This document summarizes recent advancements in immunization. It discusses the goals of immunization as preventing disease in individuals and ultimately eradicating diseases worldwide. Data from the US shows significant decreases in morbidity from diseases like smallpox, polio, measles, and haemophilus influenza type B due to immunization programs. It also discusses common concerns parents have about immunization and ways to address those concerns. The document then describes the different types of immunization including active and passive immunization. It provides guidelines for many common vaccines and discusses considerations around vaccine handling, scheduling, and specific diseases.

1. RECENT ADVANCEMENT IN
IMMUNIZATION

2. GOALS OF IMMUNIZATION
• IMMEDIATE :prevention of disease in
individuals
• ULMITIMATE : eradication/ elimination of
disease from the world

3. EFFECTS OF IMMUNIZATION( US BASED DATA )DISEASE SMALL POX POLIO
PARALYTIC
MEASELS HAEM.INFLUEN
ZA
TYPE B
MORBIDITY
20TH CENTURY
48164 16311 503282 20000
MORBIDITY
2007
ZERO ZERO 43 22
% DECREASE 100 100 >99 >99%

4. PARENTS CONCERNS ABOUT
IMMUNIZATION
• Safety of immunization
• Objections due to religious thoughts
• Past experience or hear say
• Disease would give better protection than vaccine
• Combine vaccines given on one visit may have more
side effects
• Cost.
• They should be counselled in detail, referred to
different literatures and websites like
www.aapnews.org / www.immunizationfo.org

5. Types of immunization
1. Active immunization
2. Passive immunization
ACTIVE IMMUNIZATION:
1. The administration of all, part of micro organism
,modified product of that organism , resulting in an
immunologic response that mimics that of the natural
disease but usually present no or little risk for the
recipient
It may provide life long protection ,partial protection
or may require administration at regular intervals.

6. PASSIVE IMMUNIZATION
• It is the administration of preformed antibodies to
recipients
• It is available as
• immunoglobulin, I/M
• specific immunoglobulins ,
• Immunoglobulin I/V
• Indications are immunodeficiency states, ITP, Rabies
(rabies Ig) Tetanus(TIG), tetanus antitoxin, Diptheria
anti toxin

7. VACCINE HANDLING AND STORAGE
• Transported/stored at recommended
temperature
• Live virus attenuated vaccine are heat
sensitive and destroyed at high
temperature e.g MMR Rota Virus OPV etc
• Inactivated vaccine are cold sensitive but
they are destroyed by freezing e.g DPT, IPV,
HiB, Hep A & B etc

8. SCHEDULING IMMUNIZATION
• Two programmes are available in our country
• Expanded Programme for immunization (EPI)
• Programme recommended by American
Academy of Pediatrics (AIP)

9. GUIDLINES FOR MAJOR VACCINES
• BCG
• Prepared from live attenuated M. Bovis
• Method of administration
• Natural course of BCG vaccine
• Accelerated BCG response
• Evidence of successful BCG vaccine
• Protective efficacy
• Adverse reaction like abscesses disseminated fatal
disease, axillary adenitis etc
• Contraindiactions include burns, skin infections,
primary and secondary immunodeficiencies

10. POLIO
• Two types
• 1)inactivated polio virus IPV given parentally I/M or
S/C
• 2)live virus vaccine given orally OPV
• OPV is easy to administer low cost and more
effective immunization
• Both vaccines contain 1,2&3 polio strains
• Two doses of IPV results in 95% and 3 doses results
in 99-100% immunity probably life long
• Three doses of OPV gives excellent antibody
response

11. • Adverse Effects of IPV
• No serious side effect except the
hypersensitivity to neomycin streptomycin
and polymyxin and can be given to
immunocompromised persons
• Adverse Effects of OPV
• OPV associated VAPP =1:750000 doses
• Overall risk for VAPP =1:2.4 million doses

