Immunization

FOR C-1 MED STUDENT

DR MULUKEN
JAN/2018
DEFINITION
 Immunization is the process of inducing
immunity against a specific disease.
 Passively through administration of antibody-containing preparations
 NATURAL AND BY ADMENISTRATION ANTIBODY
 Actively by administering a vaccine or toxoid to stimulate the immune system
to produce immune response.
 Vaccination : Administration of any vaccine or Toxoid for prevention of
disease
DEFINITION…….

 Toxoid : A modified bacterial toxin that has been made

non-toxic but retains the capacity to stimulate the
formation of antitoxin.
 Antitoxin : An antibody derived from the serum of
humans or animals after stimulation with specific
antigens ,used to provide passive immunity.

Immunoglobulin: An antibody-
containing solution derived from human blood by
fractionation of large pools of plasma
PASSIVE IMMUNITY
 Passive immunity is achieved by administration of
preformed antibodies to induce transient
protection against an infectious agent.
 Products used include
 immunoglobulin (IG) administered intramuscularly (IM)
 intravenous IG (IVIG);
 specific or hyper-immunoglobulin preparations administered IV;
 antibodies of animal origin;
 monoclonal antibodies;
 and subcutaneous (SC) human IG, which has been licensed to treat
patients with primary immunodeficiencies.
 naturally through transplacental transfer of maternal antibodies (IgG)
during gestation.
PASSIVE IMMUNIZATION…
 The major indications for passive immunity:
 Immunodeficient children with B-lymphocyte defects who have difficulties
making antibodies,
 Persons exposed to infectious diseases or who are at imminent risk of
exposure where there is not adequate time for them to develop an active
immune response to a vaccine,
 Persons with an infectious disease as part of specific therapy for that disease.
IMMUNE GLOBULIN AND ANIMAL ANTISERA
PREPARATIONS
PRODUCT MAJOR INDICATIONS
Replacement therapy in primary immunodeficiency disorders
Immune globulin for
intramuscular injection Hepatitis A prophylaxis
Measles prophylaxis
Replacement therapy in primary immune-deficiency disorders
Kawasaki disease
Immune-mediated thrombocytopenia
Intravenous Pediatric HIV infection
Immunoglobulin (IVIG)
Hypogammaglobulinemia in chronic B-cell lymphocytic leukemia

Hematopoietic cell transplantation in adults to prevent graft-versus

host disease and infection
May be useful in a variety of other conditions
Postexposure prophylaxis
Hepatitis B immune
globulin (IM) Prevention of perinatal infection in infants born to HBsAg + mothers
 IMMUNE GLOBULIN AND
ANTISERA PREPARATIONS…
PRODUCT
Rabies immune globulin (IM)
Tetanus immune globulin (IM)
Varicella-zoster immune globulin (VZIG) (IM) Postexposure prophylaxis of susceptible people at
or IVIG
Cytomegalovirus IVIG
Palivizumab (monoclonal antibody) (IM)
Vaccinia immune globulin (IV)
Botulism IVIG human
Diphtheria antitoxin, equine
Trivalent botulinum (A,B,E) and bivalent (A,B)
botulinum antitoxin, equine
ANIMAL
MAJOR INDICATIONS
Postexposure prophylaxis
Wound prophylaxis
Treatment of tetanus
high risk for complications from varicella
Prophylaxis of disease in seronegative transplant
recipients
Prophylaxis for infants against respiratory
syncytial virus (RSV)
Prevent or modify serious adverse events
following smallpox vaccination due to vaccinia
replication
Treatment of infant botulism
Treatment of diphtheria
Treatment of food and wound botulism
Active Immunization
 Vaccines are defined as whole or parts of
microorganisms administered to prevent an infectious
disease.
 Vaccines can consist of
 whole inactivated microorganisms (e.g., polio and HepA),
 parts of the organism (e.g., acellular pertussis, HPV, and HepB),
 polysaccharide capsules (e.g., pneumococcal and meningococcal
polysaccharide vaccines),
 polysaccharide capsules conjugated to protein carriers (e.g., Hib,
pneumococcal, and meningococcal conjugate vaccines),
 live-attenuated microorganisms (measles, mumps, rubella, varicella,
rotavirus, and live-attenuated influenza vaccines), and
 toxoids (tetanus and diphtheria).
Active Immunization
CURRENTLY AVAILABLE VACCINES IN THE USA BY TYPE
PRODUCT
Anthrax vaccine adsorbed
Bacille Calmette-Gu?rin (BCG) vaccine
Diphtheria and tetanus toxoids and acellular
pertussis (DTaP) vaccine
DTaP with Haemophilus influenzae type b
(DTaP/Hib)
DTaP–hepatitis B–inactivated polio vaccine
(DTaP-HepB-IPV)
DTaP with IPV and Hib (DTaP-IPV/Hib)
DTaP and inactivated polio vaccine (DTaP-IPV) DTaP with inactivated whole polio viruses
Hib conjugate vaccine (Hib)
Hepatitis A vaccine (HepA)
TYPE
Cell free filtrate of components including protective antigen
Live-attenuated mycobacterial strain used prevent tuberculosis
in very limited circumstances
Toxoids of diphtheria and tetanus and purified and detoxified
components from Bordetella pertussis
DTaP and Hib polysaccharide conjugated to tetanus toxoid
DTaP with hepatitis B surface antigen produced through
recombinant techniques in yeast with inactivated whole
polioviruses
DTaP with inactivated whole polio viruses and Hib
polysaccharide conjugated to tetanus toxoid
Polysaccharide conjugated to either tetanus toxoid or
meningococcal group B outer membrane protein
Inactivated whole virus
 Active Immunization…
Product Type
Hepatitis A-hepatitis B vaccine (HepA-HepB) Combined hepatitis A and B vaccine
HBsAg produced through recombinant techniques in
Hepatitis B vaccine (HepB)
yeast
Combined hepatitis B–Hib vaccine; the Hib component is
Hepatitis B-Hib vaccine (Hib-HepB) polysaccharide conjugated to meningococcal group B
outer membrane protein

