COMMUNITY HEALTH NURSING SKILLS LAB: MIDTERMS • 2013 TD and MR vaccines provided in high schools in selected
high-risk provinces and cities MMR second dose provided for
Expanded Program on Immunization
(National Immunization Program)
Rationale
• The Expanded Program on Immunization (EPI) was established in 1976
to ensure that infants/children and mothers have access to routinely
recommended infant/childhood vaccines.
• Six vaccine-preventable diseases were initially included in the EPI:
tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles.
Program Objectives/Goals
Over-all Goal:
• 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.
A Brief History of the Immunization Program in the Philippines
• The immunization program was officially launched in 1976.
• The BCG vaccine against TB was administered to school entrants.
• This was followed by vaccines against poliomyelitis, diphtheria,
tetanus, pertussis (DPT) and measles.
• A comprehensive program implementation review was conducted
in 1986.
• The review revealed that coverage was still less than optimal.
• In 1989, the country achieved for the first time the universal child
immunization goal of 90% - one year ahead of the target date.
• The Philippines together with other nations pledged to attain three
immunization global goals by 1995:
(i) eradication of poliomyelitis,
(ii) elimination of neonatal tetanus (NT) and
(iii) control of measles.
• The Philippines reached polio-free status in 2000.
• The country also completed the second validation for the
declaration of ot elimination in 2014.
• Supplementary immunization campaigns (SIA) against measles
were conducted beginning 1998, followed by nationwide
campaigns in 2004, 2007, 2011 and 2014.
• The country increased the scope and coverage of the NIP by
adding new vaccines for children and women and including other
age groups like school children, adolescents/youth and the elderly.
Milestones of the Immunization Program in the Philippines
• Vaccines introduced by the program 1976 BCG first administered
among school entrants DPT introduced in priority areas
• 1979 BCG and DPT provided nationwide; OPV and tetanus toxoid
(TT) for pregnant women provided in high-risk areas
• 1980 OPV and TT provided nationwide
• 1982 MV provided among 35% of the eligible population
• 1983 MV provided nationwide
• 1992 Hepatitis B provided among 40% of eligible population
• 2005 Hepatitis B provided nationwide
• 2010 MMR administered in selected areas
• 2012 PENTA administered nationwide rotavirus vaccine provided
among children in indigent families, anti-influenza vaccine provided
for indigent senior citizens
children 12 – 15 months of age
• 2014 HPV vaccine introduced in pilot areas in car and region 7
Mandates
Republic act no. 10152 “mandatory infants and children health
immunization act of 2011 signed by President Benigno Aquino III in July
26, 2010. The mandate includes basic immunization for children under
5 including other types that will be determined by the secretary of health.
Pd 996 – compulsory basic immunization to all children before reaching
8 years old
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
Concept and Importance of Vaccination
General principles in vaccinating children
• It is safe and immunologically effective to administer all EPI
vaccines on the same day at different sites of the body
• The vaccination schedule should not be restarted from the
beginning even if the interval between doses exceeded the
recommended interval by months or year
• Giving doses of a vaccine at less than the recommended 4 weeks
interval may lessen the antibody response. Lengthening the
interval between doses of vaccines leads to higher antibody level.
• No extra doses must be given to children who missed a dose of
DPT/HB/OPV. The vaccination must be continued as if no time had
elapsed between doses.
• Do not give more than one dose of the same vaccine to a child in
one session. Give doses of the same vaccine at the correct
intervals
• Strictly follow the principle of never, ever reconstituting the freeze-
dried vaccine in anything other than the diluent supplied with them
• If you are giving more than one vaccine, do not use the same
syringe and do not use the same arm or leg for more than one
injection
Contraindication to Immunization
• Anaphylaxis or severe hypersensitivity reaction to a previous dose
of vaccine is an absolute contraindication to subsequent doses of
vaccine
• Person with a known allergy to a vaccine component should not be
vaccinated
• 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 child with an evolving
neurological disease
• Do not give live vaccines like BCG to an individual who are
immunosuppresed due to malignant disease (child with AIDS),
going therapy with immunosuppressive agents or radiation
• A child with a sign and symptoms of severe dehydration
• Fever of 38.5 C and above
Infants with these conditions should be immunized: (Not A
Contraindication)
• Allergy or Asthma (except if there is a known allergy to a specific
component of vaccine mentioned above)
• Minor respiratory tract infection
• Diarrhea
• Temp. Below 38.5 c
• Family history of convulsions, seizures
• Family history of adverse reaction following immunization
• Known or suspected HIV infection with no signs and symptoms of
AIDS
• Child being breastfed
• Chronic illness such as diseases of the heart, lung, kidney or liver
• Stable neurological condition such as cerebral palsy or down’s
syndrome
• Premature or low birth weight (vaccination should not be
postponed)
• Recent or imminent surgery
• Malnutrition
• History of jaundice at birth
Note: if parent strongly objects to an immunization for a sick infant, do
not give it. Ask the mother to comeback when child is well EPI routine
schedule – every Wednesday is designated as immunization day and is
adopted in all part of the country
• FIC – “fully immunized child” when a child receives 1 dose of BCG,
3 doses of DPT, HBV and 1 dose of measles before a child’s first
birthday
• 6 months – earliest dose of measles given in case of outbreak
• 9 - 11 months – regular schedule of measles vaccine
• 15 months – latest dose of measles given
• 4 - 5 years old – catch up dose
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.
• 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
The Allowable Timeframes for the Storage of Vaccines at Different
Levels are:
• 6 months – regional level
• 3 months – provincial level/district level
• 1 month – main health centers-with ref.
• Not more than 5 days – health centers using transport boxes.
• Note: 3 trips in transport box with the same vaccine – discard it
MOST SENSITIVE TO HEAT: FREEZER
• (-15 TO -25 DEGREES CELSIUS)
o OPV
o Measles
SENSITIVE TO HEAT AND FREEZING
• (BODY OF REF. +2 TO +8 DEGREES CELSIUS)
o BCG
o DPT
o HEPA B
o 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.
• 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
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
TYPES OF VACCINE WASTAGE IN UNOPENED VIALS
• Expiry
• Heat exposure
• Freezing
• Breakage
• Missing inventory
• Theft
• Discarding unused vials returned vials from an outreach session
TYPES OF 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 open vials in water
• Suspected contamination
• Patient reaction requiring more than one dose
• Target setting involves the calculation of the eligible population for
immunization services
• Eligible population (EP) consists of any group of people targeted
for specific immunizations due to their susceptibility to one or
several of the seven immunizable diseases
Pointers in determining the EPI
Infants – 3% of the total population for EPI
BCG school entrants – 3% of the total population in calculating the #
of children entering first grade in one year
Pregnant women – 3.5% of the total population
12 to 59 months old in measles high risk areas (HRA) = 11.5% of the
total population
0 to 59 months for OPV during the outbreak response immunization
(ORI) – 14.5%
15 to 44-year-old women (reproductive age) for tetox in HRA – 15%
Vaccine type Doses for Wastage Wastage Dose 6. Calculate the annual vaccine doses required (AVR)
complete allowance multiplier per AVR = TVR x WF
immunization vial/amp AVR = 90 x 2.5 = 225
DPT 3 40% 1.67 20 or 10
OPV 3 40% 1.67 20 7. Number of doses per ampule/vial = 20
MEASLES 1 50% 2.00 10
BCG INFANT 1 60% 2.50 20 8. Determine annual vaccine ampule/vial required (AVA)
BCG 1 40% 1.67 20 AVA = AVR / # of doses per amp/vial
ENTRANTS AVA = 225 / 20 = 11.25
HEPATITIS B 3 10% 1.20 1 or 10
TETOX 5 40% 1.67 20 9. Calculate the monthly vaccine doses required (MVR)
MVR = AVR / 12 months
MVR = 225 / 12 = 18.75 (19)
How to get the wastage multiplier (WM)?

