COMMUNITY HEALTH NURSING 1

LECTURE NOTES

NATIONAL HEALTH IMMUNIZATION PROGRAM

Immunization is a global health and development success story, saving millions of lives
every year. Vaccines reduce risks of getting a disease by working with your body’s natural defenses
to build protection. When you get a vaccine, your immune system responds.
Immunization is a key component of primary health care and an indisputable human right.
It’s also one of the best health investments money can buy. Vaccines are also critical to the
prevention and control of infectious-disease outbreaks. They underpin global health security and will
be a vital tool in the battle against antimicrobial resistance.

 Is one of the pioneering programs of the DOH programs that have already been
institutionalized and adopted by all local government units (LGU) in the country
 Just two years after the WHO established the program in 1974, the Philippines followed
establishing free vaccination against 6 common diseases
 Its objective is to reduce infant mortality and morbidity through decreasing the prevalence of
the seven (7) immunizable diseases (TB, diphtheria, pertussis, tetanus, polio, hepatitis B and
measles)

Why is there a need to vaccinate?

 Because vaccines save lives
 Protects children from vaccine preventable diseases that once were top killers and
disablers worldwide
 Good health promotes social development and economic growth
 Immunization is a basic right of the child and therefore no child shall be deprived of this
right

Legal Basis of NIP

 The fundamental law of the land – the 1987 Philippine Constitution – says that “The state
shall adopt a comprehensive approach to health development which shall endeavor to make
essential goods, health and other social services available to all people at affordable cost.
There shall be priority for the needs of the underprivileged, sick, elderly, disabled, women and
children” (Article 13, Sec. 11)
 Presidential Decree No. 996 (September 16, 1976) – provides for compulsory
immunization for infants and children age 8 years old and below of the 6 immunizable
diseases (TB, diphtheria, pertussis, tetanus, polio, and measles)
 Presidential Proclamation No. 6 – implementing the Expanded Program on
Immunization (EPI) in response to the United Nation’s goal of Universal Child
Immunization by 1990
 Proclamation No. 46 (September 16, 1992) – reaffirmed the Philippines’ commitment
to universal goal of eradicating polio by 2000 through child and mother immunization
 RA No 7846 – an act requiring compulsory immunization against Hepatitis B for
infants and children below 8 years old
 These include vaccination against: Tuberculosis (TB), Diphtheria, Pertussis,
Tetanus (DPT), Poliomyelitis (administered orally), Measles, Rubella, Hepatitis B in
newborns within 24 hours after birth, and Provision of other basic immunization
services for infants and children below 8 years old
 DOH Administrative Order No. 39, s 2003 (April 21, 2003) – guided the nationwide
implementation of the EPI
 RA 10152 (July 2, 2011)– an act providing for mandatory basic immunization services
for infants and children, repealing for the purpose PD 996
 Mandatory Infants and Children Health Immunization Act of 2011

Mandatory Infants and Children Health Immunization Act of 2011 (RA 10152)
 The Mandatory basic immunization for all infants and children of the following
vaccine-preventable diseases:
◦ Tuberculosis
◦ Diphtheria, pertussis and tetanus
◦ Poliomyelitis
◦ Measles (Rubeola)
 ◦ Mumps
◦ Rubella or German measles
◦ Hepatitis B
◦ H. Influenza Type B (HIB)

◦ Other types as may be determined by the Secretary of Health in a

department circular
◦ The mandatory immunization shall be given for free at any government hospital or
health centers to infants and children up to 5 years of age

 RA 7846 – provided for compulsory immunization against Hepatitis B for infants and children
below 8 years old.
◦ It also provided for Hepatitis B immunization within 24 hours after birth of babies of
women with hepatitis B

What is immunization?
 Process where a person is made resistant to an infectious disease through the
administration of a vaccine

Immunity
Passive Immunity
 Acquired through administration of products from human or animals providing short
term protection (few weeks or months)
Active Immunity
 Formed by stimulation of the immune system producing antibodies through exposure
to an infection and/or vaccination
Types of Vaccines
Live attenuated vaccines
 Weakened or modified wild viruses or bacteria
 uses a living but weakened version of the virus or one that’s very similar
 Immunity through replication of the organism in the person
 measles, mumps and rubella (MMR) vaccine and the chickenpox and shingles vaccine
are examples of this type of vaccine
 BCG, OPV, MMR, JE

