IMMUNIZATION (2)

Dr. Mukesh Bhatta

BACILLUS CALMETTE–GUÉRIN
VACCINE
• Developed in 1921
• Named after French bacteriolologist Leon Charles Albert Calmette and
vetenarian Camille Guerin
• Live attenuated
• Derived from bovine tuberculosis strain
• In India produced from Danish 1331 strain
• Contains 0.1-0.4 million bacilli per dose
• Supplied as lyophilized (freeze-dried) powder in multi dose, vacuum
sealed, dark colored ampoules or 2 mL vials with normal saline as
diluent

• Light and heat sensitive and deteriorates rapidly on exposure to UV

rays.
BACILLUS CALMETTE–GUÉRIN
VACCINE
• Diluent should be used for reconstitution, sterile normal saline may be used, if diluent
is not available.
• As the vaccine contains no preservative, bacterial contamination and consequent toxic
shock syndrome may occur, if kept for long after reconstitution.
• The reconstituted vaccine should be stored at 2–8°C, protected from light, and
discarded within 4–6 hours of reconstitution.
• Even though BCG has demonstrated significant effectiveness, protection has not been
consistent against all forms of TB and in all age groups.
• BCG is not effective when used as post-exposure prophylaxis.
• Several new TB candidate vaccines are in development, some are designed to be used
for booster vaccination
• Administered by intradermal injection.
• Correct intradermal administration can be verified by a wheal of 5 mm formation.
• The vaccine should be given preferably in the lateral aspect of the upper arm.
• Sequence of events after vaccination:
The injected site usually shows no visible change for several days.
Subsequently, a papule develops after 2–3 weeks, which increases to a size of 4–8 mm
by the end of 5–6 weeks.
This papule often heals with ulceration and results in a scar after 6–12 weeks.
The ulcer at vaccination site may persist for a few weeks before formation of the final
scar. No treatment is required for this condition.
• There are no details related to efficacy/effectiveness and safety for
other anatomic sites of administration.
• BCG vaccination usually causes a scar at the site of injection due to
local inflammatory processes.
• Approximately, 10% of vaccine recipients do not develop a scar and
that does not mean that protection has not been achieved.
• The standard dose of reconstituted vaccine is 0.05 mL upto 1 month
age, thereafter 0.1 mL for infants aged 1 year.
• BCG vaccine is not available in combination with other vaccines.
Duration of Protection and Revaccination in BCG

• A systematic review concluded that protection after primary infant

BCG vaccination could last for up to 15 years in some populations.

• About 95% experience a reaction at the injection site

Adverse events following
immunization (AEFI) after BCG:
• injection site abscess
• severe ulceration
• suppurative lymphadenitis
• Disseminated BCG diseases (1.56 and 4.29 cases per million doses) :high-case fatality
rate.
• BCG vaccine-related complications may occur distal to the site of inoculation in the skin,
intestines, bones (osteitis) or bone marrow (osteomyelitis) >12 months after vaccination.
• BCG immune reconstitution inflammatory syndrome (IRIS) also occurs in association with
HIV infection.
• Other: uveitis and skin lesions such as lupus vulgaris.
• severe AEFI can occur in HIV-infected infants.
• Preterm infants and low birth weight infants: safe and effective.
Co-administration of Vaccines with
BCG

• BCG vaccine can be safely coadministered with diphtheria-pertussis-

tetanus (DTP), polio, hepatitis B, Haemophilus influenzae type b (Hib)
and measles and rubella vaccines.
BCG vaccination of older age groups

BCG vaccination of unvaccinated, TST-negative school children may provide long-term

protection (Up to 20 years or longer).
BCG vaccination of older age groups is recommended for the following:
Unvaccinated TST- or interferon-gamma release assay (IGRA)-negative older children,
adolescents, and adults from settings with high incidence of TB and/or high leprosy
burden.
Unvaccinated TST- or IGRA-negative older children, adolescents, and adults moving
from low to high TB incidence or leprosy burden settings.
Unvaccinated TST- or IGRA-negative persons at risk of occupational exposure in low-
and high-TB incidence areas (e.g., healthcare workers, laboratory workers, medical
students, prison workers, other individuals with occupational exposure).
Management of common problems
during BCG
• Simple or Non-suppurative lymphadenitis: spontaneous regression
over few weeks (antibiotics/ ATT not effective)
• Suppurative lymphadenitis: needle aspiration (usually single effective;
may need repeated aspiration); surgical excision done if repeated
needle aspiration fails.
• Disseminated BCG disease: Symptomatic plus ATT
Vaccination of Special Populations,
Contraindications, and Precautions

• Allergic to any component of the vaccine.

