Dr. Chamath Fernando Lecturer, Department of Family Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka.

1. Precautions for Vaccinations
1. Vaccines should not be administered if – there has been anaphylaxis to a certain vaccine or a component of a particular
vaccine
2. Live vaccines are contraindicated if-
a. Malignancy of the Reticulo-endothelial system
b. Pregnancy
c. Any live vaccine been administered within one month
d. Having received blood, blood products or immunoglobulin within three months
e. Having stopped immunosuppressive therapy within three months
f. Two weeks after stopping long term oral steroids
 However Varicella Vaccine can be administered to leukemic children in remission
3. Postpone Vaccination
a. If the vaccinnee is suffering from an acute infection or fever
4. Ba cautious if there is
a. A bleeding disorder
b. History of Guillain Barre Syndrome
c. Progressive neurological disorder
5. Postpone pregnancy
a. For three months after Varicella vaccination
b. For one month after MMR
6. Vaccination should be administered in a hospital if there is a history of severe allergy
7. Vaccination should be given in a unit with minimum facilities to resuscitate. (adrenalin, syringes, cannula, saline, bed…
preferably an emergency tray)

2. Immunological Basis of Vaccination
All vaccines produce antibodies which canneutralize extracellular pathogens.
Types of Vaccines
1. Live attenuated
2. Killed/ Inactivated
3. Subunit
4. Recombinant
5. Conjugate
Immune Response to vaccines
Vaccine induced immunity is mainly due to IgG antibodies. Antibodies are capable of binding toxins and extracellularpathogens. The
quality of the antibody (avidity), the persistence of response and generation of memory cells capable of rapid response to
reinfection are the key determinants of vaccine effectiveness.
Live inactivated and subunit vaccines evoke a T dependent response, producing high quality antibody and memory B cells.
Polysaccharide vaccines (eg: pneumococcal 23valent vaccine) evoke a T cell independent response where the IgG produced is of
poor affinity and memory B cells are not produced. However conjugation of the polysaccharide with a protein (conjugate vaccines)
evokes a T cell dependent response.
Inactivated, subunit and conjugate vaccines will only evoke antibodies. Live viral vaccines will in addition activate cytotoxic T
lymphocytes. Therefore it is a strong immune response and it persists for decades.

3. Determinants of primary vaccine response
1. Intrinsic immunogenicity of the vaccine
2. Whether live or non-live vaccine
3. Dose – for a non-live vaccine to elicit a sufficient immunological response, a higher dose of the antigen is required
4. Nature of the protein carrier
5. Genetic composition of the individual
6. At extremes of age the response is weaker and persistent
7. “Adjuvants” are incorporated into non-live vaccines to provide a danger signal to the antigen presenting cells as well as
prolong the antigen delivery at the site of inoculation.
Determinant of duration of vaccine response
1. Live vaccines as opposed to the non-live counterparts are most efficient in evoking the antibody response and it may last
lifelong. This is less efficient with non-live vaccines, but doesn’t occur with polysaccharide vaccines.
2. Two doses of a vaccine given one week apart evokes a rapid onset short lived response where as two doses give four weeks
apart may be longer lasting
3. Vaccination at extremes of age is again short lived.

4. VACCINE-
National
Immunization
Programme
AGE Comments
BIRTH 2 M 4 m 6 M 9 M 12 M 18 M 3
Y
School
Entry
10-
15 Y
PREG
BCG
* Before leavinghospital within
24 hours of birth.To be given
to childrenbetween6months
and 5 yearsof age,withno
evidentBCGscar.
Polio
* * * * *
DTP-HepB-Hib
* * *
DTP
*
JE
*
MMR
* * * Femalesonly.(one doseat
15044yrs for all femaleswho
have not beenimmunized
earlier)
DT
*
aTd (adult
tetanus
&diphtheria)
*
Tetanus
* Firstpregnancy – 1st
dose:
afterthe 12th
weekof
pregnancy,2nd
dose:6-8
weeksafterthe firstdose.One
dose of tetanustoxoidshould
be administeredduringevery
subsequentpregnancyuptoa
maximumof five total doses.

5. Vaccines outside NIP
VACCINES –
Outside NIP
AGE Comments
Birth 2m 4m 6m 12m 18m 2nd
yearof
life
School
entry
>10 yrs
DTaP-HepB-
IPV-Hib * * * * DTP-HepB and Hibwhenprovidedbythe same
manufacturercan be mixedtogetherandadministeredas
one doseDTP-Hib
*
Hib
* * * *
Pneumococcal
conjugate * * *
Rotavirus
* * * To infantsfrom6 weeksto24 weeksof age,3 dosesat
2,4,6 months
JE killed
vaccine * * 2 doses2 weeksapartand 3rd
dose one yearlater
Varicella 1 yearto 12 yearsof age 1st
dose at 12-15 monthsand2nd
dose 4-6 years or >13 yrs 2 doses4-8 weeksapart
dTpa (reduced
antigenDTP) * * Adolescentsandadults
Human
papillomavirus
Bivalent–females>10yrs of age, 3 dosesat 0.1.6
months.Quadrivalent- malesandfemales3dosesat0,2,6
months
Individuals
Hepatitis A For those who have not previously received Hep A vaccination – 2 doses at 0 & 6 to 12 months later (over 2 years)
Hepatitis B For those who have not previously received Hep B vaccination – 3 doses at 0,1 & 6 months
Hepatitis A +B For those who have not previously received Hep A & B vaccination – 3 doses at 0,1 & 6 months later (over 2 years)
Typhoid Injectable: 1 dose every 3 years

