This document discusses newer vaccines and an MR vaccination campaign. It provides background on vaccine history and types. Recent developments include vaccines for pneumococcal, influenza, meningococcal, HPV, and rotavirus. Future vaccines discussed include ones for HIV. The document also outlines the need for vaccination, recently added vaccines in India's national program, and details of vaccination schedules and target groups for campaigns like one for MR in 2017.
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Newer vaccine new ppt
1. Newer vaccines/ MR Compaign
Presenter: Dr. Walied K Balwan
Moderator : Dr Rohul Jabeen Shah
2. 1. INTRODUCTION
• i. HISTORY.
• ii. CONCEPT OF VACCINE.
2. NEED AND NECCESITY OF VACCINE.
3. NEWER VACCINE.
• i. RECENTALY DEVELOPED VACCINE
• ii. DEVELOPING VACCINE
• iii. FUTURE VACCINE
4. MR vaccination compaign 2017
5. New techniques for delivering vaccine
3. • “A vaccine is a biological preparation that improves
immunity to a particular disease.”
• A vaccine typically contains an agent that resembles a
disease-causing microorganism, and is often made
from weakened or killed forms of the microbe.
• The agent stimulates the body's immune system to
recognize the agent as foreign, destroy it, and
"remember" it, so that the immune system can more
easily recognize and destroy any of these
microorganisms if later encounters.
4. History
18th century
• 1796 First Vaccine for Smallpox ( the first vaccine ever
developed )
19th century
• 1879 First vaccine for cholera
• 1885 First vaccine for rabies by Louis Pasteur
• 1890 First vaccine for tetanus
• 1896 First vaccine for typhoid fever
• 1897 First vaccine for bubonic plague
1796 First Vaccine for Smallpox ( the first vaccine ever
developed )
5. 20th century
• 1921 First vaccine for diphtheria
• 1921 First vaccine for Tuberclousis
• 1926 First vaccine for pertussis (whooping cough)
• 1932 First vaccine for yellow fever
• 1937 First vaccine for typhus
• 1945 First vaccine for influenza
• 1952 First vaccine for polio by Jonas Salk
• 1954 First vaccine for Japanese encephalitis
• 1954 First vaccine for anthrax
• 1957 First vaccine for adenovirus-4 and 7
• 1962 First oral polio vaccine
• 1963 First vaccine for measles
6. • • 1967 First vaccine for mumps
• • 1970 First vaccine for rubella
• • 1974 First vaccine for chicken pox
• • 1977 First vaccine for pneumonia (Streptococcus
• pneumoniae)
• • 1978 First vaccine for meningitis ( Neisseria
meningitides )
• • 1981 First vaccine for hepatitis B (first vaccine to target a
• cause of cancer.)
• • 1985 First vaccine for Haemophilus influenzae type b
(HiB)
• • 1992 First vaccine for hepatitis A
• • 1998 First vaccine for Lyme disease
• • 1998 First vaccine for rotavirus
7. 21st century
• 2003 First nasal vaccine for influenza approved
in US
• 2006 1ST vaccine for Human Papillomavirus.
8. Term VACCINE AND TYPE
• The term vaccine derives from Edward Jenner's 1796
use of cow pox (Latin variola vaccinia, adapted from
the Latin vaccīn, from vacca, cow), to inoculate
humans, providing them protection against smallpox.
Types
• Vaccines are dead or inactivated organisms or purified
products derived from them. There are several types of
vaccines in use. These represent different strategies
used to try to reduce risk of illness, while retaining the
ability to induce a beneficial immune response. So
different type of vaccines are:
9. Killed –
Some vaccines contain killed, but previously virulent,
microorganisms that have been destroyed with
chemicals, heat, radioactivity or antibiotics.
Attenuated—
Some vaccines contain live attenuated
microorganism. Many of these are live viruses that
have been cultivated under conditions that disable
their virulent properties, or which use closely related
but less dangerous organisms to produce a broad
immune response. They typically provoke more
durable immunological responses and are the
preferred type for healthy adults. But they may get
reverted to the virulent form and cause the disease.
10. • Subunit :-Rather than introducing an
inactivated or attenuated microorganism to an
immune system (which would constitute a
"whole-agent" vaccine), a fragment of it can create
an immune response.
