IMMUNITY & IMMUNIZATIONS

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Outline

• Principles of Vaccination

• The different types of vaccines used

• Vaccine Safety

• Vaccine Storage and Handling

•Vaccine Administration

•Vaccine Adverse Reaction

Objectives

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IMMUNIZATION - VACCINATION….A LONG STORY

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• One of the most effective «weapons» in

medicine

• 10th century in Central Asia Smallpox ➔Africa - Europe

• 1798 Edward Jenner immunizes first time

against smallpox

• 1885 Louis Pasteur prepares the 1st vaccine against Rabbies

• 1923 Diphteria, Tetanus.

• 1926 Pertussis.

• 1927 BCG (bacillus Galmette-Guerin)

• 1955 Salk vaccine (IPV) against poliomyelitis

• 1960 OPV, MMR.

• 1964 Measles.

• 2000 HPV vaccine

History of Vaccination

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INTRODUCTION

• Ability of human body to tolerate the presence of material indigenous to the body and to eliminate foreign material

• This discriminatory ability provide protection from infectious disease

• Indicated by the presence of antibody to the organism causing infectious disease

Immunity

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Immunity5

INTRODUCTION6

Vaccination versus Immunization

Vaccination

• Vaccination is a process of inoculating the vaccine/ antigen into the body irrespective of seroconversion

Immunization

• Immunization is the process of inducing immune response in an individual either humoral or cell mediated

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Vaccines

Vaccines are whole or parts of microorganisms administered to prevent an infectious disease

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Biology of Vaccines9

• Eliminating disease producing capacity of the microorganism.

• The immune response-similar to natural infection but causes little or no clinical symptoms.

• Produces immunity in most of the recipients with 1 dose, except those administered orally

• Sensitive to heat, and can’t be given to immunodeficient patients or those on immunosuppressive therapy.

• Could revert to its original pathogenic form, only OPV

Live attenuated vaccine: Consist of

whole inactivated

microorganisms

Biology of Vaccines10

• LA viral vaccines: measles, mumps, rubella, varicella, yellow fever, rotavirus, OPV & intranasal influenza

• LA bacterial vaccines: BCG & typhoid (oral)

Live attenuated vaccine: Consist of

whole inactivated

microorganisms

Biology of Vaccines

• Could not cause disease from infection even in an immunodeficient person

• Require multiple doses to cause immunity.

• Immune response is mostly humoral, no cellular immunity.

• Antibody titer against IV diminish with time

• Inactivated whole virus vaccines: IPV, Hep-A & rabies

• Inactivated whole bacterial vaccines: Pertusis

• Fractional vaccines: subunits-Hep B, influenza, acellular pertussis, HPV; toxoids-Diptheria & tetanus

Inactivated vaccine:

Produced by growing the

microorganism in culture media,

inactivating with heat and/or

chemicals (formalin)

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Modification of Toxin to Toxoid

toxin moiety antigenic determinants

chemical

modification

Toxin Toxoid

Biology of Vaccines

• The immune response to pure PS vaccine is T-cell independent, therefore not immunogenic in children<2 years of age; pneumococcal, meningococcal & typhoid polysaccharide vaccines

• Repeat dose of PS vaccine do not cause a booster response; predominant antibody produced in response to PS vaccine is IgM

• Conjugation of PS vaccine with a protein molecule changes the immune response from T-cell independent to T-cell dependent- increased immunogenicity in infants & booster response; Hib, Pneumococcal & Meningococcal conjugate vaccine

Polysaccharide vaccine: A type of

inactivated subunit vaccine composed of long chain of

sugar molecules that make up the surface of

certain bacteria

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Free vaccines are provided to protect

the baby against these 14 diseases:

✓ Diphtheria Rotavirus Pneumococcal disease

✓ Pertussis Hepatitis B Varicella

✓ Tetanus Measles

✓ Polio Mumps

✓ Influenza Rubella

✓ Haemophilus influenzae type B

✓ Meningococcal disease

✓

Childhood immunization program is

one of the best in the world. 14

Immunization schedule

Ideal Immunization schedule

• Epidemiologically relevant

• Immunologically competent

• Technologically feasible

• Socially acceptable

• Affordable

• Sustainable

For Government Programs it is cost first, efficacy next, safety lastFor Individual it is safety first, efficacy next, cost last

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Factors may influence the immune

response to vaccination

• The presence of maternal antibodies

• Nature and dose of antigen

• Route of administration &presence of an adjuvant (improve the immunogenicity of the vaccine)

• Host factors such as (age, nutritional status, and coexisting disease)

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Scheme of immunization

• Primary vaccination

• One dose vaccines (BCG, varicella, measles, mumps, rubella, yellow fever)

• Multiple dose vaccines (polio, DPT, hepatitis B)

• Booster vaccination

• To maintain immunity level after it declines after some time has elapsed (DT, MMR).

