1. Basics of
immunization and
IMMUNIZATION IN
SPECIAL SITUATIONS
Dr.Nupur Sinha
Dept. Of Pardiatrics
Lourdes Hospital
Kochi

2. Immunization
schedules

7. Some definitions
• Vaccination: Process of inoculating the vaccine
or the antigen
• Immunisation: Process of inducing immune
response, humoral or cell mediated.
• Seroconversion: Change from antibody
negative state to antibody positive state.
• Seroprotection: The state of protection (from
disease) due to presence of humoral immunity
or antibody detectable in serum

8. Types of vaccines
• Live attenuated bacterial- BCG, Ty 21 a
• Live attenuated viral – OPV, MEASLES, MMR,
VARICELLA
• Killed or inactivated bacteria – DTPw
• Killed or inactivated virus – IPV, RABIES, HAV
• Toxoid – DT, TT
• Capsular polysaccharide – Hib, PNEUMO, MENINGO
• Viral subunit - HBsAg
• Bacterial capsular polysaccharide –S.Typhi(Vi), Hib,
MENINGOCOCCAL, PNEUMOCOCCAL, ACELLULAR
PERTUSSIS

9. Cold chain
• Cold Chain is a system of storing and transporting
vaccine at the recommended temperature range from
the point of manufacture to point of use.
• Vital link in immunisation
• If not maintained, vaccine efficacy will grossly suffer
• Safe temp. zone – mandatory to maintain potency
• Safe zone for short term storage (1-2 months)is 2-8 deg
C. For long term storage –20 degC is used only for
BCG,OPV,Measles/MMR
• The T series of vaccine(DPT,DT,TT),typhoid Vi,Hep B
should not be frozen as once frozen the aluminium salts
used as adjuvant will be desiccated and will act as
irritantsterile abcess

10. • In order to provide potent and effective vaccine
to the beneficiaries a vast cold chain
infrastructure is required, which should have a
network of Vaccine Stores, Walk-in-coolers (WIC),
Walk-in-freezers (WIF), Deep Freezers (DF), Ice
lined Refrigerators (ILR), Refrigerated trucks,
Vaccine vans, Cold boxes, Vaccine carriers and
icepacks from national level to states up to the
out reach sessions.
• The cold chain system and vaccine flow in the
country:- The vaccines are transported from the
manufacturer through air transport under the
temperature range of 2-8oC to the primary
vaccine stores (GMSDs/State head quarter).

13. VACCINE VIAL MONITORS
• VVM is time and temperature sensitive coloured
label.
• Consists of temperature sensitive material.
• Changes colour gradually on being exposed to
heat.
• Corresponds to heat induced damage to vaccine
inside the vial.
• Do not give information about cold injury
• Especially used for OPV which is most thermo
labile vaccine.

15. Special situations

16. Immunization in preterm/low birth weight
infants
• All vaccines as per schedule irrespective of
birth weight or POG.
• According to chronological age
• BCG/OPV at time of discharge
• Hepatitis B after ≥ 2kg weight.
• In < 2kg babies delay for one month after birth
• PCV, rotavirus, influenza if possible

17. Hepatitis B positive mother
• ≥ 2kg baby:
Hep B vaccine + HBIG within 12 hours of birth.
Followed by 2 doses at 1, 6 months.
• < 2kg baby:
Hep B vaccine + HBIG within 12 hours of birth.
 Followed by 3 more doses at 1, 2, 6 months.
• If HBIG not available/affordable –Hep B
vaccine at 0, 1, and 2 mnths, additional dose
bet 9-12 months.

18. Immunocompromised individual
• Severe immunodeficiency- all live vaccines
contraindicated
• Inactivated vaccines –higher dose, greater
number of dose of Hep B.
• Check antibody titres.(>10IU)
• Regular boosters if needed
• Contaminated wounds- TIG with TT even if 3
doses of TT received in past.
• Pneumococcal, varicella, hepatitis A, influenza
vaccine recommended

19. Household contacts of Immunocompromised
• Should not receive transmissible vaccines-
OPV
• Non transmissible vaccines –varicella, MMR
are safe
• Should be fully immunized- varicella, influenza

20. IMMUNODEFICIENCIES
• Severe B cell immunodeficiency
Live vaccines contraindicated
Inactivated vaccines are ineffective
• Less severe B cell immunodeficiency
Only OPV contraindicated
• Severe T cell immunodeficiency
Live vaccines contraindicated
All vaccines ineffective

21. Children receiving
corticosteroids/chemotherapy/radiotherapy
• Live vaccine contraindicated if
1. High dose oral/iv corticosteroids(20mg/day in
children weighing >10kg or >2mg/kg/day)
2. Duration> 2weeks
• Can be administered if
1. Low dose steroids
2. Alternate day therapy
3. Inhaled or topical steroids
4. ≥ 4weeks after stopping steroids.

