Midwife Licensure Exam The Midwife's Public Health Service Delivery — Immunization / EPI Delivery by the MidwifeRevision Notes

Exam Tips

• Memorize: '+2°C to +8°C = BHS storage temperature.' This appears in virtually every MLE review.
• Remember the heat sensitivity order: OPV is MOST heat-sensitive, followed by BCG and MCV/MMR. These three go near the cold source.
• The freeze-sensitive group can be remembered by the mnemonic 'HePPITT': HepB, Pentavalent, PCV, IPV, TT/Td — NEVER freeze these.
• VVM rule: 'Inner as dark as outer = discard' — the inner square must be LIGHTER than the ring to use the vaccine.
• Shake test is ONLY for freeze-sensitive vaccines, not for OPV, BCG, or MCV.
• Reconstituted vaccine time limits are high-yield: BCG = 4 hours, Measles/MMR = 6 hours.

Key Points

• The cold chain is the unbroken system of storage and transport that maintains vaccines at a safe temperature from the manufacturer to the child's arm.
• At the health center and BHS level, the required storage temperature is +2°C to +8°C — this is the most critical number in the entire EPI program.
• During outreach, vaccines are transported in vaccine carriers with ice packs, still at +2°C to +8°C.
• At regional/provincial cold rooms, OPV may be stored frozen at -15°C to -25°C, but at the BHS level, ALL vaccines are stored at +2°C to +8°C.
• Vaccines are grouped by their sensitivity: heat-sensitive vaccines (OPV, BCG, MCV/MMR) go nearest the cold source; freeze-sensitive vaccines (HepB, Pentavalent/DPT-HepB-Hib, PCV, IPV, TT/Td) go on middle/lower shelves, never near the freezer.
• FEFO rule: First Expiry, First Out — always use the vaccine with the nearest expiry date first.
• Vaccine Vial Monitor (VVM): discard the vaccine when the inner square is as dark as or darker than the outer ring.
• Shake Test: used for freeze-sensitive vaccines suspected of being frozen; if flakes/sediment are visible and cannot be resuspended, discard the vial.
• Temperature must be recorded TWICE daily (morning and afternoon) using a thermometer kept inside the refrigerator.
• The refrigerator is for vaccines ONLY — no food, no drinks.
• Reconstituted BCG must be used within 4 hours; reconstituted measles/MMR within 6 hours. Both must be kept on ice and any remaining doses discarded after the session.

Definitions

Section Title

The Cold Chain: Keeping Vaccines Potent

Common Mistakes

• Confusing the storage temperature: some reviewees memorize -15°C to -25°C (which is the provincial cold room temperature for OPV) as the BHS temperature. The BHS temperature is always +2°C to +8°C.
• Storing freeze-sensitive vaccines (HepB, Penta, TT/Td) near the freezer compartment — these must NEVER be frozen.
• Placing OPV (most heat-sensitive) on the lower shelf away from the cold source — it must be nearest the cold source.
• Applying FIFO (First In, First Out) instead of FEFO — the rule is based on expiry date, not arrival date.
• Continuing to use a reconstituted BCG vial after 4 hours or a measles/MMR vial after 6 hours — these must be discarded.
• Placing food or drinks in the vaccine refrigerator — vaccines only.

Exam Tips

• Use the table: Birth → 6 wks → 10 wks → 14 wks → 9 mos → 12 mos. Know which vaccines go at each visit.
• High-yield fact: 'HepB birth dose within 24 hours' — expect this as a direct MLE question.
• IPV1 is the only 'new addition' at 14 weeks (alongside OPV 3, Penta 3, PCV 3); IPV2 is at 9 months.
• MCV1 at 9 months, MCV2 at 12 months — two doses, two different ages.
• FIC vs CIC distinction is frequently tested: FIC = before 12 months; CIC = after 12 months but before 24 months.

