KEPI and IMMUNIZABLE DISEASES.pdf

KEPI (KENYA EXPANDED PROGRAMME ON IMMUNIZATION ) & IMMUNIZABLE DISEASES VACCINES AND COLD CHAIN Definition of vaccine, antigen, immunity and immunization Immunizable diseases in Kenya Principles of EPI Objectives of EPI Cold chain system Packing of vacc...

KEPI (KENYA EXPANDED PROGRAMME ON IMMUNIZATION ) & IMMUNIZABLE DISEASES VACCINES AND COLD CHAIN Definition of vaccine, antigen, immunity and immunization Immunizable diseases in Kenya Principles of EPI Objectives of EPI Cold chain system Packing of vaccines in refrigerator Maintenance of cold chain, IMMUNIZATION SCHEDULE Schedules of immunization in Kenya including vaccines and dosages given at each Period EPI Vaccines including BCG, Polio, Tetanus, Measles, Rotavirus, DPT/HIB, Pneumococcal Including dose, site of administration, nature of the vaccines, route, dosage health messages shared and Complications. Ways of increasing immunization coverage Drops outs Reducing missed opportunities Adverse events following immunization (AEFIs) Reporting and documentation of adverse events following immunization RED Strategy and its components KEPI (KENYA EXPANDED PROGRAMME ON IMMUNIZATION ) Immunity Refers to the resistance on the part of the host to a specific infectious agent. Immunity can be humoral (antibodies in the blood )or cellular (specific to each type of cell ) A Humoral immunity Humoral immunity comes from B-cells (bone marrow derived lymphocytes ) which proliferate and manufacture specific antibodies after antigen presentation by macrophages (phagocytic cells). The antibodies are localized in the immunoglobular fraction of the serum There are five main classes of immunoglobulins i.e. IgM, IgA, IgD, IgE, IgG. Each class represents a different functional group. The antibodies circulate in the body and act directly by neutralizing the microbe or its toxin rendering the microbe susceptible to attack by the polymorphonuclear leucocytes and monocytes B Cellular immunity -It is mediated by the T-Cells (thymus derived lymphocytes) which differentiate into subpopulations able to help B—Cells. The T--Cells do not secrete antibodies but are responsible for recognition of the antigen. -On contact with the antigen, the T-Cells initiate a chain of responses e.g. Activation of macrophages, Release of cytotoxic factor, Mononuclear inflammatory reactions, Delayed hypersensitivity reactions , Secretion of immunological Mediators. The role of each type of immunity varies with the infectious agent and with the immune response of the host. Allergic reactions Allergies are caused by an immune response to abnormally innocuous substance e.g. pollen, dust etc The antigen-antibody reaction in the cells greatly increases the permeability of the cell membrane and may damage the cell protoplasm releasing histamines(protein involved in many allergic reactions) into the extracellular fluid.  Histamines promote vasodilatation, venous pooling (accumulation of blood in the veins “of legs” due to gravitational pull when a person changes position from lying down to standing up) and diminished venous return. Histamines cause oedema of the mucosa and increases the tone of the smooth muscles. e.g. muscles of the respiratory tract. An example of an allergic reaction is anaphylactic shock where death occurs due to insufficient venous return to the heart. The cardiac output falls immediately to “shock level” C Herd immunity Resistance of a group to invasion and spread of an infectious agent, based on the immunity of a high proportion of individual members of the group. The elements which contribute to herd immunity are : 1 Occurrence of clinical and subclinical infections in the herds 2 Immunization of the herd 3 Herd structure Thus immunity is the power of resistance of a host’s body which it posses against the infecting organisms and their products. Antigens are the substances which when introduced into the body of a host induce the formation of antibodies in that host. D Acquired immunity Immunity can be acquired naturally or artificially and both forms may be active or passive. In active immunity the host has responded to an antigen and produced his own antibodies, while in passive immunity he has received antibodies produced by someone else. Immunity is said to occur when there are sufficient antibodies within the body to prevent successful invasion by pathogenic micro-organisms Immunity depends on individual’s genetic make-up, age, general state of health and his past experience with the micro-organisms  Introduction of K E P I Kenya Expanded Programme on Immunization was established in June 1980 with financial assistance from (DANIDA). The aim was to strengthen, improve and expand the existing immunization services. It was to focus on children of 0-5 yrs and pregnant women with the available recommended EPI vaccines, so as to reduce the morbidity, mortality, and disability from the immunizable diseases. The immunization was to be offered in government and non- governmental facilities. Motivation rather than coercion being the preferred approach to increase public participation in immunization activities. Historical background of EPI During 1950s and 1960s most developing countries already had elements of immunization services which were available on a small scale or offered sporadically. The vaccines used were not always potent and most children did not Complete their immunization schedules. Thus maximum benefit was not derived from these services. This was reflected in the continuing incidence, mortality and disabilities from the vaccine preventable diseases Child survival and development especially in developing countries, has been negatively affected by the six vaccine preventable diseases of childhood The WHO reviewed the existing immunization services and noted six weaknesses. 