Childhood

Immunization
Addishiwot Melesse, M.D

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Outlines
 Introduction
 Definition and Types of vaccine
 Immunization in Ethiopia
 Routine immunization schedule
 Specific vaccines
 References

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History of vaccine development

● Vaccines are one of modern medicine’s miraculous breakthroughs — but they

existed thousands of years earlier in primitive forms, referred to today using the
term “variolation.”
.

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 History of Vaccines
More vaccines available, including
Edward Jenner
diphtheria,tetanus,whooping cough,
and (TB).
‘’ Father of Immunology’’
900-1000 AD Introduced modern vaccinology
.
Late 19th 1952
century

The Chinese developed a Jonas Salk and his research

Louis Pasteur
primitive form of a vaccine around team at the University of
1796 discovered vaccine 1920s 
the 10th century, known as Pittsburgh developed the
against Chicken
variolation or inoculation. first effective polio vaccines
cholera , Anthrax &
Rabies
Immunity

Natural immunity
Passive (maternal antibody)

Active (consequence of
infection)
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 Types of vaccine

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Live attenuated Viruses

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Inactivated Whole-Cell vaccines

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Subunit vaccines

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Conjugated vs Polysaccharide Vaccines

Polysaccharides Conjugates

● T-cell independent antigens. ● T cell dependent antigens.

● Not immunogenic in infants. ● Immunogenic in infants as of
● DO NOT induce an immune memory 6weeks.
( no booster effect) ● Establish immune memory.
● Herd Protection

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Toxoid vaccines

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Adjuvants

● appear to restrict the dispersion of antigen from the injection site.

● may also modulate the immune response, triggering a stronger T h2 type response
resulting in higher levels of antibodies.

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Vaccination in Ethiopia

● The Expanded Programme on Immunization (EPI) was established by the World Health
Organization in 1974 to control vaccine preventable diseases.

● In Ethiopia, EPI programme was launched in 1980 with the objective of achieving 100%
immunization coverage of all children under two years old by 1990.

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Specific vaccines

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BCG vaccine

● Live strain of Mycobacterium bovis developed by

Calmette and Guérin for use as an attenuated vaccine to
prevent tuberculosis and other mycobacterial infections.

● The vaccine was first administered to humans in 1921

and remains the only vaccine against tuberculosis in
general.

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Duration of protection  
● Approximately 10 to 15 years; this is the period for which BCG has
been shown to be protective against childhood tuberculosis.

 Efficacy
● Incidence of TB meningitis was reduced by 73%.
● Incidence of miliary TB was reduced by 77%.

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 EFFICACY  
 Underlying immune status of the recipient.
 Exposure to mycobacteria prior to vaccination.
 Potency of the BCG strain used in the vaccine.

 Collectively, trials demonstrated an efficacy of 73 percent for

protection against active disease and 87 percent against death.

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 Who should be vaccinated?
 The WHO does not recommend use of BCG vaccine in the countries
meeting the following criteria:
 Average annual rate of smear-positive pulmonary TB below 5 per 100,000
(83per 100,000; Ethiopia TB Guideline).
 Average annual rate of tuberculous meningitis in children under five years
below 1 per 10 million population
 Average annual risk of TB infection below 0.1 percent.

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Adverse reaction
● Bluish-red pustule, ulceration, scar
● Osteitis
● Osteomyelitis
● Disseminated disease

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 Contraindication
● HIV
● Primary immunodeficiency.
● Immunosuppressive drugs.

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 Polio vaccine
● Immunization against poliovirus infection represents one of the world's
greatest medical achievements.
● The last case of poliomyelitis caused by naturally circulating (WPV2) was
recorded in India in 1999.
● Global eradication of WPV2 was certified in 2015.
● The last indigenous case of wild poliovirus (WPV) in Ethiopia was
interrupted in December 2001.

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 IPV
● Inactivation of naturally occurring
polioviruses by treatment with
dilute formalin.
● Antibodies are detectable to all
three poliovirus types in >93 %
after 2 doses, and 100 % after the
third dose
● Efficacy decreased by maternal
antibodies & short interval b/n
doses
● Low adverse reaction
OPV
● By repeated passage of wild
type polioviruses in cell
culture and in vivo.
● Trivalent, monovalent, Bivalent
● Cost, ease of administration.
● Herd immunity
● Mucosal immunity
● VDPP, VAPP
● Efficacy decreased by enteric
infections.
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 Pentavalent
● Dipitheria
● Pertusis
● Tetanus
● Hepatitis B
● Haemophilus influenza type b

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 Diphtheria Vaccine

● Diphtheria toxoid-containing vaccines are among the

oldest vaccines in current use
● Available in combination with tetanus toxoid(T) as DT,
or with tetanus and pertussis antigens (DTP).
● After completion of the full 3-dose primary series DTP-
containing vaccine, 94–100% of children have anti-
diphtheria antibody levels >0.01 IU/mL.
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● Diphtheria toxoid is one of the safest vaccines available.
● However, local reactions at the site of injection are
common.
● Clinical trials have shown that DTwP and DTaP
are comparable in terms of both local and systemic
reactogenicity when used for primary vaccination of
infants.

