Historical background of immunization programme in

Kenya.

• The programme EPI was globally implemented

in 1977.
• In Kenya it was launched in June 1980 as KEPI
with the assistance of the Danish International
Development Agency (DANIDA).
• The target population were children 0-5 years
• The six common childhood infectious diseases
targeted were:
• -tuberculosis.

• -poliomylitis.

• -tetanus.

• -whooping cough (pertusis).

• -measles.

• -diptheria.
• Immunizations were to be offered in GOK
health facilities and Non GOK health
facilities.
• Motivation rather than coercion was being
used as an encouragement approach.
• KEPI was established as a unit within
ministry of Health.
• Immunization coverage.

• Proposed immunization coverage in a given district

was:
• -75% for single short antigens i.e BCG and measles.

• -60% for multiple shot ones i.e DPT,polio, TT.

• This were to be achieved during the first 3 years of

KEPI operation there after maintain at a minimum
of 80% for all the antigents.
• Cold chain system.

• Cold chain system was to be reinforced to ensure better

vaccine storage and handling.
• Vaccine stores were to be set up:

• -one central vaccine store in Nairobi.

• -two regional vaccine stores in mombasa and kisumu.

• Cold chain equipment were to be sent to all hospitals,

health centres and dispensaries offering immunization i.e
refrigerators and cold boxes.
• Implementation.
• This was planned in 4 stages:
• 1.preparatory stage (mid 1980 –mid 1981):
• A KEPI management unit was set up in Nairobi, this stage also
dealt with:
• -equipment.
• -transport, procurement and distribution.
• -training schedules to include identification of trainers and
number of cadres of staffs to be trained.
• -training materials – data collection and public mobilization.
• 2.Demonstration or pretesting stage
(mid 1981-mid 1982).
• KEPI field operations were tried in
Kirinyaga district.
• Evaluation was carried out and it was
encouraging.
• 3.operational stage.

• KEPI programme was introduced step by step in

provinces starting from coast, nyanza and western.
• For KEPI to be operational it implied that:

• -staff had to be retrained.

• -cold chains need to be met.

• -transport had to be provided.

• -public motivation had been met.

• The achievement recorded during this stage were:

• -by 1984 immunization coverage had rised to 43%.

• -there were no vaccine shortages.

• -trained nurses on supervisory skills, operational

level and cold chain had been created.
• Total of 950 immunization centres were set up
which had cold chain equipment.
• -a kenyan design and written
operational level training manual was
produced.
• KEPI was evaluated in 1984 and 1986
by an external mission and indeed it
met the approval.
• 4.consolation stage (1987 –1990) and beyond.

• The main aim of this final stage was to:

• -offer better quality immunization services.

• -increase and sustain immunization coverage.

• -reduce EPI target diseases e.g Neonatal tetanus.

• -to in cooperate one new antigen i.e Hepatitis B.

• This is making KEPI a well functioning component of

PHC (primary health care).
• -increase and sustain the
immunization coverage by 11
months with a target coverage
by 1990 of 90% for BCG, 80% for
DPT3, OPV3 and measles and 75%
for tetanus toxoid.
• reduce the EPI target diseases as follows:

• - reduction of neonatal tetanus from 10 per 1,000 live births in

1985 to 5 per 1,000 live births.

• •- to interrupt the transmission of poliomyelitis by 1993 and

possibly eliminate it altogether by 1995.

• •- to shift age specific incidence of measles from age group 1-2

years to age group 4-6 years by 1993.

• -to incorporate one new antigen namely Hepatitis B (initially as a

pilot project in one of the districts), with effect from mid 1990.
• based on cost effectiveness and sustainability

considerations, KEPI was guided by the following principles

to help it achieve its target:

• • -the use of “fixed”/static health facilities for immunization

• •- the integration of the KEPI programme within Maternal

and Child Health services

• •- the provision of cold chain equipment to all hospitals, all

health centres and 50% of dispensaries

• • -training of personnel in all areas of operation

• •- biennial evaluations of district programmes

by external teams

• • regular feed back to staff.

• NB Sentinel Station Reporting for measles,

poliomyelitis, and neonatal tetanus was planned
to start from 1990.
• In April 2000 programme evaluation
recommended:
• -improvement in supervision and evaluation.

• -healthy communication.

• -programme monitoring.

• -disease surveilance.

• -training of health workers.

• The progremme has been dependent on donors
for the financial and technical assistance but
now the government is playing an important
role.
• The national health sector strategic plan of 1999
recommended KEPI to be decentralized in all
aspects of programme planning, monitoring and
evaluation.
• KEPI management unit is to be reponsible
for development of policies and standards,
donor coordination, vaccine procurement,
technical advice, research, monitoring and
evaluation.
• To achieve its objectives KEPI had
programme components.
 COMPONENTS OF KEPI.
• To achieve and improve existing immunization activities
through effective management, KEPI has seven operational
components.
• 1.intergration in mch/fp programmes.

• Immunization is an integral part of MCH/FP and PHC activities.

• Immunization services are delivered mainly through static

clinics, outreach and mobile units.
• Every health facility should offer immunoization on a daily
basis to every eligible child or pregnant woman.
• 2.Training.

• There are 3 types of KEPI training courses:

• -mid-level training course.

• This is a two weeks training programme

designed for public health management team
at provincial level, trainers in KMTC, and also
mission and private health institutions.
• -the operational level training course.

• This is designed for health workers from all health

facilities who paricipate in immunization activities.
• It is included in basic medical training programme.

• -cold chain training course.

• This is designed for those health workers who have

already had the mid level and operational level
training.
• 3.Social mobilization.

• It is one of the most important activities of the

programme.
• To achieve the key objectives the families need to
be convinced to bring their children for
immunization.
• In this case there is increased community
involvement and participation.
• 4.Surveillance.

• This is collection and analysis of data for action.

• It is done through:

• -routine reporting.

• -sentinel reporting – (taking sample from patients).

• -surveys.

• The targeted diseases must be routinely and accurately

reported so as to assess the success or failure of
immunization programme.
• 5.Cold chain.

• This is a system of keeping vaccines cold

and in a potent state from the
manufacturer's level until it is administered
to a child or a pregnant woman.
• A break in cold chain system will render
the vaccines useless.
• 6.monitoring and evaluation.

• This is an on going function at all levels.

• Supervision is being carried out in 3 levels:

• -health centre level by the officer in charge.

• -at district level by the DHMT and at the provincial level

by PHMT.
• -at the central level by management unit team, this
make regular supervisory visits to the district and
provinces.
• 7.Logistic and supplies.

• This include vaccines, child health card,

reporting forms, cold chain equipments,
transport cars, needles and syringes etc.
• The EPI,MU,DHMT’S have the responsibility
of ensuring that all the immunizing facilities
have the required items on time.
• National goals on EPI target diseases.

• Eradication of poliomylitis by the year

2000.
• Elimination of neonatal tetanus by the
year 2000.
• Control of measles by the year 2000.
• FROM KEPI TO UVI.

• the Ministry of Health in 2007, consolidated all vaccination services

under a single unit called the Division of Vaccines and Immunization

(DVI) and developed a policy to integrate all current vaccination

practices.

• The aim was to standardize practices and opportunities for

vaccination services.

• This unit is now called Unit of Vaccines & Immunization (UVI) replaced

the DVI after restructuring of the Ministry of Health in line with

devolution as per The Constitution of Kenya (2010).

 Unit of Vaccines and Immunization

• The Unit of Vaccines & Immunization (UVI) replaced the Division of

Vaccines & Immunization after restructuring of the Ministry of Health

in line with devolution as per The Constitution of Kenya (2010).

• The Division of Vaccines & Immunization (DVI) became effective from

1st July 2007, and represents the Ministry of Health’s new direction in

the coordination of immunization services for the general public.

