IMMUNIZATION

Definition
Vaccination :
 Is the process of administration of any vaccine or toxoid
(inactivated toxin) for prevention of a diseas
 One of the most beneficial and cost-effective disease-
prevention measures

Immunization
 The process of inducing immunity against a specific
disease by administration of antigen/antibody.
For most diseases of childhood preventable by vaccination,

incidence of most vaccine-preventable diseases of

childhood has been reduced by ≥99% from the annual
morbidity prior to development of the corresponding
vaccine.

IMMUNITY
The ability of the human body to tolerate the presence
of material indigenous to the body (“self”), and to
eliminate foreign (“nonself”) material
Indications for passive immunity
To provide protection to immunodeficient children
with B-lymphocyte defects .
Persons with an infectious disease as part of specific
therapy for that disease
Post exposure prophylaxis
HBV
Passive immunisation
Active Immunization
Vaccines are whole or parts of microorganisms
administered to prevent an infectious disease
Vaccines can induce immunity by stimulating
antibody formation, cellular immunity, or both
Protection induced by most vaccines is thought to be
mediated primarily by B lymphocytes, which produce
antibody
Most B-lymphocyte responses require the assistance
of CD4 helper T lymphocytes
T lymphocyte – dependent vaccines
• Includes protein moieties
• Induce high levels of functional antibody with high
avidity
• Mature over time from primarily an IgM response to
long-term persistent IgG
• Induce good immune responses even in young infants
• Immunologic memory leading to booster responses on
repeat exposure to the antigen.
T lymphocyte- independent vaccines
• Polysaccharide antigens
• Poor immune response in children < 2yr of age
• Induce B-lymphocyte response in the absence
of T-lymphocyte help
• short-term immunity
• lacks booster response
• To overcome problems of plain polysaccharide vaccines,
have been conjugated, or covalently linked, to protein
carriers, converting the vaccine to a T lymphocyte–
dependent vaccine
In contrast to plain polysaccharide vaccines, conjugate
vaccines:
• Induce higher avidity antibody
• Immunologic memory leading to booster responses on
repeat exposure to the antigen
• Long-term immunity
• Herd immunity by decreasing carriage of the organism.

E.g.
Hib and pneumococcal and
meningococcal vaccines
 Vaccination
• long-term protection
• cost-effective
antibody concentration

• safe

4 8 12 16 20 weeks
injection
of vaccine
The ideal vaccine
Benefits of vaccines
To prevent disease and/or its progression to severe
form at individual level.
(immediate)
To eradicate or eliminate the pathogen.
(ultimate)
Herd immunity
Herd immunity
Types of vaccines
Live-attenuated vaccines
Viral : measles, polio Sabin (OPV), mumps, rubella,
varicella, yellow fever, Rotavirus,
Bacterial : BCG, cholera, typhoïd fever
Whole inactivated (killed) microorganisms
Viral : polio Salk (IPV), hepatitis A, Rabies, Influenza
Bacterial : whole cell pertussis (DTPw)
Types of vaccines
Toxoids
Tetanus
Diphtheria

Combined vaccines
– DTPw-HepB (Tetra); DTPw-HepB/Hib (Penta)
– DTPw-HepB/Hib-MenAC (Hepta)
– DTPa-HepB-IPV/Hib
– Hib-MenC; Hib-MenCY; Hib-MenAC(W?)
– Men ACWY polysaccaride vaccines (MPSV4)
– MenACWY conjugate PS vaccines (MCV4)
– HepA/Vi; HepAHepB
Live-attenuated vaccines
Advantages

• Mimic natural infection

• Produce a large antigenic stimulus

• Generally induce T&B lymphocyte responses

• Provide long-lasting protection

Killed, inactivated vaccines
Disadvantages
• Often less effective than live-attenuated vaccines
• Several doses needed for long-term
protection
• Repeat administration may increase reactogenicity
• Limited production capacity & higher price
• sub-unit vaccines
– diphtheria, tetanus, pertussis toxoids
– purified acellular pertussis (Pa) components
– genetically engineered HBsAg, HPV, malaria
– polysaccharides (Typhoid fever, Men, Pneumo)
– conjugated polysaccharides (Hib, Men, Pneumo)
– split or sub-unit influenza vaccines H1N1, H3N2 (H5NI
Sub-unit vaccines
 Adjuvants

A substance (Aluminum salt) that is added during

production to increase the body’s immune response to
a vaccine
Adjuvants
Appear to restrict the dispersion of antigen from the
injection site.
May also modulate the immune response, triggering a
stronger Th2 type response resulting in higher levels of
antibodies.
Some recruit Th1 and cytolytic T cells (CTLs).
Some antigens can behave as adjuvants themselves.
The constituents of immunizing agents include:
Suspending fluid: simple as sterile water or saline,
but it may be a complex fluid containing small
amounts of proteins
Preservatives, stabilizers, antibiotics
To stabilize the antigen
Expanded Programme of Immunization
(EPI)/WHO
History
 1974: WHO proposed the principles of EPI with the
objective of vaccinating all children in the world.
 1984: First schedule was introduced by WHO with four
vaccines. BCG, DPT, Oral polio and measles.
 EPI schedule of Ethiopia

