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CHN211 LESSON 7
EXPANDED PROGRAMS ON IMMUNIZATION
➔ Now known as the “National Immunization Program” ➔ Immunization is an essential public health service, and it is usually offered for free. ➔ The EPI (Expanded Programs on Immunization) was established in 1976 and this is committed to guarantee free immunization service and ensures Filipinos, especially the less fortunate, have access to routinely recommended vaccines. ➔ Usually these immunizations would cover six preventable diseases:
- Tuberculosis (TB)
- Poliomyelitis
- Diphtheria
- Tetanus
- Kurtosis
- Measles ➔ These are free in health centers IMMUNIZATION WHO MEANING ➔ Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine ➔ Immunization is a proven tool for controlling and eliminating life-threatening infectious diseases. IMMUNITY ➔ The condition of being secure against any particular disease ➔ Immunity is the ability of the human body to tolerate the presence of material indigenous to the body, and to eliminate foreign material ➔ When a person goes into immunization the body becomes immune to a particular antibody TWO TYPES OF IMMUNITY
- Active Immunity
- Passive Immunity ACTIVE IMMUNITY ➔ is protection that is produced by the person’s own immune system. This type of immunity usually lasts for many years, o en during a lifetime. ➔ Active immunization is the induction of immunity a er exposure to an antigen. ➔ Antibodies are created by the recipient and may be stored permanently. ➔ Two subtypes of Active Immunity: Natural Immunity and Artificial or Vaccine-induced Immunity NATURAL ACTIVE IMMUNITY ➔ It is acquired from the exposure to the disease organisms through infection with actual disease. ➔ It can be attained through exposure, being a carrier, or if you get infected and acquire the actual disease ARTIFICIAL OR VACCINE-INDUCED ACTIVE IMMUNITY ➔ It is acquired first through introduction of the killed or weakened form of the disease. ➔ Ex. Rotavirus, BCG and AMZ though it is considered active PASSIVE IMMUNITY ➔ Is protection by products produced by an animal or human and transferred to another human, usually by injection. ➔ This passive immunity o en provides effective protection, but this protection disappears through time, usually within a few weeks or few months. ➔ Passive immunization is the transfer of active humoral immunity in the form of readymade antibodies, from one individual to another ➔ Two types Passive Immunity: Natural NATURAL PASSIVE IMMUNITY ➔ It is acquired through placenta (i.e IgG) or through breastmilk (i.e IgA) ➔ This is when a person is given antibodies through a disease rather than producing through his/her own system. ARTIFICIAL PASSIVE IMMUNITY ➔ It is getting antibodies through antibody-containing products, just like the immunoglobulin ➔ It is a transfer of active humoral immunity in a form of ready made antibodies from one individual to another. VACCINE ➔ A vaccine helps the body’s immune system to recognize and fight pathogens like viruses or bacteria, which then keeps us safe from the diseases they cause. ➔ Vaccines protects more than 25 debilitating or life threatening diseases including such as Measles, Poliomyelitis, Tetanus, Diphtheria, Meningitis, Influenza, Typhoid and Cervical Cancer Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
TYPES OF VACCINES:
- Live-attenuated vaccine (LAV)
- Inactivated vaccines (killed antigen)
- Subunit (purified antigen) a. Protein-based b. Polysaccharide c. Conjugate
- Toxoid (inactivated toxins) TYPES OF VACCINES Live-attenuated vaccine (LAV) ➔ This is available since 1950 ➔ This is derived from a disease causing pathogens or virus or bacteria that have been weakean under laboratory conditions. ➔ They will grow in a vaccinated individuals because they’re weak , they will cause no or very mild disease only Examples: BACTERIA : Tuberculosis (BCG) VIRUS : Oral polio vaccine (OPV) ● Measles ● Rotavirus ● Yellow fever Inactivated ➔ Also called as killed antigens ➔ This vaccine is made of microorganisms such as viruses, bacteria that have been killed through physical or chemical processes and this killed organisms cannot cause disease. Examples: BACTERIA : Whole-cell pertussis (wP) VIRUS : Inactivated poliovirus (IPV) Sub-Unit PROTEIN BASED ➔ This are protein based subunit vaccine present an antigen to immune system without viral particle using specific isolate protein of a antigen ➔ A weakness of this technique is that isolated protein if denatured may bind to different antibodies that are potent to a pathogen. Examples : BACTERIA : Acellular pertussis (aP) POLYSACCHARIDE ➔ Some materials of infected humans are o en protected by a polysaccharide capsules that helps organism evade the human defense system especially in infants and young children ➔ This vaccines create a response against the molecule in the pathogens capsules ➔ These molecules are small and o en not very immunogenic. ➔ So a consequence they tend to not effective in infant and young children under 18 to 24 months and only induces short term immunity Example: VIRUS : Hepatitis B (HepB) ● Pneumococcal ● Meningococcal ● Salmonella typhi CONJUGATE ➔ This also create a response against the molecules to pathogens capsule ➔ So in comparison to polysaccharide vaccines they benefit from technology that binds polysaccharides to a carrier protein that can somehow induce a long term protective response even in an infant. Examples : BACTERIA :
- Haemophilus influenzae type b (Hib)
- Pneumococcal ● PCV- ● PCV- ● PCV- Toxoid ➔ This vaccine surveys on a toxin produced by a certain bacteria, the toxin invades the bloodstream and is largely responsible for the symptoms of the disease. ➔ The protein based toxins is rendered harmless and used as an antigen in the vaccine to elicit immunity EXAMPLES: BACTERIA : ● Tetanus toxoid (TT) ● Diphtheria toxoid Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
GOALS OF THE PROGRAM
➔ These immunization targets to lower down the morbidity (occurrence and prevalence) and mortality (death) cases
- To immunize all infants/children against the most common vaccine preventable disease
- To sustain polio-free status of the Philippines
- To eliminate measles infection
- To eliminate maternal and neonatal tetanus
- To control diphtheria, pertussis, hepatitis B, and German measles
- To prevent extrapulmonary TB among children EPI DISEASES
- Tuberculosis (TB)
- Diphtheria
- Poliomyelitis (Polio)
- Measles
- Pertussis
- Tetanus
- Hepatitis B
