60

Vaccination updated

Wa'el Hayajneh

Nadeen alshra'a and Doa'a Alzoubi-

hope
 Vaccination

 Definitions
- A vaccine : is a suspension of attenuated live or killed MO administered
to induce immunity .
- Active immunization induces immunity by vaccination with a vaccine
or toxoid (inactivated toxin).
- Passive immunization includes trans-placental transfer of maternal
antibodies and the administration of antibody, either as
immunoglobulin or monoclonal antibody .

 Types of vaccines
• Live attenuated :
- Viral : MMR, rubella, varicella, nasal influenza, OPV and rota vaccine .
- Bacterial : BCG , oral typhoid .
• Inactivated or Killed :
1. Inactivated whole organism : Hepatitis A , Whole cell pertussis .
2. Detoxified exotoxins ( toxoid ) : Dephtheria , Tetanus.
3. Purified protein Antigen : Hepatitis B , Acellular Pertussis .
4. Polysaccharide : Capsular meningioceal.
5. Capsular polysaccharide conjugated to protein : Hib , pneumococcal.
6. Component of organism : Influenza vaccine .

 Immune Response to Vaccine

• In live attenuated vaccine , the organism multiply in recipient so it is

more like the infection , and more likely to produce life-long
protection after 1st dose of vaccine .
• Killed vaccine : less antigenic, usually need booster doses
• Primary response to vaccine is IgM serum antibody detected within
7-10 days then IgG type peaks at 2-6 weeks .
• T-cell independent antigens: antigens induce B cells proliferation and
antibody production, without the help of T cells .
 T-cells independent antigen induce inadequate immune response at
age at age less than 2 years . The lack of immune response may be

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 overcome by conjugating the polysaccharides to a carrier protein,
e.g, Hib & Conjugated pneumococcal vaccines .

Extra : For most protein antigens, the production of antibodies by B

lymphocytes is dependent on stimulation of helper T cells. However
bacterial polysaccharides and lipopolysaccharides, and some polymeric
proteins, can stimulate B lymphocytes without involvement of helper T
cells. The non-protein microbial antigens can't stimulate classical T cell
response by themselves, but they are able to elicit the production of
antibodies, so that is why we call them T or thymus independent antigens.

 Special conditions
1. Breast feeding is not a contraindication to any vaccine, although most
live attenuated vaccine replicate in mother they aren't excreted in
human milk.
2. Lapsed immunizations:
if interval between vaccine doses exceeds those recommended , this
doesn't adversely affect the immune response, so no need to restart
the series or to give extra dose . (( A lapse in schedule does not require
reinstitution of the entire series ))
3. Inactivated vaccines are generally not affected by circulating antibody
to the antigen. Live attenuated vaccines may be affected by circulating
antibody to the antigen.
 The presence of circulating antibody to a vaccine antigen may reduce
or completely eliminate the immune response to the vaccine. The
amount of interference produced by circulating antibody generally
depends on the type of vaccine administered and the amount of
antibody.
 Inactivated antigens, which include recombinant vaccines, are generally
not affected by circulating antibody, so they can be administered
before, after, or at the same time as the antibody.
 Simultaneous administration of antibody (in the form of immune
globulin) and vaccine is recommended for post-exposure prophylaxis of
certain diseases, such as hepatitis B, rabies, and tetanus.
 Live Injected Vaccines .

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 Live vaccines must replicate in order to cause an immune response.
Antibody against injected live vaccine antigen may interfere with
replication.

