• Vaccination Workshop

Principles of Vaccination
•
• Antigen
• - A live of inactivated substance capable of producing an immune
response
•
• Antibody

What are Vaccines?

• - Antigen substance prepared from the causative agent of a disease or
a synthetic used to provide immunity against 1 or several diseases
• — Way of priming the immune system to provide protection from
disease without subjecting person to disease

Vaccines reproduce a natural infection with less complications

- Immunization

Active immunity
- Protection produced by the person’s own system
- Administration of all or a part of the microorganism to evoke an
immunologic response
- Developed after infection with disease-causing organism or after
vaccination
- Usually long term

Passive immunity
- Protection transferred from another human or animal
- e.g. maternal antibody transfer through placenta
- Temporary protection that wanes with time

Vaccination
- Active immunity produced by vaccine
— Vaccine delivers a killed or attenuated form of the pathogen
- Immunity and immunologic memory similar to natural infection but without
risk of disease
— Immunologic memory allows for an anamnestic response after the primary
immune response, so that antibody reappears when the antigen is
introduced
- Primary antibody response and memory cells formed (IgM)
- Secondary antibody response and rapid and effective response (IgG) in
response to pathogen

Factors affecting immune response

- Presence of maternal antibodies
- Nature and amount of antigen in vaccine
- Route of administration
- Presence of an adjuvant (ingredient that promotes a stronger immune
response)
- Storage and handling of vaccine
- Vaccinee age, nutritional status, genetics, co-existing disease

Classification of Vaccines
- Live attenuated
- Viral
- Bacterial
- Inactivated
- Whole (e.g. DPT)
- Fractional (e.g. DTaP)
- Protein based
- Polysaccharide-based

Live attenuated vaccines

- Attenuated (weakened) form of the “wild” virus or bacterium
- Must replicate to be effective
- Unstable
- All vaccines NOT given intramuscularly (should be intradermal or
subcutaneous)
- Immune response very similar to natural infection —> can present with
fever, rash up to 3 days after —> standby paracetamol and antihistamine
secondary to vaccine
- Usually produce immunity with one dose (except vaccines given orally)
- Viral: measles, mumps, rubella, varicella zoster, yellow fever, rotavirus, oral
polio, intranasal influenza, Japanese encephalitis (chimeric)
- Bacterial: BCG, oral typhoid, oral cholera (only given during outbreaks)

Inactivated vaccines
- Cannot replicate
- Less interference from circulating antibodies than live vaccines —> less
effective
- Always require multiple doses
- Immune response mostly humoral
- Antibody titer diminishes with time
- May require periodic supplemental doses
- Inactivated whole cell vaccines
- Viral: polio, hep A, rabies, influenza
- Bacterial: pertussis, typhoid, cholera, plague
- Inactivated fractional vaccines (protein based)
- Subunit: hep B, influenza, acellular pertussis, HPV, anthrax
- Toxoid: diphtheria, tetanus
- Polysaccharide Vaccines
 - Unique type of inactivated subunit vaccine composed of long chains of
sugar molecules that make up the surface capsule of certain bacteria
- no booster response
- antibody with less functional activity
- pure polysaccharide vaccines are not immunogenic in children <2
years of age
- Immunogenicity improved by conjugation
- Inactivated fractional vaccines (protein based)
- Pure polysaccharide vaccines
- Pneumococcal
- Meningococcal
- Salmonella typhi (IV)
- Conjugate polysaccharide
- Pneumococcal
- Meningococcal
- Hib

Simultaneous and non-simultaneous administration

- All vaccines can be administered at the same visit following the minimum
age requirement for each vaccine
- Vaccines not given simultaneously should follow appropriate intervals
- Live vaccines must be given 6 months after IG administration because of
interference to the antigen
- There is no contraindication to simultaneous administration of any vaccine
(use different sites)
- ACIP recommends that vaccine doses given up to 4 days before the
minimum interval age as valid

