COMMUNITY HEALTH NURSING MA’AM PERLA

GONZALES
NCMA216 (A.Y. 24-25) FIRST SEMESTER

Expanded Program on Immunization

IMMUNIZATION bacteria, which then keeps us safe from the
Immunization is the process whereby a person is diseases they cause. Vaccines protect against
made immune or resistant to an infectious more than 25 debilitating or life-threatening
disease, typically by the administration of a diseases, including measles, polio, tetanus,
vaccine. Vaccines stimulate the body’s own diphtheria, meningitis, influenza, tetanus, typhoid
immune system to protect the person against and cervical cancer. There are many types of
vaccines, categorized by the antigen used in their
subsequent infection or disease. Immunization is
preparation. Their formulations affect how they
a proven tool for controlling and eliminating life-
are used, how they are stored, and how they are
threatening infectious diseases and is estimated administered.
to avert between 2 and 3 million deaths each
year. It is one of the most cost effective health
investments, with proven strategies that make it Types of Vaccines:
accessible to even the most hard-to-reach and Live-attenuated vaccines (LAV)
vulnerable populations. Available since the 1950s, live attenuated
vaccines (LAV) are derived from disease-
causing pathogens (virus or bacteria) that have
IMMUNITY been weakened under
Immunity is the condition of being secure against laboratory conditions. They will grow in a
any particular disease. Immunity is the ability of vaccinated individual, but because they are
the human body to tolerate the presence of weak, they will cause no or very mild disease.
material indigenous to the body, and to eliminate
foreign material. This discriminatory ability
provides protection from infectious disease, since Inactivated vaccines (killed antigen)
most microbes are identified as foreign by the Inactivated vaccines are made from
immune system. Immunity to a microbe is usually microorganisms (viruses, bacteria,
indicated by the presence of antibody to that other) that have been killed through physical or
chemical processes. These killed organisms
organism.
cannot cause disease.
There are two basic mechanisms for acquiring
immunity, active and passive.

Active immunity is protection that is produced Subunit (purified antigen)

by the person’s own immune system. a. Protein-based subunit vaccines -Protein
This type of immunity usually lasts for many based subunit vaccines present an antigen to the
years, often during a lifetime. Active immune system without viral particles, using a
immunization is the induction of immunity after specific, isolate protein of the pathogen. A
exposure to an antigen. Antibodies are weakness of this technique is that isolated
created by the recipient and may be stored proteins, if denatured, may bind to different
permanently. antibodies than the protein of the pathogen.

Passive immunity is protection by products

produced by an animal or human and b. Polysaccharide vaccines- Some bacteria
transferred to another human, usually by when infecting humans are often protected by a
injection. Passive immunity often provides polysaccharide (sugar) capsule that helps the
effective protection, but this protection wanes organism evade the human defense systems
(disappears) with time, usually within a especially in infants and young children.
few weeks or months. Passive immunization is Polysaccharide vaccines create a response
the transfer of active humoral immunity in the against the molecules in the pathogen’s capsule.
form of readymade antibodies. These molecules are small, and often not very
immunogenic.
VACCINE
vaccine helps the body’s immune system to As a consequence, they tend to:
recognize and fight pathogens like viruses or

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 Not be effective in infants and young EXPANDED PROGRAM ON

children (under 18–24 months) IMMUNIZATION
 Induce only short-term immunity The Expanded Program on Immunization (EPI)
c. Conjugate subunit vaccines- Conjugate was established in 1976 to ensure that
subunit vaccines also create a response against infants/children and mothers have access to
the molecules in the pathogen’s capsule. In routinely recommended infant/childhood
comparison to plain polysaccharide vaccines, vaccines. Six vaccine preventable diseases were
they initially included in the EPI: TB, poliomyelitis,
benefit from a technology that binds the diphtheria, tetanus, pertussis, and measles.
polysaccharide to a carrier protein that
100
can induce a long-term protective response even 9194 9093 90 9193
in infants. 90 86 86 8790 85 85
79 80 80 80
80
70
70
Toxoid (inactivated toxins) 60
Toxoid vaccines are based on the toxin produced 2003
by certain bacteria. The toxin invades the 50
bloodstream and is largely responsible for the 40
2008
symptoms of the 30
disease. The protein-based toxin is rendered 20
harmless (toxoid) and used as the 10
antigen in the vaccine to elicit immunity
0
Type of vaccine Examples BCG DPT1 DPT2 DPT3 OPV1OPV2OPV2 AMV AII
Live-attenuated BACTERIA: Tuberculosis
Percentage of children aged 12-23 months with
(BCG)
specific immunizations (information gathered
VIRUS: Oral polio vaccine
from vaccination card or mother’s report),
(OPV)
Philippines, 2003 and 2008.
: Measles
: Rotavirus The immunization coverage of children has
: Yellow fever improved (see figure 1). The 2009 National
Inactivated BACTERIA: Whole-cell Demographic and Health Survey showed that 3
pertussis (wP) out of 4 births were protected against neonatal
VIRUS: Inactivated polio virus tetanus, that is, women whose last birth was
(IPV) protected against neonatal tetanus was 76%. The
differentials in protection against neonatal
Sub-unit
tetanus among subgroups of women vary. Across
: Protein- BACTERIA: Acellular
regions, tetanus toxoid (TT) coverage ranged
based pertussis (aP)
from 39% in ARMM to 88% in Central Visayas and
VIRUS: Hepatitis B (HepB) Cagayan Valley. By level of education, TT
: Pneumococcal, coverage was lowest for women with high school
Polysaccharide Meningococcal, Salmonella education at 80% (NSO, 2009).
: Conjugate typhi
BACTERIA: Haemophilius Goals for the expanded program on
influenzae type b (Hib) immunization and supporting legislation
: Pneumococcal To achieve the over-all EPI goal of reducing the
(PCV-7, PCV-10, PCV-13) morbidity and mortality among children
Toxoid BACTERIA: Tetanus toxoid against the most common vaccine-
(TT) preventable diseases, the following laws have
: Diphtheria toxoid given the mandate of protecting children through
immunization to the DOH and LGUs:

