IMMUNIZATION

By: Selemaye Z. (MSc. In PCHN)

 OBJECTIVES
 At the end of the topic, you will be able to
describe the:
 Background of immunization
 Nature of vaccine antigens
 Types of vaccines
 Route of vaccination and dose
 Immunization schedule
 Safe injection practices
 Cold chain 2
 DEFINITIONS
 A vaccine is an immuno-biological substance

designed to produce specific protection against a

given disease.

 Immunity is the body's ability to fight off harmful

micro-organisms –pathogens- that invade it.

 Vaccination is the administration of any vaccine or

toxoid for prevention of disease. 3

 Immunization is the process of inducing immunity

 BACKGROUND AND EPIDEMIOLOGY

 Vaccine-preventable diseases are responsible for

nearly 20% of the 8.8 million deaths/year among
children <5 years
 WHO launched Expanded Programme on Immunization
(EPI) in 1974 to develop and expand immunization
programs around the world
– As a result, by 2005, 80% of children immunized in
their first year against 6 targeted diseases
– EPI efforts prevent an estimated 3 million 4

deaths/year
WHO’S EXPANDED PROGRAMME ON
IMMUNIZATION

5
CONT...
 Vaccinations are one the most successful and cost-
effective public health investments
 1980, global smallpox eradication achieved.
 1988, polio targeted for global eradication with
infections falling by 99%

6
CONT...

7
CONT...
 For many years, six diseases were considered
vaccine-preventable and included in any standard
immunization program:
 Bacillus Calmette-Guerin (BCG),
 oral polio vaccine (OPV),
 diphtheria-tetanus-pertussis (DTP),
 and measles.

8
CONT...
 This has now been expanded to 11 which include
 Hepatitis B,

 Haemophilus influenzae type B (Hib),

 pneumococcal,

 rotavirus,

 and rubella vaccines

 as well as inactivated polio vaccine (IPV), which is

given in addition to oral polio vaccine (OPV).
 These vaccines are recommended by WHO for universal
9
child vaccination that is, vaccination of ALL children.
ROUTINE IMMUNIZATION (RI)
 The EPI program was introduced in Ethiopia
in 1980 with the aim of reducing child and
maternal mortality and morbidity from
vaccine preventable diseases (VPD).
 The initial target groups were children under

two years of age, which was subsequently

changed in 1986 to children under the age of
one to be in line with global immunization
target.
 Current immunization services are rendered

to 3million children under the age of one in

most health facilities as well as through 10

outreach services.
CONT...
 In addition to the traditional six vaccines that
are given at both public and private facilities,
newer vaccines and formulations are
continuously being introduced.
 The most recently introduced vaccines are:
 Penta-valent formulations→ DPT, HepB-Hib,
introduced in 2007 EFY
 Pneumococcal conjugate vaccine (PCV),
introduced in October 2011
 Rota virus vaccine, introduced in November
2013
 IPV, HPV and others are currently on the pipeline
11
 TYPES OF IMMUNITY

 1. Congenital or innate non-specific

immunity.

 It is the natural resistance of body e.g. skin, WBC

etc.

 2. Acquired or specific immunity

 Active acquired immunity

12

 Passive acquired immunity

CONT...
 Active immunity is provided by a person's own
immune system. This type of immunity can come
from exposure to a disease or from vaccination.
Active immunity usually lasts for many years and
often is permanent.

 Passive immunity results when antibodies are

transferred from one person or animal to
another.
13
CONT...

 The most common form of passive immunity

occurs when a fetus receives antibodies from his

or her mother across the placenta during

pregnancy.
 E.g Neonatal tetanus can be prevented by providing

women of childbearing age with tetanus toxoid, either

during or before pregnancy.

 Passive immunity disappears over time, usually 14

within weeks or months.

 ACTIVE ACQUIRED IMMUNITY

 a. Naturally acquired active Immunity.

 The child makes immunity after Exposure to a
disease.

 b. Artificial acquired active Immunity.

