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EXPANDED PROGRAM ON IMMUNIZATION (EPI) OF THE PHILIPPINES

Rationale of the EPI

The Expanded Program on Immunization (EPI) was established in 1976 to ensure that infants/children and
mothers have access to routinely recommended infant/childhood vaccines. Six vaccine-preventable diseases were
initially included in the EPI: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles.

In 1986, 21.3% fully immunized children less than fourteen months of age based on the EPI
Comprehensive Program review.

I. Global Situation
In 2002, WHO estimated that 1.4 million of deaths among children under 5 years due to diseases that
could have been prevented by routine vaccination. This represents 14% of global total mortality in
children under 5 years of age.

II. CURRENT GLOBAL UPDATE (WHO 2014 report)

A. WHO reported 78% drop in global measles deaths.
B. 83% of infants worldwide are already vaccinated with 3 doses of DTP vaccine in 2012
-During 2012, about 110.6 million infants worldwide got three doses of DTP3 vaccine, protecting
them against infectious diseases that can cause serious illness and disability or be fatal.
- By 2012, 131 countries had reached at least 90% coverage of DTP3.

C. 22.6 million children are still incompletely vaccinated at 12 months of age

D. The Global Vaccine Action Plan (GVAP) is a roadmap to prevent millions of deaths through more
equitable access to vaccines.
E. Countries are aiming to achieve vaccination coverage of 90% nationally and 80% in every district by
2020.
a. While the GVAP should accelerate control of all vaccine-preventable diseases, polio eradication
is set as the first milestone.
b. It also aims to spur research and development for the next generation of vaccines.

III. EPI in the Philippines

A. Definitions
2003 guidelines Administrative order No. 39 s. 2003 SUBJECT: Policies on the nationwide
Implementation of the Expanded Program on Immunization
Fully immunized child (FIC) evolved through the 20 years of EPI
implementation. In the 1986 EPI guidelines, The fully immunized child must
have completed: one 1) dose of BCG , three (3) dose each DPT and OPV and one
(1) dose of anti-measles vaccine (AMV) before the infant reaches 12 months of
age. Hepatitis B vaccine (HBV) and Tetanus toxoid2+ (TT2+) was included

EPI was changed to NIP (National Immunization Program)

o The National Immunization Program (NIP) consists of the following
antigens:
BCG vaccine, single dose given at birth
Monovalent Hepatitis B vaccine given at birth
DPT-Hib-Hep B vaccine, 3 doses given at 6-10-14 weeks of age
Oral Polio vaccine (OPV), 3 doses given at 6-10-14 weeks of age, a
single dose of Inactivated Polio vaccine (IPV) is given with the 3rd
dose of OPV at 14 weeks
Pneumococcal conjugate vaccine (PCV), 3 doses given at 6-10-14
weeks of age
Rotavirus vaccine given at a minimum age of 6 weeks with a
minimum interval of 4 weeks between doses (The last dose should be
administered not later than 32 weeks of age).
Measles containing vaccine (either monovalent measles vaccine or
MMR) given at 9 months of age
Measles-Mumps-Rubella (MMR) vaccine given at 12 months of age
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2016 DOH revision on EPI

B. Program objectives and Performance

Since the launching of the EPI in 1976, the Department of Health has issued sets of guidelines
(1976, 1986, 1992, 2003) with its own targets.

1976 OBJECTIVES:
Guidelines 1. To decrease the mortality and morbidity rates of the 6
immunizable disease by increasing the proportion of fully
immunized children
2. To decrease the incidence of neonatal tetanus by immunization
of pregnant women with tetanus toxoid

1986 After determining in an evaluation conducted in 1985 that immunization

Guidelines rates were very low despite the 10-year implementation of the program,
the following targets were set. That by the following years, the %
coverage of the eligible population should be as follows:
1. 1986 30%
2. 1987 50%
3. 1988 70%
4. 1989 80%
5. 1990 90%

1992 With the attainment of 90% coverage of the eligible population in 1990,
Guidelines the following targets were set:
1. To maintain 90% FIC beyond 1992
2. To increase Hepatitis B vaccine coverage from 40% in 1992 to
90%% in 1997
3. To increase tetanus toxoid coverage from 70% in 1992 to 90%
in 1995
4. To eradicate polio and neonatal tetanus by 1995

