General Principles of Immunization

1. Key differences between live attenuated and inactivated vaccines.

2. Types of vaccines and examples

Live Attenuated Inactivated Vaccines

 Weakened form of the “wild” virus/bacteria  Cannot replicate, and not live
 Must replicate to be effective  Minimal interference from circulating Ab
 Immune response similar to natural infection  Not as effective as live vaccines
 Usually effective w/ 1 dose  Require multiple doses (3-5)
 Severe reactions are possible  Immune response mostly humoral
 Interference from circulating antibiody  Ab titer falls over time requiring booster dose
 Heat labile  Whole cell vaccine: influenza, polio, rabies,
 Viral: measles−mumps−rubella, varicella, herpes hepatitis A, Japanese encephalitis, pertussis,
zoster, yellow fever, oral polio, influenza nasal typhoid, cholera
spray, rotavirus, dengue virus  Fractional Vaccine: hepatitis B, influenza,
 Bacterial: Bacille Calmette−Guérin, oral typhoid acellular pertussis, human papillomavirus,
typhoid vaccine
 Toxoids: Diphtheria toxoid, tetanus toxoid
 Conjugate Polysaccharide: Pneumococcal,
meningococcal, Haemophilus influenzae type b
(Hib)
 Whole cell vaccines: from whole organisms that have been inactivated by chemical, thermal, or other means
 Fractional: from components of the whole organism
 Toxoids: inactivated toxins of toxin−producing bacteria
 Polysaccharide vaccines: polysaccharide is linked to proteins to increase effectiveness

3. Guidelines on timing and spacing of vaccines

Timing and Spacing of Vaccines
• Vaccines should not be administered at intervals less than minimum intervals
• For multi-dose vaccines: may administer < 4 days prior to next schedule. “Grace period”
• NOT applicable with RABIES vaccine
• NOT applicable with 2 live vaccines
• If next dose is administered > 5days earlier than interval or age: Dose should NOT be counted as valid dose and should be repeated.
• Repeat dose should be spaced after the invalid dose by the recommended minimum interval

Simultaneous administration of vaccines

• Administrations of more than one vaccine
• On same clinic day
• Different anatomic sites
• Not combined in the same syringe
• 2 live vaccines should always be administered on same day,
• If NOT possible: live vaccines should be separated at least 4 weeks
• If given < 4 weeks: 2nd vaccine should not be counted and dose should be repeated at least 4 weeks
• < 4 day “grace period” not applicable
Exception/s
• Yellow fever vaccine given < 4 weeks after MMR or Univalent Varicella vaccine
• Persons with functional or anatomic asplenia
• PCV13 should be given first and then followed by meningococcal conjugate vaccine 4 weeks later
Non-simultaneous administration of vaccines
• Any inactivated vaccine can be administered either simultaneously or at any time before or after a different inactivated or live vaccine
Exception/s
• 4-week interval between PCV13 and quadrivalent polysaccharide-protein conjugate vaccine in a person with anatomic asplenia
• Separation of doses between PCV 13 and pneumococcal polysaccharide vaccine (PPSV)
• If PCV 13 is given first: PPSV is given 6-12 months for non-high risk, 8 weeks minimum
• If PPSV is given first: PCV 13 is given 1 year minimum

4. Valid and invalid contraindications to vaccinations

Permanent contraindications:

 severe allergic reaction to a vaccine component or following a prior dose

 encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination
Invalid Contraindications
 Mild illness- Low-grade fever is not a contraindication to vaccination. Measuring temperature is not necessary before vaccination if the patient does not
appear ill and does not report currently being ill. ACIP has not defined a body temperature above which vaccines should not be administered. The
decision to vaccinate should be based on the overall evaluation of the person rather than an arbitrary body temperature.
 Nonanaphylactic Allergy- If an allergy to a vaccine component is not severe (e.g., is not anaphylaxis), it is not a contraindication to that vaccine. Only a
severe allergic reaction (e.g., anaphylaxis) to a vaccine component is a true contraindication to vaccination.
 Allergy to Products Not Present in Vaccines- There is no contraindication or precaution for persons with nonspecific allergies, duck or feather allergies,
or penicillin allergy, or for persons who have relatives with allergies or those taking allergy shots. Anyone with these allergies can and should be
vaccinated. No vaccine available in the United States contains duck antigen or penicillin.
 Antimicrobial Therapy- Antimicrobials do not influence the immune response to most vaccines. However, antiviral drugs may affect vaccine replication
in some circumstances. FluMist should not be administered until 48 hours after cessation of oseltamivir and zanamivir, 5 days after cessation of
peramivir, and 17 days after baloxavir. If possible, antiviral drugs (acyclovir, famciclovir) that are active against herpesviruses should be discontinued
24 hours before administration of a varicella-containing vaccine.
  Breastfeeding- Breastfeeding does not decrease the response to any routinely recommended childhood vaccine and is not a contraindication to
vaccination; however, breastfeeding is a precaution for yellow fever vaccine. Breastfeeding also does not extend or improve the passive immunity to
vaccine-preventable disease that is provided by maternal antibody.
 Household Contacts of Pregnant or Immunosuppressed Persons- Being a household contact of a pregnant woman or immunosuppressed person is
usually not a contraindication to vaccination. In fact, it is critical that healthy household contacts of pregnant women and immunosuppressed persons be
vaccinated. Vaccination of healthy contacts reduces the chance that pregnant women and immunosuppressed persons will be exposed to vaccine-
preventable diseases.
Most routinely recommended vaccines, including live vaccines (MMR-II, Varivax, RotaTeq/Rotarix, and FluMist), can be administered to persons who
are household contacts of pregnant or immunosuppressed persons. If a varicella vaccine recipient has a rash after vaccination, direct contact with
susceptible household contacts with altered immunocompetence should be avoided until the rash resolves. All members of the household should wash
their hands after changing the diaper of an infant who received rotavirus vaccine. This minimizes rotavirus transmission, as shedding may occur up to
one month after the last dose. FluMist should not be administered to close contacts and caregivers of severely immunosuppressed persons who require a
protected environment.
 Preterm Birth- Vaccines should be started on schedule based on the child’s chronological age. Preterm infants have been shown to respond adequately to
vaccines used in infancy.
Studies demonstrate that decreased seroprotection rates might occur among infants with low birth weight (less than 2,000 grams) after administration of
hepatitis B vaccine at birth. However, by the chronological age of 1 month, all preterm infants, regardless of initial birth weight or gestational age, are
likely to respond as adequately as older and larger infants.
 Tuberculin Skin Test- Persons who need a tuberculin skin test (TST) can and should be vaccinated. All vaccines can be administered on the same day as
a TST or at any time after a TST is administered. For most vaccines, there are no TST timing restrictions.
MMR-containing vaccine may decrease the response to a TST, potentially causing a false-negative response in someone who has a tuberculosis
infection. MMR-II can be administered the same day as a TST, but if MMR-II has been administered and 1 or more days have elapsed, it is
recommended in most situations to wait at least 4 weeks before administering a routine TST.

