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

The cold chain is the unbroken system of storage and transport that maintains vaccines within their safe temperature range from the manufacturer to the child's arm. Without proper cold-chain management, vaccines lose potency and fail to protect—a preventable tragedy that wastes resources and leaves children unprotected. **CRITICAL TEMPERATURE AT SERVICE DELIVERY LEVEL: +2°C to +8°C** This is the single most important number in the entire EPI program. At the RHU and BHS, all vaccines are stored in a vaccine refrigerator at this temperature. During transport to outreach sites or barangay clinics, vaccines are carried in vaccine carriers with ice packs, still maintained at +2°C to +8°C. At higher levels of the system (provincial cold rooms), oral polio vaccine may be stored frozen at −15°C to −25°C, but at the service-delivery level where you work as a midwife, everything stays at +2°C to +8°C. **Why Temperature Matters:** Vaccines are living biological products (either live-attenuated or inactivated). Heat denatures the antigens and weakens immunity. Freezing causes crystal formation that destroys vaccine potency. The +2°C to +8°C range protects against both extremes. **Heat-Sensitive vs. Freeze-Sensitive Vaccines:** Not all vaccines fail the same way. Understanding this distinction determines proper shelf placement inside the refrigerator: *Heat-Sensitive Vaccines (Live-Attenuated):* These are damaged fastest by heat exposure and must be stored nearest the cooling source: 1. **OPV (Oral Polio Vaccine)** — MOST heat-sensitive; store on top shelf or closest to freezer compartment 2. **BCG (Bacille Calmette-Guérin)** — heat-sensitive; store on upper portion of refrigerator 3. **MCV/MMR (Measles-Containing Vaccine)** — heat-sensitive; store on upper shelves Remember: Live vaccines are damaged by heat first, so they "live" closest to the cold source. *Freeze-Sensitive Vaccines (Inactivated):* These are destroyed by freezing and must NEVER be frozen. They are stored on middle and lower shelves, away from the freezer compartment and never in the refrigerator door: 1. **Hepatitis B** — must never be frozen 2. **Pentavalent (DPT-HepB-Hib)** — must never be frozen 3. **PCV (Pneumococcal Conjugate Vaccine)** — must never be frozen 4. **IPV (Inactivated Polio Vaccine)** — must never be frozen 5. **TT/Td (Tetanus-containing vaccines)** — must never be frozen **The Vaccine Refrigerator Setup:** - Holds **vaccines only** — no food, drinks, or medicines - Contains a **thermometer** inside (not on the door) that records temperature **twice daily** (morning and afternoon) on a monitoring chart - Uses **ice packs and water bottles** arranged strategically to stabilize temperature - Door is used minimally and only for quick access - A temperature-monitoring log is kept for DOH review and for detecting trends **Cold Chain Safety Checks the Midwife Performs:** 1. **FEFO — First Expiry, First Out** - Use vaccines with the nearest expiration date first, not the oldest vial - Check expiry dates when restocking and when preparing vaccines - This prevents wasting vaccines and ensures potency 2. **Read the Vaccine Vial Monitor (VVM)** - A heat-sensitive label on each vial showing a color-changing square inside a ring - When the inner square becomes **as dark as or darker than the outer ring**, the vaccine has experienced excessive heat and must be **discarded immediately** - The VVM is a built-in safety mechanism—if the label says "discard," discard - VVM changes are IRREVERSIBLE; a darkened VVM means the vaccine is no longer safe 3. **The Shake Test for Freeze-Sensitive Vaccines** - If you suspect a freeze-sensitive vaccine (Penta, HepB, PCV, TT/Td) has been frozen, perform the shake test - **Procedure:** Gently shake the vial vigorously for a few seconds - **If frozen and thawed:** The vial shows visible flakes or sediment that settles to the bottom quickly and CANNOT be resuspended evenly when shaken - **Result:** Discard the vial immediately; it is unsafe and ineffective - **If normal:** The vaccine reconstitutes smoothly and suspension is even 4. **Reconstitution Times** - **Reconstituted BCG:** Use within 4 hours; keep on ice; discard any remainder at session end - **Reconstituted MCV/MMR:** Use within 6 hours; keep on ice; discard any remainder at session end - Keeping reconstituted vaccines on ice minimizes temperature fluctuation during a clinic session **Transport During Outreach:** - Use **vaccine carriers** (insulated containers) with pre-frozen ice packs - Place vaccines in the center of the carrier, surrounded by ice packs - Avoid direct contact of vaccines with ice packs (use cloth barriers) - Monitor temperature with a thermometer inside the carrier - Open the carrier minimally; long exposure reduces insulation efficiency - Return unused vaccines to the cold-chain refrigerator promptly **Common Cold-Chain Errors to Avoid:** - Storing vaccines in the refrigerator door (temperature fluctuates with door openings) - Freezing inactivated vaccines (Penta, IPV, TT, Hepatitis B) - Storing heat-sensitive vaccines in lower shelves near the freezer - Failing to read the VVM or ignoring a dark VVM - Not recording refrigerator temperature twice daily - Using old stock before new stock (not following FEFO) - Leaving vaccines outside the cold chain during immunization clinics (vaccines left on tables warm up quickly) - Overstocking the refrigerator (reduces air circulation and temperature stability)

The DOH routine childhood immunization schedule is built around critical contact points in infancy, each strategically timed to provide protection during high-risk periods. Understanding the schedule is fundamental to your practice as a midwife—you must know WHEN to give WHAT to WHOM, and why the timing matters. **Overview of the Schedule:** The schedule has three "heavy contact" phases: 1. **Birth phase:** BCG and Hepatitis B (within 24 hours) — immediate protection against vertical transmission and TB 2. **Early infancy phase (6, 10, 14 weeks):** Pentavalent, OPV, PCV — core protection against common childhood infections 3. **Mid-infancy phase (9 and 12 months):** Measles-containing vaccine and additional IPV — immunity boosting and second-antigen coverage **DETAILED SCHEDULE:** | **Age** | **Vaccine(s)** | **Protects Against** | **Key Notes** | |---|---|---|---| | **At Birth (within 24 hours)** | **BCG** (0.05 mL ID) + **Hepatitis B** (0.5 mL IM) | Tuberculosis; Hepatitis B (MTCT prevention) | **CRITICAL:** Hep B must be given within 24 hours to prevent mother-to-child transmission. Do not delay. | | **6 Weeks** | **Pentavalent 1** (0.5 mL IM) **OPV 1** (2 drops oral) **PCV 1** (0.5 mL IM) | Diphtheria, pertussis, tetanus, Hepatitis B, Haemophilus influenzae type b; Polio; Pneumococcus | First series of primary vaccines. Pentavalent combines DPT-HepB-Hib in one injection, reducing needle burden. | | **10 Weeks** | **Pentavalent 2** **OPV 2** **PCV 2** | (Second doses — same antigens) | Continuation of primary series. No new antigens; boosting immunity. | | **14 Weeks** | **Pentavalent 3** **OPV 3** **PCV 3** **IPV 1** (0.5 mL IM) | (Third Pentavalent/OPV/PCV doses); Inactivated Polio | Third primary dose of pentavalent, OPV, PCV. **IPV1 is introduced here** as part of the two-dose IPV strategy for polio eradication. IPV and OPV together provide enhanced polio protection. | | **9 Months** | **MCV1** (Measles-Containing Vaccine / MMR) (0.5 mL SC) **IPV 2** (0.5 mL IM) | Measles, Mumps, Rubella; Inactivated Polio (2nd dose) | **MCV1 at 9 months:** First measles-containing vaccine. Timing chosen because maternal antibodies are low, but infant's immune system is mature enough to respond. **IPV2 completes the two-dose IPV series.