2003 Program Objectives/Goals:

Guidelines Over-all Goal:
To reduce the morbidity and mortality among children against the most
common vaccine-preventable diseases.
Specific Goals:
1. To immunize all infants/children against the most common vaccine-
preventable diseases.
2. To sustain the polio-free status of the Philippines.
3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus
5. To control diphtheria, pertussis, hepatitis b and German measles.
6. To prevent extra pulmonary tuberculosis among children.
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2008 All health facilities (health centers and barangay health stations) have at
Guidelines least one (1) health staff trained on REB (Reaching Every Barangay
strategy)

C. Status of implementation/ Accomplishment (2008) 2

Polio Eradication:
The Philippines has sustained its polio-free status since October 2000. Declining Oral
Polio Vaccine (OPV) third dose coverage since 2008 from 91% to 83%. A least 95%
OPV3 coverage need to be achieved to produce the required herd immunity for
protection.
Acute Flaccid Paralysis (AFP) reporting rate has decreased from 1.44 in 2010 to 1.38 in
2011. Only regions III, V and VIII have achieved the AFP rate of 2/100,000 children
below 15 years old. (Source: NEC, DOH). A decreasing AFP rate means we may not be
able to find true cases of polio and may experience resurgence of polio cases.

Measles Elimination
Conducted 4 rounds of mass measles campaign: 1998, 2004, 2007 and 2011.
Implemented the 2-dose measles-containing vaccine (MCV) in 2009
MCV1 (monovalent measles) at 9-11 months old
MCV2 (MMR) at 12-15 months old.

A supplemental immunization campaign for measles and rubella (German measles) was
done in 2011. This was dubbed as Iligtas sa Tigdas ang Pina s 15.6 million (84%) out
of the 18.5 million children ages 9 months to 8 years old were given 1 dose of the
measles-rubella (MR) vaccine between April and June 2011.

Maternal and Neonatal Tetanus Elimination

Three (3) round s of TT vaccination are currently on-going in the 10 highest risk areas.
An estimated 1,010,751 women ages 15 - 40 years old women regardless of their TT
immunization will receive the vaccine during these rounds. This is funded by the Kiwanis
International through UNICEF and World Health Organization.

IV. Status of implementation/ Accomplishment (2012)

Introduction to New Vaccines

For 2012, Rotavirus and Pneumococcal vaccines was introduced in the national immunization
program.
Immunization among the infants of families listed in the National Housing and Targeting
System (NHTS) for Poverty Reduction nationwide is prioritized.
The Government of the Philippines has allocated PhP 1.6 billion for the procurement of these
2 vaccines.

The Government of the Philippines allocated budget for the immunization of all
infants/children/women/older persons nationwide. For 2012, the budget for EPI is
PhP1.8 billion and another P1.5 Billion for the immunization for senior citizen and
children for the NHTS families. This is great leap towards universal access to quality
vaccines for the prevention of the most common vaccine-preventable diseases

V. Control of other common vaccine-preventable diseases (Diphtheria, Pertussis, Hepatitis B and

Meningitis/Encephalitis secondary to H. influenzae type B)

Continuous vaccination for infants and children with the DPT or the combination DPT-HepB-
HiB Type B. Annex1 EPI Annual Accomplishment Report. DOH procures all the vaccines and
needles and syringes for the immunization activities targeted to infants/children/mothers.

Hepatitis B Control
Republic Act No. 10152 has been signed. It is otherwise known as the Mandatory
Infants and Children Health Immunization Act of 2011, which requires that all children
under five years old be given basic immunization against vaccine-preventable diseases.
Specifically, this bill provides for all infants to be given the birth dose of the Hepatitis-B
vaccine within 24 hours of birth.
One strategy to strengthen Hepatitis B coverage is to integrate birth dose in the Essential
Intrapartum and Newborn Care Package (EINC). In 2011, 11 tertiary hospitals are
already EINC compliant.
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The goal of Hepatitis B control is to reduce the chronic hepatitis B infection rate as
measured by HBsAg prevalence to less than 1% in five-year-olds born after routine
vaccination started 100% Hepatitis B at birth vaccination.

Hepatitis B Coverage. Philippines, 2001-2011

Timing of administration/dose 2009 2010* 2011*
<24 hours 34% 38% 14%

>24 hours 62% 55% 24%

Hep B 3rd dose 86% 81% 30%
*both 2010 and 2011 data are as of October 2011

VI. VACCINES OF THE EPI

Contraindication to Vaccination

1. NOT a contraindication:
Fever <38.5C
Treatment with antibiotics, local steroids low-dose systemic steroids
Mild respiratory infections
Diarrhea and vomiting
History of the same infectious disease, incubation of an infectious disease,
convalescence after an infectious disease
Malnutrition period
Several vaccines given on the same day (as long as administered preterm birth at
different sites)

2. RELATIVE contraindications:
Fever >39C
Hospitalization

3. ABSOLUTE contraindications:
Adverse drug reactions (anaphylaxis, seizure, etc.) to a previous dose
Immunocompromised (as in HIV/clinical AIDS)
Pertusis vaccine in a child >6 years old (no need for the vaccine because
children at this age group are not high risk of contracting the disease anymore)

VII. FAILURE TO IMMUNIZE

In case of missed succeeding doses (for DPT, HIB, OPV, HBV) there is no need to repeat
previous doses. The 2nd/3rd dose may still be given even after 1 year has passed since the
previous dose.

