IMMUNIZATION

Definition:
Immunization is a procedure where the immunizing agents are administered artificially to
produce specific protection against a given disease.

Immunizing agents: 1) Vaccines

2) Immunoglobulin
3) Anti-sera / (anti-toxins)

There are two types of immunity-

1) Active Immunity
2) Passive Immunity

Active Immunity:
It is the immunity which an individual develops as a result of infection or by specific
immunization, and is usually associated with presence of antibodies or cells having a specific
action on micro-organisms concerned with a particular infections disease or on its toxin.

Passive Immunity:
When antibodies produced in one body (human or animals) are transferred to another to
induce protection against disease, this is known as passive immunity. In other words, the
body does not produce its own antibodies but depends upon readymade ones.

VACCINES:
They are immunobiological substances designed to produce specific protection against a
given disease. It stimulates the production of protective antibodies and other immune cellular
fractions.
Vaccines may be prepared from live modified organisms, inactivated or killed
organisms, extracted cellular fractions, toxids or combination of these.

A) Live Vaccines:
Prepared from live organisms. They are more potent immunizing agents then killed vaccines.
Eg: BCG, Measles, Oral Polio.

Contraindications:
 Persons with immuno-deficiency diseases or persons whose immune response may be
suppressed due to leukemia, lymphoma or malignancy or treatment on corticosteroids.
 Pregnancy is also another contraindication to some live vaccines because of risk to the
foetus.

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B) Inactivated (Killed) Vaccines:

Prepared from organisms killed by heat or chemicals, when injected into the body stimulates
active immunity.
Eg. Typhoid, Cholera pertussis, Influenza, rabies

Killed vaccines are less effective than live vaccines; usually require a primary series of 2-3
doses of vaccine to produce an adequate antibody response and in most of cases booster
doses are required.

NATIONAL IMMUNIZATION SCHEDULE

a) For Infants:

At birth - BCG and OPV - 0 dose

(for instutional deliveries)
BCG (if not given at birth) at 6 weeks
At 6 weeks - DPT-1, OPV-1 & Hepatitis B-1 (or Pentavalent-1& OPV-1)
10 weeks - DPT-2, OPV-2 & Hepatitis B-2 (or Pentavalent-2& OPV-2)
14 weeks - DPT-3, OPV-3 & Hepatitis B-3 (or Pentavalent-3& OPV-3)
At 9 months - Measles

b) At 16-24 months - DPT and OPV (1st booster)

c) At 5-6 years - DT / OPV (second booster dose)

d) At 10 and at 16 years - Tetanus toxoid

e) For pregnant women:

Early in pregnancy - TT-1 dose or Booster (if previous
pregnancy was within 3 years)
One month later - TT-2 dose

B.C.G. (BACILLI CALMETTE GUERIN)

Aim: Is to induce a benign artificial primary infection, which will stimulate an acquired
resistance to possible subsequent infection with virulent tubercle bacilli.

Types: 1) Liquid (fresh) vaccine & (2) Freeze – dried vaccine (more stable)

If BCG is stored at subzero temperature (-20 oC), the vaccine will remain good for use up to 2
yrs. If it is stored at 2-8oC it is good for use for one month at city or district stores. At
peripheral level, at 2-8oC good for use up to one week.

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Strain: Danish 1331

Dosage: 0.1ml; Newborn (< 4 weeks) - 0.05 ml.

Diluent: Normal saline (Nacl2), as distilled water may cause irritation.

The vaccine must be protected from exposure to light during storage (wrapped up in a double
layer of red or black cloth).

Route & site of administration: Intradermally using a ‘Tuberculin Syringe’ just above the
origin of the left deltoid muscle at acromion process of left arm.

Schedule: At birth or at 6 weeks

Complications:
1. Most common: a) Suppurative lymphadenitis
b) Local abscess
c) Prolonged severe ulceration at site of vaccination
d) Neurosis

2. Serious complications: a) Disseminated infection with BCG virus.

b) BCG ostroitis/osteomyelitis

Contraindications: 1) Generalized eczema

2) Infective dermatosis
3) Hypogammaglobunemia
4) H/o deficient immunity.

Protection value: Duration of protection is for 15 to 20 years. Range of protection varies

from 0 to 80% in different parts of world.