- Yellow Fever Tuberculosis ➔ A child with a history of contact with a suspect or confirmed case of pulmonary tuberculosis. ➔ Any child who does not return to normal health a er measles or whooping cough ➔ Loss of weight, cough, and wheeze which does not respond to antibiotic therapy for acute respiratory disease ➔ Child with tuberculosis have abdominal swelling with a hard painless mass and free fluid ➔ It is caused by a bacterium ( Mycobacterium tuberculosis ) that is carried by almost 2 billion people. The disease killed more than 3 million people in 1995. It usually attacks the lungs, but other parts of the body, including the bones, joints and brain can also be affected. ➔ There is a difference between tuberculosis infection and disease. People with the infection only do not feel ill and have no symptoms. The infection may last for a lifetime and the infected person may never develop the disease. Persons with the infection but not the disease cannot spread the infection to others. HOW IS TUBERCULOSIS SPREAD? ➔ Tuberculosis is spread through the air. When a person with the disease coughs or sneezes the germs enter the air. A person inhaling air that contains TB germs may become infected. TB can spread rapidly where people are living in crowded conditions, have difficulty in obtaining medical care, and are poorly nourished. In some areas it is possible to become infected from cattle with the disease, for instance by consuming unpasteurized milk. WHAT ARE THE SIGNS AND SYMPTOMS? ➔ The symptoms of TB include general weakness, weight loss, fever and night sweats. In TB of the lungs (pulmonary TB) the symptoms include persistent cough, the coughing up of blood, and chest pain. However, in young children the only sign of pulmonary tuberculosis may be stunted growth or failure to thrive. Other signs and symptoms depend on the part of the body that is affected. For instance, in TB of the bones and joints there may be swelling, pain and crippling effects in the hips, knees or spine. WHAT ARE THE COMPLICATIONS? ➔ TB weakens the body generally, increasing the likelihood that the affected person will contract other diseases or that existing diseases will become more severe. HOW IS TUBERCULOSIS TREATED? ➔ People with TB must complete a course of curative therapy , which usually includes taking two or more anti-tuberculosis drugs for at least six months. Unfortunately, some people fail to take the medications as prescribed or to complete their course of therapy, or they may be given ineffective treatments. This may lead to multidrug-resistant TB, which can be spread to other people. HOW IS TUBERCULOSIS PREVENTED? ➔ The best protection available for children against tuberculosis infection is immunization with BCG vaccine. In persons who have been thus immunized it is impossible to determine whether a positive tuberculin skin test reaction is caused by the immunization or by infection with the TB bacterium. However, such individuals can be further examined to determine whether they are infected. Agent: ➔ Mycobacterium tuberculosis Reservoir: ➔ Man ➔ Diseased cattle Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
Sources of Infection: ➔ Droplet infection, that is through inhalation of bacilli from patients Occurrence: ➔ Worldwide ➔ Mortality and morbidity high in developing countries Transmissible Period ➔ A person who excretes tubercle bacilli is communicable ➔ The degree of communicability depends upon: ◆ The number of bacilli in the air ◆ Virulence of the bacilli ◆ Environmental conditions like overcrowding Duration of Normal Immunity ➔ Not known ➔ Reaction of old infection usually causes disease Risk Factors for Infection ➔ Low access to care ➔ Immunodeficiency ➔ Malnutrition ➔ Alcohol ➔ Diabetes Diphtheria ➔ Is an acute pharyngitis, acute nasopharyngitis, or acute laryngitis with a pseudo membrane ➔ Diphtheria is caused by a germ called Corynebacterium diphtheriae. Major epidemics have occurred in Eastern Europe and Central Asia since the late 1980s. It tends to be a disease of the colder months and of temperate climatic zones. ➔ The germ produces a toxin that can harm or destroy human body tissues and organs. One type of the disease affects the pharynx and other parts of the throat. Another type, commoner in the tropics, causes ulcers on the skin. ➔ Diphtheria affects people of all ages, but mostly non-immunized children under 15 years of age. HOW IS DIPHTHERIA SPREAD? ➔ The type of diphtheria that affects the throat is spread in droplets and secretions from the nose , throat and eyes when there is close contact between infected and uninfected people. The other type is spread through contact with skin ulcers. This form of the disease is o en disseminated on clothing and other articles that have been contaminated with fluid from skin ulcers. ➔ People infected with diphtheria usually become ill within two to four days, although the symptoms may not appear until six days have elapsed. Infected individuals can usually spread the disease to others for up to four weeks, although rarely this can happen for up to six months. During outbreaks and epidemics some children may carry the germ without showing any signs or symptoms but can still spread the disease to other people. ➔ The spread of the disease is favored in overcrowded and poor living conditions. WHAT ARE THE SIGNS AND SYMPTOMS? ➔ When diphtheria affects the throat and tonsils, the early symptoms are sore throat, loss of appetite and slight fever. ➔ Within two to three days a bluish-white or grey membrane forms in the throat and tonsils. ➔ If there is bleeding the membrane may become greyish-green or black. It sticks to the so palate of the throat, and bleeding may occur if attempts are made to remove it. The patient may recover at this point or may develop severe weakness and die within six to ten days. Patients with severe disease do not show high fever but may develop swelling of the neck and obstruction of the airway. ➔ In the type of diphtheria affecting the skin, the lesions may be painful, reddened and swollen. Any chronic skin lesions may become infected with diphtheria. WHAT ARE THE COMPLICATIONS? ➔ Abnormal heart beats may occur during the early phase of the illness or weeks later, and heart failure may result. There may be inflammation of the heart muscle and valves, leading a er many years to chronic heart disease and heart failure. Death occurs in 5-10% of cases. HOW IS DIPHTHERIA TREATED? ➔ Persons in whom diphtheria is suspected should be given diphtheria antitoxin and antibiotics such as erythromycin or penicillin , and should be isolated to avoid exposing others to the germs. Throat cultures Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