1 Low immunization coverage, ranging from 5-20% in most developing countries. 2 Frequent use of non –potent vaccines. 3 Inadequate managerial skills in the health workers offering immunization services. 4 Shortage of human and material resources invested in immunization activities. 5 Limited community participation in the immunization programme. 6 Lack of regular monitoring, periodic evaluations and little attempt to make appropriate adaptations. Due to weakness, there was a felt need to strengthen, improve and expand those existing immunization services. KEPI GENERAL POLICY ON IMMUNIZATIONS 1 Only healthy infants weighing above 2kgs can be immunized. Critically ill and hospitalized children should not be given immunization until they recover and then be immunized on discharge. 2 A correct record of the type of vaccine given, dates when given and dosage must be written both on the child’s health card and on the immunization tally sheet 3 Great care must be taken to store vaccines at the recommended temperature of +20C to +8OC. Vaccines should never be exposed to direct heat or light. 4 All vaccines should be administered in a sterile procedure. Equipment must be well cleaned and sterilized 5 Read manufacturer’s instructions on the container carefully before administering any vaccine 6 Never use vaccines after expiry date which is clearly printed on the label of each vaccine container 7 Measles vaccine should discarded after six hours of reconstitution or dilution and BCG is discarded after 4 hours Objectives Of K E P I 1 To increase immunization coverage to a minimum of 80% for all antigens 2 To reinforce cold chain system in terms of better vaccine storage so as to ensure that the increased immunization coverage goes with potent vaccines. 3 To improve the managerial skills of health workers through training 4 To integrate K E P I with maternal and child health services at the peripheral level. 5 To increase public participation in the programme through motivation 6 Programme monitoring and evaluation 7 Operational research for better programme management Five pillars of K E P I 1 Training; To focus on basic training in medical and paramedical institutions in Kenya and On The Job Training by health supervisors 2 Cold chain; Accurate maintenance of cold chain is basic to the success of an immunization programme. KEPI has also included cold chain in the curriculum for hospital equipment maintenance trainees. 3 Supervision Meaningful supervision at district level needs to be regular and carried out by use of ‘checklists’. KEPI has provided vehicles and uniform checklists 4 Surveillance; KEPI health information system is computerized. This enables KEPI management units to get the EPI target disease returns 5 Health communication; Health Education and social mobilization are the combined function of the health communication component of KEPI  Principles of KEPI 1 Integration in MCH/FP Programme The programme is designed to strengthen the health services as a whole particularly the MCH/FP The staff working in MCH/FP clinic will be expected to carry out KEPI activities which are meant to strengthen & improve (complementary) immunization activities. 2 Training; There are 4 types of training courses High level training course; This course is designed for top Epi managers Mid level training course; This two weeks training course is designed for County health management teams to include mission, private and government institutions  Operational level training course This training is for the staff in the hospitals, health Centre's and dispensaries who perform the actual immunization activities. The staff are drawn from mission, private and government health facilities Cold chain training course This is a comprehensive training on cold chain maintenance and repair After one week operational training course in KEPI, some of the incharges and their assistances are selected for cold chain training course for one week. The course consist of both theory and a lot of practical demonstrations and practice 3 Health Education This is the most important activity of the programme so as to increase public participation in the programme. The only way to obtain the targeted immunization coverage is to convince families to utilize the services 4 Surveillance The EPI target diseases must be reported so that the success or failure of KEPI can be known. It is important that staff administering immunization record and report on the activities accurately. For proper management of immunization programme in a health facility : a) Find out the population of the area (catchment population) b) Find out how many children need immunization (target population) c) Record all the immunizations given each months d) Calculate percentage of target achieved each month e) Discuss the programme with colleagues (other staff in a meeting ) f) Evaluate the programme 5 Cold chain A system of keeping