LECTURE 3.

2: IMMUNIZATION
Dr. Ramos | 17 September 2019

b.Nature and dose of antigen

OUTLINE:
c.Route of administration
I. Facts About Immunization
d.Presence of adjuvant
II. General Considerations and Mechanism
e.Host factors: age, nutritional
Involved in Vaccination
factors, genetics and coexisting
III. Classification of Vaccines
disease
IV. Schedule and Administration Concerns
V. Recommended Childhood and Adolescent
2. PASSIVE IMMUNIZATION
Immunizations • administration of an antibody produced
VI. Pointers on Immunization by a person or animal to another person.
VII. Reference • temporary protection against some
infections.
IMMUNIZATION • this protection does not persist as the
o One of the important accomplishments of antibodies degrade within weeks to
medical science. months.
o Most successful and cost-effective public health • e.g.
interventions for preventing infectious diseases ü transplacental transfer of
and its complications. maternal antibodies to the infant
o Eradicated small pox, lowered global incidence ü exogenous antibodies— from
of poliomyelitis by 99%. blood products used for
o Reduction of illness, disability and death from transfusion
diptheria, tetanus, pertussis and measles. ü immunoglobulins derived from
o Help achieve the millennium development goal plasma of human donors or
by reducing child mortality and morbidity. produced in animals— equine-
derived antibodies
GENERAL CONSIDERATIONS AND
MECHANISM INVOLVED IN VACCINATION CLASSIFICATION OF VACCINES
2 BASIC MECHANISMS IN THE PREVENTION OF TWO BASIC TYPES OF VACCINES
INFECTIOUS DISEASES
1. LIVE ATTENUATED VACCINES – modified
1. ACTIVE IMMUNIZATION viruses or bacteria that are weakened but
• stimulation of the person’s immune retain the ability to replicate and produce
system through the administration of immunity without causing illness
antigens, usually before natural o generally produce most effective immune
exposure to an infectious agent. response
• production of specific humoral (antibody) o produce immunologic memory similar to
immunity and cell mediated immunity by that acquired through the actual disease
vaccines. o fragile and can be damaged or destroyed
• vaccines contain 1 or more antigens that by heat and light
interact with the immune system. o e.g., viral: measles, mumps, rubella,
• immune response produced is similar to varicella, rotavirus, oral polio; bacterial:
that produced by the natural infection BCG, oral typhoid vaccine
without subjecting the recipient to the 2. INACTIVATED VACCINES – composed of
disease itself and its complications. killed microorganisms or inactivated
• factors that may influence the reaction to components such as toxoids, subunit or
vaccination: subvirion products or cell wall
a. Presence of maternal antibody polysaccharides

