immunization

Level 400
Immunity
• Immunity refers to the ability of one’s body cells to resist infection
wholly or partially.
• Antigen- is a substance that stimulates the formation of an antibody.
• Antibody- are proteins that are formed in response to an antigen and
react specifically with the antigen that provoked their production.

TYPES OF IMMUNITY
• Innate or inborn (non-specific) immunity
• Acquired or specific immunity
 Innate or Inborn or Inherent Immunity

• the body’s ability to resist disease independently of antibodies or of specifically

developed tissue responses. innate have an inherited components.
• This type of immunity is peculiar to species, race or individuals.

a. Species innate immunity – different species of animals have their different

innate immunity. Certain diseases that affect man,.

• b. Racial innate immunity – different races within the same species may vary in
their protection against certain diseases, eg sickle cell disease in black race.
• c. Individual innate immunity – individuals in the same species and/or race may
show variations in their immunity.
Acquired Immunity

• This refers to the protection an individual develops against certain types of

microbes or foreign substances. It is developed during an individual’s lifetime.
• Immunity can be acquired either actively or passively;
• Immunity is acquired actively when a person is exposed to microorganisms or
foreign substances and the immune system responds.
• Immunity is aquired passively when antibodies are transferred from one
person to another. Passive immunity in a reciepient last only as long as
antibodies are presence – in most cases a few weeks or months. Both actively
and passively immunity can be acquired natural and artificial means.
•
Immunity
• i. Naturally Acquired Active Immunity
• Naturally acquired active immunity is obtained when a person is
exposed to antigens in the course of daily life. Once acquired,
immunity is lifelong for some diseases, such as mealses and chicken
pox.

• Ii. Naturally Acquired Passive Immunity

• It involves the natural transfer of antibodies from the mother to her
infant.
Immunity
• Artificially Acquired passive Immunity
• It involves the introduction of antibodies into the body. These
antibodies come from an animal or person who is already immune to
the disease
• Artificially Acquired active Immunity
• Artificially Acquired active Immunity results from vaccination, the
introduces specially prepared antigen called vaccines into the body.
Duration of Natural – Passive Antibody Transfer from Mother
to the Foetus

• Tuberculosis – the child receives no protection from the mother so the

child is immunized at birth or within the first few weeks of life
• Poliomyelitis – this may last about six weeks after delivery. The child is
immunized at birth (birth-two weeks) or begins at six weeks of birth.
• Diphtheria – the child gets absolute protection for the first six weeks of
life and protection becomes partial for about six months. The baby of a
susceptible mother, however, has no protection. The children are
immunized at six weeks.
• Pertussis – this has a very short maternal antibody protection. The
newborn infant is highly susceptible to pertussis. Children as young as
two weeks have been known to have the disease.
Duration of Natural – Passive Antibody Transfer from Mother
to the Foetus

• Tuberculosis – the child receives no protection from the mother so the child is immunized at birth or
within the first few weeks of life
• Poliomyelitis – this may last about six weeks after delivery. The child is immunized at birth (birth-two
weeks) or begins at six weeks of birth.
• Diphtheria – the child gets absolute protection for the first six weeks of life and protection becomes
partial for about six months. The baby of a susceptible mother, however, has no protection. The children
are immunized at six weeks.
• Pertussis – this has a very short maternal antibody protection. The newborn infant is highly susceptible to
pertussis. Children as young as two weeks have been known to have the disease.
• Measles – this lasts for the first four – six months after delivery and disappears rapidly between six and
nine months.
• Haemophilius influenza B – maternal antibody is not established. New born are immunized at six months
after birth.
• Hepatitis B – protection lasts for six weeks after birth, when its immunization starts.
• Tetanus – this protection may last six weeks to three months.
Immunity
• HERD IMMUNITY
• This describes the immunity level that is present in a group of people.
A community can be said to have either high or low herd immunity.
• CROSS-IMMUNITY: refers to a situation in which a person’s immunity
to one causative organism provides immunity to another related
organism as well. Immunization with a vaccine made from one
disease-causing organism can provide immunity to another related
disease-causing organism.
IMMUNIZATION

• Definition – immunization is the process of stimulating an active

immunologic defense in preparation of meeting the challenge of
future exposure to diseases (Bullough and Bullough 1990).
• Thus it is the introduction of weakened, live or dead micro-organism
called vaccines to the body system to stimulate the production of the
antibodies to confer immunity.
Vaccines
• A VACCINE is a suspension of organisms or fraction of organism (antigens in a base)
that is used to induced immunity.

