IMMUNIZATION PRINCIPLES AND VACCINE USE  Passive immunity: natural process exemplified by

transpolacental transmission of maternal antibodies

Vaccination to the fetus to provide protection against several
• Ranked as one of the greatest public health diseases during the first months of life
achievements of the twentieth century • Vaccines contain all protective antigens of the organism
• One of the few cost-saving interventions to prevent however there is a possibility of adverse responses to
infectious disease reactive but non-protective antigens present in the mix
• Principal factor contributing to the reduction of
morbidity and mortality among children around the world APPROACHES TO ACTIVE IMMUNIZATION
Disease 2001 2002 Decrease, • Use of live, generally, attenuated, infectious agents
Morbidity Morbidity %
Smallpox 0 0 100  Consists of selected or genetically altered organisms
Poliomyelitis 0 0 100 that are avirulent or attenuated yet remain
(paralytic) immunogenic → long-lasting immunity
Diphtheria 2 1 100  May cause subclinical illness and immunologic
Rubella 23 14 99.9 response mimicking natural infection
Hemophilus 27 27 99.9  Offer advantage of replication in vivo
influenza type b  Increases antigenic load presented to the host’s
Measles 116 37 99.9 immune system
Mumps 266 238 99.8  May conger lifelong protection with one dose
Congenital rubella 3 3 99.6  Present all expressed antigens thus overcoming
syndrome immunogenetic restrictions in some hosts
Neonatal tetanus 29 1 98.1  Reach local sites most relevant to the induction of
Tetanus 27 23 98.1 protective immunity
Pertussis 7580 8296 94.6  May produce important protective antigens in vivo
that are not efficiently expressed in vitro
IMPACT OF IMMUNIZATION
• Global eradication of smallpox • Use of inactivated agents of their constituents or
• Eliminated naturally transmitted poliomyelitis from products obtained by genetic recombination
Western Hemisphere, Europe and Western Pacific  Require multiple dosese and periodic boosters
• Measles has been effectively eliminated from most of (except pure polysaccharide vaccine)
Western Hemisphere  Nonviable vaccines administered parenterally fail to
• Virtual elimination of congenital rubella syndrome, elicit mucosal IgA-mediated immunity as they lack a
tetanus and diphtheria in the US delivery system that can effectively transport them
• Dramatic reduction in pertussis, rubella, measles, and to local antigen-processing cells
mumps
• Hib eliminated haemophilus infections since it elicits • Despite their advantages, live vaccines are no always
durable immunity by the time maternal-derived preferable
antibodies have dissipated and reduces nasopharyngeal  OPV contraindicated in children with immune
carriage of HIB thus reducing risk of transmission deficiency or adults contacts
• Polyvalent pneumococcal polysaccharide conjugate
APPROACHES TO PASSIVE IMMUNIZATION
vaccine has impact on invasive pneumococcal disease • Passive immunization
including otitis media
 Provides temporary immunity in an immunized
subject exposed to an infectious disease when active
DEFINITIONS
immunization in not available (RSV) or has not been
• Vaccination: administration of vaccine
implemented before exposure (Rabies)
• Immunization: process of inducing or providing immunity
 Used in treatment of disorders associated with toxins
by any means (diphtheria, bites, Rho Immunoglobulin and
• Active immunization: induction of immune defenses by antilymphocyte immunoglobulin)
the administration of antigens in appropriate forms
• Passive immunization: provision of temporary protection • Preparations used in passive immunization
by the administration of exogenously produced immune
substances  Standard human immune serum globulin for general
use (γ-globulin), administered IM or IV
Definition of Immunizing Agents  Special immune serum globulins with a known
Term Definition content of antibody to specific agents (HBV, VZV)
Vaccine Attenuated or killed microorganisms or antigenic  Animal sera and antitoxins
portions are presented to a potential host to
induce immunity and prevent disease ROUTE OF ADMINISTRATION
Toxoid Modified bacterial toxin that has been mad
• Oral, intranasal, intradermal, subcutaneous,
nontoxic but retains capacity to stimulate
formation of antitoxin intramuscular
Immune Antibody-containing protein fraction derived from • Parenteral: may not induce mucosal secretory IgA
globulin human plasma • Mucosal: may not induce good systemic response
Used primarily for maintenance of immunity of • HepB: should be administered into deltoids to ensure
