IT 2 - Imunisasi Anak - YLI

B L O K 2 6

PRINCIPLES OF IMMUNIZATION

LEARNING OBJECTIVES

At the end of this lecture the student should be able to describe: Active and Passive Immunizations Types of Vaccines (eg.whole-cell vaccines and subunit

vaccines). Use of Adjuvants in Immunization. Problems in Immunization

Understand the term Cold-chain monitoring and storage conditions for the different types of vaccines.

Mode of Administration Contraindications in Immunizations (side-effects).

The Extended Program of Immunization (EPI) in Indonesia. Targeted-Immunizable Diseases in Indonesia Immunization schedule

INTRODUCTION

Immunity and Immunization Immunity to contagious disease protect

individu from infection. Types of Immunity:

Innate immunity Acquired immunity or adaptive immunity

INTRODUCTION

Innate immunity Is present before any exposure to pathogens and is effective

from the time of birth Involves non specific responses to pathogen

Acquired immunity or adaptive immunity Develops only after exposure to inducing agents such as

microbes, toxins, or other foreign substances Involves a very specific response to pathogen

INTRODUCTION

Active and passive immunization Active immunity

Develops naturally in response to an infection Can also develop following immunization, also called

vaccination organism exposure, vaccine In immunization

A non pathogenic form of a microbe or part of a microbe elicits an immune response to an immunological memory for that microbe

INTRODUCTION

Passive immunity, which provide immediate, short time protection Is conferred naturally when IgG crosses the placenta from

mother to fetus or when IgA passes from mother to infant in breast milk

Can be conferred artificially by injecting antibodies into a non immune person

INTRODUCTION

Immunization remarkably successful very cost-effective

Infectious disease

EVOLUTION OF IMMUNIZATION PROGRAMME

DEFINING AIMS / GOALS

Prevention of disease in individuals or groups (immediate goal)

Reducing prevalence of disease (changed disease epidemiology)

Eradication of disease (ultimate goal)


Potential goals for reducing vaccine-preventable disease burden: eradication, elimination, or control

Eradication: reduction of the worldwide incidence of infection

by a specific agent to zero as a result of deliberate efforts;

intervention measures are no longer needed


Elimination: reduction to zero, or to the level at which it is no

longer a public health problem, of the incidence of a specified disease, or of infec-tion caused by a specific agent, in a defined geographic area;

continued intervention measures are required to prevent reintroduction.

Control: reduction of disease incidence, prevalence,

morbidity, or mortality. Continue intervention maintaining reduction


Herd immunity: indirect protection observed in the unimmunised segment

of a population in which a large proportion is immunised

DEFINITION AND GENERAL CONCEPT

Vaccination: administration of any vaccine or toxoid

(inactivated toxin) for prevention of disease.

Immunization: process of inducing immunity artificially by either

vaccination (active immunization) or administration of antibody (passive immunization).

Consist of: Active immunization Passive immunization


Active immunization: administration of all or part of a microorganism or a modified

product of that microorganism (eg, a toxoid, a purified antigen, or an antigen produced by genetic engineering) to evoke an immunologic response that mimics that of natural infection but that usually presents little or no risk to the recipient.

stimulating the immune system to produce antibodies and cellular immune responses that protect against the infectious agent.


Passive immunization: provides temporary protection through administration of

exogenously produced antibody, such as immune globulin.

also occurs naturally through transplacental transmission of antibodies to a fetus, which provides protection against many infectious diseases for the first several months of the infant's life.


Immunizing agents protection against disease:

Nearly complete lifelong protection

Partial protection

Immunizing agents include vaccines, toxoids, antitoxins, and immune globulins derived from human or animal donors (Table 1.)


