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NATIONAL IMMUNIZATION PROGRAM (EPI)

SEVEN IMMUNIZABLE DISEASES

1. Pulmonary tuberculosis
2. Diphtheria
3. Pertussis
4. Tetanus
5. Polio
6. Measles
7. Hepatitis B

EPIDEMIOLOGICAL FEATURES

1. TUBERCULOSIS

WHO STANDARD CASE DEFINITION

An ill child:
 With a history of contact with a PTB suspect or patient;
 Who does not return to normal health after measles or whooping cough;
 Who has had a loss of weight and exhibits cough and wheeze which does not respond to antibiotic
therapy for acute respiratory disease;
 Who has an abdominal swelling due to hard, painless mass and free fluid;
 Who has painful, firm or soft swelling of lymph nodes;
 With any slow-onset bone or joint lesion; and
 Who shows signs suggesting meningitis or disease of the CNS.

Clinical Manifestations: a chronic communicable disease that affects many organs of the body, and commonly the lungs.
Cough, fatigue, fever, weight loss, hoarseness, chest pain, and hemoptysis may occur.

Infectious Agent: Mycobacterium tuberculosis

Reservoir: primarily man; in some areas, also diseased cattle

Mode of Transmission: by droplet infection, that is, through inhalation of bacilli fresh from patients, or by dust
inhalation of bacilli from droplets which have dried on the ground (or other surfaces) and suspended in the air.

Incubation Period: about 4-12 weeks from infection to the appearance of a demonstrable primary lesion. The
subsequent risk of progressive pulmonary or extrapulmonary tuberculosis is greatest within a year or two after
infection. It may also relapse from a latent infection time.

Period of Communicability: a person who excretes tubercle bacilli is communicable. The degree of communicability
depends upon the number of excreted bacilli in the air, virulence of the bacilli and environmental conditions such as
overcrowding.

Susceptibility: risk of developing the disease is highest in children under three years of age. Susceptibility to infection is
general.
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2. DIPHTHERIA

WHO standard case definition – a bacterial (toxin-related) disease:

 Acute pharyngitis with a pseudomembrane, OR

 Acute nasopharyngitis with a pseudomembrane, OR
 Acute laryngitis with a pseudomembrane

A typical diphtheria illness in a CHILD

 DAYS 1-3: child complains of a mild sore throat and is unwell.

 DAYS 4-6:
 Child is very ill
 Swollen neck; obvious pseudomembrane on throat which may obstruct breathing
 AFTER TWO WEEKS: diphtheria toxin may cause heart failure and paralysis of the respiratory system.

Clinical Manifestations: it is an acute contagious disease characterized by local inflammation and fibrin formation
(pseudomembrane) of the mucous membrane of the upper respiratory tract (tonsils, pharynx, larynx, or nose). A toxin is
produced, which when absorbed into the bloodstream causes deleterious effects on various parts of the body, especially
the heart and the nerves.

Infectious Agent: Corynebacterium diphtheria

Reservoir: Man

Mode of Transmission: it is transmitted by respiratory droplets (nasal and throat discharge) from a case or carrier.

Incubation Period: it is usually 2-5 days, but may be longer.

Period of Communicability: it may last for 2 to 3 weeks, but may be shortened in patients with antibiotic treatment.
Diphtheria transmission is increased in schools, hospitals, households, and in crowded areas.

Susceptibility: infants born to immune mothers may be protected for up to 5 months. Immunity is often acquired
through inapparent infection or complete immunization with diphtheria toxoid.

3. PERTUSSIS

WHO standard case definition – a bacterial (toxin-related) disease

History of severe cough and history of any of the following:

 Cough persisting for 2 or more weeks

 Fits of coughing
 Cough followed by vomiting

A typical pertussis illness in a child

 FIRST WEEK: child shows symptoms of a cold

 SECOND WEEK:
 The cough gets worse and doesn’t stop
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 The child struggles to breathe and “whoops” in a breath

 The child may then vomit and repeat the cycle: cough-whoop-vomit
 THIRD WEEK or later: cough slowly subsides

Clinical Manifestations: an acute, highly contagious disease of the respiratory tract characterized by severe paroxysms
of coughing, which ends in a prolonged inspiratory whoop often followed by vomiting.

