Child Healthcare: Immunisation
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Child Healthcare: Immunisation



Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin ...

Child Healthcare addresses all the common and important clinical problems in children, including:immunisation history and examination growth and nutrition acute and chronic infections parasites skin conditions difficulties in the home and society.



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Child Healthcare: Immunisation Child Healthcare: Immunisation Document Transcript

  • 2 Immunisation white cells to provide immunity (protection). Objectives Immunity can follow a natural infection or be induced by immunisation. When you have completed this unit you should be able to: Immunity is the protection which the body • Define immunisation. develops against further damage by an organism • Write the immunisation schedule. or toxin. • Understand the advantages of immunisation. • List the contraindications and 2-2 What is immunisation? complications of immunisation. Immunisation is a method of artificially • Give immunisations safely. stimulating the immune system to provide • Store vaccines safely in a clinic or protection against specific serious infections. hospital. This is done by giving a vaccine. A vaccine may be any one of the following:INTRODUCTION • A live, but specially weakened (attenuated), organism such as oral polio vaccine. • A dead organism such as intramuscular2-1 What is immunity? polio vaccine. • An inactivated substance (a toxoid)Children may become infected with many produced by an organism such asbacteria or viruses, which can cause illness. diphtheria vaccine.Some of these organisms may also produce • Part of an organism such as hepatitis Btoxins, which can result in serious damage. vaccine.Following most infections the body developsprotection (resistance) against furtherinfections by the same organism or against the Immunisation is a method of preventing sometoxins which these organisms produce. The serious infectious diseases.body is now said to be immune to (protectedagainst) that specific organism or toxin. This NOTE It is best not to use the word ‘vaccination’protection is called immunity. The body as it means to immunise with vaccinia (cowpox)produces immunoglobulins (antibodies) and to protect against smallpox. However, the word
  • 30 IMMUNISATION vaccine is still used. Therefore, a vaccine is used to 2-5 What is the expanded programme on immunise an infant. immunisation The Expanded Programme on Immunisation2-3 What are the advantages of (EPI) of the World Health Organisationimmunisation? recommends that all children be immunisedImmunisation is strongly recommended as against these infections. It aims to provideit can prevent many serious infections. The free immunisation for children against theintroduction of immunisation for all children important childhood infections.has been one of the most important advances in NOTE EPI was started in 1974. It was calledmodern medicine and saves the lives of millions ‘expanded’ as measles and polio vaccines wereof children throughout the world each year. added to BCG and DPT, and the number ofIt is far better to prevent an infectious illness children immunised in developing countries wasthan to treat the illness and its complications. greatly increased. The purpose of EPI is to preventImmunisation is therefore very cost effective. the childhood diseases for which vaccines exist,Immunisation has greatly reduced the mortality to provide high quality vaccines, and surveillancerate of children in many countries. of these diseases. 2-6 How are immunisations given? Immunisation of young children is strongly recommended. They may be given as drops by mouth, as with polio immunisation, or by intramuscular injection, as with hepatitis B. BCG2-4 What immunisations should be given to immunisation is injected into the skin.young children?All children should be routinely immunised 2-7 Which vaccines are used in South Africa?against the following eight important infections: • BCG is used to immunise against1. Tuberculosis tuberculosis, especially tuberculous2. Polio (poliomyelitis) meningitis and miliary tuberculosis in3. Diphtheria children, which are two of the most severe4. Whooping cough (pertussis) forms of tuberculosis.5. Tetanus • A live polio virus vaccine is used to protect6. Hepatitis B children against poliomyelitis, which is a7. Measles viral infection that can cause permanent8. Haemophilus influenzae paralysis. • Diphtheria toxoid and tetanus toxoidIn South Africa, children are immunised are used to protect against the effectsagainst these eight infections as part of the of diphtheria and tetanus infections.State immunisation programme. As a result, Diphtheria infection can cause airwaymany of these infections (polio, diphtheria, obstruction and damage to the hearttetanus, measles) have become uncommon. In and nerves. Tetanus infection causesfuture, additional immunisations are likely to convulsions and muscle added. • Pertussis vaccine protects against theSome additional immunisations may be infection which causes whooping cough.given to specific children when indicated, e.g. It is usually given together with diphtheriaviral influenza, polyvalent pneumococcal, and tetanus toxoid (DPT).meningoccal and yellow fever vaccine. • A live measles vaccine is used to protect children against measles. • Hepatitis B vaccine is used to protect against hepatitis B.
  • IMMUNISATION 31• Haemophilus influenzae B vaccine (Hib), When Vaccines which is the latest vaccine to be added to At birth BCG the South African expanded programme Oral polio 0 (OPV 0) on immunisation, protects against serious At 6 weeks Oral polio 1 (OPV 1) infections, such as meningitis, caused by DPT 1 (diphtheria, Haemophilus influenzae type B. pertussis, tetanus) NOTE Some vaccines are alive (BCG, oral polio, Hepatitis B 1 measles) while others are dead (diphtheria, Hib 1 tetanus, pertussis, hepatitis B and Haemophilus At 10 weeks Oral polio 2 (OPV 2) influenza B). A toxoid is an inactivated toxin. DPT 2In future, MMR (measles, mumps and rubella) Hepatitis B 2vaccine will replace measles immunisation Hib 2alone, while hepatitis A, pneumococcal and At 14 weeks Oral polio 3 (OPV 3)chickenpox (varicella) immunisations should DPT 3be added to the routine immunisations. Hepatitis B 3Yellow fever immunisation is routinely given Hib 3in countries where yellow fever occurs. New At 9 months Measles 1vaccines, such as the Rota virus vaccine, could At 18 months Oral polio 4 (OPV4)be very important, but are expensive. DPT 4It is easier to give combined vaccines such as Measles 2 or MMRDPT plus Hib as less injections are needed. In (measles, mumps,future more combination vaccines will be used. rubella) At 5 years Oral polio 5 (OPV 5)2-8 When should immunisations be given? DT 5 (diphtheria, tetanus)The recommended schedule for immunisationlists the age at which specific immunisationsshould be given. Some immunisations need Table 2.1: The schedule for the immunisation ofonly be given once while others have to be children in South Africarepeated a number of times.The schedule for the immunisation of children 2-9 Why is it important to givein South Africa (Table 2.1) is as follows: immunisations at the recommended time?• Polio 0 is the dose of polio vaccine at birth 1. If an immunisation is given too early• DPT 1 is the first dose of DPT (e.g. if measles immunisation is given at 3• Hepatitis B 2 is second dose of hepatitis B months), the infant may not develop the vaccine expected resistance to the illness due to the• Hib 3 is the third dose of Hib vaccine, etc. immune system still being too immature to respond fully.The primary immunisations are given between 2. If an immunisation is given too late (e.g. notbirth and 9 months. The immunisations given giving measles immunisation at 9 months),at 18 months and 5 years (polio, measles, the infant may develop that illness beforediphtheria and tetanus) are often called the immunisation can be given.‘boosters’ as they help to improve the immune 3. If immunisations are given too soon afterresponse produced by the initial course of the previous immunisation (e.g. if DPTimmunisation. immunisations are given a week apart), the infant may not develop the expected resistance to the illness.
