EPI Vaccines Handouts

Lecture Notes on EPI (Expanded Program on Immunization)
Prepared By: Mark Fredderick R Abejo R.N, MAN 1
Clinical Instructor

E.P.I Concept and Importance of
Expanded Program on Vaccination
Immunization Immunization – is the process by
which vaccines are introduced into the
body before infection sets in.

Objective: Vaccines are administered to
To reduce the morbidity and introduced immunity thereby
mortality among infants and children causing the recipient’s immune
caused by the seven childhood system to react to the vaccine that
immunizable diseases. produces antibodies to fight
infection.
Four Major Strategies Vaccinations promote health and
Sustaining high routine FIC protect children from disease –
coverage of at least 90% in all causing agents.
provinces and cities.
Infants and newborn need to be
Sustaining the polio free country for
vaccinated at an early age since they
global certification.
belong to vulnerable age group.
Eliminating measles by 2008
Eliminating neonatal tetanus by
2008
General Principles in
Vaccinating Children
Elements of EPI
It is safe and immunologically
Target Setting (main element)
effective to administer all EPI
Information, Education and
vaccines on the same day at different
Communication
sites of the body.
Cold chain logistic management
Assessment and Evaluation of The vaccination schedule should
overall performance not be restarted from the beginning
Surveillance, Studies and Research even if the interval between doses
exceeded the recommended interval
Seven (7) Childhood by months or year.
Immunizable Diseases
Giving doses of a vaccine at less
Tuberculosis ( Primary Complex if than the recommended 4 weeks
less than 3 years old ) interval may lessen the antibody
Diphteria response. Lengthening the interval
Pertussis between doses of vaccines leads to
Neonatal Tetanus higher antibody levels.
Poliomyelitis
Hepatitis B No extra doses must be given to
children who missed a dose of
Measles
DPT/HB/OPV. The vaccination
must be continued as if no time had
PD 996 : “ Providing for elapsed between doses.
compulsory basic immunization for
infants and children below 8 years old

Clinical Instructor

Do not give more than one dose of The following are NOT
the same vaccine to a child in one contraindication. Infants with
session. Give doses of the same these conditions SHOULD be
vaccine at the correct intervals.
immunized:
Strictly follow the principle of
never, ever reconstituting the freeze Allergy or asthma ( except if there
dried vaccine in anything other than is a known allergy to a specific
the diluent supplied with them. component of vaccine mentioned
above )
If you are giving more than one Minor respiratory tract infection
vaccine, do not use the same syringe Diarrhea
and do not use the same arm or leg
Temp. below 38.5 C
for more than one injection.
Family history of adverse reaction
following immunization
Contraindication to Family history of convulsions,
Immunization seizures
Known or suspected HIV infection
with no signs and symptoms of
Anaphylaxis or severe
AIDS
hypersensitivity reaction to a
previous dose of vaccine is an Child being breastfed
absolute contraindication to Chronic illness such as diseases of
subsequent doses of vaccine heart, lung, kidney or liver
Stable neurological condition such
Person with a known allergy to a as cerebral palsy or Down’s
vaccine component should not be Syndrome
vaccinated. Premature or low birthweight
(vaccination should not be
DPT2 or DPT3 is not given to a postponed )
child who has convulsions or shock
Recent or imminent surgery
within 3 days after DPT1. Vaccines
containing the whole cell pertussis Malnutrition
component should not be given to a History of jaundice at birth
children with an evolving Note:
neurological disease. If parent strongly objects to
an immunization for a sick infant,
Do not give live vaccines like BCG do not give it. Ask the mother to
to a individuals who are comeback when child is well.
immunosuppressed due to malignant
disease ( child with AIDS) , going
therapy with immunosuppressive EPI Routine Schedule
agents or radiation. Every Wednesday is
designated as immunization day and is
A child with a sign and symptoms adopted in all part of the country
of severe dehydration
FIC “Fully Immunized Child” when
Fever of 38.5 C and above a child receives one dose of BCG, 3
doses of OPV, 3 doses of DPT, 3 doses
of HepB and one dose of measles
before a child’s first birthday.

