المركز الصحي pdf - طلاب كروب B

stage

Pediatrics

lec.3

د.دمحم خضر

Tutorial

2016/8/18

Vaccination

The immune system is a complex network of specialized organs and cells
protects the body from destruction by foreign agents and microbial
pathogens , degrades and removes damaged or dead cells, and exerts a
surveillance function to prevent the development and growth of
malignant cells. The immune system is composed of immune cells and
central and peripheral lymphoid structures. The immune cells move
throughout the body, searching for and destroying foreign substances
but avoiding cells regarded as self.

Natural immunity:

It is not produced by the immune response. This type of immunity is
present at birth and appears to be present in all members of a species.

Acquired immunity:

It develops after birth as a result of exposure to an antigen, thereby
activating the immune response. Acquired immunity can be either active
or passive, depending on whether the immune response took place in
the host or a donor.

Differences of immune system of children and adult

The normal human no fully active immune system at birth because of
immaturity. It relies instead on passively transferred antibodies from the
mother. This maternal antibody slowly decreases in concentration and
for all practical purposes, has waned by 1 year.

The infant own production of antibody begins to be meaningful at 7 or 8
months of age when the total of maternal and infant antibody is low.

One has waned and the other is not up to full strength. This is age when
many of the infectious disease processes of infancy begin /e.g. otitis
media, pneumonia.

Vaccination

• Administration of a substance to a person with the purpose of

preventing a disease

• Traditionally composed of a killed or weakened microorganism

• Vaccination works by creating a type of immune response that

enables the memory cells to later respond to a similar organism
before it can cause disease

• Early History of Vaccination

• Pioneered India and China in the 17th century

• The tradition of vaccination may have originated in India in AD

1000

• Powdered scabs from people infected with smallpox was used to

protect against the disease

• Smallpox was responsible for 8 to 20% of all deaths in several

European countries in the 18th century

• In 1721 Lady Mary Wortley Montagu brought the knowledge of

these techniques from Constantinople (now Istanbul) to England

• Two to three percent of the smallpox vaccinees, however, died

from the vaccination itself

• Benjamin Jesty and, later, Edward Jenner could show that

vaccination with the less dangerous cowpox could protect against
infection with smallpox

• The word vaccination, which is derived from vacca, the Latin word

for cow.

Era of Vaccination

English physician Edward Jenner

observed that milkmaids stricken with a viral disease called
cowpox were rarely victims of a similar disease, smallpox

Jenner took a few drops of fluid from a pustule of a woman who
had cowpox and injected the fluid into a healthy young boy who
had never had cowpox or smallpox

Six weeks later, Jenner injected the boy with fluid from a smallpox
pustule, but the boy remained free of the dreaded smallpox.

Era of Vacinnation

In those days, a million people died from smallpox each year in
Europe alone, most of them children.

Those who survived were often left with blindness, deep scars,
and deformities

In 1796, Jenner started on a course that would ease the suffering
of people around the world for centuries to come.

By 1980, an updated version of Jenner vaccine lead to the total
eradication of smallpox.

In 1879 Louis Pasteur showed that chicken cholera weakened by
growing it in the laboratory could protect against infection with
more virulent strains

1881 he showed in a public experiment at Pouilly-Le-Fort that his
anthrax vaccine was efficient in protecting sheep, a goat, and
cows.

In 1885 Pasteur developed a vaccine against rabies based on a live
attenuated virus

A year later Edmund Salmon and Theobald Smith developed a
(heat) killed cholera vaccine.

Over the next 20 years killed typhoid and plague vaccines were
developed

In 1927 the bacille Calmette-Guérin (BCG vaccine) against
tuberculosis vere developed

Since Jenner's time, vaccines have been developed against more
than 20 infectious diseases

• The date of introduction of first generation of vaccines for use

in humans*

1798 Smallpox

1885 Rabies

1897 Plague

1923 Diphtheria

1926 Pertussis

1927 Tuberculosis (BCG)

1927 Tetanus

1935 Yellow Fever

• After World War II

1955 Injectable Polio Vaccine (IPV)

1962 Oral Polio Vaccine (OPV)

1964 Measles

1967 Mumps

1970 Rubella

1981 Hepatitis B

• Vaccination Today

• Vaccines have been made for only 34 of the more than 400 known

pathogens that are harmful to man.

