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GENERAL PRINCIPLES OF IMMUNITY
INTRODUCTION
The dictionary meaning of immunity is ‘security* and the term
immunity relates to the resistance of the body to the deleterious
effect of (pathogenic) agents such as bacteria/viruses etc. Immuni
sation has played a significant role in the reduction of morbidity
and mortality from bacterial and viral infections in many countries.
The measurement of any immunisation programme can only be
made in the field—the index being the reduction in the number of
cases. The process of immunisation plays a dual role. The indi
vidual participating in the programme achieves a degree of
immunity sufficient to resist infection and if sufficient number of
individuals in a community are made resistant this way, the cycle
of infection and contact is broken and the remaining susceptibles
are protected probably by virtue of a ‘herd* immunity against the
related communicable diseases.
2.
TYPES OF IMMUNITY
2.1
Natural'. Immunity may be natural (innate) defence
mechanism to resist infection. It is part of the complex
mechanism by which a normal body protects itself, It is
of tremendous importance and includes mechanical barriers
to the entry and spread of bacteria, viruses and substances
capable of killing them and present in the body fluids and
secretions and many specialised cells concerned in the
defence mechanism.
2.2 Acquired'. The resistance is developed in the body through
experience of actual infection or Immunisation.
For
example; a person who has suffered from smallpox is not
likely to get the reinfaction in his life span and again smollpox can well be prevented by vaccination. Acquired or
active immunity takes time to develop, but lasts longer.
2.3
Passive : The resistance is supplied readymade to the body
e.gv, immunity by maternal antibodies in the infants and
protection in adults by giving serum and anti-toxins provid
ing greater immunity.
3.
DURATION OF IMMUNITY
Immunity may be long-lasting or may wane quickly, depend
ing upon the nature of the immunising agent, body reaction,.
nutritional status and many other factors. If the immunising agent
is made of live attenuated organisms, such as polio vaccines, BCG
vaccine, allowing its reproduction in the body, the resultant resis
tance is of long duration. When the immunising agent is a
suspension of the corresponding dead pathogenic organism, the
resultant resistance is of short duration and requires frequent
boosters. The resistance can be increased by addition of adjuvants.
4.
HERD IMMUNITY
Communicable diseases may break out in an explosive
manner (epidemics) in isolated pockets or may simmer on undetect
ed in persons who do not suffer in the classical manner. This may
be due to sub-clinical infection, carrier state or may result from
man to man transmission of live attenuated organisms used in
immunisation as in the case of oral polio vaccine. Such conditions
are likely to produce a degree of resistance in the community who
otherwise would neither have suffered nor have acquired resistance
through active immunisation.
5.
TYPES OF IMMUNISING AGENTS
The immunising agents can be divided into the following
groups:—
1.
The killed suspension of viruses/bacteria.
2. The live attenuated viruses/bacteria.
3. Toxoids with or without adjuvants.
The broad differences between No. 1 and 2 are that the
former, being a killed suspension, requires very high concentration
of particles and frequent booster doses to produce satisfactory
resistance. In contrast, the live attenuated agents reproduce in the
body simulating a natural infection and thereby produce a more
durable resistance.
6.
VACCINE ASSOCIATION
Combination of different vaccines has a clear advantage in
the mass immunisation. Combination limits the procedures,
2
speeds up administration and assists in better coverage with lesser
manpower. The combination can be made between vaccines of the
same group, combining toxoids and killed suspension or live
attenuated bacteria or viruses. For example, Triple Vaccine.
7. CARE AND HANDLING
All vaccines must be handled and stored carefully as these
may deteriorate if not kept at the recommended temperature.
Liquid vaccines are readily damaged whereas freeze-dried vaccines
and toxoids are relatively stable. The potency of each vaccine is
guaranteed for a specific period only.
X
The vaccine must, therefore, be used before the date of expiry.
8. PRECAUTIONS
While immunising, certain precautions have to be taken.
Some precautions are mandatory; some are desirable and may be
discouraged under logistic and epidemiological limitations. Certain
generally accepted contra-indications are:
1.
acute illness;
2., extreme malnutrition; and
3.
9.
while under steroid therapy.
RECOMMENDED SCHEDULE OF IMMUNISATION
Right from birth children are .exposed to various health,
hazards including communicable diseases. The natural resistance
ofthebodyto fight disease is of low order with the result that
children fall an easy prey to diseases.
