1. Pneumococcal vaccine Polyvalent Untoward reaction in older children and adult Responsiveness is unpredictable in children younger than 2 23-valent pneumococcal vaccine contains purified polysaccharide from 23 pneumococcal serotype responsible for more than 95% of cases of bacteremia and meningitis and 85% of cases of otitis media.

2. Clinical efficacy is controversial Pneumococcal serotype 6A is one of the strains most likely to produce disease in children. Antigens 6A, 14, 19F, 23F, are poorly immunogenic in children younger than 6. New protein-conjucate pneumococcal polysaccharide vaccine are being evaluated. Pneumococcal vaccine

3. Indication for immunization Children older than 2 years Sickle cell anemia Functional or anatomic asplenia Nephrotic syndrome Splenectomy after staging laparatomy Cerebrospinal fluid leaks HIV infection Chronic cardiovascular, pulmonary, or liver disease

4. Not recommended for: Prevention of recurrent otitis media or sinusitis

5. Revaccination Need for revaccination is uncertain Children 10 years of age or younger at the time of revaccination A single revaccination 3 years after the first dose Children 10 years of age or older at the time of revaccination A single revaccination 5 years after the first dose

6. Immunization dose not prevent pneumococcal disease related to serotypes not found in the vaccine Many report of serious and even fatal infections in vaccinated children have been described Pneumococcal vaccine

7. Meningococcal vaccine A quadrivalent vaccine composed of capsular polysaccharide of meningococcal groups A, C, Y, W135 is licensed. Immunogenic in adult but not reliable in children younger than 2 No vaccine is available for serogroup B Routine use is not recommend

8. indication Military recruits Control of outbreaks Travelers to high endemic area Close contact of individual with A, C, Y, W135,. Anatomic and functional asplenia. Complement component deficiency

9. Haemophylus influenza The most important element of host defense is antibody directed against the type b capsular polysaccharide,PRP. it is related to it’s opsonic activity Antibody against outer membrane protein and lipopolysaccharide may also have role in opsonization.

10. Lack of antibody in young infant may reflect maturational delay in immunologic response to thymus independent antigen like unconjugated PRP The conjugated vaccine has thymus independent properties and elicit antibody response in young infant.

11. Currently available combination are PRP- OMP combined with hepatitis B vaccine Attempts to combine DTaP with H influenza vaccine have resulted in decreased anti-PRP antibody.

12. Varicella zoster immune globulin Post exposure prophylaxis is recommended in immunocompromised children Pregnant women Newborn exposed to maternal varicella Close contact of a susceptible with herpes zoster 1 vial (125 unit) for each 10 kg (max 5 vial) Should be given IM As soon as possible but within 96 hours It is not indicated after onset of symptoms

13. New born whose mother develop varicella 5 days before or 2 days after delivery should receive 1 vial. Adult should be tested before VZIG administration. VZIG may ameliorate disease but dose not eliminate the possibility of progressive disease

14. Patient who have received high dose IVIG (100-400 mg/kg )within 2-3 weeks ago have serum antibody to VZV. Vaccine given to normal children within 3 days exposure may be effective

15. Rubella post exposure prophylaxis Nonpregnant susceptible contacts of person with rubella should be vaccinated (dose not prevent infection but ensure protection) All pregnant women regardless of immunization history should make effort to avoid exposure to rubella

16. Unknown immune state exposure Antibody test Immune Reassure Not immune Repeat test 3-4 week later Seroconversion infection negative Repeat test 3 week later positive negative

17. If termination of pregnancy is not an option immunoglobulin administration is indicated. The dose is 0.55 mg/kg

18. Measles post exposure prophylaxis Immunoglobulin is effective for prevention and attenuation of measles within 6 days of exposure. -indication Susceptible pregnant (0.25 ml/kg ) Children below 12 mon(0.25 ml/kg ) Immunocompromised (0.5 ml/kg ) Susceptible children 6-12 should also be vaccinated

19. Rabies posexposure prophylaxis It is indicated for all persons with a history of a rabid animal bite. Prevention depend on three complementary means of reducing the risk. Local wound care Passive immunization with human rabies Ig Immediate blockage of attachment of virus to the nerve ending

20. Passive immunization for Rabies Is available as HRIG Dose is 20 IU /kg with as much as possible of the full dose of HRIG infiltrated in the area around the wound Any remaining should be administered IM at a site distant from vaccine inoculation. If vaccine was started previously, passive immunization should not be given once 8 days have elapsed Corticosteroid should be avoided in the treatment of reaction because it activate rabies virus

21. Diphteria antitoxin Specific antitoxin is the mainstay of therapy and should be administered on the basis of clinical diagnosis It neutralize only free toxin Antitoxin is administered once at empiric dosage based on the degree of toxicity site and size of the membrane and duration of illness. Probably of no value for local manifestation

22. Diphtheria Antitoxin First used in 1891 Produced in horses Used only for treatment of diphtheria Neutralizes only unbound toxin

23. Basis of dose antitoxin dosage Cutaneous lesion only 20000-40000 Pharyngeal laryngeal disease 20000-40000 Nasopharyngeal lesions 40000-60000 Extensive disease 80000-100000 Diffuse swelling of the neck 80000-100000

24. Tetanus Wound Management Vaccination History Unknown or <3 doses 3+ doses TdTIG YesNo No*No TdTIGYes No**No Clean, minor wounds All other wounds * Yes, if >10 years since last dose ** Yes, if >5 years since last dose

25. Tetanus immunoglobulin Once tetanus toxin has begun its axonal ascent to the spinal cord it can not be neutralized by TIG. TIG should be given as soon as possible TIG optimal dose has not been determined 500 IU is sufficient but as high as 3000-6000 U are also recommended Infiltration of TIG in to the wound is unnecessary If TIG is not available human IVIG which contain 4- 90 U/ml of TIG can be used

26. Tetanus Toxoid Formalin-inactivated tetanus toxin ScheduleThree or four doses + booster Booster every 10 years EfficacyApproximately 100% DurationApproximately 10 years Should be administered with diphtheria toxoid as DTaP, DT, or Td

27. Age vaccine birth1 mo2 mo4 mo6 mo12 mo15 mo18 mo24 mo4-6 y11-12 y14- 16 y Polio IPV Mumps measles rubella MMR Influenza INFLUENZA Pneumococpneumo coccal Rotavirus CONTRANDICATED in all HIV infected persons varicella CONTRANDICATED for many HIV infected persons