Vaccination
Dr. Nisreen Amayiri
November 11/2007
Lec no. 19&20
Today we will talk about vaccination which is a unique topic 4
pediatric as nutrition & development .U will not hear about
these topics in other courses.
Importance of vaccination:
It is an effective mechanism of preventing infectious diseases
in population.
The most common example is the global eradication of small
pox. Once the vaccine was introduced small pox was
completely eradicated from the whole world. Now the
organism that is responsible to cause small pox infection is
present in the lab only.
Definitions:
Immunization: is a process of inducing immunity .
Active immunization: when the vaccine (Ag) introduce to
the body it stimulate immune sys. To produce Abs
Passive immunity: direct Abs (from the serum or produced in
the lab)
Example of natural occurring passive immunity:
First 6 month of age is a clear example of passive immunity
(Abs from mother to the baby)
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Vaccine: a protein, polysaccharide, toxin or nucleic acid
delivered to body to produce immunity
Toxoid: a modified bacterial toxin (not toxic but capable of
producing antitoxin)
Constituents of vaccine:
Protein, polysaccharide, nucleic acid, Adjuvant (salts)
Preservative, stabilizer, antibiotic, suspending fluid
P.S: Some individuals have allergy to Ags and other to
preservative.
Types of vaccines:
Live attenuated: MMR, BCG
Live but weak organism. Body capable to produce Abs against
this Ags but incapable to introduce the disease unless the
patient is immunocompromized.
Inactivated or killed:
1. Inactivated whole organism:
Hepatitis A, whole cell pertussis
2. Detoxified exotoxins: Tetanus, Diphtheria
3. Purified protein antigen: Acelluar pertussis, Hepatitis B
4. Polysaccharide: Capsular Meningococcal
5. Capsular polysaccharide conjugated to protein: Hib,
Pnemoccocal conjugated vaccine
6. Component of organism: Influenza vaccine
Immune response to vaccine:
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In live attenuated vaccines, once they r introduced to the
body the organisms multiply in recipient & stimulate the
immune system to produce Abs so it is more like the natural
infection, but its very mild .so it is likely to produce life long
protection after 1st dose of vaccine.
Killed (inactivated) vaccines: less antigenic so usually need
booster doses.
Nature and magnitude of immune response depend on many
factors:
1. Age at administration (body response differs from age to
other & the peak incidence of disease is related to age)
2. Presence of maternal antibodies younger than 6 months
3. Relative immaturity of immune system (humoral
immunity "Abs production" mature around 1.2-2 YO)
4. Host factors: good nutrition & good immunity response
not like immunocopromised response
5. Route of administration:
IPV: inactivated vaccine give serum Abs (IgM, IgG)
OPV: oral live attenuated vaccine gives secretory IgA
Subcutaneous hepatitis B at buttock less immunogenic than
IM at deltoid
IM at deltoid more antigenic more Abs production
T cell independent antigens are those that produce B cells
proliferation and Abs production without help of T cells
T cell independent antigens are poor immunogenic in
younger than 2 years (as we said humoral immunity mature
around 1.5-2 YO) so this vaccine will not be effective b4 2
YO).Therefore, conjugation with protein carrier will induce
more immunity like Hib, Conjugated pneumoccocal vaccine.
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Primary response to a vaccine :
IGM serum antibody is usually detected 7-10 days
IGGS type peaks at 2-6 weeks.
A vaccine schedule depends on many factors:
1)Epidemiology of disease: BCG is used 4 epidemic TB
infection which is common in our countries according to
poverty, crowding & a lot of condition that induce TB
infection related to this BCG vaccine should be introduce
early in life.
2) Age specific morbidity/mortality: Hib is given early in life
it's not effective >5 YO because the disease won't be severe like
in early age.
3) Vaccine immunogenisity
4) Risk of vaccine adverse effects
5) Cost effectiveness
6) At times of health care visits
Generally a vaccine is recommended:
1) Youngest age
2) Maximum morbidity & mortality (significant risk of a
disease)
3) Mature immunity
There r 2 type of schedules:
1) Universal schedules (JNP, UNRWA)
2) Schedules 4 selected populations e.g.:
Specific diseases (nephrotic syndrome…)
Travel (yellow fever vaccine…)
Post exposure (rabies…)
Special conditions:
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1) Most vaccines can be given simultaneously with out
impairment of vaccines effectiveness or safety (more than one
vaccine can be given in the same day and this is the usual)
Live attenuated vaccine like MMR, OPV should be given in
the same day if not, there must be one month interval b/w
them.