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R.A. 10152, also known as Mandatory Infants with the infection but not the disease cannot
and Children Health Immunization Act of 2011, spread the infection to others.
mandates basic immunization covering the
vaccine-preventable diseases. Added to the six People of all ages can contract tuberculosis. It
immunizable diseases previously mentioned are spreads rapidly, particularly where people are
hepatitis B, mumps, rubella, diseases caused by living in crowded conditions, have poor access to
Haemophilus influenzae type B (Hib), and other care, and are malnourished.
diseases as determined by the Secretary of How do tuberculosis spread?
Health in a department circular. It gives the
directive to government hospitals and health Tuberculosis is spread through the air. When a
centers to provide for free mandatory basic person with the disease coughs or sneezes the
immunization to infants and children up to 5 germs enter the air. A person inhaling air that
years of age. contains TB germs may become infected. TB can
spread rapidly where people are living in crowded
R.A. 7846 provided for compulsory immunization conditions, have difficulty in obtaining medical
against hepatitis B for infants and children below care, and are poorly nourished. In some areas it is
8 years old. It also provided for hepatitis B possible to become infected from cattle with the
immunization within 24 hours after birth of babies disease, for instance by consuming unpasteurized
of women with hepatitis B. milk.
the specific goals of the program: The incubation period is 4-12 weeks but the
1. To immunize all infants/children against infection may persist for months or years before
the most common vaccine-preventable the disease develops. A person with the disease
diseases. can infect others for several weeks after he or
she begins treatment. The risk of developing TB is
2. To sustain the polio-free status of the highest in children aged under 3 years and in
Philippines. very old people, although anyone may be
affected. Persons with TB infection who have
3. To eliminate measles infection. weakened immune systems, for instance people
4. To eliminate maternal and neonatal with HIV/AIDS, are more likely to develop the
tetanus. disease than are those with normal immune
systems.
5. To control diphtheria, pertussis, hepatitis
B, and German measles. Concern about TB has been heightened recently
because some strains of the causative organism
6. To prevent extrapulmonary TB among have developed resistance to drugs.
children.
What are the signs and symptoms?
EPI Diseases The symptoms of TB include general weakness,
TUBERCULOSIS (TB) weight loss, fever and night sweats. In TB of the
Tuberculosis is caused by a lungs (pulmonary TB) the symptoms include
bacterium (Mycobacterium tuberculosis) that is persistent cough, the coughing up of blood, and
carried by almost 2 billion people. The disease chest pain. However, in young children the only
killed more than 3 million people in 1995. It sign of pulmonary tuberculosis may be stunted
usually attacks the lungs, but other parts of the growth or failure to thrive. Other signs and
body, including the bones, joints and brain can symptoms depend on the part of the body that is
also be affected. affected. For instance, in TB of the bones and
There is a difference between tuberculosis joints there may be swelling, pain and crippling
infection and disease. People with the infection effects in the hips, knees or spine.
only do not feel ill and have no symptoms. The What are the complications?
infection may last for a lifetime and the infected
person may never develop the disease. Persons

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TB weakens the body generally, increasing the People infected with diphtheria usually become ill
likelihood that the affected person will contract within two to four days, although the symptoms
other diseases or that existing diseases will may not appear until six days have elapsed.
become more severe. Infected individuals can usually spread the
disease to others for up to four weeks, although
How is tuberculosis treated? rarely this can happen for up to six months.
People with TB must complete a course of During outbreaks and epidemics some children
curative therapy, which usually includes taking may carry the germ without showing any signs or
two or more anti-tuberculosis drugs for at least symptoms but can still spread the disease to
six months. Unfortunately, some people fail to other people. The spread of the disease is favored
take the medications as prescribed or to in overcrowded and poor living conditions.
complete their course of therapy, or they may be What are the signs and symptoms?
given ineffective treatments. This may lead to
multi-drug-resistant TB, which can be spread to When diphtheria affects the throat and tonsils,
other people. the early symptoms are sore throat, loss of
appetite and slight fever. Within two to three
How is tuberculosis prevented? days a bluish-white or grey membrane forms in
The best protection available for children against the throat and tonsils. If there is bleeding the
tuberculosis infection is immunization with BCG membrane may become greyish-green or black. It
vaccine. In persons who have been thus sticks to the soft palate of the throat, and
immunized it is impossible to determine whether bleeding may occur if attempts are made to
a positive tuberculin skin test reaction is caused remove it. The patient may recover at this point
by the immunization or by infection with the TB or may develop severe weakness and die within
bacterium. However, such individuals can be six to ten days. Patients with severe disease do
further examined to determine whether they are not show high fever but may develop swelling of
infected. the neck and obstruction of the airway.

