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immunization in special situations


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immunization in special situations

  1. 1. Basics of immunization and IMMUNIZATION IN SPECIAL SITUATIONS Dr.Nupur Sinha Dept. Of Pardiatrics Lourdes Hospital Kochi
  2. 2. Immunization schedules
  3. 3. 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
  4. 4. 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
  5. 5. 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 irritantsterile abcess
  6. 6. • 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).
  7. 7. 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.
  8. 8. Special situations
  9. 9. 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
  10. 10. 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.
  11. 11. 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
  12. 12. Household contacts of Immunocompromised • Should not receive transmissible vaccines- OPV • Non transmissible vaccines –varicella, MMR are safe • Should be fully immunized- varicella, influenza
  13. 13. IMMUNODEFICIENCIES • Severe B cell immunodeficiency Live vaccines contraindicated Inactivated vaccines are ineffective • Less severe B cell immunodeficiency Only OPV contraindicated • Severe T cell immunodeficiency Live vaccines contraindicated All vaccines ineffective
  14. 14. Children receiving corticosteroids/chemotherapy/radiotherapy • Live vaccine contraindicated if 1. High dose oral/iv corticosteroids(20mg/day in children weighing >10kg or >2mg/kg/day) 2. Duration> 2weeks • Can be administered if 1. Low dose steroids 2. Alternate day therapy 3. Inhaled or topical steroids 4. ≥ 4weeks after stopping steroids.
  15. 15. • 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.
  16. 16. • Complement deficiency All vaccines safe Pneumo, Hib, meningococcal vacc indicated • Chronic granulomatous disease Live vaccines contraindicated Other vaccines safe and effective YES if CD4 count>200(≥15%)
  17. 17. HIV INFECTION VACCINE 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
  18. 18. 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
  19. 19. TRANSPLANT RECIPIENTS • Hematopoietic stem cell transplant recipient Loose all memory cells Are like unimmunized Killed vaccines started 12 months post transplant Live vaccines 24 months post transplant if recipient is immunocompetent Influenza vaccine given pretransplant, restarted 6 months post transplant
  20. 20. • Contacts of HSCT- varicella and influenza. Completed 6 weeks before transplant date. • Solid organ transplant recipient Live vaccines completed 2 weeks prior to transplant Post transplant- live vaccines CI Check seroconversion Recommence inactivated vaccines- 6 months post transplant (immunosuppression lowered) Boosters for Hep A and B Annual influenza vaccine Contacts- varicella and influenza
  21. 21. 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
  22. 22. UNIMMUNIZED CHILD VISIT SUGGESTED VACCINES First Measles/MMR if >12mths DTwP1/DTaP1/Tdap if ≥7years OPV1/IPV1 (if < 5years) Hib1 (if < 5 years) Hep B1 Second- after 1 month of 1st visit BCG(if < 5years) DTwP2/DTaP2/Td if ≥7years OPV2 Hib 2 Hep B2 Third –after 2 month of 1st visit OPV3/IPV2 MMR if >12 months Typhoid if > 2years Fourth –after 6 month of 1st visit DTwP3/DTaP3/Td if ≥7years OPV4/IPV3 Hep B3
  23. 23. IAP recommendations for adolescent travellers vaccine Place of travel dose Meningococcal 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
  24. 24. Children with chronic illness • Live vaccines are safe • Other recommended vaccines: Pneumococcal Hep A Varicella Influenza Rotavirus • Immunogenicity, efficacy, duration of protection- low • More doses- Hep B, Boosters
  25. 25. 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.