Inactivated Vaccines
 Grown in media culture
 Must contain sufficient antigenic mass to stimulate desired response since it is unable
to replicate inside the host
 the disease-carrying virus or bacterium, or one very similar to it, and inactivate or kill
it using chemicals, heat or radiation

Viral Vector Vaccines

 This type of vaccine uses a safe virus to deliver specific sub-parts – called proteins – of the
germ of interest so that it can trigger an immune response without causing disease
 The safe virus then serves as a platform or vector to deliver the protein into the body.
 The protein triggers the immune response.
 The Ebola vaccine is a viral vector vaccine

Policy Statement
 Immunization is a basic right of the child therefore no child shall be deprived of this right
 The mandatory basic immunization shall be given FREE at any government hospital or
health center to infants and children up to five (5) years of age

Program Goals
 Maintenance of at least 95% Fully Immunized Child (FIC) coverage
 Maintenance of polio eradication
 Elimination of measles
 Elimination of maternal and neonatal tetanus
 Control of Diphtheria, Pertussis, Hepatitis B infection, Tuberculous Meningitis and
other disseminated forms of TB

Basic Immunization Schedule

 Giving of 1 dose of BCG at birth, birth dose of Hepatitis b vaccine, 3 doses of OPV, 3
doses of Pentavalent vaccine, 1 dose of MCV at 9 months and another 1 dose of
MCV at 10-12 months
 = FULLY IMMUNIZED CHILD (FIC)

Tetanus Diphtheria Immunization Schedule for Women

Principles of NIP
 Based on the epidemiological feature of the disease
 Mass approach
 Basic health service – given for free at the health center

Elements of NIP
 Cold chain
 Target setting
 Information, education, communication (IEC)
 Studies, surveillance and research
 Evaluation
Goals of NIP
 To immunize all infants/children against the most common vaccine-preventable
diseases
 To sustain the polio-free status of the Philippines
 To eliminate measles infection (Presidential Proc. No. 4 s. 1998 – Philippine Measles
Elimination Campaign)
 To eliminate maternal and neonatal tetanus (Presidential Proc. No. 1066 s. 1997
declared a national neonatal tetanus elimination campaign starting 1997)
 To control diphtheria, pertussis, hepatitis B and German measles
 To prevent extrapulmonary TB among children

Important Consideration on the Schedule and Administration of Immunizations

 Use only one sterile syringe and needle per client
 There is no need to restart a vaccination series regardless of the time that has elapse
between doses
 All EPI antigens are safe and effective when administered simultaneously, that is, during
same immunization session but at different sites
 It is NOT recommended 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
 If more than one injection has to be given on the same limb, the injection sites should be
2.5-5cm apart to prevent overlapping of local reactions
 The recommended sequence of the co-administration of vaccines is OPV first followed
by Rotavirus vaccine, then other appropriate vaccines
 OPV is administered by putting drops of the vaccine straight from the dropper onto the
child’s tongue. Do not let the dropper touch the tongue
 Only monovalent hepatitis B vaccine 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
 Children who have not received Anti-measles vaccine 1 (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 after the AMV1 dose
 All children entering day care centers/preschool and Grade 1 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

Vaccine Preventable Diseases

 EPIDEMIOLOGICAL FEATURE OF THE DISEASE

1. TUBERCULOSIS

Signs and Symptoms of Tuberculosis:

 General weakness
 Stunted growth
 Failure to thrive
 Loss of appetite
 Weight loss
 Fever
 Chest pain
 Night sweats
 Cough, hemoptysis, chest pain

BCG (Bacillus Calmette-Guerin) Vaccine

 Prevent milliary and meningeal TB in the first years of life
 Protects infants infected with TB from progressing to more dangerous forms
 Does not prevent TB itself; little protection against the pulmonary forms

Take Note: For BCG

 TB negative mother: given to newborn preferably 90 minutes after birth
 TB positive mother: given to newborn 1 month after a negative PPD Test
 HIV Positive Baby: do not give BCG
 Discard after 6 hours

2. HEPATITIS B

Signs and Symptoms of

Hepatitis B

 Abdominal swelling
 Abdominal bleeding
 Jaundice
 Vomiting
  95% effective in preventing chronic infection
 Monovalent, used as birth dose (within 24 hours); may be given within 7 days
 Should never be frozen

3. POLIOMYELITIS

Signs and Symptoms of Poliomyelitis

 Influenza-like symptoms:
◦ Fever, loose stools, sore throat, headache, upset stomach
 Pain/stiffness in the neck, back

