PREVENTIVE PEDIATRIC MEDICINE PART 4 – DR.

CALIGAGAN

PREVENTIVE PEDIATRIC MEDICINE PART 4 CLASSIFICATION OF VACCINES

Christian T. Caligagan, M.D.  LIVE-ATTENUATED
Live = Alive
IMMUNIZATION Attenuated = Weakened or reduced potency

 Vaccination/Immunization is an ACT  Live microorganisms

 It is actually the one that protects children and adults
from infections or from diseases that are caused by
microorganisms
 Are vaccines protective?
 They are supposed to be protective when they are
given to patients
 Actual infection ensues after administration with little or
 If you have not yet injected the vaccines (still inside
the refrigerator), they are not protective
 It is the process of vaccination which is protective
 Provision of an individual with antibodies possessing power
to destroy or inactivate the disease producing agent or
neutralize its toxin
 Giving of an antigen or an antibody
 Comes in lyophilized form  Powdered
 Cannot be suspended right away
 When they are lyophilized, they are stable
 You only dilute it when you need it
 Most of the time vaccines come in lyophilized form
NO adverse host reaction
 REMEMBER: You are administering a live vaccine 
Potential Side Effect = Getting the same kind
manifestations as the actual infection but it is
“attenuated,” meaning it is weakened, so it is not
enough to cause the actual infection that they
create among individuals

 Ultimate Goal: Eradication of the disease  Examples:

─ BCG
 Small Pox and Polio  Already been eradicated ─ Influenza (Intranasal)  Not locally available in the
Philippines
 Immediate Goal: Prevention of the disease in an individual ─ Measles,
─ MMR
DEFINITION OF TERMS ─ Rotavirus
 ACTIVE IMMUNIZATION ─ Varicella
 Administration of the microorganism or any of its ─ OPV
modified products to evoke an immunologic response
 Direct or pure microorganism to patient = Antigen  KILLED
 Slow Action = Permanent  NOT capable of replicating in the host and must contain a
sufficient antigenic mass to stimulate a desired response
 If you are giving a KILLED OR LIVE VACCINE  You are
giving an ANTIGEN  Most of the vaccines are conjugated/
 It takes time before the vaccine to work  Takes time coupled/combined with another vaccine for it to
to evoke a response work  You must have a bigger molecular weight
 Example: Tetanus Toxoid to evoke an antigen-antibody response

 Sub-Classifications:
 PASSIVE IMMUNIZATION ─ Inactivated - Pertussis
 Administration of preformed antibody to a recipient ─ Toxoid – Diptheria, Tetanus
 Introduction of Antibody ─ Recombinant - Hepa B
 Fast Action = Temporary  Examples:
─ DTaP  Diptheria, Tetanus, Pertussis
 Immediately protects a person from infection
 Short term protection  Diptheria and Tetanus  TOXOID
 Example: Immunoglobulins  Pertussis  INACTIVATED
 Can be acellular or whole-cell
 EXAMPLE: If they give you a live vaccine (active ─ HiB  Hemophilus Influenza Serotype B
immunization), you won’t get protected right away.
What gives you that immediate protection, for example,  Recombinant Form
if you have been exposed to a dog bite, is a passive
─ Meningococcal and Pneumococcal Vaccine
immunization in the form of an immunoglobulin right.

