2. epi & recommended vaccines

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Lec 2: EPI & Recommended Vaccines by Ruby Ann L. Punongbayan, MD June 28, 2010

IMMUNIZATION

Ultimate goal: eradication of disease

Immediate goal: prevention of disease

Two Types:

1. Active immunization2. Passive immunization

ACTIVE IMMUNIZATION

Efficacy is assessed by the evidence of protectionagainst the particular disease.

Antibody formation indirect measure

Types of antigen for active immunization:1. Live attenuated virus or bacteria (weakened)2. Killed microorganisms (inactivated)

PASSIVE IMMUNIZATION

For IM administration: peaks at 48-72 hrs not toexceed 5 ml

Indications:a. Congenital or acquired B-lymphocyte cell

defects alone or in combination with otherimmunodeficiencies

b. When time does not permit adequateprotection by active immunization alone(hepatitis B, measles, rabies)

c. When a person susceptible to a disease is

exposed to or has a high likelihood ofexposure to that infection or has a high riskof complications from the disease (leukemicchild exposed to a person with varicella ormeasles)

d. When a disease is already present andantibody may aid in suppressing its toxineffects (botulism, tetanus) or theinflammatory response (Kawasaki disease)

COLD CHAIN

It is a system for ensuring the potency of a vaccinefrom the time of manufacture to the time it is givento a child.

supplier abroad central storage (vaccine lab)

regional cold rooms and freezers hospitals

clinics / rural health units infant / child Two essential elements: people and equipment

Vaccines will confer immunity only when they arepotent, and to be potent they must be properlystored, handled, and transported.

PRINCIPLES OF IMMUNIZATION

Breastfeeding does not interfere with successfuimmunization with oral vaccines. Vomiting within 10minutes of receiving an oral dose is an indicationfor repeating the dose. If the second dose is noretained, neither dose should be counted, and thevaccine should be re-administered.

Parenteral vaccine should be administered in a site asfree as possible from risk of local neural, vascularor tissue injury.

Recommended route is based on studies designed todemonstrate maximum safety and efficacy.

For IM injections, the choice of site is based on thevolume of the injected material and the size of themuscle.

In children younger than 1 year of age, theanterolateral aspect of the thigh provides thelargest muscle and is the preferred site.

In older children, the deltoid muscle is usually largeenough for IM injection.

The upper, outer aspect of the buttocks should not beused for active immunization because the glutea

region is covered by a significant layer osubcutaneous fat and because of the possibility odamaging the sciatic nerve.

Preterm newborns: 5/8-inch long needle

Term infants: 7/8- to 1-in long needle

Toddlers & young infants: 7/8- to 1 -inch longneedle

22-25-gauge needle for most IM vaccines

Subcutaneous: 23-25-gauge needle and 5/8-3/4-inchlong

Intradermal: gauge 25-27

Simultaneous administration of multiple vaccineso most vaccines can be safely and effectively

given simultaneously

o EXCEPTION: cholera and yellow fevevaccines: decrease in immunogenicity whengiven together or 1-3 weeks aparto use separate syringes and sites

Antigen CombinationRecommended Minimum Interva

Between Doses

Equal or > 2

inactivated vaccines

None; can be given simultaneously

at any interval between doses

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Outline

I. Immunization

a. Active Immunization

b.Passive Immunization

c. Cold Chain System

d.Principles Of Immunization

II. Expanded Program of Immunization

a. Influenza Vaccineb.Varicella Vaccinec. MMR Vaccined.H. Influenzae B Vaccine


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Inactivated and live

vaccines

None; can be given simultaneously or

at any interval between doses

Equal or > 2 live

parenteral vaccines

28-day minimum interval if not given

simultaneously

Lapsed Immunizationso a lapse does not require reinstitution of the

entire serieso subsequent immunizations should be given

at the next visit as if the usual interval had

elapsed Unknown or uncertain immunization status

o In general, when in doubt, immunizations

should be initiated without delay on a schedulecommensurate with the persons current age.o No evidence that giving vaccines to already

immune recipients is harmful.

