PCMC 27th COMPREHENSIVE REVIEW Championing Immunization

Fatima Ignacio Gimenez, MD, FPPS, FPIDS

IMMUNIZATION o Not consistently immunogenic in

• Process whereby a person is made immune or children younger than 2 years of age
resistant to an infectious disease, typically by the o No booster response
administration of a vaccine o Antibody with less functional activity
• Immunity and immunologic memory similar to o Immunogenicity improved by
natural infection but without risk of disease conjugation
- Cannot replicate
TYPES OF IMMUNITY
- Less affected by circulating antibody than live
• Active Immunity
vaccines
- Protection produced by the person`s own
- Always require multiple doses
immune system
- Immune response mostly humoral
- Lasts for many years , usually a lifetime
- Antibody titer diminish with time
- Sources: active infection and vaccination
- May require periodic supplemental booster
• Passive immunity doses
- Protection transferred from another human or
animal GENERAL RECOMMENDATIONS ON IMMUNIZATION
• Inactivated vaccines are generally not affected by
- Temporary protection that wanes with time
circulating antibody to the antigen. Live attenuated
- Transfer of antibody to placenta
vaccines may be affected by circulating antibody to
FACTORS THAT AFFECT IMMUNE RESPONSE TO VACCINES the antigen.
• Presence of maternal antibodies • All vaccines can be administered at the same visit as
• Nature and amount of antigen in vaccine all other vaccines.*
• Route of administration • Increasing the interval between doses of a
• Presence of an adjuvant (ingredient that promotes multidose vaccine does not diminish the
a stronger immune response) effectiveness of the vaccine.* Decreasing the
• Storage and handling of vaccine interval between doses of a multidose vaccine may
• Vaccinee: interfere with antibody response and protection
- Age *after the series has been completed
- Nutritional status
Antibody Measles and Varicella Containing* Vaccines
- Genetics
Product Given First Action
- Coexisting disease
Vaccine Wait 2 weeks before giving
CLASSIFICATION OF VACCINES antibody
• Live attenuated Antibody Wait 3 months or longer
- Viral or bacterial before giving vaccine
- Attenuated (weakened) form of the “wild” * Except zoster vaccine
virus or bacterium
Suggested Intervals Between Immune Globulin
- Must replicate to produce an immune
Administration and Active Immunization with MMR,
response MMRV or Monovalent Varicella Vaccines
- Immune response virtually identical to natural Indications/Product Interval
infection (months)
- Usually produce immunity with one dose* Blood transfusion
- Severe reactions possible Washed RBCs 0
- Interference from circulating antibody RBCs, adednine-saline added 3
- Fragile - must be stored and handled carefully Packed RBCs 6
- *except those administered orally Whole blood 6
Plasma/platelet products 7
• Inactivated Botulinum IG 6
- Non-live or fraction of the organism CMV IVIG 6
- Viral or bacterial Hepatitis A prophylaxis as IG
- Protein-based (e.g. toxoid or subunit vaccines) Contact prophylaxis 3
- Polysaccharide based (e.g., bacterial cell wall International travel 3
polysaccharide) HBIG 3
Tetanus prophylaxis as TIG 3

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

Measles prophylaxis as IG for people NOT 6 • Parenteral live vaccines (MMR, MMRV, varicella,
pregnant/severely immunocompromised zoster, and yellow fever) and LAIV are not believed
Measles prophylaxis as IG for pregnant 8 to have an effect on live vaccines given by the oral
and/or severely immunocompromised route (OPV, oral typhoid, and rotavirus). Live oral
Rabies prophylaxis as RIG 4 vaccines may be given at any time before or after
Replacement for immune deficiency as IVIG 8 live parenteral vaccines or LAIV.
RSV prophylaxis (palivizumab monoclonal None
antibody) Timing: 2 Live Vaccines
IVIG for ITP • The 4 day grace period should not be applied to the
400 mg/kg 8 4 week interval between 2 different live vaccines.
800 – 1000 mg/kg 10 • This is only applicable if either vaccine was given
IVIG for KD alone.
1600 – 2000 mg/kg 11 - MMR1 given < 4 days to second dose of MMR
Varicella prophylaxis is VALID
As IVIG 8 - MMR and Varicella < 4 days to second dose of
As VariZIG (IM) 5 MMR is NOT VALID
- MMRV < 4 days to second dose of MMRV is
Case Number 1: An 3 year old who was born preterm was NOT VALID
recently diagnosed for Kawasaki disease. Patient was given
IVIG and aspirin. Interval Between Doses of the Same Vaccine
Mother is worried that she will be unable to complete her • Doses should not be given earlier than the
immunization on time. She particularly asks you at what age minimum age
can the varicella vaccine be given? • Vaccine doses given 4 days before the minimum
Upon review of her immunization record, you find out that interval or age is counted as valid ( ACIP )
she has been given two doses of MMR and one Varicella at • Doses administered up to 4 days before the
2 years of age. minimum interval or age can be counted as valid*
She is currently on antibiotic for treatment of UTI. • Any vaccine administered ≥5 days earlier than the
Your plan of action. minimum interval or age should not be counted as
valid doses and should be repeated as age
Questions appropriate.
Can she receive vaccines? • The repeat dose should be spaced after the invalid
Considerations to be taken into account.. dose by the recommended minimum interval.
If so, what vaccine/vaccines may be given ? • It is not necessary to restart the series or add doses
Timing of the vaccine ? because of an extended interval between doses
*Exception: Rabies Vaccine

