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MMUNSATON MMUNSATON

A Practical approach A Practical approach


Dr. Satheesh Kumar MBBS.,DCh Dr. Satheesh Kumar MBBS.,DCh
How important is the roIe of immunization in
controI of infectious diseases
Successful eradication of small-pox is a shining example Successful eradication of small-pox is a shining example
of how immunization can be used to eradicate an of how immunization can be used to eradicate an
infectious disease. infectious disease.
. They help to build up immunity in the immunized . They help to build up immunity in the immunized
individuals against specific diseases and thus help to individuals against specific diseases and thus help to
decrease the transmission of diseases from one person decrease the transmission of diseases from one person
to another. to another.
However it must be remembered that the incidence of However it must be remembered that the incidence of
most of the infectious diseases in the developed most of the infectious diseases in the developed
countries was largely controlled even before many of the countries was largely controlled even before many of the
vaccines became available (Fig. 1). This was achieved vaccines became available (Fig. 1). This was achieved
by implementing simple public health measures like by implementing simple public health measures like
sanitation, water supply, proper housing etc. sanitation, water supply, proper housing etc.
What is the meaning of vaccine and vaccination? What is the meaning of vaccine and vaccination?
Originally the vaccine word was used for cow pustule Originally the vaccine word was used for cow pustule
material which was used by Jenner to render humans material which was used by Jenner to render humans
immune to small pox. Consequently the method was immune to small pox. Consequently the method was
called vaccination. called vaccination.
s the baby
unwell today
has a disease which lowers immunity (eg. leukaemia,
cancer, HV/ADS)
or is having treatment which lowers immunity (eg. oral
steroid medicines
such as cortisone and prednisone, radiotherapy,
chemotherapy)
has had a severe reaction following any vaccine
has ,3severe allergies (to anything)
Pre Pre- -vaccination screening checkIist vaccination screening checkIist
Pre Pre- -vaccination screening checkIist vaccination screening checkIist
has had any vaccine in the past month has had any vaccine in the past month
has had an injection of immunoglobulin, or received any has had an injection of immunoglobulin, or received any
blood blood
products or a whole blood transfusion within the past products or a whole blood transfusion within the past
year year
is pregnant is pregnant
has a past history of Guillain has a past history of Guillain- -Barr syndrome Barr syndrome
was a preterm infant was a preterm infant
has a chronic illness has a chronic illness
has a bleeding disorder has a bleeding disorder
Contraindications to vaccination Contraindications to vaccination
There are onIy 2 absoIute contraindications appIicabIe to There are onIy 2 absoIute contraindications appIicabIe to , ,vaccines: vaccines:
(i) anaphylaxis following a previous dose of the relevant vaccine, and (i) anaphylaxis following a previous dose of the relevant vaccine, and
(ii) anaphylaxis following any component of the relevant vaccine. (ii) anaphylaxis following any component of the relevant vaccine.
There are 2 further contraindications appIicabIe to Iive (both parenteraI There are 2 further contraindications appIicabIe to Iive (both parenteraI
and oraI) vaccines: and oraI) vaccines:
(iii) Live vaccines should not be administered to individuals with impaired (iii) Live vaccines should not be administered to individuals with impaired
immunity, regardless of whether the impairment is caused by disease immunity, regardless of whether the impairment is caused by disease
or treatment. The exception is that, with specialist advice, MMR can be or treatment. The exception is that, with specialist advice, MMR can be
administered to HV administered to HV- -infected individuals in whom impaired immunity infected individuals in whom impaired immunity
is mild. is mild.
/:094/80,8047970,92039 /:094/80,8047970,92039, and individual vaccine chapters. , and individual vaccine chapters.
(iv) n general, live vaccines should not be administered during pregnancy, (iv) n general, live vaccines should not be administered during pregnancy,
and women should be advised not to become pregnant within 4 weeks of and women should be advised not to become pregnant within 4 weeks of
receiving a live vaccine receiving a live vaccine
False contraindications to vaccination False contraindications to vaccination
mild illness without fever (T <38.5 mild illness without fever (T <38.5C), C),
family history of any adverse events following family history of any adverse events following
immunisation, immunisation,
past history of convulsions, past history of convulsions,
treatment with antibiotics, treatment with antibiotics,
treatment with locally acting (inhaled or low treatment with locally acting (inhaled or low- -dose dose
topical) steroids, topical) steroids,
replacement corticosteroids, replacement corticosteroids,
asthma, eczema, atopy, hay fever or 'snuffles', asthma, eczema, atopy, hay fever or 'snuffles',
previous pertussis previous pertussis- -like illness, measles, rubella, like illness, measles, rubella,
mumps or meningococcal disease, mumps or meningococcal disease,
False contraindications to vaccination False contraindications to vaccination
prematurity (vaccination should not be postponed), prematurity (vaccination should not be postponed),
history of neonatal jaundice, history of neonatal jaundice,
low weight in an otherwise healthy child, low weight in an otherwise healthy child,
any neurological conditions including cerebral palsy and any neurological conditions including cerebral palsy and
Down syndrome, Down syndrome,
contact with an infectious disease, contact with an infectious disease,
child's mother is pregnant, child's mother is pregnant,
child to be vaccinated is being breastfed, child to be vaccinated is being breastfed,
woman to be vaccinated is breastfeeding, woman to be vaccinated is breastfeeding,
recent or imminent surgery, recent or imminent surgery,
poorly documented vaccination history. poorly documented vaccination history.
