Immunization


Article Author:
Jacob Ginglen


Article Editor:
Michael Doyle


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/26/2019 12:06:23 PM

Introduction

Immunization has become a vital part of public health and disease prevention, and yet, remains a controversial topic in our society today. Diseases which were once responsible for significant morbidity and mortality have now become all but eradicated, thanks to the introduction of vaccines. Immunization has contributed to increased life expectancy and improved quality of life[1][2].

The first vaccine is credited to Edward Jenner, who in 1796 inoculated a 13-year-old boy with the virus responsible for cowpox, and he demonstrated immunity to smallpox. The first smallpox vaccine was created in 1798 using that premise. Over the following centuries, and leading up to present-day, vaccine technology has improved, and vaccines to many illnesses have been developed. In 1979, global eradication of smallpox was achieved, thanks to immunization[3][4][5].

The World Health Organization has made lifelong immunization a priority, including it as a core to the 2030 Sustainable Development Goals. In fact, in 2012, the World Health Assembly adopted the Global Vaccine Action Plan, which aims to prevent millions of deaths by 2020 by increasing access and utilization of vaccines throughout all parts of the world. The first milestone this action plan hopes to achieve is the worldwide eradication of polio.

A vaccine is a pharmacologic compound that improves a person's immunity to a particular disease. When a disease-causing bacterium or virus invades the human body, the immune system recognizes the material as foreign, usually by detecting specific protein portions of the invading organism, known as antigens. Vaccines contain a form of the disease-causing agent, whether it be a weakened or killed form of the microbe itself, an inactivated version of its toxins, or a protein from the surface of the microbe. By introducing a form of the agent, the vaccine presents the antigen to the immune system, allowing it to recognize the antigen as foreign and develop antibodies and memory T-lymphocytes against those antigens. This allows a more rapid and robust immune response should the body be exposed to the organism in the future. In the absence of vaccination, the first exposure to the natural organism may prove fatal before the immune system can mount a sufficient immune response.

Anatomy

Vaccines affect the immune system, primarily through B-lymphocytes and T-lymphocytes. Before exposure, the immune system contains B-Lymphocytes and T-Lymphocytes, each with the potential to respond to a unique antigen. Many antigens require a combined response of both B-Lymphocytes and T-Lymphocytes. This form of immunity is termed T-cell-dependent. Less commonly, an antigen causes stimulation of B-Lymphocytes and antibody production without the help of T-lymphocytes. This form of immunity is termed T-cell-independent.

The vaccine introduces the antigen to begin the process, which stimulates the initiation of the immune response. Initially, the foreign material is phagocytized, and broken down by macrophages. The resultant peptides created by the breakdown of the protein material is sent to the surface of the macrophage cell, where it is displayed. These antigens are displayed by molecules called Major Histocompatibility Complexes, which exist in two forms: I or II (MHC-I or MHC-II). The presentation of the antigen stimulates the secretion of several inflammatory mediators, including cytokines and various interferons, which stimulate a further response.

In T-cell dependent immunity, so-called T-helper cells recognize the antigen and stimulate the corresponding B-lymphocytes to proliferate and produce antibodies. As the B-lymphocytes proliferate, they also differentiate into antibody-forming plasma cells. The antibodies produced have various functions, the most important of which include those which inactivate soluble protein toxins (antitoxins), those which facilitate intracellular digestion of bacteria by damaging the bacterial membrane (lysins), those that prevent reproduction of pathogenic viruses (neutralizing antibodies), and those that prevent bacterial adhesion to mucosal surfaces (antiadhesion). In response to vaccines, the first antibodies produced are primarily IgM, with a gradual switch to IgG in the following weeks.

Indications

Childhood vaccinations are indicated for the prevention of a multitude of viral and bacterial infections and their sequelae. Specific vaccination recommendations for children vary by region, as exposure to diseases varies by region.