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 PREVENTIVE PEDIATRIC MEDICINE PART 4 – DR. CALIGAGAN

 Meningococcal and Pneumococcal  Sneezing after administration: May not repeat

 Comes in a polysaccharide form, sugar-coated  Live Attenuated Influenza Vaccine (5-49y/o)
vaccine  Flu Vaccine given Intranasally  Not commonly
 Conjugate Vaccine  Combined with another practiced here in the Philippines
substance, making it more antigenic  Flu Vaccine here in the Philippines is
administered IM
─ IPV  Inactivated Polio Vaccine
─ Rabies
ANTIGEN COMBINATION
SITE AND ROUTE OF IMMUNIZATION ANTIGEN RECOMMENDED MINIMUM
 PER OREM (PO) COMBINATION INTERVAL BETWEEN DOSES
 Breastfeeding does not interfere with oral vaccination NONE  Can be administered
 Vomiting within 10 minutes of vaccination REPEAT the ≥ 2 Inactivated
simultaneously or at any interval
DOSE Vaccines
between doses
 If a patient vomits after administration of an orally NONE  Can be administered
Inactivated & Live
simultaneously or at any interval
administered vaccine, specially OPV (only OPV)  Vaccines
between doses
REPEAT THE DOSE
 Rotavirus  No need to repeat 28-day minimum interval in NOT
≥ 2 Live Vaccines
administered at the same visit
 Expensive
 There is a study among Rotavirus Vaccines that
even just a small drop, it could be enough to  In general, there is no contraindication in giving
evoke an immunologic response simultaneous vaccines.
But if the patients insist, you could repeat   If you are 2 Inactivated Vaccines  No minimum interval
between injection
 OPV, Rotavirus  1 Inactivated and 1 Live Vaccine  No minimum interval
between injection
 INTRAMUSCULAR (IM)  2 Live Vaccines  Wait at least 1 month (28 days
minimum) before you could administer another Live
 Injected perpendicularly  90° angle Vaccine
 Based on volume and size of the muscle
 Anterolateral Aspect of the Thigh: < 1 year old CONTRAINDICATIONS TO VACCINATION
 Best Site of Injection for Younger Children ABSOLUTE
 Severe anaphylactic reaction or allergic reaction to
 Deltoid Area: Older Children previous vaccine
 Encephalopathy within 7 days of administration
 Rarely used because of the danger of hitting the (Pertussis)
Sciatic Nerve
RELATIVE
 Buttocks: Rarely Used  Immunosuppressive Therapy  Corticosteroid,
 DTP, Hepatitis B Vaccines Chemotherapy, Blood Transfusion, etc.
 Egg Allergy
 SUBCUTANEOUS (SQ)  Seizures within 3 days of administration
 45° angle into the anterolateral aspect of the thigh or  Shock within 48 hours of last dose
upper outer triceps  Fever >/+ 40.5°C within 48 hours of last dose
 Measles, MMR, Varicella NOT
 Mild illness with or without low grade fever
 INTRADERMAL (ID)  Current antibiotic therapy
 Volar aspect of the forearm (PPD only)  Recent infectious disease
 BCG – deltoids or buttocks  Positive PPD
─ (R) Deltoid: ID  Ideal site for BCG  Prematurity, EXCEPT in infants still hospitalized at 2
months, OPV should be delayed until discharge. OR until
 INTRANASAL mother is HBs Ag (-) Hep B vaccine should be delayed until
 Upright position, 0.25 mL is sprayed into one nostril, the child is >2000 g
2nd half is administered to the other nostril

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 PREVENTIVE PEDIATRIC MEDICINE PART 4 – DR. CALIGAGAN

EXPANDED PROGRAM ON IMMUNIZATION (EPI) TAKE NOTE: Maraming discrepancies sa EPI Part, siguro dahil
naupdate na ‘to as compared sa PPT ni doc, so I suggest na
 Also called National Immunization Program (NIP) in basahin niyo nalang din yung nasa handbook para sure 
other countries
BACILLE CALMETTE GUERIN (BCG)
 Main Objectives
 Prevents extra-pulmonary manifestations of tuberculosis
 To reduce the morbidity and mortality rates of the
 Live Attenuated Vaccine
common EPI diseases which are:
 Any time after birth
─ Poliomyelitis
─ Measles  DOSE:
─ Diphtheria  0.05 ml for <1 month
─ Pertussis  0.1 ml for infants >1 month
─ Tetanus  HANDBOOK (Preventive Pediatric Health Care
─ Tuberculosis Handbook 2014):
─ Hepatitis  0.05 ml  Children < 12 months of age
 0.1 ml  Children > 12 months of age
 ADDITIONAL:
 2010:  2nd Month of Age: Do PPD first
─ MMR  Measles, Mumps, Rubella  ROUTE: Intradermal
─ HIB Infections  Can cause Pneumonia,  NATURAL COURSE (Natural BCG Reaction)
Meningitis, Cellulitis, Osteomyelitis, etc.
 Wheal Formation: Disappears after 30 minutes of
 2012:
injection
─ Rotavirus  Induration: Occurs after 2-3 weeks of injection
 2013:  Pustule Formation: After 2-3 weeks or induration
─ Pneumococcal Infections  Ulceration: After 2-3 weeks of pustule formation
 12 Infections as of 2014:
1. Poliomyelitis  Lecture: After 5-6 weeks
2. Measles
3. Diptheria  Scar Formation: After 8-12 weeks after injection
4. Pertussis  ADVERSE REACTION
5. Tetanus  Koch Phenomenon: Accelerated BCG phenomenon
6. Tuberculosis
7. Hepatitis
 BCG becomes a diagnostic test if you inject it, but
8. Mumps
instead of the usual 8-12 weeks, it would heal and
9. Rubella
have a scar formation at 2-3 weeks after injection
10.HIB Infections
 Accelerated BCG Phenomenon
11.Rotavirus
 Indolent Ulcers: Ulceration of more than 3 weeks
12.Pneumococcal Infections
 Uncommonly (1-2%) result in local adverse reactions
 To reduce the incidence of neonatal tetanus by providing  Subcutaneous abscess and lymphadenopathy
pregnant women with tetanus toxoid immunization  Osteomyelitis and muscle necrosis

