1. 1 Dr. Vidumini De Silva

2. Describe the current schedule for the Expanded Programme on Immunization (EPI) 2

3. Immunization The process by which a person becomes protected ( immune) against a disease by administration of a live modified agent, a suspension of killed organism or an inactivated toxin. (1)Vaccine A killed or weakened infective organism used to prevent disease 3

4. Vaccines included in EPI Live attenuated BCGTB OPVPolio MMRMeasels, Mumps, Rubella LJEVJapanese Encephalitis Inactivated PertussisWhooping cough Toxoids Tetanus DiphtheriaDiptheria Subunits HepBHepatitis B HibHeamophillous influenza B 4

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6. At birthBCGIDDeltoid of left arm At completion of 2 nd, 4 th and 6 th months Pentavalent (DPT, Hep B, Hib) + OPV IMAnterolateral aspect of the thigh 9 monthsLJEVSCDeltoid 1 yearMMRSCDeltoid 18 monthsDPT, Hep B + OPV IMDeltoid 3 yearsMMRSCDeltoid 5 yearsDT + OPVIMDeltoid 12 yearsaTdIMDeltoid 15-44 years (Females) MMR ( if not immunized with Rubella containing vaccine previously) SCDeltoid 6

7. Tetanus Toxoid (TT) 1 st pregnancy1 st doseAfter 12 weeks of pregnancy 2 nd dose6-8 weeks after the 1 st dose 2 nd pregnancy3 rd dose 3 rd pregnancy4 th dose 4 th pregnancy5 th dose 1 Booster dose (TTb) During 1 st pregnancy with a written evidence of previously being immunized with 6 doss of TT as per National EPI schedule during childhood and a gap of 10 years or more after the last TT containing immunization 7

8. 8 Tetanus Toxoid is not indicated in Mothers who have received 5 doses of TT during previous pregnancies Mothers who have received 6 doss of TT according to the National EPI schedule during childhood and if the gap between last TT containing immunization and the present pregnancy is less than 10 years Mothers who have received 6 doss of TT according to the National EPI schedule during childhood and have received at least 1 booster dose of TT during pregnancy or due to trauma within last 10 years

9. Dosage of vaccines DoseNo. of doses in 1 vial BCG0.05ml10 doses Penta0.5 ml1 dose OPV2 drops10 doses JE0.5 ml5 doses MR0.5 ml10 doses DPT0.5 ml10 doses DT0.5 ml10 doses TT0.5 ml10 doses 9

10. Up to 5 years of age vaccines are given at the child Welfare Clinic After 5 years vaccines are given at school during School Medical Inspection If DT is not given to a child at 5 years it is given to that child at school during School Medical Inspection 10

11. Why do we need booster doses for some vaccines? Live Attenuated Vaccine Killed/ Inactivated Vaccine 11

12. Reasons for modifying current schedule of EPI MMR – In most countries immunization for mumps is delivered through MMR. According to the WHO, by December 2010, 2-dose MMR schedule has been implemented in 132 countries out of 193 member states in their national immunization schedules (2). Furthermore, the current trend in private sector in Sri Lanka is for MMR JE – In most countries JE is given at 9 months Rubella – Is no longer given as a monovalent vaccine at 14 years but is included in MMR 12

13. Some important points BCG – If the scar is not present at 6 months a 2 nd dose of BCG is given ( 2 nd dose can be given from 6 months to 5 years of age) If a vaccine is missed - There is no need to recommence the schedule or give additional doses. Missing doses should be provided as early as possible. The next dose should be scheduled after an appropriate minimal interval. 13

14. In MOH office and field immunization clinics 14

15. Q4.2 Describe the steps that are taken to maintain the cold chain in the MOH office and the field immunization clinics 15

16. Cold chain is a….. System of – people equipment To ensure that correct quantity of potent vaccine reach the women and the children (1) 16

17. Equipment used to maintain the cold chain 1. Refrigerator 2. Data lodger 3. Vaccine vial monitor 4. Vaccine stock management 5. Cold boxes and vaccine carriers 17

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19. 1. Refrigerator Deep freezer OPV 1 st shelf BCG, MMR, JE, Typhoid 2 nd shelf Penta, DPT, DT, aTd 3 rd shelf TT Bottom Diluents 19

20. Arrange the stocks according to “ earliest expiration date – first out” (EEFO) Stocks of vaccine that have been taken to clinics and brought back unused should be stored separately from the bulk stocks and should be taken to the very next clinic and used before using the other stocks Maintain free space to allow air to circulate around. This refrigerator should only be used to store vaccines 20

21. 2. Data lodger The temperature in the fridge is recorded to a micro chip in the data lodger With this data a temperature chart is maintained A weekly refrigerator temperature record is sent to Regional Director of Health Services (RDHS) 21

22. 3.Vaccine vial monitor For OPV, Pentavalent and Hep B The monitor in the vial changes colour according to room temperature 22

23. 23 Utilize as soon as possible

24. 4. Vaccine stock management Vaccine movement register Monthly stock return of vaccine is send to RDHS and drug stores 24

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26. 5. Vaccine Carrier… 26

27. In the vaccine carrier … Ice packs are placed against the sides of the box OPV and MR are stored in the bottom Other vaccines are stored on the top None of the vaccines are in contact with ice The box is kept in a cool shaded place 27

28. At the clinic All unopened vials of vaccine should not be taken out of the vaccine carrier till ready for use All opened vaccine vials should be placed in a cup of ice or in a special cold pack during immunization 28

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30. Q4.3 Describe the process of monitoring the Adverse Events of Immunization (AEFIs) 30

31. Why should we monitor AEFI? To provide safe immunization. To avoid refusal of further immunization due to adverse events 31

32. Classification of AEFI Vaccine reaction - Event caused or precipitated by the vaccine by its inherent properties Program error - event caused by an error in vaccine preparation,handling or administration Coincidental – event happen after immunization but not cause by the vaccine Injection reaction - event from anxiety about or pain from the injection itself 32

33. After Administration of a vaccine Keep the mother and the child in the clinic for 20 minutes When administrating more than 2 vaccines keep an interval of 15 – 20 minutes Educate mother about Common reactions Mild fever, local swelling, redness Serious reactions Febrile convulsions, skin rash 33

34. Surveillance of AEFI 34 Notification for AEFI (Form : AEFI –1) Health worker (government /private) should report AEFI through this form One copy is sent to the relevant MOH office One copy remain in the Register One copy sent to Regional Epidemiologist

35. 35 AEFI case investigation form (AEFI - 3) Severe AEFI should be investigated by MOH & report should be sent to the Epidemiologist & RDHS/RE Monthly Surveillance Report on AEFI (AEFI - 2) One copy to RDHS/RE One copy to Chief Epidemiologist

36. Reference 1. National Expanded Programme on Immunization Sri Lanka [Internet] Epidemiological Unit Ministry of Health, Nutrition & Welfare; 2002 [cited 2011.09.30] Available from http://www.epid.gov.lk/pdf/Immunization%20Handbook.pdf 2. Introduction of Measels, Mumps, Rubella Vaccine (MMRV) into National Immunization Programme and changes to the National Immunization Schedule, general circular no. 02-123/2011 [Internet] Ministry of Health; 2011 [cited 2011.09.30] Available from http://www.epid.gov.lk/pdf/Immunization/MMRV%20circuler.pdf 36

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