Mei Neni Sitaresmi, dr, Ph.D, Sp.A(K) Position: – Member of Immunization Task force, Indonesian Pediatric Society – Member of Indonesia Technical Advisory Group on Immunization (ITAGI) – Member of Developmental Behavioural Social Pediatric working Group, IPS – Head of Adverse Effect Following Immunization Commission, DIY – Member of ISSOP (International Society of Social Pediatric and Child Health) – Vice Dean for Collaboration, Alumny, Community Services, FK-KMK, UGM Education: – Medical Doctor, FK-KMK UGM (1990) – Pediatrician, FK-KMK UGM (2002) – Consultant , Indonesian Pediatric Collegium (2008) – PhD, VUMC Netherland (2009) Email: [email protected] ; [email protected] 3/09/2020 WEBINAR IDI Yogya
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Mei Neni Sitaresmi, dr, Ph.D, Sp.A(K)
Position:– Member of Immunization Task force, Indonesian Pediatric Society– Member of Indonesia Technical Advisory Group on Immunization (ITAGI)– Member of Developmental Behavioural Social Pediatric working Group, IPS– Head of Adverse Effect Following Immunization Commission, DIY– Member of ISSOP (International Society of Social Pediatric and Child Health)– Vice Dean for Collaboration, Alumny, Community Services, FK-KMK, UGM
Education:– Medical Doctor, FK-KMK UGM (1990)– Pediatrician, FK-KMK UGM (2002)– Consultant , Indonesian Pediatric Collegium (2008)– PhD, VUMC Netherland (2009)
Email: [email protected]; [email protected]
3/09/2020 WEBINAR IDI Yogya
Basic vaccinology
Mei Neni Sitaresmi
FK-KMK UGM/ DR. Sardjito
IDAI Cabang DIY
3/09/2020 WEBINAR IDI Yogya
outline
• Introduction: the role of vaccination in disease
prevention
• General recommendation on vaccination
• Vaccine administrations
3/09/2020WEBINAR IDI Yogya
The role of vaccination in
disease prevention
The number of reported cases of many VPDs
has decreased substantially over recent years
VPD: Vaccine preventable disease
World Health Organization (WHO), 2017. Immunization, vaccines and biologicals – data, statistics and graphics. Global and regional immunization profile.
http://www.who.int/immunization/monitoring_surveillance/data/gs_gloprofile.pdf?ua=1 (accessed June 2018)
No. of cases:
1980: 1,982,355
2016: 123,003
Pertussis
94%
DiphtheriaNo. of cases:
1980: 98,000
2016: 670093%
Tetanus
(total)No. of cases:
1980: 114,000
2016: 13,00089%
PolioNo. of cases:
1980: 53,000
2016: 42>99%
RubellaNo. of cases:
2000: 671,000
2016: 26,00096%
Tetanus
(neonatal)No. of cases:
1980: 13,000
2016: 200085%
Global reduction in reported cases of VPDs over time
Discontinuation/reintroduction of vaccination is associated with
a corresponding rise/fall in disease incidence
6
• Gangarosa EJ et al. Lancet 1998;351:356–361
Year
0
40
20
10
30
1955 1965 1985 19951975
Acellular vaccine
introduced in 1981
DTP vaccination
introduced in 1947
Few cases and no
deaths in 1974
Vaccination
interrupted
Acellular pertussis vaccines were
introduced in 1981, and a major fall in
pertussis incidence followed
In Japan, a pertussis epidemic occurred
in 1979 following cessation of vaccination
(≥13,000 cases and 41 deaths)
Incid
en
ce
of p
ert
ussis
pe
r 1
00
,00
0 in
div
idu
als
Kekebalan Populasi Rendah
Kebal/Imun PenderitaRentan
Kemungkinan penderita kontak dengan yang rentan sangat tinggi
Sudah Divaksin tapi SAKIT
Herd Immunity? Scenario 1
Penderita
Kekebalan Populasi Tinggi
Kekebalan Populasi yang tinggi kemungkinan penderita kontakdengan yang rentan adalah kecil.