Table 1. Immunizing Agents Agent Definition

Vaccine A preparation of proteins, polysaccharides, or nucleic acids of pathogens that are delivered to the immune system as single entities, as part of complex particles, or by live-attenuated agents or vectors, to induce specific responses that inactivate, destroy, or suppress the pathogen

Toxoid A modified bacterial toxin that has been made nontoxic but retains the capacity to stimulate the formation of antitoxin

Immune globulin

An antibody-containing solution derived from human blood obtained by cold ethanol fractionation of large pools of plasma and used primarily for the maintenance of immunity of immunodeficient persons or for passive immunization; available in intramuscular and intravenous preparations

Antitoxin An antibody derived from the serum of humans or animals after stimulation with specific antigens; used to provide passive immunity


Most immunizing agents contain preservatives, stabilizers, antibiotics, adjuvants, and a suspending fluid (Table 2).

Component Use and Examples Preservatives, stabilizers, antibiotics

Constituents can inhibit or prevent bacterial growth or stabilize the antigen. Materials such as mercurials or antibiotics are used. Allergic reactions to any of the additives may occur.

Adjuvants An aluminum salt is used in some vaccines to enhance the immune response (e.g., toxoids, hepatitis B).

Suspending fluid Sterile water, saline, or more complex fluids derived from the growing media or biologic system in which the agent is produced (e.g., egg antigens, cell culture ingredients, serum proteins).

IMMUNE RESPONSE TO VACCINATION

How do vaccines work? Immunological memory is the basis of vaccine protection


The immune system remembers

TYPES OF VACCINE

Vaccine Live-attenuated or killed microorganisms Inactivated or detoxified agents or their purified

components DNA vaccine

TYPES OF VACCINE

Live attenuated vaccine immunologic response ~ natural infection. humoral and cell-mediated responses long-lasting immunity, possibly lifelong

However, the strength of response, particularly the humoral response, usually is less than that in natural infection, and detectable antibodies can wane with time, resulting in some loss of protection.

Induction immunity can be inhibited by passive antibody

TYPES OF VACCINE

Inactivated or purified Ag vaccines response only to components in vaccine. The nature of response depends on Ag type.

Protein (and glycoprotein) Ag both humoral immunity and memory (T-helper lymphocytes)

Polysaccharide Ag only humoral antibody without T-lymphocyte stimulation and fail to induce anamnestic response with repeated antigenic challenge. conjugation of polysaccharides to protein carriers

TYPES OF VACCINE

Generally, multiple doses, usually three or more, are necessary to induce satisfactory antibody levels that persist for long periods; booster doses at longer intervals (10 or more years) are sometimes needed to ensure lasting protection.

TYPES OF VACCINE

Inactivated vaccine: Types:

Whole organism Purified protein or polysaccharide Ag from whole

organism Purified antigen produced from genetically altered

organism Chemically modified antigen

TYPES OF VACCINE

TYPES OF VACCINE

lBCG lOPV lMeasles

lMMR lVaricella lYellow fever

lDiphtheria lTetanus lPertusis lCholera

lMeningococ lPneumococ lHib lTyphoid Vi

lInfluenza lIPV lRabies

lHepatitis B lHepatitis A

Bacterial Vaccine Viral Vaccine

Heat-sensitive vaccines

Freeze-sensitive vaccines

Freeze- sensitive vaccines

CHILDHOOD IMMUNIZATION

BCG Vaccine - live attenuated bacterial vaccine - at birth or anytime after birth - booster dose given at school entry

Contraindications: immunodeficiency, progressive dermatoses Reaction: abscess at the site; axillary lymphadenopathy

BCG VACCINE

Usual reactions induration: 2 4 wks pustule formation: 5 7 wks scar formation: 2 3 months

Accelerated Reactions: induration: 2-3 days pustule formation: 5-7 days scar formation: 2-3 weeks

HEPATITIS B VACCINE

- inactivated viral antigen - 0, 1 & 6 months - children and adolescents who have not been vaccinated with Hep B may begin series during any visit

Contraindication: anaphylactic reaction to previous dose Reactions: pain and swelling at site, fever

HEPATITIS B VACCINE

DIPHTHERIA, TETANUS & PERTUSSIS

Usual Side Effects:

fever up to 72 hours (low to moderate grade) restlessness and irritability local reaction: pain and swelling at the site of injection

