primary care

1. IMMUNISATION (part. 3)
NUR FARRA NAJWA BINTI ABDUL AZIM
082015100035

2. LEARNING OBJECTIVES
1. Varicella Vaccine
2. Hepatitis A Vaccine
3. Influenza Vaccine
4. HPV Vaccine
5. Typhoid Vaccine
1. JE Vaccine
2. Yellow Fever Vaccine
3. Cholera Vaccine
4. Rabies Vaccine
5. Meningococcal
Vaccine

3. VARICELLA
• Dosage/mode of
administration
– 0.5 ml
– lyophilised
– SC
• Schedule
– <12 year, 2 doses
• 1st dose : 12-15 month
• 2nd dose : 5-6 year
– > 12 year
• 2 doses, 6-8 week interval
• Indication
– Children > 12-18 month
– Adolescent and adult > 15
year
– Immuno-compromised child
– Health child > 1 year
– Healthy close contact
– Health care worker
– International travellers
• Contraindication
– Fever
– Hypersensitivity
– Pregnancy & lactation
– Depressed cellular immunity
(TLC <1200/mm3)

4. Varicella Immunoglobulin
• Dosage/mode of
administration
– 12.5 unit/Kg BW (max 625
units) *50kg
– IM
• Schedule
– Within 72hr of exposure
– Repeat dose in 3 weeks
• Indication
– To susceptible person
• People with immuno-
suppresive theraphy
• Congenital cellular
immuno-deficient
• HIV/AIDS
• Susceptible/exposed
person (pregnant lady)
• Newborn
• Premature infant of low
birth weight
• Contraindication
– With varicella vaccine

5. HEPATITIS A
INACTIVATED HEPATITIS A VACCINE
• Aluminium adjuvant vaccine
• Havrix ®
• Adult vaccine (1 ml dose)
• Junior vaccine ( 0.5 ml)
• Avaxim®
• Adult vaccine (0.5ml with 160 U3
of viral content)
• Pediatric vaccine (0.5ml with 80
u3 of viral content)
• Virosome adjuvant vaccine
• Not using any aluminium content
• Using virus enveloped
• Havpur®
LIVE ATTENUATED VACCINE
• Biovac®

6. HEPATITIS A
• Dosage/mode of administration
– IM
– SC for live attenuated vaccine and
hemophiliac
– Table 1*
• Schedule
– Primary dose : > 1 year
– Booster dose : 6-12 month after
primary dose
– For SC (live-attenuated vaccine :
single dose)
• Indication
– Close contact with infected person
– Chronic liver diseases
– Armed forces/inmates of instituition
– Medical personnel
– Sewage worker
– Food handlers
– Travellers
– Hemophiliac
– Drug addict
– Homosexual
– Healthy child > 1 year
• Contraindication
– Hypersensitivity to vaccine
– Pregnancy
– Fever
– Lactation
– Immunosupressed for live attenuated
vaccine

7. Table 1: Dosage recommendation for hepatitis a vaccine
Vaccine brand Pediatric dose Adult
HAVRIX® 0.5 ml (1- 18 years) 1 ml (> 18 years)
AVAXIM® 0.5ml (1-15 years) 0.5 ml (>15 years)
HAVPUR®
0.5 ml for all ages (>1 year)
BIOVAC®
0.5 ml for all ages (>1 year)

8. Hepatitis A Human Immunoglobulin
• Protective efficacy at
dose :
– 1-2 month (0.02ml/kg)
– 3-5 month (0.06ml/kg)
• Prophylaxis protection
– 90% achieved by time of
injection before and no
later than 14 day of
exposure
• Uses
– Control of susceptible
population
– Declining
• Insufficient preparation
• Expensive preparation
cost
• Limited duration of
protection following
passive immunization
• Efficient vaccine
developed

