Download IMMUNITY

IMMUNIZATION
PREPARED BY:
DR. SALMA ELGAZZAR
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Learning objectives
Define the following terms and understand their significance :
a. Active and Passive immunization
b. Booster immunization, toxoid and antitoxin
c. Killed, live and attenuated vaccine
.d. Conjugated and unconjugated vaccine
Discuss the indications for administration, appropriate dosage schedule, possible side effects
and contraindications for use of the commonly used vaccine
Describe the standard vaccination schedule for the Ministry of health and World health organization
Identify the indications of the less commonly used vaccines
.a. Meningococcal vaccination
.b. Rota Vaccination and RSV immunoglobulibn
c. Influenza virus vaccination
d. Rabies vaccine
.
Overview of the Immune Response
PASSIVE IMMUNIZATION
Passive immunity is the transfer of ready-made antibodies, from one
individual to another.
Passive immunity can occur naturally, when maternal antibodies
are transferred to the fetus through the placenta.
It is induced artificially:
when high levels of human (or horse) antibodies specific for
a pathogenor toxin are transferred to non-immune individuals.
INDICATIONS
Passive immunization is often used:
 When there is a high risk of infection and insufficient time for the body to develop its own immune
response.
 To reduce the symptoms of ongoing diseases or immunosuppressive diseases.
 In children who have weakened immune systems or may not be good candidates for routine
vaccinations for other reasons.
 It can be used with people who haven’t been vaccinated against a disease to which they’ve been
exposed.
 To treat poisoning.
For example
The passive rabies immunization (rabies immune globulin) is commonly used after a certain type of wild
animal bites a child.
Passive immunizations for hepatitis A (gamma globulin) may be helpful for people traveling to a part of
the world where hepatitis A is common. They are typically given before children or adults leave on their
trip. These are used less now that there is a vaccine for hepatitis A.
Artificially acquired passive immunity is a short-term
immunization achieved by the transfer of antibodies, which
can be administered in several forms:
• Human or animal blood plasma or serum.
• Pooled human immunoglobulin for intravenous
(IVIG) or intramuscular (IG) use.
• High-titer human IVIG or IG from immunized donors
or from donors recovering from the disease.
• Monoclonal antibodies (MAb).
FDA approved products for passive immunization and immunotherapy
DISEASE
PRODUCT
SOURCE
USE
Treatment of wound and food borne forms of
botulism,
infant botulism is treated with human botulism
immune globulin (BabyBIG)
Botulism
Specific equine
IgG
Horse
Cytomegaloviru
-s
(CMV)
hyper-immune
IVIG
human
Prophylaxis, used most often
in kidney transplant patients.
Hepatitis A
Measles
Pooled human
Ig
human serum
Prevention of Hepatitis A and measles infection,
treatment of congenital or
acquired immunodeficiency.
Hepatitis B
Hepatitis B Ig
human
Post-exposure prophylaxis, prevention in high-risk
infants
(administered with Hepatitis B vaccine).
human serum
Treatment of ITP and Kawasaki disease,
prevention/treatment of opportunistic infection
with IgG deficiency.
ITP, Kawasaki
Pooled human
disease and IgG IgG
deficiency
DISEASE
PRODUCT
SOURCE
USE
Rabies
Rabies Ig
human
Tetanus
Vaccinia
Tetanus Ig
Vaccinia Ig
human
human
Post-exposure prophylaxis
(administered with rabies vaccine).
Treatment of tetanus infection.
Treatment of progressive vaccinia
infection
including eczema and occular forms
(usually resulting from
smallpox vaccination in immunocom
promised individuals).
Varicella
(chickenpox)
Varicellazoster Ig
human
Post-exposure prophylaxis in high risk
individuals.
DISADVANTGES:


Immunity derived from passive immunization lasts for a few weeks or months.
There is also a potential risk for hypersensitivity reactions, and serum sickness, especially
from gamma globulin of non-human origin.
 Passive immunity provides immediate protection, but the body does not develop
memory, therefore the patient is at risk of being infected by the same pathogen later.
 Injection site reactions following receipt of standard human Ig include tenderness,
erythema and stiffness of local muscles, which may persist for several hours. Mild fever or
malaise may occasionally occur.