DIPHTHERIA In the type of diphtheria affecting the skin, the

Diphtheria is caused by a germ lesions may be painful, reddened and
called Corynebacterium diphtheriae. Major swollen. Any chronic skin lesions may become
epidemics have occurred in Eastern Europe and infected with diphtheria.
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 What are the complications?
can harm or destroy human body tissues and
organs. One type of the disease affects the Abnormal heart beats may occur during the early
pharynx and other parts of the throat. Another phase of the illness or weeks later, and heart
type, commoner inthe tropics, causes ulcers on failure may result. There may be inflammation of
the skin. Diphtheria affects people of all ages, but the heart muscle and valves, leading after many
mostly non-immunized children under 15 years of years to chronic heart disease and heart failure.
age. Death occurs in 5-10% of cases.

How is diphtheria spread? How is diphtheria treated?

The type of diphtheria that affects the throat is Many people who contract polio do not become
spread in droplets and secretions from the seriously ill but may spread the disease to others
nose, throat and eyes when there is close contact who may become ill
between infected and uninfected people. The
other type is spread through contact with skin
ulcers. This form of the disease is often Persons in whom diphtheria is suspected should
disseminated(spread) on clothing and other be given diphtheria antitoxin and antibiotics
articles that have been contaminated with fluid such as erythromycin or penicillin, and should
from skin ulcers. be isolated to avoid exposing others to the

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germs. Throat cultures should be obtained in headache or stomachache. Sometimes there may
order to secure correct diagnosis. Patients be pain or stiffness in the neck, back and legs.
become non-infectious about two days after the
commencement of antibiotic treatment. The most serious form of the disease is paralytic
polio. It begins with the milder forms but usually
How is diphtheria prevented? causes severe muscle pain as well as the other
symptoms. Paralysis usually develops during the
The most effective way of preventing diphtheria first week of illness. The use of one or both legs
is to maintain a high level of immunization in the or arms may be lost, and breathing may be
community. A mother can pass protective impossible without the help of a respirator. The
antibodies to her baby but this protection lasts degree of recovery varies from person to person.
only about six months.
In childhood polio there is initially a slight fever.
In most countries, diphtheria toxoid vaccine is Within three to five days the child develops a
given together with pertussis vaccine and tetanus headache, stiff neck, and muscle pain, and the
toxoid. A combination of tetanus and diphtheria fever then increases. After a further period of one
vaccine may be recommended as a booster to to three days the child becomes paralyzed in the
maintain protection every ten years. legs, arms, face or chest.
POLIOMYLITIS (POLIO) The incubation period ranges from 3 to 35 days.
Polio is caused by a virus. It is a crippling disease
Laboratory testing of the stools or throat
that can occur in adults but it is much commoner
secretions is used to confirm cases of polio.
in children.
What are the complications?
How is polio spread?
About 1% of infected children become paralyzed,
The virus enters the body through the mouth
and a larger percentage of these children have
when people eat food or drink water
some permanent paralysis. Death may occur if
contaminated by feces carrying it.
the muscles used for breathing are paralyzed and
Consequently, the disease is most likely to spread
no respirator is available.
in areas of poor sanitation. The virus enters the
bloodstream and may invade certain types of How is polio treated?
nerve cell, which it can damage or destroy.
There is no treatment but the symptoms can be
It also occurs in throat secretions, and is relieved somewhat. Sometimes the patient has to
sometimes spread in airborne droplets through use a respirator in order for breathing to
close contact with persons carrying the infection continue.
who are sneezing,or coughing, or through
exposure to throat and nose secretions in other How is polio prevented?
ways. The disease is very easily spread. Nearly all Polio prevention involves immunization with
children living in households where someone is oral polio vaccine (OPV). Antibodies from the
infected themselves become infected. Persons mother provide protection to the infant for two to
are most likely to spread the virus seven to ten three months after birth. Infected people who
days before and seven to ten days after they recover can develop natural immunity that
first experience symptoms of the disease. protects them against future infection.
Infected persons who do not have symptoms can
also spread the disease. 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,
What are the signs and symptoms? starting at birth and ending at 14 weeks of age.

People infected with the virus may not feel ill.

Some may have influenza-like symptoms such Polio is caused by a virus and can lead to
as fever, loose stools, sore throat, stomach upset, severe, possibly lifelong, paralysis.

The disease is easily spread from person to

person and from hand to mouth, through
eating food or drinking water that has beenJAKE
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Pneumonia is the commonest cause of death

associated with measles. This is usually because
MEASLES the measles virus weakens the immune system.
Measles kills more children than any other of the
The pneumonia may be caused by the measles
EPI target diseases. It is caused by a virus and is
virus itself or by other germs. Encephalitis, a
highly infectious, i.e., very easily spread. It is
dangerous swelling of the brain, may also
constantly present in some populations and often
develop.
occurs in epidemic proportions. In conditions of
crowding and poverty where large numbers of Children aged under 12 months, if not
non-immunized people are in close contact the immunized, are the most likely to acquire
stage is set for measles epidemics. The disease is measles infection. Severe measles is particularly
more severe in infants and adults than in likely in poorly nourished children, especially
children. those not receiving sufficient vitamin A, in
children living in crowded conditions, and in those
How is measles spread?
with immune systems that have been weakened
Measles is spread by contact with nose and by AIDS or other diseases. Measles is a major
throat secretions of infected people and in cause of blindness among children in Africa.
airborne droplets released when an infected
person sneezes or coughs. Transmission by
airborne droplets can occur even two hours
after an infected person has left a room or other Measles is a highly infectious viral disease
closed area. that is spread from person to person through
sneezing, coughing and close personal
An infected person can infect others a few days contact.
before and for several days after he or she
develops symptoms. The disease spreads easily
wherever infants and children gather together.
All children should receive measles vaccine
What are the signs and symptoms? before the age of 1 year.

