PEDIATRICS 1
Midterm Exam
BLACK: Slides | BLUE/ITALICS: Audio | RED: EMPHASIZED
IMMUNIZATIONS
EXPANDED PROGRAM ON IMMUNIZATION (EPI) – covers 1 y/o & below
 1974 (WHO)
 They wanted to make sure that ALL children have access to all of the
routinely recommended vaccines.
 It used to just be the 4 CORE vaccines: BCG, DPT, Polio, & Measles.
 Coverage went from as low as <5% up to 84% with the institution of the EPI.
It has evolved since then.
 We now have a Philippine version of the EPI. It began in 1979 and was
revised in 1986 to conform with the UN goal of “Universal Child
Immunization by the year 1990.”
 Major strategies of Philippine EPI:
o High Fully Immunized Child (FIC) coverage of 90%
o To sustain a polio-free country for global certification (1979.
Already achieved in year 2000.
o Elimination of measles by 2008 (Problem now are the outbreaks)
o Elimination of Neonatal Tetanus by 2003
 FIC: 1 dose of BCG, 3 doses of DPT, 3 doses of Oral Polio, 3 doses of Hep B., &
a dose of Measles vaccine by the time they reach 12 months of age. This was
the initial goal. This has evolved over time with government.
 Now: BCG given at birth or any time after birth (single dose, ID), DPT & Oral
Polio vaccine (given at 6 weeks of age first, so remember there are three
st
doses. And they are given 4 weeks apart), Hep B (1 dose at birth &
subsequently given 2 other doses 4 weeks apart), MMR
• Bacillus Calmette-Guerin (BCG)
o Oldest of vaccines currently used throughout the world
o Live vaccine prepared from attenuated strains of
Mycobacterium bovis
▪ Immunocompromised patients not allowed to
receive live attenuated vaccines
o “It’s the only live attenuated vaccine given intradermally”
o “It’s given as early as possible after birth. or within the first 2
months of life. BCG protects against extra-pulmonary and
disseminated forms of tuberculosis. It doesn’t really protect
(8M) Preventive Pediatrics: Part 4
Dr. Elizabeth Gallardo | March 29, 2016
against primary pulmonary TB but against the most severe
forms.
o Dose:
▪ 0.05 mL for infants <12 months of age
▪ 0.1 ml for children >12 months of age
• Hepatitis B Vaccine
o Given Intramuscularly (IM)
o The first dose is given within 12 hours of life (birth dose).
o “So BCG and Hep B vaccine, given after birth.”
o “Hep B is the best way for you to protect against carriage
especially if we don’t know the immune status of the
mother”
o The Hep B birth dose may be used as the first dose in a 3-
dose primary series. Doses are given at least 4 weeks apart
o The final dose is administered not earlier than 24 weeks of
age. Otherwise, another does is needed before 1 year of age.
“If the final dose is administered in a baby who’s less than 6
months of age, usually this is the one that is not associated
with long lasting immunity. So you have to give a 4th dose
before 1 year of age. Otherwise, you can delay your third dose
to six months of age.”
o For infants born to HBsAG (+) mothers, administer HBV
(active immunisation) and HBIG (passive immunisation) 0.5
ml within 12 hours of life
o HBIG should be administered not later than 7 days of age if
not immediately available. “Why? because by then since you
have already given you vaccine,and you vaccine would have
started to trigger formation of Ab?”
• Diphtheria-Tetanus-Pertussis (DTP) Vaccine
o One of the first combined vaccines to become available
o Available as either of the following
▪ DTwP (diphtheria toxoid, tetanus toxoid and
inactivated whole cell pertussis vaccine)
▪ DTaP (acellular Pertussis component)
 • Contains pertussis toxin, filamentous
hemaglutinin, pertactin and fimbrial
antigens
• Got the portion of organism that increases
immunogenicity but less reactivity
• Less side-effects
o Given Intramuscularly (IM)
o Primary series consists of 3 doses given at a minimum age of
6 weeks with a minimum interval of 4 weeks
o 4th dose (Booster 1) – given at 18 months but may be given
as early as 12 months provided there is a minimum interval
of 6 months from the third dose. “So you can follow a 6, 10,
14 weeks schedule or 2, 4, and 6 months schedule. The you
give a booster at 1 year old or 1 year and six months of age”
o 5th dose (Booster 2) may be given before school entry at 4-6
years old
o 6th dose (Tdap) may be given at 10 years old onwards
(Booster 3)
▪ Consists of Reduced dose of diphtheria toxoid
combined with pertussis component
o Pertussis component
▪ Not recommended after 6 years of age because of
increased risk of neuroparalytic reactions
▪ Not a contraindication if you give the acellular type
o Adverse reactions to whole cell pertussis vaccine include:
use acellular if with ADRs
▪ Collapse or shock-like state (hypotonic-
hyporesponsive episode)
▪ Persistent screaming
▪ Fever >40 deg C
Convulsions
▪ Alteration in consciousness
▪ Other neurologic symptoms
• Poliovirus vaccine
o 2 forms of vaccine are available
▪ Live attenuated trivalent oral polio vaccine (TOPV or
Sabin vaccine)
• Per orem (orally)
▪ Enhanced inactivated polio vaccine (eIPV or Salk
vaccine)
• IM
• Salk = killed
o Primary series consists of 3 doses given at minimum age of 6
weeks with a minimum interval of 4 weeks plus 2 additional
doses at 18 months and 4-6 years
o “Polio 2 has been already eradicated so we’re now shifting
from a trivalent to a bivalent polio vaccine”
o Advantages of OPV
▪ Ease of administration
▪ Confers better intestinal immunity reduces spread
of wild virus in the community
o Contraindications for use of OPV use IPV instead
▪ Persons with altered competence who are
unimmunized or partially immunized
▪ Household contacts of an immunocompromised
patient
• Can be transmitted to feco-oral
▪ Unimmunized adults at future risk of exposure to
poliomyelitis who have been partially immunized
with IPV or OPV
▪ Adults at future risk of exposure to poliomyelitis
who have had a primary series of IPV
• Haemophilus Influenzae Type B Conjugate Vaccine (HiB)
• Consists of HiB capsular polysaccharide linked to carrier proteins
(e.g Diptheria toxoid, tetanus toxoid and meningococcal group B
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outer membrane protein)
• Given intramuscularly (IM)
• Given as a 3 dose primary series with a minimum age of 6 weeks
with a minimum interval of 4 week (6, 10 14 weeks or 2, 4, 6
months)
• “Give a booster dose at 12- 18 mos of age or with an interval of 6
mos from the third dose. And if the child is not immunised and is
more than 5 years of age but is immunocompromised, then the child
need conjugate vaccine from the capsulated organism”
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• Pneumococcal Vaccine
o Given Intramuscularly (IM)
o Can be co-administered with other vaccines, but with
separate syringes and at different sites of injection
o than 32 weeks of age
2 Types
▪ Pneumococcal conjugate vaccine (PCV10, PCV13)
• Minimum age is 6 weeks given IM
• Given as a 3-dose primary series with a
minimum age of 6 weeks, with an interval of
at least 4 weeks between doses plus a
booster does given 6 months after the third
dose.
• Healthy children 2-5 years old who have no
previous PCV vaccination may be given 1
dose of PCV 13 or 2 dose of PCV 10 at least 8
weeks apart. “Catch up vaccine"
• Routine use of PCV is NOT recommended for
healthy children 5 years and above
▪ Pneumococcal polysaccharide vaccine (PPV23)
• Minimum age is 2 years old
• Includes 23 purified capsular polysaccharide
antigens
• Recommended for high risk children > 2
years old (e.g. Sickle Cell Dse, functional or
anatomic asplenia, HIV infection, chronic
illnesses and other immunocompromising
conditions) in addition to PCV
• For healthy children, no additional doses of
PPV are needed if PCV series are completed
• Rotavirus Vaccine
o Given per orem (orally)
o 2 types
▪ Monovalent human rotavirus vaccine (RV1)
• Given as a 2 dose series beginning at 6
weeks of age with the 2nd dose administered
not later than 24 weeks of age
▪ Pentavalent human bovine rotavirus vaccine (RV5)
• Given as a 3 dose series with the 1st dose
given between 6 weeks to 14 week and 6
days and the 3rd dose administered not later
o Minimum interval between doses is 4 weeks
o “Earliest age: 6 weeks. Max age- 32 weeks. Why? The
incidence of intussusception usually corresponds to age
group of 8 months or 32 weeks. So if you give it to patients
more than 8 months, the vaccine might be blamed as the
cause of intussusception.”
• Influenza Vaccine
o “2 types: trivalent (2 Influenza A virus and 1 B) and
quadrivalent (2 A and 2 B)”
o Given IM or SQ to all children from 6 months to 18 years old
except for quadrivalent that is purely given IM
▪ New: live attenuated Influenza vaccine given
Intranasally
o Annual vaccination is recommended preferably (start
February but can be given all through out the year)
o Children 6 months to 8 years receiving the influenza vaccine
for the first time should receive 2 doses separated by at
least 4 weeks.
o Children 9 years and above even if it’s the first time, will
receive single doses
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• Measles Vaccine
o Given Subcutaneously (SQ) at 9 months of age due to high
incidence of measles in infants <1 year old in the Philippines