VIII. THE COLD CHAIN

The Cold Chain is a system to ensure the potency of a vaccine from the time of
manufacture to the time it is administered to an eligible child or woman. The system
involves equipment (refrigerators, vaccine carriers, etc.) and the people who do the
requisition, storage and distribute the vaccines. The recommended storage temperature
are as follows.

State/ Regional District Primary health Sub-center

Center
6 months 3 months 1 month Immunization
Day
OPV -15C to -25C
Measles (MV)
BCG
Hep B
DPT +2C to +8C
DT
TT
Diluent
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BCG vaccine are discarded 4 hours after opening,

DPT/OPV/MV/TT/HBV should be discarded after one day of opening.
Live attenuated vaccines (BCG, OPV, MV) have to be autoclaved, boiled or disinfected with
chloramines and hypochloride
DPT/HBV/TT vials can be emptied onto the sink.

IX. ISSUES/PROBLEMS IN THE EPI IMPLEMENTATION

A. Technical Problems
1. There have been reports of children contracting diseases against which they have already
been immunized. Among the EPI vaccines, BCG, pertusis and measles vaccine have been
reported to afford INCOMPLETE PROTECTION. Breaks in the cold chain and maternal
antibodies have been proposed as possible causes for the decreased efficacy of these
vaccines.
2. The right time to immunize a child against measles is also an issue.
The EPI recommends giving the vaccine at 9 mos. of age while other programs do so at 6
mos.
The rationale for earlier vaccination is that at 6 mos. of age the child has only 1/10 of the
maternal antibody concentrations it had at birth and is therefore already at risk of
contracting measles.
Measles vaccine should not be given before the effect of the maternal antibodies
disappeared because these antibodies act against the live vaccines, prevent their
multiplication and thereby reduce their ability to immunize a child
3. Adverse reactions may occur with immunization. However, the risk of serious complications
from the EPI vaccines is much lower than the risks of the natural disease.

B. Administrative problems
1. Errors in vaccine administration
Lapses in aseptic technique
Giving of right doses
Right route of administration
2. Breaks in the cold chain resulting to loss of vaccine potency
3. Errors in recording and monitoring such that vaccine coverage figures may not reflect the
true situation.
4. Shortage of materials (vaccines, syringes and needles) and human resources.

C. Socio-cultural and Ethical issues.

1. In the early 1990s, there were reports that administration of tetanus toxoid to pregnant women
may cause abortion. In consequence,
Immunization rates of tetanus toxoid dropped
The issue also affected immunization rates of the EPI vaccines (from a high >90%
coverage in the early 1990s to the present 85%)
DOH had to change the tetanus toxoid immunization schedule to allay the fears of the
public.
2. Studies on immunization knowledge and behavior reveal that there is a high awareness
regarding the benefits of vaccination but low submission in some target groups.
The reason given for the low submission include the fear of adverse effects and the lack
of access to health centers.
3. The issue of informed consent when administering vaccines.

Types of Vaccines

Live-attenuated vaccines BCG, OPV, Measles, mumps and rubella

Killed viral vaccines
Killed bacterial vaccines
Toxoids (modified bacterial
products/toxins)
Hepatitis B, influenza, rabies vaccine
Haemophlus influenza type B, pertussis, cholera,
typhoid, meningococcal or pneumococcal
polysaccharide vaccines
Diphtheria and tetanus toxoid
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THE NIP VACCINES