Contraindications: encephalopathy within 7 days of administration of previous

dose anaphylactic shock after a previous dose progressive neurologic disorders

POLIOMYELITIS VACCINE

1. Oral Polio Vaccine (OPV) - live attenuated (Sabin)

Absolute contraindications: 1. altered immune states, high dose steroids, radiation,

HIV/AIDS 2. pregnancy 3. household contacts of immunocompromised patients

Relative contraindications: vomiting and diarrhea Adverse Reaction: paralysis

2. Inactivated or Killed Polio Vaccine (IPV) - recommended to decrease the incidence of vaccine-associated

paralytic polio (VAPP)

MEASLES VACCINE

- live attenuated - given at 9 months but may be given as early as 6 months during epidemics

Adverse reactions:

1. fever with or without rashes (5-12 days after administration)

2. hypersensitivity reaction

Contraindication: immunocompromised state, pregnancy Relative Contraindication: untreated active tuberculosis

MEASLES, MUMPS, RUBELLA (MMR) VACCINE

- live attenuated - given at 12-15 months; a booster dose is recommended at 4-6 years old

Reactions: 1. fever with or without rashes (5-12 days after

administration - measles) 2. fever, swelling of parotid gland (mumps) 3. fever, mild rash, transient arthritis or arthralgia, post-

auricular lymphadenopathy (rubella)

MEASLES, MUMPS, RUBELLA (MMR) VACCINE

Reasons for giving 2 doses of MMR:

1. only 87-90% of children actually receive the measles vaccine

2. 5% of children who receive the first vaccine wont develop immunity

3. children who had an immune response to the first dose could get a booster effect

Contraindications: same as other live vaccines

VARICELLA VACCINE

- live attenuated - routinely given at age 12 months and up but can be given as early as 9 months

- can be given within 5 days of exposure - varicella vaccine prevents moderate to severe cases of chickenpox

Reactions: -may develop few varicella-like lesions about 1 month after vaccination

HEMOPHILUS INFLUENZAE B (HIB) VACCINE

- polysaccharide protein conjugate Reactions: low grade fever (2%)

pain and swelling (10-15%)

PNEUMOCOCCAL VACCINE

- PPV is given for children 2 yrs and above

Indications:

1. patients undergoing splenectomy 2. sickle cell disease 3. asplenia 4. HIV 5. Routinely for children 2 months and above

HEPATITIS A VACCINE

- inactivated viral antigen Indications:

1. persons traveling to areas with high prevalence of Hepatitis A

2. occupational hazards 3. hemophiliacs contacts of infected persons

Reactions: pain and local swelling

INFLUENZA VACCINE

- inactivated vaccine - should be administered before the start of flu season (February to June)

Indications:

1. prophylaxis in children older than 6 months and adults 2. over 60 years 3. suffer from disease of cardiovascular system, metabolic

disease, cystic fibrosis, chronic respiratory disease, chronic renal insufficiency

VACCINE RECOMENDATIONS

VACCINE RECOMMENDATIONS

Development of recommendations and schedule for vaccine administration:

epidemiology of the disease, age-specific morbidity and mortality, vaccine immunogenicity, risks of vaccine-related adverse reactions, cost effectiveness, ages of recommended routine health care visits.


Priority: delivering the primary childhood immunization series and protecting adult women and their newborns against

tetanus.


Each country has each own policies Immunization schedule in Indonesia recommended by

IDAI (non PPI) and government (EPI/PPI) PPI (Program Pengembangan Imunisasi):

BCG, Polio, Hepatitis B, DPT, Campak, Hib IDAI (Ikatan Dokter Anak Indonesia):

PPI (diwajibkan) Non PPI (dianjurkan)


Expanded Program of Immunization (EPI) or Pengembangan Program Imunisasi (PPI) Goverements program in immunization to

achieve international commitment: Universal child immunization (UCI): Polio eradication = ERAPO Maternal and neonatal tetanus elimination Measles reduction Improve immunization service quality Establish safe injection practices standard Safe waste disposal management

