IMMUNIZATION

KEY TERMS

 Cold chain
 Immunization card
 Vaccine
 Vaccine vial monitor

INTRODUCTION

In 1974, the WHO launched its "Expanded Program on Immunization (EPI) against six, most common vaccine
preventable childhood diseases, Le, diphtheria, pertussis (whooping cough), tetanus, polio, tuberculosis, and
measles. From the beginning of the program UNICEF has been providing significant support to EPI. 'Expanded in
the WHO definition meant adding more disease controlling antigens of vaccination schedules, extending
coverage to all the corners of the country and spreading services to reach the less privileged sectors of the
society. The Government of India launched EPI in 1978 with the objective of reducing mortality and morbidity
resulting from vaccine preventable diseases of childhood and to achieve self sufficiency in the production of
vaccines. The Universal Immunization Program was started in India in 1985. It has two vital components:

 Immunization of pregnant women against tetanus.

 Immunization of children in their first year of life against the six EPI target diseases

OBJECTIVE OF IMMUNIZATION

1) To protect an individual against disease or infection.

2) To decrease prevalence of disease or infection in community.

3) To decrease the probability of contact between susceptible $ infected.

4) To decrease the proportion of laten or carrier infection.

5) To prevent outbreaks by decreasing the number of susceptible i.e. to decrease the supply of susceptible in all
definable sub-groups in a heterogeneous herd.

6) To increase herd immunity.

7) To eradicate wild type of virus.

BASIC PRINCIPLES OF IMMUNIZATION

 A minimum interval of 4 weeks is recommended between the administration of 2 live antigens , if not
administered simultaneously exceptions are OPV and MMR ,OPV and oral typhoid (Ty 21 a ),where
administration of one before or after another is permissible if indicated .

 Two or more killed antigens may be administered simultaneously or at any interval between the
doses .However , a minimum gap of 3- 4 weeks is recommended between two doses of cholera or yellow
fever vaccine .

 There is no minimum recommended time interval between two types of vaccines -a live and an
inactivated viral vaccine can be administered simultaneously at two different sites .

 A delay or lapse in the administration of a vaccine doesnot require the whole schedule to be
repeated .The missed dose can be administered to resume the course at the point it was interrupted .

 If the immunization of a child is not known , he may be administered age appropriate vaccines .

 The recommended dose of each vaccine should be adhered to , excessive dose may result in adverse
events while an inappropriately low dose may not evoke the required immune response .

 Mixing of vaccines in the same syringe is not recommended .

 There is no evidence to suggest that combination vaccines are more efficacious than individual vaccines .

 The following are not contraindications to immunization , minor illnesses such as upper respiratory tract
infection and diarrhoea ,mild fever ,prematurity , allergy to penicillin ,history of
allergies ,malnutrition ,recent exposure to infection and current therapy with antibiotics .

 Immunoglobulins interfere with the immune response to measles and MMR. Hence the vaccine should
not be given to children who have received such agents in the last 3 months. Immunoglobulins do not
interfere with the immune response to OPV and yellow fever vaccine .Hepatitis B ,tetanus and rabies
vaccine or toxoid may be administered concurrently with their corresponding immunoglobulin .

 Congenital immunodeficiency , therapy with high dose steroids and illnesses associated with
considerable immunosuppression are contraindications to the administration of BCG and live viral
vaccines .Live viral vaccines should be avoided in children with symptomatic HIV (AIDS).They may be
given after short courses (less than 2 weeks ) of low dose steroids .OPV should be avoided in healthy
siblings of immunocompromised children due to risk of face – oral transmission to the
immunocompromised children .

 Risk of adverse events following whole cell pertussis vaccine is increased in infants with progressive
neurological disease and in those with convulsions following a previous dose of the vaccine .active
immunization should be carried out following exposure to rabies, measles,varicella , tetanus and
hepatitis B.
TYPES OF IMMUNIZATION

There are 2 types of immunization.

Active Immunization Passive Immunization

Live Attenuated Inactivated or killed

Vaccines Vaccine

1)ACTIVE IMMUNIZATION:-

Consists of inducing the body to develop defense against disease. This is achieved by
administration of vaccine or toxoid that stimulate the immune system to produce antibodies $ cellular immune
response.

2) PASSIVE IMMUNIZATION:--

Consists of providing temporary protection through administration of exogenously produced

antibodies. Examples include administration of specific immunoglobulin in tetanus $ diphtheria.

IMMUNITY

Immunity is a biological term that describes a state of having sufficient biological defenses to avoid infection,
disease or other unwanted biological invasion. Immunity involves both specific and nonspecific components

Adaptive immunity is often subdivided into two major types depending on how the immunity was introduced.

Naturally acquired immunity occurs through contact with a disease causing agent, when the contact was not
deliberate, whereas artificially acquired immunity develops only through deliberate actions such as vaccination.
Both naturally and artificially acquired immunity can be further subdivided depending on whether immunity is
induced in the host or passively transferred from a immune host. Passive immunity is acquired through transfer
of antibodies or activated T-cells from an immune host, and is short lived-usually lasting only a few months-
whereas active immunity is induced in the host itself by antigen lasts much longer, sometimes life-long.

VACCINATION

Vaccination is the administration of antigenic material (a vaccine) to produce immunity to a disease. The term
cation was coined by Edward Jenner and adapted by Louis Pasteur for his pioneering work in vaccination. The
method Pasteur used entailed treating the infectious agents for those diseases so they lost the ability to cause
serious disease. Vaccines can prevent or ameliorate the effects of infection by many pathogens.

Most vaccines are given by hypodermic injection as they are not absorbed reliably through the intestines. Live
attended polio, some typhoid and some cholera vaccines are given orally in order to produce immunity based in
the bowel.

Types of Vaccines

Live Vaccines

Live vaccines are prepared from live organisms. These organisms are passed through chick embryos or other
such media repeatedly till they lose their capacity to induce the disease fully, but retain the capacity to trigger off
the defense mechanism. Live vaccines are usually more potent than inactivated vaccines. They multiply within
the host and produce more antigens. Live virus vaccines are used for tuberculosis (BCG), measles and polio

Inactivated or Killed Vaccine

Certain organisms when killed by heat or chemicals and then introduced into the body induce immunity. Killed
vaccines are 1105 not as effective as live vaccines. For instance, the pertussis vaccine, after three doses is about
80% effective in the first 3 years and after 12 years not at all. Inactivated vaccines may require two or three
doses. These are administered by injections. Pertussis, cholera, rabies and hepatitis B are some diseases that are
combated with killed vaccines.

Toxoids

For bacteria that secrete toxins, or harmful chemicals, a toxoid vaccine might be the answer. These vaccines are
used when a bacterial toxin is the main cause of illness. Scientists have found that they can inactivate toxins by
treating them with formalin a solution of formaldehyde and sterilized water Such 'detoxified toxins, called
toxoids, are safe for use in vaccines. When the immune system receives a vaccine containing a harmless toxoid, it
learns how to fight off the natural toxin. The immune system produces antibodies that lock onto and block the
toxin. Vaccines against diphtheria and tetanus are examples of toxoid vaccines.

Conjugate Vaccines
In the late 1980s, it was discovered that the problems with polysaccharide vaccines could be overcome through a
process called conjugation. Conjugation changes the immune response from T-cell independent to T cell
dependent, leading to increased immunogenicity in infants and antibody booster response to multiple deses of
vaccine. The first conjugated polysaccharide vaccine was for hemophilus influenzae type b (Hib). Also now
available are conjugate vaccines for pneumococcal disease and meningococcal disease.

Combination Vaccines

This is a mix of two or more types of vaccines. This enables easier administration, reduces cost and avoids
repeated contact with the patient. DPT (Diphtheria, Pertussis and Tetanus) vaccine is given in a single shot. Some
vaccines combine two strains of the same species. Polio and influenza vaccines are prepared this way.