  • 32 IMMUNISATIONAll the most important immunisations should Whenever a child visits a doctor or clinic, thebe given by the time the child reaches 9 months opportunity must be used to detect and giveof age. missing immunisations. In addition, a visit to a doctor or nurse often exposes an unimmunised child to other children with preventable It is important to give immunisations at infections such as measles. It is important to the recommended time according to the look at the infants immunisation record in immunisation schedule. the Road-to-Health Card at every visit to a clinic or hospital and to make sure that all the2-10 What should be done if immunisations recommended immunisations have been given.are missed or never started? Outstanding immunisations must be given immediately before the child goes home.This depends on how old the child is and whatimmunisations have been missed. Opportunities for immunisation are also lost when health facilities do not offerIf the immunisation schedule was not started immunisation services every day. Therefore,when it should have been, immunisations can this essential service should be made availablebe started immediately with the normal time on a daily basis at all clinics and hospitalsintervals between immunisations, e.g. the where children are managed.second DPT would follow 4 weeks after thefirst. A child may develop a serious infection as theHowever, some immunisations may not be result of a missed immunisation.given as they are no longer needed or they arenot safe in an older child: 2-12 How should immunisations be• Pertussis vaccine is not given after 18 recorded? months.• Hib and BCG are not given over 1 year. It is very important that all immunisations• Measles need not be repeated if it is given are carefully recorded on the infant’s Road- after 18 months. to-Health Card. Both the type and the date of the immunisation must be recorded. It isIf immunisations were started correctly, but an essential and important part of primarylater immunisations were missed, these can be health care to record all immunisationsgiven using the normal time intervals between carefully. Even though DPT and Hib are givenimmunisations. If the immunisation schedule as a single injection, they must be recordedis interrupted it need not be started again from separately on the card. The Road-to-Healththe beginning. Card is the official immunisation record needed for clinic visits, hospital admission and2-11 Why are immunisations opportunities attendance at crèche and school.often missed?Many opportunities to immunise children 2-13 What should be done if the Road-to-are missed. This is a serious mistake as the Health Card is lost?child may become ill, or even die, from a All mothers have the right to carry a Road-to-preventable disease. Children often visit Health Card. If the card is lost or destroyed,doctors or attend clinics or hospitals without the mother should be given a new card,being immunised because of stock shortages, clearly marked as a duplicate. All availablebecause the child’s immunisation status is not information must be entered. The motherchecked on the Card or because it is too much should be asked whether the infant has beentrouble to give the correct immunisations. immunised and which immunisations have been given. If she can give a good account
  • IMMUNISATION 33of her child’s immunisations or if they are NOTE Infants with immunosuppression due torecorded in the clinic records, these should other causes, such as leukaemia or cytotoxicbe entered in the new card and do not need drugs or large doses of steroids should not beto be repeated. If she is uncertain of the given live vaccines (e.g. polio and measles). They must be protected from exposure to thesechild’s immunisation history, the missing illnesses.immunisations should be repeated. It isnot dangerous to repeat an immunisation,provided that the child is not too old. Infants who are exposed to HIV but are otherwise well should receive routine immunisations.2-14 Should infants born to HIV-positivewomen be immunised? 2-16 Should malnourished infants beYes. It is particularly important that these immunised?infants are immunised as they are at high Yes. Malnutrition (undernutrition) isrisk of infections if they later develop AIDS. not a contraindication to immunisation.The immune system of infants born to HIV- Even children with severe malnutritionpositive women is usually normal in the first (kwashiorkor or marasmus) should befew months after delivery. This provides an given the routine immunisations. Measlesopportunity for routine immunisations to be immunisation can be given when thesegiven, even to those children who have been children are admitted for care. The rest ofexposed or infected with HIV. However, most the immunisation schedule must be startedinfants born to HIV-positive women are not before discharge home. It is important toinfected with HIV. All immunisations can be make sure that they will receive all the routinegiven according to the normal schedule to immunisations.HIV-exposed infants provided they have noclinical signs of HIV infection. 2-17 Should small or sick newborn infants be immunised?2-15 Should infants with HIV infection beimmunised? Low birth weight (less than 2500 g) or sick newborn infants should be given BCG andInfants who are known to be infected with polio vaccine when they are well enough toHIV but have no clinical signs of HIV be discharged home from hospital. By thisinfection (and a normal CD4 count) should be time some preterm infants may already beimmunised. There is no danger giving them a few months old. After discharge they canmost live vaccines such as polio and measles follow the routine immunisation schedule. Ifas their immune system is still functioning a preterm infant is older than 6 weeks whennormally. However, BCG should not be given. it is discharged home, the routine 6 weekIn contrast, infants with clinical signs of immunisations can be given at discharge andHIV infection should not be given any live then repeated at 4 week intervals. It is rare thatvirus vaccines, such as BCG, oral polio and preterm infants need immunisation beforemeasles, but should receive the other routine they are ready for discharge.immunisations. Giving BCG to infants withHIV infection may result in a generalised 2-18 Should routine immunisations beinfection with BCG as their immune system given to a sick child?is damaged and not able to control the spread There are very few general contraindicationsof BCG. Children with AIDS on antiretroviral to immunisation. Infants with a skin rash ortherapy my benefit from waiting until the CD4 minor illness such as a ‘cold,’ cough or mildcount is normal before giving measles and fever below 38 °C should be immunised. If theOPV immunisations. infant has diarrhoea when OPV is due, give