Examples include the subunit vaccine against
Hepatitis B Virus that is composed of only the
surface proteins of the virus. Previously it
extracted from the blood serum of chronically
infected patients, but now produced by
recombination of the viral genes into Yeast, Other
examples are Human Papillomavirus (HPV) that
is composed of the viral major Capsid protein,
11. • Toxoid-Toxoid vaccines are made from
inactivated toxic compounds that cause illness
rather than the microorganism. Examples of
toxoid-based vaccines include tetanus and
diphtheria. Toxoid vaccines are known for their
efficacy.
• Conjugate – Certain bacteria have polysaccharide
outer coats that are poorly immunogenic. By
linking these outer coats to proteins (e.g. toxins),
the immune system can be led to recognize the
polysaccharide as if it were a protein antigen. This
approach is used in the Haemophilus influenzae
type B vaccine
12.
13. Recombinant DNA Vaccine
• In recombinant DNA Vaccine, immunogenic part of
antigen produced by recombinant DNA and that
immunogenic part injected in body.
• Like in Hep-B vaccine , H.P.V. vaccine
1. Gene taken for Surface protein, of hep-b + yeast
cell genome.
2. kept in culture media (work as a production unit)
3.Produce surface protein
4. purified surface protein use as vaccine
14. Valence :-
• Vaccines may be monovalent (also called
univalent) or multivalent (also called polyvalent). A
monovalent vaccine is designed to immunize against
a single antigen or single microorganism. A
multivalent or polyvalent vaccine is designed to
immunize against two or more strains of the same
microorganism, or against two or more
microorganisms. In certain cases a monovalent
vaccine may be preferable for rapidly developing a
strong immune response.
16. The efficacy of these vaccine.
• the disease itself (for some diseases vaccination
performs better than for other diseases)
• the strain of vaccine (some vaccinations are for
different strains of the disease)
• whether one kept to the timetable for the vaccinations
• some individuals are "non-responders" to certain
vaccines, meaning that they do not generate
antibodies even after being vaccinated correctly
• other factors such as ethnicity, age, or genetic
predisposition.
17. NEED AND NECCESITY OF VACCINE
Always said “prevention is better then cure”
Vaccines are the important tool in preventive
medicine as well as in public health.
vaccines are the one of the important tool to
control the emergence of disease ,stop that to make
public health problem.e.g. swine flu pandemic
Vaccines is work at very grass root level and
compare to treatment it become cost effective then
other measures e.g. Small Pox , Polio , Measles are
good examples
18. NEWER VACCINE
• 1. RECENTALY DEVELOPED VACCINE
• 2. DEVELOPING VACCINE
• 3. FUTURE OF VACCINES
19. Some Recently Developed Vaccine
• SINGLE ANTIGEN VACCINE
1. pneumococcal conjugate vaccine 2002
2. 1st live attenueted influenza vaccine 2003
3. 1st killed Influenza vaccine 2004
4. new meningococcal vaccine 2005
5. Rotateq (Rota vaccine) 2006
6. HPV vaccine (Gardasil)2006
7. Varivax (for chicken pox)2007
8. Flumist nasal vaccine of 1st live attenueted influenza
vaccine
9. Rotarix (rota virus vaccine) 2008
10. Influenza-A (H1N1) 2009
20. Panenza/ Humenza (H1N1)
• Both vaccines are for influenza A H1N1 virus but
basic difference is panenza is non-adjuvant and
humenza is adjuvant vaccine, so humenza need less
strenght of vaccine.
• STORAGE:- Store in a refrigerator between +2°C
and +8°C.
• DISCARD opened vials within 7 days (opened vials
can be used for a maximum of 7 days) if kept
between +2°C and +8°C
22. SWINE FLU VACCINE
• Recommended influenza vaccine formulation for
2017
• the trivalent IIV 2017
• A/Michigan/45/2015 (H1N1)pdm09-like virus
• A/Hong Kong/4801/2014 (H3N2)-like virus and
• B/Brisbane/60/2008-like virus.
• The IIV is available in both the public sector (at
designated clinics and hospitals) and the private
sector (at pharmacies, certain healthcare facilities,
etc.)
