The Expanded Program On The Expanded Program On ImmunizationImmunization

(EPI)(EPI)

Bacille Calmette-Guérin (BCG) Bacille Calmette-Guérin (BCG) VaccineVaccine::

Live attenuated vaccineLive attenuated vaccine

Store at 0° to 8°CStore at 0° to 8°C

Age : at birth or 6 weeksAge : at birth or 6 weeks

Route of administrationRoute of administration : :

a single intra dermal injection over the deltoid a single intra dermal injection over the deltoid muscle of the arm or left forearmmuscle of the arm or left forearm. .

At site of injection: development of erythema At site of injection: development of erythema and either a papule or ulceration, followed by and either a papule or ulceration, followed by a scar at the immunization sitea scar at the immunization site..

Bacille Calmette-Guérin (BCG) VaccineBacille Calmette-Guérin (BCG) Vaccine::

Side effectsSide effects::

LymphadenitisLymphadenitisContraindicationContraindication::

Immune deficiency diseases, including congenital Immune deficiency diseases, including congenital immunodeficiency, HIV infection and impaired immune immunodeficiency, HIV infection and impaired immune function secondary to treatment with corticosteroids, function secondary to treatment with corticosteroids, chemotherapeutic agents or radiation. chemotherapeutic agents or radiation.

ORAL POLIO VACCINE (OPV)ORAL POLIO VACCINE (OPV)

Contents:Contents:  Sabin attenuated polio virus (live  Sabin attenuated polio virus (live attenuated vaccine)attenuated vaccine)

Ideal age of Initiating primary vaccinationIdeal age of Initiating primary vaccination : :

66 weekweek

( ( an additional dose recommended at birth by an additional dose recommended at birth by W.H.O. OPV0W.H.O. OPV0 ) )

ORAL POLIO VACCINE (OPV)ORAL POLIO VACCINE (OPV)

Boosters:Boosters: Two, at 1.5 years and between 4-5 Two, at 1.5 years and between 4-5 yearsyears..

Dose: Dose: 2 drops2 drops . .

Route of administration:Route of administration: Oral Oral..

ORAL POLIO VACCINE (OPV)ORAL POLIO VACCINE (OPV)

Contra – Indications: Contra – Indications:

Immunocompromised host or household Immunocompromised host or household member. member.

Side effects: NoneSide effects: None . . Complications: Vaccine induced Complications: Vaccine induced

poliomyelites (one in 3 million vaccine) poliomyelites (one in 3 million vaccine) The dose of OPV given during an episode of The dose of OPV given during an episode of

diarrhea should not be counted and shoud diarrhea should not be counted and shoud be to given at the earliest opportunity be to given at the earliest opportunity

ORAL POLIO VACCINE (OPV)

Pentavalent VaccinePentavalent VaccineContents:Contents: Each 0.5 ml contains Each 0.5 ml contains::

    Diphtheria toxoid, Tetanus toxoid, pertussis, Hepatitis B, Diphtheria toxoid, Tetanus toxoid, pertussis, Hepatitis B, Haemophilus influenzae bHaemophilus influenzae b..

TheThe vaccine should not kept frozen or exposed to freezingvaccine should not kept frozen or exposed to freezing

Store at 2° to 8°CStore at 2° to 8°C

Dose: Dose: 0.5 ml0.5 ml . .

Pentavalent VaccinePentavalent Vaccine

Route of administration:Route of administration: Deep intramuscular Deep intramuscular . .

Site of administration:Site of administration: Anterolateral aspect of Anterolateral aspect of thighthigh..

Pentavalent VaccinePentavalent Vaccine

Side effects:Side effects: Fever, local pain and swelling Fever, local pain and swelling..

Instruction to the mother after vaccination: Instruction to the mother after vaccination: To give antipyretic (paracetamol) in case of To give antipyretic (paracetamol) in case of

feverfever . .

Complications: Convulsions, shock, encephalitis .

Contra- Indications:       a. Progressive neurological disease.

b. Uncontrolled convulsions       . c. Severe reactions to first or subsequent dose

local reactions : swelling, redness, or pain at the injection site.

Measles VaccinesMeasles Vaccines

Contents:Contents: live attenuated measles virus grow in chick live attenuated measles virus grow in chick embryo cellsembryo cells . .

Store at 0 to 8°CStore at 0 to 8°C

Ideal age of Primary vaccinationIdeal age of Primary vaccination::

99 monthsmonths . .

