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Protection from preventable diseases, disabilities and deaths. Birth right of every child Most cost effective healthcare intervention Greek word mmune means to be protected .
Some definitions
Acquired immunity: protection offered by introduction of various antigens or antibodies The process by which this is obtained is known as immunization Active immunization: Specific antigens evoke the needed immune response Passive immunization: Antibodies are supplied readymade as immunoglobulin and sera.
Vaccination: Process of inoculating the vaccine or the antigen Immunization: Process of inducing immune response, humoral or cell mediated. Seroconversion: Change from antibody negative state to antibody positive state. Seroprotection: The state of protection (from disease) due to presence of humoral immunity or antibody detectable in serum
History
Jenner: Cowpox vaccine 1796 Pasteur: Rabies prophylaxis 1885 EPI: WHO 1974, India 1978 UIP: India 1985 Child vaccine initiative: with support from several international agencies 1991 Global programme on vaccines: WHO 1993 Global alliance for vaccine and immunization - 1999
Achievements
Small pox eradicated in 1977 EPI coverage of > 80% by 1990 Certification for polio eradication by 2005 Over 3 million lives saved globally, annually
Types of vaccines
Live bacteria- BCG, Ty 21 a Live virus OPV, MMR Killed bacteria Pertussis, S.typhi Killed virus IPV, Rabies, HAV Toxoid DT, TT Capsular polysaccharide HiB, Pneumo, Meningo Viral subunit - HBsAg Bacterial subunit Acellular pertussis
TT / dT 2 doses of TT
Additional vaccines
Cold chain
The system of transporting, distributing and storing vaccines from the manufacturers right up to the point of use under refrigeration using any convenient method is referred to as cold chain
Vital link in immunization
Safe zone for short term storage (1-2 months)is 2-8 deg C. For long term storage 20 degC is used only for BCG,OPV,Measles/MMR
The T series of vaccine(DPT,DT,TT),typhoid Vi,Hep B should not be frozen as once frozen the aluminium salts used as adjuvant will be desiccated and will act as irritantsterile abscess
BCG-LAV (Danish bovine strain) BCG strain of bovine mycobacterium-3-10 million bac/dose Lyophilised At birth/first contact Single dose Nil 0.05 ml(newborn)0.1 ml(infants and children Intra dermal left deltoid 0-80%
C/I S/E
NAME CONTENT
DPT-KILLED PERTUSIS+TOXOID DIPHTHERIA & TETANUS Diph tox 20 Lf,Tet tox 5 Lf.Pertusis 6 IU(40,000 million killed bacteria +ALPO4-3 m
Liquid 6 wks 3 doses 6,10,14 wks 15- 18 mo, 5 yrs 0.5 ml I/M lat thigh P80%D80%T100% Prog neuro dis,uncontrolled cry,convulsion, severe rxn for 1st dose
Fever, local induration, pains
OPV-LAV SABIN, type 1-106(CCID 50),type-2-105(CCID 50),type-3- 105(CCID50 Liquid Birth Birth,6,10,14 wks 15- 18 mo,5 yrs 2 drops Oral 80-90%
C/I
S/E
Immuno defeciency,HIV
none
NAME CONTENT
PREPARATN Liquid INITIATION Birth within 48 hrs6 wks SCHEDULE Birth,6,14 wks/0,1,6 months BOOSTER DOSE Nil 10 microgram,0.5 ml(<10 yrs), 1 ml(>10 yrs)
ADMNSTRN I/M deltoid EFFICACY 90% C/I S/E None Local pain,erythema
NAME CONTENT
PREPARATN Lyophilised INITIATION >9 mo SCHEDULE 1 dose at 9-12 mo.2nd doseafter 3 mo if 1st dose<9 mo BOOSTER DOSE ADMNSTRN EFFICACY C/I S/E Nil 0.5 ml S/C deltoid 95% Imm def,anaphylaxis,egg protein allergy Fever ,rash after a week
MMR (LAV) Measles as above,Mumps5000 TCID of Urabe AM-9,Rubella 1000 TCID of Wistar RA/3M Lyophilised 15 mo Single dose
BOOSTER DOSE
ADMNSTRN
Nil 0.5ml
SC deltoid
EFFICACY
C/I S/E
95%
As in measles+pregnancy As in measles
NAME
CONTENT PREPARATN INITIATION SCHEDULE BOOSTER DOSE ADMNSTRN EFFICACY C/I S/E
MUMPS(LAV)
