Immunization in Adults, Geriatrics and

PaediatricsDr. Milan. C. Patel.

DNB (Family Medicine).

Inlaks and Budhrani Hospital, Pune.

What is immunization?

Immunization is the administration of antigenic material to stimulate an individual’s immune system to develop adaptive immunity to a pathogen.

Active immunity develops as a result of infection or by specific immunization and is usually associated with presence of antibodies.

Passive immunity develops when antibodies produced in a human or animal body are transferred to another to induce protection against disease.

History of Vaccination

429 BC : Greek historian Thycudides noticed that people who survive smallpox do not get reinfected.

900 AD : Chinese discovered variolation 1700s : Variolation spreads around the world 1796 : Edward Jenner discovered vaccination in its

modern form and proved to the scientific community that it worked.

Edward JennerJenner vaccinated baby with the lymph from a cowpox infected dairymaid. He also used lymph from sores on cow teats – found it equally effective

EDWARD JENNERDiscovered the small pox vaccine in its modern form and proved to the scientific committee that it worked.

History of Vaccination

1890: Emil von Behring discovers the basis of DT vaccine 1920s: Vaccines become widely available. 1955: Polio vaccination begins. 1956: WHO fights to eradicate smallpox. 1980: Smallpox eradicated from the world. 2008: Professsor Harald zur Hausen awarded Nobel Prize

for discovery of HPV Vaccine. 2013: Rotavirus vaccine and shingles vaccine introduced.

Louis PasteurDiscovered the rabies vaccine

Vaccine Preventable Diseases

Tuberculosis Diptheria Pertussis Tetanus Poliomyelitis Measles Mumps Rubella Typhoid

Haemophilus influenza B Hepatitis A Hepatitis B Influenza (H1N1) Varicella Zoster Pneumococcal disease Meningococcal disease Rotavirus and HPV infection

Recommended Adult Immunization Schedule by vaccine and age group

Influenza vaccine One dose annually for all adults, 0.5 ml im or id. Healthy and non-pregnant adults can receive live

vaccine. Others should receive the inactivated vaccine. For adults aged 65 years and older there is also a high

dose influenza vaccine. Special consideration for people with chronic diseases,

immunosuppression with high risk of influenza, pregnancy and people > 65 yrs of age.

Is an intranasally administered vaccine

0.1 ml in each nostril

Trivalent Inactivated Influenza Vaccine

Tdap/Td Vaccine

All adults not (I) earlier Contacts of infants Health care personnel Post exposure

Minor wound:1TT booster if last > 10 yrs ago

Major wound:1TT booster if last dose>5 yrs ago

Primary : 3 doses, 0,1, 6-12 months, 0.5 ml im

Contacts: single dose 2 wks before contact

Booster : every 10 yrs Tdap for 19-64 yrs age

group and Td for > 65 yrs of age.

Varicella Vaccine

2 doses of varicella 4 weeks apart, 0.5 ml sc

Special consideration for Teachers and child care

employees Health care staff Adults and adolescents in

contact with children Contacts of persons with ICS Non pregnant women of child

bearing age International travellers

C/I in pregnancy, ICS, HIV infection with CD4 count < 200.

Post exposure administration: within 3 days of exposure to varicella rash , can be given upto 5 days of exposure to rash

Human Papilloma Virus Vaccine

Quadrivalent ( Gardasil) or Bivalent ( Cervarix) vaccine

For females , at age 11-12 yrs and catch up vaccination between 13-26 years.

For males, routine vaccination at age 11-12 yrs and for those between 13-21 yrs. MSM may benefit by prevention of condyloma and anal cancer.

3 doses to be given. Second dose 1-2 mths after the first dose, third dose 6 months after the first dose.

Quadrivalent HPV VaccineContains types 6,11,16,18.

Bivalent HPV VaccineContains types 16 and 18

Herpes Zoster vaccine

Single dose 0.65 ml sc for adults more than 60 years of age.

