Child Health Care

CHILD HEALTH CARE

Objectives
Recognize the importance of CHC & list the most important preventive programmes.Understand the principles of Apgar’s ScoreState the objectives of EPI.Recognize the scientific principles of immunization .Outlines the schedule of compulsory immunization In Iraq.List the side effects & contraindications to vaccination.Explain the four strategies for the vaccine delivery.Define the cold chain.Discuss the three components of the cold chain.Interpret the tools for the cold chain monitoring.

Child Health Care

Preventive services are needed for children for the following reasons: Many causes of morbidity and morality are avoidable, Existence of a socioeconomic gradient Vulnerability of children and their parents during the earlier years of their life

Child Health Care

Prevention can be primary, secondary or tertiary through many Programs like: Growth Monitoring, Control of Diarrhoeal Diseases, Breast Feeding, Expanded Program on Immunization, Family Planning, Food Fortification and supplementation, Female Education Control of Acute Respiratory Infections.


Apgar’s Score measures 5 signs, each is given a score of 0, 1 or 2 depending on the state of the newborn.
Score
Sign
2
1
0
>100/minute
Slow (100/minute)
Absent
Heart Rate
Regular, crying
Slow irregular
Absent
Respiratory effort
Active movement
Some flexion of the extremities
Limp
Muscle Tone
Cough and Sneeze
Grimace
No reaction
Response to catheter in nostril
Pink all over
Pink body, pale extremities
Pale or blue
Skin color
Apgar Score Measurement
The range is between zero which means a dead infant to 10 which is very rare at the first minute. Apgar score ≤3 at 5 minutes: the infant is at a higher risk of neonatal death, or of having respiratory and/or cerebral complications during the neonatal period and need urgent referral to the neonatal intensive care unit.


The Expanded Program on Immunization (EPI)
Most of the vaccines used currently were introduced in the 1960s. During the early 1980s the EPI was introduced in most countries.What determines a high immunization coverage rate?Integrity of the health services (vaccine availability on regular basis, functional cold chain system) Awareness of the parents of the availability of the vaccines and the program and their motivation to vaccinate their child.Motivation and dedication of the health workers.Note: If we attain 90-95% vaccine coverage of children against a certain disease we are virtually attaining a 100% protection of children, & this is the concept of “Herd immunity” which means that those who are vaccinated will protect those who are not through cutting the cycle of transmission.

EPI objective

Reduce morbidity and mortality of EPI targeted diseases. Promote EPI services in all PHC. Achieve 95% coverage rate at district level by vaccines (a. BCG. b. Polio3. c. DPT3. d. HepB 3. e. measles (

Strategies

Routine Campaigns Surveillance Health promotion and education RED ( Reach Every District) approach

Immunity

Specific defenses Immunity
Passive immunity
Active immunity
Following clinical infection
Following subclinical infection
Following vaccination
Following administration of Immunoglobulin or antiserum
Transfer of maternal Antibodies Through milk

Transfer of maternal Antibodies Through placenta

natural
acquired

Basic Data on EPI Vaccines

Vaccine against
Nature
Form
Dose
Route
Heat Stability
Type of Immunity
Diphtheria
Toxoid
Fluid
0.5ml
IM*
High
IgG
Tetanus
Toxoid
Fluid
0.5ml
IM*
High
IgG
Hepatitis B
HBs Ag**
Fluid
0.5ml
IM
High
IgG
Pertusis
Whole killed Bac.
Fluid
0.5ml
IM*
Medium
IgG,A,M
Measles
Attinuated live V.
Freeze-Dried
0.5ml
S.C.
High/dri Low/reco
IgG,A,M
T.B.
Attinuated live BCG
Freeze-Dried
0.1ml
I.D.
Medium/dried –Low/reco T cell Mediated
Polio-myelitis
Attinuated live V.
Fluid
3 drops
oral
Low
IgG,A,M intestinal + circulating
Polio-myelitis
Killed V.
Fluid
IM
Medium
Same only circulating
Rubella
Attinuated live V.
Freeze-Dried
0.5m
S.C.
High/ Low
IgG,A,M

The National Immunization Schedule in Iraq

Age/Population Group
Vaccine
0-one week
BCG, OPV0 , HBV1(HBV1:within 24 hrs after birth)
2 months
Penta (DPT1, HIB1 , HBV2) +Rota Virus 1+ OPV1
4 months
Tetra (* DPT2, HIB2)+ Rota Virus 2 + OPV2
6 months
Penta (DPT3, HIB3 , HBV3) +Rota Virus 3+ OPV3
9 months
Measles + Vitamin A (100,000 IU)
15 months
( Measles, Mumps, Rubella) MMR1
Boosters
18 months
(1st booster); Tetra (* DPT, HIB)+ OPV Vitamin A (200,000 IU)
School entry age (4-6 ys)
DPT + OPV (2nd booster)+ MMR 2
Every 10 years
Td (full dose of tetanus toxoid and a reduced dose of diphtheria toxoid after the age of 6 years)
* If the infant develops a severe reaction to a prior dose, give DT not DPT, because the pertussis component is responsible for this severe reaction


