Transcript Vaccination

Vaccination
The immune system is a complex network of
specialized organs and cells protects the body from
destruction by foreign agents and microbial pathogens
, degrades and removes damaged or dead cells, and
exerts a surveillance function to prevent the
development and growth of malignant cells. The
immune system is composed of immune cells and
central and peripheral lymphoid structures. The
immune cells move throughout the body, searching for
and destroying foreign substances but avoiding cells
regarded as self.
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Natural immunity:
It is not produced by the immune response. This type of
immunity is present at birth and appears to be present in
all members of a species.
Acquired immunity:
It develops after birth as a result of exposure to an antigen,
thereby activating the immune response. Acquired
immunity can be either active or passive, depending on
whether the immune response took place in the host or a
donor.
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Differences of immune system of children and adult
The normal human no fully active immune system at birth
because of immaturity. It relies instead on passively
transferred antibodies from the mother. This maternal
antibody slowly decreases in concentration and for all
practical purposes, has waned by 1 year.
The infant own production of antibody begins to be
meaningful at 7 or 8 months of age when the total of
maternal and infant antibody is low. One has waned and
the other is not up to full strength. This is age when many
of the infectious disease processes of infancy begin /e.g.
otitis media, pneumonia.
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Vaccination
Vaccination
•Administration of a substance to a person with the purpose of preventing a disease
•Traditionally composed of a killed or weakened microorganism
•Vaccination works by creating a type of immune response that enables the memory cells to
later respond to a similar organism before it can cause disease
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Early History of Vaccination
•Pioneered India and China in the 17th century
•The tradition of vaccination may have originated in India in AD 1000
•Powdered scabs from people infected with smallpox was used to protect against the disease
•Smallpox was responsible for 8 to 20% of all deaths in several European countries in the 18th century
•In 1721 Lady Mary Wortley Montagu brought the knowledge of these techniques from Constantinople
(now Istanbul) to England
•Two to three percent of the smallpox vaccinees, however, died from the vaccination itself
•Benjamin Jesty and, later, Edward Jenner could show that vaccination with the less dangerous cowpox
could protect against infection with smallpox
•The word vaccination, which is derived from vacca, the Latin word for cow.
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Era of Vaccination
English physician Edward Jenner
observed that milkmaids stricken with a viral disease
called cowpox were rarely victims of a similar disease,
smallpox
Jenner took a few drops of fluid from a pustule of a
woman who had cowpox and injected the fluid into a
healthy young boy who had never had cowpox or
smallpox
Six weeks later, Jenner injected the boy with fluid
from a smallpox pustule, but the boy remained free
of the dreaded smallpox.
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Era of Vacinnation
In those days, a million people died from
smallpox each year in Europe alone, most of
them children.
Those who survived were often left with
blindness, deep scars, and deformities
In 1796, Jenner started on a course that
would ease the suffering of people around
the world for centuries to come.
By 1980, an updated version of Jenner
vaccine lead to the total eradication of
smallpox.
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Early History of Vaccination
•In 1879 Louis Pasteur showed that chicken cholera weakened by growing it in the laboratory could
protect against infection with more virulent strains
•1881 he showed in a public experiment at Pouilly-Le-Fort that his anthrax vaccine was efficient in
protecting sheep, a goat, and cows.
•In 1885 Pasteur developed a vaccine against rabies based on a live attenuated virus
•A year later Edmund Salmon and Theobald Smith developed a (heat) killed cholera vaccine.
•Over the next 20 years killed typhoid and plague vaccines were developed
•In 1927 the bacille Calmette-Guérin (BCG vaccine) against tuberculosis vere developed
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Since Jenner's time, vaccines have been developed
against more than 20 infectious diseases
• The date of introduction of first generation of vaccines for use in humans*
