Immunization is a process of deliberate inoculation of live attenuated or dead vaccines and toxoids to induce immunity against a specific disease.

Immunization against a specific disease provides artificially acquired active immunity.

Artificially acquired immunity against some diseases may require periodic booster injections to keep an adequate antibody level (or antibody titer) circulating in the blood.

A booster injection is the administration of an additional dose of the vaccine to boost the production of antibodies to a level that will maintain the desired immunity. The booster is given months or years after the initial vaccine and may be needed because the life of some antibodies is short.

Types of immunization agents

1. Toxoids: is a toxin that is attenuated (or weakened) but still capable of stimulating the formation of antitoxins.

2. Vaccines

3. Immune globulins.

Vaccines

Vaccine: Vaccines are special preparations of antigenic materials that can be used to stimulate the development of antibodies and thus confer active immunity against a specific disease or a number of diseases capable of causing fatal consequences.

Types of vaccines

1. Live attenuated vaccines: These vaccines contain live microbes that have been weakened (attenuated). Live attenuated vaccines usually confer immunity with a single dose which is of long duration. They may be dangerous in recipients who are immune-compromised because these patients are unable to mount an effective immune response.

Examples;

• Mumps vaccines

• Measles vaccines

• BCG vaccines

1. Killed or inactivated vaccines: This type of vaccines contains whole inactivated microbes. e.g. polio vaccines. Inactivated vaccines may require a series of injections in order to produce an adequate body response and in most cases booster doses are required.

Examples

• DPT (diphtheria, pertussis, tetanus) Vaccine.

• PCV (Pneumococcal Conjugate Vaccine)

Indications of vaccines and toxoids:

1. Routine immunization of infants and children

2. Immunization of adults against tetanus

3. Immunization of adults at high risk for certain diseases (e.g., pneumococcal and influenza vaccines)

4. Immunization of children or adults at risk for exposure to a particular disease (e.g., hepatitis A for those going to endemic areas)

5. Immunization of pre-pubertal girls or non-pregnant women of childbearing age against rubella and cervical cancer.

Adverse reactions of Vaccines and Toxoids

Adverse reactions from the administration of vaccines or toxoids are usually mild.

Chills, Fever, muscular aches and pains, rash, and lethargy may be present.

Pain and tenderness at the injection site may also occur.

Although rare, a hypersensitivity reaction may occur.

Contraindications and Precautions of Vaccines and Toxoids

Hypersensitivity

Vaccines and toxoids are contraindicated during acute febrile illnesses, leukemia, lymphoma, immunosuppressive illness or drug therapy, and non-localized cancer.

The measles, mumps, rubella, and varicella vaccines are contraindicated in patients who have had an allergic reaction to gelatin, neomycin, or a previous dose of one of the vaccines.

The measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy, especially during the first trimester, because of the danger of birth defects. Women are instructed to avoid becoming pregnant at least 3 months after receiving these vaccines.

POLIO VACCINE

This is a live attenuated vaccine that gives protection against the three types of poliomyelitis that is: type 1, 2 and 3.

It is a liquid that comes in two types of vials which have their fixed droppers.

STORAGE

It is stored at the temperature of +2 to +8 degrees centigrade.

INDICATION

Active immunization against poliomyelitis.

DOSE

It is given two drops orally.

If the child has diarrhea, give as usual but administer an extra dose. When administering polio vaccines, the dropper should not touch the child’s lips.

KEY ISSUES:

Live polio vaccines lose potency once opened; therefore, any used preparation should be discarded after use. Breast feeding does not interfere with immunization even though polio vaccine may be excreted in the breast milk. If vaccines are vomited repeat the dose immediately.

INACTIVATED POLIO VACCINES (IPV)

This was introduced by the World Health Organization (WHO) to supplement the Oral Polio Vaccine (OPV) due to resistance of the poliomyelitis virus of type 2.

STORAGE

IPV is sensitive to heat and freezing, it should be stored at +2 to +8 degrees centigrade at all levels of the cold chain.

Note: Freezing and heating of IPV vaccine will lead to the loss of its potency.

DOSAGE

It’s given once at the fourteenth week (14 weeks). It is given together with OPV 3, PCV 3, DPT Hep Hib 3. 0.5mls is administered intramuscularly in the outer aspect of right thigh 2.5cm away from PCV site.

IPV is first administered before PCV – because PCV is more painful than IPV.

CONTRAINDICATION

Should not be given to children who had a previous reaction to streptomycin, polymyxin B, which are components of polio vaccines.

ADVERSE EFFECTS of IPV

• Redness at the injection site

• Swelling

• Fever

• Pain / irritability

BACILLUS CALMATTE GUARIN (BCG) VACCINE

BCG vaccine is a vaccine primarily used against tuberculosis. Or it’s used to prevent and protect against tuberculosis. It comes in powder form, and it is reconstituted with its diluents of the same company or manufacturer before used.

It should be given soon after birth or during the first contact.

