Unit 2 :

Immunization
Ms Farzana Kauser
SONAM, PIMS
Islamabad.
Objectives :
At the end of the session, learners will be able to :
 Overview of Expended Program for Immunization (EPI) in

Pakistan
 Review different types of immunity.

 List seven childhood communicable diseases covered by EPI.

 Explain the types of vaccines.

 Describe the Importance of childhood immunization in family

context.
 Discuss the process of cold chain and responsibilities of nurse to

maintain cold chain.

 Discuss the family/communities practices towards immunization.

 Health education and post vaccination teaching.

Expended program on immunization

• Definition :
• EPI is a disease prevention activity at reducing
illness, disability and mortality from childhood
diseases preventable by immunization.
• EPI was launched in 1978 to protect children by
immunizing them against childhood diseases.
• It also aims to protect mothers and newborn against
tetanus.
• Immunizing children with these vaccines may avert
up to 17% of childhood mortality in Pakistan.
Cont…,
 These diseases are referred as target diseases and cause
millions of ailments, disabilities and death each year.
 This expended program on immunization protect

children under 2 years by immunizing them against

childhood Tuberculosis, diphtheria, pertusis, polio ,
measles, tetanus, hepatitis, pneumonia and meningitis.
 The purpose of the EPI is reduction of mortality and

morbidity resulting from the Nine EPI target diseases

by immunizing children of the age 0-11months and
women of child bearing age.
There are many training workshops and
refresher courses are arranged by
WHO/UNICEF to protect children and their
mothers and aimed that all children must be
immunized to be protected and 80% are
eliminated the risk of epidemics.
National Immunization Program
 The National immunization program has
contributed to significantly decreasing
childhood morbidity and mortality due to
vaccine preventable diseases.
 A child needs only 5 visits during the first year

and one visit during the 2nd year of his/her life

to complete the vaccination with 6 visits
against 9 dreadful diseases.
Programme Objectives:
The objectives of the EPI are to :
 Affirm the commitment of the Government of

Pakistan to provide safe and cost – effective

vaccination against vaccine preventable diseases.
 Set National standards and guidelines for
immunization aligned with the global goals and
evidence base, and encourage the generation of local
evidence for vaccination against vaccine preventable
diseases.
Cont…,
 The Pakistan EPI programme has adopted its goals and
strategies in accordance with priorities set at the global and
regional level.
 The National Immunization Technical Advisory Group was
established in 2008 by the Ministry of Health in accordance
with WHO guidelines.
 A programme policy/ guideline document was developed in
2015 with the support of partners.
 The document lays out policy direction and guidelines for
involvement of lady health workers in immunization service
delivery, and in the area of the private sectors role in
immunization.
Cont…,
 The new immunization policy invisages
Pakistan's Vision 2025 by addressing the key
goal- to reduce infant mortality rate from 74 to
less than 40 (per 1000 births) and reduce
maternal mortality rate from 276 to less than
140,( 9 per 1000 births) and continue reducing
the IMR through immunization targets and
activities in order to achieve goals for the
country.
Role of health care team:
 The participation of community health nurse is
necessary for these programs.
 She should give the necessary details for
immunization session in clinic, in communities and
each member of health care related to immunization.
 She should educate parents of children about
importance of vaccine and affects of target diseases .
 Officer In charge of a health center may have to
calculate the vaccine according to the requirement of
the area and ensure the maintenance of the cold chain.
Immunization as a process:
 Immunization is a process of protecting an
individual from a disease through introduction
of live, killed or partial component of invading
organisms into an individual system.
 It is a process whereby a person is made

immune or resistance to infectious diseases

typically by the administration of vaccine.
Vaccine stimulate the body's own immune
system to protect the person against infection.
Antigen:
Definition :
 It is a substance which when introduced into a

body, stimulates specific immune response and

production of antibody or specifically
sensitized T-cell form in response to antigen.
Chemically it is usually protein but may be
carbohydrates, lipid or nucleic acid, red blood
cell, egg albumen, snake venom, milk and
plant may act as antigen.
Antibody :
Definition :
 It is a blood protein substance produced in

lymphatic tissue and able to counteract the

effect of a specific bacterial antigen or
exposure to foreign substances, with which it
combines chemically. Antibodies
(immunoglobulin) are group of glycoproteins
present in serum and tissue fluids of all
mammals.
Active Immunization:
It occur naturally when person come in contact with
microbe. Immune system creates antibodies and
other defense against microbe.
Artificial active immunization is where the microbe is
injected to person before they are able to take it in
naturally. They are pre-treated, so that it will not
harm the infected person. For example the result of
vaccination.
Common examples of vaccine include polio ,
Hepatitis B , Chicken pox, and Small pox.
Passive Immunization:
Definition:
A process in which individuals receive antibodies from another
source rather than producing those antibodies on their own.
 It is an immunization where pre-synthesized elements of

immune system are transfer to person. Currently antibodies

can be used for passive immunization. This method of
immunization begins to work very quickly but it short
lasting, because the antibodies are naturally breakdown. It is
normally administrated by injection and used it where has
been a recent outbreak of a particular disease or an
emergency treatment for toxicity as in for tetanus.
Immunization Schedule by W.H.O
Disease Causative Vaccine Dose Age
organism
Childhood TB Bacteria BCG 0.05ml (1) At birth

