This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
6. • Most common used are the Inactivated vaccines – split product vaccines or surface antigen vaccine.
• These are monovalent or trivalent.
• Trivalent vaccines contain 15mcg of each of WHO recommended two influenza A strains (H1N1 and
H3N2) and one influenza B strain.
• Monovalent vaccine contains 15mcg of novel H1N1 2009 strain.
• The composition is periodically changed according to the prevalent circulating strains.
• When the circulating virus and the vaccine virus strains match closely, the vaccine can prevent illnes
s in up to 90% of healthy adults and 30-70% elderly people and 45-90% healthy children.
• Trivalent vaccines are preferred over the monovalent ones.
• Recently, a quadrivalent vaccine has been launched (FluQuadri) which has been approved for use in
adults.
Influenza vaccine
Dr. Sonali Paradhi Mhatre
7. • These are available as whole, split virus and subunit form (surface antigen).
• Whole virus vaccines are now not used due to their increased adverse reactions.
• They are given IM as 2 doses in children between 6 months to 9 yrs & as a single dose i
n those above 9 yrs.
• This vaccine is effective only 6 months to 1 year.
• Adverse reactions – local reactions, fever , chills , malaise. Rarely, allergic reactions.
Inactivated influenza virus vaccine
Dr. Sonali Paradhi Mhatre
8. • Vaccine containing 2 A viruses – H1N1 and H3N2 and 2 B virus strains – Victoria and Ya
magata.
• This has been currently approved for active immunization in adults of age 18 – 64 yrs b
y the drug Controller General of India (DCGI).
• Sanofi’s quadrivalent influenza vaccine was licensed for use by US FDA in 2013 and is lic
ensed in 26 countries.
• It has a better protection as it covers all 4 strains.
• In Feb 2018, WHO has issued an official recommendation for a quadrivalent vaccine. “It
is recommended that a quadrivalent
Quadrivalent influenza virus vaccine
Dr. Sonali Paradhi Mhatre
9. • A trivalent, live attenuated influenza virus vaccine (LAIV) is available as a nasal spray.
• It contains WHO recommended strains which replicate only in the nasal passages.
• Easier to administer and can induce broad mucosal and systemic immunity.
• It is 87% effective in children.
• Contraindicated in <2 yrs children, >49yrs adults, known case of reactive airway disease
, pregnant women, concurrent administration of other live virus vaccines, anaphylactic
reactions to eggs, or components of flu vaccine.
• Store at 2 – 8° C
Live attenuated influenza virus vaccine
Dr. Sonali Paradhi Mhatre
10. Time
Of
Administration
• Data about influenza virus circulation in India suggests a peaking of circulation during rainy
season across the country – ‘June to August’ in north (Delhi), west (pune) and east (Kolkata)
and ‘October to December’ in south (Chennai).
• This data illustrates the difficulty in having a uniform vaccination timing for a vast country
like India.
• Hence, the best timing for vaccine for people residing in southern states would be just before
October , whereas for the rest of the country it should be before June.
• WHO classifies India under the ‘South Asia’ transmission zone of influenza circulation and
strongly points India’s alignment with the availability of the Southern hemisphere vaccine
(March – April) to ensure we have the latest available strain for early vaccination before the
peak influenza season.
• However, the vaccine should be given as soon as the new vaccine is released in the market or
at the time of presentation to the health care provider.
Influenza Vaccine
Dr. Sonali Paradhi Mhatre
11. Dose
&
Schedule
•When used in children 6 months – 9 years age, the vaccines (TIV) is
given as 2 doses, 4 weeks apart for those who did not eceive vaccine in
the previous season.
•Only 1 dose can be given to those who have received atlest 1 dose in the
previous season.
•LAIV can be given in children >3 yrs age with the same schedule.
•>9 yrs age, a single dose of vaccine is sufficient.
•Revaccination is recommended with a single annual dose irrespective of
age at the beginning of flu season, with the updated antigen composition.
Influenza Vaccine
Dr. Sonali Paradhi Mhatre
12. Special
cases
•The vaccine is especially recommended to be offered to the following category of high
risk individuals:
•1. Congenital or acquired immunodeficiency.
•2. Chronic cardiac, pulmonary, hematologic, renal, liver disease and diabetes mellitus.
•3. Children on long term aspirin therapy.
•4. Any neurological disease that might cause respiratory compromise or impair the
ability to handle secretions.
•5. Asthma requiring oral steroids.
•All household contacts of Immunodeficient patients should receive Influenza vaccine to
prevent disease transmission.
Influenza Vaccine
Dr. Sonali Paradhi Mhatre
14. These are derived from the HM 175 / GBM viral strains and grown of MRC5 human
diploid cells.
They are formally inactivated and adjunvanted with aluminium hydroxide.
They should be stored at 2 – 8 °C.
The vaccines are given Intramuscularly.
2 doses are given 6 – 12 months apart.
The vaccine can be given with other childhood vaccines.
Inactivated Hepatitis A Vaccine
Dr. Sonali Paradhi Mhatre
15. Protective antibodies are seen in 95 – 100% one month after the first dose and approx.
100% after the second dose.
The protective efficacy is around 90 – 100% and the onset of protection is 2 weeks to 1
month after the first dose of the vaccine.
Interchanging brands can be done but not routinely recommended.
Adverse reactions are minor & local in nature.
Another inactivated vaccine which is available is liposomal adjuvanted Hep A vaccine
derived from RG-SB strain with same efficacy and safety profile as the other
inactivated vaccines.