persons with immunodeficiency disorders
For passive immunization when there is no
induction of adequate immune response
opportunity for active immunization • DTP: should be administered IM to reduce risk of reaction
Antitoxin Antibody derived from the serum of animals after
stimulation with specific antigens AGE
Used to provide passive immunity to the toxin
proteins which is directed
• Presence of high levels of maternal antibody and/or the
immaturity of the immune system in the early months of
PRINCIPLES OF IMMUNIZATION life impairs the initial immune response to some vaccines
• Artificial induction of immunity closely follows two well- (Measles of Hib polysaccharide) but not to others (HepB)
tested principles of nature: • In the elderly: responses may be diminished because of
 Active immunization: traced as far back as natural waning of the immune system hence, larger
Thucydides who noted that people surviving amounts of antigen may be required to produce desired
epidemics of plague in Athens were spared during response
later outbreaks of the same disease
ADJUVANT POTENTIATION
• Used with inactivated products (diphtheria, tetanus
toxoids, DTaP, and hepB)
• Adjuvants:
 Aluminum salts or polysaccharides (polyribose
phosphate oligosaccharide of Hib)
 Conjugation to a carrier protein
• Mechanisms:
 Relates in part to the rendering of soluble antigens
into a particulate form
 Mobilization of phagocytes to the site of antigen
deposition
 Slowing down of release of antigens which prolongs
stimulation of immune response
THE IMMUNE RESPONSE
The Primary Response
• Apparent latent period precedes the detection of
humoral and cell-mediated immunity
• Immune response begins with recognition of antigen by
the immune system but antibodies do not appear for 7 to
10 days
• Characterized by early-appearing IgM antibodies which
exhibits low affinity for the antigen
• Later-appearing IgG antibodies display high affinity
• For thymus-dependent antigens, CD4+ T-helper
lymphocytes control the switch from IgM to IgG
• Primary vaccine failure: no response despite repeated
administration with vaccine antigen because of lack of
major histocompatibility complex determinants required
to recognize the antigen
The Secondary Response
• Heightened humoral or cell-mediated responses elicited
by second exposure to the same antigen and occur
rapidly (within 4-5 days)
• Depends on immunologic memory after 1st exposure
• Characterized by marked proliferation of IgG antibody-
producing B lymphocytes and /or effector T cells
Polysaccharide vaccines (S. pneumoniae) evoke
immune responses that are independent of T
cells and are not enhanced by repeated
administration
• Conjugation proteins converts polysaccharides to T cell-
dependent antigens that induce immunologic memory
and secondary responses to revaccination
• Secondary vaccine failure: revaccination or exposure to
the organisms elicits a rapid protective secondary
response consisting of IgG antibodies with little or no
detectable IgM
 Anamnestic respnse indicates that immunity has
persisted
 Mere presence of detectable antibodies after
administration of some vaccines and toxoids does not
ensure clinical protection
 Minimal circulating level of antibody is known to be
require for protection from diseases (0.01IU/mL for
tetanus antitoxin)
Hypersensitivity Reactions
• Independent of antibody production, stimulation of the
immune system by vaccination may elicit unanticipated
responses
• Killed measles vaccine induced incomplete humoral
immunity and cell-mediated hypersensitivity resulting in
development of atypical measles in some children after
subsequent exposure
Mucosal Immunity
• Vibrio cholerae (replicate at mucosal surface) & polio,
rubella and influenza (penetrate mucosa and replicate)
induce secretory IgA
• Induction of secretory IgA by vaccine may be an efficient
way to block essential first steps in pathogenesis whether
the organism is restricted to mucosal surfaces or invades
the host across mucosal surfacaes
Measurement of the Immune Response
• Concentration of specific antibody in serum
• Subconversion: dependable indicator but measures only
one immunologic parameter and does not indicate
protection
• Development of circulating antibodies after
immunization correlates directly with clinical protection
• Some responses may not confer immunity but may be
sufficiently associated with protection that they may
remain useful proxy measures of protective immunity
(vibriocidal serum antibodies in cholera)
HERD IMMUNITY
• Vaccination provides direct protection against infection
