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Immunization: Basics & Newer Vaccines

Dr. Chandki Kishore Consulting Pediatrician

Center for Disease Control & Prevention (CDC-ACIP) publishes Childhood and Adolescent Immunization Schedules at least annually since 1995 Indian Academy of Pediatrics (IAP) revises the Immunization Schedule almost every 3 years: Latest 2011 Many care givers/parents are not aware of importance of various vaccines/newer additions Parents may be mislead by media/peer groups

Shots Hurt! Why Do We Have To Give Them?

Shots Hurt! Why Do We Have To Give Them?

Shots Hurt! Why Do We Have To Give Them?

Enteric fever Hepatitis-A Hepatitis-B Miliary TB

Why vaccination rates low?

COST Confusing, conflicting vaccine schedules Need for a doctor visit & physical before giving a vaccine Office policies: no vaccine review, no vaccination at sick visits No easy way to track, and check vaccine status Over use of contraindications Many believe that natural infection confers better immunity, e.g. chicken pox

Shots Hurt! Why Do We Have To Give Them?

Vaccines work! Vaccines are THE most effective

preventive measure that modern medicine has derived

Immunization Schedule
Every country has its own immunization schedule because: Low prevalence of disease/not cost effective e.g. no BCG in US/UK Certain diseases are prevalent in particular age group, e.g. Measles at 9 mo; MMR in India given at 15 mo & 5 yrs. In UK at 13 yrs Suitability of preparations & disease prevalence. e.g. IPV instead of OPV in US/UK, influenza vaccine to all children in cold countries Operational convenience. e.g. In India DPT-Hib given at 6 weeks rather at 2 months Guidelines change: Hep-B booster at 5 years age was recommended earlier no longer now!

Immunization Schedule for Birth- 6 yrs: 2011

Immunization Schedule for 7 18 yrs: 2011

Immunity & Immunization

IMMUNITY INNATE (Inborn/Natural)
Nonspecific/specific (Species, racial, individual)


ACTIVE (Own antibodies)

PASSIVE (Ready-made Ab)

NATURAL Maternal Ab, Colostrum ARTIFICIAL e.g. TIG, RIG

NATURAL By infection

ARTIFICIAL By immunization

Immunization can be active/passive, Vaccination is always active. Vaccination does NOT guarantee immunization!

National Immunization Schedule: UIP (1985)


They were optional few years back?

$ MMR is available in some states only. $$ Hib is being introduced in two states to begin with

IAP Immunization Schedule-2007

Painless DPT

60-70% Efficacy

< 13 yrs: only one dose of chicken pox vaccine recommended

IAP Immunization Schedule-2008*

IAP Immunization Schedule-2011: LATEST

IAP Immunization Schedule-2011

IAP Immunization Schedule-2011

* OPV alone if IPV cannot be given *# Rotavirus vaccine (2/3 doses depending on the brand at 4-8 weeks interval) ** The third dose of Hepatitis B can be given at 6 months $ The second dose of MMR vaccine can be given at any time 4-8 weeks after the first dose $ $ Varicella (2nd dose may be given any time 3 months after the 1st dose) # Typhoid revaccination every 3 years & Tdap preferred to Td, followed by repeat Td every 10 years ^ Only females, three doses at 0, 1-2 (depending on brands) & 6 months

oIAP Schedule-2001: Additional vaccine: Hep-B, Hib,

MMR, Typhoid. Optional: Hep-A, Chicken Pox

Optional Vaccine?
o Optional = Vaikalpik/Aechhik, Not Swechchhik o Formerly: Hep-A, Hib & Varicella vaccine o Presently there is no compulsory vaccine in our

country! o For any Indian going to USA for study or job, MMR vaccine is mandatory. We do not have any mandatory vaccine, any person coming to our country gets Typhoid vaccine or Hepatitis A vaccine in his or her own interest oThe option is with the persons or the parents to go for a particular vaccine or not, at their own risk. The doctor should consider no vaccine as optional vaccine!
Indian Pediatrics 2001; 38: 99-101

Delayed Immunization

Common Mistakes
o Administration of two vaccines at short intervals:
weekly or after 15 days oAdministration of two vaccines simultaneously despite recommendation e.g. BCG with measles, MMR with chicken pox o Administration of vaccines at wrong site: e.g. giving Rabies/Hep-B vaccine at Hips, or DPT at hips in infants, Tetanus toxoid in hips in older children/adults o Failure to give good advice regarding vaccine e.g. Pneumococcal to SCA patient, Influenza to Asthmatics o Mixing of vaccines in the same syringe (prior to injection) unless specifically recommended by the manufacturer