2) Breast feeding is not a contraindication to any vaccine,
although most live attenuated vaccines replicate in mother
they are not excreted in human milk.
Lapsed immunizations:
If interval between vaccine doses exceeds those
recommended, this does not adversely affect the immune
response provided the series is completed, so no need to
restart the series or to give extra doses (e.g. if someone take
the 1st dose of HBV then he travel, after more than one
month (which is the interval b/w 1st & 2nd dose) came back
there is no need to restart the series.2nd dose can be given
followed by 3rd 6 month later.
HBV: the interval b/w 1st & 2nd dose is one month, b/w 2nd &
3ed is 6 month
Preterm infants:
1) Immune response to vaccination is a function of postnatal
age rather than gestational age
2) Prematurity does not increase the incidence of vaccine
related sides effects
3) Doses are same as those for term infants (NOT reduced)
4) Should be vaccinated at same chronological age as full
term, according to schedule.
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Corticosteroids: it's an immunosuppressive; it will affect live
attenuated vaccine
Physiologic or low doses (less than 2mg/kg/day) of
prednisone, inhaled (asthma) or topical steroids (eczema) the
child can be immunized while on steroid.
If the dose is more than 2mg/kg/day, or alternate-day steroid
(in nephritic syndrome):
1) For less than 14 days, should have live vaccine deferred until
at least stopping steroid (once u stop steroid u can receive the
vaccine)
2) If more than 14 days defer the vaccine for at least 1 month.
Immunodeficiency (ID):
1) Humoral ID
2) Cellular ID
3) ID secondary to leukemia, lymphoma or steroids
Vaccination in ID individual Depends on degree of
immunodeficiency and underlying cause.
1) Live attenuated vaccines are contraindicated e.g. OPV
2) Vaccines are indicated e.g. Influenza vaccine and
Pneumoccocal vaccine to induce their immunity
General notes related to all vaccine:
Contraindications:
Severe allergic reactions after a vaccine dose or to some
vaccine component
Precautions:
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Moderate or severe acute illness with or with out fever
(benefits & risks of a vaccine is individualized)
Adverse effects:
Usually Mild Problems:
Redness, warmth, swelling, Fever
The Jordanian National Immunization Program
Age Recommended Vaccines
First Month BCG
61 Days DPT-HBV-Hib IPV
91 Days DPT-HBV-Hib IPV OPV
121 Days DPT-HBV-Hib OPV
9 Months Measles OPV
18 Months DPT OPV MMR
6 Years (First Grade) Td OPV
15 Years (10th Grade) Td
BCG:
Bacillus Calmette Gueran
There is evidence that BCG provides appreciable protection
against tuberculosis meningitis (50-80%) and miliary disease.
According to JNP, BCG vaccine is given at 1st month of age
It is given intra-dermal injection in the left deltoid
Various schedules through world:
WHO : BCG only at birth
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Europe: BCG once in childhood
Europe: Repeated/booster BCG (to reach maximum
immunity)
USA : No routine BCG use
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BCG: it is live attenuated vaccine that induces T cell
response.Therefore; its reaction won't be acute
2 weeks after vaccine injection, Local lesion, and papule
develop.
4-6 weeks Small abscess might develop
At 6 weeks (crust, detaches, ulcerates), then a scar (typically
round and slightly depressed) remains
BCG Complication:
1. Local abscess (at the site of injection)
2. “Not so serious” Lymphadenitis (axillary, cervical
lymphadenopathy)
Non-suppurative (no pus), Suppurative (contains pus)
3. Serious Lymphadenitis:
It can be Persistent, axillary, large, recurrent or multiple
(neck, axilla)
4. BCG osteitis (affect the bone)
5. Disseminated (generalized) BCGosis in immune
compromised
BCG contraindication:
Only “symptomatic HIV infection (i.e. AIDS)” is a
contraindication for BCG according to WHO.
DTP Vaccine:
D: diphtheria (toxoid) T: tetanus (toxoid) P: pertussis
(killed organism) also known as whooping cough
DTP: it is divided into 2 types according to pertussis
1) Inactivated whole organism vaccine (DTP)
2) Acellular type (DTaP): removed cell wall from pertussis
organism, it has less side effects
After 6 years of age only Td is given (pertussis infection is so
mild)
There are 6 doses of DTP (at 61, 91,121 days, 18 months, 6YO,
and 15YO)
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Side effects:
Mild Problems (Common):
Fever, Redness, swelling, Soreness (1 in 4)
Fussiness (irritable, crying), Tiredness or poor appetite and
Vomiting (1 in 50)
These problems occur more often after the 4th and 5th doses
of the DTP series than after earlier doses.