9. INFLUENZA
MONOVALENT
• Pandemic uses
• Antigenic shift
• Single strain (H1N1)
TRIVALENT
• Routine immunization
• Seasonal uses
• WHO annually recommended
• 3 strain, influenza A strain
(H1N1, H3N2, influenza B
strain
• 2 type
• TIV (trivalent inactivated
influenza vaccine)
• LAIV (live attenuated
influenza vaccine)

11. TIV
• Type
– Whole cell vaccine
– Split virus vaccine
– Sub-unit vaccine
– Virosomal vaccine
– Adjuvant vaccine
• Dosage/mode of administration
– Pediatric (6 month-3 year/0.25ml)
– Adult & above 3 year (0.5ml)
– IM
– Immunity last 6-12 month
• Schedule
– 1st dose
• 2 doses, 1 month interval (6 month-8
year)
• 1 dose (>8 year)
– Booster dose
• Any age, yearly- 1 dose
– < 9 year, never been vaccineted
• 2 doses : 3-4 weeks interval
• Indication
– India, not recommended, not in EPI.
– Advised to high risk
• Congenital immunodeficiency
syndrome
• Acquired immunodeficiency (aids,
steroid)
• Senior citizen
• Chronic diseases.
• Contraindication
– Past history allergy/anaphylaxis
– h/o allergy to vaccine with
egg/formaldehyde,TWEEN
– h/o gullain barre sydrome after
influenza vaccine
– Ongoing acute, severe infection

12. LAIV
• Intro
– Developed on concept of ‘cold
adaptation’ of influenza virus
– India (NosoVac-S®)
• Dosage/mode of administration
– Freeze-dried form single dose vial,
with sterile water
– No preservative
– Equipped with sprayer (1ml syringe)
– Nasally administered in upright
position
– both nostril-0.25ml/nostril
• Schedule
– Seasonal , age > 2 years (2-49 year)
• Indication
– > 2 year , healthy individual
• Contraindication
– child <2 year
– Children receiving salicylates
– Past history asthma/wheezing
– Past history allergy/anaphylaxis
– h/o allergy to vaccine with egg
protein/gelatin
– h/o gullain barre sydrome after
influenza vaccine
– Ongoing acute, severe infection
– Immuno-compromised patient
– Pregnancy, lactation

13. BIVALENT AND QUADRIVALENT VACCINE
FEATURES BIVALENT-CERVARIX QUADRIVALENT-
GARDASIL
COMPOSITION TYPE
SEROTYPE
TECHNOLOGY
PRESERVATIVE
•Subunit vaccine
•Bivalent (16,18)
•Recombinant
•None
•Subunit vaccine
•Quadrivalent (6,11,
16,18)
•Recombinant
•None
INDICATION Not included in EPI, offered to child from affordable
section
DOSAGE 0.5 ml
ROUTE IM, deltoid
AGE 10-45 years (before initiation
of sexual activity)
9-45(before initiation
of sexual activity)
SCHEDULE
1ST
2ND
3RD
0
1
6
0
2
6
CONTRAINDICATION Hypersensitivity, fever, pregnancy
HPV

14. TYPHOID
OLDER ANTI-TYPHOID VACCINE
• Traditional vaccine (non exist in INDIA!)
• Whole cell inactivated vaccine
• 3 type
• TAB vaccine
• S. typhi, S. paratyphi (A & B)
• Many AEFI, doubtful efficacy
• Mono-valent vaccine
• S. typhi antigen
• 2 subtype
• Phenol preserves
• AKD (acetone killed and dried)
• Bi-valent vaccine
• Same 2 subtype
NEWER ANTI-TYPHOID VACCINE
• Subunit vaccine
• The only available in INDIA!
• Oral Ty21a
• Parenteral Vi antigen vaccine
• Vi-polysaccharides
• > 2 years
• Low efficacy
• Vi-conjugate vaccine
• Vi polysaccharides conjugate with
protein carrier (tetanus toxoid)
• Long lasting immunity
• < 2 years can be used
• Peda-typh®
• Typbar®