TYPES OF VACCINES
• There are three main types of vaccines:
• Attenuatted whole – agent or Live vaccines: consist of living but weakened micro-
organism (attenuated) grown in the laboratory. Examples are Poliomyelitis, Measles
and BCG vaccines.
• Inactivated whole – agent or Dead vaccine: use microbes that have been killed,
usually by phenol or formalin. Example is DPT/HibHepB vaccine.
• Toxoids or Antitoxins: they are inactivated toxins, are vaccines directed at the toxin
produced by a pathogen
The Expanded Programme on Immunization (EPI)

• The Expanded Programme on Immunization (EPI) is a programme

instituted by the WHO to be followed by all member countries
including Ghana.
• aims at achieving 70 – 80% coverage on vaccine preventable disease
in children from 0-5 years.
• The purpose is to reduce the number of diseases and deaths that
occur from vaccine – preventable diseases.
• The target for Ghana has been 80% coverage
 Expanded Program on Immunization (EPI)
• Launched by WHO in 1974 with a standard
immunization schedule of 6 basic antigens for
infants
- Tuberculosis (BCG)
- Polio
- Diphtheria, tetanus, pertussis (DTP)
- Measles
• 3rd DTP dose (DTP3) is a standard
immunization measure of EPI performance
BCG, Bacillus Calmette-Guerin
.
13
EPI – the Expanded Programme on Immunization
Programme on Immunization
• Success of smallpox helped to launch the EPI
• EPI - first organized global routine vaccination
programme
• targeting infants in developing countries with 6
basic vaccines, including OPV
• set up and managed using lessons learned (and
staff) from smallpox eradication
• 1980 – 1990: rapid improvement in EPI
coverage
• 1990: achievement of 'universal childhood
immunization' – 80% coverage in all countries
The recommended schedule of
immunization considers
• The immunization that are necessary
• The age of starting the immunization
• The order in which they are given
• The route of administration
• The doses and intervals
Immunization services strategies:

• Statistic or fixed facilities (Health Centers and Clinics) where immunizations are given
every day or on weekly basis, where each client is immunized once a month.
• Outreach points: these are selected vantage places outside the health facility where
immunizations are given within the month by clinic staff who visit those points. These
sessions are usually run on monthly basis.
• Mobile teams also travel to areas that are difficult to reach for regular immunization
services.
• Intensive programme such as Mass, National Immunization Day (NIDs) and Child
Health Days (CHD’s) where all children under 5 years are immunized.
• House-to-house immunization in CHPS zones
• Immunizations are also given in institutions like Day – Care Centers and during School
hygiene inspection
Before an immunization session
• Before any immunization session, the following tasks need to be
performed:
• i. Determine the number of children to be immunized in a month
• ii. Determine how often to conduct the immunizations
• iii. Determine the catchment areas that need to be covered within a
month
• iv. Determine a day that would be convenient for clients.
 The expanded programme on immunization (EPI) in
Vaccine GhanaAge Dosage Interval No. Doses Route of Reaction and
Administration Management
B.C.G At birth 0.05mls None 1 Intradermal A mole, then scar. No
treatment
O.P.V. 0 At birth 2-3 drops 6 weeks No reaction
O.P.V. 1/Rotavirus 6 weeks 2-3 drops 4 weeks 3-4 doses Oral
O.P.V. 2/Rotavirus 10 weeks 2-3 drops 4 weeks
O.P.V. 3 14 weeks 2-3 drops 4 weeks

D.P.T./HibHep B1 6 weeks 0.5mls 4 weeks Slight rise in

Pneumococcal temperature
D.P.T/HibHep B2 10 weeks 0.5mls 4 weeks Give paracetamol
Pneumococcal syrup
D.P.T/HibHep B3 14 weeks 0.5mls 4 weeks 3 doses Intramuscularly
Pneumococcal
Vitamin A 24 weeks Blue 1000,000 IU 6 months 10 doses Oral

