Acquired Immunity

Artificial

Active

Natural

Passive

Passive

Active

Toxoid

Homologous

Subclinical
Infection

Live Vacc

Heterologous

Clinical
Infection

Killed vacc

Transplacental

IMMUNITY
Immunity refers to the ability of the human body
to resist disease agents and their toxins
through possession of antibodies.

Ab Titre

20

40

60

Days After First Injection

THE IMMUNE RESPONSE:

When an antigen (Ag) is introduced into the human body, it
stimulates the production of antibodies (Ab). Micro-organisms
(and their toxins) and vaccines are antigens which evoke an
immune response. The immune response is two types:1) The primary response: when an Ag is introduced into the
body for the first time, there is a latent period of 3-10 days
before Abs appear in the blood. A peak is quickly reached and
the level of Abs gradually falls over a period of weeks or
months.

2) The secondary (booster) response: the

response to a booster dose of the same Ag
differs in a number of ways from the primary
response:
- has a shorter latent period and more
rapid production of Abs.
- Abs are produced in abundance and a
high level is maintained for a longer period.
- the Abs produced tend to have a greater
capacity to bind to the Ags.
The accelerated response is attributed to the
immunological memory.

THE IMMUNE SYSTEM:

A. Humoral Immunity:
This type of immunity is due to circulating Abs (Gamma globulin's also called immunoglobulins).
It is a major defense against bacterial infections.
On stimulation, B-lymphocytes divide and its daughter
cells are transformed into plasma-cells.
The latter secrete the Abs into the circulation.

The types of immunoglobulins are:

(i)

IgG: Most Abs to infection belong to this class.

It is widely distributed in the tissue fluids and are equally

available in the intra and extravascular spaces.
It can cross the placenta, and so it provides passive immunity
to the newborn.
(ii) IgM: This is the first type produced by the maturing
foetus, and it is the main type responsible for the primary
immune response.
It is mainly intravascular but it does not cross the placenta.

(iii) IgA: Found in high concentration in the external

secretions: Colostrum, Saliva, tears and intestinal
and bronchial secretions. Because of this, IgA is part
of the first line of defence against infectious agents.

(iv) IgE: Very low in serum and tissue fluids. It has a

particular affinity to fix to tissues and so it is able to
sensitize mast cells so that upon contact with Ags,
the biologically active material present in mast cells is
released. Because of this it is called a "reagin".

v) Igd: Ab-activity has rarely been demonstrated,

and the biologic function is uncertain.

B. CELLULAR IMMUNITY:
Another way of establishing host resistance is through
T-lymphocytes.
These cells synthesize and release pharmacologically
active substances ("lymphokines") which can kill
cells carrying foreign Ags.
T-lymphocytes also act against the invader by
stimulation of macrophages.
This activity of the immune system is known as cell
mediated immunity. The peak of activity occurs
around the tenth day.

Rechallenge by a subsequent infection evokes a

secondary response more rapid and of greater
intensity.
This type of immunity is responsible for intracellular
infection (due to viruses and some bacteria e.g.
Tubercle bacilli) and fungal infection.
Besides infection, cellular immunity is responsible for
delayed hypersensitivity reactions, lysis of tumor
cells and rejection of tissue or organ transplants.

C. The complement system:

All vertebrates possess in their serum certain

proteins and other factors which participate in
the immune response.
Complements facilitate the A-AB reactions.

D. Enzymes effect systems

which serve to control clotting, laying down of

fibrin and dilatation of local capillaries to
facilitate passage of WBCs.
When functioning efficiently,

the body is usually

well protected by its immune defenses. There

are situations in which production of immunity
is depressed. Examples are:-

 Congenital and acquired immune-deficiencies.

Certain infections like mumps and measles.
Presence of passive immunity (maternal Abs).
Treatment with immuno suppressive drugs (e.g.
steroids)
Malnutrition
Diabetes mellitus
Old age

IMMUNIZATION

Vaccination and Immunization

These terms are often used interchangeably.
Vaccination and vaccine derive from vaccinia, the virus once
used as smallpox vaccine.
Thus, vaccination originally meant inoculation with vaccinia
virus to render a person immune to smallpox.
Although some persons still prefer that vaccination be
restricted to this use, most use it to denote the
administration of any vaccine or toxoid.

