immunization in adults, geriatrics and paediatrics
TRANSCRIPT
Immunization in Adults, Geriatrics and
PaediatricsDr. Milan. C. Patel.
DNB (Family Medicine).
Inlaks and Budhrani Hospital, Pune.
What is immunization?
Immunization is the administration of antigenic material to stimulate an individual’s immune system to develop adaptive immunity to a pathogen.
Active immunity develops as a result of infection or by specific immunization and is usually associated with presence of antibodies.
Passive immunity develops when antibodies produced in a human or animal body are transferred to another to induce protection against disease.
History of Vaccination
429 BC : Greek historian Thycudides noticed that people who survive smallpox do not get reinfected.
900 AD : Chinese discovered variolation 1700s : Variolation spreads around the world 1796 : Edward Jenner discovered vaccination in its
modern form and proved to the scientific community that it worked.
Edward JennerJenner vaccinated baby with the lymph from a cowpox infected dairymaid. He also used lymph from sores on cow teats – found it equally effective
EDWARD JENNERDiscovered the small pox vaccine in its modern form and proved to the scientific committee that it worked.
History of Vaccination
1890: Emil von Behring discovers the basis of DT vaccine 1920s: Vaccines become widely available. 1955: Polio vaccination begins. 1956: WHO fights to eradicate smallpox. 1980: Smallpox eradicated from the world. 2008: Professsor Harald zur Hausen awarded Nobel Prize
for discovery of HPV Vaccine. 2013: Rotavirus vaccine and shingles vaccine introduced.
Vaccine Preventable Diseases
Tuberculosis Diptheria Pertussis Tetanus Poliomyelitis Measles Mumps Rubella Typhoid
Haemophilus influenza B Hepatitis A Hepatitis B Influenza (H1N1) Varicella Zoster Pneumococcal disease Meningococcal disease Rotavirus and HPV infection
Recommended Adult Immunization Schedule by vaccine and age group
Influenza vaccine One dose annually for all adults, 0.5 ml im or id. Healthy and non-pregnant adults can receive live
vaccine. Others should receive the inactivated vaccine. For adults aged 65 years and older there is also a high
dose influenza vaccine. Special consideration for people with chronic diseases,
immunosuppression with high risk of influenza, pregnancy and people > 65 yrs of age.
Tdap/Td Vaccine
All adults not (I) earlier Contacts of infants Health care personnel Post exposure
Minor wound:1TT booster if last > 10 yrs ago
Major wound:1TT booster if last dose>5 yrs ago
Primary : 3 doses, 0,1, 6-12 months, 0.5 ml im
Contacts: single dose 2 wks before contact
Booster : every 10 yrs Tdap for 19-64 yrs age
group and Td for > 65 yrs of age.
Varicella Vaccine
2 doses of varicella 4 weeks apart, 0.5 ml sc
Special consideration for Teachers and child care
employees Health care staff Adults and adolescents in
contact with children Contacts of persons with ICS Non pregnant women of child
bearing age International travellers
C/I in pregnancy, ICS, HIV infection with CD4 count < 200.
Post exposure administration: within 3 days of exposure to varicella rash , can be given upto 5 days of exposure to rash
Human Papilloma Virus Vaccine
Quadrivalent ( Gardasil) or Bivalent ( Cervarix) vaccine
For females , at age 11-12 yrs and catch up vaccination between 13-26 years.
For males, routine vaccination at age 11-12 yrs and for those between 13-21 yrs. MSM may benefit by prevention of condyloma and anal cancer.
3 doses to be given. Second dose 1-2 mths after the first dose, third dose 6 months after the first dose.
Herpes Zoster vaccine
Single dose 0.65 ml sc for adults more than 60 years of age.
For persons with chronic medical conditions. Contraindicated in pregnancy, immunocomprimising
conditions and HIV.
MMR Vaccine
Measles and Mumps component: two doses of MMR vaccine are recommended, the second dose administered a minimum of 28 days after the first dose for adults Who have been recently exposed to measles or mumps or
are in an outbreak setting
Are students in postsecondary educational institutions
Work in a health care facility
Those who plan to travel internationally
MMR Vaccine
Rubella component: for women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon termination of pregnancy and before discharge from the health care facility.
Pneumococcal polysaccharide Vaccine
All adults more than 65
Chronic medical
conditions• Asthma, CAD• CLD,CRF,DM• Asplenia• Elective
splenectomy
Other conditions
• Residents of nursing homes
• Chronic smokers
Revaccination with PPSV
0.5 ml im/sc; 1-2 doses may be required. One dose of PPSV is recommended after 5 years for
persons aged 19 through 64 years with chronic renal failure, nephrotic syndrome, asplenia and immune compromising conditions,
For persons aged 65 years or older, one time revaccination is recommended if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination.