permanent paralysis. Death may occur if the muscles used for breathing are paralyzed and no respirator is available. HOW IS POLIOMYELITIS TREATED? ➔ There is no treatment but the symptoms can be relieved somewhat. Sometimes the patient has to use a respirator in order for breathing to continue. HOW IS POLIOMYELITIS PREVENTED? ➔ Polio prevention involves immunization with oral polio vaccine (OPV). Antibodies from the mother provide protection to the infant for two to three months a er birth. Infected people who recover can develop natural immunity that protects them against future infection. ➔ OPV is recommended by EPI for the eradication of polio. It is cheap, easy to give, highly effective and safe. The EPI schedule comprises four doses , starting at birth and ending at 14 weeks of age. ➔ The recommended method of prevention in children is to immunize with oral polio vaccine (OPV). Agent: ➔ Poliovirus type 1, 2, 3 Reservoir: ➔ Man. Mostly Children Sources of Infection: ➔ Fecal-oral route ➔ Oral route through pharyngeal secretion ➔ Contact with infected persons Occurrence: ➔ Cyclical ➔ Worldwide ➔ Morbidity and mortality higher in developing countries Transmissible Period ➔ 7-16 days before onset of symptoms ➔ First few days a er onset of symptoms Duration of Normal Immunity ➔ Type specific lifelong Risk Factors for Infection ➔ Poor environmental hygiene Measles ➔ Measles is a highly infectious viral disease that is spread from person to person through sneezing, coughing and close personal contact. ➔ A highly communicable disease with a history of the following: ● Generalized blotchy rash, lasting for three or more days ● Fever (38 C or “hot” to touch and ● Any of the following: ○ Cough ○ Runny nose ○ Red eyes/conjunctivitis ➔ Measles kills more children than any other of the EPI target diseases. ➔ It is caused by a virus and is highly infectious, i.e., very easily spread. It is constantly present in some populations and o en occurs in epidemic proportions. In conditions of crowding and poverty where large numbers of non-immunized people are in close contact the stage is set for measles epidemics. ➔ The disease is more severe in infants and adults than in children HOW IS MEASLES SPREAD? ➔ Measles is spread by contact with nose and throat secretions of infected people and in airborne droplets released when an infected person sneezes or coughs. Transmission by airborne droplets can occur even two hours a er an infected person has le a room or other closed area. ➔ An infected person can infect others a few days before and for several days a er he or she develops symptoms. The disease spreads easily wherever infants and children gather together. WHAT ARE THE SIGNS AND SYMPTOMS? ➔ The incubation period ranges from 7 to 18 days. The first sign of infection is a high fever lasting one to seven days. During this period there may be a runny nose, cough, red and watery eyes , and small white spots inside the cheeks. A er several days a slightly raised rash develops , spreading from the face and upper neck to the body and then to the hands and feet over a period of about three days. It lasts for five to six days and fades successively from the same areas. There may also be loss of appetite and loose stools , especially in infants. WHAT ARE THE COMPLICATIONS? ➔ Complications occur particularly in children aged under 5 years and in adults aged over 20 years. Severe diarrhea may be a problem, especially in infants, possibly causing dehydration. In children there may Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
be inflammation of the middle ear , respiratory tract infections and croup. ➔ Pneumonia is the commonest cause of death associated with measles. This is usually because the measles virus weakens the immune system. The pneumonia may be caused by the measles virus itself or by other germs. Encephalitis, a dangerous swelling of the brain, may also develop. ➔ Children aged under 12 months , if not immunized, are the most likely to acquire measles infection. Severe measles is particularly likely in poorly nourished children, especially those not receiving sufficient vitamin A, in children living in crowded conditions, and in those with immune systems that have been weakened by AIDS or other diseases. Measles is a major cause of blindness among children in Africa. People who recover from measles are immune for the rest of their lives, and infants born to mothers who have had measles are usually immune for six to eight months. HOW IS MEASLES TREATED? ➔ The treatment of children suffering complications of measles can save their lives. Vitamin A administration can help to avoid the complications of eye damage and blindness. All children with severe measles, and all children in developing countries with measles, should receive vitamin A supplementation as soon as they are seen at a health facility, and a second dose should be given the next day. General nutritional support and the treatment of dehydration with oral rehydration solution may be necessary. It is very important to encourage children with measles to eat and drink. HOW IS MEASLES PREVENTED? ➔ The prevention of measles involves immunization with measles vaccine. Children should receive one dose before the age of 1 year. In some countries, measles vaccines are combined with vaccines against the mumps and rubella viruses. Two doses of measles vaccine are recommended in some instances, as in refugee camps where there is a high probability of exposure to the disease. ➔ Children should be immunized against measles on admission to hospital because of the danger of infection. If they are aged 6-9 months the initial dose should be followed by a second as soon as possible a er the age of 9 months. Children admitted to hospital with measles should be isolated for at least four days a er the skin rash appears. Malnourished children with measles should be isolated for the duration of the illness. ➔ Some 124 million children under 5 years of age suffer vitamin A deficiency. In areas known to be deficient in vitamin A it can be given at the same time as measles vaccine or any other recommended EPI vaccine. Agent: ➔ Rubeola virus Reservoir: ➔ Humans Sources of Infection: ➔ Close respiratory contact and aerosolized droplets Occurrence: ➔ Worldwide ➔ Mortality and morbidity higher in developing countries Transmissible Period ➔ 4 days before until 2 days a er rash Duration of Normal Immunity ➔ Lifelong a er attack Risk Factors for Infection ➔ Crowding ➔ Low socio-economic status Pertussis ➔ Pertussis is a bacterial infection spread from person to person by sneezing and coughing. ➔ The disease is extremely contagious, especially where people live in crowded conditions and nutrition is poor ➔ History of severe cough and history of any of the following: ● Cough persisting 2 or more weeks ● Fits of coughing, and ● Cough followed by vomiting ➔ Also known as whooping cough, is a disease of the respiratory tract caused by a germ called Bordetella pertussis which lives in the mouth, nose and throat. Many children with pertussis have coughing spells lasting four to eight weeks. The disease is common in non-immunized children everywhere. It has become increasingly so in recent years and severe epidemics have occurred in countries where immunization Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
