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EPI Vaccines Handouts

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  • 1. 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 therebymortality among infants and children causing the recipient’s immunecaused by the seven childhood system to react to the vaccine thatimmunizable 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 ChildrenElements 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 intervalSeven (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 hadPD 996 : “ Providing for elapsed between doses.compulsory basic immunization forinfants and children below 8 years old
  • 2. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 2 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 immunizationContraindication 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.
  • 3. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 3 Clinical InstructorEPI COLD CHAIN and LOGISTICSCold 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 openingMost Sensitive to OPV -15 to -25 CHeat Measles At the freezer Hepa B 8 hoursMost Sensitive to DPT 2 to 8 CCold Tetox Body ofSensitive to Sunlight BCG refrigerator 4 hoursand Fluorescent lightVaccine can be stored in Refrigerator: Regional – 6 months Municipal / City – 3 months Main Health Center – 1 monthsTransport Box : 5 days Note: 3 trip in transport box with the same vaccine discard itFEFO ( first expiry and first out ) vaccine is practiced to ensure that allvaccines are utilized before its expiry date. Proper arrangement of vaccines and labeling of vaccines expiry date are done to identify those near to expire vaccinesVaccine Wastage Wastage is defined as loss by use, decay, erosion or leakage or throughwastefulnessWastage rate = Doses supplied – doses administered x 100 Doses supplied
  • 4. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 4 Clinical InstructorTypes 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 doseWastage Factor: ( constant ) DPT = 1.67 OPV = 1.67 Measles = 2 BCG = 2.5 HepB = 1.10 Tetox = 1.67
  • 5. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 5 Clinical InstructorTarget SettingSteps and examples in calculating vaccine requirements Steps Formula Infant Mothers BCG DPT Hep B TetoxTotal Population( TP ) 3,000 3,000 3,000 3,000e.g 3,000Determine the EP = TP x 3%Eligible Population (Infants/Children) 90 90 90 105( EP ) EP = TP x 3.5 % ( Mothers )Required number ofdoses to immunize a 1 3 3 2child/ motherDetermine the totalvaccine required TVR = EP x number 90 270 270 210( TVR ) of dosesWastage Factor Given wastage factor 2.5 1.67 1.1 1.67 ( WF ) (constant )Calculate theAnnual Vaccine AVR = TVR x WF 225 451 297 351doses required( AVR )Number of doses per 20 10 or 1 or 10 10 or 20ampule/vial 20Determine Annual AVA = AVR / # ofVaccine doses per 12 46 or 297 or 36 or 18Ampule/Vial ampule/vial 23 30required ( AVA )Caculate theMonthly Vaccinedoses Required MVR = AVR / 12 19 38 25 29( MVR ) monthsDetermine MonthlyVaccine MVA = AVA / 12 1 4 or 2 25 or 3 or 1.5Ampule/Vial 2.5required ( MVA)
  • 6. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 6 Clinical Instructor EPI VACCINESBCG ( Bacille Calmette-Guerin ) VaccineType of Vaccine Live BacterialForm of Vaccine Freeze driedMinimum Age at 1st Dose Birth or anytime at birthNumber of Doses to 1st dose : at birthComplete the Immunization 2nd dose: school entranceReason 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 )AmpuleDosage At birth : 0.05 ml At school entrance : 0.10 mlRoute of Administration Intradermal ( a special syringe and needle is used for the administration of BCG vaccine )Site of Administration Right deltoid region of the armStorage 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 usingSpecial Precautions Correct ID administration is essential. A special syringe and needle is used for the administration of BCG vaccineSide 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
  • 7. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 7 Clinical InstructorReconstituting 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
  • 8. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 8 Clinical InstructorDPT ( Diphteria-Pertussis-Tetanus ) VaccineType of Vaccine Diphteria and Tetanus as “toxiods” which is a weakened toxin Pertussis as killed whole-cell bacteriumForm of Vaccine Liquid vaccineMinimum Age at 1st Dose 6 weeksNumber of Doses to 3Complete the ImmunizationInterval 4 weeks / minimum of 28 daysReason An early start with DPT reduces the chance of severe pertussisNumber of Doses per 20 or 10AmpuleDosage 0.5 mlRoute of Administration IntramuscularSite of Administration Upper outer portion of the thigh ( Vastus lateralis ) in infant ( R – L – R ) Outer upper arm if olderStorage Temperature 2 C to 8 C ( in the body of refrigerator ) Note: “DT” component is damage by freezing “P” component is damage by heatSpecial Precautions DPT not usually given over 6 years of ageSide 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.