Catch up guidelines Catch up guidelines
Vaccine doses should not be administered at less than Vaccine doses should not be administered at less than
the recommended minimum interval the recommended minimum interval
n exceptional circumstances, where early vaccination n exceptional circumstances, where early vaccination
is required, minimum age at which the first dose of a is required, minimum age at which the first dose of a
vaccine may be given. vaccine may be given.
Doses administered earlier than the minimum interval Doses administered earlier than the minimum interval
should not be considered as valid doses and should be should not be considered as valid doses and should be
repeated as appropriate repeated as appropriate
When commencing the catch When commencing the catch- -up schedule, the up schedule, the
standard scheduled interval between doses may be standard scheduled interval between doses may be
reduced or extended, and the numbers of doses required reduced or extended, and the numbers of doses required
may reduce with age. For example, from 15 months of may reduce with age. For example, from 15 months of
age, only 1dose of (any) Hib vaccine is required age, only 1dose of (any) Hib vaccine is required..
Catch up guidelines Catch up guidelines
As a child gets older, the recommended number of vaccine doses may As a child gets older, the recommended number of vaccine doses may
change change
(or even be omitted from the schedule), as the child becomes less vulnerable (or even be omitted from the schedule), as the child becomes less vulnerable
to specific diseases. to specific diseases.
For incomplete or overdue vaccinations, build on the previous documented For incomplete or overdue vaccinations, build on the previous documented
doses. doses.
Never start the scheduIe again, regardIess of the intervaI since the Iast Never start the scheduIe again, regardIess of the intervaI since the Iast
dose. dose.
f more than 1 vaccine is overdue, 1 dose of each due or overdue vaccine f more than 1 vaccine is overdue, 1 dose of each due or overdue vaccine
should be given now. Further required doses should be scheduled after the should be given now. Further required doses should be scheduled after the
appropriate minimum interval appropriate minimum interval
A catch A catch- -up schedule may require multiple vaccinations at a visit. Give all the up schedule may require multiple vaccinations at a visit. Give all the
due vaccines at the due vaccines at the 8,20 8,20visit visit do not defer. do not defer.
Catch up guidelines Catch up guidelines
The standard intervals and ages recommended The standard intervals and ages recommended
in the NP schedule should be used once the in the NP schedule should be used once the
child or adult is up child or adult is up- -to to- -date with the schedule date with the schedule
Some individuals will require further doses of Some individuals will require further doses of
antigens that are available only in combination antigens that are available only in combination
vaccines. n general, the use of the combination vaccines. n general, the use of the combination
vaccine(s) is acceptable, even if this means the vaccine(s) is acceptable, even if this means the
number of doses of another antigen number of doses of another antigen
administered exceeds the required number. administered exceeds the required number.
The cuddIe position for vaccination of a chiId
<12 months of age
Positioning an infant on an examination tabIe
for vaccination
Positioning an oIder chiId in the cuddIe
position
Positioning a chiId in the straddIe position
Diagram of the muscIes of the thigh showing the anatomicaI
markers to identify the recommended (vastus IateraIis) injection site (X)
Photograph of the thigh showing the recommended (vastus
IateraIis) injection site (X)
Photograph with infant prone across carer's Iap, showing markers
to identify the ventrogIuteaI injection site
Diagram showing the anatomicaI markers to identify the deItoid
injection site
A subcutaneous injection into the deItoid area of the upper arm
using a 25 gauge, 16 mm needIe, inserted at a 45 angIe
What is the efficacy of DPT injections? What is the efficacy of DPT injections?
f DPT vaccination is given at the proper and at right f DPT vaccination is given at the proper and at right
intervals, then more then 80% efficacy has been intervals, then more then 80% efficacy has been
observed against pertussis. The efficacy is over 95% observed against pertussis. The efficacy is over 95%
against diphtheria and tetanus. against diphtheria and tetanus.
If first does of DPT is given at the right time If first does of DPT is given at the right time
i.e. at 6 weeks of age and there is a Iapse of i.e. at 6 weeks of age and there is a Iapse of
more then 6 months for the second does, is more then 6 months for the second does, is
there any need for restarting the series once there any need for restarting the series once
again or onIy second then third does is to be again or onIy second then third does is to be
given ? given ?
There is no need to restart the series of D.P.T. There is no need to restart the series of D.P.T.
vaccine if any of the vaccine doses is missed, vaccine if any of the vaccine doses is missed,
irrespective of the lapsed interval, as the irrespective of the lapsed interval, as the
immunological memory once induced is never immunological memory once induced is never
lost. Only the remaining doses i.e.2nd and 3rd lost. Only the remaining doses i.e.2nd and 3rd
doses are to be given. doses are to be given.