Immunisation builds up the resistance of defence mechanism
in the children and this enables the body to fight and overcome
infections. A child needs to be protected against infections through
immunisation. Immunisation should be done early in life and
repeated periodically.
3
SCHEDULE OF VACCINATION
Age
Pre-natal
16-20 weeks
20-24 weeks
36-38 weeks
Children
3-9 months
9-12 months
18-24 months
Vaccination
Tetanus toxoid — 1st dose
-do— 2nd dose
-do— 3rd dose
—
—
—
— Smallpox vaccine
— BCG vaccine
— Diphtheria - Pertussis - Tetanus (Triple
Vaccine) 3 doses at an interval of 1-2
months.
— Polio (Trivalent oral vaccine) 3 doses at an
interval of 1-2 months.
— Measles vaccine: One dose.
— Diphtheria - Pertussis - Tetanus
(triple
vaccine) Booster dose.
— Polio (Trivalent oral vaccine) — Booster
dose.
5-6 years
— Diphtheria-Tetanus (bivalent vaccine)—Booster
dose.
(School entry)
— Typhoid (Monovalent or bivalent vaccine)—
One dose.
— After an interval of 1-2 months the typhoid
vaccine—one dose.
— Tetanus Toxoid—Booster dose.
10 years
— Typhoid (Monovalent or bivalent vaccine)—
Booster dose.
—
Tetanus
Toxoid—Booster dose.
16 years
— Typhoid (Monovalent or bivalent vaccine)—
Booster dose.
Pre-natal: When mothers are registered late in pregnancy atleast
two doses of Tetanus Toxoid should be given. For a mother who
has been immunised, one booster dose of Tetanus Toxoid should
be given in subsequent pregnancy preferably four weeks before the
expected date of delivery.
4
Children'. Ages indicated are considered to be the best times.
However if there is any delay in starting the first dose of triple
vaccine the ages may be adjusted accordingly. It should be the
aim to ensure that child receives smallpox, BCG, DPT, and polio
vaccination where available, before it reaches one year of age. The
different vaccines indicated against the various age groups can be
given simultaneously: example: BCG, Triple vaccine and polio
vaccine; smallpox, triple vaccine and polio; etc.
When typhoid vaccine is being given for the first time two
doses at an interval of 1-2 months are required to be given.
10.
RECORDS & REPORTS
It is important to keep correct records of vaccinations done.
Personal data to identify the person receiving the vaccination, the
batch of the vaccine used and the signature of the vaccinator should
be recorded. In some places family folders or family registers are
maintained which contain pages for recording the immunisation
status of each member of the family. In other areas, special cards
are kept for children and pregnant mothers. Such child health
and antenatal cards provide columns for recording the particulars
of immunisations given to the child or pregnant mother. Approp
riate entries should be made on such cards immediately after the
vaccination is given either at home or in a clinic. Where the
course of immunisation comprises of more than one dose of vaccine
e.g., triple vaccination, the date for the subsequent dose of vaccine
should also be indicated.
Records of receipts, issues and balance of the vaccine available
with the workers should be kept in the stock register prescribed for
the purpose.
1
/Monthly reports on the number of beneficiaries covered under
each type of immunisation with their age break-up, as also, the
position of receipts of vaccine, quantity used and balance on hand
at the end of the month should be submitted in the prescribed form.
5
Chapter II
BCG VACCINATION
BCG stands for Bacillus Calmette Guerin. The principle of
BCG vaccination is the substitution of being primary infection for
a virulent and potentially dangerous one. BCG prepares the body
to e table it to stand up to the “invaders” i.e., the virulent tubercle
bacilli capable of producing TB d sense and nullify their destructive
operation.
2.
FREEZE DRIED VACCINE
BCG vaccine is produced in the BCG Vaccine Laboratory in
G a indy, near Madras. Tne vaccine to be supplied for rural pro
gramme will be in freeze dried form which is prepared from concen
trated liquid BCG vaccine first by freezing it followed by drying.
Soot after drying the ampoules of freeze dried BCG vaccine are
heat-sealed under vacuum. Freeze dried BCG vaccine cannot be
used in powder form. It has to be re-suspended or reconstituted
by dissolving it in normal saline.
3.