EPIDEMIOLOGCAL FEATURES OF THE EPI DISEASES

MEASLES
CLINICAL MANIFESTATIONS -Acute, highly communicable disease
-Fever, cough, colds, conjunctivitis and typical reddish spots on
the mucosa of the mouth (Kopliks spot)
-dusky red, blotchy rash appears on the 3rd and 7th day
beginning on the face and becoming generalized.
-lasting for 4-6 days, ending in bran-like desquamation
INFECTIOUS AGENT Measles virus, member of genus Morbillivirus of the family
Paramyxodiae
RESERVOIR Man, mostly children
MODE OF TRANSMISSION -Droplet spread or direct contact with nasal, throat, urine
secreation of infected person.
INCUBATION PERIOD Usually about 10 days with a range of 8-13 days from the
exposure to onset of fever
PERIOD OF COMMUNICABILITY From 1-3 days before the beginning of fever and cough
Decreases rapidly after onset of rash
SUSCEPTIBILITY/RESISTANCE -Highly communicable
-80% attack rate among household contacts
-Permanent immunity is usual after acquiring the disease
-immunization confers an immunity of 20 years
-Infants born to immune mothers are protected until 5-9 months
of age.
-Measles immunization given prior to 9 months of age and may
not confer immunity due to interference with maternal
antibodies.

PERTUSSIS
CLINICAL MANIFESTATIONS -Highly contagious of the respiratory tract
-Severe paroxyxms of coughing which end in a prolonged
inspiratory whoop often followed by vomiting.
INFECTIOUS AGENT Bordatella pertussis
-a Gram (-) coccobacillus
RESERVOIR Man
MODE OF TRANSMISSION -Primarily by direct contact with discharge from respiratory
mucusous membranes
-by airborne route probably by droplets
-or indirect contact with articles freshly soiled with the discharges
of infected person.
INCUBATION PERIOD 7days but ranges from 5-15 days
PERIOD OF COMMUNICABILITY -Highly communicable in early catarrhal stage, before aroxysmal
cough.
-Antibiotics may shorten the period of communicability from 7
days after exposure to 3 weeks after onset of typical paroxysm to
only 5-7 days after onset of therapy.
SUSCEPTIBILITY/RESISTANCE -Susceptibility is general
-One attack confers a prolonged immunity, although exposed
adults may have another attack.

TETANUS
CLINICAL MANIFESTATIONS -An acute disease by the exotoxin of the tetanus bacillus growing
anaerobically at the site of an injury.
- characterized by painful muscular spasms which frequently are
aggravated by any external stimulus
-Severe spasms persist for one week or more
INFECTIOUS AGENT Clostridium tetani, a bacillus
RESERVOIR -Soil and intestinal canals of animals, especially horses in which
the organism is harmless normal inhabitant
-Man
MODE OF TRANSMISSION -Transmission in new borns is due to unhygienic cutting of
umbilical cord or improper handling of cord stump especially
when treated with contaminated substances
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-In other age groups, transmission is through punctured wounds

created by contaminated material or the infection of wound
INCUBATION PERIOD -Usually 6 days but ranges from 3-21 days
PERIOD OF COMMUNICABILITY -Not directly transmitted from man to man
SUSCEPTIBILITY/RESISTANCE -Susceptibility is general
-Passive immunity lasts for five months to infants born to immune
mothers.
-Natural infection does not play a significant role in immunity
-Recovery from tetanus does not result in solid immunity, second
attacks may occur.

POLIOMYELITIS
CLINICAL MANIFESTATIONS -A highly communicable disease wherein only 1% of cases are
recognized clinically by muscle weakness and paralysis
-99% of cases have symptoms to the gastrointestinal or respiratory
tract or may exhibit evidence of meningeal irritation
INFECTIOUS AGENT -Polio virus 1,2,3 a picornavirus of the genus Enterovirus
-Type 1 is usually isolated from paralytic cases and most
frequently causes epidemics
-Most vaccine-associated cases are due to Types 2 and 3
RESERVOIR Man, most frequently persons with inapparent infections,
especially children
MODE OF TRANSMISSION -Oro-fecal route, very common in developing countries
-Oral route through pharyngeal secretions is common in areas
where sanitation is good.
-Polio virus are spread by intimate contact of infected persons or
rarely by contaminated milk and water
INCUBATION PERIOD Usually 7-12 days with a range of 3-21 days
PERIOD OF COMMUNICABILITY Patients reach maximal infectivity 7-16 days before and in the first
few days after onset of symptoms
SUSCEPTIBILITY/RESISTANCE -Susceptibility is general
-Infants born to immune mothers remain immune for about 5 mos.
-Immunity following natural infection is lifelong
-Immunity may be obtained also from exposure to persons who
have been immunized and are excreting vaccine virus