Normal phenomena after vaccination:

Papule – within 2-3 weeks

Increases in size about 4-8 mm in about 5 weeks

Breaks in to shallow ulcer & covered with crust. Healing occur in 6-12 weeks.

Leaving permanent tiny round scar. Typically 4-8 mm. in diameter this is normal reaction.

Maximum age for immunization of BCG is up to 1 year, if not given at birth .

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POLIO VACCINE

Two kinds are available: - Oral Polio Vaccine (Sabin type or live attenuated vaccine)
- Inactivated Polio Vaccine (Salk type or killed vaccine)

I. Oral Polio Vaccine (Live Vaccine – Sabin Type)

Each dose consists of (Trivalent)

Type I Virus – 3 lakh TCID 50
Type II Virus – 1 lakh TCID 50
Type III Virus – 3 lakh TCID 50 (TCID – Tissue Culture Infective Dose)

Dose: 2-3 drops

Route: Oral
Schedule: 0 dose - at birth or at 1st contact in uncontrolled areas
1st dose - 6 weeks
2nd dose - 10 weeks
3rd dose - 14 weeks
Booster - 18 months
Strains: Lansing, Leon and Brunhide

Advantages: 1) Easy to administer

2) Does not require training
3) Provides double immunity – Humoral/ Intestinal
4) Immunity is life long
5) Useful in controlling epidemics
6) Relatively inexpensive.

Contraindications: 1) Acute infectious disease

2) High degree fever
3) Immuno compromised and Immune suppressants

Instructions to mother: Hot fluids like hot water and milk should not be given for half an hour
after vaccination.

OPV is a live attenuated vaccine but it is given with repeated doses, why ?
1. In children gut immunity is not so good to produce antibodies with single dose.
2. There are 3 strains and one type does not protect completely against the other two
types of viruses

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Pulse Polio Immunization

Definition: PPIs are when oral polio vaccine is given to all children 0-5 yrs. of age in the
country on a single day regardless to previous immunization.

Two rounds are conducted during low transmission season of polio with 4-6 weeks apart
between November to February.

II. Inactivated (Salk) Polio Vaccine:

Consists of all three types of viruses inactivated by formalin.

Dose: 4 doses are given:

First 3 doses: At an interval of 1-2 months
Fourth doses: 6-12 months after three doses.
Additional doses are recommended prior to school entry and then every 5 years until age of
18 yrs.

Route: Intramuscular

Advantages: 1) Safer as it does not contain live viruses

2) Can be administered to persons with safety who are :
3) Immune deficient
4) Undergoing treatment with corticosteroid or radiation therapy

Disadvantages: 1) Not useful in controlling epidemics because.

2) It does not induce cold or intestinal immunity
(Hence spread to others not prevented)
3) Immunity not rapidly achieved
4) Injections are avoided during epidemics as they may precipitate
paralysis or an attack of paralytic polio.
Differences

IPV (SALK TYPE) OPV (SABIN TYPE)

1. Killed formulized vaccine 1. Live attenuated vaccine

2. Subcutaneous or IM 2. Orally
3. Induces circulatory antibody 3. Prevent not only paralysis
but no local immunity but also intestinal reinfection
4. Not useful in controlling epidemics 4. Effective in epidemics.
5. More difficult to manufacture 5. Easy
6. Costlier 6. Cheap.

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DPT AND DT

DPT = Diphtheria, Pertussis, Tetanus

DT = Diphtheria, Tetanus.

Advantages: a) 3 diseases are benefitted

b) Pertussis enhances the potency of the diphtheria toxoid.

Two types: 1) Plain – less effective

2) Adsorbed – more effective (Aluminium hydroxide)

Adsorption is usually carried out on a mineral carrier like aluminium Phosphate or hydroxide.
Adsorption increases the immunological effectiveness of the vaccine.

Storage: Vaccine should be stored in a refrigerator between 4 to 8 oC vaccine should not be

frozen.
Dose: 0.5 ml
Route: Deep intramuscular in anterolateral aspect of thigh
Schedule: 3 doses at 6, 10 & 14 weeks
Booster at 18-24 months and DT only at 5-6 years of age

For Children of 5 years age who have not received DPT they need only 2 doses with Booster
dose 6 months to 1 year later.

Complications:
1. Local swelling, tenderness, fever
2. Most severe complications are neurological complications because of pertussis
component, are Encephalopathy, conclusions, Reyes Syndrome, Infantile spasms.

