Vaccination

Dr. Hajer Elkout

Plan
• Background.
• The immune system.
• Types of vaccines.
• The cold chain.
• Vaccine preventable diseases.
• Expanded Programme of Immunisation.
• National immunisation programme.
 Background: History of vaccination
Edwards Jenner (1749-1823)

• Jenner’s Vaccine:

▫ Observation: cowpox or
smallpox.

▫ Hypothesis: cowpox infection,

protects from smallpox
(milkmaids).

▫ Test: Jenner inoculated 8-year-

old boy with matter from a cowpox
blister on the hand of milkmaid .
The immune system and
principles of vaccination
A basic understanding of
immunology explains
• How vaccine works
• Adverse events
• Intervals between vaccines
• Timing of adverse events
What Happens during an infection?
• Innate immunity.
the troops are called to battle…
▫ It is a rapid but non-specific response which
includes:
 inflammation,
 phagocytosis,
 activation of the complement system.

• Acquired immunity….
Acquired immunity
1. Active Immunity:
▫ Protection produced by the person's own
immune system.
▫ Usually permanent.

1. Passive Immunity:
▫ Protection transferred from another person
or animal.
▫ Temporary protection that wanes with time.
Active immunity
• Active immunity may be acquired naturally
or artificially.

1. By an attack of disease, e.g. chickenpox,

measles (natural active immunity).

2. By subclinical infection, e.g. polio,

diphtheria (natural active immunity).

3. By administration of vaccines (Artificial

active immunity).
Passive immunity
• When antibodies produced in one body
(human or animal) are transferred to
another to induce protection against
disease:
1. Maternal antibodies to the foetus via
placenta or breast milk (Natural).
2. By administration of antisera, e.g. ATS,
anti-rabies serum (artificial).
3. By administration of gamma globulin.
(Artificial).
Ways to get immunised
Active immunity Passive immunity
actively passively

disease transplacentarly

Prirodzene získaná Prirodzene získaná

Naturally

immunisation
Vaccination immunotherapy
immune sera

Artificiallyy
Umelo navodená Umelo navodená
Active vs passive immunity
• Passive immunity differs from active
immunity in the following aspects:
1. Immunity is rapidly established.
2. Immunity produced is of short duration.
3. There is no education of the reticulo-
endothelial system.
What is a vaccine?

• It is an immuno-biological substance
designed to produce specific
immunity against certain disease.
What is a vaccine?
• Vaccination is the deliberate stimulation of
the immune system to produce specific
protection against a disease.

• Work by mimicking what happens during

natural infection without causing illness.

• Use altered versions of viruses or bacteria

to trigger an immune response.

• Are the most effective means of controlling

infectious diseases.
Primary response
to a vaccine

19
Secondary
response to an
infection
primed by
vaccine

20
Primary & secondary antibody responses

21
Herd immunity
• Vaccines not only protect those who
get them, but they also help in
protecting the community; this is
called herd immunity.

• Defined as the level of resistance in a

community.
Herd immunity
Types of vaccines
1. Live-attenuated vaccine.
2. Inactive (killed) vaccine.
3. Subunit vaccine.
4. Toxoid.

• Made by:
• Weakening the virus or bacteria
• Inactivating the virus or bacteria
• Using part of the virus or bacteria
• Inactivating a toxin (poison) made by the
bacteria
Live Attenuated Vaccines
• Attenuated (weakened) form of the
"wild" virus or bacterium
• Immunogenic but not pathogenic (can
not induce the full blown disease)
• Live organism multiply in the host and
the resulting antigenic dose is larger than
what is injected
• Live vaccines have all the major and
minor antigenic components
*except those administered orally
Live Attenuated Vaccines
• Severe reactions possible.

• Fragile – must be stored and handled

carefully.

• Usually produce immunity with one dose*.

• Examples:
▫ Bacterial (BCG, Typhoid).
▫ Viral (Polio {Sabin}, Measles, Mumps, Rubella, Yellow
fever, Rotavirus ).
* Except the oral vaccines
Inactivated (killed) Vaccines
• killed by heat or chemicals.

• Cannot replicate in the host.

• Generally not as effective as live
vaccines.
• Antibody titer may diminish with
time.
Inactivated (killed) Vaccines
• Usually safe.

• Usually require multiple doses to

produce adequate antibody response.

