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Immunization in Clinical Practice
Nitin K Shah, Naveen Thacker
BASICS IN IMMUNIZATION
1:
General Immunology and Principles of Vaccination
INTRODUCTION
IMMUNE SYSTEM
Types of Immunity
Nonspecific Immunity
Specific Immunity
Humoral Immune Response
Antigen Presenting Cells
Cell-Mediated Immunity
Role of Various Types of Immune Responses in Infections
Primary versus Secondary Immune Response
T Cell-Dependent Immune Response
Passive Immunity
Transplacental Passive Immunity
Acquired Passive Immunity
Active Immunity
Vaccines
Live Vaccines
Inactivated Vaccines
Immune Memory
Immunomodulation
2:
General Guidelines for Immunization
SIMULTANEOUS ADMINISTRATION OF VACCINES
RECOMMENDATIONS FOR SPACING ADMINISTRATION OF VACCINES AND ANTIBODY-CONTAINING PRODUCTS
RECOMMENDATIONS ON SPACING ADMINISTRATION OF DIFFERENT VACCINES
RECOMMENDATIONS ON SPACING OF MULTIPLE DOSES OF THE SAME VACCINE
Lapsed Immunizations
Number of Doses
RECOMMENDATIONS ON INTERCHANGEABILITY OF VACCINES OF DIFFERENT MANUFACTURERS
RECOMMENDATIONS FOR CHILDREN WITH UNKNOWN OR UNCERTAIN IMMUNIZATION STATUS
Dose of Vaccine
RECOMMENDATIONS ON SITE AND ROUTE OF IMMUNIZATION
OPV
Injectable Vaccines
CONTRAINDICATIONS AND PRECAUTIONS TO VACCINATION
Misconceptions Regarding True Contraindications to Vaccination
Children having Minor Ailments
Children under Antimicrobial Therapy
Children exposed to a Disease or Children in Convalescence Phase
Breastfed Children and Children with History of Pregnancy in the Household
Children with History of Nonanaphylactic Allergy to Vaccine Component
Screening for Contraindications and Precautions to Vaccination
3:
Immunization Schedules
INTRODUCTION
VACCINE SCHEDULING UNDERLYING PRINCIPLES
IMPROVING KNOWLEDGE, INFORMATION AND TRAINING
PRACTICAL CONSIDERATIONS
WHO IMMUNIZATION SCENARIO
NATIONAL IMMUNIZATION SCHEDULE
The IAP Immunization Schedule
INTERNATIONAL IMMUNIZATION SCHEDULES
Immunization Schedule of an Adolescent
IMMUNIZATION SCHEDULE OF AN UNIMMUNIZED CHILD
4:
Storage of Vaccines and Maintenance of Cold Chain
INTRODUCTION
COLD CHAIN
Vaccine Stock
Estimate of Vaccine Requirement
Vaccine Stock Report
Storage of Vaccines
Sensitivity to Heat
Sensitivity to Light
Recommended Storage Temperature for Vaccines
Correct Conditions for Storing Diluents
COLD CHAIN EQUIPMENT
Equipment Required for Vaccine Transport
Cold Box
How to Load a Cold Box?
Vaccine Carrier
Levels of Vaccine Storage
At National Level
Cold Room
At Regional Level
At District Level
At Health Facility Level
Installation of Household Refrigerators
Voltage Control
Maintenance of Cold Chain Equipment
Defrosting
Temperature Monitoring
Monitoring During Immunization Sessions
PERSONNEL
5:
Adverse Events Following Immunization
INTRODUCTION
VACCINATION COMPLICATIONS AND THEIR MANAGEMENT
BCG
DTP
OPV
IPV
Measles
MMR
Mumps
Rubella
Hepatitis B Vaccine
Hepatitis A Vaccine
Typhoid Vaccine
Tetanus Toxoid (TT)
Hib Vaccine
Varicella Vaccine
Rabies Vaccine
Meningococcal Vaccine
Pneumococcal Vaccine
Japanese Encephalitis Vaccine
Influenza Vaccine
VACCINES AND CONTRAINDICATIONS
Guidelines for Safe Vaccination3
PREVENTION AND TREATMENT OF VACCINE REACTION
Reporting AEFIs
When to report? Who should report?
