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Curriculum Vitae

Nama : Dr. dr. Iris Rengganis, SpPD, K-AI, FINASIM


TTL : Jakarta, 29 June 1958
Pendidikan:
• DU/S1 : FKUI 1983
• Internis/S2: FKUI 1994
• Konsultan Alergi Imunologi: FKUI 2000
• Doctor/S3: IPB 2009
Riwayat Pekerjaan:
• Puskesmas Kel. Cikoko, Kec.Mampang Prapatan, DKI,1984-1988
• Jakarta Hajj Hospital, Pondok Gede, DKI, 1995-1997
• FKUI/RSCM, DKI, 1998-sekarang
• Ketua Divisi Alergi g dan Imunologig Klinik,, Dept.
p Ilmu Penyakit
y Dalam,,
FKUI/RSCM, September 2014-sekarang
Organisasi:
• Pengurus Besar IDI (Ikatan Dokter Indonesia)
g
• Pengurus Besar PAPDI ((Perhimpunan
p p
Spesialis y
Penyakit Dalam Indonesia))
• Ketua Pengurus Besar PERALMUNI (Perhimpunan Alergi Imunologi Indonesia)
• Anggota PERALMUNI JAYA
• Pengurus IIF (Indonesian Influenza Foundation)
gg WAO ((World Allergy
• Anggota gy Organization)
g )
• Board Member of APAAACI (Asia Pacific Association of Allergy, Asthma and Clinical
Immunology)
Vaccinology Workshop

Wh Ad
Why Adult
lt V
Vaccines
i are
Important

Iris Rengganis
Division of Allergy and Clinical Immunology
Department of Internal Medicine
Faculty of Medicine, University of Indonesia
Dr.Cipto Mangunkusumo Hospital
A History of Vaccine Development
Vaksinasi
V ksi si pada
d Dewasa
D s

Pierce G dan Schaffner


Kurangnya perhatian imunisasi usia dewasa karena:
Keraguan keamanan vaksin
G ti rugii yang tidak
Ganti tid k memadai
d i /asuransi
/ i
Belum berkembang sistem imunisasi dewasa
Vaksinasi

Adalah suatu cara untuk meningkatkan


kekebalan seseorang secara aktif
terhadap suatu antigen, sehingga bila kelak terpajan
pada antigen yang serupa, tidak terjadi penyakit.
Tujuan Vaksinasi
Untuk mencegah terjadinya
penyakit tertentu pada seseorang,
masyarakat/populasi atau bahkan
melenyapkan
y p p
penyakit
y tertentu dari
dunia seperti cacar.
Antigen
B-cell

Extra cellular CD4


Antibody
pathogens
production
T-helper cell
Activated
CD4 T-Helper 2-cell Memory
B-cell
B ll

CD4

Antigen-
A ti Intra
presenting cellular Activated
cell pathogens T-Helper 1-cell
Memory
T cell
T-cell

CD 8
TCR

Vaccine Cytotoxic
Antigen Activated
T-cell Virus-infected
Cytotoxic T-cell
Immunogenic
Target-cell
Antigen
B-cell

Extra cellular CD4


pathogens Antibody
production
p
T-helper cell
Activated
CD4 T-Helper 2-cell Memory
B-cell

CD4

Antigen- Intra
presenting cellular Activated
cell pathogens T-Helper 1-cell
Memory
T-cell

CD 8
TCR

Vaccine Cytotoxic
Antigen Activated
T-cell Virus-infected
Cytotoxic
y T-cell
Immunogenic
Target-cell
Bahan ACTIVE Bahan INACTIVE

Preservative
Antigen Adjuvant pengawet Stabilizer
St bili

• Mikroorganisme Memperkuat Mencegah Menjaga


yang dilemahkan vaksin- pertumbuhan efektifitas
atau dimatikan imunitas bakteri atau vaksin selama
• Komponen terinduksi fungi penyimpanan
antigen dari
mikroorganisme

Adapted from: Plotkin SA,Orenstein WA,


eds. Vaccines 3rd ed.;1999: 40-46
Imunisasi pasif
p dan aktif
Imunitas alami Imunitas artifisial