thereby decreasing susceptible persons within a
population
• Herd immunity: at a definable prevalence of immunity in
the population, an organism can no longer circulate
freely among the susceptibles
• Herd immunity effect: indirect proportion of
unvaccinated (nonimmune) persons
• Level of vaccination coverage needed to elicit a herd
immunity effect is dependent on the mixing patterns of
the population and the biology of the specific infectious
agents
 Measles and Varicella: high transmission rates and
require higher level of vaccine coverage to elicit
herd immunity
 Loss of herd immunity led to renewed circulation of
the organism and subsequent large outbreaks
TARGET POPULATIONS AND TIMING OF IMMUNIZATION
• Different age groups, different attack rates, different
responses to vaccine depends on
 Demographic features of the population
 Duration and character of the immunologic response
• Common and highly communicable childhood disease
 Target population: Susceptible individuals
 Time of immunization: early in life as feasible
 Industrialized nations: live virus immunization at 12
to 15 months
 Developing nations: 4 to 6 months
• Hib
 Causes meningitis, epiglotitis, pneumonia in early
childhood
 T-cell dependent antigen by conjugation (infants) is
used since polysaccharide vaccine failed because of
age-related inability to response to polysaccharide
antigens
• Rubella
 Primary threat to fetus
 Immunize all women of reproductive age before
pregnancy
 Administer MMR in infancy (?)
 Screen for rubella antibodies during pregnancy plus
postpartum vaccination of seronegative individuals
• Adults only: influenza virus and polyvalent pneumococcal
polysaccharide
 Target: healthy elderly
 Possible vaccination of children with pneumococcal
conjugate cavvines and cold-adapted influenza strain
as well as of administration by nasal spray
THE DEVELOPMENT OF VACCINES
BIOLOGIC IMPEDIMENTS
• Problem with influenza virus: new antigenic version can
cause global pandemic and new vaccine must be devised,
produced, distributed and administered
• Problem with pneumococcal polysaccharide serotypes:
immunity is serotype specific and an individual is
susceptible to all serotypes against which he or she lacks
antibody → solution: vaccine contains 23 polysacchardies
(80% of virulent serotypes) BUT serotypes are poorly
 immunogenic and immunized individuals remain Diphtheria Local reaction:
susceptible to the serotypes not included in the vaccine tetanus hypersensitivity
DT, Td neutralizing to tetanus toxoid
Toxoid
(adult) antitoxins, Reduced local
STRATEGY FOR VACCINE DEVELOPMENT 0.1IU/mL reactions
• Four-phase strategy: each compared with
 Studies in animals to identify protective antigens Inactivated Not whole-cell
aP
bacterial antigen estabilished pertussis vaccine
 Determination of how to present this antigen Not No serious
effectively to the immune system DTaP Acellular
estabilished reactions
 Assessment of the safety and immunogenicity of the Antibody to reported
I
preparation in small and in large human populations Bacterial capsular
M
Few local, no
at various ages Hib polysaccharide- polysacchari serious reactions
protein conjugate de, 0.15µ reported
 Evaluation of safety and efficacy in the target g/mL Few (?GBS)
population Inactivated
Antibody to
• Postlicensing monitoring needed to ensure effectiveness serum-derived
surface
and occurrence of adverse events of low frequency (e.g. HepB antigen or
antigen, ?GBS with swine
rhesus rotavirus vaccine associated in intussusception of recombinant
10mIU/mL influenza
antigen
the bowel in infants Inactivated virus
vaccine
Neutralizing
Influenza or viral
antibody
VACCINE FORMULATIONS component
• Goal: select correct antigens and ensure that the Neutralizing
Acute
encephalopathy
vaccines will result in the type of immune response measles
(measles)
needed for protection, without T cell-mediated antibody,
S Rare parotitis or
activation of macrophages or the generation of cytotoxic MMR Live viruses 100mIU/mL;
C orchitis (mumps)
not known
T cells, B cell-mediated secretory IgA or a particular IgG for mumps
Arthralgia and
subtype response to a specific polysaccharide epitope rare arthropathy
or rubella
(rubella)
• Constituents of a vaccine can affect the immunogenicity, Capsular I
efficacy and safety of a vaccine and can render one Pneumococ
polysaccharide M
polysacch Local reactions;
formulation superior to another (23 types) Antibody to or
rare anaphylaxis
Polysaccharide- polysacchari S
Constituents of Vaccine Pneumococ protein de C
Constituents Examples/Purpose conjugate conjugates (7-11 I
