1. Faculty of Medicine Applied VaccinationBy
Hatim Jaber
MD MPH JBCM PhD

2. Presentation outline Introduction to Immunology 14:00– 14:10
Time
Introduction to Immunology
14:00– 14:10
Vaccine-preventable diseases
Classification of Vaccines
14:10– 14:20
Principles of Vaccination
Routes of administration
14:20– 14:30
General Recommendations = Precautions and Contraindications
14:30– 14:50

3. World Immunization Week
24-30 April
Immunization averts 2 to 3 million deaths annually; however, an additional 1.5 million deaths could be avoided if global vaccination coverage improves.
Today, an estimated 18.7 million infants – nearly 1 in 5 children – worldwide are still missing routine immunizations for preventable diseases, such as diphtheria, pertussis and tetanus.

5. World Immunization Week, 24-30 April 2017

8. Global Vaccine Action Plan Goals of the Decade of Vaccines (2011–2020)

9. Defense Mechanisms
External defense
Internal Defense
Immune Defense

10. What is immunity?
Immunity is the body's ability to fight off harmful micro-organisms –PATHOGENS- that invade it.
The immune system produces antibodies or cells that can deactivate pathogens.

11. Vaccination
Vaccination is a method of giving antigen to stimulate the immune response through active immunization.
A vaccine is an immuno-biological substance designed to produce specific protection against a given disease.
A vaccine is “antigenic” but not “pathogenic”.

12. What’s the difference between Vaccination and Immunization
Immunization is the process of protecting people against harmful infections before they come into contact with them. It does this by using the body’s own natural defense system, the immune response.
Vaccination just means having the injection. When you are vaccinated, your body produces an immune response, just as you would if you were exposed to the infection, but without having the symptoms, and this builds up your resistance to that infection.

14. Vaccine-preventable diseases
Vaccine-preventable diseases include:
Cervical cancer
Cholera
Diphtheria
Hep B
Influenza
Japanese encephalitis
Measles
Mumps
Pertussis
Vaccine-preventable diseases include:
Pneumonia
Polio
Rabies
Rotavirus
Rubella
Tetanus
Typhoid
Varicella
Yellow Fever

15. Hib=(Haemophilus influenzae type b)

16. Vaccine Preventable Diseases (VPDs)
World immunization coverage up from 10% in 1970s to 80% in 1990s, then to 77% in 2004
Smallpox eradication achieved 1982
Polio eradication ????????????????
Measles still kills >0.4 million per year, need for a two dose policy (MMR)
Many new vaccines available and coming
Costs effectiveness and priorities
Coverage is good; Adapt and expand

17. NON-Vaccine Preventable Diseases????????

18. Eradication or Control of VPDs
Diseases under discussion for eradication –
- measles, TB, and some tropical diseases e.g. malaria and dracunculiasis
Eradication - no further cases of a disease occur anywhere in nature; continued control measures may be unnecessary e.g. smallpox, polio
Reducing epidemic and endemic VPDs in selected areas or target groups, may achieve local elimination
Local elimination is where domestic circulation of a virus is interrupted with cases occurring from importation only

19. Herd Immunity
Herd immunity can be defined as the resistance of a population to the introduction and spread of an infectious agent, based on the immunity of a high proportion of individual members of the population, thereby lessening the likelihood of a person with a disease coming into contact with b susceptible.
Example - If 90 % of the children are vaccinated for measles, the remaining 10 % of the children who are not vaccinated might not become infected with measles because most of the children (90 %) are vaccinated.
That means transmission from infected person to other susceptible children will not be easier.
Can lead to disappearance of diseases (smallpox)
Vaccination no longer necessary

21. Types of Acquired Immunity

22. Immunoglobulin and antiserum
Human normal immunoglobulin
Human specific immunoglobulin
Non human Ig (antisera, antitoxins)
Hepatitis A
Measles
Rabies
Tetanus
Mumps
Hepatitis B
Varicella
Diphtheria
Gas gangrene
Botulism

23. Types of vaccines Live vaccines Attenuated live vaccines
Inactivated (killed vaccines)
Toxoids
Polysaccharide and polypeptide (cellular fraction) vaccines
Surface antigen (recombinant) vaccines.

