Expanded program of

Immunisation (EPI)

MRS CHISANGA W.
Lecture Objectives
At the end of this lecture, you should be able to:
1. Explain the Expanded Program on Immunization (EPI)
2. Describe the immunization guidelines and schedules
3. Outline contraindications to immunizations
4. Explain the Reaching Every District (RED) Strategy
5. Describe immunization strategies and campaigns
6. Explain the cold chain and Logistics
7. Report effectively and keep records
 INTRODUCTION TO EXPANDED PROGRAMME IN
IMMUNIZATION (EPI)

• The Expanded Program on Immunization is a

World Health Organization program with the goal to make
vaccines available to all children throughout the world.

• The World Health Organization (WHO) initiated the

Expanded Program on Immunization (EPI) in May 1974 with
the objective to vaccinate children throughout the world
.

• Ten years later, in 1984, the WHO established a

standardized vaccination schedule for the original EPI
vaccines: Bacillus Calmette-Guérin (BCG),
diphtheria-tetanus-pertussis (DPT), oral polio, and
measles.
.• Increased knowledge of the immunologic factors of
disease led to new vaccines being developed and
added to the EPI’s list of recommended vaccines

• The vaccines included Hepatitis B (HepB), yellow fever

in countries endemic for the disease, and
Haemophilus influenza meningitis (Hib) conjugate
vaccine in countries with high burden of disease.
 .

• In 1999, the
Global Alliance for Vaccines and Immunization (GAVI)
was created with the sole purpose of improving child
health in the poorest countries by extending the reach
of the EPI.

• The creation of the GAVI has helped to renew interest

and maintain the importance of immunizations in
battling the world’s large burden of infectious diseases.
 .

The current goals of the EPI are:

• To ensure full immunization of children under one year of age in

every district
• To globally eradicate poliomyelitis
• To reduce maternal and neonatal tetanus to an incidence rate of less
than one case per 1,000 births by 2005
• To cut in half the number of measles-related deaths that occurred in
1999.
• To extend all new vaccines and preventive health interventions to
children in all districts in the world.
.• In addition, the GAVI had to set up specific milestones to
achieve the EPI goals:
that by 2010 all countries have routine immunization coverage
of 90% of their child population,
that HepB be introduced in 80% of all countries by 2007
that 50% of the poorest countries have Hib vaccine by 2005.
 Vaccination schedule
• Vaccination is the giving of vaccines to prevent disease. A
vaccination schedule is a series of vaccinations, including
the timing of all doses, which may be either recommended
or compulsory, depending on the country of residence.
Target groups for vaccinations

• Infants 0-12 months

• Pregnant and Post-Partum Women

• School Entrants - Grade 1 / 7

 Immunization schedule in Zambia
Vaccine Dose Site Age

BCG 0.05ml <1 yr ID in the upper outer aspect At birth or 1st contact. Repeat
0.1> 1yr of the left lower arm if no scar after 12wks

OPV 2-3 drops Oral From birth to 13 days;

6,10,14 wks and at 9moths (if
OPV0 was missed)

DPT.Hib.HepB 0.5mls IM into the thigh 6,10,14 wks

PCV 0.5mls Right thigh 6, 10, 14wks

Measles 05.Mls SC into the upper left arm 9 months, 18 – 24months

TT 0.5mls IM into the deltoid muscle of School entry (Grade ones)

the upper arm Women of Child Bearing age
Pregnant women

Rota 0.5mls Oral 6, 10, 14 weeks

Preparing Polio Vaccine: do the following.
.

• If a dropper is separate, attach it securely to the vial

(bottle).
• Keep polio vaccine shaded from sunlight during the
immunization session.
• Place the vial on a frozen ice pack or place it in the hole of
the sponge placed at the mouth of a vaccine carrier, which
is provided for this purpose to maintain the temperature.
 .
Preparing BCG and Measles Vaccines:

• Use the diluent provided for each vaccine. Diluent should be cold:
+4˚C - +8˚C

• Use ordinary 10ml syringes for mixing measles and BCG vaccines.

• Draw up the full, required amount of the diluent provided as per

instruction on the vial and inject diluent into vial.
.
• Draw and expel mixture back into the bottle three
times or until the vaccine is mixed.

