The Expanded Program On Immunization (EPI)

Bacille Calmette-Guérin (BCG) Vaccine: Live attenuated vaccine Store at 0° to 8°C Age : at birth or 6 weeks Route of administration: a single intra dermal injection over the deltoid muscle of the arm or left forearm.

At site of injection: development of erythema and either a papule or ulceration, followed by a scar at the immunization site.

Bacille Calmette-Guérin (BCG) Vaccine: Side effects: LymphadenitisContraindication: Immune deficiency diseases, including congenital immunodeficiency, HIV infection and impaired immune function secondary to treatment with corticosteroids, chemotherapeutic agents or radiation. Immune deficiency diseases, including congenital immunodeficiency, HIV infection and impaired immune function secondary to treatment with corticosteroids, chemotherapeutic agents or radiation.

ORAL POLIO VACCINE (OPV) Contents: Sabin attenuated polio virus (live attenuated vaccine) Ideal age of Initiating primary vaccination: 6 week (an additional dose recommended at birth by W.H.O. OPV0) (an additional dose recommended at birth by W.H.O. OPV0)

ORAL POLIO VACCINE (OPV) Boosters: Two, at 1.5 years and between 4-5 years. Dose: 2 drops. Route of administration: Oral.

ORAL POLIO VACCINE (OPV) Contra – Indications: Contra – Indications: Immunocompromised host or household member. Side effects: None. Complications: Vaccine induced poliomyelites (one in 3 million vaccine) Complications: Vaccine induced poliomyelites (one in 3 million vaccine) The dose of OPV given during an episode of diarrhea should not be counted and shoud be to given at the earliest opportunity The dose of OPV given during an episode of diarrhea should not be counted and shoud be to given at the earliest opportunity

ORAL POLIO VACCINE (OPV)

Pentavalent Vaccine Contents: Each 0.5 ml contains: Diphtheria toxoid, Tetanus toxoid, pertussis, Hepatitis B, Haemophilus influenzae b. Diphtheria toxoid, Tetanus toxoid, pertussis, Hepatitis B, Haemophilus influenzae b. The vaccine should not kept frozen or exposed to freezing Store at 2° to 8°C Dose: 0.5 ml. Dose: 0.5 ml.

Pentavalent Vaccine Route of administration: Deep intramuscular. Site of administration: Anterolateral aspect of thigh.

Pentavalent Vaccine Side effects: Fever, local pain and swelling. Instruction to the mother after vaccination: To give antipyretic (paracetamol) in case of fever.

Complications: Convulsions, shock, encephalitis. Contra- Indications: a. Progressive neurological disease. b. Uncontrolled convulsions. c. Severe reactions to first or subsequent dose

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

Measles Vaccines Measles Vaccines Contents: live attenuated measles virus grow in chick embryo cells. Store at 0 to 8°C Ideal age of Primary vaccination: 9 months. In epidemics & household contacts should be between 6-9 months In epidemics & household contacts should be between 6-9 months

Measles Vaccines Dose: 0.5 ml. Route of administration: Subcutaneous. Site of administration: Upper arm or anterolateral aspect of thigh..

Measles Side effects: : Mild fever & rash may appear after 5-7 days. Contra-Indications: Contra-Indications: Immuno compromised host. Immuno compromised host. Severe (anaphylactic) egg allergy.

Rotavirus Vaccines Contains one strain of live attenuated Contains one strain of live attenuated rotavirus (type G1P[8] Store at (2-8 o C) and protect from light Store at (2-8 o C) and protect from light

Rotavirus Vaccine Dose: 1.5 ml 2 doses minimum interval between doses is 4 week Age:- beginning at 6weeks of age Early immunization is favoured with the first dose of rotavirus vaccine to be administered from Early immunization is favoured with the first dose of rotavirus vaccine to be administered from 6 weeks of age, however, in order to benefit those who may come late infants can receive doses 6 weeks of age, however, in order to benefit those who may come late infants can receive doses without age restriction. Because of the typical age distribution of rotavirus gastroenteritis without age restriction. Because of the typical age distribution of rotavirus gastroenteritis ( rotavirus vaccination of children >24 months of age is not recommended. ( rotavirus vaccination of children >24 months of age is not recommended.

Rotavirus Vaccine Contraindications Severe allergic reaction to a vaccine component or following a prior dose of vaccine

Rotavirus Vaccine Precautions* Altered immunocompetence History of intussusception *the decision to vaccinate if a precaution is present should be made on a case-by-case risk and benefit basis

Rotavirus Vaccine Adverse Reactions VomitingDiarrheaIrritabilityFever Serious adverse reaction None

Contraindications to vaccinations: Absolute Temporary

Contraindications to live attenuated vaccines: Absolute: 1- History of anaphylactic reactions. 2- Subsequent doses of pertussis vaccines are absolutely contraindicated if the child gets (within 48 hours of vaccination ) Fever (40.5º), Collapse or shock. Persistent crying for 3 hours without apparent cause. Convulsion with or without fever within 3 hours after vaccination. Give a single dose vaccine of diphtheria + tetanus pediatric formula ( avoid pertussis component).