Immunoglobulins

Immunoglobulins are specific protein substances that are produced by certain cells in the body to help in fighting
infection. They are also referred to as antibodies and are a vital part of the body's defense mechanism.
Immunoglobulins are of five different types-Immunoglobulin G. A. M. D and E. These are classified based upon
the speed with which they are formed in response to the infection, as well as their mechanism and site of action.
The invading organisms or vaccines promote the production of immunoglobulins (antibodies) against that
particular disease-causing organism which is then destroyed. The body also retains in its memory the template of
the disease-causing organism so that the next time it attacks, the antibodies are quick 10 counter any threat to
the body and the person does not develop the disease

MAINTENANCE OF COLD CHAIN TO RESTORE POTENCY OF VACCINE

It is a universal fact that all vaccines are sensitive to heat and some are sensitive to freezing. Therefore, vaccines
should be kept at an appropriate temperature range from the time of manufacture to the time of use. A vaccine
must have two characteristics, one is safety and other is potency. The vaccines lose their potency if they are not
stored or transported at an appropriate temperature Cold chain is a system of storing and transporting vaccine at
the recommended temperature range from the point of manufacture to point of use. In order to provide potent
and effective vaccine to the beneficiaries a vast cold chain infrastructure is required, which should have a
network of vaccine stores, walk-in-coolers (WIC), walk-in-freezers (WIF), deep freezer (DF), ice-lined refrigerators
(ILR), refrigerated trucks, vaccine vans, cold boxes, vaccine carriers and icepacks from national level to states up
to the outreach sessions

The recommended temperature range for most of the vaccine is from 2°C 10 °C. however the range varies for the
storage and transport, even long storage and short storage temperature also varies. Few vaccines are stored at a
frozen state.

COLD CHAIN EQUIPMENT FOR VACCINES

Refrigerated truck and insulated vaccines vans: Refrigerated trucks are used infrequently in India for
transportation of vaccines. Insulated vans are used for bulk transportation of vaccines by road. Up to 10 lakh
mixed antigen vaccines can be transported at a time. All vaccines are transported in cold boxes with frozen or
conditioned ice packs or with dry ice (Rotary International).

Walk-in-freezers: These are used for bulk storage of OPV, and also to prepare frozen ice packs at state stores.
They maintain a temperature around (-) 20 oC.

Walk-in-coolers: These are used for bulk storage of vaccines at State and Regional/Divisional Stores: They
maintain a temperature of +2°C to +8°C.

Deep freezer: The cabinet temperature is maintained between -15°C and -25°C This is used for storing of OPV
(district level and above only) and also for freezing ice packs. In case of power failure, it can maintain the cabinet
temperature in the range of 15 to -25°C for 18 and 26 hours at ambient temperatures of 42°C and 32°C
respectively, if not opened.

Ice-lined refrigerator: These type of refrigerators are top opening because they can hold the cold air inside
better than a refrigerator with a front opening. It can keep vaccine safe with us little as 8 hours continuous
electricity supply in a 24-hour period. Inside the ILR there is a lining of water containers (ice packs or tubes) fitted
all around the walls and held in place by frame. The ILR has got two sections-the top and bottom. The bottom of
the refrigerator is the coldest place and is known as section A. The DPT, DT, TT and BCG vaccines should never be
kept directly on the floor of the refrigerator as they can freeze and get damaged. The top section of the ILR is
known as section B and it maintains the temperature of 20 to +5°C All the vaccines should be kept in the basket
provided with the refrigerator. OPV and measles can be kept at bottom of the basket while BCG. DPT, DT and TT
vaccines are kept in upper part of the baskets. In case basket is not available keep two layers of empty ice packs
laid flat on the floor, do not keep the vaccines on the floor of the ILR.

Vaccine carriers: Vaccine carriers are used for carrying small quantities of vaccines (16-20 vials) to the subcenters
of session sites. The vaccine carriers are made of insulated material, the quality of which determines the cold life
of the carrier Four ice packs are laid in the vaccine carrier as per manufacturer's guidelines Frozen ice packs
should only be placed and the lid of the carrier should be closed tightly.

Ice Packs: Ice packs are key component of the cold chain. It is used for ice lining inside the cold box and vaccine
carrier. The ice packs are frozen inside the deep freezer under the temperature range of (-) 15 to (-) 25°C. The
specifications of ice packs vary with the manufacturers. The ice packs for cold box are different from vaccine
carrier and these should be med as per the manufacturer's guidelines

MONITORING OF THE COLD CHAIN

All vaccines are damaged by temperatures more than +&C, whether they are exposed to a lot of heat in a short
time (e.g. a result of keeping vaccine in a closed vehicle in the sun) or a small amount of heat over a long period
(e.g. as a result of the frequent opening of lid of ILR). Reconstituted BCG, measles and IE vaccines are the most
sensitive to heat and light. Since these live vaccines do not contain preservatives, there is risk of contamination
with Staphylococcus aureus leading to toxic shock syndrome and, therefore, they should not be used after 4
hours of reconstitution.

THE VACCINE VIAL MONITOR

To check the heat damage before opening a vial. A vaccine vial is impected which is containing a beat-sensitive
material as label to register cumulative heat exposure over time. The combined effects of time and temperature
cause the inner square of the vaccine vial monitor (VVM) to darken gradually and irreversibly.

Vaccines loose their potency due to either exposure to excessive heat or excessive cold (some vaccines like DPT,
TT. Hep B) and light (some vaccines like BCG and measles). Table I shows the sensitivity of vaccine to heat, cold
and light. It also tells about optimum storage temperature at PHC.

TABLE 1: Heat and Temperature Sensitivity of Different Vaccines

Steps of Procedure

 Wash your hands/use alcohol rub before preparation of drug

 Check vaccine vial monitor if it is there on vial to check potency of vaccine.

 Dissolve the vaccine (as per instruction) with NS or distilled water if it is in powdered form after cleaning
the cap of vial with alcohol/spirit swab and let the cap dry before inserting the needle into vial (Fig. 4A).
 Withdraw the required amount of NS/distilled water and push it into the powdered vaccine vial (Fig. 4B).
 Dissolve the powdered medicine by moving the vial on the table by holding from the upper tide instead
of shaking the Withdraw the required amount by inserting the needle into vial through rubber stopper
vial up and down.
 Expel any air bubbles from the syringe by inverting the syringe 2-3 times and push the plunger of syringe
 Hold syringe between thumb and forefinger of dominant hand with bevel of needle pointing up

 Latest National Immunization Schedule

Age Vaccines given
Birth Bacillus Calmette Guerin (BCG), Oral Polio
Vaccine (OPV)-0 dose, Hepatitis B birth dose
6 Weeks OPV-1, Pentavalent-1, Rotavirus Vaccine
(RVV)-1, Fractional dose of Inactivated Polio
Vaccine (fIPV)-1, Pneumococcal Conjugate
Vaccine (PCV) -1*
10 weeks OPV-2, Pentavalent-2, RVV-2
14 weeks OPV-3, Pentavalent-3, fIPV-2, RVV-3, PCV-
2*
9-12 months Measles & Rubella (MR)-1, JE-1** , PCV-
Booster*
16-24 months MR-2, JE-2**, Diphtheria, Pertussis &
Tetanus (DPT)-Booster-1, OPV –Booster
5-6 years DPT-Booster-2
10 years Tetanus & adult Diphtheria (Td)
16 years Td
Pregnant Mother Td-1, Td-2 or Td-Booster***


 
 Latest National Immunization Schedule (NIS) for Infants, Children and Pregnant
Women (Vaccine-wise)

