This document provides information on immunization in special situations. It discusses immunization for preterm/low birth weight infants, children of hepatitis B positive mothers, immunocompromised individuals, and those receiving corticosteroids or chemotherapy. It also addresses immunization for HIV infected individuals, transplant recipients, unimmunized children, and adolescent travelers. Recommendations are provided for vaccination schedules and specific vaccines in each of these special situations. Maintaining the cold chain is emphasized as vital for ensuring vaccine efficacy.

1. Basics of
immunization and
IMMUNIZATION IN
SPECIAL SITUATIONS
Dr.Nupur Sinha
Dept. Of Pardiatrics
Lourdes Hospital
Kochi

2. Immunization
schedules

7. 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

8. 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

9. 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

10. • 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).

13. 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.

15. Special situations

16. 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

17. 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.

18. 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

19. Household contacts of Immunocompromised
• Should not receive transmissible vaccines-
OPV
• Non transmissible vaccines –varicella, MMR
are safe
• Should be fully immunized- varicella, influenza

20. 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

21. 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.

22. • 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.

23. • 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%)

24. 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

25. 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

26. 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

27. • 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

28. 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

29. 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

30. 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

31. 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

32. 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.