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Jordan

Jordan was one of the first middle east countries that

established a national immunization program in

1979.

Vaccination coverage ≥90% reduced mortality and

morbidity rates caused by diseases included in the

schedule.

Combination vaccines were used despite its high cost

were used to reduce pain and no. of injections in the

same visit.

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New vaccines are introduced to the schedule with

time:

- HBV 1995

- HiB 2001

- Penta (IPV, DTaP, HiB) 2010.

- Rota 2015

- Hexa (IPV, DTaP, HiB, HBV) 2017.

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National Immunization Schedule

Age Vaccines

Birth BCG,

2 months DTaP1, IPV1, HepB1, Hib1, Rota1, (PCV1)

3months DTaP2, IPV 2,OPV1, HepB2, Hib2,Rota 2

4months DTaP3, IPV 3,OPV2, HepB3, Hib3,Rota 3, (PCV2)

9 months Measles,OPV 3,Vitamin A(100.000IU)

12months MMR1

18-24 months DTP, OPV4, MMR2,Vitamin A(200.000IU)

7 years dT,OPV5

16 years dT

Pregnant T according to the history of each person

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Tow Important TERMS

Contraindication: is a condition that greatly increases the chance of a

serious adverse reaction.(MMR)

Permanent Contraindications: All vaccines

Anaphylactic reaction to prior dose of vaccine

Anaphylactic reaction to a component of the vaccine

Precaution : a condition that mightincrease the chance or severity of a

serious adverse reaction

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The following are also NOT

contraindications to vaccination:

Family history of any adverse reactions following immunisation

Previous history of pertussis, measles, rubella or mumps infection

Prematurity: immunisation should not be postponed

Stable neurological conditions such as cerebral palsy and Down’s syndrome

Contact with an infectious disease

Asthma, eczema, hay fever or ‘snuffles’

Treatment with antibiotics or locally-acting (e.g. topical or inhaled) steroids

Child’s mother is pregnant

Child being breast fed

History of jaundice after birth

Under a certain weight

Over the age recommended in immunisation schedule

‘Replacement’ corticosteroids

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HIGH-RISK children

Recommended vaccines for HIGH-RISK children (Vaccines under special circumstances)

1. Influenza vaccine

2. Meningococcal vaccine

3. Cholera vaccine

4. Rabies vaccine

5. Yellow fever vaccine

6. PPSV 23

High-risk category of children:➢Congenital/acquired immunodeficiency➢Chronic cardiac, pulmonary, hematologic, renal, liver disease & diabetes mellitus➢Children on long term steroids, salicylate, immunosuppressive or radiation therapy➢Cerebrospinal fluid leak, Cochlear implant, Malignancies➢Children with functional/anatomic asplenia/hyposplenia➢During disease outbreaks➢Laboratory personnel & health care workers➢Travelers

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Different type of adverse events following immunization

Vaccine reaction Event caused/precipitated by the inherent properties of the vaccine (active component, adjuvant, preservative, stabilizer) when given correctly

Program errors Event caused by an error in vaccine preparation, handling or administration

Coincidental Event that happens after immunization but is not caused by the vaccine

Injection reaction

Event arising from anxiety about, or pain from, the injection itself rather than the vaccine

Unknown The cause of the event cannot be determined

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Common minor vaccine reactions

Vaccine Local reaction (pain, redness, swelling)

Fever Irritability, malaise & non specific reactions

BCG common

Hib 5-15% 2-10%

Hep-B Adults-15%Children-5%

1-6%

Measles/MMR

10% 5-15% 50% (rash)