The L1 capsid proteins of HPV types 6, 11, 16, 18 and to

Human papillomavirus vaccine (bivalent) (HPV2) and
prevent cervical cancer and genital warts (HPV4) and
(quadrivalent) (HPV4)
types 16 and 18 to prevent cervical cancer (HPV2)

Trivalent (A/H3N2, A/H1N1, and B) split and purified

Influenza virus vaccine inactivated (TIV) inactivated vaccine containing the hemagglutinin (H) and
neuraminidase (N) of each type and other components

Live-attenuated, temperature-sensitive, cold-adapted

trivalent vaccine containing the H and N genes from the
Influenza virus vaccine live, intranasal (LAIV)
wild strains reassorted to have the 6 other genes from the
cold-adapted parent

Japanese encephalitis vaccine Inactivated whole virus that is purified

 Active Immunization…
Product Type

Measles, mumps, rubella (MMR) vaccine Live-attenuated viruses

Measles, mumps, rubella, varicella (MMRV) vaccine Live-attenuated viruses

Meningococcal conjugate vaccine against serogroups A, Polysaccharide from each serogroup conjugated to
C, W135, and Y (MCV4) diphtheria toxoid or CRM 197

Meningococcal polysaccharide vaccine against

Polysaccharides from each of the serogroups
serogroups A, C, W135, and Y (MPSV4)

Pneumococcal polysaccharides conjugated to a nontoxic

form of diphtheria toxin CRM197

Pneumococcal conjugate vaccine (13 valent) (PCV13)

Contains 13 serotypes that accounted for >80% of
invasive disease in young children prior to vaccine
licensure.

Pneumococcal polysaccharide vaccine (23 valent) Pneumococcal polysaccharides of 23 serotypes

(PPSV23) responsible for 85-90% of bacteremic disease in the USA
 Active Immunization… Product Type
Poliomyelitis (inactivated, enhanced potency) (IPV) Inactivated whole virus
Rabies vaccines (human diploid and purified chick
Inactivated whole virus
embryo cell)
Bovine rotavirus pentavalent vaccine (RV-5) live
Rotavirus vaccines (RV5 and RV1) reassortment attenuated virus, and human live-attenuated
virus (RV1)
Vaccinia virus, an attenuated pox virus that provides
Smallpox vaccine
cross-protection against smallpox
Tetanus toxoid plus a reduced quantity of diphtheria
Tetanus and diphtheria toxoids, adsorbed (Td, adult use) toxoid compared to diphtheria toxoid used for children
<7 yr of age

