Vaccines
Vaccines/ sera….?
• Biological products which reinforce the
immunological defence against foreign bodies
(organisms or toxins).
Active immunization
• Administration of antigen to host to induce formation of antibodies &
CMI.
• Inactivated (killed) materials of microbes
• Live organisms
Passive immunization
• Transfer of immunity to host using preformed immunologic products.
• Examples- Immunoglobulins
Interferons
Indications for passive immunization
• Individuals who are unable to form antibodies.
• Prevention of disease when time doesn’t permit active
immunisation.(post exposure)
• Treatment of cetain diseases that are normally preventable (tetanus).
• Treatment of conditions wherein active immunisation is unavailable
• Vaccines ------- active immunity.
• Sera (ready made antibodies)----------- passive
immunity
Advantages of active immunization
• Higher antibody levels
• Longer lasting
• Promote the development of passive immunity (some cases).
• Disadvantage
Latent period
Vaccines
• Killed (inactivated vaccines): killed by heat or
chemicals.
• Live attenuated vaccines:
rendered avirulent
mulitply in the body to limited extent
• Toxoids-modified bacterial exotoxins-toxicity is lost ,
antigenicity is retained
Inactivated vaccines Live attenuated vaccines
• Hepatitis B • BCG
• Hepatitis A • OPV (SABIN)
• Rabies • Mumps
• Influenza • Measles
• Polio inactivated (SALK) • Rubella
• Plague • Yellow fever
• Meningococcal • Varicella
Toxoids
Tetanus
Diphtheria
Combined vaccines
Triple antigen (DPT)
Measles, Mumps, Rubella (MMR)
Antisera ( from horses)
• Tetanus anti toxin (ATS)
• Gas gangrene anti toxin (AGS)
• Diphtheria anit toxin (ADS)
• Anti snake venom (poly valent)
Immunoglobulins (human)
• Anti D immunoglobulin
• Tetanus immunoglobulin
• Rabies immunoglobulin
• Hepatitis B immunoglobulin
Case 1
• Patient, Rameshwaram 40 year male brought in emergency with
bleeding wound on right thigh and scratch mark over right cheek with
history of dog bite 30 mins back.
• Which category of dog bite it belongs to?
• What is the management for this patient?
Rabies Epidemiology
• The number of human deaths globally due to dog-mediated rabies is
estimated to be 59,000 annually,
• The majority of deaths are estimated to have occurred in Asia (59.6%)
and Africa (36.4%).
• An estimated 20,000 human rabies deaths and 17.4 million animal
bites occur per year.
• India accounts for the most deaths in Asia (59.9% of human rabies
deaths) and globally (35% of human rabies deaths).
Pathogenesis of Rabies
Local treatment &
RIG
Risk Assessment
• Categorization based on Exposure
Category of Type of Exposure
Exposure
• Touching or feeding of animals
I • Licks on intact skin
• Contact of intact skin with secretions/excretions of rabid animal /human case
II • Nibbling of uncovered skin
• Minor scratches or abrasions without bleeding
III • Single or multiple transdermal bites or scratches,
• Licks on broken skin
• Contamination of mucous membrane with saliva (i.e. licks)
Category II
Category III
• Single or multiple transdermal bites or scratches,
• Licks on broken skin
• Contamination of mucous membrane with saliva (i.e. licks)
Category Type of Exposure Recommended Post-Exposure
of Exposure Prophylaxis
Touching or feeding of animals None, if reliable case history is
Licks on intact skin available
I
Contact of intact skin with secretions/excretions of Wash Exposed area with Water &
rabid animal/human case Soap and apply Antiseptic
Nibbling of uncovered skin Proper wound management
II
Minor scratches or abrasions without bleeding Rabies vaccine
Single or multiple transdermal bites or scratches,
Wound Management
Licks on broken skin
III Rabies Immunoglobulin
Contamination of mucous membrane with saliva (i.e.
Rabies Vaccine
licks)
Wound Management (Do’s)
Do’s Act Effect
Wash with running water Mechanical removal of virus
Physical
from the wound
Wash the wound(s) with soap and water Apply antiseptic
Chemical Inactivation of the virus
Infiltrate immunoglobulin into the depth and around the
Biological Neutralization of the virus
wound(s) in Category III exposures
• Washing of wounds is desirable up to 15 minutes and should be carried out as
soon as possible with soap and water.
