2 Common immunisations
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- Expanded programme on immunisations
- Non scheduled immunisations
- The method of giving immunisations
- Case studies
When you have completed this chapter you should be able to:
- Understand the expanded programme on immunisations
- List the scheduled immunisations
- Know about some non-scheduled immunisations
- Explain how each immunisation is given
Expanded programme on immunisations
2-1 What is the expanded programme on immunisation?
The expanded programme on immunisations (EPI) is the national schedule of routine immunisations which are given to all children in South Africa. Each immunisation is given at a certain age. Some immunisations are given once but most are given a number of times.
Every few years a new immunisation is added to the national schedule of immunisation and this expands the number of diseases that are protected by immunisation in South Africa.
The expanded programme on immunisations is the national immunisation schedule
2-2 What are the routine immunisations given to children in South Africa?
The routine immunisations protect against:
- TB (tuberculosis)
- Whooping cough
- Severe throat infection
- Severe diarrhoea
- Hepatitis B
- Human papilloma virus
2-3 Why is BCG immunisation so important?
Because TB (tuberculosis) remains a common cause of illness and death among children in South Africa. Unlike other immunisations BCG does not give complete protection against TB. However, it prevents some serious types of TB, such as TB meningitis, and reduces the risk of TB of the lungs which is the commonest form of TB.
BCG immunisation decreases the risk of severe tuberculosis in children
2-4 What is polio?
Polio is a viral disease which can cause muscle weakness or paralysis and sometimes death. Before polio immunisation started in the late 1950s it was a common and serious childhood illness in South Africa. Since immunisation started polio has almost disappeared. It is hoped that, like smallpox, polio will one day no longer exist.
2-5 What is the difference between oral and intramuscular polio vaccines?
There are two types of polio vaccine used in South Africa:
- Oral polio vaccine (OPV) given at birth and at 6 weeks is a weakened but live vaccine. The virus in the vaccine protects the child against the dangerous wild polio virus.
- Intramuscular vaccine is a dead polio virus and therefore cannot be passed onto other children. This vaccine is used in countries where there is no risk of polio. Both forms of immunisation are very effective.
2-6 Why are two types of polio immunisation used in South Africa?
The live virus in oral polio vaccine multiplies in the baby’s bowel and passes out in the baby’s stool. This can infect and thereby immunise other children. This makes sure that most children are immunised against polio which is very important in countries where polio still occurs. The virus in the intramuscular vaccine is not live and therefore cannot be passed on to other children.
In South Africa we have not seen polio for many years but there is still a danger that an immigrant child who is ill with with polio may come into South Africa from another country where polio is still seen, such as Nigeria. We use both vaccines as there is still a small risk of polio but in future when there is no longer a risk of polio we many only use the intramuscular vaccine.
Both oral and intramuscular polio immunisation are used in South Africa
2-7 What is diphtheria?
Diphtheria is a severe throat infection which used to be common in South Africa. A membrane could form in the throat which could obstruct the airway and prevent the child breathing. The bacteria causing diphtheria also produced a toxin that can damage the heart. Diphtheria used to be a common cause of death in children before the immunisation against diphtheria was started. It is now a rare disease.
Acellular vaccine (aP) is used today as it has fewer side effects than the earlier vaccine.
2-8 What is tetanus?
Tetanus occurs in children with an infection of a dirty wound or in newborn babies with an infection of the umbilical cord. It causes convulsions and was once an important cause of death in newborn infants. With good cord care and immunisation of both pregnant women and babies, it is only rarely seen today.
2-9 What is whooping cough?
Whooping cough is an infection of the upper airways which causes a severe cough and was a common cause of death in young children. Between coughs the child would take a deep breath (a whoop). Babies with whooping cough often stopped breathing altogether. With immunisation whooping cough is now much less common but still occurs in South Africa.
2-10 What is meningitis?
Meningitis is an infection of the membranes over the brain. There are a number of causes of meningitis but important causes in children are Pneumococcus and Haemophilus bacteria. Therefore both CPV (Pneumococcal vaccine) and Hib (Haemophilus vaccine) reduce the risk of childhood meningitis.
