Imunisasi

Bambang Mulyawan
FK-UMM
Pendahuluan

• Imunisasi : pemindahan / transfer

antibodi secara pasif
• Vaksinasi : pemberian vaksin
(antigen) yang dapat merangsang
pembentukan imunitas (antibodi) dari
sistem imun di dalam tubuh
• Istilah imunisasi lebih umum dipakai
mencakup kedua pengertian di atas
 Maksud dan tujuan imunisasi
• Maksud :
cara untuk meningkatkan kekebalan seseorang secara
aktif terhadap suatu antigen, sehingga bila kelak ia
terpajan pada antigen yang serupa tidak terjadi penyakit
• Tujuan :
- mencegah penyakit tertentu pada seorang anak
- menghilangkan penyakit tertentu pd sekelompok
masya-rakat (populasi)
- menghilangkan penyakit tertentu dari dunia (variola)
• Tujuan jangka panjang /akhir:
- eradication of disease

• Tujuan jangka pendek/segera:

- prevention of disease
 Terminologi
• Immunization – conferring immunity by artificial
means

• Vaccination – conferring immunity to a disease

using a vaccine or special antigenic material to
stimulate the formation of appropriate antibodies

• Vaccine – preparation of antigenic material

– stimulates Ab production
– confers active immunity vs. disease

• Latin “vacca” = cow (from cowpox) 5

 Edward Jenner

Discovery of small pox vaccine

6
Milestones in immunization

1780AD
 Edward Jenner discovers
small pox vaccine

7
Imunisasi menyelamatkan....
• Immunization saves
the lives of
approximately 3
million people each
year, all over the
world.
2.3 million still die each year
 Fakta / kebenaran vaksin
• Vaccines are one of the most important public
health achievements
• Public concern about vaccines is pervasive
• Fear of vaccines can lead to public harm
• Vaccines are not 100% safe
• Parents want what is best for their children
• The public has little understanding of the
vaccine development process
 Fakta / kebenaran vaksin.....
• Risk perception is critical
• There are anti-vaccine champions
• Questions remain
• The decision not to vaccinate is an active
decision to accept the risk of the disease.
• (Marshall, G. 2003).
 Beberapa pengertian
• Vaksin merupakan material biologis yang
sangat mudah kehilangan potensinya.
• Dengan kehilangan potensi,berarti akan
terjadi kegagalan vaksin untuk menstimuli
respon imunologi, akibatnya daya proteksi
akan berkurang.
• Pencegahan terjadinya penurunan potensi
meliputi : tranportasi,penyimpanan, dan
penanganan yang benar.
Different modes of acquiring immunity

Immunity

Natural Acquired
resistance

Passive Active

Artificial Natural Artificial Natural

 Jenis imunisasi
• Active immunization :
- vaccine
- live attenuated
- killed inactivated

• Passive immunization
 Jenis / karakteristik vaksin
• inactivated (killed) antigen: Flu , Hep. A
• live attenuated (weakened) antigen: MMR,
Varicella
• synthetic (laboratory synthesized)
microbial materials:Toxoids DTaP
• conjugate vaccines use outer- coats of the
bacteria: Hib, PCV
• recombinant vaccines use the virus
genetic material: Hep B
 Jenis/karakteristik vaksin
• Live attenuated vaccines generally
produce long-lasting immunity with a
single dose.
• Inactivated vaccines require multiple
doses and may require periodic
boosting to maintain immunity.
 Imunisasi aktif
Penetrate cells
- intracell. Ag
Formulations: processing to
1. Live pathogens – attenuated surface of cells
- cytotoxic T cell
2. Killed micro-orgs response

3. Microbial extracts
4. Vaccine conjugates
5. Toxoids
Do not enter host cells:
1ary B cell-mediated
humoral response 18
 Imunisasi aktif

Natural Artificial
Attenuated
organisms

killed organisms
exposure to sub-
sub-cellular
clinical infections
fragments

toxins

others
 Live Attenuated Vaccines

polio* hepatitis A
not used in std. schedule standard 2006

measles, mumps yellow fever

& rubella Military and travelers

Varicella zoster Influenza

children with no history of selected age group (5-49)
chicken pox
tuberculosis
not used in this country
Killed Whole-Organism Vaccines

polio Q fever
population at risk

influenza typhoid, cholera, plague

elderly and at risk epidemics and travelers

rabies pertussis
post exposure replaced by the
acellular vaccine
Microbial Fragment Vaccines

