Integrated Management of Newborn and Childhood Illness Module: 12. Immunization and Related Interventions

Study Session 12  Immunization and Related Interventions

Introduction

In this study session, you will learn about the types of vaccines routinely given in the Expanded Programme of Immunization (EPI) and the schedule of their administration. Immunization is known as the single most cost-effective strategy to decrease childhood morbidity and mortality. The objective of the EPI is to reduce and control illness, death and disability among children caused by vaccine-preventable diseases. You will also learn about the routine administration of vitamin A and deworming of children.

Learning Outcomes for Study Session 12

When you have studied this session, you should be able to:

12.1  Define and use correctly all of the key words printed in bold. (SAQs 12.1 and 12.3)

12.2  Describe the type of vaccines covered under the EPI and their schedule of administration. (SAQs 12.1 and 12.2)

12.3  Describe how to check for immunization status and when the child needs immunizing. (SAQs 12.1, 12.2 and 12.3)

12.4  List the contraindications to vaccine administration. (SAQs 12.1 and 12.2)

12.5  Describe the schedule of vitamin A administration and deworming for children. (SAQ 12.3)

12.1  The Expanded Programme of Immunization

In this study session you are going to look at the vaccines covered in the Expanded Programme of Immunization (EPI) and their schedule of administration. You will then go on to learn how to check a child’s immunization status and understand when it is necessary to provide a child with a vaccine on the same day of the visit. You should be aware that the terms ‘immunization’ and ‘vaccination’ can be used interchangeably, so you will see both terms used in this study session.

Ideally, every child must complete his or her full vaccination before celebrating their first birthday. Therefore you must check every child when you meet them in their home or at the health post. You need to check whether they have been vaccinated against the EPI diseases and if not, you should give any missed vaccinations on the same day of the visit.

12.2  Vaccines covered under EPI and their schedule of administration

Currently, the EPI delivers eight vaccines to protect children against the following serious childhood illnesses: tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, Haemophilus influenzae-B (Hib) infections, hepatitis B disease and measles.

• Haemophilus influenzae type B and the hepatitis B vaccines are new vaccines introduced into the EPI programme in Ethiopia in 2007.
• Haemophilus influenzae type B vaccine prevents meningitis, pneumonia, epiglottitis and other serious infections caused by Haemophilus influenzae type B bacteria. The vaccine will not protect against these conditions if they are caused by other infectious agents such as viruses.
• Hepatitis B vaccine protects against liver disease. Hepatitis B infection in young children is usually asymptomatic (they don’t develop symptoms). However, a larger proportion of children than adults may become chronic carriers who can transmit the hepatitis B virus to others for many years without showing symptoms themselves. Chronic carriers are more likely to develop severe chronic liver disease or liver cancer in later life.

Table 12.1 shows the recommended immunization schedule and the mode of administration of the eight childhood vaccines. The recommended vaccine should be given when the child reaches the appropriate age for each dose. If the vaccination is given too early, protection may not be adequate. If there is any delay in giving the appropriate vaccine, this will increase the risk of the child getting the disease. If you see a child who has not been immunized at the recommended age, you should give the necessary immunizations as soon as possible. Most vaccines (except BCG and measles) require administration of repeated doses, usually three times. For these vaccines, after the first dose, give the remaining doses at least four weeks apart.

• BCG vaccine protects against tuberculosis (TB) and is given once only.
• OPV is the oral polio vaccine, given in four doses numbered 0 to 3.
• DPT is the diphtheria, pertussis, tetanus vaccine, combined in a single preparation with the Hepatitis B vaccine and the Haemophilus influenzae type B vaccine. Together, these five vaccines are known as the pentavalent vaccine (‘penta’ means five). Children get three doses.
• Measles vaccine is given only once.

You should not give OPV0 (the first dose of oral polio vaccine) to an infant who is more than 14 days old. Therefore, if an infant has not received OPV0 by the time he or she is 15 days old, you should wait until the child is four weeks old to give OPV-1. Then also give DPT1-HepB1-Hib1 at four weeks.