22. • Other immunosuppressive therapy: avoid live
vaccines.
• Chemo /radiotherapy: avoid live vaccines during
therapy and upto 3 months after stopping therapy.
• Asplenia /hyposplenia: vaccination with
pneumococcal Hib, meningococal + all routine live
and inactivated vaccines.
• Planned splenectomy: vaccination initiated 2 weeks
prior to splenectomy.

23. • Complement deficiency
All vaccines safe
Pneumo, Hib, meningococcal vacc indicated
• Chronic granulomatous disease
Live vaccines contraindicated
Other vaccines safe and effective
YES if CD4 count>200(≥15%)

24. HIV INFECTION
VACCINE ASYMPTOMATIC SYMPTOMATIC
BCG YES NO
DTwP/DTaP/TT/Tdap YES YES
IPV/OPV IPV, OPV if IPV not
affordable
IPV, OPV if IPV not
affordable
Measles vaccine YES YES if CD4
count>200(≥15%)
MMR YES YES if CD4
count>200(≥15%)
Hepatitis B YES YES, 4 doses ,double dose,
check seroconversion,
boosters
Hib YES YES

25. VACCINE ASYMPTOMATIC SYMPTOMATIC
PCV & PPV23 YES YES
Inactivated influenza
vaccine
YES YES
Rotavirus Insufficient data Insufficient data
Hepatitis A vaccine YES YES, check seroconversion,
boosters
Varicella vaccine YES YES if CD4
count>200(≥15%)
Vi typhoid vacc YES YES if CD4
count>200(≥15%)
HPV YES YES

26. TRANSPLANT RECIPIENTS
• Hematopoietic stem cell transplant recipient
Loose all memory cells
Are like unimmunized
Killed vaccines started 12 months post transplant
Live vaccines 24 months post transplant if recipient is
immunocompetent
Influenza vaccine given pretransplant, restarted 6
months post transplant

27. • Contacts of HSCT- varicella and influenza.
Completed 6 weeks before transplant date.
• Solid organ transplant recipient
Live vaccines completed 2 weeks prior to transplant
Post transplant- live vaccines CI
Check seroconversion
Recommence inactivated vaccines- 6 months post
transplant (immunosuppression lowered)
Boosters for Hep A and B
Annual influenza vaccine
Contacts- varicella and influenza

28. IVIG/PLASMA/PRBC/WHOLE BLOOD
RECIPIENTS
• Inactivated vaccines- safe
• After receiving antibody containing products-
Live vaccines avoided for 3 months.
• Antibody products avoided for 2 weeks after
live vaccine
• If immunization outside prescribed period
occurs- check seroconversion, revaccination
• OPV not contraindicated

29. UNIMMUNIZED CHILD
VISIT SUGGESTED VACCINES
First Measles/MMR if >12mths
DTwP1/DTaP1/Tdap if ≥7years
OPV1/IPV1 (if < 5years)
Hib1 (if < 5 years)
Hep B1
Second- after 1 month of 1st visit BCG(if < 5years)
DTwP2/DTaP2/Td if ≥7years
OPV2
Hib 2
Hep B2
Third –after 2 month of 1st visit OPV3/IPV2
MMR if >12 months
Typhoid if > 2years
Fourth –after 6 month of 1st visit DTwP3/DTaP3/Td if ≥7years
OPV4/IPV3
Hep B3

30. IAP recommendations for adolescent travellers
vaccine Place of travel dose
Meningococcal vaccine USA/UK/endemic areas
Saudi Arabia and Africa.
2 doses 4-8 weeks apart
Yellow fever Yellow fever endemic
zones
10 days before travel
Oral cholera vaccine Endemic area or an
outbreak
2 doses 1 week apart
Japanese B encephalitis Endemic areas Single dose(upto 15
years)
Rabies vaccine(pre
exposure prophylaxis)
For adolescents going
on trekking
0,7,28

31. Children with chronic illness
• Live vaccines are safe
• Other recommended vaccines:
Pneumococcal
Hep A
Varicella
Influenza
Rotavirus
• Immunogenicity, efficacy, duration of protection-
low
• More doses- Hep B, Boosters

32. IMMUNIZATION DURING ILLNESS
• Postponed only during serious illness
• Vaccination encouraged during minor illness :
mild diarrhea, URTI
INTERCHANGEABILITY OF BRANDS
• Brands of Hib, Hep B and Hep A safely
interchanged
• Same brand preferred for DTaP
• If previous brand not known/not available- any
brand used
• Vaccination should not be delayed/cancelled due
non availability of brand.