Bordetella. Pertussis
virulence factor protein

Haemophilus influenzae B
protein conjugated polysaccharide

Streptococcus pneumoniae
Polysaccharide mixture

Neisseria meningitidis
polysaccharide
Microbial Fragment Vaccines

Clostridium tetani (tetanus)

inactivated toxin (toxoid)

Corynebacterium diphtheriae
inactivated toxin (toxoid)

Vibrio cholerae
toxin subunits

Hepatitis B virus
cloned in yeast
Figure 10-17
 Imunisasi pasif

25
Mims C et al. Medical Microbiology. 1998.
 Imunisasi pasif

Natural Artificial

Placental transfer of Antibodies or

IgG immunoglobulins

Colostral transfer of Immune cells

IgA
 Imunisasi pasif

disease antibody indication

source
diphtheria, tetanus human, horse prophylaxis, therapy

vericella zoster immunodeficiencies

human
gas gangrene,
botulism, snake horse post-exposure
bite, scorpion sting
rabies, human post-exposure

hypogamma- human prophylaxis

globulinemia
Advantages and Disadvantages of
Passive Immunization

Advantages Disadvantages
no long term
protection

serum sickness
immediate protection
risk of hepatitis and
Aids

graft vs. host

disease (cell
graft only)
Perjalanan penyakit infeksi

Susceptible Diseased

Not at risk
Perjalanan penyakit infeksi

Susceptible Diseased

Not at risk
 Perjalanan penyakit infeksi

Vaccination

Susceptible Diseased

Not at risk
Perjalanan penyakit infeksi
Therapy producing
temporary cure

Susceptible Diseased

Not at risk
Perjalanan penyakit infeksi
Therapy producing
permanent cure

Susceptible Diseased

Not at risk
Perjalanan penyakit infeksi
Education

Susceptible Diseased

Not at risk
 Trias epidemiologi

Disease is the result of forces

within a dynamic system consisting
of:

agent of infection
host
environment
Manfaat/tujuan cara pemberian
vaksinasi yang benar

• Promote optimal antibody response

• Reduce risk of local adverse

reactions
Penanganan dan penyimpanan
vaksin
• Freezer:
- varicella

• Refrigerator (2-8 degrees C):

- use plug guard to prevent accidents
- thermometer in refrigerator and
freezer
- logbook
- fill with bottle of chilled water and icepack
 Cara penyuntikan
• Hand hygiene
• Gloves are not required
• IM - <1y anterolateral aspect of the thighs
- >1y deltoids
• SQ 45 angle
-MMR,Varicella
-IPV, menomune
-Yellow fever
 Vaksinasi pada bayi prematur dan
BBLR
• They should receive all routinely
recommended childhood vaccine at the
same chronologic age as full term infants.
 Adverse Reactions Following Vaccination
( Kejadian Ikutan Paca Imunisasi )