vaccines cold and in a potent state from the manufacture (producer) via all distributers until the vaccine is administered to the child or pregnant woman (consumer). This involves people and equipment. The people maintains the recommended temperatures and the equipment keep the vaccines cold at every place they are stored (regional and county vaccine stores) and where they travel from place to place as required  The role of each team members in immunization in a health facility Clinical Officer (RCO); Is the In-Charge at health Centre. Is responsible for all the activities organized at the health centre and outreach/mobile stations. The role is mainly supervisory to include : Calculate the target for immunization and evaluate achievements monthly and forward reports to the DMOH Identify available resources for immunization and request additional resources as required. Order the required vaccines monthly Ensure cold chain is maintained  Ensure that the cold chain equipment are always in good working order Liaise with the DHMT as regards supply and arrival of vaccines, equipment and stationeries (logistics) Plan immunization programme in the H/centre and outreach services Organize regular staff meetings to discuss the immunization activities Maintain discipline and team work among the staff Ensure that all necessary records are properly maintained in order to monitor vaccine usage and morbidity of relevant diseases Nurses; They Administers vaccines Motivate mothers to complete immunizations as scheduled Maintaining cold chain. Keep accurate records of the vaccines administered and those wasted. Public health technician/officer Educates the community about the immunizable diseases Identify and follow-up defaulters and motivate them to participate in the immunization programme Report on immunization activities to DPHO monthly Maintain cold chain equipment and carry out minor repairs when necessary Health Records and information officer Compiles and store the records in a systematic manner to facilitate easy retrieval. Ensure availability of enough stationeries Information of immunization achievement should be drawn on graphs and charts that are regularly updated The role of the county supervisors 1 Provide regular monthly supply of vaccines and other supplies 2 Arrange for major repairs of equipment 3 Take samples of vaccines for routine laboratory testing when indicated 4 Arrange and assist in immunization coverage survey 5 Provide materials for use in health education activities 6 Provide encouragement and support through supervisory visits monthly  How to organize immunization activities in a health facility Total population (catchment population); The census figures can be obtained from the local leaders Target population; The number of children that need immunization in the catchment area e.g. 5% of the total catchment population. Monthly vaccine requirement (ordering procedure) ✓Minimum stock levels of two weeks ✓Total number of dosages per vaccine as required by the target population ✓Consider the wasted doses ✓Consider the actual number of vaccines doses used the previous month for every antigen ✓Divide the target population by 12 (months of the year) The average number of vaccine is : 1 BCG 4 ORAL POLIO (OPV) 3 PENTAVALENT 3 ROTA VIRUS 1 IPV at 14 wks 3 PCV(Pneumococcal Vaccine) 2 MEASLE VACCINE Consider the wasted vaccines from unfinished vials For BCG and Measles vaccine is estimated as 1/2 for the others 1/3 Wastage of vaccines From unfinished vials which must be destroyed, Vaccines left in syringes, Expired vaccines etc The knowledge of your monthly average target immunizations is helpful in ; -Estimating the amount of vaccines needed each month -Evaluating your immunization coverage In a target population of 6000 BCG monthly requirement is; 6000/12 = 500 x1 (dose per child) then plus 500x1/2= 250 (wastage), therefore total requirement is 500+250= 750 doses.  If the children coming for immunization falls below the target population, you should order less vaccines or else you may be overstocked, and vaccines may expire. Consider the time it takes for you to receive a new order of vaccines. You should keep in stock the number of doses you would normally use as you wait for the new stock (minimum stock level) usually a two weeks stock.  How to increase public participation ▪Create awareness about immunization to the community ▪Discuss the importance of immunizations with mothers ▪Create time convenience in the clinic i.e. 8am through to 5pm ▪Enhance a good client flow in the clinic ▪Reduce cost of services to affordable levels ▪Ensure high quality services e.g. availability of resources, cleanliness ▪Maintain proper records of the health activities ▪Ensure good interpersonal relationships ▪Maintain staff discipline, positive attitude, punctuality, neatness ▪Improve infrastructure e.g. access roads bridges etc Outreach and Mobile Clinic An outreach clinic is where MCH/FP services are given by staff from a health facility (static clinic) and return back the same day A mobile clinic means giving MCH/FP services to a community away from the static clinic lasting for more than one day. Services offered Comprehensive basic health services e.g. curative – treatment Preventive ------immunizations, chemoprophylaxis etc Promotive -------health messages, growth monitoring, family planning etc. Staff