Neonatal Tetanus ➔ Tetanus is caused by a germ found in the natural environment. ➔ A newborn with history of all three of the following: ● Normal suck for first two days of life ● Onset of illness between 3 to 26 days ● Inability to suck followed by stiffness of the body and/or convulsions ➔ In tetanus or lockjaw , the affected person's muscles all contract, making the body stiff. The disease is particularly common and serious in newborn babies , when it is called neonatal tetanus. ➔ Tetanus is caused by the germ Clostridium tetani , which grows in dead tissue, for instance in a wound or in a baby's umbilical cord. The germ is common in the environment, o en occurring in soil containing manure. The bacteria form spores that can survive in the environment for years. The toxin they produce poisons the nerves that control the muscles, and this causes stiffness. ➔ People of all ages can catch tetanus. Neonatal tetanus kills between 500 000 and 1 million babies every year. Almost all babies who catch the disease die. It is particularly common in rural areas and tropical lowlands. HOW IS TETANUS SPREAD? ➔ Infection occurs when unclean objects puncture or cut the skin and umbilical cord and during unclean delivery practices ➔ Tetanus is not transmitted from person to person. A person may become infected if soil or dung enters a wound or cut. This may happen, for example, if a wound is made with a dirty tool. Tetanus germs are likely to grow in deep puncture wounds caused by dirty nails, needles, barbed wire, thorns, wood splinters and animal bites. ➔ A newborn baby may become infected if the knife, razor or other instrument used to cut the umbilical cord is dirty. Infection may also occur if cow dung or ash is used to dress the cord, or if soil enters the baby's navel. If the hands of the person delivering are not clean the baby may become infected. Infants and children may also contract tetanus when dirty instruments are used for circumcision, scarification and skin-piercing, and when dirt, charcoal or other unclean substances are rubbed into a wound. ➔ Neonatal tetanus remains a serious problem in countries with poor immunization coverage and unclean practices associated with childbirth. ➔ If untreated, tetanus is a very serious disease at any age. Almost every person contracting tetanus dies WHAT ARE THE SIGNS AND SYMPTOMS? ➔ In newborn babies the symptoms usually appear 4- days a er birth. The incubation period is usually between three and ten days but may be as long as three weeks. The shorter the incubation period, the higher is the risk of death. ➔ Muscular stiffness in the jaw is a common first sign. This is followed by stiffness of the neck, difficulty in swallowing, stiffness of the stomach muscles, muscle spasms, sweating and fever. ➔ Newborn babies with tetanus appear normal at birth but stop sucking three to ten days later. At 5-13 days they are still not breast-feeding, the whole body becomes stiff, severe muscle contractions and convulsions occur, and death follows in most cases. WHAT ARE THE COMPLICATIONS? ➔ Fractures of the spine or other bones may occur as a result of muscle spasms and convulsions. Abnormal heartbeat, coma, pneumonia and other infections may also occur. Death is particularly likely in very young and old age groups. ➔ Nearly all newborns with tetanus die. WHAT IS THE TREATMENT FOR TETANUS? ➔ Wounds should be thoroughly cleaned and dead tissue should be removed. For persons with wounds that are neither clean nor minor and who are not fully protected against tetanus, tetanus immune globulin should be given. Antibiotics may also be used. Persons who recover from tetanus do not have natural immunity. HOW IS TETANUS PREVENTED? ➔ The prevention of neonatal tetanus requires women of childbearing age to receive tetanus toxoid. This results in the protection of mothers and in tetanus antibodies being transferred from them to their fetuses. Infants are thus protected against the disease at birth. Clean practices during delivery and clean wound care are also very important in preventing tetanus. ➔ All children should be immunized against tetanus because antibodies transferred from the mother before birth last for only a few months. ➔ The most important way to achieve prevention is to immunize women of childbearing age and to ensure clean delivery practices. Agent: ➔ Clostridium Tetani Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
Reservoir: ➔ soil ➔ intestinal canals of animals (esp horses) ➔ man Sources of Infection: ➔ Unhygienic cutting of umbilical cord, improper handling of cord stump esp when treated with contaminated substance Occurrence: ➔ Worldwide ➔ Morbidity higher in developing countries more common in agricultural and underdeveloped areas where contact with animal excreta is more likely Transmissible Period ➔ Susceptibility is general ➔ immunity can be obtained a er 2 primary doses of tetanus toxoid at 4 weeks interval in mothers one month before delivery ➔ three booster doses increase antibody levels in mother Duration of Normal Immunity ➔ No immunity induced by infection Risk Factors for Infection ➔ Contamination of umbilical cord ➔ Agricultural work Hepatitis B ➔ It is the liver infection caused by type B of hepatitis virus. It attacks the liver o en resulting in inflammation. ➔ This disease, caused by the hepatitis B virus, affects the liver. People usually recover, but some continue to carry the virus for many years and can spread the infection to others throughout the time that they are chronic carriers. ➔ The disease occurs in both acute and chronic forms. ➔ The younger a person is on becoming infected, the less probable it is that symptoms will occur but the more probable it is that he or she will become a carrier of the disease and develop a severe liver condition later. ➔ Most people are infected by non-symptomatic carriers of the disease, and many children are infected by mothers who are carriers. HOW IS HEPATITIS B SPREAD? ➔ The hepatitis B virus is carried in the blood, saliva, semen, vaginal fluids and most other body fluids. However, it is usually spread by contact with blood in the following ways:
- Injection with unsterilized needles or syringes containing hepatitis B virus from an infected person, for instance another patient or a needle-user.