  • 34 IMMUNISATIONOPV but ask the mother to bring the child immunisations can be given if the infantback for an extra dose of polio drops when the is HIV positive without signs of HIVinfant is again well. Mark on the card that an infection (and a normal CD4 count).extra dose of OPV is needed due to diarrhoea. 3. Live viruses should not be given toIt is important to immunise sick and children with immunosuppression suchmalnourished children to protect them against as children with leukaemia or receivingthese illnesses. If a child is not immunised cytotoxic drugs. Kwashiorkor, marasmusbecause of a minor illness, they may not be and low dose or inhaled steroid treatmentbrought back later and the opportunity to are not contraindications.immunise is lost. 4. DPT vaccine should not be given to infants with: • A high temperature (38 °C or above). Minor illnesses and malnutrition are not a • Fits or collapse within 3 days of a contraindications to immunisation. previous DPT immunisation • A serious progressive neurological2-19 Can immunisations be safely given to abnormality such as repeated allergic child? In these situations DT should be used instead of DPT.Yes. Allergic reactions to immunisations arerare, even in children with signs of allergy (e.g.eczema). 2-21 Is immunisation safe? Yes. Serious complications of immunisation2-20 When are immunisations are rare. However, mild fever and irritabilitycontraindicated? are common, especially 6 to 12 hours afterThere are very few contraindications to DPT immunisation. A mild fever, irritabilityimmunisations and serious thought must and slight rash are common about a week afterbe given before deciding not to give a measles and MMR immunisation. These mildscheduled immunisation. Mild illness is not side effects can be treated with paracetamola contraindication. Neither is a skin rash (Panado) 6 hourly for 4 doses if needed (2.5or eczema. Antibiotics or allergic illnesses ml if under 1 year and 5 ml if 1 to 5 years).are also not contraindications. If an ill or The benefits of immunisation are far greatermalnourished child is well enough to go home, than the risks. Therefore, as many infants ashe/she can be immunised before going home. possible should be fully immunised. NOTE There is no evidence that immunisation increases the risk of cot death. An infant who is well enough to go home is well enough to be immunised.Contraindications are: BCG IMMUNISATION1. A seriously ill child who needs hospitalisation can be given measles 2-22 What is BCG? immunisation on admission. The other immunisations can be postponed and BCG (Bacille Calmette Guerin) is a freeze- given when the child has recovered, but dried, live but weakened (attenuated) form before discharge from hospital. of Mycobacteria, the bacteria which causes2. Live viruses (polio, measles and BCG) tuberculosis (TB). BCG reduces the risk of should not be given in infants with TB meningitis and disseminated (miliary) clinical signs of HIV infection (or a low TB in young children. Unfortunately it is CD4 count). However, all scheduled less effective in preventing pulmonary TB,
  • IMMUNISATION 35especially in malnourished children. It also than 2 mm into the skin. The needle cangives less protection in adults. be seen through the skin. NOTE In South Africa the Danish strain of BCG is 6. Inject the 0.05 ml of vaccine. A weal (raised being used. lump) indicates that the intradermal injection has been given successfully. The most common error is to inject under2-23 How should BCG be stored and the skin when no weal will be seen. Withmixed? no weal, start again at a different site andBCG vaccine should be stored in a refrigerator inject into the skin.(fridge) between 2 and 8 °C and must not befrozen. Keep it and the diluent on the middle 2-26 What are the side effects of BCGshelf. It must also be kept out of direct sunlight. immunisation?To prepare the vaccine for administration thevial of diluent should be added to the vial of In the majority of infants a raised noduledried vaccine. Do not use alcohol or ether to develops at the site of the immunisation afterclean the top of the vial as it may kill the BCG. 2 to 4 weeks. A small crust may develop or itAfter making up the vaccine it will last for 6 may ulcerate. The nodule will heal by itself andhours if kept in a refrigerator or cool box. no dressing should be applied. After 8 weeks the nodule starts to decrease in size and by 6 months a small flat scar will form. The lymph2-24 When should BCG be given? nodes in the axilla on that side may enlargeBCG should be given to well infants at birth slightly, which is normal. BCG immunisationand on the day of discharge from hospital does not always leave a scar in an infant. It isor clinic to infants who have been ill or are not necessary to repeat the BCG immunisationlow birth weight. If there is any doubt about if no scar is seen.whether BCG was given after birth, it should The most common side effects are local painbe given at 6 weeks with the first polio, DPT and ulceration at the site of the immunisationand hepatitis B vaccines. BCG is not usually and enlarged lymph nodes in the axilla andgiven to children older than 1 year. sometimes the neck.2-25 How is BCG given? Serious side effects which require referral are very rare. They include:BCG is given by intradermal injection on theright upper arm as follows: • An abscess may form at the site of the immunisation.1. Inject 1 ml of diluent into the vial (brown) • Axillary lymph nodes may enlarge rapidly containing BCG. Gently turn the vial to more than 3 cm. upside down at least five times until fully mixed. Do not shake. NOTE BCG lymphadenitis or local abscess must2. The reconstituted BCG vaccine can be be reported to the local health authorities. Rarely suppurative adenitis may require needle drainage stored up to 6 hours in a refrigerator or a sinus may form. Antituberculous treatment is between 2 and 8 °C. seldom needed (usually in immunocompromised3. Draw up 0.05 ml of BCG vaccine in a children only). sterile syringe (a special syringe to measure 0.05 ml accurately ). 2-27 What are the contraindications to BCG4. Clean an area of skin over the right deltoid immunisation? muscle (upper arm) with soap and water.5. Stretch the skin over the right deltoid BCG can be given to HIV-exposed infants but muscle with your thumb and forefinger. not infants with HIV infection, especially if Slowly insert the needle intradermally clinical signs of HIV infection are present. It is (bevel facing up). Insert the needle for less not used over one year of age.
