Expanded Program on Immunization (EPI)

1. Coverage
1. a.Target Setting:
1. Target Population is the population group meant to be benefited by the EPI Programs where DOH is responsible
1. Infants (0-12)-get the 3% of population
2. School Entrants-get the 3% of population (dictum of DOH)=6 years
3. Pregnant Women-get the 3.5% of population (MWKA)=15-49 years
2. Eligible Population (EP) are those qualified to receive specific immunizations where PHW is responsible→ PHN, RHM, MO
• 3 Population Groups to benefit:
1. Infants (I)-BCG, DPT, OPV, HBV, MV
2. School entrants (SE)-Booster of BCG
3. Pregnant women (PW)-Tetanus toxoid
• To determine Eligible Population:
• EP=Population of the Community x 0.03 (Infant & SE) or x 0.035 (PW)
• Example: Lanting Community with a population of 7000
1. a) DPT=for infants
• EP=7000 x 0.03=210 to receive DPT
2. b) Tetanus Toxoid=for pregnant women
• EP=7000 x .035=245 to receive TT
3. c) Booster BCG=for school entrants
• EP=7000 x 0.03=210 to receive booster BCG
2. Fully Immunized Child (FIC)-is a child who receives the 5 sets of vaccines (BCG, DPT, OPV, Hep B & Measles and who receives 11 doses of vaccines
• MV may be given 6 months if there is an epidemic.
3. Wastage Allowance
• DOH don’t produce vaccines biologically and therefore dependent on suppliers abroad: Germany & Switzerland to economize:
1. 1) Be aware of the availability of vaccines:
• Example: BCG CHN: vial Private Practice: ampule Frozen powder with a diluent (1 ml per content)
2. How many recipients:
• Availability Dosage for I=.05 ml
• Dosage to be given Dosage for SE=0.1 ml
• I=1 ml (availability), .05 ml (dosage) =20 recipients in 1 vial/1 ml
• SE=1 ml(availability), .1 ml(dosage) =10 recipients
• Follow DOH Dictum: On the day of immunization, if 50% & above of computed recipients arrive in the health center, open a vial but if less than 50%, don’t open.
• Example: In 20 recipients, 10 arrived=open a vial
• Half life of Vaccines is the duration of potency:
1. Vaccine with 4 hours half life: BCG, MV (need to mix).
• If open at 8:00 am, it’s good till 12:00 noon. 12:30 pm, don’t give anymore because it’s not potent anymore.
2. Vaccine with 8 hours half life: DPT, OPV, HBV, TT (already in solution/liquid form ready to administer).
• Parenteral=Salk vaccine (sinasaksak) has 5 ml per content.
• Oral Polio Vaccine (OPV)=Sabin (sa bibig).
• For OPV: 5 ml (availability)→ 1 ml=15 gtts→ 1 ml=15 gtts=5 recipients
• 3 gtts (dosage) 2ml=30 gtts=10 recipients
• 3 ml=45 gtts=15 recipients
• 4 ml=60 gtts=20 recipients
• 5 ml=75 gtts=25 recipients
• Examples:
1. Mrs Dela Cruz received the 1st booster dose (TT3) on November 20, 2004. When is the 2nd booster? November 20, 2005.
2. As a child, you have 3 doses of DPT. Now you become pregnant. What you need to receive are the 3 booster doses only-TT3, TT4 & TT5 respectively.
3. If as a child, only 1 dose of DPT was given, is there a definite immunity? There’s no definite # of years of immunity. If until 3 years she failed to receive vaccine, she got to start with the 1st dose.

Steps to Compute the Number of Vaccine to be Requested from DOH

1. Determine the Eligible Population (EP)
• EP=Population of the Community x 0.03 (I & SE) or 0.035 (PW)
2. Determine the Annual Dose (AD)
• AD=EP x # of doses of the vaccine
3. Determine the Wastage Allowance (WA)
• WA=computed AD x MF of the vaccine
4. Determine the Complete Coverage (CC)
• CC=WA ÷ # of recipients per vaccine
• OT=CC x 1.25 (constant), DOH usually grants an allowance of 25% of the CC
5. Determine the Overall Total in Allowance (OT)
• OT=CC x 1.25 (constant), DOH usually grants an allowance of 25% of the CC
• Example: Determine the # of vaccines to be requested from DOH of DPT for Lanting
• Community with a population of 4000
1. EP=4000 x 0.03=120
2. AD=120 x 3 doses=360
3. WA=360 x 1.67=601
4. CC=601 ÷ 20=30
5. 30 x 1.25=37.5 or 38 vials to be given by DOH (or 8 vials allowance)
2. Cold Chain: tools or procedures to follow to keep vaccine potent (expected desired effect)
3. Immunization

Policies:

