The Expanded Program on Immunization (EPI) was initiated in 1974 by the World Health Organization (WHO) with the goal to make vaccines available to all children throughout the world. They established a standardized vaccination schedule for the original EPI vaccines: BCG (Bacillus Calmette-Guerin), DTP (diphtheria-tetanus-pertussis), oral polio, and measles. The program has been a phenomenal success - increasing immunisation coverage from less than 5% of all children to about 80% in a span of thirty years.
In the last decade a number of countries have included additional vaccines like hepatitis B (Hep B), Haemophilus influenzae type b (Hib) and yellow fever (where the disease is endemic) into the routine schedule. Immunization against hepatitis B is currently offered to infants in 163 of 192 WHO Member States (WHO, 2006). Immunization against Haemophilus influenzae type b (Hib) is recommended where resources permit its use and the burden of disease is established and is provided in 104 countries. Yellow fever vaccine is offered in about three quarters of the nations and territories at risk for yellow fever outbreaks in Africa and Asia.
In the next few years it is expected that new vaccines such as rotavirus and the conjugate pneumococcal vaccine will also be part of EPI.
At a national level the EPI program is run by the Ministry of Health (MoH) and is usually implemented at a district or regional level by the local government health authority. Where necessary, WHO, the United Nations Children’s Fund (UNICEF) and other agencies provide technical assistance to the Ministry of Health and assist in planning, resource mobilisation and social mobilisation.
Global Immunisation Facts:
- Over 2 million children die every year from diseases that are entirely preventable.
- 26 million infants have no access to basic immunisation each year.
- In almost 50 nations, 60 percent of the children are not immunised.
- A child in the developing world is ten times more likely to die of a vaccine-preventable death than a child in an industrialised nation.
- One child can be fully immunised for $17.
- Every $1 spent on immunisation saves society up to $29.
Routine Immunisation
Routine immunisation is the basis of the EPI activities. Vaccines to prevent measles, diphtheria, pertussis, tetanus, polio, tuberculosis and others such as Hib and Hep B are provided, usually free of charge, at fixed or mobile health facilities all over the country. Vaccines need to given at an age when an optimal immune response will be elicited and before the children are at highest risk of vaccine-preventable diseases. In practice this means giving the vaccines as soon as possible after birth. However, acquired immunity from mother to infant frequently interferes with vaccine-induced immunity. This classically occurs with viruses such as measles, mumps and rubella. These vaccines are most effective therefore when the maternal antibodies have decreased to such a level that they do not interfere with the vaccines. Typically this happens after 9-12 months of age.
On the other hand there is little maternally granted immunity against bacterial infections and vaccines such as DTP (diphtheria, pertussis, tetanus) are thus administered as soon as possible after birth. Vaccines against bacterial diseases usually require more doses than vaccines against viral diseases because the immunity against these disease decreases with time. Booster doses of such vaccines are therefore necessary.
Vaccination schedules have been developed over time and need to be amended according to changing epidemiology of diseases and with the development of new vaccines. The current national immunisation schedules in most African countries includes BCG (against tuberculosis), OPV (against poliomyelitis), DTP, Hib (against Haemophilus inluenzae type b) and HBV (against hepatitis B virus) vaccines and the primary series is given at 6,10 and 14 weeks, with the measles vaccine given at 9 months; in accordance with WHO guidelines. The basic immunisation schedule including these vaccines stretches over the child’s first year.
Routine EPI schedule used in most African countries
| Age of child | Vaccine |
| At birth | BCG |
| 6 weeks | OPV HepB DTP Hib |
| 10 weeks | OPV HepB DTP Hib |
|
14 weeks |
OPV |
| 9 months | Measles |
South Africa EPI schedule
SA is in the process of introducing rotavirus vaccine, the conjugate pneumococcal vaccine and a pentavalent combination consisting of diphtheria, tetanus, acellular pertussis, inactivated polio and Haemophilus influenzae type b. The schedule is as follows:
| Age of child | Vaccine | How and where given |
| At birth | BCG OPV |
Intra-dermal, right arm Drops by mouth |
| 6 weeks | OPV RV Hep B DTaP-IPV/Hib PCV7 |
Drops by mouth Liquid by mouth Intramuscular, right thigh Intramuscular, left thigh Intramuscular, right thigh |
| 10 weeks | Hep B DTaP-IPV/Hib |
Intramuscular, right thigh Intramuscular, left thigh |
| 14 weeks | RV* Hep B DTaP-IPV/Hib PCV7 |
Liquid by mouth Intramuscular,right thigh Intramuscular, left thigh Intramuscular, right thigh |
| 9 months | PCV7 Measles |
Intramuscular, right thigh Intramuscular, left thigh |
| 18 months | Measles DTaP-IPV/Hib |
Intramuscular, right arm Intramuscular, left arm |
| 6 years | Td | Intramuscular, left arm |
| 12 years | Td | Intramuscular, left arm |
* Rotavirus vaccine should NOT be administered after 24 weeks
Abbreviations.