 Less common side effects following receipt of standard human Ig include flushing,
headache, chills and nausea.
 Urticaria, angioedema and anaphylactic reactions may occur rarely.
Botulism antitoxin (BAtx, equine) and botulism immune
globulin (BIG-IV, human)
Botulism antitoxin or botulism immune globulin is used
therapeutically in people with established or suspected
botulism .
Prophylactically in asymptomatic people strongly
suspected of having eaten food contaminated with the
botulism toxin.
Varicella zoster immune globulin (VarIg)
Varicella zoster immune globulin (VariZIG™) is a freeze-dried preparation of varicella zoster Ig prepared
from the pooled human plasma of screened donors with high titres of antibodies to varicella zoster virus.
VarIg is recommended for the prevention or reduction in severity of infection within 4 days (96 hours) of
the most recent exposure to the varicella zoster virus.
1. The exposed person is susceptible to varicella (except for recipients of HSCT).
2. There has been a significant exposure to a person with varicella or herpes zoster (HZ).
3. The exposed person is at increased risk of severe varicella including:
 Pregnant women
 Newborn infants of mothers who develop varicella during the 5 days before to 48 hours after
delivery
 Selected neonates in intensive care settings
 Immunocompromised persons (including those with HIV with CD4 cell count < 200 x 106/L or
CD4 percentage < 15%)
 Recipients of HSCT regardless of pre-transplant varicella immune status, history of varicella
disease or vaccination, or positive serologic test results
4. Post-exposure immunization with univalent varicella vaccine is contraindicated.
Hepatitis B post-exposure prophylaxis, recommendations for use of HBIg
Post-exposure prophylaxis
circumstance
Infant born to a mother with acute or chronic
hepatitis B infection
Percutaneous or mucosal exposure to blood or body
fluids potentially containing hepatitis B virus
Recommendations
•All infants born to infected mothers should be given an
IM dose of 0.5 mL HBIg as soon as possible after birth
(preferably within 12 hours) in addition to the first of a
three dose series of HB vaccine (premature infants
weighing less than 2,000 grams at birth require four
doses of vaccine). The efficacy of HBIg decreases
significantly after 48 hours, but HBIg may be given up
to 7 days after birth.
•HBIg should be given to susceptible individuals (based
on their immunization and antibody status, and the
infectious status, if known, of the source) within 48
hours after exposure1. Efficacy of HBIg decreases
significantly after 48 hours, but HBIg may be given up
to 7 days after exposure.
•Dose of HBIg for older infants, children and adults is
0.06 mL/kg of body weight IM
ARTIFICIALLY ACQUIRED ACTIVE
IMMUNIZATION
Artificially acquired active immunization
Artificially acquired active immunity can be induced
by a vaccine, a substance that contains antigen.
A vaccine stimulates a primary response against
the antigen without causing symptoms of the
disease.
VACCINATION
It is the administration of vaccines or toxoids that stimulate
the body immune system to produce antibodies and
cellular immune responses that protect against the
infectious agent.
A vaccine stimulates a primary response against the
antigen without causing symptoms of the disease.
WHY WE NEED VACCINES
For a few weeks after birth, babies have some protection from
germs that cause diseases.
This protection is passed from their mother through the placenta
before birth.
After a short period, this natural protection goes away.
Vaccines help protect against many diseases that used to be
much more common.
Examples include tetanus, diphtheria, mumps, measles, pertussis
(whooping cough), meningitis, and polio.
Many of these infections can cause serious or life-threatening
illnesses and may lead to lifelong health problems.
Because of vaccines, many of these illnesses are now rare.
TYPES OF VACCINES
LIVE, ATTENUATED VACCINES
INACTIVATED VACCINES
SUBUNIT VACCINES
TOXOID VACCINES
LIVE VACCINES
RECOMBINANT VECTOR VACCINES
DNA VACCINES
LIVE, ATTENUATED VACCINES
 Live, attenuated vaccines are composed of micro-organisms that
have been cultivated under conditions which disable their ability to
induce disease.
 These responses are more durable and do not generally require
booster shots. Examples include yellow fever, measles, rubella, and
mumps
 Examples of Live, attenuated bacteria vaccines include BCG and
typhoid oral vaccines.
