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University of Gondar

2002

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MODULE \ Expanded Program in Immunization For the Ethiopian Health Center Team Mesfin Addisie, Ato Amsalu Feleke, Ato Melkie Edris, Ato Daniel Mengi...

MODULE \ Expanded Program in Immunization For the Ethiopian Health Center Team Mesfin Addisie, Ato Amsalu Feleke, Ato Melkie Edris, Ato Daniel Mengistu, Ato Abebaw Eredie, Ato Kassa Woreta, Ato Ebba Abate, Ato Endris Mekonnen, Ato Tesfaye Tilaye, Ato Mamo Wubshet, Ato Gashaw Andargie, Yigzaw Kebede, Ato Mesfin Nigussie, Ato Takele Tadesse, and Ato Baye Gelaw Gondar University College In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education 2002 Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. ©2002 by Mesfin Addisie, Ato Amsalu Feleke, Ato Melkie Edris, Ato Daniel Mengistu, Ato Abebaw Eredie, Ato Kassa Woreta, Ato Ebba Abate, Ato Endris Mekonnen, Ato Tesfaye Tilaye, Ato Mamo Wubshet, Ato Gashaw Andargie, Yigzaw Kebede, Ato Mesfin Nigussie, Ato Takele Tadesse, Ato Baye Gelaw All rights reserved. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. TABLE OF CONTENTS TOPIC PAGE Table of Contents........................................................................................... i Preface............................................................................................ ii Acknowledgement......................................................................................... iii UNIT ONE Introduction 1.1. Purposes and uses of the module............................................. 1 1.2. Directions for using the module................................................ 2 UNIT TWO Core Module 2.1. Pre-test..................................................................................... 3 2.2. Learning Objectives.................................................................. 7 2.3. Learning Activity One: Case Study.......................................... 8 2.4. Definition and Epidemiology of EPI Target Diseases............... 10 2.5. Characteristics and Management of EPI Target Diseases....... 14 2.5.1. Pertussis (Whooping Cough).......................................... 14 2.5.2. Tetanus........................................................................... 16 2.5.3. Poliomyelitis.................................................................... 18 2.5.4. Diphtheria....................................................................... 19 2.5.5. Measles.......................................................................... 20 2.5.6. Tuberculosis................................................................... 21 2.6. Prevention Control EPI Target Diseases.................................. 23 2.7. Immunization........................................................................... 23 Types of Vaccines.................................................................... 23 Side Effects............................................................................... 23 Contraindications...................................................................... 24 Immunization Schedule............................................................ 25 2.8. The Cold Chain......................................................................... 26 2.9. EPI Delivery Strategies............................................................. 27 2.10. Indicators.................................................................................. 28 2.11. Immunization Problems............................................................ 28 2.12. Assessment and Evaluation of EPI Services............................ 30 UNIT THREE Satellite Module 3.1. Health Officer............................................................................ 34 3.2. Public Health Nurse.................................................................. 47 3.3. Environmental Health Technician............................................. 58 3.4. Medical Laboratory Technician................................................ 66 3.5. Community/Front lines Health Workers................................... 76 3.6. Take-home Messages for care givers...................................... 78 UNIT FOUR Glossary............................................................................. 80 UNIT FIVE Abbreviations.................................................................... 84 UNIT SIX References......................................................................... 85 UNIT SEVEN Annex Annex I Vaccination Reporting form.................................. 86 Annex II Key for pretest, posttest and learning Activities... 87 Annex III The Authors....................................................... 91 i PREFACE The need of teaching materials in addition to the usual text and reference books is increasing as our demands are increasing. Hence, many modules to fill the gap are prepared and being prepared in collaboration with The Carter Center. Gondar University College of Medical Science has so far produced two modules on Pneumonia in Under Five Children and Malaria Uncomplicated and this is the third on Expanded Program on Immunization (EPI). EPI is one of the main integrated health services in the country. Expanding this program will decrease the morbidity and mortality due to vaccine preventable diseases. Basically, this module is prepared for the health center team, but other professionals at the service areas can also use it. It should be clear that this module is not a substitute for text books, but rather can help students to understand the program in a simplified way and push students to make the teaching student-centered and team approach. ii ACKNOWLEDGMENTS This module is the contribution of many scholars at Gondar University College. Hence, we would like to thank all those who contributed directly or indirectly for the development of this module. We would like to extend our deep appreciation to Gondar University College and The Carter Center for funding and arranging everything for the completion of the module. We would like also to extend our heart-felt gratitude for those National and International experts who had spent their precious time on reviewing the whole document, to mention some, Professor Dennis Carlson, Professor Nicholas Cunningham, Dr. Jacobs Troy, and Dr. Endale Tefera of Addis Ababa University. Alemaya University, Faculty of Health Sciences deserves special thanks for reviewing and giving feed-back on time. Teda Health Management Training Center staff and the management have to get special thanks for allowing us to use the facilities freely during the process of developing the module. Special thanks has to go to Ms. Carla Gale, Resident Technical Advisor, and Ato Aklilu Mulugeta, Business Manager, for The Carter Center, A.A. for the support and encouragement to complete the module. Without their support this material could have not been completed. Finally, the Community Health, Health Officer, Environmental Health, Nursing and Medical Laboratory Technology Departments are highly appreciated to finalize this valuable teaching material through team work. iii UNIT ONE INTRODUCTION 1.1 Purposes and uses of the module The expanded Program on Immunization (EPI) was launched in 1974 by the World Health Organization (WHO). In 1977 EPI set the following three long-term objectives: ♦ To reduce morbidity and mortality from six major childhood diseases, i.e. measles, tuberculosis, tetanus, pertussis, poliomyelitis and diphtheria by immunizing all children throughout the world by 1990, ♦ To promote national self-reliance in delivering immunization services within the comprehensive health service, and ♦ To promote regional self-reliance in vaccine production and quality control. The Ethiopian health policy had given emphasis to the prevention and control of major communicable diseases. Thus, in Ethiopia EPI was initiated in 1980. The objective of the National Immunization Policy was to reduce mortality and morbidity in children from the EPI target diseases through the immunization of all children under the age of one. The program had been planned to make immunization services available to 10% of the population in 1980 and to increase immunization access by 10% each year. Despite various initiatives and campaigns over the years, immunization coverage (DPT3)1 in most parts of Ethiopia remains low (41.91%), and this contributes to high morbidity and mortality among children. Some of the factors accounting for under immunization service are: ƒ lack of transportation ƒ ineffective cold chain ƒ shortages of trained health personnel 1 ƒ poor inter-sectoral collaboration ƒ inadequate community involvement and participation. The main purposes of this module are: a. To bring a significant change in EPI coverage, together with other strategies, proper training of health professionals is mandatory. This module will contribute a lot in training of the Health Center Team and other health professionals in the health service areas. b. To help students/users to learn through self-help, and c. To assist the shortage of texts and referenced books on the subject. 1.2. Directions for using the module Attempt to answer all the pre-test questions and write your answers. Continue with the part of the core module. Do learning activity one in the core module - Case Study. Go through the rest of the core module. Each category of students should read their respective Satellite Module. Study and discuss the specific learning objectives, activities, roles and tasks of each category of students, and CHWs/Front-line health workers as well as caregivers. Answer all post-test questions. Compare your answers of the pre-test and post-test by checking against the key given. 