Kebal/Imun Rentan
Herd Immunity? Scenario 2
The threshold of vaccination coverage required to
interrupt transmission varies among infectious
diseases1,2
*Basic reproduction number, or the average number of other individuals that each infected individual will infect in a population that has no
immunity; †The minimum proportion of the population that needs to be immunised to eliminate infection. This is dependent on both the R0
and the effectiveness of the vaccine
1. Metcalf CJE et al. Trends Immunol 2015;36:753–755; 2. Doherty M et al. Vaccine 2016;34:6707–6714
Disease R0* Herd immunity
threshold (%)†
Diphtheria 6–7 85
Measles 12–18 83–94
Mumps 4–7 75–86
Pertussis 12–17 92–94
Polio 5–7 80–86
Rubella 6–7 83–85
Smallpox 5–7 80–85
The proportion of the population
that must be vaccinated to provide
full herd protection depends on:1,2
Transmissibility of the
pathogen
Demographic characteristics
of the population (eg, higher
coverage may be required in
high-birth-rate contexts)
Herd immunity thresholds for several VPDs2
Vaccines are the most cost-effective
public health interventions
Improving vaccine coverage to 90%
in 72 LMICs is estimated to prevent
deaths of 6.4 million children
between 2011 and 2020
This represents $231 billion
(range: $116–614 billion) in the
value of statistical lives saved
Vaccin
e-p
reventa
ble
child
hood
death
s (thousa
nds)
Valu
e-o
f-st
ati
stic
al-
life
savin
gs
(billions
USD
)
Top 10 countries with value-of-statistical-life savings (estimates for 2015)
181.3
12.7
91.1
15.926.7
8.9 6.1
28.4
9.3 11.2
0
40
80
120
160
200
Category1
Category2
Category3
Category4
7.5
4.13.6
2.4
0.7 0.6 0.5 0.3 0.3 0.3
0
1
2
3
4
5
6
7
8
India Angola Nigeria Indonesia Pakistan Sudan Bhutan Afghanistan Kenya Cameroon
immunity
• Non specific: innate, non adaptive
• Specific: adaptive
– Passive :
• Protection transferred from another person or animal as antibody (Ig G)
• Temporary protection that wanes with time
• Maternal antibody, HBIG, ATS, ADS
– Active:
• Protection produced by the person's own immune system
• Usually permanent
• natural infection or vaccination
Vaccines induce immunity by imitating natural
infections1
Natural infection Vaccination
However, like natural infection, immunity from vaccination may wane over time,
so maintaining immunity through boosting may be necessary2
1. Centers for Disease Control and Prevention (CDC), 2013. Understanding how vaccines work. https://www.cdc.gov/vaccines/hcp/conversations/downloads/vacsafe-understand-color-office.pdf (accessed July 2017); 2. World Health Organization (WHO). Wkly Epidemiol Rec 2017;92:53–76
Immunity
Generates an immune
response without
causing illness
Associated with
disease, symptoms and
mortality
Immune respond
Classification of vaccine
• Live attenuated:
– Bacteria (BCG, oral typhoid)
– Virus (rotavirus, MR/MMR, OPV, varicella, JE, Dengue)
• Inactive vaccines:
– Whole (influenza, IPV, Hep.A, pertussis)
– Fractional:
• Protein based:
– Toxoid (tetanus, Dipteria)
– sub unit (:Hep.B, acellular pertusis, typ.Vi, HPV)
• Polysacharide based: Hib, Pneumo, meningo)
– Conjugated T dependent, booster effect
– Pure T independent, > 2 tahun, no booster effect
• Mimic the natural infection and retain most
defensive triggers/immunogenic elements;
may retain immune evasion factors
• Strong priming usually achieved with 1–2
doses
• Long-term persistence of immunity
BCG, Bacille Calmette–Guérin; HAV, hepatitis A virus vaccine; IC, immunocompromised; IPV, inactivated polio vaccine;
MMR, measles-mumps-rubella; OPV, oral polio vaccine; VZV, varicella zoster virus vaccine
