IMMUNIZATION
Prof. Dr. Muhammad Akbar
Nizamani
Liaquat University of Medical and
Health Sciences Jamshoro
Immunization Global Situation
Each year 130 million children are born, 91 million
of them in developing countries.
Almost 30 million children have no access to
immunization.
"Nearly 2 million children worldwide still die
needlessly each year of vaccine-preventable
illnesses.
Success Story
 Eradication of disease EX: smallpox
 Elimination of disease EX: polio
 Control of disease EX: diphtheria
Immunization
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“The health of the people is the
foundation upon which all their
happiness and their power as state
depends.”
“An ounce of prevention is worth a
pound of cure”
Immunization
Infectious disease deaths 2001
WHO estimates
diphtheria
4 000
measles
554 000
poliomyelitis
<100
tetanus
201 000
Pertusis
285 000
hepatitis B
3000
yellow fever
15 000
Hib
450 000
meningitis AC
12 000
rotavirus
338 000
pneumococcal 841 000
total
2 703 000
1 000
191 000
1000
80 000
1 000
518 000
15 000
0
14 000
162 000
768 000
1 751 000
5 000
745 000
1000
281 000
286 000
521 000
30 000
450 000
26 000
500 000
1 609 000
4 454 000
PAKISTAN
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Infant Mortality rate: 67 per 1000 live births
Under Five Mortality: 85 per1000 L. Births
Neonatal Mortality: 38 per 1000 L. Births
What Kills: approx 600000 per year
• Pneumonia 200000 per year
• Diarrhea
200000 per year
• Vaccine preventable
120000 [20%]
• ?ROUTINE EPI COVERAGE: 30 – 60 % , 80-85%UNICEF
• IN 1990 OUR COVERAGE WAS > 90%
One of the 5 countries in EMRO not on target to achieve MDG 4
• WHERE ARE WE GOING?
• WHERE WE SHOULD BE?
• SHOULD LOOK AFTER OUR CHILDREN?
Diseases covered by EPI
immunization
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Poliomyelitis
Tuberculosis
Diphtheria
Pertusis
Tetanus
Hepatitis B
H.Influenzae: Pneumonia , Meningitis
Measles
ROUTINE IMMUNIZATION: Every
journey begins with a single step
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At Birth : OPV , BCG (HEP B)
6 WEEKS : OPV1 ,PENTA 1
(PENTA: Diphtheria, Pertusis, Tetanus,
Homophiles Influenza Type B, Hepatitis B)
10 WEEKS : OPV 2 ,PENTA2 , HEP B 2
14 WEEKS : OPV 3 ,PENTA 3, HEP B 3
9 MONTHS : MEASLES 1
12 MONTHS: MEASLES 2
TT IMMUNIZATION for Child bearing age women
Minimum two vaccines during pregnancy
Active Immunization
Types
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Live attenuated
• Virus
• Bacteria
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Killed
BCG
• Virus
• Bacteria
 Whole
 Toxoid
 Polysaccharide
OPV,Measles, mumps,
IPV
Pertusis
Tetanus
Meningococcal
Genetically Engineered
• Hepatitis B

rubella
TT Immunization
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TT immunization for CBA women, pregnant women
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Most unfortunate to still see mothers and babies dying of
neonatal tetanus
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TT 1: First contact with a girl reaching CBA or As early as
possible in pregnancy
TT2: 4 weeks after TT1
TT3: At least 6 months after TT2 or in next pregnancy
TT 4:At least one year after TT3 or in next pregnancy
TT5: At least one year after TT 4
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For Trauma/ wound in Immunized person single dose TT
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Plus…
the Pentavalent Advantage
Pertussis
5
Hep B
Protection against
5
diseases
in
just
one
injection:
First do no harm:
Hippocrates oath
H. Influenza type b vaccine
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H. Influenza type b is a common
cause of bacterial meningitis,
pneumonia, epiglottis and sepsis in
infants and children
H. Influenza type b (Hib) vaccine is
polysaccharide vaccine
Administered together with PENTA
vaccine
Dose is 0.5ml intramuscularly
Hib
(Haemophilus influenzae type b)
A serious infectious disease causing meningitis
and pneumonia in infants and children
• At least 3 million infected worldwide 1
• Children aged between 4
and 12 months most at risk 1,2
• 400,000 – 700,000 deaths worldwide each year 1
• Prevalence of Hib disease is 15-50% or more in developing countries 3
• 500,000 children die from Hib pneumonia every year 4
• 50,000 children die from Hib meningitis every year 4
3
McIntyre P. JAMA (SEA Suppl) 1993; 9: 5-10. 4 Shapiro ED, Ward, JI. The epidemiology and prevention of disease caused by Haemophilus
influenzae type b. Epidemiologic Reviews 1991; 13:112-143.
1WHO
position paper Wkly Epidemiol Rec 1998; 73: 64-68 2Cambell H. et al Drugs 1993; 46: 378-383
Pneumonia
Hepatitis B key facts
Over 2 billion people infected worldwide1
350 million chronic carriers worldwide1,2
4 million new acute hepatitis B cases per year3
1-2 million deaths annually directly related to HBV infection2,4
HBV is 100 times more infectious than HIV5
Around 62% of liver cancer cases in Pakistan
are due to hepatitis B
HBsAg the seventh EPI antigen
‘Only by mass vaccination of infants
with HB vaccine as part of EPI
will the burden of HB infection
be significantly reduced globally’
WHO, 1992
Measles Rash
Measles Pharyngitis
Koplik Spots
AVAILABLE VACCINES NOT
YET PART OF EPI
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Conjugated Pneumococcal Vaccine for IPD
at 2 ,4 and 6 months or with routine
immunizatioin.
