Host defenses to

infection

BY
Dr Tarek Amin
Dr Amira Gamal
immunity

Natural Artificial
Types of immunity

Passive
Passive (seroprophylaxis)

Active
Active immunization
 Active artificial immunization
By vaccines or toxoids
[I] Vaccines:
1-Live vaccine (naturally attenuated): smallpox vaccine
2-Live attenuated (avirulent): BCG, Sabin, MMR

3-Inactivated (killed) vaccine: Salk

4-Polysaccharide: e.g. mingococcus & pneumococcus

vaccines

5-Surfaces- antigen: HBV

[II] Toxoids:
Diphtheria & tetanus toxoid stimulate antitoxic
humoral immunity

Routes of vaccination:
*Deep S.C or IM: DPT, Measles, MMR
*Oral: Sabin, oral BCG, oral typhoid vaccine
*I.D: BCG
*Scarification or multiple puncture: Smallpox
vaccine
*Intranasal: live attenuated influenza vaccine
System of active immunization
Primary, booster or revaccination
*Primary immunization:
-Single dose: BCG, MMR, YF
-Multiple doses (with adequate spacing): DPT,,
Sabin, HB vaccine
*Booster immunization: DT, YF

Mixed-antigen vaccines: given simultaneously

e.g. DPT, Salk DPT,HBDPT, MMR
Effectiveness of active immunization:

*Absolutely protective (100%): YF & rabies

vaccine

*Almost absolutely protective (99%): MMR, DT

*Highly protective (80-95%): Polio vaccine,

HB vaccine

*Moderately protective (40-60%): BCG

 Application of active immunization
(1)Immunization of infants & children
(EPI)
(2)Adult immunization:
-BCG: at-risk tuberculin non-reactors
-MMR (never during pregnancy)
-TT (mothers before or during
pregnancy)
-Any disease in case of epidemics
Application of active immunization
(3)Immunization of occupational groups:

- Farmers
-Troops (TT, BCG, Rabies)
-Medical profession: BCG, HBV

(4)International travelers: YF,

meningococcal vaccine
 Passive immunization
(Sero-prophylaxis)

-Given for rapid temporary protection before

exposure
-Provide ready-formed Ab
-Includes: Human preparations: Ig
Animal preparation: antitoxins
 Immunoglobulin (IG)
(human serum = immune serum globulin)
Forms:
-Human normal Ig: from pooled human blood
in endemic areas. Contains Ab against
MMR, HAV

-Plasma specific Ig (hyperimmune gamma

globulin): from plasma of immunized donors
Antiviral & antitoxins – anti-pertussis
Immunoglobulin (IG)
(human serum = immune serum globulin)

Application:
prevention of some viral dis. (HAV, measles),
tetanus, diphtheria, pertussis
Sero-therapy: tetanus & diphtheria
 Animal antisera

(1)Antitoxin: prevention & ttt of toxemic dis.

e.g. diphtheria, tetanus, gas gangrene,
botulism

(2)Antiviral serum: antirabies serum (Ig is

better)
The Susceptible Host
I- Active Immunization
The most powerful and cost-effective technique for
prevention of infectious diseases.
Diseases that been classified according to the
preventive role of active immunization into:
Vaccine-preventable-diseases:
‘poliomyeilitis, meseales, tetanus,
pertusis, diphtheria, and tuberculosis?.
This vaccines are given as a routine during
infancy and childhood.
.
The Susceptible Host
I- Active Immunization
Special risk vaccination ‘ geographic, high risk
population:
cholera, yellow fever, influenza, plague, and typhoid
fever.
These vaccines given in responses to local as well as the
international circumstances of diseases occurrence.

Diseases which need improved or less costly vaccines:

pertusis, tuberculosis, meningococcal meningitis,
rabies, hepatitis B, Japanese encephalitis
Hazards of immunization (AEFI)
1-Reaction inherent to vaccine
2-Reaction due to faulty techniques
3-Reaction due to hypersensitivity
4-Neurological involvement
5-Provocative reactions
6-Others
1-Reaction inherent to vaccine
-Local: pain, swelling, redness, tenderness, small nodule,
sterile abscess
-General: fever, malaise, headache
-Most of killed vaccines (typhoid), toxoids

2-Reaction due to faulty techniques

-Faulty production: inadequate attenuation
-large dose
-improper site or route of administration
-Diluents: wrong amount, contaminated
-Ignored contra-indication
-Contaminated syringes
3-Reaction due to hypersensitivity
-Antisera causes anaphylactic shock
(bronchospasm, dyspnea, pallor, hypotension &
collapse) & serum sickness (fever, rash, edema
& joint pain)
-Allergy to constituents (antibiotics, eggs)

4-Neurological involvement
-Neurologic involvement: post vaccinial
encephalitis, & encephalopathy after, Pasteur
vaccine & smallpox vaccine
5-Provocative reactions
-DPT is provocative factor for onset of
paralytic polio

