This document discusses 19 scenarios related to immunization in children. It addresses questions about appropriate vaccine schedules and intervals between live and antibody-containing vaccines. It provides guidance on immunizing high-risk groups like immunocompromised or premature infants. It also covers management of exposures like dog bites or rabies, recommending wound care and appropriate vaccines or immunoglobulins depending on the situation. The document is a useful reference for pediatric vaccine questions and handling common immunization cases.

1. Immunization in children
case based scenarios
Dr Gururaja R
MD,DNB (Paed)

2. Scenario 1
• Avinash, received his 2nd dose DPT on 27 May
2023 and now has come on 19 Jun 2023 for 3
rd dose.
• Can he be offered vaccine?

3. • Interval between two doses of same vaccine
should be minimum 4 weeks
• Any dose taken more than 4 days before the
due date is considered invalid
• Why?

5. Scenario 2
• 15 month old child, who had received MMR
two weeks back is now brought with advice
for an intra familial contact with varicella.
• Can he be given varicella vaccine?
• If given, which will be ineffective?
• MMR/Varicella/both
• What to do?

6. • Two live injectable vaccines should be
separated by at least 4 weeks
• If two live vaccines given at an interval of less
than four weeks, if not given simultaneously, it
is the second vaccine that is ineffective

7. Scenario 3
• Rahul received pentavac from local hospital.
• Brought to your hospital three days later for
IPV.
• Is it scientifically correct?
• Will it give a good immune response?
• How?

8. Scenario 4
• 3 yr old female child, developed diphtheria
with complications in the form of renal failure,
myocarditis and polyneuropathy.
• Immunization history – received 1 dose of
pentavalent vaccine at 6 weeks of age
• Did not take any further dose of pentavalent
vaccine.
• Can we call it vaccine failure?

9. Scenario 5
• 8 month old male infant admitted at a tertiary
care centre with H influenzae meningitis.
• Immunization history – taken pentavalent
vaccine at 6, 10 and 14 weeks
• Recovered uneventfully
• What went wrong with vaccine?

10. Scenario 6
• 10 yr old unimmunized brought with an injury
while playing foot ball.
• The wound is a cut lacerated with mud
particles
• What is your management?

11. • Protect now – tetanus immunoglobulin
• Future protection – –
0 - - - Tdap
1 month – Td
6 month – Td
1 yr later – Td
• Give protection for 10 years

12. 10 yr old unimmunized
0 month Tdap MMR Hepatitis B Varicella
Hepatitis A
HPV
1 month Td/Tdap MMR Hepatitis B
6 month Td/Tdap Hepatitis B Varicella
Hepatitis A
HPV
1 yr later Td

13. Scenario 7
• Whom to blame?
• What to do?

14. BCG Adenitis
• No one to blame!!!
• Wait and watch
• NO ATT
• NO ANTIBIOTICS
• Fluctuant – aspirate
• Too big - excision

15. Scenario 8

16. • Dissseminated BCGiosis
• Look for immunodeficiency state

17. Scenario 9
• 4 month old rama brought with no BCG scar
• What does BCG scar mean?
• Till what age can BCG be given?
• What if no scar?
• Is Mantoux required before BCG?

18. • Not given or given subcutaneous
• See vaccine documentation
• If no documentation – go ahead and give BCG
• But wait for six months – for scar
• Mantoux is not required before BCG
• Maximum age for BCG vaccination -1 yr(NIS)
and 5 yr (IAP)

19. Scenario 10
• Shruthi, a sputum positive pulmonary TB gives
birth to a baby boy.
• What is to be done?

20. • Give BCG at birth.
• Evaluate for disease
• INH prophylaxis for 6 months

21. Scenario 11
• 16 month old Shubhan
admitted with kawasaki
disease 1 week after he
received MR vaccine
• Will the vaccine efficacy
be compromised?

22. • Antibody containing products
eg. Blood, FFP, IVIG
• Live injectable vaccine at least 2 weeks before
giving antibody containing products
• Live vaccine interval depends on antibody
content

23. Product Live vaccine interval
PRBC 3 months
FFP 7 months
IVIG 400mg/kg 8 months
IVIG 2g/kg 11 months

24. Scenario 12
• Preterm baby 28 weeker is planned for
discharge on day 60 with a weight of 1.5 kg
• h/o receiving blood transfusion and IVIG.
• Immunization advice?

