EXPANDED PROGRAM OF

IMMUNIZATION
(EPI)
 LEGAL BASIS FOR IMMUNIZATION
Administrative Order No. 39 s. 2003 ( April 21, 2003)
Policies on the Nationwide Implementation of the Expanded Program on
Immunization.
Immunization is a basic right of the child and therefore no child shall be deprived of
this right.
The State regards children as one of the most important assets of the nation and
therefore every effort should be exerted to promote their welfare and full
development of their potentials for a useful and quality life.

Executive Order No. 663

Implementing the National Commitment for Bakuna ang Una sa Sanggol at Ina
Attaining WHOs goals to eliminate measles and neonatal tetanus, eradicate polio,
control hepatitis B and other vaccine-preventable diseases.

Republic Act No. 101521 (June 8, 2011) Mandatory Infants and Children Health
Immunization Act of 2011
An act providing for mandatory basic immunization services for infants and children,
repealing for the purpose Presidential Decree No. 996 as amended.
The mandatory basic immunization for all infants and children shall cover the
following vaccine-preventable diseases: TB, diphtheria, tetanus, pertussis, polio,
measles, mumps, rubella, heap B and Influenza (HIB)

 Philippine EPI Milestones

1976- Official launching of EPI, BCG given to
school entrants
1978- BCG and DPT for 3-14 mos expanded
nationwide, OPV and TT started
1982- Measles vaccine for 35% population
1992- Start of Hepa B immunization
2010- Start of MMR , Pentavalent vaccination
2012- Start of Rotarix , Influenza, Pneumonia
vaccination
Polio Diphtheria Measles

Tetanus
Pertussis Hepatitis B
 Case Definition
Measles
Suspect:
1. Fever of at least three days duration with
2. Maculopapular rash and
3. Any of the following: cough, coriza (runny nose),
conjunctivitis
Confirmed: A suspect case positive for measles IgM
antibody thru blood examination or suspect case with
epidemiologic linkage to an IgM antibody positive case
Red Blotchy Rash
 Measles Identification
Infectious agent : Measles virus
Incubation period : 7-18 days, average 10 days
Reservoir / Host : Humans
Diagnosis : Clinically and epidemiologic
linkage
 MEASLES VACCINE
Type of vaccine Live attenuated virus

Number of Doses One dose

Schedule At 9 11 months of age; booster in campaigns

Contraindications Severe reaction to previous dose, pregnancy,

congenital or acquired immune disorders
Adverse reaction Malaise, fever, rash 5-12 days later

Special precautions none

Dosage 0.5 ml

Injection site Outer mid-thigh in infants/outer upper arm

Injection type SUBCUTANEOUS

Storage -15 to -25C

 Case Definition

Diphtheria:
An illness of the upper
DIPHTHERIA

respiratory tract characterized by

laryngitis or pharyngitis or
tonsillitis, and adherent membranes
of tonsils, pharynx
and/or nose, or other mucus
membranes
 Identification
Infectious agent : Corynebacterium
diphtheriae
Incubation period : 2-5 days, occasionally
DIPHTHERIA

longer
Reservoir / Host : Humans
Diagnosis : Clinically-confirmed
DIPHTHERIA

Bull Neck
 Identification
An acute disease induced by an exotoxin of the
tetanus bacillus
A serious health problem where maternity care
services are limited and immunization against
tetanus is inadequate

Infectious agent : Clostridium tetani

Incubation period: 3-28 days (average 6 days)
Reservoir / Host : Intestines of horses, other
animals
Diagnosis : Clinically-confirmed
 Mode of Transmission
Introduction of tetanus spores into the
umbilical cord during delivery
cutting the cord with an unclean
instrument contaminated with tetanus
spores

After delivery
dressing the umbilical stump with
substances/instruments contaminated
with tetanus spores
 Opisthotonus

Trismus
Clinical Picture
Case Definition
Whooping Cough (Pertussiss)

Cough lasting at least two weeks

with at least one of the following:

paroxysms (i.e.. fits) of coughing

inspiratory whooping
post-tussive vomiting (vomiting
immediately
after coughing)
without other apparent cause
Paroxysmal Cough
 Hepatitis B
Infectious agent : Hepatitis B virus