• UVIS has an extended scope to consolidate all vaccination services

previously coordinated by other divisions within the Ministry of

Health.
• Vision: Efficient and high quality
immunization services that are
accessible, equitable, and affordable
to every Kenyan.
• Mission: To promote and guide in the
provision of high quality immunization
services to all Kenyans
• Mandate.

• • To coordinate vaccination services for all vaccine

preventable diseases through the provision of
guidelines and selected priority vaccines and related
biological (sera, immunoglobulins)

• • Advice on immunization schedules for all age

cohorts in line with the Kenya Essential Package for
Health (Ref. NHSSP-II 2005-2010).
• The portfolio of UVI includes:
• 1. EPI infant vaccines
• 2. Tetanus for pregnant women
• 3. Tetanus toxoid for trauma.
• 4. Vaccinations for special groups:

• • -TT for special occupational risk groups

• • -Hepatitis B vaccine for health workers and other

persons at risk e.g prisoners
• • -Typhoid vaccine for food handlers and special
categories of health workers
• • -Vaccination for foreign travelers (e.g yellow
fever, meningitis).
• 5.Routine emergency vaccinations

• • For animal (dog) bites

• • For snake bites

• 6. Special emergency (outbreak response). Vaccinations

including the following

• • Poliomyelitis

• • Measles

• • Meningitis

• • Emerging infections – influenzas

• 7. Specialized products
• •- Immune sera – e.g. rabies
immunoglobulins
• • -Anti-D sera for rhesus O-negative
pregnant women
 Core functions of the unit of vaccines &
immunization

• 1. Policy regulation and oversight

• 2. Commodity security & quality
assurance
• 3. Monitoring and evaluation
• 4. Advocacy and Resource
Mobilization
• 1. Policy regulation and oversight

• i. C oordinating periodic reviews of the National

Immunization Policy
• ii. Developing and updating training guidelines
and materials for immunization service delivery
• iii. Facilitating the training of national and
regional trainers.
• 2. Commodity security & quality assurance

• i. T o ensure continuous availability of adequate

stocks of all Ministry of Public Health & Sanitation
procured vaccines, related immunologicals and
support logistics at all levels of service delivery.

• ii. T o ensure that all vaccines, anti-sera and

vaccination devices used for human health within the
country meet defined minimum quality standards
• 3. Monitoring and evaluation

• i. Develop multi-year and annual operational plans

• ii. T o set multi-year and annual performance targets

• iii. T o monitor national immunization coverage

trends and provide periodic reports on the same.

• iv. T o monitor respective disease burden trends and

correlate the same against immunization coverages.

• 4. Advocacy and Resource Mobilization

• i. Annually review country wide vaccination social

mobilization/advocacy needs.

• ii. Develop and periodically revise social mobilization guidelines &

strategies in line with vaccination performance trends in the country

• iii. Determine multiyear and annual funding needs for universal

immunization activities and develop comprehensive resource

mobilization plans.

• iv. Develop and periodically review resource mobilization guidelines &

strategies in line with immunization funding needs.

• 5. Capacity strengthening

• i. Develop and periodically review guidelines and training

materials/teaching aids on vaccine preventable diseases

• ii. Spearhead the revision of curricula of medical

institutions in relation to :

• -current information on vaccine preventable diseases

• •- updates required by different cadres of health workers

 Terms used in immunology.

• Immunogenicity: The inherent ability of an

antigen to induce an immune response.

• Seroconversion: When an individual following a

disease or vaccination generates antigen-specific

antibodies.

• Vaccination: The process of administering a

vaccine or manipulation of the immune system to

induce protective immunity.

• Vaccine adjuvant: Substance that is added to a vaccine to its

immunogenicity without having any specific antigenic effect in

itself. These may include mineral salts (aluminium and calcium

phosphate),organic adjuvants, particulate adjuvants, virosomes,

microbial derivatives, oil emulsions and surfactant based

formulations

• Incubation period: the interval between exposure to an

infectious agent and onset of clinical symptoms. The incubation

period varies for different diseases from a few hours to several

months or even longer for some diseases, e.g. leprosy.

• Antigen: Any substance, usually a protein that is capable

of eliciting an immune response. The antigens that can

cause a disease are called pathogens.

• Antibody: A protein produced by plasma cells in response

to an antigen

• Immunization:this is the process of introducing weakened

or killed germs (vaccine) into the body which increase

body immunity to protect one from a particular disease.

• Immunity: Protection against infectious disease.

• -means that the individual has enough defense
mechanism to fight and kill or weaken
microorganism.
• -it therefore means that the body has the ability
to fight against certain disease organism.
• -an individual whose body has this ability is said
to be immune to that disease.
 classifications of immunity.

• 1.innate immunity/non-specific.

• It’s determinant include factors such as:

• -physical barriers e.g skin, mucus membrane.

• -genetic factors.

• -certain soluble components i.e body secretions e.g

gastric acid, saliva and enzymes.
• Innate immunity is the first line of body defense
mechanism.
• 2.specific immunity/adaptive.

• This is also known as acquired immunity because

it develops during an individual encounters
various specific harmful antigens stimulating the
formation of antibodies.
• It is divided into 2 :

• -natural immunity.

• -artificial immunty.
 Natural immunity.
• This type of immunity can be acquired naturally or
artificially and in turn both forms can be acquired
actively or passively.
• When immunity is acquired actively the individual has
responded to the antigen and has produced his own
antibodies.
• Passive immunity occurs when the individual has been
given specific antibodies which has been produced by
someone else.
Types of acquired immunity.
• (a) active naturally acquired immunity.

• This occurs when the body has been involved actively in

producing antibodies naturally.
• Examples:

• -(i).by having clinical infection i.e one getting the actual

disease.
• -in this case micro-organism invade the body
successfully , they grow and multiply in sufficient
numbers after which clinical features are produced.
• -in the course of the disease antibodies are produced in
sufficient numbers to overcome micro-organisms and the
individual recovers from the disease.
• -those antibodies remains as future protection against that
particular antigen that caused the disease.
• -(ii) by having sub clinical infection in this case the body is
exposed to minute numbers of micro-organisms which are
insufficient to give rise to recognizable disease signs and
symptoms but are sufficient to stimulate the body to produce
antibodies.
• (b).passive naturally acquired immunity.

• This type of immunity is conferred by maternal

antibodies that enter the fetal circulation through
the placenta or through colostrum or breast milk
therefore the infant makes no contribution in the
immunity development.
• This type of immunity is known to be short-lived
(about 6-9 months).
• (c) artificial active acquired immunity.

• It develops in response to introduction of vaccine

into the body.
• The vaccine could be in form of live-attenuated
micro-organism or detoxicated toxins e.g tetanus
toxoid.
• This retain their antigen identity but cannot cause
the disease.
• (d)artificial passive acquired immunity.

• In this type of immunity the individual is

given ready made antibodies from human or
animal serum.
• The animal serum may be used
prophylatically to prevent to prevent infection
or therapeutically to treat infections.
 immunity

adaptive innate

artificial natural

Active
e.g live attenuated Passive
vaccine Passive e.g Maternal
Active
Inactive vaccine e.g
e.g disease. transfer via
Toxoid vaccines immunoglobuline placenta or
Polysacharide breast milk.
vaccines.
 HERD IMMUNITY.
• This is used to refer to the level of immunity in a
community as a whole.
• A community is said to have a high level of herd
immunity when a high percentage (70-80%) of it’s
children population has been protected through
immunization.
• An infection introduced into a community with a high
level of herd immunity will not spread since most of the
children have immunity and very few are susceptible.
 Ways of developing herd immunity.

• 1.high natural vaccination rate in the

community.
• 2.artificial immunization.