** | | **12 Months (1 Year)** | **MCV2** (Measles-Containing Vaccine / MMR) (0.5 mL SC) | Measles, Mumps, Rubella (second dose for seroconversion assurance) | **MCV2 at 12 months:** Booster dose of measles-containing vaccine. Two doses are required because a single dose does not guarantee seroconversion in all children. The 3-month interval (9–12 months) allows immune memory to develop. | **Understanding Key Vaccines in the Schedule:** **1. Pentavalent (DPT-HepB-Hib)** - **Combines five antigens** in a single injection: Diphtheria, Pertussis (whooping cough), Tetanus, Hepatitis B, and Haemophilus influenzae type b (Hib) - **Reduces injection burden:** Instead of separate DPT, HepB, and Hib injections, one pentavalent shot protects against all five - **Reduces anxiety:** Fewer injections mean less fear and better compliance - **Given as three primary doses** at 6, 10, and 14 weeks - **Route:** Intramuscular (vastus lateralis / anterolateral thigh) - **Dose:** 0.5 mL per injection - **Cold-chain requirement:** Freeze-sensitive; never freeze; use shake test if freezing suspected **2. OPV (Oral Polio Vaccine)** - **Type:** Live-attenuated poliovirus (Types 1, 2, 3) - **Route:** Oral (2 drops placed in the mouth) - **Schedule:** OPV 1 at 6 weeks, OPV 2 at 10 weeks, OPV 3 at 14 weeks - **Purpose:** Provides mucosal immunity in the gut; prevents wild poliovirus circulation in communities - **Cold-chain requirement:** MOST heat-sensitive; store on top shelf of refrigerator - **Special consideration:** OPV is given orally, so if a child vomits within 15 minutes, the dose may need to be repeated (check local protocols) **3. IPV (Inactivated Polio Vaccine)** - **Type:** Inactivated (killed) poliovirus; cannot cause polio even in immunocompromised children - **Route:** Intramuscular (vastus lateralis / anterolateral thigh) - **Dose:** 0.5 mL per injection - **Schedule in DOH:** IPV 1 at 14 weeks, IPV 2 at 9 months (two-dose approach) - **Why both OPV and IPV?** OPV provides community protection (herd immunity); IPV provides individual protection and is safer for immunocompromised children. Using both strengthens overall polio eradication strategy. - **Cold-chain requirement:** Freeze-sensitive; never freeze **4. BCG (Bacille Calmette-Guérin)** - **Type:** Live-attenuated Mycobacterium bovis - **Protects against:** Tuberculosis (especially severe forms like TB meningitis in young children) - **Route:** Intradermal (ID) — the ONLY intradermal vaccine in the schedule - **Dose:** 0.05 mL (a very small volume to inject just under the skin) - **Site:** Right upper arm / deltoid region - **Timing:** At birth (within 24 hours preferred, but can be given at any age if missed) - **Expected response:** A small induration (bump) at the injection site followed by a scar; this is NORMAL and indicates successful vaccination, not infection - **Cold-chain requirement:** Heat-sensitive; store on upper shelves; reconstituted BCG must be used within 4 hours **5. Hepatitis B (HBV)** - **Protects against:** Hepatitis B virus (HBV) - **Birth dose significance:** **Must be given within 24 hours of birth** to prevent mother-to-child transmission (MTCT), which occurs during delivery. A newborn born to a Hepatitis B-positive mother has a 90% risk of chronic infection if the birth dose is not given promptly. - **Route:** Intramuscular (vastus lateralis / anterolateral thigh) - **Dose:** 0.5 mL (birth dose), 0.5 mL (subsequent doses at 6, 10, 14 weeks as part of Pentavalent) - **Cold-chain requirement:** Freeze-sensitive; never freeze; use shake test if freezing suspected **6. PCV (Pneumococcal Conjugate Vaccine)** - **Protects against:** Streptococcus pneumoniae (causes pneumonia, meningitis, otitis media) - **Route:** Intramuscular (vastus lateralis / anterolateral thigh) - **Dose:** 0.5 mL per injection - **Schedule:** PCV 1 at 6 weeks, PCV 2 at 10 weeks, PCV 3 at 14 weeks - **Cold-chain requirement:** Freeze-sensitive; never freeze **7. Measles-Containing Vaccine (MCV) or MMR** - **Protects against:** Measles, and if MMR, Mumps and Rubella - **Type:** Live-attenuated virus - **Route:** Subcutaneous (SC) — NOT intramuscular; upper outer arm - **Dose:** 0.5 mL - **Schedule:** MCV1 at 9 months, MCV2 at 12 months - **Why two doses?** A single dose of measles vaccine seroconverts approximately 85–90% of vaccinated children. The second dose is given to ensure that the remaining 10–15% develop immunity. Two doses achieve >99% seroconversion. - **Timing rationale for 9 months:** By 9 months, maternal antibodies (from a vaccinated or immune mother) have waned enough that they don't interfere with the infant's response, yet the infant's immune system is mature enough to mount an effective response. - **Cold-chain requirement:** Heat-sensitive; store on upper shelves; reconstituted vaccine must be used within 6 hours **Key Timeline Points:** - **Birth to 6 weeks:** BCG, HepB birth dose given at birth; then waiting period for first Pentavalent/OPV/PCV clinic - **6 weeks to 14 weeks:** Three contacts spaced 4 weeks apart (6, 10, 14 weeks) — the "golden window" for primary immunization - **14 weeks to 9 months:** Gap in routine contacts; this is when defaulter tracking becomes critical - **9 months to 12 months:** Two more contacts for MCV doses; completion of primary series - **After 12 months:** Child should be fully or completely immunized; transition to booster schedules (if any) and school-entry vaccines **The Meaning of Timing:** The schedule is not random. Each age is chosen based on: - **Immune system maturity:** Infants are too young to respond at birth (except for BCG/HepB); by 6 weeks, they can respond to most vaccines - **Maternal antibody levels:** These wane over the first year; vaccines are timed to be given when maternal antibodies are low enough not to interfere - **Risk of disease:** The 6–14 week period is when infants become vulnerable to pertussis, polio, and pneumococcal disease; vaccines are timed to provide protection during this high-risk window - **Booster need:** By 9–12 months, primary doses have induced some immunity; booster doses (MCV, IPV) enhance and solidify this protection

Administering a vaccine correctly is as important as giving it on time. A wrong route, wrong site, or poor technique can render a vaccine ineffective or cause harm. As a midwife, you are trusted with a child's health; precision in administration is non-negotiable. **ADMINISTRATION QUICK REFERENCE TABLE:** | **Vaccine** | **Dose** | **Route** | **Site** | **Special Notes** | |---|---|---|---|---| | **BCG** | 0.05 mL | Intradermal (ID) | Right upper arm (deltoid) | Only ID vaccine; creates a wheal; scar is expected | | **Hepatitis B (birth dose)** | 0.5 mL | Intramuscular (IM) | Anterolateral thigh (vastus lateralis) | Must be given within 24 hours of birth | | **Hepatitis B (with Pentavalent)** | 0.5 mL (in Penta) | IM | Anterolateral thigh | No separate HepB needed 6–14 weeks; it's in Pentavalent | | **Pentavalent (DPT-HepB-Hib)** | 0.5 mL | IM | Anterolateral thigh (vastus lateralis) | Five-in-one; gives at 6, 10, 14 weeks | | **PCV (Pneumococcal Conjugate)** | 0.5 mL | IM | Anterolateral thigh (vastus lateralis) | Given at 6, 10, 14 weeks | | **IPV (Inactivated Polio)** | 0.5 mL | IM | Anterolateral thigh (vastus lateralis) | Given at 14 weeks and 9 months | | **OPV (Oral Polio Vaccine)** | 2 drops | Oral | Mouth (depressed on tongue or buccal mucosa) | Given at 6, 10, 14 weeks; no IM route | | **MCV1 (Measles, 9 months)** | 0.5 mL | Subcutaneous (SC) | Upper outer arm (not IM) | Subcutaneous, NOT intramuscular | | **MCV2 (Measles, 12 months)** | 0.5 mL | SC | Upper outer arm (not IM) | Subcutaneous, NOT intramuscular | **DETAILED ADMINISTRATION TECHNIQUE:** **1. BCG (Bacille Calmette-Guérin) — Intradermal Route** *Why intradermal?