BCG - bacille Calmette Guérin
OPV – oral polio vaccine
RV- Rotavirus
Hep B – hepatitis B vaccine
DTaP-IPV/Hib - diphtheria, tetanus, acellular pertussis, inactivated polio combined with haemophilus influenzae type b
Supplementary Immunisation Activities
Supplementary immunisation activities are carried out in addition to routine immunization when there is a special need to improve the coverage of a certain vaccine in a certain area. Measles and polio vaccination campaigns are conducted at national or sub-national levels (depending on the local epidemiology of the poliovirus) as part of an overall global control and eradication strategy. Of the 22 countries conducting measles vaccination campaigns in 2007, 18 (82%) countries integrated the campaigns with at least one other child survival intervention such as an insecticide-treated bed net, de-worming medicine, vitamin A, or polio vaccine
Cold chain
Vaccines must be stored at the proper temperature in order not to degrade before use. A vaccine that has lost its potency before administration is not only useless in terms of protecting against disease it may also cause undesirable events. The system for guaranteeing vaccine quality is generally referred to as the “cold chain”. The cold chain consists of the network of refrigerators, cold stores, freezers and cold boxes organised and maintained so that vaccines are kept at the right temperature to remain potent during vaccine orders and supplies, their transportation, storage and distribution from manufacturing factory to the point of administration to the target population as well as the accompanying human, material and financial resources.
EPI managers at all administrative levels should attach high priority to the maintenance of the cold chain including the main equipment and cold rooms. Storekeepers and repair technicians should receive proper training to manage this important component of the EPI. Only by doing so can the safety of the cold chain be assured. The cold chain is an integral part of any immunisation programme and, as such, it should be seen within the entire EPI management framework (planning, monitoring and evaluation). During the planning of immunisation activities, EPI management should determine the best possible cold chain option as well as ensure the availability of high-quality vaccines at all administrative levels in the country.
More information on the EPI cold chain is available from http://www.who.int/vaccines-documents/DoxGen/H5-CC.htm
Injection safety
A safe injection is one that does not harm the recipient, does not expose the provider to any avoidable risk, and does not result in any waste that is dangerous for any other people. A sterile packaged syringe and needle must be used for each injection and they must be disposed of safely immediately after use. Single-use syringes (preferably auto-disable syringes) and needles are appropriate for all types of immunisation strategies, including use in fixed clinics, outreach sites and mass campaigns. Auto-disable (AD) syringes are designed so that it is impossible to use them more than once.
AD syringes virtually eliminate the risk of patient-to-vaccinator transmission of blood-borne pathogens (such as hepatitis B or HIV) because they cannot be re-used. Of course, they do not prevent needle stick of health workers, particularly if recapping still takes place. To prevent risk of infection, the safe disposal of used needles and syringes is a critical component of any vaccination programme. Without recapping, vaccinators should place needles and syringes in safety boxes immediately after administering vaccines. To avoid an accidental needle prick during disposal, safety boxes should not be over-filled. When the safety box is about three-quarters full, it should be securely shut and stored in a safe place until it can be properly disposed of.
More information on injection safety is available from http://www.who.int/immunization_safety/safe_injections/en/
Adverse events following immunisation
An adverse event following immunisation (AEFI) is a medical incident that takes place after an immunisation and is believed to be caused by the immunisation. Although modern vaccines are safe, no vaccine is entirely without risk. After immunisation, some people experience reactions ranging from mild local reactions to (rare) life-threatening illnesses. In some cases, these reactions are caused by the vaccine; in others, they are caused by an error in the administration of the vaccine; and in others, there is no causal relationship. Whatever the cause, an AEFI may upset the public and lead to refusal of (further) immunisation. If this is allowed to occur, thousands of people will continue to contract vaccine-preventable diseases and die each year. Therefore, each AEFI requires a thorough investigation to establish whether it is caused by the vaccine itself, by an error in the administration of the vaccine, or its occurrence merely coincided with vaccine administration (i.e. it is not related to the vaccine or its administration). Staff should be trained in diagnosing, treating, investigating and reporting of AEFI, and in differentiating between mild non-significant reactions and more serious events.