 The child makes anti bodies after administration
of antigen vaccine .

15
 Passive acquired immunity

a. Natural-acquired passive immunity

 Trans placentaly transferred Maternal
antibodies in the body of the child. E.g. TT
vaccine for the mother.

b. Artificial acquired passive immunity.

 Formed antibodies are administered to the
child.
16

e.g. T.A.T
IMMUNE RESPONSE

 Primary immune response occurs when an

antigen is introduced for the first time and the

immune system responds primarily after a lag

phase of up to 10 days.

 Besides lag phase, primary response is short-lived,

predominantly IgM type and has low titer.

17
CONT...

 On reintroduction of the same antigen, there

is no lag phase.

 The immune system responds by producing

antibodies immediately. This is called

secondary immune response.

 Secondary response is immediate, long-

lasting, has very high titer. 18

VPDS AND UNIVERSAL VACCINES

 World Health Organization now recommends

that vaccines that protect against 11
diseases be part of the schedule of most
national immunization programs.
 The table below highlights each of these 11
vaccine-preventable diseases (VPD) or
causative agents, and the vaccines used to
protect against them 19
THE MAIN VACCINE-PREVENTABLE
DISEASES TARGETED BY THE EPI

20
CONT...

21
TYPES OF VACCINE
 There are many types of vaccines,
categorized by the antigen used in their
preparation.
 Their formulations affect how they are used,

how they are stored, and how they are

administered.
 The globally recommended vaccines fall into

the four main antigen types shown in the

diagram.

22
23
 CONT...
 Live attenuated vaccines are derived from
disease-causing viruses or bacteria that have been
weakened under laboratory conditions.
 They will grow in a vaccinated individual, but
because they are weak, they will cause either no
disease or only a mild form.
 Usually, only one dose of this type of vaccine
provides life-long immunity, with the exception of
24

oral polio vaccine, which requires multiple doses.

CONT...

 Live attenuated vaccines, particularly viral ones

like measles, confer life long protection after a

single immunizing dose.

 Their drawbacks are:

 Reversion to wild type can lead to disease

 They can cause severe disease in

immunocompromised children

 Some people exhibit hypersensitivity to viral antigens. 25

LIVE ATTENUATED VACCINES

26
CONT...
 Inactivated vaccines are produced by growing viruses
or bacteria and then inactivating them with heat or
chemicals.
 Because they are not alive, they cannot grow in a
vaccinated individual and therefore cannot cause the
disease.
 They are not as effective as live vaccines, and multiple
doses are required for full protection.
 Booster doses are needed to maintain immunity because
27
protection by these vaccines diminishes over time.
SUBUNIT VACCINES

28
CONT...
 Subunit vaccines can be further
categorized into:
 Protein-based subunit vaccines,
 Acellular pertussis (aP)
 Hepatitis B (HepB)

 Polysaccharidevaccines,
 Conjugate subunit vaccines.
 Haemophilius influenzae type b (Hib),
 Pneumococcal (PCV

29
CONT...

 Recombinant vaccines are produced by

inserting genetic material from a disease-
causing organism into a harmless cell, which
replicates the proteins of the disease-causing
organism.
 The proteins are then purified and used as
vaccine.

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TOXOID VACCINE

31
TOXOID VACCINES
 Toxoid vaccine are based on the toxin
produced by certain bacteria (e.g.
tetanus or diphtheria).
 The toxin invades the bloodstream and

is largely responsible for the symptoms

of the disease.
 The protein-based toxin is rendered

harmless (toxoid) and used as the

antigen in the vaccine to elicit immunity.
Toxoid - Inactivated or killed toxin
32
(poison) used in vaccine production.
MILESTONES IN VACCINE DEVELOPMENT

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CONT...

