Most about immunization

1. By Dr.Anant Aaditya
Shivam,MBBS,PG 1st
year.Dept. of Community
Medicine,DMCH
PREVENTIVE IMMUNIZATION,
IMMUNIZATION PROGRAM

2. General Objectives
 Define Immunization.
 Significance of Immunization.
 Types of Immunity.
 Immunizing Agents.
 National Immunization Schedule.
 Contraindications to vaccinations.
 Reactions to EEPI Vaccines.

3. Introduction
 Immunization is the artificial means by which the
state of immunity is increased. This is the most
important invention that conferred the highest
benefit to children in the world. It has prevented
many communicable diseases such as diphtheria and
polio. It has helped eradicate polio and small pox for
the community. Recently, a highly successful
introduction of immunization against Haemophilus
influenzae type b (Hib) has achieved that reduced
invasive infections such as Hib meningitis.

4. Definition
 “Immunization is a process of protecting an
individual form a disease through introduction of
live or killed or attenuated organisms in the
individual system to create immunity.”

5. Significance
 It is one of the ‘best buys’ in community health and
one of the most cost effective health interventions in
reduction of communicable diseases related
morbidity and mortality.
 It is a mass means of protecting the largest number
of people from various diseases. It gives resistance
to an infectious diseases by producing or augmenting
the immunity.
 Artificially acquired immunity is developed by
immunization.

6. Immunity
 Immunity is the security against a particular disease
and nonsusceptibility to the invasive or pathogenic
effects of foreign microorganisms or to the toxic
effect of antigenic substances. Acquired immunity
can be active or passive.

7. Active Immunity
 Active immunity is produced by stimulating
immunological defence mechanism through
administration of antigen usually prior to natural
exposure to infection. Active immunizing agents are
known as vaccines.
 Divided into Primary immune response and
Secondary immune response

8. Primary Immune response(Active immunity)
 First exposure to Antigen.
 IgM antibodies are produced first(3-7 days).Presence
of IgM antibody suggests recent infection because
IgM antibodies disappear rapidly.Half life is around
7 days.
 IgG antibodies are produced subsequently and its
alone presence suggest past infection.Half life is
about 21 days.

9. Secondary Immune response(Active immunity)
 Repeated exposure to same antigen Rapid
immune response and antibodies are produced in
large amounts.
 Humoral Response: Formation of immunoglobulins
by B cells.
 T-Cell mediated immune response is also called Cell
mediated immunity.T-cells are the one which have
memory function.

10. Passive Immunity
 Passive Immunity is produced temporarily by
supplying preformed exogenous animal or human
antibody to suppress the disease, given soon after or
prior to exposure of an infection. It is readymade
antibodies. Passive immunity agents are antisera and
immunoglobulins.
 This type of immunity is very short lived and hence
used only in emergencies and in previously
unimmunized individuals.

11. Examples of Human immune globulins with
Dose
 Hep A: 0.02-0.05ml/Kg Body weight
 Hep B: 0.05ml/kg Body weight
 Hep C: 0.05ml/kg Body weight
 Rubella: 20ml
 Varicella Zoster: 15-25 units/kg body weight
 Measles: 0.25ml/kg body weight
 Rabies: 20IU/kg body weight
 Tetanus: 250 units

12. Examples of Non Human immune globulins
(Antisera) with dose
 Diptheria: 500-1000 IU as IM
 Tetanus: 1500 units equine ATS as IM
 Rabies: 40IU/kg equine ARS
 Botulism: 10000 units polyvalent antitoxin
 Gas Gangrene: 10000 IU as IM, Polyvalent antitoxin

13. Immunizing Agents
 The immunizing agents may be classified as vaccines
immunoglobulin's and antisera.

14. Vaccines
 Vaccines are immuno-biological substances which
produce specific protection against a given disease. It
stimulates active production of antibody and other
immune mechanisms.
 Vaccines are prepared from live attenuated
organisms, or inactivated of killed organisms,
extracted cellular fractions, toxoids or combination
of these. More recent preparations are sub unit
vaccines and recombinant vaccines.