• Examples:
▫ Viral (polio, hep-A, rabies, influenza).
▫ Bacterial (pertussis, typhoid, cholera, plague).
Subunit Vaccines
• Antibody with less functional activity.
• Immunogenicity improved by
conjugation.

• Examples:
▫ Capsular polysaccharides (Pneumococcal
vaccine).
▫ Cell wall polysaccharides (Meningococcal
vaccine).
Toxoids
• Certain organisms produce exotoxins.

• Toxins are detoxicated and used in the

preparation of vaccine.

• Toxoid vaccines are highly effective and

safe immunizing agents.

• Examples:
▫ diphtheria, tetanus.
Combinations vaccines
• More than one type of immunising
agent.
▫ MMR, DPT, DT, Hexa (IPV, Hib, HepB, DPT)

• Combined to:
▫ simplify administration.
▫ reduce costs .
▫ minimize the number of contact of the
individual with health system.
Combination vaccines...
• Polyvalent vaccine: more than one
strain of the same species.
▫ Oral polio vaccine (1,2,3), meningococcal
vaccine (A,C,Y,W135)
• Conjugated vaccine:
▫ a special type of subunit vaccine,
▫ made by linking to a carrier protein to enhance the
immune response.
▫ E.g. Meningococcal vaccine.

• Recombinant vaccine
▫ it is prepared by cloning genes for determined
antigens in yeast cells where it is expressed.
▫ then used for vaccine preparations.
▫ genes for determined antigens are inserted into a
vector, usually a virus, that is not dangerous.
▫ HepB vaccine, HPV vaccine.
The cold chain
The cold chain
• Cold Chain is the strict system (people
and equipments) used for storage and
distributing vaccines in good condition.

• Vaccines are sensitive to heat and

freezing and must be kept at the correct
temperature from the time they are
manufactured until they are used.
Heat sensetivity
• All Vaccines
OPV
tend to lose
Measles
potency on
BCG
exposure to
heat above DTP,Yellowfever

+8 C TT, Hep-B
Freezing sensitivity
• Some Vaccines
lose potency Hep-B

when exposed to
DPT
freezing
temperatures. DT

• The damage is TT

irreversible. Measles
Sensitivity to light
• BCG, measles and MMR vaccines are
sensitive to light.

• Normally, these vaccines are supplied

in vials made from dark brown glass.

• Should be kept away from direct light.

Key elements of the cold chain

• Personnel: to manage vaccine storage

and distribution.

• Equipment: to monitor, store and

transport vaccine.

• Procedures: to ensure that vaccines are

stored and transported at appropriate
temperatures.
Maintenance of the cold chain
• Vaccines and diluents should be:
▫ collected from the manufacturer or an airport
as soon as they are available;
▫ transported between 2ºC and 8ºC from the
airport and from one store to another;
▫ stored at the correct temperature in
primary/central and intermediate vaccine
stores and in health facilities;
▫ kept between 2ºC and 8ºC range during
immunization sessions.
Vaccine storage equipments
• Cold room/freezer room.
• Refrigerator and ice lined refrigerator.
• Cold box.
• Vaccine carrier.
Loading Vaccine Refrigerators
• Put vaccines and diluents on the top and
middle shelves of the main section:
▫ OPV and measles vaccine on the top shelf.
▫ BCG, Penta and TT vaccines on the middle shelves.
▫ Diluents next to the vaccines with which they were
supplied.
▫ Arrange the boxes of vaccine in stacks and allow
airflow.
▫ Store water bottles in the bottom shelf (why).
 help keep the temperatures stable in the event of a power
failure
Loading Ice Lined Refriegirator
• Use the basket provided.

• Measles, BCG and OPV in

the bottom only.

• Freeze-sensitive vaccines
(Penta, TT) in the top
only .
Packing cold boxes and vaccine
carriers
• Put ice packs
against each of
the four sides of
the cold box or
vaccine carrier.

• Put the vaccines

and diluent in the
middle of the cold
box or carrier.
Cold box and ice packs
Storage principles
• Vaccines must not be kept:
– In the door compartments of domestic refrigerators.
– In the salad trays at the bottom of the refrigerator.

• Must not be confused with other heat sensitive

pharmaceuticals.