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 People who recover from measles are immune for
be a runny nose, cough, red and watery eyes, the rest of their lives, and infants born to mothers
and small white spots inside the cheeks. After who have had measles are usually immune for six
several days a slightly raised rash develops, to eight months.
spreading from the face and upper neck to the
body and then to the hands and feet over a What is the treatment for measles?
period of about three days. It lasts for five to six The treatment of children suffering complications
days and fades successively from the same of measles can save their lives. Vitamin A
areas. There may also be loss of appetite and administration can help to avoid the
loose stools, especially in infants. complications of eye damage and blindness. All
What are the complications? children with severe measles, and all children in
developing countries with measles, should
Complications occur particularly in children aged receive vitamin A supplementation as soon as
under 5 years and in adults aged over 20 they are seen at a health facility, and a second
years. Severe diarrhea may be a problem, dose should be given the next day. General
especially in infants, possibly causing nutritional support and the treatment of
dehydration. In children there may be dehydration with oral rehydration solution may be
inflammation of the middle ear, respiratory tract necessary. It is very important to encourage
infections and croup. children with measles to eat and drink.

How is measles prevented?

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The prevention of measles involves coughing. The incubation period can be up to 21

immunization with measles vaccine. Children days.
should receive one dose before the age of 1
year. In some countries, measles vaccine is What are the signs and symptoms?
combined with vaccines against the mumps and There are usually three stages in the illness.
rubella viruses. Two doses of measles vaccine are Initially a child appears to have a common cold,
recommended in some instances, as in refugee with runny nose, watery eyes, sneezing, fever
camps where there is a high probability of and a mild cough. The cough gradually worsens
exposure to the disease. and the second stage involves numerous bursts
Children should be immunized against measles of rapid coughing. At the end of these bursts the
on admission to hospital because of the danger of child takes in air with a high-pitched whoop. The
infection. If they are aged 6-9 months the initial child may turn blue because of a lack of oxygen
dose should be followed by a second as soon as during a long burst of coughing. Vomiting and
possible after the age of 9 months. Children exhaustion often follow the coughing attacks,
admitted to hospital with measles should be which are particularly frequent at night. This
isolated for at least four days after the skin rash stage usually lasts one to six weeks but may go
appears. Malnourished children with measles on for up to ten weeks. The attacks become
should be isolated for the duration of the illness. milder with the passage of time.

Some 124 million children under 5 years of age In the third stage, when recovery takes place, the
suffer vitamin A deficiency. In areas known to be coughing gradually becomes less intense and
deficient in vitamin A it can be given at the same stops in two to three weeks. There is not usually a
time as measles vaccine or any other high fever during the illness.
recommended EPI vaccine. What are the complications?

Complications are most probable in young

PERTUSSIS infants. The commonest and the cause of most
Pertussis, or whooping cough, is a disease of the deaths is bacterial pneumonia. Convulsions and
respiratory tract caused by a germ seizures may occur, these complications arising
called Bordetella pertussis which lives in the because of the reduced oxygen supply to the
mouth, nose and throat. Many children with brain during coughing attacks or because of the
pertussis have coughing spells lasting four to toxins released by the pertussis germs. Less
eight weeks. The disease is common in non- serious complications include loss of appetite,
immunized children everywhere. It has become inflammation of the middle ear, and dehydration.
increasingly so in recent years and severe What is the treatment for pertussis?
epidemics have occurred in countries where
immunization coverage has declined. The disease Treatment with an antibiotic, usually
is most dangerous in children aged under 1 year. erythromycin, may make the illness less severe.
The use of antibiotics also reduces the ability of
How is pertussis spread? the patient to infect others because the
Pertussis spreads very easily from person to medicaments kill germs in the nose and throat.
person in droplets produced by coughing or Plenty of fluids should be given to prevent
sneezing. Most persons exposed to the germs dehydration. Sometimes people in the same
become infected. In many countries the disease household as a patient are given antibiotics to
occurs in regular epidemic cycles of three to five reduce the probability of infection.
years. The most susceptible people are the How is pertussis prevented?
youngest non-immunized children.
Prevention involves immunization with pertussis
The disease is most readily transmitted as from vaccine, which is usually given in combination
seven days after a person has been exposed to with diphtheria and tetanus vaccines. Newborns
the germs until three weeks after the start of and infants are not protected against pertussis by

