immunization

Mei Neni Sitaresmi Pediatric Dept. Faculty of Medicine, Gadjah Mada University

introduction
Infectious diseases morbidity & mortality in infant/ children, some of them are vaccine preventable diseases Goal of vaccination: Individual : prevent or reduce severity from vaccine preventable diseases Global/ community :

Reduction : measles Eradication (no wild virus/ bacteria circulation) variola, poliomyelitis
human

Elimination : neonatal tetanus

is the only host, all children are protected at the same time interrupt transmission

immunity
Non specific: innate, non adaptive Intact Skin, saliva, gastric acid, urine neutrophil, macrophage, interleukin, interferon, complement Specific: Lymphocyte-B cells (humoral immune response) Lymphocyte-T cells (cellular immune response)

 Specific:

adaptive

Passive :
Protection

transferred from another person or animal as antibody (Ig G) Temporary protection that wanes with time
Maternal

antibody, HBIG, immunoglobulin, ATS, ADS

Active:
Protection

produced by the person's own immune system Usually permanent

natural infection vaccination

immune respond

Vaccination:
immunity

and immunologic memory are similar to natural infection but without risk of disease (Immunogenicity, Reactogenicity) Classification contains of vaccine:
live

Classification
EPI

attenuated vaccine: Inactive vaccine

(expanded program immunization): BCG, Hepatitis B, DPT, Measles, polio vaccine Non EPI: Hep A, Hib, varicella, MMR, typhoid, influenza, meningococcal, pneumococcal, HPV

Program:

Live and inactive vaccine

Live attenuated vaccine

Must replicate to be effective severe reactions possible immunodeficiency , pregnant immune response is similar to natural inf
interference from circulating antibody

Cant replicate: save in immunodeficiency

Inactive vaccines

generally is not as effective as live vaccines titer fall over time require 3-5 doses minimal interference from circulating Ig

Live attenuated vaccine

Inactive vaccines

unstable : carefully handle : 2-8 C, freeze Oral, intra dermal, subcutan Viral: MMR, OPV, varicella, yellow fever, influenza bacterial : BCG, oral typhoid.

Freeze sensitive

Deep im whole cell : influenza, IPV, Hep.A, pertussis, typhoid fractional: Hep.B, acellular pertusis, typ.Vi, toxoid (tetanus, diphtheria) polisacharide: -Conjugated: Pneumococcal, Hib

The consideration on Basic immunization schedule and strategies

Age specific risk of disease Age- specific immunological response to vaccine Potential interference with the immune response by passively transferred maternal antibody Age-specific risk of vaccine associated complications Programme feasibility recommendation: the youngest age group at risk for developing the disease Develop an adequate antibody response Without adverse effects

Issues regarding spacing and timing of vaccine

General

rule:

In-active vac. generally arent be affected by CA live attenuated may be affected by CA: there arent contraindication to simultaneous administration of any vaccine

 Interval

between doses of the same vaccine:

Increasing the interval doesnt diminish the effectiveness of the vaccine. It isnt necessary to restart the series of any vaccine due to extended interval between doses ( except oral typhoid) Decreasing the interval may interference with Ig response and protection.

Antibody and live vaccine

Live

vaccine is given first, wait 2 weeks before giving IG IG is given first, wait > 3 months before giving vaccine. 2 live vaccine: minimum interval 4 weeks Live oral vaccine may be given at any time before and after live inj. Vac.

Contra indications and precautions

Permanent

severe allergy/ adverse reaction to prior vaccine

encephalopathy following pertussis vac. T > 105oF, shock, persistent crying >3 hours,

temporary:

seizure

live vaccine:
pregnancy,

moderate/ severe acute illness

immunodeficient, recent receipt of Ig/ Ig-containing blood product

Invalid contraindications to vaccine

Mild illness with or without low grade fever Low or moderate reaction/ fever after vaccination antibiotic therapy disease exposure or convalescents pregnancy in the household Breastfeeding, malnutrition, premature birth allergies to product not in vaccine need for multiple vaccine

missed

opportunity

Vaccine adverse reactions

Vary: Mild to severe anaphylaxis, Local or systemic, immediate or delayed Local:

pain, swelling, redness at site of injection common with inactive vaccine: adjuvant usually mild and self -limited

systemic:

allergic

fever, malaise, headache live vac.: symptoms similar to mild case of diseases, occur after incubation period due to vaccine, component or an unrelated environmental allergen ? rare, can be minimized by screening