Measles rubella 9 months 0.5mls 9 months Subcutaneously No rise in

Yellow fever Months 0.5mls temperature

Measles rubella 0.5mls 10 years Booster every 10 Subcutaneously No reaction

Men A 18 months 0.5 mls years intramuscularly

Vitamin A 200000 iu

C.S.M 2 years 0.5mls 5 years Booster every 5 years Subcutaneously

 The expanded programme on immunization
(EPI) in Ghana
Vaccine Dosage Interval between doses
T.T. 1 0.5mls 1st contact – No Protection

T.T. 2 0.5mls 4 weeks after 1st dose –Protect for 3

years

T.T. 3 0.5mls 6 months after 2nd dose-Protects for

5 years

0.5mls 1 year after 3rd dose – Protect for 10

T.T. 4 year

T.T. 5 0.5mls 1 year after 4th dose-Protects for life

How to reconstitute a freeze dried Vaccine (powdered Vaccine)

• Wait until you are ready to give the vaccine

• Wash your hands and pick a sterile 2ml or 5ml syringe depending on the number of doses,
and sterile mixing needle (this is used for mixing only).
• Take a vial or ampoule of the appropriate diluents for the vaccine and open it.
• Check if you have taken the correct vaccine
• Draw up the correct volume of diluents into the mixing syringe.
• Open the ampoule or vial of vaccine. Tap the ampoule to make sure all the powder falls to
the bottom.
• Insert the mixing needle into the ampoule or vial of vaccine and empty the diluents into
the vaccine. Do not shake the vaccine, since shaking may create heart to damage it.
• Record and put the mixing syringe and needle into the vaccine carrier, if it has to be
reused. Ideally, use one syringe and needle for mixing each vial or ampoule.
Routine Immunization Services
 About Routine Immunization
Delivery
• Continuous (not time-limited)
• Location of services
• Fixed post sessions
• Health clinic, post, or hospital
• Daily or weekly
• Outreach sessions
• Remote areas
• Usually monthly
• Global target population: 0-12 months = 130 million
How Do Campaigns Differ?
• Campaigns
• Time-limited and infrequent
• Objective of reaching children who do not access routine
services
• Usually a wide age-range
• Seroconversion of those who don’t seroconvert after routine
vaccination
The Core Routine Immunization System Goal
• Reach all infants by 1 year of age with a schedule of
immunizations as set by the country in accordance
with WHO Guidelines
• Adult vaccination programs have similar goals
• Example: Vaccinate all pregnant women with TT
What are the Routine Immunizations?
• WHO Recommendations for all children
• BCG - bacille Calmette-Guérin (tuberculosis)
• Polio
• oral poliovirus vaccine (OPV)
• Inactivated polio vaccine (IPV)
• DTP (DPT, DTaP, DTC) - Diphtheria, tetanus, and pertussis
vaccine
• Pentavalent version also available (DTP + HepB + Hib)
• Tetravalent version also available (DTP + HepB or Hib)
What are the Routine Immunizations?
• HepB – hepatitis B vaccine
• HIB – Haemophilus Influenzae type B vaccine
• Measles (MCV) – measles containing vaccine
• Rubella (MR-included with measles vaccine)
• PCV – Pneumococcal conjugate vaccine
• RV – Rotavirus vaccine
• HPV - Human Papillomavirus vaccine
What are the Routine Immunizations?
• Recommendations for children residing in certain regions
• YF – Yellow Fever vaccine
• JE – Japanese Encephalitis vaccine

• TT (NTT) – Neonatal tetanus vaccine (Early adulthood and

pregnant women)
 Summary of WHO-Recommended# Childhood
Routine Immunizations
Traditional Hepatitis B Vaccine Newer
Age H. Influenza
Vaccines 1 or 2 vaccines

Birth BCG, OPV0 HepB1

PCV1,
6 weeks DTP1, OPV1 HepB2 HepB1 Hib1
RV1*
PCV2,
10 weeks DTP2, OPV2 HepB2 Hib2
RV2*

PCV3,
14 weeks DTP3, OPV3 HepB3 HepB3 Hib3
RV3*

9 or 12 Measles, Rubella
months (YF and JE**)