1 DPT3 = EPI coverage is measured using the third dose of DPT as indicator. 2 UNIT TWO CORE MODULE 2.1. Pre-test Before going into the core module, all categories of the Health Center Team should attempt to answer the following the questions. Instruction: Choose the best answer and write on a separate paper. 1. Crippling is due to a) Measles b) Pertussis c) Tetanus d) Poliomyelitis 2. Which of the following is a chronic mycobacterium disease? a) Whooping cough b) Tuberculosis c) Pertusis d) Diphtheria 3. In terms of etiological agent, which one of the following is different? a) Whooping cough b) Poliomyelitis c) Tetanus d) Tuberculosis 4. Which one of the following EPI target diseases is highly contagious? a) Tuberculosis b) Poliomyelitis c) Measles d) Neonatal tetanus 3 5. Which one of the following is not an EPI target disease in Ethiopia? a) Hepatitis b) Tuberculosis c) Measles d) Whooping cough 6. What percentage of the poliovirus infections leads to symptomatic poliomyelitis? a) 25% b) 1% c) 50% d) 75% 7. Which one of the following EPI target diseases is targeted for eradication? a) Neonatal tetanus b) Pertussis c) Poliomyelitis d) Tuberculosis 8. Which of the following is not a predisposing factor for acquiring neonatal tetanus? a) Non-immunized mother b) Unclean cutting of the umbilical cord c) Application of mud/cow dung on the umbilical stump d) Coughing 9. The clinical features of neonatal tetanus include a) Board like abdomen b) Hunger and crying c) Stiffness to touch d) All of the above 4 10. The etiology of diphtheria is a) Clostridium tetani b) Bordetella pertussis c) Polio virus type III d) None of the above 11. Which of the following prevention and control methods work for all EPI diseases? a) Health education about the importance of immunization b) Early diagnosis and treatment c) Mass mobilization d) All of the above 12. Oral Polio vaccine is a) Attenuated microorganism b) Killed microorganism c) Harmless form of toxin or poison d) All of the above 13. The first DPT vaccine should be given at a) Birth b) 6 weeks of age c) 10 weeks of age d) 9 months of age 14. The cold chain includes a) The equipment that ensure vaccine potency b) The people that handle the vaccine c) Keeping the vaccine cold all the way d) All of the above 5 15. Polio and DPT vaccine should be stored at health centre and out reach sites respectively a) Up to 6 months and a week b) Up to a month and a week c) Up to a week and a month d) Up to 9 months and a year. 16. The best acceptable proof of immunization includes a) BCG scar on the right shoulder b) Immunization card c) Mothers oral confirmation d) A and B 17. In cases of pertussis infection, the stage which is defined by the gradual decreasing in intensity of the cough is a) Catarrhal b) Paroxysm c) Convalescent d) All of the above 18. Which one of the following is part of strategies to deliver EPI services? a) Outreach b) Mobile c) Static d) All of the above 6 2.2. Learning Objectives Upon the completion of this module, the user will be able to: - explain EPI - mention EPI-target diseases - describe the epidemiology of EPI target diseases - State the etiology and pathogenesis of EPI target diseases - describe the clinical features of EPI target diseases - explain how to diagnoses EPI target diseases - manage cases of EPI target diseases - mention the preventive and control measures of EPI target diseases - manage the cold chain - describe schedules and strategies of EPI - identify the tasks and roles of the health center team members regarding EPI and the EPI target diseases - identify the contribution that could be made by the care-givers and community health workers in the prevention and control of EPI target diseases. 7 2.3. Learning Activity One: CASE STUDY Part I Woizero Kenubish Alemu, who delivered a week ago, came to Kossoyie health post with her male newborn. The mother complained that her baby is unusually crying, has difficulty of sucking and swallowing. She gave further history that the delivery took place at home and was attended by local traditional birth attendant. The assistant had used a blade to cut the cord and applied cow-dung. The mother responded that she had no history of any immunization and follow up of antenatal clinic. Questions 1. What do you think the cause of illness of this child? 2. Why do you ask about immunization and antenatal care? 3. What do you advise to the local traditional birth attendant? Part II The Front-line community health worker (CHW) examined the newborn. On physical examination, he found out that the newborn was restless, difficulty of opening the mouth, and unhealed umbilical stump Questions 1. What is your impression now as to the cause of this child’s illness? 2. What measures should be taken by the community health worker to save the baby? Part III The CHW advised the mother to take her sick newborn to the nearest health center where you work. Questions 1. What would you do for this baby? 8 Part IV After proper management in the health institutions the baby recovered from his illness. W/ro. Kenubish thanked the health worker and returned home after two weeks. The newborn was in a good condition and the family was very happy. Unfortunately, after a month, the child became sick again and developed fever, sneezing, running nose, and mild cough. Gradually the cough became worse and was continuous. Because of this problem, the mother took the newborn to a local “Awaki” (local healer). Then the local healer looked at the child and gave chopped materials. He advised the mother to dissolve in water and give the child to drink. The mother gave the dissolved “medication” but there was no improvement and finally she took him back to the health center. Questions 1. What is/are your probable impression/s of the infant’s illness? 2. What will be the management of this case? 3. What do you advise to the mother? 9 2.4. Definition and Epidemiology of EPI Target Diseases Table 1. Definition of EPI Target Diseases Ser. Target Disease Definition No. 1 Pertussis / Whooping An acute bacterial disease of the respiratory tract characterized by cough intense cough in paroxysms and sometimes with forceful inspiratory gasp and absence of fever, tachypnea, soar throat, hoarseness, etc. 2 Tetanus A neurological disease characterized by generalized increased rigidity and convulsive spasms of skeletal muscles from the bacterial toxin. 3 Poliomyelitis / Polio An acute viral disease with severity ranging from in apparent infection to paralytic disease. It is a crippling disease that can occur in adults but it is mainly commoner in children. 4 Diphtheria An acute bacteria disease of tonsils, pharynx, larynx, and nose. It occasionally affects the conjunctiva, genitalia and can damage the heart. 5 Measles It is a highly contagious acute viral disease characterized by fever, runny nose, cough, irritability, conjunctivitis, lacrimation, enanthema (Koplik’s spots) on the buccal and labial mucosa, and maculopapular rash appearing in a shower distribution over a period of 3 days. 6 Tuberculosis (TB) It is a chronic mycobacterial disease with a wide variety of clinical forms, pulmonary tuberculosis being the predominant form. 10 Table 2. Epidemiology of EPI Target diseases Disease Transmission Predisposing factors Magnitude and distribution Pertussis - Spreads from - Not being immunized - 60,000,000 cases of pertussis occur per year world person to person - Overcrowding wide, with more than half a million deaths by droplets, i.e. - Poor ventilation through coughing - Malnutrition or sneezing etc. Tetanus - Neonatal tetanus - Cutting umbilical cord with non - Tetanus occurs worldwide and is endemic in 90 mainly occurs as a sterile instrument. developing countries, but its incidence varies result of umbilical - Lack of adequate tetanus toxoid considerably. cord contamination (TT) immunization of mothers. - Neonatal tetanus is the most common form, which at birth. - Applying cow dung, mud and other kills approximately 800,000 infants each year. - A person may contaminated materials on the - In developing countries, neonatal tetanus represents become infected if umbilical stump. about half of all neonatal deaths and about 25% of contaminated soil - Home deliveries attended by infant mortality. or dung enters a untrained traditional birth - In Ethiopia neonatal tetanus accounts for two thirds of wound or cut. attendants. all tetanus deaths. - Harmful traditional health practices like uvulectomy, tonsillectomy. - Feco-oral (main) - Not being immunized ƒ It occurs in many regions of the developing world. Poliomyelitis - Airborne droplets - Poor sanitation and hygienic Globally in 2001 were: (rare). practices - 80% decrease in number of polio cases (from 2979 to - Overcrowding 480) - Poverty - 50% decrease in endemic countries (from 20 to 10) - 51 countries in Europe have been polio-free for 3 years. - No wild poliovirus type 2 isolated for the last 2 years. 11 Table 2. continued … Disease Transmission Predisposing factors Magnitude and distribution - By droplets and - Over crowding - It tends to be a disease of the colder months and of temperate secretions from the nose, - Poor living conditions climatic zones. Diphtheria throat and eyes. - Not being immunized - Affects people of all ages but mostly non-immunized children - Contact with skin ulcers - Malnutrition under 15 years old. - Clothing and other - Although incidence has decreased worldwide, it remains articles that have been endemic in many developing countries. contaminated with fluid from skin ulcers - By droplet spread or - Not being immunized - In countries with low immunization coverage, measles is Measles direct contact with - Overcrowding common in children noise/throat secretions of - Malnutrition - In countries with effective childhood immunization programme infected persons. such as Europe and U.S.A. measles is limited to older age - Also spread by indirect groups. contact with articles - In Ethiopia measles is among the most common cause of soiled by secretions morbidity and mortality in children. - Major outbreaks with large attack rates resulting in as high as 15-20oC case fatality rates have been reported in Ethiopia - It is highly contagious disease affecting nearly 90% of susceptible household contacts. - Epidemics occur every 2 – 3 years in population with large susceptible group. 