o1798
o1885
o1897
o1923
o1926
o1927
o1927
o1935
Smallpox
Rabies
Plague
Diphtheria
Pertussis
Tuberculosis (BCG)
Tetanus
Yellow Fever
•After World War II
o1955 Injectable Polio Vaccine (IPV)
o1962 Oral Polio Vaccine (OPV)
o1964 Measles
o1967 Mumps
o1970 Rubella
o1981 Hepatitis B
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Vaccination Today
•Vaccines have been made for only 34 of the more than 400 known pathogens that are harmful to man.
•Immunization saves the lives of 3 million children each year, but that 2 million more lives could be saved
if existing vaccines were applied on a full-scale worldwide
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Human Vaccines
against
pathogens
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Immunological Bioinformatics, The MIT press.
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Type of Vaccination
Type of Vaccination
Live Vaccines
•Characteristics
•Able to replicate in the host
•Attenuated (weakened) so they do not cause disease
•Advantages
•Induce a broad immune response (cellular and humoral)
•Low doses of vaccine are normally sufficient
•Long-lasting protection are often induced
•Disadvantages
•May cause adverse reactions
•May be transmitted from person to person
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Subunit Vaccines
•Relatively easy to produce (not live)
•Classically produced by inactivating a whole virus or bacterium
•Heat
•Chemicals
•The vaccine may be purified
•Selecting one or a few proteins which confer protection
•Bordetella pertussis (whooping cough)
•Create a better-tolerated vaccine that is free from whole microorganism cells
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Subunit Vaccines: Polysaccharides
•Polysaccharides
•Many bacteria have polysaccharides in their outer membrane
•Polysaccharide based vaccines
•Neisseria meningitidis
•Streptococcus pneumoniae
•Generate a T cell-independent response
•Inefficient in children younger than 2 years old
•Overcome by conjugating the polysaccharides to peptides
•Used in vaccines against Streptococcus pneumoniae and Haemophilus influenzae.
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Subunit Vaccines: Toxoids
•Toxins
•Responsible for the pathogenesis of many bacteria
•Toxoids
•Inactivated toxins
•Toxoid based vaccines
•Bordetella pertussis
•Clostridium tetani
•Corynebacterium diphtheriae
•Inactivation
•Traditionally done by chemical means
•Altering the DNA sequences important to toxicity
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Subunit Vaccines: Recombinant
•The hepatitis B virus (HBV) vaccine
•Originally based on the surface antigen purified from the blood of chronically infected individuals.
•Due to safety concerns, the HBV vaccine became the first to be produced using recombinant DNA
technology (1986)
•Produced in bakers’ yeast (Saccharomyces cerevisiae)
•Virus-like particles (VLPs)
•Viral proteins that self-assemble to particles with the same size as the native virus.
•VLP is the basis of a promising new vaccine against human papilloma virus (HPV)
•Merck
•In phase III
For more information se: http://www.nci.nih.gov/ncicancerbulletin/NCI_Cancer_Bulletin_041205/page5
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Genetic Vaccines
•Introduce DNA or RNA into the host
•Injected (Naked)
•Coated on gold particles
•Carried by viruses
•vaccinia, adenovirus, or alphaviruses
•bacteria such as
•Salmonella typhi, Mycobacterium tuberculosis
•Advantages
•Easy to produce
•Induce cellular response
•Disadvantages
•Low response in 1st generation
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Type of Vaccination
Live attenuated
Vaccine
OPV
Measles
Rubella
Mumps
BCG
Varicella Vaccine
Inactivated organism
or their products
Diphtheria
Tetanus
Pertussis( whole
cell/acellular)
Hepatits Avaccine
Hepatitis B
Pneumococcal
Polysaccharide
vaccine
Influenza
IPV
Hib
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Passive Immunity
Transfer of antibody produced by one human
or other animal to another
Transplacental most important source in
infancy
Temporary protection
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Sources of Passive Immunity
Almost all blood or blood products
Homologous pooled human antibody
(immune globulin)
Homologous human hyperimmune
globulin
Heterologous hyperimmune serum
(antitoxin)
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IMMUNOGLOBULIN PREPARETION
Normal human Ig.
Normal human Ig is an antibody-rich fraction, obtained from a pool of at least
1000 donors. The preparation should contain at least 90% intact IgG; it should
be as free as possible from IgG aggregates; all IgG sub-classes should be
present; there should be a low IgA concentration; the level of antibody against
