EPI & OTHER RECOMMENDED VACCINES

Ruby Ann L. Punongbayan, MD, FPPS

*

Active ImmunizationEfficacy is assessed by the evidence of protection against the particular disease.Antibody formation indirect measure

Types of antigen for active immunization:

1. Live attenuated virus or bacteria (weakened)2. Inactivated vaccine (killed microorganisms)

Lithium smallest drug known to maam

Thrombolytics largest drug known to maam for acute M.I. for thrombolysis, and for strokes too.

Warfarin is NOT used in pregnancy because it has a SMALL size unlike Heparin. Warfarin can also cause teratogenic effects. (Antidote to Heparin: PROTAMINE SULFATE)*

Inactivated vaccinesHepatitis B vaccineDPT vaccineH.influenzae b vaccinePneumococcal vaccineHepatitis A vaccineMeningococcal vaccineInfluenza trivalent vaccineHuman papillomavirus vaccine Typhoid fever vaccine (IM)Rabies vaccineInactivated polio vaccine (IPV)

Live vaccinesBCG vaccineMeasles vaccineMMR vaccineVaricella vaccineRotavirus vaccineInfluenza attenuated vaccine (intranasal)Typhoid fever (oral) vaccine

Passive ImmunizationDEFINE passive immunizationFor IM administration: peaks at 48-72 hrs not to exceed 5 ml

Indications:

Congenital or acquired B-lymphocyte cell defects alone or in combination with other immunodeficiencies When time does not permit adequate protection by active immunization alone (hepatitis B, measles, rabies, varicella)

DEFINITIONS:covalent bond = sharing of pairs of electrons between atoms. Strongest type of bond.electrostatic bonds = ionic bonds, one atom loses an electron gets a positive charge, the other atom gains an electron, gets a negative chargehydrogen bond = interaction of ahydrogenatom with nitrogen,oxygenor fluorinevan der Waals = nonspecific minor attractive or repulsive forces betweenmoleculeshydrophobic bonds = keep hydrophobic parts away from aqueous environment (ie, micelle formations assumed by lipids)

Malathion, parathion organophosphate. Pralidoxime has to be given within a golden period (Less than 6 hours). *

Passive Immunizationc) When a person susceptible to a disease is exposed to or has a high likelihood of exposure to that infection or has a high risk of complications from the disease (leukemic child exposed to a person with varicella or measles)

d) When a disease is already present and antibody may aid in suppressing its toxin effects (tetanus) or the inflammatory response (Kawasaki disease)

*

The concept of cold chainsupplier abroad central storage (vaccine lab) regional cold rooms and freezers hospitals / clinics / rural health units infant / child

No energy requird in aqueous diffusion. Moves from high concetration to low concentration*

Cold ChainIt is a system for ensuring the potency of a vaccine from the time of manufacture to the time it is given to a child.Two essential elements: people and equipmentVaccines will confer immunity only when they are potent, and to be potent they must be properly stored, handled, and transported

Histologic basis of BBB: astrocytes foot process. For glomerulus: podocytes foot process.NON-POLAR ka dapat to pass through the lipid membranes

Usually ito ang limiting factor.Pwede ka ngang makapasok sa mga aqueous channels via aqueous diffusionPero how about that lipid barrier?Lipid: Aquous partition coefficient ratio, measure of solubility between two solvents. In this case, solubility in water, and solubility in a lipid/hydrophobic substance. High partition coefficient: preferentially distributed sa mga hydrophobic compartments Low partition coefficient: preferential sa hydrophilic compartments blood seerumWeak acids and weak bases: special name determined by the Henderson Hasselbalch equation

Governed by FICKS LAW OF DIFFUSION

*

Important points to remember:Breastfeeding does not interfere with successful immunization with oral vaccines. Vomiting within 10 minutes of receiving an oral dose is an indication for repeating the dose. If the second dose is not retained, neither dose should be counted, and the vaccine should be re-administered.