Poliomyelitis Virus OPV 2 drops (4) At birth, 4 wks, 10 wks,

14 wks
Diphtheria Bacteria Pentavalent 0.05ml DPT (3) AT 8 WKS, 10 WKS, 14
Pertussis, Vaccine WKS
Tetanus
Hepatitis B Virus HepB+ Hib 0.05ml (3) At 8wks, 10 wks, 14 wks

Hib pneumonia Bacteria HepB+Hib 0.05ml

and meningitis
Measles Virus Measles 0.05ml At 9 month and 15
month
Immunity:
Definition :
 Immunity is a power of resistance of a body against
infectious diseases based on the immune system.
 In biology, immunity is a balance state of having adequate

biological defense to fight infection.

 The structure of this system comprises of bone marrow,

thymus, lymph, glands, spleen, tonsils and adenoids.

 The system consists of different cell such as B cell, T cell,

plasma cell, macrophages, follicular dendritic cell, poly-

morphs and mast cell. It is a capability of body to resist
harmful microorganisms or viruses from entering it.
Types of immunity :
There are three main types of immunity, innate, adoptive and
passive.
1) Innate immunity:
Innate or nonspecific, immunity is the defense system with which
you were born and protect you against all antigens.
 Everyone is born with innate or natural immunity, a type of

general protection. It provides resistances through several

physical, chemical and cellular approaches.
 Innate immunity also includes the external barriers of body, like

skin and mucus membrane that line nose, throat and GIT, which
are first line of defense in preventing diseases from entering the
body.
Innate Immunity
 Healthy skin is forming a good barrier
against entering of the germ.
 Skin secretion is forming a surface which

kills the germs.

 Action of cilia on the mucus membrane

of air passage removes the microbes.

 Tear protecting the eyes.
 Stomach acids and juices which also act

against some germs.

Adoptive Immunity:
 Definition:

Immunity produced by transferring lymphoid

cells (e.g. T cells) from an immune donor to a
genetically identical recipient.
In cancer patients, for example, adoptive
immunization is performed to boost immunity
following intensive therapy, using the patients
own T cells harvested prior to the treatment.
2 ) Adoptive active immunity:
 The 2nd kind of protection is adoptive or active immunity,
which develop throughout our lives.
 Active immunity is the resistance develops by an individual
as a result of stimulation by an antigen. Antigen is a
substance, introduce into a body will stimulate an immune
response. When B and T cells are activated by pathogen, in
immune system a memory (B and T cell) develop and
primary immune response occur. It responds more quickly
when it is exposed again.
 Adoptive immunity involves the lymphocyte and develops as
people are exposed to disease or immunized against diseases
through vaccination.
Cont…,
 Naturally acquired active immunity.
This immunity occurs when a person is exposed
to a live pathogen and develops a primary
response. Which lead to immunological
memory.
 Artificial active immunity.

It can be introduce by a vaccine, a substance

that containing antigens without causing
symptoms of disease. It is long-lasting.
3) Passive immunity:
 The short- term immunity is the transfer of active immunity in the
form of readymade antibodies from one individual to another.
There is no antigenic stimulus, instead performed antibodies are
administered.
 In passive immunity there is immediate protection with no longer
period.
 It is less effective than that by active immunity.
 Passive immunity can occur naturally when maternal antibodies
are transfer to the fetus through placenta. It is borrowed from
another source and it last for a short time.
 Passive immunity provides immediate protection but the body does
not develop memory, therefore the patient is at risk of being
infected by the same pathogen later.
Natural acquired passive immunity.
 Maternal passive immunity is a type of
naturally acquired immunity and refers to
antibody to fetus by its mother during
pregnancy.
 The human colostrum which is also rich

in IgA antibodies is resistance to

intestinal digestion and gives protection
to neonate.
Artificial acquired passive immunity.
 It is short term immunization induced by the
transfer of antibodies which can be
administered in several forms, as human or
animal blood plasma.
 Passive transfer is used prophylactic in case of

immunodeficiency diseases for prophylaxis

and therapy.
 It is also used in the treatment of several types

of acute infection and treats poisoning.

