Expanded program on immunization

(EPI)

By: Wandimu M. (BSC, MSC In PCHN)

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Immunization……
Learning objectives

At the end of this lesson the students will be able to:

 Define immunization, immunity and vaccine

 Discuss about classification of immunity.

 List EPI target disease.

 Identify immunization schedule.

 Identify the target population.

 Identify vaccine delivery strategies.

 able to describe cold chain management

 Calculate immunization coverage

 Calculate vaccine forecasting

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Target disease
 Tuberculosis
 Poliomyelitis/polio
 Diphteria
 Pertusis
 Tetanus
 Measles
 Hepatitis B.Virus
 Haemophilus influenza type b
 Pneumonia
 Diarrhea/Rota virus

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Background
 Immunization is the most cost-effective intervention in public health and

 It is one of the indicators of development in most developing countries.

 EPI started in Ethiopia in 1980 with the aim of

 Reducing morbidity and mortality of children and mothers from

vaccine preventable diseases.

 In Ethiopia, EPI was launched in 1980 with six antigens (BCG, Polio,

DPT and Measles vaccines).

 Several new vaccines have been introduced over time (HepB and Hib in

combination with DPT as Pentavalent , PCV, Rota, IPV and HPV.

 Currently, 12 antigens are provided through routine EPI.

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EPI…
 Immunity is the ability of the body to tolerate material that is

indigenous to it and eliminate material that is foreign.

 It is the resistance of the body against a disease producing agent.

 Active immunity: is provided by a person’s own immune system.

 This type of immunity can come from exposure to a disease or from

vaccination.
 Active immunity can be acquired through natural immunity or vaccine-

induced immunity.
 Passive immunity: results when antibodies are transferred from one

person or animal to another.

 The most common form of passive immunity occurs when a fetus

receives antibodies from his or her mother across the placenta during
pregnancy.
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EPI…
 Immunization: is the process whereby a person is made immune or

resistant to an infectious disease, typically by the administration of a

vaccine.
 Vaccines stimulate the body's own immune system to protect the

person against subsequent infection or disease.

 A vaccine is a biological preparation that improves immunity to a

particular disease.
 A vaccine typically contains an agent that resembles a disease-

causing microorganism, and is often made from weakened or

killed forms of the microbe, its toxins or one of its surface
proteins.
 Vaccination: is the administration (injection and Po) of a killed or

weakened organism that produces immunity in the body against that

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organism.
Immunity can be divided in to two

1. Congenital /innate non- 2. Acquired or specific immunity

specific immunity. 2.1. Active acquired immunity

 It is the natural -The child body makes its own

antibodies.
resistance of body e.g.
–Long lasting immunity
skin,
2.2. Passive acquired immunity
WBC e.t.c
 The child gets ready-made

antibodies (Abs).
 Short live immunity.

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1.2.2 Passive acquired immunity

a. Natural-acquired b. Artificial acquired

passive immunity passive immunity.
 Trans-placentally
 Formed antibodies are

transferred Maternal administered to the

antibodies in the body of child.
the child. E.g Td vaccine
E.g T.A.T
from the mother.

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1.2 Immunization Delivery sites.
 There are “3” types of vaccination delivery strategies.

1. Static : - vaccination is given at the health facility.

 Performed as apart of routine activity of the health

units.

2. Out reach - the health staffs of the health unit go out &
administer vaccine to the mothers & children in their
catchments area.
 It is scheduled sessions.

3.Mobile - used in a single doss of vaccination.

 used to control epidemic / such as meningitis & measles/

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Types of vaccine
I. Live but weakened-attenuated The organism in these
vaccine are weakened so that no harm /no infected/ the child,
rather than stimulate the child to produce Ab. e.g measles, BCG,
OPV and Rotarix.
II. Killed vaccine (micro organism)
 A vaccine consisting of virus particles, bacteria, or other
pathogens that have been grown in culture and then killed
to destroy disease-producing capacity. e.g Pertussis, IPV,
COVID -19 Vaccines
 Toxoid : Tetanus, diphtheria
 Polysaccharide based:
 Pure: meningococcal

12/17/2024 Conjugated:
wandimuHaemophilus influenza type b (Hib),

M. 10
Types of vaccine Cont…
1.2.1. Target group for EPI.
 All <1 years of children &
 All women of child bearing age.

1.2.2. Acceptable proof for Immunization

 BCG scar
 Immunization card.