* BCG is a live vaccine that needs to replicate in the skin to induce a strong local and systemic immune response. Intradermal placement ensures the antigen stays in the dermis where it can be recognized by immune cells. *Procedure:* - Site: Right upper arm, deltoid region (anatomical landmark: top third of the upper arm) - Position: Infant sitting on parent's lap or on a flat surface; arm extended and externally rotated - Needle: 26-gauge, 10 mL syringe (sometimes a 1 mL tuberculin syringe is used for precision) - Angle: Hold the syringe at a **very shallow angle (nearly parallel to the skin surface, about 15 degrees)** - Insertion: Pierce the skin and insert the needle just beneath the epidermis into the dermis; the bevel should be visible under the skin (don't push in too far) - Injection: Slowly inject 0.05 mL — this is a VERY SMALL VOLUME - Observation: A small **wheal** (raised bump, about 6–10 mm diameter) appears at the injection site immediately; this is CORRECT and EXPECTED - Do NOT massage or rub the site; let it air dry - Do NOT apply a bandage (it promotes infection; the BCG needs to drain and crust over) *Expected Response After BCG:* - **1–2 weeks:** Wheal at injection site; may become slightly red or itchy - **2–4 weeks:** Induration (firmness) develops; may develop a small pustule (pus-filled bump) or crust - **4–8 weeks:** Pustule may drain slightly; a small scab forms - **8–12 weeks:** Scab falls off, leaving a **characteristic scar** (usually 5–10 mm) *What this means:* The scar is PROOF that BCG "took" (successfully infected the skin and stimulated immunity). Do NOT treat the scar as an infection or problem. Parents must be counseled that the scar is normal and protective. *If no response by 12 weeks?* The child may need revaccination; discuss with your supervisor or refer to the RHU. **2. Intramuscular Injections (IM) — Vastus Lateralis Site (Anterolateral Thigh)** *Which vaccines are IM?* Hepatitis B, Pentavalent, PCV, IPV, and any other inactivated vaccines. *Why the anterolateral thigh in infants?* - **Large muscle mass:** The vastus lateralis is the largest, most developed muscle in infants; IM injections here are absorbed reliably - **Avoids nerves:** Unlike the gluteal (buttock) region, the vastus lateralis does NOT overlie major nerves; risk of sciatic nerve injury is eliminated - **Avoids fat layer:** The buttock has more adipose tissue, which impairs vaccine absorption and effectiveness - **Accessibility:** Easy to access and visualize; parents can hold the infant comfortably *Anatomical landmark for vastus lateralis:* - Divide the infant's thigh into thirds from hip to knee - The **middle third, on the lateral (outer) side** of the thigh is the injection site - Avoid the medial (inner) thigh, which has major blood vessels - Avoid the lower third (above the knee), which has less muscle mass *Procedure for IM injection:* - Positioning: Infant lying on their back or sitting; thigh flexed at hip and knee (not extended) - Skin prep: Clean the skin with an alcohol swab; let it dry (wet alcohol causes discomfort and reduces effectiveness) - Needle: 25-gauge, 5/8-inch needle for infants (adequate length to reach muscle, short enough to avoid deeper structures) - Angle: Insert at **90 degrees (perpendicular) to the skin surface** - Insertion: Advance the needle about 5/8 inch deep (to the middle of the muscle); the needle should be fully inserted - Aspiration: OPTIONAL but acceptable — gently pull back the syringe plunger slightly to check for blood. If blood enters the syringe, withdraw the needle, discard, and use a new syringe at a different site (this avoids IV administration). If no blood, proceed. - Injection: Inject the full 0.5 mL slowly (over 5–10 seconds) — quick injection causes pain and tissue trauma - Withdrawal: Remove the needle quickly; apply gentle pressure with a dry gauze (no rubbing) - Observation: No wheal should form; a small area of redness may appear briefly *Common IM Errors to Avoid:* - Using the gluteal region (buttock) — risk of sciatic nerve injury and poor absorption - Injecting at an angle instead of perpendicular — risks missing the muscle - Using too long a needle — risks hitting bone or deeper structures - Not allowing alcohol to dry — causes discomfort and reduced effectiveness - Injecting into the medial (inner) thigh — risk of hitting the femoral artery - Rubbing or massaging the site after injection — increases local inflammation **3. Subcutaneous Injections (SC) — Upper Outer Arm** *Which vaccines are SC?* Measles-containing vaccines (MCV/MMR) *Why subcutaneous?* Measles vaccine is given SC to induce strong systemic immunity; the tissue layer under the skin (subcutaneous tissue) is an ideal depot for immune activation. *Procedure for SC injection:* - Site: Upper outer arm, in the area between shoulder and elbow, on the lateral (outer) surface - Positioning: Infant's arm relaxed or held by parent; no need to flex muscles - Skin prep: Clean with alcohol swab; let dry - Needle: 25-gauge, 5/8-inch needle - Angle: Insert at a **45-degree angle** to the skin surface (not perpendicular like IM) - Insertion: Advance about 1/4 to 1/2 inch into the subcutaneous tissue (just below the skin, but not into muscle) - Injection: Inject 0.5 mL slowly; do NOT aspirate (SC injections rarely hit blood vessels) - Withdrawal: Remove quickly; gentle pressure with gauze - Observation: A small bump (bleb) may form at the site; it resolves within minutes *SC vs. IM Error:* Do NOT give MCV (measles) as IM. Giving SC vaccine by IM route may cause more local reaction. Always use the SC route for measles-containing vaccines. **4. Oral Administration — OPV** *Route:* Oral; 2 drops placed in the mouth *Procedure:* - Preparation: Hold the dropper bottle upright; dispense 2 drops - Administration: Place the drops directly into the infant's mouth — on the tongue or in the buccal mucosa (cheek pouch); do NOT put drops on the lips (they may drip off) - Swallowing: Allow the infant to swallow; do NOT administer water to wash it down - Timing: If the infant vomits within 15 minutes, re-dosing may be needed (check local protocol); vomiting after 15 minutes is unlikely to affect absorption - Documentation: Record OPV 1, 2, or 3 as appropriate *OPV Special Considerations:* - No needle anxiety (advantage over injectable vaccines) - Cannot be given if infant has a cleft palate (drops may pool and not be swallowed) - Avoid administration if infant is actively vomiting or has severe diarrhea (may not be absorbed) **5. Multi-Vaccine Administration at One Visit** A key principle: **Give all vaccines due at a visit in the same session, in DIFFERENT SITES.** *Why?* - Reduces the number of return visits (better for busy families) - Completes the schedule on time (reduces defaulting) - Vaccines do not interfere with each other *How to administer multiple vaccines:* - Site 1 (IM): Right anterolateral thigh — give Pentavalent and PCV (two separate injections, but in the same thigh since they are both IM) - Site 2 (Oral): Mouth — give OPV (2 drops) - If IPV is due (at 14 weeks): Can be given IM in right thigh alongside Pentavalent/PCV, OR in left thigh if three IM vaccines are too much for one thigh - If MCV is due (at 9 months): Give SC in the upper outer arm (different site from IM vaccines) *Spacing of injections:* At least 2–3 cm apart (about one finger width) so that local reactions do not overlap. **6. Syringe and Needle Safety — Auto-Disable Syringes** *Standard in the EPI:* - Use a **new sterile auto-disable syringe for every dose** - **One needle, one child** — never reuse syringes or needles - Auto-disable syringes have a plunger mechanism that retracts or locks after injection, preventing reuse *Procedure:* - Open syringe and needle from sterile packaging immediately before use - Draw vaccine into the syringe - Administer to the child - Do NOT recap the needle (recapping causes needle-stick injuries) - Immediately drop the entire syringe (with needle attached) into a sharps collector box (a puncture-resistant container with a biohazard label) - NEVER put hands back into the sharps box *Why auto-disable syringes?* - Eliminate reuse of syringes and needles - Prevent transmission of blood-borne pathogens (HIV, Hepatitis B, Hepatitis C) through shared needles - Are safe and cost-effective **7. Dose Precision — Never Reduce or Split Doses** The doses listed in the schedule (0.05 mL for BCG, 0.5 mL for others) are **tested and proven to generate protective immunity**. You MUST give the FULL DOSE. *Why not reduce a dose?