DIPTHERIA
CLINICAL MANIFESTATIONS -an acute contagious disease characterized by local inflammation
with fibrin formation (pseudo-membrane) of the mucous
membrane of the upper respiratory tract (tonsils, pharynx, larynx
or nose)
- a toxin is produced which, when absorbed into the bloodstream,
causes deleterious effects on various parts of the body especially
the heart and nerves
INFECTIOUS AGENT Corynebacterium diphtheria
RESERVOIR Man
MODE OF TRANSMISSION -respiratory droplets from discharge of nose and throat of a case or
carrier
INCUBATION PERIOD Usually 2-5 days or longer
PERIOD OF COMMUNICABILITY -May last for 2-3 weeks but maybe shortened in patients with
antibiotic treatment
-Diphtheria transmission is increased in schools, hospitals and in
crowded places
SUSCEPTIBILITY/RESISTANCE -Infants born to immune mothers may be protected up to 5 mos.
-Recovery from clinical attack is not always followed by lasting
immunity.
-Immunity may also be acquired through inapparent infection.

TUBERCULOSIS
CLINICAL MANIFESTATIONS -A chronic communicable disease that affects many organs of the
body but commonly affects the lungs
-Cough, fatigue, fever, weight loss, hoarseness, chest pain and
hemoptysis may occur but often are absent until advanced stages
INFECTIOUS AGENT Mycobacterium tuberculosis, an acid-fast bacilli
RESERVOIR Primarily in man; in some area, also in diseased cattle
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MODE OF TRANSMISSION
INCUBATION PERIOD
PERIOD OF COMMUNICABILITY
SUSCEPTIBILITY/RESISTANCE
-by droplet infection, that is through inhalation of bacilli fresh
from patients, or by dust inhalation of bacilli which have dried on
the surface of the ground or floor and become suspended in air.
-the latter is not very significant
-about 4-12 weeks fro infection to demonstrable primary lesion
- the subsequent risk of progressive pulmonary or extrapulmonary
tuberculosis is greatest within a year or two after infection
-it may also relapse from a latent infection anytime
-a person who excretes tubercle bacilli is communicable
-the dgree of communicability depends upon the number of
excreted bacilli in the air, virulence of the bacilli and
environmental conditions like overcrowding.
-Most children are not efficient transmitters since they do not
usually produce sputum
-Susceptibility to infection is general
-The risk of developing the disease is highest in children under 3
years of age.

HEPATITIS B
CLINICAL MANIFESTATIONS -Onset is usually insidious with anorexia, vague abdominal
discomfort, nausea, vomiting, sometimes arthralgias and rash,
often progressing to jaundice.
-Fever maybe absent or mild
-Severity ranges from inapparent cases detectable only by liver
function tests to fulminating fatal cases of acute hepatic necrosis
INFECTIOUS AGENT Hepatitis B virus (HBV), a hepadna virus
RESERVOIR Man; Chimpanzees are susceptible but an animal reservoir in
nature has not been recognized
MODE OF TRANSMISSION -Transmission occurs by percuteneous (IV, IM, subcutaneous or
intradermal) and permucosal exposure to infective body fluids, as
mau occur in needle stick accidents, perinatal and sexual
exposures
INCUBATION PERIOD -usually 45-180 days, average of 60-90 days
-as short as 2 weeks to the appearance of HBsAg, and rarely as
long as 6-9 months
-the variation in related in part to the amount of virus in the
inoculums
-the mode of transmission and host factors
PERIOD OF COMMUNICABILITY -blood from experimentally inoculated volunteers has been shown
to be infective many weeks before the onset of first symptoms and
to remain infective through the acute clinical source of the disease
and during the chronic carrier state, which may persist for life.
SUSCEPTIBILITY/RESISTANCE -Susceptibility is general
-usually the disease is milder and often anicteric in children
-in infants it is usually asymptomatic.
-Protective immunity follows infection if antibody to HBsAg
(Anti-HBs) develops and HBsAg is negative.

REFERENCES
1. Administrative Order no. 39 s. 2003. Policies on the Nationwide Implementation of the Expanded
Program on Immunization. Department of Health 2003
2. Expanded Programme on Immunization. Department of Health, 1986
3. Final Results from the 2002 Maternal and Child Health Survey (National Statistics Office). 2003-06-02. .
Retrieved 2007-05-11.
4. "Six Out of Ten Children 12 to 23 Months Are Fully Immunized" (http:/ / www. census. gov. ph/ data/
pressrelease/ 2003/ pr0351tx. html).
5. Lankien, Kari., et. Al. Health and Disease in Developing Countries. McMillan Press Ltd, London, 1994
6. World Health Organization. Immunization Coverage. Updated February 2014
7. http://www.pidsphil.org/pdf/2016/16LEC-10-PIDSP-Immunization-Schedule-2016-Aguirre.pdf