In epidemics & household contacts should be In epidemics & household contacts should be between 6-9 monthsbetween 6-9 months

Measles VaccinesMeasles Vaccines

Dose:Dose: 0.5 ml 0.5 ml . .

Route of administration:Route of administration: Subcutaneous Subcutaneous . .

Site of administration:Site of administration: Upper arm or anterolateral aspect of Upper arm or anterolateral aspect of

thighthigh..

..

MeaslesMeasles

Side effects: :Side effects: : Mild fever & rash may appear Mild fever & rash may appear after 5-7 daysafter 5-7 days . .

Contra-IndicationsContra-Indications::             

Immuno compromised hostImmuno compromised host    .    .

Severe (anaphylactic) egg allergySevere (anaphylactic) egg allergy . .

Rotavirus VaccinesRotavirus Vaccines

Contains one strain of live attenuatedContains one strain of live attenuated

rotavirus (type G1P[8]rotavirus (type G1P[8]

Store at (2-8Store at (2-8oo C) and protect from light C) and protect from light

Rotavirus VaccineRotavirus Vaccine

Dose: 1.5 mlDose: 1.5 ml22 dosesdoses

minimum interval between doses is 4 weekminimum interval between doses is 4 week

AgeAge-:-:

beginning at 6weeks of agebeginning at 6weeks of ageEarly immunization is favoured with the first dose of rotavirus vaccine to Early immunization is favoured with the first dose of rotavirus vaccine to

be administered frombe administered from66 weeks of age, however, in order to benefit those who may come late weeks of age, however, in order to benefit those who may come late

infants can receive dosesinfants can receive doseswithout age restriction. Because of the typical age distribution of rotavirus without age restriction. Because of the typical age distribution of rotavirus

gastroenteritisgastroenteritis ( (rotavirus vaccination of children >24 months of age is not recommendedrotavirus vaccination of children >24 months of age is not recommended..

Rotavirus VaccineRotavirus VaccineContraindicationsContraindications

Severe allergic reaction to a vaccine Severe allergic reaction to a vaccine component or following a prior dose of component or following a prior dose of vaccinevaccine

Rotavirus VaccineRotavirus VaccinePrecautionsPrecautions**

Altered immunocompetenceAltered immunocompetence

History of intussusceptionHistory of intussusception

*the decision to vaccinate if a precaution is present should be made on a case-by-case risk and benefit basis

Rotavirus VaccineRotavirus VaccineAdverse ReactionsAdverse Reactions

VomitingVomiting DiarrheaDiarrhea Irritability Irritability FeverFever

Serious adverse reactionSerious adverse reaction None None

Contraindications to vaccinations:

•Absolute

•Temporary

Contraindications to live attenuated vaccines:Absolute:1- History of anaphylactic reactions.

2- Subsequent doses of pertussis vaccines are absolutely

contraindicated if the child gets (within 48 hours of vaccination )

• Fever (40.5º) ,

•Collapse or shock .

•Persistent crying for 3 hours without apparent cause.

•Convulsion with or without fever within 3 hours after

vaccination.Give a single dose vaccine of diphtheria + tetanus pediatric formula ( avoid pertussis component).

Contraindications to live attenuated vaccines:Absolute:

3- HIV infection is an absolute contraindication to administration of

live attenuated vaccines ( OPV & BCG).

Temporary:

1- Severe illness that needs hospitalization.Deferred immunization till the infant recovers and could be at discharge.

2- Immunosuppression.

The strategy for the vaccine delivery

The strategy for the vaccine delivery:

(I) The fixed site strategy.

(II) Outreach site strategy.

(III) Mopping up Immunization.

(IV) The National Immunization Days (NIDs).

1. The fixed site strategy:

There is integration of immunization services through (MCH): Advantages:-

1-Available resources.

2- Cold Chain maintenance.

3- Save ,time, effort and money.

2.The out reach Strategy The outreach is carried for routine immunization that is compulsory

for the targets in certain areas where:

- immunization services are not accessible.

- vaccination coverage is Low.

Limitations:

(i) Expensive

(ii) Cold chain failure.

(iii) Difficulty to arrange the immunization schedule.

(Outreach immunization

(3) Mopping up Immunization:

• It is house-to-house immunization with OPV in high risk districts.

• High risk districts are those:

• Where the wild polio virus is still circulating

• With low immunization coverage.

• Population, with overcrowding poor sanitary environment

and low access to health services.

