Immunization

ALBERTO I GABRIEL, MD, DTM&H, MPA, DPBMM, FPSMID, FPSVI, FPAMS, CFA

Department of Medicine-College of Medicine Pamantasan Ng Lungsod Ng Maynila

GENERAL PRINCIPLES OF VACCINATION DEFINITIONS: VACCINATION - denotes the administration of the vaccines or toxoid

IMMUNIZATION - descibe the process of inducing or

providing immunity by any means, whether active or passive

ACTIVE IMMUNIZATION - refers to induction of the immune defenses by the administration of antigens in appropriate forms

PASSIVE IMMUNIZATION - the provision of

temporary protection by the administration of exogenously produced immune substances

GENERAL PRINCIPLES OF VACCINATION Active Immunization comes in two forms:

1) the use of live, generally attenuated infectious agents 2) the use of inactivated agents of their products obtained by genetic recombination

Passive Immunization comes in three types:

1) standard human immune globulin for general use (gammaglobulin) 2) special serum immune globulins with a known content of antibody for specific agents (HBV or Varicella Zoster Imune Globulin) 3) animal sera and antitoxins

ROUTINE ADULT IMMUNIZATION FOR FILIPINOS VACCINE NAME

SCHEDULES

CONTRAINDICATION

3 DOSES 0, 1, 6-12 Mos BOOSTER EVERY 19 YRS

Severe allergic reaction to vaccine component

Recommended for IMMIGRANT, HEMODIALYSIS, HOMOSEXUALS, IV DRUG USER, HOUSEHOLD CONTACT, RECIPIENT OF BLOOD PRODUCT, HEALTHCARE WORKER

3 DOSES O, 1, 6 MONTHS 4 DOSES 0, 1, 2, 12 MONTHS BOOSTER IS NOT ROUTINELY RECOMENDED

Severe allergic reaction

Live attenuated Vaccine

Recommended for Persons> 13 yrs of age without history of varicella, HEALTH CARE WORKERS, TEACHERS OF YOUNG CHILDREN, NON-PREGNANT WOMEN, INTERNATIONAL TRAVELLER, MILITARY

<13 years – 1 dose >13 years – 2 dose 0, 1 month

Severe allergic rxn Pregnancy Immunosuppression Recently received blood products, Untreated active TB, Severe Acute Illness

MMR Live attenuated vaccine

Recommended for all adults particularly All susceptible adoslescent s and adults Non-pregnant women of child-bearing age

2 doses 0, 1 month

Pneumococcal Vaccine Inactivated vaccine

Persons >60 yrs of age <60 yrs of age with Chronic Illness ( Cardio Pulmo, Diabetes, Alcoholism, Cirrhosis ) Immunocompromised Conditions

Single dose

Influenza Vaccine Inactivated vaccine

Persons at increased risk for complication: - Pesons >50 yrs of age - Chronic illness ( Cardio-pulmo, Diabetes, Chronic Metabolic, Renal Dysfunction, - Immunosuppressed Patients - Healthcare Workers

Tetanus-diptheria Toxoid Hepatitis B Inactivated Vaccine

Varicella

INDIVIDUALS Recommended for PREGNANT WOMAN HEALTH CARE WORKERS

Severe allergic reaction Severe Acute Illness Pregnancy, Received BT Immunosuppression Thrombocytopenia/ITP

SAME AS ABOVE

Revaccination may be given after 5 years Given once a year preferably from February to June

Serious allergic reaction Severe acute illness Guillain-Barre Syndrome

ADDITIONAL VACCINES FOR HCW VACCINE NAME

INDIVIDUALS

TYPHOID A) Oral enteric coated cap live attenuated Ty21a B) IM VI Capsular Polysaccharide Ty2

RABIES PVRV – Purified Verocell Rabies Vaccine PCECV – Purified Chick Embryo Cell Vaccine

SCHEDULES

ORAL – for 1. 2. 3.