Aktif Pasif Pasif Aktif

Setelah Transfer Injeksi Pemaparan


Infeksi antibodi antibodi antigen
melalui
placenta Imunisasi Imunisasi
Pasiff Aktif
Imunisasi pasif
Kerugian :
Proteksi jangka pendek, tidak ada sel memori
Harga mahal
odi

Efek samping
Konsentrasi antibo

4 8 12 16 20 Minggu
Injeksi
Imunisasi Aktif / Vaksinasi
Keuntungan :
Proteksi jangka panjang
onsentrasi antibodi

Murah dan efektif


Aman
Ko

4 8 12 16 20 Minggu
Injeksi vaksin
Sifat
Sif t yang dibutuhkan
dib t hk vaksin
ki

Vaksin yang ideal :


I
Imunogenik
ik → meniru
i iinfeksi
f k i yang alami
l i
Memberikan proteksi jangka panjang
Tidak memberikan efek samping yang tinggi
Stabil
Various Types of Adult Vaccines
Type
yp of Vaccines
Vaksin virus
• Hidup yang dilemahkan
• Inaktif / dimatikan
• Sub unit

Vaksin bakteri
• Sel utuh
• Toxoid
• Sub-unit
• Polisakarida

Vaksin kombinasi (MMR)


( )
Klasifikasi Vaksin
Vaksin Bakteri Vaksin Virus

BCG Campak OPV


Parotitis
Vaksin Rubela Yellow
Hidup Varisela Fever
Influenza

Difteria Meningo HPV


Vaksin Tetanus Pneumo Infuenza
Inaktif Pertusis Hib Hepatitis A
Kolera Typhim
yp Vi Hepatitis B
Rabies
Adjuvants
Substance
S b t added
dd d tto many vaccines
i tto
increase their immunogenicity and efficacy

Aluminium salts (alum) have been widely used as adjuvants


and are generally considered safe

Aluminium salts have limitations in terms of adjuvant effect

Wide range of novel adjuvants now being evaluated for use in


new or improved
p vaccines: immunostimulators,,
microparticulate carriers and emulsions as well as various
combinations of these.

WHO website. Global Advisory Committee on Vaccine Safety; Adjuvants.


http://www.who.int/vaccine_safety/topics/adjuvants/en/index.html (Accessed Oct 2006)
Ajuvan
j
Respon Ajuvan
entasi antibodi
Konse

Respon Primer

2 4 6 8 10 Minggu
Vaksinasi
V k i i
Why Vaccinate ?

25
Vaccine
i Preventable Disease
i
Hepatitis A
Hepatitis A
Hepatitis B
Typhoid Fever
Varicella
Influenza
Meningococcal
Pneumococcal
26
GENERAL
RECOMMENDATION
IN VACCINATION
Principles of Vaccination

General Rule
General Rule
All vaccines can be administered at the 
same visit as all other vaccines
same visit as all other vaccines

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. 
National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.
Nonsimultaneous Administration of
Two Live Parenteral Vaccines

Administration of live vaccine should be given on same time.

Interference can occur between two live vaccines given less


than 28 days apart.

If two live p
parenteral vaccines ((MMR, MMRV, varicella, zooster,
yellow fever), or live intranasal influenza vaccine, are given less
than 28 days apart the vaccine given second should be repeated.

Exception is yellow fever vaccine given less than 4 weeks after


measles vaccine.

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. 
National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.
Principles of Vaccination

Increasing the interval between doses of a multidose
vaccine does not diminish the effectiveness of the vaccine*
Ex: Hepatitis B vaccine 0,1,6  Æ 0, 2, 6?

Decreasing the interval between doses of a multidose
vaccine may interfere with antibody response and 
protection
Ex: Hepatitis B vaccine 0,1,6  Æ 0,1,2?

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and 
Respiratory Diseases. CDC. Revised April 2009.
VACCINES
ADMINISTRATION
Prefilled Syringes
y g Samples
p
NEEDLES

Hub Glue Canula

Disposable Needle

Softpack needle

Needles conditioned by 5 into a


soft plastic packaging. They
Hardpack needle are used for syringe by 10
packs.
Sole needle conditioned into a
hard plastic packaging
packaging. They
are only used for syringe by
one packs.
NEEDLES

Needle size 23G1.


