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Friday, August 04, 20171
Basic immunology
and
practical aspects of immunization
Basic definitions
 Immunity-process of fighting with infection, disease
and other unwanted biological invasions with having
adequate tolerance to avoid allergy and autoimmune
diseases.
Friday, August 04, 2017
2
Are vaccination and immunization same?
 Both used interchangeably but minor technical
difference
 Vaccination – inoculation of antigen or vaccine into
the body. The recipient may or may not seroconvert
the vaccine
 Immunization- actual process of inducing immune
response which can be humoral or cell mediated in
the recipient
Friday, August 04, 2017
3
Types of Immunity
Friday, August 04, 2017
4
Innate Adaptive
 Comprise of skin and
mucosal barriers,
phagocytes(neutro,mono
cytes and macrophages)
 Response is antigen
independent
 There is immediate
response
 Exposure does not result
in induction of memory
cells
 Comprise of humoral
and cellular immunity
 There is a lag time
between exposure and
maximal response
 It is antigen specific
 Exposure result in
induction of memory
cells
Inmate and Adaptive immunity
Friday, August 04, 2017
5
Friday, August 04, 20176
Humoral Cell mediated
 Principal defence against
extracellular microbes.
 Involves b lymphocytes
which produces antibodies
 Antibodies act by
neutralisation, complement
activation, promoting
opsonophagocytosis
 Antibodies are of different
types IgA, IgG,IgE,IgM,IgD
 Principal defense against
intracellular microbes
 Effectors are t cells that
May be helper or cytotoxic
 Helper t cells secrete
cytokines that stimulate the
proliferation and
differentiation of t cells as
well as b cells and NK cells
 The cytotoxic t cells acts by
lysing infected cells
Humoral vs cell mediated immunity
Friday, August 04, 2017
7
What is a vaccine?
 An immuno biologocal substance that is introduced
in the body to produce specific protection against a
given disease.
 Antigenic but not pathogenic.
 It often made from weakened or killed forms of the
microbe, its toxins or one of its surface proteins
 The vaccine stimulates the body immune system to
recogonize the agent as a threat, destroy it and keep
a record of it so that the immune system can more
easily recogonise and destroy any of these micro-
organisms that it later encounters
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8
Friday, August 04, 20179
Friday, August 04, 201710
priming
 By priming the immune system by vaccination,,
when the vaccinated individual is later exposed to
the live pathogen in the environment the immune
system can destroy them before they can cause
disease
Friday, August 04, 2017
11
How do vaccine work?
 Mainly by production of antigen specific antibodies
 CMI just have supporting role in antibody
production
 T cell independent mech in polysaccharide vaccines
 Not stimulate CMI -no long lasting immunity
Friday, August 04, 2017
12
Response after immunization
Vaccines attract dendritic and monocytic cells.
These migrate to LN and cause activation of T & B
lymphocytes
Killed
Local unilateral
LN activation
Live
Multifocal LN
activation due to
microbial
replication and
dissemination
Hence
immunogenecity
of killed less
than live{so
adjuvant
required}
Friday, August 04, 2017
13
polysaccharide protein
T cell independent
Injection site to spleen
and directly bind with b
receptors
Response sets in 2to 4
weeks
Predomnantly with IgM
Immune response
T cell dependent
Trigger T cell which
stimulate b cell
causing germinal
center reaction
Plasma cell move to
bone marrow and
survive there resulting
in memory cells
Friday, August 04, 2017
14
Determinants of intensity and duration of
immune responses
 Depends on-
vaccine type, nature and vaccination schedule
 Live attenuated more than inactivated
 Nature- protein more than polysacharide
 Vaccination schedule 0-1-6 schedule better than 6-
10-14.
