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Topic 1: EXPANDED PROGRAM ON IMMUNIZATION (EPI)

The Expanded Program on Immunization was launched in July 1976 by the Department of Health in
cooperation with the World Health Organization and the UNICEF.

The original objective was to reduce the morbidity and mortality among children against the most common
vaccine-preventable diseases.

Specific Goals:

1. To immunize all infants/children against the most common vaccine-preventable diseases.

2. To sustain the polio-free status of the Philippines.
3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus
5. To control diphtheria, pertussis, hepatitis b and German measles.
6. To prevent extra pulmonary tuberculosis among children.

Principles:

1. The program is based on epidemiological situation; schedules are drawn on the basis of the occurrence and
characteristics epidemiological features of the disease.
2. The whole community rather than just the individual is to be protected thus mass approach is utilized.
3. Immunization is a basic health services and such it is integrated in to the health services being provided for
by the Rural Health Unit.

Legal Basis/Existing Policies

• Presidential Decree No. 996 (September 16, 1976)

“Providing for compulsory basic immunization for infants and children below eight years of age.”
• Presidential Proclamation No. 6 (April 3, 1986)
“Implementing a United Nations goal on Universal Child Immunization by 1990”
• Presidential Proclamation No. 46 (September 16, 1992)
“Reaffirming the commitment of the Philippines to the Universal Child and Mother Immunization goal on of
the World Health Assembly”
• Presidential Proclamation No. 147 (March 3, 1993)
“Declaring April 21 and May 19, 1993 and every third Wednesday of January and February thereafter, for
two years, as National Immunization Days (NIDs)”
• Presidential Proclamation NO. 7846 (December 30, 1994)
“An Act requiring compulsory immunization against hepatitis B for infants and children below eight (8) years
old”
• Presidential Proclamation No. 773 (March 28, 1998)
“Declaring April 17 and May 15, 1996 and every Third Wednesday of April and May from 1996 to 200 as
“Knock Out Polio Days”
• Presidential Proclamation No. 1066 (August 26, 1997)
“Declaring a national neonatal tetanus elimination campaign starting 1997”
• Presidential Proclamation No. 1064 (August 27, 1997)
“Enjoining all sectors of society to participate in the Acute Flaccid Paralysis (AFP) surveillance component of
polio eradication campaign of the Philippines”
• Presidential Proclamation No. 4 (July 29, 1998)
“Declaring the period from September 16 to October 14, 1998 as the Ligtas Tigdas Month” and launching the
Philippines Measle Elimination Campaign.

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• Republic Act No. 10152 (July 26, 2010) “MandatoryInfants and Children Health Immunization Act of 2011
which is the mandatory includes basic immunization for children under 5 including other types that will be
determined by the Secretary of Health.

Target Setting

▪ Infants 0-12 months

▪ Pregnant and Post Partum Women
▪ School Entrants/ Grade 1 / 7 years old

The 7 immunizable diseases

1. Tuberculosis
2. Diptheria
3. Pertussis
4. Measles
5. Poliomyelitis
6. Tetanus
7. Hepatitis B

Elements of EPI

▪ Target Setting

▪ Cold chain Logistic Management- Vaccine distribution through cold chain is designed to ensure that the
vaccines were maintained under proper environmental condition until the time of administration.

▪ Information, Education and Communication (IEC)

▪ Assessment and evaluation of Over-all performance of the program

▪ Surveillance and research studies

Administration of Vaccines

# of
Vaccine Content Form & Dosage Doses Route

Freeze dried
BCG (Bacillus Live attenuated Infant-
Calmette Guerin) bacteria 0.05mlPreschool-0.1ml 1 ID

DT- weakened
toxin
DPT (Diphtheria
Pertussis Tetanus) P-killed bacteria liquid-0.5ml 3 IM

OPV (Oral Polio

Vaccine) weakened virus liquid-2drops 3 Oral

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Plasma
Hepatitis B derivative Liquid-0.5ml 3 IM

Measles Weakened virus Freeze dried- 0.5ml 1 Subcutaneous

Schedule of Vaccines

Age at 1st Interval between

Vaccine dose dose Protection

BCG is given at the earliest possible age protects

against the possibility of TB infection from the other
BCG At birth family members

An early start with DPT reduces the chance of

DPT 6 weeks 4 weeks severe pertussis

The extent of protection against polio is increased

OPV 6weeks 4weeks the earlier OPV is given.

An early start of Hepatitis B reduces

@birth,6th
Hepa B @ birth week,14th week the chance of being infected and becoming a carrier.

9m0s.- At least 85% of measles can be prevented by

Measles 11m0s. immunization at this age.

