The process of inducing immunity against a specific Measles, mumps, rubella,
disease varicella, rotavirus, and live Passive through administration of antibody- attenuated influenza vaccines containing preparations o Toxoids Active by administering a vaccine or toxoid to Modified bacterial toxin made stimulate the immune system to produce a non-toxic but still able to induce prolonged humoral and/or cellular immune an active immune response response Tetanus and diphtheria
Passive Active Most B-lymphocyte response re quire the assistance of
Administration of Injection of an antigen CD4 helper T lymphocytes. These T-lymphocyte- preformed Ab dependent responses tend to induce high levels of Can be induced naturally Protection produced by functional antibody with high avidity, mature over time through transplacental the persons own from primarily an IgM response to a long-term persistent transfer of Ab during immune system IgG response and induce immunologic memory that gestation leads to enhanced responses upon boosting. Protection may persist Usually permanent T-lymphocyte-dependent vaccines for months to as long as o Include protein moieties a year after birth o Induce good immune responses even in young infants T-lymphocyte-independent vaccines PASSIVE IMMUNIZATION o Polysaccharide antigens induce B- Major indication - to provide protection to: lymphocyte responses in the absence Immunodeficient children with B- of T-lymphocyte help lymphocyte defects who have difficulties o Associated with poor immunity, and making Ab absence of an enhanced or booster Persons exposed to infectious diseases or response on repeat exposure to the at imminent risk of exposure where there is not antigen adequate time to develop an active immune o To overcome this, polysaccharides response to a vaccine have been conjugated, or covalently Persons with an infectious disease as part of linked, to protein carriers, converting specific therapy for that disease the vaccine to a T-lymphocyte- dependent vaccine ACTIVE IMMUNIZATION Live Attenuated Vaccines VACCINES Tend to induce long-term responses Defined as whole or parts of microorganisms They replicate, often similarly to natural administered to prevent an infectious disease infections, until an immune response shuts Can induce immunity through stimulation of down reproduction antibody formation, cellular immunity, or both Mostly administered as single-dose schedules Protection is thought to be mediated primarily Repeat dose, like MMR, is to induce an initial by B-lymphocytes, which produce antibody immune response in persons who failed to Can consist of: respond to the first dose o Whole inactivated microorganisms IPV, Hepatitis A Inactivated Vaccines o Parts of microorganism Tend to require multiple doses to induce an Acellular pertussis, HPV, adequate immune response Hepatitis B More likely to need boosters to maintain o Polysaccharide capsules immunity Pneumococcal and Some inactivated vaccines, however, appear meningococcal polysaccharide to induce long-term immunity, perhaps life-long, vaccines after a primary series o Polysaccharide capsules conjugated to o e.g. Hep B vaccine, IPV protein carrier Hib, pneumococcal, and meningococcal conjugate vaccines ROUTE OF ADMINISTRATION A rapid plunge of the needle through the Injectable vaccines should be administered in skin without aspirating and rapid injection areas unlikely to cause local neural, vascular, or may decrease discomfort tissue injury. Rubbing or stroking the skin near the o Upper, outer quadrant of the buttocks injection site with moderate intensity before should not be used because the gluteal and during vaccination also may reduce the region consists mostly of fat in young sensation of pain children and because of potential injury Psychological Techniques for Minimizing to the sciatic nerve Injection Pain Intramuscular (IM) injections for infants and Parent-led or physician-led age- young children appropriate distraction can reduce o Anterolateral thigh muscle pain-related distress at the time of preferred because of its muscle injection mass relative to other sites Pharmacologic Techniques for Minimizing o Needle length Injection Pain 58 in. for newborn infants Topically applied agents may reduce 1 in. for infants 2-12 mo./o the pain of injection 1 to 1 14 in for older children o Currently available topical IM injections for adolescents and adults anesthetics require 30-60 o Deltoid muscle of the arm minutes to provide adequate o Needle length: 1 1 12 in anesthesia so planning ahead is Subcutaneous inoculations also usually necessary should be given in the thigh of infants and the deltoid area of older children Simultaneous Administration of Multiple Vaccines Intradermal vaccines generally should be Most vaccines can be given simultaneously administered on the volar aspect of the forearm without impairment of effectiveness or safety Data indicate possible impaired immune Most inactivated vaccines, including DTaP, Hep responses when 2 or more parenterally A, Hep B, Hib, inactivated influenza vaccine, administered live-virus vaccines are not given PCV13, MCV4, and Tdap, are administered simultaneously but rather within 28 days of each intramuscularly (IM). other Commonly used live attenuated vaccines, MMR and varicella, should be dispensed subcutaneously (SC) IPV and PPS23 (pneumococcal polysaccharide vaccine) can be given IM or SC RV vaccine and OPV are the only US-licensed vaccines for children that are administered by the oral route
