Immunization

Oriji Damilola Olajide

 Introduction - 1
• Africa is witnessing a surge in outbreaks of Vaccine
Preventable Diseases.
• Vaccine preventable diseases are a major
contributor to child morbidity and mortality
especially in Nigeria.
• Nigeria has 2.5% of world population and yet
account for 10% of global burden of infant, child
and maternal mortality.
• 4.3 million children in Nigeria still miss out on
vaccination every year.
 Introduction - 2
• Immunization is the most successful cost
effective method of reducing childhood
morbidity & mortality.
• Immunization is a “Safe way” of obtaining
specific protection against a given disease.
• Mass means of protecting the greater number
• Major breakthrough in the 20th century leading
to eradication, elimination, and great
reduction in disease.
 Introduction - 3
• Widespread use of vaccines led to:
- the global eradication of smallpox in 1977
- regional elimination of measles and polio,
and
- substantial reductions in the morbidity and
mortality attributed to diphtheria, tetanus and
pertussis.
• National coverage in Nigeria for full
immunization is 33% (95% CI: 31, 35).
 Definitions - 1
• VACCINE is an immunobiological substance
designed to produce specific protection
against a given disease, stimulating the
immune system to produce antibodies
without the individual becoming infected with
actual disease
• Vaccination is the administration of a vaccine
for prevention of disease
 Definitions - 2
• Immunization: Protection of individuals from
communicable diseases by administration of a
living modified agent, a suspension of killed
organisms, or an inactivated toxin
• Immunization is the process by which an
individual's immune system becomes fortified
against an agent (i.e an immunogen or
antigen).
• Immunization is the stimulating of an immune
response, via use of an infectious agent.
 Definitions - 3
• Immunization can be done through various
techniques, most common is vaccination.
• Immunization implies that the administration
of an immunologic agent actually results in
the development of adequate immunity.
• Vaccination and Immunization are often used
interchangeably but immunization is more
inclusive.
 Definitions - 4
• Immunity: The status of being immuned, i.e.
free from the possibility of acquiring a given
infectious disease by means of antibodies.
• Immunology: is the study of the immune
system and its reaction to pathogens.
 Composition
• A dose of vaccine may contain :
- a suspending fluid to carry the vaccine
into the body.
- preservatives and stabilizers to ensure
safe storage.
- an adjuvant to improve the body’s
immune response e.g. aluminium hydroxide,
aluminium phosphate, water-in-oil.
 Immunity
• Innate & non- Specific:
e.g. -Physical barriers,
-body secretions which contain bactericidal
substances (lysozymes, interferons, c-reactive
proteins, complements, N-K cells). E.g mucus,
tears, gastric secretions.

-reflex responses
 Immunity
• Specific immunity- may be genetic or acquired

Natural (maternal antibodies)

Passive
Specific: Artificial (immunoglobulins)
Natural (Infection)

Active
Artificial (Vaccination)
 Specific Immunity
• Passive Immunity: conferred when
antibodies are transferred from one
(human or animal) to another to induce
protection.
• The Process is called Adaptive
Transfer
• Vertical – from mother to child either through
the placenta or via breast milk- Ig G
• Horizontal – therapeutic administration eg
HBV-Ig G
 Active immunity

• It is developed as a result of infection or by

specific immunization and is usually associated
with the presence of antibodies.