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LECTURE 3.2: IMMUNIZATION
Dr. Ramos | 17 September 2019
o cannot replicate or caused disease from
infection
o less affected by circulating antibodies
o maybe given in the presence of maternal
antibodies or after receiving antibody
containing blood products
o generally, require multiple and periodic
supplemental doses to increase or
“boost” antibody titers
o immune response is mostly humoral,
with little or no cellular immunity
o inactivated whole cell viral vaccines:
polio, hep A, rabies
o inactivated whole cell bacterial vaccines:
pertussis, cholera
o fractional vaccines: subunits: hep B,
influenza, acellular pertussis, human
papilloma virus
o toxoids: diptheria, tetanus
o pure polysaccharide vaccines:
pneumococcal, meningococcal, typhoid
vaccines
o conjugated polysaccharide vaccines:
Hib, pneumococcal, meningococcal
o inactivated, genetically engineered
recombinant products: hep B, human
papilloma virus vaccines
SCHEDULE AND ADMINISTRATION CONCERNS
I. VACCINATION SCHEDULE
Factors that determine the optimal schedule to
provide a vaccine:
1. Epidemiology of naturally occurring diseases
2. Age-specific risk for complications caused by
the natural disease
3. Anticipated immunologic response of the host
to the antigens
4. Duration of immunity
5. Recommended ages for routing health visits
• Please see attached tables at the last page
II. SITE AND ROUTE OF ADMINISTRATION
• Oral
• Injections: ID, IM, SC
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• IM: anterolateral aspect of the upper part of
the thigh for infants, deltoid muscle of the
upper part of the arm for older children
III. VACCINE DOSE
• Some vaccines may provide nearly complete
and lifelong protection after 1 or 2 doses
• Others provide partial protection
• Some must be re-administered at regular
intervals
• Inactivated vaccines cannot replicate in the
host, repeated doses are required to achieve
long lasting immunity
IV. SIMULTANEOUS ADMINISTRATION OF
MULTIPLE VACCINES
• Most vaccines can be given simultaneously
during the same clinic visit without an
impairment of effectiveness or safety
• Important for inadequately immunized
children whose return for further
immunization is doubtful
• For patients with imminent travel plans
• Administered at different sites
• Different vaccine should not be mixed in the
same syringe unless licensed for mixing
V. VACCINE SPACING AND INTERVALS
• Following the recommended ages and
intervals between doses provide optimal
protection and best evidence of efficacy
• For multidose vaccine schedule using the
minimum age or minimum interval should be
followed
• Doses should not be given at intervals less
than the recommended minimal intervals or
earlier than the minimal ages
• 2 or more inactivated vaccines and one
inactivated vaccine and another live virus
vaccine can be given simultaneously or at
any interval between doses
ü Exceptions:
o Tdap and meningococcal vaccines
(MCV4) – should be separated by at
least 4 weeks if simultaneously
administration is not feasible
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LECTURE 3.2: IMMUNIZATION
Dr. Ramos | 17 September 2019
o Yellow fever vaccine (live) and cholera
vaccine (inactivated vaccine) should
be separated by an interval of at least
3 weeks – diminished antibody
response if administered
simultaneously
• 2 parenteral live vaccines may be
administered simultaneously at the same
clinic visit; if not administered on the same
day, an interval of at least 4 weeks between
doses is recommended
• If live virus vaccines are given within 4 weeks
of another, the immune response to 1 live
virus vaccine – usually the 2nd live vaccine
administered can be impaired
ü Exception:
o live oral vaccines – live oral poliovirus,
rotavirus, and oral TyTa typhoid
vaccines can be administered
simultaneously or at any interval before
or after inactivated or live parenteral
vaccines
VI. LAPSED IMMUNIZATION
• An interruption of the recommended
schedule or a delayed dose does not reduce
the response to the vaccine, provided that
the immunization series is completed
• No need to restart a series or give additional
doses after an interruption of the schedule
regardless of the time that has elapsed
between doses
ü Exception:
o Oral typhoid vaccine: recommended
repeating the series of the 4 doses if
extended to more than 3 weeks
VII. COMBINATION VACCINES
• May be given whenever any component of
the combination is indicated, and its other
components are not contraindicated
• When patients have received the
recommended immunizations for some of the
components in a combination vaccine,
administering the extra antigen/s in
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combination vaccines is permissible if they
are not contraindicated – will reduce the
number of the injections required
• Combination vaccines – advantageous for
preterm infants, for those with limited muscle
– will avoid the administration of multiple
injections
VIII. VACCINE INTERCHANGEABILITY
• Interchanging one brand when the previous
one is unavailable or unknown dose not
adversely affect safety and immunogenicity
IX. ADVERSE REACTION FOLLOWING
VACCINATION
• adverse reactions or side effect – an
untoward response caused by a vaccine that
is extraneous to its primary purpose of
producing immunity
3 General Categories
1. LOCAL REACTIONS
• Least severe
• Pain, swelling, and erythema at the
injection site
2. SYSTEMIC ADVERSE REACTIONS
• More generalized
• Include fever, malaise, myalgia,
headache and loss of appetite
• These symptoms are common and
nonspecific
3. ALLERGIC REACTIONS
• The most severe and least frequent
• May be caused by the vaccine antigen
itself
• May be caused by some components of
the vaccine such as cell culture material,
stabilizer, preservative or antibiotic that
inhibit bacterial growth
• Anaphylaxis – severe allergic reaction
that may be life threatening
• Risk – minimized by good screening prior
to vaccination
• Must have an emergency protocol and
supplies to treat anaphylaxis
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LECTURE 3.2: IMMUNIZATION
Dr. Ramos | 17 September 2019
X. CONTRAINDICATIONS TO VACCINATION
Contraindication
• a condition in a recipient that greatly
increases the chance of serious adverse
reactions or death if the vaccine is given
• screen patients for contraindications and
precautions before giving the dose
• 2 conditions are generally considered to be
permanent contraindications to further doses
of a vaccine
1. Severe anaphylactic / allergic reaction to
a vaccine component or following a prior
dose of a vaccine.
2. Encephalopathy not due to another
identifiable cause occurring within 7 days
of pertussis vaccination.
Two conditions that are temporary contraindications
to vaccination with live vaccines but not with
inactivated vaccines:
1. Pregnancy
2. Immunosuppression
• Live virus vaccine should be postponed
until after delivery, chemotherapy, or long
term, high dose steroid therapy
PRECAUTION
• a condition in a recipient that might increase
the chance or severity of a serious adverse
reaction
• conditions that are considered as permanent
precaution to further doses of pertussis
containing vaccine (DPT) when occurring
within 48 hours of a dose:
1. Temperature of 40.5 C or higher
2. Collapse of shock-like state
(hypotonic-hyporesponsive
episode)
3. Persistent or inconsolable crying
lasting 3 or more hours
4. Seizure with or without fever
occurring within 3 days of a dose
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• an unstable progressive neurologic problem
is a precaution to the use of DTaP or Tdap
• a history of GBS (Guillaine-Barre syndrome)
is a precaution for tetanus-containing
vaccine, influenza, and meningococcal
conjugate vaccines
• two conditions that are temporary
precautions to administering measles and
varicella containing vaccines:
1. moderate or severe acute illness
2. recent administration of an antibody
containing blood products
• mild illness or convalescence following an
illness are not contraindications to
vaccination with live or inactivated vaccines
• vaccinations can be delayed only in those
with moderate to severe to acute illness
XI. VACCINE SAFETY
• no vaccine is perfectly safe or completely
effective
• report any unusual or serious adverse events
possibly associated with vaccination
• parents or patients should be advised at the
time of immunization regarding common
minor vaccine reactions and how to manage
them
• to prevent perinatal transmission – LBWs
born to Hep B surface Ag (HBsAg) positive
mothers or to mothers whose HBsAg status
is unknown should still receive hep B vaccine
at birth – this dose is not counted as part of
the standard series
• Hep B immunoglobulin should be given
within 12 hours of birth
• by chronologic age of 1 month, preterm and
infants less than 2,000 grams are likely to
respond in a similar manner to term infants
more than 2,000 grams
• infants weighing < 2, 000 grams born to
HBsAg negative mother, the first dose of
vaccine can be given at the chronologic age
of 30 days or at hospital discharge even if the
infant weighs <2,000 grams at the time
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LECTURE 3.2: IMMUNIZATION
Dr. Ramos | 17 September 2019

