EXPANDED

PROGRAM ON
IMMUNIZATION
Introduction:
With the commitment of our country to Universal Child Immunization (UCI) Goal
acceleration of EPI coverage had began in 1986. The achievement of the fully immunized
child (FIC) coverage of 80% was noted one year ahead of the target date of UCI in 1990.
This was attributed to the strong political will and support from international partners,
better program management, and improvement in cold chain facilities for better
performance at all levels of health facilities. The development of the EPI Manual of
Operations with its clear guidelines for better planning, correct targeting, correct
immunization procedures, strategies appropriate for better link aging/coordination and
program implementation had contributed much for the success of the program.
Hepatitis B immunization has been integrated into the EPI in 1992 among infants 0-1
year of age. Due to high cost of vaccines only 40% of eligible targets were prioritized and
given with vaccination. This was the period of EPI Acceleration (1987-1992) that system
has been put in place.
The conceptualization and Introduction of the disease reduction initiative in early 90s
contributed to the declined of numerous cases of the immunizable disease. The four
major strategies includes:
1) Sustaining high routine FIC coverage of at least 90% in all provinces and cities,
2) Sustaining the polio free country for global certification,
3) Eliminating measles by 2008,
4) Eliminating neonatal tetanus by 2008. The development of National Plan of Action
for Polio Eradication has been done in 1990 which help a lot in the implementation of
the eradication of polio. Polio Eradication Project has been created in 1992 with the
expansion of sentinel sites for AFP reporting. The high routine coverage of FIC of 92%
has been achieved nationwide in the same year. This year also marked the
Presidential Proclamation # 46 with the affirmation of the commitment to the
Universal Child.
FAMILY HEALTH

Immunization and the Mother Immunization Goal which was

highlighted by the launching of the Polio Eradication Project.
National Immunization Days were conducted in 1993 to 1996
nationwide and Sub National Immunization Days in selected
areas with cases of polio and with low OPV coverage. This was
the period of excitement from 1993 to 1997 where all concerned
agencies public and private sector participated for the Oplan Alis
Disis.
The challenging period had started in 1998 up to the present
wherein our country had embarked on the Measles Elimination
to achieve the goal of eliminating measles by 2008. Mass
Measles vaccination among children ages 9 months to less
than 15 years were given nationwide regardless of
immunization status. This was the initial phase called the
Measles Catch-Up Campaign vaccinating 28 million children
(96%) that resulted to a drastic reduction of measles cases by
70%. In 2004, the Follow-Up Measles Campaign immunizing
children 9 months to less than five years of age had achieved
94% in all parts of the country.
In 2000 our country has been certified polio free in Kyoto Japan. This was
the greatest achievement of the Philippines as one of the certified polio
free in Western Pacific Region. The challenge is difficult to sustain since we
are at risk of importing polio from endemic areas. In 2000, the circulating
vaccine derived polio (cVDPV) had occurred in Cagayan de Oro, Laguna
and Cavite. In response to the CVPDPV outbreak a “Balik Polio Patak” has
been conducted nationwide immunizing children 0 to less than five years
of age regardless of immunization status with a coverage of 98.5% during
the first round and 101% for the second round while the routine coverage
of OPV3 remained low for many years. Many children are susceptible to
get polio infection and/or at risk of getting the disease.
The country’s neonatal tetanus (NT) rate is below 1/1,000 live
births. There are few cities and provinces remained to have
high NT rates. The focus of NT elimination was in areas with
low TT coverage and poor delivery care of babies but with
continuing TT routine vaccination in areas with good coverage
and good delivery care practices to sustain NT elimination. A
Maternal and Neonatal Tetanus Elimination Plan has been
developed for appropriate sourcing of funds and
implementation for NT elimination.
The Concept and Importance of Vaccination
Immunization is the process by which vaccines are introduced
into the body before infection sets in. Vaccines are
administered to induce immunity thereby causing the
recipient’s immune system to react to the vaccine that
produces antibodies to fight infection. Vaccinations promote
health and protect children from disease-causing agents.
Infants and newborns need to be vaccinated at an early age
since they belong to vulnerable age group. They are
susceptible to childhood diseases.
There are several general principles which apply in vaccinating children:
• It is safe and immunologically effective to administer all EPI vaccines on the same
day at different sites of the body.
• Measles vaccine should be given as soon as the child is 9 months old, regard less
of whether other vaccines will be given on that day. Measles vaccines given at 9
months provide 85% protection against measles infection. When given at one year
and older provides 95% protection
• The vaccination schedule should not be restarted from the beginning even if the
interval between doses exceeded the recommended interval by months or years.
• Moderate fever, malnutrition mild respiratory infection, cough, diarrhea and
vomiting are not contraindications to vaccination. Generally, one should immunize
unless the child is so sick that he needs to be hospitalized
• The absolute contraindications to immunization are:
✓DPT2 or DPT3 to a child who has had convulsions or shock within 3 days the
previous dose. Vaccines containing the whole cell pertussis component should not
be given to children with an evolving neurological disease (uncontrolled epilepsy
of progressive encephalopathy)
✓Live vaccines like BCG vaccine must not be given to individuals who are
Immunosuppressed due to malignant disease (child with clinical AIDS),