• Tetanus and antibiotic prophylaxis: Tetanus prophylaxis should be given as per
national guidelines. To prevent sepsis in the wound(s), a suitable course of an
antibiotic may be prescribed.
Wound Management (Don’ts)
Touch the wound(s) with bare hand
Apply irritants like soil, chillies, oil, lime, herbs, chalk, betel
leaves, etc.
Suturing of the wounds-
As far as possible suturing of wound is avoided.
In case suturing cannot be avoided, clean the wound and the wound(s)
should first be thoroughly infiltrated with ERIG or HRIG.
Rabies vaccine Dosage Schedule
Route of Number of
Total Number of
Administratio Dose of Vaccine Day of Dose injections Per
Visits
n Visit
Intra Dermal 0.1ml per dose Day 0, 3, 7 and 28 2 4
1 entire vaccine
Intra Muscular Day 0, 3, 7, 14 and 28 1 5
vial
Intradermal rout is the preferred route of administration of Rabies Vaccines Human
DOSAGES OF RABIES IMMUNOGLOBULIN:
All Category III exposures require administration of RIG
Generic Name Preparation Available Dose
ERIG 300 IU per ml 40 IU per kg body weight
HRIG 150 IU per ml 20 IU per kg body weight
Infiltration of RIG in wound
The entire immunoglobulin dose, or as much as anatomically possible(but avoiding possible compartment
syndrome), should be infiltrated carefully into or as close as possible to the wound(s) or exposure sites.
Evidence suggests that injecting the remaining RIG volume intramuscularly at a distance from the wound
provides little or no additional protection against rabies as compared with infiltration of the wound(s)
alone.
Pre-Exposure Prophylaxis
• Laboratory staff handling the virus and infected material,
clinicians and individuals attending to human rabies cases.
• Veterinarians, animal handlers and dog catchers.
• Wildlife wardens, quarantine officers etc.
• Travelers from rabies-free areas to rabies endemic areas.
Number of
Dose of Vaccine Day of Dose
injections Per Visit
Intra Dermal 0.1ml per dose Day 0, 7, and 21 or 1
28
Intra Muscular 1 entire vaccine vial Day 0, 7, and 21 or 1
28
Summary
Number
Dose of Vaccine Total
Type of Route of of Site of
Day of Dose Number
Prophylaxis Administration injections Injection
of Visits
Per Visit
Day 0, 3, 7 and 28 2 4 Adults: Deltoid
Intra Dermal 0.1ml per dose
Post Exposure Muscle Infants
Prophylaxis Day 0, 3, 7, 14 and 28 1 5 and small
Intra Muscular 1 entire vaccine vial Children:
Anterolateral
Day 0, 7, and 21 or 28 1 3
Intra Dermal 0.1ml per dose Thigh
Pre Exposure
Prophylaxis Day 0, 7, and 21 or 28 1 3
Intra Muscular 1 entire vaccine vial
Day 0 & 3 1 2
Intra Dermal 0.1ml per dose
Re-exposure
Intra Muscular 1 entire vaccine vial Day 0 & 3 1 2
Case 2
• Newly joined female Nurse in surgery department wants to take
prophylaxis vaccine.
Which vaccine she has to take and what is vaccination schedule ?
• Hepatitis B vaccine
• Route: IM (deltoid)
• Dose: 0.5 ml
• Dosing schedule:
• 0 day
• 1 month
• 6 month
Case 3
• A normal healthy male baby is delivered in hospital.
Which vaccine will be given at birth and what is further vaccination
schedule for this child ?
Case 4
• Raju brought in emergency with history of fall from bike on road.
On examination patient is having multiple abrasion on bilateral thigh
and knee region, forehead and right arm lateral aspect. Patient also has
contaminated lacerated wound approx. 10*5*2 cm over right leg and
one deep wound approx. 3*3 cm over right forearm lateral region.
• Elaborate about diagnosis and management in this case?
• Polytrauma patient
• wound care should be done in such patients
• Wound wash should be done with Normal saline.
• After washing the wound, wound closure should be done under
aseptic conditions.
• After closing the wound dressing should be done.
• Antibiotic coverage should be given.
• Inj TT(Tetanus toxoid) 0.5 ml IM stat should be
given
• Inj TIG(Tetanus immunoglobulins) 500 IU IM
should be given as wound is deep and
contaminated.