Why shouId DPT be given deep IntramuscuIar Why shouId DPT be given deep IntramuscuIar
injection? injection?
Deep intramuscular injection causes less local reaction. Deep intramuscular injection causes less local reaction.
Do you recommend first dose of antipyretic to Do you recommend first dose of antipyretic to
be given at the time of injection? be given at the time of injection?
No. Not routinely. Paracetamol (15mg/kg/dose) Should No. Not routinely. Paracetamol (15mg/kg/dose) Should
be advised to be taken as and when the child has fever. be advised to be taken as and when the child has fever.
t may be preferable to give paracetamol at the first time t may be preferable to give paracetamol at the first time
of injection itself, to a child with personal or family history of injection itself, to a child with personal or family history
of convulsive disorders. of convulsive disorders.
Is there a different ScheduIe for vaccination Is there a different ScheduIe for vaccination
of maInourished chiIdren? of maInourished chiIdren?
No, studies have clearly shown that even severely No, studies have clearly shown that even severely
malnourished children are capable of adequate malnourished children are capable of adequate
immunological response to DPT vaccine immunological response to DPT vaccine. .
Can BCG, DPT, and poIio be administered Can BCG, DPT, and poIio be administered
simuItaneousIy in case the infant has simuItaneousIy in case the infant has
reported for the first time, say at the age of 2 reported for the first time, say at the age of 2
months? months?
es there is no harm in giving these vaccines on the es there is no harm in giving these vaccines on the
same day. This in fact will be preferable same day. This in fact will be preferable..
Which other vaccines can simuItaneousIy be Which other vaccines can simuItaneousIy be
administered with DPT & which vaccines can administered with DPT & which vaccines can
not be given? not be given?
Any EP vaccine except typhoid vaccine can be Any EP vaccine except typhoid vaccine can be
administered simultaneously with DPT but at separate administered simultaneously with DPT but at separate
sites. sites.
A chiId of convuIsive disorder is on reguIar A chiId of convuIsive disorder is on reguIar
doses of anticonvuIsant. Can this chiId be doses of anticonvuIsant. Can this chiId be
given DPT, or shouId DT be given in such given DPT, or shouId DT be given in such
cases? cases?
DPT can be given if the child is already on DPT can be given if the child is already on
anticonvulsants and the convulsions are well controlled. anticonvulsants and the convulsions are well controlled.
The child should receive antipyretics at the time of The child should receive antipyretics at the time of
injection. DT is to be given if the seizures are not injection. DT is to be given if the seizures are not
controlled controlled..
ShouId 'precious' chiIdren be given DT ShouId 'precious' chiIdren be given DT
instead of DPT (to avoid the possibIe instead of DPT (to avoid the possibIe
adverse effects of DPT) adverse effects of DPT)
Every child is precious, moreover, if the child is Every child is precious, moreover, if the child is
'precious' there is more reason to give him DPT rather 'precious' there is more reason to give him DPT rather
than DT. Remember the complication with pertussis than DT. Remember the complication with pertussis
vaccine are far less than those with natural disease. vaccine are far less than those with natural disease.
A two years oId chiId has recovered from A two years oId chiId has recovered from
whopping cough. A primary series of whopping cough. A primary series of
vaccination is to be started. ShouId DPT or vaccination is to be started. ShouId DPT or
DT be given in such a case? DT be given in such a case?
A natural infection with pertussis does not ensure A natural infection with pertussis does not ensure
protection against future attacks of whooping cough. protection against future attacks of whooping cough.
Therefore DPT should be given to this child. No adverse Therefore DPT should be given to this child. No adverse
reactions are expected. reactions are expected.
A chiId suffered. From concvuIsions after the A chiId suffered. From concvuIsions after the
first dose of DPT. Can second dose of DPT be first dose of DPT. Can second dose of DPT be
given safeIy to this chiId or shouId DT be given in given safeIy to this chiId or shouId DT be given in
future in such cases? OR shouId DPT be given future in such cases? OR shouId DPT be given
under cover of anticonvuIsants? under cover of anticonvuIsants?
Second and successive doses should be DT and not DPT Second and successive doses should be DT and not DPT
t is not advisable to give DPT even under cover of t is not advisable to give DPT even under cover of
anticonvulsants. anticonvulsants.
Only convulsions occurring within 3 days of immunization, Only convulsions occurring within 3 days of immunization,
with or without fever should be considered to be due to DPT with or without fever should be considered to be due to DPT
vaccine vaccine..
A chiId became very sick (kept on screaming A chiId became very sick (kept on screaming
for 4 hours continuousIy) after first dose of for 4 hours continuousIy) after first dose of
DPT. What precautions shouId be used for DPT. What precautions shouId be used for
the next dose of DPT? the next dose of DPT?