Mode of transmission : sexual contact

:blood transfusion
: perinatal transmission
: sharing of unsterilized
needles, razors
Incubation period : 45-180 days
Hepatitis B
 PENTAVALENT VACCINE
Number of Doses Three primary doses
Schedule 6, 10, 14 weeks of age
Contraindications Anaphylactic reaction to previous dose
Adverse reaction Mild local or systemic reactions
Special precautions Not given over 5 years of age
Dosage 0.5 ml
Injection site Outer mid-thigh in infants/outer upper
arm if older
Injection type Intramuscular
Storage +2 - +8C and never be frozen
HEPATITIS B VACCINE
Type of vaccine Recombinant DNA or plasma-derived
Number of Doses Three doses
Schedule At or as soon as possible after birth,
6, 10, and 14 wks
Contraindications Anaphylactic reaction to previous dose
Adverse reaction Local soreness and redness
Dosage 0.5 ml
Injection site Outer mid-thigh (infants)/outer upper
arm (children & adults)
Injection type Intramuscular
Storage +2 to +8C . Never freeze.
 POLIO
AFP case definition
Acute: rapid onset of paralysis,3-4 days
usually to reach the maximum but may extend
to two weeks.

Flaccid: loss of muscle tone, floppy

(as opposed to spastic or rigid).

Paralysis: loss of muscular force, loss or

diminution of motion.

24
Polio
 ORAL POLIO VACCINE (OPV)
Type of vaccine
Live oral polio vaccine (OPV)
Number of Doses
Three doses
Schedule
6, 10, 14 weeks of age
Contraindications
None
Adverse reaction
Very rare
Special precautions
Rare congenital immune deficiency
syndromes
Dosage
2 drops
Storage
-15 to -25C
 BCG VACCINE
Type of vaccine Live bacteria
Number of Doses One dose
Schedule At or as soon as possible after birth
Contraindications Symptomatic HIV infection
Adverse reaction Local abscess, regional lymphadenitis
Special precautions Correct intradermal administration
Dosage 0.05 ml
Injection site Outer upper right arm
Injection type Intradermal
Storage +2 to +8C
 Immunization Schedule for Infants:
Recommended by WHO - Expanded Program on Immunization

Age Vaccines
Birth = BCG, HepB
6 weeks = Penta 1, OPV 1, PCV1
10 weeks = Penta 2, OPV 2, PCV2
14 weeks = Penta 3, OPV 3, PCV3
9 months = Measles
12-15 mos = MMR
 Dosage, Route and Site of Administration
VACCINE DOSE ROUTE SITE
BCG 0.05 Intradermal Deltoid region of the
R arm
OPV 2 drops Oral Mouth
Hep B 0.5 ml Intramuscular Upper outer portion
of the thigh
PCV 13 0.5 ml Deep IM Upper outer portion
of the thigh

