Overview of Immunization and

EPI in Ghana
Dr. Rosemary Richardson
 OBJECTIVES
• At the end of this presentation, students will
have knowledge about the following:
– What Immunization is
– Background of EPI
– Elements of a good immunization system
– Immunization services in Ghana
– Vaccine estimation and procurement
– Adverse Events Following Immunization (AEFI)
 INTRODUCTION
IMMUNITY
• The condition of being protected against
infectious diseases or agents.

May be classified as;

• Active

• Passive
 Immunity cont’d
Active immunity
• Develops as a result of infection or specific
immunization
May be acquired in 3 ways:
• Following clinical infection eg. Chickenpox
• Following inapparent/subclinical infection eg.
Polio
• Following immunization with specific antigen
e.g. vaccine
 Immunity cont’d
Passive immunity may be induced by:

• Administration of immune globulin/antiserum

• Transfer of maternal antibodies across

placenta + breast milk
Immunity cont’d
 Immunity cont’d

Herd immunity

• Level of resistance of a community or group of

people to a particular disease

• Provides an immunological barrier to the

spread of disease in the human herd
 What is Immunization ?
• Immunization is the process by which an antigen,
that is, a vaccine is introduced into the body.
• The vaccine then produces antibodies in the body
which makes the person immune to the actual
infection or germ.
• The objective of an immunization is to produce in
an individual a degree of resistance or protection
to a disease equal to that which follows natural
infection
 Immunizing Agents
Classification

• Vaccines

• Immunoglobulins

• Antisera
 Immunizing Agents cont’d
Vaccine

• Immuno-biological substance designed to

produce specific protection against a given
disease

• May be prepared from; live attenuated

organisms, killed or inactivated organisms,
toxoids, extracted cellular fractions or a
combination of these.
 Immunizing Agents cont’d
Live attenuated vaccines
• BCG, oral polio, yellow fever, measles, rubella,
mumps, influenza

Killed vaccines
• Typhoid, cholera, pertussis, rabies, polio
(salk), CSM

Toxoids
• Tetanus, diphtheria
 Immunizing Agents cont’d
Immunoglobulins
• Structurally related glycoproteins that
function as antibodies

• Divided into 5 classes on the basis of structure

and biologic activity; IgG, IgA, IgM, IgE, IgD

• Hepatitis A, measles, rabies, tetanus, varicella,

diphtheria, hepatitis B, etc
 Immunization
History
• In the 16th century “variolation”, where powdered form
of small pox scabs was used to induce immunity was
practised in China, spreading to rest of Asia.

• It was observed in Turkey in 1717 and introduced in

England by the wife of the British Ambassador

• Around 1880 Edward Jenner inoculated an 8 year old

boy with fluid from cowpox sore and later exposed the
boy to small pox. The boy was protected!
 Why immunize?
• The WHO estimates that millions of children die each
year in the third world, and countless others are
disabled, as a result of vaccine-preventable diseases.

• The concern for the lives lost which could have been
saved led to the creation of the Expanded Programme
on Immunization (EPI) in Ghana in 1974 to protect
children against six killer diseases by 1990.

• The diseases are measles, diphtheria, pertusis

(whooping cough), tetanus, polio and tuberculosis.
(mttdpp)
Child Survival and Immunization in Africa

4 million children die in Africa

Out of 1,000 African Children, 174 die before the

age of 5

1 million African children deaths could be prevented

with existing vaccines
 VPDs in Ghana
It is estimated that without immunization,

• 20% of all infants will die from neonatal tetanus

• 3% of all children will die from measles

• 2% from whooping cough

• 0.5% will be crippled by Polio

• VDP- Vaccine Preventable Deaths
Elements of an effective immunisation
system
Basic elements of an immunization system