• Not given in pregnant; given in lactation.
• HIV: clinically well, immunologically stable, on ART should be vaccinated
• Neonates born to women of unknown HIV status should be vaccinated
• Neonates of unknown-HIV status born to HIV-infected women should be vaccinated, if
they have no clinical evidence suggestive of HIV infection, regardless of whether the
mother is receiving ART.
• Neonates born to mothers with pulmonary TB (PTB): If an infant remains
asymptomatic and has no immunological evidence of TB at the end of preventive
treatment (INH preventive therapy) , and is also HIV-negative, BCG vaccination should
be provided using a normal infant dose.
Polio Vaccines

• 2 types:
• Live attenuated oral Polio vaccine (OPV)
• Inactivated polio vaccine (IPV)
Live attenuated OPV
Albert sabin; licensed in 1961
The wild polio virus is attenuated by repeated passage on non-optimal tissue
culture
The OPV is given orally, and to be effective, the virus needs to multiply in the GIT.
The OPV contains 105 to 106 median cell culture infectious doses of all 3 types of
polio virus derived from the original sabin strain

magnesium chloride is the stabilizing agent.

At 6,10 and 14 weeks
Dose: two drops (~0.1 mL), directly into the mouth.
• OPV as a monovalent (mOPV) vaccine was initially licensed in 1961
followed by a trivalent version (tOPV) in 1963.
• Bivalent OPV (bOPV containing types 1 and 3 Sabin viruses) has been
licensed and used in some settings since December 2009.
• Following the planned global switch from tOPV to bOPV in April 2016,
tOPV will no longer be available and will be replaced by bOPV.
Thereafter, mOPV2 will be stockpiled for emergency.
• After oral dose, the vaccine virus infects the intestinal mucosa and
multiply in the mucosal cells, called as TAKE of the vaccine
• Mucosal immunity in response to this TAKE protects from paralytic
poliomyelitis by reducing the chances of infection when wild type
poliovirus is encountered
• The wild virus is excreted for a shorter period and lesser in number
thus reducing feco-oral transmission and interrupting wild virus
circulation.
• Heat-sensitive and must be kept frozen for long-term storage or, after
thawing, at temperatures between +2°C and +8°C for a maximum of 6
months.

• Potency falls with temperature fluctuations

• Vaccine vial monitors used.

Why are multiple doses (3 doses) of
OPV essential?
• Multiple doses essential to ensure TAKE, which may be affected by:
competition for mucosal infection by other enteroviruses
concomitant diarrhea (rapid intestinal transit)
Cold chain interruption
• Seroconversion rates after 3 doses of OPV are highest for serotype 2
(90%) and lowest for serotype 3 (70%)
• Persistence of protective effects lasts nearly 10 years even if
antibodies are undetectable.
• Breastfeeding and mild diarrhea are not contraindication for OPV
• Inherited or acquired immunodeficiency children, pregnant should
not receive OPV
• OPV avoided in household contacts of immunodeficient patients, due
to the risk of feco-oral transmission of OPV strain.
Zero dosing of OPV
• In this, hospital born children are administered another dose
immediately, or within 14 days of birth (not beyond 14 days)