15. Cont..
 The ideal vaccines should induce permanent
immunity, be free of toxic substances, have minimal
side effects, not produce disease to the recipient and
be easy to administer.

16. Types of Vaccines
 Live Attenuated Vaccines
 Killed Vaccines
 Subunit Vaccines

17. Live Attenuated Vaccines
 Serial Cultures are done to retain immugenicity but
reduce pathogenicity. This Process is called
attenuation.Organisms can multiply and thus produces
an immune response much more than a killed
vaccine.Can Provide community protection
also.Contraindicated in immunocomprised states and
pregnancy.
Examples
 Bacterial – BCG, Typhoid (oral) Plague
 Viral- Oral polio, Measles, Mumps, Rubella, Yellow fever,
Influenza.
 Rickettsial- Epi, typhus.

18. Killed or Inactivated Vaccines
Organisms are killed using chemicals.Most commonly used
chemical is formalin.These type of vaccines produce
relatively lesser immune response since the organisms do
not multiply.Not contraindicated in immunocompromised.
Examples
 Bacterial- Pertussis, Typhoid, Cholera, Plague, , CS
Meningitis.
 Viral- Rabies, Hepatitis ‘B’, Influenza, Salk Polio,
Japanese encephalitis.

19. Subunit vaccines
These are synthetically manufactured vaccines
Types
 Toxoids
 Protein Vaccine
 Polysaccride Vaccine
 Glyco-conjugate vaccine
 Recombinant Vaccine

20. Toxoids
 Made from exotoxin produced by bacteria. E.g
Diptheria, Teatanus

21. Protein Vaccine
 Prepared from protein subunit of an organism. E.g
Influenza, acellular pertussis vaccine, Novavax(Covid
vaccine prepared from spike protein)

22. Polysaccride vaccine
 Prepared from outer capsular polysaccharide of an
organism. It should be serotype specific. It cannot be
given to children < 2 years because significant
immune response is not seen. E.g Hib, Typhoid,
Pneumococcal vaccine

23. Glyco-conjugate vaccine
 Polysaccharide is conjugated with protein molecule.
 Should be serotype specific.
 Increased immunity induction is seen and hence can
be used in children<2 years.
 Examples: PCV, Meningococcal(A,C,W135,Y )

24. Recombinant Vaccine
 Antigen is cultured on yeast/host and amplified.
 Examples: Meningococcal, HPV, Cholera toxin
Vaccine (Dukoral, Shankol)

25. Other Types
 Mixed Vaccine: Example: Pentavalent, DPT, DTaP
 Freeze dried Vaccine: Vaccine is in powder form.
They should be reconstituted with diluents such as
normal saline or distilled water or buffers.There is
risk of contamination by staph aureus and hence
should be used same day after reconstituition.
Examples are BCG, Measles, JE.
 BCG and measles should be used within 4-6 hours of
reconstituition.
 JE should be used within 2 hours of reconstituition.

26. Vaccine Constituents
 Adjuvant: Increase the potency of vaccine and
hence called immunoboosters. Example: Aluminium
hydroxide/Alum in Pentavalent,DPT and PCV. AS
O1 in Malaria vaccine, AS O3 and AF O3 in influenza
vaccine and AS O4 in HPV and Hep B vaccine.
 Exipients: These are inert substances added during
manufacture. They have no immunological role.
 Stabilizers: Proteins that stabilize the vaccine by
preventing chemical reactions and precipitation.
They do not stick to vaccine vial walls.Examples are
albumin, gelatin and globulin.

27. Vaccine constituents(2)
 Preservatives: Increase the shelf life of the
vaccine. Examples are Phenoxyethanol(Most
commonly used), Phenol, Thiomersal(No Longer
used)
 Buffers: Inhibits the action of pH on vaccine.
Examples are (1)Gastric buffer in cholera
vaccine(Dukoral) prevents the destruction of Subunit
B toxin by gastric pH, (2) Phosphate Buffer in
Japanese encephalitis vaccine. Most commonly used
buffer is sodium chloride.