Moderate Problems (Uncommon):
Seizure (1 in 14,000), continuous crying for 3 hours or more
(1 in 1,000), High fever (1in 16,000)
Severe Problems (Very Rare) :
Serious allergic reaction (1 in a million doses)
Long-term seizures, coma, or lowered consciousness,
Permanent brain damage.
So RARE that it is hard to tell if they are caused by the
vaccine.
If child presents with mild or moderate reaction, no
contraindication to give pertussis but if it is severe pertussis
is contraindicated (DT 6 YO)
Contraindications:
1. Encephalopathy (coma, altered level of consciousness,
prolonged seizures) within 7 days of previous dose, so next
dose shouldn't be given.
2. Progressive neurological disorder till neurological state is
clarified.
Cerebral palsy (CP) it is static not progressive disorder so it
isn't contraindicated.
Precautions:
1. Fever more than 40.5, during 48 hrs of previous dose
2. Collapsed or shock like state during 48 hrs of previous
vaccine dose
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3. Seizures during 3 days or less of previous vaccine dose
4. Persistent inconsolable crying more than 3 hr during 48 hr
of previous vaccine dose
Hepatitis B vaccine (HBV):
Is a very safe vaccine, very effective without side effects
Infants born to HBsAg-positive mothers should receive (1)
the vaccine and (2) HBIG within 12hr of birth to make
maximum protection to the baby; one is given in the left leg
& the other on the right because they work against each
other.
There r 3 doses of HBV (at 61, 91,121 days)
Hib Vaccine:
Capsular polysaccharide conjugated to protein carrier
Contraindicated in less than 6 weeks of age
Children > 5 years old usually do not need Hib vaccine
The idea of conjugation: the Ags bind to protein carrier that
increases the immune response.
There r 3 doses of HBV (at 61, 91,121 days)
OPV, IPV:
OPV :( live attenuated) oral polio vaccine
IPV: is inactivated polio vaccine
IPV serum IgG antibody
OPV produce mucosal IgA immunity and limit virus
replication in gastrointestinal system (polio is an enterovirus
that replicate in GIT so once u block its replication u block
the disease)
OPV is used 4 sth which is called herd immunity (once the
vaccine is introduced to the body orally, shed some of it in
the stool & this lead to immunize the individuals around in
the same community).
IPV is more expensive than OPV
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There r 6 doses of OPV/IPV (at 61, 91,121 days, 9 months, 18
months &6 YO)
Side effects:
IPV has no adverse effects
OPV may cause (vaccine associated paralytic polio) in 1 in 6.2
million doses.
MMR vaccine:
M: measles
M: mumps
R: rubella
Live attenuated vaccine, subcutaneous injection
Measles is given at 9 months & MMR at 18 months.
Side effects :
Mild Problems:
1. Mild rash (1 in 20)
2. Swelling of glands in the cheeks or neck (rare) if these
problems occur, it is usually within 7-12 days after the shot.
They occur less often after the second dose
Moderate Problems :
1. Seizure secondary to fever (1 in 3,000 doses)
2. Temporary pain and stiffness in the joints,
Teenage or adult women who r vaccinated with MMR to
protect the fetus from congenital rubella (up to 1 out of 4)
3. Thrombocytopenia (1 in 30,000 doses)
Severe Problems (Very Rare) :
Serious allergic reaction (1 in a million doses)
“Several other severe problems have been known to occur
after a child gets MMR vaccine. But this happens so rarely,
experts cannot be sure whether they are caused by the vaccine
or not”
Contraindications:
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1. A life-threatening allergic reaction to gelatin, neomycin
(antibiotic), or to a previous dose of MMR vaccine. The
viruses is grown in fibroblast culture generated from chicken
embryo so children with history of anaphylaxis to egg should
be immunized with MMR under medical supervision but it
isn't contraindicated
2. Pregnant women
3. Known severe immunodeficiency like severely symptomatic
HIV infection
Precautions:
Recent blood transfusion or were given other blood products
less than 11 months the cause is Abs in the blood will make
the MMR not effective
BCG, OPV, MMR Live attenuated vaccine
HBVRecombinant
Hibpolysaccharide conjugated
IPVkilled vaccine
Other Vaccines
(1)Pneumococcal polysaccharide vaccine (PPV)
23 valent vaccine (according to serotype)
Usually 2 doses (1st dose at any age >2 YO, the 2nd dose after
3-5 years)
Help prevent serious pneumococcal disease which is a serious
illness that affects children
E.g. meningitis, bacteremia, pneumonia
Anyone older than 2 years with:
Heart disease, lung disease, sickle cell disease, diabetes,
cirrhosis, lymphoma, leukemia, kidney failure, nephrotic
syndrome, asplenia, HIV infection or AIDS.
