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Expanded Program on Immunization (Philippines)

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The Expanded Program on Immunization (EPI) in the Philippines began in July 1979. And, in 1986, made a response to the Universal Child Immunization goal. The four major strategies include:[1]
1. Sustaining high routine Full Immunized Child (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.

Contents

1 Routine Schedule of Immunization 2 Routine Immunization Schedule for Infants 3 General Principles in Infants/Children Immunization 4 Tetanus Toxoid Immunization Schedule for Women 5 Care for the Vaccines 6 References

Routine Schedule of Immunization [edit]

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 [edit]

The standard routine immunization schedule for infants in the Philippines is adopted to provide maximum immunity against the seven vaccine preventable diseases in the country before the child's first birthday. The fully immunized child must have completed BCG 1, DPT 1, DPT 2,

DPT 3, OPV 1, OPV 2, OPV 3, HB 1, HB 2, HB 3 and measles vaccines before the child is 12 months of age.[2]
Minimum Number Age of Dose at 1st Doses Dose Minimum Interval Between Doses

Vaccine

Route

Site

Reason

Bacillus CalmetteGurin

Birth or 0.05 anytime 1 dose mL after birth

none

Right deltoid Intradermal region of the arm

BCG given at earliest possible age protects the possibility of TB meningitis and other TB infections in which infants are prone[3]

DiphtheriaPertussisTetanus Vaccine

6 weeks old

3 doses

0.5 mL

Upper 6 weeks(DPT outer 1), 10 weeks portion of (DPT 2), 14 Intramuscular the thigh, weeks (DPT Vastus Lateralis (L3) R-L)

An early start with DPT reduces the chance of severe pertussis.[4]

Oral Polio Vaccine

6 weeks old

3 doses

2-3 drops

4 weeks

Oral

Mouth

The extent of protection against polio is increased the earlier the OPV is given. Keeps the Philippines polio-free.[5]

Hepatitis B Vaccine

At birth

3 doses

0.5 mL

4 weeks interval

An early start of Hepatitis B vaccine Upper reduces the chance outer portion of of being infected and [6] Intramuscular the thigh, becoming a carrier. Prevents liver Vastus cirrhosis and liver Lateralis cancer which are (R-L-R) more likely to develop if infected

with Hepatitis B early in life.[7][8] About 9,000 die of complications of Hepatitis B. 10% of Filipinos have Hepatitis B infection[9] Upper outer portion of Subcutaneous the arms, Right deltiod At least 85% of measles can be prevented by immunization at this age.[10]

Measles Vaccine

9 months 1 dose old

0.5 mL

none

(not MMR)

General Principles in Infants/Children Immunization [edit]

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.[11] 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.[12] Vaccine combinations (few exceptions), antibiotics, low-dose steroids (less than 20 mg per day), minor infections with low fever (below 38.5 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 pregnancy.[13] 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.[14] 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.[15] 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.[16]

Tetanus Toxoid Immunization Schedule for Women [edit]

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]
Vaccine Minimum Age/Interval As early as possible during pregnancy At least 4 weeks later Percent Protected 0%

Duration of Protection

TT1

protection for the mother for the first delivery infants born to the mother will be protected from neonatal tetanus gives 3 years protection for the mother infants born to the mother will be protected from neonatal tetanus gives 5 years protection for the mother infants born to the mother will be protected from neonatal tetanus gives 10 years protection for the mother gives lifetime protection for the mother all infants born to that mother will be protected

TT2

80%

TT3

At least 6 months later

95%

TT4

At least 1 year later

99%

TT5

At least 1 year later

99%

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.[18]

Care for the Vaccines [edit]

To ensure the optimal potency of vaccines,a 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.[19] Inappropriate storage, handling and transport of vaccines wont protect patients and may lead to needless vaccine wastage.[20] 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.[21]