Guidelines for Spacing of Live and Inactivated Antigens

Case Number 2: A healthy 6 month female child was brought
Combination Interval
your clinic and mother hands over the baby book. Upon
All others None
perusal you saw that she only received a BCG and Hepatitis
Exceptions: PCV 13 & Menactra* PCV 13 & PPSV23 B at birth and a dose of OPV two weeks ago as part of the SIA
*In children with functional and anatomic asplenia and or
(supplemental immunization campaign)
HIV infection Your plan of actions.
2 live parenteral vaccines, 4 weeks List down all vaccines to be given.
or live intranasal vaccines If <4 weeks, repeat the
second vaccine give
CONTRAINDICATIONS AND PRECAUTIONS
Exception: Yellow Fever Vaccine after Monovalent
CONDITION LIVE INACTIVATED
Measles
Allergy to Component C C
The effect of nonsimultaneous administration of rubella,
Encephalopathy -- C
mumps, varicella, and yellow fever vaccines is unknown.
Pregnancy C V*
Simultaneous and Nonsimultaneous Administration Immunosuppression C V
• Live vaccines administered by the oral route (oral Moderate/severe illness P P
polio vaccine [OPV] oral typhoid, and rotavirus) are Recent Blood Product P** V
Legend:
not believed to interfere with each other if not C- Contraindication P- Precaution V- Vaccinate if indicated
given simultaneously. These vaccines may be given *HPV vaccine should be deferred in pregnancy
at any time before or after each other. **MMR and varicella containing ( except Zoster ) only

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

PERMANENT CONTRAINDICATIONS - Stable neurologic conditions (e.g., cerebral

• Severe allergic reaction to a vaccine component or palsy, well-controlled seizures, or
following a prior dose developmental delay)
• Encephalopathy not due to another identifiable - History of collapse or shock-like state within 48
cause occurring within 7 days of pertussis hours after receiving a previous dose of
vaccination DTP/DTaP
• Severe combined immunodeficiency (rotavirus
- History of seizure with or without fever within
vaccine)
3 days after receiving a previous dose of
• History of intussusception (rotavirus vaccine)
• Guillain-Barré syndrome (GBS) occurring 6 weeks or DTP/DTaP
more after a previous dose of a tetanus toxoid or - History of persistent, inconsolable crying
influenza vaccine lasting >3 hours within 48 hours after receiving
• History of thrombocytopenia or thrombocytopenic a previous dose of DTP/DTaP
purpura: MMR vaccine
• Tdap
• Chronic gastrointestinal disease, spina bifida,
- Fever of ≥40.5°C for <48 hours after
bladder extrophy, or altered immunocompetence
other than SCID: Rotavirus vaccine vaccination with a previous dose of DTP or
DTaP
Precaution - History of collapse or shock-like state within 48
• In general, vaccines should be deferred when a hours after receiving a previous dose of
precaution is present DTP/DTaP
- History of seizure with or without fever within
Temporary Precaution 3 days after receiving a previous dose of
• History of Arthus-type hypersenstivity reaction DTP/DTaP
after a previous dose of diphtheria toxoid or - History of persistent, inconsolable crying
tetanus toxoid vaccine; risk-benefit decision exists lasting >3 hours within 48 hours after receiving
until at least 10 years have elapsed since the last
a previous dose of DTP/DTaP
tetanus-toxoid-containing vaccine
- History of extensive limb swelling after
• Progressive neurologic disorder, including infantile
DTP/DTaP/Td that is not an Arthus-type
spasms, uncontrolled epilepsy, progressive
encephalopathy; risk-benefit decision exists until reaction
neurologic status has been clarified and stabilized - Stable neurologic disorder, history of brachial
neuritis
INVALID CONTRAINDICATIONS TO VACCINATIONS - Breastfeeding
• Mild illness - Immunosuppression
• Antimicrobial therapy
• Disease exposure or convalescence Case Number : A 9 month F is brought to the clinic as mother
• Pregnant or immunosuppressed person in the is frantic having heard of measles outbreak in her
household community. Her only child, a 2 year old received an MMR at
• Breastfeeding 12 months of age.
• Preterm birth
• Allergy to products not present in the vaccine or On review of records, you see that child has received BCG, 3
allergy that is not anaphylactic doses of Hexavalent vaccine and 2 doses of PCV (latter given
• Family history of adverse events 2 months ago).
• Tuberculin skin test
• Multiple vaccines Mother volunteers that baby is fully breastfed and she had
measles when she was a teenager
CONDITIONS COMMONLY MISPERCEIVED AS
CONTRAINDICATIONS Mothers volunteers to have a family history of seizures
Vaccine may be administered under these conditions You plan of action
• DTaP (MMWR Recomm Rep 2018;67(No. RR-2)
- Fever of <105°F (<40.5°C), fussiness or mild VACCINATION OF IMMUNOSUPPRESSED PERSONS
drowsiness after a previous dose of DTP/DTaP • Live vaccines should not be administered to
- Family history of seizures, sudden infant death severely immunosuppressed persons
syndrome or an adverse event after DTP or • Persons with isolated B-cell deficiency may receive
DTaP administration varicella vaccine

