IMMUNIZATION

INTRODUCTION :- ( UIP )

• AIM : To reduce the mortality and morbidity due

to vaccine preventable diseases.

• OBJECTIVE : Full course, at right age and potent

vaccine.
History :-
• 1. On 14 May 1796 Sir Edward Jenner inoculated a
boy named James Phillips with cowpox lymph
taken from Sarah Nelmes a maid servant as there
was a belief that if a person suffers from cowpox,
he will not get smallpox. After 6 wks the boy was
inoculated with lymph of smallpox and he did not
develop small pox.
• 2. In India and China vaccination was carried out
as early as 10th century . It was done in India by
Scarification and powder was blown into the nose
by Chinese. In 1802 a Swiss physician Jean-de-
Carro who lived in Vienna succeeded in bringing
viable vaccine to Bombay via Baghdad.
• 3. From 1827 an organized programme was
started in Mumbai.
• 4. In 1868 some type of vaccination programme
was established in all provinces but little was
done in 560 independent Princely states.
• 5. By 1941 Primary vaccination was compulsory in
80% of towns and 60% of villages. Revaccination
was compulsory in Madras only.
• 6. James Lind 1747- Vit C, Pasteur 1883 (1885) –
ARV, Anthrax – 1883, Choler – 1892. ( 6 gps Cider;
elixir vitriol; vinegar; sea water; a mixture of
nutmeg, garlic, mustard and tannic acid; 2
oranges & 1lemon for six days led to recovery
from Scurvy ) .
• 7. On 01st Apr 1974 WHO launched EPI.
• 8. On 01st Jan 1978 India launched EPI with aim
of immunization coverage in less than 2 yrs
children with 3 doses of DPT, one dose of BCG,
Pregnant mothers with 1 or 2 doses of TT. EPI
integrated with general health service ,
Surveillance system strengthened to decrease in
incidence of 6 diseases.
• 9. In 1979 OPV was added starting from Urban
areas and strengthening cold chain system.
Enteric in highly endemic areas.
• 9. In 1979 OPV was added starting from Urban
areas and strengthening cold chain system.
Enteric in highly endemic areas.
• 10. UNICEF started participating in world wide
campaign and renamed it as Universal Child
Immunization. There is no difference between UCI
& EPI. It was renamed as Universal Immunization
Programme in India on 19 Nov 1985 ie Smt Indira
Gandhi’s birth day. Measles was added. TAB was
deleted. Coverage for vaccination was increased
to 100%.
• 11. In 1986 it was taken as one of the five Technology
missions of PM- ‘Technology mission on vaccination and
immunization of vulnerable populations specially
children’ , handled by Sam Pitroda. Adequate funds for
cold chain and logistic network, Supply and monitoring,
Trg of personnel, Indigenous self sufficiency, and Dist
wise UIP.
• 12. In 1992 it became part of CSSM ie on 20 Aug, Rajiv
Gandhi’s birth day. Fixed site immunization sessions,
High risk pockets incl, IEC, Dist wise Data base, cold
chain strengthened, Trg of MO’s & paramedics to
promote team work and high quality of service.
• 13. On 15 Oct 1997 it became part of RCH.
• It is the largest cost effective powerful programme for VPDs.
• Present aim is eradication of Polio, elimination of NNT and
Measles.
• The main advantage is High level of contact and high demand
of public service leading to confidence building of staff but
laxity is the risk.
• It was EXPANDED in terms of vaccines, more area and to cover
less privileged.
• In 1981 total deaths due to all six diseases was 1.5 million /yr.
Paralytic Polio 0.15 million children/ yr (7/1000 live births). NNT
0.3 million/yr(13.3/1000 live births rural &3.2/1000 urban). 12
April 2005 – Part of NRHM.
DEFINITIONS :-
• Universal : Applicable to Universe ( The entire
celestial world ).
• Immunization : Process of making an individual
immune or not susceptible.
• Program : It is a sequence of activities
designated to implement policies & accomplish
objectives. It gives a step by step approach to
guide the action necessary to reach a pre
determined goal. Prgm must be closely
integrated with objectives.
• Policy : is a guiding principle stated as an
expectation not as a commandment.
• Objective : Planned end point of all activities. It
is precise and it is either achieved or not
achieved.
• Goal : is the ultimate desired state towards
which objectives and resources are directed.
• Target : is a discrete activity ie No of children
immunized.
• Plan : is a blue print for taking action .
• Schedule : is a time sequence for the work to be
done.
• Procedure : are a set of rules for carrying out
work which when observed by all help to ensure
• the max use of resources.
• Vaccine : Immunobiological substance designated
to produce specific protection against a Given
disease.
• Adjuvant : Is a substance that is added to vaccine
with intent of potentiating the immune Response
so that grater amount of Abs are produced.
• Immunity : The ability of the body to recognize,
destroy and eliminate antigenic material foreign
to its own. ( Burnet and Medawar – noble prize
winners of 1960 put forth the concept of self and
non- self and immunological tolerance for self.
• Antibody : A protein substance that appears in the
body as a result of invasion of antigen. It is capable
of reacting specifically with the same antigen which
provokes its production or closely related one.
• Immune : When he possesses specific protective
antibodies or cellular immunity as a result of
previous infection or immunization or is so
conditioned by previous such experience as to
respond adequately with production of Ab sufficient
to prevent clinical illness following exposure to
specific infectious agent of the disease.
BASIS OF IMMUNIZATION
SCHEDULE
• 1. Epidemiologically relevant : Public health
problem and effective vaccine present.
• 2. Immunologically effective : Capable of forming
Ab, Maternal Ab lost & not short interval.
‘Biological Shield of mother’. Breast milk & fetal
Hb protect.
• 3. Operationally feasible : Cost and ability to
achieve high coverage.
• 4. Minimum visits : Now 5 but require 18 visits.
( 19 if JE also )
• 5. Right time : Before infection.
• 6. Socially acceptable : Local customs, beliefs and
practice ie not before 6 wks in many societies
that to after visit to temple. Seasonal and
climatic factors, daily work patternand no long
waiting in case of campaigns.
• 7. Immunological memory : No repetition of inj in
case of ‘T’ cell dependant Ab production ie other
than polysaccharide vaccines.

