SHIFT #

PEDIATRICS 1

IMMUNIZATION
Kristine Bernal, MD | Nov. 4, 2019
2
PEDIA # 14
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OUTLINE
I. Immunization Basics Herd Immunity
A. Principles V. Vaccines for High Risk
B. Routes of Administration and Special Groups
C. Components of VI. Summary
Vaccines VII. Review Questions
D. Rules on Administration VIII. References
II. Childhood Immunization IX. Appendices
Schedule
III. Vaccines in the
National Immunization
Program (NIP)
IV. Recommended
Vaccines other than NIP Figure 2. Herd immunity
LEGEND
MUST KNOW BOOK PREVIOUS TRANS Immunization
    The process of inducing immunity against a specific disease
(infectious diseases)
I. IMMUNIZATION BASICS  2 types of Immunity: Passive and Active
A. PRINCIPLES
 Why should we learn about immunization? Passive Immunity
 Administration of preformed antibodies
 One of the most beneficial and cost-effective disease
 Do not need immune system to develop antibodies to prevent
prevention measures disease because you already given the preformed antibodies
 Protection is immediate (yet transient), lasting weeks to months
 Examples
 Transfer of maternal antibodies transplacentally or through
breastfeeding
 IGIM (measles and Hepatitis A
 prophylaxis)
 IVIG (i.e. replacement therapy for immunodeficiency
disorders)

Figure 1. Comparison of 20th Century Annual Morbidity and Current
Morbidity: Vaccine Preventable Diseases
Benefits of Immunization
 Vaccination programs are implemented to reduce the outbreak
of particular infectious diseases within populations
 Confers immunity to vaccinated individuals but also indirectly
protects non-vaccinated individuals via herd immunity (ex.
Mass vaccination of polio in children)
Active Immunity
 Whole or parts of the organism administered to prevent an
infectious disease
 Mimics natural infection but presents little or no risk to the
patient (not enough to produce disease and not enough for you
to transmit the disease) 
 You need a good immune system because it is the patient`s
immune system who would start producing own antibodies
 Long-lasting immunization
 Examples:
 Whole inactivated (polio, hepatitis A)
 Parts of the organism (acellular pertussis, HPV, hepatitis B)
 Polysaccharide capsules (Pneumococcal and
Meningococcal)
 Polysaccharide capsules conjugated to protein carriers (Hib,
pneumococcal and meningococcal)
 Live attenuated (Measles, Mumps, Rubella)
 Toxoid (Tetanus, Diptheria)

Active Immunity Passive Immunity

Life-long immunity Immediate protection but transient
Adminstration of pre-formed You make your own antibodies after
antibodies the administration of the organism in
the vaccine

Table 1. Passive Immunity vs Active Immunity

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B. ROUTES OF ADMINISTRATION


Table 1. Guidelines for spacing live and inactivated antigens (CDC)
 Live vaccines
 Wait 2 weeks before giving immunoglobulins
 Immunoglobulins
 Wait 3 months or longer before giving vaccines
 Giving 2 or more IM injections
 Distance of 2.5 cm on the same thigh
Figure 3. Administration techniques (WHO Vaccine Safety Basics)
 Anaphylaxis
 Epinephrine 1:1000
 Most live vaccines are given subcutaneously  0.01 mL/kg up to maximum 0.5mL IM
 Vaccine storage and transport
C. COMPONENTS OF VACCINES
 maintain cold chain always