Immunocompromised Children ü 2 weeks: the recommended period

between administration of vaccines and
o Children with altered immunocompetence –
the start of immunosuppressive therapy
primary and secondary (or acquired) disorders
ü Immunocompromised patients may
o Primary disorders: involve any part of the
need to wait 3 months to 1 year before a
immune system – deficiencies affecting B-cell, T-
satisfactory response to inactivated
cell, and complement and phagocyte function
vaccines can be expected
o Secondary immune deficiencies – infected with
HIV or those who are receiving Children with Chronic Diseases
immunosuppressive, antimetabolic and radiation
A. LIVE VACCINES 1. Vaccines recommended for healthy children
ü Contraindicated for patients with T-cell – should also be administered to those with
deficiencies chronic diseases
ü Contraindicated for patients with B-call 2. Live vaccines are contraindicated
deficiencies Children with Personal or Family History of
ü Except for measles and varicella Seizures
vaccines which can be considered
ü IVIG may interfere with viral replication o Family history of seizures or other CNS
necessary to elicit an adequate antibody disorders is not a contraindication to the
response – protection may not be administration of vaccines – DPT, measles,
consistent varicella – usually febrile seizures
ü complement deficiencies – can safely o Pertussis vaccination in infants and children
receive live vaccines with recent history of seizures should be
ü phagocyte function disorders – may postponed until their neurologic status has
receive all immunizations except live been evaluated
bacterial vaccines Adolescents
ü those on systemic corticosteroids
>2mg/k/day or a total dose of >20mg/day adolescents are not optimally protected because of
– live vaccines are contraindicated the ff. reasons:
ü with leukemia, lymphoma or other
1. failure to complete the age appropriate
malignancies who are in remission and
vaccination schedule earlier in life
chemotherapy has been terminated for at
2. suboptimal response to vaccines previously
least 3 months can receive live virus
given
vaccine
3. warning immunity despite appropriate
ü asymptomatic HIV-infected children -
vaccination strategies:
inactivated and live vaccines may be
a. plan a routine appointment in
given except BCG
early adolescence
ü screen for immunocompromised
b. review of vaccination records
household members when deciding to
c. school setting as venue for
administer live vaccines
vaccine delivery
B. INACTIVATED VACCINES
ü All inactivated vaccines can be safely
given to immunocompromised persons
with the usual doses and schedules
recommended

