College of Nursing Silliman University Dumaguete City

Resource Unit on: Expanded Program on Immunization

Submitted by: Dave Daniel I. Dales Submitted to: Ms. Grace A. Gloria

Time allotment: 1 hour 30 mins Placement: Community Health Nursing Dawin, Negros Oriental Topic Description: This discussion deals with principles, guidelines, and information regarding immunization. It emphasizes on the program of the DOH: Expanded Program on Immunization and also includes the strategies used by the DOH, a brief discussion on the disease targets, and some special considerations to keep in mind. General Objective: By the end of one hour discussion, the learners will acquire skills, knowledge, values and positive attitudes in one of the DOH programs: Expanded Program on Immunization, in order to deliver effectively their care for the community and to promote the prevention of disease for the betterment of society. OBJECTIVES TOPIC T/A 3 mins TEACHING STRATEGY SOURCES EVALUATION

At the end of one hour I. Introduction discussion, the learners With the collaboration of the DOH, WHO, and UNICEF, the EPI was launched in shall: the aims of controlling the occurrence of preventable diseases especially in children. This in turn will lower the morbidity and mortality rate due to the disease conditions. This was mandated under the Presidential Decree No. 996 dated on September 1976 to provide free basic immunization to eligible population. This program covers immunization for BCG, DPT, OPV, Hep B, and measles. To make the distribution faster, the DOH is assisted by LGUs which in turn is being helped by us student nurses. 1. Be familiar II. Strategies used by the DOH with the A. Sustaining high routine FIC coverage of at least 90% in all provinces strategies used and cities by the DOH for EPI or the Expanded Program on Immunization was started in 1986 with the the EPI commitment of the Philippines to the Universal Child Immunization. To facilitate this strategy, an EPI manual of Operations with guidelines was made to facilitate the success of the program. 2. Have basic It is also important to note that Hepatitis B was integrated into the EPI in 1992 understanding among infants 0-1 year of age.

12 mins

Socialized discussion

Cuevas, F.L. et. al. Ed. (2007). Public Health Nursing in the Philippines. (10th ed). National League of Philippine Government

regarding different disease conditions covered by EPI and effects on body

B. Sustaining the polio free country for global certification In 2000 our country was certified polio free in Kyoto Japan, although this is difficult to maintain since we keep on importing from countries with polio endemics. the It was also in the year 2000 that the use of circulating vaccine derived its poliovirus (cVDPV) was noted in Cagayan de Oro, Laguna and Cavite. In the response, a Balik Polio Patak was conducted which immunized children less than 5 years of age regardless of immunization status. C. Eliminating measles by 2008 This was especially troublesome goal. Mass measles vaccination among children ages 9 months to less than 15 years of age were given nationwide regardless of immunization status. This was called Measles Catch Up Campaign which resulted to drastic reduction of measles cases by 70%. In 2004, the campaign had achieved 94% of herd immunity in all parts of the country. D. Eliminating neonatal tetanus by 2008 A Maternal and Neonatal Tetanus Elimination Plan has been developed for appropriate sourcing of funds and implementation for NT elimination. The focus was to deliver TT vaccines to areas with poor delivery care for babies but also to continue the vaccinations to areas with good delivery care to babies (Cuevas, 2007). EPI target diseases A. Tuberculosis Etiologic Agent: Mycobacterium tuberculosis, M. Africanum, M. bovis Defining Characteristics: Tuberculosis is a respiratory disease common among malnourished individuals living in crowded places. It is usually characterized by a cough lasting for more than a week with presence of fresh blood in the sputum and is confirmed with microscopic a sputum test to identify the tubercle bacilli. Mode of Transmission: The disease, according to Reyala (2000), is transmissible through either airborne droplet, direct invasion through mucous membranes or breaks in the skin although rare, or ingestion of unpasteurized milk from and infected cattle. III. 20 mins Socialized discussion with visual aids

the

Nurses, Inc; Philippines.

Reyala, J. P. et al. (2000). Community Health Nursing Service in the Philippines. (9th ed). National League of Philippine Government Nurses, Inc.; Philippines