• 8. Thresh hold level : Repeated inj will not

increase Ab production eg. TT inj .
IMMUNIZATION SCHEDULE
Age Vaccine (s) Route And Dose

At Birth BCG ID, 0.05 ml on the left

upper arm
Hepatitis B (Birth Dose) IM, 0.5 ml on the
anterolateral side of mid-
thigh
OPV-0 Oral, 2 drops

6 Weeks Pentavalent-1 (DPT, IM, 0.5 ml on the

Hepatitis B, Hib) anterolateral side of mid-
thigh
OPV-1 Oral, 2 drops

Rotavirus Vaccine (RVV)- Oral, 1.5 ml

1
IMMUNIZATION SCHEDULE
Age Vaccine (s) Route And Dose

10 Weeks Pentavalent-2 IM, 0.5 ml

OPV-2 Oral, 2 drops

RVV-2 Oral, 1.5 ml

IMMUNIZATION SCHEDULE
Age Vaccine (s) Route And Dose

14 Weeks Pentavalent-3 IM, 0.5 ml

OPV-3 Oral, 2 drops

RVV-3 Oral, 1.5 ml

PCV-2* IM, 0.5 ml

Fractional dose of Intradermal, 0.1 ml on

Inactivated Polio each arm
Vaccine (fIPV)-1
IMMUNIZATION SCHEDULE
Age Vaccine (s) Route And Dose