HEPATITIS B VACCINE
 There are 2 vaccines which can be given at birth  BCG  Killed/Inactivated Vaccine
and Hepatitis B  Given at birth
 DPT and OPV share the same schedule  Earliest time  Follows 2 Schedules:
these two can be given is at 6 weeks  0-1-6 schedule  0 (At birth/Anytime after birth), 1 (1
 Both are given at a 4 week interval  6 weeks  10 month from 1st injection), 6 (6 months from 1st injection)
weeks  14 weeks  0-1-2 + 1 booster a year after the 3rd dose
 Two vaccines that can cause notorious FEVER in children  DOSE: 0.5 ml
 DPwT and Measles (Measles Vaccine/MMR)  ROUTE: IM
 DPwt  Within 24 hours  ADVERSE REACTIONS:
 Measles  7 to 12 days later  Pain at injection site
 BCG  Natural Course  Fever (≥ 37.7°C)
 Should be explained well to patients  Allergic reactions

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 PREVENTIVE PEDIATRIC MEDICINE PART 4 – DR. CALIGAGAN

DIPHTHERIA, PERTUSSIS AND TETANUS (DPT)  IVIG at a dose of 100-400mg/kg

 Inactivated Vaccine
 AGE: As early as 6 weeks old HAEMOPHILUS INFLUENZA TYPE B VACCINE (HIB)
 PRIMARY SERIES INTERVAL: 4 weeks apart for 3 doses  Inactivated Vaccine
 BOOSTER DOSES  AGE: 2 months*
 1st: 1st year after the last dose  Children
 2nd: At 4-6 years old  <6 Months: 3 doses at 2 months apart
 DOSE: 0.5 ml, IM  6-12 Months: 2 doses, 2 months apart
 ADVERSE REACTION  >1/2 Years old: 1 dose
 Local and febrile reactions  5 Years old & Above: No need
 Bacterial or sterile abscesses at the site of  DOSE: 0.5 ml
 injection are infrequent  ROUTE: IM
 Allergic reactions
 Seizures BASED ON THE LECTURE/RECORDINGS:
 Hypotonic Hyporesponsive Episodes (HHE)  Given as early 6 weeks*
 “Collapse” or “Shock-like state”  If given separately from the 5-in-1 or 6-in-1 formulation,
 High Grade Fever  Fever of 40.5°C (within 24 hours) Hib is given every other month.
 Incessant crying  If given with the 5-in-1 or 6-in-1 formulation, it can be
given for 3 consecutive months.
POLIO VACCINE  If you see a child more than 18 months, you may not
 OPV – Live Vaccine give any more  As the child grows older, they have
 Virulent after passing gastric  Pass down to feces already developed antibodies against Hib.
 IPV – Inactivated Vaccine
 AGE: As early as 6 weeks
 PRIMARY SERIES INTERVAL: 4 weeks apart for 3 doses ROTAVIRUS VACCINE
 BOOSTER DOSES  Live Attenuated
 1st: 1 year after the last dose  As early as 6 weeks of age
 2nd: At 4-6 years old  2 Types Available in the Market:
 DOSE: 0.5 cc or 2 drops  ROTARIX
 ROUTE: ─ Follows a 2-dose schedule – should be COMPLETED at 6
 OPV: Per orem months of life
 IPV: IM ─ Human; Available in the Philippines
 ADVERSE EFFECT  ROTATEQ
 OPV: Vaccine Associated Paralytic Polio (VAPP) ─ Follows a 3-dose schedule – last dose should be given
until 8 months
 IPV: Hypersensitivity Reaction (not common)
─ Bovine; approved in the US
MEASLES VACCINE  ADVERSE EFFECTS:
 Live Attenuated Vaccine  Diarrhea after 24 hours
 3 days constipation
 AGE: 6 or 9 months