• Therapy with immunosuppressive agents, or irradiation. It is safe and effective with

mild side effects after vaccination. Local reaction, fever and systemic symptoms can
result as part of the normal immune
response.
• Giving doses of a vaccine at less than the recommended 4 weeks interval
may lessen the antibody response Lengthening the interval between doses
of Vaccines leads to higher antibody levels.
•No extra doses must be given to children/mother who missed a dose of
DPT/ HB/OPV/TT. The vaccination must be continued as if no time had
elapsed between doses. Strictly follow the principle of never, ever
reconstituting the freeze dried vaccines in anything other than the diluent
supplied with them.
• False contraindications to immunizations are children with malnutrition,
low grade fever, mild respiratory infections and other minor illnesses and
diarrhea should not be considered a contraindication to OPV vaccination.
Repeat BCG vaccination if the child does not develop a scar after the 1st
injection.
• Use one syringe one needle per child during vaccination.
The EPI Target Diseases
• Vaccination among infants and newborns (0-12 months) against the seven vaccine
preventable diseases. These include: tuberculosis, diphtheria, pertussis, tetanus,
poliomyelitis, measles and Hepatitis (See list of EPI Diseases with the corresponding WHO
standard case definition)

WHO STANDARD CASE DEFINITION OF EPI TARGET

DISEASES
Disease: Measles
Standard Case Definition: A highly communicable
disease with the history of the following:
• Generalized blotchy rash, lasting for 3 or more days
Fever(above 38°C or "hot" to touch and
•Any of the following:
cough
runny nose
red eyes/ conjunctivitis
Agent: Virus
Reservoir: Humans
Source of Infection: Close respiratory contact and aerosolized droplets
Occurrence: Worldwide Mortality and morbidity higher in developing countries
Transmissible Period: 4 days before until 2 days after rash
Duration of Natural Immunity: Lifelong after attack
Risk Factor of Infection: Crowding Low socio economic status
Disease: Tuberculosis
Standard Case Definition: • A child with history
of contact with a suspect or confirmed case of
pulmonary tuberculosis
• Any child who does not return to normal
health after measles or whooping cough
• Loss of weight, cough, and wheeze which
dose 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 lympnodes
•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
Source of Infection: Droplet infection, that is through
inhalation of bacilli from patients
Occurrence: • Worldwide
• Mortality and morbidity higher in
developing countries
Transmissible Period: A person who excretes tubercle
bacilli is communicable
• The degree of communicability depends upon :
-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 of Infection: •Low access to care
Immunodeficiency
•Malnutrition Alcoholism Diabetes
Disease: Diphtheria Duration of Natural Immunity:
Standard Case Definition: It is an acute pharyngitis, Usually lifelong
acute nasopharyngitis or acute laryngitis with a Risk Factor of Infection: Crowding
pseudo membrane Low socio economic status
Agent: Coryne bacterium diphtheria
Reservoir: Man
Source 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.
Disease: Pertussis
Standard Case Definition: History of severe
cough and history of any of the ff: cough
persisting 2 or more weeks; fits of coughing,
and cough followed by vomiting
Agent: Bordet Ella pertussis
Reservoir: Man
Source 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
Duration of Natural Immunity: Usually
lifelong
Risk Factor of Infection: Young age
crowding
Disease: Hepatitis B
Standard Case Definition: It is the liver
Hepatitis b infection caused virus by the B type
of hepatitis virus. I attacks the liver often
resulting in inflammation.
Agent: Hepatitis b virus
Reservoir: Man
Source of Infection: Hepatitis B spreads
through the ff:
-from child to child or mother to child after
birth -from mother to child during birth
- through sharing od unsterilized needles,
knives or razors
-through sexual intercourse
Occurrence:
• In the Phillis. 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 esp. dangerous for children
Transmissible Period:
•Infants are 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 unapparent infection or
complete immunization series with diphtheria toxoid.
Duration of Natural Immunity: If develops, lifelong
Risk Factor of Infection: HBeAg + mother Multiple sexual
partners;
Disease: Poliomyelitis
Standard Case Definition: A suspect cases of
polio is defined any patient below 15 years of
age with acute flaccid paralysis (including those
with infected persons diagnosed to have
Guillaine Barre Syndrome) for which no other
cause can be immediately identified.
Agent: Poliovirus type 1,2, and 3
Reservoir: Man mostly children
Source 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
Duration of Natural Immunity: Type
specific immunity lifelong
Risk Factor of Infection: Poor
environmental hygiene
Disease: Neonatal Tetanus
Standard Case Definition: A newborn with history
of all three of the ff:
•normal suck for the first two days of life
•onset of illness between 3 to 26 days
•inability to suck followed by stiffness of the body
and /or convulsions
Agent: Clostridium tetany
Reservoir:
•soil
•intestinal canals of animals (esp. horses)
• man
Source of Infection: -Unhygienic cutting of
umbilical cord
-Improper handling of cord stump esp when
treated with contaminated substance
Occurrence:
•Worldwide
•morbidity higher in developing agriculture and
Countries more common in 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 of Infection: Contamination of
umbilical cord Agricultural work
The EPI Routine Schedule of Immunization
Every Wednesday is designated as immunization day and is adopted in all
parts of the country. In a barangay health station immunization is done
monthly while in far flung areas it is done quarterly. However, some areas
adopted local practices to provide everyday vaccination in their areas to
cover all targets.

