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Partha’s Immunization Digest
A Parthasarathy, Alok Gupta
CHAPTER 1:
Immunization: The Way Forward
INTRODUCTION
GAVI, NTAGI, IEAG, IPEI RECOMMENDATIONS
DEVELOPMENT OF NEW VACCINES AND NEW TECHNIQUES FOR VACCINE ADMINISTRATION
LEARNING POINTS
Yesterday
Today
Tomorrow
CHAPTER 2:
Basics of Vaccinology
INTRODUCTION
Terminologies
Principles of Immunization
Sources of Passive Immunity
Monoclonal Antibody
Vaccination
CLASSIFICATION OF VACCINES
Live Attenuated Vaccines
Inactivated Vaccines
Whole-cell Vaccines
Fractional Vaccines
Polysaccharide Vaccines
Pure Polysaccharide
Conjugate Polysaccharide
Pure Polysaccharide Vaccines
Immune Response
Primary Response
Latent Period
Peak Period
Period of Decline
Secondary Response
CHARACTERISTICS OF VACCINES
Main Pediatric Vaccines
Immune Response to Protein Vaccines (Fig. 2.1)
Why so many vaccine doses?
Immune Memory and the Booster Requirements (Fig. 2.2)
Why booster doses are not required for hepatitis B vaccine?
The Response to Polysaccharide Vaccines (Fig. 2.3)
The Responses to Glycoconjugate Vaccines (Fig. 2.4)
COMPOSITION OF VACCINES
Immunizing Antigens
1. Active Immunizing Antigens
2. Suspending Fluid
3. Preservatives, Stabilizers and Antibiotics
4. Adjuvants
COMMON MISCONCEPTIONS ABOUT IMMUNIZATION
LEARNING POINTS
CHAPTER 3:
Immunization Schedules
INTRODUCTION
NATIONAL IMMUNIZATION SCHEDULE 20162
Notes
IAP IMMUNIZATION SCHEDULE TIME TABLE 2016
Footnotes
I. General instructions
II. Specific Instructions
IAP RECOMMENDED VACCINES FOR HIGH-RISK* CHILDREN
POINTS TO NOTE
IMMUNIZATION OF ADOLESCENTS (TABLE 3.4)2,3
SUMMARY
YOU ARE NEVER TOO OLD TO GET IMMUNIZED
Footnotes
TRAVEL RELATED VACCINES (TABLE 3.5)
IMMUNIZATION SCHEDULES FAQS BY PARENTS ON IMMUNIZATION5,6
FAQS IMMUNIZATION SCHEDULES
FAQs by Doctors
FAQS IMMUNIZATION OF ADOLESCENTS
FAQs by Parents
FAQs by Doctors
LEARNING POINTS
CHAPTER 4:
Vaccines, Immunoglobulins and Antisera
INTRODUCTION
Vaccines
IMMUNOGLOBULINS
ANTISERA
VACCINES
Vaccines Administered at Birth
BCG Vaccine
Oral Polio Vaccine (Sabin)
What exactly is polio eradication?
Hepatitis B Vaccine
Pre-vaccination Serologic Testing
Vaccines Administered at 6, 10 and 14 Weeks
Diphtheria, Pertussis, Tetanus, DTPw/DTPa Vaccines
Routine DTPa Schedule for Children Younger Than 7 years of Age
Routine Td Schedule for Unvaccinated Persons 7 Years of Age and Older
Diphtheria and Tetanus Toxoids Contraindications and Precautions
Diphtheria and Tetanus Toxoids Advance Reactions
DTPw/DTPa–Vaccine–Current Concepts
DTPw/DTPa/ Tdap Vaccines Current Concepts.
Haemophilus Influenzae type b Vaccine
Haemophilus Influenzae Type to Risk Factors for Invasive Disease
Haemophilus Influenzae type b Polysaccharide Vaccine
Polysaccharide Vaccines
Polysaccharide Conjugate Vaccines
Haemophilus influenzae type b Vaccine
Haemophilus Influenzae type b Vaccine
Haemophilus Influenzae type b Vaccine
Pentaxim Vaccine
Hexaxim Vaccine
Haemophilus Influenzae type b Vaccine
Hib vaccine—Current Status/How Many Doses?