If a live injectable vaccines )measles-mumps-rubella [MMR], varicella,

or combination measles-mumps-rubella-varicella [MMRV]) must be
given around the time that antibody is given, the two must be
separated by enough time so that the antibody does not interfere with
viral replication.
If the live vaccine is given first, it is necessary to wait at least 2 weeks
(i.e., an incubation period) before giving the antibody. If the interval
between the vaccine and antibody is less than 2 weeks, the recipient
should be tested for immunity or the vaccine dose should be repeated .
If the antibody is given before a dose of MMR or varicella containing
vaccine, it is necessary to wait until the antibody has waned (degraded)
before giving the vaccine to reduce the chance of interference by the
antibody. The necessary interval between an antibody-containing
product and MMR or varicella-containing vaccine (except zoster
vaccine) depends on the concentration of antibody in the product, but
is always 3 months or longer. The interval between administration of
an antibody product and MMR or varicella vaccination can be as long as
11 months. Zoster vaccine is not known to be affected by circulating
antibody so it can be administered at any time before or after receipt
of an antibody-containing blood product.
 Live Oral and Intranasal Vaccines
Oral typhoid vaccine is not known to be affected by the administration
of immune globulin or blood products. Oral typhoid vaccine may be
given simultaneously with blood products, or separated by any interval.
The replication of General Recommendations on Immunization 11 2 live
attenuated influenza (LAIV) and rotavirus vaccines are not believed to
be affected by antibody-containing blood products. These can be given
any time before or after administration of antibody-containing blood
products.

4 . All vaccines can be administered at the same visit as all other vaccines.

 Simultaneous administration (that is, administration on the same day)

of the most widely used live and inactivated vaccines does not result in
decreased antibody responses or increased rates of adverse reaction.
Simultaneous administration of all vaccines for which a child is eligible
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 is very important in childhood vaccination programs because it
increases the probability that a child will be fully immunized at the
appropriate age .
 Non- simultaneous Administration of Different Vaccines.
If live parenteral (injected) vaccines (MMR, MMRV, varicella, zoster, and
yellow fever) and live intranasal influenza vaccine (LAIV) are not administered
at the same visit, they should be separated by at least 4 weeks. This interval is
intended to reduce or eliminate interference from the vaccine given first on
the vaccine given later. If two live parenteral vaccines or LAIV are
administered at an interval of less than 4 weeks, then the vaccine given
second should be repeated in 4 weeks or confirmed to have been effective by
serologic testing of the recipient (serologic testing is not recommended
following LAIV, varicella, or zoster vaccines). An exception to this
recommendation is yellow fever vaccine administered less than 4 weeks after
single-antigen measles vaccine.

Live vaccines administered by the oral route (oral polio vaccine [OPV] oral
typhoid, and rotavirus) are not believed to interfere with each other if not
given simultaneously. These vaccines may be given at any time before or after
each other.

Parenteral live vaccines (MMR, MMRV, varicella, zoster, and yellow fever) and
LAIV are not believed to have an effect on live vaccines given by the oral route
(OPV, oral typhoid, and rotavirus). Live oral vaccines may be given at any time
before or after live parenteral vaccines or LAIV

5 . Increasing the interval between doses of a multi-dose vaccine does not

diminish the effectiveness of the vaccine. Decreasing the interval between
doses of a multi-dose vaccine may interfere with antibody response and
protection.

 Premature Infants
1. Prematurity doesn't increase the incidence of vaccines related side
effects.
2. Doses are the same as those for term infant .
3. Preterm infant should be vaccinated at same chronological age as full term;
because immune response to vaccination is a function of postnatal age
rather than gestational age.

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 Contraindications & precautions .
All vaccines have certain contraindications and precautions that guide their
administration. A contraindication indicates that the potential vaccine
recipient is at increased risk of a serious adverse event. A vaccine should not
be given when a contraindication to that vaccine is present, whereas a
precaution indicates a circumstance that might increase the risk of adverse
events or diminish the effectiveness of the vaccine. In the setting of
precautions, the risks and benefits of vaccination must be carefully weighed
prior to a decision regarding vaccination. Precautions are often temporary, in
which case vaccination can resume once the precaution no longer applies.

 Healthy Children
 Minor acute illnesses, with or without low-grade fever, are not
contraindications to vaccination.
 A moderate to severe febrile illness may be a reason to postpone
vaccination.

