Expanded Program on Immunization (EPI)

Immunity
Is the ability of the body to resist becoming infected upon exposure to
a microorganisms or parasite, it is classified as:
1. Nonspecific: (Skin, Mucosa Membrane, Phagocytosis)
2. Specific: (Active, Passive).
Types of Specific Immunity
A. Active immunity
 Long-term resistance, permanent – sometime lifelong (acquired
immunity naturally or artificially).
 Is stimulation of the immune system to produce antigen – specific
humeral (antibody) and cellular immunity.
 Protection produced by a person's own immune system.
Examples:
Artificial active immunity: can be induced by a vaccine
(a substance that contains antigen). A vaccine stimulates a primary
response against the antigen without causing symptoms of the
disease. e.g. vaccination.
Naturally active immunity: Naturally acquired active immunity
occurs when a person is exposed to a live pathogen, and develops
a primary immune response, which leads to immunological
memory. This type of immunity is “natural” because it is not
induced by deliberate exposure. e. g. Measles.
B. Passive immunity
 Short-term resistance (acquired naturally or artificially)
 Usually provide effective immunity but this immunity disappears
by time.

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 Examples:
Artificial passive immunity: Achieved by the transfer of
antibodies, which can be administered in several forms; as human
or animal blood plasma or serum, as pooled human
immunoglobulin for intravenous (IVIG) or intramuscular and as
monoclonal antibodies. It is also used in the treatment of several
types of acute infections and to treat poisoning.
Naturally passive immunity: refers to antibody-mediated
immunity conveyed to a fetus by its mother during pregnancy.
Maternal antibodies (MatAb) are passed through the placenta to the
fetus.
Antigen & antibody definition
 Antigen: a live or inactive substance capable of producing an
immune response, e.g. (protein, polysaccharide).
 Antibody: protein molecules (immunoglobulin) produced by
B-lymphocytes to help elimination of antigen.
The expanded program on immunization is program adopted by the
WHO in 1974, it included:
1- Child immunization: immunization of children with vaccines to
protect them against six-target disease (T.B– Poliomyelitis –
Measles– Diphtheria –Tetanus – Pertussis ), then in 1996 WHO
added Hepatitis B vaccine.
2- Vaccination of pregnant woman: with tetanus toxoid vaccine to
protect woman and newborn from neonatal tetanus.

The EPI objectives:

• Achieve and sustain high immunization coverage.
• Establish reliable diseases surveillance.
• Implement disease control and elimination.

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Immunization
- Is one of the most effective examples of the primary prevention methods
of controlling communicable diseases in population.
- Vaccines are not presently available for all communicable disease.
- Vaccination programs have been responsible for global eradication of
small box and are close to elimination others (poliomyelitis, measles).
Causes of Inadequate Immunization
1. Limited access.
2. Vaccination cost.
3. Patient disinterested.
Prevention and Control of Communicable Diseases:
 The goal of prevention and control programs: is to reduce the
prevalence of disease to a level at which it no longer poses major
public health problem.
 The goal of elimination: is to remove a disease from a large
geographical area.
 Eradication: is irreversible termination of all transmission of
infection by extermination of infectious agent worldwide (smallpox:
1980).
World Health Organization
1. Reduce mortality, disability and morbidity from vaccine preventable
diseases(VPD).
2. Attain the WHO of elimination and eradication.
3. Reduce undesirable outcomes of immunization.

Vaccine preventable diseases (VPDs)

VPDs are those preventable by currently available vaccines. The most
effectively way to prevent childhood illness, death or disability is
providing effectively immunization.

