TIME TO

VACCINATE!
POST GRADUATE INTERN
Gequillo, June Nathanie
Gerapusco, Angely June
Gubagaras, Patricia
Lee, Andrea
Lim, Andrea
 01
Immunization
 What is Immunization?
Ability of an organism to recognize and defend itself against
IMMUNITY specific pathogens or antigens.

Involves production of antibodies and generation of

IMMUNE RESPONSE specialized lymphocytes against specific antigens.

Is the administration of agent-specific, but safe, antigenic

components that in vaccinated individuals can induce
VACCINATION protective immunity against the corresponding infectious
agent.
 General Considerations
• Mechanisms involved
• Classifications of vaccines
• Schedules
• Routes of administration
• Adverse effects of contraindications to vaccination
• Vaccine safety
• Immunization in special clinical circumstances
 02
Mechanisms Involved in
Vaccination
 Immunity

Innate Acquired

Anatomic Phagocytic Cytokines Passive Immunity Innate

barriers barrier
Naturally Artificially Naturally Artificially
acquired acquired acquired acquired
PASSIVE VS ACTIVE IMMUNIZATION
Passive Immunization Active Immunization

Administration of Administration of antigens

preformed human or animal to stimulate the immune
antibodies system
 03
Classification
of Vaccine
Live-Attenuated Vaccines

• Derived from live antigens

• Most effective immune responses
• Contain weakened form of the “wild
or disease causing virus or bacteria
which must replicated in the
vaccinated person to produce an
immune response.
Inactivated Vaccines

• These vaccines contains no live

bacteria or viruses and cannot
replicate or cause disease from
infection, even in an
immunodeficient person.
 Multiple different antigens of an
organism mixed as a single product
to immunize against multiple
serotypes. Combination
Examples: Vaccines
Pneumococcal conjugate/
Polysaccharide vaccines
Polio vaccines

Antigens from pathogens causing

different diseases

Examples:
DTP,MMR
 04
Schedules and
Administration Concern
Vaccination Status
Age and timing of immunization are critical for the success of
vaccination.

Factors that determine optimal schedule to provide vaccines:

o Epidemiology of naturally-occurring disease

o Age-specific risk of complications caused by natural disease
o Anticipated immunologic response of host to the antigens
o Duration of immunity
o Recommended ages for routine health care visits
 05
Routes of
Administration
Site and Route of Administration
•Administered in areas UNLIKELY to cause local neural,
vascular, or tissue injury

•Demonstrate maximum safety and efficacy

•Vaccines with adjuvants can cause:

Local irritation, inflammation, granuloma formation or
necrosis if subcutaneous or intradermal routes are used
Route of Administration
ORAL INTRAMUSCULAR (IM) SUBCUTANEOUS (SC) INTRADERMAL (ID)
OPV DTwP, DTaP, DT, Td, TT Measles BCG

Rotavirus Hepatitis A Yellow Fever

Hepatitis B Varicella
IPV
HPV
Hib
PCV-7
Influenza
Intramuscular (Infants):
Anterolateral Aspect of the Upper part of the leg
Intramuscular (Older Children):
Deltoid Muscle of the Upper part of the arm
Subcutaneous:
Upper Outer Aspect of the Buttocks
Intradermal: Deltoid
Vaccine Dose
Can be:
oNearly complete and lifelong protection against a disease
after 1 or 2 doses

oPartial protection

oReadministered at regular intervals to maintain defense

Inactivated immunizing agents cannot replicate in the host and

repeated doses are required to achieve long-lasting immunity.
Vaccine Dose
Giving of smaller or divided doses DOES NOT reduce
inadequate response and less protection against the disease
oPreterm and low birth weight infants SHOULD still be given
full recommended doses to achieve optimal protection

However, exceeding the recommended dose is

POTENTIALLY hazardous
oEx: Toxoid vaccine – extensive local reactions
Simultaneous Administration of
Multiple Vaccines

