The document outlines the Expanded Program on Immunization (EPI), which aims to provide vaccines to all children under the age of one to prevent diseases and reduce child mortality. It explains types of immunity, immunization strategies, vaccination schedules, vaccine types, and specific vaccines for various diseases. Additionally, it addresses challenges in immunization coverage, such as dropouts and missed opportunities, and proposes solutions to improve immunization rates.

1. The Expanded Program
The Expanded Program
On Immunization
On Immunization
(EPI)
(EPI)
By Mr. Teklu w.
By Mr. Teklu w.

2. OBJECTIVES
At the end of the session you will be able to:
 Define immunization
 Explain the schedule for vaccination
 Discuss strategies of immunization
 Explain the cold chain
By Mr. Teklu . 2

3. IMMUNITY
Brainstorming
What is Immunity ?
What is Immunization ?
Types of Immunization ?
What is Vaccination ?
By Mr. Teklu . 3

4. Cont…
1. Congenital or innate
 It is the natural resistance of the body eg:- skin, mucous
membrane, enzymes
 Immunity is provided by WBC, reticuloendothelial cells of
spleen, lymph nodes, liver etc
2. Acquired or specific immunity
 It is classified in to two
2.1. Active acquired immunity
2.2. Passive acquired immunity
By Mr. Teklu . 4

5. Active acquired immunity
 Acquired actively through exposure to the antigen (naturally
through infection or artificially by immunization)
 Child body makes its own antibodies, it is the long lasting
immunity, it is two types.
1) Naturally acquired active immunity:
 After exposure to or an attack of disease
2) Artificially acquired active immunity:
 After administration of vaccine (antigen and toxoid)
By Mr. Teklu . 5

6. Passive acquired immunity
 Acquired passively through the antibodies which came directly
from maternal antibodies (through placenta) or through
immunoglobulin given parentally.
 The child gets ready made antibodies, it is short lived immunity.
1) Naturally acquired passive immunity:
 Transferred maternal antibodies in the body of child. Eg: measles,
tetanus.
2) Artificially acquired passive immunity:
 It is acquired by administration of antibodies. Eg: TAT
By Mr. Teklu . 6

7. Active & Passive immunity
Natural immunity Artificial immunity
post- infection
Active
maternal
antibody
transfer to the
fetus
Passive
exposure to
antigen (active
immunization)
Active
injection of
antibodies
(passive
immunization)
Passive
By Mr. Teklu . 7

8. IMMUNIZATION
 A process of inducing immunity artificially by either vaccination
(active) or administration of antibodies (passive).
• Vaccination is administration of any vaccine or toxoid for
prevention of disease.
 Active immunization:- stimulating the immune system to produce
antibodies and cellular immune responses by giving antigens.
 Passive immunization:- providing temporary protection by
administration of exogenously produced antibodies or naturally
from the mother to the child.
By Mr. Teklu . 8

9. Expanded Program on Immunization
• The Expanded Program on Immunization is a World Health
Organization program with the goal to make vaccines
available to all children in order to prevent certain diseases.
• The objective of the EPI is to reduce mortality and morbidity
in children from the EPI target diseases through immunization
of all children under the age of one.
• “Expanded” means:-
By Mr. Teklu . 9

10. Objectives of EPI
1. To achieve 100% coverage with all EPI vaccines.
2. Eradication of polio to maintain polio free status.
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11. 3. Elimination of measles.
By Mr. Teklu . 11

12. 4. Reduce
seroprevalence of
(HBsAg) to <1%
among under five.
HBV
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13. 5.Elimination of Neonatal Tetanus .
By Mr. Teklu . 13

14. 6. To maintain zero level of diphtheria.
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15. 7. Prevention of severe forms of TB ( TB meningitis & miliary TB).
12 year old girl with TB meningitis
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16. 8. To reduce the incidence of whooping cough
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17. 9) Reduce the incidence of Bacterial meningitis due to
haemophelus influenza
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10) Reduce the incidence of pneumonia.
11) To maintain immunization safety.

18. By Mr. Teklu . 18
 What are EPI target diseases ??
 There are nine vaccine preventable diseases.
1. Tuberculosis 6. Tetanus
2. Measles 7. Hepatitis B
3. Poliomyelitis 8. Heamophillus influenza type B
4. Diphtheria 9. Pneumonia
5. Pertussis or whooping cough
 How many times should a child go for immunization?
 A child should be taken for immunization five times to complete
the immunization.

