EXPANDED PROGRAM ON IMMUNIZATION

 History

The World Health Organization (WHO) initiated the Expanded Program on Immunization (EPI) in May
1974 with the objective to vaccinate children throughout the world. Ten years later, in 1984, the WHO
established a standardized vaccination schedule for the original EPI vaccines:Bacillus Calmette-
Guérin (BCG), diphtheria-tetanus-pertussis (DPT), oral polio, and measles. Increased knowledge of
the immunologic factors of disease led to new vaccines being developed and added to the EPI’s list
of recommended vaccines: Hepatitis B (HepB), yellow fever in countries endemic for the disease, and
Haemophilus influenzae meningitis (Hib) conjugate vaccine in countries with high burden of disease.
[1]

In 1999, the Global Alliance for Vaccines and Immunization (GAVI) was created with the sole purpose
of improving child health in the poorest countries by extending the reach of the EPI. The GAVI
brought together a grand coalition, including the UN agencies and institutions (WHO,UNICEF,
the World Bank), public health institutes, donor and implementing countries, the Bill and Melinda
Gates Foundation and The Rockefeller Foundation, the vaccine industry, non-governmental
organizations (NGOs) and many more. The creation of the GAVI has helped to renew interest and
maintain the importance of immunizations in battling the world’s large burden of infectious diseases.

The current goals of the EPI are: to ensure full immunization of children under one year of age in
every district, to globally eradicate poliomyelitis, to reduce maternal and neonatal tetanus to an
incidence rate of less than one case per 1,000 births by 2005, to cut in half the number of measles-
related deaths that occurred in 1999, and to extend all new vaccine and preventive health
interventions to children in all districts in the world.

In addition, the GAVI has set up specific milestones to achieve the EPI goals: that by 2010 all countries
have routine immunization coverage of 90% of their child population, that HepB be introduced in 80%
of all countries by 2007 and that 50% of the poorest countries have Hib vaccine by 2005.

 The Expanded Program on Immunization (EPI) in the Philippines began in July 1979.

 With the commitment of our country to Universal Child Immunization (UCI) Goal
acceleration of EPI coverage had began in 1986.
 EPI 4 major strategies includes:
1. Sustaining high routine FIC coverage of at least 90% in all provinces and cities
2. Sustaining the polio free country for global certification
3. Eliminating measles by 2008
4. Eliminating neonatal tetanus by 2008
  Routine Schedule of Immunization
Every Wednesday is designated as immunization day and is adopted in all parts of the
country. Immunization is done monthly in barangay health stations, quarterly in remote areas of
the country.

 Routine Immunization Schedule for Infants

Minimum
Minimum Number
Interval
Vaccine Age of Dose Route Site Reason
Between
at 1st Dose Doses
Doses

BCG given at earliest

possible age
Right
protects the
Bacillus Birth or deltoid
0.05 possibility of TB
Calmette- anytime 1 -- Intradermal region
mL meningitis and other
Guérin after birth of the
TB infections in
arm
which infants are
prone

Upper
Diphtheria- An early start with
outer
Pertussis- 0.5 DPT reduces the
6 weeks 3 4 weeks Intramuscular portion
Tetanus mL chance of severe
of the
Vaccine pertussis.
thigh

The extent of
protection against
polio is increased the
Oral Polio 2-3 earlier the OPV is
6 weeks 3 4 weeks Oral Mouth
Vaccine drops given.
Keeps the
Philippines polio-
free.

Hepatitis B At birth 3 0.5 6 weeks Intramuscular Upper An early start of

Vaccine mL interval outer Hepatitis B vaccine
from portion reduces the chance
1st dose to of the of being infected
 and becoming a
carrier.
Prevents liver
cirrhosis and liver
2nd dose,
cancer which are
8 weeks
more likely to
interval
develop if infected
from thigh
with Hepatitis B
2nd dose
early in life.
to third
About 9,000 die of
dose.
complications of
Hepatits B. 10% of
Filipinos have
Hepatitis B infection

Upper At least 85% of

Measles outer measles can be
Vaccine 0.5 Subcutaneou
9 months 1 -- portion prevented by
mL s
of the immunization at this
(not MMR) arms age