•Most vaccines can be given simultaneously during same

clinic visit WITHOUT an impairment of effectiveness of safety

•Simultaneously administered vaccines are AS EFFECTIVE

and carry NO greater risk for adverse reactions
Simultaneous Administration of
Multiple Vaccines
Things to note:

•Vaccines should be given at DIFFERENT SITES to avoid

interference with the immune response

•Different vaccines SHOULD NOT be mixed in the same

syringe unless licensed for mixing by the vaccine
manufacturer
Vaccine Spacing and Intervals

•Intervals between doses provide optimal protection or

have the best evidence of efficacy.

•Administering doses of a multidose vaccine should

follow a schedule using the minimum age or
minimum interval criteria
Vaccine doses SHOULD NOT be given at intervals LESS than the
recommended minimal intervals or earlier than the minimal ages

However, vaccine doses administered up to 4

days before the minimum interval or age can be
counted as valid
Lapsed Immunization
An interruption of the recommended schedule or a delayed dose
DOES NOT REDUCE the response to the vaccine

No need restart a series or give additional doses after an

interruption of the schedule regardless of the time that has
elapsed between doses.

Exception:
o Oral typhoid vaccine – recommended to repeat series if
4-dose series is extended to more than 3 weeks
Vaccine Interchangeability

•IDEALLY, vaccination series with a particular

vaccine brand should complete the series with the
SAME brand.

•HOWEVER, studies suggest that interchanging one

brand when the previous one is UNAVAILABLE or
UNKNOWN does not adversely affect safety and
immunogenicity.
 06
Adverse Effects and
Contraindications to
Vaccination
Adverse Reactions Following VAccination

Adverse reaction or Side effect

oIs an untoward response caused by a vaccine that is
extraneous to its primary purpose of producing immunity

3 categories of adverse reactions:

oLocal reactions
oSystemic reactions
oAllergic reactions
 CATEGORIES OF ADVERSE
REACTIONS
LOCAL REACTIONS SYSTEMIC ALLERGIC
REACTIONS REACTIONS
• Least severe • More generalized • Most severe
• Most frequent • Symptoms are common • Least frequent
• Commonly seen and nonspecific • Severe allergic
reactions (Anaphylaxis)
– rare but may be
life-threatening
• Pain • Fever • Hives
• Swelling • Malaise • Swelling
• Redness at injection site • Myalgia • Wheezing
• Headache • Respiratory distress
• Loss of appetite
 Contraindications to Vaccination

Every person who administers vaccines should screen patient for

contraindications and precautions before giving the dose to
prevent or reduce risk of serious adverse reactions

Contraindication – condition in a recipient that greatly increases

the chance of a serious adverse reaction or death

Precaution – condition in a recipient that might increase the

chance or severity of a serious adverse reaction or compromise
the ability of the vaccine to produce immunity
 VACCINES SHOULD NOT BE ADMINISTERED
WHEN A CONTRAINDICATION IS PRESENT

PERMANENT TEMPORARY
CONTRAINDICATIONS CONTRAINDICATIONS
(Live vaccines)

1. Severe (Anaphylactic) Allergic 1. Pregnancy

reaction to a vaccine
component of following a prior 2. Immunosuppression
dose of a vaccine

2. Encephalopathy not due to

another identifiable cause
occurring within 7 days of
pertussis vaccination
Vaccines are DEFERRED when precautions is present

Vaccines are deferred UNLESS the

benefit of protection from the vaccine
OUTWEIGHS its potential harm
 PERMANENT PRECAUTIONS TEMPORARY PRECAUTIONS
(Measles- and Varicella-
containing vaccines)

1. Stop further doses of pediatric 1. Moderate or severe acute illness (all

pertussis-containing vaccine when these vaccines)
occur within 48 hours of dose: 2. Recent administration of an
• Temperature of 40.5oC or higher antibody-containing blood product
• Collapse or shock-like state (hypotonic
hyporesponsive episode)
• Persistent inconsolable crying lasting 3 or
more hours