19. By Mr. Teklu . 19
 The target groups for immunization are:-
 Under 1-years children and
 Women in the child bearing age (15-49 years).
 Acceptable proof of immunization are:-
 BCG scar
 Immunization card.
 The recommended interval between two doses of live attenuated
and inactivated vaccine is only minimum limit of 1 month but
there is No maximum limit.

20. VACCINES AND ADMINISTRATION
• Vaccines are produced from the same microorganisms or toxins that
cause disease, but in either case are modified so as to be harmless to
humans. Three main substances are used for the production of
vaccines:
– LIVE microorganisms, e.g., weakened measles and polio viruses
or tuberculosis bacteria;
– KILLED microorganisms, e.g., pertussis microorganisms used in
DPT production; and
– TOXOIDS, e.g., inactivated toxins such as tetanus toxoid and
diphtheria toxoid.
By Mr. Teklu . 20

21. In addition, some vaccines are produced using genetic engineering
technologies, e.g. recombinant DNA Hepatitis B vaccine.
 Types of vaccines
1. Live vaccines
2. Live attenuated vaccines
3. Inactivated or killed vaccines
4. Toxoids
5. Polysaccharide and polypeptide (cellular fraction) vaccines
6. Surface antigen (recombinant) vaccines
By Mr. Teklu . 21

22. Contact
Contact Age of Child
Age of Child Vaccines
Vaccines
1st
1st At birth
At birth BCG and OPV0
BCG and OPV0
2nd
2nd 6 weeks
6 weeks DPT1-HepB1-Hib1, RV1, OPV1,
DPT1-HepB1-Hib1, RV1, OPV1,
PCV1
PCV1
3rd
3rd 10 weeks
10 weeks DPT2-HepB2-Hib2, RV2, OPV2,
DPT2-HepB2-Hib2, RV2, OPV2,
PCV2
PCV2
4th
4th 14 weeks
14 weeks DPT3-HepB3-Hib3, OPV3, PCV3
DPT3-HepB3-Hib3, OPV3, PCV3
5th
5th 9 months
9 months Measles
Measles
Immunization Schedule
Immunization Schedule
By Mr. Teklu . 22

23. Dose
Dose Minimum interval
Minimum interval Duration of protection
Duration of protection
TT1
TT1 -
- 0
0
TT2
TT2 4 weeks
4 weeks 3 years
3 years
TT3
TT3 6 months
6 months 5 years
5 years
TT4
TT4 1 year
1 year 10 years
10 years
TT5
TT5 1 year
1 year Life long
Life long
Tetanus toxoid vaccine schedule for women (15-49 years)
By Mr. Teklu . 23

24. Dose & Route Of Administration Of Vaccine
Vaccine Dose No of
dose
Route Site S/E
BCG <1yr=0.05
>1yr=0.1ml
1 I.D Right
upper
arm
-Local
inflammatio
n or deep
abscess.
Polio 2 drops 4 Orally Mouth -Usually
none
Rota full drop 2 Orally Mouth Minor side
effects
DPT-HepB-
Hib
0.5 ml 3 I.M Anterior-
thigh
-Fever
-Local
swelling
-Convulsion
Measles 0.5 ml 1 SC. Left
upper arm
-Fever
&Rash
By Mr. Teklu . 24

25. Methods of administration
Subcutaneous Intramuscular
Intradermal
Oral
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26.  Task done at immunization session
 Arranging the flow of mothers & children
 Registering
 Weighting
 Health education on immunization
 Screening clients
 Treating clients
 Immunization
By Mr. Teklu . 26

27. By Mr. Teklu . 27
Immunization Delivery Sites
I.Static: immunization performed as part of routine activity of the
health units.
II.Outreach: an immunization approach in which the staffs of health
unit go out and administer vaccine to mothers and children in their
catchment areas.
III.Mobile: an immunization approach only single dose vaccination
(measles, BCG) in nomadic, settlement areas and mostly used for
controlling epidemic such as measles & meningitis.
IV.Campaign: an immunization approach conducted by mobilizing
the community, example polio and measles vaccination.