Spacing and Administration for Live and Inactivated Vaccines

- 2 or more inactivated: none; may be administered simultaneously or at any
interval between doses
- Exception in children with functional or anatomic asplenia: PCV13 and
Menactra MCCV should not be administered at the same visit; separate these
vaccines by at least 4 weeks
- Inactivated and live: none; may be administered simultaneously or at any
interval between doses
- 2 or more live parenteral: 4-week minimum interval if not administered
simultaneously
- 2 or more live oral: none; may be administered simultaneously or at any
interval between doses
- Live oral vaccines (e.g. oral polio, rotavirus, typhoid) can be
administered simultaneously or at any interval before or after inactivated or
live parenteral vaccines

General Rules
- Inactivated vaccines generally are not affected by circulating antibody to
the antigen
- Live attenuated vaccinees may be affected

Antibody and Live Vaccines

- Live vaccine given first, then wait two weeks before giving antibody
- Antibody given first, then wait at least 3 months before giving vaccine

Spacing of antibody-containing products and MMR and varicella vaccines

- Washed RBCs: 0 months
- Hepatitis A Ig: 3 months
- Measles prophylaxis IG (immunocompetent patient): 6 months
- Plasma/platelet products: 7 months
- IVIG: 7 to 11 months

Interval between doses of the same vaccine

- Increasing the interval between doses of a multidose vaccine does not
diminish the effectiveness of the vaccine
- Not all variations among all schedules for all vaccines have been
studied
- Available studies of extended intervals have shown no significant
difference in the final titer
- Decreasing the interval between doses of a multidose vaccine may interfere
with antibody response and the effectiveness of the vaccine

Minimum intervals and ages

- Vaccine doses should not be administered at intervals less than the
minimum intervals or earlier than the minimum age
- When minimum intervals can be used
- Catch-up or lapsed immunization schedule
- Impending international travel

Violations of minimum intervals and minimum ages

- Minimum interval/age has been violated, then dose is invalid
- The repeat dose should be administered at least a minimum interval from
the invalid dose
- ACIP recommends that vaccine doses given up to 4 days before the
minimum interval or age be counted as valid

Vaccine Handling and Storage

- Vaccines are delicate biological substances sensitive to heat and freezing
- Vaccines lose their effectiveness when exposed to incorrect temperature

Cold chain flowchart

Vaccine manufacturing —> vaccine distribution —> vaccine arrival at
provider facility —>vaccine storage and handling at provider facility —>
vaccine administration
Vaccine sensitivity to light
- Keep in packaging as long as possible
- BCG, measles, measles-rubella, MMR

YOU CANNOT TELL FROM APPEARANCE A PROPERLY STORED AND

IMPROPERLY STORED VACCINE

WHO recommended vaccine storage conditions:

- For all vaccines are recommended to be transported and stored at 2 to 8
degrees celsius
- Always store the vaccine with their diluent between 2 to 8 degrees Celsius

Where do you store the vaccines

- Vaccines should be stored in the middle of a refrigerator
- Vaccines with early expiration dates should be kept in front
- Do not store any vaccine in a dormitory-style or bar-style combined
refrigerator/freezer under any circumstance
- Keep vaccines and diluents in original packaging with lids closed
- Stack in rows of same type of vaccine or diluent 2-3 inches apart
- Monitor vaccine refrigerator temperature 2x daily
- Use water bottles to maintain temperature
- CONTAINS VACCINE: DO NOT UNPLUG Sticker

Storage Don’t
- Do not store vaccines near wall, coils, cooling vents, top shelf, ceiling, door,
floor, and back of unit
- Do not store with food

About diluents
- Diluents are not interchangeable
- Diluents made by one manufacturer cannot be used for reconstituting the
same vaccine produced by another manufacturer
- Diluents must never be frozen or allowed to be in contact with any frozen
surface