Infectious Agent: Bordetella pertussis

Reservoir: Man

Mode of Transmission: primarily by direct contact with discharges from the respiratory mucous membranes of infected
persons via the airborne route; probably by droplets; or by indirect contact with articles freshly soiled with the
discharges of infected persons

Incubation Period: usually 7 days, but ranges from 5 to 15 days

Period of Communicability: patient is highly communicable in the early catarrhal stage, before paroxysmal cough
develops. Antibiotics may shorten the period of communicability from 7 days after exposure to 3 weeks after onset of
typical paroxysms, to only 5 to 7 days after onset of therapy.

Susceptibility: one attack confers prolonged immunity, although exposed adults may have another attack; three doses
of DTP confer immunity to pertussis.

4. NEONATAL TETANUS

WHO standard case definition – a bacterial toxin disease

A newborn history of ALL three of the following:

 Normal suck and cry for the first two days of life
 Onset of illness between 3 and 28 days of age
 Inability to suck, followed by stiffness of the body and/or convulsions

A typical neonatal tetanus illness in a child

 AT BIRTH: baby appears healthy and sucks well

 5 to 7 days after birth:
 The baby has a tight mouth that does not open
 The baby stops sucking
 7 to 10 days after birth:
 The baby still does not suck
 The entire body is tight and there are severe fits
 The baby dies

Clinical Manifestations: an acute disease induced by the toxin of the tetanus bacillus growing anaerobically at the site of
an injury. It is characterized by painful muscular spasms, which are frequently aggravated by any external stimulus.
Severe spasms persist for one week or more.

Infectious Agent: Clostridium tetani

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Reservoir: found in soil and intestinal canals of animals, especially horses, in which the organism is a harmless normal
inhabitant; also found in man

Mode of Transmission: transmission to the newborn due to the unhygienic cutting of the umbilical cord or improper
handling of cord stump, especially when treated with a contaminated substance. In other age groups, transmission is
through puncture wounds created by contaminated material or infection of wounds.

Incubation Period: usually 6 days, but ranges from 3 to 21 days

Period of Communicability: not directly transmitted from man to man

Susceptibility: immunity lasts for 5 months to infants born to immune mothers. Natural infection does not play a
significant role in immunity. Recovery from tetanus does not result in solid immunity, where second attacks may occur.
Immunity can be obtained after 3 doses of DPT at 4 weeks interval in young children.

5. POLIOMYELITIS

WHO standard case definition – a viral disease

A suspect case of polio is defined as ANY patient below 15 years of age with acute flaccid paralysis (including those
diagnosed to have Guillain – Barre Syndrome) for which no other cause can be immediately identified.

A serious case of polio in a child:

 DAYS 1-3: the child appears unwell, may have a slight fever
 DAYS 3-5: child complains of headache, stiff neck, muscle pains, and increased fever
 DAYS 5-7: paralysis of one or both legs; in severe cases, arms and legs and even breathing may be paralyzed.

Clinical Manifestations: a highly communicable disease caused by a virus; 1% of cases are recognized clinically thru by
muscle weakness and paralysis, while 99% of the symptoms are referable to the gastrointestinal or respiratory tract or
shows evidence of meningeal irritation.

Infectious Agent: Poliovirus types 1, 2 and 3

Reservoir: man, most frequent persons with inapparent infections, especially children.

Mode of Transmission: transmission is by the fecal-oral route; oral route through pharyngeal secretions is common in
areas where sanitation is good. Poliovirus is spread by intimate contact of infected persons or, rarely, by contaminated
milk and water.

Incubation Period: usually 7 to 12 days, with a range of 3 to 21 days

Period of Communicability: patients reach maximal infectivity 7 to 16 days before and in the first few days after onset of
symptoms.