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● For previously unimmunized children aged 1–7 years, 3 doses with
a minimum interval of 4 weeks between the first and the second
dose, and an interval of at least 6 months between the second and
third dose, using DTP-containing vaccine.

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 Pertusis Vaccine
● Pertussis (whooping cough) is an important cause of morbidity
and mortality in infants worldwide, and continues to be a public
health concern despite high vaccination coverage.
● Endemic in all countries.
● Epidemic cycles occur every 2 to 5 years (typically 3 to 4 years),
even after the introduction of effective vaccination programmes
and the achievement of high vaccination coverage.

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Whole-cell pertussis vaccines
● All wP vaccines are
combined(DTwP).
● Not used in older children because of
concerns regarding reactogenicity.
● The pooled efficacy of wP vaccine
against pertussis disease in children
was 78%
● vaccine effectiveness falls from 100%
in the first year after the primary
vaccination to 84% in the 4th year,
52% in the 5th year and to 46% in the
6th year
Acellular pertussis vaccines
● Administered in combination with
diphtheria and tetanus toxoids (DTaP),
● protective efficacies of 76% -85%
● Vaccine effectiveness decreased from
98 percent in the first year to 71 percent
by ≥60 months.
● Boosters of aP vaccine in combination
with tetanus toxoid and reduced-dose
diphtheria vaccine (TdaP).
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 CORTICOSTEROID ADMINISTRATION AND IMMUNIZATION.
 Only high dose systemic steroids for more than 2 weeks interfere
with vaccine induced immune responses.
 A period of at least 3 months should elapse between high dose
steroid use and administration of both inactivated or component
vaccines (to ensure immunogenicity) and live vaccines (to reduce
the risk of dissemination).
 Children receiving physiologic replacement doses of
glucocorticoids can follow the routine immunization
schedule without restriction.
 Topical and inhaled steroids have no known impact on oral or
injected vaccines.
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 Immunization in patients with Cancer
● Cancer patients should generally be vaccinated with inactivated vaccines.

● Ca pts should not be receiving live virus vaccines.

● CDC recommend leukemia,lymphoma,and others can receive if in

remission or 3mon chemotherapy termination .

● All indicated vaccines should be received

before( chemo,radiation,splenectomy or any immunosupressive Rx)

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● Contraindications
 Anaphylactic reaction to the DTP.
 Encephalopathy within seven days of the administration of a previous dose
of the vaccine
 Some DTaP vaccines contain latex and are contraindicated in patients with
anaphylactic reaction to latex

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Adverse reaction
● Mild local and systemic reactions
● Entire limb swelling
● Persistent, inconsolable crying (≥3 hours)
● Hypotonic-hyporesponsive episode (collapse or shock-like state)
● Seizures
● Fever ≥105ºF (40.5ºC)
● Anaphylaxis

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 Haemophilus influenza vaccine

● Hib was once the most common cause of

bacterial meningitis and a frequent cause of
other serious bacteremic infections.

● The widespread use of Hib conjugate

vaccines led to a dramatic decline in the
incidence of invasive Hib disease in
children.

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 Vaccine types
 PRP-T
PRP-tetanus toxoid conjugate vaccine (PRP-T) conjugates PRP to tetanus toxoid
 Combination
DPT-Hib-Hep B

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Efficacy/effectiveness
Protective efficacy of ≥95 percent against invasive Hib disease after completion of the
two- or three-dose primary series as recommended
 Adverse effects 
 Systemic reactions (eg, fever, irritability) are
infrequent
 Local reactions(25%)
Pain
Redness,
Swelling at the injection site

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 Hepatitis B vaccine
● In 2015 the global prevalence of HBV infection in the general
population was estimated at 3.5% with about 257 million persons
living with chronic HBV infection.

● The national hepatitis strategic action plan strongly recommended the

introduction and scale up of hepatitis B birth dose (within 24 hours) in
Ethiopia.