• Immunization saves the lives of 3 million children each year, but

that 2 million more lives could be saved if existing vaccines were
applied on a full-scale worldwide

• Human Vaccines against pathogens

Human Vaccines

against

Type of Vaccination

Live Vaccines

• Characteristics

• Able to replicate in the host

• Attenuated (weakened) so they do not cause disease

• Advantages

• Induce a broad immune response (cellular and humoral)

• Low doses of vaccine are normally sufficient

• Long-lasting protection are often induced

• Disadvantages

• May cause adverse reactions

• May be transmitted from person to person

• Subunit Vaccines

• Relatively easy to produce (not live)

• Classically produced by inactivating a whole virus or bacterium

• Heat

• Chemicals

• The vaccine may be purified

• Selecting one or a few proteins which confer protection

• Bordetella pertussis (whooping cough)

• Create a better-tolerated vaccine that is free from whole

microorganism cells

• Subunit Vaccines: Polysaccharides

• Polysaccharides

• Many bacteria have polysaccharides in their outer

membrane

• Polysaccharide based vaccines

• Neisseria meningitidis

• Streptococcus pneumoniae

• Generate a T cell-independent response

• Inefficient in children younger than 2 years old

• Overcome by conjugating the polysaccharides to

peptides

• Used in vaccines against Streptococcus

pneumoniae and Haemophilus influenzae.

• Subunit Vaccines: Toxoids

• Toxins

• Responsible for the pathogenesis of many bacteria

• Toxoids

• Inactivated toxins

• Toxoid based vaccines

• Bordetella pertussis

• Clostridium tetani

• Corynebacterium diphtheriae

• Inactivation

• Traditionally done by chemical means

• Altering the DNA sequences important to toxicity

• Subunit Vaccines: Recombinant

• The hepatitis B virus (HBV) vaccine

• Originally based on the surface antigen purified from the

blood of chronically infected individuals.

• Due to safety concerns, the HBV vaccine became the first to

be produced using recombinant DNA technology (1986)

• Produced in bakers’ yeast (Saccharomyces cerevisiae)

• Virus-like particles (VLPs)

• Viral proteins that self-assemble to particles with the same

size as the native virus.

• VLP is the basis of a promising new vaccine against human

papilloma virus (HPV)

• Merck

• In phase III

• Genetic Vaccines

• Introduce DNA or RNA into the host

• Injected (Naked)

• Coated on gold particles

• Carried by viruses

• vaccinia, adenovirus, or alphaviruses

• bacteria such as

• Salmonella typhi, Mycobacterium tuberculosis

• Advantages

• Easy to produce

• Induce cellular response

• Disadvantages

• Low response in 1st generation

Type of Vaccination

Live attenuated Vaccine

OPV

Measles

Rubella

Mumps

BCG

Varicella Vaccine

Inactivated organism or their products

Diphtheria

Tetanus

Pertussis( whole cell/acellular)

Hepatits Avaccine

Hepatitis B

Pneumococcal Polysaccharide vaccine

Influenza

IPV

Hib

Passive Immunity

Transfer of antibody produced by one human or other animal to
another

Transplacental most important source in infancy

Temporary protection

Sources of Passive Immunity

Almost all blood or blood products

Homologous pooled human antibody (immune globulin)

Homologous human hyperimmune globulin

Heterologous hyperimmune serum (antitoxin)

IMMUNOGLOBULIN PREPARETION

Normal human Ig.

Normal human Ig is an antibody-rich fraction, obtained from a
pool of at least 1000 donors. The preparation should contain at
least 90% intact IgG; it should be as free as possible from IgG
aggregates; all IgG sub-classes should be present; there should be
a low IgA concentration; the level of antibody against at least two
bacterial species and two viruses should be ascertained

Normal human Ig used to prevent measles in highly susceptible
individuals and to provide temporary protection /up to 12 weeks/
against hepatitis A infection.

Live vaccines should not normally be given for 12 weeks after an
injection of normal human Ig.

· Specific human Ig.

These preparations are made from the plasma of patient who
have recently recovered from an infection or are obtained from
individuals who have been immunized against a specific infection.

The advantages of Ig-s are:

1. freedom from hepatitis B

2. concentration of the antibodies into a small volume for
intramuscular use.

3. stable antibody content, if properly stored.

Vaccine Preventable Diseases

 An infectious disease for which an effective preventive vaccine

exists.

 If a person dies from it, the death is considered a vaccine-

preventable death.