INDICATION

Active immunization against Tuberculosis

CONTRAINDICATION

• • Immune suppressed patients

  • Previous TB infection

  • Generalized edema

  • Generalized skin diseases

STORAGE

It should be stored under a temperature of +2 to +8 degrees centigrade. The reconstituted BCG vaccine should be discarded after 6 hours or at the end of the immunization/session.

DOSAGE

0.05ml is given to infants under 12 months or at birth. 0.1ml to children above 12 months.

ROUTE

It is given intradermal in the right upper arm.

SIDE EFFECTS

• Pain at the injection site

• Keloid formation

• Localized necrotic ulceration

• Lymphadenitis

DRUG INTERACTION

Concomitant administration with immunosuppressant drugs.

PNEUMOCOCAL CONJUGATE VACCINE (PCV)

It is a vaccine which protects children against (pneumonia) pneumococcal infections, bacteremia and meningitis.

STORAGE

It is stored at the temperature of +2 to +8 degrees centigrade.

INDICATION

• • Sickle cell disease in children above 2 years

  • Immune-compromised patients above 5 years

CONTRAINDICATIONS

It should not be given to infants who had severe allergic reactions previously to the vaccine.

DOSE

The first dose at 6 weeks.

It’s given 0.5ml deep subcutaneous in the upper outer aspect of the thigh.

The second dose at 10 weeks.

The third dose at 14 weeks.

ADVERSE EFFECTS

• • Pain

  • Redness and swelling

  • Fever (38 degrees centigrade)

  • Drowsiness

  • Irritability and crying

  • Loss of appetite

  • Hardness at the site of injection

DPT-HEPB-HIB VACCINE

This vaccine protects the children against the five diseases, that’s why it’s called a prevalent vaccine. And the five diseases include:

• • Diphtheria

  • Pertussis (whooping cough)

  • Tetanus

  • Hepatitis B

  • Haemophilus influenza of type B infection

SIDE EFFECTS

• • Fever

  • Headache

  • Irritability

  • Swelling of the limb

  • Loss of appetite

STORAGE

It should be stored at the temperature of +2 to +8 degrees centigrade. The vaccine should not be frozen because it can be damaged by freezing and separate from the freezing compartment. Mark the date of opening, and it should not exceed 4 weeks from the date of opening to avoid contamination.

DOSE

0.5ml intramuscularly on the mid-upper aspect of the left thigh.

It’s given in the first contact at 6 weeks.

Second dose at the 10th week.

Third dose at the 14th week.

Note: NEVER give DPT-HEPB-HIB vaccine in the buttocks because it can damage the nerves in the injection site.

CONTRAINDICATIONS

Every sick child who is admitted should receive their vaccination at the time of discharge.

Children with a history of convulsions within 2 days or 48 hours following the vaccination of a previous same vaccine.

Children one year of age.

ADVERSE EFFECTS

• • Fever

  • Soreness at the site of injection

  • Abscess may be formed a week or more after vaccination because of an abnormal reaction which is takes place due to:

    • The use of unsterile needles.

    • The injection may not have been into the muscle.

    • Improper insertion of the needle during the vaccine administration.

    • Failure to hold the baby well.

    • Not cleaning and wiping of the site well.

The side effects are managed like:

• • Fever by tepid sponging the child and giving Paracetamol.

  • Abscess by giving antibiotics.

  • The mother or caregiver is also health educated on how to be responsible following the health talk before discharge.

TETANUS TOXOID VACCINE

The vaccine is an inactivated tetanus toxoid toxin that protects against Tetanus. It is an injection which comes in a vial containing 10 or 20 doses.

STORAGE

It should be stored at the temperature of +2 to +8 degrees centigrade.

It should not be frozen, and it should be kept away from the freezing chamber (fridge).

If it freezes, a shake test is performed.

INDICATION

Active immunization against tetanus and neonatal tetanus.

DOSE

It is given to all women of childbearing age between 15 to 45 years.

First dose:

It is given 0.5mls deep subcutaneous or intramuscular injection on the upper arm at the first contact or as early as possible during pregnancy (TT 1).

Second dose:

0.5mls at least 4 weeks after (TT 1) or during subsequent pregnancy.

Third dose:

0.5mls at least 6 months after (TT 2) or during subsequent pregnancy.

Fourth dose:

0.5mls at least 1 year after TT 3.

Fifth dose:

0.5mls at least 1 year after TT 4.

ADVERSE EFFECTS

• • Mild pain

  • Redness

  • Warmth or swelling for 1 to 3 days

All children should be immunized against because the antibodies transferred from the mother before birth lasts for a short time about 6 weeks.

To have a long life protection against tetanus is to complete the five doses of tetanus toxoid vaccines required and ensure safe delivery practice.

MEASLES VACCINES

It is a live attenuated vaccine that protects children against measles.

It must be reconstituted with its diluent from the same manufacturer.

INDICATION

Active immunization against measles.

STORAGE

It should be stored between the temperatures of +2 to +8 degrees centigrade.

It can be stored at freezing temperature, and its diluent kept at room temperature.

CONTRAINDICATION

• • Hypersensitivity to any antibiotic present in the vaccine, like neomycin and kanamycin.