PRESERVATION
Freeze dried BCG vaccine in powder form can be stored for
six months in a refrigerator. If ice chests are used it should not be
stored for more than three months. In areas where ice is not avail
able and it has to be stored at room temperature, stocks sufficient
for about 2 to 4 weeks should only be kept. It is always better to
preserve it in a refrigerator. Whether in powder or liquid form
(after suspension) the freeze dried BCG vaccine must be protected
from light. After dissolving the vaccine for vaccination, the
vaccine may be used only the same day. After completion of
vaccination on the same day, the balance, if any, should be destroyed
and should not be carried over for use next day even if kept in a
refrigerator.
4.
OPENING OF FREEZE DRIED BCG VACCINE
AMPOULES AND RECONSTITUTION
4.1
The ampoules of freeze dried BCG vaccine are sealed
6
under vacuum i.e., there is no air or very little air in the
ampoules. The method of opening the ampoules to avoid
rush in of air and reconstitution are described below :
4.2 First open the saline ampoule. Hold the ampoules in the
left hand securing it firmly between fingers. Make a tran
sverse scratch with the file on the ampoule and break off
the neck of the ampoule at the scratch.
4.3 Fill the sterilised 5 cc syringe with the saline as follows :
(i) Hold the opened ampoule in the left hand. Flame
the needle and the mouth of the ampoule.
(ii) Lower the needle of 5 cc syringe held in the right
hand into the ampoule.
(iii) Pull the piston very slowly so that barrel of the
syringe is filled with saline. Do not touch other part
of the piston.
(iv) Take out the needle from the syringe and check
whether it is completely filled. If not, flame the
mouth of the saline ampoule and the needle
again and fill the syringe exactly upto 5 cc mark.
After it is thus filled, keep the syringe in the syringe
box.
4.4
Now take the ampoule of freeze dried BCG vaccine.
Whenever a new consignment of freeze dried BCG vaccine
is received, the vaccinator should check each one of the
ampoules. If 15% or more of these show vaccine sticking
to the side walls of the ampoule or there is a change in its
colour or consistency, or there' is a crack in the ampoule,
or there is no label on the ampoule, or the date of expiry
is over, the entire consignment should be discarded.
(i) If all the above conditions are found in order, the
ampoule is to be opened. Tap the ampoule gently
so that most of the powder is at the bottom of the
ampoule and no powder left in the neck.
(ii) After holding the ampoule in the left hand, make a
transverse scratch in the middle of the neck of the
7
ampoule with a sharp cutting file. Now flame the
neck of the BCG ampoule and cover the neck and
the upper part of the bulb of the ampoule with a
plastic sheet, so that the scratch faces the technician
and there is as little as possible air between the plastic
sheet and the ampoule and in between the folds of
the sheet.
(iii) Break the ampoule now but do not be in a hurry
to remove the plastic sheet as soon as the neck is
broken. Wait for 2 to 3 seconds and then remove
plastic sheet with the broken end of the neck of
ampoule gently, so that small pieces of glass do not
fall into the open ampoule. Do not use the ampoule
if any glass pieces are seen in ths ampoule.
(iv) Now take 5 cc syringe filled with saline in the right
RECONSTITUTION OF B.C G
VACCINE
hand, flame its needle and mouth of vaccine ampoule
held in the left hand. Insert the needle into the
8
ampoule and release 1 cc of saline. Take out the
needle and shake the ampoule gently ano see that no
part of the vaccine remains in dry form.
(v) Flame the mouth of the ampoule and syringe needle
again. Now slowly release 2cc of saline into the
ampoule, rotating it constantly so that no part of
the powder remains stuck to the saline of the
ampoule particularly near the neck or in the neck.
After taking out the needle, shake the ampoule
gently again, add 2 cc again and shake gently. It is
ready for use. Cover the ampoule with black paper
and put it into the wooden block to protect it from
light. If quantity of sa'ine released into the ampoule
is not exactly 5 cc and some is spilt over, di not use it
for vaccination.
5.
EQUIPMENT
In the kit containing equipment the detailed list of the equip
ment has been provided. The following will be the main equip
ment :
1. 1 cc Omega microstat syringes for BCG vaccination.
2. Steel needles for 1 cc. microstat Omega syringes.
3. A metal box containing these syringes.
4. Metal shields.
5. Block for holding the opened BCG ampoule.
6. Mantoux ruler for measuring the weal caused by 3.1 gc
vaccine.
7. 5 cc. syringe with needles for reconstitution of freeze dried
vaccine.