Interchangeability of Vaccine Productso May be used interchangeably from different

manufacturers include diphtheria & tetanus toxoidvaccines, live & inactivated polio vaccines,hepatitis A vaccines, hepatitis B, rabies vaccine,Hib conjugate vaccines

EXPANDED PROGRAM ON IMMUNIZATION (EPI)

Most cost-effective public health intervention

In the Philippines, the EPI was launched by the DOHon July 12, 1976.

Implementation of EPI contained in PD No. 996 (Sept.16, 1976) providing for compulsory immunization forinfants and children below 8 years

Presidential proclamation No. 6 (April 3, 1986)enjoined all governmental and non-governmentalagencies to achieve the goal of immunizing everyFilipino child

In 1993, the number of EPI diseases was expandedfrom 6 to 7 with the inclusion of hepatitis B.

Senate Bill No. 1654: 14th Congress: an ActRequiring Mandatory Basic Immunization Services

Against Hepatitis B for Infants (Oct. 2, 2007)

Fully Immunized Child one who has received 1dose of BCG at birth or any time before reaching 12months, 3 doses of DPT and polio with at least 4weeks interval between each dose, one dose ofmeasles at age 9 months or before 12 months, and 3doses of hepatitis B with at least 4 weeks intervalbetween doses

Recommended

AgeVaccine Comments

At birth Hep B1; BCG1 month Hep B2

2 months DPT1, OPV1May be given as early

as 6 wks old

4 months DPT2, OPV2

6 monthsDPT3, OPV3,

Hep B3

9 monthsMeasles

vaccineMay be given as early

as 6 mos.old

Beyond 1 yr old: Recommendations

Recommended

AgeVaccine Comments

15 months old

MMR(measles-mumps-rubella)

Given 6 months afterthe first measles

vaccine

18 months old DPT, OPV First booster dose

4-6 years oldDPT, OPV,

MMR

Second booster dosegiven at or before

school entry

11-12 years oldTd (tetanus

toxoid)Repeat every 10

years for life

EPI

Vaccine Age Dose RouteAdverse

Reactions

BCGNewbor

n>1 mo.

0.05ml0.1ml

ID

Abscess orulcers at site ;axillary lymph-

adenopathy

DPT8, 12, 16wks old

0.5ml

IM

Fever,convulsions,

irritability,prolonged crying

OPV8,12,

16 wksold

2-3drops

PO

VAPP (0.06

million dosesamong

recipients); 0.14million doses

among contactsof recipients

HepatitisB

Soonafter

birth; ifmother

is+HBsAg; 0-1-6months

old

0.5ml

IM

Pain at theinjected site;

local redness,warmth and

swelling

Measlesvaccine

9 mosold or 6months

old ifendemic

0.5ml

SCFever 5-12 daysafter vaccination;

rashes

INFLUENZA VACCINE

Trivalent inactivated influenza vaccine (TIV) - IM

Live attenuated influenza vaccine (LAIV) intranasally

6 months old to 18 years old

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Give 2 doses to first time vaccinees 6 mos.through 8 yrs spaced 4 wks apart

For TIV, give 0.25 ml dose to 6 mos-35 mos oldand 0.5 ml to 3 yrs old and older

Contraindications:o Previous anaphylaxis to the vaccine, its

components, or to eggso For LAIV only: age < 2yrs old, HIV, current

long-term aspirin therapy for 2-4 yrs old,wheezing or asthma within the past 12

months Precaution: history of GBS within 6 wks of a

previous flu vaccination

VARICELLA VACCINE

2 doses: 12-15 mos old & 4-6 yrs old

Subcutaneous

Give a 2nd dose to all older children &adolescents with history of only 1 dose

For catch-up or missed doses:1. For < 13 yrs old, space dose #1 and #2 at

least 3 months apart2. For > 13 yrs old, space at least 4 wks apart

MMR VACCINE

Give dose #1 at age 12-15 months

Give dose #2 at age 4-6 yrs

Give a 2nd dose to all older children andadolescents with history of only 1 dose

If MMR and either varicella, LAIV, and/or yellowfever vaccine are not given on the same day,space them at least 28 days apart

When using MMR for both doses, minimuminterval is 4 wks

H. INFLUENZAE B VACCINE

ActHib: 2m, 4,m 6m, 12-15m (booster dose)

PedvaxHIB or Comvax: 2m, 4m, 12-15m (boosterdose)

