Administrative Principles of Vaccination

Prof. Dr. AHMET ARVASI.U. Cerrahpasa Medical Faculty, Department of Pediatrics

Vaccine preventable diseases

infant mortality in world-2010

Lancet 2012;380:2095-125

child mortality-2010 (1-4 y)

Lancet 2012;380:2095-125

Vaccine preventable deaths in world-2008

Measles 118.000Hib inf. 199.000Pertussis 195.000Tetanus 2.000N. Tetanus 59.000Yellow fever 30.000Diphteria 4.000Rotavirus inf. 453.000Pneumococcal dis. 476.000Hepatitis B inf. 10.000

1.5 million of deaths among children under 5 years are due todiseases that could have been prevented by routine vaccination

Measles: 2011:111; 2012:101 cases

Active vaccination

Protection produced by vaccine

Usually permanent

Immunity and immunologic memory similar to natural infection but without risk of disease

Classification of vaccines

Live attenuated bacterial viral

Inactivated whole: viruses, bacteria fractional: protein based (toxoid, subunit) polysaccharide-based (pure, conjugate)

Live Attenuated Vaccines

• Attenuated (weakened) form of the "wild" virus or bacterium

• Must replicate to be effective• Immune response similar to natural infection• Usually produce immunity with one dose(except those administrated orally)

*except those administered orally

Inactivated Vaccines

• Cannot replicate• Generally not as effective as live vaccines• Less interference from circulating antibody

than live vaccines• Generally require 3-5 doses• Immune response mostly humoral• Antibody titer may diminish with time

General RulesInactivated vaccines are generally not affected by circulating antibody to the antigen

Live attenuated vaccines may be affected by circulating antibody to the antigen

Polysaccharide Vaccines

• pneumococcal• meningococcal• Salmonella Typhi (Vi)

• Haemophilus influenzae type b• Pneumococcal (PCV-7, PCV-10, PCV13)• Meningococcal (MenC, MCV4)

Pure polysaccharide

Conjugate polysaccharide

2012Immunization Schedule-Turkeybirth 1

month2

months

4months

6months m m

First school grade (6

yrs)

Eighth school grade (13-14

yrs)

PCV

MMR

OPV

B

B

B

vP

DaPT/IPV +HepA II Varicella ı

Immunization coverage rate in Turkey (%)

Source: Turhish Health Ministry Public Health Institute

Immunization schedule (unvaccinated children: > 1 year)

12-59 mos(1-5 yrs) 6-13 yrs >14 yrs

at first time DaPT/IPV/Hib,HepB,ppd

DaPT/IPV, HepB, KKK Td, OPV, HepB, KKK

>2 days KKK, ppd: BCG - -

2 months DaPT/IPV/Hib orDaPT/IPV,HepB,OPV

DaPT/IPV, HepB, KKK,OPV

Td, OPA, HepB, KKK

8 months DaPT/IPV,HepB,OPV DaPT/IPV, HepB, OPV Td, HepB

All vaccines can be administered at the same visit as all other vaccines

Combination

two live injected or intranasal influenza vaccine

all other

Minimum Interval

4 weeks

None

Spacing of Vaccine Combinations Not Given Simultaneously

Increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine. It is not necessary to restart the series or add doses because of an extended interval between doses

Decreasing the interval between doses of a multidose vaccine may interfere with antibody response and protection

Vaccine doses should not be administered at intervals less than the minimum intervals or earlier than the minimum age

*after the series has been completed

Time limits for using vaccines after reconstitution

MMR≤ 8 hrs

BCG ≤ 4-8 hrs protect from ligth

Varicella ≤ 30 min

Types of administration errors

wrong vaccine or wrong diluent

wronge dosage

expired vaccine

wrong route/site/needle size

wrong time

wrong patient

Correct route, site, needle size

Vaccine Adverse Reactions

• Local– pain, swelling, redness at

site of injection– common with inactivated

vaccines– usually mild and self-limited

Vaccine Adverse Reactions

• Systemic– fever, malaise, headache– nonspecific– may be unrelated to vaccine

Vaccine Adverse Reactions

• Allergic– due to vaccine or vaccine

component– rare– risk minimized by screening

Contraindication

• A condition in a recipient that greatly increases the chance of a serious adverse reaction