34
VACCINATION SCHEDULE

35
 IMMUNIZATION SCHEDULE

PRIMARY SCHEDULE FOR INFANTS BELOW ONE YEAR IN

STATIC HEALTH SERVICES:

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37
38
 ADMINISTRATIONS OF VACCINES
ROUTE OF
SITE OF Time of
VACCINE DOSE ADMINISTRATIO
ADMINISTRATION administration
N

Infants: 0.05
Right deltoid
BCG ml, 0.1ml for Intradermal At birth
region of the arm
children>1yr

Pentavalen Left upper, outer 6, 10, 14 weeks of

0.5 ml Intramuscular
t portion of the thigh age

6, 10, 14 weeks of
Right upper, outer
PCV 0.5 ml Intramuscular age
portion of the thigh

At birth, 6, 10, 14
Polio 2 drops Oral Mouth
weeks of age
6, 10 weeks of
Rota Full dose Oral Mouth
age
Outer ,upper part 39
Measles 0.5 ml Subcutaneous At 9 & 15 months
of left arm
ROUTES OF ADMINISTRATION VARY TO
MAXIMIZE EFFECTIVENESS OF VACCINE

40
BCG INJECTION

41
At what age should IPV be administered?
 Give IPV at or after age 14 weeks, usually with OPV3
and DTP3/Penta3
 IPV should be given in addition to OPV
 OPV is still the primary vaccine to achieve
eradication
Vaccine Birt 6 wks 10 wks 14 wks
h
BCG
Pentaval
ent
PCV
Rotaviru
s*
OPV
*rotavirus vaccine may be 2 or 3 doses, depending upon the
vaccine used
42
IPV
 COMBINATION VACCINES

 Some vaccines are combined into a single

injection.
 For example, pentavalent vaccine combines
vaccines against five diseases: diphtheria,
tetanus, pertussis, hepatitis B, and Haemophilus
influenzae type b (Hib).

 Their benefits include

 Reduction in number of pricks
43
 Reduction in number of visits to the health center
CONT...

 Reduction in cost of administering and

stocking vaccines
 Reduction in pressure on cold chain
 Increase in compliance
 Facilitation in introduction of new vaccines
in the immunization schedule

44
CONT...

 DTP and MMR are examples of combination

vaccines available since 1945 and 1971,

respectively.

 It is around DTP that various antigens tetravalent

and pentavalent vaccines are built up.

 DTPa -Hep B

 DTPa+HepB + Hib

 45
HepB-Hep A
 SAFE INJECTION PRACTICES
 The World Health Organization (WHO) defines a safe
injection as an injection that DOES NOT do the
following:
 Harm the recipient
 Expose the health care worker to any avoidable risks
 Result in waste that is dangerous to the community

 Factors that contribute to unsafe injection are:

 Reuse of a single syringe and needle
 Inadequate supply of injection material
46
 Inadequate disposal of used syringes and needles
CONT...

 Guidelines on injection safety include:

 Use of a single sterile syringe and needle for
each dose of vaccine
 Separate anatomical sites and separate limb for
multiple injections
 Observation of the child for at least 15 minutes
after administration of an injection.

47
CONT...
 Use of AD syringes preferably
 Provision of safety boxes for disposal of used
syringes
 Incineration of full safety boxes
 Removal and proper burial of residue from the
incinerator
 No disposal of used syringe, needle or full safety
boxes in open garbage or dumped randomly.
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UNSAFE IMMUNIZATION PRACTICES

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UNSAFE IMMUNIZATION PRACTICES

50
PROVISION OF ROUTINE
IMMUNIZATION SERVICES

• Immunization services can be delivered through fixed facilities, outreach, or

51
a mobile strategy.
CONT...

 Delivery through fixed facilities involves

regular delivery of vaccinations in a health

facility during specified days of the week and

hours of the day.