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EPI…

 How many times should a child go for Immunization?

 A chilled should be taken for immunization six(6) times to

complete the immunization.

 pentavalent vaccine (DPT-HepB + Hib).

 The vaccine consists of (" 5" )antigens i.e diphtheria ,

tetanus, pertusis ,Hepatitis, & H. influenza).

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Immunization Schedule
Contact Vaccine Age of child

 1st vaccination Polio-o & BCG, Hep bV At birth

 2nd. Vaccination DPT1-HepB+Hib (penta-1)

6wks
PCV -1& polio-1 Rota.v1
 3rd Vaccination DPT2-HepB-+Hib (penta-2) 10
wks.
PCV-2& polio-2, Rota .v2

 4th vaccination DPT3-HepB- Hib (penta-3) 14

wks.
PCV-3 & polio-3, IPV

 5th vaccination Measles

9 month

15 month
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wandimu M. 13
Dose & route of administration of vaccine
Vaccine dose No of Route Site S/E
dose

BCG <1yr=0.05 one I.D right -Local

upper inflammation
arm or deep
abscess.

Polio 2drops 4 Orally Mouth -Usually none

DPT-HepB- 0.5 ml 3 I.M Anterior -Fever

Hib - Lt -Local
PCV -13 0.5ml thigh swelling
IPV Pcv on -Convulsion
right ),
Rt
thigh=
IPV 2cm
away
Measle
12/17/2024+ 0.5 ml wandimutwo
M. SC. left -Fever &Rash
14
1.2.3. Contra indication (C/I)

I. Infants with clinical AIDS should not received BCG

vaccination.

II. Do not give Pentavalent V. to a child has developed

convulsions or shock with in the previous does of Penta.

III. The child with diarrhea should be give oral polio

vaccine.

 But this should not be counted.

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Route of administration of vaccine…

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Route of administration of vaccine…

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Route of administration of vaccine…

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Tetanus immunization schedule for women.
Conta Minimum interval Duration of S/E (Side
ct protection effect)

Td1 At the 1st contact during 0 -Pain

pregnancy or all women -Redness
child bearing age (15-49) -Swelling
a few days
Td2 At least 4wks after Td1 3 Years at the
Td3 A t least 6 month after 5 Years injection.
Td2

Td4 at least 1 year's after Td3 10 Years

TTd5 at least 1 yr after Td4 Life long
years

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 What damages vaccines?

 Vaccine can easily damage if not handle properly.

 If the vaccine is in good condition, and able to make a child

immune is potent.

 If vaccine is damaged, and not able to make a child

immune, then it has lost its potency.

 Vaccine has an expiry date.

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 Heat, sun light and freezing

 Heat and sunlight damage all vaccine, but (live vaccine)

most sensitive

 Freezing damage DPT-HepB+Hib(Pentavalent) and Td

vaccine.

 Keep all vaccine at the correct cold temp.

 If vaccine once damaged, you can’t make potent it again.

 Chemicals (disinfectant, soap) e.t.c can damage the

vaccine.
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 Temperature

 The correct temperature to store all vaccine is between

+2c0 and +8c0.(+2c0 to +8c0)

 Use thermometer in your refrigerator or vaccine carrier

to measure the temperature of your vaccine.

Polio-Vaccine

 has clear pink or pale orange liquid.

 Has comes in small bottle with dropper cap.

 Has damaged very quickly by heat than other vaccines.

 Does not damage by freezing.

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 Measles vaccine

 It is freeze dried.

 To use the vaccine, mix the dry vaccine with diluent’s water.

 This is called reconstituting the vaccine.

 is easily damaged by heat.