Children with diarrhoea who are due for OPV (any dose) should still receive the prescribed dose. However, you should not count this as it may be passed through the body. You should tell the mother to return with the child in four weeks’ time so that you can give the child an extra dose of OPV.

12.3  How to check for immunization status

You must check the immunization status of all the children who visit your health post or when you visit them at home. You can use the Assess and Classify chart to help you find the recommended immunization schedule. Box 12.1 outlines the steps you need to take to check the immunization status of each child.

Box 12.1  Steps for checking immunization status of children

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(Source: Assess and Classify the Sick Child Module: IMNCI Training Modules, FMOH Ethiopia, June 2008)

In order to decide whether the child needs immunizing right away, you should look at the child’s age on the clinical record. If you do not have this, ask the mother about the child’s age.

ASK the mother if the child has an immunization card. If the mother answers yes, ask her if she has brought the card with her to the health post.

• If she has brought the card with her, ask to see the card.
• Compare the child’s immunization record with the recommended immunization schedule. Decide whether the child has had all the immunizations recommended for the child’s age.
• On the recording form, check all immunizations the child has already received. Write the date of the immunization the child received most recently. Circle any immunizations the child needs in the current visit. These will be any vaccines the child should have already received but has not. For example, if a nine-week-old infant has not yet been vaccinated with DPT1-HepB1-Hib1 and OPV1 (which he should have received at six-weeks-old), you should give the child these vaccines while he is at the health post.
• If the child is not being referred, the mother needs to be advised that the child should receive the relevant immunization (or immunizations) during the visit.

If the mother says that she does not have an immunization card with her:

• Ask the mother to tell you what immunizations the child has received.
• Use your judgement to decide if the mother has given a reliable report. If you have any doubt, immunize the child. Give the child OPV, DPT-HepB-Hib and the measles vaccine according to the child’s age.

Give an immunization card (as shown in Box 12.2) to the mother and ask her to bring it with her each time she brings the child to the health post.

Box 12.2  Example of immunization card

(Source: As for Box 12.1)

So far, you have gone through the eight EPI vaccines, their schedule of administration and how to check immunization status of children. In the next section you will learn the contraindications for vaccination.

12.4  Contraindications to vaccine administration

A contraindication is one or more conditions which makes administration of vaccines inadvisable due to some potential side effects. Common illnesses are not contraindications for immunization, so no sick child, including the malnourished child, should miss immunization, unless there is a clear contraindication.

There are only three situations which are considered to be contraindications to immunization:

• Do not give BCG to a child known to have AIDS
• Do not give DPT2-HepB2-Hib2 or DPT3-HepB3-Hib3 to a child who has had convulsions or shock within three days of the last dose of the vaccine
• Do not give any doses of DPT-HepB-Hib to a child with recurrent convulsions or another active neurological disease of the central nervous system.

In all other situations, here is a good rule to follow:

• There are no contraindications to immunization of a sick child if the child is well enough to go home
• If you are referring a child, you do not need to give him or her a vaccine before referral. The staff at the referral site should make the decision about immunizing the child when the child is admitted. This will avoid delaying referral.

As you read earlier, children with diarrhoea who are due for OPV should still receive this during their visit to the health post. However, the dose should not be counted and you should tell the mother to return with the child in four weeks for an additional dose of OPV.

You should also advise the mother to be sure the other children in the family are immunized.

12.5  Recording the child’s immunization status

When you have checked the child’s immunization status and given the correct dose of vaccines for the child’s age you should use the case recording form (see Case Study 12.1). Put a check mark (✓) for the immunizations already given and circle the immunizations needed at the current visit. If the child needs to return for an immunization, write the date that the child should return in the classification column.

The case study below illustrates how you should record the immunization status in the correct section of the case recording form.

Case Study 12.1  Selam

Selam is four months old. She has no general danger signs. She is classified as having diarrhoea with no dehydration. Her immunization record (on the case recording form) shows that she has received BCG, OPV0, OPV1, OPV2, DPT1-HepB1-Hib1 and DPT2-HepB2-Hib2. You can see this below.

