Paediatric Immunization

Consultation Info Sheet

 Written information consists of the
following documentation:
Paper: BIMC Standard Vaccination Schedule and
Record in English or Japanese.
Papers: Growth Charts / and also Development Check
Up Forms
Paper: comparison on Effect of Disease and
Immunization, Common Reactions To
Immunizations, What To Do
Folder: Blue immunization folder including print outs
from Australia and Indonesia regarding the
vaccines as per brand names.
 The book: The Australian Immunization
Handbook, 6th edition
The booklet: Immunization, Myths & Realities.
The paper: Signs of Anaphylactic Reaction
& Adrenaline Dosage
Papers (copied documents from WHO)
Assess feeding problems and
recommend regarding feeding.
Papers (copied) regarding Storage, Transport
and Stability of vaccines.
 Use preferably consult room 2 or 3.
(Dr. Donna not always there). If not
available use an observation room or
treatment room.
 Inform the doctor on duty that you will
have an immunization (What age, what
vaccines). Just so they know in case of
anaphylactic reaction occurs.
 Adjust the A/C in the consult room to be
warm and comfortable for a small child to
be naked
 Prepare all you possibly will need. Scale,
tailors measure band, plastic mat for
laying on (disinfected and dried with 70%
alcohol before/after each child),
thermometer, 25G/25mm needles, 1 ml
100 U plus 3 & 5 ml syringes, sharps box,
plasters, alcohol swabs, gloves, literature
and forms. Wash your hands.
Confidence, patience and a smile
 DONT FORGET:

Anaphylactic shock pack

Ready beside you
 Review the childs present immunization
records and check with caretaker what
vaccine they request today. Update any
records if they are not completely filled
out, ex. child has own Baby Book and
they had some vaccines in Australia ->
make sure these also get recorded on the
record in the childs BIMC file.
 If the child already been given some
vaccines and also given an immunization
record or Baby Book but the caretaker
does not bring it to the appointment, they
must be told to get hold of that record by
any means ASAP (a fax or copy is ok) and
bring it to BIMC at next and all following
appointments
 Without a written record the child is to be
considered as unvaccinated no matter what
the caretaker says. If there is a case like that
and the caretaker verbally is sure about previous
immunizations you can go ahead and vaccinate
as if what the caretaker says is correct BUT
the written record must be presented at the
soonest possible time afterwards. Otherwise we
cannot guarantee that the child is given optimal
immunizations.
 Recommend / explain what vaccine you
want to give today and have the verbal or
written consent from the caretaker.
Explain if it is the 1st, 2nd or 3rd etc dose
of the vaccine.
 If there will be many (>2) injections or if
the parent request it is in most cases ok to
spread them over a couple of days.
But be aware of live vaccines!
Explain about different choices of
vaccines if any, f.ex. DTP and HIB as
separate vaccines or combined. Pros &
Cons (difference in side effects, amount of
needle sticks, price difference etc).
 If it is the first time the child has come to BIMC
for immunization you can give them the BIMC
handouts regarding: Immunization Schedule &
records, Growth Charts / Development Check
Up Forms, Common Reactions To
Immunizations and What To Do plus
Comparison on Effect of Disease and
Immunization unless they already have this info
in any previous Baby Book etc.
Encourage them to read them!!
 If they have been here before ask them to
read above info again,
or read it / explain it verbally for them as
well.
You can also give the leaflet that comes in
the package of the vaccine.
 Ask the child / caretaker if there were any
reactions from previous immunizations or any
other known allergies (drugs, animals, food,
preservatives etc). If any find out what in detail
and record in pats medical report. If severe
reactions are being reported, try to find out
exactly what vaccine it could have been, incl.
brand name and batch number. Talk to / Consult
with doctor before giving (same) vaccine again.
 If the side effects are mild or among the
expected you can immunize again with that
vaccine. Reassure the child / caretaker about
the normality of the side effect and that the
child can have the same vaccine again and the
reaction this time might be the same or less or
slightly worse. Pre-treat with Panadol at time of
vaccination. Give (10-)15 mg/kg up to 4
times/day.
Ask what actions were taken against these side
effects and the result of them.