Susceptibility: infants born to immune mothers remain immune for about 5 months; immunity following natural
infection, or that provided by 3 doses of polio vaccine at 4-week intervals may be lifelong.

6. MEASLES

WHO standard case definition – a highly communicable disease with history of the following:
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 Generalized blotchy rash, lasting for 3 or more days fever (above 38°C or hot to touch)
 Any of the following: cough, runny nose, red eyes/conjunctivitis

A typical measles (Rubeola) illness in a child:

 DAY 1-3: the child has a cold, cough and high fever. Eyes are pink, watery, and sensitive to light.
 DAY 2-4: a rash spreads over the face and body, ever so slightly raised. After about a week, the rash disappears
and skin may peel.

Clinical Manifestations: an acute highly communicable disease characterized by fever, cough, colds, conjunctivitis, and
typical reddish spots on the mucosa of the mouth (Koplik spots). A characteristic dusky red, blotchy rash appears on the
3rd to the 7th day, beginning on the face then becomes generalized, lasting 4 to 6 days and sometimes ending in bran-like
desquamation.

Infectious Agent: Measles virus

Reservoir: man

Mode of Transmission: by droplet spread or direct contact with nasal/throat/urine secretions of infected persons.

Incubation Period: usually about 10 days with a range of 8 to 13 days from exposure to onset of fever.

Period of Communicability: from 1 to 3 days before the beginning of fever and cough. Decreases rapidly after the onset
of rash.

Susceptibility: considered a highly communicable disease with an 80% attack rate among susceptible household
contacts. Practically all people are susceptible. Permanent acquired immunity is usual after the attack. Immunization
confers an immunity of 20 years. Infants born to immune mothers are protected until 5 to 9 months of age. Measles
immunization given prior to 9 months of age may not confer immunity due to interference with maternal antibodies.

7. HEPATITIS B

WHO STANDARD CASE DEFINITION – Hepatitis B is a liver infection caused by the B type of Hepatitis virus. It attacks the
liver, often resulting in inflammation.

INFECTIOUS AGENT: Hepatitis B. Virus (HBV)

RESERVOIR: Man

MODE OF TRANSMISSION: Hepatitis B spreads through the following:

 From child to child or mother to child after birth

 From mother to child during birth
 Blood transfusion
 Sharing of unsterilized needles, knives, or razors
 Sexual intercourse

INCUBATION PERIOD:

 Usually 45 to 180 days

 Average of 60 to 90days
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 As short as 2 weeks until the appearance of HBsAg

 Rarely: as long as 6 to 9 months

PERIOD OF COMMUNICABILITY: Blood from experimentally inoculated individuals is shown to be infective for many
weeks; blood test which is positive to HBsAg indicates that the person in infective and can transmit the virus through the
blood

SUSCEPTIBILITY: Susceptibility is general. Disease in children is milder an anicteric. Infants are predominantly
asymptomatic.

THE FULLY IMMUNIZED CHILD

A fully immunized child is one who has received ALL of the following:

 One dose of BCG at birth or anytime before reaching 12 months

 Three doses of DPT, Hepatitis B, and Polio, with at least four-week interval between each dose, the first dose
given six weeks after birth or thereafter, as long as the third dose is given before the child reaches 12 months of
age
 One dose of measles vaccine at the age of nine months or before 12 months

VACCINE SIDE EFFECTS

1. BCG KOCH’S PHENOMENON

WHEAL – raised by injection; disappears in about 30
minutes DEEP ABSCESS AT VACCINATION SITE OR LYMPH NODES

SMALL RED TENDER SWELLING about 10 mm across, INDOLENT ULCERATION

appears at the injection site after approximately 2
weeks. After 2 to 3 weeks, the swelling becomes a small GLANDULAR ENLARGEMENT
ABSCESS, which then ulcerates

ULCER – heals by itself and leaves a scar

SCAR FORMATION - about 12 weeks

2. DPT FEVER

LOCAL SORENESS

ABSCESS

CONVULSIONS

3. POLIO Usually none

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4. HEPATITIS B LOCAL SORENESS

5. MEASLES FEVER and RASH

6. TETANUS TOXOID PAIN, REDNESS AND SWELLING

COLD CHAIN – is system used to maintain the potency of a vaccine from the time of manufacture to the time it is given
to the child or the pregnant woman.