25. • OPV
• BCG
• Hepatitis B

26. Hepatitis B
• > 2 kg or > 1 month of age
• Which ever is earlier
• < 2kg @ birth dose – 68% seroconversion
• < 2kg @ 1 month – 96% seroconversion
• If given to < 2kg – minimum 4 doses are
required for seroconversion

27. Preterm and LBW
• They are more vulnerable than healthy term
babies
• They have less of maternal antibodies
• Chronological age Vs post conceptional age
• Routine immunization schedule

28. Scenario 13
• 5 yr old child has culture positive typhoid
• Given two doses of TCV @ 9mo and 2 yrs
• Parents are worried
• Can Typhoid occur in vaccinated?
• Will you give another shot thinking that the
child doesn’t have adequate protection?

29. • Typhoid fever is caused by S typhi and
paratyphi A and B
• TCV protects only against S typhi
• TCV efficacy 85-95%
• Single dose recommended
• No need for revaccination in the above case

30. Scenario 14
• Your friendly neighborhood Amazon delivery boy
had a dog bite and you got him fully vaccinated
• After that he got 7 times dog bite in a span of 6
months
• What do you do after each bite?
• What about pet dog bites? Owners may say dog
is vaccinated
• How do you protect animal handlers?

31. • Initial event of dog bite – 0,3,7,14-28 - ARV
• Fully immunized – 3 months – no need for vaccination
• PEP – 2 doses id or im (0 and 3)
• No RIG
• Any dog bite – local care
• Frequent exposure – following full course of PEP, 6 monthly testing
of anti-rabies antibodies
• >0.5IU/ml desirable
• < 0.5 IU/ml – booster dose of ARV required
• Prexposure prophylaxis for animal handlers – 0,7 21-28

32. Scenario 15
• 5 yr old boy had an abrasion with some
bleeding, following exposure to a stray dog 2
months back. Nothing was done. Now the
mother gets the news that the dog was
suspected rabid and was killed by the people.
• What should be done?

33. • It should be categorized as fresh class 3
exposure and RIG/Mab administered with
0,3,7,14-28 ARV

34. Monoclonal antibodies against rabies
• Rabishield – 3.3IU/kg
• Twinrab (Docaravimab + Miromavimab) – 40
IU/Kg
• Reduced risk of adverse events
• Use similar to HRIG/ERIG
• IAP endorses its use in place of HRIG/ERIG.(WHO
position paper on rabies -2018)

35. Scenario 16
• During your routine rounds in pediatric ward,
a mother says that her child was bitten by rat
yesterday night and you observe slight
bleeding from left index finger.
• Is ARV/RIG indicated?

36. • House rat bites do not require ARV/RIG
• Rabbit/Sqirrel bites – do not require ARV/RIG

37. Scenario 17
• Khushi was diagnosed with ALL at 2 years of
age. She is on chemotherapy.
• What immunization advice will you give for
her 6 weeks old brother?
• Her cousin who is 15 months of age and
staying in the same house?

38. • No OPV
• IPV at 6 weeks
• MR/MMR and varicella

39. Scenario 17
• Last case of Polio was seen in 2011 in India
and India is certified Polio free since 2014
• Why are we still giving Polio Vaccine?
• With availability of IPV why are we giving OPV
which is prone for VAPP and VDPV?

41. • We have our neighbor with wild polio
• Bivalent OPV does not cover type 2
• Hence IPV is always required
• IPV also prevents against VDPV

43. • Conversion to total IPV based regimen if
immunization coverage>95%.(WHO)

44. Scenario 18
• Your colleague who is a medicine resident calls
you and asks your advice for immunization for 19
yr old patient who is planned for splenectomy.
• Can we give pneumococcal and meningococcal
vaccine together?
• What is the minimum interval between PCV and
PPV?

45. • No
• Pneumococcal first --- 4 weeks later
meningococcal vaccine
• PCV FIRST
• 8 weeks later PPV

46. Scenario 19
• Name some situations where vaccine and
immunoglobulin are given together

47. • Hepatitis B
• Tetanus toxoid
• Rabies Vaccine

48. •Thank you