Immunization

ImmunizationImmunization

ImmunizationImmunization

Dr.Khalid Hama salih,

Pediatrics specialist M.B.Ch.; D. C.H

F.I.B.M.S.ped

Historical point:Historical point:in 1796Edward Jenner’s use of material from in 1796Edward Jenner’s use of material from cowpox pustules to provide protection against cowpox pustules to provide protection against smallpox. smallpox. Louis Pasteur’s 1885 rabies vaccine was the next Louis Pasteur’s 1885 rabies vaccine was the next to make an impact on human diseaseto make an impact on human disease1923 dyphtheria1923 dyphtheria1926 pertusis1926 pertusis1955 IPV1955 IPV 1960 OPV 1960 OPV1964 Measles1964 Measles

Taking pus from a cowpox lesion on a milkmaid’s hand, Jenner inoculated an eight-year-old boy, James Phipps. Six weeks later Jenner variolated two sites on Phipps’s arm with smallpox, yet the boy was unaffected by this as well as subsequent exposures

ImmunityImmunity

Specific defensesImmunity

Passive immunityActive immunity

Following clinical infection

Following subclinical infection

Following vaccination Following administration ofImmunoglobulin or antiserum

Transfer of maternal Antibodies Through milk

Transfer of maternal Antibodies Through placenta

natural

acquired

Active immunityActive immunity

Resistance developed in response to stimulus Resistance developed in response to stimulus by an antigen (infecting agent or vaccine) and by an antigen (infecting agent or vaccine) and is characterized by the production of is characterized by the production of antibodies by the host.antibodies by the host.

Passive immunityPassive immunity

Immunity conferred by an antibody produced Immunity conferred by an antibody produced in another host. It may be acquired naturally or in another host. It may be acquired naturally or artificially (through an antibody-containing artificially (through an antibody-containing preparation).preparation).

immunizationimmunization: is the process by : is the process by which an individual's which an individual's immune system becomes fortified against an agent (known becomes fortified against an agent (known as the as the immunogen).through either active or).through either active orpassive immunizationpassive immunization

vaccination :is a process of live vaccination :is a process of live attenuated,inactivated,fractionate of attenuated,inactivated,fractionate of organismorganism

Immunizing agentsImmunizing agents

Immunizing agents

antiseraimmunuglobulinsvaccines

ImmunoglobulinsImmunoglobulins

There are 5 major classes: IgM, IgA, IgG, IgE, There are 5 major classes: IgM, IgA, IgG, IgE, IgD.IgD.

Two types of immunoglobulin preparations are Two types of immunoglobulin preparations are available for passive immunization:available for passive immunization: Normal human immunoglobulinNormal human immunoglobulin Specific (hyper-immune) human immunoglobulinSpecific (hyper-immune) human immunoglobulin

Antisera or antitoxinsAntisera or antitoxins

These are materials prepared in animals or non These are materials prepared in animals or non human sources such as horses.human sources such as horses.

Immunoglobulin and antiserumImmunoglobulin and antiserum

Human normal immunoglobulin

Human specific immunoglobulin

Non human ig (antisera)

Hepatitis A

Measles

Rabies

Tetanus

Mumps

Hepatitis B

Varicella

Diphtheria

Diphtheria

Tetanus

Gas gangrene

Botulism

Rabies

VaccinationVaccination

Vaccination is a method of giving antigen to Vaccination is a method of giving antigen to stimulate the immune response through active stimulate the immune response through active immunization.immunization.

A vaccine is an immuno-biological substance A vaccine is an immuno-biological substance designed to produce specific protection against a designed to produce specific protection against a given disease.given disease.

A vaccine is “antigenic” but not “pathogenic”.A vaccine is “antigenic” but not “pathogenic”.

Types of vaccinesTypes of vaccines

Live vaccinesLive vaccines Attenuated live vaccinesAttenuated live vaccines Inactivated (killed vaccines)Inactivated (killed vaccines) ToxoidsToxoids Polysaccharide and polypeptide (cellular Polysaccharide and polypeptide (cellular

fraction) vaccinesfraction) vaccines Surface antigen (recombinant) vaccines.Surface antigen (recombinant) vaccines.

