12.3 Ghana Expanded Programme on Immunization (EPI) & Pediatric Malnutrition

12.3 Ghana Expanded Programme on Immunization (EPI) & Pediatric Malnutrition

Quick Answer: Ghana's Expanded Programme on Immunization (EPI) schedule runs from birth (BCG, OPV0, hepatitis B birth dose) through 6, 10 and 14 weeks (pentavalent, OPV, PCV and rotavirus, plus IPV1 at 14 weeks), 7 months (IPV2), 9 months (measles-rubella 1, yellow fever) and 18 months (MR2, MenA), with the malaria vaccine at 6, 7, 9 and 18 months where introduced. The cold chain must maintain +2°C to +8°C for refrigerators, with freeze-sensitive vaccines evaluated via the Shake Test. Pediatric Severe Acute Malnutrition (SAM) is diagnosed via MUAC < 11.5 cm, WHZ < -3 SD, or bilateral pitting edema (Kwashiorkor). Inpatient SAM demands the WHO 10-step protocol: Stabilization using low-protein F-75 formula and ReSoMal (strictly avoiding standard IV fluids and iron), followed by Rehabilitation with F-100 or RUTF and delayed iron supplementation.

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The Ghana National Expanded Programme on Immunization (EPI)

Established by the Ministry of Health and Ghana Health Service in accordance with WHO guidelines, the Expanded Programme on Immunization (EPI) is one of Ghana's most successful public health initiatives, drastically slashing mortality from measles, pertussis, neonatal tetanus, polio, and tuberculosis.

Complete National Immunization Schedule

Every nurse and midwife in Ghana must memorize the precise antigens, timings, dosages, routes, and anatomical injection sites of the national schedule:

Schedule notes (Ghana Health Service): after 18 months, vitamin A (200,000 IU) is given every 6 months until age 5; a long-lasting insecticidal net (LLIN) is given at 18 months; the malaria vaccine has had a phased introduction since 2019; HPV introduction was planned for 2025; Td for pregnant women follows a separate schedule (section 11.1); and missed doses follow the national catch-up policy.

The Ghana Malaria Vaccine Implementation Programme (MVIP)

Ghana was selected alongside Kenya and Malawi as pioneering rollout nations for the RTS,S/AS01 (Mosquirix) and newly approved R21/Matrix-M malaria vaccines. The vaccine is administered across implementing districts to prevent severe Plasmodium falciparum malaria and cerebral complications. The schedule consists of four primary doses:

• Dose 1: 6 months of age;
• Dose 2: 7 months of age;
• Dose 3: 9 months of age (co-administered with Measles-Rubella 1 and Yellow Fever);
• Dose 4: 18 months of age on the current GHS schedule (the pilot programme gave it at 24 months).

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Vaccine Cold Chain Management and Safety

Vaccines are delicate biological substances that permanently lose potency when exposed to excessive heat, light, or freezing temperatures.

1. Temperature Regimes and Monitoring

• Health Facility Refrigerator Compartment: Maintained strictly between +2°C and +8°C (optimum target: +4°C to +5°C);
• Central / Regional Vaccine Store Freezers: Maintained between -15°C and -25°C (historically for bulk OPV storage and freezing water packs);
• Temperature Logging: Temperature readings from calibrated thermometers or digital data loggers (Fridge-Tag) must be recorded twice daily (first thing in the morning and end of work day), 7 days a week, on the temperature chart affixed to the refrigerator door;
• Refrigerator Storage Architecture:
  • Freeze-sensitive vaccines (Pentavalent, PCV, Td/TT, HepB, IPV) must be placed in the middle shelf, never touching the evaporator plates or bottom;
  • Heat-sensitive live viral vaccines (OPV, Measles-Rubella, BCG, Yellow Fever) are placed on the top shelf (below the freezer);
  • The bottom compartment/crisper contains bottles of water to maintain thermal inertia during power cuts;
  • The door shelves must NEVER hold vaccines (subject to severe temperature fluctuations during opening).

2. The Vaccine Vial Monitor (VVM)

The Vaccine Vial Monitor (VVM) is a heat-sensitive chemical indicator label affixed to the vaccine vial, reflecting cumulative heat exposure over time:

• Principle: A light-colored square nested inside a darker circular reference ring.