References [edit]
1. ^ Public Health Nursing in the Philippines. Manila, Philippines: National League of Philippine Government Nurses, Inc. 2007. p. 141. ISBN 978-971-91593-2-2. 2. ^ "Six Out of Ten Children 12 to 23 Months Are Fully Immunized". Final Results from the 2002 Maternal and Child Health Survey (National Statistics Office). 2003-06-02. Retrieved 2007-05-11. 3. ^ Puvacic, S.; Dizdarevi, J; Santi, Z; Mulaomerovi, M (2004-02). "Protective effect of neonatal BCG vaccines against tuberculous meningitis". Bosnian Journal of Basic Medical Sciences 4 (1): 469. PMID 15628980. 4. ^ "Immunisation". Dialogue on Diarrhoea Online (30): 16. 1987. Retrieved 2007-05-11. 5. ^ Centers for Disease Control and Prevention (2001-10-12). "Public Health Dispatch: Acute Flaccid Paralysis Associated with Circulating Vaccine-Derived Poliovirus --- Philippines, 2001". Morbidity and Mortality Weekly Report 50 (40): 8745. PMID 11666115. Retrieved 2007-05-11. More than one of |author1= and |last= specified (help) 6. ^ Ni, Y. H.; M.H. Chang, L.M. Huang, H.L. Chen, H.Y. Hsu, T.Y. Chiu, K.S. Tsai, and D.S. Chen (200111-06). "Effects of Universal Vaccination for Hepatitis B". Annals of Internal Medicine 135 (9): 796800. PMID 11694104. Retrieved 2007-05-12. 7. ^ "A Look at Each Vaccine: Hepatitis B Vaccine". Vaccine Education Center. The Children's Hospital of Philadelphia. Archived from the original on 2007-06-29. Retrieved 2007-05-11. 8. ^ Chang, MH; C.J. Chen, M.S. Lai, H.M. Hsu, T.C. Wu, M.S. Kong, D.C. Liang, W.Y. Shau, D.S. Chen (1997-06-26). "Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. Taiwan Childhood Hepatoma Study Group". The New England Journal of Medicine 336 (26): 18551859. doi:10.1056/NEJM199706263362602. PMID 9197213. 9. ^ Salazar, Tessa R. (2004-05-24). "Cancer Preventable Says US Doctor" (PDF). The Philippine Daily Inquirer. Archived from the original on 2007-02-21. Retrieved 2007-05-11. 10. ^ Orenstein, WA; L.E. Markowitz, W.L. Atkinson, A.R. Hinman (1994-05). "Worldwide measles prevention". Israel Journal of Medical Sciences 30 (56): 46981. PMID 8034506. 11. ^ "Measles (Catch Up Campaigns) - Toolkit for Volunteers". Health Initiative 2010. African Red Cross & Red Crescent. Archived from the original on 2007-04-15. Retrieved 2007-05-12. 12. ^ Zimmerman, Richard Kent (2000-01-01). "Practice Guidelines - The 2000 Harmonized Immunization Schedule". American Family Physician. Retrieved 2007-05-12.[dead link] 13. ^ "Management of the Traveler: Vaccination". Travel Medicine. Portal de Sade Pblica. 1997. Retrieved 2007-05-12. 14. ^ "General Recommendations on Immunizations" (PDF). Epidemiology & Prevention of VaccinePreventable Diseases--The Pink Book 10th Edition. Centers for Disease Control and Prevention. 2007-02-14. Retrieved 2007-05-12. 15. ^ Department of Vaccines and Biologicals (2000-12). "WHO Recommendations for Diluents" (PDF). Vaccines and Biologicals Update (World Health Organization). p. 3. Retrieved 2007-05-12. 16. ^ Hoekstra, Edward. "Immunization: Injection Safety". UNICEF Expert Opinion (UNICEF). Retrieved 2007-05-12. 17. ^ "Tetanus - The Disease". Immunization, Vaccines and Biologicals. World Health Organization. Retrieved 2007-05-12. 18. ^ "Maternal and Neonatal Tetanus" (PDF). UNICEF. 2000-11. Retrieved 2007-05-12. 19. ^ "Temperature Sensitivity of Vaccines" (PDF). Immunization, Vaccines and Biologicals (World Health Organization). 2006-08. Retrieved 2007-05-12. 20. ^ "Handle Vaccines with Care". British Columbia Center for Disease Control. Archived from the original on 2007-10-07. Retrieved 2007-05-12.

21. ^ Expanded Program on Immunization Manual. Manila, Philippines: Department of Health, Philippines. 1995.

http://www.doh.gov.ph/node/1067.html

Expanded Program on Immunization

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I.

Rationale

The Expanded Program on Immunization (EPI) was established in 1976 to ensure that infants/children and mothers have access to routinely recommended infant/childhood vaccines. Six vaccine-preventable diseases were initially included in the EPI: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. In 1986, 21.3% fully immunized children less than fourteen months of age based on the EPI Comprehensive Program review.

II.

Scenario

Global Situation The burden In 2002, WHO estimated that 1.4 million of deaths among children under 5 years due to diseases that could have been prevented by routine vaccination. This represents 14% of global total mortality in children under 5 years of age.