Vaccine When to give Dose Route Site
For Pregnant Women
Tetanus & adult Diphtheria (Td)-1 Early in pregnancy 0.5 ml Intra- Upper
muscular Arm
Td-2 4 weeks after Td-1 0.5 ml Intra- Upper
muscular Arm
Td- Booster If received 2 TT/Td 0.5 ml Intra- Upper
doses in a muscular Arm
pregnancy within
the last 3 years*
For Infants
Bacillus Calmette Guerin (BCG) At birth or as early 0.1ml Intra- Left
as possible till one (0.05ml dermal Upper
year of age until 1 Arm
month
age)
Hepatitis B - Birth dose At birth or as early 0.5 ml Intra- Antero-
as possible within muscular lateral
24 hours side of
mid-thigh
Oral Polio Vaccine (OPV)-0 At birth or as early 2 drops Oral Oral
as possible within
the first 15 days
OPV 1, 2 & 3 At 6 weeks, 10 2 drops Oral Oral
weeks & 14 weeks
(OPV can be given
till 5 years of age)
Pentavalent At 6 weeks, 10 0.5 ml Intra- Antero-
1, 2 & 3 weeks & 14 weeks muscular lateral
(can be given till side of
one year of age) mid-thigh
Pneumococcal Conjugate Two primary doses 0.5 ml Intra- Antero-
Vaccine(PCV) at 6 and 14 weeks muscular lateral
followed by side of
Booster dose at 9- mid-thigh
12 months
Rotavirus (RVV) At 6 weeks, 10 5 drops Oral Oral
weeks & 14 weeks (liquid
(can be given till vaccine)
one year of age) 2.5 ml
(lyophili
zed
vaccine)
Inactivated Polio Vaccine (IPV) Two fractional dose 0.1 ml Intra Intra-
at 6 and 14 weeks dermal dermal:
of age two Right
 fractional upper arm
dose
Measles Rubella (MR) 1 dose
st 9 completed 0.5 ml Sub- Right
months-12 months. cutaneous upper
(Measles can be Arm
given till 5 years of
age)

Intramuscular Route
Checklist Yes No
Approach the child in a pleasant manner
Explain the procedure to the child/parents clearly using understandable language
and take consent from parents to administer vaccine to the child
Use nonthreatening/diversional approach
Select appropriate site according to age of child (outer lateral aspect of thigh that is
vastus lateralis, is the only site to be used for IM injection up to the age of 5 years,
Le. the outer lateral aspect of thigh (vastus lateralis) can be used (Figs SA to C).
To select vastus lateralis place a finger of one hand at greater trochanter and another
hand's finger at lateral femoral condyle
Now measure the total length between these two finger and inject the vaccine at
center of total length of vastus lateralis
Clean the site with chlorhexidine/spirit swab using an outward circular motion.
Grasp the muscle between the thumb and fingers and insert the needle gently and
quickly at a 90° angle
Draw back on the plunger to ensure that the needle is not in a blood vessel. (If blood
appears, withdraw needle, discard and repeat procedure with new medication,
needle and syringe).
Inject contents steadily using a slow and continuous movement at a rate of about 1
ml per 10 seconds
Withdraw the needle and put a dry sterile cotton swab at the site. Do not massage
the site but apply pressure for some time

Burn the needle in needle burner and cut the nozzle of syringe.

Make the child comfortable.

Assist parents consoling the child if crying.
Encourage the child to move/walk to facilitate absorption of the drug once needle
removed.
Praise the child/use nonverbal approach for cooperation.
Observe the child for 15-20 minutes for any side effects and ask the parents to
inform you any untoward sign/symptom appearing after drug administration.
Allow the child the opportunity to express his or her feeling (if applicable).
Reassure the child that next time will be easier (if applicable).
Terminate the Biomedical waste (BMW) (Figs 8A to C) The needle in the needle
burner or sharp-container (blue bucket) without recapping Cut the syringe hub and
separate the plunger and discard in red bucket
Discard the used swabs into yellow bucket
Discard the used vial/ampules/glass bottles in blue bucket
Remove gloves and put in red bucket (if worn) and wash hands
Wrapper/packing of drug to be discarded in the black bucket
Record the medication with signature, date, time, dose and observed effects.
Stay with the child and give feedback/instruction to the child/parent (if required).

Remind/tell the parents about the timings of next dose of vaccine.

ORAL POLIO VACCINE
Vaccine Vial Monitor

VVMs have been in use with oral polio vaccine (OPV) since 1996. If adequate training is provided they are well
accepted by health workers and managers. They have contributed to the success of national immunization days,
particularly in areas with a weak cold-chain infrastructure, and they clearly help to reduce vaccine wastage.
Agencies purchasing vaccines should request manufacturers to supply all vaccines with VVMs that meet WHO
specifications.

The VVM shows the health worker if a specific vial of polio vaccine can be used. The combined effects of time
and temperature cause the VVM to change color gradually and irreversibly. A VVM on one vial cannot be used to
indicate whether the vaccine in another vial lacking a VVM is suitable for use. Inner square lighter than outer
ring. If the expiry date has not been passed, use the vaccine. At a later time: Inner square still lighter than outer
ring. If the expiry date has not been passed, use the vaccine (Table 3).

Discard point: Inner square matches color of outer ring, DO NOT use the vaccine Beyond the discard point: Inner
square darker than outer ring. DO NOT use the vaccine

TABLE 3: How to Check Vaccine Vial Monitor

Purposes
  To prevent polio and to give adequate prophylactic protection against polio disease decreases
progressively over the count of time
 The desired goal of effective immunization of every child.

Contraindications

 No contraindication.

General Instructions

Before administration:

 Identify the child by checking the immunization card.

 Check the label of the vaccine vial before administration for:

a. Check the date of expiry.

b. Check for color of VVM label

 Vaccine, removed from cold storage, must be used within 30 days, provided it is stored continuously
between 2 +5°C in a refrigerator If the temperature exceeds +8C even for a short period, it loses its
potency significantly
 The vaccine contains phenol red as pH indicator The usual color is pink. If the vaccine deteriorates, there
is a distinct color change.
 As far as possible, only vaccine should be stored in a particular refrigerator However, if other things have
to be stored side by side, the vaccine containers should be kept in a closed airtight Styrofoam box and
stored in the middle or the upper shelves
 A thermometer must be kept next to the vaccine box.

During Administration

Follow the five rights of administration of OPV

Right patient: Identify the child by checking the immunization card and with the parent

Check with the doctor's prescription.

 Call the child's name along with father's name and ask the parent to repeat the same
 Child's age should not be more than 5 years.
Right vaccine Read the physician's order.

 Check with the VVM colour, color of vaccine.

 Check with the last administration date and calculate the child's age correctly.

Right dose: Two drops of OPV

Right time: According to National Immunization Schedule

Right route: By oral route

Procedure for OPV administration

 Explain the procedure to the parents and its necessity
 Check the identification of the child
 Check the immunization card for due date of vaccination (OPV)
 Check for any contraindication.
 Check the condition of the OPV vial (VVM).

