IMMUNIZATION IN PEDIATRIC PATIENTS

IMMUNITY The term immunity refers to resistance exhibited by the host towards injury caused by microorganisms and their products. Protection against infectious or pathogenetic agents is only one consequences of immune response, which in entirely is concerned with reactions of body against any foreign antibody. Immunity hence by different mates plays a significant role in normal life of an individual without which survival is almost compromised. Study of immunity has a long history where in ! "

# " t h century$ people used small pox infectious sites for inoculation in their children at an early age. This proved very much successful by preventing further attac% of small pox in children at on older age. This began the process or method of immuni&ation of children so as to prevent further attac%s from a similar organism.

Types of immunity: Immunity against infectious agents is of different types namely' . Innate immunity' a$ Specific Species (acial b$ )on specific *. +cquired immunity' +cute )atural +rtificial Passive )atural +rtificial Innate immunity: Innate immunity or native immunity of an individual is the immunity, which an individual possesses by virtue of his genetic and constitutional ma%e up. It does not depend upon the caries contact of an individuals with infectious agents or immuni&ation. Individual

It may be non,specific when the degree of resistance to an infection is considered in general or specific when resistance to a particular pathogen is concerned. Innate immunity is considered at the level of species, race and individual. Immunity at the level of species is shown by total or relative refractoriness to a pathogen shown by all individuals of a species. -or example, human beings are resistant to infections from plant pathogens and to pathogens of animals. The mechanism of this immunity is not understood fully but may be due to changes in physiological and biochemical properties between tissues of different host species which determines whether or not the pathogen can grown in them. (acial immunity is evidenced by differences in total resistance capacities of individuals of different races. It can be seen mainly in animals. In human beings it is seen that the overall resistance of negroes is more when compared to whites. Infections li%e malaria are more frequently in whites when compared to negroes possibly because, the high incidence of sic%ling #sic%le cell carcinoma$ provides

resistance against malaria organisms. /ach racial differences are %nown to be genetic in origin and by selection and in breeding possible to develop at will races that have higher degree of resistance or susceptibility to various disease pathogens. Immunity #innate$ at individual level can be considered under various aspects as follows' . +ge' Two extremes of life present with increased susceptibility to infections. The immune system in children is wea% as it is still in a developing stage. In fatal life infections are reduced by immune system of mother. In younger age

increased susceptibility may be due to hormonal alterations. +s the age is progressed towards old age the immune system gets waned and again susceptibility to infections is increased. Hormona Inf uen!es: /ndocrine disturbances li%e diabetes, adrenal

dysfunction, hypothyroidism etc are activated with enhanced susceptibility to infections. In all these cases immune mechanisms are compromised. The corticosteroids suppress

immune system by their action as anti,inflammatory and antiphagocytic. +t the same time steroids also exhibit properties li%e neutrali&ation of bacterial endotoxins. Nutrition: The relation between nutrition and immunity very complex. In general both cell mediated and humoral

immunity are reduced in malnutrition. It is also seen that certain conditions may not be seen in severely ill patients. The malarial infection in very severe illness may not induce fever but when diet #nutrition$ is improved it may produce fever. It is found hence that certain viruses and bacterias can not grow in cases of severe illness. Me!"anism of Innate Immunity: Skin and mucous membrane: +n intact s%in and mucous membrane provide

considerable protection against invasion by microorganisms. 1ealthy s%in possesses bactericidal property by means of high concentration of salt in drying, sweat. The sabecious glands and long chained free fatty acidic also impart a protective action against microorganisms.

3ucosa

of

respiratory

tract

has

several

innate

mechanisms to provide immunity. 4efore the air could enter the lungs starting from the point of entry of air into nasal orifices the air is filtered to remove all impurities, the larger particles are removed in nasal cavity by ciliac and mucous secretions. The smaller particles which escape from nasal cavity are removed by mucous secreted along the bronchus. 5nce the particles are caught they are ultimately coughed out. +ny other small particles escaped through these ways are removed by phagocytes in respiratory alveoli. 3outh is constantly bathed by saliva which has several antibacterial properties. The particles in mouth are subjected to various digestive juices and ultimately digested. Strong acidic p1 in stomach helps in fighting against many organisms. If organisms can survive in acidic environment these are ultimately %illed in intestine when the p1 of secretions increases gradually and becomes al%aline. Intestinal mucosa consists of normal microbial flora which prevents further coloni&ation by other organisms. 6onjunctiva is freed from foreign particles by the flushing action of lacrimal secretions. Tears contain