OPV <1% <1%

TT/DT/Td

10% 10% 25%

DwPT 50% 50% 60%

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Rare serious vaccine reactions

Vaccine Reaction

BCG Suppurative adenitis, BCG osteitis, Disseminated BCGitis

Hep-B Anaphylaxis

Measles/MMR Febrile seizures, thrombocytopenia, anaphylaxis

OPV VAPP

TT Brachial neuritis, anaphylaxis, sterile abscess

DTP Persistent inconsolable screaming, seizures, HHE, anaphylaxis, shock

Rota Serious allergic reactions,intussuseption

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Managing Acute Vaccine Reactions

Staff should be familiar with the signs and symptoms of anaphylaxis because they usually begin within minutes of vaccination:

- can include, but are not limited to: flushing, facial edema, urticaria, itching, swelling of the mouth or throat, wheezing, and difficulty breathing.

❑ Epinephrine and equipment for maintaining an airway should be available for immediate use.

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Patient care before administering vaccine

- The patient’s immunization history should be reviewed at every healthcare visit.

- Use the current immunization schedule based on the age of the patient to determine all recommended vaccines that are needed.

- Patient or Parent Education including Vaccine Safety & Risk Communication

- The prophylactic use of antipyretics before or at the time of vaccination is not recommended.

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- Screening for contraindications and precautions can prevent adverse events following vaccination.

- The patient’s status may change from one visit to the next or recommendations regarding contraindications and precautions may have changed.

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Screening for contraindications and

precautions to vaccination

Is the child sick today?

Does the child have allergies medications, food, or any

vaccine?

Has the child had a serious reaction to a vaccine in the past?

Has the child had a seizure, or brain or nerve problem?

Has the child a health problem with asthma, lung disease,

kidney disease, metabolic disease such as diabetes, or a

blood disorder?

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Screening for contraindications and

precautions to vaccination (Continue)

Does the child have cancer, leukemia, ADIS, or any other immune system problem?

Has the child taken cortisone, prednisone, other steroids, or anticancer drugs, or had x-ray treatments in the past 3 months?

Has the child received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulins in the past year?

Is the child/pregnant pregnant or there is a chance she could become pregnant during the next month?

Has the child received vaccination in the past 4 weeks?

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Patient Care During Vaccine

Administration

Simple strategies that can be used by both parents and

providers to make receiving vaccines easier include:

- Displaying a positive attitude through facial expressions, body

language, and comments

- Using a soft and calm tone of voice

- Making eye contact, even with small children

Explaining why vaccines are needed.

- Being honest and explaining what to expect (e.g., do not say

that “the injection won’t hurt”).

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Procedural Pain Management

Breastfeeding

Sweet tasting solutions.

Injection technique (aspiration and slowly injecting

the vaccine may increase pain)

Order of injections (administer most painful vaccine

last)

Tactile stimulation (rub/stroke near injection site

prior to and during injection

Distraction

Topical anesthetics.

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Infection Control

Hand hygiene

Gloves

Equipment Disposal

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Vaccine Administration

Preparation

Injection technique

Choice of needle length

and size

Injection site

These are all important

considerations as each

factor can affect both the

immunogenicity and the

risk of local reactions at

the injection site

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Reconstitution of vaccine

Each vaccine should only be reconstituted and drawn up when required in order to:

- Avoid errors

- Maintain efficacy and stability

Reconstitution of freeze-dried vaccines:

- -Only use diluent supplied and use within specified time period

- -Only mix vaccines that are licensed and recommended to be mixed with other vaccines

Before administration:

- -Check colour and composition of vaccine is as specified in description in vaccine’s

- -Check vaccine to ensure is right product and correct dose for patient

- -Check expiry date

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Route of Injection

Vaccines should not be given intravenously

Most vaccines* should be given intramuscularly:

This reduces the chance of local reactions and leads to a better immune response to the vaccine

It is important the vaccine is injected into muscle and not into fat. This is why the deep subcutaneous route is no longer recommended for most vaccines

However:

Individuals with a bleeding disorder should receive their vaccines by deep subcutaneous injection to reduce risk of bleeding.