Responding to AEFIs
Communicating with the Media
Immunization Safety and Safe Injection Practices
CONCLUSION
6:
Safe Injection Practices
MAGNITUDE OF THE PROBLEM
DEFINITIONS
MISUSE OF INJECTIONS
UNSAFE INJECTION PRACTICES
Problems Associated with Unsafe Injection Practices
Hepatitis B Virus
Hepatitis C Virus
Human Immunodeficiency Virus
STEPS FOR SAFE INJECTION PRACTICES
STRATEGIES FO R SAFE AND APPROPRIATE USE OF INJECTIONS
Changing Behavior of Health Care Workers and Patients
Managing Waste Safely and Appropriately
Recommended Routes of Injection and Needle Length
Subcutaneous Injections
Intramuscular Injections
Intradermal Injections
Multiple Vaccinations
Injection Devices
Reusable Glass Syringes and Needles
Disposable Plastic Syringes and Needles
Autodisable Syringes
Jet Injectors
Prevention of Needle-Stick Injuries to the Provider
Movement of Patients
Recapping of Needles
Sharps Collection
Best Practices for Use of Safe Injections
VACCINES WIDELY USED IN CHILDREN
7:
Immunization Against Tuberculosis
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Pathogenesis
PREVENTION OF THE DISEASE
Immunity Against Tuberculosis
BCG Vaccination
History
Type of Vaccine
Storage
Reconstitution
Dosage
Administration
Phenomena Seen After Vaccination
Complications with Intradermal BCG
Contraindications to BCG Vaccination
BCG Vaccination and the Mantoux Test
Age of BCG Vaccination
Efficacy of BCG Vaccination
Revaccination
BCG Immunization and HIV
Other Uses of BCG
Combined Vaccination
Newer Vaccines for TB
Attenuated Auxotrophic Vaccines
Attenuated Pro-apoptic Vaccines
Attenuated Environmental Strains of Mycobacteria
Nonmycobacterial Live Vectors
Recombinant BCG
Whole Cell Inactivated Vaccines
Subunit Vaccines and DNA Vaccines
8:
Immunization Against Diphtheria, Tetanus and Pertussis
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Host
Mode of Transmission
Disease Mortality
Prevention of the Disease
Natural Immunity
Vaccine
Characteristics
Efficacy
Vaccination Schedule
Booster Doses
Adverse Reactions
Contraindication and Precautions
Vaccine Storage and Handling
Special Considerations
Administration with other Vaccines
The IAP Recommendations
Postexposure Management
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Host
Mode of Transmission
Disease Morbidity, including Clinical Spectrum
Disease Mortality
PREVENTION OF DISEASE
Prevention of Neonatal Tetanus
Natural Immunity
VACCINE
Characteristics
Immunogenicity
Vaccine Efficacy
Vaccination Schedule
Booster Doses
Adverse Reactions Following Vaccination
Contraindication and Precautions
Vaccine Storage and Handling
Special Considerations
Administration with Other Vaccines
The IAP Recommendations
Postexposure Management13
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Host
Mode of Transmission
Disease Morbidity including Clinical Spectrum
Disease Mortality
PREVENTION OF DISEASE
Natural Immunity
VACCINE
Characteristics
Acellular Pertussis Vaccines
Immunogenicity
Vaccine Efficacy
Vaccination Schedule
Booster Dose
Adverse Reactions Following Vaccination
Local
Systemic
Mild
Moderate
Severe
Contraindications and Precautions to Vaccination
Contraindications
Precautions (Warnings)
Misconceptions Concerning Contraindications to DTP
Vaccine Storage and Handling
Special Considerations
Pertussis Vaccination for Persons Older than or Equal to 7 Years of Age
Children who have Recovered from Pertussis
Preterm Infants
Young Children who have Underlying Neurologic Disorders
Interchangeability of Vaccine
Administration with Other Vaccines
The IAP Recommendations
Postexposure Management
Combination Vaccines
9:
Immunization Against Poliomyelitis
INTRODUCTION
Pathogen
Host
Mode of Transmission
Morbidity including Clinical Spectrum
Disease Mortality
Vaccines Against Poliomyelitis
Inactivated Polio Vaccine
Oral Polio Vaccine
