Sukamto Koesnoe

Division of Allergy-Clinical Immunology Department of Internal Medicine Faculty of Medicine University Indonesia Dr. Cipto Mangunkusumo Hospital Satgas Imunisasi Dewasa PAPDI (Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia)

VACCINATION PROCEDURES

CURRICULU M VITAE
Dr. Sukamto Koesnoe, SpPD
Pendidikan
Fakultas Kedokteran UI, tahun 1993

Spesialis Ilmu Penyakit Dalam FKUI, Tahun 2005

Pendidikan konsultan allergi & klinik imunologi di Divisi Alergi Imunologi dept. FKUI S3 Epidemiologi Klinik FKM-UI

Jabatan
Staf Pengajar FKUI-RSUPN-CM
Kepala K3RSCM

GENERAL RECOMMENDATION IN VACCINATION

Principles of Vaccination

All vaccines can be administered at the same visit as all other vaccines

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Nonsimultaneous Administration of Two Live Parenteral Vaccines

Administration of live vaccine should be given on same time Interference can occur between two live vaccines given less than 28 days apart If two live parenteral vaccines vaccines (MMR, MMRV, varicella, zooster, yellow fever), or live intranasal influenza vaccine, are given less than 28 days apart the vaccine given second should be repeated Exception is yellow fever vaccine given less than 4 weeks after measles vaccine
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Principles of Vaccination

Increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine* Ex: Hepatitis B vaccine 0,1,6 0, 2, 6?

Decreasing the interval between doses of a multidose vaccine may interfere with antibody response and protection Ex: Hepatitis B vaccine 0,1,6 0,1,2?
*after the series has been completed
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Minimum Intervals and Ages

Vaccine doses should not be administered at intervals less than the minimum intervals or earlier than the minimum age Vaccination in school: class or age Ex: HPV minimum age 10 (4th class)

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Violation of Minimum Intervals or Minimum Age

ACIP recommends that vaccine doses given up to four days before the minimum interval or age be counted as valid Immunization programs and/or school entry requirements may not accept all doses given earlier than the minimum age or interval
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Extended Interval Between Doses

Not all permutations of all schedules for all vaccines have been studied Available studies of extended intervals have shown no significant difference in final titer It is not necessary to restart the series or add doses because of an extended interval between doses

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

VACCINES ADMINISTRATION

Preparation
Screening Vaccine safety and risk communication Atraumatic care: - Positioning & Comforting Restraint - Pain Control Infection control Vaccine preparation - Equipment Selection - Inspecting Vaccine - Reconstitution - Prefilled Syringes - Labelling
Epidemiology and Prevention of Vaccine-Preventable Diseases. Appendix D Vaccine Administration. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Prefilled Syringes Samples

NEEDLES
Hub Glue Canula

Disposable Needle

Softpack needle
Needles conditioned by 5 into a soft plastic packaging. They are used for syringe by 10 packs.

Hardpack needle
Sole needle conditioned into a hard plastic packaging. They are only used for syringe by one packs.

Vials Samples

Need to be reconstituted

Screening Questions Example

Is the child (or are you) sick today? Does the child (or are you) have an allergy to any medications, food, or any vaccine?
Has the child (or are you) had a serious reaction to a vaccine in the past?

Is the child/teen (or are you) pregnant or is there a chance she could become pregnant during the next month? Does the child (or are you) have cancer, leukemia, AIDS, or any other immune system problem?
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Subcutaneous injection

Epidemiology and Prevention of Vaccine-Preventable Diseases. Appendix D Vaccine Administration. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Intramuscular injection

Epidemiology and Prevention of Vaccine-Preventable Diseases. Appendix D Vaccine Administration. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

VACCINE STORAGE & HANDLING

Storing the Vaccines

CDC: Vaccine Storage and Handling Toolkit. Accessed 14th Oct 2009: http://www2a.cdc.gov/vaccines/ed/shtoolkit/

Managing Vaccine Storage

CDC: Vaccine Storage and Handling Toolkit. Accessed 14th Oct 2009: http://www2a.cdc.gov/vaccines/ed/shtoolkit/

Expiration Date (1)

Vaccine may be used up to and including the expiration date

Vaccine storage and handling toolkit. National Centre for Immunization and Respiratory Diseases. Vaccine Inventory Management. Centers for Disease Control and Prevention. Downloaded at: http://www2a.cdc.gov/vaccines/ed/shtoolkit/pages/inventory_management.htm ( Accessed 10 Nov 2009)

Expiration Date (2)

EXP: 10/2010

EXP BY: 10/2010

EXP BEFORE: 10/2010

Expiry would be 31/10/2010

Use through 31/10/2010. DO NOT use on or after 1/11/2010

Expiry would be 30/9/2010

Expiry would be 30/9/2010

Use through 30/9/2010. DO NOT use on or after 1/10/2010

NHS. Vaccine Handling Recommendations for Clinics, Hospitals, Community Pharmacies and GP Practices July 2007.