PNEUMOCOCCAL VACCINE Pneumovac 23 contains 23 serotypes
7 valent and 13 valent Prevnar is also available
Meningococcal Vaccine
2 doses at 0 and 2 months
Persons with anatomic and
functional asplenia
Persistent complement deficiencies
People with HIV 0.5 ml sc
Meningococcal Vaccine
Single dose for microbiologists, military recruits, students living in dormitories and
travellers to endemic regions
Conjugate vaccine (MCV 4 ) for adults less than 55 years
Revaccination recommended every 5 years
Polysaccharide vaccine for adults more than 55 years
Vaccination must for travellers to
Hajj
Hepatitis A Vaccine
MSM and injection drug
users
Persons working in laboratories
Persons with CLD
Travellers to endemic regions
Unvaccinated persons who
anticipate close personal contact
Hepatitis A Vaccine
It should be administered in a 2 dose schedule at either 0 and 6-12 months or or 0 and 6-18 months.
If the combined hepatitis A and B vaccine ( Twinrix) is used, administer 3 doses at 0, 1 and 6 months. Alternatively, a 4 dose schedule may be used, administered on days 0,7, 21-30, followed by a booster dose at 12 months
Hepatitis B vaccine
3 doses at 0,1 and 6 months
Sexually active persons not in a long term monogamous
relationship
Persons with ESRD,CLD,
HIV
Contacts of chronic HBV
infection
MSM, IDU, persons with
STD
International travellers
Administering Vaccine to Adults:Dose and route
Vaccine Dose Route
Hep A <=18 yrs: 0.5 ml>=19 yrs: 1 ml
im
Hep B <=19 yrs: 0.5 ml>=20 yrs: 1 ml
im
Hep A+B ( Twinrix) >=18 yrs: 1 ml im
HPV 0.5 ml im
Influenza, live 0.1 ml in each nostril Intranasal spray
Influenza,inactivated 0.5 ml im
Fluzone 0.1 ml id
Administering vaccines to Adults:Dose and Route
Vaccine Dose Route
MMR 0.5 ml sc
MPSV 0.5 ml sc
MCV 0.5 ml im
PCV 0.5 ml im
PPSV 0.5 ml im / sc
Tdap 0.5 ml im
Varicella 0.5 ml sc
Zoster 0.65 ml sc
National immunization schedule for infants
vaccine When to give
dose route site
BCG At birth or asap till 1 yr of age
0.1 ml ( 0.05 ml until I mth of age)
id (L) Upper arm
Hep - B At birth or asap within 24 hours
0.5 ml im Anterolateral side of mid thigh
OPV 0 At birth or asap within first 15 days
2 drops oral oral
OPV 1,2 & 3 6,10,14 wks 2 drops Oral oral
DPT 1,2 & 3 6,10,14 wks 0.5 ml im AL mid thigh
Hep B 1,2,3 6,10,14 wks 0.5 ml im AL mid thigh
measles 9 completed months to 12 mths( upto 5 yrs if not given
0.5 ml sc (R ) upper arm
Vitamin A 9 mths with measles
1 lac IU oral oral
National immunization schedule for children
vaccine When to give
Dose route site
DPT booster 16-24 mths 0.5 ml im AL mid thigh
OPV booster 16-24 mths 2 drops Oral oral
Measles ( 2nd)
16-24 mths 0.5 ml sc R upper arm
JE** 16-24 mths 0.5 ml sc L upper arm
Vit A ( 2nd -9th dose )
16 mths with DPT/OPV booster. Then 1 dose every 6 months upto 5yrs of age.
2 lac IU oral oral
DPT booster 5-6 years 0.5 ml im Upper arm
TT 10 yrs & 16 yrs
0.5 ml im Upper arm
National Immunization schedule for pregnant women
vaccine When to give
dose route site
TT-1 Early in pregnancy
0.5 ml im Upper arm
TT-2 4 weeks after TT-1
0.5 ml im Upper arm
TT-booster If taken 2 TT doses in a pregnancy within last 3 yrs. Give before 36 wks. give TT to a woman in labour if she has not got TT before.
0.5 ml im Upper arm
IAP Immunization Schedule.
Age (completed wks/mo/y) Vaccine
Birth BCGOPV 0Hep B-1
6 weeks DTwP-1IPV – 1Hib -1Rotavirus -1PCV-1Hep B-2
10 weeks 2ND dose of DTwP, IPV,Hib,Rotavirus,PCV
14 weeks 3RD dose of DTwp,IPV, Hib,Rotavirus,PCV
IAP Immunization Schedule
Age ( completed wks/mo/y) Vaccines
6 months OPV-1, Hep –B 3
9 months OPV-2, MMR-1
9-12 months Typhoid conjugate vaccine
12 months Hep-A 1
15 months MMR-2, Varicella-1, PCV Booster
IAP Immunization Schedule
Age (completed wks/mo/y) Vaccines
16 -18 months DTwP-B1, IPV-B1,Hib-B1
18mths – 2yrs Hep-A 2, Typhoid booster
4 – 6 years DTwP-B 2, Varicella 2, Typhoid booster, OPV 3
10-12 years Tdap/Td, HPV.
