1. PRINCIPLES OF VACCINATION Dr. Khadiga Dandash

2. Overview  Vaccination principles  vaccination storage  Vaccination techniques

3. Self vs. nonself Protection from infectious disease Usually indicated by the presence of antibody Very specific to a single organism Immunity

4. Active Immunity Protection produced by the person's own immune system Usually permanent Passive Immunity Protection transferred from another person or animal Temporary protection that wanes with time

5. Antigen A live or inactivated substance (e.g., protein, polysaccharide) capable of producing an immune response Antibody Protein molecules (immuno- globulin) produced by B lymphocytes to help eliminate an antigen Active Immunity

6. Passive Immunity Transfer of antibody produced by one human or other animal to another Temporary protection Transplacental most important source in infancy

7. Sources of Passive Immunity Almost all blood or blood products Homologous pooled human antibody (immune globulin) Homologous human hyperimmune globulin Heterologous hyperimmune serum (antitoxin)

8. Vaccination  Active immunity produced by vaccine  Immunity and immunologic memory similar to natural infection but without risk of disease

9. Classification of Vaccines Live attenuated viral bacterial Inactivated

10. Inactivated Vaccines Whole viruses bacteria Fractional protein- based toxoid subunit polysaccha ride-based pure conjugat e

11. General Rule-1 The more similar a vaccine is to the disease- causing form of the organism, the better the immune response to the vaccine.

12. Live Attenuated Vaccines 1. Attenuated (weakened) form of the "wild" virus or bacterium 2. Must replicate to be effective 3. Immune response similar to natural infection 4. Usually effective with one dose (except oral vaccines) 5. Severe reactions possible 6. Interference from circulating antibody 7. Fragile – must be stored and handled carefully

13. Live Attenuated Vaccines Viral: measles, mumps, rubella,varicellaYellow fever,rotavirus, Influenza intranasal Bacterial:BCG, oral typhoid

14. Inactivated Vaccines  Cannot replicate  Generally not as effective as live vaccines  Less interference from circulating antibody than live vaccines  Generally require 3-5 doses  Immune response mostly humoral  Antibody titer may diminish with time

15. Inactivated Vaccines Viral: polio, hepatitis A, rabies, influenza Bacterial : pertussis,typhoidcholera, plague

16. Inactivated Vaccine s Fractional Vaccines Subunit hepatitis B,influenza,pertussis, human papillomavirus, anthrax Toxoid: diphtheria,tetanus

17. Pure Polysaccharide Vaccines  Not consistently immunogenic in children younger than 2 years of age  No booster response  Antibody with less functional activity  Immunogenicity improved by conjugation

18.  pneumococcal  meningococcal  Salmonella Typhi  Haemophilus influenzae type b  pneumococcal  meningococcal Pure polysaccharide Conjugate Polysaccharide

19. General Rule- 2 # Inactivated vaccines are generally not affected by circulating antibody to the antigen. # Live attenuated vaccines may be affected by circulating antibody to the antigen.

20. Product Given First Vaccine Antibody Action Wait 2 weeks before giving antibody Wait 3 months or longer* before giving vaccine Antibody and Measles- and Varicella-Containing Vaccines

21. General Rule -3 In multidose vaccines: # Increasing the interval between doses does not diminish the effectiveness of the vaccine. # Decreasing the interval between doses of a may interfere with antibody response and protection *after the series has been completed

22. Minimum Intervals and Ages Vaccine doses should: Not administered at intervals less than the minimum intervals Not earlier than the minimum age

23. Extended Interval Between Doses  No significant difference in final titer  Not necessary to restart the series  Not necessary to add doses

24. Vaccine Adverse Reactions  Local  pain, swelling, redness at site of injection  common with inactivated vaccines  usually mild and self-limited  Systemic  fever, malaise, headache  nonspecific  may be unrelated to vaccine

25. Contraindication  A condition in a recipient that greatly increases the chance of a serious adverse reaction

26. severe allergic reaction to a vaccine component or following a prior dose encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination Permanent contraindications

27. Invalid Contraindications  Mild illness  Antimicrobial therapy  Disease exposure or convalescence  Pregnant or immunosuppressed person in the household  Breastfeeding  Preterm birth  Allergy to products not present in vaccine  Family history of adverse events  Tuberculin skin testing  Multiple vaccines

28. Vaccination During Acute Illness  Acute illness  Not reduce vaccine efficacy  Not increases vaccine adverse reactions  Mild illness, NOT a contraindication to vaccination  Delayed until the illness has improved