Tetanus toxoid plus a reduced quantity of diphtheria

toxoid plus acellular pertussis vaccine to be used in
Tetanus and diphtheria toxoids adsorbed plus acellular
adolescents and adults and in children 7 through 9 yr of
pertussis (Tdap) vaccine
age who have not been appropriately immunized with
DTaP
Typhoid vaccine (polysaccharide) Vi capsular polysaccharide of Salmonella typhi
Typhoid vaccine (oral) Live-attenuated Ty21a strain of Salmonella typhi
Varicella vaccine Live-attenuated Oka strain
Yellow fever vaccine Live-attenuated 17D strain
Active Immunization…
 Immunizing agents can contain a variety of other
constituents besides the immunizing antigen.
 Suspending fluids
 Preservatives, stabilizers, and antimicrobial agents
 Adjuvants (enhance the immune response)
 Suspending fluids may be sterile water or saline but could be a complex
fluid containing small amounts of proteins or other constituents derived
from the biologic system used to grow the immunobiologic.
 Preservatives, stabilizers, and antimicrobial agents are used to inhibit
bacterial growth and to prevent degradation of the antigen.
 Such components may include gelatin, 2-phenoxyethanol, and specific
antimicrobial agents.
Active Immunization…

The only vaccines in the recommended

schedule for young children that contain
thimerosal as a preservative are some
preparations of influenza vaccine.
Adjuvants are used in some vaccines to
enhance the immune response.
In the United States, the only adjuvants
currently licensed by the FDA to be part of
vaccines are aluminum salts.
Active Immunization…
 Vaccines can induce immunity by stimulating antibody
formation, cellular immunity, or both.
 Protection induced by most vaccines is thought to be mediated
primarily by B lymphocytes, which produce antibody.
 Most B-lymphocyte responses require the assistance of CD4 helper
T lymphocytes.
 T lymphocyte–dependent vaccines, which include protein
moieties, induce good immune responses even in young infants.
 In contrast, polysaccharide antigens induce B-lymphocyte responses
in the absence of T-lymphocyte help.
 These T lymphocyte–independent vaccines are associated with
poor immune responses in children <2 yr of age, short-term
immunity, and absence of an enhanced or booster response on
repeat exposure to the antigen.
Active Immunization…
 Serum antibodies may be detected as soon as 7-10 days
after injection of antigen.
 Early antibodies are usually of the IgM class that can fix
complement.
 IgM antibodies tend to decline as IgG antibodies increase.
 The IgG antibodies tend to peak approximately 1 month
after vaccination and with most vaccines persist for some
time after a primary vaccine course.
• Secondary or booster responses occur more rapidly
(within 4-5 days) and result from rapid proliferation of
memory B and T lymphocytes.
Active Immunization…
 Immune response to most vaccines is performed by
measuring serum antibodies.
 Detection of serum antibody at levels considered
protective after vaccination can indicate immunity.
 Loss of detectable antibody over time does not
necessarily mean susceptibility to disease(immunologic
memory  a booster/ anamnestic response on exposure
to the microorganism).
 In some instances, cellular immune response is used to
evaluate immune status.
 For some vaccines (e.g., acellular pertussis), there is
no accepted serologic correlate of protection.
Active Immunization…
 Live-attenuated vaccines routinely recommended for
children and adolescents include measles, mumps, and
rubella (MMR); rotavirus; and varicella.
 Live-attenuated vaccines tend to induce long-term
immune responses.
 They replicate, often similar to natural infections, until
an immune response shuts down reproduction.
 Most live vaccines are administered in 1- or 2-dose
schedules.
 The purpose of repeat doses, such as a second dose of the
MMR vaccine, is to induce an initial immune response in
persons who failed to respond to the first dose.
Active Immunization…
 Inactivated vaccines tend to require multiple
doses to induce an adequate immune
response and are more likely to need booster
doses to maintain that immunity than live-
attenuated vaccines.
 Some inactivated vaccines appear to induce
long-term immunity, perhaps life-long
immunity, after a primary series, including
HepB vaccine and inactivated polio vaccine
(IPV).
Determinants of the immune response

 Chemical and physical state of the

antigen
 Mode of administration
 Host factors –
– Age,
– Nutrition
– Preexisting antibodies
Advantages of immunization

 Saves the lives of millions of children.

 Very cost- effective.
 Led to global eradication of small pox.
 Elimination of poliomyelitis from some
continents.
 More than 95% reduction of Haemophilus
Influenza type B desease.
 In USA it eliminated completely congenital
rubella syndrome, tetanus, pertussis, polio and
diphtheria
Vaccine Delivery
 Vaccines should be stored at recommended temperatures before and
after reconstitution.
 Expiration dates should be noted, and expired vaccine should be
discarded.
 Lyophilized vaccines often have long shelf lives.
 However, the shelf life of reconstituted vaccines generally is short,
ranging from 30 min for the varicella vaccine to 8 hr for the MMR vaccine.
 Most inactivated vaccines, including DTaP, HepA, HepB, Hib, TIV, PCV13,
MCV4, and Tdap, are administered IM.
 The commonly used live-attenuated vaccines, MMR, MMRV and varicella,
should be dispensed SC and rotavirus vaccine is administered orally.
 IPV and PPS23 (pneumococcal polysaccharide vaccine) can be given IM or
SC.
Vaccine Delivery………
For
 IM injections, the anterolateral thigh muscle is the preferred
site for infants and young children.
The recommended needle length varies depending on age and

size:
5/8 inch for newborn infants,

1 inch for infants 2-12 mo of age, and


1 to 1.25 inches for older children.



