Expanded Program on Immunization

Reference

Nies, M., McEwen, M. (2020). National Immunization Program. In Community and Public Health Nursing (2nd Philippine ed., pp. 287-294). C&E Publishing, Inc.

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Immunization is an essential public health service and is commonly defined as the process of conferring artificial immunity to population groups. Immunity is described as resistance and protection from disease attributed to the presence of antibodies in the blood. The National Immunization Program (NIP) is committed to guaranteeing free immunization services and ensures that Filipinos, especially the poor, have access to routinely recommended vaccines. It further guarantees the immunization of neonates, infants, children, adolescents, mothers, and elderly populations as part of the comprehensive strategy for disease prevention and control following the life stage approach. Its goal is to reduce morbidity and mortality among infants and children caused by common childhood immunizable diseases. Specifically, the NIP has the following goals.

• To immunize all infants against vaccine preventable diseases
• To sustain polio-free status of the Philippines
• To eliminate measles infections
• To eliminate maternal and neonatal tetanus
• To control Diphtheria, Pertussis, Hepatitis B infection and German Measles (Rubella)
• To prevent extrapulmonary tuberculosis among children

Related laws:

• PD No. 996 of 1976: providing compulsory basic immunization for infants and children below 8 years old
• RA 7846 of 1994: inclusion of Hepatitis B immunization for infants and children below 8 years old
• RA 10152 of 2011: Mandatory Infants and Children Health Immunization Act of 2011 for children up to 5 years of age and inclusion of new vaccines: Hepatitis B, Mumps, Rubella, and Haemophilus Infuenza type B (Hib). This repealed PD 996 and is considered the current legal basis of the NIP.
• Presidential Proclamation No. 6 of 1996: Implementing a United Nations Goal on Universal Immunity by 1990; and designating Wednesdays as Immunization day.

General Considerations for Implementation

1. Remind caregivers of children to comply with the prescribed schedule of routine immunization.
2. Previous doses do not have to be repeated regardless of interval.
3. The eligible age for Pentavalent vaccines is up to 5 years old.
4. Booster doses are not really necessary.
5. Vaccines may be given on the same day, but in different sites:
   • If through the same leg, space the site at least 2.5 to 5 centimeters (1 to 2 inches; at least two fingerbreadths).
   • Start with OPV, then Rotavirus, then the other vaccines.
6. Observe the “First Expiry, First Out” (FEFO) or “First In, First Out” (FIFO) principle in utilizing vaccine stocks.
7. Use cotton in cleaning the injection site. If with alcohol, thoroughly dry before administrating the vaccine.
8. BCG, AMV, and MMR have special diluents. After reconstitution, these vaccines are only valid for 6 hours. This used to be 4 hours
9. Protect BCG from sunlight, and Rotavirus from light. This principle may be used in questions that ask which location is appropriate for vaccination
10. Information caregivers of children for immunization about common side effects, and how to deal with it.
11. Reusable vaccines such as OPV, Pentavalent, Hepatitis B, and Tetanus Toxoid may last for a maximum of 4 weeks as long as the vaccine has (a) not expired, (b) been maintained in appropriate cold chain conditions, (c) remained uncontaminated during aspiration, (d) a VVM that does not indicate discarding, and (e) the vaccine septum has not been submerged in water.

In cases of a measles outbreak, a supplemental measles vaccine is administered.

• For children under 9 months old, give MR (no vaccine for mumps) reconstituted with two vials of special diluent (6 mL total), giving 0.5 mL subcutaneously to the child.
• For children 9 months to 5 years old, give MMR.

These are NOT CONTRAINDICATIONS:

1. Fever up to 38.5°C “up to” means a fever of 38.5°C still permits vaccination.
2. Mild acute respiratory infection
3. Simple diarrhea
4. Malnutrition conversely, this is an indication; malnutrition poses greater risk for disease

Vaccines and Administration

Vaccine	Diseases	Age	Dose	Route	Site
Bacillus Calmette-Guerin (BCG)	Tuberculosis Meningitis Leprosy	At birth	0.05 mL	ID	Right upper arm/deltoid
Hepatitis B Vaccine (HBV)	Hepatitis B Liver Cancer	At birth	0.5 mL	IM	Vastus Lateralis
Pentavalent (DPT-HepB-Hib)	Diphtheria Pertussis Tetanus Hepatitis B Pneumonia Meningitis	6, 10, 14 weeks	0.5 mL	IM	Vastus Lateralis
Oral Polio Vaccine (OPV)	Poliomyelitis	6, 10, 14 weeks	0.5 mL; 2-3 drops	PO	Mouth
Inactivated Polio Vaccine (IPV)	Poliomyelitis	14 weeks, 9 months	0.5 mL	IM	Vastus Lateralis
Pneumococcal Conjugate Vaccine (PCV)	Pneumonia Meningitis	6, 10, 14 weeks	0.5 mL	IM	Vastus Lateralis
Mumps Measles Rubella (MMR)	Mumps Measles Rubella	9, 12-15 months	0.5 mL	SC	Outer arm
Tricks for memorization:

• Chunking: BCG and HBV at birth; Penta, OPV and PCV at week 6, 10, 14; and MMR at the 9th and 12th month
• Only BCG and OPV have varied doses
• Only BCG, OPV, and MMR have different sites
• Only BCG, IPV, and MMR have varied schedules

Common Vaccination Side Effects and Management

Vaccine	Side Effect	Management
BCG	Wheal for 30 minutes followed by ulceration for 2 weeks then scar formation within 12 weeks	Normal Reaction
BCG	Koch’s Phenomenon: an acute inflammatory reaction within 2 to 4 days after vaccination usually due to previous exposure to tuberculosis.	No management is needed.
BCG	Deep (subcutaneous) abscess at vaccination site; almost invariably due to subcutaneous or deeper injection depth	Refer to the physician for incision and drainage (I&D).
BCG	Indolent ulcer: an ulcer which persists after 12 weeks from vaccination date	Treat with Isoniazid (INH) powder.
BCG	Glandular enlargement: enlargement of the lymph glands draining the injection site	Treat as deep abscess (I&D) if suppuration occurs.
HBV	Local soreness at injection site	No treatment necessary. Cold compress may be used.
DPT-HepB-Hib	Fever that usually last for only 1 day. A fever beyond 24 hours is not due to the vaccine.	Advise parents to give an antipyretic.
DPT-HepB-Hib	Local soreness at the injection site	Reassure parents that soreness will disappear after 3 to 4 days. Paracetamol may be given for pain.
DPT-HepB-Hib	Abscess after a week or more usually indicates that the injection was not deep enough or the needle was not sterile.	I&D may be necessary.
DPT-HepB-Hib	Convulsions, although very rare, may occur in children older than 3 months caused by the pertussis component.	Proper management of convulsion; may give DT next vaccination.
OPV	None	- Nothing per orem for 30 minutes to prevent vomiting and to enhance absorption - If the child vomits, administer another dose. - If the child has simple diarrhea, the dose may be given, but it is not counted and another dose will be given the next visit.
IPV	Local tenderness	Cold compress
MMR	Local soreness, fever, irritability, and malaise in some children	- Reassure parents and instruct parents to give an antipyretic to the child. - Give 200,000 IU of Vitamin A to promote epithelialization and increase immunity.