12 Table 2. continued … Disease Transmission Predisposing factors Magnitude and distribution - Respiratory route: - Poor nutritional status - About one third of the world’s population is infected with Tuberculosis Airborne droplet nuclei - Not being immunized tuberculosis. from sputum of person - Infection with HIV/AIDS - Every year 3 million people die from tuberculosis, mostly in with infectious - Habit of drinking non- developing countries where it kills one in five adults. tuberculosis. boiled/non-pasteurized - Nearly 75% of pulmonary tuberculosis cases in developing - Alimentary route: milk countries belong to the economically active group of the Ingestion of infected - Overcrowding population. raw or non- - Contact with pulmonary - In Ethiopia in 1993 E.C. was the 3rd leading causes of out pasteurized milk. tuberculosis cases patient morbidity and the first cause in hospital death? 13 2.5. Characteristics and Management of EPI Target Diseases 2.5.1. Pertussis (Whooping Cough) Etiologic agent - A gram-negative bacterium called Bordetella pertussis. Pathogenesis - The organism produces exotoxin and affects the pharynx, larynx, trachea, bronchi, bronchioles and sometimes the alveoli. Clinical features - Incubation period is 7 – 17 days. The symptoms of classical pertussis last about 6 weeks and are divided into 3 stages. A. Catarrhal stage - The onset is insidious, - Sneezing - Running nose - Anorexia - Malaise lasts 1- 2 weeks - Night cough B. Paroxysmal stage - Lasts 2-4 weeks following the infection. - Characterized by rapid consecutive (5-15) cough before a breath is taken and followed by deep hurried inspiration (whoop). - Post cough vomiting is common at all ages, - Factors stimulating cough include fright, anger, crying, sneezing, inhalation of irritant, and over distention of the stomach. C. Convalescent stage - It begins after 4 weeks of the illness, and is manifested by a decrease in the frequency and severity of the paroxysms of coughing. Diagnosis A. Clinical - The child is well appearing and playful between patoxysms of cough. - Presence of children with similar illness in the family or vicinity. - There is no chest finding on physical examination. - The diagnosis is usually made on the distinctive clinical feature of the cough. To observe the classical type of cough put tongue depressor to stimulate the coughting. N.B. Not all children with pertussis whoop. Whooping is uncommon in infants < 3 months. 14 B. Laboratory - WBC 15000 - 20000/mm3 (rarely to 50,000/mm3) - 60 - 80% Lymphocytes - Microscopy; Gram stain - Culture to isolate the organism Differential Diagnosis - Aspiration of foreign bodies - Viral pneumonia - Influenza - Acute bronchitis and broncholitis. Management A. Specific measures - Antimicrobial - Erthromycine - Ampicillin - Sedatives - Promethazine Hydrochloride - Phenobarbitone (when there is seizure) - Steroid - Predinsolone B. General measures - Frequent small feeding and continue feeding if vomiting occurs soon after meal. - Oxygen if needed - Severe cases especially infants are best managed in hospital. - Prophylactic Erythromycin for all house hold members and other contacts regardless of age, history of immunization of symptoms. Complications - Apnea - Conjunctival hemorrhage - Otitis media - Pneumonia - Atelectasis - Encepalopath 15 2.5.2. Tetanus Etiologic agent A gram positive anaerobic bacterium called Clostridium tetani (Cl.tetani). Pathogenesis Tetanus toxin, after germination of the Cl.tetani spores in a contaminated umbilical stump or wound in other parts of the body, is released to the peripheral nerves and circulation. This causes sustained excitatory neuronal discharge and muscle contraction. Clinical features Tetanus occurs in several clinical forms. One of the most important manifestations is neonatal tetanus (NNT). Its incubation period is from 1-14 days (in 90% of the cases) but it can last up to 54 days. The period of onset (the time between the first symptom and start of the spasm) ranges from hours to day. The clinical feature has two forms: A. Local tetanus - pain around the umbilicus - dirt, dung and clotted blood are usually present B. Generalized tetanus - It is the most common form of the disease and presents with early symptoms. - Progressive difficulty in feeding (sucking and swallowing) - Hunger and crying. This is followed by paralysis or diminished movement - Lock jaw (clenched) - Stiffness to the touch and spasms with or without opisthotonus. - Board like abdomen. - Hyper extended extremities. 16 Diagnosis Diagnosis of neonatal tetanus is mainly by clinical features. Prognosis Indicators of poor prognosis are: - Incubation period < 7 days - Period of onset < 48 hrs. - Presence of spasm - Autonomic nervous system disturbances like, tachycardia, bradycardia, hypertension, hypotension, arrhythmia. Complications - Respiratory arrest - Laryngeal spasm - Presence of autonomic nervous system disturbances. Prevention - Immunization of children and women. - Health information on harmful practices - Training of Traditional Birth Attendants (TTBA). 17 2.5.3. Poliomyelitis Etiologic agent - It is caused by polioviruses type I, II and III. Pathogenesis - The virus affects the anterior horn cells of the spinal cord and several areas of the brain. Damage may be reversible with recovery, but it may go on to irreversible nuclear destruction where muscle paralysis results. Clinical features - Incubation period is 6 – 14 days - Fever, malaise, headache and muscle pain - Nausea, vomiting, soar throat and stiffness of the neck and back with or without paralysis. - Paralysis usually affects the legs, more often one. Diagnosis - It is mainly by clinical features. Management Acute phase - Keep the limbs position with cushions - Apply warm packs - Provide analgesics - Active and passive movements are assisted by physiotherapist after the acute phase ended. Recovery phase - Continue with full range of passive/active movement of the affected limb every day. Residual phase - Regular out patient supervision of physical, social and economic problems if needed. 18 2.5.4. Diphtheria Etiologic agent - It is caused by Gram-positive bacterium called Coryne- bacterium diphtheriae. Pathogenesis - The bacterium produces exotoxin which causes local tissue inflammation and necrosis. In cases where the pharynx is involved, there are patches of a grayish membrane with a surrounding dull red inflammatory zone, which may cause pharyngeal obstruction. Clinical features - The incubation period is usually 2 - 5 days. - Sore throat which may be followed by stridor. - Grayish white membrane seen in oropharynx. - Upper airway obstruction by the membrane. Diagnosis - Clinical signs mentioned above - Microscopy -Gram stain Management A. Specific - Diphtheria antitoxin if the diagnosis is strongly suspected clinically. - Antimicrobial therapy with penicillin or erythromycin B. General - Strict bed rest and sedation - Intubations if needed. Complications - Airway obstruction - Toxic cardiomyopathy (50 – 60% of diphtheria deaths) - Vocal cord paralysis 19 2.5.5. Measles Etiologic agent - It is caused by Measles Virus. Pathogenesis - The essential lesion of measles is found in the skin; the mucous membranes of the nasopharynx, bronchi, and intestinal tract; and in the conjunctivae. Clinical features - The incubation period ranged from 7 - 18 days. - The initial stage (catarrhal stage) starts with fever, cough, sneezing, running nose and red, runny eyes. Koplik’s spots in the mouth occur before the rash. - A characteristic red blotchy rash appears on the third to 7th day, beginning on the face becoming generalized, lasting 4 – 7 days. Diagnosis - It is made mainly by clinical features epidemiological grounds. Management - Severe cases only are admitted to the hospital. - Mothers are advised about care at home which includes – reducing fever, maintaining hydration and nutrition. - Serious complications are treated in hospitals. Complications - Pneumonia - Otitis media - Malnutrition - Encephalitis - Eye problems and blindness (abscised with Vitamin A deficiency) 20 2.5.6. Tuberculosis Etiologic agent - Pulmonary tuberculosis is caused by Mycobacterium tuberculosis. Tuberculosis of the gastrointestinal tract is caused by Mycobacterium bovis. Pathogenesis - Tubercle bacilli infect the lung forming a tubercle (lesion). - The tubercle: ƒ May heal, leaving scar-tissue ƒ May continue as a granuloma ƒ May eventually proceed to necrosis, liquefaction, sloughing, and cavitations. - The initial lesion may disseminate tubercle bacilli: ƒ By extension to adjacent tissue ƒ Via bloodstream ƒ Via lymphatic system ƒ Through the bronchi. Clinical features - The incubation period ranged is 4 – 12 weeks but the infection may persist for months or years before the disease develops. - The clinical features of pulmonary tuberculosis are: ƒ Persistent cough for more than 3 weeks. ƒ Sputum production, which may or may not be blood stained. ƒ Weight loss ƒ Chest pain ƒ Shortness of breath ƒ Intermittent fever, night sweats ƒ Less of appetite ƒ Fatigue and malaise 21 Diagnosis - Clinical features - Laboratory diagnosis ƒ Sputum smear microscopy using Ziehl Neelson Acid-Fast Staining technique-this is the commonly used laboratory technique ƒ Culture - Tuberclin skin testing - Chest X-ray Management - Chemotherapy: there are two phases of treatment 1. Intensive or initial phase - the first two or three months of treatment. 