NOTE: Passive active immunity involves giving

both immunoglobulins and a vaccine to give
immediate and long term protection
Differences Between Active & Passive Immunity
Active Passive
• Takes time to develop. • Established rapidly.
• Education of the reticulo- • No education of the
edothelial system reticulo endothelial
• Duration of protection is system.
long. • Duration of protection is
• Protective efficacy is short.
greater sometimes almost • Protective efficacy is
100%. limited.
• It is less expensive to • It is more expensive.
produce. Useful for those who are
slow at or can’t develop
antibodies
 The Immunogens
• Live Attenuated Vaccines:
Have lost the capacity to induce full blown
disease but retains their immunogenicity.
Contraindicated in immunosuppressed &
pregnancy.
They include:
Bacterial:- BCG, Typhoid, Plague.
 Viral:- Oral Polio (Sabin), Yellow Fever,
Measles, Mumps, Rubella, Influenza.
Rickettsial:- Epidemic Typhus.
• Inactivated or Killed Vaccine:
Organisms killed by heat or chemical, but can
stimulate immunity when introduced into the
body.
Only contraindication is severe reaction to
previous ones.
They include:-
Bacterial:- Typhoid, Cholera, Pertussis,
Plague, Cerebrospinal meningitis.
 Viral:- Rabies, Salk (Polio), Hepatitis B,
Influenza, Japanese
• Toxoids:
 Detoxification of toxins or exotoxin producing organisms.
 Highly efficacious & Safe.
 They include:-
Bacterial:- Diphtheria, Tetanus.
• Cellular Fractions:
 Prepared from extracted cellular fractions.
 Highly efficacious and Safe.
 They include:-
Bacterial:- Meningococcal, Pneumococcal
 Viral :- Hepatitis B polypeptide
Live attenuated Vaccines Killed Vaccine
• More Potent • Less Potent
• Doesn’t need adjuvant • Need for adjuvant
• Immunity is long. • Immunity is short.
• Usually one dose is • Will require booster
enough. doses.
• Stability at room temp • Stability is high at room
is low temp.
 Historical Background
• Human beings have benefited from vaccines for
more than two centuries.
• Edward Jenner created the world’s first vaccine
for smallpox in the 1796.
• The brilliant French chemist Louis Pasteur
developed what he called a rabies vaccine in
1885.
• In the twentieth century, diphtheria, measles,
mumps, and rubella, vaccines were developed.
• Smallpox declared eradicated in May 8 1980,last
case 1977 in Somalia.
• Expanded Program on Immunization (EPI), was
launched by WHO in 1974.
Objectives of EPI:-
Reduce drastically the no of deaths among children
from vaccine preventable diseases (VPDs).
• In 1977, launched the Universal Declaration on
Childhood Immunization, (UCI).
Objectives of UCI:-
– Immunize 0-2yrs at 80% coverage by 1990.
– Reduce VPDs by 50% by 1990.
– Establish Surveillance & monitoring Systems.
– Foster intersectoral collaboration & community
Participation.
 History in Nigeria
• Immunization activities started in Nigeria in
1956.
• In 1978, EPI was launched
• In 1984,EPI was revised.
• In 1990, Nigeria attained the 80% coverage.
• In, 2003 the immunization coverage came
down to <13% due to inability to sustain it.
• In 1996, EPI was renamed to National Program
on Immunization (NPI) & became a Parastatal.
• NPI became operational in 1998.
 National Program on
Immunization
• Launched by Mrs Abacha in 1996 to replace
EPI & within FMOH.
• It had three main activities which include:
– Strengthening of routine NPI services
through accelerated social mobilisation
campaigns to boost routine immunisation
coverage
– Surveillance for NPI target diseases .
– National Immunisation Days (NIDs) for
eradication of poliomyelitis in Nigeria
• In 1997 it was separated from FMoH and became
a parastatal answerable to its Board and the
Minister.
• Established to manufacture, procure & distribute
vaccines.
• In December 2004 the FG abolished the Boards.
• Pneumonia and meningitis vaccines were
introduced into the national immunization
schedule in 2012.
 Btw. Doses on
Table 1:Routine Immunization Schedule for <1yr in Nig.
1 At birth or ............. Intradermal 0.05ml Upper left
ASAP after 0.1ml arm
>1yr old . (Deltoid)

4 At birth, 6, 4 weeks. Oral 2 drops Mouth

10,14, wks.

3 At 6, 10, 14 4 weeks. Intramuscul 0.5ml Rt outer

weeks. ar. part of thi

tis B 3 At birth 4 weeks. Intramuscul 0.5ml Outer part

ar of thigh

3 At 6, 10, 14 4 weeks. i/m 0.5ml Lt outer pa

weeks of thigh

s 1 At 9 ............. Subcutaneo 0.5ml Upper left

months. us arm
Fever 1 At 9 .............. Subcutaneo 0.5ml Upper righ
Table 2: Administration Guidelines of Tetanus Toxoid for Women In
The Reproductive Age Group.
Recommendation Comment

Period of Protection:
Age TT1: at first contact, or early in
pregnancy. No Protection.
TT2: At least 4weeks after TT1. 3 years.
TT3: At least 6 months after TT2. 5 years.
TT4: At least 1 year after TT3. 10 years.
TT5: At least 1 year after TT4 Life time.

