Preventive Pediatrics

Celia T. Sy, M.D.

Pediatric Pulmonologist
Department of Pediatrics
Fatima Medical Center
Immunization
Vaccinations
Type of vaccine
Route of administration
Immune response
Post- exposure drug prophylaxis

Immunization
Denotes the process of inducing or
providing immunity artificially by
administering an immunologic
substances
Active
Passive
Active Immunization
When it produces the desired beneficial
effects by stimulation of endogenous
antibody production by the patient
Tetanous toxoid
MMR
BCG
Passive Immunization
Administration of preformed human or
animal antibodies to individuals already
exposed or about to be exposed to
certain infectious agents
Tetanus antitoxins
Immune globulins
Vaccination
Denotes the physical act of
administrating any vaccine or toxoids

Immunobiologic Substances
Vaccine - a suspension of live or inactivated
microorganism or fractions thereof
administered to induce immunity and prevent
infectious disease or its sequela

Toxoid modified bacterial toxin that has
been made nontoxic but retains the ability to
stimulate the formation of antitoxins






Antitoxins a solution of antibodies
derived from the serum of animals
immunized with specific antigens
Passive immunization
Diphtheria antitoxin
Tetanus antitoxin
Immune globulin (IG) - a sterile
solution containing antibodies from
human blood. Intended for IM use
for passive immunization
Measles immune globulin
hepatitis b immune globulin
IV IG a product derived from blood
plasma from the donor pools similar to
the IG pool but prepared for IV used
Used in primary antibody-deficiency
disorders
- Kawasaki disease
- ITP
- Hypogammaglobulinemia

Immunologic Constituents
Suspending fluids sterile water, saline
Preservatives, Stabilizers, Antibiotics
used to inhibit or prevent bacterial growth
Stabilize the antigens or antibodies
albumin, phenols, neomycin, mercurial
Adjuvants evoke suboptimal immunologic
response
To enhance immunogenicity
Al hydroxide, Al phosphate



Vaccines & Toxoids
Live vaccines
BCG
MMR
Oral polio
Varicella
Oral typhoid
Killed antigens
Toxoids
DPT
Tetanus
Killed antigens
Inactivated Virus
IPV (inactived polio
virus)
Influenza
Rabies
Hepatitis A
Hepatitis B
Killed antigens
Bacterial
polysaccharide
Hib
Route of Administration
Intramuscular (IM)
DPT
IPV (as DPT-IPV-HIB
combination)*
Hep A & B
HiB
Influenza
Pneumococcal
Meningococcal
Typhoid

Subcutaneous (SC)
Measles
Mumps
Rubella
MMR
Varicella
IPV
Pneumococcal
Meningococcal


Route of Administration
Oral
OPV
Typhoid
Intradermal
BCG
Where to inject?
General rules:
For children < 1 year old lateral thigh
For children > 1 year old - deltoid
Buttocks should not be used for active
vaccinations because of the potential
risk of injury to the sciatic nerve
If the buttocks are to used use only
the upper outer quadrant
Fever:
To give or not to give?
Minor febrile illness or malnutrition is
not a contraindication to immunization
Immunization is deferred in the
presence of severe febrile illness
Vomiting:
What to Do?
Regurgitated oral vaccine
If the child vomit or regurgitate within 5
10 mins after giving OPV another dose
should be given at the same visit
If repeated dose is not retained,
re-administered at the next visit
Diarrhea:
Could OPV be given?
Diarrhea should not be considered as a
contraindication for OPV but to ensure
full protection, doses given to children
with diarrhea SHOULD NOT BE
COUNTED as part of the series
Need to give 2 or more vaccines:
How to give?
Multiple vaccinations
Administer each vaccine at a different site
using different needles and syringes
If > 1 vaccine is to be used in a single
limb, use the thigh muscle and given at 1 -
2 inches apart

Interruption of Schedule
What to do?
Interruption with a delay between
doses does not interfere with the final
immunity achieved
No need to start the series again
Contraindications?
Live attenuated vaccines is
contraindicated in:
Pregnant woman
Immunocompromised person leukemia,
lymphoma, malignancy, therapy with
steroids, alkylating agents, antimetabolites
Radiotherapy
Trivia
Which of the following are live
vaccines?
DPT Measles
TOPV Pneumococcal
IPV Meningococcal
BCG Oral Typhoid
Hep B
MMR
Guidelines for Giving Live
vaccines and killed Antigens
2 or more killed antigens may be
administered simultaneously or at any
interval between doses
Example:
DPT and Hep B
DPT and Hib
Hep A and Hep B


Killed and live antigens may be
administered simultaneously or at any
interval between doses
Example:
DPT and OPV
Hep b and MMR
DPT and Measles
DPT and varicella
2 or more live antigens may administered
simultaneously or at 4 week minimum interval
if not given simultaneously
Example:
Measles and varicella
MMR and varicella

** OPV can be administered at any time before,
with or after MMR if indicated

Guidelines for administration
of IG & Vaccines
Simultaneous administration
IG and killed antigen given at the same
time or at any time between doses
Hepatitis B immune globulin and hepatitis B
vaccine
Tetanus antitoxins and anti-tetanus vaccine
IG and live antigen should generally NOT
BE ADMINISTERED simultaneously
GuidelinesIG & Vaccines
Non-simultaneous administration
First Second
IG Killed Ag No interval needed
IG Live Ag dose related
Killed Ag IG No interval needed
Live Ag IG 2 weeks