Strugnell R, et al. Perspect Vaccinol 2011;1:61–88
Advantages and disadvantages of
live-attenuated vs killed vaccines
• Usually require adjuvants due to reduced
immunogenicity/missing defensive triggers
• Multiple doses usually required for priming
• Booster doses may be needed to maintain
long-term immunity
• Do not induce disease symptoms
• No risk of reactivation, non-infectious;
suitable for IC subjects
• Low risk of immunological interference
• Relatively stable over time, better resistance
to cold chain deviation
• Generally not affected by administration of
blood or blood-derived products
• May induce mild disease symptoms
• Rare reversion to virulence; unsuitable for IC
subjects
• Potential for immunological interference with
other live vaccines
• Less stable over time, heat labile
• Affected by recent administration of blood or
blood-derived products or presence of
maternal antibodies in infants
Live-attenuated vaccines
(e.g. OPV, MMR, VZV, some influenza, BCG)
Killed/inactivated vaccines
(e.g. IPV, HAV, whole-cell pertussis)
schedule
• All vaccines can be administered at the same
visit as all other vaccines
– exception: in persons with functional or anatomic
asplenia pneumococcal conjugate vaccine (PCV13)
and Menactra (meningococcal conjugate vaccines)
should not be administered at the same visit;
separate these vaccines by at least 4 week
• Multiple injection
3/09/2020 WEBINAR IDI Yogya
Multiple injection
• Advantages:
– protection during the vulnerable early months
– Fewer vaccination visits, reduce pain experience
or discomfort.
– Increasing efficiency
• Administer at different site, if in the same thigh,
separated by 2.5 cm
• Use a separate limb for most reactive vaccines (e.g.,
tetanus toxoid-containing and PCV13)
• order of injections (administer most painful vaccine
last)3/09/2020 WEBINAR IDI Yogya
Non simultaneous Administration
of Different Vaccines
• If live parenteral (injected) vaccines (MMR,
MMRV, varicella, zoster, and yellow fever) are
not administered at the same visit, they should
be separated by at least 4 weeks
• Oral live vaccines (OPV and Rotavirus) may be
given at any time before or after each other
• Live oral vaccines may be given at any time
before or after live parenteral vaccines
• All other combinations of two inactivated
vaccines, or live and inactivated vaccines, may
be given at any time before or after each other3/09/2020 WEBINAR IDI Yogya
Timing and Spacing of
Vaccines
• Inactivated vaccines are generally not affected
by circulating antibody to the antigen.
– Hep B vaccine and HbIG
• Live attenuated vaccines may be affected by
circulating antibody to the antigen
– Measles vaccine is given at least 9 months
– Interval 2 live vaccines (if are not given at the same
visit) minimal 4 week
https://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html3/09/2020 WEBINAR IDI Yogya
Interval Between Doses
of the Same Vaccine
• Increasing the interval between doses of a
multidose vaccine does not diminish the
effectiveness of the vaccine in final titer, but may
delay the protection
• Decreasing the interval between doses of a
multidose vaccine may interfere with antibody
response and protection
– Vaccine doses administered up to 4 days
before the minimum interval or age can be
counted as valid3/09/2020 WEBINAR IDI Yogya
Principles of
catch up immunization
• provide optimal protection against disease as quickly as
possible by completing a person’s recommended
vaccination schedule in the shortest but most effective
time frame.