 Outreach involves the delivery of services to

people who cannot easily get to a health

facility and is usually conducted within 5 km to

52

15 km of the facility.
 WHAT IS THE COLD CHAIN?
 Ensuring that vaccines, supplies, and staff arrive
on time and where they are needed requires an
integrated system of equipment, people, policies,
and procedures. This integrated system is called
the cold chain.
 The “Cold chain” is a system of storing and
transporting vaccines at low temperature from the
manufacturer to the actual vaccination location, so
that their potency and efficacy are preserved. 53
THE COMPLETE COLD CHAIN

54
CONT...

 Three vital elements in successful cold

chain are
1. Cold chain equipment,

2. Transportation and

3. Motivated and trained manpower for

maintaining the link.

55
HEALTH FACILITY COLD CHAIN
EQUIPMENT

 Refrigerators
 Cold boxes
 Vaccine carriers
 Water packs
 Foam pads

56
CONT...
 Cold box -This can transport large quantities of
vaccines by vehicle to outreach sites, preserving
the vaccine for up to one week without any
power supply at all.

57
CONT...

 Vaccine carrier -This is designed to transport

small quantities of vaccine by a vehicle,

bicycle or on foot to outreach sites, preserving

the vaccine for up to 3 days.

 Flask -This is only a substitute for carrier but

should not be much encouraged.

 Ice-Packs -These are employed for use in box, 58

carrier or flask
CONT...
 Vaccine carrier  Ice-Packs

 Flask

59
60
 STORAGE OF VACCINES
 The amount of stock on hand should always
be counted at each vaccine storage point
before new stock is ordered.
 The health worker should ensure the following:
 Adequate amounts are available
 Space is available to store the stock
 Vaccine is used before the expiry date
 The duration of storage is consistent with
61
recommendations
Where do you store the vaccine?

 Store in a refrigerator,
between +2⁰C and
+8⁰C
 Do not open the door
frequently
 Monitor fridge
temperature regularly
 Do not put IPV in the
freezer
62
 WHICH VACCINE SHOULD BE STORED
?IN FRONT
Vaccines with
later expiration
dates should
be stored in
the back

Vaccines with earlier

expiration dates and
VVM at or near Stage 2
should be kept in front
and used first
Earliest Expiry First Out
(EEFO)
Principle 63
 REDUCING VACCINE WASTAGE
 Vaccine wastage reduces the cost-effectiveness
of programs.
 Use of vaccine vial monitors and the multi-dose
vial policy (MDVP) can help reduce wastage,
but a heavy focus on reducing vaccine wastage
may lead to reluctance to immunize eligible
children because the remaining unused part of
the vaccine would be wasted.
64
CONT...
 Under the multi-dose vial policy, vials of some
vaccines, including OPV, DTP, pentavalent vaccine,
and TT, may be used for up to 28 days after being
opened, provided that all of the following conditions
are met:
 The expiry date has not passed
 The vaccines are stored under appropriate cold chain
conditions
 The vaccine vial septum has not been submerged in water
 Aseptic technique has been used to withdraw all doses 65

 The VVM, if attached, has not reached its discard point

CONT...

 For safety, the MDVP does not apply to

vaccines that do not contain preservatives,
including BCG, measles, PCV-10, or yellow
fever.
 These vaccines must be discarded within 4-6
hours of reconstitution, according to national
policy.
66
TEMPERATURE REQUIREMENTS
FOR VACCINES
 Vaccines are sensitive biological products.
 Some vaccines are sensitive to freezing,

some to heat and others to light.

 Vaccine potency, meaning its ability to

adequately protect the vaccinated patient,

can diminish when the vaccine is exposed to
inappropriate temperatures.
 Once lost, vaccine potency cannot be

regained.
 To maintain quality, vaccines must be

protected from temperature extremes.

67
RECOMMENDED VACCINE STORAGE
TEMPERATURES

68
 TEMPERATURE MONITORING

 Vaccines have different cold storage

requirements, which change at different
levels of the cold chain.
 The majority of vaccines now in use need to
be refrigerated, not frozen.
 This requires a greater volume of storage
capacity in refrigerators than in freezers.
69
CONT...