VACCINE RECOMENDATIONS

JADWAL IMUNISASI

VACCINATION PROCEDURE


Vaccine storage and transportation Prepare the equipment and supplies: for

vaccination and emergency proceduse

Prepare the administering: Anamnesis, age, AEFI history, contra indication,

previous immunization interval and specific precaution

Informed consent: benefit, AEFI risk Physical examination


Administering vaccine: Dose, interval Location, angle and depths of injection (route,

site and needle length)

AEFI monitoring Pack opened vaccines and disposing of

used equipment (used syringes and needles, vials and rubbish)

Documentation

STORAGE AND DISTRIBUTION

Vaccine = biological product

Fragile/ easily damage

Decrease vaccine effectivity


Cold chain Vaccines sensitive to heat & freezing kept at

correct temperature from the time they are manufactured until used.

The system used for keeping and distributing vaccines in good condition = cold chain.

The cold chain consists of a series of storage and transport links, all designed to keep vaccines within an acceptable range until it reaches the user.


Maintenance of the cold chain requires vaccines and diluents to be: collected from the manufacturer or an airport as soon as

they are available; transported between 2C and 8C from the airport and from

one store to another; stored at the correct temperature (see Figure 3A) in

primary/central and intermediate vaccine stores and in health facilities;

transported between 2C and 8C to outreach sites and during mobile sessions;

kept between 2C and 8C range during immunization sessions; and

kept between 2C and 8C during return to health facilities from outreach sites.


Factors decrease vaccine effectivity :

* Type of vaccine

* Exposed to Inappropriate temperature

* Storage time/expired date

* Directly exposed to sunlight


The shake test: Can help give an idea whether

adsorbed vaccines (DTP, DT, Td, TT or hepatitis B) have been subjected to freezing temperatures likely to have damaged them.

After freezing, the vaccine no longer has the appearance of an homogenous cloudy liquid, but tends to form flakes which settle at the bottom of the vial after shaking.

VACCINE VIAL MONITOR (VVM)


Heat marker / Vaccine Vial

Monitor

HEPATITIS B VACCINE

USE the vaccine


Heat marker / Vaccine Vial

Monitor

DPT-HB VACCINE


MEASLES VACCINE

CONTRAINDICATIONS TO IMMUNIZATION

Anaphylaxis or a severe hypersensitivity reaction absolute contraindication to subsequent doses of a vaccine. Persons with a known allergy to a vaccine component should not be vaccinated.

Do not give BCG or yellow fever vaccine to an infant who exhibits the signs and symptoms of AIDS. Other vaccines should be given.

If a parent strongly objects to an immunization for a sick infant, do not give it. Ask the mother to come back when the infant is well.

CONTRAINDICATIONS TO IMMUNIZATION

ADMINISTERING VACCINE

AEFI

Adverse event following immunization = KIPI Definition

Is a medical incident that takes place after an immunization, causes concern and is believed to be caused by the immunization

AEFI

Classification Vaccine reaction: event caused or precipitated by

the vaccine when given correctly; caused by inherent properties of the vaccine.

Programme error: event caused by an error in vaccine preparation, handling, or administration.

Coincidental event: event that happens after immunization but is not caused by the vaccine - a chance association.

Injection reaction: event from anxiety about, or pain from, the injection itself rather than the vaccine.

Unknown: whose cause cannot be determined.

AEFI

Estimated AEFI rates following some childhood vaccines

Vaccine Estimated rate* BCG 1 in 1 000 - 1 in 50 000 doses OPV (oral polio vaccine)

1 in 2-3 million doses (or 1 in 750 000 doses for the first dose)

Measles 1 in 1 million doses DTP 1 in 750 000

* Only the rate for severe reactions has been quoted.

AEFI

Errors which can lead to AEFIs Too much vaccine given in one dose. Improper immunization site or route. Syringes and needles improperly sterilized. Vaccine reconstituted with incorrect diluent. Wrong amount of diluent used. Drug inadvertently substituted for vaccine or

diluent (can result from inattention when reading labels on vials resulting in mistaken content).

AEFI

Vaccine prepared incorrectly for use e.g. an adsorbed vaccine not being shaken properly before use.