required PHO/PHT :Identifying defaulters and giving health messages Nutritionist : growth monitoring and follow-up Nurses :giving immunizations, Fp (contraceptive), treatment, attending to ante natal mothers, maintains records) Attendant :cleaning and running errands as directed Equipment required Make a check list of what you need for the outreach clinic Planning and organization of the outreach clinic 1. Situational analysis -Discuss your plan with colleagues in a staff meeting -Involve the DHMT for technical and material support -Involve community leaders e.g. Chief, assistant chief, village elder e.t.c. 2. Meet the community members -disseminate information about the services, days, time, venue e.t.c. Implementation Putting the activities into action. Be punctual and reliable as you embark on the planned activities for the sessions. Evaluation check on the performance and whether you are achieving the set objectives. Concept of missed opportunity for immunization A missed opportunity for immunization occurs when any eligible client comes to a health facility and does not receive any or all of the vaccine for which he or she is eligible. Possible reasons 1. the health facility does not offer immunization 2. the health workers do not use appropriate contraindications to immunizations 3. the H/workers do not routinely screen clients for their immunization status and offer the recommended vaccines 4. the H/workers fails to give all the vaccines for which the clients are eligible. 5. there is shortage of the required vaccines 6. there is shortage of other supplies like syringes and needles Ways To Reduce Missed Opportunities For Immunizations 1 Identification of missed opportunities by examining health facility records and immunization cards (child welfare and ante natal cards) 2 Conducting surveys to measure missed opportunities 3 Checking immunization status of every child 0-23 months and pregnant women visiting the facility for any reason e.g. for curative services 4. Avoiding false contra-indications to immunization e.g. fever, coryza, diarrhea and vomiting etc. Example of real contra-indication is history of convulsions. 5. Ensuring that all eligible clients have an immunization card , and that they bring the card to every clinic visit 6. All the details of the administered vaccines must be documented 7. Ensuring that those too sick and admitted are immunized during convalescent stage or before discharge from hospital 8. Ensure availability of required resources e.g. vaccines and other supplies 9. All health facilities should offer integrated health service 10.All under fives & antenatal mothers should channeled through MCH/FP for routine screening for immunizations. Social mobilization for immunization A strategy which aims at correctly, adequately, and persuasively informing the vast majority of a community to come forward to demand and use certain services Social mobilization for immunization (S M I )is an approach aimed at the promotion of good family and community health through efficient and Effective utilization of immunization services. It requires an all out effort be made to inform and support the vast majority child-bearing age women to accept to come forward, demand and use immunization services  It also involves the mobilization of resources so as to improve the availability and access to vaccines by those eligible to use them. Thus it is a demand – supply situation. Social mobilization for immunization is achieved when immunization services are offered to every one, when every one is aware and knows about these services. Objectives of social mobilization for immunizations 1 Families should be stimulated to make the intelligent, informed, and free choice of demanding and using immunization services 2 Programme managers to mobilize resources (human, and material supplies so that the services meet and satisfy the demand created Importance of social mobilization 1 Raising the immunization coverage for the target group 2 Reduction of vaccine preventable diseases (EPI target diseases) 3 Reduce drop-out rates The role of the health facility staff (implementers of social mobilization) Health education, information &communication Ordering vaccines and other supplies Administering vaccines Screening children and pregnant mothers for immunization needs Maintaining cold chain and also maintain the relevant records Evaluating immunization sessions Follow-up for defaulters The role of the CHMT (County Health Mngnt Team) in SMI 1 Assist in planning, implementing, monitoring and evaluating social mobilization activities 2 Training of the staff involved in the social mobilization activities 3 The team will continuously monitor the progress being made through planned supervisory visits 4 Evaluation and feedback 5. CHMT develops the evaluation tool 6. seeks collaboration with other government ministries in terms of manpower, equipment and transport needs during the exercise. 7. Periodic evaluation is an in-built component of the social mobilization plan of action Target groups for social mobilization for immunization Women groups, school children, teachers, politicians, religious leaders, administration personnel e.g. Chief assistant chief , Extension workers How to Enhance Patient /client flow in the Clinic 1 Use two doors, for coming in and for exit (one way traffic) 2 All stations should be labeled e.g. antenatal room, FP room 3 Place the immunization trolley at the corner to allow enough room for movements. 