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Vaccine:
Is a suspension of live or killed microorganisms, these agents presented to
potential host to induce immunity to a specific disease caused by that
organism.
Types of Vaccine:
1. Live attenuated (Sabin–Measles–Mumps– BCG).
2. Inactivated or killed (Salk–Pertussis–Rabies).
3. Cellular fraction (Pnumoccocal Pneumonia–Meningococcal).
4. Recombined vaccine (Hepatitis B).
5. Toxoids or Antisera (Tetanus, Diphtheria).
6. Immunoglobulin (Hepatoglobulin).
7. Antitoxin (Tetaglobulin).
General Rules:
o For live vaccines, the first dose usually provides protection, the
additional doses is given to insure seroconversion; example 95% -
98% of recipients will response to a single dose of measles vaccine,
the second dose is given to insure that 100% of people are immune.
o Live attenuated vaccines generally produce long- lasting immunity
with single dose.
o The minimum interval between the injections of the same live vaccine
is 3-4 weeks.
o Decrease the interval between doses of multi-dose vaccine may
interfere with antibody response and protection.
o For the inactivated vaccines, the first dose usually does not provide
protection, the proactive immune response may not develop until
second or third doses.
o The antibody titer for inactivated vaccines may decrease below
protective levels after few years (e.g. tetanus, diphtheria), so required
multi doses and may require periodic boosting to maintain immunity.

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 Tuberculosis vaccine (BCG)

What is BCG vaccine?

• BCG vaccine protects infants' agonist tuberculosis; the letters B.C.G
stand for Bacilli Calmette –Guerin, Bacilli describes the shape of
a bacterium, Calmette and Guerin are the names of people who
developed the vaccine.
 BCG vaccine should be kept at 2°– 8°C after reconstitution.
 Must be discarded after six hours or at end of immunization
session, which comes first.
When BCG should not be given
 BCG vaccine should not be given to people who are
immunosuppressed (e.g. people have symptomatic HIV infection or
organs transplant).
 Pregnant should not be given
 Patients with past history of TB.

 Clients with acute illness with fever or systemic disorder.

 Vaccine comes in powder, it must be reconstituted with diluents

before used.

How safe is BCG vaccine and what potential side – effects are:
• Most children do have a reaction at the site of injection, normally,
when BCG vaccine is injected a small raised lump appears at the
injection site, usually disappears within 30 minutes.
After about two weeks a red sore forms that is about the size of the
end of an unsharpened pencil, the sore remains for another two weeks
and then heals and a small scar about 5 mm across remains, this is
a sign that the child has been effectively immunized.

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Other reactions include:
• Swelling or abscesses, sometimes the glands in a child's armpit or near
the elbow swell up after injection with BCG vaccine, may develop an
abscess, swollen glands or abscesses occur because an unsterile needle
or syringe was used, too much vaccine was injected, or most
commonly, the vaccine was injected incorrectly under the skin instead
of in its top layer.
• There are very few serious reactions following BCG vaccine,
generalized infection due to BCG vaccination occurs at a rate of five
per million doses of vaccine given, primarily in HIV – infected
persons or those with severe immune deficiencies.

Administration Summary: BCG Vaccine

Type of vaccine Live attenuated bacteria

Number of doses One
Schedule At or as soon as possible after birth
Booster None
Contraindication Symptomatic HIV infection
Adverse Local abscess, regional lymphadenitis (rare), distant
reactions spread to osteomyelitis, disseminated disease
Special Correct intradermal administration is essential,
precautions a special syringe and needle is used for administration
Dosage 0.05 ml
Injection site Outer upper left arm or shoulder
Injection type Intradermal (I.D.)
Storage Store between 2°– 8°C
Vaccine may be frozen for long term storage but not
the diluent.

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 Hepatitis B (Hep B) vaccine

What is hepatitis B Vaccine?

• Hepatitis B vaccine is a cloudy liquid that is provided in a single or
multi- dose vials or in prefilled auto-disable (AD) device injection.
Hep B vaccine have monovalent and vaccine is also available in
combination Hep B + DTP, Hep B + Hib vaccines.
 Only monovalent hep B vaccine should be used as a birth dose, the
dose given within the first week of life. Combination vaccines
should not be used at birth, but may be used in subsequent doses.
 If hep B vaccine stands for a long time the vaccine may separate
from the liquid, so shake the vial to mix the vaccine and liquid
before using the vaccine.
 Hep B should never be frozen.