Live vaccinesLive vaccines

Live vaccines are made from live infectious Live vaccines are made from live infectious agents without any amendment.agents without any amendment.

The only live vaccine is “Variola” small pox The only live vaccine is “Variola” small pox vaccine, made of live vaccinia cow-pox virus vaccine, made of live vaccinia cow-pox virus (not variola virus) which is not pathogenic but (not variola virus) which is not pathogenic but antigenic, giving cross immunity for variola.antigenic, giving cross immunity for variola.

Live attenuated (avirulent) vaccinesLive attenuated (avirulent) vaccines

Virulent pathogenic organisms are treated to become Virulent pathogenic organisms are treated to become attenuated and avirulent but antigenic. They have lost attenuated and avirulent but antigenic. They have lost their capacity to induce full-blown disease but retain their capacity to induce full-blown disease but retain their immunogenicity. their immunogenicity.

Live attenuated vaccines should not be administered Live attenuated vaccines should not be administered to persons with suppressed immune response due to:to persons with suppressed immune response due to: Leukemia and lymphomaLeukemia and lymphoma Other malignanciesOther malignancies Receiving corticosteroids and anti-metabolic agentsReceiving corticosteroids and anti-metabolic agents RadiationRadiation pregnancypregnancy

Inactivated (killed) vaccinesInactivated (killed) vaccines

Organisms are killed or inactivated by heat or Organisms are killed or inactivated by heat or chemicals but remain antigenic. They are chemicals but remain antigenic. They are usually safe but less effective than live usually safe but less effective than live attenuated vaccines. The only absolute attenuated vaccines. The only absolute contraindication to their administration is a contraindication to their administration is a severe local or general reaction to a previous severe local or general reaction to a previous dose.dose.

ToxoidsToxoids

They are prepared by detoxifying the exotoxins of They are prepared by detoxifying the exotoxins of some bacteria rendering them antigenic but not some bacteria rendering them antigenic but not pathogenic. Adjuvant (e.g. alum precipitation) is used pathogenic. Adjuvant (e.g. alum precipitation) is used to increase the potency of vaccine. to increase the potency of vaccine.

The antibodies produces in the body as a consequence The antibodies produces in the body as a consequence of toxoid administration neutralize the toxic moiety of toxoid administration neutralize the toxic moiety produced during infection rather than act upon the produced during infection rather than act upon the organism itself. In general toxoids are highly organism itself. In general toxoids are highly efficacious and safe immunizing agents. efficacious and safe immunizing agents.

Polysaccharide and polypeptide (cellular Polysaccharide and polypeptide (cellular fraction) vaccinesfraction) vaccines They are prepared from extracted cellular fractions They are prepared from extracted cellular fractions

e.g. meningococcal vaccine from the polysaccharide e.g. meningococcal vaccine from the polysaccharide antigen of the cell wall, the pneumococcal vaccine antigen of the cell wall, the pneumococcal vaccine from the polysaccharide contained in the capsule of from the polysaccharide contained in the capsule of the organism, and hepatitis B polypeptide vaccine.the organism, and hepatitis B polypeptide vaccine.

Their efficacy and safety appear to be high.Their efficacy and safety appear to be high.

Surface antigen (recombinant) vaccinesSurface antigen (recombinant) vaccines..

It is prepared by cloning HBsAg gene in yeast It is prepared by cloning HBsAg gene in yeast cells where it is expressed. HBsAg produced is cells where it is expressed. HBsAg produced is then used for vaccine preparations.then used for vaccine preparations.

Their efficacy and safety also appear to be Their efficacy and safety also appear to be high.high.

