immunization in special situations
TRANSCRIPT
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Basics of immunization and IMMUNIZATION IN SPECIAL SITUATIONS
Dr.Nupur SinhaDept. Of PardiatricsLourdes HospitalKochi
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Immunization schedules
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Some definitions
• Vaccination: Process of inoculating the vaccine or the antigen
• Immunisation: Process of inducing immune response, humoral or cell mediated.
• Seroconversion: Change from antibody negative state to antibody positive state.
• Seroprotection: The state of protection (from disease) due to presence of humoral immunity or antibody detectable in serum
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Types of vaccines• Live attenuated bacterial- BCG, Ty 21 a• Live attenuated viral – OPV, MEASLES, MMR,
VARICELLA• Killed or inactivated bacteria – DTPw• Killed or inactivated virus – IPV, RABIES, HAV• Toxoid – DT, TT• Capsular polysaccharide – Hib, PNEUMO, MENINGO• Viral subunit - HBsAg• Bacterial capsular polysaccharide –S.Typhi(Vi), Hib,
MENINGOCOCCAL, PNEUMOCOCCAL, ACELLULAR PERTUSSIS
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Cold chain• Cold Chain is a system of storing and transporting
vaccine at the recommended temperature range from the point of manufacture to point of use.
• Vital link in immunisation• If not maintained, vaccine efficacy will grossly suffer• Safe temp. zone – mandatory to maintain potency• Safe zone for short term storage (1-2 months)is 2-8 deg
C. For long term storage –20 degC is used only for BCG,OPV,Measles/MMR
• The T series of vaccine(DPT,DT,TT),typhoid Vi,Hep B should not be frozen as once frozen the aluminium salts used as adjuvant will be desiccated and will act as irritantsterile abcess
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• In order to provide potent and effective vaccine to the beneficiaries a vast cold chain infrastructure is required, which should have a network of Vaccine Stores, Walk-in-coolers (WIC), Walk-in-freezers (WIF), Deep Freezers (DF), Ice lined Refrigerators (ILR), Refrigerated trucks, Vaccine vans, Cold boxes, Vaccine carriers and icepacks from national level to states up to the out reach sessions.
• The cold chain system and vaccine flow in the country:- The vaccines are transported from the manufacturer through air transport under the temperature range of 2-8oC to the primary vaccine stores (GMSDs/State head quarter).
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VACCINE VIAL MONITORS
• VVM is time and temperature sensitive coloured label.
• Consists of temperature sensitive material.• Changes colour gradually on being exposed to heat.• Corresponds to heat induced damage to vaccine
inside the vial.• Do not give information about cold injury• Especially used for OPV which is most thermo labile
vaccine.
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Special situations
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Immunization in preterm/low birth weight infants
• All vaccines as per schedule irrespective of birth weight or POG.
• According to chronological age• BCG/OPV at time of discharge• Hepatitis B after ≥ 2kg weight.• In < 2kg babies delay for one month after birth• PCV, rotavirus, influenza if possible
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Hepatitis B positive mother
• ≥ 2kg baby: Hep B vaccine + HBIG within 12 hours of birth. Followed by 2 doses at 1, 6 months.
• < 2kg baby: Hep B vaccine + HBIG within 12 hours of birth. Followed by 3 more doses at 1, 2, 6 months.
• If HBIG not available/affordable –Hep B vaccine at 0, 1, and 2 mnths, additional dose bet 9-12 months.
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Immunocompromised individual
• Severe immunodeficiency- all live vaccines contraindicated
• Inactivated vaccines –higher dose, greater number of dose of Hep B.
• Check antibody titres.(>10IU)• Regular boosters if needed• Contaminated wounds- TIG with TT even if 3 doses of
TT received in past.• Pneumococcal, varicella, hepatitis A, influenza vaccine
recommended
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Household contacts of Immunocompromised
• Should not receive transmissible vaccines- OPV
• Non transmissible vaccines –varicella, MMR are safe
• Should be fully immunized- varicella, influenza
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IMMUNODEFICIENCIES
• Severe B cell immunodeficiencyLive vaccines contraindicatedInactivated vaccines are ineffective
• Less severe B cell immunodeficiencyOnly OPV contraindicated
• Severe T cell immunodeficiencyLive vaccines contraindicatedAll vaccines ineffective
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Children receiving corticosteroids/chemotherapy/radiotherapy
• Live vaccine contraindicated if1. High dose oral/iv corticosteroids(20mg/day in
children weighing >10kg or >2mg/kg/day)2. Duration> 2weeks• Can be administered if1. Low dose steroids2. Alternate day therapy3. Inhaled or topical steroids4. ≥ 4weeks after stopping steroids.