Key Points

• The EPI schedule is organized around key age milestones: at birth, 6 weeks, 10 weeks, 14 weeks, 9 months, and 12 months.
• Birth doses: BCG and Hepatitis B — both given at birth. The Hepatitis B birth dose MUST be given within 24 hours of birth to prevent mother-to-child (vertical) transmission.
• At 6, 10, and 14 weeks: Pentavalent (DPT-HepB-Hib), OPV, and PCV are given (three doses each).
• IPV is given in TWO doses: IPV1 at 14 weeks (with the third Pentavalent/OPV/PCV) and IPV2 at 9 months (with MCV1).
• MCV1 (measles-containing vaccine / MMR) is given at 9 months; MCV2 at 12 months. Two doses are required because a single dose does not achieve seroconversion in every child.
• The Pentavalent vaccine is a combination vaccine: DPT + HepB + Hib in one injection, reducing the number of separate shots.
• Prematurity does NOT change the schedule — immunize by chronological (actual) age, not corrected age.

Definitions

Section Title

The Routine EPI Schedule

Common Mistakes

• Forgetting that the Hepatitis B birth dose has a strict 24-hour window — giving it at 6 weeks along with Pentavalent is too late for birth-dose purposes.
• Confusing IPV doses: IPV1 is at 14 WEEKS, not 6 weeks. IPV2 is at 9 MONTHS, given WITH MCV1.
• Thinking one dose of measles vaccine is enough — two doses (MCV1 at 9 months, MCV2 at 12 months) are required.
• Restarting the vaccination series from the beginning if a child defaulted — the series is CONTINUED from where it left off.
• Immunizing a premature baby based on corrected gestational age — always use chronological (calendar) age.

Exam Tips

• BCG is unique: it is the ONLY vaccine given by intradermal route and the ONLY one with a dose of 0.05 mL (all others are 0.5 mL or 2 drops).
• Know the 'thigh group' (IM): HepB, Penta, PCV, IPV — all 0.5 mL IM anterolateral thigh.
• Know the 'arm group' (SC): MCV/MMR — 0.5 mL SC upper outer arm.
• OPV is the only oral vaccine — 2 drops by mouth.
• A question asking about a BCG scar forming: this is NORMAL and expected — do not treat it as a complication.

Key Points

• BCG: 0.05 mL intradermal (ID), right upper arm/deltoid — the ONLY intradermal vaccine in the schedule.
• Hepatitis B (birth dose): 0.5 mL intramuscular (IM), anterolateral thigh (vastus lateralis).
• Pentavalent (DPT-HepB-Hib): 0.5 mL IM, anterolateral thigh (vastus lateralis).
• PCV: 0.5 mL IM, anterolateral thigh (vastus lateralis).
• IPV: 0.5 mL IM, anterolateral thigh (vastus lateralis).
• OPV: 2 drops oral (given by mouth).
• MCV1/MCV2 (MMR): 0.5 mL subcutaneous (SC), upper outer arm.
• Infant IM injections are given in the vastus lateralis (anterolateral thigh), NOT the buttock — the gluteal area risks sciatic nerve injury and has too much fat for proper absorption.
• BCG normally produces a small scar at the injection site — this is the expected response, not an infection.
• Use a new sterile auto-disable syringe for every dose — one needle, one child. Used sharps go into the safety collector box; do not recap needles.
• Give all vaccines due at a visit in one session, at different sites — no benefit in splitting visits.

Definitions

Section Title

Administration: Route, Site, Dose, and Technique

Common Mistakes

• Giving BCG intramuscularly instead of intradermally — BCG is the ONLY ID vaccine; it must raise a small wheal.
• Injecting IM vaccines (HepB, Penta, PCV, IPV) into the buttock — use the anterolateral thigh only.
• Giving MCV/MMR IM instead of subcutaneously — MMR is SC, upper outer arm.
• Giving OPV by injection — OPV is 2 drops ORAL, not injected.
• Recapping needles after use — increases needle-stick injury risk; always discard directly into the safety collector box.
• Reducing the dose to 'save vaccine' — always give the full prescribed dose.

