Immunization Review GP

8/2/2019 Immunization Review GP

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Immunization: BasicsImmunization: Basics& Newer Vaccines& Newer Vaccines

Dr. Chandki Kishore

Consulting Pediatrician


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ImmunizationImmunization

Center for Disease Control & PreventionCenter for Disease Control & Prevention(CDC-ACIP) publishes Childhood and(CDC-ACIP) publishes Childhood and

Adolescent Immunization SchedulesAdolescent Immunization Schedules at leastat least

annuallyannually since 1995since 1995

Indian AcademyIndian Academy of Pediatrics (IAP) revisesof Pediatrics (IAP) revisesthe Immunization Schedule almostthe Immunization Schedule almost every 3every 3

yearsyears: Latest: Latest 20112011

Many care givers/parents areMany care givers/parents are not awarenot aware ofofimportance of various vaccines/newerimportance of various vaccines/newer

additionsadditions

Parents may beParents may be misleadmislead by media/peerby media/peer

groupsgroups


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Shots Hurt! Why Do We Have To Give Them?Shots Hurt! Why Do We Have To Give Them?


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Enteric fever

Hepatitis-AHepatitis-B

Miliary TB


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Why vaccination rates low?Why vaccination rates low?

COSTCOSTConfusing, conflicting vaccine schedulesConfusing, conflicting vaccine schedules

Need for a doctor visit & physical beforeNeed for a doctor visit & physical before

giving a vaccinegiving a vaccine

Office policies: no vaccine review, noOffice policies: no vaccine review, no

vaccination at sick visitsvaccination at sick visits

No easy way to track, and check vaccineNo easy way to track, and check vaccine

statusstatusOver use of contraindicationsOver use of contraindications

Many believe that natural infection confersMany believe that natural infection confers

better immunity, e.g. chicken poxbetter immunity, e.g. chicken pox


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Vaccines work!Vaccines work! Vaccines are THE most effectiveVaccines are THE most effective

preventive measure that modernpreventive measure that modern

medicine has derivedmedicine has derived


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Immunization ScheduleImmunization Schedule

Every country has itsEvery country has its own immunization scheduleown immunization schedule

because:because:Low prevalence of disease/not cost effective e.g. noLow prevalence of disease/not cost effective e.g. no

BCG in US/UKBCG in US/UK

Certain diseases are prevalent in particular age group,Certain diseases are prevalent in particular age group,

e.g. Measles at 9 mo; MMR in India given at 15 mo & 5e.g. Measles at 9 mo; MMR in India given at 15 mo & 5yrs. In UK at 13 yrsyrs. In UK at 13 yrs

Suitability of preparations & disease prevalence. e.g.Suitability of preparations & disease prevalence. e.g.

IPV instead of OPV in US/UK, influenza vaccine to allIPV instead of OPV in US/UK, influenza vaccine to all

children in cold countrieschildren in cold countriesOperational convenience. e.g. In India DPT-Hib givenOperational convenience. e.g. In India DPT-Hib given

at 6 weeks rather at 2 monthsat 6 weeks rather at 2 months

Guidelines changeGuidelines change: Hep-B booster at 5 years age was: Hep-B booster at 5 years age was

recommended earlierrecommended earlier(IAP-2001)(IAP-2001) no longer now!no longer now!


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Immunization Schedule for Birth- 6 yrs:2011


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Immunization Schedule for 7 18 yrs: 2011


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Immunity & ImmunizationImmunity & Immunization

IMMUNITY

INNATE

(Inborn/Natural)

Nonspecific/specific(Species, racial, individual)

ACTIVE

(Own antibodies)

PASSIVE

(Ready-made Ab)

NATURAL

By infection

ARTIFICIAL

By immunization

NATURAL

Maternal Ab, Colostrum

ARTIFICIAL

e.g. TIG, RIG

ACQUIRED

Immunization can be active/passive, Vaccination is always active.Vaccination does NOT guarantee immunization!