Definitions of Immunogenicity and Mucosal Immunity
Immunogenicity of IPV
Immunogenicity of OPV
Vaccine Efficacy
Combination Vaccines
Vaccine Schedule
Vaccine Storage, Handling and Inoculation
Adverse Reactions Following Vaccination
Contraindications
Special Considerations
10:
Immunization against Measles, Mumps and Rubella
INTRODUCTION
Epidemiology
Pathogen
Host
Age
Measles in Adolescents
Season
Mode of Transmission
Disease Morbidity
Natural Immunity
Vaccine
Types
Live Attenuated Vaccine
Combination Feasibilities
With Mumps and Rubella (as MMR)
Compatibility with Other Vaccines
Immunogenicity
Seroconversion
Impact of Age on Seroconversion
Vaccine Efficacy
Host Factors
Transplacentally Aquired Maternal Antibodies
Intercurrent Illnesses
Malnutrition
Some Unknown Reasons
Vaccine Factors
Vaccine Strain
Improper Handling
Secondary Failure
Vaccine Schedule
Dose and Route of Administration
Timing and Number of Doses
Second Dose
IAP Recommendations
Side Effects
Adverse Events
Thrombocytopenia
Encephalitis/Encephalopathy
Autism
Precaution and Contraindications
Allergic Reactions
Measles Vaccine and Egg Allergy
Tuberculosis
Immunization during Pregnancy
Recent Administration of Immunoglobulins/Blood Products
Immuno-compromised Child
Immunization of Child with HIV Infection
Immunization of a Child on Steroid Therapy
Children with History of Seizure and Family History of Seizure
Post-exposure Management
Special Considerations
Measles Vaccine for Measles Disease Outbreak Control
Different Schedule for Prematurely Born Children
High Titer Vaccine
Two Doses Schedule
INTRODUCTION
Epidemiology
Pathogen
Host
Mode of Transmission
Disease Morbidity and Clinical Spectrum
Disease Mortality
Prevention of the Disease
Natural Immunity
Vaccine
Characteristics
Immunogenicity
Vaccine Efficacy
Vaccination Schedule
IAP Recommendations
Second Dose
Impact of Immunization
Adverse Reactions
Aseptic Meningitis
Contraindications and Precautions to Vaccination
Febrile Illness
Allergies
Mumps Vaccine and Egg Allergy
Altered Immunity
Recent Administration of Immunoglobulins or Blood Products
Steroid Therapy
Pregnancy
Post-exposure Use
Combination Vaccine
Administration with Other Vaccines
Special Considerations
Vaccination of Adolescents
INTRODUCTION
Epidemiology
Pathogen
Host
Spread and Mode of Transmission
Infectivity
Disease Morbidity
Disease Mortality
Prevention of the Disease
Natural Immunity
Vaccine Characteristics
Live Attenuated
Immunogenicity
Vaccine Efficacy
Vaccination Dose
Schedule
Side Effects
Adverse Reactions
Contraindications and Precautions to Vaccination
Other Illnesses
Pregnancy
Vaccine Storage and Handling
Combination Feasibility
IAP Recommendations
Special Considerations
Rubella Immunization of Female Adolescents
Post-exposure Management
Special Consideration
11:
Immunization against Hepatitis B
SUMMARY
12:
Immunization against Typhoid Fever
INTRODUCTION
EPIDEMIOLOGY
Host
Mode of Transmission
Clinical Presentation
Drug Resistance
Prognosis
PREVENTION OF DISEASE
Vaccines
Parenteral Killed Whole Cell Vaccine
Vi Polysaccharide Vaccine
Efficacy of Vi Polysaccharide Vaccine against Vi Negative Salmonella
Oral Ty21a Vaccine
IAP Recommendations for Typhoid Vaccination
Newer Typhoid Vaccines
13:
Immunization against Haemophilus influenzae type b
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Host
Mode of Transmission
Disease Morbidity
Clinical Spectrum
Carrier State
Meningitis
Pneumonitis
Others
Mortality
Drug Resistance
Hib Prevention
Natural Immunity
Hib VACCINES
Characteristics
PRP
Conjugated Hib Vaccines
Types of Conjugated Hib Vaccines
PRP-T
HbOC
HbOC without Adjuvant
HbOC with Adjuvant
PRP OMP Vaccine
PRP-D Vaccine
Immunogenicity
Anti-PRP Antibody
Vaccine Immunogenicity
Comparison of Immunogenicity
Vaccine Efficacy
Effect on Carrier State
Impact of Mass Vaccination
Vaccine Schedule
Availability
Route