6. Special circumstances
Meningococcal
Pneumococcal
Cholera
Rabies
Yellow fever
Name ofthe
vaccine
Type Efficacy Indications Dosage and
administration
Contraindications Adverse effects
1. BCG
(M.
tuberculosis)
Live
attenuated
50% At birth(before discharge
fromthe hospital)
Childrenbetween6
monthsand 5 years of
age withoutBCGscar. (A
tuberculintestisnot
requireduptothe age of
5 years)
Childrenover5yearsand
adultswhoare tuberculin
negative (<10min)
Vaccine shouldbe
storedbetween2-8’C
and protectedfrom
light
Use onlynormal
saline forskin
preparation
Given0.05ml for
infantsand0.1ml for
childrenover1 year
and adults
ID route
Skinoverleftdeltoid
to raise a papule of
3-4mm in infantsand
Hypersensitivity/
anaphylaxis toany
componentof the
vaccine
Immunodeficiency
affectingcell
mediatedimmunity
HIV infection
(General
contraindications)
Abscessat the site
of injection
Axillaryorcervical
adenitiswith
suppuration –very
rarely
(Local reactionwith
an induration,
vesicle whichlater
on turnsintoan
ulcerisnormal)

7. 6-8mm in adults
2. DTP
(Coryneb
acterium
diphtheri
ae,
Clostridiu
m tetani,
Bordetell
a
pertussis)
(DTwP-
Purified
diphtheria
toxoid,
purified
tetanus
toxoidand
inactivated
whole cell
B.
Pertussis.
DTaP –
Purified
diphtheria
and
tetanus
toxoids
with
acellularB.
pertussis
componne
nts/
antigens)
Primaryimmunizationas
DTP-HepB-Hibat2,4,6
monthsof age and as
DTwP at 18 monthsof
age.
If interruptedthe doses
are notrepeatedbut
resumedandgivenat8
weeksintervalsasabove
schedule
If unimmunizedcanbe
givenupto 7 yearsof age
Storedat a dry 2-8’C
place.Shouldn’t
allowdirectcontact
withice or heat
0.5ml of the vaccine
isgivendeep
intramuscularlyinto
the anterolateral
thighof infantsand
intothe deltoidin
olderage groups.
DTwP
Previoussevere
reactions
(local reaction,
laryngeal oedema,
bronchospasm,
encephalopathy
within7 days,
prolonged
inconsolable
screaming>3hrs,
convulsionswithin72
hours,Progressive
neurological disorder
like infantile spasms)
If these occurred,give
DTaP ot DT for
subsequent
vaccinations
DTaP
(Highersafetymargin)
Anaphylacticreaction
to previousDTaPor
any component
Local reactions:
Pain,rednessand
swellingatthe
injectionsite may
occur and persistfor
several days;
persistentnodules
at the injectionsite
may arise if the
injectionisnotgiven
deepenough
Systemicreactions:
Headache,lethargy,
malaise pyrexia,
Rarelyanaphylaxis
Crying,screaming,
feverandrarely
neurological
sequelae like
convulsionsafter
pertussis
component.
3. DT
(Coryneb
acterium
diphtheri
ae and
Clostridiu
m tetani)
The
diphtheria
and
tetanus
toxoid
antigens
are
Childrenimmediately
before school entryon
completionof 5years of
age
For primary
immunizationwhen
immunizationwith
Storedat a dry 2-8’C
place.Shouldn’t
allowdirectcontact
withice or heat
0.5ml of the vaccine
isgivendeep
intramuscularlyinto
General
contraindications
Local reactions:Mild
and confinedtothe
site of injection.
Occasionallya
painlessnodule
developsatthe site
and disappearswith

8. adsorbed
on to
aluminium
phosphate
adjuvant.
pertussisantigen
containingvaccine (DTP)
iscontraindicated
the anterolateral
thighof infantsand
intothe deltoidin
olderage groups.
time.
Systemicreactions:
Transientfever,
malaise,irritability
4. aTD
(Coryneb
acterium
diphtheri
ae and
Clostridiu
m tetani)
Potency
reduced
purified
diphtheria
toxoidand
purified
tetanus
toxoidare
adsorbed
on to
aluminium
phosphate
adjuvant
For primaryvaccination
and revaccinationof
adultsand adolescents
whohave
contraindicationsforDTP
primaryvaccinationand
re-vaccinationof children
olderthansevenyears.
(Routinelygivenbetween
10-12yrs of age in NIS)
Storedat a dry 2-8’C
place.Shouldn’t
allowdirectcontact
withice or heat
0.5ml of the vaccine
isgivendeepintothe
deltoid.
General
contraindications
Similartobut milder
than DT
5. Hib
(Haemop
hilus
influenza
e type b)
Conjugated
(with
protein
carrier)
vaccine
90%
reductio
n inthe
invasive
Hib
infectio
ns
Infantsandchildren<
5yrs of age (at 2,4,6th
monthsof life)
Olderchildrenandadults
whoare at a riskof
invasive Hibdisease(HIV,
immune /complement
deficiency,Hodgekin’s
disease,recipientsof
stemcell transplants,
patientson
chemotherapyfor
malignancies,asplenia,
sickle cell anaemiaand
thalassaemia, children
withnephrotic
0.5ml deep
Intramuscular
General
Contraindications
Uncommon
The mildlocal and
systemicadverse
effectsare self
limiting

9. syndrome)
1-5 years:1 dose is
sufficient
>5 years:not requiredif
healthy
If interrupted:resume
the schedule without
repeatingthe givendoses
Children<2 years:if
have had invasive Hib
disease,needsthe full
course (as natural
infectiondoesn’tprovoke
sufficientresponse) and
shouldbe startedaround
one monthof onsetof
the infection
6. Hep
B
(