For adolescents and adults, the deltoid muscle is the preferred


site for IM administration with needle lengths of 1- inches
depending on the size of the patient.
Most IM injections can be made with 23-25 gauge needles.

For SC injections, needle lengths generally range from 5/8 to 3/4

inches with 23-25 gauge needles.
Recommended Immunization Schedule Of Ethiopia

Expanded Programme of Immunization

(EPI)/WHO
 Aims to provide free immunization for children
against the important childhood infections
 Started in 1974
 The Expanded Programme for Immunisation
(EPI) in Ethiopia launched in 1980
 Main purpose:
 Prevent childhood diseases
 Provide high quality vaccines
 Surveillance of these diseases
Ethiopia introduced the pneumococcal conjugate vaccine (PCV) and
monovalent human rotavirus vaccine (RV) into the national infant
immunisation programme in November 2011 and October 2012, respectively.
Recommended immunization schedule for
age 0 to 18 months, USA 2015
 BCG (Bacille Calmette
 Guerin)
The highest VACCINE
priority of any tuberculosis control program:
case finding and treatment.
 The only available vaccine against tuberculosis is the BCG,
named for the 2 French investigators responsible for its
development.
 Freeze dried, live attenuated form of mycobacteria
 Reduces/prevents severe form of Tb (Tb meningitis and
disseminated Tb)
 Stored at 2 to 8 oc and mustn’t be frozen, The vaccine is
reconstituted with DILUTED SAUTON
 Once prepared, BCG vaccine should be used within 2-3 hours
& discarded thereafter
 Avoid sunlight
 BCG VACCINE……
 Give 0.05 ml of vaccine intradermal on the right upper arm
 Don’t use alcohol to clean the top of the vial as it may kill the
BCG
 Side effects:
 The BCG vaccines: extremely safe in immunocompetent hosts.
 Local ulceration and regional suppurative adenitis occur in 0.1-1%
of vaccine recipients.
 Local lesions do not suggest underlying host immune defects and do
not affect the level of protection afforded by the vaccine.
 As measles can depress cell mediated immunity & as BCG
induces cell mediated immunity BCG should not be given along
with measles or MMR
BCG VACCINE…
 Most reactions are mild and usually resolve
spontaneously, but chemotherapy is needed
occasionally.
 Systemic complaints such as fever, convulsions, loss of
appetite, and irritability are extraordinarily rare after
BCG vaccination.
 Profoundly immunocompromised patients can develop
disseminated BCG infection after vaccination.
 Children with HIV infection appear to have rates of
local adverse reactions to BCG vaccines that are
comparable with rates in immunocompetent children.
OPV (ORAL POLIO VACCINE)
 The oral polio vaccine (OPV) was developed in 1961 by Albert Sabin
 Two forms of trivalent polio vaccines of vaccine: OPV and IPV
 OPV is live attenuated vaccine
 Adv of OPV:
1. induce lifelong immunity in much the same way as a natural infection,
thereby avoiding the need for boosters.
2. because of the induction of mucosal immunity (pharyngeal, intestinal) as
well as systemic immunity, the natural transmission of wild-type virus in
the population is interrupted.
3. Because of fecal shedding of the vaccine viruses for several weeks after
vaccination, indirect immunization or boosting of immunity in contacts is
also achieved.
4. The lack of the need for injections
5. the lower cost of OPV
OPV….

 The disadvantage of the use of OPV is its

ability to cause paralytic disease in both the
recipient and his or her contacts
 Itis extremely rare cases (approx. 1 in every
2.7 million first doses of the vaccine)
 Immunodeficient individuals are at increased
risk
 Three doses produce immunity in more than
95% of recipients.
 Immunity is long-lasting and probably life-long
OPV….

