Immunization / EPI Delivery by the Midwife - Cheat Sheet
Your last-minute revision companion for EPI mastery at the BHS. Cold chain, schedules, routes, sites, and the few true contraindications. This is exam-critical material—every detail counts.
Cold Chain: The Foundation
Common values
Value
+2°C to +8°C
Symbol
T(storage)
Quantity
Cold chain storage temperature (BHS/health center)
Value
-15°C to -25°C
Symbol
T(frozen)
Quantity
Frozen OPV storage (higher levels)
Value
4 hours
Symbol
t(BCG)
Quantity
BCG reconstitution time limit
Value
6 hours
Symbol
t(MCV)
Quantity
MCV/MMR reconstitution time limit
Important facts
- Storage temperature at health center/BHS: +2°C to +8°C (THE critical number)
- Regional/provincial cold rooms may store OPV frozen at -15°C to -25°C (not BHS level)
- Temperature recorded twice daily (morning and afternoon) on monitoring chart
- Refrigerator holds vaccines only—no food, drinks, or non-vaccine items
- Heat-sensitive vaccines (heat-labile): OPV > BCG > MCV (most to least); store near cooling source (top shelf)
- Freeze-sensitive vaccines (freeze-labile): Hepatitis B, Pentavalent, PCV, IPV, TT/Td—never freeze; store middle/lower shelf
- FEFO rule: First Expiry, First Out—use vaccines with nearest expiry date first
- Reconstituted BCG: use within 4 hours; discard remainder
- Reconstituted MCV/MMR: use within 6 hours; discard remainder
- Both reconstituted live vaccines kept on ice during session
Key definitions
Cold Chain
Example
Refrigerator at BHS holds vaccines at +2°C to +8°C; ice packs in carriers maintain same temperature during outreach.
Unbroken system of storage and transport maintaining vaccine potency from manufacturer to child's arm via controlled temperature.
VVM (Vaccine Vial Monitor)
Example
After vaccine exposure to heat, VVM inner square becomes dark gray; vaccine is no longer safe to use.
Heat-sensitive label on vaccine vial; inner square darkening to match outer ring signals heat damage—vaccine must be discarded.
Shake Test
Example
Pentavalent suspected of freezing: shake gently—if flakes appear and do not resuspend, discard immediately.
Assessment for freeze damage in freeze-sensitive vaccines: if frozen-thawed vial shows flakes/sediment that settle quickly, vaccine is damaged.
Diagrams to know
- Cold chain flow from manufacturer to child
- Refrigerator shelf arrangement (heat-sensitive vs. freeze-sensitive zones)
- VVM color interpretation chart
- Temperature monitoring chart template
Routine EPI Schedule — DOH Childhood Immunization
Common values
Value
Before 12 months (< 365 days)
Symbol
FIC_age
Quantity
Age for FIC completion
Value
12–23 months
Symbol
CIC_age
Quantity
Age range for CIC
Value
3 doses (6, 10, 14 weeks)
Symbol
Penta_doses
Quantity
Pentavalent doses in routine schedule
Value
2 doses (9, 12 months)
Symbol
MCV_doses
Quantity
Measles doses in routine schedule
Important facts
- At birth (within 24 hours): BCG + Hepatitis B → Hepatitis B prevents mother-to-child transmission
- 6 weeks: Pentavalent 1 + OPV 1 + PCV 1
- 10 weeks: Pentavalent 2 + OPV 2 + PCV 2
- 14 weeks: Pentavalent 3 + OPV 3 + PCV 3 + IPV 1 → IPV is inactivated polio vaccine
- 9 months: MCV 1 (measles-containing/MMR) + IPV 2 → Two antigens at this visit
- 12 months: MCV 2 (second measles dose) → Completes routine infant schedule
- Pentavalent = DPT + Hep B + Hib (five antigens in one shot, spares three separate injections)
- IPV schedule: 1st dose at 14 weeks (with OPV), 2nd dose at 9 months (with MCV1)
- Measles requires two doses (MCV1 at 9 mo, MCV2 at 12 mo)—one dose does not guarantee seroconversion in all children
- FIC is the program goal; it protects children during highest-risk period (6–12 months)
Key definitions
Fully Immunized Child (FIC)
Example
Baby completed all doses by 11 months 29 days = FIC; critical for DOH program targets.
Child who received all required antigens (BCG, 3× Pentavalent, 3× OPV, 3× Hepatitis B, 1× MCV) before turning 12 months old.
Completely Immunized Child (CIC)
Example
Baby completed measles dose at 13 months = CIC; not ideal, but schedule is complete.