 Explain about possible side effects of
the vaccine to be given today. What can
be done to prevent them (be healthy, give
Panadol) and what to do if they occur.
What would be a severe reaction needing
to see a doctor ASAP anaphylactic, see
handout. Severe reactions might occur,
but are very, very, very rare.
 These are in general expected and normal
side effects from all the vaccines on the BIMC
list: fever (<38.5 or >38.5 but could easily be
lowered with Panadol till <38.5), pain at injection
site / radiating in the injected limb, minor (<5cm
) swelling or redness. Mostly the side effects
would start within 24 hours and be gone within
24-48 hours. F.ex and especially MMR plus
Japanese Encephalitis can have more than
these and also start/last later/longer.
 Explain that it is recommended that they wait in
the clinic for up to 15 minutes after the vaccine
has been injected, just in case there would be an
immediate severe reaction. As the most severe
reactions tend to come <10 min.
For Japanese Encephalitis where they should
wait 30 min, NOT shorter.
Always be up to date on dosages and
administration way of adrenaline.
 Ask about the childs general well being
now.
 A Child suffering from any illness/disease
which affect/alter the immune
system/response etc, ex. HIV/AIDS,
cancer under treatment etc plus some
other chronic disorders (which?) must
have special consideration regarding most
types of vaccines. Child to be consulted
with doctor for assessment and
individualized immunization schedule
 Briefly ask about the childs feeding now.
Exclusively breastfeeding? Bottle? Foods
what? How many times per day? Any
snacks between main meals? Nightly
feeding? Does child seem satisfied after
finished the meal?
If something seems strange, give advice
or refer to doctor / midwife.
 Check the childs temperature. Ear
thermometer ok. Lift the outer ear slightly up-
outwards before insert probe in ear. If in doubt
of the measured temperature re-measure or
check with rectal thermometer.
If temp >38.5 rectally (approx. 37.7 ear) ie.
Severe febrile illness the vaccination is
contraindicated that day. If slight fever and not
generally affected immunization can be done.
If in doubt ask doctor.
 Check weight, length and head
circumference. Input on the growth
chart and discuss the result with the
caretaker. Any gross abnormalities? If so,
ask to f.ex. increase/change feedings and
come back in 1 months time for re-
measuring or refer them to doctor/midwife.
 How to do it? Be very careful and
thorough when measuring the child.
It is difficult.
 Weight: Use laying scale for the child who
cannot stand properly & still by
themselves. Best if child is naked.
Make sure the room temperature is warm.
 Length: You will need two persons who know what to do
or a very co-operative caretaker to be able to measure
the childs length. Measure the child laying down if s/he
cannot stand properly & still by him/herself looking up,
hips, knees pressed firmly down and feet straight
upwards.

If the child can stand by him/her self, use the Giraffe:

childs back towards Giraffe, keep head straight-looking
at you, both heels towards Giraffe, whole sole flat to
floor, put a book flat on the childs head ask child to
walk off from Giraffe and read the result.
 Head C: Measure over the biggest part of
the head, i.e. the most protruding part of
neck and forehead ask someone to help
you keep the tailors measure band still-
this means you can still measure well
even if the child moves the head.
 If everything seems ok,
Give to caretaker the
PRE-VACCINATION
QUESTIONNAIRE/CONSENT FORM
to sign by
caretaker/parents
 Now, prepare practically and mentally the vaccines
and child plus caretaker. Wash your hands.
Disinfect the area to be injected with 70% alcohol and
let it evaporate until dry. Also do the same with the
rubber membrane on the vaccine vial. Check expiry
date of the vaccine. If an already used oral Polio vial,
make sure it hasnt been opened for >7days. Keep
vaccines on ice at all times until just before you will inject
it, then warm the syringe a bit in your hand. Always use a
new needle after reconstitute the vaccine or aspirate it
via a rubber membrane before you inject it in the child.
 Position the child well either on the bed
(on the back with knee flexed) or in
caretakers lap (cuddle position), secure
all movable body parts(!) as a child can be
incredibly strong. Be fast, calm and firm
but gentle. Make sure the caretaker is
aware of what will happen and what you
expect from him/her or use a colleague
to help you
 Admin vaccine:
The majority of the vaccines are to be given i.m. in the
vastus lateralis muscle at the anterolateral part of the
thigh, at the upper-middle thirds i.e. the bulkiest outer
part of the thigh. The needle should be inserted with a
45-60 angle and pointing down towards the knee.
