IMMUNIZATION

Types of vaccines
Live attenuated vaccines Killed or inactive vaccine
It’s C.I in immune-compromised patients (Chemotherapy, anemia, HIV and high dose POLIO injection only, HEPATITIS A /B, INFLUENZA
cortisone doses), and pregnant. (IM,SC), HPV & DTap
 VIRUSES: MMR, VARICELLA/ZOSTER, YELLOW FEVER, ROTA VIRUS, INTRANASAL
INFLUENZA. ORAL POLIO
BACTERIA: ORAL TYPHOID
FRACTIONATED (2 years of Age)
PURE POLYSACCHARIDES Conjugated polysaccharides RECOMBINANT VACCINES
Made from specific part of the M.O capsule Part of protein that make its response and can HPV, HBV & RIV
be given to < 2 years
Children < 2 years can’t make this immune
response , Examples PPSV23 and MPSV4 HiB, PCV13, Men ACwy
Timing and spacing
1. There is no limit to the number of vaccines that can be administered in one visit. EXAAAM
 Inactive vaccines, can be given any time after IG when given simultaneously, they should be given at different sites.
2. Live attenuated if not given in same visit must be separated by at least 4 weeks *No timing spacing between inactive and any others+
3. Antibody- live attenuated vaccine interactions:
 If live vaccine was taken first  Wait 2 weeks before IG
 If IG was taken first  Wait 3-4 months before vaccine
 A baby born to a mother has hepatitis B must take the vaccine and the IG in the same setting within 12 hours of delivery. EXAM
4. Vaccine should not be given earlier than the minimum age requirement except in case of measles outbreaks, the MMR vaccine can be
taken before the age of 12 months.
5. Administration of immunosuppressive and vaccines :
Any live attenuated vaccines should be given after 3 months of chemotherapy OR at least 2 weeks before
Considerations in special populations
 Preterm Infants: Immunize according to chronologic age week of born
 Patients receiving corticosteroids :
Delay live vaccines for a 1 month in case of systemic ↑dose corticosteroids ≥ 20 mg prednisone equiv. daily OR 2 mg/Kg/day for ≥14 days
 Patients with HIV
 MMR should be taken unless patient is severely immune-compromised
 Varicella should be considered for asymptomatic or mildly symptomatic
 What make the Routine vaccination to be considered Contraindicated?
Permanent contraindication Temporary contraindications
 anaphylactic reaction to vaccine or its components  Acute moderate to severe febrile illness.
 IPV, MMR, varicella contain neomycin.  Household contacts of the contraindicated patient
 Influenza vaccine : some types expt: LAIV  Immunodeficiency or chemotherapy : any live attenuated vaccines ( should give live
should be avoided in patients with severe egg vaccine after 3 month of chemotherapy OR at least 2 weeks before)
allergy  pregnancy: any live attenuated vaccines or HPV only ( till birth)
 Encephalopathy within 7 days of administration of  Recent administration of Ig should delay the other vaccinations
DTaP  Long term high dose of systemic steroids
From birth through 6 years: 5 visits: 5 vaccines
 2 months (Hib, IPV , RV ,PCV 13 , DTaP)  El pasha 1 : Hep B 3 doses (at birth , 1 or 2 month , 6 month)
 4 months (Hib, IPV , RV ,PCV 13 , DTaP)  El pasha 2 : Influenza vaccine annually
 6 months (Hib, IPV , RV ,PCV 13 , DTaP)  After 1 year: The baby will take:
 1 year (Hib, -- , -- , PCV 13 , ---- ) MMR/V Hep A (2 doses) after 1 year
 6 year (-- , IPV , -- , -- , DTaP ) MMR /V DTaP 1.5 years
From 7 years till 18 years:
11-12 years old (Tdap , HPV 3 doses series , Meningococcal) Update 2016 : HPV
16 – 18 years old ( booster dose for meningococcal) Start vaccination of HPV starting from 9 years for sexual
abuse children