Source: Weekly Epidemiological Record, WHO: No.46,2011,86.509-520)

Burden of Diseases The immunization coverage of all individual vaccines has improved as shown in Figure 1: (Demographic Health Survey 2003 and 2008). Fully Immunized Child (FIC) coverage improved by 10% and the Child Protected at Birth (CPAB) against Tetanus improved by 13% compared to any prior period. Thus, the Philippines has now historically the highest coverage for these two major indicators.

Figure 1: Comparison of the 2003 and 2008 EPI indicators, Source: NDHS

III.

Interventions/ Strategies

Program Objectives/Goals:

Over-all Goal: To reduce the morbidity and mortality among children against the most common vaccinepreventable diseases.

Specific Goals: 1. To immunize all infants/children against the most common vaccine-preventable diseases. 2. To sustain the polio-free status of the Philippines. 3. To eliminate measles infection. 4. To eliminate maternal and neonatal tetanus 5. To control diphtheria, pertussis, hepatitis b and German measles. 6. To prevent extra pulmonary tuberculosis among children.

Mandates: Republic Act No. 10152MandatoryInfants and Children Health Immunization Act of 2011Signed by President Benigno Aquino III in July 26, 2010. The mandatory includes basic immunization for children under 5 including other types that will be determined by the Secretary of Health.

Strategies:

Conduct of Routine Immunization for Infants/Children/Women through the Reaching Every Barangay (REB) strategy

REB strategy, an adaptation of the WHO-UNICEF Reaching Every District (RED), was introduced in 2004 aimed to improve the access to routine immunization and reduce drop-outs. There are 5 components of the strategy, namely: data analysis for action, re-establish outreach services, , strengthen links between the community and service, supportive supervision and maximizing resources.

Supplemental Immunization Activity (SIA)

Supplementary immunization activities are used to reach children who have not been vaccinated or have not developed sufficient immunity after previous vaccinations. It can be conducted either national or sub-national in selected areas.

Strengthening Vaccine-Preventable Diseases Surveillance

This is critical for the eradication/elimination efforts, especially in identifying true cases of measles and indigenous wild polio virus

Procurement of adequate and potent vaccines and needles and syringes to all health facilities nationwide

IV. Status of implementation/ Accomplishment

All health facilities (health centers and barangay health stations) have at least one (1) health staff trained on REB.

Polio Eradication:

The Philippines has sustained its polio-free status since October 2000. Declining Oral Polio Vaccine (OPV) third dose coverage since 2008 from 91% to 83%. A least 95% OPV3 coverage need to be achieved to produce the required herd immunity for protection.

Figure 2 OPV1 and OPV3 Coverage, Philippines, 2005-2010

There is an on-going polio mass immunization to all children ages 6 weeks up to 59 months old in the 10 highest risk areas for neonatal tetanus. These areas are the following: Abra, Banguet, Isabela City and Basilan, Lanao Norte, Cotabato City, Maguindanao, Lanao Sur, Marawi City and Sulu.

Acute Flaccid Paralysis (AFP) reporting rate has decreased from 1.44 in 2010 to 1.38 in 2011. Only regions III, V and VIII have achieved the AFP rate of 2/100,000 children below 15 years old. (Source: NEC, DOH). A decreasing AFP rate means we may not be able to find true cases of polio and may experience resurgence of polio cases

Measles Elimination

Conducted 4 rounds of mass measles campaign: 1998, 2004, 2007 and 2011. Implemented the 2-dose measles-containing vaccine (MCV) in 2009

MCV1 (monovalent measles) at 9-11 months old MCV2 (MMR) at 12-15 months old.

Implemented and strengthened the laboratory surveillance for confirmation of measles. Blood samples are withdrawn from all measles suspect to confirm the case as measles infection. A supplemental immunization campaign for measles and rubella (German measles) was done in 2011. This was dubbed as Iligtas sa Tigdas ang Pinas 15.6 million (84%) out of the 18.5 million children ages 9 months to 8 years old were given 1 dose of the measles-rubella (MR) vaccine between April and June 2011.