Second and successive doses should be DT. As the Second and successive doses should be DT. As the
incidence of recurrence of persistent screaming is high if incidence of recurrence of persistent screaming is high if
DPT is again given. DPT is again given.
What are the contraindications to second & What are the contraindications to second &
successive doses of DPT? successive doses of DPT?
Second and successive doses of DPT are Second and successive doses of DPT are
contraindicated if any of the following complications contraindicated if any of the following complications
occur after the previous dose. occur after the previous dose.
Convulsions. Convulsions.
Encephalopathy. Encephalopathy.
Anaphylaxis Anaphylaxis
Hyporesponsive or Hypotensive (Shock like Hyporesponsive or Hypotensive (Shock like
syndrome) episode. syndrome) episode.
Hyperpyrexia with fever, equal to or greater than Hyperpyrexia with fever, equal to or greater than
105* F 105* F
Persistent and high pitched crying for more than 3 Persistent and high pitched crying for more than 3
hours. hours.
Convulsions occurring within 72 hours and Convulsions occurring within 72 hours and
encephalopathy occurring within 7 days of DPT injection encephalopathy occurring within 7 days of DPT injection
should be attributed to DPT vaccine and be considered should be attributed to DPT vaccine and be considered
as contraindication to further doses of DPT. This time as contraindication to further doses of DPT. This time
frame is important if these reactions are be considered to frame is important if these reactions are be considered to
be due to DPT itself. be due to DPT itself.
A chiId has suffered from encephaIopathy A chiId has suffered from encephaIopathy
foIIowing DPT vaccination. ShouId DPT be foIIowing DPT vaccination. ShouId DPT be
given of not to the younger sibIing? Is there given of not to the younger sibIing? Is there
any genetic predisposition to adverse any genetic predisposition to adverse
reactions? reactions?
DPT can be safely given to the younger sibling of the DPT can be safely given to the younger sibling of the
child who developed encephalopathy following DPT child who developed encephalopathy following DPT
vaccination as there is no known genetic predisposition vaccination as there is no known genetic predisposition
to adverse reactions. to adverse reactions.
If after 2 years of age primary Immunization If after 2 years of age primary Immunization
is to be started then how many doses of is to be started then how many doses of
DPT/DT shouId be given. And what about DPT/DT shouId be given. And what about
booster doses? booster doses?
f the child has come before 4 years of age, 3 doses of f the child has come before 4 years of age, 3 doses of
DPT should be given as usual, followed by one booster DPT should be given as usual, followed by one booster
after 3 years of first booster if the child is still below 6 after 3 years of first booster if the child is still below 6
years of age. f the child is more than 6 years of age then years of age. f the child is more than 6 years of age then
two primany doses of DT and one booster needs o be two primany doses of DT and one booster needs o be
given given
any doctors give a dose of TT after every any doctors give a dose of TT after every
triviaI injury. Is this justified? triviaI injury. Is this justified?
No. t will be determined by the immune status of the No. t will be determined by the immune status of the
individual i.e. Whether the child as received tetanus individual i.e. Whether the child as received tetanus
toxoid as DPT, DT or TT and in how many doses. The toxoid as DPT, DT or TT and in how many doses. The
accompanying table gives the guidelines for rational use accompanying table gives the guidelines for rational use
of TT and TG. of TT and TG.
Type of wound Type of wound Clean wound Clean wound Other Wounds Other Wounds
Vaccination Vaccination
Status Status
TT TG TT TG TT TG TT TG
Unknown or <3 Unknown or <3
Doses Doses
es No es No es es es es
3 or more 3 or more
Doses Doses
No No No No No No No No
es if last dose has been given more than 5 years above
Tetanus toxoid is a strong immunogenic agent and Tetanus toxoid is a strong immunogenic agent and
immunity once achieved, lasts for 5 immunity once achieved, lasts for 5- -10 years and hence 10 years and hence
routine boosters are not required earlier than 10 years. routine boosters are not required earlier than 10 years.
However in cases of deep wounds (e.g burns. trauma) However in cases of deep wounds (e.g burns. trauma)
the levels of antitoxin may be inadequate even 5 yre the levels of antitoxin may be inadequate even 5 yre
after the last dose of TT. n such cases a booster may after the last dose of TT. n such cases a booster may
be given if the gap been 5 or more years. be given if the gap been 5 or more years.
Is there any hazard of giving unnecessary Is there any hazard of giving unnecessary
doses of TT? doses of TT?
es, repeated doses of tetanus toxoid administration es, repeated doses of tetanus toxoid administration
may lead to adverse side reactions and theoretically may lead to adverse side reactions and theoretically
decreased immunity. decreased immunity.
A 5 year oId unvaccinated chiId has been A 5 year oId unvaccinated chiId has been
brought with a contaminated accidentaI brought with a contaminated accidentaI
wound. What shouId be done? wound. What shouId be done?