Schedule of immunization is designed according to

epidemiological terms of diseases together with
sociocultural &economic factors
In US as of 2006, infants, children, and adolescents
routinely are vaccinated against 16 diseases .
Since 2007, three doses of pentavalent vaccine (DPT –
HepB – Hib) are given in place of the three doses of
DPT vaccine.
Against 10 diseases in Ethiopia as of NOV. 7,2013)
Vaccination practice in Ethiopia
Recommendations
• children receive the complete schedule of vaccination
before their first birthday.
• children who are at least 1 month behind in their
immunizations, catch-up immunization schedules are
available
Ethiopian DHS report (2011)

Overall, 15 percent of children in Ethiopia have not

received any vaccination ( 24 % in 2005 report.)
Overall, 24 percent of children age 12-23 mon. are fully
vaccinated.
Regionally, children with full vaccination coverage
range from
79% in Addis Ababa
59% in Tigray and Dire Dawa
lowest of 9% in Afar.
Fully vaccinated child (WHO)
If he or she received a BCG vaccination against TB,Three

doses of DPT, at least three doses of polio vaccines, and

One dose of measles vaccines.
Injection sites

* = PCV 10 – 1,4,5,6B,7F,9V,14,18C,19F and

23F.
Methods of administration
EPI Delivery Strategies
Static: immunization performed as part of routine activity
of the Health units.
Outreach: an immunization approach in which the staffs
of health unit go out and administer vaccine to mothers
and children in their catchments areas.
Mobile: an immunization approach only single dose
vaccination (measles, BCG) in nomadic, settlement areas
and mostly used for controlling epidemics of measles.
Campaign: an immunization approach conducted by
mobilizing the community, example polio and measles
vaccination.
BCG (Bacille Calmette Guerin)
Freeze dried, live attenuated form of mycobacteria
( M. bovis)
Reduces/prevents severe form of Tb
Stored at 2to 8 oc and shouldn’t be frozen
Avoid sunlight exposure
Don’t use alcohol to clean the top of the vial as it
may kill the BCG
Give 0.05 ml of vaccine intradermal on the right
upper arm
Limits infection and hematogenous spread of the
disease.
Sensitive to heat and light
Efficacy as high as 80% for severe form of the disease
and 0-80% for pulmonary TB.
Given at birth of as soon as possible.
Site :- right upper arm
Small swelling at the site of injection with in 2weeks
and after a week it form a small abscess, ulcerate and
leaves a scar.
The scar has 2 uses
a.Witnesses the child is vaccinated
b.Good degree of immune response
 Other rare S/E
 Deep abscess and involvement of LN (axillary LAP
 Extension of infection to bones osteomyelitis
Pentavalent Vaccine
The Pentavalent vaccine combines five different
vaccines in one injection to protect against
Five diseases:
 Diphtheria
 Pertussis
 Tetanus
 Haemophilus influenzae type B (Hib) disease
 Hepatitis-B
Tetanus toxoid
It is inactivated by heat and freeze.
If the person has previously suffering from the disease,
he should be vaccinated.
Booster injection should be given after every 5-10yrs.
Efficacy:- >95% (>80% after 2 doses)
S/E :- extremely safe preparation
Diphteria toxoid
Damaged by freezing and heat.
Efficacy:- >80%
Duration of immunity: variable, probably around 5 yrs
S/E :- no significant adverse reaction have been
associated.
Pertussis vaccine
It is killed B. pertusis.
Sensitive to heat.
DPT( Pw) vs Pa (lesser reactogenicity)
Efficacy:- variable; around 80% for severe disease
Duration of immunity:- unknown
:- 4th and 5th doses at 12th
month and < 7 yr.(Pa)
Precaution
Fever (high grade), local soreness (3-4days), an abscess
at the site of injection, febrile convulsion 0.3-
9/100,000dose
Permanent brain damage, encephalitis (0.3-
0.6/100,000dose & shock like state are common
>6month age
Contraindications
Convulsion with in 3 days following vaccine.
Shock like state
High grade fever (400C)
Progressive neurologic deficit
Hepatitis B vaccine
It is inactivated product produced by genetic
engineering.
It protects the child against hepatitis B.
There is no S/E.
For a newborn delivered from HBSAg +ve mother it is
given together with immunoglobulin.
Haemophilus influenza type B
It consists of a capsular polysaccharide conjugated to a
protein.
Keep it at +20C -+80C, don’t freeze
Measls
Live attenuated measles virus.
Damaged by heat.
9month is the age if given earlier the maternal
antibody will damage the vaccine.
Some recommend the vaccine at the age of 6 month
because there is risk of acquiring virus at the age <
9months
Side effect
Fever (after 1wk) & a mild measles like rash self
limited.