INACTIVATED VACCINES
Inactivated vaccines are composed of microorganisms that have been killed with chemicals
and/or heat and are no longer infectious.
Examples are vaccines against flu, cholera, plague,
and hepatitis A.
Most vaccines of this type are likely to require
booster shots.
SUBUNIT VACCINES
Subunit vaccines are composed of small fragments
of disease causing organisms.
 A characteristic example is the subunit vaccine
against Hepatitis B virus.

TOXOID VACCINES
Are inactivated toxic compounds from microorganisms in cases where these (rather than the
micro-organism itself) cause illness, used prior to an
encounter with the toxin of the micro-organism.
Examples of toxoid-based vaccines include tetanus
and diphtheria.
Surface antigen (recombinant) vaccines.
It is prepared by cloning HBsAg gene in yeast cells where it is
expressed. HBsAg produced is then used for vaccine
preparations.
Their efficacy and safety also appear to be high.
Conjugate vaccine
 Conjugate vaccines are somewhat similar to recombinant vaccines: they’re made using a
combination of two different components.
 Conjugate vaccines are made using pieces from the coats of bacteria.
 These coats are chemically linked to a carrier protein, and the combination is used as a
vaccine. Conjugate vaccines are used to create a more powerful, combined immune
response: typically the “piece” of bacteria being presented would not generate a strong
immune response on its own, while the carrier protein would.
 The piece of bacteria can’t cause illness, but combined with a carrier protein, it can
generate immunity against future infection.
 Two important vaccines in child health care are the pneumococcal conjugate vaccine
(PCV) and the meningococcal conjugate vaccine (MCV).
 PCV is routinely used in many countries to prevent bacterial meningitis, pneumonia, and
related infections , it does not protect immunized children against all pneumococcal
bacteria. It only protects against seven of these.
 The meningococcal vaccine :
to protect children against a different strain of meningitis, which is caused by
a bacterium called meningococcus.
Live vaccines
 Live vaccines are made from live infectious agents without any
amendment.
 The only live vaccine is “Variola” small pox vaccine, made of live
vaccinia cow-pox virus (not variola virus) which is not pathogenic but
antigenic, giving cross immunity for variola.
Vaccine type
Vaccines of this type on U.S. Recommended Childhood (ages 0-6)
Immunization Schedule
Live, attenuated
Measles, mumps, rubella (MMR combined vaccine)
Varicella (chickenpox)
Influenza (nasal spray)
Rotavirus
Inactivated/Killed
Polio (IPV)
Hepatitis A
Toxoid (inactivated toxin)
Diphtheria, tetanus (part of DTaP combined immunization)
Subunit/conjugate
Hepatitis B
Influenza (injection)
Haemophilus influenza type b (Hib)
Pertussis (part of DTaP combined immunization)
Pneumococcal
Meningococcal
Vaccine type
Other available vaccines
Live, attenuated
Zoster (shingles)
Yellow fever
Inactivated/Killed
Rabies
Subunit/conjugate
Human papillomavirus (HPV)
Scheme of immunization
Primary vaccination
One dose vaccines (BCG, variola, measles, mumps, rubella, yellow fever)
Multiple dose vaccines (polio, DPT, hepatitis B)
Booster vaccination
an extra administration of a vaccine after an earlier (prime) dose.
After initial immunization.
a booster injection or booster dose is a re-exposure to the
immunizing antigen cell.
It is intended to increase immunity against that antigen back to
protective levels after it has been shown to have decreased or
after a specified period. i.e To maintain immunity level after it
declines after some time has elapsed (DT, MMR)
Recent schedule for Vaccination of Newborns in Saudi Arabia. Starting 2008.
Age at visit
At birth
2 - Months
4 - Months
6 - Months
9 - Months
12 - Months
18 - Months
Vaccines
•
•
•
•
BCG
HepB
IPV
[ DTP, HepB , Hib ]
•
•
•
•
•
OPV
[ DTP, HepB, Hib ]
OPV,
[ DTP, HepB , Hib ]
Measles ( mono )
• OPV ,MMR
• Varicella
• OPV
• DTP, Hib
• Hepatitis (A)
24 - Months
• Hepatitis (A)
4 - 6 Years
• OPV,DTP, MMR, Varicella.