 Paralysis
What is the presentation of inactivated poliovirus vaccine (IPV)?
 Liquid suspension providing protection against all 3 types of poliovirus
 Multi dose vials, 10 doses per vial
 Does not require reconstitution
 Preservatives in multi-dose vials of IPV do not meet WHO requirements to preserve the
vaccine for 28 days
 Multi-dose vials of this vaccine must be discarded at the end of the immunization session
or within 6 hours after opening, whichever comes first

Vaccines OPV and IPV

 3 doses of OPV and 1 dose of IPV produces immunity for all poliovirus types
 With OPV, vaccine associated paralytic polio (VAPP) occurs in 1 in 2.7
million, and this is associated with immunodeficiency or immunocompromised
individuals
4. DIPHTHERIA

Signs and Symptoms of Diptheria

 Sore throat, loss of appetite, fever
 Bluish-white or grey membrane at the tonsils or pharynx

Pseudo membrane
Swollen throat “Bull Neck”

5. PERTUSSIS (Whooping Cough)

Pertussis Signs and Symptoms

 Runny nose, watery eyes, fever, mild cough
 Cough worsens to rapid bursts (high pitched whoop)
6. TETANUS

Agent Clostridium tetani

Reservoir Soil, animal intestines

Spread Spores enter through wound sites

Duration of community induced -

infection

Exposure to animal feces,

Risk Factor for Infection infections with rusty metals,
untreated wounds

Signs and Symptoms of Tetanus

 Spasms and stiffness on jaw and muscles
 Difficulty swallowing
 Stiffness of abdominal muscles
 Spasms are triggered by minor occurrences (air draft, loud noise, physical
touch, light

7. HAEMOPHILUS INFLUENZA TYPE B DISEASE

Agent Haemophilus Influenza Type B

Reservoir Humans

Spread Close Respiratory Contact

Duration of community induced Usually lifelong

infection

Risk Factor for Infection Crowding

Signs and Symptoms of Haemophilus Influenza Type B

 Fever, chills, cough, rapid breathing, chest wall retractions
 Meningitis: fever, headache, sensitivity to light, neck stiffness, confusion,
altered consciousness
8. PNEUMOCOCCAL DISEASE

Bacteria (Streptococcus
Agent
Pneumonae)

Reservoir Humans

Close Respiratory Contact,

Spread
Airborne Droplets

Duration of community induced Some type-specific immunity

infection

Risk Factor for Infection Crowding

 Middle Ear Infection

(Otitis media), sinusitis,
and bronchitis (Mild case
– non-invasive)
 Freeze-sensitive vaccine
 Storage at +2 - +8
degrees Celsius
 Postpone vaccination if
the child has moderate
to severe illness with
temp >39°C

Pneumococcal Polysaccharide
Vaccine (PPV)
- 1 dose for adults

9. MEASLES (RUBEOLA)

Agent Measles virus

Reservoir Humans

Close Respiratory Contacts,

Spread
Aerosolized Droplets

Duration of community induced Lifelong

infection

Risk Factor for Infection Crowding

Signs and Symptoms

 Cough, coryza, conjunctivitis
  Rash (cephalocaudal distribution)
 Complications: pneumonia, otitis media

10. MUMPS
Agent Virus

Reservoir Humans

Close Respiratory Contact, Airborne

Spread
droplets

Duration of community induced Lifelong

infection

Risk Factor for Infection Crowding

Signs and Symptoms of Mumps

 Swelling of salivary glands
 Pain in chewing or swallowing
 Fever
 Testicular swelling and tenderness

11. GERMAN MEASLES (RUBELLA)

Agent Rubella Virus

Reservoir Humans

Close Respiratory Contact, Airborne

Spread
Droplets

Duration of community induced Lifelong

infection
 Risk Factor for Infection Crowding

Signs and Symptoms

 Usually mild in children and adults
 3-day rash, fever
 Complication: Congenital Rubella Syndrome
 Deafness, cardiac defects, cataracts, mental retardation

Forchheimer Spots on the soft palate

For persons with German Measles

12. HUMAN PAPILLOMA VIRUS

Agent Human Papilloma Virus

Reservoir Humans

Spread Sexual Intercourse

 Duration of community induced Not Known
infection

Risk Factor for Infection Unsafe Sexual Practices

 Known to be the cause of 99% of cervical cancer

 Infects skin and mucous membrane of the genital areas of men and women
 Abnormal vaginal bleeding, vaginal discharges, fatigue, weight loss

Vaccine: HPV (Bivalent, Quadrivalent, Nonavalent)

