Immunization in adults, geriatrics and paediatrics

1. Immunization in Adults,
Geriatrics and
Paediatrics
Dr. Milan. C. Patel.
DNB (Family Medicine).
Inlaks and Budhrani Hospital, Pune.

2. What is immunization?
 Immunization is the administration of antigenic
material to stimulate an individual’s immune system to
develop adaptive immunity to a pathogen.
 Active immunity develops as a result of infection or by
specific immunization and is usually associated with
presence of antibodies.
 Passive immunity develops when antibodies produced
in a human or animal body are transferred to another
to induce protection against disease.

3. History of Vaccination
 429 BC : Greek historian Thycudides noticed that people
who survive smallpox do not get reinfected.
 900 AD : Chinese discovered variolation
 1700s : Variolation spreads around the world
 1796 : Edward Jenner discovered vaccination in its
modern form and proved to the scientific community that
it worked.

4. Edward Jenner
Jenner vaccinated baby with the lymph from a cowpox infected dairymaid. He also used lymph from sores on cow teats –
found it equally effective

5. EDWARD JENNER
Discovered the small pox vaccine in its
modern form and proved to the scientific
committee that it worked.

6. History of Vaccination
 1890: Emil von Behring discovers the basis of DT vaccine
 1920s: Vaccines become widely available.
 1955: Polio vaccination begins.
 1956: WHO fights to eradicate smallpox.
 1980: Smallpox eradicated from the world.
 2008: Professsor Harald zur Hausen awarded Nobel Prize
for discovery of HPV Vaccine.
 2013: Rotavirus vaccine and shingles vaccine introduced.

7. Louis Pasteur
Discovered the rabies vaccine

8. Vaccine Preventable Diseases
 Tuberculosis
 Diptheria
 Pertussis
 Tetanus
 Poliomyelitis
 Measles
 Mumps
 Rubella
 Typhoid
 Haemophilus influenza B
 Hepatitis A
 Hepatitis B
 Influenza (H1N1)
 Varicella
 Zoster
 Pneumococcal disease
 Meningococcal disease
 Rotavirus and HPV infection

9. Recommended Adult Immunization
Schedule by vaccine and age group
 Influenza vaccine
 One dose annually for all adults, 0.5 ml im or id.
 Healthy and non-pregnant adults can receive live vaccine.
 Others should receive the inactivated vaccine.
 For adults aged 65 years and older there is also a high dose
influenza vaccine.
 Special consideration for people with chronic diseases,
immunosuppression with high risk of influenza, pregnancy
and people > 65 yrs of age.

10. Is an intranasally administered vaccine
0.1 ml in each nostril

11. Trivalent Inactivated Influenza Vaccine

12. Tdap/Td Vaccine
 All adults not (I) earlier
 Contacts of infants
 Health care personnel
 Post exposure
 Minor wound:1TT booster
if last > 10 yrs ago
 Major wound:1TT booster
if last dose>5 yrs ago
 Primary : 3 doses, 0,1, 6-
12 months, 0.5 ml im
 Contacts: single dose 2
wks before contact
 Booster : every 10 yrs
 Tdap for 19-64 yrs age
group and Td for > 65 yrs
of age.

13. Varicella Vaccine
 2 doses of varicella 4 weeks
apart, 0.5 ml sc
 Special consideration for
 Teachers and child care
employees
 Health care staff
 Adults and adolescents in
contact with children
 Contacts of persons with ICS
 Non pregnant women of child
bearing age
 International travellers
 C/I in pregnancy, ICS, HIV
infection with CD4 count < 200.
 Post exposure administration:
within 3 days of exposure to
varicella rash , can be given
upto 5 days of exposure to rash

14. Human Papilloma Virus Vaccine
 Quadrivalent ( Gardasil) or Bivalent ( Cervarix) vaccine
 For females , at age 11-12 yrs and catch up vaccination
between 13-26 years.
 For males, routine vaccination at age 11-12 yrs and for
those between 13-21 yrs. MSM may benefit by prevention
of condyloma and anal cancer.
 3 doses to be given. Second dose 1-2 mths after the first
dose, third dose 6 months after the first dose.

