Chapter 107: Immunization Principles & Vaccine Use
Thus vaccination may not gurantee immunity
“An ounce of prevention is worth a pound of cure”
Best Treatment – Preventive Measure
Goal: Universal Immunization
Key Terms
Vaccine – preparation of attenuated live or killed microorganism
or antigen particles of these agents presented to a potential host
to induce immunity and prevent disease.
Toxoid – modified bacterial toxin made nontoxic but retains it’s
capacity to stimulate the formation of antitoxin
Immunoglobulin – antibody containing protein fraction derived
from human plasma used primarily for maintenance of the
immunity of persons with immunodeficiency disorders or for
passive immunization
Antitoxin – antibody derived from the serum of animals after
stimulating with specific antigens and used to provide passive
immunity to the toxin protein to which it is directed.
Routine Immunization during first 18 months – Total of 21
antigens, some in form of combinations
• Diphtheria/tetanus/acellular pertusis vaccine (DtaP)
• Trivalent inactivated poliovirus vaccine (IPV)
• Measles/Mumps/Rubella Vaccine (MMR)
• Haemophilus influenzae type b vaccine (Hib)
• Hepatitis B (HepB) & A (HepA) vaccine
• Varicella vaccine
• (& recently)
• Heptavalent pneumococcal vaccine
• Influenza vaccine (given annuall)
5 Vaccine Routinely used for Adults:
• Tetanus/diphtheria toxoids (Td)
• HepB vaccine
• Influenza virus vaccine
• Polyvalent pneumococcal polysaccharide vaccine
• Varicella Vaccine
Other special used vaccine: ex PTB
• For outbreak response
• Prophylaxis for travellers
• Regional Use
No vaccine yet for Eukaryotic pathogen (protozoa & helminthes)
Healthy People 2010 objective – that by 2010, 80% children
received DtaP, IPV, MMR, Hib & HepB and 90% adult received
influenza & pneumococcal vaccine (mukhang malabo mangyari
sa pilipinas)
I. Impact of Immunization – Resut of Vaccine
• Global Eradication of smallpox
• Eliminated naturally transmitted poliomyelitis
• Measles nearly 100% infectivity rate in prevaccination
• Hib conjugate vaccine for infants eliminate invasive H.
influenzae infection (pneumonia & meningitis)
• Polyvalent pneumococcal vaccine present significant
impact against invasive pneumococci
Definition: Vaccination vs Immunization
• Vaccination – simply administration of vaccine
• Immunization – process of inducing or providing immunity
 Active Immunization – induction of immune defense
by administration of antigen (Ag) in apparent form
 Passive Immunity – provision of temporary protection
by administration of exogenous product of immunity –
Antibody(Ab/Immunoglobulin(Ig)
II. Principles of Immunity
• Active Immunization – pathologic process
• Passive immunization – natural process ex. Placental
transfer
• Combination of Active & Passive – Complementary
action (ex. HepB + HepBIg) but some may cause
interferring action (ex. Measles vaccine + MeaslesIg)
*Whole organism vaccine – contain all protective Ag of the
organism
III. Approach to Active Immunization
1. Use of live generally attenuated infectious agent (ex.
Measles virus) – avirulent yet remain immunogenic which
produce long lasting immunity (because of advantage of
replicating in vivo increasing antigenic response level)
although cause some subclinical illness/immune response
(caution: OPV contraindicated for immunodeficient child &
its contact as it could cause vaccine-associated polio)
2. Use inactivated agent or their constituent or products
obtained by genetic recombination (ex. Acellular pertusis) –
require multiple doe & periodic booster as maintenance
(exception is pure polysaccharide vaccine – useless ang
booster [why? See later])
3. Use both approach.
IV. Approach to Passive Immunity
-provide temporary immunity: (1) to unimmunized subject
exposed to the infectious disease (2) used if active immunization
is unavailable, implemented before exposure [ex. Treatment of
disorder associated with toxin (diphtheria), certain bites (snake
or spider) and specific/nonspecific immunity (RhIg)]]
3 types of Preparation:
• Standard Human immune serum globulin given IM/IV
• Special immune serum globulin with known content of Ab to
specific Ag (ex. HepBIg)
• Animal sera & Antitoxin
V. Route of Administration – orally, intranasal,
intradermal, Subcutaneous, IM & IV
• Parenteral (IV) may not induce mucosalsecretory IgA
• Mucosal Immunity – may not inducegood systemic
immunity
VI. Age – schedule for immunization based on age dependent
respose
Ex. Infant has immature immunity + maternal antibody, while
elderly experience natural waning of immunity, so that they
needed large dose of vaccine
VII. Adjuvant Potentiation (ex. Aluminum salt & carrier protein)
• Render soluble antigen into particulate one (para di
matunaw agad)
• Mobilize phagocyte to the site of antigen deposition
• Slow down release of Ag to prolong stimulation of immune
response
VIII. Immune Response
Primary response – characterize by early appearance of IgM
Antibody(M-aaga), which has low affinity & nonspecific to Ag
(latent period of 7-10 days before immune response). Then the
“thymus dependent” antigens, CD4+ T helper lymphocytes
which shift IgM to IgG (high affinity and more specific Ab) – if
person lack Major Histocompatibility Complex (MHC)
determinants which is required for antigen presentation, there
would be no antibody shift to IgG (Primary Vaccine Failure)
Secondary Response – heightened humoral & cell mediated
response in second exposure to antigen within 4-5 days (rapid)
depending on Immunologic memory characterized by marked
proliferation of IgG Ab produced by B Lymphocyte &/or T effector
cell. Although level of vaccine-induced Ab decline over time
(secondary vaccination failure) so that revaccination is needed
(exeption is the pneumococcal polysaccharide vaccine which
evoked immune response independent of T cell & is not
enhanced by repeat administration)
IX. Hypersensitivity Reaction – unanticipated over-stimulation
of immune system by vaccination
X. Mucosal Immunity – secretory IgA – efficient way to block
the essential first step in pathogenesis
XI. Herd Immunity
Vaccination of individual give direct protection from infection of
individual which decrease the %susceptible persons within a
population. Therefore if prevalence of immunization is increase
in a population (Herd Immunity), infection will not circulate and
the remaining small % of unvaccinated person is indirectly
protected (Herd Immunity Effect).
XII. Target Population & Timing of Immunization
• Different age group differ in disease attack rate
• Effectiveness of vaccine depends on variety of factors
(individual responsiveness, demographic feature of