Dose 0.5ml

Number of 5
doses

Injection Site Muscle of Upper arm ( Deltoid)

Vaccines on The Routine Immunization Schedule
In Nigeria
• BCG – Baccillus of Calmette and Guerin

• Vaccine is against tuberculosis.

• A live attenuated Vaccine prepared from a

strain of Mycobacterium bovis.
• 2 forms- liquid(fresh) form and a freeze dried
form.
• Powdered form, must be reconstituted with
accompanying diluents before use.

• Reconstituted vaccine must be used in 6hrs.

• BCG vaccine & diluents is stored at
temperature between 2⁰C – 8⁰C. ( sensitive to
heat & light).

• Reconstituted BCG is wrapped in paper or foil.

• Dry BCG can be freeze at -20⁰C

• Dose is 0.05ml, or 0.1ml for >1yr old child.

• Site – upper left arm, intradermal.

 BCG
• After the vaccination, small raised lump
appears.
• It disappears in 30mins.
• Red sore develops two weeks after &
lasts for two weeks.
• It then heals with a scar that remains for
life.
• Absence of a nodule/ scar at injection site after
six weeks, repeat the injection.

• Absence of a scar six weeks after second

injection, must see a doctor.

• Side effects of BCG include: lymphadenitis, fever,

redness or abscess at the site.

• Contraindicated in children with clinical HIV/AIDS

 Oral Polio Vaccine
• Protects against three serotypes of the virus.
• Dr Jonas Salk produced the 1st trivalent
vaccine against polio in 1952.
• In 1963, Albert Bruce Sabin developed the
oral polio (also trivalent)
• A live attenuated vaccine produced in a liquid
form.
• Stored between 0⁰C – 8⁰C at health facility
level.
• Preferably kept frozen at -15⁰C to -25⁰C.
 OPV
• Not to be thawed and re- frozen.
• Most heat sensitive vaccine.
• Excreted into breast milk.
• Diarrhoea in a child is not contraindicated, but
give a fifth (repeat) dose.
• Contraindicated in immunosupressed and
their contacts. ( give the salk vaccine).
• Contraindicated in people with anaphylactic
allergy to neomycin or streptomycin.
 OPV cont.
• Side effects are rare but vaccine induced
polio virus may cause paralysis.
• Polio Eradication Initiative was launched in
Nigeria in 1999.
• Trivalent type is given at routine
immunization.
• Vaccine efficacy is 95% for the three
doses.
 Comparing Salk and Sabin Polio Vaccine
SABIN
SALK
• Live vaccine • Killed
• Oral • Im/subcut
• Less expensive • More expensive
• Herd immunity • Large coverage needed to
• Possible immediate protect population
protection
• Interference by enteric • Not affected by other
viruses viruses
• May cause paralytic polio • Does not
• Less stable • More stable
 Hepatitis B Vaccine
• Used to prevent Hepatitis B Infection.
• A killed vaccine produced as a cloudy
liquid.
• Mixed well before administration.
• Stored between 2⁰C – 8⁰C.
• Can be damaged by heat and freezing.
• Shake test is applicable.
• Side effect can be a mild fever 1 to 2
days after.
• Recommended schedule is at
-birth
-6weeks
-10weeks
-14weeks
o Doses are given each of 0.5ml.
• Hepatitis B virus has three distinct antigens which can
all have antibodies developed against them:-
– HbsAg with Anti HBs, HBcAg with Anti HBc, HBeAg
with Anti Hbe.
• Anti HBs is seen in a successfully immunized
person, or following recovery from an acute
infection.
• Complete dose induces immunity in 95% of
vaccines.
• Not contraindicated in pregnancy & lactation
& HIV patients.
• Contraindicated in people with allergic
reactions to components of the vaccine.
• Persons infected with hepatitis B need not
receive the vaccine.
 Penta
• Penta (Hib+DTP+Hep B) – a pentavalent
vaccine.
• Haemophilus influenza b vaccine which
became available in 1987 is only being
introduced in Nigeria in 2012 - 25 years later.
• Nigeria is the 45th out of 46 countries in the
WHO African region to introduce the Hib
vaccine (only before Guinea Bissau).
 PENTA
• DPT - Diphtheria, Pertussis, Tetanus Vaccine + Hib +
Hep B

• Must be stored at 2⁰C – 8⁰C.