15. Quadrivalent HPV Vaccine
Contains types 6,11,16,18.

16. Bivalent HPV Vaccine
Contains types 16 and 18

17. Herpes Zoster vaccine
 Single dose 0.65 ml sc for adults more than 60 years of
age.
 For persons with chronic medical conditions.
 Contraindicated in pregnancy, immunocomprimising
conditions and HIV.

18. Zoster Vaccine
Live virus vaccine recently launched for adults > 60 years

19. MMR Vaccine
 Measles and Mumps component: two doses of MMR vaccine
are recommended, the second dose administered a
minimum of 28 days after the first dose for adults
 Who have been recently exposed to measles or mumps or are in an
outbreak setting
 Are students in postsecondary educational institutions
 Work in a health care facility
 Those who plan to travel internationally

20. MMR Vaccine
 Rubella component: for women of childbearing age,
regardless of birth year, rubella immunity should be
determined. If there is no evidence of immunity, women
who are not pregnant should be vaccinated. Pregnant
women who do not have evidence of immunity should
receive MMR vaccine upon termination of pregnancy and
before discharge from the health care facility.

21. Pneumococcal polysaccharide Vaccine
All adults more
than 65
Chronic medical
conditions
• Asthma, CAD
• CLD,CRF,DM
• Asplenia
• Elective
splenectomy
Other conditions
• Residents of
nursing homes
• Chronic smokers

22. Revaccination with PPSV
 0.5 ml im/sc; 1-2 doses may be required.
 One dose of PPSV is recommended after 5 years for
persons aged 19 through 64 years with chronic renal
failure, nephrotic syndrome, asplenia and immune
compromising conditions,
 For persons aged 65 years or older, one time revaccination
is recommended if they were vaccinated 5 or more years
previously and were aged less than 65 years at the time of
primary vaccination.

23. PNEUMOCOCCAL
VACCINE
Pneumovac 23
contains 23 serotypes
7 valent and 13 valent
Prevnar is also
available

24. Meningococcal Vaccine
2 doses at 0 and 2
months
Persons with
anatomic and
functional
asplenia
Persistent
complement
deficiencies
People with HIV 0.5 ml sc

25. Meningococcal Vaccine
Single dose for microbiologists,
military recruits, students living in
dormitories and travellers to
endemic regions
Conjugate vaccine (MCV 4 ) for
adults less than 55 years
Revaccination recommended every
5 years
Polysaccharide vaccine for adults
more than 55 years
Vaccination must
for travellers to
Hajj

26. Hepatitis A Vaccine
MSM and injection
drug users
Persons working
in laboratories
Persons with CLD
Travellers to
endemic regions
Unvaccinated
persons who
anticipate close
personal contact

27. Hepatitis A Vaccine
 It should be administered in a 2 dose schedule at either 0
and 6-12 months or or 0 and 6-18 months.
 If the combined hepatitis A and B vaccine ( Twinrix) is
used, administer 3 doses at 0, 1 and 6 months.
Alternatively, a 4 dose schedule may be used,
administered on days 0,7, 21-30, followed by a booster
dose at 12 months

28. Hepatitis B vaccine
3 doses at 0,1 and 6 months
Sexually active persons not in a
long term monogamous
relationship
Persons with
ESRD,CLD, HIV
Contacts of
chronic HBV
infection
MSM, IDU,
persons with
STD
International
travellers

29. Administering Vaccine to Adults:
Dose and route
Vaccine Dose Route
Hep A <=18 yrs: 0.5 ml
>=19 yrs: 1 ml
im
Hep B <=19 yrs: 0.5 ml
>=20 yrs: 1 ml
im
Hep A+B ( Twinrix) >=18 yrs: 1 ml im
HPV 0.5 ml im
Influenza, live 0.1 ml in each nostril Intranasal spray
Influenza,inactivated 0.5 ml im
Fluzone 0.1 ml id

30. Administering vaccines to Adults:
Dose and Route
Vaccine Dose Route
MMR 0.5 ml sc
MPSV 0.5 ml sc
MCV 0.5 ml im
PCV 0.5 ml im
PPSV 0.5 ml im / sc
Tdap 0.5 ml im
Varicella 0.5 ml sc
Zoster 0.65 ml sc