Vaccine Preparation
- Only open a single dose vial when ready to use
- Once protective cap is removed, vaccine should be used. If not used,
discard it at end of workday
- Once a manufacturer-filled syringe is activated, vaccine should be used or
discarded at end of work day
- Do not pre-draw vaccines because it increases risk for administration errors,
wasted vaccine, and microbe growth
- General use administration syringes are not for storage
Vaccine Expiration Dates
- Monitor at least 1 time each week and each time vaccines are delivered,
check and arrange vaccines and diluents in storage unit according to
expiration dates
- Exceptions: reconstitution with a beyond use date or time (BUD)
- Multidose vial with BUD once opened
- Manufacturer-shortened expiration date

Vaccine Administration
- Explain to caregiver what the procedure is
Identify site and route of vaccine administration
Demonstrate aseptic technique

Before administration
- Obtain complete immunization history
- Use recommended schedule to determine vaccines needed based on age,
medical condition, risk factors

Positioning and comforting patient

- Encourage parent/guardian to hold the child sitting down rather than lying
down during injection
- Be aware of syncope (fainting)
- Observe patients for 15 to 20 minutes after vaccination
- Be prepared for emergency care of a person who experiences an
anaphylactic reaction
- If syncope develops, observe patients until symptoms resolve; never leave
patient alone
- Epinephrine and equipment for maintaining an airway should be available
for immediate use

Pain Management Strategies

- Pharmacological
- Topical analgesia
- Sweet tasting analgesia
- Physical
- Breastfeeding
- Positioning - parent holding the infant or young child
- Sitting upright rather than lying down
- Tactile stimulation
- Psychological
- Distraction
- Deep breathing
- Procedural
- Order of injection: administer the vaccine most painful when injected
last
- Rapid injection without aspiration
Infection control during vaccination
- Hand hygiene
- Gloves are not required when administering vaccines

Vaccine Preparation “Nevers”

- Never combine vaccines into a single syringe except when specifically
approved by the FDA and packaged for that specific purpose
- Never transfer vaccine from one syringe to another
- Never draw partial doses of vaccine from separate vials to obtain a full dose

Importance of proper vaccination administration technique

- Promote antibody response

Administration techniques
- IM 90 into anterolateral thigh if less than 12 months or deltoid if > 12
months
- Deep subcutaneous 45 angle into thigh or deltoid
- Intradermal 0 —> volar surface of forearm, deltoid, or buttock

Multiple vaccinations
- Separate injections by at least 1 inch (or more if possible)

Documentation (PHOTO)

Vaccine Safety
- Vaccinations are universally recommended

What is Safe?
- No vaccine is 100% safe
- No vaccine is 100% effective
- Remind parents that doing nothing is to take a risk, but safety also means
being preserved from a real danger
- In this sense, benefits outweigh risks

Screening
- Specific questions intended to identify contraindications or precautions to
vaccination
- Screening must occurs at every immunization
- Does the child have any cancer, leukemia, AIDS, or any other immune
problem?
- Steroid intake?
- Irradiation therapy?
- Blood product and IG transfusion

Permanent contraindications
- Severe allergy to a prior dose of a vaccine or to a vaccine component (all
vaccines)
- Rotavirus: SCID, history of intussusception
- Pertussis vaccines: encephalopathy not due to another identifiable cause
within 7 days of administering pertussis

Corticosteroids and Immunosuppression

- Dose generally believed to be a concern
- 20 mg or more per day of prednisone for 2 weeks or longer
- 2 mg/kg per day of prednisone for 2 weeks or longer

Anaphylaxis
- is a very rare allergic reaction

Tips on Vaccine Safety

- Prior to vaccination

Immunization Training / Workshop

BCG
- < 12 months: 0

Senate bill 1860 for Hepa B

Oral polio/IPV
—> schedules follow DTP
Minimum age of immunization is 6 weeks old
Minimum interval between doses is 4 weeks

If 5 in 1 in private —> no hep B

If pentavalent in public —> no IPV
if 6 in 1 —> all

If OPV given to all patients < 5 —> herd immunity

If IPV given —> individual immunity

FOR HIB —> pneumonia, OM, meningitis

Note: give vitamin A with measles

S. pneumonia, H. influenzae, Moraxella catarrhalis —> otitis media,

pneumonia, and meningitis