Dose #1 should not be given earlier than age 6wks old

The last dose (booster dose) is given not earlierthan age 12 months & a minimum of 8 wks afterthe previous dose

Hib vaccines are interchangeable; however, ifdifferent brands of Hib vaccines are given fordose #1 & #2, a total of 3 doses are needed tocomplete the primary series in infants

Any Hib vaccine may be used for the boosterdose

Not routinely given to >5 yrs old

Hiberix is approved ONLY for booster dose at 15mos through 4 yrs old

PNEUMOCOCCAL CONJUGATE VACCINE

PCV13: 2m, 4m, 6m, 12-15m; IM route

Dose #1 may be given as early as 6 wks

Give 1 dose to unvaccinated healthy children age24-59 months old.

NOT routinely given to healthy children older than5 yrs old

High-risk children : with sickle cell disease,

anatomic or functional asplenia, chronic cardiac,pulmonary, or renal disease, DM, HIV infection,

CSF leaks, who have or who will have cochleaimplant, radiation therapy

High-risk ages 24-71 mos: give 2 doses at least 8wks apart if they previously received fewer than 3doses; give 1 dose at least 8 wks after the mosrecent dose if they previously received 3 doses

When behind on schedule: minimum interval fodoses given to


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older who have recently (during the past 2 wks)been exposed to Hep A virus

Precautions: pregnancy, moderate or severeacute illness

MENINGOCOCCAL VACCINE

Conjugate vaccine1. MCV4: Menactra 2-55 yrs old, IM2. MCV4: Menveo 11-55 yrs old, IM

Polysaccharide vaccine : MPSV4, SC

Give 1 time dose of MCV4 to adolescents 11-18yrs old

Vaccinate all college freshmen living in dormswho have not been vaccinated

Use MPSV4 ONLY if there is a permanentcontraindication or precaution to MCV4

Vaccinate all children age 2 yrs & older who haveany of the risk factors:1. Anatomic or functional asplenia, persistent

complement deficiency2. Travel or reside in countries in which

meningococcal disease is hyperendemic orepidemic (the meningitis belt of Sub-Saharan Africa)

3. Military recruits

HUMAN PAPILLOMAVIRUS VACCINE

HPV2, Cervarix - serotypes 16 & 18 (cervicalcancer)

HPV4, Gardasil - serotypes 6 & 11(genital warts)plus 16, 18

o Give 3-dose series to girls age 11-12 yrs

old on a 0, 1-2, 6m schedule (may begiven as early as 9 yrs old)

o Vaccinate all older girls & women

through age 26 yrs who were notpreviously vaccinated

Consider giving HPV4 to males age 9 through 26yrs to reduce their likelihood of acquiring genital

warts Minimum interval between doses: 4 wks bet. #1 &

#2; 12 wks bet. #2 & #3

Overall, there must be at least 24 wks bet. #1 .

If possible, use the same vaccine product for alldoses.

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TIPPED SCALES

Christs love is greater than anyone can

ever know, but I pray that you will be

able to know that love.

(Ephesians 3:19)

It wasnt right that spikes pierced

the hands that formed the earth. And it

wasnt right that the Son of God was

forced to hear the silence of God.

It wasnt right, but it happened.

For while Jesus was on the cross,

God sat on his hands. He turned his

back. He ignored the screams of the

innocent.

He sat in silence while the sins of

the world were placed upon his Son.

And he did nothing while a cry a million

times bloodier than Johns echoed in

the black sky: My God, my God, why

have you forsaken me?

Was it right? No.

Bible Verses for the Week: Isaiah 53:4-6

4Surely he took up our infirmities

and carried our sorrows,

yet we considered him stricken by God,smitten by him, and afflicted.

5But he was pierced for our transgressions,

he was crushed for our iniquities;

the punishment that brought us peace was

upon him,

and by his wounds we are healed.

6We all, like sheep, have gone astray,

each of us has turned to his own

way;
http://bible.cc/isaiah/53-4.htmhttp://bible.cc/isaiah/53-5.htmhttp://bible.cc/isaiah/53-6.htmhttp://bible.cc/isaiah/53-4.htmhttp://bible.cc/isaiah/53-5.htmhttp://bible.cc/isaiah/53-6.htm

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