Managing Injection Pain
Truthful & empathetic preparation for injections is beneficial, using the words that are explanatory without evoking anxiety pressure, squeezing and poking rather than pain, hurt and shot Parents and medical care providers should not VACCINE CONTRAINDICATIONS AND tell children that it wont hurt because this type PRECAUTIONS of statement has been show to ineffective in Contraindication reducing pain at the time of injection o A condition in a patient that increases Physical Techniques for Minimizing Injection the risk of a serious adverse reaction and for whom this increased risk of an Pain adverse reaction outweighs the benefit Breastfeeding of the vaccine Children should be held on the lap of a parent or other caregiver Older children may be more comfortable sitting on the examination table edge & hugging their parent chest to chest Precaution Family history of sudden unexpected death o A condition in a recipient that might Family history of an adverse event following increase the risk or seriousness of an immunization adverse reaction or complicate making Breastfeeding or pregnancy in a household another diagnosis because of a contact possible vaccine-related reaction Established, generic contraindications are: Lapsed Immunizations o moderate or severe illness A lapse in the immunization schedule does not o a previous anaphylactic reaction to the require reinitiating the entire series or addition of specific vaccine, and doses to the series for any vaccine in the o a severe hypersensitivity reaction, such recommended schedule as anaphylaxis, to a vaccine constituent Subsequent immunizations should be given at The decision to defer immunization in a febrile the next visit as if the usual interval had elapsed child should be based on the physicians o For RV vaccine, the doses to be assessment of the severity of the illness rather administered are age limited, so catch- than the degree of fever up may not be possible o Children with minor illness and low- grade fever generally should be Unknown or Uncertain Immunization Status vaccinated, especially if a child is A person with unknown or uncertain unlikely to return promptly for the immunization status should be considered deferred immunization disease-susceptible, and recommended Administration of live virus vaccines such as immunizations should be initiated without delay MMRV generally is contraindicated in patients on a schedule commensurate with the persons with altered immunity current age o Morbidity & mortality rates of measles Serologic testing is an alternative to vaccination and lack of complication from for certain antigens (e.g. measles, rubella, vaccination of children infected with HIV hepatitis A, and tetanus) have led to recommendations that No evidence suggests that administration of these children, unless significantly vaccines to already immune recipients is immunocompromised, receive the harmful MMR vaccine Because of a theoretical risk to the developing Interchangeability of Vaccine Products fetus, administration of live virus vaccines in When possible, effort should be made to most cases is not recommended for pregnant complete a series with vaccine made by the women same manufacturer Although data documenting the effects of MISCONCEPTIONS interchangeability are limited, most experts Common conditions that should not delay vaccination have considered vaccines interchangeable but often are considered mistakenly to be when administered according to their contraindications include: recommended indications Diarrhea Licensed vaccines that may be used Minor upper respiratory tract illnesses (including interchangeably during a vaccine series otitis media) with or without fever include: Mild to moderate local reactions to a previous o Diphtheria & tetanus toxoid dose of vaccine vaccines Exposure to an infectious disease o Hepatitis A vaccines Current antimicrobial therapy o Hepatitis B vaccines Being in the convalescent phase of an acute o Rabies vaccines illness o RV vaccines Allergy to duck meat or duck feathers as long as recommendations Allergy to an antibiotic (except anaphylactic concerning conversion from a 2- reaction to neomycin, gentamicin, dose regimen to a 3-dose or streptomycin, if any of these are in the regimen are followed vaccine to be administered) o Hib conjugate vaccines History of non-anaphylactic allergy to egg as