• Never to be frozen, The diphtheria & tetanus toxoid

parts are damaged by freezing.

• Pertussis part is damaged by heat

• Conduct a shake test if damaged by freezing.
 PENTA
Contraindicated in children >5yrs old, a
child with a previous severe reaction e.g.
Immediate anaphylactic shock or
encephalopathy within 7days.
• Pertussis part is contraindicated in
patients with anaphylactic reaction,
encephalopathy, hx of epilepsy.
• Precaution in unexplained fever >40.5°C
within 48hrs.
• Side effects are mild fever, pain, inflammatory
reaction at the site, abscess collection
• Treat symptomatically.
• Reported to cause brain damage, fits of
screaming, unresponsiveness, shock,
vomiting, localized paralysis, and convulsion
occasionally.
• Two doses of Diphtheria & Tetanus Toxoids =
>80% protection.
• Two doses of Pertussis = 50% protection.
 Tetanus Toxoid Vaccine
• Prevents maternal and neonatal tetanus.
• A toxoid in liquid form, derived from
inactivation of clostridium tetani.
• The antibodies formed cross the placenta
to the fetus.
• Stored at 2⁰C – 8⁰C.
• Side effects include; pain at site, acute
inflammatory reaction.
 Measles Vaccine
• Prevents measles infection.
• A live attenuated produced in powdered form.
• Reconstituted before use, & discarded after 6hrs.
• Stored between 2⁰C – 8⁰C.
• 0.5ml single dose given subcut.
• Available since 1963, improved in 1968.
• Not damaged by freezing.
• Can also be given as a combined vaccine-MMR
 Measles Vaccine
• It is given regardless of if child had had measles
infection before or not.
• Side effect include; a mild fever and rash about 1
wk after vaccination, lasting 1-3 days, toxic shock
syndrom.
• May treat side effect with analgesic.
• Not contraindicated in children with clinical HIV /
AIDS.
• Immunity develops about 11-12days after
vaccination.
 Measles vaccine
• Susceptible contact if given the vaccine within
3 days of exposure can be protected.
• Often, not effective if given before 9 months.
• In an epidemic, give children between 6-
9months, repeat again at 9months. (at least 4
wks apart).
• Second doze is given at 15 months.
 Yellow Fever Vaccine
• Prevention of Yellow fever.
• A live vaccine produced in powdered form
• Reconstituted before use.
• Stored at 2⁰C – 8⁰C.
• Easily destroyed by heat.
• It can be freezed.
• Not contraindicated in people with clinical
HIV/AIDS with CD4 count > 200cells/mm. If
less than, it should be postponed.
 Yellow Fever Vaccine cont.
• HIV patients respond less effectively to
the vaccine.
• Protective effects wear off more quickly
by 5 years.
• There is a low risk of serious side effect ,
(3%)
• Side effect include; fever, headache, mild
muscle or joint pain.
 Yellow fever vaccine
• Dose is 0.5ml given subcut.
• Immunity begins 10-12days after vaccination.
• Lasts for about 10yrs.
• Only vaccine required for international travel
Pneumococcal Conjugate Vaccine (PCV)
• PCV 13 its a conjugate vaccine.
• A polysaccharide chemically linked to the
protein carrier diphtheria toxin which increase
the immunogenicity.
• This ensures T cells are involve in the activation
of B cells immune response.
• Its an inactivated vaccine, so no risk of infection
from the vaccine.
• Prevent streptococcus pneumonia.
 National Immunization Day(NID) &
Supplemental National Immunization Day(SNID)
• NID: conduct in 2 rounds, 1 month apart
• 3 – 5 yrs needed to eradicate, but more where
the coverage is low.
• Conducted during cool dry period
• SNID: it complement RI
• To interrupt circulation of polio
• 2 doses given to every child less than 5 yrs
• To catch those not immunised or partially
immunised and boost those immunised
 Contraindications to Vaccination.
• Severely ill child & hospitalised.