Child who completed all required doses after turning 12 months (aged 12–23 months).
Defaulter
Example
Child missed 10-week Pentavalent 2 and has not returned by week 12; is a defaulter requiring home visit.
Child who missed a scheduled vaccination and did not return by the next appointment.
Diagrams to know
- DOH EPI schedule timeline from birth to 12 months
- Pentavalent vaccine composition breakdown
- Comparison of OPV (oral live) vs. IPV (injectable inactivated)
Administration: Routes, Sites, Doses, and Technique
Common values
Value
0.05 mL
Symbol
D(BCG)
Quantity
BCG dose
Value
0.5 mL
Symbol
D(IM)
Quantity
HepB, Penta, PCV, IPV dose
Value
2 drops
Symbol
D(OPV)
Quantity
OPV dose
Value
0.5 mL
Symbol
D(SC)
Quantity
MCV/MMR dose
Important facts
- BCG: 0.05 mL intradermal (ID), right upper arm (deltoid area)—only ID vaccine in routine EPI
- Hepatitis B (birth): 0.5 mL intramuscular (IM), anterolateral thigh (vastus lateralis)
- Pentavalent (DPT-HepB-Hib): 0.5 mL IM, anterolateral thigh
- PCV (pneumococcal): 0.5 mL IM, anterolateral thigh
- IPV (inactivated polio): 0.5 mL IM, anterolateral thigh
- OPV (oral polio): 2 drops oral (by mouth)
- MCV/MMR (measles): 0.5 mL subcutaneous (SC), upper outer arm
- NEVER use buttock for infant IM injection → risk of sciatic nerve damage and impaired absorption
- Use new sterile auto-disable syringe for every dose (one needle, one child); never recap
- Give all vaccines due at one visit in different sites; no benefit to splitting doses across visits
- Never reduce or split a dose—full dose required for immunity
- Used sharps go into safety collector box; never dispose in regular trash
Key definitions
Intradermal (ID)
Example
BCG 0.05 mL ID into right upper arm raises small wheal; later forms a scar (normal response, not infection).
Injection into the skin itself (superficial layer), forming a small wheal; used only for BCG.
Intramuscular (IM)
Example
Pentavalent 0.5 mL IM into outer thigh of infant; provides good absorption and avoids nerve damage.
Injection into muscle; for infants, the anterolateral thigh (vastus lateralis) is the site (never buttock).
Subcutaneous (SC)
Example
MCV 0.5 mL SC into upper outer arm of infant; standard site for live measles vaccine.
Injection into subcutaneous tissue (under skin, above muscle); used for measles/MMR vaccine.
Oral (PO)
Example
OPV 2 drops placed in infant's mouth at each visit (6, 10, 14 weeks).
Vaccine administered by mouth; OPV (oral polio vaccine) is given as drops.
Diagrams to know
- Infant thigh anatomy showing vastus lateralis and safe injection site
- Comparison of ID vs. IM vs. SC needle angles and depth
- Vaccine administration quick-reference card (route × site × dose)
Contraindications — True vs. False
Important facts
- TRUE contraindications (DO NOT vaccinate):
- - Anaphylaxis or severe allergic reaction to prior dose of same vaccine or vaccine component
- - Prior severe reaction to DPT/Pentavalent (e.g., encephalopathy) → do not give further pertussis-containing doses
- - BCG not given to child with clinical signs of AIDS (symptomatic HIV); live vaccine risk in severely immunocompromised
- - Live vaccines used with caution in known immunodeficiency states
- FALSE contraindications (IMMUNIZE ANYWAY—do not miss opportunity):
- - Mild illness (cough, cold, runny nose)
- - Low-grade fever (< 39°C)
- - Mild diarrhea
- - Malnutrition (undernourished child needs vaccines more)
- - On antibiotics
- - Recovering from illness
- - Prematurity or low birth weight (immunize by chronological age, not corrected age)
- - Breastfeeding (breastfeeding is not a contraindication to any vaccine)
- The EPI principle: Missed opportunities harm more children than rare adverse events.
- Every contact with a child ≤ 12 months is a chance to check and update the immunization card
Key definitions
True Contraindication
Example
History of anaphylaxis to previous dose of same vaccine = true contraindication; do not re-vaccinate.
Medical condition or prior reaction that means the vaccine should not be given.
False Contraindication
Example
Low-grade fever, mild cough, or malnutrition = false contraindication; child should still be immunized.
Condition commonly mistaken as a reason to withhold vaccine but is NOT a reason to defer immunization.
Diagrams to know
- Decision tree: Is this a true contraindication?