Routine Immunization Schedule for Infants

The standard routine immunization schedule for infants is adopted to
provide maximum immunity against the seven vaccine preventable diseases
before a child’s first birthday. A child is said to be “Fully Immunized Child
when a child receives one dose of BCG, 3 doses of OPV, 3 doses of DPT, 3
doses of HB and one dose of measles before a child’s first birthday.
Vaccine Minimum Age at 1st Number of doses Minimum interval Reason
dose between

BCG Birth or anytime 1 BGC given at earliest

after birth possible age
protects the
possibility of TB
meningitis and other
TB infants are prone.
DPT 6 WEEKS 3 4 weeks An early start with
DPT reduces the
chance of severe
pertussis
Vaccine Minimum Age at 1st Number of doses Minimum interval Reason
dose between doses
OPV 6 weeks 3 4 weeks The extent of
protection against
polio is increased the
earlier the OPV is
given keeps the polio
free
Hep B At birth 3 6 weeks interval An early start of Hep
from 1st dose to 2nd B reduces the
dose and 8 weeks chance of being
imterval from 2nd infected and
dose to third dose becoming a carrier
prevent liver cancer.
About 9000 die of
complications of HB.
10% of Filipinos have
chronic HB infection.
Eliminate HB before
2012(A Western
Regional goal
Vaccine Minimum Age Number of Minimum Reason
at 1st dose doses interval
between doses
Measles 9 months At least 85% of
measles can be
prevented by
immunization at
this age Prevents
deaths(2% die),
malnutrition,
pneumonia,
diarrhea (at
least 20%) get
these
complications
from measles by
2008
Tetanus Toxoid Immunization Schedule for Women Tetanus toxoid vaccination for women is
important to prevent tetanus in both mother and the baby. When two doses of TT injection
given at one month interval between each dose during pregnancy or even before pregnancy
period the baby is protected against neonatal tetanus. Completing the five doses following
the schedule provide lifetime immunity (see vaccination schedule below).
Vaccine Minimum Age/interval Percentage Protected Duration of Protection

TT1 As early as possible during

pregnancy

TT2 At least 4 weeks later 80% • Infants born to the

mother will be
protected from
neonatal tetanus
Vaccine Minimum Age/interval Percent Protected Duration of Protection