9-13 years HPV1-3***

#See WHO recommendation summary tables: http://www.who.int/immunization/policy/immunization_tables/en/index.html

* doses required for Rotarix; 2 doses required for Rota Teq
**Yellow fever and JE vaccine are given to children residing in certain regions
***HPV-quadrivalent requires 3 doses; 2 nd dose given 2 months after 1st and 3rd dose given 4 months after 2nd dose.
However, Schedule Can Vary By Country
Age Bangladesh Kenya Haiti

Birth BCG BCG, OPV0 BCG, OPV0

Penta1, OPV1,
6 weeks Penta1, OPV1 DTP1, OPV1
PCV1
Penta2, OPV2,
10 weeks Penta2, OPV2 DTP2, OPV2
PCV2

Penta3, OPV3,
14 weeks Penta3, OPV3 DTP3, OPV3
PCV3

36 weeks OPV4, Measles

Measles, Yellow
9 months Measles-Rubella
Fever

Source: WHO immunization schedule database, October 2011

http://www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm
These are the operational components of the RI System

Vaccine Supply & Logistics

Quality

Service delivery

Surveillance Advocacy &

Communication
 Components & Resources for RI
• Service Delivery
• Through primary health facilities and outreach sessions by
health workers
• Logistics
• District and National staff manage equipment and non-vaccine
supplies
• Vaccine Supply & Quality
• Health workers manage vaccine supply and quality at facilities
and request additional vaccines. National staff request
vaccine from external partners. District supervisors monitor
quality too
Components & Resources for RI
• Surveillance
• Health workers watch for cases, report to district staff,
who report to national staff
• Advocacy & Communications
• Health workers and community volunteers promote
immunization session times and locations. National staff
create posters, radio messages
 Plans of Action Describe Activities of each
RI System Component
1. Planning
2. Management
3. Coordination
4. Supervision
5. Training

 Plan of Action (POAs)

 Include planned implementation activities and projected costs for
reaching RI System objectives
 5 year & 1 year plan
 National, provincial, district level plans
 “Living” document
 Used to monitor routine immunization services
 Current strategies For
Reaching the RI System Goal
 Key WHO/UNICEF Strategies and the
Global Goals Document
“Increasing Immunization Reaching Every District (RED)
Coverage at the Health Facility • Guide for District Health
Level” Management Teams
• Guide for health workers • Not new ideas, but more
• Use data to identify problems systematic implementation
and improve services
• Topic of another talk…

Global Immunization Vision and Strategy (GIVS)

• Immunize more people, from infants to seniors, with a greater
range of vaccines
• Goal: by 2015 or earlier, reduce illness and death due to vaccine-
preventable diseases by at least two thirds compared to 2000
levels
Reaching Every District: 5 RED Components

· Re-establish outreach services

· Conduct supportive supervision
· Establish community links with service
delivery
· Monitor and use data for action
· Improve planning and management of
resources
 Disclaimer…
• RED focuses on district-level results
• Traditionally too much focus on national results
• Importance of decentralization
• Identification of and improvement in poorly performing
districts critical to reduce outbreaks
• Really want to reach every:
• Village or health center catchment area
• Child
Matching RED strategies to barriers
Poor High Missed Manage- Community
access dropout/ Oppor- ment barriers
poor tunities
utilization
Matching RED strategies to barriers
Poor High Missed Manage- Community
access dropout/ Oppor- ment barriers
poor tunities
utilization
+++ ++ + + ++

+ + ++ ++ +

+ + + +++

+ +++ +++ ++ +

+ + + +++ +
Matching RED strategies to barriers
Poor High Missed Manage- Community
access dropout/ Oppor- ment barriers
poor tunities
utilization
Outreach +++ ++ + + ++

Supportive + + ++ ++ +
supervision
Community + + + +++
links
Monitoring, use + +++ +++ ++ +
of data
Resource + + + +++ +
management
1) Re-establish Outreach Services
• Conduct initial analysis to assess status
• Make a map in every district and every health facility
showing population, communities, roads etc.
• Develop session plan showing how every community
will be reached regularly
• Implement workplan showing activities, persons
responsible and timetable, including supervisory visits
 MAKING A
DISTRICT MAP