* - A smaller dose may not stimulate enough immune response to create lasting protection - The child appears vaccinated on paper but is actually unprotected - This is a form of "silent failure" — worse than no vaccination at all *Why not split doses?* - If you split one vaccine dose between two children (e.g., 0.25 mL each of a 0.5 mL dose), each child receives a partial dose and neither achieves full immunity - This is unsafe and violates the standard of care *Guidance:* - If you accidentally give less than the full dose, the child must be revaccinated at a later date (with the correct full dose) - Do not attempt to adjust or "make up" a partial dose by giving extra vaccine at the next visit **Reconstituted Vaccine Handling:** Some vaccines (BCG and measles-containing vaccines) come as a **lyophilized (freeze-dried) powder** and must be reconstituted with **sterile diluent (distilled water)** just before use. *BCG Reconstitution:* - Use only the diluent provided by the manufacturer - Aseptically inject the diluent into the vaccine vial - Gently swirl (do NOT shake vigorously) to dissolve the powder - The solution becomes a milky suspension - **Use within 4 hours of reconstitution** - Keep the reconstituted vial on ice during the clinic session - **Discard any unused reconstituted BCG at the end of the session** (do NOT save for the next session) *Measles/MMR Reconstitution:* - Use only the diluent provided - Aseptically inject diluent into the vaccine vial - Gently swirl to dissolve - **Use within 6 hours of reconstitution** - Keep on ice - **Discard unused reconstituted vaccine at the end of session** *Why the strict time limits?* - Once reconstituted, the live virus begins to lose potency - The clock starts from reconstitution, not from time of first use - Keeping on ice slows deterioration but does not stop it **Injection Safety Summary:** - BCG: 0.05 mL intradermal, right upper arm, raises a wheal, leaves a scar (normal) - IM vaccines: 0.5 mL, anterolateral thigh, 90-degree angle, never the buttock - SC vaccines (measles): 0.5 mL, upper outer arm, 45-degree angle - OPV: 2 drops oral, in the mouth - One new auto-disable syringe per vaccine dose; discard immediately after use - Give all due vaccines at one visit in different sites - Never reduce, split, or adjust doses - Full dose = full protection

A major public health failure is the **missed opportunity** — when a child is turned away from vaccination for a reason that is not actually a contraindication. A child with a minor illness, malnutrition, or fever is often told to "come back when you are feeling better," and many never return. Understanding which conditions are TRUE contraindications (and which are FALSE) protects children from preventable disease. **The Reality of Contraindications:** True contraindications to immunization are surprisingly few and mostly involve severe allergic reactions or profound immunodeficiency. Most of the conditions that parents and even some health workers believe are contraindications are actually NOT barriers to vaccination. The DOH and WHO guidance is clear: **it is safe and often MORE important to vaccinate a sick child** because ill children are at higher risk of serious infection. **TRUE (GENUINE) CONTRAINDICATIONS:** **1. Anaphylaxis to a Previous Dose of the Same Vaccine** *What is anaphylaxis?* A severe, immediate allergic reaction occurring within minutes to hours of receiving a vaccine. Signs include: - Difficulty breathing or wheezing - Severe swelling of lips, tongue, or throat (angioedema) - Rapid or weak pulse - Collapse or loss of consciousness - Widespread rash or hives - Severe vomiting or diarrhea *Action:* If a child had a true anaphylactic reaction to a previous dose of a vaccine, that specific vaccine is NOT given again. HOWEVER: - Anaphylaxis is extremely rare with modern vaccines - Most "reactions" reported as anaphylaxis are actually vasovagal syncope (fainting) or anxiety - Immunization clinics must have emergency equipment and trained staff (adrenaline/epinephrine, antihistamines) to manage true anaphylaxis if it occurs - A child with a history of anaphylaxis to one vaccine may still receive other vaccines, just not the one that caused the reaction **2. Anaphylaxis to a Vaccine Component** *Common components:* - **Egg protein:** Some vaccines (especially measles/MMR) are grown in egg cultures. A child with severe egg allergy may have anaphylaxis to measles vaccine. - **Gelatin:** Used as a stabilizer in some vaccines; rare allergen - **Neomycin:** An antibiotic used in vaccine production; rare allergen *Action:* If a child has a documented history of anaphylaxis to a vaccine component, they should not receive vaccines containing that component. However: - Most children with egg allergy tolerate measles vaccine (even if allergic to eggs) - True severe allergy to vaccine components is rare - The benefits of vaccination usually outweigh the small risk - Vaccination in a clinical setting with emergency equipment is safer than leaving the child unvaccinated **3. Severe Reaction to DPT/Pentavalent (Pertussis-Specific)** *What is a "severe reaction"?* Rare neurological complications associated with the pertussis (whooping cough) component: - **Encephalopathy** (brain inflammation) — seizures, persistent crying, or altered consciousness within days of DPT - **Guillain-Barré syndrome** (very rare nerve paralysis) *Action:* If a child had a documented severe neurological reaction (specifically encephalopathy) to a previous DPT or Pentavalent dose, further **pertussis-containing doses are NOT given**. However: - The child may still receive the DT (diphtheria-tetanus) components without the pertussis part (if a DT-only formulation is available — though not routine in the Philippine EPI) - These severe reactions are extremely rare - The decision to withhold further pertussis vaccination should be made by a physician, not by you as a nurse - In the Philippines, if a child has a documented severe reaction to Pentavalent, you REFER to the RHU or hospital for physician evaluation before deciding on further DPT doses **4. Live Vaccine in a Child with Symptomatic HIV/AIDS (Clinical AIDS)** *BCG and measles are LIVE vaccines*. They replicate mildly in the vaccinee's body to induce immunity. In a severely immunocompromised child, a live vaccine can spread beyond the injection site and cause disseminated disease. *What is "clinical AIDS"?* A child with: - CD4 count <200 cells/mm³ (very low; indicates severe immunosuppression) - Severe opportunistic infections (PCP, CMV, disseminated TB) - Severe malnutrition with developmental delay - Clinical signs of symptomatic HIV: chronic diarrhea, failure to thrive, lymphadenopathy, hepatosplenomegaly *Action:* - **BCG is NOT given to a child with clinical (symptomatic) AIDS** - **Measles (MCV) may be deferred until immune reconstitution** (after CD4 count rises on antiretroviral therapy) - **Other vaccines (inactivated: Pentavalent, IPV, Hepatitis B, PCV)** are STILL GIVEN because they are not live and pose no risk - **OPV (live oral polio vaccine)** is also not given to a child with clinical AIDS - As a midwife, you identify signs of severe immunodeficiency (failure to thrive, severe infections, developmental delay) and REFER the child to the RHU or pediatrician before vaccinating - If a child has HIV but is asymptomatic (no clinical signs), and CD4 count is above the threshold, all vaccines (including live) are safe and SHOULD be given *In the Philippine context:* - HIV testing in children is not routine at the BHS - Most children presenting for vaccination are not known to have HIV - Signs of clinical AIDS (severe malnutrition, failure to thrive, recurrent infections) may trigger a REFERRAL to the RHU for evaluation, but this is not a contraindication to vaccination in the BHS—the evaluation happens before vaccination - Asymptomatic HIV-positive children (on antiretroviral therapy and thriving) receive all vaccines normally **FALSE CONTRAINDICATIONS — CONDITIONS THAT ARE NOT BARRIERS TO VACCINATION:** **1. Mild to Moderate Illness (Low-Grade Fever, Cough, Cold, Mild Diarrhea)** *Why it's not a contraindication:* - A mildly ill child's immune system is "primed" and may respond even better to vaccine - Delaying vaccination until the child is completely well risks missing the vaccine dose - Mild illness is common in childhood; waiting for a "perfect health" state delays immunization indefinitely - The vaccine does not worsen a mild illness *WHO and DOH guidance:* Vaccinate the child AS SCHEDULED, even with: - Mild fever (up to 37.5°C or 99.5°F) - Cough or rhinorrhea (runny nose) - Mild diarrhea (1–2 stools per day) - Mild rash - Mild ear infection *Action:* Assess the child briefly for signs of serious illness (see below). If the child is alert, active, and eating, vaccinate. Do not postpone unless the illness is severe. **2. High Fever (Even Fevers >39°C / 102°F)** *Common misconception:* "The child has a high fever; let's wait until it comes down." *The reality:* Even high fever itself is NOT a contraindication. HOWEVER, a **very high fever may indicate a serious underlying infection** (like pneumonia or meningitis), and the child should be evaluated and treated first. *How to decide:* - **Fever + child appears well, active, eating, alert:** Vaccinate. Fever from teething, mild viral illness, or teething is not a barrier. - **Fever + child appears ill, lethargic, refusing food, pale, or has other danger signs:** Refer the child to the RHU or physician for evaluation BEFORE vaccinating. The fever itself is not the barrier; you are referring for the underlying illness. *Guidance:* Fever is a sign of the body's immune response to infection or inflammation. Giving a vaccine to a child with mild fever does not hurt the child and does not reduce the vaccine's effectiveness. **3. Malnutrition** *Common misconception:* "The child is malnourished; let's wait until nutrition improves." *The reality:* Malnutrition is NOT a contraindication. In fact, **malnourished children NEED vaccines even MORE** because they are at higher risk of severe infection. *Why:* - A malnourished child's immune system is weakened and cannot fight off infections as well - Vaccines help protect malnourished children during this vulnerable period - Delaying vaccination worsens the child's risk - Vaccination does not harm a malnourished child - Vaccines are effective in malnourished children, though the immune response may be slightly lower *Action:* Vaccinate the malnourished child on schedule. Simultaneously, refer the family for nutritional support (to the Barangay Nutrition Scholar, mother-child health program, or feeding program). Do NOT use malnutrition as an excuse to delay vaccines. **4. Prematurity and Low Birth Weight** *Common misconception:* "The baby was born early/small; let's wait until she catches up." *The reality:* Premature and low birth weight infants are vaccinated on their **chronological age (age since birth)**, NOT corrected age. *Example:* A baby born 2 months early is still vaccinated at 6 weeks of chronological age (not at corrected age of 4 weeks). This ensures timely protection during the critical early months. *Special consideration for birth dose:* - Hepatitis B and BCG birth doses are still given at birth, regardless of prematurity - These vaccines are not withheld because the baby is small *Action:* Premature infants follow the standard EPI schedule based on chronological age. **5. Breastfeeding** *Common misconception:* "The baby is breastfeeding; vaccines might hurt the milk or the baby won't tolerate them." *The reality:* Breastfeeding does NOT interfere with vaccines. In fact: - Breast milk provides some passive immunity, making vaccines even MORE important as active protection - Breastfeeding is the optimal nutritional status and makes vaccination even safer - No vaccine needs to be delayed because the child is breastfeeding *Action:* Vaccinate breastfeeding infants on schedule. Breastfeeding can continue immediately before and after vaccination. **6. Recent Infection or Recovery from Illness** *Common misconception:* "The child just got over a cold; let's wait a week or two before vaccinating." *The reality:* A child recovering from recent infection can be vaccinated safely. *When to vaccinate after recent illness:* - **Mild viral illness (cold, mild diarrhea):** Vaccinate immediately; do not wait - **Moderate illness (pneumonia treated at home, gastroenteritis):** Vaccinate as soon as the child is improving - **Severe illness (hospitalized for sepsis or severe pneumonia):** Once discharged and stable, vaccinate at the next routine visit *Why:* The immune system is activated after fighting off infection, and vaccination during this "primed" state may result in a stronger immune response. **7. Antibiotics** *Common misconception:* "The baby is on antibiotics; let's wait until the course is finished." *The reality:* Being on antibiotics is NOT a contraindication. Antibiotics do not interfere with vaccine effectiveness. Vaccinate while on antibiotics. *Exception:* **Live vaccines (BCG, OPV, measles) are best NOT given while on certain immunosuppressive antibiotics** (very rare), but routine antibiotics for common infections are fine. If you are unsure, ask the pharmacist or physician, but do not delay routine vaccination. **8. Family History of Allergies or Reactions** *Common misconception:* "The child's sibling had a reaction to a vaccine; maybe we should skip this child." *The reality:* Family history does NOT predict an individual child's response. Each child is vaccinated individually, and reactions are rare. *Action:* Vaccinate the child. Having a sibling with a rare vaccine reaction does not mean this child will have the same reaction. Observe the child for 15–30 minutes after vaccination (standard practice) and you will detect any rare immediate reaction. **9. Jaundice or Hyperbilirubinemia** *Common misconception:* "The newborn has jaundice; let's delay vaccines until bilirubin is treated." *The reality:* Jaundice is NOT a contraindication to birth vaccines (BCG, Hepatitis B). The birth doses are STILL GIVEN. *Why:* Jaundice does not affect the baby's ability to mount an immune response. In fact, delaying Hepatitis B birth dose increases the risk of mother-to-child transmission if the mother is Hepatitis B-positive. *Action:* Vaccinate with BCG and Hepatitis B at birth, even if the baby is jaundiced. The baby can receive phototherapy or other treatment for jaundice simultaneously. **10. Concurrent Vaccinations and Other Medical Treatments** *Common misconception:* "The baby needs a blood test today; let's skip vaccines so we don't stress the baby." *The reality:* Multiple procedures on the same day are acceptable. Multiple needle sticks do not contraindicate vaccination. *Action:* Vaccinate as scheduled. If blood tests or other procedures are needed, they can be done at the same visit. **SUMMARY TABLE: TRUE vs. FALSE CONTRAINDICATIONS** | **Condition** | **True Contraindication?