▪ 6 months – earliest dose of measles given in case of outbreak

▪ 9months-11months- regular schedule of measles vaccine

▪ 15 months- latest dose of measles given

▪ 4-5 years old- catch up dose

▪ Fully Immunized Child (FIC)– less than 12 months old child with complete immunizations of DPT, OPV, BCG,
Anti Hepatitis, Anti measles.

*School Entrance

BCG immunization shall be given to all school entrants both in private and public school regardless of the
presence or absence of BCG scar.

Tetanus Toxoid Immunization Schedule for Women

Vaccine Minimum Age Interval Percent Protected Duration of Protection
TT1 As early as possible during 80%
pregnancy
TT2 At least 4 weeks later 80% • Infants born to the mother will be
protected from neo-natal tetanus

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• Gives 3 years Protection for the
mother
TT3 At least 6 months later 90% • Infants born to the mother will be
protected from neo-natal tetanus
• Gives 5 years protection for the
mother
TT4 At least 1 year later 99% • Infants born to the mother will be
protected from neo-natal tetanus
• Gives 10 years protection for the
mother
TT5 At least 1 year later 99% • Gives lifetime protection for the
mother
• All infants born to that mother will
be protected.
Note: If the woman received DPT in infancy 3 or 3 doses of DPT during infancy, this should be considered as TT1 and
TT2. The succeeding doses will be TT3 and so forth.

▪ There is no contraindication to immunization except when the child is immunosuppressed or is very, very ill
(but not slight fever or cold). Or if the child experienced convulsions after a DPT or measles vaccine, report
such to the doctor immediately.

▪ Malnutrition is not a contraindication for immunizing children rather; it is an indication for immunization
since common childhood diseases are often severe to malnourished children.

Cold Chain under EPI

▪ Cold Chain is a system used to maintain potency of a vaccine from that of manufacture to the time it is given
to child or pregnant woman.

▪ The allowable timeframes for the storage of vaccines at different levels are:

▪ 6months- Regional Level

▪ 3months- Provincial Level/District Level

▪ 1month-main health centers-with ref.

▪ Not more than 5days- Health centers using transport boxes.

▪ Most sensitive to heat: Freezer (-15 to -25 degrees C)

▪ OPV

▪ Measles

▪ Sensitive to heat and freezing (body of ref. +2 to +8 degrees Celsius)

▪ BCG

▪ DPT

▪ Hepa B

▪ TT

▪ Use those that will expire first, mark “X”/ exposure, 3rd- discard,

▪ Transport-use cold bags let it stand in room temperature for a while before storing DPT.

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▪ Half-life packs: 4hours-BCG, DPT, Polio, 8 hours-measles, TT, Hepa B.

▪ FEFO (“first expiry and first out”) – vaccine is practiced to assure that all vaccines are utilized before the
expiry date. Proper arrangement of vaccines and/or labeling of vaccines expiry date are done to identify
those near to expire vaccines.

Topic 2: INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

The Integrated Management of Childhood Illness strategy has been introduced in an increasing number of
countries in the region since 1995. IMCI is a major strategy for child survival, healthy growth and development and
is based on the combined delivery of essential interventions at community, health facility and health systems levels.
IMCI includes elements of prevention as well as curative and addresses the most common conditions that affect
young children. The strategy was developed by the World Health Organization (WHO) and United Nations Children’s
Fund (UNICEF).

In the Philippines, IMCI was started on a pilot basis in 1996, thereafter more health workers and hospital
staff were capacitated to implement the strategy at the frontline level.

Objectives of IMCI

• Reduce death and frequency and severity of illness and disability, and

• Contribute to improved growth and development

Components of IMCI

• Improving case management skills of health workers

11-day Basic Course for RHMs, PHNs and MOHs

5 - day Facilitators course

5 – day Follow-up course for IMCI Supervisors

• Improving over-all health systems

• Improving family and community health practices

Rationale for an integrated approach in the management of sick children

Majority of these deaths are caused by 5 preventable and treatable conditions namely: pneumonia,
diarrhea, malaria, measles and malnutrition. Three (3) out of four (4) episodes of childhood illness
are caused by these five conditions

Most children have more than one illness at one time. This overlap means that a single diagnosis may
not be possible or appropriate.

Who are the children covered by the IMCI protocol?