FULLY IMMUNIZED CHILD

 A child who received

One dose of BCG,

Three doses of DPT and OPV,

One dose of measles

before one year of age.

 This gives a child the best chance for survival.

Control

 Reduction of prevalence or incidence of disease to lower

acceptable level.

Elimination

 Eradication of disease from a large geographic region or political

jurisdiction

 Either reduction of infectious disease’s prevalence in regional

population to zero or reduction of global prevalence to a
negligible amount.

Eradication

 Termination of all transmissions of infection by extermination of

infectious agent through surveillance and containment.

 Reduction of infectious disease’s prevalence in global host

population to zero.

EXPANDED PROGRAMME ON IMMUNISATION (EPI)

 EPI launched in 1974

 Build on smallpox infrastructure

 Targeted 6 diseases

 EPI progressively adopted by all countries

Universal by early 1098s

Addition to EPI

 Yellow fever in 1988

• For endemic countries only : 33 in Africa, 11 in S. America.

• Given with measles vaccine

 Hepatitis B in 1992

• In high seroprevalence countries by 1995

• In all countries by 1997

 Haemophilus influenzae type b (Hib)

• 1998 : based on disease burden and capacity

• 2006 : all countries. ( lack of data should not be obstacle)

3
slides of coverage fm unicef

COMPONENTS of program

1. Immunization of pregnant women against tetanus.

2. Immunization of children in their first year of life against 6 VPDs.

3) Immunisation in preterm infants

 All vaccines except Hepatitis B

 If BW < 2Kg & mother HBsAg negative :- postpone till baby

attaines 2kg wt or 2 mths of age.

 If BW < 2Kg & mother HBsAg positive :- give vaccine +

immunoglobulin.

4) Children receiving corticosteroids

 Children receiving corticosteroids at the dose of 2 mg/kg/day for

more than 14 days should not receive live virus vaccines until
steroid has been discontinued for at least 1 month.

Tetanus toxoid

 Intramuscular – upper arm – 0.5 ml

 Pregnancy – 2 doses - 1

dose as early as possible and second

dose after 4 weeks of first dose and before 36 weeks of pregnancy

 Pregnancy – booster dose (before 36 weeks of pregnancy) – If

received 2 TT doses in a pregnancy within last three years. Give TT
to woman in labour, if she has not received TT previously

 TT booster for both boys and girls at 10 years and 16 years

 No TT required between two doses in case of injury

BCG

 At birth or as early as possible till one year of age

 0.1 ml (0.05ml until one month of age)

 Intra-dermal

 Left upper arm

Hepatitis B

 Birth dose – within 24 hours of birth

 0.5 ml

 Intramuscular

 Antero-lateral side of mid-thigh

 Rest three doses at 6 weeks, 10 weeks and 14 weeks

OPV

 Zero dose – within first 15 days of birth

 2 drops

 Oral

 First, second and third doses at 6, 10 and 14 weeks with DPT-1, 2

and 3

 OPV booster with DPT booster at 16-24 months

DPT

 Three primary doses at 6, 10 and 14 weeks with OPV-1, 2 and 3

 0.5 ml

 Intra-muscular

 Antero-lateral side of mid-thigh

 One booster at 16-24 m with OPV booster (antero-lateral side of

mid-thigh) and second booster at 5-6 years (upper arm)

Measles

 At 9 completed months to 12 months

 Give up to 5 years if not received at 9-12 months age

 Second dose at 16-24 months (select states after catch-up

campaign) – Measles Containing Vaccine

 0.5 ml

 Sub-cutaneous

 Right upper arm

 Along with Vitamin A (1

dose) – 1ml (1 lakh IU) - oral

Constraints

 Illiteracy

 Non uniform coverage

 Poor implementation

 Poor monitoring

 High drop outs

 Declining coverage in some major states

 Over reporting

 Poor injection safety

 Reorientation of staff being not carried out

 Vacany of staff at field level not filled

 Poor surveillance of vaccine preventable diseases

 Poor vaccine logistics

 Poor maintainance of equipments

 Extra ordinary emphasis on polio vaccine

Route of Administration

Site of Administration

Who should not be vaccinated?