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

• Inactivated vaccines are safe to use in • LIVE VACCINES should be administered ≥4 weeks
immunosuppressed persons but the response to prior to immunosuppression and should be
the vaccine may be decreased avoided within 2 weeks of initiation of
immunosuppression.
Timing of Vaccinations • INACTIVATED VACCINES should be administered ≥2
• Vaccines should be administered prior to planned weeks prior to immunosuppression
immunosuppression if feasible. • Delay live vaccines for at least 1 month after
discontinuation of high-dose therapy of steroids

SAFETY OF ADMINISTRATION OF LIVE VACCINES TO CONTACTS OF IMMUNOCOMPROMISED PERSONS

LIVE VACCINE SHEDDING OF TRANSMISSIBILITY FROM RECOMMENDATION FOR ADMINISTERING
AGENT (SITE)? VACCINATED VACCINES (WHEN INDICATED) TO HEALTHY
IMMUNOCOMPETENT PERSON? IMMUNOCOMPETENT CONTACTS OF
IMMUNOCOMPROMISED PATIENTS
Influenza, live, Yes (nasal secretions) Rare (from 1 vaccinated toddler) Administer (strong, low); vaccinated persons
attenuated to avoid close contact with persons with
nasal hematopoietic stem cell transplant or severe
combined immune deficiency for 7 days
(weak, very low)
Measles, Measles: no No, except mother-to-infant Administer (strong, moderate)
mumps, and Mumps: no transmission of rubella vaccine
rubella Rubella: yes virus via breast milk
(nasopharynx, in low
titer; breast milk)
Polio, oral Yes (stool) Yes, with rare cases of vaccine- Do not administer (strong, high)
associated paralytic poliomyelitis
Rotavirus, oral Yes (stool) Yes, but no reported cases of Administer (strong, low)
symptomatic infection in contacts
Typhoid, oral No No Administer (strong, low)
Varicella Yes (skin lesions) Rare, limited to vaccines with skin Administer (strong, moderate); if skin lesions
lesions develop, avoid close contact with
immunocompromised persons
Yellow fever No, except possibly Yes (at least 3 cases of Administer (strong, moderate) except to
shed in breast milk encephalitis in infants exposed to women who are nursing
the vaccine via nursing)
Zoster Yes (rarely recovered Not reported Administer to those aged ³60 y (strong,
from injection site moderate); if skin lesions develop, avoid
vesicles) close contact with immunocompromised
persons
IDSA 2013 Guidelines
2021 VACCINES IN THE PHILIPPINE NATIONAL
Case Number 5: A 4 year old M is about to undergo a IMMUNIZATION PROGRAM (NIP)
splenectomy. Mother claims that patient has received all the The following vaccines are in the 2021 NIP:
recommended vaccines. Upon review, you see received the • Bacille Calmette Guerin (BCG)
primary series plus a booster of DPT, IPV, Hib, Hep B with 3 - Given intradermally (ID)
doses of PCV, the last having been given at 7 months of age. - Given at the earliest possible age after birth
He also received dose of Hepatits A, a dose of MMR, and preferably within the first 2 months of life
Varicella and had her annual influenza 6 months ago. - For healthy infants and children > 2 months of
age who are not given BCG at birth, PPD prior
2020 Disclaimer to BCG vaccination is not necessary
The Childhood Immunization Schedule presents recommendations for
immunization for children and adolescents based on updated literature review,
- PPD is recommended prior to BCG vaccination
experience and premises current at the time of publication. The PPS, PIDSP and if any of the following is present:
PFV acknowledge that individual circumstances may warrant a decision differing
o Congenital TB
from the recommendations given here. Physicians must regularly update their
knowledge about specific vaccines and their use because information about o History of close contact to known or
safety and efficacy of vaccines and recommendations relative to their suspected infectious cases
administration continue to develop after a vaccine is licensed.
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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

o Clinical findings suggestive of TB

and/or chest x-ray suggestive of TB • Haemophilus influenzae type b Conjugate Vaccine
- In the presence of any of these conditions, an - Given intramuscularly (IM)
induration of 5 mm is considered positive and - Given as a 3-dose primary series with a
BCG is no longer recommended minimum age of 6 weeks and a minimum
- Dose: interval of 4 weeks
o 0.05 ml for children < 12 months of - A booster dose is given between 12-15 months
age of age with an interval of 6 months from the 3rd
o 0.1 ml for children ≥ 12 months of age dose