Immunization: Facts
There is no age limit for immunization, even adults need vaccines for protection If the vaccination was discontinued or delayed, it should be started from where it was stopped. No need to repeat the doses! No need no give hepatitis-A vaccines if child had it once. But this does not apply to measles, mumps, tetanus, diphtheria, typhoid, etc Malnourished/underweight children also require timely vaccination Vaccination site should never be rubbed. It should be pressed for a minute!

Immunization: Facts
If the child had confirmed varicella or laboratory evidence of prior disease, it is not necessary to vaccinate regardless of age at infection. If there is any doubt that the illness was actually varicella, the child should be vaccinated. Children can be breastfed soon after giving oral polio vaccine Children with mild fever, cough, cold or diarrhea can take all the vaccines Pulse polio immunization is supplementary to routine vaccination Preterm babies should be given vaccination at usual age (except Hep-B when >2 Kg or > 1mo)

Tetanus Toxoid & Injury

oThere is no urgency for the administration of tetanus
toxoid in the acute setting, as it provides protection against the next injury and not the current injury. Persons discovered not to have completed the threeshot primary series should do so. oIt is not possible to clinically determine which wounds are tetanus prone, as tetanus can occur after minor, seemingly innocuous injuries, yet is rare after severely contaminated wounds. oGiving Tetanus toxoid with each injury or every 6 months: Not justified. If TT is given frequently, it will hyper-immunize the patient. Such a patient can develop arthus like phenomenon with development of fever, rash, joint pain, joint swelling etc.

Tetanus Toxoid & Injury

oA TT/dT should be administered if the history of the
last booster was > 10 years. If the history is not available, TT may be considered when convenient. oIf the history demonstrates that the last immunization was >10 years ago, then Tetanus Immune Globulin (TIG) should be administered. The severity of the wound should not be a factor in the administration of TIG. oTT: dT is preferred over TT at all times. Cold chain should be well maintained. Should be given 0.5 mL IM over deltoid!

Tetanus Toxoid & Injury

Completed Age 6 weeks 10 weeks 14 weeks 16-18 months 5 years 10 years Tetanus Vaccination DPT1 DPT2 DPT3 DPTB1 DPTB2 dT/tdaP
No need to give TT inBetween the DPT doses! However In case of injury, Dose of coming DPT can Be lowered e.g. DPTB1 can Be given as early as 15 mo, DPTB2 can be given as Early as 4 years!

dT/TT every 5-10 years thereafter!

Measles, Mumps, Rubella (MMR)

oMeasles is highly infectious & may cause
complications such as diarrhea, ear infections, pneumonia and encephalitis. oMumps is also infectious & can cause complications such as meningitis and deafness. It may also cause pancreatitis. In boys, it can cause orchitis & infertility. In girls, it can cause swelling of the ovaries. oRubella (German measles) is usually a mild illness however, it can be harmful to pregnant women. If women become infected in the first 16 weeks of pregnancy, its very likely to affect unborn baby. It can cause blindness, deafness, brain damage & heart damage to baby. Rubella can also lead to miscarriage. If become infected within 16 and 20 weeks of pregnancy, there is a risk that baby will be deaf. After 20 weeks, there is no increased risk. oMMR vaccine can prevent each of these illnesses!

Measles, Mumps, Rubella (MMR)

oIAP-COI recommends the use of MMR
vaccine instead of monovalent rubella vaccine so as to provide additional protection against Mumps and Measles oNo upper age limit oShould be given even if child had suffered from measles/mumps oIf child if above 1 year of age, not yet received measles vaccine, MMR can be given oDose is 0.5 mL Subcutaneous oVaccine can be given along with all other childhood vaccines except BCG

Measles, Mumps, Rubella (MMR)

oSeroconversion rates against Mumps are
more than 90% but clinical efficacy & long term protection with single dose is 60-90%. Hence two doses. oTwo doses are recommended: 12-15 months & second at school entry (4-6 years) or at any time 8 weeks after the first dose. oCatch up vaccination with two doses of the vaccine should be given to all those not previously immunized (with no upward age limit) and especially to HCV, adolescent girls & students traveling for studies oversea.