23. • Dosage of influenza vaccine –
• Adults 0.5ml IMI single dose
• 3 years - 8 years – 0.5ml IMI 1 or 2 doses
• 6 months-2 years-0.25ml IMI 1 or 2 doses
• 2 doses should be administered ≥ 1 month apart
during 1st year of vaccination, thereafter one dose
24. Groups that are prioritized for the targeted public
funded influenza vaccination campaign in 2017:
• Pregnant women at all stages of pregnancy, including
the postpartum period
• HIV-infected individuals
• Individuals (adults or children ≥ 6 months) who are at
high risk for influenza and its complications because of
underlying medical conditions
• who are receiving regular medical care for conditions
such as chronic pulmonary (including tuberculosis) and
cardiac diseases, chronic renal diseases, diabetes
mellitus and similar metabolic disorders,
• individuals who are immunosuppressed.
• Persons aged >65 years
25. Recently added in NIS
• Presently ROTAVIRUS vaccine its intriduced in
four states Andhra Pradesh, Haryana, Himachal
Pradesh and Odisha
• PCV has recently been added in UIP in Five
states Himachal pradesh,Bihar, Uttar pradesh,
Rajasthan and madhya pradesh
29. 2. In adults 50 years of age and
• Older Active immunization for invasive disease
caused By streptococcus pneumoniae serotypes 1, 3,
4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F.
• Adults 50 years and older: a single dose.
30. Rota virus
Rota shield:- in 1998, a rotavirus vaccine (rot shield,
by Wyeth) was licensed for use in the united states,
but withdrawal from market due toincreased
incidence of intussusception,in 1999-2000.
31. Currently Licensed Rotavirus Vaccines
• There are three Rotavirus Vaccines available in
market;
Rotavac® (ORV116E), a monovalent vaccine containing
suspension of live rotavirus 116E (G9P[11])prepared in
Vero cells manufactured by Bharat Biotech. It is derived
from a neonatal strain isolated in India and given in 3
doses at ages 6 weeks, 10 weeks and 14 weeks.
Rotarix® (RV1), a monovalent Rotavirus Vaccine
(contains the RIX4414 rotavirus strain; G1P[8])
manufactured by GlaxoSmithKline Biologicals. It is
given in 2 doses at ages 2 months and 4 months.
RotaTeq® (RV5), a live Attenuated Pentavalent human
bovine reassortant Rotavirus Vaccine (containing G1,
G2, G3, G4, or P1A[8]) manufactured by Merck and Co.
It is given in 3 doses at 2, 4 and 6 months of age.
32. • The US Federal Drug Administration licensed
Merck’s RotaTeq® in February of 2006 and GSK’s
Rotarix® in April of 2008. The European
Commission and the European Medicines Agency
(EMA) licensed GSK’s Rotarix® in February 2006
and Merck’s RotaTeq® in June 2006. The WHO
prequalified Rotarix® in January 2007 and
RotaTeq® in October 2008. Following a multisite
clinical trial, Rotavac® was licensed in India by
Drug Controller General (India) in 2013 and 2015.
33. Menactra (N. Meningitidis)
INDICATIONS AND USAGE :-
• Menactra vaccine is indicated for active immunization to
prevent invasive meningococcal disease caused by N
meningitidis serogroups A, C, Y and W-135. Menactra is
approved for use in individuals 9 months through 55 years of
age. Menactra vaccine does not prevent N meningitidis
serogroup B disease.
DOSAGE AND ADMINISTRATION A 0.5 mL dose for
intramuscular injection• Children 9 through 23 months of age:
Two doses, three months apart. Individuals 2 through 55 years
of age: A single dose.
CONTRAINDICATIONS Severe allergic reaction (eg,
anaphylaxis) after a previous dose of a meningococcal capsular
polysaccharide-, diphtheria toxoid- or CRM197-containing
vaccine, or to any component of Menactra vaccine.
34. HUMAN PAPILLOMA VIRUS (HPV) VACCINE 34
Vaccine GARDASIL® HPV
Quadrivalent vaccine (2006)
Types 6,11,16,18
CERVARIX,Bivalent
vaccine (2009) Types
16,18
Indications Girls & women 9-26 years
boys & men 9-26 years
Females 9 – 25 years of
age
Dose &route 0.5ml IM. 0.5ml IM.