● Major progress in the global response to viral hepatitis has been

achieved through the expansion of routine hepatitis B vaccination,
which was facilitated by the introduction of new combination vaccines.
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 Hepatitis B Perinatal Transmission rates

1. If mother positive for HBsAg and HBeAg

 70%-90% of infants infected.
2. If positive for HBsAg only
 10% of infants infected.
 90% of infected infants become chronically infected
in the absence of post-exposure prophylaxis.
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● In 2015, global coverage with the
three doses of hepatitis B vaccine in
infancy reached 84%.

● This has substantially reduced HBV

transmission in the first five years of
life, as reflected by the reduction in
HBV prevalence among children to
1.3%.

● However, coverage with the initial

birth dose vaccination is still low at
39%. (WHO GLOBAL HEPATITIS
REPORT,2017)

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Dosing schedule
● HBsAg-Positive mother
The HepB vaccine should be administered in three doses: ideally, to infants during the
birth hospitalization; at 1 to 2 months of age; and at 6 to 18 months of age.

• Alternatively, infants born to HBsAg-negative mothers and who weigh more than
2000 g can receive the HepB vaccine during routine health maintenance
examinations at 1 to 2 months, 4 months, and 6 to 18 months of age.

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 HBsAg- positive exposed baby ,≥2kg

Vaccinate with monovalent HBV

Administer HBIG within 12 hours

2nd & 3rd vaccine at 1st & 6th

Testing for HBsAg and anti-HBs (9-18months)

If the HBsAg test is negative and the anti-HBs antibody level <10 mIU/mL, 4 th dose.

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 Pneumococcal vaccine
● S. pneumoniae is a leading cause of serious illness among children
worldwide .

● Before introduction of PCV ,It was the most frequent cause of

bacteremia, pneumonia, bacterial meningitis, sinusitis, and AOM.

● After PCV incidence has decreased by 60-90%

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● Serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F are the most prevalent in children,
accounting for between 60 and 80 percent of infections, depending upon the area
of the world.
● Polysaccharide vaccines are poorly immunogenic in children younger than two
years.

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 Conjugate vaccines Polysaccharide vaccine

PCV 7
PCV10 (Synflorix) PCV13 PCV 15 PPSV23

4 4 4 4 4 2
6B 6B 6B 6B 6B 8

9V 9V 9V 9V 9V 9N

14 14 14 14 14 10A

18C 18C 18C 18C 18C 11A

19F 19F 19F 19F 19F 12F

23F 23F 23F 23F 23F 20

1 1 1 1 22F

3 3 3 33F

5 5 5 5

7F 7F 7F 7F

19A 19A 19A

6A 6A 6A

22F
33F 11/26/2022
Efficacy
Diseases Efficacy
Invasive pneumococcal disease 80%

pneumonia 27% vs 65%

Acute otitis media 6-7%

● In pooled analysis of six randomized controlled trials (including more

than 113,000 children) conducted in Africa, Finland, the Philippines, and
the United States, the efficacy of pneumococcal conjugate vaccines

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 In addition, a single dose of PCV13 (10) may be administered to
children aged 6 through 18 years who are at increased risk for IPD.
 Anatomic or functional asplenia (SCD)
 HIV or other immunocompromising condition,
 Chronic renal failure,
 Nephrotic syndrome,
 Cochlear implant, or
 Cerebrospinal fluid leak

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Side Effects

● Injection site reaction, fever, decreased appetite, irritability, and

increased or decreased sleep are common adverse effects.

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 Measles vaccination
● This live attenuated vaccine
was licensed for use in
1968.
● It is available in combination
as a measles-mumps-
rubella (MMR) vaccine , and
as the quadrivalent MMRV
vaccine (measles, mumps,
rubella, and varicella)

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● Vaccine effectiveness  
● In the United States, anti-measles antibody develops in 95 percent
of individuals vaccinated at age 12 months, and 98 percent of
individuals vaccinated at age 15 months .
● Secondary vaccine failure, has been reported but is relatively rare.

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 Timing of vaccination
● The World Health Organization (WHO) recommends that in high-
prevalence settings, the first dose of MMR be administered at age nine
months (given high risk of transmission), whereas in low-prevalence areas
it can be given at 12 months.
● In Ethiopia MCV2 has been Initiated December- January 2018.

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 Contraindications
● Pregnancy
● ITP
● Immunocompromised
● Recent blood products & immunoglobulin administration
● Allergy
● Concurrent febrile illness

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 Rota virus vaccines
● Rotaviruses infect nearly every child by the age of 3–5
years and are globally the leading cause of severe,
dehydrating diarrhoea in children aged <5 years.