 Stored at 2to 8 oc
 The only vaccine which can be frozen safely
 Can be stored for years at -20
 For one year at -10
 Two drops of the vaccine given orally
 Givean extra dose at later time when there is
diarrhea or vomiting
 SE:rare hypersensitivity and anaphylactic
reactions, primarily caused by trace amounts of
neomycin, streptomycin, and polymyxin B and
paralytic polio
Diphtheria, Pertusis, Tetanus (DPT)
Vaccine
 The DTP is composed of diphtheria toxoid, tetanus
toxoid, and inactivated whole Bordetella pertussis
cells
 Whole-cell pertussis-containing vaccines are no
longer available in the United States
 When compared with DTwP, DTaP was as effective
or more effective, with fewer adverse effects
 Stored at 2to 8 oc
 Don’t freeze and avoid sunlight
 0.5 ml of the vaccine intramuscular over left thigh
DPT vaccine

 Side effects:
 Redness, tenderness and swelling at site of injection
 Mild fever and irritability
 Rarely severe side effects:
 fever ≥ 40.5 oc,
 inconsolable crying, shock,
 drowsiness,
 confusion or encephalopathy
Tetanus vaccine

CLEAN, MINOR WOUNDS OTHER WOUNDS*

HISTORY OF
ABSORBED
TETANUS Tdap or Td[†] TIG[‡] Tdap or Td[†] TIG[‡]
TOXOID

Uncertain, or
Yes No Yes Yes
<3 doses

3 or more doses No[?] No No[‖] No

Adapted from the Centers for Disease Control and Prevention:

Preventing tetanus, diphtheria, and pertussis among adolescents: use of
tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
vaccines. Recommendations of the Advisory Committee on Immunization
Practices (ACIP), MMWR Morbid Mortal Wkly Rep 55:1–43, 2006.
Hepatitis B (HepB) VACCINE
 Hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) are available
for prevention of HBV infection.
 Hepatitis B vaccine : It is inactivated product produced by genetic
engineering
 Seropositivity is >95% with all vaccines, achieved after the 2nd dose in
most patients.
 The 3rd dose serves as a booster and may have an effect on maintaining
long-term immunity.
 In immunosuppressed patients and infants <2,000 g birthweight, a 4th
dose is recommended, as is checking for seroconversion.
 There is no S/E
 Hepatitis B (HepB)
VACCINE DOSE
SCHEDULE
Recombivax HB (?g) Engerix-B (?g)
UNIVERSAL PROPHYLAXIS
Infants of HBsAg− women 5 10 Birth, 1-2, 6-18 mo
Children and adolescents (11-19
5 10 0, 1, and 6 mo
yr)
POSTEXPOSURE PROPHYLAXIS IN SUSCEPTIBLE INDIVIDUALS
Contact with HBsAg-Positive Source
Infants of HBsAg+ women 5 10 Birth* (+HBIG[†]), 1 and 6 mo
Intimate or Identifiable Blood Exposure
0-19 yr old 5 10 Exposure (+HBIG[†]), 1 and 6 mo

>19 yr old 10 20 Exposure (+HBIG[†]), 1 and 6 mo

Household
0-19 yr old 5 10 Exposure, 1 and 6 mo
>19 yr old 10 20 Exposure, 1 and 6 mo
Casual None None None
Immunocompromised[‡] 40 40 Exposure (+HBIG[†]), 1 and 6 mo
Contact with Unknown HBsAg Status; Intimate or Identifiable Blood Exposure
>19 yr old 10 20 Exposure, 1 and 6 mo
Immunocompromised[‡] 40 40 Exposure (+HBIG[†]), 1 and 6 mo
Haemophilus influenzae Type B Vaccine

 Consists of Hib capsular polysaccharide linked to a

different carrier protein
 the conjugate H. influenzae vaccines do not protect
against nontypeable strains of H. influenzae
 a dose of 0.5 mL is given IM
 Side effects are minimal and include: primarily local
tenderness, swelling, erythema, and low-grade fever in
a minority of recipients (25%).
 There are no specific contraindications to vaccination
with Hib vaccines
 Efficacy: 95% (70 to 100 %)
Pneumococcal Vaccine
 More than 90 different pneumococcal serotypes have
been identified.
 The surface capsular polysaccharide provokes a type-
specific protective immune response
 Serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F are the
most prevalent in children, accounting for between 60
and 80 percent of infections
 Two type of vaccine
1. Unconjugated vaccine: pneumococcal polysaccharide
vaccines (PPSV23)
2. Conjugated: PCV 7, PCV 10 AND PCV 13
Pneumococcal Vaccine….
PNEUMOCOCCAL
CARRIER PROTEIN CAPSULAR MANUFACTURER
POLYSACCHARIDES

Diphtheria CRM197 protein Wyeth Lederle (PCV7,

4,6B, 9V, 14, 18C, 19F, 23F
Prevnar)