Important points to remember:Parenteral vaccine should be administered in a site as free as possible from risk of local neural, vascular, or tissue injury.

Recommended route is based on studies designed to demonstrate maximum safety and efficacy.

Important points to remember:In older children, the deltoid muscle is usually large enough for IM injection.

The upper, outer aspect of the buttocks should not be used for active immunization because the gluteal region is covered by a significant layer of subcutaneous fat and because of the possibility of damaging the sciatic nerve.

Important points to remember:Preterm newborns: 5/8-inch long needle Term infants: 7/8- to 1-in long needle Toddlers & young infants: 7/8- to 1 -inch long needle22-25-gauge needle for most IM vaccinesSubcutaneous: 23-25-gauge needle and 5/8-3/4-inch longIntradermal: gauge 25-27

Case:A 9 month-old boy came in for a well-baby visit. You intended to give him measles vaccine for this visit. Upon reviewing his record, you noted that he missed his 3rd dose of hepatitis B vaccine. His mother told you his baby was sick hence, he was not given the said vaccine at that time. Plan of action:

a) You will give both measles and hepatitis B vaccine.b) You will give measles vaccine today and ask him to come back after 4 weeks for the hepatitis B vaccine administration.

Principles of immunization:1. Simultaneous administration of multiple vaccines (for missed doses):most vaccines can be safely and effectively given simultaneously

EXCEPTION: cholera and yellow fever vaccines: decrease in immunogenicity when given together or 1-3 weeks apart

use separate syringes and sites

Antigen Combination Recommended Minimum Interval Between Doses Equal or > 2 inactivated vaccinesNone; can be given simultaneously or at any interval between doses Inactivated and live vaccinesNone; can be given simultaneously or at any interval between doses Equal or > 2 live parenteral vaccines28-day minimum interval if not given simultaneously

CORRELATIONS:

ANATOMY/PHYSIOLOGY: Where is intrinsic factor secreted? Gastric fundus of the Stomach, parietal cellWhat is the importance of intrinsic factor? Absorption of vitamin B12What is the only function of the stomach that is essential for life? Production of intrinsic factorWhat must you supplement to your patients who have undergone gastrectomy? Vitamin B12

Food rich in B12: meatsFood rich in folic acid: cauliFlower, Frocolli (Brocolli)

Iron: absorbed in the PROXIMAL DUODENUM. Needs Tranferrin.

PATHOLOGY: What autoimmune condition results from autoimmune destruction of parietal cells in the stomach? Pernicious anemiaHow will pernicious anemia manifest in a bloodsmear? Macrocytic (megaloblastic) anemia*

Case:A mother of a 3 year-old girl asked you if there is a need to repeat the primary series of DPT, OPV, and hepatitis B vaccines of her daughter. She left her child with her mother-in-law when she worked in Singapore. Unfortunately, the grandmother was not able to bring back the child to the doctor after her second dose of DPT & OPV and first dose of hepatitis B vaccine.

Ionizationis thephysicalprocess of converting anatomormoleculeinto anionby adding or removing charged particles such aselectronsor other ions When we ionize, we create a charged molecule.Charged molecules have increased aqueous solubility, and decreased lipid solubility

ABSORBED: nonpolarExcreted: polar *

Principles of immunization:2. Lapsed Immunizations

a lapse does not require reinstitution of the entire series

subsequent immunizations should be given at the next visit as if the usual interval had elapsed

pH power of hydrogenAmphoteric - Can function both as an acid and base (e.g. WATER)Amphipathic- has both hydrophobic and hydrophilic properties

ACID: donates ahydrogen ion(H+) to another compound (called abase). acid lang ang may D, so DONATE. Anything that has this property is an ACID or is called ACIDIC.BASE: receivespH of the medium measure of acidity or basicity of a medium

pH is the negative logarithm of the hydrogen ion concentration.In water at room temp, concentration of H+ is 1 x 10-7. Yung -7 na yun yung pH.*

Case:A 2 year-old boy was brought to you for a well-child visit. His parents claimed that their childs health record was lost when their house was burned down by fire several months ago. The previous doctor of their child has relocated to Australia and they could not get a health record of their son. Plan of action?