15. Older Anti-typhoid Vaccine
• Dosage/mode of administration
– Adult-
• 0.5ml
• 2 doses, 4-6 week interval
– < 10 year
• 0.25ml
– SC
• Schedule
– 1st dose (adults and < 10 years)
– Booster dose
• every 3 years (> 3 years elapsed, repeat all primary doses)
• Indication
– Nil

16. ORAL Ty21a
• Intro
– Mutant of S. typhi (genetic
engineering)
– Lack enzyme UDP-4 galactase-
4-epimerase
– Not available in INDIA!
• Dosage/mode of
administration
– Enteric coated tablet
– Lyophilized form
– Oral
• Schedule
– > 5 years
– 3 dose regimen
• Alternate day (day 1, 3 ,5)
• Lukewarm water
– Repeat dose
• Travelling (non-endemic
to endemic area)
• People living in endemic
area
• Indication
– nil
• Contraindication
– Fever
– Immuno-deficient state
– Pregnancy
– Diarrhae

17. Vi-Polysaccharides Vaccine
• Dosage/mode of
administration
– 0.5 ml
– IM/SC
• Schedule
– > 2 years, (1 dose)
– Booster (every 3 years)
• Indication
– India, not recommended,
not in EPI.
– private practices
recommendation
• >2 years (1 doses)
• Every 3 year repeated
• Contraindication
– Hypersensitivity to
vaccine constituent
– Pregnancy

18. Pedatyph ®
• Dosage/mode of administration
– 0.5 ml
– IM
• Schedule
– 3 month-2 year
• Primary dose
– 2 injection , 4-8 week
interval)
• Booster
– 1st booster at 2-2 ½ after
1st doses,
– 2nd booster, every 10 year
– > 2 year
• Primary dose (same as above)
• Booster , every 10 year
• Indication
– Waiting for post-licensure date to
be used in wider population
• Contraindication
– Hypersensitivity to vaccine
constituent
– Pregnancy
– Fever

19. Typbar ®
• Dosage/mode of
administration
– 0.5 ml
– IM
• Schedule
– Primary dose
• Single dose at > 6 month
(> 9 month)
– Booster
• After 3 year (before 2 year)
• Indication
– India, not recommended,
not in EPI.
– Expensive vaccine, offered
to child of affordable
society.
• Contraindication
– Hypersensitivity to vaccine
constituent
– Pregnancy
– Fever
– Lactation

20. JE VACCINE
MOUSE BRAIN DERIVED
INACTIVE VACCINE
• Older generation
• Disadvantages
• Multiple schedule
• Booster dose requirement
• Adverse effect
• Availability of other safer
vaccine
CELL-CULTURED DERIVED
VACCINE
• Live attenuated
SA14-14-2 vaccine
• Inactivated vero-cell
derived vaccine
• SA14-14-2 strain vaccine
• Kolar strain vaccine
• Live, attenuated
recombinant JE vaccine

21. Mouse Brain Derived Inactivated Vaccine
• Adequate protection in childhood
– Children age 1-3 year
• Dose
– 0.5 ml (<3 year)
– 1 ml (>3 year)
• Schedule
– 2 primary dose, 4 week apart
– Booster,
• After 1 year,
• Subsequently every 3 year.
• Till age 10-15 year

22. Travellers
1. Age> 1 year
2. Visiting rural area of endemic countries for at
least 2 weeks
3. Dosage/schedule
3 PRIMARY
DOSE
• Day 0, 7, 21
2 PRIMARY
DOSE
• 4 week apart
BOOSTER
• After 1 year,
then every 3
year@

23. Live Attenuated SA14-14-2 Vaccine
• Dosage/mode of
administration
– Single-dose or 5-dose
vial
– Lyophilized powder to
be reconstituted with
diluents.
– SC
• Schedule
– 1st dose
• > 9 month (0.5ml)
– Booster dose
• 18 month age
• Recommendation
– India, recommended, 2
dose as immunity
wanes after some times
• Contraindication
– Hypersensitivity for
vaccine component
– Pregnancy
– Immuno-suppression