  • 36 IMMUNISATIONPOLIO IMMUNISATION vaccine should not be given to immunosuppressed children, e.g. children with AIDS. Usually, a single dose of polio vaccine is given2-28 Which polio vaccine is used? at the same time as BCG after delivery andBoth live, oral (Sabin) and killed, then a further 3 doses are given with DPTintramuscular (Salk) vaccines can be used vaccine at 6, 10 and 14 weeks. Follow up dosesto protect against polio. In South Africa the (boosters) are given at 18 months and 5 years.trivalent live oral polio vaccine is used. It hasbeen weakened (attenuated) to give immunity 2-31 Should oral polio immunisation be(against all 3 strains of polio virus) without given to a breastfeeding infant?causing clinical infection. The killed vaccine Breastfeeding is not a contraindication tois equally effective as the live vaccine. Only immunisation. There is no need to avoid athe oral vaccine is used in South Africa. It breastfeed before or after giving oral poliois hoped that universal immunisation will immunisation.eradicate polio as has happened to smallpox. NOTE Live (oral) attenuated polio vaccine was introduced in 1962. It is excreted in the stool Breastfed infants can be given oral polio and can infect others asymptomatically and immunisations. thereby boost the immunity of the whole community. It is best used in communities 2-32 What are the contraindications to where wild polio virus may still occur. With the elimination of clinical polio, the inactivated polio immunisation? (intramuscular) Salk vaccine can be used Only the killed (Salk) vaccine can safely be instead as part of a single combination vaccine used in children with symptomatic HIV (e.g. DPT/ Hib/ inactivated polio). The Salk infection. However, the live vaccine is safe in vaccine avoids the rare cases of oral polio vaccine induced paralysis. infants who are HIV infected but well. Polio vaccine can be given to children2-29 How should polio vaccine be stored? with diarrhoea and vomiting but an extra dose should later be given as the diarrhoeaLive polio vaccine must always be kept cold to or vomiting may prevent successfulavoid heat killing the virus. In a standard clinic immunisation.or hospital refrigerator it should be stored at 2to 8 °C. Direct sunlight kills the vaccine. Keep NOTE Very rarely (1 in 500 000), paralysis canthe vial of vaccine cool in a home refrigerator follow use of oral Sabin polio vaccine. This doesor cool bag while it is being used. It can be not occur with the killed Salk vaccine. All cases of acute flaccid paralysis must be notified tosafely kept in this way for up to 30 days. determine whether polio has been eradicated. NOTE Polio vaccine can be stored for years at –20 °C or for one year at –10 °C. IMMUNISATION AGAINST2-30 How is live polio vaccine given? DIPHTHERIA, PERTUSSISTwo drops are given directly into the infant’smouth from the plastic dropper bottle. If the AND TETANUS (DPT)drops are spat out or vomited the dose shouldbe immediately repeated. It is not necessary 2-33 What is DPT vaccine?to avoid either a bottle or breastfeed before orafter giving the vaccine. It is a combined vaccine against diphtheria, NOTE Usually, the trivalent vaccine, which includes pertussis and tetanus. Pertussis is another name types 1, 2 and 3 polio virus is used. Live Sabin for whooping cough. The vaccine contains both oth
  • IMMUNISATION 37diphtheria and tetanus toxoids, as well as killed If infants are not fully immunised with DPTpertussis (whooping cough) bacteria. because of minor side effects, they may later develop diphtheria, whooping cough orToxoids are inactivated toxins. Toxins are tetanus which remain very serious illnesses.produced by the diphtheria and tetanusbacteria and cause most of the clinical signs in The side effects can usually be managed withthese infections. Toxoids stimulate the body to paracetamol 6 hourly for 2 days.produce immunity to these toxins. 2-37 What are the possible serious2-34 How should DPT vaccine be stored? reactions to pertussis immunisation?In a refrigerator or cold box at 2 to 8 °C. Do Very rarely, fever above 40.5 °C, fits, collapsenot freeze DPT vaccine as this damages the and shock, severe irritability with persistentvaccine. Avoid direct sunlight as this may also crying and screaming attacks or drowsiness,damage the vaccine. It is best to keep DPT on confusion and brain damage (encephalopathy)the middle shelf of a fridge. may follow pertussis immunisation. The risk of fever and fits is one in a thousand infants immunised with pertussis vaccine while the Do not freeze DPT as this damages the vaccine. risk of encephalopathy is one in a million. If a serious rection occurs, pertussis vaccine must2-35 How is DPT vaccine given? not be given again.1. The 10 ml vial of DPT vaccine is ready to A new, safer, cell-free pertussis vaccine, with use. Shake the vial well and draw 0.5 ml fewer local and systemic side effects, is now of the vaccine into a syringe. Use a new 23 available. However, parents have to pay for this gauge needle for each child. Never use the as it is expensive. same needle for more than one child. NOTE Fever above 40.5 °C within 2 days, fits within2. Clean an area over the skin on the outer 3 days or encephalopathy within 7 days of DPT side of the left thigh (upper leg) with an immunisation must be reported to the local alcohol swab (NOT buttocks). health authorities.3. Inject 0.5 ml of the vaccine intramuscularly.Three doses of DPT vaccine are given together 2-38 When should pertussis vaccine not bewith polio vaccine at 6, 10 and 14 weeks. A given?follow up (booster) dose is given with polio Pertussis immunisation should not be given tovaccine at 18 months. the following infants: • A progressive central nervous system2-36 What are the side effects of DPT disease such as uncontrolled epilepsy.immunisation? Children with mental retardation or• Mild redness, tenderness and swelling at cerebral palsy can be given routine the site of the injection for a few days. immunisations including DPT as these are• A mild fever and irritability for a few days not progressive condition. is common. • Infants who have had a severe reaction or• Rarely serious side effects may occur to the clinical signs of encephalopathy within 7 pertussis vaccine. days of a previous DPT immunisation, e.g. persistent screaming, collapse, drowsiness, confusion, fits or a fever over 40.5 °C. Minor side effects to DPT immunisation are • Usually, pertussis vaccine is not given to common and are not a contraindication to further children over the age of 18 months as the immunisations. risk of severe reactions to pertussis vaccine