29. Vaccination of Immunosuppressed Persons  Live vaccines: Not administered.  Inactivated vaccines: safe but the response to the vaccine may be decreased

30. Vaccination of Pregnant Women  Live vaccines : Not administered  Inactivated vaccines: may be administered  HPV vaccine: delayed during pregnancy

31.  Inactivated influenza : only at the second or third trimester during pregnancy.  Tetanus Toxoid  Three-dose course: protection against maternal and neonatal tetanus for at least five years.  Five doses: protect women throughout their childbearing years. Vaccination of pregnant woman

32. Vaccination of Health Care Personnel Hepatitis B Influenza: MMR Varicella Tetanus Diphtheria Pertussis Meningococcal

33. Yellow Fever  All travelers arriving from infected countries  Valid certificate: 10 days after vaccination to 10 y Meningococcal Meningitis  All arrivals  valid certificate:10 days after vaccination to 3 years Poliomyelitis  infants and children 15 years or younger.  Certificate of polio vaccination Vaccination in Hajj

34. VACCINE STORAGE Dr Khadiga Dandash

35. Effect of Temperature on Vaccines  Live vaccines  deteriorate rapidly after removal from freezer  Inactivated vaccines  damaged by exposure to freezing temperatures

36. Cold Chain  Vaccines must be stored properly from the time they are manufactured until they are administered to your patients

37. Cold Chain

38. Typical Cold Chain

39. Vaccine Storage  Written protocol  One responsible person  One back-up person  Training

40. Vaccines destroyed by temperature

41. Vaccine Storage  Maintain required temperature  Separate doors ( Refrigerator / freezer  Large enough  No food or beverages!

42. Recommended Temperatures Refrigerator 2 o - 8 o C Average (5 o C) Freezer <-15 o C ( varicella /zoster, MMRV, LAIV)

43. Vaccine Storage Refrigerator

44. Temperature Monitoring  Thermometer for refrigerator  Thermometer for freezer  Temperature log for refrigerator  Temperature log for freezer  Check and record twice a day  Keep temperature logs for at least 3 years  immediate action when the temperature is outside the recommended range

45. Preventive Measures

46.  No vegetable bins  Bottles of water to stabilize refrigerator temperature  Extra cold packs or blue ice in the freezer  Never store vaccines in the door of the refrigerator or freezer

47. Prefilling Syringes  Increases the risk for administration errors  Increases vaccine wastage  May result in bacterial growth in vaccines that do not contain a preservative

48. Vaccine Inventory Control  Monthly vaccine inventory  Monitor expiration dates  Never use expired vaccine or diluent

49. Emergency Planning  Emergency vaccine retrieval and storage plan  Back-up site with a generator

50. VACCINE ADMINISTRATION

51. Proper Vaccine Administration  Promote optimal antibody response  Reduce risk of local adverse reactions

52. Subcutaneous Tissue Dermis Fatty Tissue Muscle Tissue 45° Angle Dermis Usual sites are thigh and upper outer triceps area of the arm

53.  Gauge23 to 25  Length5/8 inch  Needle inserted at a 45 o angle Subcutaneous needle Subcutaneous injection techniques

54.  Gauge: 22 to 25  Length: Newborn 5/8 inch Infant 1 inch Older Children 5/8* to 1¼ inch Adolescent/adult 1 to 1½ inch Intramuscular (IM) Tissue Intramuscular needle Dermis 90°Angle

55. Intramuscular Sites  Site selection depends on  person’s age  muscle development  Use deltoid muscle for older children, adults (toddlers only if adequate muscle mass)

56. IM Site - Infant Anterolateral Thigh (vastus lateralis muscle)

57. IM Sites Child/Adolescent/Adult Deltoid Muscle (preferred site) Site of Injecti on Vastus lateralis Muscle (alternative site)

58. Intramuscular Injection Technique

59. Vaccine Administration  Injection sites in same limb should be separated by at least 1 inch if possible

60. Vaccine Administration Errors  Wrong formulation  Wrong diluent  Incorrect route of administration

61. Infection Control  Hand hygiene  recommended between patients  alcohol-based waterless antiseptic can be used  Gloves potential for exposure to blood or body fluids open lesions on the hands or Equipment disposal never detach, recap or cut a used needle puncture-proof container dispose as infectious medical waste Safety needles

62. References  CDC.gov 2010  WHO.int 2010