Vaccine or diluent contaminated. Vaccine stored incorrectly. Contraindications ignored e.g. a child who

experienced a severe reaction after a previous dose of a vaccine is immunized with the same vaccine.

Reconstituted vaccine used beyond six hours after reconstitution or not thrown out at the end of an immunization session and used at a subsequent one.

SISA VAKSIN

BCG setelah dilarutkan harus segera diberikan dalam 3

jam(simpan dalam suhu 2 8 C)

Polio Setelah dibuka harus segera diberikan dalam 7 hari(simpan

dlm suhu 2 8 C)

SISA VAKSIN

DPT Bila ada penggumpalan atau partikelyang tidak hilang

setelah dikocok jangan dipakai

Campak Setelah dilarutkan harus diberikan dlm 8 jam(simpan dlm

suhu 2 8 C)

PEMANTAUAN SETELAH VAKSINASI

Perhatikan keadaan umum Tunggu 30 menit di ruang tunggu

SAFE INJECTION

Mengapa perlu? Estimasi WHO : 30 % suntikan imunisasi tidak aman (WHO

bull. Oktober, 1999)

Imunisasi rutin(Soewarta,1999: 4 propinsi): tidak disterilkan : spuit 38%, jarum 23 %alat suntik pakai ulang :krn tidak ada jarum (18%), tidak ada spuit (4%)

Aman bagi Yang disuntik Penyuntik lingkungan

SAFE INJECTION

Suntikan dapat menularkan : hepatitis B, Hepatitis C, HIV, jamur, parasit, bakteri, menyebabkan abses

Penyebaran melalui suntikan lebih cepat daripada melalui udara, mulut atau seks

SAFE INJECTION

TIDAK AMAN BAGI YANG DISUNTIK

*Vaksin * Suhu > 8C, atau VVM telah terpapar panas * Botol vaksin bocor, retak, atau terpasang jarum * Ada partikel dalam larutan * Telah dilarutkan lebih dari 6 jam * Beku : DPT, DT, TT, HepB, Hib (tidak boleh beku) * Uji kocok tetap menggumpal (kecuali HepB atau Hib)

SAFE INJECTION

* Alat suntik Spuit disposable dipakai ulang Hanya mengganti jarum Tidak dibersihkan dulu langsung disterilkan Hanya dengan desinfektan Membakar jarum di api Merebus dalam panci terbuka Menyentuh ujung jarum

SAFE INJECTION

* Cara melarutkan / pengambilan vaksin * Cairan pelarut untuk vaksin lain atau > 8C * 1 spuit diisi beberapa dosis sekaligus * jarum ditinggalkan menancap di vial * Mencampur isi 2 vial

* Lokasi, posisi , kedalaman penyuntikan * Tidak ada alat / obat gawat -kedaruratan

SAFE INJECTION

* Menekan luka berdarah dengan jari (semua cairan tubuh dapat menularkan kuman)

* Membawa atau meletakkan alat suntik bekas sembarangan (tidak langsung membuang ke kotak limbah)

* Menyentuh atau mencabut jarum suntik

SAFE INJECTION

* Menutup kembali (recapping) jarum suntik * Mengasah jarum bekas * Memilah-milah tumpukan jarum bekas * Tidak ada alat / obat gawat darurat

Tidak aman bagi lingkungan: Meninggalkan alat suntik bekas sembarangan

TEMPAT PEMBUANGAN LIMBAH

PEMUSNAHAN KOTAK DAN ISI LIMBAH

* Dibakar dalam insinerator khusus (suhu 600 -1100C) * risiko pencemaran kecil * Rp. 10 30 juta, BBM / kayu bakar

* Dibakar dalam lubang atau drum * Digiling

* Milling atau shreeding * Serbuk masih infeksius * 375-750 alat suntik / jam * listrik 750 w

PENCATATAN

Nama dagang dan produsen No. lot / seri vaksin Tgl penyuntikan Bagian tubuh yang disuntik (deltoid kiri, paha kanan

mis)

IT 2 - Imunisasi Anak - YLI

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