Make sure it is a true i.m. injection and not s.c.!!
Stretch the skin do NOT pinch it! Do NOT use the
alcohol swab to cover when removing the needle. After
removing the needle a plaster can be put on just to
protect clothing from bloodstain, can be removed as
soon as the child is home again. Safe to mandi same
day.
 NB
No bandages for BCG or
PPD injections
 The deltoid muscle can be used if
children >12 months of age, and if they
are not to skinny. Insert the needle in the
middle part of the muscle with a 45-60
angle and the needle pointing upwards to
the acromion.
 The gluteal region should be avoided, as
there is risk to damage the sciatic nerve
plus vaccines as Hepatitis B and Rabies
are not sufficiently absorbed there. It can
be used with great care as a deep s.c.
injection of HIB (Act-Hib), when 3
injections are needed in an infant.
 A 100% true Intradermal injection is to be used
for BCG and PPD vaccines. Make absolutely
sure that the alcohol has dried before the
vaccine to be in contact with a disinfected area.
Use a 1 ml, 100 Unit syringe, 26-27G & 10-
13mm long. Inject at the upper/mid arm (BCG)
or mid lower arm (PPD). Difficult to do and child
MUST be STILL. Do not cover the injected area
with bandage. Inform in dept about expected
reactions, see handout. Vaccinator and any
assisting person to use protective attires such
as goggles
 Oral vaccines.
This only applies to Polio (OPV).
Do NOT use the dropper, pull up the vaccine in
a syringe (0.1-0.2ml) and remove the needle
before the vaccine is dropped in childs mouth.
Vaccinated person NOT to take anything by
mouth incl. dummy for up to 20 min, to assure
good absorption of the vaccine. Saliva in contact
with the vaccine will destroy it. Put the date on a
newly opened vial and quickly
refrigerate/refreeze.
 Remember to ask any caretakers who might get
in contact with the stool of the immunized child
regarding their Polio immunizations status. If
they have not had a Polio dose within last 10
years, they should be given one at same time.
Polio viruses can spread via stool and infect a
person with Polio up to 6 weeks after
vaccination. Often the adult person will get
stomach upset/diarrhoea so please tell them
this. Children normally not
 Record the immunization in childs private
record (book or BIMC paper), BIMC paper
record in file and in M.R. in computer.
Record the type of vaccine, brand-name,
batch number and where the vaccine was
injected, ex. Right thigh. If any vaccine
also was given to the caretaker or maid etc
also record this in the childs Medical
report or better also in that persons
medical file (private and clinic).
 Remind about side effects, when to come
for next immunization and ask if they have
any questions.
 If appropriate and time allows, assess and
recommend any other household member
regarding their immunization status/needs,
such as parent, grandparent or maid.
 Comments on vaccines in
general and the vaccines
in the BIMC standard
schedule in particular
 Vaccine storage
A separate fridge should be used for vaccines
and no food, drinks or other drugs are to be kept
in it. To be stored in a fridge at a temperature
between +2 and +8 C. Fridge temperature to
be controlled daily and recorded. If adjustment
of thermostat is needed the temperature must be
rechecked and recorded every 1-2 hours until
within limits and stable. If there is proof or a
strong suspicion that the vaccines have been
frozen or temperature has been higher than
recommended for a longer period the vaccines
are to be destroyed without questioning!
 Most vaccines will be destroyed if frozen and
loose their efficiency (slowly or rapidly) if kept at
a higher temperature than recommended. Many
vaccines are also sensitive to (sun) light. Most
sensitive to heat and sunlight are vaccines
containing measles. See separate paper copy.
NB! OPV (Polio) to be stored frozen (better) or
refrigerated
 Due to hygienical / aseptic and efficiency
safety reasons a single dose vial should
preferably be used instead of a multi
dose vial. Applies to all kind of vaccines.
 Many countries have slightly different schedules
regarding which vaccines are included and intervals they
are to be given at. Just keep in mind that the minimum
time to pass between 2 doses of same vaccine is
normally more important than if there is a delay / longer
time passing between the doses than recommended.