Young infants are the most likely to contract

pertussis and the most likely to develop JAKE 7
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maternal antibodies. A person infected with Muscular stiffness in the jaw is a common first
pertussis usually acquires lifelong immunity. sign. This is followed by stiffness of the neck,
difficulty in swallowing, stiffness of the stomach
TETANUS muscles, muscle spasms, sweating and fever.
In tetanus or lockjaw, the affected person's
muscles all contract, making the body stiff. The Newborn babies with tetanus appear normal at
disease is particularly common and serious in birth but stop sucking three to ten days later. At
newborn babies, when it is called neonatal 5-13 days they are still not breast-feeding, the
tetanus. whole body becomes stiff, severe muscle
contractions and convulsions occur, and death
Tetanus is caused by the germ Clostridium
follows in most cases.
tetani, which grows in dead tissue, for instance in
a wound or in a baby's umbilical cord. The germ What are the complications?
is common in the environment, often occurring in
soil containing manure. The bacteria form spores Fractures of the spine or other bones may occur
that can survive in the environment for years. as a result of muscle spasms and convulsions.
The toxin they produce poisons the nerves that Abnormal heartbeat, coma, pneumonia and other
control the muscles, and this causes stiffness. infections may also occur. Death is particularly
likely in very young and old age groups.
People of all ages can catch tetanus. Neonatal
tetanus kills between 500 000 and 1 million What is the treatment for tetanus?
babies every year. Almost all babies who catch Wounds should be thoroughly cleaned and dead
the disease die. It is particularly common in rural tissue should be removed. For persons with
areas and tropical lowlands. wounds that are neither clean nor minor and who
How is tetanus spread? are not fully protected against tetanus, tetanus
immune globulin should be given.
Tetanus is not transmitted from person to
person. A person may become infected if soil or Antibiotics may also be used. Persons who
dung enters a wound or cut. This may happen, for recover from tetanus do not have natural
example, if a wound is made with a dirty tool. immunity.
Tetanus germs are likely to grow in deep How is tetanus prevented?
puncture wounds caused by dirty nails, needles,
barbed wire, thorns, wood splinters and animal The prevention of neonatal tetanus requires
bites. women of childbearing age to receive tetanus
toxoid. This results in the protection of mothers
A newborn baby may become infected if the and in tetanus antibodies being transferred from
knife, razor or other instrument used to cut the them to their fetuses. Infants are thus protected
umbilical cord is dirty. Infection may also occur if against the disease at birth. Clean practices
cow dung or ash is used to dress the cord, or if during delivery and clean wound care are also
soil enters the baby's navel. If the hands of the very important in preventing tetanus.
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.

What are the signs and symptoms?

All children should be immunized against tetanus
In newborn babies the symptoms usually appear because antibodies transferred from the mother before
4-14 days after birth. The incubation period is birth last for only a few months.

usually between three and ten days but may be

as long as three weeks. The shorter the
Tetanus is caused by a germ found in the natural
incubation period, the higher is the risk of death. environment.

Infection occurs when unclean objects puncture or cut

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HEPATITIS B Infected people may feel weak and may

This disease, caused by the hepatitis B virus, experience stomach upsets and other influenza-
affects the liver. People usually recover, but like symptoms. They may also have very dark
some continue to carry the virus for many years urine or very pale stools. Jaundice may appear as
and can spread the infection to others throughout yellow skin or a yellow color in the whites of the
the time that they are chronic carriers. eyes. The symptoms may last several weeks.
General weakness and fatigue may continue for
How is hepatitis B spread?
months. A laboratory blood test is required to
The hepatitis B virus is carried in the blood, determine with certainty whether a person has
saliva, semen, vaginal fluids and most other body hepatitis B virus or disease.
fluids. However, it is usually spread by contact
Most acute infections in adults are followed by
with blood in the following ways:
complete recovery, and the affected people rarely
 Injection with unsterilized become chronic carriers. However, many
needles or syringes containing children, even though they are not acutely ill as a
hepatitis B virus from an infected rule, do become chronic carriers, and many
person, for instance another develop severe complications.
patient or a needle-user.
What are the complications?
 Transmission of hepatitis B virus by
Infected persons who recover and do not become
mothers to their babies during
carriers possess antibodies and are protected
the birth process, when contact
throughout their lives.
with blood always occurs.
The consequences of acute infection can be
 Transmission between children
severe. Death occurs in a small percentage of
during social contact through
adults. Most serious complications, including
cuts, scrapes and scratches.
chronic hepatitis, cirrhosis, liver failure and liver
 Transmission during sexual cancer, occur in persons with chronic infection.
intercourse through contact with
What is the treatment for hepatitis B?
blood or other body fluids.
There is no treatment for the acute condition. In
The virus does not occur in an infected person's
chronic infection the disease can sometimes be
stools unless they contain blood. It does occur in
stopped by certain medications.
the milk of infected mothers but in such small
amounts that nursing can proceed.
Most babies born to mothers who are carriers also become
carriers.
The disease occurs all over the world and can
affect all age groups. Most chronic carriers are in About 25% of untreated babies who are infected with
China, South-East Asia, and Africa. hepatitis B virus subsequently develop severe chronic liver
disease or even liver cancer.
The incubation period averages six weeks but
may be as long as six months.
How is hepatitis B prevented?
What are the signs and symptoms?
Safe and effective hepatitis B vaccine is available.
The younger a person is when infected the more EPI recommends that children receive three
likely it is that he or she will show no signs or doses during the first year of life, the first dose
symptoms. A person with no symptoms may being administered either at birth or at about six
remain infected for many years and can spread weeks of age on the occasion of the first clinic
the infection to others. Such a person is more visit, and the third at 14 weeks. If possible, all
likely than one showing symptoms to suffer pregnant women should be tested to determine
complications caused by liver damage in the long whether they carry the virus in their blood. Babies
term. of mothers who are carriers should then receive
an injection of hepatitis B antibodies (hepatitis B

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NCMA216 (A.Y. 24-25) FIRST SEMESTER

immune globulin) together with the first dose of the urine. There may be jaundice and black
vaccine at birth. vomiting.