▪ Other countries: 1 year old
o May be given as early as 6 months of age in cases of
outbreaks as declared by public health officials
o In lieu of monovalent measles vaccine, MMR may be given if
recommended by public health authorities
▪ Increase in number of highly transmissible diseases
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 o Presence of transplacentally transferred maternal
antibodies in infants <1 year old interferes with effective
immune response to the vaccine
o Children who receive a dose of measles containing vaccine at
less than 12 months of age should be given 2 additional
doses beginning at 12 through 15 months of age, separated
by at least 4 weeks (preferably MMR)
• Measles, Mumps, Rubella (MMR Vaccine)
o Combined live , attenuated vaccine given subcutaneously
(SQ)
o Minimum age is 12 months
o A 2nd dose is administered at 4 to 6 years or at an earlier age
provided that the interval between the first and second dose
is at least 4 weeks. “It’s not considered a booster dose, but a
second dose to cover the possibility of vaccine failure”
• Varicella Vaccine
o Live attenuated vaccine given Subcutaneously (SQ)
o The first dose is administered from 12-15 months old
o The second dose is administered at 4-6 years or at an earlier
age provided the interval between the first and second
dose is at least 3 months
o Children >13 years and without previous evidence of
immunity should receive 2 doses given at least 4 weeks
apart
• Measles, Mumps, Rubella, Varicella Vaccine (MMRV)
o Given Subcutaneously (SQ)
o May be given as an alternative to separately administered
MMR and varicella vaccine for healthy children 12 months-
12 years of age.
o A second dose is administered at 4-6 years or at an earlier
age provided the interval between the first and second dose
is at least 3 months
• Hepatitis A Vaccine
o Given Intramuscularly (IM)
o Given as a 2-dose series at a minimum age of 12 months,
o A second dose is given 6-12 months after
• Japanese Encephalitis Vaccine
o Live attenuated vaccine
o Given subcutaneously (SC)
o Given at a minimum age of 9 months
o Children 9 months to 17 years old should receive one primary dose
followed by booster dose 12-24 months after the primary dose
o Individuals 18 years and older should receive a single dose only
• Tetanus and Diphtheria Toxoid (Td)/Tetanus and Diphtheria Toxoid
and Acellular Pertussis (Tdap)
o Given Intramuscularly (IM)
o In children who are fully immunized (5 doses of DTaP or 4
doses of DTaP if the 4th dose was administered on or after
the 4th birthday), Td booster doses are given every 10 years
o Children and adolescents 7-18 years of age who are not fully
immunized with DPT vaccine should be given a single dose of
Tdap. The remaining doses are given as Td. “Children more
than 6 do not need the pertussis anymore”
o Children and adolescents 7-18 years of age who have never
been immunized with DPT vaccine should be given the 3-
dose series of tetanus containing vaccine using the 0-1-6
months schedule
o A single dose of Tdap is given, preferable as the first dose
8M PEDIATRICS1: Preventive Pediatrics Part 4 
and the remaining doses are given as Td\
o For pregnant adolescents give the vaccine anytime after 20
weeks AOG
• HPV Vaccine
o Given Intramuscularly (IM)
o Given as a 3 dose series with a minimum age of 9 years. “we
give it as early as 9 years old para nagmomount na sila ng
immune response before they get exposed to the virus”
o 2 types
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 ▪ Bivalent HPV vaccine (16, 18-) 70% of HPV and Vaccine Minimum Number of Minimum Route Site
cervical Ca age at 1st doses Interval
• Given at 0, 1 and 6 months dose between
▪ Quadrivalent vaccine (16, 18, 6, 11)- 6 and 11 doses
serotypes cause genital warts
• Given at 0, 2 and 6 months MMR 12 months 2 At least 4 SQ Upper outer
o Alternative schedule for girls 9-14 years old (for females weeks portion of the
only) arms
▪ 2 doses at 0,6 months Haemophi 6 weeks 3 At least 4 IM Vastus lateralis
o Use of quadrivalent HPV vaccine in males 10-18 years of age lus weeks
for the prevention of anogenital warts. Influenzae Booster: 1
Type B
• Dengue Vaccine Conjugate
o Live attenuated tetravalent vaccine given subcutaneously (SC)
o Given as a 3-dose series 6 months apart at 0,6 and 12 months Rotavirus 6 weeks RV1: 2 At least 4 Oral Mouth
o Minimum age is 9 years until 45 years RV5: 3 weeks
o There is currently insufficient data for safe use of the vaccine in Pneumoco PCV: 6 weeks PCV: 2 or 3 PCV: 6-8 IM Vastus lateralis
children younger than 9 years ccal PPV: 2 years depending weeks
on age