Storage at Clinic: Cold Chain

Storage at Clinic: Cold Chain

Storage at Clinic: Cold Chain

TARGET 5: Guide on vaccine storage & handling: 1st Ed, Dec 2006, IAP SURAT

Storage at Clinic: Cold Chain

Spacing of Vaccines

Time limits for using vaccines after reconstitution

Vaccination Sites
Anterolateral thigh (vastus lateralis):
The infants nappy must be undone to ensure the injection site is completely exposed and the anatomical markers easily identified. Position the leg so that the hip and knee are flexed and the vastus lateralis is relaxed. The upper anatomical marker is the midpoint between the anterior superior iliac spine and the pubic tubercle, and the lower marker is the upper part of the patella. Draw an imaginary line between the 2 markers down the front of the thigh. The correct site for IM vaccination is lateral to the midpoint of this line, in the outer (anterolateral) aspect. Do not inject into the anterior aspect of the thigh where neurovascular structures can be damaged.

Vaccination Sites
Ventrogluteal area: [Do not confuse with the dorsogluteal area (buttock)] The ventrogluteal site provides an alternative site for administering vaccines to a child of any age, especially when multiple injections at the same visit are required. The ventrogluteal area is relatively free of major nerves and blood vessels, and the area provides the greatest thickness of gluteal muscle.25,26 There is a relatively consistent thinness of subcutaneous tissue over the injection site

Vaccination Sites
The deltoid area: It is essential to expose the arm completely from the top of the shoulder to the elbow when locating the deltoid site. Roll up the sleeve or remove the shirt if needed. The injection site is halfway between the shoulder tip (acromion) and the muscle insertion at the middle of the humerus (deltoid tuberosity). Draw an imaginary, inverted triangle below the shoulder tip, using the identified anatomical markers. The deltoid site for injection is the middle of the muscle (triangle) SC vaccines can also be administered over same region! Vaccination site should never be rubbed!

Vaccination: Positioning

Medicolegal Aspects
o The vaccine administrator must explain in detail the
characteristics and anticipated side effects of the vaccine in reasonable detail to the caregivers prior to immunization. o A verbal consent is usually adequate. In any case, the recipient must be observed for any allergic effects for at least 15 minutes after vaccination and all resuscitative equipment must be kept standby for possible anaphylaxis. The care givers should also be counseled about possible side effects, their management and danger signs before the vaccinee is sent home. o Minimum equipment: Airway, ambu bag, mask, IV access (scalp vein, venflon), O2 cylinder, Inj. Adr (1: 1000 sol.), IV hydrocortisone, Normal saline
Indian Academy of Pediatrics: Guidebook on Immunization, 2011

Anaphylaxis: Vaccination

Immunization for HCV

Not Your Parents Vaccine Schedule!

Birth 6 weeks 10 weeks 14 weeks 9 months 5 years 10 years 16 years Total

BCG + OPV DPT1 + OPV DPT2 + OPV DPT3 + OPV Measles DT TT TT 6 diseases, 9 shots

+ HB + HB + Hib + IPV + PCV + Rota + HB + Hib + IPV + PCV + Rota* Hib + IPV 12 mo: Hep-A, Varicella, MMR Hib + IPV, Hep-A2, 2 yrs: Typhoid DPT + Varicella2 + MMR2, Typhoid2 Tdap/dT, HPV for girls dT 16 diseases, 22 shots at least

18 months DPTB + OPV


Immunization: Q & A
Is there any need of documentation in case of refusal to vaccinate the child? Is it compulsory to wear gloves or change the needle while vaccinating the child? What should be done if child vomits the oral vaccine? What is the preferred site of vaccination for i/m injection or vaccination on children? What should be done if a 1 month old child accidentally given DPT? Is there any need of aspiration before injection of vaccines or toxoids?

Immunization: Q & A
What measures should be take to prevent anaphylaxis? Is there any need of rubbing the site after vaccination? What should be done if previous vaccination records are not available? What should be done if there is a long lapse of time between the doses? e.g. 2 years lapsed after 1st dose of HAV vaccine What should be the ideal time interval between various vaccine? Does it apply to oral vaccine (like OPV, Rota, Ty21a, Cholera) also?

Immunization: Q & A
What is the time limit to delay the vaccine from the scheduled date?