Pneumococcal Vaccine
Pneumococcal Vaccines
Pneumococcal Polysaccharide Vaccine
Pneumococcal Conjugate Vaccine
Pneumococcal Polysaccharide Vaccine
Pneumococcal Conjugate Vaccine
Pneumococcal Polysaccharide Vaccine Recommendations
Pneumococcal Polysaccharide Vaccine Revaccination
Pneumococcal Polysaccharide Vaccine
Pneumococcal Vaccines
Pneumococcal Vaccines
Vaccines Recommended by IAP
Pneumococcal vaccine—For whom?
Vaccines Recommended by IAP
Pneumococcal vaccine—increasing valance?
Pneumococcal Vaccine—For High-risk Group?
Recommendations for Pneumococcal immunization with PCV13 or PPV23 Vaccine for Children at High Risk
Inactivated Polio Vaccine (IPV) (SALK)
Inactivated Polio Vaccine
Polio Vaccination Schedule in the United States
Schedules that Include Both IPV and OPV in the US
Polio Vaccine Contraindications and Precautions
Rotavirus Vaccine
Rotavirus Vaccines
Rotavirus Vaccine Effectiveness
Rotavirus Vaccine Recommendations
Rotavirus Vaccine
Rotavirus Vaccine—Conditions Not Considered to be precautions
Rotavirus Vaccine and Preterm Infants
Immunosuppressed Household Contacts of Rotavirus Vaccine Recipients
Pregnant Household Contacts of Rotavirus Vaccine Recipients
Rotavirus Vaccine and Intussusception*
Rotavirus Vaccine: Adverse Reactions
Rotavirus vaccine storage and handling
Rotavirus Vaccine
VACCINES ADMINISTERED at 9 MONTHS
Measles Vaccine/MMR Vaccine
Measles Vaccine
Measles Vaccines
Measles Vaccines
Measles–Mumps–Rubella (MMR) Vaccine
MMR vaccine–the old and new controversies
Vaccine Administered At 15 Months
Varicella (Chickenpox) Vaccine)
Varicella in the United States
Herpes Zoster
Varicella-containing Vaccines
Varicella- Vaccine Immunogenicity and Efficacy
Varicella Breakthrough Infection
Varicella Vaccine Recommendations in Children
Varicella Vaccine Recommendations: Adolescents and Adults
Varicella Vaccine Recommendations: Health care personnel
Herpes Zoster Vaccine
Herpes Zoster Vaccine Efficacy
MMR-V Vaccine (Priorix Tetra)
Qualitative and Quantitative Composition
Varicella Vaccine Post-exposure Prophylaxis
Zoster Vaccine Contraindications and Precautions
Varicella Vaccine Adverse Reactions
Zoster Following Vaccination
Varicella-containing Vaccines Contraindications and Precautions
Varicella Vaccine Use in Immunocompromised Persons
Varicella-containing Vaccine Storage and Handling
Varicella vaccine
Vaccines Administered At 18 Months (Booster)
Vaccines Administered At 12 Months
Hepatitis A Vaccines
Hepatitis A Vaccine Immunogenicity
IAP ACVIP Recommendation for Routine Hepatitis A Vaccination of Children
Vaccines Administered At 2 Years of Age
Vaccines Administered At 5 Years
Vaccines Administered At 10 Years
Tetanus Toxoid
Routine DTPa Primary Vaccination Schedule
Children Who Receive DT
Routine Tdap Schedule Children Younger than 7 years of Age
Routine Td Schedule Unvaccinated Persons 7 years of Age or Older
Diphtheria and Tetanus Toxoids Contraindications and Precautions
Diphtheria and Tetanus Toxoids Adverse Reactions
DT/TT/Td/Tdap vaccines—For whom and when?