70
CONT...
 Some vaccines spoil if they are frozen. DTP, TT,

Td, hepatitis B, PCV, meningococcal, rotavirus,

HPV, and liquid formulations of Hib should NEVER

be frozen.
 Extra care and precautions to prevent freezing

should be emphasized in training, supervision,

and monitoring.
71
TEMPERATURE MONITORING
CHART

72
CONT...
 It is critically important to keep a record of
temperature changes. The shaded area on the chart
represents the temperature range that is acceptable
(from +2 to +8 degrees C).
 The numbers in the top row are calendar days. The
columns in the second row are divided into morning
(M) and evening (E) for recording temperatures twice
a day.
 Health workers should record the temperature of
73
their vaccine refrigerator twice a day.
 THE SHAKE TEST
 The Shake Test is used to check whether freeze-
sensitive vaccines have been damaged by exposure
to temperatures below 0 °C.
 The "Shake Test" helps determine whether absorbed
vaccines, such as DTP, DT, Td, TT, or hepatitis B have
been frozen.
 Absorbed vaccines are manufactured in such a way
that one substance attaches to the surface of another
material.
 After freezing, the vaccine is no longer a uniform
cloudy liquid, but tends to form flakes that gradually 74

settle to the bottom after the vial has been shaken.

THE SHAKE TEST...

75
 TEMPERATURE MONITORING
DEVICES
 A vaccine vial monitor(VVM) is a thermo-chromic
label put on vials containing vaccines which gives a
visual indication of whether the vaccine has been
kept at a temperature which preserves its potency.
 A vaccine vial monitor (VVM) is a small
colored disk printed on a vial label, or for
freeze-dried vaccines, placed on the vial cap.
 Always check the VVM before using the vial.
76
CONT...
 There are currently four types of VVM,
chosen to match the heat sensitivity of the
vaccine.
 These four types are VVM2, VVM7, VVM14

and VVM30.
 The VVM number is the time in days that it

takes for the inner square to reach the colour

indicating a discard point if the vial is
exposed to a constant temperature of 37 °C.
 The main purpose of VVMs is to ensure that

heat-damaged vaccines are not

77
administered.
WHERE IS THE VVM?
 There are two different locations for VVMs and each is

associated with specific guidance for handling opened multi-

dose vials of vaccine:

 the VVM, if attached, is on the label of the vaccine. The vaccine

vial, once opened, can be kept for subsequent immunization

sessions up to 28 days, regardless of the formulation of the product

(liquid or freeze-dried).

 the VVM is attached in a location other than on the label (e.g.,

cap or neck of ampoule). In this instance, the vaccine vial, once

opened, must be discarded at the end of the immunization session

78

or within six hours of opening, whichever comes first.

LOCATION OF VVMS ON AMPOULES
AND VIALS

79
CHECKING THE VACCINE VIAL
MONITOR (VVM)
 IPV vial has a VVM on the vial cap
 The VVM registers cumulative heat
exposure, and changes from light to dark
 Check the VVM on each vaccine vial
 If inside square is the same color, or darker
than the circle (stage 3 or 4), do not use the
vaccine

Stage 1: Vaccine OK

Stage 2: Vaccine OK but use first

Stage 3: Do not use the vaccine

80
Stage 4: Do not use the vaccine
81
TEMPERATURE MONITORING
DEVICES (CONT'D)
• placed with the vaccine in the refrigerator

82
PROVIDING IMMUNIZATION
SERVICES

83
 KEY STEPS TO IMPLEMENTING A SAFE
AND EFFECTIVE IMMUNIZATION SESSION

84
STEP 1: PLAN
 The first critical step in implementing an
immunization session is to plan for the session.
 Each immunization site, whether outreach or fixed,
should ensure the following:
 The immunization site is suitable for providing
immunization services
 There is a clear flow for clients to follow at the site
 Adequate cold chain and vaccines for the session
 Health workers with proper training to provide safe 85
immunizations and communicate clearly with clients
IMMUNIZATION STATION: EXAMPLE
ARRANGEMENT