 Immunodeficient Children
 Congenitally immunodeficient children should not be immunized with
live-attenuated virus (oral polio vaccine [OPV], MMR, VAR, MMRV,
yellow fever, or live-attenuated influenza vaccine [LAIV]) or live-
bacteria vaccines (BCG or live typhoid fever vaccine).
 Depending on the nature of the immunodeficiency, other vaccines are
safe, but may fail to evoke an immune response. Children with cancer
and children receiving high dose corticosteroids or other
immunosuppressive agents should not be vaccinated with live-virus or
live-bacteria vaccines.
 This contraindication does not apply if the malignancy is in
remission and chemotherapy has not been administered for at least
90 days ( 3 months ) .
 Live-viral vaccines may also be administered to previously healthy
children receiving low to moderate doses of corticosteroids (defined
as up to 2 mg/kg/d of prednisone or prednisone equivalent, with a
20 mg/d maximum) for less than 14 days; children receiving short
acting alternate-day corticosteroids; children being maintained on
physiologic corticosteroid therapy without other immunodeficiency;
and children receiving only topical, inhaled, or intra-articular
corticosteroids.
 If the dose is more than 2mg/kg/day, or alternate-day steroid :
1- For less than 14 days, should have live vaccine deferred until
at least stopping steroid (once u stop steroid u can give the

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 vaccine)
2- If more than 14 days defer the vaccine for at least 1 month.

 Contraindication of live-pathogen vaccines also applies to children

with HIV infection who are severely immunosuppressed ( except
asymptomatic HIV patient ).
Allergic or Hypersensitive Children
 Hypersensitivity reactions are rare following vaccination (1.53
cases/million doses).
 They are generally attributable to a trace component of the vaccine
other than to the antigen itself; for example, MMR, IPV, and VAR
contain microgram quantities of neomycin, and IPV also contains trace
amounts of streptomycin and polymyxin B. Children with known
anaphylactic responses to these antibiotics should not be given these
vaccines.
 Trace quantities of egg antigens may be present in both inactivated
and live influenza and yellow fever vaccines. Children who have had
anaphylactic reactions to eggs should not be given these vaccines;
children with less serious reactions to eggs can generally be safely
immunized.
 Some vaccines (MMR, MMRV, and VAR) contain gelatin, a substance to
which persons with known food allergy may develop an anaphylactic
reaction.

 For any persons with a known history of anaphylactic reaction to

any component contained in a vaccine, the vaccine package insert
should be reviewed and additional consultation sought, such as from
a pediatric allergist .

 National Jordanian Vaccines

1. BCG ( Bacillus Calmatte Guerin ) ‫مطعوم التدرن او السل‬
 Bacteria :
- Prepared from mycobacterium bovis
- BCG provides protection against TB meningitis ( 50-80%) and miliary
disease .
 Type :
BCG: it is live attenuated vaccine that induces T cell response.
 Doses :
One dose is given within the 1st month of life.
 Route :
intradermal injection in left deltoid.

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  BCG induces T cell response ,therefore; its reaction won't be acute
- 2 weeks after vaccine injection  Local lesion, and papule
develop.
- 4-6 weeks  Small abscess might develop
- At 6 weeks  (crust, detaches, ulcerates), then a scar (typically
round and slightly depressed) remains

 Side effects :
1. Local abscess (at the site of injection)
2. “Not so serious” Lymphadenitis (axillary, cervical
lymphadenopathy); Non-suppurative (no pus) or suppurative (contains pus)
3. Serious Lymphadenitis : It can be persistent, axillary, large, recurrent or
multiple (neck, axilla)
4. BCG osteitis (affect the bone)
5. Disseminated (generalized) BCGosis in immunecompromised
 Contraindication:
Only “symptomatic HIV infection (i.e. AIDS)” is a contraindication for BCG
according to WHO.
 How to know if the child is vaccinated or not? look for the scar in his
left deltoid , but remember that 10% don't develop the scar .

