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IMUNISASI

IRMA LUSIANA TANTRI, M.D


NDT 2007 - BIMC
PRELUDE
• IMMUNITY. Immunity to a disease is achieved through the presence
of antibodies to that disease in a person’s system.
• ANTIBODY. Antibodies are proteins produced by the body to
neutralize or destroy toxins or disease-carrying organisms.
Antibodies are disease-specific.
• TWO TYPES OF IMMUNITY : PASSIVE and ACTIVE.
• ACTIVE IMMUNITY. Exposure to a disease organism triggers the
immune system to produce antibodies to that disease. Exposure to
the disease organism can occur through infection with the actual
disease (resulting in natural immunity), or introduction of a killed or
weakened form of the disease organism through vaccination
(vaccine-induced immunity).
Active immunity is long-lasting, and sometimes life-long.
• PASSIVE IMMUNITY. Person is given antibodies to a disease rather than
producing them through his or her own immune system. Example : A
newborn baby acquires passive immunity from its mother through the
placenta or a person can also get passive immunity through antibody-
containing blood products such as immune globulin.
Passive immunity lasts only for a few weeks or months.
RISK OF VACCINATION VS
NOT BEING VACCINATED
VACCINATION RISK OF RISK OF
VACCINATION NOT VACCINATING
Hib Infection to the blood, brain, lung,
throat, bones and joint.
Meningitis Infection of the surface of the
brain and spinal cord, leading to
mental retardation, deafness,
even death
Polio Paralysis and death
Measles Death
Pertusis Serious illness and death
Chicken pox
Anthrax
VACCINE INFORMATION STATEMENTS
(VISs)
• A Vaccine Information Statement (VIS) is a one-page (two-sided) information sheet,
produced by CDC. VISs inform vaccine recipients — or their parents or legal
representatives — about the benefits and risks of a vaccine.

• WHO? All provider of vaccines, both public and private sector must give out VISs

• WHY ? It is a requirement of the National Childhood Vaccine Injury Act of 1986. Their
purpose is to inform vaccine recipients, or parents of children getting vaccines, about the
benefits and risks of vaccines.

• WHEN? They must be given out at the time of each vaccination — prior to administration of
the vaccine.

• WHICH VISs to use?


As of August 2007, VISs that must be used are: DTaP, Td, MMR, Polio, Hepatitis A,
Hepatitis B, Hib, Varicella, Influenza, and Pneumococcal Conjugate.
Other VISs that are available are Pneumococcal Polysaccharide, Meningococcal*, Tdap*,
Rabies, Rotavirus*, HPV*, Shingles, Yellow Fever, Typhoid, Japanese Encephalitis,
Anthrax, and Smallpox.
• VISs have been translated into 30 languages by the California and
Minnesota immunization programs.
Arabic, Armenian, Bosnian, Cambodian, Chinese, Croatian, Farsi, French,
German,Haitian,Creole, Hindi, Hmong, Ilokano, Japanese, Korean Laotian,
Marshallese, Polish, Portugese, Punjabi, Romanian, Russian, Samoan,
Serbo-Croatian, Somali, Spanish, Tagalog, Thai, Turkish, Vietnamese

Translations can be found on the Immunization Action Coalition's website


(www.immunize.org/vis)(exit).
GENERAL GUIDLINES
FOR VACCINATIONS
ADMINISTRATION
– In general :
• Inactivated vaccines  IM
• Live-virus vaccines  SC
• Inactivated polio & pneumococcal  IM / SC
– IM  deltoid muscle / in anterolateral of mid-
thigh for children < 24 months
– HDCV  contraindicated for IM administration
in gluteal muscle
– Multiple vaccinations :
• If 2 vaccines ≥ or a vaccine + a immune globulin
are to be administered simultaneously :
– Each is administered with separate syringe
– Preferably at different anatomical sites
– Into separate limbs
– Preferably AVOID administering two IM inj IN THE SAME
limb
– If 1 vaccines ≥ must be administered into a single limb
» THIGH is preferred site.
» Should be separated 1-2 inches apart
– Cholera and Yellow fever vaccines :
should be administered at a minimal interval
of 3 weeks
– MMR and varicella vaccines :
if not be given at the same time, should be
given at least 30 days apart
RESTARTING VACCINATION SERIES
Not necessary to restart the series of any childhood
vaccine EXCEPT for oral typhoid vaccine.