Pentavalent 0.5 ml Deep IM Upper outer portion

of the thigh
Measles 0.5 ml Subcutaneous Deltoid region of the
arm
TT 0.5 ml Deep IM Deltoid region of the
arm.
MMR 0.5 ml Subcutaneous Deltoid region of the
arm
How to locate deltoid muscle
Different Needle Positions
 HOW TO GIVE VACCINES
Important points to Remember when giving a
vaccine
1) Before using any vaccine, look to check:
If this is the right vaccine that you need
The dose that you should give and site of
administration
The vaccine is not expired
Look for the expiry date
Color change in the VVM
The vaccine is stored in the right place at the right
temperature.
 Important points to Remember when giving a
vaccine
2) Always remember the following:
* right dosage
* right site
* right vaccine
* right individual
3) Maintain cold chain
4) Use one sterile disposable syringe with one
disposable needle for each injection
5) Observe aseptic technique
 Record and discard properly if:
If the label has come off
If the vaccine has passed its expiry date
If the VVM has reached discard point (the
inner square matches or is darker than the
outer ring of the VVM)
If the opened vial has NO DATE when it was
opened
If the reconstituted vaccines (AMV, BCG) has
passed 6 hours
** Record it as wasted. Bury the vaccine.
 Positioning a Child for Injection
You must show each mother exactly how you want
her to hold her child.
Make sure that there is a chair, bench, or stool for
the mother to sit on.
Ask her to remove the childs clothing from the part
where you want to give the injection
Position the child and position the mothers arms
securely.
If a mother cannot hold her child securely by
herself, ask someone else to help her.
Administration of Vaccine
Wipe the skin on the site for injection with a small piece of cotton
moistened with pre-boiled water. Discard the used cotton.
Hold the injection site bet. your thumb and fingers of your left
hand and the syringe with the other hand.
Push the needle quickly keeping your hands steady.
After inserting the needle, pull the plunger out slightly enough to
see if any blood enters the syringe. If there is blood, it means that
you hit a blood vessel, so withdraw the needle and syringe and
discard.
Inject again using new set with vaccine in another site slowly and
steadily pushing the plunger with your thumb.
Withdraw the needle when full dose is injected.
If blood forms on the injection site, press it gently with clean, dry
cotton. BCG sites however should not be touched after injection.
Do not recap the needle .Discard the syringe and needle in a
safety box.
CONTRAINDICATIONS TO IMMUNIZATION

All infants should be immunized except in

these two rare situations:
1. Anaphylaxis or a severe hypersensitivity reaction is an
absolute contraindication to subsequent doses of a
vaccine. Persons with a known allergy to a vaccine
component should not be vaccinated.
2. Do not give BCG vaccine to an infant that exhibits the
signs and symptoms of AIDS.
IF A PARENT STRONGLY OBJECTS TO AN IMMUNIZATION
FOR A SICK INFANT, DO NOT GIVE IT. Ask the mother to
come back when the infant is well.
 MDVP Conditions
C = Vaccine not contaminated
A = Vaccines stored under appropriate cold
chain conditions
L = Label intact
V = VVM has not reached the discard point
E = Expiry date has not passed
S = Vial septum not submerged in water
 Follow-up
Defaulters started with
immunization and did not come back for
the next schedule.
Missed children within the target
group but still unimmunized
Adverse Event Following
Immunization
 What is a Vaccine?

A biological substance that is

administered to individuals to elicit
immunity (protection) against a specific
disease.
 What is an adverse event following
immunization (AEFI)?
It is a medical incident that happens after
immunization, causes concern and is
believed to be caused by immunization.

Surveillance of AEFI is an effective means of

monitoring immunization safety and
contributes to the credibility of the
immunization programme.
 What is surveillance?
It is a continuing, systematic collection of health data that is analyzed
and disseminated to enable public health decision-making and action to
protect the health of the population.

Players and their roles in surveillance:

Infectious Disease Office Technical monitoring, Policy
recommendation
BFAD Regulator
NEO Investigator
RITM Technical Supervision
CHD Technical monitoring
LGUs - Implementors
 Classification of AEFIs
Vaccine Reaction Event caused or precipitated by the vaccine
when given correctly, caused by the inherent
component of the vaccine.

Program Error Event caused by an error in vaccine

preparation, handling or administration.

Coincidental Event that happens after immunization but

not caused by the vaccine, a chance
association.

Injection Event attributed to anxiety about or pain

from the injection itself rather than the
Reaction vaccine.

Unknown Events cause cannot be determined.

 Programme Errors
1. Non-Sterile Injections
- reuse disposal syringe or needle
- contaminated syringe or needle
- contaminated vaccine or diluent
- reused or reconstituted vaccine at subsequent
session

Adverse Event:
Infection - (e.g., Local suppuration at
injection site abscess,
cellulitis, systemic
infection, sepsis, toxic
shock
 Programme Errors
2. Vaccine Prepared Incorrectly
- Vaccine reconstituted with incorrect
diluent
- Drugs substituted for vaccine or diluent

Adverse Event:
Local reaction or abscess
 Programme Errors
3. Immunization injected into wrong site
- subcutaneous instead of intradermal for
BCG
- Too superficial for toxoid vaccine (DPT,
TT, Hepa B)
- Buttocks