Precaution

• A condition in a recipient that might increase the chance or severity of an adverse reaction, or

• Might compromise the ability of the vaccine to produce immunity

Contraindications

• severe allergic reaction to a vaccine component or following a prior dose

(anaphylactic reaction: all vaccines)

• Encephalopathy/encephalitis not due to another identifiable cause occurring within 7 days of pertussis vaccination

• Severe combined immunodeficiency (live vaccines)

Permanent contraindications to vaccination:

Immunosuppression• Disease– congenital immunodeficiency– leukemia or lymphoma– generalized malignancy

• Chemotherapy– alkylating agents– antimetabolites– radiation

Immunosuppression• Corticosteroids– 20 mg or more per day

of prednisone*– 2 mg/kg or more per day of prednisone*– NOT aerosols, alternate day, short courses,

topical

*for 14 days or longer

Vaccination of household contacts of immunosuppressed persons

• Healthy household contacts of immunosuppressed persons should receive MMR and varicella vaccines and annual influenza vaccination

Invalid contraindications to vaccination

• Mild illness• Antimicrobial therapy• Disease exposure or convalescence• Pregnant or immunosuppressed person in the

household• Breastfeeding• Preterm birth• Allergy to products not present in vaccine or allergy

that is not anaphylactic• Family history of adverse events• Tuberculin skin testing• Multiple vaccines

Vaccination during acute illness

• No evidence that acute illness reduces vaccine efficacy or increases vaccine adverse reactions

• Vaccines should be delayed until the illness has improved

• Mild illness, such as otitis media or an upper respiratory infection, is NOT a contraindication to vaccination

A healthcare encounter in which a person is eligible to receive vaccination but is not vaccinated completely

Missed opportunity

Reasons for missed opportunities

• Lack of simultaneous administration• Unaware child needs additional vaccines• Invalid contraindications• Inappropriate clinic policies

Vaccine Adverse Event Reporting System (VAERS)

National reporting system

Vaccine Adverse Event Reporting System (VAERS)

• Detects–new or rare events– increases in rates of known side effects–patient risk factors

• Additional studies required to confirm VAERS signals

• Not all reports of adverse events are causally related to vaccine

Adverse Event Classification

• Vaccine-induced: Due to the intrinsic characteristic of the vaccine preparation and the individual response of the vaccinee. These events would not have occurred without vaccination (e.g., vaccine-associated paralytic poliomyelitis after oral polio vaccine).

• Vaccine-potentiated: The event would have occurred anyway, but was precipitated by the vaccination (e.g., first febrile seizure in a predisposed child).

• Programmatic error: Due to technical errors in vaccine storage, preparation, handling, or administration.

• Coincidental: The reported event was not caused by vaccination but happened by chance occurrence or due to underlying illness.

Vaccine-associated paralytic polio (VAPP): overall incidence of once case of VAPP: per2.4 million doses of OPV

Rotavirus vaccine/ increased risk of intussusception: no evidence for a causal link (coins.)

MMR-V: additional 4.3 febrile seizures per 10.000 MMR-V doses compared to MMR andV administered separately

MCV4/ Guillain-Barre Syndrome: no evidence for a causal link (coincidental)

Hep B V/ Guillain-Barre Syndrome, transverse myelitis: no evidence for a causal link

MMR/ autism, inflammatory bowel diseases: no evidence for a causal link (coinc.)

Thimerosal (mercury containing preservative)-containing vaccines/ autism, inflammatory bowel diseases, ADHD : no evidence for a causal link (coincidental)

Vaccines/ ITP: vaccine potentiated