EXPANDED PROGRAM ON IMMUNIZATION (EPI)

 Established in 1976
 Ensure infants, children and mothers have access to routinely recommended vaccines
 Seven vaccine-preventable disease: TB, Polio, diphtheria, tetanus, pertussis, HepB and
measles
 According to NSO (2009), TT coverage was lowest for women with no education (34%)
and highest for women with high-school education (80%)
 ARMM (39%) vs Central Visayas and Cagayan Valley (88%)
LEGAL BASIS OF EPI
 Reduce the morbidity and mortality among children against common vaccine-
preventable diseases
 RA 10152, also known as Mandatory Infants and Children Health Immunization Act of
2011, mandates basic immunization covering the vaccine-preventable diseases; free in
government hospitals and health centers up to 5 years of age
o Also covers: Hepatitis B, mumps, rubella, Hib
 RA 7846 provided for compulsory immunization against hepatitis B for infants and
children below 8 years old; hep B immunization within the first 24 hours of life
GOALS OF EPI
1. To immunize all infants/ children against the most common vaccine-preventable disease
2. To sustain the polio-free status of Philippines
3. To eliminate measles infection
4. Presidential Proclamation no. 4, s. 1998 launched the Philippine Measles Elimination
Campaign
5. To eliminate maternal and neonatal tetanus
6. Presidential Proclamation no. 1066, s. 1997 declared a national tetanus elimination
campaign starting 1997
7. To control diphtheria, pertussis, hepatitis B, and German Measles
8. To prevent extra-pulmonary TB among children
IMMUNIZATION SCHEDULE FOR INFANTS AND YOUNG CHILDREN

 Available in all health facilities for women and children nationwide

 Wednesday is designated as immunization day in government health facilities
 Refer to page 225, table 10.6 for schedule and manner of administration of infant
immunization 
 Receiving the antigens at the earliest possible age reduces the chance of child getting
infected of the immunizable disease
 
ANTIGEN AGE DOSE ROUTE SITE

BCG At birth 0.05 ml ID Right deltoid

arm

Hep B At birth 0.5 ml IM Anterolateral

thigh muscle

Pentavalent 6 weeks, 10
(DPT + Hep B + weeks, 14 weeks 0.5 ml IM Anterolateral
HIB) (4 weeks thigh muscle
interval)

OPV 6 weeks, 10
weeks, 14 weeks 2-3 drops PO Mouth
(4 weeks
interval)

AMV 1 9-11 mos. 0.5 ml SQ Outer part of

the upper arm

MMR 12-15 mos. 0.5 ml SQ Outer part of

the upper arm

Rotavirus 6 weeks, 10 1.5 ml PO mouth

weeks

 In 2012, two new vaccines were added as part of EPI: Hib and rotavirus

  Rotavirus infects the large intestine (common cause of severe diarrhea in infants
and children; 30% of diarrhea-related hospitalization)

 Hib is responsible for meningitis and pneumonia

Considerations related to schedule and manner of administration

 One sterile syringe and needle per client

 No need to restart a vaccination series regardless of the time that has elapsed between
doses
 All the EPI  antigens are safe and effective for simultaneous administration BUT in
different sites
 It is not recommended to mix different vaccines in one syringe; or to use a fluid vaccine
for reconstitution of a freeze-dried vaccine 
 When 2 vaccines are to be injected in the same time, use 2 different sites; however, if
more than one injection has to be given on the same limb, the injection site should be
2.5- 5 cm apart to prevent local reactions
 Recommended sequence of the co-administration of vaccines is as follows: OPV,
Rotavirus, then other appropriate vaccines
 For OPV, do not let the dropper touch the tongue of the child 
 ONLY monovalent hepatitis B vaccine must be used for the birth dose
 Children who have not received AMV1 as scheduled should be given AMV1 as soon as
possible, then AMV2 (or MMR) after a month

