6 Immunization 2009

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immunizationMei Neni Sitaresmi

Pediatric Dept.

Faculty of Medicine, GadjahMada University


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introductionInfectious diseases morbidity & mortality

in infant/ children, some of them arevaccine 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 is the only host, all children are protected at

the same time interrupt transmission

Elimination : neonatal tetanus


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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 immuneresponse)


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Specific: adaptive Passive :

Protection transferred from another person oranimal as antibody (Ig G)

Temporary protection that wanes with timeMaternal antibody, HBIG, immunoglobulin, ATS, ADS

Active: Protection produced by the person's own immune system

Usually permanent

natural infection

vaccination


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immune respond


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Vaccination:

immunity and immunologic memory aresimilar to natural infection but withoutrisk of disease

(Immunogenicity, Reactogenicity)

Classification contains of vaccine:live attenuated vaccine:Inactive vaccine

Classification Program:EPI (expanded program immunization): BCG,Hepatitis B, DPT, Measles, polio vaccine

Non EPI: Hep A, Hib, varicella, MMR, typhoid,influenza, meningococcal, pneumococcal, HPV


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Live and inactive vaccine

Live attenuated vaccine Must replicate to be

effective severe reactions possible

immunodeficiency ,pregnant

immune response is similarto natural inf

interference fromcirculating antibody

Inactive vaccines Cant replicate: save in

immunodeficiency

generally is not as effectiveas live vaccines titer fall over time

require 3-5 doses minimal interference from

circulating Ig


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Live attenuated

vaccine unstable : carefully

handle : 2-8 C, freeze Oral, intra dermal,

subcutan Viral: MMR, OPV,

varicella, yellowfever, influenza

bacterial : BCG, oraltyphoid.

Inactive vaccines

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


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The consideration on Basicimmunization 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 associatedcomplications

Programme feasibility

recommendation: the youngest age group at risk for developingthe disease

Develop an adequate antibody response

Without adverse effects


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Issues regarding spacing and timing ofvaccine

General rule: In-active vac. generally arent be affected

by CA

live attenuated may be affected by CA: there arent contraindication tosimultaneous administration of any vaccine


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Interval between doses of thesame vaccine: Increasing the interval doesnt

diminish the effectiveness of thevaccine. It isnt necessary to restart

the series of any vaccine due toextended interval between doses (except oral typhoid)

Decreasing the interval may

interference with Ig response andprotection.


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Antibody and live vaccine

Live vaccine is given first, wait 2weeks before giving IG

IG is given first, wait > 3 months

before giving vaccine.2 live vaccine: minimum interval 4

weeksLive oral vaccine may be given at any

time before and after live inj. Vac.


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Contra indications and precautions

Permanent : severe allergy/ adverse reaction to prior

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

seizure

temporary: live vaccine:

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

moderate/ severe acute illness


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Invalid contraindications to vaccine

Mild illness with or without low grade fever Low or moderate reaction/ fever aftervaccination

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


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Vaccine adverse reactions

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

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

systemic: fever, malaise, headache live vac.: symptoms similar to mild case of diseases, occur

after incubation period

allergic due to vaccine, component or an unrelated environmental

allergen ? rare, can be minimized by screening


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Jadwal DEPKES

BCG =0-12 bulan

Hep B (uniject)= 0-7 hari

DPT-Hep B= 2,3,4 bulanOPV= 0,2,3,4

IPV*= 2,3,4 and 9 bulan

Campak= 9 bulanBoster= SD (campak dan DT)


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Potensi vaksin

Produk biologi yang rentan terhadap kehilanganpotensi bila penangannanya tidak baik

Sekali rusak, potensi hilang, irreversibel

Pemeriksaan fisik/ mata tidak dapat mendeteksikerusakan Penyimpanan/ transportasi: rantai dingin Potensi:

Kadaluwarso

Test kocok (DPT/DT/TT) VVM (Vaccine vial monitor) Warna (polio)


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penyimpanan

Polio: - 20 C : 2 tahun 2-8 C: 6 bulan, bila telah dibuka : 7 hari Tutup: jangan di frezer, pecah

BCG:

Serbuk: 2-8 C, lebih baik beku Pelarut: ruang/ kulkas pintu Dilarutkan : 3 jam

DPT/ DT/ TT; Hib Jangan sampai beku, rusak test kocok 2-8 C

Campak/ MMR/ varicella Serbuk : < 8 C, lebih baik -20 C Pelarut nggak boleh beku

Setelah dilarutkan 2-8 C, maksimum 8 jam


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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)