Vaccine Transport
Be sure to place an insulating barrier between the refrigerated/frozen packs and the vaccines to prevent accidental freezing. The layer should be as follows refrigerated/frozen packs barrier vaccine -thermometer- barrier additional refrigerated/frozen packs. Pack vaccines in their original packing on top of the barrier. Do not remove vaccine vials from boxes.

Vaccine Storage Practice in Vaccine Storage and Handling Tool Kit by NCIRD

Disposal
Dispose of sharps immediately after use at the point of care. Needles and syringes must be disposed of as a single unit. Do not over fill the sharps bin or fill beyond the fill line. Lock and tag the bin to identify the clinic source when full for disposal. Full sharps bins must be stored in a secure locked area away from the public
Storage, Distribution and Disposal of Vaccines Policy. North East London NHS. June 2007

Unsafe Immunization Practices

WHO. Immunization Practice. Module 4:Ensuring safe injections ;2004

Vaccination Safety and in Special Condition

Vaccine Safety

Contraindication
A condition in a recipient that greatly increases the chance of a serious adverse reaction
A condition in a recipient that might

increase the chance or severity of an adverse reaction, or Might compromise the ability of the vaccine to produce immunity
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Contraindications and Precautions

Permanent contraindications to vaccination:

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
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Vaccine Adverse Reactions

Adverse reaction

extraneous effect caused by vaccine side effect reactogenicity

Adverse event

any event following vaccination may be true adverse reaction may be only coincidental KIPI

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Tenaga Kesehatan di Daerah

Laporan KIPI dari pasien / orang tua Memberitahu tenaga kesehatan

Kejadian berada dl daftar KIPI dilaporkan
ya tidak

Perhatian masyarakat terhadap KIPI

Tingkat Kabupaten

Tidak ada pelacakan, tetapi laporan KIPI dicatat

tidak

Melengkapi laporan KIPI

Informasi sudah adekuat untuk dinilai

ya

Tingkat Propinsi

Menyediakan informasi selanjutnya

tidak

Memenuhi definisi Kasus KIPI

ya

tidak

Perhatian masyarakat tinggi

Memenuhi kriteria Pelacakan lainnya?

ya

tidak

ya

PELACAKAN

Workshop KIPI dr. Dahlan Ali Musa 28 Oct 2009

Form Laporan KIPI

FORMULIR PELAPORAN KEJADIAN IKUTAN PASCA IMUNISASI (KIPI) 2005
Identitas pasien
Nama : ......................................... Nama Orang Tua : ......................................... Alamat : .......................................................... .......................................................... RT/RW : ....../...... Kel./Desa ............................ Kec. : .......................................................... Kab/Kota : .......................................................... Prop. : .......................................................... Telp. : .......................................................... Kode Pos : Pemberi Imunisasi : Dokter / Bidan / Perawat / Jurim diberikan dalam 4 minggu terakhir Pabrik No. Batch Tanggal Jam Pemberian Oral / intrakutan / subkutan / i.m Lokasi penyuntikan Jumlah dosis Vaksin-vaksin yang No. 1 2 3 4 Tempat pemberian imunisasi : 1. RS; 2. RB; 3. Puskesmas; 4. Dokter Praktek; 5. Bidan Praktek; 6. BP; 7. Posyandu; 9. Balai Imunisasi; 10. Bidan Desa (Polindes); 11. Rumah; 12. Pustu ; 13. Pos PIN Waktu gejala timbul Tanggal Jam Mnt Lama gejala Mnt Jam Hari 8. Sekolah; Jenis Vaksin Tanggal lahir : ...../...../ Jenis Kelamin 1. Laki-laki; Penanggung jawab (dokter) .......................................................................... Alamat (RS, Puskesmas, Klinik) ............................................................................ RT/RW : ....../...... Kel./Desa ............................ Kec. : ........................................................... Kab/Kota: ........................................................... Prop. : ........................................................... Telp. : ........................................................... Kode Pos : Kolom ini hanya diisi oleh Komnas PP KIPI Kode sumber data : .......................................... Tgl. terima : ././.. 2. Perempuan

Bagi Wanita Usia Subur (WUS) 1. Hamil; 2. Tidak Hamil Keadaan umum : .............................................