L-Zagreb/Jerry Lynn strain 5000TCID Lyophilised 15 mo with M&R or at 11 yrs Single dose Nil 0.5 ml SC deltoid 90-95% Imm def Fever
INITIATION SCHEDULE
BOOSTER DOSE ADMNSTRN EFFICACY C/I S/E
NAME
TYPHOID(KILLED)
CONTENT
PREPARATN INITIATION SCHEDULE BOOSTER DOSE ADMNSTRN EFFICACY C/I S/E
NAME CONTENT
NAME CONTENT
HEP-A (inactivated vaccine) HM 175 of HAV 720 ELU antigen/ml Liquid >2 yrs 2 doses 0, 6 mo Nil 0.5 ml IM antero lat thigh
NAME CONTENT
NAME
VARICELLA VACCINE
CONTENT
PREPARATN INITIATION SCHEDULE BOOSTER DOSE ADMNSTRN
NAME CONTENT
PREPARATN INITIATION
SCHEDULE
BOOSTER
Single dose
5 yrs
0.5 ml SC/IM-deltoid/Ant lat thigh 90-100% None Local rxn, mild fever
NAME
JAPANESE ENCEPHALITIS(KILLED MONOVALENT) Mouse brain(Nakayama/NIH strain) or Baby hamster kidney(P-3) or Recombinant DNA vaccine
CONTENT
NAME
CONTENT PREPARATN INITIATION SCHEDULE BOOSTER DOSE
INFLUENZA VACCINE (INACTIVATEDSPLIT VIRION) 1.5 mcg hemaglutinin of each of the chosen strain as suspension
Liquid All ages Single dose Every year with current strain 0.5 ml
DPT WC+HIB D &T toxoid PWC+capsular polysaccharide of Hib Lyophilised/liquid 6 wks 6,10,14 wks Nil
DOSE ADMNSTRN
EFFICACY C/I S/E
0.5 ml IM
90-100% None Mild fever,local induration
NAME CONTENT
DPT WC+HB COMBINATION D and T toxoid+PWC+ yeast derived r-DNA HBsAg Liquid 6 weeks 6,10,14 wks Nil 0.5 ml IM 90-100% Same as DPT
S/E
Fever,pain,local induration
NAME CONTENT
HDCV(virus grown in Human Diploid fibroblasts) 2. PCEC (Chick embryo cells) 3. Vero cell(vervet monkey kidney cell) PREPARATN Lyophilised INITIATION Any age-/after dog bite
SCHEDULE
BOOSTER DOSE ADMNSTRN EFFICACY C/I S/E
Pre expo:0.7,21 days.Post expo:0,3,7,14,28.Re expo0,7(<5 yrs), full course(>5 yrs) First after 1 year then every 3 yrs 0.5 ml/1ml depending on preparatn S/C deltoid/ ant lat thigh 90-100% None Local pain,rarely encephalopathy
BCG Vaccine
Attenuated M. Bovis developed in 1921 Protects against TB meningitis , Miliary T B Maternal antibodies do not interfere as CMI not transplacentally transferred Induces long term protection Supplied freeze dried and stored frozen or refrigerated Reconstituted vaccine to be used w/I 4-6 hrs Dose 0.05 ml(infants),0.1 ml(infants and children) Intra-dermal over left deltoid Local lesion due to bacterial multiplication which heals leaving a scar in 12 wks(repeat if no scar) C/I- Immune deficiency Side effect-Axillary adenitis
OPV
Live attenuated polio virus types1,2&3-developed by sabin ,1961 Temperature sensitive store frozen or refrigerated Can be given simultaneous with any other vaccine Multiple doses necessary to ensure vaccine virus take and response to all three types of viruses IAP recommends additional doses of opv as a part of pulse polio program every year till age of 5 yrs
On national immunisation days(NIDs) pulse doses of oral polio vaccine has to be administered as simultaneous feeding of vaccine to all susceptibles is neede to produce immunity, by preventing wild polio viruses from multiplying in the gut
It is mandatory to give all reccomended doses in NIDs so that no wild virus remains in circulation
OPV is contraindicated in immunodeficiency,HIV,active viral infections No side effects
IPV
Formaldehyde killed polio virus grown in monkey kidney or human diploid cell Contains 20,8,32 D antigen units against type 1,2,3 polio viruses respectively Seroconversion 90-95% after 2 doses,99% after 3 doses
DPT
Diphteria toxoid(Ramon &Glenny,1923) Killed Bordetella pertusis(Madsen ,1923) Tetanus toxoid(Ramon & Zoeller,1927) Toxoids adjuvated (Aluminium hydroxide/ phosphate) Vaccine supplied as liquid, stored refrigerated Aluminium adjuvated vaccine must not be frozen 0.5 ml injected IM on anterolateral asoect of thigh.