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National Immunization Schedule: UIP (1985)National Immunization Schedule: UIP (1985)

$ MMR is available in some states only.$ MMR is available in some states only.

$$ Hib is being introduced in two states to begin with$$ Hib is being introduced in two states to begin with

HepB0*

They wereoptional fewyears back?


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IAP Immunization Schedule-2007IAP Immunization Schedule-2007

< 13 yrs: only one dose of< 13 yrs: only one dose of

chicken pox vaccinechicken pox vaccinerecommendedrecommended

Painless

DPT

60-70%Efficacy


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IAP Immunization Schedule-2008*IAP Immunization Schedule-2008*


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IAP Immunization Schedule-2011: LATESTIAP Immunization Schedule-2011: LATEST


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* OPV alone if IPV cannot be given* OPV alone if IPV cannot be given

*# Rotavirus vaccine (2/3 doses depending on*# Rotavirus vaccine (2/3 doses depending onthe brand at 4-8 weeks interval)the brand at 4-8 weeks interval)

** The third dose of Hepatitis B can be given at 6** The third dose of Hepatitis B can be given at 6

monthsmonths

$ The$ The second dose of MMRsecond dose of MMR vaccine can be givenvaccine can be given

at any time 4-8 weeks after the first doseat any time 4-8 weeks after the first dose$ $$ $ Varicella (2Varicella (2ndnd dosedose may be given any time 3may be given any time 3

months after the 1months after the 1stst dose)dose)

# Typhoid revaccination every 3 years# Typhoid revaccination every 3 years

& Tdap preferred to Td, followed by repeat Td& Tdap preferred to Td, followed by repeat Td

every 10 yearsevery 10 years^ Only females, three doses at 0, 1-2 (depending^ Only females, three doses at 0, 1-2 (depending

on brands) & 6 monthson brands) & 6 months

oIAP Schedule-2001: Additional vaccine: Hep-B, Hib,IAP Schedule-2001: Additional vaccine: Hep-B, Hib,

MMR, Typhoid. Optional: Hep-A, Chicken PoxMMR, Typhoid. Optional: Hep-A, Chicken Pox


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Optional Vaccine?Optional Vaccine?

o Optional = Vaikalpik/Aechhik, Not SwechchhikOptional = Vaikalpik/Aechhik, Not Swechchhik

o Formerly: Hep-A, Hib & Varicella vaccineFormerly: Hep-A, Hib & Varicella vaccine

o Presently there isPresently there is no compulsory vaccineno compulsory vaccine in ourin ourcountry!country!

o For any Indian going to USA for study or job, MMRFor any Indian going to USA for study or job, MMRvaccine is mandatory. We do not have any mandatoryvaccine is mandatory. We do not have any mandatoryvaccine, any person coming to our country getsvaccine, any person coming to our country gets

Typhoid vaccine or Hepatitis A vaccine in his or herTyphoid vaccine or Hepatitis A vaccine in his or her

own interestown interest

oThe option is with the persons or the parents to go forThe option is with the persons or the parents to go fora particular vaccine or not,a particular vaccine or not, at their own riskat their own risk. The. The doctordoctor

should consider no vaccine as optionalshould consider no vaccine as optional vaccine!vaccine!

Indian Pediatrics 2001; 38: 99-101Indian Pediatrics 2001; 38: 99-101


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Delayed ImmunizationDelayed Immunization


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Common MistakesCommon Mistakes

o Administration of two vaccines at short intervals:Administration of two vaccines at short intervals:

weekly or after 15 daysweekly or after 15 days

oAdministration of two vaccines simultaneouslyAdministration of two vaccines simultaneouslydespite recommendation e.g. BCG with measles, MMRdespite recommendation e.g. BCG with measles, MMR

with chicken poxwith chicken pox

o Administration of vaccines at wrong site: e.g. givingAdministration of vaccines at wrong site: e.g. givingRabies/Hep-B vaccine at Hips, or DPT at hips in infants,Rabies/Hep-B vaccine at Hips, or DPT at hips in infants,

Tetanus toxoid in hips in older children/adultsTetanus toxoid in hips in older children/adults

o Failure to give good advice regarding vaccine e.g.Failure to give good advice regarding vaccine e.g.