9-12 Months Measles & Rubella SC, 0.5 ml

(MR)-1
JE-1 (Japanese SC, 0.5 ml
Encephalitis) **
PCV-Booster* IM, 0.5 ml

16-24 Months MR-2 SC, 0.5 ml

DPT Booster-1 IM, 0.5 ml

OPV Booster Oral, 2 drops

JE-2 ** SC, 0.5 ml

IMMUNIZATION SCHEDULE
Age Vaccine (s) Route And Dose

5-6 Years DPT Booster-2 IM, 0.5 ml

10 Years Tetanus and adult IM, 0.5 ml

diphtheria (Td)
16 Years Td IM, 0.5 ml
Note :-
PCV is included in select states under the Universal Immunization
Programme (UIP).
JE vaccine is administered in endemic areas.
• The Pentavalent vaccine combines DPT, Hepatitis B, and Hib
vaccines into a single injection.
• The minimum interval between two doses of DPT/OPV should be
4 weeks.
• Other vaccines like MMR, Hepatitis A, Typhoid, and Varicella
(Chickenpox) can be administered based on affordability and
risk assessment.
• For more detailed information, refer to the National
Immunization Schedule by the Ministry of Health and Family
Welfare, India.
MANAGE COLD CHAIN SYSTEM
Def : The cold chain is a system of transporting
and storing vaccine at an appropriate temperature
from the manufacturer to the point of use. ( earlier
low, then recommended )
• It is necessary because vaccines are heat
sensitive.
• Once potency is lost it can not be regained and
hence no protection.
• The most sensitive vaccine is Polio, followed by
DPT, Measles, BCG, DT and Tetanus. Measles and
Polio can be frozen, BCG can be frozen as ampoule
may crack ( now in vial )‘T’ series should not be
frozen as they contain AlPO4/ Al(OH)3 as adjuvant.
Testing done by shake test of these vaccines.
• Vaccines should not be exposed to direct sun
light or antiseptic.
• Opened vial used to discarded at the end of
session early but not now due to VVM.
• The loss of potency depends on temperature and
duration. Now most vaccines are stabilized and
can be stored at + 2 to + 8 oC.
ESSENTIAL ELEMENTS OF COLD
CHAIN:
• People who organize and manage the vaccine distribution.
• Equipment to store and transport vaccine.
• Transport facilities.
• Maintain equipment.
• Monitor – availability of eqpt and working; supplies; storage tempr
and potency testing (not now ).
• Of these people are the most important.
Activities for managing the cold chain ;
• 1. Enumerate the eligible. ( Now done from data,
earlier by house to house survey )
• 2. Obtain vaccines.
• 3. Maintain equipment.
• 4. Maintain vaccine.
• 5. Maintain cold chain.
• Activities vary according to the point along cold
chain system.
ACTIVITIES at SC level :
Main activities are Obtain vaccines, maintain eqpt and
maintain vaccines as enumeration is not required.
• 1. Obtain vaccine as per birth rate and IMR + 10% extra.
• 2. Maintain eqpts are Vaccine carrier and Ice packs. Day
carrier is no more in use.
• Vaccines kept in a polythene bag & ‘T’ series vaccines are
not in direct contact with ice packs, Packs fully frozen and
lid secured tightly. Maintain after use by checking for any
cracks. Keep it dry, not to expose plastic carriers to sun
light and not to sit on it.
• IF TWO CARRIERS ARE USED, STOCK ALL VACCINES IN
BOTH.
• 3. Maintain vaccines : Select shady site. Open
carrier when required. Secure lid properly. Keep
vaccines in ice cup. Wrap BCG in foil or black
paper. Mark unused. Keep record. Third time
taken vaccines used to be discarded early but not
now VVM.
COLD CHAIN EQUIPMENTS :
• Cold chain eqpts are used for storing and /or
transporting them in an appropriate temp in
order to maintain potency.
1. Walk in Freezer (WIF) : Available in two
capacities of 16.5 Cu Mt and 30.0 Cu Mt, -200C is
maintained. Provided with two identical cooling
units with stand by generator and hooting unit.
Starts automatically. Used for bulk storage of OPV
& Measles and to prepare ice packs at
regional/state level/manufacturer. Holds 3 months
+ 25% stock.
• 2. Walk in Cooler (WIC) : Same as WIF except
tempr is +2 to + 80C. Tempr recorder present.
Used for DPT, BCG, HBV etc. Now all vaccines are
stored being stabilized.
• 3. Deep freezers : Top openers, tempr -18 to -20
0C, used for storing OPV & measles and making
ice packs. 300 ltr capacity for Dist Hq and 140 ltr
for each PHC. Diluents not kept. Now Non-CFC