• Herd immunity depends upon a high

percentage of children immunized and an
even distribution of immunization coverage
without pockets of unimmunized children.
 POLICY OF
IMMUNIZATION
• Each country has an immunization policy which usually follows

WHO’s general guidelines.

• Immunization policies enable a country to standardize

immunization procedures/practices.

• The policy in Kenya is to:

• All vaccines for human use in Kenya must meet quality

requirements as determined by the Pharmacy and Poisons

Board and must be duly approved for use within the country by

the Pharmacy and Poisons Board.

• All vaccines for human use must be qualified as safe

under normal circumstances of use. All known and

unknown adverse effects of specific brands should be well
articulated.

• Where the safety profile of a particular vaccine or

immunological cannot be guaranteed but the risk of the
disease is serious, then the vaccine/immunological should
be administered after obtaining consent from the client.
• All vaccines intended for simultaneous use with other
antigens must have proven immunological efficacy in the
presence of the other vaccine and must not significantly
interfere with the immune response to the other vaccine.

• • Administration of vaccines outside the National

Immunization Schedules should be guided by the known
disease burden/risk of the area/region or specific
individual/community risk of exposure to the targeted
disease or a specific medical indication of the client.
• All vaccines for human use must be stored in specialized

medical refrigerators as prescribedby the World Health

Organization. The specifications for these refrigerators can be

obtained from the Division of Vaccines and Immunization or

from the WHO official website.

• All injectable vaccines must be administered only by duly

registered clinicians

• All injectable vaccines are to be administered using non re-

useable injection devices.

• Reconstitution of all lyophilized (freeze dried)

vaccines must only be done with their

matching diluents as provided by the specific
manufacturer.

• All reconstituted multi-dose vial vaccines must be

discarded after the manufacturer’s
prescribed maximum duration of use (usually
between 4-6 hours).
• All unused doses of a liquid multi-dose vial vaccine
without a preservative must be discarded 6 hours
after opening of the vial - e.g. multi-dose vials of liquid
Pneumococcal Conjugate Vaccines

• Routine screening for immune status of individuals

(including infants) prior to vaccination is not
advocated. However where special circumstances
dictate this should be overseen by a qualified clinician.
• Routine screening for HIV status prior to vaccination
is also not advocated except in special
circumstances as determined by a consultant
clinician.

• A fully immunized child is one who has received all

the prescribed antigens and Vitamin A doses
under the national immunization schedule
before the first birthday.
• A fully immunized person – (other than an
infant) refers to an individual who has:

•- received all the prescribed doses for a

particular antigen or,
• •- is beyond the ‘window period of efficacy’
of an antigen - where only one dose is
required (e.g. yellow fever vaccine).
• Some Vaccine Preventable Diseases (VPDs) are notifiable and

information on all suspected cases of these diseases must be

fully documented and reports forwarded immediately to the

Division of Disease Surveillance and Response (DDSR) of the

Ministry of Public Health & Sanitation.

• • ALL notifiable VPDs must be investigated as per the

prescribed guidelines from the Division of Disease

Surveillance and Response.

• All efforts must be made by health workers to
prevent drop-outs from all immunization
schedules through careful counseling of clients
regarding:

• -the importance of vaccines,

•- possible side effects and how to manage them,

• -the consequences of not completing the schedule.

• All efforts must be made by health workers to identify and

respond to missed opportunities for vaccinations by:

• -Screening all children aged below five years presenting at

health facilities and outreach sites for their vaccination status

•- Screening all women of child bearing age at health facilities

and outreach sites for their vaccination status (esp. for tetanus

toxoid)

•- Screening all special target groups for vaccination status

whenever possible (e.g. food handlers etc.)

• All health workers must advocate for comprehensive
utilization of immunization services to their community
leaders and members.

• All immunizing facilities must ensure that vaccinators are

updated annually on the principles and practice of
immunization service delivery through attendance of
Continuous Medical Education sessions (CMEs) or updates
to be conducted by District Health Management Teams,
either through seminars or during supervisory visits.
• NB.

• There are very few absolute contraindications to immunization. In general,

health workers should immunize all eligible children whether they are sick

or not.

• • In case a child requires admission in the ward, the decision whether or not

to immunize is left to the admitting doctors. They should follow the principle

“no child above 9 months of

• age should enter a ward without being immunized against measles

and no child should be discharged from the hospital without having

its immunization status checked and vaccines due administered

accordingly”.
 Immunizable diseases.
• The following childhood diseases can be prevented through vaccination:
• Tuberculosis
• Yellow fever
• Diptheria
• Hepatitis B
• Measles
• Whooping cough
• Poliomylitis
• Tetanus
• Pneumonia
• Meningitis.
• Cholera
• Diarrhoea.
• The above diseases were selected because:
• -the diseases are among the highest causes of deaths
(mortality) and constant sickness (morbidity) among children
below 9 years of age and especially the under five children.
• -the vaccine for their immunization are available,
cheap,effective and give long term immunity.
• -the diseases are highly transmitted (spread easily) among
children hence leading to epidemics yet if many are vaccinated
a community may develop herd immunity thus reducing the
spread of the disease.
 Sources of vaccines.
• Vaccines antigens are of 3 types:

• -live attenuated – (weakened or tamed organism)

e.g BCG, measles, polio, yellow fever, rabies.
• -dead organisms e.g pertusis, cholera, typhoid.
These pathogens are killed by either heat or
chemicals, they produce shorter period of immunity.
• -toxoids- they are prepared from chemical extracts
(toxins) or death organism e.g T.T, and diptheria.
• NOTE:

• Vaccines to be diluted before administering

are BCG and measles vaccines.
• BCG diluent is sodium chloride and it is 1ml.

• Measles diluent is sterile water, diluted with

5mls.
• Other vaccines come in diluted form.
 Immunization schedule
vaccine dose Age of Route Side X NOTE.
child/tim effects
e given
-formation of
BCG 0.05 MLS At birth or Intraderm Pain
wheal after
(BACILLUS (for child first al – left *contrain injection.
-ulceration
CALMETT below contact fore arm dicted in
after 6 weeks.
E- 1year). *intrader a child -remaining
scar persisting.
GUERIN) 0.1mls mal with
-check if the
(for child injection active scar is present
at 14 weeks.
above is the HIV/AIDS.
-*the vaccine is
one year) injection sensitive to
light and
of a
looses much
substance potency when

into the exposed to

light,so need to
dermis, be covered by
Bivalent – it contain vaccine against two polio strains, type 1
and type 3.

vaccine dose Age of route Side NOTE.

child/tim effects
e given

Polio 2 drops -birth orally -1st dose

vaccine orally dose at is 6
(bivalent birth or weeks
oral polio within 2 from birth
vaccine(b weeks or first
OPV) -1st dose contact.
at 6 Then
weeks. count
-2nd dose interval of
at 10 4 weeks .
vaccine dose Age of route Side NOTE.
child/tim effect
e given

IPV 0.5 mls 14 weeks Injection -pain, It is a

(Inactivat (intramus redness dead
ed polio cularly in on vaccine.
vaccine) the right injection -it
outer site, prevent
thigh fevers. against
2.5cm (2 polio.
fingers
apart )
from the
 Pentavalent- it has 5

Vaccine dose
vaccines.
Age of Route Side NOTE.
child/tim effect
e given
1st dose at 6
Diphtheri 0.5mls Intramusc -rise in Manage
weeks.
a/ ular at temperat side
pertussis/ left outer ure effect
tetanus/ thigh. -painful with
hepatitis thigh for paraceta
B/haemop 24 hours mol.
hilus after
influenza injection
type b.
2nd dose at 10
Pneumococcal vaccine protects the child from pneumococcal
bacterium i.e pneumonia,meningitis and ear infections such
as otitis media.

