Ministry of Health

Kingdom Of Saudi Arabia

Aseer Health

EPI
Expanded Program Immunization

Lecture 9 – Epidemiology:
Expanded Program in Immunization
General Objective, Goal

• Protection of Saudi Arabian children, and

children lives in Saudi Arabia against infectious
diseases targeted by immunization.

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Specific Goals
 Control of VPD
(Diphtheria, Whooping cough, Hepatitis B,
TB, Hib Meningitis).

 Elimination of Measles, Rubella, Rubella

Congenital Syndrome, Mumps, (N.N.T.
already eliminated).

 Eradication of Poliomyelitis.

3
Development & progress in EPI

• 1963 : The last case of

indigenous smallpox .
• 1977 The last case of smallpox in the world ( Somalia
• 1964 : BCG was made available
for high risk groups .

• 1968 : Using of injectable

polio-vaccine.
• 1970 : The routine use of BCG
for newborns.
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 “Cont.”

1974 : National use of oral polio-vaccine.*

1979 : The Royal Decree linking the birth
certificate with completion of :
BCG, 3 doses Of DPT & OPV
vaccines .
1983 : Measles vaccine was added as a
condition for obtaining birth
certificate.
• WHO initiated (EPI) in May 1974.
• 1984, WHO established a standardized vaccination schedule :
EPI vaccines: (BCG), (DPT), oral polio, and measles. 5
Cont.

• 1991: A new national schedule of

immunization was adopted for all health
sectors including: MMR and Hepatitis B
vaccines.

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Cont

• 2002 : Combined Vaccines: Tetra vaccine (DTP

+ Hib).

• 2002 Vaccination schedule

• 2005 : Penta vaccine (DTP +Hib +Hep B).

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Vaccination Schedule,KSA,2005

Age Vaccine
BCG , HepB At Birth
OPV , 2 Months
(DTP , HepB, Hib)
OPV ,
(DTP , HepB, Hib) 4 Months
OPV , 6 Months
(DTP , HepB, Hib)
MMR 12 Months
OPV , DTP , Hib 18 Months
OPV , DTP , MMR 4 – 6 years

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Cont

• 2008: Introduce
– 1st polio dose as IPV at age of 2/12
– Measles monoval dose at age of 9/12
– Varicella & Hep A 2 doses each
• 2008 Vaccination Schedule

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Vaccination Schedule,KSA,2008
Vaccine Age
BCG , HepB At Birth
IPV , (DTP , HepB, Hib) 2 Months
OPV , (DTP , HepB, Hib) 4 Months
OPV , (DTP , HepB, Hib) 6 Months
Measles 9 Months
MMR, Varicella ,OPV 12 Months
OPV , (DTP , Hib), HepA 18 Months
HepA 24 Months
OPV , DTP , MMR , Varicella 4 – 6 years
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Cont

• 2009: Introduced
– PCV (pneum conj vaccine)

• 2009 Vacc Schedule

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Vaccination Schedule,KSA,2009
Vaccine Age
At Birth
BCG , HepB

IPV , (DTP , HepB, Hib), PCV 2 Months

IPV , (DTP , HepB, Hib), PCV 4 Months
OPV ,IPV (DTP , HepB, Hib),
6 Months
PCV
Measles 9 Months
MMR, Varicella ,OPV, PCV 12 Months
OPV , (DTP , Hib), HepA 18 Months
HepA 24 Months
OPV , DTP , MMR , Varicella 4 – 6 years
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EPI, components

• Basic Routine vaccination

• Disease surveillance (VPD )
• Cold chain
• Vaccine Safety
• Adverse Effects following immunization
• Health Education & Training
• Monitoring of national and international
update
• Introduction of new vaccines 13
Vaccination coverage ,KSA
Years :1980,90,2000,2009

BCG DTP& HepB

Year MMR%
% OPV% %

1980 38.5 66.1

1990 90.4 92.3 25 66.3

2000 92 93.5 94.1 92.7

2009 97.5 98 97.9 98

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Immunization coverage
2000-2010
BCG HepB DPTHib2 MMR
100

98
96

94

92
90

88
2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010
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DPT Coverage & Pertussis Incidence,
KSA, 1980-2010

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DPT Coverage & Diphtheria Incidence,
KSA, 1980-2010

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DPT Coverage & Neonatal tetanus Incidence,
KSA, 1980-2010

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Polio Vaccine Coverage & Polio Incidence Rate, KSA, 1980-
2010

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Measles Vaccines Coverage & Incidence, KSA,
1980-2009

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Diphtheria Cases, Saudi Arabia, 1980-2009

250

200

150

100

50

0
1980

82

84

86

88

1990

92

94

96

98

2000

2002

2004

2006

2008
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Whooping cough Cases, Saudi Arabia
1980-2009

10000
9000
8000
7000
6000
5000
4000

3000
2000
1000
0
1980

82

84

86

88

1990

92

94

96

98

2000

2002

2004

2006

2008
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NNT Cases, Saudi Arabia, 1980-2009

160

140

120

100

80

60

40

20

0
1980

82

84

86

88

1990

92

94

96

98

2000

2002

2004

2006

2008
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Incidence Rate of EPI Diseases and Decline
Percentage in KSA comparing years 1983 & 2005
Diseases 1983 2005 Decline
%
TB 52.2 14.1 73
Diphtheria 1.28 0.03 98
W. Cough 17.29 0.28 98
Neonatal T. 7. 0.08 89
Polio 1.02 0 100
Measles 304.38 1.16 99.6
Mumps 279.7 0.5 99.9
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Polio Eradication Program