• Assessing the immunization status
– if the immunization status is not available, the vaccine
should be considered as not received
• a catch-up schedule based on the previous documented
doses the person has received, do not start the
schedule again, regardless of the interval since the last
dose (count previous doses as part of the schedule)
https://immunisationhandbook.health.gov.au/catch-up-vaccination
3/09/2020 WEBINAR IDI Yogya
Principles of
catch up immunization
• As a child gets older, the recommended number of
vaccine doses may change, or the child may not need
any doses (HiB, PCV)
• For some vaccines, catch-up vaccination is not
recommended (rotavirus)
• Give a combined vaccines or multiple injection
• Schedule further required doses after the
appropriate minimum interval
3/09/2020 WEBINAR IDI Yogya
P.1 /1
0
Antig
enAg
e of 1
st D
ose
Dose
s in
Prim
ary
Serie
s (m
in in
terv
al be
twee
n do
ses)
**
Inte
rrupt
ed
prim
ary
serie
s***
Dose
s for
thos
e who
star
t vac
cinat
ion
late
Boos
ter
If ≤ 12 months of
age
If > 12 months of age
Reco
mm
enda
tions
for a
ll im
mun
izatio
n pr
ogra
mm
es
BCG
1As
soon
as po
ssibl
e afte
r birt
h1 d
ose
NA1 d
ose
1 dos
eNo
t rec
omme
nded
Hepa
titis
B 2
As so
on as
poss
ible a
fter b
irth (
<24h
)Bir
th do
se <
24 hr
s plus
2-3
dose
s with
DTP
CV (4
wee
ks)
Resu
me w
ithou
t re
peat
ing pr
eviou
s
dose
3 dos
es3 d
oses
Not r
ecom
mend
ed
Polio
3
bOPV
+ IP
V6 w
eeks
(see f
ootn
ote f
or bi
rth do
se)
4 dos
es (I
PV do
se to
be
given
with
bOPV
dose
from
14
wee
ks of
age)
(4 w
eeks
)
Resu
me w
ithou
t
repe
ating
prev
ious
dose
4 dos
es (I
PV to
be gi
ven w
ith
1st d
ose o
f bOP
V)4 d
oses
(IPV
to be
give
n with
1st
dose
of bO
PV)
Not r
ecom
mend
ed
IPV
/ bO
PV S
eque
ntia
l8 w
eeks
(IPV
1st )1-
2 dos
es IP
V an
d2 d
oses
bOPV
(4 w
eeks
)
Resu
me w
ithou
t re
peat
ing pr
eviou
s do
se
1-2 d
oses
IPV
and 2
dose
s bO
PV1-
2 dos
es IP
V an
d 2 do
ses b
OPV
Not r
ecom
mend
ed
IPV
8 wee
ks3 d
oses
(4 w
eeks
)Re
sume
with
out
repe
ating
prev
ious
dose
3 dos
es3 d
oses
If th
e prim
ary s
eries
begin
s < 2
mont
hs
of ag
e, bo
oster
to be
give
n at l
east
6
mont
hs af
ter t
he la
st do
se
DTP-
cont
aini
ng va
ccin
e (DT
PCV)
46 w
eeks
(min)
3 dos
es (4
wee
ks)
Resu
me w
ithou
t re
peati
ng pr
eviou
s
dose
3 dos
es
3 dos
es w
ith in
terva
l of a
t lea
st 4
week
s betw
een 1
st &
2nd d
ose,
and a
t lea
st 6 m
os be
twee
n 2nd
&
3rd d
ose
(if >
7 yr
s use
only
aP co
ntain
ing
vacc
ine; i
f > 4
yrs T
d con
tainin
g
vacc
ine is
prefe
rred a
nd sh
ould
only
be us
ed fo
r >7 y
rs)
3 boo
sters:
12-2
3 mon
ths (
DTP-
cont
aining
vacc
ine);
4-7 y
ears
(Td/
DT
cont
aining
vacc
ine),
see f
ootn
otes
; and
9-
15 yr
s (Td
cont
aining
) (if >
7 yr
s use
on
ly aP
cont
aining
vacc
ine)
If te
tanus
vacc
inatio
n sta
rted d
uring
adole
scen
ce or
adult
hood
only
5 dos
es
requ
ired f
or lif
elong
prote
ction
Haem
ophi
lus
influ
enza
e ty
pe b
5
Optio
n 1
6 wee
ks (m
in)
3 dos
es (4
wee
ks)
Resu
me w
ithou
t
repe
ating
prev
ious
dose
3 dos
es1 d
ose
>5 yr
s not
reco
mmen
ded i
f he
althy
None
Optio
n 22-
3 dos
es (8
wee
ks if
2 do
ses;
4 wee
ks if
3 dos
es)
2-3 d
oses
At le
ast 6
mon
ths (
min)
after
last
dose
Pneu
moc
occa
l (Co
njug
ate)
66 w
eeks
(min)
3 dos
es (3
p+0)
with
DTP
CV
(4
week
s)or
2 do
ses (
2p+1
) (8 w
eeks
)
Resu
me w
ithou
t re
peati
ng pr
eviou
s
dose
2-3 d
oses
1-5 y
rs at
high-
risk:
2 do
ses
Boos
ter a
t 9-1
8 mon
ths i
f foll
owing
2do
se sc
hedu
le
Anoth
er bo
oster
if HI
V+ or
prete
rmne
onat
e
Rota
virus
76 w
eeks
(min)
2 or 3
depe
nding
on pr
oduc
t