One dose of DPT to be given immediately and repeated One dose of DPT to be given immediately and repeated
6 6- -8 wks later followed by booster 6 months later. n 8 wks later followed by booster 6 months later. n
addition, tetanus immunoglobulin (TG) should also be addition, tetanus immunoglobulin (TG) should also be
administered at the time of injury in the dose of 250 units administered at the time of injury in the dose of 250 units
.M. .M.
A 6 months oId unvaccinated chiId is to A 6 months oId unvaccinated chiId is to
undergo emergency surgery. Does the chiId undergo emergency surgery. Does the chiId
protection against tetanus protection against tetanus??
There is no role of giving DPT or DT immediately before There is no role of giving DPT or DT immediately before
an emergency surgery to an unvaccinated child as a an emergency surgery to an unvaccinated child as a
minimum of 2 weeks time is required to produce minimum of 2 weeks time is required to produce
antibodies for protection against the disease. f asepsis antibodies for protection against the disease. f asepsis
cannot be ensured then TG may be given. cannot be ensured then TG may be given.
Does TIG interfere in deveIopment of Does TIG interfere in deveIopment of
immunity against tetanus if given immunity against tetanus if given
concurrentIy with tetanus toxoid? concurrentIy with tetanus toxoid?
No, but it should be given at separate sites and in two No, but it should be given at separate sites and in two
separate syringes. separate syringes.
A neonate has been successfuIIy treated for tetanus A neonate has been successfuIIy treated for tetanus
neonatorum. ShouId this situations or coryza? neonatorum. ShouId this situations or coryza?
es, because tetanus infection does not lead to es, because tetanus infection does not lead to
development of immunity against future infection development of immunity against future infection..
It is aIways the pertussis fraction which is It is aIways the pertussis fraction which is
bIamed for reactions. What is there in the bIamed for reactions. What is there in the
pertussis fraction which creates aII the pertussis fraction which creates aII the
probIems? probIems?
Presently available pertussis is a whole cell vaccine Presently available pertussis is a whole cell vaccine
which contains many antigenic components which are which contains many antigenic components which are
toxigenic and immunogenic. This vaccine contains are toxigenic and immunogenic. This vaccine contains are
both toxigenic and immunogenic. This vaccine contains both toxigenic and immunogenic. This vaccine contains
ymphocyte promoting factor (LPE) and filamentous ymphocyte promoting factor (LPE) and filamentous
haemagglutination antigen (FHA) Which are responsible haemagglutination antigen (FHA) Which are responsible
for reactions. LPF is responsible for local reactions. for reactions. LPF is responsible for local reactions.
Can preterm chiIdren aIso be given OPV at Can preterm chiIdren aIso be given OPV at
birth? birth?
As far as immunological apparatus is concerned, the As far as immunological apparatus is concerned, the
preterms should guite capable of reacting to OPV like preterms should guite capable of reacting to OPV like
normal newborns. The preterms should be immunized as normal newborns. The preterms should be immunized as
per their chronological age like any other new born. But per their chronological age like any other new born. But
babies still in hursery should not be given OPV as it can babies still in hursery should not be given OPV as it can
then spread to other susceptible hospitalized individuals then spread to other susceptible hospitalized individuals
and can even cause paralytic poliomyelitis in them. and can even cause paralytic poliomyelitis in them.
AccidentaIIy I have given 7 AccidentaIIy I have given 7- -8 drops of oraI 8 drops of oraI
poIio vaccine instead of 2 drops to an infant poIio vaccine instead of 2 drops to an infant
What compIications are anticipated? What compIications are anticipated?
There is no risk administration of a higher dose of OPV There is no risk administration of a higher dose of OPV
but should use only the recommended dose. but should use only the recommended dose.
Clinical experience tells that mild diarrhea may occur in Clinical experience tells that mild diarrhea may occur in
these cases. these cases.
TiII what age poIio vaccination may be TiII what age poIio vaccination may be
given? In other words, after what age poIio given? In other words, after what age poIio
vaccination is not required? vaccination is not required?
n developing countries, with very high chances of n developing countries, with very high chances of
orofecal contamination, due to unsatisfactory sanitary orofecal contamination, due to unsatisfactory sanitary
conditions, the administration of polio vaccine is usually conditions, the administration of polio vaccine is usually
unwarranted beyond the age of 5 years unwarranted beyond the age of 5 years..
Which vaccines can be given concurrentIy Which vaccines can be given concurrentIy
with OPV and which vaccines can not be with OPV and which vaccines can not be
given concurrentIy with OPV? given concurrentIy with OPV?
Any vaccine can be given concurrently with OPV Any vaccine can be given concurrently with OPV
What shouId be done to protect What shouId be done to protect
chiIdren during poIio epidemic? chiIdren during poIio epidemic?
All under All under 5 year children should be given one dose of 5 year children should be given one dose of
OPV (irrespective of their immunization status). DPT and OPV (irrespective of their immunization status). DPT and
other intra other intra- -muscular injections and surgical operations muscular injections and surgical operations
like tonsillectomy should be withheld during an epidemic like tonsillectomy should be withheld during an epidemic
and pupic awareness should be created to prevent and pupic awareness should be created to prevent
orofecal transmission of poliovirus. orofecal transmission of poliovirus.