Schedule
Boosters
Side Effects
Local
Systemic
Contraindications
Storage and Handling
Hib Combination Vaccines
Interchangeability of Vaccines
Primary Doses
Booster Dose
Cost Effectiveness of Mass Vaccination
The IAP Recommendations
14:
Immunization against Hepatitis A
INTRODUCTION
Clinical Spectrum of HAV Infection
HAV Epidemiology
Epidemiological Shift and Its Consequences
Indian Scenario
HAV Vaccines
Immunogenicity
Need for Boosters
Immunogenicity in Special Circumstances
Age of Immunization
Schedule
Formulations
Safety
Combination Vaccines
Live HAV Vaccine
Strategies to Prevent HAV Infection
Considerations for Regions in Epidemiological Transition
Recommendations for HAV Vaccination in India
CONCLUSIONS
15:
Immunization Against Chickenpox
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Host
Mode of Transmission
Disease Morbidity including Clinical Spectrum
Disease Mortality
Prevention of Varicella
Natural Immunity
VACCINE
Characteristics
Immunogenicity
Vaccine Efficacy
Vaccination Schedule
Adverse Events Following Vaccination
Contraindications and Precautions to Vaccination
Vaccine Storage and Handling
Special Considerations
Administration with other Vaccines
Recommendations for Use
Future
Post-exposure Prophylaxis
IMMUNIZATION IN SPECIAL CIRCUMSTANCES
16:
Immunization of Children in Special Situations
INTRODUCTION
Preterm and Low Birth Weight Infants
Child not Immunized in the First Year of Life
Child with Uncertain Immunization Status
Child with Lapsed Immunization
Adolescents
Adopted Child
Children Residing in Institutions
Children Residing in Refugee Camps
Immunosuppressed Host
A. Primary Immunodeficiency States
B. Secondary Immunodeficiency States
Immunosuppression due to Steroid Therapy
Hodgkin's Disease
Transplant Recipients
HIV Infection
Asplenic Children
The Child with Coagulopathy
Children with Progressive Neurological Disorder
Post-exposure Vaccination
Foreign Travel
Immunization During Epidemics
17:
Immunization Against Rabies
INTRODUCTION
EPIDEMIOLOGY
Virus
Pathogenicity
Reservoir
Modes of Transmission
Course of Virus after Getting Entry in Human Body
Clinical Presentation of Rabies in Human
Incubation Period
Clinical Forms
Prevention of Rabies
Rabies Immunoglobulin (RIG)
Choice of RIG
Failure of RIG Treatment
ANTIRABIES VACCINES9
Neural Tissue Vaccine
Suckling Mouse Brain Vaccine
Duck Embryo Vaccine
Modern Tissue Culture Vaccine (MTCV)
Schedules of Vaccinations against Rabies
Revaccination for Fresh Exposures in Previously Vaccinated Persons
Pre-exposure Vaccination
Adverse Reactions of MTCV
Is it Possible to Include Rabies Vaccines in EPI Schedule
Observation Period of 10 Days and Improvization or Conversion of Post-exposure Schedule to Pre-exposure Schedule
Doubling or Trebling of the Initial Vaccine Dose in Essen Protocol
Cell Culture Rabies Vaccine to Pregnant and Lactating Mothers
Is DNA Vaccine a Possibility in near Future?
Recommendations of IAPCOI and APCRI Regarding Anti-rabies Vaccines21
WHO Rabies Vaccine Initiative
18:
Immunization Against Japanese Encephalitis
INTRODUCTION
EPIDEMIOLOGY
Pathogen
The Vector, Host and Transmission
Immunological Responses to JEV Infection
Disease Prevalence and Morbidity
Clinical Spectrum
Laboratory Diagnosis
Disease Mortality and Prognosis
Prevention of the Disease
Cost-effectiveness of JE Vaccination Program
Mouse Brain-der ived Inactivated Vaccine
Dosage and Schedule1
Vaccine Efficacy
Immunogenicity
Vaccine Associated Adverse Effects
Precautions and Contraindications
Age
JE Vaccine in Pregnancy
Compatibility
Drawbacks of Mouse-derived Vaccines
Cell Culture-derived Inactivated Vaccine
Cell Culture-derived Live Attenuated Vaccine
Newer JE Vaccines
Current Status of Indian JE-Vaccine
IAP Recommendations on JE Vaccination
Should Vaccination against JE be included in National Immunization Program in India?