Pneumococcal to SCA patient, Influenza to AsthmaticsPneumococcal to SCA patient, Influenza to Asthmatics

o Mixing of vaccines in the same syringe (prior toMixing of vaccines in the same syringe (prior toinjection) unless specifically recommended by theinjection) unless specifically recommended by the

manufacturermanufacturer


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Immunization: FactsImmunization: Facts

There isThere is no age limit for immunizationno age limit for immunization, even adults, even adults

need vaccines for protectionneed vaccines for protectionIf the vaccination was discontinued or delayed, itIf the vaccination was discontinued or delayed, it

should beshould be started from where it was stoppedstarted from where it was stopped. No. No

need to repeat the doses!need to repeat the doses!

No need no give hepatitis-A vaccines if child had itNo need no give hepatitis-A vaccines if child had it

once. But this does not apply to measles, mumps,once. But this does not apply to measles, mumps,

tetanus, diphtheria, typhoid, etctetanus, diphtheria, typhoid, etc

MalnourishedMalnourished/underweight children also require/underweight children also require

timely vaccinationtimely vaccination

Vaccination site shouldVaccination site should never be rubbednever be rubbed. It should. It should

be pressed for a minute!be pressed for a minute!


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Immunization: FactsImmunization: FactsIf the child hadIf the child had confirmed varicellaconfirmed varicella or laboratoryor laboratory

evidence of prior disease, it is not necessary toevidence of prior disease, it is not necessary tovaccinate regardless of age at infection. If there isvaccinate regardless of age at infection. If there is

any doubt that the illness was actually varicella, theany doubt that the illness was actually varicella, the

child should be vaccinated.child should be vaccinated.

Children can beChildren can be breastfed soon afterbreastfed soon aftergiving oralgiving oralpolio vaccinepolio vaccine

Children with mild fever, cough, cold or diarrheaChildren with mild fever, cough, cold or diarrhea

can take all the vaccinescan take all the vaccines

Pulse polio immunization is supplementaryPulse polio immunization is supplementary toto

routine vaccinationroutine vaccination

Preterm babiesPreterm babies should be given vaccination atshould be given vaccination at

usual age (except Hep-B when >2 Kg or > 1mo)usual age (except Hep-B when >2 Kg or > 1mo)


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Tetanus Toxoid & InjuryTetanus Toxoid & Injury

oThere isThere is

no urgency for the administration of tetanusno urgency for the administration of tetanus

toxoid in the acutetoxoid in the acute setting, as it provides protectionsetting, as it provides protection

against the next injury and not the current injury.against the next injury and not the current injury.

Persons discovered not to have completed the three-Persons discovered not to have completed the three-

shot primary series should do so.shot primary series should do so.

oIt is not possible to clinically determine whichIt is not possible to clinically determine which woundswoundsare tetanus proneare tetanus prone, as tetanus can occur after minor,, as tetanus can occur after minor,

seemingly innocuous injuries, yet is rare after severelyseemingly innocuous injuries, yet is rare after severely

contaminated wounds.contaminated wounds.

oGiving Tetanus toxoidGiving Tetanus toxoid with each injury or every 6with each injury or every 6months: Not justifiedmonths: Not justified. If TT is given frequently, it will. If TT is given frequently, it will

hyper-immunize the patient. Such a patient can develophyper-immunize the patient. Such a patient can develop

arthus like phenomenon with development of fever,arthus like phenomenon with development of fever,

rash, joint pain, joint swelling etc.rash, joint pain, joint swelling etc.