Schedule 0, 2 & 6 months 0, 1 & 6 months
Side effects Syncope, Headache, Fever, Nausea,
dizziness, Injection site pain,
erythema, pain, pruritus, swelling
≥20% of patients – pain,
redness & swelling at
injection site, fatigue,
headache, GI symptoms,
arthralgia, myalgia
Contra-
indications
Severe allergic reactions to
previous dose, severe acute illness,
pregnant females
Same
Protection 70% against cervical cancers 70% against cervical
cancers
35. Varivax ( against Varicella)
INDICATIONS AND USAGE :- VARIVAX is indicated for
vaccination against Varicella in individuals 12 months of age
and older. The duration of protection of VARIVAX is unknown;
however, long-term efficacy studies have demonstrated continued
protection up to 10 years after vaccination.
DOSAGE AND ADMINISTRATION:
(FOR SUBCUTANEOUS ADMINISTRATION )
• Children :- 12 months to 12 years of age should receive a
0.5-mL dose administered subcutaneously. If a second 0.5-mL
dose is administered, it should be given a minimum of 3 months
later.
Adolescents and Adults :-Adolescents and adults 13 years
of age and older should receive a 0.5-mL dose administered S.C.
at elected date and a second 0.5-mL dose 4 to 8 weeks later.
CONTRAINDICATION :- Individuals with leukemia,
lymphomas of any type, or other malignant neoplasm affecting
the bone marrow or lymphatic systems.
36. Developing Vaccine
1. HIV Vaccine: In 1984, after the confirmation of
the etiological agent of AIDS by scientists at the
U.S. National Institutes of Health and the Pasteur
Institute, the United States Health and Human
Services Secretary Margaret Heckler declared that a
vaccine would be available within two years. But
still it is a dream.
37. The ineffectiveness of previously developed vaccines
primarily stems from two related factors.
• First, HIV is highly mutable. Because of the virus'
ability to rapidly respond to selective pressures
imposed by the immune system,
• Second, HIV isolates are themselves highly variable.
HIV can be categorized into multiple clades and
subtypes with a high degree of genetic divergence.
Therefore, the immune responses raised by any
vaccine need to be broad enough to account for this
variability. Any vaccine that lacks this breadth is
unlikely to be effective
38. • AIDSVAX experimental HIV vaccine( San
Francisco)
• synthetic version of a protein gp120.
• stimulates the production of neutralizing
antibodies, proteins that block HIV from infecting
cells.
• The ALVAC-HIV vaccine - an attenuated
(weakened) canarypox virus that has been
genetically altered and when injected it stimulates
the body’s production of CTLs against HIV
39.
40.
41. Classification of all theoretically
possibleHIV vaccines
• Any theoretically possible HIV vaccines must inhibit or
stop the HIV virion replication cycle. So, the targets of
the vaccine are the following phases of the HIV virion
cycle:
• Phase I. Free state
• Phase II. Attachment
• Phase III. Penetration
• Phase IV. Uncoating
• Phase V. Replication
• Phase VI. Assembling
• Phase VII. Releasing
42. Future work
• First, greater translation between animal models
and human trials must be established.
• Second, new, more effective, and more easily
produced vectors must be identified.
• Finally, and most importantly, there must arise a
robust understanding of the immune response to
potential vaccine candidates.
• A vaccine, SAV001, that has had success in
animal subjects began Phase 1 human trials in
London, Ontario in 2011.
43. 43
IF THE VACCINE
TARGETS..
ITS GOAL IS TO..
Pre- erythrocytic stage Prevent infection
Blood stage Reduce clinical disease
Sexual stage or
transmission blocking
(altruistic)
Prevent the spread of
parasites by mosquitoes
MALARIA VACCINE – Concept of stage
targeting
44. • Malaria vaccine community goal
• Strategic Goal: To develop an 80%
efficacious malaria vaccine by 2025 that
would provide protection for at least four
years
• Landmark goal: To develop and license a
first-generation malaria vaccine that has protective
efficacy of more than 50% against severe disease
and death and lasts longer than one year
• Malaria Vaccine Technology Roadmap
• P. vivax and Pf / Pv transmission-blocking
vaccines
45. RTS,S/AS01 (commercial name:
Mosquirix)
• which started Pivotal Phase III evaluation in May
2009.
• It is designed not for travellers but for children
resident in malaria-endemic areas who suffer the
burden of disease and death related to malaria.
