1. Preventive Pediatrics
Celia T. Sy, M.D.
Pediatric Pulmonologist
Department of Pediatrics
Fatima Medical Center

2. Immunization
Vaccinations
Type of vaccine
Route of administration
Immune response
Post- exposure drug prophylaxis

3. Immunization
Denotes the process of inducing or providing immunity artificially by administering an immunologic substances
Active
Passive

4. Active Immunization
When it produces the desired beneficial effects by stimulation of endogenous antibody production by the patient
Tetanous toxoid
MMR
BCG

5. Passive Immunization
Administration of preformed human or animal antibodies to individuals already exposed or about to be exposed to certain infectious agents
Tetanus antitoxins
Immune globulins

6. Vaccination
Denotes the physical act of administrating any vaccine or toxoids

7. Immunobiologic Substances
Vaccine - a suspension of live or inactivated microorganism or fractions thereof administered to induce immunity and prevent infectious disease or its sequela
Toxoid – modified bacterial toxin that has been made nontoxic but retains the ability to stimulate the formation of antitoxins

8. Antitoxins – a solution of antibodies derived from the serum of animals immunized with specific antigens
Passive immunization
Diphtheria antitoxin
Tetanus antitoxin

9. Immune globulin (IG) - a sterile solution containing antibodies from human blood. Intended for IM use
for passive immunization
Measles immune globulin
hepatitis b immune globulin

10. IV IG – a product derived from blood plasma from the donor pools similar to the IG pool but prepared for IV used
Used in primary antibody-deficiency disorders
Kawasaki disease
ITP
Hypogammaglobulinemia

11. Immunologic Constituents
Suspending fluids – sterile water, saline
Preservatives, Stabilizers, Antibiotics
used to inhibit or prevent bacterial growth
Stabilize the antigens or antibodies
albumin, phenols, neomycin, mercurial
Adjuvants – evoke suboptimal immunologic response
To enhance immunogenicity
Al hydroxide, Al phosphate

12. Vaccines & Toxoids Live vaccines Killed antigens BCG MMR Oral polio
Varicella
Oral typhoid
Killed antigens
Toxoids
DPT
Tetanus

13. Killed antigens Killed antigens Inactivated Virus
IPV (inactived polio virus)
Influenza
Rabies
Hepatitis A
Hepatitis B
Killed antigens
Bacterial polysaccharide
Hib

14. Route of Administration
Intramuscular (IM)
DPT
IPV (as DPT-IPV-HIB combination)*
Hep A & B
HiB
Influenza
Pneumococcal
Meningococcal
Typhoid
Subcutaneous (SC)
Measles
Mumps
Rubella
MMR
Varicella
IPV
Pneumococcal
Meningococcal

15. Route of Administration
Oral
OPV
Typhoid
Intradermal
BCG

16. Where to inject? General rules:
For children < 1 year old – lateral thigh
For children > 1 year old - deltoid
Buttocks should not be used for active vaccinations because of the potential risk of injury to the sciatic nerve
If the buttocks are to used – use only the upper outer quadrant

17. Fever: To give or not to give?
Minor febrile illness or malnutrition is not a contraindication to immunization
Immunization is deferred in the presence of severe febrile illness

18. Vomiting: What to Do? Regurgitated oral vaccine
If the child vomit or regurgitate within 5 – 10 mins after giving OPV – another dose should be given at the same visit
If repeated dose is not retained,
re-administered at the next visit

19. Diarrhea: Could OPV be given?
Diarrhea should not be considered as a contraindication for OPV but to ensure full protection, doses given to children with diarrhea SHOULD NOT BE COUNTED as part of the series

20. Need to give 2 or more vaccines: How to give?
Multiple vaccinations
Administer each vaccine at a different site using different needles and syringes
If > 1 vaccine is to be used in a single limb, use the thigh muscle and given at 1 -2 inches apart

21. Interruption of Schedule What to do?
Interruption with a delay between doses does not interfere with the final immunity achieved
No need to start the series again

22. Contraindications? Live attenuated vaccines is contraindicated in:
Pregnant woman
Immunocompromised person – leukemia, lymphoma, malignancy, therapy with steroids, alkylating agents, antimetabolites
Radiotherapy

23. Trivia Which of the following are live vaccines? DPT Measles
TOPV Pneumococcal
IPV Meningococcal
BCG Oral Typhoid
Hep B
MMR

25. Guidelines for Giving Live vaccines and killed Antigens
2 or more killed antigens – may be administered simultaneously or at any interval between doses
Example:
DPT and Hep B
DPT and Hib
Hep A and Hep B

26. Killed and live antigens – may be administered simultaneously or at any interval between doses
Example:
DPT and OPV
Hep b and MMR
DPT and Measles
DPT and varicella

27. 2 or more live antigens – may administered simultaneously or at 4 week minimum interval if not given simultaneously
Example:
Measles and varicella
MMR and varicella
** OPV can be administered at any time before, with or after MMR if indicated

28. Guidelines for administration of IG & Vaccines
Simultaneous administration
IG and killed antigen – given at the same time or at any time between doses
Hepatitis B immune globulin and hepatitis B vaccine
Tetanus antitoxins and anti-tetanus vaccine
IG and live antigen – should generally NOT BE ADMINISTERED simultaneously