(4) The National Immunization Days (NIDs):

It is periodic immunization of all the eligible targets in a defined

group over a large geographic areas within a short period of time. It

is one of the strategy for polio eradication and tetanus elimination.

The cold chain

The cold chain:

It is the system of storage and transportation of the

vaccine at low temperature (cold condition) from the

manufacture till it is consumed.

The cold chain:

• Polio vaccine is the most sensitive vaccine to heat.

• Live attenuated vaccines are allowed to be frozen (OPV,

Measles and BCG).

• Inactivated vaccines must not be frozen ( DPT, DT, dT , TT

and HB) .

The levels of cold chainThe levels of cold chain

The administrative level

Storage period

TemperatureThe vaccines

Central & regional stores

Maximumthree months

-20° to- 30°COPV, Measles,

MMR,BCG

+2° to +8°CDPT, DT, dT, TT& HB,Hib

Districts stores& local immunization

centers

Maximumone month

0°C to+8°COPV, Measles,

MMR, BCG

+2° to +8°CDPT, DT, dT, TT& HB,Hib

The administrative levels of cold chain according to the duration of the storage and the temperature required to keep

the vaccine potent

The equipment and tools

The proceduresThe health staff

The components of the cold chain :

Refrigeration equipment: Refrigerator

Cold boxes

Vaccine carriers

The ice packs retained in the freezer

-To stabilize the temperature of the refrigerator at the

optimum level.

- Fully frozen ice-packs are used for lining the vaccines

carriers and the cold boxes during storing the vaccines

Cold Chain EquipmentCold Chain EquipmentCold Chain EquipmentCold Chain Equipment

The recommendedThe recommended

equipment  equipment  typically used for typically used for vaccine storage are vaccine storage are ::

cold rooms, cold rooms, refrigerators and refrigerators and freezers.  freezers. 

The recommendedThe recommended

equipment  equipment  typically used for typically used for vaccine storage are vaccine storage are ::

cold rooms, cold rooms, refrigerators and refrigerators and freezers.  freezers. 

For transporting For transporting vaccinesvaccines

equipment such equipment such asas

cold boxes, cold boxes, vaccine carriers vaccine carriers

andand

For transporting For transporting vaccinesvaccines

equipment such equipment such asas

cold boxes, cold boxes, vaccine carriers vaccine carriers

andand

Cold chain equipmentCold chain equipment “For vaccine storage” “For vaccine storage”

Cold room

refrigerators

Freezer

Cold chain equipmentCold chain equipment “for transporting vaccine” “for transporting vaccine”

Cold boxVaccine carrier

Ice bags

Cold box

ice Packs

Vaccine carrier

Vaccine carrier

The refrigerator :

• Placed in the coolest place of the health centers away from sunlight

• Well ventilated and adequate air circulation around it .

• Kept locked and open only when necessary.

•Ice packs are kept in the freezer.

• Its temperature is recorded twice daily.

• Both the monitor and thermometer are placed in the refrigerator.

• The temperature chart is stuck on the door outside the refrigerator.

• The diluents should be kept on the lowest shelf.

• Drugs, drinks or food must not be stored in the refrigerator

Tools for monitoring the cold chain

Tools for monitoring the cold chain:

1- Cold Chain Monitor Card.

2- Freeze Watch Indicator

3- Cold Chain Refrigerator Graph

4- Vaccine Vial Monitors

5- Shake Test

Cold Chain Refrigerator Graph The vaccines are stored in refrigerators, they are monitored twice a day and readings are recorded on a chart to ensure a safe temperature is maintained

+2°C

+8°C

2-Cold Chain Monitor Card: is used to show cumulative exposure to Temp. above the safe range during storage& transportation.

2-Cold Chain Monitor Card:

3-Vaccine vial monitors:

Every vial is also shipped with a

temperature-sensitive label, that health

workers monitor during vaccination

sessions.

SAFEIf the inner square is lighter than the outer

ring and the expiration date is valid, the

vaccine is usable

SPOILEDIf the inner square

matches or is darker than the outer ring, the vaccine must be

discarded.

4-The shake test

DPT, hepatitis B and

tetanus toxoid vaccines

can all be damaged by

freezing. By shaking two

vials, side-by-side, one

that might have been

frozen and one that has

never been frozen, health

workers can determine if a

vaccine has spoiled.

What damage the Vaccines?

1. Any defect in the cold chain.

2. Out date expiry.

3. Exposure of the vaccine to unacceptable temperature

during the immunization session.

4. Exposure of the vaccine to direct sunlight (BCG)