8. A small plastic sheet for opening the ampoule.
9. Spirit lamp, and
10. A bottle of spirit.
6.
STERILISATION OF THE EQUIPMENT
The sterilisation should be carried out before proceeding for
the field work. Syringes, needles and their box, forceps are to be
sterilised by boiling in water for 20 minutes.
The red rubber rings and sections of rubber tubing meant for
protection of vaccine from light are not to be boiled but should only
be washed with soap and water.
9
7.
TECHNIQUE OF VACCINATION
7.1 Filling of vaccine in the Syringe : Vaccine ampoules are
kept in wooden blocks and syringes have to be filled in
without taking the ampoules out. While tilting the wooden
blocks for flaming the mouth of the ampoule or filling
the syringe therefrom, the wooden block will have to be
held by the middle finger and the little fingers below and
supported by part of the palm of the left hand. The
vaccine syringes must be covered with rubber tubings.
Before every filling the ampoules along with the wooden
block should be shaken and the mouth of the ampoules
and the needle of the syringe must be flamed. Only one
vaccine syringe should be filled at a time and in no case
should any part of contents of the syringe be used for
more than 15 minutes after filling the syringe.
7.2 Injection of BCG Vaccination : BCG vaccinations are given
intradermally or intracutaneously (i.c. in the superficial
layers of the skin) in the middle of deltoid region (below
the shoulder). Care should be taken that vaccination is
not given high up at or near the shoulders. When an
intradermal injection is given, hair follicles aie seen as
small pits on the wheal produced. This wheal should be
clearly seen for all intradermal injections. When correct
volume (0.1 cc) of vaccine is injected the wheal produced
has a diameter of 8 mm. It is not possible to inject
exactly 0.1 cc of vaccine with the record syringes, so tech
nicians should see that diameter of wheal is not less than
8 mm. To maintain this uniformity, every tenth wheal should
be measured with mantoux riders provided in the kit. If
diameter of a wheal is 6 mm instead of 8 mm, the vaccine
injected will not be 3/4th of the volume needed, but only
about half.
7.3
The Procedure of Vaccinaticn is given below :
(i) Hold the arm of the person to be vaccinated at the
deltoid region (near the shoulder) in your lefthand.
Stretch the skin over the deltoid region between thumb
and index finger. The remaining three fingers of your
hand should grip the arm on the inner aspect. No
special preparation of the skin is necessary before
10
giving BCG vaccination, i.e. washing with disinfec
tants, like alcohol, dettol, etc. is not to be done/
(ii)
Hold the barrel of the syringe between the middle
(below) and index finger (above) so that both fingers
touch the rubber ring in front and the thumb supports
the ring from behind opposite to index finger.* Do
not touch the piston.
(iii) Flame the needle of the syringe till a crackling sound
is heard. Eject out a few drops of vaccine to discard
the heated vaccine and to cool the needle.
(iv) With the eye of the needle facing towards you (towards
the vaccinator) prick the skin al the maximum stretch,
keeping thcsyiinge at as acute an angle as possible
with the arm of the person, to ensure a superficial
injection.
Sec that the syringe is away from the thumb, stretch
ing the skin or just touching its lip and not astride it.
It is very important to see the needle pricks only the
superficial layers of the skin.
If the needle slips and does not prick the skin or if
it goes deep, flame the needle again, eject a few
drops, attempt the prick again at a fresh site.
11
O
I
(v)
Push the syringe a little so that the eye of the needle
completely penetrates into the skin Now, move the
thumb of the right hand from the rubber ring of the
syringe to the end plate of the piston. Push the piston
a little and see whether the wheal is being formed. If
so, push the piston more to obtain a wheal of 8 mm
diameter. However, when Omega syringe or some
other long barrelled syringe is used, 0.1 cc of vaccine
should be injected, as measured from the markings
on the barrel of the syringe.
(vi) The vaccination should not be given in bright sunlight
end should prefcrcbly be given indoors, or at least in
shade. Ampoules and filled syringes should prefercbly
be covered with black paper when not actually in use.
8.