** | **Action** | |---|---|---| | Anaphylaxis to prior dose of same vaccine | **YES** | Do not repeat that vaccine; refer for physician evaluation | | Anaphylaxis to vaccine component | **YES** | Avoid vaccines with that component; refer for evaluation | | Severe neurological reaction (encephalopathy) to DPT/Pentavalent | **YES** | Refer for physician evaluation before further pertussis doses | | Clinical (symptomatic) AIDS/severe immunodeficiency | **YES (for live vaccines only)** | Defer BCG and OPV; inactivated vaccines still given; refer for evaluation | | Mild fever (up to 37.5°C) | **NO** | Vaccinate as scheduled | | High fever (>39°C) with serious signs | **NO (fever itself is not a barrier)** | Evaluate for serious illness; if serious, refer first, then vaccinate after treatment | | Malnutrition | **NO** | Vaccinate; refer for nutritional support | | Prematurity/low birth weight | **NO** | Vaccinate by chronological age | | Breastfeeding | **NO** | Vaccinate; breastfeeding can continue | | Recent infection/recovery | **NO** | Vaccinate as soon as improving | | On antibiotics | **NO** | Vaccinate; antibiotics do not interfere | | Family history of allergy or reaction | **NO** | Vaccinate this child individually | | Jaundice | **NO** | Vaccinate with BCG and Hepatitis B at birth | | Concurrent procedures or blood tests | **NO** | Vaccinate; other procedures can be done same day | **The Missed Opportunity Concept:** In many low-resource settings, the biggest threat to vaccination coverage is not a contraindication—it is a **missed opportunity**. A child comes to the health center for an unrelated reason (diarrhea, cough, or follow-up care) but is not vaccinated because of a false belief that the child is "not well enough." The child leaves unvaccinated. Weeks later, no follow-up occurs, and the child misses the opportunity to be protected. **Your Role as a Midwife:** - Screen every child for TRUE contraindications (rare) - Recognize FALSE contraindications and vaccinate anyway - Make every encounter an opportunity to advance a child's immunization status - Counsel parents that mild illness is NOT a reason to delay vaccination - Refer genuinely concerning signs (severe illness, suspected immunodeficiency) to the physician, but do not let fear of rare complications prevent routine vaccination

An immunization record exists for one reason: to know which children are protected and which children are not. A vaccine given but not recorded is as good as a vaccine not given at all—because you will not know to follow up when the next dose is due. Recording and tracking are the "paperwork" side of immunization, but they are as critical as the vaccines themselves. Without accurate records, vaccination coverage falls, immunity gaps open, and disease resurges. As a midwife at the BHS, you are responsible for: 1. Recording every vaccine dose on **two places**: the child's individual immunization card AND the Target Client List (TCL) at the health center 2. Tracking children who miss appointments (defaulters) 3. Following up defaulters through home visits and community outreach 4. Understanding the two key measures of immunization coverage **THE IMMUNIZATION CARD: The Child's Personal Record** *What is it?* A small card, given to the child's mother at or soon after birth, that documents every vaccine the child receives. The card is **kept by the mother** and brought to every health visit. *What goes on it?* - Child's name, date of birth, sex, and identification number - Mother's name and address - Dates of each vaccine received - Name of vaccine, dose, route, site, and batch number - Health worker's initials or signature - Any adverse events or notes *Your responsibility:* - **Record immediately** after giving the vaccine (do not delay; you may forget details) - **Use legible writing** in black or blue pen (not pencil; pencil fades) - Record the **full date** (day, month, year) - Record the **vaccine name, dose, route, and site** (e.g., "Pentavalent 0.5 mL IM, right thigh") - Record the **batch number** of the vaccine vial (important for traceability if a batch has issues) - **Sign or initial** the entry - Handle the card with care (do not fold or damage it; it is a legal record) - **Counsel the mother** to keep the card safe and bring it to every visit *Why the card matters:* - It is the mother's proof that the child is vaccinated - It is used at school enrollment to confirm immunization status - It is a legal record if questions arise about vaccination - It helps the family remember which vaccines were given and when the next dose is due - It enables any health worker (at any facility) to see what the child has received and what is missing **THE TARGET CLIENT LIST (TCL): The Health Center's Registry** *What is it?* A systematic list kept at the BHS/RHU that records all infants in the barangay and their immunization status. It is called the "Target Client List" because these children are the "target" for immunization coverage. *How is it set up?* - **One row per child**, with columns for: - Child's name, date of birth, address - Each vaccine (BCG, HepB birth dose, Penta 1/2/3, OPV 1/2/3, PCV 1/2/3, IPV 1/2, MCV1, MCV2) - Column for "Date Received" for each vaccine (filled in when given) - Column for "Status" (Received, Due, Defaulted, Not Reached) - **Master list by age group:** A TCL for "0–2 months" might have children due for birth vaccines and 6-week doses; a "3–5 months" list has children due for 10-week vaccines, etc. - **Updated monthly or quarterly** as new cohorts of infants are born *How it's used:* - **Clinic preparation:** Before each immunization session, you review the TCL to see which children are due - **Session record:** As you vaccinate children, you mark the date on the TCL - **Identifying defaults:** After a scheduled clinic date, children who did not appear are marked as "defaulted" on the TCL - **Performance tracking:** The TCL is used to calculate vaccination coverage (how many children received each vaccine by a target age) *Your responsibility at the BHS:* - **Maintain the TCL** — keep it updated with current infant cohorts - **Record doses as given** — every vaccination session, update the TCL to reflect which children were vaccinated - **Identify defaulters** — after a scheduled clinic, review the TCL to see which children were due but did not appear - **Submit data to FHSIS** — the Field Health Services Information System, which is DOH's national health data platform **FIELD HEALTH SERVICES INFORMATION SYSTEM (FHSIS)** *What is FHSIS?* The national health information system that collects data from all RHUs and health centers in the Philippines. It tracks vaccinations, maternal health, disease surveillance, and other health indicators at the barangay and municipal levels. *Your role:* - You do not enter data into FHSIS directly; your supervisor (RHU nurse or health center coordinator) inputs data from your TCL - Your accurate TCL is the SOURCE data that flows into FHSIS - Data from FHSIS is used by DOH to assess coverage, identify low-performing areas, and allocate resources **VACCINATION COVERAGE INDICATORS: FIC and CIC** Two key indicators measure how well the immunization program is working in your area: **1. Fully Immunized Child (FIC)** *Definition:* A child who received all required antigens **before reaching 12 months (one year) of age**. *Required antigens for FIC status:* 1. **BCG** — 1 dose (at birth) 2. **Hepatitis B** — 3 doses (birth dose + doses in Pentavalent at 6, 10, 14 weeks) 3. **DPT (Diphtheria, Pertussis, Tetanus)** — 3 doses (via Pentavalent at 6, 10, 14 weeks) 4. **Haemophilus influenzae type b (Hib)** — 3 doses (via Pentavalent at 6, 10, 14 weeks) 5. **OPV (Polio)** — 3 doses (at 6, 10, 14 weeks) 6. **PCV (Pneumococcal Conjugate Vaccine)** — 3 doses (at 6, 10, 14 weeks) 7. **Measles-containing vaccine (MCV)** — **1 dose** (either MCV1 at 9 months OR MCV2 at 12 months) *Timing:* All these antigens must be received **by the child's first birthday (before 12 months of age)**. *Example of an FIC child:* - Born June 15, 2023 - BCG + HepB at birth (June 15) ✓ - Pentavalent 1 + OPV 1 + PCV 1 at 6 weeks (late July) ✓ - Pentavalent 2 + OPV 2 + PCV 2 at 10 weeks (late August) ✓ - Pentavalent 3 + OPV 3 + PCV 3 + IPV 1 at 14 weeks (late September) ✓ - MCV1 at 9 months (March 2024) ✓ - **By the child's first birthday (June 15, 2024), all required antigens have been given.** - **This child is FIC.** *FIC target:* The DOH aims for 90%+ FIC coverage in all municipalities. High FIC coverage means most children are protected on time during the critical first year when infections are most dangerous. **2. Completely Immunized Child (CIC)** *Definition:* A child who received all required antigens **by 23 months of age (within the first two years), regardless of whether all doses were on-time**. *Key difference from FIC:* CIC includes children who missed doses during the first year but caught up later. *Example of a CIC (but not FIC) child:* - Born June 15, 2023 - Missed the 6-week and 10-week clinics (defaulted) - Caught up at 6 months with Pentavalent doses and OPV/PCV - Received all antigens by 18 months of age (well before 23 months) - **By the child's second birthday, all required antigens have been given.