• This enhances seroconversion and protect babies who subsequently

receive 3 conventional doses.
National Immunization Days

• Conducted twice annually for a period of 1–3 days when one dose of OPV is
administered to all children <5 years of age, regardless of prior vaccination
history.
• A second dose is repeated similarly after 4–6 weeks.
• The NIDs usually take place during the low transmission season for both the
polio and enteroviruses (enteroviruses may interfere with poliovirus
seroconversion)—the optimal period to interrupt the few remaining chains of
poliovirus transmission.
• The NIDs are necessary in developing countries to rapidly increase immunity
levels in the population to achieve and surpass herd immunity threshold levels
for poliomyelitis and, hence, rapidly interrupt the transmission of polioviruses.
• Oral polio vaccine administered in campaigns also seems to be more immunogenic compared
with OPV administered in the routine program.
• National immunization days are conducted during the low poliovirus transmission season
because this is the period when the fewest chains of poliovirus transmission are maintained.
• Massive use of OPV probably also results in intensive secondary spread of shed virus.
• Children residing in polio-endemic countries using NIDs may receive 13–14 doses of OPV by
the time they reach their fifth birthday.
• Mopping-up campaigns usually target children younger than 5 years of age where in two
doses of OPV given with an interval of 4–6 weeks.
• These campaigns include house-to-house administration of OPV with an objective to eliminate
the last potential or known reservoirs of WPV circulation, critical component to achieve
interruption of the final chains of poliovirus transmission in all polio-endemic areas.
Adverse effects of OPV
• Vaccine associated paralytic poliomyelitis (VAPP): Defined as those cases of AFP
which have residual weakness 60 days after the onset of paralysis and from whose
stool samples, vaccine related poliovirus (but not wild polio virus) is isolated.
• VAPP may occur in vaccine recipient called vaccine recipient VAPP or in contact of
vaccine recipient called contact VAPP.
• Occurs in 1 case per 1.5 million OPV recipients
• Live attenuated poliovirus, while in the GIT of the recipients regains its neurovirulence
• The reverted virus might reach the CNS and spread like the wild polio virus
• Risk of VAPP is higher with the first dose that takes with p2 virus (serotype 2) and in
patients with B cell immunodeficiency.
• C/Fs resemble natural paralytic polio.
Circulating Vaccine Derived polio
Virus (CVDPV)
• The virus strain of OPV undergoes mutation resulting in new strain
Circulating Vaccine Derived polio Virus (CVDPV)
• This new strain is virulent; causes paralytic polio.
• Can also cause community outbreak, esp in low OPV coverage area
Inactivated polio virus vaccine (IPV)
• Killed vaccine; developed by salk in 1955

• The vaccine primarily induces humoral immune response, but pharyngeal and possibly,
intestinal mucosal antibodies are also induced
• Vaccine potency is measured by its D antigen content
• Each dose of IPV contains 40, 8, 32 D antigens units of the type 1,2 and 3 viruses,
respectively.
• Highly immunogenic, with seroconversion noted in 90-95% infants given 2 doses of IPV, 2
months apart beyond 8 weeks of age and in 99% of those given 3 doses 4 weeks apart.
• Titers of secretory IgA and extent of herd immunity induced by IPV are lower than with OPV
• However, efficacy in preventing poliomyelitis is excellent.
• Doesn’t cause VAPP
Inactivated polio virus vaccine (IPV)
• Should be refrigerated to preserve potency but not frozen as this
could diminish potency.
• IPV is very safe, whether given alone or in combination with other
vaccines.
• There may be transient minor local erythema (0.5–1%), induration (3–
11%), and tenderness (14–29%).
• IPV is the choice of vaccine in immunodeficient patients, and in
siblings and closed contacts of such patients.
Sequential IPV-OPV schedule
• First IPV given and then OPV
• Advantage: risk of OPV induced VAPP is minimized by prior IPV, while
ensuring that adequate mucosal immunity interrupts wild polio virus
circulation.
• Thus this sequential regimen maintains a high mucosal immunity,
preventing VAPP.
• All IPV schedule: small risk of VAPP through contact or environment
(before seroprotection by IPV)
• Birth dose or zero dose of OPV unlikely to cause VAPP (d/t maternal
Ab)
Fractionated IPV (fIPV)

• Fractional doses of IPV 1/5 of a full dose reduces the cost

• single fractional dose of IPV gives lower seroconversion than full dose
but after two doses, the rates are similar to those after two full doses.
• Using two fractional doses instead of one full dose, increases the
immunogenicity of IPV
Vaccination with OPV plus IPV

• For all countries using OPV in the national immunization program, WHO continues to recommend the inclusion
of at least one dose of IPV in the vaccination schedule.
• The primary purpose of this IPV dose is to induce an immunity base that could be rapidly boosted if there is
an outbreak of polio due to poliovirus type 2 after the introduction of bOPV2.
• The inclusion of IPV may reduce risks of VAPP and also boost both humoral and mucosal immunity against
poliovirus types 1 and 3 in vaccine recipients.
• For polio-endemic countries and countries at high risk for importation and subsequent spread of poliovirus,
WHO recommends a bOPV birth dose (zero dose) followed by a primary series of three bOPV doses and at least
one IPV dose. The zero dose of bOPV should be administered at birth or as early as possible within 7 days.
• Schedule could be three bOPV doses plus one IPV dose initiated from the age of 6 weeks with a minimum
interval of 4 weeks between the bOPV doses.
• One dose of IPV should be given at 14 weeks of age or later (when maternal antibodies have diminished and
immunogenicity is significantly higher
•
The Polio Eradication and Endgame
Strategic Plan 2013–2018
DPT
• Availaible as monovalent (TT; tetanus only), bivalent (DT-pediatric; dT-
adult) and trivalent DPT

• Trivalent available in 2 forms: DTwP containing whole cell pertussis

vaccine and DTaP containing Acellular pertussis.
DPT:
DTwP:
• Whole cell pertussis vaccine.
• Diphtheria toxoid = 25 Lf
• Tetanus toxoid = 5 LF
• Pertussis = 4 IU of formalin inactivated Bordtella
pertussis cells (20,000 million killed pertussis)
• Diphtheria vaccine contain modified bacterial toxin with
aluminium hydroxide as adjuvant(increases immunogenicity)
• Dose = 0.5 ml, route = intramuscular. 6,10 and 14 wks of age
• Interval between the doses is 4 weeks.
• Protective efficacy is P = 70- 80%, D = 80%, T = 100%.
• First booster at 16-24 months and second at 4.5 – 5years.
• DwPT or DaPT can be used only upto 7 years, thereafter dT
should be used.
Side effects of DwPT

1. Local- redness, swelling, pain, abscess.

2. Systemic- fever, drowsiness, vomiting, anorexia
3. Serious- fever> 40.5OC, convulsion, persistent inconsolable cry> 3
hr, shock, encephalopathy.
• Local and febrile reactions less common and less severe with Acellular
than whole cell pertusis vaccine.
• A child who has recovered from diphtheria or tetanus must be
actively immunized because amount of toxin responsible for disease
in humans does not elicit protective immunity.
Contraindications:
1. Progressive neurologic diseases
2. Encephalopathy within 7 days of vaccination
3. Anaphylaxis with first dose.
Precautions
4. Convulsion (with/out fever) within 3 days of vaccination
5. Collapse/Shock like state (hypotonic-hyporesponsive episode ) within 48 hours of vaccination
6. Persistent inconsolable cry lasting for more than 3 hours within 48 hrs
7. Fever> 40.5OC within 48 hr
DTaP (acellular pertussis vaccine)
• Subunit of pertussis containing pertussis toxin, FHA, fimbrial agglutinogen and pertactin
Measles:
• Live attenuated measles virus developed by Enders in 1960.
• Developed from Edmonston Zagreb strain grown in human diploid cells.
• Formulation alone or in combination as MMR or MR.
• Heat labile lyophilized vaccine stored at 2-8 degree centigrade.
• Use reconstituted vaccine (sterile water) within 4-6 hours.
• Given at 9 months of age as MR
• However during an outbreak, infants as young as 6 months can be
vaccinated. However this dose should not be counted. i.e. repeated to be
given at 12-15 months.
• Efficacy: 85-90%
• Considering 15% primary vaccine failure rate, booster dose at 15 months
is recommended.
• Most infants protected from maternal antibodies till 6-8 months of age.
• Route: subcutaneous, dose: 0.5 ml (1000 TCID)
• Malignancy, immunosupressant therapy, severe immunocompromised
state, allergy to neomycin are contraindications to measles vaccine
• Not to be given in untreated tubercular patients.
Rubella
• Given as MR; contains 1000 TCID of rubella virus
• 95% efficacy; lifelong protection
• Rubella vaccination is mainly for prevention of congenital rubella
syndrome (CRS).
• For prevention of rubella and CRS, double pronged approach is
required. All adolescent girls need to be vaccinated with MR if they
have not received it earlier
• MR vaccine doesn’t cause autism, associated disorders or
inflammatory bowel disease
Hepatitis B vaccine:

• Highly purified HBsAg from the serum of individuals with acute infection.
• Two types, Plasma derived and Recombinant DNA available.
• Store at 2-8 degree C
• Route: intramuscular on deltoid region> 2 years and anterolateral aspect of
thigh < 2 years, dose= 0.5 ml (10 µg).
• 95% of efficacy in terms of preventing infection per se, or at least
preventing the development of chronic infection.
• Regimen : 0,1 and 6 mnth (immunologically best) ; 0,6 and 14 wks; 6,10
and 14 wks
• Routine booster doses not recommended for immunocompetent
• To be given as soon as possible (preferably within 12 hours) after birth in
baby with sero-positive mother along with HBIG.
• No association with SID , DM and MS
Hib conjugate vaccine:

• Polysaccharide conjugate to a protein carrier like

1. Diphtheria toxoid (PRP-D)

2. CRM197 Diphtheria toxin (PRP- HbOC)

3. Tetanus toxoid (PRP- T)

4. Meningococcal outer membrane protein (PRP- OMP)

• Monovalent or quadruple vaccine (DPT and Hib)

• Also decrease the carrier state

• >95% efficacy

• Dose = 0.5 ml, route = intramuscular

• Not recommended above 5 years.

Pneumococcal vaccine
• 2 types: unconjugated and conjugated
• PPV23 (23 valent unconjugated polysaccharide vaccine) contains 25 mcg
of polysachharide of each of 23 serotypes
• PPV23 poorly immunogenic below 2 years of age; doesn’t reduce NP
carriage; no herd immunity
• PPV 23: Protective efficacy<70%
• Pneumococcal conjugate vaccine (PCV) available as 13 valent (PCV13)
and 10 valent (PCV10)
• PCV reduce NP carriage, hence herd effect
• 95-99% efficacy
PCV
• Dose : 0.5 ml IM
• NIP: routine 6 wk,10 wk and 9 month
• Adverse effect: fever,pain,malaise
• Children in high risk categories must receive additionally the
polysachharide vaccine (PPV23) more than 8 weeks after the last dose
of PCV AT 2 YEAR OF AGE.; REVACCINATE WITH ppv23 at 3-5 yr of age
if risk continues.
JE
• Cell culture derived live attenuated vaccine based on strain SA-14-14-
2
• 98-99% efficacy
• Dose: 0.5 ml SC (AL thigh or upper arm)
• At 12-23 months
• Adverse effect:’ fever, malaise
Rota virus
• Currently 2 live oral vaccines exist : rotatrix (used in Nepal NIP) and
rota teq)
• Rotatrix is a monovalent (RV1) LA vaccine
• Orally 2 dose schedule at 6 and 10 wks
• Rota Teq (RV5) is Pentavalent, given orally in 3 dose schedule at 2,4
and 6 months
Rotatrix Rota Teq
Minimum age 6 wks 6 weeks
Total dose: 2 oral doses (1.5 ml each) 3 oral doses (2 ml each)
Schedule: 6 and 10 wks (minm 4 wks gap) First dose at 6-12 weeks and 2nd and 3rd doses at an
interval of 4-10 wks
Maximum age: 14 weeks 6 days (not to be given 8 months
beyond)
C/I: past H/o intussusception, severe immunodef Same
Precaution: postpone vaccination during ongoing Same
diarrhea or moderate illness
Storage: 2-8 degree; do not freeze; protect from light; same
use immediately after opening
Rabies vaccine

Vaccination against rabies is used in two distinct situations:

• Pre-exposure vaccination: who are at risk of exposure
• Post-exposure prophylaxis: after exposure has occurred

Rabies immunoglobulin is used only for post-exposure prophylaxis.

Modern tissue culture vaccines include purified chick embryo cell

vaccine, PCEC (Rabipur), Human Diploid Cell Vaccine, HDCV vaccine
(Rabivax) and purified vero cell vaccine, PVRV (Verorab, abhayrab)
Dose: 1 ml for all modern tissue culture vaccines except PVRV (0.5 ml)
Pre-exposure vaccination
• Offered to people at high risk
• Pre-exposure rabies vaccination consists of three full intramuscular (i.m.)
doses of cell-culture- or embryonated-egg-based vaccine given on days 0, 7
and 21 or 28 (a few days’ variation in the timing is not important).
• For adults, the vaccine should always be administered in the deltoid area of
the arm
• For young children (under 1 year of age), the anterolateral area of the thigh
is recommended.
• Rabies vaccine should never be administered in the gluteal area:
administration in this manner will result in lower neutralizing antibody
titres.
Intradermal vaccination for pre-
exposure prophylaxis
• intradermal (i.d.) vaccination in 0.1-ml volumes on days 0, 7 and
either 21 or 28 may be considered.