 Routinely given to females 9-10 years old
 Given twice 6 months apart

13. INFLUENZA

Agent Virus

Reservoir Humans

Close Respiratory Contacts, Airborne

Spread
Droplets

Duration of community induced infection Unknown, Weak immunity

Risk Factor for Infection Crowding

Vaccine: Seasonal Influenza Vaccine

 2 types: Trivalent and Quadrivalent
 Adults 60 years of age or older should get vaccine ideally before flu season
(May-October)

14. JAPANESE ENCEPHALITIS

Agent Virus

Reservoir Mosquitoes

Spread Bite by infected mosquito

Duration of community induced Lifelong

infection

Presence of high burden disease

Risk Factor for Infection
causing vectors

Signs and Symptoms

 Sudden onset of fever, chills, headache, nausea, vomiting
 Gastrointestinal pain
 Seizures

Vaccine: Japanese Encephalitis Vaccine (JEV)

 4 types. Live attenuated – most commonly used
 Single dose at less than 8 months old
 Contraindications: pregnancy, immunodeficient individuals 9chronic disease,
congenital problems)
15. ROTAVIRUS GASTROENTERITIS
a. A highly infectious diarrheal disease caused by strains of rotavirus infecting small intestine
b. Rotaviruses are a leading cause of severe diarrheal disease and dehydration in infants and
young children throughout the world
c. Also called as the “stomach flu”

Signs and Symptoms

 Mild loose stools to severe watery diarrhea and vomiting leading to dehydration
 Fever and vomiting can occur before diarrhea
 Incubation period can range from 1-3 days
 Diarrhea can last from 3 days to 1 week

How is Rotavirus Transmitted?

 Spreads by fecal to oral route
 Large quantities of virus can be shed in the feces of an infected child
 Shedding can occur from 2 days to 10 days after the onset of symptoms
 Rotavirus is stable in the environment and can spread via contaminated food, water
and objects

How is Rotavirus Prevented?

 Improved nutrition, good hygiene (handwashing) and sanitation

 Two oral, live, weakened rotavirus vaccine: Rotarix™ and RotaTeq™ are available
internationally
 Both are considered safe and effective in preventing gastrointestinal disease

Vaccine: Rotavirus Vaccine

 Live, attenuated virus
 Clear, colorless liquid in a container with an oral applicator

DIPHTHERIA-TETANUS VACCINE
 Weakened toxin
 Sometimes slightly turbid in appearance; clear, colorless liquid sometimes slightly
turbid
 Damaged by heat or freezing
 Store at +2 ºC to +8 ºC (body of the refrigerator)
 Given to pregnant women to protect against tetanus and neonatal tetanus
The Shake Test
 Compare the vaccine that you suspect has been frozen and thawed with vaccine from
the dame manufacturer that you are sure was never frozen:

1. Shake the containers of vaccine

2. Inspect the contents carefully
3. Leave the vaccines to stand side by side for 15-30 minutes for the sediments to
settle
4. Inspect the contents carefully again

Testing Tetanus-Diphtheria and Pentavalent Vaccine for Damage

TARGET SETTING

 Vaccine requirement is calculated based on eligible population

 The following formulas are used:
o Estimated number of infants = total population x 2.7%
o Estimated number of 12 to 59-month-old children = total population x 10.8%
o Estimated number of pregnant women = total population x 3.5%

Computation of Vaccine Requirements:

To compute vaccine requirements, use the following formula:

o Vaccine requirement for the year = eligible population x number of doses x wastage
multiplier
o The wastage multiplier may also be computed using the following formula:
Wastage multiplier = total number of doses per unit (ampule or vial)
-----------------------------------------------------------
number of doses used
o To convert vaccine requirement for the year to number of units (ampule or vial, or bottles)
divide by the number of doses per unit
Sample Computation:
To determine OPV requirement for a municipality with total population of 15,000:
Eligible population = 15,000 x.027
= 405 infants
OPV requirement = 405 infants x 3 doses for the year per infant x 1.67
= 2,029 doses

There are 20 doses/bottle of OPV. To convert doses to bottles:

Requirement for the year in bottles = Requirement for the year in doses
number of doses per bottle
= 2,029 doses
20 doses per bottle
= 101.45 bottles

If requisition of immunization supplies is done monthly, divide the number of bottles by 12

Monthly OPV requirement = 101.45 bottles
12
= 8.45 or 9 bottles per month
Note: A reserve stock of 25% of the supply period should be maintained at the facility
The Koch’s Phenomenon