FOLLOW-UP OF VACCINATION
A proper intradermal injection will cause a wheal about 8 mm
in diameter. The wheal is absorbed in 20 to 90 minutes and would
disappearand nothing will be seen at the site injection for some
days. By about the 3rd or 4th week an area of infiltration (indura
tion) may be felt at the site of vaccination which increases to a lump
or a papule, 5 to 8 mm in diameter. It is generally not painful but
is tender to touch. The papule increases in size and reaches its
maximum by about the 6th week when its average diameter is 6 to
10 mm. The nodule softens with formation of pus which may later
escape leaving a tiny ulcer which heals by itself without any special
treatment. At the end of about 10 to 12 weeks all that is visible is
12
a tiny scar about 5-7 mm in diameter with a little pigmentation at
the spot.
9.
ELIGIBILITY FOR VACCINATION
Efforts have to be made to offer BCG vaccination to all child
ren, between 3-9 months. All persons below the age of 19 years
who have not received BCG vaccination earlier are also to be offered
vaccination.
10.
CONTRA-INDICATIONS
BCG vaccination may not be given to an individual if he is
known to be a case of tuberculosis or if two or more than two scars
are seen at the site of vaccination. It may also be not given to
children who are highly emaciated or, who have extensive skin
disease or have high fever or look acutely ill.
11.
RECORDS
Cards and registers for the immunisation programme will be
common for all vaccinations and relevant columns indicating full
identity of the person concerned, namily, head of the family, age of
[ the infant/child/person vaccinated, date of vaccination, vaccine batch
number, etc., will have to be fully recorded.
13
Chapter III
immunisation againstidiphtheriajvvhooping
COUGH AND TETANUS
1.
DIPHTHERIA
1.1
Susceptible Age Group : Children in the age group 1 to 5
years are susceptible to diphtheria. Occasional cases may
occur among adults. The maximum incidence is in the
age group between two and five years. The disease may
occur in seasonal outbreaks. The mortality is very high
especially in rural areas where facilities for prompt treat
ment do not exist.
1.2 Nitural Immunity—Schick Test: Children who are extre
mely susceptible to the disease in the younger age groups
acquire immunity against it as they grow up. This is
brought about through repeated contacts with small doses
of diphtheria bacilli which do not produce the clinical
disease. The susceptibility of individuals to diphtheria
can be determind by the ‘Schick Test’.
1.3
2.
Active Immunisation : The purified absorbed diphtheria
toxoid when administered at suitable intervals gives a
high degree of protection against Diphtheria. All children
below 10 years should be actively immunised. A preli
minary Schick Test is not considered necessary for this
age group. Experience of Western countries shows that
the disease can be eradicated by immunising susceptible
individuals.
WHOOPING COUGH
2.1
Susceptible Age Group : Susceptible age group in children
is below five years. The disease is most severe when it
occurs in younger children and mortality is at its maximum
in the first year of life. Besides, the complications and
sequelae of the disease undermine the health and nutrition
of children and affect their later growth and development.
14
2.2 Active Immunisation : The disease can be prevented by
immunising infants with a vaccine containing dead whoop
ing cough (Pertussis) bacilli.
TETANUS
3.1
Susceptible Age Group : Tetanus affects all age groups,
but appears to be more in persons below 40 years of age.
Pregnant women and new-born infants are found to be
more vulnerable to tetanus infection on account of non
availability of skilled midwifery service for the majority
of women, especially in rural areas.
3.2 Active Immunisation : Protection against tetanus infection
can be got by active immunisation with purified tetanus
toxoid.
An adequate course of immunisation consists of three inject
ions of the toxoid given at intervals of 8 to 12 weeks. A person
who is protected by the basic course of immunisation can enjoy
protection against tetanus throughout life by taking booster doses
at 5 to 10 yearly intervals or when he suffers a tetanus-prone
injury.
3.3
4.
Immunisation of Pregnant MothersImmunising pregnant
mother against tetanus will protect not only the mother
but also the new-born infant. The antibodies circulating
in the mother’s blood pass through the placenta into the
blood circulation of the foetus so that the new-born infant
is protected. This is of special interest to us in view of
the fact that large majority of child-births in the country
are still being assisted by untrained traditional midwives.
COMBINED
IMMUNISATION AGAINST DIPHTHERIAWHOOPING COUGH AND TETANUS (WITH TRIPLE
VACCINE)
Children can be immunised against the three diseases—
diphtheria, whooping cough and tetanus by a combined vaccine—
the triple vaccine. This vaccine contains the toxoid of diphtheria
and tetanus bacilli adsorbed on a mineral carrier like aluminium
phosphate and dead Pertussis (Whooping Cough) bacilli. The
combination of the three together into one vaccine increases the
production of antibodies and the length of protection, much more
15
than when the vaccines are given individually. Triple vaccine is
meant for children below 5 years of age. The vaccine is marketed
in rubber capped vials containing 20 or 10 doses and also in single
dose ampoules.