 Reconstituted vaccine losses its potency very quickly, you

must use it in same immunization session, or throw it out.

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 BCG-Vaccine.
 B=Bacillus C= Calmette G=Guerin:
 has come as dry powder in container

 is damaged most easily by sun light.

 Damage by heat but not as quick as (polio and measles)

DPT-HepB + Hib and Td Vaccine

 Has contains “5” vaccine.

 Damaged by heat but not as quickly as the live vaccine.

 Are liquid vaccine

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 Summery

Precaution for vaccines

 a. All vaccine to be stored at +2c0 to 8c0.

 b. Vaccine storage time at health center is up to 1 month.

 c. measles & polio be kept frozen.

 d. Never freeze DPT- HBV-Hib or tetanus vaccine(Td).

 E. Keep diluents in refrigerator Or diluents must never be

frozen.

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Principles of the immunization program
 The aim of the EPI program is to improve management of

immunization activities at all levels.

 To achieve this EPI uses the following principles:

 integration in MCH program

 health education

 disease surveillance

 monitoring and evaluation

 operational research
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 Cold chain

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Cold chain…
 Cold chain is the backbone of a vaccine supply chain system.

 is an equipment that ensure vaccine potency by keeping vaccine cold

from the manufacturer to the mother /child?

Equipment for cold chain includes:

-Cold boxes

-Refrigerator

-Ice packs

-Vaccine carriers
 Check the temperature twice daily at the morning & evening.

 Manufacturer national airport  central vaccine stores 

regional store  zonal stores  district - health center  health

post or child & mother.
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Cold chain…
1. Cold box:

 A cold box is an insulated container that can be lined with ice-

packs to keep vaccines cold during transportation (from two

to seven days).

 Cold boxes are used to collect and transport monthly vaccine

supplies from district stores to the health facility.

 They are also used to store vaccines when the refrigerator is out

of order or being defrosted and for outreach and mobile sessions.

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Cold box

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COLD CHAIN con,t…
Vaccine carriers
 Similar definition Like cold boxes.

 They are smaller than cold boxes and are easier to carry if

walking.
 But they do not stay cold as long as a cold box – maximum for

48 hours with the lid closed.

 Vaccine carriers are used to transport vaccines and diluents to

outreach sites immunization sessions.

 Vaccine carriers are also used to store vaccines when the

refrigerator is out of order or is being defrosted.

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COLD CHAIN cont…
 Ice-packs

 Ice-packs are flat, square plastic bottles that are filled with water

and frozen.

 Ice-packs are used to keep vaccines cool inside the vaccine carrier

or cold box.

 The number of icepacks required for a cold box or vaccine carrier

varies.

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Ice-packs

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Placement of vaccines when at RI session site

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Cold chain monitoring equipment

 Vaccine vial monitors (vvm)

 Thermometer

 The shake test etc.

 Freezetag

vaccine vial monitors (vvm) test

 A vaccine vial monitor (VVM) is a label that changes color

when the vaccine vial has been exposed to heat over a

period of time.

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12/17/2024 wandimu M. 37
VVL con’t…

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Cold chain monitoring equipment Cont…
shake test
 To find out if freezing has damaged Penta-vaccine or Td

vaccine, look for the following conditions after shaking it.

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12/17/2024 wandimu M. 40
Cont…
N.B –
 Don't take out the vaccines from the refrigerator until the vaccine

carrier is ready.
 Don't let DPT-HBV + HIb & Td vaccines touch the ice /cover them

with news paper.

Task done at immunization session
 Arranging the flow of mothers & children

 registering

 weighting

 health education on immunization

 screening clients

 treating clients

 immunization
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Looking vaccine at H.C refrigerator.

1.Load and use the refrigerator correctly.

a. In the main compartment store vaccine

 OPV & measles at the top shelf(1st compartment)

 BCG-At the middle comportment. (2nd compartment)

 Diluents, Penta & Td at the lower compartment(3rd

compartment)

-Bottle of water at 4th comportment if the refrigerator

consists 4 comportment.