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Now that you have seen how to enter information about immunization on the child’s record, you are going to learn about routine administration of vitamin A and deworming a child.

12.6  Routine administration of vitamin A and deworming

Vitamin A deficiency and worm infections are common in developing countries and both have serious health effects for a growing child. Preventive therapy should be given routinely for both conditions.

12.6.1  Vitamin A

Vitamin A helps maintain the surface linings of the eyes and the respiratory, intestinal and urinary tracts. It also helps the immune system to resist severe infections.

Vitamin A deficiency (VAD) is a public health problem in many countries, including Ethiopia. It is the leading cause of preventable blindness in children and increases the risk of disease and death from severe infections, particularly measles, diarrhoea and pneumonia. Improving the vitamin A status of children aged 6−59 months can reduce measles and diarrhoea mortality rates by 50% and 33% respectively, and can decrease overall under-five mortality by 23%.

Thus, routine bi-annual (every six months) supplementation of vitamin A is recommended for all children aged 6−59 months of age. You should give one dose if the child has not received a dose within the last six months. The first dose is usually given at nine months of age together with the measles vaccine, and it should then be given every six months up to five years of age. Table 12.2 sets out the correct dose according to the child’s age.

To administer vitamin A, cut across the nipple of the capsule with a clean instrument (surgical blade, razor blade, scissors or sharp knife). If the vitamin A capsule does not have a nipple, pierce the capsule with a clean needle. Squeeze the capsule gently so drops of vitamin A fall onto the child’s tongue. Record the date each time you give vitamin A to a child. This is important. If you give repeated doses of vitamin A in a short period of time (in less than six months), there is danger of an overdose.

12.6.2  Deworming

Soil-transmitted intestinal worms represent a serious public health problem wherever the climate is tropical and inadequate sanitation and unhygienic conditions prevail. Three types of worms are the most prevalent and have the most damaging effect on the health of preschool children: roundworms, hookworms and whipworms.

Worm infections are associated with a significant loss of micronutrients from the child’s body and contribute to vitamin A deficiency, anaemia, growth failure and malnutrition in children. An infected child’s physical fitness and appetite are negatively affected and their school performance is impaired.

Therefore, all children 24 months of age or older need to be given Mebendazole or Albendazole every 6 months to treat intestinal parasites, especially hookworm and whipworm infections. Table 12.3 sets out the correct doses according to the child’s age, for children who have not been tested in the previous 6 months.

When you see a child aged 24 months or older, you should check whether they have been given a dose of Mebendazole or Albendazole in the previous six months. If not, you should give them Mebendazole or Albendazole as indicated in Table 12.3 above.

Only chewable deworming tablets which taste good should be given to children under five years of age. For children under three years of age, tablets should be broken and crushed between two spoons, then water added to help administer the tablets.

Bear in mind that vitamin A supplements are given from the age of six months and deworming tablets are given from the age of two years.

Summary of Study Session 12

In Study Session 12, you have learned that:

1. The EPI delivers eight vaccine antigens to protect children against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, Haemophilus influenzae type B (Hib) infections, hepatitis B and measles.
2. Most vaccines (except BCG and measles) require administration of repeated doses.
3. Ideally, every child must complete his or her full vaccination programme before celebrating their first birthday.
4. You must check the immunization status of all the children who visit your health post or when you visit them at home. If you have any doubt whether the child has received all the relevant vaccinations you should immunize the child.
5. Common illnesses are not contraindications for immunization, and if the sick child is well enough to go home he or she should be vaccinated.
6. Vitamin A deficiency and worm infections are common. Both have serious health effects for a growing child and therefore preventive therapy should be given routinely for both conditions. Routine bi-annual supplementation of vitamin A is recommended for all children aged 6−59 months and deworming for all children 2–5 years of age.

Self-Assessment Questions (SAQs) for Study Session 12

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

Read Case Study 12.2 and then answer the questions below.

Read Case Study 12.3 and then answer the questions below.