Parents must be alerted about local reaction and fever(PCT given) IAP recommends 2nd booster at 5 yrs H/O convulsion not contradiction Progressive neurological disease or serious adverse reaction to earlier dose are contraindications for DPT(replace with DT)
Measles
Live attenuated vaccine developed by Enders-1960 Vaccine further attenuated by Schwarz, EdmonstonZagreb Supplied freeze dried- store frozen or refrigerated Use reconstituted vaccine in 4-6 hrs(refrigerate do not freeze) 0.5 ml injected S/C preferably right upper arm Age at which recommended 9 months During outbreak>6 months If given < 9 mo repeat dose after 3 mo Possibility of fever for 5-10 days MMR-0.5ml S/C over deltoid(15 mo)
Typhoid
WHOLE CELL:
Killed S.typhi often with S.paratyphi A(TA) Developed by Wright ,1896 Liquid,store refrigerated,inject S/C Primary course:2 doses 4 wks apart at 6-9 mo of age or at any age Boosters once in 3-5 yrs Dose :0.25-0.5 ml S/C for primary,0.1ml for booster
Vi POLSACCHARIDE:
Developed by Robbins,1984 Liquid, adjuvated,store refrigerated Inject IM at or after 2 yrs of age(0.5 ml) Booster after 3 yrs
ORAL:
Live attenuated S.typhi developed by Germanier,1975 Strain name:Ty 21a Enteric coated capsules,store refrigerated, administer orally 3 doses on alternate days Repeat 3-5 yrs later Recommende age7 yrs or above
Hib vaccine
H . Influenza B-capsular polysaccharide Liquid or freeze dried Age of initiation 6 wks 3 doses 6,10,14 wks/2,4,6 mo Booster 1 yr after primary dose Dose 0.5 ml SC/IM over deltoid or anterolateral aspect of thigh
ADDITIONAL VACCINES
Varicella vaccine:
Developed by Takahashi in 1971,Japan Live attenuated Oka strain. Vaccine available as lyophilized powder Dissolve in 0.5 ml diluent SC 0.5 ml Single dose 1-12 yrs >13 yrs 2 doses at 1 mo interval
Hepatitis A
Inactivated vaccine containing H M 175 strain grown in MRC5 cell line. Pediatric formulation 720 ELU IM; 2 doses 6 mo apart between 2-18 yrs >19 yrs 1440 ELU 2 doses 6 months apart Efficacy 94-100% No boosters
Polysaccharide vaccine(23 valent) 7 Valent conjugated with CRM 197 diphtheria toxin 23 valent effective after 2 yrs of age Single dose 0.5 ml IM with booster every 3-5 yrs
Indications
Sickle cell disease Nephrotic syndrome in remission Congenital or acquired asplenia/splenic dys function HIV Chronic cardiac/pulmonary disease Immunodeficient conditions CSF leak Diabetes mellitus
Combination vaccines
DPT/HiB/HepB Benefits: 1. Reduced number of injections 2. Reduced pain and parental anxiety 3. High compliance, low drop out rates,enhanced coverage 4. Reduced no: of visits 5. Less storage space 6. Less burden on cold chain
BCG,OPV,DPT,H TT/Td,HB B OPV,DPT,HB TT/Td,HB OPV,DPT,MMR/ Measles,Typh OPV,DPT,HB Typh booster MMR,Typh HB Typh booster
Newer vaccines
Live attenuated varicella(oka)strain Killed hep A virus vaccine 23 valent pneumococcal vaccine Influenza virus vaccine Combination vaccines
Conjugated pneumococcal vaccine(7 valent) Conjugated S.typhi Vi vaccine Rota virus vaccine Combination vaccines
ADVERSE EVENT
VACCINE SYMPTOMS
MANAGEMENT
Anaphylaxis
any
Within 12 hrs.Acute IV fluids, paleness.Transient dexamethasone,ox decreased levels/loss ygen of consciousness.Dec muscle tone
ADVERSE EVENT
VACCINE SYMPTOMS
MANAGEMENT
Within 48-72 Sedation with hrs.Excessive triclofosinconsolable crying 50mg/kg/day+PCT+ feeding advice
ADVERSE EVENT
VACCINE SYMPTOMS Within 2-6 months firm-soft axillary lmphadenitis1.5-3 cm with/ without sinus
lymphadenitis BCG
Bacterial abcess
Any vaccine
ADVERSE EVENT
Any vaccine
ADVERSE VACCINE SYMPTOMS EVENT Seizures with fever(rare) DPT, measles Always generalised simple/complex
MANAGEMENT
The IAPCOI-Indian Academy of Pediatrics Committee On Immunisation,has formulated several scientific recommendations to other agencies pertaining to Immunisation
To adopt routine testing of all pregnant women for HBV infection and if mother is positive baby should be given HBIG+HB vaccine soon after birth
2. 3.
4.
5.
6. 7.
The academy should be represented on National Technical Advisory Group on Immunisation At 5 yrs booster immunisation with DPT rather than DT. Inactivated polio vaccine should be licensed and gradually introduced in phased manner Hep B and MMR vaccine should be included in national immunisation schedule immediately Govt. should consider inclusion of typhoid vaccine(Vi polysaccharide/whole cell inactivated) in the national immunisation schedule Another vaccine to be included is Hib Ensuring adequate supply of chick embryo/ tissue culture rabies vaccine