Manifestasi kejadian ikutan (keluhan, gejala klinis)

Keluhan & Gejala Klinis Bengkak pada lokasi penyuntikan Perdarahan pada lokasi penyuntikan Perdarahan lain .................................................. Gatal Bengkak pada bibir / kelopak mata / kemaluan Bentol disertai gatal Muntah Diare Pingsan (sinkop) Kejang Sesak nafas Demam tinggi (>390 C) lebih dari satu hari Pembesaran kelenjar aksila Kelemahan/kelumpuhan otot: lengan/tungkai Kesadaran menurun Menangis menjerit terus menerus > 3 jam Lain-lain 1. ......................................................... 2. ......................................................... Diagnosis Ensefalitis Ensefalopati Sindrom Guillain Barre Hipotonik hiporesponsif Pengobatan KIPI Adrenalin Infus Meningitis Abses Abses dingin Selulitis Neuritis brankhialis Syok anafilaksis Urtikaria Poliomielitis paralitik Perawatan / tindakan Tindakan darurat Rawat inap Rawat jalan Kondisi akhir pasien Sembuh Tidak sembuh Gejala sisa Meninggal ( tgl. ...........................) Tidak ada keterangan

Diagnosis : lain ?

Purpura trombositopenia Kejang demam Sepsis BCGitis Tindakan penanganan KIPI

Limfadenitis BCG Hemofilia APCD Eritema multiform

Kortikosteroid Antihistamin

Antipiretik Antibiotik .......................... ..........................

.......................... .......................... Data laboratorium penunjang KIPI

Obat-obat yang sedang diberikan .......................... .......................... .......................... ..........................

Diagnosis lain: alergi, kelainan sejak lahir, pengobatan khusus

Riwayat efek samping obat/vaksin yang pernah dialami

Berita KIPI diperoleh dari Nama Hubungan dengan pasien Tanggal

: (kader, keluarga, masyarakat, .............................. ) : : : ...../...../..........

............................................, tanggal ...../...../.......... Tanda tangan petugas (........................................................)

Vaccine Adverse Events

Local
Systemic

pain, swelling, redness at site of injection

common with inactivated vaccines usually mild and selflimited

fever, malaise, headache

nonspecific may be unrelated to vaccine

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Vaccine Adverse Reactions

Allergic
due to vaccine or vaccine component rare risk minimized by screening

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Contraindications and Precautions

Condition
Allergy to component Encephalopathy Pregnancy Immunosuppression Severe illness Recent blood product

Live
C --C C P P**

Inactivated
C C V* V P V

C=contraindication P=precaution V=vaccinate if indicated *except HPV and Tdap. **MMR and varicella-containing (except zoster vaccine) only
Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Vaccination During Acute Illness

No evidence that acute illness reduces vaccine efficacy or increases vaccine adverse reactions

Vaccines should be delayed until the illness has improved Mild illness, such as otitis media or an upper respiratory infection, is NOT a contraindication to vaccination

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Invalid Contraindications to Vaccination

Mild illness Antimicrobial therapy Disease exposure or convalescence Pregnant or immunosuppressed person in the household Breastfeeding Preterm birth Allergy to products not present in vaccine or allergy that is not anaphylactic Family history of adverse events Tuberculin skin testing Multiple vaccines

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Anaphylaxis Algorithm

Working Group of the Resuscitation Council (UK); Resuscitation (2008) 77, 157169

Working Group of the Resuscitation Council (UK); Resuscitation (2008) 77, 157169

VACCINATION IN SPECIAL CONDITION

INTRODUCTION
Advanced in medicine, science and technology lead population with altered host defenses
In US reported :
2001 40 000 cases HIV infection 2002 1 284 900 cases cancer 23 848 cases solid organ transplant 20 000 hematopoetic stem cell transplant

Indonesia data ?
Mei 2008 270,000 HIV infection Selected immunocompromised persons

Vaccination of Pregnant Women

Live vaccines should not be administered to women known to be pregnant

In general inactivated vaccines may be administered to pregnant women for whom they are indicated