-The freezing compartment “freezer” used to make ice

packs, hence it’s Tc0 should be <0c0.

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Arranging Vaccine in the CC
Vertical refrigerators:
 Top: Ice packs

 Shelf 1: Live viral vaccines (OPV,

Measles)
 Shelf 2: BCG, returned vials of

other antigens
 Shelf 3: Penta, Td on lowest

shelf away from freezer space

 Diluents: next to its vaccine or

clearly marked
 Bottom: Water bottles
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12/17/2024 wandimu M. 44
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Loading top-opening (chest) refrigerators
 All the vaccines should be stored in the basket provided with

the refrigerator

1. Measles, BCG and OPV in the bottom only; and

2. Freeze-sensitive vaccines (DPT, hepB, Hib, Td, vaccines) in

the top only.

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Calculation of target population & EPI coverage

 Target population /children under one years old/:

- Their proportion depends on the available recent

demographic data of the area e.g. if it is k %

 yearly target children = total population X k/100

 monthly target children = yearly target children / 12

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 Immunization coverage with specific vaccine. e.g.Penta-1

-Monthly coverage =No of children who received

Penta-1 in the specific month X 100

target popn for the month

-Annual coverage = No of children who received

Penta3 in the specific year X100

target popn for the year

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Vaccine stock on hand
 The quantities of usable stock available in the system

 It does not include damaged, expired, and VVM stage at discard

point.

 The amount of stock on hand should be calculated before

ordering new stock to avoid;

 having too much vaccine delivered with no place to store it or

 storing vaccine for too long at the most peripheral level

where the cold chain is weakest.

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Supply Interval

It is the period of time during which vaccine store and

frequency of delivering vaccines at each level.

The supply periods determined based on:
 transport availability

 cold chain storage capacity

 stock management system and

 continuity of energy supply and level of the supply chain.

In Ethiopia the supply period at:

 EPSA hub level - Three months

 Woreda stores and health facilities - One month

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Vaccine utilization and wastage
 It is factor in forecasting vaccine needs.
 Vaccine utilization is the proportion of vaccine
that is supplied and administered.
 Vaccine wastage is the proportion of;

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Reserve requirements
 Reserve stock is the additional amount of vaccine needed in

case of an emergency, such as

 a sudden increase in demand,

 higher than expected wastage, or

 delays in re-supply.

 Most programs maintain a reserve stock of 25% over the

amount they expect to use during the supply period, but

experience should dictate this proportion.

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Forecasting vaccine needs
 calculated on the basis of population, coverage and wastage factor,
and increasing annually in order to allow for programme growth.
 Estimation of Requirements

 There are three methods of forecasting

 target population,

 previous consumption, and

 size of immunization sessions) that are commonly used to

estimate vaccine and safe-injection equipment needs.

 Target population method is suitable for higher level (Central ESPA

and hubs woreda level)

 whereas number and type of sessions planned is more suitable for

planning at lower levels health-facility level.

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Formula to be used in target population method

 During new vaccine introduction and initial forecasting for

newly established health facility of cold store, the forecasting of
vaccine and other related supplies should include the buffer
stock which is expected to be 0.25 of the requirement for
the supply period.

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Cont….
WHO indicative Wastage rate and Wastage factor commonly used for
forecasting

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Vaccine management
 Wrong estimation of vaccine needs, with overstocks or stock-

outs
 Wrong vaccine storage with freezing of cold-sensitive vaccines

or discarded monitors
 Poor implementation of the multi-dose vial policy (MDVP), also

known as the opened vial policy

 Vaccine not reconstituted properly

 Vaccines are expensive, particularly new vaccines

 Global capacity for vaccine production is limited.

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Cont…
 To calculate:

 BCG Mixing syringes (2ml) – divide the calculated doses of BCG

vaccine by 20 and multiply by wastage factor 1.05 (5%).