None thus far
types) M
Preservatives, Components are used to prevent
Inactivated virus No significant
stabilizers, deterioration of the vaccine before use, to
of 3 types, reactions
antibiotics inhibit or prevent bacterial growth, or IPV Neutralizing S
enhanced Local reaction;
stabilize the vaccine antibody C
immunogenicity varicella-like
Can cause allergic response Varicella Live virus rash
Adjuvants Aluminum salts or alum
Intended to enhance the immune response
Tetanus toxoids, Hep B vaccine • Administration of doses at intervals longer than those
Suspending fluid Sterile water, saline, buffer or more complex recommended does not diminish the ultimate protective
fluids response but merely delays it
Derived from the growth medium or biologic • Giving vaccines at shorter-than-recommended intervals
system in which the agent is produced may result in poor responses
Egg antigens, cell culture ingredients, serum
proteins
•
Special Vaccines for Infants, Children and Adults
Immunizing R
PRODUCTION OF VACCINES Vaccine Indications Adverse Events
Agent t
• Quality assurance: vaccine manufacturers For high risk
Anthrax
• Standards of manufacture of biologics: FDA-regulated of exposure
(6 doses Inactivated No serious
and military S
• Proof of safety, efficacy, sterility and purity of product is primary, avirulent
risk of C
adverse effects
required before licensure and sterility and purity are annual bacteria known
biowarfare
booster)
continually monitored exposure
• Problems: PPD- Regional
negative adenitis,
 High cost of vaccine development (Higher Living bacteria
Tuberculosis individuals disseminated
profitability from investment in other products) (attenuated ID
(BCG) in prolonged BCG in
M.bovis)
 Decline in number of vaccine manufacturers contact with immunocompro
active TB px mised hosts
 Increased cost of basic childhood vaccine
Travelers or
persons
ADMINISTRATION OF VACCINES Killed virus I Local reactions,
HepA living in
antigen M mild
• Precautions: high-risk
areas
 Hand washing between immunizations
Not
 Do not mix different vaccines in the same syringe recommend S
Frequent fever
 Discard disposable syringe safely to prevent ed for public C
Inactivated and local
needlestick injury or reuse of these items Cholera health use or
whole bacteria reactions, pain,
because of I
• Where effective primary health care systems ensure limited M
swelling
access to medical services and population is educated efficacy
about the need for and efficacy of vaccines, coverage Military
personel;
rates for basic immunization are usually high regardless Bacterial travelers to
of the route of vaccine administration or the number of Meningococ A, polysacch from endemic S
doses necessary Rare
C, Y, W-135 4 serotypes, areas; C
• The catch: if without attention to completion of not type B college
students in
multiple-dose vaccine schedules, booster doses may
dormitories
drop-off significantly Lab
10% local
workers;
reactions; rare
Inactivated foresters in I
Plague sterile abscesses
bacteria endemic M
and
areas; ?
USES OF VACCINES travelers
hypersensitivity
Routinely Recommended Vaccines Rabies Inactivated Travelers; I 25% of local
for Infants, Children and Adults (human virus grown in lab workers; M reaction; 6%
Protective R diploid) cell culture veterinarian or arthropathy,
Vaccine Immunizing Agent Adverse Events
Antibody t ID arthritis,
 angioedema • Categories of Immunization
Live Encephalitis,
 Group 1: Routine vaccines for all children in US to
Yellow fever attenuated Lab workers encephalopathy,
virus death receive DTaP, polio, MMR, Hib, HepB, varicella, and
Anaphylactic/sev pneumococcal conjugate vaccines unless there are
S
ere delayed specific contraindications
allergic  Group 2: Vaccines for high-risk exposure groups
Travelers to C
Japanese B Inactivated reactions
encephalitis virus
endemic
common;
(health care and other institutional workers,
areas prisoners, students, military personnel, travelers to
recipient should
be observed for endemic areas, injection to drug users, men who
10 days have sex with men)
Not Frequent fever,  Group 3: Vaccines for persons at high risk for severe
routinely local swelling,
Heat- or recommend
outcomes of infection (pregnant women; the elderly;
pain
phenol-killed ed; used for persons with chronic medical conditions including
bacteria or travelers, Local reaction, diabetes, alcoholism, immunodeficiency and renal,
Typhoid contacts of mild hepatic, respiratory or cardiac disease)
carriers I  Group 4: Vaccines for household contacts of persons
M in group 3
Purified Vi
Travelers
polysacch