6-Other hazards
-Damage to fetus (rubella vaccine during
pregnancy)
-Displace age distribution of disease e.g.
MMR
National Immunization Schedule
For infants
BCG + OPV-0 dose At birth
BCG (if not given at birth) At 6 weeks
DPT-1 +OPV-1+HBV-1
DPT-2+OPV-2+HBV2 At 10 weeks
DPT-3+OPV-3+HBV3 At 14 weeks
Measles At 9 months
DPT+OPV (HIB) At 16-24 months
DT + BCG (booster) At 4-5 years
Tetanus toxoid At 10 & 16 years
For pregnant
women
TT-1 or booster Early
One moth after
TT-2 TT-1
Active Immunization Recommended under Special
Circumstances
Immunization Disease

Two SC. Doses of 0.5 ml at interval of 4-6 weeks, during *Cholera

campaign only one 1.0 ml dose is given. Immunity develops
.after 6 days after inoculation. Booster every 6 months
Given SC. Or IM in 2 doses at an interval of 7 to 14 days Plague
Immunity starts 5-7 days after inoculation and lasts about 6
months
For adults: 2 doses 0.5 ml SC. at an interval of 4-6 months Typhoid
.Immunity develops 10-21 days after inoculation **fever
Booster dose of 0.5 ml is recommended yearly for high risk
D vaccine is given in one single dose of 0.5 ml SC. -17 Yellow fever
.Immunity begins after 10-12 days and lasts for 10 years

Inactivated vaccine is given in 2 doses of 1.0 ml each SC.

Interval of 1-2 months, booster given on yearly basis.
Influenza
Single dose may be used during epidemic threats.
Immunity only lasts for 6 months.

.an effective oral vaccines are available **, *

Requirements of Immunization
Schedule
Vaccinations should be included only against Epidemiologically
diseases which are representing a public health relevant
problem and against which an effective vaccine
.exists

Children must be vaccinated at an age when Immunologically

they can benefit from it ‘ capable of forming effective
anti-bodies when they have lost the passive
immunity transferred from maternal
.circulation
.Includes cost and a high percentage of coverage Operationally
Minimize the number of visits, by simultaneous feasible
.administration of multiple vaccines

The local customs, beliefs, practices, seasonal, Socially acceptable

.climatic and work pattern of the community
Reduce waiting time and proper guidance
 II- Passive Immunization
:Three types of preparations are available
 Normal human immunoglobulin,
 Specific ‘hperimmune’ human immunoglobulin,
 Antisera or anti-toxins.
It is a short term method for protection, used when
exposure to infection has just occurred or is imminent
within the next few days.
The duration of protection is short and variable ‘1-6
weeks’
Side effect can occur specially with the non-human
preparations.
 Appropriate uses for human immunoglobulin in the prevention and

treatment of diseases
Status Dose preparation Target population Agent /
condition
Prevention IM / 4 months 0.02-0.05 IG Family contacts Hepatitis A
Institutional outbreak
travelers
Prevention IM repeated 0.05-0.07 HGIG Percutaneous or mucosal Hepatitis B
accordingly exposure
Newborn of infected
mother, sexual contacts
Prevention ml 20 IG Women exposed during Rubella
early pregnancy
Prevention units /kg 15-25 VZIGd Immunocompromized Varicella-
contacts, newborn zoster
Prevention ml/kg to 0.5 for 0.25 IG Infants < 1 year, Measles
immunosuppressed immunosuppressed
Prevention IU/kg 20 RIG Subjects exposed to Rabies
rabid animals
Prevention and units for prevention to 250 TIG Significant exposure of Tetanus
treatment 3000-6000 units for unimmunized person or
therapy immediately following
diagnosis
 Passive Immunization Procedures
with Anti-sera
Passive immunization (Anti-sera) Disease

IU of antitoxin given IM to susceptible contacts 500-1,000 Diphtheria

.immediately after exposure. Gives protection for 2-3 weeks

.units of horse ATS given SC. Or IM soon after injury 1500 Tetanus

Polyvalent antitoxin is used in a dose of 10,000 IU of Cl. Gas gangrene

Perfringens, antitoxin, 5,000 units of Cl. Septicum antitoxin, and
10,000 units of Cl. Oedmateins antitoxin, IM, or IV in
.emergencies
Anti rabies serum in a dose of 40 IU /kg given IM within 72 hours Rabies
preferably within 24 hours of exposure. A part should be applied
.locally to the wound
units of polyvalent anti toxin is recommended every 3-4 10,000 Botulism
.hours IV
 III-Combined Passive and Active
Immunization
In some disease ‘tetanus, diphtheria, rabies’ passive
immunization is often undertaken in conjunction with
inactivated vaccine products, to provide both immediate yet
temporary passive immunity and slowly developing active
immunity.

if injection is used for inoculation, separate sites should be

implemented to guard against impairment of the active agent
due to immunoglobulin.