• Local the most common; such as pain,

swelling, and redness at the site of
injection.
• Systemic include fever, myalgias, muscle
pain, headache, loss of appetite.
• Allergic is the most severe and least
frequent.
 Reaksi samping
• High fever
• Behavior changes
• Seizures
• Allergic reaction:diffic. Breathing,
weakness, hoarseness, wheezing, rapid
heart rate, hives, dizziness, paleness, or
mucus membrane swelling.
• Reported by parent and/or provider using
a Vaers form from the CDC.
 Beberapa kontra indikasi
• Vaccination with live vaccines :
• Pregnancy
• Immunosuppression (chemotherapy,
Corticosteroids, HIV infection)
• Vaccination with all vaccines:
• Moderate or severe acute illness
• Recent receipt of an antibody-containing blood
product (MMR and varicella only)
 Adverse Events Occurring
Within 48 Hours of DTP Vaccination
Event Frequency
local
redness, swelling, pain 1 in 2-3 doses
systemic: Mild/moderate
fever, drowsiness, fretfulness 1 in 2-3 doses
vomiting
anorexia 1 in 5-15 doses
systemic: more serious
persistent crying, fever 1 in 100-300 doses
collapse, convulsions 1 in 1750 doses
acute encephalopathy 1 in 100,000 doses
permanent neurological deficit
1 in 300,000 doses
47
 Examples of types & frequency of AEFIs (in some
common vaccines)
Onset Rates per
Vaccine Reaction Interval million doses
Suppurative lymphadenitis 2-6 months 100 to 1000
BCG osteitis 1-12 months 1 to 700
BCG Disseminated BCG-it is 1-12 months 2
Hib Nil known
Anaphylaxis 0-1 hour 0 to 2
Hepatitis BGuillain-Barrè Syndrome (plasma derived) 1-6 weeks 5
Febrile seizures 5-12 days 333
Thrombocytopaenia 15-35 days 33
Measles/MMR Anaphylaxis 0-1 hour 1 to 50
OPV Vaccine associated paralytic polio (VAPP) 4-30 days 1.4 to 3.4
Persistent (>3 hrs) inconsolable crying 0 -24 hours 1000 to 60000
Seizures 0 - 3 days 570
Hypotonic, hyporesponsive episode 0-24 hours 570
Anaphylaxis 0 - 1 hour 20
DTP Encephalopathy 0 - 3 days 0 to 1
400 to 4000 (in
Post-vaccination encephalitis 7-21 days infants <6 m)
Yellow Fever Allergic/anaphylaxis WHO/V&B/AVI 0-1 hour 5 to 20
Jadwal imunisasi di U.S
Jadwal imunisasi di U.S
Jadwal imunisasi di U.S ( dewasa)
Ayo belajar
Thank you for your attention
“ selamat belajar”
 Pediatric Fundamentals

Growth and Development

Drs. Greg and Joy Loy Gordon

January 2005
Pediatric Fundamentals - Growth and Development
Maturational change in form and function

Prenatal Growth
Gestational age (wks) Mean birth wt (Gm)
25 850
28 1000
30 1400
33 1900
37 2900
40 3500

Postnatal Growth
Birth weight doubles by 5 months
triples by 1 year
Birth length doubles by 4 years
Pediatric Fundamentals - Growth and Development
Maturational change in form and function

Percent body water

Term newborn 80
1 year old 70
Adult 60

Surface area:Weight
premature > full term > infant > child
greater surface area
greater evaporative heat loss
rapid hypothermia if unprotected

Girls Boys
Puberty onset 11 years 11½ years
Peak growth Tanner stage 3 Tanner stage 4
 Pediatric Fundamentals - Growth and Development
Fluid requirements

Metabolism of one calorie of energy consumes one ml of H2O,

so fluid requirements thought to reflect caloric requirement:
Body weight (kg) Calories needed (kcal/kg/day) = Fluid requirement (ml/kg/day)
0-10 100
10-20 1000 + 50/(kg>10)
> 20 1500 + 20/(kg>20)

Dividing by 24 (hours/day) yields the famous

4:2:1 Rule for hourly maintenance fluid:

4 ml/kg/hr 1st 10 kg +
2 ml/kg/hr 2nd 10 kg +
1 ml/kg/hr for each kg > 20
Pediatric Fundamentals - Growth and Development
Airway/respiratory system

Gas exchange first possible approximately 24 weeks gestation

Surfactant production appears by approximately 27 weeks
produced of Type II pneumocytes
exogenous form available

Number (and size) of alveoli increase to age 8 years

(size only after 8 years)

First breaths of air

pneumothorax or pneumomediastinum less than 1%
several hours to reach normal lower lung fluid levels
some expelled during birth canal compression
transient tachypnea of newborn (TTN)
increased incidence after C-section
Pediatric Fundamentals - Growth and Development

Respiratory rate/rhythm
pauses up to 10 seconds normal in prematures
without cyanosis or bradycardia
Age (years) Normal Rate
1-2 20 - 40
2-3 20 – 30
7-8 15 - 25

Obligate nose breathing

especially prematures
able to mouth breath if nares occluded
80% of term neonates
almost all term infants by 5 months
Pediatric Fundamentals - Growth and Development

Airway differences – infant vs adult

epiglottis and tongue relatively larger
glottis more superior, at level of C3 (vs C4 or 5)
cricoid ring narrower than vocal cord aperture
until approx 8 years of age
4.5 mm in term neonate
11 mm at 14 years
 Pediatric Fundamentals - Growth and Development