Diphtheria CRM197 protein 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, Wyeth Lederle (PCV13,
18C, 19A, 19F, 23F Prevnar 13)
Haemophilus influenzae
protein D 1, 4, 5, 6B, 7F, 9V, 14, 18C, GlaxoSmithKline (PCV10,
Tetanus and diphtheria 19F, 23F Synflorix)
toxoids

1, 2, 3, 4, 5, 6B, 7F, 8, 9N,

9V, 10A, 11A, 12F, 14, 15B, Sanofi Pasteur MSD
None
17F, 18C, 19A, 19F, 20, 22F, (PPSV23, Pneumovax II)
23F, 33F
Pneumococcal Vaccine……
 The 13-valent vaccine is used in the United States; the
10-valent vaccine is used in Europe and developing
countries.
 The potential efficacy of the 7-, 10-, 11-, and 13-
valent vaccines varies
 PCV7 was shown to reduce invasive disease caused by
vaccine serotypes by up to 97% and to reduce invasive
disease caused by all serotypes, including serotypes
not in the vaccine, by 89%.
 PCV is routinely given for all children
 PPSV 23 is given for high risk chldren above two years
of age.
Red Book Online. Available at: http://aapredbook.org
Pneumococcal Vaccine……
 Storage: 2 to 8oc
 Dosage: 0.5 ml, ROUT: IM
 SIDE EFFECT:
 injection site reaction, fever, decreased appetite, irritability, and increased or
decreased sleep
 Increased rates of febrile seizures
 Rare but serious adverse events included seizures, anaphylactic reactions,
serum sickness, and thrombocytopenia


CI: hypersensitivity to any component of the vaccine
 moderate or severe illness
Rotavirus Vaccine
 Twotypes: pentavalent rotavirus vaccine and
monovalent rotavirus vaccines licensed in the USA.

 Monovalent rotavirus vaccines is an attenuated

monovalent human rotavirus and is administered
as 2 oral doses at 6 and 10 weeks of age.
 The vaccine has 85% efficacy against severe
gastroenteritis and was found to reduce hospital
admissions for all diarrhea by 42%.
 the
vaccine is effective in prevention of all 4
common serotypes of human rotavirus.
Rotavirus Vaccine…..

 RV1 is administered orally; each dose is 1 mL

 SE: Vaccine-associated disease has been reported in
vaccine recipients who have severe combined
immunodeficiency disease
 vaccine-derived virus may undergo reassortment and become
more virulent, producing diarrhea in unvaccinated siblings
 CONTRAINDICATION: immunodeficiency
 severe (anaphylactic) allergy to latex
Measles VACCINE

 Freeze dried, live attenuated virus

 Stored at 2to 8 oc
 Avoid direct sunlight
 Give 0.5 ml of the vaccine intramuscular
 Seroconversion 87% at 9 mo., 95% at 12 mo., and 98% at
15 mo., because of persisting maternal antibody.
 A second dose at 4-6 yr of age is necessary
Measles Vaccine………

 SE include: fever (usually 6-12 days following

vaccination),
 rash in about 5% of vaccines,
 transient thrombocytopenia.
 Children prone to febrile seizures may experience an event
following vaccination.
 Encephalopathy and autism have not been shown to be
causally associated with the MMR vaccine nor vaccine
constituents.
 Passively administered immune globulin may inhibit the
immune response to live measles vaccine, and
administration should be delayed
 Measles vaccine……….
CATEGORY RECOMMENDATIONS
A 2-dose schedule (with MMR) is recommended
Unimmunized, no history of measles (12-15 mo of
The first dose is recommended at 12-15 mo of age;
age)
the 2nd is recommended at 4-6 yr of age

Immunize (with monovalent measles vaccine, or if

Children 6-11 mo of age in epidemic situations or not available, MMR); reimmunization (with MMR)
prior to international travel at 12-15 mo of age is necessary, and a 3rd dose is
indicated at 4-6 yr of age
Children 4-12 yr of age who have received 1 dose
Reimmunize (1 dose)
of measles vaccine at ≥12 mo of age
Students in college and other post–high school
institutions who have received 1 dose of measles Reimmunize (1 dose)
vaccine at ≥12 mo of age
History of immunization before the 1st birthday Consider susceptible and immunize (2 doses)
History of receipt of inactivated measles vaccine or
Consider susceptible and immunize (2 doses)
unknown type of vaccine, 1963-1967
 Measles vaccine…..
CATEGORY RECOMMENDATIONS
Further attenuated or unknown vaccine given
Consider susceptible and immunize (2 doses)
with IG
Allergy to eggs Immunize; no reactions likely
Neomycin allergy, nonanaphylactic Immunize; no reactions likely
Severe hypersensitivity (anaphylaxis) to
Avoid immunization
neomycin or gelatin