Contraindications to live attenuated vaccines: Absolute: 3- HIV infection is an absolute contraindication to administration of live attenuated vaccines ( OPV & BCG).

Temporary: 1- Severe illness that needs hospitalization. Deferred immunization till the infant recovers and could be at discharge. 2- Immunosuppression.

The strategy for the vaccine delivery

The strategy for the vaccine delivery: (I)The fixed site strategy. (II)Outreach site strategy. (III) Mopping up Immunization. (IV)The National Immunization Days (NIDs).

1. The fixed site strategy: There is integration of immunization services through (MCH): Advantages:- 1-Available resources. 2- Cold Chain maintenance. 3- Save,time, effort and money.

2.The out reach Strategy  The outreach is carried for routine immunization that is compulsory for the targets in certain areas where: - immunization services are not accessible. - vaccination coverage is Low. Limitations: (i) Expensive (ii) Cold chain failure. (iii) Difficulty to arrange the immunization schedule.

(Outreach immunization

(3) Mopping up Immunization: It is house-to-house immunization with OPV in high risk districts. High risk districts are those: Where the wild polio virus is still circulating With low immunization coverage. Population, with overcrowding poor sanitary environment and low access to health services.

(4) The National Immunization Days (NIDs): It is periodic immunization of all the eligible targets in a defined group over a large geographic areas within a short period of time. It is one of the strategy for polio eradication and tetanus elimination.

The cold chain

The cold chain: It is the system of storage and transportation of the vaccine at low temperature (cold condition) from the manufacture till it is consumed.

The cold chain: Polio vaccine is the most sensitive vaccine to heat. Live attenuated vaccines are allowed to be frozen (OPV, Measles and BCG). Inactivated vaccines must not be frozen ( DPT, DT, dT, TT and HB).

The levels of cold chain

The administrative level Storage period TemperatureThe vaccines Central & regional stores Maximum three months - 20° to- 30°C OPV, Measles, MMR,BCG +2° to +8°CDPT, DT, dT, TT& HB,Hib Districts stores& local immunization centers Maximum one month 0°C to+8°C OPV, Measles, MMR, BCG +2° to +8°CDPT, DT, dT, TT& HB,Hib The administrative levels of cold chain according to the duration of the storage and the temperature required to keep the vaccine potent

The equipment and tools The procedures The health staff The components of the cold chain :

Refrigeration equipment:  Refrigerator  Cold boxes  Vaccine carriers  The ice packs retained in the freezer -To stabilize the temperature of the refrigerator at the optimum level. - Fully frozen ice-packs are used for lining the vaccines carriers and the cold boxes during storing the vaccines

Cold Chain Equipment  The recommended equipment typically used for vaccine storage are : equipment typically used for vaccine storage are : cold rooms, cold rooms, refrigerators and refrigerators and freezers. freezers.  For transporting vaccines equipment such as equipment such as  cold boxes,  vaccine carriers and

Cold chain equipment “For vaccine storage” Cold room refrigerators Freezer

Cold chain equipment “for transporting vaccine” Cold box Vaccine carrier Ice bags

Cold box ice Packs

Vaccine carrier

The refrigerator : Placed in the coolest place of the health centers away from sunlight Well ventilated and adequate air circulation around it. Kept locked and open only when necessary. Ice packs are kept in the freezer. Its temperature is recorded twice daily. Both the monitor and thermometer are placed in the refrigerator. The temperature chart is stuck on the door outside the refrigerator. The diluents should be kept on the lowest shelf. Drugs, drinks or food must not be stored in the refrigerator

Tools for monitoring the cold chain

Tools for monitoring the cold chain: 1- Cold Chain Monitor Card. 2- Freeze Watch Indicator 3- Cold Chain Refrigerator Graph 4- Vaccine Vial Monitors 5- Shake Test

Cold Chain Refrigerator Graph The vaccines are stored in refrigerators, they are monitored twice a day and readings are recorded on a chart to ensure a safe temperature is maintained +2°C +8°C

2-Cold Chain Monitor Card: is used to show cumulative exposure to Temp. above the safe range during storage& transportation.

2-Cold Chain Monitor Card:

3-Vaccine vial monitors: Every vial is also shipped with a temperature-sensitive label, that health workers monitor during vaccination sessions.

SAFE If the inner square is lighter than the outer ring and the expiration date is valid, the vaccine is usable SPOILED If the inner square matches or is darker than the outer ring, the vaccine must be discarded.

4-The shake test DPT, hepatitis B and tetanus toxoid vaccines can all be damaged by freezing. By shaking two vials, side-by-side, one that might have been frozen and one that has never been frozen, health workers can determine if a vaccine has spoiled.

What damage the Vaccines? 1. Any defect in the cold chain. 2. Out date expiry. 3. Exposure of the vaccine to unacceptable temperature during the immunization session. 4. Exposure of the vaccine to direct sunlight (BCG)