24. Inactivated Vero-cell Derived Vaccine
(SA14-14-2 Strain Vaccine)
• Intro
– IXARO ®
– Licensed in india as alternative
vaccine for JE
– No preservative (liquid
preparation)
• Dosage/mode of
administration
– 1-3 year (0.25ml)
– 3 year (0.5ml)
– IM
• Schedule
– 1-3 year (2 doses, 4 week
interval)
– 3 year (2 doses, 4 week
interval)
– Booster, not recommended
• Efficacy
– After 2 doses, >90 % immunity
– Wanes after 1 year.
• Contraindication
– Hypersensitivity for vaccine
component
– Pregnancy

25. Inactivated Vero-cell Derived Vaccine
(Kolar Strain Vaccine)
• Intro
– JENVAC ®
– Isolated from patient in
Kolar, Karnataka, area
endemic for JE.
– Licensed to be used India
– liquid preparation
• Dosage/mode of
administration
– >1 year (0.5ml)
– IM
• Schedule
– >1 year (2 doses, 4 week
interval)
– Booster, not recommended
(manufacturer administer
booster after 1 year of
primary dose)
• Efficacy
– After 2 doses, >90 %
immunity
– Wanes after 1 year.
• Contraindication
– Hypersensitivity for vaccine
component
– Pregnancy

26. Live,Attenuated Recombinant JE
Vaccine
• Intro
– IMOJEV ®
– Mono-valent, live-
attenuated
– Recombinant dna
engineering
– Immunizing antigen
(prM & E) of live
attenuated JE virus
strain SA14-14-2
– Clinical trial show
• highly efficacious
• Long term immunity
• Lacking neurotropic
quality
– Not available in india

27. YELLOW FEVER
17D Vaccine
• Currently used
• Live attenuated
• 2 subtype
• 17 DD
• 17-204
French Neurotrophic
Vaccine
• Discontinued

28. 17 D Vaccine
• Dosage/mode of
administration
– > 6 month, 0.5 ml
– SC
– Lyophilized vaccine
• Schedule
– Single dose, > 6 month
– Booster dose
• > 10 year pass vaccination
• Indication
– All traveller aged > 6 month.
– Travelling to endemic area
of Africa & South Africa
– Vaccination certification
valid for 10 years is issued
• Contraindication
– Absolute
• Infant, < 6 month (except
during epidemic)
• Hypersensitivity to vaccine
component
• Immuno-suppression
– Relative
• Children 6-9 month
• Senior citizen >65
• Pregnancy (except during
outbreak)
• Lactation
• HIV with moderate cd4 count

29. CHOLERA VACCINE
PARENTERAL
VACCINE
• Short lived
duration of action
• No local immunity
• Failure to halt
epidemic
ORAL VACCINE
• Induce local
immunity
• Dukoral®
• Shanchol®

30. Parenteral Cholera Vaccine
• Dosage/mode of
administration
– 0.2 ml (1-2 years)
– 0.5 ml (2-10 years)
– IM/SC
• Schedule
– > 1 year age
– 2 doses, 4-6 week
interval
– Booster, every 6
month
• Indication
– NIL

31. Oral Cholera Vaccine- Dukoral ®
• Intro
– Mono-valent vaccine
– First WHO- prequalified
oral cholera vaccine
– Available globally
– Cost, difficulty to implies
at rural area!
• Dosage/mode of
administration
– 3 ml
– Single dose with
bicarbonate buffer
– Mixed in
• 150 ml water (>5 year)
• 75 ml water (2-5 year)
• Schedule
– > 2 years @ adult
– 2 doses, 1-6 week interval
• Contraindication
– Nausea
– Vomitting
– Diarrhae