4 The waiting area should be common for all clinic activities 5 Allow clients to enter one after the other to prevent overcrowding 6 Using the 1st come 1st served rule with an exception of emergencies. 7 Directing clients to different stations  Effective patient/client flow will facilitate your clinic management. All under fives & pregnant mothers must be channeled to MCH/FP area, where they are offered integrated health services. Children are screened for their immunization needs, and antenatal mothers are given TT vaccine All other TTs are administered in OPD injection room. Preparation of the working area in MCH/FP 1 Clean and dust the room 2 Take out from the fridge all the vaccines you will need for the session. 3 Place vaccines in a vaccine carrier with frozen ice packs and a dial thermometer. 4 Avoid on and off opening of the fridge or vaccine carrier Simple rules during immunization session - Be warm & friendly to mothers and children - Screen the children for immunization needs - Give immunization to all children, even the sick ones unless they are too sick requiring admission. - If a child come late for immunizations , give him all the eligible vaccines. - Explain to mothers the return dates and the reaction to expect - After immunization session, return into the fridge partially used pentavalent, TT, & OPV. the others should be discarded - Maintain records , and evaluate the day’s session. THE COLD CHAIN A system of maintaining vaccines in a potent state as they travel from the manufacturer to the central stores, to regional stores, then to district stores and eventually to the consumers (from the manufacturer to the consumers) The cold chin consist of people and equipment. The people pass vaccines from : -Airport to the vaccine central stores (Nairobi) -Central stores to regional stores (Mombasa and Kisumu) -Regional stores to the District vaccine stores/ District Hospital -District stores to the health facilities. -Eventually to outreach and mobile clinics Looking after vaccines (3 rules) 1 Keep the vaccines cold (maintain vaccine potency) 2 Distribute vaccines efficiently 3 Keep cold chain equipment working Some vaccines are more sensitive to heat than others e.g. OPV is the most sensitive to heat/light whilst TT is the least sensitive. The order of their arrangement is; ❑ Polio ❑ Measles ❑ BCG ❑ Pentavalent ❑ Pneumococcal vaccine ❑ Tetanus Toxoid,  Sun rays damages vaccines easily and so vaccines should be covered at all times. Exposed vaccines become damaged(useless) and so should be discarded. Giving useless vaccines does not harm them directly but: i. It can not protect them from diseases ii. The staff waste time and effort iii. Government waste resources on useless health services iv. The people will loose their trust in the health services Rules of maintaining cold chain 1 Keep all vaccines at the recommended temperature +2 to +8 degrees Celsius. 2 Keep vaccines in order of their sensitivity to light/heat i.e. from the coldest compartment (near the freezer). Frozen pentavalent and Tetanus Toxoid granules which do not form a homogenous solution even with rigorous shaking (small white frozen white particles seen in a clear liquid) 3 Stack vaccines neatly in piles with air spaces around them. 4 Do not allow vaccines to touch the back or sides of the fridge. 5 Keep the doors of the fridge tightly closed at all times 6 Defreeze the fridge when the layer of ice is ½ - 1cm thick 7 Avoid warm needles and syringes as the vaccines may loose potency or reduce their efficacy. Efficient distribution of vaccines will ensure that the immunization services are efficient and reliable. Cold chain equipment The equipment must be of the desired quality and quantity to enable the correct storage of vaccines. Regular maintenance and minor repairs can be done by the PHT/PHO and the complicated repairs requires specialist. 1 Gas/Electricity refrigerator with assorted spare parts 2 Gas cylinders 3 Dial thermometers 4 Vaccine carrier 5 Ice packs 6 Refrigerator record sheet &instructional manual 7 Cold boxes 8 Cold rooms(in central &regional stores) Cold boxes and vaccine carriers They are designed to keep cold air inside and to prevent warm air from entering. Vaccines are placed in these containers to protect from heat. Frozen ice packs are used to keep vaccines cool in a cold chain container that is well insulated How to pack correctly 1 Place fully frozen ice packs side by side against the inside walls and floor of the cold chain container. 2 Stack the BCG,OPV and measles vaccine directly on the ice packs 3 Wrap TT & Pentavalent to prevent them from becoming frozen 4 Put a dial thermometer on top of the vaccines 5 Place ice packs over the top of the vaccine and diluents so that they are completely covered 6 Secure the lid tightly. How to keep the container in a good condition i, Leave the lid open after each use so that the inside can dry out ii, examine inside and out side surfaces after each use for cracks which should be repaired immediately. iii, check whether the rubber seal around the lid is broken which should be replaced.  