DT/TT/Td/Tdap vaccines
HPV Vaccine
Human Papillomavirus
Human Papillomavirus (HPV)
Human Papillomavirus Types and Disease Association
HPV-associated Disease
Natural History of HPV Infection (Fig. 4.2)
HPV Clinical Features
HPV Epidemiology
Cervical Cancer Screening
Human Papillomavirus Vaccine
HPV Vaccine Efficacy*
Routine HPV Vaccination Recommendations
HPV Vaccination Schedule (Tetravalent)
HPV Vaccine Special Situations
HPV Vaccine Contraindications and Precautions
HPV Vaccine Adverse Reactions
Vaccination During Pregnancy Provisional Recommendation
HPV-vaccine Storage and Handling
Human Papilloma Virus Vaccine
Rubella Vaccine
A Brief Update on CYD-TDV (Dengvaxia®) Dengue Vaccine
SEASONAL/TRAVEL-RELATED VACCINES
1. Flu Vaccines
Influenza Vaccine – For Whom?
Dose of Inactivated Seasonal Flu Vaccine
2. Japanese B Encephalitis Vaccine
Japanese Encephalitis (JE)
Two Types of JE Vaccines are Available (see Chapter 8)
Japanese B Encephalitis Vaccine
Japanese Encephalitis Vaccine
3. Meningococcal Vaccine
Meningococcal Polysaccharide Vaccine (MPSV4)
Meningococcal Endemic Areas 2004
Meningococcal Conjugate Vaccine (MCV4)
Meningococcal Vaccine Recommendations
Meningococcal Vaccine Recommendations
Meningococcal Vaccines Adverse Reactions
Meningococcal vaccine– For whom?
4. Cholera Vaccine
CHOLERA VACCINE
1. Oral Cholera Vaccine
2. Combination Vaccine (Chol-Ecol-O)
Meningococcal vaccine (For details see Chapter 3)
3. Yellow Fever Vaccine
Recommended Immunization for Travelers to Developing Countries
Post-exposure Prophylaxis Vaccines
Rabies Vaccine (Cell Culture)
WHO Recommendations for Management of Animal Bites
Adverse Reactions
Post-exposure Prophylaxis
Pre-exposure Prophylaxis
2. Hepatitis B Vaccine
Combination Vaccines
Manufacturing Issues
Developmental Issue
Researcher's Point of View
Pediatricians Point of View
Combination Vaccines Available
Hep A – Hep B
Combination Vaccines Recently Developed DTPa–Hib, DTPa Hib–eIPV, MMR-V
MMR–Varicella Vaccine
DTPa – Hib – IPV Hep B
New Thinking and Rethinking
TO SUMMARIZE
Combination Vaccines
‘Lyophilized/liquid’ combinations. What we need to know?
Triple “I” Strategy
Integrated Infant Immunization Strategy
Immunoglobulins
1. Hepatitis B Immunoglobulin
Hepatitis B Immunoglobulin Preparations
2. Tetanus Immunoglobulin
3. Rabies Immunoglobulin
4. Gammaglobulin
5. Human Normal Immunoglobulin
6. Human Anti-D Immunoglobulin
C. Antisera
I. Anti-snake Venom
VACCINES LICENSED IN INDIA
LEARNING POINTS
CHAPTER 5:
Immunization in Special Clinical Circumstances
IMMUNIZATIONS REQUIRED OR RECOMMENDED BECAUSE OF RISK OF DISEASES
Preterm Infants Born to Mothers Not Tested During Pregnancy for HBsAg
RECOMMENDED SCHEDULE OF HEPATITIS B IMMUNOPROPHYLAXIS TO PREVENT PERINATAL TRANSMISSION (TABLE 5.1)
Breastfeeding
Household Contacts of Persons with Acute HBV Infection
RECOMMENDATIONS FOR POSTEXPOSURE IMMUNE PROPHYLAXIS OF HEPATITIS A INFECTION (TABLE 5.2)
RECOMMENDED IMMUNIZATION SCHEDULES FOR CHILDREN NOT IMMUNIZED IN THE FIRST YEAR OF LIFE (TABLE 5.3)