Friday, August 04, 2017
15
Type of vaccines
 Live atteneuted vaccine- live bacteria rendered
avirulent
 Inactivated vaccine-microorganisms killed by heat
and chemicals
 Subunit vaccine- only the antigens that best
stimulate the immune system are included
 Toxoid vaccine– modified exotoxins in which toxicity
lost but antigenecity remains
 Conjugate vaccine
Friday, August 04, 2017
16
Live attenuated
 These are modified strains of pathogens that retain
anigenicity but lost its pathogenicity
 May be bacterial or viral
 These replicate or multiply in the body after
administration and stimulate the immune system
 Eg viral- polio(sabin), measles,rubella, varicella,
yellow fever, rota virus
 Bacterial-bcg and oral typhoid
Friday, August 04, 2017
17
Friday, August 04, 201718
Killed
 Organisms are killed by phenol, formaldehyde, and
gamma radiation
 Usually safe but less effective than live vaccines
 The only absolute contra indication is severe local or
general reaction to the previous dose
Friday, August 04, 2017
19
toxoid
 Detoxified toxins called toxoid is inactivated by
treating them with formalin a solution of
formaldehyde and sterlised water
 These are used when bacterial toxins are main cause
of infection
 Eg tetanus, diptheria
Friday, August 04, 2017
20
Friday, August 04, 201721
subunit
 include only the antigens that best stimulate the
immune system
 use epitopes—the very specific parts of the antigen
that antibodies or T cells recognize and bind to.
 Because subunit vaccines contain only the essential
antigens and not all the other molecules that make
up the microbe, the chances of adverse reactions to
the vaccine are lower.
 Eg tetanus pertusis hep b
Friday, August 04, 2017
22
conjugated
Strong response
T cell dependent
No booster required
Friday, August 04, 2017
23
types ADVANTAGES DISADVANTAGES
Live attenuated •Excellent immune
response
•sufficient time for
memory cell production
Revert to original form
can cause disease
Not given in
immunocompromised
Less stable
killed Safe
Cheap
Easy to store
Booster doses required
Only humoral response
there
Vaccine induced
disease can occur
Sub unit Have no live
component so no risk of
inducing the disease
Safe and stable
No guarantee of future
memmory cells
Low immune response
conjugated Exellent immune
response
No booster required
Friday, August 04, 201724
Vaccine Efficacy
Friday, August 04, 2017
25
It is percentage reduction in disease incidence
attributable to vaccination
Calculated by– VE=1-RV/RU*100
RU=attack rate in unvaccinated people
RV=attack rate in vaccinated indivisuals
Measles -90-95%, mumps-72-88%, rubella-95-98%
Vaccine Effectiveness
Friday, August 04, 2017
26
 Reduction in the clinical events that might be
expected to be associated with the disease but could
also to be caused by other agents.
 Assesed by case control study and odds ratio
 Effectiveness=(1-OR)*100
 Basically it is attack rate among vaccinated vs attack
rate among non vaccinated
Vaccine Failure
Friday, August 04, 2017
27
When fully vaccinated person develop the disease
against which they have been vaccinated its called
vaccine failure
Two types primary and secondary
Primary-when recipient does not produce enough
antibodies when first vaccinated
Secondary- adequate number of antibodies are
produced immediately after vaccination but level fall
over time
Concept of HERD immunity?
Friday, August 04, 2017
28
 Resistance of a group or a community
against invasion and spread of infectious
agents as a large number of grps being
immunized
 May be in immunised or non immunised
individuals
 Asessed by cross sectional and
serological surveys
Herd Effect
Friday, August 04, 2017
29
 It is reduction of infection or disease in the
unimmunized segment as a result of immunizing a
proportion of the population
OR
 It is the change induced in epidemiology(incidence
reduction) among unvaccinated members when a
good proportion is vaccinated.
EPIDEMIOLOGICAL SHIFT
Friday, August 04, 2017
30
 Imp concept
Denotes change in pattern of disease in specified
population
Associated with partial immunization coverage
Disease of imp are hep A, rubella and varicella
Severity of disease worsens with advancing age
R O U T E S A N D T E C H N I Q U E S
G E N E R A L I N S T R U C T I O N S
F A Q S
Practical aspects of
immunisation
Friday, August 04, 2017
31
Routes
 With the exception of BCG and sometimes rabies, all
parentral vaccines are given by either intramuscular (IM)
or subcutaneous (SC) route.