Although people often think that a medical incident after an immunisation must be caused by the immunisation, many such incidents are coincidental. Another belief, that vaccine is the most common cause of AEFI, is also mistaken. Programme error, which can be prevented, is more often the cause. Programme error can generally be prevented through proper staff training and an adequate supply and proper use of safe injection equipment and diluents. Diluents supplied with a vaccine are part of the licensed product and are specific for each vaccine. The vaccine package is not complete without the diluent. Diluents are specifically designed for the needs of each vaccine with respect to volume, pH and chemical properties of the final solution containing the immunising agent. Using the wrong diluent may result in incorrect doses of vaccines, local or general reactions or even death. It is essential that diluents for vaccines are stored, distributed and used in the proper way so that they are not the cause of adverse events or incorrect doses. Tragedies have occurred, related to reconstitution of freeze-dried vaccines with insulin, muscle relaxant and other wrong solutions.
In 1999 WHO established the Global Advisory Committee on Vaccine Safety (GACVS) to respond promptly, efficiently, and with scientific rigour to vaccine safety issues of potential global importance. GACVS held its 19th meeting in Geneva, Switzerland, on 17-18 December 2008.
A report of this meeting is available from http://www.who.int/wer/2009/wer8405.pdf
More information on adverse events following immunization is available from http://www.who.int/immunization_safety/aefi/en/
Communication
Communication is an essential component of the EPI. Effective communication helps to mobilize resources for the immunisation programme (advocacy); encourages wide participation and ownership among all stakeholders (social mobilisation); and leads to positive changes in knowledge, attitudes and behaviour in the community served (behaviour change). EPI staff should maintain permanent dialogue not only with vaccinators but also with the whole community, including caregivers and political, traditional and religious leaders, to enhance their understanding of the importance of immunisation for the protection and quality of life of children.
Advocacy might be best characterized as any effort to influence policy and decision makers, to fight for social change, to transform public perceptions and attitudes, to modify behaviours, or to mobilise human and financial resources. In order to improve immunisation and child health, advocacy might encompass all these definitions in one form or another. Anyone can be an advocate – the only requirement is to actively support a cause. Advocates for immunisation can include health or child-focused nongovernmental organisations (NGOs), international and regional agencies, government officials, researchers, health providers, private business people, parents, young people, faith groups, and community members.
More information on communication for EPI is available from
http://afro.who.int/ddc/vpd/epi_mang_course/docs/english/mod%2003.rtf
The GAVI Alliance
At the end of the 1990s, in spite of the significant efforts of many individual organisations, approximately 34 million children were born annually in countries and regions with no immunisation programmes or inadequate ones. As a result of this failure to reach all children with life saving vaccines, three million lives were being lost each year to vaccine-preventable diseases. The scale of the global challenge required concerted action. National governments, UNICEF, WHO, the World Bank, the Bill & Melinda Gates Foundation, the vaccine industry, research and technical health institutions, and civil society organisations saw the need and an historic opportunity to pool their skills and resources to extend the coverage and effectiveness of global immunisation programmes, especially in the poorest nations. The concerted efforts of this public-private partnership led to the creation of the GAVI Alliance (GAVI) in 2000 with the aim of saving children's lives and protecting people's health by increasing access to immunisation in low-income countries. GAVI enables the partners to agree goals, share strategies, and coordinate efforts. National governments of the 72 world’s poorest countries (GNI in 2003 below US$1000) are eligible to apply for support from GAVI.
The GAVI Alliance obtains public financing commitments from governments and the European Commission, and from the private sector, adding to its start-up grant from the Bill & Melinda Gates Foundation. The GAVI Alliance model is designed to aggregate resources to create results beyond the capability of any single agency. It is also designed to make a rapid positive impact, using independent financial and administrative structures to ensure efficient transfer of support from donors to countries. GAVI provides support directly to country governments, not through other agencies. In addition, the inclusive nature of the Alliance encourages vaccine manufacturers to take a positive view of developing country markets and add relevant, affordable products to their portfolios. GAVI provides time-limited funding (usually over five years) for the supply of vaccines and other forms of support to strengthen implementing country health systems and immunisation services. GAVI resources are also being used to investigate accelerating the development and introduction of vaccines against two diseases, rotavirus and pneumococcus, which are responsible for significant mortality in low-income countries.
More information on the GAVI Alliance is available from http://www.gavialliance.org/