vaccine dose Age of route Side NOTE

child/tim effect
e given

Pneumoc 0.5mls 1st dose at Intramusc GIVEN IN

occal 6 weeks ular right 3 DOSES.
vaccine outer
thigh

2nd dose
at 10
weeks

3rd dose
at 14
 Rota virus – given to prevent diarrhoea in children.

vaccine dose Age of route Side NOTE

child/tim effect
e given

Rota virus 1.5mls 1st dose at Orally,

vaccine 6 weeks slowly
(rotarix)

2nd dose
at 10
weeks
vaccine dose Age of Route Side NOTE
child/tim effect
e given

Measles 0.5mls At 6 Subcutan -Mild It is made

rubella months in eously fever6-10 from live
the event
vaccine right days after attenuate
of a
(MR) upper vaccinatio d virus
measles
arm n.
rubella
outbreak or -rash
HIV lasting for
exposed some
children days
(HEI).
vaccine dose Age of route Side NOTE.
child/tim effect
e given

YELLOW 0.5 mls 9months Subcutan -pain. It is alive

*duration of attenuated
fever eously
immunity is vaccine,com
vaccine right 10 years. es in powder
upper *once form with
reconstituted diluent,given
arm.
it must be to travellers
used within or in areas
one hour. such as
baringo,mar
akwet,koibat
ek, and
 VITAMIN A.
vaccine Dose Age of Route Side effect NOTE
child/time
given
VITAMIN A 100,000iu 6 months orally
CAPSULE
200,000iu 12 months

200,000iu 18 months

200,000iu 24 months

200,000iu 30 months

200,000iu 36 months

200,000iu 42 months

200,000iu 48 months

200,000iu 54 months

200,000iu 59 months
• Vitamin A deficiency reduces resistance to infections.

• The WHO recommend the integration of vitamin A

supplements within routine immunization services.
• Administered to mother immediately after delivery, gives
immunity to the baby through breast milk.
• Function of Vitamin A.

• Strengthen resistance to infection.

• Increases child’s chances of surviving an infection.

• Protects cornea of the eye (good eye sight).

 Rabies vaccine
• It is a live attenuated vaccine .

• Given to protect against rabies.

• There are many different types of rabies vaccine but the

commonly used one is Human diploid cell substrate
vaccine(HDCV).
• Pre-exposure.

• Three doses are given spaced one week apart.

• Booster after six months, then repeated after every 2-3

years as long as the exposure continues
• Post-exposure.

• Day 0 - 0.1mls

• 3rd day- 0.1mls.

• 7th day – 0.1mls.

• 14th day – 0.1mls.

• 30th day – 0.1mls.

• It is given intradermally on thigh or arm.

• Storage is +2 - +8degree centigrade.

 Hepatitis B vaccine.
• Protects against hepatitis b disease.

• It contain hepatitis b virus

• Supplied in liquid form.

• Dose 0.5mls -0 day

• -4 weeks later.
• - 6 months from 1st dose.
• Given intramuscularly, - deltoid muscle of upper
arm.
• Side effects of hebatitis b vaccine.
• Redness,pain, swelling at injection
site.
• Fever
• Allergic reaction.
 Tetanus toxoid for expectant mothers.

• All the antenatal clients should be asked about the

number of tetanus toxoid injections they have received in
their life to date – including those given after injuries and
through schools.
• If none given start as follow:

• -T.T.1 – Give to primigravida or on first contact.

• T.T.2 – Give not less than 4 weeks after T.T.1.

• T.T.3 – Give during the 2nd pregnancy, any time before 8

months of pregnancy.
• T.T.4 – Give during the 3rd pregnancy, any time before 8
moinths of pregnancy.
• T.T.5 – Give during the 4th pregnancy. Gives protection for life.
• NOTE: DOSE – 0.5MLS.
• - ROUTE I.M.
• When using the 5-T.T. schedule during F.A.N.C, the interval
between pregnancies is not relevant (unless greater than or
equal to 10years between the 1st and 2nd pregnancies) because
the body’s immunological memory responds well to booster
doses given even beyond the recommended time for boosters.
• Only when the interval between the 1 st and 2nd
pregnancy is greater than (or equal to) 10 years,
should the schedule be re-started from T.T.1.
• This rule does not apply to intervals greater than 10
years between the 2nd – 3rd pregnancies or the 3rd – 4th
pregnancies.
• Meaning that a long delay between T.T.2 AND T.T.3 is
more risky than a long delay between T.T.3 AND T.T.4
or between T.T.4 AND T.T.5.
 Holding an immunization session.

• The following are steps to follow:

• 1.setting up immunization session.

• Prepare vaccine carrier.

• Prepare working place and gather equipment

for immunization session e.g syringes,
needles,immunization cards,tally sheets,waste
disposal bins,safety box,cotton balls.
• Get the ice packs (ice cold water).

• Remove vaccines and diluents out of refrigerator

and check if they are safe for use:
• -expiry date.

• -the vaccines are stored under appropriate cold

chain condition.
• -the vaccine vial monitor (VVM) if attached has not
reached the discard point.
• -inspect for any foreign particles matter or variation
of physical aspect prior to administration.
• All vaccine must be stored at refrigerator in +2 -
+8 degree centigrade.
• 2.Assess infant and women.

• Determine current immunization status (by

checking card).
• Determine health status of infant or women.
• Communicate with parent during and after
immunization session.
• Give the right vaccine safely after swapping with
cotton swap moisten with plain water.
• Communicate on side effects,disease prevented,next
visit (written on the card) and verbally communicated
to the mother and importance of child card (coming
with the card for every visit to the hospital).
• Record the vaccine administered and any vitamin A
supplementation given on tally sheet and the child
health card and also in the permanent child register.
• 3.concluding the session.

• Complete immunization tally sheet.

• Count the vaccines to know the number used and see

if they are tallying well with the tally sheet.
• Take care of the unused vaccines.

• NOTE: opened vial of OPV, TT, pentavalent, Heb B may be

used in subsequent immunization session.
• Measles, yellow fever, BCG, if opened must be discarded.

• Take care of vitamin A capsules – store them properly.

• Dispose all used equipment and vials through burying or

inceneration.
• Clean vaccine carrier, leave them to dry ready for next
day’s use.
 Important points to remember.

• Never take 2 vials of the same vaccine out of vaccine

carrier at the same time.
• Do not mix vaccine until mothers and children are
present (arrive).
• Mix one vial of a particular vaccine at a time.

• Keep opened vial of polio, measles and BCG on a frozen

pack.
• Do not keep vial of pentavalent or TT directly on frozen
pack.
• Open the vaccine carrier only when necessary.

• Use one sterile syringe and needle per vaccine per child or
mother.
• Avoid holding loaded syringes in your hands for long so as not
to expose vaccines to heat or direct sunlight.
• Inform each parent what type of vaccine you are giving the
child, the possible reactions to it, what to do about reaction and
when to bring the baby back for immunization.
• Ask the mother to hold the child firmly to restrict his/her
movement during immunization.
 Discarding vaccines.
• All reconstituted vaccines and opened single and multi
dose vial must be used within the recommended
period by the manufacturer or should be discarded at
the end of immunization session by sealing in a proper
puncture resistant “sharps” box for inceneration.
• The sharps container should be replaced once it is 2/3
full and should not be accessed by any unauthorized
individual.
 INJECTION SAFETY.
• Use of safe injection equipment and technique during
immunization is recommended by WHO in all
immunization services.
• Prepare injection in a clean area.

• Never leave the needle in the top of vaccine vial.

• Follow specific recommendation for each vaccine e.g

usage, storage, handling of the vaccine.
• Follow safe procedures to reconstitute vaccines e.g use
the correct diluent and use sterile syringe and needle.
• Avoid contamination during the procedure e.g
touching the needle.
• Use new needle syringe and needle for every
child.
• All used syringes and needles should be
discarded in a safety box immediately after use.
• Avoid re-caping.
 How to assess whether an infant is eligible for vaccines
(immunization).