Principles of immunization: 3. Unknown or uncertain immunization statusIn general, when in doubt, immunizations should be initiated without delay on a schedule commensurate with the persons current age.

No evidence that giving vaccines to already immune recipients is harmful.

What is the absolute contraindication of immunization?

Expanded Program on Immunization (EPI):Most cost-effective public health interventionIn the Philippines, the EPI was launched by the DOH on July 12, 1976.Implementation of EPI contained in PD No. 996 (Sept. 16, 1976) providing for compulsory immunization for infants and children below 8 years

EPI:In 1993, the number of EPI diseases was expanded from 6 to 7 with the inclusion of hepatitis B.

Senate Bill No. 1654: 14th Congress: an Act Requiring Mandatory Basic Immunization Services Against Hepatitis B for Infants (Oct. 2, 2007)

EPI:FULLY IMMUNIZED CHILD one who has received 1 dose of BCG at birth or any time before reaching 12 months, 3 doses of DPT and polio with at least 4 weeks interval between each dose, one dose of measles at age 9 months or before 12 months, and 3 doses of hepatitis B with at least 4 weeks interval between doses

MMR and Hib vaccines have now been included in the Philippine EPI of the DOH.

EPI

Vaccine Age Dose Route Adverse Reactions BCGNewbornup to 12 months old

>12 months old 0.05 ml

0.1 mlintradermalAbscess or ulcers at site ; axillary lymph-adenopathy

EPI

Vaccine Age Dose Route Adverse Reactions DPT8, 12, 16 wks old 0.5 ml intra- muscularFever, convulsions, irritability, prolonged crying OPV8,12,16 wks old 2-3 drops POVAPP (0.06 million doses among recipients)

EPI

Vaccine Age Dose Route Adverse ReactionsHepatitis BSoon after birth; if mother is +HBsAg; 0-1-6 months old 0.5 ml IMPain at the injected site; local redness, warmth and swellingMeaslesvaccine9 mos old or 6 months old in cases of outbreak0.5ml SCFever 5-7 days after vaccination; rashes

EPI

Vaccine Age Dose Route Adverse ReactionsMMR vaccine(measles, mumps, rubella)6 months after the 1st measles vaccine; booster shot anytime bet. 4-6 yrs old 0.5 ml SCPain at the injected site; local redness, warmth, and swellingHib vaccine (H.in-fluenzae bvaccine)2 months - 4 months - 6 months old0.5ml IMErythema at the injection site

Recommended AgeVaccineCommentsAt birthHep B1; BCG1 monthHep B22 monthsDPT1, OPV1May be given as early as 6 wks old4 monthsDPT2, OPV26 months DPT3, OPV3, Hep B3

9 monthsMeasles vaccineMay be given as early as 6 mos.old

Beyond 1 yr old: Recommendations

15 months old MMR (measles-mumps-rubella)Given 6 months after the first measles vaccine 18 months old DPT, OPVFirst booster dose (given 12 months after the 3rd dose) 4-6 years old DPT, OPV, MMRSecond booster dose given at or before school entry11-12 years oldTd (tetanus toxoid)Repeat every 10 years for life

Hepatitis b vaccineA 4th dose is needed for the following:

If the 3rd dose is given at age less than 6 months

b) If no birth dose is given using the EPI schedule of 6, 10, 14 weeks old

c) For preterms less than 2 kgs, the initial dose should not be counted in a 3-dose immunization schedule

BCG vaccine (Bacille Calmette Guerin):BCG should be given preferably within the 1st 2 months of life

For healthy infants & children >2 months who are not given BCG at birth, PPD prior to BCG vaccination is not necessary.