Contraindications:
1. DPT should not be repeated if a severe reaction occurred after a previous dose.
2. Convulsions,
3. Anaphylactic reactions.

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MEASLES VACCINE

It is a live attenuated vaccine

It is presented as freeze dried product

Storage: At subzero temperature (-20oC at regional store, potency lasts upto 3 months).
If stored in the freezer of a refrigerator the potency lasts for only 1 month.
Diluting fluid should also be kept at 4-8oC.

Dose: 0.5 ml

Route: Subcutaneous at insertion of right deltoid

Schedule: At 9 months.
 If given before the age of 9 months, it runs the risk of the vaccine being rendered
ineffective by the natural antibodies got from the mother.
 If there is outbreak of measles the vaccine can be given at 6 months but a second dose of
vaccine should be given after 4 weeks of interval.

Protection: Immunity develops after 11-12 days and gives 95% protection for atleast 15
years. The vaccine also provides immunity to severely malnourished children.

Contraindications:
1. Immuno comprised patient
2. Past history of convulsion
3. History of allergy eczema
4. Pregnant women
5. Active tuberculosis
6. Vaccine should not be given 4 hours of opening of vial.

Adverse effects: Toxic shock syndrome - watery diarrhoea, fever, vomiting

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TETANUS TOXOID

It is a monovalent vaccine –
Two types: 1) Plain 2) Adsorbed or purified.

Dose: 0.5 ml

Route: Intramuscular

Schedule: 10th & 16th year

Booster doses - 1st dose given a year after initial primary 2 doses
2nd dose given 5 years after 1st Booster dose.

For pregnant women:

2 dose are given (adsorbed) if not immunized earlier.
1st dose – 16-20 weeks
2nd dose – 20-24 weeks of pregnancy.

 The minimum interval should be one month preferably second dose be given one month
prior to delivery. For women who have been immunized earlier within 3 years, one
booster dose is sufficient.
 For pregnant women, in areas where neonatal tetanus is high the primary 2 dose course
can be extended to all women of child bearing age

Storage: Between 4 to 10oC; should not be frozen.

Adverse effects: Are local and rarely allergic type.

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HEPATITIS –B VACCINE

There are 2 types.

1. Plasma Derived Vaccine (SUB UNIT VACCINE)
2. RDIV – Yeast Derived Vaccine.

A} PLASMA DERIVED VACCINE (SUB UNIT VACCINE):

Dose: 0.5 ml

Route: Deep intramuscular in deltoid

Schedule: 0, 1 & 6 months

Childrens below 10 years of age should be given half of the above dosage at the same
time intervals.

Storage: 2-8oC: should not be freezed

Adverse Reactions:
1. Allergic reactions
2. Anaphylatic reaction.

B} RDNA YEAST DERIVED VACCINE:

Genetically engineered vaccine is as Immunogenic, safe & effective than the plasma derived
vaccine.

Dose: Adult: 10-20mg

Paediatrics: 5-10mg

Schedule: 0, 1st & 6th months.

Protection: upto 9 years, booster dose not routinely recommended.

In neonates born to HBs of +ve mother:

1st start HBIG – 0.5 ml. should be administered “IM” in thigh immediately after birth
followed by active immunization with vaccine.

Dose – 0, 1st & 2nd month

booster at 12th month of age.

Note: Vaccine has no effect on HBS of carriers.

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ANTI RABIES VACCINE

1. Nervous Tissue Vaccine (Ntv):

a) Derived from adult animal nervous tissue (eg. Sheep)
b) Derived from suckling mouse brain.

2. Duck Culture Vaccine (Dev):

3. Cell-Culture Vaccine:
a) Human-diploid culture (HDC) vaccine
b) “Second generation” tissue culture (animal cell) vaccines.

Aim: To produce an immune system status as quickly as possible, so that the virus will not
become established, in the peripheral nerves along which it will travel to central nervous
system.

Classification of exposures:
Class I: a) Licks on healthy unbroken skin
b) Consumption of unboiled milk of the suspected animal
c) Scratches without oozing of blood.

Class II: a) Licks on fresh cut

b) Scratches with oozing of blood
c) All sites except on head, neck, face, palms & fingers.