iv, Oil the hinges and locks if they become stiff. v, Avoid direct sunlight, dropping or mishandling vaccine carriers as they may get damaged. ICE PACKS A plastic flat bottle filled with water and then frozen in the freezer. THE REFRIGERATOR The new KEPI refrigerators work on both gas and electricity. The ice lined refrigerator is designed to protect vaccines even in times of electricity failure. it has special walls which contain ice tubes that help to keep vaccines cold for some hours when electricity has failed. Care of the refrigerator 1 The fridge is fitted with a dial thermometer for monitoring the temperature 2 The fridge must be in good working order 3 The vaccines must remain within the recommended temperature 4 Read and record the temperature twice a day 5 Keep careful records of these temperature readings on the record sheet e.g. - The date - The time of day - The temperature now - Any period during which the power supply had failed - Any faults or problems noted How to defrost the refrigerator 1 Transfer all the vaccines from the fridge to a cold box 2 Switch off the fridge and leave it open 3 Remove all the loose ice from the cabinet by hand 4 Do not use any tools or sharp objects for removing ice or frost 5 Close the fridge door and switch it on 6 Wait until the temperature reaches the level of +4 to +8 degrees 7 Replace all the vaccines from the cold box in their correct position on the shelves. 8 Close the refrigerator door firmly Types of thermometers 1 Dial thermometers (two types) i, An alarm thermometer and can also record minimum and maximum temperature readings. They are used in central, regional and district vaccine stores. ii, The type that neither have an alarm nor the capacity to record the minimum and maximum temperature readings. They are commonly used during vaccine transportation and in the majority of the refrigerators. 2 Thermo graphic thermometers Large thermometers in-built on the walls of cold rooms that graphically record the temperature of the cold room on continues basis. They are used in large vaccine stores.  Multi Dose Vial Policy (MDVP ) The policy determines which of the opened vaccine vials may be preserved at the end of an immunization session and used the following days up to a maximum of four weeks. Freeze dried vaccines e.g. measles, BCG, Pentavalent should be discarded at the end of the session or 6 hours Oral polio vaccine (OPV) and TT (Tetanus Toxoid) can be used in subsequent visits. The policy also gives the conditions under which these vaccines may be stored and re-used without any risk 1 The expiry date has not passed 2 The vaccines are stored under appropriate cold chain conditions 3 The vaccine vial septum has not been submerged in water 4 Aseptic technique has been used to withdraw all doses 5 No visible contamination 6 The vaccine vial monitors (VVM )if attached has not reached the discard point N/B MDVP Policy does not change recommended procedures for handling reconstituted vaccines i.e. BCG, Measles yellow fever, Pentavalent vaccines. Once they are reconstituted , vials of these vaccines must be discarded at the end of the immunization session or at the end of six hours, whichever comes first.  EVALUATION OF IMMUNIZATION ACTIVITIES The purpose of evaluation is to determine whether the set targets are being met. Evaluation should be done monthly, quarterly and annually Questions to consider ✓ did we hold immunization sessions daily ✓ did we have enough vaccines ✓ did we have enough syringes an needles ✓ did we have enough human resource to run the programme ✓ was the cold chain maintained during the immunization session ? ✓ And were the refrigerator temperatures recorded twice a day, and remained in the recommended range ✓ Were the cold chain equipment adequate and in good working order? ✓ Did we check (screen ) all children and mothers who came to the clinic for their immunization needs? ✓ Any identified missed opportunities for immunizations ✓ Any important events e.g. immunization campaign? ✓ Social mobilization for immunization ? E.t.c. ✓ How many doses of antigen were given? E.g. BCG OPV Measles Pentavalent Tetanus Toxoid. How many new cases how many fully immunized ✓ Any drop-outs ? total number of children attended to total number of pregnant mothers. ✓ Were the set targets met (expected percentage Any identified problems e.g. Electricity black out , lack of some diluents Any corrective measures taken Monthly monitoring Continuous overseeing of an activity during its implementation. every month the following questions should be answered what percentage of the monthly target children received each vaccine this month? Formula to use No of children who received pentavalent 1 Monthly target population x 100 = % immunized  Formula for drop-out rate in % What % of children who received pentavalent 1 did not receive pentavalent3 No who received penta1- No eligible for penta 3 No who received penta1 x 100 =drop- out rate Are there any reported cases of EPI target diseases? If in a given month no cases are diagnosed , this should be recorded as zero cases for that month  IMMUNIZABLE DISEASES Tuberculosis A common and severe respiratory disease among children in developing countries. It is caused by Tubercle bacilli (mycobacterium tubercle) is characterized by cough, fever, (night sweats ), loss of appetite and loss of weight BCG (Bacilli Calmetti Guerin ) provides protection against serious forms of childhood tuberculosis e.g. miliary TB and TB meningitis. It is given at birth or to any one