2. Seizure with or without fever occurring

within 3 days of a dose
3. Unstable progressive neurologic problem
to the use of DTaP and Tdap
4. History of Guillain-Barre syndrome for
tetanus-containing influenza and MCV4.
INVALID CONTRAINDICATIONS
• Prematurity
• Breastfeeding
• Allergies that are not anaphylactic in nature
• Stable neurologic disorder (including seizure)
unrelated to vaccination
• Family history of adverse events
• Family history of seizure or a neurological
condition
 07
Vaccine Safety
Vaccine Safety

•No vaccine is perfectly safe or completely effective

•Clinicians and health providers should report any unusual or

serious adverse events possibly associated with vaccination

•Parents or patients SHOULD be advised at the time of

immunization the common minor vaccine reactions and how to
manage them

•If a serious problem occurs, they should be advised to return or

seek medical attention
Immunizations in
Special Clinical
Circumstances
Preterm and Low Birth Weight Infants

•Medically stable infants born at less than 37 weeks

and weighs <2500g SHOULD receive all routinely
recommended vaccines

•Given at the same chronologic age as term infants

•Exception: Hepatitis B vaccine

Immunocompromised Children
PRIMARY DISORDERS
Involves any part of the immune
system:
• Deficiencies affecting B-cells,
T-cells, and complement and
phagocyte function
SECONDARY OR ACQUIRED
DISORDERS
• HIV infection
• Receive immunosuppressive,
antimetabolic and radiation
therapy (eg. Malignancies, renal
and connective tissue diseases)
Children with Chronic Diseases

•Vaccines recommended for healthy children should also

be administered to those with chronic diseases

•All vaccines are given EXCEPT for live vaccines which

are CONTRAINDICATED

•Household contacts of patients with chronic illness should

be encouraged to receive vaccines recommended for
their age groups
Children with Personal or Family History of Seizures

•Increased risk of seizures among those with a

personal or family history (DPT, measles, or
varicella vaccination)

•Only a febrile seizure and is NOT a

contraindication to administration of vaccines
Adolescents

Likely to be exposed to vaccine-preventable diseases but may not be

optimally protected because:

oFailure to complete age-appropriate vaccination schedule earlier in life

oSuboptimal response to vaccines previously given
oWaning immunity despite appropriate vaccination

Strategies to address infrequent visits:

oPlanning a routine appointment in early adolescence

oVaccine delivery through school settings
 08
NATIONAL IMMUNIZATION
PROGRAM IN THE
PHILIPPINES
 Bacille Calmette-Guerin (BCG)

TYPE ROUTE DOSE AND TIMING INDICATION CONTRA-INDICATION ADVERSE EFFECTS

Live - ID • 0.05mL – children <12 Single dose given • TB patients • Keloid scar
attenuated months of age to all infants as • people with burns • suppurative regional
• 0.1mL – children >12 soon as possible adenitis
months of age after birth • skin infections • disseminated BCG
(preferable within • primary or infection
the first 2 months of secondary • Osteomyelitis in
life) immuno-compromise
immuno-deficiency
d

NOTES:

● Protects infants and young children against TB meningitis and disseminated TB disease
● DOES NOT protect against TB infection or reactivation of latent TB infection
 Hepatitis B Vaccine (HBV)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRA-INDICATION ADVERSE EFFECTS

Recombinant IM 0.5 mL Infants at birth, Severe allergic reaction • Arthralgia

/ Inactivated children, adults at • Neurologic
1st dose: 24 hrs of life high risk • Mild Fever
2nd dose: 1-2 months • Redness at the
after birth
injection site
3rd / Final dose: not
earlier than 24 weeks of
life

NOTES:
● For preterm infants with HBsAg NEGATIVE mother:
● 1st dose: Given at chronologic age of 1 month or at hospital discharge
● 2nd dose: 1 month old
● 3rd dose: 1-2 months after 2nd dose
● 4th dose: 6 months old