1. Storage of vaccine should not exceed:

 6 months at the regional level
 3 months at the provincial level / district level
 1 month at the main health centers (with refrigerators)
 Not more than 5 days at health centers
2. Transport of vaccines
3. Handling of vaccines
4. DISCARD
 BCG vaccines after 4 hours
 DPT, Polio, Measles, and tetanus toxoid vaccines after 8 hours or at the end of a working day.

DOH STRATEGIES

 23 in ‘93
 National Immunization Day Slogan: Ceasefire for Children: Support National Immunization Day!”
 Concept: No shooting of bullets, only shooting of vaccines
 Project included the goal to completely eradicate polio by 1995
 Formalization of plans for an improved biologic production service was done to develop self-sufficiency
in vaccine production while deceasing dependence on imported vaccines.

 Health for More in ‘94

 Buwan ng Oplan Alis Disease II
 Goals: to completely eradicate or control immunizable killer childhood diseases; to promote a healthy
lifestyle that will decrease every Filipino’s risk of having heart disease, most especially those belonging
to 35 years above.

 Measles Elimination Campaign (LIGTAS TIGDAS 2004)

Ligtas Tigdas 2004 is a special nationwide vaccination month for children between the ages of 9 months to less
than 8 years old. It is primarily a door-to-door campaign performed by vaccination teams known as Bakuna
DOORS, who visited homes and schools in February 2004 to immunize 100% of the children in the
abovementioned age group against measles.
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VACCINES: CONTENTS, FORMS, EXPOSURE TO CERTAIN CONDITIONS

Vaccine Contents Form Conditions when exposed Storage temperature

to heat
BCG Live, attenuated bacterial Freeze-dried Destroyed by heat, 2 to 8°C (body of the
vaccine and to be sunlight, not destroyed by refrigerator)
reconstituted freezing
with a special
diluent
DPT D – weakened toxin Liquid D – destroyed by 2 to 8°C (body of the
P – killed bacteria freezing/heat refrigerator)
T – weakened toxin P – damaged by heat
T – damaged by heat and
freezing
Polio Vaccine Live, attenuated virus Liquid Easily damaged by heat, -15 to -25°C (freezer)
not destroyed by freezing
Measles Live, attenuated virus Freeze-dried Easily damaged by heat, -15 to -25°C (freezer)
Vaccine and to be not destroyed by freezing
reconstituted
with a special
diluent
Tetanus toxoid Weakened toxin Liquid Damaged by heat or 2 to 8°C (body of the
freezing refrigerator)
Hepatitis B Plasma-derived; Liquid Damaged by heat or 2 to 8°C (body of the
Vaccine RNA - recombinant freezing refrigerator)

DOH issuances related to the Measles Elimination Campaign:

 Department Circular No. 273-A, s. 2003 – Implementation of the Health Promotion Plan for the Philippine
Follow-up Measles Elimination Campaign 2004
 Department Order No. 162-E, s. 2003 – Creation of a Sub-committee for Social Mobilization/IEC on Philippine
Measles Elimination Campaign, dubbed as “Ligtas Tigdas”
 Memorandum No. 164-A, s. 2003 – identifying Priority Areas of the Philippine Measles Elimination Campaign for
February 2004
 NCDPC Order No. 123-E, s. 2003 – Authority for Selected NCDPC Staff to Monitor Pre-implementation Activities
of the Philippine Follow-up Measles Elimination Campaign and Garantisadong Pambata Campaign on October
2003 to November 2003
 Legal Basis of EPI: PD 996 – Compulsory for Basic Immunization for Infants and Children Below 8 Years of Age (0-
8 years); thus, it covers two age groups, infants, and school entrants.