• Do not shake the vial.

• Measles and BCG vials should be placed on a frozen

ice pack or use the sponge in the vaccine carrier for
maintaining the correct temperature.
.
Preparing DPT and TT vaccines:
DPT and TT vaccines come in liquid form. You will
not need to dissolve or mix them.
• Remove metal top from the vial
• Draw 0.5ml into the sterile syringe
• Remove bubbles and inject on the left mid thigh
• Keep the vaccines shaded from light.
 Dos and Dont’s of vaccines
• Use one sterile syringe and needle per vaccine (antigen) per
child or mother.

• Avoid holding loaded syringes in your hands for long so as

not to expose vaccine to heat or direct sunlight.

• Inform each parent what type of vaccine you are giving the
child, the possible reactions to it, what to do about the
reactions, and when to bring the child back for more
immunization.
.• Listen to parents and encourage questions.
• Remove any child’s clothes that are in your way when
vaccinating

• Never take two vials of the same vaccine out of the vaccine
carrier at the same time.

• Do not mix vaccines until mothers and children are present.

• Mix one vial of a particular vaccine at a time

• Keep. opened vials of polio, measles, and BCG vaccines on a frozen ice

pack or use the sponge in the vaccine carrier. Their temperature must
be carefully maintained.
• Do not keep vials of DPT and TT vaccines directly on the frozen ice
pack.
• Open the vaccine carrier only when necessary.
• After preparing vaccines, the next step is to administer them.

Before administering vaccines you should always remember the

above important points.
 Steps for administering Oral Polio Vaccine
• Ask the child's mother whether the child has diarrhoea. If "yes"
note this on the child's card and tell the mother that this dose of
polio needs to be repeated after one month.

• This child (with diarrhoea) should have a total of 4 to 9 doses of

Polio vaccine, depending on whether the child got Polio 0 or not.

• Use the dropper or device supplied with the vaccine.

• If the child will not open his mouth, gently squeeze his cheeks to
open his mouth.
 Administering BCG Vaccine

• Clean the skin with cotton wool soaked in clean water and let it dry.

• Hold the middle of the child's upper right arm firmly with your left
hand.

• Hold the syringe by the barrel with the millilitre scale upward and
the needle pointing in the direction of the child's shoulder. Do not
touch the plunger.
.• Point the needle against the skin, barrel turned up, about
3cm above your thumb. Gently insert its tip into the upper
layer of the skin.

• Make sure that the needle is in the skin (intradermal) and

not under the skin. If the needle goes under the skin, take it
out and insert it again.
 .

• If you bend the needle, replace it with another sterile one.

• Holding the barrel with your index and middle finger, put your
thumb on the plunger.

• Holding the syringe parallel to the surface of the skin, inject the
vaccine intradermally. For children above 11 months of age,
inject 0.1 ml. For children under 11 months of age, inject 0.05
ml.
.• If the vaccine is injected correctly into the skin, a wheal, with
the surface pitted like an orange peel, will appear at the
injection site.

• An indication that the vaccine has been injected incorrectly is

that the plunger will move much more easily when the
needle is injected under the skin than when it is injected in
the skin
.• If there is no local reaction, re-immunise the child.

• Give the mother health information about BCG. This is what

you should say:
• In 9 to 7 days a small sore will appear at the place
where the injection was given.
• The sore might ooze a bit and will last for 6 to 8
weeks.
• Keep the baby's arm clean with soap and water.
• Do not put medicine or dressing on the sore.
• The sore will not hurt, and it will heal by itself.
 .

• Fill in the Immunization Tally Sheet in BCG section.

• Administer the next antigen.

Administering DPT vaccine

• DPT vaccine is a Killed vaccine and it is called Pentavalent vaccine.

• Killed vaccines are given three times because they do not

stimulate the body to produce antibodies as well as the live
vaccines do.

• When the second and the third doses are given, the body’s
memory of the earlier dose quickly leads into production of more
antibodies.
.

most common adverse reactions

• The adverse reactions after Hib vaccination are

• Local reactions: swelling, redness, or pain at the injection site.

• Fever also can occur in as many as 5% of recipients. Fever usually starts within
the 1st 24 hours of vaccination and may last for 2 to 3 days.