 General Principles in Infant/ Child Immunization

 Because measles kills, every infant needs to be vaccinated against measles at the age of 9
months or as soon as possible after 9 months as part of the routine infant vaccination schedule.
It is safe to vaccinate a sick child who is suffering from a minor illness (cough, cold, diarrhea,
fever or malnutrition) or who has already been vaccinated against measles.
 If the vaccination schedule is interrupted, it is not necessary to restart. Instead, the schedule
should be resumed using minimal intervals between doses to catch up as quickly as possible.
 Vaccine combinations (few exceptions), antibiotics, low-dose steroids (less than 20 mg per
day), minor infections with low fever (below 38.5º Celsius), diarrhea, malnutrition, kidney or liver
disease, heart or lung disease, non-progressive encephalopathy, well controlled epilepsy or
advanced age, are not contraindications to vaccination. Contrary to what the majority of doctors
may think, vaccines against hepatitis B and tetanus can be applied in any period of the pregnan.
 There are very few true contraindication and precaution conditions. Only two of these
conditions are generally considered to be permanent: severe (anaphylactic) allergic reaction to a
vaccine component or following a prior dose of a vaccine, and encephalopathy not due to
another identifiable cause occurring within 7 days of pertussis vaccination.
 Only the diluent supplied by the manufacturer should be used to reconstitute a freeze-dried
vaccine. A sterile needle and sterile syringe must be used for each vial for adding the diluent to
the powder in a single vial or ampoule of freeze-dried vaccine.
 The only way to be completely safe from exposure to blood-borne diseases from injections,
particularly hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus
(HIV) is to use one sterile needle, one sterile syringe for each child .

 Tetanus Toxoid

When given to women of childbearing age, vaccines that contain tetanus toxoid (TT or Td) not only
protect women against tetanus, but also prevent neonatal tetanus in their newborn infants [17].

Minimum Percent
Vaccine Duration of Protection
Age/Interval Protected

As early as possible
TT1 -- --
during pregnancy

 infants born to the mother will be protected from

At least 4 weeks
TT2 80% neonatal tetanus
later
 gives 3 years protection for the mother

At least 6 months  infants born to the mother will be protected from

TT3 95%
later neonatal tetanus
 gives 5 years protection for the mother

 infants born to the mother will be protected from

TT4 At least 1 year later 99%
neonatal tetanus
 gives 10 years protection for the mother

TT5 At least 1 year later 99%  gives lifetime protection for the mother
 all infants born to that mother will be protected

In June 2000, the 57 countries that have not yet achieved elimination of neonatal tetanus were
ranked and the Philippines was listed together with 22 other countries in Class A, a classification for
countries close to maternal and neonatal tetanus elimination.
  Care for the Vaccines

To ensure the optimal potency of vaccines, careful attention is needed in handling practices at the
country level. These include storage and transport of vaccines from the primary vaccine store down
to the end-user at the health facility, and further down at the outreach sites . Inappropriate storage,
handling and transport of vaccines won’t protect patients and may lead to needless vaccine wastage.

A "first expiry and first out" (FEFO) vaccine system is practiced to assure that all vaccines are utilized
before its expiry date. Proper arrangement of vaccines and/or labeling of expiry dates are done to
identify those close to expiring. Vaccine temperature is monitored twice a day (early in the morning
and in the afternoon) in all health facilities and plotted to monitor break in the cold chain. Each level
of health facilities has cold chain equipment for use in the storage vaccines which included cold
room, freezer, refrigerator, transport box, vaccine carriers, thermometers, cold chain monitors, ice
packs, temperature monitoring chart and safety collector boxes.

 Bacillus Calmette-Guérin 

Bacillus Calmette-Guérin (or Bacille Calmette-Guérin, BCG) is a vaccine against tuberculosisthat is

prepared from a strain of the attenuated (weakened) live bovine tuberculosis
bacillus,Mycobacterium bovis, that has lost its virulence in humans by being specially cultured in an
artificial medium for years. The bacilli have retained enough strong antigenicity to become a
somewhat effective vaccine for the prevention of human tuberculosis. At best, the BCG vaccine is
80% effective in preventing tuberculosis for a duration of 15 years; however, its protective effect
appears to vary according to geography.