 Measles Mixing syringes (5ml) - divide calculated doses of

Measles vaccine by 10 and multiply by wastage factor 1.05 (5%)

 Safety box – Divide the sum of all AD and mixing syringes by 100

and multiply by wastage factor 1.05 (5%)

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 Exercise1: Vaccine Forecast

 It is August 2023, and the forecast for 2024 is being prepared for

woreda health office “X”. The total population served under its
catchment is 28,000 and under one children proportion estimated to
be 3.2% of the total population. Expected coverage of PCV for next
year is 90% and estimated PCV wastage was 10%. The hub is
collecting vaccine from EPSA center in quarterly basis. Because of
hub “X” located in the remote part of the region the time it takes to
collect and come back from EPSA center is one week.
 Calculate the following:

1. Total number of PCV doses needed per supply period?

2. AD syringe and safety box needed for the supply period?

3. Maximum and minimum?

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Immunization problems & solution

1. Dropout: - a child or women who failed to return for

subsequent doses of vaccine.

Possible cause of dropout.

1. Unsure date of return.

2. Long wait at the vaccination center.

3. Failure to explain the need of completing vaccination.

4. Negative attitude of H.W to words the program.

5. Mother usually busy. e.t.c.

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Possible cause of dropout Cont…
6. Missed opportunities

7. Culture beliefs.

8. Lack of accessibility (distance, cost of transportation) e.t.c

9. Lack of inter-sector collaboration.

10. The problem associated with the vaccine.

e.g. BCG :efficacy is uncertain .

11. In effective management.

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Drop out rate calculation.
 Over all drop out rate

= coverage with BCG - coverage with measles* 100

Coverage with BCG

 Drop out rate for single antigen e.g. (opv).

=Coverage with opv1- coverage with opv3* 100

Coverage with opv1

 There is a problem when ever the drop out rate is > 10%.

 It is essential to determine why the failure occurred.

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 Missed opportunities
 All children & mothers at health facility for any reason should

be screened for immunization status & vaccinated if eligible.

 If not vaccinated these eligible called Missed opportunities.

Common cause
 Lack of Acceptability

 Health worker (H.W) screen but tell pt,s to return later.

 H.W only open avial if there are enough client.

 logistical problem

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 Drop out & missed opportunities are the major cause of

low vaccination coverage.

Potential solution
 Social mobilization

 Drop out tracing mechanisms.

 Get commitment by the local leaders.

 Monitoring & supervision the program.

 In service training to community H.w.

 Ensure financial & logistic support for the health institutions.

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Communication gaps in EPI

REASONS FOR NOT BEING FULLY IMMUNIZED FOR CHILDREN

Unaware of need for immunization

Unaware of need to return

Place and time of immunization unknown

Immunization site too far

Fear of side reactions

Time not convenient

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Immunization Safety
 Immunization injections are safe when the correct & potent vaccine is properly
administered with sterile equipment that is subsequently disposed of safely.

 No harm to the recipient

 No harm to the health-care worker

 No harm to the community

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Vaccine safety and quality
 Diluents should be

 Specific for each vaccine

 Vary in composition ( bactericides, dissolving chemicals, buffers etc)

 Diluents for vaccines have to be from same manufacturers

 Kept between 2- 8 degree centigrade

 Discard reconstituted vaccine after 6 hrs

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Selection of equipment
 Single use syringes and needles

 Ad syringes are the preferred type of injection equipment.

 Avoids patient to people transmission of blood born diseases.

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Monitoring AEFI
 AEFI is a medical incident that takes place after immunization and is believed to

be caused by the immunization.

 Many such incidents are not due to immunization

 Cause of AEFI’s

 Program errors (handling, reconstitution and administration)

 Nature of Vaccine (vaccine properties) or individual reaction to the vaccine

 Coincidental (chance)

 Unknown

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Program errors and their consequences
Adverse events
 Program Error
 Local abscess, septic
 Reuse of disposable syringe
shock, Blood borne
 Reconstitution error diseases
- Local abscess, negative
 Injection at incorrect site
effect of drugs
Abscess, Sciatic nerve

damage, Loss of vaccine

efficacy

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 THANK YOU !

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