Jadwal DEPKES
BCG

=0-12 bulan Hep B (uniject)= 0-7 hari DPT-Hep B= 2,3,4 bulan OPV= 0,2,3,4 IPV*= 2,3,4 and 9 bulan Campak= 9 bulan Boster= SD (campak dan DT)

Potensi vaksin

Produk biologi yang rentan terhadap kehilangan potensi bila penangannanya tidak baik Sekali rusak, potensi hilang, irreversibel Pemeriksaan fisik/ mata tidak dapat mendeteksi kerusakan Penyimpanan/ transportasi: rantai dingin Potensi:
Kadaluwarso Test kocok (DPT/DT/TT) VVM (Vaccine vial monitor) Warna (polio)

penyimpanan

Polio:

BCG:

- 20 C : 2 tahun 2-8 C: 6 bulan, bila telah dibuka : 7 hari Tutup: jangan di frezer, pecah Serbuk: 2-8 C, lebih baik beku Pelarut: ruang/ kulkas pintu Dilarutkan : 3 jam Jangan sampai beku, rusak test kocok 2-8 C Serbuk : < 8 C, lebih baik -20 C Pelarut nggak boleh beku Setelah dilarutkan 2-8 C, maksimum 8 jam

DPT/ DT/ TT; Hib

Campak/ MMR/ varicella

Poliovaccines
There are two types of poliovaccine
Live attenuated poliovaccine for oral administration (oral poliovaccine - OPV)

Inactivated poliovaccine (IPV), injectable

Both vaccines contain the 3 types of vaccine virus (1, 2, 3)

Both vaccines are highly immunogenic and effective (seroconversion rate: 99-100% after 3 doses)

OPV

cheap, easy to administer Live attenuatted

IgG & IgAs, intestinal immunity interupst wild virus transmition

polio eradication Can be neurovirulent vaccine-associated paralytic poliomyelitis (VAAP) vaccine derived polio virus (VDPV)

IPV Expensive, need skill person inactive Ig G

Safer not cause VAAP and VDPV Can be given to Immunodeficiency child Consideration:
High coverage > 90 % Good surveillance of AFP No wild virus 3 years

Polio eradication

Primary immunization: 4 doses of OPV are given at birth, followed by 6, 10 and 14 weeks of age Boster dose: 1 year after the last immunization National Immunization Days (NIDs): to rapidly increase population immunity to deliver 2 doses of OPV (1 month apart) to all children in a country <5 years of age regardless of their prior immunization status all children are protected at the same time interrupt transmission. 3 years in polio-endemic countries For mopping-up immunization activities the same approach is used in areas with final reservoirs of poliovirus transmission AFP survaillance

BCG
a

live vaccine prepared from attenuated strains of Mycobacterium bovis WHO recommends countries with high incidence of TB: universal BCG immunization, a single dose at or soon after birth 0,05 ml, intracutaneously

Contraindications and Precautions

BCG should not be administered to persons whose immunologic responses

have been suppressed by steroids, alkylating agents, antimetabolites, or radiation or are impaired because of congenital immunodeficiency, leucemia, lymphoma, generalized malignancies, or HIV infection

WHO recommends BCG for asymptomatic HIV-infected children in populations with high TB risk)

Efficacy, Reactogenicity, Complications BCG Vaccine

Efficacy: two meta-analyses of published clinical trials and case-control studies concluded that BCG provides 80% protection against miliary and meningeal TB in children; clinical efficacy in preventing pulmonary TB has ranged from zero to 80% protection

Duration of protection: valid data missing

Reactogenicity and complications
1-2% local adverse reactions, e.g., abscess, lymphadenopathy isolated reports of complications (osteitis, disseminated BCG)

DPT

Contains: Diphtheria toxoid and Tetanus toxoid are a formaldehyde-inactivated preparation of diphtheria/ tetanus toxin, adsorbed onto aluminium salts to increase its antigenicity; whole-cell-pertussis vaccine (DTwP ) or acellular pertussis vaccine (DTaP)

Primary immunization: 3 doses, the first dose at 2 months, interval at least 4 weeks Booster: 1 year after 3th vaccin Contain aluminium adjuvant deep intramusculary

The use of 4-, 5-, and 6-valent combinations (based on DTwP or DTaP and including additional Hib and/or IPV, and/or Hep B components) increases both in developed and developing countries

Immunogenicity, Efficacy DPT

Dipteria:
Duration of immunity after primary and booster immunization: at least 10 years Efficacy: about 90%; if disease occurs in fully immunized persons the course is milder and less likely to be fatal

Pertusis:
Duration of pertussis immunity: 5-10 years after primary wP immunization Efficacy: 70-90% after 3 doses

