RECENT ADVANCES IN

IMMUNIZATION

BY: Dr. Abdul Malik

MBBS, DCH, MCPS (PAEDS) M.D
Pediatric consultant
BETTER TO BE SAFE THAN
SORRY AFTERWARDS!

PREVENTION IS BETTER THAN CURE

WHAT IS IMMUNIZATION?
Immunization is the process of conferring increased
resistance (or decreased susceptibility) to infection.
 GOALS OF IMMUNIZATION

 IMMEDIATE :prevention of disease in individuals

 ULMITIMATE : eradication/ elimination of disease from the world

 National Immunization objectives and targets
To reach more than 90% coverage with 3rd dose of Pentavalent vaccine
among children under 1 year of age at national level and at least 80%
coverage in every district through routine immunization by 2025 and sustain
it.
FULLY IMMUNIZED CHILD
A fully immunized child is defined as a child who has
received at least BCG dose at birth, 3 doses of polio and 2
doses of inactivated polio vaccine, 3 doses of Penta, 3 doses
of pneumococcal vaccine and 2 doses of Rota, 1 dose of
Measles and Rubella (MR) vaccine before 12 months of
age.
ZERO DOSE CHILD
WHO/UNICEF definition: A child will be considered as
Zero Dose child who has not received Pentavalent 1
vaccine.
Defaulters: are those who started the routine Immunization
but failed to complete the schedule for whatever reason.
Missed opportunity for vaccination: refers any contact
with Health Services by an individual, child or person of
any age who is eligible for vaccination (e.g. unvaccinated
or partially vaccinated) but does not receive vaccine for
minor reasons including minor or moderate illnesses.
 EFFECTS OF IMMUNIZATION( US BASED DATA )

DISEASE SMALL POLIO MEASELS HAEM.INFLU

POX PARALYTIC ENZA
TYPE B

MORBIDITY 48164 16311 503282 20000

20TH CENTURY

MORBIDITY ZERO ZERO 43 22

2007

% DECREASE 100 100 >99 >99%

PARENTS CONCERNS ABOUT
IMMUNIZATION
Safety of immunization
Objections due to religious thoughts
Past experience or hear say
Disease would give better protection than vaccine
Combination vaccines given on one visit may have more
side effects
Cost
They should be counselled in detail, referred to different
literatures and websites like www.aapnews.org /
www.immunizationfo.org
Types of immunization
1. Active immunization
2. Passive immunization

ACTIVE IMMUNIZATION:
1. The administration of all, part of micro organism ,modified
product of that organism , resulting in an immunologic
response that mimics that of the natural disease but usually
present no or little risk for the recipient
It may provide life long protection ,partial protection or may
require administration at regular intervals.
PASSIVE IMMUNIZATION

It is the administration of preformed antibodies to recipients

It is available as
immunoglobulin, I/M
specific immunoglobulin ,
Immunoglobulin I/V
Indications are immunodeficiency states, ITP, Rabies
(rabies IG) Tetanus(TIG) Diptheria anti toxin & Tetanus
antitoxin
VACCINE HANDLING AND STORAGE

Transported/stored at recommended temperature

Live virus attenuated vaccine are heat sensitive and
destroyed at high temperature e.g MMR Rota Virus OPV
etc
Inactivated vaccine are cold sensitive but they are destroyed
by freezing e.g DPT IPV HiB Hep A & B etc.
SCHEDULING IMMUNIZATION

 Two programmes are available in our country

 Expanded Programme for immunization (EPI)

To achieve the universal immunization coverage leaving no one
behind to die from a vaccine preventable disease.
 Programme recommended by American Academy of
Pediatrics (AAP)
 Our vaccination programme is based on the combination of both
EPI and AAP programmes to suit our needs on national basis and
may be considered as EPI PLUS programme.
PROCUREMENT OF VACCINE
All EPI vaccines are procured at federal level on behalf of
provinces as pooled procurement system and further
distributed to the provinces according to their respective
share.
Procurement of vaccines is carried on annual basis.
Vaccines like BCG, OPV and Td are procured through
Federal government funds. Vaccines like measles, MR,
Pentavalent, PCV, IPV , TCV and Rotavirus Vaccine are
procured as country co-financing share with GAVI.
Other vaccines are imported by private importers.
TRENDS IN CHILD MORTALITY IN
PAKISTAN
Deaths per 1000 live births
Neonatal mortality 42
Infant mortality 62
Under-5 mortality 74
SIMPLE PROVEN SOLUTIONS
Exclusive breastfeeding for babies for first six months.
Vaccination
Safe drinking water and good sanitation
Frequent hand washing with soap
Good nutrition for babies aged 6 months to 2 years.
BREAST FEEDING PRACTICES IN
PAKISTAN
Exclusive breast feeding up to six months. 48.4%
Continued breast feeding at one year 68.4%
Continued breast feeding for two years 56.5%
 GUIDELINES FOR MAJOR VACCINES
BCG
Prepared from live attenuated M. Bovis
Method of administration
Natural course of BCG vaccine
Accelerated BCG response
Evidence of successful BCG vaccine
Protective efficacy
Adverse reaction like abscesses dissemenated fatal disease
& axillary adinitis
Contraindications include burns skin infections primary
and secondary immunodeficiencies
POLIO
Two types
1)inactivated polio virus IPV given parenterally I/M or S/C
2)live virus vaccine given orally OPV
OPV is easy to administer low cost and more effective
immunization
Inactivated Polio vaccine contains 1,2,3 polio strains and is
parenteral. Oral polio contains type 1 and type 3 strains.
Type 2 strain has been deleted from Oral vaccine as type 2
polio disease has been eradicated from Pakistan.
Two doses of IPV results in 95% and 3 doses results in 99-
100% immunity probably life long
Three doses of OPV give excellent antibody response
Adverse Effects of IPV
No serious side effect except the hypersensitivity to neomycin
streptomycin and polymyxin and can be given to
immunocompromised persons