• Previous severe reaction to the immunization.

• Children with a history of anaphylactic shock

following egg ingestion should not be given
vaccines that have been grown of hen’s eggs –
yellow fever vaccine and influenza vaccines.
• Live vaccines not given to pregnant women,
immune deficient children.

• It is contraindicated to give more than one

dose of the same vaccine at the same time.

• Other contraindications specific to each

vaccine.
 False Contraindications
• Allergy or asthma (except if to a component of the
vaccine).
• Minor illness like, URTI, Diarhoea, Fever < 38.5⁰C.
• Family history of adverse events from
immunization.
• Family history of convulsions, seizures, fits.
• Child on treatment with antibiotics.
• Known or suspected HIV infection with CD4 count
>200 except with BCG.
• Child just breastfed.
 False Contraindications
• Chronic illnesses such as chronic disease of
the heart, lung, kidney, liver.
• Stable neurological conditions like cerebral
palsy, downs syndrome.
• Prematurity or low birth weight.
• Recent surgery or imminent surgery.
• Malnutrition.
• History of jaundice at birth.
 Vaccine Failure
• Occurs when one develops a disease in spite
of being vaccinated against it.

• Primary vaccine failure is when enough

antibodies are not produced by the immune
system when first vaccinated.

• Secondary vaccine failure is when enough

antibodies are produced immediately after
the vaccination, but the levels fall over time.
 Vaccine Safety
• Vaccines are biological agents that can be
compromised during processing.

• It is mandatory to ensure quality control.

Sterilization and monitoring in vaccine
production and up to the administration.

• Must be closely supervised to ensure vaccines

induce immunity.
Missed immunization opportunity
• A missed opportunity for immunization
occurs when a child or a woman comes
to a health facility, for what ever reason
and does not receive the immunization
for which they are eligible for.
 Missed immunization opportunity
REASONS-
• Failure to administer all the vaccines for which
the child is eligible for
• False contraindications
• Health worker practices – not wanting to open
multiple dose vaccines for few children in
order to avoid wastage
• Logistical problems – vaccine shortages, poor
clinic organization and inefficient clinic
scheduling.
 Protesting Vaccination
• Protest that vaccination is an intrusion on their
privacy and bodily integrity.
• Viewed vaccination laws as assault by the ruling
class on common men.
• In Nigeria, the political campaign that the polio
vaccines were contaminated with anti- fertility
agents created lasting fear in the Muslims in
Northern Nigeria.
• All these can contribute to low vaccination coverage
rates, and persistence of the disease.
 Challenges to Vaccination
• It takes time to produce a vaccine.
• It is very costly producing a vaccine, eg.
Hepatitis B & Yellow fever.
• Vaccines for many diseases, including very
crucial ones like Malaria & HIV still remains
elusive.
• Ethical issues hinder vaccine production
because these vaccines are tested on the
vulnerable populations in Sub- Saharan
THE COLD CHAIN
 The Cold Chain

• This is defined as a system of distributing of vaccines

in a potent state ( at prescribed temperature) from
manufacturer to the actual vaccination site.
• Revers cold chain as the name implies is the
transportation of specimen from site of collection to
the point of analysis at prescribe temperature.

• It includes all the equipment and people that

preserve, transport, distribute and store the vaccines
in a potent state.
 Cold Chain Equipments
• Cold Boxes
• Vaccine carriers
• Foam Pad
• Ice Packs
• Chilled Water Packs
• Refrigerator & Freezers
• Cold Chain Monitoring Equipments
- thermometer
- thermostat
- Vaccine Vial Monitor
 Cold Chain Equipments
• Cold Boxes:
An insulated container lined with ice packs to
keep vaccines and diluents cold.
Used to collect and transport vaccines.
Used to store vaccines of 1month supply.
There are different types with varying vaccine
storage capacity, and cold life.
Cold life is time taken for the temperature
inside the cold box to rise from 3 ⁰C to 10 ⁰C
with the lid closed.
 Cold Chain Equipment: Vaccine carriers.

• Smaller but similar to cold boxes.

