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chap 107 -- immunization principles & vaccine use

chap 107 -- immunization principles & vaccine use

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Published by: api-3704562 on Oct 16, 2008
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Chapter 107: Immunization Principles & Vaccine Use

\u201cAn ounce of prevention is worth a pound of cure\u201d
Best Treatment \u2013 Preventive Measure
Goal: Universal Immunization

Key Terms
Vaccine \u2013 preparation of attenuated live or killed microorganism
or antigen particles of these agents presented to a potential host
to induce immunity and prevent disease.
Toxoid \u2013 modified bacterial toxin made nontoxic but retains it\u2019s
capacity to stimulate the formation of antitoxin
Immunoglobulin \u2013 antibody containing protein fraction derived

from human plasma used primarily for maintenance of the immunity of persons with immunodeficiency disorders or for passive immunization

Antitoxin \u2013 antibody derived from the serum of animals after
stimulating with specific antigens and used to provide passive
immunity to the toxin protein to which it is directed.
Routine Immunization during first 18 months \u2013 Total of 21
antigens, some in form of combinations
Diphtheria/tetanus/acellular pertusis vaccine (DtaP)
Trivalent inactivated poliovirus vaccine (IPV)
Measles/Mumps/Rubella Vaccine (MMR)
Haemophilus influenzae type b vaccine (Hib)
Hepatitis B (HepB) & A (HepA) vaccine
Varicella vaccine
(& recently)
Heptavalent pneumococcal vaccine
Influenza vaccine (given annuall)
5 Vaccine Routinely used for Adults:
Tetanus/diphtheria toxoids (Td)
HepB vaccine
Influenza virus vaccine
Polyvalent pneumococcal polysaccharide vaccine
Varicella Vaccine
Other special used vaccine: ex PTB
For outbreak response
Prophylaxis for travellers
Regional Use
No vaccine yet for Eukaryotic pathogen (protozoa & helminthes)

Healthy People 2010 objective \u2013 that by 2010, 80% children received DtaP, IPV, MMR, Hib & HepB and 90% adult received influenza & pneumococcal vaccine (mukhang malabo mangyari sa pilipinas)

I. Impact of Immunization \u2013 Resut of Vaccine
Global Eradication of smallpox
Eliminated naturally transmitted poliomyelitis
Measles nearly 100% infectivity rate in prevaccination
Hib conjugate vaccine for infants eliminate invasive H.
influenzae infection (pneumonia & meningitis)
Polyvalent pneumococcal vaccine
present significant
impact against invasive pneumococci
Definition: Vaccination vs Immunization
Vaccination \u2013 simply administration of vaccine
Immunization \u2013 process of inducing or providing immunity
\ue000Active Immunization \u2013 induction of immune defense
by administration of antigen (Ag) in apparent form
\ue000Passive Immunity \u2013 provision of temporary protection
by administration of exogenous product of immunity \u2013
Thus vaccination may not gurantee immunity
II. Principles of Immunity
Active Immunization \u2013 pathologic process
Passive immunization \u2013 natural process ex. Placental
Combination of Active & Passive \u2013 Complementary
action (ex. HepB + HepBIg) but some may cause
interferring action (ex. Measles vaccine + MeaslesIg)
*Whole organism vaccine \u2013 contain all protective Ag of the
III. Approach to Active Immunization

1. Use of live generally attenuated infectious agent (ex. Measles virus) \u2013 avirulent yet remain immunogenic which produce long lasting immunity (because of advantage of replicating in vivo increasing antigenic response level) although cause some subclinical illness/immune response (caution: OPV contraindicated for immunodeficient child & its contact as it could cause vaccine-associated polio)

2. Use inactivated agent or their constituent or products obtained by genetic recombination (ex. Acellular pertusis) \u2013 require multiple doe & periodic booster as maintenance (exception is pure polysaccharide vaccine \u2013 useless ang booster [why? See later])

Use both approach.
IV. Approach to Passive Immunity

-provide temporary immunity: (1) to unimmunized subject exposed to the infectious disease (2) used if active immunization is unavailable, implemented before exposure [ex. Treatment of disorder associated with toxin (diphtheria), certain bites (snake or spider) and specific/nonspecific immunity (RhIg)]]

3 types of Preparation:
Standard Human immune serum globulin given IM/IV
Special immune serum globulin with known content of Ab to
specific Ag (ex. HepBIg)
Animal sera & Antitoxin
Route of Administration \u2013 orally, intranasal,
intradermal, Subcutaneous, IM & IV
Parenteral (IV) may not induce mucosalsecretory IgA
Mucosal Immunity \u2013 may not inducegood systemic
VI. Age \u2013 schedule for immunization based on age dependent

Ex. Infant has immature immunity + maternal antibody, while elderly experience natural waning of immunity, so that they needed large dose of vaccine

VII. Adjuvant Potentiation (ex. Aluminum salt & carrier protein)
Render soluble antigen into particulate one (para di
matunaw agad)
Mobilize phagocyte to the site of antigen deposition
Slow down release of Ag to prolong stimulation of immune
VIII. Immune Response
Primary response \u2013 characterize by early appearance of IgM
Antibody(M-aaga), which has low affinity & nonspecific to Ag
(latent period of 7-10 days before immune response). Then the
\u201cthymus dependent\u201d antigens, CD4+ T helper lymphocytes

which shift IgM to IgG (high affinity and more specific Ab) \u2013 if person lack Major Histocompatibility Complex (MHC) determinants which is required for antigen presentation, there would be no antibody shift to IgG (Primary Vaccine Failure)