12. DIPTHERIA TETANUS AND PERTUSSIS
IMMUNIZATION
• DwPT and DaPT
• Contains
• 1)Diptheria Toxoids
• 2 )Pertussis(killed whole cell/Acellular) and
• 3)Tetanus Toxoid
• Schedule : 5 doses at 2, 4, 6, 15-18 months
and 4-6 years of age, over 7 years child should
receive Tdap

13. TETANUS
• 5 doses as mentioned above in the form of
DTwP, DtaP, DT, Tdap
• Wound management
H/o Tetanus Toxoid (doses) Clean wound
Td/Tdap TIG
All other wounds
Td/Tdap TIG
Less than 3 or unknown Yes No Yes Yes
More than 3 No No No No

14. Tetanus prophylaxis
• TIG 250 units I/M regardless of age and weight
• IVIG can be used if TIG is not available
• ATS (equine Antitoxin Serum) is better avoided
because of anaphylaxis and serum sickness
• Tetanus immunization with Tetanus Toxoids
can be initiated simultaneously

15. Prevention of neonatal tetanus
(prenatal immunization)
• Pregnant women who have not completed their
primary series (3 doses) should do so preferably
before delivery
• 2 doses of Td 4 weeks apart 2nd being given 2
weeks before delivery
• Immunization with TdaP/Td is not contraindicated
during pregnancy
• Adverse reaction with Tetanus Toxoids include
Anaphylaxis, GBS, Brachial neuritis but are rare

16. PERTUSSIS
• 5 Doses as mentioned earlier
• DwPT contains whole cell killed Pertussis
organism and is immunogenic as well as
reactogenic
• Acellular pertussis contains two or more
immunogens derived from B-Pertussis

17. Side effects
Whole cell vaccine Acellular vaccine
Local reaction more Much less
Systemic More Much less
Anaphylaxis 2 per million Much less
Seizures 1:1750 doses Much less
HHE 1:1750 Much less
Temp 105F In 0.3% reciepients Much less
crying for more than 3 hrs 1% Much less

18. CONTRAINDICTIONS FOR DTaP
• Anaphylactic reaction
• Encephalopathy with in 7 days after receipt
of Dtap
• Progressive neurological disorder

19. HEPATITIS B VACCINE
• HBV is produced by Recombinant DNA
technology
• 3 doses of HBV (Engerix-B)10 microgram I/M 0,1
and 6 months upto age of 20 years .Over 20 years
20 microgram I/M is needed
• 4 doses of HBV may be administered at birth. If
birth dose is given and a combination of vaccine
is used to complete the series
• Efficacy and duration of protection is 90-95% and
immune memory is intact for 20 years

20. INDICATION FOR BOOSTER DOSES OF
HBV
• Patients on hemodialysis
• Immunocompromised
• Health workers
MANAGEMENT OF NON RESPONDERS
Re immunization with additional 3 doses series

21. MANAGEMENT OF BABIES BORN TO
HBSAge+VE MOTHERS
• Safe delivery
• Baby should receive HBIG 0.5ml I/M as soon
as possible but within 7 days of birth
• Baby should be given 1st dose of Hep B vaccine
if baby weight is over 2 kg and if <1kg after 1
month
• Remaining doses of HBV can be given alone or
in combination

22. HEPATITIS A VACCINE
• Inactivated Hep A given in 2 doses starting from 1
year and 2nd dose 6 months after 1st dose
• Doses are 720 ELU 1 -18 year of age
• And 1440 ELU 19 years and older
• For post exposure prophylaxis(contact with near and
dear ones)
• IG(0.02ml/kg) given within 2 weeks after exposure
and is effective upto 85% in preventing Hep A upto 3
months
• Twinrix a combination vaccine of Hep A and Hep B
for age 18 years and above

23. MEASLES
• Measles is immunosuppresive disease
associated with chronic mortality, morbidity
and serious complications
• Measles vaccine is a live attenuated and is
available as a monovalant and also in
combinations (MMR , MMRV)
• Pakistan being endemic state for measles ,
recommendation for measles are
• 1) measles at 9 months of age (MMR)
• 2)MMR/MMRV at 15 months and at 4-6 years
of age