** - **This child is CIC, but NOT FIC** (because not all antigens were completed by the first birthday) *CIC target:* DOH aims for 95%+ CIC coverage, ensuring that even children who miss early appointments still receive complete protection by their second birthday. *Why CIC is higher than FIC:* CIC is easier to achieve because late vaccination is still accepted. The goal, though, is to make every child an FIC, because on-time protection is better than late protection. **FIC and CIC Calculation:** *Formula:* - **FIC % = (Number of children aged 0–11 months who are fully immunized) / (Total target children in that age group) × 100** - **CIC % = (Number of children aged 12–23 months who are completely immunized) / (Total target children in that age group) × 100** *Example:* In a barangay with 200 infants aged 0–11 months (FIC cohort), 165 children have received all antigens on time. - **FIC % = 165 / 200 × 100 = 82.5%** If the same barangay has 180 infants aged 12–23 months, and 170 have received all antigens (some late, but by 23 months): - **CIC % = 170 / 180 × 100 = 94.4%** **DEFAULTER TRACKING: Bringing the Missed Children Back** *Who is a defaulter?* A child who was due for a vaccine dose (based on the EPI schedule) but did not appear at the scheduled clinic. *Why defaulters matter:* - A child with a missed dose is temporarily unprotected against one or more diseases - The longer the default, the higher the risk of disease - If many children default, herd immunity in the community breaks down, and outbreaks can occur *How you identify defaulters:* 1. **After each immunization session,** review the TCL: - Which children were scheduled to come? - Who actually came and was vaccinated? - Who was due but did not appear? 2. **Mark the TCL** to show "Defaulted" for children who did not come 3. **Set a follow-up timeframe:** - If a child misses a dose, contact the family within **1–2 weeks** of the missed appointment - Do not wait months to follow up; the child's health is at risk *How you track down defaulters:* **Home Visits (First-Line Follow-Up):** - Visit the child's home address (from the TCL or immunization card) - Speak with the mother or guardian - Ask why the child missed the clinic (obstacle: distance? busy schedule? lost card? did not know the appointment date?) - Explain the importance of the next dose - Offer to schedule a follow-up appointment or refer the mother to an outreach clinic in her area - Document the visit and outcome on the TCL **Community Health Worker / Barangay Health Worker (BHW) Support:** - If you cannot reach the family directly, contact the Barangay Health Worker (BHW) assigned to that area - Ask the BHW to identify the family and encourage them to attend the next clinic - BHWs know their neighborhoods well and can be effective advocates **Outreach / Mobile Clinics:** - Some barangays conduct "outreach" immunization sessions in remote sitios (small communities) where access to the RHU/BHS is difficult - Identify common barriers to vaccination (far distance, busy farming season) and schedule outreach to reach those families **Reminder Systems:** - Post announcements in the barangay about upcoming immunization clinics - Distribute flyers or send SMS reminders to mothers (if available) - Mark immunization dates prominently on the community bulletin board **Addressing Barriers:** - **Distance:** Conduct outreach clinics in remote areas or partner with BHWs to reduce travel burden - **Lack of knowledge:** Counsel parents on the importance and timing of vaccines; dispel myths - **Lost immunization card:** Reconstruct vaccination history from the TCL and reissue a new card - **Mistrust or vaccine hesitancy:** Listen to concerns; provide accurate information; involve community leaders to build trust - **Busy schedule:** Offer flexible clinic times (evening or weekend sessions) to accommodate working parents **CONTINUING A SERIES AFTER DEFAULT: Never Restart** A critical principle: **When a child returns after missing one or more doses, you give the NEXT DUE DOSE, regardless of how much time has passed. You DO NOT restart the series from the beginning.** *Example:* - A child was due for Pentavalent 2 at 10 weeks but missed it - The child returns at 6 months old (very late) - You do NOT give Pentavalent 1 again - You give Pentavalent 2 (the next due dose in the series), then schedule Pentavalent 3 for 4 weeks later *Why?* - Restarting delays completion and increases risk of default again - The child has partial immunity from any prior doses and benefits from continuing the series - Spacing between doses matters less than overall series completion *Exception:* If more than **5 years** have passed since the last dose of a series, some experts recommend restarting (though this is rare in the first-year EPI). For practical purposes in the Philippines, continue the series. **YOUR TCL AND FOLLOW-UP WORKFLOW: A Day in the Life** *Monday: Clinic Day* 1. Review the TCL in the morning: 25 children are due for 6-week vaccines today 2. Record which children show up and which vaccines you give 3. 18 children arrive and are vaccinated; 7 do not appear 4. You record the dates on the TCL and mark 7 as "Defaulted" *Wednesday: Follow-Up* 1. You review the 7 defaulters and plan home visits 2. You visit 4 homes in your catchment area; families say they forgot or thought clinic was on Thursday 3. You reschedule them for the next clinic session (a week later) 4. You ask the BHW to visit the remaining 3 homes 5. You update the TCL with follow-up notes *Next Monday: Re-Clinic* 1. From last week's 7 defaulters, 5 show up; you vaccinate them 2. 2 are still absent; you mark them again for follow-up 3. You continue follow-up until all children are vaccinated or are referred for home-based vaccination if access is severely limited *Monthly Data Submission:* 1. At the end of the month, you tally the TCL data: FIC status, coverage percentages, defaulter rate 2. Your supervisor aggregates data from all BHS in the municipality and submits to the RHU 3. RHU submits to the district; district to the provincial level; province to DOH 4. DOH uses this data to monitor national coverage and identify areas needing support **DOCUMENTATION CHECKLIST FOR RECORDING AND TRACKING:** - [ ] Immunization card: Vaccine name, dose, route, site, date, batch number, health worker initials - [ ] TCL: Child's name, DOB, address; vaccine date columns filled in when given - [ ] TCL: Defaulters identified and marked after each clinic - [ ] Home visit notes: Reason for default, follow-up action, date of next appointment - [ ] Adverse event reporting: Any unusual reactions documented and reported - [ ] Monthly data compilation: FIC/CIC calculations and coverage reports - [ ] Batch number recording: Allows traceability if vaccine batch has issues