Rapid coverage assessment (RCA) were conducted in selected areas to validate immunization coverage, assess high quality and that there are NO missed child in every barangay. Overall RCA results showed that 70,594 (97.6%) out of 72,353 9 months to 8 years old living in the randomly selected barangays were vaccinated. There are 3,494 barangays with a population of 1000 and above that were randomly selected. 97.6% of all eligible children were given the MR vaccine during the immunization campaign. The Government of the Philippines spent PhP 635.7M for the successful conduct of the MR campaign.ss high quality and that there are NO missed child in every barangay. Overall RCA results showed that 70,594 (97.6%) out of 72,353 9 months to 8 years old living in the randomly selected barangays were vaccinated. There are 3,494 barangays with a population of 1000 and above that were randomly selected. 97.6% of all eligible children were given the MR vaccine during the immunization campaign. As of Morbidity Week 8 of 2012, there were 92 confirmed cases: 60 cases were laboratory confirmed, 5 cases were epidemiologically-linked and 27 clinically confirmed. This means we have at least 60 true measles at present. Measles is said to be eliminated if we have 1 case per million or below 100 cases in a year

Maternal and Neonatal Tetanus Elimination

10 areas were classified as highest risk for neonatal tetanus (NT). Figure 3 shows the areas categorized as low risk, at risk and highest risk based on the NT surveillance, skilled birth attendants and facility based delivery and the tetanus toxoid 2+ (TT 2+) vaccination.

Figure 3: Level of Risk for NT, Philippines

Three (3) rounds of TT vaccination are currently on-going in the 10 highest risk areas. An estimated 1,010,751 women age 15 - 40 year old women regardless of their TT immunization will receive the vaccine during these rounds. This is funded by the Kiwanis International through UNICEF and World Health Organization.

Control of other common vaccine-preventable diseases (Diphtheria, Pertussis, Hepatitis B and Meningitis/Encephalitis secondary to H. influenzae type B) Continuous vaccination for infants and children with the DPT or the combination DPT-HepBHiB Type B. Annex1 EPI Annual Accomplishment Report. DOH procures all the vaccines and needles and syringes for the immunization activities targeted to infants/children/mothers. Hepatitis B Control

Republic Act No. 10152 has been signed. It is otherwise known as the Mandatory Infants and Children Health Immunization Act of 2011, which requires that all children under five years old be given basic immunization against vaccine-preventable diseases. Specifically, this bill provides for all infants to be given the birth dose of the Hepatitis-B vaccine within 24 hours of birth. One strategy to strengthen Hepatitis B coverage is to integrate birth dose in the Essential Intrapartum and Newborn Care Package (EINC). In 2011, 11 tertiary hospitals are already EINC compliant. The goal of Hepatitis B control is to reduce the chronic hepatitis B infection rate as measured by HBsAg prevalence to less than 1% in five-year-olds born after routine vaccination started 100% Hepatitis B at birth vaccination.

Figure 4

Hepatitis B Coverage. Philippines, 2001-2011

Timing of administration/dose <24 hours >24 hours Hep B 3rd dose

2009 34% 62% 86%

2010* 38% 55% 81%

2011* 14% 24% 30%

*both 2010 and 2011 data are as of October 2011

Vaccines and cold chain management

Upgraded the cold chain equipment in the 80 provinces, 38 cities and 16 regions since 2003. An effective vaccine management assessment was conducted last December 2011 and revealed cold chain capacity gaps from the national up to the implementers level. A total of PhP 267 million is required to address the gaps identified during the assessment.

Introduction to New Vaccines

For 2012, Rotavirus and Pneumococcal vaccines will be introduced in the national immunization program. Immunization will be prioritized among the infants of families listed in the National Housing and Targeting System (NHTS) for Poverty Reduction nationwide. The Government of the Philippines has allocated PhP 1.6 billion for the procurement of these 2 vaccines.

V. Future Plan/ Action

Strengthening the Cold Chain to support the Immunization Program Capacity Building for Health Workers for the Introduction of New Vaccines Advocacy for the financial sustainability for the newly introduced vaccines for expansion. Development of the comprehensive multi-year plan for immunization program.

VI. Other Significant information worth mentioning

One significant milestone is that the budget allocation for the immunization program has continued to increase year by year The Government of the Philippines allocated budget for the immunization of all infants/children/women/older persons nationwide. For 2012, the budget for EPI is PhP1.8 billion and another P1.5 Billion for the immunization for senior citizen and children for the NHTS families. This is great leap towards universal access to quality vaccines for the prevention of the most common vaccine-preventable diseases.

Program Managers: Dr. Joyce Ducusin Medical Specialist IV National Center for Disease Prevention and Control - Family Health Office Telephone Number: 651-7800 locals 1726-1730

Ms. Luzviminda Garcia Supervising Health Program Officer National Center for Disease Prevention and Control - Family Health Office Telephone Number: 651-7800 locals 1726-1730