VACCINES FOR HIGH RISK/SPECIAL GROUPS PPV: 1

o Pneumococcal conjugate vaccine (PCV)/Pneumococcal Influenza 6 months Annually Annually IM Vastus lateralis,
Polysaccharide vaccine(PCV) SQ Upper outer
st st
o .Haemophilus influenza type B Conjugate Vaccine (HiB). 1 time: 2 1 time: At Intran portion of the
o Meningococcal vaccine doses least 4 weeks asal arms, Nose
o Rabies vaccine
Varicella 12-15 2 At least 3 SQ Upper outer
o Typhoid vaccine
months months portion of the
o Cholera vaccine

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arms

IMMUNIZATION OF TEENS AND PREE-TEENS (7 TO 18 YEARS OLD) MMRV 12 months 2 At least 3 SQ Upper outer
o Hepatitis B vaccine months portion of the
o Hepatitis A vaccine arms
o MMR vaccine Hepatitis 12 months 2 At least 6 IM Vastus lateralis
o Varicella vaccine A months
o Influenza vaccine
o Human Papillomavirus vaccine Td/Tdap 7-18 years Variable IM Vastus lateralis
o Td/Tdap
Booster:
every 10

5
 years o Tetravalent Dengue vaccine –given as 3 doses to children 9-10 years
old enrolled in public schools in priority provinces (three high priority
areas: NCR, Bicol region and CALABARZON)

HPV 10-18 years 3 Bi: 0, 1 and 6 IM Deltoid SCREENINING FOR TUBERCULOSIS (MANTOUX TEST)
Quad: 0, 2
and 6 o Recommended at least once for asymptomatic children between 1
and 14 years of age using 5 TU(tuberculin unit) PPD or 2TU-RT23
o Test is read after 48 -72 hours
o Regardless of BCG status, an induration of > 5 mm is considered
SUMMARY TABLE Immunization of Teens and Preteens 2016 (7-18 years old) POSITIVE in the presence of any or all of the ff.

NATIONAL IMMUNIZATION PROGRAM (NIP) 2016 1. History of close contact with a known or suspected
case of TB
o BGC vaccine ,single dose given at birth 2. Clinical findings suggestive of TB
o Monovalent Hepatitis B vaccine given at birth 3. Chest x-ray suggestive of TB
o DPT –HiB- Hep B (Penta) vaccines ,3 doses given at 6 -10-14 weeks of 4. Immunosuppressed condition
age
o Oral polio vaccine- “as of 2016 we are shifting from trivalent to o In the absence of above factors, an induration of >10 mm is
bivalent. Since bivalent is not yet available, we give a dose of IPV considered positive
together with third dose of OPV at 14th week. “
o Pneumococcal conjugate vaccine, 3 doses given at 6-10-14 weeks of Preferred Sites of Vaccine Administration
age
o Measles –containing vaccine (either monovalent or MMR) given at 9 o Infants and children with inadequate muscle mass- Anterolateral
months of age thigh( Vastus lateralis muscle)
o Measles-Mumps-Rubella(MMR) vaccine given at 12 months of age o Older children and adolescents (2 years ad above)-Deltoid muscle
o Rotavirus vaccine given at a minimum age of 6 weeks with minimum
interval of 4 weeks between doses. The last dose should be

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administered not later than 32 weeks. Vaccine Injection Techniques
o Intramuscular- 90 degree angle
o Subcutaneous - 45 degree angle
School-Based Immunization Program o Intradermal- 10-15 degree angle

o Done to provide catch-up doses for school children and adolescents

o Measles-Rubella (MR) vaccine and Tetanus –Diptheria (Td) vaccine - DEA ANGELA BELMONTE | AFRA JOY DULAY
Administered to Grade 1 and Grade 7 students enrolled in public
schools
o Quadrivalent Human Papillomavirus vaccine(HPV)-given as 2 doses
(0,6 mos) for female children 9-10 years old at health facilities in
priority provinces
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