Can poIio vaccine (OPV) be given to Can poIio vaccine (OPV) be given to
chiIdren on steroid therapy chiIdren on steroid therapy
(compromised hosts)? (compromised hosts)?
OPV should not be given in immunocompromised OPV should not be given in immunocompromised
patients and chidren receiving daily steroid therapy in patients and chidren receiving daily steroid therapy in
high doses. high doses.
OPV should be given in such cases. OPV should be OPV should be given in such cases. OPV should be
avoided not only in such indiuals, but even in their close avoided not only in such indiuals, but even in their close
contacts. contacts.
Can poIio vaccine be given to a chiId Can poIio vaccine be given to a chiId
suffering from AIDS or who is in cIose suffering from AIDS or who is in cIose
contact with such a patient? contact with such a patient?
There is a generalized depression of immunity in patients There is a generalized depression of immunity in patients
with ADS and hence knowing the capacity of OPV to with ADS and hence knowing the capacity of OPV to
produce paralytic poliomyelitis in immunocompromised produce paralytic poliomyelitis in immunocompromised
hosts (or family contacts) it would be logical not to give hosts (or family contacts) it would be logical not to give
OPV to such cases. However on reaction has been OPV to such cases. However on reaction has been
observed in a few cases of ADS who have been observed in a few cases of ADS who have been
accidently given OPV in USE. Nevertheles it is prudent accidently given OPV in USE. Nevertheles it is prudent
to avoid OPV and instead to give PV in such cases. to avoid OPV and instead to give PV in such cases.
What are the contraindications to oraI poIIo What are the contraindications to oraI poIIo
vaccination? vaccination?
The main contraindications to OPV include acute fabrile The main contraindications to OPV include acute fabrile
illness, severe diarrhea, immunocompromised host and illness, severe diarrhea, immunocompromised host and
pregnancy. n all these cases. PV can be given if pregnancy. n all these cases. PV can be given if
required. required.
easIes vaccine is recommended to be given at the easIes vaccine is recommended to be given at the
age of 9 months. Good number of chiIdren get measIes age of 9 months. Good number of chiIdren get measIes
before the age of 9 months. Why can't it be given at before the age of 9 months. Why can't it be given at
earIier age say at 5 to 6 months ? earIier age say at 5 to 6 months ?
The measles vaccine can't be given at 5 to 6 months The measles vaccine can't be given at 5 to 6 months
because of the poor serocoversion response at this age because of the poor serocoversion response at this age
(upto 50 (upto 50- -60%) as compared to 90% when given at 9 60%) as compared to 90% when given at 9
months or later. The passively acquired maternal antibodies months or later. The passively acquired maternal antibodies
against measles persist in infants upto 7 against measles persist in infants upto 7- -8 months of age 8 months of age
which interfere with the successful take of the vaccine at which interfere with the successful take of the vaccine at
earlier ages. earlier ages.
A A Child of 6 to 9 months of age should also be given Child of 6 to 9 months of age should also be given
measles vaccine, (i) during an epidemic (ii) during the measles vaccine, (i) during an epidemic (ii) during the
measles season (usually January to May) or (iii) on measles season (usually January to May) or (iii) on
exposure to a case of Measles (within 72 hours) These exposure to a case of Measles (within 72 hours) These
infants would however require a booster (Measles or MMR) infants would however require a booster (Measles or MMR)
between 15 to 18 months of age between 15 to 18 months of age..
If the measIes vaccine is given at the right If the measIes vaccine is given at the right
time (9 months) is there any need for time (9 months) is there any need for
repeating another dose ? repeating another dose ?
There is no need for repeating another dose of measles There is no need for repeating another dose of measles
vaccine if the first dose is given at or after 9 months. The vaccine if the first dose is given at or after 9 months. The
immunity persists for 15 years as has been shown by immunity persists for 15 years as has been shown by
many prospective studies. many prospective studies.
A booster of measles is not usually required after a A booster of measles is not usually required after a
primary dose of measles vaccine given at or after 9 primary dose of measles vaccine given at or after 9
months. However 10 months. However 10- -15% of such children fail to 15% of such children fail to
seroconvert and may benefit from a second dose. f seroconvert and may benefit from a second dose. f
available MMR may be given at 15 available MMR may be given at 15- -18 months of age. 18 months of age.
Besides ensuring seroconversion against measles in Besides ensuring seroconversion against measles in
those who failed to seroconvert with the first dose, it will those who failed to seroconvert with the first dose, it will
also protect against Mumps and Rubella. also protect against Mumps and Rubella.
Can measIes occur after measIes Can measIes occur after measIes
immunization? immunization?
es Measles can occasionally occur even after es Measles can occasionally occur even after
measles vaccination. measles vaccination.
The reasons for suffering from measles after The reasons for suffering from measles after
vaccination may be: vaccination may be:
mmunisation at for very early age i.e. at 6 months or mmunisation at for very early age i.e. at 6 months or
earlier. earlier.