2. Continuation phase - the remaining duration of treatment. - Drug Regimens There are two recommended standard tuberculosis drug regimens: ƒ Directly observed Treatment short course (DOTS), which is for 8 months; in DOTS the patients are given the drugs under observation by health worker for the first two months. ƒ Long course chemotheraph (LCC); which is given for 12 months. During the initial phase of short course therapy the recommended regimen of uncomplicated pulmonary tuberculosis is two months of INH, Rifamcpin and Pyrazinamide followed by four months of Isoniazid and Rifampin. 22 2.6. Prevention and Control of EPI target diseases - Health Information about the importance of immunization. - Proper management and inspection of vaccines. - Early diagnosis and treatment. - Ensuring a clean and safe environment. - Avoid harmful traditional health practices. - Training of community health workers (CHW) and traditional birth attendants (TBA) - Integration of immunization into all aspects of primary health care - Mass mobilization. - Integration of nutrition education with health services. - Provision of services and expansion of outreach sites. - Integrated package of school health interventions. 2.7. Immunization Immunization is the process of administrating a weakened or killed microorganism or its product to stimulate the host’s immunologic response to that antigen. Types of Vaccines: Vaccines can be - Killed microorganisms (pertussis), - live but weakened – attenuated – microorganisms (measles, polio TB) - toxoids (tetanus and diphtheria). Target group - all under one year children and women of childbearing age (15 - 49 years). Side effects of vaccines BCG 1. Normal reaction - a small red, tender swelling about 10 mm across appears at the place of immunization after about 2 weeks - Abscess: due to injection errors - Ulcer - Scar 23 2. Severe reaction - Sometimes there is severe local inflammation or deeper abscess. - Sometimes the lymphatic glands near the elbow or in the axilla swell. This may be because: You used a needle that was not sterile You injected too deeply under the skin by mistake You gave too large a dose of vaccine. DPT - Fever - Soreness at the injection site - Abscess - Convulsion (rare) Polio - Usually none Tetanus Toxoid (TT) - Pain, redness and swelling at the infection site. Measles - Fever 5 – 8 days late - Occasional rash Contraindications of vaccines DPT should not be given if the child has developed severe reactions like shock, convulsions, anaphylactic reaction, etc. to the previous dose of DPT. This is a rare side effect due to the pertussis component of DPT vaccine. Infants with clinical AIDS should not receive BCG vaccine and oral polio, but should be given the other EPI vaccines. 24 Immunization Schedule A. For those who start at birth: Contact Age of Child Vaccines st 1 At birth BCG and Polio 0 nd 2 6 weeks OPV1 and DPT1 rd 3 10 weeks OPV2 and DPT2 4th 14 weeks OPV3 and DPT3 th 5 9 months Measles B. For those who start later Age of child Antigens Less than 6 weeks BCG and OPV1 BCG if not given previously Above 6 weeks OPV (3 doses) DPT (3 doses) BCG if not given previously OPV Above 9 months DPT Measles C. Tetanus toxoid vaccine schedule for women (15 - 49 years) Dose Minimum interval Duration of protection TT1 - 0 TT2 4 weeks 3 years TT3 6 months 5 years TT4 1 year 10 years TT5 1 year Life long Note: If a woman was given 3 doses of DPT vaccine when she was a child, provided that a written document of her immunization is available, and the doses are given at the right intervals, the 3 doses of DPT can be counted as two doses of TT. 25 Childhood Immunization Schedule Age Birth 1 2 3 4 5 6 …9 month months months months months months months Vaccine BCG BCG Diphtheria DPT1 DPT2 DPT3 Pertussis Tetanus Oral polio Polio OPV1 OPV2 OPV3 0 Measles Measles vaccine Age in week 6th 10th 14th weeks weeks weeks 2.8. The cold chain The cold chain is the interconnection of equipment or people that ensure vaccine potency by keeping vaccine cold all the way from the manufacturer to the mother/child. Manufacturer Airport Central Vaccine stores Regional Stores Zonal stores Health Center District Health office store Mobile or Outreach Service Health post Mother and Child Source: WHO: immunization in practice 1989 (Slightly modified). 26 Equipment Materials that are used in the cold chain include: - thermometers - ice packs - vaccine carriers - cold boxes - refrigerators and freezers. Note: Skilled human power to maintain the cold chain is necessary. Precautions for vaccines - All vaccines have to be stored at 0oC to 8oC both at the health center and the outreach unit. - Storage time for all vaccines is up to a month at the health center/health station and up to 1-2 days at the outreach unit. - Measles and polio be kept frozen. - Never freeze DPT or tetanus vaccine. - Keep diluents with vaccine in refrigerator if there is space. - If not, refrigerate at least the diluents needed for the following day. 2.9. EPI Delivery Strategies Static: immunization performed as part of routine activity of the Health units. Outreach: an immunization approach in which the staffs of health unit go out and administer vaccine to mothers and children in their catchments areas. Mobile: an immunization approach only single dose vaccination (measles, BCG) in nomadic, settlement areas and mostly used for controlling epidemics of measles. Campaign: an immunization approach conducted by mobilizing the community, example polio and measles vaccination. 27 2.10. Indicators The following are some indicators that show a successful immunization programme: - BCG scar on the right shoulder. - Completed immunization card. - Vaccine storage times and temperatures at health centre and out reach level. 2.11. Immunization Problems A. Drop Out A drop out is defined as a child or a woman who failed to return for subsequent doses for which he or she is eligible. The possible causes of drop out rates are: - unsure of dates of return - long wait at the vaccination centre - vaccination centers open at inconvenient hours - some health workers do not explain the need of completing vaccination. - negative attitude of some health workers towards the program. - mothers usually busy on other engagements. - family left the place for a while. - child develops side effects or was sick on the appointed date. - was sick on the appointed date. A child or a woman who discontinued the immunization program should not have to restart the immunization. There is no maximum interval between two immunizations. B. Missed opportunities Current policy is that all children and mothers at the health facility for any reason should be screened for immunization status and vaccinated if eligible. 28 Common causes of missed opportunities are: - health workers do not know the policy - health workers screen but tell patients to return later - health workers only vaccinate women with TT if they are pregnant - health workers only vaccinate the index child, miss the siblings. - health workers only open a vial if there are enough clients who need it - false contraindications to immunization, example not giving polio vaccine to a child with diarrhea. - logistical problems, such as vaccine shortages, poor clinic organization, and inefficient clinic scheduling - the failure to administer simultaneously all vaccines for which a child was eligible - accessibility; time (women carry household responsibilities), distance, cost of transportation - Acceptability: culture, rumors, beliefs, etc. Dropouts and missed opportunities are causes of low vaccination coverage, and have potential solutions. These are: - Social mobilization - Dropout tracing mechanisms - In service training to community health workers and utilization of other motivation mechanisms. - High level advocacy. - Get commitment by the local leaders. - Monitoring and supervision the program - Ensure financial and logistics support for the health institutions. - Monitor coverage periodically. - Daily integrated health service for all women and children attending the health units. 29 2.12. Assessment and Evaluation of EPI Services The ultimate goal of EPI is not to provide immunizations to all populations but rather it is to significantly reduce the morbidity and mortality from the vaccine preventable diseases. Always priority should be placed on monitoring immunization coverage and disease incidence. This can be found from: - Health institution reports, - Surveillance: It is defined as a regular collecting, compiling, analysis, and interpretation of current data on the frequency of specific diseases (WHO). It is the regular dissemination of acquired information to those responsible for disease control and health service planning. Purposes of surveillance system include A. To facilitate the early recognition of changes in the patterns of diseases; B. To identify changes in environmental and host factors that may lead to an increase in the frequency of the diseases; C. To monitor the safety and effectiveness of prevention and control measures; - Survey, cluster survey The EPI Coverage Survey Often routine reports are inaccurate and one may have to resort to EPI coverage survey to determine the coverage, and provide additional information. WHO’s Expanded Program of Immunization has developed a rapid survey methodology which is valuable not only to determine vaccination coverage, but also reasons underlying for failure to vaccinate children. The main advantage of this methodology is that it can be completed quickly and it’s technically much easier to carry out than a simple random sample survey in populations that are not censured. 