Childhood Immunization and Catch

Up Immunization
Li Faung
Nuradilah
Nurul Hassanah
 Definition
• Immunization : An attempt to replace the anticipated
natural primary contact between the human body
and a hostile organism, with a safer artificial
contact, so that any subsequent natural contact
takes place in a state of heightened immunity.
 Definition
• Antigen : Substances that bind to specific lymphocyte
receptors, whether or not they stimulate immune
responses.

• Immunogens : Substance that stimulate immune

responses

• Antibody : Protein found mostly in serum that is formed

in response to exposure to a specific antigen
 Why immunization?
• Immunization is one of the most cost-effective
health interventions.

• Prevention of infectious spread worldwide

• Protection for one self and the surrounding in
contact
• To eradicate diseases (smallpox)
 Types of immunity
1. Innate/natural/native immunity or non-specific
immunity

2. Adaptive/acquired immunity or specific immunity

 Innate/natural/native immunity
• Physical & chemical barriers
• Phagocytic cells (neutrophils, macrophages),
dendritic cells, natural killer cells
• Complement system & other mediators of
inflammation
• Cytokines
 Adaptive immunity
3 main strategies :

• Secrete antibodies bind to extracellular microbes

• Phagocytes ingest microbes & helper T cells
enhance microbicidal abilities of the phagocyte
• Cytotoxic T lymphocytes (CTLs) destroy cells
infected by microbes that are inaccessible to
antibodies & phagocytic destruction.
Adaptive/acquired immunity
 Herd Immunity
• Herd immunity is when a significant portion of
population is vaccinated.
• This provide protection for those who cannot be
vaccinated.
Common Misconceptions on
Immunization
 1. Vaccine and Autism Spectrum Disorder
(ASD)
• 2013 CDC study : vaccines do not
cause ASD. The study looked at the
number of antigens from vaccines
during the first two years of life. The
results showed that the total amount
of antigen from vaccines received
was the same between children with
ASD and those that did not have
ASD.
• IOM 2004 : One vaccine ingredient –
Thimerosal (in flu vaccine) does not
cause autism
 2. Hygiene and Better Nutrition Are
Responsible for the Reduction in Disease
Rates, Not Vaccination
• Permanent drop in measles coincided
with the licensure and wideuse of
measles vaccine beginning in 1963
 3. Harmful Effects of Vaccines
Whooping Cough Makes Whopping Comeback
• Great Britain, Sweden & Japan cut back the use of pertussis
vaccine because of fear of the vaccine – brain damage or Sudden
Infant Death Syndrome
• In Japan, a drop in vaccination rates from 70% to 20%-40% led to
a jump in pertussis from 393 cases and no deaths in 1974 to
13,000 cases and 41 deaths in 1979
 4. The majority of people who get disease
have been vaccinated
• 1. No vaccine is 100% effective. To make vaccines safer than the
disease, the bacteria or virus is killed or weakened. For reasons
related to the individual, not all vaccinated persons develop immunity.
Most childhood vaccines are effective for 85-95% of recipients.
• 2. In a country such as the United States the people who have been
vaccinated vastly outnumber those who have not.