Tetanus Toxoid for Pregnant Women
Dose
Date of vaccination
1st
4th month of pregnancy
2nd dose
5th month of pregnancy
3rd dose
6 month after the 2nd dose
4th dose
1 year after the 3rd dose
5th dose
1 year after the 4th dose

Tetanus Toxoid for Child Bearing Age Women(CBAW)

Dose
Date of vaccination
1st dose
1st visit
2nd dose
1 month from date of 1st dose
3rd dose
6 month from date of 2nd dose
4th dose
1 year from date of 3rd dose
5th dose
1 year from date 4th dose



Diphtheria: full dose to children over 6 years of age Pertusis Any abnormality of the CNS e.g. Spina bifida Acute febrile illness Severe local or general reaction to a previous dose (give DT) History of convulsions in a child Family history of convulsions (controversial)
Contraindications to Killed Vaccines & Toxoids


General PregnancyAcute febrile illnessImmunological dysfunction e.g. hypo-gamma-globulinaemiaMalignant disease, e.g. Leukaemia, Hodgkin’s disease Steriod therapy, immuno-suppressants & radiotherapySpecificOral Poliomyelitis: diarrhoea & vomiting Measles: Active TB, allergy to polymyxin & neomycin, family history of convulsions.BCG: Local septic condition, premature & LBW baby, chronic skin diseaseRubella: pregnancy, allergy to neomycin & polymyxin, thrombocytopenia. Contraindications to Live Vaccines

Characteristics of Vaccines; BCG

It has an efficacy of 60-90% which can be lower when the infection is due to an antigenic variant. BCG prevents the forms of TB developing through haematogenous spread of bacteria (TB meningitis & miliary TB). Efficacy is particularly high in high incidence situations where protection may last for up to 20 y. Side Effects 1. Small Red papule at the site of injection, which appears 6 - 8 weeks after vaccination, and progresses to a scar after 12 w. 2. If given subcutaneously (instead of the usual intra-dermal route) it will lead to abscess formation & regional lymphadenopathy. 3. If the child is Tuberculin positive, it will lead to a severe reaction. Storage: Sensitive to sunlight & heat. It should be stored at refrigerator temperature (4-8 0C) for up to 2 years. Note: Physiological neonatal jaundice is not a contraindication to BCG vaccination.

Characteristics of Vaccines; DPT

Efficacy is 90% (after 3 doses). Side Effects & Adverse reactions -Swelling, tenderness & redness develop at the site of injection with fever lasting for about 24 hours. - Increase in frequency and severity with increasing age, so we give Td (full dose of Tetanus & reduced dose of Diphtheria toxoids) after the age of 6 years. -Severe Side effects include screaming attacks, convulsions, collapse, and brain damage. -The incidence of such complications is about 1/180,000 doses, which is much rarer than the complications of the diseases targeted by these vaccines. -Pertussis vaccine is a killed vaccine the components of which may cause a reaction. -Currently, an acellular vaccine is being developed to minimize these side effects. Storage: Refrigerator temperature.

Characteristics of Vaccines; Poliomyelitis Vaccines

There are two types of poliomyelitis vaccine, Salk and Sabin Comparison Between Salk and Sabin Poliomyelitis Vaccines
Salk (IPV)
Sabin (OPV)
1
Inactivated (killed)
Live attenuated
2
Injectable
Oral
3
In developed countries
In developing countries
4
Prevents spread of wild polio virus to the nervous system through blood
Limits multiplication of wild poliovirus in the intestine and therefore reduces faecal transmission.
5
No shedding of vaccine virus in the stool
Shedding of vaccine leading to passive immunity of close contacts
6
Expensive (needles & syringe)
Cheap & Easy
7
No side effects
Side effects: vaccine associated paralysis (1/3,000,000 doses)
Storage:OPV: -20 oC (up to 2 years), 0 – 8 oC (up to 1 year), 37 oC (1 day).IPV: 0 - 8 oC (18 months), 37 oC (4 weeks).


Eradication of Polio Virus
Global eradication of poliomyelitis is possible because the virus can only survive in humans. The principle for eradication is that we need 3 years to pass by from the last case registration in order to announce eradication. The last case reported in Iraq was on the 28th of January 2000, During 2014 another baby was the victim Strategies 1. Routine Immunization: We must have a coverage rate of at least 90% at both national & district level. 2. Polio National Immunization Days (NIDs): Two round of vaccination (one month apart) are done nationwide during the low transmission season (spring and autumn) The aim is to interrupt the circulation of poliovirus by immunizing every child. A child can take up to 15 doses of OPV without side effects. These campaigns can be implemented at the same time in neighbouring countries (cross-border), so that virus transmission is cut between countries.