For persons with chronic medical conditions. Contraindicated in pregnancy, immunocomprimising

conditions and HIV.

Zoster VaccineLive virus vaccine recently launched for adults > 60 years

MMR Vaccine

Measles and Mumps component: two doses of MMR vaccine are recommended, the second dose administered a minimum of 28 days after the first dose for adults Who have been recently exposed to measles or mumps or

are in an outbreak setting

Are students in postsecondary educational institutions

Work in a health care facility

Those who plan to travel internationally

MMR Vaccine

Rubella component: for women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon termination of pregnancy and before discharge from the health care facility.

Pneumococcal polysaccharide Vaccine

All adults more than 65

Chronic medical

conditions• Asthma, CAD• CLD,CRF,DM• Asplenia• Elective

splenectomy

Other conditions

• Residents of nursing homes

• Chronic smokers

Revaccination with PPSV

0.5 ml im/sc; 1-2 doses may be required. One dose of PPSV is recommended after 5 years for

persons aged 19 through 64 years with chronic renal failure, nephrotic syndrome, asplenia and immune compromising conditions,

For persons aged 65 years or older, one time revaccination is recommended if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination.

PNEUMOCOCCAL VACCINE Pneumovac 23 contains 23 serotypes

7 valent and 13 valent Prevnar is also available

Meningococcal Vaccine

2 doses at 0 and 2 months

Persons with anatomic and

functional asplenia

Persistent complement deficiencies

People with HIV 0.5 ml sc

Meningococcal Vaccine

Single dose for microbiologists, military recruits, students living in dormitories and

travellers to endemic regions

Conjugate vaccine (MCV 4 ) for adults less than 55 years

Revaccination recommended every 5 years

Polysaccharide vaccine for adults more than 55 years

Vaccination must for travellers to

Hajj

Hepatitis A Vaccine

MSM and injection drug

users

Persons working in laboratories

Persons with CLD

Travellers to endemic regions

Unvaccinated persons who

anticipate close personal contact

Hepatitis A Vaccine

It should be administered in a 2 dose schedule at either 0 and 6-12 months or or 0 and 6-18 months.

If the combined hepatitis A and B vaccine ( Twinrix) is used, administer 3 doses at 0, 1 and 6 months. Alternatively, a 4 dose schedule may be used, administered on days 0,7, 21-30, followed by a booster dose at 12 months

Hepatitis B vaccine

3 doses at 0,1 and 6 months

Sexually active persons not in a long term monogamous

relationship

Persons with ESRD,CLD,

HIV

Contacts of chronic HBV

infection

MSM, IDU, persons with

STD

International travellers

Administering Vaccine to Adults:Dose and route

Vaccine Dose Route

Hep A <=18 yrs: 0.5 ml>=19 yrs: 1 ml

im

Hep B <=19 yrs: 0.5 ml>=20 yrs: 1 ml

im

Hep A+B ( Twinrix) >=18 yrs: 1 ml im

HPV 0.5 ml im

Influenza, live 0.1 ml in each nostril Intranasal spray

Influenza,inactivated 0.5 ml im

Fluzone 0.1 ml id

Administering vaccines to Adults:Dose and Route

Vaccine Dose Route

MMR 0.5 ml sc

MPSV 0.5 ml sc

MCV 0.5 ml im

PCV 0.5 ml im

PPSV 0.5 ml im / sc

Tdap 0.5 ml im

Varicella 0.5 ml sc

Zoster 0.65 ml sc

National immunization schedule for infants

vaccine When to give

dose route site

BCG At birth or asap till 1 yr of age

0.1 ml ( 0.05 ml until I mth of age)

id (L) Upper arm

Hep - B At birth or asap within 24 hours

0.5 ml im Anterolateral side of mid thigh

OPV 0 At birth or asap within first 15 days

2 drops oral oral

OPV 1,2 & 3 6,10,14 wks 2 drops Oral oral

DPT 1,2 & 3 6,10,14 wks 0.5 ml im AL mid thigh

Hep B 1,2,3 6,10,14 wks 0.5 ml im AL mid thigh

measles 9 completed months to 12 mths( upto 5 yrs if not given

0.5 ml sc (R ) upper arm

Vitamin A 9 mths with measles

1 lac IU oral oral

National immunization schedule for children

vaccine When to give

Dose route site

DPT booster 16-24 mths 0.5 ml im AL mid thigh

OPV booster 16-24 mths 2 drops Oral oral

Measles ( 2nd)