 Can be given as early as 6 months, especially if there PNEUMOCOCCAL VACCINE

is an outbreak but routinely it is given at 9 months  23-Valent Polysaccharide Vaccine:
 For 2 years old & up only
 2nd Dose: 6 months after the first as MMR  Booster every 5 years
 3rd Dose: 4-6 years old  7-Valent Conjugate Vaccine:
 DOSE: 0.5 ml  <2 years old, as early as 6 weeks of age
 ROUTE: subcutaneous  Interval: 2 months
 ADVERSE EFFECT:  Booster after 3rd dose
 Fever after 5-7 days from the time of injection  DOSE: 0.5 ml (3 doses)
 Local swelling or pain from site of injection  ROUTE: IM or SQ
 Rashes  ADVERSE REACTIONS:
 PASSIVE IMMUNIZATIONS  Mild erythema
 In susceptible & immunocompromised patients  Pain at injection site
 Give Ig within 6 days after exposure  Fever
 DOSE: 0.25 ml/kg IM

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 PREVENTIVE PEDIATRIC MEDICINE PART 4 – DR. CALIGAGAN

BASED ON THE LECTURE/RECORDINGS:

 Given every other month: 6 weeks  Skip at 10th week  ≥ 3 years old – 1 dose (1 shot yearly)
 Give again on the 14th week and so on…  DOSE: 0.5ml
 If the patient is more than 1 year old but less than 2 and  ADVERSE EFFECTS:
has not yet received the vaccine, the patient only needs  Pain at site of injection
2 shots of Pneumococcal Vaccine  Fever
 If patient is more than 2 years old and with no
VARICELLA VACCINE (Chicken Pox)
Pneumococcal Vaccine yet, the patient only needs 1 shot
of the vaccine  Live Attenuated Vaccine
 Administer the 2-dose series to all susceptible adolescents
RECOMMENDED VACCINES aged ≥ 13 years
HEPATITIS A VACCINE  DOSE: 0.5 mL either SQ or IM
 Inactivated, Routine  Age 12-18 Months: 1 dose for universal immunization
 Given beginning 1 year old  Age 19 Months- 13 year old: Susceptible
 Follows a 2-dose schedule
 1st dose: 1 year old SPECIAL VACCINES
 2nd dose: 6-12 months after TYPHOID VACCINE
 ADVERSE EFFECTS:  Given at 2 years old
 Pain and swelling at site of injection  DOSE: 0.5ml (1 dose)
 ROUTE: IM
HPV VACCINE  Revaccination after 2-3 years if with continued re-exposure
 Recently became a routine vaccine
 2 Types: MENINGOCOCCAL VACCINES
 GARDASIL  Routine immunization is NOT recommended
─ Genital and oral  Indicated for children of  2 years old in high risk groups
─ 0, 2, 6  Functional/anatomic asplenia
─ Has 4 strains (HPV 6, 8, 16 & 18  Quadrivalent)  Terminal component prosperdin deficiency
─ Given to 9-26 y/o ♀  Beneficial for travelers to hyperdynamic countries
 CERVARIX
─ Genital *RABIES
─ 0, 1, 6
─ Has 2 strains (HPV 16 and 18  Bivalent) COMBINATION VACCINES
─ Given to 10-55 y/o ♀  For ease of injection; patient does not have to keep
 coming back – 1 injection only
INFLUENZA (FLU) VACCINE  Available combinations:
 IM or SQ (Available here in the Phils.)  6in1 – DPT (counted as 3), IPV, HIB Hepa B
 Given at 6 months then yearly given  5in1 – DPT, IPV, HIB
 Following antigenic shift  4in1 – DPT, IPV
 < 3 years old – need 2 shots 1 month apart  As early as 6 weeks
 DOSE: 0.25ml  Follows 0, 1, 2 schedule

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