Immunization is more inclusive term denoting the process of

inducing or providing immunity artificially. Immunization
can be active or passive.
Infectious diseases can be prevented by stimulating the
individual to develop an active immunologic defence in
preparation for meeting the challenge of future natural
exposure (active immunization) or by supplying preformed
human or animal antibody to individuals already exposed
or about to be exposed, to certain infectious agents
(passive immunization).

In

1979G/1399H

the

vaccination

against

certain

childhood diseases became obligatory secondary to

the issue of a Royal Decree which dictated the
sustain of birth certificates until the completion of the
primary series of vaccination against:
T.B., Diphtheria, Tetanus neonatorum, whooping
cough, measles, and poliomyelitis.
Latter on the list included coverage against mumps,
rubella , hepatitis B viral infections and hib. .

In 1991G/1411H a change in the schedule of vaccine

administration was implemented (table 1), and
continued until the a subsequent schedule of
vaccination was approved and implemented in Shawal
17th 1422H/January 1st 2002. The most recent
schedule is applied starting Jan. 2008.
The changes included in the new vaccination schedule
reflect the efforts of continuous monitoring and
evaluation of the previous system.
It depended largely on the incidence of certain diseases
and their impact.
It also followed the most recent developments in the
manufacturing and industry of vaccines internationally
employed.

National and local studies and continuous research in the field of

immunizable childhood diseases had a great influence and
impact. The scientific recommendation of including:
- the haemophilus influenza b vaccine (Hib) to the previous
schedule was supported by a Royal approval.
[The use of adjuvant vaccines for the first time in Saudi Arabia
was a real achievement in this field (DPT + Hib)].
- IPV has been recommended for the first time since ever.
- Hepatitis A ,and Varicella vaccines have been recently added.
- Measles (mono) vaccine has been indicated at an earlier age.
-The two MMR doses are partially considered as boosters to
measles vaccine.

(see the attached schedule).

The routine schedules for active immunization of

normal infants and children, and of children not
immunized in early infancy have recently been
revised by the immunization Practices Advisory
Committee, Ministry of Health.
The birth certificate will not be issued until the child
has

completed

the

recommended

primary

immunization of infancy period including ( MMR,

Varicella and OPV ) at 12 months of age.

Active immunization involves administration of all or part of a

microorganism or a modified product of that microorganism
(e.g. toxoid) to evoke an immunologic response that
provides partial or complete protection to the recipient.
Vaccines incorporating an intact agent may be either live
(usually attenuated) or killed (inactivated).
The current available routine schedule for active immunization
in Saudi Arabia has been revised and implemented starting
January 2008 (Table 3).
The types and routes of administration of various vaccines are
shown in (Table 4).

Schedule for Immunization

Several factors influence recommendations
concerning the age at which vaccines are
administered.
a. They are age-specific risks of diseases.
b. They are age-specific risks of complications.
c. Ability of persons of a given age to respond
to the vaccine(s).
d. Potential interference with the immune
response by maternal antibodies (measles).

Modification of the recommended schedule may be

necessary because of missed appointment or
intercurrent illness.
Interruption of a recommended series does not require
starting the series over again or adding extra doses,
regardless of the interval elapsed.
If a dose of DPT or OPV is missed, immunization should
occur on the next visit as if the usual interval had
elapsed.
In contrast, giving doses of a vaccine or toxoid at less
than recommended intervals may lessen the antibody
response and therefore should be avoided.

Doses given at less than recommended intervals should

not be counted as part of a primary series.
Some vaccines produce local or systemic symptoms in
certain recipients when given too frequently (e.g., Td,
DT, and rabies).
Such reactions are thought to result from the formation
of antigen-antibody complexes.
* Td = Adult tetanus toxoid (full dose) and diphtheria
toxoid (reduced dose) for adult use.
* DT = Diphtheria and tetanus toxoids for use in children
aged < 7 years old.

Table 1: Routine immunization schedule for normal infants and children in

Saudi Arabia applied 1991.
Recommen Vaccine(s)**
Comments
ded Age
Birth

BCG, HBV

6 weeks

DTP, OPV,
HBV

3 months

DTP, OPV

5 months

DTP, OPV

6 months

HBV, Measles

Completion of primary series of DTP and OPV.

Completion of HBV series.

12 months

MMR

Should not be given before 12 months of age.