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● Type G1P[8] is the most prevalent combination.
● Currently, 5 G-P combinations G1P[8], G2P[4], G3P[8], G4P[8]) and G9P[8]) account for approximately 90% of all human rotavirus
infections in many parts of the world. 11/26/2022
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 Vaccine Type ROTARIX (RV1) ROTATEQ (RV5)
Adminstration oral oral

•Pentavalent
• Monovalent • human-bovine reassortant rotavirus
vaccine
• G1P[8] strain

schedule 2 doses at 4 and 6 months 3 oral doses at 2, 4, and 6 months

of age ,minimum interval 4 wks

Intussusception risk –vaccine vs Increased risk in some population Same

placebo recipient

Efficacy
against severe rotavirus 85 percent 98 percent strain specific.
gastroenteritis

40 %against severe gastroenteritis from 74% efficacious against rotavirus

any cause. gastroenteritis of any serotype

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● ROTARIX
Should not be initiated for >= 15wks of age
Maximum age for final dose - 8 months

● RV1 contraindications  
 Who are allergic to any of the ingredients of the vaccine
With severe combined immunodeficiency
With a history of intussusception .
With severe (anaphylactic) allergy to latex (the applicator
contains latex).
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 Meningococcal vaccine
● N. meningitides can cause both
endemic and epidemic infection.
● Neisseria meningitides serogroups A,
B, C, X, W135 and Y
● In Ethiopia serotype A is the
predominant serogroup followed by
serotype C.
● Currently W-135 serotype is drawing
attention

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 Monovalent serogroup A conjugate vaccine

● Intended for use mainly in the African meningitis belt, it was licensed in 2010.
● For vaccination of individuals 1–29 years of age.
● Has reduced incidence of meningitis up to 94%

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 HPV
● Selected types of HPV cause cervical cancer, anogenital warts, and
other anogenital and head and neck cancers.
● HPV types 16 and 18 cause about 70% of cervical cancers.
● HPV types 6 and 11 cause about 90% of anogenital warts.
● 528,000 cases of cervical cancer and 266,000 women deaths each
year.
● Most cases (>85%) in less developed regions.
● Most in females not screened or who do not receive early
treatment.

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● Cervical cancer is the leading cause of cancer deaths among
women in Ethiopia.
● May be due to the high prevalence of high-risk human
papillomavirus (HR-HPV) genotypes in the population.
● So far, few studies have been done that showed the presence of
HR-HPV genotypes. The HR-HPV-16, -18, -52, -56, -31 and -58 were
the most common genotypes reported in Ethiopia

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● Bivalent vaccine: protein antigens for HPV16 and18.
● Qudarivalent vaccine: protein antigens for HPV 6, 11, 16, and 18.
● Nanovalent vaccine Non-infectious protein antigens for HPV 6, 11,
16, 18,31, 33, 45, 52 and 58.

 Neither vaccine will treat women with current HPV infection or related disease: HPV
vaccines most efficacious in HPV naive individuals i.e. if administered before sexual
debut.

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Efficacy
Among HPV-naïve populations, the efficacy of quadrivalent HPV
vaccine for preventing CIN2 or more severe disease due to HPV
types included in the vaccine, was 97 to 100 percent.

 Duration of protection
For the quadrivalent vaccine no breakthrough cases of cervical/genital
disease related to HPV types 6, 11, 16, and 18 were observed among
vaccinated pre-adolescents and adolescents during 10 years of follow-
up.
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 New and Upcoming Vaccines

COVID Vaccine
 Viral vector vaccines for COVID-19 (Astrazaneca)
 Genetic vaccines for COVID-19 (Moderna and Pfizer/BioNTech)
 Inactivated vaccines for COVID-19
 Attenuated vaccines for COVID-19
 Protein sub-unit vaccines for COVID-19

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Malaria Vaccine
 The World Health Organization (WHO) is recommending widespread use of the
RTS,S/AS01 (RTS,S)(a recombinant protein-based malaria vaccine),among
children in sub-Saharan Africa and in other regions with moderate to high P.
falciparum malaria transmission.

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 Reading Assignment
● Catch- Up Vaccinations.

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 References
● Nelson Text Book of Pediatrics 20th edition
● UP TO DATE 21.6
● WHO Position papers 2013-2018.
● ETHIOPIA NATIONAL EXPANDED PROGRAM ON IMMUNIZATION
COMPREHENSIVE MULTI-YEAR PLAN (2016 - 2020) ,Federal Ministry of Health,
Addis Ababa
● GAVI International.
● CDC Resources.

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Questions!!!

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