Use of expired or impotent vaccine. Use of expired or impotent vaccine.
Not maintaining the proper cold chain and Not maintaining the proper cold chain and
precautions. precautions.
True vaccine failures of around 10 True vaccine failures of around 10- -15% 15%
Simultaneous administration of immunoglobulings. Simultaneous administration of immunoglobulings.
Administration in immunosuppressed or congeni tally Administration in immunosuppressed or congeni tally
immunodeficient individuals immunodeficient individuals
A chiId has aIready suffered from doubtfuI A chiId has aIready suffered from doubtfuI
measIes. ShouId this chiId be given measIes measIes. ShouId this chiId be given measIes
vaccine? vaccine?
es. There is no adverse reaction expected in such a es. There is no adverse reaction expected in such a
case following vaccination. case following vaccination.
What shouId be done to contacts of What shouId be done to contacts of
measIes? RecentIy measIes vaccine is being measIes? RecentIy measIes vaccine is being
recommended for prevention of measIes in recommended for prevention of measIes in
househoId contacts. What areyour views on househoId contacts. What areyour views on
this? WiII you prefer this over this? WiII you prefer this over
gammagIobuIins? gammagIobuIins?
Measles vaccine is recommended for prevention of Measles vaccine is recommended for prevention of
measles in susceptible household contacts only if it can measles in susceptible household contacts only if it can
be given within 72 hours of exposure. After that time be given within 72 hours of exposure. After that time
only gammaglobulin is not presently available in our only gammaglobulin is not presently available in our
country. country.
A 3 months oId infant is in contact with A 3 months oId infant is in contact with
his eIder sibIing who is suffering from his eIder sibIing who is suffering from
measIes. Does this chiId need measIes. Does this chiId need
prevention? prevention?
No, nfants upto No, nfants upto- -5 5- -6 months of age have 6 months of age have
adequate levels of maternally derived measles adequate levels of maternally derived measles
antibodies which protect them against the antibodies which protect them against the
disease and hence such infants do not need any disease and hence such infants do not need any
immunoglobulins or vaccine for protection. immunoglobulins or vaccine for protection.
What are the absoIute contraindications of What are the absoIute contraindications of
measIes vaccine measIes vaccine??
The absolute contraindication are: The absolute contraindication are:
Leukemia, Hodgkin's disease or other malignant Leukemia, Hodgkin's disease or other malignant
conditions. conditions.
Congenital immunodeficiency states. Congenital immunodeficiency states.
Acute illnesses or active tuberculosis. Acute illnesses or active tuberculosis.
Anaphylactic sensitivity to hen's egg or neomycin. Anaphylactic sensitivity to hen's egg or neomycin.
Pregnant women. Pregnant women.
On theritical grounds measles vaccine should not On theritical grounds measles vaccine should not
be administered to pregnant women. However be administered to pregnant women. However
measles vaccine virus has not been shown to cross measles vaccine virus has not been shown to cross
the placenta and infect the foetus the placenta and infect the foetus
Can measIes vaccine be given to a chiId who Can measIes vaccine be given to a chiId who
has received bIood transfusion a week back? has received bIood transfusion a week back?
deally measles vaccine should not be given not be given deally measles vaccine should not be given not be given
for upto 6 weeks following a blood transfusion. for upto 6 weeks following a blood transfusion.
Can measIes vaccine be given to a chiId with Can measIes vaccine be given to a chiId with
active tubercuIosis? active tubercuIosis?
No, it should not be given to a child with active No, it should not be given to a child with active
tuberculosis as it may further flare up the disease. tuberculosis as it may further flare up the disease.
BCG VACCNE BCG VACCNE
Contents Contents 0.1 to 0.4 million viable Bacilli/ dose 0.1 to 0.4 million viable Bacilli/ dose
deal age deal age At birth or at earliest contact At birth or at earliest contact
Booster Booster Not recommended but can be given to Mx Not recommended but can be given to Mx
negative > 5 years negative > 5 years
Route and Site Route and Site ntradermal ntradermal Lt upper arm Lt upper arm
Storage Storage- - 2 to 8 c in the middle compartment of the 2 to 8 c in the middle compartment of the
refrigerator refrigerator
BCG at birth may not produce any BCG at birth may not produce any
immunity. Is this true ? immunity. Is this true ?
This is not true. t has been shown that cell mediated This is not true. t has been shown that cell mediated
immune response (CMR) could be induced in a immune response (CMR) could be induced in a
comparable proportion of cases at birth (78.2%) and at 3 comparable proportion of cases at birth (78.2%) and at 3
months of age (72.5%). t is, therefore, considered that months of age (72.5%). t is, therefore, considered that
new borns are capable of evoking CMR at birth and the new borns are capable of evoking CMR at birth and the
practice of giving BCG at birth should be continued practice of giving BCG at birth should be continued..
