeks to two months after immunization
Pertusis: Infection confers life long immunity
Do not give DPT to a child above five years.
IT a child develops fever 24 hours after DPT vaccine; it is unlikely to be due to DPT.
Measles: Exposure to measles is not a contraindication to vaccination if given within three days of exposure, it may provide protection.
< Maternal antibodies lasts longer than other antibodies, so immunization with measles vaccines is often not effective before six months.
< During epidemics, children between six – nine month may receive a dose, but a second dose has to be given at nine month of age, at least four
weeks apart.
< All children between six- nine month of age admitted to hospital should be given a dose of measles vaccine, this should not be marked on their
immunization card. < Another dose should be given at nine months
Preterm babies- immunize as others except:
< HBV for those born to HBsAg negative mothers,
delay vaccine till infant is 2kg or two month of age.
< Oral Rotavirus and OPV if used instead of IPV should not be administered to preterm infant until hospital discharge.
< first dose not administered before six weeks of age.
< minimal interval between doses is three weeks
< should not be initiated at seven month of age or after.
< all doses should be completed by the first birthday.
CI: 1. Hypersensitivity to amino- glycosides, amphoterricin B, or monosodium glutamate.
 < Moderate to severe febrile illness, known immuno deficiency
< Children of HIV infected mothers until test for HIV infection in the infant are negative at 2 month or above of age by PCR
or culture.
NB
Dose of various vaccines should not be reduced for any vaccine.
 
 
FAILURE OF VACCINE.
Due to a number of reasons.
a. Vaccine may have lost its potency thus no longer antigenic due to temperature change, sun-
light, detergents and antiseptic.
b. Vaccine may have expired
c. Antibodies acquired from the mother can neutralize the vaccine in the child’s body leading
to low immunological response and vaccine failure.
d. Some infection may make a vaccine ineffective.
e. severe malnutrition may also affect immunization response in a child whose immunological status is already poor.
 
SUCCESS STORY
Since the establishment of EPI of the WHO immunization rates for
the basic children’s vaccine has tremendously improved ;
< worldwide. 5% - 80%, in some countries.
< At least 2.7 million deaths due to measles, neonatal tetanus and Pertusis and 200, 000 cases of paralysis due to poliomyelitis are prevented each year.
< The program has helped reduce several thousands of deaths among the under five in addition to reducing the burden of morbidity due to infectious diseases and thus of growth faltering. < Indirectly, it has improved
their nutritional status.
< In addition, immunization against measles and Pertusis protects the child to an extent from the two major causes of acute respiratory tract infection (ARI) mortality.
< Measles immunization also reduced mortality from diarrhea and pneumonia--two main post-measles complications.
 
ARE THERE SOME CONTRA- INDICATIONS TO IMMUNIZATION?
We know certainly that no vaccine is totally without adverse re-
actions; but the risks of serious complications from EPI vaccine
are much lower than the risks from the natural diseases, thus
absolute contraindication to immunization are very few and as
listed below:
1.Acute severe illness accompanied by fever or systemic
upset, Such children should be immunized as soon as
possible after recovery.
2.Immunodeficiency diseases e.g. agammagblobulinaemia or
hypogammagblobulinaemia., immunosupression due to
malignant diseases such s leukaemia or tumours of the reticulo-
endothelial system or due to drugs such as systemic
corticosteroid at high dose.
HIV positive children may receive immunization, including live
virus as risk of diseases like measles is very high in such
children. In such children IPV may, however, be given as an
alternative to OPV>
3. History of severe adverse effects (anaphylaxis, collapse or
shock, encephalopathy, non-febrile convulsion) after a previous
does of a vaccine. In such a case subsequent dose of the same
vaccine should not be given.
4. History of allergic reactions (generalized urticaria, difficulty
in breathing, swelling of mouth and throat, hypotension, shock)
following egg ingestion. Persons in this category should not
receive vaccine prepared on hen’s egg tissue, e.g. yellow fever
and influenza vaccines.
5. Pregnancy is a contraindication to the use of live virus
because of the theoretical possibility of harm to the fetus
6. Children with neurological disorders such as uncontrolled
epilepsy, infantile spasms, progressive encephalopathy, should
not be given vaccine containing Pertusis antigen.
 