30 Its principal disadvantage is that it allows one to draw conclusions about the population as a whole; one can’t compare sub-populations. For example, one cannot compare rates between the boys and girls in the sample population using the standard 30 by 7 cluster methodology. However, with modification of sample size, this too is possible. The standard cluster survey methodology involves choosing 30 different “clusters” of 7-10 households. A “cluster” is a randomly chosen group which, for the EPI coverage survey, contains 7-10 children of appropriate age (12-23 months). Thus, each unit randomly selected is a group or “cluster” of persons rather than an individual. In order to select the clusters, one must first know the total population of the area under consideration, as well as the populations of the various towns, villages, or other centers in the area. These populations' centers are listed with their population, and a cumulative population besides it. A sampling interval is determined by dividing the total population by 30. A random number will be selected between one and the determined sampling interval. The community for which the cumulative population equals or exceeds the random number is selected. It will contain the first cluster. Add the sampling interval to that random number. The community for which the cumulative population equals or exceeds this value is selected as the community containing the second cluster. And so on, until the all 30 communities have been chosen. Large communities may contain more one cluster. Once the communities have been selected, one then chooses the cluster. This is done by selecting a starting household. If the community has been censured and a list of households available, this is relatively easy procedure. One numbers the houses and selects, at random, one house, the first house. If no household number exists, one goes to the center of the community (churches, mosque, 31 school, market, etc.) and selects a random direction in which to proceed (usually by spinning a bottle). One then counts the number of houses between the center and the periphery of the selected quarter and selects one house at random, this becomes the starting house. The second household to be visited is the one closest to the first (i.e. the household with the front door nearest to the first door) and so on until you complete the required cluster number. If any of your households contain more than one child, it is advisable to consider including hem all. The vaccination status of each child is determined usually by card. Once all 30 clusters have been finished, one will have 210 or up to 300 children. So, after this procedure, we know where we are in terms of the coverage of vaccination for the target group is concerned. What is next? In addition to determining coverage, the EPI coverage survey allows one to identify reasons for immunization failure. For all those in the target group who are found not to have been completely vaccinated, the mothers are asked to identify the major reasons why? 32 Immunization Monitoring Chart It shows the progress you are making in raising immunization coverage in your catchement areas. This chart enables the number of people you actually immunize each month with your coverage targets. 33 UNIT THREE SATELLITE MODULES Satellite Module for Health Officer Students on Expanded Program on Immunization 3.1.1. Introduction Purpose This satellite module is prepared for health officer students on EPI. The module emphasizes on some points that are not well described and covered by the core module. Directions After completion of the core module, attempt to answer the pre-test question of the satellite module. Go through this satellite module and are advised to refer to the core module whenever indicated. Attempt to answer the questions on learning activity one. After reading the entire satellite module attempt to revise the pre-test questions again as a post-test 3.1.2. Learning Objectives At the end of the session the student will be able to: - define immunity - understand types of immunity - identify the types of vaccines and their properties - know the importance and mechanism of cold chain - identify the major problems of EPI and their solutions - understand the management of EPI - assess and evaluate EPI - identify the roles and tasks of health officer on EPI. 34 3.1.3. Pretest Instruction: Answer the following questions before reading the satellite module. 1. Immunity can be a. Induced b. Natural c. All of the above d. None 2. Vaccination /Immunization is an example of a. Active immunization b. Passive immunization c. Both d. None 3. DPT vaccine is an example of a. Live attenuated organisms b. Inactivated organisms c. Killed suspended organisms d. None of the above 4. Toxins are produced only from the serum of human beings. True __________ False ___________ 5. The target population for EPI in Ethiopia are a. Under five years of children b. All pregnant and non-pregnant women aged 15-49 years c. Less than one year children d. All men e. a + d f. b + c 35 6. BCG vaccine is an example of a. Live attenuated organism b. Inactivated organism c. Killed suspended organism d. None of the above 7. Tetanus toxoid should be given only for pregnant women. True __________ False _________ 8. When do you consider to find out the reasons for drop out? If it is a. 1% b. 5% c. 8% d. >10% 9. The range of missed opportunities in Ethiopia is a. 20 - 25% b. 35 - 47% c. 50 - 60% d. >70% 10. Causes of missed opportunities include ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 11. Reasons for dropouts include ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ __________________________________________________________ 36 12. The problems associated with EPI include a. Culture and beliefs b. Accessibility c. Vaccines related d. All of the above e. Only a and b 13. Managements of EPI include a. Identifying the target population b. Planning the strategy to be used c. Allocating resources d. All of the above e. All of the above except "a" 3.1.4. Immunization A. Active immunization The protection of the host in which either the altered organism or its product induces the host to produce antibodies. It involves stimulating the immune system to produce antibodies and cellular immune responses that protect against the infectious agents. B. Passive immunization The protection of the susceptible host by administration of protective antibodies produced by another host, e.g. tetanus antitoxin. It consists of providing temporary protection through administration of exogenously produced antibody such as immune globulin. 3.1.5. Assessment and Evaluation of EPI A. Health institution reports B. Surveillance See the core module C. Survey, cluster survey 37 3.1.6. Immunization problems, solutions and drop out rates calculation Problems - Reasons for drop out - See core module Dropout rates calculations - Over all drop out rate = Coverage with BCG – Coverage with measles x 100 Coverage with BCG - Drop out rate for a single antigen (e.g. OPV) = Coverage with OPV1 – Coverage with OPV3 x 100 Coverage with OPV1 There is a problem whenever the dropout rate is greater than 10%. It is essential to determine why the failure occurred. - Missed opportunities- See core module - Culture and Beliefs Though the immunization service is accessible, there are some people who are not using the service because of culture and beliefs. - Lack of geographic access includes lack of transportation facilities and spare parts for vehicles. - Problems associated with the vaccines a) BCG Efficacy is uncertain b) Pertussis - Low immunogenecity - Requires 3 doses 38 - Common minor side effects in 50% - Rare serious toxicity e.g. Seizures, neurological disorder c) OPV - Thermal instability - Poor immunogenecity - Requires multiple doses d) Measles - Thermal instability - Inadequate immunogenesity when circulating maternal antibodies present. Problems of knowing the target population - Knowing the target population is important because the necessary vaccines and logistic could be prepared earlier. Problems related to the supplies, cold chain and maintenance. - Shortages of supplies like syringes, needles, vaccines, ice boxes, vaccine carriers, etc. - Maintenance of cold chain equipment is costly and unavailability of spare parts. Problem of community involvement - Without the involvement of the community EPI program will fail. They are important in the planning, implementation & evaluation process. 39 Lack of inter-sector collaboration - EPI is the responsibility of all sectors/ministerial offices, not only left to health workers. It needs the collaboration of all bodies/authorities. Without them it is impossible to reach EPI goal. Ineffective management - Assignment of unskilled manager. - Poor scheduling and allocation of resources. - Poor information system resulting in inadequate recording and reporting. Solutions Developing dropout or defaulters tracing mechanisms like using community health workers/front line health workers to trace defaulters. This is sensitizing the population through health education, discussion, etc. about the program. Refer to the core module for other solutions. Calculations on Drop Out Rate Instruction: Work out the following questions based on the data given in the table. In 2000, the Family Health Department of one of the Regional Health Bureaus conducted EPI cluster survey. A total of 300 children age 12 month of 23 months were identified by the survey. Out of the 300 children, 70 didn’t start vaccination at all. The vaccination cards of the remaining 230 children were checked. The table below shows the number of children who got different vaccines. 