PRINCIPLES OF
IMMUNIZATION
BLOK 26
LEARNING OBJECTIVES
At the end of this lecture the student should be able to describe:
Active and Passive Immunizations
Types of Vaccines (eg.whole-cell vaccines and subunit
vaccines).
Use of Adjuvants in Immunization.
Problems in Immunization
Understand the term Cold-chain monitoring and storage
conditions for the different types of vaccines.
Mode of Administration
Contraindications in Immunizations (side-effects).
The Extended Program of Immunization (EPI) in Indonesia.
Targeted-Immunizable Diseases in Indonesia
Immunization schedule
INTRODUCTION
Immunity and Immunization
Immunity to contagious disease protect
individu from infection.
Types of Immunity:
Innate immunity
Acquired immunity or adaptive immunity
INTRODUCTION
Innate immunity
Is present before any exposure to pathogens and is effective
from the time of birth
Involves non specific responses to pathogen
Acquired immunity or adaptive immunity
Develops only after exposure to inducing agents such as
microbes, toxins, or other foreign substances
Involves a very specific response to pathogen
INTRODUCTION
Active and passive immunization
Active immunity
Develops naturally in response to an infection
Can also develop following immunization, also called
vaccination
organism exposure, vaccine
In immunization
A non pathogenic form of a microbe or part of a microbe elicits an
immune response to an immunological memory for that microbe
INTRODUCTION
Passive immunity, which provide immediate, short time
protection
Is conferred naturally when IgG crosses the placenta from
mother to fetus or when IgA passes from mother to infant in
breast milk
Can be conferred artificially by injecting antibodies into a non
immune person
INTRODUCTION
Immunization
remarkably successful
very cost-effective
Infectious disease
EVOLUTION OF IMMUNIZATION
PROGRAMME
DEFINING AIMS / GOALS
Prevention of disease in individuals or groups
(immediate goal)
Reducing prevalence of disease (changed
disease epidemiology)
Eradication of disease (ultimate goal)
DEFINING AIMS / GOALS
Potential goals for reducing vaccinepreventable disease burden: eradication,
elimination, or control
Eradication:
reduction of the worldwide incidence of infection
by a specific agent to zero as a result of
deliberate efforts;
intervention measures are no longer needed
DEFINING AIMS / GOALS
Elimination:
reduction to zero, or to the level at which it is no
longer a public health problem, of the
incidence of a specified disease, or of infec-tion
caused by a specific agent, in a defined
geographic area;
continued intervention measures are required
to prevent reintroduction.
Control:
reduction of disease incidence, prevalence,
morbidity, or mortality.
Continue intervention maintaining reduction
DEFINING AIMS / GOALS
Herd immunity:
indirect protection observed in the unimmunised segment
of a population in which a large proportion is immunised
DEFINITION AND GENERAL CONCEPT
Vaccination:
administration of any vaccine or toxoid
(inactivated toxin) for prevention of disease.
Immunization:
process of inducing immunity artificially by either
vaccination (active immunization) or
administration of antibody (passive immunization).
Consist of:
Active immunization
Passive immunization
DEFINITION AND GENERAL CONCEPT
Active immunization:
administration of all or part of a microorganism or a modified
product of that microorganism (eg, a toxoid, a purified antigen,
or an antigen produced by genetic engineering) to evoke an
immunologic response that mimics that of natural infection but
that usually presents little or no risk to the recipient.
stimulating the immune system to produce antibodies and
cellular immune responses that protect against the infectious
agent.
DEFINITION AND GENERAL CONCEPT
Passive immunization:
provides temporary protection through administration of
exogenously produced antibody, such as immune globulin.
also occurs naturally through transplacental transmission of
antibodies to a fetus, which provides protection against many
infectious diseases for the first several months of the infant's life.
DEFINITION AND GENERAL CONCEPT
Immunizing agents protection against
disease:
Nearly complete lifelong protection
Partial protection
Immunizing agents include vaccines,
toxoids, antitoxins, and immune globulins
derived from human or animal donors
(Table 1.)
DEFINITION AND GENERAL CONCEPT
Table 1. Immunizing Agents
Agent
Definition
Vaccine
A preparation of proteins, polysaccharides, or nucleic acids of
pathogens that are delivered to the immune system as single entities, as
part of complex particles, or by live-attenuated agents or vectors, to
induce specific responses that inactivate, destroy, or suppress the
pathogen
Toxoid
A modified bacterial toxin that has been made nontoxic but retains the
capacity to stimulate the formation of antitoxin
Immune
globulin
An antibody-containing solution derived from human blood obtained by
cold ethanol fractionation of large pools of plasma and used primarily for
the maintenance of immunity of immunodeficient persons or for passive
immunization; available in intramuscular and intravenous preparations
Antitoxin An antibody derived from the serum of humans or animals after
stimulation with specific antigens; used to provide passive immunity
DEFINITION AND GENERAL CONCEPT
Most immunizing agents contain preservatives,
stabilizers, antibiotics, adjuvants, and a suspending
fluid (Table 2).