In some countries the hepatitis B vaccine is What are the complications?

offered to or recommended for adolescents and
young adults, since the virus is sexually The disease usually lasts two weeks, after which
transmitted and is also easily spread through the patient either recovers or dies. Death may
needle-sharing. follow convulsions and coma. In areas where the
disease is endemic about 5% of infected persons
Persons with hepatitis B virus should not donate die from the disease. In epidemics, when large
blood and should not allow other persons to come numbers of people are infected during a short
into contact with their blood or other body fluids. period, up to 50% of infected people may die.
They should use barrier methods when having
sex and should not share eating utensils, Yellow fever is diagnosed by performing a
toothbrushes, needles or razors with other laboratory blood test. Persons recovering from
people. yellow fever have lifelong immunity.

Health care workers should use all necessary

precautions with all patients because patients
who are carriers of the virus can spread the
infection to them quite easily through blood What is the treatment for yellow fever?
contact.
There is no specific treatment. Patients may
YELLOW FEVER require fluids to compensate for dehydration.
Yellow fever, an acute disease of short duration,
is caused by a virus. It occurs in tropical and How is yellow fever prevented?
subtropical areas, mainly in sub-Saharan Africa The disease is prevented by immunization with
and Central and South America, and affects yellow fever vaccine, which is given to children in
people of all ages. a single dose, usually when they are aged 9
How is yellow fever spread? months and at the same time as measles
vaccine. The vaccine is very safe and effective,
The yellow fever virus is spread by mosquitos producing antibodies against yellow fever which
when they bite humans. It is not spread directly can last for 30 years or longer.
from person to person. The mosquitos act as
hosts for the infection and deliver it to people, Prevention should also involve the elimination of
and are said to be vectors of the disease. They the accumulations of stagnant water in which the
breed in small accumulations of stagnant water. Yellow fever causes about 30 000 deaths annually.
Once infected, mosquitos carry the virus for life.
Children in 33 African countries are at highest risk for the
Mosquitos may acquire the virus by biting either disease.
infected monkeys or infected humans, and they The disease is of short duration and can be fatal.
can subsequently spread it to humans.
Yellow fever is caused by a virus that is transmitted by
What are the signs and symptoms? mosquitos.

The illness may be so mild that it is not noticed or It is an acute disease from which patients either recover
diagnosed. It can be confused with malaria, completely or die.
hepatitis and other diseases. Three to six days There is a safe and effective vaccine against the disease
after a person has been infected by a mosquito, for children.
he or she suddenly develops fever, chills,
headache, backache, general muscle pain. upset vector mosquitos breed.
stomach and vomiting. When the disease
progresses, the person becomes slow and weak
and there is bleeding of the gums and blood in

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NCMA216 (A.Y. 24-25) FIRST SEMESTER

Immunization schedule for infants and Rotavirus infection. In the Philippines, at least
young children 30% of diarrhea-related hospitalizations are
Immunization is an essential health intervention caused by Rotavirus.
for eligible children and women, and this service
Hib is a bacterium responsible for serious illness,
is available in all health facilities and institutions
such as meningitis and pneumonia, with almost
providing health services for women and children
all cases younger than 5 years, with those
nationwide. Wednesday is the immunization day
between 4 and 18 months of age especially
in government health facilities unless otherwise
vulnerable.
revised by local traditions, customs, and other
exceptions. The following are important considerations
Antigen Age Dose Route Site related to the schedule and manner of
administering infant immunizations:
BCG vaccine At birth 0.05 ml Intradermal Right deltoid
region (arm)

Hepatitis B At birth 0.5 ml Intramuscular Anterolateral

vaccine thigh muscle
 Use only sterile syringe and needle per client
DPT-HepB-Hib 6 weeks 0.5 ml Intramuscular Anterolateral  There is no need to restart a vaccination series
thigh muscle regardless of the time that has elapsed
(Pentavalent 10
vaccine) weeks between doses.
 All the EPI antigens are safe and effective when
14
weeks administered simultaneously, that is, during
the same immunization session but at different
Oral polio 6 weeks 2 drops Oral Mouth
vaccine
sites. It is not recommended, however, to mix
10 different vaccines in one syringe before
weeks injection, or to use a fluid vaccine for
14 reconstitution of a freeze-dried vaccine. When
weeks a vaccine is administered to an infant at the
Anti-measles 9-11 0.5 ml Subcutaneous Outer part of the same time with another injectable vaccine, the
vaccine months upper arm vaccines should be administered on different
(AMV1)
sites. However, if more than one injection has
to be given on the same limb, the injection
Measles- 12-15 0.5 ml Subcutaneous Outer part of the
sites should be 2.5-5cm apart to prevent
mumps- months upper arm
rubella overlapping of local reactions.
vaccine  The recommended sequence of the
(AMV2)
coadministration of vaccines is OPV first
Rotavirus 6 weeks 1.5 ml Oral Mouth followed by Rotavirus vaccine, then other
vaccine
10 appropriate vaccines.
weeks  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.
Receiving the antigens at the earliest possible  Only monovalent hepatitis B vaccine must be
used for the birth dose. Pentavalent vaccine
age reduces the chance of the child getting
must not be used for the birth dose because
infected or sick of the immunizable diseases. DPT and Hib vaccine should not be given at
Administration of the hepatitis B vaccine at birth birth. A monovalent vaccine is one that
reduces the chance of the child becoming a contains an antigen against a single disease.
carrier. Studies also show that measles vaccine is Pentavalent vaccines contain antigens against
85% effective. five diseases: diphtheria, pertussis, tetanus,
hepatitis B, and Hemophilus influenzae B.
In 2012, two new vaccines were introduced as  Children who have not received AMV1 as
part of EPI: Rotavirus vaccine and Hib vaccine. scheduled and children whose parents or
Rotavirus infects the large intestine. It is the most caregivers do not know whether they have
common cause of severe diarrhea I infants and received AMV1 shall be given AMV1 as soon as
children. Children between the ages of 6 and 24 possible, then AMV2 one month after the AMV1
dose.
months are at great risk of developing severe