Operations
1. Vaccine Supply & Quality
2. Logistics
3. Service Delivery
4. Surveillance
5. Advocacy & Communication
 Cold Chain
• It is the system used to keep vaccines potent
from the manufacturer to the recipient
• Vaccines must be stored properly from the
time they are manufactured until the time
they are administered.
• Excess heat or cold will reduce their potency,
increasing the risk that recipients will not be
protected against vaccine-preventable
diseases
 Cold Chain cont’d
• The cold chain has three main components:
- transport and storage equipment,
- trained personnel,
- efficient management procedures
• All three elements must combine to ensure
safe vaccine transport and storage
• Proper storage temperatures must be
maintained at every link in the chain
 Ensuring vaccine POTENCY
Vaccine is always stored and transported in the cold chain, at a temperature between
+2 - +8. the freezing compartment of the vaccine fridge is for ice packs

Temperature monitoring 2* daily

Immunization service in Ghana
 HISTORY OF IMMUNIZATION IN GHANA
• EPI started in 1978 in Ghana

– 1978-1992: BCG, Measles, OPV &DPT (Total = 6) + TT

(Pregnant women)

– 1992+: Yellow Fever introduced into routine services

(BCG, MLS, OPV, DPT & YF (Total = 7) + TT (WIFA)

– 2002: HepB and Hib introduced (BCG, MLS, OPV, DPT-

HepB+Hib & YF (Total = 9) + TT (WIFA)
– MLS-measles??
 EPI Cont’d
• Cost –efficient intervention that prevents nine
common childhood diseases
• Provides an entry point into communities for
other MCH interventions e.g. vitamin A
supplementation, nutrition promotion
BCG - Bacillus Calmette Guerin

– Live attenuated

– Best given at birth

– Prematurity & preterm NOT contraindicated

– HIV infection not contraindicated unless

Symptomatic
 OPV
- Live weakened virus(oral Sabin; killed
injectable - Salk)

- Easily damaged by heat

- Prematurity & preterm NOT contraindicated

- HIV infection not contraindicated

 MEASLES

– Live weakened virus

– All severely immuno-compromised infants have

high risk of severe measles complications & death
if infected
Therefore:
– Prematurity & preterm NOT contraindicated

– HIV infection not contraindicated

** Avoid in all children if severely ill
 Pertussis

– Whole-cell killed bacteria

– Good immunogenic response at varying (3, 4, 5, 6

doses) schedules

– Prematurity & preterm NOT contraindicated

– HIV infection not contraindicated

 Yellow Fever

– Live attenuated virus

– Increased risk of post-vaccination encephalitis if given <6

months

– Prematurity & preterm NOT contraindicated

– HIV infection not contraindicated unless symptomatic

 Hepatitis B Vaccine (HbsAg)
– Genetically engineered or plasma derived

– Good immunogenic response at 6,10,14 wks

– Prematurity & preterm NOT contraindicated

– HIV infection not contraindicated

 Diphtheria, Tetanus
• Toxoids

• Damaged by freezing

• Prematurity & preterm NOT contraindicated

• HIV infection not contraindicated

 H influenza type b
• Killed bacteria

• Damaged by freezing

• Prematurity & preterm NOT contraindicated

• HIV infection not contraindicated

 Pentavalent vaccine
• DPT- Hep B + Hib vaccine comes in two
different vials.
• A liquid containing DPT- Hep B and a white
powder Hib.
• There is no maximum interval between two
doses of the same antigen.
• However, the minimum interval between two
doses of the same antigen should be strictly
followed.
 IMMUNISATION STRATEGIES

• Static- daily at health facilities/hospitals

• Outreach – To remote communities- Based on
district/sub-district plans, catchment locations
etc.
• Mini-mass (mop up)- to capture defaulters and
also reach out to children missed in routine
services
• Persons involved – mostly CHNs(comm. Health
nurse) /DCOs (disease control officer)(supported
by some midwives,PHNs, Drs)
IMMUNIZATION SCHEDULE (FOR CHN)
• BCG/OPV 0 - AT BIRTH

• DPTHepBHib 1 & OPV1- 6 WEEKS

• DPTHepBHib 2 & OPV2- 10 WEEKS

• DPTHepBHib 3 & OPV3- 14 WEEKS

• VITAMIN A - 6 MONTHS

• MEASLES / YELLOW FEVER – 9 MONTHS

DOSES AND SITES FOR IMMUNIZATION
• OPV - 2 DROPS ORALLY

• DPTHepBHib - 0.5 ml im on lateral aspect of Left Thigh

•
• MEASLES –0.5 ml sub-cutaneous on Right Upper arm

• YELLOW FEVER – 0.5 ml s-c on Left Upper arm (9months

• BCG - 0.05 ml intra-dermal on Right upper arm

• TT – 0.5 ml I.M. on Left Upper arm

 The Ghana EPI schedules are appropriate for
ALL infants including the Preterm

Vaccine Preterm Term Best

Schedule
BCG Yes Yes Birth

DPT/HepB/Hib Yes Yes 6, 10, 14

wks
OPV Yes Yes 6, 10, 14
wks
Measles Yes Yes 9 mths

Yellow fever Yes Yes 9 mths

 The Ghana EPI schedules are appropriate
for the HIV-infected children

Vaccine Asymptoma Symptomatic Best

Schedule
tic HIV inf HIV inf
BCG Yes Birth
No
DPT/HepB/Hib Yes Yes 6, 10, 14
wks
OPV Yes Yes 6, 10, 14
wks
Measles Yes Yes 6 & 9 mths

Yellow fever Yes 9 mths

No
Tetanus toxoid Yes Yes 5 doses
TT IMMUNIZATION SCHEDULE (for women)
• TT 1 - FIRST CONTACT : NO PROTECTION

• TT 2 - 4 WEEKS AFTER FIRST: OFFERS PROTECTION

FOR 3 YEARS

• TT 3 - 6 MONTHS AFTER 2ND: PROTECTS FOR 5

YEARS

• TT 4 - 1 YEAR AFTER 3RD: OFFERS PROTECTION FOR

10 YEARS

• TT 5 - 1 YEAR AFTER 4TH: PROTECTS FOR LIFE!

 Vaccine Estimation
Routine immunisation
• Total no. of vaccines required are estimated by
population projection for chn < 1 year
• It is estimated that chn < 1year make up 4% of the
general population
Campaigns
• Target population used is usually under fives
• This is estimated as 20% of the population
 Vaccine Procurement
Vaccine Procurement
• All vaccines are procured through UNICEF
• All vaccines are paid for by GAVI and the
Ghana government.
• GAVI pays for the bulk of the pentavalent and
YF vaccine ($3.5 per dose) whiles govt.
subsidizes with 0.15 cents per dose
 Limiting factors to Immunisation
Performance (Challenges)
• Inconsistent denominator issues
• Data management deficiencies – recording errors at
various levels
• Many hard-to-reach areas (relying on boat services)
posing threat to coverage
• Urbanization – hard-to-reach economically active
population
• User fees in selected areas discouraging mothers
• Mobility problems to remote communities
• Irregular support/supervision from higher levels to
service delivery points.
• Staff attrition, no training for more than decade
 Factors Contributing to existing
Immunisation Performance
• Political Support
- Penta 3 coverage used as a major indicator for performance of
the health sector by government
- Financial Sustainability Plan prepared for Ghana
• Committed EPI team at all levels with national and
technical / financial support from partners.
• Monitoring and supervision from higher level
- Regular review of performance and feedback to districts
• Quarterly distribution of vaccines to avoid internal
shortage
• Training in all forms etc.
Immunisation Safety Surveillance

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 What is an adverse event following
immunisation (AEFI)?

A medical incident that takes place after an

immunisation, causes concern, and is believed
to be caused by the immunisation
 Why do AEFI surveillance?
Critical function of National Regulatory Authority

• Safety
– identify and fix programme errors
• Quality
– monitor performance
– increase confidence
• Infrastructure
– build reporting and response capacity
• Perception
– AEFIs more visible as disease controlled
– manage ‘crisis’ events
 Causes of AEFI
• Vaccine reaction caused by vaccine’s inherent properties

• Programme error caused by error in vaccine preparation,

handling, or administration
• Coincidental happens after immunisation but not caused by it
- a chance association
• Injection reaction anxiety or pain of injection not vaccine

• Unknown cause cannot be determined

 Vaccine reactions
• Common, minor reactions
– vaccine stimulates immune system
– settle on their own
– warn parents and advise how to manage

• Rare, more serious reactions

– anaphylaxis (serious allergic reaction)
– vaccine specific reactions
 Programme errors
• non-sterile injection
– infection
• incorrect preparation
– abscess (inadequate shaking)
– drug effect (use of drug instead of diluent)
• injection in wrong site
– local reaction/abscess (wrong tissue level)
– nerve damage
• vaccine frozen
– local reaction
• contraindication ignored
– avoidable severe reaction
 Common, minor reactions
Local reaction Fever >38C Irritability, malaise &
(pain, swelling, redness) systemic symptoms
BCG 90 - 95% - -
Hib 5 - 15% 2 - 10% -
HepB Adults: 15%; Child: 5% - 1 - 6%
Measles/ 5% rash
~10% 5 - 15%
Polio
(OPV) - <1% <1%**
Tetanus ~10%* ~10% ~25%
DPT
(pertussis) Up to 50% Up to 50% Up to 55%
*Rate of local reactions likely to increase with booster doses, up to 50-85%
**Systemic symptoms include diarrhoea, headache, and/or muscle pains
 Rare, more serious reactions

Reaction Incidence
• Suppurative lymphadenitis • 1 in 1,000 to 1 in 10,000
BCG • BCG Osteitis • 1 in 3,000 to 1 in 100 million
• Disseminated BCG infection • ~1 in 1 million

Hib • None known

HepB • Anaphylaxis • 1 in 6-900,000

• Febrile seizures • 1 in 3,000

• Thrombocytopaenia • 1 in 30,000
Measles/
(low platelets)
MMR/ • Severe allergic reaction • ~1 in 100,000
MR • Anaphylaxis • ~1 in 1 million
• Encephalopathy • <1 in 1 million
 Rare, more serious reactions (2)

Reaction Incidence
Polio • Vaccine associated • 1 in 2.4-3.3 million
paralytic poliomyelitis
(OPV) Risk is higher for first dose, • 1 in 750,000 first dose
adults, and compared to 1 in 5.1 million
immunocompromised for subsequent doses
Tetanus • Brachial neuritis • 0.5 - 1 in 100,000
• Anaphylaxis • 1 in 100,000 to 1 in 2,500,000
• Persistent inconsolable • 1 in 15 to 1 in 1,000
screaming
• Seizures • 1 in 1,750 to 1 in 12,500
Pertussis • Hypotonic, hyporesponsive • 1 in 1,000 to 1 in 33,000
(DTP- episode (HHE)
whole cell) •• Anaphylaxis
Encephalopathy
• 1 in 50,000
• 0 - 1 in 1 million
(Note: Risk may be zero)
 Objectives for Immunisation Safety
Surveillance System
• Detect, correct, and prevent programme errors
• Identify problems with vaccine lots or brand
• Prevent false blame from coincidental events
• Maintain confidence by properly responding to
parent/community concerns while increasing
awareness (public and professional) about vaccine
risks
• Generate new hypotheses about vaccine reactions
that are specific to the population
• Estimate rates of occurrence on AEFI in the local
population, compared with trial and international data
 What Events to report
• All Injection site abscesses
• Injection site bleeding (uncontrollable)
• All cases of BCG lymphadenitis
• Acute Flaccid Paralysis
• All deaths that are thought by health workers
or the general public to be related to
immunization
• Other unusual events occurring up to 4
weeks after an immunisation and not
covered above
 Barriers to reporting

• Not considering the event as related to

immunisation
• Not knowing about reporting system and process
• Lethargy - procrastination, lack of interest or time,
inability to find report form
• Fear that the report will lead to personal
consequences
• Guilt about having caused harm and being
responsible for the event
• Self doubt about reporting an event when not
confident about the diagnosis
 Conclusions

• Health workers should use every opportunity to

immunise eligible children.

• A wide range of people are needed to work together to

detect, report, investigate and respond to AEFIs.

• Setting up an effective immunisation system is

challenging and will require the commitment,
enthusiasm and resources of all health workers at the
different levels.