1. Influenza vaccination
Inactive Influenza Vaccine “ IIV”(killed vaccine): IM,SC Live Attenuated Influenza Vaccine “ LAIV”: Nasal Spray
 ≥6 months , ≥ 65 For healthy 2–49 years
 Pregnant each pregnancy Contraindicated in :
 Health-care personnel who care for severely immunocompromised Pregnant, Asthma or wheezing , Immunocompromised, High dose
 All types are egg based except RIV3 is completely egg free - only corticosteroids systemic , Healthcare personnel who care for
used for 18 years and older immunocompromised and if taken no contact with them for 7 days
1. In case first time Children < 9 years should receive two doses, at least 1 month apart.
2. Individuals with egg allergy manifesting hives only should receive the influenza vaccine and should be observed for at least 30 minutes
3. Annual vaccination from October to March for all persons aged 6 months or older (Preferred in October and November)
4. ‫ ينفع يتاخد وال ال؟ أيوة يتاخد‬3 ‫طيب مصل اتوفر في شهر‬
 2. Hepatitis A
 Routinely
 2 doses Hep A vaccine for: Children aged 1 to 2 year  Separate the 2 doses by 6 to 18 months
 If the vaccine combined with hep B give 3 doses 0 , 1, and 6 months
 Catch-up vaccination:
 For any person aged ≥2 years: 2 Doses of Hep A vaccine separated by 6 months
 Pre exposure prophylaxis: Hep A Ig
 For travelers to endemic countries
 Children < 1 year who need to be protected against HAV infection.
 These populations need vaccinations:
 MSM and persons who use injection or non-injection illicit drugs
 Persons working with HAV-infected primates or with HAV in a research laboratory setting
 Persons traveling to or working in countries that have high or intermediate endemicity (4 weeks for full protection )
 Persons with chronic liver disease and persons who receive clotting factor concentrates
3. Hepatitis B
 Catch-up vaccination :
 3-dose series can be started at any age 0, 1 , 4 or 6 months.
 2-dose series of adult formulation (Recombivax HB) is licensed for use in children aged 11-15 years.
 If mother is HBs Ag positive : administer HBIG as soon as possible:
1- If (HBsAg)-positive mothers : Hep B vaccine + 0.5 mL of (HBIG) within 12 hours of birth.
 If mother’s HBsAg status is unknown :
 Within 12 hours of birth administer Hep B vaccine regardless of birth weight.
If weight < 2,000 grams : administer HBIG within 12 hours of birth only .
If weight > 2,000 grams : Determine mother’s HBsAg status as soon as possible
1. Sexually active persons. 8. Persons with ESKD or HIV or Chronic Liver disease
For high risk
2. Persons seeking evaluation or ttt for (STD) 9. Persons with HIV infection
patients: give
10. Chronic liver disease
series of 3 doses
3. MSM 11. International travelers to countries with high or intermediate
at baseline , after
4. Sex partners of hepatitis B prevalence of chronic HBV infection
one month and
5. Current or recent injection-drug users Health-
after
care personnel
6 months for :
6. Household contacts of HB s Ag positive persons
7. Diabetes < 60 years
Prophylaxis in  Pre exposure prophylaxis  Post exposure prophylaxis
hepatitis A,B  Vaccine or IMg  Vaccine or IMg
  Hep A Ig indications mainly for:  Hep B vaccine prefer to use within 7 days of exposure
 Travelers to endemic countries  Perinatal transmission
 Children younger than age 1 who need to be  Sexual contact with an infected person.
protected against HAV infection  healthcare professionals
 Hep A vaccine within 14 days of exposure
4. Haemophilus influenza type b (Hib)
 Routine Vaccination: at 2 ,4 ,6 and booster dose at 1 year
 Catch-up vaccination: < 5 years and not vaccinated Administer 3 doses of Hib
children aged: 1 -5 years with one of the following should have vaccine Adult : should receive vaccine with
children who received either no dose or only one dose before 12 months  anatomic or functional asplenia (including sickle cell disease)
should receive 2 more doses >>>>> if not previously vaccinated
children who received ≥2 doses should receive 1 additional dose for the  14 days before Elective splenectomy>>>>>> if not previously
following cases: vaccinated