This section distills the highest-yield concepts for the PRC Midwife Licensure Examination. These are the facts, numbers, and principles that appear repeatedly on exams and are critical to safe practice. **COLD CHAIN: THE MUST-KNOW FACTS** 1. **Service-delivery temperature: +2°C to +8°C** — the single most important number; record twice daily 2. **Heat-sensitive vaccines (store on top/upper shelves):** OPV (most sensitive), BCG, MCV/MMR 3. **Freeze-sensitive vaccines (store on middle/lower shelves, never freeze):** Hepatitis B, Pentavalent/DPT, PCV, IPV, TT/Td 4. **FEFO — First Expiry, First Out** — use nearest expiry date first 5. **VVM (Vaccine Vial Monitor):** If inner square is as dark as or darker than outer ring, DISCARD 6. **Shake test:** If frozen-and-thawed vaccine shows flakes that settle and do not resuspend, DISCARD 7. **Reconstituted BCG:** Use within 4 hours; keep on ice; discard remainder 8. **Reconstituted measles/MMR:** Use within 6 hours; keep on ice; discard remainder 9. **Vaccine carriers:** Use for outreach; maintain +2°C to +8°C; return unused vaccines to cold storage 10. **Refrigerator holds vaccines only;** no food or drinks **EPI SCHEDULE: THE TIMELINE** | **Age** | **Vaccines** | **Remember** | |---|---|---| | **At birth** | BCG (ID, right arm) + HepB (IM, thigh) | **Within 24 hours** | | **6 weeks** | Penta 1 + OPV 1 + PCV 1 | **Start of primary series** | | **10 weeks** | Penta 2 + OPV 2 + PCV 2 | **4 weeks after 6-week** | | **14 weeks** | Penta 3 + OPV 3 + PCV 3 + IPV 1 | **4 weeks after 10-week; IPV added** | | **9 months** | MCV1 + IPV 2 | **Booster antigens** | | **12 months** | MCV2 | **Second measles dose** | **ADMINISTRATION QUICK TABLE** | **Vaccine** | **Dose** | **Route** | **Site** | |---|---|---|---| | BCG | 0.05 mL | ID | Right upper arm (deltoid) | | HepB (birth & with Penta) | 0.5 mL | IM | Anterolateral thigh (vastus lateralis) | | Pentavalent | 0.5 mL | IM | Anterolateral thigh | | PCV | 0.5 mL | IM | Anterolateral thigh | | IPV | 0.5 mL | IM | Anterolateral thigh | | OPV | 2 drops | Oral | Mouth | | MCV/MMR | 0.5 mL | **SC (not IM)** | Upper outer arm | **KEY FACTS ON INJECTION TECHNIQUE** 1. **BCG is the ONLY intradermal vaccine** — shallow angle, raises wheal, leaves scar 2. **All IM vaccines in infants go in anterolateral thigh** — NEVER buttock (sciatic nerve risk, poor absorption) 3. **IM angle: 90 degrees perpendicular** to skin; needle 5/8 inch 4. **SC angle: 45 degrees** to skin; needle 1/4–1/2 inch 5. **OPV: 2 drops oral;** place in mouth, not on lips 6. **Auto-disable syringe:** One new syringe per dose; do NOT recap; drop entire syringe in sharps box 7. **Multiple vaccines at one visit:** Give in DIFFERENT SITES, same session; reduces visits and defaulting 8. **Never reduce, split, or adjust doses** — full dose = full protection **TRUE vs. FALSE CONTRAINDICATIONS AT A GLANCE** **TRUE (Rare, Require Deferral):** - Anaphylaxis to prior dose or component - Severe neurological reaction to DPT/Pentavalent - Live vaccine in clinical (symptomatic) AIDS **FALSE (Do NOT defer vaccination):** - Mild fever, cough, cold, diarrhea - High fever (evaluate for serious illness, then vaccinate) - Malnutrition (vaccinate; refer for nutrition support) - Prematurity/low birth weight (vaccinate by chronological age) - Breastfeeding - Recent infection/recovery - On antibiotics - Family history of allergy - Jaundice - Concurrent procedures **Coverage Indicators:** - **FIC (Fully Immunized Child):** All antigens completed BEFORE 12 months; DOH target >90% - **CIC (Completely Immunized Child):** All antigens completed by 23 months; DOH target >95% **Recording and Defaulter Tracking:** - Immunization card: Mother keeps; you record immediately; vaccine name, dose, route, site, date, batch, signature - TCL: Health center registry; updated with each clinic - Defaulter: Child due but did not appear; follow up within 1–2 weeks - Continue series, never restart: Missed dose = give next due dose, not dose 1 **PRC MLE-STYLE QUESTIONS YOU MIGHT SEE:** *Question 1: Cold Chain* "A vaccine refrigerator at the BHS is set to +10°C. What action should the midwife take?" - Answer: The temperature is TOO HIGH (above +8°C). Adjust the refrigerator immediately. Check VVM on all vaccines in the fridge for heat damage. Document the incident and report to the RHU. *Question 2: Schedule* "An infant is brought to the BHS at 12 weeks of age for the first time. The infant has received no prior vaccines. What vaccines should the midwife give TODAY?" - Answer: **Pentavalent 1, OPV 1, PCV 1** (the 6-week vaccines given now at 12 weeks). Schedule Pentavalent 2, OPV 2, PCV 2 for 4 weeks later (16 weeks), and Pentavalent 3, OPV 3, PCV 3, IPV 1 for 4 weeks after that (20 weeks). Birth doses (BCG and HepB) are given as soon as the child is identified. *Question 3: Injection Site* "A midwife is vaccinating a 2-month-old infant with Pentavalent. Where should the injection be given?" - Answer: **Anterolateral thigh (vastus lateralis) muscle, not the gluteal (buttock) region.** The buttock is avoided in infants to prevent sciatic nerve injury and ensure better vaccine absorption. *Question 4: MCV Route* "A mother asks why the measles vaccine is given as an injection under the skin (SC) rather than into the muscle (IM). What is the best explanation?" - Answer: Measles vaccine is a live-attenuated vaccine that is given subcutaneously to induce strong systemic immunity. The SC route is the proven route for measles; giving it IM would not provide the intended immunity. *Question 5: Contraindication* "A 6-month-old infant has a mild fever (37.3°C) and a mild cough from a cold. The infant is alert, feeding well, and gaining weight. The mother asks if the infant can receive the scheduled vaccines today. What should the midwife advise?" - Answer: **Yes, vaccinate the infant today.** Mild fever and mild cold are NOT contraindications. Delaying vaccination for minor illness risks missing the dose. The infant's immune system is primed by the minor illness and may respond even better to the vaccine. *Question 6: Defaulter* "A child missed the 6-week immunization clinic. The child returns at 4 months old (8 weeks late). The mother asks if the child should restart the vaccine series. What is the correct response?" - Answer: **No, do not restart the series.** The child should receive **Pentavalent 1, OPV 1, PCV 1** (the next due doses from where the child left off, which is the 6-week vaccines). The child continues the schedule from the point of default, not from the beginning. *Question 7: FIC Calculation* "A barangay has 200 infants aged 0–11 months. Of these, 150 have received all required antigens (BCG, 3 Penta, 3 OPV, 3 PCV, and 1 MCV) before turning 12 months old. What is the FIC coverage percentage?" - Answer: **FIC % = 150 / 200 × 100 = 75%.** This is below the DOH target of 90%; the BHS should strengthen defaulter tracking and outreach to improve coverage. *Question 8: VVM* "A nurse is preparing vaccines for an immunization clinic. She notices that a measles vial has a VVM where the inner square appears slightly darker than the outer ring. What should be done?" - Answer: **Discard the vial immediately.** The VVM indicates the vaccine has been exposed to excessive heat and has lost potency. Using a darkened-VVM vaccine is unsafe and ineffective. Do not administer this vaccine. *Question 9: Hepatitis B Birth Dose Timing* "A newborn is born at 8:00 AM on a Monday. The mother's Hepatitis B status is unknown. When should the Hepatitis B vaccine be given?" - Answer: **Within 24 hours of birth, ideally as soon as possible.** If the mother is later found to be Hepatitis B-positive, the early birth dose provides critical protection against mother-to-child transmission. Do not delay the birth dose. *Question 10: Cold Chain Monitoring* "How often should the BHS refrigerator temperature be recorded, and at what temperature range should vaccines be stored?" - Answer: **Twice daily (morning and afternoon)** on a temperature monitoring chart. **Temperature range: +2°C to +8°C.** Any temperature outside this range should trigger immediate corrective action. **SUMMARY: WHY THIS MATTERS** As a midwife, you are often the only health worker a child sees in their first year of life. The vaccines you administer, the cold chain you maintain, the schedule you follow, and the children you track determine whether that child is protected against serious, preventable disease. A mistake in temperature management can render an entire batch of vaccines useless. A missed appointment that you do not follow up on leaves a child unprotected for weeks. An injection given in the wrong site can fail to provide immunity. The EPI is one of the Philippines' greatest public health successes—a program that has saved millions of children's lives. Your role in delivering it safely and completely is non-negotiable. Master these concepts, apply them with precision, and every child in your care will have a chance at a healthy, productive life.