2. DTP ‫البكتيي‬
‫ر‬ ‫المطعوم الثالث‬
 Bacteria :
 Corynebacterium Diphtheria; Gram positive rod. ‫الدفثييا \الخانوق‬
‫ر‬
 Clostridum tetani ; Gram positive rod . ‫الكزاز‬
 Bortedella Pertussis ; Gram negative bacillus . ‫السعال الديك‬

 Type :
D : toxoid
T : toxoid
P : Inactivated whole organism
 DTP has two types according to pertussis :
* Inactivated whole organism = DTP , or
*Acellular DTaP, cell wall is removed from the bacteria to reduce
side effects.
 DOSES :
DTP/DTaP : 6 doses given at day 61,day 91, day 121, 18 month , 6
years , 15 years.
Td : given after age of 6 ,,,, clostridum tetani & low dose Diphtheria
 ROUTE :

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 Given as Intramuscular injection in LUQ at the left upper quadrant of
thigh .
 Effectiveness :
Tetnus vaccine is effective for 10 yrs , so you have to repeat it every
10 yrs .
 Side effects:
1- Mild Problems (Common):
✓ Fever, Redness, swelling, Soreness (1 in 4)
✓ Fussiness (irritable, crying), Tiredness or poor appetite and
✓ Vomiting (1 in 50)
✓ These problems occur more often after the 4th and 5th doses of
the DTP series than after earlier doses.
2- Moderate Problems (Uncommon):
✓ Seizure (1 in 14,000), continuous crying for 3 hours or more
✓ (1 in 1,000), High fever (1in 16,000)
3- Severe Problems (Very Rare) :
✓ Serious allergic reaction (1 in a million doses)
✓ Long-term seizures, coma, or lowered consciousness, Permanent
brain damage .
✓ So RARE that it is hard to tell if they are caused by the vaccine.
 If child presents with mild or moderate reaction, no
contraindication to give pertussis but if it is severe >> pertussis is
contraindicated (DT <6 YO, dT >6 YO)

 Contraindicated :

1) Encephalopathy (coma, altered level of consciousness,

prolonged seizures) within 7 days of previous dose.
# Next dose shouldn't be given.

2) Progressive neurological disorder (Cerebral palsy (CP) is static not

progressive disorder so it isn't contraindicated.)

 Precaution :
1. Fever > 40.5 during 48 hours of previous vaccine.
2. Getting collapsed or shocked during 48 hours of previous vaccine.
3.seizure during 3 days of previous vaccine.
4. Persistent inconsolable crying more than 3 hours during the 1st 48
hours of pervious vaccine.

3. HBV : Hepatitis B virus ‫التهاب الكبد نوع ب‬

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  Bacteria :
Hepatitis B virus ( DNA virus ).
** Hepatitis A,C,D,E viruses are RNA virus.
** No hepatitis C vaccine.

 Type :
HBV vaccine is a Recombinant DNA surface antigen (Killed ).
 Effectiveness :
HBV vaccine is very effective & very safe .
 Doses :
3 doses are given at day 61, day 91, day 121 .
 Route :
Given as intramuscular injection at buttock.
SC HBV at buttock is less immunogenic than IM at deltoid.