- Transmission of hepatitis B virus by mothers to their babies during the birth process, when contact with blood always occurs.
- Transmission between children during social contact through cuts, scrapes and scratches.
- Transmission during sexual intercourse through contact with blood or other body fluids ➔ The virus does not occur in an infected person's stools unless they contain blood. It does occur in the milk of infected mothers but in such small amounts that nursing can proceed. ➔ The disease occurs all over the world and can affect all age groups. Most chronic carriers are in China, South-East Asia, and Africa. ➔ The incubation period averages six weeks but may be as long as six months. WHAT ARE THE SIGNS AND SYMPTOMS? ➔ The younger a person is when infected the more likely it is that he or she will show no signs or symptoms. A person with no symptoms may remain infected for many years and can spread the infection to others. Such a person is more likely than one showing symptoms to suffer complications caused by liver damage in the long term. ➔ Infected people may feel weak and may experience stomach upsets and other influenza-like symptoms. They may also have very dark urine or very pale stools. Jaundice may appear as yellow skin or a yellow color in the whites of the eyes. The symptoms may last several weeks. General weakness and fatigue may continue for months. A laboratory blood test is required to determine with certainty whether a person has hepatitis B virus or disease. ➔ Most acute infections in adults are followed by complete recovery, and the affected people rarely become chronic carriers. However, many children, even though they are not acutely ill as a rule, do become chronic carriers, and many develop severe complications. Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
➔ Large epidemics of yellow fever occur when infected people introduce the virus into heavily populated areas with high mosquito density and where most people have little or no immunity, due to lack of vaccination. In these conditions, infected mosquitoes of the Aedes aegypti specie transmit the virus from person to person ➔ Yellow fever is prevented by an extremely effective vaccine, which is safe and affordable. ➔ A single dose of yellow fever vaccine is sufficient to confer sustained immunity and life-long protection against yellow fever disease. ➔ A booster dose of the vaccine is not needed. ➔ The vaccine provides effective immunity within 10 days for 80-100% of people vaccinated, and within 30 days for more than 99% of people vaccinated. HOW IS YELLOW FEVER SPREAD? ➔ The yellow fever virus is spread by mosquitos when they bite humans. It is not spread directly from person to person. The mosquitos act as hosts for the infection and deliver it to people, and are said to be vectors of the disease. They breed in small accumulations of stagnant water. Once infected, mosquitos carry the virus for life. ➔ Mosquitos may acquire the virus by biting either infected monkeys or infected humans , and they can subsequently spread it to humans. WHAT ARE THE SIGNS AND SYMPTOMS? ➔ The illness may be so mild that it is not noticed or diagnosed. It can be confused with malaria, hepatitis and other diseases. Three to six days a er a person has been infected by a mosquito, he or she suddenly develops fever, chills, headache, backache, general muscle pain, upset stomach and vomiting. When the disease progresses, the person becomes slow and weak and there is bleeding of the gums and blood in the urine. There may be jaundice and black vomiting. WHAT ARE THE COMPLICATIONS? ➔ The disease usually lasts two weeks , a er which the patient either recovers or dies. Death may follow convulsions and coma. In areas where the disease is endemic about 5% of infected persons die from the disease. In epidemics, when large numbers of people are infected during a short period, up to 50% of infected people may die. ➔ The hepatitis B virus is spread through contact between people's blood and other body fluids. The disease occurs in both acute and chronic forms. ➔ The younger a person is on becoming infected, the less probable it is that symptoms will occur but the more probable it is that he or she will become a carrier of the disease and develop a severe liver condition later. ➔ Most people are infected by non-symptomatic carriers of the disease, and many children are infected by mothers who are carriers. ➔ Yellow fever is diagnosed by performing a laboratory blood test. Persons recovering from yellow fever have lifelong immunity. ➔ Yellow fever causes about 30, 000 deaths annually. ➔ Children in 33 African countries are at highest risk for the disease. ➔ The disease is of short duration and can be fatal. WHAT IS THE TREATMENT FOR YELLOW FEVER? ➔ There is no specific treatment. Patients may require fluids to compensate for dehydration. HOW IS YELLOW FEVER PREVENTED? ➔ There is a safe and effective vaccine against the disease for children. ➔ The disease is prevented by immunization with yellow fever vaccine , which is given to children in a single dose , usually when they are aged 9 months and at the same time as measles vaccine. The vaccine is very safe and effective, producing antibodies against yellow fever which can last for 30 years or longer. ➔ Prevention should also involve the elimination of the accumulations of stagnant water in which the vector mosquitoes breed. EXPANDED PROGRAM ON IMMUNIZATION Immunization schedule for infants and young children ANTIGEN AGE DOSE ROUTE SITE BCG vaccine At birth 0.05 ml ID Right deltoid region arm Hepatitis b vaccine At birth 0.5 ml IM Anterolateral thigh muscle Pentavalent Vaccine 6 weeks 10 weeks 14 weeks 0.5 ml IM Anterolateral thigh muscle Oral Polio vaccine 6 weeks 10 weeks 14 weeks 2 drops Oral Mouth Anti-measles vaccine (AMV1) 9- months 0.5 ml Subcu Outer part of the upper arm Measles-mu mps-rubella vaccine (AMV2) 12- months 0.5 ml Subcu Outer part of the upper arm Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
Rotavirus 6 weeks 10 weeks 1.5ml Oral Mouth ➔ Receiving the antigens at the earliest possible age reduces the chance of the child getting infected or sick of the immunizable diseases. Administration of the hepatitis B vaccine at birth reduces the chance of the child becoming a carrier. Studies also show that measles vaccine is 85% effective. ➔ In 2012, two new vaccines were introduced as part of EPI: Rotavirus vaccine and Hib vaccine. Rotavirus infects the large intestine. It is the most common cause of severe diarrhea I infants and children. Children between the ages of 6 and 24 months are at great risk of developing severe Rotavirus infection. In the Philippines, at least 30% of diarrhea-related hospitalizations are caused by Rotavirus. ➔ Hib is a bacterium responsible for serious illness, such as meningitis and pneumonia, with almost all cases younger than 5 years, with those between 4 and 18 months of age especially vulnerable. Schedule and manner of administering infant immunizations:
- Use only sterile syringe and needle per client
- There is no need to restart a vaccination series regardless of the time that has elapsed between doses.