Steps of Procedure

 Ask mothers when the child has taken least feed (umally child should not have any thing by mouth half
an hour before and half an hour after the vaccination).
 Wash hands with soap and water to prevent from infection
 Read the physician's order in immunization card. Make sure that proper due date for proper vaccine. For
administration of correct vaccine in correct dose to the correct child at right time by right route
  Take out the oral polio vaccine vial from refrigerator after reading the immunization card
 To check the possibility of pouring a wrong vaccine
 To ensure the right and potent vaccine, check the OPV vial for VVM label, expiry date and color of the
vaccine
 Take out the vaccine vial, open the cap
 Do not touch the tip of the vial with hand
 Give proper position to infant/child either in lap of mother or in sitting position pour the 2 drops into the
mouth and ensure not to touch with the tip of the vial with the mouth
 Wait and watch for sometimes to watch not to spit out or not to vomit the vaccine
 To get required vaccine in potent condition
 Prevent contamination of the vial by using not touching with tip of the vial with the mouth of the baby.
 Recap the vaccine vial
 Replace the vial in ice box/refrigerator
 Record the vaccination with date in the immunization card. Explain follow-up and timing of next dose.
 Observe the baby, if spit out. Then readministered 2 drops of OPV
 Replace the articles
 Wash hands
 Advice to mother not to feed the infant or avoid giving eatable for next 30 minutes

TYPES OF AGENTS USED IN IMMNUIZATION

1) LIVE VACCINES:--
The objective is to induce protective immunity without producing the actual, full-
blown, clinical illness. To accomplish this, the organisms are attenuated which means the virulence has
been diminished to a level at which immunity is achieved, but the clinical illness is avoided. Measles,
mumps, rubella, varicella $ polio vaccines are examples of live attenuated viruses. Bacillus calmette
Guerin (BCG) vaccine is an example of live attenuated bacteria.

2) KILLED VACCINES:--
Immunity is stimulated by the host’s reaction to the killed microbe. Polio $ influenza
vaccines are example of killed viruses. Pertussis vaccine is an e.g. of a killed bacteria.

3) TOXOIDS:--
 A toxoid is a bacterial toxin that has been treated by heart or by chemicals to destroy its toxic
properties, but to retain its antigenic quality (i.e. ability to stimulate antibody production) tetanus
toxoid $ diphtheria toxoids are e.g.:- of treated toxins.
This response protects against the infectious agent. The principle
approaches to active immunization are use of live, usually attenuated infectious agents (oral polio
vaccine measles vaccine) $ use of inactivated or detoxified agents (DPT vaccine), or specific products of
recombination (HEP.B).

(A) LIVE ATTENUATED VACCINES:-

Induce an immunological response more like that elicited by natural infection.
The major advantage of live vaccines is that a single dose is sufficient for immunization whereas killed
vaccines require multiple doses, including periodic boosters for prolonged protection against disease.
The oral polio virus vaccine is an exception to this general principle
because oral feeding does not consistently result in infection (take) with the vaccine virus. Therefore
multiple doses are necessary. Flucations in temp. Of storage $ transportation reduce the potency of
live vaccine more rapidly than of killed $ toxoid vaccine BCG, OPV $ measles are important live
vaccines.

(B) INACTIVATED OR KILLED VACCINE:--

Consists of inactivated whole cell (pertussis vaccine), detoxified exotoxins
(tetanus toxoid), endotoxin linked to carrier protein, soluble capsular material (pneumococcal vaccine)
or conjugated capsular material (hib conjugated vaccine), extract of some components (HEP.B) or
components of organism (sub-unit influenza vaccine).

4) ADSORBED AGENTS $ FLUID AGENTS:--

Adsorbed agents (vaccine $ toxoids have substances to the immunizing agent
to enhance its antigenic effect. Antigens are therefore released more slowly, enhancing the response
by prolonged contact. Adsorbed agents must be given intramuscularly.

5) HUMAN IMMUNE SERUM GLOBULIN:--

Human immune serum globulin may be prepared from pooled plasma $ is used
to reduce the severity of disease or to prevent disease such as measles, viral HEP-B $ viral HEP-B (if
specific hepatitis b immune globulin is not available). Specific human immune serum globulin is also
available. This is prepared from the plasma of patients recuperating from specific illness such as
tetanus, pertussis, hepatitis b, mumps $ varicella zoster (chicken pox). Plasma of a recuperating patient
contains the antibody for that specific illness.

6) ANIMAL ANTISERUM (ANTITOXIN):--

 Animal antiserum is prepared from animal serum (horses, cows) in which the
antibody has been actively produced. Because reaction to the foreign serum may occur, the individual
is first pretested to determine hypersensitivity. E.g. of this method of passive immunity are tetanus
antitoxin $ diphtheria antitoxin.

AVAILABLE VACCINES
The available vaccines can be divided into 3 categories.

A) VACCINES INCLUDED IN NATIONAL IMMUNIZATION SCHEDULE:--

BCG against tuberculosis, triple vaccine against diphtheria, pertussis $ tetanus (DPT),
measles vaccine, DT $ tetanus toxoid.

B) VACCINES COMMERCIALLY AVAILABLE NOT INCLUDED NATIONAL SCHEDULE:--

HEP-B, measles, mumps, rubella vaccine (MMR), oral typhoid, hemophillus influenza B
(HIB) vaccine, anti rabies vaccine, meningococcal vaccine, pneumococcal vaccine, Japanese B
encephalitis vaccine, yellow fever vaccine $ chicken pox vaccine.

C) VACCINE NOT COMMERICALLY AVAILABLE $ UNDER EXPERIMENT:--

HIV vaccine, dengue fever vaccine, HEP-C $ malaria vaccine

PRECAUTION TO BE TAKEN WHILE IMMUNISING

Since immunization is an elective procedure a few contraction should be
kept in mind before it is carried out.
1) Post pone immunization if there is an acute febrile illness.
2) Possible interval of 3 weeks should be allowed between administrations of 2 live vaccines.
3) Immunization should not be done when the patient is on immunosuppressive therapy, irradiation,
lymphomas, leukemia $ hypogammaglobulinaemia.

NATIONAL IMMUNIZATION SCHEDULE

Immunization schedule should be planned according to the needs of the
community. The WHO launched global immunization program in 1974, known as expanded program on
immunization (EPI) to protect all children of the world against six killer diseases. In India EPI was
launched in January 1978. The EPI is now renamed as universal child immunization, as per declaration
sponsored by UNICEF. In India it is called as universal immunization program (UIP) $ was launched in
1985 NOV for the universal coverage of immunization to the eligible population.
The global alliance for vaccines $ immunization (GAVI) was established in
1999. GAVI is collaborative mission of govt, NGO’S, UNICEF, WHO $ also adopted the objective of
introduction new but under used vaccines in the developing countries, where the disease like HEP-B $
HEP-influenza B (HIB) are highly prevalent.
National immunization schedule as recommended by govt, of India for
uniform implementation through out the country was formulated. The schedule contents the age at
which the
vaccines are best given $ the no. of doses recommended for each vaccine. The schedule also covers
immunization of women during pregnancy against tetanus.

INJECTION SITE, TYPE OF NEEDLE AND TECHNIQUE

Site Type of needle Comments

Intra muscular injections (needle should enter at a 90° angle)

Preterms & neonates Anterolateral thigh 22-25 gauge, 5/8 inch Skin should
(Junction of middle & bestretched between
lower third ) thumb and forefinger
Infants (1 to <12 Anterolateral thigh 22-25 gauge, 1 inch Bunch the skin,
months) subcutaneous tissue
and muscle to prevent
striking the bone
Toddlers & older Deltoid or 22-25 gauge, 5/8 inch Skin should
children (12 months- Anterolateral thigh 22-25 gauge, 1 inch bestretched between
10 years) thumb and forefinger
Bunch the skin,
subcutaneous tissue
and muscle
Adolescents and adults Deltoid or >60 kg 1.5 inch
(11 yrs onwards) Anterolateral thigh >60 kg 1.5 inch

Subcutaneous injections (needle should enter at 45° to the skin)

Infants Thigh 22-25 G, 5/8 inch

>12 months Outer triceps 22-25 G, 5/8 inch

Intradermal injections

All ages Left Deltoid 26/27 G, 0.5 inch A 5 mm wheal should

be raised.

IMMUNIZATION OF CHILDREN

1) BCG VACCINATION: -- (BACILLUS OF CALMETTE $ GUERIN)

 “DANNISH” 1331 found vaccine is live attenuated bacterial vaccine produced from
strain of tubercle bacilli. It produces active immunity to protect the child from tuberculosis.