given
with
DTP
CV
Resu
me w
ithou
t re
peati
ng pr
eviou
s
dose
2 or 3
depe
nding
on pr
oduc
t>2
4 mon
ths l
imite
d ben
efit
Not r
ecom
mend
ed
Meas
les 8
9 or 1
2 mon
ths
(6 m
onth
s min,
see f
ootn
ote)
2 dos
es (4
wee
ks)
Resu
me w
ithou
t re
peat
ing pr
eviou
s do
se2 d
oses
2 dos
esNo
t rec
omme
nded
Rube
lla 9
9 or 1
2 mon
ths
1 dos
e with
mea
sles
cont
aining
vacc
ineNA
1 dos
e1 d
ose
Not r
ecom
mend
ed
HPV
10As
soon
as po
ssibl
e fro
m 9 y
ears
of
age (
female
s)2 d
oses
(5 m
onth
s)
If 1s
t dos
e give
n be
fore 1
5 yea
rs of
age r
esum
e with
out
repe
ating
prev
ious
dose
NAGi
rls: 9
-14 y
ears
2 dos
es
(see f
ootn
ote)
Not r
ecom
mend
ed
Tabl
e 3:
Rec
omm
enda
tions
* fo
r Int
erru
pted
or D
elay
ed R
outin
e Im
mun
izatio
n - S
umm
ary o
f WHO
Pos
ition
Pap
ers
* For
some
antig
ens t
he W
HO po
sition
pape
r doe
s not
prov
ide a
reco
mmen
datio
n on i
nter
rupt
ed or
delay
ed sc
hedu
les at
this
pres
ent t
ime.
Whe
n the
posit
ion pa
per i
s nex
t rev
ised t
his w
ill be
inclu
ded.
In th
e mea
ntim
e, so
me of
the r
ecom
mend
ation
s are
base
d on
expe
rt op
inion
.**
See
Table
2: S
umma
ry of
WHO
Posit
ion Pa
pers
- Rec
omme
nded
Rou
tine I
mmun
izatio
ns fo
r Chil
dren
for f
ull de
tails
(www
.who
.int/i
mmun
izatio
n/do
cume
nts/p
ositio
npap
ers/)
.
*** S
ame i
nter
val a
s prim
ary s
eries
unles
s oth
erwi
se sp
ecifie
d
.
(Updated April 2019)
https://www.who.int/immunization/policy/Immunization_routine_table3.pdf?ua=13/09/2020 WEBINAR IDI Yogya
Vaccine administration
• Vaccine Administration – Key to ensuring vaccination is as safe and effective
as possible
– Incorporate with: professional standards for medication administration and manufacturer’s vaccine specific guidelines
• Rights of Medication Administration – Right patient
– Right vaccine and diluent (when applicable)
– Right time (including the correct age and interval, as well as before the product expiration time/date)
– Right dosage
– Right route & site
– Right documentation
3/09/2020WEBINAR IDI Yogya
https://www.cdc.gov/vaccines/pubs/pinkbook/vac-admin.html
Patient Care Before
Administering Vaccine
• Immunization Assessment
• administer the vaccines that are indicated based
on the person’s age, medical condition and other
risk factors
• Screen for contraindications and precautions
prior to administering any vaccine
• Discuss vaccine benefits and risks and vaccine-
preventable disease risks using VISs
• Provide after-care instructions
3/09/2020 WEBINAR IDI Yogya
Contraindications and
PrecautionsPermanent contraindications
• Severe allergic reaction following a prior dose
• Encephalopathy within 7 days of pertussis vaccination
• History of intussusception (rotavirus vaccine)
Temporary contraindications:
• Moderate or Severe Acute Illness
• Lives attenuated vaccines: pregnancy, Immunosuppressed
Precautions: after previous DPT
• Occurring within 48 hours : T > 40.5, shock-like state
(hypotonic hyporesponsive episode), persistent
inconsolable crying lasting 3 or more hours
• a seizure, with/without fever, occurring within 3 days of
DPT3/09/2020 WEBINAR IDI Yogya
Invalid Contraindications to
Vaccination
• Mild illness
• Antimicrobial therapy
• Disease exposure or
convalescence
• Pregnant or
immunosuppressed
person in the
household
• Family history of
adverse events
• Breastfeeding
• Preterm birth
• Allergy to products
not present in vaccine
or allergy that is not
anaphylactic
• Tuberculin skin
testing
• Multiple vaccines
https://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html#invalid
3/09/2020 WEBINAR IDI Yogya