• WM = 10. Determine monthly vaccine amp/vial required (MVA)

total doses in vial MVA = AVA / 12
doses used MVA = 11.25 / 12 = 0.94 (1)

• Doses used = 11. Determine the vaccine need per month with reserve stock
total doses in vial – (dose per vial or ampule x wastage Monthly vaccine needs = (total vials or ampules / 12 months) x 1.25
allowance) = 1 x 1.25 = 1.25

How to Calculate Needle and Syringe Requirements

Example: BCG infants
1. Determine the eligible population
2. Determine the monthly vaccine doses
• Total doses in a vial = 20
Monthly vaccine doses = annual vaccine doses / 12 months
• Wastage allowance = 60%
= 225 / 12 = 18.75
• Number of doses used = 20 – (20x0.60)
= 20 – (12)
3. Determine the total requirement including additional allowance for
=8
syringes and needles.
• Wastage Multiplier (WM) = 20 / 8 = 2.5
Total required syringes = monthly injections x 1.25
Steps in Calculating Vaccine Requirements = 18.75 x 1.25 = 23.44 (23)

1. Total population (TP) Total required needles = monthly injections x 1.5

2. Determine the eligible population (EP) = 18.75 x 1.5 = 28.13 (28)
3. Required # of doses to immunize a child/mother
4. Determine the total vaccine required (TVR)
TVR = EP x # of doses
Compute your DPT monthly need for a population of 10,000 plus your
5. Wastage factor (WF) constant
syringe and needle requirements.
6. Calculate the annual vaccine doses
Required (AVR) AVR = TVR x WF 1. EP - 10,000 X 0.03 = 300
7. Number of doses per ampule/vial 2. MVR – 125.25
8. Determine annual vaccine ampule/vial required AVA) SYRINGES – 125.25 X 1.25 = 156.56 (157)
AVA = AVR / # of doses per amp/vial NEEDLES – 125.25 X 1.5 = 187.875 (188)
9. Calculate the monthly vaccine doses required
(MVR) MVR = AVR / 12 months Bacille Calmette Guerin (BCG)
10. Determine monthly vaccine amp/vial required
(MVA) MVA = 12 / 12 = 1 • Given intradermally (ID)
11. Determine the vaccine need per month with reserve stock • The dose of BCG is 0.05 ml for children < 12 months and 0.1 ml for
Monthly vaccine needs = (total vials or ampules / 12 months) x 1.25 children ≥ 12 months
• Given at the earliest possible age after birth preferably within the
first 2 months of life
Example: • For healthy infants and children > 2 months who are not given BCG
at birth, PPD prior to BCG vaccination is not necessary.
1. Total population (TP) - Ex. 3,000
• However, PPD is recommended prior to BCG vaccination if any of
2. Determine the eligible population (EP)
the following is present:
EP = TP x 3% (infants and children)
o congenital TB
= TP x 3.5% (mothers)
o history of close contact to known or suspected infectious
cases
EP = 3,000 x 0.03 = 90
o clinical findings suggestive of TB and/or chest x-ray
suggestive of TB
3. Required # of doses to immunize a child/mother
• In the presence of any of these conditions, an induration of 5 mm
BCG = 1
is considered positive and BCG is no longer recommended
4. Determine the total vaccine required (TVR) • Tuberculosis (TB) is an infection that most often attacks the lungs.
TVR = EP x # of doses In infants and young children, it affects other organs like the brain.
TVR = 90 x 1 = 90 A severe case could cause serious complications or death.
• TB is very difficult to treat when contracted, and treatment is
5. Wastage factor (WF) constant lengthy and not always successful. According to the 2020 World
BCG = 2.5 Health Organization global TB report, the Philippines has the
highest TB incidence rate in Asia, with 554 cases for every 100,000
Filipinos.
• Note: Poliovirus Vaccine
o The small raised lump appears at the injection at the injection
site, usually disappears within 30 minutes • Inactivated polio vaccine (IPV)
o After 2 weeks, a red sore forms that is about the size of an • Given intramuscularly (IM), as a monovalent formulation or in
unsharpened pencil combination with DPT containing vaccines
o The sore remains for another two weeks and then heals, a • Given at a minimum age of 6 weeks, at least 4 weeks apart
small scar, about 5mm across remains. This is a sign that the • The primary series consists of 3 doses given at 6, 10, and 14
child has been effectively immunized weeks.
o Repeat BCG vaccination if the child does not develop a scar • The first booster is given at 12-18 months. The minimum interval
after the 1st injection between the third dose and the first booster dose is 6 months.
• The second booster is given at age 4-6 years.
Diphtheria, Tetanus, Pertussis Vaccine (DTP) • If the fourth dose is given at age 4 years onward, no further doses
are necessary
• Given intramuscularly (IM)
• Given at a minimum age of 6 weeks. Oral Polio Vaccine (OPV)
• The primary series consists of 3 doses with a minimum interval of
4 weeks • Only available as part of the government’s NIP
• booster series consists of 3 doses until adolescence with the • The primary series consists of 3 doses beginning at age 6 weeks
following schedule: with a minimum interval of ≥4 weeks; a dose of monovalent IPV is
• 12 - 23 months (DTP) given together with the third dose
• 4 - 7 years (DTP) • Polio is a virus that paralyzes 1 in 200 people who get infected.
• 9 - 15 years (TD/TDAP) • Among those cases, 5 to 10 per cent die when their breathing
• Ideally, the minimum interval between booster doses should be at muscles are paralyzed.
least 4 years • There is no cure for polio once the paralysis sets in.
• Full-dose DTP should preferably be used only until age 7 years, but
package inserts should be consulted for maximum age indications Oral Polio Vaccine (OPV)
of specific products Type of vaccine Live attenuated vaccine
• Diphtheria infects the throat and tonsils, making it hard for children Form of vaccine Liquid vaccine
to breathe and swallow. Severe cases can cause heart, kidney Minimum age at 1st dose 6 weeks
and/or nerve damage. No. of doses to complete the 3
immunization
• Pertussis (whooping cough) causes coughing spells that can last
Interval 4 weeks/minimum of 28 days
for weeks. In some cases, it can lead to troubled breathing,
The extent of protection against
pneumonia, and death. Reason polio is increased the earlier the
• Tetanus causes very painful muscle contractions. It can cause OPV is given
children’s neck and jaw muscles to lock (lockjaw), making it hard No. of doses per amp. 20 (10 children)
for them to open their mouth, swallow, breastfeed or breathe. Even Dosage 2 drops
with treatment, tetanus is often fatal. Route of Administration Oral
Site of Administration Mouth
Diphtheria, Tetanus, Pertussis Vaccine (DTP) -15C to -25C (at the freezer)
Route Administration Intramuscular Storage temperature Note: it is easily damaged by
Upper outer portion of the thigh heat but is not harmed by
Site of Administration (vastus lateralis) in infant (R-L- freezing
R) Outer upper arm if older Children known to have a rare
2C to 8C (in the body of the congenital immune deficiency
refrigerator) Special precautions syndrome should receive IPV
Storage temperature Note: “DT” component is (injectable polio vaccine) rather
damaged by freezing “P” than OPV
component is damaged by heat Causes almost no side effects.
Special precautions DPT not usually given over 6 Less than 1% of the people who
years of age Side effects receive the vaccine develop a
Fever in the evening after headache, diarrhea or muscle
receiving the injection pain
Side effects Soreness, children may have Contraindication None
pain, redness or swelling at the Nothing by mouth (NPO) 30
injection site Health teaching minutes before and after OPV
DPT2 or DPT3 is not given to a Do not touch the dropper bottle
child who has convulsions or to the tongue
Contraindication shock within 3 days after DPT1
vaccines containing the whole • Read the manufacturer’s instructions to determine number of drops
cell pertussis component should
to be given
not be given to children with an
evolving neurological disease • Two types of OPV container
If the child has fever give o Small plastic dropper bottle
Paracetamol or any appropriate o Glass vials with dropper in a separate plastic bag
Health teaching antipyretic at the time and at 4 • If the child has diarrhea when OPV is given, administer an extra
and 8 hrs. Cold to warm dose – that is, a 4th dose at least 4 weeks after the last dose in the
compress if there is pain and schedule
soreness.
 Hepatitis B Vaccine (HBV)
• Given intramuscularly (IM)
• Administer the first dose of monovalent HBV to all newborns ≥2kgs
within 24 hours of life
• A second dose is given 1-2 months after the birth dose
• The final dose is administered not earlier than 24 weeks of age
• Another dose is needed if the last dose was given at age <24 weeks
• For infants born to HBsAG (Hep B Surface Antigen) (+) mothers
(preterm or term infants):
o Administer HBV* and HBIG (Hep B Immune Globulin) (0.5ml)
within 12 hours of life.
o HBIG should be administered not later than 7 days of age, if
not immediately available
• For infants born to mothers with unknown HBsAG status:
o With birth weight ≥2 kgs, administer HBV within 12 hours of
birth and determine the mother’s HBsAG as soon as possible.
o If HBsAG (+), administer HBIG not later than 7 days of age.
o With birth weight <2 kgs, the 1st dose received at births is not
counted as part of the vaccine series.
o Additional 3 HBV doses are needed
• Hepatitis B virus is a dangerous liver infection that, when caught
as an infant, often shows no symptoms for decades.
• It can develop into cirrhosis and liver cancer later in life.
• Children less than 6 years old who become infected with the
hepatitis b virus are the most likely to develop chronic infections.
Hepatitis B Vaccine
Type of vaccine “Monovalent vaccine” contains
only 1 antigen
Form of vaccine Cloudy liquid vaccine
Minimum age at 1st dose At birth
No. of doses to complete 3 Site of Administration
the immunization
6 weeks interval from 1st dose to
Interval 2nd dose
8 weeks interval from 2nd dose
to 3rd dose
An early start of Hep B vaccine
reduces the chance of being
Reason infected and becoming a carrier.
Prevent liver cirrhosis and liver
cancer
1 for single dose vial
No. of doses per amp. 10 for multi-dose vial (10
children)
Dosage 0.5 ml
Route of Administration Intramuscular
Upper outer portion of the thigh
Site of Administration (vastus lateralis) in infant with
DPT (L-R L)
2C to 8C (body)
Storage temperature Note: Both heat and freezing
damages the vaccine
Note: combination vaccine
Special precautions should not be given at birth, only
monovalent Hep B vaccine)
Mild fever that lasts 1 to 2 days
after injection
Side effects Soreness, children may have
pain, redness or swelling at the
injection site
Anaphylactic reaction such as
Contraindication severe rashes, difficulty in
breathing and choking to a
previous dose
If the child has fever give
Paracetamol or any appropriate
antipyretic at the time and at 4
Health teaching and 8 hrs. Alternating cold
compress for 24 hrs to warm
compress if there is pain and
soreness
Measles Vaccine
• Given subcutaneously (SC)
• Given at the age of 9 months, but may be given as early as age 6
months in cases of outbreaks as declared by public health
authorities
• If monovalent measles vaccine is not available, then MMR/MR
vaccine may be given as substitute for infants below 12 months of
age
• In such cases, the recipient should receive 2 more MMR vaccines
starting at 1 year of age, following recommended schedules
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 epidemic
No. of doses to complete the 1
immunization
Measles vaccine given at 9
months provide at least 85%
protection against measles
infection. When given at 1 year
and older provides 95%
Reason protection
Note: an infant with known or
suspected HIV infection should
receive measles vaccine at 6
months and then again at 9
months
No. of doses per amp. 10 (10 children)
Dosage 0.5 ml
Route of Administration Subcutaneous
Outer part of the upper arm
-15C to -25C (at the freezer)
Note: but can also be safely
Storage temperature stored between 0C to 8C until its
expiry date
Diluent should also be kept cold
before using
Special precautions Birth dose must be given if there
is a risk of perinatal transmission
Fever that lasts 1-2 days after
injection
Soreness, children may have
pain, redness or swelling at the
injection site within 24 hours of
Side effects immunization
It usually resolves within 2-3
days
About 1 in 20 children develop a
mild rash 5-12 days after
receiving the vaccine. The rash
usually lasts about 2 days
Severe reaction to previous dose
Contraindication Pregnancy
Congenital or acquired immune
disorder
If the child has fever give
Paracetamol or any appropriate
antipyretic at the time and at 4
Health teaching and 8 hrs. Alternating cold
compress for 24 hrs to warm
compress if there is pain and
soreness
Measles-Mumps-Rubella (MMR) Vaccine
• Given subcutaneously (SC)
• Given at a minimum age of 12 months
• 2 doses of MMR vaccine are recommended
• The second dose is usually given at 4-6 years of age but may be
given at an earlier age with a minimum of 4 weeks interval between
doses.
 Measles-Mumps-Rubella-Varicel La Vaccine (MMRV)
• Given subcutaneously (SC)
• Given at a minimum age of 12 months
• MMRV may be given as an alternative to separately administered
MMR and varicella vaccines
• The maximum age is 12 years
• The recommended minimum interval between doses is 3 months,
but a second dose given 4 weeks from the first dose is considered
valid
• Measles is a highly contagious disease with symptoms that include
fever, runny nose, white spots in the back of the mouth and a rash.
Serious cases can cause blindness, brain swelling and death.
• Mumps can cause headache, malaise, fever, and swollen salivary
glands. Complications can include meningitis, swollen testicles and
deafness.
• Rubella infection in children and adults is usually mild, but in
pregnant women it can cause miscarriage, stillbirth, infant death or
birth defects.
• For previously unvaccinated infants age 7-11 months, give a total
of 3 doses.
• The first 2 doses are given 1 month apart. The interval between the
second and third dose is at least 2 months but should ideally be
given at or after the first birthday.
• For previously unvaccinated older children age 12 months to 5
years
• PCV 10: 1-5 years old: give 2 doses at least 2 months apart
• PCV 13: 12-23 months: give 2 doses at least 2 months apart
• 2 to 5 years old: give 1 dose
Rotavirus Vaccine (RV) Human (RV1)
• Given per orem (PO) as oral liquid formulation
• Given as a 2-dose series
• Given at a minimum age of 6 weeks with a minimum interval of 4
weeks between doses.
• The last dose should be administered not later than 24 weeks of
age