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LECTURE 3.2: IMMUNIZATION
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RECOMMENDED CHILDHOOD AND
ADOLESCENT IMMUNIZATION
1. BCG – Bacille Calmette-Guerin
- from attenuated strain of M. Bovis
- intradermal route, at the right deltoid at
birth
- 0.05 mL initially and 0.1 mL for older
children
- for immunocompetent host
- given at birth
- 50% effective in preventing pulmonary TB
in adults and children
- 50-80% protective effect from disseminated
and meningeal TB (severe TB) in young
children
- does not protect against TB infection or
reactivation of latent TB.
- vaccine protection wanes after 10-20 years
thus booster is needed.
Reactions:
- most are mild, usually resolve
spontaneously
- fever, convulsions, loss of appetite,
irritability (extraordinarily rare)
- local ulcerations and regional suppurative
adenitis in 0.1- 1%
- OSTEITIS in 0.6- 46/1 million vaccinated
children
Contraindications:
- impaired immunity due to congenital or
acquired immune deficiency (HIV, leukemia,
lymphoma, and other malignancy)
- immunosuppressive treatment (eg.
Steroids)
- pregnant
2. Hepatitis B
- soon after birth; use only monovalent Hep B
can be used at birth
- monovalent or combination vaccine
containing Hep B may be used to complete
the series
- four doses of vaccine may be administered
when a birth dose is given
- second dose should be given at least 4
weeks after the first dose
- for combination vaccines, it should not be
given before 6 weeks of age
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- 3rd dose should be given at least 16 weeks
after the first dose and at least 8 weeks
after the second dose
- the last dose should not be administered
before 6 months old
Infants born to HBsAg (+) mothers – should
receive Hep B vaccine and Hepatitis B
Immunoglobulin (HBIG) within 12 hours of birth at
separate sites. Test for HBsAg and antiHBs should
be given at 9-15 months of age.
Infants born to mothers whose HBsAg status is
unknown – should receive the first dose of Hep B
series within 12 hours of birth.
- get maternal HBsAg status; if HBsAg
positive give Hep B Ig as soon as
possible, not later than 1 week.
3. Diphtheria, Tetanus, Pertussis (DTwP, DTaP,
DTP)
- primary series— 0.5 ml 2, 4, and 6 months
of age, with a 4th dose at 6 – 12 months
after the third dose
- booster dose at 4 to 6 years of age
- for 7 years and older, three 0.5ml of dT is
used for primary series of two doses 4 to 8
weeks apart, and the third dose given 6 to
12 months after the second dose
- only contraindication is a history of
neurologic or severe hypersensitivity
reaction after a previous dose
- booster doses of 0.5 ml of dT is given every
10 years starting at 11 to 12 years of age
Reactions:
- mild local and systemic adverse events
include – high fever, persistent crying ≥3
hours duration, hypotonic, hyporesponsive
episodes, and seizures – occur less
frequently with the use of DTaP
- up to 2% of 4th to 5th doses of DTaP can be
associated with entire limb swelling with
concurrent pain and erythema in
approximately half of children affected;
swelling subsides spontaneously without
sequelae
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Contraindications:
- history of severe allergic reaction to a
vaccine component following a prior dose of
the vaccine
- in persons with history of encephalopathy
not due to another unidentifiable cause
occurring within 7 days after administration
of a pertussis containing vaccine, you
should not give the next dose
Precautions:
- moderate or severe acute illness especially
those with history of Guillaine- Barre
syndrome within 6 weeks after a dose of
tetanus containing vaccine
- progressive neurologic disorder
4. Hemophilus influenza b –
- commonly causes pneumonias and
meningitis
- a gram negative microorganism
- primary series— 3 doses given in the first
6 months of life; can start from age of 6
weeks; 0.5 mL, IM
- booster— between age 6 to 12 months of
age previously unvaccinated should receive
2 injections one month interval followed by a
booster in the 2nd year of life
- unvaccinated children aged 1 to 5 years old
should be given 1 dose of vaccine
5. Measles / MMR
- it can be monovalent or combined with
mumps and rubella (MMR) or mumps,
rubella, and varicella (MMRV)
- given subcutaneously
- EPI given at 9 mos. old, or as early as 6
mos.
- initial measles immunization usually as
MMR at 12 to 15 mos. of age
- MMR given at < 1 yr. of age a repeat dose
should be given at 15 mos. old
- a second immunization as MMR is
recommended routinely at 4-6 yrs. old
6. Varicella
- may be in combination with mumps,