 leukemia, malignant neoplasm's anatomic or functional  3 doses After successful hematopoietic stem cell transplant
asplenia (including sickle cell disease) >>>>>> regardless prior vaccination
(HIV) infection, or other immune-compromising conditions  Not given any more for HIV
5. Human Papilloma Virus
 The strains of HPV are spread during sex ( 2vHPV, 4vHPV4, 9vHPV)
 For HPV: The products differ in the HPV types against which they provide protection:
o HPV4: protects against types 6, 11, 16, and 18.
o HPV2 protects against types 16 and 18.
o HPV types 6 and 11 are associated with genital warts
o Types 16 and 18 are associated with gynecologic, anal, and penile cancers.
 3 dose series at age 11 or 12 years may be started at age 9 years using interval 0, 1-2, 6 month (UPDATE 2016)
 Not recommended for use in pregnant women I should make sure that the women after delivery to have the vaccine if not get it before ,
However, pregnancy testing is not needed before vaccination
3 doses :
First dose  1-2 months  second dose  >3 months 3rd dose
First dose ≥ 6 months  3rd dose
Male Female
 4vHPV4 OR 9vHPV  Either 2vHPV OR 4vHPV4 OR 9vHPV
 Catch up: 13 - 21 years  Catch up: 13 years through 26 years. After 26 years not indicated
 For Special Populations: Through age 26 years if:
i. MSM
ii. Immunocompromised >26 years not indicated.
 6. Meningococcal vaccine
 Types of vaccine : MenACWY , MPSV4 , Men B ( Update 2016)
 Routine dose :
 Single dose of vaccine at age 11- 12 years with a booster dose at age 16 years
 Give for : Dose 11-12 years another dose at when go to university or for people in crowd places like hagi in army or for microbiologist
 Catch-up vaccination: 2 Doses (2 months apart) at age 13-18 years if not previously vaccinated
 REVACCINATION : Each 5 years by MenACWY is preferred for
 Asplenia "EXAAAAM"
 persistent compliment deficiencies ( deficiency in specific enzyme )
 microbiologists
MenACWY MenB vaccine
CHILDREN: 11-12 YEARS and booster at 16y  For Asplenia or complement deficiencies, microbiologists , and
CHILDREN: 13-18 YEARS not vaccinated or need catch-up after 16 outbreak settings EXAAAM
years old.  Young adults aged 16–23 years (preferred age 16–18 years) may
For adult be vaccinated to provide short-term protection against most strains
1- Adult with Functional asplenia or persistent complement of MenB disease”
deficiencies. (2 DOSES, 2 month )  May be administered concomitantly with MenACWY vaccine, but
2- Microbiologists routinely exposed to isolates of N. meningitidis at a different anatomic site if feasible
3- Military recruits  MenB not recommended for travelers
4- Who travel to or live in countries in which meningococcal disease  No recommendation for MenB revaccination
is hyperendemic or epidemic MPSV4
5- First-year college students up through age 21 years who are Preferred in patients at age 56 years and didn’t received
living in residence halls if have not received a dose on or after their MenACWY and need vaccine eg. Travelers
16th birthday
6- Single dose of meningococcal for all except NO 1
7- FOR vaccinated previously with MenACWY and are
recommended for revaccination every 5 years EXAAAM
8- For whom multiple doses (need doses of MenACWY ) are
anticipated need revaccinated every 5years.
7. Rotavirus 8.IPV
Minimum age is 6 weeks for routine vaccination At age 2 , 4 , 6 months Administer a series of IPV at ages 2, 4, 6–18 months, with a booster at
Catch up: no catch up age 4–6 years
Maximum age for the 1st dose in the series is 14 weeks
Maximum age for final dose in the series is 8 months
 9. PCV 13 & PPSV 23 Vaccine (pneumococcal vaccine)
6 Important Info you should know about Pneumococcal Vaccine:
1. Adults are recommended to receive 1 dose of 13-valent pneumococcal conjugate vaccine (PCV13) and 1, 2, or 3 doses (depending on indication) of 23-valent
pneumococcal polysaccharide vaccine (PPSV23).
2. Spacing:
PPSV23  at least 1 year  PCV13
PCV13  at least 1 year  PPSV23
 [Except among adults with immune-compromising conditions, anatomical or functional asplenia , CSF leak, or cochlear implant
PCV13  at least 8 wks  PPSV23
PPSV23 at least 5 years  PPSV23
 In pediatrics < 18 years, all intervals are 8weeks