Clinical Instructor

EPI COLD CHAIN and LOGISTICS

Cold Chain Manager = Public Health Nurse

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

Type of Vaccine Storage Temp. Hours of
Life after
opening
Most Sensitive to OPV -15 to -25 C
Heat Measles At the freezer
Hepa B 8 hours
Most Sensitive to DPT 2 to 8 C
Cold Tetox Body of
Sensitive to Sunlight BCG refrigerator 4 hours
and Fluorescent light

Vaccine can be stored in Refrigerator:
Regional – 6 months
Municipal / City – 3 months
Main Health Center – 1 months

Transport Box : 5 days
Note: 3 trip in transport box with the same vaccine discard it

FEFO ( first expiry and first out ) vaccine is practiced to ensure that all
vaccines are utilized before its expiry date.

Proper arrangement of vaccines and labeling of vaccines expiry date are done to
identify those near to expire vaccines

Vaccine Wastage
Wastage is defined as loss by use, decay, erosion or leakage or through
wastefulness

Wastage rate = Doses supplied – doses administered x 100
Doses supplied

Clinical Instructor

Types of Vaccine Wastage

Vaccine wastage in unopened vials
Expiry
Heat exposure
Freezing
Breakage
Missing inventory
Theft
Discarding unused vials returned from
an outreach session

Vaccine wastage in opened vials
Discarding remaining doses at end of
session
Not being able to draw the number of
doses indicated on the label of a vial
Poor reconstitution practices
Submergence of opened vials in water
Suspected contamination
Patient reaction requiring more than
one dose

Wastage Factor: ( constant )
DPT = 1.67
OPV = 1.67
Measles = 2
BCG = 2.5
HepB = 1.10
Tetox = 1.67

Clinical Instructor

Target Setting

Steps and examples in calculating vaccine requirements

Steps Formula Infant Mothers
BCG DPT Hep B Tetox
Total Population
( TP ) 3,000 3,000 3,000 3,000
e.g 3,000

Determine the EP = TP x 3%
Eligible Population (Infants/Children) 90 90 90 105
( EP )
EP = TP x 3.5 %
( Mothers )

Required number of
doses to immunize a 1 3 3 2
child/ mother
Determine the total
vaccine required TVR = EP x number 90 270 270 210
( TVR ) of doses

Wastage Factor Given wastage factor 2.5 1.67 1.1 1.67
( WF ) (constant )
Calculate the
Annual Vaccine AVR = TVR x WF 225 451 297 351
doses required
( AVR )
Number of doses per 20 10 or 1 or 10 10 or 20
ampule/vial 20
Determine Annual AVA = AVR / # of
Vaccine doses per 12 46 or 297 or 36 or 18
Ampule/Vial ampule/vial 23 30
required ( AVA )
Caculate the
Monthly Vaccine
doses Required MVR = AVR / 12 19 38 25 29
( MVR ) months
Determine Monthly
Vaccine MVA = AVA / 12 1 4 or 2 25 or 3 or 1.5
Ampule/Vial 2.5
required ( MVA)