Case Number 5: A healthy 4 month old infant is brought to Refer to Vaccines for Special Groups for Hib
your clinic. Mother claims there was no BCG given at the recommendation in high risk children
health center at the time of birth. She recently learned that
the baby father tested positive on sputum smear. • Diphtheria and Tetanus Toxoid and Pertussis
What is your plan of action? Vaccine (DTP)
- Given intramuscularly (IM)
• Hepatitis B Vaccine (HBV) - Given at a minimum age of 6 weeks
- Given intramuscularly (IM) - The primary series consists of 3 doses with a
- Administer the first dose of monovalent HBV to minimum interval of 4 wks
all newborns >2kgs within 24 hours of life. - Booster series consist of 3 doses until
- A 2nd dose is given 1-2 months after the birth adolescence with the following schedule:
dose o 12-23 months (DTP)
- The final dose is administered not earlier than o 4-7 years (DTP)
24 weeks of age. Another dose is needed if the o 9-15 years (Td/Tdap)
last dose was given at age <24 weeks. - Ideally, the minimum interval between booster
- For infants born to HBsAg (+) mothers: doses should be at least 4 years
o Administer HBV and HBIG (0.5ml) - Full dose DTP should preferably be used only
within 12 hours of life. HBIG should be until age 7 years but package inserts should be
administered not later than 7 days of consulted for maximum age indications of
age, if not immediately available. specific products
- For infants born to mothers with unknown
• Inactivated Poliovirus Vaccine (IPV)
HBsAg status: - Given intramuscularly (IM), as a standalone IPV
o Birth weight ≥2 kgs: administer HBV or in combination with DTP containing vaccines
within 12 hours of birth and - The primary series consists of 3 doses
determine the mother’s hbsag as soon - Given at a minimum age of 6 weeks, at least of
as possible. 4 weeks apart in between doses
o Hbsag (+): administer also HBIG not - First booster at 12-18 months of age. The
later than 7 days of age. minimum interval between the third dose and
o Birth weight <2 kgs: administer HBIg in and the first booster is 6 months.
addition to HBV within 12 hours of - The second booster is given at 4-6 years of age
life. - If the 4th dose is given at age 4 years onward ,
o <2 kgs: the 1st dose received at birth is no further doses are necessary
not counted as part of the vaccine
series. Additional 3 HBV doses are • Oral Polio (LHC)
needed. - Only available as part of the government`s NIP
- Given per orem ( PO )
Case Number 6: A mother comes to you as she is set to - The primary series consists of 3 doses
deliver in 7 weeks. She found out that she was HBsAg beginning at age 6 weeks with a minimum
positive and negative for all STI`s including HIV. The child was interval of 4 weeks
born prematurely and weighed 1.8 grams
Your plan of action? How many doses will constitute the
primary series?

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

Administration of IPV, DOH Memorandum N0 2015-0164 (May 21, 2015)

INFANTS IMMUNIZATION SCHEDULE
Vaccines Route & Site of Administration Age of the Child
At Birth 1 ½ mos 2 ½ mos 3 ½ mos 9 mos 12 mos
BCG Intradermal (upper arm) ✓
Hepatitis B Intramuscular (upper thigh) ✓
DPT-HepB-Hib Intramuscular (upper right thigh) ✓ ✓ ✓
OPV Oral (mouth) ✓ ✓ ✓
IPV Intramuscular (upper left thigh) ✓
Rotavirus Oral (mouth) ✓ ✓
PCV Intramuscular (upper left thigh) ✓ ✓ ✓
Measles Subcutaneous (upper arm) ✓
MMR Subcutaneous (upper arm) ✓

• Rotavirus Vaccine (RV) o PCV 13 :