measles, and rubella
- live virus vaccine recommended for children
12 – 18 months of age
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- two doses with second dose given at 4-6
years old
- children 13 years and above and adults
should be given 2 doses 4 weeks apart
Contraindications:
- pregnant women
- immunocompromised persons
7. Streptoccoccus pneumonia (Invasive
pneumococcal disease)
- also causes meningitis and pneumonia
- conjugate polysaccharide vaccine is
recommended for infants in a schedule of 4
doses administered at 2, 4, 6 and 12-15
mos. of age
- adverse events— fever slight swelling and
redness on the site of administration
- Pneumococcal Polysaccharide Vaccine
(PPV) f or high risk individuals
- also given to individuals who are having
sickle cell, functional or anatomic asplenia,
nephrotic syndrome, chronic renal failure,
immunosuppressive conditions, HIV
infection.
8. Hepatitis A
- inactivated vaccines
- given at a minimum age of 12 months
- IM – 2 dose schedule – 2nd dose is given 6-
12 months after the 1st dose
- >90% seroconversion after the 1st dose
- > 100% seroconversion after the second
dose
9. Influenza Virus
- inactivated vaccines
- recommended annually for children age ≥ 6
mos. old
- 2 doses – 0.25 ml. for 6 – 36 months of age;
0.5 ml. for 3 to 8 years old 1 month apart
10. Rotavirus
- pentavalent
- given orally
- given at 2, 4,and 6 months, first dose is
given is given between 6 and12 weeks of
age, with all 3 doses completed by 32
weeks of age
- attenuated, monovalent vaccine
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Dr. Ramos | 17 September 2019
- administered as 2 oral doses at 2 and 4
months of age
NOT ROUTINELY RECOMMENDED
1. Meningococcal vaccine
- tetravalent capsular polysaccharide
vaccine; not routine
- immunogenic in adults, unreliable in
children less than 2 years old
2. Typhoid vaccine
- 2 types— oral, live attenuated
preparation Ty21A given 4 enteric-
coated capsules on alternate days,
recommended for ≥6 y.o.
- Vi capsular polysaccharide vaccine
given IM, for persons ≥ 2 yrs. old;
effectivity is at 75% lasting for 3
years
3. Human Papilloma Virus vaccine
- given to females 10 years onwards
- for prevention of cervical cancer
caused by HPV 16 and 18
- given 3 dose series at 0, 1, and 6
months, at 0.5ml. IM
- also licensed to be administered in a
3-dose series to males aged 9 to
- 26 years to reduce their likelihood of
acquiring genital warts and
developing anal dysplasia and
cancer
POINTERS ON IMMUNIZATION
1. The attainment of effective antibody level in active
immunization takes sometime.
- it cannot be relied upon in non-immune
individuals who have already been exposed,
or are already suffering from the disease.
2. Live attenuated vaccines evoke more effective
and longer lasting immunologic response than
inactivated ones.
- contraindicated in pregnant women, in
immune deficiency states, persons whose
immunologic response may be suppressed
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3. Induction of long lasting immunity may require
periodic administration of booster doses to maintain
an adequate level immunity.
- the recommended schedule for all the
vaccines must be followed
4. The presence of minor febrile illness or
malnutrition is not a contraindication to
immunization.
- immunization be deferred in the presence
of severe febrile illness
5. A high percentage (90% or more) of immunization
among susceptible should be targeted for
community protection.
6. Interruption of schedule with a delay between
doses does not interfere with the final immunity
achieved nor does it necessitate starting with the
series again, regardless of the length of time
elapsed.
- individual is at risk during the period of
delay
7. There is no definite contraindication to giving
multiple vaccines at the same time provided they are
given at different sites using different needles and
syringes.
8. All vaccines must be properly stored at
recommended temperatures to maintain their
potency.
9. Vaccines made by different manufacturers but
directed against the same infections are generally
considered interchangeable for the primary series
and recommended booster doses.
10. Preterm infants, including those of very low
birthweight, should be vaccinated at the same
chronologic age as fullterm infants and according to
the routine childhood immunization schedule.
11. Human milk does not adversely affect the
immune response of infants and breast-feeding is
not a contraindication to any vaccine.
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LECTURE 3.2: IMMUNIZATION
Dr. Ramos | 17 September 2019