3- No additional dose of PPSV23 is indicated for adults vaccinated with PPSV23 at age ≥65 years.
4- When both PCV13 and PPSV23 are indicated, PCV13 should be administered first
5- PCV13 and PPSV23 should not be administered during the same visit.
6˗ PCV13 and PPSV23 should be administered to adults whose pneumococcal vaccination history is incomplete or unknown.
1. Didn’t receive both before:
PCV13  at least 1yr PPSV23
2.Recieved 1 dose PPSV23 at age > 65
wait 1 yr PCV13

3.Recieved ≥1 PPSV23 at age <65

1.Pt ≥65yrs ( immune-
wait 1 yrPCV13  at least 1 yr  PPSV23 [ &at least 5 yrs after the most recent PPSV23]
competent)
4. Received PCV13 at age <65 years
wait 1 yr  PPSV23

5. Received PCV13 and ≥1 PPSV23 at age <65:

wait 1 yr  PPSV23 [&at least 5 yrs after the most recent PPSV23]
2.Adults 19-64 yrs with
CHD(exclude HTN),chronic
Administer single dose of PPSV23
pulmonary disease ( COPD,
emphysema, asthma), DM, Imp Note:
asthma, smokers, alcoholic, In children <18 yrs : Asthma should be treated with high-dose oral corticosteroid therapy to be a risk here
chronic liver disease (including
Cirrhosis)
3. cochlear implants or CSF leaks PCV13  8 WEEKS  PPSV23
4.Adults living in nursing home
PPSV23 NO LONGER RECOMMENDED “UPDATE”
or long-term care facility
Didn’t receive both PCV13 or PPSV23:
PCV13 8 wks PPSV23 then PPSV23 after 5yrs
Received 1 dose of PPSV23:
wait 1 yr  PCV13  8 wks PPSV23 [& at least 5 yrs after the 1st dose of PPSV23]
5. Immuno-compromised Received 2 doses of PPSV23:
A. Adults 19-64yrs wait 1 yr  PCV13
Received PCV13:
B. Functional or anatomical 8 wks  PPSV23  5 yrs PPSV23 [& at least 5 yrs after the first dose of PPSV23]
asplenia Received PCV13 and 1 dose of PPSV23:
wait 8 wks after PCV13  PPSV23 [at least 5 yrs after the 1st dose of PPSV23]

Note: If the most recent dose of PPSV23 was administered at age <65 years, at age ≥65 years, administer a dose of
PPSV23 at least 8 weeks after PCV13 and at least 5 years after the last dose of PPSV23.
Immunocompromising conditions in adults & Children Anatomical or functional asplenia in adults & Children
1- Congenital or acquired immunodeficiency (including B- or T-lymphocyte 1-Sickle cell disease and other hemoglobinopathies
deficiency, complement deficiencies, and phagocytic disorders excluding EXAAAM
chronic granulomatous disease) 2- Congenital or acquired asplenia, splenic dysfunction, and splenectomy.
2- HIV infection
3- Chronic renal failure, nephrotic syndrome, solid Administer pneumococcal vaccines at least 2 wks before
4- Leukemia, lymphoma, Hodgkin disease, generalized malignancy, multiple immunosuppressive therapy or an elective splenectomy, and as soon as
myeloma possible to adults who are newly diagnosed with asymptomatic or
5-Organ transplant, and iatrogenic immunosuppression (including long-term symptomatic HIV infection
systemic corticosteroids and radiation therapy). EXAAAM
Pneumococcal Vaccination in Children
Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23)

Routine vaccination with PCV13:

• Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months.

Catch-up vaccination with PCV13:

• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.
 Vaccination of children with high-risk conditions with PCV13 and PPSV23
Age (2-5 years old) Age (6-18 years old)
The Following high risk conditions: The Following high risk conditions:
1-CHF (particularly cyanotic congenital heart disease & HF) 1-CSF leak; cochlear implant
2-chronic lung disease (Asthma should be treated with high-dose oral 2-Anatomical or functional asplenia
corticosteroid therapy) 3- Immuno-compromising conditions
3-DM 
4-CSF leak; cochlear implant 1. Didn’t receive both:
5-Anatomical or functional asplenia  Administer 1 dose of PCV13 now and 1 dose of PPSV23 at least 8
6-Immuno-compromising conditions weeks later.
 2. Received PCV13:
1. Incomplete schedule of 3 doses of PCV (PCV7 and/or PCV13): Administer 1 dose of PPSV23 at least 8 weeks after the most recent
 Administer 1 dose of PCV13 dose of PCV13.
2. Unvaccinated or any incomplete schedule of < 3 doses of PCV (PCV7 3. Received PPSV23:
and/or PCV13):  Administer 1 dose of PCV13 at least 8 weeks after the most recent
 Administer 2 doses of PCV13 at least 8 weeks apart dose of PPSV23.
3. If 4 doses of PCV7 or other age-appropriate complete PCV7 series:
 Administer 1 supplemental dose of PCV13
4. If no history of PPSV23 vaccination:
 Administer PPSV23 at least 8 wks after the most recent PCV13.
The Following high risk conditions:
1-CHF (particularly cyanotic congenital heart disease & HF)
2-chronic lung disease (Asthma should be treated with high-dose oral
corticosteroid therapy)
3-DM
4-Alcoholism, or chronic liver disease