• Determine the infant age by looking at the child health

card or asking the mother.
• Determine immunization status – which vaccine the infant
has received by checking the card or asking the mother.
• -Check on the permanent register for children.

• -check for BCG scar.

• Determine all vaccines for which the child is eligible.

• Never give more than one dose of same vaccine at one

time.
Adverse events following immunization (AEFI).

• Vaccines induce protection by eliciting active

immune responses to specific antigens.
• There may be predictable adverse reaction
of which most are mild and resolve quickly.
• It is not always possible to predict
individuals who might have a mild or serious
reaction to a vaccine.
• WHO classifies AEFI according to four
main categories:
• 1.programme related.

• 2.vaccine induced.

• 3.coincidental.

• 4.unknown.
• 1.Programme related AEFIs.

• This result from inappropriate practices in provision

of vaccines and may include:
• -wrong dose of vaccine administered.

• -vaccine used beyond expiry date.

• -vaccine used at inappropriate intervals.

• -inappropriate route, site or technique of

administration.
• -wrong amount of diluent used.

• -vaccine prepared incorrectly.

• -drugs substituted for vaccine or diluent.

• -vaccine or diluent stored incorrectly.

• -contaminated vaccine or diluent.

• -contraindication not elicitated or ignored.

• -reconstituted vaccine kept beyond the

recommended period.
• 2.Vaccine induced AEFIs.

• These are reactions in individual specifically caused

by a particular vaccines or its component parts.
• This may be induced – direct effect of the vaccine or
one of its components or due to underlying medical
condition or idiosyncratic (unexpected response
towards a drug) response in recipient.
• Direct effects of vaccines include:

• -local reaction and fever within 48 hours.

• -idiosyncratic responses include anaphylaxis and

fainting immediately after vaccination.
• 3.coincidental AEFIs.

• These are not true adverse reaction to

immunization but are only linked because of the
timing of their occurrence.
• 4.unknown AEFIs.
• They are defined as AEFIs but there
is insufficient evidence to classify as
one of the above.
 Common vaccines induced AEFIs.

• These include:

• -pain, swelling or redness at site of

injection.
• -fever, malaise, loss of appetite.

• NOTE: such reactions does not

contraindicate vaccines.
 Managing common vaccine induce AEFIs.

• Parents should be given advice about

AEFIs that they can expect and how such
events should be managed.
• Fevers over 37.5degree centigrade are
common in children, advice the mother on
the use of appropriate dose of
paracetamol.
 SUPPORTIVE SUPERVISION STRATEGY.

• Supportive supervision is a process that

promotes quality at all levels of health system by
strengthening relationship with the system,
focusing on the identification and resolution of
problems and helping to optimize allocation of
resources.
• Promoting high standard team work and a better
2 way communication.
• A corner stone of supportive supervision is working
with health staffs to establish goals, monitor
performance, identify and correct problems and
proactively improve the quality of service.
• Together, the supervisor and health workers
identify and address weaknesses on the spot thus
preventing poor practices from becoming routine.
• Supervisory visit are also an opportunity to
recognize good practices and help workers
to maintain their high level performance.
• Therefore, supportive supervision is
helping to make things work rather than
checking to see what is wrong.
Setting up a supportive supervision system.

• The three main “R” for an effective supportive supervision

system are:
• 1.right supervisors – well trained on supportive
supervision technique and with updated information and
skills on immunization issues.
• 2.right tools – availability of training materials to update
skills for health workers during supervision visit.
• 3.right resources – sufficient vehicles and time allocated
for supervision and follow-up.
 Implementing supportive supervision.

• 1.prepare in advance supervisory visit.

• Plan to conduct regular supervisory visits as one is

able to monitor performance and identify and
address problems before they negatively impact
service delivery.
• Arrange visit when supervisors can observe an
immunization session, interview client and arrange
staff meeting to give a feedback.
• 2.set expectation for performance.
• Determine measurable performance
goals together with the staffs.
• Develop measurable indicators and
tools so that the staff can monitor
their progress towards their goals.
• Introduce a self assessment /
feedback system.
• 3.Monitor and assess performance of health facility.

• Observe immunization session and note the strength and

weaknesses.
• Talk to clients about the quality of services.

• Check the availability of stock and the condition of the

equipments.
• Check cold chain and vaccine quality.

• Keep a written log/record of items discussed to include

strength and weaknesses and actions to be taken.
• 4.identify gaps and solve problems in
positive ways.
• Praise health workers in public for good
performance BUT correct performance only
in private.
• Provide staffs with informational updates on
policies or new recommended practices.
• 5.provide support and strengthen capacity of
health care providers.
• Identify information/training needs together
with staffs.
• Provide on site updates and training.

• Work on ways to improve the delivery system

with the district or central level authorities.
 REACHING EVERY DISTRICT ( RED).

• The background information.

• The global immunization vision and strategy of 2006

– 2015 was developed by WHO and UNICEF whose
idea is a world in which every child, adolescent and
adult has equal access to immunization services.
• It calls for “at least” 90% national vaccination
coverage and at least 80% vaccination coverage in
every district by year 2010 or sooner.
• Primary or routine immunization is facing many
challenges to reach all children in difficult access areas
as well as to ensure that children start and complete
the vaccination series.
• There is also high drop-out impossible to reduce
without improved service delivery and
communication .
• In the same country high national coverage can hide
big difference between districs.
 Immunization challenges.
• To increase routine coverage and quality with
existing vaccines.
• Reduce mortality secondary to all vaccine
preventable diseases and eradicate polio.
• Mobilize sustained national financing.

• Use immunization as vehicle for other population

based intervention and reaching the unreached.
 THE AIM OF RED APPROACH IS
TO:
• 1.Improve the organization of immunization
services.
• 2.maximize the use of available resources
guarantee sustainability.
• 3.equitable immunization coverage for every
eligible woman and child.
• 4.the RED approach strengthens national routine
immunization but it does not replace them
 Strategies of RED.
• The RED approach focuses on those steps in planning,
managing, and monitoring health services that if carried out
appropriately will improve immunization coverage and impact.
• The primary implementation level of RED is the district e.g
empowering district to plan, implement, and monitor their
immunization services.
• RED also promotes partnership between districts, health
workers and communities to improve population access to and
utilization of services and emphasizes the continuous use of
programme data to monitor progress and solve problems.
 COMPONENTS OF RED.
• 1.planning and management of resources(human, material and

finances).

• At the district and facility level planning should identify what

resources are needed to reach all target population in a way

that can be managed well and thus maintained

• Good planning involves:

• -understanding the district/ health facility catchment area.

• -prioritizing problems and designing micro plans that address

key gaps.
• -developing a budget that realistically reflect the
human, material, and financial resources available.
• -regularly updating and revising costing micro plans to
address changing needs.
• 2.Reaching the target population.

• This is a process to improve access and use of

immunization and other health services in a cost
effective manner through a mix of service delivery
strategies.
• 3.linking services with communities.

• This encourage health staffs to partner with

communities in managing and implementing
immunization and other health services.
• Through regular meeting district health teams and
health facility staffs engage with community to
make sure that immunization and other health
services are meeting their needs.
• 4.supportive supervision.

• Regular on-site training, feedback and

follow up with health staffs.
• This focuses on promoting quality services
and periodically accessing and
strengthening provider’s skills, attitude and
working conditions.
• 5.monitoring for action (self monitoring feedback and tools).
• District health team and health facility staffs need a continuos
flow of information that tells them whether health services are of
high quality and accessible to the target population who is and is
not being reached, whether resources are being used efficiently.
• Monitoring health information involves:
• -observing, collecting data and examining programme data.
• After analyzing the data the information collected is used to direct
the programme in measuring progress, identifying areas needing
specific intervention and making practical revision to plan.
 COLD CHAIN.
• The cold chain is a system process of maintaining
vaccines in a potent state from manufacturer to
mother and child.
• Vaccines are very delicate and easily loose their
potency when exposed to :
• -high temperature.