○ Testing of HBsAg and anti-HBs – recommended at 9-18 months of age

○
Diphtheria, Tetanus, Pertussis Vaccine
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Recombinant / IM 0.5mL Hypersensitivity • Fever

Inactivated
6 weeks
• Restlesness
10 weeks • Irritability
14 weeks • Local signs of
symptoms
Booster series of 3
doses

12- 18 months (DTP)

4-6 yrs (DTP)
10 yrs (Td/Tdap)
NOTES:

• Protects against diphtheria, tetanus, and pertussis (whooping cough)

• Fully immunized – defined as 5 doses of DTP, or 4 doses of DTP if 4th dose was given on or after the 4th birthday
 Pentavalent (DTaP-Hib-Hep B)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated IM 0.5 mL • Diptheria • immunodeficient • pain

• tetanus • anatomic functional • tenderness
6 weeks • hep b asplenia with sickle • infection on the
10 weeks • pertussis cell disease injection site
14 weeks • meningitis • fever
• pneumonia

NOTES:
 Haemophilus Influenzae Type B Vaccine (HiB)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated IM 0.5mL All infants, including Severe allergic • Pain

those born reactions • Redness
6 weeks prematurely
• Swelling at the
10 weeks
14 weeks injection site
• Fever and
• 1 booster dose irritability
between 12- 15
months / 6
months interval
NOTES:
 Poliovirus Vaccine (OPV)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Live Oral 0.5 mL The extent of • Anaphylactic Paralytic polio

attenuated protection against reaction to previous (extremely rare)
6 weeks polio is increased dose of OPV
10 weeks the earlier the OPV • Primary/acquired
14 weeks is given immunodeficiency
disorder
Booster dose:
4th birthday
NOTES:

• If 3rd dose of OPV is administered before the 4th birthday, a 4th dose should be provided before school entry (4-6
years old)
• The 4th dose is NOT needed if 3rd dose is administered on or after the 4th birthday
 Inactivated Poliovirus Vaccine (IPV)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated IM 0.5 mL The extent of • Anaphylaxis to • redness

protection against streptomycin, • swelling
6 weeks polio is increased polymyxin B or • lump
10 weeks the earlier the OPV neomycin after • pain
14 weeks is given previous dose of • low fever
IPV • vomiting
Booster dose: • Severe allergic • drowsiness
4th birthday reaction • joint pain
NOTES:
 Rotavirus
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE
EFFECTS
Monovalent 1 mL/ 2mL
Human vaccine 2 doses in 6-10 weeks,
(RV1) minimum interval of 4
weeks.
Last dose SHOULD NOT be
administered >24 weeks of
age
• Intussusception
Human-Bovine 1 mL/ 2mL
live-attenuated
Live Oral 3 doses in 6, 10, 14 weeks. Rotavirus • severe allergic • Diarrhea
reassortant attenuated (Minimum interval of 4-10 gastroenteritis reaction • Fever
(RV5) weeks)
(Oral liquid • anaphylaxis • Vomiting
formulation) Last dose SHOULD NOT be following • Cough
administered >32 weeks of age
Human-Bovine 1mL/2mL
previous dose
live-attenuated 3 doses in 2, 4, 6 months
reassortant Last dose SHOULD NOT be
(RV5) administered >12 months of
(Oral age
Freeze-dried
formulation)
Pneumococcal Conjugate Vaccine (PCV 13 or PCV 10)

TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Conjugate IM 0.5 mL Severe allergic • Erythema

vaccine/ reaction • Pain at the
purified 6 weeks injection site
capsular 10 weeks
polysaccha 14 weeks
ride
Booster dose:
6 months after 3rd
dose
NOTES:
 Pneumococcal Conjugate Vaccine (PCV)/
Pneumococcal Polysaccharide Vaccine (PPSV23)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Conjugate IM • 0.5 mL Given for high risk

vaccine/ • minimum age of 2 population
purified years old
capsular • Give one dose
polysaccha atleast 8 weeks
ride after final dose of
PCV to high-risk
children 2 years
and older
NOTES:
 Pneumococcal Conjugate Vaccine (PCV)/
Pneumococcal Polysaccharide Vaccine (PPSV23)
Patients aged 2-64 years with any of the listed medical
conditions should get 1 dose of PPSV23
Patients aged 2-64 years with any of the following
immunocompromised conditions should get 2 dose of PPSV23 5
years apart

• Chronic heart disease, heart failure and • Congenital Immunodeficiency

cardiomyopathies
• HIV infection
• Chronic lung disease (COPD, Asthma ,
emphysema) • Chronic renal failure of nephrotic syndrome

• Diabetes Mellitus • Leukemia or lymphoma

• CSF leaks • Generalized malignancy

• Cochlear Implant • Solid organ transplant

• Alcoholism • Multiple Myeloma

• Chronic liver disease • Iatrogenic Immunosuppression (treatment with

immunosuppressive drugs, radiation therapy)
 Influenza Vaccine (Trivalent/Quadrivalent)

TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated Trivalent 0.25 mL: 6-35 months History of anaphylaxis to

influenza 0.5 mL: 36 mos-18 yo egg/ previous dose of
vaccine (TIV) – influenza
IM or SC • Given at a minimum
age of 6 months
Quadrivalent • Children 6 mos to 8 yo
influenza receiving for the first
vaccine (QIV) time should receive 2
IM doses separately by at
least 4 weeks
• Children aged 9-18 yo
should receive 1 dose
of the vaccine yearly
NOTES:

● If only 1 dose was given in the previous influenza season, 2 doses should be administered for the current year and 1 dose
YEARLY thereafter
● Children given single dose for 2 consecutive years should continue to receive single annual doses
 Measles Vaccine
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Live SC • 0.5 mL Severe allergic Fever and rash

attenuated • 9 months reactions 5-10 days after
• If monovalent dose
measles is not
available, MMR
may be given

NOTES:

Can be given to children as young as 6 months during outbreaks or conditions with increase risk of measles
transmission.
Measles-Mumps-Rubella Vaccine (MMR)
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Live SC • 0.5 mL Severe allergic • Fever

attenuated • Given at a reaction to a vaccine • Rash
minimum age of 12 component / • loss of appetite
months anaphylaxis following
• 2 doses of MMR previous dose
vaccine are
recommended
atleast 4 weeks
apart
• 2nd dose usually
given from 4-6
years of age
NOTES:
Measles-Mumps-Rubella and Varicella Vaccine (MMR V)

TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Live SC • 0.5 mL Severe allergic • Fever

attenuated • Given at a reaction to a vaccine • Rash
minimum age of 12 component / • loss of appetite
months anaphylaxis following
• 2 doses of MMR previous dose
vaccine are
recommended
atleast 4 weeks
apart
• 2nd dose usually
given from 4-6
years of age
NOTES:
 Varicella Vaccine
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Live SC • 0.5 mL • Pregnant women • pain

attenuated • Given at a • Immunocompromis • redness
minimum age of 12 ed individuals • swelling at the
months injection site
• 2 doses • fever
• 2nd dose is usually • skin rash
given at 4-6 years
of age but may be
given earlier at an
interval of 3
months from first
dose
 Hepatitis A
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated IM • <18 yo: 0.5 mL Hypersensitivity • Pain

HAV • >19 yo: 1 mL reaction to any of the • Tenderness
• minimum age of 12 vaccine • Infection on the
mos injetion side
• 2 doses
• 6 mos apart
Live SC • minimum age of 18
attenuated mos
HAV • single dose only

