PRINCIPLES OF IMMUNIZATION  Severe reactions possible (may cause
IN INFANTS AND CHILDREN untoward effects to immune-compromised
Dr. JoselitoVillaruz
June 18, 2013
Group 4
IMMUNIZATION
 An effective measure in preventive medicine
 Provision of antibodies in order to destroy or
inactivate the disease-producing agent, or to
neutralize toxins (e.g. tetanus)
PRINCIPLES OF IMMUNIZATION
I. Active
- Long-lasting
- Body participates in the production of antibodies
upon exposure to a pathogen or a vaccine, e.g.
tetanus toxoid.
- Response similar to natural infection
- Expected responses
a. Complete protection for life
b. Partial protection
c. Readministration at intervals
(Principle of booster dose)
FACTORS AFFECTING RESPONSE TO VACCINATION
 Presence of maternal antibody
 Nature and dose of vaccine antigen
o Recombinant
o Plasma-derived
 Administrative route
 Presence of adjuvants
o Aluminum
o Mercury
 Host factors
e.g. Those immunocompromised, HIV/AIDS
patients
 Cell-mediated immunity is affected by nutritional
status
 Give full strength and not any less or else the
vaccine won’t be effective
TYPES OF ACTIVE IMMUNIZATION
1. Live attenuated vaccines
 Contains “wild” or disease-causing virus or
bacteria that are markedly weakened in the
laboratory over time
 Derived from wild virus or bacteria
 Virus must replicate to be effective
 Immune response similar to natural infection
hosts)
 Potential for reversal to pathogenic form
 Interference from circulating antibody
 Unstable
 Administered intranasally and
intramuscularly for not live attenuated
 In cases of Kawasaki disease, one should wait
some time before continuing vaccine
Examples:
 Viral: measles, mumps, rubella, oral
polio, rotavirus, varicella
 Bacterial: BCG, oral typhoid
 Live attenuated vaccines may be affected by
circulating antibody to the antigen (measles
vaccine after giving Ig)
 Oral polio vaccine is not affected by the
administration of IG or blood products. It
must be given simultaneously with blood
products or separated by an interval.
1. Advantages
 Mimic natural infection without causing
the disease
 Usually effective with one dose
 Provide long-lasting protection
2. Disadvantages
 Must be stored in cool conditions
 May retain some pathogenicity
 Severe reactions possible
 Affected by circulating antibodies
especially in babies under 12 months
o Measles vaccine after giving
immunoglobulin -> delay 11
months to 1 year before
injecting;
 As an exception, OPV is not affected by
IgG/immunoglobulin/blood products
o It may be given with blood
products or separated with
interval
 Additional doses are given at 12-15
months
2. Inactivated vaccines
 Incapable of replicating in the host
 Generally not as effective as live vaccines
 Minimal interference from circulating
antibody
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  Generally require 3-5 doses
 Immune response is mostly humoral
 Antibody titer falls over time
 Should contain sufficient antigen mass to
stimulate response
 Contains killed microorganisms
 Not affected by circulatory blood products
but needs multiple doses
 Booster doses are essential since its effects
wanes over time
 Tetanus toxoid given every 10 years
Examples:
 Whole cell vaccines
o Viral: influenza, polio, rabies, Hep A
o Bacterial: pertussis, typhoid, cholera
 Fractional vaccines
o Protein-based
o Polysaccharide-based: contain T-cell
independent antigens which interact
directly with B-cells
 Recombinant vaccines
o Live or sub-unit
o Hepatitis B
(more immunogenic; thousand-fold
more response compared to plasma-
derived; Hep B antibodies reach
more than 100)
o New HPV
3. Combination vaccines
 Multiple different antigens of an organism
mixed as a single product to immunize
against multiple serotype (pneumococcal
conjugate, polysaccharide vaccines, polio
vaccine)
 Antigen from pathogen causing different
diseases (DPT, MMR)
IMMUNIZING AGENTS (CONSTITUENTS OF VACCINES)
1. Active immunizing agents
o Live attenuated
o Inactivated/subunit preparations
2. Suspending fluid
o Sterile water/saline
o Tissue-culture fluid (egg antigen, gelatin)
3. Preservatives, stabilizers, antibiotics
o Mercurials, neomycin, streptomycin
o May cause hypersensitivity
4. Adjuvants
o Substances used to increase immunogenicity and
prolong stimulatory effect
o Enhances immune response
o Newer generations available
Adjuvant Vaccine
Aluminum salts DPT, HBV, HAV
MF-59 Influenza
Virosomes Influenza H1N1, HAV
Extoxoprim Intranasal influenza
vaccine
ASB4(Ipopolysaccharide) HPV
II. Passive
- Short-lived
- Administration of preformed of human or animal
origin to another e.g. HTIG, transplacental
transfer of antibodies during gestation.
Note: It takes at least a month to produce antibodies
GENERAL RECOMMENDATIONS ON IMMUNIZATION
A. Timing and spacing of Vaccines
1. Simultaneous and non-simultaneous
administration
2. Interval between doses of the same vaccine
Note: Increasing interval between doses of a multi-
dose vaccine does not diminish the effectiveness of
the vaccine but decreasing the interval between
doses of multi-dose vaccine may interfere with the
antibody response and protection.
POINTERS TO IMMUNIZATION
 Long lasting immunity may require periodic
administration of booster doses
 Effective antibody level in active immunization takes
some time (4 weeks - 1 month).
 Live attenuated vaccines evoke more effective and
longer-lasting immunologic response than inactivated
ones.
- Contraindicated in pregnant women,
immunodeficiency states, and
immunosuppressive states
 Minor febrile illness and malnutrition are not
contraindications to vaccination.