without a BCG scar up to age 15 years Poliomyelitis An infection of the spinal cord and sometimes the brain by poliomyelitis virus. The virus is passed in stools and is spread through oral -faecal route The most affected group is the infants and pre-school children. It is chacterised by paralysis of one or more limbs. The muscles of respiration may also be involved (the intercostals and the diaphragm ) Oral polio vaccine (O P V ) protects he child from poliomyelitis caused by any of the types of polio virus. It gives active artificial immunity. It is given at birth and one requires 4 doses in 4 weeks interval. Pentavalent vaccine is made from toxoids and dead bacteria of 5 different disease causing organisms e.g. Hepatitis B -----Infection of the liver transmitted through blood contact Haemophilus type b infections e.g. pneumonia, meningitis, septicaemia, osteomyelitis cellulitis e.t.c. Diphtheria --------A respiratory condition caused by diphtheria bacilli that produce lesions mainly on the throat Whooping cough-------A highly infectious respiratory disease caused by Bordetella Pertussis and is characterized by prolonged cough Tetanus ----------A disease of the nervous system caused by toxins (chemical substance ) produced by the bacteria Clostridium Tetani. The organism usually enter the body through the site of an injury. The organisms may also enter through the umbilical cord in new born babies particularly if the cord is cut with dirty instrument or is covered with dirty dressings The bacteria multiply in the body producing the toxins which affects the nerves , spinal cord and brain. The disease is characterized by involuntary contraction of muscles (spasms)  Measles vaccine -----it protects the children from measles infection. It is given at age 9months and at 18 months. Measles is an acute viral infection of the respiratory system characterized by fever and a typical body rash Tetanus toxoid (T T ) for antenatal mothers --------- It is given to pregnant mothers to sensitize their bodies to form antibodies , then they provide maternal antibodies to their unborn babies and this protect them from neonatal tetanus. TT1 is given at 1st contact or as early as possible in pregnancy. TT2 is given after four weeks Immunization schedule-----primary vaccination 1. BCG At birth or any other contact till age 15 years Birth OPV 2. Pentavalent 1 (PCV) at 6 weeks or at 1st contact after that age OPV 1 “ “ Pneumococcal 1 “ “ Rota virus 3. Pentavalent 2 at 10 weeks. 4 weeks after the 1st dose OPV 2 “ “ Pneumococcal 2 “ “ Rota virus 4. Pentavalent 3 14 weeks 4 weeks after 2nd dose OPV 3 “ “ Pneumococcal 3 “ “ 5. Measles 9 months and at 18 months. -N/B; Yellow fever vaccine is being administered to children in Baringo & Marakwet counties -Vitamin A at 6(50,000 IU), 12(100,000 IU) and 18 months(200,000 IU) Tetanus toxoid during pregnancy , or any time during child-bearing age. Other Vaccinations 1 Cholera vaccine made of killed Vibrio cholerae bacilli. It is given during epidemics , and gives 50% protection for 3-6 months only. It is of low potency 2 Salmonella typhi made of suspensions of killed bacilli. It is given for individual prophylaxis in endemic areas. It should be repeated annually. This vaccine is of little value in control of typhoid fever epidemic International travel vaccinations Travelers requiring vaccination are specified by the international health regulations e.g. Yellow fever vaccine prepared with live attenuated yellow fever virus (arbo virus ). IMMUNIZATION SCHEDULES ARE VERY IMPORTANT. They must be ; 1 Epidemiologically relevant 2 Immunologically effective 3 Operationally feasible 4 Socially acceptable Vaccines available but not yet in KEPI Programme Pneumococcal vaccine: There are two types of pneumococcal vaccine Conjugate vaccine, given together with DPT-HepB-Hib at 6, 10 and 14 weeks. Polysaccharide vaccine , which can be given to any person aged 2 yrs and above. It is Recommended for people with high risk conditions such as; ✓ Sickle cell disease and any person who has had splenectomy ✓ Immune deficiency status such as HIV, malignancy, congenital immune deficiency, transplant patients, high dose corticosteroid therapy Chronic cardiac or pulmonary diseases, Diabetes mellitus  MMR (Measles, Mumps, Rubella): given at 12-15 months Meningococcal vaccine: Polysaccharide type for age above 2 years is often used to control epidemics. A conjugate type is Currently available in developed countries. Hepatitis B (not combined): can be used at birth or outside the age when the combined vaccine is not recommended. Varicella vaccine (live attenuated varicella virus): can be given either routinely to all children, or post exposure to high risk groups e.g. immunocompromised patients without a history of having had varicella infection Rotavirus vaccine: Recommended for children from 6 months VITAMIN A SUPPLEMENTS It is an important immune booster currently recommended to all under five children. The schedule The 1st dose is at 6 months then every 6 months (twice a year) up to the age of 60 months. All mothers are given 200,000 IU immediately after birth or within 1st month of delivery. Dosage in children 12 months – 200,000 IU Details of specific vaccines and Techniques of Administration 1 Bacilli Calmetti Guerin (B C G) B C G is a freeze dried vaccine made of attenuated (weakened) tubercle bacilli. Its life span is 12 months from the date of preparation Indications BCG provides good protection against serious forms of childhood tuberculosis e.g. miliary TB and TB Meningitis Age when given -It is given at birth or at 1st contact with the child. -Give BCG to anyone who has not had tuberculosis and is between 2-15 yrs and does not have a BCG scar. -If a child has been given a BCG but no local reaction, repeat the Vaccine after 6 weeks.  