at least two bacterial species and two viruses should be ascertained
Normal human Ig used to prevent measles in highly susceptible individuals
and to provide temporary protection /up to 12 weeks/ against hepatitis A
infection.
Live vaccines should not normally be given for 12 weeks after an injection of
normal human Ig.
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
Specific human Ig.
These preparations are made from the plasma of patient who have recently
recovered from an infection or are obtained from individuals who have been
immunized against a specific infection.
The advantages of Ig-s are:
1. freedom from hepatitis B
2. concentration of the antibodies into a small volume for
intramuscular use.
3. stable antibody content, if properly stored.
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Vaccine Preventable Diseases
An infectious disease for which an effective
preventive vaccine exists.
If a person dies from it, the death is
considered a vaccine-preventable death.
TUBERCULOSIS
DIPHTHERIA
PERTUSSIS
POLIOMYELITIS
MEASLES
TETANUS
FULLY IMMUNIZED CHILD
A child who received
One dose of BCG,
Three doses of DPT and OPV,
One dose of measles
before one year of age.
This gives a child the best chance for survival.
Control
 Reduction of prevalence or incidence of disease to lower
acceptable level.
Elimination
 Eradication of disease from a large geographic region or
political jurisdiction
 Either reduction of infectious disease’s prevalence in
regional population to zero or reduction of global
prevalence to a negligible amount.
Eradication
 Termination of all transmissions of infection by
extermination of infectious agent through surveillance
and containment.
 Reduction of infectious disease’s prevalence in global
host population to zero.
EXPANDED PROGRAMME ON
IMMUNISATION (EPI)
 EPI launched in 1974
 Build on smallpox infrastructure
 Targeted 6 diseases
 EPI progressively adopted by all countries
Universal by early 1098s
Addition to EPI
 Yellow fever in 1988
• For endemic countries only : 33 in Africa, 11 in S. America.
• Given with measles vaccine
 Hepatitis B in 1992
• In high seroprevalence countries by 1995
• In all countries by 1997
 Haemophilus influenzae type b (Hib)
• 1998 : based on disease burden and capacity
• 2006 : all countries. ( lack of data should not be obstacle)
3 slides of coverage fm unicef
3 slides of coverage fm unicef
COMPONENTS of program
1. Immunization of pregnant women against tetanus.
2. Immunization of children in their first year of life
against 6 VPDs.
3) Immunisation in preterm
infants
 All vaccines except Hepatitis B
 If BW < 2Kg & mother HBsAg negative :- postpone till
baby attaines 2kg wt or 2 mths of age.
 If BW < 2Kg & mother HBsAg positive :- give vaccine +
immunoglobulin.
4) Children receiving corticosteroids
 Children receiving corticosteroids at the dose of 2
mg/kg/day for more than 14 days should not receive
live virus vaccines until steroid has been
discontinued for at least 1 month.
Tetanus toxoid
 Intramuscular – upper arm – 0.5 ml
 Pregnancy – 2 doses - 1st dose as early as possible and
second dose after 4 weeks of first dose and before 36
weeks of pregnancy
 Pregnancy – booster dose (before 36 weeks of
pregnancy) – If received 2 TT doses in a pregnancy
within last three years. Give TT to woman in labour, if
she has not received TT previously
 TT booster for both boys and girls at 10 years and 16
years
 No TT required between two doses in case of injury
BCG
 At birth or as early as possible till one year of age
 0.1 ml (0.05ml until one month of age)
 Intra-dermal
 Left upper arm
Hepatitis B
 Birth dose – within 24 hours of birth
 0.5 ml
 Intramuscular
 Antero-lateral side of mid-thigh
 Rest three doses at 6 weeks, 10 weeks
and 14 weeks
OPV
 Zero dose – within first 15 days of birth
 2 drops
 Oral
 First, second and third doses at 6, 10 and 14 weeks with
DPT-1, 2 and 3
 OPV booster with DPT booster at 16-24 months
DPT
 Three primary doses at 6, 10 and 14 weeks with OPV1, 2 and 3
 0.5 ml
 Intra-muscular
 Antero-lateral side of mid-thigh
 One booster at 16-24 m with OPV booster (anterolateral side of mid-thigh) and second booster at 5-6
years (upper arm)
Measles
 At 9 completed months to 12 months
 Give up to 5 years if not received at 9-12 months
age
 Second dose at 16-24 months (select states after
catch-up campaign) – Measles Containing Vaccine
 0.5 ml
 Sub-cutaneous
 Right upper arm
 Along with Vitamin A (1st dose) – 1ml (1 lakh IU) -
Constraints
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Illiteracy
Non uniform coverage
Poor implementation
Poor monitoring
High drop outs
Declining coverage in some major states
Over reporting
Poor injection safety
Reorientation of staff being not carried out
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Vacany of staff at field level not filled