SIMULTANEOUS ADMINISTRATION OF MULTIPLE VACCINES
LAPSED IMMUNIZATIONS
UNKNOWN OR UNCERTAIN IMMUNIZATION STATUS
ACTIVE IMMUNIZATION OF PERSONS WHO RECENTLY RECEIVED IMMUNOGLOBULIN
PREGNANCY
CHILDREN ON STEROIDS
HODGKIN'S DISEASE
ASPLENIC CHILDREN (CONGENITAL ASPLENIA, SICKLE CELL DISEASE, SPLENECTOMY)
CHILDREN WITH HIV/AIDS
IMMUNIZATION IN BLEEDING DISORDERS
IMMUNIZATION IN CHILDREN WITH HISTORY OF ALLERGY
ORGAN TRANSPLANT INDIVIDUALS
VACCINATION OF THE INDIVIDUAL WITH CANCER/CHEMOTHERAPY
IMMUNIZATION IN RELATION TO ANTIBODY CONTAINING PRODUCTS
IMMUNIZATION FOR TRAVELERS
LEARNING POINTS
CHAPTER 6:
Adverse Events Following Immunization
VACCINE SAFETY—A UNIVERSAL CONCERN
WHO RECOMMENDATIONS TO MINIMIZE AEFI
Prevention of Acute Vaccine Reactions
CAUSES AND ERRORS LEADING TO AEFI
VACCINES AND CONTRAINDICATIONS
ANAPHYLAXIS AND DRUGS
Epinephrine in the Treatment of Anaphylaxis
Subcutaneous or Intramuscular Administration
Dosages of Commonly Used Secondary Drugs in the Treatment of Anaphylaxis
THREATS TO IMMUNIZATION—SAFETY CONCERNS
AEFI: PRACTICAL GUIDELINES
Precautions
COMMON ADVERSE EVENTS TO VACCINES
BCG Vaccine
DTPw/DTPa Vaccine
Hib Conjugate Vaccine
Hepatitis A Vaccine
Hepatitis B Vaccine
Human Papilloma Virus Vaccine
Haemophilus Influenzae Vaccine/s (Livestock inactivated)
Japanese B Encephalitis Vaccine/s (Livestock inactivated)
Measles-Mumps-Rubella Vaccine
Meningococcal Vaccine
Pneumococcal Vaccine (PCV, PPSV)
Polio Vaccines (OPV, IPV)
Rabies Vaccine
Rabies Immunoglobulins (RIG)
Rotavirus Vaccine
Typhoid Vaccine
Varicella Zoster Vaccine
LEARNING POINTS
CHAPTER 7:
The Cold Chain for Vaccines
COLD CHAIN
COLD CHAIN EQUIPMENTS
REFRIGERATORS
VACCINE VIAL MONITORS
Storage of Vaccines in Domestic Refrigerator
RECOMMENDED STORAGE OF COMMONLY USED VACCINES
POWER FAILURE
LEARNING POINTS
CHAPTER 8:
Vaccine Preventable Disease Surveillance
ACUTE FLACCID PARALYSIS SURVEILLANCE
Containment and Certification Process
Certification of Wild Poliovirus Eradication and Containment
The Plan has Four Objectives
ENDGAME STRATEGIC PLAN—MILESTONES AND CHALLENGES
OUTCOMES
Questions Which Arise to HCW
Maintaining Immunity (Table 8.3)
Recommendations: SIAs
Recommendations: SIA Quality
Detecting and Responding
Recommendations: Surveillance
Recommendations: Emergency Response
Certification Process
Recommendations: Certification Process
Recommendations—Reducing Risk of Importation
Recommendations: IPV Introduction Process
Recommendations: Mitigating Risk of Vaccine Supply Gaps
Recommendations: Operational Assessments
Building on polio
2012-2013: Year of Intensification of UIP
Recommendations
Protecting the Investment
INTEGRATED DISEASE SURVEILLANCE PROGRAM
REPORTING REQUIREMENT OF IDSP
Diseases Under Surveillance by Health Providers
Method of Surveillance
REPORTING FORMAT FOR SENTINEL SITES
PRIVATE SECTOR COLLABORATION IN TUBERCULOSIS CONTROL PROGRAM
Quality Control
Method of Recruitment
Incentives
IAP INFECTIOUS DISEASE SURVEILLANCE PROGRAM
LEARNING POINTS
CHAPTER 9:
Newer Developments in Immunization