5.
COMBINED IMMUNISATION AGAINST DIPHTHERIA &
TETANUS (BIVALENT VACCINE)
Bivalent vaccine containing the toxoids of diphtheria and
tetanus bacilli adsorbed on a mineral carrier like aluminium phos
phate are also available in the market. This vaccine is meant for
older children of 5-10 years of age. The whooping cough compo
nent is not required for children over five years of age.
The vaccine is available in rubber capped vials containing 20
or 10 doses and in single dose ampoules.
6.
TETANUS TOXOID
Mineral adsorbed tetanus toxoid is available in rubber capped
vials containing 20 or 10 doses and in single dose ampoules.
The Central Research Institute, Kasauli, is the main centre
for the production of the vaccines. In addition, Haffkine Institute,
Bombay, Glaxo Laboratories, Bengal Immunity Co. and a few other
pharmaceutical firms also produce them.
7. storage of vaccine
Most of the vaccines lose potency with age, particularly if
exposed to heat and light. Instructions on the label should be
followed strictly DPT. DT and TT should be stored in a refri
gerator between + 4°c and l(Pc. When issued to the sub-centre, the
vaccine should be used up within a period of 8 to 10 days. The
vaccine will loose potency if kept at room temperature over a longer
period. The vaccine sh >uld be used before the date of expiry indicat
ed on the vial. If on account of any unforeseen circumstances the
vaccine gets stored beyond the date of expiry, the vial should be
sent to the Director of Central Research Institute, Kasauli, to test
its potency. Some of the vials may retain potency and could be
used after testing.
16
8.
SCHEDULE OF IMMUNISATION
8.1
The primary course of triple immunisation should be start
ed when the infant is three months old. The ideal is to give
three doses at intervals of four to eight weeks.
The immunity produced by the primary course of injec
tion should be reinforced by booster doses as the child
grows older. The first booster dose should be given when
the child reaches 4-2 years of age with one dose of triple
vaccine and the second booster dose with one dose of
diphtheria—tetanus vaccine, at five years of age—at school
entry or immediately thereafter.
8.2 In actual practice the majority of children do not receive
the triple vaccine during infancy as scheduled. Therefore,
all children under four years of age may have to be given
the primary immunisation with three doses of triple vaccine
as described above. Such children should receive their
first booster dose with one dose of diphtheria—tetanus (DT)
vaccine (at five years of age) at school entry or immediately
thereafter.
9.
IMMUNISATION OF PREGNANT MOTHERS AGAINST
TETANUS
Pregnant mothers can be immunised effectively by giving
three doses of Tetanus Toxoid as indicated below:—
1st dose
2nd dose
3rd dose
16-20 weeks
20-24 weeks
36-38 weeks
When mothers are registered late in pregnancy, at least two
doses of Tetanus Toxoid should be given.
Mothers who received their primary immunisation with two
doses of Tetanus Toxoid during pregnancy should be given a
booster dose of Tetanus Toxoid during subsequent pregnancies and
when they are exposed to tetanus-prone injury.
17
10.
DOSE
Usual dose is 0.5 ml or 1.0 ml of the vaccine as prescribed by
the manufacturer. The dos: is the s.ime for ail ag: groups.
11.
SITE OF INJECTION
The injection should be given in the lateral part of the thigh,
uppar and outer quadrant of the buttocks or over the shoulder
(deltoid muscles).
12.
sterilisation
The syringe and needle should be sterilised by boiling in water
for 20 minutes. Sterilised syringes and needles should not be touched
18
by unwashed hands, nor kept on tin; ter He surface. A pair of forceps
sh ould be used for picking up the sterilised things. The cap of the
vital containing the vaccine should be sterilised by rubbing it with
a swab of tincture of iodine. The skin over the site of injection
should be sterilised by painting tincture of iodine.
19
TECHNIQUE OF INJECTION
All vaccines containing mineral carriers or adjuvants should be
administered deep intra-muscular. Wash hands with soap and water.