Vaccine information statement
3/09/2020 WEBINAR IDI Yogya
https://www.idai.or.id/artikel/klinik/imunisasi/informasi-vaksin-untuk-
orangtua-ivo
Patient Care During Vaccine
Administration • Consider patient’s age and stage of development
• Use simple strategies to ease vaccination process
– positive attitude, soft, calm voice, eye contact
– explain why the vaccine is needed, honest about what
to expect
• Encourage participation of parent, hold the child
• Sitting, rather than lying down
• Be aware of syncope (fainting)
– have patient seated or lying down during vaccination
– if patient faints, provide supportive care and protect patient
from injury
– observe patient for at least 15 minutes after vaccination 3/09/2020 WEBINAR IDI Yogya
Vaccine preparation
• Inspect vaccine and diluent vial for damage or contamination
• Check the expiration date; never administer expired vaccine
or diluent
• Reconstitute vaccine according to manufacturers guidelines
just before administration, using ONLY the manufacturers
supplied diluent for that vaccine, and agitate vial to
thoroughly mix vaccine
3/09/2020 WEBINAR IDI Yogya
VVM = Vaccine Vial Monitor
Vaccine preparation
• Beyond Use Date
– time after a needle is inserted into a multidose vial (4
weeks for pentabio, IPV)
– A frame time after vaccine was reconstituted (BCG 3
hours, MR 6 hours
• Once the protective cap is removed, vaccine in
single-dose vial should be used or discarded at
end of workday
• Once manufacturer-filled syringe is activated
(remove needle cap or attach needle) sterile
seal is broken and should be used or discarded
at end of workday3/09/2020 WEBINAR IDI Yogya
Vaccine Preparation
• single-dose vials should only be used for a single dose
• Do not predraw vaccine
– increases risk for administration errors
– wasted vaccine
– possible bacterial growth in vaccines that do not
contain a preservative
• Never:
– Never combine vaccines into a single syringe except
when specifically approved by the manufacture
– Never draw partial doses of vaccine from separate
vials to obtain a full dose
– Never transfer vaccine from one syringe to another3/09/2020 WEBINAR IDI Yogya
Route and site• Route:
– Oral: OPV, Rotavirus
– Intradermal: BCG
– Subcutaneous : MMR, Varicella, JE, dengue
– Intramuscular: Hepatitis B, DPT Vaccines, IPV,
PCV, Tifoid, Influenza
• needle size and site of injection depend
on:
– the size of the muscle
– the thickness of adipose tissue at the injection
site
– the volume of the material to be administered3/09/2020 WEBINAR IDI Yogya
Oral Route Rotavirus
Vaccines
• Administer oral vaccines prior to administering
injections
• Administer liquid slowly down one side of the inside
cheek (between the cheek and gum) toward the
back of infant’s mouth
• Take care not to go far enough back to initiate the
gag reflex
• Never administer or spray (squirt) vaccine directly
into the throat
• Do not readminister a dose of rotavirus vaccine if
the infant regurgitates, spits out or vomits during or
after administration3/09/2020 WEBINAR IDI Yogya
Intradermal
• Site: deltoid region of
the upper arm
• BCG, 0.05 ml
3/09/2020 WEBINAR IDI Yogya
Subcutaneous injection
• Site:
– the thigh < 1 YoA
– the upper outer triceps
of the arm > 1 YoA
• Needle Gauge and
Length
– 5/8-inch, 23- to 25-
gauge needle
3/09/2020 WEBINAR IDI Yogya
Intra muscular injection
• Site:
– the vastus lateralis
muscle (anterolateral
thigh) and the deltoid
muscle (upper arm)
– Because there are no
large blood vessels,
aspiration is not
necessary
• Needle Gauge and
Length