4 ) Cellular immunity.
 The leucocytes of the blood are geared into
action and engulf the invaders. These cells are
called phagocytes. When disease producing
organisms penetrate into the body, the person
will get the disease and protect many further
attacks of this disease if survives. Different
vaccines are given to diseased person to
protect against infectious disease and develop
antibodies.
Types of Cellular immunity.
B cells activates humoral immunity
Whereas
T cells activate cell – mediated immunity.
 The major difference b/w humoral and

cell- mediated immunity is that humoral

immunity produces antigens- specific
antibodies, whereas, cell – mediated
immunity does not.
5 ) Herd immunity.
 It refers to the overall level of immunity in the
community and is relevant in the control of
epidemic.
 Eradication of communicable diseases depends
on the development of high level of immunity in
individual also.
 Herd immunity can be increased by vaccination
of large number of people in the community. So
herd immunity is the immunity developed in the
large proportion of individuals in population,
reduces the epidemic arising in that community.
Cont…,
 Herd immunity describes a type of immunity
that occurs where the vaccination of a portion
of population provides protection to
unprotected individual.
 Vaccination act as a sort of immunological

barrier in the spread of the disease, slowing

or preventing further transmission of the
disease to others.
Communicable Diseases:
 Childhood communicable diseases covered by EPI.
 There are some diseases which can occur in young children
and can cause the great deal of suffering and mortality but can
be prevented by immunization.
 These diseases include tuberculosis, diphtheria, pertussis,
Tetanus, poliomyelitis and measles polio , hepatitis A and
hepatitis B.
 In order to prevent and control the occurrence of these
diseases, it is necessary to take not only primary level
preventive measures but also secondary and tertiary level
preventive measures, especially early recognition and
treatment, control of environment and health education.
Tuberculosis: (bacterial Infection)

 Tuberculosis is an infectious disease suffered

by all ages. Pulmonary tuberculosis is an
infectious disease of lungs but it can attack
any part of the body.
 It is caused by Mycobacterium tuberculosis.

The major source of infection is infected

sputum of persons having tuberculosis who are
either not being treated or not being fully
treated.
Cont…,
 They are source of infection to environment and people around
them. It is also found in pus. Pleural and peritoneal.
 The other source of infection is infected milk of affected
animal that can cause intestinal tuberculosis.
 The incidence of infection increases sharply from infancy to
adolescent. The risk of develop tuberculosis high in preschool
years. The children who are malnourished and live in dark and
overcrowded places, having poor resistance have increased
chances of tuberculosis.
 The disease is transmitted mainly by infected droplet exhaled
out by sputum of positive patients especially by coughing,
sneezing.
Cont…,
 The incubation period of disease ranges from few week
to months or years depending on the tuberculosis
bacilli.
 The disease is characterized by toxemic symptoms such
as low grade fever, especially in the evening, loss of
weight, lethargy and localized symptoms depending on
the site of infection can be persistence cough with or
without sputum, blood in sputum, pain in chest and
dysponea and hoarseness of voice if the infection in the
lungs. In some cases there is loss of appetite, anorexia
and wasting of muscles.
Pathophysiology:
 The tubercle bacilli require ready access to oxygen for
growth. In favorable circumstances cell division of the
bacilli occurs. In unfavorable condition it may become
weak in necrotic tissue for years. Bacterial
multiplication spread to the regiment nodes in the
hilum of lung and gain entry into the blood stream. It
may progress particularly when child is malnourished
or contact measles or whooping cough. The lymph
nodes are enlarged, cellular; necrosis may develop and
eventually classify proving the so called ghon’s
complex.
Diagnosis/Assessment :

In pulmonary tuberculosis diagnosis is confirmed by:

• chest x-ray examination,
• examination of sputum
• tuberculin test
• Physical examination of the chest.
• Blood C//P (ESR)
• Blood c/s
Prevention and control

 There should be health education of parents and other

family members.
 Tuberculosis is preventable by health promotion and

specific protection of children.

 Improve general health and resistance of children by

improving living condition, clean, well ventilated and

open houses.
 There should be a good nutrition, healthful habits,

and good environmental sanitation.

 Specific protection by BCG vaccination of children.
Cont…,
 In order to control further spread of infection it is very
important to find out cases, confirm diagnosis and initiate
and complete the course of treatment.
 It is therefore necessary for all health workers to help to
identify tuberculosis cases and refer to PHC chest clinic.
 They should follow up cases to continue regular treatment
when put on anti tubercle treatment without any break.
 Health supervisor, community health nurse must
supervise and guide health workers in carrying these
responsibilities.
Diphtheria :
 Definition :
 It is an acute infectious disease caused by toxigenic

strain of corn bacterium diphtheria. The disease spreads

mainly by droplet infection through respiratory route
and none respiratory routs too. The skin where the cuts,
wounds and ulcers are not properly healed or through
infected umbilical cord in a new born. The person
remains infective usually for two weeks to four weeks.
 It is very serious disease , if it is not treated

immediately, it leads to high mortality.