In a high school of 1,000 students, none has ever had measles. All but five of the
students have had two doses of measles vaccine, and so are fully immunized. The entire
student body is exposed to measles, and every susceptible student becomes infected.
The five unvaccinated students will be infected, of course. But of the 995 who have been
vaccinated, we would expect several not to respond to the vaccine. The efficacy rate for
two doses of measles vaccine can be as high as >99%. In this class, seven students do
not respond, and they, too, become infected. Therefore seven of 12, or about 58%, of the
cases occur in students who have been fully vaccinated.
 5. Vaccine-preventable diseases have been
virtually eliminated from my country, so there is
no need for my child to be vaccinated
6. Natural Immunity Is Better Than Vaccine-
acquired Immunity
• The risks of natural infection outweigh the risks of
immunization for every recommended vaccine.
• Wild measles infection causes encephalitis for one in
1,000 infected individuals, and, for every 1,000 reported
measles cases, two individuals die.
• The combination MMR vaccine, however, results in
encephalitis or a severe allergic reaction only one in
every million vaccinated individuals, while preventing
measles infection.
• Hib (Haemophilus Influenzae type b) and tetanus
vaccines actually provide more effective immunity than
natural infection.
 7. “Overloaded Immune System”
Misconception
• studies have repeatedly demonstrated that the
recommended vaccines are no more likely to cause
adverse effects when given in combination than
when they are administered separately.
• Some parents decide to “spread out” the time
period during which their children receive
vaccinations -> delaying vaccinations puts children
at risk of contracting preventable diseases.
IMMUNISATION SCHEDULE

IMMUNISATIONS
CONTRAINDICATIONS
 Contraindications:
A) Absolute Contraindications
A) For any vaccine
B) Active vaccine
C) Killed vaccine

B) Relative contraindications
C) Not Contraindications
 a) Absolute contraindications:
For any vaccine severe anaphylaxis reactions to previous dose of the vaccine or to a component of
the vaccine.
Live vaccine Immunosuppressed children
malignancy, irradiation, leukaemia, lymphoma, primary immunodeficiency
syndromes (but NOT asymptomatic HIV).

On chemotherapy or < 6 months after last dose.

On High dose steroids, i.e. Prednisolone ≥ 2 mg/kg/day for > 7 days or low dose
systemic > 2 weeks - delay vaccination for 3 months.

If given another LIVE vaccine including BCG < 4 weeks ago

Within 3 months following IV Immunoglobulin (11 months if given high dose IV

Immunoglobulins, e.g. in Kawasaki disease).

Pregnancy
Killed vaccine SEVERE local (induration involving > 2/3 of the limbs) or severe generalised
reactions in the previous dose.
b) Relative Contraindication
avoid a vaccine within 2 weeks of elective surgery

c) Not Contraindications
Mild illness without fever
Asthma, eczema, hay fever, impetigo, heat rash
Treatment with antibiotics or locally acting steroids.
Child’s mother is pregnant.
Breastfed child
Neonatal jaundice.
Underweight or malnourished.
Over the recommended age.
Past history of pertussis, measles or rubella (unless confirmed medically)
Non progressive, stable neurological conditions like cerebral palsy, Down syndrome,
History of heart disease, acquired or congenital.
Prematurity
 Vaccines, route of administration,
indications, contraindications, side
effects
Vaccin Route of Indication/Dose
e administrati
on
BCG Intradermal To be given at
birth and to be
repeated if no
scar is present
Contraindication Side effects Notes
s
Not to be given BCG Local reaction: a papule at
to symptomatic adenitis vaccination site may
HIV infected occur in 2-6 weeks. This
children grows and flattens with
scaling and crusting.
Occasionally a
discharging ulcer may
occur. This heals leaving a
scar of at least 4mm in
successful vaccination
Vaccin Route of Indication/dose contraindication Side effects notes
e administrati
on
Hepatit Intramuscul All infants, Severe Local reactions. For infants of
is B ar including those hypersensitivity to Fever and flu HBsAg positive
born to HBsAg aluminium. The like symptoms mother, give with
positive mothers. vaccine is also no in first 48 hours. Hep B
All health care indicated for HBV Rarely, immunoglobulin
personnel. carrier or erythema
immuned patient multiforme or
(i.e HBsAg or Ab urticaria
positive)
Vaccine Route of Indication/dose contraindication Side effects notes
administr
ation
Diphtheria intramusc All infants should Severe Swelling, redness and -
, Tetanus ( ular receive 5 doses hypersensitivity pain. A small painless
DT) including booster to aluminium and nodule may develop at
doses at 18 months thiomersal. injection site. Transient
and standard 1 fever, headaches, malaise,
rarely anaphylaxis.
Neurological reactions rare

Does Tetanus cause Gullain Barre

Syndrome?