Immunize; if patient has untreated tuberculosis disease,

Tuberculosis
start antituberculosis therapy before immunizing

Measles exposure Immunize and/or give IG, depending on circumstances

HIV-infected Immunize (2 doses) unless severely immunocompromised

Immunize; advise parents of slightly increased risk of

Personal or family history of seizures
seizures
IG or blood recipient Immunize at the appropriate interval
CATCH-UP IMMUNIZATION
Vaccines Recommended in Special Circumstance

 Immunization of children with immunocompromise poses the following

potential concerns:
 the incidence or severity of some vaccine-preventable diseases is higher, and
therefore certain vaccines are recommended specifically for certain
conditions;
 vaccines may be less effective during the period of altered
immunocompetence and may need to be repeated when immune competence
is restored;
 because of altered immunocompetence, some children and adolescents may be
at increased risk for an adverse event following receipt of a live viral vaccine.
 Live-attenuated vaccines generally are contraindicated in immunocompromised
people. The EXCEPTIONS include MMR, which may be given to a child with HIV
infection provided the child is asymptomatic or symptomatic without evidence
of severe immunosuppression, and varicella vaccine, which may be given to
HIV-infected children if the CD4+ lymphocyte count is at least 15%.
 MMRV is not recommended in these situations.
Vaccines Recommended in Special Circumstances…

 Altered immunocompetence is considered a precaution for

rotavirus; however, the vaccine is contraindicated in
children with severe combined immunodeficiency disease.
 Inactivated
vaccines may be administered to
immunocompromised children, although, depending on
the immune deficit, their effectiveness might not be
optimal.
 Children with complement deficiency disorders may
receive all vaccines, including live-attenuated vaccines.
 Children with phagocytic disorders may receive both
inactivated and live-attenuated viral vaccines but not
live-attenuated bacterial vaccines.
Vaccines Recommended in Special
Circumstances…

 Corticosteroids can suppress the immune system.

 Children receiving corticosteroids (≥2 mg/kg/day or ≥20
mg/day of prednisone or equivalent) for 14 or more
days should not receive live vaccines until therapy has
been discontinued for at least 1 month.
 Children on the same dose levels but for <2 wk may
receive live viral vaccines as soon as therapy is
discontinued, although some experts would wait 2 wk
post-therapy.
 Children receiving lower doses of steroids may be
vaccinated while on therapy.
Vaccines Recommended in Special
Circumstances….
 Children and adolescents with:
 malignancy, and
 those who have undergone solid organ or hematopoietic stem cell
transplantation and
 immunosuppressive or radiation therapy,
should not receive live virus and live bacterial vaccines depending
on their immune status.

 Children who have undergone

chemotherapy for leukemia may need to be
reimmunized with age appropriate single
doses of previously administered vaccines.
Vaccines Recommended in Special Circumstances…

 Preterm infants generally can be vaccinated at the

same chronologic age as full-term infants according to
the recommended childhood immunization schedule.
 An exception is the birth dose of HepB vaccine.
 Infants weighing ≥2 kg and who are stable may receive
a birth dose.
 However, HepB vaccination should be deferred in
infants weighing <2 kg at birth until 30 days of age, OR
at discharge if born to an HBsAg-negative mother.
 All preterm, LBW infants born to HBsAg-positive
mothers should receive HepB IG and HepB vaccine
within 12 hr of birth with additional 3 doses of vaccine
Vaccines Recommended in Special
Circumstances…

 In general, vaccines may be given

simultaneously on the same day, whether
inactivated or live.
 Different inactivated vaccines can be
administered at any interval between doses.
 However, because of theoretical concerns
about viral interference, different live-
attenuated vaccines (MMR, varicella, LAIV)
if not administered on the same day, should
be given at least 1 mo apart.
Vaccines Recommended in Special
Circumstances…

 An inactivated and a live vaccine may be spaced at any

interval from each other.
 IG does not interfere with killed vaccines.
 However, IG can interfere with the immune response to
measles vaccine and by inference to varicella vaccine.
 In general, IG, if needed, should be administered at
least 2 wk after measles vaccine.
 Depending on the dose of IG received, MMR should be
deferred for as long as 3-11 mo.
 IG is not expected to interfere with the immune
response to LAIV or rotavirus vaccines.
Vaccines Recommended in Special
Circumstances…
SPECIFIC RISK-SPECIFIC
CONTRAINDICAT EFFECTIVENESS
CATEGORY IMMUNODEFICIE RECOMMENDED
ED VACCINES* AND COMMENTS
NCY VACCINES*