 The SC route is recommended for measles, MMR,
varicella, meningococcal polysaccharide, JE, Yellow fever
vaccines; either SC or IM route may be used for
pneumococcal polysaccharide vaccines, IPV; the rest of
the vaccines should be given intramuscularly.
 there is no harm done if SC vaccines are given IM.
However, vaccines designated to be given IM should not
be given SC due to risk of side effects (as seen with
aluminium adjuvanted vaccines) or reduced efficacy (due
to reduced blood supply in SC tissue and hence reduced
immunogenicity).
Friday, August 04, 2017
32
continued..
 The gluteal region should never be used for
administration of IM injections due to risk of sciatic
nerve injury and reduced efficacy (rabies and hepatitis B
vaccines).
 When used at the recommended sites where no large
blood vessels exist, pulling back of the syringe to check
for blood is not recommended.
 The needle should be withdrawn a few seconds after
finishing administration of the vaccine (to prevent
backflow of vaccine into the needle track) following
which the injection site should be pressed firmly for a few
seconds with dry cotton. The injection site should not be
rubbed following injection
Friday, August 04, 2017
33
technique
Friday, August 04, 2017
34
General instructions
 Vaccination at birth means as early as possible within 24 to 72
hours after birth or at least not later than one week after birth.
 Whenever multiple vaccinations are to be given simultaneously,
they should be given within 24 hours if simultaneous
administration is not feasible due to some reasons.
 The recommended age in weeks/months/years mean completed
weeks/months/years.
 Any dose not administered at the recommended age should be
administered at a subsequent visit, when indicated and feasible.
 The use of a combination vaccine generally is preferred over
separate injections of its equivalent component vaccines.
 When two or more live parenteral/intranasal vaccines are not
administered on the same day, they should be given at least 28 days
(4 weeks) apart; this rule does not apply to live oral vaccines.
Friday, August 04, 2017
35
If given<4 weeks apart, the vaccine given 2nd should
be repeated
The minimum interval between 2 doses inactivated
vaccines is ussually 4 weeks
Vaccines doses administered upto 4 days before the
minimum interval or age can be counted as valid. If
the vaccine is administered >5days before minimum
period, it is counted as invalid dose.
Friday, August 04, 2017
36
 Changing needles between drawing vaccine into the syringe and
injecting it into the child is not necessary.
 Different vaccines should not be mixed in the same syringe unless
specifically licensed and labeled for such use.
 Patients should be observed for an allergic reaction for 15 to 20
minutes after receiving immunization(s).
 When necessary, 2 vaccines can be given in the same limb at a single
visit. The anterolateral aspect of the thigh is the preferred site for 2
simultaneous IM injections because of its greater muscle mass.
 The distance separating the 2 injections is arbitrary but should be at
least 1 inch so that local reactions are unlikely to overlap
 A previous immunization with a dose that was less than the
standard dose or one administered by a nonstandard route should
not be counted, and the person should be reimmunized as
appropriate for age.
Friday, August 04, 2017
37
Friday, August 04, 201738
Question 1
 Am too scared about side effects of vaccines
after media reports.
Answer
Serious side effects are extremely rare
and mostly due to human error, rather
than vaccine itself
Friday, August 04, 201739
QUESTION 2
My child was immunised against this disease, yet
he/she got it. Why?
No vaccine provides 100 percent protection.
the incidence is decreased drastically, and even if
the child gets the disease, it is mild.
Friday, August 04, 201740
Friday, August 04, 201741
Question 3
•My child has so many pending vaccinations.
Can they be given 1 week apart, so as to
finish them early?
•No.
•Any number of vaccines can be given on the
same day.
however, if not given on the same day, a
minimum of 28 interval should be maintained
before next vaccination.
Friday, August 04, 201742
Question 4
I have missed giving my child a vaccine at the
recommeded date. Should I start all over again
No. immune system has good memory function.