Clean the rubber cap of the vial. Draw air into the sterilised
syringe equal to the dose of the vaccine (0.5 ml or 1 ml) by pulling
back the plunger. Inject the air into the vaccine vial. Invert the
vial and withdraw the plunger to draw the dose of vacccine in
syringe. Paint the skin over the site to be injected, with tincture
of iodine. Stretch it between the thumb and forefinger of left hand.
Quickly insert the needle vertically into the muscle with the right
hand. Withdraw the plunger a little to make sure that the needle
is not in a vein. If the needle has gone into a vein blood will flow
into the syringe. Pull the needle ud and insert in another direction
till you are sure that it is not a vein. Inject the vaccine slowly.
Withdraw the needle and massage the area lightly.
13.
14.
EXPECTED REACTIONS
In children under five years of age slight to moderate pain at
the site of injection with mild fever in an occasional child is all that
need be expected. In older children, in the age group 5 to 10 years,
the incidence of local pain and fever is likely to be more frequent and
more noticeable. These reactions, however, subside within 24 to
48 hours.
ABNORMAL REACTIONS
High fever, convulsion etc. are indications of undue reaction
which may occur in a very small proportion of vaccinated
children due to some unknown factor in whooping cough vaccine.
Further doses of vaccine should not be given to such children with
15.
out strict medical supervision.
Abcess formation at the site of injection or transfer of homo
logous serum hepatitis cannot be considered to be intrinsic hazards
of immunisation. These result from carelessness in maintaining
sterility of syringes and needles.
16.
CONTRA-INDICATIONS
A medical check up and treatment of illness discovered during
such examinations will popularise immunisations. Such an ex
amination will help to exclude children who are likely to react
unfavourably to the immunisation procedure. Immunisation of
children who are ill should be postponed. The following conditions
should be treated as contra-indications for giving Triple/DT
innocultions :
1. History of convulsions or central nervous system disease
in the child or family.
20
2. Recent history of infectious disease/fever in the child.
3.
History of allergic diseases like urticaria and eczema.
4. History of any hypersensitivity reaction in the past.
5. Children who are on steriod therapy.
17.
WHO WILL VACCINATE AND WHERE
The vaccination should be given regularly at the children
Clinics and Aute-natal Clinics of Institutions like Primary Health
Centres and hospitals. In addition it should be given in the field by
collecting children and mothers at sub-centres, office of the B.H.
Workers, the office of Panchayats, Mahila Mandals, Youth Clubs,
Primary Schools etc. It is desirable to fix a particular day for
giving the immunisations which should be made known to the
community in advance. All health functionaries working in the
area like ANM, BHW,the Vaccinator, the LHV, the Health Inspector
should be involved. Teams comprising the LHV and ANM and
the Health Inspector and BHW could simultaneously be engaged
in giving the vaccination in the selected village so that more children
and mothers could be reached. On the day the first dose of the
vaccine is given in the village it is desirable that the medical officer
is present.
Normally children/mothers should be collected in a pre
determined place for receiving the vaccine. However, in the case
of children/pregnant mothers who have defaulted to turn up to
receive the second or third dose, the workers should try to contact
them in the home during their routine home visits and complete the
schedule of two doses which is required to produce immunity.
18.
RECORDS AND REPORTS
Triple immunisation and tetanus immunisations do not leave
behind any visible or palpable mark in the recipient unlike in the
case of Smallpox and BCG. Therefore, it is necessary to give
mothers cards writing down the dates on which the vaccine was
administered for safe custody and future reference. In addition
the child health card and ante-natal card kept at the institutions
should record the particulars of immunisation. The dates of
immunisation should be recorded in the normal register of
children. Stock register showing the receipt and issue of vaccines
should be maintained.
;
21
OI
C M I S'°
Chapter IV
IMMUNISATION AGAINST POLIOMYELITIS
1.
INTRODUCTION
There is no programme for mass immunisation of children
against poliomyelitis in the country. However, large scale immuni
sations may have to be done in the event of outbreak of epidemic
of the disease in an area. It may also have to be undertaken in
selected areas for reasons, such as, high or unusual endemicity, as
shown by the presence of crippled children in different age groups,
peculiar features in the area rendering personal hygiene measures
impracticable, etc. The oral polio vaccine (Sabine vaccine) is
used for immunisation.
2.