Adverse Effects of OPV

OPV associated VAPP=1:750000 doses
Overall risk for VAPP =1:2.4 million doses
DIPTHERIA TETNUS AND PERTUSIS
IMMUNIZATION
DwPT and DaPT
Contains
1)Diptheria Toxoids
2 )Pertusis(killed whole cell/A cellular) and
3)Tetanus Toxoid
Schedule : 5 doses at 6, 10 and 14 weeks, 15-18 months and
4-6 years of age. over 7 years child should receive Tdap
 TETANUS
5 doses as mentioned above in the form of DTwP, DtaP, DT,
Tdap
Wound management
H/o Tetnus Toxoid (doses) Clean wound
Td/Tdap TIG all other wounds
Td/Tdap TIG

Less than 3 or unknown Yes No Yes Yes

More than 3 No No No No
Tetanus prophylaxis
TIG 250/500 units I/M regardless of age and weight
IVIG can be used if TIG is not available
ATS (equine Antitoxin Serum) is better avoided because of
anaphylaxis and serum sickness
Tetanus immunization with Tetanus Toxoids can be initiated
simultaneously
VACCINATION SCHEDULE FOR PREGNANT WOMEN
FOR PREVENTION OF NEONATAL TETANUS
Vaccine When to give Dose & Site Expected duration
of protection
Td1 First contact during 0.5 ml I/M injection None
pregnancy on upper arm
Td2 At least 4 weeks -do- 1-3 years
after Td1
Td3 At least 6 months -do- 5 years
after Td2
Td4 At least 1 year after -do- 10 years
Td3 or subsequent
pregnancy
Td5 At least 1 year after -do- Throughout
Td4 or subsequent productive years.
pregnancy
 All women during their 1st pregnancy shall be targeted for 2 doses of Td
vaccination through routine immunization
 The 2nd dose or any subsequent dose of Td vaccine (if due) preferably to be
given to a pregnant mother at least 2 weeks before delivery.
 After delivery, these women shall complete 5 doses of Td vaccination schedule
with remaining doses at appropriate interval irrespective of pregnancy.
 If a pregnant women has received 5 doses of Td according to above schedule,
there is no need of additional doses of Td during subsequent pregnancies
 Women entering reproductive age (>15 years) with documented evidence of
three valid doses of DTP or Td containing vaccines (e.g. DTP, Tetravalent,
Pentavalent vaccine) during childhood should resume the scheduled outlined
above Td3 onwards.
 Immunization with Tdap/Td is not contraindicated during pregnancy
 Adverse reaction with Tetanus Toxoids include Anaphylaxis GBS and
Brachial neuritis but are rare.
 PERTUSIS

5 Doses as mentioned earlier

DwPT contains whole cell killed Pertusis organism and is
immunogenic as well as reactogenic
Acellular pertusis contain two or more immunogens derived
from B-Pertusis, is equally immunogenic but less reactogenic.
Side effects
Whole cell vaccine Acellular vaccine

Local reaction more Much less

Systemic More Much less

Anaphylaxis 2 per milliopn Much less

Seizures 1:1750 doses Much less

HHE 1:1750 Much less

Temp 105F In 0.3%reciepients Much less

crying for more than 3 hrs 1% Much less

CONTRA INDICTIONS FOR DTaP
Anaphylactic reaction
Encephalopathy with in 7 days after reciept of Dtap
Progessive neurological disorder
HEPATITIS B VACCINE
HBV is produced by Recombinant DNA technology
3 doses of HBV (Engerix-B)10 microgram I/M 0,1 and 6
months upto age of 20 years. Over 20 years 20 microgram
I/M is needed
4 doses of HBV may be administered at birth zero dose is
given as monovalent vaccine and later combination of
vaccine is used to complete the series
Efficacy and duration of protection is 90-95% and immune
memory is intact for 20 years
INDICATION OF BOOSTER DOSES OF
HBV
 Patients on hemodialysis
 Immuno compromised
 Health workers & Regular Sex Contacts of HBsAg +ve people