VACCINATION OF PRETERM INFANTS


• Regardless of birth weight, should be vaccinated at the
SAME chronological age as a full-term infants and
children, EXCEPT for low-birth weight premature infants
of HBsAg-negative mothers
• Dose : use the full recommended dose of each vaccine.
DO NOT divided or reduce doses
BREAST-FEEDING

• Does not adversely affect immunization


• Is not a contraindicated for any vaccine
• Breast-fed infants should be vaccinated
according to routine recommended schedules
• No vaccine affects the safety of breast-feeding
for mothers or infants
PREVACCINATION SCREENING
Likely to cost effective for :
• Hep A for person > 40 yo or younger person with
a high prevalence of HAV infection
• Hep B  depend on the specific level of risk
and/or likelihood of previous exposure to HBV
• Varicella  adults
GENERAL CONTRAINDICATIONS

• Anaphylactic reaction to a VACCINE


contraindicates further doses of that vaccine
• Anaphylactic reaction to a vaccine
CONSTITUENT contraindicates the use of
vaccines containing that substance
• Moderate to severe illnesses with or without
fever
NOT CONTRAINDICATIONS
• Mild to moderate local reaction (swelling, soreness,
redness) following a dose of an injectable antigen
• Mild acute illness with or without low-grade fever
• Breast-feeding
• Recent exposure to an infectious disease
• Convalescence phase of illness
• Prematurity
• Current antimicrobial therapy
• History of penicillin or other nonspecific allergies or
family history of such allergies.
MINIMUM AGE FOR INITIAL VACCINATION
AND MINIMUM INTERVAL BETWEEN
VACCINE DOSES
Vaccine Min. Age Min. Interval Min. Interval Min. Interval from
for 1st dose from dose 1 from dose 2 dose 3 to 4
to 2 to 3
Hep B Birth 1 mo 2 mo ( ≥4 mo -
after dose I)
DPT (or DT) 6 weeks 1 mo 1 mo 6 mo

DTaP 6 weeks

HbCV
HbOC 6 weeks 1 mo 1 mo 2 mo and at least 12 mo
of age
PRP-T 6 weeks 1 mo 1 mo 2 mo and at least 12 mo
of age
PRP-OMP 6 weeks 1 mo 2 mo and at
least 12 mo of No dose 4
age
Vaccine Min. Age Min. Interval from Min. Interval Min. Interval
for 1st dose dose 1 to 2 from dose 2 from dose 3
to 3 to 4
Combined 6 weeks 1 mo 1 mo 6 mo
DTP/HbCV
OPV 6 weeks 6 weeks 6 weeks
IPV 6 weeks 1 mo 6 mo
Rotavirus 6 weeks 3 weeks 3 weeks
Measles or 12 mo 1 mo
MMR
Varicella 12 mo 1 mo
Special vaccines
Hep A
Havrix 2 years 6 mo
Vaqta 2 years 6 mo

Influenza 6 mo 1 mo in children < 9


yo for the 1st series
only; single dose
annually thereafter
Vaccine Min. Age for Min. Interval Min. Interval Min. Interval
1st dose from dose 1 from dose 2 from dose 3
to 2 to 3 to 4
Typhoid
• Vi capsular 2 years Booster every 2
polysacaride years
•Heat-phenol 6 mo 4 weeks;
inactivated booster every 3
years
•Oral live Booster (repeat
6 years series) every 5
attenuated
(Ty21a) years
Japanese 1 years 7 days 7 days
Encephalitis
Cholera 6 mo 1 week

One month is defined operationally as 28 days.