ROUTES OF ADMINISTRATION
A vaccine administration may be oral, by injection
(intramuscular, intradermal, subcutaneous), by
puncture, transdermal or intranasal.
Several recent clinical trials have aimed to deliver the
vaccines via mucosal surfaces to be up-taken by
the common mucosal immunity system, thus avoiding the
need for injections.
Certain available vaccines and their routes of administration.
Vaccine
Type
BCG
Live attenuated Bacteria
DTP
D&T = Toxoids
Route
Intradermal (preferred)
Intramuscular
P = inactivated bacteria
Hepatitis B(HBV)
Subunit , recombinant
Intramuscular
Haemophilus
Influenza b
(Hib)
Polysaccharide
Intramuscular
MMR
Live attenuated viruses
BCG =
DPT =
MMR =
OPV =
Subcutaneous
Bacillus Calmette – Guerin vaccine (tuberculosis).
Diphtheria, pertussis and tetanus vaccine.
Live measles, mumps and rubella viruses in a combined vaccine.
Oral Poliovirus vaccines containing attenuated poliovirus types 1,2 and 3.
ADVERSE REACTIONS OF SOME VACCINES
Local reaction:
Irritation ,redness and swelling.
Systemic reaction:
Fever ,rash and allergy.
SPECIFIC REACTIONS:
 MEASLES VACCINE:
Fever (usually the nineth day), transient rash and arthralgia.
 Rubell vaccine:
Fever ,transient rash, transient lymphadenopathy and arthralgia.
 Mumps vaccine:
Mild parotid enlargement.
 BCG VACCINATION:
-persistent ulcer ,axillary lymhadenitis ,cold abcess and sinus formation.
- generalized tuberculosis in immunocompromised.
 PERTUSIS VACCINE:
- redness , pain and swelling locally , fever drowsiness and somnolence.
- convulsions , encephalopathy and shock. These side effects are extremely rare and non-existent with
acellular pertussis vaccine.
CONTRAINDICATIONS TO VACCINATION
 Live attenuated vaccine like BCG , OPV ,MMR and varicella should not be given to
immunocompromised infants and children or to their contacts.
CONTRAINDICATIONS TO PERTUSSIS VACCINE
1. Encephalopathy within 7 days of previous vaccination.
2. Convulsions or history of convulsions.
3. Persistent unusual cry.
4. Fever above 40.5 c
5. Shock or somnolence.
6. Allergy
The Cold Chain
The "cold chain" is a system of storage and
transport of vaccines at low temperature from the
manufacturer to the actual vaccination site.
The cold chain system is necessary because
vaccine failure may occur due to failure to store
and transport under strict temperature controls.
The Cold Chain Equipment
Cold chain equipment consists of the following:
(a) Walk in cold rooms: They are located at regional level,
meant to store vaccines up to 3 months and serve districts.
(b) Deep freezers (300 ltr) and Ice lined Refrigerators:
supplied to all districts and the WIC locations to store
vaccines. Deep freezers are used for making ice packs and
to store OPV and measles vaccines.
(c) Small deep freezers and ILR (140 ltr) : One set is provided
to PHCs, and Family Planning Centers
(d) Cold boxes: Cold boxes are supplied to all
peripheral centers. These are used mainly for
transportation of the vaccines.
(e) Vaccine carriers: Vaccine carriers are used to
carry small quantities of vaccines (16-20 vials) for the
out of reach sessions. 4 fully frozen ice packs are
used for lining the sides, and vials of DPT, DT, TT and
diluents should not be placed in direct contact with
frozen ice packs. The carriers should be closed
tightly.
(f) Ice packs: The ice packs contain water and no
salt should be added to it.
Among the vaccines, polio is the most
sensitive to heat, requiring storage at minus 20
degree C.
Vaccines which must be stored in the freezer
compartment are :
polio and measles.
Vaccines which must be stored in the cold
part but never allowed to freeze are :
typhoid, DPT, tetanus toxoid, DT, BCG and
diluents
Less commonly used vaccines

MENINGEOCOCCAL VACCINE
 There are meningococcal vaccines that help provide protection against five types (serogroups) of
meningococcal disease.