Haemophilus Influenzae Type B Conjugate Vaccine Tetanus and Diphtheria Toxoid (TD)/ Tetanus and Diphtheria
Toxoid and Acellular Pertussis (TDAP) Vaccine
• Given intramuscularly (IM)
• Given as a 3-dose primary series with a minimum age of 6 weeks • Given intramuscularly (IM)
and a minimum interval of 4 weeks • For children who are fully immunized, TD /TDAP booster doses
• A booster dose is given between age 12-15 months with an interval should be given every 10 years
of 6 months from the third dose • For children age >7 years a single dose of TDAP can be given to
• Refer to vaccines for special groups for HIB recommendation in replace due TD.
high-risk children • Tdap can be administered regardless of the interval since the last
tetanus and diphtheria-toxoid containing vaccine
Hepatitis A Vaccine (HAV) • Subsequent doses are given s TD/TDAP.
• Fully immunized is defined as 5 doses of DTP, or 4 doses of DTP if
• Inactivated hepatitis A vaccine the 4th dose was given on or after the 4th birthday
o Given intramuscularly (IM)
• Give 1 dose of TDAP for every pregnancy
o Minimum age: 12 months
• For fully immunized pregnant adolescents, administer 1 dose of
o 2 dose series: minimum interval between first and second
TDAP vaccine at 27 to 36 weeks AOG, regardless of previous td or
dose is 6 months
TDAP vaccination
• Live attenuated hepatitis A vaccine
• For unimmunized pregnant adolescents, administer a 5-dose
o Given subcutaneously (SC)
tetanus-diphtheria (TD)-containing vaccine following a 0-,1- , 6-,18-
o Minimum age: 18 months
, and 30-month schedule.
o Given as single dose
• Use TDAP as one of the 5 doses, preferably given at 27-36 weeks
Human Papillomavirus Vaccine (HPV) AOG