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Tetanus Toxoid & InjuryTetanus Toxoid & Injury

oAA TT/dTTT/dT should be administered if the history of theshould be administered if the history of the

last booster was > 10 years. If the history is notlast booster was > 10 years. If the history is notavailable, TT may be considered when convenient.available, TT may be considered when convenient.

oIf the history demonstrates that the last immunizationIf the history demonstrates that the last immunizationwaswas >10 years ago, then Tetanus Immune Globulin>10 years ago, then Tetanus Immune Globulin (TIG)(TIG)

should be administered. The severity of the woundshould be administered. The severity of the woundshould not be a factor in the administration of TIG.should not be a factor in the administration of TIG.

oTT: dT is preferred over TT at all times. Cold chainTT: dT is preferred over TT at all times. Cold chainshould be well maintained. Should be given 0.5 mL IMshould be well maintained. Should be given 0.5 mL IM

over deltoid!over deltoid!


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Tetanus Toxoid & InjuryTetanus Toxoid & InjuryCompleted

Age

Tetanus

Vaccination6 weeks DPT1

10 weeks DPT2

14 weeks DPT3

16-18months

DPTB1

5 years DPTB2

10 years dT/tdaP

dT/TT every 5-10 yearsthereafter!

No need to give TT in-

Between the DPT doses!

However In case of injury,

Dose of coming DPT can

Be lowered e.g. DPTB1 can

Be given as early as 15 mo,DPTB2 can be given as

Early as 4 years!


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Measles, Mumps, Rubella (MMR)Measles, Mumps, Rubella (MMR)

oMeaslesMeasles is highly infectious & may causeis highly infectious & may cause

complications such as diarrhea, ear infections,complications such as diarrhea, ear infections,pneumonia and encephalitis.pneumonia and encephalitis.oMumpsMumps is also infectious & can cause complicationsis also infectious & can cause complicationssuch as meningitis and deafness. It may also causesuch as meningitis and deafness. It may also causepancreatitis. In boys, it can cause orchitis & infertility.pancreatitis. In boys, it can cause orchitis & infertility.

In girls, it can cause swelling of the ovaries.In girls, it can cause swelling of the ovaries.oRubellaRubella (German measles) is usually a mild illness(German measles) is usually a mild illnesshowever, it can be harmful to pregnant women. Ifhowever, it can be harmful to pregnant women. Ifwomen become infected in the first 16 weeks ofwomen become infected in the first 16 weeks ofpregnancy, its very likely to affect unborn baby. It canpregnancy, its very likely to affect unborn baby. It can

cause blindness, deafness, brain damage & heartcause blindness, deafness, brain damage & heartdamage to baby. Rubella can also lead to miscarriage. Ifdamage to baby. Rubella can also lead to miscarriage. Ifbecome infected within 16 and 20 weeks of pregnancy,become infected within 16 and 20 weeks of pregnancy,there is a risk that baby will be deaf. After 20 weeks,there is a risk that baby will be deaf. After 20 weeks,there is no increased risk.there is no increased risk.

oMMR vaccine can prevent each of these illnesses!MMR vaccine can prevent each of these illnesses!


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oIAP-COI recommends the use of MMRIAP-COI recommends the use of MMRvaccinevaccine instead of monovalent rubellainstead of monovalent rubella vaccinevaccineso as to provide additional protection againstso as to provide additional protection against

Mumps and MeaslesMumps and Measles

oNo upper age limitNo upper age limitoShould be givenShould be given even if child had sufferedeven if child had sufferedfrom measles/mumpsfrom measles/mumps

oIf child if above 1 year of age, not yetIf child if above 1 year of age, not yet

received measles vaccine, MMR can be givenreceived measles vaccine, MMR can be givenoDose isDose is 0.5 mL Subcutaneous0.5 mL SubcutaneousoVaccine can be given along with all otherVaccine can be given along with all otherchildhood vaccines except BCGchildhood vaccines except BCG


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oSeroconversion rates againstSeroconversion rates against MumpsMumps arearemore than 90% but clinical efficacy & longmore than 90% but clinical efficacy & longterm protection with single dose isterm protection with single dose is 60-90%60-90%..