Clinical Instructor

EPI VACCINES

BCG ( Bacille Calmette-Guerin ) Vaccine

Type of Vaccine Live Bacterial
Form of Vaccine Freeze dried
Minimum Age at 1st Dose Birth or anytime at birth
Number of Doses to 1st dose : at birth
Complete the Immunization 2nd dose: school entrance
Reason BCG given at earliest possible age protects the
possibility of TB meningitis and other TB infectious in
which infants are prone.
Number of Doses per 20 ( 20 children )
Ampule
Dosage At birth : 0.05 ml
At school entrance : 0.10 ml
Route of Administration Intradermal ( a special syringe and needle is used for
the administration of BCG vaccine )
Site of Administration Right deltoid region of the arm
Storage Temperature 2 C to 8 C ( in the body or refrigerator )
Note: Freezing does not damage it but ampules may
break.
Diluents should also be kept cold before using
Special Precautions Correct ID administration is essential. A special
syringe and needle is used for the administration of
BCG vaccine
Side Effect A wheal formation
Koch phenomenon ( inflammatory reaction 2-4 days )
Undesired Effect Indolent ulceration
Abscess on the injection site
Enlarged lymph nodes
Note: Swollen glands or abscesses occur because an
unsterile needle or syringe was used, too much vaccine
was injected or most commonly, the vaccine was
injected incorrectly under the skin instead of its top
layer.
Contraindication Immunosuppressed indvidual due to malignant disease
( child with clinical AIDS ) ; therapy with
immunosuppressive agent or radiation.
Health Teaching Do not massage the area of injection
A scar will formed 12 weeks after injection
Repeat BCG vaccination if the child does not
develop a scar after first injection

Clinical Instructor

Reconstituting the freeze dried BCG Vaccine:

Always keep the diluent cold
Using a 5ml. syringe fitted with along needle, aspirate 2 ml. of saline solution from
the opened ampule of diluent.
Inject the 2ml. saline into the ampule of freeze dried BCG.
Thoroughly mix the diluent and vaccine by drawing the mixture back into the
syringe and expel it slowly into the ampule several times.
Return the reconstituted vaccine on the slit of the foam provided in the vaccine
carrier.

Giving BCG Vaccine:

Clean the skin with a cotton ball moistened with water and let skin dry.
Hold the child’s arm with your left hand so that your hand is under and your thumb
and finger come around the arm and stretch the skin.
Hold the syringe in your right hand with the bevel and the scale pointing up
towards you.
Lay the syringe and needle almost flat along the child’s arm.
Insert the tip of the needle into skin – just the bevel. Keep the needle flat along the
skin and the bevel facing upwards, so the vaccine only goes into the upper layers of
the skin.
Put your left thumb over the needle end to hold it in position. Hold the plunger e
between the index and middle fingers of the right hand and press the plunger in
with your right thumb.
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.
Withdraw needle gently.

Note:
 Any remaining reconstituted vaccine must be discarded after 6 hours or at the end
of the immunization sessions, whichever comes first.
 The small raised lump appears at the injection site, usually disappears within 30
minutes.
 After 2 weeks, a red sore forms that is about the size of the end of an unsharpened
pencil.
 The sore remains for another two weeks and then heals, a small scar, about 5mm
across remains. This is a sign that the child has been effectively immunized.
 Repeat BCG vaccination if the child does not develop a scar after the 1st injection

 BCG vaccine is moderately effective. It has a protective efficacy of:
50 % against any TB disease
64 % against TB meningitis
74 % against death from TB

Clinical Instructor

DPT ( Diphteria-Pertussis-Tetanus ) Vaccine
Type of Vaccine Diphteria and Tetanus as “toxiods” which is a
weakened toxin
Pertussis as killed whole-cell bacterium
Form of Vaccine Liquid vaccine
Minimum Age at 1st Dose 6 weeks
Number of Doses to 3
Complete the Immunization
Interval 4 weeks / minimum of 28 days
Reason An early start with DPT reduces the chance of severe
pertussis
Number of Doses per 20 or 10
Ampule
Dosage 0.5 ml
Route of Administration Intramuscular
Site of Administration Upper outer portion of the thigh ( Vastus lateralis ) in
infant ( R – L – R )
Outer upper arm if older
Storage Temperature 2 C to 8 C ( in the body of refrigerator )
Note: “DT” component is damage by freezing
“P” component is damage by heat
Special Precautions DPT not usually given over 6 years of age
Side Effect Fever in the evening after receiving the injection.
Soreness, children may have pain, redness or
swelling at the injection site.
Contraindication DPT2 or DPT3 is not given to a child who has
convulsions or shock within 3 days after DPT1.
Vaccines containing the whole cell pertussis
component should not be given to a children with an
evolving neurological disease.
Health Teaching If the child has fever give paracetamol or any
appropriate antipyretic at the time and at four and
eight hours after immunization.
Alternating cold compress for 24 hours to warm
compress if there is pain and soreness .