24. Types of vaccines Live vaccines Attenuated vaccines Killed
Inactivated vaccines
Toxoids
Cellular fraction vaccines
Recombinant vaccines
Small pox variola vaccine
BCG
Typhoid oral
Plague
Oral polio
Yellow fever
Measles
Mumps
Rubella
Intranasal
Influenza
Typhus
Typhoid
Cholera
Pertussis
Rabies
Salk polio
Intra-muscular influenza
Japanise encephalitis
Diphtheria
Tetanus
Meningococcal polysaccharide vaccine
Pneumococcal polysaccharide vaccine
Hepatitis B polypeptide vaccine
Hepatitis B vaccine

25. Routes of administration
Deep subcutaneous or intramuscular route (most vaccines)
Oral route (sabine vaccine, oral BCG vaccine)
Intradermal route (BCG vaccine)
Scarification (small pox vaccine)
Intranasal route (live attenuated influenza vaccine)

26. Vaccine administration
Intranasal route (live attenuated influenza vaccine)

27. Injection site Intramuscular Injections Site Preterms & neonates
Anterolateral thigh (junction of middle & lower third)
Infants
Toddlers & older children
Deltoid or Anterolateral thigh
Adolescents & adults
Deltoid
Subcutaneous Injections
thigh
>12 months
Outer triceps
Intradermal Injections
All age
Left deltoid

29. Vaccination schedule preschool -Jordan
Vaccine
Age
BCG
1st contact
DaPT1+HepB1+Hib1+IPV1
2 months
DaPT2+HepB2+Hib2+IPV2+OPV
3 months
DaPT3+HepB3+Hib3+OPV
4 months
Measles + OPV
9 months
MMR1
12 months
DPTbooster1 +OPV booster1 +MMR2
18 months

30. IAP recommendations for immunization in adolescents
Vaccines
Schedule
MMR
2 doses at 4-8 weeks interval
Hepatitis B
3 doses at 0,1 & 6 months
Hepatitis A
2 doses at 0 & 6 months
Typhoid
1 dose every 3 years
Varicella
Influenza
1 dose every year
JE vaccine
Catch-up up to 15 years
Tdap
1 dose followed by Td booster every 10 years

31. Vaccination for travelers the most frequent vaccine-preventable diseases and the dose schedules

32. Scheme of immunization
Primary vaccination
One dose vaccines (BCG, variola, measles, mumps, rubella, yellow fever)
Multiple dose vaccines (polio, DPT, hepatitis B)
Booster vaccination
To maintain immunity level after it declines after some time has elapsed (DT, MMR).

33. Changes in immunoglobulin levels with age

35. Why multiple doses necessary?
Single does may not provide sufficient immunity (e.g. HIB)
Immunity wanes over time; “booster” dose is needed (DTaP)
Single dose does not produce immunity for everyone (e.g. measles)
Vaccine components change over time (e.g. influenza)

36. Periods of maintained immunity due to vaccines
Short period (months): cholera vaccine
Two years: TAB vaccine
Three to five years: DPT vaccine
Five or more years: BCG vaccine
Ten years: yellow fever vaccine
Solid immunity: measles, mumps, and rubella vaccines.

37. Levels of effectiveness
Absolutely protective(100%): yellow fever vaccine
Almost absolutely protective (99%): Variola, measles, mumps, rubella vaccines, and diphtheria and tetanus toxoids.
Highly protective (80-95%): polio, BCG, Hepatitis B, and pertussis vaccines.
Moderately protective (40-60%) cholera vaccine, and influenza killed vaccine.

38. The Cold Chain
The "cold chain" is a system of storage and transport of vaccines at low temperature from the manufacturer to the actual vaccination site.
The cold chain system is necessary because vaccine failure may occur due to failure to store and transport under strict temperature controls.

39. Principles of vaccination

40. Principles of Vaccination
The primary goal in vaccination is to provide protective immunity by inducing a memory response to an infectious microorganism using a non-toxic antigen preparation. It is important to produce immunity of the appropriate kind: antibody / or cellular immunity.
Antibodies produced as a result of immunization are effective primarily against extracellular organisms and their products e.g., toxins. Passively administered antibodies have the same effect as induced antibodies.
Cell-mediated immunity (T cells, macrophages) induced by vaccination is important particularly in preventing intracellular bacterial and viral infections and fungal infections.

41. Principles of Vaccination
4.The ultimate goal of any immunization program is the eradication of the disease.
5.This requires that the infection is limited only to humans, with no animal or environmental reservoir, and the absence of any subclinical or carrier state in humans.
6.Achieving elimination requires a high level of herd immunity to prevent person to person spread.
7.This requires considerable infrastructure support to ensure that all at-risk populations are targeted for immunization.
8.This has been achieved for small pox, although we are close to the elimination of polio.

42. HAZARDS OF IMMUNIZATION
No immune response is entirely free from the risk of adverse reactions or remote squeal. The adverse reactions that may occur may be grouped under the following heads:
Reactions inherent to inoculation
Reactions due to faulty techniques
Reactions due to hypersensitivity
Neurological involvement
Provocative reactions
Others

43. Adverse events after vaccination are grouped into five categories, depending on whether they are due to:
• the vaccine product: an adverse event caused or precipitated by a vaccine due to one or more of its inherent properties. Example: extensive limb swelling after administration of DTP vaccine
• quality: an adverse event caused or precipitated by a vaccine with one or more defects, including the administration device provided by the manufacturer. Example: paralytic poliomyelitis due to failure by a manufacturer to completely inactivate a lot of poliovirus vaccine
• vaccination error: an adverse event due to inappropriate handling, prescription or administration of a vaccine. Example: transmission of infection from a contaminated multidose vial
• anxiety: an adverse events arising from anxiety about the procedure. Example: vasovagal syncope in an adolescent during or after vaccination
• a coincidental event: an adverse event caused by an event other than the vaccine, vaccination error or anxiety. Example: a fever occurring at the time of vaccination (temporal association) that is in fact due to a viral infection

44. Main minor and severe reactions associated with vaccination

45. Different type of adverse events following immunization
Vaccine reaction
Event caused/precipitated by the inherent properties of the vaccine (active component, adjuvant, preservative, stabilizer) when given correctly
Program errors
Event caused by an error in vaccine preparation, handling or administration
Coincidental
Event that happens after immunization but is not caused by the vaccine
Injection reaction
Event arising from anxiety about, or pain from, the injection itself rather than the vaccine
Unknown
The cause of the event cannot be determined

46. Common minor vaccine reactions
Local reaction (pain, redness, swelling)
Fever
Irritability, malaise & non specific reactions
BCG
common
Hib
5-15%
2-10%
Hep-B
Adults-15%
Children-5%
1-6%
Measles/MMR
10%
50% (rash)
OPV
<1%
TT/DT/Td
25%
DPwT
50%
60%

47. Rare serious vaccine reactions
BCG
Suppurative adenitis, BCG osteitis, Disseminated BCGitis
Hep-B
Anaphylaxis
Measles/MMR
Febrile seizures, thrombocytopenia, anaphylaxis
OPV
VAPP TT
Brachial neuritis, anaphylaxis, sterile abscess
DTP
Persistent inconsolable screaming, seizures, HHE, anaphylaxis, shock JE
Serious allergic reactions, neurological events YF
Allergic reactions/anaphylaxis

48. Differential diagnosis of fainting and anaphylaxis

49. Reactions due to anxiety about vaccination
Fainting is relatively common, mainly among older children and adults. This vasovagal reaction may lead to loss of postural tone and consciousness
• Hyperventilation due to anxiety about vaccination can cause light-headedness, dizziness and tingling around the mouth and in the hands.
• Vomiting: Vomiting is a common anxiety symptom in young children. Breath-holding spells may occur, which can result in brief unconsciousness, during which breathing resumes.
• Convulsions: An anxiety reaction to injection can, on rare cases, include convulsions. Convulsions usually occur in the context of a vasovagal reaction and syncope, soon after or with the loss of postural tone and consciousness that characterizes syncope. Such seizures are due to anoxia, are usually self-limited and benign and do not require antiepileptic drug therapy.

