RNB30704

COMMUNITY HEALTH NURSING

I. IMMUNIZATION
II. COLD CHAIN
 Learning Outcomes
At the end of this session, students should be able to:
 define immunization
 describe immunity, active and passive immunity
 explain primary and secondary response
 describe the factors that reduce the potency of the
vaccine
 describe the live attenuated, killed vaccine and their
advantages and disadvantages
 describe the side effects of immunization
 explain the ‘cold chain’
 Learning Outcomes
 Describe the Malaysian immunisation schedule
 Describe the expanded programme on
immunisation
 Define the nursing aspect in the responsibilities in
the management of immunisation, cold chain and
the process of immunisation sessions
 Maintain cold chain during an immunisation
session
 Advise the mother and maintain records keeping
 Introduction of Immunization
 Immunization is a process of protecting an individual
from a disease through the introduction of live, killed or
partial components of the organism (bacteria or virus).
 The individual acquires immunity by the production of
the antibodies in the body.
 Immunization is one of the most effective and efficient
ways to prevent infectious diseases.
 The infant is protected from infections through the
mother’s antibodies during the early months of his life.
 Introduction of Immunization
 The antibodies are transmitted through the placenta
to the infant.
• The maternal antibodies will remain in the infant for
several months. By the time the infant reaches 1 year,
the antibodies are no more effective and the infant
therefore has to start developing his own antibodies.
 Thus vaccines are introduced to the infant to make
him/her build and produce own antibodies.
 Vaccines are used to immunize children and adults
from the occurrence of diseases through the
production of antibodies in the individual.
 Classification of Immunity
 Immunity is classified into innate
immunity and acquired immunity.
 The innate immunity is the
immunity that an individual
possesses due to genetic make up
and his constitution. It is well
known that certain races are
immune to certain diseases due to
innate immunity.
 The acquired immunity can further
be classified as active immunity
and passive immunity.
 Classification of Immunity
Active immunity
 Is the immunity when an individual develops as a result of
infection or by specific immunization.
 Active immunity can be humeral or cellular or a
combination of both. It is associated with antibodies or
cells having specific action on the microorganisms
concerned.
 It can be acquired after:
• An infection like chicken pox, measles and rubella
• A subclinical infection as in polio, pertussis and
diphtheria
• An immunization using killed vaccines, live attenuated
vaccines or a toxoid
 Classification of Immunity
Passive immunity
 The vaccine is produced by one’s body (human or
animal) and then transferred to another to induce
protection.
 In this case, therefore, the body does not produce the
antibodies. The antibodies are produced elsewhere and
given to an individual.
 The passive immunity can be induced by:
• Administering an immunoglobulin or antiserum which is an
antibody containing preparation.
• Placental transfer of maternal antibodies through the
placenta to the baby
• Breast milk also contains some antibodies
 Classification of Immunity
Comparison of active & passive immunity
 When compared with active immunity, passive
immunity is rapidly established but the immunity is
only temporary and the body does not have a
mechanism to remember it.
 Herd Immunity
 It is the immunity of a group or community.
 It is referred to the resistance of a group to invasion and
spread of an infectious agent.
 This is based on the premise that a high proportion of
individuals are immunized and so the group is resistant to
infection.
 Herd immunity provides an immunological barrier to the
spread of disease in the community.
 If diseases attack a population which has no herd
immunity or has not been immunized, the chances are
that the population may experience many cases and the
mortality rate will increase.
 It is very difficult to define the exact percentage of
cases that need to be immunized, but 80–90% is
considered good herd immunity.
Herd Immunity

Contagious diseases can be

kept from spreading with herd
immunity
Herd Immunity
 Primary Response
 When an antigen is administered to humans or animals
for the first time (never been exposed to it before), there
is a delay of 3 to 10 days in the production of the
antibodies.
 The antibody that is produced initially is the IgM type
and the IgM titre will rise for 2–3 days and then reach a
peak level. It then declines as quickly as it developed.
 If the antigen was sufficient, IgG antibodies will appear
in a few days and the IgG will peak in 7–10 days. It then
gradually declines over a few weeks and months.
 For a small dose of the antigen, only the IgM antibody may
be produced.
 Primary Response

IgG 7–10 days

Antibody
concentration
IgM
2–3 days
 Primary Response
 The primary response to an antigen depends on a few
factors:
• Nature of antigen
• Dose of antigen
• Adjuvant (substance which enhances
the body's immune response to an antigen)