FOOD HANDLERS MICROBIOLOGY LAB TECHNICIANS PERSONS WITH CONTACT WITH TYPHOID CARRIERS OR PATIENTS

HCW THAT TREAT DOGBITE VICTIMS RABIES RESEARCH DIAGNOSTIC LAB WORKERS VETERINARY & VET STUDENTS FIELD WORKERS AND DOG HANDLERS

Primary & booster 1 cap on Day 0, 2, 4, before meals

IM – for primary

CONTRAINDICATIO and PRECAUTION Mod & Seevere Acute Illness Vomiting or diarrhes After alcohol intake Antibiotic intake Immunocompromisd

& booster 0.5 ml IM on deltoid BOOSTER – every 2-3 years POST-EXPOSURE For IM Schedule D0, 3, 7, 14, 28 PRE-EXPOSURE D0, 7, 21 For ID Schedule D0, 3, 7, 28

Intake of Corticosteroids, AntiMalarials, Anti Cancer Drugs

GENERAL PRINCIPLES OF VACCINATION A.

IMMUNITY

Ability of the body to tolerate the presence of material indigenous to the body (self) and to eliminate foreign material (non-self). This ability provides protection from infectious diseases. Usually indicated by the presence of antibody. Very specific to a single antigen. ANTIGEN

- a live or inactivated substance (e.g. protein, polysaccharide) capable of producing an immune response

ANTIBODY – protein molecules (immunoglobulins) produced by B lymphocytes to help eliminate an antigen

TWO BASIC MECHANISMS FOR ACQUIRING IMMUNITY

1.

Active Immunity a) Protection produced by the person’s own immune system b) usually permanent also produced by vaccination

2.

Passive Immunity

a) Protection transferred from another person or animal as antibody b) transplacental most important source in infancy c) usually temporary

GENERAL PRINCIPLES OF VACCINATION 

CLASSIFICATION OF VACCINES

1. Live attenuated vaccines 

attenuated (weakened) form of the “wild” virus or bacteria



Must replicate to be effective



Immune response similar to natural infection



Usually effective with one dose



Severe reactions possible



Interference from circulating antibody



unstable VIRUSES: BACTERIA:

MMR, Varicella, Polio, Yellow fever, Influenza nasal spray BCG, Oral Typhoid

GENERAL PRINCIPLES OF VACCINATION 1. Inactivated Vaccines  cannot replicate because not live  minimal interference from circulating antibody  generally NOT as effective as live vaccines  generally requires 3-5 doses  immune response mostly humoral  antibody titer falls over time VIRUSES:

Influenza, Poliomyelitis, Rabies, Hepatitis A

BACTERIA:

Pertussis, Typhoid, Cholera

THE IMMUNE RESPONSE Primary Response  detection of humoral and cell-mediated immunity  measurable circulating antibodies appears beyond 7-10 days  early appearance of IgM exhibit low affinity for the antigen  late appearance of IgG shows high affinity for the antigen  some would not response due to lack of histocompatibility complex determinants

Secondary Response  heightened humoral or cell-mediated responses by second exposure to the same antigen  responses usually with 4-5days with increased titers IgG

GENERAL PRINCIPLES OF VACCINATION C.

Timing and spacing of vaccines

1. Interval between receipt of antibody containing blood products and measles vaccine • inactivated antigens are NOT substantially affected by circulating antibody, so that they can be administered before, after, or at the same time as the antibody. • All live vaccines must replicate in order to cause an immune response, so that antibody against live injected vaccine antigen may interfere with replication. • If the live vaccine is given first, it is necessary to wait for AT LEAST 2 WEEKS before giving the antibody. • If the interval between the vaccine and antibody is less than 2 weeks, the recipient should be tested for immunity or the vaccine dose should be repeated. • There is NO contraindication to the simultaneous administration of any vaccines EXCEPT for cholera and yellow fever. • Individual vaccines should NOT be mixed in the same syringe unless they are licensed for mixing by the FDA

GENERAL PRINCIPLES OF VACCINATION ANTIBODY AND LIVE VACCINES PRODUCT GIVEN FIRST

ACTION

VACCINE

Wait 2 weeks before giving the antibody

ANTIBODY (blood/blood

products, immune globulin)

2.