Interval between IG & Live
Measles Vaccine
IVIG Interval
ITP 400 mg/kg 8 month
ITP 1000 mg/kg 10 months
Kawasaki 11 months
Blood transfusion
Whole blood & packed RBC 6 months
Plasma/platelets 7 months
IntervalIG & live measles
vaccine
IG measles prophylaxis
Normal contact 0.25ml/kg 5 mons
Immunocompromised 0.50ml/kg 6 mons
Trivia
Which of the following vaccines can be
given simultaneously?
Hep B & Measles
BCG & DPT
Oral polio & measles
DPT & MMR
Measles & MMR
DPT & IPV + HiB
Immune Response
Immune response to one live virus
vaccine might be impaired if
administered within 30 days of another
live virus vaccine
Only OPV and MMR can be
administered at anytime before, with or
after each other
Immune Response
Live virus vaccines can interfere with
the response to a tuberculin test
Tuberculin testing can be done either
on the same day that live virus vaccines
are administered or 4 6 weeks later
Special Conditions
Special Considerations
Persons with hemophilia
Increased risk of hepatitis B & hematomas
Assess the patients bleeding risk
Use fine needle & apply pressure to the
site
Special considerations
Altered immunocompetence
Killed or inactivated vaccines can be
administered to all immunocompromised
patients
OPV should not be given to any household
contacts of an immunocompromised
patient
IPV can be given
Special considerations.
Altered immunocompetence
MMR is not contraindicated to close
contacts of immunocompromised persons
MMR vaccine is recommended for all
asymptomatic HIV-infected persons and
should be considered for all symptomatic
HIV-infected persons
Special consideratios
Preterm infants
Regardless of birth weight should be
vaccinated at the same chronological age
and according to the same schedule
Use full recommended dose except BCG
OPV should be deferred until discharge
from the nursery
Special considerations
Pregnancy
Combined tetanus and diphtheria toxoids
ARE THE ONLY vaccine indicated
Vaccines
BCG (Bacille-Calmette-Guerin)
Attenuated bovine strains of tubercle bacilli
Route: intradermal
Dose: 0.05 ml preterm
0.1 ml term
Complications
Abscess
Indolent ulcer
lymphadenopathy

BCG
Normal course
Wheal diappear in 30
mins
Induration after 2-
3 wks
Pustular formation
after 4 6 wks
Full scarification
after 6 12 wks
Accelerated
reaponse 91-
100% correlation
with TB infection
Induration after 2
3 days
Pustular formation
after 5 7 days
Scar after 2 -3 wks

Polio vaccine
OPV live attenuated vaccine
IPV inactive polio virus
Combination vaccine:
DPT + IPV + Hib
DPT
Toxoids of diphtheria & tetanus;
inactivated pertussis component
adsorbed into aluminum salts
Dose: 0.5 ml
Route: IM
Side effect: swelling at injection site
DTaP
Diphtheria, tetanus, acellular pertussis
component
Decrease risk of neuroparalytic
reactions due to component of pertussis
Measles
Live attenuated vaccine
Freeze dried
Dose: 0.5 ml SQ
Side effects: fever between 5
th
-14
th
day after
injection, rashes, arthritis
Prophylaxis: may be given within 72
hours after measles exposure
Measles IG 0.25 ml/kg IM may be within 6
days of exposure


Hepatitis B Vaccine
Infant born to HBs Ag-positive mother
should received:
Hep b Vaccine + Hep B immune globulin
(HBIG) within 12 hours of birth at different
site
Next dose: Hep B at 1-2 months of age
and 3
rd
dose at 6
th
month of age
Schedule: 0, 1, 6
Hepatitis B Vaccine
Infant born to mother whose HBsAg
status is unknown:
Hep B vaccine within 12 hours of birth
Request for mothers HBsAg status if (+)
Infant should received HBIG Asap
(no later than 1 week of age)
Recommended Schedule
BCG

DPT, TOPV, IPV, Hib

Hepatitis B



Measles
At birth or anytime after
birth
2, 4, 6 month of age

0, 1, 6 month of age
0, 1, 3 month of age
(endemic country)

9 month of age
( can be given at 6
month of age)

Schedule.
MMR
Hepatits A
Pneumococcal (IPD
7 valent)
Pneumococcal (23-
valent)
Meningococcal
Typhoid
15 month of age
After 1 year of age
2, 4, 6 months up to
9 years of age
2 years of age

2 years of age
3 years of age
Post-exposure Drug
Prophylaxis
Diphtheria Erythromycin
Pertussis Erythromycin
Cholera Tetracycline
Plasmodia Chloroquine
N. gonorrhea Amoxicillin/Penicillin
Meningococcemia Rifampicin
Sulfisoxazole
Ceftriaxone
Tuberculosis Isoniazid


Case 1
A 3 y/o child was exposed to a person with measles. Past
immunization hx: he had received 1 dose of BCG, 3 doses of
DPT, TOPV & Hepatitis B. If you are the attending physician,
how are you going to manage the patient?
Give measles vaccine if the exposure is within 72 hours
Give measles immunoglobulin if the exposure is more than 72
hours
Give MMR if the exposure is within 72 hours
Give Mesles vaccine and immune globulin at the same time
Observe the patient