II. CHILDHOOD IMMUNIZATION SCHEDULE

Figure 4. Common Components of Vaccines

 Conjugating agents 
 carrier proteins that enhance immunologic response Figure 5. Childhood Immunization Schedule 2019
 Preservatives, stabilizers, antimicrobial agents or chemical
agents  III. VACCINES IN THE NATIONAL IMMUNIZATION
 Thimerosal: preservative to kill or inhibit growth of PROGRAM (NIP)
microorganisms Ten Vaccines Included in NIP
 Suspending fluids or vehicle (saline, sterile water) The following are vaccines given in health centers for free:
 Adjuvants: aluminum salt to increase immunogenicity and  BCG
prolong stimulatory effect  Monovalent Hep B
 Pentavalent vaccine (DTwP-Hib-Hep B)
D. RULES FOR VACCINATIONS  Bivalent OPV
 Unknown immunization status  IPV
 can start all over again  PCV
 A lapse in the immunization status does not necessitate to start  MMR
all over again  MR
 All vaccines can be administered at the same visit following the  Td
minimum age requirements for all vaccine  HPV
 Vaccines not given simultaneously should follow appropriate
intervals 1. Bacille Calmette-Guerin (BCG)
 Spacing and administration of LIVE and INACTIVATED  Live vaccine; Given at birth
ANTIGENS (ex. 2 live vaccines at least 4 weeks interval- BASIC  Route: Intradermal (ID)
RULE)  It is given at the right deltoid
 When: Earliest possible age after birth preferably within the first
2 months of life
 Dose:
 0.05 mL for children < 12 months of age
 PEDIA Trans 2.14 Immunization 3 of 6

 0.1 mL for children > 12 months of age  For infants born to HBsAg (+) mothers: Administer HBV
 Special Remarks: and HBIG (0.5 mL) within 12 hours of life.
 For healthy infants and children > 2 months not given BCG at  HBIG should be administered not later than 7 days of age if
birth- PPD prior to BCG vaccination is not necessary not immediately available.
 PPD- screening test for TB; BCG is the vaccine for TB  For infants born to mothers with unknown HBsAg
 However, PPD is recommended prior to BCG vaccination if status:
any is present:  Birth weight > 2kgs: administer HBV within 12 hours of
 Congenital TB (if the mother has active TB) birth and determine the mother’s HBsAg ASAP. If HBsAg
 History of close contact to known or suspected infectious (+), administer also HBIG not later than 7 days of age.
TB cases  Birth weight <2 kgs: HBIG in addition to HBV within 12
 Clinical findings suggestive of TB and/or chest x-ray hours of life
suggestive of TB  For preterm infants:
 In the presence of any of these conditions, an induration of ≥ 5  If born to HBsAg (-) mothers and medically stable, the 1st
mm is considered positive and BCG is no longer dose of HBV may be given at 30 days of chronological
recommended age regardless of weight, and this can be counted as part
 Contraindications of the 3-dose primary series.
 Immunodeficiency  For those <2 kgs, the 1st dose at birth not counted as
 Progressive dermatoses near the site of infection part of the vaccine series. Additional 3 HBV doses are
 Adverse Reactions needed.
 Abscess at the site of infection
3. Haemophilus influenza Type b Conjugate vaccine
 Regional lymphadenopathy (specifically axillary
(Hib)
lymphadenopathy)
 Rare: Osteitis affecting epiphysis of long bones can occur  Influenza- virus; Haemophilus influenza- bacteria (common
several years after BCG. cause of CNS infection, pneumonia, otitis media for babies)
 Polysaccharide protein conjugate
 Route: Intramuscular (IM)
 When:
 Given as a 3 dose primary series with a minimum age of 6
weeks and a minimum interval of 4 weeks
 Must know table  A booster dose is given between 12-15 months of age with
Usual Reaction Accelerated an interval of 6 months from the 3rd dose
Reaction
4. Diptheria and Tetanus Toxoid and Pertussis
Induration 2-4 weeks 2-4 days Vaccine (DTP)
Pustule Formation 5-7 weeks 5-7 days  Pertussis is whole cell (wP) or acellular (aP)
(bacterial infection  Whole cell- more side effects; acellular –less side effects
“nana”)  Route: Intramuscular (IM)
Scar Formation 2-3 months 2-3 weeks  When:
 Minimum age of 6 weeks with a minimum interval of 4 weeks
 Dosing:
 Complete a 5-dose series at ages 2, 4, 6, 15 through 18
months, and 4 through 6 years. The recommended interval
between the 3rd and 4th dose is 6 months, but a minimum
interval of 4 months is valid.
 The 5th dose of DTaP vaccine may not be given if the 4th
dose was administered at age 4 years or older.