Secondary Response \u2013 heightened humoral & cell mediated
response in second exposure to antigen within 4-5 days (rapid)

depending on Immunologic memory characterized by marked proliferation of IgG Ab produced by B Lymphocyte &/or T effector cell. Although level of vaccine-induced Ab decline over time (secondary vaccination failure) so that revaccination is needed (exeption is the pneumococcal polysaccharide vaccine which evoked immune response independent of T cell & is not enhanced by repeat administration)

IX. Hypersensitivity Reaction \u2013 unanticipated over-stimulation
of immune system by vaccination
X.Mucosal Immunity \u2013 secretory IgA \u2013 efficient way to block
the essential first step in pathogenesis
XI.Herd Immunity

Vaccination of individual give direct protection from infection of individual which decrease the %susceptible persons within a population. Therefore if prevalence of immunization is increase in a population (Herd Immunity), infection will not circulate and the remaining small % of unvaccinated person is indirectly protected (Herd Immunity Effect).

XII. Target Population & Timing of Immunization
Different age group differ in disease attack rate

Effectiveness of vaccine depends on variety of factors (individual responsiveness, demographic feature of population at risk & the duration & character of response)

Vaccination program is much effective if applied to
community than to an individual
Target Population: susceptible individual
Time of Immunization: early in life as is feasible
XIII. The Development of Vaccine
A. Biologic Impediments (Problems)
Antigenic drift of Influenza virus which annually produce
new antigenic version of the virus which differ from the
previous vaccine
Many pneumococcal polysaccharide serotype which render
some sero-specific pneumococcal vaccine ineffective.
B. Strategy of Vaccine Development
Phase 1 \u2013 Studies of animal to identify protective antigen
Phase 2 \u2013 Determination of how to present this antigen
effectively to the immune system

Phase 3 \u2013 Assessment of safety & Immunogenecity of the preparation in small an then large human population at various age

Phase 4 \u2013 Evaluation of safety & efficacy in the target
C. Vaccine Formulation
Living vs dead antigen does not induce the same immune
response & differ with every organism

Goal is not only to select the correct antigen, but to ensure that the vaccine will result in a type of immune response needed for protection & to create a deliverable vaccine, constituent other than the antigen:

Preservative/Stabiulizer/Antibiotics \u2013 prevet deterioration
Adjuvant \u2013 enhance immune response
Suspending Medium
D. Production of Vaccine \u2013 effecacious but does not cause
Good Manufacturing Practice Standard regulated by USFDA \u2013 to
ensure safety, efficacy, sterility & purity
High cost
Vaccine manufacturer decline
Future availability decline
E. Administration of Vaccine

Minimized the risk of spreading the disease during administration (universal precaution ex handwashing, aseptic/antiseptic)

Discourage of multiple injection \u2013 combination vaccines are
created for single shot
Primary healthcare should ensure access of medical
service & educate about vaccine \u2013 for patient compliance
XIV. Use of Vacine (recommended in 2003)
Routine administration in Infants, Children & Adults
(refer to Table 107-4, page717)
Vaccine for Special Use (Refer to Table 107-5, page 718)
Schedule of Immunization (Refer to Figure 107-1 & 2,
page 719-720)
A. Recording & reporting Requirement

Regulated by National Children Injury Act of 1986 (mod 1995 & 2002) requiring all vaccine must be recorded permanently by healthcare professional including the date of administration, the manufacturer and lot number of vaccine and name of the provider.


Health provider should inform the parents the benefit and risk of vaccination and the importance of up-to-date immunization record.

B. Vaccine for routine Use

Infants & Children \u2013 DtaP, IPV, MMR, Hib, HepB, Varicella, Pneumococcal conjugate vaccine; others: HepA \u2013 if there is risk of exposure or in case of travel to endemic area, Influenza vaccine \u2013 children 6-24months of age, in Europe \u2013 meningococcal conjugate vaccine is routinely administer (sa philippines, pTB ata routine)

Adults (>18y/o) vaccine classified into 4 categories:
1 - Routinely use for adult \u2013 ex. all adult completed the pediatric
series should be boosted with Td (adult form) every 10 years

2 - For high risk exposure (ex. Healthcare worker, student, military personel) \u2013 ex. 2nd dose of MMR for high risk medical practitioner

3 - For person at high risk for severe outcomeof infection (ex. Pregnant, elderly, with chronic systemic disease) \u2013 ex. Rubella- susceptible pregnant women should be vaccinated as early as possible in the postpartum period, Influenza vaccine to adult with chronic disease or >50 y/o, HepA with those risk of clotting disorder or liver disease

4 \u2013 vaccine for household contacts of person in group 3 \u2013 ex. HepB vaccine to household living with patient with Hepatitis B infection

C. Adverse Event
Adverse event \u2013 can either be true vaccine reaction or
coincident evet
Adverse reaction or Side Effect \u2013 untoward effect extrenous to
its primary purpose
XV. Use of Vaccine in Special Circumstance
A. Influenza Pandemic Preparedness
B.Pregnancy \u2013 because of theoretical risk to the fetus & the

real risk of litigation to the practitioner, routine immunization of women is avoided. Only live vaccine should not be given to pregnant women which could cause risk of congenital disorder to the fetus. If indicated some inactivated vaccine such as HepB may be given in the 2nd or 3rd trimester.

C. Breastfeeding \u2013 vaccine does not affect safety of
D. Occupational Exposure \u2013 work risk-related protective

E. HIV Infection & other Immunocompromised states \u2013 persons known to be infected with HIV should be immunized with recommended vaccine the same manner

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