The history of BCG is tied to that of smallpox. Jean Antoine Villemin first recognized bovine
tuberculosis in 1854 and transmitted it, and Robert Koch first distinguished Mycobacterium
bovis from Mycobacterium tuberculosis. After the success of vaccination in preventing smallpox,
scientists thought to find a corollary in tuberculosis by drawing a parallel between bovine
tuberculosis and cow pox: It was hypothesized that infection with bovine tuberculosis might protect
against infection with human tuberculosis. In the late 19th century, clinical trials using M. bovis were
conducted in Italy with disastrous results, because M. bovis was found to be just as virulent as M.
tuberculosis

Albert Calmette, a French bacteriologist, and his assistant and later colleague, Camille Guérin, a
veterinarian, were working at the Institut Pasteur de Lille (Lille, France) in 1908. Their work included
subculturing virulent strains of the tubercle bacillus and testing different culture media. They noted
that a glycerin-bile-potato mixture grew bacilli that seemed less virulent, and changed the course of
their research to see if repeated subculturing would produce a strain that was attenuated to be
considered for use as a vaccine. The BCG vaccine was first used in humans in 1921 .
Method of administration
Except in neonates, a tuberculin skin test should always be done before administering BCG. A
reactive tuberculin skin test is a contraindication to BCG. If someone with a positive tuberculin
reaction is given BCG, there is a high risk of severe local inflammation and scarring. It is a common
misconception that tuberculin reactors are not offered BCG because "they are already immune" and
therefore do not need BCG. People found to have reactive tuberculin skin tests should be screened
for active tuberculosis.

BCG is given as a single intradermal injection at the insertion of the deltoid. If BCG is accidentally

given subcutaneously, then a local abscess may form (a BCG-oma) that may ulcerate and often
requires treatment with antibiotics. However, it is important to note that an abscess is not always
associated with incorrect administration, and it is one of the more common complications that can
occur with the vaccination. Numerous medical studies on treatment of these abscesses with
antibiotics have been done with varying results, but the general consensus of opinion is that once
pus is aspirated and analysed, providing there are no unusual bacilli present, the abscess will
generally heal spontaneously in a matter of weeks.

BCG immunization leaves a characteristic raised scar that is often used as proof of prior
immunization. The scar of BCG immunization must be distinguished from that of small pox
vaccination which it may resemble.
Other uses

 Leprosy: BCG has a small protective effect against leprosy of around 26%,although it is not
used specifically for this purpose.
 Buruli ulcer: It is possible that BCG may protect against or delay the onset of Buruli ulcer.
 Cancer Immunotherapy: BCG is useful in the treatment of superficial forms of bladder cancer.
Since the late 1980s evidence has become available that instillation of BCG into the bladder is an
effective form of immunotherapy in this disease. While the mechanism is unclear, it appears that
a local immune reaction is mounted against the tumor. Immunotherapy with BCG prevents
recurrence in up to 67% of cases of superficial bladder cancer. BCG also finds use for
immunotherapy of colorectal cancer and for the treatment of equine sarcoid in horses. There are
a number of cancer vaccines in development that use BCG as an adjuvant to provide an initial
stimulation of the patients' immune system.
 Diabetes, Type I: Clinical trials based on the work of Denise Faustman use BCG to induce
production of TNF-α which can kill the T-cellsresponsible for Type 1 diabetes. Studies using mice
 have shown that a similar treatment results in a permanent cure for about a third of the test
subjects.
 Interstitial Cystitis (IC) / Painful Bladder Syndrome (PBS): BCG has been useful in treating
some people with IC and/or PBS, which are chronic inflammatory bladder problems with
unknown etiology. It is instilled directly into the bladder. It is not clear how it works, but the
mechanism is likely immunotherapeutic, as the chronic inflammation could be the result of an
autoimmune problem.
Evaluation
Identifying the fetal heart tone, doing the Leopold’s Maneuver, mastering the vital signs and

assessing the patient’s chief concern, these are the content of my 3 weeks stay in the health center

and it has been a great experience to add another chapter of clinical practice. Using the scale of 10, I

would rate the privilege I had in the clinical exposure with 6 due to the short span of time. Though it

was a very short exposure, I learned how to do short-hand assessments with our senior year class.

In terms of our clinical instructor, I would give him a rate of 8. He was our supervisor; editor

as well as counselor and I felt the worth of the fees we’ve been investing to the university. Even if we

do not have patients, he gave us pretest to assess our knowledge as well as the post evaluation after

dealing bulks of patients.

I really hope that the institute would expand its efficacy in terms of lengthening the time of

the students’ clinical exposure. Moreover, I am looking forward for efficient professors especially in

NCM, we really need an educator who could give us a clear picture of understanding the theories

inside our books. I hope for the best education that the university can give.sss