Usual Reaction Adverse Reaction

Low to moderate fever up to 72 High fever 40 C and above
hours
Restlessness Seizure
Irritability Severe Irritability
Pain and swelling Somnolence
Lethargy
Inconsolable crying for 3-6
hours
Table 2. DTP Adverse Reactions
Figure 6. Induration with BCG Note: If a patient develops any of the adverse reactions after
DTwP, recommended next dose of DTaP because it is the
2. Hepatitis B pertussis that is causing the side effects
 Inactivated vaccine; Given at birth
 Route: Intramuscular (IM) 5. Inactivated Poliovirus Vaccine (IPV)
 When:  Route: Intramuscular (IM)
 First dose: newborns > 2kg – within 24 hours  Usually given in combination with DTaP and Hib, with or without
 2nd dose: 1-2 months after the birth dose Hep B
 Final dose: administered not earlier than 24 weeks of age  When:
 Another dose is needed if the last dose given at < 24 weeks  Minimum age of 6 weeks with a minimum interval of 4 weeks
 Special Remarks:  Dosing:
 The primary series consists of 3 doses
 PEDIA Trans 2.14 Immunization 4 of 6

 A booster dose should be given on or after the 4th birthday 9. Tetanus and Diphtheria Toxoid (Td)/Tetanus and
and at least 6 months from the previous dose Diphtheria Toxoid and Acellular Pertussis Vaccine (TdaP)

Note: 5 in 1 vaccine- DTP, IPV, Hib  Route: Intramuscular (IM)

6 in 1 vaccine- plus Hep B  When: fully immunized children – Td booster doses should be
4 in 1 vaccine- DTP, IPV given every 10 years
 Dosing: for children aged >7 years old, a single dose of Tdap
5a. Bivalent Oral Polio Vaccine can be given and replace due Td. Administered regardless of
 Live vaccine the interval since the last tetanus and diphtheria toxoids.
 Route: Oral Subsequent doses are given as Td.
 When: Same as IPV  Fully immunized is defined as 5 doses of DTP or 4 doses of
 Contraindications: DTP if the 4th dose was given on or after the 4th birthday
 Altered immune state  For pregnant adolescents (for preventing neonatal tetanus)
 Antineoplastics or chemotherapy  Fully immunized: Administer 1 dose of Tdap vaccine at 27 to
 High dose steroids 36 weeks AOG regardless of previous Td or Tdap
 HIV vaccination
 Pregnancy  Unimmunized: administer a 3 dose tetanus-diphtheria
 Radiation therapy containing vaccine (Td) following a 0-1-6 month schedule.
 Household contacts of immunocompromised patients Tdap should replace one dose of Td given during 27 to 36
 Adverse reactions: Paralysis (VAPP- Vaccine Associated weeks AOG.
Paralytic Polio-most common in oral polio)
Note: DTP (all capital letters)- more component; TdaP (small
6.Pneumococcal Conjugate Vaccines (PCV) letter)- less component
 Polysaccharide protein conjugate
 Route: Intramuscular (IM)
9. Human Papillomavirus Vaccine (HPV)
 When:
 Minimum age of 6 weeks for PCV10 and PCV13
 Inactivated vaccine
 Dosing:
 Route: Intramuscular
 Primary vaccination consists of 3 doses with an interval of at
 Best given before sexual intercourse
least 4 weeks between doses plus a booster dose given 6
 When: for ages 9-14 years, a 2-dose series is recommended:
months after the 3rd dose.
Bivalent HPV (2vHPV), quadrivalent (4vHPV) or nonvalent
 Special Remarks:
(9vHPV) given at 0 and 6 months.
 Healthy children 2 to 5 years old who do not have previous
 Dosing: If the interval between the 1st and 2nd dose is less than
PCV vaccination may be given 1 dose of PCV13 or 2 doses
6 months a 3rd dose is needed. The minimum interval between
of PCV10 at least 8 weeks apart.
the 2nd and 3rd dose is 3 months
 For ages 15 years and older, a 3-dose series is recommended:
Bivalent (2vHPV), quadrivalent (4vHPV) or nonavalent (9vHPV)
7.Measles Vaccine
at 0,2 and 6 months.
 Live, attenuated
 The minimum interval between 1st and 2nd dose is 1 month and
 Route: Subcutaneous (SC) the minimum interval between the 2nd and 3rd dose is 3 months.
 When: Given at the age of 9 months but may be given as early  The 3rd dose should be given at least 6 months from the 1st
as 6 months of age in cases of outbreaks as declared by the dose.
public health authorities. (why not earlier than 6 months?
 For males 9-18 years of age, a 4vHPV and 9vHPV can be given
because the baby still have the mother`s antibody)
for the prevention of anogenital warts and anal cancer
 Special Remarks: If monovalent measles is not available, MMR
may be given. SUMMARY: The National Immunization Program (NIP) consists of
 Adverse Reaction: Fever with or without rash 5-12 day after the following:
vaccination BCG Vaccine Single dose given at birth
Monovalent Hepatitis B Vaccine Given at birth
8. Measles-Mumps-Rubella (MMR) Vaccine
DPT-Hib-HepB Vaccine 3 doses usually given at
 Live attenuated 6,10,14 weeks of age
 Route: Subcutaneous (SC) Oral Polio Vaccine/IPV 3 doses usually given at
 When: Given at a minimum age of 12 months 2 doses of MMR 6,10,14 weeks of age
are recommended Pneumococcal Conjugate 3 doses usually given at
 Dosing: the 2nd dose is usually given from 4-26 years of age but Vaccine 6,10,14 weeks of age
may be given at an earlier age with a minimum of 4 weeks Measles (Monovalent or MMR) Given at 9 months
interval between doses. MMR Given at 12 months
 Reactions: Td/TdaP Given >7 years of age (every
 Measles: fever with or without rash 5-12 days after 10 years)
 Mumps: Swelling of parotid glands HPV Given >9 years of age
 Transient arthritis or arthralgia (2doses); >15 years of age
 Post auricular lymphadenopathy (3doses)
 Contraindications:
 Immunocompromised patients
 Pregnant patients
 PEDIA Trans 2.14 Immunization 5 of 6