long as recommendations for a Personal or family history of seizures total of 3 doses in the first year of life are followed The National Immunization Program (NIP) o Measles-Mumps-Rubella (MMR) Previously known as the Expanded Program on vaccine given at 12 months of age Immunization (EPI) A school based immunization program to Consists of the following antigens: provide catch-up doses for school children and o BCG vaccine, single dose given at birth adolescents has been established o Monovalent Hepatitis B vaccine given at o Measles-Rubella (MR) and Tetanus- birth Diphtheria (Td) vaccines are o DPT-Hib-Hep B vaccine, 3 doses given administered to Grade 1 and Grade 7 at 6-10-14 weeks of age students enrolled in public schools o Oral Polio vaccine (OPV), 3 doses given o Human Papillomavirus (HPV) shall be at 6-10-14 weeks of age, a single dose given to female children 9-10 years old of Inactivated Polio vaccine (IPV) is at health facilities in priority provinces given with the 3rd dose of OPV at 14 Quadrivalent HPV 2 doses are weeks given at 0, 6 months o Pneumococcal conjugate vaccine (PCV), 3 doses given at 6-10-14 weeks Other recommended vaccines not part of the NIP of age o Japanese Encephalitis vaccine o Rotavirus vaccine given at a minimum o Influenza vaccine (Trivalent/Quadrivalent) age of 6 weeks with a minimum interval o Hepatitis A vaccine of 4 weeks between doses. The last dose should be administered not later Interim recommendation for use than 32 weeks of age. o Dengue tetravalent vaccine o Measles-containing vaccine (either monovalent measles vaccine or MMR) given at 9 months of age BACILLE CALMETE-GURIN (BCG) VACCINE Special Indications Live attenuated strain derived from o For pre-term infants Mycobacterium bovis Born to HBsAg (-) mothers & Used primarily in young infants in an attempt to medically stable give 1 dose st
prevent disseminated and other life-threatening at 30 days chronological age
manifestations of M. tuberculosis disease regardless of weight and this can o However, does not prevent infection with be counted as part of the 3-dose M. tuberculosis primary series Given on the right upper deltoid, intradermally, at Another dose of HBV is needed birth or at earliest possible age after birth, for those < 2 kg whose 1 dose st
preferably within the first 2 months was received at birth
Dose: o For term infants o 0.05 mL children less than 12 months Born to HBsAg (+) mothers - o 0.1 mL children more than 12 months give HBV and HBIg (0.5 mL) Contraindications: within 12 hours of life. HBIg o Burns, skin infections, certain primary or should be administered not later secondary immunodeficiencies (including than 7 days of age, if not HIV infection), persons receiving immediately available immunosuppressive medications o For infants born to mothers w/ (including high-dose corticosteroids) unknown HBsAg status Adverse Reactions BW 2 kg o Uncommon (1-2%) Administer HBV within Subcutaneous abscess 12 hours of birth and Regional (axillary) determine mothers lymphadenopathy HBsAg ASAP. If HBsAg o Rare (0.1 to 1 case per million) (+), administer HBIg not Osteitis affecting the epiphysis of later than 7 days of age long bones BW < 2 kg Disseminated fatal infection Administer HBIg in addition to HBV within Usual Accelerated 12 hours of life Reactions Reactions Contraindications Induration 2-4 weeks 2-3 days o History of anaphylaxis to a previous dose Pustule formation 5-7 weeks 5-7 days of vaccine Scar formation 2-3 months 2-3 weeks Adverse Reactions o Soreness at injection site o Possible association with GBS following HEPATITIS B VACCINE first dose of plasma-derived vaccine; no HBV infection is a leading cause of acute hepatitis evidence of association with recombinant Incidence is especially high in many Asian and vaccine African countries Given intramuscularly, in the anterolateral thigh or DIPHTHERIA AND TETANUS TOXOID AND PERTUSSIS deltoid area (depending on the age and size of the (DTP) VACCINE recipient) Diphtheria and Tetanus component are toxoids o Only single-antigen hepatitis B vaccine while Pertussis component can either be whole- can be used for doses given to infants cell (DTP) or acellular (DTaP) between birth and 6 weeks of age o Incidence of local and systemic reactions o Single-antigen or combination vaccine are more associated with whole-cell may be used to complete the series; four pertussis vaccine doses of vaccine may be administered if a Given intramuscularly birth dose is given and a combination vaccine is used to complete the series Given at a minimum age of 6 weeks with a Schedule: Birth-6-10-14 weeks (minimum interval minimum interval of 4 weeks o Recommended interval between 3rd and of 4 weeks) Dose: 0.5 mL 4th dose is 6 months but a minimum of 4 months is valid o 5th dose may not be given if the 4th dose was administered at age 4 years or older Contraindications Adverse Reactions o Immediate anaphylactic reaction o Hib vaccines are