• Route of administration
• Nutritional status of the host
 Secondary Response
 Is the response to the immunization given for the
second time to the body.
 Because of past immunological memory, the response
in the production of antibodies is much faster.
 Differences between the primary response and the
secondary response:
• The latent period is shorter.
• The production of the antibody is much faster.
• Antibody is produced in large quantities.
• The antibody response is maintained at higher levels for a
longer period of time.
• The antibody has greater avidity to bind the antigen.
• There is a short period of IgM production and then a
much longer and larger production of IgG antibody.
 Factors that can Influence
the Outcome of Vaccination
i. Age of the infant
• The newborn is able to produce antibodies to
vaccines.
• Premature baby may be too immature to take the
vaccine, so the vaccine should be given at the
appropriate time.
ii. Dosage of the vaccine
• The vaccine dosage must be adequate to provide the
protection.
 Factors that can Influence
the Outcome of Vaccination
iii. Temperature of the vaccine
• The vaccines lose their potency if not kept in appropriate
temperatures (2 ⁰C– 8 ⁰C).
• The vaccines have to be kept at low temperatures from
the production facility to the site of use (cold chain).
iv. Timing of vaccination
• Some vaccines require more than one dose for full
protection. This will increase the immunity by secondary
response.
 Vaccines
 Vaccines are immuno-biological substances
designed to produce specific protection against a
given disease.
 Vaccines stimulate the production of antibodies and
other immune mechanisms in the body.
 Classification Vaccines
1. Live attenuated vaccines
• Live attenuated vaccines are generally from live
organisms which are weakened and thus do not have
the virility to cause the disease.
• The organisms have been cultured in the laboratory
repeatedly on tissue culture and they have lost the
capacity to produce the disease.
• However, they retain the immunogenicity.
• Live vaccines are better than killed vaccines because
they are more potent.
• Must be properly stored at the right temperature
 Classification Vaccines
2. Killed vaccines
• These vaccines are those from organisms that are
killed but can still be used to produce antibodies in
the body.
• The organisms are killed by heat or chemicals.
• They are safe but less effective than live vaccines.
 Classification Vaccines
Organisms Live attenuated Killed vaccines Toxoids
vaccines
Bacterial BCG Typhoid Diphtheria
Typhoid Cholera Tetanus
Pertussis
Meningitis

Viral Oral polio Rabies

Yellow fever Polio
Measles Influenza
Rubella Hepatitis B
Mumps Japanese B
Influenza Encephalitis
 Combined Vaccines

 Combined vaccines are those that have more than

one kind of immunizing agent.
 Examples:
– DPT (Diphtheria, Pertussis and Tetanus)
– DT (Diphtheria and Tetanus)
– MMR (Mumps, Measles and Rubella)
 The main purpose of combining vaccines is to
provide convenience to the mother.
 Combined vaccines will help to reduce the number
of visits of the mother to the health clinic.
 Combined Vaccines
 Why combined vaccines?
• Vaccines are combined for cost-effective purposes.
• The immune response in combined vaccines is not
reduced and the adverse reactions are not increased.
 However, the live and killed vaccines are not
supposed to be mixed.
 Route of giving the vaccines
• Each vaccine has the recommended route of
administration and we have to follow the instructions
carefully.
 Polyvalent Vaccines
 Polyvalent vaccines are vaccines that are produced
by two or more strains of the same vaccine.
 Polio and influenza are two types of vaccines that
are polyvalent as they contain all the strains of the
virus.
 Toxoids
 Toxoids are toxins that have been detoxified.
 Toxins are produced by certain bacteria and when
these toxins are detoxified, they are called toxoids.
 Tetanus toxoid is one example of toxoids.
 The antibody will neutralize the toxins produced by
the bacteria.
 Vaccine Potency
 Vaccine potency can be defined as a
quantitative measure of the specific ability of the
vaccine to achieve its intended biological effect
in the desired biological assay.
 If a vaccine loses some or all of its potency due to
extremes of temperature or if the cold chain is
broken, its outward appearance may be unchanged.
 A vaccine can lose its potency due to exposure to
heat although its outward appearance may be
unchanged.
 National Immunization Programme
Age Vaccine Components
At birth BCG Bacillus Calamite Guerin
Hepatitis B (Dose 1) Hepatitis B vaccine

2 month DTaP Diphtheria, Tetanus, Pertussis

Hib Hamophilus influenza
IPV Dose 1 Intramuscular Polio Vaccine
Hepatitis B Hepatitis B vaccine
3 month DTaP Diphtheria, Tetanus, Pertussis
Hib Hamophilus influenza
IPV Dose 2 Intramuscular Polio Vaccine
Hepatitis B Hepatitis B vaccine
4 month Pneumococcal Dose 1 Pneumococcal

5 month DTaP Diphtheria, Tetanus, Pertussis

Hib Hamophilus influenza
IPV Dose 3 Intramuscular Polio Vaccine
Hepatitis B Hepatitis B vaccine
6 month Measles (Sabah only) Measles
Pneumococcal Dose 2 Pneumococcal
 National Immunization Programme

Age Vaccine Components

9 month JE (Dose 1) (Sarawak) Japanese Encephalitis
MMR (Dose 1) Mumps, Measles,
Rubella
12 month MMR (Dose 2) Mumps, Measles, Rubella