Poor surveillance of vaccine preventable diseases
Poor vaccine logistics
Poor maintainance of equipments
Extra ordinary emphasis on polio vaccine
Route of Administration
Route of Adminstration
Oral
OPV
Intradermal
BCG, Rabies
Subcutaneou Measles, Mumps, Rubella, MMR,
s
IPV, Pneumoccocal, Influenza
Intramuscula DPT, DT Tetanus, HepatitisA,
r
HepatitisB, Pneumococcal,
Rabies, Hib, Influenza
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Site of Administration
Intradermal
Over the insertion of left deltoid
muscle
Subcutaneou Anterolateral aspect of the thigh
s
or the upper arm
Intramuscula Anterolateral aspect of the thigh
r
in infants and deltoid muscle in
older children or adult.
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Who should not be vaccinated?
Allergy
Fever
HIV infection
Immunodeficiency
IG administration
Neurological
disorder
Prematurity
Reactions to
Previous vaccine
Simultaneous
administration of
Vaccines
Thrombocytopenia
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Allergy
A. Allergic Reactions to Egg-related
antigens
1.
2.
Yellow fever and influenza vaccines do contain
egg proteins and rarely induce immediate
allergic reactions. Skin testing is recommended
before administration with an history of allergic
to egg
MMR- Even those with severe hypersensitivity
are at low risk of anaphylaxis.
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Allergy
B. Antibiotic-induced allergic reaction
Delayed type local reaction 48-96 hours
afterwards and is usually minor
IPV and OPV – streptomycin, neomycin
and polymyxin B
MMR and varicella vaccine-neomycin
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Allergy
C. Gelatin- MMR, Varicella vaccine
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Fever
Low-grade fever or mild illness is not a
contraindication for vaccination
Children with moderate or severe febrile
illnesses can be vaccinated as soon as
they are recovering and no longer
acutely ill
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Vaccination in Pregnancy
Risk to a developing fetus from vaccination of the
mother during pregnancy is mostly theoretical
Only smallpox vaccine has ever been shown to
injure a fetus
The benefits of vaccinating usually outweigh
potential risks
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Vaccination in Pregnancy
Inactivated vaccines
Routine (influenza)
Vaccinate if indicated (hep B, Td, mening, rabies)
Vaccinate if benefit outweighs risk (all other)
Live vaccine – do not administer
Exception is yellow fever vaccine
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HIV Infection
No BCG
OPV is Contraindicated
in household contact, in recipient ( asymptomatic
or symptomatic)
IPV for these children and household contacts
MMR vaccination should be considered for all
asymptomatic and to all symptomatic HIVinfected persons who do not have evidence of
severe immunosuprresion or measles
immunity
Pneumococcal vaccine, Hib, DTP (or DTaP),
Hepatitis B vaccine, Influenza vaccines are all
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indicated
Immunosupression
No live viral vaccines and BCG. IPV for
these patients, their siblings and their
household contacts
No live vaccine (except varicella) until
six months after immunosuppressive
therapy
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Neurological disorder
Progressive developmental delay or changing
neurological findings (e.g. infantile spasm) defer pertussis immunization
Personal history of convulsions
Recent seizures - defer pertussis
immunization
Conditions predisposing to seizures or
neurological deterioration (e.g. tuberous
sclerosis) - defer pertussis immunization
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Reactions
Severe Reactions to DTP
Insonable cry lasting more than 3 hrs with 48 hrs
of dose
Seizure with 3 days
Severe local reactions
Family hx of adverse event
Not a contraindication, but consider carefully
the benefits and risks, if need to vaccinate
can use acellular DTP for less reactions
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Reactions
GBS with 6 weeks after a dose of DTP
Again based on risks and benefits for
further dose of DTP and risk of GBS
recurrence.
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Reactions
Contraindication for further dose of DTP
encephalopathy within 7 days of a dose of
DTP
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VACCINE REACTIONS
Common, minor reactions
vaccine stimulates immune system
settle on their own
warn parents and advise how to manage
Rare, more serious reactions
anaphylaxis (serious allergic reaction)
vaccine specific reactions
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RARE, MORE SERIOUS REACTIONS
Reaction