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• Other immunosuppressive therapy: avoid live vaccines.
• Chemo /radiotherapy: avoid live vaccines during therapy and upto 3 months after stopping therapy.
• Asplenia /hyposplenia: vaccination with pneumococcal Hib, meningococal + all routine live and inactivated vaccines.
• Planned splenectomy: vaccination initiated 2 weeks prior to splenectomy.
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• Complement deficiencyAll vaccines safePneumo, Hib, meningococcal vacc indicated
• Chronic granulomatous diseaseLive vaccines contraindicatedOther vaccines safe and effectiveYES if CD4 count>200(≥15%)
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HIV INFECTIONVACCINE ASYMPTOMATIC SYMPTOMATIC
BCG YES NO
DTwP/DTaP/TT/Tdap YES YES
IPV/OPV IPV, OPV if IPV not affordable
IPV, OPV if IPV not affordable
Measles vaccine YES YES if CD4 count>200(≥15%)
MMR YES YES if CD4 count>200(≥15%)
Hepatitis B YES YES, 4 doses ,double dose, check seroconversion, boosters
Hib YES YES
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VACCINE ASYMPTOMATIC SYMPTOMATIC
PCV & PPV23 YES YES
Inactivated influenza vaccine
YES YES
Rotavirus Insufficient data Insufficient data
Hepatitis A vaccine YES YES, check seroconversion, boosters
Varicella vaccine YES YES if CD4 count>200(≥15%)
Vi typhoid vacc YES YES if CD4 count>200(≥15%)
HPV YES YES
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TRANSPLANT RECIPIENTS
• Hematopoietic stem cell transplant recipientLoose all memory cellsAre like unimmunizedKilled vaccines started 12 months post transplantLive vaccines 24 months post transplant if recipient is
immunocompetentInfluenza vaccine given pretransplant, restarted 6
months post transplant
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• Contacts of HSCT- varicella and influenza. Completed 6 weeks before transplant date.
• Solid organ transplant recipientLive vaccines completed 2 weeks prior to transplantPost transplant- live vaccines CICheck seroconversionRecommence inactivated vaccines- 6 months post
transplant (immunosuppression lowered)Boosters for Hep A and BAnnual influenza vaccineContacts- varicella and influenza
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IVIG/PLASMA/PRBC/WHOLE BLOOD RECIPIENTS
• Inactivated vaccines- safe• After receiving antibody containing products-
Live vaccines avoided for 3 months.• Antibody products avoided for 2 weeks after
live vaccine• If immunization outside prescribed period
occurs- check seroconversion, revaccination• OPV not contraindicated
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UNIMMUNIZED CHILDVISIT SUGGESTED VACCINES
First Measles/MMR if >12mthsDTwP1/DTaP1/Tdap if ≥7yearsOPV1/IPV1 (if < 5years)Hib1 (if < 5 years)Hep B1
Second- after 1 month of 1st visit BCG(if < 5years)DTwP2/DTaP2/Td if ≥7yearsOPV2Hib 2Hep B2
Third –after 2 month of 1st visit OPV3/IPV2MMR if >12 monthsTyphoid if > 2years
Fourth –after 6 month of 1st visit DTwP3/DTaP3/Td if ≥7yearsOPV4/IPV3Hep B3
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IAP recommendations for adolescent travellers
vaccine Place of travel doseMeningococcal vaccine USA/UK/endemic areas
Saudi Arabia and Africa.2 doses 4-8 weeks apart
Yellow fever Yellow fever endemic zones
10 days before travel
Oral cholera vaccine Endemic area or an outbreak
2 doses 1 week apart
Japanese B encephalitis Endemic areas Single dose(upto 15 years)
Rabies vaccine(pre exposure prophylaxis)
For adolescents going on trekking
0,7,28
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Children with chronic illness• Live vaccines are safe• Other recommended vaccines:
PneumococcalHep AVaricella InfluenzaRotavirus
• Immunogenicity, efficacy, duration of protection- low
• More doses- Hep B, Boosters
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IMMUNIZATION DURING ILLNESS
• Postponed only during serious illness• Vaccination encouraged during minor illness : mild
diarrhea, URTI INTERCHANGEABILITY OF BRANDS• Brands of Hib, Hep B and Hep A safely interchanged• Same brand preferred for DTaP• If previous brand not known/not available- any
brand used• Vaccination should not be delayed/cancelled due
non availability of brand.