Diameter : 0.6 mm ; length
g : 25 mm.
Usually for adults and adolescents.

Needle size 25G5/8.


Diameter : 0.5 mm ; length : 16 mm.
Usuallyy for pediatric
p vaccines.

Needle size 25G1.


Diameter : 0.5 mm ; length : 25 mm.
Usually for paediatric vaccines.

Other needles may be used but these 3 needles are the more common ones
Vials Samples

Need to be reconstituted
Screening Questions Example
Is the child (or are you) sick today?
Does the child (or are you) have an allergy to any
medications, food, or any vaccine?
Has the child (or are you) had a serious reaction to a
vaccine in the past?
Is the child/teen (or are you) pregnant or is there a
chance she could become pregnant during the next
month?
Does the child (or are you) have cancer, leukemia, AIDS,
or any other immune system problem?

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. 
National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.
B b
Berbagai
i cara pemberian
b i vaksin
k i

- Intramuskular

- Subkutan
S bk t

- Intradermal

- Intranasal

- Oral
Subcutaneous injection

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Appendix D  Vaccine Administration. 
National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.
Intramuscular injection

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Appendix D  Vaccine Administration. 
National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.
VACCINE STORAGE &
HANDLING
Storing the Vaccines

CDC: Vaccine Storage and Handling Toolkit. Accessed 14th Oct 2009: 
http://www2a.cdc.gov/vaccines/ed/shtoolkit/
Managing Vaccine Storage

CDC: Vaccine Storage and Handling Toolkit. Accessed 14th Oct 2009: 
http://www2a.cdc.gov/vaccines/ed/shtoolkit/
Expiration Date (1)

Vaccine may be used up to and including the expiration date

Vaccine storage and handling toolkit. National Centre for Immunization and Respiratory Diseases. Vaccine
Inventory Management. Centers for Disease Control and Prevention. Downloaded at:
http://www2a.cdc.gov/vaccines/ed/shtoolkit/pages/inventory_management.htm ( Accessed 10 Nov 2009)
Expiration
p Date (2)
( )

EXP: EXP BY: EXP BEFORE:


10/2010 10/2010 10/2010

E i would
Expiry ld b
be E i would
Expiry ld b
be E i would
Expiry ld b
be
31/10/2010 30/9/2010 30/9/2010
Use through 31/10/2010 Use through 30/9/2010
DO NOT use on or DO NOT use on or after
ft 1/10/2010
after 1/11/2010

NHS. Vaccine Handling Recommendations for Clinics, Hospitals, Community Pharmacies and GP Practices July 2007.
Vaccine Transport
p
y Be sure to place an insulating barrier
between the refrigerated/ frozen packs
and the vaccines to prevent accidental
freezing.

y The llayer should


Th h ld be
b as follows
f ll
refrigerated/frozen packs-barrier-
vaccine-thermometer-barrier-
additional refrigerated/frozen packs.
packs

y Pack vaccines in their original packing


on top of the barrier.
barrier

y Do not remove vaccine vials from


boxes.

Vaccine Storage Practice in Vaccine Storage and Handling Tool Kit by NCIRD
Disposal
y Dispose of sharps immediately
after use at the point of care.
y Needles and syringes must be
disposed of as a single unit.
y Do not over fill the sharps bin or
fill beyond the fill line.
y L k and
Lock d tag the
h bibin to id
identify
if
the clinic source when full for
disposal.
p
y Full sharps bins must be stored in
a secure locked area away from
the public

Storage, Distribution and Disposal of Vaccines Policy. North East London NHS. June 2007
Unsafe Immunization Practices

WHO. Immunization Practice. Module 4:Ensuring safe injections ;2004


Vaccine Adverse Reactions

Adverse
Ad • extraneous effect caused by vaccine
• side effect
reaction • reactogenicity
g y

Adverse •

any event following vaccination
may be true adverse reaction

event •

may be
KIPI
b only
l coincidental
i id l

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. National Center 
for Immunization and Respiratory Diseases. CDC. Revised April 2009.
Vaccine Adverse Reactions