Often there is not necessary to start over again with an
immunization series if there has been a delay. But if a
shorter time than recommended or alternative short
schedule has been used, then extra booster dose/s are
often necessary.
 If the child is going to be resident in Bali
and use BIMC as their place of
immunization it will be easier if we/they
use BIMC schedule. But if the caretaker
want to keep to their home countrys
schedule we should be flexible.
 Most brand vaccines for same disease
are interchangeable with each other but
the basic doses are often recommended
to be given by the same type or brand of
vaccine. Again if that is not possible the
immunity will most likely still be (very)
good if vaccines of different type or brand
are used.
 The absolute majority of the vaccines
used in BIMC are manufactured in and
imported from Europe (France/Belgium)
or Australia. Further we have no reason
to believe that there should be any
problems or unsafety, including the cold
chain conditions with these vaccines
 Regarding BCG and OPV vaccines the
only one available are locally
manufactured by Bio Farma Indonesia.
Also believed to hold a high quality and
safety in all aspects.
 Some vaccines are provided free of charge from the
Indonesian government via the Puskesmas system.
Whenever BIMC have a stock of these vaccines they
can be administered without charging for the actual
vaccine to children under 12 months age, as per the
government regulations. Though, sometime we have to
buy these vaccines as we are not given enough stock for
free and then we will charge for the actual vaccine. Ex.
Polio and BCG vaccines. If you administer a vaccines
that is free of charge it should be inputted as external
medication.
 A live vaccine can be given together with any
kind of other vaccine including other live
vaccines. But when a live vaccine is given, 4
weeks must pass before another live vaccine
can be given (same type of vaccine or other),
when it comes to other vaccines that are not live
ones there are no restrictions.
These are live vaccines available in BIMC: BCG,
OPV, MMR and Varicella
 N.b.
Normally here at BIMC we give a live
vaccine alone, f. ex. MMR, varicella.
BCG and OPV, we give together with non
live vaccines.
 Most /all vaccines interact with
immunoglobulins and blood product
transfusions and therefore a child/patient
who tell you that they had such within the
last 3 months you must read the Mims or
manufacturers information regarding if and
when it is ok or not to give the vaccine.
Also tell doctor on duty re. this situation.
 Side effects:
All vaccines used in the BIMC standard schedule
(excluding Japanese Encephalitis B) are reported to
have very mild side effects if any at all in a majority of
immunized persons. If the side effect occur it is in
general: fever (<38.5 or >38.5 but could easily be
lowered with Panadol till <38.5), pain at injection site /
radiating in the injected limb, minor (<5cm ) swelling or
redness. Mostly the side effects would start within 24
hours and be gone within 24-48 hours. Although all
immunized persons/caretakers must be informed about
the potential risk of anaphylactic reactions
 BCG
To be given before 6 months age without
any prior Mantoux/PPD test.
After 6 months age only after a negative
Mantoux/PPD test.
Only given once in life.
Immunity can be tested by Mantoux/PPD
test.
Scarring or not scarring does NOT say
anything about immune response.
 Special precautions for vaccinator and
handling of the injection site.
Residual vaccine to be handled as
biohazard waste (syringe and ampule
thrown to sharp box).
OPV (Oral (Live) Polio Vaccine):
Basic immunization consists of 3 doses 1-
2 months in between.
A 4th dose gives long term coverage (10
years) and a 5th dose might give lifelong
coverage but if the person is resident in an
endemic area (as all SEA countries) s/he
should have a 10 yearly booster dose.
 OPV can be interchanged or replaced with
IPV (Injectable/Inactivated Polio Vaccine).
As OPV is a live vaccine it should be
given at the same time as or separated by
minimum 4 weeks from other live
vaccines.
 DTP a/w:
Basic immunization consists of 3 doses 1-
2 months in between. 4th and 5th doses
gives long term coverage (10 years). First
3 doses should preferably be given by the
same brand of vaccine. Thereafter 10
yearly booster doses of DT for the rest of
life no matter where the person is resident
in the world. If booster dose is delayed
more than 20 years 2 doses are needed by
4 weeks interval to catch up.
 a = acellular vaccine (Infanrix) gives up
to 50% less side effects than

w = whole cell (Tetract-Hib &

BioFarma(?)) vaccine especially in
children above 12 months age.