lyso&ymes, an antibacterial substance in them. This lyso&yme is in an amount present in lacrimal fluid mainly active against gm positive non pathologic cocci, lyso&ymes are present in all of the tissue fluids and secretions except in 6.S.-. sweat and urine. It has been found that phagocytic cells contain significant amounts of lyso&yme in them to be active against majority of athogenic organisms. -lushing action of urine frees the bacteria from urethra. Anti#a!teria su#stan!es in # oo$ an$ tissues: 6omplement system possesses bactericidal properties

and plays an important role in destruction of pathogenic organisms that invade blood and tissues. substance present in normal serum Propordin a with

combines

complement an mg88 ions lysis of gm negative bacteria and also some viruses. Several other factors having antibacterial property in blood are' . 4eta lysine 9 + relatively hemostable substancec active against anthrax and related bacilli.

*. 4asic

polypeptides

li%e

lu%ins

secreted

from

leu%ocytes and pla%in secreted by platelets. .. :actic acid in muscles and in inflammatory &ones. +ll these substances exhibit antibacterial properties. Ce u ar fa!tors in Innate Immunity: )atural defence against invasion of blood and tissues by microorganisms and other foreign particles is mediated to a larger extent by phagocytic cells, which ingest and destroy them. Phagocytic cells are classified as microphages and macrophages. polymorphonuclear The microphages consist consist of of

leu%ocytes.

3acrophages

wandering ameboid cells. 6ells of reticuloendothelial system and monocytes. + major function of (/ system is removal of foreign particles that enter the body. The phagocytes reach the site of inflammation by different chemotactic substances and ingest the foreign bodies. The bacterias are phagocytosed into a vacuole which combines with lysosyme to form phagolysosome. The phagolysosome is subjected to various lytic en&ymes to destroy the organism. "

Inf ammation: Tissues injury or irritation initiated by the entry of microorganisms leads to inflammation which is an important nonspecific defense mechanism. The blood vessels constrict initially followed by dilatation. The processes li%e

margination ad diapedesis and emigration of leu%ocytes from blood vessels to inflammatory site ta%es place which leads to phagocytosis. -ever an increase in overall body temperature is also a defense mechanism mainly by inhibiting in growth or destroying pathogenic organisms. A!%uire$ Immunity: The resistance that is acquired during life of an individual is %nown as acquired immunity. It is different from innate immunity which is inborn. Acquired immunity is of two types namely: . +ctive immunity. *. Passive immunity.

A!ti&e immunity: +ctive immunity is the resistance developed by an individual as a result of an antigenic stimulus. This involves active functioning of persons immune system leading to synthesis of antibodies and < or immunologically active cells. +ctive immunity sets in only after a latent period which is required for the immunologic machinery to set in motion. =uring the development of active immunity there is often a negative phase during which, the measurable

immunity is lower than the immunity present prior to exposure to an antigen. This is seen because, during the process or period of initial exposure, the antibodies normally present are utili&ed for phagocytosis and therefore there is a net reduction in total immunity. 5nce the immunity sets in it increases rapidly and remains for a longer period of time. + second similar exposure leads to setting of immunologic response at a very faster rate and more efficiently. +ctive immunity is characteri&ed by immunologic memory. This means memory of prior antigenic exposure is

>

retained for a longer period of time and produces a secondary type of reaction when it meets same antigen. #+ctive immunity is more effective and confers better protection than passive immuni&ation$. Passi&e Immunity: The resistance that is transmitted in a readymade form is %nown as passive immunity. The host immune system plays no role in providing protection. preformed The antigenic are stimulus is absent, ?nli%e instead, active

antibodies

administration.

immunity, the latent period is absent. The immune actions begins almost immediately and the negative phase is absent. The immune reaction is transient and lasts for few wee%s to months. This protection is seen till the passively administered antibodies are metaboli&ed and eliminated from the body. )o secondary type of reaction is seen. Instead if the same antibody is given again for the second time it is eliminated more rapidly from the body when compared to first time. This factor of immune elimination limits the usefulness of passive immunity.