MANAGEMENT OF NON RESPONDERS

Re immunization with additional 3 doses series
Persons who remain still anti-HBs negative are unlikely to respond to
additional doses.
POST IMMUNIZATION ASSESSMENT
Not required in routine.
Recommended for persons who need booster doses
Anti HBS (>10mIU/ml) is done 2-3 months after 3 rd dose of vaccine
MANAGEMENT OF BABIES BORN TO
HBsAg +ve MOTHERS
Safe delivery
Baby should receive HBIG 0.5ml I/M as soon as possible
but within 7 days of birth
Baby should be given 1st dose of Hep B vaccine if baby
weight is over 2 kg and if <1kg then after 1 month
Remaining doses of HBV can be given alone or in
combination
HEPATITIS A VACCINE
Inactivated Hep A given in 2 doses starting from 1 year
and 2nd dose 6 months to one year after 1st dose
Doses are 720 ELU 1 -18 year of age
And 1440 ELU 19 years and older
For post exposure prophylaxis(contact with near and dear
ones)
IG(0.02ml/kg) given within 2 weeks after exposure and is
effective upto 85% in preventing Hep-A upto 3 months
Twinrix a combination vaccine of Hep A and Hep B for
age 18 years and above
 MEASLES
Measles is an immunosuppressive disease associated with
chronic mortality, morbidity and serious complications
Measles vaccine is a live attenuated and is available as a
monovalant and also in combinations(MMR , MMRV)
Pakistan being endemic state for measles , recommendation for
measles are
1) measles at 9 months of age (MMR)
2)MMR/MMRV at 15 months and at 4-6 years of age
Serum antibodies develop in 95% if MMR given at 12 months
and 99% if given at 15 months of age
Adverse effect are
Fever 5-15%
Transient rash
Thrombocytopenia
Encephalitis <1/million doses
For prevention of measles to close contacts IG 0.25 ml /kg can
be given and for immuno compromised persons 0.5ml/kg can be
given.
Persons who receive IG Active immunization with measles
should be delayed for 5-6 months.
 VARICELLA VACCINE
Contains live attenuated vaccine as a monovalent and also a
part of MMRV
Dose is 0.5ml/s/c
1st dose at 12-15 months and 2nd dose 4-6 years (minimum
interval between 2 doses is 3 months)
Single dose efficacy is 70-90% against infection and 95%
against serious infection. Recipients of 2 doses are 3.3 fold less
likely to have break through infection. Duration of immunity is
20 yrs or more.
Vaccine is safe and reactions are mild.
Hemophilus Influenza type B (Hib)
Hib conjugated vaccine consist of capsular polysaccharide and
Tetanus toxoid to make immunogenic at the age of 6 weeks and
is called conjugated vaccine.
3 doses given at 6, 10 and 14 weeks of age (minimum 2 doses
interval being 1 month), 4th dose at 12-15 months
Doses 0.5ml/IM
In patients with sickle cell disease , leukemia, HIV infection,
patients with splenectomy one dose of HIB vaccine may be
given after age of 5 years.
PNEUMOCOCCAL VACCINE
Streptococcal pneumonia causes invasive bacterial infection
like pneumonia empyema AOM meningitis etc
110 serotypes of pneumococci are identified
Two types of vaccines
1)pneumococcal conjugate vaccine (PCV) which is
immunogenic from the age of 6 weeks and onwards and is
administered at 6,10 and 14 weeks and a booster is needed
at 15-18 months of age.
2)pneumococcal polysaccharide 23 valent vaccine which is
immunogenic after the age of 2 years(PPSV23) is also
available
Pneumococcal conjugate vaccine is available as 13 valent
serotypes(Prevenar13)
Primary series consists of three doses at 6,10 and 14 weeks of
age and a booster at 12-15 months of age
Conjugate vaccine is recommended upto the age of 17 years
and all persons above 50 years.
Doses 0.5ml I/M
 PCV Q13 (CONJ) VERSUS PPSV23(PR
POLYSACCHARIDE VACCINE
PCV13(CONJ) PPSV23(PR.POLYSACCHA
RIDE VACCINE)