31. National immunization schedule for
infants
vaccine When to give dose route site
BCG At birth or
asap till 1 yr
of age
0.1 ml ( 0.05
ml until I mth
of age)
id (L) Upper arm
Hep - B At birth or
asap within 24
hours
0.5 ml im Anterolateral
side of mid
thigh
OPV 0 At birth or
asap within
first 15 days
2 drops oral oral
OPV 1,2 & 3 6,10,14 wks 2 drops Oral oral
DPT 1,2 & 3 6,10,14 wks 0.5 ml im AL mid thigh
Hep B 1,2,3 6,10,14 wks 0.5 ml im AL mid thigh
measles 9 completed 0.5 ml sc (R ) upper arm

32. National immunization schedule for
children
vaccine When to give Dose route site
DPT booster 16-24 mths 0.5 ml im AL mid thigh
OPV booster 16-24 mths 2 drops Oral oral
Measles ( 2nd) 16-24 mths 0.5 ml sc R upper arm
JE** 16-24 mths 0.5 ml sc L upper arm
Vit A ( 2nd -9th
dose )
16 mths with
DPT/OPV
booster. Then
1 dose every 6
months upto
5yrs of age.
2 lac IU oral oral
DPT booster 5-6 years 0.5 ml im Upper arm
TT 10 yrs & 16 yrs 0.5 ml im Upper arm

33. National Immunization schedule for
pregnant women
vaccine When to give dose route site
TT-1 Early in
pregnancy
0.5 ml im Upper arm
TT-2 4 weeks after
TT-1
0.5 ml im Upper arm
TT-booster If taken 2 TT
doses in a
pregnancy
within last 3
yrs. Give
before 36 wks.
give TT to a
woman in
labour if she
has not got TT
before.
0.5 ml im Upper arm

34. IAP Immunization Schedule.
Age (completed wks/mo/y) Vaccine
Birth BCG
OPV 0
Hep B-1
6 weeks DTwP-1
IPV – 1
Hib -1
Rotavirus -1
PCV-1
Hep B-2
10 weeks 2ND dose of DTwP, IPV,Hib,Rotavirus,PCV
14 weeks 3RD dose of DTwp,IPV, Hib,Rotavirus,PCV

35. IAP Immunization Schedule
Age ( completed wks/mo/y) Vaccines
6 months OPV-1, Hep –B 3
9 months OPV-2, MMR-1
9-12 months Typhoid conjugate vaccine
12 months Hep-A 1
15 months MMR-2, Varicella-1, PCV Booster

36. IAP Immunization Schedule
Age (completed wks/mo/y) Vaccines
16 -18 months DTwP-B1, IPV-B1,Hib-B1
18mths – 2yrs Hep-A 2, Typhoid booster
4 – 6 years DTwP-B 2, Varicella 2, Typhoid booster,
OPV 3
10-12 years Tdap/Td, HPV.

37. IAP recommended vaccines for high-risk
children
 Influenza vaccine
 Meningococcal vaccine
 Japanese Encephalitis vaccine
 Cholera vaccine
 Rabies vaccine
 Yellow fever vaccine
 PPSV 23

38. High Risk Category of Children
 Immunodeficiency
 Chronic medical
conditions , DM
 Long term
immunosuppressive
therapy or RT
 CSF leaks, cochlear
implants, malignancies
 Functional or anatomic
asplenia
 During outbreaks
 Having pets in home
 Who are at higher threat
of being bitten by dogs
such as hostellers, risk of
stray dogs while going
outdoor

39. Dos and Don’ts during immunization
sessions
Dos Don’ts
It is safe and effective to give BCG,
DPT,OPV and measles vaccines at
the same time to a child who has
completed 9 months and never
been vaccinated
Do not withhold the vaccine in case
of illness such as cold, cough,
diarrhoea or fever.
Give BCG to infants less than 1 year
of age
Never give BCG to children above 1
year of age
If a child is brought late for a dose ,
pick up where the schedule was left

40. Dos and Don’ts during vaccine handling
and administration
Dos Don’ts
Screen for contraindications Do not use unsterile syringe
Check label of the vial and expiry date Do not touch any part of needle
Lightly shake the vial of T-series
vaccine before drawing the dose
Do not recap the needle
Use a new syringe for each injection
and a new disposable syringe for each
reconstitution
Do not leave the needle inside the vial
Never inject in the buttock.
Use correct diluent Never use vaccine with VVM in unusable
stage
Inject using correct site and route Never massage the vaccination site
Allow dose to self dispense instead of
massaging
Never use reconstituted measles and
BCG vaccine after 4 hours and JE after
2 hours