AIM:--
To induce benign artificial primary infection this will stimulate an acquired resistance to possible
subsequent infection with virulent tubercle mortality from primary tuberculosis among risk group.

PROPERTIES $ STORAGE:--

 BCG vaccine is heat stable $ in freeze dried form.

 It should be kept away from direct light.

 Should be stored in a cool environment below 10*c (2* to 8*c).

 Normal saline is used for dilution.

 Vaccine must be used within 3 hrs $ the remaining should be discarded.

ADMINISTRATION:--
Administered at birth or at 6 wks if not given at birth.

ROUTE OR SITE:--
Middle of deltoid muscle over the left upper arm.

DOSE: -- 0.05 ml in neonates.

0.1 ml in infants.

COMPLICATIONS:--
Deep ulceration, local abscess formation, enlargement of axillary lymph glands,
osteomyelitis, keloid formation.

CONTRAINDICATION:--
Generalized eczema, infective dermatosis, hypogammaglobulinaemia, immunodeficiency
conditions, HIV infected children with symptoms of AIDS related complex (ARC) or AIDS, all
asymptomatic HIV infected children should receive the BCG vaccine.

PROTECTION:--15 to 20 years.

PARENT EDUCATION :-
After administration of BCG vaccine we have to educate to the parents that-
 Reactions to the vaccine are common, but serious long-term complications are rare.
 Most babies vaccinated with BCG develop a local reaction, followed by healing and scar
formation, within three months.
  In 1–6 weeks, a small red blister may appear where the injection was given. This should heal in
a few weeks.
 After 6–12 weeks, the blister may turn into a small, weeping sore. If this happens, cover the site
with gauze to allow air to get in. Do not use sticking plasters.
 The sore may take up to three months to heal, and may leave a small scar. This is normal.

2) POLIO VACCINATION:--
Oral polio vaccine was 1st described by sabin in 1957. It contains live attenuated
polio virus of three strains (types 1-2 $ 3). It protects the individual child from poliomyelitis $ prevents
spread of wild pathogenic poliovirus in the community. It induces both humoral $ intestinal immunity.

PROPERTIES $ STORAGE:--

 Oral polio vaccine is heat stabilized.

 It can be kept without losing potency at 4* c for a year $ for a month at room temp.
 The non-stabilized vaccine should be stored at -20*c in a deep freeze.

ADMINISTRATION:--

 Zero dose at birth, then 3 doses at 1 month interval from 6 wks of age (6wks, 10wks, and 14 wks).

 Also be given with DTP $ BCG at same time $ day.

 Booster dose at 16 to 24 months of age.

ROUTE: -- Orally.

DOSE: -- 2 DROPS.

CONTRAINDICATION: - Acute infectious disease, fever, diarrhea, dysentery, leukemia, malignancy $

corticosteroids therapy. After vaccination, breast feeding can be given, if the child is hungry, but hot
drinks, hot milk or hot water should be withheld for ½ hrs.

PROTECTION: -- Life long.

PARENT EDUCATION –

 No need of any specific instruction to the mother. The infant can be given breast feeding before
or soon after the administration of OPV.
 Many children feel a little soreness at the site of the injection. So please consult with the
pediatrician.
  No serious side effects from the IPV have been reported.

INACTIVATED POLIO VACCINES (IPV) :-

IPV is formaldehyde killed poliovirus, grown in monkey kidney cell/human diploid cells.
 Schedule –
 Primary Vaccination – 3 doses at interval of 6-8 weeks interval , starting at age of 8
weeks .
 Booster doses – At 18 months and 4-5 years of age .
Seroconversion rates are 90-100% after two doses given after the age of 2 months and at 2 months
interval or in the EPI schedule of three doses at 6,10 and 14 weeks.
A third dose, given after a suitable interval boosts the antibody levels and ensures the
perpetuation of immunity for decades and more IPV can be administered along with all other
childhood vaccines and can be used in combination with DTwP/ DTaP, Hib and Hep B vaccines without
compromising seroconversion or increasing side effects.

 DOSE – 0.5 ml
 ROUTE OF ADMINISTRATION – Intramuscularly
 SITE OF ADMINISTRATION – Anterolateral aspect of thigh .
 PREPARATION OF SITE OF ADMINISTRATION – Clean with spirit .
 ADVERSE REACTIONS – Pain at the site of injection and fever .
 EFFICACY / PROTECTION – 90 to 100 %
 STORAGE – In lower most compartment of refrigerator
 QUADRUPLE VACCINE – IPV with DPT as quadruple vaccine is also available and is quite
effective .
Several countries have shifted from all OPV to sequential OPV- IPV schedules and all IPV schedules with
elimination of wild polio. IPV will be indispensable in the post eradication era when OPV has to stop
but “vaccination against polio” cannot stop.

3) DTP (DIPTHERIA, TETANUS AND PERTUSSIS) VACCINATION:-

-
DTP is a combined vaccine administered for the protection against three disease i.e.,
diphtheria, pertussis $ tetanus. DTP vaccines is composed of diphtheria toxoid, tetanus toxoid $ killed
B-pertussis bacilli. There are 2 types of DTP vaccines.

1) PLAIN.
2) ADSORBED.
Adsorbed is usually carried out on a mineral carrier like aluminum phosphate or hydroxide. It increases
the immunological effectiveness of the vaccine. The plain DTP vaccine can be used as a booster.

STORAGE:--

 DTP/DT vaccine is stored between 4* to 8*c temperature $ should not be frozen.

 Vaccines will lose potency at room temp when kept at room temp for a long time.

ROUTE: -- Children below 1 year—Thigh (vastus lateralis muscle).

In older children – Upper $ outer quardrant of the gluteal muscle.

DOSE: -- 0.5 ML.

ADMINISTRATION:--
 3 Doses at 4 weeks of interval at 6 wks, 10 wks, and 14 wks.
 Booster doses at 16 to 24 months of age.
 Another booster dose of at 5 to 6 years without pertussis component.

COMPLICATION:--
Encephalitis, encephalopathy, prolonged convulsion, infantile spasms $ Reye’s syndrome.

CONTRAINDICATION:--
Neurological problem (shock like state, temp above 40*c, persistent crying episodes and convulsions.

PARENT EDUCATION :-

 The DTP vaccine can cause mild side effects such as pain or soreness in the local area of the
shot and occasionally a low-grade fever.
 fever, fretfulness and drowsiness occurred in as many as one-half to one-third of children who
received the vaccine

4) DT VACCINE

PROPERTIES:--

 Currently available DTaP vaccines in India include five component vaccines, three component
vaccines and a two component combination vaccine.
 The efficacy and duration of protection with DTaP vaccines against diphtheria/ tetanus and
pertussis is similar to that afforded by the whole cell vaccines.
 Progressive/evolving neurological illnesses, is a relative contraindication to first dose of DTwP
immunization. However DTwP can be safely given to children with stable neurologic disorders.
  The DTaP vaccines may be preferred to DTwP vaccines in those children with history of severe
adverse effects following DTwP vaccines or children with neurologic disorders, if resources
permit.
 The schedule is same as with DTwP vaccines. Like DTwP vaccines, All licensed DTaP vaccines are
of similar efficacy and safety as of currently available data and any one of them may be used.
DTaP combination vaccines will be discussed separately.

ADMINISTRATION:

 DTaP vaccines must not be used in children 7 years or older because of increased
reactogenicity.

ROUTE: -- Subcutaneous.

DOSE: -- 0.5 ML.

PROTECTION: -- Long life.

PARENT EDUCATION :-

 Parents should be aware of possible side effects of the DT vaccine.