population at risk & the duration & character of response)
• Vaccination program is much effective if applied to
community than to an individual
• Target Population: susceptible individual
• Time of Immunization: early in life as is feasible
XIII. The Development of Vaccine
A. Biologic Impediments (Problems)
• Antigenic drift of Influenza virus which annually produce
new antigenic version of the virus which differ from the
previous vaccine
• Many pneumococcal polysaccharide serotype which render
some sero-specific pneumococcal vaccine ineffective.
B. Strategy of Vaccine Development
• Phase 1 – Studies of animal to identify protective antigen
• Phase 2 – Determination of how to present this antigen
effectively to the immune system
• Phase 3 – Assessment of safety & Immunogenecity of the
preparation in small an then large human population at
various age
• Phase 4 – Evaluation of safety & efficacy in the target
population
C. Vaccine Formulation
Living vs dead antigen does not induce the same immune
response & differ with every organism
Goal is not only to select the correct antigen, but to ensure that
the vaccine will result in a type of immune response needed for
protection & to create a deliverable vaccine, constituent other
than the antigen:
• Preservative/Stabiulizer/Antibiotics – prevet deterioration
• Adjuvant – enhance immune response
• Suspending Medium
D. Production of Vaccine – effecacious but does not cause
harm
Good Manufacturing Practice Standard regulated by USFDA – to
ensure safety, efficacy, sterility & purity
Problems:
• High cost
• Vaccine manufacturer decline
• Future availability decline
E. Administration of Vaccine
• Minimized the risk of spreading the disease during
administration (universal precaution ex handwashing,
aseptic/antiseptic)
• Discourage of multiple injection – combination vaccines are
created for single shot
• Primary healthcare should ensure access of medical
service & educate about vaccine – for patient compliance
XIV. Use of Vacine (recommended in 2003)
• Routine administration in Infants, Children & Adults
(refer to Table 107-4, page717)
• Vaccine for Special Use (Refer to Table 107-5, page 718)
• Schedule of Immunization (Refer to Figure 107-1 & 2,
page 719-720)
A. Recording & reporting Requirement
• Regulated by National Children Injury Act of 1986 (mod
1995 & 2002) requiring all vaccine must be recorded
permanently by healthcare professional including the date
of administration, the manufacturer and lot number of
vaccine and name of the provider.
• Health provider should inform the parents the benefit and
risk of vaccination and the importance of up-to-date
immunization record.
B. Vaccine for routine Use
Infants & Children – DtaP, IPV, MMR, Hib, HepB, Varicella,
Pneumococcal conjugate vaccine; others: HepA – if there is risk
of exposure or in case of travel to endemic area, Influenza
vaccine – children 6-24months of age, in Europe –
meningococcal conjugate vaccine is routinely administer (sa
philippines, pTB ata routine)
Adults (>18y/o) vaccine classified into 4 categories:
1 - Routinely use for adult – ex. all adult completed the pediatric
series should be boosted with Td (adult form) every 10 years
2 - For high risk exposure (ex. Healthcare worker, student,
military personel) – ex. 2nd dose of MMR for high risk medical
practitioner
3 - For person at high risk for severe outcomeof infection (ex.
Pregnant, elderly, with chronic systemic disease) – ex. Rubella-
susceptible pregnant women should be vaccinated as early as
possible in the postpartum period, Influenza vaccine to adult with
chronic disease or >50 y/o, HepA with those risk of clotting
disorder or liver disease
4 – vaccine for household contacts of person in group 3 – ex.
HepB vaccine to household living with patient with Hepatitis B
infection
C. Adverse Event
Adverse event – can either be true vaccine reaction or
coincident evet
Adverse reaction or Side Effect – untoward effect extrenous to
its primary purpose
XV. Use of Vaccine in Special Circumstance
A. Influenza Pandemic Preparedness
B. Pregnancy – because of theoretical risk to the fetus & the
real risk of litigation to the practitioner, routine immunization
of women is avoided. Only live vaccine should not be given
to pregnant women which could cause risk of congenital
disorder to the fetus. If indicated some inactivated vaccine
such as HepB may be given in the 2nd or 3rd trimester.
C. Breastfeeding – vaccine does not affect safety of
breastfeeding
D. Occupational Exposure – work risk-related protective
purpose
E. HIV Infection & other Immunocompromised states –
persons known to be infected with HIV should be
immunized with recommended vaccine the same manner
 as with normal individual as early in the course of disease
before the immune function become slightly impaired. In
cased of immunocompromised state, live attenuated
vaccine is contraindicated, it is preferable then to give
passive immunization for prophylaxis.
F. Postexposure Immunization – certain infection, active or
passive, soon after exposure prevents or attenuate disease
expression.
Recommended postexposure immunization regimen (Refer
to Table 107-6, page 722)
G. Simultaneous Administration of Multiple Vaccine – no
contraindication; combinastion vaccine use to reduce
number of administration (exception DtaP & Hib should not
come together as primary immunization for infants due to
the suboptimal blunted result of Hib althogh it coul be use
as booster for adults; live virus vaccines should not be
given on the same day but with 30 days interval; increase
dose of accompanying immunoglobulin may inhibit the
efficacy of antigen vaccine – 3 months interval is
recommended)
H. Travel – travelers should have all routine immunization
updated before going to other place/country specially in
endemic area to avoid being turned back or immunized on
the spot.
A. Reemergence of Controlled Disease & Emergence of New
Disease
- fostered by the genetic potential of microbes to evolve
&exchange genetic information
- -rapid change of human demographics & behavior & global
ecology
- New infectious disease such as HIV, Lyme borelliosis,
hantavirus pulmunary syndrome, Hepatitis C &, recently,
SARS
B. New Vaccine Approach
• First-Generation Vaccine – whole-killed bacteria, partially
purified microbial products, live attenuated microorganism
• Second-Generation Vaccine – take advantage of
molecular genetic & protein chemistry, ex. Purified protein
protein or subunit of organism
• Third Generation Vaccine – nucleic acid (DNA or RNA)
are used to induce immunity.
XXIII. International Consideration – Expanded Program of
Immunization (EPI) by WHO & UNICEF (refer to the
2nd year EPI lecture of pedia1)