28. Vaccine Constituemts(3)
 Diluents: Used for freeze dried vaccines to convert
powder formulation to liquid. Examples are Distilled
water for measles, Normal saline for BCG,
 Emulsifiers: Stabilize the vaccine by decreasing the
surface tension. Examples are Polysorbate, Tween 80.
 Antibiotics:
Neomycin: Varicella, MMR, IPV
Gentamycin: Influenza vaccine
Erythromycin: Used previously in Measles/MR vaccine
Streptomycin + Neomycin: IPV
Note: Neomycin allergy is a contraindication for MMR and
IPV vaccine.

29. Sensitivity of Vaccines
BOTH
HEAT
AND
FREEZE
SENSITIVE

30. Sensitivity of Vaccines

31. Storage of Vaccine
 Cold chain is a mechanism to maintain the
temperature of vaccines.
Components of Cold chain
 Day carrier : Can carry 6-8 vials

32. Cold chain contd…
 Vaccine Carrier: Can carry 16-20 vaccine vials.Larger
in size.
 Cold Box: Can carry 25-30 vaccine vials

33. Cold chain contd..
 Ice Line Refrigerators(ILR):
 Deep Freezers
 Walk in cold room/Walk in freezers
All these require electricity

34. ICE Lined refrigerator
Temperature: 2 to 8 degree Celsius
Heat sensitive vaccines are placed at the bottom
since they are the coolest area.
Freeze sensitive vaccines are placed at the top
since they are warmer area.

35. Vaccine Placement in ice lined refrigerators

36. Deep freezers
Vaccines are never stored in deep
freezers.Used only for manufacturing or
freezing the icepacks.However in certain
situations like outbreak which would
require polio immunization centres,OPV
vaccines can be stored in a separate deep
freezer at district level.
Temperature in deep freezer ranges from
-25 degree Celsius to -15 degree Celsius.

37. Walk in Cold room
Used only for storage at
district/state or zonal levels.

38. Vaccine Vial Monitor
 Vaccine vial monitor is a chemical indicator of heat
stability of the vaccines.
 Chemical Indicator used: P-toluene
Sulfonate(PTS)
Types of VVM
 VVM2, VVM7, VVM14, VVM30
 For example VVM14 will get spoiled after 14 days if
the vaccine is stored at 37 degree Celsius.

39. Vaccine Vial Monitor
Discard Point: When inner
square colour
Becomes same as outer
circle
Note: If the VVM is on the neck or cap, the vaccine cannot be reused.
If the VVM is on the label, the vaccine can be reused after opening the vial

40. Shake Test

41. Cellular fractions
 Meningococcal and pneumococcal vaccines.

42. Combinations
 DPT – Diphtheria, Pertussis, Tetanus
 MMR- Mumps, Measles, Rubella
 DT- Diphtheria, Tetanus
 Hib- Hep.B (H. Influenzae ‘B’, Hepatitis ‘B’)
 Pentavalent – Diphtheria, Pertussis, Tetanus,
Hepatitis B, and Haemophilus influenzae type B
(Hib)

43. National Immunization Schedule
 Immunization schedule should be planned according
to the needs of the community. It should be relevant
with existing community health problems. It must be
effective, feasible and acceptable by the community.
Every country has its own immunization schedule.

44. Cont..
 The WHO, launched global immunization program
in 1974, known as Expanded Program on
Immunization (EPI) to protect all children of the
world against six killer diseases. In India, EPI was
launched in January 1978.

45. Cont..
 The EPI is now renamed as Universal Child
Immunization, as per declaration sponsored by
UNICEF. In India, it is called as Universal
Immunization Program (UPI) and was launched in
1985, November, for the universal coverage of
immunization to the eligible population.