well-tolerated subsequent immunization with any of the o Local reactions occur in approximately three components should be avoided 25% of recipients but typically are mild o Encephalopathy and last less than 24 hours Defined as a severe, acute, CNS disorder unexplained by another POLIOMYELITIS VACCINE cause and may be manifested by Two forms: major alterations in o OPV (Sabin strain) consciousness or by generalized Elimination of poliovirus infection or focal seizures that persist for has been achieved primarily more than a few hours without through the use of OPV recovery within 24 hours Induced optimal intestinal Occurring within 7 days after immunity, painless and administration of a previous dose secondarily immunized some of DTP/DTaP/Tdap not contacts by fecal-oral spread of attributable to another the vaccine virus identifiable cause o IPV (Salk strain) Should not receive additional To eliminate the risk for vaccine- doses of a vaccine that contains associated paralytic polio pertussis Since 2000, outbreaks of paralytic poliomyelitis Adverse Reactions caused by neurovirulent polioviruses that are o Whole-cell pertussis vaccine derived from Sabin OPV vaccine strain have Local & febrile reactions more occurred among underimmunized children living in common; develop within the first certain economically deprived regions 24 hours and brief in duration o Low immunization rates permitted these More serious uncommon, vaccine-derived polioviruses (VDPV) to usually occurs within the first 48 circulate for long periods of time and by hours of receiving vaccination, continuous mutation, acquire biologic resolves spontaneously without properties that are indistinguishable from sequelae: naturally occurring wild polioviruses Prolonged crying for 3 OPV given per orem; IPV given intramuscularly hours or longer Contraindications occurring o History of anaphylactic reaction after Temperature of 40.5OC receiving a previous dose of IPV or an or greater anaphylactic reaction to one of the Hypotonic- antibiotics in the vaccine preparation (i.e. hyporesponsive episode streptomycin, polymyxin B or neomycin) described as collapse or o Pregnant women shock-like state Adverse Reactions Seizure within 3 days of o OPV can cause vaccine-associated vaccination brief, self- paralytic polio limited, and generalized and occur in association PNEUMOCOCCAL VACCINE with fever S. pneumoniae is the most common cause of otitis o Acellular pertussis vaccine media, occult bacteremia, and bacterial Local & febrile reactions as well pneumonia requiring hospitalization as more serious reactions rarely Given intramuscularly, for 3 doses, at a minimum occur age of 6 weeks with an interval of at least 4 weeks between doses plus a booster dose given 6 HAEMOPHILUS INFLUENZAE TYPE B (Hib) VACCINE months after the 3rd dose Before the introduction of routine infant and Adverse Reactions childhood vaccination against Hib, this pathogen o PCV appears to be safe was the major cause of invasive bacterial o Most commonly reported reactions are infections in young children (meningitis and local reactions at the injection site epiglottitis) Contraindications Given intramuscularly o In persons who have had a severe Given as a 3-dose primary series with a minimum reaction, such as anaphylaxis or a age of 6 weeks and a minimum interval of 4 weeks; localized, severe hypersensitivity booster dose is given between 12-15 months of response, revaccination should be age with an interval of 6 months from the 3rd dose avoided ROTAVIRUS VACCINE Contraindications RV is a major cause of AGE o Immunocompromised patients Given per orem (malignancy, primary or secondary o Monovalent human RV vaccine (RV1) is immunodeficiency states) EXCEPT given as a 2-dose series asymptomatic HIV-infected patients Provided as a lyophilized powder After cessation of chemotherapy, that is reconstituted with a patients should not receive supplied diluent measles vaccine for at least 3 o Pentavalent human bovine RV vaccine months (RV5) is given as a 3-dose series o Persons who have received systemic Provided in a squeezable plastic corticosteroids in doses of 2mkday or 20 dosing tube with a twist-off cap mg daily or on alternate days for an Given at a minimum age of 6 weeks with a interval of 14 days or longer should avoid minimum interval of 4 weeks between doses; the receiving MMR vaccine for at least 1 last dose should be administered not later than 32 month after cessation of CS therapy weeks of age Contraindications MEASLES-MUMPS-RUBELLA (MMR) VACCINE o Severe hypersensitivity to any component Given subcutaneously, for 2 doses, at a minimum of the vaccine age of 12 months with a minimum interval of at RV1 oral applicator contains latex least 4 weeks o Severe combined immunodeficiency o 2nd dose is usually given from 4-6 years of (SCID) age but may be given earlier o History of intussusception Adverse Reactions o RV vaccine should not be administered to o Parotitis and fever mumps component infants with acute, moderate to severe o Fever, lymphadenopathy, or rash rubella gastroenteritis until the condition component improves Contraindications Adverse Reactions o Pregnancy o Intussusception o Sever febrile illness Associated with a tetravalent o Known history of anaphylactic reaction to rhesus-based RV vaccine; rubella vaccine, gelatin or neomycin withdrawn from the market o Immunodeficiency states Data from phase III efficacy trials of RV5 did not suggest an VARICELLA VACCINE increased risk for development of Given subcutaneously, for 2 doses, at a minimum intussusception relative to age of 12 months (12-15 mos) and 2 dose given nd