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OPV

cheap, easy to administer

Live attenuatted

IgG & IgAs, intestinalimmunity interupst wildvirus transmition

polio eradication

Can be neurovirulent vaccine-associatedparalytic poliomyelitis(VAAP)

vaccine derived poliovirus (VDPV)

IPV Expensive, need skill

person inactive Ig G

Safer not causeVAAP and VDPV Can be given to

Immunodeficiency child Consideration:

High coverage > 90 % Good surveillance of AFP No wild virus 3 years


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Primary immunization: 4 doses of OPV are given at birth, followed by 6, 10and 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


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BCG

a live vaccine prepared from attenuatedstrains of Mycobacterium bovis

WHO recommends countries with high

incidence of TB: universal BCGimmunization, a single dose at or soonafter birth

0,05 ml, intracutaneously


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Contraindications andPrecautions

BCG should not be administered to personswhose 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 asymptomaticHIV-infected children in populations withhigh TB risk)


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Efficacy, Reactogenicity, ComplicationsBCG Vaccine

Efficacy: two meta-analyses of published clinical trialsand case-control studies concluded that BCG provides80% protection against miliary and meningeal TB inchildren; clinical efficacy in preventing pulmonary TB hasranged from zero to 80% protection

Duration of protection: valid data missing

Reactogenicity and complications1-2% local adverse reactions, e.g., abscess, lymphadenopathyisolated reports of complications (osteitis, disseminated BCG)


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DPT Contains:

Diphtheria toxoid and Tetanus toxoid are aformaldehyde-inactivated preparation of diphtheria/tetanus toxin, adsorbed onto aluminium salts toincrease its antigenicity;

whole-cell-pertussis vaccine (DTwP ) or acellularpertussis vaccine (DTaP)

Primary immunization: 3 doses, the first dose at 2months, 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 onDTwP or DTaP and including additional Hib and/or IPV,and/or Hep B components) increases both in developed

and developing countries


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Immunogenicity, Efficacy DPT

Dipteria:

Duration of immunity after primary and booster immunization:at least 10 years

Efficacy: about 90%; if disease occurs in fully immunizedpersons 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%


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Contraindications and Precautions DPT Severe allergic reaction to vaccine component

Severe reaction following prior dose: temperatureof 40.50C or hypotonic-hyporesponsive episode orpersistent crying 3h within 48h; convulsions within3 days

Moderate or severe acute illness

Adverse events DPTSystemic:

fever (Common in DTwP, rare in DTaP)Rare: hypotonic-hyporesponsive episode, convulsions,shock

Local:

Swelling, pain, redness


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3 doses, the interval of 1-2 doses at least 4 weeks, the 3 dose isgiven 6 monts after the first dose

in countries where perinatal transmission is important, the firstdose of vaccine should be given at birth :

the younger the age at infection, the higher the chance of becaminga 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

HBsAg+ and HBeAg- status of mothers results in 20% infected newborns, and 90% of infected infants become chronic carriers

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

Hepatitis B


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Immunogenicity, Efficacy, Reactogenicityof HB vaccine

In healthy persons, the duration of immunity afterprimary 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 consideredthe first anti-cancer vaccine (prevention of primaryliver cancer)

Reactogenicity and side effects

3-20% minor local reactions, particularly pain at injection site mild systemic reactions (-20%) true complications are very rare


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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 ofage 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)


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Contraindications andPrecautions

Severe allergic reaction to vaccine component orfollowing prior dose

Moderate or severe acute illness Pregnancy

Immunosuppression

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


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Immunogenicity, Efficacy, ReactogenicityMeasles 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 scheduleand achieving high coverage (95%) brought measlesclose to elimination

Reactogenicity and complications: 5-15% fever; 5% rash


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Basic Hib Immunization

Schedule for Infants/ToddlersDose Age Interval

Primary 1 2 months -

Primary 2 3-4 months 4 weeks

Primary 3 4-6 months 4 weeks

Primary 4 2nd year of life 6 months

Hib immunization could be initiated as early as 6 weeks of age

Children 15 -59 months receive only 1 dose; generally Hibimmunization not recommended for children >59 months of age


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Vaksin Influenza

Ada 2 macam: Virus inaktif (suntikan) & hidup

(hidung) Bahan lain: telur, neomisin, formaldehid

Tiap tahun strain bisa berbeda Vaksinasidiulang 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

V k in H p titi A


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Vaksin Hepatitis A

Virus inaktif Indikasi : anak umur > 2 thn

endemis sering transfusi, Penderita hepatitis B

panti asuhan 2 kali, selisih 6 bulan

Indikasi kontra demam, infeksi akut hipersensitif thdp komponen vaksin

Intramuskular, jangan dipantat


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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


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Vaksin kombo

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6 Immunization 2009