Inactivated Hepatitis A Vaccine
Dr. Sonali Paradhi Mhatre
16. This vaccine is derived from the H2 strain of the virus attenuated after serial passage in human dipl
oid cells.
It has been used in China for more than 2 decades and is now available in India.
Recommended dose is 1ml SC in children aged 1 – 15 yrs.
Immunogenicity is of the order of 98% seroconversion after 2 months of vaccination and protective
antibodies persists in >80% of vaccines 10 yrs later.
Evidence has shown higher antibody titres and better seroprotection rates in 2 doses at interval of 6
months and is recommended.
No serious adverse effects has been noted.
Not effective against post exposure hepatitis.
Live attenuated Hepatitis A Vaccine
Dr. Sonali Paradhi Mhatre
17. Recommendations
• Can be offered to all healthy children with special emphasis on risk group patients with chronic liver
disease, carriers of Hep B and Hep C, congenital or acquired immunodeficiencies, transplant recipients,
adolescent seronegative for HAV and scheduled to leave for hostels, travelers to countries with high
endemicity.
• Household contacts of patients with acute Hepatitis A virus infection within 10 days of onset of illness
in the index case.
• Vaccination can be given in >12 months children.
• 2 doses – 6 months apart is recommended ( Both for inactivated and live vaccines)
• For catchup , pre vaccination screening of Hepatitis A is recommended for children >10 yrs age as at
this age the estimated seropositive rates are generally >50%.
• Prior check for Anti HAV IgG may not be cost effective below 10 years age.
Hepatitis A vaccine
Dr. Sonali Paradhi Mhatre
18. Anti Rabies vaccines are in form of tissue culture vaccines and include human diploid
cell vaccine, purified chick embryo cell culture vaccine (PCEC) and vero cell vaccine.
The vaccines are available in lyophilized form with sterile water as diluents.
They should be used within 6 hours of reconstitution.
Can be stored at 2 – 8 C for 3 years.
All these vaccines have equal efficacy and induce protective antibodies in more than
99% recipients.
Rabies Vaccine
Dr. Sonali Paradhi Mhatre
19. No. of Injections
Injection on Day
Pre exposure prophylaxis Post exposure prophylaxis
1 0 0
2 7 3
3 21 or 28 7
4 14
5 28
Rabies Vaccine
The vaccine is given by Intramuscular route.
Preexposure doses are as above. Booster doses are recommended every 2years for those who continue to be at high risk
Post exposure vaccination: Unvaccinated should receive vaccine as per the above schedule with / without RIG with the
first dose. Previously vaccinated people within 5 years should receive 2 doses of vaccine on day 0 & 7 .
Dr. Sonali Paradhi Mhatre
20. Intradermal route is of utility in anti rabies clinics catering to a large number of patients
at one session ( >50 pts per day). It is not recommended in immunocompromised
patients or those on chloroquine treatment.
Adverse reactions: Mild local reactions at the injection siteis reported among 30 – 74%
patients. Others include headache, nausea, abdominal pain, muscle aches, dizziness
(5-50%). Systemic hypersensitivity has been reported with HDCV but not with PCEC /
PVRV.
Rabies Vaccine
Dr. Sonali Paradhi Mhatre
21. Category Description Recommended Treatment
1 Touching or feeding animals, licks on inta
ct skin
None, if reliable history is
available.
2 Nibbling of uncovered skin, minor scratch
es or abrasions without bleeding, licks on
broken skin.
Administer vaccine
3 Single or multiple transdermal bites or scr
atches, contamination of mucous membra
ne with saliva or exposure to bats
Vaccine + RIG immediately
Rabies Exposure categories
Dr. Sonali Paradhi Mhatre
22. • Rabies Immunoglobulin is given with the vaccine in cases with Category 3 rabies exposure -
breach of skin, multiple bites, contamination of mucous membranes with saliva or exposure to
bats.
• They are available in 2 forms:
1. Human rabies immunoglobulin (HRIG) – Dose 20U/kg body weight with max dose of 1500 IU.
2. Equine rabies immunoglobulin (ERIG) – Dose 40U/kg body weight with max dose of 3000IU.
• HRIG is preferred but if not available or affordable, ERIG can be used.
• RIG should be infiltrated in and around the wound and no suturing to be done. Remaining part of
RIG to be given IM avoiding the site of vaccine injection.
• Adverse effects – Low grade fever, tenderness at the injection site and sensitization after repeated
injections.
Rabies Immunoglobulin
Dr. Sonali Paradhi Mhatre
23. IAP
Recommendations
•Post exposure prophylaxis is recommended following a significant contact with
any warm blooded animal like dogs, cats, monkeys, cows, buffaloes, sheep,
goats, pigs, foxes, jackals, bears, mongoose and others.
•Post exposure prophylaxis not recommended after rodent bites.
•In bites by pet animals, PEP may be deferred only if the pet is >1 yr old and has
been vaccinated receiving received atleast 2 doses of potent vaccine, the first
not earlier than 3 months of age and the 2nd within 6-12 months of the first
dose.
•If the vaccine is deferred, the pet should be observed for 10 days and if the
dog shows any illness, the patient should receive full rabies PEP urgently.
•Infancy, Pregnancy, Lactation are not contraindications.
•Persons reporting several days/months/year after a bite should be managed in
a similar manner as a recent bite (with RIG if indicated) as rabies may have a
very long incubation period.
Rabies vaccine
Dr. Sonali Paradhi Mhatre