The passive immunity is therefore less useful than active immunity in providing immune capacity. The only advantage being its immediate action. A!ti&e Immunity C assifi!ation: +ctive immunity may be' , , )atural +rtificial )atural active immunity results from either clinical or inapparent infection from a parasite. + person who has recovered from these infections develops natural active immunity. /xample, a person

recovered from small pox, chic%en pox etc. Increased resistance to poliomyelitis in individuals of developing countries due to many subclinical attac%s by poliovirys in childhood. Some viral infections may give life long immunity #measles$. The period of natural active immunity varies from the type of pathogen and virulence of pathogens. Some viral infections li%e common cold due to influen&a virus may give

only a shorter period of immunity. The common cold due to influen&a virus may recur due to reduction in immune response to second infection. The immunity following bacterial infection is less permanent when compared to viral infection some infections li%e typhoid fever provide sufficient immunity for a longer period of time. + special type of immunity called premunition is seen in syphilis. This is characteri&ed by presence of immunity to a pathogen is seen as long as the original infection is active. 5nce the original infection is cured, the person becomes susceptible to infection by the same microorganisms again. Artifi!ia A!ti&e Immunity: Immunity in children includes involves both natural active immunity and artificial active immunity. The artificial active immunity is the immunity or resistance induced by vaccine. @accine are the preparations of live or %illed microorganisms or their products used for immuni&ation.

The vaccine therefore are divided in to' . :ive vaccine 4acterial @iral *. Ailled 4acterial @iral .. 4acterial products divided vaccine 9 toxoids for

diphtheria and tetanus. :ive vaccines initiate on infection without causing any injury or disease. The immunity following live vaccine administration is similar to that following natural infection but is of a lower order. 5nce set, the immunity lasts for several years, but booster doses are < may be necessary. The administration of live vaccine in children <adults may be done or orally, #example 9 sabin vaccine and virus

poliomyelitis vaccine.

parentrally.

/xample,

Smallpox

Ailled vaccine are generally less immunigenic than live vaccine and the protection by them lasts only for a shorter period of time. Therefore they require to be administered repeatedly, usually at least two times. The first injection is 0

%nown as primary dose and second dose is %nown as booster dose. %illed vaccine can be again given either orally #taboral vaccine for typhoid$ or parenterally. The oral route is generally not as effective as by parental route. The %illed vaccine by parental route generally provide humoral antibody response. )ot all the organisms are available in avirulent form. In order to overcome this if living organisms are to be present in vaccine #live vaccine$ they have to be treated in such a way that the organisms loose their disease producing ability. This process is called as attenuation. The commonly used methods for this include adopting the organisms to unusual environmental condition so that they lose the ability to replicate completely in their usual host. 6ulturing the viruses at a temperature lower than normal is the next method. :ive attenuated vaccine provo%e a rapid protective response through stimulation of interfering production. :ive vaccine are difficult and expensive to prepare, possibility of dangerous extraneous organisms is also seen. 2

Natura Passi&e Immunity: )atural passive immunity is the resistance passively transferred from the mother to infant <baby. In humans maternal antibodies are predominantly transferred through placenta #especially IgB$ and gives immunity to the infant, human chelostrum is rich in Ig+ and also contribute for immunity of the featus. -rom about * t h wee% of I.?. the

human embryo starts developing Ig3 in its body. 4ut the Ig3 embryo at this stage is not active enough to combat all the infections. It is only at about after . months post anterior life the infant gets immune capacity independently. Till then the child utili&es immune system of mother that is transmitted to it. The transmission of antibodies from maternal to factal circulation across placenta is an active process and it is found that fectus has more concentration of antibodies than maternal circulation protection so afforded is sufficient to resist all infections during that period. 1ence any infections are more common after . months of age.

4y active immuni&ation of a pregnant women it is possible to improve the passive immunity in infants. The recommendation of titanus tunoid vaccine

prophylactically is hence of use in areus with increased tendency for neonatal titanus. Artifi!ia Passi&e Immunity: +rtificial passive immunity is the resistance passively transferred to a recipient by injecting antibodies. The agents used for this purpose are hyper immune animal and human sera, convalescent sera, and pooled human gamma globulin. The oldest and commonest method employed is to inject hyper immune horse sera. It is prepared by injecting appropriate antigen into horse serum. /xample prophylaxis 9 +nti,tetanus tetanus serum infection #+TS$ is used for by

against

prepared

administering a series of doses of antigens into horse circulation. Then the blood is collected and serum is separated from blood. The antibodies are then concentrated and purified and sterili&ed. The main problem with animal en&ymatic preparations is an increased tendency for hypersensitivity reactions. !