- Common false contraindications checklist
Recording, Tracking, and Program Indicators
Common values
Value
< 12 months (before first birthday)
Symbol
FIC_cutoff
Quantity
FIC age cutoff
Value
12–23 months
Symbol
CIC_range
Quantity
CIC age range
Value
95%
Symbol
FIC_target
Quantity
Target FIC coverage (DOH)
Important facts
- Every dose recorded on: (1) child's immunization card (kept by mother) and (2) TCL at BHS
- TCL is the midwife's tool to see, at a glance, which children are due and which are overdue
- FIC (Fully Immunized Child): All antigens before 12 months—the program target
- CIC (Completely Immunized Child): All antigens between 12–23 months—backup indicator
- Defaulter identification: TCL shows child missed last appointment and has not returned by next scheduled date
- Defaulter management: Never restart the series—continue from where the child left off (give the next due dose)
- Example: Baby missed 10-week dose but returns at 16 weeks → give Pentavalent 2 (not restart at Pentavalent 1)
- Home visit for defaulter includes: explain importance of immunization, reschedule, remove barriers (transport, work schedule)
- Barangay Health Workers (BHWs) assist with defaulter identification and home reminders
- Monthly reporting to RHU; RHU reports to provincial DOH office
- High FIC rate (> 95%) is indicator of strong BHS performance and effective midwife/BHW coordination
Key definitions
Target Client List (TCL)
Example
TCL shows 10-week Pentavalent 2 is due for baby Juan; midwife checks if he came on schedule.
BHS register of all infants in the barangay due for immunization; used to track schedule compliance and identify defaulters.
Field Health Services Information System (FHSIS)
Example
BHS reports monthly FIC rate to FHSIS; DOH uses data to track provincial immunization coverage.
National health information system that receives immunization data from BHS (via TCL) for DOH monitoring and evaluation.
Defaulter Tracking
Example
Baby Rosa missed 14-week appointment; midwife visits home to reschedule; Rosa completes Pentavalent 3 two weeks late.
Active follow-up by midwife of children who missed scheduled doses; uses home visits or reminders to bring child back and continue series.
Diagrams to know
- Immunization record flow: from individual card to TCL to FHSIS
- Defaulter tracking workflow (identification → home visit → rescheduling → completion)
Special Situations and Midwife Responsibilities
Common values
Value
Within 24 hours of birth
Symbol
t(birth)
Quantity
BCG + Hep B birth dose window
Value
0.5 mL
Symbol
V(HepB_birth)
Quantity
Hepatitis B birth dose IM volume
Important facts
- BCG and Hepatitis B are birth doses given within 24 hours of delivery
- Hepatitis B birth dose is critical for prevention of vertical transmission (mother → baby)
- Unang Yakap program mandates first immunization at point of delivery (home, BHS, hospital)
- Midwife must counsel mother on importance of completing schedule and explain return dates
- Immunization card given to mother at delivery; midwife explains how to read card and importance of keeping it safe
- Mother is educated on vaccine-preventable diseases and expected mild reactions (arm swelling after BCG)
- BHS midwife conducts post-natal check (6 weeks) and verifies Unang Yakap was completed; if not, gives BCG + Hep B immediately
- For low-birth-weight (LBW) infants: immunize by chronological age, not corrected age (same as any infant)
- Premature babies follow the same EPI schedule (by age from birth, not from due date)
- When vaccine is given late: continue from where child left off, not restart
- Catch-up immunization: if child comes at any age with incomplete record, give next due vaccine and plot remaining doses
Key definitions
Unang Yakap Program
Example
Midwife conducts home birth; within 24 hours, gives BCG ID and Hepatitis B IM to newborn; records on card.
DOH program ensuring newborn receives first immunization (BCG and Hepatitis B birth dose) within 24 hours of delivery, even at home or health center.
Birth Dose Hepatitis B
Example
Newborn of HBsAg-positive mother receives Hep B within 24 hours to stop vertical transmission.
Single 0.5 mL IM dose of Hepatitis B vaccine given within 24 hours of birth to prevent mother-to-child (vertical) transmission.
Diagrams to know
- Unang Yakap birth immunization workflow
- Hepatitis B vertical transmission prevention pathway
- Catch-up vaccination scheduling algorithm
Must remember
- Cold chain storage at BHS/health center: +2°C to +8°C—record temperature twice daily (morning and afternoon); this is THE critical number for all EPI operations.
- Heat-sensitive vaccines (OPV > BCG > MCV) are stored on top shelf near cold source; freeze-sensitive vaccines (HepB, Penta, PCV, IPV, TT/Td) are stored on middle/lower shelf AWAY from freezer (use shake test if freezing suspected).