Component
Use and Examples
Preservatives,
stabilizers,
antibiotics
Constituents can inhibit or prevent bacterial growth or stabilize the
antigen. Materials such as mercurials or antibiotics are used. Allergic
reactions to any of the additives may occur.
Adjuvants
An aluminum salt is used in some vaccines to enhance the immune
response (e.g., toxoids, hepatitis B).
Suspending fluid
Sterile water, saline, or more complex fluids derived from the growing
media or biologic system in which the agent is produced (e.g., egg
antigens, cell culture ingredients, serum proteins).
IMMUNE RESPONSE TO
VACCINATION
How do vaccines work?
Immunological memory is the basis of vaccine protection
IMMUNE RESPONSE TO
VACCINATION
IMMUNE RESPONSE TO
VACCINATION
IMMUNE RESPONSE TO
VACCINATION
IMMUNE RESPONSE TO
VACCINATION
IMMUNE RESPONSE TO
VACCINATION
IMMUNE RESPONSE TO
VACCINATION
IMMUNE RESPONSE TO
VACCINATION
The immune system remembers
TYPES OF VACCINE
Vaccine
Live-attenuated or killed microorganisms
Inactivated or detoxified agents or their purified
components
DNA vaccine
TYPES OF VACCINE
Live attenuated vaccine
immunologic response ~ natural infection.
humoral and cell-mediated responses
long-lasting immunity, possibly lifelong
However, the strength of response, particularly the humoral
response, usually is less than that in natural infection, and
detectable antibodies can wane with time, resulting in some
loss of protection.
Induction immunity can be inhibited by passive antibody
TYPES OF VACCINE
Inactivated or purified Ag vaccines
response only to components in vaccine.
The nature of response depends on Ag type.
Protein (and glycoprotein) Ag both humoral immunity and
memory (T-helper lymphocytes)
Polysaccharide Ag only humoral antibody without Tlymphocyte stimulation and fail to induce anamnestic response
with repeated antigenic challenge. conjugation of
polysaccharides to protein carriers
TYPES OF VACCINE
Generally, multiple doses, usually three or more, are
necessary to induce satisfactory antibody levels that persist
for long periods; booster doses at longer intervals (10 or
more years) are sometimes needed to ensure lasting
protection.
TYPES OF VACCINE
Inactivated vaccine:
Types:
Whole organism
Purified protein or polysaccharide Ag from whole
organism
Purified antigen produced from genetically altered
organism
Chemically modified antigen
TYPES OF VACCINE
TYPES OF VACCINE
Bacterial Vaccine
Heat-sensitive
vaccines
lBCG
lOPV
lMeasles
lMMR
lVaricella
lYellow fever
Freezesensitive
vaccines
Freezesensitive
vaccines
Viral Vaccine
lDiphtheria
lTetanus
lPertusis
lCholera
lMeningococ
lPneumococ
lHib
lTyphoid Vi
lInfluenza
lIPV
lRabies
lHepatitis B
lHepatitis A
CHILDHOOD IMMUNIZATION
BCGVaccine
- live attenuated bacterial vaccine
- at birth or anytime after birth
- booster dose given at school entry
Contraindications: immunodeficiency, progressive dermatoses
Reaction: abscess at the site; axillary lymphadenopathy
BCG VACCINE
Usual reactions
induration: 2 4 wks
pustule formation: 5 7 wks
scar formation: 2 3 months
Accelerated Reactions:
induration: 2-3 days
pustule formation: 5-7 days
scar formation: 2-3 weeks
HEPATITIS B VACCINE
- inactivated viral antigen
- 0, 1 & 6 months
- children and adolescents who have not been vaccinated with Hep
B may begin series during any visit
Contraindication: anaphylactic reaction to previous dose
Reactions: pain and swelling at site, fever
HEPATITIS B VACCINE
HEPATITIS B VACCINE
HEPATITIS B VACCINE
HEPATITIS B VACCINE
DIPHTHERIA, TETANUS & PERTUSSIS
Usual Side Effects:
fever up to 72 hours (low to moderate grade)
restlessness and irritability
local reaction: pain and swelling at the site of injection
Contraindications:
encephalopathy within 7 days of administration of previous
dose
anaphylactic shock after a previous dose
progressive neurologic disorders
POLIOMYELITIS VACCINE
1. Oral Polio Vaccine (OPV)
- live attenuated (Sabin)
Absolute contraindications:
1. altered immune states, high dose steroids, radiation,
HIV/AIDS
2. pregnancy
3. household contacts of immunocompromised patients
Relative contraindications: vomiting and diarrhea
Adverse Reaction: paralysis
2.