Allergy

Fever

HIV infection

Immunodeficiency

IG administration

Neurological disorder

Prematurity

Reactions to Previous vaccine

Simultaneous administration of Vaccines

Thrombocytopenia

Neurological disorder

Prematurity

Reactions to Previous vaccine

Simultaneous administration of Vaccines

Thrombocytopenia

Allergy

A. Allergic Reactions to Egg-related antigens

1. Yellow fever and influenza vaccines do contain egg proteins

and rarely induce immediate allergic reactions. Skin testing
is recommended before administration with an history of
allergic to egg

2. MMR- Even those with severe hypersensitivity are at low

risk of anaphylaxis.

Allergy

B. Antibiotic-induced allergic reaction

Delayed type local reaction 48-96 hours afterwards and is
usually minor

IPV and OPV – streptomycin, neomycin and polymyxin B

MMR and varicella vaccine-neomycin

Allergy

C. Gelatin- MMR, Varicella vaccine

Fever

Low-grade fever or mild illness is not a contraindication for
vaccination

Children with moderate or severe febrile illnesses can be
vaccinated as soon as they are recovering and no longer acutely ill

Vaccination in Pregnancy

Risk to a developing fetus from vaccination of the mother during
pregnancy is mostly theoretical

Only smallpox vaccine has ever been shown to injure a fetus

The benefits of vaccinating usually outweigh potential risks

Vaccination in Pregnancy

Inactivated vaccines

Routine (influenza)

Vaccinate if indicated (hep B, Td, mening, rabies)

Vaccinate if benefit outweighs risk (all other)

Live vaccine – do not administer

Exception is yellow fever vaccine

HIV Infection

No BCG

OPV is Contraindicated

in household contact, in recipient ( asymptomatic or
symptomatic)

IPV for these children and household contacts

MMR vaccination should be considered for all asymptomatic and
to all symptomatic HIV-infected persons who do not have
evidence of severe immunosuprresion or measles immunity

Pneumococcal vaccine, Hib, DTP (or DTaP), Hepatitis B vaccine,
Influenza vaccines are all indicated

Immunosupression

No live viral vaccines and BCG. IPV for these patients, their siblings
and their household contacts

No live vaccine (except varicella) until six months after
immunosuppressive therapy

Neurological disorder

Progressive developmental delay or changing neurological findings
(e.g. infantile spasm) - defer pertussis immunization

Personal history of convulsions
Recent seizures - defer pertussis immunization

Conditions predisposing to seizures or neurological deterioration
(e.g. tuberous sclerosis) - defer pertussis immunization

Reactions

Severe Reactions to DTP

Insonable cry lasting more than 3 hrs with 48 hrs of dose

Seizure with 3 days

Severe local reactions

Family hx of adverse event

Not a contraindication, but consider carefully the benefits and
risks, if need to vaccinate can use acellular DTP for less reactions

Reactions

GBS with 6 weeks after a dose of DTP

Again based on risks and benefits for further dose of DTP
and risk of GBS recurrence.

Contraindication for further dose of DTP

encephalopathy within 7 days of a dose of DTP

VACCINE REACTIONS

Common, minor reactions

vaccine stimulates immune system

settle on their own

warn parents and advise how to manage

Rare, more serious reactions

anaphylaxis (serious allergic reaction)

vaccine specific reaction

Simutaneous administration of Vaccine

A theoretical risk that administration of multiple live virus vaccine:
OPV, MMR, and varicella ) within 28 days of one another if not
given on the same day will result in a sub optimal immune
response

No data to substantiate this

Recommended Storage Temperatures

Table 5: Vaccination Schedule for Infants and Children 2012

Age Type of vaccine

0-1 Week OPV0 dose , HepB1 , BCG

2 Months OPV1 , PENTA1,ROTA1

4 Months OPV2 , TETRA1,ROTA2

6 Months OPV3 , PENTA2,ROTA3

9 Months Measles + VIT A

15 Months MMR (Measles , Mumps , Rubella)

18 Months TETRA2, OPV First Booster dose + VIT A

4-6 Years DPT , OPV Second Booster dose + MMR2

Table 6: National Immunization Schedule for Infants and
Children 2015

Age Type of vaccine

0-1 Week HepB1 , BCG + OPV0dose

2 Months HEXA 1,ROTA1 ,PREV13-1+OPV1

4 Months HEXA2,ROTA2,PREV13-2 + OPV2

6 Months HEXA3,ROTA3,PREV13-3 + OPV3

9 Months Measles + VIT A

15 Months MMR(Measles , Mumps , Rubella)

18 Months PENTA (DTP+IPV+Hib ) OPV + VIT A

4-6 Years TETRA (DTaP +IVP ) + OPV + MMR