Exam Tips

• MLE questions on contraindications often list four scenarios and ask which is a TRUE contraindication — anaphylaxis and clinical AIDS (for BCG) are the answers to know.
• Anything describing a 'mild' condition (mild fever, mild diarrhea, mild cough) is NOT a contraindication — vaccinate.
• Remember: malnutrition, prematurity, breastfeeding, antibiotics = NOT contraindications.
• The phrase 'every contact is an opportunity' is the guiding principle — if a question asks what to do when a child with colds comes to the BHS, the answer is: vaccinate.

Key Points

• True contraindications to immunization are FEW. The greatest public health danger is the 'missed opportunity' — turning away a child who should be immunized.
• TRUE contraindication: Anaphylaxis (severe allergic reaction) to a previous dose of the same vaccine or to a vaccine component — do not repeat that vaccine.
• TRUE contraindication: Previous severe reaction to DPT/Pentavalent (e.g., encephalopathy) — do not give further pertussis-containing doses.
• TRUE contraindication: BCG must NOT be given to a child with clinical signs of AIDS (symptomatic HIV/AIDS) because live attenuated vaccines can disseminate in a severely immunocompromised child.
• NOT a contraindication: Mild illness, low-grade fever, cough, colds, mild diarrhea — VACCINATE.
• NOT a contraindication: Malnutrition — an undernourished child NEEDS vaccines even more.
• NOT a contraindication: Being on antibiotics or recovering from illness — VACCINATE.
• NOT a contraindication: Prematurity or low birth weight — immunize by chronological age.
• NOT a contraindication: Breastfeeding — VACCINATE.
• The EPI principle: It is SAFE and EFFECTIVE to immunize a mildly ill child. Every contact is an opportunity.

Definitions

Section Title

Contraindications: True vs. False

Common Mistakes

• Refusing to vaccinate a child who has a mild fever, cough, or colds — mild illness is NOT a contraindication.
• Skipping vaccination for a malnourished child — malnourished children are MORE vulnerable and need vaccines urgently.
• Telling a breastfeeding mother to stop breastfeeding before or after vaccination — breastfeeding is not a contraindication and actually helps comfort the infant.
• Postponing vaccines for a premature or low-birth-weight infant until a 'corrected age' — use chronological age.
• Giving BCG to a child with known clinical AIDS — this is one of the few true contraindications.

Exam Tips

• The 'never restart a series' rule is tested frequently. If a question says a child received Penta 1 at 6 weeks but returned at 5 months, you give Penta 2 next — you do NOT restart.
• Know the FIC vs CIC distinction: FIC = before 12 months (goal); CIC = 12-23 months (still good but missed the window).
• The TCL is the tool; the FHSIS is the system — know both names.
• BHWs assist the midwife in defaulter tracking through home visits and community mobilization.

Key Points

• The midwife records every dose on two documents: the child's immunization card (given to the mother) and the Target Client List (TCL) for immunization at the BHS.
• The TCL feeds into the Field Health Services Information System (FHSIS), the national data reporting system for primary health care.
• FIC (Fully Immunized Child): received all required antigens BEFORE 12 months of age — this is the PROGRAM GOAL.
• CIC (Completely Immunized Child): completed all required doses but only after the first birthday (12-23 months).
• Defaulter: a child who missed a scheduled vaccination dose.
• Defaulter tracking: using the TCL and the master list of barangay infants, the midwife identifies defaulters and conducts home visits or sends reminders through Barangay Health Workers (BHWs).
• CRITICAL RULE: A defaulted child's series is CONTINUED from where it left off — NEVER restart a series from the beginning, regardless of how long ago the last dose was given.
• Immunization sessions at the BHS may be held on fixed schedules (Fixed Site) and during outreach activities (Outreach).

Definitions

Section Title

Recording, Defaulter Tracking, and Program Indicators

Common Mistakes

• Restarting a vaccine series from the beginning when a child defaulted — the most common error; the rule is to CONTINUE, not restart.
• Recording only on the immunization card and not updating the TCL — both records must be maintained.
• Considering a CIC child the same as an FIC — FIC means completed before 12 months; CIC means completed after 12 months. They are different program indicators.
• Not conducting home visits for defaulters — active follow-up is the midwife's responsibility.