 Haemophilus Influenza Type B
There are 2 types of HiB vaccines
available in the world. Some countries like
Australia use both in different states.
If you start with one you SHOULD
continue with the same until all 3 or 4
doses are given. The two different vaccine
types use different time schedules.
 Normally the immunization would start
from 2 months age. Again, if the same
type of vaccine cannot be given, the other
type can be used and will quite likely give
good immunity.
All HiB containing vaccines used at BIMC
(in Indonesia?) at the moment follow the
same schedule as described in BIMC
schedule.
 See separate copied schedule regarding
doses of HiB needed depending of at what
age the immunization is initiated.

If the child already is 5 years or older the

HiB vaccine is not needed, the child is old
enough to be able to cope with a
Haemophiluz Influenza infection
 Hepatitis B
3 doses needed at an interval of 0-1-6 months if
started at 1 months of age or older
For children there is no need to confirm
immunity by blood test, as all adults must do.
These 3 doses gives most likely lifelong
immunity, or at least 5-10 years coverage. If a
person is still at high risk when they are >10
years old they can have a booster dose or check
the immune response by a blood test.
 If the first dose is given at birth and in all
cases when a schedule is used that gives
a shorter time than 6 months between
dose 1 and 3 then a 4th booster dose is
needed 1 year after 1st dose.
There are full inter-changeability between
all available brand name vaccines
 MEASLES, MUMP, RUBELLA
(Trimovax Merieux)
MMR should not be given before 12
months age, because the efficiency of the
immunization cannot be guaranteed. To
even more make sure that all children
have a very, very good coverage for
especially measles and for females also
rubella a second dose of MMR is give at
pre-school age or before adolescence.
Even 1 dose given at >12months age
gives most likely lifelong protection.
 In many developing countries including Indonesia
measles only vaccine is given from 9 months of age. 9
months is the absolute earliest age when measles can
be given to have any effect, but when given at this age it
MUST always be repeated when the child is >12 months
old. The reason to give measles only at 9 months age is
to protect from epidemics or if an epidemic occurs
improve the possibility of survival among the affected
population.
As MMR is a live vaccine it should be given at the same
time as or separated by minimum 4 weeks from other
live vaccines.
 Hepatitis A (Havrix):
Can be given from 2 years of age. 2 doses
are needed with 6 -12 months interval.
1 dose give 1 years protection and 2
doses (10-) 20 years protection.
Thereafter 1 dose is needed to give long
term protection again.
Even if several years elapses between
dose 1 and 2, when a 2nd dose is given it
will give long term coverage.
 Children (<14 years old) should be given 720
Units / dose and adults 1440 Units/dose. If given
in the combination with Hepatitis B as Twinrix
all 3 doses must be given, due to reduced
amount of Units in the Twinrix.
Hepatitis A vaccine is included in the BIMC
standard schedule due to the high incidence of
Hepatitis A in all SEA incl. Indonesia plus due to
the severity of the disease.
 Typhoid (Typhim Vi)
Can be given from 2 years of age. When given
as injectable Typhim Vi one dose is enough
every 3 years. The oral capsules follow there
own schedule depending on how many capsules
taken (not available at BIMC).
Typhoid vaccine is included in the BIMC
standard schedule due to the high incidence of
Typhoid in all SEA incl. Indonesia plus due to the
severity of the disease. Typhoid vaccine
interacts with Lariam (Mefloquine)
 Varicella:
Can be given from 9 months of age. I the person already
passed 12 years s/he will need 2 doses to ensure
immunity. The vaccine has a very good coverage but an
immunized person can still get sick with Chickenpox, but
the sickness will be much, much milder. Varicella vaccine
is not generally recommended as a standard schedule
vaccine from BIMC, it is taken up in the list as a to
consider vaccine for those parents who are very
concerned about minimizing the risk for their children to
get Chickenpox. Further children with some chronic
ailments might benefit from the vaccine and have a
minimized risk of getting Chickenpox.