• Given intramuscularly (IM) Tetanus Toxoid (TeTox) Vaccine

• For ages 9-14 years, a 2-dose series is recommended Type of vaccine Weakened toxin
Form of vaccine Liquid vaccine
• For ages 15 years and older, a 3-dose series is recommended.
Minimum age at 1st dose As early as possible during
• For males age 9-18 years, a 4vhpv and 9vhpv can be given for the
pregnancy
prevention of anogenital warts and anal cancer. No. of doses to complete the 5 doses
immunization TeTox 2 is the minimum required
Influenza Vaccine (Trivalent/Quadrivalent Influenza Vaccine)
immunization during pregnancy
No. of doses per amp. 10 or 20
• Trivalent influenza vaccine (TIV) given intramuscularly (IM) or
Dosage 0.5 ml
subcutaneously (SC)
Route of Administration Intramuscular
• Quadrivalent influenza vaccine (QIV) given intramuscularly (IM)
Site of Administration Outer upper arm
• Given at a minimum age of 6 months 2C to 8C (in the body of the
• For pediatric dose, follow the manufacturer’s recommendations Storage temperature refrigerator)
• Children age 6 months to 8 years receiving influenza vaccine for Note: Never freeze
the 1st time should receive 2 doses separated by at least 4 weeks Fever in the evening after
• If only one dose was given during the previous influenza season, receiving the injection
give 2 doses of the vaccine then one dose yearly thereafter Side effects Soreness, woman may have
• Children age 9 to 18 years should receive one dose of the vaccine pain, redness, or swelling and
yearly warmth at the injection site
Contraindication Anaphylactic reaction to
• Annual vaccination should begin in February but may be given
previous dose
throughout the year
NO MEDICATION FOR
Pneumococcal Conjugate Vaccine (PCV) Health teaching PREGNANT
For pain; cold compress for 24
• Given intramuscularly (IM) hours to warm compress
• Given at a minimum age of 6 weeks
• Primary vaccination consists of 3 doses with an interval of at least
4 weeks between doses.
• Booster dose is given 6 months after the third dose.
 Vaccine Minimum Age % protected Duration of PPT NI MAAM CASANAS
interval protection
TT1 As early as 0% 0
possible
(pregnancy)
TT2 4 weeks later 80% 3 years
TT3 6 months later 95% 5 years
TT4 1 year/during 99% 10 years
the next
pregnancy
TT5 1 year 99% Lifetime
later/third
pregnancy

Role in Improving Delivery of Immunization in the Community

• Active master list of 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
• Disposed used syringes and needles properly by using collector
box and disposing it in the septic vault to prevent health hazard
• Inform, educate, communicate with the parents
o To create awareness and motivate to submit their child for
vaccination
o To provide health teachings on the importance and benefits
of immunization, importance of follow-up dose to avoid
defaulters and normal course of vaccine
o 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 from 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
 BAG TECHNIQUE • 2 test tubes
• Test tube holder
Bag technique – a tool making use of public health bag through which • Medicines
the nurse, during his/her home visit, can perform nursing procedures o betadine
with ease and deftness, saving time and effort with the end in view of o 70% alcohol
rendering effective nursing care. o ophthalmic ointment (antibiotic)
o zephiran solution
Public health bag – is an essential and indispensable equipment of the
o hydrogen peroxide
public health nurse which he/she has to carry along when he/she goes
o spirit of ammonia
out home visiting. It contains basic medications and articles which are
o acetic acid
necessary for giving care.
o benedict’s solution
RATIONALE
Note: Blood Pressure Apparatus and Stethoscope are carried
To render effective nursing care to clients and /or members of the family separately.
during home visit.
STEPS AND PROCEDURE
PRINCIPLES
Actions Rationale
1. The use of the bag technique should minimize if not totally prevent 1. Upon arriving at the client’s To protect the bag from
the spread of infection from individuals to families, hence, to the home, place the bag on the contamination.
community. table or any flat surface
lined with paper lining,
2. Bag technique should save time and effort on the part of the nurse
clean side out (folded part
in the performance of nursing procedures. It allows the nurse to
touching the table). Put the
give care efficiently. Be sure to check for completeness and for bag’s handles or strap
proper functioning before leaving the health facility. beneath the bag.
3. Bag technique should not overshadow concern for the patient 2. Ask for a basin of water and To be used for handwashing.
rather should show the effectiveness of total care given to an a glass of water if faucet is To protect the work field from
individual or family. not available. Place these being wet.
4. Bag technique can be performed in a variety of ways depending outside the work area.
upon agency policies, actual home situation, etc., as long as 3. Open the bag, take the To make a non-contaminated
principles of avoiding transfer of infection is carried out. linen/plastic lining and work field or area.
spread over work field or
SPECIAL CONSIDERATIONS IN THE USE OF THE BAG area. The paper lining,
clean side out (folded part
1. The bag should contain all necessary articles, supplies and out).
equipment which may be used to answer emergency needs. 4. Take out hand towel, soap To prepare for handwashing.
2. The bag and its contents should be cleaned as often as possible, dish and apron and the
supplies replaced and ready for use at any time. place them at one corner of
3. The bag and its contents should be well protected from contact with the work area (within the
any article in the home of the patients. Consider the bag and its confines of the linen/plastic
contents clean and /or sterile while any article belonging to the lining).
patient as dirty and contaminated. 5. Do handwashing. Wipe, dry Handwashing prevents possible
with towel. Leave the infection from one care provider
4. The arrangement of the contents of the bag should be the one most
plastic wrappers of the to the client.
convenient to the user to facilitate efficiency and avoid confusion. towel in a soap dish in the
Articles piled on top of each other must be arranged according to bag.
use. 6. Put on apron right side out To protect the nurses’ uniform.
5. Hand washing is done as frequently as the situation calls for, helps and wrong side with crease Keeping the crease creates
in minimizing or avoiding contamination of the bag and its contents. touching the body, sliding aesthetic appearance.
6. The bag when used for a communicable case should be thoroughly the head into the neck
cleaned and disinfected before keeping and re-using. strap. Neatly tie the straps
at the back.
CONTENTS OF THE BAG 7. Put out things most needed To make them readily
for the specific case (e.g.) accessible.
• Paper lining thermometer, kidney basin,
• Extra paper for making bag for waste materials (paper bag) cotton ball, waste paper
• Plastic linen/lining bag) and place at one
• Apron corner of the work area.
• Hand towel in plastic bag 8. Place waste paper bag To prevent contamination of
outside of work area. clean area.
• Soap in soap dish
9. Close the bag. To give comfort and security,
• Thermometers in case [one oral and rectal] maintain personal hygiene and
• 2 pairs of scissors [1 surgical and 1 bandage] hasten recovery.
• 2 pairs of forceps [ curved and straight] 10. Proceed to the specific To prevent contamination of bag
• Syringes [5 ml and 2 ml] nursing care or treatment. and contents.
• Hypodermic needles g. 19, 22, 23, 25 11. After completing nursing To protect caregiver and prevent
• Sterile dressings [OS, C.B] care or treatment, clean spread of infection to
• Sterile Cord Tie and alcoholize the things others.
used.
• Adhesive Plaster
12. Do handwashing again.
• Dressing [OS, cotton ball]
13. Open the bag and put back
• Alcohol lamp all articles in their proper
• Tape Measure places.
• Baby’s scale 14. Remove apron folding
• 1 pair of rubber gloves away from the body, with
 soiled sidefolded inwards, INTEGRATED MANAGEMENT OF NEONATAL and CHILDHOOD
and the clean side out. ILLNESS (IMNCI)
Place it in the bag.
15. Fold the linen/plastic lining, INTRODUCTION
clean; place it in the bag
and close the bag. • Every year millions of children in developing countries die before
16. Make post-visit conference To be used as reference for they reach their fifth birthday, many of them during the first year of
on matters relevant to future visit. life.
health care, taking • These child deaths are due to five diseases, namely pneumonia,
anecdotal notes diarrhea, malaria, measles and malnutrition, and often to a
preparatory to final combination of these conditions.
reporting.
• These diseases are also the reasons for seeking care for at least
17. Make appointment for the For follow-up care.
three out of four children who come to health facilities.
next visit (either home or
clinic), taking note of the • Surveys reveal that many sick children are
date, time and purpose. o not properly assessed and treated by these health care
providers, and
o that their parents are poorly advised.
AFTER CARE • Making a single diagnosis may not be feasible or appropriate
o Because many children present with overlapping signs and
1. Before keeping all articles in the bag, clean and alcoholize them. symptoms of diseases
2. Get the bag from the table, fold the paper lining (and insert), and o Clinical outcome depends upon treating not only the
place in between the flaps and cover the bag. immediate presenting symptom but the underlying disorders
as well
EVALUATION AND DOCUMENTATION o This is especially true for first-level health facilities where
examinations involve few instruments, little or no laboratory
1. Record all relevant findings about the client and members of the
tests, and no X-ray
family.
2. Take note of environmental factors which affect the clients/family • As children usually present with more than one of these conditions,
health. it was recognized that there was a need for an integrated approach
3. Include quality of nurse-patient relationship. to manage the child in a holistic manner (taking into account all of
4. Assess effectiveness of nursing care provided. the child’s problems including the major childhood illnesses in the
assessment and treatment of illness).
• This led to the development of the Integrated Management of
Newborn and Childhood Illness (IMNCI) strategy.