2-11 What are common causes of pneumonia?
Pneumococcus and Haemophilus are bacteria that commonly cause pneumonia (lung infection) in children. Pneumonia is an important cause of death in both children and the elderly. Therefore PCV and Hib immunisation reduce the risk of pneumonia.
2-12 What is a cause of severe throat infection?
Haemophilus can also cause a severe throat infection with stridor and life threatening swelling of the throat (epiglottitis), resulting in the child having difficulty breathing. Haemophilus also causes a severe general infection (septicaemia). Both these forms of severe Haemophilus infection were important causes of childhood death in South Africa but now can be prevented by Hib immunisation.
2-13 What was a common cause of severe diarrhoea?
Diarrhoea (gastroenteritis) is a common cause of illness and death in young children. One of the most important causes of severe diarrhoea is Rotavirus infection. This has become less common after the introduction of Rotavirus (RV) immunisation. However, it still is an important cause of childhood death in South Africa, especially where immunisation is not given to all children.
Rotavirus infection is an important cause of severe diarrhoea
2-14 What is hepatitis?
Hepatitis is an infection of the liver. The hepatitis B virus (HBV) was a common cause of severe hepatitis in children which can result in death or cirrhosis and liver cancer in adults. Women who have had this form of hepatitis years before may still spread the virus to their babies. HBV immunisation gives lifelong protection against these diseases.
2-15 What is measles?
Measles used to be a very common childhood illness which could lead to severe infection of the:
- Lungs (pneumonia)
It presented with a fever and a pink rash and was an important cause of childhood death in South Africa. With widespread immunisation in most countries like South Africa measles has become uncommon. However it still kills many children in countries where all children are not immunised.
2-16 What is Human Papilloma Virus infection?
Human Papilloma Virs (HPV) is a sexually transmitted viral infection which is the cause of cervical cancer. At present this is an important cause of cancer deaths in South Africa. Most HPV infections can be prevented by HPV immunisation before the age of sexual activity.
Non scheduled immunisations
2-17 What immunisations may be added to the national schedule in future?
Sometimes additional immunisations are offered in private practice but are not yet part of the national schedule of the Expanded Program on Immunisation. Some of these non-routine immunisations may be added to the national schedule in future:
- Measles, mumps and rubella (MMR) instead of measles alone
- Varicella (chickenpox). This will not only prevent chickenpox in children but also shingles in adults
- Meningococcus which is an important cause of meningitis especially in overcrowded conditions
- Hepatitis A which is often called “yellow jaundice”
2-18 What immunisations are only given under special circumstances?
There are a number of immunisations which may be given to children or adults when indicated:
- Viral influenza (flu) which must not be confused with Hib (Haemophilus influenza B). Flu immunisation is given each year to children with chronic conditions such as heart or lungs illnesses.
- Typhoid for visitors to countries where this disease still occurs
- Yellow fever also for visitors to countries where this disease still occurs
- Cholera if there is an epidemic of this severe form of diarrhoea
The method of giving immunisations
2-19 How are immunisations given?
The following methods are used to give immunisations:
- As drops into the mouth to be swallowed
- Injection into the skin (intradermal injection)
- Injection under the skin (subcutaneous injection)
- Injection into a muscle (intramuscular injection)
Each immunisation must be given in the correct way.
2-20 Does the skin need to be cleaned before an immunisation?
There is no need to clean the skin with alcohol before giving an immunisation by injection.
2-21 Which immunisations are given by mouth?
Oral polio and Rotavirus immunisations are given as drops into the mouth to be swallowed.
2-22 Which immunisation is given into the skin?
Only BCG. It is important that BCG is given correctly and not under the skin.
2-23 Which immunisations are given under the skin?
Only measles immunisation.
2-24 Which immunisations are given by intramuscular injection?
All the other immunisations on the national schedule are given by injection into a muscle.
2-25 On which side of the body are immunisations given?
Some immunisations by injection are always given on the left side while others are always given on the right side of the body.
2-26 When is the left side and when is the right side used for immunisations?