• The RTS,S vaccine was engineered using genes
from the outer protein of Plasmodium falciparum
malaria parasite and a portion of a hepatitis B
virus plus a chemical adjuvant to boost the immune
system response.
46. • Reconstituted 0.5mL vaccine
• Administered by intramuscular injection into,
▫ Antero-lateral thigh in 6-12 weeks age group, and
▫ Left deltoid in 5-17 months age group
47. RTS,S/AS01 – VACCINE EFFICACY
• 5-17 month old children – 4 doses (0,1,2,20m)
▫ 39% against clinical malaria
▫ 31.5% against severe malaria
• 6-14 weeks infants – 4 doses (6,10,14w & 18m)
▫ 27% against clinical malaria with 4th dose
▫ 18% against clinical malaria WITHOUT 4th dose
• Efficacy difference in 6-14 weeks infants,
▫ Lower immune responses
▫ Co-administration with DTP-containing vaccines
▫ Maternal acquired antibodies
▫ Immunological immaturity
49. DENGVAXIA (CYD-TDV)
49
• By Sanofi Pasteur – first licensed in December, 2015,
in Mexico
• Registered for use in individuals 9-45 years of age
living in endemic areas
• CYD-TDV – live recombinant tetravalent vaccine
• 3-dose vaccine given on a 0/6/12 month schedule
50. Leprosy vaccine
• A vaccine containing ICRC bacilli (which are cultivable
leprosy derived mycobacteria probably belonging to
M. Avium intracellulare complex) was prepared in
1979 at the Cancer Research Institute, Mumbai.
• Studies, both on humans and animals, show that the
ICRC bacilli exhibit antigenic cross-reactivity with M.
leprae with reference to both B and T cell antigens
52. Cancer Vaccine
Biological response modifiers.
• Two types –
• Preventive (or prophylactic)
• Treatment (therapeutic vaccines)
preventive cancer vaccines are Gardasil and
Cervarix, HPV - types 16 and 18
• Treatment vaccines by strengthening the body’s
natural defenses against the cancer. This vaccine,
sipuleucel-T (men with metastatic prostate
cancer)
53. LIFESTYLE VACCINES
• NicVAX(Nicotine Conjugate Vaccine)
• NicVAX -nicotine molecules with protein (induce
an immune response )
• Diamyd, a vaccine to prevent diabetes, It is
intended for the treatment of children and
adolescents with recent-onset type 1 diabetes.
undergoing Phase III clinical trials in Europe
54. Vaccine for Infectious diseases
• T-cell receptor peptide vaccines are under
development for several diseases using models
of Valley Fever, stomatitis, and atopic
dermatitis. These peptides have been shown to
modulate cytokine production and improve cell
mediated immunity.
72. Measles mortality: complications
Corneal scarring
causing blindness
Vitamin A deficiency
Encephalitis
Older children, adults
≈ 0.1% of cases
Chronic disability
Pneumonia &
diarrhea
Diarrhea common in developing countries
Pneumonia ~ 5-10% of cases, usually bacterial
73.
74. Complications
Rubella
• lymphadenopathy
• Arthritis
Children: rare
Adult female up to 70%
• Thrombocytopenic purpura
1/3000 cases
• Encephalitis
1/6,000 cases
• CRS is the most potential
complication
▫ 90% chance if infected during 1st
trimester of pregnancy)
Congenital Rubella Syndrome (CRS)
• Hearing Impairment
• Cataracts / Glaucoma
• Heart defects ( PDA )
• Microcephaly
• Developmental Delay
• Mental retardation
• Hematological disorder
• Liver and spleen damage
75. Congenital Rubella Syndrome
• Infection early in
pregnancy most
dangerous (<12 weeks
gestation)
▫ Weeks 1- 10 – 90% CRS*
▫ Weeks 11-12– 33%
▫ Weeks 13-14– 11%
▫ Weeks 15-16– 24%
▫ Weeks > 17– 0%
• May lead to fetal death
or premature delivery
• Organ specificity
generally related to
stage of gestational
infection
*Miller E. Lancet 1982;2:781-4.
76.