IAP recommended vaccines for high-risk children
Influenza vaccine Meningococcal vaccine Japanese Encephalitis vaccine Cholera vaccine Rabies vaccine Yellow fever vaccine PPSV 23
High Risk Category of Children
Immunodeficiency Chronic medical
conditions , DM Long term
immunosuppressive therapy or RT
CSF leaks, cochlear implants, malignancies
Functional or anatomic asplenia
During outbreaks Having pets in home Who are at higher threat
of being bitten by dogs such as hostellers, risk of stray dogs while going outdoor
Dos and Don’ts during immunization sessions
Dos Don’ts
It is safe and effective to give BCG, DPT,OPV and measles vaccines at the same time to a child who has completed 9 months and never been vaccinated
Do not withhold the vaccine in case of illness such as cold, cough, diarrhoea or fever.
Give BCG to infants less than 1 year of age
Never give BCG to children above 1 year of age
If a child is brought late for a dose , pick up where the schedule was left
Dos and Don’ts during vaccine handling and administration
Dos Don’ts
Screen for contraindications Do not use unsterile syringe
Check label of the vial and expiry date
Do not touch any part of needle
Lightly shake the vial of T-series vaccine before drawing the dose
Do not recap the needle
Use a new syringe for each injection and a new disposable syringe for each reconstitution
Do not leave the needle inside the vialNever inject in the buttock.
Use correct diluent Never use vaccine with VVM in unusable stage
Inject using correct site and route Never massage the vaccination site
Allow dose to self dispense instead of massaging
Never use reconstituted measles and BCG vaccine after 4 hours and JE after 2 hours
Vaccine Vial MonitorDo not use if the central square is equal to or darker than the surrounding circle.
Angles for inserting injections1) Intramuscular injections are given at
an angle of 90 degrees
2) Subcutaneous injections are given at an angle of 45 degrees
3) Intravenous injections are given at an angle of 25 degrees
4) Intradermal injections are given at an angle of 10-15 degrees
Vaccination in pregnancy
Live virus vaccines are contraindicated in pregnancy Most live virus vaccines, including varicella vaccine,
are not secreted in breast milk; therefore, breast feeding is not a contraindication for live virus or other vaccines.
Pregnancy is not a C/I for inactivated vaccines but most are avoided in pregnancy as relevant safety data are limited.
Trivalent inactivated influenza vaccine may be given in influenza season.
Immunosuppression
In patients with compromised immune function, enhanced replication of vaccine viruses is possible and could lead to disseminated infection with the vaccine virus. Hence live viruses are C/I in immunocompromised conditions.
HIV, hematologic or generalized malignancy and therapy with immunosuppressive agents including high dose glucocorticoids are immune compromising conditions.
Contraindications and precautions for commonly used vaccines in adultsVaccine Contraindication Precaution
All vaccines Severe allergic reaction
Moderate to severe acute illness with or without fever
Td -- GBS within 6 weeks of a previous dose of TT containing vaccineHistory of arthus type hypersensitivity reaction after a previous dose of TT containing vaccine.Defer vaccination until atleast 10 years have elapsed since the last dose.
Contraindications and Precautions
Vaccine Contraindication Precaution
Tdap History of encephalopathy eg: coma or prolonged seizures not attributable to another identifiable cause within 7 days of administration of DTaP or Tdap ie : with pertussis component
1) GBS within 6 weeks after a previous dose of TT-containing vaccine2) Unstable neurologic conditions3) History of Arthus type hypersensitivity reactions; defer vaccination until at least 10 years have elapsed since the last dose.4) Pregnancy.
Contraindications and Precautions
Vaccine Contraindication Precaution
HPV History of immediate hypersensitivity to yeast( for Gardasil)
Pregnancy
MMR 1) History of immediate hypersensitivity reaction to gelatin or neomycin2) Pregnancy3) Known severe immunodeficiency
Recent ( within 11 mths) receipt of antibody containing blood product.
Contraindications and Precautions
Vaccine Contraindication Precaution
Varicella 1) Pregnancy2) Known severe
immunodeficiency3) History of
immediate hypersensitivity reaction to gelatin or neomycin
Recent (within 11 mths) receipt of antibody containing blood products.
Influenza, injectable, trivalent
History of immediate hypersensitivity reaction to eggs
1) GBS within 6 weeks of previous dose.
2) Pregnancy is not a C/I Recommended for women who will be pregnant during influenza season.
Contraindications and Precautions
Vaccine Contraindication Precaution
Influenza, live, attenuated
1)Hypersensitivity to eggs2)Age > 50 yrs3)Pregnancy4)Immunosuppression5)Chronic medical conditions6)Close contact with severely immunosuppressed persons who require a protected environment, such as isolation in a bone marrow transplant unit.
History of GBS within 6 weeks of a previous influenza vaccine dose.
Contraindications and Precautions
Vaccine Contraindication Precaution
PPSV none none
Hepatitis A none pregnancy
Hepatitis B Hypersensitivity to yeast
Meningococcal conjugate
1) Age > 55 years2) History of severe
allergic reaction to latex or to DT containing vaccine
History of GBS
Meningococcal polysaccharide
History of severe allergic reaction to latex
Zoster 1) Age < 60 years & ICS
2) Pregnancy3) Hypersensitivity to
gelatin or neomycin.