- FEFO rule (First Expiry, First Out) and read the VVM—if VVM inner square is as dark as or darker than outer ring, vaccine is heat-damaged and must be discarded.
- Birth doses within 24 hours: BCG (intradermal, right arm) + Hepatitis B (IM, thigh)—prevents vertical transmission of Hepatitis B.
- Key schedule: 6 weeks (Penta 1, OPV 1, PCV 1) → 10 weeks (Penta 2, OPV 2, PCV 2) → 14 weeks (Penta 3, OPV 3, PCV 3, IPV 1) → 9 months (MCV 1, IPV 2) → 12 months (MCV 2) = FIC.
- Route and site are NOT interchangeable: BCG is 0.05 mL intradermal (only ID vaccine); HepB/Penta/PCV/IPV are 0.5 mL IM into anterolateral thigh (NEVER buttock); OPV is 2 drops oral; MCV/MMR is 0.5 mL SC into upper arm.
- True contraindications are rare: Anaphylaxis to prior dose, prior encephalopathy from DPT, BCG not for symptomatic HIV/clinical AIDS. Mild fever, cough, diarrhea, malnutrition, prematurity, breastfeeding, antibiotics = NOT contraindications—vaccinate anyway.
- Reconstituted live vaccines: BCG use within 4 hours (discard remainder); MCV/MMR use within 6 hours (discard remainder); keep both on ice during session.
- FIC = all antigens before 12 months (program gold standard, > 95% target); CIC = all antigens between 12–23 months (backup if FIC missed). Defaulter = child who missed appointment and did not return; never restart series—continue from where child left off (give next due dose).
- Recording and tracking: Every dose on immunization card (mother keeps) and TCL at BHS; use TCL to identify defaulters; conduct home visits to reschedule and remove barriers; report monthly to RHU for FHSIS entry.
Last minute tips
- Know the critical numbers by heart: +2°C to +8°C (cold chain), 0.05 mL (BCG intradermal), 0.5 mL (all IM/SC), 2 drops (OPV), 4 hours (BCG reconstitution), 6 hours (MCV/MMR reconstitution), < 12 months (FIC cutoff). MLE examiners test these relentlessly.
- Heat-sensitive vs. freeze-sensitive is a trap question. OPV/BCG/MCV are HEAT-sensitive (top shelf); HepB/Penta/PCV/IPV/TT are FREEZE-sensitive (never freeze, use shake test). Get this wrong and you fail the immunization scenario.
- Contraindication questions are often about false contraindications. If the question says 'fever, malnutrition, prematurity, or breastfeeding,' the answer is ALWAYS 'vaccinate anyway'—these are NOT true contraindications. Only anaphylaxis to prior dose and prior encephalopathy from DPT are real blocks.
- Defaulter management is 'continue, not restart.' If a child missed a dose, give the NEXT due dose whenever they return—do not go back to the first dose. This is a common MLE trick question.
- The Unang Yakap program test: BCG + HepB within 24 hours of birth. If asked about newborn immunization, the answer must include the 24-hour window and the Hepatitis B role in vertical transmission prevention. This ties to the midwife's role at delivery.
Comparison tables
Heat-Sensitive vs. Freeze-Sensitive Vaccines: Storage Rules
| Characteristic | Heat-Sensitive (Heat-Labile) | Freeze-Sensitive (Freeze-Labile) |
|---|---|---|
| Vaccines (priority order) | OPV (most sensitive) > BCG > MCV (measles) | Hepatitis B, Pentavalent, PCV, IPV, TT/Td |
| Damaged by | Exposure to temperatures above +8°C | Freezing (exposure to temperatures below +2°C) |
| Shelf placement in refrigerator | Top shelf (nearest freezer/cold source) | Middle and lower shelves (away from freezer); NEVER in door |
| Test for damage | VVM (Vaccine Vial Monitor)—inner square darkens with heat | Shake test—frozen-thawed vial shows flakes that settle quickly and do not resuspend |
| Live or inactivated | Live-attenuated (BCG, OPV, MCV) — sensitive to heat degradation | Mix of inactivated and live (varies by vaccine) |
Vaccine Route, Site, and Dose Quick Reference
| Vaccine | Dose (mL or drops) | Route | Site | Key Point |
|---|---|---|---|---|
| BCG | 0.05 mL | Intradermal (ID) | Right upper arm (deltoid) | Only ID vaccine; forms wheal; later scars |
| Hepatitis B (birth) | 0.5 mL | Intramuscular (IM) | Anterolateral thigh (vastus lateralis) | Within 24 hours of birth; prevents vertical transmission |
| Pentavalent | 0.5 mL | Intramuscular (IM) | Anterolateral thigh (vastus lateralis) | Never buttock; three doses at 6, 10, 14 weeks |