Cardiovascular system
In utero circulation
placenta ->
umbilical vein (UV)->
ductus venosus (50%) ->
IVC ->
RA ->
foramen ovale (FO) ->
LA ->
Ascending Ao ->
SVC ->
RA ->
tricuspid valve ->
RV (2/3rds of CO) ->
main pulmonary artery (MPA) ->
ductus arteriosus (DA) (90%) ->
descending Ao ->
umbilical arteries (UAs)->
Pediatric Fundamentals - Growth and Development

Cardiovascular system

Transition to postnatal circulation

Loss of large low-resistance peripheral vascular bed, the placenta

(UV, UAs constrict over several days)
With first air breathing
marked drop in pulmonary vascular resistance with
greatly increased pulmonary blood flow
LA pressure > RA pressure
closes FO
Elevated PaO2 constricts DA
hours to days
Hgb F impairs postnatalO2 delivery
Higher newborn resting cardiac index
with decreased ability to further increase
Pediatric Fundamentals - Growth and Development
Cardiovascular system

Normal murmurs
up to 80% of normal children
vibratory Still’s murmur
basal systolic ejection murmur
physiologic peripheral pulmonic stenosis (PSS)
venous hum
carotid bruit
S3

Murmur only in diastole = abnormal

Pediatric Fundamentals - Growth and Development

Gastrointestinal notes

Gastric pH higher at birth; decreases over several weeks

Young infants
diminished lower esophageal sphincter tone
50% have daily emesis (usually remits by 18 months)
more show reflux if esophageal pH monitored
only 1 in 600 develop complications of reflux
Physiologic jaundice
Colic < 3 months
Umbilical hernia
common
frequently resolve spontaneously
Teeth
primary: 7 months to 2 or 3 years
permanent: 6 years to 20 years
Pediatric Fundamentals - Growth and Development

Renal system

Urine production begins first trimester

Newborn

GFR

low (correlates with gestational age/size in prematures)

rises sharply first 2 weeks

adult values by age 2 years

limited concentrating ability (600 vs adult 1200 mOsm/kg)

ability to dilute urine relatively intact

Pediatric Fundamentals - Growth and Development

Hematologic system

Infant Hgb F – higher O2 affinity

Hgb A production largely replaces Hgb F by 4 months

Hgb/Hct decrease to nadir at about age 2 months

exaggerated in prematures (low total body Fe stores)

Blood volume (ml/kg)

Prematures 105
Term newborn 85
Adult 65
Pediatric Fundamentals - Growth and Development

General pharmacotherapeutic note:

On a per kg basis compared to adults

Expect lower doses in infants and

Higher doses in children

Pediatric Fundamentals - Growth and Development

Neuro notes

Nervous system anatomically complete at birth

except:
Myelination
rapid for 2 years
complete by 7 years
Posterior fontanelle closed by 6 weeks
Anterior fontanelle closed by 18 months
Primitive reflexes disappear in few months
Pediatric Fundamentals - Growth and Development

Developmental pediatrics
History and physical notes

Newborn – pregnancy and delivery

Infancy – developmental milestones
Toddler – poor localization of symptoms and very suggestible
(e.g., pharyngitis or pneumonia presenting as
abdominal pain or distress)
Older child – involve in discussion/decision
Preadolescent and older – consider interview without parents
Exam
opportunistic approach in infants and young children
observation essential
distraction useful
Pediatric Fundamentals - Growth and Development
Pediatric Fundamentals - Growth and Development
 Pediatric Fundamentals - Growth and Development
Developmental pediatrics
Approach to patient depends on stage of development
Stranger anxiety 7 months 25%
9 50
12 75
Toddlers
magical thinking (belief that own thought or deed causes external events)
temper tantrums (aggravated if tired, ill, uncomfortable)
Toilet training
ability develops by 18 months
usually complete by 2 to 3 years (day before night)
bedwetting
15 - 20 % at 5 years with gradual decrease to
1% at 15 years
6 -11 years - concrete operations phase
can consider different points of view
develop explanation based on observation
beginning logical reasoning but still tend to dogmatic
11 and older - development of abstract thinking
Adolescent - increasing need for autonomy, participation in care
 Pediatric Fundamentals - Growth and Development

For more info regarding age-related preparation of the

pediatric patient for anesthesia see:

http://metrohealthanesthesia.com/edu/ped/pedspreop3.htm