Immunisation

Dr Ahmad Ihsan Abu Bakar

Lecturer / Family Medicine Specialist
Department of Primary Care Medicine
History of Vaccination
Ancient Greece to the 21 st

century
429 BC: The Greek historian Thucydides
observed that those who survived the
smallpox plague in Athens did not get
re-infected
1890: Emil von Behring discovers the
basis of diphtheria and tetanus vaccines

900 AD: The

Chinese the first to
discover and use
variolation to
prevent smallpox
by exposing
healthy people to
tissue from the
scabs caused by
the disease – either
putting it under the
1880s: Louis skin/nostril
Pasteur
developed a
rabies vaccine

1796: Edward 1700s: Variolation

Jenner spreads around the
discovers world
vaccination
 The Value of Vaccines
• Vaccines are one of the greatest
achievements in medical science since
antibiotics.1
• Every year, 3 million deaths are
prevented2 and 750,000 children are
saved from disability.3

1. State of the World’s Vaccines & Immunisation, 3rd Edition. Obtained from http://www.unicef.org
2. Ehreth J. The Global Value of Vaccination. Vaccine 2003;21:4105-4117.
3. Ehreth J. The Value of Vaccination: a Global Perspective. Vaccine 2003;21:596-600.
The Value of Vaccines
Small pox
Eradicated

Polio
Eliminated (Western
Hemisphere)

Measles
Controlled (Americas and parts
of Europe)
 Don’t just cure. Protect!
When you protect one individual, you save
thousands.

Herd immunity leads to global protection.

 Vaccination
• Immunisation represents the single-most mass
approach to prevention

• The World Health Organisation (WHO) Expanded

Programme on Immunisation (EPI) recommends
that all countries immunise against poliomyelitis,
diphtheria, pertusis, tetanus, measles and
tuberculosis (in countries with high incidence)

• Hepatitis B vaccine was to be intergrated into

national immunisation programmes in all countries
by 1997 (Ministry of Health Malaysia, 2002)
 EPI Schedule
Age Vaccine Hepatitis B Vaccine**
Scheme A Scheme B
Birth BCG, OPV 0 HB 1
6 weeks DPT 1, OPV 1 HB 2 HB 1
10 weeks DPT 2, OPV 2 HB 2
14 weeks DPT 3, OPV 3 HB 3 HB 3
9 months Measles, Yellow fever*

• In countries where yellow fever poses a risk

** Scheme A is recommended for countries where perinatal transmission of
hepatitis B virus is frequent (e.g. South Asia), while scheme B is for those with
less frequent perinatal transmission (e.g. Sub-Saharan Africa)
• No immunisation schedule is ideal, and thus
the EPI recommends that each country
determine its own schedule that best suits its
needs.

• The strategic guiding principle of any

immunisation programme is that protection
must be achieved before infants are at high
risk of a disease.
• In Malaysia, the immunisation programme
begin with:
– DPT vaccine – in 1958
– BCG vaccine – in 1961
– OPV vaccine – in 1972
– Measles vaccine – in 1984
– Rubella vaccine – in 1988
– Hepatitis B vaccine – in 1989
– Hemophilus influenzae type B – in 2002
– MMR – in 2002
– HPV – in 2010
 Vaccines in Malaysian
Immunisation Schedule
Baccille Calmette-Guerin (BCG)

Hepatitis B

Diphtheria, Tetanus, Pertussis (DTP)

Haemophilus influenzae type B (Hib)

Polio

Measles, Mumps, Rubella (MMR)

Japanese encephalitis (JE)

• The immunisation coverage for Malaysia
in 2000 was:
– BCG – 99.97%
– DPT (third dose) – 95.3%
– OPV (third dose) – 95.4%
– Measles – 88.4%
– Hepatitis B – 93.5%
 New Immunisation Schedule
Immunisation Age (months) Age (years)
0 1 2 3 5 6 9 1 12 18 4-5 7 13 15
0
BCG
Hepatitis B
DPT
IPV
HIB
Measles (Sabah)
JE (Sarawak)
MMR
HPV*
ATT
* HPV (3 doses within 6 months)
 Additional Vaccination
• Rotavirus – btw 6 weeks to 6 months, 2 or 3 doses given 4
weeks apart

• Pneumococcal – 2 months and older, 2 to 4 doses

• Influenza – 6 months and older, 1 dose every year

• Hepatitis A – 10 months and older, 2 doses given 6 months

apart

• Chicken pox (Varicella) – 12 months and older, 2 doses

given at least 8 weeks apart
Vaccine Dosage Dosing interval
Rotateq® PO x 3 doses up to age 1st dose administered at
(Pentavalent rotavirus 32 weeks 6-12 weeks of age.
vaccine) 2nd dose administered at
4-10 weeks’ interval.
3rd dose should be
completed before 32
weeks of age.
Rotarix® PO x 2 doses up to age 1st dose between 6-14
(Monovalent attenuated 24 weeks weeks of age.
rotavirus vaccine) 2nd dose
 Impact of Vaccines
Disease 20th Century 2010 Reported % Decrease
Annual Morbidity Cases
Smallpox 29,005 0 100%
Diphtheria 21,053 0 100%
Pertussis 200,752 21,291 89%
Tetanus 580 8 99%
Polio (paralytic) 16,316 0 100%
Measles 530,217 61 >99%
Mumps 162,344 2,528 98%
Rubella 47,745 6 >99%
H. Influenzae 20,000 (est) 270 99%
 Vaccination greatly reduces disease,
disability, death and inequity worldwide

• Vaccination has greatly reduced the

burden of infectious diseases.

• Disease control benefits

– Eradication
– Elimination
 Impact of Vaccines
• Eradication

 Unless an environmental reservoir exists, an eradicated

pathogen cannot re-emerge, unless accidently or
malevolently reintroduced by humans, allowing vaccination
or other preventive measures to be discontinued.

 An ideal goal for an immunisation programme

 To date, only smallpox has been eradicated.

 The next disease targeted for eradication is polio

Polio Eradication Progress, 1988-
2009
 Impact of Vaccines
• Elimination

 Diseases can be eliminated locally without global

eradication of the causative microorganism.

 In four of six WHO regions, substantial progress has been

made in measles elimination; transmission no longer
occurs indigenously and importation does not result in
sustained spread of the virus.

 Key to this achievement is more than 95% population

immunity through a two-dose vaccination regimen.

 Combined measles, mumps and rubella (MMR) vaccine

could also eliminate and eventually eradicate rubella and
mumps
 Impact of Vaccines
• Herd protection

– Efficacious vaccines not only protect the immunized,

but can also reduce disease among unimmunized
individuals in the community through “indirect
effects” or “herd protection”.

– “Herd protection” of the unvaccinated occurs when a

sufficient proportion of the group is immune.

– Hib vaccine coverage of less than 70% in the Gambia

was sufficient to eliminate Hib disease, with similar
findings seen in Navajo populations.
Controversy
Adverse events following vaccination –
chance and causality
Vaccines and the benefit-risk balance

Benefit Risk

 Preventable disease burden  Vaccine safety

– Deaths
– Healthy recipients
– Long-term disability
 Cost
– Hospitalisation
 Vaccine efficacy
 Vaccine effectiveness