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Immunization
Center for Disease Control & Prevention (CDC-ACIP) publishes Childhood and Adolescent Immunization Schedules at least annually since 1995 Indian Academy of Pediatrics (IAP) revises the Immunization Schedule almost every 3 years: Latest 2011 Many care givers/parents are not aware of importance of various vaccines/newer additions Parents may be mislead by media/peer groups
Immunization Schedule
Every country has its own immunization schedule because: Low prevalence of disease/not cost effective e.g. no BCG in US/UK Certain diseases are prevalent in particular age group, e.g. Measles at 9 mo; MMR in India given at 15 mo & 5 yrs. In UK at 13 yrs Suitability of preparations & disease prevalence. e.g. IPV instead of OPV in US/UK, influenza vaccine to all children in cold countries Operational convenience. e.g. In India DPT-Hib given at 6 weeks rather at 2 months Guidelines change: Hep-B booster at 5 years age was recommended earlier no longer now!
(IAP-2001)
ACQUIRED
NATURAL By infection
ARTIFICIAL By immunization
Immunization can be active/passive, Vaccination is always active. Vaccination does NOT guarantee immunization!
$ MMR is available in some states only. $$ Hib is being introduced in two states to begin with
60-70% Efficacy
Optional Vaccine?
o Optional = Vaikalpik/Aechhik, Not Swechchhik o Formerly: Hep-A, Hib & Varicella vaccine o Presently there is no compulsory vaccine in our
country! o For any Indian going to USA for study or job, MMR vaccine is mandatory. We do not have any mandatory vaccine, any person coming to our country gets Typhoid vaccine or Hepatitis A vaccine in his or her own interest oThe option is with the persons or the parents to go for a particular vaccine or not, at their own risk. The doctor should consider no vaccine as optional vaccine!
Indian Pediatrics 2001; 38: 99-101
Delayed Immunization
Common Mistakes
o Administration of two vaccines at short intervals:
weekly or after 15 days oAdministration of two vaccines simultaneously despite recommendation e.g. BCG with measles, MMR with chicken pox o Administration of vaccines at wrong site: e.g. giving Rabies/Hep-B vaccine at Hips, or DPT at hips in infants, Tetanus toxoid in hips in older children/adults o Failure to give good advice regarding vaccine e.g. Pneumococcal to SCA patient, Influenza to Asthmatics o Mixing of vaccines in the same syringe (prior to injection) unless specifically recommended by the manufacturer
Immunization: Facts
There is no age limit for immunization, even adults need vaccines for protection If the vaccination was discontinued or delayed, it should be started from where it was stopped. No need to repeat the doses! No need no give hepatitis-A vaccines if child had it once. But this does not apply to measles, mumps, tetanus, diphtheria, typhoid, etc Malnourished/underweight children also require timely vaccination Vaccination site should never be rubbed. It should be pressed for a minute!
Immunization: Facts
If the child had confirmed varicella or laboratory evidence of prior disease, it is not necessary to vaccinate regardless of age at infection. If there is any doubt that the illness was actually varicella, the child should be vaccinated. Children can be breastfed soon after giving oral polio vaccine Children with mild fever, cough, cold or diarrhea can take all the vaccines Pulse polio immunization is supplementary to routine vaccination Preterm babies should be given vaccination at usual age (except Hep-B when >2 Kg or > 1mo)
TARGET 5: Guide on vaccine storage & handling: 1st Ed, Dec 2006, IAP SURAT
Spacing of Vaccines
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm
Vaccination Sites
Anterolateral thigh (vastus lateralis):
The infants nappy must be undone to ensure the injection site is completely exposed and the anatomical markers easily identified. Position the leg so that the hip and knee are flexed and the vastus lateralis is relaxed. The upper anatomical marker is the midpoint between the anterior superior iliac spine and the pubic tubercle, and the lower marker is the upper part of the patella. Draw an imaginary line between the 2 markers down the front of the thigh. The correct site for IM vaccination is lateral to the midpoint of this line, in the outer (anterolateral) aspect. Do not inject into the anterior aspect of the thigh where neurovascular structures can be damaged.
Vaccination Sites
Ventrogluteal area: [Do not confuse with the dorsogluteal area (buttock)] The ventrogluteal site provides an alternative site for administering vaccines to a child of any age, especially when multiple injections at the same visit are required. The ventrogluteal area is relatively free of major nerves and blood vessels, and the area provides the greatest thickness of gluteal muscle.25,26 There is a relatively consistent thinness of subcutaneous tissue over the injection site
Vaccination Sites
The deltoid area: It is essential to expose the arm completely from the top of the shoulder to the elbow when locating the deltoid site. Roll up the sleeve or remove the shirt if needed. The injection site is halfway between the shoulder tip (acromion) and the muscle insertion at the middle of the humerus (deltoid tuberosity). Draw an imaginary, inverted triangle below the shoulder tip, using the identified anatomical markers. The deltoid site for injection is the middle of the muscle (triangle) SC vaccines can also be administered over same region! Vaccination site should never be rubbed!
Vaccination: Positioning
Medicolegal Aspects
o The vaccine administrator must explain in detail the
characteristics and anticipated side effects of the vaccine in reasonable detail to the caregivers prior to immunization. o A verbal consent is usually adequate. In any case, the recipient must be observed for any allergic effects for at least 15 minutes after vaccination and all resuscitative equipment must be kept standby for possible anaphylaxis. The care givers should also be counseled about possible side effects, their management and danger signs before the vaccinee is sent home. o Minimum equipment: Airway, ambu bag, mask, IV access (scalp vein, venflon), O2 cylinder, Inj. Adr (1: 1000 sol.), IV hydrocortisone, Normal saline
Indian Academy of Pediatrics: Guidebook on Immunization, 2011
Anaphylaxis: Vaccination
www.immunize.org/catg.d/p2017.pdf
1985
BCG + OPV DPT1 + OPV DPT2 + OPV DPT3 + OPV Measles DT TT TT 6 diseases, 9 shots
2012
+ HB + HB + Hib + IPV + PCV + Rota + HB + Hib + IPV + PCV + Rota* Hib + IPV 12 mo: Hep-A, Varicella, MMR Hib + IPV, Hep-A2, 2 yrs: Typhoid DPT + Varicella2 + MMR2, Typhoid2 Tdap/dT, HPV for girls dT 16 diseases, 22 shots at least
Thanks
Immunization: Q & A
Is there any need of documentation in case of refusal to vaccinate the child? Is it compulsory to wear gloves or change the needle while vaccinating the child? What should be done if child vomits the oral vaccine? What is the preferred site of vaccination for i/m injection or vaccination on children? What should be done if a 1 month old child accidentally given DPT? Is there any need of aspiration before injection of vaccines or toxoids?
Immunization: Q & A
What measures should be take to prevent anaphylaxis? Is there any need of rubbing the site after vaccination? What should be done if previous vaccination records are not available? What should be done if there is a long lapse of time between the doses? e.g. 2 years lapsed after 1st dose of HAV vaccine What should be the ideal time interval between various vaccine? Does it apply to oral vaccine (like OPV, Rota, Ty21a, Cholera) also?
Immunization: Q & A
What is the time limit to delay the vaccine from the scheduled date?