41. Vaccine Vial Monitor
Do not use if the central square is equal to or darker than the surrounding circle.

42. Angles for inserting injections
1) Intramuscular injections are given at an
angle of 90 degrees
2) Subcutaneous injections are given at an
angle of 45 degrees
3) Intravenous injections are given at an
angle of 25 degrees
4) Intradermal injections are given at an
angle of 10-15 degrees

43. Vaccination in pregnancy
 Live virus vaccines are contraindicated in pregnancy
 Most live virus vaccines, including varicella vaccine, are
not secreted in breast milk; therefore, breast feeding is
not a contraindication for live virus or other vaccines.
 Pregnancy is not a C/I for inactivated vaccines but most
are avoided in pregnancy as relevant safety data are
limited.
 Trivalent inactivated influenza vaccine may be given in
influenza season.

44. Immunosuppression
 In patients with compromised immune function, enhanced
replication of vaccine viruses is possible and could lead to
disseminated infection with the vaccine virus. Hence live
viruses are C/I in immunocompromised conditions.
 HIV, hematologic or generalized malignancy and therapy
with immunosuppressive agents including high dose
glucocorticoids are immune compromising conditions.

45. Contraindications and precautions for
commonly used vaccines in adults
Vaccine Contraindication Precaution
All vaccines Severe allergic reaction Moderate to severe acute
illness with or without
fever
Td -- GBS within 6 weeks of a
previous dose of TT
containing vaccine
History of arthus type
hypersensitivity reaction
after a previous dose of
TT containing vaccine.
Defer vaccination until
atleast 10 years have
elapsed since the last
dose.

46. Contraindications and Precautions
Vaccine Contraindication Precaution
Tdap History of
encephalopathy eg: coma
or prolonged seizures not
attributable to another
identifiable cause within
7 days of administration
of DTaP or Tdap ie : with
pertussis component
1) GBS within 6 weeks
after a previous dose of
TT-containing vaccine
2) Unstable neurologic
conditions
3) History of Arthus type
hypersensitivity
reactions; defer
vaccination until at least
10 years have elapsed
since the last dose.
4) Pregnancy.

47. Contraindications and Precautions
Vaccine Contraindication Precaution
HPV History of immediate
hypersensitivity to yeast
( for Gardasil)
Pregnancy
MMR 1) History of immediate
hypersensitivity reaction
to gelatin or neomycin
2) Pregnancy
3) Known severe
immunodeficiency
Recent ( within 11 mths)
receipt of antibody
containing blood product.

48. Contraindications and Precautions
Vaccine Contraindication Precaution
Varicella 1) Pregnancy
2) Known severe
immunodeficiency
3) History of immediate
hypersensitivity
reaction to gelatin or
neomycin
Recent (within 11 mths)
receipt of antibody
containing blood
products.
Influenza, injectable,
trivalent
History of immediate
hypersensitivity reaction
to eggs
1) GBS within 6 weeks of
previous dose.
2) Pregnancy is not a C/I
Recommended for
women who will be
pregnant during
influenza season.

49. Contraindications and Precautions
Vaccine Contraindication Precaution
Influenza, live,
attenuated
1)Hypersensitivity to eggs
2)Age > 50 yrs
3)Pregnancy
4)Immunosuppression
5)Chronic medical
conditions
6)Close contact with
severely
immunosuppressed
persons who require a
protected environment,
such as isolation in a
bone marrow transplant
unit.
History of GBS within 6
weeks of a previous
influenza vaccine dose.

50. Contraindications and Precautions
Vaccine Contraindication Precaution
PPSV none none
Hepatitis A none pregnancy
Hepatitis B Hypersensitivity to yeast
Meningococcal conjugate 1) Age > 55 years
2) History of severe
allergic reaction to
latex or to DT
containing vaccine
History of GBS
Meningococcal
polysaccharide
History of severe allergic
reaction to latex
Zoster 1) Age < 60 years & ICS
2) Pregnancy
3) Hypersensitivity to
gelatin or neomycin.

51. “
”
The quest for vaccines for
diseases like HIV still continues

52. “
”
SCIENCE HOPES A VACCINE FOR
EVERY DISEASE.

53. Thank You.