GENERAL GUIDELINES FOR SPACING
THE ADMINISTRATION of KILLED
AND LIVE ANTIGENS
Antigen Recommended Minimum Interval Between Doses
Combination
≥ 2 killed antigens No minimum; may be administered simultaneously or at any
interval between doses 1

Killed and live antigens No minimum; may be administered simultaneously or at any


interval between doses 2

≥ 2 live antigens 4 week min. interval if not administered simultaneously;


however oral polio vaccine (OPV) can be administered at
any time before, with or after MMR, if indicated

1
If possible, vaccine associated with local or systemic side effects (e.g., cholera, heat phenol inactivated
parenteral typhoid, and plaque vaccines) should be administered on separate occasions to avoid
accentuated reactions.
2
The combination of cholera and yellow fever vaccine is the only exception. If the time permits, this
antigens should not be administered simultaneously, and at least 3 weeks should elapse between
administration of cholera and yellow fever vaccine.
ALGORITHM FOR TESTING AND DESENSITIZATION
FOR VACCINATING PATIENTS WITH
HYPERSENSITIVITY TO EGGS
AND EGGS PRODUCTS1
History consistent with egg allergy 2 :
Urticaria
Angioedema
Nausea and Vomiting
Diarrhea Within 2 hours of egg ingestion
Abdominal Pain
Stridor
Wheezing
Hypotension with tachycardia

Prick test with vaccine diluted 1: 10 in normal saline

Positive Negative

Intradermal test with 0.02 ml of vaccine diluted


1: 100 in normal saline

Positive Negative  Administer vaccine in usual


dose SC and observe for
Administer vaccine in 0.05 ml aliquots 30 minutes
SC every 20 minutes
1Vacinnes prepared using embryonated chicken eggs : influenza & yellow fever vaccine.
Vaccines prepared using chicken egg embryo cell cultures : measles and mumps (and
MMR). Most anaphylactic reactions to measles and mumps vaccine are to gelatin or other
components. No specific protocols for skin testing to gelatin have been established.
2Generally, person who are able to eat eggs and eggs products without adverse effects may

receive these vaccines. Person with history of anaphylactic hypersensitivity to eggs or egg
protein should not receive these vaccines.
VACCINE-PREVENTABLE
DISEASE (CDC)

•ROTAVIRUS
• ANTHRAX
•RUBELLA (GERMAN MEASLES)
• CERVICAL CANCER •SHINGLES (HERPES ZOSTER)
• DIPHTERIA •SMALLPOX
• HEPATITIS A •TETANUS
• HEPATITIS B •TUBERCULOSIS
•TYHPOID FEVER
• H. INFLUENZAE TYPE B (Hib)
•VARICELLA
• HUMAN PAPILLOMA VIRUS (HPV) •YELLOW FEVER
• INFLUENZA (FLU) •PNEUMOCOCCAL
• JAPANESE ENCEPHALITIS (JE) •POLIOMYELITIS
• LYME DISEASE •RABIES
• MEASLES
• MENINGOCOCCAL
• MONKEYPOX
• MUMPS
• PERTUSIS
VACCINES ADMINISTRATION
NAME of VACCINE TYPE OF VACCINE ADMINISTRATION
Tetanus Toxoid 0.5 ml IM
•<2 th : anterolateral
mid-thigh
•> 2 th : deltoid
Cholera Killed bacteria IM/SC
Hib Polysaccharide 0.5 ml IM
•<2 th : anterolateral
mid-thigh
•> 2 th : deltoid
Pneumococcus Polysaccharide 0.5 ml SC / IM
•<2 th : anterolateral
mid-thigh
•> 2 th : deltoid
Meningococcus Polysaccharide 0.5 ml SC sd
NAME of VACCINE TYPE OF VACCINE ADMINISTRATION

Typhoid Killed bacteria Oral / 0.5 ml IM

BCG Bacteria ‘dilemahkan’ ID / SC


• < 1 th : 0.05 ml
•> 1 th : 0.1 ml

Measles, Mumps, Virus ‘dilemahkan’ 0.5 ml SC


Rubella (MMR)

Poliovirus oral (OPV) - Virus ‘dilemahkan’ 0.5ml (unit dose) oral


children
Polio inactivated (IPV) Inactivated virus 0.5 ml SC

Yellow fever Virus ‘dilemahkan’ 0.5 ml SC

Hepatitis B DNA recombinant IM

Hepatitis A Inactivated virus IM


• 2 – 18 yo : 0.5 ml
•> 18 yo : 1 ml
NAME of VACCINE TYPE OF VACCINE ADMINISTRATION
Influenza Inactivated virus IM
• 6 – 35 mo : 0.25 ml
•3- 8 yo : 0.5 ml
•9 -12 yo : 0.5 ml
•>= 12 yo : 0.5 ml
Japanese B encephalitis Inactivated virus SC
• 1 – 3 yo : 0.5 ml
•> =3 yo : 1 ml
Rabies Inactivated virus IM : 1 ml
I.D : 0.1 ml
VACCINES @ BIMC
VACCINE TRADE CONTAIN ADM EMIMS
NAME
VACCINES AGAINST BACTERIA