• Keep vaccines cold for 24-72hrs.
• Mainly for transportation of vaccines.
• Used for temporary storage.
• Use to transport AFP stool in a reverse
cold chain.
• An example is the Giostyle.
 Cold Chain Equipment
• Foam Pad:
 The piece of soft foam that fits on top the vaccine
carrier.
 It keeps vaccine during immunization sessions.

• Ice Packs:
 These are flat, rectangular plastic bottles.
 Use to keep the freeze dried vaccines.
 There are 0.6, 0.4 and 0.3 litre packs.
 Takes 48hrs to completely freeze, use repeatedly.
• Chilled Water Packs:
These are ice packs that have been
conditioned.
Used to keep freeze- sensitive vaccines like
DPT, HBV, TT.

• Refrigerator & Freezers:

Used to store vaccines, freeze ice packs.
Powered by electricity, Gas, Solar,
 Cold Chain Monitoring Equipments
• These are used to keep track of the temperature
vaccines are exposed to during transportation &
storage.
• They include:
 Thermometers, thermostat.
These are placed in the cold chain equipments.
And checked & charted twice daily.
If any abnormality, correct appropriately and
immediately. E.g if the temperature is rising, you
increase the thermostat.
 Vaccine Cold Chain Monitor.
A card that changes colour when vaccine is
exposed to too high temperature.

Manufacturers pack them in the cold boxes

containing the vaccines.(BCG, DPT, Yellow fever,
hepatitis B, OPV and measles vaccines)

It has 4 monitoring windows, A B C D

For Polio, if The A mark is blue, use within 3

months.
For Polio, if B, C and D are blue, do a VVM test
before use.
For measles and Yellow fever, can still use within
3 months if B is blue.
For DPT & BCG, you can still use within 3months,
if C is Blue.
For TT and Hepatitis B, use unless D is blue.
Ensure that it is not close to the expiry date.
 Vaccine Vial Monitor (VVM)
 A label on the vaccine that changes colour
irreversibly when exposed to heat over a period of
time.
 VVM must be checked on a vaccine before opening.
 VVM for liquids vaccines like OPV, Hepatitis B, DPT,
are attached to the label on the vaccine.
 VVM for vaccines in powdered forms like, measles,
yellow fever, are on the cap.
 While the VVM for BCG if comes in ampoules is on
the neck.
 Freeze Watch Indicators
 This consists of a small vial of red liquid attached to a
white card and covered in plastic.

 The vial breaks if the temperature where the indicator

is located drops below 0⁰C for Ihr.(-0.5⁰C)

 If less than 1hr, the absorbing paper will turn blue.

 Manufacturers pack them with the freeze sensitive

vaccines like the DPT, TT, HB.
 Freeze Watch Indicators cont.
 The freeze watch indicator can also be placed
in the refrigerators containing these vaccines.

 To decide if to use these vaccines, conduct a

shake test.

 There are now new electronic types called the

Freeze tag which is more sensitive.
 Shake test
• Gather the potentially ‘’frozen suspect vials’’.
• Take a vial of vaccine of the same type and
batch no of the vials you want to test.
• You may even take one of the suspect vials.
• Intentionally freeze it overnight at -20 ⁰C.
• Label it as frozen
• Then allow it to thaw completely.
• Shake the ‘frozen’ vial and a suspect vial
vigorously for 10- 15 secs.
 Shake Test cont.
• Allow them to stand for about 5 – 15 mins.
• Observe the two vials & interpret the findings.
• If the sediment settles faster in the frozen vial than
in the suspect vial, IT IS NOT DAMAGED.
• If the sediment in both vials settle at the same rate ,
IT IS DAMAGED.
• Also if granules collect at the bottom of the two
vials, discard.
• If vaccines have large labels, turn upside down.
• You can use the frozen vial repeatedly.
 Loading Cold Chain Equipments
• The refrigerator has the freezing and main
compartments.
• The main compartment is kept at 2⁰C to 8⁰C.
• The freezer compartment is kept at –15 ⁰C to -25 ⁰C
• Never freeze the diluents.
• Do not put vaccines on the door shelves.
• Don’t keep anything else like food, AFP stool sample
• Open the doors occasionally.
• Regularly defrost the refrigerator .
Thank you