40 Vaccine No. of children who got the vaccine BCG 230 DPT1/OPV1 200 DPT2/OPV2 180 DPT3/OPV3 150 Measles 130 Calculate: 1. The overall drop out rate. 2. Drop out rate for DPT. 3.1.7. Management of EPI Procedures to follow in conducting EPI include: Know the catchement area. Know the target population through survey. Organize and conduct in service training for the staff. Allocate resources such as - Assign staff, - Procure the required amount of vaccines, refrigerator and other supplies, - The necessary financial support (budget), - Transportation, etc. Manage the cold chain - Arrangement of vaccines in the refrigerator - Use different mechanisms of ensuring the cold chain. Identify the strategy to be used and their frequencies. Prepare and organize immunization schedule/session (e.g. how many out reach sites?) 41 Give appropriate information for the clients such as: - be specific on the date and time of the next immunization. - give the client a written note of the date and time. - the place of the next immunization, particularly if you change the previous site. - number of visits a child and mother still need in order to be fully immunized - side-effects may occur Collect and distribute materials for recording and reporting. Social mobilization (the clients, community, other sector members, etc.) to create awareness. Devise means of monitoring, supervising evaluation, such as - Prepare and use monitoring chart. - Calculate immunization coverage, drop out rate, etc. Identify problems and give solutions. Identify those illegible who are not vaccinated and are listed as dropouts. 42 Learning Activity: Two Instruction Fill the boxes by selecting related facts listed from A - D. Pertussis Tetanus Poliomyelitis Diphtheria Tuberculosis Measles A. Causative agent B. Incubation Period C. Special features A1. Polio Virus B1. 3 – 5 days C1 – Whooping cough A2. Measles Virus B2. 4 weeks or longer C2 – Koplik’s Spot A3. Bordetella Pertussis B3. 6 – 14 days C3 – Toxin production A4. Corynebacterium Diphtheria B4. 1 – 14 days C4 – Lock jaw A5. Mycobacterium B5. 7 – 18 days C5 – Muscle paralysis A6. Clostridium Tetanis B6. 7 – 17 days C6 – Chronic Cough 43 D. Vaccine (type, administration and schedule) D1 – DPT vaccine D7 – IM injection D2 – Polio vaccine D8 – TT vaccine D3 – Start at 6 weeks D9 – Weakened toxin D4 – Start at birth D10 – Killed organism D5 – Oral drop D11 – BCG Vaccine D6 – Start at ninth months D12 – Live attenuated D13 – Intra-dermal E. Contra indication E1 – Fever E4 – Anaphylactic reaction E2 – Convulsion E5 – Clinical AIDS E3 – Diarrheas Roles and Tasks of Health Officer Students A. Knowledge, Objectives and Activities Regarding EPI Target Diseases Knowledge Objectives Activities Describe the causes of EPI target - Study the causes of EPI target diseases. diseases. Describe the modes of transmission - Study the modes of transmission of EPI target diseases. of EPI target diseases. State the diagnostic approach of EPI - Study the epidemiological pattern and clinical features. target diseases. - Study and observe methods of laboratory investigations. Describe the types of vaccines, EPI - Study the types of vaccines, EPI schedule. schedule, route of administration of - Study and observe route of administration of vaccines, vaccines, and strategies. and strategies. Describe the mechanisms of - Study and observe the mechanisms of maintaining cold maintaining cold chain. chain. Describe the problems of EPI and - Study the problems of EPI and their solutions. their solutions. Out line the managements of EPI. - Study the managements of EPI. Describe the methods of assessment - Study the assessment and evaluation methods of EPI. and evaluation of EPI. 44 B. Attitude Objectives and Activities of Health Officer Students Regarding EPI Target Diseases Attitude Objectives Activities Believe and help people to know that Make an effort to have better understanding EPI target diseases are preventable. of EPI target diseases. Believe and help people to know that Enhance in understanding of the schedule regular immunization attendance is of EPI by provide information. important for full protection. Believe and help people to know that Understand the possible side effects and immunization has no or minimal side pass this information to the clients. effects. Believe that community participation Understand and appreciate the roles of the is important for the success of EPI. community in making EPI successful. 45 C. Practice Objectives and Activities of Health Officer Students Regarding EPI Target Diseases Practice Objectives Activities Identify catchement area for EPI.. Visit the area.. Discuss with the community leaders, health workers, and other relevant bodies.. Prepare sketch map. Identify the target population.. Conduct survey.. Register the targets and know the number.. Find the total population count from possible sources and make a working estimate of the target population. Organize the EPI program.. Plan the program with other members.. Prepare the schedule for vaccination date.. Secure the necessary resources and logistics. Conduct vaccination.. Participate in vaccination.. Conduct vaccination campaigns if necessary. Regular recording and reporting.. Compile and analyze the data.. Record data.. Report. Increase community involvement.. Conduct health education.. Organize and Conduct social mobilization. Maintain cold chain.. Regular checkup of temperature of the refrigerator.. Prepare ice pack, cold box, etc.. Learn and practice to maintain the refrigerators and other cold chain equipment. Monitor and evaluate EPI. Monitor and supervise sessions, cold chain, and program. availability of resources.. Conduct EPI coverage survey and be involved in surveillance.. Do regular vaccines and supplies inventory. 46 3.2. Satellite Module for Public Health Nurse Students on Expanded Program on Immunization 3.2.1. Introduction Purpose and Use There are six important EPI target diseases that are very serious, and which kill and disable many children. This satellite module is prepared for the public health nurse students with the main goal of enabling them run vaccination program effectively. Directions After completion of the core module go through the satellite module and refer to the core module whenever needed. Attempt to read points step by step. Attempt to answer questions on learning activity. Go through the entire satellite module. 3.2.2. Learning objectives Upon completion of this module the public health nurse will be able to ƒ Describe the importance of EPI. ƒ State the six vaccine preventable diseases. ƒ Demonstrate comprehensive assessment and list pertinent nursing diagnoses of four vaccine preventable diseases. ƒ Provide holistic nursing care for individual child the EPI target diseases. ƒ Mention essential prevention and control measures. ƒ Define immunization and vaccination. ƒ Explain vaccines and how to administer them. ƒ Organize an out reach sessions. ƒ Conduct health education on immunization sessions. ƒ Evaluate the effectiveness of EPI program. 47 3.2.3. Pretest (refer the core module) 3.2.4. Causes of the childhood EPI target diseases (refer to the core module) 3.2.5. Clinical features of EPI target diseases (refer to the core module). 3.2.6 Epidemiology of EPI target diseases (refer to the core module) 3.2.7. Learning Activity (refer to the core module). 3.2.8. Client care using the Nursing process Clients Assessment Take pertinent and adequate history, subjective and objective data. Nursing diagnoses The nursing diagnoses listed below are actual and potential symptomatic patients' problem: ♦ Ineffective breathing pattern related to EPI targeted diseases. ♦ Altered body temperature (fever, hypothermia) related to the disease. ♦ Fluid volume deficit (potential or actual) related to fever, diarrhea and inability to ingest. ♦ Altered body nutrition related prolonged course of infection. ♦ Potential for spread of infection to others. ♦ Knowledge deficit in the control and prevention of EPI target diseases. Plan ƒ To easy breathing. ƒ To reduced the elevated body temperature to the normal range. ƒ To correct fluid volume deficit. ƒ To maintain nutrition according the body’s requirement. ƒ To prevent the potential spread of infection to others. 48 ƒ To give health education on the prevention and control of EPI target diseases. Nursing Intervention Attaining a normal breathing pattern. - Turn the patient frequently to drain the secretion and suction when indicated. - Encourage mobilization. - Encourage a high fluid intake. - Evaluate the respiratory rate. Attaining normal body temperature - Rest - Take vital signs - Increase fluid intake - Give frequent and hygiene. - Apply tepid sponge. Attaining fluid balance - Assess for signs of dehydration - Maintain input and output record Improving nutritional status - Monitoring the nutritional status, weight, height and arm circumference - Encourage balanced food intake. - Assess food intake and tolerance. Preventing the spread of infection - Implement an appropriate isolation technique. - Wash hands before and after each patient contact. - Control dissemination of infection droplets. - Ventilate the patient’s room. - Patient education. 49 Evaluation Maintains normal breathing pattern Demonstrates absence of elevated body temperature Attains fluid balance; normal skin. Appears to have more energy Protects self and others from spread of infection Becomes informed the infectious process of EPI targeted diseases. 