Inactivated or Killed Polio Vaccine (IPV)
- recommended to decrease the incidence of vaccine-associated
paralytic polio (VAPP)
MEASLES VACCINE
- live attenuated
- given at 9 months but may be given as early as 6 months during
epidemics
Adverse reactions:
1. fever with or without rashes (5-12 days after
administration)
2. hypersensitivity reaction
Contraindication: immunocompromised state, pregnancy
Relative Contraindication: untreated active tuberculosis
MEASLES, MUMPS, RUBELLA (MMR) VACCINE
- live attenuated
- given at 12-15 months; a booster dose is recommended at 4-6
years old
Reactions:
1. fever with or without rashes (5-12 days after
administration - measles)
2. fever, swelling of parotid gland (mumps)
3. fever, mild rash, transient arthritis or arthralgia, postauricular lymphadenopathy (rubella)
MEASLES, MUMPS, RUBELLA (MMR) VACCINE
Reasons for giving 2 doses of MMR:
1. only 87-90% of children actually receive the measles
vaccine
2. 5% of children who receive the first vaccine wont
develop immunity
3. children who had an immune response to the first dose
could get a booster effect
Contraindications: same as other live vaccines
VARICELLA VACCINE
- live attenuated
- routinely given at age 12 months and up but can be given as early
as 9 months
- can be given within 5 days of exposure
- varicella vaccine prevents moderate to severe cases of chickenpox
Reactions:
-may develop few varicella-like lesions about 1 month after
vaccination
HEMOPHILUS INFLUENZAE B (HIB) VACCINE
- polysaccharide protein conjugate
Reactions:
low grade fever (2%)
pain and swelling (10-15%)
PNEUMOCOCCAL VACCINE
- PPV is given for children 2 yrs and above
Indications:
1.
2.
3.
4.
5.
patients undergoing splenectomy
sickle cell disease
asplenia
HIV
Routinely for children 2 months and above
HEPATITIS A VACCINE
- inactivated viral antigen
Indications:
1. persons traveling to areas with high prevalence of Hepatitis
A
2. occupational hazards
3. hemophiliacs contacts of infected persons
Reactions: pain and local swelling
INFLUENZA VACCINE
- inactivated vaccine
- should be administered before the start of flu season (February to
June)
Indications:
1. prophylaxis in children older than 6 months and adults
2. over 60 years
3. suffer from disease of cardiovascular system, metabolic
disease, cystic fibrosis, chronic respiratory disease, chronic
renal insufficiency
VACCINE RECOMENDATIONS
VACCINE RECOMMENDATIONS
Development of recommendations and
schedule for vaccine administration:
epidemiology of the disease,
age-specific morbidity and mortality,
vaccine immunogenicity,
risks of vaccine-related adverse reactions,
cost effectiveness,
ages of recommended routine health care visits.
VACCINE RECOMMENDATIONS
Priority:
delivering the primary childhood immunization series and
protecting adult women and their newborns against
tetanus.
VACCINE RECOMMENDATIONS
Each country has each own policies
Immunization schedule in Indonesia recommended by
IDAI (non PPI) and government (EPI/PPI)
PPI (Program Pengembangan Imunisasi):
BCG, Polio, Hepatitis B, DPT, Campak, Hib
IDAI (Ikatan Dokter Anak Indonesia):
PPI (diwajibkan)
Non PPI (dianjurkan)
VACCINE RECOMMENDATIONS
Expanded Program of Immunization (EPI) or
Pengembangan Program Imunisasi (PPI)
Goverements program in immunization to
achieve international commitment: Universal child
immunization (UCI):
Polio eradication = ERAPO
Maternal and neonatal tetanus elimination
Measles reduction
Improve immunization service quality
Establish safe injection practices standard
Safe waste disposal management
VACCINE RECOMENDATIONS
VACCINE RECOMMENDATIONS
VACCINE RECOMMENDATIONS
VACCINE RECOMMENDATIONS
JADWAL IMUNISASI
VACCINATION PROCEDURE
VACCINATION PROCEDURE
Vaccine storage and transportation
Prepare the equipment and supplies: for
vaccination and emergency proceduse
Prepare the administering:
Anamnesis, age, AEFI history, contra indication,
previous immunization interval and specific
precaution
Informed consent: benefit, AEFI risk
Physical examination
VACCINATION PROCEDURE
Administering vaccine:
Dose, interval
Location, angle and depths of injection (route,
site and needle length)
AEFI monitoring
Pack opened vaccines and disposing of
used equipment (used syringes and needles,
vials and rubbish)
Documentation
STORAGE AND DISTRIBUTION
Vaccine = biological product
Fragile/ easily damage
Decrease vaccine effectivity
STORAGE AND DISTRIBUTION
Cold chain
Vaccines sensitive to heat & freezing kept at
correct temperature from the time they are
manufactured until used.