 All children entering Grade 1 should be screened for measles immunization; those
without are referred to the nearest health facility
 The first dose of Rotavirus vaccine (6 weeks to 15 weeks); the second dose is given 10
weeks up to a maximum of 32 weeks
 Administer the entire dose of the Rotavirus slowly on one side of the mouth (between
cheek and gum) with the tip of the applicator directed toward the back of the infant’s
mouth; stimulate sucking reflex (young infant) and stroke throat downward if 5 months
older to stimulate swallowing

PREPARATIONS OF EPI VACCINE

 Inactivated (killed) microorganisms
 Attenuated microorganisms: live that have been altered so that they are no longer
pathogenic, but are still antigenic 
 Fragments from microorganism 
 Toxoids: inactivated or altered bacterial exotoxins
 Please refer to pp. 226 Table 10.7 (Vaccines, their content and forms)

TARGET SETTING AND VACCINE REQUIREMENT

 Goal: 100% immunization of all infants and children 
  In RHU, the nurse is responsible for preparing vaccine requirements and overseeing
vaccine allocation
 Vaccine requirement is calculated based on ELIGIBLE POPULATION

ELIGIBLE POPULATION
Note: TP stands for Total Population

 Estimated No. of Infants= TP x 2.7%

 Estimated No. of 12-59 month old children= TP x 10.8%
 Estimated No. of pregnant women= TP x 3.5%

MAINTAINING THE POTENCY OF EPI VACCINES

 Vaccines must be properly stored, handled and transported to keep it POTENT. It only
confers immunity when it is POTENT!
MAINTAIN THE COLD CHAIN

 The COLD CHAIN is a system for ensuring the potency of the vaccine form the time of
manufacture to the time it is given to an eligible client

 The COLD CHAIN MANAGER is the PUBLIC HEALTH NURSE

 In-charge of maintaining the cold chain equipment, such as freezer/refrigerator,

transport box, vaccine bags/carriers, cold chain monitors and cold packs

 The nurse implements an emergency plan in the event of an electrical breakdown or

power failure
COLD CHAIN REQUIREMENTS

 OPV: -15 to -25 C; to be stored in the freezer; in the vaccine bag, it has to be placed in
contact with the cold packs

 All other vaccines are stored in the refrigerator at a temperature of +2 to +8 C. Vaccines
should stocked neatly on the shelve of the refrigerator. DO NOT STOCK ON
DOOR SHELVES.

 Hepatitis B vaccine, Pentavalent Vaccine, Rotavirus Vaccine and TT are damaged by

freezing, SO DO NOT PUT IN THE FREEZER. Wrap them with paper before putting inside
the vaccine bag with cold packs

 Keep diluents cold by storing them in the lower part or on the door shelves
OTHER CONSIDERATIONS TO MAINTAIN POTENCY

 Observe FEFO or First Expiry First Out

  Recommended duration of storage in the health center should not exceed one month

 Using transport boxes, vaccines can be kept only up to maximum of 5 days

 Take note if the vaccine container has a vaccine vial monitor (VVM) and act accordingly;
please refer to page 232 figure 10.9

 Round disc of heat-sensitive material placed on a vaccine vial

 The lower the temperature, the slower the change

 The higher the temperature, the faster the change

 Abide by the open vial policy of the DOH

 Multi-dose vial: OPV, Pentavalent, Hepatitis B and TT vaccines may be used in

the next immunization session for up to maximum of 4 weeks, provided that:
1. The expiry date has not passed
2. The vaccine has not been contaminated
3. The vial has been stored under appropriate cold chain conditions
4. The vaccine vial septum has not been submerged in water
5. The VVM has not reached discard point 
 Reconstitute freeze-dried vaccines such as BCG, AMV, and MMR only with diluents
supplied with them
 Discard reconstituted freeze-dried vaccines 6 hours after reconstitution or at the end of
the immunization session, whichever comes sooner

AGAIN!!!
OPV, Pentavelent, Hepatitis B and TT can be used up to 4 weeks
BCG, AMV1 and AMV2/MMR should be discarded within 6 hours after reconstituting