Recombinant For high risk Local reactions

outer of exposure
Lyme disease
membrane to infected Age in Years
protein ticks Vaccine
15-49 50-64 65 & above
Tetanus
RECORDING AND REPORTING REQUIREMENTS diphtheria (Td) 1 dose booster every 10 years
• Inform parents about benefits and risks of immunization Influenza 1 dose annually
for persons with
and should maintain up-to-date immunization record on indication or
their children household 1 annual dose
• National Childhood vaccine Injury Act (NCVIA) of 1986 contacts of
persons with
 Requires that all mandated childhood vaccinations indications
be recorded by health care providers in the child’s Pneumo 1 dose for persons with medical or 1 dose for
other indications unvaccinated
permanent medical record (polysacch) persons
(1 dose revaccination for
1 dose
 Date of administration immunosuppressive conditions
revaccination
 Manufacturer and lot number Hep B 3 doses (1,1-2,4-6 months) for persons with medical,
behavioral, occupational or other indications
 Name of provider administering the vaccine
Hep A 2 doses (0,6-12 months) for persons with medical,
behavioral, occupational or other indications
VACCINES FOR ROUTINE USE MMR 1 dose if MMR
Infants and Children vaccination
history is
• See table in previous page unreliable
• Administration of HepA is recommended when there is a 2 doses for
persons with
special risk of exposure to infection due to residence in occupational or
communities with elevated rates of hepatitis A or travel other indications
to highly endemic countries Varicella 2 doses (0, 4-8 weeks) for persons who are susceptible
• Influenza vaccine recommended for children 6 to 24 Meningococ 1 dose for persons with medical or other
months especially those who have certain risk factors (polysacch) indications
who reside with persons with certain chronic disorders Legend:
• In several European countires, meningococcal C Green: for all person in this group
conjugate vaccine is routinely recommended Blue: catch-up on childhood vaccinations
Pink: for persons with medical/exposure indications
Vacci Range of Catch-up Preadolescent
ne recommende vaccinati assessment • MMR and varicella
d age on (11-12 years  Young adults without lab evidence or reliable history
old) of past vaccination or disease should be immunized
MONTHS YEARS against MMR and varicella
0 1 2 4 6 1 1 1 2 4-6 1 13-  A second dose of MMR is recommended for groups
2 5 8 1- 18
1 with a higher risk of exposure and for health care
2 workers with certain other indications
HepB If
1 mom
HepB series  Rubella should be given to all nonpregnant women of
is childbearing age if without proof of immunity
HBsAg
-  Rubella-susceptible pregnant women should be
HepB# HepB#3 vaccinated as early as possible in the postpartum
2 period
DPT DTaP DTaP DTaP  Live-virus vaccine (MMR and varicella) are
contraindicated in pregnant women and
HIb Hib Hib
immunosuppressed individuals
IPV IPV IPV IPV
MMR M #2 M • Meningococcal meningitis
MR1 MR2  College students
Varicel Varicella Varicella
la
• Tetanus
Pneum PCV PCV  All adults who have completed the pediatric series
o
For selected populations only should be boosted with Td (adult formulation) every
Pneum PCV 10 years (once after age 50)
o  If not previously immunized, adults require primary
PPV immunizing course of Td
HepA HepA series • Polio
Influen Influenza (yearly)  Routine immunization against polio is not
za recommended unless they are at risk of exposure