freezers supplied. ( MF144 & MF344 ) First run to
get – 200C and allow 6-8 hrs for stabilization and
then use it.
• 4. Ice lined refrigerators (ILR) : Top openers, 8 hrs
electricity/ day is enough. 300 ltr for Dist Hq and
140 Ltr for PHC. Due to ice lining tempr remains
lower for longer duration than deep freezer. It has
two sections ie bottom – A coldest and top –B +2 to
+8 0C . vaccines are kept in basket to avoid contact
with ice lining. Electrolux type ILR ( TCW 1151 ) can
be used as deep freezer by using change over
switch. Now Non-CFC ILR supplied. ( MK144 &
MK344 ). First set to max cooling and run for 48 hrs
to form ice and adjust thermostat to +2 0C.
• 5. Refrigerator : Not used now under UIP. Used by
PPs. OPV and measles in freezer compartment ,
DPT & others in first shelf, water bottles in other
shelves. Donot keep any thing in door, no food to
be kept, install in a good ventilated room with 15-
20 cm space around it on a level floor or wooden
blocks.
• 6. Automatic voltage stabilizer : Adjusts range of
fluctuation from 155 to 280 volts to 220 +/- 10
volts.
• 7. Cold boxes : Insulated boxes of 5 & 20 ltr
capacity with requisite ice packs. 5 ltr holds 1500
dose and 20 ltr holds 6000 doses. Used for
collection, transportation and storage in case of
power failure. Hold over time is 90 hrs for 5 ltr
and 6 days for 20 ltrs at 43 oC ambient tempr.
Spacers are used to prevent ‘T’ series of vaccines
not to be in contact with ice packs. Maintain by
checking for cracks, cleaning, rubber seal,
adjusting tension on latches for lid closure and oil
the hinges.
• 8. Vaccine carriers : To carry 16 – 20 vials with
diluents. It has 4 ice packs. Vaccine kept in
polythene bag & not in direct contact with ice
packs. Packs should be fully frozen and lid
secured tightly. Maintain by checking after each
use for cracks, keeping dry, not exposing plastic
carriers to direct sunlight and not to sit on it. If
two carriers are used stock all vaccines in both.
• 9. Day carriers : No more in use now. Used to
carry 6-8 vials, has 2 ice packs, one in bottom and
one on top. Can keep vaccine safe for 6-8 hrs.
• 10. Thermocole boxes : Boxes in various shapes
and sizes available. Ice is used as no ice packs
are available. They are light and cheap. Used for
transportation of vaccines. Ice to be replenished
when transported for longer distance.
• 11. Ice packs :Plastic bottles of various shapes
and size. Fill it with water upto the mark and
keep them in freezer with edges in contact and
not flat. Donot add salt as it lowers freezing
tempr which is bad for ‘T’ series vaccines. Takes
at least 12 hrs to make. Each PHC should have 50
– 60 ready for emergency.
• 12. Dial thermometer : Used for recording temp.
Supplied one with each ILR or deep freezer. Can
record temp from +50 to -50 0C.
• 13. Alcohol thermometer : Much sensitive and
accurate than Dial thermometer. Records temp
from 0 to -50 0C. Used with deep freezer.
• 14. NEW TECHNOLOGIES FOR HEAT AND FREEZE
SENSITIVITY :
• A ) VVM : A square white heat sensitive
paperwhich changes color on exposure to temp
ppto blue, as that of outer circle. If the color of
square equals to outer circle then vaccine is
discarded. In use sine 1996 for OPV. Now for HBV
and DPT also.
• B ) Freeze watch Indicator : A freeze sensitive capillary
tube filled with colored liquid mounted on a color
sensitive paper is packed into a small plastic cover mhen
exposed to minus temp for more than two hrs, breaks
capillary tube and stains the paper dark purple. Used in
ILR. It cannot be reused & costs Rs 200 /-. One reusable
freeze tag tried.
• C ) Cold chain monitor : Temp sensitive wax like material
melts and stains blue indicating exposure to higher
tempr than recommended for a period of time. Used with
vaccine cartons to detect the range and period of
exposure.
• D ) Electronic temp monitoring and alarm system :
Automatic monitor detects and triggers alarm when temp
outside range. Alarm connected sequentially to six
telephones and alerts till the phone is lifted and
answered by central vaccine store.
• TEMP Record : Done twice daily by designated
member at the opening and closing hrs of office in a
12 month booklet. A break indicates if temp is