CHARACTERISTICS OF THE VACCINE
The oral polio vaccine is comprised of the three serotypes of
polio viruses. It is a living vaccine and its efficiency depends
entirely on the administration of live viruses to the individual. If,
somehow, any proportion of the living viruses of any of the sero
types is inactivated, the vaccines which contain a significant
proportion of inactivated virus, one is only achieving a false sense
of security since the proportion of children who would have been
successfuly immunised against poliomyelitis is very small.
3.
STORAGE AND TRANSPORTATION
To prevent the inactivation of the vaccine before administra
tion to the children it is recommended that it should be stored at
sub-zero temperatures. It is imperative that the suppliers, distribu
tors and the poliovaccine clinics store this vaccine at—20°C in a
deep-freeze. In case a deep-freeze is not available it might be stored
in the freezing chamber of the refrigerator During transport the
vaccine must be kept either on dry ice (solid carbondioxide) or a
freezing mixture.
At the polio-vaccination-clinic, the bottle containing the
vaccine should not be frozen and thawed repeatedly since repeated
freezing and thawing has a deleterious effect on the potency of
oral polio vaccines. It would be preferable to keep the vials of
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the vaccine in ice during its administration to children. Every
vaccine must be vaccinated with the appropriate volume of the
vaccine.
The person responsible for the distribution of vaccine in a
clinic must ensure that the nurse is familiar with the amount of
vaccine that has to be given to a child.
4.
STERILISATION OF SPOONS ETC
In case, the vaccine is being administered by spoons, disinfec
tants like dettol or lysol may not be used for the cleaning of spoons.
The ideal way would be to boil the spoons in water and to cool
individual spoon in ice-water before it is used for administration of
polio vaccine to a child.
5.
ACTIVE IMMUNISATION
The vaccine may be administered to any one including infants
of 3 to 6 months of age. The schedule comprises of three doses
of the vaccine to be given by mouth at intervals of 4 to 6 weeks
between doses The dose is the same irrespective of age. Normally
persons over eight years of age need not be immunised.
6.
PREPARATION OF THE VACC1NEE
Infants should not be breastfed for 4 to 6 hours before and
4 to 6 hours after the administration of the vaccine. During this
period the child can be fed artificially and should not be starved.
Hot water, hot milk, or hot coffee should not be given for half an
hour after the administration of the vaccine.
7. CONTRA-INDICATIONS
The only contra-indications for the administration of the
vaccine are acute infectious diseases, high fever, vomitting and
dysentery. Patients suffering from acute leukemia and lymphomas
generalised malignancy and receiving corticosteroids and anti
metabolites may not be given oral polio vaccine.
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INSTRUCTIONS FOR OFFICIALS RESPONSIBLE FOR
DISTRIBUTION OF ORAL POLIO VACCINE
DOs
1.
Store the oral polio vaccine in the freezing chamber
of the refrigerator or a deep-freeze at sub-zero
temperatures.
2.
Administer the appropriate quantity of vaccine by
withdrawal from the vial through a sterilised syringe.
3.
Sterilise the individual spoon in boiling water or steam
and cool it completely before transferring individual
dose to it from the vaccine vial.
DON’Ts
1.
Do not freeze and thaw the vaccine container repeatedly.
2.
Do not dilute the vaccine in water, milk or syrup before
its administration to the child.
3.
Breast feeding should be avoided four hours before and
4 to 6 hours after taking vaccine.
4.
Do not sterilise the spoon to be used for vaccination
with any disinfectant like dettol, lysol or any other
antiseptic.
5.
Do not administer any batch of oral polio vaccine
unless you are sure that the vaccine was kept frozen,
during its transport to your organisation/vaccination
clinic. Ensure proper transportation by insisting on
the transport of oral polio vaccine by the quickest
available means of transport such as an aeroplane or a
mail train. Both the supplier and the customer are
equally responsible for ensuring a sub-zero temperature
during the shipment of the vaccine. Ideally dry ice
should be used. In case dry ice is not available a
freezing mixture may be used.
6.
Do not give oral polio vaccine in a hot, humid and
crowded room. The vaccine should be given preferably
in an airconditioned room.
7.
Avoid immunisation during
seasons.
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summer and monsoon
davo
------ r
Designed aid Produced by the Directorate of Advertising & Visua
Publicity. Ministry of I. & 0 Govt, of India for the Ministry o
Health & Family Welfare and Printed at the Caxton Press, New Delhi
No. 2/30/78 PPVI
English—10,000
Sep. 1978
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