Despite some case reports, no increased risk of Gullain Barre

Syndrome has been observed with the use of tetanus toxoid in
whole cell or acellular pertussis vaccine (National Health &
Medical Research Council, Australia 1997).

No special precautions are needed when immunizing children

with history of GBS
Vaccin Route of Indication/dose contraindication Side effects notes
e administr
ation
Pertus intramus All infants should Anaphylaxis to Local reactions- Static
sis cular receive 4 doses previous dose; severe if involve 2/3 of neurological
including booster encephalopathy limbs diseases,
at 18 months. It is develops within Systemic reactions- developmental
recommended that 7 days of anaphylaxis, delay, personal
booster doses be vaccination, encephalopathy, high or family
given at Std 1 and progressive fever, fits within 72 history of fits
at Form 3 due to neurological hours, persistent are NOT
increased cases diseases. inconsolable crying, contraindicatio
hyporesponsive states ns

An Immediate anaphylactic to tetanus and diphteria toxoid

containing vaccines is a contarindication to further doses unless the
patient can be desensitized to these toxoids, due to uncertainty to
which vaccine component (diphteria, pertussis or tetanus).

Persons who experience anaphylactic reactions may be referred to to

an allergist for evaluation and possible desensitization (Ministry of
Health Malaysia 2002; American Academy of Paediatrics, 2000)
Vaccine Route of Indication/dose contraindicatio Side effects notes
administration n

Inactivated intramuscular All infants to Allergies to Local reactions

Polio be given 4 neomycin,
Vaccine(IPV) doses polymyxin and
including streptomycin.
booster at 18 previous
months severe
anaphylactic
reaction.

Haemophilus intramuscular All infants Confirmed Local swelling,

Influenza B(Hi) should receive anaphylaxis to redness and pain.
4 doses previous Hib Malaise,
including and allergies to headache, fever,
booster at 18 neomycin, irritability,
months. polymyxin and inconsolable
Patients with streptomycin crying. Very rarely
splenic seizures
dysfunction
and post
spelectomy.
vaccine Route of Indication/dose contraindication Side effects notes
administration
measles intramuscular Sabah, Orang Asli Avoid in patients Transient rash,
population at 6 with fever D5-D12
months. hypersensitivity to post
Not usually given eggs, neomycin vaccination,
to children < 12 and polymyxin. URTI symptoms,
months. Pregnancy. febrile
If there is a Children with convulsions,
measles outbreak untreated encephalopathy
can be given to leukemia, TB and
children 6-11 other cancers.
months age. immunodeficiency
This is later
followed by MMR at
12 months and 4-6
years of age

Measles, intramuscular All children from 12 Severe reaction to As above Can be

mumps, to 15 months. hen’s eggs and given
rubella( Booster at 4-6 neomycin. irrespective
MMR) years( or at std 1) pregnancy of previous
history of
Vaccine Route of Indication/d contraindication Side effects note
administration ose
mumps intramuscular All children Severe reaction Rarely transient rash, pruritis
from 12 to to hen’s eggs and and purpura. parotitis,
15 months. neomycin. orchitis and retrobulbar
Booster at pregnancy neuritis. meningoencephalitis
4-6 years.
(or at std 1)
Rubella Rash, fever, Given as
lymphadenopathy, MMR
thrombocytopenia, transient
peripheral neuritis,arthritis
and arthralgica

Teratogenic effects of rubella:

100% if infections in first 11 weeks

50% if infections in 11-12 weeks
35% if infections in 13-16 weeks
Vaccine Route of Indication/dos contraindicati Side effect Note
adminstration e on
Japanese subcutaneous Given in Immunodefici Local redness, Inactivated
Encephali Sarawak at ency and swelling, pain, vaccine
tis (JE) 9,10 and 18 malignancy. fever,chills.headache.
months. Diabetes, lassitude
Booster at 4 acute
years. exacerbation
of cardiac
hepatic and JE is a zoonotic virus.
renal Humans are incidental
conditions and dead end hosts