CARE OF VACCINES
  This entails proper cold chain
COLD CHAIN: This is a system of manufactures,
storage and distribution of vaccines in a potent state at
prescribed temperatures, from the manufacturer to the
actual vaccine site.
It is a logistic system involving equipment and
persons designated to preserve, transport distribute
and store vaccine in a potent state right from the
manufacture until it is finally administered to the target
group.
The chain stands from:
 
The manufacturing company
Via Road
 
AIR PORT (foreign)
By Air
 
User country
By Road from Airport
 
National cold store
 
Zonal stores
 
State stores
 
LG stores
 
District and PHC
 
Health facility
 National and zonal stores need cold room. (Sometimes state stores
too).
Equipment used in cold chain include:
(a) Vehicles; (Transport facility) air plane, ship, tracks, motor cycle
and
bicycle.
(b) Cold room.
- Ice lining refrigerators
- Ice pack refrigerators
- Deep freezers
- Cold boxes.
- Vaccine carriers
- Thermometers
- Temperature measuring strips
- Generators
-Spare parts for various cold chain equipments
-
The handlers (health workers) need to know;
- Which vaccines are sensitive to freezing
- Which are inactivate by heat
- Which to discard
- Which can still be used after a given period of melting
in ice pack, freezer refrigerator,
cold box or vaccine carrier.
 Vaccine storage time and temperature.
- Storage temperature is monitored twice a day including weekends.
Cold room are equipped with temperature recorders and back-up
generators are needed at the level to preserve large quantities of
vaccine.
- Refrigerators should be cleaned and defrosted regularly
SITE CENTRAL REGIONAL HEALTH CENTRE UP TO 1 MONTH TRANSPORT UP TO 1 WEEK
MAX. STORAGE TIME STORE UP TO
UP TO 3 MONTHS
8 MONTHS

Measles, Oral Polio Vaccine -150C – 250C -15_25

(OPV)

+2_8 |
DPT, Tetanus + 2OC to 8OC +20C to + 8OC
Toxoid (TT)
BCG
 
Vaccine Cold Chain monitors
This accompanies all vaccines supplied by UNICEF.
The monitors is a strip with 3 windows A, B, C, which when
exposed to increased temperature indicate by colour changes
consequently, the vaccine monitor will give the following
indicators about the vaccine in the cold box:
Half of Window A is blue = Vaccine exposed
above + 10oC.
Vaccine slightly damaged
but can still be used.
Window A completely blue = Vaccine can still be used
except non-heat
resistant polio vaccine
which must first be tested.
Window A & B blue = Vaccines can be used within
three months except heat sensitive
polio vaccine
which should be tested.
 
Window A, B, C, blue = Heat sensitive polio vaccine
to be tested
before use. Others, e.g.
measles can be sued within 3 months while
tetanus toxoid can be used
normally.
Disk labeled D is blue = Temperature over 35oC for
few hours only
but windows A, B, C are white.
Vaccines damaged but still
potent and can be used. Cold chain must be
checked.
Notes
- After dilusion- measles vaccine should be used-
up within 8hours or be discarded.
- BCG = Very unstable, use during one working
session
- OPV- Can withstand only one day at room
temperature
- Vaccine carriers stay cold for only 24-72 hours.
- Opened vials should not be put in the holes that
come with some ice packs, rather, a “foam pad”
should be used; it fits on top of the ice packs in a
vaccine carriers.
 
 
CHALLENGES OF E.P.I
Like all primary heath care programmes, the Expanded programme on
immunization poses some challenges and they include:
i. Mobilizing the community so that everyone spreads the word about immunization.
ii Getting the health authorities to ensure constant availability of vaccines
iii Educating and convincing parents to demand immunization for their children.
iv. Motivating mothers to act, to go back repeatedly until full dose is completed.

Clearly, it is only by making vaccines available in hospitals and health centers and by using all available resources to mobilize, educate, encourage, remind, and even pressurize mothers and families t take children to the vaccination centers on all
scheduled times and dates can these challenges be overcome.
CONCLUSION
Immunization, a very important component of PHC has
greatly reduced the morbidity and mortality from the
killer diseases among the under 5 thus it is very
important for us to remember that “Every contact a
child has with a health facility should be used as an
opportunity for vaccination because missed
opportunities contribute to low coverage levels and
higher incidence of the diseases.
 END

OF

PRESENTATION.

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