• Diluents must be stored at the same temperature

at the point of use. This prevents damage to the
potency of the vaccine.
Cold chain monitoring equipments
• Thermometers:
▫ Vapour pressure (max/min)
thermometer.
▫ Dial (coil) thermometer.
▫ Liquid crystal thermometer.
• Freeze watch indicator.
• Vaccine cold chain monitor.
• Vaccine vial monitor.
• Refrigerator Stop watch.
 Cold chain golden rules
• Refrigerator placed in the coolest place of the
health centres away from sunlight.
• Distance from the wall (10-15 cm).
• Source of energy.
• Refrigerator condition rust, leaking.
• temperature recording.
• Vaccine packing in shelves (air circulation)
• First in first out/ expiry dates.
• Avoid frequent opening.
• At the end of the day opened vials should be
discarded.
Vaccine preventable diseases
The Invaders . . .

• Bacteria

• Viruses

• parasites
such as fungi &
worms
Diseases Caused by Bacteria
• TB
• Diphtheria
• Haemophilus influenza type b
• Meningococcal disease
• Pertussis
• Pneumococcal disease
• Tetanus
 Tuberculosis

• X-ray of a ten year old boy with TB

 Diphtheria

• This child has diphtheria and has developed a pseudo-

membrane, a thick gray coating over the back of his throat
Haemophilus influenza

•This child has a swollen face due to Hib infection

Meningococcal Disease

• This 4-month-old has gangrene due to infection

with meningococcus
Pertussis

• Child with broken blood vessels in eyes and bruising

on face due to severe coughing caused by pertussis
Pneumococcal Disease

• Caused by the bacterium

Streptococcus pneumoniae

• Can infect different parts of the body

leading to:
• Pneumonia
• Bacteremia (blood infection)
• Meningitis
• Ear infection
Tetanus

• This child was experiencing painful muscle

spasms due to infection with tetanus
Diseases Caused by Viruses
• Polio
• Hepatitis B
• Human papilloma virus (HPV)
• Influenza
• Measles
• Mumps
• Rubella
• Rotavirus
Polio

• This young man suffers from lower extremity paralysis

due to infection with poliovirus
Hepatitis

• This man developed jaundice as a result of hepatitis

infection
Human Papillomavirus (HPV)

• HPV is the most common sexually

transmitted disease

• Most people who are infected do not

have any symptoms

• Associated with cervical cancer

Influenza

• This photo shows how influenza germs spread

through the air when someone coughs
Measles

• Head and shoulders of a boy with measles

Mumps

• This child is very swollen under the jaw and in the

cheeks due to mumps.
Rubella

• This child was born with cataracts caused by a

rubella infection his mother transmitted to him
before birth
Rotavirus

• Causes severe vomiting and diarrhea that

can lead to dehydration.

• Dehydration can lead to death.

• Before there was a vaccine virtually, all

children had this infection by the age of
five.
 Expanded programme of immunisation
EPI
• Established 1974 by the WHO.

• Its aim was to eradicate/reduce the incidence of

common and often Fatal diseases.

• The six traditional targets were diphtheria,

pertussis, tetanus, poliomyelitis, measles and
tuberculosis.

• EPI can be expanded so other diseases may be

targeted according to individual needs.
National immunisation
programme
National immunisation schedule
BCG
• Given at birth.
• Intradermal route.
• Site:
▫ about one third down the left upper arm over
the insertion of the deltoid muscle.

• Possible side effects:

▫ Abscess.
▫ Regional lymphadenitis.
The vaccine is 70-80% effective against the most
severe forms of TB (TB meningitis in children). It is
less effective in preventing respiratory disease
(more common in adults).
Clavicle

Deltoid

Injection
site

Why?
1. To avoid joint keloid.
2. To avoid subclavicular LNs.
Polio vaccine
• OPV (Sabin),
▫ Live attenuated, oral route.
▫ uphold herd immunity by cross infection
▫ At birth, 9,18 ms, school entry and
at 15 yrs.
▫ OPV is the only vaccine that still needs
to be kept frozen at -20C,
▫ However, OPV may be stored at +2 to
+8C for up to 6 months
IPV
• Inactivated polio vaccine.
• IM.
• 3 doses as a part of the Hexa vaccine
(2,4,6 months).
OPV or IPV?

OPV may cause vaccine associated paralytic polio

Hexa vaccine DPT, Hib, Hep-B, IPV
• IM route
• Recommended: 2, 4 and 6 months.