IV. RECOMMENDED VACCINES NOT INCLUDED IN THE NIP

Measles-Mumps-Rubella-Varicella Vaccine
Rotavirus Vaccine (RV)
 Live attenuated
 Live vaccine
 Route: Subcutaneous (SC)
 Route: per orem (PO)
 When: minimum age of 12 months
 When: minimum age of 6 weeks with a minimum interval of 4
 Special remarks: MMRV may be given as an alternative to
weeks between doses.
separately administered MMR and Varicella vaccines
 Dosing: the last dose should be administered not later than 32
 The maximum age is 12 years. The recommended minimum
weeks of age.(If beyond 8 months- high risk for intussusception)
interval between doses is 3 months
 Special Remarks: the monovalent human rotavirus (RV1) is
given as a 2-dose series and the pentavalent human bovine
Hepatitis A Vaccine (HAV)
rotavirus vaccine (RV5) is given as a 3-dose series
 Inactivated vaccine
Influenza Vaccine (Trivalent/Quadrivalent Influenza
 Route: Intramuscular (IM)
Vaccine)
 When: minimum age of 12 months
 Dosing: 2 doses of the vaccine are recommended
 Inactivated vaccine
 The 2nd dose is given at least 6 months from the 1st dose
 Route: Trivalent influenza vaccine (TIV) given intramuscularly
(IM) or subcutaneously (SC). Quadrivalent vaccine (QIV) given
SUMMARY: Vaccines not included in the National Immunization
intramuscularly (IM)
Program (NIP):
 Dose and When:
Rotavirus Given at 6 weeks (2 or 3 dose
 Minimum age of 6 mos
series)
 0.25mL for children 6-35 months
Influenza Given at 6 months (yearly
 0.5mL for children 36 months to 18 years
thereafter)
 Children 6 months to 8 years receiving influenza vaccine for the
Japanese encephalitis Given at 9 months (1 or 2
1st time should receive 2 doses separated by at least 4 weeks
doses depending on age)
 If only one dose was given during the previous influenza
Varicella Vaccine Given at 12 months (2doses)
season, give 2 doses of the vaccine then one dose yearly
MMRV Given at 12 months
thereafter
Hepatitis A Given at 12 months (2 doses)
 Children aged 9-18 years should receive one dose of the
vaccine yearly
 Annual vaccination should begin in February but may be guven VACCINES FOR HIGH RISK AND SPECIAL GROUPS
throughout the year.  Pneumococcal Conjugate Vaccine (PCV)/Pneumococcal
polysaccharide Vaccine (PPSV23)
Japanese Encephalitis Vaccine (JE)  Hemophilus influenza Type b conjugate vaccine (Hib)
 Meningococcal Vaccine
 Rabies Vaccine
 Live attenuated
 Typhoid Vaccine
 Route: Subcutaneous (SC)  Cholera Vaccine
 When: minimum age of 9 months  Hepatitis A Vaccine
 Dosing: children 9 moths to 17 years of age should receive one  HPV
primary dose followed by a booster dose 12-24 months after the  Dengue Vaccine
primary dose
 Individuals 18 years and older should receive a single dose only V. VACCINE HESITANCY