Only two immunisations are given on the left side:
- Hexavalent immunisation is always given on the left side. In young children all other immunisations are given in the right side. As Hexavalent is made with six vaccines it is best not to mix it with other immunisations.
- Td immunisation in school children aged six and 12 years is given on the left side as most children are right handed and the site of the injection can be painful.
- HPV immunisations to older girls are also given on the left side.
In young children most immunisations are given on the right side. The exceptions are Hexavalent and HPV immunisations which are given on the left side.
2-27 When are immunisations given into the thigh and when into the arm?
Some immunisations are given into the outer side of the thigh while others are given into the upper arm over the deltoid muscle. Injections are never given into the buttocks of young children as they may damage the nerve to the leg (sciatic nerve). It is important to know where each immunisation should be given. Except for BCG in babies, the thigh is used for young children and the arm in older children. The arm is used for older children aged 12 months or more as this is easier than using the thigh.
In young children most immunisations are given into the thigh while in older children the upper arm is used for immunisations
2-28 Which immunisations are given into the left thigh?
Only Hexavalent at six, 10 and 14 weeks. At 18 months it is given into the left arm as this is easier in older children. Hexavalent immunisation is made up of six different vaccines and is always given on the left side.
2-29 Which immunisations are given into the right thigh?
Two immunisations are given into the right thigh:
- PCV at six and 14 weeks and again at 9 months
- Measles at six months. After that measles is given into the arm
2-30 Which immunisations are given into the right arm?
Only two immunisations are given into the upper right arm:
- BCG has traditionally been given into the right arm so this site is still used today
- Measles immunisation
2-31 Which immunisations are given into the left arm?
Only two immunisations are given into the upper left arm:
- Hexavalent at 18 months (before that it is given into the left thigh) to keep it away from other immunisations
- Td (tetanus and reduced dose diphtheria) and HPV in older children as it is easier to use the left arm. If painful it should not worry a right handed child when they are writing.
Case study 1
A pregnant woman asks a community health worker whether her baby will need to get BCG immunisation. She wants to know why BCG immunisation is needed in South Africa.
1. Should all newborn babies get BCG immunisation?
Yes as it part of the national schedule of the expanded programme of immunisation.
2. Why is BCG an important immunisation?
Because it protects children against severe forms of TB (tuberculosis) such as meningitis. BCG immunisation is important as TB is a common cause of childhood illness and death in South Africa.
3. How is BCG given?
By injection into the skin (intradermal).
4. At what site is a BCG immunisation given?
Over the right upper arm.
Case study 2
A young mother asked the community health worker about the oral polio immunisation that her baby will need.
1. How is oral polio immunisation given?
As drops into the mouth.
2. When is oral polio immunisation given
At birth (OPV0) and again at six weeks (OPV1).
3. Is it a live or dead vaccine?
It is a weakened but live vaccine.
4. How common is polio in South Africa?
It used to be a common cause of muscle paralysis and death in South African children. After the introduction of polio immunisation in the 1950s this serious illness is no longer seen. The last reported case was in 1989. However there is still the risk that an immigrant child who has not been fully immunised could come into South Africa with polio.
Case study 3
A young child is brought to a district hospital with pneumonia. The community health worker asks the doctor if any immunisations can prevent pneumonia.
1. What immunisations will help protect a young child from pneumonia?
Measles immunisation to protect against measles pneumonia, PCV to protect against Pneumococcal pneumonia and HiB to protect against Haemophilus pneumonia.
2. What are two important clinical signs of measles?
Fever and a pink rash
3. When is measles immunisation given?
At six and 12 months.
4. What other serious condition can be prevented by HiB immunisation?
Case study 4
A child at six weeks is getting her first hexavalent immunisation. The nurse is not sure when to give the immunisation and asks the community health worker who has worked in the clinic for the past three months.
1. Where should the injection be given?
Into the muscle of the left thigh.
2. Where should the hexavalent immunisation be given when the child is 18 months old?
Into the left upper arm as this is easier in an older child. Hexavalent immunisation is always given on the left side of the body.
3. What six vaccines are combined in hexavalent immunisation?
Diphtheria, tetanus, pertussis, intramuscular polio, HepB and HiB.