For every health

center:
Decide delivery
strategy for
each village:
fixed, outreach,
mobile team
 Session Plan - reach each village regularly
Village Total Target Distance Session Injections Injections Sessions per
/ Town popula- population from type: per year per month (Fixed
tion (4% of total Health Fixed / (target month >50 injections per
population for population X session, or
this exercise) Center / Outreach 5)
(injections
Outreach >25
per year
other / Mobile divided by injections per
obstacles 12) session)

I II III IV V VI VII VIII

2000 167 4 - each Monday
A 10,000 400 0 F
1000 83 2 - first, third Tuesday
B 5000 200 2 F
750 63 2 - second, fourth
C 3750 150 2.5 F Tuesday
250 21 1 - first Wednesday
D 1250 50 6 O
500 42 1 - first Thursday
E 2500 100 3 F
50 4 1 - first Thursday
F 250 10 2.5 F
250 21 1 - second Wednesday
G 1250 50 10 O
125 10 1 - second Wednesday
H 625 25 8 O at G
river 150 At least 4 times a
I 750 30 M
passable in year
dry season
TOTAL 25,375 1015
Clinic Fixed and Outreach plan
 Outreach Challenges
• Cost/Logistics
• Per diem
• Transport
• Cold chain
• Access
• Organization
• Low return (few children)
• Frequency
• Need at least monthly to match schedule
• Missed sessions
2) Conduct Supportive Supervision
• Supervision that combines on-site training, problem solving,
and monitoring
• Focus on priority issues for follow-up at district and health
facility level:
• map
• session plan
• workplan
• monitoring chart
• stock/supply records
• deciding on corrective action for the quarter
• Supportive Supervision is more than just a check-list
Supportive Supervision Challenges
• Resources
• Staff
• Time
• Per diem
• Transport and fuel
• Organization
• Frequency
3) Establish Community Links
• Assist with organization of services
• Planning convenient services
• Session volunteers, informing mothers and crowd
control
• Defaulter tracing
• Vaccine transport
• Community attitudes
• Father’s permission
• Who else influences mothers’ decision making
• Who else can facilitate vaccination?
 Community Links: community -Based
Surveillance volunteers (CBSV)

Duties:
• birth registration
• defaulter follow-up
• ‘catch-up’ routine immunization (including TT)
Community Links - Challenges
• Attitudes
• Community
• Health Staff
• Language
• Organization
4) Monitor and Use Data for Action

• Compile data
• Analyze data to identify problems
• Decide what activities needed to solve problems:
existing resources or extra resources
• Go back to your work plan and add these activities,
prioritize
• Monitor and evaluate impact

• Topic of another talk…

5) Planning and Management of
Resources
• Ensure effective use of human, financial and material
resources
• Development of national, provincial, and district
POA/work plans
• Capacity building of staff
• Systematic vaccine forecasting, supply and
distribution
• Effective management of the cold chain
• Mobilization of resources
 RI: linking with other maternal &
child health services
One of the GIVS strategic areas
Integrating immunization, other linked health interventions,
and surveillance in the health systems context
Integrated services
• Integrated routine immunization visits
• Integrated immunization campaigns
• Other services provided include:
• Commodities (e.g., bed-nets, Vitamin A, deworming)
• Services (e.g., family planning, HIV testing)
• Health messages (e.g., hygiene, breastfeeding)
Integrated supervision visits
Integrated surveillance systems
Potential Benefits of Integrated Services
• Eliminate redundant operations
• Improve user satisfaction and convenience
• Benefit to other programs
• Reach and coverage of immunizations is often greater than other
health programs
• Routine immunizations are among the
most equitably delivered
• Reduce stigma
• Benefit to EPI
• Increase demand for immunization
• Additional resources available
Potential Drawbacks of Integrated Services
• Limited Resources Available
• Financial
• Personnel
• Logistical Issues
• Multiple components can create additional delays
• Timing of services may be different
• Transportation
• Negative impact on demand
• Controversial services
• Loss of incentive
Additional Routine Immunization Resources

• STOP Binder
• ImmunizationBASICS indicator list
• Implementing RED Approach,
August 2008
• Increasing Immunization
Coverage at the Health Facility
level
• MOH WHO/UNICEF
In-country immunization
partners
• STOP POC