 Special condition :
 HBV transmitted by sex , blood , vertically ( from mother to
fetus ) .Infant born to HBs Ag positive mothers should receive
the vaccine and HB Ig within 1st 12 hours of birth , one is given
in the left leg & the other on the right because they work
against each other.
 How to differentiate between infected and vaccinated person ?
✓ Infected person has (anti-HBsAg) + (anti-HbcAg )
[ antibodies against (hepatitis B surface antigen )+ (hepatitis
B core antigen )]
✓ Vaccinated person has anti - HBsAg ONLY . ( HBV is made
from the virus surface antigen by DNA-recombinant
technology )

4. Hib :
 Bacteria :
• Haemophilus Influenza ‫مطعوم السحايا‬/‫الميلية‬‫مطعوم المستديمة ز ز‬
Protect against epiglottitis and meningitis .
• Does Not cover nontypeable Haemophilus .
Doesn’t protect against otitis media ( which is caused by
nontypeable haemophilus ) .
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 Type :
Conjugated capsular vaccine .
 Doses :
3 doses given at day 61 , day 91 , day 121 .
 Route :
Given as Intramuscular injection at thigh .
 Contraindication :
• age less than 6 weeks .
 Special conditions :
Children over 5 years old usually don’t need Hib .
 Effectiveness :
Invasive disease does not confirm immunity ; pts. still require vaccines
if age appropriate, i.e , <5 yrs of age .

5. OPV,IPV :
 Virus :
POILO VIRUS : enterovirus RNA virus , Picornavirus family , it is the
leading cause of poliomyelitis; asymmetrical paralysis.

 Doses :
IPV given at day 61 , and day 91 .
OPV given at day 91 , day 121 , 10th month .

 Types :
OPV : live attenuated oral vaccine. ‫مطعوم شلل األطفال الفموي‬
IPV : Killed vaccine , given IM or SC . ( Injectable / Inactivated )
‫مطعوم شلل األطفال المقتول‬
o IPV elicit higher immunity serum IgG Ab level but OPV
produce mucosal IgA immunity and limit virus replication in
GIT.

 Side effect :
▪ OPV can cause VAPP ( vaccine associated paralytic polio ) ,
risk of having VAPP is much more after the first dose , so IPV
is given in the first dose not OPV.
▪ IPV : has no side effects , but it is more expensive than OPV

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 ** We still use OPV to achieve something called herd immunity (once the
vaccine is introduced to the body orally, some of it is shed in the stool & this
lead to immunize the individuals around in the same community), by this all
the community will be immunized **

 Contraindications :
▪ OPV is contraindicated in immunocompromised patients ( as
mentioned before.
▪ OPV is contraindicated in a patient who has another family
member who is immunocompromised ( because it's shed in
stool ).

6. MMR : Mumps Measles Rubella .

 Viruses :
Measles >> ‫الحصبة‬
Mumps >> ‫النكاف \ أبو دغيم \ أبو كعب‬
Rubella >> ‫الحصبة األلمانية‬
 Types :
Live attenuated vaccine .
 Doses :
Measles alone is given at 9 months & MMR at 18 months.
 Route :
Given as subcutaneous injection .
 Side effect :
mild rash , swelling of glands in the cheeks and neck.
 Precaution :
Recent blood transfusion within less than 11 month .
 Contraindications :
- Pregnant women or women intending to become pregnant within the
next 28 days .
- Contraindications of live – virus vaccine. ( go back )
- Person with anaphylactic egg or neomycin allergy.

** Children with minor acute illnesses (including febrile illnesses), non-

anaphylactic egg allergy, or a history of tuberculosis should be immunized.

** MMR are not contraindicated in household contacts of

immunocompromised children.

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 7. Rota vaccine

Added to the national Jordanian program in March/2015 .

 Viruse :
Rota virus .
 Route :
Oral
 Type :
live attenuated vaccine.
RotaTeq® (RV5) is given in 3 doses at ages 2 months, 4
months, and 6 months. Rotarix® (RV1) is given in 2 doses at
ages 2 months and 4 months.
 Doses :
 RotaTeq® (RV5) is given at 2nd , 3rd and 4th months in Jordan (
with the HIB, HBC , DTP )
 NO catch-up if behind (no doses after age of 8 month)
 Contraindications :
 Severe combined immunodeficiency.
 History of intussusception

 Effectiveness :
Safe and highly effective

 Other added vaccine .