NOTES:
Japanese Encephalitis Live Attenuated Recombinant Vaccine

TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated SC • Given at a Hypersensitivity to Generalized

minimum age of 9 proteins of rodents or urticarial and
months neural origin, to angioedema can
• children 9 mos to thimerosal or to occur within
17 yo should previous dose of JE minutes to as long
receive one vaccine as 2 weeks after
primary dose vaccination
followed by a
booster dose 12-24
mos after primary
dose
• 18 years and older
should receive a
single dose only
NOTES:
 Human Papillomavirus Vaccine
TYPE ROUTE DOSE AND TIMING

Recombina IM
nt 9-14 years – 2 dose series is recommended

• Bivalent HPV (2vHPV), quadrivalent (4vHPV) or nonavalent (9vHPV) given at 0 and 6 months

• If the interval between the 1st and 2nd dose is less than 6 months a 3rd dose is needed

• The minimum interval between the 2nd and 3rd dose is 3 months

15 years and older, a 3 doses is recommended

• Bivalent HPV (2vHPV), quadrivalent (4vHPV) or nonavalent (9vHPV) given at 0, 2 and 6 months

• The minimum interval between the 1st and 2nd dose is 1 month and the minimum
interval between the 2nd and 3rd dose is 3 months

• The 3rd dose should be given at least 6 months from the 1st dose
NOTES:
● For males 9-18 years of age, a 4vHPV and 9vHPV can be given for the prevention of anogenital
warts and anal cancer
etanus and Diphtheria Toxoid (Td)/ Tetanus and Diphtheria Toxoid and
Acellular Pertussis Vaccine (TdaP)
TYPE ROUTE DOSE AND TIMING

Toxoid IM • 0.05mL
(Inactivate • For children who are fully immunized, Td booster doses should be given every 10
years
d toxin)
• For children aged 7 years old, a single dose of Tdap can be given and can replace due
Td.

• It can be administered regardless of the interval since the last tetanus and diphtheria
toxoid-containing vaccine. Subsequent doses are given as Td

For pregnant adolescents:

• Fully immunized: administer 1 dose of Tdap vaccine during 27 to 36 weeks AOG
regardless of previous Td or Tdap vaccination.

• Unimmunized: administer a 3 dose tetanus-diphtheria (Td) containing

vaccine following a 0-1-6 month schedule. Tdap (preferably the
1st dose) should replace one dose of Td given during 27 to 36 weeks AOG.

NOTES:
 Schedule of the Philippine Expanded
Program on Immunization ( Philippine EPI)
Vaccines in Special
Circumstances
 Rabies Vaccine
TYPE ROUTE DOSE AND TIMING

Inactivated IM or ID • 3 doses given at 0, 7 and 21 or 28 days

o PVRV (IM): 0.5mL
o HDCV, PCEC, PDEV (IM): 1.0mL
o PVRV, PCEC (ID): 0.1mL

Booster:
• 1-visit regimen given on each of the 4 sites on day 0
0.1mL (ID) – (PVRV or PCECV)

• 2-visit regimen given at 1 site on days 0 and 3

0.1mL (ID) – (PVRV or PCECV)
OR
0.5mL (IM) – (PVRV)
OR
1.0mL (IM) – (PCECV)
NOTES
• Post-exposure prophylaxis (PEP) refers to anti-rabies treatment AFTER an exposure to potentially rabid animals
• Wound care + Administration of vaccine with or without rabies immune globulin (depending on category of
exposure)
 Typhoid Vaccine
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Vi capsular IM 0.5 mL Recommended for

polysaccha travelers to areas
ride Given at a minimum where there is risk
age of 2 yo with for exposure and for
revaccination every outbreak situations
2-3 years as declared by the
public health
authorities
NOTES:
 Cholera Vaccine
TYPE ROUTE DOSE AND TIMING INDICATION CONTRAINDICATION ADVERSE EFFECTS

Inactivated Oral 3 mL Recommended for

outbreak situations
Given at a minimum and natural disaster
age of 12 mos as a as declared by the
dose series two weeks public health
apart authorities

NOTES:
Thank you