No need to restart schedule. Continue from
where u left.
Friday, August 04, 201743
Friday, August 04, 201744
QUESTION 6
Shud I give the optionalk vaccines? Especially the expensive
ones?
All optional vaccines should be given if affordable
They are effective
Friday, August 04, 201745
Friday, August 04, 201746
Friday, August 04, 201747
Friday, August 04, 201748
Friday, August 04, 201749

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Immunology of Vaccination - Dr Arjun Tandon

  • 1. Friday, August 04, 20171 Basic immunology and practical aspects of immunization
  • 2. Basic definitions  Immunity-process of fighting with infection, disease and other unwanted biological invasions with having adequate tolerance to avoid allergy and autoimmune diseases. Friday, August 04, 2017 2
  • 3. Are vaccination and immunization same?  Both used interchangeably but minor technical difference  Vaccination – inoculation of antigen or vaccine into the body. The recipient may or may not seroconvert the vaccine  Immunization- actual process of inducing immune response which can be humoral or cell mediated in the recipient Friday, August 04, 2017 3
  • 4. Types of Immunity Friday, August 04, 2017 4
  • 5. Innate Adaptive  Comprise of skin and mucosal barriers, phagocytes(neutro,mono cytes and macrophages)  Response is antigen independent  There is immediate response  Exposure does not result in induction of memory cells  Comprise of humoral and cellular immunity  There is a lag time between exposure and maximal response  It is antigen specific  Exposure result in induction of memory cells Inmate and Adaptive immunity Friday, August 04, 2017 5
  • 7. Humoral Cell mediated  Principal defence against extracellular microbes.  Involves b lymphocytes which produces antibodies  Antibodies act by neutralisation, complement activation, promoting opsonophagocytosis  Antibodies are of different types IgA, IgG,IgE,IgM,IgD  Principal defense against intracellular microbes  Effectors are t cells that May be helper or cytotoxic  Helper t cells secrete cytokines that stimulate the proliferation and differentiation of t cells as well as b cells and NK cells  The cytotoxic t cells acts by lysing infected cells Humoral vs cell mediated immunity Friday, August 04, 2017 7
  • 8. What is a vaccine?  An immuno biologocal substance that is introduced in the body to produce specific protection against a given disease.  Antigenic but not pathogenic.  It often made from weakened or killed forms of the microbe, its toxins or one of its surface proteins  The vaccine stimulates the body immune system to recogonize the agent as a threat, destroy it and keep a record of it so that the immune system can more easily recogonise and destroy any of these micro- organisms that it later encounters Friday, August 04, 2017 8
  • 11. priming  By priming the immune system by vaccination,, when the vaccinated individual is later exposed to the live pathogen in the environment the immune system can destroy them before they can cause disease Friday, August 04, 2017 11
  • 12. How do vaccine work?  Mainly by production of antigen specific antibodies  CMI just have supporting role in antibody production  T cell independent mech in polysaccharide vaccines  Not stimulate CMI -no long lasting immunity Friday, August 04, 2017 12
  • 13. Response after immunization Vaccines attract dendritic and monocytic cells. These migrate to LN and cause activation of T & B lymphocytes Killed Local unilateral LN activation Live Multifocal LN activation due to microbial replication and dissemination Hence immunogenecity of killed less than live{so adjuvant required} Friday, August 04, 2017 13
  • 14. polysaccharide protein T cell independent Injection site to spleen and directly bind with b receptors Response sets in 2to 4 weeks Predomnantly with IgM Immune response T cell dependent Trigger T cell which stimulate b cell causing germinal center reaction Plasma cell move to bone marrow and survive there resulting in memory cells Friday, August 04, 2017 14