WHAT IS IMCI?

• IMCI is an integrated approach to child health that focuses on the

well-being of the whole child.
• IMCI aims to reduce death, illness, and disability and to promote
improved growth and development among children under five
years of age.
• IMCI include curative and preventive elements that are
implemented by families and communities and by health facilities.
• The strategy was developed by World Health Organization and
UNICEF and is used by most countries in the world.

BASIS OF IMNCI GUIDELINES

• The IMNCI clinical guidelines target children less than 5 years old
— the age group that bears the highest burden of deaths from
common childhood diseases.

The approach to case management is:

– evidence-based and syndromic that supports the rational, effective
and affordable use of drugs and diagnostic tools.

• Evidence-based medicine
o Uses the evidence from clinical research and cautions
against the use of intuition, unsystematic clinical experience,
and untested pathophysiologic reasoning for medical
decision-making.
• In situations where laboratory support and clinical resources are
limited, the syndromic approach is a more realistic and cost-
effective way to manage patients.
o Careful and systematic assessment of common symptoms
and well-selected clinical signs provides sufficient
information to guide rational and effective actions.

So the guidelines based on evidence-based syndromic approach are

used by the health worker to determine the:

o Health problem(s) the child may have;

o Severity of the child’s condition;
 o Actions that can be taken to care for the child (e.g. refer the child
immediately, manage with available resources, or manage at
home)
WHAT ARE THE BENEFITS OF THE IMCI STRATEGY?
1. Addresses major child health problems because it systematically
addresses the most important causes of children illness and death.
2. Responds to demands.
3. Promotes prevention as well as cure because IMCI emphasizes
important preventive interventions such as immunization and
breastfeeding.
4. Is cost-effective- most cost-effective interventions in low- and
middle-income countries (World Bank).
5. Promotes cost-saving.
6. Improves equity – IMCI improves inequity in global health care.
When correctly applied, IMNCI has the following advantages:
as asphyxia, sepsis, low birth weight, pneumonia, diarrhea,
malaria, meningitis and severe malnutrition in children at the
FRU
– The master trainers at state and district level are
pediatricians from tertiary hospitals and medical colleges.
Improvements in the overall health system required for effective
management of childhood illness
• essential drug supply and management
• organization of work in health facilities
• management and supervision
• referral system
Improvements in family and community health care practices and
involving them in health care process

• Promotes the accurate identification of childhood illnesses in out- For physical growth and mental development
patient settings.
• Ensures appropriate combined treatment of all major childhood • Breastfeeding
illnesses. • Complementary feeding
• Strengthens the counselling of mothers or caregivers. • Micronutrient supplementation
• Strengthens the provision of preventive services. • Psychosocial stimulation
• Speeds up the referral of severely ill children.
• Aims to improve the quality of care of sick children at the referral For disease prevention
level.
• immunization
THE 3 COMPONENTS OF THE IMNCI STRATEGY • handwashing
• sanitary disposal of feces
The strategy includes three main components: • use of insecticide-treated bednets
• dengue prevention and control
1. Improvements in the case-management skills of health staff
through the guidelines on Integrated Management of Neonatal and For appropriate home care
Childhood illness
2. Improvements in the overall health system required for effective • continue feeding
management of childhood illness; • increase fluid intake
3. Improvements in family and community health care practices and • appropriate home treatment
involving them in health care process
For seeking care
Improvements in the case-management skills of health staff
through the guidelines on Integrated Management of Neonatal and • Follow health workers advice
Childhood illness • When to seek care
• Prenatal consultation
• standard guidelines • Postnatal (postpartum) consultation
• training (pre-service/in-service)
• follow-up after training THE INTEGRATED CASE MANAGEMENT PROCESS
• role of private providers
The case management process is presented on a series of charts, which
In health facilities, the IMNCI strategy: show the sequence of steps and how to perform them.