  • 38 IMMUNISATION increases with age. These infants should be MEASLES IMMUNISATION given DT vaccine instead.Mild fever and redness with some pain iscommon with DPT immunisation and are not 2-41 What measles vaccine is used?contraindications to future immunisations. Measles vaccine is a freeze-dried preparationA family history of convulsions is also not a of a weakened (attenuated) virus. Usually, thecontraindication. Neither are cerebral palsy Schwartz strain of vaccine is used.and Down Syndrome. 2-42 How should measles vaccine be Pertussis vaccine should not be given if the stored? child had a severe reaction to a previous DPT As with BCG and polio vaccines, the storage immunisation. of measles vaccine is very important. If incorrectly stored, these live vaccines are2-39 What is DT vaccine? ineffective. The vials of measles vaccine and the diluent should be kept in a refrigerator orDT vaccine contains a reduced dose of tetanus cool bag at 2 to 8 °C. Place the vaccine on theand diphtheria vaccine and no pertussis top shelf just under the freezer compartment.vaccine. It is given together with polio vaccine Do not expose to direct 5 years. The method of storing and givingDT vaccine is the same as that for DPT 2-43 How is measles vaccine given?vaccine. The dose is 0.5 ml intramuscularly.Tetanus immunisation should also be given 1. Add 5 ml of diluent to the 10 ml vial ofafter an injury, especially if the wound is the vaccine. Do not use alcohol or ethercontaminated with soil. Usually, this is not to clean the top of the vial as this may killneeded if tetanus immunisation has been the virus. If kept cool and out of directgiven within the past 5 years. sunlight, the reconstituted vaccine will last up to 8 hours. NOTE It is important that all pregnant women 2. Use a new syringe and new 23 gauge have received tetanus immunisation as this protects newborn infants against neonatal needle for each patient. tetanus. If not, they should be immunised during 3. Give 0.5 ml of the vaccine by intramuscular the pregnancy with pure tetanus toxoid (TT), 3 injection into outer side (lateral aspect) of doses given one month apart. In areas where the right thigh. Clean the skin with soap neonatal tetanus still occurs, women who have and water. been previously immunised against tetanus 4. Always discard any remaining vaccine at should be given a single booster dose of tetanus the end of the day. Do not keep vaccine vaccine during pregnancy. Tetanus immunisation overnight. is safe during pregnancy as it is a toxoid and not a live vaccine. 2-44 When should measles immunisation be given?2-40 Why is pertussis vaccine not givenafter 18 months? The first dose of measles vaccine is given at 9 months. This is followed by a second (booster)Because whooping cough is a far less serious dose at 18 months.illness in older children and the risk of sideeffects increases after 18 months. Antibodies from the mother usually protect the infant against measles during the first few months of life. During this time measles vaccine is often ineffective as the vaccine virus may be killed by the maternal antibodies.
  • IMMUNISATION 39Unfortunately, infants often get infected Although not yet part of the EPI policy,with measles when they come into contact children who received MMR at 18 monthswith other children at health clinics, out should be given a second dose of MMRpatient departments or in hospital wards. when they start school (however the parentsAny infant of 9 months or more who visits a will have to pay). MMR vaccine needs to beclinic or hospital and does not have measles kept cold during storage in the same way asimmunisation documented on their Road-to- measles vaccine. The dose and method ofHealth Card should immediately be given a administration is the same as measles vaccine.dose of measles vaccine. NOTE Children who are immunised twice with NOTE During an epidemic of measles, if many MMR will have lifelong immunity against rubella young infants are contracting the infection, and, thereby, avoid the risk of congenital rubella measles immunisation is sometimes given at in their infants. Likewise, MMR gives protection 6 months and then repeated at 9 months to against mumps, which avoids the risk of orchitis offer some protection to infants between 6 and resultant sterility in boys in later life. and 9 months. Measles immunisation is usually ineffective before 6 months. IMMUNISATION AGAINST2-45 What are the complications of measlesimmunisation? HEPATITIS BA mild fever about 7 days after theimmunisation occurs in up to 25% of children. 2-48 What is hepatitis B ?Less commonly a faint rash may occur. Acute infectious hepatitis (infection of the liver) is caused by a number of different2-46 What are the contraindications to viruses. The hepatitis B virus may cause ameasles immunisation? severe form of hepatitis, which can result inIt should not be given to children with liver failure. This virus may also cause chronicuntreated tuberculosis. These children can liver infection resulting in cirrhosis or cancerreceive measles immunisation once the TB of the liver years after the person becomestreatment has been started. Mild fever, ‘colds’ infected. Following hepatitis B the person mayor influenza, otitis media, bronchitis or remain infectious for many years and spreaddiarrhoea are not contraindications to measles the infection to their children and otherimmunisation. family members (i.e. they are a hepatitis B virus ‘carrier’). Hepatitis B is common in poor NOTE A previous anaphylactic reaction to measles countries. Although the vaccine is expensive, or MMR immunisation may be due to egg allergy. This is a contraindication to further immunisation immunisation against hepatitis B is, therefore, with measles or MMR vaccine. important in developing countries. NOTE Hepatitis B immunisation has already2-47 What is MMR vaccine? resulted in a falling rate of liver cancer in some countries.Often vaccines against measles, mumps andrubella are given together (MMR vaccine) at 2-49 When and how is hepatitis B vaccine18 months instead of measles vaccine alone. given?Although more expensive than measlesvaccine, MMR offers important protection Hepatitis B vaccine (HepB) 0.5 ml is given byagainst meningitis, which may complicate intramuscular injection into the right thighmumps, and serious congenital abnormalities in 3 doses at 6, 10 and 14 weeks at the samein the fetus, which may complicate maternal time as polio and DPT immunisations. HepBrubella during pregnancy. vaccine must be stored in a fridge.