  • 15. Determinants of intensity and duration of immune responses  Depends on- vaccine type, nature and vaccination schedule  Live attenuated more than inactivated  Nature- protein more than polysacharide  Vaccination schedule 0-1-6 schedule better than 6- 10-14. Friday, August 04, 2017 15
  • 16. Type of vaccines  Live atteneuted vaccine- live bacteria rendered avirulent  Inactivated vaccine-microorganisms killed by heat and chemicals  Subunit vaccine- only the antigens that best stimulate the immune system are included  Toxoid vaccine– modified exotoxins in which toxicity lost but antigenecity remains  Conjugate vaccine Friday, August 04, 2017 16
  • 17. Live attenuated  These are modified strains of pathogens that retain anigenicity but lost its pathogenicity  May be bacterial or viral  These replicate or multiply in the body after administration and stimulate the immune system  Eg viral- polio(sabin), measles,rubella, varicella, yellow fever, rota virus  Bacterial-bcg and oral typhoid Friday, August 04, 2017 17
  • 19. Killed  Organisms are killed by phenol, formaldehyde, and gamma radiation  Usually safe but less effective than live vaccines  The only absolute contra indication is severe local or general reaction to the previous dose Friday, August 04, 2017 19
  • 20. toxoid  Detoxified toxins called toxoid is inactivated by treating them with formalin a solution of formaldehyde and sterlised water  These are used when bacterial toxins are main cause of infection  Eg tetanus, diptheria Friday, August 04, 2017 20
  • 22. subunit  include only the antigens that best stimulate the immune system  use epitopes—the very specific parts of the antigen that antibodies or T cells recognize and bind to.  Because subunit vaccines contain only the essential antigens and not all the other molecules that make up the microbe, the chances of adverse reactions to the vaccine are lower.  Eg tetanus pertusis hep b Friday, August 04, 2017 22
  • 23. conjugated Strong response T cell dependent No booster required Friday, August 04, 2017 23
  • 24. types ADVANTAGES DISADVANTAGES Live attenuated •Excellent immune response •sufficient time for memory cell production Revert to original form can cause disease Not given in immunocompromised Less stable killed Safe Cheap Easy to store Booster doses required Only humoral response there Vaccine induced disease can occur Sub unit Have no live component so no risk of inducing the disease Safe and stable No guarantee of future memmory cells Low immune response conjugated Exellent immune response No booster required Friday, August 04, 201724
  • 25. Vaccine Efficacy Friday, August 04, 2017 25 It is percentage reduction in disease incidence attributable to vaccination Calculated by– VE=1-RV/RU*100 RU=attack rate in unvaccinated people RV=attack rate in vaccinated indivisuals Measles -90-95%, mumps-72-88%, rubella-95-98%
  • 26. Vaccine Effectiveness Friday, August 04, 2017 26  Reduction in the clinical events that might be expected to be associated with the disease but could also to be caused by other agents.  Assesed by case control study and odds ratio  Effectiveness=(1-OR)*100  Basically it is attack rate among vaccinated vs attack rate among non vaccinated
  • 27. Vaccine Failure Friday, August 04, 2017 27 When fully vaccinated person develop the disease against which they have been vaccinated its called vaccine failure Two types primary and secondary Primary-when recipient does not produce enough antibodies when first vaccinated Secondary- adequate number of antibodies are produced immediately after vaccination but level fall over time
  • 28. Concept of HERD immunity? Friday, August 04, 2017 28  Resistance of a group or a community against invasion and spread of infectious agents as a large number of grps being immunized  May be in immunised or non immunised individuals  Asessed by cross sectional and serological surveys
  • 29. Herd Effect Friday, August 04, 2017 29  It is reduction of infection or disease in the unimmunized segment as a result of immunizing a proportion of the population OR  It is the change induced in epidemiology(incidence reduction) among unvaccinated members when a good proportion is vaccinated.