Suppurative lymphadenitis
BCG osteitis
Disseminated BCG infection

None known

BCG
Hib
HepB
Measles/
MMR/MR

Incidence

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
1 in 1000 to 1 in 10 000
1 in 3000 to 1 in 100 million
~1 in 1 million

Anaphylaxis
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1 in 6-900 000

Febrile seizures
Thrombocytopaenia
(low platelets)
Severe allergic reaction
Anaphylaxis
Encephalopathy
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1 in 3000
1 in 30 000
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~1 in 100 000
~1 in 1 million
<1 in 1 million
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RARE, MORE SERIOUS REACTIONS (2)
Reaction
Polio
Vaccine associated
paralytic poliomyelitis

(OPV)
Risk is higher for first dose,
adults, and immunocompromised
Incidence

1 in 2.4-3.3 million doses

1 in 750 000 first dose
compared to 1 in 5.1 million
for subsequent doses

Tetanus
Pertussis
(DTPwhole cell)
Brachial neuritis
 Anaphylaxis

0.5-1 in 100 000
 1 in 100 000 to 1 in 2 500 000


Persistent inconsolable
screaming
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
Seizures

Hypotonic, hyporesponsive
episode (HHE)


Anaphylaxis

Encephalopathy
(Note: Risk may be zero)
1 in 15 to 1 in 1000
1 in 1750 to 1 in 12 500
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1 in 1000 to 1 in 33 000
1-6 in million
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0-1 in 1 million
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Simutaneous administration of
Vaccine
A theoretical risk that administration of
multiple live virus vaccine: OPV, MMR,
and varicella ) within 28 days of one
another if not given on the same day
will result in a sub optimal immune
response
No data to substantiate this
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Vaccine Cold Chain
Maintaining proper vaccine temperatures
during storage and handling to preserve
potency
The success of efforts against vaccinepreventable diseases is attributable in part to
proper storage and handling of vaccines.
Exposure of vaccines to temperatures outside
the recommended ranges can affect potency
adversely, thereby reducing protection from
vaccine-preventable diseases
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Recommended Storage Temperatures
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Table 5: Vaccination Schedule for Infants
and Children 2012
Age Type of vaccine
0-1 Week OPV0 dose , HepB1 , BCG
2 Months OPV1 , PENTA1,ROTA1
4 Months OPV2 , TETRA1,ROTA2
6 Months OPV3 , PENTA2,ROTA3
9 Months Measles + VIT A
15 Months MMR (Measles , Mumps ,
Rubella)
18 Months TETRA2, OPV First Booster77
Table 6: National Immunization Schedule for Infants
and Children 2015
Age Type of vaccine
0-1 Week HepB1 , BCG + OPV0dose
2 Months HEXA 1,ROTA1 ,PREV13-1+OPV1
4 Months HEXA2,ROTA2,PREV13-2 + OPV2
6 Months HEXA3,ROTA3,PREV13-3 + OPV3
9 Months Measles + VIT A
15 Months MMR(Measles , Mumps , Rubella)
18 Months PENTA (DTP+IPV+Hib ) OPV + VIT A
4-6 Years TETRA (DTaP +IVP ) + OPV + MMR
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