46. Cont..
 The Global Alliance for Vaccines and Immunization
(GAVI) is worldwide coalition of organization,
established in 1199, to reduce disparities in life
saving vaccine access and increase global
immunization coverage. GAVI is collaborative
mission of Govt., NGOs, UNICEF, WHO and World
Bank. The GAVI and Vaccine Fund also adopted the
objective of new introduction but under used
vaccines in the developing countries, where the
disease like hepatitis B and H Influenzae ‘B’ (Hib)
are highly prevalent.

47. Cont..
 National Immunization Schedule as recommended
by Government of India for uniform implementation
through out the country was formulated.

48. Recommendations
 Interval between two doses should not be less than
one month.
 Minor cough, colds and mild fever or diarrhea are
not a contraindication to vaccination.
 In some states hepatitis ‘B’ vaccine is given as
routine immunization.
 At 9 months of age, Vitamin ‘A’ oil should be given
orally with recommended dose and then to be
continued at six months interval upto 5 years of age.

49. National Immunization Schedule
Age Vaccine Route
At Birth BCG Intradermal
At Birth OPV Oral
At Birth Hepatitis –B-0 Intramuscular
6- Weeks BCG if not given at
birth
Intradermal
6- Weeks Pentavalent Intramuscular
6- Weeks OPV - 1 Oral
6- Weeks Hepatitis –B 1 Intramuscular
2,4 and 6 months Rotavirus Oral

50. National Immunization Schedule
Age Vaccine Route
10 Weeks Pentavalent-2 Intramuscular
10 Weeks OPV - 2 Oral
10 Weeks Hepatitis –B 2 Intramuscular
14 Weeks Pentavalent-3 Intramuscular
14 Weeks OPV - 3 Oral
14 Weeks Hepatitis –B 3 Intramuscular
9 Months Measles Subcutaneous

51. National Immunization Schedule
Age Vaccine Route
16-24 Months DPT Intramuscular
16-24 Months OPV Oral
16-24 Months Measles Subcutaneous
5-6 Years DT IM
10-16 Years TT IM
Early Pregnancy TT-1 IM
After a month TT- 2 IM

52. General Contraindications of Vaccinations
 Prior allergic reactions to the same or related
vaccine.
 Live vaccines, i.e. OPV, BCG and measles, are not to
be administered in the following situations: in
immunosuppressive therapy, immunodeficiency
disorders, leukemia, lymphoma or generalized
malignancy.

53. General Contraindications of Vaccinations
 Acute illness with fever above 38
.
C. Postpone until
recovery has occurred.
 Special risk groups in whom the risk of
complications form infectious diseases is high
include those with chronic lung and congenital heart
diseases, Down syndrome, HIV infection, Low birth
weight (LBW), and asplenia or hyposplenism.

54. Conditions Not to be taken as contra-indication
to Vaccination.
 Mild or moderately ill children should be immunized
to increase individual and community protection.
Malnutrition, low grade fever, mild acute respiratory
infection, or diarrhea and other minor illness are not
contraindications for vaccinations.

55. Reactions to EPI Vaccines
 Mild Fever.
 Local Pain
 Malaise, irritability.
 Transient rash.
 A Lump or papule appears on the third week after
BCG vaccination. It is generally not painful but is
tender to touch. The papule increases in size upto 6-
10 mm in diameter by the sixth week. The nodule
softens with the formation of pus. No treatment is
necessary. At the end of 10-12 weeks, only a small
scar is visible.

56. Reactions to EPI Vaccines
 Regional Lymph node enlargement and suppuration
observed 2-8 weeks after BCG vaccination is usually
a result of the vaccine being injected subcutaneously
instead of intra-dermally.
 In very rare cases, a fever of more than 105
.
F,
convulsions or collapse after DPT vaccination has
been observed. In such cases, further doses of DPT
should not be given.

57. Conclusion
 Immunization is the process whereby a person is
made immune or resistant to an infectious disease,
typically by the administration of a vaccine.

58. Summary
 Summary includes introduction, definition, National
immunization program, Immunization Schedule and
contraindications.