Some people should not get hepatitis B vaccine or should wait:

 Anyone with a life-threatening allergy to baker’s yeast, or to any

other component of the vaccine, should not get hepatitis B vaccine.
Tell your provider if you have any severe allergies.
 Anyone who has had a life-threatening allergic reaction to
a previous dose of hepatitis B vaccine should not get another dose.
 Anyone who is moderately or severely ill when a dose of vaccine is
scheduled should probably wait until they recover before getting
the vaccine.
 Not harmful for pregnant woman.
 If mother's HBsAg - Positive, administer hep B vaccine +
immunoglobulin (HBIG) for infants weighting ≥ 2000g (no later
than 1 week).

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How Safe Is HB Vaccine, What Are Their Potential Side- Effects?
Hep B vaccine is one of the safest vaccines.
Mild reaction includes:
 Soreness: about 15% of adults and 5% of children have tenderness or
mild swelling at the injection site.
 Fever: about 1% to 6% of those who receive the vaccine develop
a mild fever that lasts one or two days after injection of the vaccine.
Notes: Reactions and complications due to the vaccine are rare; allergic
reactions (such as rash, difficulty in breathing, and choking) occur about
once every 600,000 doses, no fatal allergic reaction has been reported.

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 Administration summary: Hepatitis B vaccine

Type of vaccine Recombinant DNA or plasma derived or yeast.

Number of doses Four doses
Schedule In Palestine; monovalent before age 6 weeks, 2,4,6
month of age (PENTA)
Booster None
Contraindication Anaphylactic reaction to a previous dose
Adverse reactions Local soreness and redness, rarely anaphylactic
reaction
Special Birth dose must be given if there is a risk of
precautions perinatal transmission
Dosage 0.5ml – 1ml for adult
Injection site Outer mid-thigh (infants), outer upper arm (child
and adult)
Injection type Intramuscular
Storage Store between 2°– 8°C

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 Haemophilus influenzae type b (Hib) conjugate vaccine

What is Hib?
• Haemophilus influenzae type b vaccine prevents meningitis,
pneumonia, epiglottis, and other serious infections caused by
Haemophilus influenzae type b bacteria. The vaccine will not protect
against these conditions if they are caused by other agents.
• In 2000, H. influenzae type B (Hib) was estimated to have caused two
to three million cases of serious disease, notably pneumonia and
meningitis, and 450 000 deaths in young children.
• Pneumonia and meningitis are the most important diseases caused by
Hib bacteria, in developing countries, pneumonia is more common
than meningitis in children with Hib disease. Hib disease should be
suspected in the case of any child with signs and symptoms of
meningitis or pneumonia.
• Hib vaccine is available in two forms, liquid or freeze – dried, each is
available as monovalent vaccine or in combination with other
vaccines, many countries give Hib combined with DTP and Hep B
vaccines (DTP +Hep B + Hib) is called PENTA.
Some people should not get Hib vaccine or should wait:
1. People who have a life-threatening allergic reaction to a previous dose
of Hib vaccine should not get another dose.
2. Children less than 6 weeks of age should not get Hib vaccine.
3. People who are moderately or severely ill at the time the shot is
scheduled should usually wait until they recover before getting Hib
vaccine.
4. Children over 5 years old usually do not need Hib vaccine.

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5. But some older children or adults with special health conditions
should get it (include sickle cell disease, HIV/AIDS, removal of the
spleen, bone marrow transplant, or cancer treatment with drugs).
How Safe is Hib Vaccine and What are its Potential Side – Effects?
Haemophilus influenzae type b vaccine is very safe and there are no
known serious reaction to the vaccine.
Mild reactions include:
 Soreness.
 5% - 15% of those who receive Hib vaccine develop redness,
swelling, mild pain at the site of injection.
 Fever; a short time after immunization, between 2%-10% of people
may develop a mild fever.

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 Administration Summary (Hib) Conjugate Vaccine

Type of vaccine Conjugate

Number of doses 2 or 3 doses (depending on manufacturer)
Schedule 6,10,14 weeks of age for three doses schedule
(depending on manufacturer).
In Palestine; 2,4,6 month of age (PENTA)
Booster None
Contraindication Hypersensitivity to previous dose
Adverse reaction Mild local reaction
Special precaution None
Dosage 0.5ml
Injection site Outer mid-thigh for infants, outer upper arm for
older children
Injection type Intramuscular (IM)
Storage Storage between 2°– 8°C

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