- All the EPI antigens are safe and effective when administered simultaneously, that is, during the same immunization session but at different sites. ● It is not recommended , however, to mix different vaccines in one syringe before injection, or to use a fluid vaccine for reconstitution of a freeze-dried vaccine. ● When a vaccine is administered to an infant at the same time with another injectable vaccine, the vaccines should be administered on different sites. ● However, if more than one injection has to be given on the same limb, t he injection sites should be 2.5-5 cm apart to prevent overlapping of local reactions.
- The recommended sequence of the coadministration of vaccines is OPV first followed by Rotavirus vaccine, then other appropriate vaccines.
- OPV is administered by putting drops of vaccine straight from the dropper onto the child’s tongue. Do not let the dropper touch the tongue.
- Only monovalent hepatitis B vaccines must be used for the birth dose. Pentavalent vaccine must not be used for the birth dose because DPT and Hib vaccine should not be given at birth. A monovalent vaccine is one that contains an antigen against a single disease. Pentavalent vaccines contain antigens against five diseases: diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae B.
- Children who have not received AMV1 as scheduled and children whose parents or caregivers do not know whether they have received AMV1 shall be given AMV1 as soon as possible, then AMV2 one month a er the AMV1 dose.
- All children entering day care centers/ preschool and Grade I shall be screened for measles immunization. Those without the immunization shall be referred to the nearest health facility for immunization.
- The first dose of Rotavirus vaccine is administered only to infants aged 6 weeks to 15 weeks. The second dose is given only to infants aged 10 weeks up to a maximum of 32 weeks.
- Administer the entire dose of the Rotavirus vaccine slowly down one side of the mouth (between the cheek and gum) with the tip of the applicator directed toward the back of the infant’s mouth. To prevent spitting or failed swallowing , stimulate the rooting or sucking reflex of the young infant. For infants aged 5 months or older , lightly stroke the throat in a downward motion to stimulate swallowing
- Use cotton in cleaning the injection site,with alcohol area it should be dried before injecting the vaccine
- BCG, AMV, AMR have special diluent and should be discarded 6 hours a er reconstitution or a er clinic hour
- Protect BCG from sunlight and Rotavirus from light
- Inform the mother or the parents on the children's immunization about common side effect.
- Usable vaccines such as OPV, Pentavalent, HepB, Tetanus toxoid, Measles for maximum 4 weeks provided the following condition onward as not pass into expiration date, appropriate conditions have been observed.
- Aseptic technique was observed during aspiration of the vaccine and the vaccine vial has not reached its discard version or the vaccine septum was not submerged in water.