Mode of transmission :
Diphtheria is transmitted by;
 direct , droplet and direct airborne.

 It is also transmitted indirectly by inhaling contaminated dust

particles
 and by using contaminated articles used by the patient only

for a short period.

 The incidence of diphtheria is highest in the age group of 1-3

years.
 It occurs throughout the year but more during winter season.

 The average incubation period of disease is 3-4 days, it range

from 2-6 days. There are four clinical varieties of diphtheria.

Pharyngotonsillar :
 It is characterized by sore throat, difficulty in
swallowing, low grade fever, rapid pulse,
enlarge cervical glands.
 On examination of throat there is mild erythema,

localized exudates or membrane on the pillars of

tonsils or pharynx. The membrane may be
whitish and wipe of easily. It may extend,
become thick, blue-white to gray black. It is
adherent any attempt to remove causes bleeding.
Laryngotracheal:
 It may be primary or secondary to
pharyngotonsillar. It is characterized by
hoarseness of voice and croupy cough. There
can be loss of voice, obstruction of breathing,
respiratory failure and death. It is almost fatal
form.
Cont…,
 Nasal:

It is less toxic form of diphtheria characterized

by blood strained nasal discharge and ulcer in
the nose.
 Other Forms:

These includes conjunctiva, genital and

cotaneous diphtheria, in which often a wound
and ulcer is surrounded by erythema and
covered by membrane.
Prevention and control
 Diphtheria is preventable by specific protection by
immunization of all children with diphtheria toxoid.
 The children should be immunized as early as possible so as to
protect them before they lose their natural immunity.
 The immunization of diphtheria is done by combine or mixed
vaccines which include diphtheria, pertussis and tetanus
vaccine DPT.
 The vaccine can be safely administered as early as six weeks
after birth.
 It is very important that health workers put in all the efforts to
immunize all children. They educate parents and family
members about the same.
CONT…,
 In order to control the spread of infection it is
necessary to recognize the case clinically and refer
them immediately to hospital without loss of time.
 The treatment is administration of antidiphtheric

serum. The dosage varies depending upon the

severity of disease.
 In addition to antitoxin, antibiotics either penicillin or

erythromycin are also given for 10-12 days.

 The children must be isolated from other family

members.
 Those children who are not immunized are put on
prophylactic treatment and are placed under medical
supervision.
 Proper disinfection of clothes, fomites and sputum

should be done.
 The community health nurse and health supervisors

must see that these actions are properly implemented

by health workers and family members and ensure
effective prevention and control of diphtheria in
children. They need to be educated, trained and
supervised by health care team.
Whooping cough (pertussis)

 Definition :
Whooping cough is an acute infectious disease,
causing complication and high mortality
especially, it is dangerous during infancy.
The child coughs rapidly many time without
taking a breath until he cough up a plenty of
mucus. The cough spasm usually ends with the
vomit and some time with the whooping noise.
 It is caused by Bordetella pertussis.
Source of infection
 The source of infection is infected human being. The
infection is present in nasopharyngeal and bronchial
secretion.
 The infection is transmitted directly by droplet of

infected person.
 It is also transmitted by the use of freshly

contaminated articles.
 The period of incubation usually ranges from 7-14

days. This disease affects trachea, bronchi and

bronchioles. There are three stage of disease.
Stages of disease :
There are three stage of disease.
 Catarrhal stage: This stag is inflammatory stage
characterized by mild fever and irritating cough which is
worse at night. This stage lasts for 5-10 days. This is the most
infectious stage.
 Paroxysmal stage: This stage is characterized by bouts of

cough. In each bout the child has series of cough in quick

succession followed by holding of breath and then forced
inspiration accompanied with whooping sound. During the
bout child become flush and or blue or exhausted. But after
the bout he regains the color and strength. The child may pass
feces, urinate and may bit the tongue during the bout. The
proximal stage may lasts for six weeks.
 Convalescent Stage:
During this stage the child recovers from the
disease and regains health. This stage lasts for
1-2 weeks.
Prevention and Control

 The occurrence of pertussis can be prevented by immunization of children

which is done by combination of diphtheria and tetanus.
 Control of pertussis can be done by early recognition of disease which can
be done by microscopic examination of secretion from nose and throat.
 The child should be isolated as far as possible.
 The infants and young children should be kept away from infected cases.
 The children must be referred to PHC, so that medical care is given.
 The usual treatment is administration of antibiotics to control secondary
infection.
 Clothes, fomites should be disinfected and discarded properly to prevent
spread of infection.
 Health workers must be trained to implement these measures.
 Health workers must educate to parents and family members for
immunization of children.