• promotes the accurate identification of childhood illnesses in out-
patient settings
• ensures appropriate combined treatment of all major illnesses
• strengthens the counselling of caregivers
• speeds up the referral of severely ill children.
Pre- service IMNCI
– It is being included in the curriculum of medical colleges of the
country.
– This will help in providing the much needed trained IMNCI
manpower in the public and private sector.
Facility based IMNCI (F – IMNCI)
• The F-IMNCI training would provide the optimum skills needed by
the Medical officers and Staff Nurses at the FRU’s (First Referral
Unit)
– Thereby helps to address the acute shortage of Pediatricians
at facilities
– It focusses on providing appropriate inpatient management
of the major causes of neonatal and childhood mortality such
The charts describe the following steps:
1. Assess the young infant or child
• Means taking a history and doing a physical examination.
• ASSESS the child by checking first the danger signs (or
possible bacterial infection in a young infant)
o asking questions about common conditions
o examining the child
o checking nutrition and immunization status
o Includes checking the child for other problems
2. Classify the illness
• “Classify the Illness” means making a decision on the
severity of the illness and
• Assigning to a Colour, or “Classification,” which corresponds
to the severity of the disease
• Classifications are not specific disease diagnoses. Instead,
they are colour coded categories that are used to determine
treatment
o Urgent pre-referral treatment and referral (PINK)
o Specific medical treatment and advice (YELLOW)
o Simple advice on home management (GREEN)
3. Identify treatment
• The charts recommend appropriate treatment for each colour
coded classification
o If requires urgent referral, give essential treatment before
the patient is transferred
o If the child requires treatment at home, develop an
integrated plan for the child and give the 1st dose of
drugs in the clinic
o If a child should be immunized give immunization
4. Treat the infant or child
• “Treat” means giving treatment in clinic,
• prescribing drugs or other treatments to be given at home,
and
• also teaching the mother how to carry out the treatments.
o Teaching the caretaker on oral drug administration
o How to feed and give oral fluids during illness
o How to treat local infections at home
o Ask the caretaker to return for follow up on a specific date
o Teach the caretaker on how to recognize signs that
indicate that the child should be return immediately to the
health facility
5. Counsel the mother
• assessing how the child is fed and
• telling her about the foods and fluids to give the child and
• when to bring the child back to the clinic.
6. Give follow-up care
• The steps on the ASSESS AND CLASSIFY THE SICK
CHILD chart describe what you should do when a mother
brings her child to the health center because he or she is sick.
• The chart should not be used for a well child brought for
immunization or for a child with an injury or burn.
ASK THE MOTHER WHAT THE CHILD’S PROBLEMS ARE
• A mother (or other family member, such as the father, grandmother,
sister, or brother) usually brings a child to the health center because
the child is sick.
• But mothers also bring children for well-child visits, immunization
sessions, and for the treatment of injuries.
The steps on the ASSESS AND CLASSIFY THE SICK CHILD chart
describe what you should do when a mother brings her child to the health
center because he or she is sick.
The chart should not be used for a well child brought for immunization
or for a child with an injury or burn.
• When a young patient arrives at a health center, the center’s staff
identifies the reason for the child’s visit.
• They obtain the child’s weight and temperature and record these
on a patient chart, on another record, or on a small piece of paper.
• Then, the child and his or her mother see a health worker.
• When you see the mother and her sick child:
1. Greet the mother appropriately and ask her to sit with her
child.
• You need to know the child’s age so you can choose the right case
management chart. Look at the child’s record to find the child’s age.
• If the child is aged 2 months to 5 years, assess and classify the
child according to the steps on the ASSESS AND CLASSIFY THE
SICK CHILD chart.
• If the child is a neonate to 2 months old, assess and classify the
young infant according to the steps on the YOUNG INFANT chart.
• Look to see if the child’s weight and temperature have been
measured and recorded.
• If not, weigh the child and measure his temperature later when you
assess and classify the child’s main symptoms.
• Do not undress or disturb the child now.
2. Ask the mother what the child’s problems are.
• Ask the mother about the child’s problems and record what she tells
you.
• An important reason for asking about the child’s problems is so you
can open good communication with the mother.
• Communicating well with the mother helps reassure her that her
child will receive good care.
• When you treat the child’s illness later in the visit, you will need to
teach and advise the mother about caring for her sick child at home.
• This is why it is important to have good communication with the
mother from the beginning of the visit.
• Good communication skills:
o Listen carefully to what the mother tells you. This will
show her that you are taking her concerns seriously.
o Use words the mother will understand. If she does not
understand the questions, you ask her, she cannot give the
information you need to assess the child and to classify his
or her illness correctly.
o Give the mother time to answer the questions. She may
need time to decide whether the sign you asked about is
present.
o Ask additional questions when the mother is not sure
about her answer. When you ask about a main symptom or
related sign, the mother may not be sure if it is present. Ask
her additional questions to help her give clearer answers.
3. Determine if this is an initial or follow-up visit for this problem.
• If this is the child’s first visit for this episode of an illness or problem,
then this is an initial visit. If the child was seen a few days ago for
the same illness, this is a follow-up i visit.
• The purpose of a follow-up visit is different from that of an initial
visit. During a follow-up visit, the health worker finds outs if the
treatment he or she gave during the initial visit has helped the child.
If the child is not improving or has gotten worse after a few days,
the health worker refers the child or changes the child’s treatment.
• Determine if this is an initial or follow-up visit for this problem.
a) If follow-up visit, use the follow-up instructions on the TREAT
THE CHILD chart.
b) If initial visit, assess the child as follows:
The IMNCI Assessment
• When you are assessing a sick child, a combination of individual
signs leads to one or more classifications, rather than to a
diagnosis.
• IMNCI classifications are action-oriented illness categories which
enable a healthcare provider to determine if a child should be
urgently referred to a health center, if the child can be treated at the
health post (e.g. with oral antibiotic, antimalarial, ORS, etc.), or if
the child can be safely managed at home.
• The IMNCI guidelines describe how you should care for a child who
is brought to your health post with an illness, or for a scheduled
follow-up visit to check the child’s progress.
• The guidelines give instructions for how to routinely assess a child
for general danger signs (or possible bacterial infection in a young
infant), common illnesses, malnutrition and anemia, and to look for
other problems.
• In addition to treatment, the guidelines incorporate basic activities
for illness prevention.
IMNCI case management
• Case management can only be effective to the extent that families
bring their sick children to a trained health worker such as you for
care in a timely way.
• If a family waits to bring a child to a health facility until the child is
extremely sick, or takes the child to an untrained provider, the child
is more likely to die from the illness.
• Therefore, teaching families when to seek care for a sick child is an
important part of the case management process and is a crucial
part of your role as a Health Extension Practitioner.
• You should always use the chart booklet whenever you manage
under-five children.
• Whenever a sick baby or child under five comes to your health post
you should use the IMNCI chart booklet to help you know how to
assess, classify and treat the child.
• The IMNCI guidelines address most, but not all, of the major
reasons a sick child is brought to a health facility.
• A child returning with chronic problems or less common illnesses
may require special care.
• For example, the guidelines do not describe the management of
trauma or other acute emergencies due to accidents or injuries.
• Which IMNCI process should you follow when a mother visits your
health post with her sick child?
• There are two sets of charts, one for babies up to the age of two
months and one set of three charts for babies and children from
two months to five years.
• Therefore, you should find out the age of the child from the mother
or from a record chart if this is a follow- up visit and there is already
information available to you.
• This will tell you which chart you should use to assess, classify and
determine the correct treatment and follow-up care.
• So you can provide the best advice, you need to know what the
general danger signs are in sick infants and children.
General Danger Signs (GDS)
• Since IMNCI takes a holistic approach to assessing, classifying and
treating childhood illnesses it is important to look for general danger
signs as well as symptoms and signs of specific childhood
illnesses.
• The general danger signs are signs of serious illness that are seen
in children aged two months up to five years and will need
immediate action to save the life of the child.
• There are five general danger signs
• Make sure that any infant or child with any danger sign is referred
after receiving urgent pre-referral treatment.
• A child with a general danger sign has a serious problem. Most
children with a general danger sign need urgent referral to hospital.
• They may need lifesaving treatment with injectable antibiotics,
oxygen or other treatments that may not be available in the health
post.
• You should complete the rest of the assessment immediately and
give urgent pre-referral treatments before sending the patient to the
next facility.
• You are first going to look in more detail how you check for general
danger signs.
Check for General Danger Signs
• Inability to drink or breastfeed
• Convulsions
• Lethargy or unconsciousness
• Abnormally sleepy or difficult to awaken
• Vomiting everything taken.
ASK: Is the child able to drink or breastfeed?
• A child has the sign ‘not able to drink or breastfeed’ if the child is
not able to suck or swallow when offered a drink or breastmilk.
• When you ask the mother if the child is able to drink, make sure
that she understands the question.
• If the mother replies that the child is not able to drink or breastfeed,
ask her to describe what happens when she offers the child
something to drink.
• For example, is the child able to take fluid into his mouth and
swallow it?
• If you are not sure about the mother’s answer, ask her to offer the
child breastmilk or a drink of clean water.
• Look to see if the child is swallowing the breastmilk or water.
• A child who is breastfed may have difficulty sucking when his nose
is blocked. If the child’s nose is blocked, clear it.
• If the child can breastfeed after the nose is cleared, the child does
not have the danger sign, ‘not able to drink or breastfeed’.
ASK: Does the child vomit everything?
• A child who is not able to hold anything down at all has the sign
‘vomits everything’.
• A child who vomits everything will not be able to hold down food,
fluids or oral drugs.
• A child who vomits several times but can hold down some fluids
does not have this general danger sign.
• When you ask the question, use words the mother understands.
Give her time to answer.
• If the mother is not sure if the child is vomiting everything, help her
to make her answer clear.
• For example, ask the mother how often the child vomits.
• Also ask if each time the child swallows food or fluids, does the
child vomit?
• If you are not sure of the mother’s answers, ask her to offer the
child a drink. See if the child vomits.
ASK: Has the child had convulsions?
• During a convulsion, the child’s arms and legs stiffen because the
muscles are contracting or if the child has repeated abnormal
movements.
• The child may lose consciousness or not be able to respond to
spoken directions.
• Ask the mother if the child has had convulsions during this current
illness. Use words the mother understands.
• For example, the mother may know convulsions as ‘fits’ or
‘spasms’. See also if the child is convulsing now.
LOOK to see if the child is lethargic or unconscious
• A lethargic child is not awake and alert when he should be.
• The child is drowsy and does not show interest in what is
happening around him.
• Often the lethargic child does not look at his mother or watch your
face when you talk.
• The child may stare blankly and appear not to notice what is going
on around him.
• An unconscious child cannot be wakened.
• He does not respond when he is touched, shaken or spoken to.
• Ask the mother if the child seems unusually sleepy or if she cannot
wake the child.
• Look to see if the child wakens when the mother talks or shakes
the child or when you clap your hands.
• However, if the child is sleeping and has cough or signs of difficult
breathing, you must count the number of breaths first before you
try to wake the child because it is easier to count the exact
breathing rate when the child is calm.
• When you have completed the above steps, you should record
what you have found on the sick child case recording form.
• You must circle any general danger signs that are found, and check
(✓) against the appropriate answer (yes or no) in the classify
column.
• If the child has a general danger sign you should complete the rest
of the assessment process immediately. After checking the general