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 All children entering day care centers/ and overseeing vaccine allocation. Vaccine
preschool and Grade I shall be screened for requirement is calculated based on eligible
measles immunization. Those without the population. The nurse uses the following formulas
immunization shall be referred to the nearest
to estimate eligible population:
health facility for immunization.
 The first dose of Rotavirus vaccine is Estimated number of infants=total population x 2.7 %
administered only to infants aged 6 weeks to
15 weeks. The second dose is given only to Estimated number of 12 ¿ 59 month old children=total popula
infants aged 10 weeks up to a maximum of 32
weeks. Estimated number of pregnant women=total population x 3.5
 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 Maintaining the potency of EPI vaccines
months or older, lightly stroke the throat in a Vaccines confer immunity only when they are
downward motion to stimulate swallowing. potent, and to retain the potency, vaccines must
be properly stored, handled, and transported. The
EPI Vaccines following points are important considerations to
Preparations used in EPI are either inactivated (killed)
maintain the potency of EPI vaccines.
microorganisms, attenuated microorganisms,
fragments from microorganisms like hepatitis B Maintain the COLD CHAIN
vaccine, or toxoids. Attenuated vaccines are live The cold chain is a system for ensuring the
microorganisms that have been altered so that they
potency of a vaccine from the time of
are no longer pathogenic, but are still antigenic.
Toxoids are inactivated or altered bacterial exotoxins.
manufacture to the time it is given to an eligible
client.
Vaccine Contents Form
BCG (Bacillus
Calmette-
Live, attenuated bacteria Freeze-dried, reconstituted
with a special diluent
The person directly responsible for cold chain
Guerin) management at each level is called the Cold
Hepatitis B
vaccine
RNA-recombinant, using Hepatitis
B surface antigen (HBs Ag)
Cloudy, liquid, in an auto-
disable injection syringe if
Chain Officer. At the RHU/health center, the
available public health nurse acts as the Cold Chain Officer.
DPT-HepB-Hib Diphtheria toxoid, inactivated Liquid, in an auto-disable
(Pentavalent pertussis bacteria, tetanus toxoid, injection syringe
This means that the nurse is in charge of
vaccine) recombinant DNA surface antigen, maintaining the cold chain equipment and
and synthetic conjugate of
Haemophilus influenzae B bacilli supplies, such as the freezer/refrigerator,
Oral polio Live, attenuated virus (trivalent) Clear, pinkish liquid transport box, vaccine bags/carriers, cold chain
vaccine
Anti-measles Live, attenuated virus Freeze-dried, reconstituted
monitors, thermometers, and cold packs. The
vaccine (AMV1) with a special diluent nurse implements an emergency plan in the
Measles- Live, attenuated viruses Freeze-dried, reconstituted
mumps-rubella with a special diluent
event an electrical breakdown or power failure.
vaccine (AMV2)
Rotavirus Live, attenuated virus Clear, colorless liquid, in a EPI vaccines and the special diluents have the
vaccine container with an oral
applicator
following cold chain requirements:
Tetanus toxoid Weakened toxin Sometimes slightly turbid in
appearance: Clear, colorless  OPV: -15 to 25⁰C. OPV has to be stored
liquid; sometimes slightly
turbid… in the freezer. In the vaccine bag, OPV
is placed in contact with cold packs.

Target setting and vaccine requirements  All other vaccines, including measles
The first specific goal of EPI in the Philippines vaccine, MMR, and Rotavirus vaccine,
indicates a target of 100% immunization of have to be stored in the refrigerator at
infants/children against the most common a temperature of +2 to +8⁰C. These
vaccine-preventable diseases. At the RHU/health vaccines should be stocked neatly on
center level, the public health nurse is the shelves of the refrigerator. Do not
responsible for preparing vaccine requirements stock vaccines at the refrigerator door
shelves.