Contra-indications - Acute illness needing hospitalization - Children with impaired immune responses e.g. leukemia - Those who weigh less than 2 kgs - Generalized malignancy and people who are on steroids and radio-therapy, - HIV/AIDS - Breast-feeding children of mothers on anti-TB therapy because the drugs are secreted into the breast milk and neutralize the BCG Dosage Infants below 1 year 0.05ml Children above 1 year 0.1ml How to dilute/reconstitute BCG may be supplied in three forms; 5mgs diluted with 10ml making 100 doses 2,5mg diluted with 5ml making 50 doses Less than 2.5mg diluted with 2ml making 20 doses Always read the manufacturer’s instructions 1 Dilute the vaccine under sterile conditions with a cold diluent. 2 Mix the vaccine well before filling the syringe. Withdraw the vaccine from ampoule to the syringe and then put it back into the ampoule twice or thrice to give a homogenous opaque suspension 3 Keep the diluted vaccine with green towel to protect it from light 4 BCG potency lasts for 4 hrs after reconstitution. So dilute it as soon as the 1st child appear in the morning and discard it after 4 hours. Reconstitute another vaccine when another child appears. 5 Open a BCG vial even if only one child is to given the immunization. Route of administration and site Inject BCG intradermally into the outer (dorsal) aspect of the left forearm at the junction of the upper and middle thirds.  Clean the site with dry cotton swabs - With your left hand hold the left forearm of the child and stretch the skin over the site between your left index finger and thumb - Introduce the needle upwards into the skin, keeping it as flat as possible so as to remain intra dermally Expected reaction - A wheal appears about 7-8 mm and disappears in a bout ½ hr - After 3-8 days a small red induration nodule(hard sluggish ulcer) about 10mm appears and lasts for about 2 wks. - The nodule develops into a small superficial abscess - The skin over the nodule or abscess ulcerates in a further 2wks. This ulcer heals spontaneously leaving a small scar. Side effects 1 Acute inflammatory reaction at the site of the injection 2-4 days of Immunization. It is not serious and heals rapidly on its own 2 Deep abscesses at the immunization site. These could be due to injecting the vaccine too deep into the skin. Sterile dry dressing may be applied. 3 Excessive ulceration. An ulcer which is still present more than 12wks after immunization may need application of sterile dry dressing What to do about it 1 The local lesion requires no dressing or treatment. 2 A purulent discharging ulcer needs dry dressings 3 Deep abscesses or enlarged lymph nodes may need aspirating and treatment with 10-20mg of streptomycin into abscess cavity Polio vaccine Oral polio vaccine (OPV) is a live weakened (attenuated) viral vaccine Made from the three types of polio virus. i.e. a, Brunhilde----- common in epidemics b, Lansing ------- sporadic paralytic cases c, Leon --------- few cases The vaccine comes already diluted and a dropper is provided for administration by mouth. Indication The vaccine protects the child from poliomyelitis caused by any of the three types of polio virus. It confers active artificial immunity. Age when given Give birth polio along with BCG at birth. If the child come late start 1st oral polio together with 1st pentavalent. Make sure that each child receives 4 doses of oral polio, so that the child is completely protected from paralytic poliomyelitis. The interval between doses should not be less than 4 weeks. Contra-indication 1 Severe diarrhea , the vaccine may worsen the situation 2 Vomiting 3 Children on steroids or those who are immunologically incompetent Dose 2 drops - read the manufacturer’s instructions. Route of administration and site Oral route 1 Use a dropper or device supplied to instill 2 drops into the child’s mouth. If the child does not open his mouth gently squeeze his nose between two fingers. 2 Do not touch the child’s lip or tongue with the dropper 3 If the child spits the vaccine repeat it. Side effects ---- none N/B 1 The child needs 4 doses of polio vaccine 2 Each dose must be at least one month apart 3 OPV is the most sensitive vaccine to light and heat.  Pneumococcal vaccine (PCV 10) Conjugate bacterial vaccine (pneumococci) 2 dose vial liquid vaccine, no preservative. Age (when given) First dose at 6 weeks (3 doses at the same age as pentavalent) Dose 0.5 ml, Site right upper outer thigh, Route intramuscular(IM) Indications --- pneumococcal vaccine prevents;- -Pneumonia -Meningitis -Bacteremia -Other middle ear infections (otitis-media), sinusitis and bronchitis  Contraindications - Severe allergic reactions to a previous dose - Moderate or severe illness ( temperature > 39oC), do not vaccinate until the child improves. Expected reactions (mild reactions - very common) - Irritability , crying - Swelling, redness and hotness at injection site - Transient fever