- In cases of measles epidemic supplemental measles vaccine is administered depending on the age group, for under 9 months give measles vaccine to be reconstituted with 2 ampules of its special diluent to make 6 ml then administered 0.5 ml subcutaneously to the sha . For 9 months to 5 years of age give measles-mumps-rubella vaccine
- Take note of these absolute contraindications: Any serious condition that needs hospitalization and immunocompromised conditions such as AIDS. Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
EPI | VACCINES
➔ Preparations used in EPI are either inactivated (killed) microorganisms, attenuated microorganisms, fragments from microorganisms like hepatitis B vaccine, or toxoids. ➔ Attenuated vaccines are live microorganisms that have been altered so that they are no longer pathogenic, but are still antigenic. ➔ Toxoids are inactivated or altered bacterial exotoxins. TARGET SETTING AND VACCINE REQUIREMENTS Goal of EPI in the Philippines: ➔ The first specific goal of EPI in the Philippines indicates a target of 100% immunization of infants/children against the most common vaccine-preventable diseases. At the RHU/health center level, the public health nurse is responsible for ➔ preparing vaccine requirements ➔ and overseeing vaccine allocation. “Vaccine requirement is calculated based on the eligible population.” ➔ The nurse uses the following formulas to estimate eligible population: (usually done by public health nurse) Nip Target Setting ➔ Infants = Total population x 2.7% (0.027) ➔ 12 to 59 mon-old Children = Total Population x 10.8 % (0.108) ➔ Pregnant = total population x 3.5 % (0.035) Example:
- In a population of 25,000 people, how many pregnant mother ang kailangan na injectionan? → 25,000 x 0.035 = 875
- 54,000 population ilang infants ang dapat mabakunahan? → 54,000 x 0.027 = 1, The following are given Wastage Multiplier for some EPI vaccines: ● DPT, OPV, TT = 1. ● HbV = 1. ● AMV = 2. ● BCG = 2. ➔ Kapag kukuha ng vaccine sa munisipyo mag papa sobra ka kase may mga natatapon ➔ BCG and measles itatapon na a er 4 - 6 hours kapag na reconstitute Formula: Example: ➔ 5 doses of vaccine and give vaccine for pentavalent so ilang beses itong iinject? 3 beses ➔ 5 ÷ 3 = 1. Sample Computation ➔ Determine OPV requirement for a municipality w/ a total population of 15, Eligible Population ➔ 15,000 x 0.027 = 405 infants ➔ OPV Requirement for the year Vaccine Requirement for the year ➔ Eligible population x no. of doses x wastage multiplier ➔ 405 infants x 3 doses x 1.6 = 2,029 doses To convert doses to bottle for the year: ➔ 20 doses / bottle of OPV . ➔ 2,029 doses / 20 doses per bottle = 101.45 bottle Monthly Vaccine Requirements → 101.45 bottles/ 12 = 8.45 or 9 bottles per month MAINTAINING THE POTENCY OF EPI VACCINE ➔ Vaccines confer immunity only when they are potent, and to retain the potency, vaccines must be properly stored, handled, and transported. ➔ The following points are important considerations to maintain the potency of EPI vaccines. Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
COLD CHAIN ➔ A system for ensuring potency of vaccine from time of manufacturer ➔ Persons responsible: Cold chain officer ➔ At the RHU/health center, the public health nurse acts as the Cold Chain Officer. Cold Chain Equipment and Supplies ➔ This means that the nurse is in charge of maintaining the cold chain equipment and supplies, such as the ● Freezer/refrigerator, ● Transport box, ● Vaccine bags/carriers, ● Cold chain monitors, ● Thermometers, and ● Cold packs. ➔ The nurse implements an emergency plan in the event of an electrical breakdown or power failure Temperature Monitoring ➔ 2x a day, upon opening the health center in the morning and before closing ➔ It is no longer necessary to ship and store freeze dried vaccines (measles, yellow fever and BCG) at –20°C. Instead, they may be refrigerated at +2° to +8°C EPI vaccines and the special diluents have the following cold chain requirements:
- OPV: -15 to 25⁰C. OPV has to be stored in the freezer. In the vaccine bag, OPV is placed in contact with cold packs.
- All other vaccines, including measles vaccine, MMR, and Rotavirus vaccine, have to be stored in the refrigerator at a temperature of +2 to +8⁰C. These vaccines should be stocked neatly on the shelves of the refrigerator. Do not stock vaccines at the refrigerator door shelves.
- Hepatitis B vaccine, Pentavalent vaccine, Rotavirus vaccine, and TT are damaged by freezing , so they should not be stored in the freezer. Wrap the containers of these vaccines with paper before putting them in the vaccine bag with cold packs.
- Keep diluents cold by storing them in the refrigerator in the lower or door shelves. Other considerations to maintain potency
- Observe the first expiry- first out (FEFO) policy (ibig sabihin yung unang dumating na vaccine galing munisipyo kung ito ang unang ma papanis dapat nasa unahan siya sa or bunggad ng refrigerator tapos kung may bago at matagal pa ito mapapanis sa huli ito ikakabit.
- Comply with the recommended duration of storage and transport ● At health center/RHU with a refrigerator, the duration of storage should not exceed on month ● USing transport boxes, vaccines can be kept only up to maximum of 5 days
- Take note if the vaccine container has a vaccine vial monitor (VVM) and act accordingly. ● The VVM is a round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat exposure. ● A direct relationship exists between rate of color change and temperature: the lower the temperature, the slower the color change; the higher the temperature, the faster the color change.
HOW TO READ A VVM
- Abide by the Open-vial polic y of the DOH ● A multidose vial may be opened for one or two clients if the health worker feels that a client cannot come back for the scheduled immunization session. ● Multidose liquid vaccines , such as OPV, Pentavalent vaccine, hepatitis B vaccine, and TT from which one or more doses have been taken following standard sterile procedures, may be used in the next immunization sessions for up to maximum of 4 weeks, provided that all the following conditions are met: ➢ The expiry date has not passed. ➢ The vaccine has not been contaminated. ➢ The vials have been stored under appropriate cold chain conditions. ➢ The vaccine vial septum has not been submerged in water. ➢ The VVM on the vial, if attached, has not reached the discard point. Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