Hima ( RV 1 ) § If first dose is given at 12 -23
- Given per orem (PO) as oral liquid formulation. months: give 2 doses at least
- Given as a 2-dose series 2 months apart
- Given at a minimum age of 6 weeks with a § If first dose is given at 2-5
minimum interval of 4 weeks between doses. years of age give 1 dose only
The last dose should be administered not later
than 32 weeks of age. • Measles Vaccine
- Given subcutaneously (SC)
Human Bovine live attenuated reassortant (RV 5) oral - Given at the age of 9 months, but may be given
liquid formulation as early as 6 months of age in cases of
- Given per orem (PO) as oral liquid formulation. outbreaks as declared by public health
- Given as a 3-dose series, recommended at authorities
2,4,6 months - If monovalent measles vaccine is not available,
- First dose is given at a minimum age of 6 -12 then MMR/MR vaccine may be given as
weeks with a minimum interval of 4 weeks substitute for infants below 12 months of age
between doses. The last dose should be - In such cases the recipe should receive 2 more
administered not later than 32 weeks of age. MMR vaccines starting at 1 year of age,
• Pneumococcal Conjugate Vaccine (PCV) following recommended schedules.
- Given intramuscularly (IM) • Measles-Mumps-Rubella Vaccine (MMR)
- Given at a minimum age of 6 weeks - Given subcutaneously ( SC )
- Primary vaccination consists of 3 doses with an - Given at a minimum age at 12 months
interval of at least 4 weeks between doses plus - 2 doses of MMR vaccine are recommended
a booster dose given 6 months after the 3rd - The 2nd dose is usually given at 4-6 years of
dose. age but may be given at an earlier age with a
- For previously unvaccinated infants 7 -11 minimum of 4 weeks interval between doses
months old ; give a total of 3 doses - MMRV may be given as an alternative to
o The first 2 doses are given 1 month separately administered MMR and Varicella
apart. The interval between 2nd and vaccines
3rd doses is at least 2 months but - The maximum age is 12 years
should ideally be given at or after the - The recommended minimum interval between
first birthday doses is 3 months but a second dose given 4
- For previously unvaccinated older 12 months weeks from the first dose is considered valid
to 5 years old:
o PCV 10 : 1-5 years of age - give 2 • Influenza Vaccine (Tetravalent/ Quadrivalent
doses at least 2 months apart Influenza Vaccine)
- Trivalent influenza vaccine (TIV) given
intramuscularly (IM) or subcutaneously (SC)
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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

- Quadrivalent influenza vaccine (QIV) given • Human Papillomavirus Vaccine (HPV)

intramuscularly (IM) - Given intramuscular (IM)
- Given at a minimum age of 6 months - For males 9-18 years of age, a 4vHPV and
- Children 6 months to 8 years receiving 9vHPV can be given for the prevention of
influenza vaccine for the 1st time should anogenital warts and anal cancer
receive 2 doses separated by at least 4 weeks
9 – 14 years 15 years and older
- If only one dose was given during the previous
2- dose series 3- dose series
influenza season, give 2 doses of the vaccine
Bivalent HPV (2vHPV), Bivalent HPV (2vHPV),
then one dose yearly thereafter
quadrivalent (4vHPV), or quadrivalent (4vHPV), or
- Children aged 9 to 18 years should receive one nonavalent (9vHPV) at 0 and nonavalent (9vHPV) at 0, 2, and
dose of the vaccine yearly 6 months 6 months
- Annual vaccination should begin in February If the interval between the The minimum interval between
but may be given throughout the year 1st and 2nd dose is less than the 1st and the 2nd dose is 1
6 months, a 3rd dose is month and the minimum
• Japanese Encephalitis Live Attenuated
needed. interval between the 2nd and 3rd
Recombinant Vaccine
dose is 3 months.
- Given subcutaneously (SC)
The minimum interval
- Given at a minimum age of 9 months between the 2nd and 3rd The 3rd dose should be given at
- Children 9 months to 17 years of age should dose is 3 months. least 6 months from the 1st
receive one primary dose followed by a booster dose.
dose 12-24 months after the primary dose
- Individuals 18 years and older should receive a • Tetanus and Diphtheria Toxoid (Td)/ Tetanus and
single dose only Diphtheria Toxoid and Acellular Pertussis Vaccines
(Tdap)
• Varicella Vaccine - Given intramuscularly (IM)
- Given subcutaneously (SC) - For children who are fully immunized*,
- Given at a minimum age of 12 months Td/Tdap booster doses should be given every
- 2 doses of varicella vaccine are recommended 10 years
- The 2nd dose is usually given at 4-6 years of age, - For children aged ≥ 7 years old, a single dose of
but may be given earlier at an interval of 3 Tdap can be given and can replace due Td. It
months from the first dose. can be administered regardless of the interval
- If the 2nd dose was given 4 weeks from the first since the last tetanus and diphtheria toxoid-
dose, it is considered valid. containing vaccine. Subsequent doses are
- For children ≥ 13 years of age, he given as Td/Tdap
recommended minimum interval between - Fully immunized: 5 doses DTP or 4 doses of DTP
doses is 4 weeks. if the 4th dose was given on or after the 4th
• Hepatitis A Vaccine birthday
Inactivated Hepatitis A Vaccine (HAV) - For pregnant adolescents, give 1 dose of Tdap
- Given intramuscularly (IM) for every pregnancy
- Given at a minimum age of 12 months - Fully immunized pregnant adolescents,
- 2 doses of the vaccine are recommended administer 1 dose of Tdap vaccine at 27 to 36
- The 2nd dose is given at least 6 months from the weeks AOG, regardless of previous Td or Tdap
1st dose vaccination
- Unimmunized pregnant adolescents,
Live attenuated Hepatitis A Vaccine (HAV) administer a 5 –dose tetanus-diptheria ( Td )-
- Given subcutaneously containing vaccine following a 0,1,6,18 and 30
- Minimum age of 18 months month schedule. Use Tdap as one of the 5
- Given as a single dose doses ,preferably given at 27-36 weeks AOG