• Then x ray or other diagnostic should be done
after primary treatment and should be managed
accordingly.
Case 5
Miss Ramya, 19yrs old, residing at university campus hostel at west Delhi.
Present to ER with c/o
fever with chills for last 6 days, intermittent, relieved by medication
Pain abdomen for 2 days accompanied with headache & nausea.
H/O: eating street food frequently
Investigations: Hb-11gm, TLC-15000, PLT-4.5Lac, Widal test +ve.
Immunized up to age.
Rest of the systemic and personnel examination is normal.
What is your probable diagnosis?
What type of vaccine is useful to her in this condition?
•Enteric fever (typhoid and paratyphoid both fevers)
•Caused by gr-ve bacteria salmonella typhi or paratyphi (A,B or C).
•Humans are only reservoirs, transmission (direct or indirect contact via contaminated
food/water).
• Avoid typhoid fever, by proper sanitization, fresh water for drinking and hygiene.
•Vaccination:
Oral vaccine Live attenuated vaccine: Ty21a
This vaccine was developed in the early 1970s, requires at least three doses for optimal
protection, and is supplied as gelatin capsules coated with phthalate or sachets containing
lyophilised Ty21a, a mutant strain of Salmonella enterica serovar Typhi (S. Typhi).
Parenteral vaccines
1. Typhoid-Paratyphoid A, B (TAB vaccine)
Dose- 0.5 ml s.c.,
2 -3 injections at 2-4 weeks intervals.
Local tenderness. fever and malaise lasting 1- 2 days arc common after the first dose.
It is estimated to be 70% effective in preventing enteric fever for 1 year.
Booster doses may be given every 2- 3 years.
2. Vi Typhoid polysaccharide vaccine
A single 0.5 ml s.c./i.m. dose affords 72% protection at 18 months and 60% protection at 3
years.
Induces longer lasting immunity, but does not protect against paratyphoid A and B. Thus. it is
an improvement over the whole cell TAB vaccine.
However, it is not approved for use in children below 2 years and in pregnant women.
VACTYPH. TYPHIM Vi. TYPHIVAX 0.025 mg in 0.5 ml mj;
repeat alter 3 years.
Case 6
A 17 yrs old girl came to OBG opd with persistent genital infections and
genital warts.
Family history: Mother died due to cervical cancer.
How to protect her with vaccination?
HUMAN PAPILLOMA VIRUS
•Most Common viral infection of the anogenital tract.
•Life time risk is very high nearly 70%
•DNA tumor virus, infect all types of squamous epithelium.
•Can cause Cancers.
•Sexually transmitted (intimate contact)
•It maybe asymptomatic for long time.
•Highest among young age (<25yrs), 2nd peak at about 55yrs.
•High risk/Oncogenic types: 16, 18(cervical cancer), 31,33,35,39,45,51,52 etc
•Low risk/Non-oncogenic types: 6, 11(warts), 26, 42,44,54,70 & 73.
HPV vaccine: Gardasil (quadrivalent:6,11,16&18)
Bivalent (16, 18)
For females-9 to 26 yrs: males-12 to 15yrs
Doses: 0,2 &6 months. (if below 15yrs given 1st dose means 2doses is enough)
Is pregnant—HPV vaccine is not recommended until after pregnancy
‚ADR:Fever or headache, Soreness, redness, or swelling where the shot is given
Case 7
A 29 yrs female came to OBG opd with pregnancy positive card test.
G2P2L1A1, her blood group is B-ve.
Her 2nd pregnancy is lost due to some blood reactions.
Her last discharge summary revels due to Rh incompatibility.
What is her probable diagnosis?
How to treat?
•All the pregnant women must check the ABO grouping and Rh typing.
•If found Rh-ve, then check the husband/partner Rh typing too.
•Rh+ve means, careful monitoring pregnant women in order to establish isoimmunization is
required (to rule out DD or Dd specific typing of previous child).
•Check Rh antibodies by indirect Coombs test.
•Need to rule out blood transfusion or injections history of previous pregnancies.
•If Rh incompatibility detected in previous pregnancy, check the Rh antibodies at 20weeks.
Every 4 weeks thereafter.
•If titer is exceeding 1:16 then, other tests like amniotic fluid exam etc. should be done.
•If any antibodies found then give the anti-D immunoglobulins 300micrograms to mother
after delivery of baby.