Types of vaccinesTypes of vaccinesLive

vaccines

Live

Attenuated vaccines

Killed

Inactivated vaccines

ToxoidsCellular fraction vaccines

Recombinant vaccines

•Small pox variola vaccine

•BCG

•Typhoid oral

•Plague

•Oral polio

•Yellow fever

•Measles

•Mumps

•Rubella

•Intranasal

Influenza

•Typhus

•Typhoid

•Cholera

•Pertussis

•Plague

•Rabies

•Salk polio

•Intra-muscular influenza

•Japanise encephalitis

•Diphtheria

•Tetanus

•Meningococcal polysaccharide vaccine

•Pneumococcal polysaccharide vaccine

•Hepatitis B polypeptide vaccine

•Hepatitis B vaccine

Routes of administrationRoutes of administration

Deep subcutaneous or intramuscular route Deep subcutaneous or intramuscular route (most vaccines)(most vaccines)

Oral route (sabine vaccine, oral BCG vaccine)Oral route (sabine vaccine, oral BCG vaccine) Intradermal route (BCG vaccine)Intradermal route (BCG vaccine) Scarification (small pox vaccine)Scarification (small pox vaccine) Intranasal route (live attenuated influenza Intranasal route (live attenuated influenza

vaccine)vaccine)

Scheme of immunizationScheme of immunization

Primary vaccinationPrimary vaccination One dose vaccines (BCG, variola, measles, mumps, One dose vaccines (BCG, variola, measles, mumps,

rubella, yellow fever)rubella, yellow fever) Multiple dose vaccines (polio, DPT, hepatitis B, Multiple dose vaccines (polio, DPT, hepatitis B,

hib)hib) Booster vaccinationBooster vaccination

To maintain immunity level after it declines after To maintain immunity level after it declines after some time has elapsed (DT, MMR,opv).some time has elapsed (DT, MMR,opv).

Periods of maintained immunity due Periods of maintained immunity due to vaccinesto vaccines Short period (months): cholera vaccShort period (months): cholera vacc Three to five years: DPT vaccineThree to five years: DPT vaccine Five or more years: BCG vaccineFive or more years: BCG vaccine Ten years: yellow fever vaccineTen years: yellow fever vaccine Solid immunity: measles, mumps, and rubella Solid immunity: measles, mumps, and rubella

vaccines.vaccines.

Levels of effectivenessLevels of effectiveness

Absolutely protective(100%): yellow fever vaccineAbsolutely protective(100%): yellow fever vaccine Almost absolutely protective (99%): Variola, Almost absolutely protective (99%): Variola,

measles, mumps, rubella vaccines, and diphtheria and measles, mumps, rubella vaccines, and diphtheria and tetanus toxoids.tetanus toxoids.

Highly protective (80-95%): polio, BCG, Hepatitis B, Highly protective (80-95%): polio, BCG, Hepatitis B, and pertussis vaccines.and pertussis vaccines.

Moderately protective (40-60%) cholera vaccine, and Moderately protective (40-60%) cholera vaccine, and influenza killed vaccine.influenza killed vaccine.

StorageStorage:: Among the vaccines, polio is the most Among the vaccines, polio is the most

sensitive to heat, requiring storage at minus 20 sensitive to heat, requiring storage at minus 20 degree C. degree C.

Vaccines which must be stored in the freezer Vaccines which must be stored in the freezer compartment are : polio and measles. compartment are : polio and measles.

Vaccines which must be stored in the COLD Vaccines which must be stored in the COLD PART but never allowed to freeze are : PART but never allowed to freeze are : typhoid, DPT, tetanus toxoid, DT, BCGtyphoid, DPT, tetanus toxoid, DT, BCG

The Cold ChainThe Cold Chain

The "cold chain" is a system of storage and The "cold chain" is a system of storage and transport of vaccines at low temperature from transport of vaccines at low temperature from the manufacturer to the actual vaccination site. the manufacturer to the actual vaccination site.

The cold chain system is necessary because The cold chain system is necessary because vaccine failure may occur due to failure to vaccine failure may occur due to failure to store and transport under strict temperature store and transport under strict temperature controls. controls.