16-24 mths 0.5 ml sc R upper arm

JE** 16-24 mths 0.5 ml sc L upper arm

Vit A ( 2nd -9th dose )

16 mths with DPT/OPV booster. Then 1 dose every 6 months upto 5yrs of age.

2 lac IU oral oral

DPT booster 5-6 years 0.5 ml im Upper arm

TT 10 yrs & 16 yrs

0.5 ml im Upper arm

National Immunization schedule for pregnant women

vaccine When to give

dose route site

TT-1 Early in pregnancy

0.5 ml im Upper arm

TT-2 4 weeks after TT-1

0.5 ml im Upper arm

TT-booster If taken 2 TT doses in a pregnancy within last 3 yrs. Give before 36 wks. give TT to a woman in labour if she has not got TT before.

0.5 ml im Upper arm

IAP Immunization Schedule.

Age (completed wks/mo/y) Vaccine

Birth BCGOPV 0Hep B-1

6 weeks DTwP-1IPV – 1Hib -1Rotavirus -1PCV-1Hep B-2

10 weeks 2ND dose of DTwP, IPV,Hib,Rotavirus,PCV

14 weeks 3RD dose of DTwp,IPV, Hib,Rotavirus,PCV

IAP Immunization Schedule

Age ( completed wks/mo/y) Vaccines

6 months OPV-1, Hep –B 3

9 months OPV-2, MMR-1

9-12 months Typhoid conjugate vaccine

12 months Hep-A 1

15 months MMR-2, Varicella-1, PCV Booster

IAP Immunization Schedule

Age (completed wks/mo/y) Vaccines

16 -18 months DTwP-B1, IPV-B1,Hib-B1

18mths – 2yrs Hep-A 2, Typhoid booster

4 – 6 years DTwP-B 2, Varicella 2, Typhoid booster, OPV 3

10-12 years Tdap/Td, HPV.

IAP recommended vaccines for high-risk children

Influenza vaccine Meningococcal vaccine Japanese Encephalitis vaccine Cholera vaccine Rabies vaccine Yellow fever vaccine PPSV 23

High Risk Category of Children

Immunodeficiency Chronic medical

conditions , DM Long term

immunosuppressive therapy or RT

CSF leaks, cochlear implants, malignancies

Functional or anatomic asplenia

During outbreaks Having pets in home Who are at higher threat

of being bitten by dogs such as hostellers, risk of stray dogs while going outdoor

Dos and Don’ts during immunization sessions

Dos Don’ts

It is safe and effective to give BCG, DPT,OPV and measles vaccines at the same time to a child who has completed 9 months and never been vaccinated

Do not withhold the vaccine in case of illness such as cold, cough, diarrhoea or fever.

Give BCG to infants less than 1 year of age

Never give BCG to children above 1 year of age

If a child is brought late for a dose , pick up where the schedule was left

Dos and Don’ts during vaccine handling and administration

Dos Don’ts

Screen for contraindications Do not use unsterile syringe

Check label of the vial and expiry date

Do not touch any part of needle

Lightly shake the vial of T-series vaccine before drawing the dose

Do not recap the needle

Use a new syringe for each injection and a new disposable syringe for each reconstitution

Do not leave the needle inside the vialNever inject in the buttock.

Use correct diluent Never use vaccine with VVM in unusable stage

Inject using correct site and route Never massage the vaccination site

Allow dose to self dispense instead of massaging

Never use reconstituted measles and BCG vaccine after 4 hours and JE after 2 hours

Vaccine Vial MonitorDo not use if the central square is equal to or darker than the surrounding circle.