50. Vaccination Coverage
Vaccination coverage is the percent of at risk or susceptible individuals, or population who have been fully immunized against particular diseases by vaccines or toxoids.
To be significantly effective in prevention of disease on mass or community level at least a satisfactory proportion (75% or more) of the at risk population must be immunized.
No. persons immunized in specified age group
= X 100
No. persons in the age group during that year

52. WHO UNICEF estimates time series for Jordan

53. Vaccines Contraindications and Precautions

54. Active untreated tuberculosis.
Who should NOT receive a vaccine? Contraindications to any routine active immunization procedure
Severe allergy to any vaccine component
Severe reaction to same vaccine in past
Individuals with certain immunodeficiencies (live vaccines)
An acute febrile illness, malaise, cough, diarrhea, or other symptoms requiring medical treatment.
Children who have had convulsions, fits, cerebral damage or irritation in the neonatal period or any neurological disorder which appears to be active should not normally have DTP vaccine as a routine. They should be referred for specialist advice.
Active untreated tuberculosis.

55. Contraindications to the use of live attenuated vaccines
Immunocomproised infants and children.
Patients suffering from any malignant condition such as leukemia or Hodgkin’s disease.
Patients undergoing treatment with corticosteroid (other than topical steroids), alkalating agents, antimetabolites or those receiving radiotherapy.
Organ transplantations.
Pregnancy,
Sever protein energy malnutrition or kwashiorkor???????

56. There are very few contraindications to rotavirus vaccines.
a history of a severe allergic reaction (e.g. anaphylaxis) after a previous dose of either rotavirus vaccine or any component of the vaccine being given;
• severe combined immunodeficiency; the risk–benefit ratio for children with known or suspected altered immunocompetence should be assessed individually. Children and adults with congenital immunodeficiency, haematopoietic transplantation or solid organ transplantation sometimes experience severe or prolonged rotavirus gastroenteritis.
• a history of intussusception, which places children at greater risk than children who have never had it.

57. These are not contraindications to Routine Immunization
· Minor illnesses such as upper respiratory infections or diarrhoea, mild fever (< 38.5°C)
· Allergy, asthma
· Prematurity, underweight newborn child
· Malnutrition??????????????????????? Under nutrition, failure to thrive .
· Child being breastfed
· Family history of convulsions
· Treatment with antibiotics
· Dermatoses, eczema or localized skin infection
· Chronic diseases of the heart, lung, kidney and liver
· Stable neurological conditions, such as cerebral palsy and Down's syndrome
· History of jaundice after birth

58. Conditions which are NOT Contraindications (cont.)
- An antibiotic course just completed.
-Congenital heart disease, chronic diseases of the chest, eg. Cystic fibrosis (these are important indications for immunization)
- Prematurely, or preterm delivery.
- Nappy rash.
- Breast feeding.
- Topical steroids.

59. Invalid Contraindications Minor Illness
Low grade fever
Upper respiratory infection
Otitis media
Mild diarrhea
Only one small study has suggested decreased efficacy of measles vaccine in children with URI
Findings not replicated by multiple prior and subsequent studies
No evidence of increased adverse reactions

60. Summary Current recommended vaccinations are safe and effective
No vaccines are 100% effective or 100% risk-free
Current recommendations based on best available scientific data
Schedule reviewed/updated annually

61. Summary and Conclusion
Vaccination is cornerstone of PH
Children and other groups
Rapidly developing field
First priority in public health after safe water and food
National programs must be revised annually