Tetanus:
Duration of immunity after primary and booster immunization: at least 10 years Efficacy: approximately 90%

Adverse events DPT

Systemic:
fever (Common in DTwP, rare in DTaP)
Rare:

shock
Local:

hypotonic-hyporesponsive episode, convulsions,

Swelling,

pain, redness

Contraindications and Precautions DPT

Severe allergic reaction to vaccine component

Severe reaction following prior dose: temperature of 40.50C or hypotonic-hyporesponsive episode or persistent crying 3h within 48h; convulsions within 3 days
Moderate or severe acute illness

Hepatitis B

3 doses, the interval of 1-2 doses at least 4 weeks, the 3 dose is given 6 monts after the first dose in countries where perinatal transmission is important, the first dose of vaccine should be given at birth :
the younger the age at infection, the higher the chance of becaming a carrier and malignancy Maternal Ig G does not interfere with the respone to vaccine HBsAg+ and HBeAg+ status of mothers results in

70-90% infected newborns, and 90% of infected infants become chronic carriers 20% infected newborns, and 90% of infected infants become chronic carriers

HBsAg+ and HBeAg- status of mothers results in

Newborns of HBsAg-positive mothers receive (as soon as possible) HBIG (hepatitis B immune globulin), and the first dose of HB vaccine at different sites

Immunogenicity, Efficacy, Reactogenicity of HB vaccine

In healthy persons, the duration of immunity after primary immunization ( 3 doses) is at least 15-20 years (the period since implementation of HB vaccine) The vaccine is highly effective in preventing acute and chronic HB disease ( > 95 %), the vaccine is considered the first anti-cancer vaccine (prevention of primary liver cancer) Reactogenicity and side effects
3-20% minor local reactions, particularly pain at injection site mild systemic reactions (-20%) true complications are very rare

Measles Vaccine

Attenuated vaccine, intramuscularly or subcutaneusly

developing countries: at 9 months old

In areas of high measles risk a 1st dose at 6 months of age should be followed by a 2nd dose at 9 (to 13) months of age Non endemic area: MMR (12 month) Booster: MMR or measles (6 years)

Contraindications and Precautions

Severe allergic reaction to vaccine component or following prior dose

Moderate or severe acute illness

Pregnancy Immunosuppression Individuals with HIV infection should be immunized (measles in HIV-infected persons can be severe and often fatal) excluding severely immunocompromized (low CD4+ T-lymphocyte counts)

Immunogenicity, Efficacy, Reactogenicity Measles Vaccine

95-98% of vaccinees develop immunity after 1 dose 99% of persons receiving 2 doses separated by 4 weeks develop measles immunity Duration of immunity: lifelong (after 2 doses) Country-wide programmes based on a 2-dose schedule and achieving high coverage (95%) brought measles close to elimination Reactogenicity and complications:
5-15% fever; 5% rash

Basic Hib Immunization Schedule for Infants/Toddlers

Dose Primary 1 Primary 2 Primary 3 Primary 4 Age 2 months 3-4 months 4-6 months 2nd year of life Interval 4 weeks 4 weeks 6 months

Hib immunization could be initiated as early as 6 weeks of age Children 15 -59 months receive only 1 dose; generally Hib immunization not recommended for children >59 months of age

Vaksin Influenza

Ada 2 macam: Virus inaktif (suntikan) & hidup (hidung) Bahan lain: telur, neomisin, formaldehid Tiap tahun strain bisa berbeda Vaksinasi diulang tiap tahun Rekomendasi:
6 -36 bulan Orang tua Penderita kronis Tempat kumuh, padat Petugas kesehatan

Penyuntikan: intramuskular atau subkutan 6 35 bulan : dosis 0,25 ml > 36 bln : dosis 0,5 ml

Vaksin Hepatitis A
Virus inaktif Indikasi : anak umur > 2 thn

2 kali, selisih 6 bulan Indikasi kontra

endemis sering transfusi, Penderita hepatitis B panti asuhan

Intramuskular, jangan dipantat

demam, infeksi akut hipersensitif thdp komponen vaksin

Vaksin Varisela
Virus hidup dilemahkan Mengandung Kanamycin sulfat, eritromisin Subkutan, umur > 1 thn (IDAI 10-13 tahun) Kontra indikasi: Demam, sakit akut, penderita gangguan sistem kekebalan Perhatian:

Jangan diberikan bersama vaksin hidup Jangan hamil dalam 2 bln yad tidak effektif bila transfusi gamma globulin

Vaksin kombo