77. Measles and Rubella Targets
Global targets by 2015:
Measles vaccination coverage ≥ 90% national and ≥ 80% district
Measles reported incidence <5 cases per million
Measles mortality reduction of 95% vs. 2000
Regional targets:
Measles Elimination goals:
2000 AMRO
2012 WPRO
2015 EURO, EMRO
2020 AFRO, SEARO
Rubella Elimination goals:
2010 – AMRO, 2015 – EURO
78. Measles and Rubella Elimination Goals by WHO
Region,
2015
2015
2015
2012
Americas, Europe, E. Mediterranean, W. Pacific, Africa, South East Asia have measles elimination goals
Americas and Europe have rubella elimination goals as well
2020
2000
2010
2020
India had set a goal to Eliminate
Measles and control Rubella &
Congenital Rubella Syndrome by
the year 2020.
79. The major stake holders for planning &
implementation of MR Campaign at the District level
• District Health & Family Welfare
• Education Department (Govt, Aided, Private, Montessori,
Madrasa etc)
• Department of Women and Child Development
• PRI
• Corporations
• Railways & Defence
• Medical & Nursing Colleges
• Professional organizations- IAP, IMA, Fogsi, Private
hospitals association
• Social Welfare Department
• WHO, Unicef
• Loins, Rotary & other NGO’s
• Parents / Community
80. Achieving the Goal, (key strategic
objectives)
1. At least 95% population immunity with 2
doses against measles and rubella through routine
and/or supplementary immunization.
2. Develop case-based measles and rubella and
CRS surveillance system that fulfils
recommended surveillance performance indicators.
3. Develop accredited measles and rubella
laboratory network
4. Strengthen support and linkages to achieve the
above three strategic objective
81. Rationale for MR compaign
• Country Population Immunity is insufficient to stop
ongoing MR transmission as evident form MR surveillance
data
• MR outbreaks wide spread across the entire country
• Population immunity is waning.
• Five state/UT are providing RCV in the form of MR vaccine
including some urban municipalities, including Indian Army
• Rubella vaccine introduction requires high level of
population immunity to prevent the paradoxical effect as
a risk mitigation strategy
• NTAGI has recommended wide age range MR vaccination
campaign targeting 9 months-<15 years before
introducing RCV in routine immunization in all the states of
India
82. Phase
MR
campaign
Year
No. of
States
No. of
District
s
Estimated
Target Population
(9 m - < 15 years)
Phase 1-A 2017 5 69 35,783,000
Phase 1-B 2017 7 95 30,632,000
Phase 2 2017 16 209 110,702,000
Phase 3 2018 6 202 123,101,000
Phase 4 2018 2 108 108,582,000
Total
2017 –
2018
36 683 408,800,000
Source:
Projected Target population (9 months to 15 years) based of 2011 census data, GoI Statistical Division
Proposed Measles-Rubella Vaccine Introduction Plan,
(2017-2018)
Karnataka, Tamil Nadu, Puducherry, Goa and Lakshadweep
83. • MR vaccination campaign scheduled from 7th to 28th
February 2017
• All children between 9 months to <15 years age should
receive one dose of MR vaccine during campaign
(irrespective of previous vaccination dose with Measles
or Rubella)
• After the campaign 2 doses of MR vaccine will be
introduced into Routine Immunization schedule (UIP)
replacing 2 doses of Measles vaccine
Measles Rubella Vaccination Campaign
Measles-Rubella Vaccination Campaign February 2017
onwards
84. MR campaign: Vaccination strategy
• Target age group: 9 months to <15 years ( regardless of their prior M/R immunization
status or any past history of Measles/Rubella disease)
• Target 100% :
• Evaluated More than 95 %
• Types of MR vaccination Booths:
1. 1. School Vaccination Booth
2. 2. Outreach Vaccination Booth (Anganwadi, community hall)
3. 3. Health Facility booth
4. 4. Special teams to cover migratory populations
Average Campaign duration: ~ 3+ 1 weeks = ~16-20 working days
• 1st week: School based campaign (for 5-15 year children)
• 2nd and 3rd weeks: Community based campaign for non-school going
children
• 4th week will be for sweeping/ repeat activity based on supervision-
monitoring
• To cover one school in one day; one village in one day
85.
86. Summary
• MR Campaign started from 7th February to 28th
February 2017
• Make sure to Vaccinate all Children between
5 years to 15 years at schools
• Vaccinate all children between 9 months to 5
years at Play homes / Anganwadi centre
• MR Vaccine also available at all PHCs / UHCs/
Major Hospitals and Medical colleges