1. Pneummococcal Vaccine
 Has two types : polysaccharide and conjugated.

Polysaccharide
▪ 23 Valent vaccine
▪ Usually 2 doses are given
▪ Help prevent serious pneumococcal
disease.: pneumonia , bacteremia ,
meningitis .
▪ Given for anyone > 2 years with any of
the following conditions : Heart or lung
disease, Sickle cell disease, DM ,
lymphoma, Leukemia , Kidney failure ,
Conjugated
▪ 13 Valent vaccine.
▪ Usually 4 doses are given .
▪ Help prevent serious pneumococcal
disease.: pneumonia , bacteremia ,
meningitis , also prevent some otitis
media.
▪ Can be given for children younger than 2
years .
▪ PCV13 is routinely given to children at 2,

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 asplenia, nephrotic syndrome , HIV or 4, 6, and 12–15 months of age. It is also
AIDs. recommended for children and adults 2
▪ Has minor side effect . to 64 years of age with certain health
conditions, and for all adults 65 years of
age and older. Your doctor can give you
details.
▪ Has minor side effect .

2. Varicella Vaccine
 Type :
Live attenuated .
 Can prevent chickenpox , and if the patient got chickenpox after he
took the vaccine ; it will be mild , fewer spots , less likely to have a
fever and faster recovery .
 Doses :
First dose : between 12th-15th month ,
Second dose : between 4th-6th year old age.
 Contraindicated : ( same as MMR )
Not contraindicated in household contacts of immunocompromised
children.
 Precaution :
Recent blood transfusion or blood product less than 11 month .

3. Influenza virus vaccine

A. Inactivated Influenza Virus Vaccine :

✓ Given IM ,,,, The recommended site of vaccination is the
anterolateral aspect of the thigh for younger children and the
deltoid for older children .
✓ Contraindicated in egg allergy
✓ Annual influenza vaccination is indicated for all children older
than 6 months of age who have a chronic health condition that
increases their risk of complications from influenza infection. (
asthma, DM, HIV, CF, sickle cell disease & cardiac condition) .
✓ Children younger than age 6 months should not be immunized.
✓ Two doses are recommended for children younger than age 9
years who are receiving influenza vaccine for the first time;

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 subsequent seasons require single doses. Older children receiving
vaccine for the first time require only a single dose.
B. Live influenza vaccine :
✓ Administered intranasally .
✓ Contraindicated in immunocompromised patients .
✓ Given only to healthy people , 2-49 yrs of age who are not
pregnant and do not have certain health conditions .

4. Meningococcal Vaccine
 Protect against Neisseria meningitides
 (MCV4) >> a tetravalent meningococcal polysaccharide-protein
conjugate vaccine
✓ Given IM,,, single dose .
✓ indicated for use between 2–55 years .
✓ This vaccine is protecting against meningococcal serogroups A, C,
Y, and W-135
✓ currently recommended for routine use in young adolescents
(aged 11–12 years), those entering high school (at approximately
15 years of age), and college freshmen living in dormitories, as
well as other groups at increased risk of meningococcal disease.
✓ MCV4 vaccination is contraindicated in someone with a prior
history of Guillain-Barre syndrome.
 ( MPSV4) >> a tetravalent meningococcal pure polysaccharide vaccine
✓ Given SC ,, single dose .
✓ protect against the same four strains of meningococcus, and
both are safe and immunogenic.
✓ indicated for use in persons 2 years and older .

5. HAV ( Hepatitis A Vaccine ) ‫مطعوم التهاب الكبد نوع أ‬

 Type :
Killed / Inactivated vaccine .

 Route :
Administered intramuscularly in two doses separated by 6–12 months.

 HepA vaccination is indicated for the following groups:

(1) travelers to countries with high rates of hepatitis A
(2) children with chronic hepatitis B or hepatitis C infections or other
chronic liver disease

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 (3) children with clotting factor disorders
(4) adolescent and adult males who have sex with men
(5) persons with an occupational exposure to hepatitis A
(6) illegal drug users.