  • Hypersensitivity to eggs.

  • Pregnant mothers.

  • Immune-suppressed patients.

SIDE EFFECTS

• • Fever

  • Restlessness

ADVERSE EFFECTS

• • Pain within 24 hours of immunization.

  • Tenderness at the injection site within 24 hours of immunization which will resolve after 2-3 days without any medication or treatment.

  • Fever which may occur after 1-3 days of immunization.

All children in the age between 6-9 months who are admitted to the hospital should be given a dose of measles vaccine during an outbreak of measles.

Cold Chain

Cold chain is a system that ensures safe storage and maintenance of vaccines from the manufacturer to the consumer.

Vaccines are different from other medical supplies because they are easily damaged by heat or sunlight; therefore, they need special care to keep them safe until they are used.

What does a cold chain consist of? It consists of the following:

• People

• Equipment/tools

• Procedures

The people

These organize and manage vaccines, they transport vaccines from:

• The manufacturer to Entebbe airport

• To National Medical Stores

• To the Hospitals, Health Centres, Dispensaries, sub-dispensaries and maternity units

• Mobile clinics and outreach sessions.

Equipment

• Needed to store and transport vaccines.

• It keeps the vaccines properly cold at every place it is stored.

The procedures

• These set rules for the people and equipment on how to take care of vaccines.

• Part of the procedures are records of how much vaccine has been received and used.

• These records help people who supply in monitoring these vaccines.

• It also helps them find out problems in handling and wastage of vaccine.

Care of vaccines

a) When being delivered in Respective Places

• Vaccines are carried in Refrigerators from the manufacturer to Entebbe.

• From there vaccines are passed down through the cold chain by vehicles to District Medical Stores for supply to the Hospitals, Health Centres, and other lower units.

Note:

• Make sure that the proper vaccines in the proper quantities are in place where they are needed at the right time.

• Keep vaccines out of sunlight and heat.

• Keep vaccines at a temperature + 2 – + 8 oC.

• Care properly for equipment by keeping it clean and in good working order.

b) At Health Facility

• Vaccines are kept in a refrigerator and the temperature monitored morning to evening and charted.

• Vaccines should be arranged in proper order in the fridge, i.e.

  • First in first out

  • Polio, BCG, Measles should be near the deep freezer.

  • DPT, Hep B, Hib, PCV, Tetanus toxoid should be a distance away from the deep freezer.

• Vaccines that are to be used that day should be removed at once to avoid over opening of the fridge.

• A vaccine control book should be used to register vaccines in and out of the Refrigerator.

c) At the Immunization site

• Vaccine carriers are used to store vaccines for use at the site or outreach.

• Frozen ice packs are put in vaccine carriers to keep the vaccines at the right temperature.

• A sponge is put on top of the vaccine carrier to prevent the ice packs from getting hot and keep the right temperature.

• During the immunization session, the vaccine vial monitor should be looked at/monitored to assess whether vaccines are still potent.

• After the immunization session DPT and polio vaccine if the Vaccine vial monitor (VVM) is still white, they are put back in the fridge BUT they should be used first on the next session.

• Measles, BCG and PVC should not be put back in the fridge for the next use/session.

NB. While withdrawing the vaccine from the vial, we should ensure that the vial is handled with care to prevent wastage of vaccine.

Defrosting the fridge/cleaning

• The fridge is supposed to be cleaned, and more so if it is frozen.

• Remove all the vaccines and pack them in polythene bags with ice packs.

• Switch off the fridge and let the ice get defrosted, then clean the fridge.

• Switch it on and place the thermometer in the fridge, so that the right temperature is reached.

• When the right temperature is reached (+ 2 – + 8 o C), the vaccines are put back and in proper order and according to expiry date (first in, first out).

IMMUNOGLOBULINS

Immunoglobulins are proteins produced by the plasma cells and lymphocytes and have characteristics of these types of cells OR

Immunoglobulins are solutions obtained from human or animal blood containing antibodies that have been formed by the body to specific antigens.

The five types of antibodies are:

(1) Immunoglobulin A (IgA) which is found in high concentration in the mucus membrane, particularly those lining the respiratory passages and gastrointestinal tract, as well as saliva and tears.

(2) Immunoglobulin G (IgG) is the most abundant type antibody found in all body fluids and protects against bacterial and viral infections.

(3) Immunoglobulin M (IgM) is found mainly in the blood and in the lymph fluids and is the first antibody to be made by the body to fight against new infections.

(4) Immunoglobulin E (IgE) is mainly associated with allergic reactions (when the immune system overreacts to environmental antigens such as pollen or pet dander) and is found in the lungs, skin, and mucous membranes.

(5) Immunoglobulin D (IgD) exists in small amounts in the blood and is the least understood antibody.

Note: IgA, IgG and IgM are often measured together, that way they can give the doctor important information about the immune system functioning, especially relating to infection or autoimmune diseases.

Adverse effects

• • Fainting or feeling lightheaded

  • Pain at the site of injection