danger signs, you should assess the child for cough/difficult
breathing, diarrhea, fever, ear problems, malnutrition, anemia and
HIV. The presence of any one of the general danger signs indicates
a severe classification. A child with a general danger sign or a
severe classification should be referred immediately to the health
centre after giving appropriate pre-referral treatments.
What action should you take if a child has one or more of the general
danger signs?
• From the materials you have read so far, you know that if a child
has any one of the five general danger signs, that child must be
 considered seriously ill and therefore you should make an
immediate referral to a health centre.
Cough or Difficulty in Breathing
Assess for general danger signs. This child may have pneumonia or
another severe respiratory infection. After checking for danger signs, it
is essential to ask the child’s caretaker about this main symptom.
Clinical Assessment
Three key clinical signs are used to assess a sick child with cough or
difficult breathing:
1. Respiratory rate, which distinguishes children who have
pneumonia from those who do not;
2. Lower chest wall indrawing, which indicates severe pneumonia;
and
3. Stridor, which indicates those with severe pneumonia who require
hospital admission.
When children develop pneumonia, their lungs become stiff. One of the
body’s responses to stiff lungs and hypoxia (too little oxygen) is fast
breathing. When the pneumonia becomes more severe, the lungs
become even stiffer. Chest indrawing may develop. Chest indrawing is
a sign of severe pneumonia.
For ALL sick children, ask about cough or difficulty in breathing
ASK: Does the child have cough or difficulty in breathing?
• “Difficulty in breathing” is any unusual pattern of breathing. Mothers
describe this in different ways. They may say that their child’s
breathing is “fast,” “noisy,” or “interrupted”
• If the mother answers NO, look to see if the child has cough or
difficulty in breathing.
• If the child does not have cough or difficulty in breathing, ask about
the next main symptom, diarrhea.
• Do not assess the child further for signs related to cough or difficulty
in breathing.
• If the mother answers YES, ask the next question.
ASK: For how long has your Does the child had cough or
difficulty in breathing?
• A child who has had cough or difficulty in breathing for more than
30 days has a chronic cough.
• This may be a sign of tuberculosis, asthma, whooping cough, or
another problem.
Count the breaths taken in one minute.
• You must count the breaths the child takes in one minute to decide
if the child has fast breathing.
• The child must be quiet and calm when you look at and listen to his
breathing.
• If the child is frightened, crying, or angry, you will not be able to
obtain an accurate count of the child’s breaths.
• Tell the mother that you are going to count her child’s breath.
• Remind her to keep the child calm. If the child is sleeping, do not
wake him or her up
• Look for breathing movements anywhere on the child’s chest or
abdomen.
• Usually, you can see breathing movements even on a child who is
dressed.
• If you cannot see this movement easily, ask the mother to lift the
child’s shirt.
• If the child starts to cry, ask the mother to calm the child before you
start counting.
• If you are not sure about the number of breaths you counted (for
example, if the child was actively moving and it was difficult to
watch his or her chest, or if the child was upset or crying), repeat
the count.
Child’s Age Cut-off rate for Fast Breathing
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more
Note: The child who is exactly 12 months old has fast breathing if you
count 40 or more breaths per minute.
LOOK for chest indrawing.
• Look for chest indrawing at the lower chest wall (lower ribs) when
the child breathes IN.
• The child has chest indrawing if the lower chest wall goes IN when
the child breathes IN.
• It occurs when the effort the child needs to breathe in is much
greater than normal.
• In normal breathing, the whole chest wall (upper and lower) and the
abdomen move OUT when the child breathes IN.
• When chest indrawing is present, the lower chest wall goes IN
when the child breathes IN.
• If you are not sure that chest indrawing is present, look again.
• If the child’s body is bent at the waist, it is hard to see the lower
chest wall move.
• Ask the mother to change the child’s position so he is lying flat on
his or her back.
• If you still do not see the lower chest wall, go IN when the child
breathes IN, the child does not have chest indrawing.
• For chest indrawing to be present, it must be clearly visible and
present at all times.
• If you only see chest indrawing when the child is crying or being
fed, the child does not have chest indrawing.
• If only the soft tissue between the ribs goes in when the child
breathes in (also called & “intercostal indrawing” or “intercostal
retractions”), the child does not have chest indrawing. In this
assessment, chest indrawing is Lower-chest-wall indrawing.
• It does not include intercostal indrawing.
• If the child has abdominal distention and malnutrition, what appears
to be chest indrawing may not really be such.
• Stridor is a harsh noise made when the child breathes IN.
• It happens when there is a swelling of the larynx, trachea, or
epiglottis.
• This swelling interferes with air entering the lungs.
• It can be life-threatening when the swelling causes the child’s
airway to be blocked.
• A child who has stridor when calm has a dangerous condition.
• To look for and listen for stridor, look to see when the child breathes
IN.
• Then, listen for stridor.
• Put your ear near the child’s mouth because stridor can be difficult
to hear.
• Sometimes, you will hear a wet noise if the child has a nasal
obstruction. Clear the child’s nostrils, and listen again.
• A child who is not very ill may have stridor only when he or she is
crying or upset. Be sure to look and listen for stridor when the child
is calm.
• You may hear a wheezing noise when the child breathes OUT. This
is not stridor.
Diarrhea
Diarrhea is the next symptom that should be routinely checked in every
child brought to the clinic.
A child with diarrhea may have three potentially lethal conditions:
(1) acute watery diarrhea (including cholera);
(2) dysentery (bloody diarrhea); and
(3) persistent diarrhea (diarrhea that lasts more than 14 days).
All children with diarrhea should be assessed for:
(a) signs of dehydration;
(b) how long the child has had diarrhea; and
(c) blood in the stool to determine if the child has dysentery.
Clinical Assessment
1. duration of diarrhea
2. if blood is present in the stool
3. if dehydration is present.
Assess for general danger signs and the child’s caretaker should be
asked if the child has cough or difficult breathing.
ASK: Does the child have diarrhea?
• If the mother answers NO, ask about the next main symptom, fever.
You do not need to assess the child further for signs related to
diarrhea.
• If the mother answers YES, or if the mother said earlier that
diarrhea was the reason for their coming to the health center,
record her answer.
• Then, assess the child for signs of dehydration, persistent diarrhea,
and dysentery.
ASK: For how long has the child had it?
• Diarrhea that lasts 14 days or more is persistent diarrhea.
• Give the mother time to answer the question. She may need time
to recall the exact number of days the child has had diarrhea.
ASK: Is there blood in the stool?
• Ask the mother if she has seen blood in the child’s stool at any time
during this episode of diarrhea.
Check for Signs of Dehydration
• When a child becomes dehydrated, he is at first restless and
irritable. If the dehydration continues, the child becomes
abnormally sleepy or difficult to awaken.
• As the child’s body loses fluids, the eyes may look sunken.
• When pinched, the skin will go back to its original state slowly or
very slowly.
• Clinical Signs of Dehydration
LOOK and FEEL for the following signs:
Look at the child’s general condition. Is the child abnormally sleepy or
difficult to awaken? restless and irritable?
• A child has the sign “restless and irritable” if the child is restless and
irritable all the time.
• Many children are upset only because they are in the health center.
• Usually, these children can be consoled and calmed.
• They do not have the sign “restless and irritable”
Look for sunken eyes.
• The eyes of a child who is dehydrated may look sunken.
• Decide if the eyes are sunken.
• Then, ask the mother if she thinks her child’s eyes look unusual.
• Her opinion will help you confirm that the child’s eyes are sunken.
• Note:
o In a severely malnourished child who is visibly wasted (that is,
who has marasmus), the eyes may always look sunken even if
the child is not dehydrated.
o Even though sunken eyes are less reliable in a visibly wasted
child, use the sign nevertheless to classify the child’s
dehydration.
Offer the child fluid. Is the child not able to drink, or is he or she drinking
poorly? Is he or she drinking eagerly, or is thirsty?
• Ask the mother to offer the child some water in a cup or spoon.
• Watch the child drink.
• If the child is exclusively breastfed, offer expressed breast milk.
• A child is not able to drink if he is not able to take the fluid into his
mouth and swallow it.
• A child may not be able to drink because he is abnormally sleepy
or difficult to awaken.
• Or a child may not be able to suck or swallow.
• A child is drinking poorly if the child is weak and cannot drink
without help.
• He may be able to swallow only if the fluid is put into his mouth.
• A child has the sign drinking eagerly or thirsty if it is clear that the
child wants to drink.
• Look to see if the child reaches out for the cup or spoon when you
offer him water.
• When the water is taken away, see if the child is unhappy because
he wants to drink more.
• If the child takes a drink only with encouragement and does not
want to drink more, he does not have the sign “drinking eagerly or
thirsty”
Pinch the skin of the abdomen. Does it go back to its original state very
slowly (longer than 2 seconds)? slowly?
• Ask the mother to put the child on the examining table so that the
child is flat on his back, with his arms at his sides (not over his
head) and his legs straight. Or, ask the mother to hold the child so
he is lying flat on her lap. Locate the area on the child’s abdomen
halfway between the umbilicus and the side of the abdomen.
• Use your thumb and first finger in pinching the skin.
• Do not use your fingertips because this will cause pain.
• Place your hand so that when you pinch the skin, the fold of the
skin will be in a vertical line on the child’s body and not across the
child’s body.
• Firmly pick up all the layers of skin and the tissue under them.
• Pinch the skin for one second and then release it. When you
release the skin, see if the skin that was pinched would go back to
its original state: very slowly (longer than 2 seconds), slowly, or
immediately.
• If the skin stays up for even a brief time after you release it, decide
that the pinched skin goes back to its original state slowly.
• Note:
o In a child with marasmus (severe malnutrition), the pinched skin
may go back slowly even if the child is not dehydrated.
o In an overweight child, or a child with edema, the pinched skin
may go back immediately even if the child is dehydrated.
o Even though a skin pinch is less reliable in these children, use it
nevertheless to classify the child’s dehydration.
Fever
Clinical Assessment
a. Body temperature should be checked.
b. Children are considered to have fever if their body temperature is
above 37.5°C axillary (38°C rectal).
c. In the absence of a thermometer, children are considered to have
fever if they feel hot. Fever also may be recognized based on a
history of fever.
A child presenting with fever should be assessed for:
1. Stiff neck. A stiff neck may be a sign of meningitis, cerebral malaria
or another very severe febrile disease.
If the child is conscious and alert, check stuffiness by tickling the feet,
asking the child to bend his/her neck to look down or by very gently
bending the child’s head forward. It should move freely.
2. Risk of malaria and other endemic infections.
In situations where routine microscopy is not available or the results may
be delayed, the risk of malaria transmission must be defined.
• A high malaria risk setting is defined as a situation in which more
than 5 percent of cases of febrile disease in children age 2 to 59
months are malarial disease.
 • A low malarial risk setting is a situation where fewer than 5
percent of cases of febrile disease in children age 2 to 59 months
are malarial disease, but in which the risk is not negligible.
• If malaria transmission does not normally occur in the area, and
imported malaria is uncommon, the setting is considered to have
no malaria risk
3. Runny nose. When malaria risk is low, a child with fever and a
runny nose does not need an antimalarial.
This child’s fever is probably due to a common cold.
4. Duration of fever. Most fevers due to viral illnesses go away within
a few days.
A fever that has been present every day for more than five days can
mean that the child has a more severe disease such as typhoid fever.
If the fever has been present for more than five days, it is important to
check whether the fever has been present every day.
5. Measles. Considering the high risk of complications and death due
to measles, children with fever should be assessed for signs of
current or previous measles (within the last three months).
measles cases occur early in a child’s life (between 6 and 8 months of
age), especially in urban and refugee populations
• Classification of Measles
Before classifying fever, check for other obvious causes of fever (e.g.
ear pain, burn, abscess, etc.).
Children with high fever, defined as an axillary temperature greater than
39.5°C or a rectal greater than 39°C, should be given a single dose of
paracetamol to combat hyperthermia.
If other endemic infections with public health importance for children
under 5 are present in the area (e.g., dengue hemorrhagic fever or
relapsing fever), their risk should be also considered.
Dengue Hemorrhagic Fever
etio: Dengue virus (types 1-4)
Clinical manifestations:
Fever (27 days)