Didn’t receive PPSV23:
 Administer 1 dose of PPSV23.
Received PCV1:
 Administer PPSV23 at least 8 weeks after any prior PCV13 dose.
Revaccination:
• A single revaccination with PPSV23 should be administered 5 years after the first dose to children with [Anatomical or functional aspleni or
Immuno-compromising conditions]
 10. DTaP & TdaP Vaccine
D , P = full strength dose need for children.
d , p = partial dose need for adult
Dtap , DT Tdap & Td
• < 7 years • > 7 years
• Administer a 5-dose series at ages 2, 4, 6, 15-18 mths & 4-6 yrs • Adolescents : 11y -12y (through18 yr catch-up) Administer 1
• The same DTaP product should be used for all doses dose of Tdap followed by (Td) booster doses every 10 years
• Pregnant women during each pregnancy: receive 1 dose of Tdap
regardless Tdap/Td history at 27- 36 weeks of gestation
• Adults (>19 years) (Td) booster doses every 10years
Unvaccinated or behind schedule: Who have not received Tdap vaccine or for
 3 Doses Tdap (spaced at 0, 1–2month, and 6–12month intervals) whom vaccine status is unknown
 Substitute Tdap for any dose in the series, preferably as dose #1.
 Using tetanus toxoid (TT) instead of Tdap or Td is not recommended.
 Health Care Professional if they have not previously received Tdap
 For adults Skin Wound Management a single dose of Tdap is preferred to Td if they have not previously received Tdap Regardless of interval
since the most recent Td
Tdap can be administered regardless of interval since the most recent Td containing vaccine.

11. MMR & Varicella

 Routinely 2 Doses 1 dose at age 12-15 months and the 2nd dose at age 4 -6 years
st

 Due to higher incidence of febrile seizures separate MMR and Varicella vaccines as the first dose given to children 12–47 months of age.
Routine second dose of MMR vaccine is recommended for adults who:
a) Students in postsecondary educational institutions
b) Work in a health-care facility (Even born before 1957)
c) Plan to travel internationally
Catch-up for MMR Varicella Vaccine Catch Up for adult
 For children :  All adults without evidence of immunity to varicella should
 Ensure that all persons aged 7- 18 years without evidence of receive 2 doses varicella vaccine
immunity have 2 doses of varicella & MMR vaccine  Health-care personnel and Family contacts of persons with
 For adult : immunocompromising conditions)
 Who born before 1957 are naturally immunized and no need for
 At high risk for exposure:
vaccination.
 All Adult born in 1957 or later ** NO documentation of 1 or (e.g., teachers; child care employees; residents and staff members of
more institutional settings, including correctional institutions; college
 doses of MMR NO medical, or laboratory evidence of immunity to students; military personnel; adolescents and adults living in
each of the three diseases) and NO C.I to the vaccine households with children; non pregnant women of childbearing age;
 The CDC advises that have at least one dose of MMR vaccine and international travelers).
 For women:
 For women of childbearing age, regardless of birth year:
Upon Termination of pregnancy and before discharge from hospital
 If there is no evidence of immunity:
 Women who are not pregnant should be vaccinated. (one
dose MMR)
 Pregnant women who do not have evidence of immunity
should receive MMR vaccine upon completion of pregnancy
and before discharge from the health care facility
12. Zoster Vaccine
Routine Vaccination:
 recommended by CDC as Single dose for adults aged ≥60 years regardless of whether they report a prior episode of herpes zoster
 Indicated by (FDA) for use to persons aged 50 years