DURATION OF IMMUNITY definite Unknown, likely to be short

IMMUNOLOGIC yes no
MEMORIES

BOOSTER EFFECT WITH yes no

SUBSEQUENT DOSES

NASOPHARYNGEL yes no
EFFECT(HERD
IMMUNITY)
 ROTA VIRUS VACCINE
 Incidence is 28-30% of all diarrheal diseases
 7 distinct groups are recognized A-G
 Group A virus -major cause
 Previously Rota virus vaccine was associated with intussusceptions so it
was withdrawn (RotaShield)
 In 2008 a live oral human attenuated rota virus vaccine has been
introduced as a two dose vaccine (Rotarix)
 For children less than 2 years of age 2 doses of Oral Rota vaccine are
recommended with at least 4 weeks interval between each dose. However,
for children above 2 years of age Rota vaccine is not recommended.
 3 dose rota vaccine (Rota Teq) is not available and carries no additional
benefits.
 TYPHOID VACCINE
 Effective 50-70%only
 TAB vaccine can be given at age of 6 months
 3 doses are needed at 1-2 weeks interval (not in use now because of severe
local and side effects)
 ViCPS (Typhim or Typherix) is a polysaccharide vaccine given I/M at 2 years
of age as single dose and provides immunity for 2 years.
 Ty21 A is live attenuated vaccine replicates in gut. This vaccine consists of 4
doses given by mouth on empty stomach with a glass of water on alternate
days.
 It should not be used in acute gastroenteritis
 Antibiotics should not be used 1 day prior and 7 days after 4 th dose of vaccine
 Should not be used in immuno-compromised patients
 Now conjugated typhoid vaccine (TCV) is available and is given at 9 months
of age as a single dose I/M even if the child is above 1 year of age single dose
of TCV is sufficient, provides immunity for 3 years.
HUMAN PAPPILOMA VIRUS
Produce benign epithelial proliferation(warts) of skin and mucous
membranes
Also associated with anogenital dysplasia and cancers
HPV VACCINE is available as bivalent serotypes 16 & 18
(Ceravarix) quadrivalent(HPV4 types 6,11,16,18) vaccines
(Gardisil) is available
9 valent HPV vaccine is also available
3 doses starting from age of 9 years. upper age limit is 26 years. It
should preferable be given before marital status.
Dose is 0.5 ml I/M 2nd dose 2 months after 1st dose and 3rd dose 6
months after 1st dose.
Cervarix (bivalent HPV 2 for type 16,18). Females only
Gardisil can be given to either sex.
99% is immunogenic and has efficacy against cervical, vulvar,
 INFLUENZA
Very common disease
Associated with fevers chills headache myalgia and cough
often super added by bacterial infection
Occasionally febrile seizures and encephalitis
Influenza virus is of 3 types (A,B,C). Epidemics is caused by
type A and B and both are included in influenza vaccine. Type
C causes mild and sporadic disease and is not included in
vaccine
Circulating Human Influenza A subtypes include H1N1 H1N2
and H3N2 viruses
Diagnosis (1) Nasal swab for antigen detection (2) PCR (3)
Viral culture which takes 2-6 days.
Seasonal epidemics
Are caused by minor antigenic variations within influenza
A and B virus and are called antigenic drift
Pandemics are caused by major changes in influenza A
virus and are called antigenic shifts
Types of vaccines
Two types
Live attenuated influenza vaccine contain 3 virus strains
A(H3N2),A(H1N1)and B. it is used above 2 years through
intranasal route
May increase wheezing and may not be used in asthma and
immuno-compromised patients
Trivalent inactivated influenza vaccine is available with the
names of Vaxigrip, Agrippal, Fluarix and this vaccine is
used in Pakistan.
 SCHEDULE FOR TIV VACCINE

AGE DOSE(ml) NO. OF DOSE ROUTE

6-35 MONTHS 0.25 2 I/M

3 THROUGH 8 0.5 2 I/M

YEARS

9 YEARS OR OLDER 0.5 1 I/M

SUBSEQUENTLY YEAR ONLY DOSE IS

EACH ONE REQUIRED
 Timings for vaccine is October to January
Indications
1)All children 6 months to 18 years,
 2)household contact and children caretakers
Indications for persons 19 years of age and above
Imuno-compromised states
Hemoglobinopathies
Chronic pulmonary and cardiac diseases
Chronic renal disease and metabolic diseases
Patient on long term salicylate therapy
All persons above 65 should be vaccinated once a year.
MENINGOCOCCAL DISEASE AND ITS
PREVENTION
Neisseria meningitidis cause meningitis, bacteremia and
bacteremic pneumonia.
Meningococcal disease develops rapidly and results in high
morbidity and mortality.
Quadrivalent meningococcal polysaccharide protein
conjugate vaccine provides protection against
meningococcal subgroups A,C,W and Y is available.
Inj. Menactra before 2 years of age is given 2 doses 3
months apart. After 2 years of age single dose is enough.
SIDE EFFECTS:
Mild, loss of appetite, irritability, drowsiness, headache,
swelling, pain, fever, redness at the site of injection and
tiredness.
THANK YOU