Measles deaths occur from: +/- rash

a. Pneumonia hemorrhagic manifestations

b. Laryngotracheitis (67 percent)
c. Diarrhea (25 percent) > + torniquet test
d. Measles alone
e. And a few from encephalitis > nose bleeding

Other complications (usually nonfatal) include conjunctivitis, otitis > tarry stools
media, and mouth ulcers. Significant disability can result from measles
myalgia
including blindness, severe malnutrition, chronic lung disease
(bronchiectasis and recurrent infection), and neurologic polyarthritis
dysfunction.
Grading:
Detection of acute (current) measles is based on: fever with a
generalized rash plus at least one of the following signs: Gr. I: Fever + non-specific constitutional s/sx
1. red eyes II: Gr. I + spontaneous bleeding
2. runny nose or
3. cough. III: Gr. II + circulatory failure

The mother should be asked about the occurrence of measles within the rapid &amp; weak pulse
last three months (recent measles).
narrowing of pulse pressure
etio: Measles virus (Paramyxovirus)
Hypotension
Clinical manifestations:
Cold clammy skin
• Fever
• Cough restlessness
• Coryza
IV: Gr. III + profound shock
• Conjunctivitis
• Erythematous Maculopapular rash Signs of Shock:
• Koplik spots
Cold clammy extremities
Epidemiology: Direct contact with infectious droplets
Slow capillary refill
Assess a child for possible complications: If the child has measles
currently or within the last three months. Other diagnostic aids:

• Measles damages the epithelial surfaces and the immune system, Torniquet test:
and lowers vitamin A levels.
1. Take the patients BP and record. Ex100/70
Despite great success in improving immunization coverage in many 2. Inflate BP cuff to appoint midway between systolic and diastolic
countries, substantial numbers of measles cases and deaths continue pressure for 5 mins, (100+70)/ 2 = 85 mm Hg
to occur. 3. Reduce and wait 2 minutes
4. Count petechiae below antecubitus fossa. Positive test: &gt;20
Although the vaccine should be given at 9 months of age, immunization petechiae / square inch (6.25 square cm.)
often does not take place (because of false contraindications, lack of
vaccine, or failure of a cold chain), or is delayed. In addition, many
Typhoid Fever

etio: S. typhi

S. paratyphi

Clinical Manifestation:

Fever

Constipation / diarrhea

Abdominal pain

Anorexia

Vomiting

Headache

Hepatosplenomegaly – 2nd week

Rose Spots