Wait >3 months before giving the vaccine

Spacing of vaccine combinations not given simultaneously COMBINATION

MINIMUM INTERVAL

Two live vaccines injected

4 weeks

All other vaccines

None

GENERAL PRINCIPLES OF VACCINATION 1. Spacing of live vaccines not given simultaneously

• If two live parenteral vaccine are given < 28 days apart, the vaccine given second should be repeated. • Exception is yellow fever vaccine given < 28 days after measles vaccine

6. Interval between doses of the same vaccine

• Increasing the interval between doses of a multi-dose vaccine does NOT diminish the effectiveness of the vaccine. • Decreasing the interval between doses of the multi-dose vaccine may interfere with antibody response and protection

GENERAL PRINCIPLES OF VACCINATION 5. Minimum Intervals and Ages

Vaccine doses should NOT be given at intervals less than the minimum intervals or earlier than the minimum age.

6. Extended Intervals

It is NOT necessary to restart the series of any vaccine due to extended intervals between doses

• Number of Doses • Live attenuated vaccines generally produce lasting

immunity with a single dose. • Inactivated vaccines require multiple doses and may require periodic boosting to maintain immunity.

GENERAL PRINCIPLES OF VACCINATION D. ADVERSE REACTIONS LOCAL • pain, swelling, redness at the site of injection • •

common with inactivated vaccines usually mild and self-limited

SYSTEMIC • fever, malaise, headache • •

non-specific may be unrelated to vaccine

ALLERGIC • • •

due to vaccine or vaccine component rare risk minimized by screening

GENERAL PRINCIPLES OF VACCINATION E. CONTRAINDICATIONS & PRECAUTIONS CONTRAINDICATION - is a condition in a recipient which greatly increases the chance of a serious adverse reaction EXAMPLE:

Administering FLU VACCINE to a person with a true anaphylactic allergy to egg could cause serious illness or death in the recipient.

PRECAUTION - is a condition in a recipient which may increase the chance or severity of an adverse event, or may compromise the ability of the vaccine to produce immunity EXAMPLE:

Administering MEASLES VACCINE to a person with passive immunity to measles from a blood transfusion

GENERAL PRINCIPLES OF VACCINATION PERMANENT CONTRAINIDICATION TO VACCINATION • •

severe allergy to a prior dose of vaccine or to a vaccine component encephalopathy following pertussis vaccine

CONDITION Allergy to vaccine component

LIVE

INACTIVATED

C

C C

Encephalopathy Pregnancy

C

V

Immunosuppression

C

V

Severe Illness

P

P

Recent blood product

P

V

C – contraindication

P – precaution

V – vaccinate if indicated

GENERAL PRINCIPLES OF VACCINATION IMMUNOSUPPRESSION • • •

Live vaccine can be given after chemotherapy has been discontinued for at least 3 months Persons receiving large doses of corticosteroids should NOT receive live vaccines e.g. ( >20 mg of prednisone per day or >2 mg/kg) NOT contraindicated with steroids given via aerosols, topical, alternate day, short causes

RECENT BLOOD PRODUCTS • Varicella and MMR vaccines should be given 14 days prior to the blood product, or delayed until the antibody has degraded

•

If MMR is given sooner than the minimum interval (3-7 months depending blood products) the recipient should be tested for immunity or the dose repeated after the appropriate interval

GENERAL PRINCIPLES OF VACCINATION

F.

INVALID CONTRAINDICATIONS TO VACCINATION           

mild illness – low grade fever, URTI, Otitis media disease exposure or convalescence antibiotic therapy pregnancy in the household breastfeeding allergies to products in the vaccine premature birth family history unrelated to immunosuppression need for TB skin testing need for multiple vaccines mild diarrhea

GENERAL PRINCIPLES OF VACCINATION

SCREENING FOR CONTRAINDICATIONS AND PRECAUTIONS TO VACCINATION SCREENING QUESTIONS:      

Allergies to food or medications? If yes, when? How are you today? Any problem after the last shot? Any problem with your body resistance? Any blood products ( fresh whole blood, platelet concentrate ) received in the last year? Are you pregnant or trying to be pregnant?