• Possible side effects

▫ pain, redness and swelling at the injection site.
▫ irritability and increased crying.
▫ Fever.
Hexa vaccine

• DPT, Hib, Hep-B and IPV.

• IM, given at 2,4,6 months of age.
Hexa vaccine DPT, Hib, Hep-B, IPV
• DPT
▫ Diphtheria toxoid
▫ Pertussis, killed
▫ Tetanus toxoid
• Hib, polysaccharide conjugated
• Hep-B, recombinant vaccine
DPT, DT, Td or TT?
• DPT (NOT Hexa vaccine) at 18 months.
• DT after 2 years
• Td contain small dose of diphtheria
toxoid, recommended at school entry, 15
years.
• TT
▫ Pregnant women or those of childbearing age.
▫ workers with greater risk of injury.
▫ military personnel.

• Do not give DPT to > 2 year olds.

• Do NOT give DTP or DT to child > 7 yrs.
 Measles-Mumps-Rubella vaccine
MMR
• Recommended 2 doses; at 12,18 ms.
• SC or IM route.
• Possible side effects:
▫ Soreness and errythema
▫ Fever and rash
▫ Mini-measles
▫ Mini-mumps

• Egg allergy is NOT a contraindication

Meningitis A,C,Y,W135 vaccine
• Most invasive disease caused by A, C,
Y, W-135 serotypes.
• Recommended at 9, 12 months and at
school entry.
• Minimum interval between doses: 8
weeks.
Newly introduced vaccines
• Rotavirus vaccine
▫ Live attenuated virus
▫ Recommended at 2, 4, 6 months
▫ Oral route
▫ Side effects may include diarrhea, fever
▫ Similar to OPV, the live virus is excreted in
stool and can be a risk for immunosuppressed
people.
Newly introduced vaccines
• Pneumococcal vaccine
▫ 13-valent pneumococcal conjugate vaccine.
▫ Given at 2, 4, 12 months.

• Human papiloma (HPV) vaccine

▫ Recombinant DNA
▫ IM, 3-dose series recommended at 15 yrs old
▫ Schedule: 0, 1-2 months, 6 months after first
dose
Route of administration of vaccines
• BCG vaccine: ID.
• OPV and Rota: Oral.
• All other vaccines: IM or SC.
Side effects of immunisation

Nothing is completely “safe” but

vaccines are among the most
thoroughly tested and safest things
we put into our bodies
Side effects...
• LOCAL:
▫ pain, redness, swelling, abscess.

• GENERAL:
▫ fever, vomiting, diarrhoea, headache, malaise
▫ Hypersensitivity reaction.

• RARE:
▫ encephalitis, paralysis.
Side effects due to faulty technique
• Faulty production of vaccine.
• Too much vaccine given in one dose.
• Improper immunization site or route.
• Vaccine stored incorrectly.
• Contraindications ignored (previous
hypersensitivity reaction).
• Use of improperly sterilized syringes and
needles.
Delayed vaccinations
• Child not protected during delay.
• May require many additional visits.
• Catch up, do not restart.
• Complete the dose series.
• Minimum one month interval
between doses.
Vaccines contraindications
• In general, there are only 4 CI:
▫ Significantly immuno-compromised persons,
don’t give live attenuated vaccines.
▫ Child who develops convulsions after the first
dose of DPT → DT.
▫ Severely ill child.
▫ Hypersensitivity to the vaccine or one of its
components.
Vaccines contraindications
• BCG should not be given to:
▫ patients with current or previous tuberculosis.
▫ patients with a current febrile illness.
▫ patients with skin conditions such as eczema or
dermatitis.
▫ patients who have had a previous live vaccination
within the past four weeks.
▫ people who are HIV positive.
▫ patients receiving immunosuppressive medication
such as corticosteroids or cancer chemotherapy or
with other conditions likely to suppress immunity.
These are NOT CI to vaccines
• Simple respiratory infections.
• Mild vomiting and diarrhoea.
• Antibiotic & local steroid therapy.
• Asthma in child & family.
• Neonatal jaundice.
• Premature child.
• Malnutrition & low birth weight.
• Stable neurological conditions.
• Minor surgery.
Avoid Administration Errors

• Make sure you have the:

▫ Right child
▫ Right schedule
▫ Right vaccine & diluent
▫ Right dose
▫ Right route
▫ Right site
`

Thank you