29. Guidelines…IG & Vaccines
Non-simultaneous administration
First Second
IG Killed Ag No interval needed
IG Live Ag dose related
Killed Ag IG No interval needed
Live Ag IG 2 weeks

30. Interval between IG & Live Measles Vaccine
IVIG Interval
ITP 400 mg/kg 8 month
ITP 1000 mg/kg 10 months
Kawasaki 11 months
Blood transfusion
Whole blood & packed RBC 6 months
Plasma/platelets 7 months

31. Interval…IG & live measles vaccine
IG measles prophylaxis
Normal contact 0.25ml/kg mons
Immunocompromised 0.50ml/kg 6 mons

33. Trivia Which of the following vaccines can be given simultaneously?
Hep B & Measles
BCG & DPT
Oral polio & measles
DPT & MMR
Measles & MMR
DPT & IPV + HiB

34. Immune Response
Immune response to one live virus vaccine might be impaired if administered within 30 days of another live virus vaccine
Only OPV and MMR can be administered at anytime before, with or after each other

35. Immune Response
Live virus vaccines can interfere with the response to a tuberculin test
Tuberculin testing can be done either on the same day that live virus vaccines are administered or 4 – 6 weeks later

36. Special Conditions… Special Considerations
Persons with hemophilia
Increased risk of hepatitis B & hematomas
Assess the patient’s bleeding risk
Use fine needle & apply pressure to the site

37. Special considerations…
Altered immunocompetence
Killed or inactivated vaccines can be administered to all immunocompromised patients
OPV should not be given to any household contacts of an immunocompromised patient
IPV can be given

38. Special considerations….
Altered immunocompetence
MMR is not contraindicated to close contacts of immunocompromised persons
MMR vaccine is recommended for all asymptomatic HIV-infected persons and should be considered for all symptomatic HIV-infected persons

39. Special consideratios…
Preterm infants
Regardless of birth weight should be vaccinated at the same chronological age and according to the same schedule
Use full recommended dose except BCG
OPV should be deferred until discharge from the nursery

40. Special considerations…
Pregnancy
Combined tetanus and diphtheria toxoids ARE THE ONLY vaccine indicated

41. Vaccines BCG (Bacille-Calmette-Guerin)
Attenuated bovine strains of tubercle bacilli
Route: intradermal
Dose: 0.05 ml preterm
0.1 ml term
Complications
Abscess
Indolent ulcer
lymphadenopathy

42. BCG
Normal course
Wheal diappear in 30 mins
Induration – after 2-3 wks
Pustular formation – after 4 – 6 wks
Full scarification – after 6 – 12 wks
Accelerated reaponse – % correlation with TB infection
Induration – after 2 – 3 days
Pustular formation – after 5 – 7 days
Scar – after 2 -3 wks

43. Polio vaccine OPV – live attenuated vaccine IPV – inactive polio virus
Combination vaccine:
DPT + IPV + Hib

44. DPT
Toxoids of diphtheria & tetanus; inactivated pertussis component adsorbed into aluminum salts
Dose: 0.5 ml
Route: IM
Side effect: swelling at injection site

45. DTaP Diphtheria, tetanus, acellular pertussis component
Decrease risk of neuroparalytic reactions due to component of pertussis

46. Measles Live attenuated vaccine Freeze dried Dose: 0.5 ml SQ
Side effects: fever between 5th-14th day after injection, rashes, arthritis
Prophylaxis: may be given within hours after measles exposure
Measles IG – 0.25 ml/kg IM may be within 6 days of exposure

47. Hepatitis B Vaccine
Infant born to HBs Ag-positive mother should received:
Hep b Vaccine + Hep B immune globulin (HBIG) within 12 hours of birth at different site
Next dose: Hep B at 1-2 months of age and 3rd dose at 6th month of age
Schedule: 0, 1, 6

48. Hepatitis B Vaccine
Infant born to mother whose HBsAg status is unknown:
Hep B vaccine within 12 hours of birth
Request for mother’s HBsAg status – if (+)
Infant should received HBIG Asap
(no later than 1 week of age)

49. Recommended Schedule BCG DPT, TOPV, IPV, Hib Hepatitis B Measles
At birth or anytime after birth
2, 4, 6 month of age
0, 1, 6 month of age
0, 1, 3 month of age (endemic country)
9 month of age
( can be given at month of age)

50. Schedule…. MMR Hepatits A Pneumococcal (IPD 7 valent)
Pneumococcal (23-valent)
Meningococcal
Typhoid
15 month of age
After 1 year of age
2, 4, 6 months up to 9 years of age
2 years of age
3 years of age

51. Post-exposure Drug Prophylaxis
Diphtheria Erythromycin
Pertussis Erythromycin
Cholera Tetracycline
Plasmodia Chloroquine
N. gonorrhea Amoxicillin/Penicillin
Meningococcemia Rifampicin
Sulfisoxazole
Ceftriaxone
Tuberculosis Isoniazid

52. Case 1
A 3 y/o child was exposed to a person with measles. Past immunization hx: he had received 1 dose of BCG, 3 doses of DPT, TOPV & Hepatitis B. If you are the attending physician, how are you going to manage the patient?
Give measles vaccine if the exposure is within 72 hours
Give measles immunoglobulin if the exposure is more than 72 hours
Give MMR if the exposure is within 72 hours
Give Mesles vaccine and immune globulin at the same time
Observe the patient