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

ANNOTATIONS FOR THE RECOMMENDED VACCINES

SUMMARY TABLE: Immunization of Teens and Pre-teens 2021 (9-18 years old)
Range of Precautions and
Vaccine Dose Schedule of immunization Route
recommended age contraindications
- Severe allergic reaction to
Unvaccinated
Hep B vaccine 3 0, 1, 6 months IM vaccine component
9-18 yrs old
- Moderate to severe illness
- Severe allergic reaction to
Inactivated Unvaccinated 2nd dose given at least 6 months
2 IM vaccine component
Hep A vaccine 9-18 yrs old apart from 1st dose
- Moderate to severe illness
Unvaccinated
2 4 weeks interval between doses
9-18 yrs old
MMR Incompletely
2nd dose given at least 6 months
vaccinated 1 - Severe allergic reaction to
apart from 1st dose
9-18 yrs old vaccine component
Unvaccinated Minimum interval between doses - Pregnancy
2
9-12 yrs old is 3 months - Immunosuppression
SC
Unvaccinated Minimum interval between doses - Recent receipt of blood
2
≥ 13 yrs old is one month products
Varicella Given anytime - Moderate to severe illness
Incompletely 9-12 yrs old: 2nd dose
vaccinated 1 at least 3 mos from 1st dose
9-18 yrs old ≥13 yrs old: 2nd dose at least 1
mo from 1st dose
- Severe allergic reaction to
vaccine component,
Influenza Annually moderate to severe illness,
9-18 yrs old 1 IM/SC
vaccine Begin immunizing in February history of Guillain-Barre
syndrome following a
previous dose
- Severe allergic reaction to
For females
vaccine component
2vHPV/ 4vHP/
- Moderate to severe illness
9vHPV
9-14 yrs old 2 0, 6-12 months IM - If found to be pregnant after
For males
immunization, delay
4vHPV/
remaining doses until
9vHPV
completion of pregnancy
HPV: - Severe allergic reaction to
Females:
Bivalent HPV 3 0, 1 and 6 months vaccine component
15-18 yrs old
(2vHPV) - Moderate to severe illness
Quadrivalent Females: IM If found to be pregnant after
HPV (4vHPV) 15-18 yrs old immunization, delay
3 0, 2 and 6 months
Nonavalent Males: remaining doses until
HPV (9vHPV) 15-18 yrs old completion of pregnancy
For primary immunization, the 1st
and 2nd doses should be
delivered with an interval of at
least 4 weeks, and the 2nd and 3rd
- Severe allergic reaction to
doses with an interval of at least
Unvaccinated vaccine component
5 6 months. IM
Td/Tdap 9-18 yrs old
Two booster doses are given. The
- Moderate to severe illness
1st booster is given at least 1 year
after the 3rd dose, and the 2nd
booster is given at least 1 year
after the 1st booster

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

Incompletely
One dose Tdap then Td for
vaccinated 1-2
remaining dose
9-18 yrs old
Fully vaccinated
1 1 dose Tdap then Td every 10 yrs
9-18 yrs old

ANNOTATIONS FOR VACCINES FOR HIGH-RISK/SPECIAL

GROUPS - Revaccinate with a MCV4 vaccine every 5 years
• Meningococcal Vaccine as long as the person remains at increased risk
- Given intramuscularly (IM) or subcutaneously of infection
(SC) - MPSV4 given to children 2 years and above as
- Tetravalent meningococcal (ACYW-135) a single dose.
conjugate vaccine MCV4-D, MCV4-TT, MCV4- o If MPSV4 is used for high risk
CRM given intramuscularly (IM) individuals as the 1st dose, a 2nd dose
- Tetravalent meningococcal polysaccharide using MCV4 should be given 2 months
vaccine (MPSV4) given intramuscularly later.
(IM)/subcutaneously (SC) o Booster doses of MPSV4 are not
- Indicated for those at high risk for invasive recommended.
disease:
o Persistent complement component Co-administation of MCV and other vaccines
deficiencies (including those with - MCV4-D and PCV13
inherited or chronic deficiencies in C3, o If MCV4-D is administered to a child
C5-9, properdin, factor D, factor H) with asplenia (including sickle cell
o anatomic/functional asplenia disease) or HIV infection, do not
(including sickle cell disease) administer MCV4-D until age 2 years
o HIV and at least 4 weeks after the
o travelers to or resident of areas where completion of all PCV13 doses.
meningococcal disease is - MCV4-D and DTaP
hyperendemic or epidemic (including o If MCV4-D is to be administered to a
countries in the African meningitis child at high risk for meningococcal
belt or the Hajj) disease, it is recommended that
o belonging to a defined risk group MCV4-D be given either before or at
during a community or institutional the same time as DTaP.
meningococcal outbreak - MCV-TT with TT containing vaccines
o Whenever feasible, MCV4-TT should
MCV4-D MCV4-CRM MCV4-TT be co-administered with TT-
Minimum age is 9 Given to Minimum age is 6 containing vaccines, or administered 1
months children 2 weeks month before the other TT-
For children 9-23 mo: years and For infants 6 to 12 containing vaccines
give 2 doses 3 above as a weeks old: give first
months apart single dose 2 doses at least 2 • Rabies Vaccine
months apart; the - Given intramuscularly (IM) or intradermally
3rd (booster) dose is (ID)
at age 12 months - A repeat dose should be given if the vaccine is
For children 2 years For children from inadvertently given subcutaneously.
and above: give one 12 month of age to - Rabies vaccine should never be given in the
dose, except in cases adolescence: 1 dose gluteal area since absorption is unpredictable.
of asplenia, HIV, only
persistent Recommended regimens for pre-exposure
complement prophylaxis (PrEP):
component - For immunocompetent individuals given WHO
deficiency where 2 prequalified vaccines (Verorab ® or Rabipur ®):
doses, 8 weeks apart o (IM) regimen: Purified Vero Cell
are recommended Rabies vaccine (PVRV) 0.5 ml OR