Human intramuscular Females aged Not Headache. Myalgia, 2 vaccines

Papilloma 9-45 years recommended injection site reactions, available:
Virus(HPV in pregnant fatigue, nausea, Cervarix and
) patients vomiting, diarrhea, abd Gardasil 3
pain. Pruritis, dose schedule
rash,urticaria, myalgia, (0,1-2month, 6
arthralgia, fever month)

Why not recommended in

pregnant lady?
Nurul Hassanah Binti Muslim
1. Protect all immunocompromised children
with Immunoglobulin (HNIG) 0.25-0.5 mls/kg.
2. Check status of measles immunisation in the
other children.
- Give measles monocomponent vaccine to
unimmunised children within 24 hrs of exposure.
- Discharge the inpatient child with uncomplicated
measles.
- To notify case to the Health Office.
• Febrile seizures may occur 5 – 10 days after measles
(or MMR) vaccination or within the first 72 hours
following pertussis immunisation.
• Paracetamol (120 mg or ¼ tablet) prophylaxis after
immunisation (esp. DPT) 4-6 hourly for 48 hours
regardless of whether the child is febrile- reduces the
incidence of high fever, fretfulness, crying, anorexia and
local inflammation.
- Immunise all household, nursery or kindergarden
contacts < 4 years of age.
- Household contacts should receive Rifampicin
prophylaxis at 20 mg/kg once daily (Maximum 600
mg) for 4 days
(except pregnant women give one IM dose of
ceftriaxone )
- Index case should be immunised irrespective of age.
• Susceptible to encapsulated bacteria and malaria.
• Pneumococcal, Meningococcal A, C, Y & W-135
(Menomune), Haemophilus influenza b vaccines
should be given.
• For elective splenectomy (and also chemotherapy
or radiotherapy): give the vaccines preferably 2 or
more weeks before the procedure. However,can
be given even after the procedure.
• Babies born to mothers who are HbeAg OR HbsAg
positive should be given
- Hepatitis B immunoglobulin (200 IU)
- vaccinated with the Hepatitis B vaccine within 12
hours (not later than 48 hours, to give in different
syringes and at different sites)
• BCG: safe in child is asymptomatic and not immunosuppressed
(e.g. at birth); omit if symptomatic or immunosuppressed
• Give IPV (killed polio vaccine) as recommended in current schedule.
• MMR: safe; omit in children with severe immunosuppression
(CD4<15%)

• Other recommended vaccines:

- Pneumococcal polysaccharide vaccine when > 2 years of age;
booster 3-5 years later.(use Pneumococcal conjugate vaccine-more
immunogenic).
• Varicella-zoster vaccine, where available. 2 doses with 2 months
interval.
Omit in those with severe immunosuppression (CD4 < 15%)
• Hep B vaccine at birth if infant stable and
BW>1.8kg
-If not, can just give upon discharge or when awaiting
weight gain
• Ensure BCG given upon discharge
• For long stayers, other immunisation should
generally follow the schedule according to
chronological rather than corrected age
• Defer immunisation in the presence of acute illness
• In hospitals, airborne transmission of VZV has been
demonstrated when varicella has occured to a susceptible
person even no direct contact with the index case-patient
• Incubators are not positive pressure air flow & thus, did not
provide isolation.
• All staffs preferably should be screened and susceptible
staff vaccinated
• If not , they should receive post exposure vaccination as soon
as possible unless contraindicated, eg pregnant
• ZVIG is an option for exposed susceptible pregnant staff ( to
prevent complications to the mother rather than fetus)
 Paediatric Protocols 3 rd Edition
 Centers for Disease Control and Prevention
(CDC)
 World Health Organization (WHO)