• -sunlight.

• -freezing condition.
• The vaccine that has lost it’s potency can no longer
protect people from diseases.
• A failure in the cold chain system therefore will make
the vaccines useless.
• If such vaccines are given to babies they will not
protect them.
• The only way to safeguard vaccine is by keeping them
at the required temperature of +2 - +8 degree
centigrade all the time.
• Returning damaged vaccine to refrigerators will not
restore their potency, once damaged they must be
discarded.
• An efficient cold chain system requires the following 3
elements:
• -trained, skilled and motivated staffs.

• -efficient and reliable equipment.

• -efficient distribution of vaccines.

• Cold chain is composed of people and equipment.

 Proper vaccine
management.
• This includes:
• -keeping the vaccines cold and out of
sunlight.
• Distributing the vaccines efficiently.
• Looking after the equipments.
 Keeping vaccines cold and out of
sunlight.

• Vaccines are damaged by:

• -heat – some vaccines are more sensitive to high temperature than
others.
• KEPI vaccines are arranged inorder of their sensitivity from the most to
the least sensitive:
• -polio is the most sensitive to heat.
• -measles.
• -BCG.
• -pentavalent.
• -TT.
• -Hep B.
• -sunlight – sunlight damages the vaccines very
quickly so it is important to keep vaccine vials
covered all the time.
• Measles and BCG vaccines are the most sensitive
to sunlight.
• -freezing – pentavalent, pneumococcal, TT, Hep B
vaccines must never be frozen because they are
damaged with freezing.
 Distributing vaccines efficiently.

• Vaccines should be distributed

efficiently to ensure that the correct
vaccines and correct quantity are in
the right place at the right time.
 Looking after cold chain equipment.

• The equipment is maintained and

cleaned as recommended.
• It will work well and last longer.
• Equpment is required for storage and
transportation of vaccines.
 Cold chain equipment.
• This include refrigerators which are powered by gas,
electricity, kerosine or solar power.
• Most facilities have been supplied with refrigerators which
work on both gas and electricity and can be interchanged
when electricity is cut off.
• The health facilities have been issued with gas cylinders
so that there is no delay in changing to gas.
• There are several types of refrigerators used in the health
facilities e.g RCW42EG – (EG means electricity or gas).
How to pack vaccines in a refrigerator.

• It is important that vaccines,diluents and icepacks are in the

correct compartment on the refrigerator.
• The refrigerator has a freezing compartment which is the
coldest part of refrigerator, it is used only for making the
icepacks.
• Never store any vaccine in the freezing compartment.

• In an RCW42EG trays of different colours are used to store

each type of vaccine.
• The most sensitive being polio is kept in Blue – bottom tray
(polio).
Vaccines Colour

P – pop –pcv10 P – puppy – purple.

P – pin - pentavalent R – right – red.

T - take – tetaneous toxoid O – old – orange.

B – brother - BCG Y – you – yellow.

M – my – measles. G – genesis - green

P – pliz - polio B – be - blue

 General rules for storing vaccines in the
refrigerator.

• Place vaccines neatly in piles with air spaces all

around.
• Do not let the vaccines touch the back or side of
refrigerator.
• Put new stocks of vaccines on right side of each
shelf and older stock to the left hand side.
• As you use the stock move the remaining vaccine
further to the left of shelf.
• Do not keep any vaccine on the door shelf or bottom shelf.

• Always use the oldest vaccine (first in first out – FIFO) but be
guided by expirery date.
• NOTE:

• -never keep food or drinks with the vaccines.

• -never mix vaccine with other medicine in the refrigerator.

• -keep the doors tightly shut at all times especially if there is

power failure.
 Principles of
refrigeration.
• Remember that the refrigerator must
be labeled at least 12 inches from
the wall to allow circulation and to be
protected from sunlight.
• Read and record the temperature on
the cold chain recording sheet.
 How to use the cold chain recording chart.

• Read and record the refrigerator temperatures twice daily

including weekends.
• Carefully record this temperature readings in cold chain
recording sheet.
• You must enter:

• -name and type of refrigerator.

• -name of district.

• -name of health institution.

• -normal operations e.g E or G.

• -Date.

• -number of ice packs frozen today.

• -shortage of gas.

• -number of hours of electricity failure.

• -number of vials used today.

• -number of vials received today.

• -report on faults and problem.

• -report the temperature morning and evening.

• -note the bold line is for morning and broken line for evening.
 What to do during power failure.

• Switch the gas/electric machine immediately to gas

operation and light the gas.
• Check that the flame is burning correctly.

• If the power failure is very prolonged it may be necessary

to transfer the vaccines to other gas/electric refrigerators.
• Only if the temperature in the ice lined refrigerator reaches
+8 degree centigrade should the vaccines be moved.
• Transfer the vaccines to cold box and move the vaccine to
other refrigerator owners.
 Vaccine cold boxes and carriers.

• The cold boxes are used for transporting large

quantities of vaccines by vehicles from district stores
to the facilities.
• They are also used for carrying vaccine for several
days e.g during mobile/outreach services.
• Fully frozen icepacks are placed side to side against
the inside wall and bottom of the cold box.
• BCG, polio, and measles vaccines are placed
directly on the ice packs.
• Wrap plastic material around the TT, pentavalent
and pneumococcal to prevent them from being
frozen.
• Put a thermometer on top of vaccine.

• Ice packs are placed over the top of vaccine and

diluent.
 Maintenance of vaccine cold box.

• Leave the lid open after each use so

that the inside can dry out.
• Check that the rubber seal around
the lid is intact.
• Oil hinges and locks regularly.
 Vaccine carriers.
• These are used for collecting small quantities of vaccine
from health centre.
• Collecting vaccine sample for laboratory test.

• Fully frozen icepacks are placed around the inside wall.

• Vaccine and diluent are carefully placed into the carrier.

• Pentavalent,TT ,and HepB vaccine are wrapped in plastic

material to prevent them from freezing.
• Place a thermometer inside, cover with the provided
sponge and close the lid.
 Defrosting the refrigerator.
• A thin layer does not affect the cooling
performance.
• A thick layer of frost 6-10cm must be removed by
defrosting.
• Move the vaccine to another refrigerator or store
them in a cold box with ice packs.
• Turn off the gas supply or pull out the plug from
wall socket if on electric operation.
• Open the door of the refrigerator and freezer
compartment.
• Remove ice with your fingers when possible.

• Do not use knives or other sharp instruments to

remove the ice.
• Wipe the freezer compartment dry.

• Clean the refrigerator inside with soap and water

and dry it carefully.
• Do not use steel wool on the metallic
surface.
• Put the plug in wall socket.

• Wait until the temperature has come down

to +2 degree centigrade.
• Place the vaccines inside and close the door.
Monitoring vaccine temperatures.

• The safe storage temperature for all vaccines is

+2 - +8 degree centigrade in a health facility.
• There are several ways of monitoring vaccine
temperatures:
• 1.thermometer.

• Thermometer is used to check the

temperatures.
• 2. 3m vaccine monitor card.

• This is a heat sensitive card attached to the vaccines and

has parts labeled as A,B,C and D.
• If A is completely blue the polio vaccine must be used within
3 months.
• If the colour blue has filled part A,and B, one is supposed to :

• -test the polio vaccine or discard it.

• -use the measles vaccines within 3 months.

• -use pentavalent,BCG,HepB and TT normally.

• If the colour blue has filled windows A,B,
and C:
• -Discard polio and measles.