 If someone has been exposed to live viruses, ie.
met someone who is (or within a few days after
they met get sick with Chickenpox), they can
take the vaccine within 72 hours from that first
exposure and may get a protection.
As Varicella is a live vaccine it should be given
at the same time as or separated by minimum 4
weeks from other live vaccines.
 Japanese Encephalitis B
Can be given from 1 years of age in 3 doses. Thereafter
a person need a single booster dose every 3 years. In
some countries where people might be semi-immune a 2
doses schedule is used, but that is not recommended
from BIMC.
BIMC recommend children and adults resident in all
rural areas with a higher number of mosquitoes breeding
on pigs and birds (might be applicable also to some
urban areas in Indonesia incl. Bali) to be vaccinated.
There have been reported delayed severe side effects
and unexplained deaths with the use of this vaccine,
there for the vaccine is
 NOT to be given in combination with other vaccines also
special travel restriction applies for the immunized
person up to 10 days after each dose. Further the
vaccinated person is encouraged to report any sort of
side effect or possible side effect to BIMC.
Although these reports and higher safety thinking
regarding Jap.E.B. vaccine many immunization centres
including BIMC have NOT seen any severe side effects.
In BIMC only one young boy was reported to got a mild
rash on the body that perhaps could be due to his recent
Jap.E.B immunization.
 Rabies:
Can be given as a pre-exposure immunization of 3 doses
from ??? age. In BIMC we recommend pre-exposure
Rabies immunization for those children/adults who either
have a kennel, take care of street dogs or reportedly live
in a remote and also rabid area (all Bali official free of
rabies). Basically not many people Further, pre-
exposure immunization can give a false feeling of
safety, because a bitten person MUST still take the same
immediate actions as a non-immunized bitten person has
to do. I.e. wound cleaning and see a qualified doctor for
assessment of the wound and most likely also
administering of further doses of vaccine, depending on
the wounds severity
 The vaccine can ALWAYS be given as a post-
exposure immunization if a bitten person meets
WHOs criteria (mims aus.) to be in need of
vaccine (2 or 5 doses depending on pre-
vaccinated or not) (and perhaps also Rabies
immunoglobuline). In that case there are NO
contra indications, no age limits etc etc. Due to
the 100% fatal outcome once a person is
diagnosed having rabies. The vaccine has as
well few and mild side effects.
 Meningitis (Mencewax ACWY):
The vaccine available in BIMC can only be
given from 2 years of age as a single dose
and repeated every 3 years. ACWY stands
for the 4 different types of Meningococcus
that the vaccine protects against. These 4
types are the most common one to spread
in epidemics and cause mass deaths
among especially (young) children
 Luckily these epidemics are not a big
problem in Bali or as far known in any
other part of Indonesia so it is more for a
very concerned and protective
caretaker/person. Further if someone will
move/travel to areas of the world where
there are seasonal epidemics as parts of
Africa from time to time, then they are
recommended be immunized.
 In the UK they have had problems with
these epidemics in children settings and
therefore routinely immunize using type
C at 1-2-3 months of age. British infants
coming to BIMC and who already have
started to be immunized for Meningitis C
in the UK must be informed that we do not
have that type of vaccine and further the
risk is considered as small for the disease.
 FLU VACCINE
Vaxigrip vaccine ( flu vaccine type A & B) is available at
BIMC.
It is not for birds flu
Annual vaccination is recommended for the following
groups.
*All adult aged 65 years old and over.
*Adult and children (greater than or equal to 6 months
old) with chronic disorders of the pulmonary and
circulatory system and or other chronic disorders.
* All adult and children whom have no allergy to fowl
protein (egg, feathers or chicken meat ) or any other
component of the vaccine.
 Dosage and Administration:
Immunization is normally undertaken in
the autumn in anticipation of winter
outbreaks of influenza.
In Indonesia we suggest people to have
vaccine any time they want ( since
influenza doesnt occur seasonally).
One dose is usually sufficient.
 The vaccine should be administered by
deep SC injection.
Adult and children over 6 years old, 0.5ml
Children 2 to 6 years old, 0.25ml
Infants 6 months to 2 years old, 0.125ml
 Epinephrine for Allergic Reaction
0,01mg/kgBw to a maximum dose of
0,5mg (of the 1: 1000).
SCI