Immunoglobulin should not be administered within 3 weeks

before, or until 2 weeks after administration of a live attenuated
vaccine, exception to this rule are hepatitis B vaccine and
hepatitis B immunoglobulin.
IV-Chemoprophylaxis
Chemoprophylaxis implies protection from or prevention
.of diseases by using pharmacological preparations

Chemoprophylaxis

Causal prophylaxis Clinical prophylaxis

Implies the complete

Prevention of infection by Implies the prevention of clinical
the early elimination of Symptoms, it does not necessary
the invading or migrating Mean elimination of infection
.causal agent
 Indications of Chemoprophylaxis
Chemoprophylaxis Disease

Tetracycline, oxycycline, furadolidine for Cholera

household contacts Bacterial
.Erythromycin ophthalmic ointment conjunctivitis
.Erythromycin and 1st dose of vaccine Diphtheria
Amantadine (only for type A) for contacts Influenza
.suffering from chronic diseases
Chloroquine Malaria
Meningococc
Rifampacin for household and close community al meningitis
contacts
.Immunization should be initiated in all cases Plague
.Tetracycline for contacts of pneumonic plague
V- Non-specific Measures
Improvement of the quality of life:
Better housing, sanitary water supply, sewage
disposal, food sanitation, good nutrition,
educational improvement, and socio-
economic advancement.
Legislative measures:
For effective programs integration and
implementation.
V- Non-specific Measures
Community involvement in disease
surveillance:
Also in disease control and other public
health activities.
Availability of funds for health and laboratory
facilities.
Modification of human behavior:
Through health education.
Maintained compact surveillance system
 EPI
Extended Program of Immunization

2. Pregnant mothers
1. Child Immunization TT
Tuberculosis (TB) (protect mother &
Diphtheria neonate)
Tetanus
Measles (MMR)
Poliomyelitis
Pertussis
Hepatitis B
Hib
Objectives of EPI

a) Reducing incidence of target

diseases.
b) Reducing mortality rate from these
target diseases.
What damage vaccine
All vaccines lose their potency after a certain time
expire date printed on the vaccine.

Heat and sunlight (especially the live attenuated ones

Polio, Measles and BCG).

Freezing damages the killed vaccines and toxoids

(DPT, DT, TT)

Disinfectants or antiseptics antibiotics (streptomycin

on BCG)
Cold Chain System
1-Definition:

The cold chain is a system for distributing

vaccine in a potent state from the
manufacturer to the actual vaccination site.

It consists of a series of transportation links

during which adequate refrigeration is
required to maintain the vaccine potency.
2- Components of cold chain system?

a) People to manage the cold chain

system and to organize the vaccine’s
distribution.

b) Equipment to store and transport

vaccines.
3-Health centre and cold chain

A) Obtain vaccines

B) Maintain equipment

C) Maintain vaccines
A-Obtaining vaccines
-Estimate amount of vaccine:
Number of births or
Multiply total population by 0.03
-Add wastage rate (50% in BCG and 25% in
other vaccines) •
-Collect vaccines at regular intervals (once a
week or once every two weeks)
-Do not store vaccines longer than one month at
health center.
 -Check expiry date on each vial of vaccine
-Use shortest route to transport vaccine.
-Keep vaccine containers in shade
-Transfer vaccines and diluents quickly to
refrigerator

B- Equipment maintenance
• Refrigerator
• Cold box
• Vaccine carriers
• icepacks
Refrigerators:
1. Store vaccine at temperature between 0 ºC
and 8 ºC.

2. Freeze ice packs for cold boxes and vaccine

carriers

3. Freeze blocks of ice for cooling vaccine in a

cup during vaccination
Proper place & position of refrigerator
1.Shaded place do not expose to direct sunlight.
2.Well ventilated area.
3. Away from the wall (10 - 15 cm)
4.Ensure it is level.
5.Responsible person in charge of refrigerator.
6.Keep doors firmly shut.
7.Unbroken rubber insulation seal around the
door
Vaccines in refrigerator
1-Polio & Measles vaccine on 1st shelf , BCG in
2nd shelf, DPT, DT and TT in 3rd shelf
2.Vaccine and diluents are stacked in rows.
3.Clearly separate different types of Vaccines.
4.Leave 2 cm between rows of vaccine to permit
air circulation
Vaccines in refrigerator
5.New vaccine placed on right (use it late)
6.NO vaccine in door compartment.
7.Keep ice packs in freezer.
8.Place containers of water in bottom of
refrigerator.
9.Put thermometer inside refrigerator
10.Check temperature twice daily
Review questions:
-Enumerate EPI target diseases
-What are the objectives of EPI?
-What damages vaccines?
-Discuss the schedule of TT immunization of pregnant
mothers.
-Full account on:
Cold chain
Role of PHC center in cold chain
Cold chain equipment
THANK YOU