RECOMMENDED AGEVACCINE(S)

BIRTHBCG, Hepatitis B (HBV)opv02 MONTHS[DTP, HIB, HBV]PENTA

Opv1,ROTA14 MONTHS[DTP, HIB]TETRA

Oral Polio Vaccine (OPV2)ROTA26 MONTHS[DTP, HIB, HBV]PENTA

(OPV3),ROTA39 MONTHSMeasles vaccine (mono)+VIT.A 100000

15 MONTHSMMR

1 8 MONTHS1ST BOSTER DOSE (OPV)1ST BOSTER DOSE DTP, HIB VIT. A 200000

4 – 6 YEARS2nd booster dose (OPV)2nd booster dose DTPMMR 2

HAZARDS OF HAZARDS OF IMMUNIZATIONIMMUNIZATION

No immune response is entirely free from the risk No immune response is entirely free from the risk of adverse reactions or remote squeal. The adverse of adverse reactions or remote squeal. The adverse reactions that may occur may be grouped under the reactions that may occur may be grouped under the following heads:following heads:

1.1. Reactions inherent to inoculationReactions inherent to inoculation2.2. Reactions due to faulty techniquesReactions due to faulty techniques 3.3. Reactions due to hypersensitivityReactions due to hypersensitivity4.4. Neurological involvementNeurological involvement5.5. Provocative reactionsProvocative reactions 6.6. Others Others

11 . .Reactions inherent to inoculationReactions inherent to inoculation:: These may be local general reactions. The local These may be local general reactions. The local

reactions may be pain, swelling, redness, tenderness reactions may be pain, swelling, redness, tenderness and development of a small nodule or sterile abscess and development of a small nodule or sterile abscess

at the site of injectionat the site of injection . .The general reactions may be fever, malaise, The general reactions may be fever, malaise,

headache and other constitutional symptoms. Most headache and other constitutional symptoms. Most killed bacterial vaccines (e.g., typhoid) cause some killed bacterial vaccines (e.g., typhoid) cause some local and general reactions. Diphtheria and tetanus local and general reactions. Diphtheria and tetanus toxoids and live polio vaccine cause little reactiontoxoids and live polio vaccine cause little reaction..

2. Reactions due to faulty techniques:2. Reactions due to faulty techniques:

Faulty techniques may relate to Faulty techniques may relate to faulty production of vaccine (e.g. inadequate faulty production of vaccine (e.g. inadequate

inactivation of the microbe, inadequate detoxication), inactivation of the microbe, inadequate detoxication), too much vaccine given in one dose, too much vaccine given in one dose, improper immunization site or route, , improper immunization site or route, , vaccine stored incorrectly, vaccine stored incorrectly, contraindications ignored (e.g. a child who contraindications ignored (e.g. a child who

experienced a severe reaction after a previous dose of experienced a severe reaction after a previous dose of DPT vaccine is immunized with he same vaccine), DPT vaccine is immunized with he same vaccine),

. .

Use of improperly sterilized syringes and Use of improperly sterilized syringes and needles carry the hazard of hepatitis B virus, needles carry the hazard of hepatitis B virus, and staphylo - and streptococcal infection and staphylo - and streptococcal infection

4. Neurological involvement:4. Neurological involvement: Neuritic manifestations may be seen after the Neuritic manifestations may be seen after the

administration of serum or vaccine. The well-known administration of serum or vaccine. The well-known examples are the post vaccinial encephalitis and examples are the post vaccinial encephalitis and encephalopathy following administration of anti -encephalopathy following administration of anti -rabies and smallpox vaccines. rabies and smallpox vaccines.

Guillain Barre syndrome in association with the swine Guillain Barre syndrome in association with the swine influenza vaccine is another example. influenza vaccine is another example.

5. Provocative reactions:5. Provocative reactions: Occasionally following immunization there may Occasionally following immunization there may

occur a disease totally unconnected with the occur a disease totally unconnected with the immunizing agent (e.g., provocative polio after DPT immunizing agent (e.g., provocative polio after DPT or DT administration against diphtheria). or DT administration against diphtheria).

The mechanism seems to be that the individual is The mechanism seems to be that the individual is harboring the infectious agent and the administration harboring the infectious agent and the administration of the vaccine shortens the incubation period and of the vaccine shortens the incubation period and produces the disease or what may have been produces the disease or what may have been otherwise only a latent infection is converted into a otherwise only a latent infection is converted into a clinical attack.clinical attack.