Giving DPT Vaccine

Ask mother to hold the child across her knees so that her thigh is facing upwards.
Ask her to hold child’s leg.
Clean the skin with a cotton ball, moistened with water and let skin dry.
Grasp the injection site with your thumb and index finger.
Quickly push the needle, going deep in to the muscle.
Slightly pull the needle back to be sure it is not into a vein.
Inject the vaccine, withdraw the needle and press the injection spot quickly with a
piece of cotton.

Clinical Instructor

OPV ( Oral Polio Vaccine )

Type of Vaccine Live attenuated vaccine
Minimum Age at 1st Dose 6 weeks
Interval 4 weeks / minimum of 28 days
Reason The extent of protection against polio is increased the
earlier the OPV is given
Ampule
Dosage 2 drop
Route of Administration Oral
Site of Administration Mouth
Storage Temperature -15 C to -25 C ( at the freezer )
Note: It is easily damaged by heat but is not harmed
by freezing.
Special Precautions Children known to have rare congenital immune
deficiency syndrome should receive IPV ( injectable
polio vaccine ) rather OPV
Side Effect Causes almost no side-effects. Less than 1% of the
people who receive the vaccine develop a headache,
diarrhea or muscle pain.
Contraindication None
Health Teaching Nothing by mouth (NPO) 30 minutes before and
after OPV.
Do not touch the tip dropper bottle to the tongue.

Giving Oral Polio Vaccine

Read the manufacturer’s instructions to determine number of drops to be given.
Use the dropper provided for.
Two types of OPV containers:
- small plastic dropper bottles
- glass vials with dropper in a separate plastic bag
Let the mother hold the child lying firmly on his back.
If necessary open the child’s mouth by squeezing the cheeks gently between your
fingers to make his lips point upwards.
Put drops of vaccine straight from the dropper into the child’s tongue but do not let
the dropper touch the child’s tongue.
Make sure that the child swallows the vaccine. If he spits it out, give another dose.
If a child has diarrhea when you give OPV, administer an extra dose – that is, a
fourth dose at least four weeks after he or she has received the last dose in the
schedule

Clinical Instructor

Hepatitis B Vaccine
Type of Vaccine “Monovalent vaccine” contain only one antigen
Form of Vaccine Cloudy liquid vaccine
Minimum Age at 1st Dose At birth
Interval 6 weeks interval from 1st dose to 2nd dose
8 weeks interval from 2nd dose to 3rd dose
Reason An early start of Hep B vaccine reduces the chance of
being infected and becoming a carrier. Prevent liver
cirrhosis and liver cancer
Number of Doses per 1 for single dose vial
Ampule 10 for multi dose vial ( 10 children )
Dosage 0.5 ml
Site of Administration Upper outer portion of the thigh ( Vastus lateralis ) in
infant ( with DPT: L – R – L )
Note: Both heat and freezing damages the vaccine )
Special Precautions Birth dose must be given if there is a risk of perinatal
transmission.
Note : Combination vaccines should not be given at
birth, only monovalent HepB vaccine
Side Effect Mild fever that lasts one to two days after injection
swelling at the injection site.
Contraindication Anaphylactic reaction such as severe rashes,
difficulty in breathing and choking to a previous
dose.

Giving Hepatitis B Vaccine

Ask mother to hold the child across her knees so that her thigh is facing upwards.
Ask her to hold child’s leg.
Grasp the injection site with your thumb and index finger.
piece of cotton.