• -use pentavalent,BCG, HepB,TT within 3

months.
• If the colour blue has filled windows A,B,C
and D discard all vaccines.
• 3.vaccine vial monitor (VVM).

• This is a label made of heat sensitive material which is

placed on a vaccine vial to register cumulative heat
exposure over time.
• A direct relationship exist between the rate of colour
change and temperature.
• VVM is a cycle with a small square inside it.

• -if the inner square is lighter than the outer ring, use this
vaccine.
• If the inner square matches the colour of outer ring, do not use
the vaccine but discard it.
• If the inner square is darker than the outer ring do not use the
vaccine, it is beyond the discard point.
• 4.the freeze watch indicator.
• This tells when the vaccine has been exposed to freezing
temperature, when the temperature falls below -5 degree
centigrade the vial breaks and a bright red stain spread across
the white paper background.
• If the indicator is stained RED the vaccine should be discarded.
• 5. shake test.

• If pentavalent, HepB, TT vaccines have been frozen

perform a shake test as follows:
• -select a vial you think may be frozen.

• -select another vial of the same type that you know has
not been frozen.
• -shake them vigorously and inspect them in strong light.

• -after 30 minutes:
1st bottle 2nd bottle
Smooth and cloudy Not smooth there are granular particles.
Start to clear with no sediments Almost clear with thick sediments
Use this vaccine Do not us this vaccine
 Types of refrigerators
• There are two types:
• -compression type.
• -absorption type.
• READ AND MAKE NOTES ON THE
ABOVE TYPES OF REFRIGERATORS.
 Preparing for
emergencies
• Emergencies can interrupt immunisation services if
not planned for.
• Some of the common cold chain emergencies
include:
• • Equipment breakdown.

• • Electric power failure.

• • Shortage of gas.

• • Shortage of spare parts.

• There should be a warning system for identifying equipment failure

and make arrangements in advance for moving vaccines to the

nearest health facility or location that has appropriate substitute

equipment.

• The district should be notified as soon as possible of such failure.

• Cautions:

• • Use only one power source

• • Emergency plan

• • Transferred vaccines need to be captured in the ledger books

 Communication for immunization.

• Communication on the following:

• -cold chain and logistics.

• -training.

• -Supervision and monitoring.

• -educating the community to accept and use

immunization services.
• -educating the client about the vaccines given, side
effects, adverse reactions expected and management.
Importance of communication in immunization.

• raise and sustain immunization coverage for the target

groups and reduce the vaccine preventable diseases.

• Ensures higher immunization coverage and reduce

drop-out rate.

• Helps in correcting misconception the community

members may have about immunization.

• Helps in knowing barriers to immunizations hence

putting in place the right interventions.
Methods of communications
• Verbal.- face to face communication e.g when
interacting with supervisor and also when
offering health messages to client and members
of the community.
• Written.

• Communication channels: e.g using mass media

such as television, radion,and newspaper.
• Teach clients on the following:

• which vaccine(s) was administered

• • the disease(s) it protects against

• • which side effects to expect and what to do about

them

• • the date of return

• • importance of taking care of the Child Health Card

and bringing it at every subsequent visit
 IMMUNIZATION
COVERAGE.
• Information about immunization is routinely
collected and recorded and it is used to monitor
immunization coverage each month.
• This allows to find out what activities are
succeeding and what activities need
improvement.
• This help in correction of problems so that
progress toward the annual target continues.
• Most health workers record information about the
immunization given daily on:
• -daily tally sheets.

• -patient’s immunization cards.

• Supervisors record monthly summaries of daily

activities on:
• -monthly immunization reports.

• -immunization monitor charts.

 ASSIGNMENT.
• READ AND MAKE NOTES ON :

• -how to prepare immunization monitor

chart.
• -calculation of immunization coverage
rate.
• -calculation of drop-out rate.
Problems occurring in immunization activities.

• Drop-outs
• Missed opportunities.
• Never reached.
• Lack of geographic access.
• Drop-outs.

• Ask the following questions:

• -are the health workers telling the mothers when

to return for the next doses for themselves and
children?
• -are the immunization session schedule
convenient for the mother to return with the
child?
• Reducing drop outs.

• Ensure availability of vaccines, supplies and

logistics at all times.
• Organize regular outreach sessions.

• Make sure patients/caretakers know the

return date.
• Establish defaulter tracing systems.
• Missed opportunity.

• Opportunities for immunization are missed when health

workers do not:
• -use the recommended immunization schedule.

• -observe appropriate contraindication to immunization.

• -screen children and women at every contact and

immunize them as necessary.
• -open a vial of vaccine even if only one eligible child or
woman is present for immunization.
• Never reached.

• The annual plan may contain activities to reach

people such as the disadvantaged population
who do not come for immunization services.
• Contact the community leaders and schedule
the days and time for that activity as in mobile
or outreach services.
• Lack of geographic access.

• Provide access for people who live

beyond reasonable travelling distance.
• Begin outreach services for a remote
village to make sure that immunization
reach most of the children and women.
 WHO Multi dose vial
policy.
• Two concerns in setting the policy of
vaccines in opened multiple vial in
subsequent session are:
• -potency of the vaccine.
• -safety of its administration.
• Potency of vaccine.

• The potency of vaccine in an opened vial is determined

primarily by:
• -heat stability of the Particular vaccine.

• -whether or not the vaccine has been reconstituted.

• The vaccines in open vials of OPV,TT,pentavalent,HepB, and

liquid formulation of Hib (haemophilus influenza) remain
potent as long as the vial was stored under appropriate cold
chain conditions and expirery date has not passed.
• Safety of its administration.

• The safety of vaccine in a multi-dose vial is

primarily dependent on:
• -risk of contamination with a pathogenic
organism.
• -bacteriostatic or virucidal effects of
preservative in the vial.
• Liquid injectable vaccines such as pentavalent,TT,HepB
contain preservatives that prevent growth of bacterial
contamination.
• A time limit of 4 weeks has been set for this.

• Multi dose vials of OPV, pentavalent,TT, and liquid

formulation of Hib vaccines from which one or more doses of
vaccines have been removed during an immunization session
may be used in subsequent session for upto a maximum of 4
weeks provided that all of the following conditions are met:
• -the expirery date has not passed.

• -the vaccines are stored under appropriate cold

chain conditions.
• -the vaccine vial has not been submerged in water.

• -Aseptic technique has been used to withdraw all

doses.
• -the VVM if attached has not reached the discard
point.
 Documentations.
• Document on :

• -child health card.

• -immunization daily tally sheet.

• -monthly immunization tally sheet.

• -permanent register for children.

 Monitoring and evaluation.
• Plan your programme and set the target.

• Carry out the programme activities and record your

achievements.
• Compare your target from your summary sheet.

• Check for programme efficiency by asking yourself this

question:
• -are there children still getting e.g measles?

• -if yes, there must be something wrong.

• Fill in the measles case investigating form and report to

relevant authorities.
 Possible causes of failed efficiency.

• Expired vaccines.

• Extensive cold chain failure.

• Immunization during incubation of

measles.
• Cases occurring below age 9 months.

• Coverage less than 80%.

 Disease surveillance.
• Disease surveillance is the collection, analysis, and interpretation of

data to determine disease trends and patterns.

• Disease surveillance provides information such as:

• •- Disease incidence, morbidity, and mortality, and progress in

achieving disease control goals.

• • -Changes in patterns of morbidity and mortality among different age

groups in different geographical areas and among different economic,

social, or cultural groups.

• •- Impact of immunization strategies on disease incidence.

• • Disease trends and it’s determinants in order to improve health

• Surveillance data is used for the following:

• . Public health decision making and action

• . Improve timeliness of information exchange and dissemination

• . Standardize the data collected

• . Ensure adequate surveillance infrastructure

• . Improve local data analysis

• . Enhance teamwork amongst surveillance partners

• . Optimal use of resources

• . Formulate policy
TYPES OF DISEASE SURVEILLANCE

• 1. Facility-Based Routine Surveillance-

health workers are required to report on the
number of individuals that come to their facility
and are diagnosed with notifiable diseases.