H. Influenza ACT-Hib Bacteria IM Hiberix


(10mcg/0.5ml) capsular
Polysaccharide
+ Tetanus
Toxoid
S. pneumonia Prevenar Pneumococcal IM / SC Prevenar
0.5 ml conjugate
N. Meningitidis Mencevax Capsular SC Mencevax ACWY
(meningococcus) ACWY 0.5 ml Polysaccharide
ACWY
S. Typhi Typhim VI Polysaccharide IM Typhim
(typhoid) Thyperix VI antigen Thyperix
Clostridium Tet-Tox , Inactivated IM -
tetani (Tetanus) Adsorbed toxin (toxoid)
VACCINE TRADE CONTAIN Route DOSAGE
NAME Adm.
VACCINES AGAINST VIRUSES

Hepatitis B Engerix-B 1 ml Inactive viral IM <10 yo : 10 mcg


Adult , 0.5 ml antigen > 10 yo : 20 mcg
Pediatric
Hepatitis A Havrix 720 Inactivated IM Child 1-15 yo : not <360
junior virus u/dose
Adult not <720 ELISA u/dose
Havrix 1140 Inactivated IM 1x1 ml dose
Adult virus Booster : 6 – 12 mo later
Avaxim IM Adult : 0.5 ml

Influenza Vaxigrip 0.5 ml Inactivated IM 6 mo – 3 yo, 2 inj 0.25ml, 1


Adult ; virus mo intvl
0.25 ml Pediatric 3 – 8 yo, 2 inj 0.5 ml, 1 mo
intvl
> 8 yo, 0.5 ml
Japanese Japanese Inactivated SC For initial 2 inj 0.5 ml
encephalitis encephalitis virus
VACCINE TRADE CONTAIN Route DOSAGE
NAME Adm.
VACCINES AGAINST VIRUSES
Varicella-zoster Varilix Live attenuated SC Infant>12 mo & Child ≤12 yo :
(chicken pox) virus 0.5 ml SC single dose
Child > 13 yo & adult : 2 doses
0.5 ml SC 4-8 week intvl
Rabies Verorab Inactivated IM Preventive & pre-exposure 3 inj
virus
COMBINATION VACCINES

Diphtheria, Infanrix Diphtheria & IM Child 2 mo – 7 yr : 0.5ml


tetanus, and tetanus toxoid
acellular pertusis & inactivated B.
(DTaP) pertusis
component
Diphtheria, Tetract-Hib Diphtheria & IM 3 inj 0.5 ml at 2,4,6 mo
tetanus, pertusis tetanus toxoid
with H.Influenza & inactivated B.
type B pertusis
component,
polysaccharide
H.influenzae
VACCINE TRADE CONTAIN Route DOSAGE
NAME Adm.
COMBINATION VACCINES

Diphtheria and ADT Diphtheria & IM 0.5 ml


tetanus toxoid tetanus toxoid
adsorbent
Diphtheria, Tritanrix B Diphtheria & IM 0.5ml IM for 3 inj at interval at
tetanus,pertusis tetanus toxoid least 4 weeks
with hepatitis B & inactivated B.
pertusis
component &
Inactive hep. B
viral
Measles, mumps, Trimovax MMR Measles, IM 1 st inj administered for 12 mo
rubella mumps, rubella 2nd inj is recommended
virus between 3, 6, 7 yo
Inactivated hep A Twinrix Adult Inactivated hep ? ?
and B 720/20 A and Hep B
Twinrix Junior surface antigen
360/10
VACCINE TRADE CONTAIN Route DOSAGE
NAME Adm.
IMMUNOGLOBULINE

Human rabies Ig Imogam Rabies Immunoglobulin IM Child 2 mo – 7 yo o.5 ml

Human tetanus Ig Tetagam P Immunoglobulin IM Prophylaxis 250 iu


Contaminated wound and
wound cannot be surgical,
extensive burns 500 iu
Therapy 3000 – 6000 iu on the
1st day