The system used for keeping and distributing
vaccines in good condition = cold chain.
The cold chain consists of a series of storage and
transport links, all designed to keep vaccines
within an acceptable range until it reaches the
user.
STORAGE AND DISTRIBUTION
STORAGE AND DISTRIBUTION
Maintenance of the cold chain requires vaccines
and diluents to be:
collected from the manufacturer or an airport as soon as
they are available;
transported between 2C and 8C from the airport and from
one store to another;
stored at the correct temperature (see Figure 3A) in
primary/central and intermediate vaccine stores and in
health facilities;
transported between 2C and 8C to outreach sites and
during mobile sessions;
kept between 2C and 8C range during immunization
sessions; and
kept between 2C and 8C during return to health facilities
from outreach sites.
STORAGE AND DISTRIBUTION
Factors decrease vaccine effectivity :
* Type of vaccine
* Exposed to Inappropriate temperature
* Storage time/expired date
* Directly exposed to sunlight
STORAGE AND DISTRIBUTION
STORAGE AND DISTRIBUTION
STORAGE AND DISTRIBUTION
The shake test:
Can help give an idea whether
adsorbed vaccines (DTP, DT,
Td, TT or hepatitis B) have
been subjected to freezing
temperatures likely to have
damaged them.
After freezing, the vaccine no
longer has the appearance of
an homogenous cloudy liquid,
but tends to form flakes which
settle at the bottom of the vial
after shaking.
VACCINE VIAL MONITOR (VVM)
VACCINE VIAL MONITOR (VVM)
Heat marker /
Vaccine Vial
Monitor
HEPATITIS B VACCINE
VACCINE VIAL MONITOR (VVM)
USE the vaccine
VACCINE VIAL MONITOR (VVM)
Heat marker /
Vaccine Vial
Monitor
DPT-HB VACCINE
VACCINE VIAL MONITOR (VVM)
MEASLES VACCINE
CONTRAINDICATIONS TO
IMMUNIZATION
Anaphylaxis or a severe hypersensitivity reaction
absolute contraindication to subsequent doses of a
vaccine. Persons with a known allergy to a vaccine
component should not be vaccinated.
Do not give BCG or yellow fever vaccine to an
infant who exhibits the signs and symptoms of AIDS.
Other vaccines should be given.
If a parent strongly objects to an immunization for a
sick infant, do not give it. Ask the mother to come
back when the infant is well.
CONTRAINDICATIONS TO
IMMUNIZATION
CONTRAINDICATIONS TO
IMMUNIZATION
ADMINISTERING VACCINE
ADMINISTERING VACCINE
ADMINISTERING VACCINE
AEFI
Adverse event following immunization = KIPI
Definition
Is a medical incident that takes place after an
immunization, causes concern and is believed to be
caused by the immunization
AEFI
Classification
Vaccine reaction: event caused or precipitated by
the vaccine when given correctly; caused by inherent
properties of the vaccine.
Programme error: event caused by an error in vaccine
preparation, handling, or administration.
Coincidental event: event that happens after
immunization but is not caused by the vaccine - a
chance association.
Injection reaction: event from anxiety about, or pain
from, the injection itself rather than the vaccine.
Unknown: whose cause cannot be determined.
AEFI
Estimated AEFI rates following some childhood
vaccines
Vaccine
Estimated rate*
BCG
1 in 1 000 - 1 in 50 000 doses
OPV (oral polio
vaccine)
1 in 2-3 million doses (or 1 in 750 000
doses for the first dose)
Measles
1 in 1 million doses
DTP
1 in 750 000
* Only the rate for severe reactions has been quoted.
AEFI
Errors which can lead to AEFIs
Too much vaccine given in one dose.