 Meningococcal vaccines cannot prevent all cases of the disease, but they do protect many people
who might become sick if they didn't get vaccinated.
FOR CHILDREN
 Meningococcal conjugate vaccine (MenACWY or Hib-MenCY-TT) is recommended for children 2
months through 10 years of age who are at increased risk for meningococcal disease as:

-Certain medical conditions.
-Traveling to a country with high rates of meningococcal disease.
 -An outbreak in their community.
 Booster doses may be recommended child remains at increased risk.
FOR PRETEENS/TEENS
 Meningococcal conjugate vaccine (MenACWY) is routinely recommended for all 11 through 18 year
olds.
 The first dose should be given at 11-12 years of age and a booster dose at 16 years of age
ROTAVIRUS VACCINE
 Rotavirus is a virus that causes diarrhea, mostly in babies and young children. The diarrhea can be
severe, and lead to dehydration.
 Two brands of rotavirus vaccine are available.
 2 or 3 doses, depending on which vaccine is used.
 Doses are recommended at these ages:
• First Dose: 2 months of age
• Second Dose: 4 months of age
• Third Dose: 6 months of age (if needed)
N.B. must get the first dose of rotavirus vaccine before 15 weeks of age, and the last by age 8 months.
 Rotavirus vaccine may safely be given at the same time as other vaccines.
 Almost all babies who get rotavirus vaccine will be protected from severe rotavirus diarrhea. And most
of these babies will not get rotavirus diarrhea at all. The vaccine will not prevent diarrhea or vomiting
caused by other germs.
 There is a small risk of intussusception from rotavirus vaccination, usually within a week after the 1st or
2nd vaccine dose
CONTRAINDICATIONS TO ROTAVIRUS:
 A life-threatening allergic reaction to a dose of rotavirus vaccine should not
get another dose.
 A severe allergy to any part of rotavirus vaccine should not get the vaccine.
 Babies with “severe combined immunodeficiency” (SCID) should not get
rotavirus vaccine.
 Intussusception
 Mildly ill can get the vaccine.
 Are moderately or severely ill should wait until they recover(includes babies
with moderate or severe diarrhea or vomiting.
 If immune system is weakened because of:
• HIV/AIDS, or any other disease that affects the immune system
• Treatment with drugs such as steroids
• Cancer, or cancer treatment with x-rays or drugs
INFLUENZA VACCINE
 Inactivated
 Egg grown
 Sub-unit vaccine for children
 INDICATIONS:
-Children who have chronic pulmonary or cardiovascular disorders, including asthma
-Children who have required regular medical follow-up or hospitalization during the
last year because of chronic metabolic diseases (including diabetes mellitus), renal
dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression
caused by medications)
- Children and teenagers (6 mths to 18 yrs) receiving long-term aspirin therapy - might
be at risk for developing Reye syndrome after influenza
-Children from 0-23 mths are at increased risk for hospitalization from influenza,
vaccination is encouraged for their household contacts and out-of-home caretakers,
particularly for contacts of children aged 0–5 months because influenza vaccines have not
been approved for use among children aged <6 months.
RABIES VACCINE
 Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal.
 Rabies vaccine is given to people at high risk of rabies to protect them if they are exposed. It can also prevent the
disease if it is given to a person after they have been exposed.
 Rabies vaccine is made from killed rabies virus. It cannot cause rabies.
 PREVENTIVE VACCINATION (NO EXPOSURE)
 International travelers who are likely to come in contact with animals in parts of the world where rabies is common.
 The pre-exposure schedule for rabies vaccination is three doses, given at the following times:
 Dose 1: As appropriate
 Dose 2: 7 days after Dose 1
 Dose 3: 21 days or 28 days after Dose 1
 VACCINATION AFTER AN EXPOSURE
 Anyone who has been bitten by an animal, or who otherwise may have been exposed to rabies, should clean the
wound first.

A person who is exposed and has never been vaccinated against rabies should get four doses of rabies vaccine one dose right away, and additional doses on the third, seventh and fourteenth days.
 They should also get another shot called Rabies Immune Globulin at the same time as the first dose.
 A person who has been previously vaccinated should get two doses of rabies vaccine - one right away and another
on the third day. Rabies Immune Globulin is not needed.
THANK YOU