Angles for inserting injections1) Intramuscular injections are given at

an angle of 90 degrees

2) Subcutaneous injections are given at an angle of 45 degrees

3) Intravenous injections are given at an angle of 25 degrees

4) Intradermal injections are given at an angle of 10-15 degrees

Vaccination in pregnancy

Live virus vaccines are contraindicated in pregnancy Most live virus vaccines, including varicella vaccine,

are not secreted in breast milk; therefore, breast feeding is not a contraindication for live virus or other vaccines.

Pregnancy is not a C/I for inactivated vaccines but most are avoided in pregnancy as relevant safety data are limited.

Trivalent inactivated influenza vaccine may be given in influenza season.

Immunosuppression

In patients with compromised immune function, enhanced replication of vaccine viruses is possible and could lead to disseminated infection with the vaccine virus. Hence live viruses are C/I in immunocompromised conditions.

HIV, hematologic or generalized malignancy and therapy with immunosuppressive agents including high dose glucocorticoids are immune compromising conditions.

Contraindications and precautions for commonly used vaccines in adultsVaccine Contraindication Precaution

All vaccines Severe allergic reaction

Moderate to severe acute illness with or without fever

Td -- GBS within 6 weeks of a previous dose of TT containing vaccineHistory of arthus type hypersensitivity reaction after a previous dose of TT containing vaccine.Defer vaccination until atleast 10 years have elapsed since the last dose.

Contraindications and Precautions

Vaccine Contraindication Precaution

Tdap History of encephalopathy eg: coma or prolonged seizures not attributable to another identifiable cause within 7 days of administration of DTaP or Tdap ie : with pertussis component

1) GBS within 6 weeks after a previous dose of TT-containing vaccine2) Unstable neurologic conditions3) History of Arthus type hypersensitivity reactions; defer vaccination until at least 10 years have elapsed since the last dose.4) Pregnancy.

Contraindications and Precautions

Vaccine Contraindication Precaution

HPV History of immediate hypersensitivity to yeast( for Gardasil)

Pregnancy

MMR 1) History of immediate hypersensitivity reaction to gelatin or neomycin2) Pregnancy3) Known severe immunodeficiency

Recent ( within 11 mths) receipt of antibody containing blood product.

Contraindications and Precautions

Vaccine Contraindication Precaution

Varicella 1) Pregnancy2) Known severe

immunodeficiency3) History of

immediate hypersensitivity reaction to gelatin or neomycin

Recent (within 11 mths) receipt of antibody containing blood products.

Influenza, injectable, trivalent

History of immediate hypersensitivity reaction to eggs

1) GBS within 6 weeks of previous dose.

2) Pregnancy is not a C/I Recommended for women who will be pregnant during influenza season.

Contraindications and Precautions

Vaccine Contraindication Precaution

Influenza, live, attenuated

1)Hypersensitivity to eggs2)Age > 50 yrs3)Pregnancy4)Immunosuppression5)Chronic medical conditions6)Close contact with severely immunosuppressed persons who require a protected environment, such as isolation in a bone marrow transplant unit.

History of GBS within 6 weeks of a previous influenza vaccine dose.

Contraindications and Precautions

Vaccine Contraindication Precaution

PPSV none none

Hepatitis A none pregnancy

Hepatitis B Hypersensitivity to yeast

Meningococcal conjugate

1) Age > 55 years2) History of severe

allergic reaction to latex or to DT containing vaccine

History of GBS

Meningococcal polysaccharide

History of severe allergic reaction to latex

Zoster 1) Age < 60 years & ICS

2) Pregnancy3) Hypersensitivity to

gelatin or neomycin.

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The quest for vaccines for diseases like HIV still continues

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SCIENCE HOPES A VACCINE FOR EVERY DISEASE.

Thank You.