DEVELOPMENT OF NEW VACCINES
Vaccine Development Process
Vaccine Gestation
Current Challenges Include
Classical Strategies of Killed Vaccine Development
Inactivated Whole Virus
Inactivation of Whole Bacteria
Subunits of Viruses and Bacteria
NEWER STRATEGIES OF KILLED VACCINE DEVELOPMENT
Polysaccharide-Protein Conjugates
Genetically Created Subunits
Anti-idiotype Vaccines
Classical Strategies of Live Attenuated Vaccine Development
Live Attenuated Viruses and Bacteria
Variants from Other Species
Resorted Genomes
Temperature Sensitive Mutants
Newer Strategies of Live Attenuated Vaccine Development
Recombinant Viruses or Bacteria
Recombinant Viral or Bacterial Vectors
Genetic (DNA) Vaccines
Injectable Naked DNA Vaccines
Transgenic Plant (Edible) Vaccines
Transcutaneous Vaccines
DEVELOPMENT OF NEW VACCINE ADJUVANTS
NEW STRATEGIES FOR IMPLEMENTATION AND VACCINE DELIVERY
INTEGRATED DISEASE SURVEILLANCE
GLOBAL ALLIANCE FOR VACCINES AND IMMUNIZATION (GAVI)
NEW COMBINED SEASONAL FLU AND PH1N1 Vaccines
LEARNING POINTS
CHAPTER 10:
Future Vaccines
INTRODUCTION
NEWER TECHNOLOGIES IN VACCINE DEVELOPMENT
Genomic Vaccinology
Reverse Vaccinology
DNA Vaccines
Viral Vector Vaccines
Newer Adjuvants
Edible Vaccine
Needle-Free Vaccine Delivery
Select Vaccines
Anthrax Vaccine
Cytomegalovirus Vaccine
Group B Streptococcal Vaccine
HIV Vaccine
Hepatitis C Vaccine
Herpes Simplex Virus
New Tuberculosis Vaccine
Malaria Vaccine
Meningococcal Vaccine
Staphylococci Vaccines
Respiratory Vaccines
Dengue Vaccines
Future Trends in Immunization
Select Future Vaccines
Future Predicted Vaccine Schedule 2025 (Plotkin)
Vaccine Time Line 1780–2020
IMMUNIZATION MESSAGES
ANNEXURE I:
Frequently Asked Questions on Immunization
IMMUNIZATION—GENERAL
BCG VACCINE
ORAL POLIO VACCINE
HEPATITIS—B VACCINE
DTP/DT/TT VACCINES
HIB VACCINE
MEASLES, MMR VACCINES
TYPHOID VACCINE
HEPATITIS A VACCINE
VARICELLA VACCINE
PNEUMOCOCCAL VACCINE
ANNEXURE II:
Immunization Websites
ANNEXURE III:
Immunization Techniques
IMMUNIZATION TECHNIQUES/FOR INTRAMUSCULAR, SUBCUTANEOUS AND INTRADERMAL INJECTIONS
Intramuscular Injection
Usual Sites
Method
Special Note
Subcutaneous Injection
Method
Special Note
Intradermal Injection
Method
Special Note
ADMINISTERING VACCINES: DOSE, ROUTE, SITE, AND NEEDLE SIZE (TABLE AIII.1)
Technique
Needle Length
Multiple Vaccinations
Nonstandard Administration
Giving all the Doses Under 12 Months
Giving All the Doses Under 12 Months and Older
Giving All the Doses 12 Months Through 5 Years of Age in the US.
Using COMVAXTM (HepB/Hib) and ProQuad® (MMRV)
Giving All the Doses Including Influenza Vaccine (TIV) in US
Using PediarixTM (DTaP/HepB/IPV) and ProQuad® (MMR/Var)
Using COMVAXTM (HepB/Hib) and ProQuad® (MMR/Var) in the US
GIVING ALL THE DOSES
11–12 Years of Age
COMFORTING RESTRAINT
For Immunizations
The Method
For Infants and Toddlers
For kindergarten and older children
ANNEXURE IV:
Vaccine Formulations (Brands) Available in India
COMMERCIALLY AVAILABLE VACCINES IN INDIA
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