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These serious illness (meningitis, bacteremia, pneumonia)
usually affect children <2 YO, PPV not work b4 2 YO from
here the idea of conjugation was introduced
(2)Pneumococcal Conjugate Vaccine
7 valent vaccine (the commonest 7 serotypes)
Help prevent serious pneumococcal disease e.g. meningitis,
bacteremia, pneumonia
Also prevent some otitis media
Children under 2 years of age:
2 months - 4 months - 6 months –
12 to 15 months
Minor side effects
Varicella vaccine:
Can prevent chickenpox and if got chickenpox it is mild,
1.fewer number of spots 2. No fever 3. And will recover faster
Chickenpox not that severe illness within 7-10 days there
will be a complete recovery.The cause for introducing the
vaccine is the fatality cases(so severe death)
First dose: 12- 15 months of age
Second dose: 4- 6 years of age (may be given earlier if at least
3 months after the first dose)
Minor side effects, moderate: (Seizure 1 in 1000),
severe :Pneumonia (very rare)
Contraindications: it is like MMR
1. A life-threatening allergic reaction to gelatin, neomycin, or
to a previous dose of Varicella vaccine
2. Pregnant women
3. Known severe immunodeficiency
Precautions:
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Recent blood transfusion or were given other blood products
less than 11 months
Influenza Vaccine:
Inactivated vaccine.
Influenza viruses are always changing (shift & drift), so
influenza vaccines are updated every year, and an annual
vaccination is recommended in October or November (at the
beginning of winter).
It is recommended for
1) Children b/w 6-24 months of age & for patient 6 month
of age or older who have chronic disease (asthma, DM, HIV,
CF, sickle cell disease & cardiac condition)
2) Health care professional
Contraindications:
Influenza vaccine virus is grown in eggs. People with a severe
egg allergy & yellow fever should not get the vaccine
Meningococcal Vaccines:
1) Meningococcal polysaccharide vaccine (A/C/Y/W-135) 4
serotype. The most epidemic is A/C
Recommended to children older than 2 years AND at risk
(terminal complement component deficiency, asplenia,
military recruits ,traveling)
2)Meningococcal conjugate vaccine A/C used in Europe for
infants less than 2 YO)
Minor side effects
Rotavirus Vaccine :
An oral live vaccine
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Rotavirus it is the most common cause of gastroenteritis in
children (50-60%)
In poor countries like Africa & in the area where there is a
war, children who get gastroenteritis may die from
dehydration. According to that the vaccine was introduced
and distributed by WHO to that area.
When the vaccine was introduced for the 1st time they
supposed that the vaccine increase incidence of
intussusceptions & it was withdrawn from the market until
the new one was introduced.
Children should get 3 doses :
First Dose: 2 months of age
Second Dose: 4 months of age
Third Dose: 6 months of age
Contraindications :
Immunodeficiency
From HEMMA
2 Weeks 61 day 91 day 121 day day 272 1st 2nd 3rd
start 3rd start 4th start 5th start booster booster booster
month month month 10th 18-24 6th year after
month months After 10 Years
BCG INTRA-
DERMAL
OPV IM Oral 2 Oral 2 Oral 2 Oral 2 Oral 2
(IPV) drops drops drops drops drops
MMR SC
HBV IM IM IM
HIB IM IM IM
DTP IM IM IM IM DT dT
Measles SC
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End of the lecture
The last day 4 cases delivery on Wednesday 21/11/007 b4 our
lecture to Dr. Nisreen Amayiri
The case should be hand writing
The case must contain:
1) Detailed history (profile, chief complaint, history of present
illness sys. review, family history…)
2) Detailed examination (growth parameter, vital signs"
normal or not" &lab. Findings)
3) Assessment (summery of the case in few lines)
4) Differential diagnosis
5) Management & follow up
Admission, discharge basic, lab (urine, blood)
& X-Ray
OSCE exam:
2 station history
2 station examination
One data interpretation (growth
chart;wt/ht,normal/abnormal,e.g on a disease represent this
chart)
Management
Your colleague:
Rawan Omar Abu Soufeh
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