  • 40 IMMUNISATION2-50 What are the side effects of hepatitis B the immunisation schedules of some poorvaccine? countries. In South Africa, DPT and Hib vaccines are available as a combined vaccine.These include mild fever, pain and local Hib vaccine has few side effects.swelling but are very uncommon. 2-54 How is Hib vaccine stored?2-51 What is the management of an infantborn to a mother who is infected with In a refrigerator at 2 to 8 °C. A cold box can behepatitis B ? used to move vaccines to a clinic.People with either acute or chronic hepatitisB virus infection have pieces of viral protein, 2-55 When and how is Hib vaccine given?called hepatitis B surface antigen (HbSAg), Hib vaccine 0.5 ml is given by intramuscularcirculating in their blood stream. These people injection into the outer part of the left thigh inoften excrete the virus and may spread the 3 doses 4 weeks apart. It is most convenient toinfection to others. Infants are at high risk of give it together with polio and DPT vaccinesinfection during a vaginal delivery if the mother at 6, 10 and 14 weeks. In South Africa it isis excreting the virus. Therefore, infants born to combined with DPT and given as a singlewomen who have hepatitis B during pregnancy injection.or are HbSAg positive (i.e. have a chronic viralinfection) need special management at delivery 2-56 Which other immunisations areto protect them against infection. These infants available?should receive 0.5 ml of hyperimmune hepatitisB immunoglobulin by intramuscular injection Other immunisations are available but are notwith 72 hours of delivery. They should also given routinely. For example, influenza vaccinereceive a dose of hepatitis B vaccine. This should be offered to children with seriousshould be followed by the standard schedule of chronic lung diseases. Influenza vaccine musthepatitis B immunisation at 6, 10 and 14 weeks. not be confused with Hib vaccine. NOTE Pneumococcal, varicella (chicken pox) and hepatitis A vaccines may be included in theIMMUNISATION AGAINST immunisation schedule in future. Yellow fever vaccine is needed for international travel whileHAEMOPHILUS INFLUENZAE rabies vaccine is given to children exposed to a bite from a rabid animal. To protect children, who have been exposed to serious infections,2-52 What is Haemophilus influenzae? specific immunoglobulin is sometimes used. For example, hyperimmune immunoglobulin can beHaemophilus influenzae B (Hib) is a bacterium offered to children exposed to hepatitis B virus.which can cause serious and often fatal The use of immunoglobulin is not as effective asinfections in childhood, especially meningitis, immunisation as the protection is short-lived.pneumonia and epiglottitis (a severe infectionof the throat and epiglottis which often 2-57 Why is a booster dose of vaccineobstructs the upper airway). Children under 2 given?years are most at risk. Some vaccines (polio, DPT and measles) are repeated at 18 months as a follow up or2-53 What is Hib vaccine? booster immunisation. This makes sure thatAn effective vaccine against Haemophilus is the body develops immunity against thesenow available (the Hib vaccine) and is part important infections. At 5 years children areof the South African national immunisation given a further booster dose of polio and DTschedule. Unfortunately it is expensive and, (but not pertussis) before they start school.therefore, has still not been included into
  • IMMUNISATION 412-58 Why are some immunisations given 2-61 Which infectious diseases in childrenon the left and others on the right side of are notifiable?the body? In South Africa all the childhood diseases,By convention, BCG is given into the skin over for which vaccines are routinely given, arethe right deltoid. This helps to find the scar. notifiable. This helps to monitor the number of cases still occurring and also enables theDTP and Hib are given into the left thigh or health authorities to control any outbreaksinto the left deltoid in older children. The with mass immunisation. This is particularlyvaccines can be combined and given together as important for any case of suspected polio.they do not interfere with each others’ action. Cases of measles, polio, neonatal tetanus andHepatitis B is given into the right thigh as it is diphtheria are now rare in South Africa whilebest not given at the same site as Hib. smallpox was eradicated worldwide in 1975.Measles is usually given into right thigh orright deltoid in older children. 2-62 What are mass immunisationNew, special vaccines consisting of combi- campaigns?nations DPT, Hib, HepB and killed polio can These are arranged separately to the routinebe given together. Single vaccines must not be immunisations programme, and are once-offcombined in the same syringe (except DPT events to increase the number of immunisedand Hib). children in a region and, thereby, help to eradicate the disease. They are used in regions2-59 What equipment is used to give or whole countries where the immunisationintramuscular immunisations? rates are low and also to control unexpected outbreaks of one of the important infectiousUsually, a 1 ml syringe is used with a 23-gauge diseases. Mass immunisation campaigns haveneedle to give immunisations into the deltoid been very effective against measles and polio.or thigh muscles. Injections are never giveninto the buttocks of infants. Never re-usesyringes or needles. HANDLING VACCINES2-60 What is ‘herd immunity’?If enough children in a community are 2-63 What is important about storing andimmunised against an infection, that infection handling vaccines?will no longer be passed from one child to All live vaccines (BCG, polio, measles,another. The few non-immunised children are MMR vaccines) must be kept correctlythen partially protected as they are unlikely stored or they will be damaged. Sunlight, theto be exposed to that infection As a result, the incorrect temperature and antiseptics damagewhole community (herd) is protected against vaccines. In a clinic, all should be stored inthat infection (herd immunity). It is, therefore, a refrigerator between 2 and 8 °C (not in theof benefit to the whole community when a child freezer compartment) and kept in a cool bagis immunised. Due to the high immunisation during handling. Only polio vaccine can berate, some infections such as smallpox have safely kept frozen during storage for longdisappeared. The goal in South Africa is to have periods. Freezing damages other vaccines.90% of all children fully immunised. Live vaccines, which have been frozen in error, have a granular appearance with a deposit on standing, and must be discarded.