Allergic
◦ Due to vaccine or vaccine component
◦ Rare
◦ Risk minimized byy screeningg

Epidemiology and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. 
National Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.
Vaccine Adverse Events

Local Systemic
pain, swelling, fever, malaise,
redness at site headache
of injection

common with
inactivated nonspecific
vaccines

usually mild may be


and self- unrelated to
limited vaccine

Epidemiology and Prevention of Vaccine
Epidemiology and Prevention of Vaccine‐‐Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization 
and Respiratory Diseases. CDC. Revised April 2009.
HERD IMMUNITY
Keuntungan Vaksinasi
Melindungi individu
Melindungi komunitas – herd immunity (80%
yang divaksinasi dari populasi)
Menurunkan angka kesakitan dan kematian
Herd Immunity
y (1)
( )
Herd Immunity (2)
Herd Immunity (3)
Vaccines don't just protect yourself.
Most vaccine
vaccine--preventable diseases are spread from person to person. If one
person in a community gets an infectious disease, he can spread it to others who
are not immune.

But a person who is immune to a disease because she has been vaccinated
can’t get that disease and can’t spread it to others. The more people who are
vaccinated the fewer opportunities a disease has to spread
vaccinated, spread.
If one or two cases of disease are introduced into a community where most
people are not vaccinated, outbreaks will occur.
During
g a sneeze,, millions of tinyy droplets
p of
water and mucus are expelled at about 200
miles per hour (100 metres per second). The
droplets initially are about 10-
10-100 micrometres
diameter but they dry rapidly to droplet nuclei of
diameter,
1-4 micrometres,
micrometres, containing virus particles or
bacteria. This is a major means of transmission
of several diseases of humans

http://helios.bto.ed.ac.uk/bto/microbes/airborne.htm
Influenza IS NOT Common cold !!!
Presentation Influenza1 Common cold2
Clinical spectrum
p Systemic
y Local ((only
y on the
respiratory tract)

Onset Sudden Gradual

Fever Usually high Usually mild

Clinical manifestation Fever, chill, myalgia, Sneezing, nose


or presentation
t ti malaise,
l i cough,
h sore throat
th t bl k
blockage, sinusitis
i iti

Course of disease May be continuous Usually rapid and mild


Complications May be severe
severe, e.g.
eg Usually no or mild
pneumonia, exacerbation complications
of chronic disease
Severity of illness Tends to be more severe Usually mild
Adapted from:
1. Dolin R. Influenza. In: Kasper L et al, eds. Harrison Principles of Internal Medicine 16th Ed. McGraw-Hill 2000; 137: 1066-71
2. Dolin R. Common Viral Respiratory Infections and Severe Acute Respiratory Syndrome (SARS). In: Kasper L et al, eds. Harrison Principles of Internal
Medicine 16th Ed. McGraw-Hill 2000; 170: 1059-65
VACCINATION
INFORMATION
Kongres PAPDI di Manado 2003: Konsensus
Imunisasi Dewasa
Establishment of Adult Immunization Task Force
Vaccinology Training untuk dokter umum dan
spesialis
Buku panduan vaksinasi dewasa
Upaya meningkatkan vaksinasi

ƒ Meningkatkan kepedulian petugas


ƒ Meningkatkan kemampuan dan penyediaan vaksin
ƒ Vaksin murah, mudah dijangkau
ƒ P d
Pendanaan pemerintah
i t h - asuransii
ƒ Acara khusus
ƒ Memantau Program Imunisasi Nasional (PIN)
ƒ Penelitian dalam bidang pelaksanaan vaksinasi

Agar dampak imunisasi besar → pemutusan

rantai penularan → perlu vaksinasi massal


RECOMMENDATION
Klinik Imunisasi Dewasa

Gedung IRM, Ruang Prosedur Alergi Imunologi, RSCM


Varisela
Jl. Diponegoro No. 71, Jakarta Pusat
Ph / Fax 021-
021 3904546
e-mail : alergi@centrin.net.id
THANK YOU