The effectiveness of
any vaccine will be
uncertain if it depends
Severe antibody OPV[†]
only on the humoral
deficiencies (e.g., X- Smallpox
Pneumococcal response (e.g., PPSV,
linked LAIV
Consider measles and MPSV)
agammaglobulinemia BCG
varicella vaccination IGIV interferes with
and common variable Ty21a (live typhoid)
the immune response
B lymphocyte immunodeficiency) YF
to measles vaccine
(humoral) and possibly varicella
vaccine.

Less severe antibody OPV[†]

All vaccines probably
deficiencies (e.g., BCG
effective
selective IgA YF Pneumococcal
Immune response
deficiency and IgG Other live vaccines
may be attenuated
subclass deficiency) appear to be safe
Vaccines Recommended in Special Circumstances…

SPECIFIC RISK-SPECIFIC
CONTRAINDICAT EFFECTIVENESS
CATEGORY IMMUNODEFICIE RECOMMENDED
ED VACCINES* AND COMMENTS
NCY VACCINES*
Complete defects
(e.g., SCID disease, Vaccines may be
All live vaccines[‡][?][‖] Pneumococcal
complete DiGeorge ineffective
syndrome)
T lymphocyte (cell-
mediated and Partial defects (e.g.,
Pneumococcal
humoral) most patients with Effectiveness of any
Meningococcal
DiGeorge syndrome, vaccine depends on
All live vaccines[‡][?][‖] Hib (if not
Wiskott-Aldrich degree of immune
administered in
syndrome, ataxia- suppression
infancy)
telangiectasia)

Persistent
complement, Pneumococcal All routine vaccines
Complement None
properdin, or factor B Meningococcal probably effective
deficiency

Chronic All inactivated

granulomatous vaccines safe and
disease, leukocyte Live bacterial probably effective
Phagocytic function Pneumococcal[?]
adhesion defect, and vaccines[‡] Live viral vaccines
myeloperoxidase probably safe and
deficiency effective
 Vaccines Recommended in Special
Circumstances…
RISK-SPECIFIC
SPECIFIC CONTRAINDICATED EFFECTIVENESS AND
RECOMMENDED
IMMUNODEFICIENCY VACCINES* COMMENTS
VACCINES*

OPV[†]
Smallpox
BCG Pneumococcal MMR, varicella, rotavirus,
LAIV Consider Hib (if not and all inactivated vaccines,
HIV/AIDS
Withhold MMR and administered in infancy) and including inactivated
varicella in severely meningococcal vaccination influenza, may be effective[#]
immunocompromised
persons

Malignant neoplasm,
Live viral and bacterial, Effectiveness of any vaccine
transplantation,
depending on immune Pneumococcal depends on degree of
immunosuppressive or
status[‡][?] immune suppression
radiation therapy

Pneumococcal
Meningococcal All routine vaccines
Asplenia None
Hib (if not administered in probably effective
infancy)

Pneumococcal All routine vaccines

Chronic renal disease LAIV
Hepatitis B** probably effective
Precautions and Contraindications

 Risk benefit analysis!

 A general contraindication for all vaccines is anaphylactic reaction
to a prior dose.
 Anaphylactic hypersensitivity to vaccine constituents is also a
contraindication. However, if a vaccine is essential, there are
desensitizing protocols for some vaccines.
 The major constituents of concern are egg proteins for vaccines
grown in eggs; gelatin, a stabilizer in many vaccines; and
antimicrobial agents.
 Vaccines usually should be deferred in children with moderate to
severe acute illnesses, regardless of the presence of fever, until
the child recovers.
 However, children with mild illnesses may be vaccinated.
 Ideally HIB and HBV has no identifiable contraindication
Contraindications…
ETHIOPIAN, EDHS 2016

 In Ethiopia, four in ten children age 12-23 months

(39%) received all basic vaccinations at some
time, and 22% received these vaccinations before
their first birthday
 Vaccination coverage among children age 12-23
months is highest for the first dose of polio
vaccine (81%) followed by first dose of DPT-HepB-
Hib vaccine (73%).
 More than half (53%) of children in Ethiopia have
received three doses of DPT-HepB-Hib vaccine and
54% received the measles vaccination.
 There is a 20 percentage-point dropout rate at the
national level from the first to the third dose of
DPT-HepB-Hib vaccine.
THANK YOU!