Hence two doses.Hence two doses.

oTwo dosesTwo doses are recommended: 12-15 monthsare recommended: 12-15 months& second at school entry (4-6 years) or at any& second at school entry (4-6 years) or at anytime 8 weeks after the first dose.time 8 weeks after the first dose.

oCatch up vaccination with two doses of theCatch up vaccination with two doses of the

vaccine should be given to all those notvaccine should be given to all those notpreviously immunized (with no upward agepreviously immunized (with no upward age

limit) and especially tolimit) and especially to HCVHCV,, adolescent girlsadolescent girls &&

students traveling for studies oversea.students traveling for studies oversea.


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Storage at Clinic: Cold ChainStorage at Clinic: Cold Chain


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TARGET 5: Guide on vaccine storage & handling: 1st Ed, Dec 2006, IAP SURAT


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Spacing of VaccinesSpacing of Vaccines

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm


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Time limits for using vaccines after reconstitutionTime limits for using vaccines after reconstitution

V i ti SitV i ti Sit


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Vaccination SitesVaccination Sites

Anterolateral thigh (vastusAnterolateral thigh (vastus

lateralis):lateralis):The infants nappy must be undone toThe infants nappy must be undone to

ensure the injection site is completelyensure the injection site is completely

exposed and the anatomical markersexposed and the anatomical markers

easily identified.easily identified.

Position the leg so that the hip andPosition the leg so that the hip and

knee are flexed and the vastus lateralisknee are flexed and the vastus lateralis

is relaxed.is relaxed.The upper anatomical marker is theThe upper anatomical marker is the

midpoint between the anterior superiormidpoint between the anterior superior

iliac spine and the pubic tubercle, andiliac spine and the pubic tubercle, and

the lower marker is the upper part ofthe lower marker is the upper part of

the patella.the patella.

Draw an imaginary line between the 2Draw an imaginary line between the 2markers down the front of the thigh.markers down the front of the thigh.

The correct site for IM vaccination isThe correct site for IM vaccination is

lateral to the midpoint of this line, inlateral to the midpoint of this line, in

the outer (anterolateral) aspect.the outer (anterolateral) aspect.

Do not inject into the anterior aspectDo not inject into the anterior aspect

of the thigh where neurovascularof the thigh where neurovascular

structures can be damaged.structures can be damaged.



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Ventrogluteal area:Ventrogluteal area:

[Do not confuse with the[Do not confuse with thedorsogluteal area (buttock)]dorsogluteal area (buttock)]

The ventrogluteal site providesThe ventrogluteal site provides

an alternative site foran alternative site for

administering vaccines to aadministering vaccines to a

child of any age, especiallychild of any age, especiallywhen multiple injections at thewhen multiple injections at the

same visit are required. Thesame visit are required. The

ventrogluteal area is relativelyventrogluteal area is relatively

free of major nerves and bloodfree of major nerves and blood

vessels, and the area providesvessels, and the area provides

the greatest thickness ofthe greatest thickness of

gluteal muscle.25,26 There is agluteal muscle.25,26 There is a

relatively consistent thinnessrelatively consistent thinness

of subcutaneous tissue overof subcutaneous tissue over

the injection sitethe injection site



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The deltoid area:The deltoid area:

It is essential to expose the armIt is essential to expose the armcompletely from the top of thecompletely from the top of the

shoulder to the elbow when locatingshoulder to the elbow when locating

the deltoid site. Roll up the sleeve orthe deltoid site. Roll up the sleeve or

remove the shirt if needed.remove the shirt if needed.

The injection site is halfwayThe injection site is halfway

between the shoulder tip (acromion)between the shoulder tip (acromion)and the muscle insertion at theand the muscle insertion at the

middle of the humerus (deltoidmiddle of the humerus (deltoid

tuberosity).tuberosity).

Draw an imaginary, inverted triangleDraw an imaginary, inverted triangle

below the shoulder tip, using thebelow the shoulder tip, using the

identified anatomical markers.identified anatomical markers.