- breast-feeding women may safely receive

vaccines without interrupting breast-feeding,
and their infants should be vaccinated
according to routinely recommended
vaccines.

12. Internationally Adopted Children

- only written documentation should be
accepted as evidence of prior vaccination
- given the limitations in determining whether
child's prior vaccination history is reliable,
repeating the vaccinations is acceptable
- usually safe and avoids the need to obtain
and interpret serologic antibody tests

END OF TRANSCRIPTION
REFERENCE
Doc Ramos’ PowerPoint Presentation

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LECTURE 3.2: IMMUNIZATION
Dr. Ramos | 17 September 2019

Schedule of The Philippine Expanded Other Vaccines Recommended but not

Program on Immunization included in EPI
(Philippine EPI) IPV 6 weeks, 10 weeks, 14
BCG Birth weeks
Hep B (monovalent Birth DTaP 6 weeks, 10 weeks, 14
vaccine) weeks
DTwP-Hib-Hep B 6th, 10th, 14th week Tdap 10 years – booster
(pentavalent vaccine) Hep A 1 year; 2nd dose – 6 –
OPV 6th, 10th, 14th week 12 months after 1st
Rotavirus vaccine 6th, 10th week dose
Pneumococcal 6th, 10th, 14th week
Measles 9 months
MMR 12 months

MMRV 12 months; 4-6 years

Pneumococcal Conjugate – 6
weeks, 10 weeks, 14
weeks, 12 months
Rotavirus 6 weeks, 10 weeks,
14 weeks
Influenza 6 months, 2nd dose 1
month after
HPV 9 years; 11-12 years,
2nd dose 1-2 months
after 1st dose; 3rd
dose 6 months after
the 1st dose

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