• Gives 3 years protection

for the mother

TT3 At least 6 months later 95% • Infants born to the

mother will be protected
from neonatal tetanus
• Gives 5 years protection
for the mother

TT4 At least 1 year later 99% • Infants born to the

mother will be protected
from neonatal tetanus
• Gives 10 years protection
for the mother

TT5 At least one year later 99% • Gives life time protection
for the mother
• All infants born to that
mother will be protected
The EPI Vaccines and its Characteristics
Vaccines are substances very sensitive at various temperature. To avoid spoilage and maintain
its potency, vaccines need to be stored at correct temperature. Below are recommended
storage temperatures of EPI vaccines.
Type/Form of Vaccines Storage Temperature

Most Sensitive to Heat Oral Polio(live attenuated) -15°C to -25°C (at the freezer)

Most Sensitive to Heat Measles (freeze dried) -15°C to -25°C (at the freezer)

Least Sensitive to Heat DPT/Hep B +2°C to +8°C (in the body of the
“D” Toxoid which is a weakened toxin refrigerator)
“P” killed bacteria “T” Toxoid which is a
weakened toxin

Least Sensitive to Heat Hep B +2°C to +8°C (in the body of the
refrigerator)
Least Sensitive to Heat BCG (freeze dried) and Tetanus Toxoid +2°C to +8°C ( In the body of the
refrigerator)
When handling, transporting and storing vaccines, special care must be given to provide quality
potent vaccines among the targets.

A “first expiry and first out” (FEFO) vaccine is practiced to assure that all vaccines are utilized
before its expiry date. Proper arrangement of vaccines and/or labelling of vaccines expiry date
are done to identify those near to expire vaccines.

Temperature monitoring of vaccines is done in all levels of health facilities to monitor vaccine
temperature. This is done twice a day early in the morning and in the afternoon before going
home. Temperature is plotted every day in a temperature monitoring chart to monitor break in
the cold chain.

Each level of health facilities have cold chain equipment for use in the storage monitor, ice
packs, temperature monitoring chart, safety collector box, etc. These carrier Other cold chain
logistics supplies includes thermometers, cold chain of vaccines These are cold room, freezer,
refrigerator, transport box, vaccine are essentials in proper management of vaccines and other
EPI logistics
Administration of Vaccines
Vaccine Dose Route of Administration Site of Administration

BCG Infants 0.05 ml Intradermal Right deltoid region of the

arm

DPT 0.5ml Intramuscular Upper outer portion of the

thigh

OPV 2 drops or depending on Oral mouth

manufacture’s instructions

Measles 0.5 ml Subcutaneous Outer part of the upper

arm
Vaccine Dose Route of Administration Site of Administration

Hep B 0.5 ml Intramuscular Upper outer portion of the

thigh
Tetanus Toxoid 0.5 ml Intramuscular Deltoid region of the upper
arm

Procedures in the giving of vaccines:

Reconstituting the freeze dried BCG Vaccine:
a. Always keep the diluent cold by sustaining with BCG vaccine ampules in refrigerator or vaccine
carrier.
b. Using a 5 ml. syringe fitted with a long needle, aspirate 2 ml. of saline solution from the
opened ampule of diluent.
c. Inject the 2 ml. saline into the ampule of freeze dried BCG.
d. Thoroughly mix the diluent and vaccine by drawing the mixture back into the syringe and
expel it slowly into the ampule several times.
e. Return the reconstituted vaccine on the slit of the foam provided in the vaccine carrier.
Giving BCG Vaccine:
a. Clean the skin with a ‘cotton ball moistened with water and let skin dry.
b. Hold the child’s arm with your left hand so that: your hand is under the arm and your thumb
and fingers come around the arm and stretch the skin.
c. Hold the syringe in your right hand with the bevel and the scale pointing up towards you.
d. Lay the syringe and needle almost flat along the child’s arm.
e. Insert the tip of the needle into skin- just the bevel and a little bit more. Keep the needle flat
along the skin and the bevel facing upwards, so that the vaccine only goes into the upper
layers of the skin.
f. Put your left thumb over the needle end of the syringe to hold it in position. Hold the plunger
end of the syringe between the index and middle fingers of your right hand and press the
plunger in with your right thumb.
g. If the vaccine is injected correctly into the skin, a flat wheal with the surface pitted like an
orange peel will appear at the injection site.
h. Withdraw the needle gently.
Giving Oral Polio Vaccine:
a. Read the manufacturer’s instructions to determine number of
droplets to be given. Use the dropper provided for.
b.Let the mother hold the child lying firmly on his back.
c. If necessary open the child’s mouth by squeezing the cheeks gently
between your fingers to make his lips point upwards.
d.Put drops of vaccine straight from the dropper onto the child’s
tongue but do not let the dropper touch the child’s tongue.
e.Make sure that the child swallows the vaccine. If he spits it out, give
another dose.
Giving Hepatitis B/DPT
Hepatitis B and DPT
a. Ask mother to hold the child across her knees so that his thigh is facing
upwards. Ask her to hold child’s legs.
b. Clean the skin with a cotton ball, moistened with water and let skin dry.
c. Place your thumb and index finger on each side of the injection site and
grasp the muscles slightly. The best injection site is the outer part of the
child’s mid thigh
d. Quickly push the needle into the space between your fingers, going deep
in
e. Slightly pull the plunger back before injecting to be sure that vaccine is
not the injected into a vein (if using disposable syringes and needles).”
f. Inject the vaccine. Withdraw the needle and press the injection spot
quickly with a piece of cotton.
Measles
Reconstituting the Freeze Dried Measles Vaccine
a. Using a 10 ml. syringe fitted with a long needle, aspirate 5 ml. of special diluent, from the
ampule.
b. Empty the diluent from the syringe into the vial with the vaccine.
c. Thoroughly mix the diluent and vaccine by drawing the mixture back into the syringe and
expelling it slowly into the vial several times. Do not shake the vial.
d. Protect reconstituted measles vaccine from sunlight. Wrap vial in foil.
e. Place the reconstituted vaccine in the slit of the foam provided in the vaccine carrier.
Giving Measles Vaccine
f. Ask the mother to hold the child firmly.
g. Clean the skin with a cotton ball, moistened with water and let the skin dry.
h. With the fingers of one hand, pinch up the skin on the outer side of the upper arm.
i. Without touching the needle, push the needle into the pinched-up skin so that it is not
pointing.
j. Slightly pull the plunger back to make sure that the vaccine is not injected into a vein (if using
disposable syringes and needles).
Tetanus Toxoid
Giving Tetanus Toxoid
a. Shake the vial.
b. Clean the skin with a cotton ball, moistened with water and let skin dry.
c. Place your thumb and index finger on each side of the injection site and grasp
the muscles, slightly. The best injection site for a woman is outer side of the left
upper arm.
d. Slightly pull the plunger back before injecting to be sure that vaccine is not
injected into a vein. E. Quickly push the needle into the space between your
finger, going deep in the muscle.
e. Inject the vaccine. Withdraw the needle and press the injection spot quickly with
a piece of cotton.

Note: Shake the vial before every injection.

The Role of A Nurse In Improving the Delivery of Immunization Services in the Community
Health workers are vital to health care delivery system. The most critical problem we are facing
now is the lack of nurses and other disciplines in carrying out health activities in immunization.
Your presence in the community is a big contribution to program health development. For every
child you have been immunized reduces missed opportunity and help increase population
immunity of the population groups.

As a nurse you need to:

• Actively master list infants eligible for vaccination in the community • Immunize infants
following the recommended immunization schedule, route of administration, correct dosage and
following the proper cold chain storage of vaccines.
• Observe aseptic technique on immunization and use one syringe and one needle per child .This
reduces blood-borne diseases and promote safety injection practices.
• Dispose used syringes and needles properly by using collector box and disposing it in the septic
vault to prevent health hazard Inform, educate and communicate with the parents
- to create awareness/motivate to submit their children for vaccination
- to provide health teachings on the importance and benefits of immunization, importance
of follow up dose to avoid defaulters and normal course of vaccine
- to inform immunization schedule as adopted by local units
•Conduct health visits in the community to assess other health needs of the community and be
able to provide package of health services to targets Identify cases of EPI target diseases per
standard case definition
•Manage vaccines properly by following the recommended storage of vaccines
•Record the children given with vaccination in the Target Client list and GECD/ GMC card or any
standard recording form utilized Submit report and record of children vaccinated, cases and
deaths on EPI diseases, vaccine received and utilized and any other EPI related reports.
•Identify and actively search cases and deaths of EPI target diseases following standard case
definition
THANK YOU FOR LISTENNING