19:
Immunization Against Streptococcus pneumoniae
INTRODUCTION
EPIDEMIOLOGY
Disease Morbidity Including Clinical Spectrum
Disease Mortality
Drug Resistance
Prevention of Disease
Natural Immunity
Vaccine
Pneumococcal Polysaccharide Vaccine (PPV)
Limitations of PPV
Conjugate Pneumococcal Vaccines (PCV)
Prevnar-heptavalent Pneumococcal CRM197 Conjugate Vaccine (PCV7)
Polysaccharide Vaccines Vs Conjugate Vaccines
Immunogenicity and Efficacy
Duration of Protection
Epidemiological Impact
Indications and Schedule
General Considerations
Side Effects
Indian Scenario
20:
Immunization Against Neisseria meningitidis
INTRODUCTION
EPIDEMIOLOGY
Pathogen
Host Factors
Disease Morbidity and Sequelae due to Neisseria meningitidis
Drug Resistance
PREVENTION OF DISEASE
Natural Immunity
Meningococcal Vaccines
Conjugate Meningococcal A, C, Y and W-135 Vaccines
Serogroup B Meningococcal Vaccines
Indications17
Revaccination
Contraindications
Vaccine Schedule
Epidemic caused by group A:
Epidemic caused by groups C, Y, W-135
21:
Immunization of Adolescents
INTRODUCTION
Why Adolescent Immunization?
Immunological Considerations
Previous Infant Immunization
Undesirable Effects of Immunization
Boosters and Extra Doses of Vaccines Already Given as Earlier Immunizations
Tuberculosis
Diphtheria
Pertussis
Tetanus
Measles
Hepatitis B
MMR Vaccine
Polio
Yellow Fever
Immunization against Additional Diseases
Hemophilus Influenzae b
Influenza
Japanese Encephalitis
Meningococcal Meningitis
Mumps
Rubella
Pneumococcal Disease
Hepatitis A Vaccine
Typhoid
Varicella
Scheduling Vaccinations
Simultaneous Administration of Vaccines
IAP Committee on Immunization; Recommendations for Immunization of Adolescents11
22:
Immunization of Adults
INTRODUCTION
The Importance of Adult Immunizations
The Toll of Vaccine Neglect
Influenza
Impact
Vaccine
Inactivated Vaccine
Live Attenuated Vaccine
Pneumococcal Disease
Impact
Vaccine
Hepatitis A and Hepatitis B
Impact
Vaccines
Varicella
Impact
Vaccine
Age 50 Vaccination Check
Meningococcal Disease
Impact
Vaccines
Unconjugated Meningococcal Vaccines
Conjugated Meningococcal Vaccines
Measles, Mumps, and Rubella Vaccines
Impact
Vaccine
CONCLUSION
FUTURE IN VACCINOLOGY
23:
Combination Vaccines
INTRODUCTION
The Public Health Need for Combination Vaccines
Compliance and Coverage
Simplifying Schedules
Introduction of New Vaccines to an Existing Program
Economic Benefits of Combination Vaccines
Savings for Cold-Chain, Storage and Transport
Savings for Health Care Providers
Savings for Society at Large
Potential Concerns Related to Combination Vaccines
Can the young infant handle so many antigens?
What if an infant gets an extra dose of a particular antigen as a result of using a combination vaccine?
Do combination vaccines suffer from interferences between its constituent components?
Do combination vaccines predispose to autism or autoimmune disorders?
Are combination vaccines easy to produce?
CONCLUSIONS
24:
New Technologies and Future Vaccines
INTRODUCTION
From the “Science” of Vaccinology to the “Art” of Immunization
New Technologies
Conjugation
Recombinant Proteins
Synthetic Peptides
Viral Vectors
DNA Vaccines
Adjuvants
Potential New Vaccines
HIV
Malaria
Tuberculosis
Rotavirus Vaccines
Dengue
Respiratory Syncytial Virus
Meningococcal Meningitis
Cancer
Combination Vaccines
Pertussis, Diphtheria, Tetanus Combinations
DTaP-based Combinations
Combination with IPV
Combination with Hib Conjugate Vaccine
Combination with HB
New Combinations
CONCLUSIONS
25:
Newer Vaccine Delivery Systems: Newer Technologies for Vaccine Delivery
26:
Immunization Resources on Internet
INDEX
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