Stages of Polio Eradication Program

• Disease control
• Polio-free status
• Prevention of importation

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Disease control

• 1968: IPV
• 1974: OPV
• 1979: 3 OPV doses linked to birth certificate

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Polio Vaccine Coverage & Polio Incidence Rate
KSA, 1980-2010

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Polio-free status

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Elements of polio-free status

• Presence of effective national program

• Surveillance (AFP)
• Vacc Coverage (high >95%)
• Supplementary Immun Activities (SIAs)
– NIDs, Sub national

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AFP, Con Polio, VAP and imported cases
KSA, 1989-2008

350
300
250
200
150
100
50
0
89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8
AFP 26 17 7 4 43 79 74 75 98 84 81 86 84 88 120 110 119 102 160 298
Con.Polio 3 5 1 2 2 6 3 0 0 1 0 0 0 0 0 0 0 0 0 0
VAP 0 0 0 0 0 0 1 0 0 0 1 1 0 0 2 1 0 0 0 0
Imported 0 0 0 0 0 0 2 0 0 1 0 0 0 0 0 2 0 0 0 0

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 Yr 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8

AFP 26 17 7 4 43 79 74 75 98 84 81 86 84 88 120 110 119 102 160 298

Con.Polio 3 5 1 2 2 6 3 0 0 1 0 0 0 0 0 0 0 0 0 0

VAP 0 0 0 0 0 0 1 0 0 3 1 1 0 0 2 1 0 0 0 0

Imported 0 0 0 0 0 0 2 0 0 1 0 0 0 0 0 2 0 0 0 0

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NIDs conducted, KSA, 1995 -2000

120
100
80
60
40
20
0
1995 96 97 98 99 2000
1st dose 94.7 95 97.4 95.4 98.1 96
2nd dose 97 97.2 97.8 96.1 96.6 94.5

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Prevention of Importation of
Infectious Diseases

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Activities of preventing Importation

• Surveillance
• High Vacc coverage
• Selected vacc campaigns
• Entry ports Vacc for people coming from
endemic areas

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Measles, Mumps & Rubella Program

• Disease Control
• Elimination

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Further Elimination Strategies

• 2nd MMR dose given at schools at entry. As

campaigns as well.

• Successive vaccine campaigns for high risk

groups based on epidemiology of the disease.

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Future perspectives

• Vaccines under evaluation to be included in

basic vaccines

• In the queue:
– Meningococcal Conjugated Vaccine
– MMRV
– Seasonal Flu
– Rota Vaccine
– Human Papilloma Vaccine
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Factors influence adopting new vaccine, by
MOH
• Disease burden:
– Morbidity, Mortality, Complications.
• Cost effectiveness.
• National priority.
• International importance.
• Diseases targeted by eradication.
• Diseases targeted by elimination.

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Adverse events following
immunization (AEFI)

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Adverse events following
immunization (AEFI)
• A medical incident that takes place after an
immunization, causes concern, and is believed to be
caused by immunization(WHO).

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Classification of adverse events following
immunization (AEFI)
Vaccine reaction: event caused or precipitated by the vaccine when given
correctly, caused by the inherent properties of the vaccine.

Programme error: event caused by an error in vaccine preparation, handling,

or administration.

Coincidental: event that happens after immunization but not caused by

the vaccine - a chance association.

Injection reaction: event from anxiety about, or pain from, the injection itself
rather than the vaccine

Unknown: event’s cause cannot be determined.

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Examples of types & frequency of AEFIs
(in commonly used vaccines )
Rates per
Vaccine Reaction Onset Interval
million doses

Suppurative lymphadenitis 2-6 months 100 to 1000

BCG
BCG osteitis 1-12 months 1 to 700
Disseminated BCG-it is 1-12 months 2
Hib Nil known    
Anaphylaxis 0-1 hour 0 to 2
Hepatitis B
Guillain-Barrè Syndrome (plasma derived) 1-6 weeks 5
Febrile seizures 5-12 days 333
Measles/MMR Thrombocytopaenia 15-35 days 33
Anaphylaxis 0-1 hour 1 to 50
OPV Vaccine associated paralytic polio (VAPP) 4-30 days 1.4 to 3.4
Persistent (>3 hrs) inconsolable crying 0 -24 hours 1000 to 60000
Seizures 0 - 3 days 570
DTP
Hypotonic, hyporesponsive episode 0-24 hours 570
Anaphylaxis 0 - 1 hour 20
Encephalopathy 0 - 3 days 0 to 1
400 to 4000 (in
Yellow Fever Post-vaccination encephalitis 7-21 days infants <6 m)
Allergic/anaphylaxis 0-1 hour 5 to 20

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 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/ ~10% 5 - 15% 5% rash

MMR
Polio <1%
- <1%
(OPV)
Tetanus ~10% ~10% ~25%
DTP
Up to 50% Up to 50% Up to 55%
(pertussis)

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 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 60000 to 1 in 900,000

• Febrile seizures • 1 in 3,000

• Thrombocytopaenia • 1 in 30,000
Measles/
(low platelets)
MMR/ • Severe allergic reaction • ~1 in 100,000
• Anaphylaxis • ~1 in 1 million
• Encephalopathy • <1 in 1 million

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 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 • 1 in 750,000 first dose
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
• Hypotonic, hypo- • 1 in 1,000 to 1 in 33,000
DTP responsive
episode (HHE) • 1 in 50,000
• Anaphylaxis • 0 - 1 in 1 million
• Encephalopathy
(Note: Risk may be zero) 45
Group Activity

• In a group of 3 or 4 trainees, identify and discuss the

factors that contributes to the success (or problems)
of a vaccination programme specific in your area.
You may choose one particular vaccination
programme to be discussed.
• Identify and discuss how can this be improved, who
are responsible to do this, what other support from
stakeholders are required to make this happens.

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