15 month Pneumococcal Booster Pneumococcal

18 month DTaP
Hib
IPV Booster
Hepatitis B
21 month JE (Dose 2) (Sarawak) Japanese Encephalitis
 National Immunization Programme
Umur (Bulan)
(Tahun)
VAKSIN
0 1 2 3 4 5 6 8 9 12 15 18 21 7 13 15
Dos
BCG
1
Dos
Hepatitis B
1
DTaP-IPV- Dos Dos Booste
Dos 3
HepB-Hib 1 2 r

Sabah
Measles
sahaja

Dos
MMR Dos 2
1
Dos
JE
1 Dos 2
DT Booster
1

MR Booster

Perempu
HPV an sahaja
(2 dos)2

Boost
Tetanus
er
National Immunization Programme
Record of giving
vaccination in the
Hexa Dos 1
Children's Health
Records Book 0-6 years
Hexa Dos 2 • Hexa Dos 1 given at the age of 2 month is
recorded in the Hep B (1 month) space and
DTaP-IPV//HiB (2 month).

Hexa Dos 3 • Hexa Dos 2 given at the age of 3 month is

recorded in the DTaP-IPV//HiB ( 3 month)
space.

• Hexa Dos 3 given at the age of 5 month is

recorded in the Hep B (6 month) space and
DTaP-IPV//HiB (5 month)
Hexa
Booster • Hexa Booster Dose given at the age of 18
Dose month is recorded in the DTaP-IPV//HiB (18
month) space.
Checklist Before Giving Immunization
1. Date
2. Body temperature
3. General health
4. Past health history
5. Present health history
6. Is the child
– Having fits/seizure
– diarrhea/vomiting
– Receiving immunoglobulin
in the last 9 months
– On treatment for cancer
– Infected with HIV
COLD CHAIN
 Introduction
 The cold chain is a very important component of the
immunization programme, because most vaccines
can lose potency over time, especially if exposed to
heat.
 With the temperature in Malaysia being hot, it is very
important to maintain the cold chain.
 It is useless to immunize children if the vaccines are
not potent.
 Paying special attention to the temperature of the
vaccine during storage and transportation is
therefore a very important task of the health worker.
 Cold Chain
 The system used for storing vaccines in good
condition is called the cold chain.
 It is sometimes referred to as the vaccine supply
chain, or the immunization supply chain.
 The cold chain consists of a series of links that are
designed to keep vaccines within WHO
recommended temperature ranges, from the point of
manufacture to the point of administration in the
community health clinic.
 It involves the transporting and storing vaccines
within the temperature range of 2 ⁰Cto 8 ⁰C.
Cold Chain
Cold Chain
 Components of the Cold Chain
Personnel
 The health personnel must maintain the vaccines at
certain temperatures at all times.
 They must take responsibility and accountability of
maintaining the temperature of the vaccines.
Equipment
 The right type of equipment must be available to
maintain the cold chain at all levels.
Domestic Refrigerator
Domestic Refrigerator
Top Loading
 Components of the Cold Chain
Procedures
 The procedures to maintain the cold chain must be
available at all places and it must be made clear to
all the nursing staff.
 Proper training programmes must be conducted
regularly to educate the staff working in the health
centre on the use of the equipment and
maintenance of the cold chain.
Maintain Cold Chain during an Immunization
Session in the Clinic
 The vaccines are maintained at the temperatures in
the refrigerator/top loading at all times.
 The refrigerator should not be opened frequent.
 The minimax thermometer must be used to measure
the minimum and maximum temperature every
morning and evening.
 The minimum temperature should be > 2 ⁰Cand the
maximum temperature should not go above 8 ⁰C.
 Even during the clinic session the temperature in the
cold box should be maintained.
Minimax thermometer
 Cold Box

STOK SEMASA BCG

Cold Box
Cold Box

Dial thermometer
Cold Box
Maintain Cold Chain during an Immunization
Session in the Clinic
 The cold chain is maintained during the clinic session
by:
• Taking out the exact quantity of vaccines from the main
refrigerator/top loading required for the session.
• The number of vaccines required for the session will be
known since the clinic follows the appointment system.
 Take the vaccine from the cold box and administer after
assessing the child and explaining to the mother.
 After the session, the remainder of the vaccines are put
back in the refrigerator/top loading.
 Health Education to the Mother
 The mother must be informed regarding all the
vaccinations and the side effects and possible
complications of any vaccinations.
 After the immunization, the mother may need some
counselling regarding the child. She needs to be
informed when to come for the next immunization.
 The records and the immunization card are kept by the
mother. The public health nurse should explain
regarding the growth and development charts on the
card and the milestones on the card.
 The immunization record is maintained so that the child
gets the full immunization
 Documentation

 Similar child health record book as the copy of the

mother will be kept in the clinic.
 The records are maintained in child health clinic
registration book and the summary of all the
immunization done in the clinic is sent to the district
health office.
 The district health office compiles all the information
and sends it to the state which then sends it to the
Ministry of Health.
Student Activities and Further Reading

1. Contingency plan in maintaining cold chain in

the health clinic
2. Adverse events following immunization (AEFI)
3. Refusal of vaccination