beyond +2to+8 of ILR or above -18 in freezer.
• KEY WORDS USED IN COLD CHAIN:Down time : the
time period during which the eqpt remains out of
service. Efficient reporting reduces down time.
• Response time : Time required to attend the defect
after info is sent. This should be 1 week.
• Cold chain sickness rate : The proportion of cold
chain eqpt out of order at any given time.
• Good system maintenance: To ensure not more
than 20% of eqpt remains out of service and all
are functional, minor repairs within 1 wk and
major within 3 wks and max of 4-6 hrs to repair
electric failure of WIC.
• Float assembly : A stock of eqpt held at Dist/State
Hq for immediate replacement of defective units
brought from PHC. The norms for ILR/ deep
freezer 5% at WIC point and voltage stabilizer are
20% at Dist Hq.
UIP CALCULATIONS
• Calculations about vaccine other logistic :
• Assumptions :
1. Population covered by PHC : 30,000
2. Population of SC : 5,000
3. Birth rate : 25/1,000 MYP
4. Infant mortality
 Facts :
• 1. Vaccine administered rate : 75% for multiple dose and
50% for single dose vaccines.
• 2. Wastage multiplication factor : 1.33 for multiple dose
and 2 for single dose vaccine.
• 3. One glass syringe : For 50 inj ( Now AD syringe )
• 4. One steel needle : For 10 inj ( Now AD Syringe )( Now
three types of Syringe are supplied , for dilution normal 2
ml syringe and for injection it is AD syringes of 0.5 ml and
0.1 ml for IM and ID respectively ).
• 5. For vaccination : 125 children per booth.
• 6. Person / booth : 3 ( vaccinator + clerk + peon )
• 7. Supervisor : one for 4 booth in rural area and one for 10
booth in urban areas.
• 8. Transport : one veh for each supervisor except for
Medical officer( It will drop team in morning and will pick
up them at the end of session).
Calculations
• 1. No of ANC mothers : BR x MYP
• 2. No of Infants = MYP x BR x (1 – IMR )
• 3. No of other beneficieries like adolescent girls,
children <5 yrs = % of population x MYP.
• 4. No of M&C cards = ANC mothers + 10% extra
• 5. No of Syringes = No of inj + 10% extra.
• 6. No of Doses required = No of Beneficieries x No
of doses x WMF x coverage
EX 1 : Calculate the vaccine and
logistic requirement of one SC.
No of ANC mothers = 5,000 x 25/1,000
= 125 mothers / yr
No of Infants = 5,000 x 25/1,000 x ( 1 – 50/1,000 )
= 125 x 0.95
= 118 .75 ( 120 ) infants.
No of TT doses required = 125 x 2 x 1.33 x 100/100
= 250 * 1.33
= 333 + 33 ( 10 %) = 366 ( 370 ) / yr.
No of doses of OPV / HBV required = 120 x 4 x 1.33 x 100/100
= 638. 4 + 64 ( 10 % ) = 703 (710 ) doses / yr.
No of doses of DPT = 120 X 5 X 1.33 X 100 / 100
= 798 + 80 = 880 doses / yr
No of ANC mothers = 5,000 x 25/1,000
= 125 mothers / yr
No of Infants = 5,000 x 25/1,000 x ( 1 – 50/1,000 )
= 125 x 0.95
= 118 .75 ( 120 ) infants.
No of TT doses required = 125 x 2 x 1.33 x 100/100
= 250 * 1.33
= 333 + 33 ( 10 %) = 366 ( 370 ) / yr.
No of doses of OPV / HBV required = 120 x 4 x 1.33 x 100/100
= 638. 4 + 64 ( 10 % ) = 703 (710 ) doses / yr.
No of doses of DPT = 120 X 5 X 1.33 X 100 / 100
= 798 + 80 = 880 doses / yr
Ex 2 : You as a Medical officer of a Municipal Corporation
with a population of 2,00,000 ( Two lakhs ) are required to
plan for a measles campaign. Please prepare a logistic plan.
• No of Beneficieries = 2,00,000 X 14 %
• = 28,000.
• No of Booths = 28,000 / 125
• = 224 ( 225 ) booths.
• No of persons = 775 ( 225 vaccinators + 225 clerks + 225 peons )
• No of Supervisors = 23.
• No of vehicles = 23 excluding for Mo.
• No of vaccine doses = 28,000 x 1 x 2
• . = 56, 000 + 5600 (10 % ) = 61,600 doses.
• No of vials = 61,600 / 5 = 12,329 ( 12,330 ).
• No of syringes of 0.5 ml AD = 61,600.
• No of syringes for dilution = 12,330.
• No of vaccine carriers = 225 + 23 = 248 ( 250 ).
Ex 3 : Your PHC has a stock of 800 doses of Measles vaccine
and your supply is once a month.
Comment on the stock position.
• No of infants in a PHC = 30,000 x 25 x ( 1 – 50 / 1,000 )
= 712.5 ( 720 ) infants / yr
= 720 / 12 = 60 dose /month.
• Comment : The doses of measles are clear in excess of requirement.
The excess vaccine is to be returned to Dist Hq or transferred
laterally to other ` PHCs.
Thank you!