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 Hepatitis B vaccine, Pentavalent which one or more doses have been taken
vaccine, Rotavirus vaccine, and TT are following standard sterile procedures,
damaged by freezing, so they should may be used in the next immunization
not be stored in the freezer. Wrap the sessions for up to maximum of 4
containers of these vaccines with weeks, provided that all the following
paper before putting them in the conditions are met:
vaccine bag with cold packs. o The expiry date has not passed.
o The vaccine has not been
 Keep diluents cold by storing them in
contaminated.
the refrigerator in the lower or door
o The vials have been stored under
shelves.
appropriate cold chain conditions.
Other considerations to maintain potency o The vaccine vial septum has not
been submerged in water.
 Observe the first expiry-first out (FEFO) o The VVM on the vial, if attached,
policy. has not reached the discard point.
 Comply with the recommended duration of  Reconstitute freeze-dried vaccines such as
storage and transport. At the health BCG, AMV, and MMR only with the diluents
center/RHU with a refrigerator, the supplied with them.
duration of storage should not exceed one  Discard reconstituted freeze-dried
month. Using transport boxes, vaccines vaccines 6 hours after reconstitution of at
can be kept only up to maximum of 5 the end of the immunization session,
days. whichever comes sooner.
 Take note if the vaccine container has a  Protect BCG from sunlight and Rotavirus
vaccine vial monitor (VVM) and act vaccine from light.
accordingly. The VVM is a round disc of
heat-sensitive material placed on a Side effects of adverse reactions of
vaccine vial to register cumulative heat immunization
exposure. A direct relationship exists Vaccine recipients or their parents/guardians
between rate of color change and should be informed of side effects or adverse
temperature: the lower the temperature, reactions of vaccine(s) to be given. Adverse
the slower the color change; the higher events should be monitored closely.
the temperature, the faster the color
change. BCG injection results in the formation of a wheal
that disappears within 30 minutes. After about 2
weeks, a small red tender swelling appears at the
injection site, which may develop into a small
abscess which ulcerates. The ulcer heals by itself
and leaves a scar. The whole course from
vaccination to the formation of a scar takes about
12 weeks. This is an expected response and does
not require any management.
Vaccines Side effects Management

BCG Koch’s phenomenon: an No management is

acute inflammatory reaction needed
within 2-4 days after
vaccination; usually
indicates previous exposure
 Abide by the open-vial policy of the DOH. to tuberculosis
A multidose vial may be opened for one or
Deep abscess at vaccination Refer to the physician for
two clients if the health worker feels that a site; almost invariably due incision and drainage
to subcutaneous or deeper
client cannot come back for the scheduled injection
immunization session. Multidose liquid
vaccines, such as OPV, Pentavalent
vaccine, hepatitis B vaccine, and TT from

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Indolent ulceration: an ulcer Treat with INH powder  Pentavalent vaccine 2 or 3/DPT 2 or 3 to a child
which persists after 12
weeks from vaccination date who has had convulsions or shock within 3
days of the most recent dose.
Glandular enlargement: If suppuration occurs,
enlargement of lymph treat as deep abscess  Rotavirus vaccine when the child has a history
glands draining the injection of hypersensitivity to a previous dose of the
site
vaccine, intussusceptions or intestinal
Hepatitis B Local soreness at the No treatment is malformation, or acute gastroenteritis; and
vaccine injection site necessary
 BCG to a child who has signs and symptoms of
DPT-HepB-Hib Fever that usually lasts for Advise parents to give AIDS or other immune deficiency conditions or
only 1 day. Fever beyond 24 antipyretic who are immunosuppressed.
(Pentavalent hours is not due to the
vaccine) vaccine but to other causes
Some conditions are considered false
Local soreness at the Reassure parents that contraindications. If they are seen in children, the
injection site soreness will disappear
after 3-4 days health worker may continue with the appropriate
immunizations. These are:
Abscess after a week or Incision and drainage
more usually indicates that may be necessary
the injection was not deep
 Malnutrition, which should be considered as an
enough or the needle was indication that the child especially needs the
not sterile
protection conferred by immunization;
Convulsions: although very Proper management of  Low-grade fever;
rare, may occur in children convulsions; pertussis  Mild respiratory infection; and
older than 3 months; caused vaccine should not be
by pertussis vaccine given anymore  Diarrhea. Children with diarrhea who are due
for OPV should receive a dose of OPV during
OPV None
the visit. However, the dose is not counted. The
Anti-measles Fever 5-7 days after Reassure parents and child should return when the next dose of OPV
vaccine vaccination in some instruct them to give
children; sometimes, there antipyretic to the child
is due.
is a mild rash

MMR Local soreness, fever, Reassure parents and EPI Recording and Reporting
irritability, and malaise in instruct them to give EPI recording and reporting are accomplished using the
some children antipyretic to the child
FHSIS.
Rotavirus Some children develop mild Reassure parents and
vaccine vomiting and diarrhea, instruct them to give Fully Immunized Children (FIC) are those who were
fever, and irritability antipyretic and Oresol to
the child
given BCG, three doses of OPV, three doses of DPT and
hepatitis B vaccine or three doses of Pentavalent
Tetanus toxoid Local soreness at the Apply cold compress at vaccine, and one dose of anti-measles vaccine before
injection site the site. No other
treatment is needed reaching one year of age.

Completely immunized child refers to children who

Contraindications to immunization completed their immunization schedule at the age of
In general, there are no contraindications to 12-23 months.
immunization of a sick child if the child is well enough A child protected at birth (CPAB) is a term used to
to go home. Sending children away and telling mothers describe a child whose mother has received (a) two
to bring them back for immunization when they are doses of TT during this pregnancy, provided that the
well enough is a bad practice because it delays the second dose was given at least a month prior to
immunization. Bring the child back to the RHU/health delivery; or (b) at least three doses of TT anytime prior
center for immunization at another time may not be to pregnancy with this child.
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 another active
neurological disease of the central nervous
system.

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JAKE 15