Current recommendations for adult vaccination includes a yearly influenza vaccine and tetanus-diphtheria every 10 years, with tetanus-diphtheria-acellular-pertussis at least once in adulthood. The addition of acellular pertussis once during adulthood is intended to prevent the transmission of whooping cough to young children or those unable to be vaccinated. For those adults born after 1956 who didn't receive measles, mumps, rubella vaccinations, or varicella vaccination as children, these vaccinations are recommended in adulthood. Human papillomavirus, hepatitis A, and hepatitis B vaccines are also recommended in adulthood. Meningococcal vaccine is recommended for adults at high-risk, such as those living in close quarters (college students living in dorms, military personnel living in barracks). Pneumococcal vaccination is also recommended for adults at high risks, such as those with pre-existing pulmonary diseases like chronic obstructive pulmonary disease (COPD)[6]

Passive immunization is indicated in patients who cannot form antibodies, such as those immunocompromised. It is also indicated when the disease may develop before active immunity is capable of developing antibodies, such as in a patient exposed to rabies. In this instance, the patient may develop rabies before the active immunization effectively creates antibodies.

Contraindications

Contraindications to immunization are rare[7]. The primary contraindication is an allergy to a vaccine or a component of the vaccine. Patients with a history of a compromised immune system, such as in AIDS or another immune deficiency, should use caution when vaccinating with a live attenuated vaccine. Live attenuated vaccines should not be given to a pregnant woman, unless there is an immediate risk (such as a polio epidemic), as the live vaccines have the potential to infect the fetus.

Caution should be used when administering a vaccine to a child with an acute moderate to severe illness, with or without a fever. The cause of fever following vaccination in this population may be difficult to determine, whether it be continued illness or directly resulting from the vaccination. This may complicate the management of the illness.

Equipment

Immunizations are administered with syringes and sterile needles. The size and type of syringe and needle depending on the vaccination, the specific route of administration, and on clinician preference. Personal protective equipment, including medical gloves, is also required. Alcohol or other topical disinfectant is used to prepare the skin before vaccine administration. A simple band-aid or gauze and tape can be used to cover the site following administration. 

Personnel

Immunizations are administered by a variety of healthcare personnel, including medical assistants, licensed practical nurses/licensed vocational nurses, registered nurses, nurse practitioners, physicians' assistants, physicians, pharmacy technicians, and pharmacists.

Preparation

Immunizations come in various preparations, depending on the manufacturer. Many vaccinations are combinations, such as the measles, mumps, rubella or tetanus, diphtheria, acellular pertussis vaccines. Vaccines may be prepared in a single dose or multi-dose preparations. Some vaccines come in prefilled syringes, while others are in vials and must be drawn into a syringe before administration.

Technique

Typically, immunizations are administered intramuscularly, whereby the preparation is directly injected into a muscle belly. Some vaccines are given via the subcutaneous or transdermal route.

Complications

Most vaccines carry a small risk of B-symptoms following administration, including fever, fatigue, and myalgias[8]. These symptoms are caused by the immune response being mounted against the antigen introduced by the vaccine and usually last a day or two. Swelling and redness may occur at the injection site, and localized muscle soreness may also occur.

More serious complications are possible, though extremely rare. Anaphylaxis may occur in response to a vaccine or one of its ingredients.

Another very rare complication of vaccination is Guillain-Barre Syndrome, which is a potentially life-threatening condition affecting the peripheral nervous system. The mechanism by which vaccination causes Guillain-Barre is not known. Symptoms include ascending paresthesias and paralysis, with potential paralysis of respiratory muscles possible.

Clinical Significance

Vaccination is vital to public health. Disease prevention has been proven to prolong life expectancy and improve quality of life. As antivaccination movements gain traction, diseases once thought to be eradicated or nearly eradicated have had significant outbreaks. Unfortunately, preventive measures such as vaccines are often overlooked by primary care providers and patients[9]. For children, parents often do not know the appropriate schedule for vaccines, and therefore are often unaware of when their children are behind on vaccinations. Another common reason for missed vaccination is missed appointments for various reasons. Patient recall and reminder systems have been created and shown significant improvement in increasing vaccination compliance rates. 