18 months

DTP, OPV

First booster dose of DTP and OPV

4-6 years

DTP, OPV

Second booster dose of DTP and OPV;

preferably at or before school entry.

DTP and OPV can be initiated as age 2 wk

during epidemics.

* This schedule for active immunization has been recommended by the

Immunization Practices Advisory Committee, Ministry of Health in 1991.

Table (2): Recent schedule for Vaccination of Newborns in Saudi Arabia.( Jan. 2002-Jan.2008)

Visit No.

Age

Vaccines **(dose)

First

At birth

BCG
HBV(1)

Second

At two months

Third

At four months

DPT(2)
OPV(2)
Hib(2)

Fourth

End of sixth months

Fifth

End of 12 months

MMR(1)

Sixth

End of 18 months

DPT (Booster1)
OPV (Booster1)
Hib (Booster1)

Seventh

At school entry 4-6 years

DPT (Booster2)
OPVBooster2)
MMR (Booster2)

DPT(1)
OPV(1)
Hib(1)
HBV

DPT(3)
OPV(3)
Hib(3)
HBV(3)

The DPT + Hib vaccine is a tetraimmune adjuvant vaccine that has been introduced
for the first time in Saudi Arabia in 2002 and is given in one injectable dose.
*

Table (3): Recent schedule for Vaccination of Newborns in Saudi Arabia. Starting January 2008.

Age at visit

Vaccines

At birth

BCG
HepB

2 - Months

IPV
[ DTP, HepB , Hib ]

4 - Months

OPV
[ DTP, HepB, Hib ]

6 - Months

OPV,
[ DTP, HepB , Hib ]

9 - Months

Measles ( mono )

12 - Months

OPV ,MMR
Varicella

18 - Months

OPV
DTP, Hib
Hepatitis (A)

24 - Months
4 - 6 Years

Hepatitis (A)
OPV,DTP, MMR, Varicella.

Table 4: Certain available vaccines and their routes of administration.

Vaccine

Type

Route

BCG

Live Bacteria

Intradermal
(preferred)
subcutaneous

DTP

D&T = Toxoids

Intramuscular

or

P = inactivated bacteria
Hepatitis B(HBV)

Inactivated viral antigen

Intramuscular

Haemophilus
Influenza b
(Hib)

Polysaccharide

Intramuscular

MMR

Live attenuated viruses

Subcutaneous

OPV

Live attenuated virus

Oral

BCG =
Bacillus Calmette Guerin vaccine (tuberculosis).
DPT =
Diphtheria, pertussis and tetanus vaccine.
MMR =
Live measles, mumps and rubella viruses in a combined vaccine.
OPV = Oral Poliovirus vaccines containing attenuated poliovirus types 1,2 and 3.

The Cold Chain

Failure of a vaccine to protect an individual child
may be due to a number of reasons.

* The vaccine may no longer be "antigenic" so

that it does not stimulate the body to produce
antibodies.

* With "live vaccines", which can occur if the

vaccine is no longer alive.

* Most live vaccines are killed easily by changes

of temperature, such as might occur if they are
left out of the refrigerator for a long time.

(This is particularly true of measles vaccine).

** Vaccines must be kept constantly cold throughout the chain of
storage and transport which they have to pass through before
reaching the child.
Breaks in this "cold chain", as it has come to be called, may be
due to a batch of vaccine delivery to a Ministry of Health depot
or to a hospital or health centre.
It can happen as a result of the breakdown of the refrigerating
system. Great care must be taken to try to avoid this
happening, and it is always better to have a refrigerator which
can run on two different sources of power.
Live vaccines are also damaged by sunlight, which is especially
likely to happen after they have been prepared (reconstituted)
for injection in the clinic or at the school.

Vaccines should always be kept in the shade.

They can also be affected by detergents or
antiseptics in syringes which have not been
properly cleaned or rinsed.
Even

in

the

best

circumstances,

vaccines

eventually lose their power and it is very

important to look at the date of expiry on the
container.
(This is the date after which the manufactures
cannot guarantee the power of the vaccine).

The chances that such expired vaccines will fail to

protect increase the longer the interval after the expiry
date.
Live vaccines for injection should be used on the same
day that they are reconstituted for injection, that is,
after the water (diluent) has been added.
Oral poliomyelitis vaccine can be used after opening
until the vial is all used up, so long as it is returned
to the refrigerator after clinic and kept in the shade.

The End
Thank You