MMR : 15- 18 M
Hepatitis A Vaccine 1 y , 2nd Dose 3 – 6 M
Chicken Pox Vaccine
Typhoid Vaccine 2 years
Influenza Virus vaccine 1 y , Every Year
Yellow Fever Vaccine
Rota Virus Vaccine
Meningococcal Vaccines
(Chickenpox Vaccine)
Primary infection: varicella
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Can develop in an estimated 95% of
adults in temperate climates by the age of
25 years
is associated with complications in healthy
children as well as high-risk groups, e.g.
immunocompromised patients
is the leading cause of vaccinepreventable deaths in children in the USA
Forghani et al, 1994
Chicken Pox Encephalitis
Primary infection: varicella
Congenital varicella syndrome
Reactivation: herpes zoster
Clinical presentation of herpes
zoster
Measles-Mumps-Rubella:
what is the best choice for three in one?
MMR
PRIORIX
Measles –complications
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Otitis media: 1/10 children
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Pneumonia: 1/20 children
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Encephalitis: 1/1000 children
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Sub-acute sclerosing
panencephalitis (SSPE):
1/100,000 children
Other complications:
blindness, miscarriages,
premature births and
congenital malformations
Encephalitis
Pneumonia
Mumps – complications
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Meningo-encephalitis:
5–15%
Deafness: 0.5–5/100,000
Orchitis: 30–40% of adult
men
Mastitis: approx. 30% of
women after puberty
Oophoritis, miscarriage,
pancreatitis
Encephalitis
Congenital rubella syndrome (CRS) –
clinical features and complications
• Rubella during pregnancy:
up to 80% chance of baby
born with CRS
• Growth retardation, eye
problems, deafness, heart
defects, mental retardation
• Many other organs and
body systems can be
affected
• Onset of signs, symptoms
and abnormalities may be
delayed
Thrombocytopenia in a baby
born with CRS
Meningococcal Vaccines:
•
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Meningococcal polysaccharide
vaccine
A/C/Y/W-135
Recommended to children older than
2 years AND at risk (terminal
complement component deficiency,
asplenia, military recruits ,traveling
Meningococcal conjugate vaccine A/C
used in Europe for infants
Minor side effects
34
34 million children are
not fully immunized
2.3 million still die each year
Diseases reappear when coverage
drops
Opportunities: Best way of
escaping from a problem is to solve
it
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Vaccines are safe
Immunization is among
the safest of modern
medical interventions.
Vaccines are easier and
safer to administer than
ever before.
Being immunized is
much safer than risking
infection and disease.
Immunization can save money
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Immunizatio
n is one of
the most
costeffective
health
interventions
.
Investing in
vaccines
SAVES more
money than
it costs.
Immunization saves lives

Immunization
saves the lives of
approximately 3
million people each
year, all over the
world.
Immunization
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Challenges ???
EPI : Current Status in Pakistan
Started in 1978
 Promising start
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Coverage Rates in 80s reached >80%
 Fully immunized rates now only 47%
 Wide spread provincial differences in coverage:
Punjab 53%, KPK 47%, Sindh37%,Balochistan
35%.
 Campaign districts in 2009 reported coverage of
BCG 93%, Polio 86%, Penta 86%, Measles 85%
and TT 55% and over all coverage of 86%.
 UNICEF state of the world children reports
80-85%
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Challenges to EPI
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Poor routine coverage
Poliomyelitis eradication still serious issue
Outreach capacity of vaccinators
Service structure of EPI staff
Attitude of doctors in health facilities
Private sector involvement
Political interference in management of EPI staff;
absenteeism
Maintenance of vaccine stock and quality “ he
who should do good to another must do it in the
Minute Particulars. William Black”
Challenges to EPI
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Maintenance of cold chain ( A desk is dangerous place from where to view the world)
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Lack of accountability
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Monitoring , evaluation and information management (Not every thing that counts
can be counted and not everything that can be counted, counts. A . Einestein).
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Poor disease surveillance “ All interest in disease and death is only another
expression of interest in life”.
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Demand creation, behavior change “ Knowing is not enough we must apply, willing is
not enough we must do. Goethe’
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Lack of political will ,commitment and proper planning
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“We tackle 20 year problems with 5 year plans, staffed by two
year personnel working with one year appropriation. It is simply
not good enough”
Questions to be answered
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Why we are not able to eliminate poliomyelitis in spite of so
many rounds?
Inject able polio vaccine versus oral vaccine.
Alternative to BCG; when will be more effective vaccine
available?
Should we start Hepatitis B vaccine at birth now?
Why Pertusis resurgence?
A cellular Pertusis versus whole cell Pertusis!!
Booster of penta !!
Which should be ninth vaccine of EPI: Pneumococcal,
Typhoid, Hepatitis A, MMR ,Chicken Pox???
Measles at months ?
Why are our newborns still dying in tetanus?
References and more reading
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UNICEF state of the world’s children 2011
Immunization essentials. A practical field guide US AID
2003 ,2010
Immunization Basics:
www.immunizationbasics.jsi.com.resources.general.htm
www.who.int/pmnch/topics
www.who.int/vaccine_research
www.path.org/vaccineresources
www.cdc.gov/vaccines/
www.vaccines.org
www.niaid.nih.gov
www.immunizationinfo.org/vaccines/hepatitis B
Thank
you once
again
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