Enhancing Healthcare Team Outcomes

Nurses, pharmacists, and providers are typically responsible for providing patients with immunizations and monitoring compliance. Often patients and the patient's parents are not the only ones responsible for poor vaccination compliance. Primary care providers, nurses, and pharmacists also sometimes overlook preventive measures, as they are focused on appointments regarding specific illnesses or symptoms or the need to fill prescriptions. Provider recall and reminder systems have also been created and also have shown improvement in vaccination compliance. The team needs to work together to assure the community and individuals are protected by appropriate immunization. [Level V]


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Immunization - Questions

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Which of the following is the most common side effect of immunizations given at 2 months of age?



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Which of the following is true about immunizations during the first year of life?



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Which of the following vaccines is not routinely administered between ages 12 and 15 months?

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The mother of an 8-month-old infant telephones the clinic and states that her child is scheduled to receive immunizations today but the infant is sick with a fever over 102 F. Which of the following instructions should be given to the mother?



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Which one of the following immunizations may be administered to a pregnant woman?



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A 15-month-old has had a fever with each immunization. At the 12 month visit, the shots resulted in local cellulitis requiring oral antibiotics. Which is the best management for this patient?



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How many years after the most recent dose of tetanus is a routine booster dose indicated?

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A 2-month-old preterm infant presents for scheduled immunizations. His weight is 2.4 kg. What would be the appropriate measure to take regarding his immunization?



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Which of the following plays the most critical role in under-immunization of children?



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Which of the following interventions has been demonstrated to increase immunization rates?



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Which of the following statements is true regarding the immunization of adolescents?

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A 4-month-old infant is scheduled for routine health maintenance and immunizations, but the mother calls and says the child has upper respiratory infection symptoms and a fever of 39.8 C. Which of the following is most appropriate?



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In which situation would it be most appropriate to delay routine immunization of a 4-month-old infant?



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Which of the following is not a form of antigen utilized by vaccines?



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Which of the following immunizations should be completed before a child is 7 years of age? Select all that apply.



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An infant has just received his routine immunizations. Which of the following are appropriate discharge instructions? Select all that apply.



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Immunization - References

References

An Early American Smallpox Vaccine Based on Horsepox., Schrick L,Tausch SH,Dabrowski PW,Damaso CR,Esparza J,Nitsche A,, The New England journal of medicine, 2017 Oct 12     [PubMed]
DeStefano F,Bodenstab HM,Offit PA, Principal Controversies in Vaccine Safety in the United States. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2019 Feb 12;     [PubMed]
Gagneur A,Quach C,Boucher FD,Tapiero B,De Wals P,Farrands A,Lemaitre T,Boulianne N,Sauvageau C,Ouakki M,Gosselin V,Gagnon D,Petit G,Jacques MC,Dubé È, Promoting vaccination in the province of Québec: the PromoVaQ randomized controlled trial protocol. BMC public health. 2019 Feb 6;     [PubMed]
Bidgood SR, Continued poxvirus research: From foe to friend. PLoS biology. 2019 Jan;     [PubMed]
Liebowitz D, Smallpox vaccination: an early start of modern medicine in America. Journal of community hospital internal medicine perspectives. 2017 Jan;     [PubMed]
Ignatova GL,Antonov VN, Efficiency of vaccine prophylaxis concentrated pneumococcal vaccine in patients with chronic obstructive lung disease and chronic heart failure. Terapevticheskii arkhiv. 2018 Aug 27     [PubMed]
Edinboro M, Assessing Vaccine Contraindications Through the Use of the Immunization Action Coalition Screening Checklist. Workplace health & safety. 2019 Apr     [PubMed]
Shen SC,Dubey V, Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents. Canadian family physician Medecin de famille canadien. 2019 Mar     [PubMed]
Filia A,Bella A,D'Ancona F,Fabiani M,Giambi C,Rizzo C,Ferrara L,Pascucci MG,Rota MC, Childhood vaccinations: knowledge, attitudes and practices of paediatricians and factors associated with their confidence in addressing parental concerns, Italy, 2016. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin. 2019 Feb     [PubMed]

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