– 22- to 25-gauge needle3/09/2020 WEBINAR IDI Yogya
Vaccinating children with
Bleeding Disorders
• Individuals with bleeding disorder or receiving
anticoagulant therapy may develop hematomas in
IM injection sites
• Administer vaccines by recommended IM route IF
physician familiar with patient’s bleeding risk
determines vaccine can be safely administered
• Prior to vaccination, instruct about risk of hematoma
• Schedule shortly after antihemophelia or similar
therapy
• Use 23-gauge or finer needle and apply firm
pressure to injection site for at least 2 minutes after
injection
• Do NOT rub or massage injection site
3/09/2020 WEBINAR IDI Yogya
Procedural Pain Management
• Breastfeeding
• sweet tasting solutions
• injection technique (aspiration may increase pain)
• distraction
• Not recommended:
– Topical anaesthetics (effective but costly, availability,
additional time)
– warming the vaccine
– manual stimulation of the injection site
– administration of oral analgesics before or at the time of
vaccination.Reducing pain at the time of vaccination: WHO position paper,20153/09/2020 WEBINAR IDI Yogya
Infection Control
• Hand hygiene
• Gloves ?
– Not needed unless contact with potentially infectious body fluids or has open lesions on hands
– should be changed and hand hygiene performed between patients
• Equipment disposal
– do not recap, or detach from syringe
– Put in in a puncture-resistant biohazard container
– dispose of empty or expired vaccine vials as medical waste
3/09/2020 WEBINAR IDI Yogya
Pencegahan Kontaminasi
• Cuci tangan dengan antiseptik.
• Tidak perlu pakai sarung
tangan.
• Bila menggunakan alkohol
tunggu sampai kulit kering
(terutama vaksin hidup).
• Vaksin multidosis: tidak boleh
ada jarum yang menancap di
botol vaksin.
• Jarum untuk mengambil dari
botol dan yang disuntikkan
harus berbeda.
Tempat Pembuangan Limbah
45#
PemberianImunisasisaatPandemiCovid19
Masker
surgical
Face shieldGaun
khusus
Sarungrangan
Catat dalam Buku Paspor Kesehatan
Slide Prof Ismoedijanto pada Webinar PP IDAI 24 April 2020
3/09/2020 WEBINAR IDI Yogya
Managing Acute Vaccine
Reactions
• screening for contraindications and precautions
• Epinephrine and equipment for maintaining an airway
should be available for immediate use
• the signs and symptoms of anaphylaxis:
– flushing, facial edema, urticaria, itching, swelling of
the mouth or throat, wheezing, and difficulty breathing
3/09/2020 WEBINAR IDI Yogya
documentation
• date of administration
• vaccine type
• lot number
• route, dosage, site
• person who administered and signature
3/09/2020 WEBINAR IDI Yogya
Common vaccine
administration errors
• administered too early (before the minimum age or interval
has been met)
• Vaccine administered outside the approved age range
• Vaccine administered to a patient with a contraindication for
that vaccine
• Wrong vaccine (e.g., Pentabio vs TD, Tdap instead of
DTaP)
• Wrong dosage (e.g., influensa vaccine Pediatric and adults
dose)
• Wrong route
• Expired vaccine or diluent administered
• Vaccine which was not stored properly administered
• Wrong diluent used to reconstitute the vaccine or only the
diluent was administered
3/09/2020 WEBINAR IDI Yogya
Take home messages
• Vaccines are the most cost-effective public
health interventions
• Vaccines should be administered based on
Rights of Medication Administration (right
patients, vaccine, time, doses, route, site and
documentation) to ensure the safety and
effectiveness of the vaccine
3/09/2020 WEBINAR IDI Yogya
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