| PCV | 0.5 mL | Intramuscular (IM) | Anterolateral thigh (vastus lateralis) | Three doses; protects against pneumococcus |
| IPV | 0.5 mL | Intramuscular (IM) | Anterolateral thigh (vastus lateralis) | Inactivated polio; 1st dose at 14 weeks, 2nd at 9 months |
| OPV | 2 drops | Oral (by mouth) | Mouth (drops in) | Live polio vaccine; three doses at 6, 10, 14 weeks |
| MCV/MMR | 0.5 mL | Subcutaneous (SC) | Upper outer arm | Two doses: MCV1 at 9 mo, MCV2 at 12 mo; live vaccine |
True Contraindications vs. False Contraindications
| Category | True Contraindications (DO NOT vaccinate) | False Contraindications (DO vaccinate—do not miss opportunity) |
|---|---|---|
| Allergic reactions | Anaphylaxis or severe allergic reaction to previous dose of same vaccine or component | No contraindications; mild allergies are not barriers |
| Prior severe vaccine reaction | Encephalopathy after DPT/Pentavalent → do not give pertussis-containing doses | N/A |
| Immunocompromise | BCG not given to child with clinical AIDS (symptomatic HIV); live vaccines avoided | N/A |
| Fever and illness | N/A | Mild fever (< 39°C), cough, cold, mild diarrhea—all safe to vaccinate |
| Nutritional status | N/A | Malnutrition—child should be vaccinated (needs protection more than well-nourished child) |
| Medication use | N/A | On antibiotics—no contraindication; still vaccinate |
| Prematurity and birth weight | N/A | Prematurity, low birth weight—vaccinate by chronological age, not corrected age |
| Feeding status | N/A | Breastfeeding—no contraindication; vaccinate as scheduled |
| Recovering from illness | N/A | Recovering from acute illness—vaccinate (safe and effective) |
FIC vs. CIC: Program Indicators and Age Cutoffs
| Indicator | FIC (Fully Immunized Child) | CIC (Completely Immunized Child) |
|---|---|---|
| Definition | Child received all required antigens (BCG, 3× Penta, 3× OPV, 3× HepB, 1× MCV) | Child received all required antigens but after 12 months of age |
| Age completion window | Before 12 months (< 365 days from birth) | Between 12–23 months (365–730 days from birth) |
| Program goal | Primary target; FIC status ensures protection during highest-risk 6–12 month period | Backup indicator; child is protected but vaccination delayed |
| DOH coverage target | > 95% FIC coverage is gold standard; indicates strong immunization program | Used to calculate coverage if FIC not reached by deadline |
| Example | Baby received MCV2 at 11 months 28 days = FIC (on-time, within first year) | Baby received MCV2 at 13 months = CIC (late; completed after 1st birthday) |
Diagrams
Cold Chain Management Decision Tree: Storage Temperature and Vaccine Placement
Decision flowchart for vaccine storage: distinguishes heat-sensitive vaccines (top shelf) from freeze-sensitive vaccines (middle/lower shelf), and guides the shake test and VVM assessment. Ensures midwife follows the unbreakable cold chain rules.
DOH Routine EPI Schedule Timeline: Birth to 12 Months (FIC Completion)
Timeline showing critical vaccination milestones from birth to FIC completion. Helps midwife visualize the entire schedule and understand the key contact points (birth, 6, 10, 14 weeks, 9 months, 12 months) where doses must be given for FIC status.
Immunization: Midwife's Complete Responsibility Map
Mind map organizing all midwife responsibilities in EPI delivery: cold chain management, vaccine administration technique, scheduling adherence, accurate recording, defaulter follow-up, and mother counseling. Shows how these six pillars support FIC achievement.
Vaccine Status State Transitions: Child Progress from Birth to FIC/CIC
State diagram showing child's progression through EPI schedule. Distinguishes FIC (completed before 12 months), CIC (completed 12–23 months), and defaulter pathway with catch-up vaccination. Illustrates how every child should reach FIC or CIC, and how defaulters are brought back on schedule.
Vaccine Administration Technique: Route-Site-Dose Selector
Flowchart guiding midwife through vaccine administration: selects correct route (ID, IM, oral, SC), confirms site and dose, and ensures safe needle/syringe practices. Prevents common mistakes like using buttock for infant IM or recapping needles.