• These reactions can be treated with a non-aspirin pain reliever, if needed.

.• The main contraindication to Hib vaccine:

• Severe allergic reaction. Do not give Hib-containing vaccine

to anyone who has had a prior severe allergic reaction to a
dose of Hib vaccine or to a component in the vaccine.

• Persons who are severely allergic to diphtheria toxoid,

meningococcal vaccine, or tetanus toxoid also may be
sensitive to a particular Hib vaccine because of the protein
carriers used to create the conjugate vaccines.
 Administering Measles Vaccine
• Use a sterile syringe and needle for each injection to draw 0.5
ml dose of the mixed measles vaccine.
• Ask the mother to expose the child's left upper arm and hold
the child firmly to restrict his movement
• Clean the injection site with a cotton swab moistened with
clean water, and let it dry.
• With the fingers of one hand, pinch the skin on the outer side
of the upper arm.
• Hold the syringe at an acute angle to the child's arm.
• Inject the vaccine subcutaneously.
• To .avoid injecting vaccine into a vein, pull the plunger back slightly
before injecting the vaccine. If blood is drawn into the syringe,
withdraw the needle and discard the vaccine. Obtain another sterile
syringe, needle and vaccine. Press the plunger gently; inject 0.5 ml.
of vaccine.
• Withdraw the needle. If a drop of blood appears, wipe it off with a
cotton swab.
• Fill in the Immunization Tally Sheet appropriately.
• Give the mother health advice about measles. Tell her that
• Some children have a mild rash after 7 to 10 days of getting
measles vaccine.
• This rash is mild and it will show that the vaccine is working very
well.
 CONTRA-INDICATIONS TO IMMUNIZATION
• A contraindication is a situation in which a drug, such
as a vaccine, should not be used because the risk
outweighs any potential therapeutic benefit.

• A contraindication is considered as a condition in an

individual that increases the risk for serious adverse
reaction (e. g., not administering a live virus vaccine to
a severely compromised child).
 General contraindications to a vaccine or a component of a
vaccine

• Severe Asthma - Asthma should be managed before giving any

vaccine.

• Severe febrile illness - If the child is acutely unwell with a fever and
has a temperature >38.5 it is usually wise to defer immunization.

• Congenital malformation of gastrointestinal tract or history of

intussusception
.• Rotavirus vaccine is contraindicated in infants with a history
of intussusception or uncorrected congenital malformation
of the gastrointestinal tract that would predispose for
intussusception.
Suspicious
. family or medical history for immunodeficiency disorders

• Children who have a suspicious history for immunodeficiency

disorders (e.g., known or suspected family history of congenital
immunodeficiency disorder or HIV infection, or history of failure to
thrive and recurrent infection), should not be immunized with a live
vaccine until they have been fully investigated and T cell dysfunction
ruled out.
.Immunosuppressive therapy

• Vaccination status should be reviewed prior to commencing

immunosuppressive therapy.

• If vaccines cannot be given prior to initiation of therapy, it is

advisable to delay vaccines until after immunosuppressive
therapy has stopped.
.Guillain-Barré syndrome (GBS) with onset within 6 weeks of
immunization

• It is recommended to avoid subsequent influenza vaccination

of persons known to have had GBS within six weeks of a
previous influenza vaccination.
 REACHING EVERY DISTRICT (RED) STRATEGY
• RED strategy is an approach in EPI that was officially created by
WHO African regional office (WHO-AFRO) in early 2000s.
• The approach was created in response to stagnant
immunization performance in the African region.
• A focus on national coverage was masking the variation sub-
national coverage i.e. many districts had less than 80%
immunization coverage
.• The RED approach has five components that are
designed to strengthen capacity at the district and
health facility levels by addressing common
immunization obstacles.