 Protect BCG from sunlight and Rotavirus from light!!!
SIDE AFFECTS AND ADVERSE REACTIONS OF IMMUNIZATION

 Parents and guardians should be informed of side effects and adverse reactions of the
vaccines

 BCG injection results in the formation of a wheal that disappears within 30 minutes 

 After about 2 weeks, it will swell and may develop abscess  and later ulcerates.
The ulcer heals by itself and leaves a scar. The whole course takes about 12
weeks. (THIS DOES NOT REQUIRE ANY MANAGEMENT)

 Other side effects, please refer to pp. 233 table 10.8

Vaccines Side effects Management 

Koch’s phenomenon: an acute None

inflammatory reaction within 2-4 days after
vaccination; usually indicates previous
exposure to tuberculosis

Deep abscess at vaccination site; almost Refer to physician for I&D

invariably due to subcutaneous or deeper
injection

BCG
Indolent ulceration: an ulcer that persist Treat with INH powder
after 12 weeks from vaccination date

Glandular enlargement: enlarged lymph If suppuration occurs, treat as

glands draining the injection site deep abscess

Vaccines Side effects Management 

Local soreness of injection site None

Hep B

Fever last only for 1 day. Advise parents to

Fever beyond 24 hours, not due to give antipyretic
Pentavalent the vaccine but other causes
 Local soreness of injection site Reassure parents that soreness
will disappear after 3-4 days

Abscess formation indicates I&D may be necessary

that the injection was not
deep enough or the needles was not
sterile
Convulsions are rare (>3 months) Pertussis vaccine should not be
given anymore

Vaccines Side effects Management 

None  None 

OPV

Fever 5-7 days; sometimes with mild Give antipyretic; reassure parents

rash
AMV

Local soreness, fever, irritability, Reassure parents and instruct to

and malaise in some children give antipyretic
MMR/ AMV2

Some develop mild vomiting Reassure parents and instruct to

and diarrhea, fever and irritability give antipyretic; give Oresol 
Rotavirus
 Vaccines Side effects Management 

Local soreness  Apply cold compress at the site;

not other treatment needed
TT

CONTRAINDICATIONS:

 Generally, there are no contraindications to immunization of a sick child if the

child is well enough to go home
 There are a few absolute contraindications to EPI vaccines. DO NOT GIVE:
1. Pentavalent vaccines over 5 years old
2. Pentavalent vaccines with recurrent convulsions or other
active neurological disorders  of the CNS
3. Pentavalent vaccines 2 or 3  to a child who has had convulsions or shock
within 3 days of the most recent dose
4. Rotavirus vaccine when the child has hypersensitivity to a previous dose
of the vaccine; intussusception or intestinal malformation, or acute gastroenteritis
5. BCG to a child who has signs and symptoms of AIDS or other immune
deficiency conditions or who are immunosuppressed

FALSE CONTRAINDICATIONS:

 The health worker may continue with the immunization:

1. Malnutrition 
2. Low-grade fever (37.5 to 38.3 C)
3. Mild respiratory infection
4. Diarrhea: children for diarrhea who are due for OPV should receive a
dose of the vaccine during the visit; BUT THE DOSE IS NOT COUNTED. The child
should return when the next dose of OPV is due.  

EPI RECORDING AND REPORTING

 EPI recording and reporting are accomplished through FHSIS

 FULLY IMMUNIZED CHILD (FIC) are those who are given BCG, three doses of OPV, three
doses of DPT and hepatitis B or 3 doses of Pentavalent vaccine, and one dose of AMV1
before reaching the age of 1.

 Completely immunized child refers to children who completed their immunization

schedule at the age of 12-23 months

 Child Protected at Birth (CPAB) children born from mothers who received two doses of
TT vaccines during pregnancy, provided that the second dose is given a month prior the
delivery OR three doses of TT anytime prior the pregnancy with this child