 Very safe .

 Special conditions :
Post-exposure prophylaxis of persons who recently have been exposed
to hepatitis A and who previously have not received HepA vaccine
should be administered Intramuscular immunoglobulin , as soon as
possible but not more than 2 weeks after the last exposure.

 Additional Notes :
If HBV is missed it can be given at any time.
If Measles is missed it can be given at 12 month .
Child diagnosed with Cystic Fibrosis should take additional vaccine
:
✓ Pneumococcal conjugated vaccine 2 to 4 doses before 2
years of age at 2nd,4th,6th,18th month .
✓ Influenza after age of one year .
My kid has tonsillitis (mild infection) and he has to get vaccinated .
should I wait till the baby gets better ?
✓ No, in mild illnesses we give the vaccine .
My kid diagnosed with sickle cell anemia , what added vaccines
should he receive ?
✓ Pneumococcal (polysaccharide) > 2years.
✓ Hib.
✓ Influenza virus .
✓ HBV .

My kid diagnosed with G6PD anemia, what added vaccines should

he receive ?
✓ Hepatitis A , Hepatitis B

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 ‫‪National Jordanian Vaccination Program‬‬

‫‪Age‬‬ ‫‪1 mo.‬‬ ‫‪61 day‬‬ ‫‪91 day‬‬ ‫‪121‬‬ ‫‪10 mo.‬‬ ‫‪12 mo.‬‬ ‫‪18-24‬‬ ‫‪6 years‬‬ ‫‪15‬‬
‫‪day‬‬ ‫‪mo.‬‬ ‫‪years‬‬
‫‪vaccine‬‬

‫☻‬
‫‪BCG‬‬

‫☻‬ ‫☻‬ ‫☻‬ ‫☻‬

‫‪DTP‬‬ ‫‪Td‬‬ ‫‪Td‬‬

‫‪Polio V.‬‬ ‫‪IPV‬‬ ‫& ‪IPV‬‬ ‫‪OPV‬‬ ‫‪OPV‬‬ ‫‪OPV‬‬ ‫‪OPV‬‬

‫‪OPV‬‬

‫☻‬ ‫☻‬ ‫☻‬

‫‪HIB‬‬

‫☻‬ ‫☻‬ ‫☻‬

‫‪HBV‬‬

‫☻‬
‫‪Measles‬‬

‫☻‬ ‫☻‬
‫‪MMR‬‬

‫☻‬ ‫☻‬ ‫☻‬

‫‪Rota‬‬
‫‪vaccine‬‬
‫‪RV5‬‬

‫‪The End‬‬
‫‪Done by your colleagues from HOPE batch / 2010 :‬‬

‫‪Nadeen Al-shar'e & Doa'a Samarah Al Zou'bi‬‬

‫هذا تاري خ ر‬
‫البش‪ :‬والدة وزواج وموت‬
‫ثم والدة وزواج وموت‬
‫ثم والدة وزواج وموت‬
‫ز‬
‫كل ألف سنة من سلسلة أجيال خالية إال من الوالدة والزواج والموت‪ ،‬يظهر ف األرض مجنون‬‫ولكن ‪ّ :‬‬
‫ّ‬ ‫بش ى‬ ‫وبي ر‬
‫غي هذا العالم ر ز‬ ‫ز‬ ‫ً‬
‫أرف من سكان هذه األرض الذين ال‬ ‫ذو فكرة غريبة ويحقق حلما رآه ف عالم ر‬
‫جيان )‬ ‫ز‬
‫يرون ف أحالمهم سوى الوالدة والزواج والموت ( ر‬
‫جيان خليل ر‬
‫ً‬
‫رزقكم هللا جنونا ال شفاء منه (=‬

‫‪Edited and updated – 2017‬‬

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