XVI. Delivery of Vaccine - ensure that every child is fully ZPDM 2005
immunized by the time of school entry

XVII. Access to Immunization

4 major barriers to infant & childhood immunization:
1 – low public awareness & lack of public demand
2 – Inadequate access to immunization service
3- missed opportunities to administer vaccine
4 – inadequate resources for public health & preventive purpose

Programs:
National Immunization Week – April
AFIX Program by CDC
A-ssessment of coverage
F-eedback of diagnostic investigation
I-ncentive & Rapport
X-eXchange of information among provider

XVIII. Handling of Vaccine – stored with care & should be

kept at 2-8 degree Celsius (not frozen) with the
exception of Varicella vaccine which is kept at –15
degree celsius. Measles vaccine should be protected
from light.

XIX. Standards for Immunization Practice (Refer to Table

107-8, page 723) – highlight true contraindication of
vaccine such as anaphylaxis in contrast to non-valid
contraindication

XX. National Vaccine Injury Compensation Program –

compensation law from patient victim of adverse
reaction of vaccine

XXI. Control of Vaccine Preventable Disease – maintain

individual & Herd Immunity. Goal: immunize each
subsequent generation as long as the threat to
reintroduction of disease from anywhere of the world
occur.

XXII. Research on Vaccine Immunization

Ideal Vaccine
• Administered orally early in life
• Provide life-long protection against multiple infection
• Can be given as one or only few dose
• Less reactive & more heat stable