  • 42 IMMUNISATION on vaccines is only valid if they have been kept Vaccines rapidly lose their effectiveness if they cool during transport and storage. are not kept cold.Avoid direct sunlight and do not use alcohol or Vaccines must be kept cool at all times.ether to clean vials of live vaccines or the skinas this may kill the vaccine. If necessary, the 2-65 What is the correct use of a vaccineskin can be cleaned with soap and water. Only fridge?draw up the vaccine into the syringe when youare ready to give it. The vaccines often come in A dedicated fridge (the same type as that usedbrown vials to protect them from the light. All in the home) with a freezer compartment andvaccines have an expiry date, and must not be 3 shelves must be made available at every siteused after the expiry date. where immunisations are given. The main section of the fridge must be kept at 2–8 °CPolio vaccine has a heat sensitive spot on each while the freezer compartment will be belowvial. Normally the dot is white but it darkens if 0 °C. This fridge must be used for vaccinesthe vaccine is not kept cool correctly. If the dot only. Medicines, drugs, formula feeds and foodis the colour of the surrounding circle, or must not also be kept in the vaccine fridgedarker, it is damaged and must not be used. as repeated opening and closing of the fridgeFigure 2.1 Polio vaccine vial monitor door raises the fridge temperature and this may damage the vaccines. The coolest part of the fridge that does not freeze is the top shelf (below the freezer compartment). This is the best place to store polio and measles vaccines. Other vaccines Can use Can just use Discard (BCG, Hib, DPT, DT, TT, HepB and diluents) are best stored on the middle shelf. A fridge thermometer must be kept on the middle shelf2-64 What is ‘the cold chain’? and the temperature measured and recordedNot only do vaccines need to be kept cold daily. The thermostat of the fridge must beduring storage but they must also be kept adjusted to keep the temperature between 2cold during handling. When live vaccines are and 8 °C. If the fridge is warmer or freezes,moved from the central cold store to a clinic or vaccines may be they should be moved in a cool box. Bottles of water should be stored on theThey should also be kept in a cool box in the bottom shelf as this helps to maintain theclinic after the vial has been opened. Vaccines correct temperature in the fridge if there is amust be kept cool continuously at 2–8 °C. power failure. The freezer compartment canMeasles and MMR are commonly inactivated be used to freeze and store ice packs and iceby not being kept cool continuously. From cubes for use in cool boxes. The door must bethe time the vaccine is produced to the time kept closed at all times except when removingit is given it must be kept cold. The chain of or replacing from factory to store to health clinicto patient is called the cold chain. If possible,vaccines should be kept in a separate vaccine 2-66 What is a cool box?fridge at the health facilities. There must be a Keeping vaccines cold in rural regions andtemperature chart on the vaccine fridge and during transport is particularly difficultthe fridge temperature should be recorded when a fridge is not available. Under thesetwice a day. Where gas fridges are used a spare circumstances, a cool box is very useful.gas tank must be at hand. The expiratory date Usually, a cool box consists of a closable
  • IMMUNISATION 43polystyrene container. Frozen ice packs (they they would still be given if the infant wereshould rattle when shaken) are placed inside born prematurely and is breastfed. Thethe cool box on the bottom and sides as well as mother mentions that she had hepatitis yearsunder the lid. ago and is known to be hepatitis B positive.Measles and polio vaccines should be placedat the bottom where it is coldest. The other 1. Why should the infant receive routinevaccines can then be placed above them. immunisations?Vaccines must never be allowed to freeze. It is very important that all infants beKeep the top firmly on to protect the vaccines immunised unless there is a medical reasonfrom sunlight. not to do so. Immunisation protects the infant against many dangerous infections.2-67 What is an opened multidose vial Immunising children also helps to decreasepolicy? the spread of that infection in the community.To make sure that vaccines remain effectivewith as little wastage as possible, a policy of 2. What immunisations are given aftermanaging opened vials is needed. Opened delivery?vials can be used to withdraw a number of It is routine to give BCG and polio dropsdoses if they are stored correctly. in the first few days after delivery. TheseOpen vials of DPT, DT, TT, HepB and OPV immunisations should be given before anmay be stored for up to 1 month provided the infant is discharged from the hospital or clinic.expiry date is not past, cold chain conditionshave been maintained, and aseptic technique 3. Are immunisations given to pretermis used to withdraw doses. infants?Open vials of combined DPT and Hib vaccine It is very important to give all routinecan be kept for 7 days if the above conditions immunisations to preterm infants. Usually,are met and the vaccine vial monitor has not the BCG and first polio immunisations arereached discard point. given when the infant is ready for discharge from hospital. After discharge the routineOpen vials of measles and BCG must not be immunisation schedule is followed.kept for more than 6 hours.All opened vials must be discarded 4. Should breastfed infants be given oralimmediately if the asceptic procedures have polio drops?not been followed or there is any suspicionthat the vial is contaminated (a change in the Yes. Breast milk does not inactivate the livenormal appearance of the vaccine). polio virus in the oral drops.See the summary of the scheduled vaccines at the 5. Would loose stools be a contraindicationend of this unit. to polio immunisation? No. However, the drops should be given again when the infant is well.CASE STUDY 1 6. What should be done, as the mother isDuring a woman’s pregnancy, she and her hepatitis B-positive?husband ask the doctor whether it will be As there is a high risk that the infant will benecessary for their infant to be immunised. infected with the hepatitis B virus at or soonThey also want to know which immunisations after delivery, the infant must be given 0.5 mlare given straight after delivery and whether of hyperimmune hepatitis B immunoglobulin
  • 44 IMMUNISATIONby intramuscular injection within 72 hours CASE STUDY 3after birth. In addition, the infant shouldbe given a dose of hepatitis B vaccine after A healthy 6-week-old infant is given herbirth to be followed by the routine hepatitis B first DPT immunisation. The day after theimmunisations starting at 6 weeks. immunisation the infant has a mild fever and is slightly irritable. She also has some pain and swelling at the site of the injection. The motherCASE STUDY 2 gives a history of febrile convulsions when she was a child. She also heard on the radioA mother who is known to be HIV-positive that DPT immunisation could cause mentaldelivers a clinically well infant at term. The retardation. Because of this mild reaction andstaff tells her that her infant should not be the mother’s anxiety, the staff advises that noimmunised as it may already be infected with further DPT immunisations should be given.HIV. This will make immunisation dangerous. 1. What does DPT stand for?1. Should routine immunisations be givento infants born to HIV-positive mothers? Diphtheria, pertussis (whooping cough) and tetanus.Yes. It is particularly important that theseinfants are immunised as they are at high risk 2. At which site should the DPT injection beof infections if they later develop AIDS. The given?immune system of infants born to HIV-positivewomen is usually normal in the first few months DPT should be given by intramuscularafter delivery, which gives an opportunity to injection into the left thigh. In older children itsafely give the routine immunisations. Most can be given into the left deltoid muscle. Neverinfants born to HIV-positive mothers are not give a child an injection into the buttock,HIV infected themselves. because young children have little muscle over the buttock, and important nerves and blood2. Should routine immunisations be given vessels lie close under the skin and may beto healthy infants with HIV infection? damaged.Yes. These infants without clinical signs of HIV 3. Are side effects common after DPTinfection still have an intact immune system immunisation?and should be given routine immunisationsexcept BCG. Many infants have mild local tenderness and swelling at the site of the immunisation for a3. Should infants with clinical signs of HIV few days. Mild fever and some irritability areinfection be given routine immunisations? also common. If necessary the infant can be treated with paracetamol syrup 2.5 ml 6 hourly.As these infants have a damaged immunesystem, they should not be given live vaccines 4. Can DPT cause dangeroussuch as BCG, oral polio and measles. complications?4. What is the danger of giving BCG to an Very rarely, DPT can cause a high fever (aboveinfant with symptomatic HIV infection? 40 °C), severe irritability with screaming attacks, drowsiness, convulsions and mentalAs these infants have a damaged immune retardation. The risk of severe complications issystem, they may develop a generalised only 1 per million children.infection with BCG.