Cause s of failure
a. Destroyed vaccine by improper storage
b. Sustained transplacental immunity that may remain
for up to 15months of age.
Polio vaccines
OPV, Oral (Sabin) and IPV, killed (Salk) Polio
Vaccine available
OPV used where wild polio virus circulates
Stored at 2to 8 oc
The only vaccine which can be frozen safely
Can be stored for years at -20

For one year at -10

• Two drops of the vaccine given orally
Only IPV can be used with symptomatic HIV
infection
Give an extra dose at later time when there is
diarrhea or vomiting
Oral Polio Virus
Live attenuated viruses of the 3 types (sabin).
It produce life long local intestinal & systemic
immunity.
Damaged by heat but not by freeze
Efficacy:- 72-98% in hot climates , lower protection
against type III.
S/E
Doesn’t have common S/E
Rarely poliomyelitis has been reported; 1 case/6.2
million doses.
Contraindication for vaccination
Practically there are no major CI for vaccination.
Child with symptomatic HIV infection (BCG and
‘Yellow fever’)
Precautions and contra-indications for vaccines are
based on three factors:
The risk of disease
The benefit of vaccination
The risk associated with vaccination
History of anaphylactic reactions following egg
ingestion (yellow fever vaccine and Influenza
vaccine).
Anaphylactic reaction following a dose of vaccine is a
true contraindication to subsequent dose of the same
vaccine.
(vaccinees should remain nearby for 30 minutes)
Convulsion with in 3 days following vaccine.
Progressive neurologic deficit.
NB. Any sick child who is able to go home after
treatment should get a vaccine.
Opv 0 should not be given after 2 weeks of age ( may
extend upto 6 weeks).
A child with diarrhea on the day when OPV to be
given should get the vaccine as the schedule but will
not be counted or documented.
Second dose of measles vaccine for high risk children
(sick and hospitalized ,outbreaks, refugee camps, etc.)
Post-exposure Immunoprophylaxis
Can prevent or ameliorate disease

Vaccine prevents or modifies disease if given within 72

hours of exposure.

Immune globulin (IG) prevents or modifies disease if

given within 6 days of exposure ( special
indications).
RABIS vaccine – active immunization combined with
passive immunization with rabies IG
Varicella-zoster immune globulin (VZIG)
 Indicated in:
 Immunocompromised who are exposed to varicella
 For newborns whose mothers has onset of chicken pox within 5
days before to 2 days after delivery
 Healthy susceptible children exposed to varicella (varicella vaccine
within 72 hrs of exposure)
Measles vaccine (given within 72 hrs) or immune globulin
(given with in 6 days) – can prevent or modify the disease
Others:treatment
 Tetanus in wound TRE
 Hepatitis A and B
Cold Chain
Is a system of different elements i.e human, material
and financial resources and certain norms and
standards that ensure high quality vaccines.
A system of storage & T0 maintained all the way b/n
the site of production & site of administration
Reversed cold chain
Defn
This is a special chain which starts from taking
specimens, preserving and transporting them from the
patient to the lab.
Cold chain equipment
Cold rooms
Vertical refrigerator
Chest refrigerator
Cold boxes
Vaccines carriers
Ice packs
Each vaccine has its own storage conditions
Acceptable proofs or indicators that show a
successful immunization programme:

BCG scar on the right shoulder

Completed immunization card
Immunization Problems
Drop out
Missed opportunities
Drop out
is defined as a child or a woman who failed to return
for subsequent doses for which he or she is eligible.
A child or a woman who discontinued the
immunization program should not have to restart the
immunization. There is no maximum interval between
two immunizations
Missed opportunities
Current policy is that all children and mothers at the
health facility for any reason should be screened for
immunization status and vaccinated if eligible.
Immunization should be routinely available on daily
basis in all health facilities.
Immunization should not be denied on the basis of
vaccine wastage.
Multiple antigens can be administered simultaneously.
Common causes of missed opportunities

Health workers do not know the policy

Health workers screen but tell patients to return later
Health workers only vaccinate women with TT if they
are pregnant
Health workers only vaccinate the index child, miss
the siblings
Health workers only open a vial if there are enough
clients who need it
Common causes of missed opportunities
False contraindications to immunization, example not
giving polio vaccine to a child with diarrhea
Logistical problems, such as vaccine shortages, poor
clinic organization, and inefficient clinic scheduling
The failure to administer simultaneously all vaccines
for which a child was eligible
Accessibility; time (women carry household
responsibilities), distance, cost of transportation
Acceptability: culture, rumors, beliefs, etc
REFERENCES
Nelson text book of pediatrics 20th edition
WHO EPI .
ETHIOPIA EPI GUIDLINES
THANK YOU!