Clinical Instructor

Measles Vaccine

Type of Vaccine Attenuated Measles Virus
Form of Vaccine Freeze dried
Minimum Age at 1st Dose 9 months
6 months: if there is an epidemic
Reason Measles vaccine given at 9 months provide at least
85% protection against measles infection.
When given at one year and older provides 95%
protection.
Note: An infant with known or suspected HIV infection
should receive measles vaccine at 6 months and then
again at 9 months
Ampule
Dosage 0.5 ml
Route of Administration Subcutaneous
Site of Administration Outer part of the upper arm
Storage Temperature -15 C to -25 C ( at the freezer )
Note: But can also be safely stored between 0 C to 8C
until its expiry date.
Diluents should also be kept cold before using.
Special Precautions Birth dose must be given if there is a risk of perinatal
transmission.
Note : Combination vaccines should not be given at
birth, only monovalent HepB vaccine
Side Effect Fever that lasts one to two days after injection
swelling at the injection site within 24 hours of
immunization. It usually resolve within two to three
days.
About 1 in 20 children develop a mild rash five to
12 days after receiving the vaccine. The rash usually
lasts about two days.
Contraindication Severe reaction to previous dose
Pregnancy
Congenital or acquired immune disorder
It also prevent diarrhea

Clinical Instructor

Reconstituting the Freeze Dried Measles Vaccine

Using a 10 ml. syringe fitted with a long needle, aspirate 5 ml of special diluent,
from the ampule.
Empty the diluent from the syringe into the vial with the vaccine.
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.
Protect reconstituted measles vaccine from sunlight. Wrap vial in foil.
Place the reconstituted vaccine in the slit of the foam provided in the vaccine
carrier.

Giving Measles Vaccine

Ask the mother to hold the child firmly.
Clean the skin with a cotton ball, moistened with water and let the skin dry.
With the finger of one hand, pinch up the skin on the outer side of the upper arm.
Without touching the needle, push the needle into the pinched-up skin so that it is
not pointing.
Slightly pull the plunger back to make sure that the vaccine is not injected into a
vein.
Press the plunger gently and inject.
Withdraw the needle and press the injection spot quickly with a piece of cotton.

Immunization Schedule For Infants Recommended By The EPI

AGE

Birth 6 weeks 10 weeks 14 weeks 9 months

BCG X

OPV X X X

DPT X X X

HepB Option B X X X

Option A X X X

Measles X

Clinical Instructor

Tetanus Toxoid (TeTox) Vaccine

Type of Vaccine Weakened toxin
Minimum Age at 1st Dose As early as possible during pregnancy
Number of Doses to 5 doses ( TeTox 1 – TeTox 5 )
Complete the Immunization TeTox 2 is the minimum required immunization
during pregnancy
Number of Doses per 10 or 20
Ampule
Dosage 0.5 ml
Site of Administration Outer upper arm
Note: Never freeze
Side Effect Fever in the evening after receiving the injection.
Soreness, woman may have pain, redness or
swelling and warmth at the injection site.
Contraindication Anaphylactic reaction to previous dose
Health Teaching NO MEDICATION FOR PREGNANT
For Pain cold compress 24 hrs to warm compress

Tetox Routine Immunization of Pregnant Women

Vaccine Minimum Percent Duration of Protection
Interval Protected
TeTox 1 As early as
possible during
pregnancy
TeTox 2 4 weeks after 80% infant will be protected by
TeTox 1 neonatal tetanus
3 years protection for the mother
TeTox 3 6 months after 95 % infant will be protected by
TeTox 2 neonatal tetanus
TeTox 4 1 year after TeTox 99 % infant will be protected by
3 neonatal tetanus
TeTox 5 1 year after TeTox 99 % all infant born to that mother will
4 be protected
lifetime protection for the mother

Clinical Instructor

Giving Tetanus Toxoid ( TeTox ) Vaccine

Shake the vial.
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 upper arm.
piece of cotton.

Role of A Nurse In Improving the Delivery of Immunization
in the Community.

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 and motivate to submit their child 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 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.

EPI Vaccines Handouts

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