The deltoid site for injection is theThe deltoid site for injection is the

middle of the muscle (trianglemiddle of the muscle (triangle))

SC vaccines can also beSC vaccines can also be

administered over same region!administered over same region!

Vaccination site should never beVaccination site should never berubbed!rubbed!

V i ti P iti iV i ti P iti i


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Vaccination: PositioningVaccination: Positioning

M di l l A t


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Medicolegal AspectsMedicolegal Aspects

o The vaccine administratorThe vaccine administratormust explain in detailmust explain in detail thethecharacteristics and anticipated side effects of the vaccinecharacteristics and anticipated side effects of the vaccinein reasonable detail to the caregivers prior toin reasonable detail to the caregivers prior to

immunization.immunization.

o A verbal consent is usually adequate. In any case, theA verbal consent is usually adequate. In any case, the

recipient must berecipient must be observed for any allergic effectsobserved for any allergic effects for atfor atleast 15 minutes after vaccination and all resuscitativeleast 15 minutes after vaccination and all resuscitative

equipment must be kept standby for possibleequipment must be kept standby for possible

anaphylaxis. The care givers should also be counseledanaphylaxis. The care givers should also be counseled

about possible side effects, their management andabout possible side effects, their management anddanger signs before the vaccinee is sent home.danger signs before the vaccinee is sent home.

o Minimum equipmentMinimum equipment: Airway, ambu bag, mask, IV: Airway, ambu bag, mask, IVaccess (scalp vein, venflon), Oaccess (scalp vein, venflon), O22 cylinder, Inj. Adr (1: 1000cylinder, Inj. Adr (1: 1000

sol.), IV hydrocortisone, Normal salinesol.), IV hydrocortisone, Normal salineIndian Academy of Pediatrics: Guidebook on Immunization, 2011Indian Academy of Pediatrics: Guidebook on Immunization, 2011

A h l i V i i


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Anaphylaxis: VaccinationAnaphylaxis: Vaccination

I i ti f HCV


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Immunization for HCVImmunization for HCV

www.immunize.org/catg.d/p2017.pdfwww.immunize.org/catg.d/p2017.pdf


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Not Your Parents Vaccine Schedule!Not Your Parents Vaccine Schedule!

Age 1985 2012

Birth BCG + OPV + HB6 weeks DPT1 + OPV + HB + Hib + IPV + PCV + Rota

10 weeks DPT2 + OPV + HB + Hib + IPV + PCV + Rota*

14 weeks DPT3 + OPV Hib + IPV

9 months Measles 12 mo: Hep-A, Varicella, MMR

18 months DPTB + OPV Hib + IPV, Hep-A2, 2 yrs: Typhoid

5 years DT DPT + Varicella2 + MMR2, Typhoid2

10 years TT Tdap/dT, HPV for girls

16 years TT dT

Total 6 diseases,

9 shots

16 diseases,

22 shots at least


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Thanks

I i ti Q & AI i ti Q & A


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Immunization: Q & AImmunization: Q & A

Is there any need of documentation in case of

refusal to vaccinate the child?

Is it compulsory to wear gloves or change theneedle while vaccinating the child?

What should be done if child vomits the oralvaccine?

What is the preferred site of vaccination for i/minjection or vaccination on children?

What should be done if a 1 month old childaccidentally given DPT?

Is there any need of aspiration before injection ofvaccines or toxoids?



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What measures should be take to prevent

anaphylaxis?

Is there any need of rubbing the site aftervaccination?

What should be done if previous vaccinationrecords are not available?

What should be done if there is a long lapse oftime between the doses? e.g. 2 years lapsed

after 1st dose of HAV vaccine

What should be the ideal time interval betweenvarious vaccine? Does it apply to oral vaccine(like OPV, Rota, Ty21a, Cholera) also?



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What is the time limit to delay the vaccine from

the scheduled date?

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