• Cheap; but technically demanding

Adverse reactions

• local pain, erythema, swelling and pruritus

• Occasional systemic reactions (malaise, generalized aches and

headaches) have been noted after intramuscular or intradermal
injections.
Post-exposure prohylaxis
1. Wound treatment
2. Passive immunization
• Human rabies immunoglobulin (HRIG) or equine rabies immunoglobulin
(ERIG) should be used for category III exposures as well as for some category
II exposures .
• Passive immunization should be administered just before or shortly after
administration of the first dose of vaccine given in the post-exposure
prophylaxis regimen.
• If it is not immediately available, passive immunization can be administered
up until the seventh day after initiation of the primary series of post-
exposure prophylaxis (with cell-culture or embryonated-egg rabies vaccine).
Dosage and administration
• HRIG : 20 IU/kg and for ERIG :40 IU/kg
• The full dose of rabies immunoglobulin, or as much as is anatomically
feasible, should be administered into and around the wound site. Any
remainder should be injected i.m. at a site distant from the site of
active vaccine administration.
• Multiple needle injections into the wound should be avoided.
• If the correct dose of rabies immunoglobulin is too small to infiltrate
all wounds, as might be true of a severely bitten individual, it can be
diluted in physiological buffered saline to ensure greater wound
coverage.
Active immunization

• Cell-culture- or embryonated-egg-based rabies vaccines should always

be used for post-exposure prophylaxis.
• They can be administered either i.m. or i.d.
Intramuscular regimens for rabies
Post-Exposure Prophylaxis
• There are 3 IM schedules for category II and III exposures:
1. The 5 dose regimen (Essen protocol)
2. The 2-1-1 regimen (Zagreb schedule)
3. The 4 dose regimen with RIG in both categories II and III
• Site: deltoid for > 2yrs age and AL thigh for younger. Avoid gluteal
region.
The 5 dose intramuscular regime: (1-1-1-1-1)
• One dose of the vaccine should be administered on days 0, 3, 7, 14
and 28
The 2-1-1 regimen: (2-0-1-0-1)
• Two doses are given on day 0 in the deltoid muscle, right and left arm
• An additional one dose is administered in the deltoid muscle on day 7
and day 21
• An alternative post-exposure regimen for healthy, fully
immunocompetent exposed people who receive wound care plus
high-quality rabies immunoglobulin plus WHO-prequalified rabies
vaccines consists of four doses administered i.m. on days 0, 3, 7 and
14.
Intradermal regimens
• The intradermal (ID) regimen requires a reduced volume of vaccine to
be utilised than any of the intramuscular regimens therefore, reducing
vaccine cost by 60-80%.

• 0.1 mL per ID site is used, according to WHO recommended ID

regimen
• Vaccine administered ID must raise a visible and palpable “bleb” in
the skin. In the event that a dose of vaccine is inadvertently given
subcutaneously or intramuscularly, a new dose should administered
intradermally
• The 2-site intradermal method: (2-2-2-0-2)
• One dose of vaccine, of 0.1 ml is given intradermally at two different
lymphatic drainage sites
• Usually administered in the deltoid muscle on the left and right upper
arm and suprascapular area
• Given on days 0, 3, 7 and 28.
 PEP for immunosuppressed individuals

• Thorough wound treatment

• RIG should be administered deeply into the wound for both category
II and III exposures
• Vaccine should always be administered and no modification of the
recommended number of doses is advisable
Short rabies PEP of previously
vaccinated persons
• Local treatment of wound(s)
• Two active immunization schedules are available
• No RIG should be applied
• However full PEP should be given to persons: Who have received pre-
or post-exposure prophylaxis with vaccines of unproven potency
• Where immunological memory is no longer assured as a result of
HIV/AIDS or other immunosuppressive causes
Schedule 1:
• One dose to be injected intramuscularly or intradermally on days 0
and 3
• The dose is either 1 single immunizing intra muscular (IM) dose (1 ml
or 0.5 ml, depending on vaccine type) or one intradermal (ID) dose of
0.1 ml per site
Schedule 2:
A “4-site” intradermal (ID) PEP can be used .Consists of 4 injections of
0.1 mL equally distributed over left and right deltoids, thigh or
suprascapular areas during a single visit
Other vaccines
• Typhoid vaccine
• Varicella vaccine
• Hepatitis A vaccine
• Rabies vaccine
• Meningococcal vaccine
• Influenza vaccine
• HPV vaccine
Common misconception/myths

• Giving multiple vaccines at same time causes an

“overload” of the immune system.
• Relation between MMR vaccine and autism.
• Vaccines are triggers of disease or flares .
• Family history of a seizure disorder