Improper immunization site or route.
Syringes and needles improperly sterilized.
Vaccine reconstituted with incorrect diluent.
Wrong amount of diluent used.
Drug inadvertently substituted for vaccine or
diluent (can result from inattention when reading
labels on vials resulting in mistaken content).
AEFI
Vaccine prepared incorrectly for use e.g. an adsorbed
vaccine not being shaken properly before use.
Vaccine or diluent contaminated.
Vaccine stored incorrectly.
Contraindications ignored e.g. a child who
experienced a severe reaction after a previous dose
of a vaccine is immunized with the same vaccine.
Reconstituted vaccine used beyond six hours after
reconstitution or not thrown out at the end of an
immunization session and used at a subsequent one.
AEFI
AEFI
AEFI
SISA VAKSIN
BCG
setelah dilarutkan harus segera diberikan dalam 3
jam(simpan dalam suhu 2 8 C)
Polio
Setelah dibuka harus segera diberikan dalam 7 hari(simpan
dlm suhu 2 8 C)
SISA VAKSIN
DPT
Bila ada penggumpalan atau partikelyang tidak hilang
setelah dikocok !jangan dipakai
Campak
Setelah dilarutkan harus diberikan dlm 8 jam(simpan dlm
suhu 2 8 C)
PEMANTAUAN SETELAH VAKSINASI
Perhatikan keadaan umum
Tunggu 30 menit di ruang tunggu
SAFE INJECTION
Mengapa perlu?
Estimasi WHO : 30 % suntikan imunisasi tidak aman (WHO
bull. Oktober, 1999)
Imunisasi rutin(Soewarta,1999: 4 propinsi): tidak disterilkan :
spuit 38%, jarum 23 %alat suntik pakai ulang :krn tidak ada
jarum (18%), tidak ada spuit (4%)
Aman bagi
Yang disuntik
Penyuntik
lingkungan
SAFE INJECTION
Suntikan dapat menularkan : hepatitis B, Hepatitis C,
HIV, jamur, parasit, bakteri, menyebabkan abses
Penyebaran melalui suntikan lebih cepat daripada
melalui udara, mulut atau seks
SAFE INJECTION
TIDAK AMAN BAGI YANG DISUNTIK
*Vaksin
* Suhu > 8C, atau VVM telah terpapar panas
* Botol vaksin bocor, retak, atau terpasang jarum
* Ada partikel dalam larutan
* Telah dilarutkan lebih dari 6 jam
* Beku : DPT, DT, TT, HepB, Hib (tidak boleh beku)
* Uji kocok tetap menggumpal (kecuali HepB atau Hib)
SAFE INJECTION
* Alat suntik
Spuit disposable dipakai ulang
Hanya mengganti jarum
Tidak dibersihkan dulu langsung disterilkan
Hanya dengan desinfektan
Membakar jarum di api
Merebus dalam panci terbuka
Menyentuh ujung jarum
SAFE INJECTION
* Cara melarutkan / pengambilan vaksin
* Cairan pelarut untuk vaksin lain atau > 8C
* 1 spuit diisi beberapa dosis sekaligus
* jarum ditinggalkan menancap di vial
* Mencampur isi 2 vial
* Lokasi, posisi , kedalaman penyuntikan
* Tidak ada alat / obat gawat -kedaruratan
SAFE INJECTION
* Menekan luka berdarah dengan jari (semua
cairan tubuh dapat menularkan kuman)
* Membawa atau meletakkan alat suntik bekas
sembarangan (tidak langsung membuang ke
kotak limbah)
* Menyentuh atau mencabut jarum suntik
SAFE INJECTION
* Menutup kembali (recapping) jarum suntik
* Mengasah jarum bekas
* Memilah-milah tumpukan jarum bekas
* Tidak ada alat / obat gawat darurat
Tidak aman bagi lingkungan: Meninggalkan alat
suntik bekas sembarangan
TEMPAT PEMBUANGAN LIMBAH
PEMUSNAHAN KOTAK DAN ISI LIMBAH
* Dibakar dalam insinerator khusus (suhu 600 -1100C)
* risiko pencemaran kecil
* Rp. 10 30 juta, BBM / kayu bakar
* Dibakar dalam lubang atau drum
* Digiling
* Milling atau shreeding
* Serbuk masih infeksius
* 375-750 alat suntik / jam
* listrik 750 w
PENCATATAN
Nama dagang dan produsen
No. lot / seri vaksin
Tgl penyuntikan
Bagian tubuh yang disuntik (deltoid kiri, paha kanan
mis)