24. • Serum antibodies develop in 95% if MMR
given at 12 months of age and 99% if given at
15 months of age
• Adverse effect are
• Fever 5-15%
• Transient rash
• Thrombocytopenia
• Encephalitis <1/million doses
• For prevention of measles to close contacts IG
0.25 ml /kg can be given

25. VARICELLA VACCINE
• Contains live attenuated vaccine as a monovalent
and part of MMRV
• Dose is 0.5ml/s/c
• 1st dose12-15 months and 2nd dose 4-6 years
(minimum interval between 2 doses is 3 months)
• Single dose efficacy is 70-90% against infection
and 95%against serious infection. Recipients of 2
doses are 3.3 fold less likely to have break
through infection. Duration of immunity is 20 yrs
or more.
• Vaccine is safe and reactions are mild.

26. Haemophilus Influenza type B (HIb)
• HIb conjugated vaccine consist of capsular
polysaccharide , Tetanus toxoid (PRP-T)/outer
membrane protein complex from N.meningitidis.
• Available as a monovalent vaccine (ACT-HIB,
HIBERIX).
• 3 doses given at 2,4 and 6 months of age PRP-T,
PRP-OMP (minimum 2 doses interval being 1
month), 4th dose at 12-15 months
• Doses 0.5ml/IM
• In patients with sickle cell disease , leukemia, HIV
infection, patients with splenectomy one dose of
HIb vaccine may be given after age of 5 years.

27. PNEUMOCOCCAL VACCINE
• Streptococcal pneumonia causes invasive
bacterial infection like pneumonia, empyema,
AOM, meningitis etc
• 110 serotypes of pneumococci are identified
• Two types of vaccines
• 1)pneumococcal conjugate vaccine which are
immunogenic from 6 weeks -5years of age(PCV)
• 2)pneumococcal polysaccharide 23 valent vaccine
which is immunogenic after the age of 2
years(PPSV23)

28. • Pneumococcal conjugate vaccine are available
10(synflorix) and 13(prevenar13) serotypes
• Primary series consists of three doses at 2 ,4
and 6 months of age and booster at 12-15
months of age
• Conjugate vaccine is recommended upto the
age of 17 years and in all persons above 50
years.
• Doses 0.5ml I/M

29. PCV Q13 (CONJ) VERSUS PPSV23(PR
POLYSACCHARIDE VACCINE
PCV13(CONJ) PPSV23(PR.POLYSACCHARI
DE VACCINE)
DURATION OF IMMUNITY definite Unknown, likely to be short
IMMUNOLOGIC MEMORIES yes no
BOOSTER EFFECT WITH
SUBSEQUENT DOSES
yes no
NASOPHARYNGEL
EFFECT(HERD IMMUNITY)
yes no

30. ROTA VIRUS VACCINE
• Incidence is 28-30% of all diarrhoeal diseases
• 7 distinct groups are recognized A-G
• Group A virus -major cause
• Previously Rota virus vaccine was associated with
intussusception so it was withdrawn
• In 2008 a live oral human attenuated rota virus
vaccine has been introduced as a two dose
vaccine
• Min age of 1st dose 6weeks
• Max age of 1st dose 14 weeks and 6 days
• Min interval between doses is 4 weeks
• Max age of last dose 8 months

31. TYPHOID VACCINE
• Effective 50-70%only
• TAB vaccine can be given at age of 6 months
• 3 doses are needed at 1-2 weeks interval (not in
use now because of severe local and side effects)
• Ty21 A is live attenuated vaccine replicates in gut
• It should not be used in acute gastroenteritis
• Antibiotics should not be used 1 day prior and 7
days after 4th dose of vaccine
• Should not used in immuno-compromised
patients

32. vaccine type route Age of
recipient
doses frequency
ViCPS
(Typhim/
Typherix)
polysacchari
de
I/M 2years 1 2 years
Ty21a
(Vivotef)
Live
attenuated
oral 6 years 4 5 years

33. HUMAN PAPPILOMA VIRUS
• Produce benign epithelial proliferation(warts) of skin and
mucous membranes
• Also associated with anogenital dysplasia and cancers
• HPV VACCINES quadrivalent (HPV4 types 6,11,16,18)
vaccines (Gardisil) is available
• 3 doses starting from age of 11-13 years upper age limit
is 26 years
• Dose is 0.5 ml I/M 2nd dose 2 months after 1st dose and
3rd dose 6 months after 1st dose
• Ceravarix (bivalent HPV 2 for type 16,18)
• 99% is immunogenic and has efficacy against cervical,
vulvar,vaginal cancers genital and skin warts
• Now AIP has recommended quadrivalent for both sexes
and bivalent only for females.

34. INFLUENZA
• Very common disease
• Associated with fevers chills headache myalgia
and cough often super added by bacterial
infection
• Occasionally febrile seizures and encephalitis
• Influenza virus is of 3 types (A,B,C). Epidemics is
caused by type A and B and both are included in
influenza vaccine. Type C causes mild and
sporadic disease and not included in the vaccine
• Circulating Human Influenza A subtypes include
H1N1, H1N2 and H3N2 viruses.

35. Seasonal epidemics
• Are caused by minor antigenic variations within
influenza A and B virus and are called antigenic
drift
• Pandemics are caused by major changes in
influenza A virus and are called antigenic shifts
• In 1918 H1N1 pandemic 20 million people were
killed in USA and 50 million in the whole world.

36. Diagnosis
• High index of clinical suspicion
• Nasopharyngeal or oropharyngeal tissue swab
obtained within 72 hours of illness
• 1)viral culture (result available in 2-6 days)
• 2)Rapid diagnostic test for identification infective
antigen are available commercially- yields result in 30
mins
• 3)direct florescent antibody(DFA) and indirect
immunoflorescent antibody (IFA) for the detection of
infective antigen (results in 3-4 hours)
• PCR(higher sensitivity and specificity but lacks
availability)

37. Types of vaccines
• Two types
• Live attenuated influenza vaccine contain 3
virus strains A(H3N2), A(H1N1)and B. It is used
above 2 years through intranasal route
• May increase wheezing and may not be used
in asthma and immuno-compromised patients
• Trivalent inactivated influenza vaccine is
available with the names of Vaxigrip,
Agrippal, Fluarix

38. SCHEDULE FOR TIV VACCINE
AGE DOSE(ml) NO OF DOSE ROUTE
6-35 MONTHS 0.25 2 I/M
3 THROUGH 8
YEARS
0.5 2 I/M
9 YEARS OR OLDER 0.5 1 I/M

39. Timings for vaccine is October to
JanuaryIndications
• All children 6 months to 18 years
• Household contact and children caretakers
Indication for persons above 19 years of age
– Imuno-compromised states
– Hemoglobinopathies
– Chronic pulmonary and cardiac diseases
– Chronic renal disease and metabolic diseases
– Patient on long term salicylic therapy
– All persons above 65 should be vaccinated once a
year.

40. COMBINATION VACCINES
• DPaT- INFANNIX RS 1000
• MMR PRIORIX/TRIMOVAX RS 600
• HEP B ENGERIX/ENVAX RS220
• DPT+HBV TRITANRIX RS 350
• DPwT+HIB TETRAActHIB RS 1150
• DPwT+HIB+HEPB PENTAVALENT RS 500 also available in Govt
setups
• DPaT+HIB+IPV PENTAXIM RS 2000
• DPaT+HIB+HBV+IPV INFANRIX HEXA RS 1750
• 10 VALENT PNEUMOCOCCAL CONJ VACCINE SYNFLORIX RS 4000
• 13 VALENT PNUEMOCOCCAL CONJ VACCINE PREVENAR RS 5330
• ROTA VIRUS VACCINE ROTARIX RS 2900
• INFLUENZA VACCINE AGRIPPAL ,FLUARIX ,VAXIGRIP RS 600
approx

41. Dr. Abdul Malik
MBBS, DCH, MCPS (PEADS) M.D
Pediatric consultant