Eradication of Polio Virus

3. Acute Flaccid Paralysis (AFP) Surveillance: Any case with Acute & Flaccid paralysis in children under the age of 15 years must be reported & checked by taking two stool samples to detect the presence of the wild polio virus in the stool. The case is followed up for 60 days (if the child dies, lost for follow up or remains paralyzed for more than 60 days then this is assumed to be a case of Poliomyelitis). There should be at least one case detected per 100,000 children under the age of 15 years to ensure good and reliable surveillance. 4. Mopping Up (cleaning up): When even one case occurs in a previously polio clean area, or in high risk areas, we implement door-to-door immunization in limited areas.

Measles:

Two factors are considered when determining the age at which the vaccine is given; age incidence and maternal antibody interference. Maternal antibodies disappear at the age of 6 months and cases start to appear at the age of one year, so the best age to give the vaccine in Iraq is 9 months. The vaccine is 95% effective when given at the age of 9 months & provides a longer lasting immunity. Storage: Being a live attenuated virus it must be kept in deep freeze at a temperature of -20oC, while if it is in a powder form we can store it at room temperature for 4 weeks. Once diluted it must be used within 24 hours. When diluted, the diluent should be kept at the same cold temperature as the vaccine to prevent vaccine inactivation by high temperatures.

Measles: Side Effects

Mild Pain and tenderness within 24hrs Fever 5% on day 8 last 1-2 days Rash 2% on 7-10days last 2 days Severe Urticaria Anaphylaxis 1-1 million dose and not due to residual egg portions due to gelatine used as stabilizer in vaccine production Encephalopathy / encephalitis; The risk of encephalitis 1/106 but natural measles virus infection causes post-infections encephalomyelitis in 1-1000 infected persons so by vaccinating children, we have diluted the incidence of encephalitis by 1000 times. 50% or those affected are left with permanent CNS impairment This syndrome is considered to be immunologically mediated. Encephalopathy study 10 years follow-up did not identify an increase risk of permanent neurological abnormality following Measles vaccination .

Measles: Side Effects

Other severe but rare AEAV Sub acute sclerosing panencephlitis (SSPE) Guillan-Barre syndrome Seizures Thrombocytopenia 1-400.000 dose Inflammatory bowel diseases Autism

HB Vaccine:

Three doses are effective. Side effects: local reaction, with no contraindications. It should be stored at refrigerator temperature.



Adverse Events Following Vaccination
Vaccine
Mild
Severe
BCG
Axillary, cervical, Lymph adenitis
Osteitis TB meningitis
Diphtheria
Redness, pain, fever
Urticaria, pruritis anaphylaxis
Tetanus
Pain, erythema sterile-abscess, fever
Urticaria, brachial neuritis Gullian-Barre anaphylaxis
Pertussis
Pain, tenderness, Nodule erythema, oedema fever, irritation, loss appetite, vomiting
* persistant inconsolable cry * unusual screams * convulsion * fever 40+ o C * hypotonic- hyporesponsive episodes * encephalopathy
Hepatitis B
Fever, pain, swelling erythema, headache
Anaphylaxis Gullian-Barre Hair-loss Diabetes type 1
Measles
Pain, tenderness, fever , rash
Urinary, encephalopathy, encephalitis, SSPE, seizures Gullian-Barre thrombocytopenia, Autism inflammatory bowel disease
Mumps
Pain, tenderness, fever parotitis
Aseptic meningitis
Rubella
Pain, tenderness, fever rash, lymphadenopathy headache
Arthalgia Arthritis arthropathy
MMR
Fever, rash, parotitis lymphadenopathy
OPV
VAPP, Gullian-Barre ascptic meningitis, transverse myelitis

The Cold Chain

Vaccines are effective only if maintained at the recommended temperatures throughout their journey from the manufacturer to the consumer. Exposure to high temperatures will lead to the damage of these vaccines. To keep them cold we need equipment (freezer, refrigerator, cool boxes, vaccine carriers, thermometers & cold rooms) & people who know how to keep the vaccines at the recommended temperature. Methods used for detecting heat exposure: CCM (Cold Chain Monitor): there is a colour index with the vaccine that changes its colour when exposed to higher temperatures than recommended.


inner square still lighter than outer ring; if the expiry date is not passed, use the vaccine
inner square lighter than outer ring; if the expiry date is not passed, use the vaccine
inner square matches the colour of outer ring; discard point - do not use the vaccine
inner square darker than outer ring; beyond the discard point - do not use the vaccine
x
x

2. VVM (Vaccine Vial Monitor): used only in polio vaccine vials, where each one has a sticker (a square & a circle in it) one is purple & one is white, and when exposed to high temp both the circle & the box become purple.

Destruction of Unused Vaccines:

When vaccines are not used, because they were kept at room temperature during a vaccination session, and can not be re-refrigerated, they should be destroyed. This is done by incineration. If thrown with the wastes, or into the sewerages, they may regain their potency and cause an epidemic.

Last confirmed polio caseDiala 28/1/2000

Please no more polio cases
Forgive us

Mobile Immunization Team Diala

10 millions doses of Polio vaccine distributed through this small opening
Isolation wall surround main vaccine warehouse

PHC destroyed by terrorist

This boy was the last case of polio since 2000
During 2014 another baby was the victim