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Injection site

Intramuscular Injections Site

Preterms & neonates Anterolateral thigh (junction of middle & lower third)Infants

Toddlers & older children Deltoid or Anterolateral thigh

Adolescents & adults Deltoid

Subcutaneous Injections Site

Infants thigh

>12 months Outer triceps

Intradermal Injections Site

All age Left deltoid Region

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sciatic nerve anatomy

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Skin cleaning

Clean skin does NOT require cleaning

Visibly dirty skin need only be washed with soap

+ water

If alcohol and other disinfecting agents are used,

skin must be allowed to dry as these could

inactivate live vaccines

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Positioning of Patient

All ages: ensure vaccination area is completely exposed

Babies and young children:

sit child sideways on parent’s lap

ensure child is held securely

if anterolateral aspect of thigh being used: parent to ‘cuddle’ child closely and place child’s nearest arm around parent’s back. Parent to place one of their arms over child’s other arm and hold both legs firmly by placing their hand just above the child’s knees

if deltoid being used: parent to hold arm to be injected close to child’s body and tuck other arm behind parent’s back. Tuck child’s legs between parent’s legs or ask parent to hold legs firmly

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Common vaccine administration errors include:

Doses administered too early.

Wrong vaccine (e.g., Tdap instead of DTaP)

Wrong dosage (e.g., pediatric formulation of hepatitis B

vaccine administered to an adult)

Wrong route

Expired vaccine or diluent administered

Vaccine which was not stored properly administered

Vaccine administered to a patient with a contraindication for

that vaccine

Wrong diluent used to reconstitute the vaccine or only the

diluent was administered

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Strategies to Prevent Administration Errors

Adhere to “Rights of Medication Administration”

Provide ongoing staff training and education

Keep current reference materials available for staff

Rotate vaccines so those with shortest expiration

dates are in front and check frequently to remove

any expired vaccines

Do not store sound-alike and look-alike vaccines

next to each other

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Administer only vaccines that you have prepared

Triple check your work before administering a

vaccine

Color code and label vaccines with type, age, and

gender, if applicable

Store pediatric and adult vaccines on separate

shelves

Avoid interruptions when selecting and preparing

vaccines.

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CURRENT ISSUES

REGARDING

IMMUNISATION

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Documentation

➢ Date of administration

➢ Title of vaccine(s) administered

➢ Batch number

➢ Expiry date

➢ Site(s) of administration

➢ Information as appropriate to record

➢ Patient-held record

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Consent

➢Consent must always be obtained before every

immunisation its include:

➢What immunisation(s) are to be given

➢Which disease(s) will be prevented

➢Benefits and risks of immunisation versus risks of

disease(s)

➢Possible side effects and how to treat

➢Any follow-up/action required

➢Any new information

➢Agreement to proceed

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Deep freezer (-15 to -25O C) for ice packs & OPV stock for 3 months

ILR (+2 to +8OC) BCG, DPT, DT, TT, measles, Hep B stock for 3 months

Cold box (+2 to +8OC) for transport & power failure

Vaccine carrier (+2 to +8OC) For 12 hours

Cold chain

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Vaccine Stability

Sensitivity to HEAT

BCG

Varicella

MMR

MenC

Hepatitis B

DT and/or

aP/IPV/HIB

Sensitivity to COLD

HepB and

combination

DTand/or aP/IPV/HIB

Influenza

MenC

*MMR

*Varicella

*BCG

(*Freeze dried)LEAST

SENSITIVE

MOST

SENSITIVE

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Light Sensitive

Sensitive to strong light, sunlight, ultraviolet, fluorescents (neon)

BCG

MMR

Varicella

Meningococcal C Conjugate

Most DTaP containing vaccines

Vaccines should

always be stored in

their original

packaging until

point of use to

protect them from

light

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Temperature Monitoring

✓ Use max/min thermometer

✓ Probe should be placed in the centre of fridge

✓ Temperature should be recorded at least once a day

✓ Reset daily

✓ Calibrate as recommended

✓ Take immediate action if temperature is outside recommended range

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Sample refrigerator temperature record

chart

Available at: http://www2.cdc.gov/nip/isd/immtoolkit/content/vacstorage/logs.htm

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Storage temperature

Never exceed 8ºC or fall below 2ºC

Aim for 5ºC

Aim to maintain vaccine fridge as close as possible to 5˚C as this gives a safety margin of + or – 3˚c

✓

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Thank you

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