 Some mild side effects may include irritation, itching, or bruising at the injection site.
 Sometimes, a child may also have swelling, redness, or a hard lump there.
 Often, a child will experience no side effects at all.

5)MEASLES, MUMPS & RUBELLA VACCINES

Several combinations for protection against Measles, Mumps and Rubella are available.
These include monovalent Measles, Mumps and Rubella vaccines, MR vaccine and MMR vaccine.
Monovalent Mumps vaccine is not available in India.

 MEASLES VACCINE

Vaccine
A safe, effective and reasonably inexpensive vaccine is available against Measles. All
currently used vaccines are live attenuated vaccines. Indian vaccines are usually formulated from the
Edmonston Zagreb strain grown on human diploid cells or purified chick embryo cells. Each dose
contains at least 1000 infective units and has no preservative.

 SCHEDULE – At age of 9 months.

As MMR at age of 15 months .
If given at less than 9 months of age , repeat dose after interval of atleast 3 months .
  DOSE – 0.5 ml

 ROUTE OF ADMINISTRATION – Subcutaneously or intramuscularly

 SITE OF ADMINISTRATION – Right upper arm / Anterolateral aspect of thigh .

 PREPARATION OF THE SITE OF ADMINISTRATION – clean with spirit .

 INSTRUCTIONS TO THE MOTHER AFTER VACCINATION –

 Mild fever and rash may appear after 5-7 days.
 Paracetamol may be given for fever .

 PROTECTION / EFFICACY – Almost 95 % .

 CONTRAINDICATIONS –
 Immunocopromised host .
 Children with documented allergy to egg .
 Pregnant women .
 The vaccine may be given along with all childhood vaccines with the exception of BCG
vaccine.
 ADVERSE EFFECTS –
 Measles like illness – It occurs after 5-7 days of immunization , lasts for 2-3 days .It
consists of fever , malaise and rash .
 Febrile convulsions .
 Neurological – Encephalitis , Encephalopathy .
 Staphylococcal Sepsis – Toxic Shock Syndrome .

 COMPLICATIONS – Very rarely subacute sclerosing pancephalomyelitis .

 Storage – The vaccine may be stored frozen or at 2-8°C (shelf life 2 years).
It is supplied freeze-dried in single dose or multidose vials with distilled water as a diluent.
Reconstituted vaccine is destroyed by light and is very heat labile (loses 50% potency at 20°C and 100%
at 37°C after 1 hour) and is susceptible to contamination as it does not have any preservative.

 RUBELLA VACCINE

Rubella is a mild exanthematous illness but if acquired in the first trimester of pregnancy can
lead to disastrous consequences in the fetus/ new born such as abortion, stillbirth, mental retardation,
congenital heart disease, blindness and cataract. Hence the objective of vaccination against rubella is
protection against congenital rubella syndrome (CRS).

Vaccine
  Rubella vaccine is currently derived from RA 27/3 vaccine strain grown in human diploid/chick
embryo cell cultures.
 The vaccine is available in freeze dried form that should be stored frozen or at 2-8°C and needs
to be reconstituted with sterile diluents prior to use.
 The reconstituted vaccine must be protected from light, stored at 2-8°C and used within 6 hrs
of reconstitution.
 The dose is 0.5 ml subcutaneously. A single dose of vaccine provides lifelong protection in 95%
of the vaccines.

Adverse effects-
 5 % fever more than 39°C 7-12 days following vaccination and febrile seizures may occur.


 Aseptic meningitis can rarely occur 2-3 weeks following vaccination but is usually mild.
Transient parotitis may occur.

PARENT EDUCATION :-

 About 5 percent of children develop a rash after receiving the MMR vaccine, but the reaction is
usually mild and doesn't require treatment.

6) HEPATITIS-B VACCINATION:--

World Health Organization has recommended universal Hepatitis B vaccination.

 CONTENTS – The plasma derived vaccine ( Alum adsorbed ) 20 µg/ml , 5 µg/ml .

Recombinant DNA vaccine 20 µg/ml .

 SCHEDULE – The classical schedule is 0, 1 and 6 months. The vaccine is highly immunogenic and
seroconversion rates are greater than 90% after a three dose schedule.

 DOSE - The dose in children and adolescents (aged less than 18 years) is 0.5 ml/ 10 μg and in
those 18 yrs and older is 1 ml/ 20 μg.

 BABIES BORN TO HBSAG POSITIVE MOTHERS – HBsAg levels 1 month after completion of the
immunization schedule is recommended in children born to HBsAg positive mothers .
  ROUTE AND SITE OF ADMINISTRATION – It should be injected intramuscularly in the deltoid/
anterolateral thigh.

 INSTRUCTIONS TO MOTHER AFTER VACCINATION – Mild fever or pain at injection site may be
there. Paracetamol can be given for it .
 PROTECTION/EFFICACY – 95 %
 ADVERSE REACTIONS – Pain , erythema at injection site .
 Fever , malaise , myalgia .
 STORAGE – At + 2 to + 8°C in uppermost compartment of refrigerator .

VACCINE
 The currently available vaccine containing the surface antigen of Hepatitis B is produced by
recombinant technology in yeast and adjuvanted with aluminium salts and preserved with
thiomersol (thiomersol free vaccines is also available).
 Routine boosters are not needed in healthy children and adults.
 Studies have shown that individuals who had responded to the vaccination series and had
levels of 10 mIU/ml after vaccination are protected against hepatitis B disease for life even if
the levels drop to below protective levels or are undetectable later. This is due to immune
memory.
 In the immunocompromised and those with co morbidities such as chronic renal disease, levels
should be checked periodically and booster vaccination given whenever levels drop to below
protective levels.

HEPATITIS B IMMUNOGLOBULIN (HBIG)

 HBIG provides passive immunity and is indicated along with Hep B vaccine in management of
perinatal/ occupational/ sexual exposures to Hepatitis B in susceptible individuals.
 The dose of HBIG in adults is 0.06 ml/kg and in neonates/ infants 0.5 ml.

 HBIG should be stored at 2 to 8°C and should not be frozen. HBIG provides temporary
protection lasting 3-6 months. HBIG should never be given intravenously.
 HBIG is also used alone following exposure to Hepatitis B in patients who are non responders to
Hepatitis B vaccination (genetic reasons/ immunocompromised status). In this situation two
doses of HBIG 1 month apart are indicated.

RECOMMENDATIONS FOR USE

IAPCOI recommends offering hepatitis B vaccine to all children. Hep B vaccine may be given in any
of the following schedules:
(i) Birth, 1 and 6 months
(ii) Birth, 6 and 14 weeks
(iii) 6, 10 and 14 weeks
(iv) Birth, 6 weeks, 6 months
(v) Birth, 6 weeks,10 weeks, 14 weeks

 Immunologically 0 – 1 – 6 months schedule of hepatitis B immunization has been most

widely used and proven to be ideal with high antibody titers at the end of the
vaccination.
 Birth dose has to be given to cover for the vertical route. Hence IAPCOI recommends 0
– 6 – 14 wks schedule for public health.
 In case birth dose has been missed, 6 – 10 – 14 wks schedule can be followed.
 In office practice, one can still use 0 – 4/6wks – 6 months schedule.
 Catch up vaccination with Hep B vaccine as a 0, 1, 6 schedule should be offered to all
children/ adolescents who have not been previously vaccinated with Hep B vaccine.