3.2.9. Prevention and Control of EPI Target Diseases (For complete information refer to the core module) Vaccine and their administration a) DPT (Diphtheria, Pertussis and Tetanus) - It is a liquid vaccine - Dose: 0.5 ml - Route: intramascular (IM) - Site: thigh - Number of doses: 3 b) OPV (Oral polio vaccine) - Damaged more easily by heat than other antigens but frozen and refrozen without damages - Prepared in plastic or glass dropper. - Dose: 2 drops - Route: oral - Number of doses: 3 – 4 Note: If the child has diarrhea give the vaccine but give an extra-dose after you finish the normal course. But do not register this dose. c) Measles - Before using it you must reconstitute it with diluents - Dose 0.5ml – each time check the manufacturer instruction 50 - Route IM - Number of dose 3 - Interval at least 4 weeks apart - Keep the diluents cold - Keep the vaccine at the correct cold temperature and out of sunlight d) BCG (Bacillus Calmette Cuerin) - Before using it, you must reconstitute it with diluents dose 0.05 ml below one year and 0.1 ml above one year old child - Check manufacturer instruction - Route ID - Site (right upper arm) - Number dose 1 - Keep the diluents cold - Keep the vaccine at the correct cold temperature and out of sunlight e) Tetanus Toxoid (TT) - It is a precipitated liquid vaccine - Dose: 0.5ml - Route: IM (upper arm) - Number of doses: 5 Preparation of syringes and needles a) Syringes of: - 5 ml for mixing - 0.5ml for administration of DPT measles and TT - 0.05 ml for BCG b) Needles - 18 gauge for mixing - 22 gauge for IM and Sc. - 26 gauge for ID 51 Complications of unsafe Injection Injections of vaccines are only safe when the correct vaccines are properly administered with sterile equipment. a) Infections - Transmission of blood borne pathogens Examples: Hepatitis B - HIV/AIDS - Abscess - Septicemia b) Non-infectious Injuries due to improper injection technique E.g. nerve damage. Measures to prevent risks of vaccine compilations - Equipment and supply selection - Sterilizing the instruments using the steam sterilizes The necessary items needed for sterilization - Steam sterilizer - Round/square boiling pan - Stove - Forceps - Timer clock - Fuel or electricity Prevention of unsafe injection - Periodic assessment - Effective training and supervision of health care workers - The development of a national safe injection policy - Uninterrupted provision of supplies and equipment 52 Tasks of PHN at the immunization session There are several tasks that the public health nurse may have to do at the immunization session: - Arranging the flow mothers and children at station - Registering clients - Weighing clients - Health education on immunization - Screening clients - Treating clients - Immunizing clients - Cleaning the site and equipment Strategies of health education - Planning a program - Planning with the community - Finding a contact person - Making the program work - Training people to help you including health education - Making immunization a good experience for the families - Giving the community some feedback - Working with individuals - Working with groups - Planning what you teach about - Being polite and friendly - Teaching in an interested way - Use simple words - Demonstrate something, like role-play. - Encourage discussion 53 The role of public health nurse in evaluating the effectiveness of EPI program Why should you evaluate your work? Everybody who works in an immunization program needs to evaluate or monitor his/her work. Evaluation is not only for supervisors and program managers, it is also important for a person who gives the vaccine. The Purposes of evaluation include: - To know how successful your work is? - What you need to do to improve your program. - What help you need from your supervisors. If you know how well you are doing, you will find your work more satisfying. Then you will enjoy your work more, and you will work better. 54 Roles and Tasks of a Public Health Nurse A. Knowledge, objective and activities regarding EPI target diseases Learning Objectives Activities Describe the cause of EPI Target Identify the causes of EPI target diseases diseases Describe the modes of transmission Explain the mode of transmissions of EPI of EPI target diseases. target diseases. State the diagnostic approach of ƒ Investigate the epidemiological patterns of EPI target diseases. EPI target diseases. ƒ Assess and monitor the clinical features of EPI target diseases. ƒ Identify the specimen to be sent to the laboratory. Describe the management of EPI State the drug, dose, route and time of target diseases. administration. Describe the types of vaccines, EPI ƒ Differentiate the type of EPI vaccines. schedule, route of administration of ƒ Design the EPI schedules. vaccines and strategies. ƒ Identify the routes of vaccine administration. ƒ Explain the strategies to be used. Describe the mechanism of List how the cold chain system is maintained maintaining cold chain. from the manufacture to the delivery unit. Describe the problems of EPI and ƒ Mention the problems of EPI. their solutions. ƒ Solve the problems of EPI. Outline the management of EPI Categorize the management of EPI. Describe the method of assessment ƒ Assess the implemented activities of EPI. and evaluation of EPI. ƒ Evaluate the outcomes of the activities. Describe immunization card ƒ Maintain the immunization card to be carried by the client 55 B. Attitude, objectives and activities of PHN students regarding EPI target diseases Learning Objectives Activities Help people believe that the EPI ƒ Encourage people to come for target diseases are preventable. immunization. ƒ Teach families, community about EPI target diseases using appropriate teaching aids. Help believe that regular Provide the family and the immunization attendance is community with health information important for full protection. on EPI schedule. Help people believe that Discuss the possible side effects of immunization has very minimal side each vaccine. effects. Help people that community Initiate and convince community participation is important for the leaders and other influential people success of EPI. in the community that the community participation is vital for the prevention of EPI diseases. Help people recognize that breast Emphasize the importance of milk represents the first breastfeeding, especially the need to immunization. give colostrums. 56 C. Practice of objective and activities of PHN students regarding EPI target diseases Learning Objectives Activities Identify catchments ƒ Organize the visit with the community leaders and health area for EPI workers. ƒ Use the developed sketch map. Identify the target ƒ Conduct a working survey. population ƒ Conduct registration of the target population. Organize the program ƒ Construct vaccination schedule. ƒ Assemble the necessary equipment. Conduct vaccination ƒ Give vaccines. ƒ Create a vaccination campaigns. Regular reporting ƒ Have an organized documentation. ƒ Analyze the data. ƒ Report to the concerned body. Increase community ƒ Create a friendly atmosphere with the community. involvement ƒ Create community awareness through health education. ƒ Demonstrate EPI using appropriate teaching aids. ƒ Regulate the cold-chain system. ƒ Prepare ice pack and cold box. Maintain cold-chain ƒ Arrange the vaccine according to their temperature. Demonstrate the arrangement of the vaccine to other staff. ƒ Follow the first in and the first out principles when using vaccines. Monitor and evaluate ƒ Supervise the EPI sessions and the cold chain. EPI program ƒ Calculate the EPI coverage. ƒ Make an inventory on vaccines and supplies and report to the concerned body. 57 3.3. Satellite Module for Environmental Health Technician Students on Expanded Program on Immunization 3.3.1. Introduction Purpose and use of the Satellite Module This satellite module is prepared for Environmental Health Technician students. The satellite module emphasizes only areas that were not covered by the core module. Direction on how to use this satellite module After completion of the core module, go through the satellite module. Students are advised to refer the core module whenever indicated. After completing the satellite module answer the questions given as pretest at the beginning in the core module. Compare your results. 3.3.2. Learning objectives At the end of the satellite module you will be able to: identify the preventive and control measures of EPI targeted diseases. state the methods of health education to prevent EPI targeted diseases. describe the management and inspection of vaccines under cold chain. discuss reasons why vaccines are not effective. 