  • 9. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 9 Clinical InstructorOPV ( Oral Polio Vaccine )Type of Vaccine Live attenuated vaccineForm of Vaccine Liquid vaccineMinimum Age at 1st Dose 6 weeksNumber of Doses to 3Complete the ImmunizationInterval 4 weeks / minimum of 28 daysReason The extent of protection against polio is increased the earlier the OPV is givenNumber of Doses per 20 ( 10 children )AmpuleDosage 2 dropRoute of Administration OralSite of Administration MouthStorage 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 OPVSide Effect Causes almost no side-effects. Less than 1% of the people who receive the vaccine develop a headache, diarrhea or muscle pain.Contraindication NoneHealth 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
  • 10. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 10 Clinical InstructorHepatitis B VaccineType of Vaccine “Monovalent vaccine” contain only one antigenForm of Vaccine Cloudy liquid vaccineMinimum Age at 1st Dose At birthNumber of Doses to 3Complete the ImmunizationInterval 6 weeks interval from 1st dose to 2nd dose 8 weeks interval from 2nd dose to 3rd doseReason An early start of Hep B vaccine reduces the chance of being infected and becoming a carrier. Prevent liver cirrhosis and liver cancerNumber of Doses per 1 for single dose vialAmpule 10 for multi dose vial ( 10 children )Dosage 0.5 mlRoute of Administration IntramuscularSite of Administration Upper outer portion of the thigh ( Vastus lateralis ) in infant ( with DPT: L – R – L )Storage Temperature 2 C to 8 C ( in the body of refrigerator ) 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 vaccineSide Effect Mild fever that lasts one to two days after injection Soreness, children may have pain, redness or swelling at the injection site.Contraindication Anaphylactic reaction such as severe rashes, difficulty in breathing and choking to a previous dose.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 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. 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.
  • 11. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 11 Clinical InstructorMeasles VaccineType of Vaccine Attenuated Measles VirusForm of Vaccine Freeze driedMinimum Age at 1st Dose 9 months 6 months: if there is an epidemicNumber of Doses to 1Complete the ImmunizationReason 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 monthsNumber of Doses per 10 ( 10 children )AmpuleDosage 0.5 mlRoute of Administration SubcutaneousSite of Administration Outer part of the upper armStorage 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 vaccineSide Effect Fever that lasts one to two days after injection Soreness, children may have pain, redness or 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 disorderHealth 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 . It also prevent diarrhea
  • 12. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 12 Clinical InstructorReconstituting 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 monthsBCG XOPV X X XDPT X X XHepB Option B X X X Option A X X XMeasles X
  • 13. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 13 Clinical InstructorTetanus Toxoid (TeTox) VaccineType of Vaccine Weakened toxinForm of Vaccine Liquid vaccineMinimum Age at 1st Dose As early as possible during pregnancyNumber of Doses to 5 doses ( TeTox 1 – TeTox 5 )Complete the Immunization TeTox 2 is the minimum required immunization during pregnancyNumber of Doses per 10 or 20AmpuleDosage 0.5 mlRoute of Administration IntramuscularSite of Administration Outer upper armStorage Temperature 2 C to 8 C ( in the body of refrigerator ) Note: Never freezeSide 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 doseHealth Teaching NO MEDICATION FOR PREGNANT For Pain cold compress 24 hrs to warm compressTetox Routine Immunization of Pregnant Women Vaccine Minimum Percent Duration of Protection Interval ProtectedTeTox 1 As early as possible during pregnancyTeTox 2 4 weeks after 80% infant will be protected by TeTox 1 neonatal tetanus 3 years protection for the motherTeTox 3 6 months after 95 % infant will be protected by TeTox 2 neonatal tetanus 5 years protection for the motherTeTox 4 1 year after TeTox 99 % infant will be protected by 3 neonatal tetanus 10 years protection for the motherTeTox 5 1 year after TeTox 99 % all infant born to that mother will 4 be protected lifetime protection for the mother
  • 14. Lecture Notes on EPI (Expanded Program on Immunization)Prepared By: Mark Fredderick R Abejo R.N, MAN 14 Clinical InstructorGiving Tetanus Toxoid ( TeTox ) Vaccine Shake the vial. Clean the skin with a cotton ball, moistened with water and let skin dry. 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. 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.Role of A Nurse In Improving the Delivery of Immunizationin 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.

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