MANAGEMENT OF AN INFANT BORN TO HEPATITIS B POSITIVE MOTHER

 Pregnant women should be counseled and encouraged to opt for HBsAg screening.
 If the mother is known to be HBsAg negative, Hep B vaccine can be given along with DTP at 6,
10 and 14 weeks/6 months as there is no special requirement to start vaccination at birth itself.
The 6-10-14 wks schedule may be easier to implement in the context of the national
immunization program as higher vaccination coverage may be achieved with earlier
administration of vaccines.
 If the mother’s HBsAg status is not known, it is important that Hep B vaccination should begin
within a few hours of birth so that perinatal transmission can be prevented. Any one of the
following schedules may be used for this purpose; birth,6 and 14 weeks or birth, 6 wks and 6
months.
 If the mother is HBsAg positive (and especially HBeAg positive), the baby should be given
Hepatitis B Immune Gloulin (HBIG) along with Hep B vaccine within 12 hours of birth, using
two separate syringes and separate sites for injection.
 The dose of HBIG is 0.5 ml IM. HBIG may be given upto 7 days of birth but the efficacy of HBIG
after 48 hours is not known.
 If HBIG is not available (or is unaffordable), Hep B vaccine may be given at 0, 1 and 2 months
with an additional dose between 9-12 months. The efficacy of prophylaxis with both HBIG and
Hep B vaccine is 85-95% and that with Hep B vaccine alone (1st dose at birth) is 70-75%.

Note - All infants born to HBsAg positive mothers should be tested for HBsAg and anti HBsAg
antibodies at the age of 9-15 months to identify carriers/ non responders.
PARENT EDUCATION :-

 Hepatitis B is a very safe vaccine.

 Some times it causes Soreness where the shot was given (up to about 1 person 4)
 Temperature of 99.9°F or higher (up to about 1person in 15).

7)HEMOPHILUS INFLUENZAE TYPE B (Hib) CONJUGATE VACCINES

Capsulated H. influenzae has six serotypes of which type b is most important. Haemophilus
influenzae type b (Hib) is an important invasive pathogen causing diseases such as meningitis,
bacteremia, pneumonia, cellulitis, osteomyelitis, septic arthritis and epiglottitis. Most of invasive Hib
disease occurs in children in the first two years of life and natural protective immunity is acquired by
the age of 3-4 years.

VACCINE

All Hib vaccines are conjugated vaccines where the Hib capsular polysaccharide (polyribosyl ribitol
phosphate or PRP) is conjugated with a protein carrier so as to provide protection in the early years of
life when it is most needed.

SCHEDULE AND DOSES

 The vaccination schedule for Hib consists of three doses when initiated below 6 months, 2
doses between 6-12 months and 1 dose between 12-15 months, with a booster at 18 months.
 For children aged more than 15 months a single dose may suffice.
 The interval between two doses should be at least 4 weeks.
 As Hib disease is essentially confined to infants and young children, catch up vaccination is not
recommended for healthy children above 5 years. However, the vaccine should be
administered to all individuals with functional/ anatomic hyposplenia irrespective of age.
 Hib vaccines are now used mostly as combination vaccines with DTwP/ DTaP/Hep B/ IPV.

 DOSE – 0.5 ml
 ROUTE OF ADMINISTRATION – Intramuscular
 SITE OF ADMINISTRATION – Anterolateral surface of thigh and Deltoid region .
 ADVERSE REACTIONS – Fever , pain and swelling at injection site , febrile convulsions .
 PARENT EDUCATION :-

 Redness, warmth, or swelling where the shot was given (up to 1 out of 4 children)
 Fever over 101 degrees Fahrenheit (up to 1 out of 20 children)
  If these problems happen, they usually start within a day of vaccination. They may last 2 to 3
days.
 When you get home, give your child comfort and realize that your child may be more tired or
cranky than usual.
 He or she may want to be held more and may be sore in the arm or leg where the shot was
given.
 You can administer a pain reliever as directed by the doctor.
 If the area where the shot was given is red, tender or swollen, you can use a cool wet cloth on
the area.
 You can also give your child a lukewarm sponge bath if he or she has a fever.
 Give your child plenty of fluids and be aware that he or she may be less interested in food over
the next 24 hours.
 Watch your child for signs of a reaction from the vaccine including a rash, prolonged fever, or
unusual behaviors.
 If you have any reason for concern, call the doctor. He or she can tell you what to expect and
what to do.

8)TYPHOID VACCINES

Vaccine - Several vaccines have been available against typhoid/ paratyphoid fever:

WHOLE CELL INACTIVATED TYPHOID/ PARATYPHOID VACCINES (TA/TAB) –

 Monovalent typhoid vaccine contains not less than 1000 million S.typhi and 500 million
of S.typhi per ml . It may be either heat killed and phenol preserved or acetone killed
and freeze dried vaccine .
 Bivalent vaccine contains 1000 million Styphi and 500 million of S.Paratyphi A per ml.

 SCHEDULE AND DOSAGE –

 Two doses of 0.25 ml by subcutaneous route at interval of 4- 6 weeks .Booster dose
0.25 ml . SC every three years .
 It is not recommended under age of 2 years .

 ROUTE OF ADMINISTRATION – Subcutaneous .

 SITE OF ADMINISTRATION – Anterolateral aspect of thigh.
 INSTRUCTIONS TO THE MOTHER – Paracetamol may be given for fever and pain at site of injection
.
 PROTECTION / EFFICACY – 51-73 % with phenolized vaccine .
70 – 94 % with acetone killed vaccine .
  ADVERSE REACTIONS – fever , Malaise , headache , Local pain and swelling at injection site and
rarely seizures .

 STORAGE – 2 to 8° C .

9)TETANUS TOXOID (TT)

Antibodies to tetanus decline over time and hence regular boosting is needed to ensure
adequate levels of antibodies during any apparent/inapparent exposure to tetanus bacilli/ toxin.

 Vaccine/Toxoid
 Adsorbed tetanus (TT)
 Adsorbed diphtheria and tetanus (DT)
 Adsorbed tetanus and low dose diphtheria(Td)
 Adsorbed diphtheria, tetanus and pertusis(DPT)

 TT containing 5 Lf of toxoid is one of the most heat stable and commonly used vaccines.
Aluminium phosphate or aluminium hydroxide are used as adjuvants with tetanus
toxoid to enhance the immune response .The addition of pertusis component also acts
an effective adjuvant .
 Primary doses – 6,10 and 14 weeks of age as DPT vaccine .

 ROUTE OF ADMINISTRATION – intramuscular

 DOSE - 0.5 ml
 SITE OF ADMINISTRATION –. Deltoid & gluteal region .
 PROTECTION / EFFICACY - TT boosters every 10 years provide sufficient protection.
 STORAGE - The vaccine should be stored between 2 to 8°C
 ADVERSE REACTIONS - immune complex mediated reactions.

TT IN PREGNANCY

 For pregnant women who have not been previously immunized, two doses of TT at least one
month apart should be given during pregnancy so that protective antibodies in adequate titers
are transferred to the newborn for prevention of neonatal tetanus.
 The first dose should be administered at the time of first contact/ as early as possible and the
second dose of TT should be administered 1 month later and at least 2 weeks before delivery.
 A single dose of TT would suffice for subsequent pregnancies that occur in the next 5 years.
thereafter, 2 doses of TT would again be necessary.
  Women, who have received 5 doses of TT over a period of at least 2.5 years, get lasting
protection for their reproductive years. For women who have received 3 primary doses in
infancy, two doses during the 1st pregnancy are indicated. The 2nd pregnancy requires 1 more
dose and gives lasting protection for the reproductive years.

 Td VACCINE

The DTwP, DTaP and DT vaccines cannot be used in children aged 7 years and above due to
increased reactogenicity due to the higher diphtheria toxoid and pertussis components.

Vaccine - Td contains the usual dose of tetanus toxoid 5Lf units and only 2 units of diphtheria toxoid. It
is stored at 2 to 8°C and is administered intramuscularly in a dose of 0.5 ml.

Recommendations for use - This vaccine is indicated as replacement for DTwP/ DTaP/DT for catch up
vaccination in those aged above 7 yrs (along with Tdap) and as replacement for TT in all situations
where TT is given.