33. *PARKS
• Primary immunization
– Adult and child> 6 year
• 2 oral dose (>7 day apart ,<6 week interval)
– Child 2-5 year
• 3 dose (>7 day, < 6 week)
– If primary immunization delay >6 week, restart schedule
• Booster dose
– (Adult, child > 6 year) after 2 year,
• 1 dose
– (Child 2-5) booster > 6 month
• > 2 year between primary immunization and booster,
repeat schedule
*avoid food 1hr before and after

34. Oral Cholera Vaccine- Shanchol ®
• Intro
– Killed, whole cell, bivalent
vaccine
– The only that available at
INDIA!
• Dosage/mode of
administration
– 1.5 ml
– oral
• Schedule
– 2 doses, interval 2 weeks
– Booster, after 2 year.
• Indication
– Recommended to age > 1
year that has high
probability of exposure to
cholera
• Contraindication
– Hypersensitivity to
vaccine constituents
– Pregnancy

36. RABIES

37. Anti-rabies Vaccine
NEURAL TISSUE
VACCINE
• Oldest variety and
crude vaccine
• Suspension of animal
tissue infected with
fixed rabies virus
• Inactivated with
phenol & BPL
• Given in large doses,
daily-14 day, SC-
abdomen
• Poorly immunogenic
• Cause neurogenic
reaction
• Currently unavailable
PURIFIED DUCK
EMBRYO VACCINE
• No animal neural
tissue
• Fixed rabies virus in
duck egg, inactivated
by BPL
• Not highly
immunogenic, cause
allergic reaction
• Latest : PDEV
TISSUE CULTURE
• Highly immunogenic
• Fewer doses needed
• Extremely safe, no
risk neurological
reaction
• HDCV
• PCECV
• PVRV

40. Indication Of ImmunizationPRE-EXPOSURE
IMMUNIZATION
Veterinar
Forest staffer
Animal handlers
Lab worker
Doctor, paramedic
Hitch-hiker and
trekker
Archaeologists
POST-EXPOSURE
IMMUNIZATION
1) Animal
harbouring virus or
not
2) Animal is wild or
domestic
3) Nature of
exposure

41. Dosage, Route, Schedule
ANTIRABBIES
VACCINE
PRIMARY
INTRA-
MUSCULAR
PRE-EX POST-EX
5 DOSE
REGIMEN
4 DOSE
REGIMEN
INTRA-
DERMAL
(POST EX)
8 SITE INJ 2 SITE INJ
BOOSTER

42. DAYS:
0 – 3 – 7 – 14 - 21/28 – 90
√ √ √√
DOSES: 2-0-1-0-1-0
DOSES:
INTERPRETATION:
•2 doses in day 0,
•0 doses in day 3,
•1 doses in day 7,
•0 doses in day 14,
•1 doses in day 21,
•0 doses in day 90

43. Intra-muscular
PRE-EX
• 3 doses
• 0,7,28 (preferred 21*)
• 1-0-1-0-1-0
POST-EX
• 5 doses (essen Schedule)
• 1-1-1-1-1-1
• 4 doses (zagreb schedule)
• 2 doses on day 0
• 1 dose on day 7, 21*
• 2-0-1-0-1-0

44. Intra-dermal
2 SITE
• Thai red cross
schedule
• 2-2-2-0-1-1
• New that red cross
schedule (uses
now!)
• 2-2-2-0-2-0
8 SITE
• 8-0-4-0-1-1
• Deltoid-(2 site)
• Lat thigh-(2 site)
• Lower abd-(2 site)
• Supra-scapular-(2 site)

45. *Post-ex in Previously Vaccinated
Person
1 SITE-2 DAY
INTRA-DERMAL OR INTRA-
MUSCULAR INJECTION
• 1 dose
• Day 0, 3
• 1-1-0-0-0-0
• Not indicated for rabies
immunoglobulin
ALTERNATIVE
• Single visit
• 4 site injection
• Deltoid-(2 site)
• Lat thigh-(2 site)
• 4-0-0-0-0-0