• The process of detecting and reporting

information on diseases that bring patients to the
health facility is known as passive surveillance.
• 2. Community-Based
Surveillance - With proper
training, members of the
community can expand facility-
based surveillance by detecting and
reporting cases that may go
undetected by the health facility
• 3. Sentinel Surveillance - Sentinel
surveillance is the collection and
analysis of data by designated
institutions selected for their geographic
location, medical specialty, and ability to
accurately diagnose and report high quality
data.
Priority diseases for surveillance.

• AFP surveillance for polio eradication.

• Measles.

• Neonatal tetanus.

• Haemophilus influenza type b,

bacterial meningitis.
• Rota virus.
• Surveillance involves:

• Detection

• Investigation

• Reporting

• Analysis and interpretation

• Presentation

• Response
 NCK REVISION

•
QUESTIONS.
1.Immunization programme is a most important key in disease
prevention.
• (a).Define immunization. (2 marks).
• (b).Explain barriers to immunization programme implementation.
(8marks).
• (C).Describe the current immunization schedule. (10 marks).
• 2.Differentiate between natural and artificial immunity. (5 marks).
• 3.Vaccines are very delicate and easily lose their potency when
exposed to high temperatures, sunlight and freezing conditions.
Describe the arrangements of vaccines in RCW42EG type of
refrigerators (6 marks).
• 4.Explain who is “fully immunized child” (FIC). (5 marks).
• 5.State five (5) factors which can affect quality of vaccines. (5 marks).
• Storage.
• Mode of administration/ route of administration.
• Person administering – should be qualified personnel.
• Transportation .
• Dilution of vaccines.
• 6.Explain five (5) key messages that the health worker should tell
the mother / caretaker after immunizing a child with BCG vaccine. (5
marks).
• 7.Explain four (4) causes of missed opportunity. (8 marks).
• 8.Herd immunity is defined as immunity which:-
• (A). occurs when a group of people are immunized.

(B). vaccination used by veterinary people.

• (C). Immunity from a live vaccine.
• (D). Immunity from animals.
• 9. what is the minimum interval between OPV1 and OPV2.
• (a)Two weeks.
• (b) Three weeks.
• (c) Four weeks.
• (d) Six weeks.
• 10.A two months old child is brought for immunization for the first
time. He has not received any vaccination. Which vaccines should the
health worker give?
• (a) pentavalent, measles, OPV.

• (b) BCG, opv1, Rotavirus 1,PCV101, pentavalent 1..

• (c) BCG, measles, pentavalent.

• (d) BCG, OPV, TT.
• 11.The correct dose of measles vaccine for a child one year is
• (a) 0.05mls
• (b) 0.5mls
• (c) 1ml
• (d) 0.1ml
• 12.The correct temperatures for storing EPI vaccines in a health
centre is?
• (a) 00c to 80c
• (b) 00c to -80c
• (c) +20c to +80c
• (d) -20c to -80c.
• 13.What is your annual population for children less than one year of
age if your health centre covers a population of 8,000 people?
• (a) 400
• (b) 375
• (c) 320
• (d) 240.
• 14.Anti-tetanus serum is an example of:

• (a) Natural active immunity.

• (b) Natural passive immunity.

• (c) Artificially induced active immunity.

• (d) Artificially induced passive immunity.

• 15.Discuss how to defross the

refrigerator.(20 marks).
CONTACT VACCINE DOSE AGE OF CHILD DOSE ROUTE
3 OPV II At 10 weeks or 2 drops Oral
4 weeks after
DPT-HepB+Hib OPV I • 0.5 ml • Intramuscular
2 and DPT-HepB- into the
Hib 1 upper outer
aspect of
the left thigh
PCV10 - 2 • 0.5ml • Intramuscular
into the
upper outer
aspect of
the right thigh
Rota - 2 • 1.5ml • Oral
 g
CONTACT VACCINE DOSE AGE OF CHILD DOSE ROUTE
4 OPV III At 14 weeks or 2 drops Oral
4 weeks after
DPT-HepB+Hib OPV II • 0.5 ml • Intramuscular
3 and DPT-HepB- into the
Hib 2 upper outer
aspect of
the left thigh
PCV10 - 3 • 0.5ml • Intramuscular
into the
upper outer
aspect of
the right thigh
CONTACT VACCINE DOSE AGE OF CHILD DOSE ROUTE
5 Vitamin A At 6 months of One capsule Orally
100,000IU age
6 Measles 1st At 9 months or 0.5 ml Subcutaneous
dose first contact into the
after 9 right upper arm
months (deltoid
muscle)
7 Yellow fever At 9 months or 0.5 ml Subcutaneous
first contact into the
after 9 left upper arm
months – in (deltoid
four special muscle)
districts
8 Vitamin A At 12 months One capsule Orally
200,000IU of age
9 Measles 2nd At 18 months 0.5 ml Subcutaneous
dose or first contact into the
after 18 right upper arm
months (deltoid
• NB: Yellow fever vaccination is still
currently only given routinely to children
in Baringo and Marakwet districts.
• Vitamin A, though not a vaccine is given
during growth monitoring and/or vaccination
sessions every 6 months till 5 years.
 POINTS TO REMEMBER WHILE USING IMMUNIZATION
SCHEDULE.

• Most vaccine-preventable diseases of childhood occur very early

in life. If this schedule is followed according to specification,
children will complete their primary vaccinations before the age
of one year, and will therefore be unlikely to suffer from these
diseases. Every effort should therefore be made to
complete the primary vaccination series on schedule.

• There are few contraindications to immunization. Health workers

should immunize all eligible children whether they are sick or
not.
• In case a child requires admission to hospital the decision

whether to immunize or not is left to the receiving

doctors. They should follow the principle that no child
should be discharged from hospital without having their
immunization status checked.

• Antibodies present in breast milk do not interfere with

the take of oral polio vaccines; therefore mothers

should be encouraged to continue breast feeding.
• If polio birth dose, for some reason was not

administered within the first two weeks of life, it should

not be administered. One should then wait until the
child is six weeks old and then give OPV 1 together
with DPT-HepB+Hib1 and PCV as per the schedule.

• Regardless of the interval between the two doses of

DPT-HepB-Hib, PCV and polio vaccines, the doses
already given should not be repeated.
• All vaccines can be given at the same session if needed, but

they must be given in separate syringes and sites. This means

that every time a health worker gets into contact with a child,

the immunization record of the child should be checked and

missing immunizations for which the child is eligible

administered. For instance, if a child is seen for the first time

when ten months old, one should give BCG, DPT-HepB+Hib 1,

PCV, OPV 1 and measles and ask the mother to come back

four weeks later for DPT-HepB+Hib 2,PCV 2 and OPV 2.

• Booster doses after primary immunizations
are not included in the routine schedule.
However, these immunizations are provided
in the private health sector.

• Currently, Kenya provides a second

opportunity for measles vaccination through
supplemental immunization activities (SIAs).
Tetanus vaccination for pregnant women

• The current EPI recommendation regarding tetanus vaccination for

pregnant women is a “5-T.T.Schedule” administered as follows:

• a pregnant woman in her 1st pregnancy should receive two 0.5ml

tetanus toxoid (TT ) injections spaced at least four weeks apart

between the fourth and eighth months of gestation.

• She should receive a single additional dose of T. T. as early as possible in

her second trimester in subsequent pregnancies, up to a maximum of

three additional doses. A total of 5 doses of Tetanus Toxoid vaccine

given across four pregnancies will protect herself and all subsequent

newborns from tetanus for 20 years.