28. BCG vaccine (Bacillus Calmette Guerin)
• Live attenuated vaccine given to against tuberculosis.
• Given at birth or with in 15 days after birth.
• Dose 0.05 ml below one year and 0.1 ml above one year old child
• Route ID
• Site (right upper arm)
• Number dose 1
By Mr. Teklu . 28

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33. By Mr. Teklu . 33

34. Penta vaccine(Diphtheria, Pertussis, Tetanus, HBV and Hib)
• It is (D ,T) Toxoid , (P) Killed pertussis, hepatitis Bv and hibv
against Diphtheria, Pertussis, Tetanus, Hepatitis B, and
Meningitis.
• It is given at 6th
, 10th
, 14th
week.
• It is a liquid vaccine
• Dose: 0.5 ml
• Route: intramuscular (IM)
• Site: left thigh
• Number of doses: 3
By Mr. Teklu . 34

35. By Mr. Teklu . 35

36. Measles vaccine
 It is live attenuated vaccine given to against measles.
• It is given at 9th
month
• Dose 0.5ml
• Route Subcutaneous arm
• Number of dose 1
By Mr. Teklu . 36

37. By Mr. Teklu . 37

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39. By Mr. Teklu . 39

40. Tetanus Toxoid (TT)
• It is a precipitated liquid vaccine
• Dose: 0.5ml
• Route: IM (upper arm)
• Number of doses: 5
By Mr. Teklu . 40

41. Rota virus vaccine (RVV)
 It is a very recently introduced vaccine given for prevention of
rota virus related gastroenteritis.
 Route: oral
 Dose:1.5ml
• Frequency: started at 6wks and the 2nd
dose will be given after
4wks of the 1st
dose.
By Mr. Teklu . 41

42. By Mr. Teklu . 42

43. Pneumococcal Conjugated vaccine (PCV)
• It is given to prevent bacterial infection such as otitis media,
sinusitis and pneumonia.
• It is administered at, 6th
, 10th
and 14th
weeks of age
• Dose 0.5 ml, IM right thigh.
By Mr. Teklu . 43

44. By Mr. Teklu . 44

45. Contraindications to vaccinations
1. Absolute
• History of anaphylactic reactions.
• Subsequent doses of pertussis vaccines are absolutely
contraindicated if the child gets (within 48 hours of vaccination.
– Fever (40.5ºc) ,
– Collapse or shock .
– Persistent crying for 3 hours without apparent cause.
– Convulsion with or without fever within 3 hours after
vaccination.
By Mr. Teklu . 45

46. • A vaccine should not be administered to any patient who has
previously experienced a severe reaction to that vaccine.
This is because they are at risk of another potentially serious
allergic reaction.
• Just in case a vaccine should suffer a severe allergic reaction
to vaccination, a solution of 1:1000 adrenaline or
epinephrine should always be available for immediate
injection to counter such a reaction.
By Mr. Teklu . 46

47. • The presence of a minor infection is not a contra-indication to
vaccination.
• Vaccinations are generally not carried out during pregnancy, with
the exception of tetanus vaccination of pregnant women or women
of child bearing age, in order to prevent neonatal tetanus or
tetanus in the mother at the time of delivery.
 HIV infection with clinical AIDS is an absolute contraindication
to administer live attenuated vaccines (OPV & BCG), so infants
with clinical AIDS should not receive BCG vaccination.
By Mr. Teklu . 47

48. 2. Invalid contraindication
• Mild to moderate local reaction.
• Prematurity and low birth weight.
• Malnutrition
• Mild acute illness with or without low grade fever
By Mr. Teklu . 48

49. Side effects of vaccines
Side effects of vaccines
BCG
1. Normal reaction
– a small red, tender swelling about 10 mm appears at the place of
immunization after about 2 weeks
– Abscess: due to injection errors
– Ulcer
– Scar
• NB:- Advise not to put any medicine on the sore (it heals in 2-3
months & leave a scar).
By Mr. Teklu . 49

50. Cont’d…
2. Severe reaction
– Sometimes there is severe local inflammation or deeper abscess.
– Sometimes the lymphatic glands near the elbow or in the axilla
swell.
– This may be because:-
 of using a needle that is not sterile
 of giving too large dose of vaccine.
 of injecting too deeply under the skin by mistake & it causes
abscess and enlarged glands
By Mr. Teklu . 50

51. Cont’d…
Cont’d…
Polio
– Almost no side effect
– Less than 1% of individuals develop a headache, diarrhoea, or muscle
pain
Tetanus Toxoid (TT)
– Local Pain, redness and swelling at the injection site.
– Reassurance
Measles
– Fever and mild occasional rash a week after the injection for 1-3 days.
– Reassurance
By Mr. Teklu . 51

52. DPT-HepB- Hib
– Mild Fever starts within the 1st 24 hours of vaccination and
may last for 2 to 3 days.
– Tenderness, redness or swelling at the injection site
– Abscess a week or more after the injection
– Convulsion or shock (rare)
For abscess:- Apply warm compress, give systemic antibiotic
• If not resolved it may require incision and drainage
If convulsion:- Don’t give the subsequent DPT doses.
PCV:- Mild fever, irritability/crying
By Mr. Teklu . 52

53. Immunization Problems
Immunization Problems
Causes of low immunization coverage
A. Drop Out:- is defined as a child or a woman who failed to return
for subsequent doses for which he or she is eligible.
 The possible causes of drop out :-
• Unsure of dates of return
• Long wait at the vaccination centre
• Vaccination centres open at inconvenient dates or hours
• Some health workers do not explain the need of completing
vaccination.
• Negative attitude of some health workers towards the program.
By Mr. Teklu . 53

54. Cont’d…
Cont’d…
• Mothers usually busy on other engagements.
• Child develops side effects or was sick on the appointed date.
NB:
• A child or a woman who discontinued the immunization program
should not have to restart the immunization. There is no maximum
interval between two immunizations.
By Mr. Teklu . 54

55. Cont’d…
Cont’d…
Drop out rate calculation
i. Over all drop out rate =
Coverage with BCG - coverage with measles X 100
Coverage with BCG
ii. Drop out rate of a single antigen (e.g. DPT) =
Coverage with DPT1 - coverage with DPT3 X 100
Coverage with DPT1
NB: If drop out rate >10%, it is essential to determine why the failure
occurred.
By Mr. Teklu . 55

56. B. Missed opportunities:- it occurs when a child or a woman
in child bearing period comes to the health facility or
outreach site and does not receive any of the vaccine
doses for which he or she is eligible.
• Current policy is that all children and mothers at the
health facility for any reason should be screened for
immunization status and vaccinated if eligible.
The reasons for missed opportunity are:
Health workers practices.
health workers screen but tell patients to return later
health workers only vaccinate women with TT if they are
pregnant
health workers only open a vial if there are enough clients
who need it By Mr. Teklu . 56

57. • Logistical problems such as vaccine shortages, poor clinic
organization, and
• Failure to administer simultaneously all the vaccines for which
the child is eligible.
• Accessibility: time (women carry household responsibilities),
distance, cost of transportation
• Acceptability: culture, rumours, beliefs, etc.
• False contraindications to immunization, for example; not giving
polio vaccine to a child with diarrhea.
By Mr. Teklu . 57

58. Cont’d…
Cont’d…
False contraindications to immunization:
 Conditions that are wrongly considered as contraindications:
 Minor illness( respiratory tract infections, diarrhea, fever < 38.5°C).
 Premature or small for date infants.
 Child being breast-feed.
 Family history of convulsion.
 History of jaundice at birth
By Mr. Teklu . 58

59.  Drop out & missed opportunities are the major cause of low
vaccination coverage.
 What are the possible solutions ????
Potential solution
Social mobilization
Drop out tracing mechanisms
Get commitment by the local leaders
Monitoring & supervising the program
In service training to community HEW
Ensure financial & logistic support for the health institutions
By Mr. Teklu . 59

60. 60
By Mr. Teklu . 60

61. What damages vaccines?
• Vaccines are biological substances that may lose their effectiveness
quickly if they become too hot or too cold, especially during transport
and storage. May result in failure of the vaccine to protect, as well as
resulting in vaccine wastage.
• Vaccine can easily damaged if not handled properly.
• If the vaccine is in good condition, and able to make a child
immune, it is potent.
• If the vaccine is damaged and not able to make a child immune, it
has lost its potency.
By Mr. Teklu . 61

62.  What damage the Vaccines?
1. Any defect in the cold chain.
2. Out date expiry.
3. Using skin antiseptic at the site of injection (e.g. BCG).
4. Using the reconstituted vaccine ( measles, BCG) after the
recommended period ( 6 hours).
5. Exposure of the vaccine to unacceptable temperature
during the immunization session.
6. Exposure of the vaccine to direct sunlight (BCG)
By Mr. Teklu . 62

63. Heat, sun light and freezing
• Heat and sunlight damage all vaccine, but (live vaccine) most
sensitive
• Freezing damage DPT and TT vaccine.
• Keep all vaccine at the correct cold temp.
• If vaccine once damaged, you can’t make potent it again.
• Chemicals (disinfectant, soap) etc, can damage the vaccine.
• The correct temperature to store vaccine is between +20c and
+80c (+20c to +80c)
• Use thermometer in your refrigerator or vaccine carrier to
measure the temperature of your vaccine.
• Polio-Vaccine is damaged very quickly by heat than other
vaccines. It does not damage by freezing.
By Mr. Teklu . 63

64. BCG-Vaccine B=Bacillus C= Calmette G=Guerin:
- has come as dry powder in container
- is damaged most easily by sun light.
- Damaged by heat but not as quick as (polio and measles)
DPT & TT Vaccine
• Has contains “3” vaccine.
• Damaged by heat but not as quickly as the live vaccine.
– Are liquid vaccine
Measles vaccine
• It is freeze dried vaccine which needs reconstitution.
• is easily damaged by heat.
• Reconstituted vaccine losses its potency very quickly, you must
use it in same immunization session, or throw it out.
By Mr. Teklu . 64

65. Cold Chain
 System that ensure potency, quality & safety of vaccines by
maintaining the correct temperature from manufacturer to
children/women.
 The cold chain system is a means for storing and transporting
vaccines in a potent state from the manufacturer to the person being
immunized.
 Maintaining the cold chain ensures that vaccines are transported
and stored according to the manufacturer's recommended temp
range +20c to +80c until point of administration.
By Mr. Teklu . 65

66. The levels of cold chain
The levels of cold chain
By Mr. Teklu . 66

67. The equipment and tools
The procedures
The health staff
The components of the cold chain :
By Mr. Teklu . 67

68. 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
By Mr. Teklu . 68

69. 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.
• Drugs, drinks or food must not be stored in the refrigerator
• 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.
By Mr. Teklu . 69

70. The refrigerator
By Mr. Teklu . 70

71. By Mr. Teklu . 71

72. Cold Boxes And Vaccine Carriers
• Vaccine carriers and cold boxes must be well dried after their use. If
they are left wet with their lids closed, they will become mouldy.
Mould may affect the seal of the cold boxes and vaccine carriers.
• Knocks and sunlight can cause cracks in the walls and lids of cold
boxes and vaccine carriers. If this happens the vaccines inside will
be exposed to heat.
By Mr. Teklu . 72

73. Packing a cooler box
1. Take all the frozen ice packs you need from the freezer and
condition them.
2. Put ice packs against each of the four sides of the cold box or
vaccine carrier.
3. Take all the vaccines and diluent you need from the main section of
the refrigerator and close the door.
4. Put the vaccines and diluent in the middle of the cold box or carrier.
Vials may be kept in their boxes or packed without them, depending
on how many vials you need.
By Mr. Teklu . 73

74. 74
By Mr. Teklu . 74

75. Cold box and Vaccine Carriers
Vaccine carrier with vaccine vials in foam pad
Cold box
75
By Mr. Teklu . 75

76. Vaccine carrier
By Mr. Teklu . 76

77. Vaccine carrier
By Mr. Teklu . 77

78. Ice packs
♦ Ice packs are flat, square plastic bottles that can be filled with water
and frozen. The required number in a particular cold box or vaccine
carrier varies.
♦ Every health centre should have two sets of ice packs, one being
frozen while the other is in use.
♦ Condition the ice packs before use
78
By Mr. Teklu . 78

79. Vaccines sensitive to heat
OPV
Measles
BCG
TT
Pentavalent
Most sensitive
Least sensitive
79
By Mr. Teklu . 79

80. Vaccines sensitive to cold
Pentavalent
TT
Most sensitive
Least sensitive
80
By Mr. Teklu . 80

81. Tools for monitoring the cold chain
1. Cold Chain Refrigerator Graph
2. Shake Test
3. Vaccine Vial Monitors
By Mr. Teklu . 81

82. 1. 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.
By Mr. Teklu . 82

83. By Mr. Teklu . 83

84. 2. The shake test
Penta, 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. By Mr. Teklu . 84

85. Cont.…
Time of
observation
Not frozen vaccine A suspected frozen
vaccine.
Immediately
after shaking
 Smooth and
cloudy for
inspection
 Not smooth
(granular particles
are seen)
30 minutes
after shaking
 Start to clear.
 Not sediment.
 Use it
 Thick sediment.
 Don’t use it
By Mr. Teklu . 85

86. 3. Vaccine vial monitors
• A vaccine vial monitor
(VVM) is a label
containing a heat-sensitive
material which is placed
on a vaccine vial to
register cumulative heat
exposure over time.
By Mr. Teklu . 86

87. Reading a Vaccine Vial Monitor
87
By Mr. Teklu . 87

88. SAFE
If the inner square
is lighter than the
outer ring and the
expiration date is
valid, the vaccine
is usable.
SPOILED
If the inner square
matches or is
darker than the
outer ring, the
vaccine must be
discarded. By Mr. Teklu . 88

89. By Mr. Teklu . 89

90. By Mr. Teklu . 90
Quiz (5%)
1.What are EPI target groups ?
2.Write tools used to monitor cold chain
3.Write factors w/c determine nature and magnitude of immune
response
4.List & explain immunization delivery sites
5.What are acceptable proof of immunization ?