placebo at 4-6 years of age
o 2-dose regimen is recommended to MEASLES VACCINE prevent breakthrough varicella Given subcutaneously, at age 9 months but may (chickenpox occurring in a previously be given as early as 6 months of age in cases of vaccinated person) due to waning outbreaks as declared by public health authorities antibody titers Adverse Reactions Adverse Reactions o Immunization produces a mild or o Local reactions inapparent, non-communicable infection o Varicella-like rash at site of injection o Vaccine-associated symptoms (fever Occur within 2 weeks, usually higher than 39.4OC occurring 5-10 days maculopapular rather than after immunization or transient rash) vesicular develop in 5-18% of recipients Contraindications similar to MMR vaccine o Thrombocytopenia Usually not clinically apparent MEASLES-MUMPS-RUBELLA-VARICELLA (MMRV) but thrombocytopenic purpura VACCINE occurring after vaccination has Can be given as an alternative to separately been reported administered MMR and varicella vaccine o CNS disease (encephalitis or encephalopathy) reported at a rate of less than 1 case/1 million doses of vaccine administered o SSPE risk is extremely low (0.7 SSPE cases per million vaccine doses) o To date, no convincing evidence establishes that any vaccine causes autism or autism spectrum disorder INFLUENZA VACCINE HEPATITIS A VACCINE 2 forms Given intramuscularly, as a 2-dose series, at a o Trivalent vaccine given either minimum age of 12 months where the 2nd dose is intramuscularly or subcutaneously given at least 6 months from the 1st dose o Quadrivalent vaccine given intramuscularly HUMAN PAPILLOMAVIRUS VACCINE (HPV) Dose: Genital HPV infection is thought to be the most o 6 months to 35 months 0.25 mL common sexually transmitted viral infection o 36 months to 18 years 0.5 mL Infection with HPV causes virtually all cases of Given at a minimum age of 6 months cervical cancer o Children 6 months to 8 years receiving Given intramuscularly, as a 3-dose series, with a influenza vaccine for the first time 2 minimum age of 9 years doses, 4 weeks apart 2 types and schedule of doses o Children 9 to 18 years 1 dose annually o Bivalent HPV (HPV2) given at 0, 1 and 6 Schedule: Annual vaccination should begin in months February but may be given throughout the year o Quadrivalent HPV (HPV4) given at 0, 2 and Contraindications 6 months o Trivalent inactivated influenza vaccine The only HPV vaccine (TIV) recommended for routine Infants younger than 6 months immunization of males at 11 or 12 Children who have a moderate to years of age severe febrile illness Minimum interval between the 1st and 2nd dose is o Live attenuated influenza vaccine (LAIV) at least 1 month and the minimum interval between Pregnancy the 2nd and 3rd dose is at least 3 months. Children younger than 2 years o 2-dose schedule is an option for girls 9 to Moderate to severe febrile illness 14 years of age for both HPV2 and HPV4, Receiving aspirin or salicylates doses given at least 6 months apart Immunosuppressed states Chronic, underlying medical condition (metabolic disorders, SOURCES: DM, pulmonary, cardiac, renal disorders or Chapter 172, Nelson Textbook of Pediatrics, 20th edition hemoglobinopathies) Chapter 244, Feigin & Cherrys Textbook of Pediatric Children aged 2-4 years old with Infectious Diseases, 7th edition a history of recurrent wheezing or Red Book 30th edition, American Academy of Pediatrics a medically attended wheezing Preventive Pediatric Health Care Handbook 2016, episode in the previous 12 Philippine Pediatric Society months Children taking influenza antiviral medications should not receive kmbm 2016 LAIV until 48 hours after stopping therapy
JAPANESE ENCEPHALITIS VIRUS VACCINE
JE virus is the most important cause of epidemic arboviral encephalitis in Asia o JE is endemic in the Philippines Given subcutaneously o Children 9 months to 17 years should receive one primary dose followed by a booster dose 12-24 months after the primary dose o Individuals 18 years and older should receive a single dose only Contraindications o Previous severe allergic reaction after a previous dose of JE-VC is a contraindication to administration of subsequent doses Contains protamine sulfate Adverse Reactions o Local or mild systemic reactions