 Permanent contraindications
o Hypersensitivity with previous shot
o Encelopathy related to DPT within 7 days to shot
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 >90% susceptibles should be targeted for community FACTORS INFLUENCING VACCINE INFORMATION
production REACTIONS
 Interruption of schedule does not interfere with the  Prior experiences
final immunity achieved noe does it require repeating  Attitude
the series again (regardless of the time elapsed)  Health beliefs
 Shorter interval between doses will diminish the  Personal values
efficacy of the second shot  Educational attainment
 No definite contraindication to giving multiple  Method of data presentation
vaccines simultaneously, provided, they are given at  Perceptions of the risk of disease
different sites.  Perceived ability to control risk
 Only the diluent supplied by the manufacturer should  Risk preferences
be used to reconstitute a freeze-dried vaccine  Website/internet
 Use one sterile needle and one sterile syringe for VACCINES
each child Vaccine Type Route Temperature
 Live oral vaccines maybe given at anytime before or BCG Live bacteria ID 2-8 °C
May be frozen
after the parenteral vaccines
DPT Toxoid, IM 2-8 °C
 All vaccines must be properly stored at inactivated
recommended temperature to maintain potency (e.g. bacteria
DTaP Toxoid, IM 2-8 °C
in a refrigerator) inactivated Do not freeze
- Not on the doors of the refrigerator bacteria
Hep A Inactivated IM 2-8 °C
- No food and drinks inside the storage
viral antigen Do not freeze
 Timing and spacing of vaccines: HIB Conjugate Polysaccharide IM 2-8 °C
- Antibody-containing blood products interfere CHON Do not freeze
with live vaccines & vice-versa Influenza Inactivated IM 2-8 °C
virus Do not freeze
o If live vaccine is given first, wait for at
Influenza Live IN 2-8 °C
least 2 weeks before giving antibody attenuated
 Breastfeeding does not interfere with OPV Measles Live virus SC 2-8 °C
vaccination May be frozen
Meninggoccemia Polymerase Live virus 2-8 °C
 Vaccines containing adjuvants must be injected deep
May be frozen
in the muscle mass MMR Live virus SC 2-8 °C
 Upper outer aspect of buttocks not recommended in May be frozen
Pneumococcal Polysaccharide IM/SC 2-8 °C
ordinary circumstances
Do not freeze
 Informing patients and parents Poliovirus
o Health care professionals should inform parents IPV Inactivated SC 2-8 °C
and patients about risks/benefits Do not freeze
OPV Live Oral < 0°C
o Anticipate parents’ concern May be frozen
 Safety Rabies Inactivated IM 2-8 °C
 Refusal of certain/all vaccines Do not freeze
Tetanus Toxoid IM 2-8 °C
 Religious/philosophical objections
Do not freeze
 Don’t have to stop vaccinations on patients on low Typhoid
dose steroids or antibiotics Parenteral Inactivated SC 2-8 °C
Do not freeze
 Live vaccines should not be administered to pregnant Oral Live bacteria Oral 2-8 C
women May be frozen
Varicella Live SC -15 °C
Keep frozen
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THE EXPANDED PROGRAM ON IMMUNIZATION (EPI)
Historical Highlights:
 Pursued as a policy in 1976 in response to UN’s and
WHO’s goal of Universal Child Immunization by 1990
 Revised in 1986 by the EPI Comprehensive Program
Review
 Reduce morbidity and mortality rates of the EPI
diseases (polio, measles, diphtheria, pertussis,
tetanus, TB)
 Reduce incidence of neonatal tetanus
 Compulsory basic immunization for infants and
children, 8 years old (PD 996, 1976)
 Inclusion of Hep B (1993)
 National Immunization Days (3rd Wednesday of
January and February)
 Rotavirus, HIB, MMR, PCV were eventually included
as of 2012
EPI Components
1. Coverage
*Infants below 1 year (population most at risk),
school entrants (BCG regardless of presence of
BCG scar), pregnant women (also mothers of
neonatal tetanus cases before leaving the
hospital, all women 15-45 years old during NID)
… a FULLY IMMUNIZED CHILD under the EPI
program is one who has received: one dose of
BCG at birth; three doses of DPT and Polio with a
least 4 weeks interval; one dose of measles by 9
months and three doses of Hep B with at least 4
weeks interval by ONE YEAR OF AGE…
Vaccines for Special Groups
 Not part of EPI or other recommended
vaccines but are used in selected
populations
 Typhoid, Meningococcal, Rabies
2. Surveillance
 Continuous collection and analysis of data of
cases/deaths of the 7 EPI diseases
 WHO standard criteria for diagnosis are used
3. Immunization Activities
 Conducted on a regular basis
 Every WEDNESDAY of the week (Monday at
WVSUMC)
 NO ABSOLUTE CONTRAINDICATION to
immunizations
4. Cold Chain
Structure of a Cold Chain
2 Complementary Aspects
a. The set chain – refrigerator
b. The mobile chain – isothermic boxes and
iceboxes
Vaccine Storage Requirements
 Maintain required temperature range
throughout the year
 Separate doors for refrigerator and freezer
 Large enough to hold year’s largest vaccine
inventory
 Dedicated to biologics (no food or
beverages!)
 Dorm-style refrigerators should NOT be used
to store varicella, MMR
Rules to Follow Regarding the Refrigerator
 Cold accumulators – freezer; used in case of
break down or in iceboxes
 Empty space between packages
 Regular defrosting
 Water-filled plastic bottles to store up cold in
case of breakdown
Temperature Monitoring
 Separate thermometer for refrigerator and
freezer compartments
 Use good quality certified calibrated
thermometer (biosafe liquid, continuous
graphic, or minimum/maximum)
 Manually check temperatures twice a day
even if using continuous graphic
thermometer