  • IMMUNISATION 455. Should the second dose of DPT be given 3. When should measles immunisation notif the infant has mild side effects after the be given?first dose? Measles immunisation should be delayedYes. The second dose of DPT should be given in children with untreated 10 weeks. If the infant has had a severe Malnourished infants can safely be givencomplication to the first dose of DPT, only DT measles immunisations. This is particularlyshould be given at 10 and 14 weeks and at 18 important, as measles can be a fatal infectionmonths. in malnourished children.6. Should DPT be given if the mother had 4. Should the measles immunisation havefebrile convulsions as a child? been given to this infant with a mild cough?It is important that DPT immunisation is A mild illness, such as loose stools, coldstill given. A family history of fits is not a or cough, is not a contraindication tocontraindication to DPT immunisation. immunisation. Infants who are well enough to go home are well enough to be immunised.7. Is it recommended that DPT be givenroutinely at 5 years? 5. Why is it important to record measles immunisation on the Road-to-Health Card?No. At 5 years only DT should be given, as thechance of complications with pertussis vaccine It is very important to note all immunisationsis higher in older children (above 18 months). on the Road-to-Health Card, as this is the official record of the child’s immunisation status. This is needed when the child is takenCASE STUDY 4 to another clinic or hospital and when the child is admitted to a crèche or play school.A week after the second routine immunisationwith measles at 18 months, an infant developsa mild fever and a fine pink rash, which lasts CASE STUDY 5for 2 days. As the infant had a slight coughat the time of the immunisation, the mother A doctor notices that the fridge, which storesis worried that the fever and rash may be the vaccines in a clinic, is not working anddangerous. that the vaccines are warm. He therefore cools the vaccines by placing them in the1. Is the mild fever and rash dangerous? freezer compartment. He also notices that the expiratory date on some of the vaccines hasAbout 25% of infants develop a mild fever been reached.after measles immunisations. A rash is lesscommon. Both are not dangerous and resolve 1. Does it matter if vaccines are not kept cool?in a few days. It is very important that all vaccines are kept2. What combined immunisation instead of cool, between 2 and 8 °C. Otherwise they will bemeasles alone can be given at 18 months? damaged and possibly killed. The commonest cause of failure of immunisation to protect anMeasles, mumps and rubella (MMR vaccine). infant is the incorrect storage of vaccine.MMR vaccine should be repeated at 5 years.
  • 46 IMMUNISATION2. Is it dangerous to freeze vaccines? vaccine, may not be effective if the cold chain has been broken.With the exception of polio vaccine, freezingdamages or kills vaccines. Exposure tosunlight also damages vaccines. 5. What can be done to keep vaccines cool if the clinic cannot afford a fridge?3. What should be done with the vaccines, A cool bag or cool box can be used to keepwhich were allowed to warm and were then vaccines cool for a few hours. When used forfrozen? an immunisation clinic, this is adequate.They must be discarded. Vaccines should also bediscarded if the expiratory date has been passed. IMMUNISATION4. What is meant by the ‘cold chain’? REFERENCESThis is the method that keeps vaccines coldfrom the time of manufacture until they are See the following pages for:given to the patient. The cold chain makes • A summary of immunisations routinelysure that the vaccines are not damaged by usedbecoming warm. A vaccine, especially measles • An immunisation record
  • Vaccine Description Storage Administration CommentBCG Live attenuated 2–8 °C 0.05 ml intradermal Should not be given in children over 1Bacillus Mycobacterium Store on middle shelf Right upper arm year. Do not give if symptomatic HIV.Calmette Guerin Discard open vial after Small ulcer after a few weeks common 6 hoursDPT D – toxoid 2–8 °C 0.5 ml intramuscular Mild fever, pain, local swelling commonDiphtheria P – killed bacteria Store on middle shelf Left thigh up until 1 year Not used after 18 monthsPertussis T – toxoid Discard open vial after Left upper arm if over 1 yearTetanus 30 daysDT D – toxoid 2–8 °C 0.5 ml intramuscular Mild fever, pain, local swelling commonDiphtheria T – toxoid Store on middle shelf Left thigh up till 1 yearTetanus Discard open vial after Left upper arm if over 1 year 30 daysHepB Part of the virus 2–8 °C 0.5 ml intramuscular Mild fever, pain and local swellingHepatitis B Store on middle shelf Right thigh up until 1 year occasionally Figure 2.2: Summary of immunisations routinely used Discard open vial after Right upper arm if over 1 year 30 daysHib Part of the 2–8 °C 0.5 ml intramuscular Usually, no side effectsHaemophilus bacteria Store on middle shelf Left thigh – usually asinfluenza B Discard open vial after combined DPT Hib Vaccine 7 daysPolio (OPV) Live attenuated 2–8 °C Two drops by mouth Mild flu like illness or mild diarrhoeaOral Polio virus Store on top shelf If vomited or spat out can may occurVaccine Can use if inner square repeat immediately lighter than outer circle If diarrhoea repeat dose when Discard open vial after diarrhoea settled 30 daysMeasles Live attenuated 2–8 °C 0.5 ml intramuscular Mild fever or transient red rash areMeasles vaccine virus Store on top shelf Right thigh up until 1 year not uncommon 6–11 days post IMMUNISATION Discard open vial after Right upper arm if over 1 year immunisation 6 hours High fever is uncommon 47 Encephalitis is extremely rare