HPV vaccine should be deferred during pregnancy

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Vaccination in Pregnancy
Inactivated vaccines
Routine (influenza) Vaccinate if indicated (hep B, Td, rabies) Vaccinate if benefit outweighs risk (all other) HPV vaccine not recommended during pregnancy

Live vaccine do not administer

Exception is yellow fever vaccine

http://www.cdc.gov/nip/publications/preg_guide.pdf

Complications in pregnancy and the newborn

Congenital or neonatal varicella: Congenital varicella syndrome
2% of live births, when varicella contracted in weeks 1320 gestation1 severe damage to foetus2 increased risk of HZ in childhood3

Neonatal varicella
mother infected in late pregnancy (within 14 days of birth) infection within 5 days of birth: up to 30% mortality rate4

Image reproduced with kind permission from Dr. Barbara Watson

1. Enders G et al. Lancet 1994; 343: 154851. ;2. NACI. Can Commun Dis Rep 2004; 30: 126.; 3. Gershon AA. Adv Pediatr Infect Dis 1995; 10: 93124. 4. Nathwani D et al. J Infect 1998; 36 Suppl 1: 5971.

Vaccination in Asplenic Persons

Persons with functional or anatomic asplenia are at increased risk of infection with encapsulated bacteria Vaccines recommended (in addition to those routinely recommended for age):
Pneumococcal polysaccharide (2 doses

5 years apart)*
Meningococcal polysaccharide or

conjugate (11-55 years of age)

Vaccination of Hematopoietic Stem Cell Transplant Recipients

Antibody titers to VPDs decline during the 1-4

years after allogeneic or autologous HSCT if the recipient is not revaccinated HSCT recipients may be at increased risk of some VPDs, particularly pneumococcal disease Revaccination recommended beginning 6-12 months post-transplant

http://www.cdc.gov/mmwr/PDF/rr/rr4910.pdf

Hepatitis B in haemodialysis patients

End-stage renal disease (ESRD) haemodialysis patients are at high risk due to:
prolonged vascular access frequent hospitalisations and surgical procedures immunocompromised status

Majority develop chronic infection

CDC, MMWR Recomm Rep 2001; 50: 143

Vaccination of Household Contacts of Immunosuppressed Persons

Healthy household contacts of immunosuppressed persons should receive MMR and varicella vaccines and annual influenza vaccination

Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Varicella complications in immunocompromised individuals

More severe disease course versus healthy subjects
rash period is longer, prolonging discomfort

More frequent than in healthy individuals Mortality rates reach 710%1 Risk factors:
cancer, notably leukaemia2 HIV infection3 corticosteroid therapy4 immunosuppressant drugs with organ transplant5 malnutrition

1. Gershon A et al. In Plotkin SA et al eds. Vaccines, W.B. Saunders 2004; 784823.; 2. Leung T-F et al. Eur J Haemotol 2004; 72: 353357.; 3. Jura E et al. Pediatr Infect Dis J 1989; 8: 58690.; 4. Hill G et al. Pediatrics 2005; 116(4): e5259.; 5. Giacchino R et al. Transplantation 1995; 60(9): 10556.

Vaccination in Asplenic Persons

Persons with functional or anatomic asplenia are at increased risk of infection with encapsulated bacteria
Vaccines recommended (in addition to those routinely recommended for age):
Pneumococcal polysaccharide (2 doses 5 years apart)*
Meningococcal polysaccharide or conjugate (1155 years of age)

Vaccination of Hematopoietic Stem Cell Transplant Recipients

Antibody titers to VPDs decline during the 1-4

years after allogeneic or autologous HSCT if the recipient is not revaccinated HSCT recipients may be at increased risk of some VPDs, particularly pneumococcal disease Revaccination recommended beginning 6-12 months post-transplant

http://www.cdc.gov/mmwr/PDF/rr/rr4910.pdf

Unknown or Uncertain Vaccination Status

Self-reported doses of vaccine without written

documentation should not be accepted Accept doses* if:

written, dated record age, spacing, and timing comparable with that recommended in the U.S

If documentation is unavailable, vaccinate according to

age Judicious use of serologic testing may be considered for some antigens (measles, mumps, rubella, hepatitis B)

*including combination vaccines not approved for use in the U.S. http://www.cdc.gov/mmwr/PDF/rr/rr5515.pdf (pages 33-35)

Thank you