Tetanus toxoid Local soreness at the injection site Apply cold compress at the site. No other treatment is needed CONTRAINDICATIONS TO IMMUNIZATION ➔ In general, there are no contraindications to immunization of a sick child if the child is well enough to go home. ➔ Sending children away and telling mothers to bring them back for immunization when they are well enough is a bad practice because it delays the immunization. ➔ Bring the child back to the RHU/health center for immunization at another time may not be easy for the mother, leaving the child at risk of getting sick if an immunizable disease. There are few absolute contraindications to the EPI vaccines. DO NOT GIVE! ➔ Pentavalent vaccine/DPT to children over 5 years of age. ➔ Pentavalent vaccine/DPT to a child with recurrent convulsions or anothe r active neurological disease of the central nervous system. ➔ Pentavalent vaccine 2 or 3/DPT 2 or 3 to a child who has had convulsions or shock within 3 days of the most recent dose. ➔ Rotavirus vaccine when the child has a history of hypersensitivity to a previous dose of the vaccine , intussusceptions or intestinal malformation , or acute gastroenteritis ; and ➔ BCG to a child who has signs and symptoms of AIDS or other immune deficiency conditions or who are immunosuppressed. Some conditions are considered false contraindications. ➔ If they are seen in children, the health worker may continue with the appropriate immunizations. These are: ● Malnutrition, which should be considered as an indication that the child especially needs the protection conferred by immunization; ● Low-grade fever; ● Mild respiratory infection; and ● Diarrhea. Children with diarrhea who are due for OPV should receive a dose of OPV during the visit. However, the dose is not counted. The child should return when the next dose of OPV is due PROCEDURES IN GIVING VACCINES BCG (Intradermal site) Reconstitute: ➔ Always keep diluent cold (ref/vaccine carrier) ➔ Use 5 ml. syringe, aspirate 2 ml saline soln (diluent) ➔ Inject 2 ml Saline into vaccine the ampule of freeze dried BCG Mix ➔ Draw mixture in syringe ➔ Expel slowly in vial (Do NOT shake) ➔ Protect against sunlight (slit of foam) Inject
- Clean the skin with a cotton ball moistened with water and let the skin dry 2. Hold the child’s arm with your le hand so that your hand is under the arm, and your thumb and fingers come around the arm and stretch the skin 3. Hold the syringe in your right hand with bevel and the scale pointing up towards you 4. Let the syringe and needle almost flat alone the child’s arm 5. Insert the tip of the needle into the skin just the bevel and a little bit more. Keep the needle flat along the skin and the bevel up, so that the vaccine only goes into the upper layer of the skin 6. Put your le thumb over the needle end of the syringe to hold it in position. Hold the plunger end of the syringe between the index and middle finger of your right hand and press the plunger in the right hand 7. If the vaccine is injected correctly into the skin. A flat wheal with the surface pitted like an orange peel will appear into the injection site 8. Withdraw the need gently (do not massage) Oral Polio Vaccine
- Read the manufacturer’s instructions to determine the number of drops to be given. Used the dropper provided for:
- Let the mother hold the child lying firmly on his back
- If necessary, open the child’s moth by squeezing the cheeks gently between your fingers to make his lips point upward.
- Put drops of vaccines straight from the dropper onto child’s tongue but do not let the dropper touch child’s tongue
- Make sure that the child swallows the vaccine. If he spits it out, give another dose. Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
Hep B and DPT
- Ask the mother to hold the child across her knees so that his thigh is facing upwards. Ask her to hold the child's legs.
- Clean the skin with a cotton ball, moisten it with water and let the skin dry.
- Place your thumb and index finger on each side of the injection site and grasp the muscles slightly. The best injection is the outer part of the child's mid-thigh.
- Quickly push the needle into the space between your fingers, going deep in the muscle.
- Slightly pull the plunger back before injecting to be sure that vaccine is not injected into a vein
- Inject the vaccine. Withdraw the needle and press the injection spot quickly with a piece of cotton. Measles Vaccine Reconstitute: ➔ Using a 10 ml. Syringe fitted with a long needle, aspirate 5ml. Of special diluent, from the ampule. ➔ Empty the diluent from the syringe into the vial with the vaccine. Mix ➔ Draw mixture in syringe ➔ Expel slowly in vial (Do NOT shake) ➔ Protect against sunlight (slit of foam) ➔ Wrap Vial in Foil Inject
- Ask the mother to hold the child firmly.
- Clean the skin with a cotton ball, moistened with water and let the skin dry.
- With the fingers of one hand, pinch up the skin on the outer side of the upper arm.
- Without touching the needle, push the needle into the pinched-up skin so that it is not pointing.
- Slightly pull the plunger back to make sure that the vaccine in not injected into a vein
- Press the plunger gently and inject. Tetanus toxoid
- Shake the vial
- Clean the skin with a cotton ball, moistened with water and let skin dry.
- Place your thumb and index finger on each side of the injection and grasp the muscles, slightly. The best injection site for a women is outer side of the le upper arm.
- Slightly pull the plunger back before injecting to be sure that vaccine is not injected into a vein.
- Quickly push the needle into the space between your finger, going deep in the muscle.
- Inject the vaccine. Withdraw the needle and press the injection spot quickly with a piece of cotton SHAKE THE VIAL BEFORE EVERY INJECTION. EPI RECORDING AND REPORTING ➔ EPI recording and reporting are accomplished using the FHSIS ➔ Fully Immunized Children (FIC) are those who were given BCG, three doses of OPV, three doses of DPT and hepatitis B vaccine or three doses of Pentavalent vaccine, and one dose of anti-measles vaccine before reaching one year of age. ➔ Completely immunized child refers to children who completed their immunization schedule at the age of 12-23 months. ➔ A child protected at birth (CPAB) is a term used to describe a child whose mother has received a. To doses of TT during this pregnancy, provided that the second dose was given at least a month prior to delivery ; or b. At least three doses of TT anytime prior to pregnancy with this child ★ A er the administration of the vaccine, we made some recordings on the card that is usually given to the mother. ★ Each child has separate and own recording or paper ★ The card are usually given to the mother while the paper usually put the vaccine was given THE ROLE OF A NURSE IN IMPROVING THE DELIVERY OF IMMUNIZATION SERVICES IN COMMUNITY ➔ Actively master the list of infant eligible for vaccination in the community ➔ Immunize infants following the recommended immunization schedule, route of administration, correct dosage and following the proper cold chain storage of vaccines ➔ Disposed used syringes and needles properly by using collector box and disposing in the septic vault to prevent hazard ➔ Inform, educate and communicate with the parents ➔ To create awareness/motivate to submit their children vaccination ➔ To provide health teaching on the importance and benefits of immunization, importance of follow-up Transcribed by: Mj Beliber and Luis Mayo (BSN 2-Y1-7) Prof: Kristine Joy Anonuevo