In order to overcome this problem human sera can be utili&ed. Serum collected from patients convalescing from

infections diseases contain high concentration of specific antibodies. Such convulsing serum is utili&ed for passive immuni&ation against viral infections li%e measles and rubella. The main ris% of using human sera is transmission of serum hepatitis. Passive immuni&ation is utili&ed mainly for providing immediate and temporary protection in a non immune host having chances of infection. It is also utili&ed to provide resistance till active immuni&ation is in action. Passive immuni&ation can also be employed with active immuni&ation and this is called as Ccombined immuni&ationD. 6ombined immuni&ation is indicated whenever an immediate action is required which is given by passive immuni&ation. The immune actions remains active after words by active immuni&ation. Paediatric or childhood is the best age at which majority of disease can be prevented by means of various "

methods.

@accination

in

childhood

has

become

an

inexpensive and most useful methods by which prophylaxis can be given. Since the time of introduction of vaccine there is a decline or reduction in the overall rates of infections li%e cholera, tuberculosis, typhoid, mumps, smallpox, tetanus and polio etc. which are most common diseases affecting in early childhood. Some of the diseases against which the immuni&ation by vaccines is available at present are' . =iseases that can be prevented by environmental improvement or vaccination' , , , , , , , Eapanese encephalitis. T4. Fellow fever. Typhoid. (ubis 6holera 1epatitis 4 #1ori&ontal transmission$.

*. =iseases preventable only by vaccination' , , , , Poliomyelitis. =iphthories. 3easles. (ubella. ;

, , , , , , ,

3umps. Purtysis. 3eningococcal meningities. Influen&a. 6hic%enpox. S.pneumonia pneumonia. 1epatitis 4 #vertical transmission$.

Routine 's Spe!ia Immuni(ation: 4ased on prevalence and severity of a disease, safe and vaccine are preferred for routine repeated administration in infants and early childhood. Thus in India routine

administration is recommended for' , , , , , , 3easles. =iphthoria. Tetanus. Purtusis. Typhoid fever and Tb (obis vaccine is usually given as a post exposure prophylaxis and in more prone individuals as a pre exposure prophylaxis cholera vaccine is recommended only as a measure against epidemics. In pediatric practice immuni&ation should be given to all susceptible individuals and this vaccine is usually ta%en

*>

at an individual level. Immuni&ation can safely be given in minor illness li%e diahhroea, ?(TI etc. In order to control the vaccine preventable disease G15 and member countries including India has established on expanded programme on immuni&ation. Some of t"e Pra!ti!a Aspe!ts . There is no contraindication for concurrent

administration of multiple vaccines li%e =PT, 5P?, or 33(. *. + lapse in schedule of immuni&ation does not always necessitate reinstitution of total course. If a second hours of =PT or 5P? is missed it is not necessary to reinstitute the complete course. .. If immuni&ation scheme of a child is un%nown there is no harm in giving appropriate vaccines again. 0. =ose reduction is not appropriate since it may cause in appropriate immunologic response, increased dose is also not indicated which may cause side effects. 2. :ive vaccines of all types and 46B should not be given in individuals with congenital disorders of immune

system. These should also be avoided in children who are ta%ing steroids for rt since these causes

immunodepression. + short course of low dose of steroids is not a contraindication for vaccines. @accines of this %ind should also be avoided in children with active symptoms of +I=S. 7. 6hildren suffering from neurologic disorders or with previous history of convulsions are at a higher ris% for purtuse vaccine. !. +ctive immuni&ation after exposure to disease is indicated in' , , , , (abies. 3easles #within . days of exposure$. 1epatitis and Tetanus.

Immuni(ation s!"e$u e: @arious immuni&ation schedules are recommended in order to protect a child from infections. Some of the immuni&ation schedules are'

**

National Immunization schedule : The first visit may be made when the child is 7 wee%s old. The recommended schedule is given in next page. 4eneficiaries +ge 7 wee%s to ; months ;, * months 6hildren 7,*0 months 2,7 years > years @accine =PT P5:I5 46B 3easles =PT Polio =T Typhoid Tetanus tonoid Typhoid 7 years Pregnant women 7,.7 months Tetanus T Typhoid T,T H HH I * I I I I I )o. of doses . . H (oute of administration Im 5ral Intradermal Subcutaneous Im 5ral Im Subcutaneous Im Subcutaneous S6 S6 Im

Infants

H -or institutional deliveries 46B should be given at birth. HH 4ooster dose I * doses if not vaccinated Intervals between two doses should not be less than one month * minor illness is not a contraindication.