3.3.3. Prevention and control of EPI target diseases A. Survey and surveillance 1. Survey – An investigation in which information is systematically collected. Conditions to conduct survey when: developing new site an out break occurs 58 there is need to know EPI target groups laboratory analysis indicates a danger to health there are changes in the health of the community. Activities under survey are: mapping of the catchment areas and house numbering. identification of total number of population and house holds in the catchment area identification of target groups particularly mothers and children assessment of environmental health conditions data compilation, analysis and interpretation 2. Surveillance - is an ongoing scrutiny of the factors that determine the occurrence and distribution of diseases with the purpose of detecting changes in trends or distribution in order to initiate investigative or control measures. Surveillance systems are: routine reporting (see Annex I) compiled reporting Components of surveillance system Surveillance of cases. Surveillance of animal reservoirs or vectors Surveillance of environmental factors relevant to health. Surveillance of demographic changes. B. Information, Health Education and Communication (IEC) ¾ Mass mobilization through health information. ¾ Increase immunization awareness/knowledge for: pregnant women attending antenatal services women of child bearing age through regular health services 59 women coming with children to immunization or regular primary care facilities. women coming with or without children to immunization community as whole ¾ Ensure clean and safe delivery which can be achieved by: clean hands of the birth attendants. clean cutting and care of the umbilical stump. clean surface where the delivery is performed. ¾ Training and supervision of delivery staffs Health workers front line health workers (CHW) ¾ Eliminate use of certain traditional practices such as cow dung, ash, contaminated blades, Contaminated cord tie. C. Cold Chain 1. Management and inspection of vaccines Read the cold chain record paper about the previous dates and time. Record the external thermometer reading of the refrigerator. Open the refrigerator. Record the internal thermometer reading. See the arrangements of vaccines on the shelf inside the refrigerator Close the refrigerator. Record the thermometer reading of the refrigerator externally and check weather it has increased or not. Check the shelf life of vaccines and expiry dates. 60 2. Vaccine storage times and temperature (refer to the core module) 3. Refrigerators and Freezers ¾ Is vaccine storage space sufficient? Is there sufficient air space between the vaccines? Have you considered new activities to increase immunization coverage which may raise the maximum stokes needed in the refrigerator? Have you remembered to load bottles of water (or icepacks with water) in the refrigerator to keep the refrigerator to cool if the energy source fails? Do you have more than one-month supply of vaccine stored in the refrigerator? ¾ Is the temperature efficiently controlled? Your refrigerator is adequate for vaccine storage only if it can maintain an internal temperature between 0oC – 8oC. If the temperature rises above + 8oC Store water bottles or icepacks filled with water in every spare place in the refrigerator, except one half of the volume, which needed for air circulation. This helps stabilize the temperature stops it from fluctuating widely during the day. Close the windows or ventilator at night to keep the store room warmer. D. Environmental sanitation and proper hygienic practices related to EPI target diseases Proper disposal of human excreta and other liquid wastes. Perfect of food from all kinds contaminants. Proper hygienic practices (hand washing) Proper ventilation (through and cross ventilation)to facilitate air circulation Avoid over-crowding Proper construction, maintenance, and treatment of drinking water supplies. Proper management of infectious and other solid wastes. Provision of adequate artificial and natural lighting. 61 3.3.4. Learning Activity: Instructions A. Read carefully part I and part II. B. Part I is the strategy for prevention and control of EPI target diseases. C. Part II is the specific tasks and roles that can be performed by Environmental Health Technicians. D. Match part I with part II by writing the appropriate letter on a separate sheet of paper. Part I Strategies for prevention and control of EPI target diseases. Survey and Health Cold chain Environmental Surveillance information Health 62 Part II Specific tasks and roles to be performed A. Disinfect ion of springs and wells B. Identification of the causes of poliomyelitis. C. Check that enough vaccines are available in the refrigerator to cover the monthly supply. D. Mass mobilization E. Proper ventilation of residential houses F. Monitoring of time and temperature of the refrigerator. G. Check sufficient air space between vaccines. H. Control the refrigerator must not be used for other purposes. I. Identification of EPI target groups. J. Collect and compile data from the routine report. K. Identification of EPI sites. L. Construction of proper latrines for the community. M. Collect the monthly supply of vaccines from the district health with special precaution. N. Persuade mothers to bring their children to immunization center. O. Instruct mothers about the disadvantage of harmful health practices. P. Conduct home visit. Q. Proper disposal of all used vials, syringes and needles to appropriate site. R. Training of CHW/Front line health workers S. Identify investigate and control out breaks or epidemics. 63 3.3.5. Activity two Based on the sketch map of village A drown below answer the following questions. 64 1. Describe the role of the following variables indicated on the sketch map of village A in the prevention and control of EPI target diseases. A. mosques and churches B. protected water sources C. latrines D. health center and health posts E. housing condition 2. Identify the EPI target diseases associated with the following variables indicated in the sketch map. A. unprotected water supply sources B. open deification C. poor housing D. inaccessibility to health institutions 3. Suppose the community in the village A has no protected water supply source, poor housing condition, inaccessibility to health institution and poor sanitation and hygienic practices. These have a great impact on the EPI programme to be satisfactory. Therefore, how do you organize the community and community leaders to increase the identified problems using the role play meeting. 65 3.4. Satellite Module for Medical Laboratory Technology Students on Expanded Program on Immunization 3.4.1. Introduction Purpose and use of the satellite module This satellite module is prepared for Medical Laboratory Technology students. It emphasizes only areas that were not covered by the core module. Directions - Students are advised to study the core module before going into the satellite module. - After completing the satellite module answer all the questions given as a pretest at the beginning of the core module. - Compare your results with that of the previous pretest given. 3.4.2. Learning objectives Upon completion of the activities in this satellite module, the students will be able to: - Describe the basic microbiological procedures for specimen collection, handling, processing, examination or dispatching to a reference laboratory. - Identify and differentiate the specific bacterial agents from bacteriological specimens. - Determine some hematological tests 3.4.3. Laboratory Diagnosis The EPI target diseases are usually diagnosed based on clinical features. This is because: The diseases are acute and therefore prompt management of the patient is crucible before laboratory results are available. Health center laboratories have no adequate facilities to investigate the etiologic agents. 66 Nevertheless, the health center laboratories can perform Grains stain & investigate microscopically the etiologic agents for pertussis, diphtheria, tetanus for confirmation of cases when requested. The most important role of health center laboratory is to refer microbiological specimens to a reference laboratory for further investigation. Laboratory investigations of EPI target diseases. A. Corynebactorium diphtheria Morphology and staining characteristics - Gram positive rod - Non motile - Non capsulated, non spore former - Appear in clusters joined at angle like ‘Chinese letters’ Specimens Throat, nasopharyngeal swab, and other suspected lesions. Collection of dispatch of specimens Using a sterile cotton wool swab a specimen can be collected either from the throat or nasopharynx Put it in a sterile container with care not to contaminate the swab. To do investigation in the health center laboratory, label the specimen, make a smear, stain and look under the microscope To dispatch the specimen to a reference laboratory, put the swab in the appropriate transport media, label and send it as soon as possible. Staining method – Gram’s stain Make a smear of the specimen and fix the dried smear. Cover the fixed smear with crystal violet stain for 30 seconds. Rapidly wash off the stain with clean water. 67 Tip of all the water and cover the smear with Lugol’s iodine for 30-60 seconds. Wash of the iodine with clean water. Decolorize rapidly (few seconds) with acetone alcohol. Wash immediately with clean water. Cover the smear with neutral red stain for 2 minutes. Wash off the stain with clean water. Wipe the back of the slide clean, and air dry. Examine the smear microscopically. B. Bordetella pertussis Morphology and staining characteristics Gram negative coceobacillos (short rod) Non motile Capsulated It may occur singly or in chains and may show bipolar staining Specimen a) For bacteriological examination Nasopharyngeal secretions collected using pernasal swab or by aspiration. b) For haematological examination – blood Get blood either from the vein or finger and perform the total and differential white cell counts. Procedure for total white cell count Dilute the blood with white cell diluting fluid. Use either 1% HCl or 2% acetic acid solutions (these solutions breaks the RBCs and suspend and disperse the WBCs). Mix the solution very well and discard the first four drops before charging the counting chamber. Transfer a small representative solution taking care not to overfill or create air bubbles into the counting chamber. 68 Count the white cells in the 4 ‘W’ sections using the 10X objective. Make the calculations; add the four counts and multiply by the dilution and volume correction factors. Report the white cell count per cubic millimeter of blood. Procedure for the differential white count Make a smear of the blood specimen on a glass slide. Allow to dir dry and stain it with wrights or

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