Susceptibility and Resistance: The risk is highest in children bellow 3 years of age when the resistance is low, during adolescent years when exposure to the virus is higher, younger adults when resistance is lowered by many means, or by the very old when the resistance is again lowered (Reyala, 2000) B. Diphtheria Etiologic Agent: Corynebacterium dyptheria/ Klebs-Loeffer Bacilus Defining Characteristics: Usually characterized by an acute febrile infection of the tonsils, throat, nose, larynx or wound marked by patch or patches of grayish membrane from which the dyptheria bacillus is readily cultured. Mode of Transmission: The disease is transmitted through contact with a carrier or with articles soiled with contaminated discharges of infected person. Susceptibility and Resistance: According to Cuevas (2007), infants born of mothers who had diphtheria infection are relatively immune to the disease but the immunity disappears before 6 months of age from which the immunization should be administered. C. Pertussis Etiologic Agent: Bordetella pertussis Defining Characteristics: Pertussis shows signs and symptoms of a severe cough with any of the following: cough persisting for more than 2 or more weeks; fits of coughing and vomiting after coughing. Most people mistake the disease for a cold. But if one lets pertussis untreated, one could suffer serious consequences, including middle ear infections, pneumonia, convulsions (seizures), disorders of the brain, and brief episodes of stopped breathing and even death. Mode of Transmission: Transmission is the same as tuberculosis where in the disease can be contracted via droplet or by direct contact with discharges from an infected person. Susceptibility and Resistance: The people who are most at risk of pertussis are young aged children in

Mosby s Pocket Dictionary of Medicine, Nursing & Allied Health (4th ed). (2002). Elsevier Science; St. Louis

crowded areas as in slums (Reyala, 2000) D. Tetanus Etiologic Agent: Clostridium tetani Defining Characteristics: Tetanus is an acute disease induced by toxins of the tetanus bacilli growing nanaerobically in wounds and at site of umbilicus among infants. The toxin, tetanospasmin, is a toxin to the nervous system. The disease is characterizedirritability, headace, fever, and painful spasms of the muscles resulting in lockjaw, risus sardonicus, opisthotonus, and laryngeal spasms. Mode of Transmission: In Neonates, tetanus is contracted by contamination of unhealed umbilical stump with the bacilli, otherwise the bacterium is contracted via deep wounds. Susceptibility and Resistance: All persons exposed to the virus with the ideal condition of anaerobic area inside the wound where the Clostridium tetani can replicate without immunization is susceptible E. Poliomyelitis Etiologic Agent: Poliovirus of the Picornaviridae family Defining Characteristics: In the dictionary, polio is usually asymptomatic, but mild and paralytic forms of the disease also occurs. Asymptomatic infection has no clinical features, but it confers immunity. Abortive poliomyelitis is characterized by minor illness with fever, malaise, headache, nausea, vomiting, slight abdominal discomfort. Nonparalytic poliomyelitis is longer lasting and is marked by meningeal irritation with pain and stiffness in the back and by all signs of abortive poliomyelitis. Mode of Transmission: Usually fecal oral rout Susceptibility and Resistance: Occurrence is cyclical all around the world but mostly in developing countries. F. Measles Etiologic Agent: Number of viruses can cause measles

Defining Characteristics: This is an acute highly communicable infection characterized by fever, rashes, and upper respiratory tract infection Death is due to complication of the upper respiratory tract infection in children under 2 years of age and is almost always fatal in malnourished children.

Mode of Transmission: The measles virus is highly communicable and can be transmitted through droplet, direct contact, or indirect contact with articles contaminated with the etiologic agent. Susceptibility and Resistance: Everyone that has not have an immunization or has not had experienced being infected by the virus early in life. It is also important to note that being infected with the rubella virus does not imply being able to develop resistance to the rubeola virus an other virus that may cause measles like symptoms (Reyala, 2000). G. Hepatitis According to Reyala (2000) hepatitis is a disease of the liver which can be caused by many pathogens or toxic substances, even drugs. In viral hepatitis it can be caused by any of the strains of hepatitis namely: hepatitis A, B, non A and non B, C and D, E, or F. Ff these, only Hepatitis B can be a sexually transmitted disease with severe complications such as hepatonecrosis and hepatocarcinoma. Defining Characteristics: Common signs and symptoms of hepatitis are loss of appetite, easy fatigability, malaise, joint and muscle pains, low grade fever, nausea and vomiting, rightsided abdominal pain, jaundice, and dark-colored urine. Mode of Transmission: Hepatitis viruses are blood borne but can also be transferred through most bodily secretions.

Susceptibility and Resistance:

The most at risk with this disease condition are newborns with infected mothers, health workers, children in localities were the occurrence of Hep B is high, sexually promiscuous individuals generally those exposed to carriers (Reyala, 2000). 3. Show appreciation for the different types of vaccines and identify the different schedules and routes of each IV. Vaccine profile A. Immunization schedules according to Cuevas (2007). 1. Standard immunization 15 mins Socialized discussion with Cuevas, F.L. et. al. Ed. visual aids with (2007). Public Health review questions Nursing in the Philippines. (10th ed). VACCINE MINIMUM AGE # OF DOSES INTERVAL ROUTE SITE DOSE National League of ID Right deltoid 0.05ml Philippine Government Nurses, Inc; Philippines.