*.

)HO EPI s!"e$u e This strongly recommended institution of 46B and polio vaccines at birth or at the time of initial contact, in countries where Tb and polio have not been controlled. In all countries immuni&ation for polio is safely started at 7 wee%s of age along with =PT. The given schedule is as follows' A*e 4irth 7 wee%s > wee%s 0 wee%s ; months Dip"t"eria: 6ommon disease in India, which has sufficient number of antibodies circulating in maternal circulation. The 'a!!ine 46B, oral polio =PT, oral polio =PT, oral polio =PT, oral polio 3easles

antibodies are easily to crossed across placenta and fetal immunity is cortered till birth and for first . months. The vaccine is given as a triple vaccine =PT or =.T.

*0

Primary dose consists of . doses at 0, 7 and " wee%s of birth, I booster dose is given during second year of age, at " months. + second booster dose is given at 2 years of life. Pertusis: , , Biven as triple vaccine =PT. Since protective antibodies cannot cross placenta

vaccination is a must. , . doses are recommended at ;," wee%s of internal from ,. months of age. , 6ommon adv reactions' o :ocal pain irritability. o Screming for a prolonged time. o 6onvulsions in some cases. , )ot recommended in neuromuscular disorder and

patients with convulsive history. Tetanus: , )eonatal tetanus is an important cause of mortality in many developing countries.

*2

Since there is no natural immunity, the unimmuni&ed mothers fail to transfer the antibodies to their infants against tetanus toxin.

Immuni&ing pregnant women with T toxoid of great value.

@accination against TT is given as =PT or =T or TT alone.

4ooster dose is given at

" months, 2 years and

>

years and thereafter 7 months intervals. +C,: , 4acillus culmette guerin is an attenuated strain of mucobacterium tuberculosis. It is a line vaccine. , In order to maintain its potency the vaccine is supplied at a temperature of 0J6 at which the potency remains satisfactory for several months. Since no immunity is transferred from mother to infant 46B has to be administered after birth. The vaccine is given intradermally above the deltoid muscle. +fter *,. wee%s a papule develops at the site of injection which ultimately heals by scarring.

*7

Adverse reaction being , (egional lymphnods with infrequent dressing.

Meas es: , , , , :ive attenuated measles virus is used as a vaccine. @accine stored at 0,"J6 can be used for Biven by S.6. or Im route. (ecommended minimum age is nine months. 4ecause before this period maternal antibodies circulating in fetal blood neutrali&es the virus in live vaccine. Mumps: , , , @accine consists of live attenuated mumps. Biven as a trivalent vaccine with measles and rybella. 3umps vaccine of 33P may be given after months of age. Ru#e a: , Immuni&ation is given solely to prevent congenital rubella. , Two approaches are recommended. o /ither to selectively immuni&e girls. o Immuni&e girls and boys simultaneously. *, 2 year.

*!

, ,

In India incidence of rubella is not %nown. Prophylaxis starts at on age of * months.

Ra#ies: , , 6ause #explain$. Since the incubation period is more post exposure vaccination is safely given for infected individual. , It employs administration of %illed rabies virus

vaccine. , 3odified sempleKs vaccine is one vaccin for rabies administered S.6. over anterior abdominal wall for !, 0 days. In some cases booster doses are also required. , 3odern vaccine have advantage over semples vaccines in that no neurological symptoms are seen. , These vaccine are given Im or Sc on >, ., !, 0, .> and ;> days. Typ"oi$: , /mploys standard acetone %illed salmonelle typhi infections.

*"

Primary immuni&ation requires two S.6. doses at 0 wee% intervals. In out brea%s the period may be reduced to wee% also. > years.

, ,

=ose is 2ml for children of

4ooster doses once in . years are recommended.

C"o era: , Suspension of heat %illed vibrio cholera is used as vaccine for cholera. , (ecommended rarely and only in outbrea%s of the disease. , Biven either I=, Im or Scly.

Hepatitis + + purified suspension of ** nanometer particles

bearing 1.4. virus surface antigens found in some chronic carriers are used as vaccines. +ny residual virus is

inactivated by formaldehyde and heat. (ecently a genetically engineered recombinant vaccine is available. In pediatrics its main use is in preventing mother to transmit the disease to infant neonates borned to carrier *;

mothers should given 1uman anti hepatitis 4 globulin #+14B$ and a course of vaccines according to

recommendation by manufacturers.

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