  • 30. EPIDEMIOLOGICAL SHIFT Friday, August 04, 2017 30  Imp concept Denotes change in pattern of disease in specified population Associated with partial immunization coverage Disease of imp are hep A, rubella and varicella Severity of disease worsens with advancing age
  • 31. R O U T E S A N D T E C H N I Q U E S G E N E R A L I N S T R U C T I O N S F A Q S Practical aspects of immunisation Friday, August 04, 2017 31
  • 32. Routes  With the exception of BCG and sometimes rabies, all parentral vaccines are given by either intramuscular (IM) or subcutaneous (SC) route.  The SC route is recommended for measles, MMR, varicella, meningococcal polysaccharide, JE, Yellow fever vaccines; either SC or IM route may be used for pneumococcal polysaccharide vaccines, IPV; the rest of the vaccines should be given intramuscularly.  there is no harm done if SC vaccines are given IM. However, vaccines designated to be given IM should not be given SC due to risk of side effects (as seen with aluminium adjuvanted vaccines) or reduced efficacy (due to reduced blood supply in SC tissue and hence reduced immunogenicity). Friday, August 04, 2017 32
  • 33. continued..  The gluteal region should never be used for administration of IM injections due to risk of sciatic nerve injury and reduced efficacy (rabies and hepatitis B vaccines).  When used at the recommended sites where no large blood vessels exist, pulling back of the syringe to check for blood is not recommended.  The needle should be withdrawn a few seconds after finishing administration of the vaccine (to prevent backflow of vaccine into the needle track) following which the injection site should be pressed firmly for a few seconds with dry cotton. The injection site should not be rubbed following injection Friday, August 04, 2017 33
  • 35. General instructions  Vaccination at birth means as early as possible within 24 to 72 hours after birth or at least not later than one week after birth.  Whenever multiple vaccinations are to be given simultaneously, they should be given within 24 hours if simultaneous administration is not feasible due to some reasons.  The recommended age in weeks/months/years mean completed weeks/months/years.  Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible.  The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines.  When two or more live parenteral/intranasal vaccines are not administered on the same day, they should be given at least 28 days (4 weeks) apart; this rule does not apply to live oral vaccines. Friday, August 04, 2017 35
  • 36. If given<4 weeks apart, the vaccine given 2nd should be repeated The minimum interval between 2 doses inactivated vaccines is ussually 4 weeks Vaccines doses administered upto 4 days before the minimum interval or age can be counted as valid. If the vaccine is administered >5days before minimum period, it is counted as invalid dose. Friday, August 04, 2017 36
  • 37.  Changing needles between drawing vaccine into the syringe and injecting it into the child is not necessary.  Different vaccines should not be mixed in the same syringe unless specifically licensed and labeled for such use.  Patients should be observed for an allergic reaction for 15 to 20 minutes after receiving immunization(s).  When necessary, 2 vaccines can be given in the same limb at a single visit. The anterolateral aspect of the thigh is the preferred site for 2 simultaneous IM injections because of its greater muscle mass.  The distance separating the 2 injections is arbitrary but should be at least 1 inch so that local reactions are unlikely to overlap  A previous immunization with a dose that was less than the standard dose or one administered by a nonstandard route should not be counted, and the person should be reimmunized as appropriate for age. Friday, August 04, 2017 37
  • 39. Question 1  Am too scared about side effects of vaccines after media reports. Answer Serious side effects are extremely rare and mostly due to human error, rather than vaccine itself Friday, August 04, 201739
  • 40. QUESTION 2 My child was immunised against this disease, yet he/she got it. Why? No vaccine provides 100 percent protection. the incidence is decreased drastically, and even if the child gets the disease, it is mild. Friday, August 04, 201740
  • 41. Friday, August 04, 201741 Question 3 •My child has so many pending vaccinations. Can they be given 1 week apart, so as to finish them early? •No. •Any number of vaccines can be given on the same day. however, if not given on the same day, a minimum of 28 interval should be maintained before next vaccination.
  • 42. Friday, August 04, 201742 Question 4 I have missed giving my child a vaccine at the recommeded date. Should I start all over again No. immune system has good memory function. No need to restart schedule. Continue from where u left.
  • 44. Friday, August 04, 201744 QUESTION 6 Shud I give the optionalk vaccines? Especially the expensive ones? All optional vaccines should be given if affordable They are effective