+-----------------------------------------------------------------------------------+
|                        VACCINE VIAL MONITOR (VVM) STAGES                          |
+---------+-------------------------------------------------+-----------------------+
| Stage   | Visual Appearance of Inner Square vs. Circle    | Decision / Action     |
+---------+-------------------------------------------------+-----------------------+
| Stage 1 | Inner square is noticeably LIGHTER than circle. | USABLE: Vaccine safe  |
|         | No significant heat exposure.                   | to administer.        |
+---------+-------------------------------------------------+-----------------------+
| Stage 2 | Inner square is still LIGHTER than circle.      | USABLE: Use first if  |
|         | Mild heat exposure, but below threshold.        | not expired.          |
+---------+-------------------------------------------------+-----------------------+
| Stage 3 | Inner square MATCHES the color of the circle.   | DO NOT USE: Discard   |
|         | Heat threshold reached! Potency lost.           | immediately!          |
+---------+-------------------------------------------------+-----------------------+
| Stage 4 | Inner square is DARKER than the circle.         | DO NOT USE: Discard   |
|         | Severe heat exposure! Protein denatured.        | immediately!          |
+---------+-------------------------------------------------+-----------------------+

3. Freeze Sensitivity and The Shake Test

Aluminum-adjuvanted vaccines (Pentavalent, PCV, Td, Hepatitis B, and IPV) lose their potency and form irreversible toxic aggregates when exposed to temperatures below 0°C. Freezing dissociates the antigen from the aluminum adjuvant, precipitating heavy granules.

To confirm whether a freeze-sensitive vaccine has been damaged by accidental freezing, the nurse performs The Shake Test:

1. Take a suspect vial and deliberately freeze a control vial of the exact same vaccine, lot, and manufacturer until solid, then allow it to thaw completely;
2. Vigorously shake both the suspect test vial and the thawed control vial simultaneously for 10–15 seconds;
3. Place both vials side by side on a flat surface against a clear light source and observe the sedimentation rate;
4. Interpretation:
   • If the suspect vial sediments slower than the frozen control, the test vaccine has NOT been frozen and is usable;
   • If the suspect vial sediments at the same rate or faster than the frozen control (sediments rapidly within 15–30 minutes leaving a clear supernatant fluid), the suspect vaccine has been frozen and damaged. It MUST BE DISCARDED IMMEDIATELY.

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Pediatric Severe Acute Malnutrition (SAM)

Malnutrition underlies more than one-third of all global child deaths, impairing cell-mediated immunity and transforming common childhood infections into fatal events.

Clinical Phenotypes: Marasmus vs. Kwashiorkor

Severe Acute Malnutrition (SAM) manifests as two distinct pathophysiological extremes:

Edema Grading in Kwashiorkor:
- Mild (+): Pitting edema restricted to both feet and ankles.
- Moderate (++): Edema extending to feet, lower legs, hands, or lower arms.
- Severe (+++): Generalized anasarca involving feet, legs, hands, arms, and facial edema (periorbital swelling).

Anthropometric Diagnostic Criteria for SAM (Age 6 to 59 Months)

A child aged 6 to 59 months is classified as having Severe Acute Malnutrition (SAM) if ANY ONE of the following criteria is met:

1. Mid-Upper Arm Circumference (MUAC): < 11.5 cm (115 mm) (indicated by the Red Zone on a standard tri-color insertion tape);
2. Weight-for-Height Z-score (WHZ): < -3 SD (Standard Deviations) on WHO Growth Standards;
3. Presence of Bilateral Pitting Edema: Regardless of weight-for-height or MUAC, bilateral pedal edema automatically defines the child as suffering from SAM.

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WHO 10-Step Inpatient Management Protocol for SAM

Children with complicated SAM (poor appetite, severe edema +++, hypoglycemia, hypothermia, or systemic infection) have unstable metabolic reductive adaptation ("reductive adaptation" — suppressed sodium pumps, myocardial atrophy, impaired renal concentrating ability). They must be admitted for inpatient management following the WHO 10-Step Protocol.

+-----------------------------------------------------------------------------------+
|               WHO 10-STEP INPATIENT MANAGEMENT OF COMPLICATED SAM                 |
+----+------------------------------+-----------------------+-----------------------+
| Step / Intervention               | Phase 1: Stabilization| Phase 2 / Phase 3     |
|                                   | (Days 1 to 7)         | (Days 8 to Discharge) |
+----+------------------------------+-----------------------+-----------------------+
| 1  | Treat / Prevent Hypoglycemia | Day 1–2               |                       |
| 2  | Treat / Prevent Hypothermia  | Day 1–2               |                       |
| 3  | Treat / Prevent Dehydration  | Day 1–2 (ReSoMal)     |                       |
| 4  | Correct Electrolyte Imbalance| Days 1–7              | Throughout            |
| 5  | Treat / Prevent Infections   | Days 1–7 (Antibiotics)|                       |
| 6  | Correct Micronutrient Deficit| Days 1–7 (NO IRON!)   | Add Iron in Phase 3!  |
| 7  | Cautious Feeding             | Days 1–7 (F-75 milk)  |                       |
| 8  | Rebuild Wasted Tissue        |                       | F-100 / RUTF          |
| 9  | Provide Sensory Stimulation  |                       | Play therapy          |
| 10 | Prepare for Discharge        |                       | Maternal education    |
+----+------------------------------+-----------------------+-----------------------+