Class III: a) All bites with oozing of blood on head, neck, face & fingers
b) Lacerated wound on any part of body
c) Multiple wounds 5 or more
d) Bites from wild animals.

Cell Culture Vaccines:

Post- exposure prophylaxis :

A} Intramuscular administration

Dose: 0.5ml

Route: intramuscular into deltoid muscle or anterolateral thigh in children < 2years

Schedule:
i. 5 dose regimen - 1 dose each on days 0,3, 7, 14 & 28 (5 vials; 5visits)
ii. 4 dose regimen (2-1-1) - 2 doses on day 0, followed by 1 dose each on days 7 & 21 (4
vials; 3 visits)

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B} Intradermal administration

Dose: 0.1ml

Route: Intradermal into deltoid muscle or anterolateral thigh in children < 2years

Schedule: 2 site regimen (2-2-2-2) - 2 doses each on days 0,3, 7 & 28 (<2 vials; 4 visits)

Note: rabies immunoglobulin is given in all cases on day 0.

Pre-exposure prophylaxis:

Indicated in people who are at continuous, frequent and increased risk of exposure to rabies
virus as a result of their residence or occupation like veterinarians, animal handlers, lab
workers dealing with rabies virus, children in high risk areas, courier boys etc.

Dose: 0.5 ml intramuscular or 0.1 ml intradermal

Schedule: one dose each on days 0, 7 & 21 or 28. Booster doses at intervals of 2 yrs. as long
as exposed person is at risk.

Advantages of cell culture vaccine:

1. Efficacy & safety
2. 3-4 doses will give good antibody level.

Disadvantages - Cost is higher.

Complications:
1. General : Headache, insomnia, giddiness, palpitations and diarrhoea.
2. Local : Itching, pain, tenderness, redness and swelling.
3. Allergic : Utricaria, syncope, angioneurotic oedema.

Advise to patients:
1. They should abstain from alcohol during and a month after completion of
antirabies treatment, since it may precipitate paralytic accidents or facilitate flaring up
the infection.
2. Avoid undue physical and mental strain and late nights should be avoided.
3. Corticosteroids and other immunosuppressive agents should not be used.

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COLD CHAIN

The “COLD CHAIN” is a system of storage and transport of vaccines at low temperatures
from the manufacturer to the actual vaccination site.

The cold chain system is necessary because vaccine failure may occur due to failure to store
and transport under strict temperature controls.

Cold Chain equipment consists of:

a) COLD BOX: To transport large quantities of vaccine by vehicle to outreach sites.

It can keep vaccines cold for period up to one week.

b) VACCINE CARRIER: To transport small quantities of vaccine by vehicle to out-reach

sites. (16-20 vials)
It can keep vaccines at a safe temperature up to 3 days.

c) DAY CARRIERS: 6 – 8 vials.

d) FLASKS: Used only if vaccine carrier is not available.

e) ICE PACKS: They can be made in the freezer

They keep vaccines cool in cold boxes, carriers and flasks.
Water must be filled till the marking and stored in freezer.

f) REFRIGERATOR/FREEZER:
 Refrigerator is an important member of the “health team”
 Ice lined refrigerators are used at PHC and district levels where vaccines can be stored for
3 months
 Deep freezers are used to prepare and store ice packs.

g) WALK-IN REFRIGERATORS/ FREEZERS: Used at state levels to store vaccines in

large quantities

Vaccines that can be freezed: OPV & measles

Vaccines to be kept in cold compartment: DPT/DT, Hepatitis B, TT, Typhoid, cholera, rabies
vaccines

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Vaccine vial monitor

A VVM is a label containing a heat-sensitive material which is placed on a vaccine vial to

register cumulative heat exposure over time.

It consists of an inner square and an outer circle which changes colour on exposure to heat.

The VVM does not directly measure vaccine potency but it gives information about the main
factor that affects potency: heat exposure over a period of time. The VVM does not, however
measure exposure to freezing that contributes to the degradation of freeze-sensitive vaccines.

Reading the Stages of the VVM

1. The inner square is lighter than the outer circle. If the expiry date has not been passed USE
the vaccine

2. The inner square is still lighter than the outer circle. If the expiry date has not been
passed: USE the vaccine

3. The colour of the inner square matches that of the outer circle: DO NOT use the
vaccine

4. The colour of the inner square is darker than the outer circle: DO NOT use the
Vaccine.

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