Adults • Influenza vaccine

  Routine annual administration to individuals with  Varicella
chronic illness at any age • Can be given during 2nd or 3rd trimesters if exposure risk is
 Persons living in the same household as chronically ill great:
individuals
 Polio
 All adults >50 years of age
 Yellow fever
 Hep B
• Polyvalent pneumococcal polysaccharide vaccine
 Influenza
 Adults ≥65 years of age  Pneumococcal vaccine
 For chronically ill persons
• Hep B vaccine Breastfeeding
 Individuals at high risk from clinical, occupational, • Neither killed nor live vaccine affects the safety of
behavioral and travel exposures breastfeeding for either mother or infant
 Patients undergoing hemodialysis • Breastfed infants can be immunized on a normal
 Patients undergoing routine transfusion of clotting schedule
factors
 Health care workers exposed to potentially infected
blood or blood products
 Individuals living and working in institutions for the
mentally handicapped
 Travelers to highly endemic countries
 Persons at elevated risk for STDs
 Injection drug users
 Household contacts of known carriers of hepatitis B
surface antigens
• HepA vaccine Medical Vaccine
 Same indications as HepB conditions Td Influ Pneumo HepB HepA MMR Varicella
 Persons with clotting disorders Pregnancy A
DM, heart
 Patients with chronic liver disease dcs, chronic
pulmo dcs, B C D
Adverse Events CLD, chronic
• Adverse reaction or vaccine side effect: an untoward alcoholism
Congenital F
effect caused by a vaccine that is extraneous to its immunodef,
primary purpose (to produce immunity) leukemia,
• Adverse event: can be a true vaccine reaction or a lymphoma,
malignancy,
coincidental event alkylating
• Vaccine components can cause allergic reactions which agents,
antimetab,
may be local or systemic
radiation or E
 Most common extraneous allergen: egg protein G
large amts
introduced when vaccines such as those for measles, of glucocort
mumps, influenza and yellow fever are prepared in ESRD, Renal
failure,
embryonated eggs hemodialysis
 Gelatin: used as heat stabilizer has been implicated or clotting
in rare, severe allergic reactions factor
concentrates
• Live-virus vaccine can interfere with tuberculin test Asplenia and
responses terminal
 Do tuberculin test on the day of immunization or at complement E, H, I
component
least 6 weeks later deficiencies
HIV infection E, J K
• When influenza vaccine is given to children <13 years Legends
old, only “split-virus” preparations should be used since Green: For all persons in this group
Blue: Catch-up on childhood vaccinations
whole-virus vaccines are associated with higher rates of Pink: For persons with medical/exposure indications
adverse reactions in this age group Red: Contraindicated