86
STEP 2: SCREEN

 Screen infants for vaccination. The health

worker should do the following:
 Assess the infants' eligibility for immunization by
verifying his or her age on the immunization card
(or asking the caregiver if there is no card).
 Verify which vaccines the infant has already
received.
 Verify that the vaccines needed for the session
are available and allow time to prep. 87
 CONTRAINDICATION AND
PRECAUTIONS
 A contraindication to vaccination is a rare
condition in a recipient that increases the
risk for a serious adverse reaction.
 Ignoring contraindications can lead to
avoidable vaccine reactions.
 Most contraindications are temporary, and
the vaccination can be administered later.
 The only contraindication applicable to all
vaccines is a history of a severe allergic
reaction after a prior dose of vaccine or to a
vaccine constituent.
88
IMMUNIZING SICK CHILDREN
 Children with low-grade fever, a cold, diarrhea,
vomiting, or other mild illness can be vaccinated
safely and effectively.
 Prematurity, low birth weight, and breastfeeding
are NOT reasons to withhold a vaccination.
 It is particularly important that malnourished
children be immunized, because they are much
more likely to die from a vaccine-preventable
disease than well-nourished children.

89
CONT...
 All infants should be immunized except in
these situations:
 Do not give a vaccine if the infant has had
anaphylaxis (a serious allergic reaction) or
other severe reaction to a previous dose of the
vaccine or a vaccine component.
 Do not give a vaccine if the caregiver objects to
immunization for a sick infant after explanation
that mild illness is not a contraindication. Ask
the caregiver to come back when the infant is
well.

90
RECOMMENDATIONS FOR IMMUNIZATION
OF HIV-INFECTED CHILDREN

91
CAN IPV BE ADMINISTERED ON SCHEDULE TO
IMMUNODEFICIENT INFANTS OR INFANTS BORN
PREMATURELY?

 Yes!
 Immunodeficiency does not prevent
administration of IPV
 Vaccination of infants with
immunodeficiency, such as HIV infection,
is recommended
 Infants born prematurely should receive
IPV on schedule (at or after 14 weeks of
age)
92
CONTRAINDICATION CHECKLIST
Do I still give IPV if recipient Yes No Postpon
has….? e
… mild illness
… malnutrition
… HIV
… prematurity
… allergy to streptomycin, neomycin
or polymyxin B
… bleeding disorder
… had a previous reaction to IPV

… taking treatment that suppresses

immune response

93
 STEP 3: GIVE VACCINATION
 Injectable vaccines can be ready to use or require
reconstitution (mixing) with diluent.
 The next step is to administer the vaccine. The health
worker should welcome the family and make sure they
are at ease.
 He or she should be prepared with the appropriate
vaccines and follow the sequence for administering
them based on national guidelines.
 Oral vaccines (e.g., rotavirus and polio) should be
94
administered first, followed by injectable vaccines.
CONT...

95
SEQUENCE FOR GIVING INFANT VACCINES
BASED ON CURRENT WHO SCHEDULE

96
 SÉQUENCE AND INJECTION SITE
FOR IPV
Give oral vaccines first
 When giving IPV with Penta and PCV:
– Give IPV and PCV in one thigh, separated by at least 2.5 cm
– Give Pentavalent in the other thigh because it can cause
more swelling and redness

Step 1: OPV Step 2: Step 3: PCV Step 4:

IPV (right thigh separated by 2.5 cm)
Penta 97
(right thigh) (left thigh)
STEP 4: COMMUNICATE WITH
CAREGIVERS

98
STEP 5: RECORD DOSES GIVEN

 After the vaccine(s) have been given, the

health worker should record the doses in the
immunization card and mark the next
immunization date if needed.
 The caregiver should be informed when to
return for the next immunization.

99
End !
100
QUIZ
1. List down the type of vaccine based the
type of antigen they are formed
2. Write the dose and time of vit A for SAM
child.
3. Write the amount of ReSoMal given to a
child with dehydration.

101