 Tdap VACCINE
Immunity against pertussis following primary/ booster DTwP/DTaP vaccination wanesover
the next 6-12 years. The standard strength DTwP and DTaP vaccines cannot be used for vaccination of
children 7 years and above due to increased reactogenicity.

Vaccine
 In India, currently two brands of Tdap are licensed. It contains tetanus toxoid 5 Lf, diphtheria
toxoid 2 Lf and the three acellular pertussis components namely, pertussis toxin 8 μg,
filamentous hemagglutinin 8 μg and pertactin 2.5 μg.
 It contains aluminium hydroxide as adjuvant and no preservative.
 The vaccine should be stored between 2 to 8°C, must not be frozen.
 The dose is 0.5 ml intramuscularly.

Recommendations for use

 The IAPCOI therefore recommends offering Tdap vaccine instead of Td/TT vaccine in all
children/ adolescents who can afford to use the vaccine in the schedule discussed below .
 In those children who have received all three primary and the two booster doses of
DTwP/DTaP, Tdap should be administered as a single dose at the age of 10-12 years.
 Catch up vaccination is recommended till the age of 18 years.
 In children who have missed the 2nd booster of DTwP/DTaP and who are 7 years of age or
more, Tdap single dose is recommended at the time of presentation.
 In children who have not completed primary immunization with DTwP/ DTaP and are more
than 7 years of age, 1 dose of Tdap and 2 doses of Td at 0, 1 and 6 months respectively are
recommended.The single booster dose of Tdap may be followed by Td boosters every
 10 years.

10) DTaP VACCINE :-

Adverse effects of the pertussis component of the whole cell vaccines led to development of
the acellular pertussis vaccines .
These were licensed and now replaced the whole cell vaccines in many developed countries.

Vaccine
The components of pertussis bacilli used for preparation of the acellular vaccines include pertussis
toxin (PT) as the essential component with or without filamentous hemagglutinin (FHA), pertactin
(PRN) and fimbrial hemagglutinins 1, 2 & 3 (FIM).
Currently available aP vaccines in India include five component vaccines, three component
vaccines and a two component combination vaccine.
 The efficacy and duration of protection with DTaP vaccines against diphtheria/ tetanus and
pertussis is similar to that afforded by the whole cell vaccines.
 Progressive/evolving neurological illnesses, is a relative contraindication to first dose of DTwP
immunization. However DTwP can be safely given to children with stable neurologic disorders.

Recommendations for use

 The DTaP vaccines may be preferred to DTwP vaccines in those children with history of severe
adverse effects following DTwP vaccines or children with neurologic disorders, if resources
permit.
 The schedule is same as with DTwP vaccines. Like DTwP vaccines, DTaP vaccines must not be
used in children 7 years or older because of increased reactogenicity.
 All licensed DTaP vaccines are of similar efficacy and safety as of currently available data and
any one of them may be used. DTaP combination vaccines will be discussed separately.

NURSING RESPONSIBILITIES FOR CHILD IMMUNIZATION

 Motivation of general people about the importance of immunization and its benefits.
 Estimation of beneficiaries of the area and identification of non- participants and dropouts of
immunization .
 Assessment of problems and reasons for non- acceptance of immunization and intervening to solve the
problems.
 Information , health education and communication about the immunization session , time , place ,
available vaccines and other facilities related to immunization .
 Organization of information clinics at different health institutions , immunization camps , out reach and
home – based services .
 Arrangement and maintenance of required amount of vaccines and other necessary equipments and
materials for the particular immunization center or clinic.
 Maintenance of cold chain system at immunization center or during transportation of vaccines to
home or clinics with necessary precautions to preserve the efficacy and potency of the vaccines .Care
 of cold chain equipments and maintenance of recommended temperature for vaccines are crucial
aspects of the success of immunization programme .
 Observation of possible reactions after vaccination and providing necessary instructions , about the
care of the child following immunization , to the parent and family members .
 Information about the next date of visit to complete the immunization as per schedule and dangers of
default .
 Maintenance of immunization card with required informations and next date of visit .
 Maintenance of clinical records , registers , stocks ,number of attendance for vaccination , vaccine used
etc .
 Reporting about immunization coverage and problems of the particular area .
 Participating in research activities and new approaches related to immunization program .
 Updating own knowledge and developing skill regarding advancement of immunization practices and
changing attitudes.

CONCLUSION -

Thus, immunization is a process of protecting an individual from a disease through introduction of live
or killed or attenuated organisms in the individual system. It is one of the best buy’s in community
health and one of the cost effective health interventions .Immunization against vaccine preventable
diseases is essential to reduce the child mortality , morbidity and handicapped conditions .It gives
resistance to an infectious disease by producing or augmenting the immunity .

REPORT ON IMMUNIZATION VISIT

As a part of our clinical posting in community health nursing myself Mrs. Sapna Daniel along with my
colleague Mrs. Shirin Joseph and Mrs. Barkha Netam were posted in PHC Kohka on 11 th April, 2023 for the
immunization task, within the time from 9AM to 12PM we immunize approx. 20 – 25 children/women.

We were under the supervision of our respected community faculties Mrs. Kalpana Joshi Mam, Associate
Professor GCON Durg and Mrs. Shalini Deshmukh, Demonstrator GCON Durg.
BIBLIOGRAPHY

1. Clinical policies, procedures & guideline Approved by Quality & Patient Safety Committee. The Royal hospital
for women[caline] Available from http://www.thewomen.orgata (Accessed October 14, 1016]

2. Hague R. Lilley M. Macdonald I. Antibiotic skin test and challenge. Women & Children's Service Yorkhill Site
Nursing and Midwifery Policy Committee, Protocol No 8.13 [online] Available from
www.clinicalguidelines.scot.nhs.uk. Accessed October 14, 2015]

3. Jacob A. Clinical Nursing Procedures The Art of Nursing Practice, 2" edition. Jaypee Brothers Medical
Publishers Pvt Ltd. New Delhi. 2010. pp. 272-4

4. Jain V. Review of Preventive and Social Medicine, 6 edition, Jaypee Brothers Medical Publishers Pvt Ltd., New
Delhi: 2014 p. 255

5. Kaur B. Community Health Nursing Procedure, 1 edition: Jaypee Brothers Medical Publishers Pvt Ltd. New
Delhi: 2012 PP. 81-2.

6. Kozier B, Erb G. Fundamentals of Nursing Concept, Process and Practice, 8 edition Pearson Education 2008

7. Kumar R. Sagar BP. Cold chain for vaccines: Journal of Drug Delivery & Therapeutics, 2012-2(41-46-50. [online]
Available from http://jddtonline.info/index.php/iddt/article/viewFile/175/116. (Accessed October 14, 2016]
8. Nettina SM. Manual of Nursing Practice, 10 edition. Lippincott Williams & Wilkins. Philadelphia, 2013,

9. Park K. Textbook of Preventive and Social Medicine, 23" edition. Banarsidas Bhanot Publication. Jabalpur. 2016

10. Park K. Textbook of Preventive and Social Medicine, 21" edition. Banarsidas Bhanot Publishers, Jabalpur,
2014, pp. 97-100

11. Perry AG, Potter PA. Nursing Skills and Procedure, 7 edition, Elsevier, Mosby; 2011.

12. Smith SF, Duell DJ, Martin BC. Photo Guide of Nursing Skills Upper Saddle River Uganda; 2002

13. UNICEF Handbook for vaccine and cold chain handlers. [online] Available from
http://www.nccmc.org/PDF2/2.070 på(Accessed October 14, 2016].

14. Wilkinson JM. Leuven KV. Fundamentals of Nursing theory, concept and application, 6 edition. Jaypee
Brothers Medical Publishers Pvt Ltd., New Delhi 2013