Sick children birth up to 2 months (Sick Young Infant)

Sick children 2 months up to 5 years old (Sick child)

Strategies/Principles of IMCI

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• All sick children aged 2 months up to 5 years are examined for GENERAL DANGER signs and all Sick Young
Infants Birth up to 2 months are examined for VERY SEVERE DISEASE AND LOCAL BACTERIAL
INFECTION. These signs indicate immediate referral or admission to hospital

• The children and infants are then assessed for main symptoms. For sick children, the main symptoms
include: cough or difficulty breathing, diarrhea, fever and ear infection. For sick young infants, local bacterial
infection, diarrhea and jaundice. All sick children are routinely assessed for nutritional, immunization and
deworming status and for other problems

• Only a limited number of clinical signs are used

• A combination of individual signs leads to a child’s classification within one or more symptom groups rather
than a diagnosis.

• IMCI management procedures use limited number of essential drugs and encourage active participation
of caretakers in the treatment of children

• Counseling of caretakers on home care, correct feeding and giving of fluids, and when to return to clinic is an
essential component of IMCI

BASIS FOR CLASSIFYING THE CHILD’S ILLNESS (please see enclosed portion of the IMCI Chartbooklet) The child’s
illness is classified based on a color-coded triage system:

PINK- indicates urgent hospital referral or admission

YELLOW- indicates initiation of specific Outpatient Treatment

GREEN – indicates supportive home care

PINK YELLOW GREEN

(URGENT REFERRAL) (Treatment at outpatient (Home management)
health facility)
OUTPATIENT HEALTH FACILITY OUTPATIENT HEALTH FACILITY HOME
▪ Pre-referral treatments ▪ Treat local infection ▪ Caretaker is counseled
▪ Advise parents ▪ Give oral drugs on:
▪ Refer child ▪ Advise and teach ▪ Home treatment/s
caretaker ▪ Feeding and fluids
▪ When to return
▪ Follow-up immediately

▪ Follow-up

REFERRAL FACILITY SEVERE PNEUMONIA OR VERY ▪ Give first dose of an

▪ Emergency Triage and
Treatment (ETAT)
▪ Diagnosis, Treatment
▪ Monitoring, follow-up
SEVERE DISEASE appropriate antibiotic
▪ Give Vitamin A
▪ Treat the child to prevent
low blood sugar
▪ Refer urgently to the
hospital
▪ Give paracetamol for
fever > 38.5oC

▪ Any general danger sign or PNEUMONIA ▪ Give an appropriate

▪ Chest indrawing or antibiotic for 5 days
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▪ Stridor in calm child ▪ Soothe the throat and
relieve cough with a safe
remedy
▪ Advise mother when to
return immediately
▪ Follow up in 2 days
▪ Give Paracetamol for
fever > 38.5oC

▪ Fast breathing NO PNEUMONIA: COUGH OR ▪ If coughing more than

COLD more than 30 days, refer
for assessment
▪ Soothe the throat and
relieve the cough with a
safe remedy
▪ Advise mother when to
return immediately
▪ Follow up in 5 days if not
improving

No signs of pneumonia or very severe

disease

Assess and classify DIARRHEA

A child with diarrhea is assessed for:

▪ How long the child has had diarrhoea

▪ Blood in the stool to determine if the child has dysentery

▪ Signs of dehydration.

Classify DYSENTERY

▪ Child with diarrhea and blood in the stool

Two of the following signs?
▪ Abnormally sleepy or
difficult to awaken
▪ Sunken eyes
▪ Not able to drink or
drinking poorly
▪ Skin pinch goes back
very slowly
SEVERE ▪ If child has no other severe classification:
DEHYDRATION ▪ Give fluid for severe dehydration ( Plan C )
OR
▪ If child has another severe classification :
▪ Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way
▪ Advise the mother to continue
breastfeeding
▪ If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera

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Two of the following signs: SOME ▪ Give fluid and food for some dehydration (
▪ Restless, DEHYDRATION Plan B )
irritable ▪ If child also has a severe classification :
▪ Sunken eyes ▪ Refer URGENTLY to hospital
▪ Drinks eagerly, with mother giving frequent
thirsty sips of ORS on the way
▪ Skin pinch goes ▪ Advise mother when to return
back slowly immediately
▪ Follow up in 5 days if not improving

▪ Not enough NO DEHYDRATION ▪ Home Care

signs to classify ▪ Give fluid and food to treat diarrhea at home
as some or ( Plan A )
severe ▪ Advise mother when to return immediately
dehydration ▪ Follow up in 5 days if not improving

▪ Dehydration SEVERE ▪ Treat dehydration before referral unless the

present PERSISTENT child has another severe classification
DIARRHEA ▪ Give Vitamin a
▪ Refer to hospital

▪ No dehydration PERSISTENT ▪ Advise the mother on feeding a child who

DIARRHEA has persistent diarrhea
▪ Give Vitamin A
▪ Follow up in 5 days
▪ Blood in the DYSENTERY ▪ Treat for 5 days with an oral antibiotic
stool recommended for Shigella in your area
▪ Follow up in 2 days
▪ Give also referral treatment

Does the child have fever?

Decide:

▪ Malaria Risk

▪ No Malaria Risk

▪ Measles

▪ Dengue

Malaria Risk

▪ Give first dose of quinine ( under

medical supervision or if a hospital is
not accessible within 4hrs )

▪ Give first dose of an appropriate

▪ general danger antibiotic
VERY SEVERE
sign or
FEBRILE DISEASE / ▪ Treat the child to prevent low blood
▪ Stiff neck MALARIA sugar

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▪ Give one dose of paracetamol in
health center for high fever (38.5oC) or
above

▪ Send a blood smear with the patient

▪ Refer URGENTLY to hospital

▪ Blood smear ( + ▪ Treat the child with an oral

) antimalarial

If blood smear ▪ Give one dose of paracetamol in

not done: health center for high fever (38.5oC) or
above
▪ NO runny nose,
and ▪ Advise mother when to return
immediately
▪ NO measles,
and ▪ Follow up in 2 days if fever persists

▪ NO other ▪ If fever is present everyday for more

causes of fever MALARIA than 7 days, refer for assessment

▪ Give one dose of paracetamol in

health center for high fever (38.5oC) or
above
▪ Blood smear ( –
), or ▪ Advise mother when to return
immediately
▪ Runny nose, or
▪ Follow up in 2 days if fever persists
▪ Measles, or
Other causes of FEVER : MALARIA ▪ If fever is present everyday for more
fever UNLIKELY than 7 days, refer for assessment

No Malaria Risk

▪ Give first dose of an appropriate

antibiotic

▪ Treat the child to prevent low blood

sugar

▪ Give one dose of paracetamol in

▪ Any general danger health center for high fever (38.5oC)
sign or or above
VERY SEVERE
▪ Stiff neck FEBRILE DISEASE ▪ Refer URGENTLY to hospital

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▪ Give one dose of paracetamol in

health center for high fever (38.5oC)
or above

▪ Advise mother when to return

immediately

▪ Follow up in 2 days if fever persists

▪ No signs of very
severe febrile FEVER: NO ▪ If fever is present everyday for more
disease MALARIA than 7 days, refer for assessment

Measles

▪ Give Vitamin A

▪ Give first dose of an appropriate

antibiotic

▪ Clouding of cornea ▪ If clouding of the cornea or pus

or draining from the eye, apply
tetracycline eye ointment
▪ Deep or extensive SEVERE COMPLICATED
mouth ulcers MEASLES ▪ Refer URGENTLY to hospital

▪ Give Vitamin A

▪ If pus draining from the eye, apply

▪ Pus draining from tetracycline eye ointment
the eye or
MEASLES WITH EYE OR ▪ If mouth ulcers, teach the mother
▪ Mouth ulcers MOUTH COMPLICATIONS to treat with gentian violet

▪ Measles now or
within the last 3
months MEASLES ▪ Give Vitamin A

Dengue Fever

▪ If skin petechiae or Tourniquet

▪ Bleeding from nose or test, are the only positive signs give
gums or ORS

▪ Bleeding in stools or ▪ If any other signs are positive, give

vomitus or fluids rapidly as in Plan C

▪ Black stools or vomitus ▪ Treat the child to prevent low

or blood sugar
SEVERE DENGUE
▪ Skin petechiae or HEMORRHAGIC FEVER ▪ DO NOT GIVE ASPIRIN

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▪ Cold clammy ▪ Refer all children Urgently to
extremities or hospital

▪ Capillary refill more

than 3 seconds or

▪ Abdominal pain or

▪ Vomiting

▪ Tourniquet test ( + )

▪ DO NOT GIVE ASPIRIN

▪ Give one dose of paracetamol in

health center for high fever
(38.5oC) or above

▪ Follow up in 2 days if fever persists

or child shows signs of bleeding
▪ No signs of severe FEVER: DENGUE
dengue hemorrhagic HEMORRHAGIC ▪ Advise mother when to return
fever UNLIKELY immediately

Does the child have an ear problem?

▪ Give first dose of

appropriate antibiotic

▪ Give paracetamol for

pain

▪ Tender swelling behind the ear MASTOIDITIS ▪ Refer URGENTLY

▪ Give antibiotic for 5

days

▪ Give paracetamol for

▪ Pus seen draining from the ear and
pain
discharge is reported for less than 14
days or ▪ Dry the ear by wicking
ACUTE EAR
▪ Ear pain INFECTION ▪ Follow up in 5 days

▪ Pus seen draining from the ear and

▪ Dry the ear by wicking
discharge is reported for less than 14 CHRONIC EAR
days INFECTION ▪ Follow up in 5 days

▪ No ear pain and no pus seen draining NO EAR ▪ No additional

from the ear INFECTION treatment

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Check for Malnutrition and Anemia

Give an Appropriate Antibiotic:

A. For Pneumonia, Acute ear infection or Very Severe disease

COTRIMOXAZOLE AMOXYCILLIN
BID FOR 5 DAYS BID FOR 5 DAYS

Adult Tablet Syrup

Age or Weight tablet Syrup

2 months up to 12
months ( 4 – < 9 kg ) 5 ml 1/2 5 ml

12 months up to 5
years ( 10 – 19kg ) 7.5 ml 1 10 ml

B. For Dysentery

COTRIMOXAZOLE AMOXYCILLIN

BID FOR 5 DAYS BID FOR 5 DAYS

AGE OR WEIGHT Tablet Syrup SYRUP 250MG/5ML

2 – 4 months

( 4 – < 6kg ) ½ 1.25 ml ( ¼ tsp )

5 ml

4 – 12 months ½ 2.5 ml ( ½ tsp )

( 6 – < 10 kg ) 5 ml

1 – 5 years old 1

( 10 – 19 kg ) 7.5 ml ( 1 tsp )

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C. For Cholera

TETRACYCLINE COTRIMOXAZOLE

QID FOR 3 DAYS BID FOR 3 DAYS

AGE OR WEIGHT Capsule 250mg Tablet Syrup

2 – 4 months ( 4 – < 6kg ) ¼ 1/2 5ml

4 – 12 months ( 6 – < 10 kg ) ½ 1/2 5 ml

1 – 5 years old ( 10 – 19 kg) 1 1 7.5m

Give an Oral Antimalarial

Primaquine

Give single
Primaquine
OQUINE dose in
Sulfadoxine +
health center Give daily for
Give for 3 days Pyrimethamine
for P. 14 days for P.
Falciparum Vivax Give single dose

TABLET TABLET TABLET

AGE TABLET (150MG) (15MG) (15MG) (15MG)

DAY1 DAY2 DAY3

2months –

5months ½ ½ ½ ¼

5 months –

12 months ½ ½ ½ 1/2

12months –

3 years old

1 1 ½ ½ ¼ ¾

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3 years
old –

5 years old 1½ 1½ 1 3/4 1/2

GIVE VITAMIN A

Iron Syrup
Iron/Folate Tablet FeSo4 150 mg/5ml
FeSo4 200mg + 250mcg Folate (60mg (6mg elemental iron
AGE or WEIGHT elemental iron) per ml )

2months-4months
(4 – <6kg ) 2.5 ml

4months – 12months
(6 – <10kg ) 4 ml

12months – 3 years (10 –

<14kg) 1/2 5 ml

3years – 5 years ( 14 – 19kg ) 1/2 7.5 ml

GIVE PARACETAMOL FOR HIGH FEVER (38.5oC OR MORE) OR EAR PAIN

AGE OR WEIGHT TABLET ( 500MG ) SYRUP ( 120MG / 5ML )

2 months – 3 years ( 4 – <14kg ) ¼ 5 ml

3 years up to 5 years (14 – 19 kg ) 1/2 10 ml

Steps of the IMCI Case management Process

The following is the flow of the iMCI process. At the out-patient health facility, the health worker
should routinely do basic demographic data collection, vital signs taking, and asking the mother about the
child's problems. Determine whether this is an initial or a follow-up visit. The health worker then proceeds
with the IMCI process by checking for general danger signs, assessing the main symptoms and other
processes indicated in the chart below.

Take note that for the pink box, referral facility includes district, provincial and tertiary hospitals.
Once admitted, the hospital protocol is used in the management of the sick child.

External Resources:

http://www.doh.gov.ph/node/6035
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https://www.doh.gov.ph/expanded-program-on-immunization

https://www.doh.gov.ph/integrated-management-of-childhood-illness

https://www.rnpedia.com/nursing-notes/community-health-nursing-notes/integrated-management-childhood-
illnesses-imci/

https://www.rnpedia.com/nursing-notes/community-health-nursing-notes/expanded-program-immunization-epi/

References:

Nisce, Z L., Reyala, J.P., Martinez F.R., Hizon N.L, Ruzol C.A., Dequina R.B., Alcantara A.P., Bermudez M.T. C., Estipona
G.R., (2000) Community Health Nursing Services in the Philippines. National League of Philippine Government
Nurses, Incorporated.

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