Can preterm babies be vaccinated at birth? If Can preterm babies be vaccinated at birth? If
so, is there any point (gestationaI age) beIow so, is there any point (gestationaI age) beIow
which vaccination is contraindicated? which vaccination is contraindicated?
BCG has been found to be effective in preterm infants BCG has been found to be effective in preterm infants
also. Dawodu et al (1985) showed a tuberculin also. Dawodu et al (1985) showed a tuberculin
conversion rate of 83% in a group of preterm, conversion rate of 83% in a group of preterm,
appropriate for gestational age newborns (32 appropriate for gestational age newborns (32- -36 wks). 36 wks).
However, small for gestational age babies have a poor However, small for gestational age babies have a poor
tuberculin conversion following BCG vaccination. tuberculin conversion following BCG vaccination.
I have given BCG today. What shouId I teII I have given BCG today. What shouId I teII
the mother who asked me whether she can the mother who asked me whether she can
bathe the chiId today? bathe the chiId today?
Since the wheal settles in 20 Since the wheal settles in 20- -30 minutes after 30 minutes after
vaccination, the mother can bathe the child the same vaccination, the mother can bathe the child the same
day day..
How Iong after BCG inocuIation does mantoux test How Iong after BCG inocuIation does mantoux test
become positive? become positive?
Taking responses of 5 Taking responses of 5- -6 mm as 'converted' in the case 6 mm as 'converted' in the case
of newbors,90% of the conversions will have occurred of newbors,90% of the conversions will have occurred
by six weeks. by six weeks.
which vaccines can be given concurrentIy with BCG which vaccines can be given concurrentIy with BCG
and which vaccines shouId not be given and which vaccines shouId not be given
simuItaneousIy with BCG ? simuItaneousIy with BCG ?
BCG can be given with OPV or DPT at the same time. BCG can be given with OPV or DPT at the same time.
Measles and MMR should not be given with BCG. Measles and MMR should not be given with BCG.
Hepatitis B Vaccine Hepatitis B Vaccine
Contents Contents 20 20 : : cg/ml of recombinant DNA vaccine cg/ml of recombinant DNA vaccine
deal age deal age 6, 10, 14 weeks 6, 10, 14 weeks
Dose Dose 0.5ml i.m at Anterolateral aspect of thigh 0.5ml i.m at Anterolateral aspect of thigh
Schedule Schedule
Perinatal Perinatal HBg 0.5 ml at Birth and HBV 0.5ml i.m within HBg 0.5 ml at Birth and HBV 0.5ml i.m within
seven days of birth and at 1 and 6 months seven days of birth and at 1 and 6 months
Accidental exposure 0.06 ml/kg ( maximum 5 ml ) of Accidental exposure 0.06 ml/kg ( maximum 5 ml ) of
HBig within 24 hrs after exposure. 1 ml of HBV at 0 HBig within 24 hrs after exposure. 1 ml of HBV at 0 - - 7 7
days and at 1 and 6 months days and at 1 and 6 months
Storage Storage- - 2 to 8 c at uppermost compartment of 2 to 8 c at uppermost compartment of
refrigerator refrigerator
Can AustraIia antigen positive mother breast Can AustraIia antigen positive mother breast
feed her infant? feed her infant?
es breast feeding can be given es breast feeding can be given..
What are the contraindications? What are the contraindications?
There are no specific contraindications. t can be used There are no specific contraindications. t can be used
even in pregnancy. Non specific contraindications even in pregnancy. Non specific contraindications
include severe febrile conditions and known include severe febrile conditions and known
hypersensitivity to any components of the vaccine. hypersensitivity to any components of the vaccine.
f an infant born to HBs Ag Positive mother f an infant born to HBs Ag Positive mother
how should the baby be protected how should the baby be protected
HBG 0.5 ml i.m to be given as soon as HBG 0.5 ml i.m to be given as soon as
possible possible
HBV to be given within seven days and to be HBV to be given within seven days and to be
repeated after 1 and 6 months interval repeated after 1 and 6 months interval
Adverse Events Following mmunisation Adverse Events Following mmunisation
Management of AEF Management of AEF
Anticipation and being prepared to handle anaphylaxis are the keys Anticipation and being prepared to handle anaphylaxis are the keys
for successful outcome for successful outcome
Being prepared includes Being prepared includes
i) availability all essential drugs and equipments to treat anaphylaxis i) availability all essential drugs and equipments to treat anaphylaxis
ii) skills to identify anaphylaxis ii) skills to identify anaphylaxis
iii) initiation of appropriate treatment and efficient referral iii) initiation of appropriate treatment and efficient referral
system system
Dos After mmunnisation Dos After mmunnisation
After mmunisation keep the child in the After mmunisation keep the child in the
PHC for 1 hr under observation PHC for 1 hr under observation
nform the mother about the signs and nform the mother about the signs and
symptoms of anaphylaxis symptoms of anaphylaxis
nstruct the staff nurse/ care provider to nstruct the staff nurse/ care provider to
observe for anaphylaxis observe for anaphylaxis
Keep the emergency tray ready Keep the emergency tray ready