USE OF VACCINES IN SPECIAL CIRCUMSTANCES A. Vaccine may be given if pregnancy is at 2nd and 3rd trimester during
Influenza Pandemic Preparedness influenza season
• Occur at irregular intervals B. Although chronic liver disease and alcoholism are not indicator
• Characterized by excess deaths, hospitalizations, public conditions for influenza vaccination, give 1 dose annually if the
concern and social and economic disruptions patient is ≥50 years old, has other indications for influenza vaccine,
• National Preparedness Plan: or requests vaccination
C. Asthma is an indicator condition for influenza vaccination but not for
 Assess incidence of disease and antigenic pneumocoocal vaccination
characteristics of the prevalent strain D. Vaccinate all persons with chronic liver disease
 Promote flexibility in vaccine manufacture and E. Revaccinate once after ≥5 years have elapsed since initial
vaccination vaccination
 Based on enhancement of current capacities for F. Persons with impaired humoral (but not cellular) immunity may be
virologic surveillance, disease surveillance and vaccinated
emergency medical responses G. Hemodialysis patients: use special formulation of vaccine (40µg/mL)
or 2 1.0-mL, 20µg doses given at one site. Vaccinate early in the
Pregnancy course of renal disease. Assess antibody titers to HBsAg annually;
• Routine immunization of pregnant women is best avoided administer additional doses if tiers decline to <10IU/mL
H. Also administer meningococcal vaccine
• If hygienic conditions during delivery cannot be I. In persons undergoing elective splenectomy, vaccinate at least 2
guaranteed, ensure that pregnant women are immune to weeks before surgery
tetanus because transfer of maternal antitoxin is an J. Vaccinate as close to diagnosis as possible, when CD4+ cell counts
important means of preventing neonatal tetanus are highest
K. Withhold MMR or other measles-containing vaccines from HIV-
• Safe in pregnancy infected persons with evidence of severe immunosuppression
 Tetanus toxoids
 Diphtheria toxoid Occupational Exposure
• Withheld during pregnancy • Immunization recommendations for most occupational
 MMR groups remain to be developed
  Rubella is transmitted to and from health care Can be given as one or few doses
workers in medical facilities, particularly in pediatric Less reactive and more heat stable
practice
 Persons providing health care are also at greater risk Vaccine generations
from measles and varicella than the general public 1st generation
and those likely to come into ocontact with measles-  whole killed bacteria
and varicella-affected patients should be immune  partially purified microbial products
 Persons employed in caring for patients with chronic  (tetanus & diptheria)
diseases can transmit influenza and such workers  live attenuated microorganisms
should be vaccinated annually
2nd generation
HIV Infection and other immunocompromised states  used molecular genetics and protein chemistry
Immune responses are not as vigorous as in normal 3rd generation
individuals  DNA & RNA
Must give vaccines early in the course of the disease
Live attenuated MMR – can be given
 Live attenuated vaccines are contraindicated in
 Congenital immunodeficiency syndromes
 Persons recieveing immunosuppressive therapy
IPV – for polio; aslo given to their household contacts
It is not necessary in practice to test for HIV before
giving vaccines in high risk groups
Passive immunization w/ Ig OR antitoxin can be
considered in indiv cases

Post exposure immunization

Prevents/attenuates disease expression
Measles
 Ig (W/in 6 days  prevent/modify infxn)
 Vaccine (w/in first few days  prevent symptomatic
infxn)
Rubella (in preg)
 Passive immunization – may NOT prevent maternal
viremia, fetal infxn, & congenital rubella syndrome
 Ig (only for ♀ w/ developing rubella who will not
consider abortion)
Tetanus  Ig useful
Rabies  Ig + vaccine immediately
Hep A  w/in 2 wks exposure
Hep B  Ig

Simutaneous admin of multiple vaccines

DTaP + Hib
 NOT for primary immunization  bec will result in
suboptimal response to Hib
 Ok for booster
Live virus vaccines
 Needs 30 day interval if not given at the same day
MMR
 3 month interval between vaccine and Ig
 because ↑ dose of Ig will inhibit the efficacy of
vaccine
 post partum vaccination of rubella susceptible ♀
should NOT be delayed

Handling of vaccines
keep at 2° - 8°C; not frozen
 except Varicella
 must be frozen; at -15°C
Measles
 Protect from light (w/c inactivates it)

Standards
Infants w/ encephalopathy w/in 72hrs of DTP or DTaP
should NOT receive further doses
“Precaution” should NOT receive further doses
MMR & Varicella  contraindicated for preg women

** It is imperative to immunize each subsequent generation as

long as the threat of the reintroduction of the disease from
anywhere in the world persists

Ideal Vaccine
Can be given orally early
Provide lifelong protection against multiple infxn