However, PPD is recommended prior to BCG vaccination if any of the ff are present:

BCGSuspected congenital TB

b) History of close contact to known or suspected infectious cases of TB

c) Clinical findings suggestive of TB and/or chest x ray suggestive of TB

H. influenzae b vaccinePrimary series: 2m, 4m, 6mBooster dose at 12-15 months oldDose #1 should not be given earlier than age 6 wks oldThe last dose (booster dose) is given no earlier than age 12 months & a minimum of 8 wks after the previous doseGive only 1 dose to unvaccinated children ages 15-59 months old.

END OF LECTURE

*Lithium smallest drug known to maam

Thrombolytics largest drug known to maam for acute M.I. for thrombolysis, and for strokes too.

Warfarin is NOT used in pregnancy because it has a SMALL size unlike Heparin. Warfarin can also cause teratogenic effects. (Antidote to Heparin: PROTAMINE SULFATE)*DEFINITIONS:covalent bond = sharing of pairs of electrons between atoms. Strongest type of bond.electrostatic bonds = ionic bonds, one atom loses an electron gets a positive charge, the other atom gains an electron, gets a negative chargehydrogen bond = interaction of ahydrogenatom with nitrogen,oxygenor fluorinevan der Waals = nonspecific minor attractive or repulsive forces betweenmoleculeshydrophobic bonds = keep hydrophobic parts away from aqueous environment (ie, micelle formations assumed by lipids)

Malathion, parathion organophosphate. Pralidoxime has to be given within a golden period (Less than 6 hours). *

*No energy requird in aqueous diffusion. Moves from high concetration to low concentration*Histologic basis of BBB: astrocytes foot process. For glomerulus: podocytes foot process.NON-POLAR ka dapat to pass through the lipid membranes

Usually ito ang limiting factor.Pwede ka ngang makapasok sa mga aqueous channels via aqueous diffusionPero how about that lipid barrier?Lipid: Aquous partition coefficient ratio, measure of solubility between two solvents. In this case, solubility in water, and solubility in a lipid/hydrophobic substance. High partition coefficient: preferentially distributed sa mga hydrophobic compartments Low partition coefficient: preferential sa hydrophilic compartments blood seerumWeak acids and weak bases: special name determined by the Henderson Hasselbalch equation

Governed by FICKS LAW OF DIFFUSION

*CORRELATIONS:

ANATOMY/PHYSIOLOGY: Where is intrinsic factor secreted? Gastric fundus of the Stomach, parietal cellWhat is the importance of intrinsic factor? Absorption of vitamin B12What is the only function of the stomach that is essential for life? Production of intrinsic factorWhat must you supplement to your patients who have undergone gastrectomy? Vitamin B12

Food rich in B12: meatsFood rich in folic acid: cauliFlower, Frocolli (Brocolli)

Iron: absorbed in the PROXIMAL DUODENUM. Needs Tranferrin.

PATHOLOGY: What autoimmune condition results from autoimmune destruction of parietal cells in the stomach? Pernicious anemiaHow will pernicious anemia manifest in a bloodsmear? Macrocytic (megaloblastic) anemia*Ionizationis thephysicalprocess of converting anatomormoleculeinto anionby adding or removing charged particles such aselectronsor other ions When we ionize, we create a charged molecule.Charged molecules have increased aqueous solubility, and decreased lipid solubility

ABSORBED: nonpolarExcreted: polar *pH power of hydrogenAmphoteric - Can function both as an acid and base (e.g. WATER)Amphipathic- has both hydrophobic and hydrophilic properties

ACID: donates ahydrogen ion(H+) to another compound (called abase). acid lang ang may D, so DONATE. Anything that has this property is an ACID or is called ACIDIC.BASE: receivespH of the medium measure of acidity or basicity of a medium

pH is the negative logarithm of the hydrogen ion concentration.In water at room temp, concentration of H+ is 1 x 10-7. Yung -7 na yun yung pH.*