Adult Immunization

Vaccine Route Schedule Recommendation Contraindication

Live Attenuated
1. MMR SC 1-2 doses, at least 4 weeks apart 1 dose w/n 72H post-exposure prophylaxis Pregnant
<200 CD4 count
Severe illness, ex. TB, postpone vax,
 anaphylaxis
2. Varicella SC 2 doses, at least 4 weeks apart 1 dose w/n 72H post-exposure prophylaxis Pregnant
<200 CD4 count
Severe illness, Anaphylaxis
3. Herpes SC 1 dose Iimmunocompetent adults ≥60 years old Pregnant
Zoster with or without prior history of herpes <200 CD4 count
zoster Anaphylaxis
**Adjuvanated IM 2 doses, 2-6 mos apart NO CONTRAINDICATION
Recombinant ZV
≥50 years, for the prevention of herpes
zoster and related complications,
irrespective of prior receipt of varicella
vaccine or ZVL
Inactivated
1. Cholera Oral Killed Whole Cell Monovalent Co−administration with 3 ml bicarbonate <2 yrs old
2 liquid doses with Primary vax repeated after 2 years
2−6−weeks interval
** if 2nd dose is delayed for
more than 6 weeks, the
vaccine schedule should be
restarted.
**delay food 1 hour
before/after admin
Modified Killed Bivalent Revax more than 3 years
2. Hepa B IM Monovalent/Bivalent: 3 doses Severe allergic reaction
0,1,6 mos
Early vax: 0,2,6 WEEKS then
1 yr booster
3. HPV IM Bivalent: 0,1,6 mos 18-25y.o.
Quadrivalent and Nonavalent: 9 y.o- F
0,2,6 mos 13-21 y.o- M
4. Influenza IM Yearly Inactivated influenza vaccine can be
administered to those who are pregnant in
the 2nd or 3rd trimester or planning to be
pregnant during the influenza season
** vaccines are available in the Phi1ippines
from February−June
Medical Conditions PCV 13 indicated PSV23 indicated PPSV23 revaccination PCV13 indicated for PPSV23 indicated for age
for age 19 years or for age 19-64 years indicated for age 19-64 years age 65 years or older 65 years or older
 older
None No No No Based on shared Yes, If PCV13 has been
clinical decision- given, then give PPSV23 at
making least 1 year after PCV13
Chronic heart disease, No Yes No Based on shared Yes
chronic lung disease, clinical decision- If PCV13 has been given,
diabetes, alcoholism, making then give PPSV23 at least 1
chronic liver disease year after PCV13 and at
(including cirrhosis), least 5 years after any
current cigarette smoking, PPSV23 given at less than
asthma age 65 years
Cerebrospinal fluid leak, Yes Yes No Yes Yes
cochlear implant At least 8 weeks If no previous PCV13 At least 8 weeks after
after PCV 13 vaccination PCV13 and at least 5 years
after any PPSV23 given at
less than age 65 years
Functional or anatomic Yes Yes Yes Yes Yes
asplenia (including sickle At least 8 weeks At least 5 years after first dose If no previous PCV13 At least 8 weeks after
cell disease/other after PCV13 of PPSV23 vaccination PCV13 and at least 5 years
hemoglobinopathies) after any PPSV23 given at
less than age 65 years
Immunocompromising Yes Yes Yes Yes Yes
conditions* At least 8 weeks At least 5 years after first dose If no previous PCV13 At least 8 weeks after
after PCV13 of PPSV23 vaccination PCV13 and at least 5 years
after any PPSV23 given at
less than age 65 years

1. Recommended vaccination by age group in the absence of documented vaccination or evidence of past infection
2. Recommended vaccination in special populations; Contraindicated vaccines in special populations; Indicated vaccination in special populations if benefit of
protection outweighs risk