46. Booster
PRE-EX & POST-EX
•2 dose on day 0, 3 (*in case of exposure)
•2-2-0-0-0-0
•Continue protection
•Booster every 5 years same doses
•2-2-0-0-0-0

47. ANTIRABBIES
VACCINE
PRIMARY
INTRA-
MUSCULAR
PRE-EX POST-EX
5 DOSE
REGIMEN
4 DOSE
REGIMEN
INTRA-
DERMAL
(POST EX)
8 SITE INJ 2 SITE INJ
BOOSTER
1-0-1-0-1-0
1-1-1-1-1-1 2-0-1-0-1-0
8-0-4-0-1-1 2-2-2-0-1-1
2-2-2-0-2-0
2-2-0-0-0-0

48. Rabies Immunoglobulin
EQUINE RABIES
IMMUNOGLOBULIN
(ERIG)
• Hyperimmunize the
horse with rabies virus
• Heterologous nature
• Risk of anaphylaxis
• Dosage
• 40IU/KG (MAX 3000
IU)
HUMAN RABIES
IMMUNOGLOBULIN
(HRIG)
• Serum of
hyperimmunnized
human volunteers
• Serum collected,
filtered, purified, heat
treated
• 20IU/KG (MAX 1500
IU)

49. MENINGOCOCCAL VACCINE
MENINGOCOCCAL POLYSACCHARIDES
VACCINE
• Mono-valent group A & C
polysaccharides vaccine
• Bi-valent group A & C polysaccharides
vaccine
• Tetra-valent/quadrivalent
polysaccharides vaccine against group
A, C, Y, W135
• Only bi-valent and mono-valent
available in India!
• Limitation
• Do not induce T-cell immunity
• Poorly immunogenic in child < 2years
• No nasal colonization
• Required regular booster
MENINGCOCCAL CONJUGATE VACCINE
• To overcome limitation in
polysaccharides vaccine
• Mono-valent group A conjugate
vaccine
• Mono-valent group C conjugate
vaccine
• Quadrivalent/tetravalent conjugate
vaccine against group A,C,Y, W135

50. Meningococcal Polysaccharides
Vaccine
• Dosage/mode of
administration
– 0.5 ml
– S.C
– Lyophilized powder, reconstituted
with sterile water
• Schedule
– Primary series
• 3 month-2 year : 2 doses, 3
month interval
• >2 year : single dose only
– Booster
• 1st dose : <4 year : after 3 year
>4 year : after 4-5 year
• Indication
– India, not recommended
routinely to all children
– High risk individual
• Immunocompromised
• Travellersto endemic area
• Student mass vaccination in
epidemics
• Contraindication
– Meningococcal diseases
– Fever
– Pregnancy
– Lactation

51. Mono-valent Group A Conjugate
Vaccine
• Intro
– MenAfriVac ®
– Licensed in India
• Dosage/mode of
administration
– 0.5 ml
– IM
– Lyophilized vaccine
• Schedule
– 12 month – 29 month : single
dose
– 2-12 month : 2 doses, 2 month
interval
– Booster dose : not
recommended (park > 1 year)
• Contraindication
– Meningococcal diseases
– Fever
– Pregnancy
– Lactation
– Hypersensitivity to vaccine
content

52. Quadri-valent Conjugate Vaccine
• Intro
– Menactra ® (liquid form)
– Menveo ® (lyophilized powder)
– Licensed in India
• Dosage/mode of
administration
– 0.5 ml
– IM
• Schedule
– Single dose : 11-55 year (park >2
year)
– Booster dose
• Age 16-18 year if 1st dose given
during 11-55 year
• Every 5 year, in person with
complement deficient
• Contraindication
– Meningococcal diseases
– Fever
– Pregnancy
– Lactation
– Gullian-Barre syndrome

53. Recombinant Group B Meningococcal
Vaccine
• Sero-group B stain involved in substantial cases of
meningococcal in infant < 1 year
• Preparing vaccine against group B strain is difficult
• Recently
– Bexsero®
– TruMenba®

54. REFERENCES