6. 6. Others:Others: These may comprise damage to the fetus (e.g., These may comprise damage to the fetus (e.g.,

with rubella vaccination); displacement in the with rubella vaccination); displacement in the age-distribution of a disease (e.g., a potential age-distribution of a disease (e.g., a potential problem in mass vaccination against measles, problem in mass vaccination against measles, rubella and mumps).rubella and mumps).

Application of active immunizationApplication of active immunization

Infants and children expanded immunization program Infants and children expanded immunization program (schedule)(schedule)

Active immunization for adult femalesActive immunization for adult females Vaccination for special occupationsVaccination for special occupations Vaccination for special life stylesVaccination for special life styles Vaccination for special environmental situationsVaccination for special environmental situations Vaccinations for special health status personsVaccinations for special health status persons Vaccinations in travelVaccinations in travel

Compulsory (obligatory) vaccination for Compulsory (obligatory) vaccination for infants, and booster vaccination for infants, and booster vaccination for children (Expanded immunization children (Expanded immunization program)program)

See local schedule of vaccination See local schedule of vaccination

Note (children failing to complete childhood Note (children failing to complete childhood vaccination schedule)vaccination schedule)

Vaccination for special occupationsVaccination for special occupations

Health care workers: hepatitis B, influenza, MMR, polioHealth care workers: hepatitis B, influenza, MMR, polio Public safety personnel (police, fire fighters) and staff of Public safety personnel (police, fire fighters) and staff of

institutions for the developmentally disabled: hepatitis B, institutions for the developmentally disabled: hepatitis B, influenzainfluenza

Vets and animal handlers: rabies, plague and anthraxVets and animal handlers: rabies, plague and anthrax Sewage workers: DT, hepatitis A, polio, TABSewage workers: DT, hepatitis A, polio, TAB Food handlers: TABFood handlers: TAB Military troops and camp dwellers: pneumococcal, Military troops and camp dwellers: pneumococcal,

meningococcal, influenza, BCG (for non reactors), tetanusmeningococcal, influenza, BCG (for non reactors), tetanus

Vaccinations for special health status Vaccinations for special health status personspersons Immuno-compromised persons ( Leukemia, Immuno-compromised persons ( Leukemia,

lymphoma, HIV, malignancy…)lymphoma, HIV, malignancy…) Hemodialysis and transplantationHemodialysis and transplantation

Should receive the following vaccines according Should receive the following vaccines according to their situation:to their situation:

HBV, Influenza, Pneuomococcal vaccines HBV, Influenza, Pneuomococcal vaccines

General ContraindicationsGeneral Contraindications Moderate or severe illness with or without feverModerate or severe illness with or without fever Anaphylactic reaction to vaccine or vaccine Anaphylactic reaction to vaccine or vaccine

constituentconstituent Live attenuated vaccinesLive attenuated vaccines

Pregnant womenPregnant women Immunocompromised / Immunosuppressed Immunocompromised / Immunosuppressed

childrenchildren within 3-11 months of immunoglobulin within 3-11 months of immunoglobulin

administrationadministration

Invalid ContraindicationsInvalid Contraindications

Mild to moderate local reactionMild to moderate local reaction Mild acute illness with or without low grade feverMild acute illness with or without low grade fever Current antimicrobial therapyCurrent antimicrobial therapy Convalescent phase of illnessesConvalescent phase of illnesses Prematurity and low birth weightPrematurity and low birth weight History of penicillin or other nonspecific allergiesHistory of penicillin or other nonspecific allergies Malnutrition Malnutrition

Immunization Of Special GroupsImmunization Of Special GroupsIMMUNOCOMPROMISED HOSTSIMMUNOCOMPROMISED HOSTS Avoid Avoid MMR, measlesMMR, measles (may be used in HIV) (may be used in HIV) Avoid Avoid OPVOPV; use IPV for these children and their household ; use IPV for these children and their household

contactscontacts

PRETERM INFANTSPRETERM INFANTS Treat as term babiesTreat as term babies Avoid Avoid OPVOPV in hospital in hospital InfluenzaInfluenza vaccine in BPD vaccine in BPD may delay HBV if <2 kg & mother is HBsAG negativemay delay HBV if <2 kg & mother is HBsAG negative

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