1. Proper Storage: store vaccines in refrigerators
• RHO 3° Given 6 months to store vaccines
• MHO PHO 2° Given 3 months to store vaccines
• BHS RHU 1° Given 1 month to store vaccines RHCDS
• Freezer OPV: most sensitive to heat
• -15° C to -20° C: MV
• Body of Refrigerator: BCG
• 2° C to 8° C: DPT, HBV, TT: least sensitive to heat
• OPV & MV: highly sensitive to heat
• OPV, MV & BCG: Not damage by freezing
• DPT, HBV & TT: Damaged by freezing so not placed in the freezer
2. Proper Transport
• Vaccines are to be transported from the health center to the area of immunization (community: focused, based & oriented)
• Tools provided by DOH: Vaccine Carrier which maybe
1. Black: use by staff of HC during epidemic & needs 5 cold dogs
2. White: use by student affiliates & needs 4 cold dogs
• Cold Dogs: 4 plastic containers filled with water which is placed in the freezer a day before immunization which is used as freezant to keep vaccine potent
3. Proper Handling of Vaccine (After Care of Vaccine): Dictum of DOH
1. Vaccines which are opened, though not consumed, should be discarded
   Reasons: can’t be used for future program because vaccine have half life (duration of potency of vaccine) BCG -4 hours half life MV Other vaccines -8 hours half life BCG, OPV & MV are composed of live attenuated bacteria & virus so before discarding them, disinfect 1st with 1% Hcl or any disinfectant like zonrox, chlorox or dumex BCG (Bacilli Calmette-Guerin Vaccine): live attenuated bacteria OPV & Measles Vaccine: live attenuated virus DPT, HBV & TT can be readily discarded if not consumed DPT: Diphtheria-weakened toxoid treated with chemical solution to weaken microorganism Pertussis-killed bacteria Tetanus-weakened toxoid HBV: plasma derived, identified to be RNA & DNA recombinant from blood TT: weakened toxoid
2. Vaccines which are taken out from Health Center for 3x or more are considered overly exposed & not potent anymore therefore it should be discarded
   Put notation (state the date) on the unopened vaccine as to when it was taken out from health center example: May 19, 2006, Jun. 19, 2006, Jul. 19, 2006: can’t be used anymore after this

Guiding Principles for HW in Administering Vaccines & Screening of Children for Immunizations:

1. No BCG for a child born clinically positive to AIDS because they have a damage immune system & introducing bacteria will further aggravate their condition
2. There are no contraindications such as slight fever, LBM, cough & colds and malnutrition, in giving the immunization unless upon assessment of the practitioner that the child has serious medical problems that warrants hospitalization
3. In giving immunization with multiple doses such as DPT, OPV & HBV, continue counting in giving the doses. Never count back even though the interval exceeds weeks, months or years. As long as the child is on the eligible age
• Example: DPT, OPV & HBV 1st dose: At 6 weeks (1 ½ months), the child was given vaccination 2nd dose: The mother brought back the child when he was 8 months old instead at 10 weeks (2 ½ months). PHN should still give the 2nd dose 3rd dose: The mother brought back the child at 2 years old. PHN should still give the vaccine because child is still at the eligible age (0-59 months or 4 years & 11 months or 5 years old) to receive vaccine
4. DPT: it is a normal reaction for a child to develop high grade fever because of the pertussis component (killed bacteria)
• SOP Management: Paracetamol q 4 hours RTC for the 1st 2 days (or 3, 4 days if still febrile) If after 1st dose of DPT, the child develops high grade fever with convulsion, DPT 2 & 3 are not given anymore because convulsion affects the brain cells resulting to brain damage
  DPT vaccine is only for prophylactic/preventive use
5. Things to consider in administering vaccines:
1. Vaccine
2. Dosage
3. SOA (Site of Administration)
4. ROA (Route of Administration)
5. Side Effect: patterns of reaction that is considered normal

• If after BCG, there is no soreness & inflammation, no abscess & ulceration and no scar developed, there is wrong preparation of site where PHW used alcohol that kills the microorganism contained in the BCG vaccine. Thus, repeat the dose on same site but a little lower.
• Site preparation: Use clean cotton ball & wet with sterile water only
• For non-healing abscess & ulceration:
• BCG was wrongly administered by IM or SQ by PHW so incision & drainage should be done by MD only and INH (Odinah) tablet, an anti-bacterial, pounded, pulverized & applied on the site. Then repeat the dose again but not on the same site.

• 2 Forms of Immunization Conferring Immunity:
1. Natural
1. Active
2. Passive
2. Artificial

Immunity

Natural

• Provided by nature
• No vaccine was given
• Duration is longer/even for a lifetime

Active=person himself is involved in the production of antibodies

1. Carrier (person harbors the disease but asymptomatic) of the disease
2. Constant exposure to disease
3. Acquired or experienced the disease

Passive

1. 1. Breastfeeding→ IgA (present in colostrums)
2. 2. Perinatal→ immunity is acquired during the term of pregnancy

Artificial

• Accepts vaccine
• Duration is shorter period Example: BCG-vaccine for protection from TB gives 7-10 years immunity so booster is needed HBV-after 3 doses booster is needed after 1 year

Active=person himself has no participation and done by another person Upon receiving vaccine (antigen) for immunizable diseases such as BCG, DPT, OPV, MV and HBV

Passive

1. 1. Serum (Blood): HBV ATS (Anti-Tetanus Serum) ADS (Anti-Diptheria Serum)
2. 2. Antitoxin: poison or causes infection TAT (Tetanus Antitoxin) DAT (Diptheria Antitoxin)
3. 3. Immunoglobulins: IgA, IgD, IgE, IgG