 A delay in acceptance or refusal of vaccines despite

Varicella Vaccine availability of vaccination services
 Factors: complacency, convenience, confidence
 Live attenuated  How to persuade parents: one on one contact with an
 Route: Subcutaneous (SC) informed, caring and a concerned physician
 When: minimum age of 12 months  Assure that vaccines are tested thoroughly before
licensure, that ongoing mechanisms of monitoring safety
 Dosing: 2 doses are recommended. The 2nd dose is usually
exists after licensure
given at 4-6 years of age, but may be given earlier at an interval  Stress that serious disease can occur if a child or family
of 3 months from the first dose. are not immunized
 If the 2nd dose was given 4 weeks form the first dose, it is
considered valid. KEY TAKEAWAYS:
 For children 13 years and above, the recommended minimum  Vaccines provide passive and active immunity
interval between doses is 4 weeks.  The vaccine in the NIP and non NIP program were
discussed according to types, routes, dosing, adverse
 Adverse reaction: Varicella-like lesions 2-3 weeks to a month
reactions and special remarks.
after
 Immunization protects us and the future generations
from infectious diseases and eliminate or greatly
decreased the incidence of dangerous diseases
 PEDIA Trans 2.14 Immunization 6 of 6

III. REVIEW QUESTIONS

1. Form of immunization wherein all or part of the organism is

given to evoke an immunologic response that mimics
natural infection
a. Active immunization
b. Passive immunization
c.Herd immunity
2. Rotavirus route of administration
a. Intramuscular
b. Intradermal
c. Oral
3. Component of the DPT vaccine that is most associated with
adverse reactions
a. Acellular pertussis
b. Whole cell pertussis
4. Vaccine contraindicated to be given in patient with an
immunocompromised household contact
a. HAV
b. Inactivated Polio Vaccine
c. Oral Polio Vaccine
5. If the mother is HbsAg positive, Hep B vaccine and HBIg
should be given within what time frame from birth?
a. 8 hours
b. 12 hours
c. 16 hours

Answers: 1. A, 2. C, 3. B, 4. C, 5. B

IV. REFERENCES
SUMMARY OF ROUTES OF ADMINISTRATION

Intradermal Intramuscular Subcutaneous Oral

BCG Hepatitis B Measles Bivalent OPV
Rabies DPT/Td/TdaP MMR Rotavirus
IPV Varicella Cholera
Pneumococcal Japanese
Vaccine Encephalitis
Human
Papilloma
Virus
Hepatitis A
Meningococcal
Typhoid
Rabies

SUMMARY OF TYPES OF VACCINES

Toxoid Inactivated Live Polysaccharide

attenuated
Diphtheria Hepatitis B BCG Pneumococcal
Tetanus Pertussis OPV Meningococcal
IPV Measles Haemophilus
Influenza
HPV MMR
Influenza Varicella
Hepatitis A Rotavirus
Typhoid Japanese
Encephalitis
Cholera
Typhoid

END OF TRANSCRIPT
Transcribed by: Quintana, Quintin, Rabara, Ragudo, Ramos, Ramos,
Ramos
Checked by: