1. CHILDHOOD IMMUNIZATION

2. Immunization Practices
Immunization is one of the most beneficial and cost-effective disease-prevention measures. As a result of effective and safe vaccines, smallpox has been eradicated, polio is close to worldwide eradication, and measles and rubella are no longer endemic in the USA
Immunization is the process of inducing immunity against a specific disease. Immunity can be induced either active or passive.
As of 2011, infants, children, and adolescents routinely are vaccinated against 16 diseases in the USA

3. Active Immunization
Active Immunization: process of inducing prolonged humoral and/or cellular immune response by administering a vaccine or toxoid.
Vaccine: defined as whole or parts of microorganisms administered to prevent an infectious disease. Vaccines can consist of:
Inactvated OR killed:
whole microorganisms (viral) (e.g., HepA, IPV, inactivated influnza)
parts of the organism (e.g., acellular pertussis, HPV, and HepB)
polysaccharide capsules (e.g., pneumococcal and meningococcal polysaccharide vaccines)
polysaccharide capsules conjugated to protein carriers (e.g., Hib, pneumococcal, and meningococcal conjugate vaccines)
live-attenuated microorganisms
VIRAL (measles, mumps, rubella, varicella, rotavirus, and live-attenuated influenza vaccines).
BACTERIA (BCG)
Toxoid: (a modified bacterial toxin that is made nontoxic but is still able to induce an active immune response against the toxin). So it is produced by an individual’s own immune system and is usually long-lasting,e.g. tetanus & diphtheria

4. Vaccines can induce immunity by stimulating antibody formation, cellular immunity, or both. Protection induced by most vaccines is thought to be mediated primarily by B lymphocytes, which produce antibody.
Most B-lymphocyte responses require the assistance of CD4 helper T lymphocytes. These T lymphocyte–dependent responses tend to induce high levels of functional antibody

5. T lymphocyte–dependent vaccines, which include protein moieties, induce good immune responses even in young infants. In contrast, polysaccharide antigens induce B-lymphocyte responses in the absence of T-lymphocyte help. These T lymphocyte–independent vaccines are associated with poor immune responses in children <2 yr of age, short-term immunity, and absence of an enhanced or booster response on repeat exposure to the antigen.
To overcome problems of plain polysaccharide vaccines, polysaccharides have been conjugated, or covalently linked, to protein carriers, converting the vaccine to a T lymphocyte–dependent vaccine. In contrast to plain polysaccharide vaccines, conjugate vaccines induce higher avidity antibody, immunologic memory leading to booster responses on repeat exposure to the antigen, long-term immunity, and herd immunity by decreasing carriage of the organism.
As of 2009 in the USA, there were licensed conjugate vaccines to prevent Hib, pneumococcal and meningococcal diseases.

6. WHO Immunization Scheduale
The work with the following scheduale started in Iraq in the 2nd of January 2012
Penta vaccine: Diphtheria, Pertusis, Tetanus, Viral hepatitis type (b) and Haemophilus influenzae type b.
Tetra vaccine: Diphtheria, Pertusis, Tetanus, and Haemophilus influenzae type b.

7. Bacille Calmette-Guérin Vaccination(BCG):
The original vaccine organism was a strain of M. bovis attenuated by subculture every 3 wk for 13 yr.
The preferred route of administration is intradermal injection(i.d) with a syringe and needle(0.05 ml for babies less than 1 mo; 0.1 ml for those more than 1mo in the left upper deltoid)
Local ulceration and regional suppurative adenitis occur in 0.1–1% of vaccine recipients. Most reactions are mild and usually resolve spontaneously
Profoundly immunocompromised patients may develop disseminated BCG infection after vaccination.

9. The recommendation of the WHO is a single dose administered during infancy
The best use of BCG vaccination appears to be prevention of life-threatening forms of tuberculosis in infants and young children. BCG vaccination administered during infancy has little effect on the ultimate incidence of tuberculosis in adults, suggesting that the effect of the vaccine is time limited.
It gives protection against T.B for at least 15 yr.

10. After receiving the vaccine, the child should be separated from the possible sources of infection until it can be demonstrated that the child has had a vaccine response, demonstrated by tuberculin reactivity, which usually develops within 1–3 mo.
Occasionally, a 2nd BCG vaccination must be given to children who fail to develop skin test reactivity after the 1st dose.

11. Polio virus Vaccine:
Vaccination is the only effective method of preventing poliomyelitis. Hygienic measures help limit the spread of the infection among young children, but immunization is necessary to control transmission among all age groups.
Both the inactivated polio vaccine IPV (salk), and the live-attenuated OPV (sabin) have established efficacy in preventing poliovirus infection and paralytic poliomyelitis.
IPV elicits higher serum IgG antibody titers, but the OPV also induces significantly greater mucosal IgA immunity in the oropharynx and gastrointestinal tract that limits replication of the wild poliovirus at these sites.

12. HBV should be given to adolescents and children only in the deltoid muscle, and to infants and neonates in the anterolateral thigh muscle as IM injection of 0.1 ml.
Administration intradermally or in the buttocks has resulted in poor immune responses in some individuals, and these sites are not recommended.
Hepatitis B Vaccine :

14. At birth :
Administer monovalent HepB to all newborns before hospital discharge.
If mother is hepatitis surface antigen(HBsAg) +ve, adminster HepB and 0.5 ml of (HBIG) simultaneously at different sites within 12 hr of birth.
If mother HBsAg status is unknown, administer HepB vaccine within 12 hr of birth. Determine the HBsAg status as soon as possible & if HBsAg +ve, administer HBIG no later than 1 week.
If mother is HBsAg –ve, the birth dose can only be delayed with physician’s order.E.g. HepB vaccination should be deferred in infants weighing <2 kg at birth until 30 days of age.

15. The final dose should not be administered before 6mo.
After the birth dose:
The HepB series should be completed with either monovalent HepB or combination vaccine containing HepB.
The final dose should not be administered before 6mo.
Infant born to HBsAg +ve mother should be tested for HBsAg & Ab to HBsAg after completion of HepB series, at age 9-18 mo.

16. Diphtheria, Tetanus, Pertussis( DPT) vaccine:
It is given i.m at the gluteal or anterolateral thigh. Three diphtheria and tetanus toxoids combined with acellular pertussis (DTaP) vaccines currently are licensed in the USA for children <7 yr of age
DTaP:
Minimum age 6 wk
4th dose may be administerd as early as age 12 mo, provided 6 mo have elapsed since the 3rd dose
Administer the final dose in the series at age 4-6yr.
dT:
the adult preparation (dT; 10% of pediatric diphtheria toxoid dose)
For individuals 7 years of age or older, dT is recommended for the primary series and booster doses because the lower concentration of diphtheria toxoid is adequately immunogenic and because increasing the content of diphtheria toxoid heightens reactogenicity with increasing age .
For those with ≥ 5yr since the last Td booster dose.[The patient who experiences hypersensitivity reaction or a temperature (>39.4C) after a dose of dT, which is rare, usually has high serum tetanus antitoxin levels and should not be given dT more frequently than every 10 yr, even if he or she sustains a significant tetanus-prone injury.]

17. Mild local and systemic adverse events as well as more serious events (including high fever, persistent crying of ≥3 hr duration, hypotonic hyporesponsive episodes, and seizures) occur significantly less frequently among infants who receive DTaP compared with DTP vaccine.
entire limb swelling, with concurrent pain and erythema usually subsides spontaneously without sequelae.

18. Hemophilus influenza type b (Hib) conjucate vaccine:
Minimum age 6wk
Vaccine is not generally recommended for children ≥ 5 year.
If 1st dose was administered at age months, administer 2 doses separated by 4 weeks + booster at age mo.

19. Rotavirus vaccine 3 D Minimum age 6 wk
Administer the 1st dose at age 6-12 wk.
Do not start the series later than age 12 wk.
Do not administer the final dose in the series later than age 32 wk .
Data on safety & efficacy outside of these age ranges are insufficient.

20. Measles, Mumps & Rubella (MMR) vaccine:
2 D
Measles, Mumps & Rubella (MMR) vaccine:
Measles vaccine is available as a monovalent preparation or combined as measles-mumps-rubella (MMR) vaccine.
MMR:
Minimum age 12 mo.
The current recommendations include a first dose at 12-15 mo followed by a second dose at 4-6 yr of age. Seroconversion is slightly lower in children who receive the first dose before or at 12 mo of age because of persisting maternal antibody.
MMR may be administered before age 4-6 yr, provided ≥ 4wk have elapsed since the 1st dose.
For children who have not received 2 doses by 11-12 yr of age, a second dose should be provided.
Infants who receive a dose before 12 mo of age should be given 2 additional doses at 12-15 mo and 4-6 yr of age.
Measles vaccine:
For children 6-11 mo of age in epidemic situations or prior to international travel.

21. Adverse events from the MMR vaccine include:
Fever (usually 6-12 days following vaccination).
Rash.
Rarely, transient thrombocytopenia.
Children prone to febrile seizures may experience an event following vaccination, so the risks and benefits of vaccination should be discussed with parents.
MMR vaccine significantly diminishes the risk for subacute sclerosing panencephalitis (SSPE).

22. Passively administered immune globulin may inhibit the immune response to live measles vaccine, and administration should be delayed for variable amounts of time based on the dose of immuneglobulin. Live vaccines should not be administered to pregnant women or to immunodeficient or immunosuppressed patients. However, patients with HIV who are not severely immunocompromised should be immunized. Measles virus may suppress the cutaneous response to tuberculous antigen, therefore, skin testing for tuberculosis should be performed before or at the same time as administration of the vaccine.

24. In addition to these vaccines, others are recommended by AAP include:
Pneumococcal vaccine:
Minimum age: 6 wk for pneumococcal conjucate vaccine PCV & 2 yr for pneumococcal polysaccharide vaccine PPV
PCV given at 2,4,6 & booster dose at months.
Administer PCV at age mo in certain high risk groups.
Administer PPV to children ≥ 2yr in certain high risk groups.
PCV not generally recommended for children age ≥ 5yr.

25. 2 D
Influenza vaccine:
Minimum age 6mo for trivalent inactivated influnza vaccine TIV, & 5 yr for live attenuated vaccineLAIV.
Annual influnza vaccine recommended for:
All children aged 6 mo-18 yr should be vaccinated annually if feasible.
Other wise for children and adolescents at higher risk for influenza complications, including those who:
Are aged 6 mo–4 yr (59 mo)
Close contacts of all children 0-6mo, vaccine not indicated for these age because inadequete immunogenesity.
Children age ≥ 59 mo with certain risk as having chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, DM, ect. …
Are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus)
Are receiving long-term aspirin therapy and therefore might be at risk for experiencing Reye syndrome after influenza virus infection.
Health care workers.
Will be pregnant during the influenza season.
Two doses of vaccine at least 1 mo apart (TIV) & 6 wk (LAIV) are recommended for primary immunization.

26. Varicella vaccine: 2 D Minimum age 12 mo.
1st dose mo., 2nd dose at 4-6 yr.
Administer 2 doses to person with out evidence of immunity.
If age ≤ 13 yr, at least 3 mo apart. Do not repeat the 2nd dose, if administered ≥ 28 days after the 1st dose.
If age ˃ 13 yr at least 4 wk apart.

27. 2 D Hepatits A vaccine : Minimum age 12 mo.
HepA 2 doses series administered between mo at least 6 mo apart.
Children not fully vaccinated by 2 yr can be vaccinated at subsequent visits.
Meningococcal polysaccharide vaccine:
Minimum age 2 yr.
MPSV4 administer to children aged 2-10 yr with terminal complement deficiency or anatomic or functional asplenia & certain other high risk group.

28. THANKS