Detailed Analysis of Critical Steps

Steps 1 & 2: Hypoglycemia and Hypothermia

• Hypoglycemia (blood glucose < 3.0 mmol/L or 54 mg/dL) and hypothermia (axillary temperature < 35.0°C) frequently coexist and cause sudden death;
• Feed immediately upon admission. If hypoglycemic, administer 50 mL of 10% dextrose solution orally or via nasogastric tube (or 5 mL/kg IV 10% dextrose if unconscious);
• Maintain room warmth (28°C–32°C), dress the child with a cap and socks, practice Kangaroo Mother Care, and feed every 2 hours day and night.

Step 3: Dehydration & The Critical Fluid Protocol

• Diagnostic Challenge: Classic dehydration signs (sunken eyes, poor skin turgor) are present in marasmus solely due to subcutaneous fat loss. Over-diagnosing dehydration leads to fatal fluid overload;
• Absolute Contraindication: NEVER USE STANDARD INTRAVENOUS FLUIDS (Normal Saline or Ringer's Lactate) for rehydration in SAM unless the child is in confirmed septic shock or hypovolemic shock. Malnourished children have sodium-overloaded cells, weak cardiac output, and reduced renal excretion; IV fluid boluses rapidly cause congestive heart failure and pulmonary edema;
• ReSoMal (Rehydration Solution for Malnutrition): Oral rehydration MUST be conducted with ReSoMal, which is specifically formulated with lower sodium (45 mmol/L), higher potassium (40 mmol/L), and added magnesium, zinc, and copper;
• Administer ReSoMal orally or via nasogastric tube at 5 mL/kg every 30 minutes for the first 2 hours, then 5 to 10 mL/kg/hour over the next 4 to 10 hours.

Step 4: Correct Electrolyte Imbalance

• All SAM children have deficient intracellular potassium and magnesium, despite high intracellular sodium. Administer extra potassium (3 to 4 mmol/kg/day) and magnesium (0.4 to 0.6 mmol/kg/day) added to therapeutic feeds for at least 2 weeks. Do NOT administer supplemental sodium.

Step 5: Treat Systemic Infections

• Due to reductive adaptation, malnourished children cannot mount a fever or inflammatory leukocytosis. Severe occult bacterial sepsis is assumed in all inpatient SAM cases;
• Administer broad-spectrum empirical antibiotics from Day 1:
  • Ampicillin (50 mg/kg IM/IV every 6 hours for 2 days), followed by oral Amoxicillin (15 mg/kg every 8 hours for 5 days);
  • PLUS Gentamicin (7.5 mg/kg IM/IV once daily for 7 days).

Step 6: Correct Micronutrient Deficiencies — The Iron Rule

• Administer Vitamin A on Day 1 (50,000 IU for < 6m, 100,000 IU for 6–11m, 200,000 IU for >= 12m), unless documented within the past month;
• Daily Folic Acid (5 mg on Day 1, then 1 mg daily), zinc, and copper;
• CRITICAL CLINICAL RULE (NO IRON IN STABILIZATION): Never administer iron during Phase 1 (Stabilization). In severe malnutrition, transferrin levels are critically low. Administering iron results in unbound free iron that fuels virulent bacterial proliferation and catalyses free-radical membrane lipid peroxidation, dramatically increasing mortality. Iron is introduced ONLY during Phase 3 (Rehabilitation), after the child develops a voracious appetite and has begun active catch-up growth (> 5 g/kg/day weight gain).

Steps 7 & 8: Therapeutic Diets (F-75 to F-100 / RUTF)

• Phase 1 (Stabilization): Feed exclusively with F-75 therapeutic formula (75 kcal and 0.9 g protein per 100 mL). F-75 is low in protein, sodium, and osmolarity, designed to stabilize metabolic function without overloading the liver, kidneys, or myocardium. Feeds are given at 130 mL/kg/day (11 mL/kg every 2 hours);
• Phase 2 (Transition): When bilateral edema is reduced and appetite returns, transition gradually over 2–3 days to F-100 formula (100 kcal and 2.9 g protein per 100 mL) or Ready-to-Use Therapeutic Food (RUTF / Plumpy'Nut);
• Phase 3 (Rehabilitation): High-calorie catch-up growth (150 to 220 kcal/kg/day), weight gain monitoring (> 10 g/kg/day indicates excellent catch-up), play therapy, and maternal education.