1. Improving planning and management of resources

• Addresses the improvement of human and financial
resources, micro-planning and resource management
at the district level.
 .
2. Revitalizing outreach and static services
• Addresses the problem of poor access by : Extending regular
services to all communities and conducting initial analysis to
assess status

3. Supervision
• Supportive supervision as a key component of the RED strategy
aims to assist workers in providing quality immunization
services.
 .
4. Linking services to communities
• This is a key step in improving and sustaining high immunization coverage.
Community links’ improve long-term interactions between health staff and
communities to increase service demand and utilization.
• The RED strategy aims to involve the community in all aspects of immunization
services (planning, implementation, monitoring).
• Linking services with the community through the following:
• Community diagnosis
• Development of an activity plan for community linkages
• Sensitization meetings with communities
• Supervising community linkages activities
 .
5. Monitoring for Action
• This is the process of comparing progress with established targets.
It involves several steps:
• Planning the program
• Setting performance targets
• Conducting program activities
• Recording achievements
• Comparing results with targets to determine performance.
IMMUNIZATION CAMPAIGN
• Planning tools and campaign materials for National
Infant Immunization Week (NIIW) include media
outreach materials, banners, and other materials.

• Resources also include print, radio, and TV PSAs in

both English and local languages that can be used
year-round to highlight the importance of infant
immunization.
COLD CHAIN AND LOGISTICS
• 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.

• Cold chain can also be defined as the process used to

maintain optimal conditions during the transport,
storage, and handling of vaccines, starting at the
manufacturer and ending with the administration of
the vaccine to the client.
 . allowable timeframes for the storage of vaccines at different
The
levels are:
• 6months- Regional Level
• 3months- Provincial Level/District Level
• 1month-main health centers.
• Not more than 5days- Health centers using transport boxes.

Vaccines most sensitive to heat: keep in Freezer (-15 to -25 degrees C)

• OPV
• Measles
.
Sensitive to heat and freezing (body of ref. +2 to +8 degrees Celsius)
• BCG
• DPT
• Hepatitis B
• TT
• FEFO (“first expiry and first out”)Use those that will expire
first, mark “X”/ exposure
• 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,
Hepatitis B.
Importance of maintaining the cold chain
• Vaccines are sensitive biological products which may
become less effective, or even destroyed, when
exposed to temperatures outside the recommended
range.

• Cold-sensitive vaccines experience an immediate loss

of potency following freezing.
.• Vaccines exposed to temperatures above the
recommended temperature range experience some
loss of potency with each episode of exposure.

• Repetitive exposure to heat episodes results in a

cumulative loss of potency that is not reversible.
The Effective Cold Chain

• Three main elements combine to ensure proper

vaccine transport, storage, and handling.
• Trained personnel
• Transport and storage equipment
• Efficient management procedures
The. shake test to determine whether vaccine has been frozen
• DPT, hepatitis B and tetanus toxoid vaccines can be damaged by
freezing. You can find out whether this has occurred by using
the shake test.
• Take two DPT vials, one that you think might have been
frozen and another from the same manufacturer which you
KNOW has never been frozen.
• Shake both vials.
• Look at the vaccine inside the two vials
• Let the sediment settle for 15-30 minutes.
• Again look at the vaccine inside the two vials
Vaccine ordering and forecasting

Ordering Vaccines
• Vaccine ordering is done according to the following:
• Target population method
• Number of immunization sessions per month
• Consumption method
Vaccine Forecasting
• This is the first step in ensuring adequate
immunization supplies and is the foundation of
Vaccine Security.

• The accuracy of the forecast is important -

underestimating the requirements results in vaccine
shortages, overestimating results in excess stock -
increasing the manufacturers' costs.
.• The goal of vaccine forecasting is to estimate the quantity of
goods and financial needs necessary to conduct
immunization programs.

• The value of the forecast depends on the accuracy - taking

into consideration the type of vaccine, the presentation (vial
size), the quantity and the timing of delivery of the vaccine.
EVALUATION OF IMMUNIZATION PROGRAMME
Budgeting and Supply
• An uninterrupted supply of injection equipment is
essential for the safety of immunizations.
• A reserve stock of disposable injection equipment
amounting to at least 10% of the quantity used in
each supply period should be kept at central and
intermediate stores.
• At peripheral stores the reserve stock should be
sufficient for at least one month of immunization
activities.
SUMMARY

• In this lecture, you have covered some definition of different

key terms, described the Expanded Programme of
Immunization where information about Child Immunization
was provided. You discussed the immunization guidelines
and schedule, the target groups for vaccination and
Vaccination schedule. You further outlined the contra-
indications to immunizations, immunization campaigns, cold
chain, how to evaluate immunization programme, how to
report effectively and keep records.