BCG

Birth or 1 any time after 6 weeks 3 4 weeks

DPT

IM

Upper outer portion of thigh Mouth

0.5ml

OPV

6 weeks

4 weeks

Oral

2 drops 0.5ml

Hep B

Birth

6 weeks IM from first dose, 8 weeks from second dose

Outer portion of upper arm

Measles

9 months

IM

Deltoid of 0.5ml upper arm

2. TT for Women on the reproductive age VACCINE INTERVAL PERCENT DURATION PROTECTION as INFANT

TT1

As early possible during pregnancy

TT2

At least 4 80% weeks later At least 6 95% months later At least 1 year 99% later At least 1 year 99% later

3 years

Protected from NT Protected form NT Protected form NT Protected form NT

TT3

5 years

TT4

10 years

TT5

For life

B. Special considerations Some vaccines are heat sensitive and should be handled with care when handled and transported. Among the most sensitive to heat are OPV and Measles vaccine which should be stored under freezing, other vaccines can be stored in the refrigerator at +2oC to +8oC. Vaccine storage is done with the use of a cold chain equipment. These are: cold room, freezer, refrigerator, transport box, or vaccine carrier. These are important in the storage and proper management of vaccines (Cuevas, 2007). V. Role of Nurses 4. Be familiar to A. Vaccine administration the procedure of delivering and giving BCG: vaccines to the Reconstituting Freeze dried BCG 1. Always keep the diluents cold by sustaining the BCG ampoules inside community the refrigerator. 2. Withdraw 2ml of diluents and inject it to the freeze dried BCG 3. Thoroughly mix the diluent and the BCG 4. BCG vaccine is given IM. Hep B and DPT 1. Ask assistance in injecting the child by holding the child accrosh the knees to let the upper portion of the thighs face you 2. Clean the skin with alcohol. 3. Slightly grasp the injection site, insert the needle quickly, aspirate and inject. Provide pressure on the injected site OPV 1. Read the manufacturer s instructions on how many drop is to be given and use the dropper provided for. 2. Lie the child on his back firmly 3. Open the child s mouth and let the vaccine drop into the child s tongue 4. Make sure the child swallows the vaccine.

15 mins

Socialized discussion

World Health Organization (1989). Immunization in Practice: A Guide for Health Workers who Give Vaccines. Mcmillan Education LTD; London.

Measles 1. Aspirate 5 ml of diluents emptying the container. 2. Thoroughly mix the diluent and vaccine. 3. Give it IM B. Health Education on concepts based on Cuevas (2007) y It is safe and immunologically effective to administer all EPI vaccines on the same day at different sites of the body. y Measles vaccine should be given as soon as the child is 9 months old, regardless of whether other vaccines will be given on the same day. Measles vaccine given at 9 months provide 85 % protection against measles infection. When given one year older, provides 95% protection. y The vaccination schedule should not be restarted from the beginning even if the interval between doses exceeded the recommended interval by months or years. Continue with the immunization. y Moderate fever, malnutrition, mild respiratory infection, cough, diarrhea, and vomiting are not contraindications to vaccination. Generally, only illnesses strong enough to put the child in the hospital are the contraindications. y The absolute contraindications to immunizations are: o DPT 2 or DPT 3 to a child who has had convulsion or shock within 3 days the previous dose. Vaccines containing he whole cell pertussis component should not be given to children with an evolving neurological disease (uncontrolled epilepsy or prolonged encephalopathy). o Live vaccines like BCG must not be given to individuals who are immunosuppressed due to malignant disease (AIDS), or therapy with immunosuppresive agents. y It is safe and effective with mild side effects after vaccination. Local reaction, fever and systemic symptoms can result as part of the normal immune response y Giving vaccines at less than the recommended interval may lessen the antibody response. Lengthening the interval between doses of vaccines lead to higher antibody levels.

Oral questions regarding the covered topic with a 75% efficiency rating

y y y

No extra doses must be given to children/ mother who missed a dose of DPT/HepB/OPV/TT. Vaccination must be continued as if no time had elapsed between doses. Strictly follow the principles of never, ever reconstitute the freeze dried vaccines in anything other than the diluents supplied with them Repeat BCG vaccination if the child does not develop a scar after the first injection Use one needle, one syringe, one vaccine per child C. Improving the delivery of immunization services in the community

According to the WHO (1989), outreach programs are necessary in delivering vaccines in the community. We as professionals are already aware of the importance of immunization during an early age and its advantages but most of the community members have no idea of it. The aim is to let the community participate in the activity of immunization with prominent community leaders and respected elders being able to guide the people. With the elders and leaders have knowledge regarding immunization, it would be easier for the rest of the community to follow the lead of their leaders. 5. Update oneself on the special considerations in the use of vaccines VI. Readings Childhood Vaccines: How safe are They? 5 mins Mera, K. E. and Hckley B. Childhood Vaccines: How Safe are They? . American Journal of Nursing. February 2003; volume 103 no. 2