Adverse Event:
Local reaction or injection site abscess
 Programme Errors
4. Vaccine transported / stored incorrectly
Adverse Event:
- Increased local reaction

5. Contraindications ignored
Adverse Event:
- Avoidable vaccine reaction
 Case Definitions and Treatment for AEFI

Adverse Case Definition Treatment Vaccines

Event
Anaphylaxis Severe immediate (within 1 hour) Adrenaline All
generalized red, raised and itchy injection
(urticaria), flushing, dizziness,
nausea, vomiting leading to
circulatory failure with or without
bronchospasm and/or
laryngospasm/laryngeal edema
 Case Definitions and Treatment for AEFI
Adverse Event Case Definition Treatment Vaccines
Injection site Fluctuant or draining fluid-filled Incise and drain; All
abscess lesion at the site of injection. antibiotics, if
Bacterial, if evidence of infection bacterial
(e.g. Purulent, inflammatory
signs, fever, culture), sterile
abscess, if not.
Persistent Inconsolable continuous crying Settles within a DTP,
inconsolable lasting 3 hours or longer day or so; Pertussis
screaming/crying accompanied by high-pitched analgesics may
screaming/crying help.
Seizures Occurrence of generalized Self-limiting; All,
convulsions that are not supportive care; especially
accompanied by focal paracetamol and Pertussis,
neurological signs or symptoms. cooling if febrile; measles
Febrile seizures: if temperature rarely
elevated >38C (rectal), Afebrile anticonvulsants.
seizures: if temperature is
normal
 Case Definitions and Treatment for AEFI
Adverse Event Case Definition Treatment Vaccines

Sepsis Acute onset of severe generalized Critical to recognize All

illness due to bacterial infection and and treat early.
confirmed (if possible) by positive Urgent transfer to
blood culture. Needs to be reported hospital for
as possible indicator of programme parenteral
error. antibiotics and
fluids.

Severe local Redness and/or swelling centered at Settles All

reaction the site of injection and one or more spontaneously
of the following: within a few days to
a week.
Swelling beyond the nearest joint Symptomatic
Pain, redness and swelling of more treatment with
than 3 days duration analgesics.
Requires hospitalization Antibiotics are
inappropriate.
Local reactions of lesser intensity
occur commonly and are trivial and
do not need to be reported.
 Anaphylaxis

Sudden life-threatening reactions that are

immunologic resulting from Ig-E mediated
sensitivity to foreign substances

The more rapidly the symptoms appear after

administration, the more serious is the
reaction
 Anaphylaxis
Clinical Manifestations
Tingling sensation around
mouth or face
Feeling of warmth
Difficulty of swallowing
Tightness in the throat or
chest
Flushed
Urticaria and angioedema
Varying degrees of
hoarseness, inspiratory
stridor , dysphagia, nasal
Abdominal cramps,
diarrhea, contraction of
uterus and other organs of
smooth muscle
Loss of consciousness
Hypotensive with feeble
heart sounds, bradycardia
and sometimes arrythmia
Cardiorespiratory arrest
 Anaphylaxis
Emergency Treatment

At the vaccination site:

Aqueous epinephrine (1:1000)

Route : SQ or IM
Dose : 0.01 ml/kg (max of 0.3 ml for a child or
0.5 ml for an adult) imediately
 Anaphylaxis

Dosage of Aqueous Epinephrine (SC or IM) for Anaphylaxis

Age in Years Dose (ml)

< 1 year old 0.05
1 year old 0.10
2 years old 0.20
3 4 years old 0.30
5 years old 0.40
6 14 years old 0.50
 Anaphylaxis
The dose may be repeated at 5 minutes
intervals up to a maximum of 3 doses.
Monitor vital signs every 30 min. until stable.
Lay the patient in a left lateral position with
legs elevated.
Take the patient to the nearest hospital after
the 2nd dose of epinephrine.
The vaccinator should accompany the patient
to the hospital to be ready to administer the
3rd dose of epinephrine, if needed.