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

Purified Chick Embryo Cell vaccine INTRAMUSCULAR REGIMENS APPROVED BY WHO

(PCECV) 1 ml given on days 0 and 7
o Intradermal (ID) regimen: PVRV or ZAGREB REGIMEN SCHEDULE (2-0-1-0-1) INTRAMUSCULAR
PCECV 0.1 ml given on days 0 and 7 SCHEDULE
- For immunocompromised individuals or those Day of PVRV PCECV Site of Injection
given non-WHO prequalified vaccines, give 3 Immunization
doses on days 0, 7, 21 or 28 Left and right
deltoids or
Day 0
In the event of subsequent exposures: anterolateral thighs
- High-risk* individuals who have completed 0.5 ml 1 ml in infants
PrEP require booster doses, regardless of the Day 7 One deltoid or
interval between exposure and last dose of the Day 21 anterolateral thigh in
vaccine. infants
- Booster doses may be given through either:
SHORTENED INTRAMUSCULAR SCHEDULE (CDC) (1-1-1-1-0)
o 1-visit regimen: 0.1 ml ID (PVRV or
Day of PVRV PCECV Site of Injection
PCECV) on each of the 4 sites on day 0
Immunization
o 2-visit regimen: 0.1 ml ID (PVRV or
Day 0
PCECV) OR 0.5 ml PVRV or 1.0 ml One deltoid or
Day 3
o PCECV IM at 1 site on days 0 and 3. 0.5 ml 1 ml anterolateral thigh in
Day 7
infants
- *for high risk individuals, pls. refer to: Day14
https://ais.doh.gov.ph/uploads/aopdf/ao2018-
0013.pdf • Pneumococcal Conjugate Vaccine (PCV)/
Pneumococcal Polysaccharide Vaccine (PPSV23)
Treatment Regimen Schedule - Given intramuscularly (IM)
Updated 2-Site Intradermal Schedule (2-2-2-0-2) - All recommended PCV doses should be given
• One dose for ID aministration is equivalent to prior to PPSV23 if possible.
0.1ml for PVRV and PCECV - The two vaccines should not be co-
• One dose shall be given on each deltoid on Days administered. If a dose of PPSV23 is
0, 3, 7, and 28 inadvertently given earlier than the
• One intradermal dose should have at least 0.5 IU recommended interval, the dose need not be
vaccine potency repeated.
2-SITE INTRADERMAL SCHEDULE (2-2-2-0-2) Schedule of PCV 13-PPSV23 Vaccination Sequence
Day of PVRV/PCEV Site of Injection 1. Age: 24 mos to 5 years
Immunization - Administer 1 dose of PCV13 if any incomplete
Day 0 schedule of 3 doses of PCV13 was received
Left and right deltoids or
Day 3 previously.
0.1 ml anterolateral thighs in
Day 7 - Administer 2 doses of PCV13 at least 8 weeks
infants
Day 28* apart if unvaccinated or any incomplete
*For WHO pre-qualified vaccines, the day 28 dose may be omitted
schedule of fewer than 3 doses of PCV13 was
following the IPC Institute de Pasteur du Camboge (IPC)
Intradermal Regimen (2-2-2-0-0) received previously.
- The minimum interval between doses of PCV13
INSTITUTE DE PASTEUR DU CAMBOGE (IPC) INTRADERMAL is 8 weeks.
REGIMEN (2-2-2-0-0) - For children with no history of PPSV23
Day of PVRV/PCEV Site of Injection vaccination, administer PPSV23 at least 8
Immunization weeks after the most recent dose of PCV13.
Day 0 Left and right deltoids or 2. Age: 6 yrs to 18 years:
Day 3 0.1 ml anterolateral thighs in - Administer 1 dose of PCV13 if they have not
Day 7 infants previously received this vaccine, regardless of
whether the previous vaccine received was
PCV7 or PPSV 23

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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

Indication (exclyding chronic

- Chronic heart disease, particularly cyanotic granulomatous disease)
congenital heart disease and cardiac failure • HIV infection
- Chronic lung disease, including asthma if • Chronic renal failure of
treated with high-dose oral corticosteroid nephrotic syndrome
therapy • Leukemia or lymphoma
- Diabetes mellitus • Hodgkin disease
- Cerebrospinal fluid leaks • Generalized malignancy
- Cochlear implant(s) • Iatrogenic
- Sickle cell disease and other immunosuppression
hemaglobinopathies (diseases requiring
- Congenital or acquired asplenia, or splenic treatment with
dysfunction immunosuppressive drugs,
- HIV infection including long-term
- Chronic renal failure and nephrotic syndrome systemic corticosteroids and
- Diseases associated with treatment with radiation therapy)
immunosuppresive drugs or radiation therapy,
• Solid organ transplant
including malignant neoplasms, leukemias,
• Multiple myeloma
lymphomas, and Hodgkin disease; or solid
organ transplantation
- Congenital immunodeficiency (includes B- • Haemophilus influenzae type b Conjugate Vaccine
(humoral) or T-lymphocyte deficiency, (Hib)
complement deficiencies (particularly C1, C2, - Given intramuscularly (IM)
C3, and C4 deficiencies), and phagocytic
Indications for children with the following high risk
disorders (excluding chronic granulomatous
conditions:
disease) - Chemotherapy recipients, anatomic/functional
NUMBER OF DOSES OF PPSV 23 ACCORDING TO asplenia including sickle cell disease, HIV
INDICATION infection, immunoglobulin or 0early
Children aged 2 years • Chronic heart disease, component complement deficiency
and above with any 1 including congestive heart - Children aged 12-59 months
of the listed chronic failure and o Unimmunized* or with one Hib
medical conditions cardiomyopathies vaccine dose received before
should get 1 dose of • Chronic lung disease, - Age 12 months, give 2 additional doses 8 weeks
PPSV23 apart
including chronic
obstructive pulmonary o With ≥ 2 Hib vaccine doses received
disease, emphysema, and before age 12 months, give 1
asthma additional dose
• Diabetes mellitus - For children ≤ 5 years old who received a Hib
• Cerebrospinal fluid leaks vaccine dose(s) during or within 14 days of
• Cochlear implant(s) starting chemotherapy or radiation treatment,
repeat the dose(s) of Hib vaccine at least 3
• Alcoholism
months after completion of therapy
• Chronic liver disease
- For children who are hematopoietic stem cell
Children 2 years and • Congenital or acquired transplant recipients, revaccination with 3
above with any 1 of immunodeficiencies doses of Hib vaccine given 4 weeks apart,
the listes (includes B-(humoral) or T- starting 6-12 months after transplant, is
immunocompromising lymphocyte deficiency, recommended regardless of vaccination
conditions should get complement deficiencies history.
2 doses of PPSV23, 5 - Unimmunized* children ≥ 15 months of age
(particularly C1, C2, C3, and
years apart and undergoing elective splenectomy should
C4 deficiencies), and
phagocytic disorderd be given 1 dose of Hib-containing vaccine at
least 14 days before the procedure
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 PCMC 27th COMPREHENSIVE REVIEW Championing Immunization
Fatima Ignacio Gimenez, MD, FPPS, FPIDS

- Unimmunized* children 5-18 years old and

with either anatomic or functional asplenia
(including sickle cell disease) or HIV infection,
should be given 1 dose of Hib vaccine
* Unimmunized children are those without a primary series and
booster dose or those without at least one dose of the vaccine after
14 months of age

• Typhoid vaccine
- Given intramuscularly (IM)
- Given at a minimum age of 2 years old with
revaccination every 2—3 years
- Recommended for travellers to areas where
there is a risk for exposure and for outbreak
situations as declared by public health
authorities

• Cholera vaccine
- Given per orem (PO)
- Given at a minimum age of 12 months as a 2-
dose series two weeks apart.
- Recommended for outbreak situations and
natural disasters as declared by health
authorities

Vaccines for High Risks/Special Groups: Human

Papillomavirus Vaccine (HPV) 2018:
• Given intramuscularly (IM)
• Give 3 doses of HPV vaccine following the 0, 1-2,
and 6 month schedule, regardless of age at vaccine
initiation to the following:
- Children with history of sexual abuse or assault
starting at age 9 years
- Immunocompromised children including those
with HIV infection
• HPV vaccination is not recommended during
pregnancy. If HPV vaccine is inadvertently given
during pregnancy, delay the remaining doses until
after pregnancy. Pregnancy testing is not necessary
before initiating HPV vaccination.
References
1. cdc.gov/vaccines/pub/pinkbook/prin.vac.html
2. https://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html#vax-
administration
3. Red Book 2018-2021. Report on Committee of Infectious Diseases. 31st
Edition.
4. https://www.cdc.gov/vaccines/hcp/acip-recs/general- recs/timing.html

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